MONTHLY HEALTH UPDATE
Can the Outcome of Back Pain Be Predicted?
Chad Abramson, D.C.
Low Back Pain
Poor Seated Posture and Low Back Pain
We’ve all been told—especially as children—to stop slouching and to stand or sit up straight.
As it happens, this is great advice to keep the spine healthy and reduce the risk for a painful low back
A landmark 1981 study calculated the amount of pressure placed on the intervertebral disks in the lower back in various positions. A neutral standing position places about 100 pounds per square inch (lbs/in2 ) of pressure on the disk in the low back and laying supine (facing up) cuts the pressure dramatically to 25 lbs/in2 . On the other hand, when subjects stood leaning forward or sat slouching forward, the pressure placed on the lower back disks jumped as high as 275 lbs/in2 . All this added pressure can place the disks at increased risk for injury, which can have a dramatic effect on a patient’s ability to carry out their daily work and life activities.
To maintain and improve one’s posture (either standing or sitting), Harvard Medical School recommendations the following: 1) Visualize: Think of a straight line that passes evenly through the ears, shoulders, hips, knees, and ankles (when standing). Then imagine a strong cord attached to the top of the head pulling you upwards, making you taller (i.e., “stand tall”). 2) Shoulder blade squeeze: Sit up straight in a chair, relax the arms with the shoulders down (no shrugging), breathe deeply, and draw the shoulders back and squeeze the scapulae together keeping the chin tucked in. Repeat three to four times. 3) Chest stretch: Stand facing a corner and place your forearms and palms on each of the two walls and straddle your feet one in front of the other. Lean forward until there’s a strong stretch in the chest muscles. Hold for 20-30 seconds and take deep breaths. 4) Arm-across-chest stretch: Raise the right arm forward to shoulder height and bend at the elbow. Grasp the right elbow with the left hand and gently pull it across your chest until you feel a strong stretch in the right shoulder and arm. Hold for 20 seconds and repeat on the opposite side and repeat three times.
What about individuals who already have injured or degenerated lumbar spinal disks? What can they do to sit as pain-free as possible? In a 2018 study, researchers evaluated lumbar disk patients as they sat in various types of chairs and found that a kneeling chair is best for keeping the spine in a neutral posture, reducing the pressure on the disks. Additionally, a study published in 2021 showed that trunk muscle activity increases when patients with chronic back pain slouch forward, which means poor posture isn’t even relaxing.
In addition to providing advice and exercises for improving posture, your doctor of chiropractic can provide treatment to restore normal movement to the lumbar spine to reduce low back pain and disability.
Neck Pain / Headaches
Chiropractic Care for Older Headache and Neck Pain Patients
Neck pain and headaches are a leading cause of pain and suffering that affects
hundreds of millions of seniors worldwide. Until recently, the use of chiropractic care for
elderly adults with headaches and/or neck pain has been poorly understood. Let’s investigate
the effectiveness of chiropractic care for the elderly who are affected with these conditions.
Questionnaires completed by 288 doctors of chiropractic revealed that close to a third (28.5%) of their caseload are patients over the age of 65, of which 45.5% presented with neck pain and 31.3% had co-morbid headache. For these patients, treatment typically consisted of a combination of physical (exercise training, traction, e-stim and/or ultrasound) and manual therapy treatments (spinal manipulation, mobilization, soft tissue therapies, and/or massage) applied to the thoracic and cervical spinal regions. On average, patients required nine visits to achieve a satisfactory outcome; however, migraine patients usually required two additional visits, on average.
The authors concluded that the chiropractors surveyed used well-established conservative techniques to effectively manage neck pain the elderly population. Additionally, the researchers note that 82% of the patients in the study utilized at least one additional health service to help manage their condition.
A 2017 collaborative study between the World Health Organization (WHO) and the “Lifting the Burden” campaign emphasized the importance of interdisciplinary collaboration in the management of patients with headaches. Indeed, the study cited that patients have a “clear preference” for the use of complementary and alternative treatments for headaches, of which spinal manipulation is listed as a highly effective treatment strategy. Other studies have noted that chiropractors are one of the most common provider types for patients with migraines, and nearly a third of such patients seek out chiropractic care.
While this article mainly focuses on chiropractic care for the management of neck pain and headache in older adults, patients of all ages can benefit from a multimodal approach that includes manual therapies, specific exercises, nutrition recommendations, etc. to restore normal motion to the neck, shoulders, and upper back to reduce pain and disability.
