Neck Problems

Neck Problems (36)

US Chiropractic Directory Presents:

Neck Problems


Neck problems are one of the most prevalent issues that people worldwide suffer. Neck pain has been called torticollis, stiff neck and a host of other names, however to the public, it is literally a "pain in the neck." Chiropractic has been safely and effectively helping patents with pain in the neck for over 100 years and The US Chiropractic Directory has create a forum of information combining the entire healthcare and scientific community to bring the public evidenced and researched based answers on how and why chiropractic works to help those with neck pain/problems.

Wednesday, 27 June 2018 18:49

Vertebral Subluxation Complex - The Research

Written by

Chiropractic Vertebral Subluxation

By Mark Studin

William J. Owens

 

Citation: Studin M., Owens W. (2018) Vertebral Subluxation Complex, American Chiropractor, 40 (7) 12, 14-16, 18, 20, 22, 24, 26-27

 

A report on the scientific literature

 

INTRODUCTION

 

Chiropractic was discovered in 1895 by Daniel David Palmer and further developed by his son, Bartlett James Palmer. Together, they helped coin the phrase “vertebral subluxation,” yet to date, there has been little evidence of it in the literature. When we consider neuro-biomechanical pathological lesions that will degenerate (please refer to Wolff’s Law) based upon homeostatic mechanisms in the human body we will better understand and be able to define the chiropractic vertebral subluxation and more specifically, the chiropractic vertebral subluxation complex (VSC). In addition, the literature has provided us with a vast amount of evidence on both the biomechanical dysfunction of the spine as well as the neurological consequence as sequelae to that biomechanical dysfunction.

 

Despite over a century of reported and literature-based clinical results, detractors both outside and inside the chiropractic profession argue to limit the scope of these spinal lesions because the literature has not yet caught up to the results. Additionally, the lack of contemporary literature has been reflected in “underperforming” chiropractic utilization in the United States for conditions that have been well-documented as responding successfully in outcome studies with chiropractic care.

Murphy, Justice, Paskowski, Perle and Schneider (2011) reported:

 

Spine-related disorders (SRDs) are among the most common, costly and disabling problems in Western society. For the purpose of this commentary, we define SRDs as the group of conditions that include back pain, neck pain, many types of headache, radiculopathy, and other symptoms directly related to the spine. Virtually 100% of the population is affected by this group of disorders at some time in life. Low back pain (LBP) in the adult population is estimated to have a point prevalence of 28%-37%, a 1-year prevalence of 76% and a lifetime prevalence of 85%. Up to 85% of these individuals seek care from some type of health professional. Two-thirds of adults will experience neck pain some time in their lives, with 22% having neck pain at any given point in time.

 

The burden of SRDs on individuals and society is huge. Direct costs in the United States (US) are US$102 billion annually and $14 billion in lost wages were estimated for the years 2002-4. (p. 1)

 

In 2017, based upon Alioth Education, dollars adjusted for inflation equates to $18,141, 895,182.64 in direct costs for spinal-related conditions that fall within the chiropractic treatment category and have proven to outperform other forms of care. When considering outcome assessments for efficacy of chiropractic in a population-based study, both Cifuentes, Willets and Wasiak  (2011) and Blanchette, Rivard, Dionne, Hogg-Johnson, and Steenstra (2017) offered evidence that the results are rooted in a “first healthcare provider” or “primary spine care” solution.

 

 

Cifuentes et al. (2011) compared different treatments of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability episode after a 15-day absence and return to disability. Anyone with less than a 15-day absence of disability was excluded from the study. Please note that we kept disability outcomes for all reported treatment and did not limit this to physical therapy. However, the statistic for physical therapy was significant.

 

According to the Cifuentes, Willets and Wasiak (2011) study, chiropractic care during the disability episode resulted in:

  • 24% decrease in disability duration of first episode compared to physical therapy.
  • 250% decrease in disability duration of first episode compared to medical physician's care.
  • 32% decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care.
  • 21% decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care.

Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating, After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (Cifuentes et al., 2011, p. 404).

 

Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) reported:

The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation. (p. 388)

 

Despite compelling evidence of chiropractic being the best option for primary spine care treatment of injuries related to disabilities and pain based upon outcomes, the reasons why chiropractic works have been elusive. Despite the lack of literature-based evidence, answers are still being sought because positive results are consistently being realized in clinical chiropractic practices. When Keating et al. (2005) wrote an opinion or debate article, they concluded, “Subluxation syndrome is a legitimate, potentially testable, theoretical construct for which there is little experimental evidence” (p. 13).

 

This statement is one of the most unifying statements that could serve to reduce pain and opiate utilization, prevent premature degeneration and increase bio-neuromechanical function for our society, while significantly increasing our utilization because chiropractic is part of the answer. However, the simple question is, “Why aren’t we doing this specific research because the pieces of what is considered subluxation have been verified in the literature for quite some time?”

 

 

DISCUSSION

 

VSC starts with spinal biomechanics and when considering a pathological model, we need to define the normal functioning of the spine.

Panjabi (2006) reported:

The spinal column, consisting of ligaments (spinal ligaments, discs annulus and facet capsules) and vertebrae, is one of the three subsystems of the spinal stabilizing system. The other two are the spinal muscles and neuromuscular control unit. The spinal column has two functions: structural and transducer. The structural function provides stiffness to the spine. The transducer function provides the information needed to precisely characterize the spinal posture, vertebral motions, spinal loads etc. to the neuromuscular control unit via innumerable mechanoreceptors present in the spinal column ligaments, facet capsules and the disc annulus. These mechanical transducers provide information to the neuromuscular control unit which helps to generate muscular spinal stability via the spinal muscle system and neuromuscular control unit. The criterion used by the neuromuscular unit is hypothesized to be the need for adequate and overall mechanical stability of the spine. If the structural function is compromised, due to injury or degeneration, then the muscular stability is increased to compensate the loss. (p. 669)


Panjabi (2003) also reported:

It has been conceptualized that the overall mechanical stability of the spinal column, especially in dynamic conditions and under heavy loads, is provided by the spinal column and the precisely coordinated surrounding muscles. As a result, the spinal stabilizing system of the spine was conceptualized by Panjabi to consist of three subsystems: spinal column providing intrinsic stability, spinal muscles, surrounding the spinal column, providing dynamic stability, and neural control unit evaluating and determining the requirements for stability and coordinating the muscle response. (p. 372)

 

In defining spinal clinical instability, Panjabi (1992) previously reported:

Clinical instability is defined as a significant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits so that there is no neurological dysfunction, no major deformity, and no incapacitating pain. (p. 394)

 

 

Anatomically, we are starting with the vertebrate and more specifically, the articular facets indicating that VSC is a “complex” and not a simple problem as the anatomical pathology occurs in opposing facets. When looking at normal vertebral structures, Farrell, Osmotherly, Cornwall, Sterling and Rivett (2017) focused their study on the cervical spine. 

 

Farrell et al. (2017) reported:

Cervical spine meniscoids, also referred to as synovial folds or intra-articular inclusions, are folds of synovium that extend between the articular surfaces of the joints of the cervical spine. These structures have been identified within cervical zygapophyseal, lateral atlantoaxial and atlanto-occipital joints, and have been hypothesised to be of clinical significance in neck pain through their mechanical impingement or displacement, as a result of fibrotic changes, or via injury as a result of trauma to the cervical spine. (p. 939)

 

Farrell et al. (2017) later stated:

An understanding of the basic structure of meniscoids is necessary to assess their potential role in cervical spine pathology. As described above, cervical spine meniscoids are folds of synovium that protrude into a joint from its margins. Meniscoids lie between the articular surfaces at the ventral and dorsal poles of their enclosing joint. Their basic structure includes a base, which attaches to the joint capsule, a middle region and an apex that protrudes approximately 1–5 mm into the joint cavity. In sagittal cross section, these structures are triangular in shape, and when viewed superiorly they often appear crescent-shaped or semi-circular. Cervical spine meniscoids are thought to function to improve the congruence of articular structures, and to ensure the lubrication of articular surfaces with synovial fluid. (p. 940)

 

Should these synovial folds or “plicas” become trapped or “pinched” as described by Evans (2002), it would be the beginning of a “negative neurological cascade.”

 

 

Evans (2002) reported:

Intra-articular formations have been identified throughout the vertebral column. Giles and Taylor demonstrated by light and transmission electron microscopy the presence of nerve fibers (0.6 to 1 mm in diameter) coursing through synovial folds, remote from blood vessels, that were most likely nociceptive. They concluded, “Should the synovial folds become pinched between the articulating facet surfaces of the zygapophyseal joint, the small nerves demonstrated in this study may have clinical importance as a source of low back pain.” (p. 252)

 

 

 

Figure 1: Images of meniscoid entrapment on flexion, on attempted extension, involving flexion and gapping and realigned.

 

Evans (2002) explained the images above as follows:

Meniscoid entrapment. 1) On flexion, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with It. 2) On attempted extension, the inferior articular process returns toward its neutral position, but instead of re-entering the joint cavity, the meniscoid impacts against the edge of the articular cartilage and buckles, forming a space-occupying "lesion" under the capsule. Pain occurs as a result of capsular tension, and extension is inhibited. 3) Manipulation of the joint involving flexion and gapping, reduces the impaction and opens the joint to encourage re-entry of the meniscoid into the joint space (4) [Realignment of the joint.] (p. 253)

 

Evans (2002) continued:

Bogduk and Jull reviewed the likelihood of intra-articular entrapments within zygapophyseal joints as potential sources of pain…Fibro-adipose meniscoids have also been identified as structures capable of creating a painful situation. Bogduk and Jull reviewed the possible role of fibro-adipose meniscoids causing pain purely by creating a tractioning effect on the zygapophyseal joint capsule, again after intra-articular pinching of tissue(p. 252)

 

Evans (2002) also noted:

A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophyseal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent impaction of the meniscoid. The patient would tend to be more comfortable with the spine maintained in a flexed position, because this will disengage the meniscoid. Extension would therefore tend to be inhibited. This condition has also been termed a “joint lock” or “facet-lock,” the latter of which indicates the involvement of the zygapophyseal joint…

 

 

An HVLAT manipulation [chiropractic spinal adjustment CSA], involving gapping of the zygapophyseal joint, reduces the impaction and opens the joint, so encouraging the meniscoid to return to its normal anatomic position in the joint cavity. This ceases the distension of the joint capsule, thus reducing pain. (p. 252-253)

 

When considering VSC in its entirety, we must consider the etiology as these forces can lead to complex patho-biomechanical components of the spine and supporting tissues. As a result, a neurological cascade can ensue that would further define VSC beyond the inter-articulation entrapments. Panjabi (2006) reported:

Abnormal mechanics of the spinal column has been hypothesized to lead to back pain via nociceptive sensors. The path from abnormal mechanics to nociceptive sensation may go via inflammation, biochemical and nutritional changes, immunological factors, and changes in the structure and material of the endplates and discs, and neural structures, such as nerve ingrowth into diseased intervertebral disc. The abnormal mechanics of the spine may be due to degenerative changes of the spinal column and/or injury of the ligaments. Most likely, the initiating event is some kind of trauma involving the spine. It may be a single trauma due to an accident or microtrauma caused by repetitive motion over a long time. It is also possible that spinal muscles will fire in an uncoordinated way in response to sudden fear of injury, such as when one misjudges the depth of a step. All these events may cause spinal ligament injury. (p.668-669).

 

Panjabi (2006) goes on to explain what happens when the spinal column is affected by trauma:

The structural function provides stiffness to the spine. The transducer function provides the information needed to precisely characterize the spinal posture, vertebral motions, spinal loads etc. to the neuromuscular control unit via innumerable mechanoreceptors present in the spinal column ligaments, facet capsules and the disc annulus. These mechanical transducers provide information to the neuromuscular control unit which helps to generate muscular spinal stability via the spinal muscle system and neuromuscular control unit. The criterion used by the neuromuscular unit is hypothesized to be the need for adequate and overall mechanical stability of the spine. If the structural function is compromised, due to injury or degeneration, then the muscular stability is increased to compensate the loss. What happens if the transducer function of the ligaments of the spinal column is compromised? This has not been explored. There is evidence from animal studies that the stimulation of the ligaments of the spine (disc and facets, and ligaments) results in spinal muscle firing. (p. 669).

