CASE REPORT: Long-term chiropractic maintenance patient presents with back pain from metastatic cancer.

Peter Zilahy DC

Key Words::  thoracic spine pain, metastatic breast cancer, MRI,

Abstract: The objective was to differentially diagnose metastasis from musculoskeletal disease.

Introduction

A very athletic 37-year-old female, the owner of a CrossFit fitness center, was under my care for eight years. She participated in wellness and targeted treatment for multiple injuries and musculoskeletal complaints. Her initial presentation was cervicogenic vertigo that failed conventional ENT and PT but resolved with chiropractic care. A professional relationship ensued that included advice on various aspects of health and lifestyle. The patient looked to me as a first-line approach for many conditions. The patient presented with upper thoracic pain of musculoskeletal origin, and then six months later, lower thoracic pain resulting from metastatic disease.

CLINICAL FINDINGS

The patient’s history included breast cancer, which was successfully treated medically. She was advised to continue with Tamoxifen but chose not to. Two and a half years later, the patient presented to my office with upper thoracic pain. Plain x-rays were imaged:Three views of the thoracic spine were obtained. Thoracic spine alignment and vertebral body height were maintained. The intervertebral disc spaces were preserved. There was no evidence of acute fracture or dislocation. A visualized portion of the lung is clear. Chiropractic manipulation and acupuncture were administered with favorable results. Seven months later, the patient returns with lower thoracic pain, rated 8/10 VAS

EXAMINATION

The patient is a 37-year-old, 5', 1.5, right-handed, 120-pound female.

The patient presented with dull pain in the lower thoracic/ upper lumbar region. Examination reveals increased palpatory spasms in the paraspinal region. Tenderness

was elicited with light, digital pressure in the related musculature. Segmental joint dysfunction was evident in T11, L1, and left pelvis. Provocative factors were lifting and various movements. With digital pressure, there was sharp radiating intercostal pain.

I recommended an MRI, but the patient was hesitant and wanted to check her insurance.

10 days later, she returned with less thoracic pain and was treated without incident.

3 weeks later, the patient returns, stating that the pain is now constant in the thoracolumbar region and now radiates to the mid-axilla line. The pain wakes her up at night, and there is nothing that she could do to find relief. I then told her that she has to have the MRI imaged, but she resisted.

Four days later, she states the pain continues to be experienced daily and was rated 8/10 on a visual analog scale. With various motions, lifting, and digital pressure, the pain becomes severe. She has tried resting, home therapy, exercise, over-the-counter medications, massage, and soft tissue techniques without benefit.

I then insisted that she now had to get an MRI; she consented but did not schedule it for three weeks. She suspended care during that time with no change in her pain.

I then saw her on the day of the MRI. She reported persistent pain in her thoracic region. I reviewed her MRI findings which were positive for breast cancer metastasis. I contacted her PCP for standard medical care.

The patient underwent a course of chemotherapy along with instrumented stabilization of the T12 motion segment, which was fully mineralized without hardware failure. The patient responded favorably and is now pain-free and returned to exercise, including Cross Fit.

MRI Studies:

MR THORACIC SPINE:

TECHNIQUE: Axial and sagittal images of the thoracic spine were obtained at 3.0 Tesla.

FINDINGS: There are subtle lesions on the left side of L1, one within the anterior portion of the vertebra and one within the left pedicle. There are approximately 4 small lesions in the T11 vertebral body. There is a very small round lesion within the T7 vertebral body and another small lesion within the superior aspect of the right side of the T2 vertebral body. All of these lesions are highly suspicious for metastatic disease. The lesion within the T6 vertebral body likely represents an incidental hemangioma, as it is bright on the T1-weighted images.

 

Zilahy 1

 

The image to the left is a magnified sagittal T1 FLAIR-weighted view. The red arrows point to a decreased signal in the entire T12 vertebral body, extending into the right pedicle with smaller multiple lesions in the T11 and T10 vertebral bodies. There is a mild compression deformity along the superior endplate. 

 

Zilahy 2

 

The increased signal, as noted by the GREEN ARROW, denotes a hemangioma.

 

Zilahy 3

 

The image to the left is a magnified T2 STIR view. The red arrows point to the brighter signal throughout the T12 vertebral body, with smaller lesions in the T11 and T10 vertebral bodies evidence of the metastasis. The T6 vertebral body has a homogenous signal as noted by the GREEN ARROW, unable to see the hemangioma.

 

Zilahy 4

 

The image to the left is a magnified sagittal T1 FLAIR-weighted view. The RED ARROW points to the decreased signal in the pedicle. Compare that to the T11 pedicle with the normal signal as noted by the GREEN ARROW.

 

Zilahy 5

 

The image to the left is a magnified axial T1-weighted view of the T12 vertebral body. The RED ARROWS outline the fracture line.

 

  1. Ju, Derek G., et al. "Diagnosis and surgical management of breast cancer metastatic to the spine." World Journal of Clinical Oncology 5.3 (2014): 263.
  2. Esteva FJ, Valero V, Pusztai L, Boehnke-Michaud L, Buzdar AU, Hortobagyi GN. Chemotherapy of metastatic breast cancer: what to expect in 2001 and beyond. Oncologist. 2001;6:133–146. [PubMed] [Google Scholar]
  3. DeSantis C, Ma J, Bryan L, Jemal A. Breast cancer statistics, 2013. CA Cancer J Clin. 2014;64:52–62. [PubMed] [Google Scholar]
  4. Maccauro G, Spinelli MS, Mauro S, Perisano C, Graci C, Rosa MA. Physiopathology of spine metastasis. Int J Surg Oncol. 2011;2011:107969. [PMC free article] [PubMed] [Google Scholar]
  5. Marulanda GA, Mont MA, Lucci A, Letson GD, Khakpour N. Orthopedic surgery implications of breast cancer. Expert Rev Anticancer Ther. 2008;8:949–956. [PubMed] [Google Scholar]
  6. Levack P, Graham J, Collie D, Grant R, Kidd J, Kunkler I, Gibson A, Hurman D, McMillan N, Rampling R, et al. Don't wait for a sensory level--listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression. Clin Oncol (R Coll Radiol) 2002;14:472–480. [PubMed] [Google Scholar]
  7. Quraishi NA, Gokaslan ZL, Boriani S. The surgical management of metastatic epidural compression of the spinal cord. J Bone Joint Surg Br. 2010;92:1054–1060. [PubMed] [Google Scholar]
  8. Zadnik PL, Hwang L, Ju DG, Groves ML, Sui J, Yurter A, Witham TF, Bydon A, Wolinsky JP, Gokaslan ZL, et al. Prolonged survival following aggressive treatment for metastatic breast cancer in the spine. Clin Exp Metastasis. 2014;31:47–55. [PubMed]
  9. Sciubba DM, Petteys RJ, Dekutoski MB, Fisher CG, Fehlings MG, Ondra SL, Rhines LD, Gokaslan ZL. Diagnosis and management of metastatic spine disease. A review. J Neurosurg Spine. 2010;13:94–108. [PubMed] [Google Scholar]
  10. Laufer I, Sciubba DM, Madera M, Bydon A, Witham TJ, Gokaslan ZL, Wolinsky JP. Surgical management of metastatic spinal tumors. Cancer Control. 2012;19:122–128. [PubMed] [Google Scholar]
  11. Schirrmeister H. Detection of bone metastases in breast cancer by positron emission tomography. Radiol Clin North Am. 2007;45:669–676, vi. [PubMed] [Google Scholar]
  12. Sciubba DM, Petteys RJ, Dekutoski MB, Fisher CG, Fehlings MG, Ondra SL, Rhines LD, Gokaslan ZL. Diagnosis and management of metastatic spine disease. A review. J Neurosurg Spine. 2010;13:94–108. [PubMed] [Google Scholar]
  13. Costelloe CM, Rohren EM, Madewell JE, Hamaoka T, Theriault RL, Yu TK, Lewis VO, Ma J, Stafford RJ, Tari AM, et al. Imaging bone metastases in breast cancer: techniques and recommendations for diagnosis. Lancet Oncol. 2009;10:606–614. [PubMed] [Google Scholar]

 

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Published in Case Reports

Chiropractic Outcomes

Drug Use, Disability

& Non-Specific Back Pain

 

  1. Chiropractic Patient Successful Outcomes at 96.56%
  2. Chiropractic Drug Utilization Lower (55% fewer opiates)
  3. Chiropractic Drug Cost Lower (74% less for opiates)
  4. Chiropractic Gets 313% Lower Secondary Disability vs. Physical Therapy 

 

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 

 

CONCLUSION

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.

 

 

References:

  1. Balagué, Federico, et al. "Non-specific low back pain." The lancet 379.9814 (2012): 482-491.
  2. Government Accountability Office. Medicare Part B imaging services: rapid spending growth and shift to physician offices indicate the need for CMA to consider additional management practices. Washington, DC: Government Accountability, 2008
  3. Oliveira, Crystian B., et al. "Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview." European Spine Journal 27.11 (2018): 2791-2803.
  4. Gevers‐Montoro, C., et al. "Neurophysiological mechanisms of chiropractic spinal manipulation for spine pain." European Journal of Pain (2021)
  5. Panjabi, M. M. (2006). A hypothesis of chronic back pain: Ligament subfailure injuries lead to muscle control dysfunction.European Spine Journal,15(5), 668-676.
  6. Solomonow, M. (2009). Ligaments: A source of musculoskeletal disorders.Journal of Bodywork and Movement Therapies,13(2), 136-154.
  7. Jaumard, N. V., Welch, W. C., & Winkelstein, B. A. (2011). Spinal facet joint biomechanics and mechanotransduction in normal, injury and degenerative conditions.Journal of Biomechanical Engineering,133(7), 071010.
  8. Whedon, J. M., Toler, A. W., Goehl, J. M., & Kazal, L. A. (2018). Association between utilization of chiropractic services for the treatment of low-back pain and use of prescription opioids. The Journal of Alternative and Complementary Medicine24(6), 552-556.
  9. Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation27(3), 382-392
  10. Back Pain (2021)Mayo Clinic, retrieved from https://www.mayoclinic.org/diseases-conditions/back-pain/diagnosis-treatment/drc-20369911
  11. Ndetan, H., et al. "Chiropractic Care for Spine Conditions: Analysis of National Health Interview Survey." Journal of Health Care and Research 2020.2 (2020): 105.

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Published in Low Back Problems

Chiropractic Practice

During the COVID-19 Pandemic

 

By Mark Studin

 

In a conversation with Jonathan Epstein, an epidemiologist at the EcoHealth Alliance in New York who has traveled the globe in studying zoonotic viruses—those that can jump from animals to people, and was part of the research team in China’s Guandong Province that discovered bats were the natural reservoir for SARS, I now understand that the current COVID-19 strain is related to SARS and MERS, two other recently emergent zoonotic coronaviruses. These viruses live in certain bat species and have co-evolved with bats for the entire span of human civilization. Dr. Epstein explained, “These viruses are made up of RNA and can mutate quickly, making them promiscuous. Often, when a virus jumps from its natural host (e.g. bats) to a new host (e.g. people) it can cause disease. A virus that transmits easily and doesn’t readily kill its host has the best chance to survive in nature.”

 

A German study published just as a few weeks ago revealed that the coronavirus is an outstanding “shedder” and seeks to leave its host once it replicates. It searches mucosal exists, even our breath well before the host is experiencing symptoms.[1] The New Yorker Magazine reported, “Outside a host, in parasitical purgatory, a virus is inert, not quite alive, but not dead, either. It was found that the virus can linger on copper for four hours, on a piece of cardboard for twenty-four hours, and on plastic or stainless steel for as long as three days. They also found that the virus can survive, for three hours, floating through the air, transmitted by the tiny respiratory droplets as an infected person exhales, sneezes, or coughs out.”[2]

 

Living in New York, at the epicenter of this crisis and now self-isolated for 17 days, this is eerily reminiscent of 9-11 to many New Yorkers where we know someone infected, and someone knows someone who has lost their life. We live in fear for friends and families who are “hospital-based first responders,” and most everyone wants to be part of the solution. The Long Island Expressway dubbed the “longest parking lot in the world” is perpetually empty, and the largest railway commuter system on the planet hardly has a passenger. We are also fearful of others in our nation due to political “misinformation” because we are in the epicenter living and witnessing the truth through ourselves, family, and friends with confirmation through local media.

