Chiropractic Improves Neck Pain in a Military Veteran Population & Lowers the Need for Opiates

 

By Mark Studin

William Owens

 

A Report on the Scientific Literature

 

According to the American Academy of Pain Medicine, neck pain accounts for 15% of commonly reported pain conditions. Sinnott, Dally, Trafton, Goulet and Wagner (2017) reported:

 

Neck and back pain problems are pervasive and associated with chronic pain, disability and high healthcare utilization. Among adults 60% to 80% will experience back pain and 20% to 70% will experience neck pain that interferes with their daily activities during their lifetime. At any given time, 15% to 20% of adults will report having back pain and 10% to 20% will report neck pain symptoms. The vast majority of back and neck pain complaints are characterized in the literature as non-specific and self-limiting.” (pg. 1) 

 

The last sentence above describes why back and neck pain has contributed significantly to the opioid crisis and why our population, after decades still suffers from back and neck problems that have perpetuated. Mechanical lesions of the spine are not “self-limiting” and are not “non-specific.” They are well-defined and based upon Wolff’s Law (known since the 1800’s) don’t go away. Allopathy (Medicine) has purely focused on the pain and has vastly ignored the underlying cause of the neuro-bio-mechanical cause of the pain. 

 

Corcoran, Dunn, Green, Formolo and Beehler (2018) reported that musculoskeletal problems as the leading cause of morbidity for female veterans and females are more prone to experience neck pain than men. In addition, there has been a 400% increase in opioid overdoes deaths in females since 1999 compared to 265% for men and as a result, the Veterans Health Administration has utilized chiropractic as a non-pharmacological treatment option for musculoskeletal pain. Neck pain has also comprised of 24.3% of musculoskeletal complaints referred to chiropractors. 

 

Corcoran et. Al. also reported with chiropractic care, based upon a numeric rating scale (NRS) and the Neck Bournemouth Questionnaire (NBQ) scores, the NRS improved by 45% and the NBQ improved by 38%, with approximately 65% exceeding the minimum clinically important difference of 30%. A previous study of male veterans revealed a 42.9% for NSC and a 33.1 improvement for NBQ; statistics similar to female veterans. 

 

Although this is a very positive outcome that has helped many veterans, the percentages do not reflect what the authors have found in their clinical practices. These authors of this article (Studin and Owens) reported that for decades, cervical pain has been eradicated in 90 and 95% of the cases treated in our practices. The question begs itself, why is the population of veterans showing statistics less than half? 

 

Corcoran, et. Al. (2018) reported how the chiropractic treatment was delivered in their study:

 

The type of manual therapy varied among patients and among visits, but typically included spinal manipulative therapy (SMT), spinal mobilization, flexion – distraction therapy, and or myofascial release. SMT was operatively defined as a manipulative procedure involving the application of a high - velocity, low – ample to thrust the cervical spine. Spinal mobilization was defined as a form of manually assisted passive motion involving repetitive joint oscillations typically at the end of joint playing without application of a high- velocity, low – ample to thrust. Flexion – distraction therapy is a gentle form of a loaded spinal manipulation involving traction components along with manual pressure applied to the neck in a prone position. Myofascial release was defined as manual pressure applied to various muscles on the static state or all undergoing passive lengthening.

 

The above paragraph explains why the possible disparity in outcomes as Corcoran et. Al  do not reflect the ratios of who received high-velocity low-amplitude chiropractic spinal adjustment vs. the other therapies. When considering the other modalities; mobilization, flexion distraction therapy and myofascial release we must equate that to the outcomes physical therapist realize when treating spine as those are their primary reported treatment modalities. The following paragraphs indicate why spine care delivered by physical therapist is inferior to a chiropractic spinal adjustment, which equates to only a portion of the referenced chiropractic treatment modalities cited in the Corcoran Et. Al. The following citations conclude why these modalities provide inferior results compared to the high-velocity, low-amplitude chiropractic spinal adjustment that was exclusively used by the authors and rendered significantly higher positive outcome.


Studin and Owens (2017) reported the following:

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 (manual Therapy University) 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)

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).

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).

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)

(http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320)

The above paragraph has accurately described the problem with allopathic “politics” and “care-paths who have continued to report medical “dogma” and have ignored the scientific literature results of chiropractic vs. physical therapy.

Mafi, McCarthy and Davis (2013) concluded:

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. (p. 1574)


(http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320)

Despite the disparity in statistics, the literature is clear chiropractic renders successful out comes for both male and females, and the spine is not discriminatory for veterans versus non-veterans and offers a successful solution in lieu of the utilization of opiates for musculoskeletal spinal issues. In addition, the labels “non-specific” and “self – limiting” are inaccurate and have been placed by providers with no training in the biomechanics of spine care. Chiropractors has been trained in spinal biomechanics for over 100 years and currently there are advanced courses in spinal biomechanical engineering, of which many chiropractors have concluded. 

References:

  1. AAPM facts and figures on pain, the American Academy of pain medicine (2018), retrieved from: http://www.painmed.org/patientcenter/facts_on_pain.aspx#common
  2. Sinnott P., Dally S., Trafton J., Goulet J. and Wagner T. (2017) Trends in diagnosis of painful neck and back conditions, 2002 to 2011, Medicine, 96 (20), pgs. 1-6
  3. Corcoran K., Dunn A., Green B., Formolo L., and Beehler G. (2018) Changes in Female Veterans’ Neck Pain Following Chiropractic Care at a Hospital for Veterans, Complimentary Therapies in Clinical Practice 30, pgs. 91-95
  4. Studin M., Owens W., (2017) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine, Part 5 of 5, Retrieved from: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320

 

 

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Published in Neck Problems

Chiropractic and Prescriptive Rights

Should Chiropractors Be Allowed to Prescribe Drugs?

