Monthly Pain Update – October 2022
Taking Steps to Manage Chronic Low Back Pain
Statistically, low back pain is a condition that will affect nearly 90% of people, and it’s both a leading cause of disability and the primary reason patients visit a chiropractor. In addition to manual therapies provided in the office (like spinal manipulation), chronic low back pain patients are generally advised to stay or become more active. This not only aids in the recovery process but can also help reduce the risk of back pain recurrence. Can taking daily walks accomplish this or is a more comprehensive exercise routine required?
The beauty of walking is that it stimulates various senses (visual, olfactory, and aural), activates several muscle groups, increases circulation, opens the airways, and aids in digestion. Best of all, it can be done pretty much anywhere and at very little cost aside from a pair of good shoes.
A 2019 literature review found that for patients with chronic low back pain, walking provided similar benefits as other forms of exercise with respect to pain intensity, disability, quality of life, and fear-avoidance. Interestingly, researchers also observed that adding walking to a more structured exercise program did not lead to greater improvement in any of the previously mentioned categories. However, they noted that additional studies need to be conducted to determine if a specific walking speed or distance or another factor can improve overall outcomes.
These findings correspond to a systematic review conducted three years prior that also reported the effectiveness of walking—particularly on the ground versus a treadmill—compared with other forms of exercise for patients with chronic low back pain. Another systematic review published a year later confirmed that walking can provide both short- and long-term benefits to patients with chronic low back pain for improving both pain and disability.
Bottom line: the data suggests that a daily walk certainly has a place in a multimodal treatment approach for managing chronic back pain. This can also include spinal manipulation, mobilization, and other manual therapies, in addition to physiotherapy modalities, nutritional advice, ergonomics instruction, and more.
The Effectiveness of Manual Therapy for Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is a condition that occurs when the mobility of the median nerve is impeded as it passes through the wrist. Outside of emergency circumstances, clinical guidelines recommend that patients exhaust conservative options before consulting with a surgeon. The most common conservative treatments are splinting of the wrist (especially at night), steroid injection, electrotherapy, and manual therapy, which has gained attention in recent years.
Previously published reviews on the use of manual therapies for CTS also included other conservative therapies, which makes it a challenge to determine if manual therapies alone are effective or only when combined with other forms of treatment. To uncover the effectiveness of manual treatment for mild-to-moderate CTS, the authors of a 2022 systematic review looked at data on 410 patients from six studies and concluded that the use of manual therapies not only improves CTS-related symptoms (pain, numbness, tingling, and weakness in the hand and wrist), but also the function of the median nerve itself, as seen with nerve conduction velocity testing.
Doctors of chiropractic are trained in manual therapies of many varieties including: joint manipulation (high-velocity, low amplitude thrust), mobilization (low- to medium- velocity, low- to medium- amplitude non-thrust), instrumentation use (Activator, Graston technique, Gua Sha), soft-tissue mobilization (gliding, shearing), massage (longitudinal, transverse, friction, deep and superficial), neuromobilization methods (nerve gliding at the cervical spine, thoracic outlet, brachium/arm, antebrachium/forearm, wrist, hand and fingers), and more.
It's important to note that restriction or compression of the median nerve anywhere along its course—from the neck to the hand—can increase the risk for CTS and even lead to symptoms that mimic the condition. In fact, there’s research that supports that the use of manual therapies to reduce the perineural tethering in the forearm can improve the movement of the median nerve during finger, hand, wrist, and elbow movements. Hence the importance of evaluating the full course of the median nerve when a patient seeks care for CTS.
While the data suggests that manual therapies alone may be sufficient to manage CTS, doctors of chiropractic will often utilize a multimodal approach that also includes specific exercises, physiotherapy modalities, nocturnal splinting, nutrition recommendations, and more, all with the aim of helping the patient experience maximum improvement in the shortest amount of time so they can return to their normal life and work activities.
