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

Chiropractic Care Improves Senses and Reduces Risks of Falling in the Elderly Population

A report on the scientific literature

 

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

William J. Owens DC, DAAMLP

 

As our population ages, our most senior are being told that their heart diseases or cancers won’t be as likely to cause death as sequella from a fall. Therefore, doctors are urging that sect of population to rely more and more on canes, walkers and other devices to help offer greater support when balance issues become even slightly problematic. According to Holt et. Al (2016) “Falls account for more than 80% of injury related hospital admissions in people older than 65 years and they are the leading cause of injury related death in older adults. Approximately 30%-40% of community-dwelling older adults suffer from at least 1 fall per year.” (pg. 267)

 

Holt et. al. listed the following risks associated with falls

  1. Lower limb weakness
  2. Recent History of Falling
  3. Gait Deficits
  4. Deterioration of the sensorimotor system that occurs regularly with normal aging

 

The National Institute of Health (NIH) expanded the list of risk factors in older adults to include:

  1. Muscle weakness
  2. Balance and gait
  3. Blood pressure drops
  4. Postural hypotension
  5. Reflexes slower
  6. Foot problems
  7. Sensory problems
  8. Vision issues
  9. Confusion
  10. Medications

(http://nihseniorhealth.gov/falls/causesandriskfactors/01.html)

 

Comparatively speaking, both the Holt et. Al. and the NIH are in agreement that falling can be a multifactorial issue with often no single cause or solution. However, if an older person, who has one or more of the above risk factors can minimize those risks, the likelihood of falling can be decreased and potentially extend their life. Holt et. al. continued “There is however, a growing body of basic science evidence that suggests that chiropractic care may influence sensory and motor systems that potentially have an impact on some of the neuromuscular risk factors associated with falling.” (pg. 268) In short, the evidence has suggested that chiropractic can reduce the risk of falling in older adults.

 

Holt et. al. found that the mechanisms where chiropractic may influence sensorimotor functions are:

  1. Neuroplastic processes in the central nervous system through altered afferent input.
  2. Pain and altered cognition as a result with respect to attention focus and physical function
  3. Muscle strength and muscle activity patters
  4. Deterioration of the sensorimotor system that occurs regularly with normal aging

Looking at those neuroplastic processes or effects of chiropractic on the central nervous system, Gay et al. (2014) reported, “…pain-free volunteers processed thermal stimuli applied to the hand before and after thoracic spinal manipulation (a form of MT).  What they found was that after thoracic manipulation, several brain regions demonstrated a reduction in peak BOLD [blood-oxygen-level–dependent] activity. Those regions included the cingulate, insular, motor, amygdala and somatosensory cortices, and the PAG [periaqueductal gray regions]” (p. 615). In other words, thoracic adjustments produced direct and measureable effects on the central nervous system across multiple regions, which in the case of the responsible for the processing of emotion (cingulate cortex, aka limbic cortex) are regarding the insular cortex which also responsible for regulating emotion as well has homeostasis. The motor cortex is involved in the planning and execution of voluntary movements, the amygdala’s primary function is memory and decision making (also part of the limbic system), the somatosensory cortex is involved in processing the sense of touch (remember the homunculus) and, finally, the periaqueductal gray is responsible for descending pain modulation (the brain regulating the processing of painful stimuli).

 

This is a major step in showing the global effects of the chiropractic adjustment, particularly those that have been observed clinically, but not reproduced in large studies.  “The purpose of this study was to investigate the changes in FC [functional changes] between brain regions that process and modulate the pain experience after MT [manual therapy]. The primary outcome was to measure the immediate change in FC across brain regions involved in processing and modulating the pain experience and identify if there were reductions in experimentally induced myalgia and changes in local and remote pressure pain sensitivity” (Gay et al., 2014, p. 615). 

 

Coronado et al. (2012) reported that, “Reductions in pain sensitivity, or hypoalgesia, following SMT [spinal manipulative therapy or the chiropractic adjustment] may be indicative of a mechanism related to the modulation of afferent input or central nervous system processing of pain” (p. 752). “The authors theorized the observed effect related to modulation of pain primarily at the level of the spinal cord since (1) these changes were seen within lumbar innervated areas and not cervical innervated areas and (2) the findings were specific to a measure of pain sensitivity (temporal summation of pain), and no other measures of pain sensitivity, suggesting an effect related to attenuation of dorsal horn excitability and not a generalized change in pain sensitivity” (Coronado et al., 2012, p. 752).These findings indicate that a chiropractic spinal adjustment affects the dorsal horns at the root levels which are located in the central nervous system.  This is the beginning of the “big picture” since once we identify the mechanism by which we can positively influence the central nervous system, we can then study that process and its effects in much more depth.    