 

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

 

Citation: Studin M. (2018) Chiropractic and Prescriptive Rights; Should Chiropractors be Allowed to Prescribe Drugs? American Chiropractor, 40 (3) 16, 17, 18, 19

 

As the rhetoric and legislative agendas escalate nationally on chiropractic and pharmaceutical prescriptive rights, as a profession, we need to take pause and consider the long-term effects of our actions. The question is, “Are we responsibly evolving or are we creating a problem that could put chiropractic back decades in utilization?” Please understand that this argument is totally devoid of any philosophy or beliefs in chiropractic principles or results; it is purely focused on increasing the utilization and business of every chiropractic practice in the country for the betterment of our patients.

 

Based upon an informal, but lengthy poll of many in our profession, one of the core reasons for wanting to add prescriptive rights is to help increase utilization at the practice level. The majority believe that if we could prescribe even non-narcotics, then patients would stay in our offices vs. seeking medical care for pain relief and a pro forma prescription to physical therapy with a resultant decrease in utilization of our offices. Unfortunately, that has been the national trend for far too long.

 

The question begs, “Are prescriptive rights the solution for both the chiropractic profession and our society? Over the last decade, I have been focused on increasing the level of clinical excellence of the practicing chiropractor, which has nothing to do with technique, philosophy or documentation. The level of clinical excellence has been centered on patient management, including accurately diagnosing, prognosing and triaging patients. The reason, medicine focuses on patient diagnosis and management and chiropractic has historically focused on treatment, too often bypassing rendering a thorough and conclusive diagnosis prior to rendering care. Therefore, my areas of focus are MRI spine interpretation, spinal biomechanical engineering, accident engineering, spinal trauma pathology and diagnosing spinal issues beyond subluxation.

 

 

Why concern ourselves with the medical community? The answer, quite simply, is that medical utilization is over 95% nationally and chiropractic is well below 10% and has been eroding steadily over the last decade. IF chiropractic can “tap” into that 95% and have every medical doctor in the nation consider chiropractic as the first choice for mechanical spine issues (excluding fracture tumor or infection), then we will rapidly change the culture of our society and resolve our utilization challenges rapidly. This is called “primary spine care.”

 

Over the last 10 years, I have been teaching in both chiropractic and medical academia and have cooperatively created courses in chiropractic in the above genres. As a result, the doctors who have taken these courses are getting the exact same level of education as many of our medical counterparts. The results, we are now functioning at a “peer” level that has garnered respect NOT because we get people well without drugs. That respect is because we understand spine at an extremely high level, often more so than our medical counterparts and they find themselves consulting with us on many of their more challenging cases looking for solutions. In turn, they also have been referring us many of their mechanical spine cases to manage because many medical doctors realize they are poorly equipped with nothing but drugs that are often too often addictive or end up with surgery as the only other option.

 

The primary care medical providers, medical specialists and emergency rooms that we work with nationally have expressed their gratitude for helping these patients by redirecting their care to the properly credentialed chiropractor and preventing further opiate abuse and/or the side effects of non-narcotics as well. The way they thank us is in the form of a perpetual streams of referrals. A case in point was in Cedar Park, Texas, where one of our doctors, 8 years into practice, sat with an orthopedic surgeon and discussed MRI spine interpretation. After a 1-hour conversation, the surgeon said to the doctor, “I love chiropractic; I just couldn’t find a smart enough chiropractor to trust with my referrals until now. Your knowledge of spine and MRI is equal to mine and from here forward, you will get all of my non-surgical referrals!” That doctor left with 8 referrals instantly and 1 year later has had a steady stem of referrals   . I could share similar stories from Dayton, Ohio, Buffalo, New York, America Fork, Utah, Denver, Colorado, Fair Lawn, New Jersey and dozens of other locations across the United States. The formula is working; it is reproducible and is purely based upon clinical excellence beyond adjusting!

 

 

As a note, many get angry with our chiropractic colleges for not teaching us enough…Remember, our chiropractic colleges are charged with giving us the basics to get started and they do an outstanding job in that role. I applaud them and so should you in the form of donations to their research departments. In medicine, it is no different, they get a basic education and THEN go back to school to become specialized. What you do with YOUR career after graduation is on YOU.

 

 

We now have hospital emergency departments nationally reaching out to our doctors purely based upon their curricula vitae’s (CVs) because the doctors in our program are trained in what needs to be on their CVs with the resultant knowledge base behind those credentials. AND…for clarity (unlike my former beliefs), letters after your DC are not as important as the specific citations or credentials in your CV.

 

Utilization

 

Having been involved politically at the national and state levels for quite some time, I can say with a great degree of certainty that very little healthcare legislation (chiropractic falls under this category) in this country at either level gets passed without the blessing of the medical community. By attempting to add prescriptive rights to our scope, we will be threatening the utilization of medicine on a national scale and it will potentially close many of those doors that are currently opening at a rapid rate. The medical schools and research departments that have opened their doors to chiropractic (us) have done so primarily as a possible solution to the opiate epidemic in our country and we cannot be “Pollyannaish” and say we only want to prescribe non-narcotics. It has been clearly documented that this is a well-established “gateway” to addictive narcotics as when non-narcotics fail to offer relief, those patients need something else. Chiropractic care is that “something else” for mechanical spine pain, which is in the top 10 diagnoses for both emergency rooms and primary care medical providers who often have no solution other than drugs or surgery. Medicine’s only other historical care path with regards to mechanical spine diagnosis and management is physical therapy, which renders significantly inferior outcomes for spine vs. chiropractic based upon recent literature (a topic for another article) and one where far too many patients have ended up in pain management (narcotics) as the final solution.

