MONTHLY HEALTH UPDATE
Can the Outcome of Back Pain Be Predicted?
Chad Abramson, D.C.
Low Back Pain
Low Back Pain and Cycling
Cycling is regarded as a highly enjoyable and effective form of exercise. However,
there is some confusion about how posture while riding can affect the lower back and
whether cycling is helpful for recovery from lower back pain.
Bicyclists ride with either a round-back, flat-back, or curved-in back, which is based on the degree of pelvic rotation and spinal flexion. It appears that the choice of posture when riding a bike is primarily related to seat height, seat angle or tilt, and handlebar type. Some handlebars offer multiple options as to where you can place your hands, such as on the grips (most upright), on the bar closer to the stem (middle position), or on the drops—the lowest option offered on the curl under/racing type of handlebars.
One might think that flat-back posture would be best for the lower back, simply because it avoids the two extremes. However, this position is associated with increased wind resistance and will likely be avoided by more serious cyclists who are looking to ride as efficiently as possible. One pilot study looked at the lumbar spine angle of young adult recreational cyclists as they utilized all three postures in ten-minute intervals with different bike configurations and found that the “curve-in back” position caused by gripping the drops resulted in the greatest increase in spinal flexion over time. For individuals with a low back condition, this increased spinal flexion could result in increased pain and related symptoms over time.
Another study looked at how a bike is fit, the position of the cyclist, and the perception of comfort, fatigue, and pain. Here, twenty cyclists rode in three of nine potential positions for 45 minutes at 50% of their peak aerobic power output. The three positions were defined by two parameters: knee flexion angle (20°, 30°, 40°) and trunk flexion angle (35°, 45°, 55°), in a random order. The results showed that having the trunk upright (not bent forward) and the seat height adjusted so the knee flexion angle was 30° was the most comfortable position for participants. Additionally, the researchers found that tilting the seat forward lessened low back pain in those with the condition.
As part of the recovery process for low back pain, doctors of chiropractic often encourage patients to exercise. Because of it’s low-impact nature, as well as being highly enjoyable, cycling is a great option. However, it’s important to make sure your bike it fitted so that you can comfortably ride with good posture and as to not exacerbate your condition.
Neck Pain / Headaches
Neck Pain and Workstation Options
Neck pain is commonly associated with sitting in front of a computer for
prolonged periods of time. So is there a “best” or “ideal” type of desk to use when
working at a computer all day?
The sit-stand desk has gained significant popularity in recent years, especially with an 83% increase in sedentary jobs since the 1950s. In a 2018 study, researchers compared the effect of using a sitting and standing desk for 90 minutes among 20 healthy adults. Researchers monitored typing task performance and discomfort, vascular/blood flow, and muscular changes in the neck, shoulders, and arms and found that standing desk use resulted in greater engagement of the shoulder girdle stabilizing muscles (a good thing), less strain on the lower trapezius muscles, less upper body pain, and better typing performance. The authors of the study recommend further studies to identify how standing affects more complex computer tasks over longer work sessions in symptomatic workers.
Another type of desk that is available is a treadmill desk. In one study, researchers found that treadmill desk use resulted in less upper limb pain when compared with seated desk use, as well as healthier muscle performance from the low back paraspinal muscles, wrist extensor muscles, external abdominal obliques, lower trapezius, and anterior deltoids.
What about the trend of having a small cycling device under the desk? In a 2019 study, researchers observed that participants performed better on typing tasks when cycling, especially at greater intensity.
Doctors of chiropractic are frequently asked about sit/stand desk options, with or without lower limb exercising. A common answer is to mix it up, sit or stand as needed, and vary the level of under-the-desk exercise depending on how you feel. These studies support that standing, walking, and/or cycling may be a healthier option than the traditional sit-only, sedentary desk.
Things to Consider Before Knee Joint Replacement
When it comes to a condition like chronic knee pain, there are many treatment options
available to reduce pain and improve function, including chiropractic care. However, there
are cases when a patient may opt for total knee arthroplasty (TKA). In some instances, they
may be able to resume their everyday activities, but a segment of patients may not achieve a
satisfying outcome. What can we learn from these patients that can inform us on when to and
when not to consider surgery for knee pain?
In one study, researchers examined TKA patients one year after their procedure to assess their progress with respect to knee range of motion and function, as these are important for performing activities of daily living (ADLs) such as the ability to put on shoes and socks, squat down to pick things up off the floor, get up and down from sitting, climb and descend steps, etc. The research team found that patients with poor range of motion before surgery, as well as those with poor knee alignment (the tibial-femoral angle), were less likely to have a satisfactory outcome.
Several studies have demonstrated how hyperpronation of the ankle can affect the alignment of the knee, placing added stress on the joint, as can impaired hip function. These issues should be addressed before considering TKA. This is why it’s important for doctors to assess the whole patient for a musculoskeletal condition because the cause or contributing factors for the issue could be from outside the area of chief complaint. In many cases, a combination of manual therapies and specific exercises provided by a doctor of chiropractic can restore proper motion to the affected hip or ankle, which can then benefit the knee.
Manual therapies can also break up adhesions and scar tissue that may affect knee range of motion. When the knee can move as intended, the pressure from normal movement can help provide nutrients to the remaining cartilaginous tissue, reducing inflammation and pain.
The take-home message is that there may be a time when a TKA is the only option available to a patient with knee pain, but if the knee is poorly aligned or its range of motion is restricted, then TKA may not be the answer. Luckily, these are issues that can be addressed with chiropractic care, which may delay or even reduce the need for an eventual surgical procedure.
