November 2015

Vertigo, the Cervical Spine, and Spinal Manipulation

Vertigo is defined as “a condition in which somebody feels a sensation of whirling or tilting that causes a loss of balance.” To describe the sensation of vertigo, patients often use words such as dizziness, giddiness, unsteadiness, or lightheadedness. The neurological vertigo center is called thevestibular nucleus. The vestibular nucleus is located in the brainstem. It extends from the caudal portion of the pons through the caudal portion of the medulla.

The afferent information that enters the vestibular nucleus to initiate the sensation of vertigo arises primarily from four sources:
1)    Labyrinthine Inner Ear (1)
2)    Cerebellum (2)
3)    Temporomandibular Joint (TMJ) (3, 4, 5)
4)    Cervical spine afferents, especially from C1 – C3 (6)

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All health care providers should also be aware that vertigo could result as a consequence of vascular compromise of the posterior circulation of the brainstem (the vertebral and basilar arteries, and their branches) (7).

Pathology

The first study to link problems in the cervical spine to vertigo was published in the journal Lancetin 1955 (8). Today (October 12, 2015), a search of the National Library of Medicine with PubMed, using the words “cervical vertigo” locates 2,211 citations.

It was established in 1977 that the injection of saline irritants into the deep tissues of the upper cervical spine would create the sensation of vertigo in normal human volunteers (6).

Clinicians have documented a relationship between cervical spine trauma and the symptoms of vertigo (9). In her chapter titled “Posttraumatic Vertigo”, Dr. Linda Luxon (10) notes that this vertigo can be explained by “disruption of cervical proprioceptive input.” She notes that the major cervical spine afferent input to the vestibular nuclei “arises from the paravertebral joints and capsules, with relatively minor input from paravertebral muscles.” Dysfunctional upper cervical spinal joints and their capsules can alter the proprioceptive afferent input to the vestibular nucleus resulting in the symptoms of vertigo. Treatment would be to improve the mechanical function of these joints.

In 2001, an article appeared in the Journal of Neurology, Neurosurgery, and Psychology titled (11):

Cervical Vertigo

This article reviews the theoretical basis for cervical vertigo. These authors note:

“Proprioceptive input from the neck participates in the coordination of eye, head, and body posture as well as spatial orientation,” and this is the basis of the of cervical vertigo syndrome. Cervical vertigo is when the suspected mechanism is proprioceptive.

“Degenerative or traumatic changes of the cervical spine can induce altered sensory input causing vertigo.

“Dizziness and unsteadiness suspected to be of cervical origin could be due either to loss or inadequate stimulation of neck receptors in cervical pain syndromes.”

“Section or anesthesia of cervical roots or muscles causes an asymmetry in somatosensory input, unilateral irritation or deficit of neck afferents could create a cervical tone imbalance, thus disturbing integration of vestibular and neck inputs.”

“As somatosensory cervical input converges with vestibular input to mediate multisensory control of orientation, gaze in space, and posture, the clinical syndrome of cervical vertigo could theoretically include perceptual symptoms of disorientation, postural imbalance, and ocular motor signs.”

“A convincing mechanism of cervical vertigo would have to be based on altered upper cervical somatosensory input associated with neck tenderness and limitation of movement.”

“In summary, vertigo can be accompanied by cervical pain, associated with head injury, whiplash injury, or cervical spine disease.”

“If cervical vertigo exists, appropriate management is the same as that for the cervical pain syndrome.”

In 2002, an article appeared in the Journal of Whiplash & Related Disorders, titled (12):

A Cross-Sectional Study of the Association Between Pain and Disability in Neck Pain Patients with Dizziness of Suspected Cervical Origin

In this article, these authors state:

“The term ‘cervical vertigo’ was introduced to describe dizziness and unsteadiness associated with cervical spine pain syndromes.”

“Increasing evidence suggests that dizziness and vertigo may arise from dysfunctional cervical spine structures.”

“Whiplash patients are likely to suffer from dizziness, vertigo and associated neck pain and disability resulting from traumatized cervical spine structures.”

“Cervicogenic dizziness, especially in whiplash patients, may result from disturbed sensory information due to dysfunctional joint and neck mechanoreceptors.”

“Dizziness and vertigo are common complaints of neck pain patients with 80 to 90% of whiplash sufferers reporting these symptoms.”

“Dysfunction or trauma to connective tissues such as cervical muscles and ligaments rich in proprioceptive receptors (mechanoreceptors) may lead to sensory impairment.”

“Emerging evidence suggests that dizziness and vertigo may commonly arise from dysfunctional cervical spine structures such as joint and neck mechanoreceptors, particularly from trauma.”

In this study, the authors evaluated 180 consecutive neck pain patients over the age of 18 who were recruited from an outpatient clinic. Of these, 71 patients (40.57%) reported neck pain resulting from trauma and 60 patients (33.5%) were suffering from dizziness. Pain intensity was measured using the Numerical Rating Scale while disability was measured with the Neck Disability Index (NDI).

The authors note that dizzy patients also describe their symptoms with “lightheadedness, seasickness, instability, rotatory vertigo, etc.” Regarding dizziness, females were significantly more likely to report dizziness compared to males while no significant difference was found for dizziness versus age. Patients experiencing dizziness also reported greater intensity of neck pain compared to those without dizziness. Increasing duration of neck pain was significantly associated with increasing reports of dizziness.  Subjects who reported dizziness were significantly more likely to have been involved in an injury. Neck pain patients with dizziness reported significantly more disability (total NDI score) compared to neck pain patients without dizziness.

The authors concluded that neck pain patients with dizziness were significantly more likely to have suffered a traumatic injury, experienced greater pain intensity and disability levels, and experienced for a longer period of time, compared to neck pain patients without dizziness.

This “study results reinforce the concept of neck pain and disability leading to cervicogenic dizziness/vertigo due to dysfunction of the somatosensory system of the neck.” The basic model presented in this article is that trauma causes “dysfunctional cervical spine structures” resulting in altered “joint and neck mechanoreceptor” function, causing both pain and dizziness.

In 2003, a group from the University of Queensland, Brisbane, Australia, published a study in the Journal of Rehabilitative Medicine titled (13):

Dizziness and Unsteadiness Following Whiplash Injury: Characteristic Features and Relationship with Cervical Joint position Error

These authors note that dizziness and/or unsteadiness are common symptoms of chronic whiplash-associated disorders, and that if the cervical spine injury is the suspected origin of these complaints that it can be assessed with “joint position error.” Joint position error is the accuracy to return to the natural head posture following extension and rotation. Consequently, these authors measured joint position error in 102 subjects with persistent whiplash-associated disorder and 44 control subjects. These authors found:

“The results indicated that subjects with whiplash-associated disorders had significantly greater joint position errors than control subjects.”

“Within the whiplash group, those with dizziness had greater joint position errors than those without dizziness following rotation.”

“Cervical mechanoreceptor dysfunction is a likely cause of dizziness in whiplash-associated disorder.”

“When there is no traumatic brain injury, abnormal cervical afferent input from damaged or functionally impaired neck joint and muscle receptors is considered the likely cause.”

Dizziness of cervical origin “originates from abnormal afferent activity from the extensive neck muscle and joint proprioceptors, which converges in the central nervous system with vestibular and visual signals, confusing the postural control system.”

These authors “contend that our results support a likely cervical cause of dizziness and or unsteadiness rather than other causes of dizziness in these subjects with persistent whiplash associated disorders and the joint position error findings highlight the role of cervical mechanoreceptor dysfunction.”

“The study highlights the role of cervical mechanoreceptor dysfunction and the importance of assessment and management of this impairment in persistent whiplash     associated disorders, particularly in those complaining of dizziness and unsteadiness.”

These authors also noted that the most common words used were “lightheaded”, “unsteady” and “off-balance”. Other descriptions were clumsy, giddy, imbalance, motion sickness, falling/veering to one side, imbalance in the dark, vision jiggle (disturbance), faint feeling, might fall. Unsteadiness was the most common description, being stated by 90% of the subjects.

In 2012, neurological investigators from Buenos Aires, Argentina, and from the Chicago Dizziness and Hearing Center confirmed the existence and pathophysiology of post-traumatic cervical vertigo, and cervicogenic proprioceptive vertigo. Their article appeared in the journal Neurologia, and is titled (14):

Cervical Vertigo:
Myths, Facts, and Scientific Evidence

These authors note that aspects of “cervical vertigo” have “survived the test of time and may be found in the literature today.” They recommend that the provider rule out “rotational vertebral artery syndrome,” and state:

“Once potentially severe causes of the symptoms have been ruled out, the most appropriate strategy seems to be use of manipulative and vestibular physical therapy.”

In 2014, researchers from the University of Montreal assessed 25 subjects with cervicogenic dizziness and 25 subjects with labyrinthine dizziness to determine which clinical tests were best able to distinguish between the two groups. Their study was published in the journal Otology & Neurotology, and titled (15):

Evaluation of Para-clinical Tests in the Diagnosis of Cervicogenic Dizziness

          These authors concluded subjects with cervicogenic dizziness were more likely to:

  • Have a sensation of drunkenness and lightheadedness.
  • Have pain induced during the physical examination of the upper cervical vertebrae.
  • Have an elevated joint position error during the cervical relocation test.

Treatment

There is strong evidence spanning decades, arising from multiple countries, and published in a variety of well-respected peer reviewed medical journals indicating that the reason for cervical vertigo is a mechanical lesion/dysfunction of the cervical spine. This lesion may be articular, capsular, ligamentous, muscular, or a combination there of. The strongest evidence is that the lesion/dysfunction is in the upper cervical spine, from C1-C3. Consequently, a variety of mechanical approaches to treatment of cervical vertigo have been assessed and the results are usually quite favorable.

These mechanical therapies include physiotherapy, varieties of passive joint mobilizations, manipulation, and muscle work. This same type of mechanical therapeutic approach is also effective in treating spinal pain conditions. The explanation for this is that the improvement in mechanical function creates a neurological sequence of events that closes the “Pain Gate.” (16)

The studies below review some of these mechanical approaches and their effectiveness is duly noted:

In 1996, providers from the Department of Oto-Rhino-Laryngology, University Hospital, Lund, Sweden, completed a prospective, randomized, controlled trial of 17 individuals with dizziness of suspected cervical origin and 17 healthy control subjects. The study was published in Archives of Physical Medicine and Rehabilitation and titled Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin (17).

The subjects in this study suffered from both dizziness and neck pain. The treatment targeted their neck pain, yet measurement outcomes assessed their pain and dizziness, specifically using posturography body sway, the Visual Analog Scale ratings, and intensity/frequency of dizziness score. The authors concluded:

“Physiotherapy significantly reduced neck pain and intensity and the frequency of dizziness, and significantly improved postural performance.”

“Patients with dizziness of suspected cervical origin are characterized by impaired postural performance. Physiotherapy reduces neck pain and dizziness and improves postural performance. Neck disorders should be considered when assessing patients complaining of dizziness.”

In 1998, an article appeared in the European Spine Journal titled Vertigo in Patients with Cervical Spine Dysfunction(18). The authors defined “dysfunction” as a reversible, functional restriction of motion of an individual spinal segment or as articular malfunction presenting with hypomobility. The authors also state that upper cervical spine dysfunctions can cause vertigo, and they cite 13 references to support the premise. They explain vertigo may occur as a consequence of disturbances of proprioception from the neck. They cite an additional 4 references to claim that only dysfunctions of the upper cervical spine can cause vertigo, noting that anatomical studies identify links between upper cervical spine receptors and the vestibular nuclei.

In this study the authors used 50 patients who were referred to rule out a cervical spine problem as a cause of vertigo. All patients displayed symptoms of dizziness. Labyrinthine ear examination and neurology examination were equivocal. A reproducible manual palpation examining technique was used to diagnose segmental cervical spine dysfunction.

The cervical spine dysfunctions were treated with mobilization and manipulative techniques over a period of 3 months. Seventy-seven percent of the patients reported meaningful improvement in their vertigo, including 16% whose symptoms completely resolved. The authors state the following conclusions:

“Physical therapy is more likely to succeed in reducing vertigo symptoms if these patients present with an upper cervical spine dysfunction that is successfully resolved by manual medicine prior to physical therapy.”

“In the presence of vertigo, our presented data suggests consideration of cervical spine dysfunctions, requiring a manual medicine examination of upper motion segments.”

“A non-resolved dysfunction of the upper cervical spine was a common cause of long-lasting dizziness in our population.”

In 2005, researchers from the University of Newcastle, Australia, published an article in Manual Therapy titled Manual therapy treatment of cervicogenic dizziness: A systematic review (19). The authors note, “in some people the cause of their dizziness is pathology or dysfunction of upper cervical vertebral segments that can be treated with manual therapy.” They proceeded to review 7 electronic databases to locate both randomized controlled trials and non-randomized controlled clinical trials, finding 9 studies that met their inclusion criteria. They concluded:

“A consistent finding was that all studies had a positive result with significant improvement in symptoms and signs of dizziness after manual therapy treatment.”

“Manual therapy treatment of cervicogenic dizziness was obtained indicating it should be considered in the management of patients with this disorder.”

There is a manual therapy mobilization technique called “sustained natural apophyseal glides” (SNAGs) that is often used to treat cervical vertigo patients. In 2008, the journal Manual Therapypublished a study titled Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness (20). This aim of the study was to determine the efficacy of sustained natural apophyseal glides (SNAGs) in the treatment of cervical vertigo.

The authors performed a double-blind randomized controlled clinical trial involving 34 participants with cervicogenic dizziness who were randomized to receive four to six treatments of SNAGs (n=17) or a placebo (n=17). All were followed at 6- and 12-weeks. The authors concluded:

“The SNAG treatment had an immediate clinically and statistically significant sustained effect in reducing dizziness, cervical pain and disability caused by cervical dysfunction.”

This same group continued to assess the sustained natural apophyseal glides (SNAGs) protocol for patients with cervical vertigo and have reported similar conclusions (#21 in 2014 and #22 in 2015).

In 2013, chiropractors from the University of Zürich and Orthopaedic University Hospital Balgrist, Zürich, Switzerland, published a study in the journal Chiropractic Manual Therapy, titledComparison of outcomes in neck pain patients with and without dizziness undergoing chiropractic treatment (23). The purpose of this study was to compare clinical outcomes of neck pain patients with and without dizziness undergoing chiropractic treatment. It was a prospective cohort study comparing neck pain patients with dizziness (n = 177) to neck pain patients without dizziness (n = 228).

Eighty percent of patients with dizziness and 78% of patients without dizziness were improved at 6 months. The authors concluded:

“Neck pain patients with dizziness reported significantly higher pain and disability scores at baseline compared to patients without dizziness. A high proportion of patients in both groups reported clinically relevant improvement.”

In 2015, physicians Yongchao Li, MD, and Baogan Peng, MD, PhD, from Liaoning Medical University, Beijing, China, published a study in the journal Pain Physician titled Pathogenesis, Diagnosis, and Treatment of Cervical Vertigo (24). In this article they detail a syndrome they call “Proprioceptive Cervical Vertigo,” in which abnormal afferent input to the vestibular nucleus from damaged joint receptors in the upper cervical region alter vestibular function resulting in cervical vertigo. They note that this syndrome often occurs from whiplash trauma, noting:

“In whiplash-associated disorder, pain, limitation of movement, and strains of joint capsules, paravertebral ligaments, and cervical musculature could modify the proprioceptive cervical balance in a sustained way and produce mild but chronic vertigo.”

There are “close connections between the cervical dorsal roots and the vestibular nuclei with the neck receptors (such as proprioceptors and joint receptors), which played a role in eye-hand  coordination, perception of balance, and postural adjustments. With such close connections between the cervical receptors and balance function, it is understandable that traumatic, degenerative, inflammatory, or mechanical derangements of the cervical spine can affect the mechanoreceptor system and give rise to vertigo.”
“Evidence leads to the current theory that cervical vertigo results from abnormal input into the vestibular nuclei from the proprioceptors of the upper cervical region.”

 “Manual therapy is recommended for treatment of proprioceptive cervical vertigo.”
 
“Manual therapy is effective for cervical vertigo.”

“Cervical spondylosis and cervical muscle spasms can also cause vertigo.”

These authors note that if a patient has a chief complaint of vertigo, but no neck pain, a diagnosis of cervical vertigo is excluded. Cervical vertigo patients usually have pain in the back of the neck and occipital region, sometimes accompanied by neck stiffness. Cervical vertigo is often increased with neck movements or neck pain and decreased with interventions that relieve neck pain. The vertigo symptoms can be reproduced with head/neck movement. Pain is often elicited with palpation of the suboccipital region, cervical transverse processes of C1 and C2, cervical spinous processes of C2 and C3, levator scapulae, upper trapezius muscle, splenius, rectus, and semi-spinalis muscles.

The neck torsion nystagmus test may identify cervical vertigo: the head of the patient is stabilized while the body is rotated underneath.

Since cervical vertigo originates from proprioceptive dysfunction of the upper cervical spine, treatment should be to the upper cervical spine. Chiropractic and other manual spinal therapies have been shown to be effective in treating cervical vertigo, typically with around 80% acceptable clinical outcomes.

Another effective technique for treating cervical vertigo is a type of spinal mobilization known as “sustained natural apophyseal glides” (SNAGs), often resulting in significant immediate and sustained effect in reducing dizziness and neck pain. It restores “normal movement of the zygapophyseal joints, reducing pain and muscle hypertonicity, and thereby restoring normal proprioceptive and biomechanical functioning of the cervical spine.”

Summary

Hundreds of studies over the past 60 years have established that dysfunctions of the joints and/or muscles of the cervical spine, especially the upper cervical spine, can cause the sensation of vertigo. Neuroanatomical evidence shows that upper cervical spine mechanoreceptors/proprioceptors fire to the vestibular nucleus as a portion of our human upright balance mechanisms. These studies also link the functional neurophysiology of upper cervical spine mechanoreceptors/proprioceptors to the vestibular nucleus.

The upper cervical spine is anatomically unique, with great mobility coupled with reduced stability. Hence, it is especially vulnerable to trauma, especially whiplash-type trauma, and capable of initiating cervical vertigo.

Chiropractors are exceptionally trained in the diagnosis and treatment of cervical vertigo. This includes ruling out other potential causes for the vertigo symptoms. The safe and appropriate management of cervical vertigo requires training and skill, issues that are stressed in the education of the modern chiropractor. Chiropractic spinal adjusting (specific manipulation), and other treatment adjuncts, are safe and very effective in treating patients with cervical vertigo.

•••••

The Chiropractic Impact Report™ is a monthly publication by myself, Dan Murphy, DC. I am a 1978 graduate of Western States Chiropractic College in Portland, OR. I have managed about 10,000 whiplash-injury cases. In the past 32 years, I have taught more than 500 12-hour post graduate continuing education classes pertaining to whiplash and spinal trauma, including 21 years of coordinating a year-long certification program in spine trauma, certified through the International Chiropractic Association. Additionally, I am board certified in chiropractic orthopedics (DABCO), and I am on the faculty at Life Chiropractic College West in Hayward, CA (28 years).

The purpose of The Chiropractic Impact Report™ is to keep you updated as to relevant academic concepts pertaining to whiplash-injured patients. The hope is that the information is useful in terms of enhanced understanding, as well as helping the personal injury attorney deal with insurance claim adjusters and adverse medical experts.

The chiropractor sending you this Report is well versed and trained in these concepts, and can be a valuable asset in personal injury cases in terms of both academics and treatment. Additionally, these expert chiropractors have access to a monthly phone consultation with me to discuss any pertinent issues that they may be facing on a particular case. I hope that you find this Report and the referring chiropractor a valuable resource.

Sincerely,

Daniel J. Murphy DC, DABCO

REFERENCES

  • Epley JM; The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo; Otolaryngology Head Neck Surgery; September 1992; Vol. 107; No. 3; pp. 399-404.
  • Baloh R, Honrubia V; Clinical Neurophysiology of the Vestibular System; Third edition; Oxford University Press; 2001.
  • Jordan P, Ramon Y; Nystagmus and Vertigo Produced by Mechanical Irritation of the Temporomandibular Joint-space; J Laryngol Otol; August  1965;79; pp. 744-8.
  • Morgan DH; Temporomandibular joint surgery. Correction of pain, tinnitus, and vertigo; Dent Radiogr Photogr; 1973;46(2); pp. 27-39.
  • Wright EF; Otologic symptom improvement through TMD therapy; Quintessence International; October 2007;38(9):e564-71.
  • de Jong PT, de Jong JM, Cohen B, Jongkees LB; Ataxia and nystagmus induced by injection of local anesthetics in the Neck; Annals of Neurology; March 1977; Vol. 1; No. 3; pp. 240-246.
  • NCMIC Chiropractic Solutions; Current Concepts in Spinal Manipulation and Cervical Arterial Incidents; 2006
  • Ryan GM, Cope S; Cervical vertigo; Lancet; December 31, 1955;269(6905); pp. 1355-8.
  • Hinoki M; Vertigo due to whiplash injury: a neurotological approach; Acta Otolaryngology; Supplement 1984;419; pp. 9-29.
  • Luxon L; “Posttraumatic Vertigo” in Disorders of the Vestibular System; edited by Robert W. Baloh and G. Michael Halmagyi; Oxford University Press; 1996.
  • Brandt t, Bronstein M; Cervical Vertigo; Journal of Neurology, Neurosurgery, and Psychiatry; July 2001; Vol. 71; No. 1, pp. 8-12.
  • Humphreys KM, Bolton J, Peterson C, Wood A; A Cross-Sectional Study of the Association Between Pain and Disability in Neck Pain Patients with Dizziness of Suspected Cervical Origin; Journal of Whiplash & Related Disorders, Vol. 1; No. 2; 2002, pp. 63-73.
  • Treleaven J, Jull G, Sterling M; Dizziness and Unsteadiness Following Whiplash Injury: Characteristic Features and Relationship with Cervical Joint position Error; Journal of Rehabilitative Medicine; January, 2003; 35; pp. 36–43.
  • Yacovino DA; Cervical vertigo: myths, facts, and scientific evidence; Neurologia; September 13, 2012.
  • L’Heureux-Lebeau B, Godbout A, Berbiche D, Saliba I; Otology & Neurotology; Evaluation of para-clinical tests in the diagnosis of cervicogenic dizziness; December 2014; Vol. 35; No. 10; pp. 1858-1865.
  • Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
  • Karlberg M, Magnusson M, Malmström EM, Melander A, Moritz U; Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin; Archives of Physical Medicine and Rehabilitation; September 1996; Vol. 77; No. 9; pp. 874-82.
  • Galm R, Rittmeister M, Schmitt E; Vertigo in patients with cervical spine dysfunction; European Spine Journal; July 1998; pp. 55-58.
  • Reid SA, Rivett DA; Manual therapy treatment of cervicogenic dizziness: a systematic review; Manual Therapy; February 2005; Vol. 10; No. 1; pp. 4-13.
  • Reid SA, Rivett DA, Katekar MG, Callister R; Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness; Manual Therapy; August 2008; Vol. 13; No. 4; pp. 357-366.
  • Reid SA, Rivett DA, Katekar MG, Callister R; Comparison of mulligan sustained natural apophyseal glides and maitland mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial; Physical Therapy; April 2014; Vol. 94; No. 4; pp. 466-76.
  • Reid SA, Callister R, Snodgrass SJ, Katekar MG, Rivett DA; Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial; Manual Therapy; February 2015; Vol. 20; No. 1; pp. 148-56.
  • Humphreys BK, Peterson C; Comparison of outcomes in neck pain patients with and without dizziness undergoing chiropractic treatment: a prospective cohort study with 6 month follow-up; Chiropractic Manual Therapy; January 7, 2013; Vol. 21; No. 1.
  • Li Y, Baogan Peng B; Pathogenesis, Diagnosis, and Treatment of Cervical Vertigo; Pain Physician July/August 2015; 18:E583-E595.

