Monthly Pain Update – April 2024
Daily Living with a Herniated Lumbar Disk
While disk herniations in the lumbar spine are fairly common and may resolve on their own or persist without symptoms, if a herniation places pressure on the spinal cord or nerves exiting the spine, the patient may experience radiating pain into one or both legs. While chiropractic care can help individuals with a herniated lumbar disk, patients often ask what they can do and what they should avoid between visits to facilitate the healing process.
Recommendations can depend on the location of the herniation, but lumbar disk herniation patients should try and remain active within pain tolerances. However, they should avoid activities that involve twisting, such as golf, tennis, or pickle ball. Additionally, they should avoid prolonged bed rest as research has shown such behavior can decondition the muscles in the lower back, which can lead to persistent, chronic pain and disability.
Since MANY activities of daily living require bending (like getting dressed or putting on shoes), a very important modification is to bend the knees and arch the back (poke out the buttocks) prior to bending forward. This is called hip hinging and reduces lumbar disk compression. Interestingly, our disks are like sponges and absorb water during the night. Because of this, an interesting study reported avoiding forward bending in the morning resulted in a faster recovery compared to a group that was not educated on this important point. That means, lie on your back in bed to get dressed in the morning (shoes, socks, pants, etc.).
Neurodynamic stretching, or nerve flossing, can also benefit disk patients. If compression occurs at the L1 or L2 levels, extend the leg back with the knee fully flexed (called a femoral stretch sign). For herniation at L2 or L3, stand or lay sideways, chin up, grasping the ankle and pull the thigh backward to reproduce the radiating symptoms in the front of the thigh. While releasing the stretch, bring the chin to the chest. For L4 and L5 herniations, patients may be advised to perform leg extension exercises. For example, lay on the back with the hip and knee bent at 90 degrees. While gripping behind the knee, slowly straighten the leg until radiating leg pain is felt. Then, while releasing the leg, flex and extend the head/neck to pull on the spinal nerves. ALWAYS stay within reasonable pain boundaries. Avoid knife-like pain.
Of course, each patient is unique and depending on the nature of your clinical presentation, your doctor may recommend different or additional stretches or exercises to perform at home between visits. Patients may also receive more general exercise recommendations based on their current fitness level, as well as nutritional advice.
Cyclist’s Palsy
Though peripheral neuropathies often develop in individuals whose daily activities involve fast, repetitive motions, no rest, awkward hand postures, firm gripping, and excessive vibration exposure like office workers, construction workers, line workers, etc., there is one group that meets these various criteria that we hardly consider: cyclists.
It’s estimated that nearly 800,000 Americans commute to work via bicycle and even more use their bike for recreational activities. It’s been reported that roughly 10% of the United Kingdom population rides a bicycle at least once a week. There are many types of bikes as well, such as road, mountain, hybrid, touring, city/commuter, BMX, electric, cyclocross, recumbent, and more—each catering to a unique environment and purpose. Although cycling serves as an excellent way to keep fit and healthy, even cyclists who avoid traumatic injury can still find themselves in pain.
One such injury is called cyclist’s palsy in which the combination of prolonged dorsiflexion (bent upward) of the wrist, strong grip, carrying the weight of the upper body, and vibratory forces from the ground can hinder the ulnar nerves as they pass through the wrist. This can result in pain, numbness, and muscle atrophy in pinkie and pinkie side of the ring finger, as well as the part of the hand between those fingers and the wrist. As with carpal tunnel syndrome, symptoms tend to come on gradually and are often ignored by cyclists who wish to carry on their normal activities. It’s only after symptoms become severe enough that riding becomes unbearable that they begin exploring treatment options.
The first step in the treatment process is accurate diagnosis. This involves a careful review of the patient’s history, as well as an examination to confirm there is ulnar entrapment at the wrist. In some cases, the patient may have co-occurring median nerve entrapment at the wrist (carpal tunnel syndrome) and/or ulnar nerve entrapment elsewhere along its course from the neck (double crush syndrome). If such issues are identified, then treatment will need to address them or the patient may not have a satisfactory outcome, which in the case of a cyclist would be to get back on their bike without pain.
Treatment will involve a multimodal approach that includes manual therapies, nerve gliding exercises, stretches, rest, ice (and other anti-inflammatory measures), and even ergonomic adjustments to the bike itself, including changes to the handlebars or grip. In most cases, such a conservative approach will benefit the patient. However, if the condition has progressed too far and there is nerve damage, the patient may be referred to an allied healthcare provider for corticosteroid injections or even surgical consultation. Or worse (to the hardcore cyclist at least), they may have to give up their hobby! Hence, the importance of seeking care early in the course of the disease when symptoms are mild.
