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

Concussion:

Diagnosis-Testing-Chiropractic

 

“New testing is available using biomarkers”

 

Mark Studin, William J. Owens (2016)

 

 

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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Chiropractic’s Mechanism in Pain Modulation and the Connection to Systemic Diseases

 

A Literature Review and Synthesis on the Possible Effects of Chiropractic on Cancers, Systemic Diseases, Mental and Social Disorders and Sexual Behavior

A report on the scientific literature 


 

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

 William J. Owens DC, DAAMLP

 -----

Citation: Studin M., Owens W. (2016) Chiropractic’s Mechanism in Pain Modulation and the Connection to Systemic Disease, Dynamic Chiropractor 34(3) 26-33

 

Chiropractors for over a century have been called “quacks” and “charlatans” for reporting what they have observed in their patients as a result of their care. The maladies that chiropractors have witnessed the disappearance of include cancers, eczema, infertility, high blood pressure, diabetes, arthritis, emotional disturbances and many more. Historically, this has brought the “ire” of organized medicine and other splinter groups to attack the chiropractic profession with the mantra of “there is no scientific evidence” to support these allegations. One author of this paper, Dr Studin, has spent 35 years experiencing this phenomenon where patients reported the aforementioned maladies and a long list of other diseases which “miraculously” disappeared with treatment.

 

 

To be clear, this wasn’t an isolated instance, but rather year after year that and in meetings with other chiropractor’s similar stories were heard.  However, sharing these findings amongst chiropractors was much easier than sharing it with the healthcare community because of the persecution against chiropractors and the outcry of “quackery.” In fact, many of the chiropractic practitioners who witnessed these results felt the best way to approach this was to only discuss this with patients.  They purposefully avoided any other healthcare providers in these conversations because there was no scientific evidence to back up the repeated observations.

 

 

To the medical community, these were religious type beliefs and we, as chiropractors, were proselytizing our religion of chiropractic on patients and the community. Based on the lack of published evidence, their allegations against us was not without merit albeit misguided and fueled in part by economics. However, medicine saw beliefs based upon observations on the chiropractic side and medicine required published evidence for verification no matter the claims and testimonials from an ever-increasing segment of the public. Today, the benefits of chiropractic care have remained constant with the same stream of patients getting well. However, the evidence has now started to support these findings and the chiropractic profession has gone beyond proselytizing our beliefs to being able to cite specific research that supports and justifies chiropractic care as part of mainstream healthcare. We can now share our results, which are consistent with the scientific literature that often has been discovered or proven beyond the chiropractic profession.

 

 

NOTE: Although the following evidence verifies what our profession has been witnessing over the last decade, please understand that the research is just beginning to show evidence and much more is needed to bring our profession to where it needs to be. As a result, every practitioner and every chiropractic academic institution needs to both support and be involved in research. Our professional institutions and their research departments MUST take an active and serious role in producing and publishing research. Otherwise, it will come from another source such as osteopathy or physical therapy and prevent chiropractic from taking it’s unique place in healthcare.

 

Chiropractic Adjustment and Central Nervous System Changes

 

We have held for quite some time that studying how the adjustment works for the treatment of pain is the first step in truly understanding how the chiropractic adjustment affects systemic diseases. It has been shown that the chiropractic adjustment has a direct effect on many regions in the brain where pain mediation arises. As evidence, Reed, Pickar, Sozio, and Long (2014) reported:

…forms of manual therapy have been clinically shown to increase mechanical pressure pain thresholds (i.e., decrease pain sensitivity) in both symptomatic and asymptomatic subjects.Cervical spinal manipulation has been shown to result in unilateral as well as bilateral mechanical hypoalgesia [reduction in pain]. Compared with no manual therapy, oscillatory spinal manual therapy at T12 and L4 produced significantly higher paraspinal pain thresholds at T6, L1, and L3 in individuals with rheumatoid arthritis. The immediate and widespread hypoalgesia associated with manual therapy treatments has been attributed to alterations in peripheral and/or central pain processing including activation of descending pain inhibitory systems.

Increasing evidence from animal models suggests that manual therapy activates the central nervous system and, in so doing, affects areas well beyond those being treated. (p. 277)

 

 

Reed et al. (2014) continued stating, “Several clinical studies indicate that spinal manipulation [chiropractic spinal adjustment] alters central processing of mechanical stimuli evidenced by increased pressure pain thresholds and decreased pain sensitivity in asymptomatic and symptomatic subjects following manipulation” (p. 282).

 

In another paper, Gay, Robinson, George, Perlstein, and Bishop (2014) reported, “With the evidence supporting efficacy of MT [manual therapy or chiropractic spinal adjustments] to reduce pain intensity and pain sensitivity, it is reasonable to assume that the underlying therapeutic effect of MT is likely to include a higher cortical component” (p. 615).   The authors continued by stating, “…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]” (Gay et al., 2014, p. 615).

 

The above two studies are only a small part of a growing body of evidence showing that the chiropractic spinal adjustment directly affects the functioning of the central nervous system and is the core of pain modulation with chiropractic care and the foundation to the next level, as outlined below. 

 

The Effect of the Chiropractic Adjustment on Neuropeptides (Neurotensin-Oxytocin-Cortisol)

NOOC Axis = Neurotensin-Orexin-Oxytocin-Cortisol

Regarding neuropeptides, Burbach (2011) reports:

We know neuropeptides now for over 40 years as chemical signals in the brain. The discovery of neuropeptides is founded on groundbreaking research in physiology, endocrinology, and biochemistry during the last century and has been built on three seminal notions: (1) peptide hormones are chemical signals in the endocrine system; (2) neurosecretion of peptides is a general principle in the nervous system; and (3) the nervous system is responsive to peptide signals. These historical lines have contributed to how neuropeptides can be defined today: “Neuropeptides are small proteinaceous substances produced and released by neurons through the regulated secretory route and acting on neural substrates.” Thus, neuropeptides are the most diverse class of signaling molecules in the brain engaged in many physiological functions. (p. 1)

 

 

Simply put, neuropeptides are the transmitters that allow the brain to communicate within itself and with the rest of the body’s functions. The increase or decrease of these neuropeptides/neurotransmitters alters human physiology (function) and any action upon the body that affects the neurotransmitters can either help normalize function or conversely destroy functioning with the human body.  This is the foundation of homeostasis and, therefore, if we can affect the function of neurotransmitters, then it is safe to say we can have a level of influence on homeostasis.  This obviously ties into our founder’s observations and the beginning of chiropractic! 

 

 

In an additional paper, Plaza-Manzano et al. (2014) wrote, “Several neuropeptides, such as neurotensin, oxytocin, or orexin A have been associated with hypoalgesia and pain modulation, and it is well known that cortisol plays an analgesic role related to stress responses. Recent theories have also suggested that chronic pain could be partly maintained by maladaptive physiological responses of the organism facing a recurrent stressor, a situation related to high cortisol levels” (p. 231). The authors continued by stating, “To make better therapeutic decisions, professionals would profit from knowing whether one type of SM (adjustment) is better than others in terms of antinociceptive (authors comment: antinociceptive = pain inhibition) effects (neurotensin, orexin A, oxytocin, and cortisol). Taking these data into account, our purpose was to determine whether cervical and thoracic manipulation would induce differences in neuropeptide production or have a similar biochemical response (Plaza-Manzano et al., 2014, p. 232).

 

 

Plaza-Manzano et al. (2014) went on to say “…within-group comparisons in cervical and thoracic manipulation groups showed a significant increase in neurotensin levels immediately post-intervention compared with pre-intervention levels… At the descriptive level, an important decrease in orexin A concentration was detected after the intervention in the thoracic SM (spinal manipulation) group in comparison with the control group… the cervical SM group showed increased oxytocin values when compared with the thoracic SM group immediately post-intervention (Plaza-Manzano et al., 2014, p. 234). At 2 hours after the intervention, an increase was found only in the cervical SM group when compared with pre-intervention levels… the cervical SM group showed a significant increase in cortisol plasma concentration immediately post-intervention compared with baseline values” (Plaza-Manzano et al. 2014, p. 235). 

