MONTHLY HEALTH UPDATE
Can the Outcome of Back Pain Be Predicted?
Chad Abramson, D.C.
Low Back Pain
Lumbar Disk Herniation Size and Surgery
It stands to reason the more an intervertebral disk herniates, the more it will compress the spinal nerves, leading to a greater likelihood for surgical intervention. But what if that isn’t the case? The current standard treatment of lumbar disk herniation (LDH) involves FIRST the initial use of non-surgical care for at least six weeks. If that fails, a surgical consult can be considered. Exceptions to this rule include the presence of a red flag or a dangerous, potentially life-altering or life-ending condition like infection, fracture (unstable), cancer, and/or cauda equina syndrome (pinched cord altering bowel and bladder control)—all of which are (thankfully) NOT common. In a study that involved 368 LDH patients who underwent at least six weeks of nonsurgical care, researchers observed that 91.3% did not undergo surgery within the following year. A review of MRI findings of the patients who did vs. did not have a surgical procedure showed no difference with respect to what percentage of the spinal canal was inhibited by LDH (31.2% vs. 31.5%). The research team concluded that percentage of canal occluded by LDH does not predict which patients will fail non-surgical care and require surgery. This finding is important because many spine surgeons still use the size of the lumbar disk herniation to determine if a patient is a candidate for surgery. While the findings from the previously mentioned study suggest that 9 in 10 LDH patients can avoid surgery, is there any data to indicate which LDH patients might not respond well to surgical care if they do choose that route? A 2019 study investigated this question and reported that the persistence of leg pain may be a key factor. The authors reviewed 556 patient files over a three-year time frame and found that moderate to severe leg pain at early postsurgical follow-up correlated with higher disability scores over time. This group of patients was more likely have both a history of smoking and chronic back pain. This makes some sense as smokers often face a greater risk for post-surgical complications (many surgeons won’t operate on smokers if they can avoid it) and a history of chronic back pain suggests other factors may be responsible for the patient’s current pain and disability, not just the LDH. The good news is that treatment guidelines support chiropractic care as a non-surgical option for the LDH patient through a combination of spinal manipulation, mobilization, specific exercises, modalities, and nutritional recommendations.
Neck Pain / Headaches
Chiropractic Care for Migraines
Migraine headaches can have a serious impact on one’s quality of life and their ability to carry out their daily activities, both at home and at work. While chiropractic care has been demonstrated to be effective for tension-type and cervicogenic headaches, what does the literature say about its effect on migraines? The first thing to understand is that while migraines may not necessarily be caused by cervical dysfunction, it’s becoming increasingly clear that issues in the neck may play some role in the migraine headache process. For example, in a 2019 study published in the European Spine Journal, researchers examined the neck of 52 female migraineurs and 52 women without a history of neck pain or headaches and found that participants in the migraine group were significantly more likely to exhibit cervical dysfunction. Another 2019 study, this time published in the journal Cephalagia, reported that migraine patients with concurrent neck pain had significantly more migraine-related disability than those without neck pain. Other studies have shown that individuals with migraines are more likely to have trigger points in the cervical muscles. So, can chiropractic treatment to improve cervical function benefit migraine patients? A review of data from six randomized control trials that included a total of 667 migraine headache patients who received spinal manipulative therapy (SMT) concluded that SMT is “an effective therapeutic technique to reduce migraine days and pain/intensity.” What can a migraine patient expect when they visit a doctor of chiropractic? First, the patient will undergo a thorough examination to determine which locations in the cervical region to apply treatment, usually by examining the degree of joint “play” or restriction, point tenderness, and localized muscle guarding using static and motion palpation methods. The treatment approach will typically include a combination of spinal manipulation, mobilization, specific exercises, modalities, and nutritional recommendations, depending on the patient’s needs and preferences.
