Author: tmpl_admin

The human body is designed to effectively absorb and disperse vertical forces. This allows humans to jump off a curb, walk-run-jump, to stuff basketballs and engage in many other sports activities, plop down into a couch, etc., without injury.

In contrast, humans are not well designed to effectively absorb and disperse horizontal forces. The injuries produced by horizontal forces have been recognized for millennia. Horizontal force injuries are predominately attributed to a concept in physics termed inertia.

The laws of physics have always been with us, but they were not formally defined until the year 1687 when Sir Isaac Newton wrote the book Mathematical Principles of Natural Philosophy (1). In this publication, Newton details the principles of inertia.

Inertia is the resistance of a physical object to any change in its state of motion or to its state of rest. An object in motion will remain in motion unless an outside force acts upon that object. Likewise, an object at rest will remain at rest unless an outside force acts upon that object.

Newton’s Laws of Inertia apply to the human body. Different parts of the human body have different inertias between them. It is these inertial differences between the different parts of the body that increase their risk of injury from horizontal forces.

The most important inertia difference in the body is between a human’s trunk and head. The neck (cervical spine) connects these two distinct inertial masses and therefore the neck has a great vulnerability to inertial injury triggered by horizontal forces.

The incidence of neck (cervical spine) inertial injury from horizontal forces dramatically increased with the advent of wheeled transportation. All movements of a wheeled vehicle will move the trunk of the person sitting in the vehicle. Since the trunk inertia is separate from head inertia, the neck is vulnerable to inertial injury.

Wheeled vehicle horizontal force inertial injuries became more evident and understood following the publication of “On Railway and Other Injuries of the Nervous System” more than 150 years ago (2). The primary topic of this publication was horizontal force inertial injuries caused by train collisions and mishaps.

Newton’s concepts of inertia became well known following his publication in 1687. Newton’s Laws would dictate that when a vehicle is struck from behind:

• the vehicle is accelerated forward
• the seats in the vehicle are accelerated forward along with the vehicle
• the trunk of the occupant sitting in the seat is accelerated forward along with the seat and the vehicle
• the head of the occupant, which has different inertia than the trunk, remains at rest while the trunk is accelerated forward; i.e. the trunk is accelerated forward under the stationary head
• the neck, existing between the two larger masses (the trunk and the head), is injured

This would give an appearance of neck extension and/or hyperextension:

Trunk-Head Movement Neck Inertial Injury

It may seem stunning that early publications regarding rear-end motor vehicle collisions appeared to “get it wrong,” backwards. [or did they, discussed below] These early publication stated that during a rear-end motor vehicle collision, the head of the struck vehicle occupant would initially be thrown forward. This would be a violation of Newton’s Laws of Inertia.

As an example, in 1953, physicians James Gay and Kenneth Abbott published an article in the Journal of the American Medical Association, titled (3):

Common Whiplash Injuries of the Neck

These authors studied 50 whiplash-injured patients with symptoms and findings characteristic of a sprain of the neck. They state:

“Collision from behind thrusts body in position of acute flexion, with maximum stress at lower cervical and lumbar spinal regions.”

Drs. Gay and Abbott were quickly rebutted and the mechanisms of rear-end collision inertia were “set straight.” (4) Physician Kirk Cammack, noted in 1957 that early whiplash publications seemed to be unfamiliar with Newton’s laws of motion, believing that the first phase of a rear-end collision was flexion. Dr. Cammack clearly notes that the first phase of a rear-end collision is extension, and he criticizes other earlier studies that appear to have gotten it incorrect.

Soon, the best reference texts pertaining to rear-end motor vehicle collisions also corrected the earlier error: the first phase of a rear-end motor vehicle collisions is extension/hyperextension of the struck vehicle’s occupants head (5, 6, 7).

But What If Everyone Got It Wrong?

Clarifications of rear-end collision biomechanics began in 1991-1995 by Biodynamic Research Corporation, San Antonio, TX. In their 1995 paper, Whitman McConnell and colleagues subjected seven healthy fully informed male human volunteers to rear-end impact velocity changes between 3.6 to 6.8 mph (8). Prior to the testing, each subject’s voluntary cervical spine extension range of motion was measured. During the collision, motion beyond this voluntary range of motion (hyperextension) was never observed in any of the human test exposures. Yet, the authors noted: “All test subjects reported some test related ‘awareness’ or discomfort symptoms,” and most noted fleeting headaches. They concluded that: “Since all of our test subjects, particularly the multiply exposed ones, developed some form of typical ‘whiplash’ symptoms, it seems reasonable to finally conclude that hyperextension was not the cause of their symptoms.”

This challenge to the decades-long belief in the initial inertial extension/hyperextension during a rear-end motor vehicle collision began the new era in whiplash understanding. The basic premise is this:

There is an important biomechanical difference between having one’s shoulders still and moving the head/neck backwards into extension, v. having the head still (Newton’s Laws) and pushing the trunk and neck forward under the stationary head.

To further investigate whiplash rear-end collision biomechanics, in 1997 researchers from Yale School of Medicine began a series of whiplash experiments using fresh human cadaver cervical spines and subjected them to various magnitudes of trauma classes, using an apparatus that simulates rear-end car collisions (9). They captured their findings using high-speed cineradiography which were subsequently digitized. This method of investigation allowed the authors to assess cervical spinal segmental motion rather than the cervical global assessment performed by McConnell and associates in 1995.

The researchers found that during the rear-end collisions sequence, the head remains stationary as a consequence of its inertia, exactly conforming to Newton’s Laws of Inertia. Since the vehicle occupant’s upper back is in contact with the vehicle’s seat, as the vehicle moves forward during the collision the cervical spine begins extending from the lower cervical spine. But, at the same time, the upper cervical spine and occiput would go into flexion. Hence, with the lower neck in extension and the upper neck in flexion, the cervical spine will initially form an “S” configuration. Continued similar research has confirmed these findings (10, 11, 12).

The greatest criticism of these studies has been the use of cadaver spines rather than living human volunteers. The basic premise is that cadaver spines would not behave the same as a live-human spine; there would be meaningful differences in stiffness, reflexes, etc. That criticism was solved in 1999 (13).

In 1999, researchers from Japan used ten healthy male volunteers who were subjected to a simulated rear-end collision. The motion of the cervical spine was again recorded using cineradiography. The cineradiography images were digitized for the segmental motion analysis.

The authors considered using live human volunteers as the only way to reproduce the passenger’s neck response accurately during a collision, despite the subject’s anticipation of the impact and the restricted impact speed.

The results on these live human volunteers confirmed that initially the upper motion segments went into flexion, and the lower segments into extension; the cervical spine took an S-shaped configuration.

•••••

Protection against the cervical spine “S” configuration during the rear-end motor vehicle collision primarily addresses the position of the head restraint (head-rest). In 2011, the journal Traffic Injury Prevention, published a study titled (14):

Head Restraint Backset During Routine Automobile Driving:
Drivers Usually Exceed the Recommended Guidelines

 The authors were from the Joint Biomechanics Laboratory, School of Kinesiology, The University of Western Ontario, Canada. Their purpose was to measure the head restraint distances during routine automobile driving. They note that head restraints were introduced in the late 1960s to limit differential movement of the head and torso, in the hope of reducing spinal motion.

The average head-to-restraint distance throughout the driving route was about 3 inches. In 2007, the National Highway Traffic Safety Administration established that the distance between the back of the head and the head restraint should not exceed 2 inches. Eighty-six percent of the study subjects had average backset distances that exceeded the National Highway Traffic Safety Administration and the Federal Motor Vehicle Safety Standard guidelines, indicating that most drivers may be at risk for whiplash-like disorders if exposed to a rear impact while driving. The authors state:

“If an occupant’s head is unsupported in a rear-end collision, then it lags behind and retracts posteriorly relative to the thorax, resulting in a S-shaped spinal curvature characterized by flexion in upper and extension in lower cervical regions.”

“Properly adjusted head restraints reduce incidence of whiplash injuries.”

“Improper positioning of head restraints appears to be an ongoing issue, because our overall average backset result was significantly higher than the National Highway Traffic Safety standard.”

•••••

In 2014, a thorough review article was published in the journal Turk Neurosurgery, titled (15):

Biomechanics of Neck Injuries
Resulting from Rear-End Vehicle Collisions

The study originated from Koc University, School of Medicine, Departments of Mechanical Engineering and Neurosurgery, Istanbul, Turkey.

The authors note that an important injury prevention factor is the seat’s headrest. Most head restraints are not adjusted to effectively prevent injury.

The distance between the headrest and the head plays a vital role in influencing a whiplash injury. The authors note that head restraints can mitigate whiplash soft tissue injuries, but ideally, they should be less than ¼ inch behind the head, and should not be greater than ½ inch behind the head.

In agreement with other studies, the authors point out that whiplash injuries occur when the cervical spine takes the shape of an “S,” with flexion of the upper cervical spine and extension of the lower cervical spine.

•••••

Most recently (June 2021), a study was published in the Journal of Osteopathic Medicine, titled (16):

Assessment of Potential Strain Injury to Rectus Capitis Posterior Minor Muscles
During Whiplash Type Distortions of the Cervical Spine

        The authors of this study are from Michigan State University. Their study specifically evaluated the magnitude of stretch to the rectus capitis posterior minor muscle during the initial flexion of the upper cervical spine during a rear-end motor vehicle collision, and they evaluated how the stretch was affected by the distance between the back of the subject’s head and the vehicle’s head restraint.

Posterior View

Lateral View

As shown above, the rectus capitis posterior minor muscle originates from the posterior tubercle of the atlas (C1), ascends posterior and superior to attach to the occiput bone behind the foramen magnum. Thus, the muscle crosses the occipitoatlantal joint.

Highly important, the authors emphasize the existence of a strong anatomical connective tissue bridge between the rectus capitis posterior minor muscle and the dura mater of the spinal cord. The existence and importance of the connective tissue bridge between the rectus capitis posterior minor muscle and the dura mater has been emphasized in numerous publications (17, 18, 19, 20, 21, 22, 23).

This anatomical connective tissue bridge has great clinical significance for those injured in a rear-end motor vehicle collision. The authors note:

“On impact, the seat propels the driver’s torso forward relative to the head, resulting in forced flexion of the occipitoatlantal joint, accompanied by forced stretching of the rectus capitis posterior minor muscles.”

“Flexion of the occipitoatlantal joint and stretching of the rectus capitis posterior minor muscles continues to increase until the vehicle’s headrest strikes the back of the driver’s head.”

The backset is the distance between the driver’s head and the head restraint (head rest) at the moment of vehicle collision. The greater the backset, the greater the stretch (strain) on the rectus capitis posterior minor muscles. Backset greater than 2.8 inches resulted in tearing of a few muscle fibers to complete rupture of the muscle and separation of the tendon at the posterior process of C1.

These authors make these points:

Electromyographic evidence shows that the rectus capitis posterior minor muscles “stabilize the occipitoatlantal joint by helping maintain congruency of the joint surfaces.”

Flexion of the occipitoatlantal joint during the initial phase of a rear-end motor vehicle accident “results in a characteristic S-shaped curve resulting from flexion at the occipitoatlantal joint and extension at the lower levels of the cervical spine.”

“Muscle strain injury to the rectus capitis posterior minor muscle is directly related to the magnitude of occipitoatlantal joint flexion.”

“Increasing levels of tissue damage are significant when considering the functional tissue link that interconnects rectus capitis posterior minor muscles to the pain sensitive spinal dura.”

“Muscle strain injury would be expected to impact the functional relationship between the rectus capitis posterior minor muscles and the pain sensitive spinal dura.”

“It is certain that structural damage to the rectus capitis posterior minor muscles would have an adverse effect” on the functional relationship with the myodural bridge.

“A [rectus capitis posterior minor] muscle strain injury would be expected to significantly impact the functional relationship between the rectus capitis posterior minor muscles and the pain sensitive spinal dura.”

“The results of our study revealed that high levels of muscle strain, consistent with whiplash distortions, cause tearing of rectus capitis posterior minor muscle fascicles and separation of the tendon at the posterior process of C1.”

“Cervicogenic pain patients who have experienced whiplash associated with rear-end motor vehicle accident may show clinically relevant structural damage to the rectus capitis posterior minor muscles on MRI.”

These authors note that the risk of a whiplash type injury is directly related to the backset and to the intensity of the impact. The National Highway Traffic Safety Administration guidelines recommend that the backset not exceed 2 inches. Yet, these authors note that a backset of 2 inches produced a 24% strain on the rectus capitis posterior minor muscles, an injurious event. Consequently, the backset should be less than 2 inches. One study (15) advocates that the backset should not exceed ½ inch and that an optimal backset is ¼ inch.

These authors emphasize that a backset recommendation of 2 inches by the National Highway Traffic Safety Administration guidelines would result in a 24% strain on the rectus capitis posterior minor muscles; yet they found that the backset in the typical driver was at 3 inches. A backset of 3 inches exceeds the National Highway Traffic Safety Administration guidelines and would exceed the 30% injury threshold for skeletal muscle strain reported in prior studies. The authors note:

“For values of backset greater than 2.8 inches, whiplash distortions have the potential to result in muscle strain injuries that would range from the tearing of a few muscle fibers to complete rupture of the muscle and separation of the tendon at the posterior process of C1.”

These authors also note that MRI is sufficient to evaluate the fine structures within the occipitoatlantal interspace, diagnosing muscle strain injury to rectus capitis posterior minor muscles. However, they state:

“Unfortunately, the standard clinical protocol for the cervical spine does not include the occipitoatlantal interspace, and the relatively high cost of MRI has restricted its use as a diagnostic tool.”

Consequently, rear-end collision muscle strain injury to rectus capitis posterior minor muscles resulting in dural irritation, inflammation and symptomatology is underdiagnosed.

The authors conclude that the most important thing to protect oneself from rear-end collision injuries to the upper cervical spine is to have one’s head as close as possible to the head restraint (headrest). They state:

“Our model shows that reducing backset, either by adjusting the headrest or reducing forward head posture while driving, should reduce the risk of a strain injury to the rectus capitis posterior minor muscles from a rear-end motor vehicle accident.”

“The results of our study demonstrate that reducing the distance between the driver’s head and the headrest at the time of vehicle impact is an important factor in protecting rectus capitis posterior minor muscles from muscle strain injury.”

“Cervicogenic pain patients who have experienced whiplash-type injuries associated with a rear-end motor vehicle accident may show clinically relevant structural damage to the rectus capitis posterior minor muscles on MRI that may account for the difficulty in managing their pain.”

MANAGEMENT

For the management of rear-end collision muscle strain injury to rectus capitis posterior minor muscles resulting in dural irritation, inflammation and symptomatology, these authors recommend 3 treatments:

• Head retraction range-of-motion exercises.

These exercises have a beneficial effect for patients with head and neck pain.

• Extension strengthening exercises of the rectus capitis posterior minor muscles.

They state:

“Increased rectus capitis posterior minor muscle strength would be expected to restore normal musculoskeletal functionality of this critical component of the upper cervical spine, with a commensurate decrease in headache pain and forward head posture.”

• The use of upper cervical spine manipulation.

This approach to management is consistent with many others who advocate early mobilization, strengthening exercises, and chiropractic manipulation (24, 25, 26, 27, 28, 29).    

REFERENCES

1. Newton I; Mathematical Principles of Natural Philosophy; July 5, 1687.
2. Erichsen JE; On Railway and Other Injuries of the Nervous System; Philadelphia, PA; Henry C. Lea; 1867.
3. Gay JR, Abbott KH; Common Whiplash Injuries of the Neck; Journal of the American Medical Association; August 29, 1953; Vol. 152; No. 18; pp. 1698-1704.
4. Cammack KV; Whiplash Injuries to the Neck; American Journal of Surgery; April 1957; Vol. 93; pp. 663-666.
5. Jackson R; The Cervical Syndrome; Thomas; 1978.
6. Foreman S, Croft A; Whiplash Injuries: The Cervical Acceleration / Deceleration Syndrome; Williams & Wilkins; 1988.
7. Tollison CD, Satterthwaite JR, editors; Painful Cervical Trauma Diagnosis and Rehabilitative Treatment of Neuromusculoskeletal Injuries; Williams and Wilkins; 1992.
8. McConnell WE, Howard RP, Van Poppel J, Karuse R, Guzman HM, Bomar JB, Raddin JH, Benedict JV, Hatsell CP; Human Head and Neck Kinematics After Low Velocity Rear-end Impacts: Understanding “Whiplash”; Society of Automobile Engineers; 1995; pp. 215-238; paper 952724.
9. Grauer JN, Panjabi MM, Cholewicki J, Nibu K, Dvorak J; Whiplash Produces a S-shaped Curvature of the Neck with Hyperextension at Lower Levels; Spine; November 1, 1997; Vol. 22; No. 21; pp. 2489-2494.
10. Panjabi MM, Cholewicki J, Nibu K, Babat LB, Dvorak J; Simulation of whiplash trauma using whole cervical specimens; Spine; January 1, 1998; Vol. 23; No. 1; pp. 17-24.
11. Panjabi MM, Nibu K, Cholewicki J; Whiplash Injuries and the Potential for Mechanical Instability; European Spine Journal; 1998; Vol. 7; pp. 484-492.
12. Panjabi MM, Cholewicki J, Nibu K, Grauer J, Vahldiek M; Capsular  Ligament Stretches During in Vitro Whiplash Simulations; Journal of Spinal Disorders; June 1998; Vol. 11; No. 3; pp. 227-732.
13. Kaneoka K, Ono K, Inami S, Hayashi K; Motion Analysis of Cervical Vertebrae During Whiplash Loading; Spine; April 15, 1999; Vol. 24; No. 8; pp. 763-770.
14. Shugg JA, Vernest K, Dickey JP; Head Restraint Backset During Routine Automobile Driving: Drivers Usually Exceed the Recommended Guidelines; Traffic Injury Prevention; April 12, 2011; Vol. 12; No. 2; pp. 180–186.
15. Deniz U. Erbulut DU; Biomechanics of Neck Injuries Resulting from Rear-End Vehicle Collisions; Turk Neurosurgery; 2014; Vol. 24; No. 4; pp. 466-470.
16. Hallgren RC, Rowan JJ; Assessment of Potential Strain Injury to Rectus Capitis Posterior Minor Muscles During Whiplash Type Distortions of the Cervical Spine; Journal of Osteopathic Medicine; June 4, 2021 [epub].
17. Hack G, Koritzer R, Robinson W, Hallgren R, Greenman P; Anatomic Relation Between the Rectus Capitis Posterior Minor and the Dura Matter; Spine; December 1, 1995; Vol. 20; No. 23; pp. 2484-2486.
18. Rutten HP, Szpak K, van Mameren H, Ten Holter J, deJong J; Letters: comment on Anatomic Relation Between the Rectus Capitis Posterior Minor and the Dura Matter; Spine; April 15, 1997; Vol. 22; No. 8; pp. 924-926.
19. Alix ME, Bates DK; A proposed etiology of cervicogenic headache: the neurophysiologic basis and anatomic relationship between the dura mater and the rectus posterior capitis minor muscle; Journal of Manipulative and Physiological Therapeutics; October 1999; Vol. 22; No. 8; pp. 534-539.
20. Hack GD, Hallgren RC; Chronic headache relief after section of suboccipital muscle dural connections: a case report; Headache; January 2004; Vol. 44; No. 1; pp. 84-89.
21. Nash L, Nicholson H, Lee ASJ, Johnson GM, Zhang M; Configuration of the Connective Tissue in the Posterior Atlanto-Occipital Interspace; Spine; June 15, 2005; Vol. 30; No. 12; pp. 1359-1366.
22. Scal F, Marsili ES, Pontell ME; Anatomical Connection Between the Rectus Capitis Posterior Major and the Dura Mater; Spine; December 1, 2011; Vol. 36; No. 25; pp. E1612–E1614.
23. Zheng N, Yuan XY, Li YF, Chi YY, Gao HB, Zhao X, et. al.; Definition of the To Be Named Ligament and Vertebrodural Ligament and Their Possible Effects on the Circulation of CSF; Public Library of Science ONE; August 1, 2014; Vol. 9; No. 8; pp. e103451.
24. Kellett J; Acute Soft Tissue Injuries–A review of the Literature; Medicine and Science in Sports and Exercise; October 1986; Vol. 18; No. 5; pp. 489-500.
25. 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.
26. Rosenfeld M, Gunnarsson R, Borenstein P; Early Intervention in Whiplash-Associated Disorders: A Comparison of Two Treatment Protocols; Spine; July 15, 2000; Vol. 25; pp. 1782-1787.
27. Hoving JL, Koes BW, de Vet HCW, van der Windt DAWM, Assendelft WJJ, van Mameren H, Devillé WLJM, Pool JJM, Scholten RJPM, Bouter LM; Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain: A Randomized, Controlled Trial; Annals of Internal Medicine; May 21, 2002; Vol. 136; No. 10; pp. 713-722.
28. Woodward MN, Cook JCH, Gargan MF, Bannister GC; Chiropractic Treatment of Chronic ‘Whiplash’ Injuries; November 1996; Injury; Vol. 27; No. 9; pp. 643-645.
29. Khan S, Cook J, Gargan M, Bannister G; A symptomatic classification of Whiplash Injury and the Implications for Treatment; The Journal of Orthopaedic Medicine; 1999; Vol. 21; No. 1; pp. 22-25.

“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.”

Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.

Clinical practice guidelines define the role of specific diagnostic and treatment modalities in the diagnosis and management of patients.

Clinical practice guideline recommendations are based on evidence from rigorous systematic reviews and synthesis of the published medical literature.

••••••••••

Clinical Practice Guidelines are designed to ensure that patients receive the best of care. Ideally such care would improve recovery rates, reduce harm, and minimize future complications including disability. Cost optimization is also present. Controlling costs benefits everyone, including the patient, the insurance premiums and payments, the government, and all of society.

As noble as the intent of clinical practice guidelines is, there are problems (1):

“The volume of guidelines is overwhelming, growing in size, numbers and recommendations.”

“The average family physician would need 18 hours/day to follow the volume of recommendations for chronic disease and preventive care.”

Primary care physicians are the usual first entry provider for patients into our healthcare system. The range of healthcare conditions and their associated clinical practice guidelines is overwhelming. It is impossible for the primary care physician to be knowledgeable on all clinical practice guidelines.

Also, as a rule, primary care physicians are poorly trained in musculoskeletal healthcare, as exemplified in these statements (2, 3, 4):

•••

“79% of the participants [medical doctors] failed the basic musculoskeletal cognitive examination.”

“This suggests that training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” (2)

•••

“These findings, which are consistent with those from other schools, suggest that medical students do not feel adequately prepared in musculoskeletal medicine and lack both clinical confidence and cognitive mastery in the field.” (3)

•••

“Both orthopaedic surgeons’ and family physicians’ knowledge of treating LBP is deficient.”

“Orthopedic surgeons are less aware of current treatment than family practitioners.” (4)

•••

One recent health care policy publication notes (25):

“Medical educators have recognized for years that training in musculoskeletal medicine is suboptimal for medical students, residents, and general practitioners.”

As a consequence of these obstacles, recent publications have called for the establishment of a primary spine care practitioner, and have suggested that the provider should be a chiropractor (5, 25).

Pain is a huge problem in America. The most common location for chronic pain is the low back, accounting for nearly one third of all reported regions (6). Chronic low back pain contributes the most to long-term disability, morbidity, health care, and societal costs (7, 8). In the United States, treatment for low back pain and related spine disorders are the most expensive medical problem, with most costs accrued in ambulatory care settings, including primary care (9, 10).

What Do the Low Back Pain Guidelines Recommend?

A central theme in the evolution of Low Back Pain Clinical Practice Guidelines is a trend away from pharmacology and an emphasis on non-drug approaches.  