Laser Therapy for Knee Osteoarthritis
The Cleveland Clinic reports that knee osteoarthritis (KOA) is a very common condition that will affect about 46% of us in our lifetime, usually after age 40. The condition is characterized by the gradual breakdown of the cartilage in the knee joint until eventually the bone on either side of the joint rubs together causing pain, stiffness, swelling, limping, and instability. The goal of a conservative treatment approach—such as chiropractic care—is to reduce pain, improve function, and hopefully slow the progression of the condition with the aim of delaying or avoiding surgical intervention. One of the tools that a chiropractor may employ as part of their approach is laser therapy.
The two types of laser that may be encountered in a chiropractic setting are low-level laser therapy (LLLT), which operates at up to 500 milliwatts; and high-intensity laser therapy (HILT), which operates in excess of 500 milliwatts. Regardless of wattage, LLLT and HILT both emit energy in a specific range (600nm-1,000nm or from the red to near-infrared portion of the electromagnetic spectrum) that can penetrate the skin and stimulate reactions in the tissues to improve cellular function, which can reduce pain and accelerate healing.
A 2022 systematic review and meta-analysis that included ten randomized controlled trials (RCT) concluded that both types of lasers are effective for reducing pain and improving function, with HILT offering more significant improvements. Another study published the same year found that combining LLLT with strength training led to better outcomes at one year following the conclusion of care with respect to reduced medication use and better performance on sit-to-stand tests.
When managing a condition like osteoarthritis of the knee, a doctor of chiropractic will typically employ a multimodal approach that may include laser as well as manual therapies, specific exercises, diet/weight management, knee bracing, and physical therapy modalities. The patient may also receive treatment to address musculoskeletal issues of the foot, ankle, hip, or lower back that may contribute to added stress on the knee. If necessary, your chiropractor will co-manage your care with an allied healthcare provider.
Chiropractic Care for Neck Pain Saves Money
Each year, nearly 1-in-4 women and 1-in-6 men experience an episode of neck pain. In particular, the risk is highest for working-age adults aged 30 to 59 years. Interestingly, past research suggests that indirect costs associated with a condition like neck pain—such as missing work or lost productivity—often exceed direct healthcare expenditures. Thus, when it comes to a recommended course of care, it’s important for care to improve pain and function so that the patient can return to work, with a reduced risk for relapse or recurrence of their neck pain.
In a May 2022 study, researchers reported that prior research has found that manual therapies for neck pain management often produce better outcomes and are more cost effective than both specialist care and physical therapy. However, little research exists that directly compares a multimodal manual therapy-based approach with physician-delivered advice on how to cope with pain and to stay active.
The research team recruited working-aged adults with neck pain and split them into two groups. The first group received six treatments spread over six weeks that included spinal manipulation, mobilization, massage, and stretching—all treatments a patient may experience in a chiropractic office. Participants in the second group visited with a physician two times three weeks apart and received instruction on ways to stay active and how to cope with pain.
Over the course of the next year, participants completed outcome questionnaires used to determine health-related quality of life (physical functioning, bodily pain, general health, vitality, social functioning, mental health, etc.). The researchers also asked the participants in each group about what additional care they used to manage their pain following the conclusion of the treatment period and if they had used any sick days due to their pain in that time.
Subsequent analysis showed that not only did participants in the manual therapy group report greater improvement in health-related quality of life, but the overall cost per patient in direct and indirect costs was 49% lower. Interestingly, the research team found that patients in the manual therapy group were also two-times less likely to require more intensive, costly care. The authors summarized their finding: “The results indicate that manual therapy achieves better outcomes at lower costs compared with advice to stay active.”
Doctors of chiropractic often manage patients with neck pain using a multimodal approach that incorporates the manual therapies used in this study in addition to specific exercise advice, nutritional counseling, and physiotherapy modalities, all dependent on their clinical experience and the patient’s unique case.
