Monthly Pain Update – June 2023
When Is Low Back Surgery Appropriate?
Low back pain is the most common musculoskeletal complaint, and it is the leading cause of activity limitation and absenteeism from work. There are many treatment options available to the low back pain patient, including surgical procedures. But when is surgery appropriate and in what cases should it be avoided?
Generally, clinical guidelines don’t recommend surgery as an initial treatment, except in emergency or critical situations. For example, when a patient presents for chiropractic care, there are red flags that indicate the patient should be referred out to another healthcare provider, if not the emergency room. These include cancer, fracture with instability, infection, and cauda equina syndrome (includes loss of bowel and/or bladder control). In these cases, surgery may be the best available option for the patient to avoid a catastrophic outcome.
In addition to these red flag scenarios, a literature review published in 2023 in the Medical Journal of Australia concluded that spinal surgery may have a role in the management of non-responsive nerve compression with radiating leg pain. That is, once conservative, non-surgical options have failed. However, outside of these situations, the review concluded, “Spinal surgery for all other forms of back pain is unsupported by clinical data, and the broader evidence base for spinal surgery in the management of LBP is poor and suggests it is ineffective.” Additionally, the authors note that spinal surgery for LBP “has substantially increased over recent decades, and disproportionately among privately insured patients, thus the contribution of industry and third-party payers to this increase, and their involvement in published research, requires careful consideration.”
Unfortunately, a 2022 study found that 41.7% of low back pain patients who underwent spinal surgery had minimal, if any, engagement with non-pharmacological, non-operative treatment in the six months before their procedure. A 2013 study that used data from Washington state worker’s compensation system found that 43% of workers with a back injury who initially consulted with a surgeon ended up having surgery while just 1.5% of those who first received chiropractic treatment eventually had a surgical procedure for their back pain. Not only are patients who visit a chiropractor first less likely to end up under the surgeon’s knife but they’re also less likely to be prescribed opioids within the following year, something that offers tremendous benefits to society in light of the opioid crisis.
If you experience an episode of low back pain, consider chiropractic care as your first treatment choice. If your condition doesn’t respond to a multimodal treatment approach, your chiropractor can refer you to an allied healthcare provider for additional care.
Carpal Tunnel Syndrome and Hand Positions
The wrist is very flexible, and the reason the wrist is so supple is because it’s made up of eight small carpal bones that are lined up in two rows of four bones each. Along with the transverse carpal ligament, these rows of carpal bones form an actual tunnel in which nine muscle tendons (and their sheaths) and the median nerve pass. If inflammation or swelling occurs that reduces the space in the carpal tunnel, then the median nerve can become compressed and restricted, which stimulates the various symptoms commonly linked to carpal tunnel syndrome (CTS). Another factor that can limit space in the carpal tunnel has to do with hand positions.
In a 2023 study, researcher utilized high-frequency, diagnostic ultrasound (HFDU) to specifically look at median nerve position changes and cross-sectional area of the nerve when the wrist is bent upward (dorsiflexion) and downward (palmar flexion) in 85 patients (110 affected hands) diagnosed with mild (n=38), moderate (n=30) and severe (n=42) CTS as well as 25 healthy control subjects (50 hands). Compared with the control wrists, the CTS-affected wrists exhibited much greater median nerve compression against the floor of the tunnel (the transverse carpal ligament) in both bent wrist positions. The researchers also used a diagnostic technology called nerve conduction velocity to confirm that this compression at the end-ranges of wrist flexion and extension are associated with dysfunction of the median nerve.
While this finding is interesting, it just reinforces what many healthcare providers already know about CTS: symptoms worsen at the end ranges of motion, and prolonged, awkward wrist postures should be avoided. That’s why one of the most common tools used to manage CTS is a nocturnal wrist splint to prevent the wrist from bending during sleep. However, it’s generally not recommended to wear a wrist splint at all times as immobilization could lead to deconditioning of the muscles in the region and worsen the patient’s situation.
In addition to avoiding prolonged bending of the wrists, CTS patients are also instructed to try to keep the wrist in a neutral position, take frequent breaks, and avoid high vibration exposure when performing hands-on work or hobby-related tasks because it can increase inflammation in the carpal tunnel and exacerbate symptoms and slow recovery.
