US Chiropractic Directory Presents:
Low Back Problems
Low back problems are one of the most prevalent issues that people worldwide suffer. Low back pain has been called lumbago, sciatica and a host of other names, however to the public, it is literally a "pain in the butt." Chiropractic has been safely and effectively helping patents with pain in the back for over 100 years and The US Chiropractic Directory has create a forum of information involving 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 low back pain/problems.
Drug Use, Disability
& Non-Specific Back Pain
Yet Chiropractic Utilization Remains Relative Stagnant
By: Mark Studin DC
Citation: Studin M. (2021) Chiropractic Outcomes, Drug Use, Disability & Non-Specific Back Pain, American Chiropractor Magazine 43(6) 40, 42, 43-44
Low back pain remains an epidemic worldwide, with a lifetime prevalence, as reported by Balague et al. (2012), to be 84%. The prevalence of chronic low back pain is approximately 23%, with 11-12% of the population being disabled by low back pain.1 Despite the cost of managing back pain increasing substantially2, with consistent poor outcomes, medicine has dogmatically held onto the label of "non-specific low back pain." Non-specific low back pain is defined as low back pain not attributable to a recognizable, known specific pathology (e.g., infection, tumor, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome) and represents 90-95% of all back pain.1, 3
Both the evidence and technological advances have clarified that specific pathologies exist with this type of back pain. The label of "non-specific back pain" as a result is no longer applicable. There are mechanical lesions, they have negative neurological sequella, and are demonstrable. Gevers-Montoro (2021) reported the peripheral nervous system's effects, spinal cord mechanisms, supraspinal process, and nociceptors when treated chiropractically.4 Panjabe (2006) wrote, "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.5 (p. 669). Panjabi clarified why mechanical lesions create precise responses.
Solomonow reported (2009): "Inflammatory response in ligaments is initiated whenever the tissue is subjected to stresses which exceed its routine limits at a given time. For example, a sub-injury/failure load, well within the physiological limits of a ligament when applied to the ligament by an individual who does not do that type of physical activity routinely." 6 (p. 143) Jaumard, Welch, and Winkelstein (2011) reported: In the capsular ligament under stretch, the collagen fiber structure and the nerve endings embedded in that network and cells (fibroblasts, macrophages) are all distorted and activated. Accordingly, capsular deformations of certain magnitudes can trigger a wide range of neuronal and inflammatory responses…Although most of the proprioceptive and nociceptive afferents have a low-strain threshold (~10%) for activation, a few receptors have a high-strain threshold (42%) for signal generation via neural discharge. In addition, capsular strains greater than 47% activate nociceptors with pain signals transmitted directly to the central nervous system. Among both the low- and high-strain threshold neural receptors in the capsular ligament, a few sustain their firing even after the stretching of the capsular ligament is released. This persistent afterdischarge evident for strains above 45% constitutes a peripheral sensitization that may lead to central sensitization with long-term effects in some cases.7 (p. 12)
This type of cascading effect works in 2 directions, one to create a bio-neuro-mechanically failed spinal system, and one to correct a bio-neuro-mechanically failed system. Without delving into a myriad of evidence-based mechanisms, these alone should suffice to overcome the dogma of non-specific back pain."
As a result of these studies and many other outcome-based studies have positioned chiropractic to be considered the "best" first-line of treatment/management (Primary Spine Care Provider) for mechanical lesions. Whedon et al. reported the average annual charges per person for filling opioid prescriptions were 74% lower among chiropractic recipients than other therapies. They also reported the adjusted likelihood of filling a prescription opioid analgesic was 55% lower for recipients of chiropractic services provided by a Doctor of Chiropractic compared with other therapies.8
Blanchette et al. (2016) reported that medical care ended spinal-related compensation 12% longer than chiropractic, and physical therapy care required 239% more time to end full compensation than chiropractic. Medical care also required 20% more time and physical therapy 313% more time versus chiropractic care regarding partial compensation.9
Despite the overwhelming evidence, the Mayo Clinic, one of the world's prominent medical institutions, lists chiropractic in the last section under "Alternative Medicine" and states it "might ease symptoms" after checking with their doctor. Chiropractic is itemized near last after listing physical therapy, drugs (including antidepressants and narcotics), surgery, implanted nerve stimulators, radiofrequency neurotomy (surgery), steroid injections, and most of all, doing nothing.10
Ndetan et al. reported that over 96% of survey respondents with spine-related problems who said the use of chiropractic manipulation stated that the therapy helped them with their condition, with approximately a 46% increased odds that it helped when compared to osteopathic manipulation. (pg. 116) Compared these statistics to medicine, which persists in diagnosing 90-95% as non-specific low back and significant evidence of a perpetual failed care path.
Regarding the use of drugs, the opiate epidemic, and referrals from the medical community, Ndetan et al. continue, "Apart from the fact that chiropractic manipulation (chiropractic spinal adjustment) helped, they were less likely to report using prescription medications and surgery. Despite these potential benefits, these respondents also reported less likely to receive recommendations for chiropractic care from a medical doctor. Within this area of discussion is the consideration that since chiropractic patients are less likely to use medications for pain, perhaps a better referral system involving primary care providers would lessen the need for opiate medications and thereby play some role in the efforts to reduce the current abuse problems associated with this category of drugs in the United States." (pg. 116) With all the positive chiropractic evidence, only 10% of the population at best receives chiropractic care when 84% of people will experience back pain in their lifetime.11
Prominent medical establishments as the Mayo Clinic still list chiropractic as an alternative footnote after listing physical therapy, drugs (including antidepressants and narcotics), surgery, implanted nerve stimulators, a radiofrequency neurotomy (surgery), steroid injections, and most of all, doing nothing as primary treatment modalities. Despite the overwhelming evidence in the literature that non-specific back pain is a "very specific" patho-neuro-biomechanical lesion, medicine still ignores the proof that will help 84% of the population that will suffer back pain in their lifetime and is a financial drain on the healthcare system. With a reported 96% favorable outcome with chiropractic care, medicine still diagnosis 90-95% of back pain cases as "non-specific back pain," continues perpetual failed treatment pathways, and ignores the evidence.
CHIROPRACTIC SPINAL ADJUSTMENT / MANIPULATION
Manipulation vs. Mobilization
Part 1 of 2
Matt Erickson DC, FSBT
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
A report on the scientific literature
Kinetically,spinal manipulation is defined as a high-velocity low amplitude (HVLA) thrust maneuver. According to Ernst and Harkness (2001), “SM (spinal manipulation) involves high velocity thrusts with either a long or short lever-arm, usually aimed at reducing pain and improving range of motion (p. 879).
Kinetics and kinematics of motion (sub-areas of biomechanics) were described by Evans and Breen (2006). “Kinetics is the branch of mechanics that deals with motion (of an object) under the action of given forces. This includes static (equilibrium) states in which no movement is occurring and dynamic states in which forces may vary as movement occurs” (p. 72). “Kinematics is the branch of mechanics that deals with motion (of an object) without reference to force or mass. With a few notable exceptions, most biomechanical studies of spinal manipulation have given scant attention to kinematics” (p. 73). Thus, kinetics is the study of the type of force used with spinal manipulation while kinematics is the study of the motion geometry of the thrust.
Respectfully, spinal manipulation performed by a doctor of chiropractic is a specific chiropractic spinal adjustment (CSA). From an insurance coding a billing perspective, a CSA is also called a chiropractic manipulative treatment (CMT). In part 2 of this series, we will detail the necessity for that language. In this paper (part 1 of 2), we will focus on the definition of spinal manipulation and the different outcomes desired by disparate professions. However, the terminology of a specific chiropractic spinal adjustment needs to be considered at all times when referencing spinal manipulation in this article.
Zinovy and Funiciello (2018, Sept. 17, para. 2) regarding spinal manipulation reported, “This high-velocity, low-amplitude (HVLA) thrusts, also called chiropractic adjustments or osteopathic manipulative treatments (OMT), are carefully performed by applying enough force to push the spinal joint beyond the restricted range of motion with the goal of improving the joint’s function, increasing range of motion, and reducing pain. When a high-velocity manipulation is performed on the spine, it typically involves a cracking or popping sound that can be heard. Some people report feeling relief or enjoying the cracking sound, whereas others do not” (https://www.spine-health.com/conditions/neck-pain/manual-manipulation-and-mobilization-chronic-stiff-neck).
Conversely, spinal mobilization is kinetically defined as a low-velocity, low-amplitude force (LVLA) non-thrust maneuver used to help relieve pain, improve motion and restore function. Zinovy and Funiciello (2018, Sept. 17) regarding spinal mobilization wrote, “These low-velocity, low amplitude (LVLA) manipulations gradually work the spinal joints through their well-tolerable ranges of motion rather than forcing them beyond the normal limit. The practitioner’s hands gently move the vertebra and stretch each spinal level being worked. Spinal mobilization usually does not involve a neck-cracking sound” (para. 3).
Differentiating Spinal Manipulation Amongst Providers
In a United States-based review (which derived from an analysis of 67 articles and 9 books or textbooks) by Shekelle, Adams, Chassin, Hurwitz, Phillips and Brook (1991, P. 3), the authors stated “A recent analysis of a community-based sample of patients showed that chiropractors delivered 94% of all the manipulative care for which reimbursement was sought, with osteopaths delivering 4%, and general practitioners and orthopedic surgeons accounting for the remainder” (https://www.rand.org/pubs/reports/R4025z1.html).
In other words, DCs perform 94% of All spinal manipulations in the United States while Doctors of Osteopathy (DOs) perform 4% and subsequently, the remaining 2% of spinal manipulations are performed by Physical Therapists (PTs) and Medical Doctors (MDs).
Further, although Zinovy and Funiciello (2018, Sept. 17) reported the general goal of spinal manipulation is “improving the joint’s function, increasing range of motion, and reducing pain” (para. 2), beyond that, the intention of spinal manipulation amongst DCs, DOs and PTs is different. So, what is the difference?