 

One of the main questions asked by Corando et al. (2012) “…was whether SMT (chiropractic adjustments) elicits a general response on pain sensitivity or whether the response is specific to the area where SMT is applied. For example, changes in pain sensitivity over the cervical facets following a cervical spine SMT would indicate a local and specific effect while changes in pain sensitivity in the lumbar facets following a cervical spine SMT would suggest a general effect. We observed a favorable change for increased PPT [pressure pain threshold] when measured at remote anatomical sites and a similar, but non-significant change at local anatomical sites. These findings lend support to a possible general effect of SMT beyond the effect expected at the local region of SMT application (p. 762).

 

The above mechanisms take the effects of chiropractic care out of the realm of theory and validates the processes through which chiropractic works based upon the scientific evidence (literature).

 

 

Holt et. Al found that outcomes measured for both sensorimotor and quality of life increased with chiropractic care. The primary outcomes of improvement choice stepping reaction time (CSRT)and sound-induced flash illusion. The CSRT involves feet placement in a timed scenario and sound-induced flash illusion involves multisensory processing to ascertain reaction to perceived illusions. Both have been significantly related to older populations and falling. Although the results of this study has its limitations, as many studies do. Holt concluded” The results of this trial indicated that aspects of sensorimotor integration and multisensory integration associated with fall risk improved in a group of community-dwelling older adults receiving chiropractic care. The chiropractic group also displayed small, statistically significant improvements in health-related quality of life related to physical health when compared with a “usual care” control. These results support previous research which suggests that chiropractic care may alter somatosensory processing and sensorimotor integration.” (pg. 277)  

 

As with many of our articles from here forward, 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. Holt K., Haavik H., Lee A., Murphy B., Elley C., (2016) Effectiveness of Chiropractic Care to Improve Sensorimotor Function Associated with Falls Risk in Older People: A Randomized Controlled Trial, Journal of Manipulative and Physiological Therapeutics, 39(4) 267-278
  2. Falls and Older Adults, Causes and Risk Factors (n.d.) National Institute of Health, retrieved from: http://nihseniorhealth.gov/falls/causesandriskfactors/01.html
  3. Gay, C. W., Robinson, M. E., George, S. Z., Perlstein, W. M., & Bishop, M. D. (2014). Immediate changes after manual therapy in resting-state functional connectivity as measured by functional magnetic resonance imaging in participants with induced low back pain.Journal of Manipulative and Physiological Therapeutics, 37(9), 614-627.
  4. Coronado, R. A., Gay, C. W., Bialosky, J. E., Carnaby, G. D., Bishop, M. D., & George, S. Z. (2012). Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis, Journal of Electromyography Kinesiology, 22(5), 752-767.
  1. 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 Neck Problems

Chiropractic Care for Neck and Low Back Pain: Evidenced Based Outcomes

 

98.5% of chiropractic patients had their expectations exceeded

 

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

William J. Owens DC, DAAMLP

A report on the scientific literature

 

As the scientific, academic and reimbursement establishments further entrench in an evidenced based model, it is critical to both examine and utilize studies when treating mechanical spine patients with chiropractic care. Although there are many sects in the chiropractic profession who shun the title “mechanical spine pain,” it is universally accepted term interprofessionally for any etiology of spine pain exclusive of tumor, fracture or infection. This definition fits every licensure board’s scope of practice for chiropractic where chiropractic is licensed. 

 

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 ofThe 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 moredepressionand 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)

 

Although it has been widely reported that expenditures a decade later has far exceeded the 2005 figure, the opioid epidemic, in part from musculoskeletal etiology is another example WebMD’s reporting on the American Medical Association’s finding of increased disability from neck and back pain inclusive of depression and physical limitations. The variable therefore is not predicated on financial expenditures, but treatment paradigms that work and have been verified in an evidenced based environment. 

 

Clinicians should always be striving to offer the best care at the lowest cost available. Carriers should always strive to fulfill their contractual obligation of providing necessary care delivered in a usual and customary manner while preventing overutilization through built-in safeguards. With doctors managing their patient’s conditions, there are two major parameters that are utilized, best medical practice also known as “experience” and evidence-based practice or that which has only been concluded in the medical literature. Both have a strong place in the healthcare delivery and reimbursement systems.  

"A best practiceis a method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark. In addition, a "best" practice can evolve to become better as improvements are discovered. These are procedures in healthcare that are taught in schools, internships and residencies and are considered the “standard” by which procedures are followed. These practices are based on clinical experience and rely heavily on time-tested approaches. Surprisingly, most of the best medical practice care paths are not published in the peer-reviewed indexed literature. This is due to many factors, but the most obvious are applications of financial resources to “new” discoveries and the simple fact that the clinical arena is adequate to monitor and adjust these practices in a timely manner for practice to keep up with the literature that follows. 

 

Evidence-based practice(EBP) is an interdisciplinary approach to clinical practice that has gained ground following its formal introduction in 1992. It started inmedicineasevidence-based medicine (EBM) and spread to other fields such as dentistry, nursing, psychology,

education, library and information science and other fields. Its basic principles are that all practical decisions made should 1) be based on research studies and 2) that these research studies are selected and interpreted according to some specific norms characteristic for EBP. Typically, such norms disregardtheoretical studiesandqualitative studiesand considerquantitative studiesaccording to a narrow set of criteria of what counts as evidence.