Successful management of CTS may also involve addressing non-musculoskeletal factors that can promote inflammation or swelling in the wrist, such as diabetes. Patients may also receive advice on inflammation-promoting foods to avoid or supplements to take to reduce inflammation in the body. Your chiropractor will also assess the full course of the median nerve starting at the neck to make sure there are no other areas in which the nerve’s motion is restricted since it’s not uncommon for this to occur in multiple sites.
Exercise Can Hasten Whiplash Recovery
Whiplash-associated disorders (WAD) can be a challenging condition to manage, and the current data suggests that up to half of WAD patients may continue to experience pain and disability for up to a year following their car accident, slip and fall, or sports collision. Exercise therapy has long been considered a meaningful treatment option for many musculoskeletal conditions, but what does the current research reflect with respect to the role of exercise therapy for the WAD patient?
In 2021, researchers conducted a systematic review and meta-analysis that included 27 studies in order to gauge the effect of exercise therapy compared with other treatments, placebo interventions, or no treatment. They found that exercise therapy had short-term effects on neck pain and medium-term effects on neck-related disability, but they concluded that “the current evidence is weak” with respect to exercise as a sole treatment for WAD.
However, when used in combination with other treatments, exercise therapy can be quite beneficial to the WAD patient. In addition to the advice to stay active or even start exercising in some capacity (even if that means taking a short walk each evening to begin with), WAD patients may be prescribed more specific, neck/shoulder/upper back exercises to restore posture and strengthen the deep muscles that often become deconditioned in patients with the condition.
In addition to exercise recommendations, your doctor of chiropractic may employ a multimodal approach that includes manual therapies (massage, manipulation, mobilization, active release technique, trigger point therapy, and more); physical therapy modalities (electric stim, ultrasound, class IIIb and IV lasers, pulsed electromagnetic field, traction); patient education (including emphasizing the importance to resume normal activity as soon as possible); and ergonomic assessments (to minimize work stress and strain). When psychosocial barriers to recovery exist, your chiropractor may team with allied healthcare providers that offer cognitive behavioral therapy and other needed services.
Exercise Can Hasten Whiplash Recovery
Whiplash-associated disorders (WAD) can be a challenging condition to manage, and the current data suggests that up to half of WAD patients may continue to experience pain and disability for up to a year following their car accident, slip and fall, or sports collision. Exercise therapy has long been considered a meaningful treatment option for many musculoskeletal conditions, but what does the current research reflect with respect to the role of exercise therapy for the WAD patient?
In 2021, researchers conducted a systematic review and meta-analysis that included 27 studies in order to gauge the effect of exercise therapy compared with other treatments, placebo interventions, or no treatment. They found that exercise therapy had short-term effects on neck pain and medium-term effects on neck-related disability, but they concluded that “the current evidence is weak” with respect to exercise as a sole treatment for WAD.
However, when used in combination with other treatments, exercise therapy can be quite beneficial to the WAD patient. In addition to the advice to stay active or even start exercising in some capacity (even if that means taking a short walk each evening to begin with), WAD patients may be prescribed more specific, neck/shoulder/upper back exercises to restore posture and strengthen the deep muscles that often become deconditioned in patients with the condition.
In addition to exercise recommendations, your doctor of chiropractic may employ a multimodal approach that includes manual therapies (massage, manipulation, mobilization, active release technique, trigger point therapy, and more); physical therapy modalities (electric stim, ultrasound, class IIIb and IV lasers, pulsed electromagnetic field, traction); patient education (including emphasizing the importance to resume normal activity as soon as possible); and ergonomic assessments (to minimize work stress and strain). When psychosocial barriers to recovery exist, your chiropractor may team with allied healthcare providers that offer cognitive behavioral therapy and other needed services.
Can Hip Osteoarthritis Be Prevented?
Hyaline cartilage is the slick, translucent tissue that lines joint surfaces and allows for the smooth movement of joints in the body, including the hip. If the structure or health of this cartilage is compromised, it can gradually wear away, leading to joint pain, stiffness, and disability. Eventually, the hip osteoarthritis patient may have no choice but to accept a dramatically reduced lifestyle or undergo total hip arthroplasty. Is it possible to prevent osteoarthritis of the hip or at least slow its progression?
