Case Report: Establishing the Efficacy for Trauma Trained Chiropractors as Primary Spine Care Physicians
Donald A. Capoferri, D.C., DAAMLP
Abstract: The objective of this case report is to explore the use of chiropractic and chiropractors as a primary spine care specialty and the efficacy of early referral to a properly trained and credentialed chiropractor. Diagnostic studies included physical examination, radiographic examinations, cervical, thoracic, and lumbar spine MRI studies and brain MRI study. Treatments included non-surgical axial decompression and low-level laser treatments. Once a clinical examination and diagnosis was formed, a favorable prognosis was expected. With appropriate chiropractic management, the outcome proved excellent in pain reduction and had minimal effect on the numbness and weakness of the patient’s left upper and lower extremities.
Key Words: Disc herniation, syringomyelia, multiple sclerosis, disc bulge, demyelination.
Introduction: On 8/23/2017, a 49-year-old female presented for examination and treatment of chronic left sided lumbar spine pain that began on 8/1/1983 after a slip and fall incident. The pain was described as sharp, burning, and deep with radiation into the back of the left leg with an 8 out of 10 on the VAS (visual analog scale) scale, worsening since its onset.
Other Presenting Concerns: The patient also presented with sub-acute chest pain with radiation into the left upper arm. She described the pain as 8 out of 10 and has stayed the same since 7/1/2017 and is of unknown origin. The patient also reported numbness and tingling of the left lower extremity since 7/1/2017 of unknown origin. The final reported complaint was numbness and tingling of the left lower arm since 7/1/2017 that seems to start in the left upper back and shoulder and travels to the left lower arm rated at 8/10 on the VAS scale. The reported symptoms have made sleeping and staying asleep, bending over, using a computer, and concentrating very difficult.
Prior Treatments: Medical care including orthopedic specialist, neurology with prescription medications, chiropractic care, and physical therapy.
Past Medical History: The patient’s past history includes use of prescription and over the counter medications. Surgical history includes tonsils and adenoids in 2008, wisdom tooth extraction in 1990, partial hysterectomy in 2002 and C-section in 1998. The family health history includes Alzheimer’s disease, anemia, arthritis, diabetes, heart disease, and high blood pressure.
Clinical Findings: The patient presents as a 49-year-old female of average build, clean and neat and well groomed. The vitals are: Height: 61 inches, Weight: 168 lbs, Pulse: 74 bpm, BP: 168/117 mm/Hg in left arm. The patient’s appearance is visibly uncomfortable and restless.
Physical Findings: Palpation of the paraspinal musculature revealed moderate to severe spasms on the left neck, upper thoracic, and lumbosacral regions. Orthopedic testing produced pain and dizziness with foraminal compression. Upper thoracic pain with Soto Hall’s test and Sternal compression produced pain on the left anterior chest. Percussion test produced pain in the upper thoracic spine.
Neurologic Testing: Diminished right patella reflex and 3/5 weakness of the left deltoid muscle group and left hamstring muscle group with hypersensitivity to light touch along the C6, C8, T1, L3, L4 and L5 dermatomes were the only positive neurologic findings. All other tests are within normal limits. Digital muscle testing was ordered following up on the initial manual findings of muscle weakness. The results were profound left sided deficits in the upper and lower extremities; deltoids 35% weaker than right side, left biceps 68% weaker than right, left triceps 26% weaker than right, wrist extensors 47% weaker than right. The left hamstring group was 25% weaker than right, left quadriceps 40% weaker than right, left anterior tibialis 44% weaker than right.
Radiographic Findings: I personally reviewed cervical spine and thoracic spine x-rays taken on 8/14/17 and found the following: A severe loss of the cervical lordosis, translation of C3 on C4, C4 on C5 in extension. T3 is laterally flexed on T4 with body rotations to the left of T3, T4, and T5. A bifid spinous is noted of C6. Mild posterior osteophyte is noted on C3 and C4. Lumbar x-rays taken on 8/23/2017 revealed pelvic unleveling with right inferiority, anteriority of L5 on S1, an inferior Schmoral’s node on L5 and mild demineralization, disc degeneration and joint degeneration of the lumbar spine. Moderate to severe foraminal encroachment of L4/L5, L5/S1 is noted.
MRI findings by radiologist:
Cervical spine: MRI taken at 2.5 mm slice thickness, with gradient echo and STIR studies revealed C4-C5 right paracentral herniated disc measuring 2 x 3 mm not indenting the cord. A small syrinx of the cord is noted at level of C6-C7 interspace and extending above and below for a total of 15mm in length and 2mm in width. (Fig. 1A) (3)
Thoracic Spine: MRI taken at 3.0 mm slice thickness, angled to the disc with STIR and T2 axial views revealed a T4-T5 central protrusion measuring 2 x 4 mm in size in the midline.
Lumbar Spine: MRI taken at 3.0 mm slice thickness, angled to the disc with STIR and T2 Axial views. L5/S1 demonstrates a central disc herniation with annular tear measuring 3x 6 mm indenting the epidural space and very mildly touching the thecal sac.
I personally reviewed the MRI studies and my impression is as follows:
Cervical spine also demonstrated a C3-C4 disc bulge compressing the thecal sac and deforming the normal shape of the cord by altered CSF pressure. (Fig. 1B) (1). C5-C6 demonstrates a central protrusion with annular tear compressing the ventral cord in the midline by altered CSF pressure.
In addition to the radiologist findings, the thoracic study demonstrated significant facet arthritis at the level of T10 that indents the thecal sac and compresses the left posterolateral aspect of the cord. (Fig. 2.) In addition to the radiologist’s findings, I reviewed the lumbar spine and reported an L4-L5 left asymmetric bulge with compression of the left aspect of the thecal sac. (1)
MRI Discussion: After review of the clinical examination findings, the patient’s subjective complaints and the X-ray and MRI imaging studies, the findings were reported to the patient. I subsequently ordered a brain MRI since I did find an adequate explanation of the left sided sensation and motor deficits. The brain MRI demonstrates a right frontal/parietal subcortical white matter demyelinating lesion in T2/FLAIR images. (Fig 3).
Fig. 1A: Shows a demyelination of the central cord assessed as a syrinx by radiologist
Fig. 1B: C3-C4 disc bulge, thecal sac compression, deforming the cord shape and apparent CSF in the central canal of the cord.
Fig. 2: T10 left facet arthritis indenting the thecal sac and compressing the left posterolateral cord.
Fig. 3: T2/FLAIR shows left frontal / parietal area of demyelination
Diagnostic Impression: When arriving at a diagnosis all objective findings along with subjective complaints should be considered. When I considered the profound left sided sensory and motor deficits, the clinical findings and the imaging findings I referred the patient to a neurologist for evaluation of late onset multiple sclerosis. (3) The patient consulted the lead Neurologist in the M.S. Department at Shepard Center in Atlanta who confirmed the diagnosis.
Therapeutic Focus and Assessment: At the report of findings it was explained to the patient that she did have spinal findings that were treatable and that did contribute to her pain. It was further explained that the care provided is not expected to affect the symptoms that are caused by the M.S. condition. An 8-week course of non-surgical axial decompression was completed, aimed at reduction of the C3-C4, C4-C5, C5-6, L4-L5 and L5-S1 disc displacements. At discharge, the patient reported a 90% reduction of spine pain and improvements of the left sided upper and lower extremity weaknesses. She was discharged into the care of her neurologist at that time.
Discussion: Properly trained chiropractors are the perfect fit to be the primary spine care provider. Our education includes extensive training in identifying biomechanical and anatomical lesions of the spine in order to arrive at an accurate diagnosis, prognosis and treatment plan. This includes proper triage to other healthcare providers.
In this case the patient presented with a biomechanical issue, disc herniation and degeneration, with facet arthritis, but also with a significant non-spinal pathology that was identified properly and referred appropriately.
Numerous other physicians and chiropractors evaluated this patient, all of whom treated the obvious without finding the underlying cause of her numbness and weakness, which may have delayed necessary care. A Doctor of Chiropractic, who is well trained and credentialed as a Primary Spine Care physician knows to look beyond the obvious, taking all findings and patient subjective complaints into consideration in order to obtain a proper diagnosis, prognosis, and appropriate plan of treatment for each patient.
1. Fardon DF, Williams AL, Dohring EJ, Murtagh FR, Gabriel Rothman SL, Sze GK. Nomenclature 2.0 for Disc Pathology, Spine J. 2014 Nov 1;14 (11):2525-45.doi: 10.1016/j.spinee.2014.04.022. Epub 2014 Apr 24.
2. Schippling S. Neurodegener Dis Manag. MRI for multiple sclerosis diagnosis and prognosis. 2017 Nov;7(6s):27-29. doi: 10.2217/nmt-2017-0038
3. Pillich D, El Refaee E, Mueller JU, Safwat A, Schroeder HWS, Baldauf J. Syringomyelia associated with cervical spondylotic myelopathy causing canal stenosis. A rare association.
Neurol Neurochir Pol. 2017 Nov - Dec; 51(6): 471-475. doi: 10.1016/j.pjnns.2017.08.002.Epub 2017 Aug 14.
Primary Spine Care
A mandatory “future trend” for chiropractic success that has already begun
By Mark Studin
William J. Owens
Primary Spine Care has been proven in the market place as chiropractic’s future and the instrument to increase our utilization. Primary Spine Care simply means that the chiropractor is the first referral option for mechanical spine issues short of fracture, tumor or infection. After 10 years of development and 4 years of market testing, this paradigm has been released nationally and has far exceeded our expectations in increased utilization. If you are committed to being “the best-of-the-best” through clinical excellence, you can still create a leadership position in your community for both you and your practice.
Insurers are scrambling to “corner the market” using the lure of primary spine care. In the end, this is just another plan to further limit your reimbursements, it is “managed care in sheep’s clothing”. Hospitals are also devising primary spine care schemes to dupe you into becoming one of their devoted “minions” into a 1-way referral pattern; with you referring into THIER system while avoiding referring into YOURS. Chiropractic academia is also struggling to catch the primary spine care trend, while their true mandate is to prepare our future doctors of chiropractic to pass national and state boards. Our politicians and political organizations have realized they are also significantly behind this trend and are reaching “inward” in a hope for someone within the organization to try to take a leadership position. Although our political organizations are vocally touting their ability to grow chiropractic, we can see historically the opposite is true. Our profession has thought leading with politics was the answer and that path would finally deliver chiropractic into the mainstream, however, based upon published evidence, that approach has proven to deliver relatively stagnant growth as reported by Adams et. Al (2017). Adams states chiropractic utilization to be 8.4% of the population. It was also reported that 35.2% of the United States population takes over the counter drugs and 23.2% takes prescription medications for the same conditions that respond favorably to chiropractic care. The disparity in utilization of drugs vs. chiropractic care underscores that our global approach to the promotion of chiropractic care is failing, and it can no longer be “business as usual.”
One of the fastest growing trends in healthcare today, is defining who should be considered a “Primary Spine Care Practitioner.” There is a myriad of factors to consider and the timing, based upon a “Best Practice/Evidence Based Models” (consisting of the scientific literature, patient feedback/expectations and the doctors experience) is perfect for chiropractic to take its place as the leading profession in this critically important niche. As a society, we are failing to provide adequate spine care. One of the issues that inevitably occurs when there is a trend catching everyone’s attention, is the rise of the “fly by night, get rich quick, self-proclaimed gurus” that cut corners behind the scenes, but gives you the perception that they are true leaders. Our profession has a significant history of this occurring, particularly in the managed care arena and we are seeing it starting to happen within the contemporary Primary Spine Care Practitioner trend. We wanted to provide insight on what is occurring from our unique position, which combines both chiropractic and medical academia and clinical practice. We would like to outline the critical factors to consider so you can prepare to effectively participate and leverage this important trend in healthcare to your private practice. The end result; increase utilization (you are busier).
The following should be considered a guide to your path to success in Primary Spine Care and WHO to participate WITH and WHO to AVOID.
TRACK RECORD OF SUCCESS
One of the most important aspects of evaluating a Primary Spine Care training program, or even taking advice at the academic, political or consulting end is determining whether the program and its instructors are coming from a position of success. Do they present with a proven track record or are they are simply capturing a trend and experimenting with you and your practice? Consider the reality television show The Shark Tank, a show which has billionaire investors investigating companies that want them to invest in their products or services. The Sharks have a simple rule, which is an underlying theme of the show, what has the “wannabe” business PRODUCED in revenue or success PRIOR to a Shark considering investing their personal money? If the answer is little or none, then the Shark passes since speculation rarely leads to profit. Too many Primary Spine Care “guru’s” promote a pathway to success, but have not achieved any significant level of expertise or track record in filling offices in a profitable scenario. These are the groups that have so called “friends” on the inside and at first glance seems impressive, but as you dig deeper into their past successes they come up empty. It is important to not enter a training program that needs YOU to grow, that is a recipe for failure, frustration and no return on your investment. We suggest asking how many chiropractors are currently in the program and how may referrals they have to date in their system [most do not keep track for obvious reasons] and GET references. Facts are facts and not rhetoric and no matter how “sexy” a program appears, it means nothing if it doesn’t work. This is the difference between an experimental process and a real program achieving real results. Don’t be the experiment.
Secondly, we want to caution you to make sure every Primary Spine Care program is putting chiropractic first. We suggest asking if the program is chiropractic centric or does it concurrently invite physical therapists as Co-Primary Spine Care Providers? It has long been discussed and demonstrated [CLICK HERE FOR VERIFICATION] that the scientific literature has concluded that chiropractic care for spine is superior to that of physical therapy at many levels including pain management and in the reduction of recurrent disability.
Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) reported:
The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation. These differences raise concerns regarding the useof physiotherapists as gatekeepers for the worker’s compensation system. (pg. 388)
Programs that include physical therapy are brining chiropractic down to a level that will not ensure your success as the outcomes are far less effective than a chiropractic spinal adjustment as evidenced in the paragraph above. Physical therapy has its place in spine care, but not first. It is our experience that a program who offers both chiropractic and physical therapy as primary spine care will do this to ensure the profit of the program and NOT YOU. We also firmly believe this creates a public healthcare risk by supporting poorer outcomes, which feed the current opiate epidemic by mismanaging mechanical spine patients. In the end, this will create a perception that chiropractic and physical therapy are equal. Nothing could be farther from the truth and nothing could be more dangerous to the public and your long-term success. Only consider a Primary Spine Care program that is chiropractic only.
