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Why Do Patients Go To Chiropractors?

Inflammation

In her books, Epigenetics Revolution (2013) and Junk DNA (2017) geneticist Nessa Carey explains that the driving force in human evolution and in human biology is procreation; living long enough to make babies and pass our genes on to future generations (1, 2). At the center of the human opportunity to procreate is a biological process that increases individual survivability and hence the ability of that individual to procreate: inflammation.

Dale Bredesen, MD, is unique. He is a neurologist from the Department of Neurology, University of California, Los Angeles, CA, USA (UCLA). He is conducting ongoing clinical trials pertaining to the reversal of Alzheimer’s disease, including in individuals that are genetically homozygous (they have two alleles) for the most prominent risk factor for the disease (3, 4, 5).

A distinction between Dr. Bredesen and other researchers and clinicians in this field is that Bredesen does not believe that Alzheimer’s disease is caused by the accumulation of the fibrotic proteins amyloid and/or tau. In contrast, he proposes that amyloid and/or tau proteins exist in response to chronic inflammation of the brain. He states (5):

“When our ancestors became bipedal, descending from the trees and walking the savanna, inflammation was actually an advantage.”

“Inflammation is part of the reaction by the immune system to foreign invaders, allowing our ancestors to survive stepping on dung, puncturing their feet, eating raw meat filled with pathogens, and sustaining wounds during hunts as well as while fighting with each other.”

“In all of these situations, mounting a robust inflammatory response protects against life-threatening infection.”

“As we age, however, inflammation promotes cardiovascular disease, arthritis, and other woes—including Alzheimer’s disease.”

“This trade-off is called antagonistic pleiotropy, in which a genetic alteration enhances fitness early in life at the expense of longevity.”

The “other woes” caused by the inflammation mentioned by Dr. Bredesen includes fibrotic changes around and in joints, leading to joint dysfunction. Common terminology in the chiropractic profession for these articular fibrotic changes include “the fibrosis of repair,” “periarticular fibrosis,” “intra-articular fibrosis,” “intra-articular adhesions,” “granulation tissue,” “scar,” etc. These inflammatory driven fibrotic changes may protect an individual from the spread (and death from) infection, but they also cause articular movement or positional dysfunctions called the “subluxation.” (6)

The June 2015 issue of the journal Scientific American has an article by physician Wajahat Z. Mehal, MD, from the Department of Veterans Affairs Medical Center in Connecticut, and Yale University, titled (7):

Cells on Fire

In this article, Dr. Mehal notes that inflammation is set in motion by the cells of the immune system, and that it is helpful because it kills pathogens and blocks their spread in the body. The inflammatory cascade weakens and immobilizes adverse microbes that otherwise make humans sick and increases mortality, thus reducing procreation.

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

Historically, these concepts of inflammation (from any cause) leading to “walling-off,” repair and fibrosis have been well documented in pathology books, often being given an entire chapter of emphasis. Examples include:

In 1952, William Boyd, MD, Professor Emeritus of Pathology at the University of Toronto, published in his reference text (8):

PATHOLOGY
Structure and Function in Disease

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

In 1970, the eighth edition of Dr. Boyd’s PATHOLOGY text is published (9): In chapter 4, titled “Inflammation and Repair,” Dr. Boyd states:

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

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

In 1976, physicians WAD Anderson, MD, and Thomas Scotti, MD, published the ninth edition of their book titled (10):

Synopsis of Pathology

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

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

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

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

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

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

An important premise from Drs. Anderson and Scotti is that in chronic inflammation, “abundant” scar tissue may form, and this connective tissue scar may “itself be distinctly harmful.” Connective tissue is the tissues of joints, and the harm to the joints is reduced movement.

In 1979, Harvard Medical School professors Stanley Robbins, MD, and Ramzi Cotran, MD, published the second edition of their book, titled (11):

PATHOLOGIC BASIS OF DISEASE

Similar to Boyd, Anderson and Scotti, Robbins and Cotran also titled chapter three of their text “Inflammation and Repair.” Robbins and Cotran state:

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

“Without inflammation, bacterial infections would go unchecked.”

But, “inflammation itself may be potentially harmful.”

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

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

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

It is of particular interest to note that Drs. Robbins and Cotran specifically note that the cascade of inflammation and fibrosis may “limit the mobility of joints.”

In the second edition of their book, Guido Manjo, MD and Isabelle Joris, PhD, talk extensively about inflammation and fibrosis, stating (12):

Cells, Tissues, and Disease
Principles of General Pathology

“Inflammation is one of the basic processes in general pathology.”

“Inflammation is primarily an antibacterial phenomenon.” “Today we know that inflammation is a life-saving reaction, usually against infection.”

The evolutionary significance of inflammation is as a primary antibacterial response. “It is a matter of urgency. The doubling time of common pathogenic bacteria is of the order of 20 minutes.”

“Inflammation is also triggered aseptically by injured tissues.”

“There can be inflammation without infection; remember that inflammation is triggered by products of tissue injury, thus any aseptic injury will trigger inflammation.”

“Because local injury is part of everyday life, inflammation is probably the most common aspect of tissue pathology and has always been perceived as a central issue in the practice of medicine.”

Granulation tissue “is a key component of chronic inflammation.” “Granulation tissue arises from normal connective tissue, but it cannot be mistaken for normal connective tissue.”

“With time, granulation tissue loses most of its cells, the collagen component increases, and the terminal picture blends with that of scar.”

“When fibrosis develops in the course of inflammation it may contribute to the healing process.” “By contrast, an excessive or inappropriate stimulus can produce severe fibrosis and impair function.”

“Why does fibrosis develop? In most cases the beginning clearly involves chronic inflammation. Fibrosis is largely secondary to inflammation.”

Important observation by Drs. Manjo and Joris include:

• Injury is part of everyday life
• Inflammation is the body’s response to injury
• Inflammation results in tissue fibrosis
• Inflammation and fibrosis is the most common tissue pathology and “has always been perceived as a central issue in the practice of medicine.”

 

•••

Orthopedic, clinical management, and physiology texts also discuss inflammation and fibrosis.

In 1982, orthopedic surgeon Sir James Cyriax, MD, published the eighth edition of his book titled (13):

Textbook of Orthopaedic Medicine:
Diagnosis of Soft Tissue Lesions

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

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

In 1983, physicians Steven Roy and Richard Irvin published their book on sports injury titled (14):

Sports Medicine:
Prevention, Evaluation, Management, and Rehabilitation

In this book, Roy and Irvin state:

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

In 1986, physician and physiologist, Arthur Guyton, MD, published the seventh edition of his book, titled (15):

Textbook of Medical Physiology

Dr. Guyton states:

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

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

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

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

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

Motion

Much of life is dependent upon motion and mobility (17).

Historically, human survival is dependent upon external motion to obtain food, shelter, mates, protection, safety, etc. This is true for other animal species as well.

Internal motion is also critically important. Motion of and between the various parts of the body is critical for the internal health of the human, as well as for other animals.

The 202 joints of the human body are designed specifically to allow for motion between our various body parts. They also allow for the human body to move from place to place.

The movement of every joint in the body can be measured, quantified. The optimal movement for every joint in the body has been established. Increases or decreases in measured joint movements are not good. Such changes in joint movement are frequently associated with pain, degenerative joint arthritis, joint dysfunction, and weakness. These joint movement problems can cause impairments and disabilities. In fact, when they are precisely quantified, the results are often used by government agencies, courts, and medical personnel to establish official impairment and disability status of individuals (18).

Joint movement is divided into three categories (19, 20, 21, 22, 23):

• Active Motion
• Passive Motion
• Periarticular Paraphysiological Space Motion

Active Motion

Active Motion is the best understood category of joint motion. It is the type of motion joints experience when people move any part of their body. It requires active contraction of our muscles. Active motion is the typical motion joints experience when people engage in the activities of normal life (showering, dressing, preparing meals, driving, working, shopping, etc.), and exercise. With exercise, specific joints can be targeted for motion benefits and therapy.

Yet, it is important to understand that active motion, including specific exercise active motion, only benefits the most narrow range of tissues, and as such the therapeutic benefit of active motion is limited. When a specific joint is moved through the maximum active range of motion, a natural physiological barrier is met, beyond which no additional motion is possible without assistance (below). The important concept is that joints have the ability to move beyond the active range, and this can be done without causing any stress or injury to the joint.

Passive Motion

Passive motion is the passive moving of a joint further than the motion achieved with active motion. Passive motion always affects a greater range of tissue than does active motion. This allows passive motion techniques to better address (treat, manage) tissue fibrosis and joint stiffness.

Accepted and beneficial passive motion applications include stretching, yoga, etc. A variety of health care providers, including chiropractors, are trained and able to isolate specific joints that are lacking optimal motion and to “push” the joint beyond the active range of motion and into the passive range of motion. Again, this is accomplished without any tissue injury.

At the end of the passive range of motion, another “barrier” is encountered. This is called the elastic barrier. Movement beyond the elastic barrier is not only beneficial, it is often critically required. It is also tricky, as noted by orthopedic surgeon WH Kirkaldy-Willis (6), below:

Periarticular Paraphysiological Space Motion

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

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

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

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

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

“With experience, the manipulator can be very specific in selecting the spinal level to be manipulated.”

There are a number of benefits from moving joints past the elastic barrier and into the periarticular paraphysiological space range of motion. The best-documented benefit is the reduction of pain. The trick is to move past the elastic barrier and into the periarticular paraphysiological space without exceeding the limit of anatomic integrity. This skill requires training and practice. This is why chiropractors have four years of training, after college, and are licensed by the state.

Ancient History

For millennia humans have known the benefits of optimizing joint motion. The history of joint manipulation parallels the history of civilization. An important review of manipulation through the ages was published in The Journal of Manual & Manipulative Therapy in 2007 and titled (24):

A History of Manipulative Therapy

This review makes these comments:

“Manipulative therapy has known a parallel development throughout many parts of the world. The earliest historical reference to the practice of manipulative therapy in Europe dates back to 400 BCE.”

“Historically, manipulation can trace its origins from parallel developments in many parts of the world where it was used to treat a variety of musculoskeletal conditions, including spinal disorders.”

“It is acknowledged that spinal manipulation is and was widely practiced in many cultures and often in remote world communities such as by the Balinese of Indonesia, the Lomi-Lomi of Hawaii, in areas of Japan, China and India, by the shamans of Central Asia, by sabodors in Mexico, by bone setters of Nepal as well as by bone setters in Russia and Norway.”

“Historical reference to Greece provides the first direct evidence of the practice of spinal manipulation.”

“Hippocrates (460–385 BCE), who is often referred to as the father of medicine, was the first physician to describe spinal manipulative techniques.”

“Claudius Galen (131–202 CE), a noted Roman surgeon, provided evidence of manipulation including the acts of standing or walking on the dysfunctional spinal region.”

“Avicenna (also known as the doctor of doctors) from Baghdad (980–1037 CE) included descriptions of Hippocrates’ techniques in his medical text The Book of Healing.”

“Nobody questions these early origins of manipulative therapy.”

In her 1990 book, Mutant Message Down Under, Marlo Morgan chronicles the journey of a middle-aged, white, American woman with a group of 62 desert Aborigines, across the continent of Australia (25). Morgan chronicled a cultural habit, estimated to be millennia old, at the end of each day’s nomadic journey: members of the group manipulating each other.

Modern History

Prior to the modern era, for hundreds of years in developed and primitive societies throughout the world, practitioners of manipulation were known as bonesetters (24). All of this changed in 1874, and the global seat of change was in the United States of America.

Andrew Taylor Still was a second-generation physician who became disillusioned with medicine following the death (from disease) of three of his children. Dr. Still conceived a theory whereby health could only be maintained and, therefore, disease defeated, by maintaining normal function of the musculoskeletal system (24).

By 1874, “Still referred to himself, in what was a very successful clinical practice, as the ‘Lightening Bone Setter’.” Note this description from reference #24:

“His drugless, non-surgical approach to the treatment of disease rapidly gained acceptance among the general public. He soon found that he was unable to treat the growing numbers of patients and decided he would have to train others to help him in his work.”

“In 1892, he was confident enough in his beliefs that he established the American Osteopathic College in Kirksville, Missouri.”

“He based his theories of disease and dysfunction on the ‘disturbed artery’ in which obstructed blood flow could lead to disease or deformity. This would become known in Osteopathy as the Law of the Artery.”

“As Still’s methods continued to grow in popularity, more colleges were opened and by the time of his death in 1917, 3,000 Doctors of Osteopathy had been graduated.”

The second great addition to the practice of joint manipulation occurred in 1895. Daniel David Palmer was “well educated and an avid reader of all things scientific especially with regard to the healing arts.” Palmer became a self-trained  “natural healer.” (24)

With practice experience, “Palmer began to reason that when a vertebra was out of alignment, it caused pressure on nerves.” In 1897, in Davenport, Iowa, Palmer opened his first college, The Palmer College of Cure, now known as the Palmer College of Chiropractic.

In 1907, one the graduates was Palmer’s son Bartlett Joshua or BJ Palmer. In 1910, BJ Palmer introduced the use of X-rays into Chiropractic. Again, reference #24 states:

“The G. I. Bill at the end of World War II enabled thousands of returning soldiers to bolster the ranks of the chiropractic profession.”

“This influx seemed to provide an impetus that would propel the chiropractic profession to today’s status where it boasts 35 schools and colleges worldwide and, in the Western world at least, it is second only to the medical profession as a primary care healthcare provider.”

Summary

Chiropractic-like practitioners have existed throughout history and throughout the world. The evidence suggests that these practitioners exist as a consequence of evolutionary adaptations to protect humans from infections. The fibrotic benefits of walling-off inflammation initiated by infection causes mechanical problems of connective tissues and joints, especially when the inflammation is not infectious, but rather secondary to trauma or stress. Left unmanaged, these joint mechanical deficits impair local biomechanical function, affecting performance, generating pain, and accelerating degenerative changes. Skilled manipulation of these joints improves biomechanical function, reducing pain while improving biomechanical function and performance.

The primary provider of manipulative care today is the chiropractor. Officially started in the year 1895, chiropractic is now recognized and licensed by the federal government, all state governments, and is taught and practiced throughout the world.

REFERENCES:

1. Carey N; Epigenetics Revolution: How Modern Biology Is Rewriting Our Understanding of Genetics, Disease, and Inheritance; Columbia University Press; 2013.
2. Carey N; Junk DNA: The Journey Through the Dark Matter of the Genome; Columbia University Press; 2017.
3. Bredesen DE; Reversal of cognitive decline: A novel therapeutic program; Aging; September 27, 2014; Vol. 6, No. 9; pp. 707-717.
4. Bredesen DE, Amos EC, Canick J, Ackerley M, Raji C, Milan Fiala M, Ahdidan J; Reversal of Cognitive Decline in Alzheimer’s Disease; Aging; June 2016; Vol. 8; No. 6; pp. 1250-1258.
5. Bredesen DE; The End of Alzheimer’s: The First Program to Prevent and Reverse Cognitive Decline; Avery; 2017.
6. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
7. Mehal WZ; Cells on Fire; Scientific American; June 2015; Vol. 312; No. 6; pp. 45-49.
8. Boyd W; PATHOLOGY: Structure and Function in Disease; Lea and Febiger; 1952.
9. Boyd W; PATHOLOGY: Structure and Function in Disease; Eighth Edition; Lea & Febiger; Philadelphia; 1970.
10. Anderson WAD, Scotti TM; Synopsis of Pathology; Ninth Edition; The CV Mosby Company; 1976.
11. Robbins SL, Cotran RS; Pathologic Basis of Disease; Second Edition; WB Saunders Company; Philadelphia; 1979.
12. Manjo G, Joris I; Cells, Tissues, and Disease; Principles of General Pathology; Second Edition; Oxford University Press; 2004.
13. Cyriax, James; Textbook of Orthopaedic Medicine, Diagnosis of Soft Tissue Lesions; Bailliere Tindall; Volume 1; Eighth Edition; 1982.
14. Roy, Steven; Irvin, Richard; Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation; Prentice-Hall; 1983.
15. Guyton A; Textbook of Medical Physiology; Saunders; 1986.
16. Cohen, I. Kelman; Diegelmann, Robert F; Lindbald, William J; Wound Healing, Biochemical & Clinical Aspects; WB Saunders; 1992.
17. Korr IM; The Sympathetic Nervous System as Mediator Between the Somatic and Supportive Processes (1970), in The Collected Papers of Irvin M. Korr; American Academy of Osteopathy; 1979; pp. 170-174.
18. Cocchiarella L, Anderson GBJ; Guides to the Evaluation of Permanent Impairment; Fifth Edition; American Medical Association; 2001.
19. Sandoz R; Some Physical Mechanisms and Effects of Spinal Adjustment; Annals of the Swiss Chiropractic Association; 1976; Vol. 6; pp. 91-141.
20. Haldeman S; Modern Developments in the Principles and Practice of Chiropractic; Appleton-Century-Crofts; New York; 1980.
21. Kirkaldy-Willis WH; Managing Low Back Pain; Churchill Livingston; (1983 & 1988).
22. Kirkaldy-Willis, WH, Cassidy JD; Spinal Manipulation in the Treatment of Low-Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-40.
23. Fischgrund JS; Neck Pain, Monograph 27, American Academy of Orthopaedic Surgeons; 2004.
24. Pettman E; A History of Manipulative Therapy; The Journal of Manual & Manipulative Therapy; Vol. 15; No. 3; (2007); pp. 165–174.
25. Morgan M; Mutant Message Down Under; 1990.

The Role for Chiropractic Evaluation
and Treatment of Concussion Patients

••••••••••

On November 14, 2015 favored Ultimate Fighting Champion Ronda Rousey was knocked unconscious by her underdog opponent Holly Holm. The internet is littered with video of the knockout. It occurred as a consequence of a single kick by Holm to Rousey. The kick was not delivered to Rousey’s head. It was delivered to her neck.

••••••••••

The principles of inertia have always been with us, but they were not officially acknowledged through publication until Sir Isaac Newton wrote the book Mathematical Principles of Natural Philosophy in the year 1687.

Inertia is the resistance of a physical object to any change in its state of motion or to its state of rest. As often stated, 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.

It is now accepted that Newton’s Laws of Inertia apply to the human body. Different parts of the human body have different inertias between them. Specific to this discussion are the inertial differences between a human’s trunk and head. A classic actual-life example of these inertial concepts is the rear-end motor vehicle collision.

In a rear-end motor vehicle collision, the struck vehicle, its seat, and trunk of the occupant are quickly propelled forward, while the head, having its own inertial mass, will remain at rest. Thus, the head remains still while the body is moved forward, under the head. This gives the appearance that the head is extending upon the trunk, the so-called “hyperextension” phase of a rear-end motor vehicle collision.

Neck Hyperextension As Trunk Is Pushed Under Head

Under these circumstances, the most vulnerable body part to injury is not the trunk nor the head, but rather the part of the body that balances these two larger inertial masses to each other, the neck. Because of the large inertial masses of the trunk and the head, the neck is historically very vulnerable to “inertial injury.” In this context, an “inertial injury” means that there is no direct blow or contact injury to the neck.

The inertial loads to the neck occur in both extension and flexion directions. In a rear-end collision the neck/head complex first extends, followed by a “rebound” flexion (1, 2, 3). Or, in a head-on collision (or the hitting of a stationary object such as a tree or wall), the neck/head complex first goes into flexion (1, 2, 3).

Also specific to this discussion is the fact that in the neck exists the spinal cord and the spinal cord is attached to the brainstem and brain. As the neck experiences inertial loading, so does the spinal cord and tissues the spinal cord are contiguous with. In flexion, whether rebound or initial, there is a significant tractional/tension load to the spinal cord (4).

