MONTHLY HEALTH UPDATE
Can the Outcome of Back Pain Be Predicted?
Chad Abramson, D.C.
Low Back Pain
Nerve Flossing and Low Back Pain
The sciatic nerve is made up of five nerve roots that exit the spine in the lower back (L4 to S3) and then merge into one nerve that travels through the buttock and into the leg. At the back of the knee, the nerve divides into two nerves, the tibial and common peroneal, that travel into the inner and outer lower leg and foot.
When the sciatic nerve is compressed or pinched, a patient can feel pain, tingling, numbness, and even weakness in the hip, buttock, and leg. For individuals under the age of 60, the most common cause of sciatica is a herniated disk. For older adults, the most likely causes of sciatica are spinal stenosis (a narrowing of the openings of the spine the nerves travel through) and spondylolisthesis (when one vertebra slides forward on the neighboring vertebra).
Normally, a nerve root moves freely in and out of the spine through holes located between each vertebra called intervertebral foramen (IVF). Movements or exercises such as hamstring stretches or punting a football create tension on the sciatic nerve and pull the nerve roots out of the IVFs. Similarly, when we stand up straight and look down at our feet, this pulls the spinal cord upward and the nerve roots move into the IVFs.
When managing sciatica, chiropractors will utilize a technique called nerve flossing. Like flossing teeth, the back and forth motion of the dental floss is conceptually the same action as the back and forth motion of the five nerve roots that merge into the sciatic nerve. To pull the nerve roots out of the IVF, extend the head/neck upward and then flex the foot/ankle upward as well (toes toward the nose). To pull the nerve back into the IVF, point the foot/ankle downward while the head/neck flexes forward (chin to chest). Repeat multiple times as long as pain or other symptoms do not worsen. The idea behind this is to free up the nerve root by reducing adhesions in the IVF.
Nerve flossing is usually performed first by a doctor of chiropractic to make sure it is well tolerated and safe so that the patient can perform the exercise at home several times a day. Studies show that this method helps reduce tension on the sciatic nerve while also stretching the hamstrings, which are often tight in patients with low back pain.
Neck Pain / Headaches
Cervical Traction for Neck Pain
In addition to spinal manipulation, doctors of chiropractic often use other conservative therapies to reduce pain and improve function in patients with neck pain. When it comes to neck conditions involving herniated disks, radiating arm pain (“radiculopathy”), strains, facet syndromes or sprains, and myofascial pain, cervical traction is one such option.
As part of the initial new patient examination, a chiropractor may use their hands to gently pull on the patient’s neck while in sitting and/or supine (lying on the back) positions. If this feels good, then cervical traction may be warranted either in the office, with an at-home unit, or both. However, cervical traction is not advised if there is instability in the spine/ligaments, vertebral artery insufficiency, rheumatoid arthritis, osteomyelitis, discitis, neoplasm, severe osteoporosis, untreated hypertension, severe anxiety, cauda equina syndrome, or myelopathy.
There are various forms of cervical traction devices, so treatment may be performed while the patient is in a standing, sitting, lying horizontal, or inclined either prone or supine position, and the traction force can be continuous or sustained vs. intermittent or pulsed. Variables include body/head weight and the associated friction against the traction table in lying down types of units, and the angle can often be varied with most types of traction units.
There are pros and cons to different types of traction units. Lying down traction may allow for better relaxation vs. sitting, but more weight may be needed due to the friction of the body on the table. Generally, when hold times are longer (especially with sustained traction), less weight is used. Some doctors advocate starting at 5 lbs. (~2.67 kg) for 15 minutes with a sitting device (sustained traction) and gradually increasing the weight to maximum tolerance while keeping the time constant at 15 minutes.
There are a number of theories on why traction relieves pain: it forces rest through immobilization and by supporting the weight of the head, it pulls apart or opens the facet joints, it improves nutrition to the joint cartilage, stretches ligaments, it decreases the pressure inside the disks, it reduces pressure on nerve roots (by widening the holes through which they travel), it improves head posture, and/or it stretches the neck muscles to improve blood flow and reduce muscle spasm.
The bottom line, if you have neck pain and manual traction applied to the cervical spine provides pain relief, then your doctor of chiropractic may choose to incorporate this therapy into your treatment plan, either in the office, at home, or both.
Scapular Stabilization for Shoulder Pain
The shoulder is one of the largest and most complex joints in the body. It’s actually three joints— the AC or acromioclavicular joint (the collar bone/acromion of the shoulder blade joint), the glenohumeral joint (the ball-and-socket joint), and the scapulothoracic joint (the shoulder blade/rib cage “joint”)—all of which involve the scapula to some degree.