MANAGED CARE IN DISGUISE
This is one of the most negative aspects of the current Primary Spine Care trend and one that we see happening more and more each week. There are groups in our profession that are promoting the Primary Spine Care concept not to help chiropractic, but to “sell” chiropractic to insurance carriers or hospitals under the umbrella of third party administrators or managed care. This type of focus is NOT in the best interest of chiropractic and does not have your practice’s best interests in mind or the chiropractic profession (for verification, see all the current managed care models that allow 8 or 10 visits at a severely reduced fee, where most have chiropractors controlling your practice and paycheck). Insurance carriers are not ignorant, they realize the benefits of using chiropractic care and coverage is expanding in these plans, however there are those in our profession that continue to insert themselves between hardworking chiropractors and the insurance carriers. This is a veiled attempt to create a “network” of doctors that they can sell to the highest bidder. These “middle men” even promise doctors in their group a steady stream of patients, but in the end, it is an empty promise or worse… you get a lot of patients at such a reduced rate that paying your bills is challenging. Don’t let this happen to you and your practice. Enriching others at the expense of your practice and your family is not a recipe for success. We suggest reviewing ALL the directors of ALL programs you are considering and if there is ANY indication that they had consulted with insurance carriers, worked for managed care companies or are significant players in the independent examination world…RUN. Many are now getting astute and realizing that chiropractors have been taken advantage of for too long, so they leave these things off their CV or Resume. We suggest searching GOOGLE and Social Media, many have digital trail and an employment track record that can be uncovered. This is occurring faster and more obviously than previously thought…don’t be taken advantage of, consider WHY the program was created and to whom the money flows.
One of the more “sexy” portions of working as a Primary Spine Care Provider is the hospital component. Since doctors of chiropractic have historically worked outside of the mainstream health system, it continues to be relatively rare for DCs to be included in hospital groups. Fortunately, hospitals are working with doctors of chiropractic more than ever before, however many of the chiropractors that are leading the way are simply being taken advantage of by the system. Most chiropractors don’t know it is occurring, while hospitals are “selling” YOU on perceived success in breaking into their system. In the end, it is just a house of cards and will do nothing to move you or your practice forward. When working with the hospitals as a Primary Spine Care Provider, the point is that THEY REFER TO YOU as the first option for mechanical spine issues. If the hospital is excited to receive referrals FROM you instead of referring TO you…RUN. Hospitals not referring to chiropractic as a first choice for spine is NOT a Primary Spine Care Program, it is an enrichment program for the hospital and the consultant that is promoting or selling the program. Caveat Emptor!!! Do your homework first and do not fall into the trap of being put on a list, having access to doctors in the hospital and having an open line of communication with doctors you refer to… you already have that! A true Primary Spine Care Program ALREADY has established, or will give you the pathway for referrals INTO YOUR office. Anything other than that is to suck you into the hospital system to get your referrals. Never lose sight that chiropractic is big business for many hospitals and they will do anything to get your business and not give an inch to allow you a piece of theirs. The tide is turning with many hospitals bringing chiropractic on staff, changing by-laws to create chiropractic inclusion into their system and realizing that the best business model is the chiropractor as the first referral option and keep everything else in-house. Make sure you are creating or entering the right system, a REAL Primary Spine Care Program will teach you that and show you how it has been done in other areas of the country.
ACADEMIC AND CLINCIAL BASIS
In the chiropractic world, there are two places that a program can evolve FROM and two places that it is governed BY. The program can evolve FROM either an Academic or a Clinical perspective and it can be governed BY either Academics or Politics. These are very important points to consider. First, when a program is buried in Academics, although it may be perceived as having state of the art information, it is often built and run from predominantly a theoretical perspective. This is a prime example of a “it looks good on paper” program, which has not had any real measure of clinical success in the marketplace. Secondly, when a program is developed and run by clinicians there is often a narrow-sited approach that is missing what the literature provides and not understanding the trends in the industry. Many times, the clinicians are lacking significant post-graduate training on MRI, Spinal Biomechanical Engineering and triage protocols which ultimately will make the program ineffective or focus on one aspect too heavily. This is at the expense and ultimately the success of your practice. Another alarming trend is when politics drives the process. It is our observation over the last 4 decades that politics typically drives patients and income to those who are in control of the political process and their “friends.” Typically, the rest of the profession, no matter how hard they try, work or get better, simply can’t participate as the system has been designed for so few. In addition, politics in our profession has been controlling too much and has crossed the lines too often in our academic process; they should support academia, not lead it . The “politics first” approach has lead us to an 8.4% utilization in the United States when failing spine care is epidemic nationally and with so many patients suffering, all chiropractic offices should be on a waiting list.
When we consider how a program is governed, the options are either academia or politics and as stated above, politics should support academia, not drive it and the success of a Primary Spine Care program is a perfect example. Politics cannot drive it, there must be a mix of significant post-doctoral (graduate level) formal training and a long history of success in this paradigm.
It can no longer be business as usual, your success and future depend on it.
The perfect solution is a blend of meaningful post-doctoral (graduate level) formal training and clinical practice with a track record of success. Politics as previously stated is there to support the process, not drive the process. Historically the old way of doing things is not working based upon the 8.4% of our current utilization. Investigate the qualifications and experience of who you are listening to and who you choose to follow, and a blend of academia and successful clinical experiences is the perfect solution. This can be verified by demanding to inspect the Curriculum Vitae of all involved and then scour both Google and social media as previously suggested.
After 10 years of researching the infrastructure of primary spine care and 4 years of market testing in figuring out HOW to make it work in every chiropractic office in the world, we have ALREADY gotten 711,434 (as of 1-26-2018) referrals INTO chiropractic practices in 47 states from lawyers, primary care medical providers, medical specialists, urgent care centers and emergency room. I also want to report, that this number is an approximate, where the actual number is significantly higher, but that is all we can safely verify. It is this number that would make the “Sharks” happy because it already works, and YOU are not the market research or the EXPERIMENT. It was done with your clinical excellence, a best practice model inclusive of the literature and a business plan that includes medical primary care providers, medical specialists, urgent care centers, hospital emergency rooms and lawyers.
Right now, you are still at the beginning of this “Wave” [or future trend] and you do not have to change how you treat your patients, how you adjust or whether you believe in subluxation or purely a pain model. All you HAVE to do is work within your lawful scope of practice as set forth by your state and get smarter with a business plan to educate your referral sources, so THEY RUN AFTER YOU. Truthfully, that is the easiest part.
Chiropractic Verified as
Primary Spine Care Providers
By Mark Studin
William J. Owens
A report on the scientific literature
Primary Spine care simply means being the first referral option for spine care in instances other than fracture, tumor or infection. Having a chiropractic degree is paramount and the first step in the process, but one must not forget that any doctoral training, no matter the specialty (i.e. medicine, dentistry, podiatry, etc.) is the start of a provider’s educational journey and what we do with that training is up to the doctor in clinical practice. Erwin, Korpela and Jones (2013) stated “The function of the PSCP (Primary Spine Care Provider) could easily be assumed by chiropractic, but this window of opportunity may be limited. If chiropractic does not seek to evolve, what role does chiropractic have left to perform.” (Pg. 289)
Although these authors agree that chiropractors in clinical practice can assume the role as PSCP’s in the healthcare system, we strongly disagree with the direction suggested by Erwin, Korpela and Jones. The solution is not to prescribe more drugs in an “already over-drugged society,” the solution is being able to manage the patient in a collaborative environment on a peer level being “expert” on common healthcare issues. The underlying tenant is that there is no drug for a mechanical problem, it is with that initial focus that allows chiropractic to assume a role that no other profession can accomplish. True PSCP management includes being able to accurately diagnose/triage patients and the ability to use and understand MRI is a prime example. Herzog, Elgart, Flanders and Moley (2017) reported a 43.6% error rate of general radiologists inaccurately reporting the morphology of the intervertebral disc. This underscores that when a doctor of chiropractic relies on the MRI report without understanding how to interpret the image and clinically correlate the findings to the patient’s symptoms, there is close to a 50% error rate in rendering an accurate diagnosis, prognosis and treatment plan. A PSCP must have a complete and independent diagnostic scope of practice in order to fill a useful and clinically significant role.
To use an example in a current and modern setting, a doctor of chiropractic in Cedar Park, Texas was granted a “brief 10-minutes” to meet with an orthopedic surgeon. During that short meeting the chiropractor, an 8-year graduate spoke solely and specifically of his MRI slice thickness protocols and his MRI interpretation training which is cross-credentialed in both chiropractic and medical academia. One hour later [the meeting continued well past the initial “10-minutes” suggested], the orthopedic surgeon said, “I respect chiropractic, but have very little respect for the level of training of chiropractors in our region.” This 8-year graduate walked out with 8 referrals instantly and now 1 year later, has been getting referrals weekly. That is very definition of Primary Spine Care, the orthopedic surgeon trusts the chiropractor’s ability to manage and diagnose patients and now is “off-loading” the non-surgical patients to someone that can effectively manage that case. It is because of this specific advanced training that the chiropractor is successful.
In a second recent example, in Utah, a chiropractor decided that his post-doctoral training should be focused on spinal trauma care and triage, including more specifically, MRI Spine Interpretation, Spinal Trauma Pathology, Spinal Biomechanical Engineering and Stroke Evaluation. As a result, a hospital system that has over 900 auto accident cases monthly in 5 local hospitals reached out to him to manage their spine cases (all of them). This was based purely on his curriculum vitae and the inherent credentials and knowledge base from his continued education training in the above courses. Since then, Brigham Young University’s Athletic Department and the PGA (Professional Golf Association) have both sought his services. Please don’t overlook the fact THEY ran after him to be their first option for spine; that is Primary Spine Care and credentials matter.
Thirdly, in Buffalo NY, 5 teaching hospitals refer exclusively to one chiropractor’s office and their emergency rooms refers close to 60 spine patients per month to him with that number growing steadily. This past week, the neurosurgical department just informed this doctor that their 23 neurosurgeons will be referring their non-surgical cases to this office and will be directing many of their referral sources to START with this doctor to screen for surgery and let him decide who to refer for surgical consultation. That is Primary Spine Care.
Although individual reporting does not make a trend in the profession, these are not isolated cases, and this is NOW THE TREND in chiropractic we are seeing nationally, there are similar stories in most states. None of the successes involve adding drugs as a tool of the chiropractic, however in every case becoming smarter in spine care was mandatory. In all cases it is a properly trained doctor of chiropractic that is leading Primary Spine Care alongside medical specialty and primary care in a collaborative environment as peers, when clinically indicated.
Most of the Primary Spine Care “equation” is verifying chiropractic care as the “best choice” for the “first referral”. That is being achieved though peer-reviewed outcome based studies and involves all phases of care starting with initial pain management to corrective spine care and finally when required, health maintenance care for cases that need non-opioid and non-surgical long-term management. Historically and all too frequently in current medicine, either medical management or physical therapy is considered for mechanical spine issues as the first treatment of choice. Cleveland Clinic, one of the better-known centers of medical excellence currently posted the following regarding the treatment of back pain; “These patients may be best served through prompt access to care from physical therapists or nurse practitioners as entry-level providers. When pain persists beyond four to six weeks, the care path defines when referral to spine or pain specialists, spine surgeons or behavioral health providers is indicated.” (https://consultqd.clevelandclinic. org/2014/11/sticking-with-proven-practices-for-low-back-pain/) The Mayo Clinic Staff (2017) also reported: “Physical therapy is the cornerstone of back pain treatment.”
When considering the best option for Primary Spine Care, we should consider “what” type of provider renders the best outcomes in population based studies and has the autonomy to manage the case independent of primary care and medical specialty. Based upon population based studies, both the Cleveland and Mayo clinics got it wrong as their opinions are not based upon contemporary literature and appear to be rooted in “age-old biases.” Their suggested care paths are similar to prior care paths that perhaps have led to the long-term mismanagement of mechanical spine pain that has in part, contributed to the opioid crisis.
Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) in a population based study of 5511 injured workers in Ontario Canada as reported by the Workplace Safety and Insurance Board, a governmental agency reported a comparison of outcomes for back pain among patients seen by three types of providers: medical physicians, chiropractors and physical therapists. The found “The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation.” (pg.392) and “These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.” (pg. 382)
Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) continued, “The cohort study of American workers with back pain conducted by Turner et al. found that the first healthcare provider was one of the main predictors of work disability after a year. In accordance with our findings, workers who first sought chiropractic care were less likely to be work-disabled after 1 year compared with workers who first sought other types of medical care… We did not retrieve any study that directly compared physiotherapy care with other types of first healthcare providers in the context of occupational back pain, probably because most workers’ compensation systems still require a referral for physiotherapy. However, a study comparing primary physiotherapy care with usual emergency department care concluded that physiotherapy care leads to a prolonged time before patients return to their usual activities.” (pg. 389)
Cifuentes, Willets and Wasiak (2011) stated that chiropractic care during the health maintenance care period resulted in:
The study concluded that chiropractic care during the disability episode resulted in:
24% Decrease in disability duration of first episode compared to physical therapy
250% Decrease in disability duration of first episode compared to medical physician's care
5.9% Decrease in opioid (narcotic) use during maintenance care with physical therapy care
30.3% Decrease in opioid (narcotic) use during maintenance care with medical physician's care
32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care
21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care
Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating,“After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP (low back pain) who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (pg. 404).
The above studies continue to verify chiropractic as a better “first option” for spine and that resolves the “what provider is best” question by using an Evidence Based approach. The “who is best” within that subset is what type of chiropractor is better suited to lead in Primary Spine Care is evident. As an example, although every medical doctor is licensed to do open heart surgery not all are trained and credentialed. Would you want a psychiatrist performing the procedure? The answer should be “they are licensed, but not qualified through training.” The same holds true for contemporary chiropractic and every chiropractor has the same opportunity. We are all held to a “continuing education standard” and are all required to seek post-doctoral training to maintain our licenses. There are a significant number of courses, both live and through enduring materials (online) to enable every chiropractor on the planet to attain the level of education mandated by the “referral sources” to be considered Primary Spine Care Providers.
