Monthly Pain Update – March 2023

Exercises to Prevent Sports-Related Back Pain

According to a systematic review that included 201 studies, low back pain may affect between 10-67% of athletes at any given moment, with anywhere from 17-94% experiencing sports-related back pain each year. This broad range is due to the age, level of competition, and the specific sports included in each study. For example, the data show the risk for low back pain is higher in gymnastics, diving, weightlifting, golfing, football, and rowing. That said, what can be done to lower the risk for sports-related back pain?

In 2022, researchers recruited 70 high school volleyball players—another sport with a high prevalence of low back pain—and assigned them to one of two groups: a control group that continued their normal activities and an intervention group that performed their usual activities in addition to four weeks of stretching and exercises focused on dynamic thoracic mobility and trunk stabilization. This program, which took about ten minutes to complete, included the jack-knife stretch (to loosen the hamstrings to improve forward bending), gastrocnemius stretch (to loosen the calf muscles to enhance ankle dorsiflexion), iliopsoas stretch (to loosen the hip flexors and reduce lumbar lordosis), and trunk stabilization (front plank to strengthen the low back and gluteal muscles).

During the study, 33% of the players in the control group reported low back pain, compared with just 8.8% in the intervention group. This means the participants who worked on improving strength and flexibility were nearly four times less likely to experience low back pain. Additionally, the players in the intervention group demonstrated improved physical function with respect to back endurance; spine/back flexibility; shoulder and trunk range of motion; ankle mobility; and iliopsoas, quadriceps, and hamstring flexibility.

The study highlights the importance of a strong and flexible core for reducing the incidence of low back pain, something that also applies to non-athletes. Doctors of chiropractic often observe deficiencies in core strength and flexibility in patients with low back pain and advise such patients to perform at-home exercises to not only aid in the rehabilitation process but also reduce the risk for a future episode of low back pain.

Treatment for Chronic Non-Specific Neck Pain

While it may sound confusing, the most common type of neck pain is non-specific neck pain; that is, neck pain that occurs in the absence of an underlying disease or pathology, like an infection or osteoporotic fracture. Rather, non-specific neck pain is caused by postural or mechanical issues affecting the soft tissues in the neck. If symptoms persist longer than three months, it’s classified as chronic non-specific neck pain (CNSNP). What does the literature say is the best treatment approach for a patient with CNSNP?

In 2022, researchers published a systematic review and meta-analysis of previously published randomized-clinical trials with respect to both pharmacological and non-pharmacological treatments for CNSNP. The review included 119 randomized-clinical trials that included a total of 32 interventions and 12,496 patients. The authors focused on how each approach affected pain intensity and disability, as well as adverse events associated with treatment.

Compared with inert treatment (placebo or sham), the researchers found that a combination of active and/or passive multimodal non-pharmacological interventions is more effective for reducing pain and disability at six months post intervention. An example of such an approach would be spinal manipulative therapy applied by a chiropractor and neck-specific exercises performed by the patients at home between visits. Of note, the review did not find evidence supporting anti-inflammatory drugs for the management of CNSNP.

The authors also note that while guidelines focus more on active interventions such as education and exercise, this review shows that a combination of active (exercise) and passive (manual therapy) or a combination of two passive interventions may be among the most effective treatment options. Examples of passive interventions a patient may receive in a chiropractic office include spinal manipulative therapy, mobilization, soft tissue techniques, traction, acupuncture, etc.

From time to time, professional organizations or governing bodies will empanel a group of experts to look at the latest research to determine if treatment guidelines should be updated. If more systematic reviews like the one highlighted in this article are published that favor a multimodal approach favoring passive therapies, then guidelines may be updated to reflect that. Until then, your doctor of chiropractic will continue to use the best available evidence, as well as their clinical experience, to manage your chronic non-specific neck pain so that you can return to your normal activities as soon as possible.

 

Difficultly in Carpal Tunnel Syndrome Management

Carpal tunnel syndrome (CTS) can be a complex condition that can be a challenge to manage for several reasons.

• There can be multiple contributing causes. Seldom is CTS the result of one traumatic event, like a broken wrist that produces instant symptoms that requires emergency surgical treatment. Rather, the condition tends to develop over time as the result of an accumulation of microtraumas that affect the tissues in the carpal tunnel and place pressure on the median nerve and hamper its mobility. To complicate matters even more, conditions like hypothyroidism, pregnancy, obesity, and the use of birth control pills can also affect the function of the median nerve, either directly or indirectly through swelling/inflammation.
• Median nerve entrapment elsewhere. The median nerve originates in the cervical spine and travels from the neck to the shoulder and down the arm. Compression anywhere along the path of the nerve can stimulate CTS-like symptoms. Additionally, entrapment of the median nerve elsewhere on its course can often co-occur with entrapment at the wrist.
• It might not be carpal tunnel syndrome. While we commonly associate symptoms in the hand and fingers with CTS, there are two additional nerves—the radial and ulnar—that innervate other parts of the hand and fingers. Radial and ulnar nerve entrapment can also co-occur with CTS.
• Work can be the cause. Occupational exposure to vibration, repetitive movements, infrequent breaks, and awkward wrist postures can each increase the risk for CTS. It may not be possible for the patient to change how they perform their work, which can make recovery difficult.
• Some factors can’t be controlled. Women are three times more likely to develop CTS than men, which is believed to be due to females having a narrower carpal tunnel and possibly hormonal differences compared with males. The risk for CTS also increases with age.
• Patients often wait too long. Because CTS symptoms come on gradually, it’s easy to ignore them, and a patient may not seek care until their symptoms become so bothersome or severe that they simply can’t maintain their usual activities. Unfortunately, the longer a patient waits, the longer it may take to achieve a satisfactory resolution. In some cases, a full resolution may not be possible or surgery may be the only viable option.

