MONTHLY HEALTH UPDATE
Can the Outcome of Back Pain Be Predicted?
Chad Abramson, D.C.
Low Back Pain
Traction for Low Back Pain
When it comes to a condition like low back pain, the care a patient receives can depend
on case history and examination findings, as well as the doctor’s training and treatment
preferences. For the patient with a lumbar disk pathology, a doctor of chiropractic may employ
lumbar traction in combination with manipulation and joint mobilization techniques.
Lumbar traction (LT) is often performed on patients with radicular pain, or pain that radiates into the leg due to intervertebral disk conditions such as a herniated disk, degenerative conditions such as osteoarthritis, and/or spinal stenosis (a combination of aging factors that result in narrowing of the foramen, or holes that nerves travel through). The specific benefits of LT include increasing the disk space, which produces a negative pressure within the disk to draw in a disk protrusion, stretching ligaments, widening the foramen, and encouraging movement of the facet joints. Unfortunately, there is no hard and fast rule that exists for when and/or how to apply traction, leaving this decision up to each clinician to judge what, when, and how—that is until recently!
A group of researchers tackled the job of developing a clinical guideline to identify patients with lumbar disk herniation (LDH) that would most likely benefit from mechanical lumbar traction (MLT). Doctors applied MLT on over 100 LDH patients over the course of two weeks and measured the benefits using history and physical examination as well as various questionnaires that measure pain intensity, function, and psychological parameters. The research team defined “responders” as those who improved at least 50% over the initial, baseline evaluation.
Of the 103 participants, 24 were responders (23.3%), and from this group, the researchers used the following five features to establish clinical prediction rules: 1) limited lumbar extension (backward bending) movement; 2) low-level fear-avoidance beliefs regarding work; 3) no segmental hypomobility in the lumbar spine; 4) short duration of symptoms; and 5) sudden onset of symptoms. For those who had at least three of five of these predictors, the probability of pain and function improvement rose from 23.3% to 48.7% compared to those with fewer predictors. The authors concluded that healthcare providers can use these five predictors to help select patients with LDH who might benefit from applying lumbar traction.
A 2020 study reported that combining spinal manipulation and mobilization with traction produced better outcomes than traction alone. Doctors of chiropractic offer a multi-modal treatment approach to patient with LDH, of which traction may be included in the management plan. These non-surgical options frequently work very well, and guidelines recommend utilizing non-surgical care options before considering surgery.
Neck Pain / Headaches
Bottom-Up vs. Top-Down Treatment for Headaches
There are many types of headache and each has an underlying cause that must be addressed to achieve a satisfactory outcome. A 2020 review of research from the previous two decades suggests that the best conservative, non-pharmaceutical approach for headaches may involve either a top-down or bottom-up approach.
When the primary cause of a headache is musculoskeletal in nature, the review found that a bottom-up approach is more likely to benefit the patient. For example, cervicogenic headaches are headaches caused by dysfunction in the cervical spine. A headache in this category will likely respond well to cervical spinal manipulation and other forms of manual therapy provided by doctors of chiropractic. Tension-type headaches can have several underlying causes, but tight muscles in the back of the neck tend to be common, and treatment to relax the affected muscles can help reduce headache frequency and intensity.
While research to understand migraines is ongoing, the cause of this form of headache is believed to rest in chemical interactions in the brain. As such, the investigators reported that a top-down approach involving cognitive behavioral therapy, biofeedback, and neuroscience education may offer the most benefit to the patient.
Because each case is unique and headaches can have multiple underlying or contributing causes (they can also co-occur), the authors note that the ideal bottom-up/top-down treatments will depend on the doctor’s clinical reasoning and experience. That is, there is no one size fits all. For example, there are several studies showing that migraine headache patients may experience reduced headache frequency and intensity after receiving manual therapies to address trigger points in their cervical muscles (a bottom-up approach).
The authors conclude that a multi-modal approach may be the most effective way to manage migraine, tension-type, cervicogenic, and other types of headaches. Such an approach may include spinal manipulation, spinal mobilization (non-thrust), soft-tissue therapies (massage, trigger point therapy, stretching, myofascial release), needling (wet & dry needling of trigger points and/or acupuncture), general exercise, targeted exercise, and cognitive interventions.
Most chiropractors embrace and utilize all or at least many of these non-drug treatment strategies when managing patients with headaches, though they may co-manage with other healthcare providers if necessary.