 

 

Neurotensin

Orexin

Oxytocin

Cortisol

Cervical Adjustment

Increased levels

Not reported

Increased levels

Increased levels

Thoracic Adjustment

Increased levels

Increased levels

No Change

Significant Decrease at

2 hours

 

 

Regarding pain Plaza-Manzano et al. (2014) stated:

It is well established that neurotensin affects the activity of oxytocin-positive cells in the supraoptic nucleus. Oxytocin is a nonapeptide that plays a major neuroendocrine role, modulating several physiological functions in mammals, like somatosensory transmission, nociception, and pain. Oxytocin is synthesized and secreted by a subpopulation of the paraventricular and supraoptic nuclei of the hypothalamus. In fact, several studies now support the idea that oxytocin exerts a potent antinociceptive control after its release in the spinal cord from hypothalamo-hypophysal descending projections (from the brain) … In studies involving human subjects, pain relief was reported in central neurogenic pain and in low back pain after the intracerebroventricular and intrathecal administration of oxytocin (aka pharmaceutical intervention). No previous study has evaluated whether SM has an effect on oxytocin plasmatic concentration. Our results suggest that the increase of the plasmatic concentration of oxytocin following an SM could be partly responsible for the analgesic effect linked to manual therapy techniques due to the activation of descending pain-inhibitory pathways. Orexins are known to be a hypothalamic peptide critical for feeding and normal wakefulness...Orexinergic projections were identified in periaqueductal gray matter, the rostral ventral medulla, the dorsal horn, and the dorsal root ganglion. Emerging evidence shows that the central nervous system administration (intracranial ventricle or intrathecal injection) of orexin A can suppress mechanical allodynia and thermal hypersensitivity in multiple pain models, suggesting the regulation of nociceptive processing via spinal and supraspinal mechanisms. In addition, orexins showed antinociceptive effects on models of pain, such as neuropathic pain, carrageenan test, and postoperative pain… Cortisol is therefore one of the biochemical factors delivered in stress situations that acts to decrease local edema and pain by blocking early stages of inflammation. In addition, it is also believed that high cortisol levels promote wound healing by stimulating gluconeogenesis. The response to stress is triggered by the stimulation of the hypothalamus-pituitary-adrenal axis. It has been proven that a subject’s level of stress can be correlated with secreted cortisol levels. (p. 236) 

 

 

The above study explains the neurochemical mechanism through which pain in mediated via the chiropractic spinal adjustment. Many of the pharmacological and nutraceutical interventions also target these systems through a variety of measures, some with significant negative side-effects.  Next, let’s examine what control these neuropeptides have in the human body beyond pain control. This will begin to explain the systemic connection with the chiropractic adjustment.

 

Systemic Effect of the Chiropractic Adjustment by Increasing of the NOC Axis

 

According to St-Gelais, Jomphe and Trudeau (2006), “…we focus our attention on the roles of NT [neurotensin] in the CNS. However, it is important to point out that this peptide is also highly expressed peripherally where it acts as a modulator of the gastrointestinal and cardiovascular systems” (p. 230). These authors discussed the role of antipsychotic drugs in cases of schizophrenia and how it was used to elevate the neurotensin level.  They found it would promote partial recovery while an additional study revealed that unmediated patients displayed a lowering of neurotensin.

 

An increase in neurotensin acts as a psychostimulant. A study conducted over the course of 25 years on individuals with drug abuse issues showed that increasing neurotensin levels decreased effects of psychostimulants such as amphetamines and cocaine. This study on drug addiction, according to St-Gelais et al. (2006), was conducted on animals, but there are many in chiropractic who have reported on a case-by-case basis that integrating chiropractic has helped many with drug abuse issues. Perhaps what this article suggests can help find more answers.

 

 

St-Gelais et al. (2006) also found a strong connection with a decrease in neurotensin in the following:

 

  1. Schizophrenia
  2. Gastrointestinal function
  3. Cardiac function
  4. Parkinson’s disease
  5. Elevated blood pressure
  6. Eating disorders
  7. Cancer of the
    1. Colon
    2. Lungs
    3. Ovaries
    4. Pancreas
    5. Prostate
    6. Bones
    7. Brain
  8. Alzheimer’s
  9. Stroke (ischemic deaths)
  10. Inflammation

 

Although the literature has not yet conclusively shown that any one of the central nervous system conditions are causally involved with the reduction of neurotensin, the literature strongly suggest that it plays a significant role. There is definitely a common denominator in neurotensin levels and these seemingly uncorrelated conditions.

 

Orexins, also known as hypocretins, according to Ebrahim, Howard, Kopelman, Sharief and Williams (2002) have an important role in sleep and (mental) arousal states. They state, “The hypocretins are thought to act primarily as excitatory neurotransmitters…suggesting a role for the hypocretins in various central nervous functions related to noradrenergic innervation, including vigilance, attention, learning, and memory. Their actions on serotonin, histamine, acetylcholine and dopamine neurotransmission is also thought to be excitatory and a facilitatory role on gamma-aminobutyric acid (GABA) and glutamate-mediated neurotransmission is suggested” (p. 227).

 

Ebrahim et al. (2002) continued:

Apart from their primary role in the control of sleep and arousal, the hypocretins have been implicated in multiple functions including feeding and energy regulation, neuroendocrine regulation, gastrointestinal and cardiovascular system control, the regulation of water balance, and the modulation of pain. A role in behaviour is also postulated. The cell bodies responsible for hypocretin synthesis are localized to the tuberal part of the hypothalamus, the so-called feeding centre...[which] has led to the suggestion that the hypocretins are mediators of energy metabolism. The neuroendocrine effects of the hypocretins include a lowering of plasma prolactin and growth hormone and an increase in the levels of corticotropin and cortisol, insulin and luteinizing hormone. Central administration of the hypocretins increases water consumption, stimulates gastric acid secretion and increases gut motility. The hypocretins increase mean arterial blood pressure and heart rate. The localization of long descending axonal projections containing hypocretin at all levels of the spinal cord suggests a role in the modulation of sensation and pain. Strong innervation of the caudal region of the sacral cord suggests a role in the regulation of both sympathetic and parasympathetic functions. (p. 227-228)

 

According to Lee, Macbeth, Pagani and Young (2009), oxytocin is a product of the hypothalamus and pituitary and according to Plaza-Manzano et al. (2014) it has been linked to the endogenous synthesis of opioids, thereby adding further explanation to the antinociceptive effects in the reduction of pain centrally. This partially explains the pain mechanism of the chiropractic adjustment.

 

 

For non-pain actions of oxytocin, beyond the actions of uterine contractions and lactation (You remember that board question, right?), Lee et al. (2009) reported that oxytocin is integral in:

 

  1. Social memory
  2. Social bonding
  3. Parental behavior
  4. Human behavior
  5. Sexual behavior
  6. Social behaviors (i.e. aggression)
  7. Learning
  8. Memory (overall)
  9. Anxiety
  10. Eating behavior
  11. Sugar metabolism

 

Willenberg et al. (2000) reported, “Corticotropin-releasing hormone (CRH) and its receptors are widely expressed in the brain and peripheral tissues. This hormone is the principal regulator of the hypothalamic-pituitary-adrenal (HPA) axis and exerts its effects via two main receptor subtypes, type 1 (CRH-R1) and 2 (CRH-R2). CRH also activates both the adrenomedullary and systemic sympathetic system limbs and an intraadrenal CRH/ACTH/cortisol system…” (p. 137).

 

According to Smith and Vale (2006) “The principal effectors of the stress response are localized in the paraventricular nucleus (PVN) of the hypothalamus, the anterior lobe of the pituitary gland, and the adrenal gland. This collection of structures is commonly referred to as the hypothalamic-pituitary-adrenal (HPA) axis...In addition to the HPA axis, several other structures play important roles in the regulation of adaptive responses to stress. These include brain stem noradrenergic neurons, sympathetic adrenomedullary circuits, and parasympathetic systems” (pgs. 383-384) 

 

 

Smith and Vale (2006) also reported the following function of the HPA axis that has a direct control by corticotropin-releasing hormones:

  1. Autonomic nervous system function
  2. Learning
  3. Memory
  4. Feeding
  5. Reproduction related behaviors
  6. Metabolic changes
  7. Cardiovascular regulation
  8. Immune system

In addition, Willenberg et al. (2000) added the following”

  1. Mental disorders
  2. Depression
  3. Schizophrenia

 

Conclusion

 

For over a century, chiropractic patients have been reporting the “miracles” of the results rendered in chiropractic offices worldwide and yet chiropractors have been persecuted and often vilified by the medical profession due to the lack of scientific evidence. Although this is a very broad perspective of the potential of the chiropractic care, it is now virtually impossible to ignore the fact that the chiropractic adjustment affects changes in neuropeptides in blood sample post-adjustment. These blood markers verify that changes are made in the human body and these changes have far reaching effects on both wellness and disease care. Medicine has been attempting to reproduce these effects via pharmaceutical intervention and a part of the solution now has to be chiropractic care based upon the evidence reported. 

