Monthly Pain Update – September 2024

Aquatic Exercise for Low Back Pain  

Deconditioned and tight muscles are often observed in patients with chronic low back pain and must be addressed for the patient to achieve a satisfactory outcome. Research on physical activity to manage chronic low back pain typically involves land-based exercises—like brisk walks or cycling, for example—but what about aquatic exercises? Do water-based exercises have a place in chronic back pain management?

In January 2024, researchers conducted a systematic review and meta-analysis that included data concerning 524 chronic low back pain patients from 15 studies who participated in either water- or land-based exercise intervention, or they had been assigned to a waiting list to serve as a non-active control group. Their analysis revealed that participants in both exercise groups experienced significant improvements in pain intensity when compared with the non-active patients. Those in the water- and land-based groups also reported similar improvements with respect to low back pain-related disability and flexibility that were not evident in the control group. Ultimately, the authors concluded that aquatic exercise is as effective as land-based options for managing chronic low back pain.

For those who find land-based exercises challenging—especially if weight-bearing exercises are too stressful on the joints—aquatic exercise may be a viable option. However, water-based exercise is not just a synonym for swimming laps. There are several forms of water-based exercise available, such as water aerobics, aqua jogging, water walking, aqua Zumba, water yoga, water polo, aqua cycling, pool volleyball, resistance band training, and water tai chi. These various workouts take advantage of buoyancy so there’s less impact on joints, the natural resistance of water for strength training, and the cool-down effect of water on the skin. For individuals who get more enjoyment from group workouts, these exercises are an excellent choice!

In addition to helping manage chronic low back pain, meeting physical fitness guidelines of 150 minutes of moderate- or 75 minutes of vigorous-intensity exercise each week may also reduce the risk for developing chronic low back pain in the first place. Furthermore, patients who recover from chronic low back pain and stay physically active are also less likely to experience a recurring episode. So if traditional exercise like jogging or cycling doesn’t appeal to you and you’d rather spend time in the pool, consider an aquatic exercise routine!

Making the Diagnosis of Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a common condition that occurs when the median nerve is compressed or restricted as it passes through the carpal tunnel located at 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. During their initial appointment, a patient will complete a health history to provide their chiropractor with information on how long they’ve had symptoms and what makes them worse/better, as well as information about any current health conditions they have and have had in the past. If carpal tunnel syndrome is indeed suspected, the next step is a physical examination.

During the physical examination, the doctor of chiropractic will examine the wrist to see if tapping, pressing on the median nerve, or flexing the wrist causes a numbing or tingling sensation. They will also conduct similar tests elsewhere along the course of the median nerve to determine if its mobility is hindered beyond the wrist, which is common in CTS patients. This is also known as double crush syndrome. The chiropractor will also test the fingers for sensation and assess the strength of the muscles at the base of the hand and look for signs of atrophy or weakening. These findings will help determine the severity of the patient’s CTS and if nerve damage has occurred.

In some cases, additional diagnostic tools may be employed. This can include laboratory tests to rule out conditions like diabetes that can damage nerves; X-rays to look for fractures, arthritis, or other abnormalities; a nerve conduction study to measure the speed at which signals are transmitted along a nerve to determine if they are slowed down at the carpal tunnel; electromyography (EMG) to assess the severity of muscle damage due to CTS; and ultrasound to see if the median nerve is swollen at the carpal tunnel.

If CTS is confirmed and the underlying cause is musculoskeletal in nature, then the doctor of chiropractic will adopt a multimodal approach that may include manual therapies, therapeutic exercises, nocturnal wrist splitting, anti-inflammatory measures, activity/work modifications, and physiotherapy modalities to restore the normal movement to the wrist and movement of the median nerve through the carpal tunnel. Should the median nerve be restricted elsewhere along its course, similar treatment measures will be employed. But if the chiropractor suspects conditions beyond their scope of practice (diabetes, hypothyroidism, rheumatoid arthritis, etc.), they may refer the patient to an allied healthcare provider so these disorders can be addressed.

Shoulder and Elbow Injuries in Baseball Players

Overuse injuries in baseball—particularly in the shoulder and elbow—are a significant problem at both amateur and professional levels. Studies have shown that shoulder pain is one of the most common complaints among amateur baseball players, with a prevalence ranging from 13.4% to 20.6% of players. Elbow injuries are also very common and affect from about a fifth to a quarter of all players, with youth players at greater risk. While all position players can develop upper-extremity injuries, these injuries tend to occur more frequently and severely in the dominant arm of pitchers.