The rotator cuff is made up of four muscles, three of which sit on the back side of the scapula and rotate the arm outward (external rotation) and one in front that rotates it inward (internal rotation). The trapezius muscle is made up of three parts: the upper part pulls the shoulder blade up and in, the middle portion pulls the shoulder inward, and the lower section of the muscle pulls the scapula down and inward. The chest muscles rotate the arms inward. There is also a “bursa” or a fluid-filled sac that cushions, lubricates, and protects the rotator cuff tendon attachments. The “labrum” attaches to the rim of the “socket” or cup, to give it more depth and stability for the ball to sit in.
While this arrangement gives the shoulder a wide range of motion, it also makes it less stable and more vulnerable to injury. There are many injuries that can affect the shoulder, with one of the most common being tearing of the rotator cuff tendons (called “tendinitis” or “tendinopathies”), which often lead to a bursitis, or swelling of the bursa sac, resulting in shoulder impingement (pain raising the arm). In fact, over half of people in their 80s have tearing of the rotator cuff.
There are many exercises that help return function to the shoulder in both non-surgical and postsurgical cases. Exercises are aimed at restoring motion, strengthening weak muscles, and stabilizing the shoulder. However, studies show that the best results are achieved when scapula stablizations exercises are included in the treatment process.
One GREAT exercise for stabilizing the scapulae is called the Push-Up Plus (PUP). This is performed by positioning yourself into a push-up position (either toes or knees—you choose based on strength) with your hands shoulder width apart, elbows locked straight, and the fingers pointed outward (thumbs at 12 o’clock). Instead of dropping the chest to the floor, PUSH the middle of the back upward toward the ceiling. Hold the position for three seconds and SLOWLY return to the start position. Repeat five to ten times and gradually increase reps as you’re able.
There are several variations of this. For example, rotating your fingers inward increases activity in the rotator cuff muscles (the most important muscle group for shoulder stabilization) and reduces activity in the chest muscles (pectoralis major) and scapula elevators (levator scapula). You can also alter this by raising your feet to different heights, as the higher the feet, the greater the serratus anterior muscle activity! Your doctor of chiropractic can advise you on which shoulder stabilization exercises may provide the most benefit for your unique case.
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome 101
Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, or pinched nerve, in the extremities. The condition is estimated to affect 3-6% of the population, often in both hands. Let’s discuss what causes CTS, its symptoms, how it’s diagnosed, and how it’s treated…
Causation: Carpal tunnel syndrome occurs when pressure is placed on the median nerve as it travels through the wrist. This can be due to inflammation caused by obesity, repetitive movements, pregnancy, arthritis, hypothyroidism, diabetes mellitus, trauma, mass lesions, amyloidosis, sarcoidosis, multiple myeloma, leukemia, and more. Women are at a greater risk for CTS than men, due to having a smaller wrist and possibly hormonal reasons.
Symptoms: Pain, numbness, and tingling are common CTS symptoms that affect the thumb, index finger, middle finger, and the thumb-side of the ring finger. Symptoms can radiate up into the forearm and even into the shoulder and neck. Weakness in grip strength and nighttime/sleep interruptions are also common symptoms.
Diagnosis: The patient history is very important for diagnosing CTS, as it provides the doctor information to help determine if CTS is likely or if another condition is causing the patient’s symptoms, such as ulnar tunnel syndrome or dysfunction elsewhere along the course of the median nerve. The “flick sign” (flicking the fingers to “wake them up”) predicts electrodiagnostic abnormalities 93% of the time with a false-positive rate of <5%. Other in-office tests include provocative tests (reproducing symptoms), neurological tests for sensation (sharp vs. dull), and strength-muscle tests. More advanced electrodiagnostic tests (EMG/NCV or electromyogram/nerve conduction velocity) can quantify the severity of CTS and verify the diagnosis.
Treatment: All treatment guidelines recommend conservative, non-surgical care prior to surgery unless there is a unique, unusual case like trauma (fracture), or some other unusual situation. THIS IS WHERE CHIROPRACTIC SHINES! Besides “usual” non-surgical care (night splinting, anti-inflammatory measures, exercises, and ergonomic modifications), chiropractic treatment includes manual therapies such as soft tissue release techniques and joint manipulation. A 2018 study reported that following manipulative therapy, patients experienced an increase in the front-to-back diameter and roundness of their carpal tunnel, which reduced pressure on the tunnel’s contents. Chiropractors also perform manual therapy based on neurodynamic techniques, which a 2019 study concluded were highly effective in a group of patients with mild-to-moderate CTS. It’s important to note that patients are more likely to achieve a successful outcome if they seek treatment earlier in the course of the disease than if they wait months or even years. If you experience the symptoms associated with CTS, seek care sooner rather than later!
