Monthly Pain Update – March 2024
Herniated Disk Resorption
The intervertebral disk is made up of a tough outer annulus fibrosis while the central portion (called the nucleus pulposus) is soft, more liquid-like, giving it a shock-absorbing function. If the integrity of the annulus is compromised, the nucleus pulposus can leak through the torn fibers, which is known as disk herniation. If the direction of herniation is not near a nerve or pain-sensitive tissue, there may be few, if any, symptoms. However, if the herniated tissue presses on a nerve root as it exits the spine, an individual may feel sensory (numbness, tingling) and/or motor (muscle weakness and atrophy) symptoms in the button and down into the leg.
If a red flag is present such as cancer, fracture, infection, or a sudden inability to control bowel or bladder function (a symptom of cauda equina syndrome), the patient may require immediate emergency and/or surgical intervention. However, outside of these circumstances, current guidelines published by the North American Spine Society on the clinical assessment and management of lumbar disk herniation and lumbar radiculopathy recommend non-operative treatment as a first-line therapy approach, which includes chiropractic care.
One of the mechanisms by which non-surgical care can result in a successful, satisfying outcome is by enabling the body’s ability to resorb the herniated disc material. The authors of a 2023 study noted that resorption may occur in a significant degree in roughly 70% of disk herniation cases due to the combination of factors such as inflammation and neovascularization (the formation of a new network of blood vessels), dehydration, and mechanical traction. The paper also noted that resorption may be more likely in cases where the herniation is larger or sequestered (the material has lost all connection with the original disk material), if inflammation is present, and if the herniation is in proximity of the posterior longitudinal ligament, which has its own blood supply and can influence healing. Of note, the authors speculate that because inflammatory processes may be highly important for disk resorption, the common practice of prescribing anti-inflammatory drugs in cases of acute disk herniation may need to be reconsidered as it could impair the healing process.
To facilitate healing, doctors of chiropractic will employ a multimodal approach using manual therapies (including spinal manipulation, specific exercises, physiotherapy modalities, traction, activity modifications, and even diet/supplement recommendations). If the patient’s symptoms fail to resolve, their chiropractor may refer them to their medical physician or a specialist for more invasive treatments with surgery as a last resort.
Carpal Tunnel Syndrome and the Patient-Doctor Team
Carpal tunnel syndrome (CTS) is a condition that occurs when the median nerve is compressed or restricted as it passes through the wrist, resulting in sensory and motor symptoms, which include numbness, pain, paresthesia and sometimes weakness that can radiate from the wrist into the thumb and index, middle, and half of the ring finger. Additionally, symptoms can travel proximally into the forearm and for some, into the shoulder and neck. Unfortunately, carpal tunnel symptoms tend to come on gradually and increase in intensity slowly over time, which leads many individuals to only seek care after the condition has progressed to the point in which it has a serious impact on their ability to work and carry out other activities of daily living.
When a patient does present for care, the first order of business in evaluating the case history and conducting an examination is to determine if the symptoms are the result of median nerve compression (there are two additional nerves that travel into the hand and result in similar, yet different symptoms) and to identify if it is limited to the wrist or is there restriction elsewhere on the course of the never from the neck to the hand. The doctor of chiropractic will also attempt to establish the cause of these points of compression, which helps guide the course of treatment. If the patient frequently engages in activities that require fast and repetitive hand movements or the use of awkward wrist postures or vibratory forces, then they may be advised to take regular breaks, change their tools, or make ergonomic modifications. In some instances, health conditions that cause inflammation or water retention may play a role, and the patient may receive lifestyle advice or treatment with an allied healthcare provider to properly manage the condition.
To help restore normal motion to the affected joints and to take pressure off the median nerve, a doctor of chiropractic will perform manual therapies in the office, which may include manipulation, mobilization, soft tissue work, etc. They may also utilize modalities like cold laser, ultrasound, and e-stim, depending on the patient’s unique case, as well as the chiropractor’s training and clinical experience,
Between visits, the patient may be advised to wear a nocturnal wrist splint to keep the wrist from resting at the extreme ends of its range of motion during sleep, which can increase pressure in the carpal tunnel and exacerbate symptoms. The patient may also receive instruction on at-home neurodynamic exercises to help stretch the tissues in the wrist and reduce friction so that the median nerve can travel through the carpal tunnel more easily. Patients may also be encouraged to switch to an anti-inflammatory diet, consume supplements that reduce inflammation, reduce sedentary time, and increase the time spent exercising, even if it means taking a daily walk in the evening.
