MONTHLY HEALTH UPDATE
Can the Outcome of Back Pain Be Predicted?
Chad Abramson, D.C.
Low Back Pain
Treating Low Back-Related Leg Pain
Low back-related leg pain (LBRLP) is a common condition that drives patients into
primary care clinics, including chiropractic offices, but these cases are often complex, and
determining the underlying cause can be clinically challenging. Let’s take a look at the
current treatment strategies for LBRLP.
To begin with, the patient’s doctor will need to determine if the leg pain is radicular or referred in nature as this will help indicate which structures or soft tissues in the lower back will need to be addressed. The term “radicular” is reserved for the presence of nerve root compression or a pinched nerve root, most commonly caused by a herniated low back disk. Referred leg pain arises from a ligament, joint, or a tear in the outer layer of the disk (which can precede herniation).
Some clinical signs and symptom that support radicular leg pain include a more specific geographic tracing of leg pain that often exceeds the level of the knee affecting the outer foot (S1 nerve), the top of the foot (L5 nerve), or the inside of the foot (L4 nerve). In radicular LBRLP, there may also be neurological loss such as sensory impairment and/or muscle weakness in a specific area or in certain muscles that can help determine the specific nerve(s) involved. Patients often describe referred leg pain as a generalized deep ache or numbness that often stays above the knee. It’s also possible for the patient to have multiple contributing causes for their LBRLP, which can make the diagnostic process more complex.
From a treatment standpoint, studies show a lack of long-term benefits for managing LBRLP with prescription medication, epidural corticosteroid injections, and surgery. However, there is evidence that spinal manipulation—a treatment provided by doctors of chiropractic—is more effective than no treatment, passive modalities, and exercise in managing LBRLP. In fact, a 2019 survey of 1,907 chiropractors revealed that 81% often treat patients with LBRLP.
More recent research suggests combining spinal manipulative therapy with exercise, and patient education may provide even better results for patients with LBRLP. This makes sense as there have been several studies showing that a multimodal management approach for low back conditions such as degenerative joint and/or disk disease, spinal stenosis, and disk herniations is often superior to a single treatment strategy.
Neck Pain / Headaches
Chiropractic Management of Neck Pain and Headache
Neck pain and headaches often co-occur and are two of the most common reasons
patients seek chiropractic care. Thus, it’s important for a doctor of chiropractic to conduct a
careful history and examination to determine if the patient’s headaches and neck pain are indeed
related or if the issues need to be addressed independently. Here’s the process most patients with
a combination of neck pain and headaches can expect when consulting with a chiropractor.
Doctors of chiropractic start out with a past history that includes the following: 1) prior injuries or accidents; 2) family history, social history (including education level and occupation, sleep habits, tobacco/alcohol use, and more) 3) allergy history; 4) vaccination history; 5) current medication use to identify potential side effects; 6) review of your systems (cardiovascular, respiratory, ears/nose/throat, genito-urinary, and more).
The present history then looks at each complaint individually to determine onset, palliative, and provoking positions/activities/situations, quality of symptoms, radiation and location of complaints, severity of complaints (pain—right now, on average, at best and at worst), and timing (better in the morning or night, work-relatedness, hormonal shifts, or patterns).
The examination may include vital signs (blood pressure, pulse, respirations, height, weight, temperature, etc.); observation of posture, gait, movement, affect, facial grimace; palpation of muscles, trigger points, joint noise (crepitation), warmth; orthopedic tests that provoke an increase and/or decrease in pain/symptoms; neurological tests; and consideration for special tests like x-ray, blood tests, or specialty evaluation.
This information results in a working diagnosis from which a doctor of chiropractic can create a treatment plan for the patient. Commonly used approaches you can expect from your chiropractor may include manual therapies such as spinal manipulation (thrust and non-thrust types); mobilization (stretch-type); “drop table” methods; manual traction, trigger point, and other “soft-tissue” techniques; and modalities such as vibration, ice/heat, electric stim, ultrasound, and more. Additional self-care or at-home strategies may include specific exercise training, posture retraining, nutritional recommendations, and activity modifications.
Some patients may experience initial soreness following their first treatment but will typically feel improvements in pain and disability following a handful of visits, at which time their doctor of chiropractic may adjust the treatment plan or release the patient from care.