The Role of Neck-Specific Exercises for Whiplash Recovery
The cervical spine relies heavily on muscular support, particularly from the deep muscles in the front and back of the neck. Some experts estimate that up to 70% of the stability of the cervical spine arises from these deep neck muscles, particularly those in front of the spine. Studies have demonstrated that the rapid acceleration-deceleration forces that are placed on the neck during a motor vehicle collision can injure these deep neck muscles. Indeed, electromyographic (EMG) testing conducted on WAD patients has shown that those with higher pain intensity also had reduced deep muscle function in both the front and back of the spine. Treatment guidelines for non-specific neck pain recommend incorporating neck-specific exercises into the treatment process. But what about for WAD patients with neck pain?
A 2018 study that involved 26 patients with chronic WAD (symptoms lasting longer than three months) evaluated the role of neck-specific exercises (such as cranio-cervical flexion—tucking in the chin and approximating the chin toward the chest while looking straight ahead without bending the head forward) had in improving muscle performance, disability, and pain intensity over the course of a three-month time frame.
After three months, the researchers used a special type of diagnostic ultrasound to measure function in one large superficial muscle and two deep muscles that all reside in the front of the neck. Investigators observed that the participants in the neck-specific exercises (NSE) group experienced significant improvements with respect to muscle function, disability, and pain intensity that were not observed among those in a “wait list” group who served as controls.
Here’s where it gets more interesting… At the three-month point, the members of the control group were added to the NSE group, and three months later, the researchers observed that these participants experienced the same improvements that they previously noted in the first NSE group! This study supports the need for specific neck exercises to reduce pain and disability and improve function.
When the deep muscles are injured, it’s common for the body to recruit superficial muscles to help stabilize the body and maintain posture. While this can protect the deep muscles from further injury in the short term, it can decondition these muscles over time and allow fatty deposits to infiltrate its tissue. This helps to explain why exercises are so important in the recovery process from musculoskeletal injuries, especially since there’s research that says that up to half of WAD patients will still experience pain and disability a year after their accident. This underscores the importance of seeking treatment for WAD as soon as possible in order to reduce the risk for chronicity and while the chances for full recovery are greatest.
Whole Body Health
A Link Between Cold Sores and Alzheimer’s Disease?
Alzheimer’s disease (AD) is the #1 cause of dementia, representing an imminent threat to our senior population. It is one of mankind’s cruelest afflictions that causes patients lose their memory, personality, and eventually self-care skills. According to the Centers for Disease Control and Prevention (CDC), about 6 million people currently have AD with projections of this doubling in the next two decades. The 2015 Framingham Heart study reported that 1 in 5 women and 1 in 10 men will develop AD.
Though researchers have observed an association between beta-amyloid plaque build-up in the brain and AD, well-funded studies have failed to determine that betaamyloid plaques are the cause of the disorder. Interestingly, two studies published nearly 40 years ago concluded that the virus that causes cold sores (HSV-1) may play a role in the development of AD. This suspicion was bolstered by a 2014 study that detected the virus in the brains of AD patients, particularly in the parts of the brain related to memory. Neuroscientists propose that the plaque build-up commonly seen in AD patients may a consequence of the immune system trying to battle the presence of HSV-1 in the brain.
This finding suggests that AD could potentially be treated, or even prevented, by therapies that target HSV-1. Dr. Robert Rubey notes that as far back as 1968, researchers have known that HSV-1 requires the molecule arginine for replication, which can be blocked by the presence of the amino acid L-lysine. Double-blinded studies have demonstrated L-lysine is effective at both preventing or decreasing/reducing the severity of HSV-1 outbreaks.
Dr. Rubey concludes that AD is a disease process, NOT an aging process. The importance of preventing viral reactivation leading to brain inflammation/damage is key in preventing AD. In 2010, Dr. Rubey speculated that supplementing with 1,500mg of Llysine twice a day combined with a low-arginine diet (reduced intake of nuts, seeds, grains, and tofu) may protect against AD. However, more research is needed in this area before firm recommendations can be made.
Doctors of chiropractic often recommend anti-inflammatory diets and supplements for both aiding the recovery process from musculoskeletal injuries and living a healthier lifestyle.
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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.