Monthly Pain Update – May 2024

Chiropractic Manipulation After Lumbar Diskectomy

Lumbar diskectomy is a surgical procedure for removing herniated intervertebral disk material when non-surgical options fail to satisfactorily alleviate radiating leg pain, numbness, or weakness. However, there’s no guarantee such a procedure will provide relief. Up to 12% of patients require reoperation within three months to address post-surgical complications and up to 20% may experience continued or recurrent radiculopathy symptoms a year later. The term failed back surgery syndrome is often applied to those having more than one operation and unfortunately, studies show spinal reoperations generally have a lower success rate than the initial procedure. Furthermore, there is no consensus or agreement on the most appropriate care strategy for this patient population.

A 2023 study that retrospectively examined a decade of medical records concerning 110 million Americans found that 10.8% of those who had received chiropractic treatment for a spinal condition had a previous history of spine surgery. Treatment guidelines for low back conditions generally recommend non-surgical treatment as a front-line approach, of which chiropractic care has proven to be an excellent choice. While case studies have reported improvements in pain and disability associated with chiropractic care for the post-back surgery population, there hasn’t been much research on whether such treatment can reduce the risk for reoperation.

To find out, a group of researchers reviewed two decades of data concerning more than 114 million patients attending 80 academic medical centers, affiliated hospitals, and outpatient offices. From this data set, they extracted 756 patients who had undergone lumbar diskectomy and experienced ongoing radiculopathy symptoms, half of whom had been treated with spinal manipulative therapy, the primary treatment provided by doctors of chiropractic. The research team found that those who received spinal manipulative therapy (the median being six treatments) were nearly half as likely to undergo an additional procedure in the following year (7% vs 13%).

While additional studies are needed before treatment guidelines for the post-surgical radiculopathy patient can be established and implemented, the data suggest that the population of patients who don’t respond to lumbar diskectomy could benefit from a short-term course of chiropractic care.

Tools for Managing Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a condition that occurs following compression or restriction of the median nerve as it passes through the wrist and into the hand. Thus, the focus of treatment is to alleviate pressure on the median nerve, allowing it to transfer motor and sensory information to and from the hand. Clinical guidelines recommend exhausting conservative treatment options before considering surgery, of which chiropractic is an excellent choice. Let’s discuss the various tools at a chiropractor’s disposal for managing carpal tunnel syndrome.

• Manual Therapy: This includes manipulation, mobilization, massage therapy, and soft-tissue release techniques, including instrument-assisted approaches. Typically, these therapies are applied in proximity to the wrist, though they may be used elsewhere along the course of the median nerve if there is also compression/restriction in the neck, shoulder, elbow, or forearm.
• Wrist Splint: Because pressure in the wrist is greatest at the extreme ends of its range of motion, a wrist splint that helps maintain neutral posture can be especially effective during certain daytime activities, as well as during sleep.
• Exercise: Doctors of chiropractic may provide instruction for several exercises patients can perform throughout the day to facilitate the mobility of the median nerve, as well as relax the soft tissues in the hand and forearm.
• Modalities: Chiropractors often employ physical therapeutic modalities when treating patients with CTS such as cold laser, ultrasound, interferential electrical stimulation, and radial extracorporeal shockwave therapy.
• Nutrition: Because inflammation can contribute to CTS, patients may receive dietary and supplement recommendations that provide anti-inflammatory benefits such as the Mediterranean diet, vitamin D, omega-3 fatty acids, alpha-lipoic acid, curcumin, and more.
• Ergonomic/Activity Modifications: For work or hobby activities that require repetitive movements, especially with vibration exposure or non-neutral wrist postures, patients may be instructed to take more frequent breaks, re-orient their workstation, temporarily change job functions, or use tools that require a more neutral or less forceful grip.
• Co-Management: Because infections, several types of arthritis, diabetes, thyroid disorders, and hormonal therapies and/or fluctuations can contribute to carpal tunnel syndrome, co-management with the patient’s medical physician or a specialist may be necessary.

While each of these tools can benefit the CTS patient, studies have shown a multimodal approach that utilizes two or more therapies often provides the best result.

 

Runner’s Knee

Running is a popular recreational activity, and it’s an effective form of aerobic exercise for both young and old. It’s estimated that 50-60 million Americans regularly run or jog on tracks, city streets, or trails. However, running also carries a risk for injury. It’s estimated that at least half of recreational runners will sustain an injury each year, and a common cause of running-related pain is runner’s knee.

