Monthly Pain Update – July 2022
Cervicogenic Headache Treatment Strategies
Cervicogenic headache is defined as a headache caused by a cervical spine disorder. This type of headache is estimated to account for up to 20% of headache cases. The primary features of cervicogenic headache usually include unilateral head pain (one side only), limited neck range of motion, and are triggered by various awkward or sustained neck movements. Cervicogenic headaches often respond well to chiropractic care, but which therapies in the chiropractor’s toolkit provide the most benefit to the patient?
One of the primary forms of treatments used by doctors of chiropractic is spinal manipulative therapy. This treatment is characterized by a quick, high-velocity low-amplitude thrust, which usually results in the crack or pop noise that is often associated with chiropractic care. Another common treatment is mobilization therapy, which consists of slow, rhythmic, oscillating techniques. Research supports both methods for managing cervicogenic headaches with the decision to use one over the other based on patient and provider preference.
Doctors of chiropractic may also utilize acupuncture and dry needling in the management of cervicogenic headaches. A 2022 systematic review and several Cochrane reviews reported that acupuncture provides meaningful reductions in the frequency of migraine and tension-type headache as well as neck pain and osteoarthritis pain. Dry needling is similar to acupuncture in that the same kind of needles are used, but they are applied directly to tight muscles rather than to specific acupuncture points.
A 2021 study compared four weeks of dry needling (plus electric stim) and spinal manipulation with four weeks of mobilization and exercise in patients with cervicogenic headache. A review of assessments conducted at the start of care, at the conclusion of care, and three months following the final treatment showed patients in the first group (which included spinal manipulation) experienced greater improvements in headache intensity, frequency, duration, and disability. The patients in this group were also five times more likely to still be satisfied three months post-treatment (77% vs 15%) and three times more likely to stop taking medication for their pain (66% vs 21%). A prior randomized controlled trial found that six to eight sessions of upper cervical and upper thoracic manipulation to be superior to mobilization and exercise in patients with cervicogenic headaches.
While we often discuss musculoskeletal conditions in general terms, each patient is unique, and there is no one approach that will work for everyone. Following a thorough examination and review of the patient’s history, a doctor of chiropractic will decide on an initial treatment approach and evaluate the patient’s progress after several treatments and make adjustments as needed.
Chiropractic Treatment for the Post-Back Surgery Patient
Chiropractic care is a great conservative treatment option for the low back pain patient. While many patients visit a chiropractor to avoid progressing to surgery, there are individuals with a history of back pain who did opt for surgery but continue to experience pain and disability. Can a doctor of chiropractic help the post-surgery low back pain patient?
The current term to describe the post-surgical patient who continues to report pain is persistent spinal pain syndrome-2 (PSPS-2). Older terms the reader may have previously seen or heard include failed back surgery syndrome (FBSS), postlaminectomy syndrome, adjacent-segment degeneration, chronic spinal pain after surgery, and postsurgical spine syndrome. A 2017 systemic review estimated that—depending on the criteria used—PSPS-2 may occur in between 4%-50% of patients following low back surgery.
The average person’s lumbar spine contains five motion segments (L1-L5), but a small percentage may have an additional vertebra that can increase the movement of the spine and reduce its stability. Individuals with this spinal variation may undergo a fusion procedure to reduce spinal movement and increase stability. When such a patient seeks chiropractic care, their doctor of chiropractic will have to consider not only the effect that fusion poses on the adjacent levels above and below the fused region, but also the type of biomaterials used in the fusion process. For example, plates and rods are often anchored to the vertebra using screws, which can loosen or break. In these cases, a non-thrust treatment method, such as spinal mobilization or myofascial release, may be the appropriate choice.
Doctors of chiropractic also have the option to utilize spinal manipulation, which is a single high-velocity, low amplitude (HVLA) impulse that’s delivered to a spinal region to improve movement where it is lacking. In the end, the choice of treatment can depend on several factors, such as patient and provider preference, the presence of osteoporosis or hypermobility, safety concerns such as near or in the region of hardware, and patient comfort during the pre-manipulative set-up.
A systematic review published in 2020 that looked at data from 51 studies found moderate evidence for recommending non-thrust therapies such as neuro-mobilization and myofascial release versus other manual therapies for the post-lumbar fusion PSPS-2 patient. The review did not determine that either thrust or non-thrust therapies are more effective for other surgical interventions and recommended more research on the topic. Until then, the most appropriate approach used will depend on the patient’s unique case, their treatment preferences, and their chiropractor’s training and clinical experience.
