Personal Injury Collections by State:
2011 vs. 2013 vs. 2015 vs. 2017 vs. 2019
Comparison of Collections vs. Cost of Living Analysis
National PI Collections Increase by 24%
Reference: Studin M., (2020) Personal Injury Collections by State: 2011 vs. 2013 vs. 2015 vs. 2017 vs. 2019 Comparison of Collections vs. Cost of Living Analysis, American Chiropractor, 42 (2), pgs. 34, 36, 38-40
by Mark Studin
In 2011, 2013, 2015 and 2017 I wrote in the American Chiropractor Magazine, "Why is a life in Tennessee, South Dakota and Texas worth more than a life in Hawaii and New York?" There is no reason other than the insurance companies and state politicians that you have elected into office allow it to be. We are a country of laws and regulations per-visit and it is these laws that dictate the marketplace and how doctors are reimbursed for their services. In most states, it is based upon the usual and customary fees of the doctors and the carriers paying a percentage of those fees. However, in Hawaii, the state sets the doctors’ fees and they are driven by politics.
The collections listed in the following table depict what chiropractors are collecting as of December 2019, on a per-visit basis for a typical treatment vs. what they collected in 2011, 2013, 2015 and 2017 and are rated against the cost of living for each state in comparison to other states. The dollar amounts exclude examinations, x-rays, supports and any other ancillary services or testing and are limited to only services performed by the chiropractor in a private clinical setting for treatment inclusive of the adjustment, modalities and rehabilitation.
The number of reporting doctors in all states does not reflect a large enough cohort (sample size) to reflect statistically accurate averages. However, based on survey sampling and conversations in all 50 states, the numbers are what was reported and can be trusted as a guide. The dollar amounts accurately reflect what is currently being collected for personal injury cases on a “visit basis” in all 50 states nationally and I personally gathered the information.
As I established in 2011, 2013, 2015 and 2017 in my previous articles, the cost of living is not an indicator for reimbursement in personal injury as one would logically conclude. In a fair and equitable system, the more it costs to rent an office and run a business, the more a doctor should be entitled to charge and collect. Unfortunately, politics too often determine your fees on a state-by-state basis and the stronger the insurance lobby, the lower the reimbursable fees. As was reported previously, Hawaii, which is one of the most expensive states to live in, has the lowest levels of reimbursement nationally. New York, previously was the lowest reimbursable state nationally, just got its first substantial fee increase and in October 2020, downstate New York chiropractors can realize approximately $114 per visit and will be reflected as such in this survey, although currently it is roughly $42. The New York State legislature controls New York personal injury fees.
A 50-state reimbursement comparison between 2017 and 2019 revealed a 25% increase in collections and between 2011 and 2019, a 48% increase was reported for a personal injury visit in a chiropractic office. This statistic showed a trend in the chiropractic profession which verifies that the personal injury population of patients is a financially stable sect within the industry. Also, when managed care and other financial classes in the profession are shrinking in reimbursement, personal injury is the one sector consistently growing. Please note that this author is not suggesting that a doctor maximize his/her charges inappropriately and that only clinically indicated services should be performed based upon clinical necessity.
Many doctors will read this report and feel that they must increase those portions of their practices with personal injury patients. From a reimbursement perspective and business plan, that would appear to make sense. However, is that doctor qualified? Treating trauma cases requires a particular skill set and training no different than in any specialty in healthcare. You wouldn't want a psychiatrist performing open-heart surgery without the requisite training or an OB/GYN doing brain surgery. In the past, all a doctor of chiropractic would need beyond their doctoral training was advanced education in MRI interpretation. This is a result of improper MRI interpretations by general radiologists. Herzog et. Al (2017) reported a 43.6% error rate of general radiologists misreporting the MRI findings, something a doctor of chiropractic relies on to deliver our care. Today, to compete and be considered an expert, formal education in spinal biomechanics, connective tissue pathology and accident engineering are also required.
Understanding the differences between herniated, bulged, protruded, extruded, migrated or sequestered disk is critical in creating an accurate diagnosis prognosis and treatment plan in triaging and guiding the patient through care. Although the delivery of chiropractic may not change, when you can and cannot treat your patient might change because collaborative care with a medical specialist and or surgery might be indicated. The etiology of pain in the trauma case is often dramatically different than in a geriatric or pediatric patient. Training and credentials matter.
After consulting and educating chiropractors for 20 years nationally, 100% of the doctors who have made the effort to be trained and compete in the “personal injury space” have succeeded. Although the reported levels of success have varied, all now consider themselves better doctors and experts, allowing themselves to be successful and make their competition irrelevant in personal injury. That is our goal for the doctors we train.
Also, there are many “get rich quick schemes” in personal injury that our profession has been exposed to. These are typically a “false bill of goods” with offers of “magic reports and research articles” to garner referrals. There are programs designed to overcome the algorithmic requirements of the carriers to bolster settlements for lawyers with claims that is all the lawyers need to refer to en masse`. As verified by over 10,000’s of lawyers and hundreds of doctors nationally in the past 5 years who have tried that, confirmed it is a “plausible marketing fad” that hasn’t delivered. The primary beneficiaries of those programs are those who have created those schemes. CAVEAT EMPTOR! There is no substitute for credentials, knowledge and a strategic business plan to get your referral sources to run after you. That is the solution for chiropractic practices in 2020 and beyond; a fact that has been confirmed by extensive market research.
Too many doctors of chiropractic bypass the diagnosis and prognosis stage and delve directly into treatment. Too often, this step is taken to the detriment of the patient. If the patient has pain radiating down their arms or legs with or without associated motor weakness before you touch that patient, the first question that must be answered is “what is causing that problem?” AND… if you do not know, do not guess. Beyond your clinical examination, consider advanced imaging if clinically warranted without shying away from the carriers often “fictitious” rules of approving the advanced images. Once again, the hard, NON-NEGOTIABLE “Studin Rule” rule is: IF YOU DO NOW KNOW…DO NOT GUESS.
The only way to spiral upwards is through clinical excellence through the acquisition of knowledge and credentials. Based on the literature, chiropractic outcomes have outpaced other forms of treatment for spinal conditions within our scope. For mechanical spine pain, both physical therapy and medicine have realized far poorer outcomes with an increased incidence of secondary disabilities, increase opiate use and significantly higher costs compared to chiropractic care.
As a profession, the most direct avenue for these published studies to help increase utilization is for each doctor to be expert and credentialed in the area of desired practice. Treating personal injury patients is included in this formula and mandates graduate-level training (post-doctoral education), so choose your courses wisely as a stepping-stone to what you want your practice to be tomorrow.
With personal injury or any financial category, fair and equitable reimbursements will determine if a doctor can afford to live in any community nationally and wise legislators should take into account doctor’s reimbursements, or will soon realize there is a doctor shortage in their respective state. Many state legislators are not "penny wise and dollar foolish," unlike those elected officials in Hawaii and this has fueled the opioid crisis with only pharmacologic or surgical solutions. Therefore, for those states who are below the national average, the chiropractic political organizations should strengthen their lobbying efforts with a unified (one) chiropractic voice (organization) and that should happen not only at the state level but nationally.
NEVER LOSE SIGHT THAT THERE CAN NEVER BE A PHARMACOLOGICAL SOLUTION TO A MECHANICAL PROBLEM. Therin lies the genesis of part of the opioid crisis.
|
Survey in 2011 |
Survey in 2013 |
Survey in 2015 |
Survey in 2017 |
Survey in 2019 |
Cost of Living Ranked Lowest to Highest |
|
|
Alabama |
$80.00 |
$80.00 |
$90.00 |
$200.00 |
$ 250.00 |
8 |
|
Alaska |
$175.00 |
$225.00 |
$225.00 |
$349.00 |
$ 375.00 |
47 |
|
Arizona |
$110.00 |
$100.00 |
$135.00 |
$200.00 |
$ 333.00 |
23 |
|
Arkansas |
$115.00 |
$109.00 |
$120.00 |
$110.00 |
$ 235.00 |
2 |
|
$113.00 |
$140.00 |
$155.00 |
$225.00 |
$ 210.00 |
49 |
|
|
Colorado |
$75.00 |
$150.00 |
$185.00 |
$250.00 |
$ 275.00 |
35 |
|
Connecticut |
$100.00 |
$100.00 |
$180.00 |
$200.00 |
$ 200.00 |
50 |
|
Delaware |
$200.00 |
$200.00 |
$200.00 |
$200.00 |
$ 460.00 |
34 |
|
Florida |
$250.00 |
$250.00 |
$325.00 |
$300.00 |
$ 325.00 |
28 |
|
Georgia |
$225.00 |
$140.00 |
$202.00 |
$220.00 |
$ 366.00 |
10 |
|
Hawaii |
$75.00 |
$75.00 |
$75.00 |
$75.00 |
$ 75.00 |
51 |
|
Idaho |
$160.00 |
$135.00 |
$120.00 |
$100.00 |
$ 195.00 |
16 |
|
Illinois |
$230.00 |
$150.00 |
$220.00 |
$250.00 |
$ 357.00 |
24 |
|
Indiana |
$65.00 |
$90.00 |
$125.00 |
$225.00 |
$ 250.00 |
15 |
|
Iowa |
$100.00 |
$100.00 |
$140.00 |
$140.00 |
$ 225.00 |
6 |
|
Kansas |
$80.00 |
$150.00 |
$170.00 |
$120.00 |
$ 240.00 |
9 |
|
Kentucky |
$180.00 |
$230.00 |
$185.00 |
$250.00 |
$ 400.00 |
17 |
|
Louisiana |
$113.00 |
$90.00 |
$125.00 |
$120.00 |
$ 225.00 |
19 |
|
Maine |
$70.00 |
$160.00 |
$130.00 |
$135.00 |
$ 145.00 |
38 |
|
Maryland |
$173.00 |
$150.00 |
$200.00 |
$225.00 |
$ 300.00 |
46 |
|
Massachusetts |
$130.00 |
$170.00 |
$250.00 |
$250.00 |
$ 300.00 |
45 |
|
Michigan |
$100.00 |
$135.00 |
$250.00 |
$300.00 |
$ 350.00 |
3 |
|
Minnesota |
$160.00 |
$206.00 |
$200.00 |
$307.00 |
$ 400.00 |
29 |
|
Mississippi |
$209.00 |
$200.00 |
$210.00 |
$150.00 |
$ 225.00 |
1 |
|
Missouri |
$100.00 |
$190.00 |
$200.00 |
$375.00 |
$ 145.00 |
4 |
|
Montana |
$75.00 |
$108.00 |
$195.00 |
$199.00 |
$ 198.00 |
31 |
|
Nebraska |
$75.00 |
$138.00 |
$150.00 |
$180.00 |
$ 195.00 |
13 |
|
Nevada |
$80.00 |
$180.00 |
$130.00 |
$150.00 |
$ 221.00 |
36 |
|
New Hampshire |
$118.00 |
$129.00 |
$120.00 |
$160.00 |
$ 240.00 |
38 |
|
New Jersey |
$136.00 |
$105.00 |
$105.00 |
$105.00 |
$ 110.00 |
41 |
|
New Mexico |
$171.00 |
$250.00 |
$160.00 |
$170.00 |
$ 210.00 |
14 |
|
New York |
$40.00 |
$43.00 |
$42.00 |
$42.00 |
$ 114.00 |
48 |
|
North Carolina |
$125.00 |
$120.00 |
$160.00 |
$115.00 |
$ 155.00 |
18 |
|
North Dakota |
$145.00 |
$145.00 |
$145.00 |
$145.00 |
$ 250.00 |
30 |
|
Ohio |
$140.00 |
$120.00 |
$100.00 |
$300.00 |
$ 345.00 |
12 |
|
Oklahoma |
$167.00 |
$125.00 |
$253.00 |
$120.00 |
$ 195.00 |
5 |
|
Oregon |
$175.00 |
$120.00 |
$150.00 |
$190.00 |
$ 200.00 |
44 |
|
Pennsylvania |
$155.97 |
$115.00 |
$140.00 |
$150.00 |
$ 235.00 |
32 |
|
Rhode Island |
$140.00 |
$130.00 |
$130.00 |
$130.00 |
$ 150.00 |
42 |
|
South Carolina |
$145.00 |
$165.00 |
$200.00 |
$120.00 |
$ 145.00 |
15 |
|
South Dakota |
$100.00 |
$198.00 |
$125.00 |
$200.00 |
$ 225.00 |
27 |
|
Tennessee |
$245.00 |
$220.00 |
$155.00 |
$125.00 |
$ 325.00 |
7 |
|
Texas |
$125.00 |
$150.00 |
$225.00 |
$150.00 |
$ 525.00 |
11 |
|
Utah |
$130.00 |
$155.00 |
$170.00 |
$178.00 |
$ 227.00 |
25 |
|
Vermont |
$100.00 |
$140.00 |
$160.00 |
$160.00 |
$ 167.00 |
39 |
|
Virginia |
$120.00 |
$110.00 |
$200.00 |
$250.00 |
$ 300.00 |
33 |
|
Washington |
$120.00 |
$140.00 |
$225.00 |
$250.00 |
$ 315.00 |
37 |
|
West Virginia |
$110.00 |
$135.00 |
$185.00 |
$150.00 |
$ 208.00 |
26 |
|
Wisconsin |
$117.00 |
$130.00 |
$129.00 |
$185.00 |
$ 225.00 |
21 |
|
Wyoming |
$90.00 |
$90.00 |
$115.00 |
$120.00 |
$ 145.00 |
20 |
References:
Chiropractic Co-Management of Pre & Post-Spine Surgical Cases
By: Matt Erickson DC, FSBT
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
Ashraf Ragab, MD, Orthopedic Spine Surgeon
Reference: Erickson M., Studin M., Ragag A. (2019) Chiropractic Co-Management of Pre and Post-Surgical Cases, American Chiropractor 41(9), 34, 36,38-40
A report on the scientific literature
Introduction
When a patient presents in a chiropractic office and has clinical signs of either radiculopathy (nerve root compression) at the neural canal or central canal regions or any myelopathic findings (cord compression with ensuing neurological deficit distal to the level of the lesion), immediate referral for an MRI should be considered. Based upon your clinical findings, triage then ensues as a result of creating a clinically driven diagnosis, prognosis and treatment plan. In a smaller percentage of cases, it will be discovered that the patient has a condition that requires a referral to a spine surgeon or a pain management provider. Regardless of where the patient is directed, having the patient fully worked up (examination, x-rays and advanced imaging) before the referral takes place is an important aspect of what the Doctor of Chiropractic can and should do and is within the lawful scope of practice within all 50 states and the United States territories.