Long-Standing Hip and Groin Pain
Simply put, long-standing hip and groin pain (LHGP) is discomfort in the hip and groin region lasting six weeks or longer that often limits physical function and reduces quality of life. For some patients, simple activities like walking, climbing stairs, and sitting for prolonged periods of time can feel impossible. Unfortunately, LHGP tends to come on gradually over time and has no easily identifiable cause, which can make diagnosis (and treatment) a challenge.
Part of the difficulty in diagnosing LHGP is to determine if the patient’s symptoms are caused by a primary disorder of the hip and/or groin area or if it is referred from a nearby part of the body that may need to be addressed. Potentially, the patient’s hip pain can be a secondary injury related to a problem elsewhere in the kinetic chain. For example, dysfunction in the lower back, knees, ankles, and feet can all alter the biomechanics of the hip, increasing the risk for injury. If such issues co-occur with hip pain, they’ll likely need to be resolved as well (hopefully with conservative chiropractic care).
Then there’s the complexity of the hip joint itself and the various problems that can affect it. These include osteoarthritis, labral tears, hip dysplasia, and sports hernias. Ultimately, diagnosis will be based on a review of the patient’s history, examination findings, and possibly diagnostic imaging.
The most common underlying causes of LHGP are femoroacetabular impingement syndrome (FAIS), chondral (cartilage) lesions, and labral lesions. Individuals whose everyday activities include extensive movement of the hip joint—such as soccer or hockey players—are at increased risk for LGHP, often due to repetitive stress and acute injuries. Older and sedentary adults are also at risk for LGHP, though the cause will more often be linked to degenerative conditions like osteoarthritis.
Temporomandibular Disorders and Posture
The temporomandibular joint (TMJ) is one of the most intricate and frequently utilized joints in the human body, working in conjunction with the internal and external pterygoids, masseter, and temporalis muscles to open and close the jaw, as well as stabilizing the hyoid bone during swallowing and protecting the airway while chewing and talking. Musculoskeletal issues that affect normal TMJ function are characterized under the general term of temporomandibular disorders (TMD). Symptoms associated with TMD include joint noise (clicks, catching, or grinding), pain, altered jaw motion, and restricted opening. While there are several potential causes for TMD linked to the jaw area itself, in recent decades, there has been a growing body of research supporting cervical dysfunction, poor neck posture in particular, as an underlying cause worth investigating in the event standard treatment fails to yield a satisfactory result.
The head is balanced on the neck in alignment with the trunk, as seen from the side. However, because of the increased use of screens and electronic devices, it’s become common for people to exhibit more of a forward head posture. That is, the head rests forward of the trunk. This forces the soft tissues at the rear of the head, neck, and upper back/shoulders to work harder to keep the head upright, elevating the risk for injury to the associated tendons, muscles, ligaments, joints, and nerves—some of which may also play a role in temporomandibular function.
In cases in which a TMD patient presents with either poor neck posture or neck pain, treatment to address the cervical region may help alleviate their jaw pain and other TMD-associated symptoms. Additionally, studies have found that TMD patients with jaw pain lasting longer than three months, increased sensitivity in the masticatory muscles, co-occurring headaches, co-occurring hearing complaints, and more severe and disabling TMD symptoms may also benefit from treatment restoring normal posture and function to the cervical spine. At least three systematic reviews published in 2023 found that manual therapies applied to the neck region can lead to improvements in pain, pain sensitivity, and function in the jaw.
These findings highlight the importance of considering the whole patient when managing a musculoskeletal condition like TMD—an approach common among doctors of chiropractic. This includes a careful review of the patient’s history and a thorough examination of not only the area of chief complaint but adjacent regions of the body to identify any issues that may contribute to or even cause the patient’s current pain or disability. In the case of TMD, especially longer lasting or more severe symptoms, it makes sense to examine the cervical spine as well.
Because the underlying cause of LHGP can vary, the treatment approach used for each patient will be tailored to their unique case. The multimodal approach used by a doctor of chiropractic may include long-axis distraction, mobilization, and thrust manipulation delivered in the office with two to three treatments a week for six weeks being a common initial approach. Physiotherapy modalities and at-home stretches/exercises may also be utilized with the goal of improving strength and flexibility. Less physically active patients may also receive advice on how to incorporate more movement into their day-to-day routine to help prevent recurrence.