Spinal Manipulation (CSA) According to DCs
In addition to improving joint function, increasing range of motion and reducing pain, spinal manipulation for DCs is about normalizing neuro-biomechanical biomechanical function and reducing neurological irritation to maintain optimal function of the nervous system. Petterman (2007) explained this is known as the Law of the Nerve (p. 168). DC’s more precisely regard spinal manipulation as a specific chiropractic spinal adjustment or chiropractic manipulative treatment (CMT). Andersson, Lucente, Davis, Kappler, Lipton and Leurgans (1999) reported in the New England Journal of Medicine, “The chiropractic approach is focused more on the nervous system and advocates adjustments of the spinal vertebrae to improve neurotransmission” (p. 1426).
Evans (2002), referring to the above images, described the cause of neuro-biomechanical dysfunction due to meniscoid entrapment as follows:
Meniscoid entrapment. 1) On flexion, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with It. 2) On attempted extension, the inferior articular process returns toward its neutral position, but instead of re-entering the joint cavity, the meniscoid impacts against the edge of the articular cartilage and buckles, forming a space-occupying "lesion" under the capsule. Pain occurs as a result of capsular tension, and extension is inhibited. 3) Manipulation of the joint involving flexion and gapping, reduces the impaction and opens the joint to encourage re-entry of the meniscoid into the joint space (4) [Realignment of the joint.] (p. 253)
Evans (2002) continued:
Bogduk and Jull reviewed the likelihood of intra-articular entrapments within zygapophyseal joints as potential sources of pain…Fibro-adipose meniscoid have also been identified as structures capable of creating a painful situation. Bogduk and Jull reviewed the possible role of fibro-adipose meniscoid causing pain purely by creating a tractioning effect on the zygapophyseal joint capsule, again after intra-articular pinching of tissue (p. 252). A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophyseal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent the impaction of the meniscoid. The patient would tend to be more comfortable with the spine maintained in a flexed position, because this will disengage the meniscoid. Extension would therefore tend to be inhibited. This condition has also been termed a “joint lock” or “facet-lock,” the latter of which indicates the involvement of the zygapophyseal joint…
Evans (2002) further added, “An HVLAT manipulation [chiropractic spinal adjustment CSA], involving gapping of the zygapophyseal joint, reduces the impaction and opens the joint, so encouraging the meniscoid to return to its normal anatomic position in the joint cavity. This ceases the distension of the joint capsule, thus reducing pain” (p. 252-253).
When considering the neuro-biomechanical lesion, (or vertebral subluxation complex [VSC] as traditionally coined) in its entirety, we must consider the etiology as these forces can lead to complex patho-biomechanical components of the spine and supporting tissues. As a result, a neurological cascade can ensue that would further define the lesion beyond the inter-articulation entrapments.
Panjabi (2006) reported, “Abnormal mechanics of the spinal column has been hypothesized to lead to back pain via nociceptive sensors. The path from abnormal mechanics to nociceptive sensation may go via inflammation, biochemical and nutritional changes, immunological factors, and changes in the structure and material of the endplates and discs, and neural structures, such as nerve ingrowth into the diseased intervertebral disc. The abnormal mechanics of the spine may be due to degenerative changes in the spinal column and/or injury of the ligaments. Most likely, the initiating event is some kind of trauma involving the spine. It may be a single trauma due to an accident or microtrauma caused by repetitive motion over a long time. It is also possible that spinal muscles will fire in an uncoordinated way in response to sudden fear of injury, such as when one misjudges the depth of a step. All these events may cause spinal ligament injury” (p.668-669).
In short, chiropractors primarily use a very specific high-velocity, low-amplitude spinal manipulation/ or a specific chiropractic spinal adjustment to correct the neuro-biomechanical dysfunction and reduce the neurological irritation/interference.
Spinal Manipulation According to DOs
The outcome for DOs is to improve overall blood flow throughout the body. As written by Petterman (2007), this is known as the Law of the Artery (p. 168). This is further supported by Andersson et al., (1999) who wrote, “The focus of osteopathic medicine has been the need to optimize the blood circulation to maintain or restore health” (p. 1426).
Further, DO’s perform non-specific spinal manipulation which they regard as osteopathic manipulative treatment (OMT). According to the American Osteopathic Association, “Through OMT, physicians manually apply a specific amount of pressure to different regions in the body. These techniques can help: Treat structural and tissue abnormalities, relieve joint restriction and misalignment, restore muscle and tissue balance and promote the overall movement of blood flow throughout the body (https://osteopathic.org/what-is-osteopathic-medicine/osteopathic-manipulative-treatment/).
Spinal Manipulation According to PTs
Like DOs, PTs perform non-specific spinal manipulation that is regarded as a unique form of manual therapy that they call thrust joint manipulation (TJM). According to Puentedura, Slaughter, Reilly, Venturan and Young (2017), “Thrust joint manipulation (TJM) is defined as a high-velocity low-amplitude thrust technique which can be distinguished from other joint mobilization techniques that do not utilize a final thrust maneuver” (p. 74).
Historically, in 1920, spinal manipulation was first introduced in Britain to physical therapists by the Osteopathic profession. Paris (2000) reported, “Osteopathic medicine and surgery was founded by Andrew Taylor Still in 1874” (p. 68). Pettman (2007) reported, in 1892, Andrew Still established the American Osteopathic College in Kirksville, Missouri. Conversely, in 1897, DD Palmer opened Palmer College of Cure which is now known as Palmer College of Chiropractic in Davenport Iowa (168).
Pettman (2007) further reported:
“Two of Still’s original students, William Smith and J. Martin Littlejohn, were medical physicians from Scotland. Smith struck a deal with Still that if Still taught him osteopathy, he would teach Still’s students anatomy, greatly enhancing the scientific validity of this emerging profession.
Littlejohn would become the first dean of the College of Osteopathy in Kirksville. He would then go on to found the Chicago College of Osteopathy before returning to Britain and becoming the founder of the British College of Osteopathy in London in 1917.
Despite many frustrating attempts, Littlejohn could never get the English legislature to give osteopathy the same parity with medicine that was enjoyed by his American colleagues. Ironically, instead of behaving antagonistically, he chose to begin educating his fellow physicians and physical therapists in the art and science of spinal manipulation as of 1920.” (p. 169).
Conversely, the development of manipulation to the physical therapy profession in the United States occurred 40 years after being introduced to PTs in Britain in 1920. In a document on the history of manipulative therapy in the United States, Paris (2000) wrote, “Since the 1960s, physical therapists have developed their own body of knowledge in manipulation, emphasizing pain relief and enhanced physical function” (p. 66).
Farrell and Jensen (1992) added, “Physical therapy education has evolved considerably since 1970, when just a few programs included content and skills in "manipulative therapy"” (p. 845). Thus, physical therapists in the United States did not start developing knowledge of manipulation until the 1960s and few US PT programs taught manipulation in 1970.
PT’s Historical Confusion of Manipulation Vs. Mobilization
As already discussed, the development of spinal manipulation for PTs did not begin until the 1960s. Further, PTs did not have standardized terminology for manual therapy and often mobilization and manipulation were used interchangeably. Mintken, DeRosa, Little and Britt (2008) stated, “Seminal documents from noted professional associations and organizations, such as the American Physical Therapy Association, the American Academy of Orthopaedic Manual Physical Therapists, and the International Federation of Orthopaedic Manipulative Therapists, interchange such terms as manual therapy, mobilization, and manipulation with the implication often being that they are synonymous” (p. 51).
Mintken et al., (2008) added, “Physical therapists in particular are not immune to the consequences of this history. John Mennell, MD stated that physical therapists used a confusing array of terms that “cloud the issue by talking about degrees of manipulation using such terms as articulation and mobilization leading up to manipulation.” Such a woeful lack of language specificity ultimately precludes any ability to compare and contrast the intervention or the outcome and minimizes any opportunity to ultimately discern effective from ineffective” (p. 51).
Mintken et al., (2008) continued, “Furthermore, despite Mennell’s caution appearing many years ago, one could argue that the clarity of language concerning manipulation has not improved, but in fact has worsened” (p. 51).
To address this issue Mintken et al., (2008) published their article to standardize manipulation terminology. Mintken et al., (2008) stated, “In February 2007, the American Academy of Orthopaedic Manual Physical Therapists formed a task force to standardize manual therapy terminology, starting with the intervention of manipulation. The ultimate goal of this task force was to create a template that has the potential to be used internationally by the community of physical therapists in order to standardize manual therapy nomenclature” (pg. 50). Thus, you can see that as late as 2007, it was being reported that manipulation and mobilization in the physical therapy profession were still poorly differentiated and the terminology was not standardized.
The Mintken et al., (2008) reported, “The aim of the task force created in February 2007 by the American Academy of Orthopaedic Manual Physical Therapists was to propose a model for standardized terminology to describe manipulative techniques as simply and clearly as possible in language that is understandable to all clinicians, regardless of individual clinical practices or schools of thought” (p. 52-53).
DC’s perform 94% of All spinal manipulations in the United States. Although PTs began learning manipulation in Britain in 1920 through the osteopathic profession, the physical therapy profession did not begin developing spinal manipulation for PTs in the United States until the 1960s and in 1970 few schools included content and skills in manipulation. The purpose of this statement is not to diminish a PT trained to perform non-specific spinal manipulation, but rather to highlight the limited non-specific use and true infancy among PTs in performing spinal manipulation in the US.
Finally, spinal manipulation is kinematically regarded as HVLA and not synonymous with spinal mobilization which is regarded as LVLA. Further, while spinal manipulation acts to improve joint function, increase range of motion, and reduce pain, beyond this, it’s clinical intention is different amongst DCs (CSA: a specific form of spinal manipulation to normalize neuro-biomechanical biomechanical function and removing nerve interference), DOs (OMT: a non-specific form of spinal manipulation with intention on improving blood flow) and PTs (TJM: a non-specific form of spinal manipulation regarded as a unique form of manual therapy).