 

Panjabi (2006) described the mechanism that, coupled with the inter-articulation nociceptor “firing,” further defines the “negative neurological cascade”:

 

 

The hypothesis consists of the following sequential steps:

  1. Single trauma or cumulative microtrauma causes subfailure injury of the spinal ligaments and injury to the mechanoreceptors embedded in the ligaments.
  2. When the injured spine performs a task or it is challenged by an external load, the transducer signals generated by the mechanoreceptors are corrupted.
  3. Neuromuscular control unit has difficulty in interpreting the corrupted transducer signals because there is spatial and temporal mismatch between the normally expected and the corrupted signals received.
  4. The muscle response pattern generated by the neuromuscular control unit is corrupted, affecting the spatial and temporal coordination and activation of each spinal muscle. 
  5. The corrupted muscle response pattern leads to corrupted feedback to the control unit via tendon organs of muscles and injured mechanoreceptors, further corrupting the muscle response pattern. 
  6. The corrupted muscle response pattern produces high stresses and strains in spinal components leading to further subfailure injury of the spinal ligaments, mechanoreceptors and muscles, and overload of facet joints. 
  7. The abnormal stresses and strains produce inflammation of spinal tissues, which have abundant supply of nociceptive sensors and neural structures.
  8. Consequently, over time, chronic back pain may develop. The subfailure injury of the spinal ligament is defined as an injury caused by stretching of the tissue beyond its physiological limit, but less than its failure point. (p. 669-670)

 

One hallmark of determining vertebral subluxation complex for the chiropractic profession has been ranges of motion of individual motor units. Both hypo- and hypermobility have been clinically associated with muscle spasticity and have offered a piece of clinical history in the practice setting. NOTE: Ranges of motion, like any other findings, are no more than pieces of evidence, all of which must clinically correlate.

 

Radziminska, Weber-Rajek, Srączyńska and Zukow (2017) reported:

The definition of the neutral zone explains that it as a small range of motion near the zero position of the joint, where no proprioreceptors are stimulated around the joint and osteoligamentous resistance is minimal (lack of centripetal response and, consequently, lack of central muscle stimulation).

 

Increasing the range of motion of the neutral zone is detrimental to the joint - it can lead to its damage. Delayed proprioceptive information about the current joint position that reaches the central system will give a muscle tone response, but it may turn out to be incompatible with external force acting on the joint. The reduced range of motion of the neutral zone is also unfavorable. If the stimulation of proprioreceptors is too early it will result in an increased muscle tension around the joint. The neutral zone is disturbed by traumas, degenerative processes, and muscle stabilization weakness. (p. 72)

 

With VSC, the joint that has been misplaced creates abnormal biomechanics and abnormal pressure to the joint. This is called Wolff’s Law, formulated and accepted since the 1800’s, and is explained by Kohata, Itoha, Horiuchia, Yoshiokab and Yamashita (2017):

When mechanical stress is impressed upon bone, an electrical potential is induced; the area of bone under compression develops negative potential, whereas that under tension develops positive potential.   This phenomenon is generated by collagen piezoelectricity, and the electrical potential generated in bone by collagen displacement has been well documented. (p. 65)

 

 

CONCLUSION

 

VSC is based upon both the macro- and microtrauma induced motor unit pathology, creating interarticular meniscoid nociceptor entrapment that triggers nociceptors and affects the lateral horn for a local reflex. It then innervates the thalamus through the spinothalamic tracts and periaqueductal grey matter which is then further distributed to various cortical regions to process in the body’s attempt to compensate biomechanically. This, coupled with aberrant motor unit ranges of motion (hypo or hyper), subfailure injuries to the ligaments and the corrupted mechanoreceptors and nociceptor messages that innervate the lateral horn cause a “negative neurological cascade” both reflexively at the cord and the brain. This cascade can cause pain and inflammation and will cause premature degeneration if left uncorrected based upon Wolff’s Law because of improper motor unit biomechanical failure. Should the correction be made after remodelling of the vertebrate, then care changes from corrective to management as the spine can never be perfectly biomechanically balanced as the segments (building blocks for homeostasis) have been permanently remodelled.

 

 

The research for VSC exists in its components. However, there needs to be a concise research program that combines all the pieces to further conclude the evidence that exists. Furthermore, we need more conclusive answers as to why chiropractic patients get well, answers that goes beyond pain or aberrant curves.

 

References

 

1. Murphy, D. R., Justice, B. D., Paskowski, I. C., Perle, S. M., & Schneider, M. J. (2011). The establishment of a primary spine care practitioner and its benefits to health care reform in the United States. Chiropractic & manual therapies19(1), 17.

2. FinanceRef Inflation Calendar, Alioth Finance. (2017). $14,000,000,000 in 2004 → 2017 | Inflation Calculator. Retrieved from http://www.in2013dollars.com/2004-dollars-in-2017?amount=14000000000

3. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine53(4), 396-404.

4. Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation27(3), 382-392.

5. Keating, J. C., Charlton, K. H., Grod, J. P., Perle, S. M., Sikorski, D., & Winterstein, J. F. (2005). Subluxation: Dogma or science? Chiropractic & Osteopathy13(1), 17.

6. Panjabi, M. M. (2006). A hypothesis of chronic back pain: Ligament subfailure injuries lead to muscle control dysfunction. European Spine Journal15(5), 668-676.

7. Panjabi, M. M. (1992). The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. Journal of Spinal Disorders5, 390-397

8. Panjabi, M. M. (2003). Clinical spinal instability and low back pain. Journal of Electromyography and Kinesiology13(4), 371-379.

9. Farrell, S. F., Osmotherly, P. G., Cornwall, J., Sterling, M., & Rivett, D. A. (2017). Cervical spine meniscoids: an update on their morphological characteristics and potential clinical significance. European Spine Journal, (26) 939-947

10. Evans, D. W. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics, 25(4), 251-262.

11. Radziminska, A., Weber-Rajek, M., Strączyńska, A., & Zukow, W. (2017). The stabilizing system of the spine. Journal of Education, Health and Sport7(11), 67-76.

12. Kohata, K., Itoh, S., Horiuchi, N., Yoshioka, T., & Yamashita, K. (2017). Influences of osteoarthritis and osteoporosis on the electrical properties of human bones as in vivo electrets produced due to Wolff's law. Bio-Medical Materials and Engineering, 28(1), 65-74.

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Efficacy and Adverse Effects of Chiropractic Treatment for Migraines

 

By Mark Studin

William J. Owens

A report on the scientific literature

When considering care for migraines, there are a myriad of considerations; efficacy of treatment, costs to sufferers and insurers and the socioeconomic impact to individuals, business and families of those who suffer. When considering there are co-morbidities that must be considered in the quest for a “best-outcome,” avoiding any potential side effects, both with pharmacological and non-pharmacological care paths are critical. Chaibi, Benth, Tuchin and Bjorn (2017) reported “Manual-therapy [chiropractic spinal adjustments] is a non-pharmacological prophylactic treatment option that appears to have a similar effect as the drug topiramate on migraine frequency, migraine duration, migraine intensity and medicine consumption.” (pg. 66) Although previous reports indicate that chiropractic was upwards of 57% more effective (see ensuing comments), for this report, we are going to focus on the side effects of treatment, as efficacy has already been established.

Studin and Owens (2011) reported, “Nelson, Suter, Casha, du Plessis and Hurlbert (1998) reported on randomized clinical trials that took place over an 8-week course. The results showed there was minor statistical differences in outcomes for improvement during the trial period for chiropractic care and for amatriptyline and over-the-counter medications for treating migraine headaches. It was also reported that there was no statistical benefit in combining therapies. However, the major factor is that in the post-treatment follow-up period, chiropractic was 57% more effective in the reduction of headaches than drug therapy. In addition, it was reported that, with the drug group, "...58% experienced medication side effects important enough to report them. In the amatriptyline group, 10% of the subjects had to withdraw from the study because of intolerable side effects. Side effects in the SMT (Spinal Manipulative Therapy) group were much more benign, infrequent, mild and transitory. None required withdrawal from the study (Nelson et al., 1998, p. 511).

Using the 57% increased effectiveness that chiropractic has over drug therapy (leaving out the overlap that chiropractic could help without drugs) and the $24,000,000,000 ($24 billion) Americans pay for headaches and migraines, the savings would result in $13,680,000,000. back in the insurers, the public's and the government's pockets. In addition, if chiropractic reduced the necessity for emergency room visits by 57%, then the ED doctors could focus on what their primary purpose is, to save lives in urgent scenarios.”

Retrieved from: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=533:headaches-and-migraines-chiropractic-saves-federal-and-private-insurers-13-680-000-000-and-resolves-many-issues-facing-emergency-rooms-today&Itemid=320

 

Studin and Owens (2011) also reported, “Bryans, et. al. (2011) confirmed Nelson's findings and reported that spinal manipulation (adjusting) is recommended for patients with episodic or chronic migraines with or without aura and patients with cervicogenic headaches. This follow-up study is not a comparison or comment on the use of drugs. It simply demonstrates that chiropractic is a viable solution for many and can save the government and private industry billions in expenditures both in health care coverage, loss of productivity and avoidance of absenteeism in industry creating a new level of cost as sequella to headaches.” Retrieved from: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=533:headaches-and-migraines-chiropractic-saves-federal-and-private-insurers-13-680-000-000-and-resolves-many-issues-facing-emergency-rooms-today&Itemid=320

 

Chaibi, Benth, Tuchin and Bjorn (2017) reported,The results of the current study and previous CSMT (chiropractic spinal manipulative therapy) studies suggest that AEs are usually mild and transient, and severe and serious AEs (adverse effects) are rare (Tuchin, 2012; Cassidy et al., 2008, 2016). These findings are in accordance with the World Health Organization guidelines on basic training and safety in CSMT, which has considered it to be an efficient and safe treatment modality (WHO, 2005). AEs in migraine prophylactic pharmacological RCTs (random control trials) are common (Jackson et al., 2015). The risk for AEs during manual-therapy appears also, to be substantially lower than the risk accepted in any medical context for both acute and prophylactic migraine medication (Jackson et al., 2015; Ferrari et al., 2001). Non-pharmacological management also has the advantage of no pharmacological interactions/AEs because such therapies are usually mild and have a transient characteristic, whereas pharmacological AEs tend to be continuous.” (pg. 70)

Mackenzie, Phillips, and Lurie (2015) reported on the safety in general for chiropractic patients and based their study on 6,669,603 subjects and after the unqualified subjects had been removed from the study, the total patient number accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified”(Whedon et al., 2015, p. 5). This study supersedes all the rhetoric about chiropractic and stroke and renders an outcome assessment to help guide the triage pattern of mechanical spine patients.

When considering the outcomes for chiropractic care vs. drug therapy and the safety for migraine sufferers and all other types of chiropractic patients in a large population study, chiropractic should be considered the first option for both referrals from medical primary care providers and the first treatment option for the public. This validates the common-sense approach to healthcare of “drugless first, drugs second and surgery last.” Too often, society for issues that are not germane to this argument, rely on dogma for healthcare solutions often a large risk to themselves and the results affect the entire socio-economics of that person’s life.

References:

  1. Chaibi, A., Benth, J. Š., Tuchin, P. J., & Russell, M. B. (2017). Adverse events in a chiropractic spinal manipulative therapy single-blinded, placebo, randomized controlled trial for migraineurs. Musculoskeletal Science and Practice29, 66-71.
  2. Studin M., Owens W., (2010) Headaches and Migraines: Chiropractic Saves Federal and Private Insurers $13,680,000,000 and Resolves Many Issues Facing Emergency Rooms Today
  3. Nelson, C. F., Bronfort, G., Evans, R., Boline, P., Goldsmith, C., & Anderson, A. V. (1998). The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative & Physiological Therapeutics, 21(8), 511-519.
  4. Studin M., Owens W., (2010) Headaches & Migraines: Chiropractic vs. Medicine Effectiveness and Safety, Retrieved from: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=533:headaches-and-migraines-chiropractic-saves-federal-and-private-insurers-13-680-000-000-and-resolves-many-issues-facing-emergency-rooms-today&Itemid=320
  5. Bryans,
  6. Doheny, K. (2006). Recognizing the financial pain of migraines. Workforce Management, 85
  1. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270.

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Chiropractic Improves Neck Pain in a Military Veteran Population & Lowers the Need for Opiates

 

By Mark Studin

William Owens

 

A Report on the Scientific Literature

 

According to the American Academy of Pain Medicine, neck pain accounts for 15% of commonly reported pain conditions. Sinnott, Dally, Trafton, Goulet and Wagner (2017) reported:

 

Neck and back pain problems are pervasive and associated with chronic pain, disability and high healthcare utilization. Among adults 60% to 80% will experience back pain and 20% to 70% will experience neck pain that interferes with their daily activities during their lifetime. At any given time, 15% to 20% of adults will report having back pain and 10% to 20% will report neck pain symptoms. The vast majority of back and neck pain complaints are characterized in the literature as non-specific and self-limiting.” (pg. 1) 

 

The last sentence above describes why back and neck pain has contributed significantly to the opioid crisis and why our population, after decades still suffers from back and neck problems that have perpetuated. Mechanical lesions of the spine are not “self-limiting” and are not “non-specific.” They are well-defined and based upon Wolff’s Law (known since the 1800’s) don’t go away. Allopathy (Medicine) has purely focused on the pain and has vastly ignored the underlying cause of the neuro-bio-mechanical cause of the pain. 