History

1867 and 1885 and 1928

With the dawn of moving humans around in wheeled vehicles there has been a paralleling increase in the reports of inertial injuries to the neck from accidents involving those vehicles. In 1867, a book detailing these inertial injuries subsequent to train crashes was published (5). In 1885, a surgeon from London, England, published a 397-page book titled (6):

Injuries of the Spine and Spinal Column
Without Apparent Mechanical Lesion, and Nervous Shock
in their Surgical and Medico-Legal Aspects

As there were no automobiles in 1885, this book also highlighted injuries from train accidents. This book includes chapters on “Concussion of the Spinal Cord” and “Concussion of the Spine.”

The first official medical paper pertaining to automobile collision cervical spine inertial injuries was published in 1928 (7).

1940 and 1941

Derek Denny-Brown (1901-1981) was a New Zealand-born physician and neurologist whose distinguished career took him to Oxford, Yale, and Harvard. In 1940, Dr. Denny-Brown and colleague published a study in the Journal of Physiology titled (8):

Experimental Cerebral Concussion

In this study, the authors note that the signs and symptoms of a brain concussion could be established in animals subjected to acceleration/deceleration loads and in animals (monkeys) in which their brain had been surgically removed (the decerebrate animal). The authors reported that the injury had to be to the spinal cord and/or the brain stem. They stated:

“Acceleration in movement resulting from the blow is the essential factor in the stimulus, for if the head is prevented from moving when struck the phenomenon fails to occur.”

“The nervous effect of a blow is thus considered to be due to the physical acceleration directly transmitted to each and every centre.”

The authors further stated that the following structures played no part in the post concussive syndrome:

• Deformity of the skull
• Labyrinthine stimulation
• Rise of intracranial pressure

The following year, 1941, Dr. Denny-Brown and colleague update these concepts the Proceedings of the Royal Society of Medicine (9). In this study they coin “acceleration concussion” which “occurs in all brain-stem mechanisms examined and is brought about at and beyond a threshold value of change in velocity [acceleration]”.

1957

Kirk V. Cammack, MD, from the Hurley Hospital, Flint, Michigan evaluated 50 consecutive whiplash cases. He published the results in the American Journal of Surgery in an article titled (10):

Whiplash Injuries to the Neck

Dr. Cammack notes:

Cerebral concussion primarily occurs during the deceleration (flexion) phase to the occipital areas of the brain, “accompanied by the torsion of the brain stem.”

30% of the subjects had signs of cerebral concussion.

Initial concussion symptoms range from mental confusion or headache to loss of consciousness.

20% of the subjects had persistent symptoms (lasting more than a month) consisting of headache, vertigo and inability to concentrate.

Concussion symptoms may still be present after two years.

1960

An article was published in the Journal of Neuropathology and Experimental Neurology titled (11):

Specific Cord Damage at the Atlas Level as a
Pathogenic Mechanism in Cerebral Concussion

Thirty-two cats were purposefully head injured with the following findings/conclusions:

“Considerable damage was found in the thick fibers at the ventral surface of the upper segments of the cervical spinal cord.”

“These changes decreased considerably towards the medulla oblongata and showed maximal damage caudally from the first spinal segment. This typical distribution implies a confined damage at the level of the atlas.”

“X-ray investigations revealed flexion or strain of the cervical cord around the odontoid process. This flexion acts in forced changes of position of the head and may operate as a damaging mechanism. It is suggested that a subluxation of the odontoid process might enhance this mechanism.”

These findings “agree with the findings of Denny-Brown and Russel (9) who obtained concussion even in the decerebrate animal. The term ‘brain’ concussion would definitely be wrong if the above assumptions are correct.”

“Significant fiber damage was found in serial studies of the cervical spinal cord,” and “the damage was maximal at the atlas level but sparse above this level.”

“It seems more than reasonable to assume a specific cord injury at the atlas level is behind at least many instances of so called ‘brain’ concussion.”

“A specific mechanism of cord injury at the atlas level seems responsible for many instances of so called ‘brain’ concussion.”

1998

Researchers from the Department of Bioengineering, University of Pennsylvania, published a study in the journal Spine titled (12):

In Vivo Human Cervical Spinal Cord
Deformation and Displacement in Flexion

The human cervical spinal cord was measured in five volunteers during flexion of the neck using a magnetic resonance imaging technique. Animal studies demonstrate that at full flexion that the entire cervical cord elongates approximately 10% of its length from a neutral position. This is the first such study measuring spinal cord tension performed on living human subjects. The authors concluded:

“The cervical cord elongates and displaces significantly during head flexion in human volunteers, offering valuable information regarding the normal milieu of the cord.”

2018

Researchers from Wayne State University, Detroit, Michigan, published a study in the journal BMJ Open Sport & Exercise Medicine titled (13):

Concussion with Primary Impact to the
Chest and the Potential Role of Neck Tension

These authors note that most biomechanical research on brain injury focuses on direct blows to the head. Yet, they propose that a blow to the chest could cause an inertial flexion of the head/neck complex resulting in concussion-type injury. They also note that there are few studies on concussion with primary impact to the chest resulting in neck injury. They state:

“Studies that indicate craniocervical stretch could be a factor in concussion by causing strain in the upper spinal cord and brainstem.” 

The objective of this study was to assess the biomechanical responses to strain in the upper cervical spine and brainstem from impact to the chest in American football. The study involved four phases:

• Chest impact testing on a helmeted stationary anthropomorphic test device (ATD).
• Chest impact testing on an un-helmeted stationary anthropomorphic test device (ATD).
• A study of two NFL game collisions resulting in concussion to estimate the biomechanical forces in real-life collisions.

In these cases, the primary impact was to the chest, and the player experienced a concussion with a delayed return to play.

• A finite element study was also conducted to estimate the elongation of the cervical spine under tensile and flexion loading conditions.

Studies show that during maximum cervical spine flexion there is a caudal (downward) displacement of the spinal cord relative to the spinal column, “indicating that stretch of the spinal cord (above C5) and brainstem occurs.”

Animal studies have shown signs of neuropathology in the upper spinal cord and brainstem in response to a distraction load in a non-impact condition. These studies “concluded that craniocervical distraction (tension) and flexion are the most important factors in concussion.”

“Studies have produced signs of cerebral concussion, hemorrhages on and contusions over the surface of the brain and upper cervical cord by rotational flexion displacement of the head on the neck, without direct head impact.” These studies concluded that rotational flexion-extension acceleration of the head, flexion-extension-tension of the neck and subsequent intracranial pressure gradients development are causative factors in concussion.

Human studies have also shown concussion with loss of consciousness without impact to the head. These injuries often showed primary shoulder-to-chest contact. The proposed mechanism is angular accelerations (flexion/extension) to the head-neck complex, such as would be experienced in a whiplash inertial injury.

Studies on the head and neck of pilots who ditch in the ocean showed that the “added weight of a helmet” resulted in spinal “cord concussion due in part to upper cervical cord stretch during the combined vertical acceleration and forward deceleration of the aircraft.” This would be a spinal cord tension and flexion mechanism. Studies show that the “mass of the helmet aggravates the potential for injury by adding bending, axial and shear loads at the craniocervical junction. There is a 40% increase in upper neck tensile forces in the helmeted compared with un-helmeted impacts of equal severity. This suggests that wearing a helmet increases the loading on the brainstem and cervical spinal cord.

Neck tension increases with flexion of the head relative to the torso. The helmeted anthropomorphic test device had a 40% increase in neck tensile force and an 8% increase in neck flexion angle when compared with an un-helmeted anthropomorphic test device. This case study indicated that the neck tension in the injured players exceeded tolerable levels from volunteer studies. The helmet mass increased the effective mass of the head by 47% compared with the un-helmeted head. “This resulted in significantly greater neck forces and movements when compared with the un-helmeted impacts.” “The mass of the helmet added to the head can increase the strain at the craniocervical junction.”

The finite element analysis estimated that the strain along the axis of the upper cervical spinal cord and brainstem was 10%–20% for the combined flexion and tension loading in the two cases presented, indicating that the “strain in the upper spinal cord and brainstem from neck tension is a factor in concussion.” The maximum strain in the vertebral column occurred in the upper cervical spine (C1–C2).

These authors note:

“The axonal strain in the spinal cord and brainstem exceeds the levels that have been documented to cause changes in functional and structural response in spinal nerve roots when stretched in tension at varying strain rates.”

“The strains are similar to those documented in in vivo tests with primates which resulted in functional changes in the spinal cord as well as changes in heart rate and respiration.”

“Craniocervical stretch resulting from tension and flexion in the upper cervical spine has been reported to be an important factor in concussion.”

“Neck tension and head flexion have each been shown to result in strain of the upper cervical spinal cord and the brainstem.”

“Tension generated in the spinal cord can be transmitted from the spinal cord to the brainstem.” “The largest elongation occurred in the medulla.”

The loss of consciousness in football players is consistent with these injuries to the brainstem.

The neck tensions documented in this study “apparently resulted in injury to the upper cervical spinal cord and medulla.”

Other studies “have indicated that strains in the upper spinal cord and brainstem are important factors in concussion.”

“Neck tension or strain along the axis of the upper cervical spinal cord and brainstem is a possible mechanism of brain injury.”

This study is quite important for chiropractors as it suggests that tackle impacts can cause head-neck flexion-tractional inertial injuries to the brainstem and upper cervical spinal cord, resulting in the concussion syndrome. In such cases, management of the cervical spine may greatly improve clinical outcomes. This appreciation and approach was published in a study in 2015 in the journal The Physician and Sports Medicine titled (14):

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 discuss the cases of 5 patients with diagnosed post-concussive syndrome, who experienced very favorable outcomes following various treatment and rehabilitative techniques aimed at restoring cervical spine function. The treatment included chiropractic 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.”

Concussion injuries, or mild traumatic brain injury, have an estimated prevalence of 3.8 million per year in the United States. Concussions are one of the least understood injuries facing sports medicine and neuroscience today.

The post-concussion syndrome is the chronic phase of concussion. The patient is considered to be chronic when symptoms persist longer than 4-12 weeks. This occurs in about 10–15% of concussed patients. These patients may develop persistent symptomatology lasting weeks, months or even years after injury.

Significant concepts in this study include:

“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.”

It has been known since 2006 that brain-injured athletes concurrently injure their cervical spines. 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.

There is considerable overlap of the signs and symptoms of mild traumatic brain injury and of whiplash injury:

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. Numerous brain stem structures receive mono-synaptic inputs from the C2 dorsal root ganglion afferents, including:

• Lateral cervical nucleus
• Central cervical nucleus
• Caudal projections to C5 level
• Cuneate nucleus, lateral cuneate nucleus
• Nucleus tractus solitarius
• Intercalatus nucleus
• Nucleus X of the vestibular system
• Trigemino-cervical nucleus (for headache nociception)

Prior studies have concluded that injuries of the cervical spine are responsible for post-concussion syndrome, and have shown excellent clinical outcomes as a consequence of treatment to the cervical spine. These authors present five 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. The improved clinical outcome results were long-lasting.

Treatment included:

• Active Release Therapy
• Localized vibration therapy over the affected muscles
• Spinal manipulative therapy of the restricted joints
• Low-velocity mobilizations (on 1 patient)

The authors concluded:

“Management of persistent post concussive 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.”

This study is timely, especially considering the evidence that the cervical spine is involved in concussion has been in the literature for about 150 years. This study highlights the lack of understanding by athletes, the public, and healthcare providers that it is essentially impossible to sustain a traumatic brain injury without also injuring the soft tissues of the cervical spine. It is anatomically/biologically probable that these cervical spine injuries cause many, if not most, of the symptoms of the post-concussion syndrome.

It is also gratifying to see a published study showing that traditional chiropractic management of post-concussive syndrome patients resulted in rapid and sustained improvement in post-concussive signs and symptoms, allowing the athlete to return to full completion.

It is recommended that all patients suffering from the post-concussive syndrome should be referred to a chiropractor for cervical spine evaluation and treatment.

REFERENCES:

1. Jackson R, The Cervical Syndrome, Thomas, 1978.
2. Foreman S, Croft A’ Whiplash Injuries: The Cervical Acceleration / Deceleration Syndrome; Williams & Wilkins; 1988.
3. Cailliet R; Whiplash Associated Diseases; American Medical Association; 2006.
4. White AA, Panjabi MM; Clinical Biomechanics of the Spine; Second Edition; Lippincott; 1990.
5. Erichsen JE; On Railway and Other Injuries of the Nervous System; Philadelphia, PA; Henry C. Lea; 1867.
6. Page HW; Injuries of the Spine and Spinal Column Without Apparent Mechanical Lesion, and Nervous Shock in their Surgical and Medico-Legal Aspects; Second Edition; London; J. A. Churchill; 1885.
7. Todman D; Whiplash Injuries: A Historical Review; The Internet Journal of Neurology; Vol. 8 No 2; 2006.
8. Denny-Brown D, Russell WR; Experimental Cerebral Concussion; Journal of Physiology; Vol. 99; p. 153.
9. Denny-Brown D, Russell WR; Experimental Concussion; Proceedings of the Royal Society of Medicine; September 1941; Vol. 34; No. 11; pp 691-691.
10. Cammack KV; Whiplash Injuries to the Neck; American Journal of Surgery; April 1957; Vol. 93; pp. 663-666.
11. Friede RL; Specific cord damage at the atlas level as a pathogenic mechanism in cerebral concussion; Journal of Neuropathology and Experimental Neurology; April 1960; Vol. 19; pp. 266-279.
12. Yuan Q, Dougherty L, Margulies SS; In vivo human cervical spinal cord deformation and displacement in flexion; Spine; August 1, 1998; Vol. 23; No. 15; pp. 1677-1683.
13. Jadischke R, Viano DC, McCarthy J, King AI: Concussion with Primary Impact to the Chest and the Potential Role of Neck Tension; BMJ Open Sport & Exercise Medicine; October 16, 2018; Vol.4; No. 1; pp. e000362.
14. Marshall CM, Vernon H, Leddy JJ, Baldwin BA; The Role of the Cervical Spine in Post-concussion Syndrome; July 2015; Vol. 43; No. 3; pp. 274-284.

The chiropractic spinal adjustment (specific joint manipulation) is the passive assistance of moving a specific joint through a complete range of motion while causing no injury to the joint tissues. This adjustment is known for the cavitation process. Cavitation is the audible, palpable “popping” sensation experienced by both the patient and the chiropractor when the joint being adjusted is moved beyond the passive range of motion and into the paraphysiological range of motion. This motion is safe and causes no excessive stresses to tissues (1).

Spinal joints may lose their full ability to move through a range-of-motion for a number of reasons, including:

• Injury (whiplash, sports, lifting excessive loads, etc.)
• Chronic or prolonged mechanical stress (poor ergonomics and/or posture, excessive weight, etc.)
• Age related degenerative joint disease (arthritis)

This is important because when joints lose their full range-of-motion, they become painful. Motion activates nerves that suppress pain. This is a physiological principle that has been understood for decades (since 1965), and it is referred to as the “gate theory of pain.” Any therapeutic intervention that restores/improves the range of motion of joints suppresses the pain from that joint. Orthopedic Surgeon, Dr. WH Kirkaldy-Willis, MD, describes this phenomenon as (1):

“Beyond the end of the active range of motion of any synovial joint, there is a small buffer zone of passive mobility.” A joint can only move into this zone with passive assistance, and going into this passive range of motion “constitutes mobilization.”

“At the end of the passive range of motion, an elastic barrier of resistance is encountered. This barrier has a spring-like end-feel.”

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

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

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

Melzack and Wall proposed the Gate Theory of Pain in 1965, and this theory has “withstood rigorous scientific scrutiny.”

“The central transmission of pain can be blocked by increased proprioceptive input.” Pain is facilitated by “lack of proprioceptive input.”

“Increased proprioceptive input in the form of spinal mobility tends to decrease the central transmission of pain from adjacent spinal structures by closing the gate. Any therapy which induces motion into articular structures will help inhibit pain transmission by this means.”

The joint cavitation that occurs during the chiropractic adjustment is a byproduct of joint motion.

During the spinal adjustment, the primary joint to cavitate (“pop/crack”) is the facet (zygapophyseal) joint. Consequently, the adjustment and cavitation influence the facet joint capsular ligaments and the capsule’s neurology, as well as other effects on the joint’s muscles and cartilage.

Pain is an electrical signal that is sent to the brain. The pain electrical signal is carried into the brain by nerves. Therefore, the origin of the pain electrical signal must have a nerve supply. Every structure in the neck that has a nerve supply has the potential to cause pain.

In 1982 it was definitively established that the cervical spine facet joints are innervated with nociceptors, thus allowing the facet capsules to be a source of neck pain (2). By 1988, it became clear that the cervical spine facet joints were in fact a common source of neck pain (3). By 1992, it was established that the cervical spine facet joints were indeed the primary source of neck pain (4). This was confirmed in 2011 (5).

Cervical Spine Segmental Axial View

The facet joint capsule has nociceptors “R” which are connected to the brain through the medial branches of the posterior primary rami through the spinal cord.

The primary reason that people go to chiropractors is for the management of spine pain (6):

• 63% of chiropractic patients seek care for lower back pain
• 30% of chiropractic patients seek care for neck pain

Incredibly, 91% of these patients report acceptable positive clinical outcomes to chiropractic care for these complaints (6).

The percentage of individuals seeking chiropractic care for low back pain (63%) more than doubles the percentage of individuals seeking chiropractic care for neck pain (30%). Therefore, published studies and clinical practice guidelines have emphasized low back problems. Many of the recommendations for the management of patients with neck pain have been extrapolated from the low back pain literature, which may be inappropriate.

For low back pain, current recommendations from the Centers for Disease Control and Prevention (CDC) (7) and the American College of Physicians (ACP) (8, 9) for patients with low back pain favor non-pharmacological management as front-line treatment. It is clear that these non-drug management services are commonly offered by chiropractors.

The social and economic burdens of neck pain are immense, and neck pain is regarded as a major public health problem. Approximately half of all individuals will experience a clinically important neck pain episode over the course of their lifetime (10, 11).

The health care system entry point (ie, the type of provider a patient sees first) for an episode of low back pain affects downstream health care utilization and costs (12, 13, 14, 15). Presently, there is no consensus regarding the optimal provider to begin an episode of neck pain care, and hence it is unknown if first provider consulted for an episode of neck pain influences the long-term utilization of health care utilization and costs. Yet, a number of studies have compared the clinical outcome and service utilization between various providers for patients suffering with neck pain:

••••••••••

In 1996, a study was published in the journal Injury titled (16):

Chiropractic Treatment of Chronic ‘Whiplash’ Injuries

The 28 patients in this study had initially been treated with anti-inflammatory drugs, soft collars and physiotherapy. These patients had all become chronic, and were referred for chiropractic at an average of 15.5 months (range was 3–44 months) after their initial injury.

Following chiropractic 93% of the patients had improved. These authors state:

“The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic whiplash injury.”

•••••••••••

In 2002, a study was published in the Annals of Internal Medicine, and titled (17):

Manual Therapy, Physical Therapy, or Continued Care by a
General Practitioner for Patients with Neck Pain:
A Randomized Controlled Trial

In this study, the authors compared the effectiveness of manual therapy, physical therapy, and care by a general practitioner (pharmacology) in the treatment of neck pain. They used a randomized controlled trial design. The study involved 183 patients. These authors concluded:

“Manual therapy scored consistently better than the other two interventions on most outcome measures.”

“In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.”

“The success rates for manual therapy were statistically significantly higher than those for physical therapy.”

“Manual therapy scored better than physical therapy on all outcome measures…”

“Range of motion improved more markedly for those who received manual therapy or physical therapy than for those who received continued care.”

“The postulated objective of manual therapy is the restoration of normal joint motion, which was achieved, as indicated by the relatively large increase in the range of motion of the cervical spine.”

“Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care.”

“Manual therapy seems to be a favorable treatment option for patients with neck pain.”

“Primary care physicians should consider manual therapy when treating patients with neck pain.”