•••••

 The October 2007 issue of the journal Annals of Internal Medicine published the comprehensive and authoritative (11, 12):

Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain

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. This project was commissioned as a joint effort of the American College of Physicians and the American Pain Society. The results of their efforts are summarized in two separate articles. The first article is (11):

Diagnosis and Treatment of Low Back Pain:
A Joint Clinical Practice Guideline from the
American College of Physicians and the American Pain Society

This study recommends that for patients who do not improve with self-care options, clinicians should consider the addition of non-pharmacologic therapy with proven benefits—for acute low back pain, such as spinal manipulation.

For chronic or subacute low back pain, recommendations include intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation.

These Guidelines note that acceptable non-pharmacologic options for acute, subacute, and chronic low back pain includes spinal manipulation. In this document, spinal manipulation is the only non-drug treatment recommendation for acute low back pain. This article states:

For acute low back pain (duration 4 weeks), spinal manipulation administered by providers with appropriate training is recommended.

“For chronic low back pain, moderately effective non-pharmacologic therapies include acupuncture, exercise therapy, massage therapy, yoga, cognitive-behavioral therapy or progressive relaxation, spinal manipulation, and intensive interdisciplinary rehabilitation.”

•••••

The second article was also in the October 2007 issue of the journal Annals of Internal Medicine and was titled (12):

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

This article defines spinal manipulation as:

“Manual therapy in which loads are applied to the spine using short- or long-lever methods. High-velocity thrusts are applied to a spinal joint beyond its restricted range of movement.”

These authors note:

There is “good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (4 weeks’ duration) low back pain.”

“For acute low back pain (4 weeks’ duration), the only non-pharmacologic therapies with evidence of efficacy are superficial heat and spinal manipulation.”

•••••

The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) have been in continuous development since 1995. A recent update appeared in the Journal of Manipulative and Physiological Therapeutics in 2006, and is titled (13):

Clinical Practice Guideline:
Chiropractic Care for Low Back Pain

These Guidelines conclude:

“The evidence supports that doctors of chiropractic are well suited to diagnose, treat, co-manage, and manage the treatment of patients with low back pain disorders.”

•••••

In 2017 the European Journal of Pain published a study titled (14):

Clinical Practice Guidelines for the
Noninvasive Management of Low Back Pain:
A Systematic Review by the Ontario Protocol for
Traffic Injury Management (OPTIMa) Collaboration

These authors conclude:

“Most high-quality guidelines target the noninvasive management of nonspecific low back pain and recommend education, staying active/exercise, manual therapy, and paracetamol [acetaminophen] or NSAIDs as first-line treatments.”

It is noteworthy that these Guidelines advocate manual therapy for low back pain. They define manual therapy as the application of either manipulation or mobilization, stating:

•••••

Also published in 2017 is an article in the journal Annals of Internal Medicine, titled (15):

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline from the American College of Physicians

The authors note that the target patient population for these Guidelines includes adults with acute, subacute, or chronic low back pain. These authors note:

“…clinicians and patients should select from superficial heat, massage, acupuncture, or spinal manipulation…”

“For patients with chronic low back pain, clinicians and patients should initially select non-pharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.”

These Guidelines for Low Back Pain clearly emphasized “non-pharmacologic treatment” which included spinal manipulation.

•••••

In 2018, an updated version of clinical practice guidelines for the management of non-specific low back pain in primary care was published in the European Spine Journal (16). These Guidelines note that nonpharmacologic interventions, such as heat, massage, acupuncture, or spinal manipulation, are recommended as first-line treatment options, while initial use of diagnostic imaging, specialty consultation, and prescription of opioid medications are not recommended.

•••••

It is no longer controversial to understand that chiropractic and spinal manipulation are safe and effective treatments for back pain (17, 18, 19, 20, 21, 22, 23). It is clear that practice guidelines for the management of all phases (acute, subacute and chronic) of low back pain advocate spinal manipulation while discouraging drug therapies, especially narcotics (including opiates/opioids).

What Are the Consequences of Not Following
Low Back Pain Practice Guidelines
(Non-Concordant Care)

In 2010, a study published in the Journal of the American Medical Association indicated that 2% to 48% (median, 26%) of patients with acute LBP in primary care settings transition to chronic low back pain (24). This stunning statistic has an explanation which was published in 2021 in the Journal of the American Medical Association Network Open, in an article titled (25):

Risk Factors Associated with Transition
from Acute to Chronic Low Back Pain
in US Patients Seeking Primary Care

The author affiliations for this work include the University of Pittsburgh School of Medicine, Johns Hopkins University School of Medicine, University of Florida College of Public Health, Duke University, and Boston Medical Center.

These authors present the results of a large prospective, multicenter study conducted to determine the proportion of patients who transitioned from acute to chronic low back pain in primary care settings across four geographically dispersed health systems. The cohort used 5,233 patients with acute low back pain from 77 primary care practices.

Patient eligibility for this study was being at least 18 years of age with acute, bothersome, axial low back pain or low back pain associated with leg pain. Chronic low back pain was defined as the presence of pain for more than three months and having pain at least half the days in the previous six months.

Participant subject’s low back pain was quantified using the Oswestry Disability Index on a 0 to 100-point scale, as follows:

• Minimal Disability 0-20
• Moderate Disability 21-40
• Severe Disability  41-60
• Very severe Disability ≥61

The authors note:

“Low back pain (LBP) is the leading cause of disability in the United States, annually accounting for 4.3 million years lived with disability, nearly twice the burden of any other health condition.”

“In the United States, treatment for LBP and related spine disorders now represents the most expensive medical problem, with most costs accrued in ambulatory care settings, including primary care.”

“Chronic LBP contributes most to long-term disability, morbidity, health care, and societal costs, while acute LBP is given less attention because patients are generally considered to have a favorable prognosis.”

The authors note that acute low back pain is highly prevalent within the society. Yet, claiming that the natural history of acute low back pain is resolution of symptoms in 1-3 months is false. This presumed favorable prognosis for acute low back pain is misplaced. A medium of 26% of those with acute low back pain progress to chronic low back pain, and in some studies the incidence is as high as 48% (essentially half) (24). Once low back pain becomes chronic, it is a disabling and expensive condition.

Non-concordant recommendations are those that go against guideline recommendations. Non-concordant recommendations include these three processes:

Opioid use [First Process]

“Any prescriptions that included opioids were considered non-concordant.”

“Prescriptions that included benzodiazepines and/or systemic corticosteroids alone without the presence of nonsteroidal anti-inflammatory drugs or short-term skeletal muscle relaxants wereconsidered non-concordant.”

Referral for diagnostic imaging [Second Process]

“Non-concordant diagnostic imaging consisted of an order for lumbar radiograph or computed tomography/magnetic resonance imaging (CT/MRI) scan.”

Referral to a specialists [Third Process] 

“Non-concordant medical subspecialty referral included referrals to nonsurgical or surgical specialties (e.g., physiatrists, orthopedists, neurologists, neurosurgeons, or pain specialists).”

After controlling for all other variables, patients exposed to non-concordant processes of care within the first 21 days had these increased risks of developing chronic low back pain as compared to those with no exposure:

• 1 non-concordant processes 39% increased risk
• 2 non-concordant processes 88% increased risk
• 3 non-concordant processes 116% increased risk

In this cohort study involving more than 5,000 subjects, the transition rate from acute low back pain to chronic low back pain was substantial. The increased transition rate corresponded with early exposure to guideline non-concordant care. The authors noted:

“Exposure to non-concordant care was associated with increased odds of developing chronic low back pain.”

“Non-concordant care can lead to direct and indirect harm, given that it has been linked with medicalization and unnecessary health care utilization.” 

“These results indicate that the transition from acute to chronic low back pain is much greater than historically appreciated.”

“Early exposure to guideline non-concordant care was significantly and independently associated with the transition to chronic low back pain after accounting for patient demographic and clinical characteristics, such as obesity, smoking, baseline disability, and psychological comorbidities.”

“Our findings demonstrate that independent of these factors, exposure to non-concordant processes of care during the early phase of treatment was associated with developing chronic low back pain.”

Distressingly, 48% of these patients received at least one non-concordant care process within three weeks of their initial low back pain visit.

An interesting and important associated finding from this cohort study was that practice guidelines erroneously believe that acute low back pain has a favorable prognosis. The transition from acute to chronic low back pain for the entire group, including for those who were not given non-concordant care, was an astonishing 32% rate at 6 months. Stated differently, a third of 5,233 acute low back pain subjects went on to developed chronic low back pain at six months.

The authors ascribe this high transition to chronic low back pain on the dogmatic allopathic management approach of uniformly applying a minimalist approach (e.g., advice, reassurance, pharmacology, etc.) to all patients with acute low back pain. They state that such a minimalist approach “is unwarranted and may lead to suboptimal care.”

The authors acknowledge that the “successful management of low back pain is a vexing problem.” “Once chronic, low back pain is particularly problematic to manage; thus, preventing the transition from acute to chronic low back pain is important.” The most important goal in the management of acute low back pain is to prevent it from becoming chronic.

Yet, they also acknowledge that “medical educators have recognized for years that training in musculoskeletal medicine is suboptimal for medical students, residents, and general practitioners.” They criticize medical establishment norm of “high caseloads and the overwhelming volume of guidelines directed at primary care.”

So, what do clinical practice guidelines for low back pain recommend in an effort to improve clinical outcomes and to reduce the rate of transition from acute to chronic low back pain? Essentially it is the interventions that are routine in chiropractic clinical practice:

“Non-pharmacologic interventions, such as heat, massage, acupuncture, or spinal manipulation, are recommended as first-     line treatment options, while initial use of diagnostic imaging, specialty consultation, and prescription of opioid medications in the absence of red flags are not recommended.”

As such, the authors advocate the use of a Primary Spine Practitioner “in which chiropractors and physical therapists serve as the initial or early point of contact for patients with low back pain.” 

The conclusion key points from the authors included:

“In this cohort study of 5,233 patients with acute low back pain from 77 primary care practices, nearly half the patients were exposed to at least 1 guideline non-concordant recommendation within the first 21 days after the index visit.”

Patients were significantly more likely to transition to chronic low back pain as they “were exposed to more non-concordant recommendations.”

In this study, the “transition rate to chronic low back pain was substantial and increased correspondingly with risk strata and early exposure to guideline non-concordant care.”

•••••

Low back pain is the leading cause of disability and the most expensive medical problem in the United Sates. Medical students, residents, and general practitioners are poorly trained in the musculoskeletal system, and especially in the management of low back pain.

 Low back pain Practice Guidelines are based upon the best evidence:

• The best evidence discourages the use of narcotics, referral for imaging diagnostics, and referral to medical specialists, specifically physiatrists, orthopedists, neurologists, neurosurgeons, or pain specialists.

• The best evidence advocates as first-line treatment the use of massage, acupuncture, and spinal manipulation.

This study shows 2 problems with the allopathic management of low back pain:

• Providers often refer patients for care that is ill advised (narcotics, imaging, and specialists), all of which promote the patient transition from acute to chromic low back pain.

• Providers rarely refer out for care that is supported by their own Practice Guidelines (massage, acupuncture, chiropractic).

Chiropractors should be the initial contact and providers for patients with low back pain.

REFERENCES

1. Allan GM, McCormack P, Korownyk C, Lindblad AJ, Garrison S, Kolber MR; The Future of Guidelines: Primary Care Focused, Patient Oriented, Evidence Based and Simplified; Maturitas; January 2017; Vol. 95; pp. 61-62.
2. Matzkin E, Smith EL, Freccero D, Richardson AB; Adequacy of Education in Musculoskeletal Medicine; Journal of Bone and Joint Surgery (American); February 2005; Vol. 87; No. 2; pp. 310-314.
3. Day CS, Yeh AC, Franko O, Ramirez  M, Krupat  E; Musculoskeletal Medicine: An Assessment of the Attitudes and Knowledge of Medical Students at Harvard Medical School; Academic Medicine; May 2007; Vol. 82; No. 5; pp. 452-457.
4. Finestone AS, Raveh  A, Mirovsky  Y, Lahad  A, Milgrom  C; Orthopaedists’ and Family Practitioners’ Knowledge of Simple Low Back Pain Management; Spine; July 1, 2009; Vol. 34; Np. 15; pp. 1600-1603.
5. Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ; The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States;  Chiropractic and Manual Therapy; July 21, 2011; Vol. 19; No. 1; p. 17.
6. Wang S; Why Does Chronic Pain Hurt Some People More?; Wall Street Journal; October 7, 2013.
7. Pengel LH, Herbert RD, Maher CG, Refshauge KM; Acute Low Back Pain: Systematic Review of its Prognosis; British Medical Journal; August 9, 2003; Vol. 327; No. 7410; pp. 323.
8. Koes BW, van Tulder MW, Thomas S; Diagnosis and Treatment of Low Back Pain; British Medical Journal; July 17, 2006; Vol. 332; No. 7555; pp. 1430-1434.
9. Jin MC, Azad TD, et al; Expenditures and Health Care Utilization Among Adults with Newly Diagnosed Low Back and Lower Extremity Pain; Journal of the American Medical Association Network Open; May 3, 2019; Vol. 2; No. 5; pp. e193676.
10. Dieleman JL, Cao J, Chapin A,  et al; US Health Care Spending by Payer and Health Condition, 1996-2016; Journal of the American Medical Association; March 3, 2020; Vol. 323; No. 9; pp. 863-884.
11. Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekell, Owens DK; Diagnosis and Treatment of Low Back Pain; Annals of Internal Medicine; Vol. 147; No. 7; October 2007; pp. 478-491.
12. Chou R, Huffman LH; Non-pharmacologic Therapies for Acute and Chronic Low Back Pain; Annals of Internal Medicine;October 2007; Vol. 147; No. 7; pp. 492-504.
13. Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, DC, Whalen WM, Walters S, Kaeser M, Dehen M, DC, Augat T; Clinical Practice Guideline: Chiropractic Care for Low Back Pain; Journal of Manipulative and Physiological Therapeutics; January 2016; Vol. 39; No. 1; pp. 1-22.
14. Wong JJ, Cote P, Sutton DA, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer HM, Carroll LJ, Stern PJ, Ameis A, Southerst D, Mior S, Stupar M, Varatharajan T, Taylor-Vaisey A; Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration; European Journal of Pain; Vol. 21; No. 2 (February); 2017; pp. 201-216.
15. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians; For the Clinical Guidelines Committee of the American College of Physicians; Annals of Internal Medicine; April 4, 2017; Vol. 166; No. 7; pp. 514-530.
16. Oliveira CB, Maher CG, Pinto RZ, et al.; Clinical Practice Guidelines for the Management of Non-Specific Low Back Pain in Primary Care: An Updated Overview; European Spine Journal; November 2018; Vol. 27; No. 11; pp. 2791-2803.
17. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
18. 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; Vol. 300; June 2, 1990; pp. 1431-1437.
19. Giles LGF, Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine, July 15, 2003; Vol. 28; No. 14; pp. 1490-1502.
20. 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.
21. Kirkaldy-Willis WH; Managing Low Back Pain; Churchill Livingstone; 1983; p. 19.
22. Cifuentes M, Willetts J, Wasiak R; Health Maintenance Care in Work-Related Low Back Pain and Its Association with Disability Recurrence; Journal of Occupational and Environmental Medicine; April 14, 2011; Vol. 53; No. 4; pp. 396-404.
23. Senna MK, Machaly SA; Does Maintained Spinal Manipulation Therapy for Chronic Nonspecific Low Back Pain Result in Better Long-Term Outcome? Randomized Trial; SPINE; August 15, 2011; Vol. 36; No. 18; pp. 1427–1437.
24. Chou R, Shekelle P; Will this Patient Develop Persistent Disabling Low Back Pain? Journal of the American Medical Association; April 7, 2010; Vol. 303; No. 13; pp. 1295-1302.
25. Joel M. Stevans JM, Delitto A, Khoja SS, Patterson CG, PhD; Smith CN, Schneider MJ, Freburger JK, Greco CM, Freel JA, Sowa GA, Wasan AD, Brennan GP, Hunter SJ, Minick KI, Wegener ST, Ephraim PL, Friedman MF, Beneciuk JM, George SZ, Saper RB; Risk Factors Associated with Transition from Acute to Chronic Low Back Pain in US Patients Seeking Primary Care; Journal of the American Medical Association Network Open; February 16, 2021; Vol. 4; No. 2; pp. e2037371.

“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.”

Concept and Terminology

A common cliché is that the only certainties in life are death and taxes. Another certainty for the elderly is the increasing incidence of the wear-and-tear breakdown of one’s joints. The presence of joint breakdown increases with age at all joint sites.

These joint breakdowns have a number of names:

• Arthritis
• Osteoarthritis
• Degenerative Arthritis
• Degenerative Joint Disease (DJD)
• Spondylosis, primarily applied to the spinal facet joints
• Spondyloarthritis, again primarily applied to the spinal facet joints
• Degenerative Disc Disease (DDD)

Osteoarthritis is the clinical and pathological outcome of a range of disorders that results in structural and functional failure of synovial joints. Osteoarthritis may also occur in the intervertebral disc.

In 2006, researchers from the University of Medicine and Dentistry of New Jersey published a study in the American Journal of Physical Medicine and Rehabilitation titled (1):

Osteoarthritis
Epidemiology, Risk Factors, and Pathophysiology

The authors note that osteoarthritis is the most prevalent form of arthritis and a major cause of disability in people aged 65 and older. Osteoarthritis affects the majority of adults over age 55:

• 58% of those older than 70 years have symptomatic osteoarthritis.
• 10-30% of those with osteoarthritis have significant pain and disability.

 There are two major risk categories for osteoarthritis:

• Systemic factors: age, ethnicity, gender, hormonal status, genetics, and nutritional (especially increased levels of oxidative stress and decreased levels of antioxidants).
• Local Factors: abnormal biomechanical loading, obesity, ligamentous laxity, malalignment, impaired proprioception, muscle weakness.

 When systemic factors are present, the joint is more vulnerable to local biomechanical factors; local joint biomechanical factors will have more of an impact on joint degeneration. High-intensity direct joint impact increases the risk of osteoarthritis in the affected joint.

•••••

In 2015, researchers from Mayo Clinic, the University of Washington, Oregon Health and Science University, University of California San Francisco, and Kaiser Permanente in Oakland, California, published a study in American Journal of Neuroradiology titled (2):

Systematic Literature Review of Imaging Features
of Spinal Degeneration in Asymptomatic Populations

The objective of this study was to estimate the prevalence, by decade age (20, 30, 40, 50, 60, 70, 80 years), of common degenerative spine conditions. The authors performed a systematic literature review studying the prevalence of spine degeneration on imaging of 3,110 asymptomatic individuals taken from 33 studies that met their inclusion criteria. The imaging modalities used to assess the changes were either CT and/or MRI. The authors documented:

• Disk degeneration
• Disk herniation
• Annular fissures
• Facet degeneration

Asymptomatic individuals were those with no history of back pain. Studies with patients with minor or low-grade back pain were excluded, as were patients with motor or sensory symptoms, tumors, or trauma.

The authors note that degenerative spinal changes often occur in pain-free individuals as well as those with back pain. Prior studies have shown spinal degeneration present in a large proportion of asymptomatic individuals. “Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.”

The findings in this study included:

“Disk degeneration prevalence ranged from 37% of asymptomatic individuals 20 years of age to 96% of those 80 years of age, with a large increase in the prevalence through 50 years.”

“This systematic review indicates that many imaging findings of degenerative spine disease have a high prevalence among asymptomatic individuals.”

“Our study suggests that imaging findings of degenerative changes such as disk degeneration, disk signal loss, disk height loss, disk protrusion, and facet arthropathy are generally part of the normal aging process rather than pathologic processes requiring intervention.”

“With a prevalence of degenerative findings of >90% in asymptomatic individuals 60 years of age or older, our study supports the hypothesis that degenerative changes observed on CT and MR imaging are often seen with normal aging.”

The key concept from this study is that spinal arthritic changes are very common in the elderly (>60 years of age). Yet, these arthritic changes are largely asymptomatic. However, consistent with above (1) and explored in detail below, arthritic joints are less capable of adequately handling and dispersing traumatic loads as compared to nonarthritic joints. The consequences of such injuries include:

• Increased Injury
• Increased Pain and Disability
• Longer Recovery Time
• Acceleration of Spinal Degenerative Processes
• Increased Risk of Permanent Residuals
• Increased Need for Ongoing and Future Healthcare Interventions

A critical concept is that in the elderly (>60 years of age), essentially all persons, including those who are asymptomatic, have preexisting spinal arthritic changes.

•••••

In 1964, a study published in the American Journal of Orthopedics, titled, The Positive Findings in Neck Injuries, noted (3):

Pre-existing pathological conditions of the cervical spine, when injured, “result in more damage than would be anticipated in a so-called ‘normal’ cervical spine.”

•••

In 1977, the authoritative reference text, Orthopaedic Principles and Their Applications, states (4):

“The injury may be compounded by the presence of degenerative disease of the spine.”

“With advancing age, especially in the presence of degenerative disease, the tissues become inelastic and are easily torn.”

•••

In 1981, the book Neck and Arm Pain, states (5):

“The pre-existence of degeneration may have been quiescent in that no symptoms were noted, but now minor trauma may ‘decompensate’ the safety margin and symptoms occur.”

•••

In 1983, a study published in the Journal of Bone And Joint Surgery (British), titled, The Prognosis of Neck Injuries Resulting From Rear-end Vehicle Collisions, followed 61 whiplash-injured patients for a minimum of six months in order to establish factors that were prognostic for recovery. Their conclusions include (6):

“Factors which adversely affect prognosis include the presence of objective neurological signs, stiffness of the neck, [loss of cervical lordosis], and pre-existing degenerative spondylosis.”

Degenerative spondylosis was detected in 26% of patients with no objective findings, 33% of patients with reduced cervical range of motion, and 40% of patients with neurological loss, indicating that cervical spine degenerative changes are associated with greater injury and worse prognosis for recovery.

“Pre-existing degenerative changes in the cervical spine, no matter how slight, do appear to affect the prognosis adversely.”

“The prognosis may be modified by the presence or absence of degenerative changes, by an abnormality [degeneration] of the cervical spine on the initial radiograph, or by both.”

•••

In 1985, a study published in the Journal of the Australian Chiropractors’ Association, titled, Mechanisms and Patterns of Tissue Injury noted (7):

“Degenerative joint disease is recognized as a major influence on subsequent tissue damage both in severity and pattern.”

“In any individual where changes consistent with degenerative joint disease are present, one can expect the injury to be more severe or a very minor injury to produce severe symptoms requiring prolonged treatment.”

•••

In 1986, a study published in the journal Canadian Family Physician, titled, Cervical Whiplash: Considerations in the Rehabilitation of Cervical Myofascial Injury; noted (8):

“For the elderly, neck injury can be very serious. The degenerative spine is biomechanically ‘stiffer’, behaving more like a single long bone than like a set of articulating structures.  Deforming forces are less evenly dissipated, and more damage is done.”

•••

In 1987, a study published in the journal Instructional Course Lectures, titled, Soft-tissue Injuries of the Lower Cervical Spine, noted (9):

“If present, degenerative changes should be duly noted as they may affect the prognosis.”

“…pre-existing degenerative changes adversely affected the outcome.”

•••

In 1988, a study published in the journal Injury, titled, Whiplash Injuries of the Neck, reviewed 102 whiplash-injured patients 2 years after injury. They concluded (10):

“The analysis of the radiological results showed that pre-existing degenerative changes in the cervical spine are strongly indicative of a poor prognosis.”

•••

Also in 1988, a study published in the journal Orthopedics Clinics of North America, titled, Whiplash Syndrome, Fact or Fiction?, noted (11):

Pre-existing structural changes and degenerative changes are “frequently associated with a more difficult, more prolonged, and less complete recovery.”

“The films should be inspected especially for evidence of pre-existing structural changes or for alteration, which are frequently associated with a more difficult, more prolonged, and less complete recovery.”

•••

The 1988 reference text titled Whiplash Injuries, The Acceleration/Deceleration Syndrome, noted (12):

“…the presence of preexisting degenerative changes, no matter how slight, appears to alter the prognosis adversely.”

