Author: tmpl_admin

Chiropractic spinal adjustments (specific line-of-drive manipulations) are quite effective for the management of spinal musculoskeletal complaints and injuries. This is not controversial. Studies documenting the clinical effectiveness of chiropractic and spinal manipulation for the management of spinal musculoskeletal complaints and injuries have appeared in the literature for more than half a century (1, 2, 3, 4, 5, 6, 7, 8, 9, 10).

Consequently, in this modern era of maximizing clinical outcomes, it is commonplace for spine pain clinical practice guidelines to include chiropractic and/or spinal manipulation (11, 12, 13, 14, 15).

A related concept to clinical effectiveness of chiropractic and spinal manipulation for the management of spinal musculoskeletal complaints and injuries is assessing the cost effectiveness of such chiropractic care. Here is presented a review of published studies assessing the cost effectiveness of chiropractic care for musculoskeletal complaints.

•••••

Preliminary Academic Theoretical Evidence

In 2012, Ronald Donelson, MD, and colleagues published a study in the journal Physical Medicine and Rehabilitation titled (16):

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

In this study the authors document that recurrent low back pain episodes were common and numerous, occurring in 73% of low back pain episodes. They note that these recurrences often worsened over time, often becoming severe and chronic. Importantly, they indicate that 84% of total medical costs for patients with LBP are related to recurrences.

In 2011, Manuel Cifuentes, MD, PhD, and colleagues published a study in the Journal of Occupational and Environmental Medicine titled (17):

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

In this study the authors defined maintenance care as treatment given to patients after recovery from a low back pain episode, delivered in an effort to reduce episodes of recurrences. They noted that maintenance chiropractic care significantly reduced the incidence of low back pain recurrence.

If chiropractic maintenance care reduced incidences of low back pain recurrence, and if recurrence is responsible for the majority of low back pain treatment costs, it would suggest that chiropractic care is quite cost effective for the treatment of low back pain. The authors state:

Chiropractic patients had “less expensive medical services and shorter initial periods of disability than cases treated by other providers.”

Chiropractic patients had “fewer surgeries, used fewer opioids, and had lower costs for medical care than the other provider groups.”

These statements further support the cost effectiveness and cost savings associated with chiropractic care for low back pain.

Pertaining to the value of maintenance care delivered by chiropractors, a PubMed indexed article was published on the topic in 2011, titled (18):

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

In this article, Dr. David Taylor presents an anatomical and physiological basis for maintenance chiropractic spinal manipulation. His conclusions are the benefits of such care are lost if not delivered between every 2-4 weeks.

Cost Assessment Evidence

In 2010, Richard Liliedahl, MD, and colleagues published a study in the Journal of Manipulative and Physiological Therapeutics titled (19):

Cost of Care for Common Back Pain Conditions Initiated with Chiropractic Doctor vs. Medical Doctor/Doctor of Osteopathy as First Physician

The primary aim of this study was to determine if there are differences in the cost of low back pain care when a patient is able to choose a course of treatment with a medical doctor (MD) versus a doctor of chiropractic (DC), given that his/her insurance provides equal access to both provider types. The authors identified 85,402 subjects who meet the diagnostic criteria for a low back pain claim. They chose low back pain as the focus of study because it is a condition that is prevalent, costly, and is treated by both medical doctors and chiropractors.

The authors note that back problems are one of the top 10 most costly conditions treated in the United States. There are hundreds of millions of patient visits to chiropractors yearly. Twenty percent of those reporting back or neck pain seek chiropractic care, and patients are highly satisfied with chiropractic care.

The authors “found statistically significant lower costs in episodes of care initiated with a DC as compared to an MD.” They state:

“Our results support a growing body of evidence that chiropractic treatment of low back pain is less expensive than traditional medical care.”

“We found that episode cost of care for LBP initiated with a DC is less expensive than care initiated through an MD.”

“Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD.”

“Our results suggest that insurance companies that restrict access to chiropractic care for LBP may, inadvertently, be paying more for care than they would if they removed these restrictions.”

“Beneficiaries in our sampling frame had lower overall episode costs for treatment of low back pain if they initiated care with a DC, when compared to those who initiated care with an MD.”

•••••

In 2012, a study was published in the Journal of Occupational and Environmental Medicine titled (20):

Value of Chiropractic Services at an On-Site Health Center

The authors noted that the direct costs in the United States for the treatment of back and neck pain are escalating. Back problems are the second most common cause of disability in the United States, accounting for tens of billions of dollars in lost wages.

The authors note that chiropractic patients have lower utilization of ancillary medical services, and that chiropractic care is less invasive and more conservative than alternative treatments. They state:

“Patients with chiropractic coverage seemed to be avoiding more surgeries, hospitalizations, and radiographic imaging procedures.”

Consequently, the authors acknowledge that chiropractic care has the potential to reduce the economic and clinical burden of musculoskeletal conditions and to reduce indirect costs, including absenteeism and productivity losses. They conclude:

“Compared with alternatives, including physician visits, hospitalizations, and surgery, chiropractic care is considered a cost-effective treatment.”

•••••

In 2013, Benjamin J. Keeney, PhD, and colleagues published a study in the journal Spine titled (21):

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury:
Results from a Prospective Study of Workers in Washington State

This was a prospective population-based cohort study whose objective is to identify early predictors of lumbar spine surgery within 3 years after occupational back injury, noting:

“Back pain is the most costly and prevalent occupational health condition among the U.S. working population.”

The authors reference that the most costly aspect of treating occupational back pain is the cost of spinal surgery. They reasoned that if good clinical outcomes could be obtained without spinal surgery there would be substantial costs savings, stating:

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

In this three-year study, approximately 43% of injured workers whose first provider was a surgeon underwent spinal surgery. In contrast, when the first provider consulted was a chiropractor, the surgery rate was only 1.5%. The reduced surgery rate with chiropractic was a stunning 78%. The authors state:

“42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor.” “There was a very strong association between surgery and first provider seen for the injury, even after adjustment for other important variables.” “It is possible that these findings indicate that “who you see is what you get.”

“In Washington State worker’s compensation, injured workers may choose their medical provider. Even after controlling for injury severity and other measures, workers with an initial visit for the injury to a surgeon had almost nine times the odds of receiving lumbar spine surgery compared to those seeing primary care providers, whereas workers whose first visit was to a chiropractor had significantly lower odds of surgery.”

These authors also indicate that previous studies have shown:

• Those with occupational back injuries who first saw a chiropractor had lower odds of chronic work disability.
• Those seeing chiropractors for occupational back pain had “higher rates of satisfaction with back care.”

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

•••••

In 2015, a study was published in the journal BioMed Central (BMC) Health Services Research titled (22):

A Systematic Review Comparing the Costs of Chiropractic Care
to Other Interventions for Spine Pain in the United States

This is a comprehensive study designed to compare health care costs for patients with spine pain who received chiropractic care v. care from other healthcare providers. The search included studies published in English between 1993 and 2015. The search uncovered 1,276 citations and 25 eligible studies. This study was huge, with the number of members/episodes included in groups receiving chiropractic care ranging from 97 to 36,280.

The authors note that for those with spine pain, 61% seek care from a medical physician (MD or DO), 28% from a chiropractor, and 11 % from both a medical physician and a physical therapist. Chiropractors in the United States treat spine pain almost exclusively, with the most common indication for care being low back pain (68%), followed by neck pain (12%), and mid-back pain (6%). Only 3% of office visits to medical physicians are related to spine pain.

Chiropractors have more confidence in their ability to manage spine pain than medical physicians. Patients with spine pain report higher levels of satisfaction with chiropractic care than care from a medical physician.

The findings of this review were that 92% of the studies reported that health care costs were lower for members whose spine pain was managed by chiropractic care than by other providers, by a mean of 36%. The authors state:

“In general, the findings in this review suggest that health care costs may be lower when spine pain is managed with chiropractic care in the US, even if such differences are sometimes attributable to sociodemographics, clinical, or other factors rather than healthcare providers.”

“These findings echo that of a review published in 1993 that examined studies in which LBP was managed by spinal manipulation, chiropractic care, other interventions (e.g. physical modalities, medications, exercise) throughout the world (e.g. Australia, Canada, Egypt, Italy, the Netherlands, New Zealand, Nigeria, Sweden, United Kingdom, and US). Based on the favorable short-term clinical improvements and lower costs of care reported in those studies, the previous review concluded that health care costs could be reduced if a higher proportion of patients with spine pain received chiropractic care rather than other interventions, and recommended a greater integration of chiropractors into the publicly financed health care system.”

•••••

In 2016, a study was published in the Journal of Occupational Rehabilitation titled (23):

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 2 years.

The authors note that at any given point, the prevalence of back pain is about 9% of the population. The lifetime prevalence of back pain is about 85%. Back pain is the most common occupational injury in Canada and the United States. Back pain causes more years of life with disability than any of the other 291 conditions studied.

These authors found chiropractic care for back pain to be exceptionally cost effective, noting:

“Workers who first saw a chiropractor were less likely to become chronically work disabled.”

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.”

“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.”

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

•••••

Another study from the same group was also published in 2016, titled (24):

Workers’ Characteristics Associated with the Type of
Healthcare Provider First Seen for Occupational Back Pain

The study used 5,520 low back-injured workers to compare the factors that drive patients’ decision to choose a chiropractor, physician or physiotherapist as their first healthcare provider. They note that about one-third of low back pain is attributed to occupational injury. These authors found that the workers who first sought a physician did not have higher odds of having a severe injury.

These authors note that low back pain is “often recurrent or chronic.”

Back pain is a leading cause of disability worldwide.

Once again the cost effectiveness of chiropractic care was evident. The authors noted:

“Chiropractic care was associated with lower use of medication, radiographic investigation, and surgery.”

“We found that workers who reported a previous similar injury were more likely to seek physiotherapy and chiropractic care.”

“It is reasonable to think that workers will seek care that they perceived as effective for a similar condition, compensated or not, in the past.”

“Our results suggest that workers suffering from more severe conditions are more likely to seek physiotherapy and chiropractic care than medical care.”

•••••

In 2017, a study was published in the journal Complementary Therapies in Medicine titled (25):

Alternative Medicine, Worker Health, and
Absenteeism in the United States

This paper reviews the literature on healthcare utilization and absenteeism by exploring whether Complementary and Alternative Medicine (CAM) treatment is associated with fewer workdays missed due to illness. With the high costs of illness-related absenteeism, employers and policy makers are interested in treatments and interventions that might reduce sick days and improve worker health. This study investigates whether workers that visit a CAM practitioner exhibit improved health or miss fewer workdays due to illness. The studies involved 8820 subjects.

Five different CAM practices were considered:

• Active mind-body (e.g. yoga, meditation)
• Naturopathy
• Massage therapy
• Chiropractic
• Acupuncture

In 2012, health related absenteeism costs an estimated $153 billion annually in the United States. Most of this absenteeism is attributed to chronic health conditions, contributing significantly to employer healthcare costs. The major chronic condition contributing to absenteeism was low back pain. Specifically, in this study, chronic low back pain occurred in about 25% of the participants.

In this study of 8,820 subjects, those who utilized CAM, including chiropractic, showed the following health benefits:

• Reduced work absenteeism
• Fewer other health care costs
• Improved health
• Preventive health care services

Specifically, chiropractic was “significantly associated with improved health.”

•••••

The Anheuser-Busch Benningfield Experience

Starting in 2012, the Anheuser-Busch distributing company of Peoria, Illinois, Brewers Distributing, attempted something novel in an effort to reduce it’s workers compensation costs: they hired a young chiropractor to work on-site one day per week. The chiropractor’s assignment was to treat small injuries in an effort at preventing them from becoming larger and more expensive, and to prevent injuries all together.

Two years after implementation of this program, the startling statistics began quite evident (26):

It “saved Brewers a significant amount of money. In the two years since it was implemented, the number of employee sick days has declined by 22%, while the accident rate has been cut in half. Consequently, the company’s workers’ compensation costs have experienced a dramatic reduction with premiums declining by more than 25%.”

Updated data from this project are not available through 2016 (27). These findings include:

• 10% reduction in healthcare premiums
• 22% reduction in employee sick days
• 27% reduction in workers’ compensation premiums
• 50% reduction in accident rates

The cost effectiveness and cost savings of this program are substantial and stunning.

•••••

Studies continue to show that not only is chiropractic care effective for musculoskeletal pain, but that it is also cost effective, a money saver, and patients have higher levels of satisfaction with their outcomes. All employers, insurance companies and government healthcare reimbursement programs should be aware of these results.

REFERENCES

1. Parsons WB, Cumming JDA; Manipulation in Back Pain; Canadian Medical Association Journal; July 15, 1958; Vol. 79; pp. 013-109.
2. 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.
3. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low Back Pain; Canadian Family Physician, March 1985, Vol. 31, pp. 535-540.
4. Meade TW, Dyer S, Browne W, Townsend J, Frank OA; Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatient treatment; British Medical Journal; Volume 300, June 2, 1990, pp. 1431-7.
5. Giles LGF, Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine, July 15, 2003; 28(14):1490-1502.
6. Muller R, Lynton G.F. Giles LGF, DC, PhD; Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes; Journal of Manipulative and Physiological Therapeutics; January 2005, Volume 28, No. 1.
7. Kirkaldy-Willis WH, Managing Low Back Pain, Churchill Livingstone, 1983, p. 19.
8. Cifuentes M, Willetts J, Wasiak R; Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence; Journal of Occupational and Environmental Medicine; April 14, 2011; Vol. 53; No. 4; pp. 396-404.
9. Senna MK, Machaly SA; Does Maintained Spinal Manipulation Therapy for Chronic Nonspecific Low Back Pain Result in Better Long-Term Outcome? Randomized Trial; SPINE; August 15, 2011; Volume 36, Number 18; pp. 1427–1437.
10. Ghildayal N, Johnson PJ, Evans RL, Kreitzer MJ; Complementary and Alternative Medicine Use in the US Adult Low Back Pain Population; Global Advances in Health and Medicine; January 2016; Vol. 5; No. 1; pp. 69-78.
11. Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS; Diagnosis and Treatment of Low Back Pain; Annals of Internal Medicine; Volume 147, Number 7, October 2007, pp. 478-491.
12. Roger Chou, MD, and Laurie Hoyt Huffman, MS; Non-pharmacologic Therapies for Acute and Chronic Low Back Pain; Annals of Internal Medicine; October 2007, Volume 147, Number 7, pp. 492-504.
13. Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, DC, Whalen WM, Walters S, Kaeser M, Dehen M, DC, Augat T; Clinical Practice Guideline:
    Chiropractic Care for Low Back Pain; Journal of Manipulative and Physiological Therapeutics; January 2016; Vol. 39; No. 1; pp. 1-22.
14. Wong JJ, Cote P, Sutton DA, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer HM, Carroll LJ, Stern PJ, Ameis A, Southerst D, Mior S, Stupar M, Varatharajan T, Taylor-Vaisey A; Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration; European Journal of Pain; Vol. 21; No. 2 (February); 2017; pp. 201-216.
15. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians; For the Clinical Guidelines Committee of the American College of Physicians; Annals of Internal Medicine; April 4, 2017; Vol. 166; No. 7; pp. 514-530.
16. Donelson R, McIntosh G, Hall H; Is It Time to Rethink the Typical Course of Low Back Pain? Physical Medicine and Rehabilitation (PM&R); Vol. 4; No. 6; June 2012; pp. 394–401.
17. 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.
18. 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.
19. Liliedahl RL, Finch, Axene DV, Goertz CM; Cost of Care for Common Back Pain Conditions Initiated with Chiropractic Doctor vs. Medical Doctor/Doctor of Osteopathy as First Physician; Experience of One Tennessee-Based General Health Insurer; Journal of Manipulative and Physiological Therapeutics; November/December 2010; Vol. 33; No. 9; pp. 640-643.
20. Krause CA, Kaspin L, Gorman KM, Miller RM; Value of Chiropractic Services at an On-Site Health Center; Journal of Occupational and Environmental Medicine; August 2012; Vol. 54; No. 8; pp. 917-921.
21. 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.
22. Simon Dagenais S, O’Dane Brady O, Scott Haldeman S, Pran Manga P; A Systematic Review Comparing the Costs of Chiropractic Care to Other Interventions for Spine Pain in the United States; BioMed Central (BMC) Health Services Research; October 19, 2015; 15:474.
23. Blanchette MA, 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.
24. Blanchette MA, Rivard M, Dionne CE, Hogg-Johnson S, Steenstra I; Workers’ Characteristics Associated with the Type of Healthcare Provider First Seen for Occupational Back Pain; BMC Musculoskeletal Disorders; October 2016; Vol. 17; No. 1; 428.
25. Rybczynski K; Alternative Medicine, Worker Health, and Absenteeism in the United States; Complementary Therapies in Medicine; June 2017; Vol. 32; pp. 116–128.
26. Locke A; Saving Backs…And Costs: On-site Chiropractic Care and Improve Employee Health While Cutting Overall Costs; Peoria Magazines; September 2014; pp. 83-84.
    Personal communication for the participants; Will be published soon.

Terminology

Dissection:
A disruption or tearing of the inner layer of an artery.

Embolus (singular) or emboli (plural):
An arterial dissection may form a clot that is capable of lodging free and traveling down the source artery.

Stroke:
When a traveling embolus plugs and disrupts arterial blood flow, it is known as a stroke. Strokes result in a variety of neurological signs and symptoms.

Modern chiropractors are extensively trained about the anatomy and mechanical physiology of the vertebral artery, particularly as related to dissection and stroke. In reviewing the literature on the topic, several central themes become apparent:

Estimates of the incidence of alleged injury to the vertebral artery from spinal manipulation is extremely rare, so rare that it is extremely difficult to quantify and extremely difficult to study. An estimate of the incidence appeared in the 2004 book Neck Pain, published by the American Academy of Orthopedic Surgeons a (1). The authors state:

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

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

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

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

“It should be noted that complications rates from medications, surgery, and most other neck pain treatments for which data are available are estimated to be higher than those from manual and manipulative therapies.”

When it is alleged that spinal manipulation causes a vertebral artery dissection, much of the published literature on the topic considers “chiropractic” and “manipulation” to be synonymous. Chiropractors are extensively trained in the science and art of manipulation, while lay practitioners often are not. Reported case study analysis shows that when an untrained person manipulates a patient and allegedly causes an injury, the literature often inappropriately labels the manipulator as being a chiropractor (2). The list of discovered manipulators included:

• A blind masseur
• A barber
• A wife
• A Kung-Fu practitioner
• Self manipulation
• A medical doctor
• An osteopath
• A naturopath
• A physical therapist

A published review concluded (2):

“This study reveals that the words chiropractic and chiropractor commonly appear in the literature to describe spinal manipulative therapy, or practitioner of spinal manipulative therapy, in association with iatrogenic complications, regardless of the presence or absence of professional training of the practitioner involved.”

“The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with spinal manipulative therapy injury by medical authors, respected medical journals and medical organizations.”

“In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a non-chiropractor. The true incidence of such reporting cannot be determined.”

“Such reporting adversely affects the reader’s opinion of chiropractic and chiropractors.”

“It has been clearly demonstrated that the literature of medical organizations, medical authors and respected, peer-reviewed, indexed journals have, on numerous occasions, misrepresented the facts regarding the identity of a practitioner of manual therapy associated with patient injury.”

“Such biased reporting must influence the perception of chiropractic held by the reader, especially when cases of death, tetraplegia and neurological deficit are incorrectly reported as having been caused by chiropractic.”

“Because of the unwarranted negative opinion generated in medical readers and the lay public alike, erroneous reporting is likely to result in hesitancy to refer to and underutilization of a mode of health care delivery.”

This misuse of the literature, attributing manipulation vascular accidents to a chiropractor when in fact the manipulation was not performed by a chiropractor continues, as does the rebuttals designed to set the record straight (3, 4, 5).

Pre-manipulation tests designed to screen for individuals who might have an increased risk of a vascular injury as a consequence of a spinal manipulation are often non-revealing; such testing does not adequately identify patients who may have an increased risk of injury.

For example, a 2002 study (6), published in the journal Spine, was a retrospective review of 64 medicolegal records describing cerebrovascular ischemia after cervical spine manipulation. The authors note, that up to the publication of their article in 2002, only about 117 cases of post-manipulation cerebrovascular ischemia had been reported in the English language literature.

The authors further indicate that proposed risk factors for cerebrovascular ischemia secondary to spinal manipulation include age, gender, migraine headaches, hypertension, diabetes, birth control pills, cervical spondylosis, and smoking, and that it is often assumed that these complications may be avoided by clinically screening patients and by pre-manipulation positioning of the head and neck to evaluate the patency of the vertebral arteries. However, after an extensive review, these authors conclude:

“This study was unable to identify factors from the clinical history and physical examination of the patient that would assist a physician attempting to isolate the patient at risk of cerebral ischemia after cervical manipulation.”

