Falls Chiropractic and Injury

6009 Falls of Neuse Road Raleigh, NC 27609

(919)876-9472 (919)876-9478 FAX

RE: Sample Patient

Date: 8/3/2017

RE: Age dating C4-C5 herniated disc in a low speed crash

To whom it may concern:

Specific to Sample Patient’ case, when looking at the images there is no infiltration of calcium at the area of the protrusion type herniation of the C4-C5 disc.  Wolfe law states that a bone will adapt to the loads upon which it is placed.  When there is a herniation of an intervertebral disc, there is abnormal mechanical shearing thus creating an increase in negative charge within the joint capsule as compared to the osseous structures above and below.  As a result, the trabecular bone will give a positive charge by means of calcium (Ca+) that infiltrates into the injured joint1.  This is called the piezoelectric effect1.  This can be usually visualized beginning at a minimum of 6 months’ post trauma2.  The osteophytic changes noted in other parts of the cervical spine as well as other aspects of the C4-C5 joint itself indicate previous injury.  However, the lack of calcium infiltration and osteophytic changes around the protrusion type herniation at C4-C5 indicates that this herniation is acute in nature, is causally related to the accident, and clinically correlates with the patient’s injury. A clear contrast of this can be seen in the C3-C4 old protrusion type herniation above.

In addition, there were Modic type 1 changes present on the inferior end plate of C4 and the superior end plate of C5.

 

According to Xiong, Huang, Cun, Aghdasi and Zhou (2012)3

Histologic studies have shown that Type 1 Modic changes are characterized by edema, vascularization, and inflammation… (pg. 1943)

 

The presence of Modic type 1 changes is a direct response to the trauma and indicates a recent injury due to the presence of inflammation still present in the bone.

Therefore, the herniation at C4-C5 is acute and is causally related to her accident on 5/20/2017.

Lastly, it is important to note that low impact motor vehicle collisions can and do cause serious injury to the cervical spine. It has been clearly shown in the literature that injury to the cervical spine can occur at speeds as little as 4km/h (2.49 miles per hour)4. To completely ascertain the amount of force that was invoked on Mrs. Patient, one needs to bring into account many factors of the dynamics of the crash. One obvious fact in Mrs. Patient case is that the bullet car’s mass was significantly greater than the target car’s mass; Mrs. Patient was in a Honda Sudan and the bullet car was a Ford SUV as documented by the crash report. This means that the bullet car’s mass was greater than the target car and thus increases the amount of force that was applied to the Mrs. Patient’s vehicle. In addition, the infrastructures of most vehicles are designed to bend and flex at higher speeds to create a crash zone. In Mrs. Patient’s accident, there was little damage to the vehicle infrastructure which affords no crash zone. This thus causes the occupants, such as Mrs. Patient, to receive more force and therefore, more injury with less speed.

 

References:

  1. Issacson, B. M., & Bloebaum, R. D. (2010). Bone electricity: What have we learned in the past 160 years? Journal of Biomedical Research, 95A(4), 1270-1279.
  2. He, G., & Xinghua, Z. (2006). The numerical simulation of osteophyte formation on the edge of the vertebral body using quantitative bone remodeling theory. Joint Bone Spine 73(1), 95-101.
  3. Xiong, C., Huang, B., Cun, Y., Aghdasi, B. G., & Zhou, Y. (2014). Migration inhibitory factor enhances inflammation via CD74 in cartilage end plates with Modic type 1 changes on MRI. Clinical Orthopaedics and Related Research®472(6), 1943-1954.
  4. Brault, J. R., Wheeler, J. B., Siegmund, G. P., & Brault, E. J. (1998). Clinical response of human subjects to rear-end automobile collisions. Archives of Physical Medicine and Rehabilitation, 79(1), 72-80.

 

 

Sincerely,

 

 

Richard A. Laviano, D.C. 

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The Mechanism of the Chiropractic

Spinal Adjustment/Manipulation:

Ligaments and the Bio-Neuro-Mechanical Component

Part 2 of a 5 Part Series

By: Mark Studin

William J. Owens

A report on the scientific literature

 

Citation: Studin M., Owens W., (2017) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Ligaments and the Bio-Neuro-Mechanical Component, Part 2 of 5, American Chiropractor 39 (6), pgs. 22,24-26, 28-31

Introduction

 

When we consider the mechanism of the spinal adjustment/manipulation as discussed in part 1 of this series, for clarity for the chiropractic profession, it will be solely referred to as a chiropractic spinal adjustment (CSA) so as not to confuse chiropractic treatment with either physical therapy or osteopathy. In analyzing how the CSA works, we must go beyond the actual adjustment or thrust and look at the tissue and structures that “frame” the actions. Although there are osseous borders and boundaries, there is a significant network of connective tissue that plays a major role in the CSA. We will focus this discussion on the ligaments that both act as restraints to the human skeleton and also function as sensory organs, we will also examine the role of the muscles and tendons that interact with the ligaments. It is critical to realize that muscles act as active and amplified restraints in the spinal system.

 

The neurological innervations of the ligaments play a significant role in influencing the central nervous system, both reflexively and through brain pathways. Those innervations either support homeostasis in a balanced musculoskeletal environment or creates confusion in a system that has been impaired either post-traumatically or systemically. The human body does not discriminate the etiology of biomechanical failure, it only reacts to create a “low energy” or neutral state utilizing the lowest amount of energy to function.  This balanced or “low energy state” is considered the most optimal function state as nervous system function is not compromised by aberrant sensory input, this is why a “low energy state” is considered the highest function state.

 

 

With understanding the full functional and resultant role of the ligaments and other connective tissues in either macro or repetitive micro traumas, bio-neuro-mechanical failure (something we have historically called vertebral subluxation) occurs. This is the basis for chiropractic care and explains why immediate (pain management), intermediate (corrective) and long-term (wellness or health maintenance) care are necessary to reintegrate the bio-neuro-mechanical system of the human body. Often, the best we can accomplish as practitioners is to support compensation secondary to tissue failure to slow down the resultant joint remodeling and neurological corruption/compromise.

 

 

Ligamentous Function

 

Solomonow (2009) wrote:

 

The functional complexity of ligaments is amplified when considering their inherent viscoelastic properties such as creep, tension–relaxation, hysteresis and time or frequency-dependent length–tension behavior. As joints go through their range of motion, with or without external load, the ligaments ensure that the bones associated with the joint travel in their prescribed anatomical tracks, keep full and even contact pressure of the articular surfaces, prevent separation of the bones from each other by increasing their tension, as may be necessary, and ensuring stable motion. Joint stability, therefore, is the general role of ligaments without which the joint may subluxate, cause damage to the capsule, cartilage, tendons, nearby nerves and blood vessels, discs (if considering spinal joints) and to the ligaments themselves. Such injury may debilitate the individual by preventing or limiting his/her use of the joint and the loss of function…Dysfunctional or ruptured ligaments, therefore, result in a complex- syndrome, various sensory–motor disorders and other long-term consequences, which impact the individual’s well-being, his athletic activities, employer, skilled work force pool and national medical expenses. (p. 137)

 

Ligaments are closely packed collagen fibers that are helical at rest in a crimp pattern. This crimp pattern allows the ligament to recruit other fibers when stressed to support the joint and helps prevent ligamentous failure or subfailure (tearing of the ligament). They are comprised of collagen and elastin which give them both tensile strength and elasticity with no two joints being alike in composition.  Each joint has a specific biomechanical role and varies depending upon the needs of that joint.

 

Note. Ligaments and tendons,” by I. Ziv, (n.d.), [PowerPoint slides]. Retrieved from https://wings.buffalo.edu/eng/mae/courses/417-517/Orthopaedic%20Biomechanics/ Lecture%203u.pdf

 

Solomonow (2008) continued:

 

As axial stretching of a ligament is applied, fibers or bundles with a small helical wave appearance straighten first and begin to offer resistance (increased stiffness) to stretch. As the ligament is further elongated, fibers or fiber bundles of progressively larger helical wave straighten and contribute to the overall stiffness. Once all the fibers are straightened, a sharp increase in stiffness is observed. (p. 137)

 

Solomonow (2008) later stated:

 

Over all, the mostly collagen (75%), elastin and other substances structure of ligaments is custom tailored by long evolutionary processes to provide various degrees of stiffness at various loads and at various ranges of motion of a joint, while optimally fitting the anatomy inside (inter-capsular) or outside (extra-capsular) a given joint. The various degrees of helical shape of the different fibers allows generation of a wide range of tensile forces by the fiber recruitment process, whereas the overall geometry of the ligament allows selective recruitment of bundles such as to extend function over a wide range of motion. The large content of water (70%) and the cross weave of the long fibers by short fibers provides the necessary lubrication for bundles to slide relative to each other, yet to remain bundled together and generate stiffness in the transverse directions.(p. 137)

 

 

Solomonow (2008):

Length–tension and recruitment: The general length–tension (or strain–stress) behavior of a ligament is non-linear…The initial [reports] demonstrate rather large strain for very small increase in load. Once all the waves in the collagen fibers of the ligament have been straightened out, and all of the fibers were recruited, additional increase in strain is accompanied with a fast increase in tension…


Creep: When a constant load is applied to a ligament, it first elongates to a given length. If left at the same constant load, it will continue to elongate over time in an exponential fashion up to a finite maximum…


Tension–relaxation:When ligaments are subjected to a stretch and hold over time (or constant elongation) the tension–relaxation phenomena is observed. The tension in the ligament increases immediately upon the elongation to a given value. As time elapses, the tension decreases exponentially to a finite minimum while the length does not change…


Strain rate: The tension developed in a ligament also depends on the rate of elongation or strain rate (Peterson, 1986). In general, slow rates of elongation are associated with the development of relatively low tension, whereas higher rates of elongation result in the development of high tension. Fast stretch of ligaments, such as in high-frequency repetitive motion or in sports activities are known to result in high incidents of ligamentous damage or rupture…Fast rates of stretch, therefore, may exceed the physiological loads that could be sustained by a ligament safely, yet it may still be well within the physiological length range. Development of high tension in the ligaments may result in rupture and permanent sensory–motor deficit to the joint in addition to deficit in its structural functions. (p. 137-139)


Author’s note: A fast strain rate within the physiological limit may also cause ligamentous damage as the ligament hasn’t had enough time to adapt (stretch) to its new tensile demand and this is called a “sub-failure.”
“This phenomenon is associated with repetitive motion when a series of stretch-release cycles are performed over time (Solomnow, 1008, p. 140).


Ligament Reaction to Trauma and Healing


Solomnow (2008) stated:

Ligament Inflammation: Inflammatory response in ligaments is initiated whenever the tissue is subjected to stresses which exceed its routine limits at a given time. For example, a sub-injury/failure load, well within the physiological limits of a ligament when applied to the ligament by an individual who does not do that type of physical activity routinely. The normal homeostatic metabolic, cellular, circulatory and mechanical limits are therefore exceeded by the load, triggering an inflammatory response…


Another case where acute inflammation is present is when physical activities presenting sudden overload/stretch cause a distinct damage to the tissue which is felt immediately. Such cases, as a sudden loss of balance, a fall, collision with another person, exposure to unexpected load, etc., may result in what is called a sprain injury or a partial rupture of the ligament. Acute inflammation sets in within several hours and may last several weeks and up to 12 months. The healing process, however, does not result in full recovery of the functional properties of the tissue. Mostly, only up to 70% of the ligaments original structural and functional characteristics are attained by healing post-injury (Woo et al. 1990)...
Chronic inflammation is an extension of an acute inflammation when the tissue is not allowed to rest, recover and heal. Repetitive exposure to physical activity and reloading of the ligament over prolonged periods without sufficient rest and recovery represent cumulative micro-trauma. The resulting chronic inflammation is associated with atrophy and degeneration of the collagen matrix leaving a permanently damaged, weak and non-functional ligament (Leadbenter, 1990). The dangerous aspect of a chronic inflammation is the fact that it builds up silently over many weeks, months or years (dependent on a presently unknown dose-duration levels of the stressors) and appears one day as a permanent disability associated with pain, limited motion, weakness and other disorders (Safran, 1985). Rest and recovery of as much as 2 years allows only partial resolution of the disability (Woo and Buckwalter, 1988). Full recovery was never reported. (p. 143-144)


Hauser et al. (2013) reported that once a ligament is overloaded in either a failure or subfailure, then the tissue fails which results in partial or complete tears known as a sprain. When this occurs, the body “attempts” to repair the damaged ligament, but cannot completely.