This is just the beginning, as more evidence is needed to verify the full effects of the chiropractic spinal adjustment. We have a lot of work to do, but the scientific foundation of what chiropractors have observed since our beginning is getting stronger every month as more research is published.  

We would like to leave you with a last and seemingly unrelated statement.  We 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. Reed, W. R., Pickar, J. G., Sozio, R. S., & Long, C. R. (2014). Effect of spinal manipulation thrust magnitude on trunk mechanical activation thresholds of lateral thalamic neurons.Journal of Manipulative and Physiological Therapeutics, 37(5), 277-286.

2. 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.

3. Burbach, J. P. (2011). What are neuropeptides? In J. Walker (Ed.),Methods in molecular biology (pp. 1-36). Clifton, New Jersey: Humana Press.

4. Plaza-Manzano, G., Molina-Ortega, F., Lomas-Vega, R., Martinez-Amat, A., Achalandabaso, A., & Hita-Contreras, F. (2014). Changes in biochemical markers of pain perception and stress response after spinal manipulation.Journal of Orthopedic and Sports Physical Therapy, 44(4), 231-239.

5. St-Gelais, F., Jomphe C., & Trudeau, L. (2006). The role of neurotensin in central nervous system pathophysiology: What is the evidence?Journal of Psychiatry & Neuroscience,31(4) 229-245.

6. Ebrahim, I. O., Howard, R. S., Kopelman, M. D., Sharief, M. K., & Williams, A. J. (2002). The hypocretin/orexin system.Journal of the Royal Society of Medicine,95(5), 227-230.

7. Lee, H. J., Macbeth, A. H., Pagani, J. H., & Young, W. S. (2009). Oxytocin: The great facilitator of life.Progressive Neurobiology, 88(2), 127-151.

8. Willenberg, H. S., Bornstein, S. R., Hiroi, N., Path, G., Goretzki, P. E., Scherbaum, W. A., & Chorusos, G. (2000). Effects of a novel corticotropin-releasing-hormone receptor type I antagonist on human adrenal function.Molecular Psychiatry, 5(2), 137-141.

9. Smith, S. M., & Vale, W. W. (2006). The role of hypothalamic-pituitary-adrenal axis neuroendocrine response to stress.Dialogue in Clinical Neuroscience, 8(4), 383-395.

10. 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, 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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Published in Neck Problems

Workers Compensation and Chiropractic:

A Solution for Lowering Healthcare Costs for the Acute and Chronic Care Patient

 

by Mark Studin DC, FASBE(c), DAAPM, DAAMLP

William J. Owens DC, DAAMLP

 

Legislators and Regulators Must Stay Current on Healthcare Outcome Research in Order to Continue to Effectively Support the Needs of the People 

 

Interventions for the diagnosis, treatment and management of spinal complaints are at the forefront of the health care debate.  There are a multitude of health professionals that are involved with the care of these patients.  Let’s take a look at the current healthcare system relating to spinal injuries and subsequent costs for intervention and management.  It was reported by Zigler in 2011 that 200,000 spinal fusion surgeries are performed each year, just in the United States alone. An equal number of microdiscectomies are performed as reported by Mayer (2006), which is considered by many to be a conservative number. Let's consider the chiropractic impact of exposing the public to treatment that could avoid needless surgeries, using the 400,000 disc surgeries [spinal fusions + microdiscectomy] as a conservative number, while reducing the revenue lost to both governmental agencies and workers from absenteeism [due to recovery from surgery]. Allen and Garfin (2010) reported that spine-related health care expenditures totalled over $97.5 billion (2011 inflation adjusted), a 65% increase from 1997. With an aging population, this trend, based on the biomechanics of the aged, will continue.

It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbert in 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.

Let's do the math. If we take the 400,000 disc surgeries (adding cervical surgeries to the equation) done each year as discussed in the opening paragraph and apply McMorland et al.'s (2010) findings that 60% of surgical candidates had successful outcomes with chiropractic as an alternative to surgery, 240,000 patients yearly could avoid needless surgery if they sought chiropractic care.

According to Sherman, Cauthen, Schoenberg, Burns, Reaven and Griffith in 2010, the 2010 inflation adjusted amount per case in Medicare dollars is $13,243.82 per patient once you take into consideration the complications, but exclude many other variables such as repeated MRI's, myelograms, and many hospital charges. Allen and Garfin (2010), taking into account total charges, including mean hospital charges for a single level, uncomplicated, minimally invasive surgery, reported the cost to be $70,159 for all payors. They also went on to report that for 2-level disc surgeries the complication rate increased by 25% with significantly more costs.

If you consider 240,000 preventable surgeries at $70,159 per patient, that equates to $16,838,160,000 healthcare dollars that did not have to be spent. MEDSTAT, as reported by Chiropractic Lifecare of America (2009), estimated that the average cost of chiropractic care per patient per case is $3,918 (2011 inflation adjusted dollars.) If you take this amount and apply it to the 240,000 unnecessary surgeries, you have a net savings of $66,241 per patient. The net savings to the Medicare system and private insurers is $15,897,840,000!

Fayssoux, Goldfarb, Vaccaro, James (2010) studied the indirect costs associated with surgery for low back pain reporting the average lost productivity related to absenteeism resulted in lost wages of $2,884 per patient for the first postoperative year. "The findings demonstrate the significant, though not surprising, impact of spinal disability on productivity, and the importance of including measurement of lost productivity and return to work..." (Fayssoux et al., 2010, p. 9). This equals an additional $692,160,000 in wages to Americans per year by taking the necessity of absenteeism out of the equation with no surgeries from which to recover.  Remember, according to McMorland et al 60% of surgical candidates recovered with chiropractic care.  When surgical intervention is no longer necessary, there is no absenteeism from the procedure. 

 

When we actually look at the ‘big picture” facing spine care in the Unites States, we see that it is not only the actual occurrence of the conditions, but what to do about their recurrence over time. There are numerous recent studies that have established chiropractic as cost effective care that is clinically efficient.2,3,4,5,6,7,8,9,10,11,12,13,14  The conclusions of these recent studies are consistent; chiropractic is less expensive and returns people to work faster and with less disability, thereby alleviating the burden on the workers’ compensation system and overall economy. It begs the question, "If chiropractic care and philosophy were utilized more frequently, how many billions of dollars spent on healthcare in the United States could truly be saved?”

The current trend in healthcare implementation and policy has been labeled as “Evidence Based Care” and the goal is to align the healthcare system to interventions shown to be effective in the research.  On the surface this process seems straight forward, after all how hard could it be to review research papers and then make recommendations on care based on the results of those studies?  Utilizing research in the creation of medical care guidelines is an important step, however it requires a system that encourages updates based on the speed of research outcomes.  There is often a stark difference between the speed of research publication and legislative debates and implementation.  A prime example of this imbalance is the ruling by the New York State Workers’ Compensation Board which, on December 1, 2010, enacted new medical treatment guidelines for the neck, middle/lower back, shoulder and knee.  These guidelines were developed by the American Academy of Occupational and Environmental Health after what was, at the time, a comprehensive review of the peer reviewed research literature.  These guidelines were established for acute care intervention only. 