“Cerebrovascular accidents after manipulation appear to be unpredictable and should be considered an inherent, idiosyncratic, and rare complication of this treatment approach.”

Additional, more recent studies have arrived at similar conclusions (7, 8, 9, 10).

Recent large studies, looking at millions of follow-up years and/or millions of participants are indicating that chiropractic spinal manipulation does not cause vertebral artery dissection, but that in contrast the patient is presenting to a chiropractic office in the middle of spontaneous dissection of the artery.

A 2008 study published in the journal Spine included all residents of Ontario, CAN, over a period of 9 years, amounting to more than 109 million person years of observation. The authors noted (11):

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

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

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

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

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

A 2011 study published in the Journal of Manipulative and Physiological Therapeutics used a population-based case series with administrative health care records of all Ontario, CAN, residents hospitalized with vertebral artery stroke between April 1, 1993, and March 31, 2002. These authors note (12):

“The current evidence suggests that association between chiropractic care and vertebrobasilar artery (VBA) stroke is not causal. Rather, recent epidemiological studies suggest that it is coincidental and reflects the natural history of the disorder.”

“Because neck pain and headaches are symptoms that commonly precede the onset of a VBA stroke, these patients might seek chiropractic care while their stroke is in evolution.” 

In a 2011 editorial published in The Open Neurology Journal noted (13):

“The current best-evidence indicates no causal relationship between spinal manipulation (‘chiropractic maneuver’) and vertebrobasilar artery (VBA) stroke.”

“Evidence is mounting that the association between spinal manipulation and stroke is coincidental rather than causal and reflects the natural history of the disorder.”

“The prevailing hypothesis is that patients with vertebral artery dissections often have initial symptoms that cause them to seek care from a chiropractic or medical physician and the stroke is independent of their visit.”

“The latest scientific evidence questions whether spinal manipulation is a risk factor at all for cervical artery dissection.”

“Chiropractic spinal manipulations may very well be a demerging risk factor for stroke since there may not be any risk.”

“The evidence, albeit limited to date, suggests that spinal manipulative treatments produce stretches of the vertebral artery that are much smaller than those that are produced during normal everyday movements, and thus they appear harmless.”

A 2015 study published in the journal Chiropractic & Manual  Therapies, assessed commercially insured and Medicare Advantage (MA) health plan members in the U.S. The data set encompassed 35,726,224 commercial and 3,188,825 MA members, therefore looking at approximately 39 million people, making this the largest case–control study to investigate the association between chiropractic manipulation and vertebral artery stroke. These authors concluded (14):

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

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

A 2016 study published in the journal Cureus evaluated the evidence by performing a systematic review and meta-analysis of published data on chiropractic manipulation and cervical artery dissection (CAD). These authors state (15):

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

“In spite of the very weak data supporting an association between chiropractic neck manipulation and CAD, and even more modest data supporting a causal association, such a relationship is assumed by many clinicians. In fact, this idea seems to enjoy the status of medical dogma.”

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

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

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

“Because (on average) patients with headache and neck pain visit chiropractors more frequently, and patients with cervical artery dissection more frequently have headache and neck pain, it appears that those who visit chiropractors have more cervical artery dissections.”

Globally, there is only one lab engaging in primary research to assess the biomechanical risk of cervical spinal manipulation and vertebral artery dissection. This research is being done at the University of Calgary, CAN, and is headed by Walter Herzog, PhD. In 2012, Dr. Herzog and colleagues published a study in the Journal of Electromyography and Kinesiology presenting the first ever data on the mechanics between C1/C2 during cervical manipulation performed by chiropractic clinicians (16). These authors concluded:

“VA strains obtained during SMT are significantly smaller than those obtained during diagnostic and range of motion testing, and are much smaller than failure strains.”

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

“In summary, the maximal strain values for the ROM testing at each segmental level were always greater than the corresponding strain values for the SMTs, suggesting that neck SMTs impose less stretch than turning your head, or extending your neck while looking up at the sky.”

“Therefore, based on the mechanical tests performed here, one should be able to conclude that stretching of VA during neck SMTs does not cause any damage of the VAs.”

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

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

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

The Whiplash Injury Connection

Whiplash injury is a common cause of neck pain, headache, dizziness, etc. (17). These same symptoms are consistent with vertebral artery injury. As noted here, individuals with these symptoms often present to chiropractors looking for relief of their problems.

Could Whiplash Injury Be Responsible for Vertebral Artery Injury?

Studies implicating whiplash injury as causing vertebral artery injury have been found in the medical literature for six decades. Examples include:

In 1958 a study published in the Journal of the American Medical Association states (18):

“Very little slack exists in the vertebral artery and, during severe hyperextension and hyperflexion and especially during extreme lateral rotation, partial to complete obstruction of the vertebral artery has been demonstrated by arteriography.”

“The vertebral artery is the pipeline carrying blood and oxygen to the brain stem.”

“Angiography has shown constriction or occlusion of the vertebral artery in patients with persistent symptoms of vertigo, ataxia, headache, diplopia, and unsteadiness of gait.”

“A great majority of symptoms that have been designated as psychoneurotic, namely, attacks of vertigo, ataxia, diplopia, severe attacks of migraine-like headache, hemicrania with nausea and vomiting, and, at times disturbances of speech and swallowing, are all due to disturbed circulation of the vertebral artery after neck sprain.”

In 1995 a study was published in the American Journal of Roentgenology where the authors reviewed 37 cases of cervical spine injury with magnetic resonance angiography (MRA) (19). The authors concluded:

“Vertebral artery injuries due to major cervical spine trauma as determined by MR angiography are common.”

“Noninvasive assessment of the vertebral arteries by means of MR imaging should be an integral part of the evaluation of the acutely injured cervical spine.”

Also in 1995, a case report was published in the journal Stroke documenting a vertebral artery dissection and stroke following a whiplash trauma. The authors state (20):

“We conclude that the whiplash injury caused a lesion of the right vertebral artery.”

“We suggest that in patients with disturbances of the vertebrobasilar circulation, attention should be paid to occurrence of neck trauma in the preceding 3 months.”

In 1997 a study was published in the European Spine Journal where the researchers exposed seven fresh human cadavers to rear-end type whiplash collisions while measuring the stretch to their vertebral arteries. The authors note (21):

“Vertebral artery (VA) stretch during trauma is a possible pathomechanism that could explain some aspects of the whiplash symptom complex.”

The authors documented that the vertebral artery significantly exceeded its physiological range in every experiment completed, adding to the evidence the vertebral artery is injured during a whiplash trauma.

In 2000 a case study was published in the European Journal of Emergency Medicine (22). The authors document a case of vertebral artery dissection caused by a head-on type whiplash injury.

In 2002 a study was published in the journal Neurological Research where researchers reviewed 29 patients with vertebrobasilar dissections (VBD) to investigate the correlation between minor trauma and VBD (23). They discovered that whiplash injury may in fact result in vertebral artery dissection.

In 2003, a study published in the Canadian Journal of Neurological Sciences reviewed all consecutive cases of traumatic vertebrobasilar ischemia referred to a single neurovascular practice over 20 years, identifying 80 patients, categorized as follows (24):

“Recent media exposure of strokes from chiropractic manipulation have focused attention on traumatic vertebrobasilar ischemia. However, chiropractic manipulation, while the easiest cause to recognize, is probably not the most common cause of this condition.”

“Five were diagnosed as due to chiropractic manipulation, but the commonest attributed cause was motor vehicle accidents (MVAs), which accounted for 70 cases; one was a sports injury, and five were industrial accidents.”

“In some cases neck pain from an MVA led to chiropractic manipulation.”

“Traumatic vertebrobasilar ischemia is most often due to MVAs; the diagnosis is often missed, in part because of the delay between injury and onset of symptoms.”

“Though chiropractic manipulation is perhaps the best-known cause [alleged], it is important to recognize that MVAs are a much more common cause, which is often missed.”

In 2005 a study published in the Journal of Manipulative and Physiological Therapeutics compiled an extensive review of the literature pertaining to cervical spine manipulation vs. motor vehicle collision as causation of vertebral artery dissection (25). The authors state:

“Long-lasting abnormalities of blood flow velocity within the vertebral artery have been reported in patients following common whiplash injuries, whereas no significant changes in vertebral artery peak flow velocity were observed following cervical chiropractic manipulative therapy.”

“Perceived causation of reported cases of cervical artery dissection is more frequently attributed to chiropractic manipulative therapy procedures than to motor vehicle collision related injuries, even though the comparative biomechanical evidence makes such causation unlikely.”

“The direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures.”

In 2006, the European Spine Journal published a study in which the authors examined 20 patients to assess the correlation between vertigo or dizziness and the vertebral arteries after whiplash injury using MRA. Abnormal MRA findings were seen in 60%. They state (26):

“Whiplash injury is not only limited to neck injury but also brainstem injury that does not involve direct damage to the neck or head.”

“Our findings suggest that some subjects with persistent vertigo or dizziness after whiplash injury are more likely to have VBI on MRA.”

“VBI might be an important background factor to evoke cervical vertigo or dizziness after whiplash injury.”

In 2008, a study was published in the journal European Neurology which was to estimate the incidence of posttraumatic dissections of cervical arteries in patients with whiplash injury acquired in a car accident. The authors retrospectively analyzed the medical records of 500 patients with whiplash injury acquired in car accidents and searched for dissections of cervical arteries occurring within 12 months after injury. They identified eight such cases, or one per every 62 injured patients. Recall the risk from spinal manipulation is one per 5.8 million procedures. The authors note that this incidence makes the risk of artery dissection from whiplash injury 200 times greater that in the general population. The authors make these points:

“There is an increased risk of posttraumatic dissection and cerebrovascular events within 12 months after whiplash injury.”

“The victims of car accidents should be screened for arterial dissections.”

“The incidence of cervical arterial dissections in patients with whiplash injury was much higher than the overall incidence of cervical arterial dissections in the general population. Therefore, we assume a causal relationship between arterial dissection and cervical spine distortion injury.”

“Many dissections of cervical arteries remain clinically asymptomatic, and the association with a car accident is not recognized.”

“Motor vehicle collisions should be considered as a risk factor for cervical arterial dissections.”

“There is an association between whiplash injury with arterial dissection and delayed cerebrovascular events occurring months after a car accident.”

SUMMARY

Spinal manipulation is a published risk factor for vertebral artery dissection and stroke.

The published literature agrees that the incidence of arterial dissection caused by manipulation is extremely rare, in fact so rare that most chiropractors would have to be in clinical practice for hundreds of years to statistically be associated with one such event.

The published literature unfairly attributes many vascular accidents to chiropractic manipulation when in fact the manipulation was not done by a chiropractor, but rather by an untrained lay person or professional.

More recent published literature is noting that spinal manipulation may not be a risk factor for arterial dissection at all, but that rather a patient is entering a chiropractic office already in dissection.

The majority of cervical artery dissections are spontaneous, but there is an increased risk from being injured in a motor vehicle collision. As such, patients seeking care for motor vehicle collision injuries should be particularly well screened for possible cervical artery dissection, possibly including magnetic resonance angiogram (MRA).

Properly done spinal manipulation by trained chiropractors appears to be extremely low-risk for artery dissection.

REFERENCES

1. Fischgrund, JS; Neck Pain, “Manual Therapy Including Manipulation For Acute and Chronic Neck Pain;” American Academy of Orthopedic Surgeons; 2004.
2. Terrett AG; Misuse of the literature by medical authors in discussing spinal manipulative therapy injury; Journal of Manipulative and Physiological Therapeutics; 1995 May;18(4):203-10.
3. Wenban A; Misuse of the Terms Chiropractic and Chiropractor; Journal of Neurology, Neurosurgery, and Psychiatry; Vol. 75; pg. 794.
4. Wenban AB; Inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ in the peer-reviewed biomedical literature; Chiropractic and Osteopathy; August 22, 2006; Vol. 14:16.
5. Wenban AB; Inappropriate use of the title chiropractor: reason for concern?; Clinical Neurology and Neurosurgery; April 2008; Vol. 110; No. 4; pp. 425-426.
6. Haldeman S, Kohlbeck FJ, McGregor M; Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation; Spine; 2002 Jan 1;27(1):49-55.
7. Thiel H, Rix G; Is it time to stop functional pre-manipulation testing of the cervical spine? Manual Therapy; May 2005; Vol. 10; No. 2; pp. 154-158.
8. Childs JD, Flynn TW, Fritz JM, Piva SR, Whitman JM, Wainner RS, Greenman PE; Screening for vertebrobasilar insufficiency in patients with neck pain: manual therapy decision-making in the presence of uncertainty; Journal of Orthopedic Sports Physical Therapy; May 2005; Vol. 35; No. 5; pp. 300-306.
9. Kerry R, Taylor AJ, Mitchell J, McCarthy C; Cervical arterial dysfunction and manual therapy: a critical literature review to inform professional practice; Manual Therapy; August 2008; Vol. 13; No. 4; pp. 278-288/
10. Taylor AJ, Kerry R; Challenging editorial wisdom and raising the “VBI” debate; Manual Therapy; June 2008; Vol. 13; No. 3; p e5.
11. Cassidy JD, Boyle E, Côté P, Yaohua H, Hogg-Johnson S, Silver FL, Bondy SJ; Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study; Spine; Volume 33(4S); February 15; 2008 pp. S176-S183.
12. Choi S, Boyle E, Cote P, Cassidy JD; A population-based case-series of Ontario patients who develop a vertebrobasilar artery stroke after seeing a chiropractor; Journal of Manipulative and Physiological Therapeutics; 2011; Vol. 34; No. 1; pp. 15-22.
13. Smith DL, Cramer GC; LETTER TO THE EDITOR: Spinal Manipulation is Not an Emerging Risk Factor for Stroke Nor is it Major Head/Neck Trauma. Don’t Just Read the Abstract!; The Open Neurology Journal; 2011; 5; pp.  46-47.
14. Thomas M Kosloff, David Elton, Jiang Tao and Wade M Bannister; Chiropractic Care and the Risk of Vertebrobasilar Stroke: Results of a Case–control Study in U.S. Commercial and Medicare Advantage Populations; Chiropractic & Manual Therapies 2015; 23:19; pp. 1-10.
15. Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE; Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation; Cureus; February 16, 2016; Vol. 8; No. 2; e498.
16. Herzog W, Leonard TR, Symons B, Tang C, Wuest S; Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation; Journal of Electromyography and Kinesiology; October 2012; Vol. 22; No. 5; pp. 740-746.
17. Jackson R; The Cervical Syndrome; Thomas; 1978.
18. 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.
19. Friedman D, Flanders A, Thomas C, Millar W; Vertebral artery injury after acute cervical spine trauma: rate of occurrence as detected by MR angiography and assessment of clinical consequences; AJR Am J Roentgenol. 1995 Feb;164(2):443-7.
20. Viktrup L, Knudsen GM, Hansen SH; Delayed onset of fatal basilar thrombotic embolus after whiplash injury; Stroke; 1995 Nov;26(11):2194-6.
21. Nibu K, Cholewicki J, Panjabi MM, Babat LB, Grauer JN, Kothe R, Dvorak J; Dynamic elongation of the vertebral artery during an in vitro whiplash simulation; Eur Spine J. 1997;6(4):286-9.
22. Chong CL, Ooi SB; Neck pain after minor neck trauma, Is it always neck sprain? Eur J Emerg Med 2000 Jun;7(2):147-9.
23. Chung YS, Han DH; Vertebrobasilar dissection: a possible role of whiplash injury in its pathogenesis; Neurol Res. 2002 Mar;24(2):129-38.
24. Beaudry M, Spence JD; Motor Vehicle Accidents: The Most Common Cause of Traumatic Vertebrobasilar Ischemia; Canadian Journal of Neurological Sciences; November 2003; Volume 30, No. 4; pp. 320-325.
25. Haneline M, Triano J; Cervical artery dissection. A comparison of highly dynamic mechanisms: manipulation versus motor vehicle collision; J Manipulative Physiol Ther. 2005 Jan;28(1):57-63.
26. Endo K, Ichimaru K, Komagata M, Yamamoto K; Cervical vertigo and dizziness after whiplash injury; Eur Spine J. 2006 Jun;15(6):886-90.
27. Hauser V, Zangger P, Winter Y, Oertel W, Kesselrin J; Late Sequelae of Whiplash Injury with Dissection of Cervical Arteries; European Neurology August 18, 2010, Vol. 64, No. 4, pp. 214–218.

When viewing the human spinal column from directly in front or directly behind, it should be straight and without lateral (sideways) deviation. The health and function of the human spinal column is optimum when there is no lateral (sideways) deviation into the coronal plane. This concept is well-noted by Joel Goldthwait, MD, and well-reviewed by James Oschman, PhD (1):

Gravity is the most potent physical influence in any human life.

“Gravity pervades our bodies and our environment and affects our every activity. All of the structures around us – our homes, furniture, buildings, machinery, plant, and animal, – and our own bodies, are designed to function in a world dominated by gravity.”

“To introduce the therapeutic significance of gravity, we summarize the work of Joel E. Goldthwait and his colleagues at Harvard Medical School.” “A surgeon in Boston and founder of the orthopaedic clinic at the General Hospital, Goldthwait developed a successful therapeutic approach to chronic disorders. The aim of his therapies was to get his patients to sit, stand, and move with their bodies in a more appropriate relationship with the vertical. After years of treating patients with chronic problems, he concluded that many of these problems arise because parts of the body become misaligned with respect to the vertical, and organ functions therefore become compromised.”

“Goldthwait’s therapeutic approach was based in part on observations made while performing surgery on such patients. He noticed that abdominal nerves and blood vessels are under tension in individuals whose bodies are out of alignment. He also reported ‘stretching and kinking’ of the cerebral arteries and veins in those whose necks were bent. Various cardiac problems were correlated with ‘faulty body mechanics’ that distorted the chest cavity in a way that impaired circulatory efficiency. Goldthwait also documented with X-rays a build-up of calcium deposits around the vertebrae of individuals with chronic arthritis, and observed that these deposits can diminish when the individual acquires a more vertical stance. His therapeutic approach corrected many difficult problems without the use of drugs. He viewed the human body from a mechanical engineering perspective, in which alignment of parts is essential to reduce wear and stress. He pleaded with physicians to recognize and correct misalignments to prevent long-term harmful effects.”

“The basic principle of gravitational biology is known to any child who plays with blocks. The center of gravity of each block must be vertically above the center of gravity of the one below, to have a stable, balanced arrangement. If the center of gravity of one block lies outside of the gravity line, stability is compromised.”

“Likewise, there is only one stable, strain-free arrangement of the parts of the human body. Any variation from this orientation will require corresponding compensations in other parts of the support system.”

“Misalignment of any part will affect the whole system, and that restoration of verticality is a way to address a wide variety of clinical problems.”

Dr. Goldthwait pleaded for everyone to pay more attention to the ways they hold and move their bodies in relation to the gravity field, particularly in the coronal plane. However, medicine was being swept away in the tide of drug-based medicine that continues today, and healthcare has largely forgotten his advice. Today, the chiropractic profession champions Goldthwait’s postural advice.

In contrast to the straight-on front and back views of the spinal column, when the spine is viewed from the side, optimum health and function requires four distinct spinal curves (2):

1. Sacral Kyphosis
2. Lumbar Lordosis
3. Kyphosis
4. Cervical Lordosis

This paper reviews the clinical importance of cervical lordosis.

Loss of cervical lordosis is categorized into three groups:

1. Hypolordosis: loss of the optimum curvature, but still lordotic.
2. Military: complete loss of lordosis resulting in a straight spine.
3. Kyphosis: a reversal of the normal lordotic curvature.

Loss of the normal cervical spine lordosis is associated with a number of neuromusculoskeletal problems. The primary problems fall into five categories:

1. Lever Arm Stress and the consequent Myofascial Pain Syndromes
2. Acceleration of Degenerative Joint Disease
3. Spinal Cord Tethering
4. Spinal Cord Demyelination
5. Vertebral Artery blood flow compromise

Lever Arm Stress and the consequent Myofascial Pain Syndromes

Holding the head up is a first-class lever arm mechanical system. In a first-class lever, the fulcrum is in between the load and the effort. Examples of a first-class lever include a teeter-totter or crowbar:

With loss of cervical lordosis, the head and its weight are displaced forward of the spinal column. To prevent such a person from falling onto their face, the muscles in the back of the spinal column will contract 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).

