Category: Advanced

Safety, Effectiveness, Outcomes 

Biomechanics 101

Humans are both mechanical (they obey the laws of physics) and biological (they obey the laws of biology). The blending of the laws of mechanics and biology are referred to as biomechanics. Humans are biomechanical.

A simple concept in biomechanics is that there is a trade-off between mobility and stability. The regions of the body that have the greatest mobility also have the least stability and are thus the regions that are most vulnerable to injury. Stated differently, the regions of the body that have high stability tend to have reduced mobility and a reduced risk for injury.

The region of the spinal column that has the least stability and hence the greatest mobility is the upper cervical spine. The upper cervical spine has the greatest risk of injury of the entire spinal column.

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For more than a century, chiropractic pioneers have studied and developed practical approaches for the management of upper cervical spine biomechanical problems. The current academic leader for the understanding of upper cervical spine biomechanics and their clinical approaches is Kirk Eriksen, DC, from Dothan, Alabama, where he is in private clinical practice. In 2004, Dr. Erikson authored a book, titled (1):

Upper Cervical Subluxation Complex:
A Review of the Chiropractic and Medical Literature

This incredible review was published by a major scientific/medical publishing house, Lippincott Williams & Wilkins.

In 2011, Dr. Erikson was also the lead author of an article published in the journal BMC Musculoskeletal Disorders, titled (2):

Symptomatic Reactions, Clinical Outcomes and Patient Satisfaction Associated with Upper Cervical Chiropractic Care:
A Prospective, Multicenter, Cohort Study

In this publication the authors indicate that little research is available on the topic of side effects resulting from upper cervical chiropractic techniques. This study was the first prospective study to examine the incidence of adverse reactions following spinal adjustments using upper cervical techniques. The authors also assessed the impact of upper cervical chiropractic care on clinical outcomes.

The authors assessed 1,090 consecutive new patients (8 to 85 years of age) from 83 chiropractic offices. Seventy of the chiropractors were from the United States, eleven were from Canada, and two were from Europe (one from England and one from Spain). The mean years in clinical practice by these chiropractors was 13.0.

The 1,090 patients had 4,920 chiropractic office visits and 2,653 upper cervical adjustments over a 17-day period. The average number of career adjustments per chiropractor was 61,265 with a total of 5,085,011 career adjustments for all participating upper cervical chiropractors. Importantly:

“The doctors did not report any serious adverse events ever occurring in their practices (i.e., strokes or permanent injuries).”

The authors made an explicit distinction between a “symptomatic reaction” vs. a “serious adverse event, which refers to events resulting in death, life-threatening situations, need for admittance to a hospital, or temporary or permanent disability.”

In this study, the only chiropractic intervention was upper cervical spine chiropractic adjustments (specific line-of-drive manipulations). There was no physical therapy or spinal adjusting below the upper cervical spine.

Eighty-one percent of the patients in this study had as their primary complaint either spinal pain/dysfunction and/or headaches. Seventy-four percent of cases were chronic, with symptoms being persistent for more than 13 weeks. The entire breakdown of patient symptoms included:

Cervical pain/dysfunction	35%
Lumbo-pelvic pain	28%
Headaches	13%
Mid-back pain	5%
Lower extremity pain	4%
Shoulder pain	3%
Upper extremity	2%
Fibromyalgia	2%
Disequilibrium	2%
Temporomandibular joint pain	1%
Facial pain/dysfunction	1%
Blood pressure	1%
Neurological disease	1%
Brain dysfunction	1%
Wellness care	1%
Other complaints with < 0.5% occurrence: atopic disorders, diabetes, ear, GI dysfunction, hypothyroidism, Lyme’s disease, postural distortion, psoriatic arthritis, psychological disorders, sinus problems, sleep disorders, thorax dysfunctions, visual disturbance, autoimmune disorder, irregular menstrual cycle, and weak immune system.

The adjustments in this study were administered by hand, a hand-held instrument, or table mounted instruments. Hand adjustments were delivered in 67% of cases, while 33% were adjusted by instrument.

The primary symptoms assessed were neck pain, headache, mid back pain and/or low back pain. The clinical outcome measurement tools included:

• Neck pain disability index (NDI)
• Oswestry disability index (ODI)
• 11-point numerical rating scale (NRS) for neck, headache, midback, and low back pain
• Treatment satisfaction
• Symptomatic Reactions (SR)

The authors stated:

“The patient rated their overall neck, headache, mid back and/or low back pain using a written 11-point Numeric Rating Scale (NRS), for applicable complaints (0 = no pain, 10 = the worst possible pain).”

“To assess the impact of the patient’s pain on their ‘activities of daily living’ the patient completed a Neck Disability Index (NDI) and/or Oswestry Disability Index (ODI), depending on whether the subject had symptoms in the neck or back, respectively.”

“The NDI and ODI have been demonstrated to be reliable and valid instruments.”

“Patient satisfaction was measured at the end of the treatment period by a question that asked, ‘How satisfied are you with the treatment by your chiropractor?’”

A symptomatic reaction (SR) was defined as a new complaint that was not present at baseline or a worsening of the presenting complaint by >30% based on an 11-point numeric rating scale occurring <24 hours after any upper cervical procedure. The assessment included distinguishing between a symptomatic reaction and “soreness” which “could represent change or healing.”

The authors recognize that upper cervical chiropractic techniques have been used by chiropractors and taught in chiropractic colleges since the 1930s. All upper cervical chiropractic techniques originate from BJ Palmer, the person credited with the development of chiropractic as a separate and distinct profession.

The assessment tools used by these chiropractors included a combination of x-ray alignment, postural distortion, palpatory tenderness, range of motion, and/or paraspinal thermometry (temperature reading devices).

The upper cervical techniques reviewed in this study included:

• Atlas/Advanced Orthogonal – “Atlas Orthogonality was founded by Roy Sweat, DC in 1981. Advanced Orthogonality was founded by Stan Pierce, DC in 2001. Both procedures use a side posture patient position with a solid mastoid support, segmental contact over and directed toward the C1 transverse process via a stationary stylus on a table mounted instrument. The force is on a specific pre-calculated vector generated by a percussion wave mechanism.”
• Blair – “Blair technique was founded by Williams Blair, DC in 1960. This technique uses a side posture patient position on a drop headpiece toggle table, with the surface of the headpiece parallel to the floor. The doctor contacts the patient with his pisiform over the anterior, posterior, or inferior transverse process based upon the necessary correction. With the headpiece cocked, a toggle and 180° torque type correction is administered depending on predetermined vertebral alignment variables.”
• Knee Chest – “Knee Chest technique has been in use since BJ Palmer, DC developed UC chiropractic in 1931. The patient is in a kneeling position with their head turned on a solid headpiece table. Segmental contact point is over the posterior arch and uses a toggle-torque-recoil type thrust.”
• National Upper Cervical Chiropractic Association (NUCCA) – “NUCCA was founded by Ralph Gregory, DC in 1966. This procedure uses a side posture patient position with a solid mastoid or skull support. The segmental contact is over the C1 transverse process via the pisiform using a hand adjustment. The force is on a specific pre-calculated vector generated by a triceps pull.”
• Orthospinology/Grostic Procedure – “The Grostic Procedure was developed by John F. Grostic, DC in the late 1930s. Orthospinology was founded by a group of doctors in 1977 that implemented instrument adjusting as well as manual adjusting. Both procedures use a side posture patient position with a solid mastoid support. The segmental contact is over and directed toward the C1 transverse process via a moving stylus on a table mounted or hand-held instrument or via the pisiform using a hand adjustment. The force is a single pulse on a specific pre-calculated vector generated by a solenoid or a manual cam accelerated mechanism for instruments or a triceps pull for hand adjustments.”
• Spinal Orthopedic Neurological Advancement and Research (SONAR) – “SONAR was developed by Thomas Elliott, Jr., DC who was a NUCCA practitioner. SONAR employs procedures for taking and analyzing x-rays. The SONAR instrument uses computer generated specific sound waves in a precise vector of the size, magnitude and torque required to reposition the upper cervical spine.”
• Toggle Recoil/Duff – “Toggle Recoil was popularized in the 1930s by BJ Palmer, DC with his development of HIO technique (which was also done in the Knee Chest position)… This type of adjustment is made in the side posture patient position on a drop headpiece toggle table, with the doctor’s pisiform contact over the C1 transverse process. A quick contraction and relaxation of the triceps generates the administered force… The Duff Method of Analysis was developed by Stephen A. Duff, Sr. DC, and utilizes a specific pre/post thermographic instrumentation procedure and upper cervical x-ray analysis. The adjustive technique utilizes a modified toggle-recoil to the atlas or axis with a predetermined vector and contact point. A side posture table with a drop mechanism is used.”

The authors specifically address the alleged association between cervical manipulation and cerebrovascular incidents. They state and reference these statistics:

“Estimated occurrence ranging from no causative association, to 1 in 300,000 to 500,000 to 1.3 million to 5.85 million cervical manipulations.”

“[A study has] found that the risk of having a stroke was equal between patients consulting a chiropractor or general medical practitioner.”

“This suggests that cervical manipulation may not be a cause of cerebrovascular accidents, but associated with a stroke in progress.”

The outcomes from this study were quite good:

• Neck pain improved by a mean of 57% and 62% of the total sample had become asymptomatic.
• Headache pain improved by 63%.
• Thoracic pain improved by 59%.
• Lumbar pain improved by 57%.
• Neck disability (NDI) improved by 47%.
• Low back disability (ODI) improved by 45%.

The authors stated:

“Outcome assessments were significantly improved for neck pain and disability, headache, mid-back pain, as well as lower back pain and disability following care with a high level (mean = 9.1/10) of patient satisfaction.”

“Upper cervical chiropractic care may have a fairly common occurrence of mild intensity SRs short in duration (<24 hours), and rarely severe in intensity; however, outcome assessments were significantly improved with less than 3 weeks of care with a high level of patient satisfaction.” “[All of these symptoms were] mild intensity, short duration and little effect on daily living.”

“Non-musculoskeletal responses included ‘easier to breathe,’ ‘improved digestive function,’ ‘improved vision,’ and ‘improved circulation.’”

The authors concluded:

“Chiropractic care using upper cervical techniques may have a fairly common occurrence of mild intensity SRs short in duration (<24 hours), and rarely severe in intensity; however, outcome assessments were significantly improved with less than 3 weeks of care with a high level of patient satisfaction.”

“Patients reported a very high degree of satisfaction with upper cervical techniques chiropractic care scoring a mean of 9.1/10 using an 11-point NRS.”

“The preponderance of the evidence shows that major complications resulting from chiropractic care are very rare, although transient discomfort and other minor side effects of chiropractic care are common.”

“Local discomfort in the treatment area accounts for half to two thirds of the reactions.”

The majority of reactions began within 24 hours of the treatment visit and resolved in less than 24 hours.

The Upper Cervical Spine and “The Cork” of Cerebrospinal Fluid

A greater understanding of the biomechanics and pathoanatomy of the upper cervical spine has been advanced by the use of upright weight-bearing MRI (3, 4, 5). This enhanced understanding helps to explain the clinical benefits of upper cervical spine chiropractic care (2). The evidence and the follow-up theories are as follows:

The physiology and health of the brain and spinal cord is dependent upon the flow of cerebral spinal fluid. The cerebral spinal fluid is generated in the brain and circulates throughout the brain and the spinal cord, literally bathing these neurological structures in the nutrient-rich fluid. 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.

A biomechanical misalignment between the foramen magnum hole and the atlas vertebrae hole may impair the flow of cerebral spinal fluid between the skull and the spine (4, 5, 6, 7, 8, 9 ). The consequence of this includes an accumulation of cerebrospinal fluid in the skull. This skull fluid accumulation is easily verified with MRI technology (4, 5).

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.

Quarterback Jim McMahon

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 (10). 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 (11). It was an article detailing his struggles with dementia, headaches, and other behavior/health problems.

In 2016, Jim McMahon was 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 had quickly and dramatically improved (12).

An upright weight-bearing MRI was taken of McMahon’s head and neck. As noted above, the imaging showed an accumulation of fluid (cerebrospinal fluid) in his skull and around his brain. McMahon’s upper cervical chiropractor documented a meaningful malalignment between the skull and the atlas vertebra. Such a finding is consistent with an impairment of cerebrospinal fluid flow.