Among those patients referred to the spine surgeon, some will not require or be a candidate for surgery. This is an area where a Doctor of Chiropractic especially with post-graduate training in Primary Spine Care and spinal biomechanical engineering, can be a big help to the surgeon by ensuring that a higher portion of the referred patients presents with the condition that likely requires the surgeon’s services. By triaging those patients who more likely needs the spine surgeon or pain management doctor’s services, it allows the specialist to save time on screening patients in the clinic who do not need their services and instead, it allows them to spend more time performing medically necessary spine-related procedures which allows patients to be taken care of more efficiently.
In the event a patient does not require surgery, unless there is a contraindication to correcting a patient’s neuro-musculo-biomechanical failure leading to structural imbalance, the Doctor of Chiropractic can co-manage the patient with the pain management provider. For the pain management provider, they may recommend various pain management procedures like a spinal epidural injection, a medial branch block or a facet injection. And given that pain management providers don’t focus on spinal biomechanics, but the Doctor of Chiropractic does, for most patients, this collaborative approach is ideal for better patient outcomes.
Surgical Considerations
In patients who do require surgery, the treatment plan can be as simple as the referral to the spine surgeon. This however brings the question, “What is the Doctor of Chiropractic’s role in managing patients before and after surgery?”
In some cases, immediate surgery may be required. This would be the case where the patient has a spinal cord injury like myelomalacia-which is regarded as softening of the spinal cord due to damaged neural tissue that fills in with a glial scar. A glial scar, according to Silver and Miller (2004, February) “consists predominately of reactive astrocytes [star-shaped glial cells-cells without neurons, in the brain or spinal cord] and proteoglycans [molecules made of sugar and proteins]” (p. 146). Further, myelomalacia forms with pressure on the spinal cord which may be due to biomechanical failure and ensuing cord pressure in post-trauma cases. Immediate surgery may also be required with a disc extrusion (a type of disc herniation) which presents with myelopathic findings (ensuing neurological deficit distal to the site of the spinal cord lesion following trauma) and in patients with an advanced nerve root compression leading to pain, numbness, tingling and weakness into the upper or lower extremity at the level the nerve root has been compressed.
In other patients however, while surgery may be indicated, the Doctor of Chiropractic can work to improve the patient’s biomechanical balance before surgical intervention. This is another area a Primary Spine Care trained Doctor of Chiropractic has the additional post-graduate training to co-manage this type of case. Regardless, these considerations must be coordinated with the spine surgeon if surgery is required. Sagittally balancing the spine for better patient surgical outcomesas reported by Makhni, Shillingfor, Latatta Hyun and Kim (2018), “Adult spinal deformity with sagittal imbalance is associated with significant pain, disability, as well as directly and negatively influence health-related quality of life scores. The spine surgeon has to understand the whole global and regional alignment changes after sagittal imbalance to address the multiplanar deformity. Restoration of global alignment and minimization of complications through various surgical options can successfully improve the pain and function of spinal deformity patients” (pp. 176-177).
Importance of Sagittal Balance
Sagittally balancing the lumbar spine is further supported in an article published on Helia.com related to lectures on the outcomes of lumbar spine surgery about sagittal balance, Hu (2016, para 3) reported, “Surgical outcomes for spine surgery are improved when spinal, pelvic and hip alignment is considered in both degenerate and deformity cases, and how we better understand these will help us better improve outcomes for our patients” (https://www.healio.com/spine-surgery/lumbar/news/print/spine-surgery-today/%7B54ac5ca2-7939-407d-96a5-31fa9c0fc904%7D/proper-sagittal-balance-may-correlate-with-better-surgical-outcomes).
Hu (2016) also reported, “Sagittal imbalance in a patient can negatively affect the outcomes of a surgical procedure. But, how extensive the surgery required is to correct the imbalance must be carefully considered for the individual patient” (para. 4). r. LeHuec (2016) added, “Sagittal balance is an active phenomenon for patients. “The best course of action is to strive to achieve sagittal balance in patients” (para. 8).
In a study by
Finally, in an article by Yeh, Lee, Chen, Yu, Liu, Peng, Wang, and Wu, (2018) they concluded, “The results of this study support previous findings that functional outcomes are closely associated with sagittal radiographic parameters in the patients with the degenerative thoracolumbar spinal disease who received long-segment fusion. The achievement of global and regional sagittal alignment balance is a crucial factor for improved postoperative functional outcomes” (p. 1361).
Post-Surgical Management
According to a publication titled “A Detailed Guide to Your Surgery and The Recovery Process” by the Johns Hopkins Spine Service (n.d., p. 16), “Walking is the best activity you can do for the first 6 weeks after surgery. Further, there will be “restrictions for the first 6 weeks after surgery,” the patient should “avoid twisting and bending” and avoid lifting, pushing or pulling objects greater than 5 lbs” (https://www.hopkinsmedicine.org/orthopaedic-surgery/_documents/patient-information/patient-forms-guides/JHULumbSpineSurgeryGuide.pdf).
From the Johns Hopkins publication (n.d.), patients are advised to call the surgeon’s office to make a 6-week follow-up appointment. At that appointment, x-rays will be performed to evaluate how the surgical area is healing. If everything checks out, “patients may be given a handout of lower back exercises to begin at home.” Patients may also be provided a prescription for outpatient physical therapy, but that is dependent upon the patient’s recovery (p. 24).
When physical therapy begins, the goal is to gradually improve strength, flexibility and endurance. The patient may also receive help with activities of daily living like gate training (learning how to walk properly again). However, while beneficial, physical therapy is limited in that a physical therapist does not focus diagnosing and correcting the spinal biomechanics. Further, a physical therapist is not licensed to manage the patients on a physician level. This is where the Doctor of Chiropractic is needed as part of the long-term recovery solution.
Following the initial 6-week evaluation, according to Hayeri and Tehranzadeh (2009, para. 21), “Evaluation of the postoperative spine usually begins with conventional radiographs in AP and lateral projections. It usually takes 6 to 9 months for a solid bone fusion to be established radiographically.” Hayeri and Tehranzadeh (2009, para. 20) also reported, “Postoperative imaging plays an important role in the assessment of fusion and bone formation. It is also helpful to detect instrument failure and other suspected complications. It is necessary to compare current images with previous studies to identify any subtle changes and disease progression” (https://appliedradiology.com/articles/diagnostic-imaging-of-spinal-fusion-and-complications).
Hayeri and Tehranzadeh (2009) added, Currently, computed tomography (CT) with multiplanar reconstruction (MPR) is considered the modality of choice for imaging bony details and assessing osseous formation and hardware position despite artifact formation.” (para. 22).
It is important to understand, patients don’t need to wait 6-9 months to start treatment with the Doctor of Chiropractic. About 6 weeks following surgery, if the patient is healed enough to begin physical therapy, the patient should be able to tolerate gentle mechanical corrections above and below the level of the surgical fusion. However, the patient will need to first be cleared to do so by the surgeon. Doing this can help in the patient’s recovery process and prepare the patients spine for a more comprehensive correction process once the patient is cleared. It can also help to shorten the time needed for correction.
The Doctor of Chiropractic (trained in Primary Spine Care) therefore, can take on a critical and important role in the management of patients before and after spine surgery. Further, unlike the physical therapist, the Doctor of Chiropractic having physician class status, is licensed to fully diagnose, manage and treat biomechanical pathology of the spine when indicated.
Primary Spine Care
Despite this, not all Chiropractic Doctors have additional post-graduate training or experience to manage complex spine cases. This is no different than a Medical Doctor having just completed medical school not being able to function in the capacity of a specialist short of residency and/or a fellowship program.
One solution that provides the Doctor of Chiropractic with the additional training and experience to manage complex spine cases is an extensive post-graduate training program in Primary Spine Care as previously discussed. Currently, there is a growing body of Chiropractic Doctors through an extensive post-graduate program offered through the Academy of Chiropractic, that are becoming qualified in Primary Spine Care that is well prepared to take on the role in managing patients with complex spine related issues (https://www.academyofchiropractic.com/component/content/article.html?id=1224).
The concept of the Doctor of Chiropractic taking on the role of a Primary Spine Care provider was discussed in an article by Erwin, Korpela and Jones (2013). The stated, “Chiropractors have the potential to address a substantial portion of spinal disorders; however the utilization rate of chiropractic services has remained low and largely unchanged for decades. Other health care professions such as podiatry/chiropody, physiotherapy and naturopathy have successfully gained public and professional trust, increases in the scope of practice and distinct niche positions within mainstream health care. Due to the overwhelming burden of spine care upon the health care system, the establishment of a ‘primary spine care provider’ may be a worthwhile niche position to create for society’s needs. Chiropractors could fulfill this role, but not without first reviewing and improving its approach to the management of spinal disorders” (p. 285).
Conclusion
In conclusion, the Doctor of Chiropractic has the foundational training to diagnose, manage and treat patients when indicated both before and after spinal surgery. However, with additional post-graduate training in Primary Spine Care, the Doctor of Chiropractic can obtain the necessary skills to manage more complex spine conditions which include coordinating care with the spine surgeon, pain management doctors and even a patient’s primary care doctor. With the current opioid crisis in the United States, there is a need for a front-line provider to lead in the management of non-surgical spine care and the Doctor of Chiropractic as a licensed physician is positioned to take on that role especially with additional training in Primary Spine Care.
References
CASE REPORT: Multiple cervical and lumbar disc herniations and ligamentous injury, post MVA treated successfully with conservative chiropractic treatment
Dennis Mutell D.C.
Abstract: This case report demonstrates the use of conservative chiropractic care in the treatment of cervical and lumbar disc injuries as well as ligamentous instability in the cervical and lumbar spine of a person injured in a double impact automobile collision.
Diagnostic studies include complete case history, physical examination, including orthopedic and neurological exams, radiographic examination, including flexion extension views of the cervical and lumbar spine and MRI of the cervical and lumbar spine.
Introduction: The patient, a 48-year-old male who reports he was a passenger in a hotel shuttle van which was struck on the passenger side by another automobile, followed by a full-frontal impact of the shuttle van hitting a pole. The patient was wearing a seatbelt. From the scene of the accident, he was transported by ambulance to a local hospital emergency department where he had x-rays and a CT scan of the head taken. He received contusions to the chest, legs and shin. He was released with prescription medication and told to follow up with his doctor when he got home if he continued to have problems.
Patient complaints were as follows: At the time of the accident, the patient noted he was dizzy and had tingling and numbness in the extremities. He complained of generalized ache, pain and stiffness in the neck and back. He also suffered from confusion.
At the time of his initial evaluation at my office, approximately 10 days post-accident, he complained of neck pain and stiffness which increased with physical activity and decreased with rest and medication. Neck pain was referred to the occipital region, across the shoulders and into the upper thoracic. He reported pain into the thoracic region, described as tightness and stiffness, which also increased with physical activity and improved with rest. His low back was his primary area of complaint - with the most significant and consistent pain that increased significantly with weight-bearing activity and only improved with lying down. Patient had knee stiffness and pain on the right and soreness in both knees and ankles. There was notable bruising of the chest and a contusion. Patient continued to have symptoms of mild traumatic brain injury, consisting of feeling dazed and confused with some amnesia following the accident. Patient continues to have headaches and brain fog.