In part 2 of this series, we will further differentiate spinal manipulation amongst DCs, DOs and PTs and how it is a physician-based service for DCs and DO’s and a form of manual therapy for PTs. Moreover, we will explain in greater depth how spinal manipulation provided by DCs is regarded as specific while among DOs and PTs it is regarded as non-specific. Finally, we will discuss how a DCs intention in performing a specific CSA follow a salutogenic model (what keeps one healthy or well) while the intention of PTs and DOs in performing a non-specific spinal manipulation called TJM or OMT respectfully follows a pathogenic model(what causes disease or makes one ill).
Efficacy of Chiropractic Treatment for Post-Surgical Continued Low Back and Radicular Pain
81% of chiropractic post-surgical patients showed greater than 50% reduction in pain.
Mark Studin DC
William J. Owens DC
A report on the scientific literature
Park et. Al (2016) reported that low back pain radiating into the lower extremities have greater impact on disability and time off work that any other medical condition. Vleggeert-Lankamp, Arts and Jacobs (2013) reported “The term ‘failed back surgery syndrome’ (FBSS) is used to describe a clinical condition defined by persistent or recurrent complaints of leg pain and/or back pain regardless of one or more surgical procedures of the lumbar spine. The definition of FBSS (failed back surgery syndrome) is modified by some authors by adding that at least one surgical intervention was to be performed and that pain should persist after the last surgical intervention, for at least one year.1 The term implies that the surgery plays a role in the cause of the pain, although in most cases the surgical intervention was technically successful. It is known that nearly 20% of patients undergoing spine surgery will require secondary surgery for persistent pain or surgery-related complications during the subsequent years.” (pg. 48) El-Badawy and El Mikkawy (2016) reported that failed back surgery syndrome occurs with lateral disc surgery upwards of 17%, spinal stenosis 29% and instability 14.8%.
Perhaps the reason for failed back surgery syndrome is what the surgeons have considered their “gold standard, fusion and the ensuing loss of mobility of the spinal motor unit. Mulholland (2008) reported “Spinal fusion became what has been termed the “gold standard” for the treatment of mechanical low back pain, yet there was no scientific basis for this.” (pg. 619) The history of spinal fusion is both fascinating and disturbing and reveals why chiropractic both helps post-surgical cases and should always be considered first, prior to surgery as an option.
Mulholland (2008) continued:
In 1962 Harmon presented a review paper at the western orthopaedic association meeting in San Francisco, in which the term “Instability” appears.
However, Harmon’s description of what he meant by instability (unfortunately in a footnote) is revealing “Spinal instability refers to a low back-gluteal-thigh clinical triad of symptoms that may be accompanied (overt cases) by incapacitating regional weakness and pain. This is the effect of disk degeneration with or without disc hernia. Some may be asymptomatic or slightly symptomatic when instability is compensated by muscle or ligament control. It does not refer to spinous process or laminal hypermobility which some surgeons like to demonstrate at the operating table nor does this clinical concept parallel the common spinal hypermobility, which is the product of intervertebral disc degeneration, demonstrable in flexion-extension filming of the region, since the anatomic hypermobility is not always productive of symptoms”
Sadly this description of instability appears to have been ignored, and the concept of mechanical instability as a cause of back pain was progressively accepted. Harmon’s view of the effect of fusion was that it cured pain by reducing the irritation of the neural contents produced by movement. His paper was influential as he emphasized the importance of appropriate investigations prior to fusion and the segmental nature of back pain but unfortunately his use of the term instability was interpreted as supporting the view that segmental abnormal movement was the cause of the pain.
In 1965 Newman in an editorial concerning lumbo-sacral arthrodesis (surgical immobilization) refers to the need to stabilize the lumbar spine in patients with back pain after discectomy for a lumbar root entrapment.
At the beginning of the seventies the perception was that disc degeneration led to abnormal translational movement, and this was painful.
McNab in 1971 who had done much work on the disturbance of movement in the degenerate disc described what he termed the “traction spur,” a particular type of anterior osteophytes which he said was related to an abnormal pattern of translational movement. This view again supported the concept of instability. He added the important caveat that it “was impossible to establish the clinical significance of the traction spur as a statistically valid investigation the traction spur was revisited in the late eighties and was shown to be no different to claw osteophytes, and often both would be present in the same patient. It was not related to abnormal movement.”
Although McNab used the term instability, he used it in the sense that the spine was vulnerable to acute episodes of pain, because the degenerate disc rendered it more easily injured. He did not view it as a cause of chronic back pain.
Kirkaldy Willis set out his views on instability in 1982. In “Instability of the Lumbar Spine” he described the process of disc degeneration as passing through a stage of dysfunction, (intermittent pain), instability which caused more persistent pain but then with time stabilizing to a painless state. This was his explanation for the observed fact that many very degenerate discs were painless. However, he at that stage was somewhat unhappy with an entirely mechanistic view for pain. Hence, he writes “Instability can be defined as the clinical status of the patient with a back problem who with the least provocation steps from the mildly symptomatic to a severe episode”. Further he writes “Detectable increased motion does not always solicit a clinical response, and that abnormal motion may be abnormal increase or abnormal decrease”. He further writes “It is insufficient to detect the abnormal increased motion, but the mechanism by which it precipitates the symptomatic episode must also be identified”. Indeed in the seven cases he reported only one patient had backache alone, the others were all radicular problems. His paper shows that identifying abnormal movement establishes the fact that the segment is disordered, but he does not in that paper indicate that movement itself is the cause of pain.
Subsequently in his very influential book “Managing Back Pain” in 259 pages just one page is devoted to the rationale of lumbar fusion. The only reason for fusion appeared to be that, other treatments had failed, that it was reasonable from the psychological viewpoint, and that instability was present. Instability is defined elsewhere in the book as increased abnormal movement, and this is illustrated by x-rays purporting to show abnormal rotations and various types of abnormal tilt. He accepts that such appearances may be entirely painless, but in the patient with back pain they identify the causative level, and fusion is justified.
However, in a joint paper with Depuis in 1985 entitled “Radiological Diagnosis of Degenerative Lumbar instability” they write “A lumbar motion segment is considered unstable when it exhibits abnormal movements. The movement is abnormal in quality (abnormal coupling patterns) or in quality (abnormal increase of movement...) Pain is a signal of impending or actual tissue damage-and when present it indicates that a mechanical threshold has been reached or transgressed. Repeated transgressions will damage the stabilizing structures beyond physiological repair, thus putting abnormal demands on secondary restraints”.
Hence from being a method of identifying an abnormal degenerate disc, abnormal motion itself became the injurious agent.
In 1985 Pope and Panjabi in a paper entitled “Biomechanical definition of spinal instability” wrote “Instability is a mechanical entity and an unstable spine is one that is not in an optimal state of equilibrium. (...In the spine stability is affected by restraining structures that if damaged or lax will lead to altered equilibrium and thus instability. Instability is defined as a loss of stiffness”. Panjabi’s views were generally accepted by basic scientists interested in this field.
Subsequently Panjabi concluded that increased movement was not necessarily a feature of what he termed instability, but reduction in the neutral zone was. However, in a more recent paper he has abandoned the concept of instability altogether and ascribes chronic back pain as being caused by ligament sub-failure injuries leading to muscle control dysfunction.
However, throughout the period from the fifties to the nineties, the Panjabi view held sway, and the term instability evolved from being a useful term to denote a segment that was abnormal due to a degenerate disc, to a term denoting a diagnosis of an abnormal, (usually increased) pattern of movement with a translational component. The abnormal movement was thought to be the cause of the pain and clearly fusion or stopping movement was a logical treatment.
However, the inability to show that abnormal or increased movement was a feature peculiar to the painful degenerate disc, combined with the fact that despite more rigid fusions using pedicle fixation, the clinical results of fusion had not improved, was increasingly casting doubt on the concept of instability. The paper by Murata combining MRI examination with flexion and extension films in patients with back pain, showed that increased angular and translational movement was a feature of the normal or mildly degenerate disc, not of the markedly degenerate disc, where movements were reduced. In 1998 Kaigle et al. demonstrated that comparing patients with normal subjects there was always less movement present in the degenerate spine. It was therefore generally accepted that the effect of disc degeneration was to reduce movement not to increase it, as the term “instability” would imply. It may be argued that, unfortunately, this reduction of movement is associated with abnormal patterns of movement, and this is the meaning of “instability”. However despite considerable efforts over many years, using flexion/extension films, no clear relationship has been established between pain and such abnormal movements. In other words, patients with degenerative disc disease may exhibit abnormal patterns of movement yet have no pain.
By the mid-nineties, instability was still the term used to describe the disorder that we treated by fusion, but the failure to improve results by the introduction of pedicle fixation, caused many surgeons to question the concept of instability, but surgeons were all aware that fusion although unpredictable in terms of clinical result, was the best surgical treatment for chronic low back pain. It was well recognized that clinical success was unrelated to the success of the fusion, pseudarthrosis was as common amongst successful patients as in those who had failed. Was there anything else that a fusion did to the intervertebral disc unrelated to the fact that it stopped movement? (pgs. 619-623)
Mulholland (2008) concluded with a powerful statement that perhaps sums up why chiropractic realizes significant result when treating post-surgical cases.
Abnormal movement of a degenerated segment may be associated with back pain but is not causative. The concept of instability as a cause of back pain is a myth. The clinical results of any procedure that allows abnormal disc loading to continue are unpredictable. (pg. 624)
To underscore the point of fusion being a failed surgical paradigm in many patients, Gudavalli, Olding, Joachim, & Cox (2016) reported,
Surgical decompression of the lumbar spine in older patients had a 24% reoperation rate, and a 20-fold increase in lumbar surgical fusion rates among Medicare enrollees is reported. Lumbar cage fusion rates increased from 3.6% in 1996 to 58% in 2001, and the result was increased complication risk without improved disability or reoperation rates. Adjacent segment degenerative changes and instability at the level immediately above single-segment fusion with clinical deterioration are shown in up to 90% of the cases. The incidence of radiographic adjacent segment disease following fusion has been reported to be as high as 50% in the cervical spine and 70% in the lumbar spine at 10 years. However, the incidence of clinically relevant symptomatic adjacent segment disease is quite lower, estimated at 25% in the cervical spine and 36% in the lumbar spine at 10 years.
