Monthly Pain Update – November 2024

Yoga for Low Back Pain Management

Low back pain is the most common form of musculoskeletal pain reported around the world and the number one reason patients seek out chiropractic care. Because weak or deconditioned core muscles and reduced flexibility are common in chronic low back pain sufferers, patients are often advised to perform back-specific exercises at home and increase their overall physical activity levels. Not only can these actions supplement in-office care to help the patient experience improvements in pain and disability sooner, but staying in shape can reduce the risk for a future episode of low back pain. There are a number of exercise options available to chronic low back pain patient, including yoga.

While yoga dates back thousands of years, it didn’t begin to grow in popularity in the United States until the 1960s and 1970s. Yoga combines physical postures, breath control, and meditation that strengthens muscles, increases flexibility, and improves balance. Additional benefits attributed to yoga include reduced blood pressure, improved blood sugar control, easier breathing for both asthmatics and COPD patients, better brain function, enhanced body image, improved mood, greater resilience to stress, and social connection when performed in a group setting.

In 2020, a systematic review that included five studies concluded that yoga is as effective or potentially more effective than other exercise interventions in the management of chronic low back pain. This finding is echoed by a 2023 review that looked at data from 75 randomized controlled trials, listing yoga as a viable exercise option for improving low back pain-related pain and disability. With respect to back-specific exercises, a 2023 study found yoga is as effective as stabilization exercises for improving pain, function, metabolic capacity, and sleep quality in patients with chronic low back pain. The authors add that patients may enjoy yoga more, which increases the chances they perform their exercises and continue to do so after the conclusion of care.

While yoga is considered a safe exercise option for children, pregnant women, cardiovascular disease patients, and even frail seniors, experts note there is always a potential risk for injury. To minimize your risk, it’s recommended to talk to your doctor before starting yoga; start slowly with just the basics; choose an appropriate class for your abilities; refrain from forcing yourself into uncomfortable poses; drink plenty of water; wear clothing that allows flexibility; and stop and rest when needed.

Presently, there are roughly 50,000 yoga studios in the United States with potentially thousands of instructors conducting classes in public and private facilities elsewhere. Chances are good there are several yoga options available in your town or within a short walk or drive. If you’re not sure where to start, ask your doctor of chiropractic. If he or she doesn’t practice yoga, they certainly know many people who do and can steer you in the right direction. 

Rheumatoid Arthritis and Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a condition that occurs when the mobility of the median nerve is restricted as it passes through the wrist, resulting in symptoms including pain, numbness, tingling, and/or weakness in the thumb, index finger, middle finger, and thumb-side of the ring finger. While most often associated with repetitive hand movements—especially in conjunction with heavy forces, vibrations, and non-neutral wrist postures—any health condition that reduces the available space within the carpal tunnel enough to affect the median nerve can contribute to CTS. One such condition that can play a role in the development of CTS is rheumatoid arthritis.

Rheumatoid arthritis is an autoimmune disorder in which the body’s own immune system mistakenly attacks the membranes that line the joints, leading to inflammation. The precise cause of this form of arthritis is unknown, but the current understanding is that some people carry genes associated with a higher risk that may be triggered by unhealthy lifestyle habits (smoking and obesity, for example), environmental pollutants, hormonal changes, and even infections. Due to several factors, including their small size, the joints in the hands are among the first affected by rheumatoid arthritis. In fact, a 2016 systematic review and meta-analysis on the effect of inflammatory arthritis on carpal tunnel syndrome revealed that rheumatoid arthritis nearly doubles an individual's risk for developing CTS.

The treatment approach for CTS in a patient with rheumatoid arthritis will be multimodal in nature, starting with manual therapies, like mobilization, to help restore normal motion to the affected joints. This may also include activity modifications and the use of a nocturnal splint to avoid exposures that can exacerbate symptoms during the early phase of recovery. A doctor of chiropractic may also employ physiotherapy modalities, instruct the patient on how to perform at-home exercises to reduce pressure on the median nerve, and make nutrition recommendations to help reduce inflammation. If necessary, he or she will work in coordination with the patient’s medical physician or rheumatologist to help achieve a satisfactory outcome.

In the long-term, the patient will be encouraged to adopt a healthier lifestyle not only to reduce the risk for recurrence of their CTS symptoms, but also slow the progress of their rheumatoid arthritis. This may include reducing sedentary time, getting regular exercise, eating a low-inflammatory diet, maintaining a healthy weight, not smoking, spending time in the sun, getting sufficient sleep, and avoiding excessive alcohol intake.