The Various Causes of Hip Pain
Hip pain is a VERY common problem among older adults that can affect their ability to remain independent. While it’s common to assume that hip osteoarthritis (HOA) is responsible for the prevalence of hip pain in the aging population, the Framingham Osteoarthritis Study (FOS) found this isn’t always the case. The authors of the FOS reported that the presence or absence of HOA on x-ray correlated poorly with hip pain. Of the participants with frequent hip pain, only 15.6% had x-rays showing HOA. On the other hand, only 20.7% of the men and women with x-rays that showed evidence of HOA had frequent hip pain! If only about one-in-six patients with hip pain have HOA, where is their hip pain coming from? A common cause is bursitis. The bursae are fluid-filled sacs located near joints and muscle tendon attachments that cushion and protect the area. Bursitis is an inflamed bursa and is usually the result of trauma̶—repetitive over time or after a one-time macro-traumatic event, like a sports injury. Hip synovitis (HS) is an inflammatory condition of the hip’s synovial membrane (SM) that is located within the joint capsule. The function of the SM is to lubricate and nourish the cartilage and bones inside the joint capsule. The SM is what causes a joint to rapidly swell after an injury (think knee or ankle injury with LOTS of swelling). Due to the deep nature of the hip joint, swelling is not visible from the outside. Hip synovitis can result from trauma, such as a labral tear where the thin ring of cartilage or labrum (located on the rim of the hip socket) tears. The labrum cushions the hip joint and acts like a rubber seal or gasket that helps hold the ball into the hip socket. Sports and slip-and-fall injuries can cause labral tears. Other causes of hip pain include arthritis (several types), injury (bursitis, synovitis, dislocation, fracture, labral tear, inguinal hernia, sprains, tendinitis, or strains), pinched nerves (sciatica, femoral nerve pinch), cancer, and more. What do chiropractors do for hip pain? The first step is to establish an accurate diagnosis using the patient’s history, a thorough examination, and diagnostic tests such as x-rays or even an MRI, when warranted. If infection or certain types of arthritis are suspected, a patient may be referred out to their medical physician for blood tests. If the cause is musculoskeletal in nature, treatment may include manipulation, mobilization, and soft tissue therapy of the hip and nearby joints, including the pelvis and low back. Patients may also receive nutritional and exercise recommendations to reduce inflammation and aid the healing process.
Carpal Tunnel Syndrome
The Cost of Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy—or pinching of a nerve outside of the spine—affecting between 3-6% of the population. While we usually focus on how carpal tunnel syndrome is managed, in this article we’re going to focus on why CTS is one of the costliest musculoskeletal disorders. The symptoms associated with CTS (pain, numbness, tingling, and weakness) tend to come on gradually and worsen over time. Because of this, many CTS patients delay seeking care, often only consulting a doctor when their condition severely limits their activities. Generally, the longer a musculoskeletal condition persists, the more care that may be needed in order to achieve a satisfactory outcome for the patient. The type of care sought by the patient is also a major factor in the ultimate cost for CTS treatment. In one study that monitored 120 women with diagnosed CTS for one year, the researchers found that those treated with manual therapies—such as those provided by doctors of chiropractic— reported similar improvements at the one-year mark as participants who underwent a surgical procedure, with an average cost savings of $2,800.00 per patient. The patients in the manual therapy group also required fewer visits with healthcare providers and missed fewer days of work for recovery. Work absenteeism is another major cost associated with carpal tunnel syndrome. One report found that the average CTS patient can miss up to 27 days of work per year. The same study also reported that up to 18% of CTS patients leave their job within 18 months. It’s estimated that when healthcare costs, reduced productivity, missed work, and the potential for lost income due to changing careers are considered, the typical carpal tunnel syndrome case may have an overall cost on society of between $47,000 and $119,000! That’s not to mention the impact CTS can have on one’s hobbies, ability to carry out daily tasks, and relationships with friends and loved ones. With all this in mind, what can be done to reduce the impact CTS could potentially have on you? While there are some risk factors beyond our control such as genetics or biology (women are three times more likely to develop CTS than men, for example), there are some steps that can be taken to reduce the risk for the condition. First, understand that CTS is generally caused by inflammation in the carpal tunnel that places pressure on the median nerve as it travels through the wrist. Some modifiable causes of inflammation in the wrist can include conditions like diabetes, obesity, awkward hand postures, prolonged exposure to vibrations, and both forceful and repetitive hand motions. If you feel numbness, tingling, or pain in the hand or wrist, don’t just flick your hand until it resolves and go on with your life. The sooner you seek care, the less likely the condition will have a major effect on your ability to carry out your usual activities, including work! Treatment guidelines recommend trying non-surgical approaches first, of which chiropractic care is a highly effective option.