McMahon’s chiropractor carefully and precisely adjusted his atlas vertebra with respects to the skull with the ideal goal of establishing perfect alignment between the occiput and the atlas vertebrae. This goal was achieved, verified by post-adjustment radiographs. The improvement in McMahon’s 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 accumulation. The entire procedure was taped and aired on ESPN.

This McMahon story has been picked-up by the lay press, including the Sacramento Bee in 2016 (13) and the San Francisco Chronicle in 2017 (14). Both stories appeared in the sports pages following interviews with McMahon during celebrity golf outings.

•••••

The indexed, peer-reviewed, scientific literature is also supporting the “cork” hypothesis as a consequence of misalignment between the skull and the atlas. These studies are referenced above and briefly reviewed below:

In 2011, a study appeared in the journal Physiological Chemistry and Physics and Medical NMR, titled (4):

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

The primary author, Raymond Damadian, MD, was famous (now deceased). According to his obituary in The Wall Street Journal (August 28, 2022), Dr. Damadian was the discoverer of the technology behind MRI (15).

In this study, eight multiple sclerosis (MS) patients and seven normal volunteers were MRI scanned to visualize the overall cerebrospinal fluid (CSF) flow pattern. Abnormal CSF flows were found in all eight MS patients. None of the normal volunteers had these flow obstructions. These authors note:

“The abnormal CSF flows corresponded with the cranio-cervical structural abnormalities found on the patients’ MR images.”

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

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 brain pathology dysfunction. These authors suggest that the improvement in cranial-cervical malalignment could improve cerebral spinal fluid flow.

•••••

In 2015, another supportive study appeared in the journal Neurology Research International, titled (8):

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, and 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.”

These authors are quite clear: an acquired blockage to CSF flow, important to chiropractors, is a misalignment of the atlas on the occipital condyles. They emphasize that the cranial-cervical junction is a choke point for cerebral spinal fluid flow between the cranial vault and spinal canal. They believe that manual/mechanical care may correct cranial-cervical junction structural problems, improving faulty cranio-spinal hydrodynamics 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 (5). 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). These important points are expressed:

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

“Magnetic resonance imaging (MRI) is conveniently performed in the supine position, in which noinformation about the effect of gravity on the patient in the upright position is possible.” [emphasis added]

“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

Upper cervical specific chiropractic techniques have been an important part of the profession for more than a century. Traditionally, the alignment assessment involves some type of precise imaging. Upper cervical chiropractors tend to have similar treatment goals: as perfect as possible alignment between the skull and the atlas. Yet, there is quite a variance as to the adjustment approaches used to make the correction, all of which have their proponents. Most chiropractors consider upper cervical specific care to be a unique specialty within the chiropractic profession. Upper cervical chiropractic care offers a unique benefit for a range of clinical syndromes.

REFERENCES

1. Eriksen K; Upper Cervical Subluxation Complex: A Review of the Chiropractic and Medical Literature; Lippincott Williams & Wilkins; 2004.
2. Eriksen K, Rochester RP, Hurwitz EL; Symptomatic Reactions, Clinical Outcomes and Patient Satisfaction Associated with Upper Cervical Chiropractic Care: A Prospective, Multicenter, Cohort Study; BMC Musculoskeletal Disorders; October 5, 2011; Vol. 12; No. 219.
3. Freeman MD, Rosa S, Harshfield D, Smith F, Bennett R, Centeno CJ, Kornel E, Nystrom A, Heffez D, Kohles SS; A case-control study of cerebellar tonsillar ectopia (Chiari) and head’neck trauma (whiplash); Brain Injury; 2010; Vol. 24; Nos. 7-8; pp. 988-994.
4. 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.
5. Smith FW, Dworkin JS; The Craniocervical Syndrome and MRI; Karger; 2015.
6. 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.
7. Flannagan MF; The Downside of Upright Posture: The Anatomical Causes of Alzheimer’s, Parkinson’s, and Multiple Sclerosis; Two Harbors Press; 2010.
8. Flanagan MF;The Role of the Cranio-cervical Junction in Cranio-spinal Hydrodynamics and Neurodegenerative Conditions; Neurology Research International; November 30, 2015; Article 794829.
9. Flannagan MF; Hydrodynamics in Neurodegenerative and Neurological Disorders; Nova; 2016.
10. Hendricks M; Super Bowl-winning quarterback Jim McMahon says he wishes he had played baseball; Yahoo!; September 27, 2012.
11. Segura M; The Other Half of the Story; THE WOMEN BEHIND THE MEN; Sports Illustrated; September 10, 2012.
12. https://www.youtube.com/watch?v=4ZxIUz4sc0U
13. Furillo A; Shoeless Golf is a Perfect Fit for McMahon; Sacramento Bee; July 21, 2016; pp. 1C and 5C.
14. Ostler S; Quarterbacking a Gypsy Lifestyle, Renewed Outlook for Former NFL Star; San Francisco Chronicle, July 15, 2017; pp. B1 and B7.
15. Hagerty JR; Raymond Damadian, 1936-2022: Doctor Pioneered MRI Scanning; The Wall Street Journal; August 28, 2022.

Ischemic heart disease is the leading cause of death worldwide. It may also be referred to as coronary artery disease and/or atherosclerotic cardiovascular disease. The most up-to-date epidemiological data from the Global Burden of Disease dataset which collates data from a large number of sources, including research studies, hospital registries, and government reports, indicates that ischemic heart disease affects around 126 million individuals globally (1,655 per 100,000), which is approximately 1.72% of the world’s population. About 9 million deaths are caused by ischemic heart disease globally each year (1).

Recent analysis indicates that ischemic heart disease is the number one cause of death, disability, and human suffering globally.

The most classic acute clinical presentation of an ischemic heart event is chest pain or discomfort (2). This presentation of chest pain is referred to as angina. This is the main focus of the following presentation.

In 1927, nearly a century ago, it was established that angina symptoms could be caused ty irritation of the cervical nerve roots (3). Angina-like symptoms caused by irritation of cervical nerve roots is commonly referred to as cervical angina. Often, a cervical spine origin of chest pain is described as mild, nagging, frequent, with bilateral arm radiation (3).

A decade later (1937), a robust study involving 600 cases of chest pain indicated that nearly a third of them could be traced to a cervical spine origin (4).

•••••

The journal Spine is the most cited orthopedic journal. Its first published edition was in March 1976. In this issue, an article appeared titled (5):

Cervical Angina

The authors, Robert Booth, MD, and Richard Rothman, MD, PhD, were from the Department of Orthopaedic Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania. The abstract from this article states:

“Cervical angina, an uncommon constellation of symptoms produced by cervical osteoarthritis but closely mimicking coronary ischemic disease, will be discussed and its meager literature reviewed.  

A series of 7 cases from Pennsylvania Hospital will be evaluated, emphasizing that distinct clinical diagnosis can be made and that mechanical therapeutic techniques can be effective.  

A discussion of both known and suggested pathophysiologic mechanisms of pain production and their anatomic significance will be offered.”

The authors note that the typical patient presentation was “nagging, aching, or glowing discomfort in the chest.” These symptoms were unassociated with dyspnea (difficult breathing), nausea and/or diaphoresis (excessive sweating).

Symptoms often included shoulder/arm pain, paresthesias, numbness and/or weakness. These symptoms were usually related to cervical spine motion (suggesting a musculoskeletal etiology) rather than from exertion (which would suggest a vascular etiology).

Examination showed reduced cervical ranges of motion, along with cervical spine spasm and tenderness.

X-rays on these subjects showed cervical spine spondylosis at C5-C6 in all cases.

Importantly, these authors state that these patients “will best respond to mechanical intervention.” This would include chiropractic care.

••••

In 1991, the journal Orthopedics & Traumatology published a study titled (6):

Clinical Study of Cervical Angina

The authors are from the Department of Orthopaedic Surgery, Tottori University, School of Medicine, Japan. They evaluated eight patients with cervical angina. These patients included six women and two men; their ages ranged from 35 to 68 years of age, averaging 50 years of age. The authors state:

“Cervical angina, resembling true angina pectoris, but resulting from cervical spondylosis and nerve root compression, is also known as pseudoangina.”

“It may be concluded that the pathophysiologic mechanism of cervical angina is related with C7 root and sympathetic nerve system.”

The study from the journal Spine (6) suggested that the primary nerve root responsible for the symptoms of cervical angina is C6. In contrast, this study suggests it is primarily C7. Additionally, this study mentions the involvement of the sympathetic nervous system.

••••

The sympathetic nervous system is the portion of the nervous system that controls visceral function, including that of the heart. The sympathetic innervation of the viscera involves two nerves: the pre sympathetic chain ganglion and the post sympathetic chain ganglion.

At the nerve root level, the pre sympathetic ganglion fibers travel in the anterior root, along with the motor nerve root to the muscles. These pre sympathetic ganglion fibers terminate in the sympathetic chain ganglion (there are exceptions to this) where they synapse with the post sympathetic chain ganglion fibers that then travel to the viscera, like the heart.

Since 1916, it has been held that the cells of origin of pre sympathetic ganglion neurons are found only in T1 to L2 segments of the spinal cord, and therefore only found in nerve roots of T1-L2 (7). The pre sympathetic ganglion fibers to the heart are usually said to be from T1-T4 spinal segmental levels.

In 1960, Eugene Neuwirth, MD, published a study in the journal Lancet, titled (7):

Current Concepts of the Cervical Portion of the Sympathetic Nervous System

Dr. Neuwirth was a specialist in physical medicine, rehabilitation, and rheumatic diseases. In this article he notes that in 1940, French researchers showed that presympathetic ganglion neurons are found at the spinal cord levels of C4, C5, C6, C7, and C8. He notes that this was confirmed in 1947. This anatomical observation is quite relevant to the discussion presented here.

Although the sympathetic nervous system is considered to be an efferent system to the viscera, the sympathetic nerves also contain afferent fibers that carry pain. When a visceral organ is diseased or injured (like the heart), it is these afferent sympathetic fibers that carry the pain to the spinal cord and hence to the brain.

Musculoskeletal pain is often pinpointable. In contrast, visceral pain, transmitted by the sympathetic nervous system, is usually much more diffuse and more poorly localized.

When the sympathetic nerves are inflamed, irritated, or compressed, they are capable of sending a visceral pain signal to the brain. This can happen in the absence of heart disease.

For the heart, there are four locations for sympathetic afferent involvement:

• The anterior nerve root at any level between C4 to T4.
• The mixed spinal nerve root at any level between C4 to T4.
• The sympathetic chain ganglion, located in the front of the spinal column, traveling with the longus colli muscle.
• Post sympathetic chain ganglion fibers that exist in and around the longus colli muscle.

••••

In 2015, an article was published in the journal Neurohospitalist, titled (8):

Cervical Angina
An Overlooked Source of Noncardiac Chest Pain

The authors present a series of 6 cases of cervical angina. They note that each year, more than 7 million patients present to emergency departments with chest pain. Yet, only 15% to 25% of patients with acute chest pain will actually have acute coronary syndrome. The authors state:

“The prevalence of noncardiac chest pain is estimated to be more than 50% of all cases with chest pain that present to the emergency department.”

The authors note that cervical angina is one potential cause of noncardiac chest pain and originates from disorders of the cervical spine. Up to 70% of patients with cervical angina have cervical nerve root involvement. The most frequently affected nerve root levels are:

• C5-C6 37%
• C6-C7 30%
• C4-C5 27%
• C3-C4 4%

The authors recognize that 50% to 60% of patients who experience cervical angina also experience other autonomic symptoms such as dyspnea, vertigo, nausea, diaphoresis, pallor, fatigue, diplopia, and headaches. This adds to the model that suggests there is sympathetic nervous system involvement in cervical angina. Consistent with studies cited above (6), these authors state:

“Pain may be mediated by the sympathetic afferent fibers to the heart and coronary arteries, which originate in the dorsal root ganglia of C8 to T9.”

In this study, all subjects had been evaluated for cardiac etiology for their chest symptoms, including:

• Cardiac stress testing
• Coronary angiogram
• Electrocardiogram
• Chest x-ray
• Cardiac enzymes

All of these tests were deemed to be normal or unremarkable.

In the diagnosing of cervical angina, the authors found the most revealing physical test was the Spurling maneuver. They state:

“The Spurling maneuver, performed by rotating the cervical spine toward the symptomatic side while providing a downward compression through the patient’s head, has been shown to reproduce symptoms of cervical angina in case reports.”

“A positive Spurling maneuver correlates with findings on computer tomography with a sensitivity of 95% and specificity of 94%.”

