Monthly Pain Update – October 2024

Tricky Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy, affecting upward of 6% of adults in their lifetime. In some occupational groups, the prevalence jumps to nearly 20%! While carpal tunnel syndrome can be simply described as the symptoms that result from compression or restriction of the median nerve as it passes through the wrist, the condition can be anything but easy to diagnose and manage. This is due, in part, to three key factors:

Myriad Causes: There are multiple ways the median nerve can become compressed or restricted as it passes through the carpal tunnel. For example, non-neutral wrist postures can reduce the size of the tunnel and increase the pressure within, repetitive movements involving the hands can stimulate inflammation as the tendons in the wrist slide back and forth, and excessive vibrations can also trigger inflammation in the wrist. If the tissues don’t have the opportunity to recover, scarring can develop and lead to more frequent and worsening symptoms. Hence, CTS is much more common among workers whose job activities involve using heavy equipment repeatedly throughout the day in awkward wrist postures. Unfortunately, biomechanical factors aren’t the only potential cause of CTS. Any health condition that induces inflammation or swelling in the wrist or directly affects the health of the median nerve can play a role in CTS development.

Gradual Onset: The symptoms associated with carpal tunnel syndrome include pain, numbness, tingling, and weakness along the course of the median nerve from the wrist to the thumb, index, middle, and thumb-side of the ring finger. Because CTS tends to be the result of repetitive stressors, these symptoms tend to come on gradually. For a time, most people can ignore or self-manage their symptoms. It’s only once the condition has progressed and when the pain, numbness, tingling, and weakness becomes too much to carry out daily activities that the CTS sufferer makes an appointment to get checked out.

 Other Nerve Compression Sites: When median nerve compression occurs elsewhere on its course from the neck to the wrist, the patient may experience the same symptoms as CTS. In many cases, there may be restriction of the median nerve both at the wrist and in another location like the neck, shoulder, elbow, or forearm. Additionally, some CTS patients may experience symptoms radiating up the arm, which can lead a healthcare provider to ignore the wrist and focus on compression at the forearm or elbow.

The good news is that doctors of chiropractic are trained to look at a patient’s health history and to evaluate the full course of the median nerve to identify each contributing factor for the patient’s carpal tunnel symptoms. Then, they will employ a multimodal approach to restore normal motion to the affected joints and relieve pressure at the wrist using manual therapies, specific exercises, nocturnal wrist splinting, activity modifications, and more. If health conditions beyond their scope of practice are present, they’ll work with an allied healthcare provider with the goal of symptom resolution so the patient can return to their normal daily activities.

Hip Pain and Co-Occurring Low Back Pain

Among the roles the hip joints play in the human body, perhaps none is as important as the ability to perform everyday activities like standing, walking, and running. Of course, these actions involve multiple other body parts, so it’s no surprise that when a patient presents with hip pain, they often have additional issues. In fact, a study published in 2019 reported that among a group of 2,515 patients with hip pain, only 3% exclusively had hip pain. Of the remaining 97%, more than half had pain in at least six body sites! Due to the close proximity of the hips and lower back, as well as the roles they play in maintaining posture while performing activities like walking, it’s no surprise there’s a link between hip pain and lower back pain.

In 2024, a team of researchers from Brazil’s University of Sao Paulo reviewed findings from 54 studies with respect to the relationship between low back pain and hip function, specifically looking at factors like kinematics, range of motion, strength, and muscle activity. They concluded that patients with low back pain exhibit a significant reduction in hip range of motion, especially hip internal rotation; greater activation of the hamstrings and gluteus maximus (hip extensor) muscles and weakness of the hip abductor and extensor muscles during functional activities; and differences in performance on essential activities like sitting, standing, and walking. Another systematic review and meta-analysis looked specifically at walking ability in patients with either acute or chronic low back pain. The authors concluded that when compared to back-healthy individuals, those with low back pain walked slower and with a shorter stride, exhibiting differences in coordination between the upper back, lower back, and hips/pelvis.