Prior treatment: Patient received a prescription for anti-inflammatories and a muscle relaxer from the emergency department. He was not working and resting as much as possible and utilizing hot showers.
Past medical history: Patient reports he was involved in an automobile collision 2 to 3 years prior to this collision and received injuries to his neck and back. He had a brief course of chiropractic and physical therapy care. He was released from care without any restrictions or residual complaints. He was working without restriction since being released from that accident and was asymptomatic prior to this accident.
Clinical findings: Patient is 48 years old, 5’11” and 235 pounds. Blood pressure is 130/80 pulse is 75. Patient exhibited no swelling or edema to the extremities. Cranial nerves were intact. Patient appeared antalgic and guarded in his movements.
Physical findings: Palpation revealed significant pain and tenderness in the suboccipital region as well as guarding spasm in the cervical, upper thoracic and lumbar region. Patient had visible restrictions of range of motion in the cervical and lumbar spine, associated with pain. Patient had a positive Foramen Compression Test and Jackson’s Compression Test bilaterally. Manual cervical traction provided some relief in the C1 occipital region, but increased pain along the side the neck and out across the top of the shoulders. Patient could not perform an Apply’s Scratch Test associated with pain in the upper thoracic region. He had a positive SOTO Halls Test for pain in the cervical region into the upper thoracic region. Straight leg raise test was restricted at 60° bilaterally for increased pain in lower back into the buttock region. Patient had a positive Kemps Test bilaterally for joint pain and muscle pain. McMurray’s Test was positive the right knee. The patient was unable to obtain full flexion of the right knee.
Due to the visual restrictions of range of motion in the cervical and lumbar spine, a dual inclinometer range of motion study was ordered and performed of the cervical and lumbar spine, demonstrating loss range of motion.
Neurological testing: Dermatome testing revealed normal sensation in the upper and lower extremity to light touch and pinwheel. Deep tendon reflexes were found to be +2 bilaterally of the upper and lower extremity, except for a diminished left bicep reflex. Manual muscle testing of the upper and lower myotomes revealed 5/5 strength bilaterally, except for 4/5 of the left deltoid muscle and diminished grip strength of the left hand.
Based on the patient’s subjective symptoms and examination findings, x-rays of the cervical and lumbar spine, including flexion extension views were ordered. I personally reviewed these images.
Cervical: Significant loss of the normal lordosis.
Retrolisthesis is noted at C-4 in relationship to C-5 on the neutral lateral view.
Flexion shows significant fixation to normal movement. C-3 demonstrates anterolisthesis in relation to C-4 and it is noted that C-4 shows realignment in relationship to C-5, which is indicative of ligamentous laxity and injury.
Extension demonstrates significant fixation to normal movement. There is further retrolisthesis of C-4 in relationship to C-5 extension.
Small osteoarthritic spur is noted on the anterior inferior aspect of C-4 and posterior disc thinning.
Lumbar: Biomechanical misalignment is noted as rotation of L1, L2 and L3 to the right. Patient has a significant external rotation to the left ilium and the right ilium appears elevated in relationship to the left.
Osteophyte is noted of the anterior superior aspect of L4 associate with significant posterior disc thinning.
Retrolisthesis of L-3 in relation to L-4 on the neutral lateral image.
Flexion reveals significant fixation to normal movement and realignment of L-3 in relation to L-4 flexion - indicating some degree of ligamentous laxity.
Number 1: Cervical neutral lateral view demonstrating retrolisthesis of C4 in respect to C5 and C5 and respect to C6, indicating ligament laxity.
Number 2: Cervical flexion view demonstrating realignment of C-4 in respect to C5 and C5 and respect to C6, indicating ligament laxity. Normal movement into cervical flexion is significantly restricted.
Number 3: Cervical extension view demonstrating retrolisthesis of C4 in respect to C5, indicating ligament laxity. Significant restriction to normal cervical extension.
Cervical MRI without contrast: Following my personal review of the MRI images, my impressions are as follows:
Cervical spinal cord appears normal in signal intensity. Generalized arthritic changes to the facet joints throughout the cervical spine.
C-2 / C-3: High intensity signal in the posterior aspect of the disc, which is visualized as a radial tear.
C-3 / C-4: Disc protrusion on the left causing stenosis of the left neural canal, resulting in contact with the C-4 nerve root.
C-4 / C-5: Disc bulge associated with marginal osteophytes resulting in mild restriction of the neural canals, bilaterally.
C-5 / C-6: Disc bulge associated with marginal osteophytes resulting in mild restriction of the neural canals, bilaterally.
C-6 / C-7: Normal appearance of the vertebral discs.
C-7 / T-1: Normal appearance of the vertebral disc.
Lumbar MRI without contrast: Following my personal review of the MRI images, my impressions are as follows:
Conus terminates at L1 and appears normal in position. Generalized arthritic changes of the lumbar facet joints and mild thickening of the ligament of flava from the mid to lower lumbar.
L-1 / L-2: Vertebral disc appears normal with no central canal or neural canal stenosis.
L-2 / L-3: Vertebral disc protrusion on the left causing mild neural canal stenosis on the left.
L-3 / L-4: Vertebral disc protrusion on the right resulting in stenosis of the right neural canal with associated high signal intensity in the posterior right disc indicative of recent trauma. Disc protrusion is superimposed upon a bulging disc resulting in some left neural canal stenosis as well.
L-4 / L-5: Left lateral disc protrusion resulting in stenosis of the left neural canal. Disc protrusion superimposed upon a bulging disc which results in mild right neural canal stenosis.
L-5 / S-1: Bulging disc associated with osteophyte formation resulting in bilateral neural canal stenosis.
Number 4: Lumbar neutral lateral demonstrating loss of lumbar lordosis in the upper lumbar spine with slight retrolisthesis of L2 in relationship to L3 and L3 in relationship to L4, indicating ligament laxity.
Number 5: Cervical MRI without contrast. C2 – C3 demonstrates high intensity signal in the posterior aspect of the disc which is visualized as a radial tear on the axial view.
Number 6: Cervical MRI without contrast. Left disc protrusion causing stenosis of the left neural canal resulting in contact to the C4 nerve root.
Number 7: Lumbar MRI without contrast. Disc protrusion on the right resulting in stenosis of the right neural canal with associated high signal intensity in the posterior the right disc indicative of recent trauma.
Diagnostic impression: Considering the patient’s history, physical examination findings, x-ray findings demonstrating ligamentous laxity in both the cervical and lumbar spine, MRI findings demonstrating the vertebral disc injuries involving the cervical and lumbar spine, an initial treatment plan, consisting of conservative chiropractic treatment was initiated.
Treatment: Following review of all diagnostic imaging, there were no contraindications to cervical and lumbar spinal adjustments. Patient received chiropractic spinal adjustments to the cervical and lumbar spine in association with at home and work recommendations, as well as instructions for the utilization of ice, TENS and an at home exercise program to improve flexibility and strength.
Patient was referred to an interventional pain management medical doctor for evaluation and possible recommendations. The medical doctor initially recommended epidural steroid injections and possible consideration for facet joint ablation in both the cervical and lumbar spine. Due to the patient finding some relief with initial chiropractic care, the patient elected to continue with chiropractic care without receiving the injections. At the six week follow up with the pain management doctor, the patient experienced enough improvement and symptomatic relief that the pain management doctor recommended he continue with conservative chiropractic care.
Discussion: Doctor of Chiropractic trained in MRI spine interpretation, spinal biomechanics, and qualified as primary spine care physicians, are capable to triage patients involved in automobile collisions resulting in injury. Through proper identification of the injuries, establishing a diagnosis and a treatment plan to address the injuries and evaluate for the need of co-management with medical providers a traumatically injured patient has the best chance for a return to function.
REFERENCES
CHIROPRACTIC SPINAL ADJUSTMENT / MANIPULATION
Manipulation vs. Mobilization
Part 1 of 2
Matt Erickson DC, FSBT
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
A report on the scientific literature
Introduction
Kinetically,spinal manipulation is defined as a high-velocity low amplitude (HVLA) thrust maneuver. According to Ernst and Harkness (2001), “SM (spinal manipulation) involves high velocity thrusts with either a long or short lever-arm, usually aimed at reducing pain and improving range of motion (p. 879).
Kinetics and kinematics of motion (sub-areas of biomechanics) were described by Evans and Breen (2006). “Kinetics is the branch of mechanics that deals with motion (of an object) under the action of given forces. This includes static (equilibrium) states in which no movement is occurring and dynamic states in which forces may vary as movement occurs” (p. 72). “Kinematics is the branch of mechanics that deals with motion (of an object) without reference to force or mass. With a few notable exceptions, most biomechanical studies of spinal manipulation have given scant attention to kinematics” (p. 73). Thus, kinetics is the study of the type of force used with spinal manipulation while kinematics is the study of the motion geometry of the thrust.
Respectfully, spinal manipulation performed by a doctor of chiropractic is a specific chiropractic spinal adjustment (CSA). From an insurance coding a billing perspective, a CSA is also called a chiropractic manipulative treatment (CMT). In part 2 of this series, we will detail the necessity for that language. In this paper (part 1 of 2), we will focus on the definition of spinal manipulation and the different outcomes desired by disparate professions. However, the terminology of a specific chiropractic spinal adjustment needs to be considered at all times when referencing spinal manipulation in this article.
Zinovy and Funiciello (2018, Sept. 17, para. 2) regarding spinal manipulation reported, “This high-velocity, low-amplitude (HVLA) thrusts, also called chiropractic adjustments or osteopathic manipulative treatments (OMT), are carefully performed by applying enough force to push the spinal joint beyond the restricted range of motion with the goal of improving the joint’s function, increasing range of motion, and reducing pain. When a high-velocity manipulation is performed on the spine, it typically involves a cracking or popping sound that can be heard. Some people report feeling relief or enjoying the cracking sound, whereas others do not” (https://www.spine-health.com/conditions/neck-pain/manual-manipulation-and-mobilization-chronic-stiff-neck).
Conversely, spinal mobilization is kinetically defined as a low-velocity, low-amplitude force (LVLA) non-thrust maneuver used to help relieve pain, improve motion and restore function. Zinovy and Funiciello (2018, Sept. 17) regarding spinal mobilization wrote, “These low-velocity, low amplitude (LVLA) manipulations gradually work the spinal joints through their well-tolerable ranges of motion rather than forcing them beyond the normal limit. The practitioner’s hands gently move the vertebra and stretch each spinal level being worked. Spinal mobilization usually does not involve a neck-cracking sound” (para. 3).
Differentiating Spinal Manipulation Amongst Providers
In a United States-based review (which derived from an analysis of 67 articles and 9 books or textbooks) by Shekelle, Adams, Chassin, Hurwitz, Phillips and Brook (1991, P. 3), the authors stated “A recent analysis of a community-based sample of patients showed that chiropractors delivered 94% of all the manipulative care for which reimbursement was sought, with osteopaths delivering 4%, and general practitioners and orthopedic surgeons accounting for the remainder” (https://www.rand.org/pubs/reports/R4025z1.html).
In other words, DCs perform 94% of All spinal manipulations in the United States while Doctors of Osteopathy (DOs) perform 4% and subsequently, the remaining 2% of spinal manipulations are performed by Physical Therapists (PTs) and Medical Doctors (MDs).
Further, although Zinovy and Funiciello (2018, Sept. 17) reported the general goal of spinal manipulation is “improving the joint’s function, increasing range of motion, and reducing pain” (para. 2), beyond that, the intention of spinal manipulation amongst DCs, DOs and PTs is different. So, what is the difference?
Spinal Manipulation (CSA) According to DCs
In addition to improving joint function, increasing range of motion and reducing pain, spinal manipulation for DCs is about normalizing neuro-biomechanical biomechanical function and reducing neurological irritation to maintain optimal function of the nervous system. Petterman (2007) explained this is known as the Law of the Nerve (p. 168). DC’s more precisely regard spinal manipulation as a specific chiropractic spinal adjustment or chiropractic manipulative treatment (CMT). Andersson, Lucente, Davis, Kappler, Lipton and Leurgans (1999) reported in the New England Journal of Medicine, “The chiropractic approach is focused more on the nervous system and advocates adjustments of the spinal vertebrae to improve neurotransmission” (p. 1426).
Evans (2002), referring to the above images, described the cause of neuro-biomechanical dysfunction due to meniscoid entrapment 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 meniscoid have also been identified as structures capable of creating a painful situation. Bogduk and Jull reviewed the possible role of fibro-adipose meniscoid causing pain purely by creating a tractioning effect on the zygapophyseal joint capsule, again after intra-articular pinching of tissue (p. 252). 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 the 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…
Evans (2002) further added, “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 the neuro-biomechanical lesion, (or vertebral subluxation complex [VSC] as traditionally coined) 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 the lesion 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 the diseased intervertebral disc. The abnormal mechanics of the spine may be due to degenerative changes in 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).
