Monthly Pain Update – August 2022

Chiropractic Care for the Aging Back

Functional loss is a term used to describe the inability to carry out necessary activities of daily living such as bathing, getting dressed, getting out of bed, standing up, walking, using the bathroom, and eating. According to experts, spinal pain is a leading cause of functional loss, especially among older adults, often due to age-associated wear and tear that affects the various tissues in the lower back.

One particular condition, lumbar spinal stenosis (LSS), is characterized by a narrowing of the holes that the spinal cord passes through, as well as the nerves that branch off from the spinal cord and travel to the head, arms, trunk, and legs. The terms “central” and “lateral” stenosis apply to the spinal cord space and the nerve root spaces, respectively. It’s important to note that the blood vessels that travel with these nervous system tissues, the neurovascular structures, can also become compressed. One study, which analyzed data from the Framingham Study cohort, found that nearly half (47.2%) of adults in their 60s have some degree of LSS.

In addition to symptoms associated with LLS like low back pain and stiffness, patients may also experience poor standing and walking tolerance, which is referred to as neurogenic claudication (NC). When NC is present, patients will also report that one or both legs feel heavy, tired, achy, crampy, numb, and/or weak. They may also experience impaired balance, which can be a real problem because falls can significantly affect a senior’s long-term health and ability to remain independent.

The good news is that the majority of these patients do quite well with non-surgical care such as chiropractic treatment. A 2022 systematic review and meta-analysis LLS with NC reported that the current research supports an initial multi-modal, non-pharmacological treatment approach that includes patient education, rehabilitative exercises, and manual therapies—all of which can be provided by a doctor of chiropractic.

A Chiropractic Approach to Neck Pain

Chiropractic care is a highly effective form of treatment for many cervical or neck-related conditions. But how do chiropractors determine what’s causing the pain and what approach to take to manage the patient’s condition? Let’s take a look at what chiropractors do when a patient presents with neck pain.

HISTORY: In the detective part of the job, the chiropractor has to determine 1) pain generation or tissue involvement; 2) ruling in/out dangerous “red flags” (cancer, infection, spinal cord injury, fracture) that would require referral to the patient’s medical physician, a specialist, or the emergency room; and 3) identifying and tending to “yellow flags” (barriers to recovery like depression, anxiety, poor coping strategies, and more). This process starts with taking a history of the complaint to identify how long the patient has experienced the condition, where the pain is felt and if it radiates to other parts of the body, grading the severity of pain, when the pain worsens or improves, and more. Questionnaires are often used to help identify the red and yellow flags and to determine how the condition affects activities, mood, and other aspects of the patient’s life.

EXAMINATION: The examination phase begins by identifying the pain generator(s). To do this, chiropractors use various tests to assess pain provocation or reduction, pain radiation, and the patient’s “pain behavior” associated with the “positive” or “negative” test result. For example, if bending the head forward (chin to chest) often feels better and looking up often hurts and sometimes provokes radiating pain into an arm, then the chiropractor will perform other tests that assess nerve conductance such as strength, sensory, and nerve compression tests. The examination may also include the use of diagnostic tools, like X-ray, if necessary.

TREATMENT: Once the history and examination are complete, the doctor of chiropractic will be able to make a diagnosis and formulate a treatment approach. This can consist of manual therapies (spinal manipulation, mobilization, soft tissue work, etc.) performed in the office, possibly including modalities like traction, TENS, or cold laser. Patients may also receive instruction on the use of heat, ice, activity modifications, and nutritional/dietary information to help reduce inflammation. Additionally, the chiropractor may prescribe the patient exercises to perform at home to aid in the healing process.

Following an initial course of care—such as three visits a week for two weeks—the chiropractor may reassess the patient to determine if visits should be tapered down or if the patient can be released from care to return on an as-needed basis.

Conservative Therapy for Severe Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy, and it is estimated to affect up to 4.9% of the population. Because the condition is characterized by symptoms like pain, numbness, tingling, and weakness in parts of one or both hands, it’s easy to understand why CTS can have such a negative impact on one’s quality of life and ability to carry out everyday activities. In past articles, we’ve discussed how chiropractic care can benefit patients with mild-to-moderate CTS, but what about more severe cases, especially those in which a systemic condition—like diabetes—is also present?

