US Chiropractic Directory Presents:
Neck Problems
Neck problems are one of the most prevalent issues that people worldwide suffer. Neck pain has been called torticollis, stiff neck and a host of other names, however to the public, it is literally a "pain in the neck." Chiropractic has been safely and effectively helping patents with pain in the neck for over 100 years and The US Chiropractic Directory has create a forum of information combining the entire healthcare and scientific community to bring the public evidenced and researched based answers on how and why chiropractic works to help those with neck pain/problems.
Chiropractic Adjustments Increases Maximal Bite Forces Through Effecting Cortical Changes
By: Mark Studin
William J. Owens
Citation: Studin M., Owens W. (2019) Chiropractic Adjustments Increase Maximal Bite Forces Through Effecting Cortical Changes, American Chiropractor, 41 (1) 12, 14, 16
A report on the scientific literature
Chiropractic has been shown in the literature to affect neural plastic changes. According to Wikipedia, “Neuroplasticity, also known as brain plasticity and neural plasticity, is the ability of the brain to change throughout an individual's life, e.g., brain activity associated with a given function can be transferred to a different location, the proportion of grey matter can change, and synapses may strengthen or weaken over time. Research in the latter half of the 20th century showed that many aspects of the brain can be altered (or are "plastic") even through adulthood. However, the developing brain exhibits a higher degree of plasticity than the adult brain. Neuroplasticity can be observed at multiple scales, from microscopic changes in individual neurons to larger-scale changes such as cortical remapping in response to injury.” (https://en.wikipedia.org/wiki/Neuroplasticity) This article focuses on a specific piece of evidence to demonstrably verify the effects of those neuroplastic changes as sequella to a chiropractic “high velocity-low amplitude spinal adjustment.
Haavik, Ozyurt, Naizi, Holt, Nefergaard, Yilmaz and Turker (2018) reported “It has previously been proposed in the literature that chiropractic spinal manipulation has a central neural effect. This is because multiple studies have shown that spinal manipulation of dysfunctional spinal segments can impact somatosensory processing, sensorimotor integration, and motor control.” (pg. 6) Haavik, Naizi, Jochumsen, Sherwin, Flavel and Turker (2017) supported the previous finding by reporting “The result presented are consistent with previous findings that have suggested increases in strength following spinal manipulation were due to descending cortical drive and could not be explained by changes at the level of the spinal cord. Spinal manipulation may therefore be indicated for the patients who have lost tonus of their muscle and/or are recovering from muscle degrading dysfunctions such as stroke or orthopedic operations and/or may also be of interest to sports performers.” (pg. 12)
Lelic, Niazi, Jochumsen, Dremstrup, Velder, Murphy, Drewes and Haavik (2016) also supported the neural plastic changes of a chiropractic spinal adjustment by reporting their “study resulted in two major findings. Firstly, the study reproduced previous findings of somatosensory evoked potential (SEPs) studies that have shown that chiropractic spinal adjusting of dysfunctional spinal segments alters early sensorimotor integration (SMI) of input from the upper limb. The second major finding of this study was that we were able to show, using dipole source localization, that this change in SMI that occurs after spinal manipulation predominantly happens in the prefrontal cortex. The SEP peak showed multiple neural generators including primary sensory cortex, basal ganglia, thalamus, premotor areas, and primary motor cortex. The frontal N30 peak is therefore thought to reflect early SMI.”
Haavik, Ozyurt, Naizi, Holt, Nefergaard, Yilmaz and Turker (2018) also found “The major finding of this study was that chiropractic spinal manipulation (adjustment) increased maximum bite force immediately after the intervention and the increase in bite force remained at 1-week follow-up. This is the first study to show that a single session of chiropractic spinal manipulation can increase jaw bite strength compared to a sham intervention.
This immediate increase in jaw bit force of 11% post spinal manipulation was unlikely to be due to the placebo effect, as all subjects were naïve to chiropractic, and most of the subjects did not know which intervention was real upon questioning after both interventions. The 2.3% decrease in maximum bite force after the sham intervention may have been due to fatigue from maximum biting on the mold, or simply due to random variations in maximum efforts.
The current study now also suggests that cervical spine function can influence maximal bite force. The effort with which the subject’s bite would also influence maximum bite force, and for this reason the study was conducted in Turkey, where chiropractic is relatively unknown, to enable a more effective sham intervention. As no increase in strength occurred following the sham intervention, the effort is unlikely to have been the reason the subjects’ bite force increased after the spinal manipulation.
Increases in lower limb muscle strength in subjects with subclinical pain following chiropractic spinal manipulation has been reported. An increase in lower limb strength in elite athletes that lasted 30 min post spinal manipulation was shown. Chilibeck, et al. reported that in subjects with imbalances in lower limb muscle strength, spinal manipulation resulted in increased muscle strength of hip abductors in their weak leg. Botelho and Andrade reported increases in grip strength in a group of national level judo athletes following spinal manipulation.”
Haavik et. Al continued, “In two of these previous studies that showed lower limb muscle maximum voluntary strength increases after chiropractic spinal manipulation H-reflex excitability and V-waves were also recorded. Both studies showed increases in maximum plantarflexion force and significant increases in the cortical drive to the plantar flexors (i.e., V-wave) following spinal manipulation, and that both these measures significantly decreased after the control intervention… The increase therefore seen following the spinal manipulations was, therefore, most likely because of the increased cortical drive to the muscle.”
“It has previously been proposed in the literature that chiropractic spinal manipulation has a central neural effect. This is because multiple studies have shown that spinal manipulation of dysfunctional spinal segments can impact somatosensory processing, sensorimotor integration, and motor control as mentioned in the introduction. This current study supports this notion, as spinal manipulation appears to alter maximum biting force in this group of subjects. This study, therefore, supports the growing body of research that suggests chiropractic spinal manipulation’s main effect is neuroplastic in nature that affects cortical excitability.”
“Spinal dysfunction, even 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, suggesting spinal dysfunction can alter the brains inner body schema and maps of the body and the world around us. This may be because spinal manipulation has been shown to change both cerebellum-M1 processing as well as prefrontal cortex processing. In the current study, the subjects’ mild spinal dysfunction may have altered the somatosensory input from the neck to the brain centers involved in sensorimotor integration and motor control of the jaw, and that adjusting these dysfunctional segments therefore impacted on these same central regions altering the maximum bite force the subjects could perform.”
Haavik et. Al concluded “Knowing that spinal function can have an impact on jaw function has functional implications for patient populations. It is possible that chiropractic spinal manipulation may influence the clinical outcomes for patients with TMJ disorders, as has been suggested by individual case studies.” There are also a significant amount of other applications of maximal bite force in our population that would also benefit from a chiropractic spinal adjustment when clinically indicated.
What’s not to be lost in this reporting of the literature as mentioned previously “multiple studies have shown that spinal manipulation of dysfunctional spinal segments can impact somatosensory processing, sensorimotor integration, and motor control.” There is a myriad of signs, symptoms, conditions and disease process that emanate from the malfunction of those centrally controlled functions in the human body. Although we have proven that a chiropractic spinal adjustment positively affects these functions, we are still at the forefront of fully understanding the full extent of how the adjustment influences a patient’s overall health although these authors have seen evidence clinically for almost four decades and chiropractors since 1895 have been reporting the same.
References:
The Legal and Appropriate Use of X-Ray in Chiropractic
To Consider the American Chiropractic Association's “Choose Wisely” X-Ray Recommendations is a Potential Public Risk
[to view any of the author's credentials, please click on their name]
NOTE: After the references is visual evidence of why x-ray should not be limited in chiropractic
Let’s be very clear on who determines the appropriateness and necessity of chiropractic clinical practice including x-ray, it is the state licensure boards of Alabama, Alaska, Arizona, Arkansas, California and all the rest to the 50th state alphabetically through Wyoming. These authors are perplexed as to why a political organization, the American Chiropractic Association (ACA), has deliberately inserted itself between the practicing doctor of chiropractic and their individual state licensure boards which has quickly delivered its negative effects by limiting the diagnostic tools and reimbursement of chiropractors nationally. Additionally, instead of working towards and supporting increased access to chiropractic care they are consuming limited financial and personnel resources and those of other political organizations by pushing an agenda crafted by a distinct minority of the profession. This is despite our state licensure boards laws and regulations that already regulate the appropriate utilization of x-ray in chiropractic.
To think that this doesn’t have a far-reaching negative effect on your practice and reimbursement is Pollyannaish, as these authors predicted in their 2017 article “Should Chiropractic Follow the American Chiropractic Association/American Board of Internal Medicine’s Recommendation on X-Ray? (1), because it has already happened and will continue to happen. To further outline the gravity of the issue and lend objective evidence that the American Chiropractic Association is now cause for limitation of your services and reimbursement, ACA President R. Ray Tuck in an official ACA capacity, wrote to Blue Cross Blue Shield of Illinois the following letter on July 31, 2018:
“I write to you on behalf of the American Chiropractic Association ("ACA") in connection with the above-referenced coverage policy recently adopted by your company. We note that the coverage policy references a "Choosing Wisely" article entitled ‘Five Things Physicians and Patients Should Question and utilizes portions of the article as coverage standards.
Permit me to bring to your attention the following disclaimer appearing on the ‘Choosing Wisely’ web page:
‘Note: Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is an appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.’ (emphasis added)
Conveying information not intended or designed to be coverage standards as such, while at the same time attributing such standards to this association, conveys an unfair and false impression. This action also, in our view, constitutes a violation of the Illinois Unfair Claims Practices Act by knowingly misrepresenting relevant facts relating to coverage issues (215 ILCS 5/154.6(a)).
We, therefore, would request your company's immediate attention to this matter and the withdrawal of all coverage standards derived from the ‘Choosing Wisely’ article from the Chiropractic Services coverage policy.”
To review the American Chiropractic Association’s Choosing Wisely guidelines that were released in 2017, especially in regard to how they relate to imaging our patients in a clinical setting, they state “Do not obtain spinal imaging for patients with acute low-back pain during the six (6) weeks after onset in the absence of red flags.” (2) This controversial recommendation was adopted in conjunction with the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports.
The ACA has continued to support their position by writing articles in support of their own internal decision. Christine Goertz DC, Ph.D. wrote in an article titled Choosing Wisely X-ray Recommendations Reflect Evolving Evidence, Accepted Standards: “This recommendation is not only on ACA’s Choosing Wisely® list; a similar item is also included on the lists of seven other organizations. This includes, among others, the American College of Emergency Physicians, the North American Spine Society and the American College of Physicians. It's also one of the performance measures established by the Centers for Medicare and Medicaid (CMS) under the MIPS Program. Thus, it is a widely accepted standard.” It should be noted, while the three groups that Dr. Goertz cited above, the American College of Emergency Physicians, the North American Spine Society and the American College of Physicians, are all held in high regard, we have to examine this fact at a deeper academic level. Regarding the North American Spine Society, their recommendations specifically state they “Do not recommend advanced imaging (MRI) of the spine within the first six weeks in patients with non-specific acute low back pain in the absence of red flags.” Their recommendations do not include x-ray. (3)The American College of Physicians, as an organization, represent internal medicine physicians and while we recognize they are focused on the diagnosis and management of systemic disease, they do not have advanced training in musculoskeletal or biomechanical spine diagnosis and are not trained as spine specialists.
Dr. John Edwards, a neurosurgeon from Provo, Utah wrote:
December 1, 2018
Dear Dr. Studin,
I would like to commend you for the work you have done to integrate chiropractic into higher education, medical research, and the medical community.
Over the past few years in my neurosurgical practice, I have understood more and more the value of biomechanical testing and treatment as the foundation for spinal care. I have discovered what you have known for years-biomechanical failures in the spine do not respond nearly as well to narcotics, steroids, injections, and surgery, as they do to chiropractic spinal adjusting.
Plain x-ray of the spine is the foundation of biomechanical diagnosing and biomechanical treatment, and supplemented with MRI as needed, enables the chiropractor as a primary spinal provider to triage patient care and initiate treatment as clinically indicated.
I think it is appropriate for the American Board of Internal Medicine to limit the frequency with which their providers are ordering diagnostic spinal tests, but inappropriate to hold this same standard to chiropractors. Internists generally know little about how to diagnose and treat spinal conditions. However, as a well-trained chiropractor, you understand when to order these tests. You can interpret them. You have validated, low cost, low-risk interventions that you can implement for treatment.
I hope the biomechanically trained chiropractor will be valued, validated, and viewed as the most important primary care spinal provider in the future. In our low access, high cost, high-risk health care system, the high access, low cost, low-risk management chiropractors can provide should be embraced by the entire medical community.