In short, chiropractors primarily use a very specific high-velocity, low-amplitude spinal manipulation/ or a specific chiropractic spinal adjustment to correct the neuro-biomechanical dysfunction and reduce the neurological irritation/interference.
Spinal Manipulation According to DOs
The outcome for DOs is to improve overall blood flow throughout the body. As written by Petterman (2007), this is known as the Law of the Artery (p. 168). This is further supported by Andersson et al., (1999) who wrote, “The focus of osteopathic medicine has been the need to optimize the blood circulation to maintain or restore health” (p. 1426).
Further, DO’s perform non-specific spinal manipulation which they regard as osteopathic manipulative treatment (OMT). According to the American Osteopathic Association, “Through OMT, physicians manually apply a specific amount of pressure to different regions in the body. These techniques can help: Treat structural and tissue abnormalities, relieve joint restriction and misalignment, restore muscle and tissue balance and promote the overall movement of blood flow throughout the body (https://osteopathic.org/what-is-osteopathic-medicine/osteopathic-manipulative-treatment/).
Spinal Manipulation According to PTs
Like DOs, PTs perform non-specific spinal manipulation that is regarded as a unique form of manual therapy that they call thrust joint manipulation (TJM). According to Puentedura, Slaughter, Reilly, Venturan and Young (2017), “Thrust joint manipulation (TJM) is defined as a high-velocity low-amplitude thrust technique which can be distinguished from other joint mobilization techniques that do not utilize a final thrust maneuver” (p. 74).
Historically, in 1920, spinal manipulation was first introduced in Britain to physical therapists by the Osteopathic profession. Paris (2000) reported, “Osteopathic medicine and surgery was founded by Andrew Taylor Still in 1874” (p. 68). Pettman (2007) reported, in 1892, Andrew Still established the American Osteopathic College in Kirksville, Missouri. Conversely, in 1897, DD Palmer opened Palmer College of Cure which is now known as Palmer College of Chiropractic in Davenport Iowa (168).
Pettman (2007) further reported:
“Two of Still’s original students, William Smith and J. Martin Littlejohn, were medical physicians from Scotland. Smith struck a deal with Still that if Still taught him osteopathy, he would teach Still’s students anatomy, greatly enhancing the scientific validity of this emerging profession.
Littlejohn would become the first dean of the College of Osteopathy in Kirksville. He would then go on to found the Chicago College of Osteopathy before returning to Britain and becoming the founder of the British College of Osteopathy in London in 1917.
Despite many frustrating attempts, Littlejohn could never get the English legislature to give osteopathy the same parity with medicine that was enjoyed by his American colleagues. Ironically, instead of behaving antagonistically, he chose to begin educating his fellow physicians and physical therapists in the art and science of spinal manipulation as of 1920.” (p. 169).
Conversely, the development of manipulation to the physical therapy profession in the United States occurred 40 years after being introduced to PTs in Britain in 1920. In a document on the history of manipulative therapy in the United States, Paris (2000) wrote, “Since the 1960s, physical therapists have developed their own body of knowledge in manipulation, emphasizing pain relief and enhanced physical function” (p. 66).
Farrell and Jensen (1992) added, “Physical therapy education has evolved considerably since 1970, when just a few programs included content and skills in "manipulative therapy"” (p. 845). Thus, physical therapists in the United States did not start developing knowledge of manipulation until the 1960s and few US PT programs taught manipulation in 1970.
PT’s Historical Confusion of Manipulation Vs. Mobilization
As already discussed, the development of spinal manipulation for PTs did not begin until the 1960s. Further, PTs did not have standardized terminology for manual therapy and often mobilization and manipulation were used interchangeably. Mintken, DeRosa, Little and Britt (2008) stated, “Seminal documents from noted professional associations and organizations, such as the American Physical Therapy Association, the American Academy of Orthopaedic Manual Physical Therapists, and the International Federation of Orthopaedic Manipulative Therapists, interchange such terms as manual therapy, mobilization, and manipulation with the implication often being that they are synonymous” (p. 51).
Mintken et al., (2008) added, “Physical therapists in particular are not immune to the consequences of this history. John Mennell, MD stated that physical therapists used a confusing array of terms that “cloud the issue by talking about degrees of manipulation using such terms as articulation and mobilization leading up to manipulation.” Such a woeful lack of language specificity ultimately precludes any ability to compare and contrast the intervention or the outcome and minimizes any opportunity to ultimately discern effective from ineffective” (p. 51).
Mintken et al., (2008) continued, “Furthermore, despite Mennell’s caution appearing many years ago, one could argue that the clarity of language concerning manipulation has not improved, but in fact has worsened” (p. 51).
To address this issue Mintken et al., (2008) published their article to standardize manipulation terminology. Mintken et al., (2008) stated, “In February 2007, the American Academy of Orthopaedic Manual Physical Therapists formed a task force to standardize manual therapy terminology, starting with the intervention of manipulation. The ultimate goal of this task force was to create a template that has the potential to be used internationally by the community of physical therapists in order to standardize manual therapy nomenclature” (pg. 50). Thus, you can see that as late as 2007, it was being reported that manipulation and mobilization in the physical therapy profession were still poorly differentiated and the terminology was not standardized.
The Mintken et al., (2008) reported, “The aim of the task force created in February 2007 by the American Academy of Orthopaedic Manual Physical Therapists was to propose a model for standardized terminology to describe manipulative techniques as simply and clearly as possible in language that is understandable to all clinicians, regardless of individual clinical practices or schools of thought” (p. 52-53).
Conclusion
DC’s perform 94% of All spinal manipulations in the United States. Although PTs began learning manipulation in Britain in 1920 through the osteopathic profession, the physical therapy profession did not begin developing spinal manipulation for PTs in the United States until the 1960s and in 1970 few schools included content and skills in manipulation. The purpose of this statement is not to diminish a PT trained to perform non-specific spinal manipulation, but rather to highlight the limited non-specific use and true infancy among PTs in performing spinal manipulation in the US.
Finally, spinal manipulation is kinematically regarded as HVLA and not synonymous with spinal mobilization which is regarded as LVLA. Further, while spinal manipulation acts to improve joint function, increase range of motion, and reduce pain, beyond this, it’s clinical intention is different amongst DCs (CSA: a specific form of spinal manipulation to normalize neuro-biomechanical biomechanical function and removing nerve interference), DOs (OMT: a non-specific form of spinal manipulation with intention on improving blood flow) and PTs (TJM: a non-specific form of spinal manipulation regarded as a unique form of manual therapy).
In part 2 of this series, we will further differentiate spinal manipulation amongst DCs, DOs and PTs and how it is a physician-based service for DCs and DO’s and a form of manual therapy for PTs. Moreover, we will explain in greater depth how spinal manipulation provided by DCs is regarded as specific while among DOs and PTs it is regarded as non-specific. Finally, we will discuss how a DCs intention in performing a specific CSA follow a salutogenic model (what keeps one healthy or well) while the intention of PTs and DOs in performing a non-specific spinal manipulation called TJM or OMT respectfully follows a pathogenic model(what causes disease or makes one ill).
References
Mark Studin DC
William J. Owens DC
John Edwards MD, Neurosurgeon
A report on the scientific literature
Cervical artery dissection (CAD) is a major source of cervical ischemia in all ages, and can lead to various clinical symptoms such as neck pain, headache, Horner’s Syndrome (paresis of the eye) and cranial nerve palsy. An underlying arteriopathy, which is often genetically encoded, is believed to have a role in the development of CAD.1 There have been case studies and low-quality published literature that attempt to link chiropractic care and CAD. This type of reporting often reports dogma and as in this case, is devoid of high-quality standards of scientific examination and lacking a complete set of facts.2
When considering CAD, both the internal carotid and vertebral arteries must be considered. Dissection of one or both can lead to serious complications but can also be asymptomatic. Thrombolytic stroke is typically in the old, while cervical artery dissection causes stroke in young and middle-aged patients. Only 1-2% of ischemic strokes are caused by CAD, but in younger patients, 10-25% are caused by CAD. The overall incidence of CAD is 2.3-5 patients per 100,000; the mean age is 44 years old. CAD is rare beyond 65 years old.3, 4
Although headaches, migraine headaches, minor trauma, neck pain, and inflammatory and connective tissue diseases have been thought to play a role in CAD, patients with CAD (with or without trauma) likely have an underlying arteriopathy, an inflammatory process or structural instability of the arteries that lead to dissection. A biopsy-proven study, Cervical Artery Dissections: A Review, conducted by JJ Robertson and A. Koyfman in 2016, shows structural differences in the arterial walls of patients with spontaneous CAD and in patients who have sustained major trauma and a positive association with dissection and kinking and coiling of the internal carotid artery, which suggests an underlying predisposition.4
In 2001-2002, the number of visits to medical primary care providers and chiropractors in the US and Canada was 10.2 million. Visits to primary care providers accounted for 80% of the total, while visits to chiropractors accounted for 12%. 5
The most prevalent diagnoses in chiropractic care involve neck and back pain. 5,6 And the most common treatment at a chiropractic office is a spinal high-velocity, low-amplitude manipulation, commonly known as a chiropractic spinal adjustment.
A Meta-analysis of 253 articles on chiropractic care and cervical artery dissection by Church, et. Al.,3 3 showed that neck pain and headaches are found in approximately 80% of CAD patients. Neck pain and headaches are also common symptoms in patients with cervical artery dissection. They concluded, “There is no convincing evidence to support a causal link between chiropractic manipulation and cervical arterial dissection.” which is a correlation, but not causally related. The most prevalent co-founder is neck pain and that demographic typically visits a chiropractor. When you consider the association between chiropractic visits vs. medical primary care visits with patients who experienced a CAD, the utilization was similar, yet because chiropractors treat neck pain there appears to be a dogmatic conclusion that chiropractic is the causative factor for dissection despite the lack of evidence.
The evidence, as determined by Church et. Al. is based upon the Grading Recommendation Assessment Development and Evaluation (GRADE) system of rating quality of evidence and grading strength in systematic reviews. Those reviews ranged from high quality of evidence to very low quality of evidence.7
Church et. Al.3 found that the quality of the body of data using the GRADE criteria revealed that it fell within the “very low” category. Also, they found no evidence for a causal link between chiropractic care and CAD. 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. As previously discussed, the most likely potential confounder in this case is neck pain with no causal evidence.
Cassidy et al. (2008) studied the occurrence of vertebral basilar artery (VBA) stroke events in Ontario, Canada over nine years with a database representing almost 110 million person-years (12.2 million people, studied over 9 years, equals 110 million person-years).8 The purpose of this study was to investigate if the rates of VBA stroke, which is sometimes caused by CAD, were higher in patients treated by chiropractors than in those treated by medical primary care doctors. The premise was that if the rate of VBA stroke was higher with chiropractic care, then one could logically say there were a cause and effect relationship between chiropractic care and VBA strokes.
The results were conclusive: There was no greater likelihood of a patient experiencing a stroke following a visit to his/her chiropractor than there was after a visit to his/her primary care physician. Cassidy et al wrote:
“We found no evidence of excess risk of VBA stroke with associated chiropractic care compared to primary care.” Cassidy et al. concluded that overall, 4% of stroke patients had visited a chiropractor within 30 days of a stroke while 53% of stroke patients had visited their medical primary care providers within the same time frame. The authors suggest that because neck pain is a common symptom of CAD, patients visit their doctors with the onset of symptoms, prior to the development of a full-blown stroke scenario. Because the association between VBA stroke and visits to both chiropractic and medical physicians is the same, there appears to be no increased risk of VBA stroke from chiropractic care. In fact, the incident of chiropractic vs. medical care was substantially lower in certain situations based upon the data.8
CONCLUSION
Cervical artery dissection occurs rarely, yet often creates significant adverse outcomes to patients. Unfortunately, there has been a bias in the medical community, incorrectly linking chiropractic care and CAD. But the evidence is mounting that there is no causal relationship between them. With literature bordering on dogma devoid of the facts in high-quality studies. 12.2 million people study over 9 years equaling 110 million person-years conclude no causal relationship doing chiropractic care and cervical artery dissection.
References:
Low-Speed Accidents and Minimal Force Causing Bodily Injury
Patrick Sundby, Accident Investigator
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
Citation: Sundby P., Studin M. (2019) Low-Speed Accidents and Minimal Force Causing Bodily Injury, American Chiropractor 41(7) 44, 46, 48-49
When considering bodily injury, too often rhetoric or false perception “rules the day” in spite of sound conclusions based upon the mathematics in physics. This is commonly seen in Independent Medical Examination, Defense Medical Examination and in the courtroom. When assigning causality in the clinical setting, most doctors experienced in the diagnosis and management of trauma cases have concluded their patient's bodily injuries are directly related to the specific trauma, but don’t have the tools to render an accurate rationale. To demonstrably conclude the transference of forces from the bullet car to the target car and then to the occupant, you must first understand and then apply the principles of the “forces” involved. There are several components to discussing the forces applied to the occupant in a collision and here we will discuss the two most important, the quantity of forces delivered and how the force is applied.
