MONTHLY HEALTH UPDATE
Can the Outcome of Back Pain Be Predicted?
Chad Abramson, D.C.
Low Back Pain
Chiropractic Is an Excellent First Choice for Low Back Pain
The current available research notes that 52% of all opioid prescriptions are for patients with low
back pain, and over two million Americans suffer from opioid use disorder (OUD), with 47,000 dying
from OUD in 2017. In light of the opioid epidemic, the high cost of diagnostic tests and invasive
treatment, and the low level of patient satisfaction with such care, researchers from the Boston University
School of Public Health set out to find better options for the management of low back pain. Their findings
revealed that a patient’s INITIAL choice of healthcare provider plays an important role in their prospects
for a successful outcome from the perspective of both the patient and the insurance company.
This prompted a major health insurance carrier to send a notice to their policy holders promoting initial care for low back pain with either a doctor of chiropractic (DC) or physical therapist (PT). The carrier notes that this move is expected to reduce the use of spinal imaging tests by 21%, spinal surgeries by 21%, and opioid prescriptions by 19%, leading to lower costs for employers and plan participants.
This recommendation is not only in line with guidelines from the American College of Physicians that non-drug, non-surgical care should be the initial course of treatment for the low back pain patient, but also a growing body of research on the effectiveness of non-surgical, non-drug approaches for managing low back pain:
• A 2020 study found that 22% of patients who initially visited their primary care doctor (PCP) received a short-term opioid prescription, with those first consulting with a PT or DC being 85- 90% less likely to require an opioid prescription.
• A 2015 study found patients who first sought care from a DC were not only more satisfied with their care than those who visited a PCP first, but the overall treatment costs were lower.
• Back in 2013, researchers reviewed data from Washington state worker’s compensation cases and found that 43% of workers with a back injury who initially consulted with a surgeon ended up having surgery while just 1.5% of those who first received chiropractic treatment eventually had a surgical procedure for their back pain.
• A study published in 2019 found that low back pain patients were less likely to see DC/PTs vs. PCPs when the insurance plan had greater restrictions on DC/PT visits (higher co-pays, deductibles, participation in programs such as a health savings account). The authors stated longterm economic and social benefits would result if health insurance benefit designs were changed to encourage LBP patients to see DC/PT provider types.
BOTTOM-LINE: It’s becoming increasingly clear that conservative treatment approaches like chiropractic care should be strongly recommended for patients with low back pain and other musculoskeletal conditions. Not only will this lead to a reduced use of potentially harmful opioids and the issues that can stem from their misuse, but there will also be cost savings for patients and insurers. As with most health conditions, the sooner a patient seeks care, the greater their likelihood for a successful treatment outcome.
Neck Pain / Headaches
Chiropractic Care and the Headache Patient
According to a 2020 study, up to 1 in 5 new chiropractic patients list headaches as one of
their chief reasons for seeking care. Let’s take a look at the features and characteristics that are often
found in the chiropractic patient population…
A survey that included input from 224 adult patients with headaches as their chief complaint and 70 doctors of chiropractic revealed that 25% of patients who consult with a chiropractor concerning their headaches have headaches lasting longer than three months, known as chronic headaches, and 42% rate their headache pain as severe.
Based on International Classification of Headache Disorders criteria, 21% of these patients exhibited characteristics of migraine headaches, 17% likely had tension-type headaches, and a third experienced characteristics of two or more types of headaches. However, among the patients who rated their pain as severe, 62% had migraines and two-thirds had more than one type of headache.
A series of studies published in 2020 and 2021 compared multi-modal chiropractic care (ten treatments spread over 14 weeks) and enhanced usual care (medical treatment with migraine education literature) in the treatment of 61 adult women with episodic migraines. The patients in the chiropractic group experienced a near three-fold reduction in migraine days per month (2.9 days vs. 1 day).
Follow-up interviews with the participants in the chiropractic group on their perception of chiropractic care revealed three common themes: 1) over the course of treatment, participants became more aware of the role of muscle tension, pain, and posture in triggering a migraine; 2) participants revised their prior conceptions of chiropractic care beyond spinal manipulation; 3) participants viewed the chiropractor-patient relationship as essential and valuable for effective migraine management.
A study that included 150 patients with chronic tension-type headaches revealed that chiropractic care and the medication amitriptyline provided similar benefits during the treatment phase of the study. While three participants in the chiropractic treatment group reported neck soreness and stiffness, 82.1% of those in the group that took amitriptyline experienced side effects that included drowsiness, dry mouth, and weight gain. Of special note is that once treatment concluded, only the patients who received chiropractic care continued to experience reduced headache intensity and frequency while the participants in the medication group reverted to their initial headache intensity, frequency, and duration levels.