Let’s not be Pollyannaish not to think that chiropractic can be successful in increasing utilization independent of the medical community and even the legal community for personal injury cases. As mentioned previously, the medical community DOES NOT CARE about your treatment approach, what they do care about is the “risk” of you missing a diagnosis. They need to trust you based on your training, and the do NOT care about what technique you use. What you do in your offices is up to you just like a pain management MD or a surgeon, remember, it’s how you triage and manage your patients that is the ultimate arbiter in having them consider you as the first option for spine care. Once you have responsibly secured the referral, based upon your clinical excellence, you get to independently decide the best course of care for your patient. Then it is business as usual during the treatment phase of care because results were never, and are not an issue in chiropractic.
The Mechanism of the Chiropractic
Chiropractic vs. Physical Therapy for Spine
Part 5 of a 5 Part Series
By: Mark Studin
William J. Owens
Reference: Studin M., Owens W., (2017) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine, Part 5 of 5, American Chiropractor 39 (12) pgs. 20, 22, 24, 26, 28, 30, 31
A report on the scientific literature
According to the Cleveland Clinic (2017):
The Cleveland Clinic Spine Care Path is a process-based tool designed for integration in the electronic medical record (EMR) to guide clinical work flow and help providers make evidence-based guidelines operational.
The care path was developed by Cleveland Clinic’s Center for Spine Health with input from Department of Pain Management staff like Dr. Berenger. One goal was to match appropriate treatments and providers to patients at various points along the care continuum for low back pain.
“We know acute back pain is common and often resolves with simple therapy or even no therapy,” Dr. Berenger says. “For patients without red flags, imaging is rarely required.”
These patients may be best served through prompt access to care from physical therapists or nurse practitioners as entry-level providers. When pain persists beyond four to six weeks, the care path defines when referral to spine or pain specialists, spine surgeons or behavioral health providers is indicated. (https://consultqd.clevelandclinic. org/2014/11/sticking-with-proven-practices-for-low-back-pain/)
According to the Mayo Clinic Staff (2017):
Most acute back pain gets better with a few weeks of home treatment. Over-the-counter pain relievers and the use of heat or ice might be all you need. Bed rest isn't recommended.
Continue your activities as much as you can tolerate. Try light activity, such as walking and activities of daily living. Stop activity that increases pain, but don't avoid activity out of fear of pain. If home treatments aren't working after several weeks, your doctor might suggest stronger medications or other therapies. (http://www.mayoclinic. org/diseases-conditions/back-pain/basics/treatment/con-20020797
The Mayo Clinic Staff (2017) continued:
Physical therapy is the cornerstone of back pain treatment. A physical therapist can apply a variety of treatments, such as heat, ultrasound, electrical stimulation and muscle-release techniques, to your back muscles and soft tissues to reduce pain.As pain improves, the therapist can teach you exercises that can increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques can help prevent pain from returning. (http://www. mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797)
The above 2 scenarios are consistent with contemporary care paths for medicine regarding back pain. High velocity-low amplitude chiropractic spinal adjustments are not part of any medical institution’s care plan (to the current knowledge of the authors) despite the following compelling literature.
Coronado et al. (2012) reported:
Reductions in pain sensitivity, or hypoalgesia, following SMT [defined by the author as high velocity-low amplitude adjustment or a spinal adjustment] may be indicative of a mechanism related to the modulation of afferent input or central nervous system processing of pain. (p. 752)
Coronado et al. (2012) further asked the question:
…was whether SMT [defined by the author as high velocity-low amplitude or a spinal adjustment] elicits a general response on pain sensitivity or whether the response is specific to the area where SMT is applied. For example, changes in pain sensitivity over the cervical facets following a cervical spine SMT would indicate a local and specific effect while changes in pain sensitivity in the lumbar facets following a cervical spine SMT would suggest a general effect. We observed a favorable change for increased PPT [pressure pain threshold] when measured at remote anatomical sites and a similar, but non-significant change at local anatomical sites. These findings lend support to a possible general effect of SMT beyond the effect expected at the local region of SMT application. (p. 762)
Reed, Pickar, Sozio, and Long (2014) reported:
…forms of manual therapy have been clinically shown to increase mechanical pressure pain thresholds (i.e., decrease sensitivity) in both symptomatic and asymptomatic subjects. Cervical spinal manipulation has been shown to result in unilateral as well as bilateral mechanical hypoalgesia. Compared with no manual therapy, oscillatory spinal manual therapy at T12 and L4 produced significantly higher paraspinal pain thresholds at T6, L1, and L3 in individuals with rheumatoid arthritis. The immediate and widespread hypoalgesia associated with manual therapy treatments has been attributed to alterations in peripheral and/or central pain processing including activation of descending pain inhibitory systems.
Increasing evidence from animal models suggests that manual therapy activates the central nervous system and, in so doing, affects areas well beyond those being treated. (p. 277)
With regards to manual therapy versus physical therapy, this is where the phrase, “caveat emperor” should be used as the concept is misleading. Groeneweg et al. (2017) compared manual and physical therapies, recruiting 17 manual therapists and 27 physical therapists. The training of the manual therapists was from Manual Therapy University and were predominantly physical therapists who spent 3 years studying manual therapy.
Groeneweg et al. (2017) reported:
The manual therapist performs per protocol repeated passive joint movements with low velocity and intensity and high accuracy in different positions of the patient (sitting, supine and side-lying). The rhythm of the movements is slow (approximately 30 cycles/min) and the movements are repeated about six times. Treatment is in general painless. Passive joint movements are performed in a combination of rolling and sliding, or rocking and gliding (or swinging and sliding) in the joint, based on the arthrokinematic and osteokinematic principles of intra-articular movements. Passive movements are performed over the entire range of motion within the physiological range of motion of joints, whereby the curvature of the articular surface is followed, with manual forces directed to the joints/specific spinal level. Physiological joint range of motion is carefully respected. Traction, oscillation and high-velocity movements are not applied. In all patients, based on the assessment protocols, all joints of the spine, pelvis and extremities are mobilized in specific directions. (p. 3)
Groeneweg et al. (2017) also stated:
This pragmatic RCT [randomized control trial] in 181 patients with non-specific neck pain (>2 weeks and <1 year) found no statistically significant overall differences in primary and secondary outcomes between the MTU group and PT group. The results at 7 weeks and 1 year showed no statistically and clinically significant differences. The assumption was that MTU was more effective based on the theoretical principles of mobilization of the chain of skeletal and movement-related joint functions of the spine, pelvis and extremities, and preferred movement pattern in the execution of a task or action by an individual, but that was not confirmed compared with standard care (PT). (pg. 8)
The above article strongly confirms why language is important when describing the chiropractic spinal adjustment. Too many “lump together” all manual therapies and claim the effectiveness, or lack thereof, based on studies as the one above confirms. The article compared physical therapy to physical therapists who have gone for advanced education in what they already do in low-amplitude repetitive movements using “arthrokinematic and osteokinematic principles of intra-articular movements” meaning very specific per the anatomy. The outcome confirmed there is no difference between manual therapy and physical therapy because they are the same according to the description in the research. However, these therapies do not provide what chiropractic offers, although many hastily consider manual therapy and chiropractic care to be the same. Substance P is perhaps the most compelling evidence of why a chiropractic spinal adjustment should be considered the “first choice” for spinal care.
Evans (2002) reported:
In a series of studies, Brennan et al. investigated the effect of spinal HVLAT manipulation causing cavitation ("sufficient to produce an auditory release or palpable joint movement") on cells of the immune system. They found that a single manipulation to either the thoracic or lumbar spine resulted in a short-term priming of polymorphonuclear neutrophils to respond to an in vitro particulate challenge with an enhanced respiratory burst (RB) as measured by chemiluminescence in subjects with and without symptoms. The enhanced RB was accompanied by a two-fold rise in plasma levels of the neuropeptide substance P (SP).
SP is an 11-amino acid polypeptide and is one of a group of neuropeptides known as tachykinins. These are peptides that are produced in the dorsal root ganglion (DRG) and released by the slow-conducting, unmyelinated C-polymodal nociceptors in a process known as an "axon reflex." They are released into peripheral tissues from the peripheral terminals of the C-fibers. modulating the inflammatory process by "neurogenic inflammation.” They are also released from the central terminals of the nociceptors into the dorsal horn of the spinal cord, where they modulate pain processing and spinal cord reflex activity.
This neurophysiologic effect of spinal HVLAT manipulation seems to be force threshold-dependent. The threshold was found to lie somewhere between 450N and 500N for the thoracic spine and 400N for the lumbar spine. When compared with data from biomechanical studies of spinal manipulation, these forces would be sufficient to cause cavitation. The "SP" studies used "sham manipulation" as a control, consisting of a "low-velocity light-force thrust to the selected segment." rather like a mobilization. This illustrates that zygapophyseal HVLAT manipulations that cause cavitation produce physiological effects, not demonstrable by electromyography, that are totally different fi-om effects created by zygapophyseal manipulations that do not cause cavitation. (p. 255-256)
According to Hartford-Wright, Lewis, Vink and Ghabriel (2014):
Substance P (SP) is a neuropeptide released from the endings of sensory nerve fibers and preferentially binds to the NK1 receptor. It has a widespread distribution throughout the nervous system, where it is implicated in a variety of functions including neurogenic inflammation, nausea, depression and pain transmission as well as in a number of neurological diseases, including CNS tumors. (p. 85)
Low velocity manipulation, no matter how well it follows “arthrokinematic and osteokinematic principles of intra-articular movements,” will not effectuate the release of Substance P, only a chiropractic spinal adjustment with cavitation will do that. When considering the results of a chiropractic spinal adjustment, disability is a critical indicator with regards to the effectiveness of treatment outcomes.
Cifuentes, Willets and Wasiak (2011) compared different treatments of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability after a 15-day absence and return to disability. Anyone with less than a 15-day absence was excluded from the study. Please note that we kept disability outcomes for all reported treatment and did not limit this to physical therapy. However, the statistic for physical therapy is significant.
The Cifuentes, Willets and Wasiak (2011) study concluded that chiropractic care during the health maintenance care period resulted in:
The study concluded that chiropractic care during the disability episode resulted in:
24% Decrease in disability duration of first episode compared to physical therapy
250% Decrease in disability duration of first episode compared to medical physician's care
5.9% Decrease in opioid (narcotic) use during maintenance care with physical therapy care
30.3% Decrease in opioid (narcotic) use during maintenance care with medical physician's care
32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care
21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care
Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating, “After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (Cifuentes et al., 2011, p. 404).
Given that physical therapy has been the primary portal for mechanical spine issues (not fractures, tumors or infection) coupled with the contemporary opiate addiction and mortality issues, a different path must be sought as a matter of public safety. The only avenue for both medical primary care providers and specialists other than surgery is pain management in the form of opiates and that doesn’t resolve any issues, it only creates new addiction issues. Mechanical spine pain is one of the most common diagnoses.
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. (p. 1)
Mafi, McCarthy and Davis (2013) reported on medical and physical therapy back pain treatment from 1999 through 2010 representing 440,000,000 visits and revealed an increase of opiates from 19% to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the costs for managing low back pain patients (not correcting anything, just managing it) has reached $106,000,000,000 ($86,000,000,000 in health care costs and $20,000,000,000 in lost productivity).
Mafi, McCarthy and Davis (2013) stated:
Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005...In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period, use of recommended treatments would increase and use of non-recommended treatments would decrease. (p. 1574)
The above paragraph has accurately described the problem with allopathic “politics” and “care-paths.” Despite self-reported overwhelming evidence where there were 440,000,000 visits and $106,000,000,000 in failed expenditures, they hypothesized that increased utilization for recommended treatment would increase. The recommended treatment, as outlined in the opening two comments of this article, doesn’t work and physical therapy is a constant verifying a “perpetually failed pathway” for mechanical spine pain.
Chiropractic offers an evidence-based approach in developing an “outcome based “care path for mechanical spine pain. Although this article discusses pain, chiropractic offers more than simply pain management, however this discussion is limited to mechanical spine pain. Therefore, with chiropractic as the “first option” or “Primary Spine Care” focusing on the biomechanical pathological instability, the underlying cause of the pain can be addressed, leaving no further need to manage an issue that has been simply fixed.
1. Cleveland Clinic. (2017). Sticking with proven practices for low back pain, Introducing: Cleveland Clinic’s Spine Care Path. Retrieved from https://consultqd.clevelandclinic.org/2014/ 11/sticking-with-proven-practices-for-low-back-pain/
2. Mayo Clinic Staff. (2017). Treatments and drugs. Diseases and Conditions, Back Pain, Retrieved from: http://www.mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797
3. Coronado, R. A., Gay, C. W., Bialosky, J. E., Carnaby, G. D., Bishop, M. D., & George, S. Z. (2012). Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis. Journal of Electromyography Kinesiology, 22(5), 752-767.
4. 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.
5. Groeneweg, R., van Assen, L., Kropman, H., Leopold, H., Mulder, J., Smits-Engelsman, B. C., ... & van Tulder, M. W. (2017). Manual therapy compared with physical therapy in patients with non-specific neck pain: a randomized controlled trial. Chiropractic & Manual Therapies, 25(12), 1-12.
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. Harford-Wright, E., Lewis, K. M., Vink, R., & Ghabriel, M. N. (2014). Evaluating the role of substance P in the growth of brain tumors. Neuroscience, 261, 85-94.
8. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
9. Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine, 173(17), 1573-1581.
Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport College of Chiropractic, an Adjunct Post Graduate Faculty of Cleveland University - Kansas City, College of Chiropractic, an Adjunct Professor of Clinical Sciences at Texas Chiropractic College and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MRI spine interpretation, spinal biomechanical engineering and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www.DoctorsPIProgram.com), teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally and studies trends in healthcare on a national scale (www.TeachDoctors.com). He can be reached at www.teachchiros.com or at 631-786-4253.
