Monthly Pain Update – August 2024

Smoking Is a Risk Factor for Back Pain  

Back pain refers to pain or discomfort in the dorsal (back) region of the body, which can arise from abnormalities in spinal vertebrae, back muscles, tendons, ligaments, or neural structures.  While back pain and other musculoskeletal injuries can usually be linked to an identifiable event, like lifting with improper form, there is often a history of stressors that have compromised the integrity of the tissues involved that precede the onset of back pain. Think of the adage about the straw that broke the camel’s back. Some of these stressors may not be related to physical activity at all. One such lifestyle factor that has been linked to an elevated risk for back pain is smoking.

The current literature suggests that smoking constricts blood vessels, which restricts blood flow and the delivery of nutrients to the tissues in the body, including the back. This can lead to inflammation, slower healing, disk degeneration, reduced bone density, and muscle fatigue—all factors that can increase the risk for back pain. Additionally, smokers are less likely to be physically active and more prone to anxiety and stress, which are also linked to an elevated risk for back pain.

In a large prospective cohort study that lasted nearly 13 years and included 438,510 adults, researchers observed that current smokers are 50% more likely to develop back pain than never smokers. Additionally, the risk for low back pain among smokers increases by up to 45% for those with a history of smoking exceeding 30 pack years (a pack year equaling 365 packs of cigarettes) or those who smoke 30 or more cigarettes a day. The risk of back pain is also higher among female smokers. Another study reported that smokers may develop inflammatory back pain at a younger age and experience a worse course of disease.

For smokers who develop back pain, a population-wide study conducted in Sweden in 2010 and published in 2022 found that daily smoking reduced the risk for a favorable prognosis by about 21%. In a 2023 study, examinations of 54 chronic low back pain patients revealed an association between cigarettes smoked per day and worse scores on assessments of pain intensity, fear-avoidance beliefs, and disability.

Time for some good news. An analysis of data from the English Longitudinal Study of Aging looked at data concerning 6,467 middle-aged and older men and women and found that those who stopped smoking experienced a declining risk for low back pain. In fact, their findings suggest that former smokers may have a similar risk for low back pain as never smokers if they can maintain smoking cessation for just four years. However, if they relapse in that time frame, the risk for back pain appears to be the same as those who continued to smoke.

Unwinding Postprandial Headaches

Postprandial headaches are headaches that occur after eating a meal. While this type of headache is fairly common, there are myriad potential causes. For individuals who suffer from postprandial headaches, it’s recommended they keep a food diary and track food intake and when headaches occur to help isolate potential triggers. Some of the most common reasons a postprandial headache may occur include:

• Blood Sugar Imbalances: A drop in blood sugar levels after eating (hypoglycemia), particularly if the meal was high in simple carbohydrates, can lead to headaches. Conversely, a spike in blood sugar followed by a rapid decline (hyperglycemia) can also trigger headaches. Eating small, more frequent meals and a balanced diet may help maintain more consistent blood sugar levels post meal.
• Food Sensitivities/Allergies: Foods high in histamine (aged cheeses, fermented foods, and certain alcohols), tyramine (aged cheeses, cured meats, and fermented products), and gluten (bread, pasta, baked goods, cereal, and beer) can cause headaches in sensitive individuals and may need to be avoided.
• Dehydration: Not drinking enough water with meals, particularly meals high in salt, can cause dehydration and result in headaches.
• Food Additives: Flavor enhancers and artificial sweeteners like monosodium glutamate (MSG), aspartame, and sucralose may trigger headaches in susceptible individuals. Be sure to check labels, especially if consuming highly processed food products.
• Caffeine Withdrawal: If you regularly consume caffeine and then have a meal without your usual caffeine intake, you may experience a withdrawal headache.
• Digestive Issues: Acid reflux (gastroesophageal reflux disease, or GERD) can cause headaches due to the strain and discomfort it places on the body. Talk to your healthcare provider about lifestyle strategies/treatments to combat acid reflux.
• Hypertension: Eating foods high in salt or those that cause a spike in blood pressure can lead to headaches. Try salt alternatives or other spices instead.
• Mental Health Disorders: The act of eating or the types of food consumed can sometimes trigger stress or anxiety-related headaches. This may include individuals with a history of eating disorder and/or post-traumatic stress disorder.

If postprandial headaches persist, especially if they interfere with your daily activities, talk to your healthcare provider.  Potentially, these headaches may be co-occurring with other types of headache, and they’d need to be addressed concurrently to achieve a satisfactory outcome for the patient. This may include examining the cervical spine and associated tissues to identify musculoskeletal issues that can contribute to headaches, something your doctor of chiropractic is trained to look for and manage.