••••••••••

In 2004, the American Academy of Orthopaedic Surgeons published a monograph titled Neck Pain (18). Chapter seven of the reference is titled “Manual Therapy Including Manipulation for Acute and Chronic Neck Pain.” This chapter is authored by a chiropractor and details the benefits of chiropractic spinal manipulation for the management of neck pain.

••••••••••

Also in 2004, the Journal of Whiplash & Related Disorders published a study titled (19):

Manipulative Treatment vs. Conventional Physiotherapy Treatment
in Whiplash Injury:  A Randomized Controlled Trial

This study assessed 380 acute whiplash injured patients. They found that manipulation therapy was superior to physical therapy (active exercises, electrotherapy, ultrasound therapy and diathermy). Specifically, spinal manipulation achieved a superior result in fewer patient visits as compared to the physical therapy group. The authors state:

“Patients who had received manipulative treatment needed fewer sessions to complete the treatment than patients who had received physiotherapy treatment.”

“Results showed that the manipulative group had more benefits than the physiotherapy group.”

“Our clinical experience with these patients [whiplash-injured] has demonstrated that manipulative treatment gives better results than conventional physiotherapy treatment.”

“This clinical trial has demonstrated that head and neck pain decrease with fewer treatment sessions in response to a manipulative treatment protocol as compared to a physiotherapy treatment protocol among patients diagnosed with acute whiplash injury.”

“Manipulative treatment is more effective in the management of whiplash injury than conventional physiotherapy treatment.”

••••••••••

A related and important study pertaining to neck pain and manipulation was published in 2015 in the Journal of Manipulative and Physiological Therapeutics and titled (20):

Prognostic Factors for Recurrences in Neck Pain Patients
Up to One Year After Chiropractic Care

This is a prospective cohort study assessing 545 neck pain patients. After a course of chiropractic, they were followed up for one year regarding recurrence of neck pain. The results of this study are impressive:

• Fifty-four (54) participants (11%) were identified as “recurrent.”
• Four hundred ninety-one (491) participants (89%) were not recurrent.

These authors concluded:

“The results of this study suggest that recurrence of neck pain within one year after chiropractic intervention is low.”

This study indicates that chiropractic is effective in the treatment of neck pain and that its benefits are stable and long lasting.

•••••••••

In 2017, a study was published in the journal Mayo Clinic Proceedings and titled (21):

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

The authors of this study were from the Department of Orthopaedic Surgery, Physical Therapy Division, Duke University, and from the Department of Physical Therapy, University of Utah. The authors note:

“It is imperative to evaluate the difference in health care process and outcomes in patients initially consulting with non-pharmacological providers (ie, chiropractors [DCs] and physical therapists [PTs]) and pharmacological providers (ie, specialists [such as physiatrists and neurologist]) in comparison to PCPs.”

This study looked at a cohort of patients seeking care for a new episode of neck pain to determine the association of the initial health care provider consulted and subsequent health care utilization. The health care utilization was assessed at 14 days, 30 days, and 1 year from the initial visit between various providers. The health care utilization assessed included:

• Imaging (MRI, computed tomography, radiography)
• Opioids
• Surgery (spinal arthrodesis, discectomy, laminectomy, or fusion)
• Injections (including nerve blocks)

The study used a retrospective cohort of 1,702 patients (69% women) with a new episode of neck pain who consulted a primary care provider (PCP), physical therapist (PT), chiropractor (DC), or specialist:

• PCP 44%
• DC 23%
• PT 17%
• Specialist (physiatrists, neurologist])16%

The authors also note:

“These specific provider types were included in the analysis because they are the most common providers consulted for neck pain.” 

This is important, as it indicates that chiropractors are the second most consulted provider for neck pain.

The outcomes from this study are summarized as follows:

The Use of Interventions Compared to Primary Care Providers

 

Based upon these results, the authors make the following important observations:

“Physical therapists and chiropractors primarily treat neck pain with exercise therapy and manual therapy, which has been found to have good effectiveness in treating nonspecific neck pain.”

In contrast, “primary care provider’s first line of treatment often includes medication, imaging, specialist referral, or a combination of those factors.”

“Initial consultation from either a chiropractor or physical therapist decreases the patient’s odds of being prescribed an opioid at 30 days or within any time in the 1-year follow-up period.”

Compared with initial consultation with a primary care provider, the odds of undergoing advanced imaging (MRI or computed tomography) within 1 year “was reduced when the initial provider was a chiropractor and increased when the initial provider was a specialist or a physical therapist.”

“When patients in the sample initially consulted with a chiropractor, the odds of MRI use decreased compared with consulting with a primary care provider.”

“We found that initial consultation with a non-pharmacological provider, such as a chiropractor or physical therapist, is associated with a decrease in the downstream utilization of health care services, and importantly a decrease in opioid use 30 days and 1 year after the initial consultation.”

“Initiating care with a specialist was associated with an increase in the odds of receiving spinal injections and undergoing MRI and radiography and had the highest percentage of patients undergoing surgery.”

“Initially consulting with a specialist for a new episode of neck pain appears to escalate the level of care patients with neck pain receive.”

“These findings support that initiating care with a non-pharmacological provider for a new episode of neck pain may present an opportunity to decrease opioid exposure (chiropractor and physical therapist) and advanced imaging and injections (chiropractor only).”

Pertaining to chiropractors and the use of spinal x-rays, these authors make these observations:

“Radiographic studies have been a longstanding mainstay of chiropractic practice.”

“Radiography is routinely ordered as part of a [chiropractic] treatment plan and is often performed at the initial visit.”

“It is plausible that the use of radiography may have paradoxically shielded patients from undergoing more advanced imaging such as MRI.”

“When a provider orders imaging, this can alleviate patients’ concern about serious pathology, despite a lack of evidence for clinical utility in routine care of patients with neck pain.” 

The authors note that there are important practice and policy implications for the findings of this study.  Current recommendations favor initial front-line use of non-pharmacological management for patients with neck pain.  Yet, “many systems are not structured to provide care in this manner.” They state:

“Stronger alignment of physical therapists and chiropractors as front-line providers by health care systems may be needed in light of the widespread [drug] addiction, which has been identified as a public health epidemic.”

The public health epidemic of addiction to opioid drugs is particularly concerning, further emphasizing the need for non-drug approaches for neck pain. The authors commented that in addition to the decrease in odds of opioid prescription within 30 days of initial consultation of a non-drug provider, that this same decrease in odds persisted through the one-year follow-up assessment. This suggests that the clinical benefits from being managed by a non-drug provider resulted in a lasting protective influence in the treatment of neck pain.

THE IMPORTANCE OF CHIROPRACTIC

Compared to primary care physicians:

Chiropractors are the next most often consulted health care provider for the treatment of an acute episode of neck pain.

In every assessed parameter, chiropractic had the best outcomes, specifically:

• lowest rate of opioid prescription
• lowest use of advanced imaging
• lowest use of x-rays
• lowest referrals for injections
• lowest use (referrals) for surgery (in fact the number was zero).

These authors believe that practice guidelines should reflect their results and that healthcare systems and reimbursements should emphasize non-drug approaches to neck pain management.

These authors note that low back pain guidelines already advocate non-drug interventions as the primary approach and suggest that neck pain guidelines should “catch-up” with that perspective.

Ironically, these authors note that chiropractors are noted for the frequent use of spinal x-rays. 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 monetary, time, and personnel resources.

REFERENCES:

1. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
2. Bogduk N; The clinical anatomy of the cervical dorsal rami; Spine; 1982 Jul-Aug; Vol. 7; No. 4; pp. 319-330.
3. Bogduk N, Marsland A; The cervical zygapophysial joints as a source of neck pain; Spine; June 1988 Jun; Vol. 13; No. 6; pp. 610-617.
4. Bogduk N, Aprill C; On the nature of neck pain, discography and cervical zygapophysial joint blocks; Pain; August 1993; Vol. 54; No. 2; pp. 213-217.
5. Nikolai Bogduk; On Cervical Zygapophysial Joint Pain After Whiplash; Spine; December 1, 2011; Vol. 36; No. 25S; pp. S194–S199.
6. 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.
7. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016; Journal of the American Medical Association; April 19 2016; Vol. 315; No. 15; pp. 1624-1645.
8. 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.
9. Chou R, Deyo R, Friedly J, et al; Nonpharmacologic 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.
10. Fejer R, Kyvik KO, Hartvigsen J; The prevalence of neck pain in the world population: a systematic critical review of the literature; European Spine Journal; 2006; Vol. 15; No. 6; pp. 834-848.
11. Goode AP, Freburger J, Carey T; Prevalence, practice patterns, and evidence for chronic neck pain; Arthritis Care Res; 2010 Vol. 62; No. 11; pp. 1594-1601.
12. Hurwitz EL, Li D, Guillen J, et al; Variations in patterns of utilization and charges for the care of neck pain in North Carolina, 2000 to 2009: a statewide claims’ data analysis; Journal of Manipulative and Physiological Therapeutics; 2016; Vol. 39; No. 4; pp. 240-251.
13. Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KCG, Franklin GM; Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State; Spine; May 15, 2013; Vol. 38; No. 11; pp. 953-964.
14. Fritz JM, Kim J, Dorius J; Importance of the type of provider seen to begin health care for a new episode low back pain: associations with future utilization and costs; Journal of Eval Clinical Practice; 2016; Vol. 22; No. 2; pp. 247-252.
15. Blanchette AM, Rivard M, Dionne CE, Hogg-Johnson S, Steenstra I; Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain; Journal of Occupational Rehabilitation; September 2017; Vol 27; No. 3; pp. 382-392.
16. Woodward MN, Cook JCH, Gargan MF, Bannister GC; Chiropractic treatment of chronic ‘whiplash’ injuries; Injury; November 1996; Vol. 27; No. 9; pp. 643-645.
17. 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.
18. Fischgrund JS; Neck Pain, Monograph 27, American Academy of Orthopaedic Surgeons; 2004.
19. 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.
20. Langenfeld A, Humphreys K, Swanenburg J, Cynthia K. 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.
21. 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.

The primary reason that people go to chiropractors is for the management of spine pain. Sixty-three percent of chiropractic patients seek care for lower back pain. Thirty percent seek care for neck pain (1). Incredibly, surveys report that ninety-one percent of these patients report acceptable positive clinical outcomes to chiropractic care for these complaints (1).

Published clinical outcomes (as contrasted to surveys) are also supportive of the benefits of chiropractic for back and neck pain. As an example, a 1985 study involving 283 chronic, disabled, treatment resistant low back and leg-pain patients who were referred for chiropractic spinal manipulation showed that eighty-one percent of those without compressive neuropathology had their symptoms essentially resolve and they returned to full activity levels (2). Forty-eight percent of those with compressive neuropathology achieved similar outcomes (2).

In another series of patients with chronic neck and back pain of more than eight years duration, a nine-week trial of chiropractic spinal manipulation (two visits weekly) resulted in the resolution of all signs and symptoms in twenty-seven percent of the patients (3). Three additional observations were found from this study pertaining to the management of chronic back and neck pain:

• Chiropractic spinal adjusting was better than five time more effective in treating chronic back and neck pain as compared to the best prescription non-steroidal anti-inflammatory drugs (NSAIDs).
• Chiropractic spinal adjusting was about three times more effective in treating chronic back and neck pain as compared to needle acupuncture.
• Compared to prescription NSAIDs and needle acupuncture, chiropractic spinal manipulation was the only intervention that showed long-term (one year later) stable therapeutic benefit (4).

As a consequence of this, it is not surprising that modern clinical practice guidelines for the management of acute, subacute, and chronic back pain advocate the use of chiropractic spinal manipulation (5, 6, 7, 8).

••••••••••

An observed complication of the successful management of chronic spine pain, particularly chronic low back pain, is the recurrence rate (9, 10). Although it is commonly thought and claimed that about ninety percent of low back pain permanently resolved, this is not apparently the case.

A study on this topic was published in 1998 in the British Medical Journal and titled (9):

Outcome of Low Back Pain in General Practice:
A Prospective Study

This was a prospective study of 463 adult low back pain subjects who were followed for twelve months. The authors found that seventy-five percent of these subjects still had back problems a year later.

A related study was published in 2012 in the journal Physical Medicine and Rehabilitation, and titled (10):

Is It Time to Rethink the Typical Course of Low Back Pain?

These authors published an analysis of a survey administered to 590 subjects from 30 separate clinical practices pertaining to low back pain. Their findings include:

“Recurrent LBP episodes were common and numerous. Recurrences often worsened over time”

“Recurrences of back pain are widely recognized as common, reported as occurring in 60%-73% of individuals within 1 year after recovery from an acute episode.”

These authors suggest that there may be an underlying biomechanical cause for recurrences of low back pain that may be suboptimally managed. They also note that eighty-four percent of total costs for patients with low back pain are related to a recurrence.

••••••••••

A number of published investigations have assessed the potential for maintenance chiropractic spinal manipulation as an intervention that may reduce the incidence of recurrences of low back pain (11, 12, 13, 14). Maintenance care is the advising of the patient to return for more treatment even tough the initial signs and symptoms have either resolved or have achieved maximum improvement.

A theoretical academic basis for the use of maintenance chiropractic manipulation was published in 2011 in the Journal of Chiropractic Humanities and titled (11):

A Theoretical Basis for Maintenance
Spinal Manipulative Therapy
for the Chiropractic Profession

The author notes that the purpose of chiropractic maintenance care is to optimize spinal function and decrease the frequency of future episodes of back pain.

A search of PubMed and of the Manual, Alternative, and Natural Therapy Index System was performed with a combination of key words: chiropractic, maintenance and wellness care, maintenance manipulative care, preventive spinal manipulation, hypomobility, immobility, adhesions, joint degeneration, and neuronal degeneration, 1970-2011. The search revealed surveys of doctors and patients, an initial clinical pilot study, randomized control trials, and laboratory studies that provided correlative information to provide a framework for development of a hypothesis for the basis of maintenance spinal manipulative therapy. The author states:

“It is hypothesized that because spinal manipulative therapy brings a joint to the end of the paraphysiological joint space to encourage normal range of motion, routine manipulation of asymptomatic patients may retard the progression of joint degeneration, neuronal changes, changes in muscular strength, and recruitment patterns, which may result in improved function, decreased episodes of injuries, and improved sense of well-being.”

The author cites published surveys indicating that over ninety percent of chiropractors opined that the purpose of maintenance care was to minimize recurrences or exacerbations. Ninety-five percent of chiropractors recommended maintenance care to minimize recurrences or exacerbations of conditions. In a study of ninety-six percent of elderly patients who received maintenance care believed that it was “either considerably or extremely valuable.”

This author further states:

“It has been reported that 79% of patients in chiropractic offices are recommended maintenance care and nearly half of those patients elect to receive these services.”

Evidence “clearly demonstrates that the clinical consensus of dosage of maintenance manipulative therapy has been found to be most beneficial at an average of once every 2 to 4 weeks.”

“Taking into account the neurological and biomechanical consequences of manipulative therapy, it is plausible to hypothesize that monthly manipulative therapy retards the progression of adhesion formation, joint degeneration, neuronal changes, and changes in muscular strength and recruitment patterns. This could result in improved function, decreased episodes of injuries, and improved sense of well-being.”

A 2004 chiropractic study of chronic low back pain showed that the group of patients who received 9 months of maintenance manipulation at the frequency of once per every 3 weeks maintained their initial clinical improvement while the control group returned to their previous levels of disability. The authors “concluded that there were positive effects of preventive maintenance chiropractic spinal manipulation in maintaining functional capacities and reducing the number and intensity of pain episodes after the acute phase of treatment of low back pain patients.”

“There is a common thread of the time dependency noted in all the laboratory and clinical studies. The periods of onset of the anatomical and physiological changes ranged from 2 to 4 weeks. The clinical studies also provided manipulation every 4 weeks and noted positive changes in the pain and disability measures. This time interval also correlates with the common recommendations found in the surveys of chiropractic physicians.”

••••••••••

Physician Manuel Cifuentes, MD, published another pertinent study on this topic in 2011. It was published in the Journal of Occupational and Environmental Medicine, and titled (12):

Health Maintenance Care in Work-Related Low Back Pain
and its Association With Disability Recurrence

The objective of this study was to compare occurrence of repeated disability episodes across types of health care providers (medical physician, physical therapists, chiropractor) who treat claimants with new episodes of work-related low back pain. A total of 894 cases were followed for 1-year using workers’ compensation claims data. Provider types were defined for the initial episode of disability and subsequent episode of health maintenance care.

The authors note that an important component of the human and economic costs for low back pain are the recurrence rate. They state:

“Health maintenance care is a clinical intervention approach thought to prevent recurrent episodes of LBP. It conceptually refers to the utilization of health care services with the aim of improving health status and preventing recurrences of a previous health condition.” Health maintenance care is defined as “treatment. . . after optimum recorded benefit was reached.” 

The authors note that chiropractors are the only group of providers who explicitly state that they have an effective treatment approach to maintain health with “maintenance “care. They also noted that chiropractic patients had “less expensive medical services and shorter initial periods of disability than cases treated by other providers.” Also, chiropractic patients had “fewer surgeries, used fewer opioids, and had lower costs for medical care than the other provider groups.”

These authors noted:

“After controlling for demographics and severity indicators, the likelihood of recurrent disability due to LBP for recipients of services during the health maintenance care period by all other provider groups was consistently worse when compared with recipients of health maintenance care by chiropractors.”

“After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type.”

“After controlling for severity and demographics, no health maintenance care is generally as good as chiropractor care.”

“Our findings seem to support the use of chiropractor services, as chiropractor services generally cost less than services from other providers.”

In this study, the chiropractic patients who did suffer a recurrence did so 29 days later than the physical therapy or physician patients who suffered a recurrence. The authors speculate that the main advantage of chiropractors could be based on the dual nature of their practice, involving both regular care plus maintenance care. Chiropractic appears to be an “important advancement” in the treatment of work-related back injuries.

This study certainly supports the concept and value of chiropractic maintenance care.

••••••••••

Physician Mohammed K. Senna, MD, and colleague published another important study on this topic in 2011. It appeared in the journal Spine, and was titled (13):

Does Maintained Spinal Manipulation Therapy for
Chronic Nonspecific Low Back Pain
Result in Better Long-Term Outcome? Randomized Trial

This study is a prospective single blinded placebo controlled study that was conducted to assess the effectiveness of spinal manipulation therapy for the management of chronic nonspecific low back pain, and to determine the effectiveness of maintenance spinal manipulation in long-term reduction of pain and disability levels associated with chronic low back conditions.

Sixty patients with chronic, nonspecific low back pain lasting at least 6 months, were randomized to receive either:

• 12 treatments of sham spinal manipulation over a 1-month period
• 12 treatments consisting of spinal manipulation over a 1-month period
• 12 spinal manipulation treatments over a 1-month period plus maintenance spinal manipulation every two weeks for the following nine months

The spinal manipulation was defined as a “high velocity thrust to a joint beyond its restricted range of movement.”

Follow-up evaluations occurred at 1-, 4-, 7-, and 10-months. These assessments included:

• Pain, using the Visual Analog Scale (VAS)
• Disability, using the Oswestry Disability Questionnaire
• Generic health, using the 36-Item Short Form Health Survey (SF-36)

The authors made these observations:

The disability and pain scores in this study “are significantly reduced in the short-term evaluation—but not in long-term—when compared with the sham manipulation.”

Patients receiving real manipulation “experienced significantly lower pain and disability scores” than patients receiving sham manipulation at the end of 1-month.

“In the non-maintained spinal manipulation group, the mean pain and disability scores returned back near to their pretreatment level.”

“Spinal manipulation is effective for the treatment of chronic nonspecific of low back pain. To obtain long-term benefit, this study suggests maintenance spinal manipulation after the initial intensive manipulative therapy.”

“One possible way to reduce the long-term effects of low back pain is maintenance care (or preventive care).”

“To obtain long-term benefit, this study suggests maintenance spinal manipulation after the initial intensive manipulative.”

