CASE REPORT:  Conservative care and axial distraction therapy for the management of cervical and lumbar disc herniations and ligament laxity post motor vehicle collision.

By Josh Johnston, DC

Title: Conservative care and axial distraction therapy for the management of cervical and lumbar disc herniations and ligament laxity post motor vehicle collision.

Abstract:  This middle-aged female was injured in a vehicle collision causing her to sustain disc and additional ligament injuries in the cervical and lumbar spine.  Diagnostic studies included physical examination, orthopedic and neurological testing, lumbar MRI, multiple cervical MRI’s, CRMA with motion cervical radiographs and EMG studies.  Typically, conservative care is initiated prior to interventional procedures, and this case study seeks to explore the usage of passive therapy for mechanical spine pain and noted anatomic disc lesions after failure of interventional procedures.  She reported both short term and long term success regarding pain reduction along with improvement in her activities of daily living after initiating conservative care, and continued to report further reductions in pain with periodic pain management using conservative care.

Key Words: neck pain, low back pain, paresthesia, disc herniation, spinal cord indentation, CRMA, axial distraction therapy, DRX9000, spinal manipulative therapy, motor vehicle collision

Key: MRI (magnetic resonance imaging); EMG (electromyography study); CRMA (computerized radiographic mensuration analysis); CT (computerized topography); PTSD (Post-traumatic stress disorder); PRN (as needed); VAS (visual analog scale); HVLA (high velocity low amplitude).

Introduction:  The 49-year-old married female (Spanish speaking patient) reported that on March 4th, 2014 she was the seat-belted driver of a truck that was struck by a much larger fuel truck changing lines, hitting her vehicle at the front passenger side (far side, side impact).  The force of the impact caused her truck to be lifted up and the right wheel popped off.  Her head hit the window after impact and the spinal pain and complaints started approximately 24 hours later. Two days after the crash she went to the emergency department.  Occupant pictures were taken describing an out of position occupant injury. She did not report any additional significant trauma after the collision. 

Prior to her evaluation at our clinic, she utilized multiple providers for diagnosis and treatment over the course of 11 months.  She went to the emergency department, utilized 3 pain management medical doctors, neuropsychologist and a cognitive rehabilitation therapist.    Imaging included radiographs and MRI of the right shoulder revealing rotator cuff tear; radiographs of the lumbar and thoracic spine, and left hand; CT of the head and cervical spine were performed; MRI cervical (3) and lumbar spine.  Medications prescribed included Fentanyl, Percocet, Naprosyn, Cyclobenzaprine, Norco, Hydrocodone-acetaminophen, Soma, and Carisoprodol.  Physical therapy was provided for spinal injuries and she did not respond to treatment.  The neurosurgeon recommended epidural steroid injections and facet blocks.  Cervical nerve blocks and cervical trigger point injections, cervical and lumbar epidural steroid injections (ESI), lateral epicondyle steroid injections were performed, none of which were palliative.  Post-concussion disorder and PTSD with major depressive disorder were diagnosed.

On February 12th, 2015, she presented to our office with neck pain (average 6/10 VAS) that affected her vision, with paresthesia’s in both upper extremities radiating to the hands with numbness.  She had low back pain (average 6/10 VAS), and she additionally reported paresthesia at the plantar surface of feet bilaterally.  She had left elbow pain, right shoulder pain, knee pain, headaches and “anxiety” along with anterior sternal pain.

Her injuries were causing significant problems with her activities of daily living.  Summarily she had increased pain with lifting, increased pain and restricted movement with bending, walking and carrying.  She had been unable to perform any significant physical activity from the time of the crash in March 2014 until March 2015.  Her right hand was always hurting and her forearms.  She was not able to clean windows or do laundry, difficulty using stairs, problems with mopping, ironing and cleaning.  She had to limit her walking and jogging primarily due to neck pain and right arm pain.  She was not able to sit for long periods of time and sleeping was disrupted due to numbness in her hands.  She was only able to walk on a treadmill for 10 minutes before having to stop due to pain, prior to the crash she would exercise for an hour. 

Prior History: No significant prior musculoskeletal or contributory medical history was reported.

Clinical Findings (2/12/15):  She had a height of 5’2”, measured weight of 127 lbs.

Visual analysis of the cervical spine revealed pain in multiple ranges of motion including flexion, extension, bilateral rotation and bilateral side bending.  On extension pain was noted in the upper back, on rotation pain was noted in the posterior neck, and on lateral flexion pain was noted contralaterally.

Visual analysis of the lumbar spine revealed pain in the low back on all active ranges of motion, including flexion, extension and side bending, pain primarily at L5/S1.

Dual inclinometer testing was ordered based on visual active range of motion limitations with pain. 

Sensory testing was performed of the extremities, C5-T1 and L4-S1.  No neurological deficits other than right sided C5 hypoesthesia.  

Foraminal compression test produced pain in the cervical spine.  Foraminal distraction test caused an increase in pain in the neck.  Jackson’s test on the right produced pain bilaterally in the neck.  Straight leg raise bilaterally produced low back pain, double Straight leg raise produce pain at L5/S1 at 30 degrees.

Muscle testing of the upper extremities was tested at a 5/5 with the exception of deltoid bilaterally tested at a 4/5.  The patient’s deep tendon reflexes of the upper and lower extremities were tested including Triceps, Biceps, Brachioradialis, Patella, Achilles: all were tested at 2+ bilaterally, equal and reactive. No evidence of clonus of the feet and Hoffman’s test was unremarkable.

C3-C5 right sided segmental dysfunction was noted on palpation. T5-T12 spinous process tenderness on palpation. Low back pain on palpation, particularly L5/S1.

Imaging Results:

MRI Studies:

I reviewed the cervical MRI images taken May 2014 with the following conclusions (images attached):

  1. Dramatic reversal of the normal cervical curvature, apex C5/6.
  2. C5/6 herniation, indentation of the spinal cord anteriorly.  High signal posterior on STIR.
  3. Due to the angular kyphosis of the cervical spine and axial slices performed, C6/7 slices did not render a pure diagnostic image for disc disruption.

Fig. 1 (A) T2 Axial C5/6, 2 months post injury               Fig. 1 (B) Sag T2 C5/6

I reviewed cervical MRI images taken September 17th, 2014 approximately 6-months post injury, and rendered the following conclusions:

  1. Reversal of the normal cervical lordosis.
  2. C5/C6 herniation (extrusion type) with indentation of spinal cord, appropriate CSF noted posteriorly.

I reviewed the cervical MRI dated October 24th, 2015 (images attached):

  1. C4/5 herniation, extrusion type, left oriented into the lateral recess and neural canal causing moderate neural canal stenosis
  2. C5/C6 disc protrusion, anterior cord abutment, thecal sac involvement.
  3. C6/7 herniation with early spondylosis changes

Fig. 2 (A) 3D Axial C4/5, 19 months post injury                   Fig. 2 (B) Sag T2 C4/5

IMPRESSIONS: C4/5 herniation noted on 10/24/15 was not noted on prior images.  The patient reported no additional injury or symptoms between MRI studies, so it is postulated that initial slices revealed a false negative; or due to the severity of abnormal cervical biomechanics, it is possible that the C4/5 disc herniated between the pre/post MRI’s with no significant increase in symptomatology.  There was improvement at C5/6 related to disc abnormality and cord involvement (see below). 

Fig. 3 (A) 3D Axial C5/6, 19 months post injury    Fig. 3 (B) Sag T2 C5/6, 19 months post injury

 

Functional Radiographic Analysis (Computerized Radiograph Mensuration Analysis):

 

The cervical flexion/extension images were digitized February 2016 and interpreted by myself and Robert Peyster MD, CAQ Neuroradiology, revealing a loss of Angular Motion Segment Integrity at intersegment C6/C7 measured at 19.7 degrees (maximum allowed 11 degrees), indicating a 25% whole person impairment according to the AMA Evaluation of Permanent Impairment Guidelines 5th edition1.  CRMA provided from Spine Metrics, independent analysis.

Evidence of significant ligament injury causing functional subfailure was measured at C3/4 at 10.4 degrees and at C4/5 measuring 10.9 degrees regarding angular motion.  Abnormal paradoxical translation motion measured at C6/7 and C7/T1.

Functional Testing

  1. EMG of the upper extremity revealed bilateral C6 radiculopathy, December 16th, 2015. 
  2. Range of Motion Cervical Dual Inclinometry:          

      Initial Max       4 months later       % Improvement

Cervical                       Extension        44                    42                                -5%

                                    Flexion            40                    62                                55%

Cervical                       Left                 25                    41                                64%

Lateral flexion            Right               12                    26                                117%

Cervical                       Left                 46                    59                                28%

Rotation                      Right               43                    73                                70%

Conservative treatment rendered: A neurosurgical referral was made for assessment and surgical options.  Conservative care was initiated despite failure of other medical procedures since there is “further evidence that chiropractic is an effective treatment for chronic whiplash symptoms2-3.  The patient was placed on an initial care plan of 2-3x/week for 5 months, with a gap in passive care for 1 month.

  1. 39 cervical nonsurgical distraction/decompression visits utilizing DRX9000 therapy
  2. 23 chiropractic visits.  Instrument adjusting cervical spine was utilized with Arthrostim.  Non-rotatory HVLA (high velocity low amplitude) spinal adjustments were performed thoracic and lumbar spine, applied A-P.  No HVLA spinal adjustments to the cervical spine.

 

Prior to being placed at maximum medical improvement she had persistent low back symptoms, continued tingling in the fingertips and occasional neck pain at a 4/10, with her upper extremity paresthesia’s improved 50%.  She continued with pain management chiropractic care after MMI, approximately 1 visit every 3-4 weeks with axial distraction to the cervical and lumbar spine, chiropractic adjustments as needed (PRN).  2 years/9 months post collision, and 1 year/9 months after initiating conservative care at our clinic, she reports only slight (1-2/10 VAS) spinal complaints with her primary concern being a torn rotator cuff injury from the crash that still requires surgical intervention.  After initiating care at our clinic, no other interventional procedures were performed, although medication usage persisted.  Due to improvement in symptoms and functional status, spinal surgery was not considered. She still utilizes Aleve PRN, 1-2 tablets. No significant active spinal rehabilitation was utilized. The patient was given at home active care consisting only of cervical and lumbar stretches, walking, and ice to affected areas. 

