Archive for the ‘Neck Pain’ Category

Neck Pain and Chiropractic

Posted: October 4, 2013 in Neck Pain

Neck pain represents a major problem for people throughout the world with considerable negative impact on individuals, families, communities, health care systems, and businesses. Up to 70% of the general population will have neck pain at some point in their life. Recovery within the year from neck pain ranges between 33% and 65%, AND relapses are common throughout the life time of the neck pain patient. Generally, neck pain is more common in women, higher in high-income countries, and higher in urban regions. The greatest risk of developing neck pain occurs between 35 and 49 years of age. Since neck pain, very similar to low back pain, is very common and likely to recur over and over again, the question is, what is the best course of action regarding treatment?

A recent study on neck pain patients compared the effectiveness of manual therapy performed by a chiropractor, physical therapy performed by a physical therapist (PT), and medical care performed by medical physician (MD). The success rate determined at the seventh week was TWO TIMES BETTER for the manual therapy/chiropractic group (68.3%) compared to the medical care group. Those receiving manual therapy also had fewer absences from work compared to both the medical and PT treated groups. Lastly, both the manual therapy and PT groups used less pain relief medication compared to the medically treated group. Another study looked at the multiple approaches that chiropractors use for treating patients with neck pain to determine the “best” approach a chiropractor can use. They reported 94% had improvement or less neck pain after just one treatment when the mid-back (thoracic spine) was also adjusted. Similarly, after receiving two treatments over a one week time frame, the group receiving midback adjustments (vs. the group who did not) reported lower pain and disability scores. A similar study concluded that the best results occurred when the neck, upper back/lower neck, and mid-back were adjusted. This group, when compared to neck adjustments alone, reported greater reductions in disability scores. Thus, having the cervical spine, upper back, and mid-back all adjusted appears to yield quicker, more satisfying results than neck adjustments alone.

What about the role of exercise in the management of neck pain patients? In November 2012, a systematic review of manual therapies for nonspecific neck pain reported that the addition of neck exercises to a treatment plan provided more benefits than spinal manipulation alone. Similarly, in September 2012 (The Annals of Internal Medicine), chiropractic adjustments were compared against exercise and pain medication treatment groups involving 272 patients tracked over a one-year time frame after a 12-week treatment. Both the chiropractic and exercise groups experienced the most significant pain reduction when compared to the medication treated group with more than double the likelihood of complete pain relief. The chiropractic and exercise groups also had the best short and long term results, but ONLY the chiropractic group found the benefits to last a year or more. The authors (Bronfort, et. al) reported the success of chiropractic treatment stems from its ability to address the CAUSE of the problem rather than simply addressing the symptoms!

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Neck Pain – Where Is It Coming From?

Posted: September 16, 2013 in Neck Pain

Neck pain can arise from a number of different tissues in the neck. Quite often, pain is generated from the small joints in the back of the vertebra (called facets). Pain can also arise from disk related conditions where the liquid-like center part of the disk works its way out through cracks and tears in the thicker outer part of the disk and can press on nerves producing numbness and/or weakness in the arm. It is possible to “sprain” the neck in car accidents, sports injuries, or from slips and falls. This is where ligaments tear and lose their stability resulting in excessive sliding back and forth of the vertebrae during neck movements. When muscles or their tendon attachments to bone are injured, these injuries are called “strains” and pain can occur wherever the muscle is torn. There is also referred pain. Here, the injury is at a distance away from where the pain is felt. A classic referred pain pattern is shoulder blade pain when a disk in the neck herniates. Let’s take a closer look at two conditions we often diagnose and treat as chiropractors:

Spinal Stenosis: This occurs when the canals in the spine narrow to the point of pinching the spinal cord in the trefoil shaped central canal (called “central stenosis”) or when the nerve roots get pinched in the lateral recesses (called lateral recess stenosis). This can occur from arthritis in the facet joints, disk bulging or herniations, thickening of ligaments, shifting of one vertebra over another, aging, heredity (being born with a narrowed canal), and/or from tumors. Usually, combinations of several of the above occur simultaneously. When this is present in the neck, it can be more serious compared to stenosis in the low back as the spinal cord ends at the upper part of the low back (T12 level) so only the nerves get pinched. Stenosis in the neck however pinches the spinal cord itself. Symptoms can include pain in one or both arms, but it’s more dangerous when leg pain, numbness, or weakness occur (called myelopathy). Rarely, loss of bowel or bladder control can occur which is then considered a “medical emergency” and requires prompt surgery.

