MONTHLY HEALTH UPDATE
Can the Outcome of Back Pain Be Predicted?
Chad Abramson, D.C.
Low Back Pain
The Lower Back, Leg Pain, and Sciatica
The roots of the sciatic nerve exit the spine through several levels in the lower back, join
in the buttock region, and travel down into the lower extremities. When pressure is applied to the
sciatic nerve in the lower back area, it can generate pain and other sensations down the nerve into
one of the legs—a condition we commonly refer to as sciatica.
In younger and middle-aged adults, the most common cause of sciatica is a herniated disk in the lower back in one or more locations. Because of the structure of the sciatic nerve, the characteristics of the patient’s symptoms can direct their doctor of chiropractic on where to look for potential causes in the lower back:
• S1-2 Level (S1 nerve root): outer foot numb, difficulty walking on toes, weak Achilles tendon reflex
• L5-S1 Disk (L5 nerve root): inner foot numb, weak big toe and heel walking, no reflex changes
• L4-5 Disk (L4 nerve root): shin numb, weak heel walking, patellar tendon reflex loss
• L3-4 Disk (L3 nerve root): medial knee numb, weak walking up steps, weak patellar tendon reflex
• L2-3 Disk (L2 nerve root): front of thigh pain/numb, weak walking up steps, positive patellar reflex
• L1-2 Disk (L1 nerve root): groin pain/numb, weak squat and steps, no deep tendon reflex
• T12-L1 Disk (T12 nerve root): buttock numb, weak lower abdominal muscles, possible spinal cord compression
In sciatica patients under 55 years of age, the two lowest disks in the lower back—the L4-5 and L5-S1—are the culprit 95% of the time. The good news is that a systemic review of 49 published studies found that spinal manipulative therapy, the primary form of care provided by doctors of chiropractic, is an effective non-surgical treatment option for relieve local and radiating pain in patients with a herniated disk in the lower back.
Even though sciatic pain is often initially sharp and severe, most cases can by successfully managed non-surgically within three to six weeks; however, a referral to a specialist or a referral for advanced imaging (such as an MRI) may be necessary to identify additional pain sources if the patient’s pain persists. Surgery is usually restricted to those who have neurological loss and/or bowel or bladder control problems (the latter may become emergent in order to avoid permanency). As with many musculoskeletal conditions, the sooner one seeks care in the course of the disease, the more likely (and the faster) they will achieve a successful treatment outcome.
Neck Pain / Headaches
Manual Therapy for Neck Pain
Doctors of chiropractic often approach neck pain with manual therapy as the primary
form of treatment. However, there are several types of manual therapy, including high
velocity, low amplitude (HVLA) thrust manipulation; mobilization; and/or soft tissue
techniques. Is one type of manual therapy superior when it comes to managing neck pain?
What does the research show? A 2017 systematic review of 23 randomized controlled trials
compared various manual therapy techniques on their own (or combined), with or without
the addition of specific exercise recommendations.
For acute (recent onset) to sub-acute neck pain, the review concluded:
• High-velocity, low-amplitude thrust manipulation combined with exercise resulted in better outcomes when treatment was applied to the cervical vs. the thoracic spine.
• High-velocity, low-amplitude thrust manipulation combined with soft tissue techniques and exercise applied to both the neck and mid-back led to better outcomes than when soft tissue techniques plus exercise only targeted the neck.
For chronic neck pain, the data show:
• Both HVLA thrust manipulation and soft tissue techniques in addition to exercise are more effective than either manual therapy or exercise alone for improving pain and function.
• Thrust manipulation applied to the neck and mid-back was more effective for improving neck mobility than mobilization.
• Mobilization and soft tissue techniques are both more effective than no treatment for improving pain and disability.
This systematic review favors all types of manual therapies for the management of all stages of neck pain (acute, sub-acute, chronic), especially when combined with exercise. The data also suggests the incorporating treatment of the mid-back may lead to better outcomes.
While manual therapies in general can benefit the neck pain patient, the approach a doctor of chiropractic takes will depend on the patient’s unique case (based on patient history and exam findings) and preferences. For example, a patient may prefer a gentle, low force technique or their chiropractor may use a combination of manual therapy techniques. Additionally, care may also include nutritional/dietary recommendations or physical modalities.
