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

 Mark Studin

William J. Owens

Noah Herbert

[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 50^th 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

1. (http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=816:should-chiropractic-follow-the-american-chiropractic-association-american-board-of-internal-medicine-s-recommendations-on-x-ray&Itemid=320).
2. (https://www.acatoday.org/Patients-Choosing-Wisely?utm_campaign=sniply)
3. (http://www.choosingwisely.org/clinician-lists/north-american-spine-society-advanced-imaging-of-spine-within-first-six-weeks-of-non-specific-acute-low-back-pain/)
4. Fedorak, C., Ashworth, N., Marshall, J., & Paull, H. (2003). Reliability of the visual assessment of cervical and lumbar lordosis: how good are we?.Spine,28
5. Ohara, A., Miyamoto, K., Naganawa, T., Matsumoto, K., & Shimizu, K. (2006). Reliabilities of and correlations among five standard methods of assessing the sagittal alignment of the cervical spine.Spine,31
6. [http://www.choosingwisely.org/clinician-lists/american-association-neurological-surgeons-imaging-for-nonspecific-acute-low-back-pain/]
7. Gedin, F., Dansk, V., Egmar, A. C., Sundberg, T., & Burström, K. (2018). Patient-reported improvements of pain, disability and health-related quality of life following chiropractic care for back pain–A national observational study in Sweden.Journal of Bodywork and Movement Therapies.
8. Panjabi, M. M. (1992). The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement.Journal of spinal disorders,5, 383-383.
9. Scheer, J. K., Passias, P. G., Sorocean, A. M., Boniello, A. J., Mundis, G. M., Klineberg, E., ... & Shaffrey, C. I. (2016). Association between preoperative cervical sagittal deformity and inferior outcomes at 2-year follow-up in patients with adult thoracolumbar deformity: analysis of 182 patients: Presented at the 2015 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves.Journal of Neurosurgery: Spine,24
10. (https://www.health.harvard.edu/cancer/radiation-risk-from-medical-imaging)
11. Tubiana, M., Feinendegen, L. E., Yang, C., & Kaminski, J. M. (2009). The linear no-threshold relationship is inconsistent with radiation biologic and experimental data.Radiolog 

  

 

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

 

Chiropractic Vertebral Subluxation

By Mark Studin

William J. Owens

 

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

 

A report on the scientific literature

 

INTRODUCTION

 

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

 

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

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

 

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

 

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

 

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

 

 

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

 

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

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

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

 

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

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

 

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

 

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

 

 

DISCUSSION

 

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

Panjabi (2006) reported:

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

Panjabi (2003) also reported:

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

 

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

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

 

 

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

 

Farrell et al. (2017) reported:

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

 

Farrell et al. (2017) later stated:

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

 

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

 

 

Evans (2002) reported:

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

 

 

 

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

 

Evans (2002) explained the images above as follows:

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

 

Evans (2002) continued:

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

 

Evans (2002) also noted:

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

 

 

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

 

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

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

 

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

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

 

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

 

 

The hypothesis consists of the following sequential steps:

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

 

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

 

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

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

 

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

 

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

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

 

 

CONCLUSION

 

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

 

 

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

 

References

 

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