Conclusion:While chiropractic care is safe even in the presence of herniations and radicular symptoms, “the likelihood of injury due to manipulation may be elevated in pathologically weakened tissues”4. Due to cord involvement, the provider decided to utilize low force procedures although HVLA spinal adjustments to the cervical spine could be considered safe due to lack of cord compression.  HVLA spinal adjustments A-P were utilized in the lumbar and thoracic spine not only for short term pain relief but also as part of managing the chronic low back pain secondary to ligament/disc damage.  While previously theorized to be only episodic, low back pain can be a lifelong condition requiring patients to seek ongoing care5.  This care can be active, passive, pharmaceutical, interventional, or conservative in nature, but ongoing pain management therapy is often required for permanent ligament conditions.  There is clear benefit to the patient population to be able to avoid surgical intervention due to risks, costs, ongoing prescription medication usage and adjacent level degeneration in the future6.  Avoiding opioid usage is also a high priority in today’s environment. 

Long term conservative care utilizing instrument spinal adjusting and targeted axial distraction therapy significantly reduced subjective reporting of pain, increased activities of daily living, and allowed the patient to avoid further spinal injections or surgical intervention.  Considering that various interventional procedures failed prior to conservative care, it is important that providers work in an interdisciplinary environment such that the safest, and in this case the most effective, therapies are utilized first to reduce risk to the patient and maximize benefit and reduce costs.

In this case study, the patient utilized multiple pain management physicians, cervical nerve blocks and epidural steroid injections, and was not directed to conservative care for 11 months post injury.  Utilizing chiropractic as conservative care would have enabled this patient to regain function and decrease pain while reducing costs and risks that are associated with medications and interventional procedures.

Competing Interest:  There are no competing interests in the writing of this case report.

De-Identification: All of the patient’s data has been removed from this case.

  1. Cocchiarella L., Anderson G. Guides to the Evaluation of Permanent Impairment, 5th Edition, Chicago IL, 2001 AMA Press.
  2. Khan S, Cook J, Gargan M, Bannister G. A symptomatic classification of whiplash injury and the implications for treatment. Journal of Orthopaedic Medicine 1999; 21(1):22-25.
  3. Woodward MN, Cook JCH, Gargan MF, Bannister GC. Chiropractic treatment of chronic whiplash injuries. Injury 1996;27: 643-645.
  4. Whedon J, Mackenzie T, Phillips R, Lurie J. Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-99 years. Spine, 2015; 40:264–270.
  5. Hestbaek L, Munck A, Hartvigsen L, Jarbol DE, Sondergaard J, Kongsted A: Low back pain in primary care: a description of 1250 patients with low back pain in Danish general and chiropractic practices. Int J Family Med, 2014.    
  6. Faldini C., Leonetti D., Nanni M. et al: Cervical disc herniation and cervical spondylosis surgically treated by Cloward procedure: a 10-year-minimum follow-up study.  Journal of Orthopaedics and Traumatology, June 2010. Volume 11, Issue 2,pp 99-103.

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Published in Case Reports

Efficacy of Chiropractic Care on Cervical Herniated Discs with Degenerative Changes in the Spine

 

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

William J. Owens DC, DAAMLP

A report on the scientific literature

 

INTRODUCTION

When studying chiropractic care in relationship to herniated discs and degeneration, we must first look carefully at each component to ensure that we are consistent with language to ensure a better understanding. There have been many reports in the literature on chiropractic care and its efficacy. However, the reporting is often “muddled” based upon interchangeable terminology utilized to describe what we do. The etiology of the verbiage being used has apparently been part of a movement to gain acceptance within the healthcare community, but this attempt for a change in view by the healthcare community has cost us. Currently, the scientific community has lumped together manipulation performed by physical therapists or osteopaths with chiropractic spinal adjustments because all three professions perform “hands on” manual therapy to the spine. For example, Martínez-Segura, De-la-LLave-Rincón, Ortega-Santiago, Cleland, and Fernández-de-Las-Peñas (2012) discussed how physical therapists commonly use manual therapy interventions directed at the cervical or thoracic spine, and the effectiveness of cervical and thoracic spine thrust manipulation for the management of patients with mechanical, insidious neck pain. Herein lies the root of the confusion when “manipulation” is utilized as a “one-size-fits-all” category of treatment as different professions has different training and procedures to deliver the manipulation, usually applying different treatment methods and realizing different results and goals.

 

 

In addition, as discussed by Sung, Kang, and Pickar (2004), the terms “mobilization,” “manipulation” and “adjustment” also are used interchangeably when describing manual therapy to the spine. Some manipulation and virtually all chiropractic adjusting “…involves a high velocity thrust of small amplitude performed at the limit of available movement. However, mobilization involves repetitive passive movement of varying amplitudes at low velocity” (Sung, Kang, & Picker, 2004, p. 115).

 

To offset confusion between chiropractic and any other profession that involves the performance of some type of manipulation, for the purpose of clarity, we will be referring to any type of spinal therapy performed by a chiropractor as a chiropractic spinal adjustment (CSA) and reserve manipulation for other professions who have not been trained in the delivery of CSA. Until now, the literature has not directly supported the mechanism of the CSA. However, it has supported each component and the supporting literature, herein, will define the neuro-biomechanical process of the CSA and resultant changes. 

HERNIATED DISCS

 

When considering disc issues, Fardone et. Al (2014) defined the nomenclature that has been widely accepted both in academia and clinically and should be adhered to, to ensure that reporting and visualizing pathology is consistent with the morphology visualized. In the past, this has been a significant issue as many have called a bulge a protrusion, a prolapse or herniation. In today’s literature Fardone’s document has resolved much of those problems.

 

Herniated Disc: “Herniated disc is the best general term to denote displacement of disc material. The term is appropriate to denote the general diagnostic category when referring to a specific disc and to be inclusive of various types of displacements when speaking of groups of discs. The term includes discs that may properly be characterized by more specific terms, such as ‘‘protruded disc’’ or ‘‘extruded disc.’’ The term ‘‘herniated disc,’’ as defined in this work, refers to localized displacement of nucleus, cartilage, fragmented apophyseal bone, or fragmented annular tissue beyond the intervertebral disc space. ‘‘Localized’’ is defined as less than 25% of the disc circumference. The disc space is defined, craniad and caudad, by the vertebral body end plates and, peripherally, by the edges of the vertebral ring apophyses, exclusive of the osteophyte formation. This definition was deemed more practical, especially for the interpretation of imaging studies, than a pathologic definition requiring identification of disc material forced out of normal position through an annular defect.” (page E1454)

 

SPINAL DEGENERATION

 

Spinal degenerating is typically associated with vertebral body endplate changes, or degeneration of the bones of the spine and it starts at the edges. These changes were classified by Michael Modic MD, Neuroradiologist in 1988 and were classified into 3 categories:

Viroslav (2016) reported:

On histopathologic section, type 1 changes are associated with fissuring of the endplates and infiltration of vascularized fibrous tissue. Increased osteoclasts, osteoblasts, and reactive woven bone are also found, indicating that type 1 changes are due to an inflammatory-type response. Type 2 changes occur due to conversion of red marrow to fatty marrow, and type 3 changes represent subchondral sclerosis…. later studies have shown that endplate changes can fluctuate between types, and some changes can regress completely. Mixed Modic endplate changes are commonly seen, and support the contention that all of the changes are manifestations of the same process at different stages. Modic changes can also regress following lumbar fusion. (http://radsource.us/vertebral-endplate-changes/)

 

In short, Modic changes are stages reflective of the process the vertebrate undergoes in degeneration. First there is inflammation, then the marrow changes to fat preventing nutrients to feed the bone, followed by sclerotic or degeneration of bone. In the context of this article, how are spinal herniations responding to chiropractic care in lieu of inherent degenerative changes.

 

CHIROPRACTIC CARE

Kressig et. Al (2016) reported:

Although patients who were Modic positive had higher baseline NDI (Neck Disability Index) scores, the proportion of these patients improved was higher for all time points up to 6 months. Pg. 565

The results of the present study on patients with CDH (Cervical Disc Herniation), which indicate better treatment outcomes for patients with CDH with MCs (Modic Changes), are generally consistent with those reported for patients with LDH (lumbar disc herniation), other than the fact that the patients with CDH and MC reported no relapses…It is also important to mention that none of the patients in the present study reported worsening of their condition. Cervical HVLA manipulation (chiropractic spinal adjustment) has been controversial, with suggestions that it can lead to vertebral artery dissection and stroke. However, in 2007, a prospective national survey by Thiel et al studied almost 20 000 patients who were treated with cervical HVLA manipulation or mechanically assisted thrust. There were no reports of serious adverse events, which were defined as symptoms with immediate onset after treatment and with persistent or significant disability. Pg. 572

 

CONCLUSION

 

This report on the literature verifies that chiropractic care renders significant improvement in patients with cervical disc herniation in the presence of inflammation and/or degenerative changes using an accepted disability index in a verifiable scenario. This, in conjunction with other numerous report on the efficacy of chiropractic successfully treating patients with herniated discs offers solutions to an injured public.

 

Links to other articles:

 

Chiropractic Outcome Studies on Treatment of Fragmented/Sequestered and Extruded Herniated Discs and Radicular Pain

 

Spinal Fusion vs. Chiropractic for Mechanical Spine Pain

 

Cervical Disc Herniation with Radiculopathy (Arm Pain): Chiropractic Care vs. Injection Therapy

 

Disc Herniations and Low Back Pain Post Chiropractic Care

 

References:

  1. Kressig, M., Peterson, C. K., McChurch, K., Schmid, C., Leemann, S., Anklin, B., & Humphreys, B. K. (2016). Relationship of Modic Changes, Disk Herniation Morphology, and Axial Location to Outcomes in Symptomatic Cervical Disk Herniation Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulation: A Prospective Study.Journal of manipulative and physiological therapeutics,39(8), 565-575.
  2. Martínez-Segura, R., De-la-LLave-Rincón, A. I., Ortega-Santiago, R., Cleland J. A., Fernández-de-Las-Peñas, C. (2012). Immediate changes in widespread pressure pain sensitivity, neck pain, and cervical range of motion after cervical or thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain: A randomized clinical trial. Journal of Orthopedics & Sports Physical Therapy, 42(9), 806-814.
  1. Sung, P. S., Kang, Y. M., & Pickar, J. G. (2004). Effect of spinal manipulation duration on low threshold mechanoreceptors in lumbar paraspinal muscles: A preliminary report. Spine, 30(1), 115-122.
  2. Viroslav A. (2016) Vertebral Endplate Changes, Retrieved from: http://radsource.us/vertebral-endplate-changes/
  1. Fardon, D. F., Williams, A. L., Dohring, E. J., Murtagh, F. R., Gabriel Rothman, S. L., & Sze, G. K. (2014). Lumbar disc nomenclature: Version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine, 39(24), E1448-E1465.