Delaying Knee Replacement

It’s estimated that nearly 800,000 knee replacements are currently performed in the United States each year. Due to the combination of ageing and poor lifestyle choices, researchers expect the number of annual total or partial knee arthroplasty procedures to triple by 2040.  While many patients report significant improvements in pain and function following a knee replacement, such a procedure does carry some risks that can lead patients to exhaust non-surgical options before considering surgery. These risks can include infection, blood clots, anesthesia complications, prolonged recovery (including persistent pain and swelling, limited regain of mobility, nerve damage, and additional surgeries to repair or replace the artificial joint). What, if anything, can be done to delay or possibly prevent a knee replacement?

First, let’s take a look at what ultimately leads a patient to consider a knee replacement. Luckily, a 2024 study looked at what finally led patients to consider total knee replacement surgery and found the top two reasons are “when the existence of pain impedes the capacity to participate in daily life activities” and “fears and uncertainties regarding the progression of the disease.” Thus, patients who can manage their pain enough to perform their usual activities and feel like they have a handle on the condition are less likely to consider surgery.

There are MANY conditions that can lead up to needing a knee replacement, of which the most common is osteoarthritis. Osteoarthritis is a condition in which the smooth surfaces of the joint (called hyaline cartilage) erode, leading to eventual bone-on-bone contact, which can be painful and disabling. While genetics can play a role, osteoarthritis is typically the result of wear and tear on the joint, either from overuse and/or poor biomechanics.

When a patient seeks chiropractic care to help manage osteoarthritis of the knee, the examination will consider the patient as a whole because issues in other parts of the kinetic chain can lead to increased forces on the knee. For example, if the ankle is overly pronated (rolling inward), it can place added stress on the knee joint. Any issues potentially contributing to the patient’s knee pain will be addressed with a multimodal approach including manual therapies, like manipulation and mobilization; balance and resistance exercise training; prescription foot orthotics; physical therapy modalities such as electrical stim, ultrasound, pulsed electromagnetic field, and laser; as well as diet and weight management strategies to reduce inflammation. Patients may also be encouraged to perform weight bearing exercises as the cartilage in the knee joint requires compressive forces to absorb nutrients and stay healthy.

Managing Cervicogenic Headaches

Cervicogenic is a term derived from the Latin cervix, meaning neck, and the Greek genes, meaning produced by or originating from. In essence, cervicogenic means originating from the neck, and a cervicogenic headache is a headache that originates from the neck. Because this type of headache is a symptom resulting from the irritation of spinal nerves originating from the neck, many sufferers seek out chiropractic care to help manage it.

There are also at least 65 bones, tendons, ligaments, muscles, and other tissues in the neck that can each contribute to cervicogenic headaches. The “classic” cervicogenic headache presentation includes: unilateral pain without side shift; pain beginning in the neck, and then radiating to the occiput (back of head), temporal (side/s of head), frontal (front of head), and orbital (eyes) regions; non-throbbing, non-lancinating pain; variable duration (hours to months); constant or intermittent pain; pain triggered by neck motion or external pressure on the cervico-occipital region of the affected side; normally accompanied by neck range of motion (ROM) restriction and vague pain in the shoulder/upper back area; possibly accompanied by nausea, vomiting, photophobia (light sensitivity), and/or phonophobia (noise sensitivity) but less common than observed in migraine sufferers.

Because each patient may have a unique set of circumstances contributing to their headache and other symptoms, the specifics of treatment will vary from person to person. Conservative care for cervicogenic headaches in a chiropractic setting may include the following: spinal manipulation focusing on the upper cervical (occiput, C1, 2, & 3) regions as well as the whole spine; spinal mobilization in the cervical, cervicothoracic, and thoracic regions; soft tissue techniques including massage, trigger point therapy, vibration, myofascial release, and Graston technique; manual and/or home cervical traction methods; exercise training to stretch muscles, increase spinal range of motion, strengthen the commonly weak deep neck flexor muscles; physical therapy modalities such as electric stim, ultrasound, laser, others; relaxation exercises such as deep breathing; nutritional counseling emphasizing reduction of systemic inflammation; and education to help the patient better understand their condition, as well as encouragement to carry on their daily activities as best as possible and assurance they will experience improvement over time.

Interestingly, several studies have found that dysfunction in the neck may also play a role in other common forms of headache, like migraines. If a headache patient isn’t experiencing improvement from usual care, then it may be a good idea for them to consult with a doctor of chiropractic to find out if any issues in their neck may be a contributing factor in their headaches.