Although state licensure boards have spoken loudly in their historical support of doctors of chiropractic having the right to take x-rays within their lawful scope of practice, let’s examine the list of other organizations that have no such x-ray recommendation like the ACA has adopted. These groups are arguably in a better position to provide recommendations as they relate to and represent doctors with advanced training in spinal care and diagnosis. This list includes the American Academy of Orthopedic Surgeons, the American Academy of Physical Medicine and Rehabilitation, the North American Spine Society, the American College of Radiology, the American College of Surgeons, the American Medical Society for Sports Medicine, the American Society for Clinical Pathology, and the American Society of Clinical Oncology. These organizations have far more experience when dealing with x-rays and how they relate to treating patients for spine pain particularly in the diagnosis of spinal disorders. The ACA should have consulted with these groups before providing their recommendations for the Choosing Wisely program. Instead they sided with organizations consisting of non-spine specialties while choosing to ignore those with advanced training.
Plain film radiographs are clinically indicated to both asses anatomical (space occupying lesion, fracture, tumor or infection) and biomechanical pathology directed by thorough clinical evaluation. In the absence of an anatomical source of pathology and spine pain, associated it is critical that aberrant biomechanical motion is assessed. These paradoxical biomechanical diagnoses indicate failure of the surrounding spinal ligaments and/or tendons demonstrating the mechanical source of the ensuing nociceptive, mechanoreceptive and proprioceptive neuropathological cascade. Fedorak, Ashworth, Marshall, and Paull (2003) reported: “This study has shown that the visual assessment of cervical and lumbar lordosis is unreliable. This tool only has fair intra-rater reliability and poor interrater reliability. Visual assessment of spinal posture was previously shown to be inaccurate, and this study has demonstrated that is reliability is poor.” (4). In contrast, the reliability of x-ray in morphology, measurements, and biomechanics has been determined accurate and reproducible. Additionally, Ohara, Miyamoto, Naganawa, Matsumoto, and Shimzu (2006) reported, “Assessment of the sagittal alignment of the spine is important in both clinical and research settings… and it is known that the alignment affects the distribution of the load on the intervertebral discs”(5)
In a recent informal survey of 400 doctors of chiropractic nationally returning 152 responses asking “Does the clinical use of x-rays changes either your diagnosis, prognosis or treatment plan?” Out of 152 respondents, 98.42% of those surveyed, used x-rays in their clinical practices that changed either the diagnosis, prognosis and/or treatment plan for their patients. X-rays, and being able to visualize the biomechanical pathology in the absence of anatomical pathology, is vital to the chiropractic physician and the outcomes of their patients.
Some organizations, such as the American Association of Neurological Surgeons, have published recommendations stating, “Do not obtain spinal imaging for patients with acute “non-specific” low-back pain during the six (6) weeks after onset in the absence of red flags.” (6) Let us examine the term non-specific low back pain and how it relates to the clinical assessment of other professions outside chiropractic. Non-specific low back pain is low back pain without a known anatomical cause, meaning without structural pathology. Simply because there is no anatomical pathology present doesn’t mean the pain is “non-specific.” Doctors of chiropractic have long known the cause of non-specific low back pain, it has gone by various names, neuro-biomechanical lesions, biomechanical lesions, subluxation, vertebral subluxation complex, and spinal fixation.
Gedin et. Al (2018) reported, “it has been estimated that the vast majority of back pain cases is of non-specific origin. (7) The concept of simply focusing on the anatomical component of spine pain patients would render chiropractic no different than any other health profession. When focusing on the “non-specific” nature of spine pain, the focus must be on the biomechanical pathological component since the anatomical correlation is missing or does not correlate. The direction of care should be to the biomechanical compensation and individual motor units of the spine with a particular focus on spinal function and balance. Previous literature has verified that the supposition that “non-specific” is synonymous with “unobjectifiable” is erroneous since definite biomechanical changes in the motor units of the spine cause alterations of spinal balance, therefore resulting in “very specific” biomechanical pathology causing pain syndromes.
Panjabi in 1992, who had led the laboratory-based research into biomechanical spine pain, presented a detailed work explaining how the biomechanical systems within the human spine react to the external environment, how it can become dysfunctional and cause pain. He stated “Presented here is the conceptual basis for the assertion that the spinal stabilizing system consists of three subsystems, the vertebrae, discs, and ligaments constitute the passive subsystem, all muscles and tendons surrounding the spinal column that can apply forces to the spinal column constitute the active subsystem and finally, the nerves and central nervous system comprise the neural subsystem, which determines the requirements for spinal stability by monitoring the various transducer signals [of the nervous system] and directs the active subsystem to provide the needed stability.” He goes on to state, “A dysfunction of a component of any one of the subsystems may lead to one or more of the following three possibilities, an immediate response from other subsystems to successfully compensate, a long-term adaptation response of one or more subsystems or an injury to one or more components of any subsystem.” (8)
Panjabi continues, “It is conceptualized that the first response results in normal function, the second results in normal function but with an altered spinal stabilizing system, and the third leads to overall system dysfunction, producing, for example, low back pain. In situations where additional loads or complex postures are anticipated, the neural control unit may alter the muscle recruitment strategy, with the temporary goal of enhancing the spine stability beyond the normal requirements.” (8) Panjabi’s laboratory is where the idea of biomechanical compensation was conceptualized and proven.
Panjabi’s evidence summarized in the above work is the basis for the underlying mechanics of spine pain that does NOT correlate well to anatomical findings. Anatomical findings are fracture, tumor or infection and allopathy has labeled anything else inaccurately “non-specific.” This concept and approach to spine care continue to maintain a dogmatic perspective in both clinical decision making, provider reimbursement and all too often, the literature, despite compelling evidence to the contrary.
A recent study by Scheer et al. (2016) reports a biomechanical assessment of the spine as critical to spine care including spine surgery. This concept was originally presented at the 2015 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves. The authors state “The cervical spine plays a pivotal role in influencing adjacent and global spinal alignment as compensatory changes occur to maintain horizontal gaze. Concomitant cervical positive sagittal alignment (loss of cervical lordosis) in adult patients with a thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach minimal clinically important difference at 2-year follow-up compared with patients without cervical deformity.” (9) Here we see additional evidence that spinal biomechanical modeling has an effect even in the presence of severe anatomical pathology requiring surgical intervention. In this case, it was even in an adjacent spinal region to the surgical site!
The scientific literature and certainly the surgical community is showing that thorough biomechanical assessment of the patient is a critical component to spine care, particularly in the complex spine pain patient. Without x-rays, the doctor is simply guessing.
One of the primary caveats stated in the ACA’s Choosing Wisely suggestions to not take spinal x-rays is the patient’s exposure to ionizing radiation. Patients routinely ask us about the radiation effects of x-rays, therefore it is imperative that we look at the facts, not the deceptive rhetoric that is so often quoted. According to a recent article from April 2018 by Harvard Health Publishing at Harvard Medical School titled Radiation Risk from Medical Imaging, they state that the average effective dose of a lumbar x-ray is 1.5 mSv. (10) According to the Radiological Society of North America in an article published April 2009 titled The Linear No-Threshold Relationship Is Inconsistent with Radiation Biologic and Experimental Data, they state “Among humans, there is no evidence of a carcinogenic effect for acute irradiation at doses less than 100 mSv and for protracted irradiation at doses less than 500 mSv.” They go on to state “There are potent defenses against the carcinogenic effects of ionizing radiation. Their efficacy is much higher for low doses and dose rates; this is incompatible with the LNT (linear no-threshold) model but is consistent with current models of carcinogenesis.” (11) As one can clearly see, the ionizing radiation effects of taking a set of lumbar x-rays is well below the minimum dosage to have a carcinogenic effect.
The following is a sampling of responses received by the Academy of Chiropractic, these responses were received from an informal survey of doctors of chiropractic nationwide. The instructions were to send over x-rays demonstrating ONLY ANATOMICAL PATHOLOGY and a brief history taken in their offices, many of which showed significant anatomical pathology in the absence of “red flags.” These responses underscore why the options for doctors of chiropractic should not be limited by politics, but instead should be driven by clinical assessment and scientific data. This myopic vision will create a public health risk and is integral in creating an accurate diagnosis, prognosis and treatment plan for our patients particularly in those patients with spine pain not specific to an anatomical lesion. As responsible doctors of chiropractic, we and the profession urge the American Chiropractic Association not to amend it's policy on Choose Wisely, but to rescind its x-ray “suggestions” in any and all formats. Furthermore, terminate all efforts in recommending anything other than each doctor follow their scope of practice in their respective states regarding the utilization of x-ray in clinical practice and the care of their patients. The chiropractic profession needs a strong political advocate and the American Chiropractic Association has historically been a major component in successfully filiing that need, however we need a powerful voice to unite us and not create further division within our profession or waste our valuable and limited resources.
NOTE: Below the references is visual evidence of why x-ray should not be limited in chiropractic
References
NOTE: The following does not comment or reflect biomechanical pathology or the negative sequela of having it go undiagnosed. That is a topic for a separate article.
The following is a sampling of responses we received from a survey of doctors nationwide 3 days prior to this publishing of this article. The instructions were to send over x-rays for ONLY ANATOMICAL PATHOLGY and a brief history taken in their office within the last 3 months. These responses underscore why the utilization for chiropractors should not be limited as it will create a public health risk and is integral in creating an accurate diagnosis, prognosis and treatment plan for our patients. As responsible doctors of chiropractic we and the profession urge the American Chiropractic Association to terminate all efforts in recommending anything other than each doctor follow their scope of practice in their respective states regarding the utilization of x-ray in clinical practice.
Abdominal Aortic Aneurysm
Compression Fracture
17 year old male with chronic mid back pain from high school wrestling. Found a compression fracture.
Burst Fracture - Metastatic Cancer
Patient presented upper lumbar pain, adamant that he was cancer free, no problems whatsoever, had been cleared by PCP and oncologist in past, just "needed an adjustment" and was actually rather angry that I would not perform adjustment or treat the day of his exam.
C2 Dens Fracture
This patient is a 25-year-old female with a history of a roll-over accident 10 years ago and recurrent neck pain. During history she said "I think they said something about a neck fracture".
Lumbar Transverse Process Fracture
Lung Mass
This patient was referred by an ENT/Facial Plastic Surgeon for evaluation of TMJ/Neck pain. The patient had the mass surgically removed.
Spondylolisthesis
Patient was experiencing lower extremity radicular pain. Saw a PT 6 times and a DC 6 times with no relief. Then came to me. I found the Spondylolisthesis. He is doing great without any symptoms now.
L5 Metastatic Cancer
Onset of low back pain and sciatica. X-ray revealed enlargement of L5 spinous process. Patient was reluctant to get MRI. And then I had to fight with insurance carrier to get it authorized. But the x-rays revealed a problem. MRI confirmed metastatic lesion L5-S1 and posterior elements of L5.
Anterior Cervical Discectomy and Fusion
Patient came in complaining of neck pain. Never once stated a prior neck surgery in either the paperwork or when asking about past surgeries.
Congenital Fused Vertebra
C2 Dens Instability
54 year old male delivery driver, acute on chronic onset of low back pain constant 7/10 and neck pain intermittent 5/10 for years. Seen by numerous chiropractors and medical doctors for 30+ years, taking medication for psoriasis. Patient stated that he did not need x-rays just an adjustment and he would be on his way. After x-rays I told the patient go to Kaiser and see a neurosurgeon, I refused to treat and showed him the instability. He protested and said "you are just a f_ _ _ing chiropractor and I have seen many medical doctors over the years and no one has told me anything like I might need surgery. I called him later that day and he did go to Kaiser hospital and was seen immediately a spine specialist.
Ankylosing Spondylitis
Thoracic Compression Fracture
56 year old male lifting heavy coffee table 1 week prior, mid back pain acute. No insurance, did not want to spend the money on x-rays. No significant health history.
Lumbar Anterolisthesis of L3
Spinal Fusion from T1-L3
Cervical Fracture
I was asked by an attorney to review a case of a 16 year old female with persistent headaches and neck pain with bilateral paresthesia in her left and right hands. He said he doesn't think she has much of a case. She was involved in a side collision with a pickup truck with a plow in a 30 mph zone. She was evaluated with CT of head and X-rays of neck and back and released by Children's hospital the same day. She has undergone a year of physical therapy for cervicalgia and neurologist for post traumatic headaches. She has 6 degrees of active extension with pain and 48 degrees of active flexion with pain. So I asked for the hospital records including copies of diagnostic imaging for my review. The cervical spine imaging report stated: "unremarkable cervical radiograph without evidence of acute osseous abnormalities." Well I have attached the lateral view for you, which I must strongly disagree with and contacted the radiologist regarding. He asked me at first why I was reviewing the films. I stole your line and said "real doctor's read their own films, would you want a surgeon doing surgery on you without looking at the films." The reply was "good point." He also agreed to write the addendum. I then advised the attorney of my findings and the text message said, "HOLY S!@#! WOW that makes so much sense."
