Preventing Spinal Degeneration Through Chiropractic Care
Subluxation Degeneration/Spondylosis Explained via Wolff’s Law
Spondylosis, also known as osteoarthritis of the spine, is rarely appreciated as one of the most sigificant causes of persistent pain and disability in the world today. This form of arthropathy is so universal that it is often regarded as part of the “normal” aging process. “Osteoarthritis is usually progressive and often deforming and disabling” as reported by Gottlieb (1997). “Up to 50% of individuals will experience arthritic back pain at some point in their lives. Despite its high prevalence, there exists limited information (albeit through allopathic medicine) available regarding the factors associated with the development of lumbar spine degeneration” as reported by Weinberg, Liu, Xie, Morris, Gebhart and Gordon (2017). The projected number of older adults with arthritis or other chronic musculoskeletal joint symptoms is expected to nearly double from 21.4 million in 2005 to 41.1 million by 2030 in the United States. The assumption is so will the progression of persistent pain and disability. We see that allopathic medicine has little information to help reduce the progression of this disease process, which is why chiropractic is the only true solution since we view the body from a mechanical perspective. It is the maintenance of the mechanical workings of the spine that is the real approach to preventing degenerative “wear and tear” of the human spine.
Weinberg et. Al (2017) continued by reporting “Certain mechanical causes have been implicated in the development of degenerative joint disease of the lumbar spine, including lumbar lordosis, the length of the transverse processes, disc-space narrowing, and traction spurs. Lately, authors have begun investigating the roles of facet orientation, tropism, and pelvic incidence, although data remains limited. It has recently been suggested that the relationships between pelvic incidence and facet orientation may have profound implications in the development of adjacent segment lumbar degenerative joint disease—this has sparked enthusiastic research better defining the role of sagittal balance in osteoarthritis formation.” Pg. 1593
When we consider spinal osteoarthritis, we must compare normal spinal biomechanics and loading vs. abnormal spinal biomechanics and pathological loading that results. Teichtahl, Wluka, Wijethilake, Wang, Ghasem-Zadeh and Cicuttini (2015) reported “Julius Wolff (1836–1902), a German anatomist and surgeon, theorized that bone will adapt to the repeated loads under which it is placed. He proposed that, if the load to a bone increases, remodeling will occur so that the bone is better equipped to resist such loads. Likewise, he hypothesized that, if the load to a bone decreases, homeostatic mechanisms will shift toward a catabolic state, and bone will be equipped to withstand only the loads to which it is subjected.” Pg. 2
“It is now recognized that remodeling of bone in response to a load occurs via sophisticated mechano-transduction mechanisms. These are processes whereby mechanical signals are converted via cellular signaling to biochemical responses. The key steps involved in these processes include mechano-coupling, biochemical coupling, signal transmission, and cell response.” Pg. 1
“Bone is a dynamic tissue that is tightly regulated by a multitude of homeostatic controls. One key environmental regulator of periarticular bone is mechanical stimulation. Wolff’s law relates to the response of bone to mechanical stimulation and states that bony adaptation will occur in response to a repeated load. It is interesting to consider this in the setting of knee OA, which has a strong biomechanical component to its etiology.” Pg. 1
“When periarticular bone is subjected to increased loading, some bone properties change. These include, but are not limited to, an expanding subchondral bone cross-sectional area, changes in bone mass, and remodeling of the trabeculae network. Although these changes likely represent appropriate homeostatic responses of bone to increased loading, they also appear to inadvertently predate maladaptive responses in other articular structures, most notably cartilage.” Pg. 1
Keorochana, Taghavi, Lee, Yoo, Liao, Fei and Wang reported (2011) “Differences in sagittal spinal alignment between normal subjects and those with low back pain have been reported. Previous studies have demonstrated that changes in sagittal spinal alignment are involved in the development of a spectrum of spinal disorders. It has also been a topic of great interest in the management of lumbar degenerative pathologies, especially when focusing on the role it may play in accelerating adjacent degeneration after spinal fusion and non-fusion procedures such as dynamic stabilization and total disc replacement. Spinal morphology may influence the loading and stresses that act on spinal structures. Alterations in the stress distribution may ultimately influence the occurrence of spinal degeneration. Moreover, changes in sagittal morphology may alter the mechanics of the lumbar spine, affecting mobility.” Pg. 893
Panjabi (2006) reported:
Cramer et al. (2002) reported “One component of spinal dysfunction treated by chiropractors has been described as the development of adhesions in the zygapophysial (Z) joints after hypomobility. This hypomobility may be the result of injury, inactivity, or repetitive asymmetrical movements…one beneficial effect of spinal manipulation may be the “breaking up” of putative fibrous adhesions that develop in hypomobile or “fixed” Z joints. Spinal adjusting of the lumbar region is thought to separate or gap the articular surfaces of the Z joints. Theoretically, gapping breaks up adhesions, thus helping the motion segment reestablish a physiologic range of motion.” (p. 2459)
Evans (2002) reported “On flexion of the lumbar spine, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with it. On attempted extension, the inferior articular process returns toward its neutral position, but instead of re-entering the joint cavity, the meniscoid impacts against the edge of the articular cartilage and buckles, forming a space-occupying "lesion" under the capsule: a meniscoid entrapment. A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophyseal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent impaction of the meniscoid. The patient would tend to be more comfortable with the spine maintained in a flexed position, because this will disengage the meniscoid. The extension would therefore tend to be inhibited. This condition has also been termed a "joint lock" or "facet-lock" the latter of which indicates the involvement of the zygapophyseal joint.” Pg. 252
The sagittal spinal misalignments developed after hypo or hypermobility as a result of injury, inactivity, or repetitive asymmetrical movements as reported Cramer, creates mechanoreceptor and nociceptor pathological input, this in turn as reported by Evans creates a mechanical displacement of the zygapophyseal joint and aberrant stimulation to type III and IV nociceptors. This also, according to Panjabi causes a corrupting of neuromuscular transducers (mechanoreceptors and nociceptors) of the spinal muscular system. These combine to create spinal neuro-pathobiomechanics for the spine globally and at each affected motor unit. This is what has been historically called in chiropractic “vertebral subluxation.“ Based upon Wolff’s Law, the persistent biomechanical failure, as perpetuated by the central nervous system being corrupted and attempting to compensate through muscular activity creates premature degeneration of the spine or osteoarthritis or “Subluxation Degeneration.”
Evans (2002) concluded that a high velocity-low amplitude manipulation (chiropractic spinal adjustment) of the joint involving flexion and gapping, reduces the impaction and opens the joint to encourage re-entry of the meniscoid into the joint space and realignment of the joint.” Pg. 253 This activity reduced the irritation or pressure on the nociceptors on the zygapophyseal joints stopping the corruption of the central nervous system and allowing the body to “right itself” and halt the degenerative process of the spine.
It has already been concluded, as reported by Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) in a population-based study of 5511 injured workers in Ontario Canada as reported by the Workplace Safety and Insurance Board, a governmental agency reported a comparison of outcomes for back pain among patients seen by three types of providers: medical physicians, chiropractors and physical therapists. The found “The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of the second episode of financial compensation.” (pg.392) and “These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.” (pg. 382)
Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) continued, “The cohort study of American workers with back pain conducted by Turner et al. found that the first healthcare provider was one of the main predictors of work disability after a year. By our findings, workers who first sought chiropractic care were less likely to be work-disabled after 1 year compared with workers who first sought other types of medical care.
Considering that 50% of the population will experience some type of pain and/or potential disability as a result of spinal arthritis, chiropractic, as reported above is positioned as the best first option for spine as an evidence-based solution. This is called Primary Spine Care and chiropractic is best positioned to lead society in the prevention of osteoarthritis/subluxation degeneration through chiropractic care.
The Mechanism of the Chiropractic
Effect of Sagittal Alignment on Kinematic Changes and Degree of Disc Degeneration in the Lumbar Spine
Part 4 of a 5 Part Series
William J Owens Jr
Mark E. Studin
A report on the scientific literature
More and more evidence is coming forward demonstrating both spinal stability and biomechanical balance as an important aspect of spine care. The good news is this is well within chiropractic’s scope, however many doctors of chiropractic are missing the education to accurately evaluate and objectify these types of biomechanical lesions. Our profession has spent most the last 122 years focused on TREATING these biomechanical lesions (Vertebral Subluxation, Joint Fixation, etc.) with little regard to the “assessment” component. The reason that is a critical statement, is that too often we treat compensation vs. the unstable joint.