This study also supports the concept and value of chiropractic spinal manipulation maintenance care.

Pain (VAS) For The 3 Groups Over 10 Months

Disability (Oswestry) For The 3 Groups Over 10 Months

••••••••••

Most recently (September 2018), researchers from Sweden and Denmark published a study in the journal Public Library of Science (PLoS) One, titled (14):

The Nordic Maintenance Care program:
Effectiveness of Chiropractic Maintenance Care Versus
Symptom-Guided Treatment for Recurrent and
Persistent Low Back Pain:
A Pragmatic Randomized Controlled Trial

The aim of this trial was to investigate the effectiveness of chiropractic maintenance care on pain for patients with recurrent or persistent low back pain. It was an investigator-blinded, randomized controlled trial using 328 subjects aged 18-65 years, with non-specific low back pain, who had an early favorable response to chiropractic care.

If the initial course of chiropractic care (4 visits) resulted in substantial improvements in low back pain, the subjects were randomized to either maintenance chiropractic care (163 subjects) or not (control group, 158 subjects). The study used 35 chiropractic clinicians with mean number of years in practice of 17.9, ranging from 1 to 38 years.

The primary outcome was total number of days with bothersome low back pain during 52 weeks. The status was collected weekly via text messages.

The authors note that low back pain is often recurrent and has a large negative impact on society. Consequently, focusing on preventive strategies for recurrent low back pain is logical. “This is one of the first studies to test the effect of preventive manual care performed by chiropractors (maintenance care) for recurrent and persistent low back pain.”

The authors use two definitions for maintenance care:

• “. . .a regimen designed to provide for the patient’s continued well-being or for maintaining the optimum state of health while minimizing recurrences of the clinical status”
• “. . .treatment, either scheduled or elective, which occurred after optimum recorded benefit was reached, provided there was no evidence of relapse”

Chiropractors have traditionally used maintenance care as a prevention strategy against new episodes of low back pain, or in reducing the impact of a new episode of low back pain. Maintenance chiropractic care may improve biomechanical and neuromuscular function and address psychosocial issues, thereby reducing the risk of relapse into pain. “It is common for chiropractors to recommend maintenance care, i.e. preventive consultations/visits for recurrent and persistent musculoskeletal pain and dysfunction.”

About one fifth of all visits to Scandinavian chiropractors are maintenance care visits and 98% of Swedish chiropractors use the approach to some extent. The authors make these comments:

“Non -specific low back pain is one of the most common and costly healthcare problems in society today.”

“The burden of disabling low back pain on individuals, families, communities, industries and societies is substantial and is now the leading cause of activity limitation and work absence in the world.”

“Chiropractors are trained to assess and treat disorders of the musculoskeletal system, of which low back pain is the most common.”

“The majority of patients seeking chiropractic care receive some form of manual therapy, of which spinal manipulation and mobilization are the most common, often along with advice on exercise.”

“Chiropractic maintenance care resulted in a reduction in the total number of days per week with bothersome low back pain compared with symptom-guided treatment.” 

The maintenance group had a faster reduction in days with bothersome low back pain and reached a lower steady state earlier.

Maintenance chiropractic care was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific low back pain, and it only resulted in a higher number of treatments by 1.7. (less than two visits)

Maintenance chiropractic care should be considered an option for tertiary prevention of low back pain.

The maintenance chiropractic care group “improved faster and achieved the steady state phase earlier with a lower mean number of days with low back pain per week.”

“The treatment was not reported as being linked to any serious harm and both the intervention and the control regimes must be considered safe treatments.”

SUMMARY

The increasing range of published studies supporting chiropractic manipulation for the management of musculoskeletal pain complaints, especially for low back and neck pain, is gaining global notice and acceptance. This review adds that perhaps there is also mounting support for the use of chiropractic manipulation for maintenance care as well.

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. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. Croft PR, Macfarlane GF, Papageorgiou AC, Thomas E, Silman AJ; Outcome of low back pain in general practice: A prospective study; British Medical Journal; May 2, 1998; Vol. 31; pp. 1356-1359.
10. Donelson R, McIntosh G; Hall H; Is It Time to Rethink the Typical Course of Low Back Pain? Physical Medicine and Rehabilitation (PM&R); June 2012; Vol. 4; No. 6; pp. 394–401.
11. Taylor DN; A theoretical basis for maintenance spinal manipulative therapy for the chiropractic profession; Journal of Chiropractic Humanities December 2011; Vol. 1; No. 1; pp. 74-85.
12. 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, 2011; Vol. 53; No. 4; pp. 396-404.
13. Senna MK, Shereen A, 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.
14. Eklund A, Jensen I, Lohela-Karlsson M, Hagberg J, Leboeuf-Yde C, Kongsted A, Bodin L, Axen I; The Nordic Maintenance Care program: Effectiveness of Chiropractic Maintenance Care Versus Symptom-Guided Treatment for Recurrent and Persistent Low Back Pain: A Pragmatic Randomized Controlled Trial; Public Library of Science (PLoS) One; September 12, 2018; Vol. 13; No. 9; e0203029

Pain is a huge problem in America. Approximately half of adults in America suffer from chronic pain (1).

Classic, uncomplicated pain starts in peripheral tissues, initiating an electrical signal that travels along the pain nerve (nociceptor) to the brain. Pain is an electrical signal interpreted by the brain.

The primary reason for the initiation of pain from the peripheral tissue is inflammation (2). Consequently, minimizing and/or treating peripheral inflammation is an important approach in pain management.

The primary source of chronic lower back pain is the annulus of the disk (3, 4). The primary source of chronic neck pain is the facet joint capsule (5, 6).

It is well understood and accepted that the pain electrical signal, on its pathway from the inflamed peripheral tissue to the (parietal) brain, also communicates with the limbic (emotional) brain. Consequently, in addition to hurting, pain also causes suffering and emotional problems, such as depression (7):

The observations that chronic pain patients also have abnormal psychological profiles have led to much controversy, centering around two questions. These questions are essentially similar to the age-old question:

What comes first, the chicken or the egg?

The questions are:

Does an abnormal psychological profile cause chronic pain?

OR

Does chronic pain cause an abnormal psychological profile?

An answer to this question was provided, using primary research and gold-standard protocols by a team of well-respected researchers. Their study appeared in the journal Pain in 1997, and was titled (8):

Resolution of Psychological Distress of Whiplash Patients
Following Treatment by Radiofrequency Neurotomy:
A Randomized, Double-Blind, Placebo-Controlled Trial

The authors sought to evaluate:

• The psychological model of chronic neck pain: whether psychological distress precedes and causes the chronic pain

or

• The medical model : whether the psychological distress is a consequence of chronic pain.

The study used 17 neck pain subjects who were assessed and treated using a randomized, double-blind, placebo-controlled approach. All subjects were found to have a single painful zygapophysial joint, diagnosed by double-blind, placebo-controlled cervical medial branch blocks (see drawing).

Nine of the study subjects were treated with radiofrequency neurotomy (treatment group). Eight of the subjects (the placebo group) were similarly treated, but the machine was not turned on.

The facet joint has nociceptors “R” which are connected to the brain through the medial branches of the posterior primary rami .

Diagnostic anesthetic blocking of the medial branch of the posterior primary rami eliminated the neck pain in all 17 study subjects, indicating the facet is the source of their neck pain.

Radiofrequency neurotomy of the facet joint capsules coagulates the neurofiliment proteins, eliminating the pain in all such treated subjects.

The authors evaluated these subjects using three measurement tools:

• The SCL-90-R psychological profile
• The McGill Pain Questionnaire
• The visual analogue pain scale

The authors state the following:

• The SCL-90-R psychological symptom checklist is a suitable tool to measure psychological distress in patients with chronic pain.
• There is little evidence of useful clinical improvement following psychological treatment in chronic pain patients. Even when psychological improvement has been demonstrated, it has not been associated with a clinically useful degree of pain reduction, let alone complete relief of pain. At best, psychological interventions enable patients to return to work in spite of their pain.
• Percutaneous radiofrequency neurotomy is a 3 hour long, local anesthetic, operative neuroablative procedure which provides long-term, complete pain relief by coagulating the nerves that innervate the painful zygapophysial joint. This neurosurgical procedure has been validated in a randomized, double-blind, placebo-controlled study.
• Radiofrequency neurotomy does not effect a permanent cure. It provides long-term pain relief, from months to years. Recurrence of the pain is natural as the coagulated nerve heals.

Three months after the intervention, all of the treatment group subjects were pain free. Importantly, they all also exhibited resolution of their psychological distress. In contrast, the placebo group did not have lessened pain, and their psychological distress remained unchanged. The authors stated:

“The association between complete relief of pain and resolution of psychological distress was very strong.”

With time (months), as expected, as the treated nerve healed, the subject’s pain returned. With the return of their pain, their psychological distress also returned. A second radiofrequency neurotomy on these subjects once again relieved their pain and their psychological distress. The authors state:

“As their original pain recurred, so did their psychological distress, but when successful active neurosurgical treatment again achieved pain relief, the psychological distress was again resolved.”

“None of the patients received any formal psychological therapy. The only intervention was the operative procedure. Therefore, such changes in the psychological profile as were observed can only be ascribed to the neurosurgical intervention.”

The results of this study clearly refute the psychological model , which would have predicted that because no psychological intervention was administered, no patient should have exhibited improvement in either their pain or psychological status. Yet, the treated subjects exhibited complete resolution of psychological distress. The authors state:

“This result calls into question the present nihilism about chronic pain, that proclaims medical therapy alone to be ineffectual, and psychological co-therapy to be imperative.”

These authors concluded:

“All patients who obtained complete pain relief exhibited resolution of their pre-operative psychological distress.”

“In contrast, all but one of the patients whose pain remained unrelieved continued to suffer from psychological distress.”

“Because psychological distress resolved following a neurosurgical treatment which completely relieved pain, without psychological co-therapy, it is concluded that the psychological distress exhibited by these patients was a consequence of the chronic somatic pain.”

There is no doubt or argument that chiropractic care is both scientific and helps the majority of people with spine pain syndromes. As an example, Dr. Kirkaldy-Willis was a Professor Emeritus of Orthopedics and director of the Low-Back Pain Clinic at the University Hospital, Saskatoon, Canada. In 1985 he stated (9):

“Spinal manipulation, one of the oldest forms of therapy for back pain, has mostly been practiced outside of the medical profession.”

“Over the past decade, there has been an escalation of clinical and basic science research on manipulative therapy, which has shown that there is a scientific basis for the treatment of back pain by manipulation.”

“Most family practitioners have neither the time nor inclination to master the art of manipulation and will wish to refer their patients to a skilled practitioner of this therapy.”

More recently Jon Adams, PhD, and colleagues used the National Health Interview Survey to determine the present state of chiropractic in the United States. The aim of their study was to investigate the lifetime and 12-month prevalence, patterns, and predictors of chiropractic utilization in the US general population. Their findings were published in the journal Spine in December 2017 (10).

The authors note that chiropractors use manual therapy to treat musculoskeletal and neurological disorders. They state:

“Back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being.”

“A substantial proportion of US adults utilized chiropractic services during the past 12 months and reported associated positive outcomes for overall well-being and/or specific health problems for which concurrent conventional care was common.”

“Many respondents reported positive outcomes of chiropractic utilization agreeing that such care had helped them to improve overall health and make them feel better (66.9%), to sleep better (41.9%), and to reduce stress or to relax (40.2%).”

“Back pain or back problems (63.2%) and neck pain or neck problems (30.2%) were by far the top specific health problems for which people consulted a chiropractor in the past 12 months, followed by joint pain/stiffness (13.6%) and other pain conditions. Around two in three users (64.5%) reported that chiropractic had helped a great deal to address these health problems.”

“Our analyses show that, among the US adult population, spinal pain and problems – specifically for back pain and neck pain – have positive associations with the use of chiropractic.”

“The most common complaints encountered by a chiropractor are back pain and neck pain and is in line with systematic reviews identifying emerging evidence on the efficacy of chiropractic for back pain and neck pain.”

“Chiropractic services are an important component of the healthcare provision for patients affected by musculoskeletal disorders (especially for back pain and neck pain) and/or for maintaining their overall well-being.”

Importantly, when chiropractors treated their patients for back and/or neck pain complaints, they also noted improvements in other aspects of their well-being that could be attributed to the limbic brain:

Perhaps, as noted above (7), reducing the pain signal to the brain also reduced an adverse signal to the limbic brain.

••••••••••

Very recently (May-June 2018), a case study was published in the Journal of Family Medicine and Primary Care , titled (11):

Long-Term Relief from Tension-Type Headache
and Major Depression Following Chiropractic Treatment

This article presented a case report of a 44-year-old woman who experienced long-term relief from tension-type headaches and major depression following chiropractic treatment. The report highlights the rewarding outcomes from spinal adjustments in certain neuropsychiatric disorders.

Case Report:

• This 44-year-old female suffered with tension-type headache, daily, of 2 years duration.
• Her pain was disabling, going across the forehead to her nuchal area and right shoulder.
• She was dependent upon pharmacology. She could not maintain her daily activities without acetaminophen and aspirin.
• Blood tests, brain MRI, and cervical x-rays were all unremarkable.
• Treatment with physiotherapy, acupuncture, traditional Chinese therapy, and other drugs all failed to help or to change her headache pattern.
• She began experiencing episodes of extreme low moods, characterized by feelings of overwhelming sadness.
• She was referred to the psychiatry services and was diagnosed with a major depressive disorder.
• Six months of various drug treatments for depression failed to help her.
• Both her disabling headache and her severe depression impaired her ability to perform her job and engage in regular activities.
• Because of the stresses of her health and finances, she had recurrent thoughts of death and suicide.

Chiropractic Evaluation:

• Her headache intensity was graded as 6–8/10 on the numeric pain rating scale.
• She had decreased spinal ranges of motion in the lower cervical and upper thoracic segments.
• She had spasm of the sternocleidomastoid, suboccipital and cervical paraspinal muscles.
• The neurological findings of both upper extremities were unremarkable.

Chiropractic Treatment:

• The chiropractic strategy was to stretch and relax the spastic muscles, restore motion in the respective segments, and to rehabilitate sensorimotor integration with diversified spinal manipulation.
• The chiropractic treatment schedule is summarized in the following chart. Importantly, the authors waited six years after the resolution of signs and symptoms to publish their results. This allowed them to assess the long-term stability of their clinical outcomes. During this six-year period the patient agreed to monthly maintenance chiropractic care.

 

Clinical Outcomes:

• After 3 months (41 chiropractic visits), the patient regained confidence in her health and started reducing the dose of medications.
• At 3 months, she rated her headache as 3–5/10 on the pain scale.
• After 6 months (65 chiropractic visits) “all of her symptoms disappeared, and she was able to discontinue all medications.”
• “Having enjoyed headache free and mood stability over the past 6 years, the patient continued maintenance care on a monthly basis.”

These authors state:

“Chronic pain and depression can influence one another through complex webs of connections.”

“Psychiatric comorbidity and suicide risk are commonly found in patients with painful physical symptoms such as chronic headache, backache, or joint pain.”

Chiropractic adjustments “may lead to some therapeutic outcomes in certain neuropsychiatric disorders.”

“Chiropractic care is a way to reduce the frequency of pain, and the duration and intensity of headaches.”

“Better pain control from chiropractic care might be further beneficial for reducing depressive mood.”

In this case study, the clinical goal of the chiropractors was to help their patient with her chronic debilitating headaches. The purpose of their publication is to share adjunct benefits of successful resolution of chronic headache from chiropractic care.

SUMMARY

Chiropractors primarily treat musculoskeletal pain syndromes. Studies continue to show that for treating musculoskeletal pain syndromes, chiropractic care is effective, safe, and cost effective. Patient satisfaction levels with their chiropractic care is extremely high (10). Chiropractic care is especially helpful in chronic pain syndromes (12, 13, 14, 9).

Chronic musculoskeletal syndromes have an emotional, limbic component that can manifest as psychological signs and symptoms as well as an abnormal psychological profile. Improvements in other aspects of health and well being while receiving chiropractic care for musculoskeletal pain is a welcome addition.

REFERENCES

1. Foreman J; A Nation in Pain, Healing Our Biggest Health Problem; Oxford University Press; 2014.
2. Omoigui S; The biochemical origin of pain: The origin of all pain is inflammation and the inflammatory response: Inflammatory profile of pain syndromes; Medical Hypothesis; 2007; Vol. 69; pp. 1169–1178.
3. 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.
4. Izzo R, Popolizio T, D’Aprile P, Muto M; Spine Pain; European Journal of Radiology; May 2015; Vol. 84; pp. 746–756.
5. Bogduk N, Aprill C; On the nature of neck pain, discography and cervical zygapophysial joint blocks; Pain. August 1993; Vol. 54; No. 2; pp. 213-217.
6. Bogduk N; On Cervical Zygapophysial Joint Pain After Whiplash; Spine; December 2011; Vol. 36; No. 25S; pp. S194–S199.
7. Blair MJ, Robinson RL, Katon W, Kroenke K; Depression and Pain Comorbidity, A Literature Review; Archives of Internal Medicine; November 10, 2003; Vol. 163; No. 24; pp. 2422-2445.
8. Wallis BJ, Lord SM, Bogduk N; Resolution of Psychological Distress of Whiplash Patients Following Treatment by Radiofrequency Neurotomy: A Randomized, Double-blind, Placebo-controlled Trial; Pain; October 1997; Vol. 73; No. 1; pp. 15-22.
9. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
10. 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.
11. Chu ECP, Ng M; Long-Term Relief from Tension-Type Headache and Major Depression Following Chiropractic Treatment; Journal of Family Medicine and Primary Care May-June 2018; Vol. 7; No. 3; pp. 629-631.
12. Meade TW, Dyer S, Browne W, Townsend J, Frank OA; Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatient treatment; British Medical Journal; Volume 300, June 2, 1990; pp. 1431-1437.
13. …; Chiropractors and Low Back Pain; Lancet; July 28, 1990; p. 220.
14. Woodward MN, Cook JCH, Gargan MF, Bannister GC; Chiropractic treatment of chronic ‘whiplash’ injuries; Injury; November 1996; Vol. 27; No. 9; pp. 643-645.

There are 18 chiropractic colleges in the United States. There are 227 Physical Therapy Schools in the United States. All of these educational programs are accredited by the United States Department of Education.

Chiropractic and Physical Therapy are separate professions. Legally, they have different licensing requirements, testing, and different oversight boards. Yet, there are many overlaps in the education of chiropractors and physical therapists. Consequently, there are overlaps in the practice of chiropractic and physical therapy. These overlaps are officially within the scope of practice of both professions.

Traditionally, physical therapy uses modalities (electrical and others), physical interventions (tissue work, massage, stretching, etc.), orthopedic appliances (braces, supports, etc.) and advice (exercise, ergonomics, etc.) to address different stages of a pathophysiological process. Chiropractors are similarly trained in the use of these modalities and approaches, and hence they are legal components of chiropractic clinical practice. However, the primary clinical emphasis of chiropractic is different than that of physical therapy. Chiropractic clinical practice emphasizes joint (primarily spinal) manipulation.

Spinal manipulation uses the vertebrae (usually the transverse and/or spinous process) as a lever to influence tissue integrity and improve the movement parameters of spinal articulations. It is established that joint manipulation can influence a larger range of tissue problems than exercise or mobilization techniques. Hence, joint manipulation is able to help a larger range of musculoskeletal problems, especially in more chronic cases (1, 2, 3, 4, 5, 6). These improvements are achieved quickly and simply, and without injury risk. The musculoskeletal benefits of joint manipulation tend to be long lasting (7, 8).