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Published in Neck Problems

Case Report:

The Assessment of Traumatic Cervical Spine Injury and Utilization of Advanced Imaging in a Chiropractic Office.

Vincent M. Simokovich, D.C., Donald A. Capoferri, D.C., DAAMLP, Mark Studin DC, FASBE(C), DAAPM, DAAMLP 

Abstract: the objective is to explore the standard of care regarding the assessment of cervical spine injuries in a setting of a chiropractic office.  Diagnostic studies include physical examination, range of motion studies, orthopedic testing and cervical spine. MRI.

Key words: radicular pain/complaints, adjustment, extrusion, subluxation, herniation, stenosis and spinal manipulation.

Introduction:  On January 30, 2017 a 49 year old female presented in my office to a second opinion examination at the request of her attorney.  She had been involved in a rear-end collision on 12/12/2015. (2) She was transported to a local hospital and arrived with complaints of headaches, disorientation, right-sided neck pain and right arm pain.  At the hospital emergency department CAT scan was taken of her brain, which proved to be negative. She received prescriptions of muscle relaxers and pain relievers and instructed to visit her primary care physician if her symptoms persisted.

She consulted a local Chiropractor on December 15, 2015.  The initial examination included the following from my review of the doctor’s notes: Presenting complaints were right-sided neck pain that radiates to the right arm.  The doctor’s records show a positive cervical compression test and a positive maximum cervical compression test.  Both produced pain bilaterally worse on the right.  Facet provocation tests were positive for facet disease.  Right side radicular pain pattern includes the trapezius and deltoid.  No x-ray studies were included in the doctor’s orders. The patient received 23 chiropractic treatments from 12/15/2015 through 4/5/2016 for a diagnosis of cervical sprain/strain.  The treatments consisted of spinal manipulation and a variety of soft tissue therapies.

Around January 15, 2017 I received a phone call from a local attorney regarding this patient and asking if I would do a second opinion examination on her due to persistent neck pain and right upper extremity pain.  The patient presented on January 30, 2017 for my evaluation.   My clinical findings are as follows:

Vitals:  Age 49, weight 170 lbs. height 5’ 8”, B.P 126/82, pulse 64, Resp. 16/min.

Appearance: in pain

Orthopedic/Range of motion: All cervical compression tests produced pain with radiation bilaterally worse on the right.  Range of motion studies revealed: 40 degrees of left rotation and 32 degrees of right rotation with radiating pain produced by both motions. 

Palpation: cervical spine palpation produced centralized spine pain that radiates to the right shoulder with numbness in the right arm and hand. 

The patient informed me during the examination that her pain made it difficult to sleep through the night.  If she was on her right side her right arm and hand would go numb immediately.  A big part of this patient’s life was riding and caring for her horse and she could not do either because it resulted in severe neck and arm pain.

My recommendation to her and her attorney was to obtain a cervical spine MRI with a 1.5 Tesla machine due to the high quality images it can produce. MRI is a highly sensitive tool to evaluation of neurologic tissue including the spinal cord and nerve roots. (1) I bypassed the x-ray at this time due to the clinical presentation and 12% of spinal cord with injuries having no radiographic abnormality. (3)

Imaging:

Figure 1: T2 Sagittal Cervical Spine MRI

Fig 2: T2 Axial Cervical Spine with Scout line through C3/4.

Radiology Report:  The report and the images demonstrated a right paracentral disc extrusion measuring 9 mm and extending 8 mm cranial/caudal causing abutment of the spinal cord. (Fig 1)(2) Additionally the diameter of the central canal was reduced to 8.1mm and projected into the right lateral recess resulting in severe stenosis of the right neural canal. (Fig 2)  Additional findings not pictured: C4/5 demonstrated a 2.5 mm bulging disc with facet hypertrophy with moderate stenosis of the left neural canal and severe stenosis of the right neural canal.  C5/6 demonstrated a 1.5 mm posterior subluxation narrowing the central canal to 9.1 mm with unconvertebral joint hypertrophy resulting in moderate right and severe left neural canal stenosis.  C6/7 revealed a broad based disc herniation worse on the left measuring 3.6 mm resulting in severe neural canal stenosis bilaterally complicated by unconvertebral joint hypertrophy. The MRI findings correlate with the patient’s clinical presentation.  (4)

Discussion: When the patient returned to a consultation on the MRI findings my recommendation was to consult a neurosurgeon. (3) Her attorney asked me if the treating doctor acted incompetently.  My only response was that I would have ordered the MRI immediately before treating the patient with manual manipulation.  The case is likely to go to trial and there is a good chance that I will be called in as an expert witness.  It is almost a guarantee that the defense attorney will ask me if I would have treated the patient for such a long period of time without an MRI or whether the treating doctor could have made the problem worse.  The failure to accurately determine a diagnosis may result in malpractice action or a board hearing or both for this treating doctor and I would have ordered the MRI immediately considering the radicular findings and symptoms.  After any myelopathic or significant radiculopathic symptoms a referral of advanced imaging needs to be performed in order to conclude and accurate diagnosis, prognosis and treatment plan prior to rendering care.  Diagnostic appropriateness in the case of traumatic injury or with any etiology with neurologic symptoms or findings necessitates following triage protocols.  In this case, an immediate 2-3mm MRI of the cervical spine is clinically indicated and proved integral to the safe care of this patient.

References:

1.         Haris, A.M., Vasu, C., Kanthila, M., Ravichandra, G., Acharya, K. D., & Hussain, M. M. 2016. Assessment of MRI as a modality for evaluation of soft tissue injuries of the spine as compared to intraoperative assessment. Journal of Clinical and Diagnostic Research, 10(3), TC01-TC05

2.         Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal cord injury, with special reference to the mechanisms involved in hyperextension injuries of cervical spine. J Neurosurg 1954; 11: 546–577.

3.         Tewari MK, Gifti DS, Singh P, Khosla VK, Mathuriya SN, Gupta SK et al. Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients. Surg Neurol 2005; 63:

204–209.

4.         Miyanji F, Furian J, Aarabi B, Arnold PM, Fehlings MG. Acute cervical traumatic spinal cord injury: MR imaging Findings correlated with neurologic outcome-prospective study with 100 consecutive patients. Radiology 2007; 243: 820–827.

           

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Published in Case Reports

Chiropractic’s Role in Decreasing Premature Death with Associated Back Pain

 

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

William J. Owens DC, DAAMLP

A report on the scientific literature      

 

In the United Kingdom, Field and Newell (2016) reported that back pain accounts for 4.8% of all social benefit claims with overall costs reaching $7 billion pounds or $9.35 billion US dollars. Boyles (2016) reported in the Feb. 13 issue of The Journal of the American Medical Association. After adjustment for inflation, total estimated medical costs associated with back and neck pain increased by 65% between 1997 and 2005, to about $86 billion a year… Yet during the same period, patients reported more disability from back and neck pain, including more depression and physical limitations. MD Lynx on Family Medicine reported “Nearly four million people in Australia suffer from low back pain and the total cost of treatment exceeds $1 billion a year.(https://www.mdlinx.com/family-medicine/top-medical-news/article/2017/03/08/7076443?utm_source=in-house&utm_medium=message&utm_campaign=mh-fm-march17)

 

When we consider mortality and the causes, most only attribute causality to the last diagnosis or pathology associated with the immediate cause of death. In recent literature, there have been studies studying the effects of long-term pain and all-causes of death inclusive of cancers and cardiovascular issues and are now considering these co-morbidities, rather than “stand-alone causes.”  

 

Docking et. Al (2015) reported:

 “This study confirmed previous findings regarding the relationship between pain and excess mortality. Further, we have shown that among older adults, this association is specific to disabling pain and to woman. Clinicians should be aware not only of the short-term implications of disabling back pain, but also the long-term effects.” (pg. 466)

 

 

The Family Medicine, MD Lynx reported on March 8, 2017:

New research from the Faculty of Health Sciences finds that older people with back pain have a 13 per cent higher chance of dying prematurely. The 600,000 older Australians who suffer from back pain have a 13 per cent increased risk of dying from any cause, University of Sydney research has found. Published in the European Journal of Pain, the study of 4390 Danish twins aged more than 70 years investigated whether spinal pain increased the rate of all–cause and disease–specific cardiovascular mortalityOur study found that compared to those without spinal pain, a person with spinal pain has a 13 per cent higher chance of dying every year. This is a significant finding as many people think that back pain is not life–threatening,” said senior author Associate Professor Paulo Ferreira, physiotherapy researcher from the University’s Faculty of Health Sciences.

 

The Family Medicine, MD Lynx also reported on March 8, 2017:

 “Medications are mostly ineffective, surgery usually does not offer a good outcome.”

 

It was reported byShaheed, Mahar, Williams, and McLachlin(2014) that out of the 4,336 studies they identified,concluded that,

“None of the trials evaluating [medical] advice or bed rest reported statistically and clinically important effects at any time point…The effects of advice on disability are similar to those for pain, with pooled results showing no clinical significant effect for the short and long-terms” (Shaheed, 2014, p. 5). “Pooled results from 2 studies on bed rest showed a statistically significant negative effect of bed rest in the immediate term…” (Shaheed et al., 2014,p. 10).

 

Shaheed et al. (2014) continued

 “There is no convincing evidence of effectiveness for any intervention available [with] OTC (over the counter drugs) or advice in the management of acute low back pain” (p. 11). The authors did report, “In the intermediate term, results from one of the studies involving referral to an allied HCP [health care provider] and reinforcement of key messages at follow-up visits showed significant effects in the intermediate and long-terms” (Shaheed et al., 2014, p. 12).