If the weight of the head is 10 lbs. and the loss of lordosis displaces the head’s center of gravity forward by 3 inches, the required counter balancing muscle contraction on the opposite side of the fulcrum (the vertebrae) would be 30 lbs. (10 lbs. X 3 inches):

In such cases, muscle therapy (massage and various forms of interventional modalities) is helpful, but not a long-term solution. The best solution is improvement of cervical lordosis, reducing lever-arm stress, allowing the counterbalancing muscles to relax.

Acceleration of Degenerative Joint Disease

As noted above, holding the head up is a first-class lever arm mechanical system. In a first-class lever, the fulcrum is in between the load and the effort. The fulcrum of a first-class lever is the place where the load is the greatest. In the spine, the fulcrum of the first-class lever of upright posture is primarily the vertebral body/disc, and the two facet joints.

Loss of cervical lordosis not only displaces the head forward resulting in counterbalancing muscle contraction, it also significantly increases the load on the fulcrum (the intervertebral disc and facet joints) (7, 8). This causes and accelerates degenerative disc and joint disease in the cervical spine (9, 10).

The acceleration of degenerative disc and joint disease is most pronounced when there is a reversal of the cervical lordosis (kyphosis) (11, 12).

Spinal Cord Tethering

With loss of cervical lordosis there is an elongation (stretching) of the spinal cord (7). Chronic elongation, or tethering, of the spinal cord can result in both spine neuron dysfunction and/or spinal cord vascular compromise (13, 14). These can result in both autonomic and musculoskeletal symptoms.

Spinal Cord Demyelination

An important experimental study was published in the journal Spine in 2005 pertaining to cervical spine kyphosis and demyelination of the spinal cord (15). The article was titled:

Spinal Kyphosis Causes Demyelination and Neuronal Loss
in the Spinal Cord: A New Model of Kyphotic Deformity

This study showed that cervical spine kyphosis resulted in compression of the anterior vascular supplies to the spinal cord, eventually resulting in spinal cord demyelination. The demyelination was greatest at the apex of the kyphotic deformity. Angiography showed a reduction in the density of capillary networks and interruption of capillaries at the compressed spinal cord from kyphosis. The authors state:

“Demyelination of the compressed white matter due to kyphotic deformity progressed in the order of anterior, lateral, and posterior funiculus; the posterior funiculus tended to be preserved even in the cases of severe compression.”

“The anterior funiculus in the [kyphotic] group, was the most extensively compressed, showed most marked histologic changes such as demyelination and irregularity of the spared myelin sheath.”

“As the kyphotic angle increased, these changes became more marked, especially in the ventral side of the spinal cord that was directly exposed to mechanical compression.”

“As kyphosis progressed further, the demyelination of the axon spread to the lateral funiculus and then to the posterior funiculus. Marked histologic changes were seen on the ventral side of the spinal cord, probably because of continuous mechanical stress caused by the kyphotic deformity.”

“Demyelination of the axons progressed in the order of the anterior, lateral, and then posterior funiculus.”

Cervical Axial View

ASA = Anterior Spinal Artery
FT=Foramen Transversarium (where the vertebral artery resides)
IVF=Intervertebral Foramen (where the nerve root resides)

The Anterior Spinal Artery (ASA) is the primary blood supply to the neurons of the anterior and lateral spinal cord.

Cervical Kyphosis cantilevers the anterior spinal cord around the posterior intervertebral disk and vertebral bodies.

Between the posterior intervertebral disk and the anterior spinal cord resides the Anterior Spinal Artery. Cervical kyphosis compresses the Anterior Spinal Artery resulting in ischemia, first to the anterior spinal cord, and later to the lateral spinal cord, causing dysfunction and eventual spinal cord demyelination.

Vertebral Artery Blood Flow Compromise

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 termed the foramen transversarium. There is evidence that loss of cervical lordosis 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.

An important article on this topic was published in the journal Medical Science Monitor in 2016, and titled (16):

Decreased Vertebral Artery Hemodynamics in Patients with Loss of Cervical Lordosis

This is the first study to focus on the status of the vertebral artery in patients with loss of cervical lordosis. The authors evaluated the values of the vertebral arteries in patients with loss of cervical lordosis compared to strictly matched control subjects without loss of cervical lordosis.

Thirty patients with loss of cervical lordosis and 30 carefully matched controls were assessed bilaterally (60 arteries each group) with Doppler ultrasonography. Vertebral artery hemodynamics, including lumen diameter, flow volume, peak systolic velocity was measured, and values were statistically compared between the patient and the control groups. The cervical lordosis was assessed on lateral cervical radiographs using the posterior tangent method; the lordosis was defined as the angle between the posterior margins of the vertebral bodies C2 and C7. These authors make these points:

“This natural lordotic curvature of the cervical spine is considered to be an ideal posture in terms of biomechanical principles.”

“The normal cervical spine has a lordotic curve. Abnormalities of this natural curvature, such as loss of cervical lordosis or cervical kyphosis, are associated with pain, disability, and poor health-related quality of life.”

“Loss of cervical lordosis causes disrupted biomechanics, triggering a degenerative process in the cervical spine.”

“The present study revealed a significant association between loss of cervical lordosis and decreased vertebral artery hemodynamics, including diameter, flow volume, and peak systolic velocity.”

When the cervical curve flattens, the vertebral arteries “are also in danger of being stretched or compressed.”

“The results of this study indicate that loss of cervical lordosis is associated with decreased vertebral artery values in lumen diameter, flow volume, and peak systolic velocity.”

This article increases the awareness of the adverseness of loss of cervical lordosis. It also highlights the importance of improving and/or correcting cervical lordosis.

••••••••••

Chiropractic clinical practice includes the assessment and treatment of both alignment and the normal lateral spinal curves, including cervical lordosis. The most accurate assessment of spinal curves is with x-rays.

Chiropractors use a number of techniques to improve and/or restore the cervical spine lordosis. There are several studies in the PubMed Database indicating that chiropractic can improve and even reverse cervical kyphosis. The procedures usually involve combinations of certain adjustments and extension traction (17, 18, 19, 20, 21, 22, 23, 24, 25).

REFERENCES:

1. Oschman J; Energy Medicine, The Scientific Basis; Chruchill Livingstone; 2000.
2. Kapandji IA; The Physiology of the Joints; Volume Three, The Trunk and the Vertebral Column; Churchill Livingstone; 1974.
3. Cailliet R; Soft Tissue Pain and Disability; 3rd Edition; FA Davis Company; 1996.
4. Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual; New York: Williams & Wilkins, 1983.
5. Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual: THE LOWER EXTREMITIES; New York: Williams & Wilkins, 1992.
6. Simons D, Travell J; Travell & Simons’, Myofascial pain and dysfunction, the trigger point manual: Volume 1, Upper Half of Body; Baltimore: Williams & Wilkins, 1999.
7. White AA, Panjabi MM; Clinical Biomechanics of the Spine, Second Edition; Lippincott; 1990.
8. Cailliet R; Low Back Pain Syndrome, 4th edition; FA Davis Company; 1981.
9. Garstang SV, Stitik SP; Osteoarthritis; Epidemiology, Risk Factors, and Pathophysiology; American Journal of Physical Medicine and Rehabilitation; November 2006; Vol. 85, No. 11; pp. S2-S11.
10. Ruch W; Atlas of Common Subluxations of the Human Spine and Pelvis, Second Edition; Life West Press; 2014.
11. Uchida K, Nakajima H, Sato R, Yayama T, Mwaka ES, Kobayashi S, Baba H; Cervical Spondylotic Myelopathy Associated with Kyphosis or Sagittal Sigmoid Alignment: Outcome after Anterior or Posterior Decompression; Journal of Neurosurgery: Spine; November 2009; Vol. 11; pp. 521-528.
12. Grosso M, Hwang R, Mroz T, Benzel, Steinmetz M; Relationship between degree of focal kyphosis correction and neurological outcomes for patients undergoing cervical deformity correction surgery; Journal of Neurosurgery: Spine; June 18, 2013; Vol. 18; No. 6; pp. 537-544.
13. Breig A; Adverse Mechanical Tension in the Central Nervous System; Almqvist and Wiksell; 1978.
14. Wing PC, Tsang IK, Susak L, Gagnon F, Gagnon R, Potts JE; Back Pain and Spinal Changes in Microgravity; Orthopedic Clinics of North America; April 1991; Vol. 22; No. 2; pp. 255-262.
15. Shimizu K, Nakamura M, Nishikawa Y, Hijikata S, Chiba K, Toyama Y; Spinal Kyphosis Causes Demyelination and Neuronal Loss in the Spinal Cord: A New Model of Kyphotic Deformity; Spine; November 2005; Vol. 30; No. 21; pp. 2388-2392.
16. Bulut MD, Alpayci M, Şenkoy E, Bora A, Yazmalar L, Yavuz A, Gulşen I; Decreased Vertebral Artery Hemodynamics in Patients with Loss of Cervical Lordosis; Medical Science Monitor; February 15, 2016; Vol. 22; pp. 495-500
17. Leach RA. An evaluation of the effect of chiropractic manipulative therapy on hypolordosis of the cervical spine. J Manipulative Physiol Ther. 1983 Mar;6(1):17-23.
18. Harrison DD, Jackson BL, Troyanovich S, Robertson G, de George D, Barker WF. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study. Journal of Manipulative and Physiological Therapeutics; September 1994; Vol. 17; No. 7; pp. 454-64.
19. Troyanovich SJ, Harrison DE, Harrison DD. Structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther. 1998 Jan;21(1):37-50.
20. Harrison DE, Harrison, DD, Haas JW. CBP Structural Rehabilitation of the Cervical Spine, 2002.
21. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial. Arch Phys Med Rehabil. 2002 Apr;83(4):447-53.
22. Morningstar MW, Strauchman MN, Weeks DA. Spinal manipulation and anterior headweighting for the correction of forward head posture and cervical hypolordosis: A pilot study. J Chiropr Med. 2003 Spring;2(2):51-4.
23. Harrison DE, Harrison DD, Betz JJ, Janik TJ, Holland B, Colloca CJ, Haas JW. Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial. J Manipulative Physiol Ther. 2003 Mar-Apr;26(3):139-51.
24. Ferrantelli JR, Harrison DE, Harrison DD, Stewart D. Conservative treatment of a patient with previously unresponsive whiplash-associated disorders using clinical biomechanics of posture rehabilitation methods. J Manipulative Physiol Ther. 2005 Mar-Apr;28(3):e1-8.
25. Oakley PA, Harrison DD, Harrison DE, Haas JW. Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP) publications. J Can Chiropr Assoc. 200

The RAND corporation is a well-known independent research organization located in Santa Monica, CA. The September-October 2017 issue of the Rand Review has an article titled Well-Adjusted (1). The article states:

“Researchers led by Paul Shekelle, co-director of the Southern California Evidence-Based Practice Center at RAND, aggregated the results of more than two dozen prior studies on spinal manipulation.”

“The study was published in the April issue of the Journal of the American Medical Association. An accompanying editorial noted that its findings suggest that spinal manipulation could be an effective treatment for patients with uncomplicated lower-back pain.”

“Spinal manipulation—the back popping most associated with chiropractors—is about as effective at treating short-term back pain as over-the-counter drugs like ibuprofen, a recent study found.”

•••••

The October 2017 issue of Scientific American has a section titled The Science Of Health, with an article titled Back to Basics (2). The article notes:

“The US spends more on lower back and neck pain than almost any other health condition, …topping $87 billion in 2013.”

“In three separate large analysis published between 2015 and this year [2017], researchers at the University of Sydney and their colleagues compared evidence from dozens of studies to determine how well various pharmaceutical options assuage back pain and found all the drugs to be lacking.”

“The fact that opioids are the most commonly prescribed back pain medication has put added pressure on the medical community to find different solutions.”

They found “evidence supporting the use of techniques such as acupuncture and spinal manipulation for acute and chronic [back] pain.”

•••••

The October 9, 2017 issue of celebrity magazine People profiled actor Stephen Moyer. The interviewer asked him about his “last injury” and he responded by talking about the management of his musculoskeletal problems by his “amazing chiropractor.” (3) This type of unsolicited celebrity endorsement of chiropractic for musculoskeletal problems is increasingly common, increasingly accepted by the public at large, and increasingly being expressed in a cross section of media.

••••••••••

In healthcare, attitudes and procedures are slow to change. As stated by Gregory Grieve, “introductory knowledge becomes inflexibly hardened.” (4). Spinal manipulation has been used successfully to treat back pain for hundreds of years, and perhaps for millennia (5). Studies assessing and advocating the use of spinal manipulation for back pain began to appear in the scientific journals and medical reference texts in the mid twentieth century:

1954 (#6)
“Conservative Treatment of Intervertebral Disk Lesions”
American Academy of Orthopedic Surgeons, Instructional Course Lectures

1969 (#7)
“Reduction of Lumbar Disc Prolapse by Manipulation”
British Medical Journal

1969 (#8)
“Low Back Pain and Pain Resulting from Lumbar Spine Conditions:
A Comparison of Treatment Results”
Australian Journal of Physiotherapy

1977 (#9)
“Ruptured Intervertebral Disc”
“Treatment”
“Manipulation”
Orthopaedics, Principles and Their Applications

••••••••••

The study referenced by RAND Corporation above (1) was published in the Journal of the American Medical Association, April 2017, and titled (10):

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

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

The spinal manipulative therapy was provided by physical therapists in 13 studies, chiropractors in 7 studies, medical doctors in 5 studies, and osteopathic doctors in 3 studies. The studies reviewed provided moderate-quality evidence that spinal manipulative therapy has a statistically significant association with improvements in back pain and in function.

The authors also noted that none of the clinical trials reviewed reported any serious adverse event from spinal manipulative therapy. Minor transient adverse events such as increased pain and muscle stiffness were reported, but again these symptoms were not serious and they were transient.

This study concluded:

“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.”

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

This article generated an editorial titled (11):

The Role of Spinal Manipulation in the Treatment of Low Back Pain

The author of the editorial was Richard Deyo, MD, MPH, from the Department of Family Medicine, Oregon Health and Science University, Portland, OR. Dr. Deyo is a global leading authority and expert on the management of back pain. A search of the National Library of Medicine (11/8/2017) found 403 articles that he had authored or co-wrote.

In his editorial, Dr. Deyo notes that there are approximately 200 treatment options available to treat low back pain. Yet, in the majority of acute low back pain cases, a “precise pathoanatomical cause of the pain cannot be identified.”

Dr. Deyo notes that none of the trials in the study by Paige and colleagues (10) suggested that spinal manipulative therapy was less effective than conventional drug care for low back pain patients. Pertaining to chiropractic treatment for low back pain, Dr. Deyo states:

“Spinal manipulative therapy is a controversial treatment option for low back pain, perhaps in part because it is most frequently administered by chiropractors.”

“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.”

“It appears that spinal manipulative therapy 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.”

In this editorial, Dr. Deyo explains the scientific physiological mechanisms by which spinal manipulation helps people with back pain. He also offers that chiropractic and spinal manipulation have 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 

In contrast, Dr. Deyo notes the urgency for non-pharmacological approaches to the treatment of low back pain, stating:

“Renal and gastrointestinal adverse effects of nonsteroidal anti-inflammatory drugs are common.”

“Among patients taking nonsteroidal antiinflammatory drugs, renal function abnormalities occur in approximately 1% of patients, and superficial gastric erosions or asymptomatic ulcers may occur in up to 5% to 20% of users.”

“Low back pain is among the most common reasons for prescribing opioids in the United States. Among patients initiating opioid therapy, about 5% become long-term opioid users, with associated risks of dependency, addiction, and overdose.”

“The US societal cost of prescription opioid abuse in 2007 was estimated at $55.7 billion.”

Dr. Deyo notes that even though spinal manipulative therapy typically involves multiple visits, “the cost of caring for complications from pharmacologic therapies may exceed the costs of spinal manipulative therapy.” He also notes that 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 (12).

••••••••••

Last year (2016), a study from the University of Montreal, Laval University, and the University of Toronto, quantified the health care provider that occupational back injured workers would consult. The study was published in the journal BMC Musculoskeletal Disorders, and titled (13):

Workers’ Characteristics Associated with the
Type of Healthcare Provider First Seen for Occupational Back Pain

This is an injured worker study from Ontario, CAN, where injured workers can go directly (without referrals from other professionals) to a physician or a chiropractor or physiotherapist. The study used 5,520 low back-injured workers. This is the first study to compare the factors that drive patient’s decision to choose a chiropractor, physician or physiotherapist as their first healthcare provider for occupational back pain.

The authors note that low back pain is a huge societal issue, with a point prevalence of 9.4% and a lifetime prevalence of approximately 85%.

About one-third of low back pain is attributed to occupation. Occupational low back pain represents one-third of all disabilities related to occupational factors. For many jurisdictions, low back pain is the most common occupational injury and reason for Worker’s compensation.

Low back pain is “often recurrent or chronic.” Back pain is 6th among the health problems that generate the most direct medical costs in North America. Back pain is a leading cause of disability worldwide.

Of the 5,520 analyzed claims in this study:

85.3% of the patients saw a medical physician
11.4% saw a chiropractor
3.2% saw a physiotherapist

The authors found that as a rule, those with more severe injuries did not primarily seek treatment from a medical physician. They also found that a worker’s choice of back care provider was often significantly influenced by the attitude and bias of the employer. They state:

“Our results suggest that workers suffering from more severe conditions are more likely to seek physiotherapy and chiropractic care than medical care.”

Back-injured workers who chose to see chiropractors often did so because they had suffered previous similar injuries that were successfully treated chiropractically. This suggests that these injured workers had a high level of satisfaction with prior chiropractic treatment, stating:

“We found that workers who reported a previous similar injury were more likely to seek physiotherapy and chiropractic care.”

“It is reasonable to think that workers will seek care that they perceived as effective for a similar condition, compensated or not, in the past.”

“Back pain patients are more likely to seek the type of care they previously sought, and this association was particularly strong for chiropractic care.”

The authors claim that one of the reasons chiropractic care is not more frequently used is because there are too few chiropractors available to serve the community. They found that in communities that had greater numbers of chiropractors a higher percentage of injured workers chose chiropractic to treat their back injuries.

An important finding pertaining to chiropractic effectiveness and cost effectiveness is complimentary to chiropractic:

“Chiropractic care was associated with lower use of medication, radiographic investigation, and surgery.”

This study presents several lines of evidence suggesting there is an employer bias against chiropractors, and that there should not be. Chiropractic patients are happy with their prior back injury outcomes with chiropractic care.

This study shows that even those with severe injury seek non-medical care, specifically chiropractic and/or physical therapy care.

This study suggests that an explanation for fewer visits to a chiropractor is because there are fewer chiropractors available in the community.

•••••

A 2013 study emphasizing the importance of chiropractic care for back-injured workers appeared in the journal Spine, titled (14):

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury:
Results from a Prospective Study of Workers in Washington State

The authors are from Dartmouth Medical School, University of Washington School of Public Health, University of Washington School of Medicine, and Ohio State University College of Public Health. This is a prospective population-based cohort study whose objective is to identify early predictors of lumbar spine surgery within 3 years after occupational back injury.

The authors note that back injuries are the most prevalent occupational injury in the United States, stating:

“Back pain is the most costly and prevalent occupational health condition among the U.S. working population.”

The authors note that the incidence of back surgery has increased dramatically in the past several decades “with little evidence for improved population outcomes.” They state:

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

This study assessed 1,885 back-injured workers. The primary measurement outcome used was the Roland Morris Disability Questionnaire. They note:

“The Roland Morris Disability Questionnaire has been shown to be predictive of chronic work disability, longer duration of sick leave, chronic pain, and other measures of function.”

The authors found that a significant predictor of having back surgery in the following 3 years was determined by the first provider seen for their back injury. The highest risk for a future back surgery occurred when the first provider was a surgeon. The lowest predictor for a future back surgery was when the first provider was a chiropractor. The authors stated:

“In Washington State worker’s compensation, injured workers may choose their medical provider. Even after controlling for injury severity and other measures, workers with an initial visit for the injury to a surgeon had almost nine times the odds of receiving lumbar spine surgery compared to those seeing primary care providers, whereas workers whose first visit was to a chiropractor had significantly lower odds of surgery.”

“Those whose first provider seen for the injury was a surgeon had significantly higher odds of surgery, after adjusting for all other variables.”

“Factors associated with significantly reduced odds of surgery included…  chiropractor as first provider seen for the injury.”

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

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

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

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

These authors comment that previous studies have shown:

Those with occupational back injuries who first saw a chiropractor had lower odds of chronic work disability.

