Monthly Pain Update – February 2024

Vitamin D Status and Lumbar Spinal Stenosis

Vitamin D is an essential nutrient associated with numerous bodily functions, but perhaps vitamin D’s most widely known benefits are those it provides to the musculoskeletal system, namely its roles in bone mineralization and muscle function, both of which are important for reducing the risk for serious fall-related fractures in the elderly. However, there’s another musculoskeletal condition that’s been linked to vitamin D status that can impair an older adult’s ability to carry out their regular activities of daily living: lumbar spinal stenosis.

Lumbar spinal stenosis is a common degenerative spinal disease resulting in narrowing of the spinal canal by degenerative spurs, thickening of ligaments, and loss of the intervertebral disk spaces. Symptoms associated with the condition include low back and buttock/leg pain (one or both legs), difficulty tolerating unsupported standing, and limited tolerance when walking (referred to as neurogenic claudication). A 2013 study found that roughly three-quarters of lumbar spinal stenosis patients are vitamin D deficient, and because low vitamin D levels have been linked to several aspects of spinal stenosis (tissue inflammation, disk degeneration, and muscle weakness), it’s suggested that improving vitamin D status in such patients could help manage the condition.

In an October 2023 study that included 51 elderly vitamin D-deficient patients with lumbar spinal stenosis, researchers divided participants into two groups. One group received an initial hyper-dose of vitamin D delivered via injection and a daily 800 IU vitamin D supplement starting at twelve weeks that continued for three months. The control group received a placebo. Pre- and post-intervention blood tests showed that participants in the supplementation group experienced a greater increase in their vitamin D serum levels, which coincided with more meaningful improvements in both pain, disability, and quality of life. The findings support checking the vitamin D status of patients under care for lumbar spinal stenosis, which includes chiropractic care, and taking steps to improve vitamin D levels as part of the treatment process—especially since it’s such a low-cost and low-risk option.

To achieve healthy vitamin D levels, it’s recommended to spend at least 5-10 minutes outdoors on most days during the summertime with at least 35% of the body exposed to the sun. However, during the winter when just 10% of the body may be exposed to the sun, an individual may need to spend up to 45 minutes outdoors during midday on a daily basis. Of note, those living in higher latitudes or with a darker complexion may require more time in the sun to create sufficient vitamin D. If spending time in the sun is not possible, vitamin D levels can be improved by eating vitamin D-rich and fortified foods, as well as via supplementation. However, before making dietary changes or starting a supplement, consult with a health professional who is familiar with your unique medical history and can provide guidance and support.

Common Wrist and Elbow Complaints

Because of the close anatomical relationship between the wrist and elbow, it’s not uncommon for patients to present for care with symptoms that affect both regions. In some cases, they may have two distinct musculoskeletal conditions that need simultaneous treatment. But in other cases, the pain in one area may be referred by a musculoskeletal complaint in the other. Let’s take a look at some of the most common conditions doctors of chiropractic see when a patient comes in for wrist and/or elbow pain.

Perhaps the most well-known conditions affecting the elbow include lateral and medial epicondylitis (golfer’s and bowler’s elbow, respectively).  Pain in the lateral aspect of the elbow most often involves a musculotendinous injury, which includes tennis elbow or lateral epicondylitis, most frequently caused from overuse, often resulting from occupation or sport.  Although this is often described as a “self-limiting” condition—meaning it’s likely to resolve on its own—there is a high recurrence rate, and it is often associated with an extended sick leave and disability that requires professional management.

On the medial side of the elbow (the side closest to the trunk if you stood with your arms down and palms facing forward), other conditions include ulnar neuritis (cubital tunnel syndrome), ulnar collateral ligament injury (a common baseball pitcher injury), flexor pronator strain (often from overuse of hand tools), and snapping medial triceps.

Like the elbow, the wrist can be divided into various anatomical regions such as the medial and lateral side as well as the anterior (palm side) and posterior wrist. The most common condition associated with the wrist is carpal tunnel syndrome, which is often described as pins and needles or tingling in the fingers excluding the pinky and ring finger caused by restriction of the median nerve at the wrist. Additionally, there is ulnar tunnel syndrome, which manifests as symptoms in the pinky and pinky side of the ring finger. The radial nerve also passes through the wrist, and when this nerve becomes entrapped, the patient may experience symptoms on the back of the hand.