 

A 2005 study by DeVocht, Pickar, & Wilder concluded through objective electrodiagnostic studies (neurological testing) that 87% of chiropractic patients exhibited decreased muscle spasms. This study validates the reasoning behind the later study that people with severe muscle spasms in the low back respond well to chiropractic care and this prevents future problems and disabilities. It also dictates that care should not be delayed or ignored due to a risk of complications. The above statistic indicates that while medicine cannot conclude an accurate diagnosis in 85% of their back-pain patients, chiropractic has already helped 87% of the same population.

 

In a study by Leeman, Peterson, Schmid, Anklin, and Humphrys(2014), there is further successful evidence of the effects of mechanical back pain, both acute and chronic pain with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients. In this study, the acute onset patient (the patient’s pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one year marks following the onset of the original pain. Although one might argue that the patient would have gotten better with no treatment, it was reported that after two weeks of no treatment, only 36% of the patients felt better and at 12 weeks, up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to his/her normal life without pain, drugs or surgery.

 

Again, this is an environment where research has concluded that medicine has poor choices based upon outcomes for what they label “nonspecific low back pain.” The results indicate that chiropractic has defined this “nonspecific lesion” as a “bio-neuro-mechanical lesion” also known as the chiropractic vertebral subluxation and the evidence outlined on these pages, combined with the ever-growing body of outcome studies verify that medicine can reverse this epidemic by considering chiropractors as “primary spine care providers” or the first option for referral for everything spine short of fracture, tumor or infection.

 

The research is starting to show the far “reaching effects of chronic low back pain and the evidence has supported that chiropractic must take a lead role in the management of this population of patients. Based upon the evidence, anything short of that is a public health risk.

  

References:

  1. Field J., Newell D. (2016) Clinical Outcomes In a Large Cohort of Musculoskeletal Patients Undergoing Chiropractic Care In the United Kingdom: A Comparison of Self and National Health Service Referral Routes, Journal of Manipulative and Physiological Therapeutics, 39(1), pgs. 54-62
  2. Boyles S., $86 Billion Spent on Back, Neck Pain, WebMD (2016) Retrieved from:http://www.webmd.com/back-pain/news/20080212/86-billion-spent-on-back-neck-pain
  3.  Is Back Pain Killing Us? (2017) Retrieved from: https://www.mdlinx.com/family-medicine/top-medical-news/article/2017/03/08/7076443?utm_source=in-house&utm_medium=message&utm_campaign=mh-fm-march17
  4. Docking, R. E., Fleming, J., Brayne, C., Zhao, J., Macfarlane, G. J., & Jones, G. T. (2015). The relationship between back pain and mortality in older adults varies with disability and gender: Results from the Cambridge City over75s Cohort (CC75C) study.European Journal of Pain,19(4), 466-472.
  5. Abdel Shaheed, C., Mahar, C. G., Williams, K. A., & McLachlin, A. J. (2014). Interventions available over the counter and advice for acute low back pain: Systematic review and meta-analysis. The Journal of Pain,15(1), 2-15.
  6. DeVocht, J. W., Pickar, J. G., & Wilder, D. G. (2005). Spinal manipulation alters electromyographic activity of paraspinal muscles: A descriptive study. Journal of Manipulative and Physiologic Therapeutics, 28(7), 465-471.
  7. Leeman, S., Peterson, C., Schmid, C., Anklin, B., Humphrys, K. (2014). Outcomes of acute and chronic patients with magnetic resonance imaging-confirmed symptomatic lumbar disc herniations receiving high-velocity, low-amplitude, spinal manipulative therapy: A prospective observational cohort study with one year follow up. Journal (3), 155-163.

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Published in Low Back Problems

CASE REPORT: The chiropractic management of cervical Myelomalacia

By Timothy Weir, D.C., Mark Studin DC

Title:  The chiropractic management of cervical Myelomalacia

Abstract:  To examine the diagnosis and condition of a patient suffering from neck pain and radiation of pain into arms following a motor vehicle accident.   Diagnostic studies include the chiropractic orthopedic and neurological examination, digital x-rays, range of motion and cervical MRI.    

Keywords:  cervical spine pain, whiplash, myelomalacia, cervical disc degeneration, uncovertebral hypertrophy, spinal canal stenosis

Introduction:  On 10/10/2016, a 38-year-old male presented to our office for injuries he had sustained in an MVA on 10/01/2016.  The patient stated that he was stopped at an intersection when the pickup behind him hit him at a fast speed, pushing him through the intersection.  The patient stated that he had neck pain and stiffness the radiated into the trapezius area.  He also complained about “tingling” into both hands.  He also complained of lower back pain that he felt more than the neck.  His review of systems was benign, other than the current symptoms of neck and back pain and tingling.

The patients Social/Family Medical History included his mother having high blood pressure and Diabetes.

Clinical Findings:

The patient is 6’0”.   The patient weighs 211 pounds.   The sitting blood pressure measured was 122/74. 

An evaluation and management exam was performed.  The exam consisted of a visual inspection of the spinal ranges of motion, digital palpation, manual testing of muscles, deep tendon reflexes and orthopedic and neurological findings. The Cervical exam showed the following decreased motion on visual exam in flexion, extension, left rotation, right rotation, right lateral flexion and left lateral flexion.  All of the above motions produced pain.

When digital palpation was performed in the cervical and thoracic spinal areas, there was moderate spasm noted bilaterally in paraspinal areas with moderate tenderness noted.

In performing the cervical orthopedic and neurological testing, positive findings were present bilaterally with Foraminal Compression and Foraminal Decompression.  Soto Hall test was positive when performed in the thoracic spine area.  Manual, subjectively rated muscle testing was performed on certain muscles of the upper extremities.  Based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed. 2001, differences were noted using the rating scale of five to zero.  Five is full Range of Motion/Maximum Strength, Four is Full Range of motion with Moderate Resistance, Three is Full Range of Motion/Perceptible Weakness. The Deltoids and Triceps tested normally bilaterally at 5. The Biceps, forearm muscles and the intrinsic hand muscles all tested as a four on the right and a three on the left. 

Grip Strength tests the strength of the hands which indicate nerve integrity from the cervical spine.  In evaluation, the normal would be for a difference of strength in the preferred hand of 10% more.  More than that would be a weakness in the opposite hand, less than that would be a weakness in the preferred hand.   The preferred hand for this patient is the right hand.  The testing below shows a definite decrease in strength in the left hand.

Hand tested

Rep one

Rep two

Rep three

Right

28

30

30

Left

18

18

20

Deep Tendon Reflexes were performed on the patient and were noted at a plus two bilaterally.

Using a Whartenburg pinwheel, dermatomes showed normal findings except for C8, which was hyposensitive on the left.

A Lumbar orthopedic and neurological exam was then performed.  Upon visual examination, there was decreased motion in flexion, extension. right and left lateral flexion with pain present on all of the motions.

Lasegue’s Straight Leg Raising test was performed and  was negative with 80 degree movement. Braggards test was performed and was negative bilaterally. 

Kemps was done with the patient on both sides and was noted as negative.  Ely test was noted as negative.

Digital palpation was performed and there was severe tenderness and spasm bilaterally in the lumbar paraspinal muscles. 

Manual, subjectively rated muscle testing was performed on certain muscles of the lower extremities.  Based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed. 2001, differences were noted using the rating scale of five to zero.  Five is full Range of Motion/Maximum Strength, Four is Full Range of motion with Moderate Resistance, Three is Full Range of Motion/Perceptible Weakness.    Muscle testing was done bilaterally in the Quadriceps, Hamstrings, Calf Muscles and Extensor Hallicus Longus and showed Full ROM and Strength.

Deep Tendon Reflexes were performed.  They negative in the Achilles bilaterally, but +3 in the Patella bilaterally.

Based on the ortho/neuro findings and the history, the following x-rays were ordered:

AP/Lat/Flex/Ext/Bilateral Oblique’s/ APOM of the cervical spine, AP/Lat Thoracic

AP/Lat/Lateral Flexion/Oblique Lumbar’s.  The x-rays were read and the Lumbar spine showed the discs were of a normal height and Georges line was un-interrupted.  There the Lumbar curve appeared to be hypolordotic.  On visual inspection, there was a decrease in the lateral bending bilaterally.

The Cervical spine showed that there was anterior spurring present in the C5/6 region of the cervical spine.  In the lateral view, the normal curvature of the spine was no longer lordotic, but noted as a “Military Neck.”  There was decreased range of motion noted in the flexion as well as the extension views.  Also, noted on flexion and extension was paradoxical motion present at C1.  Disc spaces were normal throughout the spine, except for narrowing of the disc space at C5/6, as well as spurring noted in the anterior part of the vertebral body.

Due to the injuries, orthopedic and neurological and x-ray findings, a cervical MRI was ordered.  I recommended that the patient receive palliative therapy until a Cervical MRI could be obtained.  

The MRI was obtained and personally reviewed.  The Cervical MRI performed on 10/14/2016 revealed that C1/2 was unremarkable.  There was a mild disc bulge at C2/3 and a moderate disc bulge which abuts the ventral cord and results in mild spinal canal stenosis at C3/4.  There is also bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing noted at C3/4. At C4/5, There is a mild disc bulge which abuts the ventral cord.  There is a mild spinal canal stenosis.  There is a bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing.  At C5/6, There is a moderate disc bulge which indents the ventral cord and results in severe spinal canal stenosis.  There is a resultant T2 weighted hyperintense (high) signal abnormality in the spinal cord at this level.  This may represent edema or myelomalacia. C6/7 shows that there is a mild disc bulge which abuts the ventral cord and results in mild spinal canal stenosis.  There is bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing. C7/T1 presents as unremarkable.

IMPRESSION: At C5/6, there is a moderate disc bulge which indents the ventral cord and results in severe spine canal stenosis.  There is resultant abnormal signal in the spinal cord at C5/6, which may represent myelomalacia or edema.

An alert was placed on this study.  

Fig.1 (A)  Sagittal T2 MRI of Cervical Spine

         (B)   Axial T2 MRI of the Cervical Spine.