 

 

Where does that leave our profession?

 

I have spent the last two weeks becoming an expert on infectious disease prevention in chiropractic offices, telemedicine, home-based treatments, acquiring feedback from patients, risk management, coding, preserving referral sources, managing finances, and labor/employment laws. I have been teaching doctors how to prepare for “opening day” that will come sooner than you think and a host of other things chiropractic would have never considered.

 

For those who have chosen to stay open, the patient’s car in the parking lot has become the new waiting room, where one person at a time is allowed in the office for treatment. Most staff has been furloughed, leaving only the doctor and essential treating staff with hand and treatment table sanitizing between every patient. A mask for the doctor is strongly advised due to the “breath” transmission of this virus. If you treat a patient that has been diagnosed with Covid-19, you and your staff are then mandated by your state’s department of health to self-isolate for 15 days.

 

 

For those who have closed, telemedicine has become a necessity, and the Federal Government has relaxed its HIPAA rules, practicing over state line rule and others. Carriers have added chiropractic telemedicine services, and many have waived co-pays and deductibles because these are billable events. There have been recent E-Codes added by the AMA to create clarity in billing telemedicine codes. You should consider using modifier “95” [telemedicine services], and place of service “02” [telemedicine]. These are predominantly timed services involving patient management and have specific documentation requirements to consider.

 

 

If you would like to learn more about coding and other COVID-19 issues, I am providing a link for a 40-minute Webinar I created for the profession to help clarify these issues [there is no cost]:

 

https://app.box.com/s/l0h936zihgptgl7czfzxfm6aai5l3ynw

 

There is lots of money in the system right now with the Federal Bail-Out, but be careful not to borrow what you don’t need and start with your local bank. They have the Federally backed money that includes some type of forgiveness in the Payroll Protection Program (PPP). I have also been told by many on Wall Street that inflation is not far away. Should you have a variable rate, or high-interest loan on any property, now is the time to refinance with interest rates low. Be financially smart.

 

 

Patient communication is paramount now. You do not want to see yourself re-starting your practice from “ground-zero” because you neglected to engage them during this mandatory isolation time. If you regularly have telemedicine visits, that is great; if not, ensure you touch base with them periodically via telephone to “check on them.” The same goes for lawyers and MD’s that you have referral relationships with, communicate with them. We have instituted regular academic programs for lawyers and MD‘s to keep them engaged with our doctors at a very high level. Opening day is coming sooner than you think, and the referral sources will remember you, if you made that extra effort.

 

What you do with your time is critical. I urge every chiropractor in the nation to get better academically. Take as many online post-doctoral courses as you can. I don’t care if your state allows online courses or not. Market research has proven over the last decade; the more credentials a doctor of chiropractic has, the more they can help their patients, the more referral they get, and the financial bottom line goes up. Cleaning your garage with your extra free time is admirable, but elevating your knowledge will help the multitudes in your community, yourself included.

 

 

Should you open if you have the opportunity or not? That is a personal question for you to answer. For me, I want to be part of the solution, and today is day 17 of being self-isolated, where I work long days and sleepless nights in being creative to ensure that I am prepared for opening day.

 

 

 


[1] Woelfel, R., Corman, V. M., Guggemos, W., Seilmaier, M., Zange, S., Mueller, M. A., ... & Bleicker, T. (2020). Clinical presentation and virological assessment of hospitalized cases of coronavirus disease 2019 in a travel-associated transmission cluster. medRxiv.

[2] https://www.newyorker.com/science/elements/from-bats-to-human-lungs-the-evolution-of-a-coronavirus

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Published in Neck Problems

Personal Injury Collections by State:

 

2011 vs. 2013 vs. 2015 vs. 2017 vs. 2019

 

Comparison of Collections vs. Cost of Living Analysis

 

National PI Collections Increase by 24%

 

 

Reference: Studin M., (2020) Personal Injury Collections by State: 2011 vs. 2013 vs. 2015 vs. 2017 vs. 2019 Comparison of Collections vs. Cost of Living Analysis, American Chiropractor, 42 (2), pgs. 34, 36, 38-40

 

by Mark Studin

 

In 2011, 2013, 2015 and 2017 I wrote in the American Chiropractor Magazine, "Why is a life in Tennessee, South Dakota and Texas worth more than a life in Hawaii and New York?" There is no reason other than the insurance companies and state politicians that you have elected into office allow it to be. We are a country of laws and regulations per-visit and it is these laws that dictate the marketplace and how doctors are reimbursed for their services. In most states, it is based upon the usual and customary fees of the doctors and the carriers paying a percentage of those fees. However, in Hawaii, the state sets the doctors’ fees and they are driven by politics.

 

 

The collections listed in the following table depict what chiropractors are collecting as of December 2019, on a per-visit basis for a typical treatment vs. what they collected in 2011, 2013, 2015 and 2017 and are rated against the cost of living for each state in comparison to other states. The dollar amounts exclude examinations, x-rays, supports and any other ancillary services or testing and are limited to only services performed by the chiropractor in a private clinical setting for treatment inclusive of the adjustment, modalities and rehabilitation.

 

 

The number of reporting doctors in all states does not reflect a large enough cohort (sample size) to reflect statistically accurate averages. However, based on survey sampling and conversations in all 50 states, the numbers are what was reported and can be trusted as a guide. The dollar amounts accurately reflect what is currently being collected for personal injury cases on a “visit basis” in all 50 states nationally and I personally gathered the information.

 

 

As I established in 2011, 2013, 2015 and 2017 in my previous articles, the cost of living is not an indicator for reimbursement in personal injury as one would logically conclude. In a fair and equitable system, the more it costs to rent an office and run a business, the more a doctor should be entitled to charge and collect. Unfortunately, politics too often determine your fees on a state-by-state basis and the stronger the insurance lobby, the lower the reimbursable fees. As was reported previously, Hawaii, which is one of the most expensive states to live in, has the lowest levels of reimbursement nationally. New York, previously was the lowest reimbursable state nationally, just got its first substantial fee increase and in October 2020, downstate New York chiropractors can realize approximately $114 per visit and will be reflected as such in this survey, although currently it is roughly $42. The New York State legislature controls New York personal injury fees.

 

 

A 50-state reimbursement comparison between 2017 and 2019 revealed a 25% increase in collections and between 2011 and 2019, a 48% increase was reported for a personal injury visit in a chiropractic office. This statistic showed a trend in the chiropractic profession which verifies that the personal injury population of patients is a financially stable sect within the industry. Also, when managed care and other financial classes in the profession are shrinking in reimbursement, personal injury is the one sector consistently growing. Please note that this author is not suggesting that a doctor maximize his/her charges inappropriately and that only clinically indicated services should be performed based upon clinical necessity.

 

 

Many doctors will read this report and feel that they must increase those portions of their practices with personal injury patients. From a reimbursement perspective and business plan, that would appear to make sense. However, is that doctor qualified? Treating trauma cases requires a particular skill set and training no different than in any specialty in healthcare. You wouldn't want a psychiatrist performing open-heart surgery without the requisite training or an OB/GYN doing brain surgery. In the past, all a doctor of chiropractic would need beyond their doctoral training was advanced education in MRI interpretation. This is a result of improper MRI interpretations by general radiologists. Herzog et. Al (2017) reported a 43.6% error rate of general radiologists misreporting the MRI findings, something a doctor of chiropractic relies on to deliver our care. Today, to compete and be considered an expert, formal education in spinal biomechanics, connective tissue pathology and accident engineering are also required.

 

 

Understanding the differences between herniated, bulged, protruded, extruded, migrated or sequestered disk is critical in creating an accurate diagnosis prognosis and treatment plan in triaging and guiding the patient through care. Although the delivery of chiropractic may not change, when you can and cannot treat your patient might change because collaborative care with a medical specialist and or surgery might be indicated. The etiology of pain in the trauma case is often dramatically different than in a geriatric or pediatric patient. Training and credentials matter.

 

 

After consulting and educating chiropractors for 20 years nationally, 100% of the doctors who have made the effort to be trained and compete in the “personal injury space” have succeeded. Although the reported levels of success have varied, all now consider themselves better doctors and experts, allowing themselves to be successful and make their competition irrelevant in personal injury. That is our goal for the doctors we train.

 

 

Also, there are many “get rich quick schemes” in personal injury that our profession has been exposed to. These are typically a “false bill of goods” with offers of “magic reports and research articles” to garner referrals. There are programs designed to overcome the algorithmic requirements of the carriers to bolster settlements for lawyers with claims that is all the lawyers need to refer to en masse`. As verified by over 10,000’s of lawyers and hundreds of doctors nationally in the past 5 years who have tried that, confirmed it is a “plausible marketing fad” that hasn’t delivered. The primary beneficiaries of those programs are those who have created those schemes. CAVEAT EMPTOR! There is no substitute for credentials, knowledge and a strategic business plan to get your referral sources to run after you. That is the solution for chiropractic practices in 2020 and beyond; a fact that has been confirmed by extensive market research.

 

Too many doctors of chiropractic bypass the diagnosis and prognosis stage and delve directly into treatment. Too often, this step is taken to the detriment of the patient. If the patient has pain radiating down their arms or legs with or without associated motor weakness before you touch that patient, the first question that must be answered is “what is causing that problem?” AND… if you do not know, do not guess. Beyond your clinical examination, consider advanced imaging if clinically warranted without shying away from the carriers often “fictitious” rules of approving the advanced images. Once again, the hard, NON-NEGOTIABLE “Studin Rule” rule is: IF YOU DO NOW KNOW…DO NOT GUESS.  

 

 

The only way to spiral upwards is through clinical excellence through the acquisition of knowledge and credentials. Based on the literature, chiropractic outcomes have outpaced other forms of treatment for spinal conditions within our scope. For mechanical spine pain, both physical therapy and medicine have realized far poorer outcomes with an increased incidence of secondary disabilities, increase opiate use and significantly higher costs compared to chiropractic care.

 

 

As a profession, the most direct avenue for these published studies to help increase utilization is for each doctor to be expert and credentialed in the area of desired practice. Treating personal injury patients is included in this formula and mandates graduate-level training (post-doctoral education), so choose your courses wisely as a stepping-stone to what you want your practice to be tomorrow.

 

With personal injury or any financial category, fair and equitable reimbursements will determine if a doctor can afford to live in any community nationally and wise legislators should take into account doctor’s reimbursements, or will soon realize there is a doctor shortage in their respective state. Many state legislators are not "penny wise and dollar foolish," unlike those elected officials in Hawaii and this has fueled the opioid crisis with only pharmacologic or surgical solutions. Therefore, for those states who are below the national average, the chiropractic political organizations should strengthen their lobbying efforts with a unified (one) chiropractic voice (organization) and that should happen not only at the state level but nationally.

 

 

NEVER LOSE SIGHT THAT THERE CAN NEVER BE A PHARMACOLOGICAL SOLUTION TO A MECHANICAL PROBLEM. Therin lies the genesis of part of the opioid crisis.

