Monthly Pain Update – June 2024

Low Back Pain and the Hips and Legs

It’s estimated that 84% of individuals will experience at least one episode of low back pain during their lifetime, with 23% developing chronic low back pain. While dysfunction in the lumbar region is typically thought to be the cause of a patient’s low back pain, there’s a growing body of research suggesting that the underlying cause or contributing factor to low back pain can come from the hips, hamstrings, and feet/ankles:

• Dysfunction of the lumbopelvic region has been demonstrated to alter core muscle function associated with movement, which can reduce spinal stability and place increased load on the lower back, setting the stage for back pain. In a 2023 study, researchers observed that 50% of hip osteoarthritis patients had co-occurring lumbar spinal stenosis—a debilitating condition associated with the degeneration of the spine. Interestingly, a 2022 study found that 90% of hip osteoarthritis patients with co-occurring low back pain experienced a resolution of their low back symptoms after receiving treatment to address their hip condition. Another study from 2023 found that pelvic tilt increased the risk for low back pain by 12% while a 2016 study noted that individuals who participated in a program to reduce pelvic tilt reported a reduction in back pain. Other studies have found that weak hip muscles, tight hip muscles, and reduced hip range of motion can also contribute to low back pain.
• A systematic review that included twelve studies concluded that tight hamstrings may increase the risk for low back pain by 4%. A 2021 study that included 104 younger adults revealed that nearly three-quarters of those with either chronic neck or low back pain reported tight hamstrings in one or both legs. The authors noted that hamstring tightness can affect the biomechanics of the spine, increasing the risk for disorders such as low back pain and neck pain. Additionally, a 2023 study reported that differences in hamstring flexibility between the right and left leg may also set the stage for future low back pain.
• Ankle-foot pronation is a term used to describe the inward rolling for the foot and ankle. This leads to internal rotation of the leg that encourages an anterior pelvic tilt (which in turn increases the curve in the low back and negatively affects spine biomechanics) and strain on the piriformis muscle (which can increase pressure on the sciatic nerve causing pain, numbness, and/or weakness in the lower limb). A 2021 study found that among a group of 101 chronic low back pain patients with excessive foot pronation, those provided with a custom foot orthotic reported a significant reduction in low back pain within four weeks.

The good news is that doctors of chiropractic are trained to examine the whole patient and not just focus on the area of chief complaint. So if you visit a chiropractor for low back pain, don’t be surprised if they also look at the hips, hamstrings, and feet/ankles because issues in these areas may also need to be addressed to achieve a satisfactory outcome.

The Carpal Tunnel Under Pressure

The carpal tunnel is formed by eight small bones that comprise the top of the tunnel with the transverse carpal ligament serving as the floor. The median nerve, blood vessels, and nine tendons and their sheaths pass through the tunnel. In a healthy individual, there is a constant fluid pressure within the carpal tunnel that ranges between 2.5 and 13 mmHg. If the cross-sectional size of the tunnel is reduced or if one or more of the contents swell or become inflamed, then the pressure within the carpal tunnel will increase. This increased pressure can restrict the movement of the median nerve and stimulate the symptoms we commonly associate with carpal tunnel syndrome in the thumb through thumb-side half of the ring finger such as numbness, tingling, pain, and weakness. However, there are many potential causes for increased pressure in the carpal tunnel, and they must be identified and addressed for the patient to experience a resolution of their symptoms.

The most common cause of pressure build-up in the carpal tunnel is frequent, repetitive hand movements that inflame the tendons sliding against each other in the tunnel. As inflammation increases, the median nerve is pressed against the transverse carpal ligament and symptoms arise. Working with awkward hand postures, forceful grips, and high vibration exposure, along with infrequent breaks, can exacerbate symptoms.

In mild-to-moderate cases of carpal tunnel syndrome, treatment will focus on restoring normal movement to the median nerve and reducing inflammation in the wrist. This may include manual therapies, nerve gliding exercises, diet/supplement recommendations, ice therapy, physiotherapy modalities, nocturnal wrist splinting, and job/activity modifications such as more frequent breaks and more ergonomic tools. If rheumatoid arthritis or hormonal fluctuations are present (pregnancy, menstruation, menopause, birth control pills, hormone replacement therapy, diabetes, hypothyroid, kidney disease, lymphedema, and some medications), then co-management with an allied healthcare provider may be necessary.

Unfortunately, most patients who develop carpal tunnel syndrome often delay seeking treatment because the symptoms come one gradually and can be easily ignored. By the time they contact their doctor of chiropractic, it may be months (or even years) down the line and the condition has progressed and will take longer to manage. If the symptoms are too severe, conservative care may not be sufficient and a surgical consultation may be the next logical step.

