MONTHLY HEALTH UPDATE
Can the Outcome of Back Pain Be Predicted?
Chad Abramson, D.C.
Low Back Pain
Can the Outcome of Back Pain Be Predicted?
When patients present with low back pain (LBP), they are frequently nervous and
worried about whether they’re going to respond to the treatment—especially when it comes to
getting out of pain and returning to their normal activities. A variety of studies have shown
chiropractic care to be an effective option for the LBP patient, and though there is no “crystal
ball”, there are some tests that doctors of chiropractic can perform during an examination that
can help predict outcomes!
In fact, a meta-analysis of data from 43 studies published since 2012 suggests that centralization and directional preference, which may be present in 60-70% of LBP cases, offers important prognostic clues. Directional preference means that it’s possible to move the body in a manner that feels better to the patient. Centralization implies that it’s possible to move in a way that reduces the range of the pain to a specific region.
Here’s an example… Let’s say an LBP patient presents with radiating leg pain from their lower back with numbness and tingling in the leg and foot. The focus is to find a movement that REDUCES the leg pain/numbness, so their doctor of chiropractic asks the patient to bend forward, backward, and sideways, and to rotate their torso, looking for which direction is preferred, i.e., directional preference. When pain decreases AND centralizes (the leg pain disappears), then extension is the directional preference.
When centralization occurs, this is a favorable prognostic sign indicating that improvement can be expected. Likewise, when all positions or directions increase leg pain, this is a poor prognostic sign, meaning this is likely a more challenging case.
This helps doctors better advise patients about their condition and what to expect from care in both the short and long term so the patient can make REALISTIC goals and timely plans. Over or under reassuring patients is simply not appropriate! Directional preference also allows providers a means of determining what type of treatment to emphasize. For example, if the patient feels better bending backward and leg pain disappears, the provider will approach treatment and exercise recommendations from that direction.
Patient education is an important part of treatment, and educating patients on how this process can predict treatment outcome instills trust and places realistic goals in perspective so patients know what to expect. This improves compliance with care and confidence for both the healthcare provider and the patient.
Neck Pain / Headaches
Chiropractic Methods for Treating Neck Pain
When it comes to neck pain, many patients seek out chiropractic care. In fact, there are several
studies demonstrating that manual therapies performed by doctors of chiropractic can offer significant
benefits for non-specific or mechanical neck pain as well as neck pain arising from injuries related to
sports, car accidents, and falls. What are some of these manual therapies?
Spinal manipulative therapy (SMT) involves moving the head and neck to a firm end-range of movement followed by a fast, thrust aimed at specific joints that are fixed, subluxated (partially out of position), and tender. The thrust is described as a “high-velocity, low amplitude” (HVLA) movement, and it’s also called “an adjustment”, which is more unique to the chiropractic profession. Joint cavitation (the “cracking” sound) often occurs as gas (nitrogen, oxygen, carbon dioxide) either forms within or is released from the joint.
Spinal mobilization (SM) is a low-velocity, low amplitude movement that is typically slow and rhythmic, gradually increasing the depth of a back-and-forth movement, often combined with manual traction. Here, joint cavitation is less common.
Exercise training that focuses on strengthening the deep neck flexor muscles and other exercises that are specifically designed for each individual patient based on their specific needs can result in better treatment outcomes compared to a generalized, non-specific exercise program. Studies in which SMT/SM and exercise are combined report better long-term outcomes than SMT/SM alone, but SMT/SM typically out-performs exercise therapy alone.
Physical therapy modalities (PTM) can include ultrasound, interferential, low and high volt, galvanic current, diathermy, lasers (class 3B and IV primarily), ultraviolet, ionto- and phono- phoresis, pulsed electro-magnetic field, hot/cold, and more.
Muscle release techniques (MRTs) include massage therapy, myofascial release, trigger point therapy, muscle energy techniques, active release therapy, gua sha, and many more.
Cervical traction devices can be used either in the office or at home, depending on the patient’s needs; however, it’s common for both approaches to be used. The obvious benefits of home traction include the ability to repeat its use multiple times a day, and it’s generally more cost effective. Types include static traction that can be applied sitting or supine (on the back) and intermittent traction, which is typically performed supine and is computerized, and hence, is often limited to in-office use only.
Which approaches are used in the course of care depend on the preference of the patient as well as the treating chiropractor. It’s important to discuss your preferences with your chiropractor when seeking care.