Lowering the Risk for Knee Osteoarthritis
Osteoarthritis is the most common chronic joint condition. It causes local inflammation and
breakdown of cartilage with joint structural changes that provoke pain and loss of function that
results in a considerable reduction in quality of life. Knee osteoarthritis (KOA) is one of the most
disabling osteoarthritic conditions and it’s becoming more prevalent. So, what can be done to reduce
the risk for osteoarthritis of the knee?
1) Weight loss. Obese men and women are four times more likely develop KOA than their non-obese peers! Past research suggests that a loss of 11 pounds (4.99 kg) can reduce KOA risk in some individuals by as much as 50%.
2) Exercise. Studies have shown that weakness of the quadriceps femoris (the front thigh muscle group) increases the risk of developing KOA. The good news is that strengthening exercises are very effective in reducing or eliminating that risk, as even a minor increase in strength is beneficial. Squat wall slides work well if the KOA is not too advanced. In which case, knee extension water exercises and/or light weights from sitting may be a better starting option. Your chiropractor will instruct you in this process. Additionally, cartilage does not have a blood supply and requires compression forces to draw nutrients into the tissue. Too much sedentary behavior can dehydrate the joints, elevating the risk for poor joint health.
3) Avoid knee injury. A long-term study that included 1,321 graduates of Johns Hopkins Medical School reported that a knee injury can increase the risk of future KOA by three to five times! Such injuries can largely be avoided by the following: avoid knee bending greater than 90 degrees when squatting; avoid twisting the lower leg during activities; land with the bent knees when jumping; warm up before physical activity and cool down afterward; wear shoes that fit properly, provide shock absorption, and give stability; and exercise on soft surfaces if possible (avoid asphalt or concrete). If you have an injury, prompt care is very important, and modifying activities and/or utilizing a brace to help stabilize the joint is wise. Your chiropractic can guide you in this process!
4) Proper nutrition. Although there is no specific diet that can prevent KOA, an anti-inflammatory diet pattern, such as the Mediterranean diet, can help reduce inflammation in the joints. Additionally, improper biomechanics that can result from dysfunction in the ankle, hip, and lower back can place excess stress on the knee. If you experience pain or disability in these areas, consult with your doctor of chiropractic as managing an ankle condition today could stave off a future problem in one or both knees. And if you’re experiencing pain in your knee, your doctor of chiropractic can help manage the condition with a multimodal approach that may include manual therapies, modalities, specific exercises, and nutritional advice.
Carpal Tunnel Syndrome
Three Reasons Why Carpal Tunnel Syndrome Is So Stubborn
Carpal tunnel syndrome (CTS) is by far the most frequent cause of a nerve
entrapment in the extremities. Despite it being such a common complaint (estimated to affect
1 in 1,000 American adults), CTS can be a difficult condition to manage. Here are three
1) Multifactorial. While activities (a job or hobby) that involve fast, repetitive movements, firm gripping requirements, and no rest time are commonly associated with CTS, there can be (and often are) additional risk factors involved that each need to be address. For example, hormonal changes in the body can increase swelling or water retention, which can also place pressure on the median nerve. Older adults appear to be at greater risk than young adults. There are also health conditions, like obesity and diabetes, that are linked to an elevated risk for CTS. The condition can also run in families due to shared environmental factors, genetics, or both.
2) Slow onset. While major trauma—like a wrist fracture—can lead to immediate symptoms, most cases of CTS come on very gradually. At first, it may only be a slight tingling here and there. But over weeks, months, or even years, the signs and symptoms can increase in terms of frequency, intensity, and duration to the point of being almost constant. Only at this point do many patients seek treatment, and by this time, it may be difficult to reverse. Even if a complete resolution is possible, it can take a lot longer than it would for a patient with new-onset, mild symptoms.
3) Hesitancy. Because CTS is often associated with work-related activities, an employee experiencing pain, numbness, tingling, and/or weakness in the hand/s and wrist/s may avoid reporting the injury for fear of losing a job or being ridiculed by co-workers, employers, supervisors, etc. It’s not unusual to “hide” the symptoms from others for a long time, often to the point of CTS becoming chronic.
The good news is that by managing risk factors for the condition (more breaks, modifying movements, and using tools that provide less stress on the wrist, reducing inflammation in the body, maintaining a healthy weight and blood sugar levels, for example), one can reduce their risk for the condition. When symptoms manifest, it’s important to seek care right away (of which chiropractic care is a great option) when the odds for a successful outcome are greatest.