Cervical Disk Herniation: As previously stated, the liquid-like center of the disk can work its way through cracks and tears in the outer layer of the disk and press on a nerve resulting in numbness, pain, and/or weakness in the arm. The classic presentation is the patient finding relief by holding the arm over the head, as this puts slack in the nerve and it hurts less in this position. The position of the head also makes a difference as looking up usually hurts more and can increase the arm pain/numbness while looking down reduces the symptoms. We will carefully test your upper extremity neurological functions (reflexes, muscle strength, and sensation as each nerve performs a different function in the arm), and we can tell you which nerve is pinched after a careful examination. This condition can lead to surgery so please take this seriously.

The good news is that chiropractic care can manage both spinal stenosis and cervical disk herniations BEFORE they reach the point of requiring surgery. So make chiropractic your FIRST choice when neck pain occurs!

Neck Pain Treatment Options

Posted: August 14, 2013 in Neck Pain

Neck pain is a very common problem. In fact, 2/3rds of the population will have neck pain at some point in life. It can arise from stress, lack of sleep, prolonged postures (such as reading or driving), sports injuries, whiplash injuries, arthritis, referred pain from upper back problems, or even from sinusitis! Rarely, it can be caused from dangerous problems including referred pain during a heart attack, carotid or vertebral artery injuries, or head or neck cancer, but these, as previously stated, are very uncommon. However, since you don’t know why your neck hurts, it’s very important to have your neck pain properly evaluated so the cause can be properly treated and not just covered up from the use of pain killers!

Barring the dangerous causes of neck pain listed above, treatment methods vary depending on whom you elect to consult. Classically, if you see your primary care physician, pharmaceutical care is usually the approach. Medications can be directed at reducing pain (Tylenol, or one of many prescription “pain killers”), at reducing inflammation and pain (Aspirin, Ibuprofen, Aleve, etc.), to reduce muscle spasms (like muscle relaxers) or, medications may be directed to reduce depression, anxiety, or the like. When a sinus infection affects the 2 deep sinuses (ethmoid and sphenoid sinuses which are located deep in the head), the referred pain is directed to the back of the head and neck. Here, an antibiotic may be needed and/or something specifically directed at allergies when present. In general, in cases that do not respond to usual chiropractic care, co-management with the primary care physician is a good option.

However, the good news is that chiropractic care usually works well, and the need for medication can be avoided since the side effects of medication can sometimes be worse than the benefits. Recently, The Bone and Joint Decade Task Force on Neck Pain published arguably the best review of research published between 2000 and 2010 regarding neck pain treatment approaches. They concluded that spinal manipulation and mobilization are highly effective for many causes of neck pain, especially when arising from the muscles and joints – the most common cause. Therefore it would seem logical to consult with a Chiropractor FIRST since manipulation and mobilization are so effective and safe. When we add neck exercises, the results are even better, according to some studies. As chiropractors, we will often use different modalities including electric stimulation, ultrasound, hot and/or cold (which are usually given as a good home-applied remedy), and others. In particular, low level laser therapy (LLLT) has been shown, “…to reduce pain immediately after treatment in acute neck pain and up to 22 weeks after completion of treatment in patients with chronic neck pain” [Lancet, 2009; 374(9705)]. LLLT is a commonly used modality by chiropractors and when combined with spinal manipulation, the results can be even faster! We will also evaluate your posture, body mechanics, and consider “ergonomic” or work station problems and offer recommendations for improving your work environment. We also frequently utilize anti-inflammatory nutrients including vitamins, minerals, herbs, and more to avoid the negative side effects to the stomach, liver, and kidney negative that can result from using non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, or Aleve. Make chiropractic your FIRST choice when neck pain strikes, NOT last resort!

Neck pain can arise from many sources. There are ligaments that hold bones to other bones that are non-elastic and very strong. When injured, the term, “sprain” is applied. The muscle and/or its attachment (the tendon) can tear as well, which is called a “strain.” But, what is it that people refer to when they say, “…I slipped a disk in my neck!”?

The disks lay between the vertebrae in the front of the spine, and they are part of the primary support and shock absorbing system of our neck and back. There are 6 disks in the neck, 12 in the mid-back and 5 in the low back for a total of 23. The disks in the low back are big, like the vertebral bodies they lie between, and get progressively smaller as they go up the spine towards the head. When we bend our neck forwards, the disk compresses, and opens wider when we look up. It forms a wedge shape when we side bend left or right, and it twists when we rotate or turn the head.

The terms, “…a slipped disk, a herniated disk, a ruptured disk, a bulging disk” (and more), all mean something similar, if not exactly the same thing. A central part of the disk is liquid-like and can herniate in any direction. When it does, it can create pain IF it pinches something, or it may be painless if it doesn’t. In fact, since the invention of the CAT scan and MRI, many (“normal”) people have been found on the scan to have some type of disk “derangement” (alteration of the normal integrity of the disk), with 50%+ showing bulging disk(s) and 21% showing frank herniations WITH NO PAIN AT ALL! So, in the absence of shooting pain down an arm from the neck, or when there is no numbness or weakness in the arm, why order an MRI? It may show bulges or herniations that are not “clinically” important, and may falsely lead a doctor to recommend surgery when it’s not needed.