This ruling by the New York State Workers’ Compensation System effectively ceased coverage of chiropractic intervention for injured workers for the treatment of any chronic conditions.  This included injured workers that had been awarded lifetime chronic care, many at a frequency of 2 visits per month.  These injured workers had demonstrated in a court of law that they were not only injured while working, but their conditions were permanent and required intervention in order for them to continue working.  Ultimately these patients are able to fulfill their roles as productive members of society versus due to absenteeism, becoming financial burdens to the State of New York.  The new law has become so restrictive (and perhaps a constitutional issue) that the injured workers are also denied the ability to use other health insurance or pay out of pocket for continued care.  These guidelines failed to take into consideration that many traumatic musculoskeletal injuries have permanent qualities, not unlike systemic disorders such as diabetes and congestive heart failure.  These legislative changes were enacted in December, 2010, new relevant research that could steer the guidelines to be more effective was published 3 ½ months later. Currently there is no system in place to incorporate updated research.  Evidence Based Care is only effective when the most current resources are used.  There is an apparent inequality in a system that addresses the “acute” portion of spine care and not the management of chronic recurrent spinal conditions, even though the research clearly shows effectiveness for both aspects of spine care.  How long will it take for the New York State Workers’ Compensation Board to respond to this new research?

A more effective way to address this inequality is to consider the definition of "health maintenance" as was done in a recent study released by the American Academy of Occupational and Environmental Health in April, 2011, the very organization that denied the implementation of chronic care guidelines reporting the lack of evidence for the chronic management of spine conditions. In their article, Cifuentes, Willetts and Wasiak define health maintenance care as “…a clinical intervention approach thought to prevent recurrent episodes of LBP [lower back pain]. It conceptually refers to the utilization of health care services with the aim of improving health status and preventing recurrences of a previous health condition” (p. 396).  This paper is specific to health maintenance care and working-related lower back pain and was able to effectively single out chiropractic care for definitive study.

The nuance of the paper was specific because the authors stated, “Given that chiropractors are proponents of health maintenance care, we hypothesize that patients with work-related LBP who are treated by chiropractors would have a lower risk of recurrent disability because this specific approach would be used.  Conversely, similar patients treated by other providers would have higher recurrence rates because the general approach did not include maintaining health, which is a key component to prevent recurrence” (Cifuentes et al., 2011,  p. 396). This research is unique and comprehensive in that it tracked injured workers compensation patients in multiple states (the states were chosen because the patients had the ability to select their doctors on their own and were not mandated providers) and it reviewed claims dated between January and December, 2006, including 894 cases out of a pool of 11,420 claims of non-specific low back pain cases.  

Relating to the results, the authors report, “In our study, after controlling for demographics and severity indicators, the likelihood of recurrent disability due to LBP for recipients of services during the health maintenance care period by all other provider groups was consistently worse when compared with recipients of health maintenance care by chiropractors. Care from chiropractors during the disability episode (“curative”), during the health maintenance period (main exposure variable, “preventative”), and the combination of both (curative and preventive) was associated with lower disability recurrence HRs” (Cifuentes et al., 2011,  p. 403). An interesting note is that although this research study is new, the data that it collected and the philosophy that it outlined are nothing new because the chiropractic profession has been the primary provider of these types of services for over 115 years.  When it comes to comparing the “Return on Investment” [ROI] of chiropractic care there is no other profession that has the ability to save billions in health care costs while at the same time actually delivering healthcare to the population.  Research has VALIDATED chiropractic in both the acute and the chronic phases of spine care. 

Chiropractic offers solutions to the federal government, local government, and public and private insurance companies by avoiding unnecessary surgeries. Chiropractic offers solutions to the economy of local, state and federal governments by increasing the tax base and productivity in the marketplace as a result of keeping workers at work and circulating money into local economies with increased paychecks at the end of the year. The research is conclusive and chiropractic has solutions to many of the economic and societal problems in the United States and worldwide.  It is critical that this type of philosophy of care is allowed to thrive resulting in increased production from injured workers and decreased health care expenditures related to recurring spinal conditions. Oversight and recommendations must be compatible with sustainability.  Although all disciplines are qualified to intervene in the “curative’ phase, chiropractors are unique;/  and most qualified to review, comment and drive chronic care and afford the greatest potential for cost containment.    The research demonstrates two very important facts, the first being the approach of chiropractic care to patients with acute, chronic and permanent injuries and the second, how important it is to provide a bridge between clinical published research and legislative decision making.

 

 

Appendix A –

TABLE 1

Samples of research showing the effectiveness and reduced costs of chiropractic care for spinal-related injuries and conditions.

REFERENCE

FINDINGS

Florida Workers Compensation Board2

Study examined 10,652 workers who sustained back-related injuries. Individuals who received chiropractic care as compared with standard medical care had a 51.3% shorter temporary total disability duration 58.8% lower treatment costs and a 20.3% hospitalization rate versus 52.2 in the medical care group.

Utah Workers  Compensation Board Study3

Back-related injuries treated by chiropractors produced a tenfold savings as compared with medical doctors ($68.38 vs. $668.39)

Australian Workers Compensation Study4

Individuals who had work-related mechanical low back pain who received chiropractic care for their back pain returned to work 4 times faster (6.26 days vs. 25.56 days) and their treatment was 4 times less costly ($392 vs. $1,569) than those who received treatments from medical doctors.

North Carolina Workers Compensation Patients5

A retrospective review of 43,650 claims from 1975 to 1994 showed that the average cost of treatment, hospitalization, and compensation payments (for treatment of strain injuries, specific body parts and low back injuries) were much less for patients treated by DCs than they were for patients treated by MDs.

Average treatment cost for a patient seeing a DC = $663

Average treatment cost for a patient seeing an MD = $3,519.

Chiropractic Treatment for Low Back and Neck6

For the treatment of low back and neck pain, receiving chiropractic treatment showed a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs.

Costs of Low Back Care7

6,183 patients were studied who first had contact with either a medical or chiropractic provider. Total insurance payments were much less when initial treatment was provided by a chiropractor.

           

Many recent, independent studies confirm that chiropractic can be an extremely effective modality in the treatment of low back pain and by extension, the onset of osteoarthritis, which should be of particular interest to the Workers’ Compensation Board at this time.

  • ·Regarding the link between low back pain and the onset of osteoarthritis, Stupar, Pierre, French, &Hawker
  • ·A 2009 study by Aspegren, Enebo, Miller, White, Akuthota, Hyde, & Cox and a 2005 study by DeVocht, Pickar, & Wilder have independently concluded that chiropractic care is a safe, highly effective treatment choice for low back pain patients and perhaps most importantly, that low back pain cannot be ignored, especially in light of the fact that it can be often be treated in a very cost-effective manner. 9,10 Considering that a 2009 study by Russo, Weir and Elixhauser concluded that osteoarthritis is the #2 cause of hospital stays (only behind coronary artery disease), the potential long term health care costs of low back pain as a precursor to osteoarthritis is staggering. 11
  • The study by Aspegren, Enebo, Miller, White, Akuthota, Hyde, & Cox (2009) also concluded that 81.5% of workers with an acute injury causing low back or neck pain reported immediate post-treatment relief with chiropractic treatment, with that percentage increasing over time. 9
  • The 2005 study by DeVocht, Pickar, & Wilder found through objective electrodiagnostic studies that 87% of the chiropractic patients they studied exhibited decreased muscle spasms. 10
  • In 2009, Painter reported that Consumer Reports conducted an independent survey of 14,000 subscribers who rated hands-on therapy as the #1 treatment of choice for low back pain. The report went on to state that 88% of those who tried a chiropractic adjustment reported positive outcomes and 59% were “completely” or “very” satisfied versus 34% who were highly satisfied when treated by a primary-care physician. 12
  • ·A 2010 study by O'Shaughnessy, Drolet, Roy, & Descarreaux estimated that serious side effects from a chiropractic adjustment were less than 1 out of every 3,700,000 to 1 out of every 1,000,000 with low back adjustments (the incident was so low, they had to use a range). In contrast, one of the most common medically-prescribed and over the counter treatments for low back pain is nonsteroidal anti-inflammatory drugs (NSAIDs).  It was reported by the American College of Gastroenterology in 2010 that 14 million Americans with arthritic conditions take NSAIDS regularly and up to 60% will have gastrointestinal side effects as a result.13
  • ·According to a 2010 Virginia Healthcare and Hospital Association study, the average non-surgical hospital stay for back problems in Virginia in 2009 was $15,059 and $77,107 with surgery. 14 A Virginia study by North, Kidd, Shipley and Taylor (2007) revealed that the cost to use spinal cord stimulation to treat failed back surgery syndrome was $117,901 and unsuccessful attempts at reoperation cost an additional $260,584. 15