Our founding doctors had used very specific techniques to analyze the spine from a functional perspective and most of our contemporary treatment techniques came out of these analysis, which are the basis for many of our most common techniques taught in today’s chiropractic academia. It seems in hindsight, that the major discussions of the time [early chiropractic] were about “identification” of the lesion to adjust, then evolved into the best WAY to deliver the adjustment.
Our roots and subsequently the true value and expertise of the doctor of chiropractic is in the assessment with treatment far secondary to an accurate diagnosis The medical community that both the authors and the doctors we teach no longer confuse our delivering of chiropractic care with a physical therapy manipulation or mobilization. The reason, our focus is on the diagnosis, prognosis and treatment plan BEFORE we render our treatment.
With medical specialists who understand spine, our conversation centers on spinal biomechanics and how a specific chiropractic spinal adjustment will restore sagittal/coronal alignment and coupled motion balance the spine. We discuss spinal biomechanics and have the literature and credentials to validate our diagnosis, prognosis and treatment plan. Chiropractic has been the leader in this treatment for over a century, but since we had chosen to stay outside of the mainstream healthcare system we had no platform to take a leadership position or be heard.
Medicine at both the academic and clinical levels are embracing chiropractic as the primary solution to mechanical spine issues (no fracture, tumor or infection) because as one primary care provider shared with us “traditional medical therapies inclusive of physical therapy has no basis in reality in how to treat these patients, which has led us in part, to the opiate crisis.” Part of the validation of what chiropractic offers in a biomechanical paradigm comes from surgical journals in the medical community.
Keorochana et al, (2011) published in Spine and out of UCLA, titled “To determine the effects of total sagittal lordosis on spinal kinematics and degree of disc degeneration in the lumbar spine. An analysis using positional MRI.” Remember that this article was 8 years ago and as a concept has evolved considerably since it was first discussed in the late 1990s. This is the clinical component of what Panjabi had successfully described and reproduced in the laboratory. It is now starting to become mainstream in clinical practice.
Many people ask why would surgeons care about the biomechanics of the spine when they are looking simply for an anatomical lesion to stabilize [fracture, tumor, infection, cord compression]? The authors answer this question by stating “It has also been a topic of great interest in the management of lumbar degenerative pathologies, especially when focusing on the role it may play in accelerating adjacent degeneration after spinal fusionand non-fusion procedures such as dynamic stabilization and total disc replacement.” [pg. 893]
They continue by stating “Alterations in the stress distribution may ultimately influence the occurrence of spinal degeneration. Moreover, changes in sagittal morphology may alter the mechanics of the lumbar spine, affecting mobility. Nevertheless, the relationships of sagittal alignment on lumbar degeneration and segmental motion have not been fully defined.” [pg. 893] This is precisely what our founding fathers called “Subluxation and Subluxation Degeneration!”
Regarding the type and number of patients in the study, the authors reported the following, “pMRIs [positional MRI] of the lumbar spine were obtained for 430 consecutive patients (241 males and 189 females) from February 2007 to February 2008. All patients were referred for pMRI [positional MRI – which included compression in both flexion and extension with a particular focus on segmentation translation and angular motions] due to complaints of low back pain with or without leg pain.” [pg. 894] This is the part where they looked for hypermobility.
In the first step in the analysis, the authors reviewed data regarding the global sagittal curvature as well as the individual angular segmental contributions to the curvature. The next step involved the classification of the severity of lumbar disc degeneration using the Pfirrmann classification system. [See Appendix A if you are not familiar]. This is where they looked for segmental degeneration. The patients were then classified based on the lordosis angle [T12-S1]. The groups were as follows:
Group A – Straight Spine or Kyphosis – [lordosis angle <20°]
Group B – Normal Lordosis – [lordosis angle 20° to < 50°]
Group C – Hyperlordosis – [lordosis angle >50°]
There is a structural categorization [lordosis] and a degenerative categorization [Pfirrmann] in this paper and the authors sought to see if there was a predictable relationship.