•••

In 1989, a study published in the British Medical Journal titled Neck Sprains After Car Accidents, noted (13):

“Pre-existing degenerative changes may worsen the prognosis.”

•••

In 1991, a study published in Injury titled Prognostic Factors in Soft Tissue Injuries of the Cervical Spine, radiographically reviewed 35 whiplash-injured patients 10.8 years after injury. The authors concluded (14):

“Patients with degenerative change initially have more symptoms after 2 years than those with normal radiographs at the time of injury.”

“Degenerative changes occurred significantly more frequently in patients who had sustained soft tissue injuries than in a control population.”

Also in 1991, the reference text Painful Cervical Trauma, Diagnosis and Rehabilitative Treatment of Neuromusculoskeletal Injuries, noted (15):

“The elasticity of tissues decreases with an increase in age. The range of motion in the cervical spine also decreases. In both cases, the potential for injury is increased because the neck is less resilient.”

•••

In 1995, a study published in Spine, titled: Successful Treatment of Low Back Pain and Neck Pain after a Motor Vehicle Accident Despite Litigation, noted (16):

“Pre-existing degenerative changes on initial x-rays, no matter how slight, had a worse prognosis.”

•••

In 1996, a study published in the British Journal of Bone and Joint Surgery, titled Soft-tissue Injuries of the Cervical Spine: 15-year Follow-up, published a 15.5-year follow-up evaluation of 40 patients who had been injured in a motor vehicle collision. The authors noted (17):

“The patients who had deteriorated were on average five years older than the rest of the group.”

“80% of the patients who had deteriorated in the last five years had degenerative changes.”

“100% of patients with severe ongoing problems had cervical degeneration at 11 years after injury.”

•••

In 1999, the reference text Whiplash and Related Headaches, noted (18):

Risk factors that may lead to chronicity include “pre-existing degenerative osteoarthritic changes.”

“Other conditions that may pre-exist the accident that may contribute to a chronic state following the accident are osteoarthritis, degeneration of vertebral body joints, disc degeneration and inflammatory processes.”

“Studies indicate that pre-existing osteoarthritic changes contributed to alter the prognosis adversely.”

•••

In 2002, the reference text titled Whiplash, noted (19):

“Several researchers have associated poor clinical outcomes with spondylosis, reporting a higher prevalence of spondylosis in patients with continued symptoms.”

“It is certainly theoretically possible that symptoms from a previously asymptomatic cervical spondylosis are precipitated by trauma and are responsible for the continuing pain.”

•••

In 2005, a study published in Acta Neurochirurgica, titled Whiplash injury, TOS and double crush syndrome, Forensic medical aspects, noted (20):

A substantial percentage of people will have whiplash symptoms for more than a few months, “especially the elderly or those with pre-existing neck problems who may develop chronic long-term problems which may never resolve.”

•••

In 2005, the reference text titled Motor Vehicle Collision Injuries, noted (21):

“Patients who have clinically significant pre-existing medical conditions [including spinal degeneration] may have more severe injuries, slower recoveries and poorer prognoses.”

•••

Recently, in 2019, a study published in The Spine Journal titled Association Between Cervical Degeneration and Self-perceived Non-recovery After Whiplash Injury, followed 121 whiplash-injured subjects, aged 16-70, prospectively for six months with CT scan (22). The aim of this study was to investigate associations between cervical degeneration and non-recovery after whiplash injury, addressing both disc degeneration and facet joint degeneration.

At 6 months, only 38% of the group had recovered from their injuries, and 62% had NOT recovered.

The authors note that the majority of post-whiplash injury pain is facetal in origin. Their investigation showed an association between facet joint degeneration and non-recovery from whiplash injury:

• 70% of the non-recovered subjects had moderate facet joint degeneration
• 24% of the non-recovered subjects had no facet degeneration                   

The authors noted:

“This study demonstrates an increased risk for non-recovery after whiplash trauma for patients with moderate facet joint degeneration as demonstrated on CT scans performed shortly after trauma.”

“When facet joint degeneration and disc degeneration were included in a total score of degeneration the association remained robustly significant.”

“We suggest that one of the underlying mechanisms of WAD may be that trauma triggers a painful clinical manifestation of underlying, previously asymptomatic, cervical facet joint degeneration.”

Pre-injury “cervical degeneration, especially facet joint degeneration, is a risk factor for non-recovery after whiplash trauma.”

•••

The references above indicate three things:

• Degenerative spinal disease is ubiquitous in older persons, especially those >60 years of age.
• Degenerative spinal disease is often asymptomatic until exposed to injury.
• Pre-injury degenerative spinal disease, even if asymptomatic prior to injurious event, is a significant factor associated with a poor prognosis for recovery.

These concepts were thoroughly assessed in 2016, in a study that was published in the Annals of Emergency Medicine, titled (23):

Persistent Pain Among Older Adults Discharged Home
from the Emergency Department After Motor Vehicle Crash:
A Prospective Cohort Study

These authors described the incidence, risk factors, and consequences of persistent pain among 161 older adults evaluated in the emergency department (ED) after a motor vehicle crash. It is a prospective study of patients aged 65 years or older. Persistent pain and functional decline were reassessed at 6 weeks, 6 months, and 1 year after the accident.

At the 6-month evaluation, 26% of the subjects reported moderate to severe motor vehicle crash–related pain. This pain interfered with their general activities, including walking, sleep, and enjoyment of life; 23% of the subjects with persistent moderate to severe pain at 6 months had experienced a change in living situation to obtain additional help with their activities of daily living. The most common sites of pain at 6 months were lower back (25%), upper back (17%), and neck (17%).

More than half of the subjects (54%) continued to receive an analgesic (ie, an opioid, acetaminophen, or a nonsteroidal anti-inflammatory drug), and 18% were receiving a daily opioid, 10% of the subjects had become long-term opioid users.

These subjects showed very little improvement in the 1-year evaluation, indicating that most of the chronic problems at 6 months remained chronic at 12 months.

The authors noted:

“Older adults are an important subgroup of individuals experiencing a motor vehicle crash because safe and effective pharmacologic management of their acute pain is challenging, and once pain becomes persistent in older adults, it has profound negative consequences for function and quality of life.”

“Increased age has been identified as a risk factor for persistent motor vehicle crash–related pain.”

“Among older adults discharged home from the emergency department post-evaluation after a motor vehicle crash, persistent pain is common and frequently associated with functional decline and disability.”

“Our results add to the growing body of evidence that acute injuries in older adults can have a substantial negative effect on important long-term pain and health outcomes and extend these findings to a population of independently living older adults whom most clinicians would regard as lacking injuries likely to have long-term consequences.”

“The problem of persistent pain after a motor vehicle crash in older adults is not just a problem of persistent neck pain.”

“Persistent pain is an important determinant of functional decline among older adults experiencing a motor vehicle crash.”

“In this prospective multicenter study, we found high rates of persistent pain and associated disability among older adults discharged home from the emergency department after experiencing a motor vehicle crash.”

“These findings add to the increasing body of evidence of the clinical importance of seemingly minor injuries among older adults.”

“Even minor injuries can produce lasting effects, particularly in the elderly.”

“Emergency physicians should be aware that a substantial number of older patients with minor injuries are at risk for chronic pain.”

•••

It is essentially ubiquitous, older adults, especially for those aged >65 years, have degenerative spinal disease. Often, their spinal degenerative disease is asymptomatic, but “lit-up” when exposed to the forces of a motor vehicle collision. Pre-existing degenerative spinal disease renders those joints less capable of adequately handling and dispersing the forces of a new whiplash injury; therefore, injury to these joints and the surrounding soft tissues is greater; the amount of treatment required for maximum improvement is greater, and there are more long-term subjective, objective, and functional residuals.

REFERENCES

1. Garstang SV, Stitik TP; Osteoarthritis: Epidemiology, Risk Factors, and Pathophysiology; American Journal of Physical Medicine and Rehabilitation; November 2006; Vol. 85; No. 11; pp. S2-S11.
2. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG; Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations; American Journal of Neuroradiology (AJNR); April 2015; Vol. 36; No. 4; pp. 811–816.
3. Jackson R; The Positive Findings in Neck Injuries; American Journal of Orthopedics; August-September 1964; pp. 178-187.
4. Turek S; Orthopaedics Principles and their Applications; Lippincott; 1977; p. 740.
5. Cailliet R; Neck and Arm Pain; F. A. Davis Company; 1981; p. 103.
6. Norris SH, Watt I; The Prognosis of Neck Injuries Resulting from Rear-end Vehicle Collisions; The Journal of Bone and Joint Surgery (British); November 1983; Vol. 65-B; No. 5; pp. 608-611.
7. Webb; Whiplash: Mechanisms and Patterns of Tissue Injury; Journal of the Australian Chiropractors’ Association; June 1985.
8. Ameis A; Cervical Whiplash: Considerations in the Rehabilitation of Cervical Myofascial Injury; Canadian Family Physician; September 1986; Vol. 32; pp. 1871-1876.
9. Dunn EJ, Blazar S; Soft-tissue Injuries of the Lower Cervical Spine; Instructional Course Lectures; 1987;Vol. 36; pp. 499-512.
10. Maimaris C, Barnes MR, Allen MJ; ‘Whiplash injuries’ of the neck: A retrospective study; Injury; November 1988; Vol. 19; No. 6; pp. 393-396.
11. Hirsch SA, Hirsch PJ, Hiramoto H, Weiss A; Whiplash syndrome: Fact or fiction? Orthopedics Clinics of North America; October 1988; Vol. 19; No. 4; pp. 791-795.
12. Foreman S and Croft A; Whiplash Injuries, The Acceleration/Deceleration Syndrome; Williams & Wilkins; 1988; p. 389, p. 395.
13. Porter KM; Neck Sprains After Car Accidents; British Medical Journal; April 15, 1989; Vol. 298(6679); pp. 973-974.
14. Watkinson A, Gargan M, Bannister G; Prognostic Factors in Soft Tissue Injuries of the Cervical Spine; Injury: the British Journal of Accident Surgery; July 1991; pp. 307-309.
15. Friedmann L, Marin E, Padula P; “Biomechanics of Cervical Trauma” in Painful Cervical Trauma, Diagnosis and Rehabilitative Treatment of Neuromusculoskeletal Injuries; Edited by C. David Tollison and John R. Satterthwaite; Williams and Wilkins; 1991, p. 17.
16. Schofferman J, Wasserman S; Successful treatment of low back pain and neck pain after a motor vehicle accident despite litigation; Spine; May 1, 1994; Vol. 19; No. 9; pp. 1007-1010.
17. Squires B, Gargan M, Bannister G; Soft-tissue Injuries of the Cervical Spine, 15-year Follow-up; Journal of Bone and Joint Surgery (British); November 1996; Vol. 78-B; No. 6; pp. 955-7.
18. Swerdlow B; Whiplash and Related Headaches; CRC press; 1999; p. 1040.
19. Malanga G, Nadler S; Whiplash; Hanley & Belfus; 2002; p. 91.
20. Schenardi C; Whiplash Injury, TOS and double crush syndrome, Forensic medical aspects; Acta Neurochirurgica; supplement, Vol. 92; 2005; pp. 25-27.
21. Nordhoff L; Motor Vehicle Collision Injuries, Biomechanics, Diagnosis, and Management; Second Edition; Jones and Bartlett; 2005, pp. 537-538.
22. Rydman E, Kasina P, Ponzer S, Jarnbert-Pettersson H; Association Between Cervical Degeneration and Self-perceived Non-recovery After Whiplash Injury; The Spine Journal; December 2019; Vol. 19; No. 12; pp. 1986−1994.
23. Platts-Mills TF, Flannigan SA, Bortsov AV, Smith S, Domeier RM, Swor RA, Hendry PL, Peak DA, Rathlev NK, Jones JS, Lee DC, Keefe FJ, Sloane PD, McLean SA; Persistent Pain Among Older Adults Discharged Home From the Emergency Department After Motor Vehicle Crash: A Prospective Cohort Study; Annals of Emergency Medicine; February 2016; Vol. 67; No. 2; pp. 166-176.

“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.”

Approximately 36 million Americans suffer from migraine headaches. Current pharmacological treatments are not very effective and they may have dangerous side effects (1). Migraines are the second most prevalent neurologic disorder (after tension-type headaches), with a female-to-male ratio of 3:1 and an estimated 1-year prevalence of approximately 15% in the general population (2).

The total sum of suffering caused by migraines is higher than any other kind of headache (3). “Migraine is often incapacitating, with considerable impact on social activities and work, and may lead to significant consumption of drugs.” (3)

The diagnosis of migraines is made clinically. There are no blood tests, imaging, or electro-physiologic tests to establish the diagnosis (3).

The common clinical characteristics of migraine headaches are (4, 5):

• The headache must last 4 to 72 hours.
• The headache must be associated with nausea and/or vomiting, or photophobia, and/or phonophobia.
• The headache must be characterized by 2 of the following 4 symptoms: unilateral location; throbbing pulsatile quality; moderate or worse degree of severity; intensified by routine physical activity.

Chronic migraine is defined as a migraine headache that occurs at least 15 times per month (4, 5).

The migraine diagnosis is assured when these characteristics are present:

• The headache is episodic
• The pain involves half the head
• There is an aura
• There are associated gastrointestinal symptoms
• There is photophobia and/or phonophobia
• The pain is aggravated by the Valsalva maneuver and/or by the head-low position
• The migraine attacks are triggered by the menstrual cycle; fasting; oversleeping; indulgence in alcohol; tyramine-containing foods [meats that are pickled, aged, smoked, fermented; most pork; chocolate; and fermented foods, such as most cheeses, sour cream, yogurt, soy sauce, soybean condiments, teriyaki sauce, tempeh, miso soup, and sauerkraut]
• Migraine relief occurs with sleep

A pioneering study advancing the understanding of all headaches, including migraine headaches, was authored by clinical anatomist and physician, Nikoli Bogduk, MD, PhD, from Australia. Dr. Bogduk’s article was published in the journal Biomedicine and Pharmacotherapy in 1995, and titled (6):

Anatomy and Physiology of Headache

In this article, Dr. Bogduk describes the clinical anatomy of headaches, noting that “all headaches have a common anatomy and physiology,” including migraine headaches. Specifically, he states:

“All headaches are mediated by the trigeminocervical nucleus.”

This means that all headaches, including migraine headaches, synapse in the upper aspect of the neck, in a location termed the trigeminocervical nucleus.

The trigeminocervical nucleus is “defined by its afferent fibers.” The primary afferent fibers that go into the trigeminocervical nucleus are from the trigeminal nerve (cranial nerve V), and from the upper three cervical nerves (C1, C2, C3). Second order afferent neurons arising in the trigeminocervical nucleus ascend to create an electrical signal in the brain that is interpreted as “headache.”

Disturbances of upper cervical spine afferents may be a source of the electrical signal that is interpreted as a headache in the brain, including migraine headaches. All structures that are innervated by C1, C2, and/or C3, can trigger migraine headaches when irritated and/or inflammed. Such structures include:

• Dura mater of the posterior cranial fossa
• Inferior surface of the tentorium cerebelli
• Anterior and posterior upper cervical and cervical-occiput muscles
• OCCIPUT-C1, C1-C2, and C2-C3 joints
• C2-C3 intervertebral disc
• Vertebral arteries
• Carotid arteries
• Alar ligaments
• Transverse ligaments
• Trapezius muscle
• Sternocleidomastoid muscle

••••••••••

The brain and the spinal cord have a protective layer called the dura mater. The dura mater is attached to the inside of the skull. Between the brain and the dura mater is the cerebral spinal fluid. The cerebral spinal fluid is the critical nutrient bath that nourishes the neurons of the central nervous system.

Important to the discussion of migraine headache is the realization that the dura mater itself contains blood vessels:

It is proposed that migraine headaches occur when the blood vessels of the dura mater dilate, depolarizing branches of the trigeminal nerve (cranial nerve V), sending the headache pain electrical signal to the trigeminocervical nucleus, then to the thalamus, then to the cortical brain where the pain is perceived (5, 7).

There is a synaptic communication between the trigeminal nerve (cranial nerve V) and the facial nerve (cranial nerve VII). The dilation of the dural blood vessels is via the facial nerve (cranial nerve VII), from the parasympathetic production and release of the neurotransmitter acetylcholine. The feedback loop involves relays in the superior salivatory nucleus and the sphenopalatine ganglion (5, 7).

Importantly, the entire feedback loop is influenced by the afferent integrity of the upper cervical spine nerve roots (C1-C2-C3). All of this is summarized in the following graph:

••••••••••

In 1978, a study was published in the Australian and New Zealand Journal of Medicine, titled (8):

A Controlled Trial of Cervical Manipulation of Migraine

The efficacy of cervical manipulation for migraine was evaluated in a six-month trial using 85 migraine sufferers. The cervical manipulation was randomly performed by a medical practitioner, a physiotherapist, or chiropractor. The authors stated:

“For the whole sample, migraine symptoms were significantly reduced.”

“Chiropractic patients did report a greater reduction in pain associated with their attacks.”

•••••

In 2000, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (9):

A Randomized Controlled Trial of
Chiropractic Spinal Manipulative Therapy for Migraine

This is a randomized controlled trial of 6 months’ duration. The object was to assess the efficacy of chiropractic spinal manipulative therapy in the treatment of migraine. It used 123 subjects (83 manipulation and 40 controls) with a minimum of 1 migraine per month. The majority of subjects had migraines for 18 years (chronic migraines).

The intervention was 2 months of chiropractic diversified technique manipulation at vertebral fixations, with a maximum of 16 visits. The control group received detuned interferential therapy, which consisted of electrodes being placed on the patient with no current sent through the machine. The outcome measures used included frequency, intensity (visual analogue score), duration, disability, and use of medication.

The chiropractic manipulation treatment group “showed statistically significant improvement in migraine frequency, duration, disability, and medication use when compared with the control group.”

• “Twenty-two percent of participants reported more than a 90% reduction of migraines as a consequence of the 2 months of spinal manipulative therapy.”
• “Fifty percent more participants reported significant improvement in the morbidity of each [migraine] episode.”
• 59% “reported no neck pain as a consequence of the 2 months of spinal manipulative therapy.”
• “The results demonstrated a significant reduction in migraine episodes and associated disability.”
• “The greatest area for improvement was [reduced] medication use.”
• “A significant number of participants recorded that their medication use had reduced to zero by the end of the 6-month trial.”
• “It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced.”
• “The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic spinal manipulative therapy.”

•••••

In 2014, researchers from Murdoch University in Australia, published a study in the journal Headache, titled (10):

Cervical Referral of Head Pain in Migraineurs:
Effects on the Nociceptive Blink Reflex

This study assessed the pain intensity in 15 migraine subjects with passive movements of the occipital and upper cervical spinal segments. The authors note that anatomically and neurophysiologically there is a functional convergence between the trigeminal and cervical afferent pathways.

Spinal mobilization is applied to dysfunctional areas of the vertebral column. “The clinician’s objective in applying manual techniques is to restore normal motion and normalize afferent input from the neuromusculoskeletal system.” These authors state:

Ongoing noxious sensory input arises from biomechanically dysfunctional spinal joints. Mechanoreceptors including proprioceptors (muscle spindles) within deep paraspinal tissues react to mechanical deformation of these tissues. Manual mechanical deformation can cause “biomechanical remodeling” with restoration of zygapophyseal joint mobility and joint “play.” “Biomechanical remodeling resulting from mobilization may have physiological ramifications, ultimately reducing nociceptive input from receptive nerve endings in innervated paraspinal tissues.”

These findings “corroborate previous results related to anatomical and functional convergence of trigeminal and cervical afferent pathways in animals and humans, and suggest that manual modulation of the cervical pathway is of potential benefit in migraine.”

This study showed that passive manual intervertebral movement between the occiput and the upper cervical spinal joints decreases excitability of the trigeminocervical nucleus. They note that manual cervical modulation of this pathway is of potential benefit in migraine sufferers.

•••••

In 2015, researchers from the United States and Canada published a study in the journal BioMed Research International, titled (11):

Effect of Atlas Vertebrae Realignment in Subjects with Migraine:
An Observational Pilot Study

This study followed 11 subjects who had been diagnosed with migraines by a medical neurologist. The intervention was chiropractic upper cervical vertebrae alignment, delivered over a period of 8 weeks. The authors concluded:

“Study results suggest that the atlas realignment intervention may be associated with a reduction in migraine frequency and marked improvement in quality of life yielding significant reduction in headache-related disability.”

•••••

Also, in 2015, the journal Complementary Therapies in Medicine, published a study titled (12):

Clinical Effectiveness of Osteopathic Treatment in Chronic Migraine:
3-Armed Randomized Controlled Trial

This manipulative therapy trial was the largest ever conducted on adult migraine patients. The authors assessed the effectiveness of manipulative treatment on 105 chronic migraine patients. The authors note:

• The manipulation group was statistically improved from the control and sham group.
• Manipulation “significantly reduced the frequency of migraine.”
• Manipulation “significantly reduced the number of subjects taking medications.”
• Manipulation “showed a significant improvement in the migraineurs’ quality of life.”
• No study participant reported any adverse effects of the manipulation.
• The use of manipulative therapy as an “adjuvant therapy for migraine patients may reduce the use of drugs and optimize the clinical management of the patients.”
• Manipulation “may be considered a clinically valid procedure for the management of patients with migraine.”

•••••

In 2017, researchers from Norway and Australia published a study in the journal Musculoskeletal Science and Practice, titled (13):

Adverse Events in a Chiropractic Spinal Manipulative Therapy:
Single-blinded, Placebo, Randomized Controlled Trial for Migraineurs

This study prospectively reported all adverse events in 70 migraine headache sufferers who were randomized to chiropractic manipulation or a placebo. It used 12 intervention sessions over three months. The authors concluded:

This study “showed significant differences between the chiropractic spinal manipulation group and the control group [drug group] at all post-treatment time points.”

“The risk for adverse events during manual-therapy [is] substantially lower than the risk accepted in any medical context for both acute and prophylactic migraine medication.”

Non-pharmacological management of migraines has the advantage of having mild and transient adverse events, “whereas pharmacological adverse events tend to be continuous.”

“Chiropractic spinal manipulation applying the Gonstead technique appears to be safe for the management of migraine headaches and presents few mild and transient adverse events.”

•••••

In another study from 2017, researchers from Brazil and Spain published an article in the journal European Journal of Physical and Rehabilitation Medicine, titled (14):

Musculoskeletal Disorders of the Upper Cervical Spine
in Women with Episodic or Chronic Migraine

The objective of this study was to assess the role of musculoskeletal disorders of the cervical spine in association with migraine headaches. The study subjects included 55 women with episodic migraines, 16 with chronic migraines, and 22 matched healthy women.

The assessment included active cervical range of motion, upper cervical spine mobility, and referred pain from upper cervical joints. Women with migraines showed reduced cervical rotation more than healthy women.  The authors note:

“Women with migraine exhibit musculoskeletal impairments of the upper cervical spine expressed as restricted cervical rotation, decreased upper cervical rotation, and the presence of symptomatic upper cervical joints.”

The authors concluded that treatment of the musculoskeletal impairments of the cervical spine may help the clinician better manage patients with migraines.

•••••

In 2017, another study from researchers in Germany was published in the journal Cephalalgia, titled (15):

Musculoskeletal Dysfunction in Migraine Patients

The objective of the study was to evaluate the prevalence and pattern of musculoskeletal dysfunctions in migraine patients using a rigorous methodological approach. The authors examined 138 migraine patients (frequent, episodic, and chronic), and 73 age and gender matched healthy controls. The analyses indicated 93% of the migraine patients had at least three musculoskeletal dysfunctions, which was statistically significant different compared to the control subjects. The authors concluded:

“Tests showed a high prevalence of musculoskeletal dysfunctions in migraine patients. These dysfunctions support a reciprocal interaction between the trigeminal and the cervical systems as a trait symptom in migraine.”