Dr. Bill Owens is presently in private practice in Buffalo and Rochester NY and generates the majority of his new patient referrals directly from the primary care medical community. He is an Associate Adjunct Professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences, an Adjunct Post Graduate Faculty of Cleveland University - Kansas City, College of Chiropractic, an Adjunct Assistant Professor of Clinical Sciences at the University of Bridgeport, College of Chiropractic and an Adjunct Professor of Clinical Sciences at Texas Chiropractic College. He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at www.mdreferralprogram.com or 716-228-3847
Chiropractic & Central Afferent Inhibition:
A Chiropractic Care Path & Mechanism for Chronic Pain, Tremors, Spatial and Inhibitory Distortion
By Mark Studin
William J. Owens
A report on the scientific literature
Although it is unusual in the literature to place a disclaimer in the beginning of an article, we want to ensure that our reporting is not inflammatory since the foundation of this article was written with the following limitation in our primary literary source, Haavik, Niazi, Holt and Murphy (2017) reported:
This study was not designed to test the efficacy of chiropractic care for treating chronic pain; therefore, conclusions about efficacy cannot be drawn from our findings. The study did not include randomization with an adequate control group, thus limiting the interpretations that can be made about the changes in pain observed in the trial. Causation cannot be claimed. (pg. 135)
Although Haavik, et al. reported limitations in their study, the results cannot be overlooked or minimized, particularly when those results match what doctors working within a “Best Practice Model” (the patient and doctor feedback component) have been reporting for decades. Additionally, in the clinical setting, this information provides direction to practitioners searching for answers although the mechanisms are not yet fully understood. Results often don’t mandate detailed knowledge of the mechanism and that is the primary reason why both “evidenced based” and “best practice” models must be embraced and combined (pure literature results with doctor and patient feedback or experiences) as a matter of public health.
When we consider central afferent neurological input, the inability to inhibit those signals leads to sensorimotor disturbances that are found in the chronicity of many chronic pain conditions, essential tremors, dystonia and other central spatial and temporal mismatches. In addition, we must consider to the long-term negative sequalae of those conditions, such as brain shrinkage.
Baliki, Geha, Apkarian and Chialvo (2008) reported:
Recent studies have demonstrated that chronic pain harms cortical areas unrelated to pain, long-term pain alters the functional connectivity of cortical regions known to be active at rest, i.e., the components of the “default mode network” (DMN). This DMN is marked by balanced positive and negative correlations between activity in component brain regions. In several disorders, however this balance is disrupted. Studying with fMRI [functional MRI] a group of chronic back pain patients and healthy controls while executing a simple visual attention task, we discovered that chronic back pain patients, despite performing the task equally well as controls, displayed reduced deactivation in several key default mode network regions. These findings demonstrate that chronic pain has a widespread impact on overall brain function, and suggest that disruptions of the default mode network may underlie the cognitive and behavioral impairments accompanying chronic pain.” (pg. 1398)
“The existence of a resting state in which the brain remained active in an organized manner, is called the ‘default mode of brain function. The regions exhibiting a decrease in activity during task performance are the component members of the “default-mode network” (DMN), which in concerted action maintain the brain resting state. Recent studies have already demonstrated that the brain default mode network is disrupted in autism, Alzheimer’ disease, depression, schizophrenia and attention deficit hyperactivity disorder, suggesting that the study of brain resting activity can be useful to understand disease states as well as potentially provide diagnostic information.” (pg. 1398)
This is important since for the first time we are starting to see a published correlation between spinal function, chronic pain and central nervous system changes. This is what our founders have observed yet were unable to prove.
“Thus, the alterations in the patient’s brain at ‘rest’ can result in a different default mode network organization. In turn, potential changes in the default-mode network activity could be related to symptoms (other than pain) commonly exhibited by chronic pain patients, including depression and anxiety, sleep disturbances, and decision-making abnormalities, which also significantly diminish their quality of life… chronic pain patients display a dramatic alteration in several key default-mode network regions, suggesting that chronic pain has a widespread impact on overall brain function” (pg. 1398)
This information is pointing to the fact that a doctor of chiropractic should be involved in the triage and treatment of these patients and part of a long-term spinal care program.
Baliki Et. Al (2008) continued “Consistent with extensive earlier work examining visuospatial attention tasks, dominant activations were located in posterior parietal and lateral prefrontal cortices, whereas deactivations occurred mainly within Pre-Frontal Cortex and Posterior Cingulate/Cuneate Cortexes. Although activations in chronic back pain patients’ and controls’ brains were similar, chronic back pain patients exhibited significantly less deactivations than healthy subjects in Pre-Frontal Cortex, amygdala, and Posterior Cingulate/Cuneate Cortexes. The focus was on identifying differences in the way chronic back pain patients’ brains process information not related to pain. This is the first study demonstrating that chronic back pain patients exhibit severe alterations in the functional connectivity between brain regions implicated in the default mode network. It seems that enduring pain for a long time affects brain function in response to even minimally demanding attention tasks completely unrelated to pain. Furthermore, the fact that the observed task performance, compared with healthy subjects, is unaffected, whereas the brain activity is dramatically different, raises the question of how other behaviors are impaired by the altered brain activity” (pg. 1399).
“However, the disruption of functional connectivity observed here with increased chronic back pain duration may be related to the earlier observation of brain atrophy increasing with pain duration also in chronic back pain patients. Patient’s exhibit increased pre-frontal cortex activity in relation to spontaneous pain, in addition to dorsolateral prefrontal cortex atrophy. Therefore, the decreased deactivations described here may be related to the dorsolateral pre-frontal cortex /pre-frontal cortex mutual inhibitory interactions perturbed with time. If that is the case, it will support the idea of a plastic, time-dependent, reorganization of the brain as patients continue to suffer from chronic back pain. Mechanistically, the early stages of this cortical reorganization may be driven by peripheral and spinal cord events, such as those that have been documented in animal models of chronic pain, whereas later events may be related to coping strategies necessary for living with unrelenting pain. It is important to recognize that transient but repetitive functional alterations can lead to more permanent changes. Accordingly, long term interference with normal activity may eventually initiate plastic changes that could alter irreversibly the stability and subsequently the conformation of the resting state networks” (pg. 1401).
Essential Tremors which, according to Wikipedia
Essential tremor (ET, also referred to as benign tremor, familial tremor, or idiopathic tremor) is the most common movement disorder; its cause is unknown. It typically involves a tremor of the arms, hands or fingers but sometimes involving the head, vocal cords or other body parts during voluntary movements such as eating and writing. It is distinct from Parkinson's disease—and often misdiagnosed as such—although some individuals have both conditions. Essential tremor is commonly described as an action tremor (i.e., it intensifies when one tries to use the affected muscles) or postural tremor (i.e., present with sustained muscle tone) rather than a resting tremor, such as is seen in Parkinson’s, which is usually not included among its symptoms. (https://en.wikipedia.org/wiki/Essential_tremor)
Restuccia, Valeriani, Barba, Le Pera, Bentivoglio, Albanese and Tonali (2003) reported:
...our present data seem to indicate that somatomotor cortical areas play an important role in generating ET. This finding can be important in the future understanding of its pathophysiologic mechanisms, as well as in its management. (pg. 127)
This study suggests that somatosensory cortical areas plays an important role, therefore the afferents “feeding” that region is critical in normalizing function of the cortex a that region. Another negative sequela of aberrant input.
When we consider one potential etiology of maladaptive plastic changes in the brain that can cause chronic pain, essential tremors, brain shrinkage and a host of other maladies, regulatory control of the impulses must be considered and interfered with. The lack of gating (inhibition) will lead to an overflow of impulses and crate a negative cascade that can lead to chronic and often permanent changes. Haavik, Niazi, Holt and Murphy (2017) reported:
Thus, distorted sensory information is thought to disturb SMI (sensorimotor integration) and impair accurate motor control. In normal circumstances, 2 inputs that engage the sensory system have a reciprocally inhibitory action that gates the total amount of signal at all central levels, spatially and temporally limiting the amount of input engaging the CNS. This is thought to prevent sensory “overflow.” The defective gating may cause an input-output mismatch in specific motor programs, and such mismatches in motor programs may in themselves lead to production of distorted sensory information and issue of less than ideal motor commands. In this way, the chronicity of the problem can be maintained via a self-perpetuating mechanism. The reduced frontal N30 SEP (somatosensory evoked potential) peak ratio observed in the current study after 12 weeks of chiropractic care may reflect a normalization of pain-induced central maladaptive plastic changes and may reflect one mechanism for the improvement of functional ability reported following chiropractic adjustment or manipulation. (pg. 134)
The N30 ratio change represented on average a 37.4% decrease following the 12 weeks of chiropractic care. The N30 MU (median-ulnar) amplitude changes following chiropractic care represented an 18.0% decrease in amplitude compared with baseline (pg. 131) Alongside this change in the N30 SEP ratio, the subjects reported a decrease in both current pain and average pain over the last week. A control period of 2 weeks of no intervention resulted in no significant changes in any SEP peak ratio. (pg. 134)
When considering care paths for this population of patients, the following was reported by Haavik, Niazi, Holt and Murphy (2017) reported:
The 2-week control period, during which no intervention was applied, was followed by a 12-week chiropractic care intervention. During the 12 weeks of chiropractic care, the chiropractor assessed and treated the subject as she would any other chronic pain patient. The participating chiropractor (H.H., with 7 years clinical experience) assessed the spine for segmental dysfunction using tenderness on palpation and passive intervertebral and global motion of the spine. Other treatments included as part of chiropractic care were exercises, peripheral joint adjustments/manipulations, soft tissue therapy, and pain education if deemed by the chiropractor to be appropriate based on history and examination. The chiropractic adjustment/manipulation was the delivery of a high-velocity, low-amplitude thrust to dysfunctional spinal segments. (pgs. 129-130)
The changes observed conclude (with the aforementioned disclaimer that more research is needed) that chiropractic is a verifiable treatment option. Haavik, Niazi, Holt and Murphy (2017) continued:
The changes observed in dual SEP ratios after several weeks of chiropractic care in a chronic pain population suggest that this treatment option may improve gating of peripheral afferent input to the brain, thus improving impaired SMI in cortical motor areas and improving processing of motor programs. Impaired SMI and defective motor programming is known to be present in various chronic pain populations and is implicated in the clinical symptomatology. We know from the literature that in normal circumstances, afferent input to the motor system leads to finely tuned activation of neural elements and ultimately results in the correct execution of movement. Multiple experimental and clinical studies have confirmed the importance of sensory feedback to the motor system. Thus, distorted sensory information is thought to disturb SMI and impair accurate motor control. In normal circumstances, 2 inputs that engage the sensory system have a reciprocally inhibitory action that gates the total amount of signal at all central levels, spatially and temporally limiting the amount of input engaging the CNS. This is thought to prevent sensory “overflow.” The defective gating may cause an input-output mismatch in specific motor programs, and such mismatches in motor programs may in themselves lead to production of distorted sensory information and issue of less than ideal motor commands. In this way, the chronicity of the problem can be maintained via a self-perpetuating mechanism. The reduced frontal N30 SEP peak ratio observed in the current study after 12 weeks of chiropractic care may reflect a normalization of pain-induced central maladaptive plastic changes and may reflect one mechanism for the improvement of functional ability reported following chiropractic adjustment or manipulation. (pgs. 134-135)
Haavik, Niazi, Holt and Murphy (2017) concluded:
After the 12 weeks of chiropractic care, when he was also feeling better symptomatically, this was reversed, and all of his MU traces for all SEP peak complexes were smaller in amplitude than his M + U trace, indicating a greater level of central reciprocal inhibition was occurring… Thus, if sensory “overflow” occurs, then incomplete processing of this incoming signal may occur in the brain, resulting in its perceiving not only excessive, but also spatially distorted information. (pg. 135)
The N9 SEP peak (the “N” is a location for electrodes) reflects the afferent signal over the brachial plexus before it enters the CNS, and thus can be used to ensure that the incoming signal is consistent before and after an intervention. Furthermore, these experiments demonstrated that the subjects' N30 SEP peak ratios decreased significantly after a single chiropractic manipulation of the cervical spine. As the N30 SEP peak is thought to reflect early cortical SMI, the authors argued that their results suggest that the subject's SMI networks' ability to suppress the dual input after the adjustment was increased. The N30 SEP peak ratios remained decreased even after repeating the 20-minute repetitive thumb abduction task. This suggested that the treatment effects appear to have altered the way in which each subject's CNS responded to the repetitive thumb typing task.
When considering treating chronic pain, dystonia, essential tremor or any other type of patient where there are spatial (distorted or excessive afferent) input issues, the above care path (treatment plan) should be considered. By not completed a complete treatment protocol might expose your patient to a chronic issue that may become permanent if the maladaptive cortical changes persist over time. Since there are no timetables for how long a patient can withstand for the issue to become permanent and there is an indexed peer reviewed suggestion of correction, that must be adhered as a minimum until further evidence suggests otherwise. In addition, no two patients are alike and the treatment plan should be guided with a full clinical reevaluation and consider performing that examination every 30 days of active care considering all facets, both history and clinical.
Chronic Pain and Chiropractic:
A 12-Week Solution & Necessity for Care
By Mark Studin
William J. Owens
A report on the scientific literature and commentary
How long should a patient be under chiropractic care? This has been the struggle for many in the insurance industry, the legal community, licensure boards and a “hot topic” politically. There are the CCGPP [Council on Chiropractic Guidelines and Practice Parameters], the Croft Guidelines, Best Practice for Chiropractic Care for Older Adults, Best Practices Recommendations for Chiropractic Care for Infants, Children and Adolescents, Chiropractic Practice Guidelines: Chiropractic Care for Low Back Pain. These are just some of the chiropractic industry’s guidelines, then you must consider the insurance industry’s care paths where most are hidden behind statements like “medical necessity” and “eligible charges.” Those are “buzz phrases” indicating they have a guideline, but most will neither publish or make them available to the providers, their insured or the public claiming proprietary information giving them a legal basis for the secrecy.
Aetna, as an example lists specifics for care and then goes further to limit a significant number of techniques, procedures and diagnostics claiming they are “experimental.” Although Medicare considers chiropractic a covered service they limit treatment arbitrarily according based upon significant feedback from many in the profession. Workers Compensation Boards have guidelines that are either legislated or created based upon a case law judge’s opinion which include arguments from the defense to support limiting care. At best, that is an arbitrary process based upon rhetoric or legislation that is too often ignorant of the scientific literature resulting in serious imposed limits in scope of treatment as we see in California, New York and many other states.