The quantity of the force? What do we mean when we say that? There are a lot of different scales one could use, so we need one which is reasonably universal and applicable. For this we use “g-forces.” G-Force is a relationship to gravity which can be easily quantified to any event of motion. The odds are good you (the reader) are sitting in a chair, the chair exerts a force on you to keep you from falling to the floor, this force is 1 g. You will experience this force for the entire time you are seated, which opens the second part of the discussion – time.
The g-forces you experience are one part of the issue, the time it takes to experience the force is the second part. Imagine flying in a military jet fighter and the pilot banks the plane into a turn. You will experience an increase in force on your body which is related to the angle of the bank and the radius of the turn – most importantly, you will experience this increase in force for as long as the plane stays in that flight path. If the force is 4 g’s and the plane maintains that path of travel for 10 seconds you will experience the force evenly over the 10 seconds. In most of this example the time doesn’t change.[1]
What happens when there is a time change? What happens when that same fighter jet lands on an aircraft carrier and the arresting wire take the plane from 200 miles per hour to zero in less than 4 seconds? The forces that are translated to the human body (what you feel) can be quantified in g-forces. The calculation is not quite as simple as multiplying the g forces against the time, rather we need to know the change in speed over the change in time. For the sake of discussion let’s say the slowest approach speed for the jet fighter landing on the carrier is 100 mph (147 fps) and it takes 4 seconds for the plane to come to a complete stop.
The math looks like this:
Although we commonly say g’s (meaning g force), there is no unit with this number, rather it’s a ratio of force acceleration against gravity (which is also acceleration) and the units divide out leaving us with just the 1.14. If we were in the plane in the scenario above, we would experience 1.14 times the force of gravity, 1.14 g’s.
We can apply this concept to starting to move from a complete stop. If were sitting in traffic, stopped, and we were struck from behind we would go from zero to a certain speed – let say 8 mph (11.76 fps). If the time to be accelerated took .1 or 1/10th of a second, we can also calculate the g-forces experienced by the occupant and then determine the injury potential. (See below)
The provided value of 3.65 g’s (in the calculation below) is the relationship experienced at the seat base and is not the same force experienced at the skull. We know the research shows the cervical spine and the skull experience approximately three times the force of the hip – why?
As the vehicle begins to move and so does the occupant’s hip, the skull however, isn’t moving just yet. After all the “slack” in the lumbar and thoracic spine is used the skull and cervical spine are all that’s left, and it takes time to use the slack in the lumbar and thoracic spine resulting in less time for the cervical spine and skull. As a demonstration of concept – if we said it takes 66% of the 1/10th of a second to load the lumbar and thoracic spine then 33% of the 1/10 is all that is left for the cervical spine and skull. This changes the calculations:
When we divide by 32.2 fps/s, we end up with 12.17 g’s at the cervical spine and skull. Notice this is almost exactly three times the initial 3.65 g’s at the hip.[2]
The graph below visualizes the forces experienced. The orange line is the force experienced at the cervical spine if twice the lumbar, the grey line is the force experienced at the cervical spine if three times the lumbar spine.
Now that we have explored the quantification of forces applied, let's look at how the forces act on humans. Below is a graph which depicts the forces experienced in everyday events as well as the collision we discussed earlier in this writing (8 mph at .1 seconds).
Consider how the forces on the bottom of the slide can act on a human, is coughing a natural act? Why is it then that the cited reference, (Brault et al 1998) can establish injury to the cervical spine and we can quantify that value at almost the same as coughing? By this comparison coughing and a rear-end collision at 2.49 mph should result in almost the same injury every time. Why then are doctors and hospitals everywhere not overrun with patients who have cervical spine injuries from coughing?
The answer is HOW the forces are applied to us! Walking, sneezing, coughing, hopping, sitting in a chair, etc. are actions we, as humans, are biomechanically designed to do. We do these things every day with no negative sequelae. However, when you sit in a vehicle and you are struck from behind nothing about that action mimics an activity which is normal to us. Being accelerated from behind in a short amount of time, such as a car collision, is not a natural action and not something we are designed to do.
When considering traumatic bodily injury to the human spine, advanced knowledge of spinal biomechanical engineering and spinal function at both the global and regional scale is a necessary requirement. Advanced knowledge is inclusive of the resistive forces of connective tissue attachments, bony stabilizing mechanisms and central nervous system (brain) innervation for both the guarding and the compensatory aspects of the body’s response to injury. Additional application of the principles of physics regarding the forces applied to the occupant in trauma, gives the provider a scientific rationale for causation and bodily injury devoid of false perception and rhetoric. The combination of spinal biomechanical engineering knowledge and an understanding of the physics of the forces applied will resolve most questions of fact and provides a demonstrable answer when assigning the cause of bodily injury.
References:
2. Brault J., Wheeler J., Gunter S., Brault E., (1998) Clinical Response of Human Subjects to Rear End Automobile Collisions, Archives of Physical Medicine and Rehabilitation, 79 (1) pgs. 72-80
[1] There is a change at the beginning and end of the maneuver, good for you if you recognized this!
Image Credit: Wikipedia Commons
[2] There are some variances in the results and the graphs, this is a prime example of rounding and/or truncating throughout the calculations.
Chiropractors Reduce Costs by 40% if the 1st Option for Spine
DC’s Would Save the Healthcare System 1.86 Trillion Dollars Over 10 Years
By: Matt Erickson, DC, FSBT
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
A report on the scientific literature
Citation: Erickson M., Studin M (2019) Chiropractors Reduce Costs by 40% if the 1st Option for Spine, American Chiropractor 41(8) 38, 40-43
INTRODUCTION
Currently, our country is facing a health care crisis not only with respect to the opioid epidemic, but also due the fact our health care costs in the US have skyrocketed out of control. According to Centers for Medicare and Medicaid Services (CMS), National Health Expense (NHE) fact sheet (2017), “NHE grew 3.9% to $3.5 trillion in 2017, or $10,739 per person, and accounted for 17.9% of Gross Domestic Product (GDP).” It was also predicted by CMS (2017) that “Under current law, national health spending is projected to grow at an average rate of 5.5 percent per year for 2018-27 and to reach nearly $6.0 trillion by 2027”(https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html).
In a study from data primarily from 2013-2016, Papanicolas, Woskie and Jha (2018) reported, “The United States spends more per capita on health care than any other nation, substantially outpacing even other very high-income countries. However, despite its higher spending, the United States performs poorly in areas such as health care coverage and health outcomes” (p. 1025).
Papanicolas et al., (2018), also stated, “The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations. Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries” (p. 1038). Papanicolas et al., (2018), reported, “Ten high-income countries were selected for comparison” (p. 1025). The ten countries included, “the United Kingdom (consisting of England, Scotland, Wales, and Northern Ireland), Canada, Germany, Australia, Japan, Sweden, France, Denmark, the Netherlands, and Switzerland” (p. 1025).
Singh, Andersson and Watkins-Castillo (2019, para. 1) reported “Lumbar/low back pain and cervical/neck pain are among the most common medical conditions requiring medical care and affecting an individual’s ability to work and manage the daily activities of life. Back pain is the most common physical condition for which patients visit their doctor. In any given year, between 12% and 14% of the United States adult population age 18 and older visit their physician with complaints of back pain. The number of physician visits has increased steadily over the years. In 2013, more than 57.1 million patients visited a physician with a complaint of back pain, compared to 50.6 million in 2010. Also, an unknown number of patients visit a chiropractor or physical therapist for these complaints. Singh et. al (2019, para. 4) further reported, “The estimated annual direct medical cost for all persons with a back-related condition in 2014 dollars was an average of $315 billion per year across the years 2012-2014” (https://www.boneandjointburden.org/fourth-edition/iia0/low-back-and-neck-pain).
According to Cynthia Cox of the Kaiser Family Foundation (2017) reporting on data from 2013, The top five disease-based spending categories (ill-defined conditions, circulatory, musculoskeletal, respiratory, and endocrine) account for half of all medical services spending by disease category. Ill-defined conditions each represent about 13% of overall health spending by disease while circulatory, musculoskeletal, respiratory, and endocrine conditions represent 12%, 10%, 8%, and 7% respectively.” That is to say, musculoskeletal disease represents 10% of the health care expenditures” (https://www.healthsystemtracker.org/chart-collection/much-u-s-spend-treat-different-diseases/#item-top-five-disease-categories-account-roughly-half-medical-service-spending).
The above graphic is from the 2017 Peterson-Kaiser report, “How much does the U.S. spend to treat different disease?”
As neck and back pain in one of the most prevalent issues that present to primary care physician (PCP) offices, considering the current opioid crisis and the associated health care expenditure, particularly related to neck and back pain, this raises the question if Doctors of Chiropractic-who are licensed to manage spinal disorders and comprehensive training in spine care, can not only provide similar or better outcomes and greater or equivalent satisfaction among patients, but provide care in a more cost effective manner, as well as help to unburden the already overloaded primary care practices considering the trending shortage of PCPs in our health care delivery system?
THE EVIDENCE
In an article by Houweling, Braga, Hausheer, Vogelsang, Peterson and Humphreys (2015), the authors reported on first-contact care with a medical vs. a chiropractic provider after a consultation with a Swiss telemedicine provider. The study looked to compare outcomes, patients satisfisfaction and health care costs in spinal, hip and shoulder pain patients.
Houweling et al., (2019), reported that “Pain of musculoskeletal origin represents a major health problem worldwide. In a Swiss survey conducted in 2007, back pain was a commonly reported health problem, with 43% of the population experiencing this complaint over the course of a year. Of these, 33% reported that their symptoms led to reduced productivity at work. The burden of musculoskeletal conditions on the Swiss health care system is equally staggering, with health care expenditure resulting from this condition being estimated at 14 billion Swiss Francs (CHF) per year (US $14 billion) or 3.2% of the gross domestic product” (p. 478-479).
The study by Houweling et al., (2019), also showed that spinal, hip, and shoulder pain patients had modestly higher pain relief and satisfaction with care at lower overall cost if they initiated care with DCs, when compared with those who initiated care with MDs” (p. 480). Houweling et al., further added, “Although the differences in pain relief scores between groups were statistically significant, they were likely not of clinical significance.” (p. 480). Houweling et al., explained the reason for this was, “the extent of the differences in pain relief observed might be too small for patients to notice a clinically meaningful difference” (p. 480).
With respect to patient satisfaction Houweling et al., (2019), reported, “The findings of this study pertaining to patient satisfaction were in line with previous research comparing chiropractic care to medical care for back pain, which found that chiropractic patients are typically more satisfied with the services received than medical patients” (p. 481). Houweling et al., added, “The Mean total spinal, hip, and shoulder pain-related health care costs per patient during the 4-month study period were approximately 40% lower in patients initially consulting DCs compared with those initially consulting MDs. The reason for this difference was a lower use of health care services other than first-contact care in patients initially consulting DCs compared with those initially consulting MDs” (p. 481).
Thus, Houweling et al., (2019) concluded, “The findings of this study support first-contact care provided by DCs as an alternative to first-contact care provided by MDs for a select number of musculoskeletal conditions” (p. 481). The authors also noted, “In addition to potentially reducing health care costs, direct access to chiropractic care may ease the workload on MDs, particularly in areas with poor medical coverage and hence enabling them to focus on complex cases. The minority of patients with complex health problems initially consulting a chiropractic provider would be referred to, or comanaged with, a medical provider to provide optimal care” (p. 481).
CONCLUSION
In conclusion, health care cost has skyrocketed out of control with the prediction the US expenditures will reach 6 trillion by 2027. Considering neck and back pain expenditures in between 2012-2014 averaged $315 billion annually and total health care costs in 2017 were $3.5 trillion, this means approximately 10% of health care expenditures annually are for neck and back pain which is supported by the Peterson-Kaiser Health Tracker System report. Moreover, considering the estimated health costs are predicted to be $6 trillion by 2027, if the expenditure for neck and back pain remained on par at 10% that means the cost of neck and back pain in would increase to around $600 billion over that time frame.
Considering in the Houweling et al., that by using doctors of chiropractic as a first-line provider for spine, hip and shoulder pain, it demonstrated a 40% reduction in costs, that means in 2027, if DCs were first-line providers, it is estimated this could save the health care delivery system $240 BILLION DOLLARS in one year alone (just for neck and back pain). If one considers the prediction of 5.5% annual expenditure increase, that means the estimated total expenditure for neck and back pain between 2018-2027 would be $4.65 trillion dollars. If having DCs as a first-line provider were to save 40% in costs, that would translate into saving $1.86 TRILLION DOLLARS. If that was applied to the predicted 2027 neck and back pain expenditure, that number would represent a 32% savings in that year. Given our skyrocketing health care costs, that would represent a significant savings!