Outside of emergency circumstances, these various conditions can often be managed through a multimodal approach by a doctor of chiropractic that includes manual therapies, specific exercises, orthoses/braces, activity modifications, and physiotherapy modalities. Unfortunately, as these conditions have a tendency to gradually worsen over time, patients often wait until their symptoms become severe enough that carrying out normal work and life activities becomes difficult. While conservative care may still yield satisfactory results for the patient, a longer course of treatment may be necessary. If the condition does not fully respond to this approach, then referral to an allied healthcare provider may be needed for more invasive treatments such as injections or even surgery.

The Noisy Knee Joint

It’s common for the knee joint to be very noisy, especially when performing activities such as squatting, climbing steps, or repetitive knee extensions. Patients frequently present to their chiropractor and ask, “Is that noise normal and should I be concerned?”

In most cases, crepitus (noise) emitted from the knee—which can include clicking, cracking, catching, snapping, popping, crunching, clunking, grinding and more—is physiologically normal.  However, both clinicians and patients should be aware that crepitus may be a symptom of a pathological lesions.  One study reported that several structural pathologies of the knee are associated with an increased risk of general crepitus in knee osteoarthritis (OA) while another study reported that crepitus may be the first symptom of patellofemoral-related(kneecap) conditions.  Hence, it becomes the clinician’s duty to differentiate between physiological/normal versus pathological/abnormal crepitation.

When crepitus occurs in the absence of any history of injury, it may be simply physiological or normal, but it can also indicate a chronic or long-standing cartilage lesion in an OA knee and in other cases can be caused by inflammatory arthritis. These often carry a relatively long history of crepitus that may not hurt, or if it does hurt, not very much. Your chiropractor will perform range-of-motion tests, ligament stability tests, meniscus “click” tests, patellofemoral/kneecap apprehension tests, and more to tease out the safe from harmful click.

A general rule of thumb is that pain-free crepitation is usually physiological and not to be of concern while a painful crepitation should be investigated.  In order to put the patient’s mind at ease, your doctor of chiropractic will perform a detailed history and examination to differentiate between knee-related noise that is safe versus pathological.  For example, a history of an immediate onset of pain associated with “a pop” during an activity may indicate an acute injury such as a root tear of a degenerative meniscus and/or a detachment or tearing of a ligament inside the joint (such as a cruciate ligament) or on the sides of the knee (such as a collateral ligament). An acute injury is usually accompanied by pain, swelling, and limited motion, which most definitely requires a thorough evaluation. A past history of an acute knee injury can also be very important.

Ultimately, the treatment approach to reduce knee-related noises can vary depending on the ultimate diagnosis. In addition to manual therapies and or physiotherapy modalities delivered during office visits, patients may be instructed on exercises to stretch right tissue and strengthen weakened muscles. If ankle/foot pronation is adversely affecting the knee angle, the patient may be prescribed an orthotic to address ankle/foot posture, which may take the excess pressure off the knee that may be causing the noise to occur.

Managing Migraine Headaches

Migraine headaches are classified as a primary headache disorder. Migraines are three times more common among women, especially in their premenopausal years. While migraines are still not fully understood (meaning they are likely underdiagnosed and undertreated), the available data show they are the most debilitating type of headache and rank seventh among health conditions with respect to years lived with disability.

Between 25-30% of migraineurs experience an aura lasting five minutes to one hour that precedes a migraine that is characterized by visible, sensory, or other central nervous system symptoms that increase in intensity. Common migraine symptoms include severe, throbbing pain on one side of the head, photophobia (light sensitivity), phonophobia or hyperacusis (noise sensitivity), nausea or vomiting, and neck stiffness. A migraine episode can last from a couple hours to a full day.

While there are pharmaceutical strategies for managing migraines, they may become less effective over time with adverse effects that patients may be unwilling or unable to tolerate in the long term. Such side effects include weight gain, cold extremities, dizziness, kidney damage, fatigue, dry mouth, gastrointestinal issues, constipation, muscle spasms, and oddly, headaches.

Rather, migraine management may instead focus on lifestyle changes like eating a healthy diet, stress management, regular exercise, getting sufficient quality sleep, and staying hydrated, as well as specific strategies to manage comorbidities—such as mood disorders, sleep disorders, cardiovascular disease, obesity, neurological disorders, and gastrointestinal disorders—that have been associated with migraines. Additionally, patients are advised to be on the lookout for foods, smells, sounds, or anything that may trigger a migraine so as to avoid them in the future.