 

  • A 2004 study by Legorreta compared more than 1.7 million insured patients seeking treatment for back pain. The outcomes showed when chiropractic care was utilized in comparison to the standard medical approach, the cost of treatment was reduced by 28%, hospitalizations were reduced by 41%, back surgery was reduced by 32%, and the cost of medical imaging, including x-rays and MRI’s, was reduced by 37%. Furthermore, 95% of the patients that received chiropractic care reported in the study that they were satisfied with their treatment. Utilizing chiropractic care as the first treatment option for back pain was estimated to have the potential to reduce US healthcare costs by more than $28 billion annually.16
  • ·A 2008 study by Cook, Cook and Worrell reported that manual therapy in a hospital-based setting significantly reduced hospital charges. 17
  • ·A 2007 study by Sarnat, Winterstein and Cambron reported that there was a 60.2% reduction of in-hospital admissions with a 59% decrease in hospital stays and a 62% reduction in outpatient surgeries and procedures when chiropractic was utilized. Furthermore, there was an 85% reduction in pharmaceutical costs. 18

The only responsible solution is for chiropractic to be included not only in the final equation for treating chronic care patients, but in the creation of the guidelines as occupational specialists have no experience in chiropractic and will attempt to "saddle chiropractic" with protocols of other more expensive, less successful disciplines, as outlined by Cifuentes, Willetts and Wasiak.

References

1. Cifuentes, M., Willetts, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.

2. Legorreta, A. P. (2004). Comparative analysis of individuals with and without chiropractic coverage. Archives of Internal Medicine, 164, 1985-1992.

3. Jarvis, K. B., Phillips, R. B., Morris, E. K. (1991). Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes. Journal of Occupational Medicine, 33(8), 847-852.

4. Ebrall, P.S. (1992). Mechanical low-back pain: A comparison of medical and chiropractic management within the Victorian work care scheme. Chiropractic Journal of Australia 22, 47-53.

5. Phelan, S. P., Armstrong, R. C., Knox, D. G., Hubka, M. J., & Ainbinder, D. A. (2004). An evaluation of medical and chiropractic provider utilization and costs: Treating injured workers in North Carolina. Journal of Manipulative and Physiological Therapeutics, 21(7), 442-448.

6. Nelson, C. F., Metz, R. D. & LaBrot, T. (2005). Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain.Journal of Manipulative Physiological Therapeutics, 28(8), 564-569.

7. Stano, M. & Smith, M. (1996). Chiropractic and medical costs of low back care. Medical Care, 34(3), 191-204. 

8. Stupar, M., Pierre, C., French, M. R., & Hawker, G. A. (2010). The association between low back pain and osteoarthritis of the hip and knee: A population-based cohort study. Journal of Manipulative and Physiological Therapeutics, 33(5), 349-354.

9. Aspegren, D., Enebo, B. A., Miller, M., White, L., Akuthota, V., Hyde, T. E., & Cox, J. M. (2009). Functional Scores and subjective responses of injured worker with back or neck pain treated with chiropractic care in an integrative program: A retrospective analysis of 100 cases. Journal of Manipulative and Physiological Therapeutics, 32(9), 765-771.

10. 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.

11. Russo, A., Wier, L. M., & Elixhauser, A. (2009, September). Hospital utilization among near-elderly adults, ages 55 to 64 years, 2007. Agency for Healthcare Research and Quality. Retrieved from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb79.jsp

12. Painter, F. M. (2009, April 10). Consumer reports survey shows hands-on therapies were the top-rated treatments. The Chiropractic Rescue Organization. Retrieved from http://www.chiro.org/LINKS/ABSTRACTS/Hands_on_Therapies.shtml

13. O'Shaughnessy, J., Drolet, M., Roy, J-F., & Descarreaux, M. (2010). Chiropractic management of patients’ post-disc arthroplasty: Eight case reports. Chiropractic & Osteopathy, 18(7), Retrieved from http://www.chiroandosteo.com/content/pdf/1746-1340-18-7.pdf

14. Virginia Hospital and Healthcare Association. (2010). MSDRG 552 Medical Back Problems wo MCC. Virginia Hospital and Healthcare Association PricePoint System. Retrieved from http://www.vapricepoint.org/Report_INP.aspx

15. Virginia Hospital and Healthcare Association. (2010). MSDRG 460 Spinal Fusion Exc Cervical w/o MCC. Virginia Hospital and Healthcare Association PricePoint System. Retrieved from http://www.vapricepoint.org/Report_INP.aspx

16. Legorreta, A. P. (2004). Comparative analysis of individuals with and without chiropractic coverage. Archives of Internal Medicine, 164, 1985-1992.

17. Cook, C., Cook, A., & Worrell, T. (2008). Manual therapy provided by physical therapists in a hospital-based setting: A retrospective analysis. Journal of Manipulative and Physiological Therapeutics 31(5), 338-343.

18. Sarnat, R. L., Winterstein, J., Cambron, J. A. (2007). Clinical utilization and cost outcomes from an integrative medicine independent physician association: An additional 3-year update. Journal of Manipulative and Physiological Therapeutics, 30(4), 263-269.

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Soft Tissue Injuries

What are they and the Long-Term Impact of Bodily Injury

 

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

 

According to the American Academy of Orthopedic Surgery “The most common soft tissues injured are muscles, tendons, and ligaments. Acute injuries are caused by a sudden trauma, such as a fall, twist, or blow to the body. Examples of an acute injury include sprains, strains, and contusions.”  (http://orthoinfo.aaos.org/topic.cfm?topic=A00111) We must also not forget that there are other soft tissues that can get injured and the true definition of soft tissue, which is anything not bone is soft tissue. This includes the brain, lungs, heart and any other organ in the body. However, in medicine soft tissue injuries are commonly known to be limited to the muscles, ligaments and tendons. 

When we look at the type of structures that muscles, tendons and ligament are composed of, we will realize that they are connective tissue. According to the National Institute of Health “Connective tissue is the material inside your body that supports many of its parts. It is the "cellular glue" that gives your tissues their shape and helps keep them strong. It also helps some of your tissues do their work (http://www.nlm.nih.gov/medlineplus/connectivetissuedisorders.html). Unlike fracture repair where the bone is replaced and usually heals properly if aligned and rested, connective tissue disorders undergo a different type of wound repair that has aberrant tissue replacement as sequella to bodily injury and has subsequent abnormal permanent function.

If we focus on sprains or ligamentous injuries, according to the American Academy of Orthopedic Surgery there are three types of sprains:

Sprains are classified by severity:1

  • Grade 1 sprain (mild): Slight stretching and some damage to the fibers (fibrils) of the ligament.
  • Grade 2 sprain (moderate): Partial tearing of the ligament. There is abnormal looseness (laxity) in the joint when it is moved in certain ways.
  • Grade 3 sprain (severe): Complete tear of the ligament. This causes significant instability and makes the joint nonfunctional.

Regardless of the severity of the sprain, there is tissue damage or bodily injury and the next step is to determine if there is healing or wound repair. According to Woo, Hildebrand, Watanabe, Fenwick, Papageorgiou and Wang (1999) “…as a result the combination of cell therapy with growth factor therapy may offer new avenues to improve the healing of ligament and tendon. Of course, specific recommendations regarding growth factor selection, and timing and method of application cannot be made at this time. Previous attempts at determining optimal doses of growth factors have provided contradictory results. Although growth factor treatment has been shown to improve the properties of healing ligaments and tendons, these properties do not reach the level of the uninjured tissue.” (p. s320)

According to Dozer and Dupree (2005) “No treatment currently exists to restore an injured tendon or ligament to its normal condition.” (pg. 231).