 

 

"Evidence-based behavioral practice(EBBP) entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. This is done in a manner that is compatible with the environmental and organizational context. Evidence is comprised of research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses" (Evidence-Based Practice, http://en.wikipedia.org/wiki/Evidence-based_practice).

 

This highly-debated topic of evidence-based vs. best practice has valid issues on each side, but putting them together as a hybrid would allow them to thrive in both a healthcare delivery and reimbursement system; all sides would win. This would allow advances in healthcare to save more lives, increase the quality of life and at the same time, offer enough safeguards to prevent abuse to payors. A one-sided approach would tip the scales to either the provider/patients or the payors.

Fields and Newell (2016) studied 2 groups of patients, those treated in private practices and the second in the United Kingdom’s funded National Health Service clinics. For this report, I will focus on the Government funded National Health Service statistics. The evidence sought was the satisfaction of patients with both neck and low back pain who underwent chiropractic care and in this report it satisfies both paradigms of “Best Practice and Evidenced Based Practice” models. They reported that 98.5% of neck and low back pain “patients were more likely to have had their expectations exceeded” (pg. 57) under chiropractic care.

 

 

In a healthcare environment, where overspending is both not the solution and problematic by creating iatrogenic issues in the form of opioid addiction and unresolved biomechanical failures leading to premature long-term musculoskeletal degenerative Fields and Newell have simply asked the patients, have your needs been met or exceeded. Not to diminish studies on the why or how come, patient satisfaction in an evidenced based outcome study that verifies it works with a drug-free option.

 

 

As with many of our articles from here forward, 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. 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. Best Practice. (2016). In Wikipedia. Retrieved from http://en.wikipedia.org/wiki/Best_practice
  4. Evidence-Based Practice. (2016). In Wikipedia. Retrieved from http://en.wikipedia.org/wiki/Evidence-based_practice
  5. 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 Neck Problems

Concussion:

Diagnosis-Testing-Chiropractic

“New testing is available using biomarkers”

 

Mark Studin, William J. Owens (2016)

 

Citation: Studin M., Owens W. (2016) Concussion: Diagnosis-Testing-Chiropractic “New Testing is Available Using Biomarkers”, American Chiropractor 34(7) 26, 28 -30

 

Concussion, also known as mild traumatic brain injury (mTBI) has been a poorly understood condition known to most healthcare providers as difficult to objectify and manage. It is understandable as historically there has been no definitive testing available to conclude an accurate diagnosis in a region that is imaging dependent. In the absence of objective imaging findings of bleeding in the brain, a diagnosis of “mild traumatic brain injury” has been affixed to the condition, whereas if there is evidence of traumatic bleeding the diagnosis “traumatic brain injury” is applied. Although Hartvigsen, Boyle, Cassidy and Carroll (2014) reported that 600 out of 100,000 Americans are affected every year by concussion, Jeter et al, (2012) reported that close to 40% of people experiencing a mild brain injury do not report it to their doctor, making accurate statistics very difficult to conclude. Despite potential under reporting in the population, we recognize concussion an issue that has significant negative consequences from both a clinical outcome and whole life perspective and we cannot afford to ignore this condition any longer.  

 

 

Mild traumatic brain injury or concussion results from transfer of mechanical energy from the outside environment to the brain from traumatic events where there is a sudden acceleration and then a sudden deceleration of the head and brain, such as in a Coup/Contrecoup injury during a whiplash scenario. In a Coup/Contrecoup event, the head is rapidly moving in one direction, but then suddenly changes direction. As the brain is freely moving to some degree as it is only surrounded by cerebral spinal fluid, the brain continues moving in the original direction and as the head “whips” rapidly in the opposite direction, the brain bounces off elements of the inner skull, which in turn is the catalyst for the brain to rebound shortly after the head changes direction. This is one easily defined mechanism of mTBI that does not cause gross bleeding, yet leaves the brain injured through direct compression or overstretching (axonal shearing) of central nervous system elements. 

 

 

Although this has been examined extensively in the military, it has been more recently investigated in professional sports, where after numerous lawsuits and lives ruined, there are now definitive “concussion protocols” in place. Part of those protocols as reported by the British Journal of Sports Medicine (2016) is the Sports Concussion Assessment Tool 2 or SCAT2 that has been adopted by numerous professional sports leagues. However, the majority of concussion victims are not active participants in the military or a professional sports team and many find their way into chiropractic practices as a result of similar sports injuries, car accidents, slip and falls and every other type of head trauma etiology. Although the mechanisms may vary, the traumatically induced end results are the same. 