However, it’s unclear if an existing hip condition can trigger these changes, or if consequences of low back pain are leading to hip problems. The relationship between low back pain and hip pain may even be bidirectional; that is, one raises the risk for the other. For example, a 2021 study of patients with both conditions found that treating the lower back resolved concurring hip pain in a group of 76 patients. However, a 2024 study revealed that of 34 patients with osteoarthritis of the hip, 19 also had moderate-to-severe low back pain and 14 experienced improvements in their low back pain after undergoing treatment to address their hip condition.

This is why it’s important to examine the whole patient and not just focus on the area of chief complaint. Often, the underlying cause or at least a contributing factor for a patient’s present pain and disability may be an issue in an adjacent part of the body. The good news is that this is the approach doctors of chiropractic are trained to use when examining a patient, and they’re well-equipped to address both hip pain and low back pain using conservative treatment options including manual therapies and specific exercises.

Manual Therapy Preference for Neck Pain Management

After low back pain, neck pain is one of the most common reasons patients seek out chiropractic care. In the absence of red flags like suspected cancer, infection, severe neurological loss, or a sudden headache, among others, guidelines for the management of neck pain support the use of manual therapies as an initial treatment approach, often in combination with other therapies to optimize outcomes for the patient. But which types of manual therapy are best for managing neck pain?

While there are a several manual therapies available to a chiropractor, for this discussion, we’ll divide them into thrust and non-thrust. The term high-velocity low-amplitude (HVLA) or “thrust” specifically describes a form of manual therapy accompanied by a cracking noise that results from joint cavitation. This is the type of treatment most commonly associated with chiropractic adjustments and may also be called spinal manipulative therapy or spinal manipulation. On the other hand, low-velocity low-amplitude (LVLA) manual therapies are known as the non-thrust variety as joint cavitation does not usually occur.  These manual therapies are often referred to as mobilization therapy.

A systematic review and meta-analysis of data from six clinical trials identified no differences between thrust- and non-thrust manual therapies applied to either the neck or upper back with respect to improvements in neck pain, disability, or range of motion. Why was the upper back included in a paper regarding managing neck pain? The muscles at the back of the neck that help keep the head upright connect to the upper back area and often, patients with neck pain have a forward head posture, which places added strain on these muscles and contributes to neck pain.

The good news is that doctors of chiropractic are trained to provide both forms of manual therapy, and the treatment used can depend on the patient's preferences and also their chiropractor’s clinical experience and physical examination findings. In some cases, the decision may not be made until treatment is delivered. Why’s that? If a patient has difficulty relaxing, it is VERY challenging to achieve joint cavitation (cracking) using thrust manipulation as muscle splinting or guarding decreases the ability of the thrust to effectively move the joint. For these patients, the chiropractor will opt for mobilization instead.

Bottom line: TALK to your chiropractor about manual therapy preferences (if there is one) and most likely, you will be accommodated. Further, if you are not satisfied with the results that you’re experiencing, discuss alternate methods of manual therapy and remember there are MANY other effective approaches offered by your chiropractor such as the use of modalities, exercise training, home/office traction, trigger point therapy, and much more.

Treatment Guidelines for Whiplash Management

During the last several decades, various organizations have published clinical practice guidelines to help steer providers in an evidence-based direction in the management of whiplash associated disorders (WAD). As new evidence is published and confirmed by subsequent studies, guidelines are updated to optimize recovery in a timely and economic manner, as well as reduce the risk of progression to chronic WAD, which can have a dramatic impact on an individual’s ability to work and carry out their daily activities of living. The following recommendations are currently supported in clinical guidelines for managing WAD in a chiropractic context:

• Conservative Multimodal Treatment: Unless a red flag like fracture, structural instability, or severe neurological loss is present, conservative treatment is advised. Studies have identified several therapies that benefit a WAD patient including spinal manipulative therapy, mobilization therapy, soft tissue therapy, massage, physiotherapy modalities, and more. The specific types of treatment used depend on physical examination findings, patient preference, as well as the provider’s clinical experience and training. In most cases, multiple therapies are used in conjunction as such an approach may be most likely to achieve a satisfactory outcome for the patient, often in the shortest time frame.
• Stay Active: In the past, you may recall people who had been in a car accident wearing a soft neck collar, but you seldom see this behavior in the present day. Why is that? It was believed that immobilizing the neck was important to allow the tissues to heal, just like how you immobilize an arm or leg with a broken bone using a hard cast. However, it turns out the practice was more likely to lead to deep neck muscle deconditioning and prolonged the healing process. Nowadays, doctors are advised to encourage their WAD patients to stay active within pain tolerances as much as possible. Patients may receive instruction to perform neck-specific exercises and stretches to facilitate the healing process.
• Patient Education: Most WAD cases stem from automobile collisions, which can be stressful and scary for a patient. The symptoms they’re experiencing may be more severe than any previous injury and it may have had a drastic effect on their daily lives. They may even restrict their activities to avoid worsening their pain or exaggerate their symptoms, both of which can hinder healing and set the stage for chronic WAD. That’s why it’s vital for healthcare providers to assure WAD patients they will get better and to stick to their treatment plan, including carrying on with their lives as much as possible. Referral to a mental health professional may be necessary in some cases.

The good news is that doctors of chiropractic are well-trained in the management of WAD and will co-manage patients with allied healthcare providers if necessary to help their patients to get out of pain and back to their regular lives.

Reducing the Risk for Obesity

The Global Burden of Disease Group reports that the prevalence of obesity has doubled in over 70 countries since 1980 and has continually increased in most others. It’s currently estimated that nearly 30% of the world population—more than two billion people—meet the criteria for obesity. It’s unclear if any government top-down interventions have slowed the increasing prevalence of obesity to great effect, so it’s up to each of us on the individual level to take action to achieve and/or maintain a healthy weight with the following lifestyle changes:

• Eat more produce! A high intake of fruit and vegetables is associated with increased microbe diversity in the gut, particularly an increase in bacteria linked to reduced inflammation and improved insulin sensitivity—both of which are associated with obesity.
• Avoid added sugars and processed foods. For every 10% increment that ultra-processed foods account for a person’s daily calorie intake, their risk for obesity increases by 6%. This is particularly alarming because it’s very common in richer countries for half of an individual’s caloric intake to come from ultra-processed foods. When making beverage choices, stick to water and unsweetened iced tea and avoid drinks with added sugars or artificial sweeteners.
• Calorie Restriction. Studies show that people tend to consume more calories if their portion sizes are larger. Time-restricted eating, or intermittent fasting, has also been shown to aid in weight loss.
• Don’t smoke. In addition to myriad negative effects on health, smokers are less able to experience the taste of fatty and sugary foods than non-smokers, which can lead them to consume more of these unhealthy foods.
• Avoid alcohol. Alcohol affects fat distribution in the body and adipose tissue is more likely to accumulate around the heart, liver, and kidneys of heavy drinkers. This visceral fat build-up is linked to an elevated risk for heart disease, Alzheimer’s disease, type 2 diabetes, and stroke.
• Get regular exercise. Health experts recommend engaging in 150 minutes of moderate-intensity physical activity a week in addition to strength training the major muscle groups twice a week.
• Sit less. Sedentary behaviors like watching TV are linked to increases in insulin resistance, slowed metabolism, and excess calorie consumption. Exchanging 50 minutes a day of sedentary activity with physical activity of any intensity can lead to improvements in blood sugar regulation, insulin sensitivity, and liver health, which may reduce one’s risk for type 2 diabetes and cardiovascular disease.
• Get seven-to-nine hours of sleep a night. Poor sleep can trigger changes in the body that favor fat storage and muscle breakdown.
• Manage stress. Stressed individuals are more likely to engage in unhealthy behaviors that can raise the risk for weight gain. Stress also triggers inflammation in the body, which is also linked to an elevated obesity risk. Learning healthy ways to manage stress, like meditation, breathing exercises, or getting exercise can help.

The best part about these lifestyle behaviors is that they tend to work together. For example, people who are physically active tend to sleep better. People who sleep better and eat a healthier diet tend to be less affected by stress. If you find musculoskeletal pains are interfering with your ability to live a healthy lifestyle, please contact your doctor of chiropractic and schedule an appointment.

 

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.