Comparing surgery with nonsurgical treatment for back and radicular pain shows that intensive rehabilitation is more effective than fusion surgery, and nonsurgical treatment of low back and radicular pain patients is reported to reduce lumbar disk surgery by approximately two-thirds. Chronic low back pain in 349 patients aged 18-55 years found no evidence that surgery was any more beneficial than intensive rehabilitation. A study of 600 single-operated low back patients showed that 71% did not return to work 4 years after surgery, and 400 multiple-operated backs showed that 95% did not return to work 4 years later. (pg. 124)
Gudavalli, Olding, Joachim, & Cox (2016) went on to report what has been found clinically effective in both pre and post-operative cases, "Treating lumbar disk herniation and spinal stenosis patients successfully with conservative care is documented. Chiropractic manipulation prior to spine surgery is appropriate. Previous reports of the biomechanical changes in the spine when CTFD (Cox technique, flexion-traction) spinal manipulation is applied include decreased intradiscal pressure; intervertebral disk foraminal area increase; increased intervertebral disk space height; and physiological range of motion of the facet joint." (pg. 124)
Regarding post-surgical care, Gudavalli, Olding, Joachim, & Cox (2016) concluded,
81% of the (post-surgical chiropractic) patients showed greater than 50% reduction in pain levels at the end of the last treatment. At 24-month follow-up, 78.6% had continued pain relief of greater than 50%. (pg. 121)
Although one of the goals of chiropractic care is pain relief, there are still the underlying biomechanical pathologies to consider that are concurrently treated while under chiropractic care. The more pressing issue in the post-surgical cases are “could these surgeries been avoided” in the first place with correcting the underlying biomechanical pathologies prior to surgery This underscores the overwhelming need for chiropractic as Primary Spine Care providers being the first treatment option. It goes back to the adage “drugless first, drugs seconds and surgery last.” It’s just common sense and chiropractic has been verified in numerous outcome studies proven to be the most effective 1st treatment option for spine.
A Chiropractic Adjustment Has a Direct Effect of the Pre-Frontal Cortex of the Brain
Verifying a positive effect of the chiropractic spinal adjustment on reflexes, memory, coordination and decision making
By: Mark Studin
William J. Owens
A report on the scientific literature
For most of the 20th century, based upon results in individual chiropractic offices, the profession’s success was founded on a patient-based model. This model drove utilization at predominantly a “grass roots” level and over the last 10-20 years, research has started to give reasons to why patients not only get out of pain, but executive functions such as decision making, anxiety, managing tasks and being able to focus at a higher level are improving. It is these types of results that have driven many patients to appreciate chiropractic as a “miracle cure” while others, mostly from organized medicine and insurers, who in the past have considered it an "invalid claim” because of the lack of credible evidence despite mounting feedback from patients over the last century. Factually, their arguments had merit on many issues in the past, but as research has been published through the years, those arguments are outdated and incorrect.
"Evidence-based behavioral practice (EBBP) entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. This is done in a manner that is compatible with the environmental and organizational context. Evidence is comprised of research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses" (Evidence-Based Practice, http://en.wikipedia.org/wiki/Evidence-based_practice).
When considering a purely “evidenced-based” approach, it often precludes advances through a doctor’s immediate experiences in “breakthroughs” that has historically saved lives and then set up the research to render the evidence of what doctors have found on an “experiential level.” This is formally termed best medical practice.
“Abest practice is a method or technique that has consistently shown results superior to those achieved with other means and that is used as a benchmark. In addition, a "best" practice can evolve to become better as improvements are discovered. Best practice is considered by some as a business buzzword, used to describe the process of developing and following a standard way of doing things that multiple organizations can use" (Best Practice, http://en.wikipedia.org/ wiki/Best_practice).
Sackett, Rosenberg, Gray, Haynes and Richardson (1996) stated,
“Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom (p. 71)." They go on to comment “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients" (Sackett et al, 1996, p. 72). The point is that the provider plays a huge role and ultimately is the check and balance of this process. Without the provider, the payor becomes the determining factor in the delivery of healthcare by "tying the doctor's hands" with the limitation of evidence.
They further stated:
“External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision" (Sackett et al, 1996, p. 73). Lastly, they state, “Evidence based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions" (Sackett et al, 1996, p. 73). This is often a process that takes years, preventing the final papers from being published in a timely enough fashion to meet the ever-changing advancement of medicine and the technologies that support the current needs of the patients.
When considering executive function at the central (brain) level, based upon contemporary literature, we can now go beyond the “best medical practice” model of purely patient feedback and as Sackett et. Al. suggested, add the evidence as verification. In order to better understand how chiropractic plays a role in executive function, we must start at neural plasticity. According to Leung et. Al (2015) Neural plasticity refers to the capacity of our brain to change in response to internal demand and/or external experience. Burgeoning research has corroborated that the neural plastic changes induced in our brains and behaviors are specific to the experiences. [pg. 1]
Neuroplasticity, also known as brain plasticity or neural plasticity, is an umbrella term that describes lasting change to the brain throughout an individual's life course. The term gained prominence in the latter half of the 20th century, when new research showed that many aspects of the brain can be altered (or are "plastic”) even into adulthood. (https://en.wikipedia.org/wiki/Neuroplasticity)
This article focuses on the actions and effects of neuroplasticity on the pre-frontal cortex of the brain. According to Lelic et. Al (2016)
The prefrontal cortex is known to play a vital role in SMI and is also responsible for a number of other functions. The prefrontal cortex is known to be a key structure responsible for the performance of what is known as “executive functions.” Executive function is the mechanism by which the brain integrates and coordinates the operations of multiple neural systems to solve problems and achieve goals based on the ever-changing environment around us. Executive function is considered to be a product of the coordinated operation of various neural systems and is essential for achieving any particular goal. The prefrontal cortex is believed to be the main brain structure responsible for enabling this coordination and control. It requires planning a sequence of subtasks to accomplish a goal, focusing attention on relevant information as well as inhibiting irrelevant distractors, being able to switch attention between tasks monitoring memory, initiation of activity, and responding to stimuli. [pg. 7]
Lelic et. Al.’s 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.
The current study adds to previous work by not only confirming that spinal manipulation [chiropractic spinal adjustment] of dysfunctional joints decreases the N30 SEP peak amplitude but also demonstrating that this decrease occurs predominantly in one of the known neural generators of N30, that is, the prefrontal cortex. This suggests that, at least in part, the mechanisms by which spinal manipulation improves performance are due to a change in function at the prefrontal cortex.
Lelic et. Al (2016) continued,
The prefrontal cortex is known to play a vital role in SMI and is also responsible for a number of other functions. The prefrontal cortex is known to be a key structure responsible for the performance of what is known as “executive functions.” Executive function is considered to be a product of the coordinated operation of various neural systems and is essential for achieving any particular goal. The prefrontal cortex is believed to be the main brain structure responsible for enabling this coordination and control. It requires planning a sequence of subtasks to accomplish a goal, focusing attention on relevant information as well as inhibiting irrelevant distractors, being able to switch attention between tasks, monitoring memory, initiation of activity, and responding to stimuli. A change in prefrontal activity following chiropractic care may therefore explain and/or link some of the varied improvements in neural function previously observed in the literature, such as improved joint position sense error, reaction time, cortical processing, cortical sensorimotor integration, reflex excitability, motor control, and lower limb muscle strength.
To accomplish the coordinated operations of multiple neural systems and structures, the prefrontal cortex must monitor the activities in other cortical and subcortical structures and control and integrate their operations by sending command signals in a so-called “top-down” manner. This is a complex operation, and the importance of this monitoring, integration, and coordination is highlighted in studies where damage to the prefrontal cortex has been shown to impair the ability to create new and adaptive action programs or choose the best among several equally probable alternatives, despite such individuals displaying normal IQs in most psychological tests, having normal long-term memory functions, and exhibiting normal perceptual, motor, and language skills
To accomplish the coordinated operations of multiple neural systems and structures, the prefrontal cortex must monitor the activities in other cortical and subcortical structures and control and integrate their operations by sending command signals in a so-called “top-down” manner. This is a complex operation, and the importance of this monitoring, integration, and coordination is highlighted in studies where damage to the prefrontal cortex has been shown to impair the ability to create new and adaptive action programs or choose the best among several equally probable alternatives, despite such individuals displaying normal IQs in most psychological tests, having normal long-term memory functions, and exhibiting normal perceptual, motor, and language skills .The change in prefrontal cortex as seen in this study therefore suggests that the altered input from dysfunctional joints that leads to altered processing of somatosensory inputs can influence processing of somatosensory information by the prefrontal cortex.
Chiropractic care, by treating the joint dysfunction, appears to change processing by the prefrontal cortex. This suggests that chiropractic care may as well have benefits that exceed simply reducing pain or improving muscle function and may explain some claims regarding this made by chiropractors.
Although the change in N30 due to chiropractic treatment is an important finding, it is not clear how long this finding lasts. To date, some of the authors of this study have shown that the N30 changes on average are present for at least 20–30 minutes after spinal manipulation. For some subjects, the changes were still evident at 30 minutes after spinal manipulation and we have not yet followed up for longer than 30 minutes, due to the length of the study as is.
The literature has clearly suggested that a chiropractic spinal adjustment has a clear and reproducible effect on brain physiology and function and is consistent with reports from Reed, Pickjar, Sozio and Long (2014) and Gay, Robinson, George, Peristen and Bishop (2014) on a chiropractic spinal adjustment effecting brain function. These results, in addition to chiropractic patient’s feedback since 1895, have combined both “best practice” and evidenced based” models and start to explain through science, why people are experiencing so much more than their beck or neck pain resolving.
