Monthly Pain Update – December 2023
Chiropractic Treatment for Lumbar Disk Herniation
The annulus of the intervertebral disk is comprised of tough, dense, and strong cartilaginous fibers that protect the nucleus within, which facilitates the movement of the spine. If the structure of the annulus is compromised, the nucleus can leak into or beyond the annulus, a condition that may be classified as a disk herniation, protrusion, extrusion, or sequestration. In the event a disk herniation in the lumbar spine places pressure on a lumbar nerve root, an individual may feel pain down into the leg, which is called lumbosacral radiculopathy or sciatica. Absence a red flag—infection, fracture, cancer, and cauda equina syndrome (loss of bowel and/or bladder control)—that may necessitate immediate emergency and/or surgical intervention, what treatment approach may best serve a patient with a newly diagnosed lumbar disk herniation?
In 2022, researchers conducted a retrospective cohort study that looked at outcomes of more than 11,000 patients under age 49 with a newly diagnosed lumbar disk herniation, half of whom received initial treatment from a doctor of chiropractic. While the authors of the study note that additional studies are needed, their analysis revealed that lumbar disk herniation patients whose first choice of treatment is chiropractic care are significantly (up to two-times) less likely to undergo lumbar diskectomy in the following two years than disk patients who initially seek out a different healthcare provider.
It should be noted that treatment guidelines generally advise conservative treatment approaches, which include chiropractic care, before consulting with a surgeon. However, another study published in 2022 found that, among a group of 144 patients who underwent back surgery, 60 (41.7%) did not receive any conservative treatment in the six months before their procedure. A 2021 study that looked at questionnaires completed by 3,724 adults revealed that the majority of respondents believe that surgery is always needed for a disk herniation, which is inaccurate.
For the management of a lumbar disk herniation, doctors of chiropractic will typically employ a multimodal approach that includes spinal manipulative therapy, mobilization therapy, soft tissue therapy, and exercise training. Chiropractors may also offer additional services such as traction or non-surgical decompression that can benefit such patients. If the patient does not experience improvement in their pain and disability or their condition worsens, they may be referred to an allied healthcare provider to explore other treatment options.
Neurodynamic Techniques for Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is a condition that results from pressure applied to the median nerve on the palm side of the wrist. The disorder is associated with both motor and sensory signs and symptoms such as numbness, pain, and paresthesia that radiates from the wrist first to the first three digits and can include muscle weakness, including grip weakness and hand dexterity loss. For mild-to-moderate CTS, treatment guidelines recommend pursuing non-surgical approaches before consulting with a surgeon, with chiropractic care offering patients an excellent option. Among the tools at a doctor of chiropractic’s disposal are neurodynamic techniques.
Neurodynamic techniques encompass a group of hands-on manual therapies that promote the lengthening and mobility of nerves. In the case of CTS, neurodynamic techniques are focused on the median nerve both at the wrist and elsewhere along the course of the nerve from its origin in the neck and through the shoulder, elbow, and forearm. This is especially important as restriction of the median nerve before the wrist can both stimulate similar symptoms as CTS and increase the risk for entrapment at the wrist. Regardless, failure to examine the full course of the median nerve can lead to a suboptimal outcome for the patient.
In a July 2023 systematic review and meta-analysis of twelve randomized controlled trials that included 1,000 patients with mild-to-moderate CTS, researchers found evidence that neurodynamic techniques are effective for improving CTS-related symptoms and wrist/hand function. Their findings also showed that such techniques improve function of the median nerve itself, by way of nerve conduction diagnostic testing. This echoes findings from a systematic review published in 2022 that included six randomized controlled trials and 401 CTS patients that found that neurodynamic techniques led to immediate improvements in pain, function, and nerve conduction.
Emphasizing the importance of looking at the whole patient versus just focusing on the wrist, a 2022 randomized controlled trial divided 62 CTS patients into two groups, one with treatment on just the wrist alone and the other received treatment at the wrist and elsewhere on the course of the median nerve. While both groups reported improvements in pain, grip strength, and functional status, the patients in the more comprehensive treatment group experienced greater benefits.
In addition to neurodynamic techniques, conservative chiropractic care for managing CTS may include other manual therapies, nocturnal splinting, exercise training, nutritional consulting, and physiotherapy modalities like electrical stimulation, ultrasound, laser, and pulsed magnetic field. If necessary, the patient’s chiropractor will co-manage the case with an allied healthcare professional for treatments beyond their scope of care.