Although the guideline landscape is expansive, these authors choose to rely on a hybrid of both “Best Practice” and “Evidenced Based” method in the development of treatment plans. Both have a strong place in clinical practice, academic settings, the courts and third-party reimbursement systems.
Best Practice is defined as “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 businessbuzzword, 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).
These are certain procedures in healthcare that are taught in schools, internships and residencies and are considered the “standard” by which care is expected to follow. These practices are based on clinical experience and rely heavily on time-tested approaches, that is how a profession evolves and grows. Surprisingly, most of the best medical practice care paths are not published in the peer-reviewed indexed literature. This is due to many factors, but the most obvious are applications of financial resources and grants to “new” discoveries and the simple fact that the clinical arena is well positioned to monitor and adjust these practices in a timely manner allowing practitioners to keep pace with the literature that follows. In recent times, although it has been talked about for decades, there is another parameter that exists and although focuses on best practices, there is a strong reliance on published studies, aka “evidence”, as the main driver of whether a procedure is approved and reimbursed. This is extremely problematic to healthcare outcomes.
Evidence-based practice(EBP) is an interdisciplinary approach to clinical practice that has been gaining ground following its formal introduction in 1992. It started inmedicineasevidence-based medicine (EBM) and spread to other fields such as dentistry, nursing, psychology,
education, library and information science and other fields. Its basic principles are that all practical decisions made should be based on three important criteria. First, they must be based on the practicing provider’s clinical experience, secondly, they should be based on published research studies and thirdly should consider the patients expectations.
"Evidence-based behavioral practice(EBBP) entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. This is done in a manner that is compatible with the environmental and organizational context. Evidence is comprised of research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses" (Evidence-Based Practice, http://en.wikipedia.org/wiki/Evidence-based_practice).
This highly-debated topic of evidence-based vs. best practice has valid issues on each side, but putting them together as a hybrid would allow them to thrive in both a healthcare delivery and reimbursement system; therefore, all sides would win. This would allow advances in healthcare to save more lives, increase the quality of life and at the same time, offer enough safeguards to prevent abuse to payors. A one-sided approach would tip the scales to favor either the provider/patients or the payors which, in the end, results in distrust and conflict.
Evidence-based medicine proponents argue that it would eliminate waste and reduce costs while providing patients with the most up-to-date care available. Those against this concept argue that reliance on evidence-based care would eliminate many procedures that fall under the best medical practice parameters and remove the clinical decision making and professional experience from the equation. They feel what would be left is denial of good therapies and the stifling of innovation since the process of establishing a research study, following its participants and publishing those findings can take many years not to mention poor study design or research bias can have both a profound effect on the evidence provided and severely delay the final publication. This delay would eventually cost either lives or severely diminish the quality of life for those who could have been helped during the research and publication processes.
Haavik, Niazi, Holt and Murphy (2017) reported:
Post hoc tests using the Bonferroni correction revealed significant mean differences in N30 MU amp (P = .049) and N30 MU to M + U ratio data (P = .001) during the chiropractic intervention, but no significant changes were observed during the control period (P = .1 for N30 MU amp and P = .3 for N30 MU to M + U ratio data). The effect size for the change in N30 MU amp was 0.61, and for the N30 MU to M + U ratio it was 0.66. The N30 ratio change represented on average a 37.4% decrease following the 12 weeks of chiropractic care. The N30 MU amplitude changes following chiropractic care represented an 18.0% decrease in amplitude compared with baseline. (Pg 131)
These results were based upon a limited study, but validates that a chiropractic spinal adjustment modulated aberrant afferent input by 37.4% in median and ulnar nerve rations and 18% in median and ulnar nerve amplitudes.
The authors went on to report:
The purpose of this preliminary study was to assess whether the dual SEP technique is sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck pain after a 12-week period of chiropractic care and, if so, whether any such changes related to changes in symptomatology. (pg. 128)
This was tested to determine if inhibitory innervation was affected specifically by a chiropractic spinal adjustment and the outcomes conclusively, against a 2-week control period of the same test subjects confirmed these results.
Haavik, Niazi, Holt and Murphy (2017) went on to describe the 12 weeks of chiropractic care that realized these results:
The chiropractic care plan was pragmatic and generally consisted of 2 to 3 visits per week for the first 2 to 3 weeks. Frequency was reduced based on clinical findings and patient symptomatology. By the end of the 12-week period, participants were seen once or twice a week. No requirements were placed on the treating chiropractor, other than including chiropractic adjustment or manipulation during treatment; thus, the care plan was designed in conjunction with patient preferences and was based on the patients’ history, symptoms, wishes, and time availability as well as the clinician’s clinical experience and knowledge. (pg. 130)
Although the length of care in this study does not render a specific guideline, it does validate that it takes time to realize changes in the mechanics of the spine and the human nervous system. The results are consistent with the “Best Practice Model” and the authors 57 years of combined experience and results. Twelve weeks of care is a conservative and reasonable time frame since we are observing and considering that cerebral neuroplastic changes are a direct and verifiable result of a chiropractic spinal adjustment. Less than 12 weeks of chiropractic spinal adjusting has not been evidenced to make these reported changes, therefore we must consider this threshold for care.Concurrently, what we see is that less treatment time does not allow the connective tissue to help the spine as one contiguous organ system to remodel to a homeostatic state (a conversation for a different paper).
Chiropractic care for chronic pain patients requires a both a combination of Best Practice and Evidenced Based models as the literature is now verifying that a chiropractic spinal adjustment is an effective care path and 12 weeks is a minimum to see neuroplastic changes. Clinically speaking however, to confirm the optimum care path for this particular population of patients, continuation of care should be based on re-evaluations every 30-days and should continue as clinical sign and symptoms persist and there is evidence that the patient is benefiting both in the short and long term. Additionally, no significant improvement over the first 12 weeks should be considered acceptable as neuroplastic changes are a process. Although these authors have rarely personally experienced a lack of significant neuro-biomechanical changes over that time period, it is a clinical decision that must be derived by the treating provider in a “Best Practice Model” and not a 3rd party.
The Academy of Chiropracitc has had quite few questions over a long period of time related to patient treatment outcomes and inquires as to the most accurate ways in which to both measure and document them. Bombardier (2000) published a paper in Spine entitled “Outcome Assessments in the Evaluation of Treatment of Spinal Disorders: Summary and General Recommendations.” This paper comprehensively reviewed not just outcome assessments, but how the assessment categories are broken down. Although many in the field utilize outcome assessment forms, when working in both clinical and academic environments across the globe, most doctors fall severely short with regard to comprehension of the tools they are using. Most of the time we see that doctors are simply repeating what they hear without understanding it and memorialize it in clinical notes, thereby rendering inaccurate outcomes to the detriment of the patient and the profession.
Outcome assessments were originally created as “tools” for research purposes, specifically to objectify whether specific treatments were working on a global scale within a population. Measurement of the effectiveness of treatment is important for the clinician, but the history related to outcome assessment is based upon making assumptions on large groups of people to make a homogenous statement or predictive statement based on a large group of very different people. In research, investigators want to “group everybody together” and generalize so that they can obtain a starting point to understand the issue they are researching. In this case, the research topic is the effectiveness of a specific treatment, response to chiropractic care in our offices.
With it comes to patient treatment in general and proving effectiveness in an individual patient, we want to be explicit in regard to a specific diagnosis for that specific patient, it is not a process whereby we work off of generalizations. An experienced practitioner shouldn’t conclude a definitive prognosis based on what’s going on with the rest of the world or even with larger groups of patients. A prognosis should be based upon that particular patient’s response at that particular time. As an example, if a patient were to lose a pinky finger in a work-related accident and that patient was a forest ranger, his day would most likely consist of hiking through the woods. That would render one set of conclusions regarding outcomes and his ability to function. However, if that sample patient earned his living as a concert pianist, there would be a major difference in perceived outcomes and his ability to function in their respective occupations. Although we could give both men an impairment rating for the loss of that digit, how that loss might affect their lives is very different and specific to each patient. That is what “patient centered care” is all about, focusing on the individual patient not on the population to which that patient is part. A lot of the most outcome assessment tools are designed give providers treatment pathways, however, to obtain the complete picture, you need to asses each patient’s complete clinical documentation, such as changes in pain levels, motor and sensory function, range of motion, location and degree of muscle spasm, neurological function or any other clinically valid finding. Initially in care, perhaps only modalities could be utilized, but later, it could be possible to render chiropractic spinal adjustments, changing the prognosis and plan for future outcome improvements. Therefore, the utilization of a “single assessment tool” can do harm to a patient if not all tools available are considered.
Based upon the last sentence, the inclusion of any “single” assessment tool would appear to be as irresponsible as the exclusion of any “single” assessment tool. You must consider multiple parameters, both in clinical evaluations combined with a detailed history to conclude an outcome.
Bombardier (2000) wrote, “Clinicians and researches increasingly recognize the importance of the patient’s perspective in the evaluations of effective of treatment” (p. 3100). This statement is consistent with Sackett, Rosenberg, Gary, Haynes and Richardson (1996) who stated, “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” (p. 73).
Both articles realized that effective healthcare requires more than just published research and must include patient feedback is valid in helping to determine the direction of care and outcomes. However, it cannot stop here and therein lies the problem. It is not possible to determine permanencies or lack thereof with a simple “subjective response” to make a conclusive prognosis. Evidence-based care includes 1) published research, 2) the doctor’s experience and input, and 3) the patient’s input, both verbally and through test results so that the care can be “evidence-based.” The “evidence” for care comes from three distinct areas and therefore the results of the intervention must also meet the same level of complexity. There are no shortcuts.
Bombardier (2000) also reported, “A core set of measures should include the following five domains” (p. 3100). This information is leaning a little bit more towards research, however, if you can grasp this general concept, you will begin to understand the miscommunication relating to outcome assessments and what is required to tell the patient’s “true story.” “A core set of measures should include the following five domains: back specific function, generic health status, pain, work disability, and patient satisfaction” (Bombardier, 2000, p. 3100).
When looking at a specific region of the spine, one should focus on these five domains and generically inquire as to what the patient’s presentation is overall. Is he/she an obese smoker? Is he/she fit and active? Are there other comorbidities such as diabetes, a missing limb, etc.? His/her pain should be documented in detail including whether he/she is completely or partially disabled, what his/her work duties are, and, ultimately, whether he/she is satisfied with his/her care. We know that patient satisfaction is a driver of compliance and if we have compliant patients, then we have people that are adhering to their treatment plan, and historically we’re going to get better outcomes.
When it comes to specific back function, there are two main outcome assessments: The Roland-Morris Disability Questionnaire and the Oswestry Disability and both are related directly to spine, specifically the lower back. Historically, chiropractic has considered the spine to be one contiguous organ, but many within the profession are now considering treating the spine segmentally and ignoring the whole. Medicine, conversely started by treating the spine segmentally and is now embracing a whole spine model which in part, is based upon the scientific papers published in neurosurgery journals (following chiropractic’s historic lead). Spinal biomechanics dictates that a whole spine model is critical in spinal stability and long-term spinal health. If you do not consider creating a homeostatic model, then any corrections made will be temporary at best and perhaps undo any compensatory mechanisms within the spinal system. Proper full spine biomechanical analysis is being embraced by the neurosurgical community at a very high level particularly, since it is been shown to influence spinal surgery outcomes and chiropractic shares the same goal; to create a homeostatic, biomechanically balanced spine “post-treatment.”
Scheer et al. (2016) wrote:
Patients with thoracolumbar deformity [scoliosis] without preoperative CD [cervical deformity aka loss of cervical lordosis] are likely to have greater improvements in HRQOL [health related quality of life] after surgery than patients with concomitant preoperative CD. Cervical positive sagittal alignment [cervical lordosis] in adult patients with thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach MCID [minimal clinically important difference] at 2-year follow-up despite having similar baseline HRQOL to patients without CD. This was the first study to assess the impact of concomitant preoperative cervical malalignment in adult patients with thoracolumbar deformity. These results can help surgeons educate patients at risk for inferior outcomes and direct future research to identify an etiology and improve
patient outcomes. Investigation into the etiology of the baseline cervical malalignment may be warranted in patients who present with thoracolumbar deformity. (p.109)
Neither Roland-Morris nor Oswestry takes into consideration whether the patient’s entire spine is involved. As an example, the lumbar spine is in pain, but is it a compensatory lesion with the primary lesion being in the cervical region? Roland-Morris and Oswestry continue to fragment the spine into regions which really are not regions at all, but part of an entire model or organ system. That is a significant drawback in that they’re only “assessing” one part of the spine and, therefore, only a portion of an organ system and ultimately only part of the patient’s real spinal dysfunction.
When it comes to the generic measures like health status, the SF-36 is highly regarded in that arena. To find more, do a computer search using the search terms “SF-36 outcome measure.”
According to Rand Health (n.d.):
As part of the Medical Outcomes Study (MOS), a multi-year, multi-site study to explain variations in patient outcomes, RAND developed the 36-Item Short Form Health Survey (SF-36). SF-36 is a set of generic, coherent, and easily administered quality-of-life measures. These measures rely upon patient self-reporting and are now widely utilized by managed care organizations and by Medicare for routine monitoring and assessment of care outcomes in adult patients. (https://www.rand.org/health/surveys_tools/mos/ 36-item-short-form.html)
Bombardier (2000) commented:
Moreover, the SF-36 Bodily Pain Scale provides a brief measure of pain intensity and pain interference with activities. Health-related work disability should include a minimum of measure of work status and work-time loss...No single measure of patient satisfaction is clearly preferred but guiding principles are provided to choose among available measures. (p. 3100)
Generic health status in the SF-36 includes pain and working disability. It also looks at status and time lost which are important factors that contribute to an accurate diagnosis, prognosis and treatment plan. In addition, our issue with many written, form-based tools is that they’re time consuming and can be difficult, particularly with patients of differing socioeconomic status, level of education and language. This issue is addressed by the SF-36. Consistency in patient care is critical and implementing a system that allows all patients to utilize it will render a consistent outcome measure. We don’t want to have an electronic interface in the waiting room for outcome measure that can only be utilized by 10% of patients while the other 90% have difficulty because of various issues such as literacy challenges, generations that are not used to technology, or general sloppiness when inputting data (i.e. reversing the 1-10 scale). In those cases, your “data in” is the garbage that you must deal with. In addition, too many doctors “scantily” review the patient portion of the history and if it is not accurate, it creates an inaccurate picture.