Unfortunately, the answer isn’t a firm yes or no. There appears to be a genetic component to osteoarthritis risk, so you may be destined for the condition. However, it does appear that if you manage to avoid major trauma to the hip and stay physically active and otherwise live a healthy lifestyle, then it may be possible to significantly reduce the risk for developing the condition and requiring surgical intervention.
Between 2014 and 2017, researchers in Germany conducted a study in which nearly 24,000 patients with either hip or knee osteoarthritis received usual care or participated in a structured program focused on guidelines-recommended therapies and patient empowerment, including lifestyle changes and exercise interventions. Patients in the experimental group were 33.6% less likely to be hospitalized or undergo joint replacements related to their knee/hip.
Chiropractic care offers a unique opportunity for patients as the initial history typically includes a comprehensive review of systems including all aspects of health, both past and present. This approach often extends care well past the primary presenting complaint (hip pain, in this case) to include patient education regarding diet/nutrition, stress management, sleep quality enhancement, and more. Additionally, a doctor of chiropractic will assess related areas of the body to identify problems that can affect normal movement patterns (the foot, ankle, knee, pelvis, low back) as addressing these issues may be critical to help the patient achieve a satisfactory outcome.
Complementary and Alternative Approaches to Multiple Sclerosis
Multiple sclerosis (MS) is a chronic neurological autoimmune disease that affects an estimated 2.5 million people globally and accounts for about $85 billion a year in both direct and indirect healthcare costs in the United States alone. Typical MS symptoms and clinical presentations can include sensory loss affecting sight (optic nerve), weakness (motor nerves/brain), facial muscle weakness (facial cranial nerve), ataxia (cerebellum, motor cortex, spinal cord), vertigo (inner ear, vestibular branch of the cranial nerve), pain, fatigue, bladder/bowel control, and psychological disorders. Because the condition is not fully understood and has been linked to both genetic and environmental causes, there’s no one-size-fits-all treatment available to MS patients. Conventional pharmaceutical approaches may have a limited effect, and these immunomodulating or immunosuppressing drugs can lead to adverse allergic reactions that affect the skin and other organs. This has led many patients and researchers to explore alternative and complementary treatment approaches to help slow the progression of the disease and improve a patient’s quality of life.
An October 2022 systematic review looked at ten previously published randomized-control trials to investigate the effects of manual therapies in reducing symptoms in MS patients. The authors concluded that Swedish massage, acupressure, and reflexology interventions lasting 10-30 treatments spread over 4-10 weeks were effective for improving fatigue, pain, spasticity, psychological state, and physical function.
In addition to hands-on treatment, there have been several studies exploring the role of diet and specific nutrients in MS management. Dietary approaches such as the Mediterranean diet, ketogenic diet, and the dietary approaches to stop hypertension (DASH) diet have been linked to better cognitive health and greater preservation of the thalamus (an area of the brain that relays motor and sensory data to the cerebral cortex). In particular, omega-3 fatty acid supplementation may reduce the severity of some MS symptoms and oleic acid—a fatty acid found in cooking oils, meats, cheese, nuts, seeds, eggs, pasta, milk, avocados, and olives—may stimulate the production of the regulatory T cells that help keep the immune system from attacking the central nervous system.
Staying active may also benefit MS patients. One study found that using an activity tracker helped lower the risk for relapsing-remitting MS symptoms and improved the participants’ ability to maintain normal activities, including working. There’s also research to suggest the obesity, depression, and poor sleep can have a detrimental effect on MS patients, so maintaining a healthy weight and good mental health and sleep hygiene are also important.
As with many health conditions, early detection and treatment is second only to prevention. In the case of MS, a review of medical records of more than 85,000 adults revealed that those who would eventually develop MS were more likely to make doctor visits for issues such as urinary problems, visual disturbances, abnormal skin sensations, impaired movement, and dizziness in the time preceding their diagnosis. Recognizing these clusters of symptoms can help doctors identify patients who may be at increased risk for MS earlier in the course of the disease when treatment may be more effective.
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.
