Monthly Pain Update – April 2023
Pre-Surgical Treatment for Carpal Tunnel Syndrome
Outside of an emergency situation, such as a wrist fracture, treatment guidelines for carpal tunnel syndrome generally recommend exhausting non-surgical options before consulting with a surgeon. But how well are guidelines followed? To find out, researchers surveyed 770 members of the American Society for Surgery of the Hand to better understand the current practice patterns regarding the non-surgical care for CTS patients. Roughly half of respondents had two decades or more of experience in the field with 80% completing a residency in orthopedic surgery and 81% either currently have or previously had a subspecialty in hand surgery.
According to the survey, 72.9% of the CTS patients the surgeons consulted with had previously had two or more corticosteroid injections with 41.2% of surgeons recommending an additional injection before recommending surgery. About four-in-five surgeons did not believe oral steroids are effective for managing CTS though they are included in clinical treatment guidelines developed by the American Academy of Orthopedic Surgery (AAOS). The authors of the study note there is a lack of feedback to the patient’s primary care doctor (and other authorities) when these approaches fail, which may perpetuate their use unnecessarily.
The researchers point out that the current AAOS clinical treatment guidelines cite strong evidence to support corticosteroid injections and moderate evidence that oral steroids could improve patient-reported outcomes compared to placebo. The study authors continue by noting a study that found corticosteroid injections may only provide short-term benefits compared to a placebo, and another study that concluded a second corticosteroid injections may not offer additional benefit.
The survey results appear to be contrary to the guidelines put forth by the AAOS, which may be misguiding primary care and general orthopedic physicians. The authors conclude that their findings highlight the importance of better implementation of non-surgical CTS treatment strategies that follow current evidence-based information, rather than following the clinical practice guidelines of the AAOS.
The good news is that the various treatments provided by doctors of chiropractic are highly effective in managing mild-to-moderate CTS as studies have demonstrated that such conservative therapies can be as effective as surgery over the long-term with fewer adverse events.
Nerve Injury Often Missed in Whiplash Patients
While the literature published on the topic of whiplash-associated disorders (WAD) is voluminous, it’s still somewhat of a mystery why some individuals can walk away from a motor vehicle collision without injury and others can experience chronic, persistent, and disabling symptoms. One area in which researchers have focused their efforts in recent years is on the extent that nerve injury occurs during a whiplash event, and when it occurs, whether it’s being detected early in the course of treatment.
Traditionally, WAD patients are classified the following way: WAD I—pain, stiffness, or tenderness of the neck as the only complaint with no physical exam findings (full range of motion and no muscle guarding or tenderness on examination); WAD II—pain, stiffness, or tenderness of the neck with soft tissue injury signs, loss of range of motion (ROM), and/or point tenderness of the neck (e.g., a sprain/strain neck injury); WAD III—pain, stiffness, or tenderness of the neck along with neurological signs sensory deficits, motor weakness, and/or decreased or absent deep tendon reflexes; WAD IV—pain, stiffness, or tenderness of the neck along with dislocation or fracture with or without spinal cord injury.
As you can expect, treatment guidelines can vary based on how WAD is graded. A systematic review of 54 studies that included more than 390,000 WAD patients and 900 individuals without a history of WAD (who served as controls) concluded that this classification system may need updating. The researchers found that about a third of WAD II patients—the most common WAD level—showed signs of neuropathic pain, though they had not been diagnosed as such.
The authors stress the importance of a careful INITIAL clinical examination as the presence of nerve injury/pathology may alter the treatment recommendations given to the acute WAD patient such as a wait-and-watch method that is commonly recommended after the initial examination. Researchers point out that compared to other chronic pain conditions, people with neuropathic pain experience greater interference with function and activity tolerance as well as worse quality of life and emotional wellbeing assessments—each of which is associated with an increased risk for chronicity.