 

 

Generalized patient intake protocols, based on both Medicare and academia standards, a questionnaire outlining a review of body systems is mandated, and part of those questions center on brain function. Therefore, as reported by Jeter et al neurological, cognitive and behavioral symptoms collectively referred to as post-concussion symptoms which are reported on standard patient intake questionnaires, require consideration of a diagnosis of concussion.  Prominent neurological symptoms of concussion include headache, vomiting, nausea, balance issues, vision, dizziness, fatigue, drowsiness, light or noise sensitivity and sleep disturbances. Cognitive symptoms include deficits in attention, concentration, memory, mental processing speed, and working memory or decision making. Common behavioral symptoms include anxiety, depression, irritability, aggression and depression. The researchers went on to report that approximately 25% of these cases can have these symptoms persist.

 

 

As a profession, chiropractic is a critical part of the rehabilitation for the concussion population as the post-traumatic patient typically presents to the average chiropractic practice. As chiropractors (along with all healthcare providers), if you combine the history with the above symptoms inclusive of neurological, cognitive and behavioral traits, you then have the direction or “triage road map” of how to conclusively differentially diagnose your patient, including what tests to consider conducting in order to do so. The first line of testing is to consider advanced imaging to rule out bleeding and ensure the patient does not need an immediate neurosurgical consultation. With the above set of signs and symptoms, treating blindly can put your patient at possible extreme risk.

 

 

Imaging of the brain necessitates either MRI or CAT scans, MRI being the more sensitive, and in the absence of bleeding, the diagnosis is limited to mTBI or concussion (used interchangeably). More recently, diffusion tensor imaging (DTI) has been a tool available to image mTBI victims that uses tissue water diffusion rates to determine bleeding at a very small level giving demonstrable evidence to brain injury. As reported by Soares, Marques, Alves, and Sousa, (2013), DTI has multiple issues to overcome to certify accuracy including, but not limited to, tissue type, integrity, barriers and quantitative diffusion rates that are required to infer molecular diffusion rates. Currently, DTI is a model based upon assumption with a very promising outlook as a reliable tool.

 

 

Historically, mTBI was exclusively diagnosed by an omission of advanced imaging findings and the presence and persistence of the neurology, cognitive and behavioral signs and symptoms. Today, brain-derived neurotrophic factors (BDNF) offer answers about post-traumatic brain pathology that is both conclusive and reproducible. According to Korley et al. (2015), brain-derived neurotrophic factors is a secreted autocrine (chemical hormone or messenger in blood) that promotes the development, maintenance, survival, differentiation and regeneration of neurons. BDNF also is important for synaptic plasticity (strengthening of synapses over time) and memory processing. Germane to mTBI and concussion, BDNF has been implicated in reducing secondary brain injury, with elevations providing neuro-protection and restoring connectivity traumatic brain injury.

 

 

Korley went on to report that BDNF levels were the highest in the normal group with lower values in mTBI and even lower in traumatic brain injury (TBI) subjects. In addition, very low BDNF values were associated with incomplete recovery of mTBI patients than moderate or severe TBI patients. As a result, it has been determined that BDNF has a higher prognostic value for identifying mTBI related sequelae at 6 months.

 

 

Korley et al. continued, BDNF is the most abundantly secreted brain neurotrophin and as a secreted protein and can be readily measured using well-established immune-assay techniques, identifying it as a non-necrosis brain injury biomarker. This distinguishes BDNF from other protein-based biomarkers that are structural components of neurons and myelin based proteins among other neurologic structures. In order for structural proteins to be found in high abundance in circulation, sufficient cellular necrosis and damage to the blood barrier membrane must be observed, however BDNF does not require cellular damage or necrosis to be observed in circulation allowing DDNF to be more abundant in circulation than structural proteins.

 

 

After a traumatic brain event, BDNF supports synaptic reorganization and restoration during the brain circuitry “reconnection” phase. Therefore, lowered BDNF values indicate a better prognosis. In patients with a co-morbidity of BDNF of anxiety, depressive disorders and schizophrenia low BDNF values on the day of injury predispose this population to incomplete recovery as a risk factor. Korley et al.  concluded that serum BDNF discriminates between mTBI and TBI cases with excellent diagnostic accuracy. Additionally, lowered BDNF values are associated with incomplete recovery and useful in identifying patients that are likely to retain symptoms   6-months post-trauma.

 

 

Simply put, a blood test could assist providers in concluding the presence and/or severity of traumatic brain injury or mild traumatic brain injury. The results afford an early diagnosis so that you can devise a treatment plan inclusive of altering activities of daily living to prevent further damage and maximize the repair process with minimizing further physical, chemical or emotional stressors.

 

 

Based upon interviews with leading neurologists and neurosurgeons who understand and have first-hand experience of both receiving chiropractic care and managing and treating mTBI patients, it is recommended that until the signs and symptoms of the neurologic, cognitive and behavioral abate that high-velocity rotational cervical adjustments be avoided to allow the brain to “repair and rewire” the connections without further possibilities of and Coup/ Contrecoup energy to the brain. This is a recommendation that we concur while recognizing that chiropractic care should not be avoided, just adapted to allow the brain to heal.