 

Corcoran, Dunn, Green, Formolo and Beehler (2018) reported that musculoskeletal problems as the leading cause of morbidity for female veterans and females are more prone to experience neck pain than men. In addition, there has been a 400% increase in opioid overdoes deaths in females since 1999 compared to 265% for men and as a result, the Veterans Health Administration has utilized chiropractic as a non-pharmacological treatment option for musculoskeletal pain. Neck pain has also comprised of 24.3% of musculoskeletal complaints referred to chiropractors. 

 

Corcoran et. Al. also reported with chiropractic care, based upon a numeric rating scale (NRS) and the Neck Bournemouth Questionnaire (NBQ) scores, the NRS improved by 45% and the NBQ improved by 38%, with approximately 65% exceeding the minimum clinically important difference of 30%. A previous study of male veterans revealed a 42.9% for NSC and a 33.1 improvement for NBQ; statistics similar to female veterans. 

 

Although this is a very positive outcome that has helped many veterans, the percentages do not reflect what the authors have found in their clinical practices. These authors of this article (Studin and Owens) reported that for decades, cervical pain has been eradicated in 90 and 95% of the cases treated in our practices. The question begs itself, why is the population of veterans showing statistics less than half? 

 

Corcoran, et. Al. (2018) reported how the chiropractic treatment was delivered in their study:

 

The type of manual therapy varied among patients and among visits, but typically included spinal manipulative therapy (SMT), spinal mobilization, flexion – distraction therapy, and or myofascial release. SMT was operatively defined as a manipulative procedure involving the application of a high - velocity, low – ample to thrust the cervical spine. Spinal mobilization was defined as a form of manually assisted passive motion involving repetitive joint oscillations typically at the end of joint playing without application of a high- velocity, low – ample to thrust. Flexion – distraction therapy is a gentle form of a loaded spinal manipulation involving traction components along with manual pressure applied to the neck in a prone position. Myofascial release was defined as manual pressure applied to various muscles on the static state or all undergoing passive lengthening.

 

The above paragraph explains why the possible disparity in outcomes as Corcoran et. Al  do not reflect the ratios of who received high-velocity low-amplitude chiropractic spinal adjustment vs. the other therapies. When considering the other modalities; mobilization, flexion distraction therapy and myofascial release we must equate that to the outcomes physical therapist realize when treating spine as those are their primary reported treatment modalities. The following paragraphs indicate why spine care delivered by physical therapist is inferior to a chiropractic spinal adjustment, which equates to only a portion of the referenced chiropractic treatment modalities cited in the Corcoran Et. Al. The following citations conclude why these modalities provide inferior results compared to the high-velocity, low-amplitude chiropractic spinal adjustment that was exclusively used by the authors and rendered significantly higher positive outcome.


Studin and Owens (2017) reported the following:

Groeneweg et al. (2017) also stated:

This pragmatic RCT [randomized control trial] in 181 patients with non-specific neck pain (>2 weeks and <1 year) found no statistically significant overall differences in primary and secondary outcomes between the MTU (manual Therapy University) group and PT group. The results at 7 weeks and 1 year showed no statistically and clinically significant differences. The assumption was that MTU was more effective based on the theoretical principles of mobilization of the chain of skeletal and movement-related joint functions of the spine, pelvis and extremities, and preferred movement pattern in the execution of a task or action by an individual, but that was not confirmed compared with standard care (PT). (pg. 8)

Mafi, McCarthy and Davis (2013) reported on medical and physical therapy back pain treatment from 1999 through 2010 representing 440,000,000 visits and revealed an increase of opiates from 19% to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the costs for managing low back pain patients (not correcting anything, just managing it) has reached $106,000,000,000 ($86,000,000,000 in health care costs and $20,000,000,000 in lost productivity).

Cifuentes et al. (2011) started by stating:

Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used. (p. 396). The authors concluded by stating: “After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (Cifuentes et al., 2011, p. 404).

Mafi, McCarthy and Davis (2013) stated:

Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005...In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period, use of recommended treatments would increase and use of non-recommended treatments would decrease. (p. 1574)

(http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320)

The above paragraph has accurately described the problem with allopathic “politics” and “care-paths who have continued to report medical “dogma” and have ignored the scientific literature results of chiropractic vs. physical therapy.

Mafi, McCarthy and Davis (2013) concluded:

Despite self-reported overwhelming evidence where there were 440,000,000 visits and $106,000,000,000 in failed expenditures, they hypothesized that increased utilization for recommended treatment would increase. The recommended treatment, as outlined in the opening two comments of this article, doesn’t work and physical therapy is a constant verifying a “perpetually failed pathway” for mechanical spine pain. (p. 1574)


(http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320)

Despite the disparity in statistics, the literature is clear chiropractic renders successful out comes for both male and females, and the spine is not discriminatory for veterans versus non-veterans and offers a successful solution in lieu of the utilization of opiates for musculoskeletal spinal issues. In addition, the labels “non-specific” and “self – limiting” are inaccurate and have been placed by providers with no training in the biomechanics of spine care. Chiropractors has been trained in spinal biomechanics for over 100 years and currently there are advanced courses in spinal biomechanical engineering, of which many chiropractors have concluded. 

References:

  1. AAPM facts and figures on pain, the American Academy of pain medicine (2018), retrieved from: http://www.painmed.org/patientcenter/facts_on_pain.aspx#common
  2. Sinnott P., Dally S., Trafton J., Goulet J. and Wagner T. (2017) Trends in diagnosis of painful neck and back conditions, 2002 to 2011, Medicine, 96 (20), pgs. 1-6
  3. Corcoran K., Dunn A., Green B., Formolo L., and Beehler G. (2018) Changes in Female Veterans’ Neck Pain Following Chiropractic Care at a Hospital for Veterans, Complimentary Therapies in Clinical Practice 30, pgs. 91-95
  4. Studin M., Owens W., (2017) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine, Part 5 of 5, Retrieved from: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320

 

 

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Chiropractic and Prescriptive Rights

Should Chiropractors Be Allowed to Prescribe Drugs?

 

By Mark Studin DC, FASBE(C), DAAPM, DAAMLP

 

Citation: Studin M. (2018) Chiropractic and Prescriptive Rights; Should Chiropractors be Allowed to Prescribe Drugs? American Chiropractor, 40 (3) 16, 17, 18, 19

 

As the rhetoric and legislative agendas escalate nationally on chiropractic and pharmaceutical prescriptive rights, as a profession, we need to take pause and consider the long-term effects of our actions. The question is, “Are we responsibly evolving or are we creating a problem that could put chiropractic back decades in utilization?” Please understand that this argument is totally devoid of any philosophy or beliefs in chiropractic principles or results; it is purely focused on increasing the utilization and business of every chiropractic practice in the country for the betterment of our patients.

 

Based upon an informal, but lengthy poll of many in our profession, one of the core reasons for wanting to add prescriptive rights is to help increase utilization at the practice level. The majority believe that if we could prescribe even non-narcotics, then patients would stay in our offices vs. seeking medical care for pain relief and a pro forma prescription to physical therapy with a resultant decrease in utilization of our offices. Unfortunately, that has been the national trend for far too long.

 

The question begs, “Are prescriptive rights the solution for both the chiropractic profession and our society? Over the last decade, I have been focused on increasing the level of clinical excellence of the practicing chiropractor, which has nothing to do with technique, philosophy or documentation. The level of clinical excellence has been centered on patient management, including accurately diagnosing, prognosing and triaging patients. The reason, medicine focuses on patient diagnosis and management and chiropractic has historically focused on treatment, too often bypassing rendering a thorough and conclusive diagnosis prior to rendering care. Therefore, my areas of focus are MRI spine interpretation, spinal biomechanical engineering, accident engineering, spinal trauma pathology and diagnosing spinal issues beyond subluxation.

 

 

Why concern ourselves with the medical community? The answer, quite simply, is that medical utilization is over 95% nationally and chiropractic is well below 10% and has been eroding steadily over the last decade. IF chiropractic can “tap” into that 95% and have every medical doctor in the nation consider chiropractic as the first choice for mechanical spine issues (excluding fracture tumor or infection), then we will rapidly change the culture of our society and resolve our utilization challenges rapidly. This is called “primary spine care.”

 

Over the last 10 years, I have been teaching in both chiropractic and medical academia and have cooperatively created courses in chiropractic in the above genres. As a result, the doctors who have taken these courses are getting the exact same level of education as many of our medical counterparts. The results, we are now functioning at a “peer” level that has garnered respect NOT because we get people well without drugs. That respect is because we understand spine at an extremely high level, often more so than our medical counterparts and they find themselves consulting with us on many of their more challenging cases looking for solutions. In turn, they also have been referring us many of their mechanical spine cases to manage because many medical doctors realize they are poorly equipped with nothing but drugs that are often too often addictive or end up with surgery as the only other option.

 

The primary care medical providers, medical specialists and emergency rooms that we work with nationally have expressed their gratitude for helping these patients by redirecting their care to the properly credentialed chiropractor and preventing further opiate abuse and/or the side effects of non-narcotics as well. The way they thank us is in the form of a perpetual streams of referrals. A case in point was in Cedar Park, Texas, where one of our doctors, 8 years into practice, sat with an orthopedic surgeon and discussed MRI spine interpretation. After a 1-hour conversation, the surgeon said to the doctor, “I love chiropractic; I just couldn’t find a smart enough chiropractor to trust with my referrals until now. Your knowledge of spine and MRI is equal to mine and from here forward, you will get all of my non-surgical referrals!” That doctor left with 8 referrals instantly and 1 year later has had a steady stem of referrals   . I could share similar stories from Dayton, Ohio, Buffalo, New York, America Fork, Utah, Denver, Colorado, Fair Lawn, New Jersey and dozens of other locations across the United States. The formula is working; it is reproducible and is purely based upon clinical excellence beyond adjusting!

 

 

As a note, many get angry with our chiropractic colleges for not teaching us enough…Remember, our chiropractic colleges are charged with giving us the basics to get started and they do an outstanding job in that role. I applaud them and so should you in the form of donations to their research departments. In medicine, it is no different, they get a basic education and THEN go back to school to become specialized. What you do with YOUR career after graduation is on YOU.

 

 

We now have hospital emergency departments nationally reaching out to our doctors purely based upon their curricula vitae’s (CVs) because the doctors in our program are trained in what needs to be on their CVs with the resultant knowledge base behind those credentials. AND…for clarity (unlike my former beliefs), letters after your DC are not as important as the specific citations or credentials in your CV.

 

Utilization

 

Having been involved politically at the national and state levels for quite some time, I can say with a great degree of certainty that very little healthcare legislation (chiropractic falls under this category) in this country at either level gets passed without the blessing of the medical community. By attempting to add prescriptive rights to our scope, we will be threatening the utilization of medicine on a national scale and it will potentially close many of those doors that are currently opening at a rapid rate. The medical schools and research departments that have opened their doors to chiropractic (us) have done so primarily as a possible solution to the opiate epidemic in our country and we cannot be “Pollyannaish” and say we only want to prescribe non-narcotics. It has been clearly documented that this is a well-established “gateway” to addictive narcotics as when non-narcotics fail to offer relief, those patients need something else. Chiropractic care is that “something else” for mechanical spine pain, which is in the top 10 diagnoses for both emergency rooms and primary care medical providers who often have no solution other than drugs or surgery. Medicine’s only other historical care path with regards to mechanical spine diagnosis and management is physical therapy, which renders significantly inferior outcomes for spine vs. chiropractic based upon recent literature (a topic for another article) and one where far too many patients have ended up in pain management (narcotics) as the final solution.

 

 

Currently, our profession is at a cross-road on the prescriptive rights issue and if taken, could turn out to be a “very slippery slope” that could further erode our utilization and lead to increased iatrogenic issues in our society. I empathize with those doctors clinging to hope for a “quick fix” for their individual practices. However, as outlined above, there are viable solutions for every practice in the nation with none involving “get rich quick” paradigms. As I also consult many medical providers at various levels and I can report that their prescription pads are not making them wealthy, should they practice ethically. Their utilization and income increases as they get better at what they do and in chiropractic, we are no different.

 

 

Although our paradigm for increased utilization is working through increasing our clinical excellence, we are just starting to see this happen on a larger scale and the only way to have that upward spiral go faster, is if more chiropractors realize that the only way up is though academia and a strategic plan behind your new level of clinical excellence. So please hurry because your local medical community is waiting for you with that 95% to refer.

 


 

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Chiropractic Reduces Opioid Use by 55% in Low Back Pain

 

By Mark Studin

William J. Owens

 

A report on the scientific literature  

 

In the United States, of the adults who were prescribed opioids, 59% reported back pain.1 According to Statistia, the percentage of adults in the United States in 2015 with low back pain was 29.1% (https://www.statista.com/statistics/684597/adults-prone-to-selected-symptoms-us/)  and in 2017 that number was 49% for all back-pain sufferers reporting symptoms (https://www.statista.com/statistics/188852/adults-in-the-us-with-low-back-pain-since-1997/).