Where Is This Shoulder Pain Coming From?
When people say, “My shoulder hurts,” they often point to different areas in the vicinity of
the shoulder such as the base of neck, the collar bone, the scapula (shoulder blade), the chest, and/or
their arm. The challenge with the shoulder is that it’s anatomically comprised of three joints: the
glenohumeral joint, or GHJ (ball-and-socket); the acromioclavicular joint, or ACJ (collar bone and
scapula); and the scapulothoracic joint, or STJ (shoulder blade and rib cage). Some researchers even
argue that the sternoclavicular joint, or SCJ (collar bone and sternum), should also be considered part
of the shoulder.
From a musculoskeletal standpoint, the list of conditions that can cause shoulder pain is quite lengthy (and NOT all-inclusive): avascular necrosis (the bone dies due to lack of blood flow), nerve injury (neck and/or peripheral), thoracic outlet syndrome, fractures in/around the shoulder, bursitis, shoulder dislocation, frozen shoulder, impingement, arthritis (several types), rotator cuff injury, sprains, tendinitis or rupture, and labral tears (cartilage rim around the socket).
One of the most common causes of shoulder pain is impingement, which may occur with many of the above-mentioned conditions. This is technically referred to as “subacromial impingement” (SAI), which is essentially a reduction of the normal gap between the ball and socket, thus limiting the amount of room the joint has to function. Classic symptoms include pinching and pain when trying to put a coat sleeve on or raising the arm horizontally.
To complicate matters, conditions elsewhere in the body can also refer pain to the shoulder. In 2018, a study noted instances in which athletes failed to respond to routine treatment for shoulder pain but experienced improvements in pain and function when treatment addressed dysfunction in the cervical spine. Non-musculoskeletal conditions can also result in shoulder pain, such as gall bladder disease, which classically refers pain to the right scapula/shoulder blade. Other abdominal organ conditions that can refer pain to the shoulder include pancreatitis, an ovarian cyst, an ectopic pregnancy, as well as post-surgical referred pain. A heart attack classically refers pain to the left shoulder and left arm but may also include the abdomen, jaw, and/or mid-back. A lung condition such as a blood clot (pulmonary embolism), infection (like pneumonia), or lung cancer or tumors may also refer pain to the shoulder.
Doctors of chiropractic are trained to evaluate the whole patient and identify contributing factors for the patient’s chief complaint. In instances in which a non-musculoskeletal issue is suspected, the patient may be referred to the appropriate healthcare provider. However, a combination of manual therapies (manipulation/mobilization), exercise, ergonomic modifications, nutritional counseling, and physical therapy modalities can result in a satisfying outcome in most cases of shoulder pain.
Carpal Tunnel Syndrome
Treatment on the Wrist for Carpal Tunnel Syndrome
When treating patients with carpal tunnel syndrome (CTS), doctors of
chiropractic can employ a variety of options to reduce pressure on the median nerve.
While this can include dietary recommendations (to reduce inflammation),
adjustments to address dysfunction elsewhere along the course of the median nerve, or
even working with other healthcare providers to manage conditions that contribute to
CTS (like diabetes), treatment will often focus on the wrist itself.
One such approach is referred to as neurodynamic techniques, or mobilization. In a study involving 103 patients with mild-to-moderate CTS, those who received treatment twice a week for ten weeks experienced greater improvements with respect to pain reduction, symptom severity, functional status, and nerve function than participants in a control group who received no treatment. The authors concluded, “The use of neurodynamic techniques in conservative treatment for mild to moderate forms of carpal tunnel syndrome has significant therapeutic benefits.” This finding is supported by two previous studies that found the use of manual therapies on the wrist can alter the shape of the carpal tunnel itself and allow more room for the tendons, blood vessels, and median nerve.
Additionally, studies show that when the wrist moves beyond a neutral position, it can alter the shape of the carpal tunnel and increase pressure on its contents. In a healthy wrist, full extension/flexion can double pressure in the carpal tunnel; however, for CTS patients, the pressure can increase as much as 600%. That’s why many treatment guidelines recommend wearing a wrist splint (especially at night) and modifying work and life activities to keep the wrist in a neutral position as much as possible.
The good news is that in most cases of CTS, patients will benefit from a conservative treatment approach; however, achieving a successful outcome can be more difficult if the patient delays treatment. That’s why it’s important to consult with your doctor of chiropractic when you experience the signs and symptoms associated with CTS (pain, numbness, tingling, or weakness in the hands or fingers) sooner rather than later.