Hauser et al. (2013) wrote:

With time, the tissue matrix starts to resemble normal ligament tissue; however, critical differences in matrix structure and function persist. In fact, evidence suggests that the injured ligament structure is replaced with tissue that is grossly, histologically, biochemically, and biomechanically similar to scar tissue. (p. 6)


Hauser et al. (2013) also stated:

The persisting abnormalities present in the remodeled ligament matrix can have profound implications on joint biomechanics, depending on the functional demands placed on the tissue. Since remodeled ligament tissue is morphologically and biomechanically inferior to normal ligament tissue, ligament laxity results, causing functional disability of the affected joint and predisposing other soft tissues in and around the joint to further damage. (p. 7)

Hauser et al. (2013) further said:
In fact, studies of healing ligaments have consistently shown that certain ligaments do not heal independently following rupture, and those that do heal, do so with characteristically inferior compositional properties compared with normal tissue. It is not uncommon for more than one ligament to undergo injury during a single traumatic event. (p. 8)

Author’s note: Ligaments are made with fibroblasts which produce collagen and elastin, and model the ligament throughout puberty. Once puberty is over, the fibroblasts stop producing any ligamentous tissue and remain dormant. Upon injury, the fibroblast activates, but now can only produce collagen, leaving the joint stiffer and in a biomechanically compromised functional environment. The above comment verifies that in the literature.

Hauser et al. (2013) explained:
Osteoarthritis [OA] or joint degeneration is one of the most common consequences of ligament laxity. Traditionally, the pathophysiology of OA was thought to be due to aging and wear and tear on a joint, but more recent studies have shown that ligaments play a crucial role in the development of OA. OA begins when one or more ligaments become unstable or lax, and the bones begin to track improperly and put pressure on different areas, resulting in the rubbing of bone on cartilage. This causes the breakdown of cartilage and ultimately leads to deterioration, whereby the joint is reduced to bone on bone, a mechanical problem of the joint that leads to abnormality of the joint’s mechanics.


Hypermobility and ligament laxity have become clear risk factors for the prevalence of OA. The results of spinal ligament injury show that over time the inability of the ligaments to heal causes an increase in the degeneration of disc and facet joints, which eventually leads to osteochondral degeneration. (p. 9)


Ligaments as Sensory Organs
Spinal pain and the effects of the chiropractic spinal adjustment is both central and peripheral in etiology. According to Studin and Owens (2016), the CSA also affects the central nervous system with systemic sequelae verifying that chiropractic supports systemic changes and is not comprised solely of “back pain providers.” Although chiropractic is not limited to pain, chiropractors do treat back pain, inclusive of all spinal regions. Regarding pain, much of the pain generators originate in the ligaments.


Solomonow (2009) wrote:While ligaments are primarily known for mechanical support for joint stability, they have equally important sensory functions. Anatomical studies demonstrate that ligaments in the extremity joints and the spine are endowed with mechanoreceptors consisting of: Pacinian, Golgi, Ruffini and bare nerve endings. (Burgess and Clark, 1969; Freeman and Wyke, 1967a,b; Gardner, 1944; Guanche et al., 1995; Halata et al., 1985; Jackson et al., 1966; Mountcastle, 1974; Petrie et al., 1988, Schulz et al. 1984, Sjölander, 1989; Skoglund, 1956; Solomonow et al., 1996; Wyke, 1981; Yahia and Newman, 1991; Zimney and Wink, 1991). The presence of such afferents in the ligaments confirms that they contribute to proprioception and kinesthesia and may also have a distinct role in reflex activation or inhibition of muscular activities.(p. 144)


Dougherty (n.d.) reported:
Pacinian corpusclesare found in subcutaneous tissue beneath the dermis…and in the connective tissues of bone [ligaments and tendons], the body wall and body cavity. Therefore, they can be cutaneous, proprioceptive or visceral receptors, depending on their location…


When a force is applied to the tissue overlying the Pacinian corpuscle…its outer laminar cells, which contain fluid, are displaced and distort the axon terminal membrane. If the pressure is sustained on the corpuscle, the fluid is displaced, which dissipates the applied force on the axon terminal. Consequently, a sustained force on the Pacinian corpuscle is transformed into a transient force on its axon terminal. The Pacinian corpuscle 1° afferent axon response is rapidly adapting and action potentials are only generated when the force is first applied. (http://neuroscience.uth.tmc.edu/ s2/chapter02.html)

Dougherty (n.d.) stated: 

TheRuffini corpusclesare found deep in the skin…as well as in joint ligaments and joint capsules and can function as cutaneous or proprioceptive receptors depending on their location. The Ruffini corpuscle…is cigar-shaped, encapsulated, and contains longitudinal strands of collagenous fibers that are continuous with the connective tissue of the skin or joint. Within the capsule, the 1° afferent fiber branches repeatedly and its branches are intertwined with the encapsulated collagenous fibers. (http://neuroscience.uth.tmc. edu/s2/chapter02.html) “Ruffini corpuscles in skin are considered to be skin stretch sensitive receptors of the discriminative touch system. They also work with the proprioceptors in joints and muscles to indicate the position and movement of body parts” (Dougherty, http://neuroscience.uth.tmc.edu/s2/chapter02.html).


Dougherty (n.d.) stated:
Golgi tendon organsare found in the tendons of striated extrafusal muscles near the muscle-tendon junction…Golgi tendon organs resemble Ruffini corpuscles. For example, they are encapsulated and contain intertwining collagen bundles, which are continuous with the muscle tendon, and fine branches of afferent fibers that weave between the collagen bundles…They are functionally "in series" with striated muscle. (http://neuroscience.uth.tmc.edu/s2/ chapter02.html)
“TheGolgi tendon organis a proprioceptor that monitors and signals muscle contraction against a force (muscle tension), whereas the muscle spindle is a proprioceptor that monitors and signals muscle stretch (muscle length)” (Dougherty, http://neuroscience.uth.tmc.edu/ s2/chapter02.html).


Dougherty (n.d.) stated:
…free nerve endings of 1° afferents are abundant in muscles, tendons, joints, and ligaments. These free nerve endings are considered to be the somatosensory receptors for pain resulting from muscle, tendon, joint, or ligament damage and are not considered to be part of the proprioceptive system. [These free nerve endings are called nociceptors.]


Solomonow (2009) commented:
The presence of such afferents in the ligaments confirms that they contribute to proprioception and kinesthesia and may also have a distinct role in reflex activation or inhibition of muscular activities…
Overall, the decrease or loss of function in a ligament due to rupture or damage does not only compromise its mechanical contributions to joint stability, but also sensory loss of proprioceptive and kinesthetic perception and fast reflexive activation of muscles and the forces they generate in order to enforce joint stability…


It was suggested, as far back as the turn of the last century, that a reflex may exist from sensory receptors in the ligaments to muscles that may directly or indirectly modify the load imposed on the ligament (Payr, 1900)…A clear demonstration of a reflex activation of muscles was finally provided in 1987 (Solomonow et al., 1987) and reconfirmed several times since then (beard et al., 1994; Dyhre-Poulsen and Krogsgard, 2000; Raunest et al., 1996; Johansson et al., 1989; Kim et al., 1995). It was further shown that such a ligamento-muscular reflex exists in most extremity joints (Freeman and Wyke, 1967b; Guanche et al., 1995, Knatt et al., 1995; Schaible and Schmidt, 1983; Schaible et al., 1986; Solomonow et al., 1996; Phillips et al., 1997; Solomonow and Lewis, 2002) and in the spine (Indahl et al., 1995, 1997; Stubbs et al., 1998; Solomonow et al., 1998). (p. 144).


“Ligamento-muscular reflexes, therefore, may be inhibitory or excitatory, as may be fit to preserve joint stability; inhibiting muscles that destabilize the joint or increased antagonist co-activation to stabilize the joint” (Solomonow, 2009, p. 145).
Spinal Stabilization and Destabilization


Panjabi (2006) reported:
1. Single trauma or cumulative microtrauma causes subfailure injury of the spinal ligaments and injury to the mechanoreceptors [and nociceptors] embedded in the ligaments.
2. When the injured spine performs a task or it is challenged by an external load, the transducer signals generated by the mechanoreceptors [and nociceptors] are corrupted.
3. Neuromuscular control unit has difficulty in interpreting the corrupted transducer signals because there is spatial and temporal mismatch between the normally expected and the corrupted signals received.
4. The muscle response pattern generated by the neuromuscular control unit is corrupted, affecting the spatial and temporal coordination and activation of each spinal muscle.
5. The corrupted muscle response pattern leads to corrupted feedback to the control unit via tendon organs of muscles and injured mechanoreceptors [and nociceptors], further corrupting the muscle response pattern. (p. 669)

The above stabilization-destabilization scenario is the foundation for why a CSA is clinically indicated for short, intermediate and long-term treatment (biomechanical stabilization) as clinically indicated. It also clearly outlines what the goal of the CSA is, to integrate the bio-neuro-mechanical system to bring the human body to utilize its lowest form of energy for homeostasis or as close to normal as tissue pathology allows.
This is part 2 of a 5-part series where part 1 covers the osseous mechanics of the chiropractic spinal adjustment. This part covered the ligamentous involvement from a supportive and neurological perspective. The topic of part 3 will be spinal biomechanics and their neurological components in addition to how the chiropractic spinal adjustment makes changes bio-neuro-mechanically. Part 4 will be an in-depth contemporary comparative analysis of the chiropractic spinal adjustment vs. physical therapy joint mobilization. The final part will be a concise overview of the chiropractic spinal adjustment.

References:

1. Solomonow, M. (2009). Ligaments: A source of musculoskeletal disorders.Journal of Bodywork and Movement Therapies,13(2), 136-154.

2. Ziv, I. (n.d.). Ligaments and tendons [PowerPoint slides]. Retrieved from https://wings.buffalo.edu/eng/mae/courses/417-517/Orthopaedic%20Biomechanics/Lecture%203u.pdf

3. Hauser, R. A., Dolan, E. E., Phillips, H. J., Newlin, A. C., Moore, R. E., & Woldin, B. A. (2013). Ligament injury and healing: A review of current clinical diagnostics and therapeutics.The Open Rehabilitation Journal,6, 1-20.

4. Solomonow, M. (2006). Sensory–motor control of ligaments and associated neuromuscular disorders.Journal of Electromyography and Kinesiology,16(6), 549-567.

5. Studin M., & Owens W. (2016). Chiropractic spinal adjustments and the effects on the neuroendocrine system and the central nervous system connection. The American Chiropractor, 38(1), 46-51.