Despite advancements in medical management and increased knowledge about preventive care, the rates of shoulder and elbow injuries in baseball players are on the rise. The consequences of these injuries can be significant, leading to time lost from the sport, reduced performance, the need for surgical interventions, and giving up the sport entirely.

Researchers have identified several potential risk factors for shoulder and elbow injuries in baseball players including increased mechanical load (measured by pitch count or training hours), higher pitching velocity, and decreased shoulder range of motion (ROM), particularly in flexion, internal rotation, and horizontal adduction. While the perceived stress of throwing curve balls is thought to increase the risk for arm injury, it’s not currently demonstrated in the data that this is the case. There’s limited evidence that weakness of the shoulder abductors and external rotators can contribute to shoulder pain, as can scapular dysfunction. Despite the clinical emphasis on the role of lower limb and trunk function in injury prevention and rehabilitation, there isn’t much research to support this strategy.

A study that included 60 active young adult baseball players may have uncovered a strategy for preventing upper extremity injuries. In the study, researchers assigned half the players to a stretching group and the other half to a stretching plus manual therapy group with the goal of addressing range of motion deficits between their dominant and non-dominant sides. After a single treatment session, both groups demonstrated improved range of motion (internal rotation, total arc of motion, and horizontal adduction), but the stretching plus manual therapy group experienced greater improvement. Because the loss of motion is a known risk factor for arm-related injuries, the authors reported that this combined approach should be used to prevent future injury.

Chiropractors utilize manual therapies more than any other healthcare profession with goal of breaking up scar tissue and adhesions, promoting circulation to the region to facilitate healing and strengthening of muscles and tendons, and restore normal motion to affected joints.

The Jaw Pain and Neck Pain Connection

Temporomandibular disorders (TMDs) are a common condition characterized by pain and discomfort while chewing. Traditionally, when patients complain of jaw pain, the focus has been on structures like the temporomandibular joint or the masseter muscles. However, there’s a growing body of research suggesting the intimate relationship between the jaw and the neck may be a contributing factor or even the underling cause of a patient’s TMD.

In one study, which included 40 women between 19 and 49 years of age, half of whom had chronic TMD, researchers observed that participants with jaw pain and discomfort were more likely to have neck pain and stiffness that limited their daily activities. Additionally, among the TMD patients, the more jaw muscle tenderness they exhibited, the higher their scores for both TMD- and neck-related disability. The research team observed a similar relationship between tenderness in the upper trapezius (the muscles in the shoulder and neck regions) as well as the temporalis muscles that function to close the jaw, located on the side of the head above the ear extending to the temporomandibular joint. The authors concluded that a significant correlation between neck disability and jaw disability exists and that healthcare providers should consider the neck and its related structures during the evaluation and management of patients with TMD.

These findings are echoed in a July 2022 study that found TMD patients with restricted cervical range of motion experience more severe TMD-related pain and disability than TMD patients with normal cervical range of motion. Another study published the same month found that patients with chronic (lasting longer than three months) TMD were two times more likely to have neck pain than individuals with acute (less than three months) TMD. A study published later that year linked neck pain with increased sensitivity of the masticatory muscles in TMD patients, leading the author to conclude, “In TMD treatment, we should pay attention to and actively relieve neck pain.”

In a study published in October 2021, researchers found that patients with concurrent neck pain and TMD experienced improvements in jaw function following care targeting the cervical spine. A systematic review conducted in 2023 confirmed these findings. The authors cited five studies that supported the application of manual therapies to restore normal movement to the cervical joints can improve pain, pain sensitivity, and function in the jaw. Interestingly, a systematic review published in March 2024 concluded that cervical rehabilitation interventions—such as manual therapies combined with neck-specific exercises—are effective for reducing pain intensity associated with myogenic temporomandibular disorders, which is TMD specifically linked to pain originating in the jaw muscles.

The good news is that doctors of chiropractic are well-versed in managing patients with neck pain as well as TMD using manual therapies and specific exercises to address trigger points in the jaw and neck muscles, as well as to restore normal motion to the temporomandibular joint and cervical spine.