Whiplash and Mid-Back Pain – How Can This Happen?
Research regarding whiplash or whiplash associated disorders (WAD) classically focuses
on neck pain; however, the data show acute thoracic spine / mid-back pain (MBP) occurs in 66%
of WAD injures with 23% still complaining of MBP at one-year post-injury.
It’s easy to visualize how the cervical spine or neck can be injured in an automobile collision (or sport-related collision or a fall) as the head, which weighs an average or twelve pounds, whips back and forth in a “crack-the-whip” like manner, often well beyond the normal, physiological range of motion. This same stretching (eccentric loading) followed by compression (concentric loading) also occurs in the mid-back, which can injure ligaments, joint capsules, neural structures, and more. Also, the thoracic spine contributes to 33% of flexion and 21% of rotation IN THE NECK, making the mid-back a vital spinal region that facilitates neck movement and function!
In WAD cases, mid-back pain often hides in the shadows of a more obvious and often more serious neck injury, as the brain typically perceives pain from the greatest source. Additionally, the neuronal input to the sensory cortex of the brain (the area of the brain that perceives pain) is most highly represented from the head, hands, and feet and less from the midback or torso.
The seat belt may also contribute to injury—both to the anterior chest region including rib cage, sternum, breast tissue, abdominal organs, as well as to the mid-back. The oblique angle of the chest-restraint is an important factor when discussing the mechanism of injury, as it causes trunk/torso rotation during the rebound or flexion phase of WAD. Another mechanism of injury includes blunt trauma, of which the driver is especially at risk due to the close proximity of the steering wheel and the chest. This can lead to contusion or bruising, fracture, and/or injury to the abdominal and/or chest organs (heart and lungs).
Obviously, the speed of impact, angle of the collision, bracing of the person (or lack thereof), and overall physical condition of the patient can greatly affect the outcome of WADrelated injuries. The importance of assessing the whole person is essential in obtaining an accurate diagnosis and establishing a comprehensive treatment plan for the WAD patient.
Chiropractic management focuses on the entire person, frequently uncovering complaints in other spinal regions as well as in the extremities in WAD-related injured patients. Moreover, treating postural issues such as a short leg, ankle pronation, oblique pelvis, forward head posture, protracted shoulders, and more is vitally important in obtaining satisfying patient outcomes!
Whole Body Health
Deep, Slow Breathing for Pain Management?
Deep slow breathing (DSB) has been widely used for managing various diseases
of the heart and lungs as well as for psychiatric disorders including anxiety, depression,
and stress-related conditions. There appears to be some research to support DSB as being
helpful for pain management, but the results have been inconsistent. However, a 2012
study suggests that how you “think” while practicing DSB may be the key for reducing
In the study, researchers monitored sixteen healthy adults as they performed DSB while in both a relaxed and distracted state. In the relaxed state, participants were instructed to focus only on taking slow, deep breaths while in the distracted state, participants had to actively manage their deep breathing in pace with instructions on a computer screen. In order to reduce any carry-over effects, the active/distracted portions of the study were spaced six months apart and participants were advised to avoid practicing DSB or meditation or to seek any outside education on the topic.
Interestingly, in both circumstances, participants experienced similar reductions in negative feelings (tension, anger, and depression). However, the researchers only observed improvements with respect to pain thresholds, autonomic activity (skin conductance or sympathetic tone), and thermal detection for cold and hot stimuli when participants were relaxed.
Hence, it appears to be important that focused concentration on inhaling and exhaling or “thinking about” each breath in DSB and removing distracting thoughts is KEY to achieving increasing sympathetic arousal and improving mood processing. These findings may help to explain why mindful mediation, or mindfulness, benefits patients and why Eastern disciplines such as yoga, Qi-Gong, and Tai Chi are associated with reduced pain and improved mood.
Doctors of chiropractic often advise patients to reduce stress as part of management process for chronic pain conditions, with DSB being a great choice. This study shows that when done in a relaxed state, not only can patients experience moodrelated benefits but they may also be able to reduce the effect of pain on their daily lives so they can perform their usual work and life activities.
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This information should not be substituted for medical or chiropractic advice. Any and all health care concerns, decisions, and actions must be done through the advice and counsel of a health care professional who is familiar with your updated medical history.