The authors suggest that cervical angina should be suspected when a patient has a negative cardiac workup, and has positive signs of cervical radiculopathy, including the Spurling Maneuver. The authors state:

“There should be a strong suspicion for cervical angina in any patient with inadequately explained noncardiac chest pain, especially, when neurologic signs and symptoms are present.”

“A greater awareness of this unusual radiating pattern for cervical pathology will hopefully lead to early diagnosis and a recognition that this symptom pattern is not due to dual clinical entities but unified by the diagnosis of cervical angina.”

Lastly, the authors indicate the value of conservative management of these patients, stating:

“The majority of patients with cervical angina from cervical radiculopathy will respond to conservative care.”

••••

In 2021, a study was published in the Asian Spine Journal, titled (9):

Cervical Angina:
A Literature Review on Its Diagnosis, Mechanism, and Management

The authors were from the Department of Spine Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China. They state:

“Cervical angina has been defined as chest pain that resembles true cardiac angina but originates from the disorders of the cervical spine.” 

“Chest pain is a common and highly challenging clinical problem in emergency departments. However, only 15%–25% of patients with acute chest pain actually have acute coronary syndrome.”

“Cervical angina appears to be a relatively unknown clinical syndrome compared with other angina symptoms.”

“When neurologic signs and symptoms are present, there should be a strong suspicion for cervical angina in any patient with inadequately explained noncardiac chest pain.” 

“Cervical angina can be diagnosed according to negative cardiac workups, positive neurologic examination, and cervical radiographic findings (herniated disk, spinal cord compression, or foraminal encroachment).”

The authors indicate that patients with cervical angina often present with anterior chest pain that is exacerbated by cervical range of motion or movement of the upper extremity. The patient may also have neck pain, upper arm radicular symptoms (weakness or sensory changes), and occipital headaches.

Consistent with above (8), cervical angina patients have a positive Spurling’s maneuver.

The Sympathetic Nervous System

Consistent with the studies cited above (6, 8), these authors discuss involvement of the sympathetic nervous system, stating:

“More than half of patients have been identified to experience autonomic symptoms such as dyspnea, nausea, vertigo, diplopia, and other sympathetic nervous signs.”

“Cervical angina may be mediated by the cervical sympathetic afferent fibers to the heart and coronary arteries.”

“Other autonomic symptoms, such as nausea and diaphoresis, can occur and are mediated through the sympathetic nervous system.”

The authors indicate that irritation of the sympathetic fibers that travel in the anterior root or from the plexus of sympathetic fibers are also anatomically associated with the longus colli muscle.

Diagnostic Suggestions and Precautions

The authors note that degenerative changes of the cervical joints are frequently found in the asymptomatic population, and functional tests (discography, selective nerve root block) may help to confirm the etiology of cervical angina. However, they also caution that discography and/or selective nerve root blocks are “invasive tests, which are not risk-free, [and] should be considered carefully and only applied in patients contemplating surgery.”

They also note:

“Varying degrees of cardiac workups must be performed in order to rule out true angina pectoris.”

“Cervical imaging can be critical evidence in the diagnosis of cervical angina once coronary artery disease has been adequately ruled out.”

“MRI may demonstrate degenerative changes in the cervical spine, including herniated disk, spinal cord compression, or foraminal encroachment.”

Joints of Luschka

The joints of Luschka are also known as the uncinate process. It has been suspected that cervical angina is linked to these joints. The joints of Luschka can irritate the anterior nerve root, causing diffuse pain; this pain is not clearly radicular but is less discrete. The authors state:

“It is reasonable to speculate a close association between cervical angina and the Luschka’s joint osteophytes.”

“The protrusion of Luschka’s joint osteophytes jacks up the homolateral longus colli, which might compress or stimulate adjacent sympathetic afferent fibers to the heart and coronary arteries and result in noncardiac chest pain.” 

“Luschka’s joint osteophytes may be one of pathogenic factors in cervical angina.”

The authors do not detail the clinical management of cervical angina, but do make these comments:

“Conservative treatment has been determined to be successful in most patients with cervical angina.”

“At least 3 months of conservative treatment is recommended in all but the most severe cases.”

“Conservative treatment should continue as long as the patient’s condition improves.”

“Surgical intervention may be recommended if conservative measures fail or in cases where neurologic compromise is evident by spinal cord and/or nerve root compression.”

They note that if the surgical option is used, the best long-term benefits use the anterior cervical discectomy and fusion approach.

Chiropractic Care for Cervical Angina

In 2005, an article was published in the Journal of Manipulative Physiological Therapeutics, titled (10):

Manual Therapy for Patients with Stable Angina Pectoris:
A Nonrandomized Open Prospective Trial

The objective of this study was to examine if participants with chest pain originating from the spine would benefit from manual therapy. It is a prospective clinical trial. It involved 50 subjects who were cleared of cardiac involvement following coronary angiography. These subjects were given standard chiropractic care. Assessment used the 11-point box scale and the Short Form 36 quality of life tool. The follow-up period was 4 weeks.

Approximately 75% of the patients reported improvement of pain and of general health after treatment. The authors concluded:

“This study suggested that patients with known or suspected angina pectoris and a diagnosis of cervical angina may benefit from chiropractic manual therapy.”

••••

In 2012, another study was published in the Journal of Manipulative Physiological Therapeutics, titled (11):

Chiropractic Treatment vs Self-management in Patients with Acute Chest Pain:
A Randomized Controlled Trial of Patients Without Acute Coronary Syndrome

The authors were from the Nordic Institute of Chiropractic and Clinical Biomechanics and Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark. The purpose of the present study is to evaluate the relative effectiveness of two treatment approaches for acute musculoskeletal chest pain:

• Chiropractic treatment that included spinal manipulation
• Self-home management

This is a randomized, controlled trial that used 115 patients with chest pain, set at an emergency cardiology department and 4 outpatient chiropractic clinics. The clinical trial involved 4 weeks of chiropractic treatment or self-management, with post-treatment assessment 4 and 12 weeks later. The authors found:

“Observed between-group significant differences were in favor of chiropractic treatment at 4 weeks regarding the primary outcome of self-perceived change in chest pain and at 12 weeks with respect to the primary outcome of numeric change in pain intensity.”

••••

In 2022, an article was published in the Journal of Medical Cases, titled (12):

Cervical Radiculopathy as a Hidden Cause of Angina:
Cervicogenic Angina

Journal of Medical Cases
November 2022; Vol. 13; No. 11; pp. 545-550

The author presented a case report of a 56-year-old man with non-traumatic chest pain and chronic neck pain for 2 years, as well as numbness in his right third and fourth fingers for 6 months. The patient was medically diagnosed with cervical radiculopathy, and he was treated with analgesics and physical therapy. These treatments had only provided temporary improvement over a period of 6 months. The patient then sought chiropractic care. Three months of chiropractic care completely resolved all symptoms.

The author notes that 77% of the patients with chest pain symptoms presenting to the emergency department are not cardiac related. He states:

“Cervicogenic angina is defined as paroxysmal angina-like pain that originates from the disorders of the cervical spine or other neck structures.”

“Chiropractic care aims to alleviate neck pain, improve cervical alignment, restore cervical mobility, and prevent neurological damage.”

Patient examination showed reduced neck movement, a positive Spurling test (consistent with above studies 8, 9), and hypoesthesia in the right C7 dermatome. Cervical x-rays showed degenerative spondylosis with right C5/C6 neuroforaminal stenosis and bilateral C6/C7 neuroforaminal stenosis.

Chiropractic management of this case included cervical manipulation and neck traction. Treatment was given 3 times per week for 4 weeks, then reduced to 2X per week for 8 weeks. The authors found:

“After 3 months, the patient reported that the chest pain, neck pain, and radicular symptoms had completely resolved.”

“Analgesic medicines were discontinued, and the patient received monthly chiropractic maintenance care.”

“He is currently pain-free.”

Summary

These studies inform the reader that chest pain is often not caused by a heart problem; it may be caused by inflammation-irritation-compression of the cervical nerve roots, often secondary to cervical spondylotic changes. The authors insist that in patients with chest symptoms, a cardiac etiology should be ruled out. The musculoskeletal evaluation should include radiography, motor and sensory assessments, and the Spurling’s maneuver. Chiropractic care is very often successful at managing these patients and in helping them avoid a surgical intervention.

References:

1. Khan MAB, Hashim MJ, Mustafa H Baniyas Y, and eight more; Global Epidemiology of Ischemic Heart Disease: Results from the Global Burden of Disease Study; Cureus; July 23, 2020; Vol. 12; No, 7; Article e9349.
2. https://www.mayoclinic.org/diseases-conditions/acute-coronary-syndrome/symptoms-causes/syc-20352136 Accessed 11/5/24’
3. Phillips J; The Importance of Examination of the spine in the presence of Intrathoracic or Abdominal Pain; Proceedings International Postgraduate MA North American; 1927; Vol. 3; p 70.
4. Ollie JA; Differential Diagnosis of Pain in the Chest; The Canadian Medical Association Journal; September 1937; Vo. 37; No. 3; pp. 209-216.
5. Booth RE, Rothman RH; Cervical Angina; Spine; March 1976; Vol. 1; No, 1; pp. 28-32.
6. Shimizu M, Mono Y, Okuno M, Kuranobu K, Yamamoto K; Clinical Study of Cervical Angina; Orthopedics & Traumatology; November 25, 1991; Vol. 40; No. 1; pp. 149-151.
7. Neuwirth E; Current Concepts of the Cervical Portion of the Sympathetic Nervous System; Lancet; July 1960; pp. 337-338.
8. Sussman WI, Makovitch SA, Merchant SHI, Jayant Phadke J; Cervical Angina: An Overlooked Source of Noncardiac Chest Pain; Neurohospitalist January 2015; Vol. 5; No. 1; pp. 22-27.
9. Feng F, Chen X, Shen H; Cervical Angina: A Literature Review on Its Diagnosis, Mechanism, and Management; Asian Spine Journal; August 2021; Vol. 15; No. 4; pp. 550-556.
10. Christensen HW, Vach W, Gichangi A, Manniche C, Haghfelt T, Hoilund-Carlsen PF; Manual Therapy for Patients with Stable Angina Pectoris: A Nonrandomized Open Prospective Trial; Journal of Manipulative Physiological Therapeutics; Nov-Dec 2005; Vol. 28; No. 9; pp. 654-61.
11. Stochkendahl MJ, Christensen HW, Vach W, Hoilund-Carlsen PF, Haghfelt T, Hartvigsen J; Chiropractic Treatment vs Self-management in Patients with Acute Chest Pain: A Randomized Controlled Trial of Patients Without Acute Coronary Syndrome; Journal of Manipulative Physiological Therapeutics; January 2012; Vol. 35; No. 1; pp. 7-17.
12. Chu ECP; Cervical Radiculopathy as a Hidden Cause of Angina: Cervicogenic Angina; Journal of Medical Cases; November 2022; Vol. 13; No. 11; pp. 545-550.

The Importance of Convergent Validity

The primary reason (63%) patients go to chiropractors is for the management of low back pain (1). The objective of this publication is to assess the efficacy of chiropractic care for low back pain using an evaluation tool called Convergent Validity.

The denotation of the concept of Convergent Validity has a strict definition. A clinical connotation of the concept of Convergent Validity would include an approach to answering the following question:

How effective is chiropractic care (spinal manipulation)
for the management of low back pain?

There are many ways to approach an answer to such a question. Each research group will construct a particular approach to answer the question. The quality of the research will be assessed by official journal reviewers and journal editors, and if the approach is deemed worthy, the study will be published in a peer reviewed journal.

When a clinician or patient looks at the research, they quickly become aware of the varied approaches to evaluate the question. In different studies, variables often include:

• The year the study was published.
• Country of origin of the researchers and of the patients assessed.
• The journal of publication and the journal’s country of origin.
• The number of subjects in the study.
• The length or duration of the study.
• The methodology of the study, including such categories as randomized controlled trial, randomized clinical trial, an epidemiological study, a prospective study, a retrospective study, etc.

When multiple studies with different methodological parameters, spanning a period of decades, come to the same or similar conclusion, the studies validate each other. This is clinical convergent validity. Below is a review of studies that have appeared to answer the question posed above.