The Neck Before and After Whiplash

Whiplash associated disorders (WAD) is a term used to describe the cluster of symptoms that can occur following the sudden acceleration and deceleration of the head and neck, most commonly during a motor vehicle collision (MVC). Individuals who experience such an event may experience no injury at all, while others may have catastrophic outcomes. In many cases, a whiplash sufferer may develop neck pain and stiffness that can prompt them to seek out chiropractic care. Doctors of chiropractic also treat patients with non-traumatic neck pain. Is there a difference in the presentation of patients with traumatic vs. non-traumatic neck injury?

A study published in May 2024 may help give healthcare providers greater insight into how these two types of neck disorder compare and contrast. The study included 41 patients who had sought care for neck pain at one of three health clinics within two years of an MVC, where they subsequently underwent examination and treatment. This afforded researchers a unique opportunity to identify any biomechanical, activity tolerance changes, or pain intensity differences resulting from the whiplash injury.

The research team found that pain levels increased from 2.5 to 5.0 (on a 0-10 pain scale) post-whiplash. Likewise, on a 0-100% disability scale (measured by the commonly used Neck Disability Index questionnaire), activity tolerance worsened from 15.7% to 32.8%. The results from pre- and post-whiplash X-rays revealed greater flattening of the cervical curve (an average of 8 degrees) at all cervical spine levels, but greatest in the mid-cervical spine. The patients were also more likely to exhibit forward head posture in which the head rests forward of the midline of the body, as seen from the side. Four of the patients also developed segmental translation (excess motion) in the cervical spine.

Numerous studies have reported a correlation between altered neck curves and resulting biomechanical dysfunction and its effects including neck pain and accelerated joint and disk degeneration. The loss of cervical curve following a whiplash event may help to explain why up to 50% of WAD injured patients continue to report lingering pain, dysfunction, and disability one-year post injury.  Thus, restoring cervical curvature as much as possible is often a treatment goal with WAD patients.

Doctors of chiropractic are well trained in the diagnosis and management of WAD patients, including treatment to address postural faults of the cervical spine. While specifics may vary as each patient’s case is unique, chiropractic treatment for WAD will often be multimodal in nature encompassing manual therapies, various cervical traction techniques, specific exercise approaches, self-care techniques, and dietary/supplement recommendations to aid in the healing process

Quick Overview of Carpal Tunnel Syndrome

The carpal tunnel is a narrow passageway on the palm side of the wrist, enclosed by bones and ligaments, that the median nerve and several flexor tendons pass through. When the mobility of the median nerve is restricted at this point, the resulting symptoms of numbness, tingling, pain, and weakness in the thumb, index, middle, and thumb side of the ring finger are collectively classified as carpal tunnel syndrome.

There are several potential causes of median nerve restriction or compression, which may co-occur and need to be addressed to provide the patient with a satisfactory outcome. The most commonly considered cause of CTS is repetitive movements of the hand and fingers that cause inflammation in the wrist as the tendons that pass through the carpal tunnel continuously rub against one another. This can be exacerbated by non-neutral wrist postures and excessive vibration, which increase pressure in the wrist. Additionally, compression of the median nerve elsewhere along its course from the neck to the hand can make the nerve more susceptive to restriction in the wrist.

Chronic health conditions can also contribute to carpal tunnel syndrome. For example, thyroid disorders can lead to fluid retention in the wrist, causing swelling and nerve compression. Likewise, women on birth control and who are pregnant can also experiencing hormonal changes that can lead to swelling and median nerve restriction. Rheumatoid arthritis can cause inflammation in the wrist and diabetes has been linked to nerve damage, both of which can hinder the function of the median nerve and result in the symptoms associated with CTS.

Diagnosis typically involves a review of the patient’s medical history and a physical examination, though more advanced diagnostics like nerve conduction studies, electromyography, ultrasound, and magnetic resonance imaging (MRI) may be ordered in some cases to better assess the condition. Hopefully, the patient did not delay treatment for too long and they’re a candidate for conservative treatment, such as a multimodal approach from a chiropractor.

Chiropractic treatment may include manual therapies, specific exercises, nocturnal wrist splinting, activity modification, physiotherapy modalities, and dietary/supplement recommendations all with the goal of reducing inflammation and restoring normal motion to the affected tissues. If chronic health problems may be suspected to have a role in the patient’s presentation, their chiropractor may co-manage the case with an allied healthcare provider such as the patient’s medical physician or a specialist. Should conservative chiropractic treatment fail to benefit the patient, they their chiropractor may refer them out for more invasive treatment such as corticosteroid injections or consultation with a surgeon for open or endoscopic release, which cuts the transverse carpal ligament that makes up the floor of the carpal tunnel to relive pressure. The good news is that most patients can find relief with conservative care and will not require surgical intervention.