Managing Chronic Hamstring Strains
Chronic hamstring strains are more difficult to diagnose because the pain (in the hip
region and deep in the buttocks and upper thigh) comes on gradually and is aggravated by
repetitive activities like running, rowing, or biking and worsens with prolonged sitting.
Hamstring injuries become chronic when a damaged or torn tendon fails to properly heal, often
caused by returning to the sport too quickly and/or from mismanagement. Chronic tendonitis can
lead to degenerative changes resulting in a weaker tendon, which can lead to long-term pain and
Non-surgical care for chronic high hamstring tendinopathy is often challenging because the usual treatment approaches for acute hamstring strains are less responsive. It’s not unusual for a prolonged recovery of three to six months, with many only partially recovering with a high recurrence rate. Treatment may include:
1) Rest (time away from a sport), though cross training of a different body region during this time can combat the psychological stress associated with chronic injuries.
2) Ice and heat (ice packs, baths, and ice massage is initially recommended to reduce pain and inflammation) applied for ten to twenty minutes, every two to four hours each day. Contrast therapy includes alternating between ice and heat to create a “pump” as heat vasodialates blood vesicles and draws in fluids, which loosens fibrotic scar tissue and relaxes muscles, while ice vasoconstricts and pushes out fluid (inflammation).
3) Because lack of flexibility is “the norm” for chronic high hamstring tendinopathy, regular stretching will be necessary for recovery. Stretches can include lying on the back, pulling the bent knee toward the chest, and slowly straightening the knee; the popular “hurdler” stretch, or sitting with one leg straight on a bench or ground and slowly trying to lock the knee straight while reaching for the toes; or from standing, placing the heel on a chair seat followed by an anterior pelvic tilt (arch the low back by tilting the buttocks upwards).
4) A mix of concentric (resistance as the muscle shortens, such as bringing the heel toward the buttocks) and eccentric (resistance during the opposite of concentric or the straightening of the knee during a hamstring curl) strengthening exercises will typically benefit patients with chronic high hamstring tendinopathy.
Your doctor of chiropractic can guide you in the treatment process as well as address musculoskeletal issues, such as low back pain, that may have preceded the hamstring injury. As is typical with musculoskeletal injuries, the sooner a patient seeks care, the more likely they will achieve a satisfactory treatment outcome.
Carpal Tunnel Syndrome
Tools for Managing Carpal Tunnel Syndrome
In addition to manual therapies and specific exercises to relieve pressure along the
course of the median nerve as it passes through the wrist and elsewhere, doctors of
chiropractic may utilize other high- and low-tech tools to manage the condition:
• Electric stimulation (e-stim) directs an electric current via electrodes placed on the skin over or near the painful area to either stimulate healing (higher frequencies) or reduce pain (lower frequency).
• Pulsed electromagnetic field (PEMF) uses an electromagnetic field to reduce pain, lower inflammation and muscle spasm, stimulate healing, and facilitate nerve and circulatory function. (Note: This cannot be used in a patient with a pacemaker.)
• Ultrasound uses sound waves that travel at 1-3 million cycles per second to cause cells to vibrate and produce heat leading to an increase in circulation and the stimulation of nerve cells to aid in the healing process. There is no sensation because the speed of the sound waves is far too fast.
• Low level laser therapy (LLLT) uses a specific wavelength of light that penetrates the skin to produce therapeutic effects. The term photobiomodulation is often used to describe its beneficial effects—including accelerated tissue repair—and to reduced pain and inflammation. These devices use less than 0.5 watts and are classified as a class IIIb laser, while those this more than 0.5 watts are class IV lasers, which penetrate deeper.
• Dietary modifications and supplement guidance may be offered since consuming foods/vitamins that reduce inflammation may aid in the healing process (Mediterranean diet, ginger, turmeric, Boswellia, etc.).
• Ice reduces inflammation and is beneficial in the acute stages of CTS. This is most effectively applied by directly massaging the wrist/carpal tunnel with an ice cube. Heat may help in the chronic, less inflamed stages of CTS. Rub- or roll-on analgesics may offer short-term pain-reducing benefits.
How your doctor of chiropractic approaches your care will depend on your patient history and examination/diagnostic findings as well as their clinical experience. The good news is the conservative treatment approaches used by chiropractors are often very effective, but if necessary, your doctor of chiropractic can co-manage your condition with other healthcare providers.