“Authored by Dan Murphy, D.C.. Published ChiroTrust®. This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”

October 2015

Back Pain Surgery Avoidance and Chiropractic

America’s Pain Crisis

Judy Foreman was educated at Harvard, and has been a Lecturer on Medicine at Harvard’s Medical School. In 2014, she published a book titled (1):

A Nation in Pain
Healing Our Biggest Health Problem

Ms. Foreman notes that of the 238 million adults in America, approximately half of them have chronic daily pain. The conservative estimate of the direct costs and lost productivity resulting from this pain is up to $635 billion yearly.

Americans pay $113 billion yearly for Social Security Disability benefits (2), and it’s not enough. Our Social Security Disability program is paying out $200 billion yearly. Political newspapers are buzzing about the prediction that the Social Security Disability Trust Fund will go broke next year (2016) (3). Fifteen million Americans are on Social Security Disability, and new applications average 200,000 monthly (2). The primary condition for which Americans apply for and are granted Social Security Disability is “musculoskeletal system and connective tissue” disorders, primarily back pain (2).

The drugs used to treat chronic pain are themselves creating yet another crisis. The political magazine, Time published a cover article titled (4):

They’re the most powerful painkillers ever invented;
And they’re creating the worst addiction crisis America has ever seen;
The price of Relief; Why America can’t kick its painkiller problem

This article makes these points:

  • “Around the nation, doctors so frequently prescribe the drugs known as opioids for chronic pain conditions like arthritis, migraines and lower back injuries that there are enough pills prescribed every year to keep every American adult medicated around the clock for a month.” “The result is a national epidemic.”
  • “Now, 4 of 5 heroin addicts say they came to the drug from prescription painkillers.”
  • “By 2011 the number of opioid prescriptions written for pain treatment had tripled to 219 million.”
  • “By 2011, 17,000 Americans were dying every year from prescription opioid overdoses.”
  • “The American Academy of Neurology last year concluded that the risks of long-term opioid treatment for headaches and chronic low back pain likely outweighed the benefits.”

Also in 2015, the newspaper the Wall Street Journal reviewed a booked titled Dreamland in an article titled The Great Opiate Boom (5). This article makes these points:

  • “Children of the most privileged group in the wealthiest country in the history of the world were getting hooked and dying in almost epidemic numbers from substances meant to, of all things, numb pain.”
  • These “prescriptions [opioids] for chronic pain rose from 670,000 in 1997 to 6.2 million in 2002.”

In June 2015, the front page of the newspaper USA Today published an article titled Heroin use surges among women, middle-class (6). This article makes these points:

  • “Heroin use is reaching into new communities—addicting more women and middle-class users—as people hooked on prescription painkillers transition to cheaper illegal drugs.”
  • “About 75% of new heroin users first became hooked on prescription opiates.”

In 2013, the Wall Street Journal quantifies chronic pain location by citing the Centers for Disease Control and Prevention, and the World Health Organization (7):

28.1% Low Back Pain
19.5% Knee Pain
16.1% Severe Headache or Migraine
15.1% Neck Pain
09.0% Shoulder Pain
07.6% Finger pain
07.1% Hip Pain

Back pain is at the center of America’s pain and disability crisis. It has been know for 40 years that the structure primarily responsible for back pain, especially for chronic back pain, is the intervertebral disc:

  • In 1976, internationally respected orthopedic surgeon Alf Nachemson published his detailed review on back pain in the journal Spine (8), in which he states:

“The intervertebral disc is most likely the cause of the pain.”

  • In 1981, anatomist and physician Nikoli Bogduk published an extensive review of the literature on the topic of disc innervation, along with his own primary research in the Journal of Anatomy (9). Dr. Bogduk states:

“The lumbar intervertebral discs are supplied by a variety of nerves.”

“Clinically, the concept of ‘disc pain’ is now well accepted.”

  • In 1987, the journal Spine published Dr. Vert Mooney’s Presidential Address of the International Society for the Study of the Lumbar Spine (10). In this article, Dr. Mooney states:

“We know that 10% of back ‘injuries’ do not resolve in 2 months and that they do become chronic.”

“Persistent pain in the back with referred pain to the leg is largely on the basis of abnormalities within the disc.”

“Where is the pain coming from in the chronic low-back pain patient? I believe its source, ultimately, is in the disc. Basic studies and clinical experience suggest that mechanical therapy is the most rational approach to relief of this painful condition.”

  • In 1991, Stephen Kuslich and colleagues published an article in the journal Orthopedic Clinics of North America (11). The authors performed 700 lumbar spine operations using only local anesthesia to determine the tissue origin of low back and leg pain, and they present the results on 193 consecutive patients studied prospectively. They state:

“Back pain could be produced by several lumbar tissues, but by far, the most common tissue or origin was the outer layer of the annulus fibrosis.”

  • In 2006, researchers from Japan published an article in the journal Spine showing the results of a sophisticated immunohistochemistry study of the sensory innervation of the human lumbar intervertebral disc (12). These authors note:

“Many investigators have reported the existence of sensory nerve fibers in the intervertebral discs of animals and humans, suggesting that the intervertebral disc can be a source of low back pain.”

“Both inner and outer layers of the degenerated lumbar intervertebral disc are innervated by pain sensory nerve fibers in humans.”

Pain neuron fibers are found in all human discs that have been removed because they are the source of a patient’s chronic low back pain.

The nerve fibers in the disc, found in this study, “indicates that the disc can be a source of pain sensation.”

  • In 2011, researchers from the University/Medical College of Virginia published a study in the journal Pain Medicine in which they quantified the structural source of low back pain in which diagnostic procedures were performed on 170 back pain patients (13). The authors note:

“Our data confirm the intervertebral disc as the most common etiology of chronic low back pain in adults.”

  • In 2015, a team from Naples, Italy, published a study in the European Journal of Radiology, in which they present an extensive review of the literature pertaining to spinal pain (14). The authors note:

“Spinal pain, and especially low back pain (LBP), represent the second leading cause for a medical consultation in a primary care setting and is a leading cause of disability worldwide.”

The most frequent cause of LBP is “internal disc disruption and is referred to as discogenic pain.” “Internal disc disruption refers to annular fissures, disc collapse and mechanical failure, with no significant modification of external disc shape, with or without endplates changes.”

Discogenic pain is “considered as the most frequent cause of chronic low back pain.” Discogenic pain secondary to internal disc disruption is the main cause of chronic LBP and disability.

•••••

A central theme in the back pain literature is that discogenic back pain is prevalent, and probably accounts for the majority of back pain complaints within the American Society. Chiropractic / manipulative management of patients with back and/or leg pain secondary to nerve compression has a long and impressive history of good clinical outcomes with very low risks. Representative studies include:

  • In 1954, RH Ramsey, MD published a study in the Instructional Course Lectures of the American Academy of Orthopedic Surgeons (15). Dr. Ramsey states:

“The conservative management of lumbar disk lesions should be given careful consideration because no patient should be considered for surgical treatment without first having failed to respond to an adequate program of conservative treatment.”

“From what is known about the pathology of lumbar disk lesions, it would seem that the ideal form of conservative treatment would theoretically be a manipulative closed reduction of the displaced disk material.”

  • In 1969, physicians JA Mathews and DAH Yates from the Department of Physical Medicine, St. Thomas’ Hospital, London, published a study in the British Medical Journal (16). These authors evaluated a number of patients that presented with an acute onset of low back and buttock pain who did not respond to rest. Diagnostic epidurography showed a clinically relevant small disc protrusion, along with antalgia and positive lumbar spine nerve stretch tests. These patients were then treated with manipulations of the lumbar spine. The manipulations were repeated until abnormal symptoms and signs had disappeared. Following the manipulations there was resolution of signs, symptoms, antalgia, and reduction in the size of the protrusions.
  •  Also in 1969, BC Edwards compared the effectiveness of heat/massage/exercise to spinal manipulation in the treatment of 184 patients that were grouped according to the presentation of back and leg pain. The study was published in the Australian Journal of Physiotherapy (17). This study was considered to be “a well-designed, well executed, and well-analyzed study.” (18)

“This study certainly supports the efficacy of spinal manipulative therapy in comparison with heat, massage, and exercise. The results (80 – 95% satisfactory) are impressive in comparison with any form of therapy.”

  • In 1977, the third edition of Orthopaedics, Principles and Their Applications was published (19). The author, Samuel Turek, MD (d. 1986), was a Clinical Professor, Department of Orthopedics and Rehabilitation at the University of Miami School of Medicine. In the section pertaining to the protruded disc, Dr. Turek makes the following observations:

“Manipulation. Some orthopaedic surgeons practice manipulation in an effort at repositioning the disc. This treatment is regarded as controversial and a form of quackery by many men. However, the author has attempted the maneuver in patients who did not respond to bed rest and were regarded as candidates for surgery. Occasionally, the results were dramatic.

Technique. The patient lies on his side on the edge of the table facing the surgeon, and the uppermost leg is allowed to drop forward over the edge of the table, carrying forward that side of the pelvis. The uppermost arm is placed backward behind the patient, pulling the shoulder back. The surgeon places one hand on the shoulder and the other on the iliac crest and twists the torso by pushing the shoulder backward and the iliac crest forward. The maneuver is sudden and forceful and frequently is associated with an audible and palpable crunching sound in the lower back. When this is felt, the relief of pain is usually immediate. The maneuver is repeated with the patient on the opposite side.”

  • In 1985, Dr. Kirkaldy-Willis, a Professor Emeritus of Orthopedics and director of the Low-Back Pain Clinic at the University Hospital, Saskatoon, Canada, published an article in the journal Canadian Family Physician (20). In this study, the authors present the results of a prospective observational study of spinal manipulation in 283 patients with chronic low back and leg pain. All 283 patients in this study had failed prior conservative and/or operative treatment, and they were all totally disabled. These patients were given a two or three week regimen of daily spinal manipulations by an experienced chiropractor. Eighty-one percent of the patients with referred pain syndromes subsequent to joint dysfunctions achieved a good result. Forty-eight percent of the patients with nerve compression syndromes achieved a good result.
  • In 1987, physicians Paul Pang-Fu Kuo and Zhen-Chao Loh published a study pertaining to lumbar disc protrusions and spinal manipulation in the journal Clinical Orthopedics and Related Research (21). Drs. Paul Pang-Fu Kuo and Zhen-Chao Loh are from the Department of Orthopedic Surgery, Shanghai Second Medical College, and Chief Surgeon, Department of Orthopaedic Surgery, Rui Jin Hospital, Shanghai, China. They note that manipulation has been used in Chinese healthcare for thousands of years, and by the Tang Dynasty (618-907 AD), “manipulation was fully established and became a routine for the treatment of low back pain.”

In their study, they performed a series of eight manipulations on 517 patients with protruded lumbar discs and clinically relevant signs and symptoms. Their outcomes were quite good, with 84% achieving a successful outcome and only 9% not responding. Only 14 % suffered a reoccurrence of symptoms at intervals ranging from two months to twelve years. Based upon their results, Drs. Kuo and Loh make these statements:

“Manipulation of the spine can be effective treatment for lumbar disc protrusions.”

“Most protruded discs may be manipulated. When the diagnosis is in doubt, gentle force should be used at first as a trial in order to gain the confidence of the patient.”

  • In 1989, the Journal of Manipulative and Physiological Therapeutics published a case study of a patient with an “enormous central herniation lumbar disc” who underwent a course of side posture manipulation (22). The patient improved considerably with only 2 weeks of treatment. The authors state:

“It is emphasized that manipulation has been shown to be an effective treatment for some patients with lumbar disc herniation.”

  • In 1990, Dr. TW Meade published the results of a randomized comparison of chiropractic and hospital outpatient treatment in the treatment of low back pain. This trial involved 741 patients and was published in the British Medical Journal (23). The patients were followed for a period between 1–3 years. Key points presented in this article include:

“Chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain.”

“There is, therefore, economic support for use of chiropractic in low back pain, though the obvious clinical improvement in pain and disability attributable to chiropractic treatment is in itself an adequate reason for considering the use of chiropractic.”

“Patients treated by chiropractors were not only no worse off than those treated in hospital but almost certainly fared considerably better and that they maintained their improvement for at least two years.”

“The results leave little doubt that chiropractic is more effective than conventional hospital outpatient treatment.”

  • In 1993, chiropractor J. David Cassidy, chiropractor Haymo Thiel, and physician William Kirkaldy-Willis published a “Review Of The Literature” pertaining to side posture manipulation for lumbar intervertebral disk herniations. Their article appeared in the Journal of Manipulative and Physiological Therapeutics (24). Based upon their review of the literature and their own experiences, these authors state:

“The treatment of lumbar disk herniation by side posture manipulation is not new and has been advocated by both chiropractors and medical manipulators.”

“The treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective.”

  • In 1995, chiropractors PJ Stern, Peter Côté, and David Cassidy published a study in the Journal of Manipulative and Physiological Therapeutics (25). They retrospectively reviewed the outcomes of 59 consecutive patients complaining of low back and radiating leg pain, and were clinically diagnosed as having a lumbar spine disk herniation. Ninety percent of these patients reported improvement of their complaint after chiropractic manipulation. They concluded:

“Based on our results, we postulate that a course of non-operative treatment including manipulation may be effective and safe for the treatment of back and radiating leg pain.”

  • In 2003, the journal Spine published a randomized clinical trial involving the nonsteroidal anti-inflammatory COX-2 inhibiting drugs Vioxx or Celebrex v. needle acupuncture v. chiropractic manipulation in the treatment of chronic neck and back pain (26). Chiropractic was better than 5 times more effective than the drugs and better than twice as effective as needle acupuncture in the treatment of chronic spine pain. Chiropractic was able to accomplish the clinical outcome without any reported adverse effects. One year after the completion of this 9-week clinical trial, 90% of the original trial participants were re-evaluated to assess their clinical status. The authors discovered that only those who received chiropractic during the initial randomization benefited from a long-term stable clinical outcome (27).
  •  In 2006, physicians Valter Santilli, MD, Ettore Beghi, MD, Stefano Finucci, MD, published an article in The Spine Journal (28). Their study was a randomized double-blind clinical trial of active and simulated chiropractic spinal manipulations in the treatment of acute back pain and sciatica with disc protrusion. The study used 102 patients. The manipulations or simulated manipulations were done 5 days per week by experienced chiropractors for up to a maximum of 20 patient visits, “using a rapid thrust technique.” The authors noted the following:

“Active manipulations have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion.”

“At the end of follow-up a significant difference was present between active and simulated manipulations in the percentage of cases becoming pain-free (local pain 28% vs. 6%; radiating pain 55% vs. 20%).”

“Patients receiving active manipulations enjoyed significantly greater relief of local and radiating acute LBP, spent fewer days with moderate-to-severe pain, and consumed fewer drugs for the control of pain.”

“No adverse events were reported.”

  • In 2014, a group of multidisciplinary researchers and chiropractic clinicians from Switzerland presented a prospective study involving 148 patients with low back and leg pain. The study was published in the Journal of Manipulative and Physiological Therapeutics (29). The purpose of this study was to document outcomes of patients with confirmed, symptomatic lumbar disc herniations and sciatica that were treated with chiropractic side posture high-velocity, low-amplitude, spinal manipulation to the level of the disc herniation. Evaluations were performed at 2 weeks, 1 month, 3 months, 6 months, and 12 months. The authors make the following statements:

“The proportion of patients reporting clinically relevant improvement in this current study is surprisingly good, with nearly 70% of patients improved as early as 2 weeks after the start of treatment. By 3 months, this figure was up to 90.5% and then stabilized at 6 months and 1 year.”

“A large percentage of acute and importantly chronic lumbar disc herniation patients treated with chiropractic spinal manipulation reported clinically relevant improvement.”

“Even the chronic patients in this study, with the mean duration of their symptoms being over 450 days, reported significant improvement, although this takes slightly longer.”

“A large percentage of acute and importantly chronic lumbar disc herniation patients treated with high-velocity, low- amplitude side posture spinal manipulative therapy reported clinically relevant ‘improvement’ with no serious adverse events.”

“Spinal Manipulative therapy is a very safe and cost-effective option for treating symptomatic lumbar disc herniation.”

In America, it is not uncommon for persistent back pain to be treated surgically. An analysis of America’s low back surgery rate compared internationally to other nations was published in the journal Spine in 1994 (30). The authors were from the Department of Health Services, University of Washington in Seattle. They compared rates of back surgery in eleven developed countries to determine if back surgery rates are higher in the United States than in other developed countries. Their findings include:

The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland.”

“Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country.”

In this regard, an interesting article was published in the journal Spine in 2013, designed to predict the major reason for back surgery as compared to the utilization of less invasive approaches (31). A team of investigators from Dartmouth Medical School, the University of Washington School of Medicine, and Ohio State University College of Public Health, completed a prospective cohort study to identify early predictors of lumbar spine surgery within 3 years after occupational back injury.

The authors note that back injuries are the most prevalent occupational injury in the United States, and that back pain is the most costly and prevalent occupational health condition among the U.S. workers. After adjustment for medical and general inflation, costs for occupational back pain increased over 65% from 1996 through 2002, and spine surgeries represent a significant proportion of these costs. Yet, they note:

“Spine surgeries are associated with little evidence for improved population outcomes, yet rates have increased dramatically since the 1990s.”

“Reducing unnecessary spine surgeries is important for improving patient safety and outcomes and reducing surgery complications and health care costs.”

Previous studies have shown that those with occupational back injuries who first saw a chiropractor had lower odds of chronic work disability, and that those seeing chiropractors for occupational back pain had “higher rates of satisfaction with back care.”

In this study, after controlling for injury severity, workers with an initial visit for the injury to a surgeon had almost nine times the odds of receiving lumbar spine surgery compared to those seeing primary care providers, and workers whose first visit was to a chiropractor had significantly lower odds of surgery (by 78%). The authors stated:

“42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor.”

“Approximately 43% of workers who saw a surgeon had surgery within 3 years, in contrast to only 1.5% of those who saw a chiropractor.”

“There was a very strong association between surgery and first provider seen for the injury, even after adjustment for other important variables.” [such as symptom severity]

“It is possible that these findings indicate that who you see is what you get.”

Seeing a chiropractor as the first provider for a back complaint significantly reduced odds of surgery.

These authors suggest that it is wise to use a “gatekeeper” for patients who suffer occupational back injury. This article presents substantial reason for why such a gatekeeper should be a chiropractor. The reduction of back surgeries in those consulting chiropractors for back pain represents a substantial costs savings, and also the highest levels of back care satisfaction.

REFERENCES

  1. Foreman J; A Nation in Pain, Healing Our Biggest Health Problem; Oxford University Press, 2014.
    www.ssa.gov (the Official Social Security Website): “December 2011, diseases of the musculoskeletal system and connective tissue were the primary reason disabled workers and disabled widow(er)s received benefits.”
  2. Associated Press; STEPHEN OHLEMACHER and RICARDO ALONSO-ZALDIVAR; July 22, 2015.
  3. Calabresi M; They’re the most powerful painkillers ever invented; And they’re creating the worst addiction crisis America has ever seen; The price of Relief; Why America can’t kick its painkiller problem; Time; June 15, 2015; pp. 26-33.
  4. Rommelmann N; The Great Opiate Boom; Wall Street Journal; June 6-7, 2915; p. C9.
  5. Szabo L; Heroin use surges among women, middle-class; USA Today; July 8, 2015; pp. A1.
  6. Wall Street Journal, October 7, 2013.
  7. Nachemson AL; The Lumbar Spine, an Orthopedic Challenge; Spine; Volume 1, Number 1, March 1976, pp. 59-71.
  8. Bogduk N, Tynan W, Wilson AS; The nerve supply to the human lumbar intervertebral discs; Journal of Anatomy; 1981; Vol. 132; No. 1; pp. 39-56.
  9. Mooney V; Where Is the Pain Coming From?; Spine; Vol. 12; No. 8; 1987; pp. 754-759.
  10. Kuslich S, Ulstrom C, Michael C; The Tissue Origin of Low Back Pain and Sciatica: A Report of Pain Response to Tissue Stimulation During Operations on the Lumbar Spine Using Local Anesthesia; Orthopedic Clinics of North America; Vol. 22; No. 2; April 1991; pp. 181-187.
  11. Ozawa T, Ohtori S, Inoue G, Aoki Y, Moriya H, Takahashi; The Degenerated Lumbar Intervertebral Disc is Innervated Primarily by Peptide-Containing Sensory Nerve Fibers in Humans; Spine Volume 31; Number 21; October 1, 2006; pp. 2418-2422.
  12. DePalma MJ, Ketchum JM, Saullo T; What is the source of chronic low back pain and does age play a role?; Pain Medicine; Feb 2011; Vol. 12; No. 2; pp. 224-233.
  13. Izzo R, Popolizio T, D’Aprile P, Muto M; Spine Pain; European Journal of Radiology; May 2015; Vol. 84; pp. 746–756.
  14. Ramsey RH; Conservative Treatment of Intervertebral Disk Lesions; American Academy of Orthopedic Surgeons, Instructional Course Lectures; Volume 11; 1954; pp. 118-120.
  15. Mathews JA and Yates DAH; Reduction of Lumbar Disc Prolapse by Manipulation; British Medical Journal; September 20, 1969; No. 3; 696-697.
  16. Edwards BC; Low back pain and pain resulting from lumbar spine conditions: a comparison of treatment results; Australian Journal of Physiotherapy; 15:104, 1969.
  17. White AA, Panjabi MM; Clinical Biomechanics of the Spine; Second edition; JB Lippincott Company; 1990.
  18. Turek S; Orthopaedics, Principles and Their Applications; JB Lippincott Company; 1977; page 1335.
  19. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
  20. Kuo PP and Loh ZC; Treatment of Lumbar Intervertebral Disc Protrusions by Manipulation; Clinical Orthopedics and Related Research; No. 215; February 1987; pp. 47-55.
  21. Quon JA, Cassidy JD, O’Connor SM, Kirkaldy-Willis WH; Lumbar intervertebral disc herniation: treatment by rotational manipulation; Journal of Manipulative and Physiological Therapeutics; 1989 Jun;12(3):220-7.
  22. Meade TW, Dyer S, Browne W, Townsend J, Frank OA; Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatient treatment; British Medical Journal; Volume 300; June 2, 1990; pp. 1431-7.
  23. Cassidy JD, Thiel HW, Kirkaldy-Willis WH; Side posture manipulation for lumbar intervertebral disk herniation; Journal of Manipulative and Physiological Therapeutics; February 1993;16(2):96-103.
  24. Stern PJ, Côté P, Cassidy JD; A series of consecutive cases of low back pain with radiating leg pain treated by chiropractors; Journal of Manipulative and Physiological Therapeutics; 1995 Jul-Aug;18(6):335-42.
  25. Giles LGF, Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine July 15, 2003; 28(14):1490-1502.
  26. Muller R, Lynton G.F. Giles LGF, DC, PhD; Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain
  27. Syndromes; Journal of Manipulative and Physiological Therapeutics January; 2005; Volume 28; No. 1.
  28. Santilli V, Beghi E, Finucci S; Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: A randomized double-blind clinical trial of active and simulated spinal manipulations; The Spine Journal; March-April 2006; Vol. 6; No. 2; pp. 131–137.
  29. Leemann S, Peterson CK, Schmid C, Anklin B, Humphreys BK; Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging–Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One-Year Follow-Up; Journal of Manipulative and Physiological Therapeutics; March/April 2014; Vol. 37; No. 3; pp. 155-163.
  30. Cherkin DC, Deyo RA, Loeser JD, Bush T, Waddell G; An international comparison of back surgery rates; Spine; June 1, 1994; Vol. 19; No. 11; pp. 1201-1206.
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September 2015

Arnold-Chiari Malformation and Chiropractic

A literature search of the United States National Library of Medicine using PubMed (www.pubmed.gov) with the words “Arnold Chiari Malformation” locates 2,995 citations (August 14, 1015).