 

 

Currently, our profession is at a cross-road on the prescriptive rights issue and if taken, could turn out to be a “very slippery slope” that could further erode our utilization and lead to increased iatrogenic issues in our society. I empathize with those doctors clinging to hope for a “quick fix” for their individual practices. However, as outlined above, there are viable solutions for every practice in the nation with none involving “get rich quick” paradigms. As I also consult many medical providers at various levels and I can report that their prescription pads are not making them wealthy, should they practice ethically. Their utilization and income increases as they get better at what they do and in chiropractic, we are no different.

 

 

Although our paradigm for increased utilization is working through increasing our clinical excellence, we are just starting to see this happen on a larger scale and the only way to have that upward spiral go faster, is if more chiropractors realize that the only way up is though academia and a strategic plan behind your new level of clinical excellence. So please hurry because your local medical community is waiting for you with that 95% to refer.

 


 

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Published in Neck Problems

Chiropractic Reduces Opioid Use by 55% in Low Back Pain

 

By Mark Studin

William J. Owens

 

A report on the scientific literature  

 

In the United States, of the adults who were prescribed opioids, 59% reported back pain.1 According to Statistia, the percentage of adults in the United States in 2015 with low back pain was 29.1% (https://www.statista.com/statistics/684597/adults-prone-to-selected-symptoms-us/)  and in 2017 that number was 49% for all back-pain sufferers reporting symptoms (https://www.statista.com/statistics/188852/adults-in-the-us-with-low-back-pain-since-1997/).

 

Peterson ET. AL. (2012) reported:

 

[The] Prevalence of low back pain is stated to be between 15% and 30%, the 1-year period prevalence between 15% and 45%, and a life-time prevalence of 50% to 80%” (pg. 525). 

 

While acute pain is a normal (author’s note: pain is never normal) short-lived unpleasant sensation triggered in the nervous system to alert you to possible injury with a reflexive desire to avoid additional injury, chronic pain is different. Chronic pain persists and fundamentally changes the patient’s interaction with their environment. In chronic pain it is well documented that aberrant signals keep firing in the nervous system for weeks, months, even years. (http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm)

Baliki Et. AL. (2008) stated

 

Pain is considered chronic when it lasts longer than 6 months after the healing of the original injury. Chronic pain patients suffer from more than pain, they experience depression, anxiety, sleep disturbances and decision-making abnormalities that also significantly diminish their quality of life (pg. 1398).

 

 

Chronic pain patients also have shown to have changes in brain function in sufferers with Alzheimer’ disease, depression, schizophrenia and attention deficit hyperactivity disorder giving further insight into disease states. In addition, chronic pain has a cause and effect on the morphology of the spinal cord and the brain resulting in a process termed “linear shrinkage”, which has been suggested to cause ancillary negative neurological sequella.  

 

Apkarian Et. Al. (2004) reported that “Ten percent of adults suffer from severe chronic pain. Back problems constitute 25% of all disabling occupational injuries and are the fifth most common reason for visits to the clinic; in 85% of such conditions, no definitive diagnosis can be made.” (pg. 10410) 

 

Whedon, Toler, Goel and Kazal (2018) reported the following:

 

One in 5 patients with noncancer pain or pain related diagnosis is prescribed opioids in office-based setting… primary care clinicians account for 50% of opioid prescriptions (Pg. 1). 1 day of opioid exposure carries a 6% chance of being on opioids 1year later, increasing to 13.5% by 8 days and 29.9% by 31 days. Among drug overdoses in the United States in 2014, 28,647, 61% involved an opioid. Opioids were involved in 75% of pharmaceutical deaths in 2010 and in 2015 over 22,000 deaths involved in prescription opioids were recorded-an increase of 19,000 deaths over the previous year (pg. 2).

 

 

Perhaps a portion of this phenomena is related to the training of medical primary care providers regarding musculoskeletal conditions. Studin and Owens reported (2016):

 

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

 

With continued evidence of lack of musculoskeletal medicine and a subsequent deficiency of training in spine care, particularly of biomechanical orientation, the question becomes which profession has the educational basis, training and clinical competence to manage these cases?  Let’s take a closer look at chiropractic education as a comparison. Fundamental to the training of Doctor of Chiropractic according to the American Chiropractic Association is 4,820 hours (compared to 3,398 for physical therapy and 4,670 to medicine) and receive a thorough knowledge of anatomy and physiology. As a result, all accredited Doctor of Chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. So important to practice are these courses that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education requires a curriculum which enables students to be “proficient in neuromusculoskeletal evaluation, treatment and management.” In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. As a result, students are afforded the opportunity to practice utilizing this basic science information for many hours prior to beginning clinical services in their internship.

 

http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=320

 

Whedon, Toler, Goel and Kazal (2018) continued:

 

Recently published clinical guidelines from the American College of Physicians recommended nonpharmacological treatment is the first – line approach to treating back pain, with consideration of opioids only is the last treatment option or if other options present substantial harm to the patient. Recent systematic review and meta-analysis found that for treatment of acute low back pain, spinal manipulation provides a clinical benefit equivalent to that of an NSAID’s, with no evidence of serious harm. Spinal manipulation is also shown to be an effective treatment option for chronic low back pain (pg. 2).

 

A retrospective claims study of 165,569 adults found that utilization of chiropractic services delivered by Doctor of Chiropractic was associated with reduced use of opioids. More recently, it was reported that the supply chiropractors as well as spending on spinal manipulative therapy is inversely correlated with opioid prescriptions in younger Medicare beneficiaries. This finding suggests that increased availability and utilization of services delivered by Doctor of Chiropractic could lead to reductions in opioid prescriptions. It has been reported that services delivered by Doctor of Chiropractic may improve health behaviors and reduced use of prescription drugs… Pain management services provided by Doctor of Chiropractic may allow patients use lower less frequent doses of opioids, leading to lower costs and reduce risk of adverse effects loops getting together (pg. 2).