 

Peterson ET. AL. (2012) reported:

 

[The] Prevalence of low back pain is stated to be between 15% and 30%, the 1-year period prevalence between 15% and 45%, and a life-time prevalence of 50% to 80%” (pg. 525). 

 

While acute pain is a normal (author’s note: pain is never normal) short-lived unpleasant sensation triggered in the nervous system to alert you to possible injury with a reflexive desire to avoid additional injury, chronic pain is different. Chronic pain persists and fundamentally changes the patient’s interaction with their environment. In chronic pain it is well documented that aberrant signals keep firing in the nervous system for weeks, months, even years. (http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm)

Baliki Et. AL. (2008) stated

 

Pain is considered chronic when it lasts longer than 6 months after the healing of the original injury. Chronic pain patients suffer from more than pain, they experience depression, anxiety, sleep disturbances and decision-making abnormalities that also significantly diminish their quality of life (pg. 1398).

 

 

Chronic pain patients also have shown to have changes in brain function in sufferers with Alzheimer’ disease, depression, schizophrenia and attention deficit hyperactivity disorder giving further insight into disease states. In addition, chronic pain has a cause and effect on the morphology of the spinal cord and the brain resulting in a process termed “linear shrinkage”, which has been suggested to cause ancillary negative neurological sequella.  

 

Apkarian Et. Al. (2004) reported that “Ten percent of adults suffer from severe chronic pain. Back problems constitute 25% of all disabling occupational injuries and are the fifth most common reason for visits to the clinic; in 85% of such conditions, no definitive diagnosis can be made.” (pg. 10410) 

 

Whedon, Toler, Goel and Kazal (2018) reported the following:

 

One in 5 patients with noncancer pain or pain related diagnosis is prescribed opioids in office-based setting… primary care clinicians account for 50% of opioid prescriptions (Pg. 1). 1 day of opioid exposure carries a 6% chance of being on opioids 1year later, increasing to 13.5% by 8 days and 29.9% by 31 days. Among drug overdoses in the United States in 2014, 28,647, 61% involved an opioid. Opioids were involved in 75% of pharmaceutical deaths in 2010 and in 2015 over 22,000 deaths involved in prescription opioids were recorded-an increase of 19,000 deaths over the previous year (pg. 2).

 

 

Perhaps a portion of this phenomena is related to the training of medical primary care providers regarding musculoskeletal conditions. Studin and Owens reported (2016):

 

Day Et. Al. (2007) reported that only 26% of fourth year Harvard medical students had a cognitive mastery of physical medicine (pg. 452). Schmale (2005) reported “Incoming interns at the University of Pennsylvania took an exam of musculoskeletal aptitude and competence, which was validated by a survey of more than 100 orthopaedic program chairpersons across the country. Eighty-two percent of students tested failed to show basic competency. Perhaps the poor knowledge base resulted from inadequate and disproportionately low numbers of hours devoted to musculoskeletal medicine education during the undergraduate medical school years. Less than 1⁄2 of 122 US medical schools require a preclinical course in musculoskeletal medicine, less than 1⁄4 require a clinical course, and nearly 1⁄2 have no required preclinical or clinical course. In Canadian medical schools, just more than 2% of curricular time is spent on musculoskeletal medicine, despite the fact that approximately 20% of primary care practice is devoted to the care of patients with musculoskeletal problems. Various authors have described shortcomings in medical student training in fracture care, arthritis and rheumatology, and basic physical examination of the musculoskeletal system (pg. 251).  

 

With continued evidence of lack of musculoskeletal medicine and a subsequent deficiency of training in spine care, particularly of biomechanical orientation, the question becomes which profession has the educational basis, training and clinical competence to manage these cases?  Let’s take a closer look at chiropractic education as a comparison. Fundamental to the training of Doctor of Chiropractic according to the American Chiropractic Association is 4,820 hours (compared to 3,398 for physical therapy and 4,670 to medicine) and receive a thorough knowledge of anatomy and physiology. As a result, all accredited Doctor of Chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. So important to practice are these courses that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education requires a curriculum which enables students to be “proficient in neuromusculoskeletal evaluation, treatment and management.” In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. As a result, students are afforded the opportunity to practice utilizing this basic science information for many hours prior to beginning clinical services in their internship.

 

http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=320

 

Whedon, Toler, Goel and Kazal (2018) continued:

 

Recently published clinical guidelines from the American College of Physicians recommended nonpharmacological treatment is the first – line approach to treating back pain, with consideration of opioids only is the last treatment option or if other options present substantial harm to the patient. Recent systematic review and meta-analysis found that for treatment of acute low back pain, spinal manipulation provides a clinical benefit equivalent to that of an NSAID’s, with no evidence of serious harm. Spinal manipulation is also shown to be an effective treatment option for chronic low back pain (pg. 2).

 

A retrospective claims study of 165,569 adults found that utilization of chiropractic services delivered by Doctor of Chiropractic was associated with reduced use of opioids. More recently, it was reported that the supply chiropractors as well as spending on spinal manipulative therapy is inversely correlated with opioid prescriptions in younger Medicare beneficiaries. This finding suggests that increased availability and utilization of services delivered by Doctor of Chiropractic could lead to reductions in opioid prescriptions. It has been reported that services delivered by Doctor of Chiropractic may improve health behaviors and reduced use of prescription drugs… Pain management services provided by Doctor of Chiropractic may allow patients use lower less frequent doses of opioids, leading to lower costs and reduce risk of adverse effects loops getting together (pg. 2).

 

Although chiropractic has been clinically reporting for over 100 years positive outcomes for a vast array of conditions inclusive of low back pain the American Medical Association (AMA) has been a significant opponent historically. Although the AMA’s position has been well chronicled through lawsuits such as Wilk v. American Medical Association, 895 F.2d 352 (7th Cir. 1990)

(https://openjurist.org/895/f2d/352/wilk-dc-dc-dc-dc-v-american-medical-association-a-wilk-dc-w-dc-b-dc-b-dc), in 2017 it appears they have reversed their position. In the August 2017 Journal of the American Medical Association’s “Clinical Guideline Synopsis for Treatment of Low Back Pain” under the heading MAJOR RECOMMENDATIONS, spinal manipulation is recommended as a first – line therapy, with a strong recommendation. As the AMA did not list Chiropractic specifically and based upon clinical guidelines of other highly regarded medical institutions such as the Cleveland Clinic and the Mayo Clinic, physical therapy is probably high on their list as first-line of referral for spinal manipulation (This is a  topic for another article and nomenclature utilized by chiropractic). When considering the treatment of mechanical spine issues comparatively between chiropractic and physical therapy the outcomes are overwhelmingly in chiropractic’s favor as reported by Studin and Owens (2017)

 

Mafi, McCarthy and Davis (2013) reported on medical and physical therapy back pain treatment from 1999 through 2010 representing 440,000,000 visits and revealed an increase of opiates from 19% to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the costs for managing low back pain patients (not correcting anything, just managing it) has reached $106,000,000,000 ($86,000,000,000 in health care costs and $20,000,000,000 in lost productivity). 

 

Mafi, McCarthy and Davis (2013) stated:

Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005...In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period, use of recommended treatments would increase and use of non-recommended treatments would decrease. (p. 1574)

 

The above paragraph has accurately described the problem with allopathic “politics” and “care-paths.” Despite self-reported overwhelming evidence of chiropractic vs. physical therapy outcomes for spine, where there were 440,000,000 visits and $106,000,000,000 in failed expenditures, they hypothesized that increased utilization for recommended treatment would increase. The recommended treatment, as outlined in the opening two comments of this article, doesn’t work and physical therapy is a constant verifying a “perpetually failed pathway” for mechanical spine pain.

 

http://uschiropracticdirectory.com/index.php?option.com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320

 

Whedon, Toler, Goel and Kazal (2018) reported the concluded:

In 2013, average annual charges per person for filling opioid prescriptions were 74% lower among recipients compared with non-recipients (author’s note: recipients are referring to those patients receiving chiropractic care). For clinical services provided at office visits for low back pain, average annual charges per person in 2013 were 78% lower among recipients compared with non-recipients. The authors have similar between – Cohort differences in charges in 2014: annual charges per person were 70% lower with opioid prescriptions and 71% lower for clinical services among recipients compared with nonrecipients. The Adjusted likelihood find prescription for the opiate analgesic in 2014 was 55% lower among recipients compared with nonrecipients.

 

…the Adjusted likelihood of filling a prescription opioid analgesic was 55% lower for recipients of services provided by Doctor of Chiropractic compared with non-recipients (pg. 4)

 

The above reports evidenced based outcomes verifying chiropractic must be considered as the first-line of referrals, or Primary Spine Care Providers for mechanical spine diagnosis (no fracture, tumor or infection). The evidence also reveals that chiropractic outcomes exceed those of physical therapy and medicine for mechanical spine diagnosis. Unfortunately, it has taken 10,000’s of opioid related deaths to bring chiropractic to the forefront and start to eradicate the medical dogma against chiropractic and consider chiropractic as the 1st referral option for spine.

 

 References:

 

  1. Hudson, Teresa J., Edlund, Mark J., Steffick, Diane E., Tripathi, Shanti P., Sullivan, Mark D. (2008) Epidemiology of Regular Prescribed Opioid Use: Results from a National, Population-Based Survey Journal of Pain and Symptom Management, 2008, Vol.36(3), pp.280-288
  2. Percentage of adults in the U.S. with low back pain from 1997 to 2015 (2018) retrieved from:https://www.statista.com/statistics/188852/adults-in-the-us-with-low-back-pain-since-1997/
  3. Percentage of adults in the U.S. who were prone to select symptoms as of 2017 (2018), Retrieved from: https://www.statista.com/statistics/684597/adults-prone-to-selected-symptoms-us/
  4. Whedon J., Toler A., Goehl J., Kazal L. (2018), Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Use of Opioids, The Journal of Alternative and Complementary Medicine, 2018 Feb 22. doi: 10.1089/acm.2017.0131. [Epub ahead of print]
  5. Treatment of Low Back Pain, Wenger H., Cifu A., (2017) Treatment of Low Back Pain, Journal of the American Medical Association, 318 (8) pages 743-744
  6. Studin M., Owens. W., (2016), Chiropractic vs. Medicine: Who is Most Cost Effective and Renders Better Outcomes for Spine? Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=320
  7. Whedon J., Toler A., Goehl J., Kazal L. (2018), Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Use of Opioids, The Journal of Alternative and Complementary Medicine, 2018 Feb 22. doi: 10.1089/acm.2017.0131. [Epub ahead of print]
  8. Treatment of Low Back Pain, Wenger H., Cifu A., (2017) Treatment of Low Back Pain, Journal of the American Medical Association, 318 (8) pages 743-744
  9. Studin M., Owens. W., (2016), Chiropractic vs. Medicine: Who is Most Cost Effective and Renders Better Outcomes for Spine? Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=320
  10. Wilk vs. American Medical Association, Retrieved from: https://openjurist.org/895/f2d/352/wilk-dc-dc-dc-dc-v-american-medical-association-a-wilk-dc-w-dc-b-dc-b-dc
  11. Studin M., Owens. W., (2017), The Mechanism of the Chiropractic Spinal Adjustment /Manipulation: Chiropractic vs. Physical Therapy for Spine, Part 5 of a 5 Part series (2017) Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=32

 

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Friday, 29 December 2017 17:24

Chiropractic Verified as Primary Spine Care Providers

Written by

Chiropractic Verified as

 Primary Spine Care Providers

By Mark Studin

William J. Owens

A report on the scientific literature 

 

Primary Spine care simply means being the first referral option for spine care in instances other than fracture, tumor or infection. Having a chiropractic degree is paramount and the first step in the process, but one must not forget that any doctoral training, no matter the specialty (i.e. medicine, dentistry, podiatry, etc.) is the start of a provider’s educational journey and what we do with that training is up to the doctor in clinical practice. Erwin, Korpela and Jones (2013) stated “The function of the PSCP (Primary Spine Care Provider) could easily be assumed by chiropractic, but this window of opportunity may be limited. If chiropractic does not seek to evolve, what role does chiropractic have left to perform.” (Pg. 289)

 

Although these authors agree that chiropractors in clinical practice can assume the role as PSCP’s in the healthcare system, we strongly disagree with the direction suggested by Erwin, Korpela and Jones. The solution is not to prescribe more drugs in an “already over-drugged society,” the solution is being able to manage the patient in a collaborative environment on a peer level being “expert” on common healthcare issues. The underlying tenant is that there is no drug for a mechanical problem, it is with that initial focus that allows chiropractic to assume a role that no other profession can accomplish.  True PSCP management includes being able to accurately diagnose/triage patients and the ability to use and understand MRI is a prime example. Herzog, Elgart, Flanders and Moley (2017) reported a 43.6% error rate of general radiologists inaccurately reporting the morphology of the intervertebral disc. This underscores that when a doctor of chiropractic relies on the MRI report without understanding how to interpret the image and clinically correlate the findings to the patient’s symptoms, there is close to a 50% error rate in rendering an accurate diagnosis, prognosis and treatment plan.  A PSCP must have a complete and independent diagnostic scope of practice in order to fill a useful and clinically significant role.