Further, if we consider from the study, there was a modestly higher pain relief and ever greater patient satisfaction reported, when you factor in the predicted PCP shortage, having the ability for DCs to serve as a first-line provider, not only can it help unburden the already overloaded PCPs, but doing so would have a significant financial impact in lowering health care expenditures. All things considered, it is time our decision makers take a serious look at improving access to Doctors of Chiropractic so they may serve as first-line providers for the management of all spine and even hip and shoulder related disorders.
REFERENCES
The Chiropractic Adjustment Changes Brain Function
The Evidence of Increased Muscle Strength is Added to Pain Sensitivity and Autonomic Changes
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
William J. Owens DC, DAAMLP
Matt Erickson DC, FSBT
A report on the scientific literature
There is a growing body of evidence that a high-velocity, low-amplitude (HVLA) chiropractic spinal adjustment (CSA) has a significant influence on cortical (brain) and other central (cord) changes. This is significant as the evidence is now answering more questions on why has chiropractic has had such a profound effect on a myriad of conditions beyond back pain. Technology, including but not limited to functional MRI, NCV, EEG and sEMG renders demonstrable validation of the effect the chiropractic spinal adjustment has on changes in central function.
A chiropractic spinal manipulation/adjustment is a specific HVLA thrust maneuver designed to correct spinal patho-neuro-biomechanics (remove nerve irritation/interference, restore biomechanical balance), increases important proteins such as Substance P (Evans 2002) and makes plastic changes to the central nervous system. Conversely, a spinal manipulation as manual therapy or thrust joint manipulation (TJM) performed by physical therapists (PT’s) is a generalized non-specific low-velocity, low-amplitude of non-specific HVLA thrust maneuver of joints and connective tissue to improve motion and decrease muscle tension.
Essentially, the intent of TJM is in treating pain and dysfunction. That is not to say a non-specific manipulation will not help a patient. However, when spinal manipulation is not performed as a chiropractic based neuro-biomechanical corrective adjustment or from a salutogenic health management perspective, it is something else entirely. Therefore, spinal manipulation as a chiropractic adjustment delivered by a chiropractor is not synonymous with TJM, mobilization or spinal manipulation delivered by a PT.
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 (chiropractic HVLA) 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)
Reed et al. (2014) also reported, The finding that only the higher intensity manipulative stimulus (ie, 85% BW [body weight] vs 55% BW or control) decreased the mechanical sensitivity of lateral thalamic neurons to mechanical trunk stimulation coincides with other reports relating graded mechanical or electrical stimulus intensity to the magnitude of central inhibition. Several clinical studies indicate that spinal manipulation [chiropractic spinal adjustment] alters central processing of mechanical stimuli evidenced by increased pressure pain thresholds and decreased pain sensitivity in asymptomatic and symptomatic subjects following manipulation. (p. 282)
Daligadu, Haavik, Yielder, Baarbe, and Murphy (2013) reported, There is also evidence in the literature to suggest that muscle impairment occurs early in the history of onset of spinal complaints, and that such muscle impairment does not automatically resolve even when pain symptoms improve. This has led some authors to suggest that the deficits in proprioception and motor control, rather than the pain itself, may be the main factors defining the clinical picture and chronicity of various chronic pain conditions. Furthermore, recent evidence has demonstrated that spinal manipulation (CSA) can alter neuromuscular and proprioceptive function in patients with neck and back pain as well as in asymptomatic participants. For instance, cervical spine manipulation (CSA) has been shown to produce greater changes in pressure pain threshold in lateral epicondylalgia than thoracic manipulation; and in asymptomatic patients, lumbar spine manipulation (CSA) was found to significantly influence corticospinal and spinal reflex excitability. Interestingly, Soon et al did not find neurophysiological changes following mobilization on motor function and pressure pain threshold in asymptomatic individuals, perhaps suggesting that manipulation [chiropractic spinal adjustments], as distinct from mobilization, induces unique physiological changes. There is also accumulating evidence to suggest that chiropractic manipulation can result in changes to central nervous system function including reflex excitability, cognitive processing, sensory processing, and motor output. There is also evidence in SCNP [sub-clinical neck pain] individuals that chiropractic manipulation alters cortical somatosensory processing and elbow joint position sense. This evidence suggests that chiropractic manipulation may have a positive neuromodulatory effect on the central nervous system, and this may play a role in the effect it has in the treatment of neck pain. It is hoped improving our understanding of the neurophysiological mechanisms that may precede the development of chronic neck pain in individuals with sub-clinical neck pain (SCNP) will help provide a neurophysiological marker of altered sensory processing that could help determine if an individual is showing evidence of disordered sensorimotor integration and thus might benefit from early intervention to prevent the progression of SCNP into more long-term pain states. (p. 528)
Christriansen, Niazi, Holt, Nedergaard, Duehr, Allen, Marshall, Turker and Haarvik (2018) discussed the effects of a single session of a chiropractic spinal manipulation (CSA) on strength and cortical drive. They studied the effects upwards of 60 minutes and further testing is needed to determine the long-term effects of the adjustment. They found in “blinded studies” that “the increased maximum voluntary contraction force lasted for 30 min and the corticospinal excitability increase persisted for at least 60 minutes.” (pg. 737)
Christiansen et. Al (2018) also reported, “The increased V-wave amplitudes observed in the current study possibly reflect an increased cortical drive in the corticospinal pathways and corresponding increased excitability of the MNs following SM found differences in the cortical drive in volleyball athletes competing at different levels, and argued that elite players had increased cortical drive correlating to their biomechanical performance. The absence of change in the H-reflex in the presence of the increased MVC along with increased V-waves suggests that it's possible that the change post manipulation occurred at supraspinal centers involving a cortical neural drive. The V-waves represent cortical drive. The absence of change in the H-reflex alone suggests that the spinal motor neurons and the excitability of the spindle primary afferent synapses on the spinal motor neurons did not change as a result of SM.” (pg. 745) The above paragraph indicates there is no input at the cord level as the H-Reflex exhibited no changes.
Increased motor function for a minimum of 60 minutes post-chiropractic spinal adjustment has far-reaching manifestations for a dichotomy of the population. Athletes at every level will benefit from increased motor function and patients suffering from either muscular or neuro-degenerative illnesses, such as Parkinson’s, Amyotrophic lateral sclerosis (ALS), Muscular Dystrophy and others will also potentially benefit. Although this article touched on PT manual therapy, low-velocity, low-amplitude or non-specific thrust joint manipulation; these forms of treatment do not render the outcomes a chiropractic spinal adjustment.
Christiansen et. Al (2018) concluded and perfectly positioned the effect of a chiropractic spinal adjustment and the effect on the brain, “this study supports a growing body of research that suggests chiropractic spinal manipulation’s main effect is neuroplastic in nature and affects corticospinal excitability. Changes in both cerebellum and prefrontal cortex function have been implicated post-spinal manipulation in previous research studies. The presence of mild, recurrent spinal dysfunction has been shown to be associated with maladaptive neural plastic changes, such as alterations in elbow joint position sense mental rotation ability, and even multisensory integration Furthermore, spinal manipulation of dysfunctional spinal segments has been shown to impact somatosensory processing, sensorimotor integration and motor control.” (pg. 746)
References:
Traumatic Myelomalacia
Diagnosis & Collaborative Management Between the Chiropractor as the Primary Spine Care Provider and the Neurosurgeon
By: Matt Erickson DC, FSBT
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
John Edwards MD, Neurosurgeon
Clay Wickiser DC
Introduction
Myelomalacia is defined as softening of the spinal cord and can be a result of injury and represents a serious and potentially life-threatening sequella to injury if not treated. According to Zhou, Kim, Vo and Riew (2015), “Cervical myelomalacia is a relatively uncommon finding on MRI, with anoverall prevalence of 4.2% among all patients who underwent cervical MRI. Males had a higher prevalence (5.6%) than the females (3.0%).” (pg. E250)
Zhou et al., (2015) also reported, “There were considerable variations in the prevalence of myelomalacia in patients referred by different specialties/subspecialties. Specialists in spinal cord injury had the highest rate (28.7%), followed by neurological (8.4%) and orthopedic (6.4%) spine surgeons, general neurosurgeons (5.5%), and neurologists (4.2%). Specialists who generally do not treat patients with spine problems had the lowest (1.2%) followed by non-spine orthopedists (1.6%) and primary care doctors (2.1%)” (p. E248).
Platt, McConnel and Bestbier (2006) reported, “Myelomalacia is ischemic or hemorrhagic necrosis of the spinal cord that can occur following acute spinal cord injury, and represents extensive damage of the intramedullary spinal vasculature” (pg. 78). According to Lu, Lamb and Targett (2002), “In small animal neurology, the term myelomalacia … is normally used to refer to hemorrhagic infarction of the spinal cord that can occur as a sequel to acute injuries, such as that caused by intervertebral disc extrusion. Myelomalacia may occur as a focal lesion or may spread cranially and caudally along the spinal cord, resulting in a diffuse, severe lesion. Histologic lesions of myelomalacia are compatible with ischemic necrosis” (pg. 326).
According to a website article titled, “Myelomalacia” by Foster and Wilborn (2019), “Myelomalacia is a medical condition in which the spinal cord becomes soft. It is caused by the insufficient blood supply to the spinal cord, either as a result of bleeding or because of poor circulation. Myelomalacia most often occurs as a result of the injury” (www.wisegeek.com/what-is-myelomalacia.htm). Foster and Wilborn (2019) added, “Caused by mild to severe spinal cord injury, myelomalacia leads to neurological problems, often related to muscle movement. Often, the onset of the condition is slow and subtle, making it difficult for doctors to catch at an early stage. The condition may present simply as high blood pressure, for example, and may not be diagnosed until after the point at which it has become inoperable. While symptoms vary, they may include loss of motor function in the lower extremities, sudden jerking of the limbs, an inability to sense pain, depression, difficulty breathing, and paralysis. The damage can migrate towards the brain in a condition known as ascending syndrome. Myelomalacia can be fatal if it causes paralysis of the respiratory system (para. 2-3).
Platt, McConnel and Bestbier (2006) also reported, “The exact pathophysiology is poorly understood but it seems to be the result of the concussive effects of trauma, ischemia, and the release of vasoactive substances, oxygen-free radicals and cellular enzymes. When the spinal cord is acutely damaged, cell death in the gray matter may occur within 4 hours, with this area of necrosis expanding for a few days” (pg. 78). This means that many patients can have significant underlying progressive pathology with symptoms that have not yet fully expressed themselves, but the evidence is demonstrative to the trained expert. This further supports the necessity and importance of having a primary spine care provider with trauma qualifications to diagnose the issue early on and coordinate care with the neurosurgeon.
Operative Neurosurgery, “Myelomalacia” (administrator updated) (2018, para. 4), explained, “Gradual cranial migration of the neurological deficits (problems relating to the nervous system), is known as ascending syndrome and is said to be a typical feature of diffuse myelomalacia. Although clinical signs of myelomalacia are observed within the onset (start) of paraplegia, sometimes they may become evident only in the post-operative period, or even days after the onset of paraplegia. Death from myelomalacia may occur as a result of respiratory paralysis when the ascending lesion (abnormal damaged tissue) reaches the motor nuclei of the phrenic nerves (nerves between the C3-C5 region of the spine) in the cervical (neck) region” (https://operativeneurosurgery.com/doku.php?id=myelomalacia).
As such, it is imperative for there to be collaborative case management between the primary spine care expert and the neurosurgeon. The role of the primary spine care provider is an early diagnosis to be able to identify, treat and involve the neurosurgeon when clinically indicated because if left undiagnosed and untreated, myelomalacia can become a seriously debilitating and/or life-threatening injury. Those injuries are from and trauma the spinal cord is exposed to (auto accidents, sports injuries, falls, etc.). Currently, there is a growing body of chiropractors nationally that are primary spine care and trauma qualified and trained in the early detection (diagnosis) and management of this population of patients.
Diagnosis
According to Zohrabian and Flanders, Chapter 37: Imaging of trauma of the spine from the Handbook of Clinical Neurology Part II, “MRI is the only available imaging modality that is able to clearly depict the internal architecture of the spine cord, and, as such, has a central role in depicting parenchymal changes resulting from injury” (pg. 760). Further, “It may be difficult to distinguish spinal cord white matter from gray matter, especially in the sagittal plane, due to the similar T1 and T2 relaxation characteristics. Many prior investigations have shown that MRI characteristics of (SCI) Spinal Cord Injury, including presence and extent of cord edema and hemorrhage, are concordant with neurologic impairment at the time of injury and predict recovery” (pg.760).