Manual Therapy or Surgery for Carpal Tunnel Syndrome?
Surgery to address carpal tunnel syndrome (CTS) is the most common upper limb orthopedic surgery in the United States with annual costs estimated in excess of $2 billion. In western countries, the waitlist for such a procedure is often greater than five months, and the demand is expected to double in the coming decades. This can pose a serious challenge to a country’s healthcare system. What can be done to lessen this burden?
To answer this question, researchers conducted a randomized, controlled trial using multiple treatment sites (four public hospitals) utilizing non-surgical treatment methods on 105 CTS patients who were on a surgical waitlist. The experimental group (52 patients) received education, splinting, and nerve gliding exercises while remainder served as a group that remained on the waitlist without additional care. After 24 weeks, the patients in the experimental group were less likely to require surgery (59% vs 80%) and were two times more likely to report an improvement in their symptoms with respect to pain and disability.
The authors point out that the benefits obtained in this small sample of 105 CTS patients should be cautiously interpreted when applied to the thousands of CTS patients currently on surgical waitlists. However, this study demonstrates that the non-surgical approaches had a significant impact on the treated group compared to the untreated group. Moreover, the participants reported no serious adverse effects.
Another study compared the benefits of three manual therapy treatment sessions to surgery (60 patients in each group), and the researchers observed similar improvements in both groups a year later. Intrigued by their results, the researchers followed up with these patients again after five years and noted similar outcomes between both groups.
The treatments provided in these studies—education, splinting, nerve gliding exercises, and manual therapies—are all provided by doctors of chiropractic and are often used as part of a multimodal approach for the management of CTS. Additionally, chiropractors will look for nerve entrapment elsewhere on the median nerve as it’s very common for the mobility of the nerve to be restricted at two or more sites, and these will all need to be addressed for a satisfactory outcome. If non-musculoskeletal factors are suspected, your doctor of chiropractic will co-manage the condition with an allied healthcare provider.
Chiropractic Care After Knee Replacement
Total knee arthroplasty (TKA) is the most performed operating room procedure in the United States, and the number of surgeries is projected to increase by 400% (to 3.5 million a year) in the next twenty years due to prolonged longevity, the rise in obesity, and increasing rates of osteoarthritis. The surgery itself traumatizes the surrounding tissues resulting in significant whole leg swelling that increases by 10% per day for the first three days after surgery, reaching an average peak increase of 35% within six-to-eight days. The swelling overloads the lymphatic system, and the increase in pressure results in joint and soft tissue tightness, tension, and pain, which restricts venous blood return to the heart. Post-operative swelling after TKA may persist for six months or longer causing multiple functional deficits including (but not limited to) reduced strength, decreased range of motion (ROM), and slower walking speeds. Can chiropractic care play a role in a TKA patient’s post-surgical care plan?
A March 2022 study set out to determine the benefits of a multimodal swelling intervention during the three weeks following TKA that includes the use of an inelastic adjustable compression garment (CG), manual lymph drainage (MLD) massage, and a home exercise program (HEP). The researchers assessed the participants at six time points (day 1, day 4, day 7, day 14, day 21, and day 42, which is three weeks after the conclusion of the treatment period). Their assessments measured patient satisfaction, safety, patient adherence, and swelling (using device called a Single Frequency Bio-impedance Analysis).
The results showed an overall patient satisfaction rate of 93% with no adverse side effects noted. The research team also noted very high adherence rates for each of the three treatments (CG – 85%, MLD – 99%, and HEP – 97%), but most importantly, swelling reduced throughout the treatment period with minimal change in swelling at the day 42 follow-up. This is encouraging as swelling is the leading cause of emergency room visits within 30 days post-op, and it also increases the risk of blood clots (deep vein thrombosis or DVT), infection, delayed wound healing, and often interferes with post-surgical rehabilitation.
Doctors of chiropractic utilize lymphatic drainage manual therapies, massage, and other soft tissue therapy. They’re also known to prescribe home exercise programs as part of a treatment plan. Additional services that may benefit the post-TKA patient include spine, pelvic, and extremity manipulation/mobilization, muscle balancing techniques, as well as modality use, nutritional counseling, activity modification recommendations, and orthotic prescriptions to address leg length variance, which can occur post-TKA. These are particularly important as the altered gait pattern that is common post-TKA often results in the development of faulty movement patterns that can have a significant impact on quality of life and may delay recovery.
