Mark Studin DC
A report on the scientific literature
Cervical artery dissection (CAD) is a major source of cervical ischemia in all ages, and can lead to various clinical symptoms such as neck pain, headache, Horner’s Syndrome (paresis of the eye) and cranial nerve palsy. An underlying arteriopathy, which is often genetically encoded, is believed to have a role in the development of CAD.1 There have been case studies and low-quality published literature that attempt to link chiropractic care and CAD. This type of reporting often reports dogma and as in this case, is devoid of high-quality standards of scientific examination and lacking a complete set of facts.2
When considering CAD, both the internal carotid and vertebral arteries must be considered. Dissection of one or both can lead to serious complications but can also be asymptomatic. Thrombolytic stroke is typically in the old, while cervical artery dissection causes stroke in young and middle-aged patients. Only 1-2% of ischemic strokes are caused by CAD, but in younger patients, 10-25% are caused by CAD. The overall incidence of CAD is 2.3-5 patients per 100,000; the mean age is 44 years old. CAD is rare beyond 65 years old.3, 4
Although headaches, migraine headaches, minor trauma, neck pain, and inflammatory and connective tissue diseases have been thought to play a role in CAD, patients with CAD (with or without trauma) likely have an underlying arteriopathy, an inflammatory process or structural instability of the arteries that lead to dissection. A biopsy-proven study, Cervical Artery Dissections: A Review, conducted by JJ Robertson and A. Koyfman in 2016, shows structural differences in the arterial walls of patients with spontaneous CAD and in patients who have sustained major trauma and a positive association with dissection and kinking and coiling of the internal carotid artery, which suggests an underlying predisposition.4
In 2001-2002, the number of visits to medical primary care providers and chiropractors in the US and Canada was 10.2 million. Visits to primary care providers accounted for 80% of the total, while visits to chiropractors accounted for 12%. 5
The most prevalent diagnoses in chiropractic care involve neck and back pain. 5,6 And the most common treatment at a chiropractic office is a spinal high-velocity, low-amplitude manipulation, commonly known as a chiropractic spinal adjustment.
A Meta-analysis of 253 articles on chiropractic care and cervical artery dissection by Church, et. Al.,3 3 showed that neck pain and headaches are found in approximately 80% of CAD patients. Neck pain and headaches are also common symptoms in patients with cervical artery dissection. They concluded, “There is no convincing evidence to support a causal link between chiropractic manipulation and cervical arterial dissection.” which is a correlation, but not causally related. The most prevalent co-founder is neck pain and that demographic typically visits a chiropractor. When you consider the association between chiropractic visits vs. medical primary care visits with patients who experienced a CAD, the utilization was similar, yet because chiropractors treat neck pain there appears to be a dogmatic conclusion that chiropractic is the causative factor for dissection despite the lack of evidence.
The evidence, as determined by Church et. Al. is based upon the Grading Recommendation Assessment Development and Evaluation (GRADE) system of rating quality of evidence and grading strength in systematic reviews. Those reviews ranged from high quality of evidence to very low quality of evidence.7
Church et. Al.3 found that the quality of the body of data using the GRADE criteria revealed that it fell within the “very low” category. Also, they found no evidence for a causal link between chiropractic care and CAD. Perhaps the greatest threat to the reliability of any conclusions drawn from these data is that together they describe a correlation but not a causal relationship, and any unmeasured variable is a potential confounder. As previously discussed, the most likely potential confounder in this case is neck pain with no causal evidence.
Cassidy et al. (2008) studied the occurrence of vertebral basilar artery (VBA) stroke events in Ontario, Canada over nine years with a database representing almost 110 million person-years (12.2 million people, studied over 9 years, equals 110 million person-years).8 The purpose of this study was to investigate if the rates of VBA stroke, which is sometimes caused by CAD, were higher in patients treated by chiropractors than in those treated by medical primary care doctors. The premise was that if the rate of VBA stroke was higher with chiropractic care, then one could logically say there were a cause and effect relationship between chiropractic care and VBA strokes.
The results were conclusive: There was no greater likelihood of a patient experiencing a stroke following a visit to his/her chiropractor than there was after a visit to his/her primary care physician. Cassidy et al wrote:
“We found no evidence of excess risk of VBA stroke with associated chiropractic care compared to primary care.” Cassidy et al. concluded that overall, 4% of stroke patients had visited a chiropractor within 30 days of a stroke while 53% of stroke patients had visited their medical primary care providers within the same time frame. The authors suggest that because neck pain is a common symptom of CAD, patients visit their doctors with the onset of symptoms, prior to the development of a full-blown stroke scenario. Because the association between VBA stroke and visits to both chiropractic and medical physicians is the same, there appears to be no increased risk of VBA stroke from chiropractic care. In fact, the incident of chiropractic vs. medical care was substantially lower in certain situations based upon the data.8
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.
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
Currently, our country is facing a health care crisis not only with respect to the opioid epidemic, but also due the fact our health care costs in the US have skyrocketed out of control. According to Centers for Medicare and Medicaid Services (CMS), National Health Expense (NHE) fact sheet (2017), “NHE grew 3.9% to $3.5 trillion in 2017, or $10,739 per person, and accounted for 17.9% of Gross Domestic Product (GDP).” It was also predicted by CMS (2017) that “Under current law, national health spending is projected to grow at an average rate of 5.5 percent per year for 2018-27 and to reach nearly $6.0 trillion by 2027”(https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html).
In a study from data primarily from 2013-2016, Papanicolas, Woskie and Jha (2018) reported, “The United States spends more per capita on health care than any other nation, substantially outpacing even other very high-income countries. However, despite its higher spending, the United States performs poorly in areas such as health care coverage and health outcomes” (p. 1025).
Papanicolas et al., (2018), also stated, “The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations. Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries” (p. 1038). Papanicolas et al., (2018), reported, “Ten high-income countries were selected for comparison” (p. 1025). The ten countries included, “the United Kingdom (consisting of England, Scotland, Wales, and Northern Ireland), Canada, Germany, Australia, Japan, Sweden, France, Denmark, the Netherlands, and Switzerland” (p. 1025).
Singh, Andersson and Watkins-Castillo (2019, para. 1) reported “Lumbar/low back pain and cervical/neck pain are among the most common medical conditions requiring medical care and affecting an individual’s ability to work and manage the daily activities of life. Back pain is the most common physical condition for which patients visit their doctor. In any given year, between 12% and 14% of the United States adult population age 18 and older visit their physician with complaints of back pain. The number of physician visits has increased steadily over the years. In 2013, more than 57.1 million patients visited a physician with a complaint of back pain, compared to 50.6 million in 2010. Also, an unknown number of patients visit a chiropractor or physical therapist for these complaints. Singh et. al (2019, para. 4) further reported, “The estimated annual direct medical cost for all persons with a back-related condition in 2014 dollars was an average of $315 billion per year across the years 2012-2014” (https://www.boneandjointburden.org/fourth-edition/iia0/low-back-and-neck-pain).
According to Cynthia Cox of the Kaiser Family Foundation (2017) reporting on data from 2013, The top five disease-based spending categories (ill-defined conditions, circulatory, musculoskeletal, respiratory, and endocrine) account for half of all medical services spending by disease category. Ill-defined conditions each represent about 13% of overall health spending by disease while circulatory, musculoskeletal, respiratory, and endocrine conditions represent 12%, 10%, 8%, and 7% respectively.” That is to say, musculoskeletal disease represents 10% of the health care expenditures” (https://www.healthsystemtracker.org/chart-collection/much-u-s-spend-treat-different-diseases/#item-top-five-disease-categories-account-roughly-half-medical-service-spending).
The above graphic is from the 2017 Peterson-Kaiser report, “How much does the U.S. spend to treat different disease?”
As neck and back pain in one of the most prevalent issues that present to primary care physician (PCP) offices, considering the current opioid crisis and the associated health care expenditure, particularly related to neck and back pain, this raises the question if Doctors of Chiropractic-who are licensed to manage spinal disorders and comprehensive training in spine care, can not only provide similar or better outcomes and greater or equivalent satisfaction among patients, but provide care in a more cost effective manner, as well as help to unburden the already overloaded primary care practices considering the trending shortage of PCPs in our health care delivery system?
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).
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.
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)
Diagnosis & Collaborative Management Between the Chiropractor as the Primary Spine Care Provider and the Neurosurgeon
By: Matt Erickson DC, FSBT
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
John Edwards MD, Neurosurgeon
Clay Wickiser DC
is defined as softening of the spinal cord and can be a result of injury and represents a serious and potentially life-threatening sequella to injury if not treated. According to Zhou, Kim, Vo and Riew (2015), “Cervical myelomalacia is a relatively uncommon finding on MRI, with anoverall prevalence of 4.2% among all patients who underwent cervical MRI. Males had a higher prevalence (5.6%) than the females (3.0%).” (pg. E250)
Zhou et al., (2015) also reported, “There were considerable variations in the prevalence of myelomalacia in patients referred by different specialties/subspecialties. Specialists in spinal cord injury had the highest rate (28.7%), followed by neurological (8.4%) and orthopedic (6.4%) spine surgeons, general neurosurgeons (5.5%), and neurologists (4.2%). Specialists who generally do not treat patients with spine problems had the lowest (1.2%) followed by non-spine orthopedists (1.6%) and primary care doctors (2.1%)” (p. E248).
