Monthly Pain Update – January 2024

The Five Types of Spondylolisthesis

If you consider a vertebral segment as consisting of three legs like a tripod, the front of the vertebrae is the large vertebral body and the two legs in the back are the articular facets. The spinal cord passes between these three legs as it travels its course from the brainstem down to the tail bone, with spinal nerve roots exiting each vertebral level to innervate various parts of the body. Spondylolisthesis is a term used to describe when one vertebra shifts forward with respect to an adjacent vertebra, typically in the lower back. In some instances, the patient may not experience symptoms, but in other cases, they may experience localized pain or pain that radiates along the course of the nerve that exits the spine at that level. Spondylolisthesis is generally classified by its suspected cause: degenerative, isthmic, traumatic, dysplastic, or pathologic.

• Degenerative spondylolisthesis develops gradually over time due to degenerative disk disease and other age-related changes and is NOT due to fracture. Hence, the entire vertebrae slides forward over the other and can distort the path of the spinal cord. This is more common in adults over 50 years of age, more often in females than males.
• Isthmic spondylolisthesis results from defects in a small bony area between the front and back of the vertebra called the pars interarticularis, which is often caused from repeated microtrauma into hyperextension of the spine. This is more common in young athletes.
• Traumatic spondylolisthesis results from a singular traumatic event, such as when the lumbar spine is struck by a heavy object. Fortunately, this type rarely occurs, but when it does, it’s more often found in working-age males.
• Dysplastic spondylolisthesis is congenital and secondary to variations in facet joint orientation or abnormal alignment. There is also research that suggests a genetic component exists in that spondylolisthesis is more common if a first-degree relative has the condition.
• Pathological spondylolisthesis is caused by a systemic disease such as infection, osteoporosis, or neoplasm. It may also manifest as a complication from spine surgery.

The good news is that more than three quarters of spondylolisthesis patients may experience a full recovery with chiropractic treatment. Doctors of chiropractic will often employ a multimodal treatment approach that includes patient education, at-home care with heat/ice, manual therapies; specific exercises; supplement recommendations; and physiotherapy modalities such as electrical stimulation, ultrasound, cold laser, and pulsed magnetic field. When necessary, your chiropractor will team up with an allied healthcare provider to manage more complicated cases.

The Relationship Between Migraines and the Neck

Migraine is a neurovascular brain disorder that affects about 15% of the population and is the number one cause of disability in adults under the age of 50. Neck pain has been estimated to be twelve times more likely to occur in migraine patients than in healthy subjects. Similarly, migraineurs with neck pain report more frequent and disabling headaches, as well as increased sensitization in the trigeminocervical complex where sensory input from the face and neck converge. However, there is debate on the nature of the relationship between neck pain and migraines.

On one hand, some experts feel migraines cause increased brain or central sensitization, which causes neck pain. On the other hand, there are experts who suspect sensitization mechanisms resulting from neck pain contribute to migraine. To address this “chicken or the egg” debate, an August 2023 study compared migraine patients with and without neck pain to observe the differences in clinical characteristics.

In the study, 44 migraine patients without neck pain, 64 migraine patients with neck pain, and 54 pain-free control subjects underwent physical examinations and completed multiple questionnaires to identify characteristics about their headache symptoms, neck pain/disability, and the effect of these conditions on their mental health and quality of life. As expected, both treatment groups had more positive findings than the control group. However, those in the migraine-with-neck-pain group had worse headache characteristics, more pronounced cervical musculoskeletal impairments, enhanced signs and symptoms related to sensitization, and worse psychological burden than the migraineurs without neck pain. In another 2023 study, researchers found that migraine patients with impaired balance—which may be due to altered proprioception caused by dysfunction in the cervical spine—had weaker neck muscles, more frequent migraine episodes, and more intense neck pain.

Findings such as these have led researchers to opine that migraine patients should be sub-grouped into those with or without co-occurring neck pain for the purpose of both research and formulating treatment guidelines. For those with neck pain and migraines, treatment addressing musculoskeletal impairments in the neck may be the most beneficial approach. Doctors of chiropractic are well-equipped to evaluate patients with migraines and neck pain and to provide care to address musculoskeletal conditions that may be contributing to or possibly causing the patient’s condition.

Snapping Hip Syndrome

While chronic hip pain can affect individuals of all ages and activity levels, 30-40% of those who have a history of playing sports and 12-15% of adults over age 60 may develop the condition. Although hip pain can result in a variety of diagnoses, a common form is coxa saltans, or snapping hip syndrome (SHS). This variety of hip pain is characterized by an audible or palpable snap of the hip joint, which can occur on one side or both hips, be painful or painless, and may not always have an obvious or knowable cause.