With the combination of in-office treatment and self-help care, many cases of mild-to-moderate carpal tunnel syndrome can be successfully managed without the need to consider more invasive treatment options like injections or surgery. Of course, the earlier in the disease process that treatment is started, the better the patient’s chances for not only a satisfactory outcome but also a shorter course of care.
The Scapula’s Role in Shoulder Function
When a patient seeks care for shoulder pain, they usually point to the ball and socket glenohumeral joint as the source of their problem. However, a contributing cause of the patient’s shoulder pain and disability may actually be the scapula or shoulder blade and if scapular dyskinesis is present and untreated, the patient may not experience a satisfactory outcome.
As with other joints in the body, the greater the range of motion, the less stable the joint and the more susceptible it is to injury. The glenohumeral joint allows the upper extremity to move in several directions. The scapula acts to stabilize the shoulder to prevent it from moving too far into the extreme ends of its range of motion, which could compromise the integrity of the joint and lead to injury. However, if the scapula rests in an abnormal position or if its movement is restricted, it cannot fulfill this function and the chance for a shoulder disorder increases. Conditions that can occur in the presence of scapular dyskinesis include rotator cuff tears, glenohumeral joint instability, impingement syndrome, and labral tears.
During an examination, a doctor of chiropractic will evaluate scapular position at rest (arms hanging at the sides) as well as during shoulder forward flexion, abduction (motion away from the body), and rotational movements on both the right and left side of the body. The chiropractor will also view the scapula from the side to look for excessive scapular lifting from the thorax during movement.
If scapular dyskinesis is confirmed, the goal of treatment will be to restore the scapular position and dynamics, which includes scapular retractions, posterior tilt, and external rotation. This can be accomplished via a combination of manual therapies performed in the office and at-home exercises focused on stretching and stabilization that may involve active or passive movements, as well as resistance bands, hand weights, or just body weight. The specific exercises depend on the examination findings, so each patient’s exercise recommendations may differ.
Another interesting finding regarding scapular dyskinesis is that it doesn’t just affect the shoulder. In recent years, several studies have established a link between abnormal resting of the scapular and neck pain, especially in office workers with neck pain. One study published in 2023 found that 90 of 99 office workers with neck and mid-back pain had scapular dyskinesis. Another 2023 study found that patients with both neck pain and scapular dyskinesis experienced improvements in neck pain and cervical range of motion after the application of treatment to correct scapula positioning. If you have shoulder pain (or even neck pain) and your doctor of chiropractic starts evaluating your shoulder blade, now you know why this is the case.
Why Is Neck Pain So Common?
Neck pain is one of the most frequent reasons patients seek chiropractic care, second to low back pain. One study noted that neck pain was the primary cause for work absence among 25.5 million American adults in 2012. When considering lost productivity, disability, and healthcare spending, neck pain takes a heavy financial toll on society. Why is it so common?
The answer rests with the relationship between flexibility and stability. The more stable a joint, the less flexible it will be. Likewise, the more flexible a joint, the less stable. If you notice, the neck is very flexible. We can look up, look down, tilt, and rotate from side to side. Unfortunately, this comes at the cost of stability. There are a lot of joints and soft tissues in the neck that attach to the chest, upper back, and head to allow these various movements to occur.
In the case of a traumatic event, the soft tissues in the neck can become injured, leading to acute neck pain and disability. More often, the neck pain process can develop slowly over time, especially among people with forward head posture from excessive device use. When the head rests forward of the central plane, the effort required for the muscles on the rear of the neck and upper back to keep the head upright increases dramatically, heightening the risk that a seemingly harmless event like sleeping in an awkward posture can trigger neck pain and stiffness.
While it seems logical that immobilizing the neck during a neck pain episode is a smart idea, researchers have found the practice can actually worsen the patient’s condition. When the neck is restricted either physically with a brace or through inactivity out of fear of causing further injury, the muscles can become deconditioned, allowing fat to infiltrate the muscles. This can prolong neck pain and lead to chronic neck pain that severely affects quality of life.
In addition to manual therapies to help restore normal movement to the joints and to break up adhesions and address trigger points in the muscles, doctors of chiropractic frequently provide patients with neck-specific at-home exercises to strengthen the cervical muscles as well as to encourage them to carry out their normal activities within pain tolerance. With this three-pronged, multimodal approach, patients often experience a significant reduction in neck pain and disability within a short time, especially if they sought treatment soon after their neck pain started.