Myelomalacia is ischemic or hemorrhagic necrosis of the spinal cord that can occur following acute spinal cord injury, and represents extensive damage of the intramedullary spinal vasculature” (pg. 78). According to “In small animal neurology, the term myelomalacia … is normally used to refer to hemorrhagic infarction of the spinal cord that can occur as a sequel to acute injuries, such as that caused by intervertebral disc extrusion. Myelomalacia may occur as a focal lesion or may spread cranially and caudally along the spinal cord, resulting in a diffuse, severe lesion. Histologic lesions of myelomalacia are compatible with ischemic necrosis” (pg. 326).
According to a website article titled, “Myelomalacia” by Foster and Wilborn (2019), “Myelomalacia is a medical condition in which the spinal cord becomes soft. It is caused by the insufficient blood supply to the spinal cord, either as a result of bleeding or because of poor circulation. Myelomalacia most often occurs as a result of the injury” (www.wisegeek.com/what-is-myelomalacia.htm). Foster and Wilborn (2019) added, “Caused by mild to severe spinal cord injury, myelomalacia leads to neurological problems, often related to muscle movement. Often, the onset of the condition is slow and subtle, making it difficult for doctors to catch at an early stage. The condition may present simply as high blood pressure, for example, and may not be diagnosed until after the point at which it has become inoperable. While symptoms vary, they may include loss of motor function in the lower extremities, sudden jerking of the limbs, an inability to sense pain, depression, difficulty breathing, and paralysis. The damage can migrate towards the brain in a condition known as ascending syndrome. Myelomalacia can be fatal if it causes paralysis of the respiratory system (para. 2-3).
, “The exact pathophysiology is poorly understood but it seems to be the result of the concussive effects of trauma, ischemia, and the release of vasoactive substances, oxygen-free radicals and cellular enzymes. When the spinal cord is acutely damaged, cell death in the gray matter may occur within 4 hours, with this area of necrosis expanding for a few days” (pg. 78). This means that many patients can have significant underlying progressive pathology with symptoms that have not yet fully expressed themselves, but the evidence is demonstrative to the trained expert. This further supports the necessity and importance of having a primary spine care provider with trauma qualifications to diagnose the issue early on and coordinate care with the neurosurgeon.
Operative Neurosurgery, “Myelomalacia” (administrator updated) (2018, para. 4), explained, “Gradual cranial migration of the neurological deficits (problems relating to the nervous system), is known as ascending syndrome and is said to be a typical feature of diffuse myelomalacia. Although clinical signs of myelomalacia are observed within the onset (start) of paraplegia, sometimes they may become evident only in the post-operative period, or even days after the onset of paraplegia. Death from myelomalacia may occur as a result of respiratory paralysis when the ascending lesion (abnormal damaged tissue) reaches the motor nuclei of the phrenic nerves (nerves between the C3-C5 region of the spine) in the cervical (neck) region” (https://operativeneurosurgery.com/doku.php?id=myelomalacia).
As such, it is imperative for there to be collaborative case management between the primary spine care expert and the neurosurgeon. The role of the primary spine care provider is an early diagnosis to be able to identify, treat and involve the neurosurgeon when clinically indicated because if left undiagnosed and untreated, myelomalacia can become a seriously debilitating and/or life-threatening injury. Those injuries are from and trauma the spinal cord is exposed to (auto accidents, sports injuries, falls, etc.). Currently, there is a growing body of chiropractors nationally that are primary spine care and trauma qualified and trained in the early detection (diagnosis) and management of this population of patients.
According to Zohrabian and Flanders, Chapter 37: Imaging of trauma of the spine from the Handbook of Clinical Neurology Part II, “MRI is the only available imaging modality that is able to clearly depict the internal architecture of the spine cord, and, as such, has a central role in depicting parenchymal changes resulting from injury” (pg. 760). Further, “It may be difficult to distinguish spinal cord white matter from gray matter, especially in the sagittal plane, due to the similar T1 and T2 relaxation characteristics. Many prior investigations have shown that MRI characteristics of (SCI) Spinal Cord Injury, including presence and extent of cord edema and hemorrhage, are concordant with neurologic impairment at the time of injury and predict recovery” (pg.760).
Zohrabian and Flanders also wrote, “The most common location of posttraumatic spinal cord hemorrhage is the central gray matter of the spinal cord at the point of mechanical impact. The lesion most often represents hemorrhagic necrosis; true hematomyelia is rarely encountered. The lesion appears as a discrete focus of hypointensity on T2-weighted and gradient echo images, developing rapidly after SCI” (pg.760).
Zohrabian and Flanders (2016) stated, “Moreover, the location of cord hemorrhage has been shown to closely correspond to the neurologic level of injury, with frank hemorrhage correlation with poor neurologic recovery” (p. 760).
Zohrabian and Flanders (2016) further added, “Although several MRI classification schemes have been proposed, there are three common imaging observations: spinal cord hemorrhage, spinal cord edema, and spinal cord swelling. Each of these characteristics can be further described by their rostra-caudal (top to bottom) location in the cord and the amount of cord parenchyma they involve” (p. 760).
“Spinal cord edema, colloquially referred to as a cord contusion, can occur with or without hemorrhage. Edema involves a length of the spinal cord above and below the level of injury, with the length of the spinal cord show to be proportional to the degree of initial neurologic deficit. Spinal cord hemorrhage always coexists with spinal cord edema. Cord edema alone usually confers a more favorable prognosis that cord hemorrhage” (pg. 761).
According to D.J. Seidenwurm MD (, “In traumatic myelopathy, the first priority is mechanical stability. Plain radiographs are sometimes useful for this purpose, but CT is more useful when a high probability of bony injury or ligamentous injury is present. In many centers, routine multidetector CT with sagittal and coronal reconstructions has replaced plain radiographs, especially in the setting of multiple trauma” (pg. 1032).
Concerning CT, Foster and Wilborn (2019) reported, “Myelography uses a contrast medium injected into the spine to reveal injuries in x-rays. It is more invasive than an MRI, but can also detect injury in some cases in which MRI cannot. Therefore, myelography is typically used as a follow up to MRI when the latter fails to identify the source of pain or injury.” (para. 4)Finally, Zohrabian and Flanders reported, “Unlike in spinal cord cysts, myelomalacia will not parallel CSF (cerebral spinal fluid) signal intensity and its margins will usually be irregular and ill-defined (Falcone et al., 1994). The cord may be normal in size, although it is frequently atrophic at the site of myelomalacia (Fig. 37.24).” (pg. 763)
Zhou, Kim and Vo (2015) further explain, “Myelomalacia is a radiographical finding on magnetic resonance imaging (MRI) manifested by an ill-defined area of cord signal change, visible on T1- and T2-weighted sequences as hypo- and hyperintense areas, respectively. It is commonly associated with focal cord atrophy. It occurs as a sequel to spinal cord injury (SCI) due to different causes such as cord compression, ischemia, and hemorrhage. It is the most common finding in patients with previous spinal cord injury with a prevalence of 55% among patients with SCI” (p. E248).
Due to the seriousness and progressive nature of myelomalacia, it is important for the Primary Spine Care Provider, to recognize the signs and symptoms associated with myelomalacia and to identify the lesion on MRI and if identified, immediately refer the patient for a neurosurgical consultation. This also underscores why physical therapists, although licensed to treat spine, should never be the first provider to manage a spine case as diagnosing these and other conditions are not within their scope.
Foster and Wilborn (2019, para. 5) also reported, “Unfortunately, neurological damage due to myelomalacia is permanent. It can also worsen, as the nerve damage can cause affected muscles to whither. Treatment is focused on preventing further damage. Possible treatments include spinal cord surgery and medication with steroids, which serves to relax spastic muscles, reduce pain, and reduce swelling of the spinal cord.” Foster and Wilborn (2019, para. 6) also suggested, “Stem cell therapy may be used to repair neurological damage caused by myelomalacia in the future, but the therapy is currently experimental and controversial. Recent technology suggests that adult stem cells, which can be harvested from the patient's own body, show promise in treating neurological damage by allowing new, healthy tissue to grow”(www.wisegeek.com/what-is-myelomalacia.htm).
Zhou, Kim, Vo and Riew (2015) reported, “The presence of myelomalacia in the cervical spinal cord has prognostic value after decompression surgery. Some surgeons consider operative treatment of all patients with myelomalacia based on the assumption that myelomalacia is a relatively uncommon finding.” (p. E248) The authors also reported, “Many patients with myelomalacia are clinically asymptomatic or have only mild myelopathic symptoms and signs. The extent of intramedullary changes on MRI does not always correlate with clinical symptoms. Hence, for patients with asymptomatic or mild myelopathy with myelomalacia on MRI, the appropriate management remains controversial” (p. E249).
Zhou et al (2015) further added, “Several articles have suggested that conservative management is not an unreasonable option for patients with myelomalacia and mild myelopathy. It has been reported that the condition of 56% of patients with mild CSM (cervical spine myelomalacia) had not deteriorated or required surgery after 10 years. However, 2 of 45 (4.4%) patients who were treated nonoperatively with T2 hyperintensities experienced catastrophic neurological deficits with trivial trauma. Early-stage myelomalacia may be reversible, depending on the severity of the initial SCI (spinal cord injury), and may be reversed after decompression surgery” (p. E249).
This is not suggesting surgery for myelomalacia is always required. According to Dr. Mark Kotter (n.d., para. 3) in a website article titled “Myelomalacia” from myelopathy.org,“The presence or absence of myelomalacia should not be used to define when surgery should occur.” Although he further stated, “its presence and extent may be related to prognosis” (http://www.myelopathy.org/myelomalacia.html). Myelomalacia, like any spinal related injury never uses imaging findings exclusively as an arbiter for surgery. That decision is reserved for combining a clinical examination with imaging findings and the surgeon decides if surgery will benefit the patient. It is the role of the primary spine care provider to ensure and early diagnosis and referral to try to develop treatment protocols to surgically decompress the spinal cord to help reverse this pathology and often can be done if damage has been minimized.