 

 

 

Survey in 2011

Survey in 2013

Survey in 2015

Survey in 2017

Survey in 2019

Cost of Living Ranked Lowest to Highest

Alabama

$80.00

$80.00

$90.00

$200.00

$         250.00

8

Alaska

$175.00

$225.00

$225.00

$349.00

$         375.00

47

Arizona

$110.00

$100.00

$135.00

$200.00

$         333.00

23

Arkansas

$115.00

$109.00

$120.00

$110.00

$         235.00

2

California

$113.00

$140.00

$155.00

$225.00

$         210.00

49

Colorado

$75.00

$150.00

$185.00

$250.00

$         275.00

35

Connecticut

$100.00

$100.00

$180.00

$200.00

$         200.00

50

Delaware

$200.00

$200.00

$200.00

$200.00

$         460.00

34

Florida

$250.00

$250.00

$325.00

$300.00

$         325.00

28

Georgia

$225.00

$140.00

$202.00

$220.00

$         366.00

10

Hawaii

$75.00

$75.00

$75.00

$75.00

$           75.00

51

Idaho

$160.00

$135.00

$120.00

$100.00

$         195.00

16

Illinois

$230.00

$150.00

$220.00

$250.00

$         357.00

24

Indiana

$65.00

$90.00

$125.00

$225.00

$         250.00

15

Iowa

$100.00

$100.00

$140.00

$140.00

$         225.00

6

Kansas

$80.00

$150.00

$170.00

$120.00

$         240.00

9

Kentucky

$180.00

$230.00

$185.00

$250.00

$         400.00

17

Louisiana

$113.00

$90.00

$125.00

$120.00

$         225.00

19

Maine

$70.00

$160.00

$130.00

$135.00

$         145.00

38

Maryland

$173.00

$150.00

$200.00

$225.00

$         300.00

46

Massachusetts

$130.00

$170.00

$250.00

$250.00

$         300.00

45

Michigan

$100.00

$135.00

$250.00

$300.00

$         350.00

3

Minnesota

$160.00

$206.00

$200.00

$307.00

$         400.00

29

Mississippi

$209.00

$200.00

$210.00

$150.00

$         225.00

1

Missouri

$100.00

$190.00

$200.00

$375.00

$         145.00

4

Montana

$75.00

$108.00

$195.00

$199.00

$         198.00

31

Nebraska

$75.00

$138.00

$150.00

$180.00

$         195.00

13

Nevada

$80.00

$180.00

$130.00

$150.00

$         221.00

36

New Hampshire

$118.00

$129.00

$120.00

$160.00

$         240.00

38

New Jersey

$136.00

$105.00

$105.00

$105.00

$         110.00

41

New Mexico

$171.00

$250.00

$160.00

$170.00

$         210.00

14

New York

$40.00

$43.00

$42.00

$42.00

$         114.00

48

North Carolina

$125.00

$120.00

$160.00

$115.00

$         155.00

18

North Dakota

$145.00

$145.00

$145.00

$145.00

$         250.00

30

Ohio

$140.00

$120.00

$100.00

$300.00

$         345.00

12

Oklahoma

$167.00

$125.00

$253.00

$120.00

$         195.00

5

Oregon

$175.00

$120.00

$150.00

$190.00

$         200.00

44

Pennsylvania

$155.97

$115.00

$140.00

$150.00

$         235.00

32

Rhode Island

$140.00

$130.00

$130.00

$130.00

$         150.00

42

South Carolina

$145.00

$165.00

$200.00

$120.00

$         145.00

15

South Dakota

$100.00

$198.00

$125.00

$200.00

$         225.00

27

Tennessee

$245.00

$220.00

$155.00

$125.00

$         325.00

7

Texas

$125.00

$150.00

$225.00

$150.00

$         525.00

11

Utah

$130.00

$155.00

$170.00

$178.00

$         227.00

25

Vermont

$100.00

$140.00

$160.00

$160.00

$         167.00

39

Virginia

$120.00

$110.00

$200.00

$250.00

$         300.00

33

Washington

$120.00

$140.00

$225.00

$250.00

$         315.00

37

West Virginia

$110.00

$135.00

$185.00

$150.00

$         208.00

26

Wisconsin

$117.00

$130.00

$129.00

$185.00

$         225.00

21

Wyoming

$90.00

$90.00

$115.00

$120.00

$         145.00

20

 

References:

 

  1. Studin, M. (2011, February) Personal Injury Collections by State: 2011 Comparison of Collections vs Cost of Living Analysis, The American Chiropractor, 33(2) 52-53
  2. Studin, M. (2013, July) Personal Injury Collections by State: 2011 vs. 2013 Comparison of Collections vs Cost of Living Analysis, The American Chiropractor, 35
  3. Studin M. (2015) Personal Injury Collections by State: 2011 vs. 2013 vs. 2015 Comparison of Collections versus Cost of Living Analysis, The American Chiropractor, 37(6) 40, 42-43
  4. Studin M., Personal Injury Collections by State: 2011 vs. 2013 vs. 2015 vs. 2017, (2018) Comparison of Collections vs. Cost of Living, American Chiropractor 40 (1) pgs. 12-14, 16
  5. Herzog, R., Elgort, D. R., Flanders, A. E., & Moley, P. J. (2017). Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. The Spine Journal17(4), 554-561.
  6. Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine173(17), 1573-1581.
  7. Cost of Living Data Series 2017 Third Quarter 2017 (2017), Retrieved from: https://www.missourieconomy.org/indicators/cost_of_living/

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Chiropractic Co-Management of Pre & Post-Spine Surgical Cases

 

By: Matt Erickson DC, FSBT

Mark Studin DC, FASBE(C), DAAPM, DAAMLP

Ashraf Ragab, MD, Orthopedic Spine Surgeon

 

 

Reference: Erickson M., Studin M., Ragag A. (2019) Chiropractic Co-Management of Pre and Post-Surgical Cases, American Chiropractor 41(9), 34, 36,38-40

 

A report on the scientific literature

 

Introduction

 

When a patient presents in a chiropractic office and has clinical signs of either radiculopathy (nerve root compression) at the neural canal or central canal regions or any myelopathic findings (cord compression with ensuing neurological deficit distal to the level of the lesion), immediate referral for an MRI should be considered. Based upon your clinical findings, triage then ensues as a result of creating a clinically driven diagnosis, prognosis and treatment plan. In a smaller percentage of cases, it will be discovered that the patient has a condition that requires a referral to a spine surgeon or a pain management provider. Regardless of where the patient is directed, having the patient fully worked up (examination, x-rays and advanced imaging) before the referral takes place is an important aspect of what the Doctor of Chiropractic can and should do and is within the lawful scope of practice within all 50 states and the United States territories.

 

Among those patients referred to the spine surgeon, some will not require or be a candidate for surgery. This is an area where a Doctor of Chiropractic especially with post-graduate training in Primary Spine Care and spinal biomechanical engineering, can be a big help to the surgeon by ensuring that a higher portion of the referred patients presents with the condition that likely requires the surgeon’s services. By triaging those patients who more likely needs the spine surgeon or pain management doctor’s services, it allows the specialist to save time on screening patients in the clinic who do not need their services and instead, it allows them to spend more time performing medically necessary spine-related procedures which allows patients to be taken care of more efficiently.

 

In the event a patient does not require surgery, unless there is a contraindication to correcting a patient’s neuro-musculo-biomechanical failure leading to structural imbalance, the Doctor of Chiropractic can co-manage the patient with the pain management provider. For the pain management provider, they may recommend various pain management procedures like a spinal epidural injection, a medial branch block or a facet injection. And given that pain management providers don’t focus on spinal biomechanics, but the Doctor of Chiropractic does, for most patients, this collaborative approach is ideal for better patient outcomes.

 

Surgical Considerations

 

In patients who do require surgery, the treatment plan can be as simple as the referral to the spine surgeon. This however brings the question, “What is the Doctor of Chiropractic’s role in managing patients before and after surgery?”

 

In some cases, immediate surgery may be required. This would be the case where the patient has a spinal cord injury like myelomalacia-which is regarded as softening of the spinal cord due to damaged neural tissue that fills in with a glial scar.   A glial scar, according to Silver and Miller (2004, February) “consists predominately of reactive astrocytes [star-shaped glial cells-cells without neurons, in the brain or spinal cord] and proteoglycans [molecules made of sugar and proteins]” (p. 146). Further, myelomalacia forms with pressure on the spinal cord which may be due to biomechanical failure and ensuing cord pressure in post-trauma cases. Immediate surgery may also be required with a disc extrusion (a type of disc herniation) which presents with myelopathic findings (ensuing neurological deficit distal to the site of the spinal cord lesion following trauma) and in patients with an advanced nerve root compression leading to pain, numbness, tingling and weakness into the upper or lower extremity at the level the nerve root has been compressed.

 

In other patients however, while surgery may be indicated, the Doctor of Chiropractic can work to improve the patient’s biomechanical balance before surgical intervention. This is another area a Primary Spine Care trained Doctor of Chiropractic has the additional post-graduate training to co-manage this type of case. Regardless, these considerations must be coordinated with the spine surgeon if surgery is required. Sagittally balancing the spine for better patient surgical outcomesas reported by Makhni, Shillingfor, Latatta Hyun and Kim (2018), “Adult spinal deformity with sagittal imbalance is associated with significant pain, disability, as well as directly and negatively influence health-related quality of life scores. The spine surgeon has to understand the whole global and regional alignment changes after sagittal imbalance to address the multiplanar deformity. Restoration of global alignment and minimization of complications through various surgical options can successfully improve the pain and function of spinal deformity patients” (pp. 176-177).

 

Importance of Sagittal Balance

 

Sagittally balancing the lumbar spine is further supported in an article published on Helia.com related to lectures on the outcomes of lumbar spine surgery about sagittal balance, Hu (2016, para 3) reported, “Surgical outcomes for spine surgery are improved when spinal, pelvic and hip alignment is considered in both degenerate and deformity cases, and how we better understand these will help us better improve outcomes for our patients” (https://www.healio.com/spine-surgery/lumbar/news/print/spine-surgery-today/%7B54ac5ca2-7939-407d-96a5-31fa9c0fc904%7D/proper-sagittal-balance-may-correlate-with-better-surgical-outcomes).

 

Hu (2016) also reported, “Sagittal imbalance in a patient can negatively affect the outcomes of a surgical procedure. But, how extensive the surgery required is to correct the imbalance must be carefully considered for the individual patient” (para. 4). r. LeHuec (2016) added, “Sagittal balance is an active phenomenon for patients. “The best course of action is to strive to achieve sagittal balance in patients” (para. 8).

 

 

In a study by Tang, Scheer, Smith, Deviren, Bess, Hart, Lafage, Shaffrey, Schwab and Ames (2015) regarding the thoracolumbar spine sagittal balance, the authors concluded, “Our findings demonstrate that, similar to the thoracolumbar spine, the severity of disability increase with positive sagittal malalignment following surgical reconstruction” (p. S21).

 

Finally, in an article by Yeh, Lee, Chen, Yu, Liu, Peng, Wang, and Wu, (2018) they concluded, “The results of this study support previous findings that functional outcomes are closely associated with sagittal radiographic parameters in the patients with the degenerative thoracolumbar spinal disease who received long-segment fusion. The achievement of global and regional sagittal alignment balance is a crucial factor for improved postoperative functional outcomes” (p. 1361).

 

Post-Surgical Management

According to a publication titled “A Detailed Guide to Your Surgery and The Recovery Process by the Johns Hopkins Spine Service (n.d., p. 16), “Walking is the best activity you can do for the first 6 weeks after surgery. Further, there will be “restrictions for the first 6 weeks after surgery,” the patient should “avoid twisting and bending” and avoid lifting, pushing or pulling objects greater than 5 lbs” (https://www.hopkinsmedicine.org/orthopaedic-surgery/_documents/patient-information/patient-forms-guides/JHULumbSpineSurgeryGuide.pdf).

 

From the Johns Hopkins publication (n.d.), patients are advised to call the surgeon’s office to make a 6-week follow-up appointment. At that appointment, x-rays will be performed to evaluate how the surgical area is healing. If everything checks out, “patients may be given a handout of lower back exercises to begin at home.” Patients may also be provided a prescription for outpatient physical therapy, but that is dependent upon the patient’s recovery (p. 24).

 

When physical therapy begins, the goal is to gradually improve strength, flexibility and endurance. The patient may also receive help with activities of daily living like gate training (learning how to walk properly again). However, while beneficial, physical therapy is limited in that a physical therapist does not focus diagnosing and correcting the spinal biomechanics. Further, a physical therapist is not licensed to manage the patients on a physician level. This is where the Doctor of Chiropractic is needed as part of the long-term recovery solution.

