Monthly Pain Update – June 2022

Hip Stretching and Core Strengthening for Low Back Pain

When it comes to the low back pain patient, it’s common for the muscles that attach to the hip and pelvis (hamstrings, psoas, piriformis, and tensor fasciae latae) to be overly active or tight, while at the same time, the core muscles are deconditioned and weak. When it comes to managing low back pain, should patients focus on stretching the hip muscles or strengthening the core?

In a study published in 2020, researchers recruited 66 low back pain patients and assigned them to one of three groups: core stability exercises; hip muscle stretching; or gentle massage (control group). Participants performed their exercises three times a week for six weeks. While both exercise groups outperformed the control group in pain intensity, disability, balance, and quality of life, the stretch group had the greatest improvement in low back instability and hip muscle flexibility. However, the authors recommend patients engage in both forms of exercise to manage current neck pain and to reduce the risk for recurrence. So, what are some of the exercises/stretches one might use to strengthen the core and stretch the hip muscles?

Core strengthening exercise include: 1) Abdominal bracing: Tighten up the abs “like someone is about to punch you” 2) Side Bridge (Plank): Lay on the left side of your body with your left elbow/forearm on the floor under the shoulder (use padding), raise your pelvis up, supported by the forearm and feet. Repeat on the right side. 3) Supine Bridge: Lay on your back, bend your knees while keeping your feet on the floor. Raise your buttocks off the floor supporting your weight with your feet and midback (avoid head/neck pressure). 4) Straight Leg Raise from Prone: Laying on your stomach, place your head on your arms/hands. Contract your gluteus and hamstring muscles of the right leg and then raise your leg as high as comfortable toward the ceiling. Hold and then slowly lower the leg. Repeat on the other side. 5) “Bird-Dog” Quadruped: From four-point kneeling, contract your abs to stabilize the spine and then raise one arm and the opposite leg (parallel to the floor/ceiling). Alternate sides. 6) Prone Bridge: Laying on your stomach, bend you elbows with forearms on the floor arching the low back. Raise the pelvis into a front plank (or “push-up”) position balancing on the toes and forearms, keeping the body in a straight line.

Hip muscle stretching exercises include: 1) Hamstrings: Laying on your back, passively raise one leg with the aid of a helper (or actively on your own) until you achieve a firm, pain-free stretch. Switch sides. 2) Iliopsoas: Start by sitting on the end of a table, hang one leg toward the floor while bringing the other leg’s bent knee firmly to the chest. With the assistance of a helper, lower your body into the supine (on your back) position and then push the hanging leg further toward the floor to a firm stretch. Repeat on opposite side. 3) Piriformis: Laying on the back with hip and the right knee flexed at 90 degrees, push the leg inward as far as you can. Repeat on opposite side. 4) Tensor fasciae latae: Starting on all fours, extend the right leg backward so it is parallel with the spine. Rotate the foot outward and then move the leg left so the foot crosses the centerline of the body. Hold and then repeat on the other side.

Your doctor of chiropractic may recommend some of these exercises with or without modifications for the management of your low back pain.

Mid-Back Strengthening for Neck Pain

In normal posture, the center of the shoulder joints should be vertically in line with the mastoid processes (the part of the skull just behind the ears). Unfortunately, excessive device use can lead to forward head posture where the head rests forward of the shoulders, which can lead to a condition called upper cross syndrome (UCS). This condition is characterized by weakening of the back muscles (rhomboids, serratus anterior, and lower trapezius) and shortening of the pectoralis major and minor, upper trapezius, and the levator scapulae resulting in neck pain.

Prior studies have suggested that treatment aimed at strengthening the weak muscles and stretching the short muscles in the chest, neck, and upper back can help to achieve improved postural balance and alignment. However, there is speculation that addressing the lower trapezius muscles (which sit in the mid back) may help improve results in UCS patients. To find out, researchers recruited 40 neck pain patients with both forward head posture and UCS and asked them to perform scapula and thoracic spine stabilization exercises with or without a lower trapezius strength training component three times a week for four weeks.

Here are three exercises for strengthening the lower trapezius muscles used in the study:

1) Modified Prone Cobra: Lay on your stomach with your arms to your side, palms facing up. Contract the lower trapezius muscles without engaging the upper trapezius muscles and raise your chest about four inches. Hold for ten seconds.

2) Wall Slides: Stand with your back pressed to the wall have your feet a couple inches away from the wall. Keep your arms bent at 90 degrees and pressed against the wall so the outer side of your upper and lower arms touch the wall, palms facing out. Keeping the arms and low back pressed to the wall, slowly slide your arms upward to full extension. Hold for ten seconds.

3) Prone Lower Trap: Start in the position as the first exercise but place your hands behind your head while squeezing the scapulae together (adduct) lifting the chest and elbows towards the ceiling for ten seconds.

