Chiropractic & Central Afferent Inhibition:

A Chiropractic Care Path & Mechanism for Chronic Pain, Tremors, Spatial and Inhibitory Distortion

 

By Mark Studin

William J. Owens

Michael Barone

A report on the scientific literature 

 

Although it is unusual in the literature to place a disclaimer in the beginning of an article, we want to ensure that our reporting is not inflammatory since the foundation of this article was written with the following limitation in our primary literary source, Haavik, Niazi, Holt and Murphy (2017) reported:

 

This study was not designed to test the efficacy of chiropractic care for treating chronic pain; therefore, conclusions about efficacy cannot be drawn from our findings. The study did not include randomization with an adequate control group, thus limiting the interpretations that can be made about the changes in pain observed in the trial. Causation cannot be claimed. (pg. 135)

 

Although Haavik, et al. reported limitations in their study, the results cannot be overlooked or minimized, particularly when those results match what doctors working within a “Best Practice Model” (the patient and doctor feedback component) have been reporting for decades. Additionally, in the clinical setting, this information provides direction to practitioners searching for answers although the mechanisms are not yet fully understood. Results often don’t mandate detailed knowledge of the mechanism and that is the primary reason why both “evidenced based” and “best practice” models must be embraced and combined (pure literature results with doctor and patient feedback or experiences) as a matter of public health.

 

When we consider central afferent neurological input, the inability to inhibit those signals leads to sensorimotor disturbances that are found in the chronicity of many chronic pain conditions, essential tremors, dystonia and other central spatial and temporal mismatches. In addition, we must consider to the long-term negative sequalae of those conditions, such as brain shrinkage.

 

Baliki, Geha, Apkarian and Chialvo (2008) reported:

 

Recent studies have demonstrated that chronic pain harms cortical areas unrelated to pain, long-term pain alters the functional connectivity of cortical regions known to be active at rest, i.e., the components of the “default mode network” (DMN). This DMN is marked by balanced positive and negative correlations between activity in component brain regions. In several disorders, however this balance is disrupted. Studying with fMRI [functional MRI] a group of chronic back pain patients and healthy controls while executing a simple visual attention task, we discovered that chronic back pain patients, despite performing the task equally well as controls, displayed reduced deactivation in several key default mode network regions. These findings demonstrate that chronic pain has a widespread impact on overall brain function, and suggest that disruptions of the default mode network may underlie the cognitive and behavioral impairments accompanying chronic pain.” (pg. 1398)

 

“The existence of a resting state in which the brain remained active in an organized manner, is called the ‘default mode of brain function. The regions exhibiting a decrease in activity during task performance are the component members of the “default-mode network” (DMN), which in concerted action maintain the brain resting state. Recent studies have already demonstrated that the brain default mode network is disrupted in autism, Alzheimer’ disease, depression, schizophrenia and attention deficit hyperactivity disorder, suggesting that the study of brain resting activity can be useful to understand disease states as well as potentially provide diagnostic information.”  (pg. 1398)

 

This is important since for the first time we are starting to see a published correlation between spinal function, chronic pain and central nervous system changes.  This is what our founders have observed yet were unable to prove.

 

“Thus, the alterations in the patient’s brain at ‘rest’ can result in a different default mode network organization. In turn, potential changes in the default-mode network activity could be related to symptoms (other than pain) commonly exhibited by chronic pain patients, including depression and anxiety, sleep disturbances, and decision-making abnormalities, which also significantly diminish their quality of life… chronic pain patients display a dramatic alteration in several key default-mode network regions, suggesting that chronic pain has a widespread impact on overall brain function” (pg. 1398)

 

This information is pointing to the fact that a doctor of chiropractic should be involved in the triage and treatment of these patients and part of a long-term spinal care program. 

 

Baliki Et. Al (2008) continued “Consistent with extensive earlier work examining visuospatial attention tasks, dominant activations were located in posterior parietal and lateral prefrontal cortices, whereas deactivations occurred mainly within Pre-Frontal Cortex and Posterior Cingulate/Cuneate Cortexes. Although activations in chronic back pain patients’ and controls’ brains were similar, chronic back pain patients exhibited significantly less deactivations than healthy subjects in Pre-Frontal Cortex, amygdala, and Posterior Cingulate/Cuneate Cortexes.  The focus was on identifying differences in the way chronic back pain patients’ brains process information not related to pain. This is the first study demonstrating that chronic back pain patients exhibit severe alterations in the functional connectivity between brain regions implicated in the default mode network. It seems that enduring pain for a long time affects brain function in response to even minimally demanding attention tasks completely unrelated to pain. Furthermore, the fact that the observed task performance, compared with healthy subjects, is unaffected, whereas the brain activity is dramatically different, raises the question of how other behaviors are impaired by the altered brain activity” (pg. 1399).

 

“However, the disruption of functional connectivity observed here with increased chronic back pain duration may be related to the earlier observation of brain atrophy increasing with pain duration also in chronic back pain patients. Patient’s exhibit increased pre-frontal cortex activity in relation to spontaneous pain, in addition to dorsolateral prefrontal cortex atrophy. Therefore, the decreased deactivations described here may be related to the dorsolateral pre-frontal cortex /pre-frontal cortex mutual inhibitory interactions perturbed with time. If that is the case, it will support the idea of a plastic, time-dependent, reorganization of the brain as patients continue to suffer from chronic back pain. Mechanistically, the early stages of this cortical reorganization may be driven by peripheral and spinal cord events, such as those that have been documented in animal models of chronic pain, whereas later events may be related to coping strategies necessary for living with unrelenting pain. It is important to recognize that transient but repetitive functional alterations can lead to more permanent changes. Accordingly, long term interference with normal activity may eventually initiate plastic changes that could alter irreversibly the stability and subsequently the conformation of the resting state networks” (pg. 1401).

 

Essential Tremors which, according to Wikipedia

 

Essential tremor (ET, also referred to as benign tremor, familial tremor, or idiopathic tremor) is the most common movement disorder; its cause is unknown. It typically involves a tremor of the arms, hands or fingers but sometimes involving the head, vocal cords or other body parts during voluntary movements such as eating and writing.[1] It is distinct from Parkinson's disease—and often misdiagnosed as such—although some individuals have both conditions. Essential tremor is commonly described as an action tremor (i.e., it intensifies when one tries to use the affected muscles) or postural tremor (i.e., present with sustained muscle tone) rather than a resting tremor, such as is seen in Parkinson’s, which is usually not included among its symptoms. (https://en.wikipedia.org/wiki/Essential_tremor)

 

Restuccia, Valeriani, Barba, Le Pera, Bentivoglio, Albanese and Tonali (2003) reported:

 

...our present data seem to indicate that somatomotor cortical areas play an important role in generating ET. This finding can be important in the future understanding of its pathophysiologic mechanisms, as well as in its management. (pg. 127)

 

This study suggests that somatosensory cortical areas plays an important role, therefore the afferents “feeding” that region is critical in normalizing function of the cortex a that region. Another negative sequela of aberrant input.