 

Following the initial 6-week evaluation, according to Hayeri and Tehranzadeh (2009, para. 21), “Evaluation of the postoperative spine usually begins with conventional radiographs in AP and lateral projections. It usually takes 6 to 9 months for a solid bone fusion to be established radiographically.”  Hayeri and Tehranzadeh (2009, para. 20) also reported, “Postoperative imaging plays an important role in the assessment of fusion and bone formation. It is also helpful to detect instrument failure and other suspected complications. It is necessary to compare current images with previous studies to identify any subtle changes and disease progression” (https://appliedradiology.com/articles/diagnostic-imaging-of-spinal-fusion-and-complications).

 

Hayeri and Tehranzadeh (2009) added, Currently, computed tomography (CT) with multiplanar reconstruction (MPR) is considered the modality of choice for imaging bony details and assessing osseous formation and hardware position despite artifact formation.” (para. 22).

 

 

It is important to understand, patients don’t need to wait 6-9 months to start treatment with the Doctor of Chiropractic. About 6 weeks following surgery, if the patient is healed enough to begin physical therapy, the patient should be able to tolerate gentle mechanical corrections above and below the level of the surgical fusion. However, the patient will need to first be cleared to do so by the surgeon. Doing this can help in the patient’s recovery process and prepare the patients spine for a more comprehensive correction process once the patient is cleared. It can also help to shorten the time needed for correction.

 

The Doctor of Chiropractic (trained in Primary Spine Care) therefore, can take on a critical and important role in the management of patients before and after spine surgery. Further, unlike the physical therapist, the Doctor of Chiropractic having physician class status, is licensed to fully diagnose, manage and treat biomechanical pathology of the spine when indicated.

 

Primary Spine Care

 

Despite this, not all Chiropractic Doctors have additional post-graduate training or experience to manage complex spine cases. This is no different than a Medical Doctor having just completed medical school not being able to function in the capacity of a specialist short of residency and/or a fellowship program.

 

One solution that provides the Doctor of Chiropractic with the additional training and experience to manage complex spine cases is an extensive post-graduate training program in Primary Spine Care as previously discussed. Currently, there is a growing body of Chiropractic Doctors through an extensive post-graduate program offered through the Academy of Chiropractic, that are becoming qualified in Primary Spine Care that is well prepared to take on the role in managing patients with complex spine related issues (https://www.academyofchiropractic.com/component/content/article.html?id=1224).

 

The concept of the Doctor of Chiropractic taking on the role of a Primary Spine Care provider was discussed in an article by Erwin, Korpela and Jones (2013). The stated, “Chiropractors have the potential to address a substantial portion of spinal disorders; however the utilization rate of chiropractic services has remained low and largely unchanged for decades. Other health care professions such as podiatry/chiropody, physiotherapy and naturopathy have successfully gained public and professional trust, increases in the scope of practice and distinct niche positions within mainstream health care. Due to the overwhelming burden of spine care upon the health care system, the establishment of a ‘primary spine care provider’ may be a worthwhile niche position to create for society’s needs. Chiropractors could fulfill this role, but not without first reviewing and improving its approach to the management of spinal disorders” (p. 285).

Conclusion

 

In conclusion, the Doctor of Chiropractic has the foundational training to diagnose, manage and treat patients when indicated both before and after spinal surgery. However, with additional post-graduate training in Primary Spine Care, the Doctor of Chiropractic can obtain the necessary skills to manage more complex spine conditions which include coordinating care with the spine surgeon, pain management doctors and even a patient’s primary care doctor. With the current opioid crisis in the United States, there is a need for a front-line provider to lead in the management of non-surgical spine care and the Doctor of Chiropractic as a licensed physician is positioned to take on that role especially with additional training in Primary Spine Care.

 

References

 

  1. Silver Jerry and Miller Jared H. (2004, February). Regeneration Beyond the Glial Scar. Nature Publishing Group, Volume 5, 146-156. Retrieved from https://www.nature.com/articles/nrn1326.pdf.
  2. Makhni Melvin C., MD, MBA, Shillingford, Jamal, N. MD, Laratta, Joseph, L. MD, Hyun, Seung-Jae, MD, PhD and Kim Yongjung, J., MD. (2018). Restoration of Sagittal Balance in Spinal Deformity. Journal of Korean Neurosurgery Society, 61(2), 167-179.
  3. Serena S. Hu, MD, Jean Charles LeHuec, MD, PhD and J.N. Alastair Gibson, MD, FRCS(Ed), FRCS(Tr &Orth), MFSTEd. (2016 Jan/Feb). “Proper sagittal balance may correlate with better surgical outcomes.” Retrieved from https://www.healio.com/spine-surgery/lumbar/news/print/spine-surgery-today/%7B54ac5ca2-7939-407d-96a5-31fa9c0fc904%7D/proper-sagittal-balance-may-correlate-with-better-surgical-outcomes.
  4. Jessica A. Tang, BS Justin K. Scheer, BS, Justin S. Smith, MD, PhD, Vedat Deviren, MD, Shay Bess, MD, Robert A. Hart, MD, Virginie Lafage, PhD Christopher I. Shaffrey, MD, Frank Schwab, MD and Christopher P. Ames, MD. (2015). The Impact of Standing Regional Cervical Sagittal Alignment on Outcomes in Posterior Cervical Fusion Surgery. Neurosurgery 76, S14-S21.
  5. Kuang-Ting Yeh, MD, PhD, Ru-Ping Lee, RN, PhD, Ing-Ho Chen, MD, Tzai-Chiu Yu, MD, Kuan-Lin Liu, MD, PhD, Cheng-Huan Peng, MD, Jen-Hung Wang, MD, and Wen-Tien Wu, MD, PhD. (2018). Correlation of Functional Outcomes and Sagittal Alignment After Long Instrumented Fusion for Degenerative Thoracolumbar Spinal Disease. Spine, 43(19), 1355-1362.
  6. Johns Hopkins. (n.d., pp. 1-36). “A Detailed Guide to Your Surgery and The Recovery Process. Retrieved from (https://www.hopkinsmedicine.org/orthopaedic-surgery/_documents/patient-information/patient-forms-guides/JHULumbSpineSurgeryGuide.pdf
  7. Hayeri Mohammad Reza, MD, Tehranzadeh Jamshid, MD. (August 6, 2009). “Diagnostic imaging of spinal fusion and complications.” Retrieved from https://appliedradiology.com/articles/diagnostic-imaging-of-spinal-fusion-and-complications.
  8. Studin Mark, D.C., Primary Spine Care Qualified, “What is Primary Spine Care?” Retrieved from https://www.academyofchiropractic.com/component/content/article.html?id=1224.
  9. W. Mark Erwin, DC, PhD, A. Pauliina Korpela, BSc and Robert C. Jones. (2013) Chiropractors as Primary Spine Care Providers: precedents and essential measures, Journal of the Canadian Chiropractic Association, 57(4), 285-291.

 

 

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Published in Neck Problems

CASE REPORT: Multiple cervical and lumbar disc herniations and ligamentous injury, post MVA treated successfully with conservative chiropractic treatment

Dennis Mutell D.C.

Abstract: This case report demonstrates the use of conservative chiropractic care in the treatment of cervical and lumbar disc injuries as well as ligamentous instability in the cervical and lumbar spine of a person injured in a double impact automobile collision.

Diagnostic studies include complete case history, physical examination, including orthopedic and neurological exams, radiographic examination, including flexion extension views of the cervical and lumbar spine and MRI of the cervical and lumbar spine.

Introduction: The patient, a 48-year-old male who reports he was a passenger in a hotel shuttle van which was struck on the passenger side by another automobile, followed by a full-frontal impact of the shuttle van hitting a pole. The patient was wearing a seatbelt. From the scene of the accident, he was transported by ambulance to a local hospital emergency department where he had x-rays and a CT scan of the head taken. He received contusions to the chest, legs and shin. He was released with prescription medication and told to follow up with his doctor when he got home if he continued to have problems.

Patient complaints were as follows: At the time of the accident, the patient noted he was dizzy and had tingling and numbness in the extremities. He complained of generalized ache, pain and stiffness in the neck and back. He also suffered from confusion.

At the time of his initial evaluation at my office, approximately 10 days post-accident, he complained of neck pain and stiffness which increased with physical activity and decreased with rest and medication. Neck pain was referred to the occipital region, across the shoulders and into the upper thoracic. He reported pain into the thoracic region, described as tightness and stiffness, which also increased with physical activity and improved with rest. His low back was his primary area of complaint - with the most significant and consistent pain that increased significantly with weight-bearing activity and only improved with lying down. Patient had knee stiffness and pain on the right and soreness in both knees and ankles. There was notable bruising of the chest and a contusion. Patient continued to have symptoms of mild traumatic brain injury, consisting of feeling dazed and confused with some amnesia following the accident. Patient continues to have headaches and brain fog.

Prior treatment: Patient received a prescription for anti-inflammatories and a muscle relaxer from the emergency department. He was not working and resting as much as possible and utilizing hot showers.

Past medical history: Patient reports he was involved in an automobile collision 2 to 3 years prior to this collision and received injuries to his neck and back. He had a brief course of chiropractic and physical therapy care. He was released from care without any restrictions or residual complaints. He was working without restriction since being released from that accident and was asymptomatic prior to this accident.

Clinical findings: Patient is 48 years old, 5’11” and 235 pounds. Blood pressure is 130/80 pulse is 75. Patient exhibited no swelling or edema to the extremities. Cranial nerves were intact. Patient appeared antalgic and guarded in his movements.

Physical findings: Palpation revealed significant pain and tenderness in the suboccipital region as well as guarding spasm in the cervical, upper thoracic and lumbar region. Patient had visible restrictions of range of motion in the cervical and lumbar spine, associated with pain. Patient had a positive Foramen Compression Test and Jackson’s Compression Test bilaterally. Manual cervical traction provided some relief in the C1 occipital region, but increased pain along the side the neck and out across the top of the shoulders. Patient could not perform an Apply’s Scratch Test associated with pain in the upper thoracic region. He had a positive SOTO Halls Test for pain in the cervical region into the upper thoracic region. Straight leg raise test was restricted at 60° bilaterally for increased pain in lower back into the buttock region. Patient had a positive Kemps Test bilaterally for joint pain and muscle pain. McMurray’s Test was positive the right knee. The patient was unable to obtain full flexion of the right knee.

Due to the visual restrictions of range of motion in the cervical and lumbar spine, a dual inclinometer range of motion study was ordered and performed of the cervical and lumbar spine, demonstrating loss range of motion.

Neurological testing: Dermatome testing revealed normal sensation in the upper and lower extremity to light touch and pinwheel. Deep tendon reflexes were found to be +2 bilaterally of the upper and lower extremity, except for a diminished left bicep reflex. Manual muscle testing of the upper and lower myotomes revealed 5/5 strength bilaterally, except for 4/5 of the left deltoid muscle and diminished grip strength of the left hand.

Based on the patient’s subjective symptoms and examination findings, x-rays of the cervical and lumbar spine, including flexion extension views were ordered. I personally reviewed these images.

Cervical: Significant loss of the normal lordosis.

Retrolisthesis is noted at C-4 in relationship to C-5 on the neutral lateral view.

Flexion shows significant fixation to normal movement. C-3 demonstrates anterolisthesis in relation to C-4 and it is noted that C-4 shows realignment in relationship to C-5, which is indicative of ligamentous laxity and injury.

Extension demonstrates significant fixation to normal movement. There is further retrolisthesis of C-4 in relationship to C-5 extension.

Small osteoarthritic spur is noted on the anterior inferior aspect of C-4 and posterior disc thinning.

Lumbar: Biomechanical misalignment is noted as rotation of L1, L2 and L3 to the right. Patient has a significant external rotation to the left ilium and the right ilium appears elevated in relationship to the left.

Osteophyte is noted of the anterior superior aspect of L4 associate with significant posterior disc thinning.

Retrolisthesis of L-3 in relation to L-4 on the neutral lateral image.

Flexion reveals significant fixation to normal movement and realignment of L-3 in relation to L-4 flexion - indicating some degree of ligamentous laxity.