Over the decades, there have been a number of studies comparing traditional physical therapy clinical practice to traditional chiropractic clinical practice (joint manipulation), including:

In 1969, a study was published in The Australian Journal of Physiotherapy, titled (9):

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

This is the first study to compare the results of effectiveness for low back and leg pain treated with mobilization/manipulation compared to those treated with heat, massage and exercise. The study used 184 subjects, half were treated with heat/massage/exercise and half were treated with mobilization/manipulation. A “good” and “satisfactory” result meant that the patient could discontinue treatment and return to work. The outcomes are summarized as follows:

The author concluded:

The results “indicate that treatment of low back pain and pain resulting from low back conditions by passive movement techniques of mobilization and manipulation is a more satisfactory method than by standard physiotherapy of heat, massage, and exercise, in regards to both results and number of treatments required.”

“The survey also indicated that by using techniques of mobilization good results can be obtained with patients even if neurological signs are present.”

This study by Edwards was reviewed in the 1990 reference text, White and Panjabi’s Clinical Biomechanics of the Spine. Drs. White and Panjabi make the following points pertaining to the Edwards article (10):

“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.”

It is usual for pain that travels further down an extremity to be associated with greater compression, or a larger disc protrusion. In this study by Edwards, manipulation worked excellently in patients with leg pain radiation, especially when compared to heat/massage/exercise.

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In 1990, a study was published in the British Medical Journal, titled (11):

Low Back Pain of Mechanical Origin:
Randomized Comparison of Chiropractic
and Hospital Outpatient Treatment

This study was a randomized comparison of chiropractic and hospital (physical therapy) outpatient treatment in the management of low back pain. This trial involved 741 patients. The patients were followed for a period between 1–3 years. Nearly all of the chiropractic management involved traditional joint manipulation. The authors concluded:

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

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

“Chiropractic was particularly effective in those with fairly intractable pain-that is, those with a history of severe pain.”

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

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

Important for this discussion, 84% of the hospital patients were treated with physical therapy. This observation led to an editorial follow-up in a different journal, Lancet, which stated (12):

Chiropractors and Low Back Pain

The study “showed a strong and clear advantage for patients with chiropractic.”

The advantage for chiropractic over conventional hospital treatment was “not a trivial amount” and “reflects the difference between having mild pain, the ability to lift heavy weights without extra pain, and the ability to sit for more than one hour, compared with moderate pain, the ability to lift heavy weights only if they are conveniently positioned, and being unable to sit for more than 30 minutes.”

“This highly significant difference occurred not only at 6 weeks, but also for 1, 2, and even (in 113 patients followed so far) 3 years after treatment.”

“Surprisingly, the difference was seen most strongly in patients with chronic symptoms.”

“The trial was not simply a trial of manipulation but of management” as 84% of the hospital-managed patients had [physiotherapy] manipulations.

“Chiropractic treatment should be taken seriously by conventional medicine, which means both doctors and physiotherapists.”

“Physiotherapists need to shake off years of prejudice and take on board the skills that the chiropractors have developed so successfully.”

The authors of the Meade study note that if all back pain patients without manipulation contraindications were referred for chiropractic instead of hospital treatment, there would be significant annual treatment cost reductions, a significant reduction in sickness days, and a significant savings in social security payments.

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In 1996, a study was published in the journal Injury, titled (13):

Chiropractic Treatment of Chronic ‘Whiplash’ Injuries

This was a retrospective study that was undertaken to determine the effects of chiropractic spinal manipulation in a group of 28 patients who had been referred with chronic ‘whiplash’ syndrome. These patients had all initially been treated with anti-inflammatories, soft collars and physiotherapy. They were subsequently referred for chiropractic spinal manipulation. The authors defined spinal manipulation as:

“Spinal manipulation is a high-velocity low-amplitude thrust to a specific vertebral segment aimed at increasing the range of movement in the individual facet joint, breaking down adhesions and stimulating production of synovial fluid.”

The severity of subjects’ symptoms was assessed before and after treatment using the Gargan and Bannister (1990) classification:

The Gargan and Bannister Whiplash Classification

These patients had all become chronic, and were referred for chiropractic at an average of 15.5 months (range was 3–44 months) after their initial injury. Ninety six percent (27/28) of the study subjects were classified as category C or D symptoms at the time of initial chiropractic treatment.

Following chiropractic care, 93% of the patients had improved: 16/28 (57%) by one symptom group and 10/28 (36%) by two symptom groups. These authors state:

“The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic whiplash injury.”

Complications from cervical manipulations are rare, and when they are reported in the literature, they often “arose as a result of spinal manipulation performed by non-chiropractors, who had been misrepresented in the literature as being trained chiropractors.” 

Once again, spinal manipulation appears to result in a positive clinical outcome when compared to physical therapy in the treatment of a common musculoskeletal pain syndrome, chronic whiplash injury.

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In 2002, an study was published in the Annals of Internal Medicine, and titled (14):

Manual Therapy, Physical Therapy, or Continued Care by a
General Practitioner for Patients with Neck Pain:
A Randomized Controlled Trial

The authors defined “manipulation” as:

“Orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities.”

The authors compared the effectiveness of manual therapy, physical therapy, and care by a general practitioner physician in the treatment of neck pain, using a randomized controlled trial design. The study involved 183 patients. These authors concluded:

“Manual therapy scored consistently better than the other two interventions on most outcome measures.”

“In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.”

“The success rates for manual therapy were statistically significantly higher than those for physical therapy.”

“Manual therapy scored better than physical therapy on all outcome measures…”

“Range of motion improved more markedly for those who received manual therapy or physical therapy than for those who received continued care.”

“The postulated objective of manual therapy, the restoration of normal joint motion, was achieved, as indicated by the relatively large increase in the range of motion of the cervical spine.”

“Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care.”

“Manual therapy seems to be a favorable treatment option for patients with neck pain.”

“Primary care physicians should consider manual therapy when treating patients with neck pain.”

In this study, the primary authors are physical therapists, and they found that manual manipulative therapy was superior to traditional physical therapy in the management of neck pain.

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In 2004, a study was published in the Journal of Whiplash & Related Disorders titled (15):

Manipulative Treatment vs. Conventional Physiotherapy Treatment
in Whiplash Injury: A Randomized Controlled Trial

The authors are trained as physical therapists. They state that the goal of joint manipulation is to restore maximal, pain-free movement of the musculoskeletal system. The aim of this clinical trial is to compare the results obtained with a manipulative protocol with the results obtained with a conventional physiotherapy treatment in patients suffering from whiplash injury. The study included 380 acute whiplash injured subjects.

Study subjects were divided randomly in 2 groups:

1. Treated with high velocity-low amplitude manipulation and soft tissue manipulation and mobilization techniques. Treatment was weekly.
2. Treated with conventional physiotherapy including active exercises, electrotherapy, ultrasound therapy and diathermy. Treatment was daily.

The authors concluded:

“Patients who had received manipulative treatment needed fewer sessions to complete the treatment than patients who had received physiotherapy treatment.”

“Results showed that the manipulative group had more benefits than the physiotherapy group.”

“Our clinical experience with these patients [whiplash-injured] has demonstrated that manipulative treatment gives better results than conventional physiotherapy treatment.”

“This clinical trial has demonstrated that head and neck pain decrease with fewer treatment sessions in response to a manipulative treatment protocol as compared to a physiotherapy treatment protocol among patients diagnosed with acute whiplash injury.”

“Manipulative treatment is more effective in the management of whiplash injury than conventional physiotherapy treatment.”

Once again, this study supports that joint manipulation is influencing different tissue sources of musculoskeletal pain, resulting in an improved clinical outcome.

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In 2016, a study was published in the Journal of Occupational Rehabilitation titled (16):

Association Between the Type of First Healthcare Provider
and the Duration of Financial Compensation for Occupational Back Pain

The objective of this study was to compare the duration of financial compensation and the occurrence of a second episode of compensation for back pain among injured workers seen by three types of first healthcare providers (physicians, chiropractors, and physiotherapists). The study used a cohort of 5,511 injured workers who were followed for a period of two years. The authors found:

“Physiotherapists showed the longest duration of compensation, and chiropractors showed the shortest.”

Over the first 149 days, the “workers who first sought care from a chiropractor had a significantly greater hazard of ending their compensation episode compared with the workers who first consulted a physician and those who first consulted a physiotherapist.”

“When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones.”

“Physiotherapists were associated with higher odds of a second episode of financial compensation.”

“In accordance with our findings, workers who first sought chiropractic care were less likely to be work-disabled after 1 year compared with workers who first sought other types of medical care.”

“We found that the workers who sought chiropractic care experienced shorter durations of compensation.”

“The physiotherapy patients experienced longer compensation durations and more second episodes of compensation.”

“Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest.”

“The physiotherapy patients were also more likely to experience a second episode of compensation. Our results raised concerns regarding the use of physiotherapists as gatekeepers of Ontario’s worker’s compensation system.”

“These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.”

This study argues that chiropractic spinal manipulation is very effective in the treatment of low back pain, especially in comparison to other treatment approaches. It would also support the argument, as a consequence of its superior treatment outcomes, that chiropractic should be the gatekeeper for the worker’s compensation system.

••••••••••

Earlier this year (March 2018), the journal Physical Therapy published “Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain.” (17) This article was followed in the same journal, Physical Therapy, with epub comments, dated June 28, 2018, stating (18):

“We are writing to relay our consternation about the guideline article by Bier et al [17] in the March issue of Physical Therapy Journal.”

“We fully support the increasing emphasis on critical evaluation of the assessment and intervention models used in physical therapist practice.”

“The long- overdue acknowledgment of research that does not support much of what constitutes the bulk of physical therapist practice is a refreshing and honest introspection that can potentially initiate much needed change within our profession.”

“Without such change, our profession is destined to continue on our current path of practice that is increasingly shown to be yielding outcomes that are less than desirable.”

“Such exploration inevitably leaves us with gaping holes in practice that can be unsettling.”

“The natural and responsible tendency is to search for alternate measures and interventions to fill this gap.”

These comments are particularly noteworthy because of the credentials of the authors:

Colleen M Whiteford is from Appalachian Physical Therapy, Broadway, Virginia. Dr. Whiteford is a board-certified clinical specialist in orthopaedic physical therapy and a certified myofascial trigger point therapist (pain specialist).

Larry Steinbeck is from Advance Rehabilitation Services, Jasper, Georgia. Mr. Steinbeck is a certified myofascial trigger point therapist (pain specialist).

Jan Dommerholt is from Bethesda Physiocare LLC, Bethesda, Maryland. Dr. Dommerholt is a diplomate of the Academy of Integrative Pain Management.

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SUMMARY AND FUTURE DIRECTIONS

The magnitude of pain in America and its clinical management is a nightmare. Approximately half of the adults in our country suffer from chronic pain (19). A shift in the thinking and approach to the management of our pain problem was published in the Journal of the American Medical Association, June 12, 2018, titled (20):

Medical News & Perspectives
Researching Nondrug Approaches to Pain Management
An Interview with Robert Kerns, PhD

Dr. Robert Kerns, PhD, is a clinical psychologist and a professor of psychiatry, neurology, and psychology at Yale University. He has spent four decades treating and studying pain in veterans and military service members. He is at the forefront of a research initiative investigating nondrug approaches to pain management. Dr. Kerns notes that it is important to think about alternatives to drug approaches for pain control to try to “avoid some of the complications of overuse of medications.”

Dr. Kerns notes that the only approaches to be considered in the nondrug approaches to pain management would have to “have sufficient evidence to suggest their potential value.” Importantly, Dr. Kerns notes that chiropractic and spinal manipulation are such an “evidence-based approach” to pain management. Consequently, he notes that chiropractic manipulation, as the first approach, should be assessed.

REFERENCES

1. Sandoz R; Some Physical Mechanisms and Effects of Spinal Adjustment; Annals of the Swiss Chiropractic Association; 1976; Vol. 6; pp. 91-141.
2. Haldeman S; Modern Developments in the Principles and Practice of Chiropractic; Appleton-Century-Crofts; New York; 1980.
3. Kirkaldy-Willis WH; Managing Low Back Pain; Churchill Livingston; (1983 & 1988).
4. Kirkaldy-Willis, WH, Cassidy JD; Spinal Manipulation in the Treatment of Low-Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-40.
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. Fischgrund JS; Neck Pain, Monograph 27, American Academy of Orthopaedic Surgeons; 2004.
7. 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.
8. Langenfeld A, Humphreys BK, 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.
9. Edwards BC; Low Back Pain and Pain Resulting From Lumbar Spine Conditions: A Comparison of Treatment Results; The Australian Journal of Physiotherapy; September 1969; Vol. 15; No. 3; pp. 104-110.
10. White AA, Panjabi MM; Clinical Biomechanics of the Spine. Lippincott, 1990.
11. 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.
12. Editorial; Chiropractors and Low Back Pain; Lancet; July 28, 1990; p. 220.
13. Woodward MN, Cook JCH, Gargan MF, Bannister GC; Chiropractic Treatment of Chronic ‘Whiplash’ Injuries; Injury; November 1996; Vol. 27; No. 9; pp. 643-645.
14. 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.
15. 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.
16. Blanchette AM, Rivard M, Dionne CE, Hogg-Johnson S, Steenstra I; Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain; Journal of Occupational Rehabilitation; September 17, 2016; Vol. 27; No. 3; pp. 382-392.
17. Bier JD, Scholten-Peeters WGM, Staal JB, Pool J, van Tulder MW, Beekman E, Knoop J, Meerhoff G, Verhagen AP; Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain; Physical Therapy; March 1, 2018; Vol. 98; No. 3; pp. 162-171.
18. Whiteford CM, Steinbeck L, Dommerholt J; On “Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain”; Physical Therapy; 2018; Vol.98; pp. 162-171.
19. Foreman J; A Nation in Pain; Healing Our Biggest Health Problem; Oxford University Press; 2014.
20. Abbasi J; Researching Nondrug Approaches to Pain Management; An Interview with Robert Kerns, PhD; Journal of the American Medical Association; March 28, 2018; E1.

Why Do Chiropractors Advise/Insist on X-Rays?

Chiropractic education is indirectly controlled by the US Federal Government. The US Department of Education officially recognizes the chiropractic-accrediting agency, the Council on Chiropractic Education (CCE).
Historically, the Council on Chiropractic Education was formally established in 1971, and officially recognized by the US Commissioner of Education, Department of Health, Education and Welfare in 1975. The CCE webpage states (1):

The Council on Chiropractic Education (CCE) is recognized by the United States Secretary of Education as authorized by United States law.

Much of chiropractic education is centered around x-rays (radiology). 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 (2, 3, 4).

As an example, in 2002, an important study was published in the journal Spine, titled (4):

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, 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 plain radiography of the spine is an established part of chiropractic practice, but that few studies have assessed the ability of chiropractors to read plain radiographs.

The participants of the study read a set of 300 blinded lumbosacral (lower back) radiographs, 50 of which showed an abnormality. The results were expressed in terms of reliability and validity.

The results were such that the authors concluded that the small differences between the groups were of “little clinical relevance.” The authors stated:

“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, inflammatory spondylitis, spondylolysis, and spondylolisthesis

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Why is Radiology so Emphasized in Chiropractic Education?

Chiropractic educational and practice standards mandate that a chiropractic evaluation determine if the patient’s primary complaint and clinical status are of the type that respond to chiropractic care, or if the patient should be referred out for additional diagnostic procedures or to a different health care provider. Chiropractic education, training, and licensure allow the public to directly access chiropractic services without requiring a referral from another health care provider. As such, the chiropractor will take a history and evaluate the patient to establish a working diagnosis(identification of the “leading contender” nature and cause of a certain phenomenon).

A relevant study was published in 1997 in the Journal of Manipulative and Physiological Therapeutics, titled (5):

Chiropractic Radiologists:
A Survey of Chiropractors’ Attitudes and Patterns of Use

The objective of this study was to assess the chiropractic use of radiography, referral patterns to both medical and chiropractic radiologists and attitudes toward radiologists by practicing U.S. chiropractors. The findings included:

• 74% of the chiropractors had x-ray facilities in their offices.
• 71% used x-rays to screen for contraindications to chiropractic care.
• 63% used x-rays to assess existence of pathological conditions.
• 51% used x-rays to observe/measure altered biomechanics and posture.
• 27% used 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.

The working diagnosis is the treating doctor’s best “guess” as to the root cause/causes of the patient’s symptoms and signs. As additional information is obtained, the diagnosis will often change or be confirmed.

Typically, the working diagnosis has three components, the three-point diagnostic format:

1. List the mechanism of initiation/injury. This mechanism can be acute or gradual, or even unknown. The mechanism never changes from the beginning of a case though the end of the case. The initial mechanism of injury is always the same throughout the case.
2. List things that occurred as a consequence of the mechanism. These resulting problems can change or resolve as a consequence of time and/or treatment. Therefore, updated diagnoses will often reflect these changes in the second part of the diagnostic format. X-rays are often an important part of this second component of the diagnosis. The mechanism may have resulted in a fracture, or of a ligament injury resulting in a joint instability (stress radiography).
3. The third component of the diagnostic format is a listing of factors that makes a particular case more difficult or complicated than the usual case. These factors are not caused by the mechanism of the injury, but rather they are factors that pre-existed the injury. Consequently, they complicate the recovery of those things that were caused by the injury.

Examples include:

Degenerative joint disease
Discogenic spondylosis
Facet joint arthrosis
Central canal stenosis
Cervical rib(s)
Hemi or Demi vertebrae
Scoliosis
Abnormal lordotic/kyphotic curvatures
Tropism
Lumbosacral transitional segment
Spondylolysis
Spondylolisthesis
Old/prior spinal fractures
Osteoporosis
Rheumatoid arthritis
ETC.

As noted from the list above, the majority of these complicating factors are determined by viewing x-rays. These factors are not determinable without x-rays or other more advanced imaging modalities (CT, MRI, etc.).

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Is the Ionizing Radiation Exposure
From Medical/Dental/Chiropractic X-Rays Harmful?

Starting in the late 1920s, and especially after the use of atomic weapons at the end of WWII, it was assumed that any exposure to ionizing radiation was harmful (6). This concept is termed the linear no-threshold dose-response to ionizing radiation. However, this concept has recently been challenged from a number of sources.

In 1979, a study was published in the journal Health Physics, titled (7):

A Catalog of Risks

The authors presented an analysis of loss of life expectancy attributed to a number of risk factors. They note that the risks of radiation are especially emphasized in the popular press, yet they note that the public does not understand risk. The public gets very excited about radiation risks, which are almost never fatal, whereas it largely ignores other risks, which claim thousands of lives every year. An analogy would be the irony of a smoker declining medical x-rays to avoid excess radiation risks. The authors note that both men and women should expect a loss of about 1 month of life loss for each pound they are overweight, a risk that far surpasses the risks associated with exposure to medical x-rays. Their risk analysis includes:

These authors conclude that to increase life expectancy, the priorities should be:

• Reduce the number of unmarried adults.
• Control overweight problems.
• Less attention should be paid to radiation hazards and catastrophes.

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In a parallel argument, studies began pointing out that exposure to low dose radiation, including from medical imaging, would activate within the body a series of protective responses, including the activation of the endogenous anti-oxidant array. Ironically, this up-regulation of protectors would not only neutralize damage caused by the radiation exposure, but would also neutralize damage that was caused by other non-radiation sources. In other words, exposure to low levels of medical radiation could actually be helpful to the body and for health (8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18). [This is a minor fraction of the published studies on this topic. A literature search of the National Library of Medicine using PubMed with the terms “radiation hormesis” locates 363 articles: July 7, 2018].

A central theme from these studies is that the authors are unyielding in their support for the understanding that high doses of radiation exposure are damaging and harmful. They are equally unyielding and insistent in the science that shows that low-dose radiation, including that from medical x-rays is not harmful and may also be beneficial. This concept is called hormesis.

Hormesis is a phenomenon of dose-response relationships in which something that produces harmful biological effects at moderate to high doses may produce beneficial effects at low doses. Hormesis indicates a favorable biological response to low exposures of chemicals or other stressors, but an opposite harmful effect in large doses.