•••••

In 2019, a study was published in the journal Headache, titled (16):

The Impact of Spinal Manipulation on Migraine Pain and Disability:
A Systematic Review and Meta-Analysis

This study is a systematic review and meta-analysis of published randomized clinical trials that evaluate the evidence regarding spinal manipulation as an alternative or integrative therapy in reducing migraine pain and disability. The study analysis included 677 subjects.

The intervention duration ranged from 2 to 6 months, and the number of treatments ranged from 8 to 16. Outcomes included number of migraine days (primary outcome), migraine pain/intensity, and migraine disability.  The authors note:

There is a need for evidence-based non-pharmacological approaches to treat migraines, and to “understand whether spinal manipulation, an integral component to chiropractic care, is an effective non-pharmacological approach for the treatment of migraine headaches.”

“One potential non-pharmacological approach to the treatment of migraine patients is spinal manipulation, a manual therapy technique most commonly used by doctors of chiropractic.”

“In this meta-analysis, spinal manipulation was associated with significant reductions in migraine days compared to those in active control groups.”

“Results from this preliminary meta-analysis suggest that spinal manipulation may reduce migraine days and pain/intensity.”

•••••

Also, in 2019, a study was published in the journal Global Advances in Health and Medicine, titled (17):

Integrating Chiropractic Care into the Treatment of Migraine Headaches in a Tertiary Care Hospital: A Case Series

The authors note that chiropractors are licensed to administer nonsurgical and nonpharmacological therapies for health restoration and maintenance. The chiropractic approach to patients suffering with migraine headaches may include combinations of spinal manipulative therapy, soft tissue therapies (myofascial release, massage, trigger point therapies, etc.), rehabilitation/exercises, ergonomic advice, lifestyle management, and nutritional counseling. Chiropractic has “been shown to be efficacious for a wide-range of musculoskeletal conditions including neck pain and temporomandibular pain.” The goals of chiropractic therapy are to optimize neuromusculoskeletal health and reduce the patient’s overall pain burden.

The authors present a three migraine patient case series, noting that integrating neurologic and chiropractic care for the treatment of migraine headaches resulted in:

• Improvement in pain scores
• Increase in pain-free days
• Decreased medication usage
• Patient reports of decreased anxiety/dysthymia

The authors stated:

“All patients reported greater therapeutic benefits with the addition of the integrative approach.”

“Our case series highlights the promise of and the need to further evaluate integrated models of chiropractic and neurologic care.”

Summary

These studies document what essentially every chiropractor has observed for more than a century:

Improvement of the mechanical function of the upper cervical spine with spinal manipulation and other adjunctive mechanical interventions is an effective and safe intervention for patients suffering from migraine headaches.

The benefits of chiropractic spinal manipulation are not only that it is effective and safe, but that it reduces problems associated with pharmacological treatment.

References:

1. Lee, SM; Huge Headache of a Problem; Mastering Migraines Still a Challenge for Patients, Scientists; San Francisco Chronicle; July 20, 2014; pp. D1 and D5.
2. Stovner LJ, Nichols E, Steiner TJ, et al; Global, regional, and national burden of migraine and tension-type headache, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016; Lancet Neurology; 2018; Vol. 17; pp. 954-76.
3. Olsen J, Tfelt-Hansen P, Welch KMA; The Headaches, second edition; Lippincott Williams & Wilkins; 2000.
4. Jones HR; Netter’s Neurology; 2005.
5. Ashina M; Migraine; New England Journal of Medicine; November 5, 2020; Vol. 383; pp. 1866-1876.
6. Bogduk N; Anatomy and Physiology of Headache; Biomedicine and Pharmacotherapy; 1995; Vol. 49; No. 10; pp. 435-445.
7. Ashina M, Hansen JM, Do TP, Melo- Carrillo A, Burstein R, Moskowitz MA; Migraine and the trigeminovascular system—40 years and counting; Lancet Neurology; 2019; Vol. 18; pp. 795-804.
8. Parker GB, Tupling H, Pryor DS; A controlled trial of cervical manipulation of migraine; Australian and New Zealand Journal of Medicine; December 1978; Vol. 8; No. 6; pp. 589-593.
9. Tuchin PJ, Pollard H, Bonello R; A Randomized Controlled Trial of Chiropractic Spinal Manipulative Therapy for Migraine; Journal of Manipulative and Physiological Therapeutics; February 2000; Vol. 23; No. 2; pp. 91-95.
10. Watson DH, Drummond PD; Cervical Referral of Head Pain in Migraineurs: Effects on the Nociceptive Blink Reflex; Headache 2014; Vol. 54; pp. 1035-1045.
11. Woodfield HC 3rd, Hasick DG, Becker WJ, Rose MS, Scott JN; Effect of Atlas Vertebrae Realignment in Subjects with Migraine: An Observational Pilot Study; BioMed Research International; December 10, 2015; 630472.
12. Cerritelli F, Ginevri L, Messi G, Caprari E, Di Vincenzo M, Renzetti C, Cozzolino V, Barlafante G, Foschi N, Provincial L; Clinical Effectiveness of Osteopathic Treatment in Chronic Migraine: 3-Armed Randomized Controlled Trial; Complementary Therapies in Medicine; April 2015; Vol. 23; No. 2; pp. 149—156.
13. Chaibi A, Benth JS, Tuchin PJ, Russell MB; Adverse Events in a Chiropractic Spinal Manipulative Therapy Single-blinded, Placebo, Randomized Controlled Trial for Migraineurs; Musculoskeletal Science and Practice; March 2017; Vol. 29; pp. 66-71.
14. Ferracini GN, Florencio LL, Dach F, Bevilaqua Grossi D, Palacios-Ceña M, Ordás-Bandera C, Chaves TC, Speciali JG, Fernández-de-Las-Peñas C; Musculoskeletal Disorders of the Upper Cervical Spine in Women with Episodic or Chronic Migraine; European Journal of Physical and Rehabilitation Medicine; June 2017; Vol. 53; No. 3; pp. 342-350.
15. Luedtke K, Starke W, May A; Musculoskeletal Dysfunction in Migraine Patients; Cephalalgia; April 2018; Vol. 38; No. 5; pp. 865-875.
16. Rist PM, Hernandez A, Bernstein C, Kowalski M, Osypiuk K, Vining R, Long CR, Goertz C, Song R, Wayne PM; The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta-Analysis; Headache; April 2019; Vol. 59; No. 4; pp. 532-542.
17. Bernstein C, Wayne PM, Rist PM, Osypiuk K, Hernandez A, Kowalski M; Integrating Chiropractic Care into the Treatment of Migraine Headaches in a Tertiary Care Hospital: A Case Series; Global Advances in Health and Medicine; March 28, 2019; Vol. 8; 2164956119835778.

“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.”

The “discovery” of X-rays occurred in 1895 by German physicists Wilhelm Conrad Rontgen. Rontgen did not actually discover x-rays; he identified them. He named them “x-rays” because their exact nature was not yet identified. Much of the world refers to x-rays as “Rontgen Rays.” Rontgen was awarded the first Nobel Prize in physics for his discovery in 1901.

The first biological application for x-rays was when Rontgen made an x-ray of his wife’s hand. Rontgen immediately knew that x-rays would have medical applications.

History records that the chiropractic profession pioneered the use of x-rays on the spine in 1910 (1, 2). They called spinal x-rays “spinographs.”

Today, x-ray (radiology) is at the center of much of chiropractic education. Typical chiropractic curriculum has between 6-10 courses that are wholly dedicated to radiology. Additionally, radiology is woven into the majority of clinical science and technique courses. Consequently, leading scientific/medical journals have confirmed the competency of chiropractors in reading/interpreting spinal x-rays (3, 4, 5).

In 2002, a study was published in the journal Spine, titled (5):

Reliability and Validity of Lumbosacral Spine Radiograph Reading by Chiropractors, Chiropractic Radiologists, and Medical Radiologists

The authors were from the Department of Radiology, Medical Center Alkmaar, The Netherlands. Their objective was to determine and compare the reliability and validity of contraindications to chiropractic treatment (infections, malignancies, inflammatory spondylitis, spondylolysis and spondylolisthesis) detected by chiropractors, chiropractic radiologists, and medical radiologists on plain lumbosacral radiographs. The authors acknowledge that x-rays of the spine are an established part of chiropractic clinical practice.

The participants of the study read a set of 300 blinded lumbosacral (lower back) radiographs, 50 of which showed an abnormality. The authors concluded that the small differences between the groups were of “little clinical relevance,” stating:

“All the professional groups could adequately detect contraindications to chiropractic treatment on radiographs. For this indication, there is no reason to restrict interpretation of radiographs to medical radiologists. Good professional relationships between the professions are recommended to facilitate interprofessional consultation in case of doubt by the chiropractors.”

An important inclusion in this study was that x-rays were used to determine contraindications to chiropractic care, including the presence of infections, malignancies, and inflammatory spondylitis.

The clinical use of x-rays in chiropractic clinical practice is very common. A study published in 1997 in the Journal of Manipulative and Physiological Therapeutics noted (6):

• 74%of chiropractors have x-ray facilities in their offices.
• 71%use x-rays to screen for contraindications to chiropractic care.
• 63% use x-rays to assess existence of pathological conditions.
• 51%use x-rays to observe/measure altered biomechanics and posture.
• 27%use x-rays for medico-legal protection.
• 84% of the chiropractors refer to medical radiologists and/or to chiropractic radiologists for a formal interpretation of their radiographs.

X-rays are particularly important in clinical practice when the patient presents with a history of trauma, such as whiplash-injury trauma. More than 100 years ago (1919) a study was published on this topic in the Boston Medical and Surgical Journal. The author, Herman W. Marshall, MD, noted (7):

“X-rays of cervical spines demonstrate their positive values in instances of dislocation, fracture, and of bone disease so often that it is needless to emphasize their great importance.”

Dr. Marshall notes that following trauma, initial x-rays may be considered normal, but that subsequent x-rays may show the healing of such fractures.

Marshall also noted that later x-rays (months later) can show hypertrophic changes increasing. He interprets this as meaning there is a local impairment in physiologic function of the affected tissues, and that such hypertrophic changes “are liable to increase as the result of the injury.”
Later x-rays, months after injury, may be valuable because they may show signs of an earlier missed fracture or they may show progression of degenerative disease.

He also notes that pre-injury degenerative spinal disease found on early post-traumatic x-rays indicates a weakness that results in increased injury from a given traumatic event.

In 1953, physicians James Gay, MD, and Kenneth Abbott, MD, published a study in the Journal of the American Medical Association, titled (8):

Common Whiplash Injuries of the Neck

These authors studied 50 whiplash-injured patients. Pertaining to x-rays, they note:

“The roentgen examination of the cervical spine was an important adjunct procedure in defining the pathology of the injury.”

They advocated taking 6 cervical radiographic views: anterior to posterior, lateral cervical, lateral-flexion, lateral-extension, left and right oblique views. When skull or low back injury was suspected, x-rays were taken of those regions as well.

Another study in 1953 by physician Harvey Billig, MD, was published in the Journal of the International College of Surgeons, titled (9):

Traumatic Neck, Head, Eye Syndrome

Dr. Billig noted that with traumatic neck injuries, early radiographs could show chip or compression fractures of the vertebral bodies. He also noted that post-traumatic cervical dorsal discs injuries “went on to the development of traumatic arthritic changes.”

If the facet joint ligaments were injured, radiographs would show anterior or posterior alignment subluxation. Billig specifically stated:

“In these cases, the subluxation usually did not materialize until six months or more after the date of trauma, so that it is well to remember that all injuries to the neck should be followed by periodic roentgenographic studies for several years after the injury, with this point in mind.”

In 1957, physician Kirk V. Cammack, MD, published a study in the American Journal of Surgery, titled (10):

Whiplash Injuries to the Neck

Dr. Cammack evaluated 50 consecutive whiplash cases that were hospital treated; 82% had long-term follow-up. Exposed radiographs found:

• 22% had a vertebral body compression fraction.
• 82% of the compression fractions were at the body of C5 or C6, indicating occurrence during the rebound flexion phase of whiplash.

In 1958, neurosurgeon Emil Seletz, MD published an article in the Journal of the American Medical Association, titled (11):

Whiplash Injuries: Neurophysiological Basis for
Pain and Methods Used for Rehabilitation

Dr. Seletz emphasizes the physiological and radiological importance of post-traumatic injury to the uncinate processes (joints of von Luschka). He notes that in whiplash injury, the joints of von Luschka play a very significant clinical role:

“With degenerative thinning of the disk after trauma, the processes of the lateral joints are gradually forced outward and laterally, resulting in osteophyte formation.”

“These spurs project even more, since the osteophytes are capped with cartilage and are considerably larger than is revealed by the roentgenogram.”

“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.”

Dr. Seletz notes that lateral spurs from the joints of von Luschka compress the nerve root in the foramen. When slightly more anterior to the nerve root, joints of von Luschka spurs can encroach on the vertebral artery and the vertebral nerve (sympathetic) within the foramen transversarium.
In 1964, orthopedic surgeon and whiplash injury expert Ruth Jackson, MD, published a study in the American Journal of Orthopedics, titled (12):

The Positive Findings in Neck Injuries

After analyzing 5,000 motor vehicle collisions patients, Dr. Jackson stated:

“An adequate radiographic examination of the cervical spine is essential for diagnosis.”

Pre-existing pathological conditions of the cervical spine, when injured, “result in more damage than would be anticipated in a so-called ‘normal’ cervical spine.”

Dr. Jackson recommended that 8 x-rays be exposed following whiplash trauma, including lateral radiographs of the cervical spine in maximum flexion and extension to document segmental motion problems. She noted that x-rays showing “any segmental instability, any segmental restriction of motion, and any segmental angulation may indicate severe injury.”

Dr. Jackson also noted that initial x-rays may be normal, but subsequent x-rays may reveal multiple problems. Therefore, repeat x-rays are essential:

“All radiographs should be repeated periodically. Subsequent findings may be very revealing.”

“Repeated physical and radiographic examinations are necessary for final analysis.”

In 1993, Australian physicians JR Taylor, MD, and P Finch, MD, published a study in the Annals Academy of Medicine Singapore, titled (13):

Acute Injury of the Neck: Anatomical and Pathological Basis of Pain

Their paper focused on neck sprain from road traffic accidents as a cause of pain. Their data is compiled from literature review as well as autopsy and/or histology on their own 105 subjects.

These authors emphasize the value of maximum lateral cervical extension x-rays to detect a post-traumatic “rim lesion.” Rim lesions only occur as a consequence of trauma. They represent a traumatic disruption of the annular disk fibers from their attachment to the vertebral body. They are permanent injuries, only detectable with maximum extension x-rays. A positive finding is the presence of a gas shadow (vacuum cleft) in the disk. The authors state:

“Simple investigations such as extension X-rays may reveal vacuum clefts in the same anatomical position as rim lesions.”

In extension there is a typical “rim lesion,” which is an anterior distraction-shearing injury, “a transverse tear in the disc near the attachment of the anterior annulus to the vertebral rim.”

“In patients with extension injuries, vacuum clefts may be demonstrated in extension radiographs.”

In 2017, a study was published in the Mayo Clinic Proceedings, titled (14):

Influence of Initial Provider on Health Care Utilization
in Patients Seeking Care for Neck Pain

The authors compared and contrasted 5 different health care provider groups in the management of a new episode of neck pain in a retrospective cohort of 1,702 patients. The provider groups included:

• Primary Care Provider
• Physical Therapist
• Chiropractor
• Specialist (physiatrists or neurologist)

“These specific provider types were included in the analysis because they are the most common providers consulted for neck pain.” In every assessed parameter, chiropractic had the best outcomes.

These authors note that chiropractors are noted for the frequent use of spinal x-rays. Yet, they speculate that this increase in x-ray imaging may be responsible for the reduction of the use of advanced imaging, such as MRI and CT, resulting in a net benefit for both the patient and the reimbursing parties, saving the system money, time, and personnel resources.

In 2020, a study was published in the journal Quantitative Imaging in Medicine and Surgery, titled (15):

The Role of Radiography in the Study of Spinal Disorders

This article is a comprehensive review of the value and importance of standard spinal x-rays as the initial assessment for a variety of common congenital, degenerative, traumatic, infectious, metabolic, and carcinogenic spinal disorders. The authors state:

“Radiography plays an important role in many conditions affecting the spine.”

“Radiologists are increasingly unfamiliar with the typical findings in normal and pathologic conditions of the spine.”

“Clinicians and radiologists are losing their interest in interpreting radiographs, relying more in the source of information provided by tomographic techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI).”

“Because CT and MRI have displaced radiography in the study of many spinal conditions, radiographic signs of spinal conditions have become increasingly less studied and thus less known among clinicians and radiologists.”

“Radiographs are recommended as the initial imaging study in patients with history of low-energy trauma and in patients with suspicion of vertebral compression fracture, such as osteoporotic patients or those receiving steroids.”

“When persistent pain or red flags are present (e.g., fever, trauma, history of malignancy), radiography is still considered the first imaging modality.”

The authors note that the most frequent origin of spinal pain is classified as “non-specific” (approximately 70%) because the specific nociceptive source cannot be identified. The second most prevalent cause of spinal pain is mechanical. Mechanical spinal pain includes degenerative disorders of the spine, alignment abnormalities, and vertebral fractures. X-rays are very valuable in diagnosing mechanical causes of back pain.

Back pain may also be secondary to specific causes, such as infection, inflammatory, or tumors, etc. X-rays are also very valuable in diagnosing these specific causes of back pain and hence they are recommended.

These authors advocate spinal x-rays for the assessment of these categories:

• Traumatic Fracture
• Congenital Abnormalities
• Osteoporotic Vertebral Fracture
• Degenerative Spinal Pathology
• Spinal Instability
• Spondylolisthesis
• Alterations in Spinal Curvature
• Inflammatory Pathology
• Infectious Pathology
• Neoplastic Pathology

Traumatic Fracture

Traumatic fractures are readily viewed on spinal x-rays. When fracture is suspected by history and examination, x-rays are the imaging modality of choice.

A vertebral body fracture is considered unstable if the posterior height of the vertebral body (a burst fracture) is reduced (lateral view), or when there is a widening of the interpedicular distance (AP view), or a widening of the interspinous distance (AP view). Sometimes on the AP view, a horizontal fracture line may be seen through a pedicle. The authors insist that:

“CT must be performed even after detection of a vertebral fracture in radiographs.”

Congenital Abnormalities

Congenital pathologies are easily identified with x-rays, including:

• Kyphosis
• Lordosis
• Scoliosis
• Congenital vertebral anomalies (agenesis, hemi-vertebrae, wedged or butterfly vertebrae), block vertebrae, Klippel-Feil, etc.
• Transitional vertebra (present in <25% of the population)
  • Sacralization of L5 which is fused to the sacrum
  • Lumbarization in which S1 is detached from the sacrum

Osteoporotic Vertebral Fracture

Osteoporosis is a systemic skeletal disease characterized by a reduction in bone mass “leading to increased bone fragility and fracture risk.” These fragility fractures primarily occur in the vertebral column. A vertebral fracture after minor trauma is a hallmark of osteoporosis.

Osteoporotic vertebral fractures have a high prevalence in the elderly. They affect at least 25% of all postmenopausal women, and is commonly seen among women approximately one decade after menopause. The prevalence of osteoporotic vertebral fracture in elderly men is about half of that in age-matched women.

The most frequent site of osteoporotic vertebral fracture is the thoracolumbar junction. The second most frequent region is the mid-thoracic spine.

Many osteoporotic vertebral fractures go undiagnosed because they are often relatively asymptomatic.

When symptomatic, patients often report sudden or acute onset of back pain in temporal relationship with relatively nontraumatic activities such as bending forward, standing from a seated position, or even with vigorous coughing or sneezing.

Smoking and alcohol use increase the risk for osteoporotic fractures.

Degenerative Pathology

Degenerative pathology of the spine can affect the synovial joints, atlantoaxial joints, facets, disk, costovertebral and sacroiliac joints. They are exceptionally common in all adult age groups, and their incidence increases with age (16). Disc degeneration in particular is found in nearly 100% of persons in their 8th decade, yet such degenerative pathology is often asymptomatic (16).

Disc degeneration is characterized by “narrowing of the intervertebral disc space, central vacuum phenomenon, sclerosis of the vertebral endplates and subchondral bone, and asymmetric osteophytes in any direction.” Disc degeneration is best viewed with lateral x-rays in the cervical, thoracic, and lumbar spines.

Facet joint degeneration in both the cervical and lumbar spines is best viewed with oblique x-rays.

Degenerative changes of the cervical spine will usually also involve the uncovertebral processes (uncinate processes), with formation of posterior osteophytes. Cervical oblique x-rays are best to visualize uncinate osteophytes and any foraminal stenosis. AP x-rays may show uncinate flattening with sclerosis. On lateral cervical x-rays, uncinate degeneration may show a line that leads to the false impression of a fracture.

Degenerative bone-related central canal stenosis is best visualized on the lateral x-ray in both the cervical and lumbar spines.

At the cervical level (72-inch film distance), a “sagittal canal diameter <14 mm between C4 and C7 or a ratio between the sagittal diameter of the canal and that of the vertebral body <0.8 is considered signs of central canal stenosis.”

In the lumbar spine exposed at 40 inches, “moderate stenosis is established if the sagittal diameter is between 10 and 14 mm and severe stenosis if the diameter is <10 mm.”

Diffuse Idiopathic Skeletal Hyperostosis “DISH” is a “systemic
condition, with an estimated prevalence of approximately 10% in people >50 years of age.” It is considered to be degenerative in nature. The diagnosis is made in the presence of large bridging osteophytes affecting adjacent vertebrae. Patients with DISH “may be largely asymptomatic.”
The spinal stiffness associated with the disease implies increased “spinal vulnerability to low-energy trauma.”

Instability

Stress x-rays, especially lateral flexion and extension x-rays are useful in assessing spinal stability and to diagnose post-traumatic instability.

For the lumbar spine, sagittal rotation exceeding 10° between segments, measured as the shift of the angle between the vertebral endplates, indicates instability. If there is more than 3 mm of sagittal translation, that segment is also instable.

For cervical spine instability, a 3-mm slippage is a reliable cut-off point.

For the atlantoaxial joint, the accepted criteria with flexion-extension radiographs is an interval “greater than 3 mm between the anterior margin of the odontoid process and the posterior cortex of the anterior arch of the atlas.”

Spondylolisthesis

X-rays are excellent in diagnosing all 6 types of spondylolisthesis: congenital/dysplastic, isthmic, traumatic, pathologic, iatrogenic, and degenerative.

Isthmic spondylolisthesis is the most frequent type of spondylolisthesis and is generally considered to be a stress fracture at the pars interarticularis. This fracture is adequately visualized with a lateral lumbar x-ray spot shot or with oblique x-rays. The oblique view provides better definition of the isthmic defect, showing a silhouette resembling a ‘dog’ known as the ‘Scotty dog’. Demonstration of ‘the collar or broken neck of the Scotty dog’ sign indicates isthmic spondylolisthesis.

Degenerative spondylolisthesis is secondary to facet and disc degeneration, so the vertebral neural arch remains intact. Degenerative spondylolisthesis is the “most frequent cause of spondylolisthesis in elderly subjects.”

Traumatic spondylolisthesis is a rare injury, and defined as an acute fracture or dislocation of the posterior elements associated with vertebral spondylolisthesis. “Traumatic spondylolisthesis at C2 is called the ‘Hangman’s Fracture’.”

Retrolisthesis is a “posterior shifting of a cephalad vertebra over caudal vertebra.” Retrolisthesis is generally secondary to loss of disc material caused by disc degeneration.

Alterations in Spinal Curvature

Full-spine x-rays are “essential in assessing coronal alignment and sagittal balance after fracture, in congenital or developmental abnormalities with associated deformity (scoliosis and kyphosis), or in deformity secondary to degenerative disorders.”