 

 

References:

 

1. Hartvigsen, J., Boyle, E., Cassidy, J. D., & Carroll, L. J. (2014). Mild traumatic brain injury after motor vehicle collision: What are the symptoms and who treats them? A population-based 1-year inception cohort study. Archives of Physical Medicine and Rehabilitation, 95(Suppl. 3), S286-S294.

2. Jeter, C. B., Hergenroeder, G. W., Hylin, M. J., Redell, J. B., Moore, A. N., & Dash, P. K. (2013). Biomarkers for the diagnosis and prognosis of mild traumatic brain injury/concussion. Journal of Neurotrauma, 30(8), 657-670.

3. British Journal of Sports Medicine. (2016). Sport concussion assessment tool 2. Retrieved from http://bjsm.bmj.com/content/43/Suppl_1/i85.full.pdf

4. Soares, J. M., Marques, P., Alves, V., & Sousa, N. (2013). A hitchhiker’s guide to diffusion tensor imaging. Frontiers in Neuroscience, 7(31), 1-14.

5. Korley, F. K., Diaz-Arrastia, R., Wu, A. H. B., Yue, J. K., Manley, G. T., Sair, H. I.,  Van Eyk, J., Everett, A. D., Okonkwo, D. O., Valadka, A. B., Gordon, W. A., Maas, A. I., Mukherjee, P., Yuh, E. L., Lingsma, H. F., Puccio, A. M., & Schnyer, D. M., (2015). Circulating brain-derived neurotrophic factor has diagnostic and prognostic value in traumatic brain injury. Journal of Neurotrauma, 32, 1-11.

 

Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport College of Chiropractic, an Adjunct Professor of Clinical Sciences at Texas Chiropractic College and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MRI spine interpretation, spinal biomechanical engineering and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www.DoctorsPIProgram.com), teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally and studies trends in healthcare on a national scale (www.TeachDoctors.com). He can be reached at DrMark@AcademyofChiropractic.com or at 631-786-4253.

 

Dr. Bill Owens is presently in private practice in Buffalo and Rochester NY and generates the majority of his new patient referrals directly from the primary care medical community.  He is an Associate Adjunct Professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences as well as the University of Bridgeport, College of Chiropractic and an Adjunct Professor of Clinical Sciences at Texas Chiropractic College.  He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at dr.owens@academyofchiropractic.com or www.mdreferralprogram.com or 716-228-3847  

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Fibromyalgia Improvement has been

Linked to Chiropractic Care

A report on the scientific literature 


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

William Owens DC, DAAMLP, CPC

According to the Mayo Clinic:

Fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Researchers believe that fibromyalgia amplifies painful sensations by affecting the way your brain processes pain signals. Symptoms sometimes begin after a physical trauma, surgery, infection or significant psychological stress. In other cases, symptoms gradually accumulate over time with no single triggering event. Women are much more likely to develop fibromyalgia than are men. Many people who have fibromyalgia also have tension headaches, temporomandibular joint (TMJ) disorders, irritable bowel syndrome, anxiety and depression. While there is no cure for fibromyalgia, a variety of medications can help control symptoms. Exercise, relaxation and stress-reduction measures also may help.

 

 

Symptoms Include:

 

  • Widespread pain. The pain associated with fibromyalgia often is described as a constant dull ache that has lasted for at least three months. To be considered widespread, the pain must occur on both sides of your body and above and below your waist.
  •  People with fibromyalgia often awaken tired, even though they report sleeping for long periods of time. Sleep is often disrupted by pain, and many patients with fibromyalgia have other sleep disorders, such as restless legs syndrome and sleep apnea.
  • Cognitive difficulties. A symptom commonly referred to as "fibro fog" impairs the ability to focus, pay attention and concentrate on mental tasks.
  • Other problems. Many people who have fibromyalgia also may experience depression, headaches, and pain or cramping in the lower abdomen.

(http://www.mayoclinic.org/diseases-conditions/fibromyalgia/basics/symptoms/con-20019243)

 

By Mayo Clinic’s own admission, medicine has no solution for fibromyalgia patients when they report that these case are to be managed and further report that the management includes pain medication, antidepressants, anti-seizure drugs and psychotherapy. None have a cure, but all (except the psychotherapy have side effects.

 

 

In order to fully understand the effects of the spinal adjustment on the function and potential disease processes, we must first understand there are three primary pathways by which the chiropractic adjustment effects the human body.  These are through biomechanics (local joint fixation and motion), pain management (organized and monitored through sensory input into the dorsal horn of the spinal cord to higher centers in the brain) and the autonomic systems (sympathetic and parasympathetic influences such as blood pressure changes through the endocrine system).

 

It has been well established, as reported by Studin, Owens, and Zolli (2015), that the chiropractic spinal adjustment has a direct and immediate effect on the central nervous system, outlined as part of the “pain management” pathway of the chiropractic spinal adjustment response. Research has shown that the chiropractic spinal adjustment affects the modulation of ascending and descending communication in the central nervous system within the dorsal horn. The adjustment then affects the thalamus and other areas of the brain and has a direct effect on gating pain in both directly treated and disparate regions as a result of the central nervous system connections.  There are ancillary effects within primitive centers of the brain that control anxiety, depression and chronic responses to pain. 