Surgery for Myelomalacia
A patient with myelomalacia may require surgery to decompress the spinal cord. Different techniques are used depending on the pathology that may or may not include spinal fusion. Many patients are treated with an anterior approach. The offending material is removed and the spine is reconstructed either with a fusion or an artificial disc replacement. Some patients, especially with multilevel pathology, require posterior decompression with or without fusion.
The primary goal of surgery for myelomalacia is to decompress the spinal cord. Secondary goals include maintaining spinal structural integrity, alignment, and biomechanical function.
The image on the left is courtesy of Jed Weber MD, Neurosurgeon. You can see the severe spinal cord compression creating an hour glass affect secondary to a disc extrusion. Myelomalacia is also present as a white spot in the spinal cord at the compression site.
Concerning surgically balancing the spine, sagittal (front to back) balance is associated with better post-surgical outcomes. Healia.com reported on lectures by Serena Hu, MD, Jean Charles LeHuec, MD, PhD and J.N. Alastair Gibson, MD, FRCS(Ed), FRCS (Tr &Orth), MFSTEd related to outcomes of lumbar spine surgery about sagittal balance. According to Dr. Hu (2016, para 3), “Surgical outcomes for spine surgery are improved when spinal, pelvic and hip alignment is considered in both degenerate and deformity cases, and how we better understand these will help us better improve outcomes for our patients” (https://www.healio.com/spine-surgery/lumbar/news/print/spine-surgery-today/%7B54ac5ca2-7939-407d-96a5-31fa9c0fc904%7D/proper-sagittal-balance-may-correlate-with-better-surgical-outcomes).
Dr. Hu (2016) further reported, “Sagittal imbalance in a patient can negatively affect the outcomes of a surgical procedure. But, how extensive the surgery required is to correct the imbalance must be carefully considered for the individual patient” (para. 4). Dr. LeHuec (2016) added, “Sagittal balance is an active phenomenon for patients. “The best course of action is to strive to achieve sagittal balance in patients” (para. 8).
In a study by
In an article by Yeh, Lee, Chen, Yu, Liu, Peng, Wang, and Wu, (2018) they concluded, “The results of this study support previous findings that functional outcomes are closely associated with sagittal radiographic parameters in the patients with the degenerative thoracolumbar spinal disease who received long-segment fusion. The achievement of global and regional sagittal alignment balance is a crucial factor for improved postoperative functional outcomes” (p. 1361).
The primary care spine provider and the neurosurgeon can work together to best achieve spinal alignment and balance. If the patient has been cleared for mechanical treatment, the primary care spine provider can work to balance the spine (front to back and side to side) before any necessary surgical intervention. The neurosurgeon can work to maintain and improve spinal alignment with surgery. Post-operatively, ongoing chiropractic spinal adjustments can help maintain and continue to improve spinal alignment. This can lead to the best possible surgical outcomes.
Patients with myelomalacia present an ideal opportunity to further the relationship between the Doctor of Chiropractic as the primary care spine provider and the neurosurgeon. The finding of myelomalacia requires surgical consultation. If the chiropractor identifies myelomalacia, he or she can then refer to the neurosurgeon and begin the discussion necessary for further co-management. The chiropractor can ask if surgery is necessary. If so, the Doctor of Chiropractic can ask if mechanical treatment can be done pre-operatively or ask if it should wait until after surgery. If the patient needs close monitoring over time, the astute chiropractor can regularly check on and provide education to the patient under the direction of the neurosurgeon.
In patients with myelomalacia, the ability of the Doctor of Chiropractic to monitor symptoms, prepare a patient for surgery, and manage the spine mechanically after surgery are advantageous to the surgeon, who can spend more of their time performing surgery and also enjoy greater patient satisfaction and outcomes.
Myelomalacia represents a softening of the spinal cord that commonly results from trauma. If myelomalacia is observed on imaging, the advanced trained Doctor of Chiropractic in the capacity of a primary spine care provider, should refer the patient out for a neurosurgical consultation. In the event surgery is not indicated, the chiropractor can create a treatment plan with the surgeon to help axially balance and stabilized the spine, thereby reducing the compressive forces on the spinal cord and maintaining spinal mechanics. If surgery is required, the chiropractor can coordinate conservative care with the surgeon to help biomechanically balance and then manage the patient’s spine to promote a better long term post-surgical outcome. Whether surgical or not, the chiropractor can play an integral role in the patient’s car and should the chiropractor have additional training in MRI Spine Interpretation, Spinal Biomechanical Engineering and/or other advanced spinal knowledge, it provides the basis for better collaboration.
Preventing Spinal Degeneration Through Chiropractic Care
Subluxation Degeneration/Spondylosis Explained via Wolff’s Law
Spondylosis, also known as osteoarthritis of the spine, is rarely appreciated as one of the most sigificant causes of persistent pain and disability in the world today. This form of arthropathy is so universal that it is often regarded as part of the “normal” aging process. “Osteoarthritis is usually progressive and often deforming and disabling” as reported by Gottlieb (1997). “Up to 50% of individuals will experience arthritic back pain at some point in their lives. Despite its high prevalence, there exists limited information (albeit through allopathic medicine) available regarding the factors associated with the development of lumbar spine degeneration” as reported by Weinberg, Liu, Xie, Morris, Gebhart and Gordon (2017). The projected number of older adults with arthritis or other chronic musculoskeletal joint symptoms is expected to nearly double from 21.4 million in 2005 to 41.1 million by 2030 in the United States. The assumption is so will the progression of persistent pain and disability. We see that allopathic medicine has little information to help reduce the progression of this disease process, which is why chiropractic is the only true solution since we view the body from a mechanical perspective. It is the maintenance of the mechanical workings of the spine that is the real approach to preventing degenerative “wear and tear” of the human spine.
Weinberg et. Al (2017) continued by reporting “Certain mechanical causes have been implicated in the development of degenerative joint disease of the lumbar spine, including lumbar lordosis, the length of the transverse processes, disc-space narrowing, and traction spurs. Lately, authors have begun investigating the roles of facet orientation, tropism, and pelvic incidence, although data remains limited. It has recently been suggested that the relationships between pelvic incidence and facet orientation may have profound implications in the development of adjacent segment lumbar degenerative joint disease—this has sparked enthusiastic research better defining the role of sagittal balance in osteoarthritis formation.” Pg. 1593
When we consider spinal osteoarthritis, we must compare normal spinal biomechanics and loading vs. abnormal spinal biomechanics and pathological loading that results. Teichtahl, Wluka, Wijethilake, Wang, Ghasem-Zadeh and Cicuttini (2015) reported “Julius Wolff (1836–1902), a German anatomist and surgeon, theorized that bone will adapt to the repeated loads under which it is placed. He proposed that, if the load to a bone increases, remodeling will occur so that the bone is better equipped to resist such loads. Likewise, he hypothesized that, if the load to a bone decreases, homeostatic mechanisms will shift toward a catabolic state, and bone will be equipped to withstand only the loads to which it is subjected.” Pg. 2
“It is now recognized that remodeling of bone in response to a load occurs via sophisticated mechano-transduction mechanisms. These are processes whereby mechanical signals are converted via cellular signaling to biochemical responses. The key steps involved in these processes include mechano-coupling, biochemical coupling, signal transmission, and cell response.” Pg. 1
“Bone is a dynamic tissue that is tightly regulated by a multitude of homeostatic controls. One key environmental regulator of periarticular bone is mechanical stimulation. Wolff’s law relates to the response of bone to mechanical stimulation and states that bony adaptation will occur in response to a repeated load. It is interesting to consider this in the setting of knee OA, which has a strong biomechanical component to its etiology.” Pg. 1
“When periarticular bone is subjected to increased loading, some bone properties change. These include, but are not limited to, an expanding subchondral bone cross-sectional area, changes in bone mass, and remodeling of the trabeculae network. Although these changes likely represent appropriate homeostatic responses of bone to increased loading, they also appear to inadvertently predate maladaptive responses in other articular structures, most notably cartilage.” Pg. 1
Keorochana, Taghavi, Lee, Yoo, Liao, Fei and Wang reported (2011) “Differences in sagittal spinal alignment between normal subjects and those with low back pain have been reported. Previous studies have demonstrated that changes in sagittal spinal alignment are involved in the development of a spectrum of spinal disorders. It has also been a topic of great interest in the management of lumbar degenerative pathologies, especially when focusing on the role it may play in accelerating adjacent degeneration after spinal fusion and non-fusion procedures such as dynamic stabilization and total disc replacement. Spinal morphology may influence the loading and stresses that act on spinal structures. Alterations in the stress distribution may ultimately influence the occurrence of spinal degeneration. Moreover, changes in sagittal morphology may alter the mechanics of the lumbar spine, affecting mobility.” Pg. 893
Panjabi (2006) reported:
Cramer et al. (2002) reported “One component of spinal dysfunction treated by chiropractors has been described as the development of adhesions in the zygapophysial (Z) joints after hypomobility. This hypomobility may be the result of injury, inactivity, or repetitive asymmetrical movements…one beneficial effect of spinal manipulation may be the “breaking up” of putative fibrous adhesions that develop in hypomobile or “fixed” Z joints. Spinal adjusting of the lumbar region is thought to separate or gap the articular surfaces of the Z joints. Theoretically, gapping breaks up adhesions, thus helping the motion segment reestablish a physiologic range of motion.” (p. 2459)
Evans (2002) reported “On flexion of the lumbar spine, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with it. On attempted extension, the inferior articular process returns toward its neutral position, but instead of re-entering the joint cavity, the meniscoid impacts against the edge of the articular cartilage and buckles, forming a space-occupying "lesion" under the capsule: a meniscoid entrapment. A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophyseal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent impaction of the meniscoid. The patient would tend to be more comfortable with the spine maintained in a flexed position, because this will disengage the meniscoid. The extension would therefore tend to be inhibited. This condition has also been termed a "joint lock" or "facet-lock" the latter of which indicates the involvement of the zygapophyseal joint.” Pg. 252
The sagittal spinal misalignments developed after hypo or hypermobility as a result of injury, inactivity, or repetitive asymmetrical movements as reported Cramer, creates mechanoreceptor and nociceptor pathological input, this in turn as reported by Evans creates a mechanical displacement of the zygapophyseal joint and aberrant stimulation to type III and IV nociceptors. This also, according to Panjabi causes a corrupting of neuromuscular transducers (mechanoreceptors and nociceptors) of the spinal muscular system. These combine to create spinal neuro-pathobiomechanics for the spine globally and at each affected motor unit. This is what has been historically called in chiropractic “vertebral subluxation.“ Based upon Wolff’s Law, the persistent biomechanical failure, as perpetuated by the central nervous system being corrupted and attempting to compensate through muscular activity creates premature degeneration of the spine or osteoarthritis or “Subluxation Degeneration.”