According to Hauser, Dolan, Phillips, Newlin, Moore and Woldin (2013) “injured ligament structure is replaced with tissue that is grossly, histologically, biochemically and biomechanically similar to scar tissue. Fully remodeled scar tissue remains grossly, microscopically and functionally different from normal tissues” (p. 6) “the persisting abnormalities present in the remodeled ligament matrix can have profound implications on joint biomechanics, depending on the functional demands placed on the tissue. Since remodel ligament tissue is morphologically and mechanically inferior to normal ligament tissue, ligament laxity results, causing functional disability of the affected joints and predisposing other soft tissues in and around the joints further damage.” (p.7) “studies of healing ligaments have consistently shown that certain ligaments do not heal independently following rupture, and those that didn’t feel, do so characteristically inferior compositional properties compared with normal tissue. It is not uncommon for more than one ligament undergo injury during a single traumatic event.” (p.8) “osteoarthritis for joint degeneration is one of the most common consequences of ligament laxity. Traditionally, the pathophysiology of osteoarthritis was thought to be due of aging and wear and tear on the joint, but more recent studies have shown that ligaments play a critical role in the development of osteoarthritis. Osteoarthritis begins when one or more of ligaments become unstable or lax, and the bones began to track improperly and put pressure on different areas, resulting in the rubbing the bone on cartilage. This causes breakdown of cartilage and ultimately leads to deterioration, whereby the joint is reduced to bone on bone, a mechanical problem of the joint that leads to abnormality of the joints mechanics. Hypomobility and ligament laxity have become clear risk factors for the prevalence of osteoarthritis.” (p.9)

Looking globally at the research over the last 16 years, in 1999 it was concluded that the most current treatments to repair or heal the injured ligament do not reach the level of the uninjured tissue. In in 2005 it was concluded that no treatment currently exists to restore an injured tendons or ligaments to its normal condition. In addition the current standard of ligament research in 2013 concluded that that ligaments do not feel independently, but damage ligaments are a direct cause of osteoarthritis and biomechanical dysfunction (abnormality of joint mechanics). The latest research has also concluded that ligament damage or sprains is the key element in osteoarthritis and not simply aging or wear and tear on the joint.

As a result it is now clear based upon the scientific evidence that a soft tissue injury is a connective tissue disorder that has permanent negative sequela and is the cause of future arthritis. This is no longer a debatable issue and those in the medical legal forum who are still arguing “transient soft tissue injuries” are simply rendering rhetoric out of ignorance and a possible ulterior motive because the facts clearly delineate the negative sequella based upon decades of multiple scientific conclusions.

The caveat to this argument is that although there is irrefutable bodily injury with clear permanent sequella, does it also cause permanent functional loss in every scenario? Those are two separate issues and as a result of the function of ligaments, which is to connect bones to bones the arbiter for normal vs. abnormal function is ranges of motion of the joint. That can be accomplished by either a two-piece inclinometer for the spine, which according to the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th Edition (p. 400) is the standard (and is still the medical standard as the 6th Edition refers to the 5th for Ranges of motion). The other diagnostic demonstrable evidence to conclude aberrant function is to conclude laxity of ligaments through x-ray digitizing. Both diagnostic tools confirm demonstrably loss of function of the spinal joints.   

References:

  1. Sprains, Strains and Other Soft Tissue Injuries (2015) American Academy of Orthopedic Surgery, Retrieved from: http://orthoinfo.aaos.org/topic.cfm?topic=A00111
  2. Connective Tissue Disorders (2015) National Institute of Health, Retrieved from: http://www.nlm.nih.gov/medlineplus/connectivetissuedisorders.html
  3. Woo S, Hildebrand K., Watanabe N., Fenwick J., Papageorgiou C., Wang J. (1999) Tissue Engineering of Ligament and Tendon Healing, Clinical Orthopedics and Related Research 367S pgs. S312-S323
  4. Tozer S., Duprez D. (2005) Tendon and Ligament: Development, Repair and Disease, Birth Defects Research (part C) 75:226-236
  5. Hauser R., Dolan E., Phillips H., Newlin A., Moore R. and B. Woldin (2013)  Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics, The Open Rehabilitation Journal (6) 1-20
  6. Cocchiarella L., Anderson G., (2001) Guides to the Evaluation of Permanent Impairment, 5th Edition, Chicago IL, AMA Press

Note about the author: Dr. Mark Studin teaches at the doctoral level as an Adjunct Assistant Professor of Chiropractic at the University of Bridgeport, College of Chiropractic, and an Adjunct Assistant Professor of Clinical Sciences at Texas Chiropractic College. He also teaches at the graduate medical level as a clinical presenter credentialed by the Accreditation Council for Continuing Medical Education in Joint Sponsorship with the State University of New York at Buffalo, School of Medicine and Biomedical Sciences along with being credentialed nationally for chiropractic post-doctoral education in a broad range of clinical subjects. Dr. Studin’s CV can be accessed by CLICKING HERE

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Chiropractic Linked to Increased Immunity

A report on the scientific literature 


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

 

 

From the public’s perspective, we all want to be well and not sick. During the winter months we fear the flu and colds and according to American Public Media (2016) we spend over $40 billion dollars annually just to feel better. Whether that number is accurate, underinflated or overinflated, we can all agree that as a society we spend a significant amount of money just to feel better and not to actually be better. The new buzzword over the last decade has been “wellness” and even hospitals are touting to focus on wellness although most MD’s who staff those hospitals have little to no training in wellness vs. disease care.

 

Personally, I welcome those highly trained MD’s who focus on disease care and our society desperately needs every one of them who is helping to successfully treat sick patients. However, medicine has failed at the “wellness game” and we are starting to see “functional medicine” practitioners who use holistic measures such as vitamins, herb, minerals and other natural means and most are not doctors of medicine, but practitioners who understand that wellness does not necessitate the use of pharmaceuticals. The goal of wellness is to increase our immune system to increase our immunity to various viruses and bacterial causing diseases in part of an overall health plan.

 

According to Wikipedia (2016) “In biology,immunity is the balanced state of having adequate biological defenses to fighting infection,disease, or other unwanted biological invasion, while having adequatetoleranceto avoidallergy, andautoimmune diseases. It is the capability of the body to resist harmfulmicroorganismsorvirusesfrom entering it. Immunity involves both specific and nonspecific components. The nonspecific components act either as barriers or as eliminators of wide range of pathogens irrespective of antigenic specificity. Other components of theimmune systemadapt themselves to each new disease encountered and are able to generate pathogen-specific immunity.” (https://en.wikipedia.org/wiki/Immunity_(medical)

 

According to Jeffries (1991) “The relationship between adrenocortical function and immunity is a complex one. In addition to the well-known detrimental effects of large, pharmacologic dosages of glucocorticoids upon the immune process, there is impressive evidence that physiologic amounts of cortisol, the chief glucocorticoid normally produced by the human adrenal cortex, is necessary for the development and maintenance of normal immunity.” Although many scholarly articles explain the connection between cortisol and the immune system, The Adrenal Fatigue Solution (2016) articulates it well “The hormones produced by your adrenal glands, particularly the stress hormone cortisol, play an important role in regulating your immune system. If your cortisol levels go too low or too high, this can lead to regular infections, chronic inflammation, autoimmune diseases or allergies. Maintaining a balanced level of cortisol is an important part of staying healthy." (http://adrenalfatiguesolution.com/immune-system/)


One of cortisol’s many functions is to reduce inflammation. When your body encounters a pathogen, the immune system responds by quickly attacking it. This causes inflammation, which is often a good thing (it means the immune system is working). In those with healthy immune and endocrine systems, cortisol works to moderate the inflammation caused by an immune system response, but it does not completely eliminate it.”

 

Research done at the University of Madrid Medical School in Madrid Spain and the Department of Health Sciences at the University of Jaen Spain, Plaza-Manzano (2014) and fellow researchers found a link between immunity and chiropractic care. They were studying manipulation, or what chiropractors do when we adjust our patients and the cause for eradication of pain. They concluded that certain neuropeptides, or transmitters in the brain increase when our patients get adjusted. The specific neurotransmitter is called cortisol and according to Smith and Vale (2006) “The principal effectors of the stress response are localized in the paraventricular nucleus (PVN) of the hypothalamus, the anterior lobe of the pituitary gland, and the adrenal gland. This collection of structures is commonly referred to as the hypothalamic-pituitary-adrenal (HPA) axis...In addition to the HPA axis, several other structures play important roles in the regulation of adaptive responses to stress. These include brain stem noradrenergic neurons, sympathetic adrenomedullary circuits, and parasympathetic systems” (pgs. 383-384) . Smith and Vale also reported that balanced cortisol is important in the maintenance of the immune system.