 

Kovanur Sampath, Mani, Cotter and Tumilty (2015) reported that the effects of spinal manipulation (chiropractic spinal adjustments) on various functions of the autonomic nervous system have been well identified in manual therapy literature. They reported “The common physiological mechanism proposed for these autonomic nervous system changes involves possible influence on segmental and extrasegmental reflexes with a prominent role given to the peripheral sympathetic nervous system” They concluded, “…cervical manipulation elicits a parasympathetic response and a thoracic/lumbar SM [spinal manipulation] elicits a sympathetic response” (Kovanur Sampath et al., 2015, p. 2).  

 

In summary, it is evident that spinal manipulation has an effect on the autonomic nervous system though the direction of effect may vary.  While we have spent years observing and studying the effects of the chiropractic spinal adjustment, there has never been an identified direct connection to the higher cortical areas until recently.  The literature, according to Kovanur Sampath et al. (2015), has concluded that there is a direct relationship between the autonomic system and the hypothalamus - pituitary – adrenal gland in chronic pain syndromes including autoimmune diseases such as fibromyalgia, and other maladies. Currently, research is finally linking the neuronal mechanisms involved in pain modulation to the chiropractic adjustment.

 

The key is utilizing the chiropractic spinal adjustment in balancing the autonomic nervous system and in turn helping to rectify the hypothalamus – pituitary – adrenal gland imbalance as a viable treatment modality. In conclusion, it is the neuro-endocrine pathway research that has the ability to bring chiropractic full circle into proving objectively and scientifically what we have observed for 120 years.  We can also never lose sight that these finding are just a beginning, requiring more research and more answers to help providers create more specific treatment plans an offer more options for patients suffering with fibromyalgia and other maladies.

 

As with all of our articles from here forward, 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. Fibromyalgia, Mayo Clinic (2016), Retrieved from: http://www.mayoclinic.org/diseases-conditions/fibromyalgia/basics/symptoms/con-20019243
  2. 2.Studin, M., Owens, W., Zolli, F. (2015).Chiropractic, chronic back pain and brain shrinkage: A better understanding of Alzheimer’s, dementia, schizophrenia, depression and cognitive disorders and chiropractic’s role, A literature review of the mechanisms. The American Chiropractor, 37
  3. Kovanur Sampath, K., Mani, R., Cotter, J. D, & Tumilty, S. (2015). Measurable changes in the neuro-endocrine mechanism following spinal manipulation]. Medical Hypothesis, 85, 819-824
  1. 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.

 

Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport College of Chiropractic, an Adjunct Professor of Clinical Sciences at Texas Chiropractic College and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MRI spine interpretation and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the legal community (www.DoctorsPIProgram.com), teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally and studies trends in healthcare on a national scale (www.TeachDoctors.com). He can be reached at DrMark@AcademyofChiropractic.com or at 631-786-4253.

Dr. Bill Owens is presently in private practice in Buffalo and Rochester NY and generates the majority of his new patient referrals directly from the primary care medical community.  He is an Associate Adjunct Professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences as well as the University of Bridgeport, College of Chiropractic and an Adjunct Professor of Clinical Sciences at Texas Chiropractic College.  He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at dr.owens@academyofchiropractic.com or www.mdreferralprogram.com or 716-228-3847  

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Published in Neck Problems

Case Report

 

Abatement of right leg radicular clinical signs and symptom in a 58-year-old male with advanced degenerative disc disease, disc bulging and grade II spondylolisthesis using a comprehensive approach to care including multiple modalities, non-surgical spinal decompression and chiropractic care.   

 

BY: Christopher Quigley DC, CCST

 

Abstract:  Objective:  To examine the diagnosis and care of a patient suffering from chronic low back pain with associated right leg pain and numbness.    Diagnostic studies include standing plain film radiographs, lumbar MRI without contrast, chiropractic analysis, range of motion, orthopedic and neurological examination.    Treatments include both manual and instrument assisted chiropractic adjustments, ice, heat, cold laser, Pettibon wobble chair and repetitive neck traction exercises and non-surgical spinal decompression.   The patient's’ outcome was very good with significant reduction in pain frequency, pain intensity and abatement of numbness in foot.  

 

Keywords:  degenerative disc disease, spondylolisthesis, chiropractic adjustment, Pettibon wobble chair, cold laser, non-surgical spinal decompression, nerve root compression, lumbar radiculopathy.

