Monthly Pain Update – February 2025
Stretching or Strengthening Exercises for Low Back Pain?
Research indicates that back pain is the leading cause of disability worldwide, even more than heart disease and diabetes. It’s estimated that about 80% of adults will experience an episode of low back pain during their lifetime. Additionally, more than half of those who develop back pain will either have another episode within the year or their back pain will persist and become a chronic issue. Because of these facts, a key aspect of chiropractic treatment for low back pain is to reduce the risk for both chronicity and recurrence. While maintenance or wellness chiropractic visits following the conclusion of care have proven to help in this regard, exercises performed at home by patients are especially useful. But what type of exercises are best in the goal of preventing a future low back pain episode, stretching or strengthening?
To find out, researchers recruited 90 patients with non-specific low back pain—the most common type of low back pain, which occurs in the absence of specific pathology like a herniated disk, spinal stenosis, infection, or fracture—and divided them into three groups: stretching only, strengthening only, or both. After three months, outcome questionnaires revealed the strengthening only group experienced the greatest improvements with respect to pain and disability followed by the combo group and lastly, the stretching only group. A similar study published a month later concluded that strengthening exercises are more efficacious than stretching alone. However, each patient’s condition is unique, and the specific exercises they perform should be informed by their examination findings, response to in-office treatment, personal preferences, and their chiropractor’s training and clinical experience.
One aspect to consider before starting an exercise routine is that musculoskeletal disorders elsewhere can affect the patient’s biomechanics and contribute to (or cause) their present low back pain. For example, if one foot pronates or rolls inward more than the other when standing and walking, the entire kinetic chain reacts and has to compensate for this as follows: the knee “knocks” inward, the hip outward, the pelvis drops excessively, the lumbar spine curves further (convex to the short side), the mid-upper back leans to the opposite side while the occiput or head tries to maintain a horizontal for balance purposes. The consequences of this biomechanical fault could first be experienced as low back pain and over time, they can lead to excessive wear and tear on the joints, ligaments, disks, and may lead to premature osteoarthritis and degenerative disk disease. If these issues aren’t addressed, not only could the patient’s low back pain be more likely to return, but it may make proper form during exercise more difficult and elevate their risk for injury.
The good news is that chiropractic is well-supported as an effective intervention for managing low back pain, especially if you follow your doctor’s advice to perform exercises between visits and stay active following the conclusion of care.
Neck-Focused Treatment May Benefit Multiple Sclerosis Patients
Multiple sclerosis (MS) is a demyelinating, inflammatory, chronic, and neurodegenerative disease of the central nervous system. Among the myriad symptoms that characterize the condition, about 80% of MS patients have sensory and motor impairment ranging from very mild to very severe. While there’s no cure for MS, recent studies have found that chiropractic care directed at the neck may have a role in helping to manage this aspect of the condition.
The somatosensory nervous system helps maintain balance and move through space. Part of this sense is obtained from the receptors in the joints, muscles, tendons, and ligaments and constitutes the position perception of the extremities and the body. The number of proprioceptors varies in different body structures and tissues, but their density is especially rich in the cervical region or neck.
Past research has demonstrated that manual therapies can positively affect mechanotransduction, which helps facilitate the signals from the proprioceptors to the brain. This is even more important for the proprioceptors in the tissues in the neck, which are essential for postural stability and the movement of the head and eyes. These neurophysiological benefits have been observed in orthopedic cases and healthy individuals, but little-to-no research has been conducted on the benefits of manual therapies applied to the neck region in patients with MS, until recently.
In a 2022 study, researchers recruited 12 MS patients to receive two treatments a week for four weeks consisting of joint traction and gliding types of cervical mobilization therapies in addition to myofascial relaxation techniques. The investigators observed that the participants experienced noted improvements in proprioception and forefoot loading, average foot pressure, and body weight distribution between their left and right sides following treatment. The authors added that cervical manual therapies can positively affect balance and plantar loading distribution compared to traditional treatment. A follow-up study published two years later with 16 MS patients found the same treatment approach resulted in noted benefits with respect to joint position sense, balance, and gait and these benefits persisted following the conclusion of care.
The study authors concluded that manual therapies could be used to support neurological rehabilitation in patients with MS. Doctors of chiropractic are well-versed in the delivery of several types of manual therapies, including those used in the studies covered in this article.