A

B

The patient was notified of the MRI findings.   The patient was informed that care would be discontinued until a consultation was done with a neurosurgeon.  The patient stated that he was going to do that.  He continued to try to get care, but we refused.  The patient was instructed to go to the emergency room.  The patient became angry stating that he wanted his records, that he was going to go to another chiropractor for them to “crack his neck”.   The patient went to another chiropractor and based on our records, also refused to see the patient.  The patient finally decided to go to the surgeon where disc surgery was performed to decompress the spinal cord. 

 

The patient contacted our office and thanked us for being so adamant about his treatment.  

 

DISCUSSION: 

There is much discussion in the MRI report concerning “bulges” and one must first have a handle on what is a bulge and herniation. 

General radiologists often utilize various nomenclature such as bulge, protrusion, prolapse, herniation and a myriad of other descriptors. However, the nomenclature has been standardized and accepted by the North American Spine Society, the American Spine Society of Radiology and the American Society of Radiology by Fardone, Williams, Dohring, Murtagh, Rothman and Sze (2014): 

 “Degeneration may include any or all of the following: desiccation, fibrosis, narrowing of the disc space, diffuse bulging of the annulusbeyond the disc space, fissuring (i.e. ., annular fissures), mucinous degeneration of the annulus, intradiscal gas, osteophytes of the vertebral apophyses, defects, inflammatory changes, and sclerosis of the endplates.” pg. 2528(1) 

 

“Bulging disc, bulge (noun [n]), bulge (verb [v]) (1) 

1. A disc in which the contour of the outer annulus extends, or appears to extend, in the horizontal (axial) plane beyond the edges of the disc space, usually greater than 25% (90°) of the circumference of the disc and usually less than 3 mm beyond the edges of the vertebral body apophysis. 

2. (Nonstandard) A disc in which the outer margin extends over a broad base beyond the edges of the disc space. 

3. (Nonstandard) Mild, diffuse, smooth displacement of disc. 

4. (Nonstandard) Any disc displacement at the discal level.

 

Note:Bulging is an observation of the contour of the outer disc and is not a specific diagnosis. Bulging has been variously ascribed to redundancy of the annulus, secondary to the loss of disc space height, ligamentous laxity, response to loading or angular motion, remodeling in response to adjacent pathology, unrecognized and atypical herniation, and illusion from volume averaging on CT axial images. Mild, symmetric, posterior disc bulging may be a normal finding at L5–S1. Bulging may or may not represent pathological change, physiological variant, or normalcy. Bulging is not a form of herniation; discs known to be herniated should be diagnosed as herniation or, when appropriate, as specific types of herniation.” Pg. 2537(1) 

 

Studin and Owens discuss this “nomenclature” in their article “Bulging Discs and Trauma: Causality and a Risk Factor”. 

“There is now, based upon the literature and well respected experts, categories of disc bulges that can be deemed as direct sequella from trauma vs. those cases where there is pre-existing degeneration.  It can also now be concluded, again based upon the literature that those patients can have an aggravation of the pre-existing condition that could persist a lifetime requiring perpetual care. To conclude these findings, a doctor trained in understanding the underlying pathology and sequella must be consulted to be able to render an accurate diagnosis that is demonstrable.”2 Pg. 26 

What is Myelomalacia?  According to the MedicoLexicon, it is simply the “softening of the spinal cord”.3  Basically, it is ischemia that takes place in the spinal cord from abnormal pressure placed upon it.  If left untreated, then that continues to spread and cause further damage to the cord.  Once the cord has been damaged, there is no repair.  gives us a concise definition and the ramifications of it left untreated: 

“The myelomalacia definition, strictly speaking is the “softening of the spinal cord”.  After an acute injury, bleeding of the spinal cord may occur.  As a result, there is “subsequent softening of normal tissues”.  Myelomalacia can be caused by trauma or disease, but if it worsens, and if the bleeding reaches the cervical region of the body, it can be fatal.  Bleeding can make the tissue necrotic.  Fractured vertebrae can lead to bleeding in the spinal cord, as can some back surgery.  Osteoporosis may also contribute to spinal instability and hemorrhaging.  Sometimes circulatory problems can lead to a deterioration of tissues and bleeding.  Myelomalacia can progress into impairment in the functioning of the lower extremities, below-normal or absent reflexes of the anus and pelvic limbs, loss of pain perception in the caudal region (near the coccyx), depression, respiratory problems due to “diaphragmatic paralysis”, and even neurological issues.  Death could result from the respiratory paralysis.  Damage occurs to the central nervous system.  At first, the spinal cord damage may be minor.  The most commonly injured areas are the lumbar spine (lower back) and cervical vertebrae (upper spine area). 

Disc degeneration, herniations (all variations) and bulging all describe what has happened to the disc itself.  Once you have established a definitive diagnosis, then the question becomes, how is the disc affecting surrounding neurological components?  Myelomalacia is the effect of that disc when the cord is affected by pressure.  If there is bleeding into the cord, then the cord begins a degenerative spiral that can happen rather quickly.  As you have read above, it can take what may simply appear as a minor issue to the patient that can lead to major neurological compromise and in extreme cases may lead to paralysis or death. Therefore, it is important carefully analyze the clinical indicators and image accordingly.      

Myelomalacia is a relatively rare occurrence.  According to Zhou, Kim, Vo and Riew, 

“The overall prevalence of cervical myelomalacia was relatively low in the studied population, and it was affected by age, sex, and the specialties/subspecialties of referring providers. These results may help direct treatment guidelines and allow for informed discussions with patients in terms of the risk versus the benefit of surgery.”Pg. E252

It is a very common occurrence for the presence of disc bulging and herniations in chiropractic practices.  It is of utmost importance for the chiropractor to not only order MRI when clinically indicated, it is important to be able to interpret those images as well.  Once the clinical indicators begin to show a different story than presented by the patient symptomatically, it is the responsibility of the chiropractor to make the appropriate diagnosis, prognosis and treatment plan.  In this case, that is an immediate neurosurgical referral.  Although not a common finding in a chiropractic office, one must still be alert to the possibility of Myelomalacia.   Managing the patient based upon an accurate diagnosis is your ultimate goal, and sometimes adjusting the patient isn’t the best first option as diagnosis and prognosis supersede treatment.

REFERENCES: 

  1. Fardon, D. F., Williams, A. L., Dohring, E. J., Murtagh, F. R., Gabriel Rothman, S. L., & Sze, G. K.
  2. Studin M., Owens W. (2016) Bulging Discs and Trauma: Causality and a Risk Factor, American Chiropractor 34(6) 18, 20,22-24, 26, 28
  3. http://www.medilexicon.com/dictionary/58294
  4. Carrelli, B (2016)  What is Myelomalacia?
  5. Zhou, Yihua; Kim, Sang D.; Vo, Katie; Riew, K. Daniel (2015) Prevalence of cervical myelomalacia in adult patients requiring a cervical magnetic resonance imagingSpine (Phila Pa 1976). 2015 Feb 15;40(4):E248-252. 

 

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Published in Case Reports

Chiropractic as the Solution for Mechanical Spine Failure and Failed Back Surgery.

By: William J. Owens DC, DAAMLP

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

 

A report on the scientific literature. 

 

The latest CDC statistics show that in 2012, 54 out of 100 people had self-reported musculoskeletal conditions.  By way of comparison, that is six times more than self-reported cases of cancer, double that of respiratory disease and one-third more than circulatory disorders.  If we extrapolate that to a more current population in the United States of 321 million, that equates to 173 million people reporting musculoskeletal problems in 2012.  Many of these are spine patients who suffer long-term without any type of biomechanical assessment or functional case management. 

In 2013, Itz, Geurts, van Kleef, and Nelemans reported, “Non-specific low back pain [LBP] is a relatively common and recurrent condition with major medical and economic implications for which today there is no effective cure” (p. 5).  The idea that spinal pain has a “natural history” resulting in a true resolution of symptoms is a myth and the concept that spine pain should only be treated in the acute phase for a few visits has no support in the literature.  We don’t address cardiovascular disease in this manner, i.e. wait until you have a heart attack to treat, we don’t follow this procedure with dentistry, i.e. wait until you need a root canal to treat, and we certainly don’t handle metabolic disorders such as diabetes in this way, i.e. wait until you have diabetic ulcers or advanced vascular disease to treat.  Why does healthcare fall short with spinal conditions in spite of the compelling literature that states the opposite in treatment outcomes?

The front lines of medical care for spine-related pain is typically the prescription of pain medication, particularly at the emergency care level, and then if that doesn’t work, a referral is made to physical therapy. If physical therapy is unsuccessful, the final referral is to a surgeon.  If the surgeon does not intervene with surgery, then the diagnosis becomes “non-specific back pain” and the patient is given stronger medication since there is nothing the surgeon can do.  In those surgical interventions that result in persistent pain, a commonly reported problem, there is an ICD-10 diagnosis for failed spine surgery, M96.1 

A recent article Ordia and Vaisman (2011) described this syndrome a bit further stating the following, “We propose that these terms [post laminectomy syndrome or failed back syndrome] should be replaced with Post-surgical Spine Syndrome (PSSS)” (p. 132).  They continued by reporting, “The incidence of PSSS may be reduced by a meticulous neurological examination and careful patient selection.  The facet and sacroiliac joints should always be examined, particularly when the pain is predominantly in the lower back, or when it radiates only to the thigh or groin and not below the knee” (Orida & Vaisman, 2011, p. 132). The authors finally stated, “Adherence to these simple guidelines can result in a significant reduction in the pain and suffering, as also the enormous financial cost of PSSS” (Orida & Vaisman, 2011, p. 132).  What they are referring to is a careful distinction between an “anatomical” versus a “biomechanical” cause of the spine pain. 

According to Mulholland (2008), “[Surgery] Spinal fusion became what has been termed the “gold standard” for the treatment of mechanical low back pain, yet there was no scientific basis for this” (p. 619). He continued, “However whilst that fusion [surgery] may be very effective in stopping movement, it was deficient in relation to load transfer” (Mulholland, 2008, p. 623). He concluded, “The concept of instability as a cause of back pain is a myth. The clinical results of any procedure that allows abnormal disc loading to continue are unpredictable” (Mulholland, 2008, p. 624).  Simply put, surgery does not correct the underlying biomechanical failure or the cause of the pain.