Evans (2002) concluded that a high velocity-low amplitude manipulation (chiropractic spinal adjustment) of the joint involving flexion and gapping, reduces the impaction and opens the joint to encourage re-entry of the meniscoid into the joint space and realignment of the joint.” Pg. 253 This activity reduced the irritation or pressure on the nociceptors on the zygapophyseal joints stopping the corruption of the central nervous system and allowing the body to “right itself” and halt the degenerative process of the spine.
It has already been concluded, as reported by Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) in a population-based study of 5511 injured workers in Ontario Canada as reported by the Workplace Safety and Insurance Board, a governmental agency reported a comparison of outcomes for back pain among patients seen by three types of providers: medical physicians, chiropractors and physical therapists. The found “The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of the second episode of financial compensation.” (pg.392) and “These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.” (pg. 382)
Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) continued, “The cohort study of American workers with back pain conducted by Turner et al. found that the first healthcare provider was one of the main predictors of work disability after a year. By our findings, workers who first sought chiropractic care were less likely to be work-disabled after 1 year compared with workers who first sought other types of medical care.
Considering that 50% of the population will experience some type of pain and/or potential disability as a result of spinal arthritis, chiropractic, as reported above is positioned as the best first option for spine as an evidence-based solution. This is called Primary Spine Care and chiropractic is best positioned to lead society in the prevention of osteoarthritis/subluxation degeneration through chiropractic care.
Deceptive Dogmatic Reporting Despite Successful Chiropractic Outcomes
Revealing the deception of low back pain naturally resolving
…and the dogma of non-specific back pain
Mark Studin, DC
William J. Owens DC
Timothy Weir, DC
Citation:Studin M., Owens W., Weir T. (2018) Deceptive Dogmatic Reporting Despite Successful Chiropractic Outcomes, American Chiropractor, 40 (11) 10, 12-15
A report on the scientific literature
Over the past decade, there has been a growing body of evidence demonstrating the “how and why” of chiropractic evidenced-based results. However, there has also been a historical level of reporting dogmatic issues related to the “the natural history of back pain” and “non-specific back pain” that deceptively enter and intersect the conversation to apparently discredit “pro-chiropractic” evidenced-based research that has persisted in contemporary literature. This review is centered on those issues, and the references for the above comments will ensue in the paragraphs below.
The National Institute of Neurological Disorders and Stroke reports “Most low back pain is acute, or short-term, and lasts a few days to a few weeks. It tends to resolve on its own with self-care, and there is no residual loss of function.”
https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet. Kaiser Permanente, a national health system reports, “For most patients with back pain, the condition will improve within a few days or weeks.” https://wa.kaiserpermanente.org/static/pdf/public/guidelines/back-pain.pdf
Kaiser Permanente goes on to report, “The primary goal of treatment is to maximize function and quality of life, rather than to eliminate pain. Some ongoing or recurrent pain is normal and not indicative of a serious problem. Avoid exposing the patient to unhelpful or possibly risky interventions. As a general rule, an intervention in which the patient is an active participant (e.g., physical therapy, walking, stretching, yoga) rather than a passive recipient (e.g., chiropractic, massage, acupuncture) is deemed to have greater potential to promote self-efficacy and self-management skills in the long term.”
Gedin, Edmar, Sundberg, and Burström in 2018 reported “Patients with acute back pain reported statistically significant and MCID (Minimal Clinically Important Difference) improvements in back pain intensity, back disability, HRQoL (Health-Related Quality of Life instrument), and statistically significant improvements in self-rated health, over four weeks following chiropractic care. Patients with chronic back pain reported statistically significant, albeit smaller and non MCID, changes for all PRO except self-rated health.
Interestingly, Gedin et al. have a significant level of statistics of demonstrating percentages of subjects who showed improvement and choose not to report that in the written part of the report, thereby not rendering a statistical interpretation. However, they included a caveat to perhaps minimize the positive results by reiterating the same deceptive dogma as discussed above. Gedin et. al then reported “However, it has been suggested that 90% of patients with acute low back pain recover within six weeks (van Tulder et al., 2006), which may also help explain the current findings of rapid improvements.(pg. 16) This opinion published in 2018 was referenced and supported by a 12-year old study which clearly ignored the contemporary literature.
Tamcan, Mannion, Eisenring, Horisberger (2010) reported on the only population-based study these authors were able to identify and concluded “When the 12-month follow-up period was divided into four equal time periods and, subsequently, clusters, it was seen that the majority of individuals placed in the moderate persistent [pain] cluster on the basis of the first 3 months data remained in this cluster at the following intervals. A reasonable consistency across time was also found for the clusters mild persistent and severe persistent. In contrast, the consistency of membership for the cluster initially identified as fluctuating was low, especially after six months.” (pg. 455-456) This study, which again is the only identified population-based study indicates that pain does not resolve “naturally” as was reported: “fluctuation was low, especially after six months.”
Knecht, Humphyres and Wirth (2017) reported on the recurrence of low back pain and stated, “Only 1 in 3 LBP (low back pain) episodes completely resolve within a year, and the percentage of LBP that goes from acute to chronic varies among studies from 2% to 34%.” Knecht et. Al (2017) also went on to report “Patients presenting with a subacute problem, lasting for more than 14 days at baseline, were at higher odds for a recurrent course, whereas the odds for a chronic course were higher only for patients presenting with a chronic problem (≥3 months) at baseline. Downie et al. reported that pain duration of more than five days was a factor that negatively affects prognosis. Similarly, duration of the current episode emerged as the most consistent factor for prognosis after one year in a study by Bekkering et al. and even predicted disability after five years. These findings suggest on the one hand that it might be prudent to seek professional advice [referenced chiropractic care in the article] early on in the pain episode.” (pg. 431)
These papers a part of the research trend supporting what the chiropractic profession has known all along, the natural progression of low back pain resulting in resolution is based on dogma and not supported by the research evidence. Additionally, the low back pain care path reported previously by Kaiser Permanente appears to be biased towards the denial of care and not consistent with the published literature.
Gedin et. Al (2018) also report, “it has been estimated that the vast majority of back pain cases is of non-specific origin.” (pg. 3) The concept of simply focusing on the treatment of non-specific back pain would render chiropractic no different than physical therapists when focusing on the “non-specific” nature of spine pain as the arbiter for care while the focus must be on the biomechanical compensation and individual motor units of the spine. Previous literature has verified that the supposition that “non-specific” is synonymous with ‘unobjectifiable” is erroneous since it was previously reported that chiropractic treats definite biomechanical changes in the motor units of the spine, therefore resulting in “very specific” biomechanical pathology.
Panjabi in 1992, presented a detailed work explaining how the biomechanical systems within the human spine react to the environment, how it can become dysfunctional and cause pain. He stated “Presented here is the conceptual basis for the assertion that the spinal stabilizing system consists of three subsystems, the vertebrae, discs, and ligaments constitute the passive subsystem, all muscles and tendons surrounding the spinal column that can apply forces to the spinal column constitute the active subsystem and finally, the nerves and central nervous system comprise the neural subsystem, which determines the requirements for spinal stability by monitoring the various transducer signals [of the nervous system] and directs the active subsystem to provide the needed stability.” He goes on to state, “A dysfunction of a component of any one of the subsystems may lead to one or more of the following three possibilities, an immediate response from other subsystems to successfully compensate, a long-term adaptation response of one or more subsystems or an injury to one or more components of any subsystem.”
Panjabi continues, “It is conceptualized that the first response results in normal function, the second results in normal function but with an altered spinal stabilizing system, and the third leads to overall system dysfunction, producing, for example, low back pain. In situations where additional loads or complex postures are anticipated, the neural control unit may alter the muscle recruitment strategy, with the temporary goal of enhancing the spine stability beyond the normal requirements.” (pg. 383) This is where the idea of biomechanical compensation was identified.
Panjabi’s lifelong work summarized in the above work is the basis for the underlying mechanics of spine pain that does NOT correlate well to anatomical findings. Anatomical findings are fracture, tumor or infection and allopathy has labeled anything else “non-specific low back pain” which continues to maintain a dogmatic perspective in both clinical decision making and all too often, the literature, despite compelling evidence to the contrary.