 

Although chiropractic has been clinically reporting for over 100 years positive outcomes for a vast array of conditions inclusive of low back pain the American Medical Association (AMA) has been a significant opponent historically. Although the AMA’s position has been well chronicled through lawsuits such as Wilk v. American Medical Association, 895 F.2d 352 (7th Cir. 1990)

(https://openjurist.org/895/f2d/352/wilk-dc-dc-dc-dc-v-american-medical-association-a-wilk-dc-w-dc-b-dc-b-dc), in 2017 it appears they have reversed their position. In the August 2017 Journal of the American Medical Association’s “Clinical Guideline Synopsis for Treatment of Low Back Pain” under the heading MAJOR RECOMMENDATIONS, spinal manipulation is recommended as a first – line therapy, with a strong recommendation. As the AMA did not list Chiropractic specifically and based upon clinical guidelines of other highly regarded medical institutions such as the Cleveland Clinic and the Mayo Clinic, physical therapy is probably high on their list as first-line of referral for spinal manipulation (This is a  topic for another article and nomenclature utilized by chiropractic). When considering the treatment of mechanical spine issues comparatively between chiropractic and physical therapy the outcomes are overwhelmingly in chiropractic’s favor as reported by Studin and Owens (2017)

 

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 of chiropractic vs. physical therapy outcomes for spine, 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.

 

http://uschiropracticdirectory.com/index.php?option.com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320

 

Whedon, Toler, Goel and Kazal (2018) reported the concluded:

In 2013, average annual charges per person for filling opioid prescriptions were 74% lower among recipients compared with non-recipients (author’s note: recipients are referring to those patients receiving chiropractic care). For clinical services provided at office visits for low back pain, average annual charges per person in 2013 were 78% lower among recipients compared with non-recipients. The authors have similar between – Cohort differences in charges in 2014: annual charges per person were 70% lower with opioid prescriptions and 71% lower for clinical services among recipients compared with nonrecipients. The Adjusted likelihood find prescription for the opiate analgesic in 2014 was 55% lower among recipients compared with nonrecipients.

 

…the Adjusted likelihood of filling a prescription opioid analgesic was 55% lower for recipients of services provided by Doctor of Chiropractic compared with non-recipients (pg. 4)

 

The above reports evidenced based outcomes verifying chiropractic must be considered as the first-line of referrals, or Primary Spine Care Providers for mechanical spine diagnosis (no fracture, tumor or infection). The evidence also reveals that chiropractic outcomes exceed those of physical therapy and medicine for mechanical spine diagnosis. Unfortunately, it has taken 10,000’s of opioid related deaths to bring chiropractic to the forefront and start to eradicate the medical dogma against chiropractic and consider chiropractic as the 1st referral option for spine.

 

 References:

 

  1. Hudson, Teresa J., Edlund, Mark J., Steffick, Diane E., Tripathi, Shanti P., Sullivan, Mark D. (2008) Epidemiology of Regular Prescribed Opioid Use: Results from a National, Population-Based Survey Journal of Pain and Symptom Management, 2008, Vol.36(3), pp.280-288
  2. Percentage of adults in the U.S. with low back pain from 1997 to 2015 (2018) retrieved from:https://www.statista.com/statistics/188852/adults-in-the-us-with-low-back-pain-since-1997/
  3. Percentage of adults in the U.S. who were prone to select symptoms as of 2017 (2018), Retrieved from: https://www.statista.com/statistics/684597/adults-prone-to-selected-symptoms-us/
  4. Whedon J., Toler A., Goehl J., Kazal L. (2018), Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Use of Opioids, The Journal of Alternative and Complementary Medicine, 2018 Feb 22. doi: 10.1089/acm.2017.0131. [Epub ahead of print]
  5. Treatment of Low Back Pain, Wenger H., Cifu A., (2017) Treatment of Low Back Pain, Journal of the American Medical Association, 318 (8) pages 743-744
  6. Studin M., Owens. W., (2016), Chiropractic vs. Medicine: Who is Most Cost Effective and Renders Better Outcomes for Spine? Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=320
  7. Whedon J., Toler A., Goehl J., Kazal L. (2018), Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Use of Opioids, The Journal of Alternative and Complementary Medicine, 2018 Feb 22. doi: 10.1089/acm.2017.0131. [Epub ahead of print]
  8. Treatment of Low Back Pain, Wenger H., Cifu A., (2017) Treatment of Low Back Pain, Journal of the American Medical Association, 318 (8) pages 743-744
  9. Studin M., Owens. W., (2016), Chiropractic vs. Medicine: Who is Most Cost Effective and Renders Better Outcomes for Spine? Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=320
  10. Wilk vs. American Medical Association, Retrieved from: https://openjurist.org/895/f2d/352/wilk-dc-dc-dc-dc-v-american-medical-association-a-wilk-dc-w-dc-b-dc-b-dc
  11. Studin M., Owens. W., (2017), The Mechanism of the Chiropractic Spinal Adjustment /Manipulation: Chiropractic vs. Physical Therapy for Spine, Part 5 of a 5 Part series (2017) Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=32

 

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Published in Neck Problems

Chiropractic

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 based upon the dramatic increased utilization of chiropractic services nationwide from private practice to hospitals.   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 with not losing sight that this is happening, with you or without you, and if you are not out in front you will potentially be forever behind. 

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.

CHIROPRACTIC FIRST

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. 

HOSPITAL ILLUSIONS

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 SOLUTION

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.