Runner’s knee is an umbrella term used to characterize a variety of symptoms such as pain in and around the kneecap usually during activity or after prolonged sitting with the knees bent; a sensation of weakness or an unstable knee joint; rubbing, grinding, or clicking sounds in the area of the kneecap while bending or straightening the knee; and tenderness to the touch. Primarily, runner’s knee is due to patellofemoral pain syndrome. However, other conditions that affect the knee also fall under the runner’s knee umbrella such as chondromalacia patella and iliotibial band friction syndrome.

When a patient visits a chiropractic office for runner’s knee, they’ll complete a detailed health history as well as questionnaires about the location and intensity of their current pain and any treatments they’ve already tried. Their doctor of chiropractic will then conduct a physical examination that will include palpation around the kneecap, joint line, and back of the knee, an assessment of the muscles in the front and back of the thigh and lower leg, and a gait analysis looking for excessive pronation or other abnormal biomechanics including the hip, pelvis, and spine. Diagnostic imaging may be appropriate in specific cases.

Potentially, there may be multiple contributing causes for the patient’s symptoms such as overuse, misalignment of the knee joint, muscle imbalances, and issues of the foot/ankle that will all need to be addressed for the patient to achieve a satisfactory result. Treatment will typically involve a multimodal approach that may include manual therapies to restore normal movement to affected joints, rest or activity modifications, anti-inflammatory measures (such as dietary changes and ice), exercises to address weak muscles, stretches for tight muscles, footwear changes, and foot orthotics or arch supports if excessive rolling of the ankle is present. To avoid re-injury, the patient may be instructed to gradually return to their normal running activities over time, though the exact timeline may vary from patient to patient.

X-Rays for Neck Pain?

For musculoskeletal conditions like neck pain, many people think that X-rays are an essential part of the diagnostic process. However, this isn’t always the case. X-rays may not always provide useful information as to the cause of the patient’s condition, which can result in added costs and potentially inappropriate care, not to mention unnecessary radiation exposure. To help guide healthcare providers, including chiropractors, various associations and organizations have crafted guidelines on when to and when not to use X-rays.

Generally, when neck pain arises gradually or without trauma (a fall or car accident, for example), a trial period of treatment for two-to-four weeks without X-ray is usually appropriate, especially in those under 70 years of age. If the patient fails to respond to care or symptoms worsen, then X-rays may be advisable to further investigate the condition. Additionally, guidelines typically dissuade X-rays for populations may be more sensitive to radiation exposure, such as women who may be pregnant.

All clinical guidelines recommend imaging when there is suspicion of red flags like cancer, fracture, infection, and serious neurological impairments. Indications on a patient’s history or examination findings for red flags include the following: trauma; preceding neck surgery; osteoporosis risk; myelopathy (neurological symptoms); history of cancer; unexplained weight loss (a symptom of cancer); fever; history of infections (TB or HIV, for example); history of inflammatory arthritis; constant, progressive, non-mechanical pain; insidious progression of pain; signs of spinal cord compression (clumsy hands, altered gait, or disturbances of sexual, bladder or sphincter function; clinical signs of brain or spinal cord injury);             Lhermitte’s sign (flexing the chin to chest or neck, produces an electric shock sensation down the spine and into the limbs); dizziness, drop attacks, or blackouts (indicative of vascular insufficiency, more common in the elderly); vertebral body tenderness (localized “exquisite” tenderness); lymphadenopathy/cervical rib; and pulsatile mass (carotid artery aneurysm).

In Chiropractic, the trend in the last 20 years has been that fewer patients require initial X-ray than what was once taught in many chiropractic colleges/universities. As new research evidence arises, guidelines will be updated to reflect the best evidence. In the end, the goal is to help achieve the most useful diagnoses for the patient’s present condition so that appropriate care can be provided to help them resume their normal activities in the safest and most cost-effective manner.

Whiplash Associated Disorders and Headaches

Whiplash associated disorders (WAD) is a term used to describe the constellation of symptoms that occur following the sudden acceleration-deceleration of the head and neck, most commonly during an automobile collision. Headaches are the second most common WAD symptom that drive patients to seek chiropractic care, with neck pain being first.

The International Headache Society defines headaches attributed to whiplash as those that appear within seven days post-crash or pre-existing headaches that worsen in the same time frame. Current research suggests that 60% of WAD patients experience headache within seven days of a whiplash event, with the number dropping to 23% by three months. However, the percentage jumps back up to 30% and 38% by the six- and twelve-month time points, respectively.