Cramer et al. (2002) further clarified the biomechanics of spinal failure at the motor until level and reported, “One component of spinal dysfunction treated by chiropractors has been described as the development of adhesions in the zygapophysial (Z) joints after hypomobility. This hypomobility may be the result of injury, inactivity, or repetitive asymmetrical movements… one beneficial effect of spinal manipulation may be the “breaking up” of putative fibrous adhesions that develop in hypomobile or ‘fixed’ Z joints. Spinal adjusting of the lumbar region is thought to separate or gap the articular surfaces of the Z joints. Theoretically, gapping breaks up adhesions, thus helping the motion segment reestablish a physiologic range of motion.” (p. 2459)
Evans (2002) reported, “on flexion of the lumbar spine, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with it. On attempted extension, the inferior articular process returns toward its neutral position, but instead of re-entering the joint cavity, the meniscoid impacts against the edge of the articular cartilage and buckles, forming a space-occupying ‘ lesion’ under the capsule: a meniscoid entrapment. A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophyseal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent impaction of the meniscoid.” (pg. 252)
Evans (2002) continued, “an HVLA manipulation, involving gapping of the zygapophyseal joint reduces the impaction and opens the joint, so encouraging the meniscoid to return to its normal anatomical position in the joint cavity. This ceases the distension of the joint capsule, thus reducing pain.” (p. 253)
The involvement of nociceptors and nociceptive impulses stimulates the cortical regions of the brain which evokes a cortical response to that noxious stimuli. Haavik et al. (2017) reported the effects of a chiropractic spinal high velocity-low amplitude adjustment by stating “These results are consistent with previous findings that have suggested increases in strength following spinal manipulation were due to descending cortical drive and could not be explained by changes at the level of the spinal cord.” (pg. 1)
The persistent utilization of “non-specific” in reference to specific biomechanical alterations and failure in the human spine is dogmatic and deceptive since it “lumps together” all types of manual treatment, where chiropractic, based upon its unique application differs from other forms of manual therapy performed by physical therapy, acupuncture, and massage therapy. It differs in the ability of chiropractors to diagnosis and manages spinal compensation. In comparison to each other, each discipline is disparate in goals, application, and science and when not considered as such, lends itself to continue deceptive dogmatic arguments ignoring the evidenced-based truths of chiropractic.
CASE REPORT: SEVERE DISC HERNIATION WITHOUT RADICULAR SYMPTOMATOLOGY
Richard A. Laviano DC
The patient was a very pleasant 43-year-old male presenting to the clinic with acute onset of low back pain that started 7 days ago after performing some heavy lifting at work. The pain was in the lumbosacral region and right sacral leg joint region and surrounding musculature that radiated into the posterior aspect of the right leg. No numbness or tingling was present. No loss of bowel or bladder control. Any type of movement that involves bending and twisting greatly exacerbates the pain. The pain is constant and especially worse in the mornings. The patient presented with inability to fully weight-bear on the right leg and thus presented with a right limp.
The patient indicated that he had not experienced prior symptoms similar to his current complaints and was symptom-free at the time of the incident above. The patient’s medical, surgical, and family history was unremarkable. He is a healthy Hispanic male.
His superficial appearance did not indicate any apparent distress. Further, observation showed minor’s sign to be present. This sign is present when the patient, in arising from a chair, leans forward, jackknifing the thighs and the dorso-lumbar spine so that the head is over the feet. Using the hands on the thighs or the arms of the chair, the patient pushes the body to an upright position, thus sparing lower limb effort. The presence of this sign is usually indicative of sciatica. There was no apparent spine tilt with him standing upright.
The patient was 5 feet 8 inches at 156 pounds, well-developed with a body temperature of 99.2°F. His blood pressure was slightly elevated at 149/81 mm Hg and a heart rate at 72 beats per minute. On examination, the eyes, ears, and throat appeared normal.
Gait analysis reveals complete loss of normal gait pattern greatly favoring his left leg.
The patient’s range of motion was decreased in all ranges with pain and spasm in the erector spinae muscles including the iliocostalis lumborum and iliocostalis thoracics muscles bilaterally. Muscles of the lower extremity were 5 out of 5 for all muscles in the left leg. A 3 out of 5 test was noted in right anterior tibialis muscle and right extensor hallucis longus muscle. No atrophy was noted. The patient’s deep tendon reflexes of the upper and lower extremities were noted to be a 2+ rating bilaterally for patellar and Achilles. Cranial nerve testing also showed to be normal. The patient had normal sensation symmetrically and bilaterally.
Orthopedic testing showed positive straight leg raise test both in the supine and seated position (slumps) with reproduction of patient shooting pain along the posterior aspect of the right leg with a patient audible response due to the severity of pain. Bechterew’s test also showed positive on the right side.
Palpation of the lumbar spine showed tenderness along L3-L5 facet joints and surrounding musculature. Spasming noted in during palpation of the erector spinae muscles bilaterally. Edema is noted in this region as well.
A full spine weight bearing radiographic study was taken (utilizing views: APOM, AP cervical, AP Thoracic, AP lumbopelvic, lateral cervical, lateral thoracic, and lateral lumbar). An MRI of the lumbar spine was also ordered immediately before beginning treatment. See figures below.
The radiographic study showed loss of normal lumbar lordosis consistent with an acute injury. No degenerative changes are present. Neural foramina appear patent. No evidence of fracture or dislocation. A moderate left list of the lumbar spine is noted consistent with a disc injury. Acetabular joints appear normal. The adjacent soft tissue appears normal.
Image 1 – loss of lumbar lordosis with left list, Antalgia, seen on radiograph.
Magnetic Resonance Imaging:
MRI Study was reviewed, and findings included: Marrow edema was normal with no signs of fracture. The vertebral alignment showed loss of normal lumbar lordosis and caddy lever appearance of L3 on L4. Hemangiomas noted at L1 and L5 in trabecular bone vertebral bodies. Conus medullaris and cauda equina appear normal. There is a T2 hyperintense signal cystic structure noted at the posterior aspect of the conus medullaris at T12-L1. This is incompletely evaluated in this study. L1-L2 appears normal with no stenosis of the neural foramina or central canal. L2-L3 shows posterior central annular fissure. The high signal in this fissure indicates it is acute. No central canal or neural foraminal stenosis. L3-L4 showed mild disc bulging with a superimposed right paracentral disc extrusion1 at L3-L4 with migration inferior-ward displacing the thecal sac and the fourth lumbar nerve root before it reaches the L4-L5 neural canal on the right. L4-L5 shows moderate disc bulging with a superimposed posterior left paracentral disc protrusion type herniation with an annular fissure. Due to the high signal in this fissure, it is most likely acute. L5-S1 appears normal with no central canal or neural foraminal stenosis. Recommendations included a thoracic spine study to assess cystic lesion as noted above. Immediate neurosurgical consultation is also recommended. See Images 2 through 5 below.
Image 2 – extrusion herniation with inferior migration.
Image 3 – displacement of thecal sac posteriorly on the right side.
Image 4 – compression occurring just before neural canal but displacing L4 nerve.
Image 5 – Neural Canals are patent.
After MRI results were reviewed patient was immediately referred for a neurosurgical consult. Neurosurgical consultation recommended that the patient is removed from his repetitive occupation for 2 weeks and begin oral steroid treatment. After a few weeks, the patient reported that he had significantly improved and is now able to perform all activities of daily living including work with no discomfort. Based upon the neurosurgeon’s recommendation, collaborative care with chiropractic treatment will commence ensuring biomechanical stability.
NOTE ON STEROID USE WITH MECHANICAL SPINE ISSUES: Goldberg et al. (2015) reported: Despite conflicting evidence, epidural steroid injections are frequently offered under the assumption that radicular symptoms are caused by inflammation of the affected lumbar nerve root. Epidural steroid injections are invasive, generally, require a pre-procedure magnetic resonance imaging (MRI) study and expose patients to fluoroscopic radiation. Also, the US Food and Drug Administration recently warned of rare, but serious neurologic sequella from [epidural steroid injections]. Oral administration of steroid medication may provide similar anti-inflammatory activity, does not require an MRI or radiation exposure, can be delivered quickly by primary care physicians, carries less risk, and would be much less expensive than an [epidural steroid injection]. Oral steroids are used by many community physicians, have been included in some clinical guidelines, and are noted as a treatment option by some authors. However, no appropriately powered clinical trials of oral steroids for radiculopathy have been conducted to date. To address this issue, we performed a parallel-group, double-blind, randomized clinical trial of a 15-day tapering course of oral prednisone vs. placebo for patients with acute lumbar radiculopathy associated with a herniated lumbar disk... (p. 1916).
Results showed that “participants in both blinded treatment groups showed an improvement in symptoms over the initial 6 weeks, with more gradual reductions until the 24-week visit, after which changes were more variable. Baseline ODI [Oswestry Disability Index] scores were 51.2 and 51.1 in the prednisone and placebo groups, respectively; corresponding ODI scores at 3 weeks were 32.2 and 37.5” (Goldberg, 2015, p. 1919-1920). This indicates that both at 3 and 6 weeks there was no difference in the placebo vs. oral steroid groups. “Among patients with acute radiculopathy due to a herniated lumbar disk, a short course of oral steroids, compared with placebo, resulted in modest improvement in function and no significant improvement in pain” (Goldberg, 2015, p.1922)
Although the patient presented with some classical signs of disc injury, some signs of disc injury were not present: Antalgia, numbness or tingling in the lower extremity or loss of bowel or bladder control. The outstanding feature of this case was the motor deficit noted in the right anterior tibialis and right extensor hallux longus muscle both having their roots in L4 and L5. It is important to note, however, that positive orthopedic testing with production radicular pain without motor or sensory loss is still an indication for advanced imaging particularly with straight leg raise (SLR) and slumps test3. One study showed that adding hyperextension test and Bell test to the straight leg raise test have shown to be more sensitive and specific than the SLR test alone4. The patient had not been evaluated by any other physician before being evaluated by us. This is a clear example although the patient did not have all the signs indicating acute disc injury, severe disc injury indeed occurred. The patient’s inability to axial load during a range of motion testing is also demonstrated by the two acute annular fissures as noted above. Chiropractic manipulation is contraindicated in this case due to the severe extruded disc at L3-L4 with migration. Advanced imaging, particularly Magnetic resonance imaging, in this patient’s case significantly improved our ability to give an accurate diagnosis and prognosis of their condition.