 

To use an example in a current and modern setting, a doctor of chiropractic in Cedar Park, Texas was granted a “brief 10-minutes” to meet with an orthopedic surgeon. During that short meeting the chiropractor, an 8-year graduate spoke solely and specifically of his MRI slice thickness protocols and his MRI interpretation training which is cross-credentialed in both chiropractic and medical academia. One hour later [the meeting continued well past the initial “10-minutes” suggested], the orthopedic surgeon said, “I respect chiropractic, but have very little respect for the level of training of chiropractors in our region.” This 8-year graduate walked out with 8 referrals instantly and now 1 year later, has been getting referrals weekly. That is very definition of Primary Spine Care, the orthopedic surgeon trusts the chiropractor’s ability to manage and diagnose patients and now is “off-loading” the non-surgical patients to someone that can effectively manage that case.  It is because of this specific advanced training that the chiropractor is successful.

 

In a second recent example, in Utah, a chiropractor decided that his post-doctoral training should be focused on spinal trauma care and triage, including more specifically, MRI Spine Interpretation, Spinal Trauma Pathology, Spinal Biomechanical Engineering and Stroke Evaluation. As a result, a hospital system that has over 900 auto accident cases monthly in 5 local hospitals reached out to him to manage their spine cases (all of them).  This was based purely on his curriculum vitae and the inherent credentials and knowledge base from his continued education training in the above courses. Since then, Brigham Young University’s Athletic Department and the PGA (Professional Golf Association) have both sought his services. Please don’t overlook the fact THEY ran after him to be their first option for spine; that is Primary Spine Care and credentials matter.

 

 

Thirdly, in Buffalo NY, 5 teaching hospitals refer exclusively to one chiropractor’s office and their emergency rooms refers close to 60 spine patients per month to him with that number growing steadily. This past week, the neurosurgical department just informed this doctor that their 23 neurosurgeons will be referring their non-surgical cases to this office and will be directing many of their referral sources to START with this doctor to screen for surgery and let him decide who to refer for surgical consultation. That is Primary Spine Care.

 

 

Although individual reporting does not make a trend in the profession, these are not isolated cases, and this is NOW THE TREND in chiropractic we are seeing nationally, there are similar stories in most states. None of the successes involve adding drugs as a tool of the chiropractic, however in every case becoming smarter in spine care was mandatory.  In all cases it is a properly trained doctor of chiropractic that is leading Primary Spine Care alongside medical specialty and primary care in a collaborative environment as peers, when clinically indicated. 

 

 

Most of the Primary Spine Care “equation” is verifying chiropractic care as the “best choice” for the “first referral”.  That is being achieved though peer-reviewed outcome based studies and involves all phases of care starting with initial pain management to corrective spine care and finally when required, health maintenance care for cases that need non-opioid and non-surgical long-term management. Historically and all too frequently in current medicine, either medical management or physical therapy is considered for mechanical spine issues as the first treatment of choice. Cleveland Clinic, one of the better-known centers of medical excellence currently posted the following regarding the treatment of back pain; “These patients may be best served through prompt access to care from physical therapists or nurse practitioners as entry-level providers. When pain persists beyond four to six weeks, the care path defines when referral to spine or pain specialists, spine surgeons or behavioral health providers is indicated.” (https://consultqd.clevelandclinic. org/2014/11/sticking-with-proven-practices-for-low-back-pain/) The Mayo Clinic Staff (2017) also reported: “Physical therapy is the cornerstone of back pain treatment.”

 

When considering the best option for Primary Spine Care, we should consider “what” type of provider renders the best outcomes in population based studies and has the autonomy to manage the case independent of primary care and medical specialty.   Based upon population based studies, both the Cleveland and Mayo clinics got it wrong as their opinions are not based upon contemporary literature and appear to be rooted in “age-old biases.”  Their suggested care paths are similar to prior care paths that perhaps have led to the long-term mismanagement of mechanical spine pain that has in part, contributed to the opioid crisis.  

 

Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) in a population based study of 5511 injured workers in Ontario Canada as reported by the Workplace Safety and Insurance Board, a governmental agency reported a comparison of outcomes for back pain among patients seen by three types of providers: medical physicians, chiropractors and physical therapists. The found “The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation.” (pg.392) and These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.” (pg. 382)

 

Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) continued, “The cohort study of American workers with back pain conducted by Turner et al. found that the first healthcare provider was one of the main predictors of work disability after a year. In accordance with our findings, workers who first sought chiropractic care were less likely to be work-disabled after 1 year compared with workers who first sought other types of medical care… We did not retrieve any study that directly compared physiotherapy care with other types of first healthcare providers in the context of occupational back pain, probably because most workers’ compensation systems still require a referral for physiotherapy. However, a study comparing primary physiotherapy care with usual emergency department care concluded that physiotherapy care leads to a prolonged time before patients return to their usual activities.” (pg. 389)

 

Cifuentes, Willets and Wasiak (2011) stated that chiropractic care during the health maintenance care period resulted in: 

The study concluded that chiropractic care during the disability episode resulted in:

24% Decrease in disability duration of first episode compared to physical therapy

250% Decrease in disability duration of first episode compared to medical physician's care

5.9% Decrease in opioid (narcotic) use during maintenance care with physical therapy care

30.3% Decrease in opioid (narcotic) use during maintenance care with medical physician's care

32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care

 

Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating,“After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP (low back pain) who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type(pg. 404). 

The above studies continue to verify chiropractic as a better “first option” for spine and that resolves the “what provider is best” question by using an Evidence Based approach.  The “who is best” within that subset is what type of chiropractor is better suited to lead in Primary Spine Care is evident. As an example, although every medical doctor is licensed to do open heart surgery not all are trained and credentialed. Would you want a psychiatrist performing the procedure? The answer should be “they are licensed, but not qualified through training.” The same holds true for contemporary chiropractic and every chiropractor has the same opportunity. We are all held to a “continuing education standard” and are all required to seek post-doctoral training to maintain our licenses. There are a significant number of courses, both live and through enduring materials (online) to enable every chiropractor on the planet to attain the level of education mandated by the “referral sources” to be considered Primary Spine Care Providers. 

Let’s not be Pollyannaish not to think that chiropractic can be successful in increasing utilization independent of the medical community and even the legal community for personal injury cases. As mentioned previously, the medical community DOES NOT CARE about your treatment approach, what they do care about is the “risk” of you missing a diagnosis.  They need to trust you based on your training, and the do NOT care about what technique you use.  What you do in your offices is up to you just like a pain management MD or a surgeon, remember, it’s how you triage and manage your patients that is the ultimate arbiter in having them consider you as the first option for spine care. Once you have responsibly secured the referral, based upon your clinical excellence, you get to independently decide the best course of care for your patient.  Then it is business as usual during the treatment phase of care because results were never, and are not an issue in chiropractic. 

REFERENCES:

 

  1. Erwin, W. M., Korpela, A. P., & Jones, R. C. (2013). Chiropractors as primary spine care providers: precedents and essential measures. The Journal of the Canadian Chiropractic Association, 57(4), 285.
  2. Herzog, R., Elgort, D. R., Flanders, A. E., & Moley, P. J. (2017). Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. The Spine Journal, 17(4), 554-561.
  3. Cleveland Clinic. (2017). Sticking with proven practices for low back pain, Introducing: Cleveland Clinic’s Spine Care Path. Retrieved from https://consultqd.clevelandclinic.org/2014/ 11/sticking-with-proven-practices-for-low-back-pain/
  4. Mayo Clinic Staff. (2017). Treatments and drugs. Diseases and Conditions, Back Pain, Retrieved from:http://www.mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797
  5. Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation27(3), 382-392.
  6. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine53(4), 396-404.

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The Mechanism of the Chiropractic

Spinal Adjustment/Manipulation:

Chiropractic vs. Physical Therapy for Spine

 

Part 5 of a 5 Part Series

By: Mark Studin

William J. Owens

 

 

Reference: Studin M., Owens W., (2017) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine, Part 5 of 5, American Chiropractor 39 (12) pgs. 20, 22, 24, 26, 28, 30, 31

 

A report on the scientific literature  

 

According to the Cleveland Clinic (2017):

 

The Cleveland Clinic Spine Care Path is a process-based tool designed for integration in the electronic medical record (EMR) to guide clinical work flow and help providers make evidence-based guidelines operational. 

 

The care path was developed by Cleveland Clinic’s Center for Spine Health with input from Department of Pain Management staff like Dr. Berenger. One goal was to match appropriate treatments and providers to patients at various points along the care continuum for low back pain.

 

We know acute back pain is common and often resolves with simple therapy or even no therapy,” Dr. Berenger says. “For patients without red flags, imaging is rarely required.” 

 

These patients may be best served through prompt access to care from physical therapists or nurse practitioners as entry-level providers. When pain persists beyond four to six weeks, the care path defines when referral to spine or pain specialists, spine surgeons or behavioral health providers is indicated. (https://consultqd.clevelandclinic. org/2014/11/sticking-with-proven-practices-for-low-back-pain/)

According to the Mayo Clinic Staff (2017):

 

Most acute back pain gets better with a few weeks of home treatment. Over-the-counter pain relievers and the use of heat or ice might be all you need. Bed rest isn't recommended. 

 

Continue your activities as much as you can tolerate. Try light activity, such as walking and activities of daily living. Stop activity that increases pain, but don't avoid activity out of fear of pain. If home treatments aren't working after several weeks, your doctor might suggest stronger medications or other therapies. (http://www.mayoclinic. org/diseases-conditions/back-pain/basics/treatment/con-20020797

 

The Mayo Clinic Staff (2017) continued:

 

Physical therapy is the cornerstone of back pain treatment. A physical therapist can apply a variety of treatments, such as heat, ultrasound, electrical stimulation and muscle-release techniques, to your back muscles and soft tissues to reduce pain.As pain improves, the therapist can teach you exercises that can increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques can help prevent pain from returning. (http://www. mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797)

 

The above 2 scenarios are consistent with contemporary care paths for medicine regarding back pain. High velocity-low amplitude chiropractic spinal adjustments are not part of any medical institution’s care plan (to the current knowledge of the authors) despite the following compelling literature.

Coronado et al. (2012) reported:

 

Reductions in pain sensitivity, or hypoalgesia, following SMT [defined by the author as high velocity-low amplitude adjustment or a spinal adjustment] may be indicative of a mechanism related to the modulation of afferent input or central nervous system processing of pain. (p. 752)

 

Coronado et al. (2012) further asked the question:

 

…was whether SMT [defined by the author as high velocity-low amplitude or a spinal adjustment] elicits a general response on pain sensitivity or whether the response is specific to the area where SMT is applied. For example, changes in pain sensitivity over the cervical facets following a cervical spine SMT would indicate a local and specific effect while changes in pain sensitivity in the lumbar facets following a cervical spine SMT would suggest a general effect. We observed a favorable change for increased PPT [pressure pain threshold] when measured at remote anatomical sites and a similar, but non-significant change at local anatomical sites. These findings lend support to a possible general effect of SMT beyond the effect expected at the local region of SMT application. (p. 762)

Reed, Pickar, Sozio, and Long (2014) reported:

 

…forms of manual therapy have been clinically shown to increase mechanical pressure pain thresholds (i.e., decrease sensitivity) in both symptomatic and asymptomatic subjects. Cervical spinal manipulation has been shown to result in unilateral as well as bilateral mechanical hypoalgesia. Compared with no manual therapy, oscillatory spinal manual therapy at T12 and L4 produced significantly higher paraspinal pain thresholds at T6, L1, and L3 in individuals with rheumatoid arthritis. The immediate and widespread hypoalgesia associated with manual therapy treatments has been attributed to alterations in peripheral and/or central pain processing including activation of descending pain inhibitory systems. 

 

Increasing evidence from animal models suggests that manual therapy activates the central nervous system and, in so doing, affects areas well beyond those being treated. (p. 277)

 

With regards to manual therapy versus physical therapy, this is where the phrase, “caveat emperor” should be used as the concept is misleading. Groeneweg et al. (2017) compared manual and physical therapies, recruiting 17 manual therapists and 27 physical therapists. The training of the manual therapists was from Manual Therapy University and were predominantly physical therapists who spent 3 years studying manual therapy. 