An Overlooked Cause of Carpal Tunnel Symptoms
Carpal tunnel syndrome is the most common upper limb peripheral neuropathy, and it’s characterized by pain, numbness, tingling, and weakness in the parts of the hand innervated by the median nerve, namely the thumb and index, middle, and half the ring finger. Because it’s such a common diagnosis for these symptoms, it’s not unusual for carpal tunnel syndrome to be misdiagnosed in place of another condition: pronator teres syndrome.
The median nerve runs down the center of the forearm on the palm side and passes through multiple narrow openings and tight spaces enroute to the hand, including near the pronator teres muscle in the forearm. If the mobility of the median nerve is restricted at this site, then it can produce many of the same symptoms as carpal tunnel syndrome with some differences we’ll cover shortly. If a healthcare provider assumes compression at the wrist is to blame, then they may prescribe treatment that fails to provide lasting relief for the patient, if at all. In fact, a third of misdiagnosed pronator teres syndrome cases are initially thought to be carpal tunnel syndrome, and about one-in-sixteen carpal tunnel syndrome patients have co-occurring pronator teres syndrome. One study looked at surgical outcomes of patients with both conditions who underwent carpal tunnel release and found a third continued to experience ongoing symptoms.
The clinical history and exam are most helpful to differentiate the conditions. In the case of pronator teres syndrome, symptoms may be more apparent in the forearm, especially when rotating the palm downward or during gripping activities. Pronator teres symptoms are also more present during the day and less so at night (sleep problems are more common with carpal tunnel syndrome). The palmar cutaneous branch of the median nerve splits off before the carpal tunnel and enters the hand via a different route. If compression of the median nerve occurs before the split (at the pronator teres, in this case), then the patient may also experience diminished sensation in the palm—an uncommon finding with carpal tunnel syndrome. A chiropractor will also perform compression tests over the pronator teres muscle to see how quickly symptoms are provoked (faster suggests compression is already occurring there).
Pronator teres syndrome serves as an excellent reminder on the importance of approaching musculoskeletal disorders like carpal tunnel syndrome from a holistic perspective as the symptoms associated with the condition may not always be the result of an issue exclusive to the area of chief complaint. That’s why doctors of chiropractic check the entire course of the median nerve when examining a patient. While the carpal tunnel is the likely culprit, it’s not always the case and there may also be compression at both the wrist and elsewhere on the nerve’s course, like the pronator teres muscle. The good news is that chiropractic also offers an excellent non-surgical approach for managing pronator teres syndrome!
Non-Surgical Care for Partial Anterior Cruciate Ligament Tears
The anterior cruciate ligament (ACL) is a ligament situated in the knee joint that firmly connects the femur to the tibia, providing stability when flexing and extending the knee. The ligament can tear when the knee experiences excessive stress or trauma, such as a direct impact, incorrect landing from a jump or fall, sudden deceleration, or a sudden directional change. In cases of a complete tear, surgical repair is often advised; however, there’s less support for surgery as a first-line intervention in the case of a partial ACL tear. What non-surgical options can chiropractic offer a patient with a partial ACL tear?
It's essential to understand that while the ACL can heal, the prognosis depends on several factors such as the degree of the tear (more is worse), the location of the tear (middle is worse), the patient’s age and overall health (younger and healthier is better), and the activity level of the individual (a highly physical demanding lifestyle may increase risk for further injury). A professional athlete with a severe tear sustained during a game or match may be more likely to benefit from surgical repair while a less active individual with a slight tear may elect for conservative treatment.
In the acute phase of injury, the patient is advised to rest and avoid activities that place stress on the knee, use ice to control swelling and pain, compress the knee with a wrap or brace to provide support, and elevate the leg to reduce fluid buildup. From this point, non-surgical management may involve bracing or taping to support the knee; physical therapy exercises to restore range of motion, strengthen the muscles around the knee, and balance/proprioception; and activity modifications. Doctors of chiropractic may also look at other aspects of the kinetic chain to identify faults that may have contributed to the added stress on the knee. This may involve looking at the feet, ankles, hips, pelvis, and lumbar spine. Manual therapies may be applied directly to the knee itself to restore normal joint movement. Patients may also be treated with electronic stimulation, cold laser, or other modalities to reduce pain and or facilitate healing.
As patients gain greater confidence in their knee, they may be advised to gradually return to exercise with low-impact activities like walking or Tai Chi. It’s estimated that up to 52% of patients with a partial ACL tear can recover via non-surgical interventions and return to their previous activities.