 

Introduction:  A 58 year old, 6’0”, 270 pound male was seen for a chief complaint of lower back pain with radiation into the right leg with right foot numbness.  The pain had started 9 months prior with an insidious onset.   The patient had first injured his back in high school lifting weights with several episodes of pain over the ensuing years.   The patient had been treating with Advil and had tried physical therapy, acupuncture, chiropractic and ice with no relief of pain and numbness.   Walking and standing tend to worsen the problem and lying down did provide some relief.    A number of activities of daily living were affected at a severe level including standing, walking, bending over, climbing stairs, looking over shoulder, caring for family, grocery shopping, household chores, lifting objects staying asleep and exercising.   The patient remarked that he “Feels like 100 years old.”  Social history includes three to four beers per week, three diet cokes per day.  

 

The patient’s health history included high blood pressure, several significant shoulder injuries, knee injuries, apnea, hearing loss, weight gain, anxiety and low libido.    Family history includes Alzheimer’s disease, heart disease, colon cancer and obesity.  

 

Clinical findings:   Posture analysis revealed a high left shoulder and hip with 2 inches of anterior head projection.   Bilateral weight scales revealed a +24 pound differential on the left.   Weight bearing dysfunction and imbalance suggest that neurological compromise, ligamentous instability and or spinal distortion may be present.  Range of motion in the lumbar spine revealed a 10 degree decrease in both flexion and extension. There was a 5 degree decrease in both right and left lateral bending with sharp pain with right lateral bending.

  

Cervical range of motion revealed a 30 degree decrease in extension, a 42 and 40 degree decrease in right and left rotation respectively and a 25 degree decrease in both right and left lateral flexion.   Stability analysis to assess and identify the presence of dynamic instability of the cervical and lumbar spine showed positive in the cervical and lumbar spine and negative for sacroiliac dysfunction.   Palpatory findings include spinal restrictions at occiput, C5, T5, T10, L4,5 and the sacrum.   Muscle palpation findings include +2 spasm in the psoas, traps, and all gluteus muscles.

 

Cervical radiographs reveal significant degenerative changes throughout the cervical spine. This represents phase II of spinal degeneration according the Kirkaldy-Wills degeneration classification.    Cervical curve is 8 degrees which represents an 83% loss from normal.   Flexion and extension stress x-rays reveal decreased flexion at occiput through C4 and decreased extension at C2, C4-C7.   

 

Lumbar radiographs reveal significant degenerative changes throughout representing phase II of spinal degeneration according to the Kirkaldy-Willis spinal degeneration classification.    There is a 9 degree lumbar lordosis which represents a 74% loss from normal.   There is a 2 mm short right leg and a grade II spondylolisthesis at the L5-S1 level.  

 

Lumbar MRI without contrast was ordered immediately with a 4 mm slice thickness and 1 mm gap in between slices on a Hitachi Oasis 1.2 Telsa machine for optimal visualization of pathology due to the clinical presentation of right L5 nerve root compression.  

 

Lumbar MRI revealed

 

  • Significant degenerative changes throughout the lumbar spine including multi-level degenerative disc changes at all levels.
  • Transverse Annular Fissures at L1-2 (17.3 mm), L2-3 (29.5 mm), L4-5 (14.3 mm) and L5-S1 (30.8 mm) and broad based disc bulging at all levels except L5-S1.    The fissures at L2-3 and L5-S1 both have radial components extends through to the vertebral endplate.    
  • Facet osteoarthritic changes and facet effusions at all levels.  
  • Grade II spondylitic spondylolisthesis is confirmed at L5-S1 with severe narrowing of the right neural foramen compressing the right exiting L5 nerve root.
  • Degenerative retrolisthesis at L1-2.
  • Modic Type II changes at L2 inferior endplate, L3 superior endplate, L4 inferior endplate and L5 inferior endplate.2
  • There is a 18.9 mm wide Schmorl’s node at the superior endplate of L3.  
  • There is a 5.7 mm wide focal protrusion type disc herniation at L4-5 which impinges on the thecal sac.  

 

 

T2 sagittal Lumbar Spine MRI:  Note the Modic Type II changes and the L2-3 Schmorls node.

 

T1 Sagittal Annular fissures at multiple levels and spondylolisthesis at L5S1

 

T2 Axial L4-5:  Focal Disc Protrusion Type Herniation

 

Definition –Bulging Disc: 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, over greater than 50% (180 degrees) of the circumference of the disc and usually less than 3mm beyond the edges of the vertebral body apophyses.3

 

Definition: Herniation is defined as a localized or focal displacement of disc material beyond the limits of the intervertebral disc space.3  

 

Protrusion Type Herniation: is present if the greatest distance between the edges of the disc material presenting outside the disc space is less than the distance between the edges of the base of that disc material extending outside the disc space.3   

 

Definition: Extrusion Type Herniation:  is present when, 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 of the disc material beyond the disc space or when no continuity exists between the disc material beyond the disc space and that within the disc space. 3  

 

Definition:  Annular Fissures:  separations between the annular fibers of separations of the annual fibers from their attachments to the vertebral bone. 4

 

Definition – Radiculopathy: Sometimes referred to as a pinched nerve, it refers to compression of the nerve root - the part of a nerve between vertebrae. This compression causes pain to be perceived in areas to which the nerve leads.