The good news is that chiropractic care can be an effective intervention for managing CTS, especially if you seek care sooner rather than later. If necessary, your doctor of chiropractic will co-manage the case with an allied healthcare provider to give you the best possible chance at recovery.

Chiropractic Therapy for Hip Pain and Function

Each year, surgeons perform hundreds of thousands of total hip arthroplasties (hip replacements), and the most common reason is osteoarthritis of the hip. This condition isn’t caused by an underlying disease, rather it’s due to wear and tear of the hip joint from everyday activities over time. Not only can osteoarthritis of the hip be painful, but it can reduce the range of motion of the joint, making it difficult to move around. Most patients seek to avoid or delay surgery as much as possible, which drives many to seek chiropractic care. The question is: what can a doctor of chiropractic do to manage osteoarthritis of the hip?

Doctors of chiropractic receive training in the application of several manual therapies of varying force, depending on the condition, patient preferences, and the practitioner’s clinical expertise. In one study that included 60 hip osteoarthritis patients, researchers used a technique called long-axis distraction mobilization (LADM) at varying levels of force and found that high-force LADM yielded superior results with respect to range of motion of the hip joint, although low- and medium-force treatment led to similar improvements in pain.

A follow-up study by the same researchers with another group of 60 hip osteoarthritis patients found that low-force LADM performed better with respect to reducing pain sensitivity in the hip as well as the low back and knees. On the other hand, high-force LADM brought greater improvements in overall function. A systematic review from 2022 that included ten studies found that the combination of LADM with thrust manipulation and mobilization with movement (two-to-three treatments a week for two-to-six weeks) can provide even larger improvements with respect to pain and range of motion.

When managing a patient with musculoskeletal pain, chiropractors will often use a combination of several approaches—a multimodal approach—to achieve the best possible outcomes with respect to pain and function. This includes manual therapies, specific exercises, physiotherapy modalities, nutritional recommendations, and more. In addition to treatments directed at the hip itself like those listed above, doctors of chiropractic will also assess the motion of the joints in the lower back, knees, and ankle as abnormal mechanics in these areas can put added stress on the hip and affect recovery.

A Different Perspective on Chronic Whiplash

It’s estimated that up to 50% of whiplash associated disorders (WAD) patients will continue to experience long-term symptoms that interfere with their ability to carry out activities of daily living. According to experts, the economic burden associated with chronic WAD may exceed $42 billion each year. As such, many studies have sought to better understand whiplash, both from the mechanisms of injury to why some patients recover and some don’t.

With respect to chronic WAD resulting from a motor vehicle collision (the most common cause of whiplash), factors associated with the crash itself like speed, impact direction, awareness of collision, and airbag deployment do not appear to be significantly linked to an elevated risk for chronicity. On the other hand, researchers have found that higher self-rated pain and disability, fear of movement, catastrophizing, passing coping, and low expectations of recovery are indicative of failure to fully recover.

In a 2017 study, researchers reframed the trauma of a motor vehicle collision as an event that is both potentially injurious and distressing. When an acute injury occurs (in this case whiplash), there is often damage to various anatomical structures in the head, neck, and/or upper-mid back. Additionally, there is also a stress response associated with the overall incident (including subsequent events like a trip to the hospital and dealing with the insurance company and legal system) that can interfere with the healing process. When the combination of psychological vulnerabilities and neurobiological processes exceeds a person’s given threshold, their risk for chronic WAD rises.

This finding highlights the importance of treating the whole patient when it comes to WAD as it can affect both the body and mind. In addition to therapies delivered in the office to help the soft tissues in and around the neck to heal, doctors of chiropractic and other healthcare providers need to educate the patient and assure them that they will recover and encourage them to carry on their normal activities within pain tolerance. If necessary, the patient may need a referral to a mental healthcare professional to address psychological factors that can impede recovery.

The Importance of Physical Activity

Physical activity, from housework and gardening to a structured exercise routine, is widely recognized as the most important behavior for both promoting longevity and lowering the risk for cardiovascular diseases, type 2 diabetes, several forms of cancer, and other chronic diseases. In fact, the World Health Organization lists low cardio-respiratory fitness as the number one risk factor for early death, even more than obesity and smoking! So, how much physical activity is needed to give us the best possible chance for a long and healthy life?

The short answer is, the more the better. In a review published in 2001, researchers from the Harvard Medical School of Public Health looked at the available literature related to the volume, intensity, duration, and frequency of physical activity and its relation to all-cause mortality rates in people of all ages. They concluded, “There is clear evidence of an inverse linear dose-response relation between volume of physical activity and all-cause mortality rates in men and women, and in younger and older persons.”

Of course, a mountain of research has been published since 2001, and fitness guidelines have been continuously updated and refined. The current World Health Organization guidelines included the following recommendations:

• Children and teens (ages 5-17): 60 minutes of moderate-to-vigorous physical activity each day, with bone and muscle strengthening exercise at least three times a week.
• Adults (ages 18-64): 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity physical a week, with muscle strengthening exercises at least twice a week.
• Seniors (age 65+): 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity physical a week, with muscle strengthening and balance focused exercises at least three times a week.

The most recent World Health Organization guidelines also emphasize the importance of reducing sedentary time at all age levels, noting that physical inactivity is also a risk factor for poor health.

A 2022 survey of nearly 8,000 doctors of chiropractic from around the world revealed the majority routinely provide patient education in the form of exercise training/counseling and ask patients about their level of physical activity in a typical office visit. Of course, this isn’t a surprise as there is abundant research supporting improved fitness for lowering the risk for acute musculoskeletal pain and recurrence.

 

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.