The findings from these and other studies support chiropractic care as an effective treatment option for patients with headaches, with few (if any) side effects and high patient satisfaction.
Ankle Pronation and Knee Osteoarthritis
Knee osteoarthritis (KOA) is a very common condition that is a significant cause of
disability in older adults, often resulting in knee replacement surgery. There are several
contributing factors to KOA, and perhaps one of the most important issues is excessive force
exerted on the knee joint by improper biomechanics of the foot and ankle.
In the normal gait or walking cycle, there are two primary phases called the stance phase and the swing phase. As the names imply, the stance phase refers to the entire time the foot is in contact with the ground and the swing phase occurs when the foot is off the ground.
A 2019 systematic review and meta-analysis reported that the forces across the knee are not transmitted equally during walking, with the inside of the knee joint bearing greater loads than the outer knee joint in most individuals. This leads to breakdown of the cartilage faster on the medial side of the joint, which leads to KOA. One identified cause of this is called ankle pronation, which is an excessive rolling-inward of the ankle that occurs during the stance phase. This results in the knee knocking inward, which is technically called external knee adduction moment, or EKAM.
Fortunately, this can be addressed with the use of lateral wedge insoles or shoe inserts that try to minimize or eliminate the ankle pronation aspect that reduces the EKAM and associated excess loading of the medial knee joint.
When assessing a patient, doctors of chiropractic will expand their examination to regions of the body outside of the area of chief complaint as it’s common for dysfunction in one body part to affect another. In this case, we can see that abnormal motion of the ankle can place added stress on the knee, potentially leading to knee replacement. For the patient to achieve an optimal outcome, such issues need to be addressed.
Chiropractic treatment for the KOA patient can include manual therapies to restore proper motion to the affected joints, specific exercises to strengthen weakened muscles, and nutritional recommendations to reduce inflammation. If ankle pronation is suspected to contribute to the patient’s knee condition, then an orthotic insert may also be necessary. As with many musculoskeletal conditions, it’s better to seek care sooner rather than later. The earlier treatment can be provided, the faster and more likely there will be a satisfactory outcome.
Carpal Tunnel Syndrome
Home Exercises for Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy affecting
approximately 3% of the general adult population. Individuals with jobs or hobbies that involve fast,
repetitive movements and forceful gripping with little-to-no rest may be at increased risk for CTS, as
are those with metabolic/hormonal conditions that can lead to increased
swelling/pressure/inflammation in the wrist. In most instances, treatment guidelines recommend
utilizing conservative treatment approaches, like chiropractic care, before consulting with a surgeon.
In addition to workstation modifications, manual therapies, nutritional recommendations to reduce
inflammation, nocturnal splinting, and co-management with other healthcare professionals, doctors
of chiropractic will also advise patients to perform exercises at home to speed recovery and prevent
Below is a description of four CTS-specific exercises recommended by the American Academy of Orthopedic Surgeons (AAOS).
Exercise 1: Wrist Extension Stretch. With the elbow straight (but not “locked”), bend the wrist back (as if saying “STOP”) and use the other hand to apply “over-pressure” to assist to a maximum tolerated stretch. Hold for fifteen seconds. Repeat five times for each wrist.
Exercise 2: Wrist Flexion Stretch. With a straight elbow (but not “locked”) and the palm facing down, bend the wrist downward until the fingers point toward the floor and use the other hand for to achieve the maximum tolerated stretch. Hold for fifteen seconds, repeat five times for each wrist.
Exercise 3: Median Nerve Glides. Make a fist (with the top of the hand facing upward) and then open the hand, but not the thumb, and bend the hand backward toward the forearm and extend the thumb backward. Rotate the palm up toward the ceiling, keeping the wrist/fingers/thumb extended. Grasp the thumb with the other hand and extend back (assist) to tolerance (but not too hard). Hold for three to seven seconds and repeat on the other hand.
Exercise 4: Tendon Glides Type One: Start with the hand pointed outward with the fingers straight out, palm facing down. Bend the fingers upward and then curl them downward into a fist. Tendon Glides Type Two: Start with the hand pointed outward with fingers straight out, palm facing down. Bend the fingers downward touching the end of the fingers to the base of the palm.
The AAOS recommends warming up the hands and wrists with heat for about 15 minutes before performing these exercises and using ice for 20 minutes to cool down afterward. If your symptoms to worsen, cease these exercises and consult with your doctor of chiropractic about modifications.
Whiplash and Dizziness
Whiplash associated disorders (WAD) is a term used to describe the myriad of symptoms
that can occur following the sudden acceleration and deceleration of the head and neck. One of
these symptoms is dizziness. How does the whiplash process lead to an impaired sense of
balance, and are some individuals at greater risk than others?