Doctors of chiropractic are trained in the diagnosis and management of WAD using a multimodal approach that embraces spinal and extremity manipulation, mobilization, and other manual therapies; exercise training tailored to the individual patient; nutritional counseling for reducing inflammation and promoting healing; various PT modalities including ultrasound, electrical stimulation, laser, and pulsed magnetic field; acupuncture and/or dry needling; and more. In more severe cases, doctors of chiropractic can also co-manage treatment with the patient’s medical physician, specialist, or other healthcare providers.
The Hamstring and Tension-Type Headache Connection
Patients with tension-type headaches (TTH) often experience neck pain and stiffness, which may be a contributing factor in their present headaches. Thus, it’s not uncommon for a doctor of chiropractic to use manual therapies and provide home exercise instruction focused on improving neck function in the effort to reduce headache frequency and intensity. It may surprise a TTH patient that care may also address areas of the body that seem unrelated to the head. For the TTH patient, they may receive treatment and be asked to perform at-home stretches to address their tight hamstrings. Why is that?
The superficial back line is comprised of the muscles and associated tissues that start in the back of the head and run down the neck, back, and legs. These muscles work together to keep the body upright, but when there’s a problem in one part of this chain, it can lead to issues elsewhere. Several studies have observed an association between tightness in the hamstrings—the largest muscle in the superficial chain—and tightness in the neck muscles. One study found that individuals with increased tension and shortening of the hamstrings are more likely to have neck and shoulder pain. A possible explanation is that tight hamstrings can cause the pelvis to tilt backward, which can contribute to the forward head posture—a postural fault that can place increased strain on the muscles in the back of the neck and contribute to headaches.
In a study that included 30 TTH patients, researchers split participants into two groups: one group received treatment to relax the hamstrings through a guided stretching routine in the office and the other received electrotherapy to stimulate the hamstring muscles. Both groups received instruction to perform self-myofascial release at home. Assessments conducted after four weeks of treatment revealed the hamstring relaxation group experienced greater outcomes with respect to headache-related disability, neck pain, and cervical range of motion.
This finding highlights the importance of examining the whole patient—something chiropractors are trained to do—and not just focusing on the area of chief complaint as issues elsewhere in the body may be the underlying cause or a contributing cause to the patient’s condition.
Chiropractic Care for Lateral Ankle Sprains
Most people have rolled an ankle in their lifetime. Usually, an ankle sprain heals without any consequence, but that isn’t always the case. According to the current research, a third or more of lateral ankle sprain patients may experience long-term problems like ankle instability that necessitates splinting or taping the ankle before engaging in sports or other weight-bearing physical activities. Can chiropractic care help reduce the risk of ankle instability and other chronic issues that can arise from a lateral ankle sprain?
In 2022, researchers conducted a systematic review and meta-analysis of data from three studies that included 180 patients to assess the effectiveness of manual therapy and/or exercise in the management of lateral ankle sprains. The type of manual therapies used in the three studies included non-thrust mobilization, thrust manipulation, and myofascial release methods—all techniques utilized by chiropractors on a daily basis. The exercises focused on proprioception (balance oriented), stretching, and strengthening.
The research team observed that the combination of manual therapy and exercise is more effective than exercise alone in improving ankle ranges of motion, lower limb function, and pain, leading them to conclude that the addition of manual therapy to lateral ankle sprain treatment will improve clinical outcomes. In addition to reducing the risk for ankle instability, lateral ankle sprain patients who receive manual therapy may also have a lower risk for reduced thickness of the plantar fascia, reduced cross section size (atrophy) of the peroneus brevis muscle, and altered activation patterns of select lower limb muscles, which may significantly reduce their risk for reinjury. This can be very important for rugby, tennis, football, volleyball, and basketball athletes as ankle-related issues affect roughly half of participants in these sports.
Chiropractic colleges educate students on the application of manual therapies to the upper and lower extremities. Additionally, many post-graduate programs offer continuing education courses on the same topic. The next time you, a family member, or friend suffers an ankle sprain, be sure to consider chiropractic care.
Low Back Pain and the Sacroiliac Joint
The sacroiliac joints (SIJ) sit between the sacrum (tailbone) and ilium (pelvis), which serve to connect the spine and pelvis and facilitate load transfer from the low back to the lower extremities. Generally, when we consider the cause of a patient’s low back pain, the first place investigated is the lumbar spine. But as it turns out, the culprit can often be the SIJ.