Best Treatment Approach for Knee or Hip Osteoarthritis
Osteoarthritis of either the knee or hip is characterized by a long period of progressively increasing pain and disability that may eventually result in the need for joint replacement surgery after several years. Before considering surgical intervention, clinical guidelines recommend utilizing non-surgical treatment options first, of which there are many choices available to a patient. Is there a way to know what approach may be best for a typical knee or hip osteoarthritis patient?
In a study published in 2018, researchers recruited 206 patients who met the American College of Rheumatology’s clinical criteria for diagnosing knee and/or hip osteoarthritis, had no prior history of rheumatoid arthritis or prior hip or knee joint replacement at the time of study enrollment, had not initiated opioid or corticosteroid intervention within the previous month, and were able to complete the proposed course of intervention and two-year follow-up period. The participants were then randomly assigned to one of four treatment groups: 1) usual care alone; 2) usual care plus supervised exercises; 3) usual care plus manual therapy; and 4) usual care plus combined supervised exercises and manual therapy. The members in the exercise and/or manual therapy groups received ten treatment sessions initially followed by two “booster” sessions four and thirteen months later. Usual care for all four groups was provided by each patient’s medical provider on an ongoing basis.
The researchers’ goal was to identify which approach performed best based on a combination of cost effectiveness and clinical effectiveness using the Western Ontario and McMaster (WOMAC) osteoarthritis index, which takes into account pain, stiffness, and physical function. At the conclusion of the study, the research team found that participants in groups 2, 3, and 4 (the manual therapy and/or exercise groups) not only experienced greater improvements in their WOMAC scores, but these approaches also offered the greatest cost savings with respect to both healthcare spending and related expenditures/lost productivity.
The findings of the study highlight the importance of pursuing a multimodal approach that includes manual therapies and supervised exercise in the management of conditions like knee or hip osteoarthritis. Not only can these interventions reduce pain and improve function, but they enact a lower cost on the healthcare system overall, which frees up resources to help more patients. Doctors of chiropractic are well-versed in the conservative management of osteoarthritic conditions with the goal of helping patients carry out their normal life, work, and leisure activities, pushing their need for joint replacement as far into the future as possible.
The Thoracic Spine and Neck Pain
Neck pain is a very common condition that is the second most common reason patients seek chiropractic care (after low back pain). The term “mechanical neck pain” is a common classification defined as pain located in the cervical spine or cervicothoracic junction that is elicited and/or exacerbated by cervical motion and/or palpation of cervical musculature. While it’s understandable that neck pain should be traced back to dysfunction in the neck itself, it’s suggested that the thoracic spine or mid-back may contribute to or even be the cause of neck pain in some patients.
These days, as we spend more and more time looking at screens, it’s becoming more and more common for individuals to develop postural abnormalities like forward head posture. When the head rests forward of the shoulders, the upper trapezius muscles that connect the rear of the neck and the upper back must work harder to keep the head upright. This prolonged muscle strain can lead to inflammation, which can be felt as neck pain. In fact, an April 2023 study that examined 148 adults, half with neck pain, identified an association between abnormal mid-back posture and neck pain. Similarly, a December 2022 study found that individuals with neck pain are more likely to exhibit hypermobility in the upper thoracic region.
To identify if treatment aimed at improving function in the thoracic spine can benefit neck pain sufferers, researchers performed a systematic review and meta-analysis of eight randomized controlled trials published between 2010 and 2020 that included a total of 457 patients. Their analysis revealed that thoracic thrust manipulation—a form of treatment performed by doctors of chiropractic—led to a significant reduction in neck pain and disability, more so than other treatment options including non-thrust manipulation, mobilization, strengthening exercises, infrared therapy, placebo, or no treatment. The authors point out that this study provides evidence that thoracic spine manipulation is an effective intervention for patients with mechanical neck pain and should be considered as part of a multimodal approach for managing the condition.
Other studies have found that dysfunction in the mid back may also contribute to shoulder impingement syndrome and low back pain. This highlights the importance of examining the whole patient when they present for care and not just their area of chief complaint—something doctors of chiropractic are trained to do. If you suffer from neck pain and visit a doctor of chiropractic, don’t be surprised if treatment also includes a mid-back adjustment. It may be just what’s needed to alleviate your neck pain and return you to your normal activities.