Hip Pain and Total Hip Replacement
According to medical historians, the first artificial total hip arthroplasty (THA) was
performed in Germany in the early 1890s. Since then, there have been many advancements in
the design of the artificial hip and how the procedure is performed, even to the point of the
introduction of the minimally invasive total hip arthroplasty, or miTHA, which offers similar
long-term outcomes but involves only a small incision size results in less pain and disability
in the surgical recovery period. An individual with pain or mobility issues associated with
hip dysfunction may wonder if a hip replacement is in their future, but how would they
It's estimated that more than half of hip fractures occur at the femoral neck or the angled bony stem that connects the thigh bone to the “ball” of the hip. Several studies have shown that when a femoral neck fracture does not initially lead to a hip replacement, there is a high risk for osteonecrosis, or the death of the bone due to reduced blood supply, which would need to be addressed with THA. Hence, individuals with a history of hip fracture and progressively worsening pain may be a THA candidate.
But what about those without a history of hip fracture? At the end of the 20th century, most THA patients were over 60 years old, and the advice from clinicians was to wait as long as possible before undergoing the procedure. In recent decades, that advice has shifted with some patients opting for THA in middle age.
However, one reality about surgery is that it can’t be undone if it doesn’t resolve the problem, and there is always the risk of complications. That’s why treatment guidelines often recommend exhausting non-surgical options before consulting with a surgeon. For the patient with hip pain and disability, chiropractic care may be a non-surgical approach worth considering.
Depending on examination findings, treatment may involve the application of manual therapies, modalities, and specific exercise recommendations to restore normal motion to the hip joint. Additionally, a doctor of chiropractic will look for potential issues elsewhere that may be placing added stress on the hip, such as the knees, ankles, and lower back. In many patients, there may be several contributing causes to the patient’s chief complaint, and each will need to be managed to achieve an optimal outcome.
Carpal Tunnel Syndrome
Chiropractic Care for Carpal Tunnel Syndrome
While many people may consider carpal tunnel syndrome (CTS) to be the default cause of
any pain, numbness, tingling, or weakness in the hand and/or wrist, the condition is more complex. In
some cases, a patient with such symptoms may not have CTS at all. So when a patient comes into the
office to be evaluated for CTS, how does their doctor of chiropractic determine if CTS is the culprit
and how is the condition managed?
To begin, CTS occurs when the median nerve is compressed as it travels through the wrist, which can result in pain, numbness, tingling, and weakness in the thumb, index, middle, and the thumb side of the ring finger. Traditionally, investigators believed the compression of the median nerve itself was responsible for generating these symptoms, but recent studies suggest it may be reduced mobility of the median nerve that’s to blame or it may be a combination of both compression and loss of nerve mobility.
If the patient’s symptoms are localized to the thumb and the first three fingers, as described above, then the median nerve may be affected. However, if symptoms occur on the other side of the ring finger and the pinky, then a different nerve, the ulnar, may be entrapped.
The median nerve itself doesn’t just appear at the wrist. It arises from the neck, passes through the shoulder, and runs down the arm. Compression of the median nerve at any of these locations can result in CTS-like hand and wrist symptoms, even in the absence of symptoms further up the course of the nerve. Additionally, compression can occur in multiple locations, which is described as double- or multi-crush syndrome. This was first reported in 1973 by Upton and McComas, and since then, multiple studies have reported that when a nerve is compressed in more than one location, it becomes hypersensitized and is more susceptible to damage or injury.
When median nerve entrapment is suspected, a doctor of chiropractic will examine the entire length of the nerve to identify all possible issues that should be addressed. If the contributing factors are musculoskeletal in nature, then treatment may include manipulation, mobilization, soft tissue work, modalities, nocturnal splinting, workstation modifications, stretches, and at-home exercises to reduce pressure on and increase the mobility of the median nerve. Changes in hormone levels can also lead to swelling of tissues that surround the median nerve. In which case, co-management with the patient’s physician may be required to achieve an optimal outcome.
The good news is that the non-surgical, multi-modal approach used by doctors of chiropractic is highly effective in patients with CTS, especially if the patient seeks care early in the course of the disease when the symptoms are milder.
Screening for Both Concussion and Whiplash
Whiplash injuries are often associated with car accidents and concussions are typically connected
with sports collisions, but there’s a growing body of research suggesting that patients should be screened
for both conditions following either type of incident.