Those seeing chiropractors for occupational back pain had “higher rates of satisfaction with back care.”

They also noted that no measures in the employment-related behavior, health behavior, or psychological findings were significant in predicting the outcomes in these patients.

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

•••••

The November 2017 Harvard Health Letter has an important article titled (15):

Where to Turn for Back Pain Relief

“In Most Cases, a Primary Care Doctor or Chiropractor
Can Help You Resolve the Problem”

This article makes these points:

• “Low back pain is one of the most common complaints on the planet.”
• Once low back pain starts, “Take heart. ‘In most cases, you won’t need a specialist,’ says Robert Shmerling, a rheumatologist at Harvard-affiliated Beth Israel Deaconess Medical Center.”
• When pain strikes: “You should not try to diagnose your own back pain.”; “Make that initial call if back pain is interfering with your day.”; Make your first call to a professional, such as a “primary care physician or a chiropractor.”; “35% to 42% of people with their first episode of back pain will consult an chiropractor.”
• Referral to a specialist makes sense “when conservative measures have failed to address your back pain, symptoms aren’t improving or are getting worse, or there’s a suspicion that surgery might be needed.”
• “Chiropractors use posture exercises and hands-on spinal manipulation to relieve back pain, improve function, and help the body heal itself.”
• Chiropractors “often work in conjunction with other doctors, and they can prescribe diet, exercise, and stretching programs.”
• “A well-trained chiropractor will sort out whether you should be in their care or the care of a physical therapist or medical doctor.”
• “For back sprains, strains, and herniated discs, a visit to your primary care physician or chiropractor may be all it takes to feel better.”
• Keep in mind that “it may take several types of tests, such as x-rays, MRIs, and blood tests to determine the exact cause of your back pain.”

This article emphasizes that a modern well-trained chiropractor is a preferred portal-of-entry provider for back pain. It notes that such a chiropractor will be able to determine if a referral to a specialist, such as a surgeon, is necessary for a back complaint. It also notes that a chiropractor is trained not only in diagnosing back problems, but also in treating both soft tissue problems such as sprains and/or strains, and also disc herniations.

Other pertinent comments include that improved back pain diagnostics includes special imaging (like MRI), but also x-rays, which are commonly provided by chiropractors. “Chiropractors use posture exercises and hands-on spinal manipulation to relieve back pain, improve function, and help the body heal itself.” In addition, chiropractors often prescribe diet, exercise, and stretching programs. Chiropractors work well with other healthcare providers and doctors.

•••••

When it comes to treating and managing back pain, several themes are apparent:

Back pain is epidemic in the modern society. The majority of Americans will experience back pain within their lives.
Back pain is the major cause of worker’s injuries, and the primary cause of worker’s disability, worker’s healthcare costs, and financial costs to the employers.
Even with successful treatment, back pain tends to become chronic and recurrent.
Neither drugs nor surgery for the treatment of back pain are very successful, and both approaches are saddled with steep costs and high complication rates.
Chiropractic offers a viable approach for the management of back pain, especially as the first consulted provider. Studies show that chiropractic for back pain is safe, outcome effective, cost effective, and has high patient satisfaction levels. Chiropractors are excellent diagnosticians, work well with other doctors and healthcare providers, and make referrals to these other providers when appropriate.

  REFERENCES

1. Rand Review; Well-Adjusted; September-October 2017; p. 3.
2. Yuhas D; Back to Basics; Scientific American; titled The Science Of Health; October 2017; pp. 28-29.
3. Jordan J; People; onelastthing; Stephen Moyer, October 9, 2017; p. 110.
4. Grieve G; Common Vertebral Joint Problems; Second Edition; Churchill Livingstone; 1988.
5. Cyriax J; Textbook of Orthopedic Medicine; Volume One, Diagnosis of Soft Tissue Lesions; Bailliere Tindall, 1982.
6. Ramsey RH; Conservative Treatment of Intervertebral Disk Lesions; American Academy of Orthopedic Surgeons, Instructional Course Lectures; Volume 11, 1954, pp. 118-120.
7. Mathews JA and Yates DAH; Reduction of Lumbar Disc Prolapse by Manipulation; British Medical Journal; September 20, 1969; No. 3, pp. 696-697.
8. Edwards BC; Low back pain and pain resulting from lumbar spine conditions: a comparison of treatment results; Australian Journal of Physiotherapy; September 1969; Vol. 15; No. 3; pp. 104-110.
9. Turek S; Orthopaedics, Principles and Their Applications; JB Lippincott Company; 1977; page 1335.
10. 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.
11. 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.
12. Chou R, Huffman LH; Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society and American College of Physicians Clinical Practice Guideline; Annals of Internal Medicine; October 2007, Volume 147, Number 7, pp. 492-504.
13. Blanchette MA, Rivard M, Dionne CE, Hogg-Johnson S, Steenstra I; Workers’ Characteristics Associated with the Type of Healthcare Provider: First Seen for Occupational Back Pain; BMC Musculoskeletal Disorders; October 2016; Vol. 17; No. 1; 428.
14. 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.
15. Harvard Health Letter; November 2017.

For decades, clinicians have realized that neck problems can cause headaches. For example, early whiplash expert and orthopedic surgeon, Ruth Jackson, MD (1902-1994), published a study in 1947 in the Journal of the American Medical Women’s Association titled (1):

The Cervical Syndrome As a Cause of Migraine

In this article, Dr. Jackson notes that at least half of patients suffering from cervical spine problems will also complain of headaches as one of their principle symptoms. Dr. Jackson noted that irritation of the upper cervical spine nerve roots, C1-C2-C3, are most likely to cause headache, and that it is these upper cervical spine nerve roots that are most vulnerable to whiplash trauma. She noted that these cervical spinal post-traumatic headaches may still be present decades later.

•••••

In 1957, Beverly Hills, CA, neurosurgeon Emil Seletz, MD (1907-1999), published a study in the Journal of the International College of Surgeons, titled (2):

Craniocerebral Injuries and the Postconcussion Syndrome

In this article, Dr. Seletz notes that many patients who suffer neck injury will develop incapacitating severe headaches that may persist for months or even years. He claims that the cause of the headache is injury to the 2nd cervical nerve root, explaining that the C2 nerve root communicates with the trigeminal nerve (cranial nerve V) in the lower brainstem and in the upper cervical spinal cord. He notes that these headaches are often severe, begin in the suboccipital area and radiate to the vertex of the skull or to behind one eye; or they may be located in the frontal or temporal region. He believes that the most probable source for these headaches is the upper cervical spinal nerve roots. Dr. Seletz states:

“Analysis of the symptoms of several thousands of such patients will reveal that headaches persisting for months or years after a cerebral concussion are real and that they are extracranial in origin.”

“The 2nd cervical nerve root is more vulnerable to trauma than other nerve roots because it is not protected by pedicles and facets.”

•••••

The following year, 1958, Dr. Seletz published a study in the journal California Medicine, titled (3):

Headache of Extracranial Origin

In this article, Dr. Seletz continues to discuss the neuroanatomical relationships between the cervical spine, especially the C2 nerve root, and headaches. Dr. Seletz notes that the cervical intervertebral foramina, although appearing roomy, are constricted by cartilage, by the vertebral artery, and by the lateral intervertebral joints, also known as the uncinate processes. Osteophytes, swelling or adhesions in this constricted intervertebral foramina space almost inevitably causes painful vascular or neural disorders that can lead to headache.

Dr. Seletz emphasizes that the lateral intervertebral joints are a common irritant to the cervical nerve roots, resulting in headache. These joints are located at the lateral margins of the cervical disc and are a “small synovial joint,” first described by German anatomist Hubert Von Luschka in 1858 (4). Other names for these joints of Von Luschka include:

• Uncinate processes
• Covertebral articulations
• Uncovertebral joints
• Neurocentral joints
• Lateral intervertebral joints

A recent human study confirms that these joints of Von Luschka are synovial joints with a joint capsule and innervated with pain afferents (5). This study states that the uncinate process joint is:

“A synovial or diarthrodial joint must exhibit a joint capsule, a synovial membrane, synovial fluid, and articular cartilage.”

“Our present findings support the notion that the uncovertebral complex includes a synovial joint.”

Understanding that the uncinate process joint is synovial with an innervated joint capsule is important to many chiropractors and their patients. These joints are capable of becoming subluxated (misaligned). These joints are capable of causing local pain and causing nerve root irritation, both of which can cause the pain of headache. The uncinate joint subluxation is distinct from the facet joint subluxation. The adjustment of the uncinate joint subluxation is quite distinct from the facet joint subluxation.

•••••

The following year, 1958, Dr. Seletz published yet another paper on the topic of neck injury and headache. It was published in the Journal of the American Medical Association, and titled (6):

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

In this article, Dr. Seletz continues to review similar neuroanatomical relationships, pathoanatomy, and pathophysiology that can cause headaches. Once again Dr. Seletz emphasizes the importance of the C2 nerve root in headache. He states:

“The physiological communication between the second cervical and the trigeminal nerves in the spinal fifth tract of the medulla [trigeminal-cervical nucleus] involves the first division of the trigeminal nerve [ophthalmic] and thereby gives attacks of hemicrania with pain radiating behind the corresponding eye.”

“Many headaches are not headaches at all, but really a pain in the neck.”

Interestingly, for treatment, Dr. Seletz advocates:

“The procedure outlined here includes heat, manipulation, and traction.”

•••••

In spite of these studies fully describing cervical spine dysfunction, pathology, and/or injury as causing headache in the 1940s and 1950s, official recognition of “Cervicogenic Headache” did not occur until 1983. That article, published in the journal Cephalagia, was titled (7):

“Cervicogenic Headache” An Hypothesis

This study listed the diagnostic criteria for cervicogenic headache as:

• Precipitation of head pain by neck movement and/or sustained awkward head positioning.
• Precipitation of head pain by external pressure over the upper cervical or occipital region on the symptomatic side.
• Restriction of neck range of motion.
• Ipsilateral neck, shoulder, or arm pain of a rather vague nonradicular nature, or, occasionally, arm pain of a radicular nature.
• Unilateral head pain, without side-shift.
• Head pain is moderate-severe, nonthrobbing, and nonlancinating, usually starting in the neck.
• Occasionally there is nausea, phonophobia, photophobia, dizziness, ipsilateral blurred vision, difficulties on swallowing, ipsilateral edema (mostly in the periocular area).
• The pain typically starts at the back of the head, spreading to frontal areas.

•••••

The understanding of the anatomical basis for headache was advanced significantly when Australian physician and clinical anatomist Nikoli Bogduk, MD, PhD, in 1995, published an article in the journal Biomedicine and Pharmacotherapy titled (8):

Anatomy and Physiology of Headache

In this article, Dr. Bogduk notes that all headaches have a common anatomy and physiology in that they are all mediated by the trigeminocervical nucleus. The trigeminocervical nucleus is a region of grey matter in the medulla of the brainstem that descends into the upper cervical spinal cord. The trigeminocervical nucleus receives afferents from all three branches (ophthalmic, maxillary, mandibular) of the trigeminal nerve (cranial nerve V), as well as afferents from nerve roots C1, C2, and C3.

Consequently, irritation of any of the upper three cervical nerve roots can cause headaches. In addition, Dr. Bogduk stresses that irritation or injury to any tissue innervated by the upper cervical nerve roots can cause headaches, including:

Structures innervated by C1-C3:

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

•••••

In 2001, Dr. Bogduk wrote an article pertaining specifically to cervicogenic headache. It was published in the journal Current Pain and Headache Reports, and titled (9):

 

 

In this article, Dr. Bogduk makes these points:

“Cervicogenic headache is pain perceived in the head but referred from a primary source in the cervical spine.”

“The physiologic basis for this pain is convergence between trigeminal afferents and afferents from the upper three cervical spinal nerves.”

“The possible sources of cervicogenic headache lie in the structures innervated by the C1 to C3 spinal nerves, and include the upper cervical synovial joints, the upper cervical muscles, the C2-3 disc, the vertebral and internal carotid arteries, and the dura mater of the upper spinal cord and posterior cranial fossa.”

“Experiments in normal volunteers have established that the cervical muscles and joints can be sources of headache.”

•••••

A recent (October 2017) PubMed search of the National Library of Medicine database using the key words “cervicogenic headache” listed 1,168 citations, with publication dates ranging from September 1942 to October 2017. Numerous studies have documented the effectiveness of manual therapy and manipulation in the treatment of cervicogenic headache. Three recent studies (2016 and 2017) are reviewed here:

•••••

In February 2016, a team of eleven experts from the United States and Europe published a study in the journal BMC Musculoskeletal Disorders, titled (10):

Upper Cervical and Upper Thoracic Manipulation Versus Mobilization
and Exercise in Patients with Cervicogenic Headache:
A Multi-center Randomized Clinical Trial

The authors note that the purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with cervicogenic headache, claiming that this is the first study to directly do so.

This study involved one hundred and ten participants (n = 110) with cervicogenic headache. Subjects were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). Outcomes were assessed using standard measurements (Numeric Pain Rating Scale, Neck Disability Index, Global Rating of Change, etc.)

The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after the initial treatment session. The study results and conclusions include:

“Individuals with cervicogenic headache who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity and disability than those who received mobilization and exercise at a 3-month follow-up.”

“Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period.”

“Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group.”

“Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with cervicogenic headache, and the effects were maintained at 3 months.”

“The results of the current study demonstrated that patients with cervicogenic headache who received cervical and thoracic manipulation experienced significantly greater reductions in headache intensity, disability, headache frequency, headache duration, and medication intake as compared to the group that received mobilization and exercise; furthermore, the effects were maintained at 3 months follow-up.”

The manipulation group experienced significantly reduced duration and frequency of headaches as well as perceiving greater improvement. These findings indicated that high-velocity, low-amplitude manipulation was more effective at treating cervicogenic headache than slow rhythmic mobilization techniques used as an intervention.

••••••••••

The following month, March 2016, a second study comparing cervical mobilization to manipulation in the treatment of cervicogenic headache was published. The authors are from Georgia State University, Atlanta, GA, USA. The study was published in the journal Frontiers in Neurology, and titled (11):

Mobilization and Manipulation of the Cervical Spine
in Patients with Cervicogenic Headache:
Any Scientific Evidence?

The purpose of this article was to investigate the effects of cervical mobilization and manipulation on pain intensity and headache frequency, compared to traditional physical therapy interventions in patients diagnosed with cervicogenic headache. The authors found 10 studies that met their stringent inclusion criteria, with a total of 685 subjects. “Seven of the 10 studies had statistically significant findings that subjects who received mobilization or manipulation interventions experienced improved outcomes or reported fewer symptoms than control subjects.” This article makes these points:

• Cervicogenic headache is a “secondary headache arising from musculoskeletal disorders in the cervical spine and is frequently accompanied by neck pain.”
• The estimated incidence of cervicogenic headache is: 4.1% of the total population; perhaps as high as 15% of the headache population; up to 20% of all chronic and recurrent headaches.
• Women may be affected with cervicogenic headache four times more frequently than men.
• “The symptoms of cervicogenic headache may arise from any of the components of the cervical spine, including vertebrae, disks, or soft tissue.” However, cervicogenic headache pain “most commonly arises from the second and third cervical spine (C2/3) facet joints, followed by C5/6 facet joints.”
• “Upper cervical spine mobility restriction (hypomobility), cervical pain, and muscle tightness are clinical findings associated with cervicogenic headache during physical examination.”
• The neurophysiological benefit for cervicogenic headache may be that the “afferent input induced by manual therapy may stimulate neural inhibitory pathways in the spinal cord and can also activate descending inhibitory pathways in the lateral periaqueductal gray area of the midbrain.”

 

Spinal manipulation of the upper cervical spine activates the Descending Pain Inhibitory pathway through the Periaqueductal Grey of the midbrain.

• “Cervical mobilization and manipulation are frequently used to treat patients diagnosed with cervicogenic headache.”
• “Many studies on the short-term effectiveness of manual therapy to the cervical spine (mobilization and manipulative therapy) have found it beneficial in reducing headache pain or disability, intensity, frequency, and duration.”
• The benefits of manual therapy for cervicogenic headache have been shown to be maintained at long-term follow-up assessments.
• Seven of the ten included studies examined how the effects of spinal manipulative therapy compared to an alternate intervention or a placebo; “six studies found statistically significant improvements in symptoms for participants in the manipulation group as compared to controls.”
• The “findings of the studies suggest that manual therapy on the cervical spine is more effective than traditional physical therapy interventions or sham intervention in reducing pain intensity and frequency of headaches in this population.”
• There is a growing body of evidence supporting cervical manipulation for the treatment of cervicogenic headache.
• “Patients with cervicogenic headache could benefit from manual therapy techniques, including spinal manipulative therapy.”

•••••

The final study reviewed here specifically looked at chiropractic manipulative therapy for the treatment of cervicogenic headache. The authors were from Akershus University Hospital, Norway; the University of Oslo, Norway; Innlandet Hospital, Norway; Macquarie University, Sydney, Australia. Their article was published in July 2017, in the journal BioMed Central (BMC) Research Notes, and titled (12):

Chiropractic Spinal Manipulative Therapy for Cervicogenic Headache:
A Single-Blinded, Placebo, Randomized Controlled Trial

The purpose of this study was to investigate the efficacy of chiropractic spinal manipulative therapy versus placebo (sham manipulation) and control (continued usual but non-manual management) for cervicogenic headache. It is a single-blinded, placebo, randomized controlled trial of 17 months’ duration. Twelve participants were randomized to three groups:

• A control group that continued with usual but not manual therapy: “The control group continued their usual pharmacological management without receiving manual intervention.”
• A sham manipulation (placebo) group: “The placebo group received sham manipulation at the lateral edge of the scapula and/or the gluteal region.”
• A chiropractic spinal adjustment group: “The chiropractic spinal manipulative therapy group received spinal manipulative therapy using the Gonstead method, directed to spinal biomechanical dysfunction as diagnosed by standard chiropractic tests.”

The authors note that cervicogenic headache is a disabling headache where pharmacological management has limited effect. In fact, they state:

“The efficacy of pharmacological management for cervicogenic headache is poor and medication overuse is frequent.” “Thus, non-pharmacological management is warranted.”

In this study, the Gonstead spinal adjusting was significantly superior to the sham thrusts placebo intervention and to pharmacology. The authors state:

“The control group [taking the standard drugs] remained unchanged during the whole study period.”

“Headache frequency improved at all time points in the chiropractic spinal manipulative therapy and the placebo group.”

“Headache index improved in the chiropractic spinal manipulative therapy group at all time points.”

“No severe or serious adverse events were reported in the study.” “Adverse events were few, mild and transient.”

“Our main results demonstrate reduction in headache frequency and headache index in the chiropractic spinal manipulative therapy and the placebo group, an effect that lasted at follow-up, while the control group was unchanged throughout the randomized controlled trial.”

“Our results suggest that manual-therapy might be a safe treatment option for participants with cervicogenic headache.”

“Due to insufficient pharmacological treatment strategies, spinal manipulative therapy has been recommended as a treatment option.”

This is an important and impressive study, especially for chiropractic spinal manipulation and the Gonstead technique.

A related addition would be to discuss differences in outcomes of chiropractic manipulation for cervicogenic headache based upon assessment of frequency of spinal manipulation. A study in 2004 addressed the subject, and is titled (13):

Dose Response for Chiropractic Care of
Chronic Cervicogenic Headache and Associated Neck Pain:
A Randomized Pilot Study

Specifically, this study looked at the relationship between treatment frequency and patient outcomes for subjects receiving one, three, or four chiropractic treatments per week. The study found:

• “After 4 weeks, subjects receiving four visits per week had significant reductions in headache pain and intensity compared to the subjects receiving one treatment per week.”
• “After 12 weeks, subjects receiving three or four visits per week had reduced pain and intensity compared to the once-per-week treatment group.”
• “This suggests that there may be an optimal dosage effect for spinal manipulative therapy intervention and that, to a certain extent, more frequent treatments may be related to more significant positive outcomes.”

•••••

The summary of these studies, from 1947-2017 (70 years) indicates that neck problems can cause headaches and that spinal manipulation is both safe and effective in the treatment of these cervicogenic headaches.