Spondylolysis
17 year old female presented with lower back pain after baton twirling practice. No trauma. Spondylolysis of L4 most visible on the right posterior oblique.
Multiple Myeloma
Note multiple pathologic compression fractures and lysis of right ischial tuberosity. Turned out to be multiple myeloma, Stage 4. L3 is post vertebroplasty.
Lumbar Scoliosis
Cervical Fusion
Spondylolisthesis
Lung Mass
Spondylisthesis
Spondylolisthesis
68 year old male with severe low back and right leg pain. Radiographs exhibit dextrocurvature, severe degeneration and a grade1-2 spondylolisthesis.
Compression Fracture
Cervical Mass
Kidney Stones
Sternum Fracture
AC Joint Separation
Baastrup's Disease
Coccyx Fracture
Atlantoaxial Instability
Fractured Styloid and Radius
Fractured Thumb
Aortic Aneursym
Pelvic Fracture
Deceptive Dogmatic Reporting Despite Successful Chiropractic Outcomes
Revealing the deception of low back pain naturally resolving
…and the dogma of non-specific back pain
Mark Studin, DC
William J. Owens DC
Timothy Weir, DC
Citation:Studin M., Owens W., Weir T. (2018) Deceptive Dogmatic Reporting Despite Successful Chiropractic Outcomes, American Chiropractor, 40 (11) 10, 12-15
A report on the scientific literature
Over the past decade, there has been a growing body of evidence demonstrating the “how and why” of chiropractic evidenced-based results. However, there has also been a historical level of reporting dogmatic issues related to the “the natural history of back pain” and “non-specific back pain” that deceptively enter and intersect the conversation to apparently discredit “pro-chiropractic” evidenced-based research that has persisted in contemporary literature. This review is centered on those issues, and the references for the above comments will ensue in the paragraphs below.
The National Institute of Neurological Disorders and Stroke reports “Most low back pain is acute, or short-term, and lasts a few days to a few weeks. It tends to resolve on its own with self-care, and there is no residual loss of function.”
https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet. Kaiser Permanente, a national health system reports, “For most patients with back pain, the condition will improve within a few days or weeks.” https://wa.kaiserpermanente.org/static/pdf/public/guidelines/back-pain.pdf
Kaiser Permanente goes on to report, “The primary goal of treatment is to maximize function and quality of life, rather than to eliminate pain. Some ongoing or recurrent pain is normal and not indicative of a serious problem. Avoid exposing the patient to unhelpful or possibly risky interventions. As a general rule, an intervention in which the patient is an active participant (e.g., physical therapy, walking, stretching, yoga) rather than a passive recipient (e.g., chiropractic, massage, acupuncture) is deemed to have greater potential to promote self-efficacy and self-management skills in the long term.”
https://wa.kaiserpermanente.org/static/pdf/public/guidelines/back-pain.pdf
Gedin, Edmar, Sundberg, and Burström in 2018 reported “Patients with acute back pain reported statistically significant and MCID (Minimal Clinically Important Difference) improvements in back pain intensity, back disability, HRQoL (Health-Related Quality of Life instrument), and statistically significant improvements in self-rated health, over four weeks following chiropractic care. Patients with chronic back pain reported statistically significant, albeit smaller and non MCID, changes for all PRO except self-rated health.
Interestingly, Gedin et al. have a significant level of statistics of demonstrating percentages of subjects who showed improvement and choose not to report that in the written part of the report, thereby not rendering a statistical interpretation. However, they included a caveat to perhaps minimize the positive results by reiterating the same deceptive dogma as discussed above. Gedin et. al then reported “However, it has been suggested that 90% of patients with acute low back pain recover within six weeks (van Tulder et al., 2006), which may also help explain the current findings of rapid improvements.(pg. 16) This opinion published in 2018 was referenced and supported by a 12-year old study which clearly ignored the contemporary literature.
Tamcan, Mannion, Eisenring, Horisberger (2010) reported on the only population-based study these authors were able to identify and concluded “When the 12-month follow-up period was divided into four equal time periods and, subsequently, clusters, it was seen that the majority of individuals placed in the moderate persistent [pain] cluster on the basis of the first 3 months data remained in this cluster at the following intervals. A reasonable consistency across time was also found for the clusters mild persistent and severe persistent. In contrast, the consistency of membership for the cluster initially identified as fluctuating was low, especially after six months.” (pg. 455-456) This study, which again is the only identified population-based study indicates that pain does not resolve “naturally” as was reported: “fluctuation was low, especially after six months.”
Knecht, Humphyres and Wirth (2017) reported on the recurrence of low back pain and stated, “Only 1 in 3 LBP (low back pain) episodes completely resolve within a year, and the percentage of LBP that goes from acute to chronic varies among studies from 2% to 34%.” Knecht et. Al (2017) also went on to report “Patients presenting with a subacute problem, lasting for more than 14 days at baseline, were at higher odds for a recurrent course, whereas the odds for a chronic course were higher only for patients presenting with a chronic problem (≥3 months) at baseline. Downie et al. reported that pain duration of more than five days was a factor that negatively affects prognosis. Similarly, duration of the current episode emerged as the most consistent factor for prognosis after one year in a study by Bekkering et al. and even predicted disability after five years. These findings suggest on the one hand that it might be prudent to seek professional advice [referenced chiropractic care in the article] early on in the pain episode.” (pg. 431)
These papers a part of the research trend supporting what the chiropractic profession has known all along, the natural progression of low back pain resulting in resolution is based on dogma and not supported by the research evidence. Additionally, the low back pain care path reported previously by Kaiser Permanente appears to be biased towards the denial of care and not consistent with the published literature.
Gedin et. Al (2018) also report, “it has been estimated that the vast majority of back pain cases is of non-specific origin.” (pg. 3) The concept of simply focusing on the treatment of non-specific back pain would render chiropractic no different than physical therapists when focusing on the “non-specific” nature of spine pain as the arbiter for care while the focus must be on the biomechanical compensation and individual motor units of the spine. Previous literature has verified that the supposition that “non-specific” is synonymous with ‘unobjectifiable” is erroneous since it was previously reported that chiropractic treats definite biomechanical changes in the motor units of the spine, therefore resulting in “very specific” biomechanical pathology.
Panjabi in 1992, presented a detailed work explaining how the biomechanical systems within the human spine react to the environment, how it can become dysfunctional and cause pain. He stated “Presented here is the conceptual basis for the assertion that the spinal stabilizing system consists of three subsystems, the vertebrae, discs, and ligaments constitute the passive subsystem, all muscles and tendons surrounding the spinal column that can apply forces to the spinal column constitute the active subsystem and finally, the nerves and central nervous system comprise the neural subsystem, which determines the requirements for spinal stability by monitoring the various transducer signals [of the nervous system] and directs the active subsystem to provide the needed stability.” He goes on to state, “A dysfunction of a component of any one of the subsystems may lead to one or more of the following three possibilities, an immediate response from other subsystems to successfully compensate, a long-term adaptation response of one or more subsystems or an injury to one or more components of any subsystem.”
Panjabi continues, “It is conceptualized that the first response results in normal function, the second results in normal function but with an altered spinal stabilizing system, and the third leads to overall system dysfunction, producing, for example, low back pain. In situations where additional loads or complex postures are anticipated, the neural control unit may alter the muscle recruitment strategy, with the temporary goal of enhancing the spine stability beyond the normal requirements.” (pg. 383) This is where the idea of biomechanical compensation was identified.
Panjabi’s lifelong work summarized in the above work is the basis for the underlying mechanics of spine pain that does NOT correlate well to anatomical findings. Anatomical findings are fracture, tumor or infection and allopathy has labeled anything else “non-specific low back pain” which continues to maintain a dogmatic perspective in both clinical decision making and all too often, the literature, despite compelling evidence to the contrary.
Cramer et al. (2002) further clarified the biomechanics of spinal failure at the motor until level and 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.” (pg. 252)
Evans (2002) continued, “an HVLA manipulation, involving gapping of the zygapophyseal joint reduces the impaction and opens the joint, so encouraging the meniscoid to return to its normal anatomical position in the joint cavity. This ceases the distension of the joint capsule, thus reducing pain.” (p. 253)
The involvement of nociceptors and nociceptive impulses stimulates the cortical regions of the brain which evokes a cortical response to that noxious stimuli. Haavik et al. (2017) reported the effects of a chiropractic spinal high velocity-low amplitude adjustment by stating “These results are consistent with previous findings that have suggested increases in strength following spinal manipulation were due to descending cortical drive and could not be explained by changes at the level of the spinal cord.” (pg. 1)
The persistent utilization of “non-specific” in reference to specific biomechanical alterations and failure in the human spine is dogmatic and deceptive since it “lumps together” all types of manual treatment, where chiropractic, based upon its unique application differs from other forms of manual therapy performed by physical therapy, acupuncture, and massage therapy. It differs in the ability of chiropractors to diagnosis and manages spinal compensation. In comparison to each other, each discipline is disparate in goals, application, and science and when not considered as such, lends itself to continue deceptive dogmatic arguments ignoring the evidenced-based truths of chiropractic.
References:
Chiropractic Vertebral Subluxation
By Mark Studin
William J. Owens
Citation: Studin M., Owens W. (2018) Vertebral Subluxation Complex, American Chiropractor, 40 (7) 12, 14-16, 18, 20, 22, 24, 26-27
A report on the scientific literature
INTRODUCTION
Chiropractic was discovered in 1895 by Daniel David Palmer and further developed by his son, Bartlett James Palmer. Together, they helped coin the phrase “vertebral subluxation,” yet to date, there has been little evidence of it in the literature. When we consider neuro-biomechanical pathological lesions that will degenerate (please refer to Wolff’s Law) based upon homeostatic mechanisms in the human body we will better understand and be able to define the chiropractic vertebral subluxation and more specifically, the chiropractic vertebral subluxation complex (VSC). In addition, the literature has provided us with a vast amount of evidence on both the biomechanical dysfunction of the spine as well as the neurological consequence as sequelae to that biomechanical dysfunction.
Despite over a century of reported and literature-based clinical results, detractors both outside and inside the chiropractic profession argue to limit the scope of these spinal lesions because the literature has not yet caught up to the results. Additionally, the lack of contemporary literature has been reflected in “underperforming” chiropractic utilization in the United States for conditions that have been well-documented as responding successfully in outcome studies with chiropractic care.
Murphy, Justice, Paskowski, Perle and Schneider (2011) reported:
Spine-related disorders (SRDs) are among the most common, costly and disabling problems in Western society. For the purpose of this commentary, we define SRDs as the group of conditions that include back pain, neck pain, many types of headache, radiculopathy, and other symptoms directly related to the spine. Virtually 100% of the population is affected by this group of disorders at some time in life. Low back pain (LBP) in the adult population is estimated to have a point prevalence of 28%-37%, a 1-year prevalence of 76% and a lifetime prevalence of 85%. Up to 85% of these individuals seek care from some type of health professional. Two-thirds of adults will experience neck pain some time in their lives, with 22% having neck pain at any given point in time.
The burden of SRDs on individuals and society is huge. Direct costs in the United States (US) are US$102 billion annually and $14 billion in lost wages were estimated for the years 2002-4. (p. 1)
In 2017, based upon Alioth Education, dollars adjusted for inflation equates to $18,141, 895,182.64 in direct costs for spinal-related conditions that fall within the chiropractic treatment category and have proven to outperform other forms of care. When considering outcome assessments for efficacy of chiropractic in a population-based study, both Cifuentes, Willets and Wasiak (2011) and Blanchette, Rivard, Dionne, Hogg-Johnson, and Steenstra (2017) offered evidence that the results are rooted in a “first healthcare provider” or “primary spine care” solution.
Cifuentes et al. (2011) compared different treatments of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability episode after a 15-day absence and return to disability. Anyone with less than a 15-day absence of disability was excluded from the study. Please note that we kept disability outcomes for all reported treatment and did not limit this to physical therapy. However, the statistic for physical therapy was significant.
According to the Cifuentes, Willets and Wasiak (2011) study, chiropractic care during the disability episode resulted in:
Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating, “After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (Cifuentes et al., 2011, p. 404).
Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) reported:
The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation. (p. 388)
Despite compelling evidence of chiropractic being the best option for primary spine care treatment of injuries related to disabilities and pain based upon outcomes, the reasons why chiropractic works have been elusive. Despite the lack of literature-based evidence, answers are still being sought because positive results are consistently being realized in clinical chiropractic practices. When Keating et al. (2005) wrote an opinion or debate article, they concluded, “Subluxation syndrome is a legitimate, potentially testable, theoretical construct for which there is little experimental evidence” (p. 13).
This statement is one of the most unifying statements that could serve to reduce pain and opiate utilization, prevent premature degeneration and increase bio-neuromechanical function for our society, while significantly increasing our utilization because chiropractic is part of the answer. However, the simple question is, “Why aren’t we doing this specific research because the pieces of what is considered subluxation have been verified in the literature for quite some time?”
DISCUSSION
VSC starts with spinal biomechanics and when considering a pathological model, we need to define the normal functioning of the spine.
Panjabi (2006) reported:
The spinal column, consisting of ligaments (spinal ligaments, discs annulus and facet capsules) and vertebrae, is one of the three subsystems of the spinal stabilizing system. The other two are the spinal muscles and neuromuscular control unit. The spinal column has two functions: structural and transducer. The structural function provides stiffness to the spine. The transducer function provides the information needed to precisely characterize the spinal posture, vertebral motions, spinal loads etc. to the neuromuscular control unit via innumerable mechanoreceptors present in the spinal column ligaments, facet capsules and the disc annulus. These mechanical transducers provide information to the neuromuscular control unit which helps to generate muscular spinal stability via the spinal muscle system and neuromuscular control unit. The criterion used by the neuromuscular unit is hypothesized to be the need for adequate and overall mechanical stability of the spine. If the structural function is compromised, due to injury or degeneration, then the muscular stability is increased to compensate the loss. (p. 669)
Panjabi (2003) also reported:
It has been conceptualized that the overall mechanical stability of the spinal column, especially in dynamic conditions and under heavy loads, is provided by the spinal column and the precisely coordinated surrounding muscles. As a result, the spinal stabilizing system of the spine was conceptualized by Panjabi to consist of three subsystems: spinal column providing intrinsic stability, spinal muscles, surrounding the spinal column, providing dynamic stability, and neural control unit evaluating and determining the requirements for stability and coordinating the muscle response. (p. 372)
In defining spinal clinical instability, Panjabi (1992) previously reported:
Clinical instability is defined as a significant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits so that there is no neurological dysfunction, no major deformity, and no incapacitating pain. (p. 394)
Anatomically, we are starting with the vertebrate and more specifically, the articular facets indicating that VSC is a “complex” and not a simple problem as the anatomical pathology occurs in opposing facets. When looking at normal vertebral structures,
Cervical spine meniscoids, also referred to as synovial folds or intra-articular inclusions, are folds of synovium that extend between the articular surfaces of the joints of the cervical spine. These structures have been identified within cervical zygapophyseal, lateral atlantoaxial and atlanto-occipital joints, and have been hypothesised to be of clinical significance in neck pain through their mechanical impingement or displacement, as a result of fibrotic changes, or via injury as a result of trauma to the cervical spine. (p. 939)
An understanding of the basic structure of meniscoids is necessary to assess their potential role in cervical spine pathology. As described above, cervical spine meniscoids are folds of synovium that protrude into a joint from its margins. Meniscoids lie between the articular surfaces at the ventral and dorsal poles of their enclosing joint. Their basic structure includes a base, which attaches to the joint capsule, a middle region and an apex that protrudes approximately 1–5 mm into the joint cavity. In sagittal cross section, these structures are triangular in shape, and when viewed superiorly they often appear crescent-shaped or semi-circular. Cervical spine meniscoids are thought to function to improve the congruence of articular structures, and to ensure the lubrication of articular surfaces with synovial fluid. (p. 940)
Should these synovial folds or “plicas” become trapped or “pinched” as described by Evans (2002), it would be the beginning of a “negative neurological cascade.”
Evans (2002) reported:
Intra-articular formations have been identified throughout the vertebral column. Giles and Taylor demonstrated by light and transmission electron microscopy the presence of nerve fibers (0.6 to 1 mm in diameter) coursing through synovial folds, remote from blood vessels, that were most likely nociceptive. They concluded, “Should the synovial folds become pinched between the articulating facet surfaces of the zygapophyseal joint, the small nerves demonstrated in this study may have clinical importance as a source of low back pain.” (p. 252)
Figure 1: Images of meniscoid entrapment on flexion, on attempted extension, involving flexion and gapping and realigned.
Evans (2002) explained the images above as follows:
Meniscoid entrapment. 1) On flexion, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with It. 2) On attempted extension, the inferior articular process returns toward its neutral position, but instead of re-entering the joint cavity, the meniscoid impacts against the edge of the articular cartilage and buckles, forming a space-occupying "lesion" under the capsule. Pain occurs as a result of capsular tension, and extension is inhibited. 3) Manipulation of the joint involving flexion and gapping, reduces the impaction and opens the joint to encourage re-entry of the meniscoid into the joint space (4) [Realignment of the joint.] (p. 253)
Evans (2002) continued:
Bogduk and Jull reviewed the likelihood of intra-articular entrapments within zygapophyseal joints as potential sources of pain…Fibro-adipose meniscoids have also been identified as structures capable of creating a painful situation. Bogduk and Jull reviewed the possible role of fibro-adipose meniscoids causing pain purely by creating a tractioning effect on the zygapophyseal joint capsule, again after intra-articular pinching of tissue(p. 252)
Evans (2002) also noted:
A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophyseal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent impaction of the meniscoid. The patient would tend to be more comfortable with the spine maintained in a flexed position, because this will disengage the meniscoid. Extension would therefore tend to be inhibited. This condition has also been termed a “joint lock” or “facet-lock,” the latter of which indicates the involvement of the zygapophyseal joint…
An HVLAT manipulation [chiropractic spinal adjustment CSA], involving gapping of the zygapophyseal joint, reduces the impaction and opens the joint, so encouraging the meniscoid to return to its normal anatomic position in the joint cavity. This ceases the distension of the joint capsule, thus reducing pain. (p. 252-253)
When considering VSC in its entirety, we must consider the etiology as these forces can lead to complex patho-biomechanical components of the spine and supporting tissues. As a result, a neurological cascade can ensue that would further define VSC beyond the inter-articulation entrapments. Panjabi (2006) reported:
Abnormal mechanics of the spinal column has been hypothesized to lead to back pain via nociceptive sensors. The path from abnormal mechanics to nociceptive sensation may go via inflammation, biochemical and nutritional changes, immunological factors, and changes in the structure and material of the endplates and discs, and neural structures, such as nerve ingrowth into diseased intervertebral disc. The abnormal mechanics of the spine may be due to degenerative changes of the spinal column and/or injury of the ligaments. Most likely, the initiating event is some kind of trauma involving the spine. It may be a single trauma due to an accident or microtrauma caused by repetitive motion over a long time. It is also possible that spinal muscles will fire in an uncoordinated way in response to sudden fear of injury, such as when one misjudges the depth of a step. All these events may cause spinal ligament injury. (p.668-669).
Panjabi (2006) goes on to explain what happens when the spinal column is affected by trauma:
The structural function provides stiffness to the spine. The transducer function provides the information needed to precisely characterize the spinal posture, vertebral motions, spinal loads etc. to the neuromuscular control unit via innumerable mechanoreceptors present in the spinal column ligaments, facet capsules and the disc annulus. These mechanical transducers provide information to the neuromuscular control unit which helps to generate muscular spinal stability via the spinal muscle system and neuromuscular control unit. The criterion used by the neuromuscular unit is hypothesized to be the need for adequate and overall mechanical stability of the spine. If the structural function is compromised, due to injury or degeneration, then the muscular stability is increased to compensate the loss. What happens if the transducer function of the ligaments of the spinal column is compromised? This has not been explored. There is evidence from animal studies that the stimulation of the ligaments of the spine (disc and facets, and ligaments) results in spinal muscle firing. (p. 669).
Panjabi (2006) described the mechanism that, coupled with the inter-articulation nociceptor “firing,” further defines the “negative neurological cascade”:
The hypothesis consists of the following sequential steps:
One hallmark of determining vertebral subluxation complex for the chiropractic profession has been ranges of motion of individual motor units. Both hypo- and hypermobility have been clinically associated with muscle spasticity and have offered a piece of clinical history in the practice setting. NOTE: Ranges of motion, like any other findings, are no more than pieces of evidence, all of which must clinically correlate.
Radziminska, Weber-Rajek, Srączyńska and Zukow (2017) reported:
The definition of the neutral zone explains that it as a small range of motion near the zero position of the joint, where no proprioreceptors are stimulated around the joint and osteoligamentous resistance is minimal (lack of centripetal response and, consequently, lack of central muscle stimulation).
Increasing the range of motion of the neutral zone is detrimental to the joint - it can lead to its damage. Delayed proprioceptive information about the current joint position that reaches the central system will give a muscle tone response, but it may turn out to be incompatible with external force acting on the joint. The reduced range of motion of the neutral zone is also unfavorable. If the stimulation of proprioreceptors is too early it will result in an increased muscle tension around the joint. The neutral zone is disturbed by traumas, degenerative processes, and muscle stabilization weakness. (p. 72)
With VSC, the joint that has been misplaced creates abnormal biomechanics and abnormal pressure to the joint. This is called Wolff’s Law, formulated and accepted since the 1800’s, and is explained by Kohata, Itoha, Horiuchia, Yoshiokab and Yamashita (2017):
When mechanical stress is impressed upon bone, an electrical potential is induced; the area of bone under compression develops negative potential, whereas that under tension develops positive potential. This phenomenon is generated by collagen piezoelectricity, and the electrical potential generated in bone by collagen displacement has been well documented. (p. 65)
CONCLUSION
VSC is based upon both the macro- and microtrauma induced motor unit pathology, creating interarticular meniscoid nociceptor entrapment that triggers nociceptors and affects the lateral horn for a local reflex. It then innervates the thalamus through the spinothalamic tracts and periaqueductal grey matter which is then further distributed to various cortical regions to process in the body’s attempt to compensate biomechanically. This, coupled with aberrant motor unit ranges of motion (hypo or hyper), subfailure injuries to the ligaments and the corrupted mechanoreceptors and nociceptor messages that innervate the lateral horn cause a “negative neurological cascade” both reflexively at the cord and the brain. This cascade can cause pain and inflammation and will cause premature degeneration if left uncorrected based upon Wolff’s Law because of improper motor unit biomechanical failure. Should the correction be made after remodelling of the vertebrate, then care changes from corrective to management as the spine can never be perfectly biomechanically balanced as the segments (building blocks for homeostasis) have been permanently remodelled.
The research for VSC exists in its components. However, there needs to be a concise research program that combines all the pieces to further conclude the evidence that exists. Furthermore, we need more conclusive answers as to why chiropractic patients get well, answers that goes beyond pain or aberrant curves.
References
1. Murphy, D. R., Justice, B. D., Paskowski, I. C., Perle, S. M., & Schneider, M. J. (2011). The establishment of a primary spine care practitioner and its benefits to health care reform in the United States. Chiropractic & manual therapies, 19(1), 17.
2. FinanceRef Inflation Calendar, Alioth Finance. (2017). $14,000,000,000 in 2004 → 2017 | Inflation Calculator. Retrieved from http://www.in2013dollars.com/2004-dollars-in-2017?amount=14000000000
3. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
4. Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation, 27(3), 382-392.
5. Keating, J. C., Charlton, K. H., Grod, J. P., Perle, S. M., Sikorski, D., & Winterstein, J. F. (2005). Subluxation: Dogma or science? Chiropractic & Osteopathy, 13(1), 17.
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. Panjabi, M. M. (1992). The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. Journal of Spinal Disorders, 5, 390-397
8. Panjabi, M. M. (2003). Clinical spinal instability and low back pain. Journal of Electromyography and Kinesiology, 13(4), 371-379.
9. Farrell, S. F., Osmotherly, P. G., Cornwall, J., Sterling, M., & Rivett, D. A. (2017). Cervical spine meniscoids: an update on their morphological characteristics and potential clinical significance. European Spine Journal, (26) 939-947
10. Evans, D. W. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics, 25(4), 251-262.
11. Radziminska, A., Weber-Rajek, M., Strączyńska, A., & Zukow, W. (2017). The stabilizing system of the spine. Journal of Education, Health and Sport, 7(11), 67-76.