Risk Factors for Chronic Whiplash
Whiplash describes a mechanism of injury that occurs following the sudden acceleration and deceleration of the head and neck that stretches its various soft tissues beyond their physiological limits leading to sprains, strains, tears, etc. The resulting cluster of symptoms is collectively known as whiplash associated disorders (WAD). Past research suggests that up to half of WAD patients will continue to experience chronic symptoms for up to a year or more following the initial injury event, which can place a heavy burden on the individual and their family. In recent years, much research has been conducted on uncovering why some patients experience a resolution of their symptoms and why some progress to chronic WAD.
A 2015 study monitored 599 patients who sought treatment for WAD symptoms three weeks post-injury. After one year, 30% of this group had transitioned to chronic WAD. Researchers were then able to look back at initial intake data to identify any factors that may be more common among those with chronic WAD versus those who recovered. They noted five such risk factors: high baseline disability (physical or functional impairments that interfere with the ability to carry out activities of daily living); longer predicted recovery time (an assessment of the severity of the patient’s injury taking into account the patient’s overall health and how it can affect recovery); psychological distress (symptoms such as depression and anxiety); passive coping (relying on wishful thinking or avoidance instead of actively participating in managing the condition) and a greater number of initial symptoms. The authors concluded that the presence of one risk factor resulted in 3.5 times greater risk for chronic WAD and the presence of four or more risk factors raised the risk 16 times.
A systematic review of fourteen studies conducted in 2016 found that patients with chronic WAD exhibited greater cross-sectional area in the neck muscles, which was explained by greater fat infiltration into the muscle tissue. Fat infiltration can occur when muscles become deconditioned following poor health and inactivity, leading to weaker muscles, altered biomechanics, increased pain sensitivity, reduced range of motion, and other factors that lead to ongoing neck pain and disability. If you look at the risk factors for chronic WAD, you can see how they can contribute to the neck muscles becoming less active due to the body’s reaction to injury and/or the patient’s resulting activities (or lack thereof).
In addition to in-office treatment like manual therapies and modalities to help restore normal motion to the injured joints and soft tissues, doctors of chiropractic assure patients that they can recovery and recommend WAD patients to stay as active as possible (within pain tolerances), get regular exercise, perform exercises that specifically target the neck muscles, eat an anti-inflammatory diet, and get sufficient quality sleep to aid in recovery. As with other musculoskeletal disorders, the odds for a satisfactory WAD outcome are best early in the course of the disease so seek care sooner rather than later.
Dietary Nitrate and Exercise Enhancement
Athletes from the amateur to professional levels have long sought methods to improve their performance, with some even resorting to risky and unsafe strategies that can lead to poor long-term outcomes. However, there are many natural methods to enhance exercise performance that are nutrition-based and safe. One such compound that has gained attention is dietary nitrate, which is also known as inorganic nitrate in a supplement form.
Dietary nitrate is a compound most abundant in beets and in leafy green vegetables, like spinach, arugula, and lettuce. Following ingestion, nitrate is converted in the body to nitrite and stored and circulated in the blood. During conditions of low oxygen availability, it’s converted into nitric oxide, which plays a number of important roles in vascular and metabolic health. In particular, it can relax blood vessels and increase the efficiency of transporting oxygen to muscle tissue, which can enhance exercise tolerance and performance.
In 2023, researchers conducted a systematic review with meta-analysis on the effects of dietary nitrate during single and repeated bouts of short-duration, high-intensity exercise. Compared with a placebo, the investigators observed that dietary nitrate supplementation provides positive effects on performance outcomes. The authors concluded that athletes competing in sports requiring single or repeated bouts of high-intensity exercise may benefit from nitrate supplementation.
Interestingly, the research team cited a survey of more than 1,400 active adults about inorganic nitrate, and the vast majority were either unfamiliar with it or didn’t think they needed it. This prompted the authors to comment that in spite of evidence supporting its benefits, inorganic nitrate is under-utilized and improved education to coaches, nutritionists, and others is needed.
Past research has found that consuming 5-9 mmol of nitrate per day for 1-15 days can enhance performance. While inorganic nitrate can be taken as a supplement, researchers point out that this dose can be readily consumed within a healthy eating pattern and there is no evidence of additional nitrate will provide more benefit.
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.