Hormesis was nicely explained in the July 2015 Scientific American by Mark Mattson, PhD (17). Dr. Mark Mattson has a PhD in biology. He is Chief of the Laboratory of Neurosciences at the National Institute on Aging, and Professor of Neuroscience at Johns Hopkins University. He is Editor-in-Chief of Ageing Research Reviews and NeuroMolecular Medicine, a Section Editor for Neurobiology of Aging, and an Associate Editor for Trends in Neurosciences.

In this article, Dr. Mattson states:

“Hormesis is a term used by toxicologists to refer to a biphasic dose response to an environmental agent characterized by a low dose stimulation or beneficial effect and a high dose inhibitory or toxic effect.”

“Thus, a short working definition of hormesis is: a process in which exposure to a low dose of a chemical agent or environmental factor that is damaging at higher doses induces an adaptive beneficial effect on the cell or organism.”

Dr. Mattson continues to explain why hormesis is a fundamental concept in evolutionary biology. He notes, “thousands of published articles include data showing biphasic responses of cells or organisms to chemicals or changing environmental conditions.” He emphasizes that hormesis is also implicated in the actions of a number of complementary and alternative health care disciplines.

Typical Hormesis Graph

The disagreements in the peer reviewed literature pertaining to medical radiation exposure is so contentious that authors and publications have accused the initiators and perpetuators of the linear no-threshold dose-response to ionizing radiation perspective of “scientific misconduct.” (18)

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An important article on this subject was published by authors from Nuclear Physics Enterprises (Marlton, New Jersey) and the Food and Drug Administration (retired), in 2017. The Article was published in the Journal of Nuclear Medicine and titled (19):

Subjecting Radiologic Imaging to the Linear No-Threshold
Hypothesis: A Non Sequitur of Non-Trivial Proportion

A non sequitur is Latin for “it does not follow.” It means “an invalid argument,” or a conclusion that is “fallacious.”

The linear no-threshold hypothesis (LNTH) has been applied to low-dose ionizing radiation for more than 70 years but lacks a valid scientific foundation. Yet, “this hypothesis is the orthodox foundation of radiation protection science, in turn forming the basis of regulations and public policy.” The authors further state:

“Radiologic imaging is claimed to carry an iatrogenic risk of cancer, based on an uninformed commitment to the 70-y-old linear no-threshold hypothesis (LNTH).”

“Credible evidence of imaging-related low-dose carcinogenic risk is nonexistent; it is a hypothetical risk derived from the demonstrably false LNTH.”

“The low-dose radiation of medical imaging has no documented pathway to harm.”

The author’s primary criticism of the linear no-threshold hypothesis of low-dose radiation exposure is that its proponents purposefully ignore the theory’s “fatal flaw.” This flaw is that the proponents focus only on molecular damage while ignoring protective, organismal biologic responses. Earth’s life forms have developed adaptive, biologic repair and/or removal responses to radiation damage. Low doses of radiation stimulate these biological protective responses. Yet, high doses of radiation exposure overwhelm and inhibit such protection mechanisms. The authors state:

“The primary LNTH fallacy is it excludes this evolutionary biology, ignoring the body’s differing responses to high versus low radiation doses.”

The body deals with low-dose radiation damage through a set of proven mechanisms, collectively called the adaptive response. “Numerous studies demonstrate at least 6 mechanisms for reducing cancer rates and increasing longevity, stimulated by low-dose [radiation] damage.” The authors further state:

“Low doses [of radiation] stimulate repair or removal of radiogenic damage in excess of that immediate damage, they provide enhanced protections against additional damage over time, including damage from subsequent higher radiation exposures.”

Low-dose chronic radiation exposure is associated with two adaptive cellular responses: enhanced antioxidant defense and increased apoptotic response. The immune system generally keeps cancers in check, and cancers develop mainly when the immune system is suppressed. Low-dose radiation has been shown to stimulate the immune system, causing a reduction in cancer rates.

The authors conclude that low-dose radiation exposure does not cause, but more likely helps prevent, cancer. There is an unwarranted fear of low-dose radiation. The contemporary attitude towards health care x-ray exposure has resulted in unjustified “radiophobia,” a perspective that is misplaced, wrong, and non-scientific. The authors make a strong argument why such x-ray exposures should not be avoided based upon fear of radiation.

••••••••••

A study applicable to chiropractic clinical practice on this topic appeared earlier this year (2018). It was published in the journal Dose-Response, and titled (20):

X-Ray Imaging is Essential for Contemporary Chiropractic
and Manual Therapy Spinal Rehabilitation:
Radiography Increases Benefits and Reduces Risks

The authors argue for the value of spinal x-rays for determining and measuring both postural and segmental mechanical abnormalities. They also argue that spinal x-rays improve diagnosis and reduce inappropriate treatment.

Additional benefits of spinal x-rays are that they can image both cautionary and absolute contraindications to manual therapy. Their cautionary list includes:

• Cervical rib/s
• Lumbosacral transitional segments
• Congenital fusions
• Congenital alterations in pelvic morphology
• Osteoarthritic/degenerative changes
• Spinal pathologies

Their absolute contraindication list includes:

• Serious spinal pathology
• Significant central canal stenosis
• Fracture
• Infection
• Metabolic inflammatory disorders
• Abdominal aortic aneurysm
• Significant ligament instabilities
• Malignancies

The authors cite references to support that the radiation dose employed for plain spinal x-rays radiograph is very low, about 100 times below the documented threshold dose for harmful effects. Hence, medical, dental, chiropractic x-rays must be considered to be safe.

The authors point out the primary influence of x-ray exposure is the genesis of reactive oxygen species (ROS) that have the ability to exert a damaging influence on cellular DNA. However, the quantity of ROS produced by x-rays is minor compared to the very large quantity of ROS that is constantly produced by aerobic metabolism (breathing air). This makes x-ray generated ROS quantity negligible to human health.

Also, all organisms, including humans, have evolved powerful protective mechanisms that prevent, repair, or remove damage in and to cells caused by ROS. Excessively damaged/cancerous cells may be destroyed by immune system mechanisms, preventing the growth and spread of cancerous cells.

The levels of ROS produced by low-dose x-rays sends signals to upregulate many of the biological protection systems against aerobic ROS, other toxins, pathogens, and all damage events. This stimulation produces a range of beneficial effects, including a lower risk of cancer. The authors state:

“Since low doses of radiation stimulate many protective systems, including the immune system, it is very unlikely that low-level radiation causes more damage than benefit.” [underline and italic added]

“Rather than increasing risk, such exposures would likely stimulate the patient’s own protection systems and result in beneficial health effects.”

“A radiograph may in fact stimulate our protective systems, which is a beneficial health effect.”

These authors argue that clinical practice guidelines should be updated and abandon unfounded bias against patient exposure to spinal x-rays.

SUMMARY:

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.

In contrast, the negative warnings surrounding x-rays appear to be overstated. In fact, such negative warnings may be 100% inaccurate.

REFERENCES

1. http://www.cce-usa.org
2. 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.
3. 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.
4. 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.
5. 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.
6. Calabrese E; Origin of the linearity no threshold (LNT) dose-response concept; Archives of Toxicology; September 2013; Vol. 87; No. 9; pp. 1621-1633.
7. Cohen B, Lee IS; A Catalog Of Risks; Health Physics; June 1979; Vol. 36; pp. 707-722.
8. Pollycove M, Feinendegen LE; Molecular biology, epidemiology, and the demise of the linear no-threshold (LNT) hypothesis; C R Acad Sci III; Feb-Mar 1999; Vol. 32; No. 2-3; pp. 197-204.
9. Calabrese EJ, Baldwin LA; Radiation hormesis: the demise of a legitimate hypothesis; Human Experimental Toxicology; January 2000; Vol. 1; No. 1; pp. 76-84.
10. Feinendegen LE, Pollycove M; Biologic responses to low doses of ionizing radiation: detriment versus hormesis. Part 1. Dose responses of cells and tissues; Journal of Nuclear Medicine; July 2001; Vol. 42; No. 7; pp. 17N-27N.
11. Pollycove M, Feinendegen LE; Biologic responses to low doses of ionizing radiation: Detriment versus hormesis. Part 2. Dose responses of organisms; Journal of Nuclear Medicine; September 2001; Vol. 42; No. 9; pp. 26N-32N.
12. Pollycove M, Feinendegen LE; Radiation-induced versus endogenous DNA damage: possible effect of inducible protective responses in mitigating endogenous damage; Human Experimental Toxicology; June 2003; Vol. 22; No. 6; pp. 290-306.
13. Feinendegen LE, Pollycove M, Sondhaus CA; Responses to low doses of ionizing radiation in biological systems; Nonlinearity Biol Toxicology Medicine; July 2004; Vol. 2; No. 3; pp. 143-171.
14. Feinendegen LE, Pollycove M, Neumann RD; Whole-body responses to low-level radiation exposure: new concepts in mammalian radiobiology; Experimental Hematology; April 2007; Vol. 35; No. 4 (Suppl 1); pp. 37-46.
15. Feinendegen LE, Pollycove M, Neumann RD; Low-dose cancer risk modeling must recognize up-regulation of protection; Dose Response; December 10, 2009; Vol. 8; No. 2; pp. 227-52.
16. Calabrese EJ; Flaws in the LNT single-hit model for cancer risk: An historical assessment; Environ Research; October 2017; Vol. 158; pp. 773-788.
17. Mattson MP; Toxic Chemicals in Fruits and Vegetables Are What Give Them Their Health Benefits; Scientific American; July 2015; Vol. 313; No. 1.
18. Calabrese EJ; LNTgate: How scientific misconduct by the U.S. NAS led to governments adopting LNT for cancer risk assessment; Environmental Research; July 2016; Vol. 148; pp. 535-546.
19. Siegel JA, Pennington CW, Sacks B; Subjecting Radiologic Imaging to the Linear No-Threshold Hypothesis:  A Non Sequitur of Non-Trivial Proportion; Journal of Nuclear Medicine; January 2017; Vol. 58; No. 1; pp. 1–6.
20. Paul A. Oakley PA, Jerry M. Cuttler JM, Deed E. Harrison DE; X-Ray Imaging is Essential for Contemporary Chiropractic and Manual Therapy Spinal Rehabilitation: Radiography Increases Benefits and Reduces Risks; Dose-Response: An International Journal; April-June 2018; pp. 1-7.

Why Do People Go To Chiropractors?

What Are the Clinical Assessments,
Clinical Goals, and Clinical Applications
of a Typical Chiropractic Office Visit?

••••••••••

Why Do People go to Chiropractors?

The most recent authoritative assessment of the chiropractic profession appeared in the December 2017 issue of the prestigious orthopedic medical journal Spine, and was titled (1):

The Prevalence, Patterns, and Predictors of
Chiropractic Use Among US Adults:
Results From the 2012 National Health Interview Survey

The data for this study was from the National Health Interview Survey (NHIS), which is the principle and reliable source of comprehensive health care information in the United States. The NHIS dataset provides a large-scale nationally representative sample regarding chiropractic use.

The authors note that 93% of patients go to chiropractors for low back pain (63%) and/or neck pain (30%). They found that:

65% of the patients reported that chiropractic care helped their condition “a great deal.”

26% of the patients reported that chiropractic care helped their condition “somewhat.”

Only 3% reported that the chiropractic care did not help them.

The authors also made the following points pertaining to the chiropractic profession:

“Back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being.”

“Back pain or back problems (63.2%) and neck pain or neck problems (30.2%) were by far the top specific health problems for which people consulted a chiropractor in the past 12 months, followed by joint pain/stiffness (13.6%) and other pain conditions. Around two in three users (64.5%) reported that chiropractic had helped a great deal to address these health problems.”

“Our analyses show that, among the US adult population, spinal pain and problems – specifically for back pain and neck pain – have positive associations with the use of chiropractic.”

“The most common complaints encountered by a chiropractor are back pain and neck pain and is in line with systematic reviews identifying emerging evidence on the efficacy of chiropractic for back pain and neck pain.”

“Chiropractic services are an important component of the healthcare provision for patients affected by musculoskeletal disorders (especially for back pain and neck pain) and/or for maintaining their overall well-being.”

What Are the Chiropractic Clinical Assessments?

Nerve signals can be broadly divided into two groups:

Efferents, which are nerve signals that leave the brain and spinal cord and are transmitted into the peripheral tissues, such as the muscles and the viscera. These are also known as motor nerve signals.

Afferents, which are nerve signals that begin in the peripheral tissues and are transmitted into the spinal cord and the brain. These are also known as sensory nerve signals.

Pain is a sensory nerve signal. For more than fifty years it has been understood that pain is a sensory electrical signal sent to the brain.

Importantly, there are other sensory electrical signals that are sent to the spinal cord. These other sensory signals are not painful. Examples would be touch, vibration hot and cold. The most important and abundant of these other sensory signals is proprioception.

Proprioceptive signals to the spinal cord and brain transmit mechanical information, especially mechanical factors such as position and movement. This concept is well-stated by attorney Chris Crowley and physician Henry Lodge, MD, in their book Younger Next Year, in a section they refer to as:

“The Balancing Act”

“Now it’s time to think about your brain and a concept called proprioception—the deceptively simple notion that you have to know where the different parts of your body are at all times.”

“Your body is aware of exactly where each limb is in space every second, because each muscle, tendon, ligament and joint sends thousands of nerve fibers back to the brain through the spinal cord. Those fibers signal every nuance gradation of contraction, strength, muscular tone, orientation, position and movement at every moment of the day.”

“Your brain keeps careful track of the location of every muscle and joint in you body every second, all day, every day, waiting for you to need the information.”

In 1965, pain researchers became aware that the proprioceptive signal to the brain could block the pain signal to the brain. This concept was originally proposed by pain researchers Ronald Melzack and Patrick Wall (3). Their theory is known as the Gate Control Theory of Pain. Ronald Melzack, PhD, is a Canadian psychologist. Patrick Wall, MD (d. 2001), was a British neuroscientist and pain expert, as well as the first editor of the journal Pain.

In 2002, the British Journal of Anaesthesia published a study reaffirming the validity of the Gate Theory of Pain in an article titled (4):

Gate Control Theory of Pain Stands the Test of Time

An oversimplified explanation of their Gate Control Theory of Pain is that the pain electrical signal to the brain can be blocked by non-painful electrical signals arising from other sensory afferents, especially from joint proprioceptors. Practically, this would mean that if a person’s posture became abnormal and static, and/or if a person’s joints lost or reduced their normal movement arc, there would be a proportionate reduction of the proprioceptive sensory input into the spinal cord and brain. This would allow pain signals to enter the brain because the pain gate would be open.

For more than a century, chiropractors, patients, government, insurance companies, and scientists have realized that chiropractic spinal adjusting (specific manipulation) helps people with pain syndromes. As noted in the Adams study (1):

“Chiropractic is one of the largest manual therapy professions in the United States and internationally.”

“Chiropractic is one of the commonly used complementary health approaches in the United States and internationally.”

“There is a growing trend of chiropractic use among US adults from 2002 to 2012.”

Chiropractic:

• Uses manual therapy to treat musculoskeletal and neurological disorders.
• Is covered by Medicare and Medicaid for all adults in the United States.
• Is included in the workers’ compensation systems in most US States.
• Has more than 70,000 practicing providers in the United States.
• Total costs for US visits in 2013 is estimated to be more than $10 billion.

The application of chiropractic spinal adjusting for pain control using Melzack and Wall’s Gate Control Theory of Pain was first done by Canadian orthopedic surgeon Kirkaldy-Willis in 1985 (5). Dr. Kirkaldy-Willis’ study was impressive. It presented the results of chiropractic spinal manipulation on 283 patients with chronic low back and leg pain. All 283 patients had failed prior conservative and/or operative treatment, and they were all totally disabled. (“Constant severe pain; disability unaffected by treatment”)

These patients were given a two or three week regimen of daily spinal manipulations by an experienced chiropractor. Essentially 81% of the patients who did not have compressive neuropathology had their signs and symptoms resolved and were no longer disabled. Dr. Kirkaldy-Willis notes:

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

Dr. Kirkaldy-Willis presented the following observations pertaining to chiropractic spinal manipulation and the Gate Theory of Pain:

Melzack and Wall proposed the Gate Theory of Pain in 1965, and this theory has “withstood rigorous scientific scrutiny.”

“The central transmission of pain can be blocked by increased proprioceptive input.” Pain is facilitated by “lack of proprioceptive input.” This is why it is important for “early mobilization to control pain after musculoskeletal injury.”

The facet capsules are densely populated with mechanoreceptors. “Increased proprioceptive input in the form of spinal mobility tends to decrease the central transmission of pain from adjacent spinal structures by closing the gate. Any therapy which induces motion into articular structures will help inhibit pain transmission by this means.”

Returning to the initial question, “What Are the Chiropractic Clinical Assessments?” Some spinal pain syndromes can be serious. These usually involve compressive neuropathology. Common examples of compressive neuropathology include disc herniations, lateral recess stenosis, and central canal stenosis. Although each of these can be successfully managed by chiropractors, they often need advanced diagnostics (MRIs, etc.), and rarely require a surgical intervention. Chiropractors are well trained to examine and recognize cases of compressive neuropathology and to make appropriate referrals when necessary. Statistically, compressive neuropathology is quite rare, constituting only 1-2% of chiropractic clinical practice.

In addition to the standard orthopedic and neurological tests used to determine if a patient has compressive neuropathology, chiropractic clinical assessments include posture analysis and joint range of motion. These assessments are windows into a patient’s proprioceptive integrity. The large majority of chiropractic pain patients have lack of proprioception, opening their pain gate.

••••••••••

A representative supportive study was published by the Institute of Occupational Health, Helsinki, Finland, in 1987, by physician T. Viderman, MD. His study was published in the journal Clinical Biomechanics, and titled (6):

Experimental Models of Osteoarthritis:
The Role of Immobilization

Dr. Viderman notes that when there is a lack of joint motion for any reason, the periarticular tissues adapt to the shortest distance between its origin and insertion. This profoundly and significant alters musculoskeletal function, including proprioceptive signals. He makes the following points:

“Whenever the periarticular shrinkage stems from immobilization, the process does not affect articular cartilage only; instead the whole joint is involved.”

“Immobilization, for whatever reason, is one of the pathogenic factors in musculoskeletal degeneration.”

“With respect to patients, it can be postulated that immobilization, for whatever cause, will initiate a pathogenic chain of musculoskeletal degenerative changes.”

Dr. Viderman also discusses the value of mobilization to prevent and reverse the pathological consequences of immobilization. He notes:

“If immobilization, irrespective of its cause, cannot be avoided, it would be therapeutically logical to take every possible step to limit its extent and duration.”

“When the adverse effects of immobilization have already become apparent, the earlier they are treated the better.”

“The evidence reviewed shows very clearly that early mobilization is essential.”

••••••••••

Numerous studies and publications, spanning nearly eight decades, indicate that the mobilization of injured and/or stiff tissues enhance healing and reduce pain (7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27).

If mobilization of injured and stiff tissues are so critical to the healing process and in preventing/treating pain, it is logical that exercising these tissues would be an important aspect of treatment, and indeed it is. However, it has been understood for decades that exercise alone is limited in its ability to optimize improvement of joint tissues. This is because exercise, although beneficial, only affects the tissues in the most narrow range, the Range of Active Motion.

In contrast, maximum tissue mobilization benefit can only be achieved by manipulation, which moves the tissues into the Periarticular Paraphysiological Range of Motion. Importantly, this can be done without any risk of injury as the motion never exceeds the limit of anatomic integrity. A number of well-respected references explain this distinction in detail (28, 29, 30, 31). The procedure is described by Dr. Kirkaldy-Willis as follows (5):

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

There are three categories of joint motion:

1) Active exercise range of motion.

2) “Beyond the end of the active range of motion of any synovial joint, there is a small buffer zone of passive mobility.” A joint can only move into this zone with passive assistance, and going into this passive range of motion “constitutes mobilization.”

