MONTHLY HEALTH UPDATE
Can the Outcome of Back Pain Be Predicted?
Chad Abramson, D.C.
Low Back Pain
Low Back Pain and Directional Preference for Exercises
Several studies have found that a treatment approach that combines specific exercises with
spinal manipulation, mobilization, and nutrition is often ideal for reducing pain and improving
function in patients with low back pain. But how does your doctor of chiropractic know which low
back exercises to recommend and which to avoid? The answer: it depends.
Because each patient is unique (age, health status, fitness), it’s clear that exercise prescriptions need to be individually tailored to be safe and to avoid injury. Perhaps one of the most important tools your doctor will take into consideration is the concept of directional preference. That is, which position helps your back feel good or bad? From a sitting position, first slump and slouch and then ask yourself, “Does this feel good, bad, or no different?”
Next, sit up straight and arch your lower back and ask the same question. Do you prefer one over the other? If so, the position in which you feel BEST is YOUR directional preference.
Using that concept, let’s say you feel best slumped and slouched, which is quite common. What are the “BEST” exercises for this flexion directional preference (FDP)?
• While laying down and facing upward, pull one knee to the chest followed by the other, repeating five to ten times each (staying within reasonable pain boundaries).
• While laying down and facing upward, flatten and “push” the arch of your lower back into the floor by rocking your pelvis forward and hold three to five seconds, repeating five to ten times.
• While sitting, bend forward and try to touch your toes. Repeat multiple times a day as needed.
If you feel best in the arched sitting posture, then the ideal exercises for you may be those that utilize the extension directional preference (EDP):
• While sitting or standing, place your hands behind your back, and arch your back over your hands (as far as comfortably allowed). Hold for three to five seconds, repeat five to ten times.
• Sit up as arched as your can and try to hold that position as long as possible when doing sitting tasks (computing, driving, etc.).
• Do a “saggy push-up” (also called a “Cobra,” or prone press-up) by keeping your hips on the floor while doing a push-up, arching the low back.
You can improvise and make up your own exercises using this concept, but while some discomfort is to be expected, avoid sharp lancinating pain. If you don’t have a directional preference and feel good in both positions, do ALL of the above! Your doctor of chiropractic can help monitor and train you in these and many more exercises as part of your treatment plan to reduce back pain and improve back function.
Neck Pain / Headaches
Myofascial Trigger Points and Headaches
A myofascial trigger point (TP) is a hyper-irritable area in skeletal muscle that is commonly
detected by palpating (feeling with the fingers). Although more sophisticated ways exist for locating
TPs—ultrasound, microdialysis, electromyography, infrared thermography, and MRI—palpation
remains the most utilized due to its simplicity, efficiency, and low cost. For patients with migraine
and tension-type headaches, TPs are commonly found at the base of the skull/upper neck, paraspinal
neck muscles, the upper trapezius, and/or the levator scapulae musculature.
In one study that included 34 headaches sufferers (20 had migraine headaches without aura and 14 had tension-type headaches) and 34 non-headache controls, researchers looked at what happened when they used a specific technique to recreate the effect of a trigger point on muscles in the upper neck and in the arm.
When the researchers stimulated the upper neck, 8 of the 14 (57%) members of the nonheadache control group, all 14 TTH subjects, and 19 of the 20 migraine sufferers reported headacherelated symptoms. On the other hand, when the same technique was used on the arm of each participant, none reported headache-like symptoms.
The authors concluded that the high incidence and accuracy of headache reproduction from upper neck stimulation supports the importance of evaluation and treatment of trigger points in the upper neck region in those with TTH and migraine headaches. Doctors of chiropractic commonly perform manual techniques to the upper neck region and train their headache patients in identifying and self-managing TPs located in the upper neck muscles.
Several methods can be used to self-treat TPs in the upper neck region. Perhaps the easiest approach is to reach back with your thumb to the muscle attachments along the base of the skull and apply deep (but tolerated) pressure, feeling for areas that are most sensitive and sliding the thumb up/down and across the sore TP until it becomes less tender. Work the left side with the left thumb and vice versa. Doing the same with small head movements—up/down, left/right rotations, etc. helps.