REFERENCES

1. Jackson R; The Cervical Syndrome As a Cause of Migraine; Journal of the American Medical Women’s Association; December 1947; Vol. 2; No. 12; pp. 529-534.
2. Seletz E; Craniocerebral Injuries and the Postconcussion Syndrome; Journal of the International College of Surgeons; January, 1957; Vol. 27; No. 1; pp. 46-53.
3. Seletz E; Headache of Extracranial Origin; California Medicine; November 1958, Vol. 89, No. 5, pp. 314-17.
4. Hubert Luschka (1858; Die Halbgelenke des menschlichen Körpers: Mit 6 Kupfertafeln [from Wikipedia].
5. Brismée JM, Sizer, Phillip S, Dedrick GS, Sawyer BG, Smith MP; Immunohistochemical and Histological Study of Human Uncovertebral Joints; Spine; May 20, 2009; Vol. 34; No. 12; pp. 1257-1263.
6. 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.
7. Sjaastad O, Saunte C, Hovdahl H, Breivik H, Grønbaek E; “Cervicogenic” Headache: An Hypothesis; Cephalagia; December 1983; Vol. 3; No. 4; pp. 249-256.
8. Bogduk N; Anatomy and Physiology of Headache; Biomedicine and Pharmacotherapy; 1995, Vol. 49, No. 10, pp. 435-445.
9. Bogduk N; Cervicogenic headache: Anatomic basis and pathophysiologic mechanisms; Current Pain and Headache Reports; August 2001; Vol. 5; No. 4; pp. 382-386.
10. Dunning JR, Butts R, Mourad F, Young I, Fernandez-de-Las Peñas C, Hagins M, et al; Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial; BMC Musculoskeletal Disorders; 2016; Vol. 17; No. 1; 64.
    Garcia JD, Arnold S, Tetley K, Voight K, Frank RA; Mobilization and Manipulation of the Cervical Spine in Patients with Cervicogenic Headache: Any Scientific Evidence? Frontiers in Neurology; March 21, 2016; Vol. 7; Article 40.
11. Aleksander Chaibi A, Heidi Knackstedt H, Peter J. Tuchin PJ, Michael Bjorn Russell MB; Chiropractic Spinal Manipulative Therapy for Cervicogenic Headache: A Single-Blinded, Placebo, Randomized Controlled Trial; BioMed Central (BMC) Research Notes; July 24, 2017; Vol. 10; No. 1.
12. Haas M, Groupp E, Aickin M, Fairweather A, Ganger B, Attwood M, et al.; Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: A randomized pilot study; Journal of Manipulative and Physiological Therapeutics; 2004; Vol. 27; No. 9; pp. 547–553.

Health, Productivity,
Absenteeism, Injury Prevention

In 2003, an important study was published in the journal Spine, titled (1):

Chronic Spinal Pain:
A Randomized Clinical Trial Comparing Medication,
Acupuncture, and Spinal Manipulation

In this study, researchers from the National Unit for Multidisciplinary Studies of Spinal Pain at the University of Queensland, Australia, randomly assigned 115 chronic spine pain subjects into three treatment options:

• Medication: the prescription nonsteroidal anti-inflammatory drugs Celebrex or Vioxx, daily for 9 weeks.
• Needle Acupuncture: two visits per week to a certified needle acupuncturist for nine weeks.
• Spinal Manipulation: two visits per week to a licensed chiropractor for nine weeks.

Subject progress and clinical status was assessed using standard measure outcomes:

• The Oswestry Back Pain Disability Index (Oswestry)
• The Neck Disability Index (NDI)
• The Short-Form-36 Health Survey questionnaire (SF-36)
• Visual analog scales (VAS) of pain intensity

At the end of the assessment period (nine weeks of intervention), the authors concluded that in patients with chronic spinal pain, chiropractic spinal manipulation “results in greater short-term improvement than acupuncture or medication.”

As noted, the initial treatment intervention for this group of subjects was 9 weeks. Importantly, a 12-month long-term follow-up was subsequently published on this patient population (2). The authors concluded:

“The overall results of this extended follow-up efficacy study appears to favor the application of manipulation” which successfully achieves long-term benefits in chronic spinal pain syndrome patients.

“Patients who have chronic mechanical spinal pain syndromes and received spinal manipulation gained significant broad-based beneficial short-term and long-term outcomes.”

“In patients with chronic spinal pain syndromes, spinal manipulation, may be the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.”

These studies are clearly a spinal musculoskeletal pain randomized clinical trial, and as such these patients were assessed at the beginning and the end of the trial period with pain scales, and neck and back functional disability assessment tools. Yet, a less publicized aspect of these studies is that the subjects were also assessed for systemic wellness using the Rand-36 (SF-36), which showed, importantly, chiropractic spinal manipulation also resulted in significant and lasting improvements on overall health.

Realizing that chiropractic spinal manipulation can have significant influence on systemic wellness has important implications for the workplace environment in terms of the potential to improve productivity and reduce absenteeism.

••••••••••

In 2011, physician Manuel Cifuentes, MD, and colleagues published a study in the Journal of Occupational and Environmental Medicine titled (3):

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

These authors note that low back pain is “one of the costliest work-related injuries in the United States in terms of disability and treatment costs,” and that “an additional, important component of the human and economic costs is the recurrence of low back pain.” They note that there has been little success in preventing recurrent low back pain.

To study the phenomenon of recurrent low back pain, these authors followed 894 low-back injured workers for a year. The authors specifically compared the rates of recurrent low back disability in injured workers who were categorized into three treatment groups:

• Medical physician care
• Physical Therapy
• Chiropractic

The authors concluded:

Chiropractic patients had “less expensive medical services and shorter initial periods of disability than cases treated by other providers.”

“After controlling for demographics and severity indicators, the likelihood of recurrent disability due to low back pain 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.”

“Our results, which seem to suggest a benefit of chiropractic treatment to reduce disability recurrence, imply that if the benefit is truly coming from the chiropractic treatment, there is a mechanism through which care provided by chiropractors improves the outcome.”

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

Hidden within the data of this study was evidence that receiving chiropractic care conferred other benefits to these injured workers. Specifically, it was noted that chiropractic patients had fewer surgeries, used fewer opioids, and had lower costs for medical care than the other provider groups. These “hidden” benefits from chiropractic care certainly have positive influences on workplace performance by these workers.

••••••••••

In 2013, Benjamin Keeney from Dartmouth Medical School, and colleagues from the University of Washington School of Public Health, University of Washington School of Medicine, and Ohio State University College of Public Health, published a study in the journal Spine, titled (4):

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury:
Results from a Prospective Study of Workers in Washington State

This was a prospective population-based cohort study whose objective was to identify early predictors of lumbar spine surgery within 3 years after occupational back injury. The study assessed 1,885 subjects. The authors note:

“Back pain is the most costly and prevalent occupational health condition among the U.S. working population.”

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

Patient functional disability status was measured using the Roland Morris Disability Questionnaire. Despite basic equivalency of disability scores, the authors noted that the best predictor for not having a back surgery during the three-year study period was having a chiropractor as the first health care provider, noting:

“There was a very strong association between surgery and first provider seen for the injury, even after adjustment for other important variables.” It is possible that these findings indicate that “who you see is what you get.”

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

“In Washington State worker’s compensation, injured workers may choose their medical provider. Even after controlling for injury severity and other measures, workers with an initial visit for the injury to a surgeon had almost nine times the odds of receiving lumbar spine surgery compared to those seeing primary care providers, whereas workers whose first visit was to a chiropractor had significantly lower odds of surgery.” [by 78%]

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

Once again, this study shows tremendous benefits from chiropractic care for injured workers, detailing incredible reductions of back surgery rates and its associated costs related to the surgery, rehabilitation, and lost productivity.

••••••••••

Anheuser-Busch is the world’s leading brewing company. One of their wholesalers, Brewers Distributing, is located in Peoria, IL. Many of their employees spend most of their time moving around heavy cases and kegs of beer. “Having noticed a large number of workers compensation cases due to lifting-related injuries, the company decided to introduce several workplace wellness programs to prevent these injuries from occurring in the first place. One of these programs involved weekly, on-site chiropractic visits, free of charge to any employee.” The chief financial officer at Brewers Distributing believes that on-site chiropractic has given his employees the greatest benefit.

The cost to the employee for this on-site chiropractic care is free (the doctor is paid by Brewers Distributing). If an employee needed help outside of that weekly window of time, they can visit the doctor in his office.

The strategy at Brewers Distributing is that by treating minor musculoskeletal problems their employees developed, they were preventing such problems from developing into a serious injury that would need to be covered by workers’ compensation. The view is that it is a win-win situation, a strategy that benefits the employee, reducing costs, which benefits the employer.

The author of the article, Annie Locke, notes (5):

“While some business owners and administrators might dismiss such a program as too expensive, it has actually saved Brewers a significant amount of money. In the two years since it was implemented, the number of employee sick days has declined by 22 percent, while the accident rate has been cut in half. Consequently, the company’s workers’ compensation costs have experienced a dramatic reduction, with premiums declining by more than 25 percent.”

“With that in mind, Brewers has encouraged others to adopt similar programs. At a recent industry conference, the company’s on-site chiropractic program was recognized as a ‘best practice’ among the hundreds of attendees. Katie Waddington, human resources manager, presented information about the program at the conference. ‘A lot of people at first think, Oh my goodness, that costs to have a chiropractor in your facility!’ But when you really look at the numbers… it makes sense. We have the return on investment and the statistics to prove it.’”

Once again, improving workers access to chiropractic care significantly reduced employee sick days, decreased employee accident-injury rate, dramatically reducing company worker’s compensation costs as well as worker’s compensation insurance premium costs.

••••••••••

Several other studies have documented the benefits of providing workplace on-site chiropractic care. These include the 2012 study published in the Journal of Occupational and Environmental Medicine, titled (6):

Value of Chiropractic Services at an On-Site Health Center

These authors note that the mission of on-site chiropractic is to enhance patients’ health, promote patient satisfaction, increase worker productivity, and decrease worker absenteeism.

Patients with headache, neck pain, and low back pain who were treated with on-site chiropractic showed significant improvements in both pain and functional status. In addition, on-site chiropractic reduced musculoskeletal injury insurance claims, resulted in fewer lost workdays and lower workers’ compensation payment. These authors made these following points:

“Chiropractic care offered at an on-site health center could reduce the economic and clinical burden of musculoskeletal conditions.”

“These results suggest that chiropractic services offered at on-site health centers may promote lower utilization of certain health care services, while improving musculoskeletal function.”

“Significant reductions in all functional assessment measures were observed, suggesting that the cohort experienced substantial improved functional status for all the three musculoskeletal conditions.” “Further evidence of the on-site chiropractic care’s effectiveness is the change in patient-reported functional status after treatment.” “These findings confirm that on-site chiropractic care successfully improved patients’ daily functioning.”

Treatment with “on-site chiropractic services was associated with lower utilization of certain health care services, as well as improved functional outcomes.”

“The results of this study support the value of chiropractic services offered at on-site health centers.”

There authors discuss the evidence that chiropractic care is less invasive and more conservative than alternative treatments. “Patients with chiropractic coverage seemed to be avoiding more surgeries, hospitalizations, and radiographic imaging procedures.”

The improved functional status found in this analysis indicates potential for reduced indirect costs, including absenteeism and productivity losses, with on-site chiropractic services.

This study highlights the potential benefits for all (employees, employers, costs benefits) concerned by offering on-site chiropractic services for employees.

••••••••••

Another study pertaining to on-site chiropractic care, published in 2014, was also published in the Journal of Occupational and Environmental Medicine, titled (7):

Impact of Chiropractic Services at an On-Site Health Center

The objective of this study was to compare the influence of employer-sponsored, on-site chiropractic care against community-obtained care on health care utilization. It was a retrospective claims analysis study, using 876 on-site and 759 off-site participants.

The authors make these background points:

• Musculoskeletal conditions are the primary cause of physical disability in the United States.
• About 50% of US adults have back pain, arthritis, osteoporosis, or bodily injury in excess of 3 months’ duration annually.
• Seventeen percent of US workers have absenteeism as a result of musculoskeletal conditions yearly.
• Neck pain inhibits about 14% of workers from successfully completing their jobs.
• In 2006, the average direct cost of treatment for musculoskeletal conditions was $576 billion, and indirect costs added an additional $373 billion, primarily in wage losses; a total cost of $949 billion.

These authors found that on-site chiropractic care resulted in significant improvements in headache, neck pain, and low back pain, yet while lowering utilization and healthcare cost.

••••••••••

In June 2017, an article was published in the journal Complementary Therapies in Medicine, titled (8):

Alternative Medicine, Worker Health, and
Absenteeism in the United States

The author of this study is Kate Rybczynski, from the Department of Economics, University of Waterloo, Canada. This paper reviews the literature on healthcare utilization and workplace absenteeism by exploring whether Complementary and Alternative Medicine (CAM) treatment is associated with fewer workdays missed due to illness. She notes that the high costs of illness-related workplace absenteeism may be reduced through the utilization of alternative healthcare providers.

Five different alternative healthcare practices were considered:

• Active mind-body (e.g. yoga, meditation)
• Naturopathy
• Massage therapy
• Chiropractic
• Acupuncture

Of the 8,820 subjects in this study, the author found that in the prior 12 months:

• 0.5% visited a naturopath
• 1.8% used acupuncture
• 10% visited a chiropractor
• 11.5% visited a massage therapist

As noted, chiropractic was the second most utilized alternative provider, second only to massage, and only by 1.5%.

The author notes that the major chronic conditions contributing to workplace absenteeism are:

• Lower back pain
• Diabetes
• Arthritis
• Allergies
• Asthma
• Menstrual pain
• Migraines
• Cancer
• Obesity
• Several mental conditions (bipolar disorder, anxiety, depression)

Importantly, the author found that in the prior three months, approximately 25% of the study subjects suffered from lower back pain. This is a healthcare problem that is classically successfully managed by chiropractors. In addition, chiropractors have proven effective in managing arthritis and migraine headaches.

The author notes that in 2012, “health related absenteeism costs an estimated $153 billion annually in the United States.” Most of this absenteeism is attributed to chronic health conditions. “Chronic conditions comprise the largest share of healthcare spending: 75% of spending is devoted to chronic conditions, adding about $3600 per person per year to employer healthcare costs.”

Noting that chronic health conditions are the major contributors to workplace absenteeism, the author notes that alternative healthcare providers often successfully manage these same chronic conditions. Therefore, the author assessed whether complimentary healthcare approaches could help reduce health illness-related absenteeism.

The author makes the following points:

“Massage therapy, chiropractor and acupuncture all have positive treatment effects.”

“Active mind-body practices, massage, chiropractic and acupuncture treatments are all significantly associated with improved health.”

“Estimates suggest that some complementary and alternative medicine modalities correlate with lower absenteeism, and many correlate with improved health.”

“Those who cannot afford conventional treatment might turn to complementary and alternative medicine, which often has lower overall costs despite higher frequency of visits.”

The author also notes that a growing body of literature shows the importance of shifting healthcare toward preventive care, which is an important strength of complementary and alternative medicine.

In summary, this study of 8,820 subjects, those who utilized alternative healthcare providers, including chiropractic, showed the following health benefits:

• Reduced work absenteeism
• Fewer other health care costs
• Improved health
• Preventive health care services

Specifically, the study showed that chiropractic was “significantly associated with improved health.”

The primary chronic health problem in this study’s subjects was chronic low back pain, occurring in about 25% of the participants.

SUMMARY

In total, these studies indicate that chiropractic offers employers, and employees these benefits:

• Significantly reduced employee sick days
• Reduced work absenteeism
• Fewer other health care costs
• Improved health
• Preventive health care services
• Significantly reduced back surgery rates and its associated costs related to the surgery, rehabilitation, and lost productivity
• Decreased employee accident-injury rate
• Dramatic reduction of company worker’s compensate claims
• Dramatic reduction of company worker’s compensate costs
• Increased worker function
• Improved worker productivity

Increasingly, both employers and employees are noting and taking advantage of the benefits of chiropractic healthcare.

REFERENCES

1. Giles LG, 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.
2. Muller R, Giles LG; 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.
3. 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.
4. 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.
5. Locke A; Saving Backs… and Costs; On-site Chiropractic Care Can Improve Employee Health While Cutting Overall Costs; Peoria Magazines, InterBusiness Issues; September 2014; pp. 83-84.
6. Krause CA, Kaspin L, Gorman KM, Miller RM; Value of Chiropractic Services at an On-Site Health Center; Journal of Occupational and Environmental Medicine; August 2012; Vol. 54; No. 8; pp. 917-921.
7. Kindermann SL, Hou Q, Miller RM; Impact of Chiropractic Services at an On-Site Health Center; Journal of Occupational and Environmental Medicine; September 2014; Volume 56; No. 9; pp. 990–992.
8. Rybczynski K; Alternative Medicine, Worker Health, and Absenteeism in the United States; Complementary Therapies in Medicine; June 2017; Vol. 32; pp. 116–128.

Chronic Headaches, Balance Problems, Brain Fog, and More

Chiropractic clinical practice acknowledges that there is a unique and important relationship between the alignment of the skull and the upper cervical spine. Nearly all chiropractic techniques (specific treatment approaches) treat alignment problems of the upper cervical spine, but many chiropractors only treat the upper cervical spine, a testament to the importance of the region and the clinical benefits such treatment delivers.

Chiropractors that specialize in alignment of the skull and the upper cervical spine often analyze the biomechanics of the region with precision radiography. This analysis is the basis of carefully applied vector forces to correct biomechanical alignment problems. This approach has proven to result in effective clinical outcomes (1). Recently, advanced imaging, specifically upright MRI, has been used to establish the pathology associated with skull/upper cervical spine alignment problems, as well as to explain the clinical benefits of upper cervical spine chiropractic care (2).

The Jim McMahon Story

Jim McMahon was a great football quarterback. He was born in 1959. He played college football at Brigham Young University, earning All-American status in 1980 and 1981. The Chicago Bears drafted him in the first round of the NFL draft in 1982.

In 1982, McMahon was UPI NFC Rookie of the Year. He earned a Pro Bowl appearance in 1986, and two Super Bowl Rings. He appeared on the cover of Sports Illustrated numerous times (3). During his playing career, McMahon suffered four documented concussions. McMahon retired in 1996 at the age of 37 years.

Sixteen years after he retired from football, at age 53, McMahon appeared on the cover of Sports Illustrated (September 10, 2012 issue) once again (4). It was an article detailing his struggles with dementia. McMahon’s behaviors included:

• Lying on the bed watching the ceiling fan go round and round.
• Significant excessive sleeping, like “hibernating.”
• Not remembering where he wanted to go.
• Stumbling on furniture he felt had been rearranged (it had not).
• Being unable to find the bathroom.
• Not knowing where he was.
• A change in personality: no longer charismatic, sweet, confident, funny, or warm.
• Boarding the wrong airplane flight.
• He would drop to his knees, break into a cold sweat and turn a ghostly white, complaining of a pain that he compares to having an ice pick in his brain.

To compensate, his girlfriend:

• Printed a card with his vital statistics and her phone number and placed it in his wallet.
• Programmed their car’s GPS with their address and her phone number.
• Made sure the home alarm was on at all times in case he tried to wander off alone.

Recently (2016), Jim McMahon has appeared prominently again in the media. He has been profiled in an ESPN Special Report as a consequence of a change in his clinical status. The signs and symptoms of his chronic neurodegenerative disorder have quickly and dramatically improved, and consistent with his character, he’s talking about it (5).

An upright weight-bearing MRI was taken of McMahon’s head and neck. As noted above, the imaging showed an accumulation of fluid (cerebral spinal fluid) in his skull and around his brain. Consistent with the biomechanics and physiology reviewed in this article, McMahon’s upper cervical specific chiropractor took precise radiographs of McMahon’s upper neck and skull. A careful, precise, mathematical analysis of his radiographs showed that there was a meaningful malalignment between the skull and the atlas vertebra. Such findings are consistent with an impairment of fluid flow (venous, arterial, cerebral spinal) between the skull (brain) and the spinal canal. This biomechanical finding could account for the increased fluid noted in the MRI of his brain. The increased brain fluid could account for the plethora of signs and symptoms McMahon was suffering from.

Prior to this unique treatment, the ESPN Special noted that McMahon, age 56, was suffering from:

• Bad headaches
• “Pressure in my skull”
• Couldn’t see very well
• Couldn’t talk very well
• “All I wanted to do is lay down because my head was constantly pounding”

Following the precise analysis of his upper cervical spine-occiput biomechanical relationships, Jim McMahon was carefully chiropractically adjusted. The sole goal of the adjustment was to establish perfect alignment between the occiput and the atlas vertebrae. This goal was achieved, verified by post-adjustment radiographs that were similarly biomechanically analyzed. The improvement in his signs and symptoms were essentially instantaneous.