12. Kohata, K., Itoh, S., Horiuchi, N., Yoshioka, T., & Yamashita, K. (2017). Influences of osteoarthritis and osteoporosis on the electrical properties of human bones as in vivo electrets produced due to Wolff's law. Bio-Medical Materials and Engineering, 28(1), 65-74.
Efficacy and Adverse Effects of Chiropractic Treatment for Migraines
By Mark Studin
William J. Owens
A report on the scientific literature
When considering care for migraines, there are a myriad of considerations; efficacy of treatment, costs to sufferers and insurers and the socioeconomic impact to individuals, business and families of those who suffer. When considering there are co-morbidities that must be considered in the quest for a “best-outcome,” avoiding any potential side effects, both with pharmacological and non-pharmacological care paths are critical. Chaibi, Benth, Tuchin and Bjorn (2017) reported “Manual-therapy [chiropractic spinal adjustments] is a non-pharmacological prophylactic treatment option that appears to have a similar effect as the drug topiramate on migraine frequency, migraine duration, migraine intensity and medicine consumption.” (pg. 66) Although previous reports indicate that chiropractic was upwards of 57% more effective (see ensuing comments), for this report, we are going to focus on the side effects of treatment, as efficacy has already been established.
Studin and Owens (2011) reported, “Nelson, Suter, Casha, du Plessis and Hurlbert (1998) reported on randomized clinical trials that took place over an 8-week course. The results showed there was minor statistical differences in outcomes for improvement during the trial period for chiropractic care and for amatriptyline and over-the-counter medications for treating migraine headaches. It was also reported that there was no statistical benefit in combining therapies. However, the major factor is that in the post-treatment follow-up period, chiropractic was 57% more effective in the reduction of headaches than drug therapy. In addition, it was reported that, with the drug group, "...58% experienced medication side effects important enough to report them. In the amatriptyline group, 10% of the subjects had to withdraw from the study because of intolerable side effects. Side effects in the SMT (Spinal Manipulative Therapy) group were much more benign, infrequent, mild and transitory. None required withdrawal from the study (Nelson et al., 1998, p. 511).
Using the 57% increased effectiveness that chiropractic has over drug therapy (leaving out the overlap that chiropractic could help without drugs) and the $24,000,000,000 ($24 billion) Americans pay for headaches and migraines, the savings would result in $13,680,000,000. back in the insurers, the public's and the government's pockets. In addition, if chiropractic reduced the necessity for emergency room visits by 57%, then the ED doctors could focus on what their primary purpose is, to save lives in urgent scenarios.”
Retrieved from: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=533:headaches-and-migraines-chiropractic-saves-federal-and-private-insurers-13-680-000-000-and-resolves-many-issues-facing-emergency-rooms-today&Itemid=320
Studin and Owens (2011) also reported, “Bryans, et. al. (2011) confirmed Nelson's findings and reported that spinal manipulation (adjusting) is recommended for patients with episodic or chronic migraines with or without aura and patients with cervicogenic headaches. This follow-up study is not a comparison or comment on the use of drugs. It simply demonstrates that chiropractic is a viable solution for many and can save the government and private industry billions in expenditures both in health care coverage, loss of productivity and avoidance of absenteeism in industry creating a new level of cost as sequella to headaches.” Retrieved from: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=533:headaches-and-migraines-chiropractic-saves-federal-and-private-insurers-13-680-000-000-and-resolves-many-issues-facing-emergency-rooms-today&Itemid=320
Chaibi, Benth, Tuchin and Bjorn (2017) reported,“The results of the current study and previous CSMT (chiropractic spinal manipulative therapy) studies suggest that AEs are usually mild and transient, and severe and serious AEs (adverse effects) are rare (Tuchin, 2012; Cassidy et al., 2008, 2016). These findings are in accordance with the World Health Organization guidelines on basic training and safety in CSMT, which has considered it to be an efficient and safe treatment modality (WHO, 2005). AEs in migraine prophylactic pharmacological RCTs (random control trials) are common (Jackson et al., 2015). The risk for AEs during manual-therapy appears also, to be substantially lower than the risk accepted in any medical context for both acute and prophylactic migraine medication (Jackson et al., 2015; Ferrari et al., 2001). Non-pharmacological management also has the advantage of no pharmacological interactions/AEs because such therapies are usually mild and have a transient characteristic, whereas pharmacological AEs tend to be continuous.” (pg. 70)
Mackenzie, Phillips, and Lurie (2015) reported on the safety in general for chiropractic patients and based their study on 6,669,603 subjects and after the unqualified subjects had been removed from the study, the total patient number accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified”(Whedon et al., 2015, p. 5). This study supersedes all the rhetoric about chiropractic and stroke and renders an outcome assessment to help guide the triage pattern of mechanical spine patients.
When considering the outcomes for chiropractic care vs. drug therapy and the safety for migraine sufferers and all other types of chiropractic patients in a large population study, chiropractic should be considered the first option for both referrals from medical primary care providers and the first treatment option for the public. This validates the common-sense approach to healthcare of “drugless first, drugs second and surgery last.” Too often, society for issues that are not germane to this argument, rely on dogma for healthcare solutions often a large risk to themselves and the results affect the entire socio-economics of that person’s life.
References:
Chiropractic Improves Neck Pain in a Military Veteran Population & Lowers the Need for Opiates
By Mark Studin
William Owens
A Report on the Scientific Literature
According to the American Academy of Pain Medicine, neck pain accounts for 15% of commonly reported pain conditions. Sinnott, Dally, Trafton, Goulet and Wagner (2017) reported:
Neck and back pain problems are pervasive and associated with chronic pain, disability and high healthcare utilization. Among adults 60% to 80% will experience back pain and 20% to 70% will experience neck pain that interferes with their daily activities during their lifetime. At any given time, 15% to 20% of adults will report having back pain and 10% to 20% will report neck pain symptoms. The vast majority of back and neck pain complaints are characterized in the literature as non-specific and self-limiting.” (pg. 1)
The last sentence above describes why back and neck pain has contributed significantly to the opioid crisis and why our population, after decades still suffers from back and neck problems that have perpetuated. Mechanical lesions of the spine are not “self-limiting” and are not “non-specific.” They are well-defined and based upon Wolff’s Law (known since the 1800’s) don’t go away. Allopathy (Medicine) has purely focused on the pain and has vastly ignored the underlying cause of the neuro-bio-mechanical cause of the pain.
Corcoran, Dunn, Green, Formolo and Beehler (2018) reported that musculoskeletal problems as the leading cause of morbidity for female veterans and females are more prone to experience neck pain than men. In addition, there has been a 400% increase in opioid overdoes deaths in females since 1999 compared to 265% for men and as a result, the Veterans Health Administration has utilized chiropractic as a non-pharmacological treatment option for musculoskeletal pain. Neck pain has also comprised of 24.3% of musculoskeletal complaints referred to chiropractors.
Corcoran et. Al. also reported with chiropractic care, based upon a numeric rating scale (NRS) and the Neck Bournemouth Questionnaire (NBQ) scores, the NRS improved by 45% and the NBQ improved by 38%, with approximately 65% exceeding the minimum clinically important difference of 30%. A previous study of male veterans revealed a 42.9% for NSC and a 33.1 improvement for NBQ; statistics similar to female veterans.
Although this is a very positive outcome that has helped many veterans, the percentages do not reflect what the authors have found in their clinical practices. These authors of this article (Studin and Owens) reported that for decades, cervical pain has been eradicated in 90 and 95% of the cases treated in our practices. The question begs itself, why is the population of veterans showing statistics less than half?
Corcoran, et. Al. (2018) reported how the chiropractic treatment was delivered in their study:
The type of manual therapy varied among patients and among visits, but typically included spinal manipulative therapy (SMT), spinal mobilization, flexion – distraction therapy, and or myofascial release. SMT was operatively defined as a manipulative procedure involving the application of a high - velocity, low – ample to thrust the cervical spine. Spinal mobilization was defined as a form of manually assisted passive motion involving repetitive joint oscillations typically at the end of joint playing without application of a high- velocity, low – ample to thrust. Flexion – distraction therapy is a gentle form of a loaded spinal manipulation involving traction components along with manual pressure applied to the neck in a prone position. Myofascial release was defined as manual pressure applied to various muscles on the static state or all undergoing passive lengthening.
The above paragraph explains why the possible disparity in outcomes as Corcoran et. Al do not reflect the ratios of who received high-velocity low-amplitude chiropractic spinal adjustment vs. the other therapies. When considering the other modalities; mobilization, flexion distraction therapy and myofascial release we must equate that to the outcomes physical therapist realize when treating spine as those are their primary reported treatment modalities. The following paragraphs indicate why spine care delivered by physical therapist is inferior to a chiropractic spinal adjustment, which equates to only a portion of the referenced chiropractic treatment modalities cited in the Corcoran Et. Al. The following citations conclude why these modalities provide inferior results compared to the high-velocity, low-amplitude chiropractic spinal adjustment that was exclusively used by the authors and rendered significantly higher positive outcome.
Studin and Owens (2017) reported the following:
Groeneweg et al. (2017) also stated:
This pragmatic RCT [randomized control trial] in 181 patients with non-specific neck pain (>2 weeks and <1 year) found no statistically significant overall differences in primary and secondary outcomes between the MTU (manual Therapy University) group and PT group. The results at 7 weeks and 1 year showed no statistically and clinically significant differences. The assumption was that MTU was more effective based on the theoretical principles of mobilization of the chain of skeletal and movement-related joint functions of the spine, pelvis and extremities, and preferred movement pattern in the execution of a task or action by an individual, but that was not confirmed compared with standard care (PT). (pg. 8)
Mafi, McCarthy and Davis (2013) reported on medical and physical therapy back pain treatment from 1999 through 2010 representing 440,000,000 visits and revealed an increase of opiates from 19% to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the costs for managing low back pain patients (not correcting anything, just managing it) has reached $106,000,000,000 ($86,000,000,000 in health care costs and $20,000,000,000 in lost productivity).
Cifuentes et al. (2011) started by stating:
Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used. (p. 396). The authors concluded by stating: “After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (Cifuentes et al., 2011, p. 404).
Mafi, McCarthy and Davis (2013) stated:
Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005...In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period, use of recommended treatments would increase and use of non-recommended treatments would decrease. (p. 1574)
(http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320)
The above paragraph has accurately described the problem with allopathic “politics” and “care-paths who have continued to report medical “dogma” and have ignored the scientific literature results of chiropractic vs. physical therapy.
Mafi, McCarthy and Davis (2013) concluded:
Despite self-reported overwhelming evidence where there were 440,000,000 visits and $106,000,000,000 in failed expenditures, they hypothesized that increased utilization for recommended treatment would increase. The recommended treatment, as outlined in the opening two comments of this article, doesn’t work and physical therapy is a constant verifying a “perpetually failed pathway” for mechanical spine pain. (p. 1574)
(http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320)
Despite the disparity in statistics, the literature is clear chiropractic renders successful out comes for both male and females, and the spine is not discriminatory for veterans versus non-veterans and offers a successful solution in lieu of the utilization of opiates for musculoskeletal spinal issues. In addition, the labels “non-specific” and “self – limiting” are inaccurate and have been placed by providers with no training in the biomechanics of spine care. Chiropractors has been trained in spinal biomechanics for over 100 years and currently there are advanced courses in spinal biomechanical engineering, of which many chiropractors have concluded.
References:
Chiropractic and Prescriptive Rights
Should Chiropractors Be Allowed to Prescribe Drugs?
By Mark Studin DC, FASBE(C), DAAPM, DAAMLP
Citation: Studin M. (2018) Chiropractic and Prescriptive Rights; Should Chiropractors be Allowed to Prescribe Drugs? American Chiropractor, 40 (3) 16, 17, 18, 19
As the rhetoric and legislative agendas escalate nationally on chiropractic and pharmaceutical prescriptive rights, as a profession, we need to take pause and consider the long-term effects of our actions. The question is, “Are we responsibly evolving or are we creating a problem that could put chiropractic back decades in utilization?” Please understand that this argument is totally devoid of any philosophy or beliefs in chiropractic principles or results; it is purely focused on increasing the utilization and business of every chiropractic practice in the country for the betterment of our patients.
Based upon an informal, but lengthy poll of many in our profession, one of the core reasons for wanting to add prescriptive rights is to help increase utilization at the practice level. The majority believe that if we could prescribe even non-narcotics, then patients would stay in our offices vs. seeking medical care for pain relief and a pro forma prescription to physical therapy with a resultant decrease in utilization of our offices. Unfortunately, that has been the national trend for far too long.