Whiplash and Vision
It’s estimated that half of patients with chronic whiplash associated disorders (WAD) will
experience vision-related issues such as poor reading concentration, light sensitivity, visual fatigue,
and eye strain. Why is this the case, and what can be done for such patients?
Eye movement control depends on the position of the head in space, and head position is determined by the integration of several sub-systems including the vestibular system, the visual system, and the proprioceptive system of the cervical spine. The principal source of cervical afferent (sensory) information arises from mechanoreceptors in the upper cervical spine, especially the deep upper cervical muscles where the density of muscle spindles is extremely high in comparison to other spinal regions.
Because WAD often involves injury to the upper cervical region, sensorimotor control is frequently disturbed, which can affect eye movement control and lead to clinical signs such as nystagmus (oscillating eye movements), dizziness, and balance deficits. There are three distinct eye movement tests utilized when assessing WAD patients: eye stabilization reflexes, smooth pursuit eye movements, and head-eye coordination. Positive findings on these tests could suggest injury in the upper cervical region, which will be confirmed after a comprehensive examination.
Once a diagnosis is established, treatment will often include the application of manual therapies in the clinic along with a home exercise program specific to either the deep and/or superficial cervical muscles.
This is illustrated in a published case study of a 22-year-old female who sustained a concussion and WAD with impaired eye movement control in a high-speed collision. Her treatment started two days post-injury and involved mobilization of the cervical and thoracic spine, manual cervical traction, and soft tissue release techniques. The patient also received training on how to perform deep neck flexor strengthening and eye movement exercises at home. After one clinic visit and four days of the home exercise program (HEP), the patient’s post-concussive symptoms— including dizziness and balance dysfunctions—improved. She continued to experience blurred vision with body rotation as well as reduced cervical ROMs with muscle hypertonicity, both of which resolved after four additional visits over the next two weeks in conjunction with daily exercises.
Several treatment guidelines indicate that chiropractic care is a great first-choice treatment option for the WAD patient, which may involve a multimodal approach to restore normal function to the cervical spine and associated soft tissues.
Whole Body Health
Cutting Down the Noise
When one spends time in nature, it can be surprising how quiet the world can be and just how
much noise we’ve grown accustomed to in our day-to-day lives. But what we may not understand is
that some noises can be more than a nuisance and can actually be harmful to health.
An article published in the journal Environmental Research reported that noisy environments—like living next to a highway—can increase the risk of severe stroke by 30%. This is due (at least partially) to noise stimulating a part of the brain called the amygdala. The amygdala regulates the stress response, which can involve the release of cortisol into the body and cause and increase in blood pressure. In a life-or-death situation, this can provide the drive needed to avoid danger and stay alive. In time, blood pressure will return to normal and cortisol levels will reduce. This is important because prolonged high blood pressure and high cortisol levels can be detrimental to the body and result for cardiovascular complications, such as heart attack and stroke. Additionally, studies have linked chronic stress to immune system suppression, diabetes, arterial plaque buildup (atherosclerosis), psychiatric illness, and possibly cancer.
Loud noise can also slowly damage the important hair cells in the cochlea (located in the inner ear) that are important for hearing. There is a growing body of research that hearing loss is a risk factor for cognitive decline. There are differing theories on why this is the case, from reduced stimulation in the brain to increased social isolation and withdrawal. Nonetheless, it’s a major issue that can be reduced by getting regular hearing screenings and the use of hearing aids, when necessary. The National Institute on Deafness and Other Communication Disorders notes that 25% of people between 65 and 74 years of age experience disabling hearing loss, and this number doubles after age 75.
Outside of moving to a quieter part of the world, there are several things one can do to reduce their exposure to harmful noises and the problems that can result: turn down or turn off the radio or TV when feeling anxious; keep car windows closed when driving; avoid noisy restaurants and bars, when possible; test for ambient noise using a smartphone app; and use earplugs or noise-canceling headphones in loud environments. If you’re experiencing hearing loss, talk to your doctor. The solution might be as simple as removing ear wax during an office visit. Or if indicated, a referral may be made for further testing by an audiologist or an ear, nose, and throat (ENT) specialist.
Bottom line: Avoid loud noises when you can, and if you’re having difficulty with your hearing, seek care. Not only will it help you carry out your daily activities, but it will help keep your brain in working order as you age.
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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.