6. Dougherty, P. (n.d.). Chapter 2: Somatosensory systems. Neuroscience Online. Retrieved from  http://neuroscience.uth.tmc.edu/s2/chapter02.html

7. Panjabi, M. M. (2006). A hypothesis of chronic back pain: Ligament subfailure injuries lead to muscle control dysfunction.European Spine Journal,15(5), 668-676.

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Chiropractic and Successful Outcomes with Chronic Obstructive Pulmonary Disease

 

By: Mark Studin

William J. Owens

 

A report on the scientific literature

 

Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease that makes it difficult to empty air out of the lungs. This difficulty in emptying air out of the lungs (airflow obstruction) can lead to shortness of breath or feeling tired because you are working harder to breathe. COPD is a term that is used to include chronic bronchitis, emphysema, or a combination of both conditions. Asthma is also a disease where it is difficult to empty the air out of the lungs, but asthma is not included in the definition of COPD. It is not uncommon, however for a patient with COPD to also have some degree of asthma. Chronic bronchitis is a condition of increased swelling and mucus (phlegm or sputum) production in the breathing tubes (airways). Airway obstruction occurs in chronic bronchitis because the swelling and extra mucus causes the inside of the breathing tubes to be smaller than normal. The diagnosis of chronic bronchitis is made based on symptoms of a cough that produces mucus or phlegm on most days, for three months, for two or more years (after other causes for the cough have been excluded). Emphysema is a condition that involves damage to the walls of the air sacs (alveoli) of the lung. Normally there are more than 300 million alveoli in the lung. The alveoli are normally stretchy and springy, like little balloons. Like a balloon, it takes effort to blow up normal alveoli; however, it takes no energy to empty the alveoli because they spring back to their original size. In emphysema, the walls of some of the alveoli have been damaged. When this happens, the alveoli lose their stretchiness and trap air. Since it is difficult to push all of the air out of the lungs, the lungs do not empty efficiently and therefore contain more air than normal. This is called air trapping and causes hyperinflation in the lungs. The combination of constantly having extra air in the lungs and the extra effort needed to breathe results in a person feeling short of breath. Airway obstruction occurs in emphysema because the alveoli that normally support the airways open cannot do so during inhalation or exhalation. Without their support, the breathing tubes collapse, causing obstruction to the flow of air. (http://www.thoracic.org/patients/patient-resources/resources/copd-intro.pdf)

Wearing, Beaumont, Forbes, Brown and Engler (2016) reported:

 

Extrapulmonary effects, such as skeletal muscle dysfunction, affect the severity of the disease and provide a potential target for therapeutic intervention. An estimated 18%–36% of people with COPD experience skeletal muscle dysfunction at a level that affects exercise capacity and dyspnea levels, both predictors of mortality in COPD. Because exercise capacity is a measure of the amount of exercise that can be performed before the onset of leg fatigue or exercise-limiting dyspnea, a decrease in capacity has been associated with poorer quality of life and higher hospitalization rates. Nonpharmacologic interventions benefit people with COPD.  For example, pulmonary rehabilitation (PR) is considered to be a well-developed, multidisciplinary approach to managing many extrapulmonary effects associated with COPD.  However, PR has little clinical effect on lung function. Similarly, research into the effect of acupuncture has shown that this modality has little effect on long-term lung function despite helping improve dyspnea levels and exercise tolerance. (pgs. 108-109)

  

The authors have had long-term experience in treating COPD utilizing a portion of the "Evidence-based behavioral practice“ model in observing results from patients over the past 3 decades.

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

In the observation component of the evidence-based behavioral practice model, the authors have observed COPD patients realize increased tidal volumes, forced vital volume, forced expiratory volume and residual increased volumes performed on a Renaissance Spirometer by Puritan-Bennett in the 1990’s, post chiropractic spinal adjustment. These results (the printouts have since been discarded) were consistent with both acute and chronic emphysema patients with multiple etiologies and were verified both with the spirometer volumes and the patient’s feedback. Due to limited resources (and research inexperience) of the authors in the 1990’s, this information was limited to patients who had similar issues at the local clinical level. Nonetheless, the results were consistent and reproducible, however the was no literature to corroborate or validate these findings at the time.

In contemporary literature, there is now a basis to support the authors previous findings. Wearing, Beaumont, Forbes, Brown and Engler (2016) continued:

 

This systematic review updates the results from a previous review and is the first to focus on evidence of the effect of administering SMT (spinal manual treatment of the chiropractic spinal adjustment) in conjunction with other interventions in the management of COPD. Improvements in lung function (increases in forced expiratory and forced vital volume; decrease in residual volume) and exercise capacity (increase in 6-minute walking test) were reported in three random clinical trials following a combination of SMT and exercise. While these findings were recorded in pilot and preliminary trials, they represent preliminary evidence that the combination of SMT with exercise may be more beneficial to people with COPD than exercise or SMT alone. Furthermore, the results provide additional information to the review by Heneghan and colleagues; however, the findings of this review contrast with the earlier conclusion that no evidence supported or refuted the use of MT on patients with COPD.

 

In conclusion, this appears to be the first systematic review to investigate the evidence for administering SMT in conjunction with other modalities, such as exercise, on people with COPD. The exclusion of such combinations may explain the disparity in findings between this review and the review by Heneghan et al., who found no evidence to support or refute the use of MT in the management of COPD. The importance of increasing exercise capacity, even by indirect methods such as increasing thoracic mobility should not be underestimated because exercise capacity is a predictor of mortality in COPD. As pulmonary rehabilitation does not improve lung function, the current findings may have wider implications if repeated in a larger cohort. (pg. 113)

 

Although Wearing et. Al (2016) acknowledged that this study was very limited in numbers and acknowledged that there could be benefit through co-management with exercise, the results mimicked the findings realized by the authors in the 1990’s.  In addition, Wearing et. Al.  reported no significant adverse effects of chiropractic care and is consistent with previous reports 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).

 

References:

  1. American Thoracic Society (2017) Retrieved from: http://www.thoracic.org/patients/patient-resources/resources/copd-intro.pdf
  2. Wearing, J., Beaumont, S., Forbes, D., Brown, B., & Engel, R. (2016). The use of spinal manipulative therapy in the management of chronic obstructive pulmonary disease: a systematic review.The Journal of Alternative and Complementary Medicine,22(2), 108-114.
  3. Evidence-Based Practice. (n.d.). In Wikipedia. Retrieved January 3, 2012, from http://en.wikipedia.org/wiki/Evidence-based_practice
  1. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270.

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A Chiropractic Adjustment Has a Direct Effect of the Pre-Frontal Cortex of the Brain

 

Verifying a positive effect of the chiropractic spinal adjustment on reflexes, memory, coordination and decision making

 

By: Mark Studin

William J. Owens

 

A report on the scientific literature

For most of the 20th century, based upon results in individual chiropractic offices, the profession’s success was founded on a patient-based model. This model drove utilization at predominantly a “grass roots” level and over the last 10-20 years, research has started to give reasons to why patients not only get out of pain, but executive functions such as decision making, anxiety, managing tasks and being able to focus at a higher level are improving. It is these types of results that have driven many patients to appreciate chiropractic as a “miracle cure” while others, mostly from organized medicine and insurers, who in the past have considered it an "invalid claim” because of the lack of credible evidence despite mounting feedback from patients over the last century. Factually, their arguments had merit on many issues in the past, but as research has been published through the years, those arguments are outdated and incorrect.

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

When considering a purely “evidenced-based” approach, it often precludes advances through a doctor’s immediate experiences in “breakthroughs” that has historically saved lives and then set up the research to render the evidence of what doctors have found on an “experiential level.” This is formally termed best medical practice.

“Abest practice is a method or technique that has consistently shown results superior to those achieved with other means and that is used as a benchmark. In addition, a "best" practice can evolve to become better as improvements are discovered. Best practice is considered by some as a business buzzword, used to describe the process of developing and following a standard way of doing things that multiple organizations can use" (Best Practice, http://en.wikipedia.org/ wiki/Best_practice).

Sackett, Rosenberg, Gray, Haynes and Richardson (1996) stated, 

 “Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom (p. 71)."  They go on to comment “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients" (Sackett et al, 1996, p. 72).  The point is that the provider plays a huge role and ultimately is the check and balance of this process. Without the provider, the payor becomes the determining factor in the delivery of healthcare by "tying the doctor's hands" with the limitation of evidence. 

They further stated:

“External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision" (Sackett et al, 1996, p. 73).  Lastly, they state, “Evidence based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions" (Sackett et al, 1996, p. 73). This is often a process that takes years, preventing the final papers from being published in a timely enough fashion to meet the ever-changing advancement of medicine and the technologies that support the current needs of the patients.  

When considering executive function at the central (brain) level, based upon contemporary literature, we can now go beyond the “best medical practice” model of purely patient feedback and as Sackett et. Al. suggested, add the evidence as verification. In order to better understand how chiropractic plays a role in executive function, we must start at neural plasticity. According to Leung et. Al (2015) Neural plasticity refers to the capacity of our brain to change in response to internal demand and/or external experience. Burgeoning research has corroborated that the neural plastic changes induced in our brains and behaviors are specific to the experiences. [pg. 1] 

Neuroplasticity, also known as brain plasticity or neural plasticity, is an umbrella term that describes lasting change to the brain throughout an individual's life course. The term gained prominence in the latter half of the 20th century, when new research showed that many aspects of the brain can be altered (or are "plastic”) even into adulthood. (https://en.wikipedia.org/wiki/Neuroplasticity) 

This article focuses on the actions and effects of neuroplasticity on the pre-frontal cortex of the brain. According to Lelic et. Al (2016) 

The prefrontal cortex is known to play a vital role in SMI and is also responsible for a number of other functions. The prefrontal cortex is known to be a key structure responsible for the performance of what is known as “executive functions.” Executive function is the mechanism by which the brain integrates and coordinates the operations of multiple neural systems to solve problems and achieve goals based on the ever-changing environment around us. Executive function is considered to be a product of the coordinated operation of various neural systems and is essential for achieving any particular goal. The prefrontal cortex is believed to be the main brain structure responsible for enabling this coordination and control. It requires planning a sequence of subtasks to accomplish a goal, focusing attention on relevant information as well as inhibiting irrelevant distractors, being able to switch attention between tasks monitoring memory, initiation of activity, and responding to stimuli. [pg. 7] 

Lelic et. Al.’s study resulted in two major findings. Firstly, the study reproduced previous findings of somatosensory evoked potential (SEPs) studies that have shown that chiropractic spinal adjusting of dysfunctional spinal segments alters early sensorimotor integration (SMI) of input from the upper limb. The second major finding of this study was that we were able to show, using dipole source localization, that this change in SMI that occurs after spinal manipulation predominantly happens in the prefrontal cortex. The SEP peak showed multiple neural generators including primary sensory cortex, basal ganglia, thalamus, premotor areas, and primary motor cortex. The frontal N30 peak is therefore thought to reflect early SMI.

The current study adds to previous work by not only confirming that spinal manipulation [chiropractic spinal adjustment] of dysfunctional joints decreases the N30 SEP peak amplitude but also demonstrating that this decrease occurs predominantly in one of the known neural generators of N30, that is, the prefrontal cortex. This suggests that, at least in part, the mechanisms by which spinal manipulation improves performance are due to a change in function at the prefrontal cortex.