Very few individual measures are clearly superior and we must understand that it is the totality of your findings and your patient reports in their entirety that create an accurate picture. If a lawyer, an insurance adjuster, or a medical doctor asks what type of outcome measures you use, the proper answer is, “I use the patient’s objective clinical findings correlated to his/her subjective improvement. That objective data is obtained every visit through my touching the patient, feeling for spasm, determining if the patient can move, stressing joints, and correlating those findings to his/her pain and the historical etiology of the accident/injury/episode, as well as basic and advanced imaging.” It reflects the comprehensive patient assessment performed and becomes close to “bulletproof!”
If you are exclusively using only one of the five assessments, either the Roland-Morris, Oswestry, NPI indexes or pain scales, you are measuring only one of five domains. If you’re not doing all five, you are not rendering a complete assessment and potentially doing the patient a disservice and adding an inaccurate statistic to the treatment rendered (not technique, but the chiropractic as a profession). Back specific function, generic health status, pain/disability status and patient satisfaction must be part of your outcome assessment; however, you will still need to add the clinical findings that should correlate and all modalities inclusive of ranges of motion as considered.
Bombardier (2000) wrote:
A generic measure is particularly important in populations with comorbidities…since disabilities from these comorbidities may influence the patients’ response to treatment…Generic measures also provide a more comprehensive picture of the patient health status because back specific instruments do not include measures of patients’ mental or social health. (p. 3100)
Therefore, managed care, from a business model perspective, has reaped windfall profits because it categorizes people into large populations and creates generic care paths requiring practitioners to be complicit in their profit generation by utilizing these outcome measures. If you do an Oswestry on a 25-year-old yoga instructor and then I do an Oswestry on a 65-year-old railroad worker that smokes every day and eats fast-food, those scores are irrelevant comparatively. The global picture for patient care isn’t as effective as looking at the individual patient using a larger cross-section of assessment tools outlined within the treatment record.
Bombardier (2000) stated, “Overall, the SF-36 struck the best balance between length, reliability, validity, responsiveness and experience in large populations of people with back pain” (p. 3101). She continued, “Measures of ‘pain severity’ are distinct from measures of ‘pain affect’” (Bombardier, 2000, p. 3200).
Regarding the spine, when dealing with patients that have a pain syndrome from a muscle problem, a ligament problem, a fracture, a tumor, or a disc herniation, measuring the severity includes “pain severity” questions such as, “How are you today on a scale of 0 to 10?” versus the “pain affect” which is what he/she can or can’t do. Those are critically important and they’re very different measures and should be considered when considering MMI’ing (maximum medical improvement) your patient.
Bombardier (2000) continued:
Pain severity is how much a person hurts, while pain affect is more complex and reflects a mental state triggered by the pain [like the pinky finger example above]. The measure of pain severity is relatively straightforward, while there are many unresolved questions about the construct of pain affect. For these reasons, it is recommended as part of the core set, to use a brief measure of pain severity. The bodily pain subscale of the SF-36 is the most recommended scale – it has strong psychometric support and extensive normative data. This two-item scale measures pain intensity (six levels: none, very mild, mild, moderate, sever, and very severe) and interference with activities (five levels: not at all, a little bit, moderately quite a bit, extremely). It is a generic pain scale since it asks about overall pain. (p. 3102)
The Patient Satisfaction Scale, (PSS), another outcome modality is a multi-item scale with 17 questions covering information, emotional support and assurance and the effectiveness of prescribed treatment…It, however, does not include issues of access to care, involvement in decision making, coordination of care among caregivers, or trust in one’s clinician, which are dimensions of importance to patients. (p. 3102)
Bombardier (2000) concluded by stating:
Finally, the most common reason for using patient-based outcome measures is to assess patients’ response to treatment. Is the patient better? How well do the measures described in this special focus issue detect patient improvement when it has occurred? What is their smallest clinically relevant change? There is no set answer to such questions…These are all different concepts of change. No wonder then that the responsiveness of the RDQ [Roland-Morris Disability Questionnaire] found in the literature will range from 3 to 8 points on its 0 to 24 scale…[That’s up to a 33% error rate.] (p. 3103)
When you consider a more expansive subset of subjective complaints and then clinically correlate it to changes in orthopedic, neurological and biomechanical clinical/functional tests that show objective restoration of cervical or lumbar curvatures, decreased muscle spasm, increases in range of motion, increases in functional activity, it now renders a more complete clinical picture as compared to a simple form. An individual “form” which is designed to only consider a portion of the entire spine is severely deficient in rendering any level of accuracy for a complete spinal organ. Too many providers, unfortunately, utilize these forms as a “filler” for poor documentation and render an inaccurate diagnosis, prognosis and treatment plan as a result. That is why complete clinical documentation is the only true way to monitor and assess the patient’s response to care.
One of the most important aspects in the functional care of the spine is the range of motion occurring throughout a specific region as well as the individual motor units. In this paper, we purposefully omitted research and validity of ranges of motion as discussed in both the fifth and sixth editions of The Guides to the Evaluation of Permanent Impairment published by the American Medical Association. The AMA Guides clearly position ranges of motion as a valid tool for assessing clinical progress or the lack thereof. However, it should be mentioned that ranges of motion are just one tool and the astute clinician should never rely on just one assessment parameter when determining outcomes. It is the totality of all measures that lend a valid outcome assessment.
We have heard doctors and groups discussion labeling range of motion as invalid which even according to the AMA is an important tool in assessing disability and response to care. To single out ranges of motion as an invalid tool for outcomes is “fodder” for carriers and defense lawyers to utilize against practitioners because the commentary is misleading. To denigrate ranges of motion as an outcome assessment tool is suggesting that it should not be utilized when Medicare, insurance carriers as well as every court in the nation consider it a valid analytical tool when used properly to determine biomechanical pathology.
Measuring outcomes in a patient with a spinal condition is a complex process, however it should not be a surprise. As the spine is one of the most complex systems in the body, chiropractic as a profession is in a perfect position to take a leadership position in the diagnosis, assessment, treatment and management of spinal biomechanical disorders. Leadership requires an intellectual and forward thinking approach to the patient interview, objective documentation and reporting, there is no other way to properly care for a patient and tell their story. We need to embrace the challenge and lead though both our daily clinical practices and teaching all who treat spine.
1. Feiss, R. (2017). Why you should stop using ROM as an outcome measure. Institute of Evidence-Based Chiropractic. Retrieved November 11, 2017, from http://www. researchcapsule240.com/video-library/
2. Bombardier, C. (2000). Outcome assessments in the evaluation of treatment of spinal disorders: Summary and general recommendations. Spine, 25(24), 3100-3103.
3. Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn't. British Medical Journal, 312(7023), 71-72.
4. RAND Medical Outcome Studies. (n.d.). 36-Item Short Form Survey (SF-36). RAND Health. Retrieved November 11, 2017, from https://www.rand.org/health/surveys _tools/mos/36-item-short-form.html
5. Scheer, J. K., Passias, P. G., Sorocean, A. M., Boniello, A. J., Mundis Jr, G. M., Klineberg, E.,...Shaffrey, C. I. (2016). Association between preoperative cervical sagittal deformity and inferior outcomes at 2-year follow-up in patients with adult thoracolumbar deformity: analysis of 182 patients: Presented at the 2015 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves. Journal of Neurosurgery: Spine, 24(1), 108-115.
6. American Chiropractic Association. (n.d.). Clinical documentation guidelines. Commentary on Centers for Medicare and Medicaid Services (CMS)/PART. Retrieved November 11, 2017, from http://www.chiro.org/ documentation/ABSTRACTS/Medicare_Documentation_ACA.pdf
7. Cocchiarella L., & Anderson G. (2008). Guides to the evaluation of permanent impairment, 6th edition. Chicago, IL: American Medical Association Press.
Chiropractic and Cervical Arterial Dissection:
Causal Relationship or Medical Dogma?
By Mark Studin
William J. Owens
A report on the scientific literature and commentary
There has been much controversy over the last 2 decades about the perceived causal relationship between a chiropractic cervical adjustment and dissecting arterial aneurysm on the internet, in the literature and in the beliefs of some in the medical community. Prior to examining the published facts, lets first clarify what an arterial dissection is.
According to Haneline and Rosner (2007)
Arterial dissection is an uncommon vascular wall condition that typically involves a tear at some point in the artery's lining and the formation of an intimal flap, which allows blood to penetrate into the muscular portion of the vessel wall. Blood flowing between the layers of the torn blood vessel may cause the layers to separate from each other, resulting in arterial narrowing or even complete obstruction of the lumen (Fig 1). Moreover, pulsatile pressure damages the muscular layer, resulting in a splitting or dissection of the intimal and medial layers that may extend along the artery variable distances, usually in the direction of blood flow.Another way for dissection to occur involves a primary intramural hemorrhage of the vasa vasorum, which builds pressure between the intimal and medial layers and may eventually rupture into the vessel's true lumen. Occasionally, a double lumen (also known as false lumen) is formed when the subintimal hemorrhage ruptures back into the arterial lumen distally. (pgs. 113-114)
In addition, Haneline and Rosner (2007) wrote a decade ago:
Of special interest to chiropractors is the role cervical spine manipulation [CSM] plays, if any, in the pathogenesis of CAD [Cervical Artery Dissection]. Indeed, patients do experience CAD on rare occasions after CSM, making knowledge about the cervical arteries, the predisposing factors, and the pathogenesis of the condition important for chiropractors. (pg. 110)
This comment, early in the potential relationship between cervical adjusting and cervical arterial dissection [CAD] warranted a warning to healthcare provider about CAD and cervical adjusting making it important to understand the cervical arteries. This is underscored by the authors themselves being chiropractors and memorizing this “caveat” to the profession.
In a September 2017 presentation by Candice Perkins MD, Neurology, Vascular Neurology (an attending stroke neurologist and both an Associate and Assistant Professor of Clinical Neurology at the State University of New York at Stony Brook Hospital and Medical Center from 2001 - 2016) in New York, she stated that there is zero evidence for direct causal relationship between stroke and a chiropractic cervical adjustment performed by a licensed chiropractor in the appropriate clinical presentation. Dr. Perkins went on to explain that there are numerators and denominators. The denominator are strokes and the presence of a patient with a stroke. The numerator is the associated incidence. In her vast experience with stroke, there are an unlimited number of numerators with chiropractic being one, however if one uses that same equation, there are hundreds of other equally potential factors with primary care medical visits being of equal incidence. In addition, with her understanding chiropractic as a patient and from the literature, there is scant evidence that a chiropractic adjustment can be the causative factor of cervical dissecting aneurysm.
Researchers from the University of Pennsylvania Department of Neurosurgery came to the same conclusions. In a systematic and meta-analysis of chiropractic care and cervical arterial dissection, they concluded:
There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. (pg. 1)
Church et. Al reviewed 253 published articles and scored them on a GRADE system with 4 variables, high, moderate, low and very low in reliability of the research available on CAD and chiropractic adjustments. They concluded:
Scrutiny of the quality of the body of data using the GRADE criteria revealed that it fell within the “very low” category. We found no evidence for a causal link between chiropractic care and CAD. This is a significant finding because belief in a causal link is not uncommon, and such a belief may have significant adverse effects such as numerous episodes of litigation. (pg. 6)
Perhaps the greatest threat to the reliability of any conclusions drawn from these data is that together they describe a correlation but not a causal relationship, and any unmeasured variable is a potential confounder. The most likely potential confounder in this case is neck pain. Patients with neck pain are more likely to have CAD (80% of patients with CAD report neck pain or headache), and they are more likely to visit a chiropractor than patients without neck pain. (pg. 7)
This is the same opinion of Dr. Perkins as reported above, where the presence of CAD does not have a causal relationship simply because the neck pain brought them to a chiropractor. The CAD would have happened with or without the chiropractic adjustment as is concluded by medical experts and the literature.
To further the argument, Cassidy, Boyle, Cote`, He, Hogg-Johnson, Silver and Bondy (2008) reported:
There were 818 VBA [Vertebral Basilar Artery] strokes hospitalized in a population of more than 100 million person-years. In those aged 45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than <45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. (pg. S176)
Murphy (2010) reported,
Therefore, based upon the best current evidence, it appears that there is no strong foundation for a causal relationship between CMT [Chiropractic Manipulative Therapy] and VADs [Vertebral Artery Dissection]. The most plausible explanation for the association between CMT and VADs is that individuals who are experiencing a vertebral artery dissection seek care from a chiropractic physician or other manual practitioner for relief of the neck pain and headache that results from the dissection. Sometime after the visit the dissection proceeds along its natural course to produce arterial blockage, leading to stroke. This natural progression from dissection to stroke appears to occur independent of the application of CMT. (pg. 4)
Church, Sieg, Hussain, Glantz and Harbaugh (2016) concluded, and an opinion that appears to reflect the facts of the issue and in accordance with those in chiropractic and medical academia based upon the author’s strong agreement:
Our systematic review revealed that the quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. A meta-analysis of available data shows a small association between chiropractic neck manipulation and CAD. We uncovered evidence for considerable risk of bias and confounding in the available studies. In particular, the known association of neck pain both with cervical artery dissection and with chiropractic manipulation may explain the relationship between manipulation and CAD. There is no convincing evidence to support a causal link, and unfounded belief in causation may have dire consequences. (pg. 10)
In spite of the very weak data supporting an association between chiropractic neck manipulation and CAD, and even more modest data supporting a causal association, such a relationship is assumed by many clinicians. In fact, this idea seems to enjoy the status of medical dogma. (pg. 9)
That is the final definitive opinion of the Neurosurgery Department at the University of Pennsylvania.