When we consider one potential etiology of maladaptive plastic changes in the brain that can cause chronic pain, essential tremors, brain shrinkage and a host of other maladies, regulatory control of the impulses must be considered and interfered with. The lack of gating (inhibition) will lead to an overflow of impulses and crate a negative cascade that can lead to chronic and often permanent changes. Haavik, Niazi, Holt and Murphy (2017) reported:

 

Thus, distorted sensory information is thought to disturb SMI (sensorimotor integration) and impair accurate motor control. In normal circumstances, 2 inputs that engage the sensory system have a reciprocally inhibitory action that gates the total amount of signal at all central levels, spatially and temporally limiting the amount of input engaging the CNS. This is thought to prevent sensory “overflow.” The defective gating may cause an input-output mismatch in specific motor programs, and such mismatches in motor programs may in themselves lead to production of distorted sensory information and issue of less than ideal motor commands. In this way, the chronicity of the problem can be maintained via a self-perpetuating mechanism. The reduced frontal N30 SEP (somatosensory evoked potential) peak ratio observed in the current study after 12 weeks of chiropractic care may reflect a normalization of pain-induced central maladaptive plastic changes and may reflect one mechanism for the improvement of functional ability reported following chiropractic adjustment or manipulation. (pg. 134)

 

The N30 ratio change represented on average a 37.4% decrease following the 12 weeks of chiropractic care. The N30 MU (median-ulnar) amplitude changes following chiropractic care represented an 18.0% decrease in amplitude compared with baseline (pg. 131) Alongside this change in the N30 SEP ratio, the subjects reported a decrease in both current pain and average pain over the last week. A control period of 2 weeks of no intervention resulted in no significant changes in any SEP peak ratio. (pg. 134)

 

When considering care paths for this population of patients, the following was reported by Haavik, Niazi, Holt and Murphy (2017) reported:

 

The 2-week control period, during which no intervention was applied, was followed by a 12-week chiropractic care intervention. During the 12 weeks of chiropractic care, the chiropractor assessed and treated the subject as she would any other chronic pain patient. The participating chiropractor (H.H., with 7 years clinical experience) assessed the spine for segmental dysfunction using tenderness on palpation and passive intervertebral and global motion of the spine. Other treatments included as part of chiropractic care were exercises, peripheral joint adjustments/manipulations, soft tissue therapy, and pain education if deemed by the chiropractor to be appropriate based on history and examination. The chiropractic adjustment/manipulation was the delivery of a high-velocity, low-amplitude thrust to dysfunctional spinal segments. (pgs. 129-130)

 

The changes observed conclude (with the aforementioned disclaimer that more research is needed) that chiropractic is a verifiable treatment option. Haavik, Niazi, Holt and Murphy (2017) continued:

 

The changes observed in dual SEP ratios after several weeks of chiropractic care in a chronic pain population suggest that this treatment option may improve gating of peripheral afferent input to the brain, thus improving impaired SMI in cortical motor areas and improving processing of motor programs. Impaired SMI and defective motor programming is known to be present in various chronic pain populations and is implicated in the clinical symptomatology. We know from the literature that in normal circumstances, afferent input to the motor system leads to finely tuned activation of neural elements and ultimately results in the correct execution of movement. Multiple experimental and clinical studies have confirmed the importance of sensory feedback to the motor system. Thus, distorted sensory information is thought to disturb SMI and impair accurate motor control. In normal circumstances, 2 inputs that engage the sensory system have a reciprocally inhibitory action that gates the total amount of signal at all central levels, spatially and temporally limiting the amount of input engaging the CNS. This is thought to prevent sensory “overflow.” The defective gating may cause an input-output mismatch in specific motor programs, and such mismatches in motor programs may in themselves lead to production of distorted sensory information and issue of less than ideal motor commands. In this way, the chronicity of the problem can be maintained via a self-perpetuating mechanism. The reduced frontal N30 SEP peak ratio observed in the current study after 12 weeks of chiropractic care may reflect a normalization of pain-induced central maladaptive plastic changes and may reflect one mechanism for the improvement of functional ability reported following chiropractic adjustment or manipulation. (pgs. 134-135)

 

Haavik, Niazi, Holt and Murphy (2017) concluded:

 

After the 12 weeks of chiropractic care, when he was also feeling better symptomatically, this was reversed, and all of his MU traces for all SEP peak complexes were smaller in amplitude than his M + U trace, indicating a greater level of central reciprocal inhibition was occurring… Thus, if sensory “overflow” occurs, then incomplete processing of this incoming signal may occur in the brain, resulting in its perceiving not only excessive, but also spatially distorted information. (pg. 135)

 

The N9 SEP peak (the “N” is a location for electrodes) reflects the afferent signal over the brachial plexus before it enters the CNS, and thus can be used to ensure that the incoming signal is consistent before and after an intervention. Furthermore, these experiments demonstrated that the subjects' N30 SEP peak ratios decreased significantly after a single chiropractic manipulation of the cervical spine. As the N30 SEP peak is thought to reflect early cortical SMI, the authors argued that their results suggest that the subject's SMI networks' ability to suppress the dual input after the adjustment was increased. The N30 SEP peak ratios remained decreased even after repeating the 20-minute repetitive thumb abduction task. This suggested that the treatment effects appear to have altered the way in which each subject's CNS responded to the repetitive thumb typing task.

 

When considering treating chronic pain, dystonia, essential tremor or any other type of patient where there are spatial (distorted or excessive afferent) input issues, the above care path (treatment plan) should be considered. By not completed a complete treatment protocol might expose your patient to a chronic issue that may become permanent if the maladaptive cortical changes persist over time. Since there are no timetables for how long a patient can withstand for the issue to become permanent and there is an indexed peer reviewed suggestion of correction, that must be adhered as a minimum until further evidence suggests otherwise. In addition, no two patients are alike and the treatment plan should be guided with a full clinical reevaluation and consider performing that examination every 30 days of active care considering all facets, both history and clinical.

 

 

References:

  1. Haavik, H., Niazi, I. K., Holt, K., & Murphy, B. (2017). Effects of 12 Weeks of Chiropractic Care on Central Integration of Dual Somatosensory Input in Chronic Pain Patients: A Preliminary Study. Journal of manipulative and physiological therapeutics40(3), 127-138.
  2. Restuccia, D., Valeriani, M., Barba, C., Le Pera, D., Bentivoglio, A., Albanese, A. & Tonali, P. (2003). Abnormal gating of somatosensory inputs in essential tremor. Clinical neurophysiology114(1), 120-129.
  3. Baliki N., Geha P., Apkarian A., Chialvo D., (2008) Beyond Feeling: Chronic Pain Hurts the Brain, disrupting the Default-Mode Network Dynamics, Journal of Neurosciences 28(6) 1398-1403
  4. Essential Tremor (2017) retrieved from: https://en.wikipedia.org/wiki/Essential_tremor

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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, Chronic Back Pain and Brain Shrinkage:

 

A better understanding of Alzheimer’s, Dementia, Schizophrenia, Depression and Cognitive Disorders and Chiropractic’s Role

 

A Review of the Mechanisms

 

A report on the scientific literature 


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

William J. Owens DC, DAAMLP

Frank Zolli DC, EdD

 

 

Reference: 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(10) 36-38, 4042, 44-45

 

Since its inception in 1895, Chiropractic has been focused on the spine and its role in the total health and function of the human body.  Throughout its history, the profession has moved from a “bone on nerve” model to a “biomechanical/functional” model however as we evolve (through scientific findings) in our understanding of the true nature of the chiropractic principles, we now conclusively know that chiropractic results are based on the central nervous system and the detrimental role of spinal dysfuntion in the maintenance of homeostasis and “dis-ease” in the human body.  This article bridges the gap between the foundational chiropractic principles taught by the Palmers and their predecessors and today’s breakthrough findings and the correlation between unchecked spinal dysfunction AKA chronic spine pain and its effect on the brain. 