Hands-On Care for Shoulder Impingement Syndrome

Shoulder impingement syndrome (SIS) is a very common cause of shoulder pain that affects about half of adults at some point in life. Essentially, the condition describes the pinching of pain-sensitive structures in the shoulder that restricts normal use or function, with raising the shoulder being a very common activity that triggers a painful reaction.

When you first visit your doctor of chiropractic for suspected SIS, you will complete a detailed history regarding their occupation, sports involvement, and positions or situations that increase and decrease pain or prohibit function. This information will guide the physical examination to help your chiropractor gain a greater understanding of your unique case. The exam may also encompass areas beyond the shoulder as studies have shown that forward head posture, altered scapular (shoulder blade) motion, neck/upper back joint and muscle issues can contribute to SIS and would need to be co-managed to achieve a satisfactory outcome. This is especially true in cases in which shoulder pain has increased gradually over time vs. sudden onset.

Treatment will typically involve manual therapies to reduce capsular adhesions or tightness and stretching and stabilization exercises to improve range of motion. Some of the manual therapies a chiropractor may use include mobilization to the different sub-joints of the shoulder (glenohumeral, scapulothoracic, sternoclavicular, and acromioclavicular); soft-tissue manipulation of various muscles around the shoulder region; forward, backward, and downward glides to increase external rotation, internal rotation, and abduction of the glenohumeral joint; and long-axis distraction to address hypomobility of the glenohumeral joint. In fact, a 2024 study found this approach combined with stretching and strengthening exercises (twelve visits spread over four weeks) resulted in greater improvements in pain, functional capacity, and range of motion than exercises alone in patients with chronic SIS.

If musculoskeletal issues beyond the shoulder, such as in the neck or mid back, are present, your chiropractor will address them with a similar multimodal approach. In 2019, researchers conducted a retrospective review of MRIs from SIS patients and found that 35% had nerve root compression on the same side as their affected shoulder. Because SIS and cervical radiculopathy share symptoms, the researchers note that it’s possible for one condition to be confused with the other. Additionally, several studies have found that SIS patients experience greater improvements in shoulder pain and function when their treatment plan includes manual therapies—such as spinal manipulation—applied to the thoracic spine.

The good news is that SIS can often be resolved with conservative treatment approaches, of which chiropractic care is an excellent choice.

Managing Forward Head Posture

With the rise of smartphones and social media apps that keep users glued to small screens for hours upon hours, forward head posture is becoming more common. Unfortunately, this postural fault can set the stage for neck pain. In fact, it’s estimated that up to 60% of patients with neck pain exhibit forward head posture. Let’s look at why this is the case and what chiropractic care can do about it.

The average human head is about the same size and weight (~12 lbs) as a bowling ball. The cervical spine and all the muscles and tissues in the neck have evolved to support the head so that it rests directly above the midline of the body. When the head sits forward of its normal position, either from learning in or looking down (or both), the muscles in the back of the neck, shoulders, and upper back must work harder to hold it upright. Studies have demonstrated that forward head posture increases the load on the muscles attached to the back of the neck by nearly four times! You can experience this for yourself by holding a weight close to the body and then holding the same weight with the arms extended. Over time, the normal C-shaped curve of the cervical spine can straighten or even reverse, leading to degenerative changes in the joints and intervertebral disks. These adaptations to facilitate looking down at a device both lead to neck pain and disability and increase the risk for musculoskeletal disorders in adjacent parts of the body as they too may develop abnormal biomechanics.

When a patient presents for care at a chiropractic clinic for neck pain accompanied by forward head posture, the first order of business is to review the patient’s history and conduct an examination to help establish a treatment approach. The specifics of a care plan will vary from patient to patient but will likely include both manual therapies provided in the office to facilitate normal joint motion and exercises to perform at home to help correct posture. In addition to manual therapies like spinal manipulation and mobilization applied to the cervical spine, patients may also receive therapies to address trigger points in the muscles of the neck and upper back, adjustments to the thoracic spine, scapular stabilization exercises, and more.

While chiropractic care can help manage neck pain and other symptoms associated with forward head posture, maintaining these benefits over time will require lifestyle changes. A 2021 study found that using a smartphone an average of seven hours a day or more can increase the risk for neck pain by 80%. An experiment conducted in 2021 revealed that two-thirds of adults will experience neck and/or upper back pain from just 30 minutes of smartphone use with sustained neck flexion. Reducing smartphone use is important, and when you must use a device, try holding it at eye level so the head can remain in a neutral position. Additionally, get regular exercise as the stress of movement is how the joints in the body (including those in the neck) are nurtured and hydrated. Since low grade inflammation in the body may increase the risk for neck pain, get plenty of sleep, manage stress, and eat more fruits and vegetables (and less processed food).