References:

  1. Adams, J., Peng, W., Cramer, H., Sundberg, T., Moore, C., Amorin-Woods, L., & Lauche, R. (2017). The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey. Spine42(23), 1810-1816.
  2. Studin M., Owens W. (2016) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine, Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320
  3. Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation27(3), 382-392.
 

Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport College of Chiropractic, an Adjunct Professor at Cleveland University-Kansas City College of Chiropractic, an Adjunct Professor of Clinical Sciences at Texas Chiropractic College and a Graduate Medical Clinical Presenter for the State of New York at Buffalo, Jacobs School of Medicine 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 This email address is being protected from spambots. You need JavaScript enabled to view it.">This email address is being protected from spambots. You need JavaScript enabled to view it. or at 631-786-4253. 

 

Dr. Bill Owens is presently in private practice in Buffalo 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 Jacobs School of Medicine, an Adjunct Professor at 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 This email address is being protected from spambots. You need JavaScript enabled to view it. or www.mdreferralprogram.com or 716-228-3847  

 

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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.

 

References:

  1. Aetna Chiropractic Services (2017) Retrieved from: http://www.aetna.com/cpb/medical/data/100_199/0107.html
  2. https://www.medicare.gov/coverage/chiropractic-services.html
  3. Best Practice. (n.d.). In Wikipedia. Retrieved January 3, 2012, from http://en.wikipedia.org/wiki/Best_practice
  4. Evidence-Based Practice. (n.d.). In Wikipedia. Retrieved January 3, 2012, from http://en.wikipedia.org/wiki/Evidence-based_practice
  5. 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.
  6. Haavik, H., Niazi, I. K., Holt, K., & Murphy, B. (2017). Effects of 12 Weeks of Chiropractic Care on Central Integration of Dual Somatosensory Input in Chronic Pain Patients: A Preliminary Study. Journal of manipulative and physiological therapeutics40(3), 127-138.

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Published in Neck Problems

The Mechanism of the Chiropractic

Spinal Adjustment/Manipulation:

Subluxation Degeneration

 

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. 

 

REFERENCE: 

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. Spine36(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

 

 

 

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Published in Neck Problems

The Mechanism of the Chiropractic

Spinal Adjustment/Manipulation:

Bio-Neuro-Mechanical Effect

Part 3 of a 5 Part Series

By: Mark Studin

William J. Owens

 

 

A report on the scientific literature

Citation: Studin M., Owens W., (2017) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Bio-Neuro-Mechanical Component Part 3 of 5, American Chiropractor 39 (7), pgs. 30,32,34, 36, 38, 40-41

 

In part 1 of this series, we discussed the osseous mechanisms of the chiropractic spinal adjustment (CSA) and in part 2 we discussed the mechanical and neurological functions of connective tissue. It is in this connective tissue as well as in other neurological components located in the osseous structures of the spine that the primary effector structures of a CSA are to be found. To fully understand the bio-neuro-mechanical mechanism of the CSA, we must explore the mechanical aspect of the chiropractic adjustment, what effect it has on the neurological effector organs, how the spine and brain are inter-related and finally, how the muscles and ligaments (intervertebral discs) working in tandem effectuate homeostasis.

 

HISTORICAL REPORTING

 

                Kent (1996) reported:

Dishman and Lantz developed and popularized the five component model of the “vertebral subluxation complex” attributed to Faye. However, the model was presented in a text by Flesia dated 1982, while the Faye notes bear a 1983 date.The original model has five components:

 

1. Spinal kinesiopathology

2. Neuropathology

3. Myopathology

4. Histopathology

5. Biochemical changes.

 

 

The “vertebral subluxation complex” model includes tissue specific manifestations described by Herfert which include:

 

 

1. Osseous component

2. Connective tissue involvement, including disc, other ligaments, fascia, and muscles

3.The neurological component, including nerve roots and spinal cord

4. Altered biomechanics

5. Advancing complications in the innervated tissues and/or the patient’s symptoms. This is sometimes termed the “end tissue phenomenon” of the vertebral subluxation complex.

 

Lantz has since revised and expanded the “vertebral sub- luxation complex” model to include nine components:

 

1. Kinesiology

2. Neurology

3. Myology

4. Connective tissue physiology

5. Angiology

6. Inflammatory response

7. Anatomy

8. Physiology

9. Biochemistry.

 

Lantz summarized his objectives in expanding the model: “The VSC allows for every aspect of chiropractic clinical management to be integrated into a single conceptual model, a sort of ‘unified field theory’ of chiropractic… (p.1)

 

However, like many theories, these concepts have proven close to accurate and this report of the literature, although not designed to prove or disprove the Vertebral Subluxation Complex, validated many of the previous “beliefs” based upon contemporary findings in the literature and personal clinical experience, which along with patient expectations, are the three key components to evidence-based medicine.

 

CONTEMPORARY FINDINGS      

 

In Part 1, we discussed specific biomechanical references in modern literature.

Evans (2002) reported:

 

…on flexion of the lumbar spine, the inferior articular process of a zygapophyseal joint moves upward, taking a meniscoid with it. On attempted extension, the inferior articular process returns toward its neutral position, but instead of re-entering the joint cavity, the meniscoid impacts against the edge of the articular cartilage and buckles, forming a space-occupying "lesion" under the capsule: a meniscoid entrapment…A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophyseal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent impaction of the meniscoid. (p. 252-253)

 

This verifies that with a vertebrate out of position, there is a negative neurological sequella that causes a “cascade effect” bio-neuro-mechanically. Historically, this has been objectively identified and in chiropractic practices called a vertebral subluxation. This nomenclature has been accepted federally by the U.S. Department of Health and Human Services and by the Centers for Medicare and Medicaid Services as an identifiable lesion, for which the chiropractic profession has specific training in its diagnosis and management.   