 

 

Peterson ET. AL. (2012) reported, “The … prevalence of low back pain is stated to be between 15% and 30%, the 1-year period prevalence between 15% and 45%, and a life-time prevalence of 50% to 80%” (pg. 525). While acute pain is a normal short-lived unpleasant sensation triggered in the nervous system to alert you to possible injury with a reflexive desire to avoid additional injury, chronic pain is different. Chronic pain persists and fundamentally changes the patient’s interaction with their environment. In chronic pain it is well documented that aberrant signals keep firing in the nervous system for weeks, months, even years.1 Baliki Et. AL. (2008) stated “Pain is considered chronic when it lasts longer than 6 months after the healing of the original injury. Chronic pain patients suffer from more than pain, they experience depression, anxiety, sleep disturbances and decision making abnormalities that also significantly diminish their quality of life” (pg. 1398). Chronic pain patients also have shown to have changes in brain function in sufferers with Alzheimer’ disease, depression, schizophrenia and attention deficit hyperactivity disorder giving further insight into disease states. In addition, chronic pain has a cause and effect on the morphology of the spinal cord and the brain in particular resulting in a process termed “linear shrinkage”, which has been suggested to cause ancillary negative neurological sequella.  

 

Apkarian Et. Al. (2004) reported that “Ten percent of adults suffer from severe chronic pain. Back problems constitute 25% of all disabling occupational injuries and are the fifth most common reason for visits to the clinic; in 85% of such conditions, no definitive diagnosis can be made.” (pg. 10410) Apkarian Et. AL. (2011) reported “Clinically, the most relevant conditions in which human brain imaging can have a substantial impact are chronic conditions, as they remain most poorly understood and minimally treatable by existing (author’s note: medical) therapies” (pg. S53). So in essence what these authors are stating is although many people suffer from chronic spine pain, very few of them are actually diagnosed with a “medical condition” AKA an “anatomical” lesion.  The chiropractic profession has long professed the lesion is actually functional and based on aberrant spinal biomechanics [Subluxation]. 

 

 

When we look at the human population on a larger scale and from a medical perspective, we see there is a deficit in spinal care paths with resultant negative sequella of chronic back pain.  Alkarian’s conclusion was querying allopathic doctors who have little to no training or experience in treating mechanical back pain, AKA spinal dysfunction of biomechanical origin, AKA chiropractic subluxation complex.  Raissi ET. Al. (2005) reported regarding medical providers, “(92.2%) believed that musculoskeletal education had not been sufficient in general practitioner training courses. Of the respondents, 56.8% had visited at least one disabled patient during the previous month, while 11% had visited more than 10 in the same period, but 84.3% had not studied disabilities. Musculoskeletal physical examination was the most needed educational field cited by general practitioners” (pg. 167).

 

Day Et. Al. (2007) reported that only 26% of fourth year Harvard medical students had a cognitive mastery of physical medicine (pg. 452). Schmale (2005) reported “Incoming interns at the University of Pennsylvania took an exam of musculoskeletal aptitude and competence, which was validated by a survey of more than 100 orthopaedic program chairpersons across the country. Eighty-two percent of students tested failed to show basic competency. Perhaps the poor knowledge base resulted from inadequate and disproportionately low numbers of hours devoted to musculoskeletal medicine education during the undergraduate medical school years. Less than 1⁄2 of 122 US medical schools require a preclinical course in musculoskeletal medicine, less than 1⁄4 require a clinical course, and nearly 1⁄2 have no required preclinical or clinical course. In Canadian medical schools, just more than 2% of curricular time is spent on musculoskeletal medicine, despite the fact that approximately 20% of primary care practice is devoted to the care of patients with musculoskeletal problems. Various authors have described shortcomings in medical student training in fracture care, arthritis and rheumatology, and basic physical examination of the musculoskeletal system (pg. 251).  

 

With continued evidence of lack of musculoskeletal medicine and a subsequent deficiency of training in spine care, particularly of biomechanical [Subluxation] orientation, the question becomes which profession has the educational basis, training and clinical competence to manage these cases?  Let’s take a closer look at chiropractic education as a comparison. 

 

Fundamental to the training of doctors of chiropractic according to the American Chiropractic Association is 4,820 hours (compared to 3,398 for physical therapy and 4,670 to medicine) and receive a thorough knowledge of anatomy and physiology. As a result, all accredited doctor of chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. So important to practice are these courses that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education requires a curriculum which enables students to be “proficient in neuromusculoskeletal evaluation, treatment and management.” In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. As a result students are afforded the opportunity to practice utilizing this basic science information for many hours prior to beginning clinical services in their internship.

 

To qualify for licensure, graduates of chiropractic programs must pass a series of examinations administered by the National Board of Chiropractic Examiners (NBCE). Part one of this series consists of six subjects, general anatomy, spinal anatomy, physiology, chemistry, pathology and microbiology. It is therefore mandatory for a chiropractor to know the structure and function of the human body as the study of neuromuscular and biomechanics is weaved throughout the fabric of chiropractic education. As a result, the doctor of chiropractic is expert in the same musculoskeletal genre that medical doctors are poorly trained in their doctoral education as referenced above.

 

Now that we have a general idea of why current musculoskeletal and spine care paths are failing, let’s examine what the negative effects are with a focus on what happens to the central nervous system when a patient is suffering from chronic pain.  The following paragraphs describe what happens to the brain as a result of chronic pain and then offers solutions based upon evidenced based studies.

 

Chronic Pain Affecting Brain Activity at Rest

 

Baliki ET. Al (2008) reported “Recent studies have demonstrated that chronic pain harms cortical areas unrelated to pain, long-term pain alters the functional connectivity of cortical regions known to be active at rest, i.e., the components of the “default mode network” (DMN). This DMN is marked by balanced positive and negative correlations between activity in component brain regions. In several disorders, however this balance is disrupted. Studying with fMRI [functional MRI] a group of chronic back pain patients and healthy controls while executing a simple visual attention task, we discovered that chronic back pain patients, despite performing the task equally well as controls, displayed reduced deactivation in several key default mode network regions. These findings demonstrate that chronic pain has a widespread impact on overall brain function, and suggest that disruptions of the default mode network may underlie the cognitive and behavioral impairments accompanying chronic pain.” (pg. 1398)

 

“The existence of a resting state in which the brain remained active in an organized manner, is called the ‘default mode of brain function. The regions exhibiting a decrease in activity during task performance are the component members of the “default-mode network” (DMN), which in concerted action maintain the brain resting state. Recent studies have already demonstrated that the brain default mode network is disrupted in autism, Alzheimer’ disease, depression, schizophrenia and attention deficit hyperactivity disorder, suggesting that the study of brain resting activity can be useful to understand disease states as well as potentially provide diagnostic information.”  (pg. 1398)  This is important since for the first time we are starting to see a published correlation between spinal function, chronic pain and central nervous system changes.  This is what our founders have observed yet were unable to prove.