Another method is to sit in a straight-back chair, slide down so that you cradle your upper neck over the top edge of chair back and then roll your head left to right. When you find a sore TP, add a nodding type of head motion while “digging in” over the chair-back edge (within tolerance) until it loosens and hurts less.
If you suffer from headaches, your doctor of chiropractic can train you in these and other effective exercises and render treatment to improve cervical function that can be highly effective at reducing both the frequency and intensity of headaches.
Non-Surgical Care for Rotator Cuff Tears
While the anatomy of the shoulder allows for a wide range of motion and movement, it
comes at the cost of a less stable joint, especially for those who routinely perform activities that
require lifting the arms. This is likely why shoulder pain is one of the leading reasons patients
seek chiropractic care, trailing behind low back and neck pain. The most common cause of
shoulder pain is from tearing of the rotator cuff muscles (RCMs), particularly muscles that rotate
the shoulder outward.
The “typical” rotator cuff tear patient is typically over 50 years of age with shoulder pain that has slowly worsened over time. A 2018 study found that as many as 96% of people over age 50 have RCM abnormalities, of which MANY are asymptomatic or non-painful. The study also reported that 24% of a random sample of 46 young people with an average age of 23 years old with no symptoms and no history of past injury, had degenerative changes in the RCMs. This finding supports the notion that rotator cuff injuries may occur early in adulthood and progress slowly until the symptoms drive a patient to seek care.
In a study involving 167 patients with rotator cuff tears, researchers observed no difference in outcomes one year after participants received either conservative care or surgery. This led the authors to recommend that non-surgical care, such as chiropractic care, should be considered as the PRIMARY method of treatment for rotator cuff tears of non-traumatic origin.
One study looked at impingement syndrome in a case series of four patients who received multimodal chiropractic care that included shoulder manipulation, shoulder girdle exercises, and ultrasound. In all four cases, the patients reported complete resolution of their shoulder pain and disability with five treatments. When researchers followed up with the patients four to eight weeks later, the participant’s symptoms had not returned.
A systematic review of data from 200 articles found evidence for the following nonsurgical treatment options—which are commonly provided in chiropractic clinics—for shoulder pain: exercise training (specific favored over general), manual therapy, laser, extracorporeal shockwave, pulsed electromagnetic field (PEMF), transcutaneous electrical nerve stimulation (TENS), myofascial trigger point therapy, acupuncture, and microwave and light therapy.
For a patient with a rotator cuff tear, conservative chiropractic care is an excellent option for reducing pain and improving function in the affected shoulder!
Carpal Tunnel Syndrome
Manual Therapy vs. Surgery for Carpal Tunnel Syndrome
When people suspect they have carpal tunnel syndrome (CTS), it’s typical that their
first thought is that their condition will require surgery and a lengthy recovery. While surgery
may be warranted in emergency situations, treatment guidelines encourage patients to seek
non-surgical options first. So how do non-surgical approaches like manual therapy
interventions —provided in a chiropractic setting—compare with surgery to treat CTS?
In 2018, a team of European researchers reviewed data from ten studies that compared the effectiveness of surgery vs. non-surgical care for the treatment of CTS. While the results favored non-surgical approaches at three months and surgery at six months, the available data show no difference in outcome one year later. Thus, the research team concluded that conservative treatment should be preferred unless otherwise indicated.
If both surgery and non-surgical options produce similar outcomes at the one-year mark, can CTS improve on its own?
In one study that involved 22 patients (19 of whom had CTS in both hand), researchers incorporated a twelve-week waiting period into the experiment to see if symptoms worsened, stayed the same, or improved. Questionnaires completed by the participants who abstained from manual therapy interventions showed that their symptoms worsened during the twelve-week non-treatment period.
The treatment phase of the study involved six sessions twice a week for three weeks and incorporated manual therapies to address the soft tissues of the hand and wrist and the carpal bones. The patients reported that treatment resulted in improvements with respect to both pain and function. This led the researchers to recommend manual therapy interventions as a valid non-surgical treatment approach for CTS.