The question begs, “Are prescriptive rights the solution for both the chiropractic profession and our society? Over the last decade, I have been focused on increasing the level of clinical excellence of the practicing chiropractor, which has nothing to do with technique, philosophy or documentation. The level of clinical excellence has been centered on patient management, including accurately diagnosing, prognosing and triaging patients. The reason, medicine focuses on patient diagnosis and management and chiropractic has historically focused on treatment, too often bypassing rendering a thorough and conclusive diagnosis prior to rendering care. Therefore, my areas of focus are MRI spine interpretation, spinal biomechanical engineering, accident engineering, spinal trauma pathology and diagnosing spinal issues beyond subluxation.
Why concern ourselves with the medical community? The answer, quite simply, is that medical utilization is over 95% nationally and chiropractic is well below 10% and has been eroding steadily over the last decade. IF chiropractic can “tap” into that 95% and have every medical doctor in the nation consider chiropractic as the first choice for mechanical spine issues (excluding fracture tumor or infection), then we will rapidly change the culture of our society and resolve our utilization challenges rapidly. This is called “primary spine care.”
Over the last 10 years, I have been teaching in both chiropractic and medical academia and have cooperatively created courses in chiropractic in the above genres. As a result, the doctors who have taken these courses are getting the exact same level of education as many of our medical counterparts. The results, we are now functioning at a “peer” level that has garnered respect NOT because we get people well without drugs. That respect is because we understand spine at an extremely high level, often more so than our medical counterparts and they find themselves consulting with us on many of their more challenging cases looking for solutions. In turn, they also have been referring us many of their mechanical spine cases to manage because many medical doctors realize they are poorly equipped with nothing but drugs that are often too often addictive or end up with surgery as the only other option.
The primary care medical providers, medical specialists and emergency rooms that we work with nationally have expressed their gratitude for helping these patients by redirecting their care to the properly credentialed chiropractor and preventing further opiate abuse and/or the side effects of non-narcotics as well. The way they thank us is in the form of a perpetual streams of referrals. A case in point was in Cedar Park, Texas, where one of our doctors, 8 years into practice, sat with an orthopedic surgeon and discussed MRI spine interpretation. After a 1-hour conversation, the surgeon said to the doctor, “I love chiropractic; I just couldn’t find a smart enough chiropractor to trust with my referrals until now. Your knowledge of spine and MRI is equal to mine and from here forward, you will get all of my non-surgical referrals!” That doctor left with 8 referrals instantly and 1 year later has had a steady stem of referrals . I could share similar stories from Dayton, Ohio, Buffalo, New York, America Fork, Utah, Denver, Colorado, Fair Lawn, New Jersey and dozens of other locations across the United States. The formula is working; it is reproducible and is purely based upon clinical excellence beyond adjusting!
As a note, many get angry with our chiropractic colleges for not teaching us enough…Remember, our chiropractic colleges are charged with giving us the basics to get started and they do an outstanding job in that role. I applaud them and so should you in the form of donations to their research departments. In medicine, it is no different, they get a basic education and THEN go back to school to become specialized. What you do with YOUR career after graduation is on YOU.
We now have hospital emergency departments nationally reaching out to our doctors purely based upon their curricula vitae’s (CVs) because the doctors in our program are trained in what needs to be on their CVs with the resultant knowledge base behind those credentials. AND…for clarity (unlike my former beliefs), letters after your DC are not as important as the specific citations or credentials in your CV.
Utilization
Having been involved politically at the national and state levels for quite some time, I can say with a great degree of certainty that very little healthcare legislation (chiropractic falls under this category) in this country at either level gets passed without the blessing of the medical community. By attempting to add prescriptive rights to our scope, we will be threatening the utilization of medicine on a national scale and it will potentially close many of those doors that are currently opening at a rapid rate. The medical schools and research departments that have opened their doors to chiropractic (us) have done so primarily as a possible solution to the opiate epidemic in our country and we cannot be “Pollyannaish” and say we only want to prescribe non-narcotics. It has been clearly documented that this is a well-established “gateway” to addictive narcotics as when non-narcotics fail to offer relief, those patients need something else. Chiropractic care is that “something else” for mechanical spine pain, which is in the top 10 diagnoses for both emergency rooms and primary care medical providers who often have no solution other than drugs or surgery. Medicine’s only other historical care path with regards to mechanical spine diagnosis and management is physical therapy, which renders significantly inferior outcomes for spine vs. chiropractic based upon recent literature (a topic for another article) and one where far too many patients have ended up in pain management (narcotics) as the final solution.
Currently, our profession is at a cross-road on the prescriptive rights issue and if taken, could turn out to be a “very slippery slope” that could further erode our utilization and lead to increased iatrogenic issues in our society. I empathize with those doctors clinging to hope for a “quick fix” for their individual practices. However, as outlined above, there are viable solutions for every practice in the nation with none involving “get rich quick” paradigms. As I also consult many medical providers at various levels and I can report that their prescription pads are not making them wealthy, should they practice ethically. Their utilization and income increases as they get better at what they do and in chiropractic, we are no different.
Although our paradigm for increased utilization is working through increasing our clinical excellence, we are just starting to see this happen on a larger scale and the only way to have that upward spiral go faster, is if more chiropractors realize that the only way up is though academia and a strategic plan behind your new level of clinical excellence. So please hurry because your local medical community is waiting for you with that 95% to refer.
Chiropractic Reduces Opioid Use by 55% in Low Back Pain
By Mark Studin
William J. Owens
A report on the scientific literature
In the United States, of the adults who were prescribed opioids, 59% reported back pain.1 According to Statistia, the percentage of adults in the United States in 2015 with low back pain was 29.1% (https://www.statista.com/statistics/684597/adults-prone-to-selected-symptoms-us/) and in 2017 that number was 49% for all back-pain sufferers reporting symptoms (https://www.statista.com/statistics/188852/adults-in-the-us-with-low-back-pain-since-1997/).
Peterson ET. AL. (2012) reported:
[The] Prevalence of low back pain is stated to be between 15% and 30%, the 1-year period prevalence between 15% and 45%, and a life-time prevalence of 50% to 80%” (pg. 525).
While acute pain is a normal (author’s note: pain is never normal) short-lived unpleasant sensation triggered in the nervous system to alert you to possible injury with a reflexive desire to avoid additional injury, chronic pain is different. Chronic pain persists and fundamentally changes the patient’s interaction with their environment. In chronic pain it is well documented that aberrant signals keep firing in the nervous system for weeks, months, even years. (http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm)
Baliki Et. AL. (2008) stated
Pain is considered chronic when it lasts longer than 6 months after the healing of the original injury. Chronic pain patients suffer from more than pain, they experience depression, anxiety, sleep disturbances and decision-making abnormalities that also significantly diminish their quality of life (pg. 1398).
Chronic pain patients also have shown to have changes in brain function in sufferers with Alzheimer’ disease, depression, schizophrenia and attention deficit hyperactivity disorder giving further insight into disease states. In addition, chronic pain has a cause and effect on the morphology of the spinal cord and the brain resulting in a process termed “linear shrinkage”, which has been suggested to cause ancillary negative neurological sequella.
Apkarian Et. Al. (2004) reported that “Ten percent of adults suffer from severe chronic pain. Back problems constitute 25% of all disabling occupational injuries and are the fifth most common reason for visits to the clinic; in 85% of such conditions, no definitive diagnosis can be made.” (pg. 10410)
Whedon, Toler, Goel and Kazal (2018) reported the following:
One in 5 patients with noncancer pain or pain related diagnosis is prescribed opioids in office-based setting… primary care clinicians account for 50% of opioid prescriptions (Pg. 1). 1 day of opioid exposure carries a 6% chance of being on opioids 1year later, increasing to 13.5% by 8 days and 29.9% by 31 days. Among drug overdoses in the United States in 2014, 28,647, 61% involved an opioid. Opioids were involved in 75% of pharmaceutical deaths in 2010 and in 2015 over 22,000 deaths involved in prescription opioids were recorded-an increase of 19,000 deaths over the previous year (pg. 2).
Perhaps a portion of this phenomena is related to the training of medical primary care providers regarding musculoskeletal conditions. Studin and Owens reported (2016):
Day Et. Al. (2007) reported that only 26% of fourth year Harvard medical students had a cognitive mastery of physical medicine (pg. 452). Schmale (2005) reported “Incoming interns at the University of Pennsylvania took an exam of musculoskeletal aptitude and competence, which was validated by a survey of more than 100 orthopaedic program chairpersons across the country. Eighty-two percent of students tested failed to show basic competency. Perhaps the poor knowledge base resulted from inadequate and disproportionately low numbers of hours devoted to musculoskeletal medicine education during the undergraduate medical school years. Less than 1⁄2 of 122 US medical schools require a preclinical course in musculoskeletal medicine, less than 1⁄4 require a clinical course, and nearly 1⁄2 have no required preclinical or clinical course. In Canadian medical schools, just more than 2% of curricular time is spent on musculoskeletal medicine, despite the fact that approximately 20% of primary care practice is devoted to the care of patients with musculoskeletal problems. Various authors have described shortcomings in medical student training in fracture care, arthritis and rheumatology, and basic physical examination of the musculoskeletal system (pg. 251).
With continued evidence of lack of musculoskeletal medicine and a subsequent deficiency of training in spine care, particularly of biomechanical orientation, the question becomes which profession has the educational basis, training and clinical competence to manage these cases? Let’s take a closer look at chiropractic education as a comparison. Fundamental to the training of Doctor of Chiropractic according to the American Chiropractic Association is 4,820 hours (compared to 3,398 for physical therapy and 4,670 to medicine) and receive a thorough knowledge of anatomy and physiology. As a result, all accredited Doctor of Chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. So important to practice are these courses that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education requires a curriculum which enables students to be “proficient in neuromusculoskeletal evaluation, treatment and management.” In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. As a result, students are afforded the opportunity to practice utilizing this basic science information for many hours prior to beginning clinical services in their internship.
Whedon, Toler, Goel and Kazal (2018) continued:
Recently published clinical guidelines from the American College of Physicians recommended nonpharmacological treatment is the first – line approach to treating back pain, with consideration of opioids only is the last treatment option or if other options present substantial harm to the patient. Recent systematic review and meta-analysis found that for treatment of acute low back pain, spinal manipulation provides a clinical benefit equivalent to that of an NSAID’s, with no evidence of serious harm. Spinal manipulation is also shown to be an effective treatment option for chronic low back pain (pg. 2).
A retrospective claims study of 165,569 adults found that utilization of chiropractic services delivered by Doctor of Chiropractic was associated with reduced use of opioids. More recently, it was reported that the supply chiropractors as well as spending on spinal manipulative therapy is inversely correlated with opioid prescriptions in younger Medicare beneficiaries. This finding suggests that increased availability and utilization of services delivered by Doctor of Chiropractic could lead to reductions in opioid prescriptions. It has been reported that services delivered by Doctor of Chiropractic may improve health behaviors and reduced use of prescription drugs… Pain management services provided by Doctor of Chiropractic may allow patients use lower less frequent doses of opioids, leading to lower costs and reduce risk of adverse effects loops getting together (pg. 2).
Although chiropractic has been clinically reporting for over 100 years positive outcomes for a vast array of conditions inclusive of low back pain the American Medical Association (AMA) has been a significant opponent historically. Although the AMA’s position has been well chronicled through lawsuits such as Wilk v. American Medical Association, 895 F.2d 352 (7th Cir. 1990)
(https://openjurist.org/895/f2d/352/wilk-dc-dc-dc-dc-v-american-medical-association-a-wilk-dc-w-dc-b-dc-b-dc), in 2017 it appears they have reversed their position. In the August 2017 Journal of the American Medical Association’s “Clinical Guideline Synopsis for Treatment of Low Back Pain” under the heading MAJOR RECOMMENDATIONS, spinal manipulation is recommended as a first – line therapy, with a strong recommendation. As the AMA did not list Chiropractic specifically and based upon clinical guidelines of other highly regarded medical institutions such as the Cleveland Clinic and the Mayo Clinic, physical therapy is probably high on their list as first-line of referral for spinal manipulation (This is a topic for another article and nomenclature utilized by chiropractic). When considering the treatment of mechanical spine issues comparatively between chiropractic and physical therapy the outcomes are overwhelmingly in chiropractic’s favor as reported by Studin and Owens (2017)
Mafi, McCarthy and Davis (2013) reported on medical and physical therapy back pain treatment from 1999 through 2010 representing 440,000,000 visits and revealed an increase of opiates from 19% to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the costs for managing low back pain patients (not correcting anything, just managing it) has reached $106,000,000,000 ($86,000,000,000 in health care costs and $20,000,000,000 in lost productivity).