Lelic et. Al (2016) continued,

The prefrontal cortex is known to play a vital role in SMI and is also responsible for a number of other functions. The prefrontal cortex is known to be a key structure responsible for the performance of what is known as “executive functions.” Executive function is considered to be a product of the coordinated operation of various neural systems and is essential for achieving any particular goal. The prefrontal cortex is believed to be the main brain structure responsible for enabling this coordination and control. It requires planning a sequence of subtasks to accomplish a goal, focusing attention on relevant information as well as inhibiting irrelevant distractors, being able to switch attention between tasks, monitoring memory, initiation of activity, and responding to stimuli. A change in prefrontal activity following chiropractic care may therefore explain and/or link some of the varied improvements in neural function previously observed in the literature, such as improved joint position sense error, reaction time, cortical processing, cortical sensorimotor integration, reflex excitability, motor control, and lower limb muscle strength.

To accomplish the coordinated operations of multiple neural systems and structures, the prefrontal cortex must monitor the activities in other cortical and subcortical structures and control and integrate their operations by sending command signals in a so-called “top-down” manner. This is a complex operation, and the importance of this monitoring, integration, and coordination is highlighted in studies where damage to the prefrontal cortex has been shown to impair the ability to create new and adaptive action programs or choose the best among several equally probable alternatives, despite such individuals displaying normal IQs in most psychological tests, having normal long-term memory functions, and exhibiting normal perceptual, motor, and language skills

 To accomplish the coordinated operations of multiple neural systems and structures, the prefrontal cortex must monitor the activities in other cortical and subcortical structures and control and integrate their operations by sending command signals in a so-called “top-down” manner. This is a complex operation, and the importance of this monitoring, integration, and coordination is highlighted in studies where damage to the prefrontal cortex has been shown to impair the ability to create new and adaptive action programs or choose the best among several equally probable alternatives, despite such individuals displaying normal IQs in most psychological tests, having normal long-term memory functions, and exhibiting normal perceptual, motor, and language skills [43].The change in prefrontal cortex as seen in this study therefore suggests that the altered input from dysfunctional joints that leads to altered processing of somatosensory inputs can influence processing of somatosensory information by the prefrontal cortex.

Chiropractic care, by treating the joint dysfunction, appears to change processing by the prefrontal cortex. This suggests that chiropractic care may as well have benefits that exceed simply reducing pain or improving muscle function and may explain some claims regarding this made by chiropractors.

Although the change in N30 due to chiropractic treatment is an important finding, it is not clear how long this finding lasts. To date, some of the authors of this study have shown that the N30 changes on average are present for at least 20–30 minutes after spinal manipulation. For some subjects, the changes were still evident at 30 minutes after spinal manipulation and we have not yet followed up for longer than 30 minutes, due to the length of the study as is.

The literature has clearly suggested that a chiropractic spinal adjustment has a clear and reproducible effect on brain physiology and function and is consistent with reports from Reed, Pickjar, Sozio and Long (2014) and Gay, Robinson, George, Peristen and Bishop (2014) on a chiropractic spinal adjustment effecting brain function. These results, in addition to chiropractic patient’s feedback since 1895, have combined both “best practice” and evidenced based” models and start to explain through science, why people are experiencing so much more than their beck or neck pain resolving.

References:

  1. Best Practice. (n.d.). In Wikipedia. Retrieved January 3, 2012, fromhttp://en.wikipedia.org/wiki/Best_practice
  2. Evidence-Based Practice. (n.d.). In Wikipedia. Retrieved January 3, 2012, fromhttp://en.wikipedia.org/wiki/Evidence-based_practice
  3. Leung, N. T., Tam, H. M., Chu, L. W., Kwok, T. C., Chan, F., Lam, L. C., ... & Lee, T. (2015). Neural plastic effects of cognitive training on aging brain.Neural plasticity,2015.
  4. Neuroplasticity (2017), Retrieved from: https://en.wikipedia.org/wiki/Neuroplasticity
  5. Lelic, D., Niazi, I. K., Holt, K., Jochumsen, M., Dremstrup, K., Yielder, P., ... & Haavik, H. (2016). Manipulation of dysfunctional spinal joints affects sensorimotor integration in the prefrontal cortex: A brain source localization study.Neural plasticity,2016
  6. Reed, W. R., Pickar, J. G., Sozio, R. S., & Long, C. R. (2014). Effect of spinal manipulation thrust magnitude on trunk mechanical activation thresholds of lateral thalamic neurons.Journal of Manipulative and Physiological Therapeutics, 37(5), 277-286.
  7. Gay, C. W., Robinson, M. E., George, S. Z., Perlstein, W. M., & Bishop, M. D. (2014). Immediate changes after manual therapy in resting-state functional connectivity as measured by functional magnetic resonance imaging in participants with induced low back pain. Journal of Manipulative and Physiological Therapeutics, 37(9), 614-627..

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Traumatic Ligament Laxity of the Spine and

Associated Physical Impairment

Lawrence Lefcort, DC

 

Author Note

            Correspondence concerning this article should be addressed to Lawrence Lefcort, DC at

Bayside Physical Therapy, Chiropractic, and Acupuncture, PLLC, 213-15 33rd Road Bayside,

NY 11361

 

TRAUMATIC LIGAMENT LAXITY OF THE SPINE

Abstract

This paper explores the relationship between traumatic ligament laxity of the spine and the

resultant instability that may occur. Within, there is a discussion of the various spinal

ligamentous structures that may be affected by both macro and micro traumatic events, as

well as the neurologic and musculoskeletal effects of instability. There is detailed discussion of

the diagnosis, quantification, and documentation as well.

            Keywords: ligament laxity, instability

 

                                                              

TRAUMATIC LIGAMENT LAXITY OF THE SPINE

Traumatic Ligament Laxity of the Spine and

Associated Physical Impairment

            Soft tissue cervical and lumbar sprain/strains are the most common injury in motor vehicle collisions, with 28% to 53% of collision victims sustaining this type of injury (Galasko et al., 1993; Quinlan et al., 2000). The annual societal costs of these injuries in the United States are estimated to be between 4.5 and 8 billion dollars (Kleinberger et al., 2000; Zuby et al., 2010). Soft tissue injuries of the spinal column very often become chronic, with the development of long-term symptoms, which can inevitably adversely affect the victim’s quality of life. Research has indicated that 24% of motor vehicle collision victims have symptoms 1 year after an accident and 18% after 2 years (Quinlan et al., 2004). Additionally, it has been found that between 38% and 52% of motor vehicle collision cases involved rear-impact scenarios

( Kleinberger et al.,2000; Galasko et al., 1993).

            It is well known that the major cause of chronic pain due to these injuries is directly related to the laxity of spinal ligamentous structures (Ivancic, et al., 2008). One must fully understand the structure and function of ligaments in order to realize the effects of traumatic ligament laxity. Ligaments are fibrous bands or sheets of connective tissue which link two or more bones, cartilages, or structures together. We know that one or more ligaments provide stability to a joint during rest as well as movement. Excessive movements such as hyper-extension or hyper-flexion, which occur during a traumatic event such as a motor vehicle collision, may be restricted by ligaments, unless these forces are beyond the tensile-strength of these structures; this will be discussed later in this paper.

TRAUMATIC LIGAMENT LAXITY OF THE SPINE

            Three of the more important ligaments in the spine are the ligamentum flavum, the anterior longitudinal ligament, and the posterior longitudinal ligament (Gray’s Anatomy, 40th Edition). The ligamentum flavum forms a cover over the dura mater, which is a layer of tissue that protects the spinal cord. This ligament connects under the facet joints to create a small curtain, so to speak, over the posterior openings between vertebrae (Gray’s Anatomy, 40th edition). The anterior longitudinal ligament attaches to the front (anterior) of each vertebra and runs vertical or longitudinal (Gray’s Anatomy, 40th edition). The posterior longitudinal ligament also runs vertically or longitudinally behind (posterior) the spine and inside the spinal canal (Gray’s Anatomy, 40th Edition). Additional ligaments include facet capsular ligaments, interspinous ligaments, supraspinous ligaments, and intertransverse ligaments. The aforementioned ligaments limit flexion and extension, with the exception of the ligament, which limits lateral flexion. The ligamentum nuchae, which is a fibrous membrane, limits flexion of the cervical spine (Gray’s Anatomy, 40th Edition). The four ligaments of the sacroiliac joints

(iliolumbar, sacroiliac, sacrospinus, sacrotuberous), provide stability and some motion. The upper cervical spine has its own ligamentous structures or systems; occipitoatlantal ligament complex, occipitoaxial ligament complex, atlantoaxial ligament complex, and the cruciate ligament complex (Gray’s Anatomy, 40th Edition). The upper cervical ligament system is especially important in stabilizing the upper cervical spine from the skull to C2 (axis) (Stanley Hoppenfeld, 1976). It is important to note, that although the cervical vertebrae are the smallest, the neck has the greatest range of motion.

TRAUMATIC LIGAMENT LAXITY OF THE SPINE

            Ligament laxity may happen as a result of a ‘macro trauma”, such as a motor vehicle collision, or may develop overtime as a result of repetitive use injuries, or work-related injuries. The cause of this laxity develops through similar mechanisms, which leads to excessive motion of the facet joints, and will cause various degrees of physical impairment. When ligament laxity develops over time, it is defined as “creep” and refers to the elongation of a ligament under a constant or repetitive stress (Frank CB, 2004). Low-level ligament injuries, or those where the ligaments are simply elongated, represent the vast majority of cases and can potentially incapacitate a patient due to disabling pain, vertigo, tinnitus, etc.. Unfortunately, these types of strains may progress to sub-failure tears of ligament fibers, which will lead to instability at the level of facet joints (Chen HB et al., 2009). Traumatic or repetitive causes of ligament laxity will ultimately produce abnormal motion and function between vertebrae under normal physiological loads, inducing irritation to nerves, possible structural deformation, and/or incapacitating pain.

            Patients’, who have suffered a motor vehicle collision or perhaps a work-related injury, very often have chronic pain syndromes due to ligament laxity. The ligaments surrounding the facet joints of the spinal column, known as capsular ligaments, are highly innervated mechanoreceptive and nociceptive free nerve endings. Therefore, the facet joint is thought of as the primary source of chronic spinal pain (Boswell MV et al., 2007; Barnsley L et al., 1995). When the mechanoreceptors and nociceptors are injured or even simply irritated the overall joint function of the facet joints are altered (McLain RF, 1993).

TRAUMATIC LIGAMENT LAXITY OF THE SPINE

            One must realize that instability is not similar to hyper-mobility. Instability, in the clinical context, implies a pathological condition with associated symptomatology, whereas joint hypermobility alone, does not. Ligament laxity which produces instability refers to a loss of “motion stiffness”, so to speak, in a particular spinal segment when a force is applied to this segment, which produces a greater displacement than would be observed in a normal motion segment. When instability is present, pain and muscular spasm can be experienced within the patient’s range of motion and not just at the joint’s end-point. In Chiropractic, we understand that there is a “guarding mechanism”, which is triggered after an injury, which is the muscle spasm. These muscle spasms can cause intense pain and are the body’s response to instability, since the spinal supporting structures, the ligamentous structures, act as sensory organs, which initiate a ligament-muscular reflex. This reflex is a “protective reflex” or “guarding mechanism”, produced by the mechanoreceptors of the joint capsule and these nerve impulses are ultimately transmitted to the muscles. Activation of surrounding musculature, or guarding, will help to maintain or preserve joint stability, either directly by muscles crossing the joint or indirectly by muscles that do not cross the joint, but limit joint motion (Hauser RA et al., 2013). This reflex is fundamental to the understanding of traumatic injuries.