 

It was reported that post-chiropractic adjustment (high velocity, low amplitude spinal manipulation: SM), at 2 hours after the intervention, an increase was found only in the cervical SM group when compared with pre-intervention levels… the cervical SM group showed a significant increase in cortisol plasma concentration immediately post-intervention compared with baseline values” (Plaza-Manzano et al. 2014, p. 235). This verifies that chiropractic care has a direct link to the cortisol-immunity connection through the neuro-endocrine reaction.

 

I would like to leave you with a last and seemingly unrelated statement. Our research team felt it is 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. The Cost of the Common Cold, American Public Media (2016), Retrieved from: http://www.marketplace.org/2011/01/21/life/cost-common-cold
  2. Immunity (2016) Retrieved from: https://en.wikipedia.org/wiki/Immunity_(medical)
  3. Jeffries W., (1991) Cortisol and Immunity, Medical Hypothesis, 34, 198-208
  4. Adrenal Fatigue and Your Immune System (2016). Retrieved from: http://adrenalfatiguesolution.com/immune-system/
  5. Plaza-Manzano, G., Molina-Ortega, F., Lomas-Vega, R., Martinez-Amat, A., Achalandabaso, A., & Hita-Contreras, F. (2014). Changes in biochemical markers of pain perception and stress response after spinal manipulation. Journal of Orthopedic and Sports Physical Therapy, 44(4), 231-239.
  6. Smith, S. M., & Vale, W. W. (2006). The role of hypothalamic-pituitary-adrenal axis neuroendocrine response to stress. Dialogue in Clinical Neuroscience, 8(4), 383-395.
  7. 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


by Anthony P. Calantoni, DC, CCEP, DAAMLP


Title: The Utilization of Long Term Care for Herniated Lumbar Discs with Chiropractic for the Management of Mechanical Spine Pain


Abstract: To explore the utilization of chiropractic treatment consisting of spinal adjusting, axial traction, electrical muscle stimulation, and core stabilization exercise for the management of mechanical spine pain. Diagnostic studies included physical examination, orthopedic and neurological examinations, and lumbar spine MRI.  The patient reports long-term success in reducing pain levels and increasing functionality by having the ability to perform activities of daily living (ADL’s) without frequent flare-ups which he reported of prior to undergoing chiropractic treatment.

Key Words: low back pain, sciatica, chiropractic adjustment, disc bulge, disc herniation, axial  traction, spinal manipulative therapy.

Introduction
On 2/6/2015, a 49 year old male certified nursing assistant, presented for consultation and examination due to a work injury which occurred on 11/12/2001.  The patient stated he sustained a lifting injury that resulted in severe low back pain.  He stated that he was under the care of a pain management interventionist receiving epidural injections in his lumbar spine on an ongoing basis since the injury occurred.  He added that the injections helped him to cope with the elevated pain levels he experienced on a frequent basis. The patient had previously received chiropractic and physical therapy for his injury and reported that the therapies did help him when he was actively treating.  He informed it had been over 3 years since he last treated with chiropractic or physical therapy.

The patient presented to my office on 2/6/2015 with a chief complaint of lumbar pain.  He rated the discomfort as a 7 on a visual analog scale of 10 with 10 being the worst and the pain was noted as being constant (76-100% of the time).  The onset of pain was a result of the work injury described above.  He reported that the pain would aggravate by activities which required excessive or repetitive bending, lifting, and pulling. He stated he experienced flare-up episodes 4-6 times a month depending on the type of activities he was involved with.  The quality of the discomfort was described as aching, gnawing, sharp, shooting, and painful and was noted as being the worst at the end of the day. He stated that when his pain levels were elevated, it would limit his ability of getting a good night sleep.  The patient further noted he was experiencing numbness and tingling in both legs and his right foot.

Prior History:

The patient denied any prior or subsequent low back injuries and/or traumas.

Clinical Findings:

The patient was 5 feet 10 inches and weighed 230 pounds. His sitting blood pressure was 132/86 and his radial pulse was 74 BPM.  The patient’s Review of Systems and Family History were unremarkable.

An evaluation and management exam was performed.  The exam consisted of visual assessment of range of motion, manual muscle tests, deep tendon reflexes, digital and motion palpation, and other neurological and orthopedic tests.  Palpation revealed areas of spasm, hypertonicity, asymmetry, and end point tenderness indicative of subluxation at T12, L2, and L4.  Palpation of the lumbar muscles revealed moderate to severe muscle spasms in the left piriformis, right piriformis, right sacrospinalis, right gluteus maximus, right erector spinae, right quadratus lumborum and right iliacus. He presented with postural deviations that were found using a plumb line assessment showing short right leg (pelvic deficiency), head tilted to the left, high left shoulder and high right hip.  Point tenderness was notably present along the midline of the spine at the L4 and L5 level.

Manual, subjectively rated strength tests were performed on some of the major muscle groups of the lower extremities, based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed., 2001. A rating scale of five to zero was used, with five representing normal muscle strength.  A muscle strength loss of the lower extremities indicates a neurological facilitation resulting from dysfunction in the lumbar spine.  Grade 4 muscle weakness was noted on the right extensor hallicus longus.

Dermatomal sensation was decreased at L4 on the right and decreased at L5 on the right.

Reflex testing was completed and was diminished: 0/+2 on the right patella and +1/+2 on the left patella. The following lumbar orthopedic examinations were performed and found to be positive: Ely's on the right, Hibb's on the right, Iliac compression test and Bragard's on the right.

Lumbar Range of Motion tested with Dual Inclinometers:

Range of Motion            Normal         Examination                       % Deficit

Flexion

90

40

 

56

Extension

25

10

 

60

Left Lateral Flexion

40

20

 

50

Right Lateral Flexion

40

15

 

62

Left Rotation

35

25

 

29

Right Rotation

35

20

 

43

Flexion and left lateral bending were painful at end range. The patient’s limitation to bend is corroborated by the persistent spasticity of lack of motion eliciting pain upon exertion in the lumbar spine.

MRI Results:

The MRI images were personally reviewed.  The lumbar MRI performed on 9/29/2014 revealed anterior positioning of the L4 vertebral body with respect to L5 with a right L4-L5 protrusion compromising the right neural foramen. There is a central herniation at the L5-S1 disc.

Fig. 1,  (A), (B), (C) shows in T2 MRI images (A) is Sagittal and (B) is Axial at L4-L5 and (C) is Axial at L5-S1

Fig. 1 (A)  Sagital

 

Fig. 1 (B) T2 Axial at L4-L5

Fig. 1 (C) T2 Axial at L5-S1




After reviewing the history, physical and neurological examination, and MRI’s it was determined that chiropractic treatment was medically indicated and warranted.  Frequency of treatment was determined 1 time a week.

The patient was placed on a treatment plan consisting of high velocity low amplitude chiropractic adjustments, axial traction, electrical muscle stimulation, and core stabilization exercise. The patient responded in favorable fashion to the chiropractic treatment over a 6 month period.  The patient demonstrated subjective and objective improvement and his care plan was reduced to one time every two weeks to manage and modulate pain levels associated with his permanent condition.

On follow-up re-evaluation approximately 9 months after starting supportive treatment the patient showed improvement in range of motion testing. 

Lumbar Range of Motion was tested with Dual Inclinometers:

Range of Motion            Normal         Examination                       % Deficit

Flexion

90

70

 

13

Extension

25

20

 

20

Left Lateral Flexion

40

35

 

12

Right Lateral Flexion

40

30

 

25

Left Rotation

35

30

 

15

Right Rotation

35

25

 

29

The patient also reported a reduction in pain levels rating the low back discomfort as a4 on a scale of 10 with 10 being the worst and the pain was noted as beingintermittent 25 to 50% of the time. Decreased muscle spasm in the lumbar paraspinal muscles was noted as well as better symmetry and tonicity.  The patient reported the ability of getting a better night sleep and waking up in the morning with less rigidity and achiness.  He stated he was able to perform his work duties and activities of daily living with less flare-ups and exacerbations occurring only 1-2 times a month.  The core training exercises we worked on have helped stabilize the patient’s spine and protected it from reinjuring the already injured tissues. 

