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

 

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

William J. Owens DC, DAAMLP

A report on the scientific literature

 

INTRODUCTION

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

 

 

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

 

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

HERNIATED DISCS

 

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

 

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

 

SPINAL DEGENERATION

 

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

Viroslav (2016) reported:

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

 

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

 

CHIROPRACTIC CARE

Kressig et. Al (2016) reported:

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

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

 

CONCLUSION

 

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

 

Links to other articles:

 

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

 

Spinal Fusion vs. Chiropractic for Mechanical Spine Pain

 

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

 

Disc Herniations and Low Back Pain Post Chiropractic Care

 

References:

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

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Published in Neck Problems

Case Report:

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

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

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

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

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

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

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

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

Appearance: in pain

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

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

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

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

Imaging:

Figure 1: T2 Sagittal Cervical Spine MRI

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

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

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

References:

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

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

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

204–209.

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

           

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Published in Case Reports

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

 

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

William J. Owens DC, DAAMLP

A report on the scientific literature      

 

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

 

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

 

Docking et. Al (2015) reported:

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

 

 

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

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

 

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

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

 

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

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

 

Shaheed et al. (2014) continued

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

 

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

 

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

 

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

 

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

  

References:

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

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Published in Low Back Problems

CASE REPORT: The chiropractic management of cervical Myelomalacia

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

Title:  The chiropractic management of cervical Myelomalacia

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

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

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

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

Clinical Findings:

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

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

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

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

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

Hand tested

Rep one

Rep two

Rep three

Right

28

30

30

Left

18

18

20

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

An alert was placed on this study.  

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

         (B)   Axial T2 MRI of the Cervical Spine.

A

B

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

 

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

 

DISCUSSION: 

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

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

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

 

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

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

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

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

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

 

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

 

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

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

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

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

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

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

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

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

REFERENCES: 

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

 

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Published in Case Reports

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

 

98.5% of chiropractic patients had their expectations exceeded

 

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

William J. Owens DC, DAAMLP

A report on the scientific literature

 

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

 

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

 

“We did not observe improvements in health outcomes commensurate with the increasing costs over time," lead researcher Brook I. Martin, MPH, and colleagues wrote. "Spine problems may offer opportunities to reduce expenditures without associated worsening of clinical outcomes." (http://www.webmd.com/back-pain/news/20080212/86-billion-spent-on-back-neck-pain)

 

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

 

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

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

 

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

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

 

 

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

 

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

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

 

 

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

 

 

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

 

References:

  1. Field J., Newell D. (2016) Clinical Outcomes In a Large Cohort of Musculoskeletal Patients Undergoing Chiropractic Care In the United Kingdom: A Comparison of Self and National Health Service Referral Routes, Journal of Manipulative and Physiological Therapeutics, 39(1), pgs. 54-62
  2. Boyles S., $86 Billion Spent on Back, Neck Pain, WebMD (2016) Retrieved from: http://www.webmd.com/back-pain/news/20080212/86-billion-spent-on-back-neck-pain
  3. Best Practice. (2016). In Wikipedia. Retrieved from http://en.wikipedia.org/wiki/Best_practice
  4. Evidence-Based Practice. (2016). In Wikipedia. Retrieved from http://en.wikipedia.org/wiki/Evidence-based_practice
  5. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270.

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Published in Neck Problems

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

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

Work Related Injuries, Recurring Low Back Pain, Chronic Care and Chiropractic Treatment:

A Proven Solution to Save Federal, State and Private Insurers $2,871,485,223

 

A report on the scientific literature 


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


Published in Dynamic Chiropractic 8/26/2011 

 

Low back pain and its treatment are a worldwide epidemic in human suffering and as a result, an economic burden to federal, state, public and self-insured risk takers who insure the injured. In 2009, Russo, Weir and Elixhauser reported that hospital stays for low back pain were 3.9 out of every 1000 people aged 55-64 years. That was rated as the #8 reason for hospital stays and fell closely behind cardiac conditions and degenerative arthritis. While low back pain has been well chronicled, recurring low back pain and the necessity for chronic care is now beginning to realize results that necessitate the proper approach to mitigate its frequency, duration and economic impact as sequella.

A very significant component of low back patient is its recurrence after initial care has been rendered as well as complications that ensue. Wasiak, Kim and Pransky reported in 2006 that, "Recent studies suggest that acute low back pain evolves into a chronic or recurrent condition more often than previously suspected" (p. 220). They went on to report that 40% of individuals with recurring low back pain sought additional care when the pain recurred and 42.9% of those had continued care and work disability lasting more than 201 days, underscoring the significance of the problem.