A Cause of Post-Whiplash Headaches
Headaches are a common complaint among patients with whiplash associated disorder (WAD) following a motor vehicle collision, slip and fall, or sports injury. While in some cases, the cause of WAD-associated headache can be a concussion or traumatic brain injury (TBI), in many instances the underlying cause of WAD-related headaches can be injury to the neck. How is this possible? Past research has demonstrated that irritation of the nerves that pass through the top of the cervical spine (C1, C2, and C3) can lead to tension-type or cervicogenic headaches, especially when the C2 nerve is involved. These nerves exit the spine and travel through a thick group of muscles located at the top of the neck/base of the skull or “suboccipital” region. In a 2019 study, a group of anatomists discovered the close relationship of the greater occipital nerve (C2) and a muscle called the obliquus capitus inferior (OCI) and sought to determine how the C2 might get “pinched” in injuries such as whiplash. The authors studied 20 cadavers and found three patterns. The nerves either travelled loosely around the muscle (Type I), were incorporated in the dense muscle fascia (Type II), or travelled directly through a myofascial sleeve within the muscle (Type III). Among the 40 C2 nerves (there is a left and right), the research team found seven instances of Type I, thirty-one instances of Type II, and two instances of Type III. Because of the intimate relationship between the OCI and C2 nerve, it’s understandable that during the whiplash process, the stretching of C2 nerve combined with the contraction of the OCI could set the stage for injury to the nerve. Doctors of chiropractic frequently find that WAD patients have a great deal of tenderness in the suboccipital region and respond well to upper cervical spinal manipulation and mobilization. When these muscles are more relaxed, neck pain and headaches often improve. Similarly, exercises that focus specifically on this region help the patient self-manage headaches and neck pain, which reduces the need for medications, many of which have negative side-effects. One such exercise is called the cervical brace. This is done by kneeling on all fours and is broken down as follows: 1) “poke” your chin/head straight down toward the floor; 2) in a smooth scooping motion, tuck your chin down (chin-to-chest); 3) and then scoop your head back up to neutral keeping the chin tucked. Repeat in a smooth scooping motion (avoid doing it “steps”). Repeat until your neck feels loose. You may notice some painless popping, crunching sounds as you do the exercise. As modifiers, try it sitting or standing, with or without resistance applied to the forehead. Studies show neck pain and headaches arising from WAD injuries respond very quickly to chiropractic care. Please consider chiropractic care FIRST in your post-WAD management process!
Whole Body Health
Infantile Colic and Chiropractic
Infantile colic (IC) is a distressing common childhood condition that affects 5-20% of infants. The condition is characterized by excessive crying, fussing, and irritability during the first five months, often with no obvious cause. Over the last fifty years, researchers have sought to understand the cause of infantile colic. Some hypotheses include formula intolerance, an immature gastrointestinal tract, food allergies, intestinal cramping, and excessive gas, as well as psychosocial causes, such as maternal anxiety and/or maternal-infant bonding issues. Because the cause of IC has proven elusive, there are few treatment options available to parents. In an effort to find a solution, many sleep-deprived mothers and fathers seek out complementary and alternative medicine (CAM) approaches, which includes chiropractic care. A 2019 study looked at the available research regarding CAM and infantile colic and found the following approaches showed promise to alleviate symptoms of colic (however, larger studies are needed to confirm these findings): Fennel is an herb from the carrot family that is a rich source of thiamine, riboflavin, niacin, vitamin B6, vitamin C, calcium, iron, magnesium, manganese, phosphorus, potassium, and zinc. While there is some evidence that a mixture of water and fennel can help alleviate colic symptoms, it’s unclear how fennel benefits the colicky baby. Probiotics seem to be most effective in breastfed infants with colic while more research is needed regarding babies with IC who are on a formula diet. One study showed that gentle chiropractic manipulation reduced daily crying time in colicky infants by nearly 1.25 hours a day. When all serious diagnoses have been excluded, it has been suggested that it may be appropriate to utilize a four-to-six treatment trial to determine the effectiveness of gentle chiropractic care for a colicky infant. While many doctors of chiropractic have received training on using gentle treatment approaches on pediatric patients, some may prefer to refer the care of babies and small children to chiropractors who specialize in caring for this population.
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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.