Chiropractic clinical practice involves the application of mechanical forces to a patient’s spinal column. Should the patient’s spinal column (spinal canal) have a space occupying entity, spinal manipulation may have to be delivered more cautiously.

Typical spinal canal space occupying entities include intervertebral disc herniations, tumors, and spinal cord syrinx (a fluid filled cavity within the spinal corn, also known as syringomyelia). These lesions often present with certain symptoms and signs, and their existence is confirmed with diagnostic imaging, usually an MRI. Interestingly, the presence of these entities can also be completely asymptomatic and are found only coincidently. As an example, in 1994, The New England Journal of Medicine published a study where 98 asymptomatic subjects received MRIs of their lumbar spines. Only 36% had normal intervertebral discs at all levels, and 27% had asymptomatic disc protrusions (1).

Another important space occupying entity that may or may not present with symptomology, is the Arnold-Chiari Malformation.

What is Arnold-Chiari Malformation?

At the basic level, Arnold-Chiari Malformation occurs when parts of the brain and/or brainstem slip below the foramen magnum and are found to be in the cervical spinal canal. This compromises the available space for both the cervical spinal cord and for the parts of the brain and/or brainstem that have slipped through the foramen magnum. An important component of this mechanical space occupying compromise is an impairment of the flow of cerebral spinal fluid.

A frequent and important accompaniment of the Arnold-Chiari Malformation is that of a spinal cordsyringomyelia. A syringomyelia, as noted above, is a condition in which a fluid filled cavity is present in the spinal cord and/or medulla. It creates pressure from the inside of the spinal cord, outwards:

Syringomyelia

image-01

Austrian pathologists Hans Chiari first described the Arnold-Chiari Malformation in 1891, prior to the first x-rays (Roentgen, 1895). German pathologist Julius Arnold’s name was added in 1907. Dr. Chiari described his findings based upon postmortem assessment in infants with varying degrees of congenital hindbrain deformities. Based upon Dr. Chiari’s findings, three Arnold-Chiari Malformation classifications were developed (today there are four):

Type I
There is a downward displacement of the cerebellar tonsils through the foramen magnum and into the cervical spinal canal; yet, the fourth ventricle remains in a relatively normal position.

      • Herniation of both cerebellar tonsils 3-5 mm below the plane of the foramen magnum
      • Herniation of one cerebellar tonsil 5 mm or more below the foramen magnum (2)

Type II
There is a downward displacement of the cerebellar tonsils and cerebellar vermis into the cervical spinal canal; the brain stem is displaced caudally; there is an elongation of the fourth ventricle.

Type III
There is a downward displacement of both the cerebellum and medulla into the cervical spinal canal and the development of a cervical meningocele.

Arnold-Chiari Type-I Malformation Lateral View

image-02

The degree of tonsillar herniation is measured on the sagittal MRI
A = Basion, anterior foramen magnum
B = Opisthion, posterior foramen magnum
C = tonsillar tip
Line AB represents the foramen magnum
Degree of tonsillar herniation is length of perpendicular from AB to C

Arnold-Chiari Malformation is considered to be developmental or congenital. It is often associated with scoliosis, Klippel-Feil Syndrome, hydrocephalus, and syringomyelia. Adults with Arnold-Chiari Malformation Type-I may be completely asymptomatic, or they may have many dramatic symptoms. It is often asymptomatic and does not present until adulthood. Consequently, Arnold-Chiari Malformation Type-I is often found as an incidental finding on MRIs taken for other reasons. In contrast, Arnold-Chiari Malformation Type-II and Type-III are almost always found in infancy because of significant neurological findings and the presence of meningocele.

What are the Typical Symptoms of a Patient with Arnold-Chiari Malformation?

The typical symptoms attributed to the Arnold-Chiari Malformation are:

  • Headache, usually occipital or suboccipital
  • Neck Pain
  • Vertigo / Dizziness / Light Headedness / Disequilibrium
  • Tinnitus
  • Extremity weakness
  • Extremity numbness
  • Ataxia / Gait disturbance
  • Cranial nerve palsies (nystagmus, oscillating vision, dysphagia, photophobia)
  • Apnea
  • Incontinence
  • Fatigue
  • Sleeping Difficulty

Often, the Valsalva test, or Valsalva types of activities (coughing, sneezing, straining, etc.) aggravate these symptoms. 

How is Arnold-Chiari Malformation Diagnosed?

The gold standard for a suspected Arnold-Chiari Malformation is an MRI. Standard MRIs are taken with the patient recumbent. However, as detailed below, there is evidence that in the chronic whiplash trauma patient, upright MRI is significantly superior to recumbent MRI documenting the existence of the lesion (4).

Also, syrinx/syringomyelia assessment is mandatory. The entire spinal cord (especially the brain stem, cervical cord, and thoracic cord) should be assessed with T1-weighted sagittal MRI images (3).

Can Chiropractic Spinal Adjusting (Manipulation) be Safely Used to Treat the Symptoms of Arnold Chiari Malformation?

There is evidence that chiropractic care does not benefit all patients with Arnold-Chiari Type-I Malformation. In 1994, chiropractor Ross McArthur presented two cases of Arnold-Chiari Type-I Malformation in which conservative chiropractic management did not result in improvement in the patient’s clinical presentation and symptomology (3).

The first case, a 43-year old female had been under chiropractic care for 10 years, including cervical spine adjusting/manipulation. She had been treated for back pain, neck pain and occipital pain, and she always responded well to spinal adjusting.

Following a fall with head trauma, her symptoms included dizziness, photophobia, diminished smell and taste, increased suboccipital pain, and the Valsalva maneuver increased suboccipital symptoms. X-rays of the cervical spine were normal. Chiropractic care failed to improve symptoms. An MRI was exposed and revealed herniation of the cerebellar tonsils through the foramen magnum and caudal displacement of portions of the cerebellar hemispheres. A diagnosis of Arnold-Chiari Malformation Type-I was made.

The patient was treated surgically with a posterior fossa craniectomy and a complete laminectomy of the posterior arch of the atlas. The dura was opened and microdissection was used to remove tonsillar adhesions. The presence of these tonsillar adhesions suggested that her Arnold-Chiari Malformation was a long-standing problem. The patient made a full recovery and remained under chiropractic care.

In this case, chiropractic adjustment/manipulation of her cervical spine did not worsen the patient’s symptoms; they did however fail to result in meaningful improvement.

In the second case, a 50-year old female presented with spontaneous worsening symptoms in her left arm-forearm-hand, left facial paresthesias, left TMJ symptoms, and left thigh weakness. Examination showed hypertonicity of the anterior scalene and sternocleidomastoid muscles. Cervical spine X-rays were normal.

Eight chiropractic adjustments of the cervical and thoracic spines over a period of 4 weeks did not improve symptoms, and therefore an MRI was exposed. The MRI showed a typical Arnold-Chiari Malformation with syringomyelia.

Once again, chiropractic spinal adjusting/manipulation of the cervical spine did not result in meaningful improvement of the patient’s symptoms, but it did not worsen or aggravate her symptoms or clinical presentation.

•••

In 1993, Donald Murphy, DC, and colleagues presented two cases where chiropractic high-velocity, low-amplitude adjustments were delivered to patients that had proven Arnold-Chiari Malformation Type I (4). Although the authors do not believe that the patient’s signs and symptoms were related to the Arnold-Chiari Malformation, the presenting symptoms may suggest otherwise. In any case, both patients with known Arnold-Chiari Malformation Type I received typical chiropractic adjustments of the upper cervical spine.

The first case was a 37-year old male who was asymptomatic until being involved in a rear-end followed by head-on motor vehicle collision. Presenting symptoms include headache, neck pain, photophobia, blurred vision, and right shoulder/scapular pain. Cranial nerve and cerebellar examination was unremarkable. Cervical compression, Soto-Hall, and Valsalva tests all produced local cervical pain. Cervical extension and rotation (vertebral artery tests) were negative for dizziness, nausea, nystagmus, numbness, or paresthesia.

After 20 chiropractic adjustments over a period of 6 weeks, the patient was 50% improved; yet, an MRI at that time showed an Arnold-Chiari Malformation Type I. The patient remained under chiropractic care, receiving an additional 14 adjustments over the next 6 weeks, at which time signs and symptoms were essentially resolved. The authors state:

“The patient was treated a total of 34 times and at no time during the treatment program did he note any adverse reactions to high-velocity, low-amplitude adjustments.”

The second case was a 36-year old female with a 4-year history of chronic severe vertigo and right arm pain. She had already undergone a cervical MRI showing an Arnold-Chiari Malformation Type I. She subsequently presented for chiropractic care.

The patient had an ataxic gait, could not tandem walk or stand in Romberg’s position, and had nystagmus on all eye movements. Initial chiropractic treatment consisted of 20 visits of low-velocity, low-amplitude mobilization of the upper cervical spine. This was followed by 5 visits ofhigh-velocity, low-amplitude adjustments of the upper cervical spine. These 25 chiropractic visits resulted in improvement but not resolution of her signs and symptoms. The authors state:

“At no time did she note any lasting adverse effects, even when high-velocity, low-amplitude adjustments were applied to the upper cervical spine.”

Asymptomatic Arnold-Chiari Malformation Type I is “not necessarily a contraindication to skilled adjustments to the cervical spine, and that viewing it as such would mean possibly denying the patient a form of treatment that could be helpful in the management of a health problem that may be unrelated to the malformation.”

The authors also make some cautionary comments:

“In a patient with a known Arnold-Chiari Malformation Type I, certain precautions may be taken to minimize any irritation to the cerebellar tonsils that have herniated through the foramen magnum.”

Avoid extension of the upper cervical spine during adjustment.

“Excessively vigorous adjusting to the upper cervical spine should be avoided, since this can potentially irritate neural structures in an already crowded canal.”

“Neither Occiput-C1 nor C1-C2 were adjusted in these patients, but there does not appear to be any reason why this would create any greater likelihood of complication.”

•••

In 2014, chiropractors Adam Sergent and Gregory Cofano published a study in the Journal of Chiropractic Medicine titled (5):

Chiropractic Care for Headaches and Dizziness of a 34-Year-Old Woman Previously Diagnosed With Arnold-Chiari Malformation Type-I

This 34-year-old female had a chronic history of headaches, dizziness, nausea, photophobia, and temporary loss of vision aggravated by postural positions while bending forward. These symptoms were often incapacitating. An MRI showed an Arnold-Chiari Malformation Type I, with cerebellar tonsils descending 5 mm into the cervical spinal canal. Neurosurgery was recommended.

Three years after initial diagnosis, the patient sought chiropractic and expressed her desire to avoid surgery. She was treated for 1 month with 9 visits, using high-velocity, low-amplitude adjustments of the cervical spine of prone diversified manipulation to C4/C5. She reported reduction of her headaches after this treatment.

Five years later, the patient suffered a symptomatic exacerbation. She was again treated using cervical chiropractic manipulation using prone diversified technique to C4/C5. The dizziness and headache were resolved after 3 visits. At her 3-month follow-up, she continued to be symptom-free. The authors concluded:

 “A patient with headaches and dizziness and a previous diagnosis of Arnold-Chiari Malformation Type I responded positively to chiropractic care.”

•••

Also in 2014, Oklahoma orthopedic surgeon Francio Tieppo, published a study in the British Medical Journal Case Reports, titled (6):

Syringomyelia and Arnold-Chiari malformation associated with neck pain and left arm radiculopathy treated with spinal manipulation

The abstract from this study makes the following statements:

“An 18-year-old female patient presented with left dominant neck pain after a motor vehicle collision. Her cervical spine MRI revealed syringomyelia with associated Type I Arnold-Chiari Malformation. Some researchers have reported that these might be considered contraindications to spinal manipulation. Nevertheless, her benign and functional clinical examination suggested otherwise and she underwent four manipulative treatments in 2 weeks. By the end of the treatment plan and after 1-month follow-up, she was asymptomatic, no adverse effects were noted and her outcome assessment score decreased from 56% to 0%. This case illustrates that spinal manipulation may be a useful adjunctive treatment procedure for spinal pain, even in the presence of syringomyelia and Chiari malformation, which may not necessarily be a contraindication to spinal manipulation, when performed by a skilled and well-trained physician.” 

If Chiropractic Care Does Not Achieve an Acceptable
Clinical Outcome on the Arnold Chiari Malformation Patient,
What is the Next Step of Clinical Intervention?

The standard allopathic management of the patient with subjective Arnold-Chiari Malformation who did not respond favorably to conservative treatment is surgical decompression (4). Specifically, standard surgery is a posterior fossa craniectomy and a complete laminectomy of the posterior arch of the atlas (3).

Summary

There is no doubt that asymptomatic chiropractic patients have Arnold-Chiari Malformation Type I. These patients certainly receive routine spinal adjusting to the cervical spine, and no (as of 8.14.15) adverse events have been reported in the literature (PubMed).

Chiropractic patients with subjective Arnold-Chiari Malformation Type I also present to chiropractors. The evidence presented here suggests that chiropractic spinal adjusting may not help these patients, but cervical spine adjusting is unlikely to worsen the patient’s signs and symptoms.

Also presented is evidence that patients with known subjective Arnold-Chiari Malformation Type I may benefit from chiropractic spinal adjusting, especially if it is done skillfully and not too vigorously. However, little is known about osseous adjusting of the occiput-atlas-axis on such patients, and caution is advised. Perhaps, the upper cervical spine on such patients should be adjusted with lower force approaches.

An Interesting Article

In 2010, Michael Freeman and colleagues published an article in the journal Brain Injury titled (7):

A Case-control Study of Cerebellar Tonsillar Ectopia (Chiari) and Head/neck Trauma (Whiplash)

These authors note that Chiari malformation is defined as herniation of the cerebellar tonsils through the foramen magnum, also known as cerebellar tonsillar ectopia. Individuals with existing but quiescent cerebellar tonsillar ectopia may become symptomatic following whiplash trauma. Therefore, the purpose of their study was to assess the frequency of cerebellar tonsillar ectopia in a symptomatic traumatic (whiplash) population versus a symptomatic non-traumatic control population.

Cervical MRI scans for 1200 neck pain patients were reviewed; 600 whiplash trauma cases and 600 non-trauma controls. Half of the groups were scanned in a recumbent position and half were scanned in an upright position

600 Chronic Controls

600 Chronic Whiplash Patients

Supine MR
# cerebellar tonsillar ectopia

5.3%

9.3%

Upright MR
# cerebellar tonsillar ectopia

5.7%

23.3%

In the non-trauma group, cerebellar tonsillar ectopia was found in 5.3% of the recumbent MRIs, and in 5.7% of the upright MRIs. This finding suggests:

  • Around 5% of individuals with non-traumatic neck symptoms have cerebellar tonsillar ectopia on a recumbent MRI.
  • The incidence of cerebellar tonsillar ectopia is not increased when individuals in this group (non-traumatic neck symptoms) have an upright MRI.
  • In the whiplash trauma group, cerebellar tonsillar ectopia was found in 9.8% of the recumbent MRIs, and in 23.3% of the upright MRIs. This finding suggests:
  • Around 10% of individuals with whiplash trauma neck symptoms have cerebellar tonsillar ectopia on a recumbent MRI. This would indicate that twice as many individuals with whiplash trauma neck symptoms have cerebellar tonsillar ectopia on a recumbent MRI as compared to a symptomatic non-traumatic control population. This would suggest that individuals with pre-existing cerebellar tonsillar ectopia who sustain a whiplash injury have an increased risk of sustaining prolonged symptoms.
  • In the whiplash trauma neck symptom group, the incidence of cerebellar tonsillar ectopia is increased significantly (more than doubled) when exposed to an upright MRI. This suggests that the whiplash injury creates some physiological change that increases the incidence of cerebellar tonsillar ectopia.
  • In the chronic whiplash trauma group, the incidence of cerebellar tonsillar ectopia viewed with upright MRI is 4 times greater than in the upright MRI of the control group.
  • In chronic whiplash patients, recumbent MRIs may be inadequate for the assessment of cerebellar tonsillar ectopia as compared to upright MRIs.

Although Chiari type I malformation is classically considered to be a congenital lesion, these authors note that it can be acquired. These authors note that whiplash trauma is capable of causing a cerebral spinal fluid leak. In the upright position, the reduced volume of cerebral spinal fluid allows the cerebellar tonsils to slip below the foramen magnum, creating the cerebellar tonsillar ectopia finding.

The standard diagnostic test for cerebral spinal fluid leak is using radioisotope cisternography. The standard treatment is a blood patch. This is procedure in which the patient’s own blood is withdrawn from a vein and injected into the spinal canal. The platelets in the blood will “find” the leak and create a seal, a patch. Symptoms usually quickly resolve, and recurrence is rare.

These authors make these important points:

  • Typical Chiari type I malformation symptoms include occipital headache, neck pain, upper extremity numbness and paresthesias and weakness; occasionally there may be lower extremity weakness and signs of cerebellar dysfunction.
  •  “Previously quiescent Chiari Type I malformations can become symptomatic as a result of exposure to traumatic injury.” Minor head and neck trauma can cause an asymptomatic Chiari Type I malformation to become symptomatic.
  • Patients with a history of motor vehicle crash-associated neck pain have a “substantially higher frequency” of cerebellar tonsillar ectopia than non-traumatic subjects; 4-times greater when evaluated with an upright MRI scan.
  • “Cerebellar tonsillar ectopia is substantially more prevalent in whiplash-injured neck pain patients than in neck pain patients with no recent history of trauma.”
  • In the trauma group, cerebellar tonsillar ectopia was found 2.5-times more often in the upright MR scan vs. the recumbent MR scan. “Upright position MR imaging appears to increase the sensitivity to cerebellar tonsillar ectopia over recumbent MR imaging by 2.5 times.”
  • “There is clinical evidence that dural leaks are associated with whiplash trauma and chronic symptoms.”
  • It is well established that Chiari type I can be acquired, and this study led the authors to suggest that the increased incidence of cerebellar tonsillar ectopia was caused by the whiplash trauma.
  • The incidence of cerebellar tonsillar ectopia was nearly identical (5.3% v 5.7%) in the control group in both the supine and upright MRI; but the incidence of cerebellar tonsillar ectopia was significantly greater (23.3 v 9.3) in the whiplash-injured group with the upright MRI. This can be explained by reduced cerebral spinal fluid (CSF) as a consequence of a trauma-induced leak.
  • Studies show that there is a substantial and rapid increase in cerebral spinal fluid pressure during simulated whiplash trauma.
  • In this study, neuroradiographic abnormality (cerebellar tonsillar ectopia) was found in approximately 25% of upright whiplash trauma cases. This unrecognized definable pathology may account for a patient’s chronic pain complaints. This suggests that in these cases, chronic whiplash symptoms may not be ascribable to psychosocial factors or litigation status, but rather to organic neurological injury.
  • “Clinicians may want to consider evaluating patients for cerebellar tonsillar ectopia (i.e. upright MRI of the neck and head) when there is a history of whiplash trauma and persisting suboccipital headache in combination with headache worsened by cough or bilateral sensory or motor deficits in the upper extremities.”
  • “In cerebellar tonsillar ectopia patients with headache that is relieved when supine it also may be appropriate to consider radionuclide cisternography to evaluate for the presence of a dural leak.”

Perhaps all chronic whiplash patients should be assessed with an upright MRI to look for cerebellar tonsillar ectopia.

REFERENCES 

  • Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS; Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain; N Engl J Med; 1994 Jul 14;331(2):69-73.
  • Elster AD, Chen MYM; Chiari I Malformations: Clinical and Radiological Reappraisal; Radiology; Vol. 183; No. 2; 1992; pp. 347-353.
  • McArthur RA; Arnold-Chiari Type I malformation: a look at two cases in the adult; Journal of the Canadian Chiropractic Association; Vol. 38; No. 4; December 1994; pp. 203-210.
  • Murphy DR, Goldstein D, Katz M; Chiropractic adjustment to the cervical spine and the Arnold-Chiari malformation; Journal of Manipulative Physiological Therapeutics; 1993; Vol. 16; pp. 550-555.
  • Adam Sergent A, Cofano G; Chiropractic Care for Headaches and Dizziness of a 34-Year-Old Woman Previously Diagnosed With Arnold-Chiari Malformation Type 1; Journal of Chiropractic Medicine; September 2014; Vol. 13; No. 3; pp. 192–195.
  • Tieppo Francio V; Syringomyelia and Arnold-Chiari malformation associated with neck pain and left arm radiculopathy treated with spinal manipulation; British Medical Journal Case Reports; November 9, 2014.
  • Freeman MD, Rosa S, Harshfield D, Smith F, Bennett R, Centeno CJ, Kornel E, Nystrom A, Heffez D, Kohles SS; A case-control study of cerebellar tonsillar ectopia (Chiari) and head/neck trauma (whiplash); Brain Injury; July 2010; 24(7–8): 988–994.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”

August 2015

What Really Is A Chiropractic “Adjustment”?

The June 2015 issue of the journal Scientific American has an article by primary care physician Wajahat Z. Mehal, MD, from the Department of Veterans Affairs Medical Center in Connecticut, and Yale University, titled (1):

Cells on Fire

In this article, Dr. Mehal notes that inflammation is set in motion by cells of the immune system, and that it is helpful because it kills pathogens and blocks their spread in the body. The inflammatory cascade, initiated by the innate immune response’s macrophages, weakens and immobilizes adverse microbes.

However, the same inflammatory cascade can occur when no microbes exist, triggered as a consequence of tissue damage and/or excessive tissue stress. This inflammatory response can, in-and-of-itself, become chronic and cause additional tissue damage. In other words, as much as acute inflammation can be beneficial (containing and/or killing pathogens), chronic inflammation can be deleterious, serving no useful purpose.

Consequently, Dr. Mehal broadly categorized the inflammatory response into two categories:

1)     Infectious inflammation:

This is an inflammatory response that is designed to contain and/or kill pathogens.

This response is critical for individual and species survival.

2)     Sterile inflammation:

This is an inflammatory response in which there are no associated pathogens, a response that is triggered by tissue injury and /or excessive tissue stress.

This response often becomes chronic. As such, this response is excessive and harmful.