3) “At the end of the passive range of motion, an elastic barrier of resistance is encountered. This barrier has a spring-like end-feel.”

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

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

“This constitutes manipulation.”

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

“With experience, the manipulator can be very specific in selecting the spinal level to be manipulated.”

••••••••••

Darlene Hertling, RPT, and Randolph Kessler, MD note in their authoritative book, Management of Common Musculoskeletal Disorders, that exercise in the presence of altered joint biomechanical function can damage the joint (32).

They review the case of a boy who continued to use his knee in the absence of normal external rotation of the tibia on the femur during knee extension. One and a half years later, at surgery, dimpling of the articular cartilage of the medial femoral condyle was observable with the naked eye, presumably owing to continued abnormal compression of this portion of the articular surface from loss of normal arthrokinematic movement. They state:

“The traditional approach to management of patients presenting with loss of pain-free movement at a joint usually involves active and passive measures to improve osteokinematic movement, and encouragement of normal use of the part.”

“It should be clear that this approach is inadequate and perhaps dangerous. It ignores the basic problem, which is often loss of normal arthrokinematics. It involves considerable forcing of osteokinematic movements in the absence of normal arthrokinematic movement, which may only occur at the expense of the articular cartilage.”

“A more logical approach to the management of these patients emphasizes the restoration of joint play to allow free movement between bones. This can be achieved only by  deciding if joint mobilization is indicated, choosing the appropriate techniques based on the direction and extent of restrictions, and skillfully applying techniques of specific mobilization.”

“Some movement should be encouraged in the cardinal planes, but only as normal kinematics are restored.”

“To a certain extent, functional use of the part should be restricted through careful instructions to the patient until normal joint mechanics are restored. This approach minimizes the possible danger of undue stresses to the articular cartilage during attempts to restore movement. It also minimizes the possibility of discharging a patient who has relatively pain-free functional use of the joint, but who may have some residual kinematic disturbance sufficient to cause cartilage fatigue over time and perhaps osteoarthrosis in later years.”

Hertling and Kessler are indicating that it is important to first restore normal joint motion before beginning exercise of the muscles that cross that joint. Failure to do this can result in the acceleration of joint arthritis. The goal of chiropractic manipulation is to restore normal joint motion.

••••••••••

SUMMARY

Chiropractors primarily treat and manage spinal pain syndromes.

Initially, chiropractors rule out or confirm the presence of compressive neuropathology. This involves a series of orthopedic and neurological tests, and perhaps some imaging, such as x-rays or possibly an MRI. If compressive neuropathology is present, depending upon the uniqueness of the individual case and examination findings, the chiropractor may decide to treat the condition, refer the patient to another provider, or co-treat the patient with another provider.

Very few spinal pain syndromes are the result of compressive neuropathology. Once compressive neuropathology is ruled out, the chiropractor will assess the status of the proprioceptive signals that close the pain gate. This classically involves three interrelated mechanical assessments:

1. Postural alignment
2. Regional spinal range of motion (cervical, thoracic, and lumbar)
3. Segmental range of motion (joint motion integrity)

Discovered mechanical problems are dealt with mechanically, including ergonomically, exercise, traction, tissue work, and spinal adjusting.

When spinal joints do not have optimum movement, the pain gate at that level is open. Chiropractic adjusting (specific manipulation) increases the firing of the proprioceptors, creating a neurological sequence of events that closes the pain gate. The reduction in pain is often immediate, depending on levels of concomitant inflammation.

The quality of proprioception is a significant factor in the state of the pain gate. Improved proprioception closes the pain gate. Chiropractic adjusting improves proprioception. Consequently, chiropractors are noted for their treatment and management of pain syndromes, especially for spinal pain syndromes.

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. Crowley C, Henry Lodge H; Younger Next Year: Live Strong, Fit, and Sexy—Until You’re 80 and Beyond; Workman Publishing; New York; 2007.
3. Melzack R, Wall P; Pain mechanisms: a new theory; Science; November 19, 1965;150(3699); pp. 971-979.
4. Dickenson AH; Gate Control Theory of Pain Stands the Test of Time; British Journal of Anaesthesia; June 2002; Vol. 88; No. 6; pp. 755-757.
5. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
6. Viderman T; Experimental Models of Osteoarthritis: The Role of Immobilization; Clinical Biomechanics; November 1987; Vol. 2; No. 4; pp. 223-229.
7. Stearns ML; Studies on development of connective tissue in transparent chambers in rabbit’s ear; American Journal of Anatomy; Vol. 67; 1940; p. 55.
8. 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.
9. Cyriax J; Orthopaedic Medicine, Diagnosis of Soft Tissue Lesions, Bailliere Tindall; Vol. 1; 1982.
10. Oakes BW; Acute soft tissue injuries; Australian Family Physician; 1982; Vol. 10; No. 7; pp. 3-16.
11. Roy S, Irvin R;  Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation; Prentice-Hall, Inc.; 1983.
12. Frank C, Amiel D, Woo S, Akeson W; Normal ligament Properties and Ligament Healing; Clinical Orthopedics and Related Research; June; 1985.
13. Mealy K, Brennan H, Fenelon GCC; Early Mobilization of Acute Whiplash Injuries; British Medical Journal; March 8, 1986; Vol. 292; pp. 656-657.
14. Kellett J; Acute soft tissue injuries-a review of the literature; Medicine and Science of Sports and Exercise; 1986; Vol. 18; No. 5; pp. 489-500.
15. Woo S; Injury and Repair of the Musculoskeletal Soft Tissues; American Academy of Orthopaedic Surgeons; 1988.
16. Cohen IK, Diegelmann RF, Lindbald WJ; Wound Healing, Biochemical & Clinical Aspects; WB Saunders; 1992.
17. Salter R; Continuous Passive Motion, A Biological Concept for the Healing and Regeneration of Articular Cartilage, Ligaments, and Tendons; From Origination to Research to Clinical Applications; Williams and Wilkins; 1993.
18. Jonsson H, Cesarini K, Sahlstedt B, Rauschning W; Findings and Outcome in Whiplash-Type Neck Distortions; Spine; December 15, 1994; Vol. 19; No. 24; pp. 2733-2743.
19. Buckwalter J; Effects of Early Motion on Healing of Musculoskeletal Tissues; Hand Clinics; February 1996; Vol. 12; No. 1; pp. 13-24.
20. Hildebrand K, Frank C; Scar Formation and Ligament Healing; Canadian Journal of Surgery; December 1998; Vol. 41; No. 6; pp. 425-429.
21. 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.
22. Rosenfeld M, Gunnarsson R, Borenstein P; Early Intervention in Whiplash-Associated Disorders, A Comparison of Two Treatment Protocols; Spine; 2000; Vol. 25; pp. 1782-1787.
23. Hildebrand KA, Gallant-Behm CL, Kydd AS, Hart DA; The Basics of Soft Tissue Healing and General Factors that Influence Such Healing; Sports Medicine Arthroscopic Review; September 2005; Vol. 13; No. 3; pp. 136–144.
24. Walsh W; Orthopedic Biology and Medicine; Repair and Regeneration of Ligaments, Tendons, and Joint Capsule; Orthopedic Research Laboratory, University of New South Wales, Sydney, Australia; Humana Press; 2006.
25. Rogier M. van Rijn, Anton G. van Os, Roos M.D. Bernsen, Pim A. Luijsterburg, Bart W. Koes, Professor, Sita M.A. Bierma-Zeinstra; What Is the Clinical Course of Acute Ankle Sprains? A Systematic Literature Review; The American Journal of Medicine; April 2008; Vol. 121; No. 4; pp. 324-331.
26. Schleip R; Fascia; The Tensional Network of the Human Body; The Scientific and Clinical Applications in Manual and Movement Therapy; Churchill Livingstone; 2012.
27. Hauser RA, Dolan EE, Phillips HJ, Newlin AC, Moore RE, Woldin BA; Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics; The Open Rehabilitation Journal; 2013; No. 6; pp. 1-20.
28. Haldeman S; Modern Developments in the Principles and Practice of Chiropractic; Appleton-Century-Crofts; New York; 1980.
29. Kirkaldy-Willis WH, Managing Low Back Pain; Churchill Livingston; (1983 and 1988).
30. Kirkaldy-Willis WH, Cassidy D; Spinal Manipulation in the Treatment of Low-Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-40.
31. Fischgrund JS; Neck Pain; Monograph 27; American Academy of Orthopaedic Surgeons; 2004.
32. Hertling D, Kessler R; Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods; Second Edition; Lippincott; 1990

Data from the Chiropractic Profession Continue to Become Better Defined and Understood

Background

Pain is a huge problem in America, and all Americans know that opiate drugs are not the solution to our pain problem.

In her 2014 book, A Nation in Pain, Judy Foreman claims, “Out of 238 million American adults, 100 million live in chronic pain.” (1) A conservative estimate of the direct costs and lost productivity resulting from this pain is up to $635 billion yearly (2).

Chronic pain affects every region of the body. Quantifying the anatomical regions for American’s chronic pain shows that the most significantly affected region is the lower back followed by (3):

Lower-Back Pain	28.10%
Knee Pain	19.50%
Severe Headache	16.10%
Neck Pain	15.10%
Shoulder Pain	9.00%
Finger Pain	7.60%
Hip Pain	7.10%

There are many reasons a person might have pain. The leading theory on the perception of pain was proposed more than a half century ago  (1965) by pain researchers Ronald Melzack and Patrick Wall (4). Their theory is known as the Gate Control Theory of Pain. Ronald Melzack, PhD, is a Canadian psychologist. Patrick Wall, MD (d. 2001), was a British neuroscientist and pain expert, as well as the first editor of the journal Pain.

In 2002, the British Journal of Anaesthesia published a study reaffirming the validity of the Gate Theory of Pain in an article titled (5):

Gate Control Theory of Pain Stands the Test of Time

An oversimplified explanation of their Gate Control Theory of Pain is that the pain electrical signal to the cortical brain can be inhibited by non-painful electrical signals arising from other sensory afferents, especially from joint mechanoreceptors (proprioceptors).

The application of chiropractic spinal adjusting for pain control using Melzack and Wall’s Gate Control Theory of Pain was first done by Canadian orthopedic surgeon Kirkaldy-Willis in 1985 (6). Dr. Kirkaldy-Willis notes:

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

Melzack and Wall proposed the Gate Theory of Pain in 1965, and this theory has “withstood rigorous scientific scrutiny.”

“The central transmission of pain can be blocked by increased proprioceptive input.” Pain is facilitated by “lack of proprioceptive input.” This is why it is important for “early mobilization to control pain after musculoskeletal injury.”

The facet capsules are densely populated with mechanoreceptors. “Increased proprioceptive input in the form of spinal mobility tends to decrease the central transmission of pain from adjacent spinal structures by closing the gate. Any therapy which induces motion into articular structures will help inhibit pain transmission by this means.”

Simply put, when spinal joints do not have optimum movement, the pain gate at that level is open. Chiropractic adjusting (specific manipulation) increases the firing of the mechanical nerves (mechanoreceptors/proprioceptors), which in turn creates a neurological sequence of events that closes the pain gate. This often causes an immediate reduction in pain.

The quality of the mechanoreceptive input and proprioception are a significant factor in the state of the pain gate. Improved mechanoreception and proprioception close the pain gate. Chiropractic adjusting improves mechanoreception and proprioception. Consequently, chiropractors are noted for their treatment and management of pain syndromes, especially for spine pain syndromes.

••••••••••

The most important modern review of the chiropractic profession was published in the journal Spine in December 2017, and titled (7):

The Prevalence, Patterns, and Predictors
of Chiropractic Use Among US Adults
Results From the 2012 National Health Interview Survey

The aim of this study was to investigate the lifetime and 12-month prevalence, patterns, and predictors of chiropractic utilization in the US general population. The data for this study was from the National Health Interview Survey (NHIS), which is the principle and reliable source of comprehensive health care information in the United States, utilizing a nationally representative sample of the civilian non-institutionalized population of the United States. The NHIS dataset provides a large-scale nationally representative sample regarding chiropractic use.

The authors note that chiropractic uses manual therapy to treat musculoskeletal and neurological disorders. Chiropractic is covered by Medicare and Medicaid for all adults in the United States. Chiropractic is included in the workers’ compensation systems in most US States. There are more than 70,000 practicing chiropractors in the United States. The total cost for US chiropractic visits in 2013 is estimated to be more than $10 billion.

The authors make the following points pertaining to the chiropractic profession:

“Chiropractic is one of the largest manual therapy professions in the United States and internationally.”

“Chiropractic is one of the commonly used complementary health approaches in the United States and internationally.”

“There is a growing trend of chiropractic use among US adults from 2002 to 2012.”

The review of the chiropractic profession revealed these statistics:

Findings (rounded)

Percentage that used Chiropractic:	Percentage
In Their Lifetime	24%
In The Past Year	8%
Reason to use Chiropractic	Percentage
For General Wellness or General Disease Prevention	43%
To Improve Energy	16%
To Improve Athletic or Sports Performance	15%
To Improve Immune Function	11%
To Improve Memory or Concentration	5%
Did Chiropractic Motivate to?	Percentage
Exercise More Regularly	22%
Eat Healthier	11%
Cut Back or Stop Smoking Cigarettes	6%
Eat More Organic Food	6%
Cut Back or Stop Drinking Alcohol	3%
Did Chiropractic lead to?	Percentage
Improve Overall Health and Make You Feel Better	67%
Help to Sleep Better	42%
Help to Reduce Stress Level or to Relax	40%
Make it Easier to Cope With Health Problems	38%
Give a Sense of Control Over Health	32%
Helps to Feel Better Emotionally	27%
Improve Attendance at Job or School	17%
Improve Your Relationships With Others	13%
How Important was Chiropractic for Maintaining Health and Well-being?	Percentage
Very Important	48%
Somewhat Important	30%
Slightly Important	14%
Not at All Important	9%
Used Chiropractic for a Specific Top Health Problem	70%
Specific Health Problems Chiropractic Used For	Percentage
Back Pain or Back Problems	63%
Neck Pain or Neck Problems	30%
Joint Pain or Stiffness	14%
Muscle or Bone Pain	9%
Severe Headache/Migraine	5%
Arthritis	5%
Chronic Pain	4%
Chiropractic Helped for Specific Health Problem	Percentage
A Great Deal	65%
Some	26%
Only a Little	6%
Not at All	3%
Chiropractic Practitioner Was Seen Because	Percentage
Therapy Combined with Medical Treatment Would Help	65%
It Treats the Cause and not Just the Symptoms	62%
It is Natural	38%
Medical Treatments do not Work for Your Specific Health Problem	34%
It Focuses on the Whole Person, Mind, Body, and Spirit	25%
Medications Cause Side Effects	18%
It was Part of Your Upbringing	11%
Medical Treatments Were too Expensive	6%

In addition to these statistics, the study revealed that 55 million adults in the US had been to a chiropractor; 19 million adults in the US have consulted a chiropractor within the previous 12 months. Importantly, the primary source for chiropractic information by patients was the internet.

The article included these specific comments:

“Back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being.”

“Back pain or back problems (63.2%) and neck pain or neck problems (30.2%) were by far the top specific health problems for which people consulted a chiropractor in the past 12 months, followed by joint pain/stiffness (13.6%) and other pain conditions. Around two in three users (64.5%) reported that chiropractic had helped a great deal to address these health problems.”

“A substantial proportion of US adults utilized chiropractic services during the past 12 months and reported associated positive outcomes for overall well-being and/or specific health problems for which concurrent conventional care was common.”

“Our analyses show that, among the US adult population, spinal pain and problems – specifically for back pain and neck pain – have positive associations with the use of chiropractic.”

“The most common complaints encountered by a chiropractor are back pain and neck pain and is in line with systematic reviews identifying emerging evidence on the efficacy of chiropractic for back pain and neck pain.”

“Chiropractic services are an important component of the healthcare provision for patients affected by musculoskeletal disorders (especially for back pain and neck pain) and/or for maintaining their overall well-being.”

“Our analysis suggests the use of chiropractic practice in the US population has increased from the period 2002 to 2012.”

There is a high level of satisfaction by patients who seek treatment for spinal and other pain syndromes from chiropractors. By a significant margin, the primary reason for adults in the US to seek chiropractic care is for back pain (63%), followed distantly by neck pain (30%).

Systematic reviews and meta-analysis evidence supporting chiropractic/spinal manipulation in the treatment of back pain continue to mount. These studies are published in the best scientific journals. Two recent such studies are reviewed here, one pertaining to acute back pain and the other to chronic back pain.

••••••••••

The acute back pain study was published in April 2017 in the Journal of the American Medical Association, and titled (8):

Association of Spinal Manipulative Therapy With
Clinical Benefit and Harm for Acute Low Back Pain:
Systematic Review and Meta-analysis

The objective of this article was to systematically review studies of the effectiveness and harms of spinal manipulative therapy (SMT) for acute (less than 6 weeks duration) low back pain. The authors found 26 eligible randomized clinical trials (RCTs) for review.

The measurement outcomes used in the studies included:

• Pain measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale.
• Function (measured by the Roland Morris Disability Questionnaire or Oswestry Disability Index).

The spinal manipulative therapy was provided by physical therapists in 13 studies, chiropractors in 7 studies, medical doctors in 5 studies, and osteopaths in 3 studies.

The authors note that back pain is among the most common symptoms prompting patients to seek healthcare. The lifetime prevalence estimates of low back pain exceed 50%. Acute low back pain is common and spinal manipulative therapy is a treatment option. The findings of this article included:

“In this systematic review and meta-analysis of 26 randomized clinical trials, spinal manipulative therapy was associated with statistically significant benefits in both pain and function.”

“Mild, transient harms were reported by 50% to 67% of patients. The most commonly reported adverse effects were local discomfort or increased pain. No serious harms were reported in any of these studies.”

“No RCT [randomized clinical trial] reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time.”

“Thrust-type manipulation may be more effective than nonthrust-type manipulation.”

This article generated the following editorial by Richard A. Deyo, MD, MPH (9). Dr. Deyo is from the Department of Family Medicine, Oregon Health and Science University, Portland, OR.

The etiology of back pain is often unclear. It is important to acknowledge that for many patients with acute back pain without radiculopathy, a precise pathoanatomical cause of the pain cannot be identified.

There are approximately 200 treatment options available to treat low back pain. “Spinal manipulative therapy is a controversial treatment option for low back pain, perhaps in part because it is most frequently administered by chiropractors.”

Besides the physiological mechanisms by which spinal manipulation helps people with back pain, chiropractic and spinal manipulation has other therapeutic physiologic benefits, including:

• The hands-on, high-touch nature of treatment
• An ongoing patient-clinician relationship through repeated visits
• An expectation of change
• A feeling of empowerment
• Clinician enthusiasm, reassurance, and conviction

“Chiropractic care is popular today with the US public. According to a 2012 report, among patients with back or neck pain, approximately 30% sought care from a chiropractor.”

“In a 2013 survey by Consumer Reports magazine involving 14,000 subscribers with low back pain, chiropractic care had the largest proportion of ‘highly satisfied’ patients.”

“The conclusions of the systematic review by Paige et al are generally consistent with another recently completed systematic review and clinical guideline from the American College of Physicians.”

Spinal manipulative therapy typically involves multiple visits. “However, the cost of caring for complications from pharmacologic therapies may exceed the costs of spinal manipulative therapy.”

“It appears that SMT is a reasonable treatment option for some patients with low back pain. The systematic review by Paige et al suggests a treatment effect similar in magnitude to nonsteroidal anti-inflammatory drugs.”

“If manipulation is at least as effective and as safe as conventional [drug] care, it may be an appropriate choice for some patients with uncomplicated acute low back pain.”

“This is an area in which a well-informed patient’s decisions should count as much as a practitioner’s preference.”