X-rays “play a key role in the diagnosis and management of abnormal spine curvature, including scoliosis and kyphosis.” Vertebral alignment and spinal curvatures can be readily assessed and measured using full-spine x-rays.

During adolescence, juvenile kyphosis (Scheuermann’s disease), will cause pathological kyphosis. Scheuermann’s disease is characterized by irregular endplates, Schmorl nodes, and narrowing of the intervertebral disc.

“Scoliosis is defined as a lateral curvature of the spine greater than 10° when measured on a standing radiograph according to the Cobb method.” In adolescent scoliosis, x-rays are used to monitor for curve progression.
Inflammatory Pathology

X-rays are still recommended as initial examination to rule out inflammatory diseases such as ankylosing spondylitis, inflammatory bowel disease bony changes, and psoriatic arthritis.

Infectious Pathology

X-ray findings in osteomyelitis include “destruction of two adjacent vertebral endplates with narrowing or disappearance of the disc space.”

Neoplastic Pathology

Tumors of the spine may be metastatic, primary benign or primary malignant.

“Metastatic lesions can manifest on radiographs with an osteolytic, osteoblastic, or mixed pattern.” Between 30–50% of bone destruction is needed before the lesions become visible on x-rays. Destruction of the pedicle indicates that the lesion is advanced. Metastases from breast and prostate cancer present with a sclerotic pattern.

Hemangiomas are one of the most frequent benign tumor lesions seen in the spine, with a classic “corduroy cloth” pattern.

Multiple myeloma is characterized by lytic bone lesions that can result in pathologic fractures and severe pain. “Vertebral fractures are reported in 50–70% of patients with multiple myeloma.” The radiographic appearance of multiple myeloma may resemble that of osteoporotic vertebral fractures.

These authors conclude:

“If the clinical history, physical examination, and radiographs do not lead to any specific diagnosis, MRI is advocated as the next diagnostic exam because of its high sensitivity to depict the spinal and paraspinal soft tissues, disc and vertebral abnormalities associated to back pain.”

There are many benefits for both the chiropractor and patient to having spinal x-rays to assist in the analysis, diagnosis, and treatment of spinal syndromes.

REFERENCES

1. Young KJ; Evaluation of Publicly Available Documents to Trace Chiropractic Technique Systems That Advocate Radiography for Subluxation Analysis: A Proposed Genealogy; Journal of Chiropractic Humanities; December 2014; Vol. 21; No. 1; pp. 1–24.
2. Jenkins HJ, Downie AS, Moore CS, French SD; Current evidence for spinal X-ray use in the chiropractic profession: A narrative review; Chiropractic & Manual Therapies; November 21, 2018; Vol. 26; No. 48.
3. Taylor JA; Clopton P; Bosch E; Miller KA; Marcelis S; Interpretation of abnormal lumbosacral spine radiographs. A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic; Spine; May 15, 1995; Vol. 20; No. 5; pp. 1147-1153.
4. Assendelft WJ, Bouter LM, Knipschild PG, Wilmink JT; Reliability of lumbar spine radiograph reading by chiropractors; Spine; June 1, 1997; Vol. 22; No. 11; pp. 1235-1241.
5. de Zoete A, Assendelft WJ, Algra PR, Oberman WR, Vanderschueren GM, Bezemer PD; Reliability and validity of lumbosacral spine radiograph reading by chiropractors, chiropractic radiologists, and medical radiologists; Spine; September 1, 2002; Vol. 27; No. 17; pp. 1926-1933.
6. Harger BL, Taylor JA, Haas M; Nyiendo J; Chiropractic radiologists: A survey of chiropractors’ attitudes and patterns of use; Journal of Manipulative and Physiological Therapeutics; June 1997; Vol. 20; No. 5; pp. 311-314.
7. Marshall, HW; Neck Injuries; Boston Medical and Surgical Journal; January 23, 1919; Vol. 180; No. 4; pp. 93-98.
8. Gay JR, Abbott KH; Common Whiplash Injuries of the Neck; Journal of the American Medical Association; August 29, 1953; Vol. 152; No. 18; pp. 1698-1704.
9. Billig H; Traumatic Neck, Head, Eye Syndrome; Journal of the International College of Surgeons; November 1953; Vol. 20; No. 5; pp. 558-561.
10. Cammack KV; Whiplash Injuries to the Neck; American Journal of Surgery; April 1957; Vol. 93; pp. 663-666.
11. 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.
12. Jackson R; The Positive Findings In Neck Injuries; American Journal of Orthopedics; August-September; 1964; pp. 178-187.
13. Taylor JR, Finch P; Acute Injury of the Neck: Anatomical and Pathological Basis of Pain; Annals Academy of Medicine Singapore; March 1993; Vol. 22; No. 2; pp. 187-192.
14. Horn ME, George SZ, Fritz JM; Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain; Mayo Clinic Proceedings: Innovations, Quality & Outcomes; October 19, 2017; Vol. 1; No. 3; pp. 226-233.
15. Santiago FR, Ramos-Bossini AJL, Wáng YXJ, Zúñiga DL; The Role of Radiography in the Study of Spinal Disorders; Quantitative Imaging in Medicine and Surgery; 2020; Vol. 1; No. 12; pp. 2322-2355.
16. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG; Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations; American Journal of Neuroradiology (AJNR); April 2015; Vol. 36; No. 4; pp. 811–816.

“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.”

The word “light” brings up familiar images. The common image of “light” is that of something we see. Yet, the “light” that we can see is only a small slice of a much larger range of waves that are known as the “electromagnetic” spectrum. The entire “electromagnetic” spectrum is considered to be “light.” Yet, vast majority of the “electromagnetic spectrum of light” is invisible.

This concept, and many more concepts pertaining to light, are explained in the 2017 book by astronomers Bob Berman, titled (1):

Zapped: From Infrared to X-rays, the Curious History of Invisible Light

Berman notes:

There is a “whole world of light outside our range of vision.”

Berman also explains that all light is in packets of energy (photons) that travel in waves. He states:

“Photons constitute 99.9999999 percent of everything.”

The waves of light have different lengths (known as wavelengths). The wavelength is the distance from crest to crest for two adjacent waves. What makes light visible or invisible is its wavelength. Wavelengths shorter than the visible spectrum are invisible. Wavelengths longer than the visible spectrum are also invisible. A typical graph of the electromagnetic spectrum of waves includes:

We can only see the wavelengths in the visible spectrum of light. All of the other wavelengths are invisible to the human eye. The different wavelengths of the electromagnetic spectrum have different characterizes (positive and negative applications and influences):

• Gamma: They have so much energy that they damage genetic material, causing mutations.
• X-Rays: They also have so much energy that they damage genetic material and cause mutations. But, they also have beneficial applications, such as making diagnostic images like x-rays and CAT scans.
• Ultraviolet: They also have sufficient energy to damage genetic material and cause mutations, particularly skin cancers. However, they are required to help the body make the critically important vitamin D.
• Visible: These are the wavelengths that we can see, including all of the various colors around us. The different wavelengths within the visible spectrum account for the different colors we can perceive.
• Infrared: These wavelengths have some therapeutic applications, and they are most notorious for generating heat.
• Microwave: These wavelengths can rapidly cook food and boil water. They also have a number of technological applications, such as wireless communications and radar.
• Radio: Best known for their ability to be used to broadcast radio, hence the name.

The wavelengths of X-rays have diagnostic significance. Their discovery in 1895 allowed health care providers to visualize bones, joints, and other structures. This application for x-rays was discovered by German physicists Wilhelm Conrad Rontgen. Rontgen was awarded the first Nobel Prize in Physics for his discovery in 1901. Rontgen did not understand that the high energy generated by x-rays would damage genetic material and cause genetic mutations. Rontgen died of radiation poisoning.

Polish scientist Marie Curie earned two Nobel Prizes. Her first was in Physics, awarded in 1903, for her pioneering work in radioactivity, a word she coined. Her second Nobel Prize was in Chemistry, awarded in 1911, for her discovery of the radioactive elements radium and polonium. Curie also did not understand the high energy generated by radioactivity wavelengths, including the energy produced by her elements radium and polonium, which also damaged genetic material and caused genetic mutations. Curie also died of radiation poisoning.

Walter Bradford Cannon was an American physician and physiologist. He was Chairman of Harvard Medical School’s Department of physiology for about forty years. His research expanded upon the concepts and importance of physiological homeostasis (a word he also coined) and the “fight-or-flight” response of the sympathetic nervous system. His investigations included exposing volunteer subjects to diagnostic x-rays to determine the digestion of food when exposed to periods of calm v. stress. Like Rontgen and Curie, Cannon did not understand that the high energy generated by x-rays would damage genetic material and cause genetic mutations. Cannon also died of radiation poisoning.

Computed Axial Tomography (CAT or CT scan) is technology that allows for rapid axial (“slice-of-bread”) x-rays of parts of the body. Because many slices of x-ray exposure are made, the subject is exposed to higher levels of x-ray radiation. This allows for a unique and often valuable imaging of the body, but at the cost of increased risks of genetic damage and mutations for the subject.

Magnetic Resonance Imaging (MRI or MR) also images the inner body, but without causing genetic damage. MRI exposure time is much longer and they are more expensive.

Some of the first applications for x-rays was to image the human spinal column. These early x-rays were known as spinographs. Today, chiropractors often make great use of all three modalities (x-rays, CAT, MRI), and many chiropractors have x-ray machines in their clinical offices.

The most common modality for imaging used by chiropractors is x-rays. As noted, many chiropractors have x-ray machines in their clinical offices. Chiropractors expose x-rays on patients for a number of reasons, including:

• To discover and/or rule out diseases that should be referred to medical specialists, such as cancer or infection or some metabolic diseases.
• To document degenerative diseases of the spine, particularly pertaining to the discs, facet, central canal and lateral recess.
• To document congenital anomalies such as facet tropism, lumbosacral transitional segments, hemi and/or demi vertebrae, additional or missing ribs, block vertebrae, central canal stenosis, etc.
• To document prior spinal pathologies, such as Schmorl’s nodes, spondylolysis, spondylolisthesis, fractures, etc.
• To assess the unique and specific biomechanics on an individual patient in order to optimize the specific line-of-drive for the spinal adjustment as well as to influence various rehabilitation intervention to assist with spinal remodeling programs.

••••••••••

Terminology

The structure that is most critical to spinal health is the intervertebral disk. The intervertebral disk functions as a shock absorber while allowing for the incredible mobility of the spinal column The disk itself is not seen with x-rays but the disk space can be viewed. The size of the disk space is a window into the integrity of disk function.

The internal disk structure can be viewed with both CAT and/or MRI scans.

The intervertebral disk can suffer from a number of acquired and/or pathological changes that may have clinical importance. These changes include degeneration, desiccation (drying out), fissures (cracks that breach the integrity), and herniation (movement of diskal material towards the nervous system: spinal cord, cauda equina, nerve root).

The terminology pertaining to lumbar spinal disk herniations has been confusing, inconsistent, and contradictory. In 2014, the North American Spine Society, the American Society of Spine Radiology, and the American Society of Neuroradiology convened a combined task force to agree upon the nomenclature, including (2):

The Normal Disk

The Bulging Disk

 If any part of the annulus extends beyond the normal disc space, it is considered to be a bulging disk.

The Protrusion Disk

In the protrusion disk, the base of the displaced material is greater than the distance the disk material had moved towards the intervertebral foramen and/or the central neural canal.

The Extrusion Disk

In the extrusion disk, the greatest measure of the displaced disk material is greater than the measure of the base of the displaced material.

The Sequestration Disk

In the sequestration disk, the disk material has lost all connection with the original disk material.

••••••••••

How Important Are Imaging Findings in the Genesis of Low Back Pain?

Spinal imaging finding are important for many reasons, including all of the reasons mentioned above. Ironically, one of the least important reasons for spinal imaging is to determine the source of a patient’s pain.

•••••

In 1990, researchers from the Department of Orthopaedic Surgery at George Washington University Medical Center produced a study where 67 subjects who had never had low-back pain, sciatica, or neurogenic claudication received MRIs (3).

About one-third of the subjects had a substantial abnormality on imaging:

• Of those who were less than 60 years old, 20% had a herniated nucleus pulposus.
• In the group that was more than 60 years old, 57% had abnormal imaging: 36% had a herniated nucleus pulposus and 21% had spinal stenosis.
• Disc degeneration or bulging occurred at at least 1 lumbar level in 35% of the subjects between 20 and 39 years of age.
• Disc degeneration or bulging occurred in all but one of the 60 to 80 year-old subjects.

•••••

In 1991, researchers from the Department of Neurology at the Medical College of Pennsylvania, performed magnetic resonance imaging of the lumbar spine on 66 asymptomatic subjects and found that 18% had either a disc protrusion or herniation (4).

An additional 39% had a bulge that was associated with degenerative disc disease. The authors also found examples of spinal stenosis, narrowed nerve root canals, osteophytes, and vertebral body involvement with multiple myeloma. The authors concluded:

“Degenerative disc disease is a common finding in asymptomatic adults that increases in frequency with age. It occurs more frequently in men and usually involves more than one level. The most common location is L5-S1.”

•••••

In 1994, researchers from Hoag Memorial Hospital, Newport Beach, California, performed MRI examinations on 98 asymptomatic subjects aged 20-80 years. The authors documented both disk abnormalities and non-disk abnormalities (5):

• 36% of the 98 asymptomatic subjects had normal disks at all levels.
• 52% of the subjects had a bulge at one or more level.
• 27% had a protrusion.
• 1% had an extrusion.
• 38% had an abnormality of more than one intervertebral disk.
• 19% had Schmorl’s nodes.
• 14% had annular defects.
• 8% had facet arthropathy.
• Again, only 36% had a normal disk at all levels.

The authors concluded that there was a “high prevalence of abnormalities in the lumbar spine on MRI examination of people without back pain.” 

•••••

In 2009, researchers from Hakodate Central General Hospital in Japan, performed MRIs on 200 healthy subjects to establish the baseline data of degenerative disc disease. The subjects included 68 men and 132 women whose mean age was 40 years (range 30-55 years). For the entire group, they found this incidence of disc degeneration, by spinal segmental level, was (6):

• L1-L2             7.0%
• L2-L3             12.0%
• L3-L4             15.5%
• L4-L5             49.5%
• L5-S1            53.0%

•••••

In 2010, researchers from Boston University School of Medicine assessed the role of radiographic abnormalities in the etiology of nonspecific low back pain because of the strong influence radiographic findings have on medical decision making. They specifically looked at the prevalence of lumbar spine degeneration as evaluated with computed tomography (CT) (7):

• Intervertebral disc narrowing
• Facet joint osteoarthritis
• Spondylolysis
• Spondylolisthesis
• Central canal spinal stenosis

 One hundred eighty seven subjects participated in the study: 104 men and 83 women, with a mean age of 53 years. Findings include:

• 64% had disk degeneration
• 65% had facet joint osteoarthritis
• 12% had spondylolysis

In this study, the only imaging finding that showed statistical significance associated with low back pain was central canal spinal stenosis.

Degenerative features of the lumbar spine were extremely prevalent in this community-based sample, but they were essentially not associated with low back pain.

•••••

In 2015, researchers from Mayo Clinic, the University of Washington, Oregon Health and Science University, Henry Ford Hospital in Detroit, University of California San Francisco, Kaiser Permanente in Oakland, California, reviewed the literature to estimate the prevalence, by decade age (20, 30, 40, 50, 60, 70, 80 years), of common degenerative spine conditions (8). Their systematic literature review used either CT and/or MRI imaging of 3,110 asymptomatic individuals from 33 studies that met the study inclusion criteria. The authors specifically identified and quantified the following degenerative markers:

• Disk degeneration
• Disk signal loss
• Disk height loss
• Disk bulge
• Disk protrusion
• Annular fissures
• Facet degeneration
• Spondylolisthesis

The authors began with this premise:

“Given the large number of adults who undergo advanced imaging to help determine the etiology of their back pain, it is important to know the prevalence of imaging findings of degenerative disease in asymptomatic populations.”

All study subjects were asymptomatic at the time of their imaging, and all had no history of back pain. Studies with patients with minor or low-grade back pain were excluded, as were patients with motor or sensory symptoms, tumors, or trauma.

The authors note that MR imaging is highly sensitive in detecting spinal degenerative changes, and that spinal degenerative changes often occur in pain-free individuals as well as those with back pain. They state:

“Findings such as disk degeneration, facet hypertrophy, and disk protrusion are often interpreted as causes of back pain, triggering both medical and surgical interventions, which are sometimes unsuccessful in alleviating the patient’s symptoms.”

“Prior studies have demonstrated that imaging findings of spinal degeneration associated with back pain are also present in a large proportion of asymptomatic individuals.”

“Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age.”

“Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.”

Findings by age decade included:

• “Disk degeneration prevalence ranged from 37% of asymptomatic individuals 20 years of age to 96% of those 80 years of age, with a large increase in the prevalence through 50 years.”
• “Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age.”
• “Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age.”
• “The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age.”
• “Disk signal loss (“black disk”) was similarly present in more than half of individuals older than 40 years of age, and by 60 years, 86% of individuals had disk signal loss.”
• “Disk height loss and disk bulge were moderately prevalent among younger individuals, and prevalence estimates for these findings increased steadily by approximately 1% per year.”
• “Disk protrusion and annular fissures were moderately prevalent across all age categories but did not substantially increase with age.”
• Facet degeneration was “rare in younger individuals (4%–9% in those 20 and 30 years of age), but the prevalence increased sharply with age.”
• “Spondylolisthesis was not commonly found in asymptomatic individuals until 60 years, when prevalence was 23%; prevalence increased substantially at 70 and 80 years of age.”

        These findings are summarized tin the following chart:

Imaging Findings	20s	30s	40s	50s	60s	70s	80s
Disk Degeneration	37%	52%	68%	80%	88%	93%	96%
Disc Signal Loss	17%	33%	54%	73%	86%	94%	97%
Disc Height Loss	24%	34%	45%	56%	67%	76%	84%
Disk Bulge	30%	40%	50%	60%	69%	77%	84%
Disk Protrusion	29%	31%	33%	36%	38%	40%	43%
Annular Fissure	19%	20%	22%	23%	25%	27%	29%
Facet Degeneration	4%	9%	18%	32%	50%	69%	83%
Spondylolisthesis	3%	5%	8%	14%	23%	35%	50%

This systematic review indicates that many imaging findings of degenerative spine disease have a high prevalence among asymptomatic individuals. Disk degeneration and signal loss were present in nearly 90% of individuals 60 years of age or older. The authors concluded:

“Our study suggests that imaging findings of degenerative changes such as disk degeneration, disk signal loss, disk height loss, disk protrusion, and facet arthropathy are generally part of the normal aging process rather than pathologic processes requiring intervention.”

“With a prevalence of degenerative findings of >90% in asymptomatic individuals 60 years of age or older, our study supports the hypothesis that degenerative changes observed on CT and MR imaging are often seen with normal aging.”

•••••

There are many reasons for spinal imaging, some of them are critical. Because there is poor correlation between imaged spinal degenerative changes and a patient’s back pain complaints, many chiropractors initially choose to forgo spinal imaging until response to clinical intervention is ascertained. Ultimately, the choice for spinal imaging or not is the call of the treating chiropractor who is looking out for the best interests of the patient.

REFERENCES

1. Berman B; Zapped: From Infrared to X-rays, the Curious History of Invisible Light; Little Brown and Company, 2017.
2. Fardon DR, Williams LA, Dohring EJ, Rothan SL, Sze GK; Lumbar Disc Nomenclature: Version 2.0: Recommendations of the Combined task forces of the North American Spine Society, the American Society of Spine Radiology, and the American Society of Neuroradiology; Spine Journal; 2014; No. 14; pp. 2525-2545.
3. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW; Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation; Journal of Bone and Joint Surgery; March 1990; Vol. 72; No. 3; pp. 403-408.
4. Greenberg JO, Schnell; Magnetic resonance imaging of the lumbar spine in asymptomatic adults. Cooperative study–American Society of Neuroimaging; Journal of Neuroimaging; February 1991; Vol. 1; No. 1; pp. 2-7.
5. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian G, Ross JS; Magnetic resonance imaging of the lumbar spine in people without back pain; New England Journal of Medicine; July 14, 1994; Vol. 331; Vol. 2; pp. 69-67.
6. Kanayama M, Togawa D, Takahashi C, Terai T, Hashimoto T; Cross-sectional magnetic resonance imaging study of lumbar disc degeneration in 200 healthy individuals’; Journal of Neurosurgery Spine; October 2009; Vol. 11; No. 4; pp. 501-507.
7. Kalichman L, Kim DH, Li L, Guermazi A, Hunter DJ; Computed tomography-evaluated features of spinal degeneration: prevalence, intercorrelation, and association with self-reported low back pain; Spine Journal; March 2010; Vol. 10; No. 3; pp. 200-208.
8. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG; Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations; American Journal of Neuroradiology (AJNR); April 2015; Vol. 36; No. 4; pp. 811–816.

“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.”

The sciatic nerve is a nerve that begins in the lower back and travels through the buttock and into the leg and then into the foot. It is the longest and widest nerve in the human body. The sciatic nerve is made up of five lumbosacral nerve roots, L4, L5, S1, S2, and S3.

When a nerve is inflamed, irritated, compressed, or ischemic, etc., it generates symptoms (pain, numbness, tingling, hypersensitivity, burning, achiness, etc.) and/or functional disturbances (weakness, atrophy, etc.).

Technically, the sciatic nerve is a nerve. When a nerve causes symptoms, the technical term is neuritis or neuropathy. Therefore, technically, signs and symptoms attributed to the sciatic nerve are called sciatic neuritis or sciatic neuropathy. However, most people and most health care providers simply refer to it as sciatica.

As noted, the sciatic nerve is made from five nerve roots. When any of these nerve roots are inflamed, irritated, compressed, or ischemic, etc., it will generate the signs and/or symptoms of sciatica. However, nerve root problems have their unique terminology: radiculitis and radiculopathy.

Putting this together:

• A nerve root cause of sciatica is called sciatic radiculitis or sciatic radiculopathy.
• A peripheral nerve (beyond the nerve root) cause of sciatica is called sciatic neuritis or sciatic neuropathy.

The lumbar spine nerve roots exit from behind the intervertebral disk in a hole called the intervertebral foramen. This anatomic arrangement gives three of the nerve roots that make up the sciatic nerve a particular vulnerability:

• The L4 nerve root, vulnerable between L3-L4.
• The L5 nerve root, vulnerable between L4-L5.
• The S1 nerve root, vulnerable between L5-S1.

Their vulnerability is usually linked to the integrity of the intervertebral disk. As seen here, a variety of intervertebral disk pathology narrows the nerve root hole, the intervertebral foramen. This decreases the margin of safety for the nerve root, increasing opportunities for irritation, inflammation, compression, etc.

Any irritation, inflammation, or compression of these nerve roots increases the signs and symptoms of sciatic radiculitis/radiculopathy. The primary complaint is leg pain, and especially leg pain that extends below the knee.

There is no doubt that the primary reason that patients go to chiropractors is for the management of low back pain (63%) (1). Chiropractic care for low back pain is very effective, has high levels of patient satisfaction, confers long-term clinical benefits, and is exceptionally safe (1, 2, 3, 4, 5, 6).

In randomized clinical trials comparing chiropractic spinal manipulation to prescription pain medicines for chronic low back and neck pain, chiropractic manipulation was significantly more effective, registered no significant side effects, and displayed stable long-term clinical benefits (at the one-year follow-up assessment) (5, 6).

When low back pain patients present with leg pain, the common lay person assessment is that of sciatica. But because of the anatomy, most health care providers initially assume the cause is discogenic; a discogenic radiculopathy resulting in sciatica.

It has been documented for decades that the primary anatomic tissue source for low back pain is the intervertebral disk (7, 8). Since the intervertebral disk is also the primary cause of radicular sciatica, it is not surprising that many with low back also have leg pain.