In 2021, a group of researchers reviewed data from twenty-nine studies published in the preceding decade on the management of carpal tunnel syndrome, particularly for severe cases or those attributable to a secondary condition such as diabetes, hypothyroidism, obesity, etc. They found evidence that pharmacology, electrotherapy, and manual therapy are beneficial for severe and/or systemically caused CTS. However, studies with larger sample sizes are needed.

The paper reported that manual therapies—which are commonly used by chiropractors—like carpal bone mobilization, neurodynamic techniques, and other soft tissue techniques provided benefits with respect to symptom and function improvement, especially when combined with nocturnal splinting.  The researchers also found that studies support the use of a neutral wrist position (or even slight flexion) splint rather than the commonly recommended 20 degree wrist extension splint.

The review also noted evidence that various forms of “electrotherapy”—pulsed and continuous ultrasound, diathermy, high intensity laser therapy (HILT), low level laser therapy (LLLT), pulsed electromagnetic field (PEMF), extracorporeal shockwave therapy (ESWT), pulsed radiofrequency, and electro-acupuncture—may be beneficial, especially as part of a multimodal approach. Additionally, the review found that corticosteroids may not provide a benefit when used alone but did when combined with nocturnal splinting.

Ultimately, the authors concluded that for these types of CTS cases, a multimodal treatment plan that combines pharmacology, electrotherapy, and manual therapy may be the best approach, though more research is necessary to determine which specific therapies may work best for a particular CTS case type. Doctors of chiropractic are trained in the use of several forms of manual therapies and may also offer some of the electrotherapy options noted above. If there are secondary conditions that require management in conjunction with a medical physician, your chiropractor can team up with your family doctor or a specialist.

Non-Surgical Care for Shoulder Instability

The shoulder is one of the most mobile joints of the body, which allows us to engage in overhead movements that make life easier. However, this comes at a cost. In order for the shoulder to have such a wide range of motion (ROM), it has less stability than most other joints. In fact, shoulder instability is a leading cause of disability and a common reason patients seek care.

Clinical shoulder instability is defined as symptomatic abnormal motion of the ball and socket (glenohumeral) joint. If you consider the ROM between loss of motion (hypomobile), normal ROM, increased but pain-free ROM (hypermobile), and complete dislocation, instability lies between hypermobile and dislocation. There are three classes of injury:

Type 1—traumatic with structural pathology

Type 2—atraumatic with structural pathology

Type 3—atraumatic with no structural pathology but abnormal muscle pattern (imbalance)

Shoulder instability results from an imbalance or pathology that disturbs one or more of the shoulder stabilizing structures and can be subdivided into “structural” and “functional.” Structural instability includes injuries: acute (type 1), repetitive microtrauma (multiple small injuries), and  congenital (type 2). Functional instability includes abnormal posture, muscle imbalances, altered nervous system conditions, and the like (type 3). The direction of instability can vary depending on the nature of the condition.

For type 1, surgery is usually best, especially in a young, active athlete. However, for some type 2 and most 3 classes of instability, non-surgical care (which includes chiropractic) is preferred. Doctors of chiropractic focus on whole body management, from structural issues to nutrition and wellness. Posture management is a HUGE component of chiropractic care, and poor posture is a VERY common contributor to shoulder instability and dysfunction. Specifically, upper cross syndrome (overactive posterior neck and chest muscles and underactive deep neck flexors and scapular/upper back muscles) and scapular dyskinesis (slumped, slouchy, or forward head posture) are present in nearly 90% of patients with functional shoulder instability. Manual therapy applied to joint restrictions located in the neck, mid-back, and shoulders (especially to restore external rotation motion) are very important and routinely performed by doctors of chiropractic.

For those with non-traumatic posterior instability, the current research suggests that conservative management has an excellent success rate. However, the longer the condition has been present, the more treatment it may take for the patient to achieve a satisfactory result. So, the best advice is to consult with your doctor of chiropractic early on when symptoms first present.

The Whiplash and Concussion Relationship

Whiplash associated disorders (WAD) and traumatic brain injury (TBI) share symptoms such as neck pain, headache, dizziness, concentration deficits (mental fog), noise/light sensitivity, and fatigue. Given these common symptoms and the proximity of the head and neck, these conditions may be related. However, the current state of the literature and educational process continues to separate the two, which could increase a patient’s risk for chronic, long-term symptoms.