Mutell 1

Number 1: Cervical neutral lateral view demonstrating retrolisthesis of C4 in respect to C5 and C5 and respect to C6, indicating ligament laxity.

Mutell 2

Number 2: Cervical flexion view demonstrating realignment of C-4 in respect to C5 and C5 and respect to C6, indicating ligament laxity. Normal movement into cervical flexion is significantly restricted.

Mutell 3

Number 3: Cervical extension view demonstrating retrolisthesis of C4 in respect to C5, indicating ligament laxity. Significant restriction to normal cervical extension.

Cervical MRI without contrast: Following my personal review of the MRI images, my impressions are as follows:

Cervical spinal cord appears normal in signal intensity. Generalized arthritic changes to the facet joints throughout the cervical spine.

C-2 / C-3: High intensity signal in the posterior aspect of the disc, which is visualized as a radial tear.

C-3 / C-4: Disc protrusion on the left causing stenosis of the left neural canal, resulting in contact with the C-4 nerve root.

C-4 / C-5: Disc bulge associated with marginal osteophytes resulting in mild restriction of the neural canals, bilaterally.

C-5 / C-6: Disc bulge associated with marginal osteophytes resulting in mild restriction of the neural canals, bilaterally.

C-6 / C-7: Normal appearance of the vertebral discs.

C-7 / T-1: Normal appearance of the vertebral disc.

Lumbar MRI without contrast: Following my personal review of the MRI images, my impressions are as follows:

Conus terminates at L1 and appears normal in position. Generalized arthritic changes of the lumbar facet joints and mild thickening of the ligament of flava from the mid to lower lumbar.

L-1 / L-2: Vertebral disc appears normal with no central canal or neural canal stenosis.

L-2 / L-3: Vertebral disc protrusion on the left causing mild neural canal stenosis on the left.

L-3 / L-4: Vertebral disc protrusion on the right resulting in stenosis of the right neural canal with associated high signal intensity in the posterior right disc indicative of recent trauma. Disc protrusion is superimposed upon a bulging disc resulting in some left neural canal stenosis as well.

L-4 / L-5: Left lateral disc protrusion resulting in stenosis of the left neural canal. Disc protrusion superimposed upon a bulging disc which results in mild right neural canal stenosis.

L-5 / S-1: Bulging disc associated with osteophyte formation resulting in bilateral neural canal stenosis.

 

Number 4: Lumbar neutral lateral demonstrating loss of lumbar lordosis in the upper lumbar spine with slight retrolisthesis of L2 in relationship to L3 and L3 in relationship to L4, indicating ligament laxity.

Mutell 4

Number 5: Cervical MRI without contrast. C2 – C3 demonstrates high intensity signal in the posterior aspect of the disc which is visualized as a radial tear on the axial view.

Mutell 5

Number 6: Cervical MRI without contrast. Left disc protrusion causing stenosis of the left neural canal resulting in contact to the C4 nerve root.

Mutell 6

Number 7: Lumbar MRI without contrast. Disc protrusion on the right resulting in stenosis of the right neural canal with associated high signal intensity in the posterior the right disc indicative of recent trauma.

Mutell 7

Diagnostic impression: Considering the patient’s history, physical examination findings, x-ray findings demonstrating ligamentous laxity in both the cervical and lumbar spine, MRI findings demonstrating the vertebral disc injuries involving the cervical and lumbar spine, an initial treatment plan, consisting of conservative chiropractic treatment was initiated.

Treatment: Following review of all diagnostic imaging, there were no contraindications to cervical and lumbar spinal adjustments. Patient received chiropractic spinal adjustments to the cervical and lumbar spine in association with at home and work recommendations, as well as instructions for the utilization of ice, TENS and an at home exercise program to improve flexibility and strength.

Patient was referred to an interventional pain management medical doctor for evaluation and possible recommendations. The medical doctor initially recommended epidural steroid injections and possible consideration for facet joint ablation in both the cervical and lumbar spine. Due to the patient finding some relief with initial chiropractic care, the patient elected to continue with chiropractic care without receiving the injections. At the six week follow up with the pain management doctor, the patient experienced enough improvement and symptomatic relief that the pain management doctor recommended he continue with conservative chiropractic care.

Discussion: Doctor of Chiropractic trained in MRI spine interpretation, spinal biomechanics, and qualified as primary spine care physicians, are capable to triage patients involved in automobile collisions resulting in injury. Through proper identification of the injuries, establishing a diagnosis and a treatment plan to address the injuries and evaluate for the need of co-management with medical providers a traumatically injured patient has the best chance for a return to function.

REFERENCES

  1. Hammer, C. (2004). Chiropractic Management and Rehabilitation of a 38-Year-Old Male with an L5-S1 Disc Herniation. [online] NCBI.  Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647024.
  2. Schwab, M. (2008). Chiropractic management of a 47-year–old firefighter with lumbar disk extrusion. [online] NCBI. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697593.
  3. Schenk, K. (2005). Chiropractic Management of Chronic Low Back Pain: A Report of Positive Outcomes with Patient Compliance. [online] NCBI. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647032.
  4. Santilli V, e. (2006). Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active... - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16517383.

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Published in Case Reports

CHIROPRACTIC SPINAL ADJUSTMENT / MANIPULATION

Manipulation vs. Mobilization

Part 1 of 2

Matt Erickson DC, FSBT

Mark Studin DC, FASBE(C), DAAPM, DAAMLP

 

A report on the scientific literature

 

Introduction

Kinetically,spinal manipulation is defined as a high-velocity low amplitude (HVLA) thrust maneuver. According to Ernst and Harkness (2001), “SM (spinal manipulation) involves high velocity thrusts with either a long or short lever-arm, usually aimed at reducing pain and improving range of motion (p. 879).

 

 

Kinetics and kinematics of motion (sub-areas of biomechanics) were described by Evans and Breen (2006). “Kinetics is the branch of mechanics that deals with motion (of an object) under the action of given forces. This includes static (equilibrium) states in which no movement is occurring and dynamic states in which forces may vary as movement occurs” (p. 72). “Kinematics is the branch of mechanics that deals with motion (of an object) without reference to force or mass. With a few notable exceptions, most biomechanical studies of spinal manipulation have given scant attention to kinematics” (p. 73). Thus, kinetics is the study of the type of force used with spinal manipulation while kinematics is the study of the motion geometry of the thrust.

 

 

Respectfully, spinal manipulation performed by a doctor of chiropractic is a specific chiropractic spinal adjustment (CSA). From an insurance coding a billing perspective, a CSA is also called a chiropractic manipulative treatment (CMT). In part 2 of this series, we will detail the necessity for that language. In this paper (part 1 of 2), we will focus on the definition of spinal manipulation and the different outcomes desired by disparate professions. However, the terminology of a specific chiropractic spinal adjustment needs to be considered at all times when referencing spinal manipulation in this article.

 

 

Zinovy and Funiciello (2018, Sept. 17, para. 2) regarding spinal manipulation reported, “This high-velocity, low-amplitude (HVLA) thrusts, also called chiropractic adjustments or osteopathic manipulative treatments (OMT), are carefully performed by applying enough force to push the spinal joint beyond the restricted range of motion with the goal of improving the joint’s function, increasing range of motion, and reducing pain. When a high-velocity manipulation is performed on the spine, it typically involves a cracking or popping sound that can be heard. Some people report feeling relief or enjoying the cracking sound, whereas others do not” (https://www.spine-health.com/conditions/neck-pain/manual-manipulation-and-mobilization-chronic-stiff-neck).

 

Conversely, spinal mobilization is kinetically defined as a low-velocity, low-amplitude force (LVLA) non-thrust maneuver used to help relieve pain, improve motion and restore function. Zinovy and Funiciello (2018, Sept. 17) regarding spinal mobilization wrote, “These low-velocity, low amplitude (LVLA) manipulations gradually work the spinal joints through their well-tolerable ranges of motion rather than forcing them beyond the normal limit. The practitioner’s hands gently move the vertebra and stretch each spinal level being worked. Spinal mobilization usually does not involve a neck-cracking sound” (para. 3).

 

Differentiating Spinal Manipulation Amongst Providers

 

In a United States-based review (which derived from an analysis of 67 articles and 9 books or textbooks) by Shekelle, Adams, Chassin, Hurwitz, Phillips and Brook (1991, P. 3), the authors stated “A recent analysis of a community-based sample of patients showed that chiropractors delivered 94% of all the manipulative care for which reimbursement was sought, with osteopaths delivering 4%, and general practitioners and orthopedic surgeons accounting for the remainder” (https://www.rand.org/pubs/reports/R4025z1.html).

 

In other words, DCs perform 94% of All spinal manipulations in the United States while Doctors of Osteopathy (DOs) perform 4% and subsequently, the remaining 2% of spinal manipulations are performed by Physical Therapists (PTs) and Medical Doctors (MDs).

 

 

Further, although Zinovy and Funiciello (2018, Sept. 17) reported the general goal of spinal manipulation is “improving the joint’s function, increasing range of motion, and reducing pain” (para. 2), beyond that, the intention of spinal manipulation amongst DCs, DOs and PTs is different. So, what is the difference?

 

 

Spinal Manipulation (CSA) According to DCs

 

In addition to improving joint function, increasing range of motion and reducing pain, spinal manipulation for DCs is about normalizing neuro-biomechanical biomechanical function and reducing neurological irritation to maintain optimal function of the nervous system. Petterman (2007) explained this is known as the Law of the Nerve (p. 168).  DC’s more precisely regard spinal manipulation as a specific chiropractic spinal adjustment or chiropractic manipulative treatment (CMT). Andersson, Lucente, Davis, Kappler, Lipton and Leurgans (1999) reported in the New England Journal of Medicine, “The chiropractic approach is focused more on the nervous system and advocates adjustments of the spinal vertebrae to improve neurotransmission(p. 1426).

 

Manip vs Mob

 

Evans (2002), referring to the above images, described the cause of neuro-biomechanical dysfunction due to meniscoid entrapment as follows:

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

 

Evans (2002) continued:

Bogduk and Jull reviewed the likelihood of intra-articular entrapments within zygapophyseal joints as potential sources of pain…Fibro-adipose meniscoid have also been identified as structures capable of creating a painful situation. Bogduk and Jull reviewed the possible role of fibro-adipose meniscoid causing pain purely by creating a tractioning effect on the zygapophyseal joint capsule, again after intra-articular pinching of tissue (p. 252). A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophyseal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent the impaction of the meniscoid. The patient would tend to be more comfortable with the spine maintained in a flexed position, because this will disengage the meniscoid. Extension would therefore tend to be inhibited. This condition has also been termed a “joint lock” or “facet-lock,” the latter of which indicates the involvement of the zygapophyseal joint…

 

Evans (2002) further added, “An HVLAT manipulation [chiropractic spinal adjustment CSA], involving gapping of the zygapophyseal joint, reduces the impaction and opens the joint, so encouraging the meniscoid to return to its normal anatomic position in the joint cavity. This ceases the distension of the joint capsule, thus reducing pain” (p. 252-253).

 

When considering the neuro-biomechanical lesion, (or vertebral subluxation complex [VSC] as traditionally coined) in its entirety, we must consider the etiology as these forces can lead to complex patho-biomechanical components of the spine and supporting tissues. As a result, a neurological cascade can ensue that would further define the lesion beyond the inter-articulation entrapments.

 

 

Panjabi (2006) reported, “Abnormal mechanics of the spinal column has been hypothesized to lead to back pain via nociceptive sensors. The path from abnormal mechanics to nociceptive sensation may go via inflammation, biochemical and nutritional changes, immunological factors, and changes in the structure and material of the endplates and discs, and neural structures, such as nerve ingrowth into the diseased intervertebral disc. The abnormal mechanics of the spine may be due to degenerative changes in the spinal column and/or injury of the ligaments. Most likely, the initiating event is some kind of trauma involving the spine. It may be a single trauma due to an accident or microtrauma caused by repetitive motion over a long time. It is also possible that spinal muscles will fire in an uncoordinated way in response to sudden fear of injury, such as when one misjudges the depth of a step. All these events may cause spinal ligament injury” (p.668-669).