The authors reported that although both groups improved with respect to pain, disability, and postural alignment, the trapezius group showed more significant improvement in disability and postural alignment. The researchers concluded that the addition of specific lower trapezius muscle strengthening yielded the best results and recommended its inclusion in UCS care.

For reducing forward head posture, neck pain, and improving your posture, ask your doctor of chiropractic to review these exercises with you to see if these or different movements may work best for you.

Two Hip & Core Muscle Exercises for Hip and Low Back Pain

When it comes to the human body, an issue in one area can contribute to problems elsewhere. For example, one study found that three-in-five patients with femoroacetabular (hip) impingement also suffer from clinically significant low back pain, and increased disability in one location is associated with greater disability in the other. When it comes to managing a patient with a musculoskeletal disorder of either the hip or low back, it’s often important to incorporate exercises that promote trunk stability, core strength, and hip muscle function.

In a 2021 study, researchers compared various exercises to identify which work best promote muscle activation in both the trunk and the hips. With the aid of surface electromyography, they identified two exercises that aren’t usually considered as part of a hip/low back rehabilitation program that may produce better results than the standard plank and abdominal crunch:

•  Half-Kneeling Self-oblique: Perform a standard lunge by stepping forward with your left leg and bend the knee and hip 90 degrees, resting the right knee and lower leg on the floor behind you. Next, place your right hand on the inside of the left knee and apply inwards pressure against your hand. Repeat this on the opposite side.
• Supine Self-oblique: Laying on your back, bend your left knee 90 degrees with your left foot flat on the floor. Cross your right ankle over your left knee and apply pressure with your left hand against your right knee. Repeat this on the opposite side.

The authors recommend starting with about 20-50% maximum voluntary contraction for about three-to-five seconds and then gradually increasing the pressure and repetitions over time.

Depending on your fitness level and other factors, your doctor of chiropractic may recommend modifications to these exercises so they are easier to perform or so that they can be done while seated when you’re in public or at work. Exercises like these are typically part of a multimodal approach that can include spinal manipulation, mobilization, soft tissue therapy, physiotherapy modalities, and nutrition recommendations.

Carpal Tunnel Syndrome as a Cumulative Trauma Disorder

Carpal tunnel syndrome (CTS) occurs when the mobility of the median nerve is constricted as it passes through the wrist, leading to symptoms in parts of the hand and fingers such as numbness, tingling, pain, and weakness. While it’s possible for CTS to arise following an acute injury—like a wrist fracture—or from hormonal changes that cause swelling in the wrist—like pregnancy—the disorder often progresses subtly and over time due to an accumulation of micro traumas. Hence the term cumulative trauma disorder (CTD).

The carpal tunnel is a busy place with several tendons passing through that help to move digits of the hand. Each tendon is covered by a sheath that provides lubrication so the tendons can easily slide past one another and other tissues in the wrist. Unfortunately, the structure of the wrist did not evolve to cope with the various repetitive motions that can occur in modern life. As the tendons in the wrist slide back and forth, heat can build up, which can stimulate inflammation and reduce the available space in the tunnel. This can place pressure on the median nerve and lead to the symptoms associated with CTS. To make matters more complicated, some people may have a smaller carpal tunnel to begin with. That’s why families can have a history of CTS. Women also tend to have a tighter carpal tunnel, so they may be more prone to the condition.

Generally, taking a break and having adequate rest can allow time for the inflammation to subside. However, many people will continue engaging in repetitive motions, which can lead to very small injuries within the carpal tunnel that may not have a chance to fully heal. Over time, this can reduce the threshold at which inflammation arises, which contributes to why the CTS patient may start experiencing symptoms after a short time when they were formerly able to carry out such activities much longer.

When managing a case of CTS resulting from CTD, the goals of treatment may include reducing inflammation and restoring normal motion to the affected wrist. In addition to manual therapies, physical therapy modalities, and exercise instruction to help the wrist move properly, the doctor of chiropractic may instruct the patient on dietary approaches to reduce inflammation, how to use ice and heat, to wear a nocturnal wrist splint, modify job activities, and take frequent breaks. Additionally, they will examine the full course of the median nerve as it’s common for the nerve to be entrapped at multiple sites, and these will all need to be addressed for a satisfactory result. The chiropractor will also review the patient’s history for potential non-musculoskeletal contributing factors and will work in coordination with allied healthcare professionals, when needed.