Pathology History

A decades synopsis of global leading experts, expressed in leading reference texts printed by top medical publishers

In 1952, William Boyd, MD, Professor Emeritus of Pathology at the University of Toronto, published his reference text, titled (2):

PATHOLOGY

Structure and Function in Disease

In this text, Dr. Boyd states:

“The inflammatory reaction tends to prevent the dissemination of infection. Speaking generally, the more intense the reaction, the more likely the infection to be localized.”

In 1970, the eighth edition of Dr. Boyd’s PATHOLOGY text is published

(3): In chapter 4, titled Inflammation and Repair,Dr. Boyd states:

“Inflammation is the most common, the most carefully studied, and the most important of the changes that the body undergoes as the result of disease.”

Dr. Boyd notes that in chronic inflammation, the “only cells that proliferate are the fibroblasts.” Consequently, the chronic inflammatory response is considered to be a “fibroblast reaction,” or “fibrosis.” The lesion of chronic inflammation becomes more and more fibrous as the collagen is laid down. The resulting fibrosis is much more marked than in acute inflammation situations. Also, the “newly-formed fibrous tissue invariably contracts as it becomes older.”

•••

In 1976, physicians WAD Anderson, MD, and Thomas Scotti, MD, published the ninth edition of their book titled (4):

Synopsis of Pathology

Drs. Anderson and Scotti were Professors of Pathology at the University of Miami School of Medicine. Similar to Boyd, they title chapter 3 of their text Inflammation and Repair,in which they state:

“Inflammation is the most common and fundamental pathological reaction.”

The agents leading to inflammation include “microbial, immunologic, physical, chemical, or traumatic.”

“Chronic inflammation is a process that is prolonged, and proliferation (especially in connective tissues) forms a prominent feature.”

“The proliferative activity, leading to the production of abundant scar tissue, may in itself be distinctly harmful.”

“The final healed state is achieved by development of a connective tissue scar.”

An important premise from Drs. Anderson and Scotti is that in chronic inflammation, “abundant” scar tissue may form, and this connective tissue scar may “itself be distinctly harmful.”

•••

In 1979, Harvard Medical School professors Stanley Robbins, MD, and Ramzi Cotran, MD, published the second edition of their book, titled (5):

PATHOLOGIC BASIS OF DISEASE

Similar to Boyd, Anderson and Scotti, Robbins and Cotran, title chapter 3 of their textInflammation and Repair.Robbins and Cotran state:

“Inflammation serves to destroy, dilute, or wall-off the injurious agent.”

“Without inflammation, bacterial infections would go unchecked.”

But, “inflammation itself may be potentially harmful:”

Chronic inflammation is “generally of longer duration and is associated histologically with the presence of lymphocytes and macrophages and the proliferation of small blood vessels and fibroblasts.”

Tissues are replaced by “filling the defect with less specialized fibroblastic scar-forming tissue.”

“Reparative efforts may lead to disfiguring scars, fibrous bonds that limit the mobility of joints, or masses of scar tissue that hamper the function of organs.”

       

It is of particular interest to chiropractors that this cascade of inflammation and fibrosis may “limit the mobility of joints.”

•••

In 1982, orthopedic surgeon Sir James Cyriax, MD, published the eighth edition of his book titled (6):

Textbook of Orthopaedic Medicine:
Diagnosis of Soft Tissue Lesions

In this text, Dr. Cyriax notes that harmful infections create tissue destruction, resulting in inflammation. Our body recognizes this inflammation and attempts to “wall off” the infectious pathogens by creating a fibrous response. Cyriax states:

“The excessive reaction of tissues to an injury is conditioned by the overriding needs of a process designed to limit bacterial invasion.  If there is to be only one pattern of response, it must be suited to the graver of the two possible traumas.  However, elaborate preparation for preventing the spread of bacteria is not only pointless after an aseptic injury, but is so excessive as to prove harmful in itself.  The principle on which the treatment of post-traumatic inflammation is based is that the reaction of the body to an injury unaccompanied by infection is always too great.”

Once again, a link is expressed between infection, inflammation, and excessive-harmful tissue fibrosis.

•••

In 1983, physicians Steven Roy and Richard Irvin published their book on sports injury titled (7):

Sports Medicine:
Prevention, Evaluation, Management, and Rehabilitation

In this book, Roy and Irvin state:

“It is important to realize that the body’s initial reaction to an injury is similar to its reaction to an infection.  The reaction is termed inflammation and may manifest macroscopically (such as after an acute injury) or at a microscopic level, with the latter occurring particularly in chronic overuse conditions.”

•••

In 1986, physician and physiologist, Arthur Guyton, MD, published the seventh edition of his book, titled (8):

Textbook of Medical Physiology

At the time of publication, Dr. Guyton was Chairman and Professor of Physiology and Biophysics at the University of Mississippi School of Medicine. Dr. Guyton states:

“One of the first results of inflammation is to ‘wall off’ the area of injury from the remaining tissues.”

“This walling-off process delays the spread of bacteria or toxic products.”

Once again, Guyton expresses the concept of a sequential link between infection, inflammation, and fibrosis. This fibrosis, in the absence of inflammation, creates excessive mechanical impairments that are both mechanically and neurologically deleterious to the individual.

•••

In 1992, physician I. Kelman Cohen and associates published their book titled Wound Healing, Biochemical & Clinical Aspects (9), in which they state:

“There are two important consequences of being a warm-blooded animal. One is that body fluids make optimal culture media for bacteria. It is to the animal’s advantage, therefore, to heal wounds with alacrity in order to reduce chances of infection.”

“The prompt development of granulation tissue forecasts the repair of the interrupted dermal tissue to produce a scar.” In addition to providing tensile strength, scars are believed to be a barrier to infectious migration.

•••
For more than half a century, experts in pathology, physiology, orthopedics, sports injuries, and wound healing have suggested the following model:

Inflammation is a paradox. Inflammation can directly kill pathogens. Inflammation also triggers a fibrous response that walls-off infection so that the pathogens are less likely to spread and kill the host. Without inflammation we would die of infection. All who are alive today had ancestors that could successfully initiate an inflammatory response, kill pathogens, and wall off the pathogens.

Infection can kill the young before they can reproduce. Hence, a strong inflammatory response is genetically selected, giving those with such a response a survivability advantage. Our ancestors genetically handed down these traits and we possess them. In a world prior to the availability of antibiotics, inflammation, with reactive walling-off fibrosis to contain pathogens, is desirable because it increases host survivability.

Infections were the primary cause of death for humans for millennias. Infections remained the primary cause of human death until very recent history, only a few decades ago.

Infection is not the only cause of inflammation. As noted above, inflammation is also triggered by trauma, excessive tissue stress, chemicals, and immunologic responses. Apparently, the body cannot distinguish the different causes of inflammation from each other, and they all trigger a fibrous response. “The resolution of inflammation in the body is fibrosis.”

This fibrosis response is necesasary when there is an infection, it is life-saving. However in an aseptic sterile injury or tissue stress, the fibrous response is excessive and it creates adverse mechanical deficits. These adverse mechanical deficits create tissue stiffness and limit the mobility of joints. These mechanical deficits impair local biomechanical function, affecting performance, generating pain, and accelerating degenerative changes.

•••

SOLUTIONS

The management of adverse tissue fibrosis creates the pathoanatomical basis for mechanical based health care disciplines, including chiropractic. Abnormal tissue fibrosis can be minimized with early, persistent, controlled motion. Once established, abnormal tissue fibrosis can be improved with the use of a variety of motion applications. Support for the value in using motion to treat soft-tissue injuries has been in the literature for decades. As an example, Beverly Hills neurosurgeon Emil Seletz, associated with the medical school at the University of California, Los Angeles (UCLA), noted in the Journal of the American Medical Association in 1958, the following, with respects to the management of whiplash soft-tissue injuries (10):

“During injury, hemorrhage within the capsular ligaments gives rise to swelling of the nerves and eventually adhesions between the dural sleeve and the nerve root; these factors give rise to symptoms that may be prolonged for months or even years after the injury.”

“In reviewing the types of treatment with a number of specialists in this field, it is found that, while therapy naturally varies to suit the individual need, it consists primarily of local heat in the form of hot wet packs and cervical traction, followed by very gentle massage and manual rotations.”

“The importance of a carefully planned scheme of treatment must be emphasized to the patient, and treatments must be religiously carried out daily during the first two or three weeks (and then about three times weekly), depending, of course, on the individual case.”

“Delay or faulty treatment leads to adhesions about the facets and scarring about the capsular ligaments, persistent spasm, congestive lymph edema, and fibrosis of muscles, swelling, and eventual adhesions of nerves within the nerve root canals.”

“The resultant faulty posture in neglected cases enhances the degeneration of the intervertebral disks, as well as spur formation in the lateral co-vertebral articulations, which on the roentgenogram has come to be known as traumatic arthritis.”

“I cannot too strongly emphasize the urgency of early and persistent therapy, always by a specialist in this field.”

“Occasionally, a patient is seen with persistent complaints of head, neck, and shoulder pain, who has had on surgical exposure persistent swelling and adhesions of several nerve roots within the dural sleeve of exit.  It is most likely that early, persistent, and adequate therapy by those expertly trained in physical medicine will prevent most patients from developing a surgical condition.”

On this topic, Cyriax’s comments include a review of the 1940 primary research by ML Stearns (11), stating:

“Her (Stearns) main conclusion on the mechanics of the formation of scar tissue was that external mechanical factors, were responsible for the development of the fibrillary network into orderly layers.  Within four hours of applying a stimulus, an extensive network of fibrils was already visible around the fibroblasts; during the course of 48 hours this became dense enough to hide the cells almost completely: and in 12 days a heavy layer of fibrils had appeared. At first the fibrils developed at random, but later they acquired a definite arrangement, apparently as a direct result of the mechanical factors.  Of these factors, movement is obviously the most important and equally obvious it is most effective and least likely to cause pain before the fibrils have developed an abnormal firm attachment to neighboring structures.  When free mobility was encouraged from the onset, the fibers in the scar were arranged lengthwise as in a normal ligament. Gentle passive movements do not detach fibrils from their proper formation at the healing breach but prevent their continued adherence at normal sites. The fact that the fibrils rapidly spread in all directions provides sufficient reason for beginning movements at the earliest possible moment; otherwise they develop into strong fibrous scars (adhesions) that so often cause prolonged disability after a sprain.”

Additionally, Cyriax notes:

“When pain is due to bacterial inflammation, Hilton’s advocacy of rest remains unchallenged and is today one of the main principles of medical treatment.  When, however somatic pain is caused by inflammation due to trauma, his ideas require modification.  When non-bacterial inflammation attacks the soft tissues that move, treatment by rest has been found to result in chronic disability, later, although the symptoms may temporarily diminish.  Hence, during the present century, treatment by rest has given way to therapeutic movement in many soft tissue lesions.  Movement may be applied in various ways:  the three main categories are:

(a) Active and resistive exercises:

(b) Passive, especially forced movement: and

(c) Deep massage.”

“Tension within the granulation tissue lines the cells up along the direction of stress. Hence, during the healing of mobile tissues, excessive immobilization is harmful. It prevents the formation of a scar strong in the important direction by avoiding the strains leading to due orientation of fibrous tissue and also allows the scar to become unduly adherent, e.g. to bone.”

In 1983, sports physicians Steven Roy and Richard Irvin note (7):

“The injured tissues next undergo remodeling, which can take up to one year to complete in the case of major tissue disruption. The remodeling stage blends with the later part of the regeneration stage, which means that motion of the injured tissues will influence their structure when they are healed. This is one reason why it is necessary to consider using controlled motion during the recovery stage. If a limb is completely immobilized during the recovery process, the tissues may emerge fully healed but poorly adapted functionally, with little chance for change, particularly if the immobilization has been prolonged.  Another reason for encouraging controlled motion is that any adhesions that develop will be flexible and will thus allow the tissues to move easily on each other.”

In 1986, physician John Kellett notes (12):

Acute inflammation is beneficial when one has acute infection. However, the “acute inflammatory phase of the body’s response to trauma is apparently of no benefit.”

“The micropathology of acute soft tissue trauma has been investigated. Healing of ligaments and soft tissue injuries in general has been shown to occur by fibrous repair (scar tissue) and not by regeneration of the damaged tissue.”

“Early mobilization, guided by the pain response, promotes a more rapid return to full activity.”

“Early mobilization, guided by the pain response, promotes a more rapid return to full functional recovery.”

“The collagen is remodeled to increase the functional capabilities of the tendon or ligament to withstand the stresses imposed upon it.”

“It appears that the tensile strength of the collagen is quite specific to the forces imposed on it during the remodeling phase: i.e. the maximum strength will be in the direction of the forces imposed on the ligament.”

Dr. Cohen (9) and associates also comment on the value of range of motion exercises in the management of soft tissue injury, stating:

“During the phase of wound contraction, the active cellular process is locked into position by increasing amounts of rigid collagenous scar. Frequent, gentle exercise can be used to put an extremity joint through a full range of motion and keep the newly developing scar tissue stretched and remodeled. Frequent use of the range of motion exercises is important to keep the developing and contracting scar tissue from becoming a rigid, fixed scar contracture. Range of motion exercises concentrate on remodeling the newly laid collagen before it develops into a rigid scar contracture.”

In 1994, Halldor Jonsson and associates (13) performed surgical evaluations of 50 patients with chronic whiplash symptoms, showing a “high incidence of discoligamentous injuries in whiplash-type distortions.” The authors noted:

“The injured spinal segments had become increasingly stiffer over 5 years, which may reflect healing of unrecognized soft tissue injuries.”

“The most likely source of radicular symptoms is perineural scarring.

Therefore, patients with neck distortions after traffic accidents should be mobilized early within the limits of pain to prevent scar transformation of hidden injuries.”

In 2000, Pekka Kannus, MD, Ph.D., published a study in the journal The Physician and Sports Medicine  (14). Dr. Kannus is chief physician and head of the Accident and Trauma Research Center and sports medicine specialist at the Tampere Research Center of Sports Medicine at the UKK Institute in Tampere, Finland. His article titled “Immobilization or Early Mobilization After an Acute Soft-Tissue Injury?” notes:

Prolonged inflammation may lead to excessive scarring.  Therefore, early, effective treatment seeks to prevent prolonged inflammation and excessive scarring.

“Experimental and clinical studies demonstrate that early, controlled mobilization is superior to immobilization for primary treatment of acute musculoskeletal soft-tissue injuries and postoperative management.”

“The current literature on experimental acute soft-tissue injury speaks strongly for the use of early, controlled mobilization rather than immobilization for optimal heating.”

Experimentally induced ligament tears in animals heal much better with early, controlled mobilization than with immobilization.

“The superiority of early controlled mobilization has been especially clear in terms of quicker recovery and return to full activity without jeopardizing the subjective or objective long-term outcome.”

“Controlled experimental and clinical trials have yielded convincing evidence that early, controlled mobilization is superior to immobilization for musculoskeletal soft-tissue injuries. This holds true not only in primary treatment of acute injuries, but also in their postoperative management. The superiority of early controlled mobilization is especially apparent in terms of producing quicker recovery and return to full activity, without jeopardizing the long-term rehabilitative outcome. Therefore, the technique can be recommended as the method of choice for acute soft-tissue injury.”

Spinal manipulation is a form of passive controlled motion that mechanically influences more tissue than does either active or passive motions (15). Consequently, it is superior to other therapies in remodeling periarticular fibrosis and in reducing intra-articular adhesions. As noted by orthopedic surgeon Kirkaldy-Willis, MD:

In chronic cases [of back pain], there is a shortening of periarticular connective tissues and intra-articular adhesions may form; manipulations [adjustments] can stretch or break these adhesions.

“Spinal manipulation is essentially an assisted passive motion applied to the spinal apophyseal and sacroiliac joints.”

Conclusions

The discussion and references above support the concept that adverse pathogens cause tissue destruction and subsequent inflammation. The body evolved in a manner to wall-off the area of inflammation by over healing the region with a fibrous response. The fibrous response becomes a physical barrier, reducing the ability of the pathogens to spread to other regions of the body, thereby improving the host’s chances for survival.

However, when inflammation is caused by non-infectious mechanisms, the same fibrotic tissue response occurs. In such cases, without infectious pathogens, the fibrotic tissue response is excessive, resulting in mechanical harm to the host. This harmful tissue fibrosis is worsened with early immobilization of the affected tissues. This tissue fibrosis is minimized with early persistent controlled mobilization. Established harmful tissue fibrosis is best managed with specific controlled motion. Periarticular and intra-articular adhesions probably respond best to joint manipulation.

REFERENCES

  1. Mehal WZ; Cells on Fire; Scientific American; June 2015; Vol. 312; No. 6; pp. 45-49.
  2. Boyd W; PATHOLOGY: Structure and Function in Disease; Lea and Febiger, 1952.
  3. Boyd W; PATHOLOGY: Structure and Function in Disease; Eighth Edition; Lea & Febiger; Philadelphia; 1970.
  4. Anderson WAD, Scotti TM; Synopsis of Pathology; Ninth Edition; The CV Mosby Company; 1976.
  5. Robbins SL, Cotran RS; PATHOLOGIC BASIS OF DISEASE; Second Edition; WB Saunders Company; Philadelphia; 1979.
  6. Cyriax, James; Textbook of Orthopaedic Medicine, Diagnosis of Soft Tissue Lesions; Bailliere Tindall; Volume 1; eighth edition; 1982.
  7. Roy, Steven; Irvin, Richard; Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation; Prentice-Hall; 1983.
  8. Guyton A; Textbook of Medical Physiology; Saunders; 1986.
  9. Cohen, I. Kelman; Diegelmann, Robert F; Lindbald, William J; Wound Healing, Biochemical & Clinical Aspects; WB Saunders; 1992.
  10. Seletz E; Whiplash Injuries, Neurophysiological Basis for Pain and Methods Used for Rehabilitation; Journal of the American Medical Association; November 29, 1958; pp. 1750–1755.
  11. Stearns ML; Studies on development of connective tissue in transparent chambers in rabbit’s ear; American Journal of Anatomy; Vol. 67 1940; p. 55.
  12. Kellett J; Acute soft tissue injuries–a review of the literature; Medicine and Science in Sports and Exercise; Oct. 1986;18(5):489-500.
  13. Jonsson H, Cesarini K, Sahlstedt B, Rauschning W; Findings and Outcome in Whiplash-Type Neck Distortions; Spine; Vol. 19; No. 24; December 15, 1994; pp. 2733-2743.
  14. Kannus P; Immobilization or Early Mobilization After an Acute Soft-Tissue Injury?; The Physician And Sports Medicine; March, 2000; Vol. 26; No. 3; pp. 55-63.
  15. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”

July 2015

When a force is applied to a joint, increased motion and “joint separation” occur. This can be done without causing any injury to the joint tissues (bones, cartilage, ligaments, muscles, tendons, nerves, etc.). This increased motion has a number of proposed benefits, including (1):

  • The disruption of intra-articular and peri-articular adhesions.
  • The remodeling of peri-articular fibrosis.
  • Generating spinal cord reflexes that inhibit muscle tone and spasm.
  • Improving proprioception to inhibit pain by closing the pain gate.

The classic joint cavitation process was initially described by Sandoz in 1976 (2). In this initial publication, Sandoz categorizes joint motion into three categories:

  • Active Motion
  • Passive Motion
  • Peri-articular Paraphysiological Space Motion

This model of joint cavitation is supported by others (1, 3), and is explained as follows:

There are three categories of joint motion:

1)     Active Range of Motion.

This is the motion that occurs as a consequence of performing exercise.

2)     Passive range of Motion.

This is the motion that occurs as a consequence of stretching and/or through mobilization techniques.

“Beyond the end of the active range of motion of any synovial joint, there is a small buffer zone of passive mobility.” A joint can only move into this zone with passive assistance, and going into this passive range of motion “constitutes mobilization.” [not manipulation.]

3)     Peri-articular Paraphysiological Space Motion

“At the end of the passive range of motion, an elastic barrier of resistance is encountered.”

“If the separation of the articular surfaces is forced beyond this elastic barrier, the joint surfaces suddenly move apart with a cracking noise.”

“This additional separation can only be achieved after cracking the joint and has been labeled the paraphysiological range of motion. This constitutes manipulation.”

“The cracking sound on entering the paraphysiological range of motion is the result of sudden liberation of synovial gases—a phenomenon known to physicists as cavitation.”

Following cavitation, a synovial bubble can be observed on x-rays, which is reabsorbed over the following 30 minutes.  During this “refractory period” there is no resistance between the passive and paraphysiological zones.

“At the end of the paraphysiological range of motion, the limit of anatomical integrity is encountered.  Movement beyond this limit results in damage to the capsular ligaments.”

Joint manipulation [adjusting] “requires precise positioning of the joint at the end of the passive range of motion and the proper degree of force to overcome joint coaptation” [to overcome the resistance of the joint surfaces in contact].

image-01

•••••

Physicians JB Roston and R Wheeler Haines from St. Thomas’s Hospital Medical School, London, UK, published the first study in the literature to investigate the cavitation of a joint leading to an audible “cracking” of the joint in 1947. It was published in the Journal Of Anatomy and titled (4):

Cracking in the Metacarpal-Phalangeal Joint

In this study, the subject’s middle digit was wrapped with adhesive plaster, and a stout string was tied tightly over this, around the proximal phalanx. The string was then attached to an immovable object through a tensiometer. A preliminary x-ray was taken. The subject was instructed to draw his hand away until the metacarpal-phalangeal (MC) joint “cracked”, and the tensiometer recorded the degree of traction. After “cracking,” while still under tension, a second x-ray was taken, and the degree of joint separation was measured.

When the “crack” occurred, an immediate and significant increase in joint separation also occurred, from 1-3 mm. (Picture after 1, 2, 5)

image-02

These authors noted that a tractional tension of about 6 kg is insufficient to produce a “crack,” but will slightly separate the adjacent joint surfaces. After a tension of about 7 kg or more, a “crack” will occur and there is an immediate significant separation of the joint surfaces.

After the joint “cracks” and the increased joint separation is achieved, the increased separation can be repeated for the next 17-22 minutes without having to recavitate the joint. Further direct tension on the joint will not produce a second crack; the joint is in a “refractory phase.”

After about 20 minutes (17-22 minutes), the whole cycle of joint “cracking” can be repeated. “The minimum time recorded between two cracks produced by direct tension was 17 minutes, and never more than 22 minutes rest was required before a second crack could be produced.”

After “cracking” the joint, a tractional x-ray shows a gas shadow bubble in the joint. These authors suggest that the refractory phase after cracking corresponds to the time required for the gas bubble to pass back into solution.

These authors found that some joints were difficult (or impossible) to cavitate (“crack”). They propose that the explanation for this “is inability to relax the muscles whose tendons pass across the joint.” This has clinically practical importance.

•••••

Decades later, a second, more detailed study investigating the joint cavitation and “cracking” phenomenon appeared in the Annals of Rheumatic Diseases in 1971. The investigators were from the Bioengineering Group for the study of Human Joints, at the University of Leeds in the United Kingdom. Their study is titled (5):

‘Cracking Joints’ A Bioengineering Study of Cavitation in the Metacarpal-phalangeal Joint

The authors used a similar investigational approach as the prior study (Roston/Haines, 4) on 17 test subjects. Interestingly, on 5 of their test subjects they were not able to cavitate their joints because they could “not relax sufficiently to allow a test to be performed properly.” In agreement with the prior study (4), increased muscle tension appears to impair the ability of a joint to cavitate and “crack.”