A post adjustment upright weight-bearing MRI of McMahon’s brain and spinal cord showed a remarkable reduction of fluid, as if an inverted bottle had been uncorked. McMahon’s improvement in clinical status is both substantial and appears to be long lasting. Within two minutes of the chiropractic adjustive procedure, McMahon commented:

• “It was like the toilet flushed”
• “I could feel the stuff leaving my brain”
• “My eyes cleared up”
• “My speech cleared up”

A post treatment MRI showed significantly less fluid accumulation on McMahon’s brain. McMahon commented that the procedure “kept me from having bad pains and suicidal thoughts, and having me function fairly normally.”

Following the chiropractic upper cervical spine adjustment, in July 2016, Jim McMahon was participating in the Tahoe South Celebrity-Am golf event when a Sacramento Bee sports reporter caught up with him for a story (6). The interview mentions that McMahon was one of the original plaintiffs in the concussion lawsuit that former players filed against the NFL. When questioned about his pain, fatigue, and brain function, McMahon replied:

“I’ve got my good days and bad. As long as I keep my neck and head in alignment, I’m fairly normal.”

The article notes that McMahon visits a chiropractor in New York every two or three months to keep everything lined up, stating:

“It keeps the spinal fluid flowing properly. When it gets out of whack, all I want to do is lay down in a dark room.”

A year later, July 2017, Jim McMahon is once again participating in the celebrity American Century Championship golf tournament. This time he was caught by San Francisco Chronicle sports reporter Scott Ostler (7). Ostler’s article notes that McMahon is now 57 years of age, and states:

“Five years ago, a Sports Illustrated story spotlighted his head problems. McMahon had been diagnosed with early-onset dementia.”

“The reports had McMahon in bad shape, in near constant pain, wandering through life in a fog, frustrated and angry. He’d drive to an errand, phone his girlfriend and ask, like a lost child, ‘Where am I?’”

When asked about his head:

“He says it’s good. After his woes became public in 2012, McMahon was contacted by a person who said he might be able to help him. A New York chiropractor… told McMahon he had neck-alignment problems.”

“The misaligned parts were short-circuiting the flow of cerebrospinal fluid up and down his brainstem and spine.”

“Some adjusting… freed the flow, kind of like un-kinking a garden hose.” “The relief was instant and dramatic.”

“McMahon says his short-term memory is much improved. The ice-pick headaches are gone. He’s a functioning human being. Whenever symptoms return, he goes back for a tune-up and is good to go for another few months.”

••••••••••

The physiology and health of the brain and spinal cord is dependent upon the flow and movement of cerebral spinal fluid. The cerebral spinal fluid is generated in the brain and circulates throughout the brain and the spinal cord. To get to the spinal cord, the cerebral spinal fluid must pass through a hole in the skull, the foramen magnum. The top of the spinal column also has a hole through which the cerebral spinal fluid must flow, the atlas vertebrae, also known as cervical-1 or C-1.

Starting in 2003, studies began to show that radiographically measured biomechanical misalignment between the foramen magnum hole and the atlas vertebrae hole impaired the flow of cerebral spinal fluid between the skull and the spine (8). The author, Marshall Deltoff notes (8):

“Upper cervical practitioners utilize the radiographic measurement of static vertebral misalignment to help determine on which side and at what angle the adjustment [specific spinal manipulation] should be given.” p. 59

“MRI is an invaluable aid in diagnosing disorders of the brainstem, medulla, upper cervical cord an spinal canal. Congenital lesions, intramedullary and extramedullary intradural disease, including tumours, infection, ischaemia and demyelination can be assessed. MRI also provides valuable information about the encompassing bony and ligamentous structures of the cranio-vertebral junction and the cervical spine.” p. 57

With MRI technology, water accumulation (swelling, etc.), images differently than tissues/regions that have less water (swelling, etc.). When water/fluid accumulates in a region, MRI technology can easily document this water/fluid accumulation. Impairments of water/fluid flow (cerebral spinal fluid flow) are best documented with upright weight-bearing MRI (2).

A small misalignment between the hole of the skull (foramen magnum) and the spine (atlas vertebrae) causes:

• An accumulation of cerebral spinal fluid in the brain
• An increase in cerebral spinal fluid pressure in the brain

This model of skull-atlas misalignment impairment of cerebral spinal fluid flow causing increased cerebral spinal fluid pressures in the brain, is associated with symptomology and dysfunction. The benefits of upper cervical spine chiropractic adjusting is gaining scientific support and media attention. Supportive studies include the following:

••••••••••

In 2011, a study appeared in the journal Physiological Chemistry and Physics and Medical NMR, and titled (9):

The Possible Role of Cranio-Cervical Trauma and Abnormal CSF
Hydrodynamics in the Genesis of Multiple Sclerosis

In this study, eight multiple sclerosis (MS) patients and seven normal volunteers were MRI scanned with a quadrature head-neck combination coil to visualize the overall cerebral spinal fluid (CSF) flow pattern. The findings were best visualized with an upright weight-bearing MRI. These authors note:

“Upright cerebrospinal fluid (CSF) cinematography and quantitative measurements of CSF velocity, CSF flow and CSF pressure gradients in the upright patient revealed that significant obstructions to CSF flow were present in all MS patients.”

Abnormal CSF flows were found in all eight MS patients. “The abnormal CSF flows corresponded with the cranio-cervical structural abnormalities found on the patients’ MR images.”

“Every MS patient exhibited obstructions to their CSF flow when examined by phase coded CSF cinematography in the upright position.”

“All MS patients exhibited CSF flow abnormalities that were manifest on MR cinematography as interruptions to flow or outright flow obstructions somewhere in the cervical spinal canal, depending on the location and extent of their cervical spine pathology. Normal examinees did not display these flow obstructions.”

“The abnormal CSF flow dynamics found in the MS patients of this study corresponded to the MR cervical pathology that was visualized.”

“The findings raise the possibility that interventions might be considered to restore normal intracranial CSF flow dynamics and intracranial pressure.”

“The findings further suggest that going forward, victims of Motor Vehicle Whiplash injuries with persisting symptoms, e.g., headache, neck pain, should be scanned by UPRIGHT(R) MRI to assure that their CSF hydrodynamics and cervical anatomy (C1-C7) are normal. Should their CSF hydrodynamics prove abnormal, they should be monitored by UPRIGHT(R) MRI to assure they are restoring to normal over time, or ultimately decompressed by expansion stenting or cervical realignment if they are not.”

This study is particularly important for chiropractors. These authors suggest that cervical spine malalignment obstructs the flow of cerebral spinal fluid. This obstruction of CSF flow increases intracranial pressure, leading to additional brain pathology and dysfunction.

These authors suggest that the improvement in cranial-cervical malalignment could improve cerebral spinal fluid flow, stopping the aforementioned cascade. In fact, in one of the MS patients, the UPRIGHT MRI found a malalignment of the occiput-C1. This malalignment was successfully treated by an upper cervical chiropractor. The authors noted:

“The patient’s symptoms, severe vertigo accompanied by vomiting when recumbent and stumbling from unequal leg length, ceased upon treatment [with a chiropractic upper cervical spine adjustment].” Objective improvements in obstructed CSF fluid was also noted “immediately following treatment with the [chiropractic adjustment].”

••••••••••

In 2015, another supportive study appeared in the journal Neurology Research International, and titled (10):

The Role of the Cranio-cervical Junction in Cranio-spinal
Hydrodynamics and Neurodegenerative Conditions

The author notes that cranio-spinal hydrodynamics refers to the relationship between blood and cerebral spinal fluid (CSF) volume, pressure, and flow in the relatively closed confines of the compartments of the cranial vault and spinal canal. He notes that cranio-spinal hydrodynamics can be disrupted by a number of mechanical lesions (congenital, degenerative, an acquired) of the cranio-cervical junction (CCJ), stating:

“The CCJ links the vascular and cerebrospinal fluid (CSF) systems in the cranial vault to those in the spinal canal.”

“The cranio-cervical junction (CCJ) is a potential choke point for cranio-spinal hydrodynamics and may play a causative or contributory role in the pathogenesis and progression of neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, and ALS, as well as many other neurological conditions including hydrocephalus, idiopathic intracranial hypertension, migraines, seizures, silent-strokes, affective disorders, schizophrenia, and psychosis.”

“Malformations and misalignments of the CCJ cause deformation and obstruction of blood and CSF pathways and flow between the cranial vault and spinal canal that can result in faulty cranio-spinal hydrodynamics and subsequent neurological and neurodegenerative disorders.”

Congenital malformations/anomalies of the cranio-cervical junction (CCJ) can block blood and CSF flow between the cranial vault and spine, pushing the cerebellar tonsils and/or brainstem into the cervical canal, which further blocks the flow of CSF. This causes an accumulation of fluid in the cranial vault (hydrocephalus). Such conditions include:

• Chiari malformations
• Abnormal clivoaxial angle (11)
• Hypoplasia of the posterior cranial fossa
• Basilar invagination
• Platybasia
• Hypoplasia of the foramen magnum
• Hypoplasia of the jugular foramen
• Anomalies of the odontoid process
• Premature closure of cranial sutures (craniosynostosis)

An acquired blockage to CSF flow, important to chiropractors, is a misalignment of the atlas on the occipital condyles. This author states:

“Misalignments of the CCJ [atlas-occiput articulation] can obstruct blood flow through the vertebral arteries and veins that can lead to chronic [brain/cranial] ischemia and edema.”

“Blockage of blood and CSF flow due to malformations and misalignments of the CCJ may play a role in chronic [brain/cranium] ischemia, edema, hydrocephalus, and ventriculomegaly [enlargement].”

“The CCJ is a potential choke point for blood and CSF flow between the cranial vault and spinal canal that can cause faulty cranio-spinal hydrodynamics and subsequent chronic ischemia, edema, and hydrocephalus.”

“Malformations and misalignments of the CCJ may play a role in chronic [brain/cranial] ischemia and edema, which may in turn lead to neurodegenerative processes and subsequent diseases.”

“Malformations, misalignments, and deformation of the CCJ compress the vertebral veins, which may affect CSF flow.” “An increase in CSF volume in the brain can compress veins and decrease drainage.”

This author emphasizes that the cranial-cervical junction is a choke point for cerebral spinal fluid flow between the cranial vault and spinal canal. He believes that manual, mechanical, and surgical correction of cranial-cervical junction structural problems will improve faulty cranio-spinal hydrodynamics and improve patient pathology and symptomatology, stating:

“Manual and surgical methods for correcting obstructions, as well as manipulation of blood and CSF flow, may help to restore or improve faulty cranio-spinal hydrodynamics in certain cases and decrease the prevalence, progression, and severity of neurodegenerative and other neurological conditions.”

The author notes that the blockage of cerebral spinal fluid flow at the cranial-cervical junction may be predisposed by a combination of congenital and/or degenerative conditions. Small misalignments of cranial-cervical alignment, superimposed on such congenital and/or degenerative conditions, increase the likelihood of an obstruction of the cerebral spinal fluid flow. The author notes that manual therapy/manipulation of the upper cervical spine has the potential to improve the flow of cerebral spinal fluid, improving the patient’s signs and symptoms.

••••••••••

In 2015, the most authoritative book written to date detailing the pathogenic potential, diagnosis, and treatment of cranio-cervical junction alignment problems was published (2). The reference book is titled The Craniocervical Syndrome and MRI. The editors are professor Francis W. Smith (London) and physician Jay S. Dworkin (New York). Three chapters of the book are particularly relevant to this discussion:

• “Upright Magnetic Resonance Imaging of the Craniocervical Junction” by Francis W. Smith
• “Concussion Update: Immunoexcitotoxicity, the Common Etiology of Post-concussion Syndrome, Chronic Traumatic Encephalopathy and Posttraumatic Stress Disorder” by Joseph Maroon, Jeff Bost, Austin Amos, Robert Winkelman,
• Christina Mathyssek From the Department of Neurosurgery, University of Pittsburgh
• “Cerebrospinal Fluid Physiology and Its Role in Neurologic Disease” by William Bradley from the Department of Radiology, University of California, San Diego
• “The Craniocervical Junction: Observations Regarding the Relationship Between Misalignment, Obstruction of Cerebrospinal Fluid Flow, Cerebellar Tonsillar Ectopia, and Image-Guided Correction” by Scott Rosa and John Baird

These references make the following key points:

“Upright MRI provides the decisive utility of cerebrospinal fluid flow studies around the craniocervical junction.”

“Cerebrospinal fluid accumulation may play a role in traumatic brain injury” signs and symptoms.

“Magnetic resonance imaging (MRI) is conveniently performed in the supine position, in which no information about the effect of gravity on the patient in the upright position is possible.” [emphasis added]

“Head trauma commonly results in craniocervical trauma, which is theorized to cause cervical CSF flow abnormalities.”

“MRI may show CSF accumulation.”

“C1 misalignment may contribute to cerebrospinal fluid (CSF) flow obstruction.”

“Craniocervical junction misalignments can compromise the normal flow of spinal fluid in and out of the cranial vault.”

“Craniocervical junction misalignments can cause headaches, neck pain (skull base pain), nausea, dizziness, tinnitus and facial pain, to name a few.”

Summary

The anecdotal observation of former NFL quarterback Jim McMahon is fascinating. Advances in science and imaging, especially upright weight bearing MRI, create biological plausible explanations as to why upper cervical spine chiropractic can help many persons with chronic head and neck symptoms. Cervical-occiput misalignments impair the cerebrospinal fluid flows between the brain and spinal cord. Specific upper cervical chiropractic adjustment that results in improved alignment between the occiput an the atlas can “uncork” the flow of cerebrospinal fluid between the brain and spinal cord, resulting in an improvement of a number of clinical signs and symptoms.

REFERENCES

1. Bakris G, Dickholtz M, Meyer PM, Kravitz G, Avery E, Miller M, Brown J, Woodfield C, Bell B; Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study; Journal of Human Hypertension; May 2, 2007; Vol. 21; No. 5; pp. 347-357.
2. Smith FW, Dworkin JS; The Craniocervical Syndrome and MRI; Karger; 2015.
3. Hendricks M; Super Bowl-winning quarterback Jim McMahon says he wishes he had played baseball; Yahoo!; September 27, 2012.
4. Segura M; The Other Half Of the Story; THE WOMEN BEHIND THE MEN; Sports Illustrated; September 10, 2012.
5. https://www.youtube.com/watch?v=4ZxIUz4sc0U
6. Furillo A; Shoeless Golf is a Perfect Fit for McMahon; Sacramento Bee; July 21, 2016; pp. 1C and 5C.
7. Ostler S; Quarterbacking a Gypsy Lifestyle, Renewed Outlook for Former NFL Star; San Francisco Chronicle, July 15, 2017; pp. B1 and B7.
8. Deltoff MN; “Diagnostic Imaging of the Cranio-Cervical Region”, Chapter 4, in The Cranio-Cervical Syndrome, Mechaniscm, Assessment and Treatment; Edited by Howard Vernon; Butterworth Heinemann; 2003.
9. Damadian RV, Chu D; The Possible Role of Cranio-Cervical Trauma and Abnormal CSF Hydrodynamics in the Genesis of Multiple Sclerosis; Physiological Chemistry and Physics and Medical NMR; September 20, 2011; 41; pp. 1–17.
10. Flanagan MF; The Role of the Cranio-cervical Junction in Cranio-spinal Hydrodynamics and Neurodegenerative Conditions; Neurology Research International; November 30, 2015. [epub]
11. Coban G, Coven I, Cifci BE, Yildirim E, Yazici AC, Horasanli B; The Importance of Craniovertebral and Cervicomedullary Angles in Cervicogenic Headache; Diagnostic and Interventional Radiology; March–April 2014; Vol. 20; pp. 172–177.

The Evidence Continues to Grow

The American opiate crisis and its resulting heroin/fentanyl addiction epidemic began in 1980 when the prestigious medical journal, The New England Journal of Medicine, indicated that “less than one percent” of patients given opiate drugs for pain became addicted (1). Sadly, this statistic was not based on valid scientific data. It was based on a short letter-to-the editor by physicians Jane Porter, MD, and Hershel Jick, MD, from Boston University Medical Center. This publication began the relentless marketing of opiate drugs for pain, supported by the concept that these drugs were not addictive.

Six years later, in 1986, prescribing opiates for chronic pain was further enhanced when physicians Russell Portenoy, MD, and Kathleen Foley, MD, published a small case series (38 subjects) that concluded that chronic opioid analgesics use was safe in patients with no history of drug abuse (2).

Yet, it is stunning to realize that until this year (2017), there were no published studies of opiate therapy for chronic pain that evaluated long-term (greater than one year) outcomes related to pain, function, or quality of life. Most of the placebo-controlled randomized clinical trials pertaining to opiate drugs were less than six weeks in duration (3).

The current issue of The Back Letter (July 2017) profiles the use of opiate drugs for chronic back pain with the headline (4):

Landmark Trial Punctures the Myth That Opioids Provide Powerful Relief of Chronic Pain

The opening comments from this article are:

“The deadly opioid overtreatment epidemic picked up steam in the late 1980s and early 1990s with the misguided notion that opioids are painkillers that can be used safely and effectively in the long-term treatment of chronic back pain—or other forms of non-cancer chronic pain.”

“The intervening years—and as many as 300,000 deaths in the related opioid overdose epidemic—have rebutted the idea that opioids can be used safely on a mass basis. More than 30,000 Americans will die in 2017 as the result of opioid overdoses. And the opioid overdose epidemic is still increasing in ferocity in many quarters.”

The landmark trial referenced is the first randomized controlled trial (RCT) with long-term follow-up comparing opioids with non-opioid medications. It is from the Minneapolis Veterans Health Care System (5). The authors found that opioids provided no better pain relief for patients with low back pain than other safer approaches. Comments pertaining to the study include (4):

“It is the first clinical trial comparing opioid and non-opioid medications with long-term follow-up. It provides strong evidence that opioids should not be the first line of treatment for chronic musculoskeletal pain, given that there were similar changes in pain and function with non-opioids.”

“A lot of people at the conference were impressed with this study, as it confirmed the clinical impressions of many physicians that opioids are not as effective as advertised.”

“Opioids are perceived as strong pain relievers, but our data showed no benefits of opioid therapy over non-opioid medication therapy for pain.”

“Opioids provided no advantage in terms of function at the 12-month follow-up mark, and patients in the opioid wing of the study actually reported marginally more pain at 12 months than those in the non-opioid group.”

“The data do not support opioids’ reputation as powerful painkillers.”

“Opioids are not achieving the benefits for which they are marketed. And everyone is now well aware of the adverse effects of opioids.”

A related article from the same issue of The Back Letter is titled (4):

What If the New Opioid Study Had Been Published In 1995?
How Many Lives Would Have Been Saved?

Comments from this article note that the opiate drug movement has been one of the most “destructive” and “among the most lethal in modern medical history.” The article notes:

“Had this study been conducted and published in 1995, it might have saved 300,000 lives or more—lives lost to opioid overdoses.”

“The opioid overtreatment epidemic and resulting heroin/fentanyl addiction epidemic continues to kill more than 30,000 US residents per year. And with an estimated eight million Americans on long-term opioid therapy, this issue may bedevil US society for decades.”

Opiate drugs continue their grip on America. As of this year (2017), four states (Missouri, Mississippi, Ohio, Illinois) have officially sued several of the drug company producers of opiates in an effort to recapture compensation for societal devastation caused by these drugs (6). Interestingly, these lawsuits against the drug companies are also being filed at the local level. Santa Clara County (Northern California) and Orange County (Southern California) have filed similar lawsuits in an effort to recapture some of the incredible local financial burdens associated with the opiate drug epidemic. American Indian reservations are taking a similar approach (6).

In spite of all of this, opiate drugs continue to be overly prescribed for patients with back pain (13). Yet, over the past decade, Clinical Practice Guidelines for the treatment of back pain have increasingly moved away from prescribing drugs, especially opiates, and have emphasized more on the non-drug approaches to the back pain problem:

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

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

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

••••••••••

The October 2007 issue of the journal Annals of Internal Medicine published the comprehensive and authoritative (7, 8):

Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain

An extensive panel of qualified experts constructed these clinical practice guidelines. These experts performed a review of the literature on the topic and then graded the validity of each study. The literature search for this guideline included studies from MEDLINE (1966 through November 2006), the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and EMBASE. This project was commissioned as a joint effort of the American College of Physicians and the American Pain Society. The results of their efforts are summarized in two separate articles. The first article is (7):

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

Recommendations from these guidelines include:

• For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. For most patients, first-line medication options are acetaminophen or non-steroidal anti-inflammatory drugs.
• For patients who do not improve with self-care options, clinicians should consider the addition of non-pharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation.
• For chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation.

