Vertebral Compression Fracture Management and Prevention

Compression fractures (CFs) of the spinal vertebrae can occur in two main varieties: acute and chronic. Acute CFs can occur at any age and can be quite serious, especially if the bony fragments displace into the spinal canal where the spinal cord in located. These most often represent unstable fractures and must be evaluated immediately to ensure that neurological loss is minimized or avoided. But what about the more common chronic type of compression fracture?

Studies show that our bones are most dense when we are about 30 years old. As we enter middle and older age, the bones can weaken, which is a state called osteopenia. The weakened vertebrae can accumulate small cracks, which can compromise their integrity, resulting in a chronic spinal compression fracture. A December 2020 study concluded that surgery is typically only advised when the fracture is unstable or there is neurological loss, a severe collapse, or intense pain—which may only occur in roughly 15-35% of chronic compression fracture cases.

For the majority of chronic spinal compression fracture patients, a multi-modal team approach to care is advised. A 2018 systematic review of published research on the management of spinal compression fracture recommends an initial non-invasive treatment approach that includes rest, analgesics, orthoses (braces), and early mobilization—a therapy performed by doctors of chiropractic. Once the acute pain subsides, specific exercises should be incorporated into the treatment plan—something chiropractors are trained to provide instruction for.

However, most would like to prevent this condition in the first place, and there are steps that can be taken to reduce ones’ risk. According to Harvard Health and WebMD, the following steps can help maintain healthy, strong bones: consume adequate amounts of vitamin D and calcium (supplements and diet rich in dairy, spinach, broccoli, dried beans, salmon, etc.); avoid carbonated beverages; don’t smoke; don’t drink excessive amounts of alcohol; avoid the prolonged use of medications that can weaken bones, if possible (talk to your medical doctor); and perform weight bearing aerobic and strength training exercises. A bone density scan—the most common being a DEXA-scan—is also recommended, especially for postmenopausal women, adults over 65 years of age, middle-aged adults with a history of fracture, and individuals with a family history of osteoporosis.

Neck Pain / Headaches

It’s estimated that about 1 in 6 American adults experience neck pain in a given three-month time frame. Neck pain is a major cause of work absenteeism, work-related injury, and reduced quality of life. While some risk factors for neck pain may be unavoidable, many are not.

A systematic review completed by a team of authors from the Department of Orthopedics at Duke University concluded that work requiring sustained and/or awkward postures was the most important physical risk factor for neck pain. Several recent studies have demonstrated that taking frequent breaks to reduce sitting time (especially when performing short bouts of exercise) can mitigate much of this risk, as can improving sitting posture and workstation ergonomics—especially raising the monitor height so that users do not need to look downward at a screen.

However, the Duke University team found that psychosocial risk factors may be just as, if not more, important in the development of neck pain. These psychosocial factors include depressed mood, job stress, and perceived muscular tension.

The review also looked at factors that may reduce the risk for a first-time episode of neck pain transitioning into chronic or persistent neck pain, and it identified the following protective factors: supportive work and social environment; leisure physical activity; and strong cervical extensor muscle endurance (strength).

Prior studies have reported on the presence of both psychosocial factors as well as weak neck muscles in patients suffering with chronic neck pain, especially weakness of the deep neck flexor muscles. Hence, it comes as no surprise that the same two factors that were identified by the Duke University team as being important risk factors for FIRST time neck pain onset are also prevalent in chronic neck pain patients.

For the management of neck pain, treatment guidelines generally recommend a multimodal, conservative approach that includes manual therapies (such as mobilization and manipulation performed by a doctor of chiropractic), neck-specific exercises, and instruction on dietary choices (especially avoiding inflammation-promoting foods), stress relief/relaxation techniques, and improving sleep quality, as these not only aid in the healing process but also in reducing the risk for neck pain recurrence

Joint Pain

A Connection Between Hip Pain and Limb Length

When it comes to the legs, most of us have probably never given any thought to whether they are equal in length and if not, what problems that may cause. In a 2019 systematic review, researchers found that only about 1 in 10 adults has lower limbs that are of equal length! Among the remaining 90% of adults, the difference in leg length is usually less than a centimeter (a little less than a half inch). Can such a small discrepancy be a problem and if so, what can be done to address it?