Conclusion:

Chiropractic care has been shown to be both safe and effective in treating patients with disc herniation and accompanying radicular symptoms1-4. Spinal chiropractic adjustive therapy has been proven to modulate pain6. This patient presented with chronic low back pain sequela to an injury that occurred over 13 years ago.  The patient had prior success in reduction of pain when he was treating with chiropractic in the past then discontinued treatment.  The patient has been treating with pain management intervention since the injury occurred and it has helped him reduce his pain but has done minimal for him from a functional and mechanical standpoint. The history and exam indicated the presence of 2 herniated discs in the lumbar spine. Lumbar MRI’s were ordered prior to being evaluated and the images were viewed to establish an accurate diagnosis, prognosis, and treatment plan. Long term chiropractic treatment has been utilized successfully in this case study to reduce pain levels and restore the patient’s functional capacity of performing activities of daily living and work duties with less flare ups and exacerbations of low back pain.     

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

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

  1. 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 Herniation 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. Hahne AJ, Ford JJ, McMeeken JM, "Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review,"Spine35 (11): E488–504 (2010).
  3. Rubinstein SM, van Middelkoop M, et. al, "Spinal manipulative therapy for chronic low-back pain,"Cochrane Database Syst Rev(2): CD008112. doi:10.1002/14651858.CD008112.pub2. PMID 21328304.
  4. Hoiriis, K. T., Pfleger, B., McDuffie, F. C., Cotsonis, G., Elsangak, O., Hinson, R. & Verzosa, G. T. (2004). A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. Journal of Manipulative and Physiological Therapeutics, 27(6), 388-398.
  5. 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.  Manuscript in preparation. 
  6. Whedon, J. M., Mackenzie, T.A., Phillips, R.B., & Lurie, J.D. (2014). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69. Spine,  (Epub ahead of print) 1-33.

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Published in Case Reports

Sleep Disorder Improvements

 Have Been Linked to Chiropractic Care

A report on the scientific literature 


 

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

 

“A sleep disorder, or somnipathy, is a medical disorder of the sleep patterns of a person or animal. Some sleep disorders are serious enough to interfere with normal physical, mental, social and emotional functioning. Disruptions in sleep can be caused by a variety of issues, from teeth grinding (bruxism) to night terrors. When a person suffers from difficulty falling asleep and/or staying asleep with no obvious cause, it is referred to as insomnia.

 

Sleep disorders are broadly classified into dyssomnias, parasomnias, circadian rhythm sleep disorders involving the timing of sleep, and other disorders including ones caused by medical or psychological conditions and sleeping sickness. Some common sleep disorders include sleep apnea (stops in breathing during sleep), narcolepsy and hypersomnia (excessive sleepiness at inappropriate times), cataplexy (sudden and transient loss of muscle tone while awake), and sleeping sickness (disruption of sleep cycle due to infection). Other disorders include sleepwalking, night terrors and bed wetting. Management of sleep disturbances that are secondary to mental, medical, or substance abuse disorders should focus on the underlying conditions.” (retrieved from: https://en.wikipedia.org/wiki/Sleep_disorder)

 

According to the Centers for Disease Control and Prevention “Sleep is increasingly recognized as important to public health, with sleep insufficiency linked to motor vehicle crashes, industrial disasters, and medical and other occupational errors.Unintentionally falling asleep, nodding off while driving, and having difficulty performing daily tasks because of sleepiness all may contribute to these hazardous outcomes. Persons experiencing sleep insufficiency are also more likely to suffer from chronic diseases such as hypertension, diabetes, depression, and obesity, as well as from cancer, increased mortality, and reduced quality of life and productivity.1 Sleep insufficiency may be caused by broad scale societal factors such as round-the-clock access to technology and work schedules, but sleep disorders such as insomnia or obstructive sleep apnea also play an important role.An estimated 50-70 million US adults have sleep or wakefulness disorder. Notably, snoring is a major indicator of obstructive sleep apnea.

 

According to SleepMed (2015):

 

Insomnia Statistics

1.

20-40% of all adults have insomnia in the course of any year

   
 2.

1 out of 3 people have insomnia at some point in their lives

   
 3.

Over 70 million Americans suffer from disorders of sleep and wakefulness

   
 4.

Of those, 60% have a chronic disorder


Narcolepsy Statistics


 1.

Affects as many as 200,000 Americans

   
 2.

Fewer than 50,000 are diagnosed

   
 3.

8 to 12% have a close relative with the disease

   
 4.

Affects men slightly more than women

   
 5.

20 to 25% of people with narcolepsy have all four symptoms
(excessive daytime sleepiness, sudden loss of muscle function, sleep paralysis, hallucinations)


Children & Sleep Statistics

 1.

Over 2 million children suffer from sleep disorders

   
 2.

Estimated that 30 to 40% of children to not sleep enough

   
 3.

Children require an average of 9 to 10 hours of sleep each night


Women & Sleep Statistics

 1.

Women are twice as likely as men to have difficulty falling and staying asleep

   
 2.

Pregnancy can worsen sleep patterns

   
 3.

Menopause and hormone changes cause changes in sleep


Older Adult Statistics

 1.

Over half of those over the age of 65 experience disturbed sleep

   
 2.

Those over 65 make up about 13% of the US population, but consume over 30% of prescription drug and 40% of sleeping pills


General Statistics


 1.

Adults require an average of 8 to 8.5 hours of sleep each night

   
 2.

Sleep problems add an estimated $15.9 billion to national health care costs

   
 3.

84 classifications of sleep disorders exist

 

Research done at the University of Madrid Medical School in Madrid Spain and the Department of Health Sciences at the University of Jaen Spain, Plaza-Manzano (2014) and fellow researchers found a link between sleep disorders and chiropractic care. They were studying manipulation, or what chiropractors do when we adjust our patients and the cause for eradication of pain. They concluded that certain neuropeptides, or transmitters in the brain increase when our patients get adjusted. The specific neurotransmitter is called Orexin and is commonly known in medical terms as hypocretins.

 

 

According to Ebrahim (2002) and fellow researchers “have an important role in sleep and (mental) arousal states. They state, “The hypocretins are thought to act primarily as excitatory neurotransmitters…suggesting a role for the hypocretins in various central nervous functions related to noradrenergic innervation, including vigilance, attention, learning, and memory. Their actions on serotonin, histamine, acetylcholine and dopamine neurotransmission is also thought to be excitatory and a facilitatory role on gamma-aminobutyric acid (GABA) and glutamate-mediated neurotransmission is suggested” (p. 227). If we focus simply on serotonin, that is responsible for mood, appetite and sleep and regarding the latter effects many sleep patterns if imbalanced or depleted.

 

A chiropractic adjustment has proven to increase the orexin or hypocretins in the human body, which has a direct effect on the production of serotonin in the human body. Serotonin has been known for many years and recognized in the scientific literature for playing a role in the modulation of sleep.  Although more research is still needed to quantify the results, this now gives a verified scientific explanation to the results chiropractic patients have been experiencing over the last century.

 

 

As with all of my 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. Sleep Disorder (October 2015), Retrieved from: https://en.wikipedia.org/wiki/Sleep_disorder
  2. Insufficient Sleep is a Public Health Problem (September 2015) Retrieved from: http://www.cdc.gov/features/dssleep/
  3. Sleep Statistics, (2016), retrieved from: http://www.sleepmedsite.com/page/sb/sleep_disorders/sleep_statistics
  4. Plaza-Manzano, G., Molina-Ortega, F., Lomas-Vega, R., Martinez-Amat, A., Achalandabaso, A., & Hita-Contreras, F. (2014). Changes in biochemical markers of pain perception and stress response after spinal manipulation. Journal of Orthopedic and Sports Physical Therapy, 44(4), 231-239.
  5. Ebrahim, I. O., Howard, R. S., Kopelman, M. D., Sharief, M. K., & Williams, A. J. (2002). The hypocretin/orexin system. Journal of the Royal Society of Medicine, 95(5), 227-230.
  6. 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