These authors largely agree with the finding of Roston/Haines (4) above. With increased joint traction, they state:

“The joint separation increases at a high rate, allowing the net flow of fluid into the low pressure regions. This results in collapse of the vapor phase of the cavities with consequent energy release as noise (the ‘crack’ heard externally).”

The gas removed during the period of low pressure “does not   reabsorb for 20 to 30 minutes.”

“This gas is readily visible on the radiograph, but is not responsible for causing the crack; it is there as a consequence of the cracking phenomenon.”

“The results support the view that ‘cavitation’ is responsible for the phenomenon of cracking.”

These authors extracted the post-cavitation gas bubble and analyzed it. They found it to be composed of carbon dioxide.

•••••

The most recent study investigating joint cavitation and “cracking” was published April 15, 2015, in the journal Public Library of Science One (PLOS ONE). Gregory N. Kawchuk from the Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, CAN, and colleagues titled their study (6):

Real-Time Visualization of Joint Cavitation

The objective of this study was to characterize the events associated with joint cracking within the joint itself using real-time cine-magnetic resonance imaging (cine-MRI). This article presents direct evidence from real-time magnetic resonance imaging that the mechanism of the sound obtained is from joint cavitation. The authors applied a slowly increasing long-axis traction manually to 10 metacarpal-phalangeal joints while imaging the joints with rapid cine-magnetic resonance images at a rate of 3.2 frames per second until the cracking event occurred.

This cine-MRI study, in agreement with prior x-ray studies, showed that joint cracking following joint distraction followed this sequence of events:

  • The process begins with the resting phase where joint surfaces are in close contact.
  • “As traction forces increased, real-time cine magnetic resonance imaging demonstrated rapid cavity inception at the time of joint separation and sound production after which the resulting cavity [gas bubble] remained visible.”

The evidence shows that the mechanism of joint cracking is related to cavity (gas shadow) formation. These authors make the following observations:

“Our results offer direct experimental evidence that joint cracking is associated with cavity inception.”

“Cracking” sounds require time to pass before they can be repeated despite ongoing joint motion. This is called the refractory period.

“A light distraction force will barely separate the joint surfaces. With a greater distraction force, the surfaces resist separation until a critical point after which they separate rapidly. It is during this rapid separation phase that the characteristic cracking sound is produced. Following cracking, the joint is in a refractory phase where no further cracking can occur until time has passed (approximately 20 minutes).”

“Cine-MRI demonstrated minimal joint surface separation in the resting phase prior to joint cracking followed by rapid joint separation during the crack itself.”

“Cine-MRI revealed rapid cavity inception associated with concurrent sound production and joint separation.”

These authors also observed that joint separation with cavity formation does not occur at the same traction force in each finger. This implies that some joints are easier and some joints are harder to cavitate. Other research, noted above, attribute this to tension of the muscles that cross a particular joint that one is attempting to cavitate.

These authors end their study by stating: “Habitual knuckle cracking has not been shown to increase joint degeneration.”

•••••

Is Frequent Joint “Cracking” Harmful to Joints?

Several studies have investigated as to whether habitual joint cracking is harmful to the cavitated joint, especially with respect to the incidence of degenerative joint disease (osteoarthritis). In 1975, researchers for the Departments of Medicine and Rehabilitation Medicine at the University of Southern California School of Medicine in Los Angeles, CA, published a study in the Western Journal of Medicine, titled (7):

The Consequences of Habitual Knuckle Cracking

The authors note that habitual knuckle cracking has been considered to be a cause of arthritis. Knuckle cracking appears to cause some comfort or satisfaction to the person doing it; however, it has been claimed, “arthritis would be an inevitable outcome.” As a consequence, many children with this habit are chided to stop cracking their knuckles lest arthritis or enlarged knuckles or both develop.

Knuckle cracking appears to be a habit that begins in childhood and persists into adult life.

In this study, 28 (average age 78.5 years) patients were examined clinically and by x-ray; 15 were habitual knuckle crackers and 13 were not (controls).

The authors found that only one subject with a history of knuckle cracking showed metacarpal-phalangeal degenerative joint disease (DJD). In contrast, 5 of the control subjects (non-knuckle crackers) had metacarpal-phalangeal degenerative joint disease.

Elderly people (average 78.5 years) and knuckle cracking / osteoarthritis

 

Yes Habitual Knuckle Cracking

N= 15

No Habitual Knuckle Cracking

N= 13

Yes Knuckle Osteoarthritis

1

5

No Knuckle Osteoarthritis

14

8

Percentage with Osteoarthritis

6.7%

38.5%

These authors observed that every patient with metacarpal-phalangeal degenerative joint disease, whether or not they were knuckle crackers, also had radiographic evidence of distal hand degenerative joint disease, suggesting that “metacarpal-phalangeal degenerative joint disease is a function of whatever the predisposing factors are to osteoarthritis” and that

“metacarpal-phalangeal degenerative joint disease is not a consequence of knuckle cracking.”

These authors also made these comments:

This survey of a “geriatric patient population with a history of knuckle cracking failed to show a correlation between knuckle cracking and degenerative changes of the metacarpal phalangeal joints.”

“The data fail to support evidence that knuckle cracking leads to degenerative changes in the metacarpal phalangeal joints in old age.”

“The chief morbid consequence of knuckle cracking would appear to be its annoying effect on the observer.”

This study concludes that habitual knuckle cracking does not increase the incidence of cracked knuckle osteoarthritis. However, in reviewing the data, their findings could have been interpreted differently:

1/15 knuckle crackers had knuckle DJD, = 6.7%

5/13 who did NOT crack their knuckles had knuckle DJD, = 38.5%

An alternative interpretation could be that habitual knuckle cracking significantly reduces the incidence of knuckle degenerative joint disease. Mathematically, it is an 82% reduction.

•••••

 A more recent investigation of knuckle cracking and osteoarthritis was published in the journal American Board of Family Medicine in 2011 by military physicians Kevin deWeber,  Mariusz Olszewski, and Rebecca Ortolano. Their article is titled (8):

Knuckle Cracking and Hand Osteoarthritis

These physicians note that the characteristics of hand osteoarthritis include:

  • It increases in prevalence and severity with age.
  • 22% of those aged between 71 to 100 years have symptomatic hand osteoarthritis.
  • Risk factors include prior joint trauma, family history of hand osteoarthritis, and history of heavy labor involving the hands.
  • Those with hand osteoarthritis have reduced grip strength, difficulty writing, difficulty handling small objects, and difficulty carrying objects.

Consequently, they state:

“Given this burden of suffering from hand osteoarthritis and the lack of curative or disease-modifying treatments, factors that potentially protect against osteoarthritis warrant further investigation. One such factor is knuckle cracking.”

Knuckle cracking is a behavior that involves manipulation of the finger joints that results in an audible crack, and it is often done habitually. It is estimated that 25% to 54% of people habitually crack their knuckles:

  • 25% in adults older than 45 years
  • 34% in 11-year-old children
  • 54% among nursing home residents with a mean age of 78 years

This study assessed 215 individuals; 135 with osteoarthritis, and 80 controls. Their mean age was 62 years (50 to 89 years). Twenty percent habitually cracked their knuckles. Participant’s hands were assessed radiographically.

Study subjects quantified the frequency of their daily knuckle cracking:

  • None
  • 1–5 times/day
  • 6–10 times/day
  • 10–20 times/day
  • >20 times/day

Study participants described how frequently each day they crack each knuckle and for how many years they have been doing it. This was the first study to correlate the duration and the total volume of previous knuckle cracking with osteoarthritis.

The mechanics of knuckle cracking was described as follows:

“During an attempt to crack a knuckle, the joint is manipulated by axial distraction, hyperflexion, hyperextension, or lateral deviation. This lengthens part or all of the joint space and greatly decreases intra-articular pressure, causing gases that have dissolved in the synovial fluid to form microscopic bubbles, which coalesce. When the joint space reaches its maximum distraction (up to 3 times its resting joint space distance), joint fluid rushes into the areas of negative pressure. The larger bubbles suddenly collapse into numerous microscopic bubbles, leading to the characteristic cracking sound. The maneuver leaves the joint space wider than it had been and synovial fluid more widely distributed. The stretching of joint ligaments required to produce the widened joint space also leaves the joint with greater range of motion. It typically takes at least 15 minutes for the joint to be able to be cracked again because of the time required for the microscopic bubbles to fully dissolve into solution and for the joint space to retract back to its resting position.”

Findings include:

“This study represents the most comprehensive evaluation to date of habitual knuckle cracking and any association with hand osteoarthritis. Our findings support the conclusions of 2 previous studies that the presence of knuckle cracking is not associated with hand osteoarthritis.”

“The duration of knuckle cracking has no correlation to the presence of osteoarthritis.” There was “no significant correlation of knuckle cracking ‘crack-years’ with osteoarthritis in the respective joint.”

These authors conclude, “a history of habitual knuckle cracking—including the total duration and total cumulative exposure to knuckle cracking—does not seem to be a risk factor for hand osteoarthritis.”

These authors note that some people crack their knuckles because of the sense of relief it can bring, some do so because of habit, and some for both reasons. After knuckle cracking, there is an “immediate joint tension release and increased joint range of motion.” A “common urban legend suggests that knuckle cracking will lead to arthritis of the hand joints,” but this is not “supported in the medical literature.”

•••••

A lay and/or cynical argument against regular chiropractic care is that the regular cavitation of the joints increases the risk of osteoarthritis. The reviewed articles investigated a clinically relevant number of individuals who cavitated their knuckle joints multiple times daily for years and suffered no increased risk of joint osteoarthritis. One study suggests that regular cavitation of joints may in fact reduce the risk of joint osteoarthritis.

There appears to be no controversy that joint cavitation improves joint range of motion and reduces articular symptomatology.

REFERENCES 

  • Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985, Vol. 31, pp. 535-540.
  • Sandoz R. Some physical mechanisms and effects of spinal adjustment. Ann Swiss Chiropractic Association; 1976; 6: 91–141.
  • Fischgrund, Jeffrey S, Neck Pain, monograph 27, American Academy of Orthopaedic Surgeons, 2004.
  • Roston JB, and R. Wheeler-Haines R; Cracking in the Metacarpo-Phalangeal Joint; Journal Of Anatomy; Vol. 81; Part 2; 1947; pp. 165-173.
  • Unsworth A, Dowson D, Wright V. ‘Cracking joints’ A bioengineering study of cavitation in the metacarpophalangeal joint. Ann Rheum Dis. 1971; 30: 348–358.
  • Gregory N. Kawchuk GN, Jerome Fryer J, Jacob L. Jaremko JL, Hongbo Zeng H, Lindsay Rowe L, Richard Thompson R; Real-Time Visualization of Joint Cavitation; Public Library of Science One (PLOS ONE); April 15, 2015; Vol. 10; No. 4; pp. e0119470.
  • Robert L. Swezey RL, MD, and Stuart E. Swezey SE; The Consequences of Habitual Knuckle Cracking; Western Journal of Medicine; May 1975; Vol. 122; pp. 377-379.
  • Kevin deWeber K, MD; Mariusz Olszewski M, MD; Rebecca Ortolano R; Knuckle Cracking and Hand Osteoarthritis; American Board of Family Medicine; March-April 2011; Vol. 24; No. 2; pp. 169-174.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”

June 2015

Fibromyalgia: The Influence of Chiropractic Manipulation on Clinical Outcomes

Fibromyalgia is an incredibly complex, widespread, and disabling neuromusculoskeletal disorder. Fibromyalgia affects between 2-8% of the American population, somewhere between 6 million to 25 million individuals (1). A literature search of the National Library of Medicine of the United States using the key work “fibromyalgia” will locate 8,489 citations (May 8, 2015).

Daniel Clauw, MD, is a Professor of Anesthesiology, Medicine (Rheumatology) and Psychiatry at the University of Michigan. In May, 2015, Dr. Clauw published a study in the journal Mayo Clinical Proceedings, titled (2):

Fibromyalgia and Related Conditions

The abstract from this publication includes these points:

“Fibromyalgia is the currently preferred term for widespread musculoskeletal pain, typically accompanied by other symptoms such as fatigue, memory problems, and sleep and mood disturbances, for which no alternative cause can be identified.”

“Earlier there was some doubt about whether there was an ‘organic basis’ for these related conditions, but today there is irrefutable evidence from brain imaging and other techniques that this condition has strong biological underpinnings, even though psychological, social, and behavioral factors clearly play prominent roles in some patients.”

“The pathophysiological hallmark is a sensitized or hyperactive central nervous system that leads to an increased volume control or gain on pain and sensory processing. This condition can occur in isolation, but more often it co-occurs with other conditions now being shown to have a similar underlying pathophysiology (eg, irritable bowel syndrome, interstitial cystitis, and tension headache) or as a comorbidity in individuals with diseases characterized by ongoing peripheral damage or inflammation (eg, autoimmune disorders and osteoarthritis).”

“The term centralized pain connotes the fact that in addition to the pain that might be caused by peripheral factors, there is superimposed pain augmentation occurring in the central nervous system.”

“It is important to recognize this phenomenon (regardless of what term is used to describe it) because individuals with centralized pain do not respond nearly as well to treatments that work well for peripheral pain and preferentially respond to centrally acting analgesics and nonpharmacological therapies.”

It is the “nonpharmacological therapies” that are emphasized in this review.

The world’s leading authority on fibromyalgia is Fredrick Wolfe, MD. Dr. Wolfe is a Clinical Professor of Medicine at the University of Kansas School of Medicine. A search of the National Library of Medicine of the United States using the key words “wolfe f AND fibromyalgia” finds 119 articles.

In 1990, Dr. Wolfe and colleagues published the Criteria for the Classification of Fibromyalgia for the American College of Rheumatology (3). To complete this task, Dr. Wolfe and colleagues studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Trained, blinded assessors performed interviews and examinations. The authors concluded that the clinical diagnosis of fibromyalgia required both of the following:

  • Widespread pain (axial plus upper and lower segment plus left and right-sided pain).
  • Excessive tenderness at 11 or more of 18 specific tender point sites.

These fibromyalgia diagnostic criteria became the standard for the next 20 years, from 1990 to 2010. The location of the 18 specific tender point sites is included below: 

image-02

In 2010, Dr. Wolfe and colleagues updated the Criteria for the Classification of Fibromyalgia for the American College of Rheumatology (4). There had been a growing concern in the original diagnostic criteria for fibromyalgia that relied significantly on the presence of tender points. This is because of the fact that women in general are more sensitive to pressure point tenderness than are men. Relying on pressure point tenderness could cause a sex bias, which might account for the finding that about 90% of diagnosed fibromyalgia sufferers are women. It had become apparent that the “focus on tender points was not justified.” (5) Consequently, Dr. Wolfe and colleagues developed simple, practical criteria for clinical diagnosis of fibromyalgia that did not require a tender point examination, and to provide a severity scale for characteristic fibromyalgia symptoms (4). Specifically, they used an amalgamation of two prior developed assessment protocols:

1) The Widespread Pain Index (WPI)

This is a measure of the number of painful body regions (a total of 19 locations).

2) The Symptom Severity (SS) Scale.

This scale is designed to grade adjunct fibromyalgia symptoms, specifically cognitive symptoms (trouble remembering or thinking), un-refreshed sleep, fatigue, and number of somatic symptoms.

A sample of the questionnaire is included below.

The authors concluded that this simple form correctly classified 88.1% of fibromyalgia cases, and that classifying fibromyalgia  “does not require a physical or tender point examination.” This approach to the diagnosis of Fibromyalgia Syndrome continues to be supported (6). To diagnose fibromyalgia, patients should:

  • Have pain in a number of areas of the body, widespread pain (upper body, lower body, left side, right side).
  • Be substantially bothered by fatigue.
  • Have difficulty in getting restful sleep.
  • Often have problems with memory or thinking clearly.

New Fibromyalgia Diagnostics 2010
All Three Are Needed For the Diagnosis of Fibromyalgia Syndrome

1)     Either WPI ≥ 7 and SS ≥ 5   OR    WPI 3 – 6 and SS ≥ 9

2)     Symptoms are present and essentially unchanged for ≥ 3 months

3)     There is no alternative explanation for the pain

 

Widespread Pain Index

Score: 1 For Each Spot

Shoulder Girdle L
Shoulder Girdle R
Upper Arm L
Upper Arm R
Lower Arm L
Lower Arm R
Hip (buttock/trochanter) L
Hip (buttock/trochanter) R
Upper Leg R
Upper Leg L
Lower Leg L
Lower Leg R
Jaw L
Jaw R
Chest
Abdomen
Upper Back
Lower Back
Neck
Total WPI (0-19)

 

Symptom Severity (SS)

0

1

2

3

Fatigue

No Problem

Mild

Moderate

Severe

Waking up Un-refreshed

No Problem

Mild

Moderate

Severe

Cognitive Symptoms(trouble remembering or thinking)

No Problem

Mild

Moderate

Severe

Number of Somatic Symptoms

None

Few

Moderate

Many

Total Symptom Severity (SS): (0-12)                                        

Recent studies have assessed the influence of spinal mobilization and/or manipulation on the clinical status of patients with fibromyalgia.

In 2014, Michel Reis and colleagues from the School of Medicine, Federal University of Rio de Janeiro, Brazil, published a study in the journal

Rehabilitation Research and Practice titled (7):

Effects of Posteroanterior Thoracic Mobilization on Heart Rate Variability and Pain in Women with Fibromyalgia

These authors note that fibromyalgia is classically characterized by chronic pain, fatigue, depression, insomnia, and reduced cognitive performance. In addition, fibromyalgia is also associated with cardiac autonomic abnormalities.

Heart rate variability is used to investigate cardiovascular autonomic abnormalities. It is a simple, sensitive, and noninvasive tool. Heart rate variability is reduced in fibromyalgia with increased sympathetic tone and activity. It is thought that there is a relationship between increased sustained sympathetic activity and tone and the symptoms of fibromyalgia. Studies suggest autonomic imbalance mechanistically contributes to the symptoms of fibromyalgia. The autonomic imbalance for fibromyalgia is characterized by sympathetic hyperactivity at rest.

Sympathetic hyperactivity may also be responsible for frequent complaints of cold extremities in fibromyalgia patients. Studies have shown that fibromyalgia may be related to changes in autonomic tone, shifting toward an increase in sympathetic activity.

The purpose of this study was to evaluate the effects of one session of a posteroanterior (P-A) glide technique on both autonomic modulation and pain in woman with fibromyalgia. The study used 20 women, half with diagnosed fibromyalgia. This is the first study to demonstrate the effect of a posteroanterior glide mobilization to the thoracic spine on autonomic modulation in patients with fibromyalgia. The mobilization technique used in this study was passive P-A push, sustained for 60 seconds at the T1-T2 spinal level, “corresponding to the thoracic sympathetic preganglionic neurons.”

The upper thoracic mobilization was able to improve heart rate variability and improve autonomic profile through increased vagal activity. In women with fibromyalgia and impaired cardiac autonomic modulation, one session of spinal mobilization was able to acutely improve heart rate variability. In addition, the authors note that, in agreement with other studies, manual therapy protocols are effective in improving pain intensity in fibromyalgia patients. Their conclusions include:

This study shows that “patients with fibromyalgia have increased sympathetic activity and decreased activity in the vagal control of heart rate.” “This sympathetic excitation could contribute to the diffuse pain and tenderness at specific points experienced by patients with fibromyalgia.”

 

“The potentially significant impact of our findings is the demonstration that only one session of this manual intervention to the thoracic spine was able to modify heart rate variability in women with fibromyalgia.”

“It is plausible to hypothesize that the posteroanterior glide technique utilized in the current study may significantly contribute to reducing the debilitating signs and symptoms of fibromyalgia, improve quality of life, and reduce cardiovascular risk when applied for more than one session.”

There is an optimum balance of activity between the sympathetic and the parasympathetic nervous systems. When the balance is disrupted, it adversely influences the entire body, including pain thresholds. Dysfunctional spinal joints increase sympathetic tone, creating an imbalance with parasympathetic tone. Applied mechanical forces (manual therapy, mobilization/manipulation) to the dysfunctional spinal joints inhibits sympathetic tone, restoring autonomic balance, improving homeostasis and reducing pain thresholds.

••••

David Vallez Garcia (from The Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, The Netherlands) and colleagues contributed a chapter in a 2014 book titled PET and SPECT in Neurology, pertaining to the physiology of chronic pain (8). In their review, the authors note:

  • Pain, anywhere in the body, is controlled by the periaqueductal gray (PAG) matter of the mesencephalon (the midbrain, at the top of the brainstem).
  • A major contributor to the periaqueductal gray matter is the vestibular nucleus (VN) of the medulla (the bottom of the brainstem).
  • The vestibular nucleus is also critically involved in posture control.
  • A major contributor to the vestibular nucleus is the proprioceptive neurology from the upper cervical spine, specifically from C1-C2-C3. This proprioception arises form neck muscle spindles, ligaments, and joint capsules.

image-01

Consequently, these authors propose this mechanism for widespread somatic pain syndromes: Mechanical dysfunction of the joints of the upper cervical spine alters the quality of the proprioceptive input from the upper cervical spine muscles, ligaments, and capsules to the vestibular nucleus. The vestibular nucleus becomes less efficient in activating the pain control neurons of the periaqueductal gray matter, resulting in increased chronic widespread body pain syndromes.

These authors note:

“More than 30% of all the spinal-periaqueductal gray fibers originate from the C1-C3 spinal segments.”

Chronic pain symptoms are the “result of a mismatch between aberrant information from the cervical spinal cord and the information from the vestibular and visual systems, all of which are integrated in the mesencephalic periaqueductal gray and adjoining regions.”

Chronic pain symptoms are due to a “mismatch in the midbrain and other structures via the upper cervical cord to the mesencephalon on the one hand and the intact information from the vestibular and visual systems to the mesencephalon on the other hand.”

This chapter supports the perspective that chronic pain syndromes occur as a consequence of poor quality proprioceptive (mechanoreception) input from soft tissues into the central neural axis, and that management should be directed towards improving mechanical function of the dysfunctional soft tissues. This very much supports the chiropractic approach to management of chronic pain patients, especially chiropractic care that targets the function of the joints of the upper cervical spine.

Are there any studies evaluating manipulation of the upper cervical spine in the treatment of patients suffering from fibromyalgia? See below:

•••••

In March 2015, Drs. Ibrahim M. Moustafa and Aliaa A. Diab, from the Basic Science Department, Cairo University, Giza, Egypt, published a study in the journal Rheumatology International, titled (9):

The addition of upper cervical manipulative therapy in the treatment of patients with fibromyalgia: A randomized controlled trial

The aim of this study was to investigate the immediate and long-term effects of a one-year multimodal program, with the addition of upper cervical manipulative therapy, on fibromyalgia management outcomes in addition to three-dimensional (3D) postural measures. It is a prospective, randomized, clinical trial.

These authors note that fibromyalgia syndrome is a common and chronic disorder manifested by increased pain sensitivity and a number of other symptoms such as fatigue, stiffness, non-restorative sleep patterns, memory and cognitive difficulties, and reduced quality of life. Long-term treatment outcomes on fibromyalgia patients “are typically poor.” A survey of 1200 primary care physicians in the USA found that only 14% of respondents indicated very good or excellent satisfaction with the management of patients with fibromyalgia (10).