Manual Therapy for Knee Pain
Knee pain is a common complaint, and patients often wonder if manual therapies provided by
a doctor of chiropractic can help manage their knee pain. In many cases, the answer is yes. Let’s take
a look at what the research has to say about using manual therapy to address two frequent causes of
knee pain and disability: knee osteoarthritis (KOA) and patellofemoral (PF) pain.
A recent systematic review and meta-analysis (the highest regarded level of research) studied the effectiveness of manual therapy for relieving pain, stiffness, and dysfunction in patients with KOA. The review uncovered 14 studies that showed that manual therapy offered “statistically significant” benefits in relieving pain, stiffness, and improving function, with the best results obtained when treatment extended for four or more weeks. The authors concluded that manual therapy is effective and safe and offers a complementary and alternative treatment option for KOA.
In a 2021 study, researchers found that KOA patients who received treatments that included manual therapy and supervised exercise experienced more significant improvements in pain and functions than participants in a supervised exercise-only group.
In 2018, an international panel of 41 specialists released a consensus statement following their review of the available literature with respect to the treatment of PF or kneecap pain and made strong recommendations in support of the use of exercise therapy (especially when combined with hip- and knee-focused exercise) and foot orthoses to improve PF pain and/or function. Researchers also found support for manual therapy applied to the soft tissues, dry needling, and gait retraining; however, they required additional evidence prior to issuing a strong recommendation for these treatment options.
A 2020 study reported that mobilization is an effective treatment in both weight bearing and non-weight bearing positions. Another study published in the same year recommended addressing alignment, muscle imbalance, and patellar maltracking in runners with PF pain.
A literature review published in 2021 highlighted the importance of patient education (PE) with and without targeted, knee-specific exercise intervention as important components of care in decreasing pain and improving function in patients with PF knee pain. The review recommended including individualized PE to each patient that focuses on the latest effective treatments, selfmanagement strategies (specific exercise training), and an explanation of risk factors and movement patterns that may lead to and/or exacerbate PF pain.
For both PF and KOA, doctors of chiropractic utilize a multimodal approach that may include patient education, focused exercises, manual therapies, posture correction, gait retraining, nutrition recommendations, and prescription foot orthotic fitting, if necessary.
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome Diagnosis
Despite being the most common entrapment neuropathy (pinched nerve) in the
extremities, a gold-standard test for diagnosing carpal tunnel syndrome (CTS) has yet to be
established. In part, this is due to how the symptoms develop from patient to patient, as well as
the presence of other conditions that can result in a similar collection of symptoms. So when a
patient presents with suspected CTS, how does their doctor of chiropractic determine if it’s CTS
or something else?
The most useful starting point is a review of the patient’s history, which can reveal factors that point to the possibility of carpal tunnel syndrome, such as a job that requires forceful gripping of heavy tools. On the other hand, if a patient has a history of neck pain or whiplash, then it would make sense to evaluate the neck as a possible source of median nerve entrapment or the history may point to potential contributing factors, such as hormonal issues, that may require co-management with another healthcare professional.
Patients may also complete a CTS-specific questionnaire to collect data on the symptoms they’re experiencing, the location of the symptoms, and the intensity of the symptoms (typically on a 0-10 scale where 0=no pain and 10=excruciating pain).
The subsequent examination will follow the course of the median nerve to determine if there is pressure on multiple sites. At this point, a doctor of chiropractic may have a fairly strong suspicion on what is causing the patient’s symptoms, and he or she can formulate a treatment recommendation.
However, if the case is complicated, the patient may be referred for more advanced testing—like electrodiagnostic testing—to confirm the diagnosis. Because these tests can be unpleasant and painful to the patient and there is up to a 34% possibility for a false positive, it may sometimes be more useful to inform a diagnosis rather than as the initial means to make a diagnosis. This was confirmed by a 2018 study that concluded that electrodiagnostic testing is not a reliable screening method for determining the severity of CTS.
During the course of care, patients may also be asked to complete short assessments, such as the Boston CTS Questionnaire (BCTSQ) that includes eleven questions (scored 1-5 for “normal” to “very severe”) for symptoms and eight questions for function (scored 1-5 for “no difficulty” to “cannot perform the activity at all due to hand and wrist symptoms”). Not only does this information help track a patient’s progress to determine if the treatment plan needs modification but it can be used to prove “medical necessity” to the patient’s insurance company.
The Chiropractic Treatment Approach for Whiplash
Whiplash associated disorders (WAD) describes a constellation of symptoms (neck pain,
headache, mental fog, radiating arm pain, mid- and/or lower-back pain, neck and upper back
stiffness, muscle spasms, fatigue, anxiety, memory loss, etc.) that can result from the sudden
forward and backward whipping motion of the head and neck. While motor vehicle collisions are
most often associated with WAD, such an injury can also stem from a sports collision, fall, and
physical abuse/trauma. Since the condition is a common reason individuals are referred for
chiropractic care, let’s take a look at how WAD is diagnosed and managed.