A Missing Link to Chronic Whiplash
While there’s an abundance of published work on whiplash associated disorders (WAD), one of the most perplexing issues facing investigators is why nearly half of patients experience long-term, chronic issues. However, new research suggests that we may be closer to determining why this is the case and which patients may be at greatest risk so a more comprehensive treatment approach can be provided.
Examinations of patients with chronic whiplash associate disorders (cWAD) have revealed an increased likelihood of nerve injury and neuropathic pain—pain that is usually described as a burning sensation and can make the affected area sensitive to touch—when compared with WAD patients who recovered. These cWAD patients also demonstrate decreased sensory perception, exhibit signs of nerve inflammation on MRI, have skin biopsies that reveal structural degeneration of small fiber nerves, and experience a reduction in their overall quality of life and emotional wellbeing.
A July 2022 systematic review and meta-analysis looked at clinical data concerning over 400,000 WAD patients that indicated that 34% of patients may have had neuropathic pain, while only 13% had received a diagnosis indicating nerve pathology. This is important because the most common diagnosis for WAD is grade II, which includes symptoms of pain and physical signs of reduced cervical range of motion in the absence of neurological findings.
The review also found that patients with neuropathic pain also demonstrated significantly impaired sensory (mechanical, current, cold, and warm) detection thresholds of the index finger, independent of their WAD classification (WAD I—mild symptoms without physical signs; WAD II—symptoms and signs without nerve injury; WAD III—symptoms and signs with nerve injury; WAD IV—fracture/dislocation). The authors summarize that their findings appear to have identified a subset of WAD patients that demonstrate signs of peripheral nerve injury and neuropathic pain previously not considered. They suggest modification of the current WAD classification as well as performing a more detailed assessment of nerve integrity during the patient’s initial examination.
Doctors of chiropractic utilize a structured history and assessment that includes neurological examination approaches mentioned in this study (such as two-point discrimination of the fingers, pressure pain thresholds, and neurodynamic testing) as well as the use of questionnaires to obtain an accurate diagnosis and to track patient progress. The physical techniques utilized by doctors of chiropractic to restore motion—which minimize pain and promote recovery—offer an excellent front-line treatment choice for the whiplash patient.
Chronic Pelvic Pain in Men
For men, chronic pelvic pain syndrome (CPPS) is defined as ongoing or repetitive pain episodes in the pelvic region in the absence of urinary tract infection or other relevant pathology, such as prostatitis. Because the condition is complex and satisfactory results seldom occur from just one form of treatment, researchers have proposed tackling CPPS with a multimodal approach that may include manual therapies, a form of treatment provided by doctors of chiropractic.
An April 2022 prospective study included 23 middle aged men with CPPS that presented with prostatic tenderness with no other positive clinical findings (negative clinical and/or lab tests). Each participant received three manual therapy treatments in the first week and six additional treatments spread over the next four weeks. The techniques employed were all externally applied and intended to achieve normal joint alignment, reduce muscle tightness/stress, create flexible fascial structures, and improve blood flow and nerve function to the affected area.
Questionnaires completed by the participants revealed that this approach led to clinically significant results improving pain intensity, prostate-specific symptoms, and quality of life. This study suggests that manual therapy might be a practical therapeutic approach given the exact same protocols were applied to all patients to eliminate confounding factors and confusion.
There is also research that shows the following treatment options, many of which may be provided by chiropractors, may benefit the CPPS patient: acupuncture, lifestyle modifications, specific-targeted exercises, shockwave therapy, phytotherapy (the use of medicines derived from plants or herbs to treat or prevent health conditions), and some forms of electrical, magnetic, and ultrasound physical therapy modalities.
It’s important to note that the current clinical practice guidelines for treating CPPS support pharmacologic treatment as the standard of care, and more research is needed before guidelines can be updated to include manual therapies and other non-pharmaceutical approaches in the management of CPPS. However, a patient whose condition does not respond to pharmacologic treatment may inquire with their medical physician if these alternative therapies should be considered, of which a doctor of chiropractic is well-equipped to provide.
