Diagnosing Where to Adjust

The Pathway to Central Motor Control

and Outcomes Lowering Opiates Use by 55%

& 313% Better Results than PTs

By: Mark Studin DC, FPSC, FASBE(C), DAAPM

Citation: Studin M. Diagnosing Where to Adjust. Dynamic Chiropractic, March 2024;42(3).

When investigating why a chiropractic spinal adjustment realizes superior outcomes compared to physical therapy and medical care for mechanical spine issues it answers questions on how each chiropractor needs to function in clinical practice. It has been reported that chiropractic care ends partial compensation for work-related injuries 313% quicker than physical therapy and 20% quicker than medical doctors. Chiropractic ends full compensation 239% quicker than physical therapy and 12% quicker than medicine.[1] it was also found that chiropractic lowered opiate use by 55% for back-related pain compared to medical doctors.[2] it was also found that approximately 95% of all back pain treated by medical doctors is considered “non-specific,” and the recommendation was physical therapy, which has already been validated as a poor “first choice” for spine or drugs, including narcotics if the problems persist.[3]^,[4]

Despite the evidence that over 96% of chiropractic patients with spinal-related problems reported positive outcomes,[5] the trend of physical therapy and drugs has not substantially shifted. The evidence in the literature has supported those outcomes by further explaining the connection between a chiropractic spinal adjustment, a high-velocity low-amplitude thrust (CSA), and central segmental motor control (CSMC) neuroplastic changes (changes in the central nervous system).[6]^,[7],[8]

The evidence in the literature also outlines the difference between a CSA and spinal manipulation. It appears that the outcome results listed herein, as also reported throughout the literature, lean heavily on a CSA, whereas a spinal manipulation does not realize the same outcomes. Haavik et al. (2021) reported, “It is possible to direct a thrust at any spinal segment, regardless of whether it is dysfunctional or not. Therefore, for the purposes of this review, if a thrust is directed at a spinal segment that has not been examined and identified as having clinical indicators of dysfunction, it will be referred to as spinal manipulation. In contrast, a thrust directed at a dysfunctional vertebral motion segment will be referred to as a spinal adjustment. This distinction is important, as adjustments are likely to have different physiological consequences compared to thrusting at or manipulating a vertebral segment that has no signs of motor control dysfunction.”[9]

As dysfunctional segments are at the core of CSMC, it becomes essential to define what a dysfunctional segment is and how to diagnose those vertebral segments accurately. What has been defined as a dysfunctional segment is an angular deviation and translation based on ligamentum laxity. The American Medical Association Guides to the Evaluation of Permanent Impairment, 6^th Edition, has defined translation and angular deviation as pathological vectors related to impairment, an administrative award, but not tissue damage.[10] The evidence of tissue damage has been defined as subfailures going beyond a ligament's ability to creep[11] (the viscoelastic ability of the ligament to elongate) and what occurs beyond those normal limits. Beyond those normal limits are the subfailures and tissue damage that occur well before the AMA Guide’s impairment rating.[12]^,[13],[14]

Although the pathological threshold for vertebral rotation has yet to be defined in the literature, a mathematical formula exists to determine pathology based on evidence in the literature. It is the three vectors of abnormal motion that define a dysfunctional vertebral motion segment, and although the decreased range of motion of the motor unit has historically been considered the arbiter for pathology, it is excessive motion based on ligamentous pathology where the core of the problem lies. A clinical palpatory evaluation of the spine can reveal excessive motion in static and motion palpation as the aberrant palpated spinous processes evidence the motion.