 

“Thus, the alterations in the patient’s brain at ‘rest’ can result in a different default mode network organization. In turn, potential changes in the default-mode network activity could be related to symptoms (other than pain) commonly exhibited by chronic pain patients, including depression and anxiety, sleep disturbances, and decision-making abnormalities, which also significantly diminish their quality of life… chronic pain patients display a dramatic alteration in several key default-mode network regions, suggesting that chronic pain has a widespread impact on overall brain function” (pg. 1398).  This information is pointing to the fact that a doctor of chiropractic should be involved in the triage and treatment of these patients and part of a long term spinal care program. 

 

Baliki ET. Al (2008) continued “Consistent with extensive earlier work examining visuospatial attention tasks, dominant activations were located in posterior parietal and lateral prefrontal cortices, whereas deactivations occurred mainly within Pre-Frontal Cortex and Posterior Cingulate/Cuneate Cortexes. Although activations in chronic back pain patients’ and controls’ brains were similar, chronic back pain patients exhibited significantly less deactivations than healthy subjects in Pre-Frontal Cortex, amygdala, and Posterior Cingulate/Cuneate Cortexes.  The focus was on identifying differences in the way chronic back pain patients’ brains process information not related to pain. This is the first study demonstrating that chronic back pain patients exhibit severe alterations in the functional connectivity between brain regions implicated in the default mode network. It seems that enduring pain for a long time affects brain function in response to even minimally demanding attention tasks completely unrelated to pain. Furthermore, the fact that the observed task performance, compared with healthy subjects, is unaffected, whereas the brain activity is dramatically different, raises the question of how other behaviors are impaired by the altered brain activity” (pg. 1399).

 

“However, the disruption of functional connectivity observed here with increased chronic back pain duration may be related to the earlier observation of brain atrophy increasing with pain duration also in chronic back pain patients. Patient’s exhibit increased pre-frontal cortex activity in relation to spontaneous pain, in addition to dorsolateral prefrontal cortex atrophy. Therefore, the decreased deactivations described here may be related to the dorsolateral pre-frontal cortex /pre-frontal cortex mutual inhibitory interactions perturbed with time. If that is the case, it will support the idea of a plastic, time-dependent, reorganization of the brain as patients continue to suffer from chronic back pain.

 

Mechanistically, the early stages of this cortical reorganization may be driven by peripheral and spinal cord events, such as those that have been documented in animal models of chronic pain, whereas later events may be related to coping strategies necessary for living with unrelenting pain. It is important to recognize that transient but repetitive functional alterations can lead to more permanent changes. Accordingly, long term interference with normal activity may eventually initiate plastic changes that could alter irreversibly the stability and subsequently the conformation of the resting state networks” (pg. 1401).

 

 

Brain Region

Function

Cingulate Cortex

Emotions, learning, motivation, memory

Insular Cortex

Consciousness, homeostasis, perception, motor control, self-awareness, cognitive function

Motor Cortex

Voluntary movements

Amygdala Cortex

Memory, decision making, emotional reactions

Somatosensory Cortex

Proprio and mechano-reception, touch, temperature, pain of the skin, epithelial, skeletal muscle, bones, joints, internal organs and cardiovascular systems

Periaqueductal Gray

Ascending and descending spinothalamtic tracts carrying pain and temperature fibers

 

 

 

 

 

 

 

 

 

 

 

 

THALAMUS

 

 

 

Chronic Pain Causing Brain “Shrinkage”

 

Apkarian ET. Al (2004) reported “Chronic back pain patients were divided into neuropathic, exhibiting pain because of sciatic nerve damage, and non-neuropathic groups. Patients with chronic back pain showed 5-11% less neocortical gray matter volume than control subjects. The magnitude of this decrease is equivalent to the gray matter volume lost in 10-20 years of normal aging. The decreased volume was related to pain duration, indicating a 1.3 cm3loss of gray matter for every year of chronic pain. Gray matter density was reduced in bilateral dorsolateral prefrontal cortex and right thalamus and was strongly related to pain characteristics in a pattern distinct for neuropathic and non-neuropathic chronic back pain. Our results imply that chronic back pain is accompanied by brain atrophy and suggest that the pathophysiology of chronic pain includes thalamocortical processes.

 

It is assumed that the cerebral cortex passively reflects spinal changes and reverts to its normal state after cessation of chronic pain. Our studies show that chronic back pain (sustained for >6 months) is accompanied by abnormal brain chemistry, mainly a reduction in theN-acetyl-aspartate-creatine ratio in the prefrontal cortex, implying neuronal loss or dysfunction in this region and reduced cognitive abilities on a task that implies abnormal prefrontal processing” (pg. 10410).

 

Apkarian ET. Al (2004) continued “At the whole-brain level, this reduction is related to pain duration, regionally depends on multiple pain-related characteristics, and is more severe in the neuropathic subtype. Therefore, these data present strong evidence that the pathophysiology of chronic pain includes cortical processes, and the observed changes likely constitute the physical substrate of the cognitive and behavioral properties of chronic pain” (pg. 10411).

 

“Thus, regional gray matter changes are strongly and specifically related to pain characteristics, and this pattern is opposite for neuropathic compared with non-neuropathic types. This dissociation is consistent with extensive clinical data showing that neuropathic pain conditions are more debilitating and have a stronger negative affect, which may be directly attributable to the larger decrease in gray matter density that we observe in the dorso-lateral pre-frontal cortex (DLPFC) of neuropathic chronic back pain patients.  Moreover, only 18% of whole-brain gray matter variance could be explained by pain duration. Therefore, a large portion of the whole-brain atrophy in chronic back pain cannot be accounted for by the measured pain characteristics, implying that there may be genetic and experiential predispositions contributing to the observed atrophy. In the DLPFC, a larger proportion of the variance could be explained by pain characteristics (40% for neuropathic chronic back pain; 80%for non- neuropathic chronic back pain), implying a tighter relationship between regional brain atrophy and perceived pain. Therefore, we suggest that the pattern of brain atrophy is directly related to the perceptual and behavioral properties of neuropathic chronic back pain.”

 

The observed regional pattern of atrophy is distinct from that seen in chronic depression or anxiety and shows a minimal relationship with anxiety and depression traits. Thus, it seems to be specific to chronic pain, especially because the regions showing atrophy, the thalamus and DLPFC, participate in pain perception. The DLPFC is activated in acute pain, with responses that do not code stimulus intensity. Recent evidence suggests that the DLPFC exerts “top-down” inhibition on orbitofrontal activity, limiting the magnitude of perceived pain. Thus, DLPFC atrophy may lead to a disruption of its control over orbitofrontal activity, which in turn is critical in the perception of negative affect in general and particularly in pain states. Thalamic atrophy in chronic back pain is important, because it is a major source of nociceptive inputs to the cortex and damage to this region may be a reason for the generalized sensory abnormalities commonly associated with chronic pain” (pg. 10413).