Also, for decades, publications have noted that spinal manipulation is not only effective in the management of low back pain, but also effective for discogenic radicular sciatica. Examples include:

In 1954, an article was published in the Instructional Course Lectures of the American Academy of Orthopedic Surgeons, titled (9):

Conservative Treatment of Intervertebral Disk Lesions

The author states:

“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.”

In 1969, a study was published in the British Medical Journal, titled (10):

Reduction of Lumbar Disc Prolapse by Manipulation

The patients in this study 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 rotation manipulations of the lumbar spine, 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. The authors note:

“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.”

Another 1969 study was published in the Australian Journal of Physiotherapy, titled (11):

Low Back Pain and Pain Resulting from Lumbar Spine Conditions:
A Comparison of Treatment Results

The author 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 further the sciatic pain radiated down the leg, the greater the benefit of spinal manipulation.

This study was reviewed by Augustus A. White, MD, and Manohar M. Panjabi, PhD, in their 1990 book, Clinical Biomechanics of the Spine (12). Their comments include:

“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. This reference book includes a section pertaining to the protruded disc, titled (13):

Treatment of Intervertebral Disc Herniation with 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.”

In 1987, a study was published in the journal Clinical Orthopedics and Related Research, titled (14):

Treatment of Lumbar Intervertebral Disc Protrusions by Manipulation

This study involved 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:

“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.”

“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 1989, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (15):

Lumbar Intervertebral Disc Herniation:
Treatment by Rotational Manipulation

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, a “Review of the Literature” was published in the Journal of Manipulative and Physiological Therapeutics, titled (16):

Side Posture Manipulation for Lumbar Intervertebral Disk Herniation

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, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (17):

A Series of Consecutive Cases of Low Back Pain
with Radiating Leg Pain Treated by Chiropractors

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 authors 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, a study was published in The Spine Journal, titled (18):

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 involved 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 note:

“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.”

“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.”

In 2014, a study was published in the Annals of Internal Medicine, titled (19):

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

This study included 192 patients who were suffering from back-related leg pain for least 4 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.”

Another 2014 study was published in the Journal of Manipulative and Physiological Therapeutics and titled (20):

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

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. 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 2016, an article was published in the New England Journal of Medicine, titled (21):

Herniated Lumbar Intervertebral Disk

The authors note that approximately 85% of patients with sciatica have a herniated intervertebral disk. Hence, sciatica is the single most important presenting symptom of discogenic radiculopathy/sciatica. The authors clearly acknowledge that chiropractic manipulation is acceptable conservative care for patients with low back pain and sciatica, stating:

“CT or MRI is necessary only in a patient whose condition has not improved over 4 to 6 weeks with conservative treatment.”

“The use of CT or MRI should be discouraged unless the symptoms do not decrease over 4 to 6 weeks” of conservative treatment.

Six weeks of conservative therapy is generally recommended in patients with herniated lumbar disks, in the absence of a major neurological deficit.

In the absence of severe neurologic deficits, discogenic sciatica patients should have conservative treatment for 6 weeks before agreeing to more invasive approaches.

A randomized trial of chiropractic manipulation for subacute or chronic back related leg pain “showed that manipulation was more effective than home exercise with respect to pain relief at 12 weeks.”

“A randomized trial involving patients who had acute sciatica with MRI-confirmed disk protrusion showed that at 6 months, significantly more patients who underwent chiropractic manipulation had an absence of pain than did those who underwent sham manipulations (55% vs. 20%).”

In 2020, a study was published in the journal Annals of Internal Medicine, titled (22):

Physical Therapy Referral from Primary Care
for Acute Back Pain With Sciatica
A Randomized Controlled Trial

The authors of this study note that most “sciatica is attributable to lumbar disk disorders,” and that “sciatica is estimated to occur in about 30% of low back pain episodes.” 

This study involved 220 subjects with an acute onset of low back pain and sciatica. Half were given usual care (drugs and a single education session), and have were referred for 6-8 early sessions of exercise with mechanical manual therapy. The manual therapy consisted of mobilization or high-velocity thrust manipulation of the lumbar spine.

Reassessments for pain, disability, function, and patient satisfaction were completed at 4 weeks, 6 months, and 12 months.

The authors found that referral for early mechanical-based treatment was more effective in reducing disability than usual care alone for low back pain and sciatica. They note:

The early treatment “group showed greater improvement in disability and back pain intensity across all follow-up times.” 

“Patients receiving [early mechanical treatment] were more likely to rate their treatment as successful at 4 weeks and 1 year.”

Early treatment “hastened functional improvement, indicating that [early mechanical treatment] can be offered to patients as first-line nonpharmacologic care.”

Early [mechanical] treatment “for recent-onset low back pain and sciatica resulted in greater improvement in disability and secondary outcomes than usual care across the 1-year follow-up.”

This study indicates that this “drug-wait-and-see” approach is flawed and that the best outcomes for acute low back pain with sciatica use early mechanical-based care. The use of early mechanical-based care resulted in the greatest improvements in pain, disability and patient satisfaction at 1 month, 6 months, and 1 year. This is clearly a physical therapy study, but the therapists used similar interventions that are used in chiropractic, including high-velocity-low amplitude manipulation (manual therapy), exercise, and traction.

The Bottom Line

Low back pain with sciatica is always important because it may be caused by discogenic compressive neuropathology, a problem that may require surgical decompression. However, the studies presented here indicate that early spinal manipulation is often successful at resolving both the low back and leg pain. Providers should be mindful of progressing neurological signs/symptoms and “red flags” should be watched for. The majority of such patients will experience successful outcomes within six weeks of conservative care.

References

1. Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
2. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
3. 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; June 2, 1990; Vol. 300; pp. 1431-1437.
4. The Lancet; Chiropractors and Low Back Pain; July 28, 1990, p. 220.
5. Giles LGF; Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine July 15, 2003; Vol. 28; No. 14; pp. 1490-1502.
6. 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.
7. Mooney V; Where Is the Pain Coming From?; October 1987; Spine; Vol. 12; No. 8; pp. 754-759.
8. 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.
9. Ramsey RH; Conservative Treatment of Intervertebral Disk Lesions; American Academy of Orthopedic Surgeons, Instructional Course Lectures; Volume 11, 1954; pp. 118-120.
10. Mathews JA and Yates DAH; Reduction of Lumbar Disc Prolapse by Manipulation; British Medical Journal; September 20, 1969; No. 3, 696-697.
11. Edwards BC; Low back pain and pain resulting from lumbar spine conditions: a comparison of treatment results; Australian Journal of Physiotherapy; Vol. 15; No. 104, 1969.
12. White AA, Panjabi MM; Clinical Biomechanics of the Spine; Second edition, JB Lippincott Company; 1990.
13. Turek S; Orthopaedics, Principles and Their Applications; JB Lippincott Company; 1977; page 1335.
14. 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.
15. 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):220-227.
16. Cassidy JD, Thiel HW, Kirkaldy-Willis WH; Side posture manipulation for lumbar intervertebral disk herniation; Journal of Manipulative and Physiological Therapeutics; February 1993; Vol. 16; No. 2; pp. 96-103.
17. 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; Jul-Aug 1995; Vol. 18; No. 6; pp. 335-342.
18. 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.
19. 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.
20. 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.
21. Deyo R, Mirza S; Herniated Lumbar Intervertebral Disk; New England Journal of Medicine; May 5, 2016; Vol. 374; No. 18; pp. 1763-1772.
22. Fritz JM, Lane E, McFadden M, Brennan G, Magel JS, Thackeray A, Minick K, Meier W, Greene T; Physical Therapy Referral from Primary Care for Acute Back Pain with Sciatica A Randomized Controlled Trial; Annals of Internal Medicine; October 6, 2020 [epub].

“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.”

Discussion

A disease is not a thing, but rather a process. A disease has a beginning, a middle, and an end.

A treatment intervention that is given in the middle of a disease process may be blamed for causing the disease itself. This is called protopathic bias.

Protopathic Bias is when a treatment for the symptoms of a disease or injury appears to cause the outcome, when in fact it did not.

Background

In 2017, the top-ranked orthopedic journal Spine published a study titled “The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults.” (1) The findings were not surprising:

• 63% of patients sought chiropractic care for low back pain
• 30% of patients sought chiropractic care for neck pain

The subject of this writing is chiropractic care for neck pain, which is the second most common reason for people going to chiropractors.

It is unquestioned that chiropractic care (spinal manipulation) is effective for neck pain (2, 3, 4, 5, 6, 7). This includes neck pain with associated cervical intervertebral disk herniation resulting in proven compressive neuropathology (8).

It is also unquestioned that chiropractic care is exceptionally safe (8, 9, 10, 11). In some studies, the adverse events attributed to chiropractic spinal adjusting (specific line-of-drive manipulation) is zero (9, 10). This is a factor in chiropractic care being recommended in practice guidelines for the management of spinal pain syndromes (12, 13).

However, chiropractic care is not without some risks. This is why chiropractors, like all other health care providers, use Informed Consent. Typical Informed Consent language used by chiropractors would include:

Every type of health care is associated with some risk of a potential problem. This includes chiropractic health care. We want you to be informed about potential problems associated with chiropractic health care before consenting to treatment.

Chiropractic adjustments are the moving of bones with the doctor’s hands or with the use of a mechanical device or machine. Frequently adjustments create a “pop” or “click” sound/sensation in the area being treated.

Some states require the Informed Consent to be written. Even in states that do not require written a Informed Consent, it is generally a good idea to do so. Ideally, a written Informed Consent would be signed and dated by the patient, indicating that they understood the document and had any questions pertaining to it addressed by the chiropractor.

One’s Informed Consent often will include subjects such as:

• Stroke
• Disc Herniations
• Cauda Equina Syndrome
• Soft Tissue Injury
• Rib and other Fractures
• Physical Therapy Burns
• Soreness

There is no need to inform about things that a particular chiropractor does not do. For example, if a chiropractor does not used thermal modalities (including ice packs), there is no need to include them in one’s Informed Consent.

Of the seven Informed Consent subjects listed above, the most serious is stroke. The stroke issue pertains only to the cervical spine adjustments. The remainder of this writing pertains to the stroke issue.

Definitions

Stroke means that a portion of the brain or spinal cord does not receive enough oxygen from the blood stream. The results can be temporary or permanent dysfunction of the brain, with a very rare complication of death.

Strokes are medical emergencies because the ultimate clinical outcome is often linked to the treatment given in the first three hours. Therefore, if a stroke is suspected before, during or after a chiropractic visit, a timely referral to the emergency department is important.

There are two primary forms of stroke:

• Hemorrhagic (bleeding)
• Embolic (clotting)

Chiropractic cervical adjustments are not associated with hemorrhagic strokes, and therefore they will not be discussed here other than to clarify this point: hemorrhagic strokes are medically managed very differently then embolic strokes. In fact, the most common medical management of an embolic stroke is contraindicated for a hemorrhagic stroke because it may make the patient worse. Therefore, a critical decision for the emergency department is to determine the type of stroke. The most common way to do this is via exposure of a CT scan. Many emergency departments will goal to have the CT scan exposed and read within thirty minutes of a patient’s arrival when a stroke is suspected. CT does not best document embolic stroke, but readily documents a hemorrhagic stroke. Therefore, if a CT rules out a hemorrhagic stroke, an embolic stroke is assumed and usually confirmed with MRI.

If the stroke is determined to be embolic, common medical intervention is the intravenous (IV) application of a clot-dissolving chemical, most commonly tPA (tissue plasminogen activator). Often emergency department personnel goal to have tPA administered within sixty minutes of a patient’s arrival. Again, the overall window for the administration of tPA is short, about 3 hours from first stroke symptoms. Evidence suggests that when administered after three hours of the initiation of stroke symptoms, much of the benefits of clot dissolving are lost.

It is not alleged that chiropractors directly cause strokes. Rather, the allegation is that certain chiropractic adjustments on some patients can cause a dissection of a cervical artery. An arterial dissection occurs when there is a loss of integrity of the inner lining of the arterial blood vessel. The dissection results in a vascular clot that can dislodge and float downstream into the brain, resulting in an embolic stroke.

A number of mechanical events can increase the risk of cervical artery dissection in some individuals, but by far the primary cause is “spontaneous” dissections. Suspected mechanical events that may increase the risk of dissections in some individuals include:

• Whiplash trauma
• Sports trauma
• Head rotation to check traffic
• Head extension during hair washing
• Dentistry positions
• Cervical spine manipulation (as discussed below)

Amino acids are the building blocks of protein. All of our proteins are built by twenty different amino acids. Our body can manufacture eleven of these amino acids, but the other nine (essential amino acids) must be supplied by the diet.

When a person has an adequate supply of all twenty amino acids, their assembly into a specific sequence to make a specific protein is done by our genetic material (DNA). Since everyone’s DNA is unique to them, there is a similar uniqueness to the assembly of proteins in each person.

In addition to one’s innate genetics, other environmental factors can alter the creation of one’s unique repertoire of proteins. Non-mechanical factors that may also increase the risk of dissections in some individuals include:

• Genetic mutation from exposure to ionizing radiation, smoking, and/or chemicals
• Birth control pills
• Infections
• Certain antibiotics (fluoroquinolones)
• B-vitamin deficiencies that result in elevated levels of homocysteine
• Hypertension
• Chronic stress

Collagen is a protein. It is the most common protein in our bodies. It is the biological “glue” that holds us together. It is responsible for the toughness of our skin, ligaments, tendons and intervertebral disc. Also, the blood vessel owes its vascular integrity to the quality of one’s collagen protein. All factors that weaken or degrade one’s collagen protein will weaken arterial wall vascular integrity, increasing the risk of dissection.

In the neck (cervical spine), there are two arteries that have the potential to dissect. They are the internal carotid artery and the vertebral artery.

The internal carotid arteries give rise to the blood that supplies the anterior (front) portion of the brain. The internal carotid arteries exist anterior to the spinal column.

The vertebral arteries give rise to the blood that supplies the posterior (back) portion of the brain, including the cerebellum and the brain stem. The vertebral arteries exist in the spinal vertebrae, C6 through C1, in a foramen called the foramen transversarium.

In the discussion of mechanical risk to cervical artery dissection, the vertebral artery predominates because of its location in the vertebral foramen transversarium.

Evidence

Cervical artery dissection in proximity to chiropractic spinal adjusting is so rare that it is all but impossible to effectively study. Claimed incidences range from about one in 400,000 adjustments to about one in ten million adjustments (5). What complicates the understanding of these numbers is the proof that many cervical artery strokes that are attributed to chiropractors should actually be attributed to lay (not trained) manipulators (masseuse, barber, spouse, Kung-Fu practitioner, self manipulation, medical doctor, osteopath, naturopath, physical therapist). (14, 15, 16) Apparently, some authors consider “manipulation” and “chiropractic” to be synonymous, when they are not. Chiropractors are well trained in vascular anatomy and trained to avoid any manipulations that may increase the risk of vascular injury. Lay manipulators often lack this training.

There are no published studies showing a causal link between chiropractic spinal adjusting and cervical artery dissection. The majority of evidence suggesting that there is an association between cervical artery dissection and chiropractic adjustments is weak or very weak. This evidence is typically retrospective single case anecdotes. Yet, larger population assessments involving up to 109,000,000 patient years of observation and millions of patients/controls are available, and are briefly reviewed here:

A book (monograph) published by the American Academy of Orthopaedic Surgeons in 2004 notes (5):

“Major complications from manual therapies are extremely rare but, nonetheless, have been a source of much discussion.”

“Estimates of vertebral artery dissections or stroke rates associated with cervical manipulation have ranged from 1 per 400,000 to 1 per 10 million manipulations.”

“An estimate of 1 per 5.85 million manipulations, based on 1988 to 1997 medical record and chiropractic malpractice data from Canada, reflects the experience of practitioners of manipulation.”

“No serious complications from spinal manipulation or other chiropractic forms of manual treatment have been reported from any of the published clinical trials involving manipulation or mobilization for neck pain.”

In 2008, the largest population-based case-control analysis on manipulation/vertebral artery stroke risk ever completed was published in the journal Spine. It involved an incredible 100 million person-years of analysis over a 9-year period. The authors note that most cases of vertebral arterial dissection occur spontaneously.

The authors “conclude that chiropractic care does not appear to pose an excess risk of vertebral artery stroke and to suggest that headache or neck pain from vertebral artery dissection causes people to seek care from either chiropractic or medical physicians.”

“We found no evidence of excess risk of vertebral artery stroke associated with chiropractic care.”

“Neck pain and headache are common symptoms of vertebral artery dissection, which commonly precedes vertebral artery stroke.”

“The increased risks of vertebral artery stroke associated with chiropractic and primary care physician visits is likely due to patients with headache and neck pain from vertebral artery dissection seeking care before their stroke.”

“Because patients with vertebrobasilar artery dissection commonly present with headache and neck pain, it is possible that patients seek chiropractic care for these symptoms and that the subsequent vertebral artery stroke occurs spontaneously, implying that the association between chiropractic care and vertebral artery stroke is not causal.”

“Our results suggest that the association between chiropractic care and vertebral artery stroke found in previous studies is likely explained by presenting symptoms attributable to vertebral artery dissection.”

“There is no acceptable screening procedure to identify patients with neck pain at risk of vertebral artery stroke.”

A 2012 study from the University of Calgary concluded (18):

“The vertebral artery is never really strained during spinal manipulative treatments but that the vertebral artery is merely taking up slack as the neck and head are moved during spinal manipulative treatments, but that there is no stress and thus no possibility for microstructural damage.”

“The results from this study demonstrate that average and maximal vertebral artery strains during high-speed low-amplitude cervical spinal manipulation are substantially less than the strains that can be achieved during range of motion testing for all vertebral artery segments.”

“We conclude that cervical spinal manipulations, as tested here, are safe from a mechanical point of view for normal, healthy vertebral artery.”

“We conclude from this work that cervical SMT performed by trained clinicians does not appear to place undue strain on vertebral artery, and thus does not seem to be a factor in vertebro-basilar injuries.”

A 2015 study looked at approximately 39 million Medicare patients to evaluate chiropractic care and the risk of vertebrobasilar stroke, noting (19):

“There was no association between chiropractic visits and VBA stroke found for the overall sample, or for samples stratified by age.”

“We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke.”

“Our results increase confidence in the findings of a previous study, which concluded there was no excess risk of VBA stroke associated chiropractic care compared to primary care.”

“Our results add weight to the view that chiropractic care is an unlikely cause of VBA strokes.”

A 2016 study from Penn State Hershey Medical Center, and the Johns Hopkins University School of Medicine produced a systematic review and meta-analysis of chiropractic care and cervical artery dissection, noting (20):

“We found no evidence for a causal link between chiropractic care and cervical artery dissection (CAD). This is a significant finding because belief in a causal link is not uncommon, and such a belief may have significant adverse effects such as numerous episodes of litigation.”

“Excellent peer reviewed publications frequently contain statements asserting a causal relationship between cervical manipulation and CAD. We suggest that physicians should exercise caution in ascribing causation to associations in the absence of adequate and reliable data. Medical history offers many examples of relationships that were initially falsely assumed to be causal, and the relationship between CAD and chiropractic neck manipulation may need to be added to this list.”

“There is no convincing evidence to support a causal link, and unfounded belief in causation may have dire consequences.”

“The association between a chiropractor visit and dissection may be explained by understanding that “patients with cervical artery dissection more frequently have headache and neck pain” and understanding that “patients with headache and neck pain more frequently visit chiropractors.”

A 2019 study from Norway analyzed the risk-benefit issue pertaining to cervical artery injury and cervical spine manual therapy, noting (21):

“The vertebral artery is thought to be most susceptible to injury due to extreme rotatory head movements, especially in the transverse foramen in the first cervical vertebrae, as the vertebral artery abruptly transitions from a vertical path to a horizontal orientation.”

“Several extensive cohort studies and meta-analyses have found no excess risk of cervical artery dissection resulting in secondary ischaemic stroke for chiropractic spinal manipulative therapy compared to primary care follow-up.”

“There is no strong evidence in the literature that manual therapy provokes cervical artery dissection.”

“The assumption that the cervical manual-therapy intervention triggers cervical artery dissection in rare cases has been dominated by single-case reports and retrospective case series or surveys from neurologists who naturally lack substantial methodological quality to establish definitive causality.”

“There is no sufficient evidence to support cervical vertebral artery tests to identify patients with a higher risk, and the validity and reliability of these tests are low.”

Also in 2019, a study in the journal BMJ Open evaluated the effect of cervical manipulation on vertebral artery blood flow (cerebral hemodynamics), noting (22):

“We found no significant changes within the cerebral haemodynamics following cervical manipulation or maximal neck rotation.”

“The changes observed were found to not be clinically meaningful and suggests that cervical manipulation may not increase the risk of cerebrovascular events through a haemodynamic mechanism.”

“Our work is the first to show that cervical manipulation does not result in brain perfusion changes compared with a neutral neck position or maximal neck rotation.”

“None of the participants during any of the experimental procedures reported, or were observed by the investigators, to have any signs or symptoms of neurological compromise.”

“In conclusion, we found no significant change in blood flow in the posterior cerebrum or cerebellum in chronic neck pain participants after maximum head rotation and cervical manipulation.”

“Our study does not support the hypothesis that neck manipulation or neck rotation are associated with vasospasm of the vertebral artery.”

A third in 2019, published in the Journal of Orthopaedic & Sports Physical Therapy, also assessed neck position influence of vertebral and carotid blood flow, noting (23):

“The positions and movements utilized in high velocity thrust techniques do not seem to alter blood flow.”

“Based on these data it is unlikely that head and neck movement alone, even if forceful, could mechanistically explain the aetiology of adverse events which have conventionally been purported to be related to therapeutic interventions.”

“Conventional thought within the domain of manual therapy has been that rapid, forceful interventions such as high velocity thrust techniques are considered to constitute a higher risk for neuro-vascular events resulting from cervical arterial compromise. However, we found that studies which focused specially on high velocity thrust reported no hemodynamic changes.”

“A clinical implication from this review is that the relationship between cranio-cervical movement and alterations in blood flow does not seem to be as obvious as previous data suggested.”

This study “suggests that adverse events related to cervical spine interventions might be the result of something other than the therapeutic positioning or movement of the head and neck.”

“Conclusion: Our results suggest that in most people, healthy as well as patients with vascular pathologies, cranio-cervical positions do not alter cervical blood flow. This includes vascular test positions, pre-manipulative positions and manipulations.”

“A key clinical implication from this review is that the relationship between cranio-cervical movement and blood flow does not seem to be as previously suggested.”

Clinical Presentation

Cervical artery dissections occur spontaneously, and spontaneous cervical artery dissections cause neck pain and/or headache. There are no tests that show that a person’s neck pain/headache are being caused by a spontaneous dissection:

In 2002, Dr. Scott Haldeman (DC, MD, PhD) and colleagues from the University of California, Irvine, noted (24):

“Cervical artery dissection is a rare event, creating a significant challenge for those who wish to understand it.”

In 2017, a study published in the Journal of Stroke and Cerebrovascular Disease, noted (25):

“Headache and neck pain are common presenting symptoms in patients with cervical artery dissection, and in some cases are the only presenting symptoms.”

“In the absence of neurological signs and symptoms, there are no practical, clinically valid screening tests to identify underlying dissections in patients with head or neck pain.”

Protopathic Bias

The beginning of this review discussed Protopathic Bias. Protopathic Bias is when a treatment for the symptoms of a disease or injury appears to cause the outcome, when in fact it did not. Several studies have used protopathic bias to explain the occurrences of neck pain and/or headache, including:

Journal of Stroke and Cerebrovascular Disease, 2017:

“In case-control studies, protopathic bias can lead to the illusion that the exposure caused the outcome. Even though it is not on the causal pathway.”

“Our results suggest that the association between chiropractic care and carotid artery stroke is explained by protopathic bias.”

“Younger patients with impending carotid artery stroke could be seeking care for dissection-related pain in the head and neck prior to developing stroke. Under this scenario, any care provided by chiropractors or primary care providers is coincidental to the stroke and not the causal pathway.”