Studies in recent years estimate that the SIJ may be the primary or contributing cause of 15-30% of low back pain cases. Not only can sacroiliac joint dysfunction be experienced by the patient as low back pain but it can also cause pain in the groin, and according to a 2017 study, up to 60% of SIJ patients report pain that radiates into the leg!
The mechanism of SIJ injury is often a combination of axial loading (downward/jamming pressure) and abrupt rotation (twisting). While this can be caused by a sudden fall or collision, repeated strain can also injure these joints. A 2018 study that included 271 recreational golfers found that 23% had sacroiliac joint dysfunction, presumably from repeatedly swinging a golf club, and nearly all of them (96%!) also had lower back pain. Another study, also published in 2018, found that among a group of 1,500 pregnant women, 80% had sacroiliac dysfunction. The researchers suspect the combination of weight gain and a loosening of ligaments that occurs during pregnancy is the likely cause.
Researchers have also found that leg length discrepancy (LLD) can place uneven loads on the sacroiliac joints, which can increase the risk for injury. Other causes of SIJ injury can include prior lumbar fusion, joint infection, malignancy, spondyloarthropathies, inflammatory bowel disease, gait abnormalities, scoliosis, and excessive exercise.
The good news is that doctors of chiropractic are well equipped to not only determine if the SIJ can be a factor in a patient’s low back pain (or leg or groin pain) but also to manage SIJ dysfunction. Studies have shown that a combination of manual therapies (including spinal manipulative therapy) and stabilization exercises is effective for reducing pain and improving function in the SIJ, more so than corticosteroid injections or physiotherapy. While patients may experience immediate improvement after a single treatment, it may take several treatments to achieve a satisfactory and lasting result.
Chiropractic Care for the Pediatric Population
While the typical chiropractic patient is a working-age adult, children and teenagers also experience neck pain, back pain, headaches, and other musculoskeletal conditions that may respond favorably to chiropractic treatment. In fact, a 2017 study that monitored 1,400 Danish school children for three years found that 55% experienced spinal pain during the course of the study. With the increased prevalence of sedentary behavior and obesity in the pediatric population, it’s reasonable to suggest that musculoskeletal disorders may become more common in individuals under age 18 in the coming years. To better understand the use of chiropractic care by this population, researchers in Quebec surveyed 245 chiropractors in the province.
According to the survey, pediatric patients account for less than five patient visits per week—between about .5% and 4% of a typical chiropractic practice. Among the pediatric patient population, the majority of patients were children ages 6-12 and teens aged 13-17; however, babies under 23 months of age (and under six months, in particular) are often seen in chiropractic clinics.
The data show that the most common referral source for pediatric patients is a parent, family member, or friend (presumably also a patient in the clinic), with family doctors, other chiropractors, and other healthcare professionals accounting for the remainder. Among the patients aged six and up, the most common presentations appear to be back pain and headache with conditions such as torticollis, colic/irritability, head asymmetry, motor development issues, gastrointestinal problems, sleeping difficulty, jaw/temporomandibular joint issues, and gait/walking problems being more common complaints in the under-age two patients.
Of the doctors surveyed, 24.9% report they had attained a “Diplomate in clinical chiropractic pediatrics” meaning they had undergone post-graduate training and board examination. Additionally, 54% were active members of a pediatric and perinatal care association. The participants also noted a willingness to co-manage patients with other healthcare providers and they’d immediately refer a patient to their medical physician or hospital if they uncovered any red flags including but not limited to facture/dislocation, fever, chest pain, suicidal ideation, dehydration, persistent vomiting, persistent abdominal pain, etc.
Though the authors of the study note that specific research on chiropractic treatment in the pediatric population is lacking compared to older age groups, they report that adverse events following manual therapy are rare. For pediatric patients who do not respond to conventional treatment, a consultation with a doctor of chiropractic for evaluation may be considered for a short-term course of care to evaluate the effectiveness of treatment.
This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.