There are “KEY” findings in the history and examination that leads us to the diagnosis of a cervical disk injury. From the history, the disk patient often has arm pain, numbness, and/or muscle weakness that follows a specific pathway, such as numbness to the thumb/index finger (C6 nerve), middle of the hand & 3rd finger (C7) or to the pinky & ring finger (C8). Certain positions, such as looking up, usually irritate the neck and arm, and bending the head forward relieves it. Another unique history and exam finding is if the patient finds relief by putting the arm up and over their head. Similarly, letting the arm hang down is often associated with irritation. Other examination findings unique to a cervical disk injury include reproducing the arm pain by placing the head in certain positions such as bending the head back and to the side simultaneously. Another is compressing the head into the shoulders. When lifting up on the head (traction), relief of arm pain is common. The neurological exam will usually show a reduction of sensation when we gently poke them with a sharp object, and/or they may have weakness when compared to the opposite side.

Chiropractic treatments can be very successful in resolving cervical disk herniation signs and symptoms, and should CERTAINLY be tried before agreeing to a surgical correction. Often, the surgeon will recommend a fusion of 2 or more neck vertebrae, sometimes with a metal plate in the front of the spine. This increases the load on either side of the fusion and can create problems above and below the fusion. Trust me, try chiropractic first. You’ll be glad you did!

How many times have you heard, “I have a pinched nerve in my neck and have to have surgery.” Though there certainly are cases where surgical intervention is required, surgery should ONLY be considered after ALL non-surgical treatment approaches have been tried first (and failed). It is alarming how many cases of cervical radiculopathy (i.e., “pinched nerve”) end up being surgically treated with NO trial of non-surgical care. Hence, the focus of this month’s article will look at research (“MEDICAL EVIDENCE”) that clearly states neck surgery DOES NOT improve the long term outcomes of patients with chronic neck pain.

Chronic neck pain (CNP) is, by definition, neck pain that has been present for a minimum of three months. This category of neck pain is very well represented, as many neck pain sufferers have had neck pain, “…for years” or, at least longer than three months. Depending on the intensity of pain and it’s effect on daily function, many patients with CNP often ask their primary care provider, “…is there anything surgically that can be done?” The desire for a “quick fix” is often the focus of those suffering with neck pain. Unfortunately, according to recent studies, there may not be a “quick fix” or, at least surgery is NOT the answer. The December 2012 issue of The European Spine Journal reports that spine surgery did NOT improve outcomes for patients with CNP. Moreover, they pointed to other studies that showed some VERY STRONG REASONS NOT to have spine surgery unless everything else has failed. One of the reasons was a higher hospital readmission rate after spine surgery. Another reported that most studies on surgical vs. conservative [non-surgical] care showed a high risk of bias, suggesting the research on surgical intervention was biased in the research approach used. They further reported, “The benefit of surgery over conservative care is not clearly demonstrated.” It is important to point out that the research analyzed studies that included patients with and without radiculopathy (radiating arm pain from a pinched nerve), and myelopathy (those with pinching of the spinal cord creating pain, numbness, weakness in the legs, and/or bowel / bladder dysfunction).

In February of 2008, the Neck Pain Task Force published overwhelming evidence that research supports the use of cervical spinal manipulation in the treatment of both acute and chronic neck pain with or without radiculopathy. Bronfort published similar findings in 2010 in a large UK based study that looked at the published evidence supporting different types of treatment for various conditions. They found cervical spine manipulation was effective for neck pain of ANY duration (acute or chronic). Chiropractic utilizes manipulation, manual traction, mobilization, muscle release techniques, home cervical traction, exercise, as well as a multitude of physiotherapy modalities when managing patients with CNP. Given the overwhelming research evidence that surgical intervention for CNP is NOT any better than non-surgical care, the greater amount of negative side-effects, and the obviously long recovery time post-surgically, chiropractic treatment of anyone suffering from CNP should be tried FIRST.

Last month, we looked at the published evidence that overwhelmingly supports the use of cervical traction. As promised, this month’s focus is the proper methods of applying it. The type of traction that this discussion will address will be limited to the kind that can be purchased and then used in the home, usually multiple times a day, giving it a clear advantage over in-office traction treatments which can only be applied a few times a week during office visits. In some cases however, it may be appropriate to use the in-office type for a few sessions to determine dosage and/or tolerance prior to administering a home unit, but this varies from case to case, and each type of traction unit is different. In the neck or cervical spine, there are many varieties including: sitting over-the-door types, cervical collar types, as well as supine (lying on the back) types. Each variety has its pros and cons and prices vary considerably from $10 to $600.