Carpal Tunnel Syndrome
Nerve Mobility and Carpal Tunnel Syndrome
According to the American Medical Association Guides on the Rating of Permanent
Impairment, if one loses the use of their thumb, index finger, and middle finger, they’ve lost 80% of
the use of their hand. It’s no wonder why carpal tunnel syndrome (CTS)—a condition characterized
by symptoms of numbness, tingling, pain, and weakness that affects these digits (in addition to half
of the ring finger)—can be such a debilitating condition!
Peripheral nerves—such as the median nerve that travels from the neck to the hand—are arranged in a spiral manner, which provides them the ability to lengthen when the limb (arm or leg) is straightened without damaging the nerve fibers within the nerve. In a July 2020 study, researchers reported that median nerve mobility is restricted in patients with CTS, which suggests that the condition can be caused by factors that restrict the nerve’s ability to lengthen in accordance with normal movement. Thus, treatments that are geared toward improving nerve mobility are likely to benefit the CTS patient, and that’s precisely what one systemic review found.
Using data from four published studies, researchers reported that including nerve gliding exercises, also known as nerve flossing, with standard care for CTS led to better outcomes with respect to both symptom severity and hand function than standard care alone. Nerve gliding exercises are intended to move the nerve back and forth inside the tunnel and along its course to reduce pressure and friction.
Here is a sample nerve gliding exercise (one of several that your doctor of chiropractic can teach you) that can improve median nerve mobility:
1. Stand sideways to a wall and place the palm of your hand on it, fingers pointing downward, elbow partially bent.
2. Slowly straighten the elbow, feeling for the forearm to tighten up.
3. Bend your neck sideways toward the wall when the elbow is straight and away from the wall when the elbow is bent and repeat.
Doctors of chiropractic often treat CTS patients with a multimodal approach that includes manual therapies, nerve gliding exercises, nocturnal wrist splints, activity modification, and supplemental/dietary changes. These approaches are all aimed at reducing pressure on the median nerve and to allow for nerve mobility to return to normal. If the patient history indicates that other issues—such as diabetes, hypothyroidism, and other conditions—may contribute to the patient’s symptoms, then co-management with a primary care doctor or other specialist may be required to achieve a successful treatment outcome.
Predicting Whiplash Outcomes
With up to 50% of whiplash associated disorder (WAD) patients experiencing
long-term symptoms, is there a way to predict which patients are likely to recover
following a whiplash injury? To answer this question, a team of researchers analyzed
findings from twelve systemic reviews to identify prognostic factors that could help
predict patient outcomes following a whiplash associated disorders (WAD) injury.
The authors concluded that the outcome of acute whiplash was dependent more on the association between initial pain and anxiety and less with physical factors such as MRI or x-ray findings, motor examination findings, and collision factors (impact direction, car speed at impact, seatbelt or headrest use, or the extent of vehicular damage).
What can be done for the patients who are at greatest risk for ongoing issues? A 2020 study investigated the potential benefits that a multimodal rehabilitation (MMR) program had for sub-acute (six to twelve weeks) and chronic (more than twelve weeks) WAD patients with soft tissue injuries and no nerve injury or bone fractures. The participants were first examined by a multi-professional team that included a pain and rehabilitation specialist (PM&R), a psychologist, an occupational therapist (OT), a physiotherapist (PT), a social worker, and a nurse. This same team then treated the patients over a five-week timeframe.
The investigators then compared standardized questionnaires completed by participants both before and after the treatment period and then one year later. The researchers reported that participants achieved significant long-term improvements with respect to overall physical and mental health, pain intensity, ability to carry out everyday activities, anxiety, and depression.
Many chiropractors utilize a multi-modal approach when treating WAD patients to address three goals: pain management, functional restoration, and self-management strategies to minimize the need for long-term professional care. When needed, a coordinated care approach is set up between allied healthcare professions that may include PT, OT, clinical psychology, and/or others.
Whole Body Health
The Benefits of Blocking Blue Light
The electromagnetic spectrum spans from gamma rays—which can be deadly—to the
radio waves that flow in the air all around us without any effect. Between the ultraviolet and
infrared sections of the spectrum is the most important wavelength for our eyes: visible light.
But research indicates that blue light can be problematic in high doses—especially with our
increasing use of electronic devices.
Both the sun and incandescent bulbs emits light in a broad range that our eyes have evolved to see. The light that emanates from our electronic devices may appear similar, but it’s concentrated in three main peaks of blue, green, and red. When using a phone or tablet, that means a greater than average amount of more energetic blue light is being sent to your eyes at a short distance and for (often) a prolonged period of time. Researchers have observed that this can cause the eyes to grow tired and dry out, which can lead to discomfort. Exposure to blue light at night can slow the production of the sleep hormone melatonin, resulting in sleep difficulties and the negative health effects associated with it.
To reduce the consequences of excessive blue light exposure, several tech companies have created blue light and nighttime filter settings that reduce the amount of blue light that comes from devices. Many websites and programs also offer a dark mode that reduces the amount of white on the screen, which means less light is emitted by the diodes. Users often report that these features are easier on the eyes.
While there is debate on the topic, excessive exposure to blue light may also lead to an increased risk for macular degeneration, a common cause of vision loss associated with damage to the photoreceptor cells in the retina. In laboratory studies, researchers have observed that when blue light interacts with the molecule retinal, it can lead to cell damage and even cell death. This effect did not occur with other forms of visible light. However, it’s important to note that this study was conducted in a laboratory setting and not on eyes themselves, so although the authors found a mechanism by which blue light plus retinal can cause cell damage, they’re not sure if this occurs in the eye itself.
Nonetheless, given the effect that prolonged screen use can have on eye fatigue and possible sleep interruption, it’s important to take breaks to rest the eyes and use filters or modes that reduce blue light (or wear glasses that block blue light).
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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.