Groeneweg et al. (2017) reported:

 

The manual therapist performs per protocol repeated passive joint movements with low velocity and intensity and high accuracy in different positions of the patient (sitting, supine and side-lying). The rhythm of the movements is slow (approximately 30 cycles/min) and the movements are repeated about six times. Treatment is in general painless. Passive joint movements are performed in a combination of rolling and sliding, or rocking and gliding (or swinging and sliding) in the joint, based on the arthrokinematic and osteokinematic principles of intra-articular movements. Passive movements are performed over the entire range of motion within the physiological range of motion of joints, whereby the curvature of the articular surface is followed, with manual forces directed to the joints/specific spinal level. Physiological joint range of motion is carefully respected. Traction, oscillation and high-velocity movements are not applied. In all patients, based on the assessment protocols, all joints of the spine, pelvis and extremities are mobilized in specific directions. (p. 3)

Groeneweg et al. (2017) also stated:

 

This pragmatic RCT [randomized control trial] in 181 patients with non-specific neck pain (>2 weeks and <1 year) found no statistically significant overall differences in primary and secondary outcomes between the MTU group and PT group. The results at 7 weeks and 1 year showed no statistically and clinically significant differences. The assumption was that MTU was more effective based on the theoretical principles of mobilization of the chain of skeletal and movement-related joint functions of the spine, pelvis and extremities, and preferred movement pattern in the execution of a task or action by an individual, but that was not confirmed compared with standard care (PT). (pg. 8)

 

The above article strongly confirms why language is important when describing the chiropractic spinal adjustment. Too many “lump together” all manual therapies and claim the effectiveness, or lack thereof, based on studies as the one above confirms. The article compared physical therapy to physical therapists who have gone for advanced education in what they already do in low-amplitude repetitive movements using “arthrokinematic and osteokinematic principles of intra-articular movements” meaning very specific per the anatomy. The outcome confirmed there is no difference between manual therapy and physical therapy because they are the same according to the description in the research. However, these therapies do not provide what chiropractic offers, although many hastily consider manual therapy and chiropractic care to be the same. Substance P is perhaps the most compelling evidence of why a chiropractic spinal adjustment should be considered the “first choice” for spinal care.

Evans (2002) reported:

 

In a series of studies, Brennan et al. investigated the effect of spinal HVLAT manipulation causing cavitation ("sufficient to produce an auditory release or palpable joint movement") on cells of the immune system. They found that a single manipulation to either the thoracic or lumbar spine resulted in a short-term priming of polymorphonuclear neutrophils to respond to an in vitro particulate challenge with an enhanced respiratory burst (RB) as measured by chemiluminescence in subjects with and without symptoms. The enhanced RB was accompanied by a two-fold rise in plasma levels of the neuropeptide substance P (SP).

 

SP is an 11-amino acid polypeptide and is one of a group of neuropeptides known as tachykinins. These are peptides that are produced in the dorsal root ganglion (DRG)  and released by the slow-conducting, unmyelinated C-polymodal nociceptors in a process known as an "axon reflex." They are released into peripheral tissues from the peripheral terminals of the C-fibers. modulating the inflammatory process by "neurogenic inflammation.” They are also released from the central terminals of the nociceptors into the dorsal horn of the spinal cord, where they modulate pain processing and spinal cord reflex activity.

 

This neurophysiologic effect of spinal HVLAT manipulation seems to be force threshold-dependent. The threshold was found to lie somewhere between 450N and 500N for the thoracic spine and 400N for the lumbar spine. When compared with data from biomechanical studies of spinal manipulation, these forces would be sufficient to cause cavitation. The "SP" studies used "sham manipulation" as a control, consisting of a "low-velocity light-force thrust to the selected segment." rather like a mobilization. This illustrates that zygapophyseal HVLAT manipulations that cause cavitation produce physiological effects, not demonstrable by electromyography, that are totally different fi-om effects created by zygapophyseal manipulations that do not cause cavitation. (p. 255-256)

According to Hartford-Wright, Lewis, Vink and Ghabriel (2014):

 

Substance P (SP) is a neuropeptide released from the endings of sensory nerve fibers and preferentially binds to the NK1 receptor. It has a widespread distribution throughout the nervous system, where it is implicated in a variety of functions including neurogenic inflammation, nausea, depression and pain transmission as well as in a number of neurological diseases, including CNS tumors. (p. 85)

Low velocity manipulation, no matter how well it follows “arthrokinematic and osteokinematic principles of intra-articular movements,” will not effectuate the release of Substance P, only a chiropractic spinal adjustment with cavitation will do that. When considering the results of a chiropractic spinal adjustment, disability is a critical indicator with regards to the effectiveness of treatment outcomes.

Cifuentes, Willets and Wasiak (2011) compared different treatments of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability after a 15-day absence and return to disability. Anyone with less than a 15-day absence was excluded from the study. Please note that we kept disability outcomes for all reported treatment and did not limit this to physical therapy. However, the statistic for physical therapy is significant.

 

The Cifuentes, Willets and Wasiak (2011) study concluded that chiropractic care during the health maintenance care period resulted in:

The study concluded that chiropractic care during the disability episode resulted in:

24% Decrease in disability duration of first episode compared to physical therapy

250% Decrease in disability duration of first episode compared to medical physician's care

5.9% Decrease in opioid (narcotic) use during maintenance care with physical therapy care

30.3% Decrease in opioid (narcotic) use during maintenance care with medical physician's care

32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care

 

Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating, “After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (Cifuentes et al., 2011, p. 404).

 

Given that physical therapy has been the primary portal for mechanical spine issues (not fractures, tumors or infection) coupled with the contemporary opiate addiction and mortality issues, a different path must be sought as a matter of public safety. The only avenue for both medical primary care providers and specialists other than surgery is pain management in the form of opiates and that doesn’t resolve any issues, it only creates new addiction issues. Mechanical spine pain is one of the most common diagnoses.

 

According to Block (2014): 

 

Over 100 million Americans experience chronic pain with common painful conditions including back pain, neck pain, headaches/migraines, and arthritis, in addition to other painful conditions such as diabetic peripheral neuropathy, etc... In a large study in 2010, 30.7% of over 27,000 U.S. respondents reported an experience of chronic, recurrent pain of at least a 6-month duration. Half of the respondents with chronic pain noted daily symptoms, with 32% characterizing their pain as severe (≥7 on a scale ranging from 0 to 10). Chronic pain has a broad impact on emotional well-being and health-related quality of life, sleep quality, and social/recreational function. (p. 1)

 

Mafi, McCarthy and Davis (2013) reported on medical and physical therapy back pain treatment from 1999 through 2010 representing 440,000,000 visits and revealed an increase of opiates from 19% to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the costs for managing low back pain patients (not correcting anything, just managing it) has reached $106,000,000,000 ($86,000,000,000 in health care costs and $20,000,000,000 in lost productivity).

 

 

Mafi, McCarthy and Davis (2013) stated:

 

Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005...In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period, use of recommended treatments would increase and use of non-recommended treatments would decrease. (p. 1574)

 

The above paragraph has accurately described the problem with allopathic “politics” and “care-paths.” Despite self-reported overwhelming evidence where there were 440,000,000 visits and $106,000,000,000 in failed expenditures, they hypothesized that increased utilization for recommended treatment would increase. The recommended treatment, as outlined in the opening two comments of this article, doesn’t work and physical therapy is a constant verifying a “perpetually failed pathway” for mechanical spine pain.

 

 

Chiropractic offers an evidence-based approach in developing an “outcome based “care path for mechanical spine pain. Although this article discusses pain, chiropractic offers more than simply pain management, however this discussion is limited to mechanical spine pain. Therefore, with chiropractic as the “first option” or “Primary Spine Care” focusing on the biomechanical pathological instability, the underlying cause of the pain can be addressed, leaving no further need to manage an issue that has been simply fixed.

 

 

References

1. Cleveland Clinic. (2017). Sticking with proven practices for low back pain, Introducing: Cleveland Clinic’s Spine Care Path. Retrieved from https://consultqd.clevelandclinic.org/2014/ 11/sticking-with-proven-practices-for-low-back-pain/

2. Mayo Clinic Staff. (2017). Treatments and drugs. Diseases and Conditions, Back Pain, Retrieved from: http://www.mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797

3. Coronado, R. A., Gay, C. W., Bialosky, J. E., Carnaby, G. D., Bishop, M. D., & George, S. Z. (2012). Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis. Journal of Electromyography Kinesiology, 22(5), 752-767.

4. Reed, W. R., Pickar, J. G., Sozio, R. S., & Long, C. R. (2014). Effect of spinal manipulation thrust magnitude on trunk mechanical activation thresholds of lateral thalamic neurons. Journal of Manipulative and Physiological Therapeutics, 37(5), 277-286.

5. Groeneweg, R., van Assen, L., Kropman, H., Leopold, H., Mulder, J., Smits-Engelsman, B. C., ... & van Tulder, M. W. (2017). Manual therapy compared with physical therapy in patients with non-specific neck pain: a randomized controlled trial. Chiropractic & Manual Therapies25(12), 1-12.

6. Evans, D. W. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics, 25(4), 251-262.

7. Harford-Wright, E., Lewis, K. M., Vink, R., & Ghabriel, M. N. (2014). Evaluating the role of substance P in the growth of brain tumors. Neuroscience261, 85-94.

8. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine53(4), 396-404.

9. Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine173(17), 1573-1581.

Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport College of Chiropractic, an Adjunct Post Graduate Faculty of Cleveland University - Kansas City, College of Chiropractic, an Adjunct Professor of Clinical Sciences at Texas Chiropractic College and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MRI spine interpretation, spinal biomechanical engineering and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www.DoctorsPIProgram.com), teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally and studies trends in healthcare on a national scale (www.TeachDoctors.com). He can be reached at www.teachchiros.com or at 631-786-4253.

 

 

Dr. Bill Owens is presently in private practice in Buffalo and Rochester NY and generates the majority of his new patient referrals directly from the primary care medical community.  He is an Associate Adjunct Professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences, an Adjunct Post Graduate Faculty of Cleveland University - Kansas City, College of Chiropractic, an Adjunct Assistant Professor of Clinical Sciences at the University of Bridgeport, College of Chiropractic and an Adjunct Professor of Clinical Sciences at Texas Chiropractic College.  He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at www.mdreferralprogram.com or 716-228-3847  

 

 

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Chiropractic & Central Afferent Inhibition:

A Chiropractic Care Path & Mechanism for Chronic Pain, Tremors, Spatial and Inhibitory Distortion

 

By Mark Studin

William J. Owens

Michael Barone

A report on the scientific literature 

 

Although it is unusual in the literature to place a disclaimer in the beginning of an article, we want to ensure that our reporting is not inflammatory since the foundation of this article was written with the following limitation in our primary literary source, Haavik, Niazi, Holt and Murphy (2017) reported:

 

This study was not designed to test the efficacy of chiropractic care for treating chronic pain; therefore, conclusions about efficacy cannot be drawn from our findings. The study did not include randomization with an adequate control group, thus limiting the interpretations that can be made about the changes in pain observed in the trial. Causation cannot be claimed. (pg. 135)

 

Although Haavik, et al. reported limitations in their study, the results cannot be overlooked or minimized, particularly when those results match what doctors working within a “Best Practice Model” (the patient and doctor feedback component) have been reporting for decades. Additionally, in the clinical setting, this information provides direction to practitioners searching for answers although the mechanisms are not yet fully understood. Results often don’t mandate detailed knowledge of the mechanism and that is the primary reason why both “evidenced based” and “best practice” models must be embraced and combined (pure literature results with doctor and patient feedback or experiences) as a matter of public health.

 

When we consider central afferent neurological input, the inability to inhibit those signals leads to sensorimotor disturbances that are found in the chronicity of many chronic pain conditions, essential tremors, dystonia and other central spatial and temporal mismatches. In addition, we must consider to the long-term negative sequalae of those conditions, such as brain shrinkage.

 

Baliki, Geha, Apkarian and Chialvo (2008) reported:

 

Recent studies have demonstrated that chronic pain harms cortical areas unrelated to pain, long-term pain alters the functional connectivity of cortical regions known to be active at rest, i.e., the components of the “default mode network” (DMN). This DMN is marked by balanced positive and negative correlations between activity in component brain regions. In several disorders, however this balance is disrupted. Studying with fMRI [functional MRI] a group of chronic back pain patients and healthy controls while executing a simple visual attention task, we discovered that chronic back pain patients, despite performing the task equally well as controls, displayed reduced deactivation in several key default mode network regions. These findings demonstrate that chronic pain has a widespread impact on overall brain function, and suggest that disruptions of the default mode network may underlie the cognitive and behavioral impairments accompanying chronic pain.” (pg. 1398)

 

“The existence of a resting state in which the brain remained active in an organized manner, is called the ‘default mode of brain function. The regions exhibiting a decrease in activity during task performance are the component members of the “default-mode network” (DMN), which in concerted action maintain the brain resting state. Recent studies have already demonstrated that the brain default mode network is disrupted in autism, Alzheimer’ disease, depression, schizophrenia and attention deficit hyperactivity disorder, suggesting that the study of brain resting activity can be useful to understand disease states as well as potentially provide diagnostic information.”  (pg. 1398)

 

This is important since for the first time we are starting to see a published correlation between spinal function, chronic pain and central nervous system changes.  This is what our founders have observed yet were unable to prove.