The Mechanism of the Chiropractic
Effect of Sagittal Alignment on Kinematic Changes and Degree of Disc Degeneration in the Lumbar Spine
Part 4 of a 5 Part Series
William J Owens Jr
Mark E. Studin
A report on the scientific literature
More and more evidence is coming forward demonstrating both spinal stability and biomechanical balance as an important aspect of spine care. The good news is this is well within chiropractic’s scope, however many doctors of chiropractic are missing the education to accurately evaluate and objectify these types of biomechanical lesions. Our profession has spent most the last 122 years focused on TREATING these biomechanical lesions (Vertebral Subluxation, Joint Fixation, etc.) with little regard to the “assessment” component. The reason that is a critical statement, is that too often we treat compensation vs. the unstable joint.
Our founding doctors had used very specific techniques to analyze the spine from a functional perspective and most of our contemporary treatment techniques came out of these analysis, which are the basis for many of our most common techniques taught in today’s chiropractic academia. It seems in hindsight, that the major discussions of the time [early chiropractic] were about “identification” of the lesion to adjust, then evolved into the best WAY to deliver the adjustment.
Our roots and subsequently the true value and expertise of the doctor of chiropractic is in the assessment with treatment far secondary to an accurate diagnosis The medical community that both the authors and the doctors we teach no longer confuse our delivering of chiropractic care with a physical therapy manipulation or mobilization. The reason, our focus is on the diagnosis, prognosis and treatment plan BEFORE we render our treatment.
With medical specialists who understand spine, our conversation centers on spinal biomechanics and how a specific chiropractic spinal adjustment will restore sagittal/coronal alignment and coupled motion balance the spine. We discuss spinal biomechanics and have the literature and credentials to validate our diagnosis, prognosis and treatment plan. Chiropractic has been the leader in this treatment for over a century, but since we had chosen to stay outside of the mainstream healthcare system we had no platform to take a leadership position or be heard.
Medicine at both the academic and clinical levels are embracing chiropractic as the primary solution to mechanical spine issues (no fracture, tumor or infection) because as one primary care provider shared with us “traditional medical therapies inclusive of physical therapy has no basis in reality in how to treat these patients, which has led us in part, to the opiate crisis.” Part of the validation of what chiropractic offers in a biomechanical paradigm comes from surgical journals in the medical community.
Keorochana et al, (2011) published in Spine and out of UCLA, titled “To determine the effects of total sagittal lordosis on spinal kinematics and degree of disc degeneration in the lumbar spine. An analysis using positional MRI.” Remember that this article was 8 years ago and as a concept has evolved considerably since it was first discussed in the late 1990s. This is the clinical component of what Panjabi had successfully described and reproduced in the laboratory. It is now starting to become mainstream in clinical practice.
Many people ask why would surgeons care about the biomechanics of the spine when they are looking simply for an anatomical lesion to stabilize [fracture, tumor, infection, cord compression]? The authors answer this question by stating “It has also been a topic of great interest in the management of lumbar degenerative pathologies, especially when focusing on the role it may play in accelerating adjacent degeneration after spinal fusionand non-fusion procedures such as dynamic stabilization and total disc replacement.” [pg. 893]
They continue by stating “Alterations in the stress distribution may ultimately influence the occurrence of spinal degeneration. Moreover, changes in sagittal morphology may alter the mechanics of the lumbar spine, affecting mobility. Nevertheless, the relationships of sagittal alignment on lumbar degeneration and segmental motion have not been fully defined.” [pg. 893] This is precisely what our founding fathers called “Subluxation and Subluxation Degeneration!”
Regarding the type and number of patients in the study, the authors reported the following, “pMRIs [positional MRI] of the lumbar spine were obtained for 430 consecutive patients (241 males and 189 females) from February 2007 to February 2008. All patients were referred for pMRI [positional MRI – which included compression in both flexion and extension with a particular focus on segmentation translation and angular motions] due to complaints of low back pain with or without leg pain.” [pg. 894] This is the part where they looked for hypermobility.
In the first step in the analysis, the authors reviewed data regarding the global sagittal curvature as well as the individual angular segmental contributions to the curvature. The next step involved the classification of the severity of lumbar disc degeneration using the Pfirrmann classification system. [See Appendix A if you are not familiar]. This is where they looked for segmental degeneration. The patients were then classified based on the lordosis angle [T12-S1]. The groups were as follows:
Group A – Straight Spine or Kyphosis – [lordosis angle <20°]
Group B – Normal Lordosis – [lordosis angle 20° to < 50°]
Group C – Hyperlordosis – [lordosis angle >50°]
There is a structural categorization [lordosis] and a degenerative categorization [Pfirrmann] in this paper and the authors sought to see if there was a predictable relationship.
The results of this study were interesting and validated much of what the chiropractic profession has discussed relating to segmental “compensation” in the spine. Meaning, when one segment is hypomobile, adjacent segments will increase motility to compensate. The authors stated, “The sagittal lumbar spine curvature has been established as an important parameter when evaluating intervertebral disc loads and stresses in both clinical and cadaveric biomechanical investigations.” [pg. 896] They continue by stating “In vitro [in the laboratory or outside of the living organism] biomechanical tests do not take into account the influence of ligaments and musculature, and may not adequately address the complex biomechanics of the spine.” [pg. 896]
When it comes to spinal balance and distribution of loads in the spine, the authors reported “Our results may indicate that the border segments of lordosis, especially in the upper lumbar spine (L1–L2, L2–L3, and L3–L4), have greater motion in straight or kyphotic spines, and less segmental motion in hyperlordotic patients.” [pg. 896]
They continued by stating, “A greater degree of rigidity is found at the apical portion of straight or kyphotic spines, and more mobility is seen at the apical portion of hyperlordotic spines.” [pg. 897] Therefore, in both cases we see that changes in the sagittal configuration of the human spine has consequences for the individual segments involved.
This raises the question, “how does this related to accelerated degeneration of the motion segments involved?” [Subluxation Degeneration] The authors reported, “Regarding the relationship between the degree of disc degeneration and posture, subjects with straight or kyphotic spines tended to have a greater degree of disc degeneration at border segments, with statistical significance in the lower spine (L5–S1). On the other hand, hyperlordotic spines had a significantly greater degree of disc degeneration at the apex and upper spine (L4–L5 and L1–L2). The severity of disc degeneration tended to increase with increased mobility at the segments predisposed to greater degeneration (border segments of straight or kyphotic spines and apical segments of hyperlordotic spines).” [pg. 897]
The scientific literature and medicine is now validating (proving) what chiropractic has championed for 122+ years, that the human spine is a living neurobiomechanical entity, which responds to the changes in the external environment and compensates perpetually seeking a homeostatic equilibrium. We can now have verification that changes or compensation within the spinal system as a result of a bio-neuro-mechanical lesion (vertebral subluxation) results in degeneration (subluxation degeneration) of individual motion segments.
In conclusion, the authors state…
“Changes in sagittal alignment may lead to kinematic changes and influence load bearing and the distribution of disc degeneration at each level.” [pg. 897]
“Sagittal alignment may alter spinal load and mobility, possibly influencing segmental degeneration.” [pg. 897]
“Motion and the segmental contribution to the total mobility tended to be lower at the border of lordosis, especially at the upper segments, and higher at the apex of lordosis in more lordotic spines, whereas the opposite was seen in straight or kyphotic spines.” [pg. 897]
Although medicine is addressing this at the surgical level, as a profession they realize they have no conservative solutions, which has “opened the door” for the credentialed doctor of chiropractic to be in a leadership role in both teaching medicine about the role of the chiropractor as the primary spine care provider and the central focus of the care path for mechanical spine issues.
When communicating with patients and medical professionals it is critically important to educate them on what “current research” is showing and why it is important that this chiropractic approach to spine care is the future of spine care in the United States.
1. Keorochana, G., Taghavi, C. E., Lee, K. B., Yoo, J. H., Liao, J. C., Fei, Z., & Wang, J. C. (2011). Effect of sagittal alignment on kinematic changes and degree of disc degeneration in the lumbar spine: an analysis using positional MRI. Spine, 36(11), 893-898.
2. Teichtahl, A. J., Urquhart, D. M., Wang, Y., Wluka, A. E., Heritier, S. & Cicuttini, F. M. (2015). A dose-response relationship between severity of disc degeneration and intervertebral disc height in the lumbosacral spine. Arthritis Research & Therapy, 17(297). Retrieved from https://openi.nlm.nih.gov/detailedresult.php?img=PMC4619538_13075_2015_820_Fig1_HTML&req=4
3. Teraguchi, M., Yoshimura, N., Hashizume, H., Muraki,S., Yamada, H.,Minamide, A., Oka, H., Ishimoto, Y., Nagata, K. Kagotani, R., Takiguchi, N., Akune, T., Kawaguchi, H., Nakamura, K., & Yoshida, M. (2014). Prevalence and distribution of intervertebral disc degeneration over the entire spine in a population-based cohort: the Wakayama Spine Study. Osteoarthritis and Cartilage, 22(1). Retrieved from http://www.sciencedirect.com/science/article/pii/S1063458413010029
4. Puertas, E.B., Yamashita, H., Manoel de Oliveira, V., & Satiro de Souza, P. (2009). Classification of intervertebral disc degeneration by magnetic resonance. Acta Ortopédica Brasileira, 17(1). Retrieved from http://www.scielo.br/scielo.php?pid=S1413-78522009000100009&script=sci_arttext&tlng=en
Should Chiropractic Follow the
American Chiropractic Association
/ American Board of Internal Medicine’s
Recommendations on X-Ray?
By Mark Studin
William J. Owens
In reviewing the American Chiropractic Associations’ (ACA) position on x-ray and adopting the posture of the American Board of Internal Medicine’s (ABIM) initiative, “Choosing Wisely,” regarding x-ray, we must consider both the far-reaching effects of those recommendations as well as the education of the originators of the recommendations. In addition, the ACA in their 2017 published article Five Things Clinicians and Patients Should Question, they state, “The recommendations are not intended to prohibit any particular treatment in all scenarios or to dictate care decisions. They are also not intended to establish coverage decisions or exclusions” (https://www.acatoday.org/Patients-Choosing-Wisely?utm_campaign=sniply).
The ACA, a highly-regarded chiropractic political organization that has done a great deal in advancing the profession, is adopting the ABIM’s current position and regardless of the wording of the policy which, in the form of a disclaimer, is opining and setting precedent that can be used against individual practitioners or the entire profession. Granted, the underlying tone is to prevent unnecessary exposure to ionizing radiation, but at what cost to patient care?
The scientific evidence has shown, and continues to show, chiropractic as being highly effective for managing and treating non-specific or mechanical spine pain. 2-3-4-5-6-7 In this article, we are only considering acute low back pain treatment to meet the scope of the ACA/ABIM policy and are therefore excluding all other conditions treated within the lawful scope of chiropractic. Mechanical spine pain, pain of non-anatomical origin, is defined as spine pain not originating from fracture, tumor, infection or specifically co-related to an anatomical lesion such as degenerative intervertebral disc disease, intervertebral disc bulge or intervertebral disc herniation. The ACA/ABIM states in the absence of “red flags,” imaging should not be considered for at least 6 weeks of care. Some of these “red flags” are clearly present on physical examination, others may not reveal themselves without radiographic evidence.
The definition of red flags by the American Chiropractic Association (2017):
Red flags include history of cancer, fracture or suspected fracture based on clinical history, progressive neurologic symptoms and infection, as well as conditions that potentially preclude a dynamic thrust to the spine, such as osteopenia, osteoporosis, axial spondyloarthritis and tumors. (https://www.acatoday.org/Patients-Choosing-Wisely?utm_campaign=sniply)
When considering the training of internal medicine physicians, we recognize they are focused on the diagnosis and management of systemic disease. However, when considering musculoskeletal diagnosis, basic medical training for internal medicine residency is quite the opposite. Although it is understandable given the current climate of spine pain management in the United States that the American Board of Internal Medicine would take a stance on spine care, I would consider the opinion of an internal medicine board valuable, but less authoritative than a board comprised of practicing spine specialists that is trained in the diagnosis and management of mechanical spine pain with specific treatment designed to deliver high velocity-low amplitude thrusts (chiropractic spinal adjustments). Interestingly, in this specific case, we have a chiropractic political organization agreeing with a medical board that is specifically trained on the diagnosis of internal medicine disorders with little or no training on the management of acute spine pain.
In an 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)
It should be noted that primary care medical doctors are not spine specialists and are generally comprised of family or internal medicine physicians. Medical school is lacking in musculoskeletal education, particularly in spine. Graduate level medical education including residency and fellowship training, only provides spine specialty training in those boards that are focused on spine care, namely orthopedic surgery and neurosurgery. It should also be noted that both orthopedic and neurosurgery disciplines are focused on the anatomical lesion in the spine as a primary method of determining the medical necessity of intervention.
Research has shown musculoskeletal complaints have a major impact on the healthcare system. Many patients believe that traditional medical providers are highly trained in diagnosis and management of musculoskeletal conditions and trust the referrals they provide to physical therapy as the best care path. A recent publication relating to basic competency have shown otherwise.
Humphreys et al. (2007) state:
A study by Childs et al on 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 Examination]. (p. 45)
Humphreys et al. (2007) continued by reporting a comparative analysis:
The typical chiropractic curriculum consists of 4800 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, neurodiagnosis, orthorheumatology, radiology, and psychology). As the diagnosis, treatment, and management of MSK [musculoskeletal] 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. The objective of this study was to examine the cognitive (knowledge) competency of final-year chiropractic students in MSK medicine. (p. 45).
The following results were published in the article by Humphreys et al. (2007) relating to the Basic Competency Examination and evaluating the various professions that are on the “front line” in the diagnosis and treatment of musculoskeletal conditions. Passing grades were attained by 22% of recent medical graduates, 20.7% of medical students, residents, and staff physicians, 33% of osteopathic students, 21% of MSc [masters] level physical therapy students, and 26 % of DPT [doctors of physical therapy] level physical therapy and chiropractic student 64.7%…
This indicates, that unless a “boarded internist” goes back for advanced education in physical medicine, neurology, orthopedics or neurosurgery, his/her basic competency is between 20% and 33% (if a DO) at best and it is the guidelines of that profession’s board that are being adopted by the ACA. In addition, no profession, inclusive of the ACA, is discussing the difference between a diagnosis, prognosis or treatment plan for mechanical spine pain. The only discussion is related to anatomical origins and anatomical spinal pathology. They are only considering the “red flags” of non-mechanical spine pain (to the detriment of the patient with mechanical spine pain), which only drives triage to medical specialists and ignores clinically necessary treatment plans focusing on the mechanical sources of pain found within chiropractic clinics globally.