Warning about Whiplash in the Pediatric Population
For adults, whiplash injuries are typically associated with motor vehicle collisions, particularly from a rear-end impact that causes a rapid acceleration/deceleration of the head and neck. However, in the pediatric population, there are many other causes of head and neck trauma that caregivers and healthcare providers need to be on the lookout for as the outcomes can be life threatening.
The terms most commonly associated with head trauma in infants and young children include pediatric abusive head trauma (AHT), shaken baby syndrome (SBS), and whiplash shaken infant syndrome (WSIS). In fact, shaking, blunt impact, or the combination of the two can result in neurological injury and are considered the most dangerous and deadly form of child abuse. Because AHT typically involves injury to the brain of an infant or child younger than five years of age, severe injury can result in significant brain damage or even death. However, diagnosis can be challenging as often, the responsible individuals are evasive fearing repercussions and frequently blame a fall or some other form of accidental trauma. In addition, healthcare professionals may not recognize the signs due to the lack of obvious evidence of injury.
The data show that inconsolable crying is often a trigger for AHT, as shown in infant crying and AHT risk both peaking at six-to-eight weeks of age. (Of note, studies suggest that colicky babies may respond to gentle chiropractic care and could be explored if other treatments have failed to yield satisfactory results.)
Other causes of pediatric acquired traumatic brain injury also include motor vehicle accidents, sports-related injuries, blast injuries, falls, and assaults. Abusive head trauma or shaken baby syndrome often include a pattern of injuries that includes cerebral edema, subdural hematoma, and retinal hemorrhages. Other patterns to look for include multiple repeated brain injury, rib fractures, and fractures at the ends of long bones.
Child abuse affects all ethnicities and socioeconomic groups, and perpetrators can include both biological parents or stepparents, partners of either parent, and even babysitters. The solution to avoiding pediatric head trauma lies in caregiver education, access to mental healthcare services, and proper training for healthcare providers to recognize the signs and symptoms. Chiropractors may encounter SBS and like other healthcare providers, should be equally on alert for patterns of AHT/SBS.
Pediatric Manual Therapy
While the majority of research on chiropractic treatment focuses on adults with musculoskeletal conditions like neck and back pain, there is an emerging body of work on the benefits of gentle chiropractic care for the pediatric population, which makes up around .5% to 4% of most chiropractic practices. What does the current research say about gentle hands-on care for the youngest pediatric patient population?
Babies who are born pre-term or are ill and need around-the-clock care are often admitted to a neonatal intensive care unit (NICU). In an article published in the journal Medicines, the authors reviewed data concerning the use of manual therapy techniques like soft tissue manipulation, balanced ligamentous tension, myofascial release, and cranial manipulation on outcomes for NICU patients. Researchers found that the application of these gentle techniques in addition to usual care sped up recovery and reduced NICU stays, which also lowered overall healthcare costs. Moreover, adjunctive manual therapies improved latching, suckling, swallowing, and breathing in these infants while reducing regurgitation, vomiting, milky bilious, bloody discharge, constipation, and complications from acquired pneumonia.
A systematic review that included ten studies looked at the benefits for manual therapies on two conditions that may present early on in a child’s life: congenital torticollis and positional plagiocephaly. Congenital torticollis is a condition characterized by abnormal, asymmetric position of the head and neck, likely caused by birth trauma and/or intrauterine faulty positioning pre-delivery. Positional plagiocephaly describes flattening of the baby’s head on one side. For both conditions, there’s evidence that gentle manual therapies and stretches can improve outcomes when added to usual care. Other conditions that may cause a parent to bring their young child to the chiropractor—often due to unsatisfactory results from usual care—include colic/irritability, motor development issues, gastrointestinal problems, sleeping difficulty, jaw/temporomandibular joint issues, and gait/walking problems.
Researchers who have looked at data on the use of manual therapies to manage many pediatric conditions note that while further research is certainly needed before guidelines can be updated, manual therapies can provide a safe, clinically effective, and cost-effective option, especially when other approaches have failed to yield satisfactory results. Many doctors of chiropractic take post-graduate courses on treating pediatric patients, though some may prefer to refer out children to peers who specialize in caring for the younger patients.
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.