            This reflex is designed to prevent further injury. However, the continued feedback and reinforcement of pain and muscle spasm, will delay the healing process. The ‘perpetual loop” may continue for a long period of time, making further injury more likely due to muscle contraction. Disrupting this cycle of pain and inflammation is key to resolution.

TRAUMATIC LIGAMENT LAXITY OF THE SPINE

            When traumatic ligament laxity produces joint instability, with neurologic compromise, it is understood that the joint has sustained considerable damage to its stabilizing structures, which could include the vertebrae themselves. However, research indicates that joints that are hypermobile demonstrate increased segmental mobility, but are still able to maintain their stability and function normally under physiological loads (Bergmann TF et al., 1993).

            Clinicians classify instability into 3 categories, mild, moderate, and severe. Severe instability is associated with a catastrophic injury, such as a motor vehicle collision. Mild or moderate clinical instability is usually without neurologic injury and is most commonly due to cumulative micro-trauma, such as those associated with repetitive use injuries; prolonged sitting, standing, flexed postures, etc..

            In a motor vehicle collision, up to 10 times more force is absorbed in the capsular ligaments versus the intervertebral disc (Ivancic PC et al., 2007). This is true, because unlike the disc, the facet joint has a much smaller area in which to disperse this force. Ultimately, as previously discussed, the capsular ligaments become elongated, resulting in abnormal motion in the affected spinal segments (Ivancic PC et al., 2007; Tominaga Y et al., 2006). This sequence has been clearly documented with both in vitro and in vivo studies of segmental motion characteristics after torsional loads and resultant disc degeneration (Stokes IA et al., 1987; Veres SP et al., 2010). Injury to the facet joints and capsular ligaments has been further confirmed during simulated whiplash traumas (Winkelstein BA et al., 2000).

TRAUMATIC LIGAMENT LAXITY OF THE SPINE

            Maximum ligament strains occur during shear forces, such as when a force is applied while the head is rotated (axial rotation). While capsular ligament injury in the upper cervical spine region can occur from compressive forces alone, exertion from a combination of shear, compression and bending forces is more likely and usually involves much lower loads to causes injury (Siegmund GP et al., 2001). If the head is turned during whiplash trauma, the peak strain on the cervical facet joints and capsular ligaments can increase by 34% (Siegmund GP et al., 2008). One research study reported that during an automobile rear-impact simulation, the magnitude of the joint capsule strain was 47% to 196% higher in instances when the head was rotated 60 degrees during impact compared with those when the head was forward facing (Storvik SG et al., 2011). Head rotation to 60 degrees is similar to an individual turning his/her head to one side while checking for on-coming traffic and suddenly experiences a rear-end collision. The impact was greatest in the ipsilateral facet joints, such that head rotation to the left caused higher ligament strain at the left facet joint capsule.

            Other research has illustrated that motor vehicle collision trauma has been shown to reduce ligament strength (i.e., failure force and average energy absorption capacity) compared with controls or computational models (Ivancic PC et al., 2007; Tominaga Y et al., 2006). We know that this is particularly true in the case of capsular ligaments, since this type of trauma causes capsular ligament laxity. Interestingly, one research study conclusively demonstrated that whiplash injury to the capsular ligaments resulted in an 85% to 275% increase in ligament elongation (laxity), compared to that of controls (Ivancic PC et al., 2007).

TRAUMATIC LIGAMENT LAXITY OF THE SPINE

The study also reported evidence that tension of the capsular ligaments due to trauma, requisite for producing pain from the facet joint. Whiplash injuries cause compression injuries to the posterior facet cartilage. This injury also results in trauma to the synovial folds, bleeding, inflammation, and of course pain. Simply stated, this stretching injury to the facet capsular ligaments will result in joint laxity and instability.

            Traumatic ligament laxity resulting in instability is a diagnosis based primarily on a patient’s history (symptoms) and physical examination. Subjective findings are the patient’s complaints in their own words, or their perception of pain, sensory changes, motor changes, or range of motion alterations. After the patient presents their subjective complaints to the clinician, these subjective findings, must be correlated and confirmed through a proper and thorough physical examination, including the utilization of imaging diagnostics that explain a particular symptom, pattern, or area of complaint objectively. Without some sort of concrete evidence that explains a patient’s condition, we merely have symptoms with no forensic evidence. Documentation is key, as well as quantifying the patient’s injuries objectively.

            In order to adequately quantify the presence of instability due to ligament laxity, the clinician could utilize functional computerized tomography, functional magnetic resonance imaging scans, as well as digital motion x-ray (Radcliff K et al., 2012; Hino H et al., 1999). Studies using functional CT for diagnosing ligamentous injuries have demonstrated the ability of this technique to shoe excess movement during axial rotation of the cervical spine (Dvorak J et al., 1988; Antinnes J et al., 1994).             

TRAUMATIC LIGAMENT LAXITY OF THE SPINE

This is important to realize when patients have the signs and symptoms of instability, but have normal MRI findings in the neutral position. Functional imaging technology, as opposed to static standard films, is necessary for the adequate radiologic depiction of instability because they provide dynamic imaging during movement and are extremely helpful for evaluating the presence and degree of instability.

            Although functional imaging maybe superior plain-film radiography is still a powerful diagnostic tool for the evaluation of instability due to ligament laxity. When a patient presents status-post motor vehicle collision, it is common practice to perform a “Davis Series” of the cervical spine. This x-ray series consists of 7 views: anterior-posterior open mouth, anterior-posterior, lateral, oblique views, and flexion-extension views. The lumbar spine is treated in similar fashion. X-ray views will include: anterior-posterior, lateral, oblique views, and flexion-extension views. The flexion-extension views are key in the diagnosis of instability. It is well known, that the dominant motion of the cervical and lumbar spine, where most pathological changes occur, is flexion-extension. Translation of one vertebral segment in relation to the one above and/or below will be most evident on these views. Translation is the total anterior-posterior movement of vertebral segments. After the appropriate views are taken, the images may be evaluated utilizing CRMA or Computed Radiographic Mensuration Analysis. These measurements are taken to determine the presence of ligament laxity. In the cervical spine, a 3.5mm or greater translation of one vertebra on another is an abnormal and ratable finding, indicative of instability (AMA Guides to the Evaluation of Permanent Impairment, 6th Edition).

TRAUMATIC LIGAMENT LAXITY OF THE SPINE

            Alteration of Motion Segment Integrity (AOMSI) is extremely crucial as it relates to ligament laxity. The AMA Guides to the Evaluation of Permanent Impairment 6th Edition, recognize linear stress views of radiographs, as the best form of diagnosing George’s Line

(Yochum & Rowe’s Essentials of Radiology, page 149), which states that if there is a break in George’s Line on a radiograph, this could be a radiographic sign of instability due to ligament laxity.

            Our discussion of ligament laxity and instability continues with the “Criteria for Rating Impairment Due to Cervical and Lumbar Disorders”, as described in the AMA Guides to the Evaluation of Permanent Impairment, 6th Edition. According to the guidelines, a DRE (Diagnosed Related Estimate) Cervical Category IV is considered to be a 25% to 28% impairment of the whole person. Category IV is described as, “alteration of motion segment integrity or bilateral or multilevel radiculopathy; alteration of motion segment integrity is defined from flexion and extension radiographs, as at least 3.5mm of translation of one vertebra on another, or angular motion of more than 11 degrees greater than at each adjacent level; alternatively, the individual may have loss of motion of a motion segment due to a developmental fusion or successful or unsuccessful attempt at surgical arthrodesis; radiculopathy as defined in Cervical Category III need not be present if there is alteration of motion segment integrity; or fractures: (1) more than 50% compression of one vertebral body without residual neural compromise. One can compare a 25% to 28% cervical impairment of the whole person to the 22% to 23% whole person impairment due to an amputation at the level of the thumb at or near the carpometacarpal joint or the distal third of the first metacarpal.

TRAUMATIC LIGAMENT LAXITY OF THE SPINE

            Additionally, according to the guidelines, a DRE (Diagnosed Related Estimate) Lumbar Category IV is considered to be a 20% to 23% impairment of the whole person. Category IV is described as, “loss of motion segment integrity defined from flexion and extension radiographs as at least 4.5mm of translation of one vertebra on another or angular motion greater than 15 degrees at L1-2, L2-3, and L3-4, greater than 20 degrees at L4-5, and greater than 25 degrees at L5-S1; may have complete or near complete loss of motion of a motion segment due to developmental fusion, or successful or unsuccessful attempt at surgical arthrodesis or fractures: (1) greater than 50% compression of one vertebral body without residual neurologic compromise. One can compare a 20% to 23% Lumbar Impairment of the whole person to the 20% whole person impairment due to an amputation of the first metatarsal bone.  

Conclusions

            After careful interpretation of the AMA Guides to the Evaluation of Permanent Impairment, 6th Edition, regarding whole person impairment due to ligament laxity/instability of the cervical and lumbar spine, one can certainly see the severity and degree of disability that occurs. Once ligament laxity is correctly diagnosed, it will objectively quantify a patient’s spinal injury regardless of symptoms, disc lesions, range of motion, reflexes, etc. When we quantify the presence of ligament laxity, we also provide a crucial element with which to demonstrate instabilities in a specific region. Overall, clarification and quantification of traumatic ligament laxity will help the patient legally, objectively, and most importantly, clinically.  

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The Mechanism of the Chiropractic

Spinal Adjustment/Manipulation:

Osseous Mechanisms

Part 1 of a 5 Part Series

By: Mark Studin

William J. Owens

 

Citation: Studin m., Owens W., (2017) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Osseous Mechanisms, Part 1 of 5, American Chiropractor 39 (5), pgs. 30, 32, 34, 36-38

 

A report on the scientific literature

 

Introduction

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 have 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. 

Components of the Adjustment or Thrust

Both human and animal studies have shown the tri-phasic process of the CSA and the time for the thrust duration of each phase.  In addition, the timing at each phase has been shown to be integral in understanding the neurological effect of the CSA. The forces are broken into 3 phases. These are the pre-load force, which takes the tissue close to its paraphysiological limit, the peak force or thrust stage and the resolution stage.

 

Pickar and Bolton (2012) reported the following:

CSA, referred to in the literature as spinal manual therapy, “…in the cervical region has relatively little pre-load ranging from 0 to 39.5 N. In contrast, the average pre-load forces during [CSA] in the thoracic region (139 ± 46 N, ± SD) and sacroiliac region (mean 88 N ± 78 N) are substantially higher than in the cervical region and are potentially different from each other. From the beginning of the thrust to end of the resolution phase, [CSA] duration varies between 90 and 120 ms. (mean = 102 ms.). The time to peak force during the thrust phase ranges from 30 to 65 ms. (mean = 48 ms.). Peak applied forces range from 99 to 140 N (mean = 118 N, n = 6 treatments). In the same study with [CSA] directed at the thoracic (T4) region and applied to three different patients by the same practitioner, the mean (SD) time to peak force was 150 ± 77 ms. and mean peak force reached 399 ± 119 N. During the resolution phase, force returned to pre-[CSA] levels over durations up to two times longer than that of the thrust phase. When [CSA] was applied to the sacroiliac joint, mean applied peak forces reached 328 ± 78 N, with the thrust and resolution phases having similar durations (∼100ms.). The peak force during manipulation of the lumbar spine measured by Triano and Schultz (1997) tended to be higher than during the thoracic or sacroiliac manipulation measured by Herzog et al. (1994) and the force–time profiles resembled half-sine waves with the time to and from peak taking approximately 200 ms. Peak impulse forces during thoracic manipulation approximated the >400 N peak impulse force measured by Triano and Schultz (1997). (p. 786)

 

 

Note. Spinal Manipulative Therapy and Somatosensory Activation,” by J. G. Pickar and P. S. Bolton, 2012, Journal of Electromyography and Kinesiology,22(5), 787. Copyright 2012 by Elsevier.