Mafi, McCarthy and Davis (2013) stated:
Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005...In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period, use of recommended treatments would increase and use of non-recommended treatments would decrease. (p. 1574)
The above paragraph has accurately described the problem with allopathic “politics” and “care-paths.” Despite self-reported overwhelming evidence of chiropractic vs. physical therapy outcomes for spine, where there were 440,000,000 visits and $106,000,000,000 in failed expenditures, they hypothesized that increased utilization for recommended treatment would increase. The recommended treatment, as outlined in the opening two comments of this article, doesn’t work and physical therapy is a constant verifying a “perpetually failed pathway” for mechanical spine pain.
http://uschiropracticdirectory.com/index.php?option.com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320
Whedon, Toler, Goel and Kazal (2018) reported the concluded:
In 2013, average annual charges per person for filling opioid prescriptions were 74% lower among recipients compared with non-recipients (author’s note: recipients are referring to those patients receiving chiropractic care). For clinical services provided at office visits for low back pain, average annual charges per person in 2013 were 78% lower among recipients compared with non-recipients. The authors have similar between – Cohort differences in charges in 2014: annual charges per person were 70% lower with opioid prescriptions and 71% lower for clinical services among recipients compared with nonrecipients. The Adjusted likelihood find prescription for the opiate analgesic in 2014 was 55% lower among recipients compared with nonrecipients.
…the Adjusted likelihood of filling a prescription opioid analgesic was 55% lower for recipients of services provided by Doctor of Chiropractic compared with non-recipients (pg. 4)
The above reports evidenced based outcomes verifying chiropractic must be considered as the first-line of referrals, or Primary Spine Care Providers for mechanical spine diagnosis (no fracture, tumor or infection). The evidence also reveals that chiropractic outcomes exceed those of physical therapy and medicine for mechanical spine diagnosis. Unfortunately, it has taken 10,000’s of opioid related deaths to bring chiropractic to the forefront and start to eradicate the medical dogma against chiropractic and consider chiropractic as the 1st referral option for spine.
References:
Chiropractic Verified as
Primary Spine Care Providers
By Mark Studin
William J. Owens
A report on the scientific literature
Primary Spine care simply means being the first referral option for spine care in instances other than fracture, tumor or infection. Having a chiropractic degree is paramount and the first step in the process, but one must not forget that any doctoral training, no matter the specialty (i.e. medicine, dentistry, podiatry, etc.) is the start of a provider’s educational journey and what we do with that training is up to the doctor in clinical practice. Erwin, Korpela and Jones (2013) stated “The function of the PSCP (Primary Spine Care Provider) could easily be assumed by chiropractic, but this window of opportunity may be limited. If chiropractic does not seek to evolve, what role does chiropractic have left to perform.” (Pg. 289)
Although these authors agree that chiropractors in clinical practice can assume the role as PSCP’s in the healthcare system, we strongly disagree with the direction suggested by Erwin, Korpela and Jones. The solution is not to prescribe more drugs in an “already over-drugged society,” the solution is being able to manage the patient in a collaborative environment on a peer level being “expert” on common healthcare issues. The underlying tenant is that there is no drug for a mechanical problem, it is with that initial focus that allows chiropractic to assume a role that no other profession can accomplish. True PSCP management includes being able to accurately diagnose/triage patients and the ability to use and understand MRI is a prime example. Herzog, Elgart, Flanders and Moley (2017) reported a 43.6% error rate of general radiologists inaccurately reporting the morphology of the intervertebral disc. This underscores that when a doctor of chiropractic relies on the MRI report without understanding how to interpret the image and clinically correlate the findings to the patient’s symptoms, there is close to a 50% error rate in rendering an accurate diagnosis, prognosis and treatment plan. A PSCP must have a complete and independent diagnostic scope of practice in order to fill a useful and clinically significant role.
To use an example in a current and modern setting, a doctor of chiropractic in Cedar Park, Texas was granted a “brief 10-minutes” to meet with an orthopedic surgeon. During that short meeting the chiropractor, an 8-year graduate spoke solely and specifically of his MRI slice thickness protocols and his MRI interpretation training which is cross-credentialed in both chiropractic and medical academia. One hour later [the meeting continued well past the initial “10-minutes” suggested], the orthopedic surgeon said, “I respect chiropractic, but have very little respect for the level of training of chiropractors in our region.” This 8-year graduate walked out with 8 referrals instantly and now 1 year later, has been getting referrals weekly. That is very definition of Primary Spine Care, the orthopedic surgeon trusts the chiropractor’s ability to manage and diagnose patients and now is “off-loading” the non-surgical patients to someone that can effectively manage that case. It is because of this specific advanced training that the chiropractor is successful.
In a second recent example, in Utah, a chiropractor decided that his post-doctoral training should be focused on spinal trauma care and triage, including more specifically, MRI Spine Interpretation, Spinal Trauma Pathology, Spinal Biomechanical Engineering and Stroke Evaluation. As a result, a hospital system that has over 900 auto accident cases monthly in 5 local hospitals reached out to him to manage their spine cases (all of them). This was based purely on his curriculum vitae and the inherent credentials and knowledge base from his continued education training in the above courses. Since then, Brigham Young University’s Athletic Department and the PGA (Professional Golf Association) have both sought his services. Please don’t overlook the fact THEY ran after him to be their first option for spine; that is Primary Spine Care and credentials matter.
Thirdly, in Buffalo NY, 5 teaching hospitals refer exclusively to one chiropractor’s office and their emergency rooms refers close to 60 spine patients per month to him with that number growing steadily. This past week, the neurosurgical department just informed this doctor that their 23 neurosurgeons will be referring their non-surgical cases to this office and will be directing many of their referral sources to START with this doctor to screen for surgery and let him decide who to refer for surgical consultation. That is Primary Spine Care.
Although individual reporting does not make a trend in the profession, these are not isolated cases, and this is NOW THE TREND in chiropractic we are seeing nationally, there are similar stories in most states. None of the successes involve adding drugs as a tool of the chiropractic, however in every case becoming smarter in spine care was mandatory. In all cases it is a properly trained doctor of chiropractic that is leading Primary Spine Care alongside medical specialty and primary care in a collaborative environment as peers, when clinically indicated.
Most of the Primary Spine Care “equation” is verifying chiropractic care as the “best choice” for the “first referral”. That is being achieved though peer-reviewed outcome based studies and involves all phases of care starting with initial pain management to corrective spine care and finally when required, health maintenance care for cases that need non-opioid and non-surgical long-term management. Historically and all too frequently in current medicine, either medical management or physical therapy is considered for mechanical spine issues as the first treatment of choice. Cleveland Clinic, one of the better-known centers of medical excellence currently posted the following regarding the treatment of back pain; “These patients may be best served through prompt access to care from physical therapists or nurse practitioners as entry-level providers. When pain persists beyond four to six weeks, the care path defines when referral to spine or pain specialists, spine surgeons or behavioral health providers is indicated.” (https://consultqd.clevelandclinic. org/2014/11/sticking-with-proven-practices-for-low-back-pain/) The Mayo Clinic Staff (2017) also reported: “Physical therapy is the cornerstone of back pain treatment.”
When considering the best option for Primary Spine Care, we should consider “what” type of provider renders the best outcomes in population based studies and has the autonomy to manage the case independent of primary care and medical specialty. Based upon population based studies, both the Cleveland and Mayo clinics got it wrong as their opinions are not based upon contemporary literature and appear to be rooted in “age-old biases.” Their suggested care paths are similar to prior care paths that perhaps have led to the long-term mismanagement of mechanical spine pain that has in part, contributed to the opioid crisis.
Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) in a population based study of 5511 injured workers in Ontario Canada as reported by the Workplace Safety and Insurance Board, a governmental agency reported a comparison of outcomes for back pain among patients seen by three types of providers: medical physicians, chiropractors and physical therapists. The found “The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation.” (pg.392) and “These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.” (pg. 382)
Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) continued, “The cohort study of American workers with back pain conducted by Turner et al. found that the first healthcare provider was one of the main predictors of work disability after a year. In accordance with our findings, workers who first sought chiropractic care were less likely to be work-disabled after 1 year compared with workers who first sought other types of medical care… We did not retrieve any study that directly compared physiotherapy care with other types of first healthcare providers in the context of occupational back pain, probably because most workers’ compensation systems still require a referral for physiotherapy. However, a study comparing primary physiotherapy care with usual emergency department care concluded that physiotherapy care leads to a prolonged time before patients return to their usual activities.” (pg. 389)
Cifuentes, Willets and Wasiak (2011) stated that chiropractic care during the health maintenance care period resulted in:
The study concluded that chiropractic care during the disability episode resulted in:
24% Decrease in disability duration of first episode compared to physical therapy
250% Decrease in disability duration of first episode compared to medical physician's care
5.9% Decrease in opioid (narcotic) use during maintenance care with physical therapy care
30.3% Decrease in opioid (narcotic) use during maintenance care with medical physician's care
32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care
21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care
Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating,“After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP (low back pain) who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (pg. 404).
The above studies continue to verify chiropractic as a better “first option” for spine and that resolves the “what provider is best” question by using an Evidence Based approach. The “who is best” within that subset is what type of chiropractor is better suited to lead in Primary Spine Care is evident. As an example, although every medical doctor is licensed to do open heart surgery not all are trained and credentialed. Would you want a psychiatrist performing the procedure? The answer should be “they are licensed, but not qualified through training.” The same holds true for contemporary chiropractic and every chiropractor has the same opportunity. We are all held to a “continuing education standard” and are all required to seek post-doctoral training to maintain our licenses. There are a significant number of courses, both live and through enduring materials (online) to enable every chiropractor on the planet to attain the level of education mandated by the “referral sources” to be considered Primary Spine Care Providers.
Let’s not be Pollyannaish not to think that chiropractic can be successful in increasing utilization independent of the medical community and even the legal community for personal injury cases. As mentioned previously, the medical community DOES NOT CARE about your treatment approach, what they do care about is the “risk” of you missing a diagnosis. They need to trust you based on your training, and the do NOT care about what technique you use. What you do in your offices is up to you just like a pain management MD or a surgeon, remember, it’s how you triage and manage your patients that is the ultimate arbiter in having them consider you as the first option for spine care. Once you have responsibly secured the referral, based upon your clinical excellence, you get to independently decide the best course of care for your patient. Then it is business as usual during the treatment phase of care because results were never, and are not an issue in chiropractic.
REFERENCES:
The Mechanism of the Chiropractic
Spinal Adjustment/Manipulation:
Chiropractic vs. Physical Therapy for Spine
Part 5 of a 5 Part Series
By: Mark Studin
William J. Owens
Reference: Studin M., Owens W., (2017) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine, Part 5 of 5, American Chiropractor 39 (12) pgs. 20, 22, 24, 26, 28, 30, 31
A report on the scientific literature
According to the Cleveland Clinic (2017):
The Cleveland Clinic Spine Care Path is a process-based tool designed for integration in the electronic medical record (EMR) to guide clinical work flow and help providers make evidence-based guidelines operational.
The care path was developed by Cleveland Clinic’s Center for Spine Health with input from Department of Pain Management staff like Dr. Berenger. One goal was to match appropriate treatments and providers to patients at various points along the care continuum for low back pain.
“We know acute back pain is common and often resolves with simple therapy or even no therapy,” Dr. Berenger says. “For patients without red flags, imaging is rarely required.”
These patients may be best served through prompt access to care from physical therapists or nurse practitioners as entry-level providers. When pain persists beyond four to six weeks, the care path defines when referral to spine or pain specialists, spine surgeons or behavioral health providers is indicated. (https://consultqd.clevelandclinic. org/2014/11/sticking-with-proven-practices-for-low-back-pain/)
According to the Mayo Clinic Staff (2017):
Most acute back pain gets better with a few weeks of home treatment. Over-the-counter pain relievers and the use of heat or ice might be all you need. Bed rest isn't recommended.
Continue your activities as much as you can tolerate. Try light activity, such as walking and activities of daily living. Stop activity that increases pain, but don't avoid activity out of fear of pain. If home treatments aren't working after several weeks, your doctor might suggest stronger medications or other therapies. (http://www.mayoclinic. org/diseases-conditions/back-pain/basics/treatment/con-20020797
The Mayo Clinic Staff (2017) continued:
Physical therapy is the cornerstone of back pain treatment. A physical therapist can apply a variety of treatments, such as heat, ultrasound, electrical stimulation and muscle-release techniques, to your back muscles and soft tissues to reduce pain.As pain improves, the therapist can teach you exercises that can increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques can help prevent pain from returning. (http://www. mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797)
The above 2 scenarios are consistent with contemporary care paths for medicine regarding back pain. High velocity-low amplitude chiropractic spinal adjustments are not part of any medical institution’s care plan (to the current knowledge of the authors) despite the following compelling literature.