The snapping noise is due to the iliopsoas (hip flexor tendon) or the iliotibial (IT) band located on the side of the leg. When the iliopsoas is involved, this is referred to as the “internal type” of SHS, which is reproduced by extending and internally rotating the hip and moving into flexion and external rotation where the snap is reproduced as it rides over the femoral head. When the IT band is involved (referred as the “external type”), the snapping is due to the tendon sliding over the greater trochanter when the hip is moved from extension to flexion. Both types are referred to as extra-articular in nature as the cause is beyond the hip joint itself. There are also intra-articular causes of SHS from pathologies such as from loose bodies, torn labrum, and/or fracture. Intra-articular cases are generally more serious in nature and may require more aggressive treatment. To complicate matters, intra- and extra- articular SHS can co-occur, especially with the iliopsoas variant of SHS.

A comprehensive literature review found that people who frequently engage in activities that require hip movements at extreme rotations are more likely to develop symptomatic SHS— especially young gymnasts and ballet dancers. Due to the size and growth of the pelvis during development, young women are also at elevated SHS risk. Additionally, avid exercisers and obese/overweight individuals may both develop hypertrophy and inflammation of the psoas muscle and areas of the internal hip including the iliopsoas bursa, iliopsoas muscle, and other local structures, which can also increase their risk for snapping hip syndrome.

Thankfully, outside of pathologies that require immediate pharmaceutical or surgical intervention, most SHS cases respond to conservative management approaches, which includes chiropractic care. If you’re experiencing hip pain or discomfort with movement that’s creating a snapping noise, your chiropractor will assess your mobility, palpate around the entire region, assess your range of motion (spinal, pelvic, hip) and your gait, as well as perform provocative tests such as the FADIR test (flex, adduct, and internal rotation of the hip) to determine what type (or types) of SHS you have so that they can create an initial treatment plan. A multimodal treatment approach may include manual therapies and physiotherapies provided in the office in conjunction with activity modifications and specific exercises.

Pronator Tunnel Syndrome Vs. Carpal Tunnel Syndrome

The median nerve originates from nerve roots (specifically C5-T1) that exit the cervical spine and then merge together in the brachial plexus in the neck and shoulder region traveling down the arm, through the wrist, and into the hand. Compression or restriction of the mobility of the median nerve anywhere along its course can result in the symptoms commonly associated with carpal tunnel syndrome (CTS), including numbness, tingling, pain, and weakness in the thumb and index, middle, and the thumb-side of the ring finger. So how do doctors of chiropractic differentiate between CTS where the median nerve is compressed at the wrist and another peripheral neuropathy like pronator tunnel syndrome (PTS) in which compression occurs as the nerve passes through the forearm, just below the elbow?

When a patient seeks care for suspected CTS, they’ll first complete a history. This information will direct the course of their chiropractor’s examination to best identify what is generating the patient’s symptoms. Classically, PTS will also include symptoms that start near the elbow (aching, numbness) due to activities that require repetitive elbow flexion and forearm/hand rotations (called supination and pronation) with firm gripping. However, there are presentations of CTS in which pain can be referred into the forearm and even above the elbow. One way your doctor of chiropractic can differentiate PTS from CTS is to apply compression over the pronator teres muscle for 30 seconds. If PTS is present, then this activity can reproduce paresthesia (numb/tingling) into the forearm, hand, and fingers, whereas this may not have the same result in cases of CTS.

Of note, CTS and PTS can co-occur together or along with compression of the median nerve at the neck or shoulder, which may only be identified following a thorough examination. To highlight the importance of properly identifying PTS and CTS, two separate studies have found that PTS is misdiagnosed between 32% and 49% of the time. Failure to address PTS can result in inappropriate treatment at the wrist, including unsuccessful surgical decompression.

Conservative chiropractic treatment for CTS and PTS will typically involve a multimodal approach using manual therapies, physiotherapy modalities, nutrition recommendations, nocturnal splinting, activity modification, and at-home exercises to reduce inflammation and restore the mobility of the median nerve as it travels from the neck to the hand. Because issues like hypothyroidism, diabetes, obesity, autoimmune diseases, and other systemic/chronic conditions can contribute to CTS and PTS, co-management with an allied healthcare provider may be required to achieve a satisfactory result. As with other musculoskeletal conditions, both CTS and PTS are easier to manage with conservative, non-surgical treatment approaches—including chiropractic care— earlier in the course of the disorder, so don’t delay treatment until either (or both) conditions become severe. In the most advanced cases, surgical intervention may be the only option available to a patient.