Chiropractic Care is More Effective in Lowering Disability than Medical Care for Acute and Sub-Acute Low Back Pain
By Mark Studin DC, FASBE(C), DAAPM, DAAMLP
William J. Owens DC, DAAMLP
A report on the scientific literature
By any standard, back pain is one of the most prevalent disabilities plaguing our population. 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. (pg. 1)
According to Schneider et al., 2015 “low back pain is among the most common medical elements an important public health issue. Approximately 50% of the United States working – age adults experience low back pain each year with a quarter of US adults reported in episode back pain in the previous three months. Back pain is the most common cause of disability for persons younger than 45 years old and one of the most common reasons for office visits to primary care physicians in the United States as well as Europe and Australia.” (pg. 2009)
In chiropractic, although chiropractic’s scope is significantly beyond back pain, based upon the sheer volume of low back pain sufferers, there simply aren’t enough chiropractors to manage this “epidemic sized” condition. In addition, chiropractors as a profession do not want to be labeled as solely “low back pain doctors.” Although the authors firmly agree, we also must acknowledge while treating mechanical spine pain (no fracture, tumor or infection) that the formal health care system has fallen short and in its effort, has contributed to the opiate epidemic. Healthcare in the United States has had a myopic focus on “anatomical” sources of spine pain such as herniated disc and degenerative disc disease while ignoring the impact that faulty biomechanics have on spine pain and disability. When it comes to the biomechanics of the spine, it is the responsibility of the chiropractic profession, based upon training and outcomes to lead the nation in its diagnosis, management and treatment. When we consider both anatomical and biomechanical spine conditions are significant contributors to the spine pain and disability epidemic in the United States, we must understand its full impact and the standard healthcare system’s (allopathic) inability to manage the biomechanical side.
Block, 2014 continued “In addition to the pervasive personal suffering associated with this disease, chronic pain (author’s note: where low back pain is one of the most significant contributors) has a substantial negative financial impact on the economy. Direct office visits, diagnostic testing, hospital care, and pharmacy costs are only a portion of the picture, with combined medical and pharmacy costs averaging $5,000 annually per individual. Chronic pain results in a significant economic burden on the healthcare system, with estimated costs ranging from $560 to $635 billion 2010 dollars, more than the annual cost of other priority health conditions including cardiovascular disease, cancer, and diabetes. Moreover, the estimated annual costs of the workplace impact of pain range from $299 to $335 billion from absenteeism and reduced productivity.” (pgs. 1-2) These statistics help us to understand that “management” of spine pain is a critical component of cost reduction since the costliest portion of healthcare services is when a patient enters the system. Continued mismanagement of mechanical spine pain causes patients to move in and out of disability status. That reentry is what drives up cost, chiropractic is the 3rd largest health profession in the United States and the largest with the education to lead the diagnosis and management of mechanical spine pain.
When we compare who is better educated to manage mechanical back pain cases, we also must conclude as a result, who is better educated to successfully treat those cases based upon outcomes. In this comparison, we will consider the education of chiropractic vs. traditional musculoskeletal education and competency as well as treatment outcomes.
In a recent article written by Humphreys, Sulkowski, McIntyre, Kasiban, and Patrick (2007), they stated, “In the United States, approximately 10% to 25% of all visits to primary care medical doctors are for MSK [musculoskeletal] complaints, making it one of the most common reasons for consulting a physician...Specifically, it has been estimated that less than 5% of the undergraduate and graduate medical curriculum in the United States and 2.26% in Canadian medical schools is devoted to MSK medicine” (p. 44).
Musculoskeletal complaints have a major impact on the healthcare system and although many patients believe that traditional providers are highly trained, recent publications relating to basic competency have shown otherwise. For example, the authors cited another study stating, Humphreys et al., 2007 continues by stating, “A study by Childs et alon the physical therapists’ knowledge in managing MSK conditions found that only 21% of students working on their master’s degree in physical therapy and 25% of students working on their doctorate degree in physical therapy achieved a passing mark on the BCE [Basic Competency Evaluation]” (p. 45).
The authors continued by reporting, “The objective of this study was to examine the cognitive (knowledge) competency of final-year chiropractic students in MSK [musculoskeletal] medicine" (p. 45). "The typical chiropractic curriculum consists of 4,800 hours of education composed of courses in the biological sciences (i.e., anatomy, embryology, histology, microbiology, pathology, laboratory diagnosis, biochemistry, nutrition, and psychology), chiropractic sciences, and clinical sciences (i.e., clinical diagnosis, neurodiagnostic, ortho-rheumatology, radiology, and psychology). As the diagnosis, treatment, and management of MSK disorders are the primary focus of the undergraduate curriculum as well as future clinical practice, it seems logical that chiropractic graduates should possess competence in basic MSK medicine” (Humphreys et al., 2007, p. 45).
The following results were published in this paper for the Basic Competency Examination and various professions that are in the front line of the diagnosis and treatment of musculoskeletal conditions. In Table 2 on page 47, the following results were shown when the passing score was established at 73% or greater:
Recent medical graduates (18%), medical students, residents, and staff physicians (20.7%), osteopathic students (29.6%) physical therapy (MSc level, 21%), physical therapy (doctorate level, 26%), chiropractic students (51.5%).
In Table 2 on page 47, the following results were show when the passing score was established at 70% or greater.
Recent medical graduates (22%), medical students, residents, and staff physicians (NA), osteopathic students (33%) physical therapy (MSc level, NA), physical therapy (doctorate level, NA), chiropractic students (64.7%).
According to Frank Zolli DC, former Dean at the University of Bridgeport, College of Chiropractic, “Fundamental to the training of doctors of chiropractic is 4,820 hours (compared to 3,398 for physical therapy and 4,670 to medicine) and students 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. It is so important to practice 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. To qualify for licensure, graduates of chiropractic programs must pass a series of examinations administered by the National Board of Chiropractic Examiners (NBCE) in 4 separate parts including clinical evaluations. It is therefore mandatory for a chiropractor to know the structure and function of the human body, the study of neuromuscular and biomechanics is weaved throughout the fabric of chiropractic education.” As a result, the doctor of chiropractic has an expertise in the diagnosis and management of biomechanical musculoskeletal disorders that the traditional health care system is lacking. Chiropractic offers significant insight where traditional health care has no answers.
When it comes to direct influence of the chiropractic adjustment on spine pain patients, a 2005 study by DeVocht, Pickar, & Wilder concluded through objective electrodiagnostic studies (neurological testing) that 87% of chiropractic patients exhibited decreased muscle spasms. This study validates the reasoning behind why people with severe muscle spasms in the low back respond well to chiropractic care which in turn is shown to prevent future problems and disabilities. It also dictates that care should not be delayed or ignored due to a risk of complications. This study renders evidence that chiropractic spinal adjusting provides a direct nervous system and physiologic response to the human body.
In a recently published case study and literature review in the New England Journal of Medicine, Deyo and Mirza (2016) had published a case study and literature review on the diagnosis and treatment of lumbar disc herniation with sciatica. What is useful in this publication is the review of the literature in basic, easy to use format highlighting the most common treatments associated in lumbar disc herniation with sciatica.
Regarding the chiropractic adjustment, the authors stated “A randomized trial of chiropractic manipulation for sub-acute or chronic “back-related leg pain” (without confirmation of nerve-root compression on MRI) showed that manipulation [author’s note: Chiropractic spinal adjustment] was more effective than home exercise with respect to pain relief at 12 weeks (by a mean 1-point decrease on a pain-intensity scale on which scores ranged from 0 to 10, with higher scores indicating greater severity of pain) but not at 1 year. This is important since early intervention of chiropractic care will reduce early dependency on pain medication. In addition, a randomized trial involving patients who had acute sciatica with MRI-confirmed disk protrusion showed that at 6 months, significantly more patients who underwent chiropractic manipulation had an absence of pain than did those who underwent sham manipulation (55% vs. 20%). Neurologic complications in the lumbar spine, including worsened disk herniation or the cauda equina syndrome, have been reported anecdotally, but they appear to be extremely rare.” (pg 1768)
In relationship to counseling versus supervised exercise, the authors reported,“A systematic review of five randomized trials showed that patients who participated in supervised exercise had greater short-term pain relief than patients who received counseling alone, but this reduction in pain was small and these patients did not have a long-term benefit with respect to reduced pain or disability.” (pg. 1768)
Concerning oral steroids, the paper reported, “Randomized trials show no significant advantage of systemic glucocorticoid (steroid) therapy over placebo with respect to pain relief or reduced rates of subsequent surgical intervention, and they show little, if any, advantage with respect to improvement in physical function.” (pg. 1767)
The authors commented on opioid medication by stating,“Data from randomized trials to support the use of opioids in patients with sciatica are lacking. Systematic reviews suggest that opioids have slight short-term benefits with respect to reduced back pain. Convincing evidence of benefits of long-term use is lacking, and there is growing concern regarding serious long-term adverse effects such as fractures and opioid overdose and abuse.” (pg. 1767)
Focusing on spinal injection therapy the paper continues by reporting, “A systematic review showed that patients with radiculopathy who received epidural glucocorticoid injections had slightly better pain relief (by 7.5 points on a 100-point scale) and functional improvement at 2 weeks than patients who received placebo. There were no significant advantages at later follow-up and no effect on long-term rates of surgery.” (pg. 1768)
This report serves as a nice general guideline for the primary care [conservative] management of lumbar disc herniation with sciatica. We see that in addition to any anatomical correction there is a positive response to biomechanical interventions for which the properly trained and credentialed chiropractor is an important provider.
Cifuentes et al., 2011 stated, “Given that chiropractors are proponents of health maintenance care, we hypothesize that patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because this specific approach would be used.Conversely, similar patients treated by other providers would have higher recurrence rates because the general approach did not include maintaining health, which is a key component to prevent recurrence” (Cifuentes, Willetts, & Wasiak, 2011, p. 396).