Car Crash Characteristics and Whiplash Recovery
While many cases of whiplash that result from a motor vehicle collision (MVC) have a
successful outcome, some experts estimate that up to 25% of whiplash patients will experience
chronic pain and disability. Several studies have sought to identify characteristics that
differentiate these individuals from those who recover so that additional treatment can be offered
to reduce the risk for chronicity. Let’s see if the characteristics of a MVC can shed any light on
In a 2019 study, researchers assessed 37 acutely injured patients within a week of their MVC, two weeks later, and three months later in order to determine any association between pain and disability with both specific crash measurements (head turned at time of impact, seatbelt use, whether or not airbags deployed, if the vehicle was struck while stopped or while turning, the principle direction of force, damage cost estimates, speed of impact, etc.) and patient characteristics (sex, body mass index, signs of post-traumatic distress, negative affect, etc.).
The research team identified a positive association between the percentage of selfreported neck disability at three months post-MVC and post-traumatic distress, negative affect (such as anger or sadness), and uncontrolled pain. There was no direct effect with crash characteristics such as vehicle damage, principle direction of force, or speed change. Though they recommended a larger study to confirm their findings, researchers were unable to establish a link between chronic whiplash pain and disability and specific crash characteristics. That is, there was no apparent connection between a person’s risk for ongoing whiplash issues and the severity of the collision. This study points out that recovering from a whiplash associated disorder requires a biopsychosocial care approach, not just focusing on the biology or tissue damage/diagnosis, but also the patient’s attitude about the injury and getting better.
This echoes a similar study that linked post-traumatic stress disorder (PTSD) with prolonged whiplash associated disorders recovery. In the study, researchers found that hyperarousal/numbing PTSD symptoms were predictive of long-term neck pain-related disability.
In addition to managing musculoskeletal disorders with manual therapies, nutritional recommendations, modalities, and specific exercise recommendations, doctors of chiropractic may utilize more whole body, health-oriented approaches to help patients learn how to relax and reduce stress and anxiety with techniques such as deep-breathing, visualization, contract-relax or tensing exercises, and more. When needed, your chiropractor can coordinate with primary care and specialty care providers, such as mental health counselors and clinical psychologists.
Whole Body Health
Benign Paroxysmal Positional Vertigo Management Strategies
Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo, or dizziness,
that is associated with movement of the head (though some motions may be more problematic
than others) that goes away when movement ceases. Essentially, BPPV is caused by crystals
becoming displaced within the semicircular canals (inner ear), which causes eddy currents in the
fluid that circulates in the canals. Instead of the normal flow that bends small hair-like nerves in
the same direction telling the brain that you’re standing, laying, running, etc., the brain is
essentially given mixed messages of what position you’re in, resulting in a “sea-sickness” type of
There are several “canalith reposition maneuvers” available, and the choice of which maneuver to use depends on which canal(s) is affected. According to the Mayo Clinic, these maneuvers consist of several simple head movements, which can provide release in up to 80% of BPPV patients within a few treatment sessions, though the problem can recur.
In an August 2020 study, researchers set out to determine whether vitamin D and calcium supplementation could prevent the recurrence of BPPV. A group of 518 BPPV patients from eight participating hospitals were provided with a twice daily 400 IU vitamin D and 500mg calcium carbonate supplement for a year. Another 532 BPPV patients served as a control group that did not receive a supplement.
The data show that patients in the supplement group were less likely to experience a recurrence in the following year (37.8% vs. 46.7%), especially those with low vitamin D levels at the start of the study. The researchers concluded that vitamin D and calcium can be considered in patients with frequent attacks of BPPV, especially when their blood level of vitamin D is low.
Interestingly, another study published in August 2020 found that vitamin D deficiency may be associated with up to a 3.29 times increased risk for BPPV recurrence, giving individuals yet another reason to spend time in the sun, take a vitamin D supplement, and eat vitamin D-rich foods to improve their vitamin D status.
A review of your health history and an examination can reveal if your vertigo/dizziness symptoms are indicative of BPPV. If so, your doctor of chiropractic can train you in the various canalith reposition maneuvers to relieve those frequently debilitating symptoms. He or she will also counsel you on nutritional supplementation and diet. As noted in the recent study, the recurrence rate of BPPV is high and the intake of vitamin D and calcium can significantly reduce that rate.
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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.