Researchers have also observed that neck pain is very common in migraine sufferers who often have forward head posture, trigger points in the cervical muscles, and other musculoskeletal disorders affecting the neck and upper back. Multiple studies have found that treatment to address trigger points, improve posture, and restore normal joint movement can reduce the intensity, frequency, and duration of migraines.  A 2021 international study that focused on female migraineurs receiving chiropractic care revealed consistent benefits with increased appreciation for the complex interaction between stress, muscular tension, posture, and migraine.

Whiplash and Upper Cervical Instability

The rapid flexion/extension, compression, and rotation of the cervical spine that commonly occurs in motor vehicle collisions can result in trauma that includes facet derangement, disk injury, and ligament sprain or rupture, frequently occurring in the upper cervical region. When the upper cervical spine exhibits excessive motion in combination with pain and other neurological symptoms, the patient may receive a diagnosis of upper cervical instability (UCIS).

Upper cervical instability can be seen on x-ray as anterior translation of the first cervical vertebrae (C1) over the second cervical vertebra (C2) exceeding 3.5 mm on a flexion (forward bending) stress x-ray. It can also be observed as lateral translation of C1 on C2 of more than 2.0 mm of lateral overhang of the lateral mass of C1 over C2 as noted on frontal view x-ray with an open mouth during side bending end-range loading. This is also measured by asymmetry of the periodontal space or the gap between the dens (a protrusion at the front of the vertebrae) of C2 and lateral mass (thicker boney areas on the sides of the vertebrae) of C1. Patients with UCIS often have a loss of normal cervical curve (lordosis), which can place increased force on the intervertebral disks and facet joints.

Although UCIS patients have the option for surgical fusion of C1-2, like all spinal fusion surgeries, there are associated risks and complications, not to mention the invasive approach, the expense, and future ramifications (including reduced range of motion and its negative impact on the adjacent cervical vertebral levels). This can result in the need for further treatment down the line, including additional surgical procedures, which can have a negative effect on quality of life.

Fortunately, there are non-surgical treatment options available to the UCIS patient, including chiropractic care. In a September 2023 case-series study, nine patients with radiographically confirmed UCIS and loss of cervical lordosis underwent a chiropractic treatment regimen directed primarily at restoring normal cervical lordotic curve. Treatment included three specific types of cervical traction and chiropractic spinal manipulation rendered at an average frequency of twice a week. In all nine cases, the patients reported significant symptomatic and functional improvements, with cervical lordosis and UCIS improvements observed on x-rays.

Doctors of chiropractic are well trained in the diagnosis and management of upper cervical instability, as well as pathologies that frequently occur with whiplash. The good news is that many patients experience positive outcomes as a result of a multimodal treatment approach. However, in cases that are more complex or when more invasive treatments are necessary, the patient will be referred to the appropriate healthcare provider.

Walking Speed May Aid in Diabetes Prevention

Type 2 diabetes is a gradual, progressive chronic disease that is recognized as being one of the most common metabolic disorders as it currently affects 537 million adults worldwide and is predicted to rise to 783 million by 2045. Because increased blood sugar thickens the circulating blood, people with type 2 diabetes are at greater risk of microvascular as well as larger blood vessel complications and disease, as well as reduced life expectancy.

Along with eating a healthy diet, getting regular exercise is important for reducing one’s risk for developing type 2 diabetes, particularly taking regular walks. In fact, past research suggests that taking daily walks can lower one’s risk for type 2 diabetes by 15%, but it turns out that walking speed is also important.  A 2023 systematic review and meta-analysis of ten cohort studies revealed that the risk of developing type 2 diabetes did not significantly change until walking speed exceeded 4 km/hour (~2.5 mph) or 87 steps/minute for men and 100 steps/minute for women. The review also found the risk continues to decline with faster walking speeds, at least until 8 km/hour (or about 5 mph).

But what if someone can’t maintain a brisk pace for prolonged periods of time? In another systematic review, also published in 2023, researchers found that adopting a high-intensity interval training (HIIT) approach is a viable option for improving glycemic control, aerobic resistance, and body composition. In HIIT, exercisers workout at high intensity for short burst of time separated by longer intervals at a lower intensity. For a walker, this may be achieved by walking at a brisk pace for a limited period of time, such as one minute, and then slowing down to a moderate pace for two minutes and repeating the process for several cycles. Unfortunately, there’s no one agreed-upon format for an HIIT walking intervention so further research is needed in this area.

Best of all, walking is simple and inexpensive and offers several social, mental, and physical health benefits. Several studies have shown that regular walking is associated with a lower risk of both cardiovascular events and early death. Researchers note that a greater number of steps per day may be associated with a lower risk of premature death.

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.