This research is unique and comprehensive in that it tracked injured workers’ compensation patients in multiple states and it reviewed claims dated between January 1, 2006 and December 31, 2006 including 894 cases out of a pool of 11,420 claims of non-specific low back pain cases. (The states were chosen because the patients had the ability to select their doctors on their own and were not mandated a provider.)
Relating to the results, the authors report, “In our study, after controlling for demographics and severity indicators, the likelihood of recurrent disability due to LBP for recipients of services during the health maintenance care period by all other provider groups was consistently worse when compared with recipients of health maintenance care by chiropractors. Care from chiropractors during the disability episode (“curative”), during the health maintenance period (main exposure variable, “preventative”), and the combination of both (curative and preventive) was associated with lower disability recurrence HRs” (p. 403). This article validates chiropractic's role in the prevention of the recurrence of back pain in patients with chronic spine disorders.
When analyzing why, the reasons are evident and based upon the literature. A chiropractic spinal adjustment reduces verifiable bio-neuro-mechanical failures (commonly known as vertebral subluxation in our profession) at the spinal level. Non-steroidal anti-inflammatory drugs do not and there is no “spontaneous recovery,” only less pain with the underlying biomechanical failures persisting awaiting Wollf’s law to adversely remodel the spine leading to certain increased permanent disability over time. Therefore, if “literature based outcomes” “ruled the day” (as they should in a reasonable world void of politics and financial interest) at the legislative and reimbursement levels, then we would be a healthier society and spend far less money while avoiding unnecessary side effects and increasing the potential for significantly greater disabilities in the future.
Chiropractic’s Role in Decreasing Premature Death with Associated Back Pain
By: Mark Studin DC, FASBE(C), DAAPM, DAAMLP
William J. Owens DC, DAAMLP
A report on the scientific literature
In the United Kingdom, Field and Newell (2016) reported that back pain accounts for 4.8% of all social benefit claims with overall costs reaching $7 billion pounds or $9.35 billion US dollars. Boyles (2016) reported in the Feb. 13 issue of The Journal of the American Medical Association. After adjustment for inflation, total estimated medical costs associated with back and neck pain increased by 65% between 1997 and 2005, to about $86 billion a year… Yet during the same period, patients reported more disability from back and neck pain, including more depression and physical limitations. MD Lynx on Family Medicine reported “Nearly four million people in Australia suffer from low back pain and the total cost of treatment exceeds $1 billion a year.” (https://www.mdlinx.com/family-medicine/top-medical-news/article/2017/03/08/7076443?utm_source=in-house&utm_medium=message&utm_campaign=mh-fm-march17)
When we consider mortality and the causes, most only attribute causality to the last diagnosis or pathology associated with the immediate cause of death. In recent literature, there have been studies studying the effects of long-term pain and all-causes of death inclusive of cancers and cardiovascular issues and are now considering these co-morbidities, rather than “stand-alone causes.”
Docking et. Al (2015) reported:
“This study confirmed previous findings regarding the relationship between pain and excess mortality. Further, we have shown that among older adults, this association is specific to disabling pain and to woman. Clinicians should be aware not only of the short-term implications of disabling back pain, but also the long-term effects.” (pg. 466)
The Family Medicine, MD Lynx reported on March 8, 2017:
New research from the Faculty of Health Sciences finds that older people with back pain have a 13 per cent higher chance of dying prematurely. The 600,000 older Australians who suffer from back pain have a 13 per cent increased risk of dying from any cause, University of Sydney research has found. Published in the European Journal of Pain, the study of 4390 Danish twins aged more than 70 years investigated whether spinal pain increased the rate of all–cause and disease–specific cardiovascular mortality…Our study found that compared to those without spinal pain, a person with spinal pain has a 13 per cent higher chance of dying every year. This is a significant finding as many people think that back pain is not life–threatening,” said senior author Associate Professor Paulo Ferreira, physiotherapy researcher from the University’s Faculty of Health Sciences.”
The Family Medicine, MD Lynx also reported on March 8, 2017:
“Medications are mostly ineffective, surgery usually does not offer a good outcome.”
It was reported byShaheed, Mahar, Williams, and McLachlin(2014) that out of the 4,336 studies they identified,concluded that,
“None of the trials evaluating [medical] advice or bed rest reported statistically and clinically important effects at any time point…The effects of advice on disability are similar to those for pain, with pooled results showing no clinical significant effect for the short and long-terms” (Shaheed, 2014, p. 5). “Pooled results from 2 studies on bed rest showed a statistically significant negative effect of bed rest in the immediate term…” (Shaheed et al., 2014,p. 10).
Shaheed et al. (2014) continued
“There is no convincing evidence of effectiveness for any intervention available [with] OTC (over the counter drugs) or advice in the management of acute low back pain” (p. 11). The authors did report, “In the intermediate term, results from one of the studies involving referral to an allied HCP [health care provider] and reinforcement of key messages at follow-up visits showed significant effects in the intermediate and long-terms” (Shaheed et al., 2014, p. 12).
A 2005 study by DeVocht, Pickar, & Wilder concluded through objective electrodiagnostic studies (neurological testing) that 87% of chiropractic patients exhibited decreased muscle spasms. This study validates the reasoning behind the later study that people with severe muscle spasms in the low back respond well to chiropractic care and this prevents future problems and disabilities. It also dictates that care should not be delayed or ignored due to a risk of complications. The above statistic indicates that while medicine cannot conclude an accurate diagnosis in 85% of their back-pain patients, chiropractic has already helped 87% of the same population.
In a study by Leeman, Peterson, Schmid, Anklin, and Humphrys(2014), there is further successful evidence of the effects of mechanical back pain, both acute and chronic pain with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients. In this study, the acute onset patient (the patient’s pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one year marks following the onset of the original pain. Although one might argue that the patient would have gotten better with no treatment, it was reported that after two weeks of no treatment, only 36% of the patients felt better and at 12 weeks, up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to his/her normal life without pain, drugs or surgery.
Again, this is an environment where research has concluded that medicine has poor choices based upon outcomes for what they label “nonspecific low back pain.” The results indicate that chiropractic has defined this “nonspecific lesion” as a “bio-neuro-mechanical lesion” also known as the chiropractic vertebral subluxation and the evidence outlined on these pages, combined with the ever-growing body of outcome studies verify that medicine can reverse this epidemic by considering chiropractors as “primary spine care providers” or the first option for referral for everything spine short of fracture, tumor or infection.
The research is starting to show the far “reaching effects of chronic low back pain and the evidence has supported that chiropractic must take a lead role in the management of this population of patients. Based upon the evidence, anything short of that is a public health risk.
Chiropractic as the Solution for Mechanical Spine Failure and Failed Back Surgery.
By: William J. Owens DC, DAAMLP
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
A report on the scientific literature.
The latest CDC statistics show that in 2012, 54 out of 100 people had self-reported musculoskeletal conditions. By way of comparison, that is six times more than self-reported cases of cancer, double that of respiratory disease and one-third more than circulatory disorders. If we extrapolate that to a more current population in the United States of 321 million, that equates to 173 million people reporting musculoskeletal problems in 2012. Many of these are spine patients who suffer long-term without any type of biomechanical assessment or functional case management.
In 2013, Itz, Geurts, van Kleef, and Nelemans reported, “Non-specific low back pain [LBP] is a relatively common and recurrent condition with major medical and economic implications for which today there is no effective cure” (p. 5). The idea that spinal pain has a “natural history” resulting in a true resolution of symptoms is a myth and the concept that spine pain should only be treated in the acute phase for a few visits has no support in the literature. We don’t address cardiovascular disease in this manner, i.e. wait until you have a heart attack to treat, we don’t follow this procedure with dentistry, i.e. wait until you need a root canal to treat, and we certainly don’t handle metabolic disorders such as diabetes in this way, i.e. wait until you have diabetic ulcers or advanced vascular disease to treat. Why does healthcare fall short with spinal conditions in spite of the compelling literature that states the opposite in treatment outcomes?
The front lines of medical care for spine-related pain is typically the prescription of pain medication, particularly at the emergency care level, and then if that doesn’t work, a referral is made to physical therapy. If physical therapy is unsuccessful, the final referral is to a surgeon. If the surgeon does not intervene with surgery, then the diagnosis becomes “non-specific back pain” and the patient is given stronger medication since there is nothing the surgeon can do. In those surgical interventions that result in persistent pain, a commonly reported problem, there is an ICD-10 diagnosis for failed spine surgery, M96.1
A recent article Ordia and Vaisman (2011) described this syndrome a bit further stating the following, “We propose that these terms [post laminectomy syndrome or failed back syndrome] should be replaced with Post-surgical Spine Syndrome (PSSS)” (p. 132). They continued by reporting, “The incidence of PSSS may be reduced by a meticulous neurological examination and careful patient selection. The facet and sacroiliac joints should always be examined, particularly when the pain is predominantly in the lower back, or when it radiates only to the thigh or groin and not below the knee” (Orida & Vaisman, 2011, p. 132). The authors finally stated, “Adherence to these simple guidelines can result in a significant reduction in the pain and suffering, as also the enormous financial cost of PSSS” (Orida & Vaisman, 2011, p. 132). What they are referring to is a careful distinction between an “anatomical” versus a “biomechanical” cause of the spine pain.
According to Mulholland (2008), “[Surgery] Spinal fusion became what has been termed the “gold standard” for the treatment of mechanical low back pain, yet there was no scientific basis for this” (p. 619). He continued, “However whilst that fusion [surgery] may be very effective in stopping movement, it was deficient in relation to load transfer” (Mulholland, 2008, p. 623). He concluded, “The concept of instability as a cause of back pain is a myth. The clinical results of any procedure that allows abnormal disc loading to continue are unpredictable” (Mulholland, 2008, p. 624). Simply put, surgery does not correct the underlying biomechanical failure or the cause of the pain.