Published theories as to the cause of fibromyalgia include:

  • Poor nutrition
  • Stress
  • Alterations in sleep patterns
  • Changes in neuroendocrine transmitters
  • Poor posture
  • Cervical spine dysfunction
  • Abnormal afferent processing and/or abnormal sensorimotor integration

This is a randomized clinical trial with a one-year follow-up, assessing 120 patients with fibromyalgia syndrome and definite C1-2 joint dysfunction. Subjects were assessed at 12 weeks (at the end of the treatment program) and again at a 1-year follow-up period. The subjects were randomly assigned to the experimental [upper cervical manipulation] group (n = 60) or the control group (n = 60). Both groups completed a 12-week multimodal program consisting of an education program, cognitive behavior therapy, and an exercise program.

The education program consisted of one 2-hour session per week for 12 weeks, and included:

  • Information about typical symptoms
  • The usual course for fibromyalgia
  • Potential causes of fibromyalgia
  • The influence of psychosocial factors on pain
  • Current pharmacologic and non-pharmacological treatments for fibromyalgia
  • The benefits of regular exercise on fibromyalgia

The cognitive behavior therapy consisted of one 2-hour session per week for 12 weeks, and included educational, physical, cognitive, and behavioral elements.

The exercise program was conducted for 1 hour three times per week for 12 weeks. The participants were instructed to perform the relaxation exercises at home twice daily as their home routine.

The upper cervical spinal manipulation group consisted of both:

  • Low-velocity cervical joint mobilization techniques
  • High-velocity manipulation techniques for the treatment of cervical joint disorders
  • Upper cervical manipulative therapy was conducted in 12 treatments (three times per week) over a one-month period in addition to maintenance spinal manipulations in one session per week for the following 8 weeks. [3X/week for 4 weeks, then 1X/week for 8 weeks]

The group receiving upper cervical spinal manipulation showed significant improvements in spinal posture. After 12 weeks of treatment, the two treatment arms were roughly equally successful in improving the fibromyalgia management outcomes. However, at the 1-year follow-up, the upper cervical spinal manipulation group showed greater improvements in all the fibromyalgia measurement outcomes. These authors made the following points:

        “Increasing evidence suggests that spinal dysfunction, particularly in the upper cervical region (which has more mechanoreceptors per unit surface area than any other region of the spinal column), might affect central neural processing and potentially lead to maladaptive central plastic changes.”

“Cervical manipulation might help to modulate disordered sensorimotor integration and thus counteract changes in the processing of sensory information in the brain and spinal cord.”

“Upper cervical manipulation might be required to achieve optimal full-spine postural correction because the rest of the spine orients itself in a top-down fashion.”

“At the one-year follow-up after the end of the treatment, there were statistically significant changes that indicated that the fibromyalgia syndrome management outcomes of the experimental [upper cervical manipulation] group exhibited continued improvement and that the control subjects’ scores regressed back toward the baseline values (i.e., the scores worsened).”

“The one-year improvements in the FMS management outcome measures observed in the experimental [upper cervical manipulation] group are the most significant findings of our investigation.”

“Sustained postural imbalances can result in the establishment of a state of continuous asymmetric loading. Once this state is established and maintained beyond critical weight and time threshold, degenerative changes in the muscles, ligaments, bony structures, and neural elements increase.” When postural asymmetry is reversed, and the unbalanced loading is thereby corrected the “reversible of these degenerative changes or even their improvement requires some time.”

“The continuous asymmetrical loading and muscle imbalance that results from biomechanical dysfunction due to abnormal spinal posture in the sagittal, transverse, and coronal planes elicits abnormal stress and strain in many structures, including the bones, intervertebral disks, facet joints, musculotendinous tissues, and neural elements and causes a barrage of nociceptive afferent input that results in dysafferentation.”

“Importantly, our results from the one-year follow-up revealed statistically significant changes that favored the experimental [upper cervical manipulation] group’s outcomes in terms of all of the fibromyalgis management outcome variables.”

“The addition of the upper cervical manipulative therapy to a multimodal program is beneficial in treating patients with fibromyalgia syndrome.”

This is an important study, and the data suggests this model:

Fibromyalgia is a multifaceted problem that tends to be linked to poor posture. This is because the postural system controls a large quantity of the afferent neurology into the central neural axis.

The upper cervical spine has more afferent neurons that enter the central neural axis than any other spinal region. In addition, upper cervical afferents communicate mono-synaptically in the vestibular nucleus.

The vestibular nucleus controls whole body posture.

Upper cervical spinal manipulation makes a significant and lasting improvement on whole body posture by influencing the vestibular nucleus.

This study also indicates that the benefits of chiropractic postural corrections take time to manifest, but once these benefits are obtained, they tend to be long lasting.

These authors imply that new guidelines for the treatment of fibromyalgia syndrome should be established and they should include upper cervical manipulation.

SUMMARY

Six to 25 million Americans suffer from fibromyalgia syndrome. Their symptoms are chronic, treatment resistant, and often debilitating. Only 14% of traditionally managed fibromyalgia patients achieve an acceptable clinical outcome.

Components of the proposed pathophysiology of fibromyalgia suggest that chiropractic mechanical care, especially of the upper cervical spine, makes biologically plausible sense. The evidence suggests that chiropractic care, along with other traditional approaches, result in significant clinical improvement for these patients, and that the improvement is long lasting. All chronic fibromyalgia patients should engage in chiropractic segmental and postural spinal corrections.

REFERENCES

  • Clauw DJ; Fibromyalgia: a clinical review; Journal of the American Medical Association; April 16, 2014; 311(15):1547-55.
  • Clauw DJ; Fibromyalgia and Related Conditions; Mayo Clin Proc; May 2015;90(5):680-692.
  • Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P et al.; The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee; Arthritis Rheum. 1990 Feb;33(2):160-72.
  • Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB; The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity; Arthritis Care Res (Hoboken); 2010 May;62(5):600-10.
  • Smith HS, Harris R, Clauw DJ; Fibromyalgia: An Afferent Processing Disorder Leading to a Complex Pain Generalized Syndrome; Pain Physician; 2011; 14:E217-E245.
  • Häuser W, Wolfe F; Diagnosis and diagnostic tests for fibromyalgia (syndrome); Reumatismo; Sep 28, 2012;64(4):194-205.
  • Reis MS, Durigan JL, Arena R, Rossi BR, Mendes RG, Borghi-Silva A; Effects of Posteroanterior Thoracic Mobilization on Heart Rate Variability and Pain in Women with Fibromyalgia; Rehabilitation Research and Practice; May 29, 2014 [epub].
  • Garcia DV, Dierckx R, Otte a, Holstege G; PET and SPECT in Neurology, Chapter 46 “Whiplash: Real or Not Real: A Review and New Concept”; Springer-Verlag; 2014, pp. 947-963.
  • Moustafa IM, Diab AA; The addition of upper cervical manipulative therapy in the treatment of patients with fibromyalgia: A randomized controlled trial; Rheumatology International; March 18, 2015 [epub].
  • Hartz AJ, Noyes R, Bentler SE et al; (2000) Unexplained symptoms in primary care: perspectives of doctors and patients. Gen Hosp Psychiatry 22:144–152.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”

May 2015

Using Measurement Outcomes

 

The escalation in health care spending in the United States has mandated an approach for cost containment. The contemporary approach in this effort is called “Evidenced-Based Medicine.” Proponents of Evidence Based Medicine have become increasingly organized, beginning in the 1990s. As an example, in 1996, the British Medical Journal published an editorial titled (1):

Evidence Based Medicine: What it is and What it isn’t

This article describes Evidence Based Medicine as:

“Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

A necessary component for the implementation of Evidence Based Medicine is the development and use of Clinical Practice Guidelines. As stated in the journal Health Affairs in 2005 (2):

“One common implementation of Evidence Based Medicine involves the use of clinical practice guidelines during medical decision making to encourage effective care.”

A central theme in Evidence Based Guidelines is that treatment should be reasonable andnecessary. To establish that treatment is reasonable and necessary, the treating clinician should be using measurement outcomes.

Measurement Outcomes measure the health status of a patient before treatment, and then again after treatment (or a series of treatments) is/are performed. If the post treatment measurementoutcome shows improvement, it is classically interpreted that the treatment was both reasonableand necessary. When measurement outcomes stop improving, it means that the patient’s clinical status has reached maximum improvement, or that a different clinical approach may be warranted.

There are literally hundreds of measurement outcomes available for health care providers. Each discipline of health care has developed recognized measurement outcomes that best serve their disciplines and patient’s needs. Chiropractors and other musculoskeletal disciplines often use the same measurement outcomes. These same measurement outcomes that are used clinically are often used in musculoskeletal research. Musculoskeletal health care providers, including chiropractors, commonly use these measurement outcomes:

  • Oswestry Back Pain Disability Index (ODI)
  • Roland-Morris Low Back Pain Disability Questionnaire
  • Neck Disability Index (NDI)
  • Functional Rating Index (FRI)
  • Whiplash Disability Questionnaire
  • Headache Disability Index

A sample of each of these is included below.

Clinically, measurement outcomes are primarily used for two purposes:

  • To show that the treatment given was reasonable and necessary.
  • To determine when the patient’s clinical status has reached maximum improvement.

Essentially, if measurement outcomes show progressive improvement in a patient’s clinical status, it means that the treatment given was reasonable and necessary, and that continued treatment is warranted. Additional treatment is warranted as long as the patient’s clinical status continues to improve.

In contrast, if measurement outcomes no longer show improvement, it is often interpreted as meaning that the patient’s clinical status has reached maximum improvement, and additional scheduled treatment may not be warranted. Often, maximum improvement is determined to be when there is no significant change in symptoms and measurement outcomes for approximately8 weeks (3).

Secondary reasons to use measurement outcomes include:

  • To document long-term or permanent symptoms and/or disabilities for a particular patient.
  • To help apportion treatment, residual symptoms and permanent disabilities.
  • The frequency of the use of measurement outcomes is at the discretion of the treating doctor, but here are a few suggestions:
  • Appropriate measurement outcomes should be used as a component of initial patient intake.
  • For patients under active care, measurement outcomes should be completed at least once per month.
  • For patients under maintenance care, measurement outcomes should be completed at least once every 10-12 patient visits.

Measurement outcomes are a standard component of contemporary clinical practice, including for chiropractors. Using measurement outcomes is an invaluable tool for the modern health care provider. Failure to use measurement outcomes invites criticism and conflict. Future health providers will be increasingly judged by their use of measurement outcomes and their results.

••••••••••

OSWESTRY LOW BACK DISABILITY QUESTIONNAIRE

The Oswestry Low Back Disability was first published in the journal Physiotherapy in 1980 by orthopedic surgeon Jeremy Fairbank, MD, and colleagues from Nuffield Orthopaedic Centre, Oxford, United Kingdom (4).

The Oswestry was revised in 2000 and published in the journal Spine (5).

The Oswestry has become the gold standard for measuring the degree of disability and estimating quality of life in a people with low back pain. The Oswestry is a valid and vigorous outcome measurement (5).

Scoring the Oswestry is as simple as adding the number value on the left side of the form. The total number is the disability index for that patient. The Oswestry disability index is categorized as follows:

0 – 20: Minimal disability

21- 40: Moderate Disability

41 – 60: Severe Disability

61 – 80: Crippling back pain

81 – 100: These patients are either bed-bound or have an exaggeration of their symptoms

••••••••••

Roland-Morris LOW BACK PAIN DISABILITY QUESTIONNAIRE

The Roland-Morris Questionnaire was first published in the journal Spine in 1983 (6, 7). Professor Martin Roland and colleague R. Morris from the Institute of Public Health at the University of Cambridge developed it. It is longer than the Oswestry, having 24 questions instead of 10. Similarly to the Oswestry, it is considered to be valid and sensitive.

The Roland-Morris Questionnaire is a self-administered. Each of the 24 questions that are checked off is assigned a value of 1. Higher numbers on the 24-point scale reflects greater levels of disability. Clinical improvement over time is graded based on the analysis of serial questionnaire scores. If, for example, at the beginning of treatment, a patient’s score was 18 and, at the conclusion of treatment, his/her score was 8 (10 points of improvement), we would calculate a 55% improvement. [(18-8)/18 x 100]

••••••••••

NECK DISABILITY INDEX

The Neck Disability Index was created by chiropractor Howard Vernon, DC, from Canadian Memorial Chiropractic College, Toronto, Ontario, CAN. It was initially published in the Journal of Manipulative ad Physiological Therapeutics in 1991 (8). The initial purpose of the Neck Disability Index was to determine the disability of individuals who had been injured in motor vehicle collisions.

In the construction of the Neck Disability Index, Dr. Vernon modified the Oswestry. It is now the gold standard for measuring the degree of disability and estimating quality of life in a person with neck pain caused my motor vehicle collisions. Similar to the Oswestry, it has been shown to be valid, reliable ad sensitive.

The Neck Disability Index is scored identically to the Oswestry.

••••••••••

FUNCTIONAL RATING INDEX

The Functional Rating Index is newer, first published in the journal Spine in 2001 (9). The primary authors of the Functional Rating Index are chiropractors Ron Feise, DC, and J. Michael Menke, DC. Dr. Menke is from Palmer Chiropractic College West, located in San Jose, CA.

The Functional Rating Index combines the concepts of the Oswestry Low Back Disability Questionnaire and the Neck Disability Index. It has a total of 10 questions, improving clinical utility (time required for administration).

Their initial study assessed 139 subjects. Their conclusions are:

“The Functional Rating Index appears to be psychometrically sound with regard to reliability, validity, and responsiveness and is clearly superior to other instruments with regard to clinical utility. The Functional Rating Index is a promising useful instrument in the assessment of spinal conditions.”

The Functional Rating Index has 10 questions, and each response is given a value of 0 – 4. Adding up the total score and dividing by 40 determines the percent of disability. If, for example, the summed score is 30, the total disability would be 75%. [30/40 = .75]

If, for example, the Functional Index Score was 10 on a follow-up assessment, the total disability would be 25% [10/40 = .25], and the clinical improvement would be [(30-10)/30 = 67%]

••••••••••

WHIPLASH DISABILITY QUESTIONNAIRE

        The Whiplash Disability Questionnaire was first published in the journal Spine in 2004 (10). It was designed by Melanie Pinfold and colleagues from the School of Physiotherapy, La Trobe University, Victoria, Australia. Its reproducibility and responsiveness was further assessed by the same group and published in the journal Pain (11).

  • The Whiplash Disability Questionnaire measures functional limitations and psychometrics associated with whiplash injury. It was developed from the Neck Disability Index, but it consists of 13 questions rather than 10. The authors concluded:

“The Whiplash Disability Questionnaire has excellent short- and medium-term reproducibility and responsiveness in a population seeking treatment for Whiplash Associated Disorders.”

The Whiplash Disability Questionnaire has 13 questions with a possible of 10 points per question. Scoring is done by adding the total points and dividing by 130.

••••••••••

HEADACHE DISABILITY INDEX

The Headache Disability Index was developed at the Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan. It was first published in the journalNeurology in 1994 (12), and further validated in the journal Headache in 1995 (13).

The Headache Disability Index is 25 questions, and is designed to quantify the impact of headaches on daily living. Each question has only 3 possible responses: YES = 4;  SOMETIMES = 2; NO = 0

The authors determined that a 29 point change or greater in the total score from test to retest must occur before the change can be attributed to treatment effects. The authors found the Headache Disability Index to have strong consistency and reliability. They concluded:

“The Headache Disability Index is useful in assessing the impact of headache, and its treatment, on daily living.”

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April 2015

Spinal Manipulation for Lumbar Intervertebral Disc Syndrome with Radiculopathy

For thirty years (since 1985), it has been acknowledged that spinal manipulation is successful in the treatment of the majority of patients with low back pain, and that “there is a scientific basis for the treatment of back pain by manipulation.” (1) However, the consensus pertaining to the use of spinal manipulation for the treatment of intervertebral disc syndrome with radiculopathy is less investigated. Consequently, there is the potential for an opinion that spinal manipulation may be inappropriate for patients with low back intervertebral disc syndrome and symptoms/signs of radiculopathy.  This publication will review a number of articles on this topic, spanning six decades (1954-2015).

••••••••••

In 1954, RH Ramsey, MD, published a study titled (2):

Conservative Treatment of Intervertebral Disk Lesions

Dr. Ramsey’s study appeared in the Instructional Course Lectures of the American Academy of Orthopedic Surgeons. Dr. Ramsey states:

“The conservative management of lumbar disk lesions should be given careful consideration because no patient should be considered for surgical treatment without first having failed to respond to an adequate program of conservative treatment.”

“If after a fair trial of conservative treatment, the pain and disability continue and the symptoms are of sufficient gravity to warrant surgery, the patient is advised that he should be operated upon and the offending disk lesion should be removed.”

Dr. Ramsey advocated a number of conservative treatments for this syndrome, including spinal manipulation. Pertaining to manipulation, Dr. Ramsey makes the following comments:

“From what is known about the pathology of lumbar disk lesions, it would seem that the ideal form of conservative treatment would theoretically be a manipulative closed reduction of the displaced disk material.”

“Many forms of manipulation are carried out by orthopaedic surgeons and by cultists and this form of treatment will probably always be a controversial one.”

“We limit the use of manipulation almost entirely to those patients who do not seem to be responding well to non-manipulative conservative treatment and who are anxious to have something else done short of operative intervention.”

“The patient lies on his side on the edge of the table facing the surgeon and the leg that is up is allowed to drop over the side of the table, tending to swing the up-side of the pelvis forward. The arm that is up is allowed to drop back behind the patient, tending to pull the shoulder back. The surgeon then places one hand on the patient’s shoulder and his opposite forearm on the patient’s iliac crest. Simultaneously, the shoulder is thrust suddenly back, rotating the torso in one direction while the iliac crest is thrust down and forward, rotating the pelvis in the opposite direction. This gives the lumbar spine a twist that frequently causes an audible and palpable crunch. This procedure is then repeated with the patient on his other side. The patient is then turned on his back and his hips and knees are hyperflexed sufficiently to forcibly flex the lumbar spine which tends to open up the disk spaces posteriorly.”

“The patient should be cautioned beforehand that forceful manipulation may possibly make his symptoms worse although many patients will get marked relief.”

Dr. Ramsey notes that the manipulation is “forceful” and associated with an “audible and palpable crunch.” Although he cautions that the manipulation may make the patient worse, “many patients will get marked relief.”

••••••••••

Fifteen years later (in 1969), physicians JA Mathews and DAH Yates from the Department of Physical Medicine, St. Thomas’ Hospital, London, published a study titled (3):

Reduction of Lumbar Disc Prolapse by Manipulation

This study appeared in the September 20, 1969 issue of the British Medical Journal. These authors evaluated a number of patients that presented with an acute onset of low back and buttock pain that did not respond to rest. Diagnostic epidurography showed a clinically relevant small disc protrusion, along with antalgia and positive lumbar spine nerve stretch tests. These patients were then treated with long-lever rotation manipulations of the lumbar spine, using the shoulder and iliac crest as levers. These lumbar spine manipulations were clearly accompanied with a thrust maneuver. The manipulations were repeated until abnormal symptoms and signs had disappeared. Following the manipulations there was resolution of signs, symptoms, antalgia, and reduction in the size of the protrusions. Drs. Mathews and Yates state:

“The frequent accompaniment of acute onset low back pain by spinal deformity suggests a mechanical factor, and the accompanying abnormality of straight-leg raise or femoral stretch test suggests that the lesion impinges on the spinal dura matter of the dural nerve sheaths.”

“The lumbar spine was rotated away from the painful side to the limit of its range, the buttock or thigh of the painful side being used as a lever; a firm additional thrust was made in the same direction. This manoeuver was repeated until abnormal symptoms and signs had disappeared, progress being assessed by repeated examination.”

“Rotation manipulations apply torsion stress throughout the lumbar spine. If the posterior longitudinal ligament and the annulus fibrosus are intact, some of this torsion force would tend to exert a centripetal force, reducing prolapsed or bulging disc material.” 

“The results of this study suggest that small disc protrusions were present in patients presenting with lumbago and that the protrusions were diminished in size when their symptoms had been relieved by manipulations.”

These authors conclude: “it seems likely that the reduction effect [of the disc protrusion] is due to the manipulating thrust used.”

••••••••••

In another study published in 1969, BC Edwards compared the effectiveness of heat/massage/exercise to spinal manipulation in the treatment of 184 patients that were grouped according to the presentation of back and leg pain, as follows (4):

Group

Treatment

Acceptable Outcome

Central Low Back Pain Only

heat/massage/exercise

83%

spinal manipulation

83%

Pain Radiation to Buttock

heat/massage/exercise

70%

spinal manipulation

78%

Pain Radiation Down Thigh to Knee

heat/massage/exercise

65%

spinal manipulation

96%

Pain Radiation down Leg to Foot

heat/massage/exercise

52%

spinal manipulation

79%

This study by Edwards was published in the Australian Journal of Physiotherapy.

This study by Edwards was reviewed by Augustus A. White, MD, and Manohar M. Panjabi, PhD, in their 1990 book, Clinical Biomechanics of the Spine (5). Drs. White and Panjabi make the following points pertaining to the Edwards article:

“A well-designed, well executed, and well-analyzed study.”

In the group with central low back pain only, “the results were acceptable in 83% for both treatments. However, they were achieved with spinal manipulation using about one-half the number of treatments that were needed for heat, massage, and exercise.”

In the group with pain radiating into the buttock, “the results were slightly better with manipulation, and again they were achieved with about half as many treatments.”

In the groups with pain radiation to the knee and/or to the foot, “the manipulation therapy was statistically significantly better,” and in the group with pain radiating to the foot, “the manipulative therapy is significantly better.”

“This study certainly supports the efficacy of spinal manipulative therapy in comparison with heat, massage, and exercise. The results (80 – 95% satisfactory) are impressive in comparison with any form of therapy.”

••••••••••

In 1977, the third edition of Orthopaedics, Principles and Their Applications was published. The author, Samuel Turek, MD (d. 1986), was a Clinical Professor, Department of Orthopedics and Rehabilitation at the University of Miami School of Medicine. In the section pertaining to the protruded disc, Dr. Turek makes the following observations (6):

Treatment of Intervertebral Disc Herniation With Manipulation

“Manipulation.  Some orthopaedic surgeons practice manipulation in an effort at repositioning the disc.  This treatment is regarded as controversial and a form of quackery by many men.  However, the author has attempted the maneuver in patients who did not respond to bed rest and were regarded as candidates for surgery.  Occasionally, the results were dramatic.

Technique. The patient lies on his side on the edge of the table facing the surgeon, and the uppermost leg is allowed to drop forward over the edge of the table, carrying forward that side of the pelvis.  The uppermost arm is placed backward behind the patient, pulling the shoulder back.  The surgeon places one hand on the shoulder and the other on the iliac crest and twists the torso by pushing the shoulder backward and the iliac crest forward.  The maneuver is sudden and forceful and frequently is associated with an audible and palpable crunching sound in the lower back.  When this is felt, the relief of pain is usually immediate.  The maneuver is repeated with the patient on the opposite side.”

“The patient should be cautioned beforehand that the manipulation may make his symptoms worse and that this is an attempt to avoid surgery.”