 

Pickar and Bolton (2012) reported that the physical characteristics of an CSA may vary based upon the technique being used and the individual practitioner. However, the above scenario is an illustration and guide to the time and force for of a CSA.

 

 

 

Zygapophysial (Z) joints

Cramer et al. (2002) explained the following:

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)

 

Control subject [left] before the CSA and after [right] a CSA. The red arrows depict the increase in the Z-Joint

Note. The Effects of Side-Posture Positioning and Spinal Adjusting on the Lumbar Z Joints: A Randomized Controlled Trial with Sixty-Four Subjects,” by G. D.Cramer, D. M. Gregerson, J. T. Knudsen, B. B. Hubbard, L. M. Ustas, & J. A., 2002, Spine,27(22), 2462. Copyright 2002 by Lippincott Williams & Wilkins.

 

Cramer et al. (2002) found the following:

…significant differences between several groups in this study, with the group that received chiropractic adjustments and remained in the side-posture position showing the greatest increase in gapping. This finding is consistent with the hypothesis that chiropractic adjusting gaps the Z joints…The Z joints were found gap during side-posture positioning, although not as much as during side-posture adjusting…The flexion that occurs during the side-posture position and side-posture spinal adjustment may allow for greater gapping during axial rotation and may account for the difference in results between the studies. However, because both the side-posture positioning group and the group that had side-posture adjusting followed by continued side-posture positioning received equal amounts of flexion, the thrust given during the chiropractic procedure had the effect of increasing the gapping of the Z joints. (p. 2464)

 

The average difference between the control subjects…and the subjects that received a chiropractic adjustment and remained in side-posture position was 1.33 mm…a difference of 0.71 mm was found between the side-posture group…and the group that received an adjustment and remained in the side-posture position…It will be recalled that the Z joints are very small [and this is a considerable gap in a joint as small as the Z joint]…Another important consideration is that the term “residual,” or “left-over” gapping, could be applied to the gapping measured in the adjustment group because it can be logically assumed that the Z joints gap a greater distance during the forceful loading of the manipulative procedure than recorded in this study. The tissues of the spine presumably bring the articular surfaces back toward the pre-adjustment (closed) position as the patient resumes a more typical side-posture position after the thrust of a manipulation. This “residual” gapping is what was seen during the 15- to 20-minute MRI scan taken immediately after the adjustment. (2464-2565)

 

What makes this significant is the residual time that occurs after the CSA. During this period, and the time that follows is the foundation for biomechanical  changes in the adjacent discs and ancillary connective tissue attachments that will be discussed in the next article in the series. However, this is part of the foundation for bio-neuro-mechanical changes to the spine secondary to the CSA.

 

 

Meniscoid Entrapment

 

Evans (2002) reported the following:

…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. 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.

           

The presence of fibro-adipose meniscoids in the cervical zygapophyseal joints suggests that a similar phenomenon might occur, but in the neck the precipitating movement would be excessive rotation. The clinical features of cervical meniscoid entrapment would be those of an acute torticollis in which attempted derotation would cause impaction and buckling of the entrapped meniscoid and painful capsular strain. Muscle spasm would then occur to prevent impaction of the meniscoid by keeping the neck in a rotated position. Under these circumstances the muscle spasm would not be the primary cause of torticollis but a secondary reaction to the entrapment of the meniscoid.

 

An HVLAT manipulation, involving gapping of the zygapophyseal joint reduces the impaction and opens the joint, so encouraging the meniscoid lo return to its normal anatomical position in the joint cavity. This ceases the distension of the joint capsule, thus reducing pain.  (p. 252-253)

Evans (2002) also explained the following:

 

Zygapophyseal joint gapping induced during an HVLAT manipulation would further stretch the highly innervated joint capsule, leading to a "protective" reflex muscular contraction, as shown in electromyographic studies. The most important characteristic of a manipulative procedure that will provide joint gapping, before the induction of protective reflex muscular contraction, would be high velocity…the thrusting phase of an HVLAT manipulation required 91 ± 20 ms. to develop the peak force. If this period is compared with the time delay between the onset of the thrusting force and the onset of electromyographic activity, which ranges from 50 to 200 ms., we can see that a force of sufficient magnitude to gap the joint can be applied in a shorter time than that required for the initiation of a mechanoreceptor-mediated muscular reflex. Furthermore, once the muscle is activated (i.e. there is an electromyographic signal), it will take approximately another 40 to 100 ms until the onset of muscular force. It therefore seems unlikely that there are substantial muscular forces resisting the thrusting phase of HVLAT manipulation. Thus, HVLAT manipulation would again appear to be the treatment of choice for a meniscoid entrapment.

 

The cavitation event may not be a prerequisite for a "successful" HVLAT manipulation in the case of a meniscoid entrapment and may be an incidental side effect of high-velocity zygapophyseal joint gapping (which would be a prerequisite for success). Audible indication of successful joint gapping may, however, be regarded as desirable in itself as a clinical measure of "success." A clinician's perception of the occurrence of cavitation during an HVLAT manipulation has been shown to be very accurate and would therefore be a reliable measure of a '"successful" joint gapping. (p. 253-254)

 

 

Meniscoid entrapment. A) On flexion, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with It. B) On attempted extension, the inferior articular process returns upward to its neutral position, hut 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. Pain occurs as a result of capsular tension, and extension is inhibited. C) CSA (Manipulation) 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 (D) Realignment of the joint.

 

Note. Mechanisms and Effects of Spinal High-Velocity, Low-Amplitude Thrust Manipulation: Previous Theories,” by D. W. Evans, 2002, Journal of Manipulative and Physiological Therapeutics, 25(4), 253. Copyright 2002 by Elsevier.

 

This first part of a 5-part series covers the osseous mechanics of what the chiropractic spinal adjustment is comprised of. Part 2 will cover the ligamentous involvement from a supportive and neurological perspective. The topic of part 3 will be spinal biomechanics and its neurological components. Part 4 will be an in-depth contemporary comparative analysis of the chiropractic spinal adjustment vs. physical therapy joint mobilization. The final part will be a concise overview of the chiropractic spinal adjustment.

 

References:

 

1. Martínez-Segura, R., De-la-LLave-Rincón, A. I., Ortega-Santiago, R., Cleland J. A., Fernández-de-Las-Peñas, C. (2012). Immediate changes in widespread pressure pain sensitivity, neck pain, and cervical range of motion after cervical or thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain: A randomized clinical trial. Journal of Orthopedics & Sports Physical Therapy, 42(9), 806-814.

2. Sung, P. S., Kang, Y. M., & Pickar, J. G. (2004). Effect of spinal manipulation duration on low threshold mechanoreceptors in lumbar paraspinal muscles: A preliminary report. Spine, 30(1), 115-122.

3. Pickar, J. G., & Bolton, P. S. (2012). Spinal manipulative therapy and somatosensory activation.Journal of Electromyography and Kinesiology,22(5), 785-794.

4. Cramer, G. D., Gregerson, D. M., Knudsen, J. T., Hubbard, B. B., Ustas, L. M., & Cantu, J. A. (2002). The effects of side-posture positioning and spinal adjusting on the lumbar Z joints: A randomized controlled trial with sixty-four subjects.Spine,27(22), 2459-2466.

5. Cramer, G. D., Henderson, C. N., Little, J. W. Daley, C., & Grieve, T.J. (2010). Zygapophyseal joint adhesions after induced hypombility. Journal of Manipulative and Physiological Therapeutics, 33(7), 508-518.

6. Evans, D. W. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics, 25(4), 251-262.

7. Owens, Jr., E. F., Hosek, R. S., Sullivan, S. G. B., Russell, B. S., Mullin, L. E., & Dever, L. L. (2016). Establishing force and speed training targets for lumbar spine high-velocity, low-amplitude chiropractic adjustments. The Journal of Chiropractic Education30(1), 7-13.

8. Nougarou, F., Dugas, C., Deslauriers, C., Pagé, I., & Descarreaux, M. (2013). Physiological responses to spinal manipulation therapy: Investigation of the relationship between electromyographic responses and peak force.Journal of Manipulative and Physiological Therapeutics,36(9), 557-563.

9. Solomonow, M. (2009). Ligaments: A source of musculoskeletal disorders.Journal of Bodywork and Movement Therapies,13(2), 136-154.

10. He, G., & Xinghua, Z. (2006). The numerical simulation of osteophyte formation on the edge of the vertebral body using quantitative bone re­modeling theory. Joint Bone Spine, 73(1), 95-101.

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Chiropractic Care is More Effective in Lowering Disability than Medical Care for Acute and Sub-Acute Low Back Pain

 

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

William J. Owens DC, DAAMLP

A report on the scientific literature

 

By any standard, back pain is one of the most prevalent disabilities plaguing our population. According to Block, 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. (pg. 1)

 

According to Schneider et al., 2015 “low back pain is among the most common medical elements an important public health issue. Approximately 50% of the United States working – age adults experience low back pain each year with a quarter of US adults reported in episode back pain in the previous three months. Back pain is the most common cause of disability for persons younger than 45 years old and one of the most common reasons for office visits to primary care physicians in the United States as well as Europe and Australia.” (pg. 2009)

 

In chiropractic, although chiropractic’s scope is significantly beyond back pain, based upon the sheer volume of low back pain sufferers, there simply aren’t enough chiropractors to manage this “epidemic sized” condition. In addition, chiropractors as a profession do not want to be labeled as solely “low back pain doctors.” Although the authors firmly agree, we also must acknowledge while treating mechanical spine pain (no fracture, tumor or infection) that the formal health care system has fallen short and in its effort, has contributed to the opiate epidemic.  Healthcare in the United States has had a myopic focus on “anatomical” sources of spine pain such as herniated disc and degenerative disc disease while ignoring the impact that faulty biomechanics have on spine pain and disability.  When it comes to the biomechanics of the spine, it is the responsibility of the chiropractic profession, based upon training and outcomes to lead the nation in its diagnosis, management and treatment.  When we consider both anatomical and biomechanical spine conditions are significant contributors to the spine pain and disability epidemic in the United States, we must understand its full impact and the standard healthcare system’s (allopathic) inability to manage the biomechanical side. 

 

Block, 2014 continued “In addition to the pervasive personal suffering associated with this disease, chronic pain (author’s note: where low back pain is one of the most significant contributors) 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. 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. Moreover, the estimated annual costs of the workplace impact of pain range from $299 to $335 billion from absenteeism and reduced productivity.” (pgs. 1-2) These statistics help us to understand that “management” of spine pain is a critical component of cost reduction since the costliest portion of healthcare services is when a patient enters the system.  Continued mismanagement of mechanical spine pain causes patients to move in and out of disability status. That reentry is what drives up cost, chiropractic is the 3rd largest health profession in the United States and the largest with the education to lead the diagnosis and management of mechanical spine pain.

 

When we compare who is better educated to manage mechanical back pain cases, we also must conclude as a result, who is better educated to successfully treat those cases based upon outcomes. In this comparison, we will consider the education of chiropractic vs. traditional musculoskeletal education and competency as well as treatment outcomes.