Chronic Whiplash Predictors: Psychosocial vs. Anatomical

Whiplash associated disorders (WAD) is a term used to describe the constellation of signs and symptoms that can arise following the sudden acceleration-deceleration of the head and neck that can occur in automobile collisions, physical trauma (such as sports or assault), or a serious fall. It’s estimated that half of WAD patients will continue to experience ongoing mental and physical symptoms that can dramatically affect their quality of life in many ways. This begs the question, is chronic WAD rooted in the injury itself or in the mental, social, and psychological response (psychosocial) to the condition?

When confronted with stress, the human body engages the neurobiological stress systems. This includes the hypothalamic-pituitary-adrenal axis, which produces cortisol; the sympathetic nervous system, which releases adrenaline and prepares the body for rapid action; and various neurotransmitters and areas of the brain to help make rapid decisions. In a life-or-death situation, this can help save a life. If these neurobiological stress systems remain engaged, then over time they can have a detrimental effect on the body, which can impede recovery. The aftermath of a car accident can bring additional stressors that can disrupt normal routine from caring for loved ones who may have also been injured to dealing with insurance companies, body shops, and litigation, exacerbating these unconscious biological reactions. The stress response may also trigger behaviors like kinesiophobia and catastrophizing, which can stimulate a negative disposition toward recovery or even cause one to restrict activity out of fear of worse pain or reinjury, both of which can elevate the risk for progression to chronic WAD.

On the other hand, a study that monitored more than 600 car accident victims who have visited the emergency room found that those with more severe pain were more likely to report moderate-to-severe pain in the following months. In a 2021 study, researchers observed that chronic WAD patients exhibited small but significant impairments in neck muscle control, suggesting that nervous system injury may play a role in progression to chronic WAD symptoms. A systematic review published in 2022 found that peripheral nerve injury and neuropathic pain may be more common among WAD patients than previously thought, and such issues may not be detected with current WAD diagnosis practices.

In the end, we may come to understand chronic WAD as an interplay between both more severe initial injury and the psychosocial response that arises in its aftermath. While it’s not yet possible to identify perfectly screen for which WAD patients may develop chronic pain and disability, the current data suggest that early intervention may be the best preventative course of action. Instead of a wait-and-see approach, patients may benefit from prompt treatment to address musculoskeletal injuries as well as encouragement to remain active within pain tolerance with assurance that recovery is highly likely. As for treatment options, there are many available to the whiplash patient, but a 2022 study found that the use of manual therapies—such as spinal manipulation, the primary treatment provided by doctors of chiropractic—can significantly reduce recovery time and lead to better outcomes for pain reduction, physical function, and quality of life.

Strategies for Improving Vascular Health

Efficient blood circulation is essential for the health of nearly all bodily functions, including the heart and cardiovascular system, the kidneys, and the brain. If vascular health is compromised, either from endothelial (blood vessel wall) dysfunction or stiffening of the large elastic arteries (such as the aorta and carotid arteries), then the risk for adverse health outcomes increases dramatically. Because poor vascular health reduces life expectancy, mobility, and independence, it’s important to take steps to improve vascular health before it’s too late.

In addition to a heart-healthy diet, a key tool in maintaining good vascular health is getting regular aerobic exercise. Most guidelines recommend adults engage in at least 150 minutes of moderate-intensity physical activity a week. Studies have shown these 150 minutes can be spread throughout the week or squeezed into one or two sessions, though there’s debate if weekend warriors may be at increased risk for injury (so stretch, please).

Unfortunately, aerobic exercise can be time consuming, leading people to either not exercise enough or just skip it entirely. The good news is that high-intensity interval training (HIIT) can provide similar benefits in a more compact space of time. Simply put, HIIT involves short bursts of near maximum effort between periods of low-intensity exercise. It can involve walking, running, cycling, swimming, etc. There are several options for HIIT with respect to interval time, but the typical goal is to complete 45-60 total minutes of high-intensity effort during the week.

A rather new and potentially time-efficient form of exercise is high-intensity inspiratory muscle strength training. This involves inhaling against a resistance while exhaling is unimpeded. Taking 30 breaths against higher resistance (~5 min./day) has been found to reduce blood pressure 10-12 mmHg in both normal subjects as well as those with obstructive sleep apnea over a six-week time period. Interestingly, traditional aerobic exercise only reduces BP by 5 mmHg or less.

A third approach is the use of passive heat therapy using repeated hot water immersion to raise core body temperature ~1-1.5°C, to improve macro- and microvascular cutaneous dilatation and reduce arterial stiffness. Similar to aerobic exercise, this causes an increase in body core temperature, heart rate, cardiac output, peripheral circulation, and activation of protective stress response mediators.

However, before making any changes to diet or starting an exercise program, consult with your healthcare provider to make sure you’re not potentially placing yourself at increased risk for poor outcomes, as well as to establish a baseline to compare your progress against.

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.