Efficacy of Chiropractic Treatment for Post-Surgical Continued Low Back and Radicular Pain
81% of chiropractic post-surgical patients showed greater than 50% reduction in pain.
Mark Studin DC
William J. Owens DC
A report on the scientific literature
Park et. Al (2016) reported that low back pain radiating into the lower extremities have greater impact on disability and time off work that any other medical condition. Vleggeert-Lankamp, Arts and Jacobs (2013) reported “The term ‘failed back surgery syndrome’ (FBSS) is used to describe a clinical condition defined by persistent or recurrent complaints of leg pain and/or back pain regardless of one or more surgical procedures of the lumbar spine. The definition of FBSS (failed back surgery syndrome) is modified by some authors by adding that at least one surgical intervention was to be performed and that pain should persist after the last surgical intervention, for at least one year.1 The term implies that the surgery plays a role in the cause of the pain, although in most cases the surgical intervention was technically successful. It is known that nearly 20% of patients undergoing spine surgery will require secondary surgery for persistent pain or surgery-related complications during the subsequent years.” (pg. 48) El-Badawy and El Mikkawy (2016) reported that failed back surgery syndrome occurs with lateral disc surgery upwards of 17%, spinal stenosis 29% and instability 14.8%.
Perhaps the reason for failed back surgery syndrome is what the surgeons have considered their “gold standard, fusion and the ensuing loss of mobility of the spinal motor unit. Mulholland (2008) reported “Spinal fusion became what has been termed the “gold standard” for the treatment of mechanical low back pain, yet there was no scientific basis for this.” (pg. 619) The history of spinal fusion is both fascinating and disturbing and reveals why chiropractic both helps post-surgical cases and should always be considered first, prior to surgery as an option.
Mulholland (2008) continued:
In 1962 Harmon presented a review paper at the western orthopaedic association meeting in San Francisco, in which the term “Instability” appears.
However, Harmon’s description of what he meant by instability (unfortunately in a footnote) is revealing “Spinal instability refers to a low back-gluteal-thigh clinical triad of symptoms that may be accompanied (overt cases) by incapacitating regional weakness and pain. This is the effect of disk degeneration with or without disc hernia. Some may be asymptomatic or slightly symptomatic when instability is compensated by muscle or ligament control. It does not refer to spinous process or laminal hypermobility which some surgeons like to demonstrate at the operating table nor does this clinical concept parallel the common spinal hypermobility, which is the product of intervertebral disc degeneration, demonstrable in flexion-extension filming of the region, since the anatomic hypermobility is not always productive of symptoms”
Sadly this description of instability appears to have been ignored, and the concept of mechanical instability as a cause of back pain was progressively accepted. Harmon’s view of the effect of fusion was that it cured pain by reducing the irritation of the neural contents produced by movement. His paper was influential as he emphasized the importance of appropriate investigations prior to fusion and the segmental nature of back pain but unfortunately his use of the term instability was interpreted as supporting the view that segmental abnormal movement was the cause of the pain.
In 1965 Newman in an editorial concerning lumbo-sacral arthrodesis (surgical immobilization) refers to the need to stabilize the lumbar spine in patients with back pain after discectomy for a lumbar root entrapment.
At the beginning of the seventies the perception was that disc degeneration led to abnormal translational movement, and this was painful.
McNab in 1971 who had done much work on the disturbance of movement in the degenerate disc described what he termed the “traction spur,” a particular type of anterior osteophytes which he said was related to an abnormal pattern of translational movement. This view again supported the concept of instability. He added the important caveat that it “was impossible to establish the clinical significance of the traction spur as a statistically valid investigation the traction spur was revisited in the late eighties and was shown to be no different to claw osteophytes, and often both would be present in the same patient. It was not related to abnormal movement.”
Although McNab used the term instability, he used it in the sense that the spine was vulnerable to acute episodes of pain, because the degenerate disc rendered it more easily injured. He did not view it as a cause of chronic back pain.
Kirkaldy Willis set out his views on instability in 1982. In “Instability of the Lumbar Spine” he described the process of disc degeneration as passing through a stage of dysfunction, (intermittent pain), instability which caused more persistent pain but then with time stabilizing to a painless state. This was his explanation for the observed fact that many very degenerate discs were painless. However, he at that stage was somewhat unhappy with an entirely mechanistic view for pain. Hence, he writes “Instability can be defined as the clinical status of the patient with a back problem who with the least provocation steps from the mildly symptomatic to a severe episode”. Further he writes “Detectable increased motion does not always solicit a clinical response, and that abnormal motion may be abnormal increase or abnormal decrease”. He further writes “It is insufficient to detect the abnormal increased motion, but the mechanism by which it precipitates the symptomatic episode must also be identified”. Indeed in the seven cases he reported only one patient had backache alone, the others were all radicular problems. His paper shows that identifying abnormal movement establishes the fact that the segment is disordered, but he does not in that paper indicate that movement itself is the cause of pain.
Subsequently in his very influential book “Managing Back Pain” in 259 pages just one page is devoted to the rationale of lumbar fusion. The only reason for fusion appeared to be that, other treatments had failed, that it was reasonable from the psychological viewpoint, and that instability was present. Instability is defined elsewhere in the book as increased abnormal movement, and this is illustrated by x-rays purporting to show abnormal rotations and various types of abnormal tilt. He accepts that such appearances may be entirely painless, but in the patient with back pain they identify the causative level, and fusion is justified.
However, in a joint paper with Depuis in 1985 entitled “Radiological Diagnosis of Degenerative Lumbar instability” they write “A lumbar motion segment is considered unstable when it exhibits abnormal movements. The movement is abnormal in quality (abnormal coupling patterns) or in quality (abnormal increase of movement...) Pain is a signal of impending or actual tissue damage-and when present it indicates that a mechanical threshold has been reached or transgressed. Repeated transgressions will damage the stabilizing structures beyond physiological repair, thus putting abnormal demands on secondary restraints”.
Hence from being a method of identifying an abnormal degenerate disc, abnormal motion itself became the injurious agent.
In 1985 Pope and Panjabi in a paper entitled “Biomechanical definition of spinal instability” wrote “Instability is a mechanical entity and an unstable spine is one that is not in an optimal state of equilibrium. (...In the spine stability is affected by restraining structures that if damaged or lax will lead to altered equilibrium and thus instability. Instability is defined as a loss of stiffness”. Panjabi’s views were generally accepted by basic scientists interested in this field.
Subsequently Panjabi concluded that increased movement was not necessarily a feature of what he termed instability, but reduction in the neutral zone was. However, in a more recent paper he has abandoned the concept of instability altogether and ascribes chronic back pain as being caused by ligament sub-failure injuries leading to muscle control dysfunction.
However, throughout the period from the fifties to the nineties, the Panjabi view held sway, and the term instability evolved from being a useful term to denote a segment that was abnormal due to a degenerate disc, to a term denoting a diagnosis of an abnormal, (usually increased) pattern of movement with a translational component. The abnormal movement was thought to be the cause of the pain and clearly fusion or stopping movement was a logical treatment.
However, the inability to show that abnormal or increased movement was a feature peculiar to the painful degenerate disc, combined with the fact that despite more rigid fusions using pedicle fixation, the clinical results of fusion had not improved, was increasingly casting doubt on the concept of instability. The paper by Murata combining MRI examination with flexion and extension films in patients with back pain, showed that increased angular and translational movement was a feature of the normal or mildly degenerate disc, not of the markedly degenerate disc, where movements were reduced. In 1998 Kaigle et al. demonstrated that comparing patients with normal subjects there was always less movement present in the degenerate spine. It was therefore generally accepted that the effect of disc degeneration was to reduce movement not to increase it, as the term “instability” would imply. It may be argued that, unfortunately, this reduction of movement is associated with abnormal patterns of movement, and this is the meaning of “instability”. However despite considerable efforts over many years, using flexion/extension films, no clear relationship has been established between pain and such abnormal movements. In other words, patients with degenerative disc disease may exhibit abnormal patterns of movement yet have no pain.
By the mid-nineties, instability was still the term used to describe the disorder that we treated by fusion, but the failure to improve results by the introduction of pedicle fixation, caused many surgeons to question the concept of instability, but surgeons were all aware that fusion although unpredictable in terms of clinical result, was the best surgical treatment for chronic low back pain. It was well recognized that clinical success was unrelated to the success of the fusion, pseudarthrosis was as common amongst successful patients as in those who had failed. Was there anything else that a fusion did to the intervertebral disc unrelated to the fact that it stopped movement? (pgs. 619-623)
Mulholland (2008) concluded with a powerful statement that perhaps sums up why chiropractic realizes significant result when treating post-surgical cases.