To better understand which WAD patients may be most likely to experience ongoing headaches, researchers have conducted several studies comparing the initial presentation of patients who did with those who did not develop chronic WAD headaches. These studies identified the following post-injury risk factors for WAD headaches: higher neck pain and disability; fear of movement (kinesiophobia), catastrophizing (an exaggerated mental outlook toward their pain); and anxiety.

When a patient first presents for chiropractic treatment for WAD, they will complete a detailed history of the accident including the mechanism of injury (the direction of the impact, the speed of both vehicles, awareness of the impending crash); immediate vs. delayed symptom onset; changes since the crash; prior professional and personal self-care treatment(s) and the associated responses; a past history of neck pain/headache; and a review of systems (general health status). They may also complete questionnaires regarding pain, disability, and psychosocial factors (anxiety, depression, locus of control), as well as a pain diagram to help relate where they feel pain in their body. These assessments may be repeated at various points during the course of care to track progress.

Treatment will typically involve a multimodal approach aimed at restoring normal movement to the cervical spine, which can help to reduce pain and disability, as well as address stiffness and improve range of motion. Such an approach will likely involve manual therapies like spinal manipulation and mobilization, soft tissue work, physiotherapy modalities, mechanical traction, stabilization exercises, and more. The patient will also be given advice to maintain their normal activities within pain tolerance as well as education regarding their injury and recovery prospects—all in the effort to reduce kinesiophobia and catastrophizing. If necessary, the patient’s chiropractor may co-manage the case with an allied healthcare provider who can provide services beyond the chiropractic scope of care, which may include mental health services.

Vitamins and Blood Pressure

Hypertension is a leading cause of cardiovascular disease and premature death worldwide. Lifestyle management is essential for reducing blood pressure, and strategies like eating a healthy diet (like Mediterranean); not smoking; curbing sodium, caffeine, and alcohol intake; exercising; managing stress; and losing weight have significant evidence support for such management. In conjunction with lifestyle management, researchers have also identified several vitamins and supplements that may benefit individuals with high blood pressure:

• Magnesium (Mg) helps by increasing the production of nitric oxide (which helps relax blood vessels). A literature review that included eleven randomized controlled trials found that 365-450 mg per day of Mg supplementation significantly lowers blood pressure in individuals with insulin resistance, prediabetes, or other non-communicable chronic diseases. In a large-scale study that included more than 200,000 people, researchers observed that for every 100-mg daily increase in dietary Mg, there is a 5% reduction in hypertension risk.
• Vitamin D supplementation can benefit hypertensive individuals as studies have identified an association between low vitamin D status and an elevated risk for high blood pressure. Current research suggests that maintaining healthy vitamin D levels may also be protective against hypertension.
• B vitamins such as riboflavin (vitamin B2) and folate (vitamin B9) may reduce blood pressure. Some studies suggest higher folate intake early in life may protect against hypertension later in life.
• Potassium (K) promotes urinary excretion of sodium and helps blood vessels relax. This mineral may also be the most published supplement for regulating blood pressure and reducing high blood pressure levels.
• Coenzyme Q10 (CoQ10) is a vitamin-like molecule that has been demonstrated to reduce systolic blood pressure (the first number in a reading).
• L-arginine is an amino acid (a protein building block) that has been observed to significantly improve blood vessel function and blood flow, as noted in an article that pooled findings from seven studies. This amino acid may also reduce diastolic blood pressure (the second number in a reading) in pregnant women with hypertension.
• Vitamin C is a water-soluble nutrient. A systematic review of eight studies found that an intake of 300-1000mg/day may reduce blood pressure. Researchers have also observed that people with low blood levels of vitamin C have a higher risk of hypertension than those with optimal blood levels.

Studies have also found other foods, vitamins, minerals, herbs, and supplements like beetroot, garlic, fish oil, probiotics, melatonin, green tea, ginger, basil, cinnamon, cardamom, flax seed, garlic, ginger, hawthorn, celery seed, French lavender, and Cat’s claw may have a role in blood pressure management. However, before supplementing your diet with any of these items with reducing blood pressure as a goal, consult with your healthcare provider as they may be able to inform you about which may provide the best benefit to your unique case, as well as which to avoid if there is potential for interactions with any medications you’re currently taking.

 

 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.