Zohrabian and Flanders also wrote, “The most common location of posttraumatic spinal cord hemorrhage is the central gray matter of the spinal cord at the point of mechanical impact. The lesion most often represents hemorrhagic necrosis; true hematomyelia is rarely encountered. The lesion appears as a discrete focus of hypointensity on T2-weighted and gradient echo images, developing rapidly after SCI” (pg.760).
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Zohrabian and Flanders (2016) stated, “Moreover, the location of cord hemorrhage has been shown to closely correspond to the neurologic level of injury, with frank hemorrhage correlation with poor neurologic recovery” (p. 760).
Zohrabian and Flanders (2016) further added, “Although several MRI classification schemes have been proposed, there are three common imaging observations: spinal cord hemorrhage, spinal cord edema, and spinal cord swelling. Each of these characteristics can be further described by their rostra-caudal (top to bottom) location in the cord and the amount of cord parenchyma they involve” (p. 760).
“Spinal cord edema, colloquially referred to as a cord contusion, can occur with or without hemorrhage. Edema involves a length of the spinal cord above and below the level of injury, with the length of the spinal cord show to be proportional to the degree of initial neurologic deficit. Spinal cord hemorrhage always coexists with spinal cord edema. Cord edema alone usually confers a more favorable prognosis that cord hemorrhage” (pg. 761).
According to D.J. Seidenwurm MD (for the Expert Panel on Neurologic Imaging), “In traumatic myelopathy, the first priority is mechanical stability. Plain radiographs are sometimes useful for this purpose, but CT is more useful when a high probability of bony injury or ligamentous injury is present. In many centers, routine multidetector CT with sagittal and coronal reconstructions has replaced plain radiographs, especially in the setting of multiple trauma” (pg. 1032).
Concerning CT, Foster and Wilborn (2019) reported, “Myelography uses a contrast medium injected into the spine to reveal injuries in x-rays. It is more invasive than an MRI, but can also detect injury in some cases in which MRI cannot. Therefore, myelography is typically used as a follow up to MRI when the latter fails to identify the source of pain or injury.” (para. 4)Finally, Zohrabian and Flanders reported, “Unlike in spinal cord cysts, myelomalacia will not parallel CSF (cerebral spinal fluid) signal intensity and its margins will usually be irregular and ill-defined (Falcone et al., 1994). The cord may be normal in size, although it is frequently atrophic at the site of myelomalacia (Fig. 37.24).” (pg. 763)
Zhou, Kim and Vo (2015) further explain, “Myelomalacia is a radiographical finding on magnetic resonance imaging (MRI) manifested by an ill-defined area of cord signal change, visible on T1- and T2-weighted sequences as hypo- and hyperintense areas, respectively. It is commonly associated with focal cord atrophy. It occurs as a sequel to spinal cord injury (SCI) due to different causes such as cord compression, ischemia, and hemorrhage. It is the most common finding in patients with previous spinal cord injury with a prevalence of 55% among patients with SCI” (p. E248).
Management
Due to the seriousness and progressive nature of myelomalacia, it is important for the Primary Spine Care Provider, to recognize the signs and symptoms associated with myelomalacia and to identify the lesion on MRI and if identified, immediately refer the patient for a neurosurgical consultation. This also underscores why physical therapists, although licensed to treat spine, should never be the first provider to manage a spine case as diagnosing these and other conditions are not within their scope.
Foster and Wilborn (2019, para. 5) also reported, “Unfortunately, neurological damage due to myelomalacia is permanent. It can also worsen, as the nerve damage can cause affected muscles to whither. Treatment is focused on preventing further damage. Possible treatments include spinal cord surgery and medication with steroids, which serves to relax spastic muscles, reduce pain, and reduce swelling of the spinal cord.” Foster and Wilborn (2019, para. 6) also suggested, “Stem cell therapy may be used to repair neurological damage caused by myelomalacia in the future, but the therapy is currently experimental and controversial. Recent technology suggests that adult stem cells, which can be harvested from the patient's own body, show promise in treating neurological damage by allowing new, healthy tissue to grow”(www.wisegeek.com/what-is-myelomalacia.htm).
Zhou, Kim, Vo and Riew (2015) reported, “The presence of myelomalacia in the cervical spinal cord has prognostic value after decompression surgery. Some surgeons consider operative treatment of all patients with myelomalacia based on the assumption that myelomalacia is a relatively uncommon finding.” (p. E248) The authors also reported, “Many patients with myelomalacia are clinically asymptomatic or have only mild myelopathic symptoms and signs. The extent of intramedullary changes on MRI does not always correlate with clinical symptoms. Hence, for patients with asymptomatic or mild myelopathy with myelomalacia on MRI, the appropriate management remains controversial” (p. E249).
Zhou et al (2015) further added, “Several articles have suggested that conservative management is not an unreasonable option for patients with myelomalacia and mild myelopathy. It has been reported that the condition of 56% of patients with mild CSM (cervical spine myelomalacia) had not deteriorated or required surgery after 10 years. However, 2 of 45 (4.4%) patients who were treated nonoperatively with T2 hyperintensities experienced catastrophic neurological deficits with trivial trauma. Early-stage myelomalacia may be reversible, depending on the severity of the initial SCI (spinal cord injury), and may be reversed after decompression surgery” (p. E249).
This is not suggesting surgery for myelomalacia is always required. According to Dr. Mark Kotter (n.d., para. 3) in a website article titled “Myelomalacia” from myelopathy.org,“The presence or absence of myelomalacia should not be used to define when surgery should occur.” Although he further stated, “its presence and extent may be related to prognosis” (http://www.myelopathy.org/myelomalacia.html). Myelomalacia, like any spinal related injury never uses imaging findings exclusively as an arbiter for surgery. That decision is reserved for combining a clinical examination with imaging findings and the surgeon decides if surgery will benefit the patient. It is the role of the primary spine care provider to ensure and early diagnosis and referral to try to develop treatment protocols to surgically decompress the spinal cord to help reverse this pathology and often can be done if damage has been minimized.
Surgery for Myelomalacia
A patient with myelomalacia may require surgery to decompress the spinal cord. Different techniques are used depending on the pathology that may or may not include spinal fusion. Many patients are treated with an anterior approach. The offending material is removed and the spine is reconstructed either with a fusion or an artificial disc replacement. Some patients, especially with multilevel pathology, require posterior decompression with or without fusion.
The primary goal of surgery for myelomalacia is to decompress the spinal cord. Secondary goals include maintaining spinal structural integrity, alignment, and biomechanical function.
The image on the left is courtesy of Jed Weber MD, Neurosurgeon. You can see the severe spinal cord compression creating an hour glass affect secondary to a disc extrusion. Myelomalacia is also present as a white spot in the spinal cord at the compression site.
Biomechanical Management
Concerning surgically balancing the spine, sagittal (front to back) balance is associated with better post-surgical outcomes. Healia.com reported on lectures by Serena Hu, MD, Jean Charles LeHuec, MD, PhD and J.N. Alastair Gibson, MD, FRCS(Ed), FRCS (Tr &Orth), MFSTEd related to outcomes of lumbar spine surgery about sagittal balance. According to Dr. Hu (2016, para 3), “Surgical outcomes for spine surgery are improved when spinal, pelvic and hip alignment is considered in both degenerate and deformity cases, and how we better understand these will help us better improve outcomes for our patients” (https://www.healio.com/spine-surgery/lumbar/news/print/spine-surgery-today/%7B54ac5ca2-7939-407d-96a5-31fa9c0fc904%7D/proper-sagittal-balance-may-correlate-with-better-surgical-outcomes).
Dr. Hu (2016) further reported, “Sagittal imbalance in a patient can negatively affect the outcomes of a surgical procedure. But, how extensive the surgery required is to correct the imbalance must be carefully considered for the individual patient” (para. 4). Dr. LeHuec (2016) added, “Sagittal balance is an active phenomenon for patients. “The best course of action is to strive to achieve sagittal balance in patients” (para. 8).
In a study by
In an article by Yeh, Lee, Chen, Yu, Liu, Peng, Wang, and Wu, (2018) they concluded, “The results of this study support previous findings that functional outcomes are closely associated with sagittal radiographic parameters in the patients with the degenerative thoracolumbar spinal disease who received long-segment fusion. The achievement of global and regional sagittal alignment balance is a crucial factor for improved postoperative functional outcomes” (p. 1361).
The primary care spine provider and the neurosurgeon can work together to best achieve spinal alignment and balance. If the patient has been cleared for mechanical treatment, the primary care spine provider can work to balance the spine (front to back and side to side) before any necessary surgical intervention. The neurosurgeon can work to maintain and improve spinal alignment with surgery. Post-operatively, ongoing chiropractic spinal adjustments can help maintain and continue to improve spinal alignment. This can lead to the best possible surgical outcomes.
Patients with myelomalacia present an ideal opportunity to further the relationship between the Doctor of Chiropractic as the primary care spine provider and the neurosurgeon. The finding of myelomalacia requires surgical consultation. If the chiropractor identifies myelomalacia, he or she can then refer to the neurosurgeon and begin the discussion necessary for further co-management. The chiropractor can ask if surgery is necessary. If so, the Doctor of Chiropractic can ask if mechanical treatment can be done pre-operatively or ask if it should wait until after surgery. If the patient needs close monitoring over time, the astute chiropractor can regularly check on and provide education to the patient under the direction of the neurosurgeon.
In patients with myelomalacia, the ability of the Doctor of Chiropractic to monitor symptoms, prepare a patient for surgery, and manage the spine mechanically after surgery are advantageous to the surgeon, who can spend more of their time performing surgery and also enjoy greater patient satisfaction and outcomes.
Conclusion
Myelomalacia represents a softening of the spinal cord that commonly results from trauma. If myelomalacia is observed on imaging, the advanced trained Doctor of Chiropractic in the capacity of a primary spine care provider, should refer the patient out for a neurosurgical consultation. In the event surgery is not indicated, the chiropractor can create a treatment plan with the surgeon to help axially balance and stabilized the spine, thereby reducing the compressive forces on the spinal cord and maintaining spinal mechanics. If surgery is required, the chiropractor can coordinate conservative care with the surgeon to help biomechanically balance and then manage the patient’s spine to promote a better long term post-surgical outcome. Whether surgical or not, the chiropractor can play an integral role in the patient’s car and should the chiropractor have additional training in MRI Spine Interpretation, Spinal Biomechanical Engineering and/or other advanced spinal knowledge, it provides the basis for better collaboration.
References
Preventing Spinal Degeneration Through Chiropractic Care
Subluxation Degeneration/Spondylosis Explained via Wolff’s Law
Mark Studin
William Owens
Spondylosis, also known as osteoarthritis of the spine, is rarely appreciated as one of the most sigificant causes of persistent pain and disability in the world today. This form of arthropathy is so universal that it is often regarded as part of the “normal” aging process. “Osteoarthritis is usually progressive and often deforming and disabling” as reported by Gottlieb (1997). “Up to 50% of individuals will experience arthritic back pain at some point in their lives. Despite its high prevalence, there exists limited information (albeit through allopathic medicine) available regarding the factors associated with the development of lumbar spine degeneration” as reported by Weinberg, Liu, Xie, Morris, Gebhart and Gordon (2017). The projected number of older adults with arthritis or other chronic musculoskeletal joint symptoms is expected to nearly double from 21.4 million in 2005 to 41.1 million by 2030 in the United States. The assumption is so will the progression of persistent pain and disability. We see that allopathic medicine has little information to help reduce the progression of this disease process, which is why chiropractic is the only true solution since we view the body from a mechanical perspective. It is the maintenance of the mechanical workings of the spine that is the real approach to preventing degenerative “wear and tear” of the human spine.