•••••

TITLE: Manipulation in Back Pain
COUNTRY: Canada
JOURNAL: Canadian Medical Association Journal
YEAR: 1958

In 1958, WB Parsons, MD and JDA Cumming, MD published a study to “describe a method of manipulation that for 20 years has brought gratifying results with none of the disasters that so many predict.” This article was published in the Canadian Medical Association Journal, titled (2):

Manipulation in Back Pain

This article was published 66 years ago. The authors made these statements:

“The standard medical treatment for lumbago and other acute backache is bed rest and sedation, counter-irritation and heat, possibly supplemented by massage and injections of procaine.” Yet, “patients soon find that in the majority of instances they can get rapid relief [from spinal manipulation] without the loss of time.”

“The reason we took up manipulation was an interest in backache, with the early discovery that many patients who failed to respond to routine medical treatment went to a manipulator and received immediate relief.”

“Manipulation as an art is as old as medicine.”

“That manipulation will relieve back pain in many instances, few will argue. Those who manipulate swear by it. Those who don’t, condemn it. Those who don’t manipulate warn of all the catastrophes that can result from the practice.”

“That manipulation can bring comfort to mankind there can be no doubt.”

“Since the majority of backaches will respond to manipulation, it is probable that the origin of the pain lies in relationship to one of the joints, either the zygapophysial joint or the intervertebral disc.”

“Pain so severe as to keep the patient in bed is no contraindication to manipulation. We see many patients who are afraid to make an effort to get out of bed but who, following manipulation, get up and move with ease.”

“Much is said about the hazards of manipulation. We do not know what they are.”

“It is our belief, based on long experience, that manipulation is no more beset by hazards than many other recognized procedures in therapy, while its results are often more dramatic and sure.”

“In our hands this approach to backache has proved most gratifying and, more important, has brought comfort to a large group of patients who have not been able to achieve it before.” 

•••••

TITLE: Low Back Pain and Pain Resulting from Lumbar Spine Conditions: A Comparison of Treatment Results
COUNTRY: Australia
JOURNAL: The Australian Journal of Physiotherapy
YEAR: 1969

In 1969, Brian C. Edwards, MAPA (Medical Affairs Professionals of Australia), published a study in the Australian Journal of Physiotherapy, titled (3):

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

This was the first study to compare the results of effectiveness for low back and leg pain treated with mobilization/manipulation compared to those treated with heat, massage, and exercise. The study used 184 subjects, half were treated with heat/massage/exercise and half were treated with mobilization/manipulation. The authors made these statements:

“The difference in the number of patients with ‘acceptable’ results by each method of treatment, in the third [pain radiation down thigh to knee] and fourth [pain radiation down leg to foot] groups are statistically significant.”

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

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

•••••

This study (3) was reviewed in the 1990 reference text, White and Panjabi’s Clinical Biomechanics of the Spine. Dr. White, MD, is from Harvard; Dr. Panjabi, PhD, is from Yale. They made the following statements (4):

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

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

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

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

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

•••••

TITLE: Spinal Manipulation in the Treatment of Low Back Pain
COUNTRY: Canada
JOURNAL: Canadian Family Physician
YEAR: 1985

In 1985, W. H. Kirkaldy-Willis, MD, and J. D. Cassidy, DC, published a study in the journal Canadian Family Physician, titled (5):

Spinal Manipulation in the Treatment of Low Back Pain

Dr. Kirkaldy-Willis was a Professor Emeritus of Orthopedics and director of the Low-Back Pain Clinic at the University Hospital, Saskatoon, Canada.

The authors note that spinal manipulation is one of the oldest forms of therapy for back pain, yet it has mostly been practiced outside of the medical profession. They also note that “there has been an escalation of clinical and basic science research on manipulative therapy, which has shown that there is a scientific basis for the treatment of back pain by manipulation.” The authors made these statements:

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

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

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

These authors presented the results of a prospective observational study of spinal manipulation in 283 patients with chronic low back and leg pain. All 283 patients in this study had failed prior conservative and/or operative treatment, and they were all totally disabled (“constant severe pain; disability unaffected by treatment”). These patients were given a “two or three week regimen of daily spinal manipulations by an experienced chiropractor.” Eighty-one percent of the patients achieved a good clinical outcome (“symptom-free with no restrictions for work or other activities;” “mild intermittent pain with no restrictions for work or other activities”).

The authors made these statements:

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

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

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

“The physician who makes use of this [manipulation] resource will provide relief for many back pain patients.”

•••••

TITLE: Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment
COUNTRY: United Kingdom
JOURNAL: British Medical Journal
YEAR: 1990

In 1990, epidemiologist TW Meade assembled a team that published a study in the British Medical Journal, titled (6):

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

 The objective of this study was to compare chiropractic and hospital outpatient treatment for managing low back pain of mechanical origin. It is a randomized controlled trial that involved 741 patients. Each patient was re-evaluated at weekly intervals for six weeks, at six months, and at one and two years after entry. The authors stated:

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

“For patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management.”

“The results were also analyzed according to length of the current episode of pain. Those treated by chiropractors improved more than those treated in hospital.”

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

“The effects of chiropractic seem to be long term, as there was no consistent evidence of a return to pretreatment Oswestry scores during the two years of follow up, whereas those treated in hospital may have begun to deteriorate after six months or a year.”  

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

“The results from the secondary outcome measures suggest that the advantage of chiropractic starts soon after treatment begins.”

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

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

•••••

This significant article generated an editorial comment in a different United Kingdom medical journal, The Lancet, titled (7):

Chiropractors and Low Back Pain

The editors of The Lancet note:

“[The article] showed a strong and clear advantage for patients with chiropractic.”

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

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

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

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

•••••

In this study (6), the follow-up period was up to 2 years. In 1995, the same authors published a 3-year follow-up on the same group of subjects. It was also published in the British Medical Journal, and titled (8):

Randomised Comparison of Chiropractic and Hospital Outpatient Management for Low Back Pain:
Results from Extended Follow Up

In 1990, the authors “reported greater improvement in patients with low back pain treated by chiropractic compared with those receiving hospital outpatient management.” The authors further stated:

“The beneficial effect of chiropractic on pain was particularly clear.”

“At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long-term satisfaction than those treated by hospitals.”

 “The substantial benefit of chiropractic on intensity of pain is evident early on and then persists.”

“The results of our trial show that chiropractic has a valuable part to play in the management of low back pain.”

•••••

TITLE: Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation
COUNTRY: Australia
JOURNAL: Spine
YEAR: 2003

In 2003, Lynton Giles, DC, PhD and Reinhold Muller, PhD published a study in the journal Spine, titled (9):

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

The objective of this study was to compare pain medications, needle acupuncture, and chiropractic spinal manipulation for management of chronic spinal pain. It was a randomized controlled clinical trial. Patients were assessed before treatment, and again at 2, 5, and 9 weeks after the beginning of treatment.

In this study, chiropractic manipulation achieved the best overall results. The authors stated:

“High-velocity, low-amplitude thrust spinal manipulation to a joint was performed by a chiropractor at the spinal level of involvement to mobilize the spinal joints.”

“The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%).”

“The results of this efficacy study suggest that spinal manipulation, … may be superior to needle acupuncture or medication for the successful treatment of patients with chronic spinal pain syndrome.”

“The significance of the study is that for chronic spinal pain syndromes, it appears that spinal manipulation provided the best overall short-term results, despite the fact that the spinal manipulation group had experienced the longest pretreatment duration of pain.”

•••••

In 2005, these same authors (9) published a 12-month follow-up status of these patients in the Journal of Manipulative and Physiological Therapeutics, titled (10):

Long-Term Follow-up of a Randomized Clinical Trial Assessing  the Efficacy of Medication, Acupuncture, and Spinal Manipulation  for Chronic Mechanical Spinal Pain Syndromes

In this 1-year follow up, the authors assess the long-term benefits of medication, needle acupuncture, and spinal manipulation in patients with chronic spinal pain syndromes. The authors stated:

“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.”

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

“No such benefit could be observed for medication.”

“Spinal manipulation appeared to provide the highest satisfaction.”

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

•••••

TITLE: Association of Spinal Manipulative Therapy with Clinical Benefit and Harm for Acute Low Back Pain
COUNTRY: United States
JOURNAL: Journal of the American Medical Association
YEAR: 2017

In 2017, Neil Paige, MD, and colleagues, published a study in the Journal of the American Medical Association, titled (11):

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

The objective of this article was to systematically review studies of the effectiveness and harms of spinal manipulative therapy for acute low back pain. The authors stated:

“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.”

•••••

TITLE: Comparison of Effectiveness of Chiropractic Spinal Manipulation and Conservative Therapy for Low Back Pain
COUNTRY: United Kingdom
JOURNAL: Journal of Orthopedics and Sports Medicine
YEAR: 2023

In 2023, Emmanuel Wong and colleagues published a study in the Journal of Orthopedics and Sports Medicine, titled (12):

Comparison of Effectiveness of Chiropractic Spinal Manipulation and Conservative Therapy for Low Back Pain

The objective of this study was to describe the evidence for the effectiveness of chiropractic spinal manipulation (SMT) in comparison to the conservative intervention on low back pain (LBP). It is a meta-analysis of eight randomized clinical trials (RCTs). The authors stated:

“SMT which is delivered by chiropractors, is a regularly utilized treatment that has consistently excellent effects in terms of pain intensity and functionality.”

“Clinical practice recommendations for patients with acute, subacute, and chronic LBP suggest chiropractic therapy or spinal manipulation as a scientific proof, cost-effective, conservative treatment approach.”

“Spinal manipulation or mobilization is recommended as an effective therapy for acute, subacute, and chronic LBP by four guidelines in total which include National Institute for Health and Care Excellence (NICE), The American College of Physicians Pain Society, European guidelines for chronic LBP, and European guidelines for acute LBP.”

“RCTs have demonstrated that chiropractic care and its signature treatment, spinal manipulation, is an effective conservative care option for patients with LBP.”

“Chiropractic care seems to be more effective than conservative intervention for LBP in reducing pain, increasing range of motion in lumbar spine, improving disability status, and enhancing general health.”

•••••

TITLE: Reduction of Chronic Primary Low Back Pain by Spinal Manipulative Therapy is Accompanied by Decreases in Segmental Mechanical Hyperalgesia and Pain Catastrophizing: A Randomized Placebo-controlled Dual-blind Mixed Experimental Trial
COUNTRY: Canada and Spain
JOURNAL: Journal of Pain
YEAR: 2024

In 2024, Carlos Gevers-Montoro, PhD, and colleagues published a study in the Journal of Pain, titled (13):

Reduction of Chronic Primary Low Back Pain by Spinal Manipulative Therapy is Accompanied by Decreases in Segmental Mechanical Hyperalgesia and Pain Catastrophizing:
A Randomized Placebo-controlled Dual-blind Mixed Experimental Trial

The objective of this study was to investigate the efficacy of spinal manipulative therapy to improve chronic low back pain. It involved 49 individuals with chronic low back pain and 49 controls (placebo group). The authors stated:

“Most clinical practice guidelines recommend spinal manipulative therapy for the management of chronic low back pain.”

“The present study shows that spinal manipulative therapy produces greater pain relief compared with a control intervention that was undistinguishable from spinal manipulative therapy.”

“The present results indicate that spinal manipulative therapy produced a clinically significant reduction of chronic low back pain.”

Summary Comments

When the studies presented here are viewed through the concept of convergent validity, the conclusion is clear: decades of research throughout the world converge to validate the efficacy of chiropractic spinal manipulation for the management of low back pain.

REFERENCES:

1. Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
2. Parsons WB, Cumming JDA; Manipulation in Back Pain; Canadian Medical Association Journal; July 15, 1958; Vol. 79; pp. 013-109.
3. 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.
4. White AA, Panjabi MM; Clinical Biomechanics of the Spine; Second edition; JB Lippincott Company; 1990.
5. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
6. 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.
7. _____; Chiropractors and Low Back Pain; Lancet; July 28, 1990; Vol. 336; p. 220.
8. Meade TW, Dyer S, Browne W, Frank OA; Randomised Comparison of Chiropractic and Hospital Outpatient Management for Low Back Pain: Results from Extended Follow Up; British Medical Journal; August 5, 1995; Vol. 311; No. 11; pp. 349-353.
9. Giles LGF, Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine; July 15, 2003; Vol. 28; No. 14; pp. 1490-1502.
10. Muller R, 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; Vol. 28; No. 1; pp. 3-11.
11. Paige NM, Miake-Lye IM, Suttorp Booth MS, Beroes JM, Mardian AS, Dougherty P, Branson R, Tang B, PT, DPT; Morton SC, PhD; 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.
12. Wong E, Lee WT, Chau C, Cheng HY, Kwok R; Comparison of Effectiveness of Chiropractic Spinal Manipulation and Conservative Therapy for Low Back Pain; Journal of Orthopedics and Sports Medicine; January 3, 2023; Vol. 5; No. 1; pp. 1-8.
13. Gevers-Montoro C, Romero-Santiago B, Medina-García I, Larranaga-Arzamendi B, Álvarez-Gálovich L, Ortega-De Mues A, Piché M; Reduction of Chronic Primary Low Back Pain by Spinal Manipulative Therapy is Accompanied by Decreases in Segmental Mechanical Hyperalgesia and Pain Catastrophizing: A Randomized Placebo-controlled Dual-blind Mixed Experimental Trial; The Journal of Pain; August 2024; Vol. 25; No. 8; Article 104500.