The results of this study were interesting and validated much of what the chiropractic profession has discussed relating to segmental “compensation” in the spine. Meaning, when one segment is hypomobile, adjacent segments will increase motility to compensate. The authors stated, “The sagittal lumbar spine curvature has been established as an important parameter when evaluating intervertebral disc loads and stresses in both clinical and cadaveric biomechanical investigations.” [pg. 896] They continue by stating “In vitro [in the laboratory or outside of the living organism] biomechanical tests do not take into account the influence of ligaments and musculature, and may not adequately address the complex biomechanics of the spine.” [pg. 896]
When it comes to spinal balance and distribution of loads in the spine, the authors reported “Our results may indicate that the border segments of lordosis, especially in the upper lumbar spine (L1–L2, L2–L3, and L3–L4), have greater motion in straight or kyphotic spines, and less segmental motion in hyperlordotic patients.” [pg. 896]
They continued by stating, “A greater degree of rigidity is found at the apical portion of straight or kyphotic spines, and more mobility is seen at the apical portion of hyperlordotic spines.” [pg. 897] Therefore, in both cases we see that changes in the sagittal configuration of the human spine has consequences for the individual segments involved.
This raises the question, “how does this related to accelerated degeneration of the motion segments involved?” [Subluxation Degeneration] The authors reported, “Regarding the relationship between the degree of disc degeneration and posture, subjects with straight or kyphotic spines tended to have a greater degree of disc degeneration at border segments, with statistical significance in the lower spine (L5–S1). On the other hand, hyperlordotic spines had a significantly greater degree of disc degeneration at the apex and upper spine (L4–L5 and L1–L2). The severity of disc degeneration tended to increase with increased mobility at the segments predisposed to greater degeneration (border segments of straight or kyphotic spines and apical segments of hyperlordotic spines).” [pg. 897]
The scientific literature and medicine is now validating (proving) what chiropractic has championed for 122+ years, that the human spine is a living neurobiomechanical entity, which responds to the changes in the external environment and compensates perpetually seeking a homeostatic equilibrium. We can now have verification that changes or compensation within the spinal system as a result of a bio-neuro-mechanical lesion (vertebral subluxation) results in degeneration (subluxation degeneration) of individual motion segments.
In conclusion, the authors state…
“Changes in sagittal alignment may lead to kinematic changes and influence load bearing and the distribution of disc degeneration at each level.” [pg. 897]
“Sagittal alignment may alter spinal load and mobility, possibly influencing segmental degeneration.” [pg. 897]
“Motion and the segmental contribution to the total mobility tended to be lower at the border of lordosis, especially at the upper segments, and higher at the apex of lordosis in more lordotic spines, whereas the opposite was seen in straight or kyphotic spines.” [pg. 897]
Although medicine is addressing this at the surgical level, as a profession they realize they have no conservative solutions, which has “opened the door” for the credentialed doctor of chiropractic to be in a leadership role in both teaching medicine about the role of the chiropractor as the primary spine care provider and the central focus of the care path for mechanical spine issues.
When communicating with patients and medical professionals it is critically important to educate them on what “current research” is showing and why it is important that this chiropractic approach to spine care is the future of spine care in the United States.
1. Keorochana, G., Taghavi, C. E., Lee, K. B., Yoo, J. H., Liao, J. C., Fei, Z., & Wang, J. C. (2011). Effect of sagittal alignment on kinematic changes and degree of disc degeneration in the lumbar spine: an analysis using positional MRI. Spine, 36(11), 893-898.
2. Teichtahl, A. J., Urquhart, D. M., Wang, Y., Wluka, A. E., Heritier, S. & Cicuttini, F. M. (2015). A dose-response relationship between severity of disc degeneration and intervertebral disc height in the lumbosacral spine. Arthritis Research & Therapy, 17(297). Retrieved from https://openi.nlm.nih.gov/detailedresult.php?img=PMC4619538_13075_2015_820_Fig1_HTML&req=4
3. Teraguchi, M., Yoshimura, N., Hashizume, H., Muraki,S., Yamada, H.,Minamide, A., Oka, H., Ishimoto, Y., Nagata, K. Kagotani, R., Takiguchi, N., Akune, T., Kawaguchi, H., Nakamura, K., & Yoshida, M. (2014). Prevalence and distribution of intervertebral disc degeneration over the entire spine in a population-based cohort: the Wakayama Spine Study. Osteoarthritis and Cartilage, 22(1). Retrieved from http://www.sciencedirect.com/science/article/pii/S1063458413010029
4. Puertas, E.B., Yamashita, H., Manoel de Oliveira, V., & Satiro de Souza, P. (2009). Classification of intervertebral disc degeneration by magnetic resonance. Acta Ortopédica Brasileira, 17(1). Retrieved from http://www.scielo.br/scielo.php?pid=S1413-78522009000100009&script=sci_arttext&tlng=en
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
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.
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 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.
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
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.
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