••••••••••

        In February 1987, physicians Paul Pang-Fu Kuo and Zhen-Chao Loh published an important study pertaining to lumbar disc protrusions and rotary spinal manipulation, titled (7):

Treatment of Lumbar Intervertebral Disc Protrusions by Manipulation

        Their article appeared in the journal Clinical Orthopedics and Related Research. Drs. Paul Pang-Fu Kuo and Zhen-Chao Loh are from the Department of Orthopedic Surgery, Shanghai Second Medical College, and Chief Surgeon, Department of Orthopaedic Surgery, Rui Jin Hospital, Shanghai, China. They note that manipulation has been used in Chinese healthcare for thousands of years, and by the Tang Dynasty (618-907 AD), who noted “manipulation was fully established and became a routine for the treatment of low back pain.”

In their study, they performed a series of eight manipulations on 517 patients with protruded lumbar discs and clinically relevant signs and symptoms. Their outcomes were quite good, with 84% achieving a successful outcome and only 9% not responding. Only 14 % suffered a reoccurrence of symptoms at intervals ranging from two months to twelve years. These authors state:

“The patient is placed on the sound side first with the hip and knee of the painful side flexed and the sound side straight. The operator rests one hand in front of the shoulder and the other hand on the buttock. By simultaneously pulling the shoulder backwards and pushing the buttock forwards, a snap or click can usually be heard or felt. This manipulation may then be repeated on the other side as required.”

“Manipulation of the spine can be effective treatment for lumbar disc protrusions.”   

“Most protruded discs may be manipulated. When the diagnosis is in doubt, gentle force should be used at first as a trial in order to gain the confidence of the patient.”

“During manipulation a snap may accompany rotation. Subjectively it has dramatic influence on both patient and operator and is thought to be a sign of relief.”

“If derangement of the facets or subluxation of the posterior elements near the protruded disc occurs, the rotation may have caused reduction, giving remarkable relief.”

“Gapping of the disc on bending and rotation may create a condition favorable for the possible reentry of the protruded disc into the intervertebral cavity, or the rotary manipulation may cause the protruded disc to shift away from pressing on the nerve root.”

In terms of applying manipulation, Drs. Kuo and Loh indicate “practice is necessary to become proficient in spinal manipulation techniques,” and  “expertise plays an important role in the success of manipulation.” The manipulation of disc protrusions should be performed only by trained experts. Additionally, manipulation is contraindicated if the patient is suffering from incontinence or paraplegia.

••••••••••

In 1989, the Journal of Manipulative and Physiological Therapeutics published a case study of a patient with an “enormous central herniation lumbar disc” who underwent a course of side posture manipulation (8). The patient improved considerably with only 2 weeks of treatment. The authors state:

“It is emphasized that manipulation has been shown to be an effective treatment for some patients with lumbar disc herniation.

While complications of this form of treatment have been reported in the literature, such incidents are rare.”

••••••••••

        In 1993, chiropractor J. David Cassidy, chiropractor Haymo Thiel, and physician (orthopedic surgeon) William Kirkaldy-Willis published a “Review Of The Literature” article titled (9):

Side posture manipulation for lumbar intervertebral disk herniation

These authors are from the Department of Orthopaedics, Royal University Hospital, Saskatoon, Saskatchewan, Canada, and their article appeared in the Journal of Manipulative and Physiological Therapeutics.

In their article, these authors cite studies on human cadavers that show the annulus of the disc is quite resistant to rotational stresses. Specifically, a normal disc did not show failure until 22.6° of rotational stress, and a degenerated disc could withstand an average of 14.3° of rotational stress. They therefore conclude “torsional failure of the lumbar disk first requires fracture of the posterior joints” before there is any annular tearing.

When performing rotational manipulation in the management of lumbar disc herniation, these authors suggest that it is wise to begin with mobilization prior to performing manipulation to assess the patients responses. Additionally, they state that if positioning increases leg pain, “one should not proceed to manipulation at that particular session.”

Based upon their review of the literature and their own experiences, these authors state:

“The treatment of lumbar disk herniation by side posture manipulation is not new and has been advocated by both chiropractors and medical manipulators.”

“The treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective.”

••••••••••

        In 1995, chiropractors PJ Stern, Peter Côté P, and David Cassidy published a study titled (10):

A series of consecutive cases of low back pain with radiating leg pain treated by chiropractors

        Their article appeared in the Journal of Manipulative and Physiological Therapeutics. The authors retrospectively reviewed the outcomes of 59 consecutive patients complaining of low back and radiating leg pain, and were clinically diagnosed as having a lumbar spine disk herniation. Ninety percent of these patients reported improvement of their complaint after chiropractic manipulation. The maximum complication rate associated with this treatment approach was estimated to be 5% or less. A previous history of low back surgery was a statistically significant predictor of poor outcome. They concluded:

“Based on our results, we postulate that a course of non- operative treatment including manipulation may be effective   and safe for the treatment of back and radiating leg pain.”

••••••••••

        In 2006, physicians Valter Santilli, MD, Ettore Beghi, MD, Stefano Finucci, MD, published an article in The Spine Journal titled (11):

Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion:
A randomized double-blind clinical trial of active and simulated spinal manipulations

        The purpose of this study was to assess the short- and long-term effects of spinal manipulations on acute back pain and sciatica with disc protrusion. It is a randomized double-blind trial comparing active and simulated manipulations for these patients. The study used 102 patients. The manipulations or simulated manipulations were done 5 days per week by experienced chiropractors for up to a maximum of 20 patient visits, “using a rapid thrust technique.” Re-evaluations were done at 15, 30, 45, 90, and 180 days.

The authors list rationales for using manipulation in the treatment of low back pain and sciatica to include:

  • Reduction of a bulging disc
  • Correction of disc displacement
  • Release of adhesive fibrosis surrounding prolapsed discs or facet joints
  • Release of entrapped synovial folds
  • Inhibition of nociceptive impulses
  • Relaxation of hypertonic muscles
  • Unbuckling displaced motion segments

The authors noted the following observations:

“Active manipulations have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion.”

“At the end of follow-up a significant difference was present between active and simulated manipulations in the percentage of cases becoming pain-free (local pain 28% vs. 6%; radiating pain 55% vs. 20%).”

“Patients receiving active manipulations enjoyed significantly greater relief of local and radiating acute LBP, spent fewer days with moderate-to-severe pain, and consumed fewer drugs for the control of pain.”

“No adverse events were reported.”

The authors concluded that chiropractic spinal “manipulations may relieve acute back pain and sciatica with disc protrusion.”

Real Manipulations

Simulated Manipulations

# of Subjects

53

49

% of Local Pain Free Subjects

28%

6%

% of Radiation Pain Free Subjects

55%

20%

••••••••••

        In 2014, an interdisciplinary group of physicians, chiropractors, and researchers published a study in the Annals of Internal Medicine, titled (12):

Spinal Manipulation and Home Exercise With Advice  for Subacute and Chronic Back-Related Leg Pain

        This study was funded by the United States Department of Health and Human Services. It included 192 patients who were suffering from back-related leg pain for least 4 weeks. The number of subjects in the study gave it good statistical power. The subjects were randomized into either:

  • Chiropractic spinal manipulation + home exercise and advice, or
  • Home exercise and advice alone

The treatment lasted 12 weeks. The authors concluded:

“For leg pain, spinal manipulative therapy plus home exercise and advice had a clinically important advantage over home exercise and advice (difference, 10 percentage points) at 12         weeks.”

       

“Spinal manipulative therapy with home exercise and advice improved self-reported pain and function outcomes more than exercise and advice alone at 12 weeks.”

“Spinal manipulative therapy combined with home exercise and advice can improve short-term outcomes in patients with back-related leg pain.”

“For patients with subacute and chronic back-related leg pain, spinal manipulative therapy in addition to home exercise and advice is a safe and effective conservative treatment approach,        resulting in better short-term outcomes than home exercise and   advice alone.”

“No serious treatment-related adverse events or deaths occurred.”

••••••••••

        In another 2014 study, a group of multidisciplinary researchers and chiropractic clinicians from Switzerland presented a prospective study involving 148 patients with low back and leg pain. The study was published in the Journal of Manipulative and Physiological Therapeutics and titled (13):

Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging–Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low-Amplitude, Spinal Manipulative Therapy:

A Prospective Observational Cohort Study With One-Year Follow-Up

The purpose of this study was to document outcomes of patients with confirmed, symptomatic lumbar disc herniations and sciatica that were treated with chiropractic side posture high-velocity, low-amplitude, spinal manipulation to the level of the disc herniation. It is important to emphasize that all patients in this study had clear abnormal physical examination findings of radiculopathy, including positive MRI abnormalities that corresponded with their symptoms and physical findings. Their pain was rated using the numerical rating scale and their disability was measured with the Oswestry questionnaire. Evaluations were performed at 2 weeks, 1 month, 3 months, 6 months, and 12 months.

The outcomes from this study are summarized in the following table:

Substantial Improvement (rounded)

 

2 weeks

1 month

3 months

6 months

12 months

Entire group

70%

80%

91%

89%

88%

Acute group

81%

85%

95%

91%

86%

Chronic group

47%

71%

82%

89%

89%

The authors make the following statements:

“The proportion of patients reporting clinically relevant improvement in this current study is surprisingly good, with nearly 70% of patients improved as early as 2 weeks after the start of treatment. By 3 months, this figure was up to 90.5% and then stabilized at 6 months and 1 year.”

“A large percentage of acute and importantly chronic lumbar disc herniation patients treated with chiropractic spinal manipulation reported clinically relevant improvement.”

“Even the chronic patients in this study, with the mean duration of their symptoms being over 450 days, reported significant improvement, although this takes slightly longer.”

“A large percentage of acute and importantly chronic lumbar disc herniation patients treated with high-velocity, low-  amplitude side posture spinal manipulative therapy reported clinically relevant ‘improvement’ with no serious adverse events.”

“Spinal Manipulative therapy is a very safe and cost-effective option for treating symptomatic lumbar disc herniation.”

This study shows that patients with proven lumbar intervertebral disc herniation and compressive neuropathology that receive traditional chiropractic side-posture manipulation is both safe and effective. The ultimate clinical effectiveness of about 90% is impressive when compared to any form of therapy, and with no reported serious side effects.

This study would suggest that all patients suffering from lumbar intervertebral disc herniation with compressive neuropathology should be treated with chiropractic spinal adjusting.

REFERENCES

  • Kirkaldy-Willis WH, Cassidy, JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985, Vol. 31, pp. 535-540.
  • Ramsey RH; Conservative Treatment of Intervertebral Disk Lesions; American Academy of Orthopedic Surgeons, Instructional Course Lectures; Volume 11, 1954, pp. 118-120.
  • Mathews JA and Yates DAH; Reduction of Lumbar Disc Prolapse by Manipulation; British Medical Journal; September 20, 1969, No. 3, 696-697.
  • Edwards BC; Low back pain and pain resulting from lumbar spine conditions: a comparison of treatment results; Australian Journal of Physiotherapy; 15:104, 1969.
  • White AA, Panjabi MM; Clinical Biomechanics of the Spine; Second edition, JB Lippincott Company, 1990.
  • Turek S; Orthopaedics, Principles and Their Applications; JB Lippincott Company; 1977; page 1335.
  • Kuo PP and Loh ZC; Treatment of Lumbar Intervertebral Disc Protrusions by Manipulation; Clinical Orthopedics and Related Research. No. 215, February 1987, pp. 47-55.
  • Quon JA, Cassidy JD, O’Connor SM, Kirkaldy-Willis WH; Lumbar intervertebral disc herniation: treatment by rotational manipulation; Journal of Manipulative and Physiological Therapeutics; 1989 Jun;12(3):220-7.
  • Cassidy JD, Thiel HW, Kirkaldy-Willis WH; Side posture manipulation for lumbar intervertebral disk herniation; Journal of Manipulative and Physiological Therapeutics; February 1993;16(2):96-103.
  • Stern PJ, Côté P, Cassidy JD; A series of consecutive cases of low back pain with radiating leg pain treated by chiropractors; Journal of Manipulative and Physiological Therapeutics; 1995 Jul-Aug;18(6):335-42.
  • Santilli V, Beghi E, Finucci S; Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: A randomized double-blind clinical trial of active and simulated spinal manipulations; The Spine Journal; March-April 2006; Vol. 6; No. 2; pp. 131–137.
  • Bronfort G, Hondras M, Schulz CA, Evans RL, Long CR, PhD; Grimm R; Spinal Manipulation and Home Exercise With Advice for Subacute and Chronic Back-Related Leg Pain; A Trial With Adaptive Allocation; Annals of Internal Medicine; September 16, 2014; Vol. 161; No. 6; pp. 381-391.
  • Leemann S, Peterson CK, Schmid C, Anklin B, Humphreys BK; Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging–Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One-Year Follow-Up; Journal of Manipulative and Physiological Therapeutics; March/April 2014; Vol. 37; No. 3; pp. 155-163.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”

March 2015

Safety Update:
Spinal Manipulation and Injury Risk

Four Recent Studies, Using Unique Assessment Approaches, Assess the Safety of Spinal Manipulation for the Treatment of Musculoskeletal Conditions

BACKGROUND

William H. Kirkaldy-Willis, MD, (1914-2006) was a pioneer in the understanding and treatment of spinal problems. In his life, he published 73 articles that are in the United States National Library of Medicine, and he authored four editions of the medical textManaging Low Back Pain. His other noted accomplishments include:

  • President of the East African Association of Surgeons (1959-1960).
  • Professor of Orthopaedic Surgery and Head of the Department at the University Hospital in Saskatoon, Canada, in 1967.
  • President of the Canadian Orthopaedic Research Society (1971-1972).
  • President of the International Society for Study of the Lumbar Spine (1982-1983).
  • President of the North American Spine Society (1986-1987).
  • President of the American Back Society (1988-1991).

Dr. Kirkaldy-Willis’ greatest contribution to spine care was advancing the understanding of the “degenerative cascade,” including the pathology and pathogenesis of lumbar spondylosis and stenosis, instability of the lumbar spine, and lateral recess spinal nerve entrapment. In addition, he recognized and advocated for the inclusion of chiropractic spinal manipulation and exercise in the management of low back pain (1).

Thirty years ago, in 1985, Dr. Kirkaldy-Willis was the lead author of a study published in the journal Canadian Family Physician (2), titled:

“Spinal Manipulation in the Treatment of Low back Pain”

In this study, Dr. Kirkaldy-Willis notes that spinal manipulation is one of the oldest forms of therapy for back pain, and that it has mostly been practiced outside of the medical profession. He further notes that there has been an escalation of clinical and basic science research on manipulative therapy, which has shown that there is a scientific basis for the treatment of back pain by manipulation.

Dr. Kirkaldy-Willis discusses how the key to successfully managing chronic low back pain is through the utilization of applied motion. He categorizes applied motion into three groups:

1)     Active Range of Motion

This range is achieved through active exercise.

2)     Passive Range of Motion

Beyond the end of the Active Range of Motion of any synovial joint, there is a small passive range of mobility. A joint can only move into this zone with passive assistance. Going into this Passive Range of Motion constitutes mobilization, not manipulation.

3)     Paraphysiological Range of Motion

At the end of the Passive Range of Motion, an elastic barrier of resistance is encountered. This barrier has a “spring-like end-feel.” When motion separates the articular surfaces of a synovial joint beyond this elastic barrier, the joint surfaces suddenly move apart with a cracking noise. This additional motion can only be achieved after “cracking” the joint and has been labeled theParaphysiological Range of Motion. This constitutes manipulation. Spinal manipulation is an assisted passive motion applied to the spinal facet joints that creates motion into theParaphysiological Range. Dr. Kirkaldy-Willis states:

“Spinal manipulation is essentially an assisted passive motion applied to the spinal apophyseal and sacroiliac joints.”

At the end of the Paraphysiological Range of Motion, the limit of anatomical integrity is encountered. The facet joint capsular ligaments create the limit of anatomical integrity.

KEY CONCEPTS:

  • When spinal manipulation moves a joint past the elastic barrier and into theParaphysiological Range of Motion, is there any injury to the patient?
  • Does spinal manipulation by trained chiropractors cross the limit of anatomical integrity, injuring the facet joint capsular ligaments or other soft tissue structures?

In his 1985 study, Dr. Kirkaldy-Willis presents the results of a prospective observational study of spinal manipulation in 283 patients with chronic low back and leg pain. All 283 patients in this study had failed prior conservative and/or operative treatment, and they were all totally disabled (“Constant severe pain; disability unaffected by treatment.”) These patients were given a two or three week regimen of daily spinal manipulations by an experienced chiropractor. No patients were made worse by the manipulation, yet many experienced an increase in pain during the first week of treatment. Even with this initial increase in pain, Dr. Kirkaldy-Willis emphasized the importance of continuing with manipulative treatment and not stopping treatment. He states:

“In most cases of chronic low back pain, there is an initial increase in symptoms after the first few manipulations. In almost all cases, however, this increase in pain is temporary and can be easily controlled by local application of ice.”

“Patients undergoing manipulative treatment must therefore be reassured that the initial discomfort is only temporary.”

These outcomes and words imply that chiropractic spinal manipulation is safe and it does not cause any injury. The studies presented below quantify these safety issues surrounding chiropractic spinal manipulation for musculoskeletal syndromes.

Dr. Kirkaldy-Willis notes that when applying spinal manipulation, there is, as a rule, an initial increase in local symptoms. He explains this finding by noting that in chronic low back pain cases, there is a shortening of the periarticular connective tissues and intra-articular adhesions may form; spinal manipulations can stretch or break these adhesions, causing the symptoms. He states:

“In most cases of chronic low back pain, there is an initial increase in symptoms after the first few manipulations [probably as a result of breaking adhesions]. In almost all cases, however, this increase in pain is temporary and can be easily controlled by local application of ice.”

“No patients were made worse by the manipulation, yet many experienced an increase in pain during the first week of treatment. Patients undergoing manipulative treatment must therefore be reassured that the initial discomfort is only temporary.”

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First Safety Study

Safety of Chiropractic Manipulation of the Cervical Spine
A Prospective National Survey

Spine
Volume 32(21), October 2007, pp. 2375-2378

Thiel, Haymo W. DC, PhD; Bolton, Jennifer E. PhD; Docherty, Sharon PhD; Portlock, Jane C. PhD (reference #3)

This study is a prospective national survey whose objective is to estimate the risk of serious and relatively minor adverse events following chiropractic manipulation of the cervical spine by a sample from the United Kingdom of chiropractors.

The authors confess that the injury rate for chiropractic cervical spine manipulation is unknown, but is estimated that the injury ranges from 1 in 200,000 to 1 in several million cervical spine manipulations. In order to assess the injury issue, the authors studied 377 chiropractors, 19,722 patients and 50,276 cervical manipulations. This study is the first, large-scale prospective study designed to record serious and minor adverse events following chiropractic manipulation of the neck.

In this study, manipulation was defined as the application of a high-velocity/low-amplitude or mechanically assisted thrust to the cervical spine. Serious adverse events were defined as referred to hospital and/or severe onset/worsening of symptoms immediately after treatment and/or resulted in persistent or significant disability/incapacity. Minor adverse events reported by patients as a worsening of presenting symptoms or onset of new symptoms, were recorded immediately, and up to 7 days, after treatment.

“There were no reports of serious adverse events.”

In agreement with the article by Dr. Kirkaldy-Willis above (2), minor side effects following chiropractic spinal manipulation were more common. The authors state:

“Relatively minor side effects of cervical spinal manipulation, such as neck pain, stiffness and soreness, headache, and tiredness are common in clinical practice.”

“Although minor side effects following cervical spine manipulation were relatively common, the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low.”

“Safety of treatment interventions is best established with prospective surveys, and this study is unique in that it is the only prospective survey on such a large scale specifically estimating serious adverse events following cervical spine manipulation.”

“Although minor side effects were found to be relatively common, the risk of a serious adverse event, immediately and up to 7 days after treatment, was estimated to be low to very low in these consultations.”

“On this basis, this survey provides evidence that cervical spine manipulation is a relatively safe procedure when administered by registered U.K. chiropractors.”

“Based on treatment outcomes obtained from 19,722 patients, the risk of a serious adverse event following cervical spine manipulation was estimated to be low to very low; risks of minor side effects, on the other hand, were relatively common.”

  • •••••••••

Second Safety Study

Outcomes of Usual Chiropractic:
The OUCH Randomized Controlled Trial of Adverse Events

Spine
September 2013; Vol. 38, No. 20, pp. 1723 – 1729

Bruce F. Walker, DC, MPH, DrPH; Jeffrey J. Hebert, DC, PhD; Norman J. Stomski, BHSc (hons), PhD, Brenton R. Clarke, PhD; Ross S. Bowden, M. Mathematics; Barrett Losco, M. Chiropractic; Simon D. French, MPH, BAppSc (Chiro), PhD (reference #4)

These authors note that “Chiropractic therapy is commonly used to manage musculoskeletal conditions in high-income countries.”

This study is a blinded randomized controlled clinical trial. It’s objective was to establish the frequency and severity of adverse effects from short-term usual chiropractic treatment of the spine when compared with a sham treatment group. The authors used 183 adult subjects with spinal pain, aged 20 to 85 years of age:

92 received usual chiropractic treatment

91 received a sham treatment and were told it was chiropractic.

Each participant received 2 chiropractic treatments: 98% had spinal pain for more than 3 months; 75% had spinal pain for more than 5 years. This means that the study participants were chronic spine pain sufferers.

The sham chiropractic treatment used in this study included “detuned ultrasound,” and Activator adjusting device on the lowest setting applied randomly through a tongue depressor.

Real Chiropractic Treatment92 Subjects Sham Chiropractic Treatment91 Subjects“Detuned Ultrasound”“Activator on the lowest setting applied randomly through a tongue depressor”
# With Adverse Events 42% 33%
Increased Pain 36% 29%
Muscle Stiffness 37% 29%
Headache 9% 17%
Radiating Discomfort 15% 15%
Duration < 24 hrs. 41% 51%

The authors found that the adverse event rate was essentially the same between real chiropractic treatment and sham treatment. They interpret this as meaning that there is no injury risk from real chiropractic treatment. Specifically, they note:

“Adverse events were common in both the usual chiropractic care and sham groups, but no important differences were seen between the groups and no serious adverse events were reported.”

“The rate of severe adverse events was not different between the groups.”

“No serious adverse events were reported,” such as disc injury, cauda equina syndrome, fracture, and stroke.

“Most adverse events associated with chiropractic treatment are mild, short lasting, and typical of musculoskeletal condition symptoms.”

Most adverse events attributed to chiropractic have been “benign, transient, and typically consisted of increased pain, muscle stiffness, tiredness, headache, and radiating discomfort.” “Less common events were dizziness, nausea, tinnitus, and impaired vision.”

“A substantial proportion of adverse events after chiropractic treatment may result from natural history variation and nonspecific effects.”

“A substantial proportion of adverse events experienced during chiropractic care for spinal pain may be the result of natural symptom fluctuation or from nonspecific effects.”

Most of the adverse events were benign and transitory.

“The results of our study suggest that many adverse events experienced after chiropractic treatment result from either natural history variation or nonspecific effects.”

“Some may view these results as evidence that chiropractic treatment is essentially an entirely benign intervention.”