Multimodal Care for Whiplash Associated Disorders
The term whiplash associated disorders (WAD) is used to describe the constellation of symptoms that can arise from the sudden acceleration and deceleration of the head and neck during an automobile collision, slip and fall, sports injury, etc. This process can injure several ligaments, tendons, muscles, and joints in the region, giving rise to symptoms that include neck and upper back pain and stiffness, headache, dizziness, ear ringing, cognitive fog, fatigue, jaw pain, and more. Because each WAD case is unique, there’s no consensus on what single type of treatment may work best. Rather, the common practice for managing WAD is to take a multimodal approach.
Simply put, a multimodal approach combines one or more therapies, which may include multiple providers, in hopes of producing greater overall improvement in pain and disability than a single therapy on its own. The Bone and Joint Decade 2000-2010 Task Force on WAD and NAD (Neck Associated Disorders) investigated the existing literature to identify which treatments were well supported and which looked promising but required more studies before firm recommendations could be made. The initial paper cited evidence for manual therapies, passive physical modalities, and acupuncture. An updated review published in 2016 added mobilization, manipulation, and clinical massage—all of which are commonly delivered in a chiropractic setting. Clinical guidelines such as the Ontario Protocol for Traffic Injury Management Collaboration often recommend a multimodal approach that combines these therapies as well as specific exercise and patient education, among others, for managing WAD cases of a variety of severities.
This can be observed in practice by looking at a case study that focused on a 30-year-old woman who began experiencing truncal tremors (a neurological disorder) following a motor vehicle collision. The initial physical examination conducted by a chiropractor revealed an increase in the truncal tremor during cervical compression testing by flexing the trunk during passive cervical flexion, limited cervical range of motion, and swaying during balance testing. This led to a multi-discipline management strategy including neurological consults and the diagnosis of functional truncal tremors. Multi-modal chiropractic management included spinal manipulative therapy, whole-body vibration therapy, and acupuncture as well as concurrent co-management by the neurologist that included pharmacology, as well as behavioral care. This included stress reduction techniques, caffeine elimination, and 30 minutes of daily yoga exercises. The patient was released after twelve chiropractic visits, reaching maximum improvement 95 days post-MVC with truncal tremors described as barely noticeable.
This case study represents an important point that multimodal care often results in superior outcomes. While many WAD patients experience satisfactory results from chiropractic care alone, more complex cases may require working with allied healthcare providers. As with other musculoskeletal conditions, recovery may be swifter the earlier the patient seeks care, so if you’ve sustained a whiplash injury, contact your doctor of chiropractic sooner rather than later.
Three Sleep Enhancement Supplements
It’s estimated that at least one-in-three adults fail to consistently get sufficient restful sleep each night. Over time, poor sleep can increase the risk for a variety of chronic diseases and potentially lead to an early death. This month, we’re going to discuss three supplements that can help you achieve a good night’s sleep: melatonin, magnesium, and Valerian root.
Melatonin is a hormone that is naturally released in the brain in response to reduced light exposure that prompts sleepiness. In the present day, light stimulation from interior lighting and electronic devices/screens can interrupt this process, delaying the release of melatonin. Taking a melatonin supplement can help; however, there’s no specific recommended dose. Rather, it’s recommended to start with a low dose and increase it over time. Because melatonin can interact with some medications, patients should talk with their prescribing physician before taking the supplement.
Magnesium is an essential mineral that plays a role in nerve and muscle function, bone development, blood sugar control, and heart rhythm. It can also improve sleep disorder symptoms like daytime sleepiness, snoring, and short sleep. Additionally, magnesium supplementation has been observed to help older adults fall asleep faster and sleep longer. A diet rich in nuts, leafy greens, whole grains, dairy, and soy products may provide sufficient magnesium. Otherwise, a daily dose of 300-400 mg is recommended, though a precise dose can vary based on factors such as age and sex. As with melatonin, speak with your doctor before starting a magnesium supplement.
The Mayo Clinic reports that Valerian root is an herbal supplement that may reduce the amount of time it takes to fall asleep and improve overall sleep quality. There is no recommended dose for Valerian root, and it can take up to two weeks before users experience any benefits. The supplement is considered to be fairly safe but is linked to side effects such as headache, dizziness, and indigestion. Women who are pregnant or breastfeeding, users of substances that cause sedation, and individuals who take prescription drugs should talk to their doctor before using Valerian root.
While these supplements have been demonstrated to improve sleep, they are not a magic bullet. If you have trouble falling asleep, it’s important to evaluate your diet, physical activity levels, stress management, and bedtime routine. Additionally, studies have shown that low back pain can cause poor sleep (and poor sleep can cause low back pain) and this may be true for many musculoskeletal disorders. So, if you have pain and are having trouble sleeping, then schedule an appointment with your doctor of chiropractic because the sooner your pain is addressed, the sooner you may start sleeping better.
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.