 

In a recent article written by Humphreys, Sulkowski, McIntyre, Kasiban, and Patrick (2007), they stated, “In the United States, approximately 10% to 25% of all visits to primary care medical doctors are for MSK [musculoskeletal] complaints, making it one of the most common reasons for consulting a physician...Specifically, it has been estimated that less than 5% of the undergraduate and graduate medical curriculum in the United States and 2.26% in Canadian medical schools is devoted to MSK medicine” (p. 44).

 

Musculoskeletal complaints have a major impact on the healthcare system and although many patients believe that traditional providers are highly trained, recent publications relating to basic competency have shown otherwise.  For example, the authors cited another study stating, Humphreys et al., 2007 continues by stating, “A study by Childs et alon the physical therapists’ knowledge in managing MSK conditions found that only 21% of students working on their master’s degree in physical therapy and 25% of students working on their doctorate degree in physical therapy achieved a passing mark on the BCE [Basic Competency Evaluation]” (p. 45). 

The authors continued by reporting, “The objective of this study was to examine the cognitive (knowledge) competency of final-year chiropractic students in MSK [musculoskeletal] medicine" (p. 45).  "The typical chiropractic curriculum consists of 4,800 hours of education composed of courses in the biological sciences (i.e., anatomy, embryology, histology, microbiology, pathology, laboratory diagnosis, biochemistry, nutrition, and psychology), chiropractic sciences, and clinical sciences (i.e., clinical diagnosis, neurodiagnostic, ortho-rheumatology, radiology, and psychology).  As the diagnosis, treatment, and management of MSK disorders are the primary focus of the undergraduate curriculum as well as future clinical practice, it seems logical that chiropractic graduates should possess competence in basic MSK medicine” (Humphreys et al., 2007, p. 45).

The following results were published in this paper for the Basic Competency Examination and various professions that are in the front line of the diagnosis and treatment of musculoskeletal conditions.  In Table 2 on page 47, the following results were shown when the passing score was established at 73% or greater:

Recent medical graduates (18%), medical students, residents, and staff physicians (20.7%), osteopathic students (29.6%) physical therapy (MSc level, 21%), physical therapy (doctorate level, 26%), chiropractic students (51.5%). 

In Table 2 on page 47, the following results were show when the passing score was established at 70% or greater. 

Recent medical graduates (22%), medical students, residents, and staff physicians (NA), osteopathic students (33%) physical therapy (MSc level, NA), physical therapy (doctorate level, NA), chiropractic students (64.7%). 

According to Frank Zolli DC, former Dean at the University of Bridgeport, College of Chiropractic, “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. To qualify for licensure, graduates of chiropractic programs must pass a series of examinations administered by the National Board of Chiropractic Examiners (NBCE) in 4 separate parts including clinical evaluations. It is therefore mandatory for a chiropractor to know the structure and function of the human body,  the study of neuromuscular and biomechanics is weaved throughout the fabric of chiropractic education.” As a result, the doctor of chiropractic has an expertise in the diagnosis and management of biomechanical musculoskeletal disorders that the traditional health care system is lacking. Chiropractic offers significant insight where traditional health care has no answers.

 

When it comes to direct influence of the chiropractic adjustment on spine pain patients, a 2005 study by DeVocht, Pickar, & Wilder concluded through objective electrodiagnostic studies (neurological testing) that 87% of chiropractic patients exhibited decreased muscle spasms. This study validates the reasoning behind why people with severe muscle spasms in the low back respond well to chiropractic care which in turn is shown to prevent future problems and disabilities. It also dictates that care should not be delayed or ignored due to a risk of complications. This study renders evidence that chiropractic spinal adjusting provides a direct nervous system and physiologic response to the human body. 

 

In a recently published case study and literature review in the New England Journal of Medicine, Deyo and Mirza (2016) had published a case study and literature review on the diagnosis and treatment of lumbar disc herniation with sciatica. What is useful in this publication is the review of the literature in basic, easy to use format highlighting the most common treatments associated in lumbar disc herniation with sciatica.  

Regarding the chiropractic adjustment, the authors stated “A randomized trial of chiropractic manipulation for sub-acute or chronic “back-related leg pain” (without confirmation of nerve-root compression on MRI) showed that manipulation [author’s note: Chiropractic spinal adjustment]  was more effective than home exercise with respect to pain relief at 12 weeks (by a mean 1-point decrease on a pain-intensity scale on which scores ranged from 0 to 10, with higher scores indicating greater severity of pain) but not at 1 year. This is important since early intervention of chiropractic care will reduce early dependency on pain medication. In addition, a randomized trial involving patients who had acute sciatica with MRI-confirmed disk protrusion showed that at 6 months, significantly more patients who underwent chiropractic manipulation had an absence of pain than did those who underwent sham manipulation (55% vs. 20%).  Neurologic complications in the lumbar spine, including worsened disk herniation or the cauda equina syndrome, have been reported anecdotally, but they appear to be extremely rare.” (pg 1768) 

In relationship to counseling versus supervised exercise, the authors reported,“A systematic review of five randomized trials showed that patients who participated in supervised exercise had greater short-term pain relief than patients who received counseling alone, but this reduction in pain was small and these patients did not have a long-term benefit with respect to reduced pain or disability.” (pg. 1768) 

Concerning oral steroids, the paper reported, “Randomized trials show no significant advantage of systemic glucocorticoid (steroid) therapy over placebo with respect to pain relief or reduced rates of subsequent surgical intervention, and they show little, if any, advantage with respect to improvement in physical function.” (pg. 1767) 

The authors commented on opioid medication by stating,“Data from randomized trials to support the use of opioids in patients with sciatica are lacking.   Systematic reviews suggest that opioids have slight short-term benefits with respect to reduced back pain.  Convincing evidence of benefits of long-term use is lacking, and there is growing concern regarding serious long-term adverse effects such as fractures and opioid overdose and abuse.” (pg. 1767) 

Focusing on spinal injection therapy the paper continues by reporting, “A systematic review showed that patients with radiculopathy who received epidural glucocorticoid injections had slightly better pain relief (by 7.5 points on a 100-point scale) and functional improvement at 2 weeks than patients who received placebo. There were no significant advantages at later follow-up and no effect on long-term rates of surgery.” (pg. 1768)

This report serves as a nice general guideline for the primary care [conservative] management of lumbar disc herniation with sciatica.  We see that in addition to any anatomical correction there is a positive response to biomechanical interventions for which the properly trained and credentialed chiropractor is an important provider.  

Cifuentes et al., 2011 stated, “Given that chiropractors are proponents of health maintenance care, we hypothesize that patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because this specific approach would be used.Conversely, similar patients treated by other providers would have higher recurrence rates because the general approach did not include maintaining health, which is a key component to prevent recurrence” (Cifuentes, Willetts, & Wasiak, 2011, p. 396). 

This research is unique and comprehensive in that it tracked injured workers’ compensation patients in multiple states and it reviewed claims dated between January 1, 2006 and December 31, 2006 including 894 cases out of a pool of 11,420 claims of non-specific low back pain cases.  (The states were chosen because the patients had the ability to select their doctors on their own and were not mandated a provider.)   

Relating to the results, the authors report, “In our study, after controlling for demographics and severity indicators, the likelihood of recurrent disability due to LBP for recipients of services during the health maintenance care period by all other provider groups was consistently worse when compared with recipients of health maintenance care by chiropractors. Care from chiropractors during the disability episode (“curative”), during the health maintenance period (main exposure variable, “preventative”), and the combination of both (curative and preventive) was associated with lower disability recurrence HRs” (p. 403). This article validates chiropractic's role in the prevention of the recurrence of back pain in patients with chronic spine disorders.  

When analyzing why, the reasons are evident and based upon the literature. A chiropractic spinal adjustment reduces verifiable bio-neuro-mechanical failures (commonly known as vertebral subluxation in our profession) at the spinal level.  Non-steroidal anti-inflammatory drugs do not and there is no “spontaneous recovery,” only less pain with the underlying biomechanical failures persisting awaiting Wollf’s law to adversely remodel the spine leading to certain increased permanent disability over time. Therefore, if “literature based outcomes” “ruled the day” (as they should in a reasonable world void of politics and financial interest) at the legislative and reimbursement levels, then we would be a healthier society and spend far less money while avoiding unnecessary side effects and increasing the potential for significantly greater disabilities in the future.

 

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
  1. Humphreys, B. K., Sulkowski, A., McIntyre, K., Kasiban, M., & Patrick, A. N. (2007). An examination of musculoskeletal cognitive competency in chiropractic interns. Journal of Manipulative and Physiological Therapeutics, 30(1), 44-49.
  2. Deyo, R. A., & Mirza, S. K. (2016). Herniated Lumbar Intervertebral Disk. New England Journal of Medicine, 374(18), 1763-1772.
  3. Cifuentes, M., Willetts, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
  1. Schmale, G. A. (2005). More evidence of educational inadequacies in musculoskeletal medicine. Clinical Orthopaedics and Related Research, 437, 251-259.
  2. 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.
  3. Goldberg, H., Firtch, W., Tyburski, M., Pressman, A., Ackerson, L., Hamilton, L., Avins, A. L. (2015). Oral steroids for acute radiculopathy due to a herniated lumbar disk: A randomized clinical trial.Journal of the American Medical Association (JAMA), 313(19), 1915-1923.

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CASE REPORT:  Conservative care and axial distraction therapy for the management of cervical and lumbar disc herniations and ligament laxity post motor vehicle collision.

By Josh Johnston, DC

Title: Conservative care and axial distraction therapy for the management of cervical and lumbar disc herniations and ligament laxity post motor vehicle collision.

Abstract:  This middle-aged female was injured in a vehicle collision causing her to sustain disc and additional ligament injuries in the cervical and lumbar spine.  Diagnostic studies included physical examination, orthopedic and neurological testing, lumbar MRI, multiple cervical MRI’s, CRMA with motion cervical radiographs and EMG studies.  Typically, conservative care is initiated prior to interventional procedures, and this case study seeks to explore the usage of passive therapy for mechanical spine pain and noted anatomic disc lesions after failure of interventional procedures.  She reported both short term and long term success regarding pain reduction along with improvement in her activities of daily living after initiating conservative care, and continued to report further reductions in pain with periodic pain management using conservative care.

Key Words: neck pain, low back pain, paresthesia, disc herniation, spinal cord indentation, CRMA, axial distraction therapy, DRX9000, spinal manipulative therapy, motor vehicle collision

Key: MRI (magnetic resonance imaging); EMG (electromyography study); CRMA (computerized radiographic mensuration analysis); CT (computerized topography); PTSD (Post-traumatic stress disorder); PRN (as needed); VAS (visual analog scale); HVLA (high velocity low amplitude).

Introduction:  The 49-year-old married female (Spanish speaking patient) reported that on March 4th, 2014 she was the seat-belted driver of a truck that was struck by a much larger fuel truck changing lines, hitting her vehicle at the front passenger side (far side, side impact).  The force of the impact caused her truck to be lifted up and the right wheel popped off.  Her head hit the window after impact and the spinal pain and complaints started approximately 24 hours later. Two days after the crash she went to the emergency department.  Occupant pictures were taken describing an out of position occupant injury. She did not report any additional significant trauma after the collision. 

Prior to her evaluation at our clinic, she utilized multiple providers for diagnosis and treatment over the course of 11 months.  She went to the emergency department, utilized 3 pain management medical doctors, neuropsychologist and a cognitive rehabilitation therapist.    Imaging included radiographs and MRI of the right shoulder revealing rotator cuff tear; radiographs of the lumbar and thoracic spine, and left hand; CT of the head and cervical spine were performed; MRI cervical (3) and lumbar spine.  Medications prescribed included Fentanyl, Percocet, Naprosyn, Cyclobenzaprine, Norco, Hydrocodone-acetaminophen, Soma, and Carisoprodol.  Physical therapy was provided for spinal injuries and she did not respond to treatment.  The neurosurgeon recommended epidural steroid injections and facet blocks.  Cervical nerve blocks and cervical trigger point injections, cervical and lumbar epidural steroid injections (ESI), lateral epicondyle steroid injections were performed, none of which were palliative.  Post-concussion disorder and PTSD with major depressive disorder were diagnosed.