 

“The dorsal anterior cingulate is shown to be specifically involved in pain affect in normal subjects and exhibits decreased nociceptive signaling in various chronic pain states, which may again be caused by thalamic atrophy because the anterior thalamus is a primary input to the anterior cingulate. Therefore, we suggest that regional atrophy dictates the brain activity observed in chronic pain, and it may explain the transition from acute to chronic pain by shifting brain activity related to pain affect away from the anterior cingulate to orbitofrontal cortex.”

 

“It is possible that some of the observed decreased gray matter reflects tissue shrinkage [changes in extracellular space and microvascular volume may cause tissue shrinkage without substantially impacting neuronal properties], implying that proper treatment would reverse this portion of the decreased brain gray matter. The atrophy may be also attributable to more irreversible processes, such as neurodegeneration, which we favor because the main brain region involved (the DLPFC) also exhibits decreasedN-acetyl-aspartate, and decreasedN-acetyl-aspartate has been observed in most neurodegenerative conditions. Recent evidence also suggests that after nerve injury, some components of pain behavior are a consequence of hyperactivity of spinal cord microglia, and a histological study has shown a reduction in glial numbers in the cortex in major depressive disorder and bipolar disorder” (pg. 10414).

This article suggests that there is a reversible component in brain atrophy with the resolution of the chronic back pain, with strong evidence that there are some tissue structures that will be permanently damaged should the chronic pain go beyond the defined 6 months.  Clearly there are many different professions that handle the anatomical components of spine pain such as fracture, infection, disc herniation or tumor.  There is only one profession that has the education and training to treat the aberrant spinal biomechanics; chiropractic.  Since chiropractors are trained in treating/managing/triaging the anatomical lesions while also being the best suited to treat the biomechanical component, the evidence verifies that  the first contact for spine pain be a doctor of chiropractic who is also trained in differential diagnosis of underlying pathology. .

 

Brain Regions Effected

 

Apkarian ET. AL (2011) reported “The surprise was that the brain region best reflecting high magnitude of back pain was localized to the medial prefrontal cortex, extending into anterior cingulate cortex, a region not anticipated by acute pain studies. Additionally, brain areas observed for acute pain, like portions of the insula and mid- anterior cingulate cortex were only active transiently and only when the back pain magnitude was on the increase. These results are exciting because, for the first time, we are able to observe brain activity reflecting the subjective perception of the pain that chronic back pain patients come to the clinic to complain. We interpret the transient activity as a nociceptive signal from the periphery, which then is converted into a sustained emotional suffering signal in medial prefrontal cortex (pg. S54).

 

“Thus we can assert that, at least in this group of chronic pain patients, different brain areas encode the perceived magnitude for distinct types of pain. The prevalent expectation for brain activity in chronic pain is a sustained or enhanced activation of the brain areas already identified for acute pain. This view is partly implied by the chronic pain definition and by notions of specificity theory or labeled line theory of pain (where supraspinal organization and representation of pain is assumed to be through fixed and immutable routes). This is exactly what we donotsee. Instead these results imply that functional anatomy or physiology or some combination of both have changed in the brain of chronic back pain patients. It is also important to remember that the close relationships between fundamental properties of back pain and activity in medial prefrontal cortex and insula are correlational, and that both medial prefrontal cortex and insula respond to a long list of cognitive and emotional states (pg. S55). The morphological studies show that the brain structure undergoes changes at multiple spatial and temporal scales, which are for the most part specific to the type of chronic pain studied. That some of these changes are reversible by cessation of chronic pain speaks to the specificity of the processes and also demonstrate that chronic pain may in fact by used as a unique tool with which the dynamics of brain plasticity can be studied at multiple spatial and temporal scales” (pg. S56).

 

Chiropractic as a Solution for Chronic Back Pain

 

 

Peterson ET. AL. (2012) reported “investigate outcomes and prognostic factors in patients with acute or chronic low back pain (LBP) undergoing chiropractic treatment. In chronic LBP, recent studies indicate that significant improvement is often fairly rapid, usually by the fourth visit, and that patients initially receiving treatment 3 to 4 times a week have better outcomes. Patients with chronic and acute back pain both reported good outcomes, and most patients with radiculopathy (neurogenic) also improved” (pg. 525). “At 3 months, 69% of patients with chronic pain stated that they were either much better or better. This is unlikely to be due to the natural history of LBP because these patients have already passed the period when natural history occurs “(pg. 531).  A study by Tamcan et al (2010) was the only population based study of the so called “natural history” of lower back pain and the authors found the “natural history” of chronic lower back pain was not ending in resolution of symptoms but instead they documented patients moving “in and out” of a level of pain they could tolerate.   Based on the only population-based study of chronic lower back pain, the idea that the “natural history” of lower back pain ends with resolution of symptoms is a complete myth and one that is perpetuated by our present healthcare system.

 

 

Lawrence ET. AL (2008) reported “Existing research evidence regarding the usefulness of spinal adjusting… indicates the following, as much or more evidence exists for the use of SMT [spinal manipulation] to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. The manual therapy group showed significantly greater improvements than did the exercise group for all outcomes. Results were consistent for both the short-term and the long-term” (pg. 670).

 

 

Dunn ET. AL. (2011) reported “The clinical outcomes achieved for this sample should be considered within the context of this veteran patient base, which is typically represented by older, white males with multiple comorbidities. A high percentage of overall service-connected disability was noted, with only a small percentage associated with the low back region. Considerable psychological comorbidity was found, with a high prevalence of PTSD (post-traumatic stress disorder) and depression diagnoses. PTSD and chronic pain tend to co-occur and may interact in a way that can negatively affect either disorder. A previous retrospective study of chiropractic management for neck and back pain demonstrated less improvement among those with PTSD. These points are significant because severe comorbidities and psychosocial factors lessen the likelihood of obtaining positive outcomes with conservative measures, including [chiropractic adjustments], for chronic low back pain. Mean percentages of clinical improvement exceeded the minimum clinically important difference, despite the levels of service-connected disability and comorbidity among this sample of veteran patients” (pg. 930). They went on to conclude that in spite of significant comorbidities that historically compromise positive results, 60.2% of patients met or exceeded the minimum clinically important difference for improvement (pg. 927).

 

Conclusion

 

Chronic pain as defined by that which has last for 6 months or longer which causes significant brain aberration in both morphology (size) and function.  The  literature suggests that this could be the precursor for many diseases as sequella of the human body’s natural reaction to prolonged pain.   Chronic back pain is one of the leading causes of chronic pain and medicine has little to no training or solutions as reported in the literature. Conversely, chiropractic has significant training and has been proven in “blinded” studies to have significant positive outcomes even in significantly adverse condition to help resolve chronic pain. As a result, the negative sequella on the brain of chronic pain, including shrinkage of the brain can be reversed through chiropractic care as the evidence has verified that once the chronic pain has resolved, the brain has the ability to return to its normal size and regain much function.

 

 

Although this evidence is strong, more research is needed and this further sets the foundation for understanding how chiropractic directly effects diseases in the human body. In addition, this also takes the chiropractic profession to the next level of understanding how and why a chiropractic adjustment works.  