 

To further clarify the modern literature, Panjabi (2006) stated:

 

The spinal column has two functions: structural and transducer. The structural function provides stiffness to the spine. The transducer function provides the information needed to precisely characterize the spinal posture, vertebral motions, spinal loads etc. to the neuromuscular control unit via innumerable mechanoreceptors present in the spinal column ligaments, facet capsules and the disc annulus. These mechanical transducers provide information to theneuromuscular control unit which helps to generate muscular spinal stability via the spinal muscle system and neuromuscular control unit. (p. 669)

 

Panjabi (2006) reported:

 

1. Single trauma or cumulative microtrauma causes subfailure injury of the spinal ligaments and injury to the mechanoreceptors [and nociceptors] embedded in the ligaments.

2. When the injured spine performs a task or it is challenged by an external load, the transducer signals generated by the mechanoreceptors [and nociceptors] are corrupted.

3. Neuromuscular control unit has difficulty in interpreting the corrupted transducer signals because there is spatial and temporal mismatch between the normally expected and the corrupted signals received.

4. The muscle response pattern generated by the neuromuscular control unit is corrupted, affecting the spatial and temporal coordination and activation of each spinal muscle.

5. The corrupted muscle response pattern leads to corrupted feedback to the control unit via tendon organs of muscles and injured mechanoreceptors [and nociceptors], further corrupting the muscle response pattern.

6. The corrupted muscle response pattern produces high stresses and strains in spinal components leading to further subfailure injury of the spinal ligaments, mechanoreceptors and muscles, and overload of facet joints.

7. The abnormal stresses and strains produce inflammation of spinal tissues, which have abundant supply of nociceptive sensors and neural structures. (p. 669-670)

 

This indicates that once there is a bio-neuro-mechanical lesion (aka vertebral subluxation), there is a “negative cascade” both structurally (biomechanically) and neurologically in the body’s attempt to create homeostasis. However, should the cause of the lesion not be “fixed,” the entire system will perpetually fail. Over time, due to the Piezoelectric effect and Wolff’s Law of remodeling, the skeletal structure is now permanently altered. Therefore, treatment goals then switch from curative to simply management and is a long-term process.  

 

In part 2, we discussed subfailure,and will examine it again as explained by Solomnow (2009).

 

Solomonow (2009): 

 

Inflammatory response in ligaments is initiated whenever the tissue is subjected to stresses which exceed its routine limits at a given time. For example, a sub-injury/failure load, well within the physiological limits of a ligament when applied to the ligament by an individual who does not do that type of physical activity routinely. (p. 143)

 

Jaumard, Welch and Winkelstein (2011) reported: 

 

In the capsular ligament under stretch, the collagen fiber structure and the nerve endings embedded in that network and cells (fibroblasts, macrophages) are all distorted and activated. Accordingly, capsular deformations of certain magnitudes can trigger a wide range of neuronal and inflammatory responses…Although most of the proprioceptive and nociceptive afferents have a low-strain threshold (~10%) for activation, a few receptors have a high-strain threshold (42%) for signal generation via neural discharge. In addition, capsular strains greater than 47% activate nociceptors with pain signals transmitted directly to the central nervous system. Among both the low- and high-strain threshold neural receptors in the capsular ligament a few sustain their firing even after the stretching of the capsular ligament is released. This persistent afterdischarge evident for strains above 45% constitutes a peripheral sensitization that may lead to central sensitization with long-term effects in some cases. (p. 12)

 

The cascade effect works in 2 directions, one to create a bio-neuro-mechanically failed spinal system and one to correct a bio-neuro-mechanically failed system.

 

Pickar (2002) reported:

 

The mechanical force introduced into the during a spinal manipulation (CSA) may directly alter segmental biomechanics by releasing trapped meniscoids, releasing adhesions or by reducing distortion of the annulus fibrosis. (p. 359)

 

This fact verifies that there is an osseous-neurological component that exists with the nociceptors at the facet level.

 

Pickar (2002) also stated:

 

In addition, the mechanical thrust could either stimulate or silence nonnociceptive, mechanosensitive receptive nerve endings in paraspinal tissue, including skin, muscle, tendons, ligaments, facet joints and intervertebral disc.  (p. 359)

 

CENTRAL NERVOUS SYSTEM MODULATION

 

When discussing central nervous system activity as a direct sequella to a CSA, we must divide our reporting into 2 components, reflexively at the area being adjusted and through higher cortical responses. When discussing local reflexive activity, we must also determine if it is critical to adjust the specific segment in question or if the adjustment will elicit neurological and end organ (muscle) responses to help create a compensatory action for the offending lesion.

 

Reed and Pickar (2015) reported in an animal study:

 

First, during clinically relevant spinal manipulative thrust durations (<=150 ms), unilateral intervertebral joint fixation significantly decreases paraspinal muscle spindle response compared with non-fixated conditions. Second and perhaps more importantly, this study shows that while L6 muscle spindle response decreases with L4 HVLA-SM, 60%-80% of an L6 HVLA-SM muscle spindle response is still elicited from an HVLA-SM delivered 2 segments away in both the absence and presence of intervertebral joint fixation. These findings may have clinical implications concerning specific (targeted) versus nonspecific (nontargeted) HVLA-SM. (p. E755-E756)

 

Reed and Pickar (2015) also reported:

 

The finding that nontarget HVLA-SM delivered 2 segments away elicited significantly less but yet a substantial percentage (60%–80%) of the neural response elicited during target HVLA-SM may have important clinical implications with regard to HVLA-SM thrust accuracy/specificity requirements. It may explain how target vs non-target site manual therapy interventions can show similar clinical efficacy. In a recent study using the same model as the current study, the increase in L6 muscle spindle response caused by an HVLA-SM is not different between 3 anatomical thrust contact sites (spinous process, lamina, and mammillary body) on the target L6 vertebra but is significantly less when the contact site is located 1 segment caudal at L7…The current study confirms that a nontarget HVLA-SM compared with a target HVLA-SM decreases spindle response but adds the caveat that a substantial percentage (60%–80%) of afferent response can be elicited from an HVLA-SM delivered 2 segments away irrespective of the absence or presence of intervertebral fixation. (p. E756)