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

Safety, Concerns, Chiropractic Care

A primary care provider (PCP) is a health care provider who provides the first contact for a person with a new health concern. Historically, the primary care provider is a medical doctor (MD), an osteopathic doctor (DO), a physician assistant, certified (PA-C), or an advanced registered nurse practitioner (ARNP). The provider has the education and experience to propose a likely diagnosis for the new health concern. This education and experience are commonly based upon good knowledge as well on symptoms, history, examination findings, laboratory results, imaging, electrodiagnostic testing, etc.

Once the working diagnosis is proposed, the primary care provider also has the education and experience to initiate appropriate treatment or to refer the patient to a specialist if such a referral is in the patient’s best interest.

Despite the highest standards, intelligence, logic, education, and training, diagnostic errors are commonplace. A study published earlier this year (2024) in the BMJ [British Medical Journal] Quality & Safety was titled (1):

Burden of Serious Harms from Diagnostic Error in the USA

This study was the first national estimate of permanent morbidity and mortality resulting from diagnostic errors across all clinical settings, including both hospital-based and clinic-based care each year in the USA. The goal of this research was to estimate the total number of serious misdiagnosis-related harms (i.e., permanent disability or death) occurring annually in the USA across all care settings (ambulatory clinic, emergency department, and inpatient). The authors are from Johns Hopkins School of Medicine and Harvard Medical School. The authors note:

“An estimated 795,000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed.”

“This manuscript provides the first robust, national annual US estimate for serious misdiagnosis-related harms (nearly 800,000 combined deaths (~371,000) or permanent disabilities (~424,000)) across care settings (ambulatory clinic, emergency department, and inpatient).”

“Across clinical settings (ambulatory clinics, emergency department, and inpatient), we estimate that nearly 800,000 Americans die or are permanently disabled by diagnostic error each year, making it the single largest source of serious harms from medical mistakes.”

“Total annual diagnostic errors in the USA likely number in the tens of millions.”

 Primary care providers are aware of these concerns, and as such they constantly monitor, reassess, and follow the response to initial treatment in their patients. The complexity of human genetics, epigenetics, and physiology, and the immense range of potential illnesses, are overwhelming.

Doctors of chiropractic (DC) are not considered to be primary care providers. Rather, chiropractors are portal of entry providers (POE).

A POE provider is any healthcare provider to whom a patient has direct access, and a referral is not necessary. This means a person can directly call, consult, and receive care from a chiropractor without a referral.

Other portal of entry providers includes dentists, podiatrists, and optometrists.

Primary care providers are educated and trained to provide comprehensive diagnosis and treatment of medical diseases. In contrast, chiropractors are not meant to provide treatment for medical diseases. Chiropractors are primarily trained and educated on the diagnosis and treatment of neuromusculoskeletal problems and to address them primarily from a mechanical perspective (the chiropractic spinal adjustment). Yet, chiropractors are educated and trained to be able to assess if a patient’s condition is a neuromusculoskeletal problem or if there might be some other explanation. As such, chiropractors work closely with their patient’s primary care provider and other involved specialists.

Chiropractors are licensed portal of entry providers in all 50 U.S. states. All U.S. chiropractors are graduates of fully accredited chiropractic colleges (2). Chiropractic care is reimbursed by Medicare, Medicaid (Medical), Worker’s Compensation insurance, automobile collision insurance, and most private health insurers.

Although all of chiropractic education is accredited nationally (indirectly through the U.S. Department of Education, via the Council on Chiropractic Education (2)), the licensing for chiropractors is done by the individual states. All states establish oversight boards for professionals to help protect its citizens. Examples include medical boards, insurance boards, contractors boards, etc. Similarly, all states have an oversight licensing board for the chiropractic profession. Although the name of the board will vary somewhat state to state, generally it is known as the “Board of Chiropractic Examiners.”

Each state’s licensing board will create a set of rules and regulations for its licensed chiropractors. These rules and regulations will vary somewhat state to state, but as a central theme most of them are fairly similar. A common topic is the details of using Informed Consent.

Informed Consent

Every type of health care is associated with some risks of potential problems. This includes chiropractic health care. Informing patients about potential problems associated with chiropractic health care is known as Informed Consent.

Typically, Informed Consent would include a description of the type of treatment, as follows:

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

The risks of potential problems associated with chiropractic health care are classically those associated with mechanical-based care. These might include:

• Neck Artery Dissection
• Stroke secondary to neck artery dissection
• Disc Injuries
• Nerve Injury; this would include spinal cord, nerve root, and/or the peripheral nerve
• Soft tissue injury to ligament, tendon, muscle, or fascia
• Soreness
• Fracture

More details about each of these would be explained to the patient by their chiropractor. Other risks unique to the chiropractor’s procedures or equipment would also be included. All discussions are often done both in writing and orally. As with all other health care providers, the patient is asked to sign and date their understanding of these issues.

Chiropractic meetings and lectures often advise about another potential problem that might be related to mechanically based treatment (adjustments): Cauda Equina Syndrome. An Informed Consent discussion pertaining to Cauda Equina Syndrome might include something like this:

Cauda Equina Syndrome occurs when a low back disc problem puts pressure on the nerves that control bowel, bladder, and/or sexual function.

Representative symptoms of Cauda Equina Syndrome include leaky bladder, or leaky bowels, or loss of sensation (numbness) around the pelvic sexual organs (the saddle area), or the inability to start/stop urination or to start/stop a bowel movement.

Cauda Equina Syndrome is a medical emergency because the nerves that control these functions can permanently die, and those functions may be lost or compromised forever.

The standard medical approach for Cauda Equina Syndrome is to surgically decompress the nerves, and the window to do so may be as short as 12-72 hours, depending.

If you have any of these symptoms before seeing us, during an appointment with us, or after an appointment with us, tell us immediately, and if we can’t be reached, go to the emergency department immediately.

The spinal cord terminates at the upper part of the low back, say at about the level of the first lumbar vertebrae (L1). The long nerve roots that leave the upper part of the low back to exit from the lowest portion of the low back create an appearance of a horse’s tail, hence the terminology cauda equine. Cauda Equina Syndrome occurs when a central or midline disc herniation puts pressure on the central part of the cauda equina.

Chiropractic’s Impressive Safety Record

People become healthcare providers because they want to help others with their health. Most healthcare providers are horrified at the thought that anything they did or failed to do could end up harming a patient. Yet, medical care is complex and often invasive. Medical care routinely uses drugs and surgery. As such, for decades, top universities and top medical journals have been documenting medical errors (1, 3, 4, 5, 6, 7, 8, 9, 10).

In contrast, chiropractors do not use drugs or surgery. Chiropractic care is mechanically based care. At its core is the chiropractic adjustment (specific line-of-drive manipulation). It is also quite common for chiropractors to employ adjunct mechanical interventions, such as tissue work and/or exercise.

Chiropractic’s record of safety and low risk of injury is very impressive. Two recent (2022, 2023) very large studies have confirmed the incredible safety of spinal manipulation and chiropractic spinal adjusting (11, 12). These studies are reviewed here:

In 2022, a study was published in the journal Healthcare, titled (11):

Safety of Chuna Manipulation Therapy in 289,953 Patients with Musculoskeletal Disorders

This study was from medical facilities in South Korea. It involved a form of high-velocity low amplitude spinal adjustment (specific line-of-drive manipulation). This type of traditional joint manipulation is similar to that in chiropractic. This type of manual therapy has been incorporated into the Korean health care system and is administered in 16.4% of inpatients and 83.6% of outpatients with musculoskeletal disorders in Korean medicine hospitals specializing in spine and joint diseases. The authors note:

“Manual therapy is performed in various forms by chiropractors, osteopaths, and physical therapists across the world, including the United States, Europe, and Australia.”

“The use of spinal manipulation has increased in recent decades in Western countries, as has the popularity of chiropractic therapy among American adults.”

“The UK National Institute for Health and Clinical Excellence guidelines now recommend manual therapy for treating persistent or subacute lower back pain.”

This study was very robust. The authors assessed 2,682,258 manipulation procedures that were performed on 289,953 patients from 14 different facilities. The authors state:

“In this study, 289,953 patients and more than 2.5 million cases of [manipulations] were reviewed, making it a rare, very wide-ranging, and reliable investigation of severe adverse events.”

“Our analysis of 289,953 patients and 2,682,258 cases of [manipulation] indicates that both mild–moderate and severe adverse events are rare after [manipulation].”

“Adverse events of any level of severity were very rare after [manipulation].”

“There were no instances of carotid artery dissection or spinal cord injury.”

In this study, no life-threatening or fatal events were identified. There were no cases of artery dissection or cauda equina syndrome. Eleven rib fractures were identified, and all were on elderly patients with known osteoporosis. All rib fractures healed and all patients recovered without residuals. There were no permanent injuries found in any of the study subjects.

••••

In 2023, a study was published in the journal Scientific Reports, titled (12):

A Retrospective Analysis of the Incidence of Severe Adverse Events Among Recipients of Chiropractic Spinal Manipulative Therapy

This study examined the incidence and severity of adverse events (AEs) in 54,846 patients who received 960,140 chiropractic spinal manipulations. The data originated from 30 chiropractic clinics using 38 different chiropractors. All patients received spinal manipulative therapy (SMT) administered via manual thrust (i.e., a hands-on impulse applied to the spinal joints). The authors concluded:

“In this study, severe spinal manipulative therapy-related adverse events were reassuringly very rare.”

“There were no adverse events related to stroke or cauda equina syndrome.” 

“There were no cases of stroke, transient ischemic attack, vertebral or carotid artery dissection, cauda equina syndrome, or spinal fracture.”

“No adverse events were identified that were life-threatening or resulted in death.”

“No adverse events were reported to be permanent.”

Likewise, in this study, there were no life-threatening or fatal events. There were no cases of artery dissection, stroke, or cauda equina syndrome.

There were two rib fractures, both occurring in elderly patients with a history of osteoporosis. Both patients recovered without residuals. There were no permanent injuries found in any of the study subjects.

It is noteworthy that in this study the authors specifically commented on the incidence of cauda equina syndrome; there were none.

••••

Earlier this year (2024), an article was published in the journal PLOS (Pubic Library of Science) ONE; titled (13):

Association Between Chiropractic Spinal Manipulation and Cauda Equina Syndrome in Adults with Low Back Pain:
Retrospective Cohort Study of US Academic Health Centers

The authors note that the relationship, if any, between spinal manipulation and cauda equina syndrome, has been poorly explored in the literature. The existing literature on CES from spinal manipulation “is mostly derived from individual case reports.” They specifically state:

“…there was no adequately powered and designed study to examine this potential association.”

Therefore, to clarify any potential relationship, the authors conducted this robust study. They used a cohort of 134,440 low back pain (LBP) patients with a mean age of 51 years:

• Half of the patients (n = 67,220) were treated chiropractically with spinal manipulation.
• Half of the patients (n = 67,220) were treated with physical therapy and received no spinal manipulation.

“The study hypothesis was that there would be no increase in the risk of CES [cauda equina syndrome] in adults with LBP following CSM [chiropractic spinal manipulation] compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period.” The authors do not believe that spinal manipulation is a meaningful risk factor for CES due to its rarity following manipulation when compared to the millions of manipulation treatments administered annually.

The authors remind the reader that the cauda equina is a bundle of nerve roots arising from the spinal cord at the upper lumbar spine. Compression of these nerve roots, typically by a midline/central disc herniation, can cause cauda equina syndrome (CES), which includes combinations of:

• Low back pain and/or lower extremity symptoms
• Bladder/bowel dysfunction
• Reduced saddle area sensation
• Sexual dysfunction

The authors also note:

“CES with neurological deficits is a medical emergency and surgical intervention is recommended within 48 hours to prevent permanent damage.”