When a biomechanical assessment is lacking, the patient’s pain persists and allopathic medicine is focused on “managing the pain” vs. correcting the underlying biomechanical lesion/pathology/imbalance, the medication of choice at this point in care has been opioid analgesics.  Back in 2011, the CDC reported, “Sales of OPR quadrupled between 1999 and 2010. Enough OPR were prescribed last year [2010] to medicate every American adult with a standard pain treatment dose of 5 mg of hydrocodone (Vicodin and others) taken every 4 hours for a month” (p. 1489).  That was 6 years ago, which was when people began to feel that treating musculoskeletal pain with narcotics was trending in the wrong direction.  Now, in 2016, we can see there is a problem of epidemic proportions to the point that MDs are changing how they refer spine patients for diagnosis and treatment. 

Dowell, Haegerich, and Chou (2016), along with the CDC, published updated guidelines relating to the prescription of opioid medication:

Opioid pain medication use presents serious risks, including overdose and opioid use disorder. From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States. In the past decade, while the death rates for the top leading causes of death such as heart disease and cancer have decreased substantially, the death rate associated with opioid pain medication has increased markedly.

a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain and followed for up to 13 years revealed that one in 550 patients died from opioid-related overdose at a median of 2.6 years from their first opioid prescription, and one in 32 patients who escalated to opioid dosages >200 morphine milligram equivalents (MME) died from opioid-related overdose. (p. 2)

Clearly, there needs to be a nationwide standard for the process by which patients with spine pain are handled, including academic and clinical leadership on spinal biomechanics.  The only profession that is poised to accomplish such a task is chiropractic.

In a recent study by Houweling et al. (2015), the authors reported, “The purpose of this study was to identify differences in outcomes, patient satisfaction, and related health care costs in spinal, hip, and shoulder pain patients who initiated care with medical doctors (MDs) vs those who initiated care with doctors of chiropractic (DCs) in Switzerland” (p. 477).  This is an important study which continually demonstrates maintaining access to chiropractic care, for both acute and chronic pain is critical.  We can also see from current utilization statistics that chiropractic care is underutilized on a major scale.  The authors also state, “Although patients may be comanaged with other medical colleagues or paramedical providers (eg, physiotherapists), treatment for the same complaint may vary according to the type of first-contact provider. For instance, MDs tend to use medication, including analgesics, muscle relaxants, and anti-inflammatory agents, for the treatment of acute nonspecific spinal pain, whereas DCs favor spinal manipulative therapy as the primary treatment for this condition” (Houweling et al., 2015, p. 478).  The continue by stating “This study showed that spinal, hip, and shoulder pain patients had modestly higher pain relief and satisfaction with care at lower overall cost if they initiated care with DCs, when compared with those who initiated care with MDs” (Houweling et al., 2015, p. 480).  Overall, when taking cost into consideration, “Mean total spinal, hip, and shoulder pain-related health care costs per patient during the 4-month study period were approximately 40% lower in patients initially consulting DCs compared with those initially consulting MDs” (Houweling et al., 2015, p. 481).  The authors concluded, “The findings of this study support first-contact care provided by DCs as an alternative to first-contact care provided by MDs for a select number of musculoskeletal conditions” (Houweling et al., 2015, p. 481).

Bases on the literature and outcome studies, backed up with 121 years of doctors of chiropractic and their patients’ testimonies, the time has never been better for the chiropractic profession to move into treating the 93% of the population that is not under care. Chiropractic must be moved from the accepted standard of biomechanical processes in the laboratory to the standard of care for spine beyond fracture, tumor or infection across all professions, inclusive of physical therapy. The outcomes overwhelmingly support that anything less perpetuates the epidemic of failed back treatments.   

References

1. Centers for Disease Control and Prevention. (2015). National hospital discharge survey. Retrieved from: http://www.cdc.gov/nchs/nhds.htm

2. United States Census Bureau. (n.d.). Quick facts, United States. Retrieved from https://www.census.gov/quickfacts/

3. Itz, C. J., Geurts, J. W., van Kleef, M., & Nelemans, P. (2013). Clinical course of nonspecific low back pain: A systematic review of prospective cohort studies set in primary care. European Journal of Pain, 17(1), 5-15.

4. Ordia, J., & Julien Vaisman. (2011). Post-surgical spine syndrome. Surgical Neurology International, 2, 132.

5. Mulholland, R. C. (2008). The myth of lumbar instability: The importance of abnormal loading as a cause of low back pain. European Spine Journal, 17(5), 619-625.

6. Centers for Disease Control and Prevention. (2011). Vital signs: Overdoses of prescription opioid pain relievers - United States, 1999--2008. Morbidity and Mortality Weekly Report, 60(43), 1487-1492.

7. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain - United States, 2016. JAMA, 315(15), 1624-1645.

8. Houweling, T. A., Braga, A. V., Hausheer, T., Vogelsang, M., Peterson, C., & Humphreys, B. K. (2015). First-contact care with a medical vs chiropractic provider after consultation with a swiss telemedicine provider: Comparison of outcomes, patient satisfaction, and health care costs in spinal, hip, and shoulder pain patients. Journal of Manipulative and Physiological Therapeutics, 38(7), 477-483.

 

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Published in Low Back Problems

Chiropractic Outcome Studies on Treatment of Fragmented/Sequestered and Extruded Herniated Discs and Radicular Pain

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

William J. Owens DC, DAAMLP

 

 

Citation: Studin M., Owens W. (2016) Chiropractic Outcomes on Fragmented/Sequestered and Extruded Discs and Radicular Pain, American Chiropractor, 34 (11) 26, 28, 30, 32-33

 

Research Review:

 

Disc herniations are a common diagnostic entity in chiropractic practices with varied etiologies ranging from auto accidents to sports injuries to slips and falls and any other type of trauma that can cause the disc to tear. Treatment has varied from doing nothing to conservative care to opiates and the surgery and in the recent past, opiates and surgery have been the treatment of choice leaving a population of too many addicts and too often failed surgeries. This is not to suggest that all surgeries or opiates are unnecessary, but if drugs and/or surgery can be avoided it is an obvious choice.

 

 

When considering disc issues, Fardone et. Al (2014) defined the nomenclature that has been widely accepted both in academia and clinically and should be adhered to, to ensure that reporting and visualizing pathology is consistent with the morphology visualized. In the past, this has been a significant issue as many have called a bulge a protrusion, a prolapse or herniation. In today’s literature Fardone’s document has resolved much of those problems.

 

Herniated Disc: “Herniated disc is the best general term to denote displacement of disc material. The term is appropriate to denote the general diagnostic category when referring to a specific disc and to be inclusive of various types of displacements when speaking of groups of discs. The term includes discs that may properly be characterized by more specific terms, such as ‘‘protruded disc’’ or ‘‘extruded disc.’’ The term ‘‘herniated disc,’’ as defined in this work, refers to localized displacement of nucleus, cartilage, fragmented apophyseal bone, or fragmented annular tissue beyond the intervertebral disc space. ‘‘Localized’’ is defined as less than 25% of the disc circumference. The disc space is defined, craniad and caudad, by the vertebral body end plates and, peripherally, by the edges of the vertebral ring apophyses, exclusive of the osteophyte formation. This definition was deemed more practical, especially for the interpretation of imaging studies, than a pathologic definition requiring identification of disc material forced out of normal position through an annular defect.” (page E1454)

 

 

Protruded Disc: “Disc protrusions are focal or localized abnormalities of the disc margin that involve less than 25% of the disc circumference. A disc is ‘‘protruded’’ if the greatest dimension between the edges of the disc material presenting beyond the disc space is less than the distance between the edges of the base of that disc material that extends outside the disc space. The base is defined as the width of the disc material at the outer margin of the disc space of origin, where disc material displaced beyond the disc space is continuous with the disc material within the disc space. The term ‘‘protrusion’’ is only appropriate in describing herniated disc material, as discussed previously.” (page E1455)

 

Extruded Disc: “The term ‘‘extruded’’ is consistent with the lay language meaning of material forced from one domain to another through an aperture and with reference to a disc, the test of extrusion is the judgment that, in at least one plane, any one distance between the edges of the disc material beyond the disc space is greater than the distance between the edges of the base measured in the same plane or when no continuity exists between the disc material beyond the disc space and that within the disc space.” (page E1455)

 

Extruded Sequestered, Fragmented Disc or Migrated Disc: “Extruded disc material that has no continuity with the disc of origin may be characterized as ‘‘sequestrated.” A sequestrated disc is a subtype of ‘‘extruded disc’’ but, by definition, can never be a ‘‘protruded disc.’’ Extruded disc material that is displaced away from the site of extrusion, regardless of continuity with the disc, may be called ‘‘migrated,’’ a term that is useful for the interpretation of imaging studies because it is often impossible from images to know if continuity exists. (page E1455)

 

Bulging Disc: “The terms ‘‘bulge’’ or ‘‘bulging’’ refer to a generalized extension of disc tissue beyond the edges of the apophyses. Such bulging involves greater than 25% of the circumference of the disc and typically extends a relatively short distance, usually less than 3 mm, beyond the edges of the apophyses. ‘‘Bulge’’ or ‘‘bulging’’ describes a morphologic characteristic of various possible causes. Bulging is sometimes a normal variant (usually at L5–S1), can result from an advanced disc degeneration or from a vertebral body remodeling (as consequent to osteoporosis, trauma, or adjacent structure deformity), can occur with ligamentous laxity in response to loading or angular motion, can be an illusion caused by posterior central subligamentous disc protrusion, or can be an illusion from volume averaging (particularly with CT axial images).” (page E1455)

 

It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbertin (2010) that over 250,000 patients a year undergo elective lumbar discectomy (spinal surgery) for the treatment of low back disc issues in the United States. The researchers did a comparative randomized clinical study comparing spinal microdiscectomy (surgery) performed by neurosurgeons to non-operative manipulative treatments (chiropractic adjustments) performed by chiropractors. They compared quality of life and disabilities of the patients in the study. 