BMJ Open, 2019 (22):

“Together with previous work, our results support the position that the association between cervical manipulation and stroke is due to protopathic bias.”

Recommendations

If a patient’s symptoms include more than neck pain and/or headache, and include the 5 Ds And the 3 Ns (below), additional investigations and/or referral may be prudent.

• Dizziness/vertigo/giddiness/light headedness
• Drop attacks/loss of consciousness
• Diplopia (or other visual problems)
• Dysarthria (speech difficulties)
• Dysphagia (discomfort or difficulty in swallowing)
• Ataxia of gait (walking difficulties/ incoordination)
• Nausea (with possible vomiting)
• Numbness on one side of the face and/or body
• Nystagmus

References:

1. Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
2. Woodward MN, Cook JCH, Gargan MF, Bannister GC; Chiropractic treatment of chronic ‘whiplash’ injuries; Injury; November 1996; Vol. 27; No. 9; pp. 643-645.
3. Khan S, Cook J, Gargan M, Bannister G; A symptomatic classification of whiplash injury and the implications for treatment; The Journal of Orthopaedic Medicine; Vol. 21; No. 1; 1999; pp. 22-25.
4. Hoving JC, Koes BW, de Vet HCW, van der Windt DAWM, Assendelft WJJ, Mameren H, Devillé WLJM; Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain; A Randomized Controlled Trial; Annals of Internal Medicine; May 21, 2002; Vol. 136; No. 10; pp. 713-722.
5. Fischgrund JS; Neck Pain, Monograph 27, American Academy of Orthopaedic Surgeons; 2004.
6. César Fernández-de-las-Peñas; J. Fernández-Carnero; L. Palomeque del Cerro; Manipulative Treatment vs. Conventional Physiotherapy Treatment in Whiplash Injury: A Randomized Controlled Trial; Journal of Whiplash & Related Disorders; 2004; Vol. 3; No. 2.
7. Langenfeld A, Humphreys K, Swanenburg J, Peterson CK; Prognostic Factors for Recurrences in Neck Pain Patients Up to 1 Year After Chiropractic Care; Journal of Manipulative and Physiological Therapeutics; September 2015; Vol. 38; No. 7; pp. 458-464.
8. Peterson CK; Schmid C; Leemann S; Anklin B; Humphreys BK; Outcomes From Magnetic Resonance Imaging: Confirmed Symptomatic Cervical Disk Herniation Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulation Therapy: A Prospective Cohort Study With 3-Month Follow-Up; Journal of Manipulative and Therapeutics; October 2013; Vol. 36; pp. 461-467.
9. Giles LGF; Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine July 15, 2003; Vol. 28; No. 14; pp. 1490-1502.
10. 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.
11. Whedon JM, Mackenzie TA, Phillips RB, Lurie JD; Risk of Traumatic Injury Associated with Chiropractic Spinal Manipulation in Medicare Part B Beneficiaries Aged 66-99; Spine; February 15, 2015; Vol. 40; No. 4; pp. 264-270.
12. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians; Annals of Intern Medicine; 2017; Vol. 166; No. 7; pp. 514-530.
13. Chou R, Deyo R, Friedly J, et al; Non-pharmacologic therapies for low back pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline; Annals of Intern Medicine; 2017; Vol. 166; No. 7; pp. 493-505.
14. Terrett AG; Misuse of the literature by medical authors in discussing spinal manipulative therapy injury; Journal of Manipulative and Physiological Therapeutics; May 1995; Vol. 18; No. 4; pp. 203-210.
15. Weban A, Beck J, Raabe A, Dettmann E. Seifert V; Misuse of the terms chiropractic and chiropractor; J Neurol Neurosurg Psychiatry; May 2004; Vol. 75; No. 5; p. 794.
16. Weban A; Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature; Chiropractic and Osteopathy; August 2006; Vol. 22; Vol. 14; p. 16.
17. Cassidy JD; Boyle E, Côté P, Yaohua H, Hogg-Johnson S, Bondy SJ; Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study; Spine; Vol. 33; No. 4S; February 15, 2008; pp. S176-S183.
18. Herzog W, Leonard TR, Symons B, Tang C, Wuest S; Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation; Journal of Electromyography and Kinesiology; October 2012; Vol. 22; No. 5; pp. 740-746.
19. Kosloff TM, Elton D, Tao J, Wade M Bannister WM; Chiropractic Care and the Risk of Vertebrobasilar Stroke: Results of a Case–control Study in U.S. Commercial and Medicare Advantage Populations; Chiropractic & Manual Therapies 2015; Vol. 23; No. 19; pp. 1-10.
20. Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE; Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation; Cureus; February 16, 2016; Vol. 8; No. 2; e498.
21. Chaibi A, Russell MJ; A Risk–benefit Assessment Strategy to Exclude Cervical Artery Dissection in Spinal Manual Therapy: A Comprehensive Review; Annals of Medicine; March, 2019; Vol. 19; pp. 1-10.
22. Moser N, Mior S, Noseworthy M, Cote P, Wells G, Behr M, Triano J; Effect of Cervical Manipulation on Vertebral Artery and Cerebral Haemodynamics in Patients with Chronic Neck Pain: A Crossover Randomised Controlled Trial; BMJ Open; May 28, 2019; Vol. 9; No. 5; pp. e025219.
23. Kranenburg R, Tyer R, Schmitt M, Luijckx GJ, van der Schans C, Hutting N, Kerry R; Effects of Head and Neck Positions on Blood Flow in the Vertebral, Internal Carotid and Intracranial Arteries: A Systematic Review; Journal of Orthopaedic & Sports Physical Therapy; July 2019 [epub].
24. Haldeman S, Kohlbeck FJ, McGregor M; Unpredictability of Cerebrovascular Ischemia Associated with Cervical Spine Manipulation Therapy: A Review of Sixty-four Cases After Cervical Spine Manipulation; Spine; January 1, 2002; Vol. 27; No. 1; pp. 49-55.
25. Cassidy JD, Boyle E, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S; Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study; Journal of Stroke and Cerebrovascular Disease; April 2017; Vol. 26; No. 4; pp. 842-850.

“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.”

Important Numbers

Members of our military and military veterans are plagued with musculoskeletal pain problems:

• 2007 (1) – An analysis of United States Navy Physical Evaluation Board data between February 2005 and February 2006 indicated that musculoskeletal diagnoses were frequent (43%), with back pain (29%) being the most common musculoskeletal diagnosis.
• 2008 (2) – There is evidence that military personnel in combat zones suffer increased spinal and upper extremity complaints/injuries as a consequence of prolonged wearing of body armor.
• 2015 (3) – “Low back pain (LBP) is a common cause of disability, lost worker productivity, and healthcare costs in both military and civilian populations.” Between 2010-2014, the LBP diagnoses were associated with more than 6 million outpatient healthcare encounters and more than 25,000 hospitalizations among active service members. Annual numbers of outpatient encounters for LBP increased 34% during 2010-2014. Of all service members given a LBP diagnosis, 91% were diagnosed as “nonspecific back pain.” The most common diagnosis was “lumbago.”
• 2018 (May) (4) – “Because back pain represents a large proportion of morbidity burden, it is a high-priority focus for prevention, treatment, and rehabilitation research in the military.”
• 2018 (August) (5) – “Between 2001 and 2016, low back pain was the most prevalent musculoskeletal pain-related diagnosis among active-duty US military personnel… Inflammation and pain from overuse comprised the largest proportion of injury mechanism, accounting for about 82% of all injuries among non-deployed military personnel.” The risk of musculoskeletal pain was greater for active duty personnel, females, and those with greater time in a motor vehicle. Post-traumatic headache occurred in 92% of military personnel who had sustained a mild traumatic brain injury.
• 2018 (December) (6) – A Defense Department report indicated that 25% of active-duty service members had at least one prescription for an opioid in 2017.

Including Chiropractic Care

Spinal manipulation is a central component of chiropractic care, and it provides benefits in cases of low back and neck pain. Chiropractic services for musculoskeletal conditions were introduced to the Veterans Health Administration in 2004.

In 2006, a study was published in the journal Military Medicine, titled (7):

Chiropractic Services in the Canadian Armed Forces

This article reports on satisfaction associated with the introduction of chiropractic services within a military hospital, through the Canadian Armed Forces. The authors distributed a 27-item survey that inquired about demographic information and satisfaction with chiropractic services to 102 military personnel presenting for on-site chiropractic services. They also provided a second 3-item survey, designed to explore referral patterns and satisfaction with chiropractic services to all referring military physicians.

Chronic low back pain accounted for most presentations to the hospital chiropractic clinic:

• 94% of military personnel expressed satisfaction with chiropractic services.
• 80% of referring physicians also expressed satisfaction with chiropractic services.

•••••

In 2010, Anthony Lisi, DC, published the first data on chiropractic services for Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans. It is a retrospective review of 31 consecutive cases consulted at a Veterans Health Administration chiropractic clinic. It was published in Journal of Rehabilitation Research & Development, titled (8):

Management of Operation Iraqi Freedom and Operation Enduring Freedom Veterans in a Veterans Health Administration Chiropractic Clinic

In this study, Dr. Lisi notes that the two most frequent diagnoses seen in military veterans receiving Veterans Health Administration services are musculoskeletal system and connective tissue disorders. Operation Iraqi Freedom/Operation Enduring Free¬dom (OIF/OEF) veterans now commonly seek care for musculoskeletal complaints in Veterans Health Administration facilities.

The Veterans Health Administration established chiropractic clinics at 26 facilities beginning in 2004. By 2010, the number of clinics increased from 26 to 36, a 38% increase. The number of veterans seen at these clinics increased from 4,000 to more than 13,000, an increase of 225%.

In the 31 patients reviewed for this study, the most common reasons for seeking chiropractic care were low back pain with or without leg pain (48%), and mid back (thoracic) pain (32%). The duration of complaint was on average 14 months (range 2 to 72 months).

The onset of pain in these subjects was as a result of military trauma and blast injuries. Six of the thirty-one cases (19%) were diagnosed with traumatic brain injury.

All cases in this series were chronic and had failed to adequately respond to prior treatment interventions, including:

• NSAIDs 100%
• Muscle relaxants 65%
• Physical therapy 61%
• Opioids 39%

Chiropractic Services included:

• Education on natural history and self-care
• Manual spinal manipulation
• Therapeutic exercise
• 74% of cases received physical modalities and manual myofascial release.
• Treatment duration: no improvement over 2 to 4 consecutive visits during the trial indicated the end point for additional chiropractic care.
• Pain intensity was measured using the 11-point numerical rating scale. A predetermined minimum clinically important difference of 2-points was established, and 61% of the subjects reported a pain decrease that exceeded the 2-point threshold.

Dr. Lisi concluded:

“Veterans Health Administration primary care and specialty providers may consider chiropractic services when managing musculoskeletal conditions in OIF/OEF patients.”

“Chiropractic management was safe in these cases, and the results support the hypothesis that chiropractic management may be effective in certain OIF/OEF veterans.”

Dr. Lisi also noted that 68% of the subjects screened positive for Posttraumatic Stress Disorder (PTSD). PTSD and chronic pain often co-occur and “may interact in such a way as to negatively impact the course of either disorder.” The high prevalence of PTSD in this sample may have reduced outcome.

•••••

In April 2016, an article was published in the Journal of Evidence Based Complementary and Alternative Medicine, titled (9):

Integration of Chiropractic Services in Military and
Veteran Health Care Facilities: A Systematic Review of the Literature

This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. The authors located 30 articles that met their inclusion criteria. The authors concluded:

“Doctors of chiropractic that are integrated within military and veteran health care facilities manage common neurological, musculoskeletal, and other conditions; severe injuries obtained in combat; complex cases; and cases that include psychosocial factors.”

“Chiropractors collaboratively manage patients with other providers and focus on reducing morbidity for veterans and rehabilitating military service members to full duty status.”

“Patient satisfaction with chiropractic services is high.”

“Preliminary findings show that chiropractic management of common conditions shows significant [patient] improvement.”

•••••

In June 2016, Dr. Lisi and colleague updated the status in the trends of the use of chiropractic services in the Department of Veterans Affairs. The authors presented a serial cross-sectional analysis of the VA administrative data from the first record of chiropractic services in the VA in 2004 through September 30, 2015. Their findings included (10):

• From October 1, 2004, through September 30, 2015, the annual number of different patients seen in VA chiropractic clinics increased from 4,052 to 37,349, which is an increase of 822%.
• From October 1, 2004, through September 30, 2015, the annual number of chiropractic visits increased from 20,072 to 159,366, which is an increase of 694%.
• The typical VA chiropractic patient is male, is between the ages of 45 and 64, is seen for low back and/or neck conditions, and receives chiropractic spinal manipulation, evaluation, and management services.
• The total number of VA chiropractic clinics grew from 27 to 65, and the number of chiropractic employees grew from 13 to 86.
• The typical VA chiropractic employee is a 46-year-old male who has worked in the VA for 4.5 years, and receives annual compensation of $97,860.
• During this period of time, the VA also purchased care from private sector chiropractors, growing to 159,533 chiropractic visits for 19,435 patients at a cost of $11,155,654 annually.

The authors concluded:

“Use of chiropractic services and the chiropractic workforce in VA have grown substantially over more than a decade since their introduction.”

•••••

In February 2018, a group of researchers published a study in the journal Complementary Therapies in Clinical Practice, titled (11):

Changes in Female Veterans’ Neck Pain
Following Chiropractic Care at a Hospital for Veterans

The authors note that neck pain is a common complaint among US military active duty personnel and veterans. Musculoskeletal conditions are the leading cause of morbidity for female veterans.

The objective of this study was to determine if US female veterans had demonstrable improvements in neck pain after chiropractic management at a Veterans Affairs (VA) hospital. Thirty-four veterans met the inclusion criteria and received a mean of 8.8 chiropractic treatments.

The type of manual therapy typically included spinal manipulative therapy (SMT), spinal mobilization, flexion-distraction therapy, and/or myofascial release.

• SMT was a manipulative procedure involving a high-velocity, low-amplitude thrust to the cervical spine.
• Spinal mobilization was manually assisted passive motion involving repetitive joint oscillations at the end of joint play and without the application of a high-velocity, low-amplitude thrust.
• Flexion-distraction therapy is a gentle form of spinal manipulation using traction and manual pressure applied to the neck in a prone position.

The authors note that there has been a 400% increase in narcotic overdose deaths since 1999 for women, and that 1 in 10 suicides by women in the US involves prescription opioids or narcotics. They state:

“One potential non-pharmacological treatment option for musculoskeletal pain is chiropractic care.”

“Female veterans in the present study receiving chiropractic management for neck pain had demonstrable improvement which was statistically and clinically significant.”

“Chiropractic management may be an effective treatment strategy for female veterans with neck pain complaints.”

“No significant adverse events were reported for any of the patients in the sample.”

•••••

In May 2018, a group of researchers published a study in the Journal of the American Medical Association Network Open, titled (12):

Effect of Usual Medical Care Plus Chiropractic Care
vs Usual Medical Care Alone on Pain and Disability
Among US Service Members with Low Back Pain

Chiropractic care provides conservative care focused on diagnosis, treatment, co-management, or referral for musculoskeletal conditions, including low back pain. The primary therapeutic procedure used by doctors of chiropractic is spinal manipulative therapy.

The objective of this study was to determine whether the addition of chiropractic care to usual medical care for low back pain results in better pain relief and pain-related function when compared with usual medical care alone. The study used 750 active-duty US service members aged 18 to 50 years with low back pain from a musculoskeletal source. The intervention period was 6 weeks. Clinical status was assessed at 6 weeks and 12 weeks. This is the largest trial evaluating usual medical care with chiropractic care vs usual medical care alone.

The usual medical care included:

• Self-care
• Medications
• Physical Therapy
• Pain clinic referral

The chiropractic care included:

• Spinal manipulation in the low back and adjacent regions
• Other manual therapies
• Rehabilitative exercise
• Cryotherapy Superficial heat

The outcome measures used included:

• Numerical Rating Scale (NRS)
• Roland Morris Disability Questionnaire
• Medication use

The authors note that musculoskeletal disorders are the second leading cause of disability worldwide, led by low back pain (LBP). They state:

“In the US military, LBP is one of the most common reasons members seek medical care and one of the most likely conditions to interrupt combat duty.”

“Common medical therapies for LBP, including nonsteroidal anti-inflammatory drugs, opioids, spinal fusions, and epidural steroid injections, demonstrate limited effectiveness; furthermore, many of these treatments have unacceptably high-risk profiles.”

“The US opioid crisis creates an urgent need to evaluate cost-effective and low-risk non-pharmacological treatments.”

“It is critically important to evaluate the effect of non-pharmacological treatments on low back pain and associated disability.”

The authors note that chiropractic care has been integrated into more than half of military treatment facilities across the United States, and that “spinal manipulation or chiropractic care is recommended as a first line of treatment for pain.” They also note that chiropractic care is an option to the opiate crisis, and that current clinical guidelines recommend the use of spinal manipulative therapy and/or chiropractic care for low back pain (13, 14).

In this study, the primary chiropractic service was spinal manipulation in the low back and adjacent regions. No serious related adverse events were reported. The reported outcomes included:

“Participants receiving usual medical care with chiropractic care had significantly better global perceived improvement at 6 weeks at all sites.”

“Those receiving usual medical care with chiropractic care had significantly greater mean satisfaction with care at 6 weeks at all sites.”

“Participants allocated to receive usual medical care with chiropractic care self-reported significantly less pain medication use than those receiving usual medical care alone at week 6 [by 27%] and week 12 [by 24%].”

Odds ratios “were statistically significant in favor of usual medical care plus chiropractic care overall for perceived improvement and self-reported pain medication use.”

“This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for low back pain, as currently recommended in existing guidelines.”

“Patients who received usual medical care plus chiropractic care reported a statistically significant moderate improvement in low back pain intensity and disability at 6 weeks compared with those who received usual care alone.”

“The changes in patient-reported pain intensity and disability as well as satisfaction with care and low risk of harms favoring usual medical care with chiropractic care found in this pragmatic clinical trial are consistent with the existing literature on spinal manipulative therapy in both military and civilian populations.”

“This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for LBP, as currently recommended in existing guidelines.”

“Our findings further support existing guidelines that recommend non-pharmacological treatments as a first line of treatment for LBP.”

“This is a critically important issue as the US health care delivery system struggles to adequately address the challenges of managing LBP and the opioid epidemic.”

This study generated an Invited Commentary by Daniel Cherkin, MD, PhD (15):

Innovating to Improve Care for Low Back Pain
in the Military Chiropractic Care Passes Muster

After reviewing the study’s outcomes, Dr. Cherkin notes that chiropractors are specialists in back problems and enjoy seeing patients with low back pain. He concludes:

“True integration of chiropractic care into the military health care system involving professional communication and referrals between chiropractors and medical personnel has the potential for more effectively and efficiently serving patients and for providing models for other integrated health care systems in civilian settings to follow.”

•••••

In September 2018, a study was published in the journal Pain Medicine, titled (16):

Opioid Use Among Veterans of Recent Wars
Receiving Veterans Affairs Chiropractic Care

This study explored the relationship between timing of chiropractic care and receipt of an opioid drug prescription in veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (2004-2014).

For military and veteran populations, the VA recommends that treatments for pain use evidence-based non-pharmacological therapies, including spinal manipulation, massage, acupuncture, and exercise. These types of interventions are standard in chiropractic clinical practice, especially spinal manipulation.

A reduction in opioid use remains a national priority. Apart from the potential to reduce pain and improve function in patients with musculoskeletal conditions, chiropractic care may have an impact on opioid use in such patients. In private sector populations, an increase in chiropractic care is correlated with reduced opioid use.

The outcomes from this study include:

“Nearly one-third of veterans receiving VA chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower after the index chiropractic visit than before.”

“The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before.”

“Our results, along with the previous literature, suggest that expanding access to chiropractic care should be a key policy consideration for the VA, congruent with national initiatives aimed to increase the use of evidence-based non-pharmacological treatments for chronic musculoskeletal pain.”

The percentages of veterans receiving opioid prescriptions was higher before the chiropractic visit than after the visit. The delivery of chiropractic care may have been a substitute for opioid use. These authors suggest that “chiropractic care is more likely to be a replacement for, rather than an addition to, opioid therapy for chronic musculoskeletal pain conditions in the VA.”

•••••

In 2019, a study was published in the journal Chiropractic & Manual Therapies, titled (17):

Chiropractic Services in the Active Duty Military Setting

The objective of this review was to document the current global state of knowledge related to chiropractic services in the active duty military setting. Twenty articles were included in this review: 17 from the US, 2 from Canada, one from Australia.

The studies noted that military personnel musculoskeletal conditions are associated with lost productivity, lost duty days, and impact the ability to deploy. They state:

“Musculoskeletal injuries are one of the most prevalent battle and non-battle related injuries in the active duty military.”

“Musculoskeletal injuries significantly affect the health and operational readiness of active military personnel.”

The practice of chiropractic is the assessment of conditions related to. the spine, nervous system, and joints, and in “the diagnosis, prevention, and treatment of these conditions.” Chiropractic care was initiated into the US Department of Defense legislatively (1993–2009), and has grown to 49 Military Health System commands. The chiropractic assessment included a “focused history, physical examination, clinical impressions, disability, prognosis, and treatment plan elements.”

The military chiropractic services were commonly provided on-base and were accessed by physician referral. These referrals to chiropractic occurred “commonly after initiation or non-response to other care.”

Back pain with or without radiculopathy accounted for the majority of presentations:

• About 43% used chiropractic for low back pain (LBP)
• About 28% for headaches
• About 11% for general health, wellness, and prevention

The authors concluded:

“Reported outcomes of chiropractic care were predominantly positive.”

“Randomized Clinical Trials suggest a benefit of including chiropractic care to usual medical care in managing back pain in active duty military.”

••••

In 2020, a study was published in the Journal of Alternative and Complementary Medicine, titled (18):

Effects of Chiropractic Care on Strength, Balance, and Endurance
in Active-Duty U.S. Military Personnel with Low Back Pain

This study occurred at the Naval Air Technical Training Center clinic at the Naval Hospital Pensacola, Florida. The objective of this study was to investigate whether chiropractic care influences strength, balance, and/or endurance in active-duty US military personnel with low back pain (LBP). Study participants were 110 active-duty military personnel 18–40 years of age.

It is a prospective randomized controlled trial where participants (55 in each group) were randomly allocated to 4 weeks of chiropractic care or to a wait-list control. The chiropractic spinal manipulation consisted of high-velocity thrust-type manipulation directed toward the thoracolumbar or pelvic regions. Outcomes were measured at baseline and 4 weeks.

The authors note that low back pain is the “most prevalent musculoskeletal pain-related diagnosis among active-duty US military personnel.” Low back pain represents a large proportion of morbidity burden, it is a high-priority focus for prevention, treatment, and rehabilitation research in the military.

Chiropractic services are available to active-duty personnel in the United States through health clinics on military bases:

“Spinal manipulation is a non-pharmacological therapy commonly employed by doctors of chiropractic and is a guideline-recommended treatment for low back pain.”

Four weeks of chiropractic care resulted in improvements in strength, balance with eyes closed, and endurance compared with wait-list controls. Results were “statistically significant difference in mean change between groups.” The authors concluded:

“We found improvements in isometric pulling strength, balance with eyes closed, and endurance that were statistically significantly greater in the chiropractic care group than the wait-list group.”

“Active-duty military personnel receiving chiropractic care exhibited improved strength and endurance, as well as reduced LBP intensity and disability, compared with wait-list control.”

SUMMARY

The studies reviewed here indicate that for musculoskeletal pain and dysfunction, especially for back and neck complaints, chiropractic care, including principally spinal manipulation, is effective, cost effective, safe, and has high levels of patient satisfaction.

These outcomes support the recommendation that government and non-government entities should be increasing the utilization of chiropractic services.