It's important to understand that our sense of balance is the result of input from the inner ear, eyes, and nervous system, which is then processed by the cerebellum located in the rear of the brain, just above the spinal cord. Abnormal function in any of these areas can result in the sensation of dizziness, which can dramatically affect one’s quality of life.
In a 2020 study, researchers enrolled 27 older (over 65) adult WAD patients and 32 young adult WAD patients in a battery of tests to determine which, if any, aspects of the balance system were impaired. Researchers concluded that older participants were at increased risk for vertigo and were also more likely to have abnormal proprioception and lesions near the cerebellum. This suggests that the rapid forward and backward motion associated with whiplash resulted in trauma near the area of the brain that may be most important for maintaining balance and affected the ability of the nervous system to efficiently relay sensory information to and from the rest of the body.
One hypothesis is that age-related declines in muscle strength may have reduced the neck’s ability to resist the back-and-forth whiplash motion. This can lead to increased injury to the tissues in the neck and potential injury to the brain, something that is supported by several recent studies linking whiplash and mild-traumatic brain injury.
Cervicogenic dizziness is a term used to describe dizziness caused by dysfunction in the cervical spine. A 2011 systemic review concluded that manual therapies—especially spinal manipulation and joint mobilization—are effective treatment options for this condition. A follow-up systemic review in 2019 affirmed this finding.
Doctors of chiropractic commonly evaluate and treat patients with whiplash associated disorders, including those experiencing dizziness, with a multimodal approach involving manual therapies and specific exercises. If examination findings suggest injury to areas of the body outside the scope of care, chiropractors can co-manage with the patient’s medical doctor or refer to a specialist.
Whole Body Health
Dietary Management of Joint Pain
It’s generally accepted that the normal aging process includes stiff joints and sore muscles. While
exercise, stretching, hot/cold packs, and chiropractic care are commonly used tools for the non-pharmaceutical
management of joint pain, there’s a growing body of research suggesting that dietary approaches to reduce
inflammation may be just as important.
The following list of foods and food additives can promote inflammation and should be avoided as much as possible:
• Sugar: Though it can be a challenge to resist the temptation of desserts, sodas, and some fruit juices, processed sugars trigger the release of inflammatory messengers called cytokines. But beware, the word “sugar” is camouflaged on many food labels, so watch for any word ending with “-ose”, such as glucose, fructose, and sucrose.
• Saturated Fats: Studies show that saturated fats trigger adipose inflammation, which worsens arthritis and contributes to heart disease. Saturated fats are commonly found in pizza, cheese, red meat, fulldairy products, pasta dishes, and grain-based desserts.
• Trans Fats: Since the early 1990s, researchers have warned us about trans fats triggering systemic inflammation. Fast foods and other fried products, processed snacks, frozen breakfast foods, cookies, donuts, crackers, and most margarines are popular culprits. Avoid foods containing partially hydrogenated oils listed in the ingredients.
• Omega-6 Fatty Acids: Even though we do need SOME of these fats in our diet, a balance favoring omega-3 fatty acids is important. Omega-6 fatty acids can be found in certain oils (corn, safflower, sunflower, grapeseed, soy, peanut, and vegetable), in mayonnaise, and many salad dressings.
• Refined Carbohydrates: This list includes white flour products including breads, rolls, crackers, white rice, white potatoes (instant mashed or French fries); and many cereals. Refined carbs are widely believed to be a major contributor to obesity, which increases inflammation in the body.
• MSG (mono-sodium glutamate) is commonly found in foods that utilize soy sauce. It can also be added to many fast foods, soups, salad dressings, and deli meats to enhance flavor.
• Gluten: Gluten sensitivity is a common health problem that causes joint pain and gut trouble. Gluten is found in wheat, barley, and rye. In those with gluten intolerance or Celiac disease, complete avoidance is necessary as gluten sets off an autoimmune response that damages the small intestine over time resulting in malabsorption of nutrients.
• Aspartame: This artificial sweetener can trigger an autoimmune response in some individuals, resulting in inflammatory joint pain.
• Alcohol: Excess intake can damage the liver, which interferes with many important metabolic functions resulting in inflammation.
On the other hand, a diet like the Mediterranean diet that focuses on eating fruits, vegetables, nuts, fish, olive oil, and whole grains while avoiding red and processed meats, dairy, saturated fats, and refined sugars, has been shown to reduce inflammation and reduce the risk for many chronic diseases and promote weight loss. If you have any questions on dietary approaches to reduce inflammation and fight joint pain, don’t hesitate to ask your doctor of chiropractic at your next visit.
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Abramson Family Chiropractic
10222 19 th Ave SE, Suite 103, Everett, WA 98208
This information should not be substituted for medical or chiropractic advice. Any and all health care concerns, decisions, and actions must be done through the advice and counsel of a health care professional who is familiar with your updated medical history.