Doctors of chiropractic specialize in manual therapy techniques and employ these regularly for many neuromusculoskeletal conditions, including CTS and related conditions that may contribute to a patient’s hand and wrist symptoms—something that a carpal tunnel release procedure cannot address. To achieve optimal results, it’s important to seek PROMPT assessment and non-surgical treatment for CTS.
Chiropractic Care for Whiplash Injuries
Whiplash associated disorders (WAD) describes a constellation of symptoms that can arise
following a motor vehicle collision (MVC), sports collision, or slip and fall. The typical initial
treatment approach for WAD is non-surgical care, but what does the research say is the best nonsurgical approach?
To start, most (if not all) studies on WAD center around the concept of preventing chronicity of WAD. In other words, the GOAL of care is to restore function and get the patient back to their normal lifestyle (work and play), which has been emphasized as being most important, even more so than pain resolution, though the two often go hand-in-hand. What are the best treatments in the initial stages—acute (less than two weeks) and sub-acute (two to twelve weeks)—of healing that can best reduce the risk of a patient developing chronic WAD (over twelve weeks)?
To answer the question, researchers reviewed studies from a 30-year time frame (1980-2009) and published their findings in a five-part series.
The first article in the series offered an overview and summary of the entire work. The second focused on the acute stage which included 23 studies that met the inclusion criteria. The researchers concluded that EXERCISE and MOBILIZATION treatment approaches had the strongest research support—two services STRONGLY EMBRACED by chiropractic.
The third article in the series focused on the subacute stage (2-12 weeks), which included 13 studies. The authors described research support for “the use of interdisciplinary interventions and chiropractic manipulation” but stated that the level of evidence was not strong for ANY treatment approach in the sub-acute stage. Investigators concluded that more research was needed with respect to this stage of care.
The fourth article in the series centered on the chronic stage (more than three months), of which 22 studies were included. Here, EXERCISE programs were reported to offer relief, at least over the short-term, while nine studies supported effectiveness for an interdisciplinary approach. Manual joint manipulation and myofeedback training were also reported as useful for pain relief.
The authors also stated that there was strong evidence to suggest that immobilization with a soft collar was not only ineffective but may impede recovery.
Do you see the “theme” of this research series? Services offered by chiropractic (exercise training, manipulation, and mobilization) are recommended at each stage of WAD recovery!
Whole Body Health
Sleep and Chiropractic Care
The American Sleep Association reports that 50-70 million adults in the United States
(US) have a sleep disorder. Poor sleep is associated with several adverse health outcomes,
including an elevated risk for musculoskeletal pain.
Though the exact mechanisms are not fully understood, the current research suggests the relationship between musculoskeletal pain and sleep disturbance is bi-directional. That is, individuals with a sleep disorder are more likely to develop a pain condition and people with pain are more likely to have trouble sleeping.
Chiropractic care has been studied in many populations where sleep deprivation is common—particularly in patients with fibromyalgia, a condition characterized by sleep disturbance, fatigue, and pain in several sites across the body. One such study published in 2000 reported that fibromyalgia patients who received 30 chiropractic treatments experienced substantial improvements with respect to pain intensity, fatigue, and sleep quality.
In a systematic review, researchers identified 15 studies that associated chiropractic care with benefits for patients with insomnia. For low back pain and neck pain, which are two of the most common sleep interfering chronic conditions, chiropractic management not only helps but it is RECOMMENDED as a first levels of care in clinical guidelines worldwide.
Chiropractic offers the following to help with sleep troubles: manual therapies such as manipulation, mobilization, and soft-tissue work that can help relax the nervous system; nutritional approaches, including the use of supplements like melatonin, L-theanine, 5-HTP (5-hydroxy-tryptophan), and valerian root; weight management (obesity is a risk factor for insomnia); and education/advice on sleeping position, napping, relaxation methods (breathing exercises, mindful meditation), no “screen-time” prior to bed, pillow placement and size, and more.
TAKE HOME MESSAGE: Chiropractic care helps manage pain arising from MANY conditions. Pain interferes with sleep. Sleep is NECESSARY to avoid chronic, disabling conditions (like FM) and maintain a high quality of life, so seek chiropractic care FIRST and sleep well tonight!
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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.