Non-Surgical Care for Acute Knee Injuries

The knee is a complex hinge type of joint that consists of bone, cartilage, tendons, and ligamentous structures that are vulnerable to injury during high-intensity rotational and explosive movements. As such, acute knee injuries are often associated with sporting activities. It’s estimated that 2.5 million acute knee injuries occur in the United States each year. As with most musculoskeletal conditions—outside of certain emergency situations—treatment guidelines recommend non-surgical approaches as the initial treatment option.

In a 2024 study, researchers focused on three common acute knee injuries based on ligament injury, meniscus injury, and patellar dislocation:

• Outside of a full (grade III) tear of the anterior cruciate ligament (ACL), MOST acute ligament injuries can be treated non-surgically, especially in the absence of other concurrent injuries.
• There is also limited evidence that acute traumatic meniscus tears, especially in those younger than 40 years of age, can be successfully managed non-surgically with similar one-year outcomes as patients assigned to a surgical group.
• With respect to an initial patellar dislocation, current studies support the use of a knee extension brace for a short time frame followed by progression to weightbearing to tolerance and strengthening exercises that emphasize terminal extension (fully straightening out the knee).

The diagnostic process for acute knee injury includes a review of the patient’s health history, including how the injury occurred; a physical examination, which may include analysis of gait, postural alignment, and the injured knee to determine the degree of injury to specific structures of the knee; and appropriate diagnostic imaging/tests, if needed.

At this point, a doctor of chiropractic can determine a treatment plan that may include manual therapies, knee-specific stretches/exercises, physiotherapy modalities, activity modifications, and anti-inflammatory measures, like ice or dietary/supplement recommendations. Treatment may also focus on addressing issues beyond the knee that may have led to postural faults that could have contributed to injury to the knee. This may include the foot/ankle, hip, and even lower back.

It’s estimated that about 80% of knee injuries can be managed non-surgically. Recovery will depend on the severity of injury, how well a patient adheres to their treatment plan, and their overall pre-injury health status. For minor injuries, a knee injury patient may resume their normal activities within two to six weeks, and in moderate cases, it may take six to twelve weeks to recover. However, severe knee injuries may take months to achieve maximum improvement.

Life’s Simple 7 Guidelines for Cardiovascular Health

Presently, someone in the United States suffers a heart attack about every 34 seconds, on average. In an effort to improve cardiovascular health and reduce the incidence of poor cardiovascular outcomes like heart disease and stroke, the American Heart Association released their Life’s Simple 7 guidelines in 2010. These include four modifiable behaviors and three biometric measures that can each reduce the risk for cardiovascular disease when achieved:

• Manage Blood Pressure: Blood pressure is the force exerted by circulating blood on the walls of the arteries during heartbeats and rest periods. A healthy blood pressure for most individuals is 120 mm Hg/80 mm Hg. Blood pressure can be measured using an at-home device; however, it’s recommended to bring a home blood pressure monitor to your next visit with your medical physician so it can be calibrated.
• Control Cholesterol: There are several types of lipids that circulate in the blood, and some are beneficial and some are detrimental to heart health. Your medical doctor can order a blood test to help determine your cholesterol levels and provide advice on how to reduce them if they’re elevated.
• Reduce Blood Sugar: Managing blood glucose levels can help prevent or control diabetes, which is a major risk factor for heart disease. During a wellness visit, your medical doctor may order a fasting plasma glucose test, which reveals your blood sugar levels in a fasted state, and an A1C test, which provides a more long-term look at blood sugar levels.
• Get Active: Engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity exercise each week, as well as resistance training the major muscle groups at least twice a week.
• Eat Better: Adopt a heart-healthy diet that includes plenty of fruit, vegetables, whole grains, and lean protein, while avoiding processed foods. The Mediterranean diet has been shown to be an excellent choice for this purpose. Additionally, there’s research suggesting that taking a daily omega-3 fatty acid supplement and intermittent fasting can also provide cardiovascular benefits.
• Lose Weight: Reduce body fat, especially visceral fat, which has been linked to an elevated risk for cardiovascular disease. The body mass index (BMI) is a tool that incorporates an individual’s height and weight to help determine if they are underweight, normal weight, or overweight/obese.
• Stop Smoking: If you smoke, even casually, quit. If you don’t smoke or use any tobacco products, don’t start.

Studies published since 2010 have found that for each of the Life’s Simple 7 metrics that an individual achieves, their risk for cardiovascular disease falls. For example, a 2022 study found that achieving all seven healthy behaviors/metrics may cut the risk for stroke by 65%. The benefits aren’t limited to cardiovascular outcomes either. A 2013 study found that achieving six of seven targets cut the risk for cancer by 51%!

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.