Abnormal movement of a degenerated segment may be associated with back pain but is not causative. The concept of instability as a cause of back pain is a myth. The clinical results of any procedure that allows abnormal disc loading to continue are unpredictable. (pg. 624)
To underscore the point of fusion being a failed surgical paradigm in many patients, Gudavalli, Olding, Joachim, & Cox (2016) reported,
Surgical decompression of the lumbar spine in older patients had a 24% reoperation rate, and a 20-fold increase in lumbar surgical fusion rates among Medicare enrollees is reported. Lumbar cage fusion rates increased from 3.6% in 1996 to 58% in 2001, and the result was increased complication risk without improved disability or reoperation rates. Adjacent segment degenerative changes and instability at the level immediately above single-segment fusion with clinical deterioration are shown in up to 90% of the cases. The incidence of radiographic adjacent segment disease following fusion has been reported to be as high as 50% in the cervical spine and 70% in the lumbar spine at 10 years. However, the incidence of clinically relevant symptomatic adjacent segment disease is quite lower, estimated at 25% in the cervical spine and 36% in the lumbar spine at 10 years.
Comparing surgery with nonsurgical treatment for back and radicular pain shows that intensive rehabilitation is more effective than fusion surgery, and nonsurgical treatment of low back and radicular pain patients is reported to reduce lumbar disk surgery by approximately two-thirds. Chronic low back pain in 349 patients aged 18-55 years found no evidence that surgery was any more beneficial than intensive rehabilitation. A study of 600 single-operated low back patients showed that 71% did not return to work 4 years after surgery, and 400 multiple-operated backs showed that 95% did not return to work 4 years later. (pg. 124)
Gudavalli, Olding, Joachim, & Cox (2016) went on to report what has been found clinically effective in both pre and post-operative cases, "Treating lumbar disk herniation and spinal stenosis patients successfully with conservative care is documented. Chiropractic manipulation prior to spine surgery is appropriate. Previous reports of the biomechanical changes in the spine when CTFD (Cox technique, flexion-traction) spinal manipulation is applied include decreased intradiscal pressure; intervertebral disk foraminal area increase; increased intervertebral disk space height; and physiological range of motion of the facet joint." (pg. 124)
Regarding post-surgical care, Gudavalli, Olding, Joachim, & Cox (2016) concluded,
81% of the (post-surgical chiropractic) patients showed greater than 50% reduction in pain levels at the end of the last treatment. At 24-month follow-up, 78.6% had continued pain relief of greater than 50%. (pg. 121)
Although one of the goals of chiropractic care is pain relief, there are still the underlying biomechanical pathologies to consider that are concurrently treated while under chiropractic care. The more pressing issue in the post-surgical cases are “could these surgeries been avoided” in the first place with correcting the underlying biomechanical pathologies prior to surgery This underscores the overwhelming need for chiropractic as Primary Spine Care providers being the first treatment option. It goes back to the adage “drugless first, drugs seconds and surgery last.” It’s just common sense and chiropractic has been verified in numerous outcome studies proven to be the most effective 1st treatment option for spine.
Re-Integration of Lost Cervical Curve Post-Motor Vehicle Accident
Quantifying and Qualifying Injury and Recovery of the Lateral Cervical Curve by a Serial Examination of Injured Lateral Cervical Spine via Radiographs
By: Ray Wiegand, DC
Mark Studin DC.
A patient presented in January 2018 following a motor vehicle accident (MVA) to a chiropractor licensed in Colorado. This doctor, trained in x-ray digitization and utilizing the Analysis System Software, adjusted the full spine according to the computerized rendered conclusions that identified the primary biomechanical lesions of the spine while avoiding compensatory spinal segments. In the absence of any osteophytes, as per He and Xinghua (2006), verifies this is a recent injury vs. chronic and consistent with the MVA history as causality.
The patient demonstrates the findings of a sudden impact injury with severe loss of the cervical curve and forward head translation. Loss of the cervical curve and FHT (forward head translation) is the single common etiology of almost everyone with musculoskeletal complaints from an MVA, based upon the experience of the authors. The computer graphic above is for patient education, illustrating a normal cervical for comparison for the patient. In this case the patient was rated “Very Severe” for biomechanical severity with 19.3 mm of anterior head translation based upon digitization).
As patient positioning can influence the contour of the cervical curve, the patient's plane line of the teeth was in a neutral position for the neutral x-ray view. This creates a frame of reference for future comparison. According to Kapandji (1974), this position is the true neutral position of balanced head posture. Lifting the chin to obtain a neutral posture creates the opportunity for the patient to demonstrate more of a lordosis. But typically, they will not. In this example the patient head was in 17.9° of flexion which alters upper cervical measurements.
Serial examination 1/2018 compared to 5/2018
The patient is in natural neutral posture with the plane line of the teeth horizontal.
Post chiropractic spinal high velocity-low amplitude adjustments, the patient went from 206 spinal stress units (SSU) to 89.2 SSU. The SSU measures the patient’s geometric departure from a balanced uninjured lateral cervical curve. In this example the patient decreased in stress by 116.8 SSU. This represented going from 4 SD (standard deviations) from normal to 1 SD from normal.
Upon radiographic examination post MVA, the patient presented with a reversed cervical curve. Numerically, this was rated at 206 stress units and post chiropractic spinal high velocity-low amplitude adjustments the patient was reduced by 116.8 SSU units to a value of 89.2, resulting in a minimal of loss of curve as determined numerically. Visually, the patient’s cervical curve was returned to “near normal” with the plum line going from the posterior arch of C1 through the posterior body of C7.
Chiropractic Vertebral Subluxation
By Mark Studin
William J. Owens
Citation: Studin M., Owens W. (2018) Vertebral Subluxation Complex, American Chiropractor, 40 (7) 12, 14-16, 18, 20, 22, 24, 26-27
A report on the scientific literature
Chiropractic was discovered in 1895 by Daniel David Palmer and further developed by his son, Bartlett James Palmer. Together, they helped coin the phrase “vertebral subluxation,” yet to date, there has been little evidence of it in the literature. When we consider neuro-biomechanical pathological lesions that will degenerate (please refer to Wolff’s Law) based upon homeostatic mechanisms in the human body we will better understand and be able to define the chiropractic vertebral subluxation and more specifically, the chiropractic vertebral subluxation complex (VSC). In addition, the literature has provided us with a vast amount of evidence on both the biomechanical dysfunction of the spine as well as the neurological consequence as sequelae to that biomechanical dysfunction.
Despite over a century of reported and literature-based clinical results, detractors both outside and inside the chiropractic profession argue to limit the scope of these spinal lesions because the literature has not yet caught up to the results. Additionally, the lack of contemporary literature has been reflected in “underperforming” chiropractic utilization in the United States for conditions that have been well-documented as responding successfully in outcome studies with chiropractic care.
Murphy, Justice, Paskowski, Perle and Schneider (2011) reported:
Spine-related disorders (SRDs) are among the most common, costly and disabling problems in Western society. For the purpose of this commentary, we define SRDs as the group of conditions that include back pain, neck pain, many types of headache, radiculopathy, and other symptoms directly related to the spine. Virtually 100% of the population is affected by this group of disorders at some time in life. Low back pain (LBP) in the adult population is estimated to have a point prevalence of 28%-37%, a 1-year prevalence of 76% and a lifetime prevalence of 85%. Up to 85% of these individuals seek care from some type of health professional. Two-thirds of adults will experience neck pain some time in their lives, with 22% having neck pain at any given point in time.
The burden of SRDs on individuals and society is huge. Direct costs in the United States (US) are US$102 billion annually and $14 billion in lost wages were estimated for the years 2002-4. (p. 1)
In 2017, based upon Alioth Education, dollars adjusted for inflation equates to $18,141, 895,182.64 in direct costs for spinal-related conditions that fall within the chiropractic treatment category and have proven to outperform other forms of care. When considering outcome assessments for efficacy of chiropractic in a population-based study, both Cifuentes, Willets and Wasiak (2011) and Blanchette, Rivard, Dionne, Hogg-Johnson, and Steenstra (2017) offered evidence that the results are rooted in a “first healthcare provider” or “primary spine care” solution.
Cifuentes et al. (2011) compared different treatments of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability episode after a 15-day absence and return to disability. Anyone with less than a 15-day absence of disability was excluded from the study. Please note that we kept disability outcomes for all reported treatment and did not limit this to physical therapy. However, the statistic for physical therapy was significant.
According to the Cifuentes, Willets and Wasiak (2011) study, chiropractic care during the disability episode resulted in:
Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating, “After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (Cifuentes et al., 2011, p. 404).
Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) reported:
The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation. (p. 388)
Despite compelling evidence of chiropractic being the best option for primary spine care treatment of injuries related to disabilities and pain based upon outcomes, the reasons why chiropractic works have been elusive. Despite the lack of literature-based evidence, answers are still being sought because positive results are consistently being realized in clinical chiropractic practices. When Keating et al. (2005) wrote an opinion or debate article, they concluded, “Subluxation syndrome is a legitimate, potentially testable, theoretical construct for which there is little experimental evidence” (p. 13).
This statement is one of the most unifying statements that could serve to reduce pain and opiate utilization, prevent premature degeneration and increase bio-neuromechanical function for our society, while significantly increasing our utilization because chiropractic is part of the answer. However, the simple question is, “Why aren’t we doing this specific research because the pieces of what is considered subluxation have been verified in the literature for quite some time?”
VSC starts with spinal biomechanics and when considering a pathological model, we need to define the normal functioning of the spine.