When a biomechanical assessment is lacking, the patient’s pain persists and allopathic medicine is focused on “managing the pain” vs. correcting the underlying biomechanical lesion/pathology/imbalance, the medication of choice at this point in care has been opioid analgesics. Back in 2011, the CDC reported, “Sales of OPR quadrupled between 1999 and 2010. Enough OPR were prescribed last year  to medicate every American adult with a standard pain treatment dose of 5 mg of hydrocodone (Vicodin and others) taken every 4 hours for a month” (p. 1489). That was 6 years ago, which was when people began to feel that treating musculoskeletal pain with narcotics was trending in the wrong direction. Now, in 2016, we can see there is a problem of epidemic proportions to the point that MDs are changing how they refer spine patients for diagnosis and treatment.
Dowell, Haegerich, and Chou (2016), along with the CDC, published updated guidelines relating to the prescription of opioid medication:
Opioid pain medication use presents serious risks, including overdose and opioid use disorder. From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States. In the past decade, while the death rates for the top leading causes of death such as heart disease and cancer have decreased substantially, the death rate associated with opioid pain medication has increased markedly.
…a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain and followed for up to 13 years revealed that one in 550 patients died from opioid-related overdose at a median of 2.6 years from their first opioid prescription, and one in 32 patients who escalated to opioid dosages >200 morphine milligram equivalents (MME) died from opioid-related overdose. (p. 2)
Clearly, there needs to be a nationwide standard for the process by which patients with spine pain are handled, including academic and clinical leadership on spinal biomechanics. The only profession that is poised to accomplish such a task is chiropractic.
In a recent study by Houweling et al. (2015), the authors reported, “The purpose of this study was to identify differences in outcomes, patient satisfaction, and related health care costs in spinal, hip, and shoulder pain patients who initiated care with medical doctors (MDs) vs those who initiated care with doctors of chiropractic (DCs) in Switzerland” (p. 477). This is an important study which continually demonstrates maintaining access to chiropractic care, for both acute and chronic pain is critical. We can also see from current utilization statistics that chiropractic care is underutilized on a major scale. The authors also state, “Although patients may be comanaged with other medical colleagues or paramedical providers (eg, physiotherapists), treatment for the same complaint may vary according to the type of first-contact provider. For instance, MDs tend to use medication, including analgesics, muscle relaxants, and anti-inflammatory agents, for the treatment of acute nonspecific spinal pain, whereas DCs favor spinal manipulative therapy as the primary treatment for this condition” (Houweling et al., 2015, p. 478). The continue by stating “This study showed that spinal, hip, and shoulder pain patients had modestly higher pain relief and satisfaction with care at lower overall cost if they initiated care with DCs, when compared with those who initiated care with MDs” (Houweling et al., 2015, p. 480). Overall, when taking cost into consideration, “Mean total spinal, hip, and shoulder pain-related health care costs per patient during the 4-month study period were approximately 40% lower in patients initially consulting DCs compared with those initially consulting MDs” (Houweling et al., 2015, p. 481). The authors concluded, “The findings of this study support first-contact care provided by DCs as an alternative to first-contact care provided by MDs for a select number of musculoskeletal conditions” (Houweling et al., 2015, p. 481).
Bases on the literature and outcome studies, backed up with 121 years of doctors of chiropractic and their patients’ testimonies, the time has never been better for the chiropractic profession to move into treating the 93% of the population that is not under care. Chiropractic must be moved from the accepted standard of biomechanical processes in the laboratory to the standard of care for spine beyond fracture, tumor or infection across all professions, inclusive of physical therapy. The outcomes overwhelmingly support that anything less perpetuates the epidemic of failed back treatments.
1. Centers for Disease Control and Prevention. (2015). National hospital discharge survey. Retrieved from: http://www.cdc.gov/nchs/nhds.htm
2. United States Census Bureau. (n.d.). Quick facts, United States. Retrieved from https://www.census.gov/quickfacts/
3. Itz, C. J., Geurts, J. W., van Kleef, M., & Nelemans, P. (2013). Clinical course of non‐specific low back pain: A systematic review of prospective cohort studies set in primary care. European Journal of Pain, 17(1), 5-15.
4. Ordia, J., & Julien Vaisman. (2011). Post-surgical spine syndrome. Surgical Neurology International, 2, 132.
5. Mulholland, R. C. (2008). The myth of lumbar instability: The importance of abnormal loading as a cause of low back pain. European Spine Journal, 17(5), 619-625.
6. Centers for Disease Control and Prevention. (2011). Vital signs: Overdoses of prescription opioid pain relievers - United States, 1999--2008. Morbidity and Mortality Weekly Report, 60(43), 1487-1492.
7. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain - United States, 2016. JAMA, 315(15), 1624-1645.
8. Houweling, T. A., Braga, A. V., Hausheer, T., Vogelsang, M., Peterson, C., & Humphreys, B. K. (2015). First-contact care with a medical vs chiropractic provider after consultation with a swiss telemedicine provider: Comparison of outcomes, patient satisfaction, and health care costs in spinal, hip, and shoulder pain patients. Journal of Manipulative and Physiological Therapeutics, 38(7), 477-483.
Chiropractic vs. Physical Therapy
in Treating Low Back Pain
with Spinal Adjustments vs. Exercise Rehabilitation
By: Mark Studin DC, FASBE(C), DAAPM, DAAMLP
William J. Owens DC, DAAMLP
A report on the scientific literature
In the United Kingdom, Field and Newell (2016) reported that back pain accounts for 4.8% of all social benefit claims with overall costs reaching $7 billion pounds or $9.35 billion US dollars. Boyles (2016) reported that “Researchers from the University of Washington, Seattle, found that the nation's dramatic rise in expenditures for the diagnosis and treatment of back and neck problems has not led to expected improvements in patient health. Their study appears in the Feb. 13 issue of The Journal of the American Medical Association. After adjustment for inflation, total estimated medical costs associated with back and neck pain increased by 65% between 1997 and 2005, to about $86 billion a year… Yet during the same period, patients reported more disability from back and neck pain, including more depression and physical limitations.
“We did not observe improvements in health outcomes commensurate with the increasing costs over time," lead researcher Brook I. Martin, MPH, and colleagues wrote. "Spine problems may offer opportunities to reduce expenditures without associated worsening of clinical outcomes." (http://www.webmd.com/back-pain/news/20080212/86-billion-spent-on-back-neck-pain) Part of the explanation for the rise in cost of treatment of low back pain is the utilization of physical therapy by allopath’s (medical primary care providers and medical specialists) as the primary option for the treatment of low back pain vs. the literature verified better alternative of chiropractic based upon outcome studies.
Through the years, both chiropractors and physical therapists have concurrently utilized exercise rehabilitation as a modality to treat low back pain. As a rule, the chiropractic profession has utilized exercise rehabilitation as an adjunct to the spinal adjustment where in physical therapy, it has been the main focus of the treatment plan. In addition, other passive modalities to mitigate pain, such as electrical stimulation and/or hydro/cryotherapy has been utilized as an adjunct to each professions main treatment. As a rule, exercise rehabilitation is a crucial adjunct to the treatment of low back disorders as it adds necessary motion to the joint and helps balance muscle tone required to create a biomechanically stabilized joint over time.
However, Ianuzzi and Khalsa (2005) wrote (pg. 674)
Facet joint capsule strain magnitudes during simulated high velocity low amplitude spinal manipulations were within the range of motion occurred during maximum physiological motions, indicating that the procedure is biomechanically safe and provide a stimulus that is likely sufficient to stimulate facet joint capsule neurons. However, physiological motions of the lumbar spine by themselves (e.g. Exercise) are generally ineffective in treating low back pain, suggesting that facet joint capsule strain magnitude alone would be insufficient in providing a novel stimulus for facet joint capsule afferents.
The high strain rates that occurred during spinal manipulation could provide a novel “yet biomechanically safe” stimulus for afferents innervating given facet joint capsule. Alternatively, during spinal manipulation, the relative magnitudes (patterns) of facet joint capsule strain was in a region of the lumbar spine may be unique, which could result in a novel pattern of facet joint capsule mechanoreceptor firing in the spinal region and subsequently a novel stimulus to the central nervous system.
Simply put, the facet joint capsules are comprised of ligaments where the mechanoreceptors are located. A spinal manipulation (chiropractic spinal adjustment) stimulates the neurons in the capsule where exercise (physiological motion) does not. In addition, it has been shown that chiropractic spinal adjustments are safe to the joint capsule and ligaments that comprise the capsule.
Chiropractic Outcome Studies on Treatment of Fragmented/Sequestered and Extruded Herniated Discs and Radicular Pain
By: Mark Studin DC, FASBE(C), DAAPM, DAAMLP
William J. Owens DC, DAAMLP
Citation: Studin M., Owens W. (2016) Chiropractic Outcomes on Fragmented/Sequestered and Extruded Discs and Radicular Pain, American Chiropractor, 34 (11) 26, 28, 30, 32-33
Disc herniations are a common diagnostic entity in chiropractic practices with varied etiologies ranging from auto accidents to sports injuries to slips and falls and any other type of trauma that can cause the disc to tear. Treatment has varied from doing nothing to conservative care to opiates and the surgery and in the recent past, opiates and surgery have been the treatment of choice leaving a population of too many addicts and too often failed surgeries. This is not to suggest that all surgeries or opiates are unnecessary, but if drugs and/or surgery can be avoided it is an obvious choice.
When considering disc issues, Fardone et. Al (2014) defined the nomenclature that has been widely accepted both in academia and clinically and should be adhered to, to ensure that reporting and visualizing pathology is consistent with the morphology visualized. In the past, this has been a significant issue as many have called a bulge a protrusion, a prolapse or herniation. In today’s literature Fardone’s document has resolved much of those problems.