REFERENCES:

1. Litow CD, Krahl PL; Public health potential of a disability tracking system: Analysis of U.S. navy and marine corps physical evaluation boards 2005-2006; Military Medicine; December 2007; Vol. 172; No. 12; pp. 1270–1274.
2. Konitzer LN, Fargo MV, Brininger TL, Lim Reed M; Association between back, neck, and upper extremity musculoskeletal pain and the individual body armor; Journal of Hand Therapy; 2008; Vol. 21; No. 2; pp. 143–48.
3. Clark LL, Hu Z. Diagnoses of low back pain, active component, US Armed Forces, 2010–2014; Medical Surveillance Monthly Report; December 2015; Vol. 22; No. 12; pp. 8–11.
4. Armed Forces Health Surveillance Branch; Absolute and relative morbidity burdens attributable to various illnesses and injuries, active component, U.S. Armed Forces, 2017; Medical Surveillance Monthly Report; May 2018; Vol. 25; No. 5; pp. 32–41.
5. Bader CE, Giordano NA, McDonald CC, et al. Musculoskeletal pain and headache in the active duty military population: An integrative review; Worldviews Evidence Based Nursing; August 2018; Vol. 15; No. 4; pp. 264–271.
6. Jowers K; One in Four troops have an opioid prescription in a given year; Military Times; December 4, 2018.
7. Boudreau LA, Busse JW, McBride G; Chiropractic Services in the Canadian Armed Forces: A Pilot Project; Military Medicine; June 2006; Vol. 171; No. 6; pp. 572–576.
8. Lisi AJ; Management of Operation Iraqi Freedom and Operation Enduring Freedom veterans in a Veterans Health Administration chiropractic clinic: A Case Series; Journal of Rehabilitation Research & Development; 2010; Vol. 47; No. 1; 2010; pp. 1–6.
9. Green BN, Johnson CD, Daniels CJ, Napuli JG, Gliedt JA, Paris DJ; Integration of chiropractic Services in Military and Veteran Health Care Facilities: A Systematic Review of the Literature; Journal of Evidence Based Complementary and Alternative Medicine; April 2016; Vol. 21; No. 2; pp. 115–130.
10. Lisi AJ, Brandt CA; Trends in the Use and Characteristics of Chiropractic Services in the Department of Veterans Affairs; Journal of Manipulative and Physiological Therapeutics; June 2016; Vol. 39; No. 5; pp. 381-386.
11. Corcoran KL, Dunn AS, Green BN, Formolo LR, Beehler GP; Changes in Female Veterans’ Neck Pain Following Chiropractic Care at a Hospital for Veterans; Complementary Therapies in Clinical Practice; February 2018; Vol. 30; pp. 91-95.

“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.”

The Potential Benefits of Spinal Manipulation for those Suffering the Symptoms of Concussion and the Post-Concussion Syndrome

Mild traumatic brain injuries are also known as concussions. It is estimated that these injuries have a prevalence of 3.8 million per year in the United States (1). In the majority of patients sustaining a concussion, symptoms resolve within 7–10 days. However, approximately 10–15% of these patients develop persistent symptomatology lasting weeks, months or even years after injury (2). This phase of chronic symptoms is known as the post-concussion syndrome. The patient is considered to be chronic when symptoms persist longer than 4-12 weeks.

It is assumed that the post-concussion syndrome manifests secondary to brain injury leading to alterations in brain biochemistry, neurophysiology, and metabolism; the problem is assumed to be in the brain. However, it is now understood that cervical spine injury is often involved in the post-concussion syndrome. In some cases, cervical spine injury may be primarily responsible for the symptoms of the post-concussion syndrome.

Studies have documented that there is considerable overlap of the signs and symptoms of mild traumatic brain injury, the post-concussion syndrome, and of whiplash injury to the cervical spine (2). In 2015, a study published in the journal The Physician and Sportsmedicine, titled “The Role of the Cervical Spine in Post-concussion Syndrome,” notes (2):

“Injury or dysfunction of the cervical spine has been shown to cause headaches, dizziness and loss of balance, nausea, visual and auditory disturbances, reduced cognitive function, and many other signs and symptoms considered synonymous with concussion.”

A proposed mechanism for persisting symptomatology following concussion (the post-concussive syndrome) is “concomitant low-grade sprain–strain injury of the cervical spine occurring concurrently with significant head trauma.”

“Any significant blunt impact and/or acceleration/deceleration of the head will also result in some degree of inertial loading of the neck potentially resulting in strain injuries to the soft tissues and joints of the cervical spine.”

“Acceleration/deceleration of the head–neck complex of sufficient magnitude to cause mild traumatic brain injury is also likely to cause concurrent injury to the joints and soft tissues of the cervical spine.”

It is “well established that injury and/or dysfunction of the cervical spine can result in numerous signs and symptoms synonymous with concussion, including headaches, dizziness, as well as cognitive and visual dysfunction; making diagnosis difficult.”

“The symptoms of headache and dizziness, so prevalent in concussion-type injuries, may actually be the result of cervicogenic mechanisms due to a concomitant whiplash injury suffered at the same time.”

Signs and Symptoms of Concussion	Signs and Symptoms of Whiplash Cervical Injury
Headache Pressure in Head	Headache
Neck pain	Neck/shoulder pain Reduced/painful neck movements
Nausea/vomiting	Nausea/vomiting
Dizziness Balance problems	Dizziness Unsteadiness
Blurred Vision Sensitivity to Light	Vision problems
Difficulty remembering Confusion Feeling Like “In a Fog” Difficulty Concentrating	Memory problems Problems Concentrating
Sensitivity to Noise	Ringing in Ears
Feeling Slowed Down “Don’t Feel Right” Nervous / Anxious / Irritable Sadness / More Emotional Fatigue / Low Energy / Drowsiness Trouble Falling Asleep	Reduced/painful Jaw Movements Numbness, Tingling or Pain in Arm or Hand Numbness, Tingling or Pain in Leg or Foot Difficulty Swallowing Lower back pain

There is a probability that the forces required to cause a mild traumatic brain injury will also injure the soft tissues of the cervical spine. The range of linear impact accelerations causing concussion injury is between 60—160 G, with the peak occurring at 96 G (3). Whiplash injuries can occur at accelerations of 4.5 G (4). Thus it is highly likely that individuals who experience the G forces to sustain a concussion will also experience cervical spine injury.

Anatomically and physiologically, the cervical spinal cord is connected to the brainstem and brain.

• Numerous brain stem structures receive mono-synaptic inputs from the C2 dorsal root ganglion afferents, including (5): Lateral cervical nucleus; Central cervical nucleus; Caudal projections to C5 level; Cuneate nucleus, lateral cuneate nucleus; Nucleus tractus solitarius Intercalatus nucleus; Nucleus VIII of the vestibular system; Trigemino-cervical nucleus (for headache nociception)
• ‘Cervicogenic Vertigo’ is “both [a] monosynaptic and polysynaptic reflex pathways from the upper cervical spine afferents (associated with a rich innervation from joint and muscle proprioceptors in the cervical spine) to the brainstem structures associated with balance.” (2)
• Cervical ocular and vestibular reflexes can “initiate balance disturbances and symptoms associated with this [post-concussive] problem” (6).
• Cervicogenic headache has been recognized for decades (7).

••••••••••

In 2006, researchers from the University of Guelph, Ontario, CAN, published a study in the journal Brain Injury, titled (8):

Is There a Relationship Between
Whiplash-Associated Disorders and Concussion in Hockey?

The authors examined the relationship between the occurrence of whiplash-associated disorders and concussion symptoms in hockey players. The study design was a prospective cohort observational study. Twenty hockey teams were followed prospectively for one season. Team therapists completed acute and 7-10 day follow-up evaluation questionnaires for all of the players who received either a whiplash mechanism injury or a concussion.

The authors found that essentially all patients who received a whiplash-mechanism injury also sustained some degree of mild traumatic brain injury. Likewise, all patients who received a mild traumatic brain injury also showed evidence of cervical spine injury. The authors concluded:

“There is a strong association between whiplash induced neck injuries and the symptoms of concussion in hockey injuries.”

“Both should be evaluated when dealing with athletes/patients suffering from either injury.”

••••••••••

In 2013, researchers from the University of Calgary, Calgary, Alberta, CAN, published a study in the Clinical Journal of Sport Medicine, titled (9):

Preseason Reports of Neck Pain, Dizziness, and Headache
as Risk Factors for Concussion in Male Youth Ice Hockey Players

The objective of this study was to determine the risk of concussion in youth male hockey players with preseason reports of neck pain, headaches, and/or dizziness. The authors pooled data from 2 prospective cohort studies. A total of 3,832 male ice hockey players aged 11 to 14 years (280 teams) participated.

Participants recorded baseline preseason symptoms of dizziness, neck pain, and headaches on the Sport Concussion Assessment Tool. Concussions that occurred during the season were recorded using a validated prospective injury surveillance system. The findings were as follows:

• Preseason reports of neck pain and headache increased the risk of concussion by 67%.
• Preseason dizziness increased the risk of concussion by 211%.
• A combination of any 2 symptoms (neck pain, headaches, dizziness) increased the risk of concussion by 265%.

        The authors concluded:

“Male youth athletes reporting headache and neck pain at baseline were at an increased risk of concussion during the season. The risk was associated with dizziness and any 2 of dizziness, neck pain, or headaches.”

The implication of this study is that athletes with neck pain are at an increased risk for concussion. They suggest all such athletes should be identified prior to the season.

••••••••••

The studies reviewed below have concluded that injuries of the cervical spine are responsible for post-concussion syndrome signs and symptoms. The “post-concussive syndrome: signs and symptoms showed excellent clinical outcomes following treatment to the cervical spine.”

In 1990, researchers from the Department of Rheumatology, County Hospital of Aarhus, Denmark, published a study in the journal Cephalalgia, titled (10):

An Open Study Comparing Manual Therapy with the use
of Cold Packs in the Treatment of Post-traumatic Headache

• The authors used 19 patients who had sustained head trauma and who were still suffering from headaches one year later. These patients entered a prospective clinical controlled trial to find out if specific manual therapy on the neck could reduce their headache.
• Ten patients were treated twice with manual therapy and nine patients were treated twice with cold packs on the neck. The pain index was calculated blindly.
• Two weeks after the last treatment the mean pain index was significantly reduced to 43% in the group treated with manual therapy compared with the pretreatment level. At follow-up five weeks later, the pain index was still lower in this group compared with the group treated with cold packs. The authors concluded:

“Manual therapy used in this study seems to have a specific effect in reducing post-traumatic headache.”

“The result supports the hypothesis of a cervical mechanism causing post-traumatic headache and suggests that post-traumatic dizziness, visual disturbances and ear symptoms could be part of a cervical syndrome.”

••••••••••

In 1994, researchers from the Department of Physiotherapy, University of Queensland, Australia, published a study in the journal Cephalalgia, titled (11):

Cervical Musculoskeletal Dysfunction in Post-Concussional Headache

The authors note, “persistent headache is a common symptom following a minor head injury or concussion, possibly related to simultaneous injury of structures of the cervical spine.”

This study measured aspects of cervical musculoskeletal function in a group of twelve patients with post-concussion headache and in a normal control group. The post-concussion headache group was distinguished from the control group by the presence of painful upper cervical segmental joint dysfunction, less endurance in the neck flexor muscles and a higher incidence of moderately tight neck musculature. The authors concluded:

“As upper cervical joint dysfunction is a feature of cervicogenic causes of headache, the results of this study support the inclusion of a precise physical examination of the cervical region in differential diagnosis of patients suffering persistent headache following concussion.”

••••••••••

In 2014, researchers from the University of Calgary, Alberta, CAN, and the University of British Columbia, Vancouver, British Columbia, CAN, published a study in the British Journal of Sports Medicine, titled (12):

Cervicovestibular Rehabilitation in Sport-related Concussion:
A Randomised Controlled Trial

These authors note “concussion is a common injury in sport. Most individuals recover in 7-10 days but some have persistent symptoms. The objective of this study was to determine if a combination of vestibular rehabilitation and cervical spine physiotherapy decreased the time until medical clearance in individuals with prolonged post-concussion symptoms.”

This study was a randomized controlled trial. Consecutive patients with persistent symptoms of dizziness, neck pain and/or headaches following a sport-related concussion (12-30 years, 18 male and 13 female) were randomized to the control or intervention group.

Both groups received weekly sessions with a physiotherapist for 8 weeks or until the time of medical clearance. Both groups received postural education, range of motion exercises and cognitive and physical rest until asymptomatic followed by a protocol of graded exertion. The intervention group also received cervical spine and vestibular rehabilitation. The primary outcome of interest was medical clearance to return to sport, which was evaluated by a study sport medicine physician who was blinded to the treatment group.

In the treatment group, 73% of the participants were medically cleared within 8 weeks of initiation of treatment, compared with 7% in the control group. This difference, 70% v. 7%, is quite clinically significant. The authors concluded:

“A combination of cervical and vestibular physiotherapy decreased time to medical clearance to return to sport in youth and young adults with persistent symptoms of dizziness, neck pain and/or headaches following a sport-related concussion.”

••••••••••

In 2015, researchers from Canadian Memorial Chiropractic College and State University of New York at Buffalo, published a study in the journal The Physician and Sportsmedicine, titled (2):

The Role of the Cervical Spine in Post-concussion Syndrome

This paper reviews the existing literature surrounding the numerous proposed theories of post-concussive syndrome and introduces another potential, and very treatable, cause of this chronic condition; cervical spine dysfunction due to concomitant whiplash-type injury.

The authors note that the symptoms of concussion are due to neuronal dysfunction and not due to structural damage of the involved neurons, which is “why conventional structural imaging techniques such as CT and MRI are typically unremarkable.”

The authors discuss the cases of 5 patients who were diagnosed with post-concussive syndrome, who experienced very favorable outcomes following various treatment and rehabilitative techniques aimed at restoring cervical spine function; treatment included spinal manipulation.

These authors propose that a cervical injury, suffered concurrently at the time of the concussion, acts as a “major symptomatic culprit in many post-concussive syndrome patients.”

These authors present 5 case studies of patients diagnosed with post-concussive syndrome who were treated successfully in a chiropractic clinic. Their improvement was rapid and documented using standard measurement outcomes, and the results were long lasting. Treatment included:

• Active Release Therapy (ART)
• Localized vibration therapy over the affected muscles
• Spinal manipulative therapy (SMT) of the restricted joints
• Low-velocity mobilizations (on 1 patient)

        These authors conclude:

“Management of persistent post-concussion symptoms through ongoing brain rest is outdated and demonstrates limited evidence of effectiveness in these patients.”

“Instead, there is evidence that “skilled, manual therapy-  related assessment and rehabilitation of cervical spine dysfunction should be considered for chronic symptoms following concussion injuries.”

••••••••••

In 2016, researchers from Temple University and Indiana University, published a study in the Journal of Athletic Training, titled

Cervical Injury Assessments for Concussion Evaluation

The objective of this study was to provide information on clinical tests that can differentiate cervical injury from pathologic conditions of vestibular or central origin. We will review the three most clinically supported tests below.

The authors note that concussion symptoms may actually be caused by cervical injury. They state:

“Cervical injuries and concussion can share similar mechanisms and nearly identical symptoms or causes.”

“If patients exhibit dizziness, headache, or other symptoms after a collision, they are almost automatically diagnosed as having sustained a concussion. Patients with cervical injury after a pathomechanical event affecting the head or neck may manifest nearly identical symptoms.”

“Symptoms or causes alone may be insufficient to differentiate between patients with a concussion and patients with cervical injuries.”

“Whereas concussion and cervical injury may induce almost identical symptoms, their treatment methods differ.”

Patients with cervical injury respond immediately to soft tissue massage, passive stretching, strength training, cryotherapy, thermotherapy, vestibular maneuvers, and cervical manipulations.

The common symptoms of concussion include:

• Headache
• Dizziness
• Disturbances in memory
• Disturbances in concentration
• Sleep disturbance
• Neck pain
• IrritabilityBlurred vision
• Vertigo
• Tinnitus
• Fatigue

Cervical spine injury, especially of the upper cervical spine, disrupts normal afferent input into the brainstem and brain.

Commonality Symptoms of Concussion and Cervicogenic Injury

Symptom	Concussion	Cervical Injury
Headache	YES	YES
Dizziness	YES	YES
Tinnitus	YES	YES
Irritability	YES	YES
Chronic traumatic encephalopathy	YES	NO
Sleep disturbances	YES	YES
Blurred vision	YES	YES
Neck stiffness	YES	YES
Balance disturbances	YES	YES
Depression	YES	NO
Cognitive deficits	YES	YES
Memory deficits	YES	NO
Attention deficits	YES	YES
Decreased cervical range of motion	NO	YES
Decreased isometric neck strength	YES	YES

 With the large overlap of symptoms between cervical injury and concussion, objective testing to differentiate between the two are critically important. When test show that cervical injury is causing abnormal physiology in the brainstem and brain, treatment should be directed to the cervical spinal injuries. These tests are summarized in a form at the end of the bibliography for this paper. “The primary reason more clinicians were not incorporating cervicogenic tests into their routine evaluations of head trauma was a lack of education and awareness of the appropriate tests and methods.”

Testing Concepts:

• The key to the differential diagnosis of cervicogenic syndromes is testing if cervical afferents cause symptoms or disruptions in balance and ocular motor control.
• Each test attempts to remove visual and vestibular influences and isolate cervical position or movement-sensory information.
• “The reproduction of symptoms or loss of motor-control accuracy during testing then can be attributed to cervical spine involvement.”

Cervical joint-reposition error test (JPET)

• The JPET is the ability to relocate the head to a starting neutral position after maximal rotation or flexion or extension with eyes closed.
• It is performed by attaching a laser pen to the top of the patient’s head. A target is aligned with the point of the laser pen on the wall, and patients are instructed to close their eyes. They passively flex the neck and are instructed to return to the starting position. The process is repeated for extension and left and right rotation. After each trial, a mark is made on the target where the laser pen tip stops. The distance from the marked point to the center of the target is then measured.

Smooth-pursuit neck-torsion test (SPNTT):

• Smooth eye movements occur as the eyes follow a moving object while the head is still.
• The patient sits or stands in a neutral position.
• The patient actively rotates the neck 45° to the right or left and performs a smooth pursuit eye-tracking test.
• Neck rotation will reduce smooth pursuit among patients with vertigo due to whiplash-associated disorders but will not reduce it among healthy control participants or patients with central or peripheral vertigo.

Head-neck differentiation test (HNDT)

• The HNDT is performed with the patient sitting in a chair that rotates.
• The patient is instructed to look at a point on the wall and hold the head still while the clinician rotates the body under the head.
• If symptoms worsen, it indicates cervicogenic vertigo.

••••••••••

Explanations of the biological mechanisms for the improvement and resolution of the signs and symptoms of the post-concussive syndrome by treating the cervical spine typically involve the improvement of either cervical spine nociceptive or proprioceptive input into the central neural axis.

It is anatomically/biologically probable that these cervical spine injuries cause many, and in some cases, most of the symptoms of the post-concussion syndrome.

The Marshall study (2) from The Physician and Sportsmedicine, is most appropriate (and gratifying) to the chiropractic profession. It documents that traditional chiropractic cervical spine management, including spinal manipulation, of chronic patients diagnosed with “post-concussive syndrome” results in rapid and sustained improvement in “post-concussive” signs and symptoms. This allowed the athlete to return to full competition.

All patients suffering from the post-concussive syndrome should be referred to a chiropractor for cervical spine evaluation and treatment.

References

1. Langlois JA, Rutland-Brown W, Wald MM; The epidemiology and impact of traumatic brain injury: a brief overview; Journal of Head Trauma Rehabilitation; Sept-Oct 2006; Vol. 21; No. 5; pp 375–378.
2. Marshall CM, Vernon H, Leddy JJ, Baldwin BA; The Role of the Cervical Spine in Post-concussion Syndrome; The Physician and Sportsmedicine; July 2015; Vol. 43; No. 3; pp. 274-284.
3. Broglio SP, Surma T, Ashton-Miller JA; High school and collegiate football athlete concussions: A biomechanical review; Annals of Biomedicine Engineering; January 2012; Vol. 40; No. 1; pp. 37–46.
4. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al; Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining whiplash and its management; Spine; April 15, 1995; Vol. 20; No. 8 supplemental; pp. 1S–73S.
5. Richmond FJR, Corneil BD; Afferent mechanisms in the upper cervical spine; Vernon H, Editor; The cranio-cervical syndrome: mechanisms, assessment, and treatment. Oxford, UK; Butterworth Heinemann; 2003.
6. Treleaven J, Jull G, LowChoy N; The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash; Manual Therapy; May 2006; Vol. 11; No. 2; pp. 99–106.
7. Bogduk N; Anatomy and Physiology of Headache; Biomedicine and Pharmacotherapy; 1995; Vol. 49; No. 10; pp. 435-445.
8. Hynes LM, Dickey JP; Is there a relationship between whiplash-associated disorders and concussion in hockey? A preliminary study; Brain Injury; February 2006; Vol. 20; No. 2; pp. 179-88.
9. Schneider KJ, Meeuwisse WH, Kang J, Schneider GM, Emery CA; Preseason reports of neck pain, dizziness, and headache as risk factors for concussion in male youth ice hockey players; Clinical Journal of Sport Medicine; July 2013; Vol. 23; No. 4; pp. 267-72.
10. Jensen OK, Nielsen FF, Vosmar L; An open study comparing manual therapy with the use of cold packs in the treatment of post-traumatic headache; Cephalalgia; October 1990; Vol. 10; No. 5; pp. 241–250.
11. Treleaven J, Jull G, Atkinson L; Cervical musculoskeletal dysfunction in post-concussional headache; Cephalalgia; August 1994; Vol. 14; No. 4; pp. 273–279.
12. Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, Barlow K, Boyd L, Kang J, et al; Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial; British Journal of Sports Medicine; September 2014; Vol. 48; No. 17; pp. 1294–1298.
13. Cheever K,Kawata K, Tierney R, Galgon A; Cervical Injury Assessments for Concussion Evaluation; Journal of Athletic Training; December 2016; Vol. 51; No, 12; pp. 1037–1044.

Tests To Identify Presence of Cervical Injury

Cervical spine injury alters cervical afferents to the vestibular nucleus (balance, posture, and eye stability/movements). These tests remove visual and vestibular influences and isolate cervical position and cervical afferent influences. The reproduction of symptoms (dizziness, vertigo, balance disturbance) or loss of motor-control accuracy during testing suggests cervical spine involvement.

Name:                                                              Date:                           

Clinical Test	How to Perform	Results
Cervical Joint Repositioning Error Test (JPET) The ability to relocate the head to a starting neutral position after maximal rotation or flexion or extension with eyes closed. After each test, a mark is made on the target where the laser pen tip stops, and the distance from the marked point to the center of the target is measured	Attach a laser pen to the top of the patient’s head. A target is aligned with the point of the laser pen on the wall, and patients are instructed to close their eyes. They passively flex the neck and are instructed to return to the starting position. The process is repeated for extension and left and right rotation	Distance From Target ____________ Flexion Error ____________ Extension Error ____________ Rt. Rotation Error ____________ Lt. Rotation Error ____________
Smooth Pursuit Neck Torsion Test (SPNTT) Neck torsion will reduce smooth pursuit among patients with vertigo due to neck disorders but will not reduce it among healthy control participants or patients with central or peripheral vertigo	The patients sits in a neutral position   The patient actively rotates the neck 45° to the right or left and performs a smooth pursuit eye-tracking test (following a moving object, like the tip of the doctor’s finger)	Left NORMAL ABNORMAL Right NORMAL ABNORMAL
Head Neck Differentiation Test (HNDT) Head Cannot Hold Still While Body Spins on Chair with Other Symptom Provocation. If symptoms worsen, it indicates cervicogenic vertigo	The patient sits in a chair that rotates. The patient is looks at a point on the wall and holds the head still while the clinician rotates the body under the head	Left NORMAL ABNORMAL Right NORMAL ABNORMAL

“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.”