Whiplash Challenges & Chiropractic Care
The term whiplash refers to a sudden forward (acceleration) and backward (deceleration) movement that results in hyperextension of the cervical spine. This process can injure the various soft tissues in proximity of the neck, which can lead to a wide collection of symptoms that fall under the umbrella term whiplash associated disorders (WAD). While this description may seem simplistic, the condition is anything but, and it be quite a challenge for healthcare providers to manage. In fact, the current research suggests that between 20-50% of WAD patients will continue to experience some degree of life-interfering pain and disability a year following their initial injury. Let’s look at why WAD can be a challenge and what can be done to produce the best outcome for the patient.
One difficulty with WAD is that there is no objective test that can diagnose the condition. Instead, diagnosis is heavily based on the patient’s presenting signs and symptoms. To complicate matters, many WAD symptoms can occur or overlap with other conditions, including mild-traumatic brain injury. This can be further complicated by the presence of a pre-accident condition that aggravates symptoms (like osteoarthritis), and/or other biopsychosocial factors (like pre-existing anxiety, depression, poor coping strategies, illness/disability perception, and more).
Additionally, there are post-injury factors that can prolong symptoms or increase the risk of chronicity. For example, a 2021 study reported that when soft cervical collars are used in emergency departments (EDs) in patients with acute whiplash injuries following a motor vehicle collision, there is an increased risk of delayed recovery. The group of authors noted that closer collaboration between clinicians in EDs is needed to minimize collar use. Prolonged inactivity or a reduction of movement to avoid injury can also have a negative effect on recovery.
Once a diagnosis is made and the patient’s case is better understood, treatment can commence. The current research supports a multimodal treatment approach, which involves the application of several therapies concurrently to achieve the best outcome for the patient. According to a well-respected guideline published in 2016, manual therapies (manipulation or mobilization), range of motion home exercise, and supervised graded strengthening exercise should be considered for WAD patients with recent-onset neck pain (less than three months). For WAD patients with neck pain that persists for three months or longer, the guidelines recommend manipulation with soft tissue therapy, high-dose massage, supervised group exercise, supervised yoga, supervised strengthening exercises and home exercise, and structured patient education/advice including stress management.
Chiropractic care is often recommended as the first treatment approach for the WAD patient, and patients are often advised to seek care as soon as possible.
Gout: A Short Summary
Gout is a type of inflammatory arthritis that causes pain and swelling in the joints. While it is mostly associated with the base of the big toe joint, gout can affect the knees, ankles, foot, hand, wrist, and elbow. The condition typically occurs earlier and three times more common in men than in women. For women, gout usually develops after menopause. This is because men have higher levels of uric acid (UA) most of their lives. Only after menopause do women reach similar UA levels in the blood. Hence, the condition is typically diagnosed through a simple uric acid blood test.
The human body makes uric acid through the breakdown of purines, which are chemicals found in certain foods and drinks. We usually excrete purines without issue (through urination), but if we eat too many foods or beverages rich in purines or if the kidneys can’t handle the purine load, then uric acid levels in the bloodstream can become too high and the uric acid crystals can concentrate in the joints. The crystals are sharp and needle-like in shape and directly irritate the cartilage and soft tissues surrounding the affected joint.
Symptoms include swelling, redness, burning, and pain—often intense pain can make walking difficult to impossible. The onset of a gout attack is typically sudden and can come out of nowhere, sometimes overnight. An attack can last a week or two and there may be no symptoms whatsoever between attacks. For some, it may hit once and not again for years. There is no “set pattern.” If left untreated for too long, the sharp crystals can cause cartilage damage resulting in arthritis.
Treatment strategies are classically pharmaceutical through a primary care physician or rheumatologist and consist of anti-inflammatory drugs (non-steroids or steroids), Colchicine (oral), Allopurinol, among others.
In some cases, gout can be helped through diet. Strategies may include staying hydrated; reduce the intake of foods and drinks rich in purines like alcohol (especially beer), red and organ meat, shellfish, gravy, and fructose-rich food and drinks; and drinking tart cherry juice—a recent study showed a reduction of serum urate in overweight and obese adults by consuming 100% tart cherry juice while another study showed it lowered blood uric acid levels in a group of healthy women. If you’re under treatment for gout, ask your doctor if he or she would recommend these strategies to see if they can benefit you.
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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.