 

 

References:

  1. National Institute of Neurological Disorders and Stroke, NINDS Chronic Pain Information Page (July 2015), retrieved from: http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm
  2. Baliki N., Geha P., Apkarian A., Chialvo D., (2008) Beyond Feeling: Chronic Pain Hurts the Brain, disrupting the Default-Mode Network Dynamics, Journal of Neurosciences 28(6) 1398-1403
  3. Apkarian V., Sosa Y., Sonty S., Levy R., Harden N., Parrish T., Gitelman D., (2004) Chronic Back Pain Is Associated with Decreased Prefrontal and Thalamic Gray Matter Density, The Journal of Neuroscience, 24(46) 10410-10415
  4. Apkarian A., Hashmi J., Baliki M., (2011) Pain and the brain: Specificity and plasticity of the brain in clinical chronic pain, Pain 152, S49-S54
  5. Raissi G., Mansoon K., Madani P., Rayegani S., (2006) Survey of General Practitioners’ attitudes Toward Physical Medicine and Rehabilitation, International Journal of Rehabilitation Research 26: 167-170
  6. Day C., Yeh A., Franko O., Ramirez M., Krupat E. (2007) Musculoskeletal Medicine: An Assessment of the Attitudes of Medical Students at Harvard Medical School, Academic Medicine 82: 452-457
  7. Schmale G. (2005) More Evidence of Educational Inadequacies in Musculoskeletal Medicine 437, 251-259
  8. Peterson C., Bolton J., Humphreys K., (2012) Predictors of Improvement in Patients With Acute and Chronic Low Back Pain Undergoing Chiropractic Treatment, Journal of Manipulative and Physiological Therapeutics, 35(7) 525-533
  9. Lawrence, D., Meeker W., Branson R., Bronford G., Cates J., Haas M., Haneline M., Micozzi M., Updyke W., Mootz R., Triano J., Hawk C., (2008) chiropractic management of low back pain and low back-related leg complaints: a literature synthesis, Journal of Manipulative and Physiological Therapeutics, 31(9) 659-674
  10. Dunn A., Green B., Formolo L., Chicoine D. (2011) Retrospective case series of clinical outcomes associated with chiropractic management for veterans with low back pain, Journal of Rehabilitation Research & Development, 48(8) 927-934
  11. Tamcan, O., Mannion, A. F., Eisenring, C., Horisberger, B., Elfering, A., & Müller, U. (2010). The course of chronic and recurrent low back pain in the general population. Pain, 150(3), 451-457.

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Published in Brain Function

Back Pain: Who Should Be Seen First & WHY

Chiropractor vs. Medical Primary Care Doctor

A report on the scientific literature 


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

William J. Owens DC, DAAMLP

 

Reference: Studin M., Owens W. (2015) Back Pain: Who Should Be Seen First & WHY, Chiropractor vs. Medical Primary Care Doctor, American Chiropractor 37 (9) 50, 52, 54, 56

 

 

 

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

 

The problems that exist regarding chronic back pain are compounded by an unsuspecting public that historically, initially seeks care from their primary care medical providers who do not have strong grasps on mechanical back pain. According to Apkarian et al. (2004), back problems constitute 25% of all disabling occupational injuries and are the fifth most common reason for visits to the clinic; in 85% of such conditions, no definitive diagnosis can be made. In other words, virtually every time a patient goes to see his/her primary care doctor as a result of his/her chronic back pain, the doctor does not know the cause of the problem, yet treats an area that he/she is not equipped to diagnose.  

 

When we look at the human population on a larger scale and from a medical perspective, we see there is a deficit in spinal education with resultant negative sequellae of chronic back pain.  The above conclusion was drawn by querying allopathic (medical) doctors who have little to no training or experience in treating mechanical back pain, AKA spinal dysfunction of biomechanical origin, AKA chiropractic subluxation complex.  Raissi, Mansoon, Madani, and Rayegani (2006) reported regarding medical providers. Most respondents (92.2%) believed that musculoskeletal education had not been sufficient in general practitioner training courses. Of the respondents, 56.8% had visited at least one disabled patient during the previous month, while 11% had visited more than 10 in the same period, but 84.3% had not studied disabilities. Musculoskeletal physical examination was the most needed educational field cited by general practitioners” (Raissi et al., 2006, p. 167).

 

Day, Yeh, Franko, Ramirez, and Krupat (2007) reported that only 26% of fourth year Harvard medical students had a cognitive mastery of physical medicine.  Schmale (2005) reported, “…incoming interns at the University of Pennsylvania took an exam of musculoskeletal aptitude and competence, which was validated by a survey of more than 100 orthopaedic program chairpersons across the country. Eighty-two percent of students tested failed to show basic competency. Perhaps the poor knowledge base resulted from inadequate and disproportionately low numbers of hours devoted to musculoskeletal medicine education during the undergraduate medical school years. Less than 1⁄2 of 122 US medical schools require a preclinical course in musculoskeletal medicine, less than 1⁄4 require a clinical course, and nearly 1⁄2 (57/122) have no required preclinical or clinical course. In Canadian medical schools, just more than 2% of curricular time is spent on musculoskeletal medicine, despite the fact that approximately 20% of primary care practice is devoted to the care of patients with musculoskeletal problems. Various authors have described shortcomings in medical student training in fracture care, arthritis and rheumatology, and basic physical examination of the musculoskeletal system (p. 251). 

 

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

 

Fundamental to the training of doctors of chiropractic is 4,820 hours (compared to 3,398 for physical therapy and 4,670 to medicine) and students receive a thorough knowledge of anatomy and physiology. As a result, all accredited doctor of chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. It is so important to practice these courses that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education, requires a curriculum which enables students to be proficient in neuromusculoskeletal evaluation, treatment and management. In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. As a result, students are afforded the opportunity to practice utilizing this basic science information for many hours prior to beginning clinical services in their internships.

To qualify for licensure, graduates of chiropractic programs must pass a series of examinations administered by the National Board of Chiropractic Examiners (NBCE). Part one of this series consists of six subjects, general anatomy, spinal anatomy, physiology, chemistry, pathology and microbiology. It is therefore mandatory for a chiropractor to know the structure and function of the human body as the study of neuromuscular and biomechanics is weaved throughout the fabric of chiropractic education. As a result, the doctor of chiropractic is expert in the same musculoskeletal genre that medical doctors are poorly trained in their doctoral educationas referenced above.

 

A 2005 study byDeVocht, 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. We also know that chiropractic is one of the safest treatments currently available in healthcare for spinal treatment and when there is a treatment where the potential for benefits far outweighs any risk, it deserves serious consideration. Whedon, Mackenzie, Phillips, and Lurie(2015) based their study on 6,669,603 subjects after the unqualified subjects had been removed from the study and 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”(p. 5).

 

References:

 

1. Chien, J., J., & Bajwa, Z. H. (2008). What is mechanical spine pain and how best to treat it? Current Pain and Headaches Report, 12(6), 406-411

2. Peterson, C. K., Bolton, J., & Humphreys, B. K. (2012). Predictors of improvement in patients with acute and chronic low back pain undergoing chiropractic treatment. Journal of Manipulative and Physiological Therapeutics, 35(7), 525-533.

3. Baliki, M. N., Geha, P. Y., Apkarian, A. V., & Chialvo, D. R. (2008). Beyond feeling: Chronic pain hurts the brain, disrupting the default-mode network dynamics. Journal of Neurosciences, 28(6) http://www.jneurosci.org/content/28/6/1398.full

 4. Apkarian, V., Sosa, Y., Sonty, S., Levy, R., Harden, N., Parrish, T., & Gitelman, D. (2004). Chronic back pain is associated with decreased prefrontal and thalamic gray matter density. The Journal of Neuroscience, 24(46), 10410-10415.