This publication notes that acceptable non-pharmacologic options for acute, subacute, and chronic low back pain include spinal manipulation. In fact, spinal manipulation is the only non-drug treatment recommendation for acute low back pain in this document. The article notes:

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

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

•••••

The second guideline article was also in the October 2007 issue of the journal Annals of Internal Medicine. At the time (a decade ago, 2007), it was the most comprehensive review of the literature concerning non-drug therapies used in the treatment of low back pain. It was titled (8):

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

This article defines spinal manipulation as:

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

Spinal mobilization was defined as:

“Low-velocity, passive movements within or at the limit of joint range.”

These authors note that there are many non-pharmacologic therapies available for treatment of low back pain. They therefore assessed the benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain). These authors note:

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

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

In this review, the only non-drug treatment that has proven evidence to benefit acute, subacute, and chronic back pain is spinal manipulation.

••••••••••

The Council on Chiropractic Guidelines and Practice Parameters have been in continuous development since 1995. The most recent update appeared in the Journal of Manipulative and Physiological Therapeutics in 2006, and is titled (9):

Clinical Practice Guideline:
Chiropractic Care for Low Back Pain

This publication is the most recent update of the best practice recommendations for chiropractic management of low back pain; the update included 80 references. The participants continue to perform a systematic review of published articles on the topic, as well as to entertain input from multidisciplinary experts who represent a broad sampling of jurisdictions and practice experience related to low back pain management. The panel used the RAND-UCLA methodology to reach a formal, robust consensus position. The process and review is comprehensive and detailed. The conclusion of the process is:

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

••••••••••

In February 2017 the European Journal of Pain published a study titled (10):

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

These authors performed an extensive search of published Low Back Pain Guidelines published between 2005 and 2014. Their conclusions include:

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

These Guidelines advocate manual therapy for low back pain. They define manual therapy as the application of either manipulation or mobilization. They state:

“Manual therapy, including spinal manipulation or mobilizations.”

••••••••••

The evolving nature of Low Back Evidence Based Practice Guidelines is best represented in another study published in April of 2017 in the journal Annals of Internal Medicine, and is titled (11):

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

The American College of Physicians developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain. The committee based their recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and non-pharmacologic treatments for low back pain. Updated literature searches were performed through November 2016 and included in their review. The article included 182 references.

The authors note that the target audience for this guideline included all clinicians; the target patient population includes adults with acute, subacute, or chronic low back pain. These authors note:

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

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

“Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients.”

“Low-quality evidence showed no difference between acetaminophen and placebo for pain intensity or function through 4 weeks or between acetaminophen and NSAIDs for pain intensity or likelihood of experiencing global improvement at 3 weeks or earlier.”

This most recent Guideline for Low Back Pain clearly emphasized “non-pharmacologic treatment” which included spinal manipulation. Consistent with other recent Guidelines, there is a de-emphasis for the use of acetaminophen. In addition, there is a clear warning about the use of opiate drugs for these patients.

••••••••••

As noted above, Clinical Practice Guidelines are systematically developed based upon “evidence from rigorous systematic reviews and synthesis of the published medical literature.” As such, additions to the published medical literature will be incorporated into future updates of clinical practice guidelines.

A recent study adds to the evidence that spinal manipulation is a safe and appropriate treatment for patients suffering from acute low back pain. The article was published in the Journal of the American Medical Association in April 2017, and titled (12):

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

The authors of this study were from the:

• Veterans Affairs Medical Center, Los Angeles
• University of California, Los Angeles
• RAND Corporation, Santa Monica
• Veterans Affairs Healthcare System, Phoenix
• Veterans Affairs Medical Center, Rochester
• Minneapolis Veterans Affairs Healthcare System
• White River Junction Veterans Affairs Medical Center, Vermont

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

The measurement outcomes used 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 (SMT) was provided by physical therapists in 13 studies, chiropractors in 7 studies, medical doctors in 5 studies, and osteopathic physicians in 3 studies. The studies reviewed provided moderate-quality evidence that SMT has a statistically significant association with improvements in back pain and in function. The authors made the following comments:

“Back pain is among the most common symptoms prompting patients to seek care. Lifetime prevalence estimates of low back pain exceed 50%.”

“Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option.”

“No randomized clinical trials 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.”

“Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms.”

“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.”

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

“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.”

Many studies pertaining to the use of spinal manipulation target its use for chronic back pain sufferers. This study targets spinal manipulation for acute low back pain. The study shows that spinal manipulation, including thrust-type spinal manipulation is both safe and effective for patients suffering from acute low back pain.

•••••

Richard Deyo, MD, is the contemporary leader in the contribution and understanding to Clinical Practice Guidelines pertaining to low back pain. He is a primary care internist who holds the title of Professor of Evidence-Based Family Medicine at Oregon Health and Science University. He is the Kaiser-Permanente Endowed Professor of Evidence-Based Medicine in the Department of Family Medicine at Oregon Health and Science University. Dr. Deyo is a Deputy Editor of Spine and a member of the Editorial Board of the Back Review Group of the Cochrane Collaboration. He is co-editor of the book Evidence-Based Clinical Practice: Concepts and Approaches.

Dr. Deyo has a long-standing research interest in measuring patient function, involving patients in clinical decisions, and managing low back pain. He has a national and international reputation for research on back pain. He has authored or co-authored more than 400 peer-reviewed scientific articles, mostly concerning back pain; PubMed places the number at 426 (July 13, 2017).

The above article by Paige et at (12) generated the following editorial, published in the Journal of the American Medical Association, and titled (13):

The Role of Spinal Manipulation in the Treatment of Low Back Pain

In this editorial, Dr. Deyo notes that 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.” Yet, at present, there are approximately 200 treatment options available to treat low back pain.

Dr. Deyo notes that this article by Paige and colleagues (12) presents a sophisticated systematic review and meta-analysis, including 26 eligible randomized trials of manipulation for acute back pain (less than six weeks). Their analysis was based on a thorough search of the literature. The authors concluded that for patients with acute low back pain, spinal manipulative therapy was associated with modest improvement in pain and modest improvements in function in comparison with sham manipulation, usual care, or other treatments. Dr. Deyo notes that none of the randomized trials or large observational studies reviewed by Paige et al identified any serious complications from spinal manipulation for back pain.

Dr. Deyo states:

“Low back pain is among the most common reasons for prescribing opioids in the United States. Among patients initiating opioid therapy, about 5% become long-term opioid users, with associated risks of dependency, addiction, and overdose.”

“Among patients taking non-steroidal anti-inflammatory drugs, renal function abnormalities occur in approximately 1% of patients, and superficial gastric erosions or asymptomatic ulcers may occur in up to 5% to 20% of users.”

“Renal and gastrointestinal adverse effects of non-steroidal anti-inflammatory drugs are common.”

Pertaining to spinal manipulation, Dr. Deyo makes these comments:

“Spinal manipulative therapy (SMT) is a controversial treatment option for low back pain, perhaps in part because it is most frequently administered by chiropractors.”

“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.”

“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 non-steroidal 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.”

SUMMARY

The evidence that spinal manipulative therapy is both safe and effective for patients suffering from acute or chronic low back pain continues to grow. This evidence is being published in the best scientific journals by the world’s leading experts on back pain.

In contrast, the use of drugs to treat back pain patients, especially opiate drugs, is continuing to be questioned for both its lack of effectiveness and risks of addiction and harm.

REFERENCES

1. Porter J, Jick H; New England Journal of Medicine; 1980, 302(2): 123.
2. Portenoy RK, Foley KM; Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases, Pain, 1986; 25:171ñ86.
3. Dowell D et al.; CDC Guideline for Prescribing Opioids for Chronic Pain—United States; 2016, JAMA, 2016; 315(15): 1624ñ45.
4. Wiesel SW, Executive Editor; Landmark Trial Punctures the Myth That Opioids Provide Powerful Relief of Chronic Pain; The Back Letter; Volume 32, Number 7, July 2017.
5. Krebs EE et al.; Effectiveness of opioid therapy vs. non-opioid medication therapy for chronic back & osteoarthritis pain over 12 months. Presented at the annual meeting, Society for General Internal Medicine, Washington DC, 2017.
6. Semuels A; Are Pharmaceutical Companies to Blame for the Opioid Epidemic?;The Atlantic Daily; June 2, 2017.
7. Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS; Diagnosis and Treatment of Low Back Pain; Annals of Internal Medicine; Volume 147, Number 7, October 2007, pp. 478-491.
8. Roger Chou, MD, and Laurie Hoyt Huffman, MS; Non-pharmacologic Therapies for Acute and Chronic Low Back Pain; Annals of Internal Medicine; October 2007, Volume 147, Number 7, pp. 492-504.
9. 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:
10. Chiropractic Care for Low Back Pain; Journal of Manipulative and Physiological Therapeutics; January 2016; Vol. 39; No. 1; pp. 1-22.
11. 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.
12. 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.
13. 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; 2017 Apr 11;317(14):1451-1460.
14. 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.

The Foot, The Leg, The Pelvis, And Back Pain

Foot problems are a common cause of low back pain.

Inequality of the length of the legs is a common cause of low back pain.

A pelvis that is not level is a common cause of low back pain.

The biomechanics of the low back are intimately linked to the biomechanics of the foot, leg, and pelvis. The actual tissue source for low back pain can be the intervertebral disc, the facet joints, the muscles, the ligaments, the nerves, or a combination of these. Individuals with back pain and their doctors may be tempted to only treat these tissues in the back, yet often the stresses in these tissues are caused by biomechanical problems in the feet, legs or pelvis. Failure to assess and manage biomechanical problems of the foot, leg and/or pelvis often results in poor or incomplete clinical outcomes in patients with back pain. The successful mechanical management of low back pain often requires the assessment and management of biomechanical problems of the lower extremity and pelvis because they are linked through the kinetic chain of stance, posture and ambulation.

•••••

In 1946, Lieutenant Colonel Weaver A. Rush and Captain Howard A. Steiner of the X-ray Department of the Regional Station Hospital of Fort Leonard Wood, Missouri, meticulously exposed upright lumbosacral x-rays on 1,000 soldiers for the specific purpose of measuring differences in their leg lengths and to determine if inequality of leg length was a factor in the incidence of back pain. They published their results in the American Journal of Roentgenology and Radium Therapy in an article titled (1):

A Study of Lower Extremity Length Inequality

In this study, the authors constructed a spinal fixation and stabilization device to ensure the accuracy of upright measurements of leg length and their effects on spinal alignment. The 1,000 soldiers in this study were “consecutive, non-selected cases who were sent to the roentgen department because of a low back complaint.” By using their meticulous methodology of measurement, these authors concluded, “it is possible to accurately measure differences in lower extremity lengths as manifested by a difference in the heights of the femoral heads.” The greatest difference in leg length measured was 44 mm, or about 1.75 inches. The authors made the following observations:

23% of the soldiers had legs of equal length.
77% of the soldiers had unequal length of their legs.

The incidence of limb shortness was nearly equal between the left and right, and the average shortening was slightly more than 7 mm.

Importantly, concerning spinal biomechanical function, these authors noted that the short leg was associated with a tilt of the pelvis and a scoliosis. The authors noted:

The roentgenograms were made in the upright position with the use of the stabilization device. Whenever there is a pelvic tilt, “there exists coincidentally a scoliosis of the lumbar spine.”

“Because this scoliosis, in all instances, compensates for the tilt of the pelvis, it is referred to by us as compensatory scoliosis.”

“The existence of this compensatory scoliosis in the presence of a tilted pelvis due to shortening of one or the other lower extremity is believed by us to have clinical significance and, furthermore, it is our opinion that the existence of any such condition cannot be determined with any degree of accuracy on gross physical examination.”

“Furthermore, it becomes immediately apparent that the making of roentgenograms of the lumbosacral spine in the recumbent position, as is frequently done, completely prevents the discovery of such pathology as this.”

“It was a general consistent observation that the degree of scoliosis was proportionate to the degree of pelvic tilt. An individual who has a shortened leg will have to compensate completely if he intends to hold the upper portion of his body erect or in the midsagittal plane.”

“A consistent observation which has been made is that in those cases with a shortened leg there is a corresponding tilt of the pelvis and a compensatory scoliosis of the lumbar spine.”

Posterior to Anterior View From Behind

• The sacrum is lower on the side of the short leg (left in this drawing).
• The spinal column initially tilts towards the short leg, then compensates back to the midline as a consequence of contraction of the quadratus lumborum muscle.
• The lumbar spinous processes (posterior) rotate towards the long leg. The pubic symphysis (anterior) also rotates towards the long leg. The consequent counter-rotational forces abnormally stress the L5 intervertebral disc.

•••••

Leg length differences exceeding 5 mm were associated with the greatest low back pain or disability, and therefore 5 mm is labeled as being a “marked difference.” The authors stated:

“For this reason, it is our opinion that the existence of such a condition [a short leg exceeding 5 mm] is significant from the standpoint of symptomatology and disability.”

•••••

Our nation and much of the world recently celebrated the one-hundredth anniversary of the birth of former US president John F. Kennedy (May 29, 1917). President Kennedy suffered from a notorious bad back. His back problems significantly worsened in August of 1943 during the sinking of his boat PT-109 in the Pacific during WWII. Injured (he was awarded the Purple Heart for the event) Kennedy twice swam for miles in the Pacific Ocean, towing an injured crewmember with a life jacket strap in his teeth. Kennedy’s back problems never fully recovered.

In 1954, then Senator Kennedy underwent an attempted spinal fusion operation, and it went badly; it was his second spinal surgery for his persistent low back pain. He nearly died, and his recovery took 8 months. The following year, Kennedy came under the care of myofascial pain expert Janet Travell, MD. When Kennedy was elected president of the United States (taking office in 1961), he chose Dr. Travell to be his personal White House Physician. Dr. Travell was the first female physician to hold this prestigious office (2, 3, 4). President Kennedy considered Dr. Travell to be a medical genius (5).

Dr. Janet Travell received her MD degree from the Cornell University Medical College in New York City, where she graduated at the head of her class; she was also the first female to graduate from Cornell. For three decades she practiced cardiology while teaching pharmacology at Cornell.

By 1952, Dr. Travell’s clinical interest and practice had moved away from cardiology and she became a specialist in musculoskeletal pain syndromes. With her growing positive reputation and expertise, Senator Kennedy’s orthopedic surgeon asked Dr. Travell to look at his patient’s chronic, disabling back problems (5).

When Dr. Travell first saw Senator Kennedy in May of 1955, he was non-ambulatory. He had suffered from 2 devastating spinal surgeries, yet he continued to suffer from debilitating back spasm and left leg pain. Things were so bad that Senator Kennedy was “questioning his ability to continue his political career.”(6) Dr. Travell treated Senator Kennedy. His improvement was so impressive that Dr. Travell’s daughter wrote (5):

“Senator Kennedy received so much relief of pain from my mother’s medical treatments that he had ‘new hope for a life free from crutches if not from backache’.”

In 2003, James Bagg wrote this, pertaining to Dr. Travell (6):

“Jack Kennedy saw a great many physicians over the course of his short life, but one of them, according to his brother Bobby, enabled Jack to become President of the United States.”

Following Kennedy’s assassination in 1963 and after continuing to work as White House Physician for then President Lyndon Johnson for a few years, Dr. Travell moved on to George Washington University School of Medicine. At George Washington University she teamed up with ex-Air Force Flight Surgeon David G. Simons, MD, and together they wrote the three most authoritative texts pertaining to myofascial pain syndromes ever compiled (years 1983, 1992, 1999) (references 7, 8, 9):

Myofascial Pain and Dysfunction:
The Trigger Point Manual

•••

Myofascial Pain and Dysfunction:
The Trigger Point Manual:
THE LOWER EXTREMITIES

•••

Travell & Simons’ Myofascial Pain and Dysfunction
The Trigger Point Manual:
Volume 1, Upper Half of Body

In these books, Drs. Travell and Simons discuss difficult cases caused by structural inadequacies, the most common of which were:

1. A difference in the length of the lower limbs.
2. A long second metatarsal or a short first metatarsal (Morton’s Toe).

It has been documented since 1946 that about 75% of people have legs of unequal lengths, and that about a third of people have leg length differences that can perpetuate trigger points (1). As a rule, the sacrum is lower on the side of the short leg (see drawing). The spinal column initially tilts towards the short leg, then compensates back to the midline as a consequence of chronic contraction of the quadratus lumborum muscle. According to Dr. Travell, the resulting trigger points in the quadratus lumborum muscle is a very common but frequently overlooked cause of chronic low back pain (8).

Dr. Travell “discovered that one of [Senator] Kennedy’s legs was shorter than the other and made heel lifts for all of his left shoes to counter that additional source of stress on his back.” “Dr. Travell had a workbench in her office and made lifts for both patients and family members. ‘One of the first things I did for him [Kennedy] was to institute a heel liftóa correction for the difference in leg length’.”(6)

•••••

The Morton’s Toe was described by American orthopedic surgeon Dudley J. Morton, MD, from Yale, in 1927 (10). Dr. Morton noted that people suffered from a variety of chronic pain syndromes when they had a long second metatarsal or a short first metatarsal (which he termed Morton’s Toe). This common anatomic variant would alter the normal weight-bearing function of the foot, causing a compensatory pronation. Travell observed that this would lower the pelvis on that side, creating the identical trigger points as a leg length inequality.

Dr. Travell notes that the solution is a proper heel lift if the leg was anatomically short, and a shoe orthotic that re-establishes foot mechanics and weight-bearing, usually by correcting the pronation. She notes that other causes of foot pronation can and should be similarly addressed with an orthotic.

This concept of a pronated foot lowering the pelvis on the same side, altering lumbar spine biomechanics has been confirmed in more recent publications, including sports medicine reference books authored by podiatrists (11).

•••••

Another factor for the increased incidence of low back pain in individuals with an anatomical short leg and/or a foot pronation is that such factors not only cause myofascial pain syndrome in the quadratus lumborum muscle, they also cause counter-rotational stress at the L5-S1 intervertebral disc. This phenomenon was best described by Ora Friberg, MD, from Finland. Dr. Friberg published his findings in 1987 in the journal Clinical Biomechanics, titled (12):

The intervertebral disc has two components. The center of the disc is called the Nucleus Pulposus, or simply nucleus. The nucleus is mostly water and functions as a ball bearing, allowing the vertebrae to bend and twist.

The nucleus is surrounded by tough outer fibers called the Annulus Fibrosis, or simply annulus.

The fibers of the annulus are arranged in layers, and each layer is crossed in opposite directions. During chronic rotational stress on the disc, half of the annular fibers become tense, and the other half become lax. Rotational stress applied to the annulus is resisted by only half of the annular fibers. The disc is operating at only half strength during rotationally applied stress, increasing its vulnerability to injury and degenerative disease. The disc is intolerant to chronic rotational stress (13).

Crossed Annular Fibers of the Intervertebral Disc

•••

In this study by Friberg, standing radiographs of the pelvis and lumbar spine in 288 consecutive patients with chronic low back pain and in 366 asymptomatic controls were exposed. His findings showed that 73% of the subjects assessed had meaningful inequality of a lower limb (>5 mm shortness). The incidence of leg length inequality in LBP patients was significantly higher than in asymptomatic controls (more than twice as much).

Friberg’s biomechanical findings were consistent with the findings of Rush/Steiner above. Friberg emphasized the counter-rotational stresses on the L5-S1 disc:

Axial View From Above

• The L5 spinous process has rotated to the right of midline, towards the side of the long leg. This causes a counterclockwise rotation of the L5 vertebrae and a counterclockwise rotation of the L5-S1 intervertebral disc.
• The pubic symphysis and pelvis has rotated to the right of midline, also towards the side of the long leg. Because the pubic symphysis is in the anterior, this causes a clockwise rotation of the pelvis and sacrum, and a clockwise rotation of the L5-S1 intervertebral disc.
• These “significant” counter-rotational stresses primarily affect the L5-S1 intervertebral disc. The consequences of these counter-rotational stresses at L5 are accelerated disc degeneration and degradation, back pain and sciatica.