 

The patient underwent multimodal treatment regime consisting of 4 months of active chiropractic adjustments, non-surgical spinal decompression with pretreatment spinal warm-up exercises on the Pettibon wobble chair and neck traction and heat. Post spinal decompression with ice and cold laser.   The patient reported long periods of symptom free activities of daily living with occasional short flare-ups of pain.   Exacerbations are usually of short duration and much lower frequency.  The only activity of daily living noted as affected severely at the end of care is exercising.   

 

Post care lumbar radiographs revealed a 26 degree lumbar curve a 15 degree (38%) increase

 

Post care cervical x-rays revealed a 10 mm decrease in anterior head projection and a 2 degree improvement in the cervical lordosis.

 


Range of Motion

pre

post

increase

Lumbar

     

flexion

60

60

0

extension

40

40

0

r. lateral flexion

20

25

5

l. lateral flexion

20

25

5

       

cervical

pre

Post

increase

flexion

50

50

0

extension

30

40

10

r. lateral flexion

20

35

15

l. lateral flexion

20

20

0

r. rotation

38

70

42

l. rotation

40

80

40


Discussion:  It is appropriate to immediately order MRI imaging with radicular pain and numbness.   Previous health providers who did not order advanced imaging with these long term radicular symptoms are at risk of missing important clinical findings that could adversely affect the patient’s health.   The increasing managed care induced trend to forego taking plain film radiographs is also a risk factor for patients with these problems.  

 

This case is a typical presentation of long standing spinal injuries that over many years have gone through periods of high and low symptoms but continue to get worse functionally and eventually result in a breakdown of spinal tissues leading to neurological compromise and injury.  

 

Chiropractic treatment resulted in a very favorable outcome aided by an accurate diagnosis.  This is also the case where the different treatment modalities all contributed to the success of the protocol.   The different modalities all focus on different areas of pathology contributing to the patients’ disabled condition.

 

Modality

Therapeutic Goals

   

Chiropractic adjustment

Manual and instrument assisted forces introduced to the osseous structures that focuses on improving motor segment mobility   

   

Cold laser

Increases speed of tissue repair and decreases inflammation.4

   

Pettibon

wobble chair

Loading and unloading cycles applied to injured soft tissues and

Pettibon

neck traction

speeds up & improves remodeling of injured tissue as well as rehydrates dehydrated vertebral discs.5  

   

Non-surgical

spinal decompression

Computer assisted, slow and controlled stretching of spine, creating vacuum effect on spinal disc, bringing it back into its proper place in the spine.6,7

   

Ice

Decrease inflammation through vasoconstriction

   

Heat

Warm up tissues for mechanical therapy through increasing blood flow.    

   

Posture Correction Hat

Weighted hat that activates righting reflex resetting head posture.8

 

A major factor in the success of the care plan in this case was an integrative approach to the spine.  John Bland, M.D. in the text Disorders of the Cervical Spine writes

 

 

“We tend to divide the examination of the spine into regions: cervical, thoracic and the lumbar spine clinical studies.  This is a mistake.  The three units are closely interrelated structurally and functionally- a whole person with a whole spine.  The cervical spine may be symptomatic because of a thoracic or lumbar spine abnormality, and vice versa!  Sometimes treating a lumbar spine will relieve a cervical spine syndrome, or proper management of cervical spine will relieve low backache.”9  

 

When addressing the spine as an integrative system, and not regionally it has a very strong benefit to the total care results.   The focus on the restoration of the cervical spine function as well as lumbar spine function is a hallmark of a holistic spine approach that has been a tradition in the chiropractic profession.  

 

References: 

  1. Kirkaldy-Willis, W.H, Wedge JH, Young-Hing K.J.R. Pathology and pathogenesis of lumbar spondylosis and stenosis.  Spine 1978; 3: 319-328
  2. http://radiopaedia.org/articles/modic-type-endplate-changes
  3. David F. Fardon, MD, Alan L. Williams, MD, Edward J. Dohring, MD. Lumbar disc nomenclature: version 2.0 Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. The Spine Journal 14 (2014) 2525–2545
  4. Low Level Laser Therapy to Reduce Chronic Pain:  https://clinicaltrials.gov/ct2/show/NCT00929773?term=Erchonia&rank=8
  5. https://pettibonsystem.com/blogentry/need-two-types-traction
  6. Shealy CM, Decompression, Reduction and Stabilization of the Lumbar Spine: A cost effective treatment for lumbosacral pain.   Pain management 1955, pg 263-265
  7. Shealy, CM, New Concepts of Back Pain Management, Decompression, Reduction and Stabilization.   Pain Management, a Practical guide for Clinicians.  Boca Raton, St. Lucie Press: 1993 pg 239-251
  8. https://pettibonsystem.com/about/how-pettibon-works
  9. Bland, John MD, Disorders of the Cervical Spine WB Saunders Company, 1987 pg 84

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Published in Case Reports

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