The ACA/ABIM guidelines are very specific to low back pain and refer to the “routine use of imaging,” which is understood to be x-ray as the article uses the term “ionizing imaging.” However, it is not clear if they are also including CAT scan imaging as well. What their suggested “evidence-based recommendations” omits is the diagnosis of spinal biomechanical pathology and the osseous pathology that is discovered because of a complete clinical evaluation inclusive of spinal biomechanics, which ultimately protects our patients with an accurate spinal diagnosis. That consideration is something that board certified internal medicine practitioners do not have to be concerned with as it is outside of their focus of treatment. Typically, internal medicine physicians have less chance of causing harm to their patients in the short-term with a prescription pad (drug abuse is a topic for a different conversation) vs. a high velocity-low amplitude thrust, the primary treatment modality for the doctor of chiropractic. In this specific case it is the specific type of “treatment” that requires a specific level of diagnosis to be safe.
In the process of concluding an accurate diagnosis, prognosis and treatment plan, an assessment of the structural and biomechanical integrity of the spine is integral to specific treatment recommendations and visual assessment often fails.
Fedorak, Ashworth, Marshall and Paull (2003) reported:
This study has shown that the visual assessment of cervical and lumbar lordosis is unreliable. This tool only has fair intrarater reliability and poor interrater reliability. Visual assessment of spinal posture was previously shown to be inaccurate, and this study has demonstrated that is reliability is poor. (p. 1858)
In contrast, the reliability of x-ray in morphology, measurements and biomechanics has been determined accurate and reproducible.10-11-12-13-14-15-16-17-18-19 In addition, Ohara, Miyamoto, Naganawa, Matsumoto and Shimzu (2006) reported, “Assessment of the sagittal alignment of the spine is important in both clinical and research settings… and it is known that the alignment affects the distribution of the load on the intervertebral discs” (p. 2585).
Assessment of distribution or load of spinal biomechanics, if left aberrant, will result in the initiation of the piezoelectric effect and Wolff’s Law remodeling the spine. This is the basis for the subluxation degeneration theory which historically many have scoffed at as it is not considered to be based on scientific principles. We have now verified it based upon the research, and it is now a current and verifiable event that must be taken into consideration when assigning prognosis to a biomechanically flawed spine.
A very recent and timely study by Scheer et al. (2016) takes the biomechanical assessment of the spine to an entirely different level. This concept was originally presented at the 2015 American Academy of Neurosurgery symposium.
Scheer et al. (2016) state:
Several recent studies have demonstrated that regional spinal alignment and pathology can affect other spinal regions. These studies highlight the importance of considering the entire spine when planning for the surgical correction of ASD [adult spinal deformity/scoliosis]. (p. 109)
Scheer et al. (2016) continue:
Furthermore, the cervical spine plays a pivotal role in influencing adjacent and global spinal alignment as compensatory changes occur to maintain horizontal gaze. (p. 109).
Scheer et al. (2016) also wrote:
There has been a shift from the regional view of the spine to a more global perspective, and recent work has found concomitant spinal deformities in patients. Specifically, there is a high prevalence of CD [cervical deformity/loss of cervical lordosis] among adult patients with thoracolumbar spinal deformity. (p. 109).
Finally, according to Scheer et al. (2016):
Concomitant cervical positive sagittal alignment [loss of cervical curve] in adult patients with thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach MCID [minimal clinically important difference] at 2-year follow-up compared with patients without CD [cervical deformity]. (p. 114)
We are seeing that biomechanical assessment is a critical component of spine care and is a trending topic in spine research. These topics are not addressed in the Board of Internal Medicine’s opinions and should be considered strongly prior to any chiropractic advocacy organization taking a position that would give doctors pause when attempting to fully diagnose their patients, no matter the disclaimers.
When it comes to spinal assessment particularly with stress views, Hammouri, Haimes, Simpson, Alqaqa and Grauer (2007) reported, “A survey questionnaire study recently completed by our laboratory confirmed that 43% of practicing spine surgeons also obtain dynamic flexion-extension views in the initial evaluation of those patients” (p. 2361). They later stated, “These findings led to no change in conservative management and no decision to go to surgery based solely from the dynamic flexion-extension radiographs” (p. 2363).
Hammouri et. al. (2007) also discussed the possible cumulative effects of small doses of radiation as another reason to avoid taking flexion-extension x-rays. This has been a position held by practitioners for years despite the evidence that diagnostic ionizing radiation has been proven to be non-carcinogenic. When examining the evidence, Tubiana, Feinendegen, Yang and Karminski (2009) reported:
Several studies in patients after x-ray–based examinations…have not detected any increase in leukemia or solid tumors. The only positive studies were in girls or young women after repeated chest fluoroscopic procedures for chronic tuberculosis…or scoliosis…Among these patients, excess breast cancer was detected only for cumulative doses greater than about 0.5 Gy. No other excess cancer appeared after cumulative doses up to 1 Gy. There was also no increased cancer after cardiac catheterization…
Several studies stressed the risk of cancer after diagnostic irradiation with x-rays by using the LNT [linear no-threshold] model…However, several investigators…have questioned these estimates because of their doubtful assumptions. An overestimate of the diagnostic radiology risk may deprive patients from adequate treatment. (p. 17)
When considering rendering a diagnosis, prognosis and treatment plan, Hammouri et al. (2007) concluded that flexion-extension x-rays are not a determining factor for spinal surgery. However, chiropractic renders disparate treatment compared to surgeons and medical primary care doctors (family practice and internal medicine).
The authors of this current article recently sent a survey to the chiropractic profession and asked a simple question: Does the clinical use of x-rays change either your diagnosis, prognosis or treatment plan? The question was posed with the understanding that “screening purposes” are not considered clinically necessary and all testing and treatment orders must be consistent with a patient’s presentation and physical examination. The results demonstrated that 98.42% of those surveyed, used x-rays in their clinical practices that changed either the diagnosis, prognosis and/or the treatment plan.
The next question was when should an x-ray or any other type of imaging be considered? Clinically, if the patient has pain with limited range of motion in a spinal region upon either visual evaluation or dual inclinometry testing, the clinician should ask why is there biomechanical failure coupled with pain? In the absence of diagnosing anatomical (osseous or any other space occupying lesion) pathology, the aberrant verified biomechanics indicates failure at the connective tissue level (ligaments and tendons) and the mechanical source/rationale of the ensuing nociceptive, mechanoreceptive and proprioceptive neuro-pathological cascade. This in turn allows the practitioner to conclude an accurate diagnosis, prognosis and/or treatment plan based upon the pathological “listings” visualized. As reflected above with the 98.42% response, it is clear that when considering the biomechanical assessment of the human spine, x-ray analysis outside of simple anatomic pathology can change how a doctor of chiropractic manages and treats their patients.
The following is from a small sampling of responses we received from another survey of doctors nationwide. The instructions were to send over examples of how x-ray had changed their diagnoses, prognoses and/or treatment plans within the last 2-3 months. These responses underscored why chiropractors utilize x-ray and often need it to determine accurate mechanical diagnoses, prognoses and treatment plans prior to rendering care. Please note, the clinical protocols presented and x-ray diagnoses are all taught in CCE accredited chiropractic colleges and underscore the quality of a chiropractic education.
Male 70-year old. Presented in my office for 2nd opinion after the prior doctor of chiropractic did not take films. Focal sacral pain unchanged by position or movement. Plain lumbar/pelvic films revealed large radiolucency in sacrum. Patient referred out to MD/oncology for follow up. Diagnosis: Metastatic in nature.
Here is an example of how x-ray helped save a life. I had a patient 6 weeks ago come in with lumbar pain. The patient is 68yr old male with a history of lumbar pain but the pain recently became worse. During the history the patient relayed that they had recently been to their cardiologist for his regular checkup. I completed a thorough physical exam where the only positive findings were limited range of motion with pain in extension and left lateral flexion. I took lumbar x-rays of the patient. While reviewing the x-rays I noticed the outline of an Abdominal Aortic Aneurysm that measured 5cm on my lateral films. I immediately told the patient to go to the emergency room and sent the films with him. The patient stated he did not want to go and he just was at his cardiologist. I insisted and the patient finally listened. The patient had immediate surgery to repair the aneurysm and I received a thank you call from the cardiologist!! More important the patient thanked me for saving his life!!
Abdominal Aortic Aneurysms have a symptom of back pain. I will never touch a patient without being able to x-ray a patient. Who would have been blamed if my patient's aneurysm ruptured??
We had female patient in her thirties present to our office complaining of severe and unrelenting neck pain, with bilateral pain into her shoulders. She did not want an x-ray, however one of the other associates that I worked with convinced her to have two films, AP and lateral cervical. Those films revealed a lyric metastasis of the C5 vertebra, with almost a complete destruction of the vertebral body. Had she been adjusted without the images; the results would have been catastrophic.
54-year old male post MVA, Primary complaint = Low back pain, examination findings revealed positive orthopedic tests in the cervical and lumbar spine with diminished reflexes, upper and lower muscle strength 5/5. Cervical spine x-rays revealed a 3.28 mm anteriorlisthesis of C4 on C5, flexion view revealed an increased displacement to 8.28 mm. Extension view measured 5.48 mm.
Imaging altered treatment plan: Without the x-ray study, the unstable C4 would go undetected and as a result of the x-ray findings the patient was recommended to wear a c-spine collar and have a c-spine MRI. The MRI revealed a 4 x 10 mm left paracentral herniated disc with annular tear compressing the cord by 75% with myelomalacia. It also leaked into the right neural canal compressing the right C4 nerve root. I called my neurosurgeon and he will be in surgery tomorrow. Given the fragmentation of the cord seen on MRI, I shudder to think what would have happened if a high velocity thrust was introduced to his neck!
A patient presented with mild to moderate low back pain. Images revealed a secondary spondylolesthesis and contraindicated in a lumbar side posture. This has happened many times before and once again, prevented me from hurting my patient.
I had a patient that presented with low back pain. The lumbar film showed a 66mm aneurysm. I immediately sent him to the hospital where he was admitted and went into emergency surgery for repair. This could have ended very badly without those x-rays.
36-year old female with acute neck pain, insidious, limited cervical ROM, positive cervical tests, pain worse at night, pain described as "deep, boring, nauseating". AP and lateral cervical x-rays taken in my office revealed complete absence of C5 vertebral body. I immediately referred patient to the local ER with films in hand.
Parents brought their 10-year old son for a second opinion to evaluate a mass on the side of his neck. Their pediatrician had sent them home and told them to check back in 3 days if it didn't resolve. I took AP and lateral cervical films. Both showed the mass but particularly concerning was the AP showed the laryngeal shadow deviated laterally from the pressure of the mass. I told them not to wait 3 days but to go directly to the local emergency department. The local hospital immediately put him in an ambulance and sent him to the children's hospital in Miami. Pediatricians at the children's hospital told the parents the next day, he wouldn't have survived the night had they not taken him to the E.D. on my recommendation, based on the x-ray findings.
I had a 22-year old male present to my office complaining of bilateral low back pain and occasional mild numbness and tingling in his left leg for about 4 years following an injury at wrestling practice when he was 17 years old. Even though the complaints were moderate and his injury was 4 years old, I decided to take lumbar x-rays including oblique views. The x-rays revealed bilateral L3 and L4 pars fractures. I then took lumbar flexion/extension views which revealed a 5mm anterior translation of L4 on L5. His MRI evaluation was unremarkable and without these x-rays there would have seemed to be no contraindication to diversified adjustments including side posture. Had I not taken these x-rays, I would likely have delivered a high velocity thrust into an unstable region of the patient’s spine, potentially injuring him further. Instead, I sent him for an immediate surgical consultation.
Several days ago, a 30-year old female patient presented with a primary complaint of low back pain, neck stiffness and previous diagnosis of ocular migraines by her Neurologist. Radiographs of her Cervical and Lumbar spine were taken to evaluate her spine. A fracture of the vertebral body of C5 was found at the posterior and inferior aspect with an increase in spacing noted at the fracture site on flexion view.
I had a 15-year-old girl present to my office with severe neck pain. She stated that she had no injuries or trauma that she was aware of. She just "woke up with it". The examination revealed that she was not able to turn her head at all -literally zero range of motion in any direction. Something didn't seem right and I decided to take an x-ray. Her X-ray revealed a burst fracture of C1. It turns out that her mother who signed all the consent forms and dropped her off at my office gave her strict instructions not to tell me about the minor fender bender she was in the day before. Also, the daughter explained later that she had landed on the top of her head during volleyball about a year before. After the volleyball accident she had presented to the emergency room but they decided not to take an x-ray and told her she was fine. I sent her to the emergency room. They took an x-ray and sent her home saying there was no fracture. Later the radiologist called her back insisting she return to the hospital immediately. They confirmed the fracture. I think it is quite safe to assume what would've happened if I tried to adjust her.
I had a patient who was having pain in the mid thoracic region between the spine and the scapula. The patient had been to another chiropractor who did not take x-rays, and who did not get good clinical results. I examined and x-rayed the patient. I saw an abnormal mass in the lung field. I sent the patient to a local radiology center and ordered a plain film chest x-ray, the radiologist confirmed a mass in the right lung.
Based upon the literature, radiation is not cumulative and has rendered no evidence of long term effects. Therefore, the doctor of chiropractic must weigh the risk of treating blindly in the presence of clear biomechanical markers. Treating blindly is often done at the expense of our patients and the malpractice carriers, especially in a scenario where little risk exists. Our concern is the adoption of recommendations or guidelines that are deficient in the published and clinical evidence at hand. There also needs to be a larger clinical and academic conversation interprofessionally, to educate organizations like the ABIM and others who access spine patients, where together we can collaboratively, across professional boundaries, devise care paths to better serve society.