The authors note that chiropractors are among the most commonly visited healthcare providers for new episodes of LBP, ranking second only to primary care physicians (25.2% of episodes with primary care versus 24.8% with a chiropractor). Chiropractors are increasingly sought by patients in the US for the treatment of LBP. Approximately half of chiropractic patients have low back pain.

Lumbar disc herniation is a frequent cause of low back pain and it is the most frequent cause of CES. Chiropractors use spinal manipulation more frequently than any other type of clinician.

Findings from this study include:

“The incidence of CES over three months’ follow-up from the index date of inclusion was lower in the [manipulation] cohort compared to the [physical therapy] evaluation cohort.”

The authors made these conclusions:

“Our findings are consistent with the hypothesis that patients who develop CES after [manipulation] may have evolving symptoms of CES prior to treatment and/or an already-existing disc herniation.”

“The present findings show that CES may also arise soon after PT evaluation without manipulation for LBP, suggesting that patients seeking care for LBP are already at a heightened risk of CES and [manipulation] may not be directly causative.”

“The present study involving over 130,000 propensity-matched patients found that [manipulation] is not a risk factor for CES.”

“Chiropractors may encounter patients who have a heightened risk of developing CES, as these clinicians treat those with LBP and disc disorders.”

“Findings suggest that [manipulation] is not a risk factor for CES.”

“Patients with LBP may have an elevated risk of CES independent of  treatment.”

“The present study results support the hypothesis that there is no increased risk of CES following [manipulation] in adults compared to matched controls receiving PT evaluation without spinal manipulation.”

••••

Summary

The work presented here indicates that chiropractic spinal manipulation is not causative of cauda equina syndrome. The largest assessments of adverse events following spinal manipulation (344,799 patients receiving 3,642,398 manipulations) found no incidence of cauda equina syndrome. In the management of patients with low back pain, the incidence of cauda equina syndrome is lower in those being managed by chiropractors who manipulate as compared to those being managed by physical therapy without spinal manipulation.

Although spinal manipulation is not causing cauda equina syndrome, several points should be emphasized:

• Chiropractors treat low back pain
• Low back disc herniations cause low back pain
• Low back disc herniations cause cauda equina syndrome
• Chiropractors are portal of entry providers

With every low back pain patient, a suspicion of a developing cauda equina syndrome should be ever present. Chiropractors should question patients regularly about bowel, bladder, sexual, and saddle problems. Chiropractors should educate their patients as to the signs and symptoms of a developing cauda equina syndrome. Failure to timely identify patients with a developing cauda equina syndrome and to make an appropriate referral for advanced imaging and/or a surgical consultation can have serious, and potentially life-long, adverse consequences.

This last study (13) makes these ending comments:

“Clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.”

“This reinforces that clinicians should be vigilant to detect and urgently refer patients with CES symptoms for surgical attention.”

 

REFERENCES:

1. Newman-Toker DE, Nassery N, Schaffer AC, Yu-Moe CW, Clemens GD, Wang Z, Zhu Y, Tehrani SAS, Fanai M, Hassoon A, Siegal D; Burden of Serious Harms from Diagnostic Error in the USA; BMJ [British Medical Journal] Quality & Safety; January 2024; Vol. 33; No. 2; pp. 109-120.
2. cce-usa.org; accessed August 31, 2024.
3. Leape L; Error in Medicine; Journal of the American Medical Association; December 21, 1994; Vol. 272; No. 23; pp. 1851-1857.
4. Lazarou, BH Pomeranz BH, PN Corey PN: Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-analysis of Prospective Studies; Journal American Medical Association; April 15, 1998; Vol. 279; No. 15; pp. 1200-1205.
5. Berwick D, Lucian L; Reducing Errors in Medicine; It’s Time to Take this More Seriously; British Medical Journal (BMJ); July 17, 1999; Vol. 318; pp. 136-137.
6. Rosenblatt RA; “HMO Chief: Patients are at risk: Blunders take 400,000 lives every year, Kaiser head says;” LOS ANGELES TIMES, Oakland Tribune; July 15, 1999.
7. Starfield B; Is US Health Really the Best in the World?; Journal of the American Medical Association; July 26, 2000; Vol. 284; No. 4; pp. 483-485.
8. Kilo KM, Larson EB; Exploring the Harmful Effects of Health Care; Journal of the American Medical Association; July 1, 2009; Vol. 302; No. 1; pp. 89-91.
9. Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A, James BC; ‘Global Trigger Tool’ Shows That Adverse Events in Hospitals May Be Ten Times Greater Than Previously Measured; Health Affairs; April 2011; Vol. 30; No. 4; pp. 581-589.
10. Makary MA; Medical Error: The Third Leading Cause of Death in the United States; British Medical Journal (BMJ); May 3, 2016; Vol. 353; Article i2139.
11. Kim S, Kim G, Kim H, Park J, Lee J, and nine more; Safety of Chuna Manipulation Therapy in 289,953 Patients with Musculoskeletal Disorders: A Retrospective Study; Healthcare; February 2, 2022; Vol. 10; No. 2; Article 294.
12. Chu E, Trager RJ, Lee L, Niazi IK; A Retrospective Analysis of the Incidence of Severe Adverse Events Among Recipients of Chiropractic Spinal Manipulative Therapy; Scientific Reports; January 23, 2023; Vol. 13; No. 1; Article 1254.
13. Trager RJ, Baumann AN, Perez JA, Dusek JA, Perfecto RT, Goertz CM; Association Between Chiropractic Spinal Manipulation and Cauda Equina Syndrome in Adults with Low Back Pain: Retrospective Cohort Study of US Academic Health Centers; PLOS (Pubic Library of Science) ONE; March 11, 2024; Vol. 19; No. 3; Article

Chiropractic care and spinal manipulation for low back pain has a long and rich history. The purpose of this publication is to look back at some of the highlights and to add new evidence (2024).

In 1958, a study was published in the Canadian Medical Association Journal, titled (1):

Manipulation in Back Pain

The authors “describe a method of manipulation that for 20 years has brought gratifying results with none of the disasters that so many predict.” In this article, the authors made these statements:

“The standard medical treatment for lumbago and other acute backache is bed rest and sedation, counter-irritation and heat, possibly supplemented by massage and injections of procaine.” Yet, “patients soon find that in the majority of instances they can get rapid relief [from spinal manipulation] without the loss of time.”

“The reason we took up manipulation was an interest in backache, with the early discovery that many patients who failed to respond to routine medical treatment went to a manipulator and received immediate relief.” 

“Manipulation as an art is as old as medicine.”

“That manipulation will relieve back pain in many instances, few will argue. Those who manipulate swear by it. Those who don’t, condemn it. Those who don’t manipulate warn of all the catastrophes that can result from the practice.”

“That manipulation can bring comfort to mankind there can be no doubt.”

“Since the majority of backaches will respond to manipulation, it is probable that the origin of the pain lies in relationship to one of the joints, either the zygapophysial joint or the intervertebral disc.”

“Pain so severe as to keep the patient in bed is no contraindication to manipulation. We see many patients who are afraid to make an effort to get out of bed but who, following manipulation, get up and move with ease.”

“Much is said about the hazards of manipulation. We do not know what they are.”

“It is our belief, based on long experience, that manipulation is no more beset by hazards than many other recognized procedures in therapy, while its results are often more dramatic and sure.”

“In our hands this approach to backache has proved most gratifying and, more important, has brought comfort to a large group of patients who have not been able to achieve it before.”

The reader is reminded that this article was published 66 years ago.

••••

 In 1969, a study was published in the Australian Journal of Physiotherapy, titled (2):

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

This was the first study to compare the results of effectiveness for low back and leg pain treated with mobilization/manipulation compared to those treated with heat, massage, and exercise. The study used 184 subjects, half were treated with heat/massage/exercise and half were treated with mobilization/manipulation. Patient outcomes are summarized in this chart:

Group	Treatment	Acceptable Outcome
Central Low Back Pain Only (n=46)	heat/massage/exercise (n=23)	83%
	spinal manipulation (n=23)	83%
Pain Radiation to Buttock (n=46)	heat/massage/exercise (n=23)	70%
	spinal manipulation (n=23)	78%
Pain Radiation Down Thigh to Knee (n=46)	heat/massage/exercise (n=23)	65%
	spinal manipulation (n=23)	96%
Pain Radiation Down Leg to Foot (n=46)	heat/massage/exercise (n=23)	52%
	spinal manipulation (n=23)	79%

The authors made these statements:

“The difference in the number of patients with ‘acceptable’ results by each method of treatment, in the third [pain radiation down thigh to knee] and fourth [pain radiation down leg to foot] groups are statistically significant.”

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

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

This study (2) was reviewed in the 1990 reference text, White and Panjabi’s Clinical Biomechanics of the Spine. Drs. White and Panjabi made the following statements (3):

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

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

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

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

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

••••

In 1985, a study published in the journal Canadian Family Physician, titled (4):

Spinal Manipulation in the Treatment of Low Back Pain

The authors note that spinal manipulation is one of the oldest forms of therapy for back pain, yet it has mostly been practiced outside of the medical profession. They also note that “there has been an escalation of clinical and basic science research on manipulative therapy, which has shown that there is a scientific basis for the treatment of back pain by manipulation.” The authors made these statements:

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

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

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

These authors presented the results of a prospective observational study of spinal manipulation in 283 patients with chronic low back and leg pain. All 283 patients in this study had failed prior conservative and/or operative treatment, and they were all totally disabled (“constant severe pain; disability unaffected by treatment.”) These patients were given a “two or three week regimen of daily spinal manipulations by an experienced chiropractor.”

These authors considered a good result from manipulation to be:

• “Symptom-free with no restrictions for work or other activities,” or “mild intermittent pain with no restrictions for work or other activities.”
• 81% of the patients with referred pain syndromes subsequent to joint dysfunctions achieved the “good” result.
• 48% of the patients with nerve compression syndromes, primarily subsequent to disc lesions and/or central canal spinal stenosis, achieved the “good” result.

The authors made these statements:

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

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

“In our experience, anything less than two weeks of daily manipulation is inadequate for chronic low back pain patients.”

The authors explain the benefits of spinal manipulation for chronic low back pain by referencing the 1965 Gate Theory of Pain by noted pain experts Ronald Melzack and Patrick Wall. They stated that the Gate Theory of Pain has “withstood rigorous scientific scrutiny.” Simply stated, the improved motion of the joints following manipulation creates a neurological sequence of events that close the Pain Gate. This means that the pain signal no longer gets into the brain.

The authors conclude:

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

“The physician who makes use of this [manipulation] resource will provide relief for many back pain patients.”

••••

In 1990, a study was published in the British Medical Journal, titled (5):

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

The objective of this study was to compare chiropractic and hospital outpatient treatment for managing low back pain of mechanical origin. It is a randomized controlled trial that involved 741 patients. Each patient was re-evaluated at weekly intervals for six weeks, at six months, and at one and two years after entry. The authors stated:

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

“For patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management.”

“The results were also analyzed according to length of the current episode of pain. Those treated by chiropractors improved more than those treated in hospital.”

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

“The effects of chiropractic seem to be long term, as there was no consistent evidence of a return to pretreatment Oswestry scores during the two years of follow up, whereas those treated in hospital may have begun to deteriorate after six months or a year.”

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

“The results from the secondary outcome measures suggest that the advantage of chiropractic starts soon after treatment begins.”

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

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

The authors concluded that if all back pain patients were referred for chiropractic instead of hospital treatment, there would be significant annual treatment cost reductions, a significant reduction in sickness days during two years, and a significant savings in social security payments.

This significant article generated an editorial comment in a different medical journal, The Lancet, titled (6):

Chiropractors and Low Back Pain

The editors of The Lancet note:

“[The article] showed a strong and clear advantage for patients with chiropractic.”

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

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

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

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

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

In this study (5), the follow-up period was up to 2 years. In 1995, this same group published a 3-year follow-up on this same group of subjects. It was also published the British Medical Journal, and titled (7):

Randomised Comparison of Chiropractic and  Hospital Outpatient Management for Low Back Pain:
Results from Extended Follow Up

In 1990, the authors “reported greater improvement in patients with low back pain treated by chiropractic compared with those receiving hospital outpatient management.” The authors further stated:

“The beneficial effect of chiropractic on pain was particularly clear.”