In one study, researchers measured the forces applied on the brain both as it impacted the headrest during a rear-end collision and when struck from the rear while wearing a football helmet. They found similar head angular velocities between both crash simulations, suggesting both types of collision can result in brain injury.
On the other hand, a 2015 study reported that athletes with stronger deep neck flexor muscles experienced a faster recovery after a concussion. Past research has also indicated that stronger neck muscles may reduce the severity of whiplash injury to the neck during a motor vehicle collision. This data suggests that reduced injury to the cervical spine and associated tissues during a collision may lessen the severity of an accompanying concussion.
In a 2019 study published in the Journal of Orthopedic Sports & Physical Therapy, researchers reported that the overlap in symptoms between whiplash and concussion are strikingly similar, but the guidelines for diagnosis and treatment for the two are implemented separately, which could potentially lead to misdiagnosis and a delay in appropriate management, along with an increased risk for a poor outcome. The authors concluded that proper assessment and management should incorporate the principles set forth in BOTH whiplash and post-concussive guidelines. Moreover, coordinating other diagnostic principles such as imaging guidelines should also be incorporated to offer these patients optimum quality assessment and management strategies.
These suggestions are backed by a series of case studies of whiplash-injured patients with symptoms that suggested co-existing post-concussion syndrome. The patients reported improvements in function following a course of treatment derived from guidelines for managing both whiplash and postconcussion syndrome.
Likewise, a study published in 2015 by authors affiliated with Canadian Memorial Chiropractic College revealed that the post-concussive syndrome patients experienced favorable outcomes when they received treatment similar to that provided to whiplash associated disorder patients to restore function in the cervical spine.
These findings suggest that whiplash and concussion commonly co-occur, and patients should be screened for both, regardless of how the injury occurred, whether from an automobile crash or a sporting collision. Treatment guidelines show that the non-surgical, conservative treatment provided by doctors of chiropractic is an excellent option for these types of injury.
Whole Body Health
Vitamin C Truths and Myths
Ever since Dr. Linus Pauling wrote about vitamin C (ascorbic acid) and its ability to fight
the common cold, controversy has persisted about the value of vitamin C, how much is needed,
and how to get it into the body. Let’s discuss some truths and myths about vitamin C…
MYTH: Blast a cold with vitamin C. It can fight it off! Though a lot of people ramp up their vitamin C intake during the winter months in the quest to avoid getting a cold, this unfortunately may not be as helpful as we think. While some research found that those who take vitamin C regularly may be sick for a slightly shorter duration (about 8% in adults, and up to 18% in kids that took 1-2 g/day or 1000-2000 mg/day) or have milder symptoms, for most people, boosting vitamin C does not reduce the risk of coming down with the common cold.
TRUTH: In many Western countries, like the United States and Canada, vitamin C deficiencies are rare. Although our bodies cannot produce vitamin C and we have to get it from food, most residents in richer countries are successful in getting enough in their diet to avoid deficiency symptoms such as bleeding gums, nosebleeds, joint swelling, dry/rough skin, and bruising. The minimum daily dose to target is 75mg for women and 90mg for men, though many experts believe this should be increased to 200mg/day, which is the minimum needed to saturate the body. Scurvy can be prevented with as little as 10mg/day.
MYTH: Citrus is the best source of vitamin C. Just one cup of bell pepper offers 200- 300mg of vitamin C compared with 70mg from an orange. Other good (and non-citrus) sources include broccoli, brussels sprouts, kiwi, strawberries, papaya, pineapple, and cantaloupe.
TRUTH: Reduce obesity risk by improving vitamin C intake. A study conducted by researchers at Arizona State University found that a low blood level of vitamin C has been linked to having a higher BMI, body fat percentage, and waist circumference. Researchers report that vitamin C plays a role in the body’s ability to use fat as a source of fuel during both exercise and rest.
MYTH: You can’t overdose on vitamin C. You can! Because we can’t store vitamin C, the excess surplus when taking over 2000mg/day has to be eliminated through the kidneys in urine. Though many easily tolerate that dose and more, a megadose can trigger bloating/gut upset, diarrhea, nausea, vomiting, heartburn, headache, insomnia, and kidney stones.
If you have any questions about vitamin C or other facets of nutrition or overall health, feel free to ask your doctor of chiropractic during your next visit.
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Abramson Family Chiropractic
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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.