Your doctor of chiropractic will ask you to complete initial paperwork that includes the usual biographical data as well as questionnaires specific to the event that caused the WAD injury. The physical examination will include various movement tests to help them determine the pain generator(s) and whether or not there is neurological injury. X-rays taken from the front, side, and at the end range of motion may be used to assess ligament integrity. If necessary, advanced imaging—a CT scan or MRI, for example—may be ordered to provide a clearer picture about damage to the soft tissues (such as the disks).
The current treatment guidelines for WAD recommend therapies that promote restoration of motion and for patients to continue activity as much as “normal” since immobilizing the neck (by wearing a cervical collar, for example) can actually delay recovery and prolong a return to normal activity. Doctors of chiropractic are trained to employ a number of manual therapy options for reducing pain and disability to facilitate the healing process. In-office treatment may also include massage and physical therapy modalities like electric stim, ultrasound, laser, magnetic field, and more.
A chiropractor may also prescribe specific exercises for the patient to perform at home to strengthen the deep cervical muscles and to improve the patient’s range of motion. To manage pain and inflammation, the patient may also receive instruction on the application of heat and/or ice, as well as recommendations for natural anti-inflammatory agents like ginger, turmeric, bioflavonoids, or to reduce their intake of processed foods, which can promote inflammation in the body. If brain injury is present, chiropractors frequently partner with other healthcare professionals who specialize in such matters. Often, a team approach will offer the best outcomes in more complicated cases.
Since studies have demonstrated that WAD patients who delay care are more likely to develop chronic symptoms, it’s important to receive a thorough examination of the neck and associated soft tissues sooner rather than later.
Whole Body Health
Does Lowering Cholesterol Reduce Cardiovascular Disease Risk?
For decades, the public has been told that elevated cholesterol levels are a major cause of heart
disease and stroke. However, in recent years, researchers have begun to question this notion.
In an article published in the BMJ (formerly the British Medical Journal) in 2020, an international group of authors discussed the controversy surrounding the use of current recommended cholesterol targets to determine who should be prescribed a statin medication (a primary tool for lowering cholesterol levels). They state the current important targets include: 1) patients who have sustained a cardiovascular event; 2) adult diabetic patients; 3) individuals with low density lipoprotein cholesterol (LDL-C) levels over 190 mg/dl; and 4) individuals with an estimated ten-year risk greater than 7.5%.
However, the authors note that a systematic review of 35 randomized control trials concluded that achieving these cholesterol target levels DOES NOT confer any additional benefit and that using these targets failed to identify many high-risk patients resulting in unnecessary treatment of low-risk individuals and vice versa. Researchers concluded that using LDL-C is questionable as an appropriate target for preventing cardiovascular disease. Further, they describe the significant discordance between well-accepted clinical guidelines and the empirical evidence gleaned from dozens of clinical trials that cholesterol lowering does not reduce cardiovascular disease (CVD) risk or mortality.
Similarly, an April 2018 Journal of the American Medical Association study called SPRINT (Systolic Blood Pressure Intervention Trial) concluded that participants over the age of 65 years old without diagnosed CVD who were taking statins at baseline had no significant differences in primary outcomes when compared to those not taking statins, with or without adjustment for nonrandom statin use and regardless of the ten-year cardiovascular event risk level based on survival/mortality.
So, what DOES increase the risk of heart disease and premature death? An important answer to this question was found in a 2019 study that looked at lifestyle factors and high-risk factors for developing atherosclerosis cardiovascular disease (ASCVD). The study concluded that high-risk lifestyle factors such as poor diet quality, sedentarism, ambient air pollution and noise, sleep deprivation, poor gut health, and psychosocial stress ALL affect numerous direct and indirect pathways that lead to ASCVD.
These are all factors linked to elevated inflammation in the body, suggesting that systemic inflammation may be a primary driver of ASCVD and strategies to reduce inflammation may be the key to reducing one’s risk for cardiovascular disease. These strategies include eating a heart-healthy diet, limiting sedentary behaviors, getting regular exercise, maintaining a healthy weight, not smoking, avoiding excessive alcohol intake, getting plenty of quality sleep each night, reducing exposure to pollutants, and managing stress. If aches and pains are affecting your ability to live a healthier lifestyle, schedule an appointment with your doctor of chiropractic.
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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.