•••••

Over the decades, numerous studies have continued to document the relationship between foot pronation, anatomical short leg, pelvic unleveling, and chronic back pain, including these:

• The Short Leg Syndrome in Obstetrics and Gynecology; Correction Of Anatomical Short Leg For The Treatment Of Back Pain; American Journal of Obstetrics and Gynecology, 1970 (14)
• Low-back Pain Associated With Leg Length Inequality; Spine, 1981 (15)
• Clinical Symptoms and Biomechanics of Lumbar Spine and Hip Joint in Leg Length Inequality; Spine, 1983 (16)
• Persistent Low Back Pain and Leg Length Disparity; Journal of Rheumatology, 1985 (17)
• g Length Inequality and Low Back Pain;The Practitioner, 1985 (18)
• •Conservative Correction of Leg-Length Discrepancies of 10 mm or Less for the Relief of Chronic Low Back Pain; Archives of Physical Medicine and Rehabilitation, 2005 (19)
• •Changes in Pain and Disability Secondary to Shoe Lift Intervention in Subjects With Limb Length Inequality and Chronic Low Back Pain; Journal of Orthopaedic & Sports Physical Therapy, 2007 (20)

•••••

A recent (2016) study pertaining to the biomechanical consequences of an anatomical short leg was published in the Journal of Craniovertebral Junction Spine and titled (21):

Inequality in Leg Length is Important for the
Understanding of the Pathophysiology of Lumbar Disc Herniation

These authors evaluated 39 subjects with leg length discrepancy and low back pain and 43 controls to quantify the occurrence of disc herniation between between the two groups. They concluded that leg length inequality causes spinal joint load assymetry, accelerating disc degeneration and disc herniation. They also suggest the poor low back disc surgical outcomes may be linked to the abnormal spinal loads caused by leg length inequality, They note:

“Inequality in leg length may lead to abnormal transmission of load across the endplates [causing] degeneration of the lumbar spine and the disc space.”

“Human coronal balance may be one of the causes of operative failure after disc surgery. Assessment of pathologic coronal imbalance requires a clear understanding of normal coronal alignment.”

“Patients with chronic LBP have a minor balance defect. Inequality in leg length is important for the understanding of the pathophysiology of lumbar disc degeneration and herniation.”

“Our observations suggest that LBP may have etiologies related to abnormal load transmission due to coronal imbalance. It seems that a successful treatment may sometimes exist beyond good surgery. In these situations, abnormal coronal balance may be an important factor.”

•••••

This year (2017), an important article was published in the journal Archives of Physical Medicine and Rehabilitation, titled (22):

Shoe Orthotics for the Treatment of Chronic Low Back Pain:
A Randomized Controlled Trial

The objective of this study was to investigate the efficacy of shoe orthotics with and without chiropractic treatment for chronic low back pain as compared to no treatment. It is a Randomized Controlled Trial (three groups) that involved 225 adults with symptomatic low back pain of 3 months or longer:

Group 1:Orthotics Group
The Orthotics Group received custom-made shoe orthotics.

Group 2:Plus Group
Plus Group received custom-made orthotics plus chiropractic manipulation, hot or cold packs, and manual soft tissue massage.

Group 3:Wait Group
The Wait-list Group received no care.

Both pain levels and disability were assessed at 6 weeks and 12 weeks, and then after an additional 3, 6, and 12 months. These authors note:

“The best results were in the Orthotics Plus group in which 70% had a decrease in pain and 56% a decrease in disability of 30% or more compared to baseline.”

“This large-scale clinical trial demonstrated that LBP and disability were significantly improved after six weeks of orthotics care compared to a wait-list control, and that the addition of chiropractic care with the orthotics demonstrated a significant improvement in the disability scores compared to orthotics alone.”

“Six weeks of prescription shoe orthotics significantly improved back pain and dysfunction compared to no treatment. The addition of chiropractic care led to higher improvements in function.”

“Foot dysfunction should not be overlooked as a potential contributing factor in treating individuals with LBP and dysfunction.”

SUMMARY

These concepts and studies add support for why all people should be evaluated chiropractically for pelvic asymmetry and coronal misalignment; correction of such asymmetries and misalignment may prevent low back pain and disc disease/herniation, and improve surgical outcomes.

For individuals suffering from chronic low back pain, the combination of orthotics to improve foot pronation, heel lifts to compensate for anatomical leg length inequality, and chiropractic spinal adjusting (specific manipulations) to the spinal joints appears to be a biologically sound exceptional management approach.

References

1. Rush WA, Steiner HA; A Study of Lower Extremity Length Inequality; American Journal of Roentgenology and Radium Therapy; Vol. 51; No. 5; November 1946; pp. 616-623.
2. Lacayo R; How Sick Was J.F.K.?; TIME; November 24, 2002.
3. Altman LK, Purdum TS; In J.F.K. File, Hidden Illness, Pain and Pills; The New York Times; November 17, 2002.
4. Dallek R; The Medical Ordeals of JFK; The Atlantic; December 2002.
5. Wilson V; Janet G. Travell, MD: A Daughter’s Recollection; Texas Heart Institute Journal; 2003; Vol. 30; No. 1; pp.  8ñ12.
6. Bagg JE; The President’s Physician; Texas Heart Institute Journal; 2003; Vol. 30; No. 1; pp. 1ñ2.
7. Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual; New York: Williams & Wilkins, 1983.
8. Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual: THE LOWER EXTREMITIES; New York: Williams & Wilkins, 1992.
9. Simons D, Travell J; Travell & Simons’, Myofascial pain and dysfunction, the trigger point manual: Volume 1, Upper Half of Body; Baltimore: Williams & Wilkins, 1999.
10. Morton DJ; METATARSUS ATAVICUS: The Identification of a Distinctive Type of Foot Disorder; J Bone Joint Surg Am, 1927 Jul 01;9(3):531-544.
11. Subotnick SI; Sports Medicine of the Lower Extremity; Churchill Livingstone; 1989.
12. Friberg O; The statics of postural pelvic tilt scoliosis; a radiographic study on 288 consecutive chronic LBP patients; Clinical Biomechanics; Vol. 2; No. 4; November 1987; pp. 211-219.
13. Kapandji IA; The Physiology of the Joints; Volume 3; The Trunk and the Vertebral Column; Churchill Livingstone; 1974.
14. Sicuranza B, Richards J, Tisdall L; The Short Leg Syndrome in Obstetrics and Gynecology; American Journal of Obstetrics and Gynecology; May 15, 1970; Vol. 107; No. 2; pp. 217-219.
15. Giles LG, Taylor JR; Low-back pain associated with leg length inequality; Spine; 1981 Sep-Oct; Vol. 6; No. 5; pp. 510-251.
16. Friberg O; Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality; Spine; 1983 Sep; Vol. 8; No. 6; pp. 643-651.
17. Gofton JP; Persistent Low Back Pain and Leg Length Disparity; Journal of Rheumatology; Vol. 12, No. 4; August 1985; pp. 747-750.
18. Helliwell M; Leg Length Inequality and Low Back Pain; The Practitioner; May 1985; Vol. 229; pp. 483-485.
19. Defrin R, Benyamin SB, Dov Aldubi R, Pick CG; Conservative Correction of Leg-Length Discrepancies of 10 mm or Less for the Relief of Chronic Low Back Pain; Archives of Physical Medicine and Rehabilitation; November 2005; Vol. 86; No. 11; pp. 2075-2080.
20. Golightly YM, Tate JJ, Burns CB, Gross MT; Changes in Pain and Disability Secondary to Shoe Lift Intervention in Subjects With Limb Length Inequality and Chronic Low Back Pain; Journal of Orthopaedic & Sports Physical Therapy; Vol. 37; No. 7; July 2007; pp. 380-388.
21. Balik SM, Kanat A, Erkut A, Ozdemir B, Batcik OE; Inequality in Leg Length is Important for the Understanding of the Pathophysiology of Lumbar Disc Herniation; Journal of Craniovertebral Junction Spine April-June 2016; Vol. 7; No. 2; pp. 87-90.
22. Cambron JA, Dexheimer JM, Duarte M, Freels S; Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial; Archives of Physical Medicine and Rehabilitation; April 29, 2017. [Epub]

The total sum of suffering caused by migraine is higher than any other kind of headache (1). “Migraine is often incapacitating, with considerable impact on social activities and work, and may lead to significant consumption of drugs.” (1)

The diagnosis of migraine is made clinically. There are no blood tests, imaging, or electro-physiologic tests to establish the diagnosis (1).

The strict definition of migraine headache is (2):

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

The migraine diagnosis is assured when these characteristics are present:

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

••••••••••

An article appearing in the Business Section of the San Francisco Chronicle newspaper on July 20, 2014, stated (3):

MEDICINE
Huge Headache of a Problem
Mastering Migraines Still a Challenge for Patients, Scientists

The author, Stephanie Lee, notes that 36 million Americans suffer from migraine headaches. The migraine market in developed countries will grow to about $5.4 billion in 2022. The problem is that current treatments are not very effective and they may have dangerous side effects. Ms. Lee notes (3):

“Frustrated patients often seek out opioids in the emergency room, but opioids can be dangerous. In a year, … 20,000 patients in California developed chronic migraines because of opioid overuse, and 3,000 become addicted.”

Chronic migraine is defined as a severe headache that occurs at least 15 times per month. It is ironic that opioids taken for migraines cause chronic migraines in many patients. Ms. Lee concludes (3):

“The demand for safe and effective alternatives [for migraine headaches] is urgent.”

Evidence is mounting that chiropractic and spinal manipulation may provide this sought-after safe and effective alternative.

••••••••••

In the modern era of musculoskeletal clinical anatomy, Australia’s Nikoli Bogduk, MD, PhD, is perhaps the most accomplished and respected. A search of the National Library of Medicine using the PubMed search engine with “bogduk n”, locates 259 references (as of May 12, 2017). In addition, Dr. Bogduk has written numerous books, chapters in books, and invited opinion/editorials. His expertise in clinical anatomy has extended for four decades, and continues through today.

Dr. Bogduk’s expertise in clinical anatomy includes the field of headache. A PubMed search using the words “Bogduk N and Headache” finds 25 citations (as of May 12, 2017). Perhaps his most important contribution to the understanding of the clinical anatomy of headache appeared in the journal Biomedicine and Pharmacotherapy in 1995. The article is titled (4):

Anatomy and Physiology of Headache

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

“All headaches are mediated by the trigeminocervical nucleus.”

Specifically, this means that all headaches, including migraine headaches, synapse in the upper aspect of the neck, in a location termed the trigeminocervical nucleus. The brainstem and the upper cervical spinal cord contain a contiguous region of grey matter, the trigeminocervical nucleus.

The trigeminocervical nucleus is “defined by its afferent fibers.” The primary afferent fibers to the nucleus are from the Trigeminal Nerve (Cranial Nerve V), and from the upper three cervical nerves (C1, C2, C3), and hence the name trigeminocervical nucleus. All headaches synapse in the trigeminocervical nucleus. Second order afferent neurons arising in the trigeminocervical nucleus ascend to create an electrical signal in the brain that is interpreted as “headache.”

Consequently, upper cervical spine afferents to a second-order neuron that also receives trigeminal input may be a source of the electrical signal that is interpreted as headache in the brain, including migraine headache. As such, structures that are innervated by C1, C2, C3, can cause headache, including migraine. Irritation and/or inflammation of structures innervated by C1, C2, C3 can all cause headaches. Such structures include:

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

••••••••••

Recent Clinical Studies

In June 2014, Dean Watson and Peter Drummond from Murdoch University, Perth, WA, Australia, published a study in the journal Headache, titled (5):

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

This study assessed the pain intensity and nociceptive blink reflex in 15 migraine subjects between times of symptoms with passive movements of the occipital and upper cervical spinal segments. The nociceptive blink reflex was elicited with a supraorbital electrical stimulus. The number of blinks of the nociceptive blink reflex were recorded. Head pain intensity was graded from 0-10, where 0 = “no pain” and 10 = “intolerable pain.” They note:

• Anatomical and neurophysiological studies show that there is a functional convergence of trigeminal and cervical afferent pathways.
• Migraine patients often have occipital and neck symptoms, with cervical pain being referred to the head, “suggesting that cervical afferent information may contribute to [migraine] headache.”
• Nerve blocks of the greater occipital nerve [C-2] modulate migraine pain, demonstrating a role for cervical afferents in migraine.
• “Spinal mobilization is typically applied when dysfunctional areas of the vertebral column are found.” “The clinician’s objective in applying manual techniques is to restore normal motion and normalize afferent input from the neuromusculoskeletal system.”
• There is a functional influence on trigeminal nociceptive inputs from cervical afferents. This study showed that passive manual intervertebral movement between the occiput and the upper cervical spinal joints decreases excitability of the trigeminocervical nucleus.
• “Our findings corroborate previous results related to anatomical and functional convergence of trigeminal and cervical afferent pathways in animals and humans, and suggest that manual cervical modulation of this pathway is of potential benefit in migraine.” [emphasis added]
• These findings show that “cervical spinal input contributed to lessening of referred head pain and cervical tenderness.”

These authors conclude:

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

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

This article supports the clinical anatomical perspective of Dr. Bogduk. It also extends the concept for the inclusion of manual/manipulative therapy of the cervical spine in the management of chronic migraine headache.

••••••••••

The following year, 2015, the journal Complementary Therapies in Medicine, published a study titled (6):

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

The primary measurement outcome in this study was the Headache Impact Test-6. The Headache Impact Test-6 was validated in the journal Cephalalgia in 2011, with the following conclusions (7):

“Our study shows that the Headache Impact Test-6 is a reliable and valid tool for measuring the impact of headache on daily life in both episodic and chronic migraine sufferers. Furthermore, the Headache Impact Test-6 tool discriminates well between chronic migraine, episodic migraine and non-migraine patients.”

“As a brief tool, the Headache Impact Test-6 is easy to score and interpret, and can be readily integrated into clinical practice, or clinical studies of migraine patients. It may offer clinicians a practical and easy-to-implement tool to assist them with evaluating treatment effectiveness by obtaining input directly from the patient on aspects other than just the frequency of headache days.”

The authors of this study note that this manipulative therapy trial is the largest ever conducted on adult migraine patients. The authors assessed the effectiveness of manipulative treatment on 105 chronic migraine patients using:

• Headache Impact Test (HIT-6) questionnaire (main outcome measure)
• Drug consumption
• Days of migraine
• Pain intensity
• Functional disability

This is a randomized controlled trial. Patients received 8 treatments over a period of 6 months. Patients were randomly divided into three groups:

1. Manipulation + medication therapy  (n=35) – The manipulative techniques used in this study included myofascial release, treatment of ligamentous and membrane tensions, treatment of somatic dysfunctions, and treatment to asymmetries and imbalances in the pelvis and cranium.
2. Sham manipulation + medication therapy (n=35) – The sham group received a false manipulation, in addition to drug care. Sham therapy mimicked the manipulative care in terms of evaluation and treatment; it used light manual contact to ‘‘treat’’ the subject. Both manipulative and sham therapy sessions lasted 30 minutes and were given weekly for the first two sessions, biweekly for the subsequent two, then monthly for the remained four sessions.
3. Medication only (n=35)

The criteria considered for manipulative evaluation and treatment were:

• Alteration of tissue consistency
• Asymmetry
• Range of motion restriction
• Tenderness

The authors note that manipulation in migraine could reduce the release of pro-inflammatory substances that have an effect on the nociceptive nervous system. They state:

“As a consequence [of manipulation], a cascade of biological and neurological events, potentially based on a rebalance of the abnormal activation of the habituation/sensitization mechanism, even between attacks, could occur resulting in an overall improvement of clinical outcomes.”

Key findings from this study include:

• At the end of the study period, there was a statistically significant difference on the overall HIT-6 score between the three groups; the manipulation group was statistically improved from control (drug only) and sham group.
• Manipulation “significantly reduced the frequency of migraine.”
• Manipulation “significantly reduced the number of subjects taking medications.”
• “No study participant reported any adverse effects of the [manipulation].”
• Manipulation “showed a significant improvement in the migraineurs’ quality of life.”
• The use of manipulative therapy as an “adjuvant therapy for migraine patients may reduce the use of drugs and optimize the clinical management of the patients.”
• Manipulation “may be considered a clinically valid procedure for the management of patients with migraine.”

The following remarkable graph was presented in the study:

The data indicates that the manipulation essentially eliminated migraine days per month, including pain and disability, and reduced drug consumption by 80%. For the group assigned to taking drugs-only, there was essentially no reduction in migraine days per month, pain, disability, and no reduction in drug consumption.

••••••••••

In 2017, researchers from Akershus University Hospital, Oslo, Norway, and the Department of Chiropractic, Macquarie University, NSW, Australia, published a study in the journal Musculoskeletal Science and Practice titled (8):

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

The primary objective of this study was to “report on all adverse events in a prospective chiropractic spinal manipulative therapy, single-blinded, placebo, randomized controlled trial for migraineurs.”
The authors note that migraines are a common worldwide challenge, and pharmacological management is often the first treatment of choice. However, migraine drugs can have serious and/or undesirable side effects. In contrast, manual-therapy is a non-pharmacological migraine treatment option that appears to have a similar effect as common drugs on migraine frequency, migraine duration, and migraine intensity.

This study prospectively reported all adverse events in a chiropractic spinal manipulative therapy randomized controlled trial. It is a prospective assessment; 70 migrainers were randomized to chiropractic manipulation (Gonstead full-spine adjusting) or a placebo, with 12 intervention sessions over three months. The subjects in this study were randomly placed into three groups:

1. An active spinal manipulation group, using Gonstead technique: “Active treatment consisted of chiropractic spinal manipulation using the Gonstead method, i.e., a specific contact, high-velocity, low-amplitude, short-lever spinal with no post-adjustment recoil that was directed to spinal biomechanical dysfunction (full spinal column approach) as diagnosed by standard chiropractic tests performed during each individual treatment session.”
2. A placebo manipulation group, receiving sham manipulation: “The placebo intervention consisted of sham manipulation, i.e., a broad non-specific contact approach via a low-velocity, low-amplitude sham push manoeuvre in a non-intentional and nontherapeutic directional line. All of the non-therapeutic contacts were performed outside the spinal column and included adequate joint ligament slack without soft tissue pre-tension so that joint cavitations did not occur.”
3. A control group, using usual pharmacological management: “The control group continued their usual pharmacological management without receiving manual intervention.”

The participants were interviewed and physically assessed by a chiropractor, “including meticulous investigation of the spinal column.” They also received a full spine radiographic examination. The subjects attended 12 intervention sessions over 12 weeks with follow-up at 3, 6 and 12 months post-treatment. The authors concluded:

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

“Local tenderness, tiredness and neck pain were the most common adverse events, whereas other adverse events were rare (<1%).”

“Conclusions: Adverse events [to spinal manipulation] were mild and transient, and severe or serious adverse events were not observed.”

“These findings are in accordance with the World Health Organization guidelines on basic training and safety in chiropractic spinal manipulation, which is considered to be an efficient and safe treatment modality (WHO, 2005).” (9)

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

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

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

This study used Gonstead analysis, full-spine x-rays, and full-spine adjusting, for patients with chronic migraines. Although this Gonstead adjusting resulted in a few adverse events, they were minor and transient. Additionally, the chiropractic adjusting had the best long-term results.

••••••••••

Summary

These studies explain what essentially every chiropractor has observed:

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

The presented data here suggests that manipulation actually addresses the causative pathophysiology of migraine headache; in contrast, it appears that taking drugs is nothing more than temporary pain control with no improvement to the causative pathophysiology of migraine headache.

REFERENCES

1. Olsen J, Tfelt-Hansen P, Welch KMA; The Headaches, second edition; Lippincott Williams & Wilkins; 2000.
2. Jones HR, MD; Netter’s Neurology; 2005.
3. Lee, SM; Huge Headache of a Problem; Mastering Migraines Still a Challenge for Patients, Scientists; San Francisco Chronicle; July 20, 2014; pp. D1 and D5.
4. Bogduk N; Anatomy and Physiology of Headache; Biomedicine and Pharmacotherapy; 1995, Vol. 49, No. 10, 435-445.
5. Watson DH, Drummond PD; Cervical Referral of Head Pain in Migraineurs: Effects on the Nociceptive Blink Reflex; Headache 2014; Vol. 54; pp. 1035-1045.
6. Cerritelli F, Ginevri L, Messi G, Caprari E, Di Vincenzo M, Renzetti C, Cozzolino V, Barlafante G, Foschi N, Provincial L; Clinical Effectiveness of Osteopathic Treatment in Chronic Migraine: 3-Armed Randomized Controlled Trial; Complementary Therapies in Medicine; April 2015; Vol. 23; No. 2; pp. 149—156.
7. Yang M, Rendas-Baum R, Varon SF, Kosinski M; Validation of the Headache Impact Test (HIT-6™) across episodic and chronic migraine; Cephalalgia; 2011 Feb; 31(3): 357–367.
8. Chaibi A, Benth JS, Tuchin PJ, Russell MB; Adverse Events in a Chiropractic Spinal Manipulative Therapy Single-blinded, Placebo, Randomized Controlled Trial for Migraineurs; Musculoskeletal Science and Practice ; March 2017; Vol. 29; pp. 66-71.
9. WHO, 2005. Guidelines on Basic Training and Safety in Chiropractic. World Health Organization, Switzerland.