Panjabi (2006) reported:
The spinal column, consisting of ligaments (spinal ligaments, discs annulus and facet capsules) and vertebrae, is one of the three subsystems of the spinal stabilizing system. The other two are the spinal muscles and neuromuscular control unit. The spinal column has two functions: structural and transducer. The structural function provides stiffness to the spine. The transducer function provides the information needed to precisely characterize the spinal posture, vertebral motions, spinal loads etc. to the neuromuscular control unit via innumerable mechanoreceptors present in the spinal column ligaments, facet capsules and the disc annulus. These mechanical transducers provide information to the neuromuscular control unit which helps to generate muscular spinal stability via the spinal muscle system and neuromuscular control unit. The criterion used by the neuromuscular unit is hypothesized to be the need for adequate and overall mechanical stability of the spine. If the structural function is compromised, due to injury or degeneration, then the muscular stability is increased to compensate the loss. (p. 669)
Panjabi (2003) also reported:
It has been conceptualized that the overall mechanical stability of the spinal column, especially in dynamic conditions and under heavy loads, is provided by the spinal column and the precisely coordinated surrounding muscles. As a result, the spinal stabilizing system of the spine was conceptualized by Panjabi to consist of three subsystems: spinal column providing intrinsic stability, spinal muscles, surrounding the spinal column, providing dynamic stability, and neural control unit evaluating and determining the requirements for stability and coordinating the muscle response. (p. 372)
In defining spinal clinical instability, Panjabi (1992) previously reported:
Clinical instability is defined as a significant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits so that there is no neurological dysfunction, no major deformity, and no incapacitating pain. (p. 394)
Anatomically, we are starting with the vertebrate and more specifically, the articular facets indicating that VSC is a “complex” and not a simple problem as the anatomical pathology occurs in opposing facets. When looking at normal vertebral structures,
Cervical spine meniscoids, also referred to as synovial folds or intra-articular inclusions, are folds of synovium that extend between the articular surfaces of the joints of the cervical spine. These structures have been identified within cervical zygapophyseal, lateral atlantoaxial and atlanto-occipital joints, and have been hypothesised to be of clinical significance in neck pain through their mechanical impingement or displacement, as a result of fibrotic changes, or via injury as a result of trauma to the cervical spine. (p. 939)
An understanding of the basic structure of meniscoids is necessary to assess their potential role in cervical spine pathology. As described above, cervical spine meniscoids are folds of synovium that protrude into a joint from its margins. Meniscoids lie between the articular surfaces at the ventral and dorsal poles of their enclosing joint. Their basic structure includes a base, which attaches to the joint capsule, a middle region and an apex that protrudes approximately 1–5 mm into the joint cavity. In sagittal cross section, these structures are triangular in shape, and when viewed superiorly they often appear crescent-shaped or semi-circular. Cervical spine meniscoids are thought to function to improve the congruence of articular structures, and to ensure the lubrication of articular surfaces with synovial fluid. (p. 940)
Should these synovial folds or “plicas” become trapped or “pinched” as described by Evans (2002), it would be the beginning of a “negative neurological cascade.”
Evans (2002) reported:
Intra-articular formations have been identified throughout the vertebral column. Giles and Taylor demonstrated by light and transmission electron microscopy the presence of nerve fibers (0.6 to 1 mm in diameter) coursing through synovial folds, remote from blood vessels, that were most likely nociceptive. They concluded, “Should the synovial folds become pinched between the articulating facet surfaces of the zygapophyseal joint, the small nerves demonstrated in this study may have clinical importance as a source of low back pain.” (p. 252)
Figure 1: Images of meniscoid entrapment on flexion, on attempted extension, involving flexion and gapping and realigned.
Evans (2002) explained the images above as follows:
Meniscoid entrapment. 1) On flexion, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with It. 2) On attempted extension, the inferior articular process returns toward its neutral position, but instead of re-entering the joint cavity, the meniscoid impacts against the edge of the articular cartilage and buckles, forming a space-occupying "lesion" under the capsule. Pain occurs as a result of capsular tension, and extension is inhibited. 3) Manipulation of the joint involving flexion and gapping, reduces the impaction and opens the joint to encourage re-entry of the meniscoid into the joint space (4) [Realignment of the joint.] (p. 253)
Evans (2002) continued:
Bogduk and Jull reviewed the likelihood of intra-articular entrapments within zygapophyseal joints as potential sources of pain…Fibro-adipose meniscoids have also been identified as structures capable of creating a painful situation. Bogduk and Jull reviewed the possible role of fibro-adipose meniscoids causing pain purely by creating a tractioning effect on the zygapophyseal joint capsule, again after intra-articular pinching of tissue(p. 252)
Evans (2002) also noted:
A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophyseal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent impaction of the meniscoid. The patient would tend to be more comfortable with the spine maintained in a flexed position, because this will disengage the meniscoid. Extension would therefore tend to be inhibited. This condition has also been termed a “joint lock” or “facet-lock,” the latter of which indicates the involvement of the zygapophyseal joint…
An HVLAT manipulation [chiropractic spinal adjustment CSA], involving gapping of the zygapophyseal joint, reduces the impaction and opens the joint, so encouraging the meniscoid to return to its normal anatomic position in the joint cavity. This ceases the distension of the joint capsule, thus reducing pain. (p. 252-253)
When considering VSC in its entirety, we must consider the etiology as these forces can lead to complex patho-biomechanical components of the spine and supporting tissues. As a result, a neurological cascade can ensue that would further define VSC beyond the inter-articulation entrapments. Panjabi (2006) reported:
Abnormal mechanics of the spinal column has been hypothesized to lead to back pain via nociceptive sensors. The path from abnormal mechanics to nociceptive sensation may go via inflammation, biochemical and nutritional changes, immunological factors, and changes in the structure and material of the endplates and discs, and neural structures, such as nerve ingrowth into diseased intervertebral disc. The abnormal mechanics of the spine may be due to degenerative changes of the spinal column and/or injury of the ligaments. Most likely, the initiating event is some kind of trauma involving the spine. It may be a single trauma due to an accident or microtrauma caused by repetitive motion over a long time. It is also possible that spinal muscles will fire in an uncoordinated way in response to sudden fear of injury, such as when one misjudges the depth of a step. All these events may cause spinal ligament injury. (p.668-669).
Panjabi (2006) goes on to explain what happens when the spinal column is affected by trauma:
The structural function provides stiffness to the spine. The transducer function provides the information needed to precisely characterize the spinal posture, vertebral motions, spinal loads etc. to the neuromuscular control unit via innumerable mechanoreceptors present in the spinal column ligaments, facet capsules and the disc annulus. These mechanical transducers provide information to the neuromuscular control unit which helps to generate muscular spinal stability via the spinal muscle system and neuromuscular control unit. The criterion used by the neuromuscular unit is hypothesized to be the need for adequate and overall mechanical stability of the spine. If the structural function is compromised, due to injury or degeneration, then the muscular stability is increased to compensate the loss. What happens if the transducer function of the ligaments of the spinal column is compromised? This has not been explored. There is evidence from animal studies that the stimulation of the ligaments of the spine (disc and facets, and ligaments) results in spinal muscle firing. (p. 669).
Panjabi (2006) described the mechanism that, coupled with the inter-articulation nociceptor “firing,” further defines the “negative neurological cascade”:
The hypothesis consists of the following sequential steps:
One hallmark of determining vertebral subluxation complex for the chiropractic profession has been ranges of motion of individual motor units. Both hypo- and hypermobility have been clinically associated with muscle spasticity and have offered a piece of clinical history in the practice setting. NOTE: Ranges of motion, like any other findings, are no more than pieces of evidence, all of which must clinically correlate.
Radziminska, Weber-Rajek, Srączyńska and Zukow (2017) reported:
The definition of the neutral zone explains that it as a small range of motion near the zero position of the joint, where no proprioreceptors are stimulated around the joint and osteoligamentous resistance is minimal (lack of centripetal response and, consequently, lack of central muscle stimulation).
Increasing the range of motion of the neutral zone is detrimental to the joint - it can lead to its damage. Delayed proprioceptive information about the current joint position that reaches the central system will give a muscle tone response, but it may turn out to be incompatible with external force acting on the joint. The reduced range of motion of the neutral zone is also unfavorable. If the stimulation of proprioreceptors is too early it will result in an increased muscle tension around the joint. The neutral zone is disturbed by traumas, degenerative processes, and muscle stabilization weakness. (p. 72)
With VSC, the joint that has been misplaced creates abnormal biomechanics and abnormal pressure to the joint. This is called Wolff’s Law, formulated and accepted since the 1800’s, and is explained by Kohata, Itoha, Horiuchia, Yoshiokab and Yamashita (2017):
When mechanical stress is impressed upon bone, an electrical potential is induced; the area of bone under compression develops negative potential, whereas that under tension develops positive potential. This phenomenon is generated by collagen piezoelectricity, and the electrical potential generated in bone by collagen displacement has been well documented. (p. 65)
VSC is based upon both the macro- and microtrauma induced motor unit pathology, creating interarticular meniscoid nociceptor entrapment that triggers nociceptors and affects the lateral horn for a local reflex. It then innervates the thalamus through the spinothalamic tracts and periaqueductal grey matter which is then further distributed to various cortical regions to process in the body’s attempt to compensate biomechanically. This, coupled with aberrant motor unit ranges of motion (hypo or hyper), subfailure injuries to the ligaments and the corrupted mechanoreceptors and nociceptor messages that innervate the lateral horn cause a “negative neurological cascade” both reflexively at the cord and the brain. This cascade can cause pain and inflammation and will cause premature degeneration if left uncorrected based upon Wolff’s Law because of improper motor unit biomechanical failure. Should the correction be made after remodelling of the vertebrate, then care changes from corrective to management as the spine can never be perfectly biomechanically balanced as the segments (building blocks for homeostasis) have been permanently remodelled.
The research for VSC exists in its components. However, there needs to be a concise research program that combines all the pieces to further conclude the evidence that exists. Furthermore, we need more conclusive answers as to why chiropractic patients get well, answers that goes beyond pain or aberrant curves.
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