 

In short, chiropractors primarily use a very specific high-velocity, low-amplitude spinal manipulation/ or a specific chiropractic spinal adjustment to correct the neuro-biomechanical dysfunction and reduce the neurological irritation/interference.

 

 

Spinal Manipulation According to DOs

 

The outcome for DOs is to improve overall blood flow throughout the body. As written by Petterman (2007), this is known as the Law of the Artery (p. 168). This is further supported by Andersson et al., (1999) who wrote, “The focus of osteopathic medicine has been the need to optimize the blood circulation to maintain or restore health” (p. 1426).

 

Further, DO’s perform non-specific spinal manipulation which they regard as osteopathic manipulative treatment (OMT). According to the American Osteopathic Association, “Through OMT, physicians manually apply a specific amount of pressure to different regions in the body. These techniques can help: Treat structural and tissue abnormalities, relieve joint restriction and misalignment, restore muscle and tissue balance and promote the overall movement of blood flow throughout the body (https://osteopathic.org/what-is-osteopathic-medicine/osteopathic-manipulative-treatment/).

 

 

Spinal Manipulation According to PTs

 

Like DOs, PTs perform non-specific spinal manipulation that is regarded as a unique form of manual therapy that they call thrust joint manipulation (TJM). According to Puentedura, Slaughter, Reilly, Venturan and Young (2017), “Thrust joint manipulation (TJM) is defined as a high-velocity low-amplitude thrust technique which can be distinguished from other joint mobilization techniques that do not utilize a final thrust maneuver” (p. 74).

Historically, in 1920, spinal manipulation was first introduced in Britain to physical therapists by the Osteopathic profession. Paris (2000) reported, “Osteopathic medicine and surgery was founded by Andrew Taylor Still in 1874” (p. 68). Pettman (2007) reported, in 1892, Andrew Still established the American Osteopathic College in Kirksville, Missouri. Conversely, in 1897, DD Palmer opened Palmer College of Cure which is now known as Palmer College of Chiropractic in Davenport Iowa (168).

 

 

Pettman (2007) further reported:

“Two of Still’s original students, William Smith and J. Martin Littlejohn, were medical physicians from Scotland. Smith struck a deal with Still that if Still taught him osteopathy, he would teach Still’s students anatomy, greatly enhancing the scientific validity of this emerging profession.

 

Littlejohn would become the first dean of the College of Osteopathy in Kirksville. He would then go on to found the Chicago College of Osteopathy before returning to Britain and becoming the founder of the British College of Osteopathy in London in 1917.

 

Despite many frustrating attempts, Littlejohn could never get the English legislature to give osteopathy the same parity with medicine that was enjoyed by his American colleagues. Ironically, instead of behaving antagonistically, he chose to begin educating his fellow physicians and physical therapists in the art and science of spinal manipulation as of 1920.” (p. 169).

 

Conversely, the development of manipulation to the physical therapy profession in the United States occurred 40 years after being introduced to PTs in Britain in 1920. In a document on the history of manipulative therapy in the United States, Paris (2000) wrote, “Since the 1960s, physical therapists have developed their own body of knowledge in manipulation, emphasizing pain relief and enhanced physical function” (p. 66).

 

Farrell and Jensen (1992) added, “Physical therapy education has evolved considerably since 1970, when just a few programs included content and skills in "manipulative therapy"” (p. 845).  Thus, physical therapists in the United States did not start developing knowledge of manipulation until the 1960s and few US PT programs taught manipulation in 1970.

 

PT’s Historical Confusion of Manipulation Vs. Mobilization

 

As already discussed, the development of spinal manipulation for PTs did not begin until the 1960s. Further, PTs did not have standardized terminology for manual therapy and often mobilization and manipulation were used interchangeably. Mintken, DeRosa, Little and Britt (2008) stated, “Seminal documents from noted professional associations and organizations, such as the American Physical Therapy Association, the American Academy of Orthopaedic Manual Physical Therapists, and the International Federation of Orthopaedic Manipulative Therapists, interchange such terms as manual therapy, mobilization, and manipulation with the implication often being that they are synonymous” (p. 51).

 

 

Mintken et al., (2008) added, “Physical therapists in particular are not immune to the consequences of this history. John Mennell, MD stated that physical therapists used a confusing array of terms that “cloud the issue by talking about degrees of manipulation using such terms as articulation and mobilization leading up to manipulation.” Such a woeful lack of language specificity ultimately precludes any ability to compare and contrast the intervention or the outcome and minimizes any opportunity to ultimately discern effective from ineffective” (p. 51).

 

Mintken et al., (2008) continued, “Furthermore, despite Mennell’s caution appearing many years ago, one could argue that the clarity of language concerning manipulation has not improved, but in fact has worsened” (p. 51).

 

 

To address this issue Mintken et al., (2008) published their article to standardize manipulation terminology. Mintken et al., (2008) stated, “In February 2007, the American Academy of Orthopaedic Manual Physical Therapists formed a task force to standardize manual therapy terminology, starting with the intervention of manipulation. The ultimate goal of this task force was to create a template that has the potential to be used internationally by the community of physical therapists in order to standardize manual therapy nomenclature” (pg. 50). Thus, you can see that as late as 2007, it was being reported that manipulation and mobilization in the physical therapy profession were still poorly differentiated and the terminology was not standardized.

 

The Mintken et al., (2008) reported, “The aim of the task force created in February 2007 by the American Academy of Orthopaedic Manual Physical Therapists was to propose a model for standardized terminology to describe manipulative techniques as simply and clearly as possible in language that is understandable to all clinicians, regardless of individual clinical practices or schools of thought” (p. 52-53).

 

Conclusion

 

DC’s perform 94% of All spinal manipulations in the United States. Although PTs began learning manipulation in Britain in 1920 through the osteopathic profession, the physical therapy profession did not begin developing spinal manipulation for PTs in the United States until the 1960s and in 1970 few schools included content and skills in manipulation. The purpose of this statement is not to diminish a PT trained to perform non-specific spinal manipulation, but rather to highlight the limited non-specific use and true infancy among PTs in performing spinal manipulation in the US.

 

Finally, spinal manipulation is kinematically regarded as HVLA and not synonymous with spinal mobilization which is regarded as LVLA. Further, while spinal manipulation acts to improve joint function, increase range of motion, and reduce pain, beyond this, it’s clinical intention is different amongst DCs (CSA: a specific form of spinal manipulation to normalize neuro-biomechanical biomechanical function and removing nerve interference), DOs (OMT: a non-specific form of spinal manipulation with intention on improving blood flow) and PTs (TJM: a non-specific form of spinal manipulation regarded as a unique form of manual therapy).

 

 

In part 2 of this series, we will further differentiate spinal manipulation amongst DCs, DOs and PTs and how it is a physician-based service for DCs and DO’s and a form of manual therapy for PTs. Moreover, we will explain in greater depth how spinal manipulation provided by DCs is regarded as specific while among DOs and PTs it is regarded as non-specific. Finally, we will discuss how a DCs intention in performing a specific CSA follow a salutogenic model (what keeps one healthy or well) while the intention of PTs and DOs in performing a non-specific spinal manipulation called TJM or OMT respectfully follows a pathogenic model(what causes disease or makes one ill).

 

 

References

  1. Vermeulen Henricus M., Rozing Piet m., Obermann Win R., Cessie Saskia le and Vlieland Vliet. (2006). Comparison of High-Grade and Low-Grade Mobilization Techniques in the Management of Adhesive Capsulitis of the Shoulder: Randomized Controlled Trial. Physical Therapy, 86(3), 355-368.
  2. Ernst Edzard, MD, PhD, FRCP (Edin) and Harkness Elaine, BSc. (2001). Review Article Spinal Manipulation: A Systematic Review of Sham-Controlled, Double-Blind, Randomized Clinical Trials Journal of Pain and Symptom Management, 22(4), 879-889.
  3. Evans David W., BSc (Hons) Ost and Breen Alan C., DC, PhD (2006). A Biomechanical Model For Mechanically Efficient Cavitation Production During Spinal Manipulation Prethrust Position And The Neutral Zone. Journal of Manipulative and Physiological Therapeutics, 29(1), 72-82.
  4. Zinovy Meyler, DO and Funiciello Marco, DO. (2018, Sept. 17). Manual Manipulation and Mobilization for Chronic Stiff Neck. Spine Health, Retrieved from https://www.spine-health.com/conditions/neck-pain/manual-manipulation-and-mobilization-chronic-stiff-neck.
  5. Shekelle Paul G., Adams Alan H., Chassin Mark R., Hurwitz Eric L., Phillips Reed B. and Brook Robert H. (1991). The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review. Santa Monica, CA: RAND Corporation. Retrieved from https://www.rand.org/pubs/reports/R4025z1.html.
  6. Pettman Erland, PT, MCSP, MCPA, FCAMT, COMT (2007). A History of Manipulative Therapy. The Journal of Manual & Manipulative Therapy 15(3), 165–174.
  7. Andersson Gunnar B.J., MD, PhD, Lucente Tracy, MPH, Davis Andrew M., MPH, Kappler Robert E., DO, Lipton James A., DO and Leurgans Sue, PhD. (1999). A Comparison of Osteopathic Manipulation with Standard Care for Patients with Low Back Pain. New England Journal of Medicine, 341(14), 1427-1431.
  8. Evans, D. W. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics, 25
  9. Panjabi, M. M. (2006). A hypothesis of chronic back pain: Ligament subfailure injuries lead to muscle control dysfunction. European Spine Journal15
  10. American Osteopathic Association. (n.d.). What is Osteopathic Manipulative Treatment? Retrieve from https://osteopathic.org/what-is-osteopathic-medicine/osteopathic-manipulative-treatment/
  11. Puentedura Emilio J., Slaughter Rebecca, Reilly Sean, Ventura Erwin and Young Daniel. (2017). Thrust joint manipulation utilization by U.S. physical therapists. Journal of Manual & Manipulative Therapy, 25(2), 74-82.
  12. Paris Stanley V., PhD, PT. (2000). A History of Manipulative Therapy Through the Ages and Up to the Current Controversy in the United States. The Journal of Manual & Manipulative Therapy 8(2), 66 – 77.
  13. Farrell Joseph P. and Jensen Qall M. (1992). Manual Therapy: Critical Assesment Profession of Physical Therapy. Physical Therapy 72(12), 843-852.
  14. Mintken Paul E., PT, DPT, OCS1, DeRosa Carl, PT, PhD, DPT, FAPTA2, Little Tamara, PT, DMT, FAAOMPT3, and Smith Britt, PT, DPT, OCS. (2008). A Model for Standardizing Manipulation Terminology in Physical Therapy Practice. The Journal of Manual & Manipulative Therapy, 16(1), 50–56.

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Published in Low Back Problems

No Evidence Exists Between

Chiropractic Care and Cervical Artery Dissection

 

Verified by a Study of 110 Million Person-Years

 Mark Studin DC

William J. Owens DC

John Edwards MD, Neurosurgeon

 A report on the scientific literature

Citation: Studin., Owens W., Edwards J. (2019) No Evidence Exists Between Chiropractic Care and Cervical Artery Dissection, The American Chiropractor 41(10) pgs. 28, 30-32 

 

Cervical artery dissection (CAD) is a major source of cervical ischemia in all ages, and can lead to various clinical symptoms such as neck pain, headache, Horner’s Syndrome (paresis of the eye) and cranial nerve palsy. An underlying arteriopathy, which is often genetically encoded, is believed to have a role in the development of CAD.1  There have been case studies and low-quality published literature that attempt to link chiropractic care and CAD. This type of reporting often reports dogma and as in this case, is devoid of high-quality standards of scientific examination and lacking a complete set of facts.2 

When considering CAD, both the internal carotid and vertebral arteries must be considered. Dissection of one or both can lead to serious complications but can also be asymptomatic. Thrombolytic stroke is typically in the old, while cervical artery dissection causes stroke in young and middle-aged patients. Only 1-2% of ischemic strokes are caused by CAD, but in younger patients, 10-25% are caused by CAD. The overall incidence of CAD is 2.3-5 patients per 100,000; the mean age is 44 years old. CAD is rare beyond 65 years old.3, 4 

Although headaches, migraine headaches, minor trauma, neck pain, and inflammatory and connective tissue diseases have been thought to play a role in CAD, patients with CAD (with or without trauma) likely have an underlying arteriopathy, an inflammatory process or structural instability of the arteries that lead to dissection. A biopsy-proven study, Cervical Artery Dissections: A Review, conducted by JJ Robertson and A. Koyfman in 2016, shows structural differences in the arterial walls of patients with spontaneous CAD and in patients who have sustained major trauma and a positive association with dissection and kinking and coiling of the internal carotid artery, which suggests an underlying predisposition.4 

In 2001-2002, the number of visits to medical primary care providers and chiropractors in the US and Canada was 10.2 million.  Visits to primary care providers accounted for 80% of the total, while visits to chiropractors accounted for 12%. 5 

The most prevalent diagnoses in chiropractic care involve neck and back pain. 5,6 And the most common treatment at a chiropractic office is a spinal high-velocity, low-amplitude manipulation, commonly known as a chiropractic spinal adjustment. 