Herniated Disc: “Herniated disc is the best general term to denote displacement of disc material. The term is appropriate to denote the general diagnostic category when referring to a specific disc and to be inclusive of various types of displacements when speaking of groups of discs. The term includes discs that may properly be characterized by more specific terms, such as ‘‘protruded disc’’ or ‘‘extruded disc.’’ The term ‘‘herniated disc,’’ as defined in this work, refers to localized displacement of nucleus, cartilage, fragmented apophyseal bone, or fragmented annular tissue beyond the intervertebral disc space. ‘‘Localized’’ is defined as less than 25% of the disc circumference. The disc space is defined, craniad and caudad, by the vertebral body end plates and, peripherally, by the edges of the vertebral ring apophyses, exclusive of the osteophyte formation. This definition was deemed more practical, especially for the interpretation of imaging studies, than a pathologic definition requiring identification of disc material forced out of normal position through an annular defect.” (page E1454)
Protruded Disc: “Disc protrusions are focal or localized abnormalities of the disc margin that involve less than 25% of the disc circumference. A disc is ‘‘protruded’’ if the greatest dimension between the edges of the disc material presenting beyond the disc space is less than the distance between the edges of the base of that disc material that extends outside the disc space. The base is defined as the width of the disc material at the outer margin of the disc space of origin, where disc material displaced beyond the disc space is continuous with the disc material within the disc space. The term ‘‘protrusion’’ is only appropriate in describing herniated disc material, as discussed previously.” (page E1455)
Extruded Disc: “The term ‘‘extruded’’ is consistent with the lay language meaning of material forced from one domain to another through an aperture and with reference to a disc, the test of extrusion is the judgment that, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base measured in the same plane or when no continuity exists between the disc material beyond the disc space and that within the disc space.” (page E1455)
Extruded Sequestered, Fragmented Disc or Migrated Disc: “Extruded disc material that has no continuity with the disc of origin may be characterized as ‘‘sequestrated.” A sequestrated disc is a subtype of ‘‘extruded disc’’ but, by definition, can never be a ‘‘protruded disc.’’ Extruded disc material that is displaced away from the site of extrusion, regardless of continuity with the disc, may be called ‘‘migrated,’’ a term that is useful for the interpretation of imaging studies because it is often impossible from images to know if continuity exists. (page E1455)
Bulging Disc: “The terms ‘‘bulge’’ or ‘‘bulging’’ refer to a generalized extension of disc tissue beyond the edges of the apophyses. Such bulging involves greater than 25% of the circumference of the disc and typically extends a relatively short distance, usually less than 3 mm, beyond the edges of the apophyses. ‘‘Bulge’’ or ‘‘bulging’’ describes a morphologic characteristic of various possible causes. Bulging is sometimes a normal variant (usually at L5–S1), can result from an advanced disc degeneration or from a vertebral body remodeling (as consequent to osteoporosis, trauma, or adjacent structure deformity), can occur with ligamentous laxity in response to loading or angular motion, can be an illusion caused by posterior central subligamentous disc protrusion, or can be an illusion from volume averaging (particularly with CT axial images).” (page E1455)
It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbertin (2010) that over 250,000 patients a year undergo elective lumbar discectomy (spinal surgery) for the treatment of low back disc issues in the United States. The researchers did a comparative randomized clinical study comparing spinal microdiscectomy (surgery) performed by neurosurgeons to non-operative manipulative treatments (chiropractic adjustments) performed by chiropractors. They compared quality of life and disabilities of the patients in the study.
The study was limited to patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. Based upon the authors’ review of available MRI studies, the patients participating in the study were all initially considered surgical candidates. Both the surgical and chiropractic groups reported no new neurological problems and had only minor post-treatment soreness. 60% of the patients who underwent chiropractic care reported a successful outcome while 40% required surgery and of those 40%, all reported successful outcomes. This study concluded that 60% of the potential surgical candidates had positive outcomes utilizing chiropractic as the alternative to surgery.
Although the previous report concluded that a chiropractic spinal adjustment is an effective treatment modality for herniated disc a more recent study (Lehman ET. Al. (2014), further clarifies the improvement with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients.
In this study the acute onset patient (the pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one-year mark after the onset of the original complaint. Although one might argue that the patient would have gotten better with no treatment it was reported that after two weeks of no treatment only 36% of the patients felt better and at 12 weeks up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to their normal life without pain, drugs or surgery.
Chiropractic Care and Herniated Discs with Leg Pain
2 Week Improvement
1 Month Improvement
3 Month Improvement
In a prospective outcome study, Ehrler et. Al. (2016) studied outcomes of chiropractic care on both extruded and sequestered disc patients. They reported “The purpose of this study was to evaluate whether specific MRI features, specifically axial location and type (bulge, protrusion, extrusion, sequestration) of a herniated disc, are associated with the short and long term outcomes of patients treated with high-velocity, low-amplitude SMT specifically to the level of the symptomatic, MRI confirmed, herniation. This is the first study to address this question. Studies searching for predictors of improvement after treatment in previous low back pain patients did not target type and axial location of the herniated discs.Additionally, patients with disc sequestration were not excluded from this study.” (Page 196)
Ehrler et. Al. continued “Over 77% of patients with disc sequestration reported clinically relevant “improvement” compared to 66.7% of patients with extrusion. Although not statistically significant, 100% of patients with sequestration reported clinically relevant improvement at the 3-month data collection time point and at all data collection time points a higher proportion of patients with sequestration reported clinically relevant improvement. There were no significant differences for disc herniation location either by spinal level or in the axial plane for any of the data collection time points. This now calls into question the traditional thinking that disc sequestrations are more dangerous than herniations that remain attached to the parent disc and are more likely to require surgery. However, the studies reporting this did not consider chiropractic spinal manipulative therapy as a treatment option.” (page 197)
I would like to leave you with a last and seemingly unrelated statement. I felt it was important to add this at the end since many of our critics negatively portray the safety of chiropractic care. This statement shall put that to rest leaving only personal biases left standing. Whedon, Mackenzie, Phillips, and Lurie (2015) 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.
Chiropractic vs. Medical Advice, Bed Rest, Natural History/Resolution and Over-the-Counter Drugs for Low Back Pain
By: Mark Studin DC, FASBE(C), DAAPM, DAAMLP
William J. Owens DC, DAAMLP
A report on the scientific literature
Mechanical spine pain is any back pain excluding tumor or infection and has been called low back pain, chronic low back pain, acute low back pain and non-specific low back pain. This is a societal problem and according to Panjabi (2006) “…70-85% of the population in industrialized societies experience low back pain at least once in their lifetime... The total cost of low back pain has been estimated to exceed 50 billion dollars per year in the USA” (p. 668)” Low back pain is historically one of the most prevalent conditions successfully treated in chiropractic offices and still is being questioned in too many medical conversations in spite of the evidence. This lack of referrals to the chiropractic profession by too many medical providers has contributed to perpetuating this reversible epidemic. Day, Yeh Franko, Ramirez, and Krupat (2007) reported that only 26% of fourth year Harvard medical students had a cognitive mastery of physical medicine.
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. (p. 251).
With continued evidence of lack of musculoskeletal medicine and a subsequent deficiency of training in spine care, particularly of biomechanical (subluxation or bio-neuro-mechanical lesions) 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 doctors of chiropractic, according to the American Chiropractic Association, is 4,200 hours (similar to medical doctors and osteopaths) and students receive a thorough knowledge of anatomy and physiology. As a result, all accredited doctors of chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. This material is so important to a chiropractic practice 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 internships.
It was reported by Shaheed, Mahar, Williams, and McLachlin (2014) that out of the 4,336 studies they identified, there was only 13 found to be relavent, leaving this an area that still needs more review. However, in the entire study it was concluded that, “None of the trials evaluating [medical] advice or bed rest reported statistically and clinically important effects at any time point…The effects of advice on disability are similar to those for pain, with pooled results showing no clinical significant effect for the short and long-terms” (Shaheed, 2014, p. 5). “Pooled results from 2 studies on bed rest showed a statistically significant negative effect of bed rest in the immediate term…” (Shaheed et al., 2014, p. 10).
Shaheed et al. (2014) concluded that “There is no convincing evidence of effectiveness for any intervention available [with] OTC (over the counter drugs) or advice in the management of acute low back pain” (p. 11). The authors did report, “In the intermediate term, results from one of the studies involving referral to an allied HCP [health care provider] and reinforcement of key messages at follow-up visits showed significant effects in the intermediate and long-terms” (Shaheed et al., 2014, p. 12).
A 2005 study by DeVocht, Pickar, & Wilder concluded through objective electrodiagnostic studies (neurological testing) that 87% of chiropractic patients exhibited decreased muscle spasms. This study validates the reasoning behind the later study that people with severe muscle spasms in the low back respond well to chiropractic care and this prevents future problems and disabilities. It also dictates that care should not be delayed or ignored due to a risk of complications. The above statistic indicates that while medicine cannot conclude an accurate diagnosis in 85% of their back pain patients, chiropractic has already helped 87% of the same population.
In a study by Leeman, Peterson, Schmid, Anklin, and Humphrys (2014), there is further successful evidence of the effects of mechanical back pain, both acute and chronic pain with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients. In this study, the acute onset patient (the patient’s pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one year marks following the onset of the original pain. Although one might argue that the patient would have gotten better with no treatment, it was reported that after two weeks of no treatment, only 36% of the patients felt better and at 12 weeks, up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to his/her normal life without pain, drugs or surgery.
Again, this is an environment where research has concluded that medicine has poor choices based upon outcomes for what they label “nonspecific low back pain.” The results indicate that chiropractic has defined this “nonspecific lesion” as a “bio-neuro-mechanical lesion” also known as the chiropractic vertebral subluxation and the evidence outlined on these pages, combined with the ever growing body of outcome studies verify that medicine can reverse this epidemic by considering chiropractors as “primary spine care providers” or the first option for referral for everything spine short of fracture, tumor or infection.