“At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long-term satisfaction than those treated by hospitals.”

“The substantial benefit of chiropractic on intensity of pain is evident early on and then persists.”

“The results of our trial show that chiropractic has a valuable part to play in the management of low back pain.”

This extended follow up study also showed significant improvement, attributable to chiropractic, that included:

• The ability to sit for more than a short time
• Sleeping ability
• Personal care
• Lifting
• Walking
• Standing
• Sex life
• Social life
• Travelling

••••

In 2003, a study was published in the journal Spine, titled (8):

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

The objective of this study was to compare pain medications, needle acupuncture, and chiropractic spinal manipulation for managing chronic spinal pain. It was a randomized controlled clinical trial. Patients were assessed before treatment, and again at 2, 5, and 9 weeks after the beginning of treatment.

The authors discuss that adverse reactions to nonsteroidal anti-inflammatory drugs (NSAIDs) are well documented, noting:

“Gastrointestinal toxicity induced by NSAIDs is one of the most common serious adverse drug events in the industrialized world.”

“[There is] insufficient evidence for the use of NSAIDs to manage chronic low back pain, although they may be somewhat effective for short-term symptomatic relief.”

In this study, chiropractic manipulation achieved the best overall results. The authors stated:

“High-velocity, low-amplitude thrust spinal manipulation to a joint was performed by a chiropractor at the spinal level of involvement to mobilize the spinal joints.”

“The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%).”

“The results of this efficacy study suggest that spinal manipulation, … may be superior to needle acupuncture or medication for the successful treatment of patients with chronic spinal pain syndrome, except for those with neck pain.”

“In summary, the significance of the study is that for chronic spinal pain syndromes, it appears that spinal manipulation provided the best overall short-term results, despite the fact that the spinal manipulation group had experienced the longest pretreatment duration of pain.”

In 2005, these same authors (8), published a 12-month follow-up status of these patients in the Journal of Manipulative and Physiological Therapeutics, titled (9):

Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes

In this 1-year extended follow up, the authors assess the long-term benefits of medication, needle acupuncture, and spinal manipulation in patients with chronic spinal pain syndromes. The authors stated:

“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.”

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

“No such benefit could be observed for medication.”

“Spinal manipulation appeared to provide the highest satisfaction.”

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

••••

In 2017, a study was published in the Journal of the American Medical Association, 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 article was to systematically review studies of the effectiveness and harms of spinal manipulative therapy for acute low back pain. The authors stated:

“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.”

“No serious harms were reported in any of these studies.”

This article (10) generated the following editorial, also published in the Journal of the American Medical Association, titled (11):

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

The author notes that there are approximately 200 treatment options available to treat low back pain. He stated:

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

“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.”

••••

In 2024, a study was published in the Journal of Pain, titled (12):

Reduction of Chronic Primary Low Back Pain by Spinal Manipulative Therapy is Accompanied by Decreases in Segmental Mechanical Hyperalgesia and Pain Catastrophizing: A Randomized Placebo-controlled Dual-blind Mixed Experimental Trial

The objective of this study was to investigate the efficacy of spinal manipulative therapy to improve chronic low back pain. It involved 49 individuals with chronic low back pain and 49 controls (placebo group).

“In each SMT session, the patient received a high-velocity low-amplitude spinal manipulation targeting the most painful vertebral segment, bilaterally.” These manipulations were performed side-posture, with a force sufficient to generate joint cavitation (associated with an audible release). If the manipulation did not cause joint cavitation, the procedure was repeated once. The authors stated:

“Most clinical practice guidelines recommend spinal manipulative therapy for the management of chronic low back pain.”

“The present study shows that spinal manipulative therapy produces greater pain relief compared with a control intervention that was undistinguishable from spinal manipulative therapy.”

“The present results indicate that spinal manipulative therapy produced a clinically significant reduction of chronic low back pain.”

“The present study indicates that spinal manipulative therapy produces greater reductions in clinical pain intensity, pain catastrophizing, and segmental mechanical hyperalgesia compared with a control intervention.”

Summary Comments

Decades of data, published in the finest medical journals, support and continue to support, the use of spinal manipulation for the treatment of back pain. All patients, healthcare providers, clinical practice guidelines, and healthcare reimbursement should be aware of and make use of this data.

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; Australian Journal of Physiotherapy; September 1969; Vol. 15; No. 3; pp. 104-110.
3. White AA, Panjabi MM; Clinical Biomechanics of the Spine; Second edition; JB Lippincott Company; 1990.
4. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
5. 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.
6. _____; Chiropractors and Low Back Pain; Lancet; July 28, 1990; Vol. 336; p. 220.
7. Meade TW, Dyer S, Browne W, Frank OA; Randomised Comparison of Chiropractic and Hospital Outpatient Management for Low Back Pain: Results from Extended Follow Up; British Medical Journal; August 5, 1995; Vol. 311; No. 11; pp. 349-353.
8. Giles LGF, Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine; July 15, 2003; Vol. 28; No. 14; pp. 1490-1502.
9. 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; Vol. 28; No. 1; pp. 3-11.
10. Paige NM, Miake-Lye IM, Suttorp Booth MS, Beroes JM, Mardian AS, Dougherty P, Branson R, Tang B, PT, DPT; Morton SC, PhD; 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 R; 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. Gevers-Montoro C, Romero-Santiago B, Medina-García I, Larranaga-Arzamendi B, Álvarez-Gálovich L, Ortega-De Mues A, Piché M; Reduction of Chronic Primary Low Back Pain by Spinal Manipulative Therapy is Accompanied by Decreases in Segmental Mechanical Hyperalgesia and Pain Catastrophizing: A Randomized Placebo-controlled Dual-blind Mixed Experimental Trial; The Journal of Pain; February 16, 2024 [epub].

The primary reason (93%) patients go to chiropractors is for the management of spinal pain (1). Specifically, 63% go to chiropractors for low back pain, and 30% due so for neck pain. The effectiveness of chiropractic care for spinal pain is well-documented. Chiropractic care (spinal manipulation) is routinely included in spine pain clinical practice guidelines (2, 3, 4, 5, 6, 7).

The focus of this presentation is to review published studies that assess the cost effectiveness of chiropractic care for musculoskeletal pain syndromes, primarily for back and neck pain complaints.

••••

In 2004, a 4-year study compared health care expenditures of 700,000 health plan members who had a chiropractic benefit with 1 million members of the same plan without the same benefit. The study was published in the journal Archives of Internal Medicine, titled (8):

Comparative Analysis of Individuals with and Without Chiropractic: Characteristics, Utilization, and Costs

The authors concluded that systematic access to managed chiropractic care lowers overall health care costs and results in improved clinical outcomes.

••••

Also, in 2004, a study was published in the Journal of Occupational Environmental Medicine, titled (9):

Chiropractic Care:
Is it Substitution Care or Add-on Care in Corporate Medical Plans?

The authors found that chiropractic care was primarily used as a substitution for other types of medical care that is often less effective and costlier. The authors concluded that chiropractic care “lowers cost when compared with treatment from traditional medical providers.”

••••

In 2009, researchers from Mercer Health and Benefits and Harvard Medical School published a paper titled (10):

Do Chiropractic Physician Services for Treatment of Low-back and Neck Pain Improve the Value of Health Benefit Plans?
An Evidence-based Assessment of Incremental Impact on Population Health and Total Health Care Spending

The authors noted:

• The annual cost for treatment of neck pain by chiropractors was lower than treatment from medical physicians.
• “When considering effectiveness and cost together, chiropractic  physician care for low back pain and neck pain is highly cost-effective and represents a good value in comparison to medical physician care.”
• “Our findings in combination with existing U.S. studies published in peer-reviewed scientific journals suggest that chiropractic-delivered care for the treatment of low back and neck pain is likely to achieve equal or better health outcomes at a cost that compares very favorably to most therapies that are routinely covered in US health benefit plans.”
• “Both value and clinical outcomes show marked improvement with the addition of chiropractic coverage for the treatment of low back and neck pain in US employer-sponsored health benefit plans.”

••••

In 2010, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (11):

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

The authors examined a fully BlueCross/BlueShield insured population of 85,000 subscribers over a 2-year period. Their findings included:

• “Patients who experience low back pain and seek treatment first from a chiropractor rather than an MD/DO save 40% on average of health care-related costs.”
• For BlueCross/BlueShield of Tennessee, chiropractic-initiated episodes of care could lead to an annual cost savings of approximately $2.3 million.
• “Insurance companies may be inadvertently paying more for care with restricted access to chiropractic-initiated care than if such restrictions were removed.”

••••

Also, in 2010, a study was published in the Spine Journal, titled (12):

The Chiropractic Hospital-Based Interventions Research Outcomes (CHIRO) Study:
A Randomized Controlled Trial on the Effectiveness of  Clinical Practice Guidelines in the Medical and  Chiropractic Management of Patients with Acute Mechanical Low Back Pain

The authors noted that chiropractor-delivered spinal manipulations were very effective for low back pain compared to usual care administered by primary care medical doctors.

••••

In 2013, a study was published in the journal Spine, titled (13):

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

The authors showed that spine surgeries can be avoided through chiropractic care. Specifically, the odds of surgery for those who first saw a chiropractor were only 1.4%, while the odds for those who first saw a surgeon were 42.7%.

••••

In 2014, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (14):

Cost-effectiveness of Manual Therapy for the Management of Musculoskeletal Conditions:
A Systematic Review and Narrative Synthesis of Evidence from Randomized Controlled Trials

The authors found:

• Chiropractic-delivered manipulation is less costly than physiotherapy or general practitioner care.
• “Manual therapy techniques are more cost-effective for low back and shoulder pain and disability than care delivered by general practitioners (GPs) alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management.”
• Chiropractic-delivered manipulations are less costly and more effective for neck pain than the alternatives.
• “Evidence showed manual therapy to be economically advantageous compared with other treatments of musculoskeletal conditions.”
• “Chiropractic-delivered therapy is equally effective and more cost-efficient than usual medical care.”

••••

In 2015, a study was published in the journal Spine, titled (15):

Comparison of Spinal Manipulation Methods and Usual Medical Care for Acute and Sub-acute Low Back Pain:
A Randomized Clinical Trial

The authors found:

• Of patients receiving chiropractic manipulation, 94% had a 30% reduction in low back pain after 4 weeks, while only 56% of medical care recipients had the same reduction.
• “This suggests a 38% increase in effectiveness by seeing a DC first.”

••••

In 2019, a study was published in the Journal of Chiropractic Humanities, titled (16):

Cost-Efficiency and Effectiveness of Including Doctors of Chiropractic to Offer Treatment Under Medicaid:
A Critical Appraisal of Missouri Inclusion of Chiropractic Under Missouri Medicaid

This article is an in-depth appraisal of the cost effectiveness for the inclusion of chiropractic services under Missouri Medicaid. The article includes extensive mathematical analysis determining the value of chiropractic healthcare. This article proposes that chiropractors deliver care that is more effective and less costly than the current model.

These authors suggest that when the Missouri Health Division initially assessed the value of Chiropractic, for the Missouri Medicaid program, for the management of neck and low back pain, that their scoring approach was (“unintentionally”) flawed, and as such they undervalued the fiscal benefits of chiropractic. Hence, these authors re-evaluated the value of chiropractic for the Missouri Medicaid program using improved assumptions.

These authors assessed 3 cost saving values attributed to chiropractic care:

• Cost savings from chiropractic care v. traditional MD/DO care
• Cost savings from reductions in spinal surgery
• Cost savings from reduced use and abuse of opioid prescription drugs

The distribution of providers for spine care in the United States shows that chiropractic care is second, accounting for more than a quarter of all cases:

• 61% Medical Doctor and/or Doctor of Osteopathy (MD/DO)
• 28% Doctor of Chiropractic (DC)
• 11% from a combination of providers

The authors make these points:

• “Spine pain is a pervasive health care problem in the United States.”
• “There is an 80% chance that people will have back pain at some point in their lives.”
• “In the U.S., neck pain is one of the top musculoskeletal disorders in the adult population.”
• The fourth most pervasive reason for disability globally is neck pain.
• “Between 1990 and 2010, the U.S. had a 29% increase in neck pain.”
• “More U.S. adults have chronic pain (headache, neck or back pain, arthritis, or joint pain) than heart disease, diabetes, and cancer combined.”
• “Chiropractic-delivered services for back and neck pain are significantly more cost-effective when compared with all alternative approaches.”
• “The benefits of care provided by doctors of chiropractic (DCs) have been demonstrated by research throughout the U.S. health care system.”
• “Although there are potentially numerous beneficial clinical outcomes from DC treatment, perhaps the greatest clinical outcome is the reduction of neck and low back pain.”