Managing Whiplash-Related Concussion Symptoms
Though we typically associate neck pain, stiffness, and limited range of motion with whiplash associated disorders, a symptom that’s gaining attention in the research community in recent years is mild-traumatic brain injury (mTBI), which is also known as concussion, post-concussive syndrome, and persistent post-concussion syndrome. In particular, it appears that chiropractic may have a role in managing whiplash-related mTBI.
A concussion occurs when the brain impacts the interior of the skull, even in the absence of direct head trauma. For example, the sudden back and forth motion characteristic of whiplash can lead to concussion even if the head does not strike the steering wheel, airbag, or headrest. The symptoms can vary, depending on the part (or parts) of the brain that are injured, as well as their severity. However, symptoms related to vision and visuospatial processing are very common.
How the brain processes visual information is important for how we navigate through space, but it’s not the only way the body accomplishes this task. Proprioception is the body's ability to sense where its various parts are in relation to one another for purposes of movement and balance. This is accomplished by special sensory nerves in the skin, muscles, joints, and tendons that relay information to the spinal cord, which then proceeds through the neck to the brain. If tissues are injured in the cervical spine region—something very common in whiplash cases—then proprioceptive inputs may be impeded. This suggests that some of the symptoms associated with mTBI may be due to injury in two sites: the brain and the neck.
Chiropractors are trained in the delivery of various forms of manual therapy that aim to manage spinal articular dysfunction and the corresponding altered neurologic component associated with it. Spinal joint dysfunction can result in altered sensory input to the central nervous system, which modifies the way the brain processes and integrates sensory and proprioceptive input. Once spinal dysfunction is corrected, sensorimotor integration and cognitive function can improve.
Theoretically, if an individual with mTBI also sustained trauma to the cervical spine, then treatment to address spinal dysfunction should improve concussion symptoms. That’s exactly what researchers observed when young adults with mTBI received chiropractic care as part of their treatment plan. Compared with patients in a control group, those in the chiropractic group experienced better outcomes in relation to vision and visuospatial processing, leading the research team to conclude that chiropractic has a role in managing concussion symptoms in patients who have also sustained neck injury, such as those involved in motor vehicle collisions.
Low Back Pain and The Importance of Sleep
Low back pain is the leading cause of disability worldwide, and it’s estimated 619 million people suffer an episode each year. By 2050, it’s expected this total will jump to 843 million! In addition to the direct and indirect effects low back pain can have on the individual patient, the overall healthcare costs and productivity losses associated with this musculoskeletal disorder add up to more than $230 billion dollars each year in just the United States! This in mind, identifying and mitigating risk factors for low back pain by even a small amount can result in large societal gains. One risk factor for low back pain that isn’t typically imagined is sleep.
Sleep is considered essential for survival. Many vital functions occur during slumber including tissue growth and repair, cytokines production to bolster the immune system, heart rate and blood pressure regulation, memory consolidation, and brain detoxification, just to name a few. If an individual suffers from insomnia, obstructive sleep apnea, circadian rhythm sleep-wake disorders, or sleep bruxism, these critical processes are impeded, which can make the body more susceptible to developing musculoskeletal pain, including low back pain.
In one study, researchers looked at health data concerning 6,285 older adults and found that an individual’s risk for low back pain increases by 13.6% for each hour less than seven hours of sleep he or she averages a night. However, any additional sleep beyond seven hours does not confer additional low back pain reduction benefits. Interestingly, this finding held true even after adjusting for age, gender, income level, education level, and occupation.
Not only can poor sleep increase the risk for low back pain, but it can stimulate changes in how pain is perceived, leading to greater pain sensitivity, which in turn results in increased disability and avoidance behaviors. One study, published in December 2020, found that older adults with moderate-to-severe sleep disturbances will likely accumulate chronic neuropsychiatric and musculoskeletal conditions at a faster rate than seniors with good sleep hygiene. To complicate matters, the American Academy of Sleep Medicine reports that 80% of American adults experience daytime sleepiness, meaning they either aren’t sleeping enough each night or the quality of their sleep is poor. So what can be done to improve sleep hygiene?
The Centers for Disease Control and Prevention (CDC) offers the following tips for better sleep: be consistent with bed times; make sure your bedroom is quiet, dark, relaxing, and kept at a comfortable temperature; remove electronic devices from the bedroom; avoid large meals, caffeine, and alcohol before going to bed; and get some exercise during the day. If low back pain is keeping you up at night, be sure to let your doctor of chiropractic know. They may be able to recommend additional strategies to improve your sleep and if necessary, co-manage your case with an allied healthcare provider.
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.