Weinberg et. Al (2017) continued by reporting “Certain mechanical causes have been implicated in the development of degenerative joint disease of the lumbar spine, including lumbar lordosis, the length of the transverse processes, disc-space narrowing, and traction spurs. Lately, authors have begun investigating the roles of facet orientation, tropism, and pelvic incidence, although data remains limited. It has recently been suggested that the relationships between pelvic incidence and facet orientation may have profound implications in the development of adjacent segment lumbar degenerative joint disease—this has sparked enthusiastic research better defining the role of sagittal balance in osteoarthritis formation.” Pg. 1593
When we consider spinal osteoarthritis, we must compare normal spinal biomechanics and loading vs. abnormal spinal biomechanics and pathological loading that results. Teichtahl, Wluka, Wijethilake, Wang, Ghasem-Zadeh and Cicuttini (2015) reported “Julius Wolff (1836–1902), a German anatomist and surgeon, theorized that bone will adapt to the repeated loads under which it is placed. He proposed that, if the load to a bone increases, remodeling will occur so that the bone is better equipped to resist such loads. Likewise, he hypothesized that, if the load to a bone decreases, homeostatic mechanisms will shift toward a catabolic state, and bone will be equipped to withstand only the loads to which it is subjected.” Pg. 2
“It is now recognized that remodeling of bone in response to a load occurs via sophisticated mechano-transduction mechanisms. These are processes whereby mechanical signals are converted via cellular signaling to biochemical responses. The key steps involved in these processes include mechano-coupling, biochemical coupling, signal transmission, and cell response.” Pg. 1
“Bone is a dynamic tissue that is tightly regulated by a multitude of homeostatic controls. One key environmental regulator of periarticular bone is mechanical stimulation. Wolff’s law relates to the response of bone to mechanical stimulation and states that bony adaptation will occur in response to a repeated load. It is interesting to consider this in the setting of knee OA, which has a strong biomechanical component to its etiology.” Pg. 1
“When periarticular bone is subjected to increased loading, some bone properties change. These include, but are not limited to, an expanding subchondral bone cross-sectional area, changes in bone mass, and remodeling of the trabeculae network. Although these changes likely represent appropriate homeostatic responses of bone to increased loading, they also appear to inadvertently predate maladaptive responses in other articular structures, most notably cartilage.” Pg. 1
Keorochana, Taghavi, Lee, Yoo, Liao, Fei and Wang reported (2011) “Differences in sagittal spinal alignment between normal subjects and those with low back pain have been reported. Previous studies have demonstrated that changes in sagittal spinal alignment are involved in the development of a spectrum of spinal disorders. It has also been a topic of great interest in the management of lumbar degenerative pathologies, especially when focusing on the role it may play in accelerating adjacent degeneration after spinal fusion and non-fusion procedures such as dynamic stabilization and total disc replacement. Spinal morphology may influence the loading and stresses that act on spinal structures. Alterations in the stress distribution may ultimately influence the occurrence of spinal degeneration. Moreover, changes in sagittal morphology may alter the mechanics of the lumbar spine, affecting mobility.” Pg. 893
Panjabi (2006) reported:
Cramer et al. (2002) reported “One component of spinal dysfunction treated by chiropractors has been described as the development of adhesions in the zygapophysial (Z) joints after hypomobility. This hypomobility may be the result of injury, inactivity, or repetitive asymmetrical movements…one beneficial effect of spinal manipulation may be the “breaking up” of putative fibrous adhesions that develop in hypomobile or “fixed” Z joints. Spinal adjusting of the lumbar region is thought to separate or gap the articular surfaces of the Z joints. Theoretically, gapping breaks up adhesions, thus helping the motion segment reestablish a physiologic range of motion.” (p. 2459)
Evans (2002) reported “On flexion of the lumbar spine, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with it. 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: a meniscoid entrapment. 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. The 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.” Pg. 252
The sagittal spinal misalignments developed after hypo or hypermobility as a result of injury, inactivity, or repetitive asymmetrical movements as reported Cramer, creates mechanoreceptor and nociceptor pathological input, this in turn as reported by Evans creates a mechanical displacement of the zygapophyseal joint and aberrant stimulation to type III and IV nociceptors. This also, according to Panjabi causes a corrupting of neuromuscular transducers (mechanoreceptors and nociceptors) of the spinal muscular system. These combine to create spinal neuro-pathobiomechanics for the spine globally and at each affected motor unit. This is what has been historically called in chiropractic “vertebral subluxation.“ Based upon Wolff’s Law, the persistent biomechanical failure, as perpetuated by the central nervous system being corrupted and attempting to compensate through muscular activity creates premature degeneration of the spine or osteoarthritis or “Subluxation Degeneration.”
Evans (2002) concluded that a high velocity-low amplitude manipulation (chiropractic spinal adjustment) 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 and realignment of the joint.” Pg. 253 This activity reduced the irritation or pressure on the nociceptors on the zygapophyseal joints stopping the corruption of the central nervous system and allowing the body to “right itself” and halt the degenerative process of the spine.
It has already been concluded, as reported by 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 the 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. By 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.
Considering that 50% of the population will experience some type of pain and/or potential disability as a result of spinal arthritis, chiropractic, as reported above is positioned as the best first option for spine as an evidence-based solution. This is called Primary Spine Care and chiropractic is best positioned to lead society in the prevention of osteoarthritis/subluxation degeneration through chiropractic care.
References
Preventing Spinal Degeneration Through Chiropractic Care
Subluxation Degeneration/Spondylosis Explained via Wolff’s Law
Mark Studin
William Owens
Spondylosis, also known as osteoarthritis of the spine, is rarely appreciated as one of the most sigificant causes of persistnet pain and disability in the world today. This form of arthropathy is so universal that it is often regarded as part of the “normal” aging process. “Osteoarthritis is usually progressive and often deforming and disabling” as reported by Gottlieb (1997). “Up to 50% of individuals will experience arthritic back pain at some point in their lives. Despite its high prevalence, there exists limited information (albeit through allopathic medicine) available regarding the factors associated with the development of lumbar spine degeneration” as reported by Weinberg, Liu, Xie, Morris, Gebhart and Gordon (2017). The projected number of older adults with arthritis or other chronic musculoskeletal joint symptoms is expected to nearly double from 21.4 million in 2005 to 41.1 million by 2030 in the United States. The assumption is so will the progression of persistent pain and disability. We see that allopathic medicine has little information to help reduce the progression of this disease process, which is why chiropractic is the only true solution since we view the body from a mechanical perspective. It is the maintenance of the mechanical workings of the spine that is the real approach to preventing degenerative “wear and tear” of the human spine.
Weinberg et. Al (2017) continued by reporting “Certain mechanical causes have been implicated in the development of degenerative joint disease of the lumbar spine, including lumbar lordosis, the length of the transverse processes, disc-space narrowing, and traction spurs. Lately, authors have begun investigating the roles of facet orientation, tropism, and pelvic incidence, although data remains limited. It has recently been suggested that the relationships between pelvic incidence and facet orientation may have profound implications in the development of adjacent segment lumbar degenerative joint disease—this has sparked enthusiastic research better defining the role of sagittal balance in osteoarthritis formation.” Pg. 1593
When we consider spinal osteoarthritis, we must compare normal spinal biomechanics and loading vs. abnormal spinal biomechanics and pathological loading that results. Teichtahl, Wluka, Wijethilake, Wang, Ghasem-Zadeh and Cicuttini (2015) reported “Julius Wolff (1836–1902), a German anatomist and surgeon, theorized that bone will adapt to the repeated loads under which it is placed. He proposed that, if the load to a bone increases, remodeling will occur so that the bone is better equipped to resist such loads. Likewise, he hypothesized that, if the load to a bone decreases, homeostatic mechanisms will shift toward a catabolic state, and bone will be equipped to withstand only the loads to which it is subjected.” Pg. 2
“It is now recognized that remodeling of bone in response to a load occurs via sophisticated mechano-transduction mechanisms. These are processes whereby mechanical signals are converted via cellular signaling to biochemical responses. The key steps involved in these processes include mechano-coupling, biochemical coupling, signal transmission, and cell response.” Pg. 1
“Bone is a dynamic tissue that is tightly regulated by a multitude of homeostatic controls. One key environmental regulator of periarticular bone is mechanical stimulation. Wolff’s law relates to the response of bone to mechanical stimulation and states that bony adaptation will occur in response to a repeated load. It is interesting to consider this in the setting of knee OA, which has a strong biomechanical component to its etiology.” Pg. 1
“When periarticular bone is subjected to increased loading, some bone properties change. These include, but are not limited to, an expanding subchondral bone cross-sectional area, changes in bone mass, and remodeling of the trabeculae network. Although these changes likely represent appropriate homeostatic responses of bone to increased loading, they also appear to inadvertently predate maladaptive responses in other articular structures, most notably cartilage.” Pg. 1
Keorochana, Taghavi, Lee, Yoo, Liao, Fei and Wang reported (2011) “Differences in sagittal spinal alignment between normal subjects and those with low back pain have been reported. Previous studies have demonstrated that changes in sagittal spinal alignment are involved in the development of a spectrum of spinal disorders. It has also been a topic of great interest in the management of lumbar degenerative pathologies, especially when focusing on the role it may play in accelerating adjacent degeneration after spinal fusion and non-fusion procedures such as dynamic stabilization and total disc replacement. Spinal morphology may influence the loading and stresses that act on spinal structures. Alterations in the stress distribution may ultimately influence the occurrence of spinal degeneration. Moreover, changes in sagittal morphology may alter the mechanics of the lumbar spine, affecting mobility.” Pg. 893
Panjabi (2006) reported:
1. Single trauma or cumulative microtrauma causes sub-failure injury of the spinal ligaments and injury to the mechanoreceptors [and nociceptors] 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 [and nociceptors] are corrupted.
3. The neuromuscular control unit has difficulty in interpreting the corrupted transducer signals because there is a 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 [and nociceptors], further corrupting the muscle response pattern. (p. 669)
Cramer et al. (2002) reported “One component of spinal dysfunction treated by chiropractors has been described as the development of adhesions in the zygapophysial (Z) joints after hypomobility. This hypomobility may be the result of injury, inactivity, or repetitive asymmetrical movements…one beneficial effect of spinal manipulation may be the “breaking up” of putative fibrous adhesions that develop in hypomobile or “fixed” Z joints. Spinal adjusting of the lumbar region is thought to separate or gap the articular surfaces of the Z joints. Theoretically, gapping breaks up adhesions, thus helping the motion segment reestablish a physiologic range of motion.” (p. 2459)
Evans (2002) reported “On flexion of the lumbar spine, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with it. 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: a meniscoid entrapment. 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. The 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.” Pg. 252
The sagittal spinal misalignments developed after hypo or hypermobility as a result of injury, inactivity, or repetitive asymmetrical movements as reported Cramer, creates mechanoreceptor and nociceptor pathological input, this in turn as reported by Evans creates a mechanical displacement of the zygapophyseal joint and aberrant stimulation to type III and IV nociceptors. This also, according to Panjabi causes a corrupting of neuromuscular transducers (mechanoreceptors and nociceptors) of the spinal muscular system. These combine to create spinal neuro-pathobiomechanics for the spine globally and at each affected motor unit. This is what has been historically called in chiropractic “vertebral subluxation.“ Based upon Wolff’s Law, the persistent biomechanical failure, as perpetuated by the central nervous system being corrupted and attempting to compensate through muscular activity creates premature degeneration of the spine or osteoarthritis or “Subluxation Degeneration.”
Evans (2002) concluded that a high velocity-low amplitude manipulation (chiropractic spinal adjustment) 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 and realignment of the joint.” Pg. 253 This activity reduced the irritation or pressure on the nociceptors on the zygapophyseal joints stopping the corruption of the central nervous system and allowing the body to “right itself” and halt the degenerative process of the spine.
It has already been concluded, as reported by 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 the 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. By 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.
Considering that 50% of the population will experience some type of pain and/or potential disability as a result of spinal arthritis, chiropractic, as reported above is positioned as the best first option for spine as an evidence-based solution. This is called Primary Spine Care and chiropractic is best positioned to lead society in the prevention of osteoarthritis/subluxation degeneration through chiropractic care.
References
1. Gottlieb, M. S. (1997). Conservative management of spinal osteoarthritis with glucosamine sulfate and chiropractic treatment. Journal of manipulative and physiological therapeutics, 20(6), 400-414.
2. Weinberg, D. S., Liu, R. W., Xie, K. K., Morris, W. Z., Gebhart, J. J., & Gordon, Z. L. (2017). Increased and decreased pelvic incidence, sagittal facet joint orientations are associated with lumbar spine osteoarthritis in a large cadaveric collection. International orthopedics, 41(8), 1593-1600.
3. Park, J. H., Hong, J. Y., Han, K., Suh, S. W., Park, S. Y., Yang, J. H., & Han, S. W. (2017). Prevalence of symptomatic hip, knee, and spine osteoarthritis nationwide health survey analysis of an elderly Korean population. Medicine, 96(12).
4. Teichtahl, A. J., Wluka, A. E., Wijethilake, P., Wang, Y., Ghasem-Zadeh, A., & Cicuttini, F. M. (2015). Wolff’s law in action: a mechanism for early knee osteoarthritis. Arthritis research & therapy, 17(1), 207.
5. Keorochana, G., Taghavi, C. E., Lee, K. B., Yoo, J. H., Liao, J. C., Fei, Z., & Wang, J. C. (2011). Effect of sagittal alignment on kinematic changes and degree of disc degeneration in the lumbar spine: an analysis using positional MRI. Spine, 36(11), 893-898.
6. Panjabi, M. M. (2006). A hypothesis of chronic back pain: Ligament subfailure injuries lead to muscle control dysfunction. European Spine Journal,15(5), 668-676.
7. Cramer, G. D., Henderson, C. N., Little, J. W. Daley, C., & Grieve, T.J. (2010). Zygapophyseal joint adhesions after induced hypomobility. Journal of Manipulative and Physiological Therapeutics, 33(7), 508-518.
8. 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
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