On February 12th, 2015, she presented to our office with neck pain (average 6/10 VAS) that affected her vision, with paresthesia’s in both upper extremities radiating to the hands with numbness.  She had low back pain (average 6/10 VAS), and she additionally reported paresthesia at the plantar surface of feet bilaterally.  She had left elbow pain, right shoulder pain, knee pain, headaches and “anxiety” along with anterior sternal pain.

Her injuries were causing significant problems with her activities of daily living.  Summarily she had increased pain with lifting, increased pain and restricted movement with bending, walking and carrying.  She had been unable to perform any significant physical activity from the time of the crash in March 2014 until March 2015.  Her right hand was always hurting and her forearms.  She was not able to clean windows or do laundry, difficulty using stairs, problems with mopping, ironing and cleaning.  She had to limit her walking and jogging primarily due to neck pain and right arm pain.  She was not able to sit for long periods of time and sleeping was disrupted due to numbness in her hands.  She was only able to walk on a treadmill for 10 minutes before having to stop due to pain, prior to the crash she would exercise for an hour. 

Prior History: No significant prior musculoskeletal or contributory medical history was reported.

Clinical Findings (2/12/15):  She had a height of 5’2”, measured weight of 127 lbs.

Visual analysis of the cervical spine revealed pain in multiple ranges of motion including flexion, extension, bilateral rotation and bilateral side bending.  On extension pain was noted in the upper back, on rotation pain was noted in the posterior neck, and on lateral flexion pain was noted contralaterally.

Visual analysis of the lumbar spine revealed pain in the low back on all active ranges of motion, including flexion, extension and side bending, pain primarily at L5/S1.

Dual inclinometer testing was ordered based on visual active range of motion limitations with pain. 

Sensory testing was performed of the extremities, C5-T1 and L4-S1.  No neurological deficits other than right sided C5 hypoesthesia.  

Foraminal compression test produced pain in the cervical spine.  Foraminal distraction test caused an increase in pain in the neck.  Jackson’s test on the right produced pain bilaterally in the neck.  Straight leg raise bilaterally produced low back pain, double Straight leg raise produce pain at L5/S1 at 30 degrees.

Muscle testing of the upper extremities was tested at a 5/5 with the exception of deltoid bilaterally tested at a 4/5.  The patient’s deep tendon reflexes of the upper and lower extremities were tested including Triceps, Biceps, Brachioradialis, Patella, Achilles: all were tested at 2+ bilaterally, equal and reactive. No evidence of clonus of the feet and Hoffman’s test was unremarkable.

C3-C5 right sided segmental dysfunction was noted on palpation. T5-T12 spinous process tenderness on palpation. Low back pain on palpation, particularly L5/S1.

Imaging Results:

MRI Studies:

I reviewed the cervical MRI images taken May 2014 with the following conclusions (images attached):

  1. Dramatic reversal of the normal cervical curvature, apex C5/6.
  2. C5/6 herniation, indentation of the spinal cord anteriorly.  High signal posterior on STIR.
  3. Due to the angular kyphosis of the cervical spine and axial slices performed, C6/7 slices did not render a pure diagnostic image for disc disruption.

Fig. 1 (A) T2 Axial C5/6, 2 months post injury               Fig. 1 (B) Sag T2 C5/6

I reviewed cervical MRI images taken September 17th, 2014 approximately 6-months post injury, and rendered the following conclusions:

  1. Reversal of the normal cervical lordosis.
  2. C5/C6 herniation (extrusion type) with indentation of spinal cord, appropriate CSF noted posteriorly.

I reviewed the cervical MRI dated October 24th, 2015 (images attached):

  1. C4/5 herniation, extrusion type, left oriented into the lateral recess and neural canal causing moderate neural canal stenosis
  2. C5/C6 disc protrusion, anterior cord abutment, thecal sac involvement.
  3. C6/7 herniation with early spondylosis changes

Fig. 2 (A) 3D Axial C4/5, 19 months post injury                   Fig. 2 (B) Sag T2 C4/5

IMPRESSIONS: C4/5 herniation noted on 10/24/15 was not noted on prior images.  The patient reported no additional injury or symptoms between MRI studies, so it is postulated that initial slices revealed a false negative; or due to the severity of abnormal cervical biomechanics, it is possible that the C4/5 disc herniated between the pre/post MRI’s with no significant increase in symptomatology.  There was improvement at C5/6 related to disc abnormality and cord involvement (see below). 

Fig. 3 (A) 3D Axial C5/6, 19 months post injury    Fig. 3 (B) Sag T2 C5/6, 19 months post injury

 

Functional Radiographic Analysis (Computerized Radiograph Mensuration Analysis):

 

The cervical flexion/extension images were digitized February 2016 and interpreted by myself and Robert Peyster MD, CAQ Neuroradiology, revealing a loss of Angular Motion Segment Integrity at intersegment C6/C7 measured at 19.7 degrees (maximum allowed 11 degrees), indicating a 25% whole person impairment according to the AMA Evaluation of Permanent Impairment Guidelines 5th edition1.  CRMA provided from Spine Metrics, independent analysis.

Evidence of significant ligament injury causing functional subfailure was measured at C3/4 at 10.4 degrees and at C4/5 measuring 10.9 degrees regarding angular motion.  Abnormal paradoxical translation motion measured at C6/7 and C7/T1.

Functional Testing

  1. EMG of the upper extremity revealed bilateral C6 radiculopathy, December 16th, 2015. 
  2. Range of Motion Cervical Dual Inclinometry:          

      Initial Max       4 months later       % Improvement

Cervical                       Extension        44                    42                                -5%

                                    Flexion            40                    62                                55%

Cervical                       Left                 25                    41                                64%

Lateral flexion            Right               12                    26                                117%

Cervical                       Left                 46                    59                                28%

Rotation                      Right               43                    73                                70%

Conservative treatment rendered: A neurosurgical referral was made for assessment and surgical options.  Conservative care was initiated despite failure of other medical procedures since there is “further evidence that chiropractic is an effective treatment for chronic whiplash symptoms2-3.  The patient was placed on an initial care plan of 2-3x/week for 5 months, with a gap in passive care for 1 month.

  1. 39 cervical nonsurgical distraction/decompression visits utilizing DRX9000 therapy
  2. 23 chiropractic visits.  Instrument adjusting cervical spine was utilized with Arthrostim.  Non-rotatory HVLA (high velocity low amplitude) spinal adjustments were performed thoracic and lumbar spine, applied A-P.  No HVLA spinal adjustments to the cervical spine.

 

Prior to being placed at maximum medical improvement she had persistent low back symptoms, continued tingling in the fingertips and occasional neck pain at a 4/10, with her upper extremity paresthesia’s improved 50%.  She continued with pain management chiropractic care after MMI, approximately 1 visit every 3-4 weeks with axial distraction to the cervical and lumbar spine, chiropractic adjustments as needed (PRN).  2 years/9 months post collision, and 1 year/9 months after initiating conservative care at our clinic, she reports only slight (1-2/10 VAS) spinal complaints with her primary concern being a torn rotator cuff injury from the crash that still requires surgical intervention.  After initiating care at our clinic, no other interventional procedures were performed, although medication usage persisted.  Due to improvement in symptoms and functional status, spinal surgery was not considered. She still utilizes Aleve PRN, 1-2 tablets. No significant active spinal rehabilitation was utilized. The patient was given at home active care consisting only of cervical and lumbar stretches, walking, and ice to affected areas. 

Conclusion:While chiropractic care is safe even in the presence of herniations and radicular symptoms, “the likelihood of injury due to manipulation may be elevated in pathologically weakened tissues”4. Due to cord involvement, the provider decided to utilize low force procedures although HVLA spinal adjustments to the cervical spine could be considered safe due to lack of cord compression.  HVLA spinal adjustments A-P were utilized in the lumbar and thoracic spine not only for short term pain relief but also as part of managing the chronic low back pain secondary to ligament/disc damage.  While previously theorized to be only episodic, low back pain can be a lifelong condition requiring patients to seek ongoing care5.  This care can be active, passive, pharmaceutical, interventional, or conservative in nature, but ongoing pain management therapy is often required for permanent ligament conditions.  There is clear benefit to the patient population to be able to avoid surgical intervention due to risks, costs, ongoing prescription medication usage and adjacent level degeneration in the future6.  Avoiding opioid usage is also a high priority in today’s environment. 

Long term conservative care utilizing instrument spinal adjusting and targeted axial distraction therapy significantly reduced subjective reporting of pain, increased activities of daily living, and allowed the patient to avoid further spinal injections or surgical intervention.  Considering that various interventional procedures failed prior to conservative care, it is important that providers work in an interdisciplinary environment such that the safest, and in this case the most effective, therapies are utilized first to reduce risk to the patient and maximize benefit and reduce costs.

In this case study, the patient utilized multiple pain management physicians, cervical nerve blocks and epidural steroid injections, and was not directed to conservative care for 11 months post injury.  Utilizing chiropractic as conservative care would have enabled this patient to regain function and decrease pain while reducing costs and risks that are associated with medications and interventional procedures.

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

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

  1. Cocchiarella L., Anderson G. Guides to the Evaluation of Permanent Impairment, 5th Edition, Chicago IL, 2001 AMA Press.
  2. Khan S, Cook J, Gargan M, Bannister G. A symptomatic classification of whiplash injury and the implications for treatment. Journal of Orthopaedic Medicine 1999; 21(1):22-25.
  3. Woodward MN, Cook JCH, Gargan MF, Bannister GC. Chiropractic treatment of chronic whiplash injuries. Injury 1996;27: 643-645.
  4. Whedon J, Mackenzie T, Phillips R, Lurie J. Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-99 years. Spine, 2015; 40:264–270.
  5. Hestbaek L, Munck A, Hartvigsen L, Jarbol DE, Sondergaard J, Kongsted A: Low back pain in primary care: a description of 1250 patients with low back pain in Danish general and chiropractic practices. Int J Family Med, 2014.    
  6. Faldini C., Leonetti D., Nanni M. et al: Cervical disc herniation and cervical spondylosis surgically treated by Cloward procedure: a 10-year-minimum follow-up study.  Journal of Orthopaedics and Traumatology, June 2010. Volume 11, Issue 2,pp 99-103.

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

 

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

William J. Owens DC, DAAMLP

A report on the scientific literature

 

INTRODUCTION

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

 

 

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

 

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

HERNIATED DISCS

 

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

 

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

 

SPINAL DEGENERATION

 

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

Viroslav (2016) reported:

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

 

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

 

CHIROPRACTIC CARE

Kressig et. Al (2016) reported:

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

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

 

CONCLUSION

 

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

 

Links to other articles:

 

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

 

Spinal Fusion vs. Chiropractic for Mechanical Spine Pain

 

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

 

Disc Herniations and Low Back Pain Post Chiropractic Care

 

References:

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

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Case Report:

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

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

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

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

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

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

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

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

Appearance: in pain

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

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

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

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

Imaging:

Figure 1: T2 Sagittal Cervical Spine MRI

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

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

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

References:

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

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

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

204–209.

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

           

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