CONDITIONS: Probably the most common condition treated with cervical traction is “cervical radiculopathy,” or a pinched nerve. When a nerve root in the neck is pinched, pain, numbness, tingling, and/or muscle weakness occurs in the area the particular nerve innervates. For example, if a patient presents with pain and numbness radiating down the arm to the thumb and index finger and/or have weakness in bending their elbow and extending their wrist, then we know that the C6 nerve is pinched. When pulling or stretching the neck relieves the arm pain, traction is usually helpful. If pain worsens, the person is probably not ready for traction yet.

PROTOCOL (DOSAGE): The key to a successful outcome using cervical traction is finding the right dosage. If you start with too much weight, it may leave you feeling sore, or worse, making you reluctant to try it a second time. Therefore, rather than relying on using a certain percentage of body weight, it’s safest to start with less weight and then gradually increase it, such as 5# (# = pounds or .45 kg) for 15-20 minutes. If that dose feels fine, try 7#/15-20 min., then 9#, 11#, 13#, etc., until you find it just isn’t quite as comfortable at the last weight. You have now found your current threshold and should drop down to the last most comfortable weight and use that for a few days and then MAYBE try increasing it again. Studies show a maximum stretch is usually achieved within 15-20 minutes, so extending the time longer may be less productive. Facing the over-the-door unit may be better tolerated than facing away. Try it both ways and you decide which feels best. The next most important issue is frequency.

How often to repeat the traction sessions depends on: 1. The condition’s severity and your response; 2. Your time availability. If there is a severe nerve pinch with muscle twitching, weakness and dense numbness/tingling, then the traction be repeated MANY times a day, gradually increasing the weight to find the optimum amount. We’ve had people repeat the traction 10x/day! With the option of wearing a cervical collar traction unit, you can actually travel and/or do certain activities during traction. We’ve had people travel to and from work while performing traction! Since each case is unique, we’ll discuss that individually. The bottom line, IT WORKS GREAT with proper chiropractic management and in many cases, surgery CAN be avoided!

We realize that you have a choice in where you choose your healthcare services. If you, a friend or family member requires care for neck pain, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.

Traction is defined as, “…the act of pulling a body part.” Therefore, it is commonly used in many regions including legs, arms, low back, mid-back, and the neck. We will be limiting this discussion to cervical or neck traction, and the question of the month is, “…does it help patients with neck pain and headaches?” Though I’m assuming you already know, the answer is YES! You may want a little “proof,” so here it goes!

1. REDUCES DISK PROTRUSIONS: In 2002, a medically based study found traction to be very effective in the treatment of cervical radiculopathies (pinched nerves in the neck that radiate pain into the arms). A 2008 study using MRI (images) described the effect traction had on the disk protrusions in the neck reporting 25 of 35 (or 71%) were reduced while in traction with a 19% increase in the spacing (disk height) and improved neck range of motion after the traction was applied. They postulated that by pulling the vertebrae in the neck apart, there was a suction-like effect pulling the disk material back in place.

2. RECOMMENDED BY GUIDELINES: Around the world, guidelines have been published giving doctors information that allows us to know how well certain forms of treatment work for different conditions. In a 2008 publication, it was reported that, “Clinicians should consider the use of mechanical intermittent cervical traction, combined with other interventions such as manual therapy and strengthening exercises, for reducing pain and disability in patients with neck and neck-related arm pain.”

3. CLINICAL PREDICTION RULES: These help us determine who is most likely to benefit from a certain type of treatment (in this case cervical traction and exercise). If 3 of 5 variables are found, the likelihood of success with traction & exercise was reported to be 79%, and if 4 of the 5 are found, 90%. The 5 variables are: 1. Radiating neck to arm pain in certain positions; 2. Positive shoulder abduction sign; 3. Age >55years old; 4. Positive limb tension test; 5. Relief of symptoms using manual distraction test (if pain is relieved while the neck is being pulled).

4. INTERMITTENT AND CONTINUOUS TRACTION: Either way, significant improvement in neck and arm pain, neck mobility, and nerve function occurred with both approaches.

5. TRACTION VS. SURGERY: In this study, patients with radiating arm pain and positive neurological findings on exam were offered a course of traction before surgical options. They reported 63 of 81, or 78%, of the patients experienced significant or total relief, 3 could not tolerate traction and 15 simply didn’t respond. They concluded that when neck and arm symptoms with neurological deficits were present for 6 weeks, that 75% will respond to neck traction over the next 6 weeks.

There are MANY additional studies available that show well beyond doubt that cervical traction is a GREAT option in the management of neck and arm pain and sometimes headaches. Next month, we will discuss “HOW TO” apply cervical traction.

We realize that you have a choice in where you choose your healthcare services. If you, a friend or family member requires care for neck pain, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.