 

The study was limited to patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. Based upon the authors’ review of available MRI studies, the patients participating in the study were all initially considered surgical candidates. Both the surgical and chiropractic groups reported no new neurological problems and had only minor post-treatment soreness. 60% of the patients who underwent chiropractic care reported a successful outcome while 40% required surgery and of those 40%, all reported successful outcomes. This study concluded that 60% of the potential surgical candidates had positive outcomes utilizing chiropractic as the alternative to surgery.

 

Although the previous report concluded that a chiropractic spinal adjustment is an effective treatment modality for herniated disc a more recent study (Lehman ET. Al. (2014), further clarifies the improvement with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients.

 

In this study the acute onset patient (the pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one-year mark after the onset of the original complaint. Although one might argue that the patient would have gotten better with no treatment it was reported that after two weeks of no treatment only 36% of the patients felt better and at 12 weeks up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to their normal life without pain, drugs or surgery.

 

             Chiropractic Care and Herniated Discs with Leg Pain

2 Week Improvement

1 Month Improvement

3 Month Improvement

80.6%

84.6%

94.5%

 

In a prospective outcome study, Ehrler et. Al. (2016) studied outcomes of chiropractic care on both extruded and sequestered disc patients. They reported “The purpose of this study was to evaluate whether specific MRI features, specifically axial location and type (bulge, protrusion, extrusion, sequestration) of a herniated disc, are associated with the short and long term outcomes of patients treated with high-velocity, low-amplitude SMT specifically to the level of the symptomatic, MRI confirmed, herniation. This is the first study to address this question. Studies searching for predictors of improvement after treatment in previous low back pain patients did not target type and axial location of the herniated discs.Additionally, patients with disc sequestration were not excluded from this study.” (Page 196)

 

Ehrler et. Al. continued “Over 77% of patients with disc sequestration reported clinically relevant “improvement” compared to 66.7% of patients with extrusion. Although not statistically significant, 100% of patients with sequestration reported clinically relevant improvement at the 3-month data collection time point and at all data collection time points a higher proportion of patients with sequestration reported clinically relevant improvement. There were no significant differences for disc herniation location either by spinal level or in the axial plane for any of the data collection time points. This now calls into question the traditional thinking that disc sequestrations are more dangerous than herniations that remain attached to the parent disc and are more likely to require surgery. However, the studies reporting this did not consider chiropractic spinal manipulative therapy as a treatment option.” (page 197)

 

I would like to leave you with a last and seemingly unrelated statement.  I felt it was important to add this at the end since many of our critics negatively portray the safety of chiropractic care.  This statement shall put that to rest leaving only personal biases left standing. Whedon, Mackenzie, Phillips, and Lurie (2015) based their study on 6,669,603 subjects and after the unqualified subjects had been removed from the study, the total patient number accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified” (Whedon et al., 2015, p. 5). This study supersedes all the rhetoric about chiropractic and stroke and renders an outcome assessment to help guide the triage pattern of mechanical spine patients.

 

References:

  1. Fardon, D. F., Williams, A. L., Dohring, E. J., Murtagh, F. R., Gabriel Rothman, S. L., & Sze, G. K. (2014). Lumbar disc nomenclature: Version 2.0. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine, 39(24), E1448-E1465.
  1. Leeman S., Peterson C., Schmid C., Anklin B., Humphryes B., (2014) Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging-Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One-Year Follow Up, Journal of Manipulative and Physiological Therapeutics, 37 (3) 155-163
  2. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiscectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33 (8) 576-584
  3. Ehrler M., Peterson C., Leeman S., Schmid C., Anklin B., Humphreys B. K., (2016) Symptomatic, MRI Confirmed, Lumbar Disc Herniations: A Comparison of Outcomes Depending on the Type and Anatomical Axial Location of the Hernia in Patients Treated with High-Velocity, Low-Amplitude Spinal Manipulation, Journal of Manipulative and Physiological Therapeutics, 39 (3) 192-199
  4. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270

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Published in Low Back Problems

Chiropractic vs. Physical Therapy

 in Treating Low Back Pain

with Spinal Adjustments vs. Exercise Rehabilitation

 

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

William J. Owens DC, DAAMLP

A report on the scientific literature

 

In the United Kingdom, Field and Newell (2016) reported that back pain accounts for 4.8% of all social benefit claims with overall costs reaching $7 billion pounds or $9.35 billion US dollars. Boyles (2016) reported that “Researchers from the University of Washington, Seattle, found that the nation's dramatic rise in expenditures for the diagnosis and treatment of back and neck problems has not led to expected improvements in patient health. Their study appears in the Feb. 13 issue of The Journal of the American Medical Association. After adjustment for inflation, total estimated medical costs associated with back and neck pain increased by 65% between 1997 and 2005, to about $86 billion a year… Yet during the same period, patients reported more disability from back and neck pain, including more depression and physical limitations.

 

“We did not observe improvements in health outcomes commensurate with the increasing costs over time," lead researcher Brook I. Martin, MPH, and colleagues wrote. "Spine problems may offer opportunities to reduce expenditures without associated worsening of clinical outcomes." (http://www.webmd.com/back-pain/news/20080212/86-billion-spent-on-back-neck-pain) Part of the explanation for the rise in cost of treatment of low back pain is the utilization of physical therapy by allopath’s (medical primary care providers and medical specialists) as the primary option for the treatment of low back pain vs. the literature verified better alternative of chiropractic based upon outcome studies.  

 

Through the years, both chiropractors and physical therapists have concurrently utilized exercise rehabilitation as a modality to treat low back pain. As a rule, the chiropractic profession has utilized exercise rehabilitation as an adjunct to the spinal adjustment where in physical therapy, it has been the main focus of the treatment plan. In addition, other passive modalities to mitigate pain, such as electrical stimulation and/or hydro/cryotherapy has been utilized as an adjunct to each professions main treatment. As a rule, exercise rehabilitation is a crucial adjunct to the treatment of low back disorders as it adds necessary motion to the joint and helps balance muscle tone required to create a biomechanically stabilized joint over time.

However, Ianuzzi and Khalsa (2005) wrote (pg. 674)

           

Facet joint capsule strain magnitudes during simulated high velocity low amplitude spinal manipulations were within the range of motion occurred during maximum physiological motions, indicating that the procedure is biomechanically safe and provide a stimulus that is likely sufficient to stimulate facet joint capsule neurons. However, physiological motions of the lumbar spine by themselves (e.g. Exercise) are generally ineffective in treating low back pain, suggesting that facet joint capsule strain magnitude alone would be insufficient in providing a novel stimulus for facet joint capsule afferents.

 

The high strain rates that occurred during spinal manipulation could provide a novel “yet biomechanically safe” stimulus for afferents innervating given facet joint capsule. Alternatively, during spinal manipulation, the relative magnitudes (patterns) of facet joint capsule strain was in a region of the lumbar spine may be unique, which could result in a novel pattern of facet joint capsule mechanoreceptor firing in the spinal region and subsequently a novel stimulus to the central nervous system.

 

Simply put, the facet joint capsules are comprised of ligaments where the mechanoreceptors are located. A spinal manipulation (chiropractic spinal adjustment) stimulates the neurons in the capsule where exercise (physiological motion) does not. In addition, it has been shown that chiropractic spinal adjustments are safe to the joint capsule and ligaments that comprise the capsule.

 

References:

 

  1. Field J., Newell D. (2016) Clinical Outcomes In a Large Cohort of Musculoskeletal Patients Undergoing Chiropractic Care In the United Kingdom: A Comparison of Self and National Health Service Referral Routes, Journal of Manipulative and Physiological Therapeutics, 39(1), pgs. 54-62
  2. Boyles S., $86 Billion Spent on Back, Neck Pain, WebMD (2016) Retrieved from:http://www.webmd.com/back-pain/news/20080212/86-billion-spent-on-back-neck-pain
  3. Ianuzzi A., Khalsa P. (2005) High Loading Rate During Spinal Manipulation Produces Unique Facet Joint Capsule Strain Patterns Compared With Axial Rotations, Journal of Manipulative and Physiological Therapeutics 28 (9), 673-687

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Published in Low Back Problems

Chiropractic vs. Medical Advice, Bed Rest, Natural History/Resolution and Over-the-Counter Drugs for Low Back Pain

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

William J. Owens DC, DAAMLP

A report on the scientific literature

 

Mechanical spine pain is any back pain excluding tumor or infection and has been called low back pain, chronic low back pain, acute low back pain and non-specific low back pain. This is a societal problem and according to Panjabi (2006) “…70-85% of the population in industrialized societies experience low back pain at least once in their lifetime... The total cost of low back pain has been estimated to exceed 50 billion dollars per year in the USA” (p. 668)” Low back pain is historically one of the most prevalent conditions successfully treated in chiropractic offices and still is being questioned in too many medical conversations in spite of the evidence. This lack of referrals to the chiropractic profession by too many medical providers has contributed to perpetuating this reversible epidemic. Day, Yeh Franko, Ramirez, and Krupat (2007) reported that only 26% of fourth year Harvard medical students had a cognitive mastery of physical medicine.

 

           Schmale (2005) reported:

 

Incoming interns at the University of Pennsylvania took an exam of musculoskeletal aptitude and competence, which was validated by a survey of more than 100 orthopaedic program chairpersons across the country. Eighty-two percent of students tested failed to show basic competency. Perhaps the poor knowledge base resulted from inadequate and disproportionately low numbers of hours devoted to musculoskeletal medicine education during the undergraduate medical school years. Less than 1⁄2 of 122 US medical schools require a preclinical course in musculoskeletal medicine, less than 1⁄4 require a clinical course, and nearly 1⁄2 have no required preclinical or clinical course. In Canadian medical schools, just more than 2% of curricular time is spent on musculoskeletal medicine, despite the fact that approximately 20% of primary care practice is devoted to the care of patients with musculoskeletal problems. Various authors have described shortcomings in medical student training in fracture care, arthritis and rheumatology, and basic physical examination of the musculoskeletal system. (p. 251).

 

With continued evidence of lack of musculoskeletal medicine and a subsequent deficiency of training in spine care, particularly of biomechanical (subluxation or bio-neuro-mechanical lesions) orientation, the question becomes, “Which profession has the educational basis, training and clinical competence to manage these cases?”  Let’s take a closer look at chiropractic education as a comparison.