The Challenge of Whiplash-Associated Vertigo

In addition to more common symptoms like neck pain and stiffness, the whiplash associated disorders (WAD) patient may also experience vertigo or dizziness. However, the link between vertigo and WAD is somewhat controversial. In 2021, a team of international researchers published a meta-analysis (a review of previously published studies) entitled “The Enduring Controversy of Cervicogenic Vertigo, and its Place among Positional Vertigo Syndromes.” In the paper, the authors note that despite considerable scrutiny and research, little progress has been made to clarify the cause and underlying mechanisms of the disease.

The term “cervicogenic” implies that the problem stems from the cervical spine. A cervicogenic vertigo (CV) patient will either experience neck symptoms in addition to dizziness or will have a history of neck injury that precedes the onset of vertigo. An issue the authors cite is that most “neck” injuries are not focal but involve more than just the neck. Whiplash is a great example, as post-WAD vertigo usually involves several structures that can affect balance, including the otolith system (inner ear/balance organ), the brain (cortical and subcortical structures), the brainstem, the vertebral arteries, and the various structures in the neck and upper back.

Despite many attempts (and failures) at finding a single diagnostic test to solidify the diagnosis of vertigo, the good news is that chiropractic care helps a lot! There is strong evidence that spinal manipulation of the neck and midback helps by stimulating the mechanoreceptors located in the neck muscles and ligament insertions. More specifically, the muscle spindle cells located in the deep short neck muscles and the sensory fibers connecting the facet joint proprioceptors with the spinal cord that feeds information to and from the vestibular (balance) system and other parts of the brain all play important roles in helping to resolve vertigo in WAD patients.

In 2011, a group of Australian researchers uncovered 14 prior studies that reported improvement in dizziness using both unimodal (manual therapy only) or multimodal (more than one) therapy interventions. They cited improvements in postural stability, joint positioning, range of motion, muscle tenderness, neck pain, and vertebrobasilar artery blood flow velocity in their systematic review. A more recent 2020 systematic review that included 22 clinical trials identified manual therapy, vestibular rehab (eye exercises), Tai Chi, and canal repositioning exercises as effective for the management of cervicogenic vertigo. Doctors of chiropractic may incorporate these methods into a treatment plan for the CV patient as well as team up with allied healthcare providers when appropriate.

Diabetic Neuropathy Management Strategies

Peripheral neuropathy (PN) results from damage to the nerves that carry motor and sensory information from the brain and spinal cord to the rest of the body. This condition often causes weakness, numbness, and pain, usually in the feet and/or hands, but it can affect the organ systems as well. Although PN can result from traumatic injuries, infections, metabolic conditions, inherited/genetic conditions, and exposure to toxins, one of the most common causes is diabetes. Left untreated, diabetic peripheral neuropathy (DPN) can cause irreversible damage to nerve tissue, kidney, retina, and blood vessels. Let’s discuss strategies for managing DPN…

• Vitamin D: A 2021 study found that type 2 diabetics with painful DPN are three times more likely to have severe vitamin D deficiency. Another study found that type 2 diabetic patients with DPN experienced a significant improvement in their neuropathy symptoms after taking a 50,000 IU vitamin D3 supplement once a week for twelve weeks.
• B Vitamins: The Mayo Clinic reports that B-vitamin deficiency (especially B1, B6, niacin and B12) is a risk factor for DPN as these vitamins are “crucial to nerve health.”
• Avoid Gluten: Individuals with celiac disease are about 2.5 times more likely to be diagnosed with neuropathy later in life when compared to those without celiac disease. Celiac disease is a condition in which the immune system attacks and damages the small intestine as a result of consuming a protein called gluten that's normally found in wheat, barley, and rye. One study found that adopting a gluten-free diet led to significant reductions in pain in the hands and feet.
• Sleep: A literature review that included eleven studies concluded that diabetics with obstructive sleep apnea have an 84% higher risk for DNP than diabetics without a sleep-related disorder. Hence the importance of managing concurrent sleep apnea and getting sufficient, restful sleep.
• Avoid Repetitive Movements, When Possible: Engaging in activities that require repetitive motions of the hands and wrists can be especially problematic for diabetics. An analysis of long-term data concerning 30,466 Swedish adults found the type 2 diabetics are two times more likely to develop a compression neuropathy of the upper extremities, with carpal tunnel syndrome and ulnar nerve entrapment being the most common diagnoses. In another study, researchers studied the elbows of 82 type 2 diabetics and found that 36 (over a third!) had ulnar neuropathy, even though only three were symptomatic at the time of testing.
• Meditation: Mindful meditation is the practice of focusing one’s awareness on their body, breath, or sensations, or whatever arises in each moment. One study found that participants who practice mindful mediation for twelve weeks were less likely to need pain medication.

In addition to these approaches, your doctor of chiropractic can provide treatment in the office to facilitate proper joint motion and to reduce the pressure on any affected nerves. Your chiropractor will also work in coordination with allied healthcare providers, when necessary, to help best manage your condition.

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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.