A Meta-analysis of 253 articles on chiropractic care and cervical artery dissection by Church, et. Al.,3 3   showed that neck pain and headaches are found in approximately 80% of CAD patients.  Neck pain and headaches are also common symptoms in patients with cervical artery dissection.  They concluded,  “There is no convincing evidence to support a causal link between chiropractic manipulation and cervical arterial dissection.”  which is a correlation, but not causally related. The most prevalent co-founder is neck pain and that demographic typically visits a chiropractor. When you consider the association between chiropractic visits vs. medical primary care visits with patients who experienced a CAD, the utilization was similar, yet because chiropractors treat neck pain there appears to be a dogmatic conclusion that chiropractic is the causative factor for dissection despite the lack of evidence. 

The evidence, as determined by Church et. Al. is based upon the Grading Recommendation Assessment Development and Evaluation (GRADE) system of rating quality of evidence and grading strength in systematic reviews. Those reviews ranged from high quality of evidence to very low quality of evidence.7 

Church et. Al.3 found that the quality of the body of data using the GRADE criteria revealed that it fell within the “very low” category. Also, they found no evidence for a causal link between chiropractic care and CAD. Perhaps the greatest threat to the reliability of any conclusions drawn from these data is that together they describe a correlation but not a causal relationship, and any unmeasured variable is a potential confounder. As previously discussed, the most likely potential confounder in this case is neck pain with no causal evidence. 

Cassidy et al. (2008) studied the occurrence of vertebral basilar artery (VBA) stroke events in Ontario, Canada over nine years with a database representing almost 110 million person-years (12.2 million people, studied over 9 years, equals 110 million person-years).8 The purpose of this study was to investigate if the rates of VBA stroke, which is sometimes caused by CAD, were higher in patients treated by chiropractors than in those treated by medical primary care doctors. The premise was that if the rate of VBA stroke was higher with chiropractic care, then one could logically say there were a cause and effect relationship between chiropractic care and VBA strokes. 

The results were conclusive: There was no greater likelihood of a patient experiencing a stroke following a visit to his/her chiropractor than there was after a visit to his/her primary care physician. Cassidy et al wrote: 

“We found no evidence of excess risk of VBA stroke with associated chiropractic care compared to primary care.” Cassidy et al. concluded that overall, 4% of stroke patients had visited a chiropractor within 30 days of a stroke while 53% of stroke patients had visited their medical primary care providers within the same time frame. The authors suggest that because neck pain is a common symptom of CAD, patients visit their doctors with the onset of symptoms, prior to the development of a full-blown stroke scenario.  Because the association between VBA stroke and visits to both chiropractic and medical physicians is the same, there appears to be no increased risk of VBA stroke from chiropractic care. In fact, the incident of chiropractic vs. medical care was substantially lower in certain situations based upon the data.8

 

CONCLUSION

 

Cervical artery dissection occurs rarely, yet often creates significant adverse outcomes to patients. Unfortunately, there has been a bias in the medical community, incorrectly linking chiropractic care and CAD. But the evidence is mounting that there is no causal relationship between them. With literature bordering on dogma devoid of the facts in high-quality studies. 12.2 million people study over 9 years equaling 110 million person-years conclude no causal relationship doing chiropractic care and cervical artery dissection.

 

References:

 

  1. Debette, S., & Leys, D. (2009). Cervical-artery dissections: predisposing factors, diagnosis, and outcome. The Lancet Neurology, 8(7), 668-678.
  2. Artenstein, A. W. (2012). The discovery of viruses: advancing science and medicine by challenging dogma. International Journal of Infectious Diseases, 16(7), e470-e473.
  3. Church, E. W., Sieg, E. P., Zalatimo, O., Hussain, N. S., Glantz, M., & Harbaugh, R. E. (2016). Systematic review and meta-analysis of chiropractic care and cervical artery dissection: no evidence for causation. Cureus, 8(2).
  4. Robertson J., Koyfman A., (2016). Cervical Artery Dissection: A Review, the Journal of Emergency Medicine, 51 (5, 508-515
  5. Riddle, D. L., & Schappert, S. M. (2007). Volume and characteristics of inpatient and ambulatory medical care for neck pain in the United States: data from three national surveys. Spine, 32(1), 132-140.
  6. Hurwitz, E. L., & Chiang, L. M. (2006). A comparative analysis of chiropractic and general practitioner patients in North America: findings from the joint Canada/United States Survey of Health, 2002–03. BMC Health Services Research, 6(1), 49.
  7. Guyatt, G., Oxman, A. D., Akl, E. A., Kunz, R., Vist, G., Brozek, J., ... & Jaeschke, R. (2011). GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. Journal of clinical epidemiology, 64(4), 383-394.
  8. Cassidy, J. D., Boyle, E., Côté, P., He, Y., Hogg-Johnson, S., Silver, F. L., & Bondy, S. J. (2008). Risk of vertebrobasilar stroke and chiropractic care: Results of a population-based case-control and case-crossover study. Spine,33(45), S176-S183.

 

 

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Published in Neck Problems

Chiropractors Reduce Costs by 40% if the 1st Option for Spine

 

DC’s Would Save the Healthcare System 1.86 Trillion Dollars Over 10 Years

 

By: Matt Erickson, DC, FSBT

Mark Studin DC, FASBE(C), DAAPM, DAAMLP

 

A report on the scientific literature

 

Citation: Erickson M., Studin M (2019) Chiropractors Reduce Costs by 40% if the 1st Option for Spine, American Chiropractor 41(8) 38, 40-43

 

INTRODUCTION

 

Currently, our country is facing a health care crisis not only with respect to the opioid epidemic, but also due the fact our health care costs in the US have skyrocketed out of control. According to Centers for Medicare and Medicaid Services (CMS), National Health Expense (NHE) fact sheet (2017), “NHE grew 3.9% to $3.5 trillion in 2017, or $10,739 per person, and accounted for 17.9% of Gross Domestic Product (GDP).” It was also predicted by CMS (2017) thatUnder current law, national health spending is projected to grow at an average rate of 5.5 percent per year for 2018-27 and to reach nearly $6.0 trillion by 2027”(https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html).

 

 

In a study from data primarily from 2013-2016, Papanicolas, Woskie and Jha (2018) reported, “The United States spends more per capita on health care than any other nation, substantially outpacing even other very high-income countries. However, despite its higher spending, the United States performs poorly in areas such as health care coverage and health outcomes” (p. 1025).

 

Papanicolas et al., (2018), also stated, “The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations. Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries” (p. 1038). Papanicolas et al., (2018), reported, “Ten high-income countries were selected for comparison” (p. 1025). The ten countries included, “the United Kingdom (consisting of England, Scotland, Wales, and Northern Ireland), Canada, Germany, Australia, Japan, Sweden, France, Denmark, the Netherlands, and Switzerland” (p. 1025).

 

 

Singh, Andersson and Watkins-Castillo (2019, para. 1) reported “Lumbar/low back pain and cervical/neck pain are among the most common medical conditions requiring medical care and affecting an individual’s ability to work and manage the daily activities of life. Back pain is the most common physical condition for which patients visit their doctor. In any given year, between 12% and 14% of the United States adult population age 18 and older visit their physician with complaints of back pain. The number of physician visits has increased steadily over the years. In 2013, more than 57.1 million patients visited a physician with a complaint of back pain, compared to 50.6 million in 2010. Also, an unknown number of patients visit a chiropractor or physical therapist for these complaints. Singh et. al (2019, para. 4) further reported, “The estimated annual direct medical cost for all persons with a back-related condition in 2014 dollars was an average of $315 billion per year across the years 2012-2014(https://www.boneandjointburden.org/fourth-edition/iia0/low-back-and-neck-pain).

 

According to Cynthia Cox of the Kaiser Family Foundation (2017) reporting on data from 2013, The top five disease-based spending categories (ill-defined conditions, circulatory, musculoskeletal, respiratory, and endocrine) account for half of all medical services spending by disease category. Ill-defined conditions each represent about 13% of overall health spending by disease while circulatory, musculoskeletal, respiratory, and endocrine conditions represent 12%, 10%, 8%, and 7% respectively.” That is to say, musculoskeletal disease represents 10% of the health care expenditures” (https://www.healthsystemtracker.org/chart-collection/much-u-s-spend-treat-different-diseases/#item-top-five-disease-categories-account-roughly-half-medical-service-spending).

 

The above graphic is from the 2017 Peterson-Kaiser report, “How much does the U.S. spend to treat different disease?”

 

 

As neck and back pain in one of the most prevalent issues that present to primary care physician (PCP) offices, considering the current opioid crisis and the associated health care expenditure, particularly related to neck and back pain, this raises the question if Doctors of Chiropractic-who are licensed to manage spinal disorders and comprehensive training in spine care, can not only provide similar or better outcomes and greater or equivalent satisfaction among patients, but provide care in a more cost effective manner, as well as help to unburden the already overloaded primary care practices considering the trending shortage of PCPs in our health care delivery system?

 

THE EVIDENCE

 

In an article by Houweling, Braga, Hausheer, Vogelsang, Peterson and Humphreys (2015), the authors reported on first-contact care with a medical vs. a chiropractic provider after a consultation with a Swiss telemedicine provider. The study looked to compare outcomes, patients satisfisfaction and health care costs in spinal, hip and shoulder pain patients.

 

Houweling et al., (2019), reported that “Pain of musculoskeletal origin represents a major health problem worldwide. In a Swiss survey conducted in 2007, back pain was a commonly reported health problem, with 43% of the population experiencing this complaint over the course of a year. Of these, 33% reported that their symptoms led to reduced productivity at work. The burden of musculoskeletal conditions on the Swiss health care system is equally staggering, with health care expenditure resulting from this condition being estimated at 14 billion Swiss Francs (CHF) per year (US $14 billion) or 3.2% of the gross domestic product” (p. 478-479).

 

 

The study by Houweling et al., (2019), also showed that spinal, hip, and shoulder pain patients had modestly higher pain relief and satisfaction with care at lower overall cost if they initiated care with DCs, when compared with those who initiated care with MDs” (p. 480). Houweling et al., further added, “Although the differences in pain relief scores between groups were statistically significant, they were likely not of clinical significance.” (p. 480). Houweling et al., explained the reason for this was, “the extent of the differences in pain relief observed might be too small for patients to notice a clinically meaningful difference” (p. 480).

 

With respect to patient satisfaction Houweling et al., (2019), reported, “The findings of this study pertaining to patient satisfaction were in line with previous research comparing chiropractic care to medical care for back pain, which found that chiropractic patients are typically more satisfied with the services received than medical patients” (p. 481). Houweling et al., added, “The Mean total spinal, hip, and shoulder pain-related health care costs per patient during the 4-month study period were approximately 40% lower in patients initially consulting DCs compared with those initially consulting MDs. The reason for this difference was a lower use of health care services other than first-contact care in patients initially consulting DCs compared with those initially consulting MDs” (p. 481).