 

“Thus, the alterations in the patient’s brain at ‘rest’ can result in a different default mode network organization. In turn, potential changes in the default-mode network activity could be related to symptoms (other than pain) commonly exhibited by chronic pain patients, including depression and anxiety, sleep disturbances, and decision-making abnormalities, which also significantly diminish their quality of life… chronic pain patients display a dramatic alteration in several key default-mode network regions, suggesting that chronic pain has a widespread impact on overall brain function” (pg. 1398)

 

This information is pointing to the fact that a doctor of chiropractic should be involved in the triage and treatment of these patients and part of a long-term spinal care program. 

 

Baliki Et. Al (2008) continued “Consistent with extensive earlier work examining visuospatial attention tasks, dominant activations were located in posterior parietal and lateral prefrontal cortices, whereas deactivations occurred mainly within Pre-Frontal Cortex and Posterior Cingulate/Cuneate Cortexes. Although activations in chronic back pain patients’ and controls’ brains were similar, chronic back pain patients exhibited significantly less deactivations than healthy subjects in Pre-Frontal Cortex, amygdala, and Posterior Cingulate/Cuneate Cortexes.  The focus was on identifying differences in the way chronic back pain patients’ brains process information not related to pain. This is the first study demonstrating that chronic back pain patients exhibit severe alterations in the functional connectivity between brain regions implicated in the default mode network. It seems that enduring pain for a long time affects brain function in response to even minimally demanding attention tasks completely unrelated to pain. Furthermore, the fact that the observed task performance, compared with healthy subjects, is unaffected, whereas the brain activity is dramatically different, raises the question of how other behaviors are impaired by the altered brain activity” (pg. 1399).

 

“However, the disruption of functional connectivity observed here with increased chronic back pain duration may be related to the earlier observation of brain atrophy increasing with pain duration also in chronic back pain patients. Patient’s exhibit increased pre-frontal cortex activity in relation to spontaneous pain, in addition to dorsolateral prefrontal cortex atrophy. Therefore, the decreased deactivations described here may be related to the dorsolateral pre-frontal cortex /pre-frontal cortex mutual inhibitory interactions perturbed with time. If that is the case, it will support the idea of a plastic, time-dependent, reorganization of the brain as patients continue to suffer from chronic back pain. Mechanistically, the early stages of this cortical reorganization may be driven by peripheral and spinal cord events, such as those that have been documented in animal models of chronic pain, whereas later events may be related to coping strategies necessary for living with unrelenting pain. It is important to recognize that transient but repetitive functional alterations can lead to more permanent changes. Accordingly, long term interference with normal activity may eventually initiate plastic changes that could alter irreversibly the stability and subsequently the conformation of the resting state networks” (pg. 1401).

 

Essential Tremors which, according to Wikipedia

 

Essential tremor (ET, also referred to as benign tremor, familial tremor, or idiopathic tremor) is the most common movement disorder; its cause is unknown. It typically involves a tremor of the arms, hands or fingers but sometimes involving the head, vocal cords or other body parts during voluntary movements such as eating and writing.[1] It is distinct from Parkinson's disease—and often misdiagnosed as such—although some individuals have both conditions. Essential tremor is commonly described as an action tremor (i.e., it intensifies when one tries to use the affected muscles) or postural tremor (i.e., present with sustained muscle tone) rather than a resting tremor, such as is seen in Parkinson’s, which is usually not included among its symptoms. (https://en.wikipedia.org/wiki/Essential_tremor)

 

Restuccia, Valeriani, Barba, Le Pera, Bentivoglio, Albanese and Tonali (2003) reported:

 

...our present data seem to indicate that somatomotor cortical areas play an important role in generating ET. This finding can be important in the future understanding of its pathophysiologic mechanisms, as well as in its management. (pg. 127)

 

This study suggests that somatosensory cortical areas plays an important role, therefore the afferents “feeding” that region is critical in normalizing function of the cortex a that region. Another negative sequela of aberrant input.

When we consider one potential etiology of maladaptive plastic changes in the brain that can cause chronic pain, essential tremors, brain shrinkage and a host of other maladies, regulatory control of the impulses must be considered and interfered with. The lack of gating (inhibition) will lead to an overflow of impulses and crate a negative cascade that can lead to chronic and often permanent changes. Haavik, Niazi, Holt and Murphy (2017) reported:

 

Thus, distorted sensory information is thought to disturb SMI (sensorimotor integration) and impair accurate motor control. In normal circumstances, 2 inputs that engage the sensory system have a reciprocally inhibitory action that gates the total amount of signal at all central levels, spatially and temporally limiting the amount of input engaging the CNS. This is thought to prevent sensory “overflow.” The defective gating may cause an input-output mismatch in specific motor programs, and such mismatches in motor programs may in themselves lead to production of distorted sensory information and issue of less than ideal motor commands. In this way, the chronicity of the problem can be maintained via a self-perpetuating mechanism. The reduced frontal N30 SEP (somatosensory evoked potential) peak ratio observed in the current study after 12 weeks of chiropractic care may reflect a normalization of pain-induced central maladaptive plastic changes and may reflect one mechanism for the improvement of functional ability reported following chiropractic adjustment or manipulation. (pg. 134)

 

The N30 ratio change represented on average a 37.4% decrease following the 12 weeks of chiropractic care. The N30 MU (median-ulnar) amplitude changes following chiropractic care represented an 18.0% decrease in amplitude compared with baseline (pg. 131) Alongside this change in the N30 SEP ratio, the subjects reported a decrease in both current pain and average pain over the last week. A control period of 2 weeks of no intervention resulted in no significant changes in any SEP peak ratio. (pg. 134)

 

When considering care paths for this population of patients, the following was reported by Haavik, Niazi, Holt and Murphy (2017) reported:

 

The 2-week control period, during which no intervention was applied, was followed by a 12-week chiropractic care intervention. During the 12 weeks of chiropractic care, the chiropractor assessed and treated the subject as she would any other chronic pain patient. The participating chiropractor (H.H., with 7 years clinical experience) assessed the spine for segmental dysfunction using tenderness on palpation and passive intervertebral and global motion of the spine. Other treatments included as part of chiropractic care were exercises, peripheral joint adjustments/manipulations, soft tissue therapy, and pain education if deemed by the chiropractor to be appropriate based on history and examination. The chiropractic adjustment/manipulation was the delivery of a high-velocity, low-amplitude thrust to dysfunctional spinal segments. (pgs. 129-130)

 

The changes observed conclude (with the aforementioned disclaimer that more research is needed) that chiropractic is a verifiable treatment option. Haavik, Niazi, Holt and Murphy (2017) continued:

 

The changes observed in dual SEP ratios after several weeks of chiropractic care in a chronic pain population suggest that this treatment option may improve gating of peripheral afferent input to the brain, thus improving impaired SMI in cortical motor areas and improving processing of motor programs. Impaired SMI and defective motor programming is known to be present in various chronic pain populations and is implicated in the clinical symptomatology. We know from the literature that in normal circumstances, afferent input to the motor system leads to finely tuned activation of neural elements and ultimately results in the correct execution of movement. Multiple experimental and clinical studies have confirmed the importance of sensory feedback to the motor system. Thus, distorted sensory information is thought to disturb SMI and impair accurate motor control. In normal circumstances, 2 inputs that engage the sensory system have a reciprocally inhibitory action that gates the total amount of signal at all central levels, spatially and temporally limiting the amount of input engaging the CNS. This is thought to prevent sensory “overflow.” The defective gating may cause an input-output mismatch in specific motor programs, and such mismatches in motor programs may in themselves lead to production of distorted sensory information and issue of less than ideal motor commands. In this way, the chronicity of the problem can be maintained via a self-perpetuating mechanism. The reduced frontal N30 SEP peak ratio observed in the current study after 12 weeks of chiropractic care may reflect a normalization of pain-induced central maladaptive plastic changes and may reflect one mechanism for the improvement of functional ability reported following chiropractic adjustment or manipulation. (pgs. 134-135)

 

Haavik, Niazi, Holt and Murphy (2017) concluded:

 

After the 12 weeks of chiropractic care, when he was also feeling better symptomatically, this was reversed, and all of his MU traces for all SEP peak complexes were smaller in amplitude than his M + U trace, indicating a greater level of central reciprocal inhibition was occurring… Thus, if sensory “overflow” occurs, then incomplete processing of this incoming signal may occur in the brain, resulting in its perceiving not only excessive, but also spatially distorted information. (pg. 135)

 

The N9 SEP peak (the “N” is a location for electrodes) reflects the afferent signal over the brachial plexus before it enters the CNS, and thus can be used to ensure that the incoming signal is consistent before and after an intervention. Furthermore, these experiments demonstrated that the subjects' N30 SEP peak ratios decreased significantly after a single chiropractic manipulation of the cervical spine. As the N30 SEP peak is thought to reflect early cortical SMI, the authors argued that their results suggest that the subject's SMI networks' ability to suppress the dual input after the adjustment was increased. The N30 SEP peak ratios remained decreased even after repeating the 20-minute repetitive thumb abduction task. This suggested that the treatment effects appear to have altered the way in which each subject's CNS responded to the repetitive thumb typing task.

 

When considering treating chronic pain, dystonia, essential tremor or any other type of patient where there are spatial (distorted or excessive afferent) input issues, the above care path (treatment plan) should be considered. By not completed a complete treatment protocol might expose your patient to a chronic issue that may become permanent if the maladaptive cortical changes persist over time. Since there are no timetables for how long a patient can withstand for the issue to become permanent and there is an indexed peer reviewed suggestion of correction, that must be adhered as a minimum until further evidence suggests otherwise. In addition, no two patients are alike and the treatment plan should be guided with a full clinical reevaluation and consider performing that examination every 30 days of active care considering all facets, both history and clinical.

 

 

References:

  1. Haavik, H., Niazi, I. K., Holt, K., & Murphy, B. (2017). Effects of 12 Weeks of Chiropractic Care on Central Integration of Dual Somatosensory Input in Chronic Pain Patients: A Preliminary Study. Journal of manipulative and physiological therapeutics40(3), 127-138.
  2. Restuccia, D., Valeriani, M., Barba, C., Le Pera, D., Bentivoglio, A., Albanese, A. & Tonali, P. (2003). Abnormal gating of somatosensory inputs in essential tremor. Clinical neurophysiology114(1), 120-129.
  3. Baliki N., Geha P., Apkarian A., Chialvo D., (2008) Beyond Feeling: Chronic Pain Hurts the Brain, disrupting the Default-Mode Network Dynamics, Journal of Neurosciences 28(6) 1398-1403
  4. Essential Tremor (2017) retrieved from: https://en.wikipedia.org/wiki/Essential_tremor

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Chronic Pain and Chiropractic:

A 12-Week Solution & Necessity for Care

 

By Mark Studin

William J. Owens

A report on the scientific literature and commentary 

 

 

How long should a patient be under chiropractic care? This has been the struggle for many in the insurance industry, the legal community, licensure boards and a “hot topic” politically. There are the CCGPP [Council on Chiropractic Guidelines and Practice Parameters], the Croft Guidelines, Best Practice for Chiropractic Care for Older Adults, Best Practices Recommendations for Chiropractic Care for Infants, Children and Adolescents, Chiropractic Practice Guidelines: Chiropractic Care for Low Back Pain. These are just some of the chiropractic industry’s guidelines, then you must consider the insurance industry’s care paths where most are hidden behind statements like “medical necessity” and “eligible charges.” Those are “buzz phrases” indicating they have a guideline, but most will neither publish or make them available to the providers, their insured or the public claiming proprietary information giving them a legal basis for the secrecy.

 

 

Aetna, as an example lists specifics for care and then goes further to limit a significant number of techniques, procedures and diagnostics claiming they are “experimental.” Although Medicare considers chiropractic a covered service they limit treatment arbitrarily according based upon significant feedback from many in the profession.  Workers Compensation Boards have guidelines that are either legislated or created based upon a case law judge’s opinion which include arguments from the defense to support limiting care.  At best, that is an arbitrary process based upon rhetoric or legislation that is too often ignorant of the scientific literature resulting in serious imposed limits in scope of treatment as we see in California, New York and many other states.

 

 

Although the guideline landscape is expansive, these authors choose to rely on a hybrid of both “Best Practice” and “Evidenced Based” method in the development of treatment plans. Both have a strong place in clinical practice, academic settings, the courts and third-party reimbursement systems.

 

Best Practice is defined as “a method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark. In addition, a best practice can evolve to become better as improvements are discovered. Best practice is considered by some as a businessbuzzword, used to describe the process of developing and following a standard way of doing things that multiple organizations can use" (Best Practice, http://en.wikipedia.org/ wiki/Best practice).