 

Coronado, Gay, Bialosky, Carnaby, Bishop and George (2012) reported that:

 

 

Reductions in pain sensitivity, or hypoalgesia, following SMT [spinal manipulative therapy or the chiropractic adjustment] may be indicative of a mechanism related to the modulation of afferent input or central nervous system processing of pain…The authors theorized the observed effect related to modulation of pain primarily at the level of the spinal cord since 1.) these changes were seen within lumbar innervated areas and not cervical innervated areas and 2.) the findings were specific to a measure of pain sensitivity (temporal summation of pain), and not other measures of pain sensitivity, suggesting an effect related to attenuation of dorsal horn excitability and not a generalized change in pain sensitivity. (p. 752)

 

These findings indicate that a chiropractic spinal adjustment affects the central nervous system specifically at the interneuron level in the dorsal horn.  This is part of the cascade effect of the CSA where we now have objectively identified the mechanism of the central nervous system stimulation and its effects. 

 

Gay, Robinson, George, Perlstein and Bishop (2014)

 

 

…pain-free volunteers processed thermal stimuli applied to the hand before and after thoracic spinal manipulation (a form of MT [Manual Therapy]).  What they found was, after thoracic manipulation, several brain regions demonstrated a reduction in peak BOLD [blood-oxygen-level–dependent] activity. Those regions included the cingulate, insular, motor, amygdala and somatosensory cortices, and the PAG [periaqueductal gray regions].

 

 

The purpose of this study was to investigate the changes in FC [functional changes] between brain regions that process and modulate the pain experience after MT [manual therapy]. The primary outcome was to measure the immediate change in FC across brain regions involved in processing and modulating the pain experience and identify if there were reductions in experimentally induced myalgia and changes in local and remote pressure pain sensitivity. (p. 615)

 

Therefore, a thoracic CSA adjustment produced direct and measurable effects on the central nervous system across multiple regions, specifically the cingular cortex, insular cortex, motor cortex, amygdala cortex, somatosensory cortex and periaqueductal gray matter.  This could only occur if “higher centers,” also known as the central nervous system, were affected.

 

Gay, Robinson, George, Perlstein and Bishop (2014) went on to report:

 

Within the brain, the pain experience is subserved by an extended network of brain regions including the thalamus (THA), primary and secondary somatosensory, cingulate, and insular cortices. Collectively, these regions are referred to as thepain processing network(PPN) and encode the sensory discriminate and cognitive and emotional components of the pain experience. Perception of pain is dependent not merely on the neural activity within the PPN [pain processing network] but also on the flexible interactions of this network with other functional systems, including the descending pain modulatory system. (p. 617)

Daligadu, Haavik, Yielder, Baarbe, and Murphy (2013) reported that:

 

 

Numerous studies indicate that significant cortical plastic changes are present in various musculoskeletal pain syndromes. In particular, altered feed-forward postural adjustments have been demonstrated in a variety of musculoskeletal conditions including anterior knee pain, low back pain and idiopathic neck pain. Furthermore, alterations in trunk muscle recruitment patterns have been observed in patients with mechanical low back pain. (p. 527)

 

This concludes that there are observable changes in the function of the central nervous system seen in patients with musculoskeletal conditions and chronic pain.  Chiropractors have observed this clinically and it demonstrates the necessity for chiropractic care for both short and long-term management of biomechanical spinal conditions.

 

 

CONCLUSION

 

Although there is significantly more research verifying what occurs with a CSA, the above outlines the basics of how the adjustment works both biomechanically and neurologically from the connective tissue and peripheral nerves to the central nervous system both at the cord level and higher cortical regions. The final question is one of public safety.

 

Based on their study on 6,669,603 subjects after the unqualified subjects had been removed, Whedon, Mackenzie, Phillips, and Lurie (2015) concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified” (p. 265).

 

Part 4 will be the evidence of subluxation degeneration and the literature verifying the mechanisms. Part 5, the final part of our series, will be an in-depth contemporary comparative analysis of the chiropractic spinal adjustment vs. physical therapy joint mobilization.

 

References:

 

1. Kent, C. (1996). Models of vertebral subluxation: A review. Journal of Vertebral Subluxation Research1(1), 1-7.

2. 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.

3. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2017). Medicare coverage for chiropractic services – Medical record documentation requirements for initial and subsequent visits. MLN Matters, Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1601.pdf

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

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

6. Jaumard, N. V., Welch, W. C., & Winkelstein, B. A. (2011). Spinal facet joint biomechanics and mechanotransduction in normal, injury and degenerative conditions.Journal of Biomechanical Engineering,133(7), 071010.

7. Pickar, J. G. (2002). Neurophysiological effects of spinal manipulation.Spine,2(5), 357-371.

8. Reed, W. R., & Pickar, J. G. (2015). Paraspinal muscle spindle response to intervertebral fixation and segmental thrust level during spinal manipulation in an animal model.Spine,40(13), E752-E759.

9. 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.

10. Gay, C. W., Robinson, M. E., George, S. Z., Perlstein, W. M., & Bishop, M. D. (2014). Immediate changes after manual therapy in resting-state functional connectivity as measured by functional magnetic resonance imaging in participants with induced low back pain.Journal of Manipulative and Physiological Therapeutics, 37(9), 614-627.