 

Fundamental to the training of doctors of chiropractic, according to the American Chiropractic Association, is 4,200 hours (similar to medical doctors and osteopaths) and students receive a thorough knowledge of anatomy and physiology. As a result, all accredited doctors of chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. This material is so important to a chiropractic practice that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education, requires a curriculum which enables students to be “proficient in neuromusculoskeletal evaluation, treatment and management.” In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. As a result, students are afforded the opportunity to practice utilizing this basic science information for many hours prior to beginning clinical services in their internships.

 

It was reported by Shaheed, Mahar, Williams, and McLachlin (2014) that out of the 4,336 studies they identified, there was only 13 found to be relavent, leaving this an area that still needs more review. However, in the entire study it was concluded that, “None of the trials evaluating [medical] advice or bed rest reported statistically and clinically important effects at any time point…The effects of advice on disability are similar to those for pain, with pooled results showing no clinical significant effect for the short and long-terms” (Shaheed, 2014, p. 5). “Pooled results from 2 studies on bed rest showed a statistically significant negative effect of bed rest in the immediate term…” (Shaheed et al., 2014, p. 10).

 

Shaheed et al. (2014) concluded that “There is no convincing evidence of effectiveness for any intervention available [with] OTC (over the counter drugs) or advice in the management of acute low back pain” (p. 11). The authors did report, “In the intermediate term, results from one of the studies involving referral to an allied HCP [health care provider] and reinforcement of key messages at follow-up visits showed significant effects in the intermediate and long-terms” (Shaheed et al., 2014, p. 12).

 

A 2005 study by DeVocht, Pickar, & Wilder concluded through objective electrodiagnostic studies (neurological testing) that 87% of chiropractic patients exhibited decreased muscle spasms. This study validates the reasoning behind the later study that people with severe muscle spasms in the low back respond well to chiropractic care and this prevents future problems and disabilities. It also dictates that care should not be delayed or ignored due to a risk of complications. The above statistic indicates that while medicine cannot conclude an accurate diagnosis in 85% of their back pain patients, chiropractic has already helped 87% of the same population.

 

In a study by Leeman, Peterson, Schmid, Anklin, and Humphrys (2014), there is further successful evidence of the effects of mechanical back pain, both acute and chronic pain with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients. In this study, the acute onset patient (the patient’s pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one year marks following the onset of the original pain. Although one might argue that the patient would have gotten better with no treatment, it was reported that after two weeks of no treatment, only 36% of the patients felt better and at 12 weeks, up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to his/her normal life without pain, drugs or surgery.

 

Again, this is an environment where research has concluded that medicine has poor choices based upon outcomes for what they label “nonspecific low back pain.” The results indicate that chiropractic has defined this “nonspecific lesion” as a “bio-neuro-mechanical lesion” also known as the chiropractic vertebral subluxation and the evidence outlined on these pages, combined with the ever growing body of outcome studies verify that medicine can reverse this epidemic by considering chiropractors as “primary spine care providers” or the first option for referral for everything spine short of fracture, tumor or infection.

 

References:

 

  1. Panjabi, M. M. (2006). A hypothesis of chronic back pain: Ligament subfailure injuries lead to muscle control dysfunction. European Spine Journal, 15(15), 668-676.
  2. Day, C. S., Yeh A. C., Franko, O., Ramirez, M., & Krupat, E. (2007). Musculoskeletal medicine: An assessment of the attitudes and knowledge of medical students at Harvard Medical School. Academic Medicine, 82(5), 452-457
  3. Chiropractic Education, American Chiropractic Association (2016) Retrieved from: http://www.acatoday.org/Patients/Why-Choose-Chiropractic/Chiropractic-Qualifications
  4. Abdel Shaheed, C., Mahar, C. G., Williams, K. A., & McLachlin, A. J. (2014). Interventions available over the counter and advice for acute low back pain: Systematic review and meta-analysis. The Journal of Pain, 15(1), 2-15.
  5. DeVocht, J. W., Pickar, J. G., & Wilder, D. G. (2005). Spinal manipulation alters electromyographic activity of paraspinal muscles: A descriptive study. Journal of Manipulative and Physiologic Therapeutics, 28(7), 465-471.
  6. Leeman, S., Peterson, C., Schmid, C., Anklin, B., Humphrys, K. (2014). Outcomes of acute and chronic patients with magnetic resonance imaging-confirmed symptomatic lumbar disc herniations receiving high-velocity, low-amplitude, spinal manipulative therapy: A prospective observational cohort study with one year follow up. Journal(3), 155-163.

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Published in Low Back Problems

Spinal Fusion vs. Chiropractic for Mechanical Spine Pain

 

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

William J. Owens DC, DAAMLP

 

A report on the scientific literature

 

As Chien and Bajwa (2008) pointed out, one of the most common maladies in our society today is back pain and 97% of the time, the pain is considered mechanical back pain. That is pain that arises from things other than fractures, tumors or infection and is one of the leading causes of visits to primary care medical doctors. Peterson, Bolton and Humphreys (2012), Baliki, Geha, Apkarian, and Chialvo (2008), and Apkarian et al. (2004) all agreed that at any given time, upwards of 10% of the population suffers from back pain and upwards of 80% of those back pain sufferers have chronic problems.  For pain to be considered chronic, it must persist for greater than 6 months.

 

Mulholland reported (2008)

The cause and hence the best treatment of “mechanical” low back pain remains unsolved, despite nearly a century of endeavour. It is now generally accepted that some form of failure of the intervertebral disc is central to causation. In the latter half of the twentieth century, failure of the disc leading to abnormal movement, popularly called instability, legitimised the use of fusion as treatment. However, the unpredictable results of fusion, which did not improve despite progressively more rigid methods of fusion cast doubts on the concept that back pain was movement related and that stopping movement was central to its treatment. (Pg. 619)

 

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. (Pg. 620)

However, whilst that fusion may be very effective in stopping movement, it was deficient in relation to load transfer. (pg. 623)

 

The reason load transfer is critical to normal spinal biomechanics (function) is one of remodelling and the prevention of premature and unnecessary advanced arthritic changes. Based upon Wolff’s Law, with abnormal load, the entire joint will remodel in the body’s innate goal of creating homeostasis from a structural perspective.

 

 

In support of the above consideration, Mulholland concluded:

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.

If it is accepted that load transfer disturbance is the central issue in mechanical back pain, then treatment can be directed to remedy this. Fusion will only do this if it reliably takes over the loading function of the disc. Movement preserving procedures such as “flexible stabilization” or an artificial disc are compatible with preserving motion but with an artificial disc bony integration between plate and vertebrae would appear to be essential, not just to stop movement, but to transfer load normally. (pg. 624)

 

 

It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbert in 2010 that approximately 250,000 patients annually undergo elective lumbar discectomy (spinal surgery) for the treatment of low back disc (mechanical spine) issues in the United States. The researchers did a comparative randomized clinical study comparing spinal microdiscectomy (surgery) performed by neurosurgeons to non-operative manipulative treatments (chiropractic adjustments) performed by chiropractors. They compared quality of life and disabilities of the patients in the study. 

The study was limited to patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. Based upon the authors’ review of available MRI studies, the patients participating in the study were all initially considered surgical candidates. Both the surgical and chiropractic groups reported no new neurological problems and had only minor post-treatment soreness. 60% of the patients who underwent chiropractic care reported a successful outcome while 40% required surgery and of those 40%, all reported successful outcomes. This study concluded that 60% of the potential surgical candidates had positive outcomes utilizing chiropractic as the alternative to surgery.

 

Although the previous report concluded that a chiropractic spinal adjustment is an effective treatment modality for mechanical spine pathology, a more recent study by Leemann et al. (2014), further clarifies the improvement with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients.

 

In this study, the acute onset patient (the pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one year marks following the onset of the original pain. Although one might argue that the patient would have gotten better with no treatment, it was reported that after two weeks of no treatment, only 36% of the patients felt better and at 12 weeks, up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to his/her normal life without pain, drugs or surgery.

 

Although the literature clearly indicates chiropractic as a superior choice for mechanical back pain for both disability and pain indicating function has normalized and that spinal fusion creates permanent abnormal load transfers leading to a higher risk of premature arthritis and spinal biomechanical failures, the consideration that was omitted in Mulholland’s paper was that of aberrant neurological sequella. The arbiter for surgery vs. chiropractic care that should be strongly considered is where the delay in surgery will possibly cause permanent neurological damage.

 

Clinically, regardless of the mechanical failure, (including, but not limited to disc extrusions both migrated and sequestered) and/or the presentation of exquisite pain, should the patient present with intact motor and sensory function upon examination, there is less consideration of adverse issues developing from chiropractic care that will take time in the rehabilitation process. However, if there is significant motor and/or sensory loss indicating compression or significant abutment of the cord or root, then delaying surgery can increase the risk of creating long-term neurological damage. In either scenario, while managing these types of patients, the chiropractor should consider co-managing with a spine surgeon who is versed in chiropractic care and contemporary literature that has objectified both treatment outcomes.

 

References:

  1. Chien, J., J., & Bajwa, Z. H. (2008). What is mechanical spine pain and how best to treat it? Current Pain and Headaches Report, 12(6), 406-411
  2. Baliki, M. N., Geha, P. Y., Apkarian, A. V., & Chialvo, D. R. (2008). Beyond feeling: Chronic pain hurts the brain, disrupting the default-mode network dynamics. Journal of Neurosciences,28(6) http://www.jneurosci.org/content/28/6/1398.full
  3. Apkarian, V., Sosa, Y., Sonty, S., Levy, R., Harden, N., Parrish, T., & Gitelman, D. (2004). Chronic back pain is associated with decreased prefrontal and thalamic gray matter density. The Journal of Neuroscience, 24(46), 10410-10415.
  4. Mulholland R. (2008) The myth of lumbar instability: the importance of abnormal loading as a cause of low back pain, European Spine Journal 17 (5) 619-625
  5. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. . Journal of Manipulative and Physiological Therapeutics, 33(8), 576-584.
  6. Leeman S., Peterson C., Schmid C., Anklin B., Humphrys K. (2014) Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging Confirmed Symptomatic Lumbar Disc Herniations Receiving High Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study with One Year Follow Up, Journal(3), 155-163.

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Published in Low Back Problems

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