For years, most orthopedic surgeons and those researching leg length discrepancy (LLD) took the stance that any discrepancy in leg length less than 2 cm (2.4 cm = 1 inch) could be ignored and was irrelevant in terms of causing dysfunction. A recent overview and narrative report by authors affiliated with the department of orthopedic surgery in New York City stated that discrepancies greater than 2 cm can alter biomechanics and loading patterns that lead to compensatory pelvic unleveling and concomitant scoliosis (to the short leg side) that if not corrected, can lead to permanent arthritic changes in the facet joints and disks in the lumbar spinal region. The review did not cover LLDs less than 2 cm, but studies are beginning to look into this and are concluding that even slight LLD can lead to long-term problems.

A 2017 systematic review identified a “significant relationship” between anatomic leg length discrepancy and gait deviation, especially with a greater than 1 cm LLD, with even greater impact observed as the discrepancy increases. Researchers found that compensatory changes occurred in both the long and short leg and throughout the lower limb with sagittal plane deviations to be the most common compensation (such as bending the long leg knee in attempt to equalize limb length). The review also noted that frontal plane compensations occur in the pelvis, hip, and foot in the presence of such a small LLD.

Another study identified leg length discrepancy as a significant and important risk factor that creates excessive abnormal mechanical joint loading, which can lead to premature osteoarthritis in the knee, hip, and lumbar spine. This study focused on “mild LLD” (less than 2 cm) and examined the accuracy of various methods used to measure LLD.

Doctors of chiropractic often assess leg length in patients, especially those presenting with knee, hip, and low back complaints. If LLD is identified, it can usually be corrected with the use of heel lifts, combined heel-sole lifts, and/or foot orthotics. The concept of balancing the spine and pelvis has been a tenant of chiropractic since its inception. As time and scientific studies evolve, the importance of LLD is now reaching other healthcare professions with collaborative efforts in researching its significance when managing and preventing neuromusculoskeletal conditions.

Carpal Tunnel Syndrome

When Carpal Tunnel Syndrome Surgery Fails

The carpal tunnel is a structure in the wrist that is primarily comprised of the carpal bones and the transverse carpal ligament. In addition to the median nerve, several tendons and other tissues pass through this region. If the shape of the carpal tunnel is altered or if any of the tissues within the tunnel are inflamed, pressure may be applied to the median nerve, which can reduce its mobility and function, stimulating the various hand and wrist symptoms typically associated with carpal tunnel syndrome.

Except in rare circumstances of major trauma, treatment guidelines advise patients to exhaust all conservative treatment options before considering surgery. In addition to the risks and prolonged recovery that come with undergoing a surgical procedure, the current research doesn’t indicate that surgery is any more effective over the long-term than non-surgical options. One study that included 120 women with carpal tunnel syndrome found that those who received non-surgical care had better results in the short term (at one and three months) and similar results with respect to pain relief and reduced disability after one year.

A study published in May 2021 that included 259 patients who underwent surgical care for carpal tunnel syndrome found that 76% had received some form of conservative care before their operation. This means nearly 1-in-4 of these patients proceeded directly to surgery as their initial form of treatment. Perhaps the most interesting finding from this study is that 2-in-3 patients received post-surgical conservative care, which suggests they did not find lasting relief from their procedure.

So why does surgery to reduce pressure in the carpal tunnel fail to produce lasting results for so many patients? There are several possible reasons but one worth considering is that pressure may be applied to the median nerve at any number of sites along its course from the neck to the hand. In fact, it’s common for median nerve entrapment to occur in two or more areas such as the wrist, forearm, elbow, shoulder, and neck. Pressure on the median nerve at any of these sites outside of the wrist can produce symptoms that can be mistaken for carpal tunnel syndrome. That’s why doctors of chiropractic examine the full course of the median nerve so that they can address all instances of potential median nerve entrapment.

For the carpal tunnel syndrome patient, chiropractors often utilize a multi-modal therapeutic approach that includes manual therapies such as joint manipulation and mobilization in addition to nocturnal splinting, specific exercises, workstation assessments/work modifications, and nutritional advice.

Whiplash

Chiropractic Care for Concussion Recovery

In the past decade, mild-traumatic brain injury (mTBI, or concussion) has been a major topic in the sports landscape. While most mTBI patients recover within a few weeks, some can experience ongoing issues, which can be described as post-concussive syndrome. Let’s look at what the current literature says about it and if chiropractic care may play a role in promoting recovery.