According to Dagenais, Caro and Haldeman in 2007, "The economic burden of a disease is the sum of all costs associated with that condition which would not otherwise be incurred if that disease did not exist. Given the many categories of costs that must be considered, it can be challenging to fully estimate the economic burden of an illness as data are often unavailable. The term 'cost' in health economics refers to the value of the consequences of using a particular good or service rather than its price...Despite this example, it should be made clear that estimating the economic burden of a disease is not simply a matter of tabulating the amount reimbursed for all clinician services related to a particular diagnosis. The total cost of illness—or economic burden—has three components: (1) direct (medical and nonmedical) costs; (2) indirect costs; and (3) intangible costs" (p. 9). Although indirect and intangible costs are significant burdens, this paper will focus solely on direct costs.

When considering direct costs for work related claims, studies indicate that non-work related indemnity plans should be included for work related low back injuries. Lipscomb, Dement, Silverstein, Cameron, and Glazner reported in 2009 that, "The private health insurance payment rates for workers with one work-related injury were 40% higher than for those with no history of work injury..." (p. 1188). The reasons are simple; indemnity carriers are victims of many workers' compensation carrier tactics created by the indemnity carriers, as reported by Griffin (2007), to deny, delay and defend. Patients need care and will access any system at their disposal so they can get necessary care and return to a normal, pain free lifestyle, leaving the indemnity carriers to absorb those financial costs. Although this is a significant factor, it is difficult to assign numbers and amounts that are directly tied to work related injuries, although those statistics undoubtedly tally in the billions.

Utilizing the Joint Report to the Governor by New York State Workers’ Compensation Board in 2009 as a reference, in 2004 the total number of claims in New York was 143,667 and out of those claims, 19.3% were low back related. The total costs for treating low back was $579,675,476.96, calculated for inflation to 2011 (Tom's Inflation Calculator, 1997-2011, http://www.halfhill.com/inflation.html). This equates to $29.88 per resident to treat work related low back pain. Nationally, this equates to $9,262,855,559 based upon US Census statistics.

Cifuentes, Willets and Wasiak (2011) compared the treatment of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability after a 15 day absence and return to disability. Anyone with less than a 15 day absence was excluded from the study.

The study concluded that chiropractic care during the health maintenance care period resulted in:

16% Decrease in disability duration of first episode compared to physical therapy

240% Decrease in disability duration of first episode compared to medical physician's care

6.6% Decrease in opioid (narcotic) use during maintenance care compared to physical therapy care

17.2% Decrease in opioid (narcotic) use during maintenance care compared medical physician's care

32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care

The study concluded that chiropractic care during the disability episode resulted in:

24% Decrease in disability duration of first episode compared to physical therapy

250% Decrease in disability duration of first episode compared to medical physician's care

5.9% Decrease in opioid (narcotic) use during maintenance care compared to physical therapy care

30.3% Decrease in opioid (narcotic) use during maintenance care compared medical physician's care

19% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

43% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care

Based upon the Joint Report to the Governor (2009) and the statistics rendered by Cifuentes et al. (2011), the savings with chiropractic care utilized exclusive from medicine and physical therapy ranges from $1,759,942,556 with physical therapy to $3,983,027,890 with medicine. Understanding that most medical physicians utilize physical therapy as a primary tool for back related pain, we will average the savings to $2,871,485,223 by utilizing chiropractic care.

Cifuentes et. al (2011) started by stating, "Given chiropractors are proponents of health maintenance care...patients with work related Low back pain who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used (p. 396). They concluded by stating, " After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type (Cifuentes et. al, 2011, p. 404).

References

1. 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

2. Wasiak, R., Kim, J., & Pransky, G. (2006). Work disability and costs caused by recurrence of low back pain: Longer and more costly than in first episodes. Spine, 31(2), 219-225.

3. Dagenais, S., Caro, J., & Haldeman, S. (2008). A systematic review of low back pain cost of illness studies in the United States and internationally. Spine, 8(1), 8-20.

4. Lipscomb, H., Dement, J., Silverstein, B., Cameron, W., & Glazner J. (2009). Who is paying the bills? Health care costs for musculoskeletal back disorders, Washington State Union Carpenters, 1989-2003. Journal of Occupational and Environmental Medicine, 51(10), 1185-1192.

5. Griffin, D. (2007, February 7). Insurance companies fight paying billions in claims. Anderson Cooper Blog 360°, Retrieved from http://www.cnn.com/CNN/Programs/anderson.cooper.360/blog/2007/02/ insurance-companies-fight-paying.html

6. New York State Workers’ Compensation Board (2009, March). Joint report to the Governor, From the Superintendant of Insurance and Chair, Workers' Compensation Board, summarizing and benchmarking workers' compensation data and examining progress on prior recommendations for improvement in data collection, Retrieved from http://www.wcb.state.ny.us/content/main/TheBoard/ 2009DataCollectionReport.pdf

7. Halfhill, T. R. (1997-2011). Tom's Inflation Calculator. Retrieved from http://www.halfhill.com/inflation.html

8. U.S. Census Bureau (2010, December 22). U.S. POPClock Projection, Retrieved from http://www.census.gov/population/www/popclockus.html

9. Cifuentes, M., Willets, 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.

 

 

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Published in Work Injuries
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