Coronado et al. (2012) reported:
Reductions in pain sensitivity, or hypoalgesia, following SMT [defined by the author as high velocity-low amplitude adjustment or a spinal adjustment] may be indicative of a mechanism related to the modulation of afferent input or central nervous system processing of pain. (p. 752)
Coronado et al. (2012) further asked the question:
…was whether SMT [defined by the author as high velocity-low amplitude or a spinal adjustment] elicits a general response on pain sensitivity or whether the response is specific to the area where SMT is applied. For example, changes in pain sensitivity over the cervical facets following a cervical spine SMT would indicate a local and specific effect while changes in pain sensitivity in the lumbar facets following a cervical spine SMT would suggest a general effect. We observed a favorable change for increased PPT [pressure pain threshold] when measured at remote anatomical sites and a similar, but non-significant change at local anatomical sites. These findings lend support to a possible general effect of SMT beyond the effect expected at the local region of SMT application. (p. 762)
Reed, Pickar, Sozio, and Long (2014) reported:
…forms of manual therapy have been clinically shown to increase mechanical pressure pain thresholds (i.e., decrease sensitivity) in both symptomatic and asymptomatic subjects. Cervical spinal manipulation has been shown to result in unilateral as well as bilateral mechanical hypoalgesia. Compared with no manual therapy, oscillatory spinal manual therapy at T12 and L4 produced significantly higher paraspinal pain thresholds at T6, L1, and L3 in individuals with rheumatoid arthritis. The immediate and widespread hypoalgesia associated with manual therapy treatments has been attributed to alterations in peripheral and/or central pain processing including activation of descending pain inhibitory systems.
Increasing evidence from animal models suggests that manual therapy activates the central nervous system and, in so doing, affects areas well beyond those being treated. (p. 277)
With regards to manual therapy versus physical therapy, this is where the phrase, “caveat emperor” should be used as the concept is misleading. Groeneweg et al. (2017) compared manual and physical therapies, recruiting 17 manual therapists and 27 physical therapists. The training of the manual therapists was from Manual Therapy University and were predominantly physical therapists who spent 3 years studying manual therapy.
Groeneweg et al. (2017) reported:
The manual therapist performs per protocol repeated passive joint movements with low velocity and intensity and high accuracy in different positions of the patient (sitting, supine and side-lying). The rhythm of the movements is slow (approximately 30 cycles/min) and the movements are repeated about six times. Treatment is in general painless. Passive joint movements are performed in a combination of rolling and sliding, or rocking and gliding (or swinging and sliding) in the joint, based on the arthrokinematic and osteokinematic principles of intra-articular movements. Passive movements are performed over the entire range of motion within the physiological range of motion of joints, whereby the curvature of the articular surface is followed, with manual forces directed to the joints/specific spinal level. Physiological joint range of motion is carefully respected. Traction, oscillation and high-velocity movements are not applied. In all patients, based on the assessment protocols, all joints of the spine, pelvis and extremities are mobilized in specific directions. (p. 3)
Groeneweg et al. (2017) also stated:
This pragmatic RCT [randomized control trial] in 181 patients with non-specific neck pain (>2 weeks and <1 year) found no statistically significant overall differences in primary and secondary outcomes between the MTU group and PT group. The results at 7 weeks and 1 year showed no statistically and clinically significant differences. The assumption was that MTU was more effective based on the theoretical principles of mobilization of the chain of skeletal and movement-related joint functions of the spine, pelvis and extremities, and preferred movement pattern in the execution of a task or action by an individual, but that was not confirmed compared with standard care (PT). (pg. 8)
The above article strongly confirms why language is important when describing the chiropractic spinal adjustment. Too many “lump together” all manual therapies and claim the effectiveness, or lack thereof, based on studies as the one above confirms. The article compared physical therapy to physical therapists who have gone for advanced education in what they already do in low-amplitude repetitive movements using “arthrokinematic and osteokinematic principles of intra-articular movements” meaning very specific per the anatomy. The outcome confirmed there is no difference between manual therapy and physical therapy because they are the same according to the description in the research. However, these therapies do not provide what chiropractic offers, although many hastily consider manual therapy and chiropractic care to be the same. Substance P is perhaps the most compelling evidence of why a chiropractic spinal adjustment should be considered the “first choice” for spinal care.
Evans (2002) reported:
In a series of studies, Brennan et al. investigated the effect of spinal HVLAT manipulation causing cavitation ("sufficient to produce an auditory release or palpable joint movement") on cells of the immune system. They found that a single manipulation to either the thoracic or lumbar spine resulted in a short-term priming of polymorphonuclear neutrophils to respond to an in vitro particulate challenge with an enhanced respiratory burst (RB) as measured by chemiluminescence in subjects with and without symptoms. The enhanced RB was accompanied by a two-fold rise in plasma levels of the neuropeptide substance P (SP).
SP is an 11-amino acid polypeptide and is one of a group of neuropeptides known as tachykinins. These are peptides that are produced in the dorsal root ganglion (DRG) and released by the slow-conducting, unmyelinated C-polymodal nociceptors in a process known as an "axon reflex." They are released into peripheral tissues from the peripheral terminals of the C-fibers. modulating the inflammatory process by "neurogenic inflammation.” They are also released from the central terminals of the nociceptors into the dorsal horn of the spinal cord, where they modulate pain processing and spinal cord reflex activity.
This neurophysiologic effect of spinal HVLAT manipulation seems to be force threshold-dependent. The threshold was found to lie somewhere between 450N and 500N for the thoracic spine and 400N for the lumbar spine. When compared with data from biomechanical studies of spinal manipulation, these forces would be sufficient to cause cavitation. The "SP" studies used "sham manipulation" as a control, consisting of a "low-velocity light-force thrust to the selected segment." rather like a mobilization. This illustrates that zygapophyseal HVLAT manipulations that cause cavitation produce physiological effects, not demonstrable by electromyography, that are totally different fi-om effects created by zygapophyseal manipulations that do not cause cavitation. (p. 255-256)
According to Hartford-Wright, Lewis, Vink and Ghabriel (2014):
Substance P (SP) is a neuropeptide released from the endings of sensory nerve fibers and preferentially binds to the NK1 receptor. It has a widespread distribution throughout the nervous system, where it is implicated in a variety of functions including neurogenic inflammation, nausea, depression and pain transmission as well as in a number of neurological diseases, including CNS tumors. (p. 85)
Low velocity manipulation, no matter how well it follows “arthrokinematic and osteokinematic principles of intra-articular movements,” will not effectuate the release of Substance P, only a chiropractic spinal adjustment with cavitation will do that. When considering the results of a chiropractic spinal adjustment, disability is a critical indicator with regards to the effectiveness of treatment outcomes.
Cifuentes, Willets and Wasiak (2011) compared different treatments of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability after a 15-day absence and return to disability. Anyone with less than a 15-day absence was excluded from the study. Please note that we kept disability outcomes for all reported treatment and did not limit this to physical therapy. However, the statistic for physical therapy is significant.
The Cifuentes, Willets and Wasiak (2011) study concluded that chiropractic care during the health maintenance care period resulted in:
The study concluded that chiropractic care during the disability episode resulted in:
24% Decrease in disability duration of first episode compared to physical therapy
250% Decrease in disability duration of first episode compared to medical physician's care
5.9% Decrease in opioid (narcotic) use during maintenance care with physical therapy care
30.3% Decrease in opioid (narcotic) use during maintenance care with medical physician's care
32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care
21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care
Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating, “After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (Cifuentes et al., 2011, p. 404).
Given that physical therapy has been the primary portal for mechanical spine issues (not fractures, tumors or infection) coupled with the contemporary opiate addiction and mortality issues, a different path must be sought as a matter of public safety. The only avenue for both medical primary care providers and specialists other than surgery is pain management in the form of opiates and that doesn’t resolve any issues, it only creates new addiction issues. Mechanical spine pain is one of the most common diagnoses.
According to Block (2014):
Over 100 million Americans experience chronic pain with common painful conditions including back pain, neck pain, headaches/migraines, and arthritis, in addition to other painful conditions such as diabetic peripheral neuropathy, etc... In a large study in 2010, 30.7% of over 27,000 U.S. respondents reported an experience of chronic, recurrent pain of at least a 6-month duration. Half of the respondents with chronic pain noted daily symptoms, with 32% characterizing their pain as severe (≥7 on a scale ranging from 0 to 10). Chronic pain has a broad impact on emotional well-being and health-related quality of life, sleep quality, and social/recreational function. (p. 1)
Mafi, McCarthy and Davis (2013) reported on medical and physical therapy back pain treatment from 1999 through 2010 representing 440,000,000 visits and revealed an increase of opiates from 19% to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the costs for managing low back pain patients (not correcting anything, just managing it) has reached $106,000,000,000 ($86,000,000,000 in health care costs and $20,000,000,000 in lost productivity).
Mafi, McCarthy and Davis (2013) stated:
Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005...In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period, use of recommended treatments would increase and use of non-recommended treatments would decrease. (p. 1574)
The above paragraph has accurately described the problem with allopathic “politics” and “care-paths.” Despite self-reported overwhelming evidence where there were 440,000,000 visits and $106,000,000,000 in failed expenditures, they hypothesized that increased utilization for recommended treatment would increase. The recommended treatment, as outlined in the opening two comments of this article, doesn’t work and physical therapy is a constant verifying a “perpetually failed pathway” for mechanical spine pain.
Chiropractic offers an evidence-based approach in developing an “outcome based “care path for mechanical spine pain. Although this article discusses pain, chiropractic offers more than simply pain management, however this discussion is limited to mechanical spine pain. Therefore, with chiropractic as the “first option” or “Primary Spine Care” focusing on the biomechanical pathological instability, the underlying cause of the pain can be addressed, leaving no further need to manage an issue that has been simply fixed.
References
1. Cleveland Clinic. (2017). Sticking with proven practices for low back pain, Introducing: Cleveland Clinic’s Spine Care Path. Retrieved from https://consultqd.clevelandclinic.org/2014/ 11/sticking-with-proven-practices-for-low-back-pain/
2. Mayo Clinic Staff. (2017). Treatments and drugs. Diseases and Conditions, Back Pain, Retrieved from: http://www.mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797
3. Coronado, R. A., Gay, C. W., Bialosky, J. E., Carnaby, G. D., Bishop, M. D., & George, S. Z. (2012). Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis. Journal of Electromyography Kinesiology, 22(5), 752-767.
4. Reed, W. R., Pickar, J. G., Sozio, R. S., & Long, C. R. (2014). Effect of spinal manipulation thrust magnitude on trunk mechanical activation thresholds of lateral thalamic neurons. Journal of Manipulative and Physiological Therapeutics, 37(5), 277-286.
5. Groeneweg, R., van Assen, L., Kropman, H., Leopold, H., Mulder, J., Smits-Engelsman, B. C., ... & van Tulder, M. W. (2017). Manual therapy compared with physical therapy in patients with non-specific neck pain: a randomized controlled trial. Chiropractic & Manual Therapies, 25(12), 1-12.
6. Evans, D. W. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics, 25(4), 251-262.
7. Harford-Wright, E., Lewis, K. M., Vink, R., & Ghabriel, M. N. (2014). Evaluating the role of substance P in the growth of brain tumors. Neuroscience, 261, 85-94.
8. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
9. Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine, 173(17), 1573-1581.
Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport College of Chiropractic, an Adjunct Post Graduate Faculty of Cleveland University - Kansas City, College of Chiropractic, an Adjunct Professor of Clinical Sciences at Texas Chiropractic College and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MRI spine interpretation, spinal biomechanical engineering and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www.DoctorsPIProgram.com), teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally and studies trends in healthcare on a national scale (www.TeachDoctors.com). He can be reached at www.teachchiros.com or at 631-786-4253.
Dr. Bill Owens is presently in private practice in Buffalo and Rochester NY and generates the majority of his new patient referrals directly from the primary care medical community. He is an Associate Adjunct Professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences, an Adjunct Post Graduate Faculty of Cleveland University - Kansas City, College of Chiropractic, an Adjunct Assistant Professor of Clinical Sciences at the University of Bridgeport, College of Chiropractic and an Adjunct Professor of Clinical Sciences at Texas Chiropractic College. He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at www.mdreferralprogram.com or 716-228-3847
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