In agreement with Dr. Kirkaldy-Willis (2) and Dr. Thiel (3) and colleagues above, chiropractic treatment is associated with minor increases in symptoms. However, this study found similar symptomology in patients receiving sham chiropractic, suggesting that the increased symptoms are probably not secondary to the chiropractic treatment, but rather due to the natural history of their condition. An important comment by the authors is:

“Some may view these results as evidence that chiropractic treatment is essentially an entirely benign intervention.”

Third Safety Study

Risk of Traumatic Injury Associated with Chiropractic Spinal Manipulation in Medicare Part B Beneficiaries Aged 66-99

Spine
December 9, 2014 [epub]

James M Whedon, DC, MS; Todd A Mackenzie, PhD; Reed B Phillips DC, PhD; Jon D Lurie, MD, MS (reference #5)

The primary authors from this study are from the Dartmouth Institute for Health Policy and Clinical Practice. This is a retrospective cohort study. The objective of this study was to compare the risk of injury to the head, neck or trunk following an office visit for chiropractic spinal manipulation for neuromusculoskeletal pain, as compared to office visits to a primary care physician. The study subjects were aged 66-99 years.

This study was quite large. It assessed:

  • 13,536,595         primary care office visits
  • 10,532,213         chiropractic office visits

This is the first nationwide population-based study in the United States on the risk of injury following chiropractic spinal manipulation. It is also the first study of the risks of chiropractic to focus specifically on older adults, aged 66-99 years.

The cumulative probability of injury was:

  • In the chiropractic cohort:    40 injury incidents per 100,000 subjects
  • In the primary care cohort: 153 incidents per 100,000 subjects

The authors state:

“Spinal Manipulation as performed by chiropractors is an effective option for the treatment of certain types of spinal pain and some headaches.”

“The adjusted risk of injury in the chiropractic cohort was lower as compared to the primary care cohort [by 76%].”

“Among Medicare beneficiaries aged 66-99 with an office visit risk for a neuromusculoskeletal problem, risk of injury to the head, neck or trunk within 7 days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician.”

“It is unlikely that chiropractic care is a significant cause of injury in older adults. The lower risk [of injury] in the chiropractic cohort may suggest to some that chiropractic care is protective against injury in older adults.”

“The risk of injury in patients with intervertebral disc disorder with myelopathy was actually reduced, suggesting that this condition is not a risk factor for injury due to chiropractic spinal manipulation.”

“In conclusion, among Medicare beneficiaries aged 66-99 with an office visit risk for a neuromusculoskeletal problem, risk of injury to the head, neck or trunk within seven days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician.”

The authors did identify factors that increased the risk of injury from chiropractic. Chiropractors are well schooled in these factors, which include:

  • A chronic coagulation defect
  • Inflammatory spondylopathy
  • Osteoporosis
  • Aortic aneurysm and dissection
  • Long-term use of anticoagulant therapy

The authors suggest that chiropractors use caution in providing spinal manipulation in older patients with these conditions.

Third Safety Study

Tissue Damage Markers after a Spinal Manipulation in Healthy Subjects:

A Preliminary Report of a Randomized Controlled Trial

Disease Markers

December 25, 2014

  1. Achalandabaso, G. Plaza-Manzano, R. Lomas-Vega, A. Martínez-Amat, M. V. Camacho, M. Gassó, F. Hita-Contreras, and F.Molina (reference #6)

The primary author is from the Department of Medicine, Universidad Complutense de Madrid, Spain. This is the first work that focused on the study of spinal manipulation and mechanically induced tissue damage through the analysis of damage biomarkers in blood samples. All the researchers were blinded to the therapist’s intervention.

These authors note that spinal manipulation is a common form of intervention used by a wide range of practitioners used to relieve pain and disability of the musculoskeletal system. Spine manipulation “presents benefits for patients such as an anti-inflammatory effect, pain relief, and reduction of drug consumption.” However, conceptually, spinal manipulation could be associated with injury because of these factors:

“The spinal manipulation is frequently defined as a manual procedure that involves a directed impulse to move a joint past its physiologic ROM without exceeding its anatomical limit.”

“Spinal manipulation is a manual therapy technique frequently applied to treat musculoskeletal disorders because of its analgesic effects.” It involves “a directed impulse to move a joint past its physiologic range of movement (ROM).”

“In this sense, to exceed the physiologic ROM of a joint could trigger tissue damage, which might represent an adverse effect associated with spinal manipulation. The present work tries to explore the presence of tissue damage associated with spinal manipulation through the damage markers analysis.”

To assess the possibility of spinal manipulation causing tissue injury, thirty healthy subjects were randomly assigned to:

  • A placebo spinal manipulation (control group; n = 10)
  • A single lower cervical spinal manipulation (n = 10)
  • A thoracic manipulation (n = 10)

Before and after intervention, each had their blood analyzed for 7 tissue injury biomarkers. “The detection of these proteins in serum and cerebrospinal fluid is a tell-tale of cell breakage produced by tissue damage.”

Creatine phosphokinase (CPK) [muscle injury]

Lactate dehydrogenase (LDH) [general tissue damage]

C-reactive protein (CRP) [systemic marker of inflammation and tissue damage]

Troponin-I [muscle injury]

Myoglobin [muscle injury]

Neuron-specific enolase (NSE) [neuronal damage]

Aldolase [general tissue damage]

The thoracic spinal manipulation technique involved a high-velocity, end-range, anterior-posterior force through the elbows to the middle thoracic spine in a supine position with patient’s arms crossed. “There is no evidence of serious adverse events related to thoracic spinal manipulation.”

The cervical manipulation was a high-velocity, midrange left rotational force to the lower cervical spine while supine, with left rotation and right side bending.

Control participants were treated following the cervical manipulation protocol with regard to hand contact, but without intention of mobilization, nor application of tissue tension by the treating clinician.

“Our data show no changes in any of the studied damage markers.”

“After the analysis of seven tissue damage markers, our data do not show any significant differences in [their] concentrations.”

“Neither cervical manipulation nor thoracic manipulation did produce significant changes in the CPK, LDH, CRP, troponin-I, myoglobin, NSE, or aldolase blood levels.”

“Our data suggest that the mechanical strain produced by spinal manipulation seems to be innocuous to the joints and surrounding tissues in healthy subjects.”

Muscle soreness following spinal manipulation should be “regarded as a minor, and expected, consequence of treatment.”

“Most adverse events reported by manual therapy patients are thought to be benign and transient and are often unknown to the practitioner unless patients show observable signs (e.g., loss of motion or neurological deficits) or report pain or discomfort.”

“Lower cervical and thoracic manipulative techniques seem to be safe manual therapies techniques which cause no harm to the health of the subject.”

SUMMARY

The four safety studies presented here show that chiropractic spinal manipulation is incredibly safe for the management of musculoskeletal syndromes. Each study looked at the safety issue from a unique perspective, and each reached essentially the same conclusion.

It is noteworthy that those receiving chiropractic spinal manipulation will experience minor increase in symptoms, which are not indicative of injury or harm. Patients should be told to expect such soreness, so as not to be alarmed.

REFERENCES

  •  In Memoriam, A Tribute to William Kirkaldy-Willis; Spine; Vol. 31; No. 18; Aug. 15, 2006; pp. 2034-2035.
  • Kirkaldy-Willis WH and Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985, Vol. 31, pp. 535-540.
  • Thiel, Haymo W. DC, PhD; Bolton, Jennifer E. PhD; Docherty, Sharon PhD; Portlock, Jane C. PhD; Safety of Chiropractic Manipulation of the Cervical Spine: A Prospective National Survey; Spine; Volume 32(21), October 2007, pp. 2375-2378.
  • Bruce F. Walker, DC, MPH, DrPH; Jeffrey J. Hebert, DC, PhD; Norman J. Stomski, BHSc (hons), PhD, Brenton R. Clarke, PhD; Ross S. Bowden, M. Mathematics; Barrett Losco, M. Chiropractic; Simon D. French, MPH, BAppSc (Chiro), PhD; Outcomes of Usual Chiropractic: The OUCH Randomized Controlled Trial of Adverse Events; Spine; September 2013; Vol. 38, No. 20, pp. 1723 – 1729.
  • James M Whedon, DC, MS; Todd A Mackenzie, PhD; Reed B Phillips DC, PhD; Jon D Lurie, MD, MS; Risk of Traumatic Injury Associated with Chiropractic Spinal Manipulation in Medicare Part B Beneficiaries Aged 66-99; Spine; December 9, 2014 [epub].
  • Achalandabaso, G. Plaza-Manzano, R. Lomas-Vega, A. Martínez-Amat, M. V. Camacho, M. Gassó, F. Hita-Contreras, and F. Molina; Tissue Damage Markers after a Spinal Manipulation in Healthy Subjects: A Preliminary Report of a Randomized Controlled Trial; Disease Markers; December 25, 2014.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”

February 2015

How Much Treatment is Necessary? Understanding Measurement Outcomes

The cost of healthcare is extremely high in the United States. According to the California HealthCare Foundation, these are the most recent numbers (1):

United States Health Care Spending

2012

2014 (projected)

Total Health Spending

$2.8 Trillion

$3.1 Trillion

Health Care as Share of GDP

17.2%

18.3%

Per Capita Spending

$8,915

$9,697

Growth in Total Spending

3.0%

5.2%

In 2012 (the most recently available data), approximately 44% of the United States costs of Health Care were paid by government (Federal and State) agencies. This would amount to approximately $1.23 trillion.

This escalation in Health Care spending, especially by government agencies, has mandated an approach for cost containment, hopefully without compromising the quality of health care. The contemporary approach in this effort is called “Evidenced-Based Medicine.”

Evidence Based Medicine has been around for centuries, but its proponents have become increasingly organized in the 1990s. As an example, in 1996, the British Medical Journal published an editorial titled (2):

Evidence Based Medicine: What it is and What it isn’t

This article describes Evidence Based Medicine as:

“Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

The accepted delivery of healthcare in the United States is increasingly becoming “Evidence Based.” A necessary component for the implementation of Evidence Based Medicine is the development and use of Clinical Practice Guidelines. As stated in the journal Health Affairs in 2005 (3):

“One common implementation of Evidence Based Medicine involves the use of clinical practice guidelines during medical decision making to encourage effective care.”

Evidence Based Medicine is not without criticism. A common criticism is that practice guidelines take the “doctoring” out of being a doctor. Doctors are increasingly being judged by Evidence Based Practice Guidelines. Doctors were (are) often questioned about their treatment approach to a particular patient when the approach varied from Evidence Based Practice Guidelines. Again, in 2005, the journal Health Affairs published a study titled (3) The Promises And Pitfalls Of Evidence-Based Medicine, which states:

“While advocates welcome the stronger scientific foundation of such guidelines, critics fear that they will lead to ‘cookbook medicine’.”

Another criticism of Evidence Based Practice Guidelines is that sometimes, “evidence” will “slip through the cracks.” As an example, apparently Evidence Based Practice Guidelines pertaining to the management of Low Back Pain, worldwide, advocate the use of the drug acetaminophen (the primary ingredient in Tylenol) as the first line treatment for acute low back pain. Astonishingly, this advice had never been subjected to the “gold standard” of evidence, the “double-blind, randomized controlled clinical trial.” Such a trial was completed last year, and published (November 1, 2014) in the journal The Lancet, and titled (4):

Efficacy of Paracetamol [Tylenol] for Acute Low-back Pain:
A Double-blind, Randomised Controlled Trial

The authors for this study are from the Sydney Medical School, Sydney, Australia. The study was a multicenter, double-blind, randomized, placebo controlled trial involving 1,652 patients with acute low-back pain. The authors made the following points:

  • Low-back pain is the leading cause of disability worldwide.
  • Guidelines for acute low-back pain universally recommend paracetamol [Tylenol] as the first-line analgesic; No direct evidence supports this universal recommendation.
  • Regular paracetamol is the recommended first-line analgesic for acute low-back pain; however, no high-quality evidence supports this recommendation.
  • There was no difference between treatment groups for time to recovery in this study.

“Our findings suggest that regular or as-needed dosing with paracetamol does not affect recovery time compared with placebo in low-back pain, and question the universal endorsement of paracetamol in this patient group.”

 “Although guidelines endorse paracetamol for acute low-back pain, this recommendation is based on scarce evidence.”

 “Neither regular nor as-needed paracetamol improved recovery time or pain intensity, disability, function, global change in symptoms, sleep, or quality of life at any stage during a 3-  month follow up.”

The results of this study “suggest that simple analgesics such as paracetamol might not be of primary importance in the management of acute low-back pain, and the universal recommendation in clinical practice guidelines to provide paracetamol as a first-line treatment should be reconsidered.”

 “Our results convey the need to reconsider the universal endorsement of paracetamol in clinical practice guidelines as first-line care for low-back pain.”

A follow-up Comment made in The Lancet pertaining to this study stated (5):

“Do patients with acute low-back pain need paracetamol?”

The findings of the Paracetamol for Low-Back Pain Study, show that paracetamol was not more effective than placebo in patients with acute low-back pain.

“In a well-designed and large clinical trial in Australia, 1652 patients with acute low-back pain were randomly assigned to receive paracetamol in regular doses, paracetamol as needed, or placebo.” The investigators reported no differences in the primary outcome (time to recovery) in any of the groups.

“Nor were differences recorded in secondary outcomes (eg, pain intensity, disability, symptom change, and function) between the three study groups.”

“This study is the first randomised clinical trial to assess paracetamol versus placebo for patients with acute low-back pain, and its results could have a substantial effect on the management of patients with low-back pain. Worldwide, national clinical guidelines recommend paracetamol as the first choice for prescribed analgesics for acute low-back pain.”

Evidence Based Guidelines for the chiropractic management of spinal problems began in 1992 with the publication of Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference (6). These Guidelines are often referred to as the “Mercy Guidelines,” named after the location of the conference, the Mercy Conference Center in Burlingame, CA.

In 1989, the United States federal government established the Agency for Health Care Policy and Research.  At that time the message was clear – either the health professions developed their own guidelines or third parties would impose them. The task of attempting to do something for the chiropractic profession was taken up by the Congress of Chiropractic State Associations or COCSA. Through a slow and detailed process, 35 chiropractors participated in developing a consensus document on chiropractic quality assurance and parameters of practice. The group had broad support from chiropractic colleges and organizations.

Despite being 23 years old, the Mercy Guidelines set the stage for more contemporary guidelines. The Mercy Guidelines make the following statements:

  • “These recommendations do not give a ‘cookbook’ approach to the duration of care or number of treatments.”
  • “They are NOT designed as a prescriptive or cookbook procedure for determining the absolute frequency and duration of treatment/care for any specific case.”
  • Note: statistical descriptions of treatment frequency such as mean/median/mode, should NOT be used as a standard to judge care administered to an INDIVIDUAL patient.”

Today, there are a number of guidelines for the management of spinal problems, including the recent, comprehensive, and authoritative Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain that was published in the October 2007 issue of the journal Annals of Internal Medicine. An extensive panel of qualified experts constructed these clinical practice guidelines. These experts performed a review of the literature on the topic and then graded the validity of each study. The literature search for this guideline included studies from MEDLINE (1966 through November 2006), the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and EMBASE. This project was commissioned as a joint effort of the American College of Physicians and the American Pain Society. The specific document pertaining to the chiropractic profession is titled (7):

Non-pharmacologic Therapies for Acute and Chronic Low Back Pain:
A Review of the Evidence for an American Pain Society
And American College of Physicians Clinical Practice Guideline

This article is probably the most comprehensive review of the literature concerning non-drug therapies used in the treatment of low back pain. It was prepared for the American Pain Societyand the American College of Physicians Clinical Practice Guideline. These authors note that there are many non-pharmacologic therapies available for treatment of low back pain. They therefore assessed the benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain). This article has 188 references.

Importantly, the Co-chairs and members of the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel included one chiropractor, Donald R. Murphy, DC, DACAN.

The following chart summarizes the guideline’s recommendations for the treatment of acute, sub-acute, and chronic low back pain. Importantly, the only treatment approved for all three stages of low back pain is spinal manipulation.

The Following Chart Summarizes The Treatment Benefit For Low Back Pain 

  Acute Subacute Chronic
       
Manipulation yes yes yes
       
Massage insufficient insufficient yes
       
Acupuncture no no yes
       
Exercise Therapy no no yes
       
Yoga no no yes
       
Back Schools no no no
       
Psychological Therapies no no no
       
Interdisciplinary Rehabilitation no no yes
       
Interferential Therapy no no no
       
Low-Level Laser Therapy no no yes
       
Lumbar Supports no no no
       
Shortwave Diathermy no no no
       
Superficial Heat yes no no
       
Traction no no no
       
TENS no no no
       
Ultrasound no no no

A central theme in Evidence Based Guidelines is that treatment should be reasonable andnecessary. To establish that treatment is reasonable and necessary, the treating clinician should be using measurement outcomes.

Measurement Outcomes measure the health status of a patient before treatment, and then again after treatment (or a series of treatments) is/are performed. If the post treatment measurementoutcome shows improvement, it is classically interpreted that the treatment was both reasonableand necessary. When measurement outcomes stop improving, it means that the patient’s clinical status has reached maximum improvement, or that a different clinical approach may be warranted.

There are literally hundreds of measurement outcomes available for health care providers. Each discipline of health care has developed recognized measurement outcomes that best serve their disciplines and patient’s needs. Chiropractors and other musculoskeletal disciplines often use the same measurement outcomes. These same measurement outcomes are often used in musculoskeletal research. For example, note:

  • The number one ranked musculoskeletal journal in the world is the journal Spine. Spine is the official journal of publication for the world’s top thirteen orthopedic societies. In 2003,Spine published a study using the “gold standard” randomized clinical trial, comparing the benefits of prescription non-steroidal anti-inflammatory drugs (NSAIDs) to needle acupuncture to chiropractic spinal manipulation (adjusting) in patients suffering from chronic back and neck pain (8).
  • The study evaluated patient progress using standard and accepted measurement outcomes:
    • Oswestry Back Pain Disability Index (ODI)
    • Neck Disability Index (NDI)
    • Visual analog scales (VAS)
  • Using these measurement outcomes, it was shown that needle acupuncture was twice as effective than the drugs in improving the patient’s pain and disability. Chiropractic spinal adjusting was better than five times more effective than the drugs. Also, importantly, only those receiving chiropractic spinal adjusting showed a long-term clinical benefit at the one-year follow-up assessment (9).

Drugs

Acupuncture

Chiropractic Adjustments

Asymptomatic within 9 weeks

5%

9.4%

27.3%

Another research example using measurement outcomes is a study published in the journal Public Library of Science ONE (PloS One) in 2011 (10). The authors, from Harvard’s Medical School, used Positron Emission Tomography (PET) imaging to assess residual inflammation on patients suffering from chronic whiplash injuries. The authors used standard measurement outcomes to assess the patient’s clinical status:

  • Neck Disability Index (NDI)
  • Visual analog scales (VAS)

The authors showed that chronic whiplash patients do have regions of chronic inflammation that are consistent with their complaints, and that matched normal controls do not have these inflammatory regions. They conclude that their findings support an anatomical basis for chronic whiplash pain.

Clinically, measurement outcomes are primarily used for two purposes:

  • To show that the treatment given was reasonable and necessary.
  • To determine when the patients clinical status has reached maximum improvement.

Essentially, if measurement outcomes show progressive improvement in a patient’s clinical status, it means that the treatment given was reasonable and necessary, and that continued treatment is warranted. Additional treatment is warranted as long as the patient’s clinical status continues to improve.

In contrast, if measurement outcomes no longer show improvement, it is often interpreted as meaning that the patient’s clinical status had reached maximum improvement, and additional scheduled treatment may not be warranted. As an example, California chronic pain specialist, Jerome Schofferman, MD, used standard measurement outcomes to determine the recovery rate of people injured in motor vehicle accidents (11). Patients were treated until they became pain free, or until they reached maximum improvement, as assessed with measurement outcomes. Maximum improvement was determined to be when there was no significant change in symptoms and measurement outcomes for approximately 8 weeks.

Interestingly, the mean duration of treatment was 29 weeks (7 months 1 week); the range of treatment was 8 weeks (2 months) to 108 weeks (2 years and 1 month).

Secondary reasons to use measurement outcomes include:

  • To document long-term or permanent symptoms and/or disabilities for a particular patient.
  • To help apportion treatment, residual symptoms and permanent disabilities.

Reading the literature and a number of practice guidelines, the most important measurement outcomes for chiropractors are these:

  • Quantify the symptoms with the Visual Analog Scale (VAS).
  • Use a standard Pain Drawing, ideally large enough for the patient to mark individual fingers and toes.
  • The Oswestry Back Pain Disability Index (ODI).
  • The Neck Disability Index (NDI).
  • Samples of the Visual Analog Scale and Pain Drawing are attached.
  • The frequency of the use of measurement outcomes is at the discretion of the treating doctor, but here are a few suggestions:
  • All four of these should be used as a component of initial patient intake. The exception is that there is no need to do the Oswestry if the patient has no low back complaints, and there is no need to do the Neck Disability Index if the patient has no neck complaints.
  • For patients under active care, these measurement outcomes should be completed at least once per month.
  • For patients under maintenance care, these measurement outcomes should be completed at least once every 10-12 patient visits.
  • At the discretion of the treating doctor, the Visual Analog Scale of the patient’s major symptoms may be done every visit.
  • At the discretion of the treating doctor, the Pain Drawing may also be done every visit.

Measurement outcomes are now a standard component of contemporary clinical practice, including for chiropractors. Using measurement outcomes are an invaluable tool for the modern health care provider. Failure to use measurement outcomes invites criticism and conflict. Future health providers will be increasingly judged by their use of measurement outcomes and their results.

REFERENCES

  • Wilson KB; Health Care Costs 101: US Health Care Spending; California HealthCare Foundation; www.chcf.org.
  • Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WE; Editorials: Evidence based medicine: what it is and what it isn’t; British Medical Journal; January 13, 1996; 312:71.
  • Timmermans S, Mauck    A; The Promises And Pitfalls Of Evidence-Based Medicine; Health Affairs; January 2005; Vol. 24; No. 1; pp. 18-28.
  • Williams CM, Maher CG, Latimer J, McLachlan AJ, Hancock MJ, Day RO, Lin CW; Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014 Nov 1;384(9954):1586-96.
  • Koes BW, Enthoven WT; Do patients with acute low-back pain need paracetamol?; The Lancet; July 24, 2014 (published online).
  • Haldeman S, Chapman-Smith D, Peterson DM; Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference; Aspen publications; 1992.
  • Chou R, Huffman LH; Non-pharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society And American College of Physicians Clinical Practice Guideline; Annals of Internal Medicine; October 2007, Volume 147, Number 7, pp. 492-504.
  • Giles LGF, Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine July 15, 2003; 28(14):1490-1502.
  • Muller R, Giles LGF; Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes; Journal of Manipulative and Physiological Therapeutics; January 2005, Vol. 28; No. 1; pp. 3-11.
  • Linnman C, Appel L, Fredrikson M, Gordh T, Soderlund A, Langstrom B, Engler H; Elevated [11C]-D-Deprenyl Uptake in Chronic Whiplash Associated Disorder Suggests Persistent Musculoskeletal Inflammation; Public Library of Medicine (PLoS) ONE; April 6, 2011, Vol. 6 No. 4, pp. e19182.
  • Schofferman J, Wasserman S; Successful treatment of low back pain and neck pain after a motor vehicle accident despite litigation; Spine; May 1, 1994;19(9):1007-10.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust™ – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”
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