Returning to Work After Whiplash

Whiplash injuries involving the head and neck constitute the most common non-fatal injuries associated with motor vehicle collisions. Unfortunately, these injuries often result in persistent, chronic pain and poor work outcomes including sick leave, delayed return to work, and impaired work ability. Among working-age adult chiropractic patients, resuming usual work activities is a treatment goal only second to pain relief.

On a societal level, the productivity losses linked to whiplash injuries run into the hundreds of billions of dollars a year worldwide. As such, from a top-down perspective, there’s been a push to identify treatments for whiplash associated disorders (WAD) that help patients return to work at their pre-injury levels as quickly as possible. A systematic review and meta-analysis that included 27 studies identified key factors for shortening return to work time among WAD patients:

• Patients who received hands-on treatment returned to work nearly 18 days sooner, were more likely to resume their full duties, and had less neck pain and disability.
• Treatment aimed at improving full range of motion in the neck not only reduced neck pain intensity but also sick leave.
• Early intervention (within 96 hours) increased the likelihood of full range of cervical motion three years later when compared with delaying treatment more than two weeks.
• Multimodal interventions that used three or more therapies led to better outcomes than usual medical care or minimal treatment—especially with the inclusion of neck-specific rehabilitation exercises.

Doctors of chiropractic are well-versed in both the diagnosis and management of whiplash associated disorders with many taking ongoing training and education specifically on the topic. Chiropractic care for WAD will often include a multimodal approach involving manual therapies like spinal manipulation, mobilization, and soft tissue work; specific exercises to perform between visits; anti-inflammatory measures like nutritional/supplement/diet recommendations and the use of ice and heat; physiotherapy modalities; and patient education regarding the importance of maintaining an active lifestyle within pain tolerances, which is  important to reduce the risk for transitioning to chronic WAD.

The Benefits of Golf for the Ageing Player

The National Golf Foundation reports there are approximately 36.9 million golfers in the United States, averaging more than 500 million rounds of golf each year. Golf is one of the most popular sports in the country with participants of all ages, genders, and skill levels. Interestingly, unlike many other sports, golfers tend to spend more time playing the sport as they age.

This is great news because several studies have noted that golf gives seniors an excellent means to not only work toward physical activity goals but also to engage socially with their peers—both of which can benefit longevity. In fact, a February 2023 study found that playing a round of golf without the aid of a golf cart has a greater effect on cholesterol and blood sugar levels than 3.7 miles of vigorous walking. The American Heart Association’s Dr. Donald M. Lloyd-Jones once wrote, “The regular exercise, time spent outside enjoying nature, social interaction, and even the friendly competition of a round of golf are all elements that can foster mental and physical wellbeing… The American Heart Association recommends most people get at least 150 minutes of moderate-intensity exercise a week. Golfing qualifies as a moderate-intensity exercise, specifically if you are walking an 18-hole course, carrying your golf clubs.”

Golf also benefits older adults with health challenges. A survey of 459 golfers with osteoarthritis revealed that that over 90% rated their health as good, very good, or excellent, compared with just 64% of non-golfer osteoarthritis patients. The data also show that golfers are three times less likely to report severe psychological distress. A study published in 2021 found that golfing provides similar benefits to Parkinson’s patients as tai chi, but participants were three times more likely to continue to golf after the study, which is important for maintaining those benefits!

Unfortunately, improper swing mechanics, inadequate warm-up routines, overuse, and equipment failures can result in acute injuries to golfers. By some estimates, low back pain accounts for roughly half of golf-related injuries. In one study, researchers observed that nearly all golfers with sacroiliac joint dysfunction also had mechanical low back pain. This demonstrates the importance of examining the whole patient and not just focusing on the area of chief complaint.  The second most common part of the body injured in golfers is the upper extremities (shoulder, elbow, and wrist in particular). Ironically, golfers are three times more likely to develop lateral epicondylitis (tennis elbow) than medial epicondylitis, which is also known as golfer’s elbow.

The good news is that chiropractic care, particularly a multimodal approach that includes manual therapies and specific exercises, offers an excellent treatment option for golfers with musculoskeletal pain. As with most musculoskeletal conditions, the sooner you seek care, the more likely (and faster) you’ll achieve a satisfactory outcome.

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.