When considering an accurate clinical evaluation, motion palpation is a clinically sound starting point; however, static and motion palpation have poor intra and inter-rater reliability outcomes.[15]^{,[16],[17],[18]} Once concluded in a thorough clinical evaluation, imaging should be considered to validate a dysfunctional vertebral motion segment. X-ray is a reliable tool to diagnose dysfunctional segments conclusively.[19]^{,[20],[21],[22],[23]}

Although there is still misinformation regarding spinal diagnostic X-rays, there is no health risk if used as trained. To realize a health risk, it would require over 5,000 cervical X-rays, 100 thoracic X-rays, and 50 lumbar X-rays in one sitting (X-ray is not cumulative) to realize 1 in 100,000 adverse effects.[24] Not having a clinically indicated X-ray evaluation places substantial risk with yet “undiagnosed pathology” over “false hypothetical cancer incidence and death.”[25] Despite the necessity to accurately conclude a biomechanical pathological conclusion with an X-ray, the American Chiropractic Association (ACA) persists in pushing its “Choose Wisely” platform to limit X-rays within the first 6-weeks except when anatomical pathology (i.e., fracture, tumor, infection) is considered.[26] Following the ACA’s recommendation potentially creates a public health risk as that forces doctors to fall back to the failed static and motion palpation as described herein.

When diagnosing a dysfunctional segment, it is consistent with the evidence in the literature to use excessive motion in any of the three planes: translations, angular deviation, or rotation. It is those dysfunctional segments when treated with a CSA, that will initiate the neuroplastic cascade affecting CMSC. To conclude an accurate diagnosis, based on the evidence in the literature, there needs demonstrative evidence, and X-rays are best positioned to render the evidence as discussed herein.

An X-ray digitizing program that utilizes computerized mensuration is far superior to a ruler. A ruler can only measure between 1/32 and 1/64 inch. A computer measurement is closer to the true value because it can use up to an infinite number of decimals to calculate the measurement.[27] Doctors also conflate alteration of motion segment integrity (AOMSI) for pathology when using digitizing systems. AOMSI is not a pathology and should not be considered when diagnosing a dysfunctional motion segment. The underlying excessive movement independent of AOMSI is the dysfunction and what is needed to conclude an accurate diagnosis.

There is technology whose algorithms are based on the evidence in the literature that will give you the three planes of dysfunctional motion segments (pathology) independent of AOMSI. Beyond the three planes, a clinician must consider the Atlanto-Dental interval and the possible complication of a CSA beyond a 3 mm translation and the Atlanto-Dental and Alar Ligament failure. The practitioner must ensure that their software can accomplish all of the above.

To conclude, an accurate “demonstrative diagnosis” of a dysfunctional vertebral motion segment, based on the evidence in the literature, requires X-ray digitizing software. This will give the clinician a precise lesion level, with “vectors of treatment” suggestions in translation, angular deviation, and rotation. Short of that, with no demonstrative validation, the doctor of chiropractic could be rendering a manipulating or mobilizing of the joint with far less significant outcomes than a CSA with CSMC neuroplastic changes.

REFERENCES

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[2] Whedon, J. M., Toler, A. W., Goehl, J. M., & Kazal, L. A. (2018). Association between utilization of chiropractic services for treatment of low-back pain and use of prescription opioids. The Journal of Alternative and Complementary Medicine, 24(6), 552-556.

[3] Oliveira, Crystian B., et al. "Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview." European Spine Journal 27.11 (2018): 2791-2803

[4] Balagué, Federico, et al. "Non-specific low back pain." The lancet 379.9814 (2012): 482-491

[5] Ndetan, H., et al. "Chiropractic Care for Spine Conditions: Analysis of National Health Interview Survey." Journal of Health Care and Research 2020.2 (2020): 105

[6] Haavik, Heidi, et al. "The contemporary model of vertebral column joint dysfunction and impact of high-velocity, low-amplitude controlled vertebral thrusts on neuromuscular function." European Journal of Applied Physiology 121.10 (2021): 2675-2720.
Integration  

[7] Pickar JG, Wheeler JD (2001) Response of muscle proprioceptors to spinal manipulative-like loads in the anesthetized cat. JMPT24:2–11