Whiplash and the Thoracic Spine

Though whiplash associated disorders (WAD) is a term used to encompass the myriad of symptoms associated with whiplash injury, research has largely focused on the neck, and more recently, brain. However, there is another area of the body that often experiences injury during trauma involving the sudden back and forth movement of the head and neck: the thoracic spine, or mid back.

In a large-scale study that looked at the medical records of more than 6,000 whiplash patients, researchers found that two-thirds complained of post-injury thoracic or midback pain and 23% still experienced these symptoms a year later. This can be explained by the mechanism of a whiplash injury that involves forceful stretch loading to the upper back muscles, which affects both the cervical and thoracic spine. More recently, researchers observed microscopic injury to the mid and lower fibers of the trapezius muscle located in the mid back and thoracolumbar region in WAD patients.

Interestingly, the thoracic spine contributes up to 33% and 21% of the movement occurring during cervical flexion and rotation, respectively. Thus, injury that restricts the range of motion of the soft tissues of the neck can place added strain on the mid-back. Likewise, injury to the midback can force the tissues of the neck to work harder to accommodate cervical range of motion. This could worsen existing injuries or even result in a secondary injury to the neck or midback.

A systematic review that included 38 studies and more than 50,000 WAD patients in total revealed the more than 60% had thoracic pain, and about the same percentage had myofascial pain and trigger points in the trapezius muscles. It was also common for WAD patients to have injuries that affect the muscles that attach to the base of the neck/upper back, which could affect the activity of tissues in the adjacent regions, including the thoracic spine. Due to these findings, the authors of the review recommend healthcare providers perform a more extensive clinical evaluation of the thoracic spine when patients present with WAD to prevent chronic pain and to restore function as quickly as possible so that patients can resume their normal activities.

When examining a patient with suspected WAD, doctors of chiropractic will focus on the whole patient as dysfunctional elsewhere in the body can often contribute to the patient’s presenting complaint, including the thoracic region. Once these potential causes are identified, the chiropractor can put together a treatment recommendation to address each to help alleviate pain and disability. This will often involve a multimodal approach that includes manual therapies, specific exercises, nutrition recommendations, and physiotherapy modalities. In more severe cases, the patient may be referred to an allied healthcare provider for treatment that falls beyond the chiropractor’s scope of practice.

Non-Pharmacological Interventions to Improve Sleep

Sleep is a basic and essential need that allows the body to rejuvenate, which provides both physical and mental health benefits. Lack of quality sleep can increase the risk for chronic health conditions and significantly reduce an individual’s quality of life. Sleep troubles tend to become more common with age, which can worsen existing health problems. A 2020 study 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. While there are pharmaceutical treatments available, patients may be hesitant to use them long term due to a variety of factors and instead seek out non-pharmacological interventions to improve their sleep.

For many patients, the first step may include an evaluation of their bedroom and nighttime habits. Tips offered by leading health organizations include the following: go to bed and get up at the same time every day, even on the weekend; avoid nicotine, caffeine, and alcohol before bedtime; have a relaxing routine before bed, such as taking a bath, reading, or meditating; maintain a comfortable temperature in your bedroom; keep your bedroom dark and quiet; avoid napping close to bedtime; do not watch TV or use any other electronic devices just before bed; and if you can’t fall asleep, go to another room and read a book or listen to music until you feel tired and then return to bed.

Lifestyle choices can also impact sleep quality such as poor diet and physical inactivity. To give yourself the best chance for a good night’s sleep, spend some time in the sun during the day; eat lean protein sources and plenty of servings of fruit and vegetables; avoid processed food products and sugary drinks, especially in the evening; be sure to engage in at least 150 minutes of moderateto-vigorous exercise each week, but avoid strenuous exercise before bed; break up prolonged sessions of sedentary behavior with a break every 30 minutes or exchange sedentary time with other activities that engage the body or brain; and develop strategies to manage work and life stress.

If improved bedtime habits and a healthier lifestyle fail to improve sleep quality and duration, a February 2023 systematic review that included 15 studies found evidence that aromatherapy, auricular acupuncture, cognitive behavioral therapy (CBT), and stimulation therapy may help. In some cases, these services may be offered by your doctor of chiropractic or they can make a referral to an allied healthcare provider.

Lastly, know that sleep and chronic pain often have a bi-directional relationship. That is, the presence of one elevates the risk for the other. This is especially the case with low back pain but is likely true for other musculoskeletal disorders, though research may be lacking. So, if you are experiencing poor sleep and also have musculoskeletal pain, schedule an appointment with your chiropractor to address it because you may find that as your pain is better managed, it might be easier to fall asleep and stay asleep each night.

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.