A 2021 case study illustrates how chiropractic treatment—which is normally associated with managing WAD—can benefit the TBI patient experiencing long-term symptoms, referred to as post-concussive syndrome (PCS). The case study concerns a 21-year-old male who had experienced a TBI one year prior and received no follow-up care. The patient reported periods of worsening symptoms with significant disability and functional loss. This is not unusual; more than half of patients discharged from emergency departments following concussion injuries don’t receive any follow-up care or patient education on the condition. It’s reported that up to 20% of TBI patients will develop long-term symptoms.

A thorough examination revealed a loss of cervical range of motion, balance dysfunction (vestibular, or inner ear), posture instability, and cognitive and emotional symptoms. Treatment included manual therapy (neck and mid-back vertebral mobilization), vestibular rehab (eye and head movement exercises), and neuromotor retraining (balance exercises)—all therapies provided in a chiropractic clinic.

Following eight sessions spread over five weeks, the patient reported improvement in nearly all symptom categories, as well as dramatic improvement on a concussion questionnaire. This finding corresponds to another paper that reviewed multiple cases studies of PCS patients who experienced favorable outcomes after utilizing chiropractic services that included manual therapies and rehabilitative methods aimed at restoring cervical spine function.

Unfortunately, TBI and WAD diagnostic and treatment guidelines were developed separately, and because there is no gold standard test to differentiate the two conditions, it’s possible for a healthcare provider to misdiagnose a concussion following a car accident or a whiplash injury after a sports collision. This may explain why a high number of patients from both camps continue to experience long-term, chronic symptoms.

If you or a loved one experienced a whiplash injury or concussion, be sure to keep track of all symptoms, even if they might not seem to be related to WAD or TBI as they may help your doctor more accurately assess your injury.

GERD and Chiropractic Treatment

When an individual decides to seek out chiropractic care, it’s typically for musculoskeletal (MSK) complaints such as low back and neck pain, headaches, and/or shoulder/hip/wrist/knee problems. However, there is a growing body of evidence that some services offered by doctors of chiropractic can provide some benefit to patients with ailments that do not fall into the MSK category such as gastrointestinal (GI) conditions like acid reflux or GERD (gastro-esophageal reflux disease).

According to the Cleveland Clinic, GERD affects about 20% of the United States population.  Gastro-esophageal reflux disease is chronic acid reflux where the stomach’s acid-containing contents leak back up and irritate the esophagus (the tube connecting the mouth and stomach) causing heartburn. In some cases, the lower esophageal sphincter (the opening into the stomach) doesn’t close properly, allowing the regurgitation of acid into the tube. The GERD patient may not have heartburn but may experience hoarseness, difficulty swallowing, a dry cough, halitosis, or the feeling of food getting stuck in the throat and choking.

The classic treatment for GERD usually involves over-the-counter medications starting with antacids, followed by H-2 receptor blockers, proton pump inhibitors (PPIs), or a prescription to relax the lower esophageal sphincter. Patients may also be advised to stop smoking, raise the head of their bed by approximately 6-8 in (15.24-20.32 cm), avoid pre-bedtime eating, eat smaller portions, lose weight, and reduce their intake of fat, dairy, and other trigger foods (spicy, fried, and fatty foods; chocolate; tomato sauce; onion; garlic; citrus fruits; alcohol; coffee; and carbonated drinks).

Up to 15 million Americans take PPIs and are often told they should take such medications indefinitely. Unfortunately, significant side-effects from long-term use can occur resulting in osteoporosis and bone fracture, chronic kidney disease, pneumonia, gut infection (include C-Diff), inflammatory bowel disease, heart disease, upper GI cancer, and more. While evidence is largely limited to case and small-scale studies, there may be a place for the chiropractic co-management of GERD with the use of manual therapies.

An interesting 2021 paper reported on a 35-year-old female who experienced full resolution of GERD after receiving chiropractic spinal manipulation to correct forward head posture and upper cross syndrome. A 2016 study found that between three and sixteen treatments consisting of thoracic spinal manipulation, diaphragm mobilization, traction of the cardia, and posture correction—all of which can be provided in a chiropractic setting—provided significant improvement in all but two of twenty-two GERD patients. Even better, the patients continued to report such benefits during a follow-up visit three months following the conclusion of treatment.

The findings from these studies suggest that GERD may have a musculoskeletal component that can be addressed with chiropractic care. However, more research is needed before treatment guidelines can be updated.

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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.