 

Thus, Houweling et al., (2019) concluded, “The findings of this study support first-contact care provided by DCs as an alternative to first-contact care provided by MDs for a select number of musculoskeletal conditions” (p. 481). The authors also noted, “In addition to potentially reducing health care costs, direct access to chiropractic care may ease the workload on MDs, particularly in areas with poor medical coverage and hence enabling them to focus on complex cases. The minority of patients with complex health problems initially consulting a chiropractic provider would be referred to, or comanaged with, a medical provider to provide optimal care” (p. 481).

 

CONCLUSION

 

In conclusion, health care cost has skyrocketed out of control with the prediction the US expenditures will reach 6 trillion by 2027. Considering neck and back pain expenditures in between 2012-2014 averaged $315 billion annually and total health care costs in 2017 were $3.5 trillion, this means approximately 10% of health care expenditures annually are for neck and back pain which is supported by the Peterson-Kaiser Health Tracker System report. Moreover, considering the estimated health costs are predicted to be $6 trillion by 2027, if the expenditure for neck and back pain remained on par at 10% that means the cost of neck and back pain in would increase to around $600 billion over that time frame.

 

Considering in the Houweling et al., that by using doctors of chiropractic as a first-line provider for spine, hip and shoulder pain, it demonstrated a 40% reduction in costs, that means in 2027, if DCs were first-line providers, it is estimated this could save the health care delivery system $240 BILLION DOLLARS in one year alone (just for neck and back pain). If one considers the prediction of 5.5% annual expenditure increase, that means the estimated total expenditure for neck and back pain between 2018-2027 would be $4.65 trillion dollars. If having DCs as a first-line provider were to save 40% in costs, that would translate into saving $1.86 TRILLION DOLLARS. If that was applied to the predicted 2027 neck and back pain expenditure, that number would represent a 32% savings in that year. Given our skyrocketing health care costs, that would represent a significant savings!

 

Further, if we consider from the study, there was a modestly higher pain relief and ever greater patient satisfaction reported, when you factor in the predicted PCP shortage, having the ability for DCs to serve as a first-line provider, not only can it help unburden the already overloaded PCPs, but doing so would have a significant financial impact in lowering health care expenditures. All things considered, it is time our decision makers take a serious look at improving access to Doctors of Chiropractic so they may serve as first-line providers for the management of all spine and even hip and shoulder related disorders.

 

REFERENCES

 

  1. “National Health Expenditure Fact Sheet” (2019, April 26). Centers for Medicare and Medicaid. Retrieved from https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html.
  2. Irene Papanicolas, Liana R. Woskie, Ashish K. Jha. (2018). Health Care Spending in the United States and Other High-Income Countries, Journal of the American Medical Association, 319(10), 1024-1039.
  3. Kern Singh, MD, Gunnar Andersson, MD, PhD and Sylvia I. Watkins-Castillo, PhD. (2019) United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States (BMUS), forthcoming. Rosemont, IL. Retrieved from https://www.boneandjointburden.org/fourth-edition/iia0/low-back-and-neck-pain.
  4. Cox Cynthia. (2017, May 22). How much does the U.S. spend to treat different disease? Peterson-Kaiser Health Tracker System. Retrieved from https://www.healthsystemtracker.org/chart-collection/much-u-s-spend-treat-different-diseases/#item-top-five-disease-categories-account-roughly-half-medical-service-spending.
  5. Houweling, Braga, Hausheer, Vogelsang, Peterson and Humphreys. (2015). First-Contact Care with a Medical vs. Chiropractic Provider After Consultation with a Swell 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.

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Published in Neck Problems

The Chiropractic Adjustment Changes Brain Function

 

The Evidence of Increased Muscle Strength is Added to Pain Sensitivity and Autonomic Changes

 

Mark Studin DC, FASBE(C), DAAPM, DAAMLP

William J. Owens DC, DAAMLP

Matt Erickson DC, FSBT

 

A report on the scientific literature

 

There is a growing body of evidence that a high-velocity, low-amplitude (HVLA) chiropractic spinal adjustment (CSA) has a significant influence on cortical (brain) and other central (cord) changes. This is significant as the evidence is now answering more questions on why has chiropractic has had such a profound effect on a myriad of conditions beyond back pain. Technology, including but not limited to functional MRI, NCV, EEG and sEMG renders demonstrable validation of the effect the chiropractic spinal adjustment has on changes in central function.

 

A chiropractic spinal manipulation/adjustment is a specific HVLA thrust maneuver designed to correct spinal patho-neuro-biomechanics (remove nerve irritation/interference, restore biomechanical balance), increases important proteins such as Substance P (Evans 2002) and makes plastic changes to the central nervous system. Conversely, a spinal manipulation as manual therapy or thrust joint manipulation (TJM) performed by physical therapists (PT’s) is a generalized non-specific low-velocity, low-amplitude of non-specific HVLA thrust maneuver of joints and connective tissue to improve motion and decrease muscle tension.

 

 

Essentially, the intent of TJM is in treating pain and dysfunction. That is not to say a non-specific manipulation will not help a patient. However, when spinal manipulation is not performed as a chiropractic based neuro-biomechanical corrective adjustment or from a salutogenic health management perspective, it is something else entirely. Therefore, spinal manipulation as a chiropractic adjustment delivered by a chiropractor is not synonymous with TJM, mobilization or spinal manipulation delivered by a PT.

 

Reed, Pickar, Sozio, and Long (2014) reported, “.forms of manual therapy have been clinically shown to increase mechanical pressure pain thresholds (i.e., decrease sensitivity) in both symptomatic and asymptomatic subjects. Cervical spinal manipulation (chiropractic HVLA) has been shown to result in unilateral as well as bilateral mechanical hypoalgesia. Compared with no manual therapy, oscillatory spinal manual therapy at T12 and L4 produced significantly higher paraspinal pain thresholds at T6, L1, and L3 in individuals with rheumatoid arthritis. The immediate and widespread hypoalgesia associated with manual therapy treatments has been attributed to alterations in peripheral and/or central pain processing including activation of descending pain inhibitory systems. Increasing evidence from animal models suggests that manual therapy activates the central nervous system and, in so doing, affects areas well beyond those being treated. (p. 277)

 

Reed et al. (2014) also reported, The finding that only the higher intensity manipulative stimulus (ie, 85% BW [body weight] vs 55% BW or control) decreased the mechanical sensitivity of lateral thalamic neurons to mechanical trunk stimulation coincides with other reports relating graded mechanical or electrical stimulus intensity to the magnitude of central inhibition. Several clinical studies indicate that spinal manipulation [chiropractic spinal adjustment] alters central processing of mechanical stimuli evidenced by increased pressure pain thresholds and decreased pain sensitivity in asymptomatic and symptomatic subjects following manipulation. (p. 282)

 

Daligadu, Haavik, Yielder, Baarbe, and Murphy (2013) reported, There is also evidence in the literature to suggest that muscle impairment occurs early in the history of onset of spinal complaints, and that such muscle impairment does not automatically resolve even when pain symptoms improve. This has led some authors to suggest that the deficits in proprioception and motor control, rather than the pain itself, may be the main factors defining the clinical picture and chronicity of various chronic pain conditions. Furthermore, recent evidence has demonstrated that spinal manipulation (CSA) can alter neuromuscular and proprioceptive function in patients with neck and back pain as well as in asymptomatic participants. For instance, cervical spine manipulation (CSA) has been shown to produce greater changes in pressure pain threshold in lateral epicondylalgia than thoracic manipulation; and in asymptomatic patients, lumbar spine manipulation (CSA) was found to significantly influence corticospinal and spinal reflex excitability. Interestingly, Soon et al did not find neurophysiological changes following mobilization on motor function and pressure pain threshold in asymptomatic individuals, perhaps suggesting that manipulation [chiropractic spinal adjustments], as distinct from mobilization, induces unique physiological changes. There is also accumulating evidence to suggest that chiropractic manipulation can result in changes to central nervous system function including reflex excitability, cognitive processing, sensory processing, and motor output. There is also evidence in SCNP [sub-clinical neck pain] individuals that chiropractic manipulation alters cortical somatosensory processing and elbow joint position sense. This evidence suggests that chiropractic manipulation may have a positive neuromodulatory effect on the central nervous system, and this may play a role in the effect it has in the treatment of neck pain. It is hoped improving our understanding of the neurophysiological mechanisms that may precede the development of chronic neck pain in individuals with sub-clinical neck pain (SCNP) will help provide a neurophysiological marker of altered sensory processing that could help determine if an individual is showing evidence of disordered sensorimotor integration and thus might benefit from early intervention to prevent the progression of SCNP into more long-term pain states.  (p. 528)

 

Christriansen, Niazi, Holt, Nedergaard, Duehr, Allen, Marshall, Turker and Haarvik (2018) discussed the effects of a single session of a chiropractic spinal manipulation (CSA) on strength and cortical drive. They studied the effects upwards of 60 minutes and further testing is needed to determine the long-term effects of the adjustment. They found in “blinded studies” that “the increased maximum voluntary contraction force lasted for 30 min and the corticospinal excitability increase persisted for at least 60 minutes.” (pg. 737)

 

Christiansen et. Al (2018) also reported, “The increased V-wave amplitudes observed in the current study possibly reflect an increased cortical drive in the corticospinal pathways and corresponding increased excitability of the MNs following SM found differences in the cortical drive in volleyball athletes competing at different levels, and argued that elite players had increased cortical drive correlating to their biomechanical performance. The absence of change in the H-reflex in the presence of the increased MVC along with increased V-waves suggests that it's possible that the change post manipulation occurred at supraspinal centers involving a cortical neural drive. The V-waves represent cortical drive. The absence of change in the H-reflex alone suggests that the spinal motor neurons and the excitability of the spindle primary afferent synapses on the spinal motor neurons did not change as a result of SM.” (pg. 745) The above paragraph indicates there is no input at the cord level as the H-Reflex exhibited no changes.

 

 

Increased motor function for a minimum of 60 minutes post-chiropractic spinal adjustment has far-reaching manifestations for a dichotomy of the population. Athletes at every level will benefit from increased motor function and patients suffering from either muscular or neuro-degenerative illnesses, such as Parkinson’s, Amyotrophic lateral sclerosis (ALS), Muscular Dystrophy and others will also potentially benefit. Although this article touched on PT manual therapy, low-velocity, low-amplitude or non-specific thrust joint manipulation; these forms of treatment do not render the outcomes a chiropractic spinal adjustment.

 

Christiansen et. Al (2018) concluded and perfectly positioned the effect of a chiropractic spinal adjustment and the effect on the brain, “this study supports a growing body of research that suggests chiropractic spinal manipulation’s main effect is neuroplastic in nature and affects corticospinal excitability. Changes in both cerebellum and prefrontal cortex function have been implicated post-spinal manipulation in previous research studies. The presence of mild, recurrent spinal dysfunction has been shown to be associated with maladaptive neural plastic changes, such as alterations in elbow joint position sense mental rotation ability, and even multisensory integration Furthermore, spinal manipulation of dysfunctional spinal segments has been shown to impact somatosensory processing, sensorimotor integration and motor control.” (pg. 746)

 

References:

 

  1. Reed, W. R., Pickar, J. G., Sozio, R. S., & Long, C. R. (2014). Effect of spinal manipulation thrust magnitude on trunk mechanical activation thresholds of lateral thalamic neurons. Journal of Manipulative and Physiological Therapeutics, 37
  2. Daligadu, J., Haavik, H., Yielder, P. C., Baarbe, J., & Murphy, B. (2013). Alterations in cortical and cerebellar motor processing in subclinical neck pain patients following spinal manipulation. Journal of Manipulative and Physiological Therapeutics, 36.
  3. Christiansen, T. L., Niazi, I. K., Holt, K., Nedergaard, R. W., Duehr, J., Allen, K., ... & Haavik, H. (2018). The effects of a single session of spinal manipulation on strength and cortical drive in athletes. European journal of applied physiology118

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