••••••••••

The chronic back pain study was just published [Epub ahead of print, 2018] in The Spine Journal, and titled (10):

Manipulation and Mobilization for Treating Chronic Low Back Pain:
A Systematic Review and Meta-analysis

The primary author of this study is from RAND Corporation. The purpose of this study was to determine the efficacy, effectiveness, and safety of various mobilization and manipulation therapies for treatment of chronic low back pain. This is a systematic literature review and meta-analysis from published studies between 2000-2017. The authors selected randomized controlled trials comparing manipulation or mobilization therapies with sham, no treatment, other active therapies, and multimodal therapeutic approaches. Fifty-one studies were included in this systematic review. Initially, 7,360 published citations were captured and a total of 64 randomized clinical trial (RCT) publications reporting on patients with chronic, non-specific low back pain were included. The total number of participants across the 51 unique studies used was 8,748.

Chronic pain was defined as “ongoing or recurrent pain, lasting beyond the usual course of acute illness or injury or more than 3–6 months, and which adversely affects the individual’s well-being.”

Non-specific low back pain was defined as “pain not attributable to a recognizable, known specific pathology (infection, tumor, osteoporosis, fracture, structural deformity, rheumatoid arthritis, radicular syndrome). Therefore, the etiology of the pain is often unknown and it is not categorized as major pathogenic etiology.”

The outcome measures were self-reported pain, function, health-related quality of life, and adverse events. The specific measurement outcome tools seen in the studies assessed included:

• Pain intensity or severity, measured by a VAS (visual analog scale) or NRS (numeric rating scale)
• Disability, measured by the RMDQ (Roland-Morris Disability Questionnaire)
• HRQoL (health-related quality of life) measured by the SF-36

These authors also note that “non-specific chronic low back pain is difficult to evaluate, and the nature of the pain and its underlying pathophysiology are poorly understood.” The lifetime prevalence of low back pain in the US may be as high as 84% of the population, and the prevalence of chronic low back pain is about 23%. The authors make these points:

In treating low back pain, “many physicians rely on non-steroidal anti-inflammatory drugs, opioid, and neurotropic medications, or steroid injections and surgery as their main tools. Because of the potential or apparent risks associated with these tools, non-pharmacological approaches, thought to involve minimal adverse events, have become popular.”

“Given the current interest in non-pharmacological alternatives for the treatment of chronic pain, in particular non-opioid treatments, a systematic review of manipulation and mobilization for chronic low back pain is timely.”

“Mobilization and manipulation therapies are widely used to benefit patients with chronic low back pain.”

“Recent systematic reviews suggest that spinal manipulation and mobilization are ‘viable’ options for pain treatment.”

“The overall evidence suggests that manipulation and mobilization are effective treatment modalities compared with other therapies.”

“All studies showed a statistically significant larger reduction in disability from thrust [manipulation] vs. non-thrust [mobilization] interventions.”

“Mobilization interventions, compared with other active comparators including exercise regimens, significantly reduced pain but not disability.”

“There is moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function for patients with chronic low back pain; manipulation appears to produce a larger effect than mobilization. Both therapies appear safe.”

The “analyses showed that manipulation significantly reduced pain and disability, compared with other active comparators including exercise and physical therapy.”

“Mobilization and manipulation appear to be safe, based on what was reported in the literature.”

••••••••••

The effectiveness and satisfaction with chiropractic treatment for back pain is quite high. Not only is chiropractic effective, it is also extremely safe. Additionally, chiropractic’s non-drug approach to the management of pain syndromes eliminates the potential adverse effects that are coupled with drug approaches to pain management, especially for chronic pain.

The evidence to support chiropractic for pain and especially for spinal pain management continues to escalate.

REFERENCES:

1. Foreman J; A Nation in Pain, Healing Our Biggest Health Problem; Oxford University Press; 2014.
2. Pho, K; USA TODAY, The Forum; September 19, 2011; pg. 9A.
3. Wang S; Why Does Chronic Pain Hurt Some People More?; Wall Street Journal; October 7, 2013.
4. Melzack R, Wall P; Pain mechanisms: a new theory; Science; November 19, 1965;150(3699); pp. 971-979.
5. Dickenson AH; Gate Control Theory of Pain Stands the Test of Time; British Journal of Anaesthesia; June 2002; Vol. 88; No. 6; pp. 755-757.
6. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
7. 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.
8. Paige NM, Miake-Lye IM, Booth MS, Beroes JM, Mardian AS, Dougherty P, Branson R, Tang B, Morton SC, Shekelle PG; Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis; Journal of the American Medical Association; April 11, 2017; Vol. 317, No, 14; pp. 1451-1460.
9. Deyo RA; The Role of Spinal Manipulation in the Treatment of Low Back Pain; Journal of the American Medical Association; April 11, 2017; Vol. 317; No, 14; pp. 1418-1419.
10. Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Booth MS, Herman PM; Manipulation and Mobilization for Treating Chronic Low Back Pain: A Systematic Review and Meta-analysis; The Spine Journal; January 31, 2018 [Epub ahead of print].

A Modern Epidemic of Poor Posture, Neck Pain, Shoulder Pain, Arm/Hand Neurological Symptoms and Accelerated Spinal Degenerative Arthritis

[“Text Neck” and “Tech Neck” are synonymous]

On Monday, March 3, 2018, the front page of the newspaper USA Today printed a “snapshot” noting that “US consumers spend an average of 7.8 hours each day engaging with digital content.”

Representative Background Story #1

On April 14, 2017, reporter Carolyn Crist wrote an article, published in Reuters Health, titled (1):

Leaning Forward During Phone Use May Cause ‘Text Neck’

In this article, Ms. Crist makes the following points:

• Spine surgeons are noticing an increase in patients with neck and upper back pain, likely related to poor posture during prolonged smartphone use.
• Young patients who should not have back and neck issues are reporting disk hernias and spinal alignment problems.
• “In an X-ray, the neck typically curves backward, and what we’re seeing is that the curve is being reversed as people look down at their phones for hours each day,” said Dr. Todd Lanman, a spinal neurosurgeon at Cedars-Sinai Medical Center in Los Angeles.
• “By the time patients get to me, they’re already in bad pain and have disc issues,” he told Reuters Health. “The real concern is that we don’t know what this means down the road for kids today who use phones all day.”
• People often look down when using their smartphones, particularly when texting as compared to browsing online or watching videos.
• Studies have found that people hold their necks at around 45 degrees forward when using their smartphones.
• When in a neutral position looking forward, the head weighs about 10 to 12 pounds. At a 15-degree forward flexion position, it functions as if it weighed 27 pounds.
• At 60 degrees of forward flexion, the stress on the spine increases to about 60 pounds.
• These prolonged abnormal stresses on a growing spinal column may lead to abnormal spinal development with dire long-term spinal health consequences in adulthood.
• Simple lifestyle changes are suggested to relieve the stress from the “text neck” posture, including holding cell phones in front of the face while texting, and using two hands and two thumbs to create a more symmetrical and comfortable position for the spine.
• Also, people who work at computers or on tablets should use an elevated monitor stand so it sits at a natural horizontal eye level.
• Take frequent rest breaks and/or engage in some physical exercise that can strengthen the neck and shoulder muscles. 1) Lie on a bed and hang one’s head backward over the edge, extending the neck to restore the normal arc in the neck. 2) While sitting/standing, attempt to align the neck with the ears over the shoulders and the shoulders over the hips.

Representative Background Story #2

This week (March 5, 2018), reporter Kirsten Fleming wrote an article that was published in The New York Post, titled (2):

Tech is Turning Millennials Into a Generation of Hunchbacks

In this article, Ms. Fleming profiles the situation of a young man, CY, who began suffering from upper-back pain and neck soreness while in his late teens, subsequent to a habit of hunching over his cellular phone. As his symptoms progressed he developed constant pain, he hunched his shoulders, and the pain caused him to wake up numerous times throughout every night, causing constant fatigue. His upper back and neck would become incredibly tight; his neck was always bent forward.

After a decade of suffering, CY’s chiropractor diagnosed him with “tech neck,” explaining that the cause was the forward/bent neck posture he assumed while using his laptop and iPhone. “Tech neck” is a painful forward head syndrome. It is an increasingly common condition caused by slumping over devices for hours a day, leading to a reversal of the natural neck spinal curve and triggering a physiological imbalance in the upper body.

“Previously seen in middle-age or older desk jockeys and dentists who hunch over patients, it’s now materializing in younger generations who grew up with smartphones, tablets and other personal devices.” Not only does the syndrome cause structural problems in the neck and back, it can also spark breathing and panic issues.

The loss or reversal of the normal cervical curve is easily diagnosed with postural x-rays.

“As posture worsens, the upper back muscles stretch out, while the muscles in the front of the body become weaker and the neck creeps forward.” Young women are particularly susceptible to the condition because they have lower muscle density in their upper body.

“iPhone-obsessed millennials poring over Instagram and Snapchat all day don’t want to admit that their precious electronic lifelines might be detrimental to their health.”

“Undoing the damage is a process that includes breaking bad habits, taking standing breaks and doing exercises such as yoga, foam rolling and stretches that promote good carriage and strengthen core and upper body muscles. Experts also advise patients to hold mobile devices with their elbows at 180 degrees so the screen is in front of their faces.”

Treatment options outlined by Ms. Fleming include chiropractic, restorative postural traction, postural and core exercises.

Consulting chiropractors made the following comments pertaining to tech neck:

• “We’re seeing it in younger and younger children because they’re getting their phones at a younger age.”
• “Now, 20-year-olds have the spine health of a 30- or 40-year-old. It’s an epidemic.”

••••••••••

Understanding the Biomechanics of Text/Tech Neck

The understanding of the biomechanics of text/tech neck requires the understanding that upright posture, and the holding of one’s head upright, is a first-class lever mechanical system. In a first-class lever, the fulcrum is in between the load and the effort. An example of a first-class lever is a teeter-totter or a seesaw:

In all first-class lever mechanical systems, the fulcrum is the point of greatest mechanical stress. Excessively large loads with excessively large balancing efforts will cause the lever to break at the fulcrum. When the fulcrum is exposed to excessive prolonged sub-catastrophic loads, the fulcrum itself suffers from wear and tear damage.

The effective load on the fulcrum is greater than the sum of the weight of the load plus the counterbalancing effort because the distance they are from the fulcrum is mechanically multiplied:

If a 10-pound load is 10 inches from the fulcrum, the effective load on the fulcrum is 100 pounds. The addition of the counterbalancing effort would bring the effective load on the fulcrum to 200 pounds.

In the human body, upright and on two feet, the fulcrum is the spinal column, specifically the vertebrae, and more the vertebral joints (the disc and the facets). In the text/tech neck position, the head is no longer ideally positioned over the fulcrum (the spinal column and vertebrae); rather the head is displaced forward of the fulcrum.

If the weight of the head is 10 pounds and the head is displaced forward by 3 inches, the load on the spinal fulcrum (the vertebrae) is 30 pounds (10 pounds X 3 inches). The required counter balancing muscle contraction on the opposite side of the fulcrum (the vertebrae) would also be 30 pounds. The net total increased fulcrum (spinal vertebral) load is 60 pounds. This exposes the spinal column (vertebrae) to chronic wear and tear damage. The common lexicon for this wear and tear damage is degenerative joint disease, or more simply, spinal arthritis.

When the head is chronically bent forward, the muscles (the effort) on the opposite side of the spinal column must chronically contract to prevent the person from falling forward and to maintain balance (3).

The chronic counterbalancing muscle contraction results in chronic inflammation, pain, muscle tissue fibrosis, and functional disability (3). The syndrome associated with this sequence of events has been termed myofascial pain syndrome (4, 5, 6).

Chronic forward bending of the head/neck causes a number of clinical problems, including:

• Chronic contraction of the muscles at the back of the head, neck, shoulders, and upper back. This causes muscle fatigue, soreness, tightness, inflammation, and pain. This is called myofascial pain syndrome (4, 5, 6).
• The chronic muscle contraction often results in headaches (7, 8).
• Acceleration of degenerative joint disease (arthritis) of the spinal joints (9, 10, 11, 12).
• Spinal Cord Tethering (13, 14): this is an abnormal elongation (stretching) of the spinal cord that can result in both spine neuron dysfunction and/or spinal cord vascular compromise. These can result in both autonomic and musculoskeletal symptoms.
• Spinal Cord Demyelination (15): chronic forward head compromises the blood flow to the spinal cord with a long-term consequence of the loss of the insulation (demyelination) of the neurons of the spinal cord.
• Vertebral Artery blood flow compromise (16): the vertebral artery is the pipeline carrying blood, nutrients and oxygen to the brainstem. The vertebral artery resides inside the cervical spine vertebrae in an opening called the foramen transversarium. There is evidence that loss of cervical lordosis (kyphosis, forward head) results in a compromise of blood flow from the heart, through the vertebral artery in the foramen transversarium and into the brain stem. This would adversely affect cranial nerve and other vital function.

Text/Tech Neck Studies From the Scientific/Medical Literature

The explosion of text/tech neck health problems has not gone unnoticed in the scientific/medical literature:

Kenneth K. Hansraj, MD, is Chief of Spine Surgery, at the New York Spine Surgery & Rehabilitation Medicine facility. In 2014, Dr. Hansraj, published an article in the journal Surgical Technology International, titled (17):

Assessment of Stresses in the Cervical Spine
Caused by Posture and Position of the Head

In this article, Dr. Hansraj notes that billions of people are using cell phone devices on the planet, essentially in poor posture. Consequently, the purpose of this study was to assess the forces incrementally seen by the neck (cervical spine) as the head is tilted forward, into worsening forward head posture. Dr. Hansraj notes that this data is necessary for cervical spine surgeons to understand in the reconstruction of the neck.

Dr. Hansraj indicates that an average person spends 2-4 hours a day with their heads tilted forward reading and texting on their smart phones / devices, amassing 700-1400 hours of excess, abnormal cervical spine stress per year. A high school student may spend an extra 5,000 hours in poor posture per year.

Dr. Hansraj created a cervical spine model to calculate the forces experienced by the cervical spine when in incremental flexion (forward head position). His mathematical analysis used a head weight of 13.2 pounds. He claims that there are no other prior studies assessing the stresses about the neck when incrementally moving the head forward. His calculations are as follows:

Dr. Hansraj makes the following key points in his study:

“Poor posture invariably occurs with the head in a tilted forward position and the shoulders drooping forward in a rounded position.”

“The weight seen by the spine dramatically increases when flexing the head forward at varying degrees.”

“Loss of the natural curve of the cervical spine leads to incrementally increased stresses about the cervical spine. These stresses may lead to early wear, tear, degeneration, and possibly surgeries.”

••••••••••

In January of 2017, researchers from the Department of Occupational and Environmental Medicine, University of Gothenburg, Sweden, published a study in the journal Applied Ergonomics, titled (18):

Texting on Mobile Phones and Musculoskeletal
Disorders in Young Adults: A Five-year Cohort Study

The aim of this study was to examine whether texting on a mobile phone is a risk factor for musculoskeletal disorders in the neck and upper extremities in a population of young adults, aged 20-24 years. The study duration was 5 years.

The authors indicate that young adults today have grown up with mobile phones as an evident part of their lives. Access to mobile phones was 99% in the group of young adults they studied. In the United States, text messaging is the most frequently used type of communicative medium.

The authors note that text messaging places a repetitive physical exposure on the neck, shoulders, arms and thumbs. Studies have identified musculoskeletal disorders in the forearm and thumb, tendonitis, tenosynovitis, and first carpometacarpal (CMC) arthritis, in relation to excessive texting on a mobile phone. “Texting can be associated with musculoskeletal disorders of the neck and upper extremity.”

In the subjects with symptoms, almost all individuals had the neck flexed forward and did not support their arms. “This causes static muscular load in the neck and shoulders. Furthermore, they held the phone with one hand and used only one thumb, implying increased repetitive movements in hand and fingers. This distinguished them from the group without symptoms, in which it was more common to sit with a straight neck, to support the forearm, to hold the phone with two hands and to use both thumbs.” The authors concluded:

“Sitting with the head bent forward while texting was more common among those with musculoskeletal symptoms.”

“Associations were found between text messaging and reported pain in the neck/upper back, shoulder/upper extremities, and numbness/tingling in the hand/fingers for both men and women.”

“There were clear associations between the highest category of text messaging and pain in the neck/upper back.”

“Sustained neck flexion may be a risk factor for developing pain in the neck, shoulder, and upper extremities.”

“Sitting with the head bent forward without supporting the arms causes a static load in the neck and shoulder muscles, which could explain the reported pain from neck/upper back.”

“Sustained muscle load and posture are considered to be risk factors for developing musculoskeletal disorders.”

“Associations with neck and upper extremity pain were found at levels of text messaging as low as 6 texts/day.”

“The strongest associations with neck/upper back and shoulder pain concerned the highest exposure category (>20 texts/day) in both men and women.”

“A prospective study with a working population showed that flexing the neck >20° for more than 40% of the working day was a risk factor for sick leave due to neck pain.”

These authors believe that the associations between cell phone use and health symptoms are underestimated because they did not include data on how much the participants use their mobile phones for other activities, e.g. gaming.

••••••••••

In June 2017, physicians from the Departments of Orthopaedic Surgery and Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA, published a study in The Spine Journal, titled (19):

“Text Neck”
An Epidemic of the Modern Era of Cell Phones?

The authors note that cellular/smart phones are everywhere. They are being extensively used by people of all ages. A concern to the modern era physician is the potential musculoskeletal consequence of this extensive cell phone usage, especially texting.

Extensive cell phone use and postures cause spondylotic changes consistent with an aged spine, but they are now being found in younger and younger age groups, including:

• Disc herniations
• Kyphotic alignment
• Abnormal imaging studies

As spine surgeons, the authors have been noticing a rise in the number of patients complaining of neck and upper back pain. It is plausible that these increased stresses upon the cervical spine result in accelerated cervico-thoracic disc degeneration. These authors propose that there are significant increases in intradiscal pressure during flexion, and that “chronic increased intradiscal pressure likely contributes to disk degeneration [cervical spondylosis] and herniation.”

These authors cite a finite element analysis that measured the increased loads imparted onto the cervical spine at progressively flexed postures. The findings included:

• While in a neutral position, the head weight on the neck is about 10–12 lbs.
• Flexing the head/neck forward 15° increases the weight on the cervical spine to 27 lbs.
• Flexing the head/neck forward 30° increases the weight on the cervical spine to 40 lbs.
• Flexing the head/neck forward 45° increases the weight on the cervical spine to 49 lbs.
• Flexing the head/neck forward 60° increases the weight on the cervical spine to 60 lbs.

These authors also cite a study of over 7,000 young adult subjects (age 20–24) over a 5-year period that showed “persistent neck pain and upper back pain is associated with time spent text messaging.” This same study also showed increased “shoulder pain, numbness, and tingling in the hand or fingers in those subjects who spent the most time texting.”

“It now seems rather clear that repetitive texting, or similar activity while using a forward flexed neck position, may lead to neck pain or ‘text neck’.”

These authors have great concern for the consequences of prolonged cervical spine flexion while texting on the developing (growing) spine. They note that persistent, prolonged forward flexed neck position may lead to anterior ligamentous contractures, accelerating cervical disk degeneration and cervical kyphosis.

These authors make these recommendations to avoid and/or treat text/tech neck:

• Patients hold their cell phone up at or near eye level while texting.
• Texting with two hands and two thumbs may provide more extremity and interscapular muscle symmetry.
• “For patients who spend significant time working at a computer or tablet we recommend the use of elevated stands for desktop monitors so that the monitor is at a natural horizontal gaze level.”
• Subjects should perform basic exercises that stretch and strengthen the cervical and upper thoracic soft tissue.

••••••••••

Chiropractors are expertly trained in the ergonomic avoidance of the postures that lead to text/tech neck, advising and coaching thousands of patients on these issues daily. Chiropractic clinical practice offers a variety of treatment approaches that are very effective in the management of the text/tech neck syndrome (20, 21, 22, 23, 24, 25, 26, 27, 28).

Perfection:

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