11. Daligadu, J., Haavik, H., Yielder, P. C., Baarbe, J., & Murphy, B. (2013). Alterations in coritcal and cerebellar motor processing in subclinical neck pain patients following spinal manipulation.Journal of Manipulative and Physiological Therapeutics, 36(8), 527-537.

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

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Published in Neck Problems

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

 

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

William J. Owens DC, DAAMLP

A report on the scientific literature

 

By any standard, back pain is one of the most prevalent disabilities plaguing our population. According to Block, 2014, over 100 million Americans experience chronic pain with common painful conditions including back pain, neck pain, headaches/migraines, and arthritis, in addition to other painful conditions such as diabetic peripheral neuropathy, etc... In a large study in 2010, 30.7% of over 27,000 U.S. respondents reported an experience of chronic, recurrent pain of at least a 6-month duration. Half of the respondents with chronic pain noted daily symptoms, with 32% characterizing their pain as severe (≥7 on a scale ranging from 0 to 10). Chronic pain has a broad impact on emotional well-being and health-related quality of life, sleep quality, and social/recreational function. (pg. 1)

 

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

 

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

 

Block, 2014 continued “In addition to the pervasive personal suffering associated with this disease, chronic pain (author’s note: where low back pain is one of the most significant contributors) has a substantial negative financial impact on the economy. Direct office visits, diagnostic testing, hospital care, and pharmacy costs are only a portion of the picture, with combined medical and pharmacy costs averaging $5,000 annually per individual. Chronic pain results in a significant economic burden on the healthcare system, with estimated costs ranging from $560 to $635 billion 2010 dollars, more than the annual cost of other priority health conditions including cardiovascular disease, cancer, and diabetes. Moreover, the estimated annual costs of the workplace impact of pain range from $299 to $335 billion from absenteeism and reduced productivity.” (pgs. 1-2) These statistics help us to understand that “management” of spine pain is a critical component of cost reduction since the costliest portion of healthcare services is when a patient enters the system.  Continued mismanagement of mechanical spine pain causes patients to move in and out of disability status. That reentry is what drives up cost, chiropractic is the 3rd largest health profession in the United States and the largest with the education to lead the diagnosis and management of mechanical spine pain.

 

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

 

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

 

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

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

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

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

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

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

According to Frank Zolli DC, former Dean at the University of Bridgeport, College of Chiropractic, “Fundamental to the training of doctors of chiropractic is 4,820 hours (compared to 3,398 for physical therapy and 4,670 to medicine) and students receive a thorough knowledge of anatomy and physiology. As a result, all accredited doctor of chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. It is so important to practice these courses that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education, requires a curriculum which enables students to be proficient in neuromusculoskeletal evaluation, treatment and management. In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. To qualify for licensure, graduates of chiropractic programs must pass a series of examinations administered by the National Board of Chiropractic Examiners (NBCE) in 4 separate parts including clinical evaluations. It is therefore mandatory for a chiropractor to know the structure and function of the human body,  the study of neuromuscular and biomechanics is weaved throughout the fabric of chiropractic education.” As a result, the doctor of chiropractic has an expertise in the diagnosis and management of biomechanical musculoskeletal disorders that the traditional health care system is lacking. Chiropractic offers significant insight where traditional health care has no answers.

 

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

 

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

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

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

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

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

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

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

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

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

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

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

 

References:

  1. Block, C. K. (2014). Examining neuropsychological sequelae of chronic pain and the effect of immediate-release oral opioid analgesics (Order No. 3591607). Available from ProQuest Dissertations & Theses Global. (1433965816). Retrieved from http://search.proquest.com/docview/1433965816?accountid=1416
  1. Humphreys, B. K., Sulkowski, A., McIntyre, K., Kasiban, M., & Patrick, A. N. (2007). An examination of musculoskeletal cognitive competency in chiropractic interns. Journal of Manipulative and Physiological Therapeutics, 30(1), 44-49.
  2. Deyo, R. A., & Mirza, S. K. (2016). Herniated Lumbar Intervertebral Disk. New England Journal of Medicine, 374(18), 1763-1772.
  3. Cifuentes, M., Willetts, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
  1. Schmale, G. A. (2005). More evidence of educational inadequacies in musculoskeletal medicine. Clinical Orthopaedics and Related Research, 437, 251-259.
  2. DeVocht, J. W., Pickar, J. G., & Wilder, D. G. (2005). Spinal manipulation alters electromyographic activity of paraspinal muscles: A descriptive study. Journal of Manipulative and Physiologic Therapeutics, 28(7), 465-471.
  3. Goldberg, H., Firtch, W., Tyburski, M., Pressman, A., Ackerson, L., Hamilton, L., Avins, A. L. (2015). Oral steroids for acute radiculopathy due to a herniated lumbar disk: A randomized clinical trial.Journal of the American Medical Association (JAMA), 313(19), 1915-1923.

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Published in Low Back Problems

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

 

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

William J. Owens DC, DAAMLP

A report on the scientific literature

 

INTRODUCTION

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

 

 

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

 

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

HERNIATED DISCS

 

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

 

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

 

SPINAL DEGENERATION

 

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

Viroslav (2016) reported:

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

 

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

 

CHIROPRACTIC CARE

Kressig et. Al (2016) reported:

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

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

 

CONCLUSION

 

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

 

Links to other articles:

 

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

 

Spinal Fusion vs. Chiropractic for Mechanical Spine Pain

 

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

 

Disc Herniations and Low Back Pain Post Chiropractic Care

 

References:

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

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Published in Neck Problems

Case Report:

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

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

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

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

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

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

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

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

Appearance: in pain

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

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

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

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

Imaging:

Figure 1: T2 Sagittal Cervical Spine MRI

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

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

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

References:

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

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

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

204–209.

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

           

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Published in Case Reports
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