Neck-Specific Exercises for Managing Whiplash

Individuals suffering from chronic whiplash-associated disorders (WAD) may experience ongoing symptoms beyond neck pain such as dizziness, impaired balance, and difficulty with fine motor control of the upper limbs. It’s suspected that muscle activation patterns can change in response to injury to the soft tissues in the neck, which can hinder the function of the vestibular (balance), eye, and arm movement control systems. To give them the best chance at recovery, a patient’s WAD treatment plan may include exercises intended to restore normal strength and function to the muscles in the neck, including the deep muscles that provide cervical stability and control of intersegmental motion. Here are a few exercises to improve strength and function in the neck muscles:

• Chin tucks: While sitting, look straight ahead and tuck in your chin/head (create a “double chin”), hold ten seconds and rest three seconds, and repeat ten times. Do this one time every hour of your awake day during the first week.
• Deep neck flexor isolation: While laying on your back, place about a half inch- to one-inch-thick folded towel under the back of your head (modify the towel thickness to ensure a good neutral head/neck/trunk posture). The aim is to facilitate (contract) the deep neck flexors while minimizing contraction of the superficial/large muscles. Now, imagine looking up (but don’t move your head) to facilitate the dorsal neck muscle activation reflex. Hold three-to-five seconds, repeat five times. Then, look down with just your eyes. Use your fingers over the front of neck to make sure the superficial muscles do not contract. Hold three-to-five seconds, repeat five times.
• Eye Rotation: Imagine rotating to the right but don’t move your head, only your eyes (to the right); hold 3-5 seconds, repeat 5 times. Then, perform the same process, but now focused on the left side.

Once you’re comfortable with these exercises, introduce resistance. Start by gently using your fingers or hand to push against your movement. Over time, you can increase resistance with the use of resistance bands. You can (and should) also increase holding times and the number of reps as your neck muscles grow stronger.

This routine was featured in an August 2024 study that included chronic WAD patients and healthy age-matched controls. The WAD group exhibited neck strength and function deficits that were not observed in the control group. After three months, the WAD patients experienced a return to normal neck muscle function. If you are continuing to experience ongoing symptoms like dizziness, impaired balance, and difficulty with fine motor control of the upper limbs following a motor vehicle collision, slip and fall, or sports collision, consult a doctor of chiropractic to see if hands-on care in the office accompanied by at-home neck exercises like these can help you return to your normal activities.

Healthier Ageing and Independence

Activities of daily living (ADL) are defined as essential tasks a person would need to perform to maintain their own health and wellbeing. This encompasses both fundamental self-care tasks (like getting dressed, feeding oneself, bathing, using the restroom, and sitting, standing, and moving from one location to another) and more complex activities necessary for meeting one’s needs like taking medications on a schedule, cleaning the house, managing finances, preparing meals, shopping, staying connected with friends, and getting around town as needed. As we age, chronic disease and other factors can encroach on our ability to perform ADL, potentially leading to a loss of independence, potentially resulting in a need rely on caregivers or even move into an assisted living facility.

A meta-analysis of data from 83 studies that included more than 108,000 adults identified several physical risk factors for disability in the coming years. These include slower gait speed, weak grip, poor balance, and impaired performance on a sit-stand test. Taken as a whole, seniors who stay in good physical shape appear to be more likely to remain independent as they age. The authors of the meta-analysis add that low muscle mass more than triples the risk for a reduced ability to carry out ADL.

As with working age adults, the United States Department of Health and Human Services recommends seniors engage in 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity physical activity a week and to reduce sedentary time as much as possible. Because maintaining muscle mass and balance are each important for healthy ageing, older adults are also advised to strength train and perform balance exercises at least three times a week. Unfortunately, only 15% of adults older than age 65 in the United States presently meet these guidelines.

For seniors living an inactive lifestyle who would like to become more active to help maintain their independence, it’s best to talk to your doctor first to make a plan to work around any present health conditions that could be exacerbated by a sudden increase in physical activity. Once given the all clear, it may be best to start with lower intensity activities like walking or low-impact activities like swimming, water aerobics, tai-chi, or yoga. This can help the joints and muscles regain some lost function, increasing strength and balance, with a lower risk for injury or overtraining.

If musculoskeletal aches and pains are getting in the way, make an appointment with your doctor of chiropractic. He or she can not only provide in-office care to help reduce pain and improve range of motion, but they can also show you additional exercises or activities that may be a better fit for your unique case. In fact, while pain is the number one driver of young and middle-aged adults into chiropractic offices, older adults often make an appointment to address loss of function in relation to a musculoskeletal disorder!

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.