5. Raissi, G. R., Mansoon, K., Madani, P., & Rayegani, S. M. (2006). Survey of general practitioners’ attitudes toward physical medicine and rehabilitation. International Journal of Rehabilitation Research, 29(2), 167-170.

6. Day, C. S., Yeh, A. C., Franko, O., Ramirez, M., & Krupat, E. (2007). Musculoskeletal medicine: An assessment of the attitudes of medical students at Harvard Medical School. Academic Medicine, 82(5), 452-457.

7. Schmale, G. A. (2005). More evidence of educational inadequacies in musculoskeletal medicine. Clinical Orthopaedics and Related Research, 437, 251-259.

 8. 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.

 9. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270.

 

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Published in Low Back Problems

Chiropractic Can Prevent Absenteeism in the Workplace from Chronic Pain

 

  • A Potential Savings of $140 - $159,000,000,000 (billion) in Unnecessary Health Care Expenditure to Federal and Private Insurers
  • A Potential Savings of $52 - $58,000,000,000 (billion) from Absenteeism and Lowered Productivity to the United States Economy

 

 

A report on the scientific literature 


 

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

 

According to Cady (2014) over 100 million Americans experience chronic pain with common painful conditions including back pain, neck pain, headaches/migraines, and arthritis, in addition to other painful conditions such as diabetic peripheral neuropathy, etc...In a large study in 2010, 30.7% of over 27,000 U.S. respondents reported an experience of chronic, recurrent pain of at least a 6-month duration. Half of the respondents with chronic pain noted daily symptoms, with 32% characterizing their pain as severe (≥7 on a scale ranging from 0 to 10). Chronic pain has a broad impact on emotional well-being and health-related quality of life, sleep quality, and social/recreational function.

Peterson ET. AL. (2012) reported, “The … prevalence of low back pain is stated to be between 15% and 30%, the 1-year period prevalence between 15% and 45%, and a life-time prevalence of 50% to 80%” (pg. 525).  Apkarian Et. Al. (2004) reported that “Ten percent of adults suffer from severe chronic pain. Back problems constitute 25% of all disabling occupational injuries and are the fifth most common reason for visits to the clinic; in 85% of such conditions, no definitive diagnosis can be made.” (pg. 10410) The reference to no definitive diagnosis is reflective of allopathy, or in common terms, the medical community.

 

 

In contrast, Peterson ET. AL. (2012) reported “investigate outcomes and prognostic factors in patients with acute or chronic low back pain (LBP) undergoing chiropractic treatment. In chronic LBP, recent studies indicate that significant improvement is often fairly rapid, usually by the fourth visit, and that patients initially receiving treatment 3 to 4 times a week have better outcomes. Patients with chronic and acute back pain both reported good outcomes, and most patients with radiculopathy (neurogenic) also improved” (pg. 525). “At 3 months, 69% of patients with chronic pain stated that they were either much better or better. This is unlikely to be due to the natural history of low back pain because these patients have already passed the period when natural history occurs “(pg. 531).  As a note, this author has been caring for chronic back pain sufferers for 34 years and my personal observation is that 90%+ of all patients feel better and have significantly increased function in a short amount of time. However, for the purposes of this article, I will utilize the published 69%.  

 

Cady (2014) wrote “In addition to the pervasive personal suffering associated with this disease, chronic pain has a substantial negative financial impact on the economy. Direct office visits, diagnostic testing, hospital care, and pharmacy costs are only a portion of the picture, with combined medical and pharmacy costs averaging $5,000 annually per individual (Pizzi, 2005). Chronic pain results in a significant economic burden on the healthcare system, with estimated costs ranging from $560 to $635 billion 2010 dollars, more than the annual cost of other priority health conditions including cardiovascular disease, cancer, and diabetes (Gaskin & Richard, 2012). Moreover, the estimated annual costs of the workplace impact of pain range from $299 to $335 billion from absenteeism and reduced productivity (Gaskin & Richard, 2012).” (pg. 1-2)

 

We have already established that 10% of adults suffer from chronic pain and that back pain constitutes 25% of that population and chiropractic helps 69% of chronic sufferers. Therefore if 25% of all chronic pain is back pain and chiropractic helps 69%, then the numbers extrapolate as follows: 

 

Economic burden on the healthcare system:

$560-$635 billion x 25% (back pain) = $140-$159 billion

$140-$159 billion x 69% (chiropractic helps) = $97-$110,000,000,000 (billion)

 

Absenteeism and Reduced Productivity Costs

$299-$335 billion x 25% (back pain) = $75-$84 billion

$75-$84 billion x 69% (chiropractic helps) = $52-$58,000,000,000 (billion)

 

We also know that chiropractic is one of the safest treatments currently available in healthcare and when there is a treatment where the potential for benefits far outweighs any risk, it deserves serious consideration. Whedon, Mackenzie, Phillips, and Lurie (2015) based their study on 6,669,603 subjects after the unqualified subjects had been removed from the study and 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).

 

Unfortunately, the likelihood that a medical provider in any subspecialty will encounter chronic pain and its complications will only increase in the future as the population advances in age and body mass. In addition, based upon the statistics there needs no extrapolation as to who should be the primary spine care provider or first option to treat chronic back pain or any mechanical back pain (no fracture, tumor or infection). We have verified that allopathy (medical doctors) not being able to conclude a diagnosis 85% of the time, where chiropractic has verified diagnosis and solutions 69% (or my 90% +) in verified scientific outcomes.

 

 

The conclusions are not an indictment against medicine, it is a conclusion based upon science to put billions back into our economy while first helping those in chronic pain with a “best outcome” solution.

 

 

References:

  1. Block, C. K. (2014). Examining neuropsychological sequelae of chronic pain and the effect of immediate-release oral opioid analgesics (Order No. 3591607). Available from ProQuest Dissertations & Theses Global. (1433965816). Retrieved from http://search.proquest.com/docview/1433965816?accountid=1416
  2. Peterson C., Bolton J., Humphreys K., (2012) Predictors of Improvement in Patients With Acute and Chronic Low Back Pain Undergoing Chiropractic Treatment, Journal of Manipulative and Physiological Therapeutics, 35(7) 525-533
  3. Apkarian V., Sosa Y., Sonty S., Levy R., Harden N., Parrish T., Gitelman D., (2004) Chronic Back Pain Is Associated with Decreased Prefrontal and Thalamic Gray Matter Density, The Journal of Neuroscience, 24(46) 10410-10415
  4. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270.

 

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Published in Low Back Problems

Chronic Low Back Pain:

Chiropractic vs. Medicine

Research Results: Chiropractic is 457% more effective

A report on the scientific literature 


 

By

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

 

As reported in 2003 by the National Institute of Neurological Disorders and Stroke, "If you have lower back pain, you are not alone. Nearly everyone at some point has back pain that interferes with work, routine daily activities, or recreation. Americans spend at least $50 billion each year on low back pain, the most common cause of job-related disability and a leading contributor to missed work. Back pain is the second most common neurological ailment in the United States — only headache is more common" (http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm)

They went on to report many of the causes of low back pain. " As people age, bone strength and muscle elasticity and tone tend to decrease. The discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae"
(National Institute of Neurological Disorders and Stroke, 2003, http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm).