 

These are certain procedures in healthcare that are taught in schools, internships and residencies and are considered the “standard” by which care is expected to follow. These practices are based on clinical experience and rely heavily on time-tested approaches, that is how a profession evolves and grows.  Surprisingly, most of the best medical practice care paths are not published in the peer-reviewed indexed literature. This is due to many factors, but the most obvious are applications of financial resources and grants to “new” discoveries and the simple fact that the clinical arena is well positioned to monitor and adjust these practices in a timely manner allowing practitioners to keep pace with the literature that follows. In recent times, although it has been talked about for decades, there is another parameter that exists and although focuses on best practices, there is a strong reliance on published studies, aka “evidence”, as the main driver of whether a procedure is approved and reimbursed. This is extremely problematic to healthcare outcomes.

Evidence-based practice(EBP) is an interdisciplinary approach to clinical practice that has been gaining ground following its formal introduction in 1992. It started inmedicineasevidence-based medicine (EBM) and spread to other fields such as dentistry, nursing, psychology,

education, library and information science and other fields. Its basic principles are that all practical decisions made should be based on three important criteria.  First, they must be based on the practicing provider’s clinical experience, secondly, they should be based on published research studies and thirdly should consider the patients expectations.

 

"Evidence-based behavioral practice(EBBP) entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. This is done in a manner that is compatible with the environmental and organizational context. Evidence is comprised of research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses" (Evidence-Based Practice, http://en.wikipedia.org/wiki/Evidence-based_practice).

 

This highly-debated topic of evidence-based vs. best practice has valid issues on each side, but putting them together as a hybrid would allow them to thrive in both a healthcare delivery and reimbursement system; therefore, all sides would win. This would allow advances in healthcare to save more lives, increase the quality of life and at the same time, offer enough safeguards to prevent abuse to payors. A one-sided approach would tip the scales to favor either the provider/patients or the payors which, in the end, results in distrust and conflict.

Evidence-based medicine proponents argue that it would eliminate waste and reduce costs while providing patients with the most up-to-date care available. Those against this concept argue that reliance on evidence-based care would eliminate many procedures that fall under the best medical practice parameters and remove the clinical decision making and professional experience from the equation. They feel what would be left is denial of good therapies and the stifling of innovation since the process of establishing a research study, following its participants and publishing those findings can take many years not to mention poor study design or research bias can have both a profound effect on the evidence provided and severely delay the final publication. This delay would eventually cost either lives or severely diminish the quality of life for those who could have been helped during the research and publication processes.

Haavik, Niazi, Holt and Murphy (2017) reported:

 

Post hoc tests using the Bonferroni correction revealed significant mean differences in N30 MU amp (P = .049) and N30 MU to M + U ratio data (P = .001) during the chiropractic intervention, but no significant changes were observed during the control period (P = .1 for N30 MU amp and P = .3 for N30 MU to M + U ratio data). The effect size for the change in N30 MU amp was 0.61, and for the N30 MU to M + U ratio it was 0.66. The N30 ratio change represented on average a 37.4% decrease following the 12 weeks of chiropractic care. The N30 MU amplitude changes following chiropractic care represented an 18.0% decrease in amplitude compared with baseline. (Pg 131)

 

These results were based upon a limited study, but validates that a chiropractic spinal adjustment modulated aberrant afferent input by 37.4% in median and ulnar nerve rations and 18% in median and ulnar nerve amplitudes.

 

The authors went on to report:

 

The purpose of this preliminary study was to assess whether the dual SEP technique is sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck pain after a 12-week period of chiropractic care and, if so, whether any such changes related to changes in symptomatology. (pg. 128)

 

This was tested to determine if inhibitory innervation was affected specifically by a chiropractic spinal adjustment and the outcomes conclusively, against a 2-week control period of the same test subjects confirmed these results.

Haavik, Niazi, Holt and Murphy (2017) went on to describe the 12 weeks of chiropractic care that realized these results:

 

The chiropractic care plan was pragmatic and generally consisted of 2 to 3 visits per week for the first 2 to 3 weeks. Frequency was reduced based on clinical findings and patient symptomatology. By the end of the 12-week period, participants were seen once or twice a week. No requirements were placed on the treating chiropractor, other than including chiropractic adjustment or manipulation during treatment; thus, the care plan was designed in conjunction with patient preferences and was based on the patients’ history, symptoms, wishes, and time availability as well as the clinician’s clinical experience and knowledge. (pg. 130)

 

Although the length of care in this study does not render a specific guideline, it does validate that it takes time to realize changes in the mechanics of the spine and the human nervous system.  The results are consistent with the “Best Practice Model” and the authors 57 years of combined experience and results. Twelve weeks of care is a conservative and reasonable time frame since we are observing and considering that cerebral neuroplastic changes are a direct and verifiable result of a chiropractic spinal adjustment. Less than 12 weeks of chiropractic spinal adjusting has not been evidenced to make these reported changes, therefore we must consider this threshold for care.Concurrently, what we see is that less treatment time does not allow the connective tissue to help the spine as one contiguous organ system to remodel to a homeostatic state (a conversation for a different paper).

 

Chiropractic care for chronic pain patients requires a both a combination of Best Practice and Evidenced Based models as the literature is now verifying that a chiropractic spinal adjustment is an effective care path and 12 weeks is a minimum to see neuroplastic changes.  Clinically speaking however, to confirm the optimum care path for this particular population of patients, continuation of care should be based on re-evaluations every 30-days and should continue as clinical sign and symptoms persist and there is evidence that the patient is benefiting both in the short and long term.   Additionally, no significant improvement over the first 12 weeks should be considered acceptable as neuroplastic changes are a process. Although these authors have rarely personally experienced a lack of significant neuro-biomechanical changes over that time period, it is a clinical decision that must be derived by the treating provider in a “Best Practice Model” and not a 3rd party.

 

References:

  1. Aetna Chiropractic Services (2017) Retrieved from: http://www.aetna.com/cpb/medical/data/100_199/0107.html
  2. https://www.medicare.gov/coverage/chiropractic-services.html
  3. Best Practice. (n.d.). In Wikipedia. Retrieved January 3, 2012, from http://en.wikipedia.org/wiki/Best_practice
  4. Evidence-Based Practice. (n.d.). In Wikipedia. Retrieved January 3, 2012, from http://en.wikipedia.org/wiki/Evidence-based_practice
  5. Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996) Evidence based medicine: What it is and what it isn't. British Medical Journal, 312(7023), 71-72.
  6. Haavik, H., Niazi, I. K., Holt, K., & Murphy, B. (2017). Effects of 12 Weeks of Chiropractic Care on Central Integration of Dual Somatosensory Input in Chronic Pain Patients: A Preliminary Study. Journal of manipulative and physiological therapeutics40(3), 127-138.

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Chiropractic and Cervical Arterial Dissection:

Causal Relationship or Medical Dogma?

By Mark Studin

William J. Owens

A report on the scientific literature and commentary

There has been much controversy over the last 2 decades about the perceived causal relationship between a chiropractic cervical adjustment and dissecting arterial aneurysm on the internet, in the literature and in the beliefs of some in the medical community. Prior to examining the published facts, lets first clarify what an arterial dissection is.

 

According to Haneline and Rosner (2007)

Arterial dissection is an uncommon vascular wall condition that typically involves a tear at some point in the artery's lining and the formation of an intimal flap, which allows blood to penetrate into the muscular portion of the vessel wall. Blood flowing between the layers of the torn blood vessel may cause the layers to separate from each other, resulting in arterial narrowing or even complete obstruction of the lumen (Fig 1). Moreover, pulsatile pressure damages the muscular layer, resulting in a splitting or dissection of the intimal and medial layers that may extend along the artery variable distances, usually in the direction of blood flow.Another way for dissection to occur involves a primary intramural hemorrhage of the vasa vasorum, which builds pressure between the intimal and medial layers and may eventually rupture into the vessel's true lumen. Occasionally, a double lumen (also known as false lumen) is formed when the subintimal hemorrhage ruptures back into the arterial lumen distally. (pgs. 113-114) 

 

 

Fig. 1

 

In addition, Haneline and Rosner (2007) wrote a decade ago:

Of special interest to chiropractors is the role cervical spine manipulation [CSM] plays, if any, in the pathogenesis of CAD [Cervical Artery Dissection]. Indeed, patients do experience CAD on rare occasions after CSM, making knowledge about the cervical arteries, the predisposing factors, and the pathogenesis of the condition important for chiropractors. (pg. 110)

 

This comment, early in the potential relationship between cervical adjusting and cervical arterial dissection [CAD] warranted a warning to healthcare provider about CAD and cervical adjusting making it important to understand the cervical arteries. This is underscored by the authors themselves being chiropractors and memorizing this “caveat” to the profession.

 

 

In a September 2017 presentation by Candice Perkins MD, Neurology, Vascular Neurology (an attending stroke neurologist and both an Associate and Assistant Professor of Clinical Neurology at the State University of New York at Stony Brook Hospital and Medical Center from 2001 - 2016) in New York, she stated that there is zero evidence for direct causal relationship between stroke and a chiropractic cervical adjustment performed by a licensed chiropractor in the appropriate clinical presentation. Dr. Perkins went on to explain that there are numerators and denominators. The denominator are strokes and the presence of a patient with a stroke. The numerator is the associated incidence. In her vast experience with stroke, there are an unlimited number of numerators with chiropractic being one, however if one uses that same equation, there are hundreds of other equally potential factors with primary care medical visits being of equal incidence. In addition, with her understanding chiropractic as a patient and from the literature, there is scant evidence that a chiropractic adjustment can be the causative factor of cervical dissecting aneurysm.

 

 

Researchers from the University of Pennsylvania Department of Neurosurgery came to the same conclusions. In a systematic and meta-analysis of chiropractic care and cervical arterial dissection, they concluded:

There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. (pg. 1)

 

Church et. Al reviewed 253 published articles and scored them on a GRADE system with 4 variables, high, moderate, low and very low in reliability of the research available on CAD and chiropractic adjustments. They concluded:

Scrutiny of the quality of the body of data using the GRADE criteria revealed that it fell within the “very low” category. We found no evidence for a causal link between chiropractic care and CAD. This is a significant finding because belief in a causal link is not uncommon, and such a belief may have significant adverse effects such as numerous episodes of litigation.  (pg. 6)

 

 

Perhaps the greatest threat to the reliability of any conclusions drawn from these data is that together they describe a correlation but not a causal relationship, and any unmeasured variable is a potential confounder. The most likely potential confounder in this case is neck pain. Patients with neck pain are more likely to have CAD (80% of patients with CAD report neck pain or headache), and they are more likely to visit a chiropractor than patients without neck pain. (pg. 7)

 

This is the same opinion of Dr. Perkins as reported above, where the presence of CAD does not have a causal relationship simply because the neck pain brought them to a chiropractor. The CAD would have happened with or without the chiropractic adjustment as is concluded by medical experts and the literature.

 

 

To further the argument, Cassidy, Boyle, Cote`, He, Hogg-Johnson, Silver and Bondy (2008) reported:

There were 818 VBA [Vertebral Basilar Artery] strokes hospitalized in a population of more than 100 million person-years. In those aged 45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than <45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. (pg. S176)

 

Murphy (2010) reported,

Therefore, based upon the best current evidence, it appears that there is no strong foundation for a causal relationship between CMT [Chiropractic Manipulative Therapy] and VADs [Vertebral Artery Dissection]. The most plausible explanation for the association between CMT and VADs is that individuals who are experiencing a vertebral artery dissection seek care from a chiropractic physician or other manual practitioner for relief of the neck pain and headache that results from the dissection. Sometime after the visit the dissection proceeds along its natural course to produce arterial blockage, leading to stroke. This natural progression from dissection to stroke appears to occur independent of the application of CMT. (pg. 4)

 

Church, Sieg, Hussain, Glantz and Harbaugh (2016) concluded, and an opinion that appears to reflect the facts of the issue and in accordance with those in chiropractic and medical academia based upon the author’s strong agreement:

Our systematic review revealed that the quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. A meta-analysis of available data shows a small association between chiropractic neck manipulation and CAD. We uncovered evidence for considerable risk of bias and confounding in the available studies. In particular, the known association of neck pain both with cervical artery dissection and with chiropractic manipulation may explain the relationship between manipulation and CAD. There is no convincing evidence to support a causal link, and unfounded belief in causation may have dire consequences. (pg. 10)

In spite of the very weak data supporting an association between chiropractic neck manipulation and CAD, and even more modest data supporting a causal association, such a relationship is assumed by many clinicians. In fact, this idea seems to enjoy the status of medical dogma. (pg. 9)

 

That is the final definitive opinion of the Neurosurgery Department at the University of Pennsylvania.

 

 

References:

  1. Haneline, M. T., & Rosner, A. L. (2007). The etiology of cervical artery dissection. Journal of chiropractic medicine6(3), 110-120.
  2. Church, E. W., Sieg, E. P., Zalatimo, O., Hussain, N. S., Glantz, M., & Harbaugh, R. E. (2016). Systematic review and meta-analysis of chiropractic care and cervical artery dissection: no evidence for causation. Cureus8(2).
  3. Murphy, D. R. (2010). Current understanding of the relationship between cervical manipulation and stroke: What does it mean for the chiropractic profession? Chiropractic & Osteopathy, 18

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