An April 2021 systematic review on the clinical prevalence, diagnostic methods, and treatment options for neck-related symptoms that occur during the acute and chronic stages following concussion concluded that the rate of symptom resolution is significantly reduced when neck symptoms are present following concussion. Because of the heterogeneity of the available data, the researchers were unable to find out how often neck symptoms are present during the acute stage of concussion, but their estimates show it can occur in up to 69% of cases, though the true number is likely lower. However, researchers were able to calculate that the risk for developing post-concussive symptoms (PPCS) increased between 2.58 times and 6.38 times in mTBI patients with neck pain in the acute stage! Additionally, the review found that the use of cervical manual therapies, which can be provided by a doctor of chiropractic, can benefit PPCS patients by reducing symptoms and speeding recovery.

Is there any further support for chiropractic care in managing PPCS? A December 2020 study used a multi-modal management approach in a group of three patients (two sports-related and one non-sports related concussion), and each within a different stage of recovery (acute, sub-acute, and chronic). Treatment plans were tailored individually and included patient education, sub-symptom threshold exercise, soft-tissue therapy, manipulative therapy, and visual/vestibular rehabilitation exercises. The study made three important observations: 1) the efficacy of three different multi-modal treatment plans based on suggested clinical profiles for patients with PCS (post-concussive symptoms); 2) that the delineation of concussion literature based on mechanism of injury (sport vs. non-sport) may be unnecessary; and 3) these cases provide encouraging evidence to support the use of manual therapists— such as chiropractors—as part of the multi-modal, interdisciplinary healthcare team.

As an interesting side note, the authors cited recent studies that reported cognitive rest until the point of symptom resolution—one of the most common treatment recommendations for concussed patients—may NOT be necessary. They also highlighted a systematic review that stated that complete rest for more than a few days was not supported by recent literature, and this was seconded by a statement from the American Medical Society for Sports Medicine. Also noteworthy, they discussed the use of anti-inflammatory nutritional supplementation, especially in the acute stage including omega-3 essential fatty acids, vitamin D3, and curcumin as well as limiting the intake of white sugar and processed meats.

Many chiropractic providers offer a multi-modal treatment approach for patients with cervical musculoskeletal disorders that routinely incorporates a combination of manual therapies (joint manipulation, soft tissue mobilization, massage therapy, trigger point therapy, myofascial release, and more), exercise training, diet and nutritional counseling, physical therapy modality applications, and more.

Whole Body Health

Exercise Saves Lives!

If there was one prescription that could reduce the severity or even prevent dozens of diseases—including diabetes, hypertension, heart disease, stroke, obesity, osteoporosis, some cancers, depression, and dementia—and it also had a low risk for adverse effects, who wouldn’t consider it? Good news. There is such a prescription. It’s EXERCISE!

In addition to better cardiovascular and metabolic health, adults who exercise have a reduced risk for poor mental health, better balance and joint mobility, a lower risk for disturbed sleep, and a reduced risk for musculoskeletal disorders like neck and back pain. Exercise also helps to bring nutrients to cartilaginous tissues, which can keep the joints healthy and reduce symptoms in patients with arthritis. These benefits help working-age adults carry out their daily work and family obligations, and they help seniors stay active and independent due to better cognitive health, a reduced risk for comorbidities, and a lower risk for serious falls.
Exercise also benefits young adults by improving their ability to manage stress and to perform better in school and the workplace. Several studies have even shown that children who are more active tend to perform better academically. Furthermore, teens who are physically active are more likely to be active as adults, which sets the stage for a lifetime of good health.
Unfortunately, the Centers for Disease Control and Prevention (CDC) reports that only about half of adults meet federal guidelines of 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity a week. Additionally, 1-in-2 adults live with a chronic disease and about half of this group have two or more chronic illnesses. It’s estimated that meeting physical activity guidelines can prevent 1-in-10 premature deaths, 1-in-8 cases of breast cancer and colorectal cancer, 1-in-12 cases of diabetes, and 1-in-15 cases of heart disease. The Department of Defense has stated that 1-in-4 young adults who apply for a position in the armed forces is too heavy to be accepted.
While exercise is important for maintaining good health, it’s also worth noting that any intensity of physical activity is beneficial, especially when it replaces prolonged periods of sedentary behavior, which studies show can lead to a number of poor health outcomes.
If you’re already active, that’s great. Keep it up. If you’re out of shape and looking to get started, take it a day at a time and experiment with different forms of exercise to see what you like best so that you’ll be consistent. If aches and pains are getting in the way, contact your doctor of chiropractic so that he or she can evaluate you and work with you to manage your condition so that you can start exercising and get back to the activities you enjoy most.