"Pain can occur when, for example, someone lifts something too heavy or overstretches, causing a sprain, strain, or spasm in one of the muscles or ligaments in the back. If the spine becomes overly strained or compressed, a disc may rupture or bulge outward. This rupture may put pressure on one of the more than 50 nerves rooted to the spinal cord that control body movements and transmit signals from the body to the brain. When these nerve roots become compressed or irritated, back pain results"
(National Institute of Neurological Disorders and Stroke, 2003, http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm).

"Low back pain may reflect nerve or muscle irritation or bone lesions. Most low back pain follows injury or trauma to the back, but pain may also be caused by degenerative conditions such as arthritis or disc disease, osteoporosis or other bone diseases, viral infections, irritation to joints and discs, or congenital abnormalities in the spine. Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, posture inappropriate for the activity being performed, and poor sleeping position also may contribute to low back pain. Additionally, scar tissue created when the injured back heals itself does not have the strength or flexibility of normal tissue. Buildup of scar tissue from repeated injuries eventually weakens the back and can lead to more serious injury"
(National Institute of Neurological Disorders and Stroke, 2003, http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm).

Chronic low back pain is where the symptoms have persisted for longer than 3 months, as reported by Bogduk in 2004, although recent studies have classified chronic low back pain as pain persisting for only 4 weeks. The duration is important from a diagnosis and prognosis perspective, where it is critical for the doctor to develop an accurate plan of care. The most important component is not the label, but a complete history being performed, including examination and subsequent testing, when indicated, to develop the right treatment plan.

Wilkey, Gregory, Byfield, & McCarthy reported in 2008 that the proportion of the population that suffers from persistent or chronic low back pain is between 8% and 33%. 13% accounts for those whose pain never goes away and the remainder fluctuate in and out of pain. They also reported that the low back pain was generally recurring, indicating that doing nothing is a poor choice.

While there are a limitless number of treatments, the National Institute of Health in the United States and the National Health Service in the United Kingdom have listed accepted treatment modalities for this very prevalent condition. While there are choices for the public, the question is what is the best treatment choice for each individual back pain sufferer? The answer has to be based on real evidence and outcome based studies offer the answer.

As mentioned ealier,
Wilkey, Gregory, Byfield, & McCarthy (2008) studied randomized clinical trials comparing chiropractic care to medical care in a pain clinic. "The treatment regimens employed by the pain clinic in this study consisted of standard pharmaceutical therapy (nonsteroidal anti-inflammatory drugs, analgesics, and gabapentin), facet joint injection, and soft-tissue injection. Transcutaneous electrical nerve stimulation (TENS) machines were also employed. These modalities were used in isolation or in combination with any of the other treatments. Chiropractic groupsubjects followed an equally unrestricted and normal clinical treatment regimens for the treatment of [chronic low back pain] were followed. All techniques that were employed are recognized within the chiropractic profession as methods used for the treatment of [low back pain]. Many of the methods used are common to other manual therapy professions" (p. 466-467).

After 8 weeks of treatment, the 95% confidence intervals based on the raw scores showed improvement was1.99 for medicine and 9.03 for the chiropractic group. This research indicates that chiropractic is 457% more effective than medicine for chronic low back pain. To say that the medical approach doesn't have a place in healthcare would be inaccurate and irresponsible, but based upon evidenced based outcome studies, research concludes that for chronic low back pain, the path is chiropractic first and drugs 457% second. Chiropractic doctors are trained to determine the cause of the injury and are expert at formulating an accurate and effective diagnosis, prognosis and treatment plan. The cornerstone of that plan is the chiropractic adjustment.

These studies along with many others conclude that a drug-free approach of chiropractic care is the best solutions for patients with chronic low back pain. To find a qualified doctor of chiropractic near you go to the US Chiropractic Directory at
www.USChiroDirectory.com and search your state.
 

 

References

1. National Institute of Neurological Disorders and Stroke. (2003, July). Low Back Pain Fact Sheet. Retrieved from http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm

2. Bogduk, N. (2004). Management of chronic low back pain. The Medical Journal of Australia, 180(2), 79-83.Retrieved from http://www.mja.com.au/public/issues/180_02_190104/bog10461_fm.html

 

3. Wilkey, A., Gregory M., Byfield, D., & McCarthy, P. W. (2008). A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic. The Journal of Alternative and Complementary Medicine, 14(5), 465-473.

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Published in Low Back Problems

Balance, Chronic Pain and Chiropractic

A report on the scientific literature 




The results showed decreased pain and increased balance; helping to avoid falls

By

William J. Owens DC, DAAMLP
Mark Studin DC, FASBE (C), DAAPM, DAAMLP

 

When we age, it seems that there are more and more challenges to our health and well being.  Falling and chronic pain are most likely fighting to be #1 on that list.  Whether there was a prior injury, decades of hard labor, years of inactivity or just simple daily wear and tear, chronic pain is difficult to manage.  Our societal tendencies are to medicate to “make the pain go away,” but the TRUTH is, it is still there, we just feel it less.  What happens to our bodies when year after year, we continue to work through it?  Well, the problem gets worse and we take more pills! 

In a recent study from the University of California’s Geriatric Primary Care lecture, the presenter stated, “Ambulatory elderly fill between 9-13 prescriptions a year...”
(Johnston, 2001, slide 3 ).She goes on to state, “Surveys indicate that elders take average of 2-4 nonprescription drugs daily” (Johnston, 2001, slide 5).  Adding additional “pills” to the mix for pain is often not a very good idea.  Although necessary medications are clearly indicated and needed, what are the options for those medications that are optional and potentially dangerous when taken over a long period of time? 

In a recent study published in a chiropractic research journal, the authors stated, “The purpose of this study was to collect preliminary information on the effect of a limited and extended course of chiropractic care on balance, chronic pain, and associated dizziness in a sample of older adults with impaired balance" (Hawk, Cambron, & Pfefer, 2009, p.438). The results showed decreased pain and increased balance (helping to avoid falls).

The authors finally reported, "Another interesting finding in this study that warrants further investigation is that it appeared that for the group on the extended care schedule, pain and disability decreased and remained at a lower level than for the limited care schedule, for the year we followed patients.  This provides preliminary support for chiropractic maintenance care for older adults with chronic pain”
(Hawk, Cambron, & Pfefer, 2009, p.445).

This study along with many others concludes that a drug-free approach of chiropractic care is one of the best solutions for pregnant patients with balance disorders and chronic pain. To find a qualified doctor of chiropractic near you go to the US Chiropractic Directory at www.uschirodirectory.comand search your state.


References:

1. Johnston, C. B. (2001, May). Drugs and the Elderly: Practical Considerations. PowerPoint presentation presented at the UCSF Division of Geriatrics Primary Care Lecture Series.
2.  Hawk, C., Cambron, J. A., & Pfefer, M. T. (2009). Pilot study of the effect of a limited and extended course of chiropractic care on balance, chronic pain and dizziness in older adults. Journal of Manipulative and Physiological Therapeutics, 32(6), 438-477
.

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Published in Balance