[8]Sung PS, Kang YM, Pickar JG (2005) Effect of spinal manipulation duration on low threshold mechanoreceptors in lumbar paraspinal muscles: a preliminary report. Spine 30:115–122

[9] Haavik, Heidi, et al. "The contemporary model of vertebral column joint dysfunction and impact of high-velocity, low-amplitude controlled vertebral thrusts on neuromuscular function." European Journal of Applied Physiology 121.10 (2021): 2675-2720.
Integration  

[10] Rondinelli RD, ed. AMA Guides to the Evaluation of Permanent Impairment. Chicago, IL; American Medical Association Press, 2008

[11] Zhou, J., Tan, Y., Song, Y., Shi, X., Lian, X., & Zhang, C. (2021). Viscoelastic mechanical behavior of periodontal ligament: Creep and relaxation hyper-viscoelastic constitutive models. Mechanics of Materials, 163, 104079.

[12] Lin, Tsai, Chu, Chang (2001) Characteristics of sagittal vertebral alignment in flexion determined by dynamic radiographs of the cervical spine. Spine, 26(3), 256-261

[13] Knopp R, Parker J, Tashjian J, Ganz W. Defining radiographic criteria for flexion-extension studies of the cervical spine. Ann Emerg Med. 2001 Jul;38(1):31-5.

[14] Wu S., Kuo L, Lan H, Tsai W, Chen C., Su F. The quantitative measurements of the intervertebral angulation and translation during cervical flexion and extension. 2007, European Spine Journal, 16(9), 1435-1444.

[15] Jonsson, Anders, and Eva Rasmussen-Barr. "Intra-and inter-rater reliability of movement and palpation tests in patients with neck pain: A systematic review." Physiotherapy theory and practice 34.3 (2018): 165-180.

[16] Kawchuk, Gregory N., et al. "Clinicians’ ability to detect a palpable difference in spinal stiffness compared with a mechanical device." Journal of Manipulative and Physiological Therapeutics 42.2 (2019): 89-95.

[17] Nolet, Paul S., et al. "Reliability and validity of manual palpation for the assessment of patients with low back pain: a systematic and critical review." Chiropractic & manual therapies 29.1 (2021): 33.

[18] Cooperstein, Robert, Morgan Young, and Michael Haneline. "Interexaminer reliability of cervical motion palpation using continuous measures and rater confidence levels." The Journal of the Canadian Chiropractic Association 57.2 (2013): 156

[19] Fedorak, C., Ashworth, N., Marshall, J., & Paull, H. (2003). Reliability of the visual assessment of cervical and lumbar lordosis: how good are we?. Spine, 28(16), 1857-1859

[20] Marques, Catarina, et al. "Accuracy and reliability of X-ray measurements in the cervical spine." Asian Spine Journal 14.2 (2020): 169

[21] Jang, Jun-Su, et al. "Reliability Analysis of Vertebral Landmark Labelling on Lumbar Spine X-ray Images." Diagnostics 13.8 (2023): 1411

[22] Yeager, Matthew S., Daniel J. Cook, and Boyle C. Cheng. "Reliability of computer-assisted lumbar intervertebral measurements using a novel vertebral motion analysis system." The spine journal 14.2 (2014): 274-281

[23] Yi, Yoon-Sil, et al. "Reliability and validity of rasterstereography measurement for spinal alignment in healthy subjects." Physical therapy rehabilitation science 5.1 (2016): 22-28

[24] Mettler FA, Huda W, Yoshizumi TT, Mahesh M (2008) Effective doses in radiology and diagnostic nuclear medicine: A catalog Radiology 248: 254-263.

[25] American Association of Physicists in Medicine. Position statement of the American Association of Physicists in Medicine. Radiation risks from medical imaging procedures. December 2011. http://www.aapm. org/.

[26] https://www.acatoday.org/practice-resources/choosing-wisely/

[27] https://math.hws.edu/eck/math204/guide2020/07-accuracy-of-computation.html

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