The authors note that seeing a chiropractor does not increase overall healthcare spending. They report:

• Overall medical spending is not increased from seeking care from a chiropractor.
• “Hospitalization expenditures were significantly lower for those who used complementary and alternative providers, including chiropractic.”
• Chiropractor-delivered spinal manipulations are very effective for low back pain compared to usual care administered by primary care MDs.

The authors also understand that an important but often under-appreciated benefit of chiropractic care is its potential to reduce the costly and dangerous incidence of spinal surgery as well as reducing the use of opioid drugs. The authors make these points:

• “Research shows that chiropractors are the safest and most effective alternative to surgery for most cases of back pain.”
• “60% of patients with sciatica benefited from spinal manipulation after attempting medical management and failing to experience any improvement.”
• Chiropractic treatment “leads to 60% reduction in spinal surgery.”
• “In light of the research showing that chiropractic-managed care can reduce the incidence of spinal surgery, it is reasonable to suppose that a number of surgeries could be avoided through routine chiropractic management.”
• “One fact is sure, patients in the Missouri Medicaid system would benefit from the avoidance of spinal surgeries, and this would lead to significant cost savings for the state.”
• “Chiropractors treat low back and neck pain without resorting to the prescription of opioids or any other type of drugs.”

A summary of the important findings from this study includes:

• The Missouri Health Division had used increasingly flawed assumptions and methodologies over the past years in their cost estimates pertaining to chiropractic care, resulting in flawed conclusions pertaining to chiropractic care.
• Current research on the cost-effectiveness of chiropractic-delivered care compared to usual medical care reveals: “People with insurance coverage that includes chiropractic had lower annual health care costs”; “Those who seek chiropractic-guided treatment first saved an average of 40% on annual health care costs”; “Seeking treatment from a chiropractor did not add to overall medical spending”; “Chiropractic-directed treatment led to a 60% decrease in spinal surgeries”; “Chiropractic-directed care was 38% less costly than usual medical care”; “Chiropractic-delivered care lowered costs and increased positiveoutcomes.”
• “Too often, people who seek relief from lower back pain through usual medical care end up taking painkillers, which are addictive and lead to negative outcomes.”
• “Patients who visit DCs not only find relief from neck and lower back pain at lower annual cost, but also they report their outcomes to be more effective.”
• “Chiropractic care leads to cost savings from reduced use and abuse of opioid prescription drugs.”
• “There are now a dozen states that have embraced alternative therapies such as DC care to combat the cost of the opioid abuse epidemic.”
• “This study supports the proposition that treatment by DCs for neck and lower back pain may reduce the use and abuse of opioid prescription drugs.”
• “Chiropractic treatment and care leads to a reduction in cost of spinal surgery.”

••••

In 2021, a study was published in the Journal Spine, titled (17):

Longitudinal Care Patterns and Utilization Among Patients with New-Onset Neck Pain by Initial Provider Specialty

 The authors were from the University of California, Davis; Yale University School of Medicine; and Harvard Medical School. This study was a retrospective cohort design involving 777,326 patients, aged 18 to 89 years. Its objective was to compare utilization patterns for patients with new-onset neck pain by initial provider specialty. All patients had new-onset neck pain.

This study was the first evaluation of a national sample of the care patterns of patients with acute neck pain with classifications by initial provider specialty. Provider specialties included:

• Chiropractor
• Primary care, including family practice and internal medicine
• Emergency medicine
• Orthopedics
• Physical therapy/occupational therapy (PT/OT)
• Neurology
• Rehabilitation medicine

The authors noted that “neck pain is the fourth most common cause of disability worldwide, resulting in substantial activity limitation, work time lost, and associated costs.”

In this analysis, chiropractic care was the most often healthcare provider seen for patients with new-onset neck pain. The specific breakdown was as follows:

Chiropractor	45%
Primary Care	33%
Emergency Medicine	8%
Orthopedic Surgeon	5%
Physical/occupational Therapist	3%
Neurologist	3%
Rehabilitation Medicine	3%

The authors state:

• “Within [this] large national cohort, chiropractors were the initial provider for a plurality of patients with new-onset neck pain.”
• “The most common initial provider specialty was chiropractor (45.2%), followed by primary care (33.4%).”
• In patients initially seen by orthopedists: 6.8% received therapeutic injections; 3.4% received major surgery
• In patients initially seen by chiropractors: 0.4% received therapeutic injections; 0.1% received major surgery

This indicates that patients who initially saw a chiropractor for their neck pain were 40% less likely to have injections compared to patients who initially saw an orthopedic surgeon. Patients who initially saw a chiropractor for their neck pain were 97% less likely to have major surgery compared to patients who initially saw an orthopedic surgeon.

Also, these authors note that patients seeing chiropractors were significantly less likely to use expensive advanced imaging, particularly CT and MRI. The authors state:

• Patients initially seen by chiropractors “received fewer and lower-intensity imaging studies, perhaps because these providers prioritize physical diagnosis and immediate therapeutic intervention.”

The authors concluded:

• “Within [this] large, national cohort of patients with new-onset neck pain, we found that chiropractors were the initial provider for a plurality of patients and that patients with chiropractor or PT/OT initial providers received fewer and less costly imaging services and were less likely to receive invasive therapeutic interventions, such as injection or major surgery, during follow-up.”
• “Starting with a chiropractor was associated with lower rates of invasive therapeutic interventions and surgery, our study suggests initial care for new-onset neck pain by chiropractors is likely associated with lower longer-term care intensity and costs.”
• “Our findings raise the question whether more frequent referrals from physicians to chiropractors or PT/OTs might enhance the efficiency of care for patients with new-onset neck pain.”
• “Health systems may also seek means of engendering more frequent referrals from primary care or specialist physicians to chiropractors for patients with new-onset neck pain.”

••••

In 2024, a study was published in the journal Chiropractic & Manual Therapies, titled (18):

Cost of Chiropractic Versus Medical Management of Adults with Spine‑related Musculoskeletal Pain:
A Systematic Review

 The purpose of this study was to update, summarize, and evaluate the evidence for the cost of chiropractic care compared to conventional medical care for management of spine-related musculoskeletal pain. The literature search used 44 studies (26 cohort studies, 17 cost studies, and 1 randomized controlled trial).

The authors note that “spine-related musculoskeletal pain is the leading cause of disability worldwide and one of the most common reasons for missed work.” In the U.S., chiropractic care is one of the most commonly utilized approaches to treatment of spine-related musculoskeletal pain.

In this review, no studies found that chiropractic care had higher overall costs. No studies found higher long-term healthcare costs in those using chiropractic care. Specifically, these authors found:

• Fifteen studies found that diagnostic imaging, particularly advanced imaging like MRI, was used less with DC care.
• Eleven studies found that fewer opioid prescriptions were dispensed or filled with DC care.
• Eight studies found fewer surgeries with DC care.
• Seven studies found fewer hospitalizations with DC care.
• Six studies analyzed cost factors related to having a DC as the 1^st care provider, and generally, this was associated with lower downstream costs.
• Five studies found decreased use of injection procedures with DC care.
• Five studies found fewer referrals for specialist visits with DC care.
• Two studies found that fewer ED visits were associated with DC care.

These authors state:

“This study adds further confidence in the emerging body of evidence on provider-related cost differentials and provides a compelling case for the influence of conservative care providers as the first provider managing for spine-related musculoskeletal pain.”

“Diagnostic imaging, opioid utilization, surgery, hospitalizations, injection procedures, specialist visits, and emergency department visits were all reduced where chiropractors were involved early in the case.”

“When considering this evidence, it may be in society’s best interest for U.S. healthcare organizations and governmental agencies to consider modifying benefit designs to reduce barriers to access chiropractic providers.”

 “Eliminating these barriers [preauthorization requirements, medical doctor gatekeepers, arbitrary visit limits, co-pays, and deductibles] would allow  easier access to chiropractic services, which based on currently available  evidence consistently demonstrates reduced downstream services and  associated costs.”

 “Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management.”

“The recurrent theme of the data seems to support the utilization of chiropractors as the initial provider for an episode of spine-related musculoskeletal pain.”

“Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals, and injection procedures.”

••••

Summary

For decades, the best evidence has found that chiropractic care is both effective and safe for the management of spinal pain syndromes. The evidence presented in this publication also shows that chiropractic care is exceptionally cost-effective as well. This adds to the position that chiropractic care should be the “go-to” provider for spine pain syndromes.

REFERENCES

1. Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
2. Chou R; Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK; Diagnosis and Treatment of Low Back Pain; Annals of Internal Medicine; Vol. 147; No. 7; October 2007; pp. 478-491.
3. Chou R, Huffman LH, MS; Non-pharmacologic Therapies for Acute and Chronic Low Back Pain; Annals of Internal Medicine; October 2007; Vol. 147; No. 7; pp. 492-504.
4. 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.
5. Intentionally left blank.
6. 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.
7. 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.
8. Legorreta A, Metz D, Nelson S, Ray H, Chernicoff O, DiNubile N; Comparative analysis of individuals with and without chiropractic: characteristics, utilization, and costs; Archives of Internal Medicine; October 11, 2004; Vol. 164; No. 18; pp. 1985-1992.
9. Metz R, Nelson C, LaBrot T, Pelletier K; Chiropractic care: is it substitution care or add-on care in corporate medical plans? Journal of Occupational Environmental Medicine; August 2004; Vol. 46; No. 8; pp. 847–855.
10. Choudhry N, Milstein A; Do chiropractic physician services for treatment of low-back and neck pain improve the value of health benefit plans? An evidence-based assessment of incremental impact on population health and total health care spending; Mercer Health and Benefits; 2009.
11. Liliedahl R, Finch M, Axene D, 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; Nov-Dec 2010; Vol. 33; No. 9; pp. 640–643.
12. Bishop P, Quon J, Fisher C, Dvorak M; The chiropractic hospital-based interventions research outcomes (CHIRO) study: A randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain; Spine Journal; December 2010; Vol. 10; No. 12; pp. 1055–1064.
13. Keeney B, Fulton-Kehoe D, Turner J, Wickizer T, Chan K, Franklin G; Early predictors of lumbar surgery after occupational back injury: Results from a prospective study of workers in Washington State; Spine; May 15, 2013; Vol. 38; No. 11; pp. 953–964.
14. Tsertsvadze A, Clar C, Court R, Clarke A, Mistry H, Sutcliffe P; Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: A systematic review and narrative synthesis of evidence from randomized controlled trials; Journal of Manipulative and Physiological Therapeutics; Jul-Aug 2014; Vol. 37; No. 6; pp. 343–362.
15. Schneider M, Hass M, Glick R, Stevans J, Landsittel D; Comparison of spinal manipulation methods and usual medical care for acute and sub-acute low back pain: A randomized clinical trial; Spine; February 15, 2015; Vol. 40; No. 4; pp. 209–217.
16. McGowan JR, Suiter L; Cost-Efficiency and Effectiveness of Including Doctors of Chiropractic to Offer Treatment Under Medicaid: A Critical Appraisal of Missouri Inclusion of Chiropractic Under Missouri Medicaid; Journal of Chiropractic Humanities; December 2019; Vol. 10; No. 26; pp. 31-52.
17. Fenton JJ, MD, Fang SY, Ray M, Kennedy J, Padilla K, Amundson R, Elton D, Haldeman S, Lisi AJ, DC, Jason Sico S, MD, MHS, Peter M. Wayne PM, Romano PS; Longitudinal Care Patterns and Utilization Among Patients with New-Onset Neck Pain by Initial Provider Specialty; Spine; October 15, 2023; Vol. 48; No 20; pp. 1409–1418.
18. Farabaugh R, Hawk C, Taylor D, Daniels C, Noll C, Schneider M, McGowan J, Whalen W, Wilcox R, Sarnat R, Suiter L, Whedon J; Cost of Chiropractic Versus Medical Management of Adults with Spine‑related Musculoskeletal Pain: A Systematic Review; Chiropractic & Manual Therapies; March 6, 2024; Vol. 32; No. 1; Article 8.

A recent large and comprehensive review of the chiropractic profession establishes that 93% of patients initially go to chiropractors for spine pain complaints (1). The same review documents that chiropractic care is exceptionally effective and safe for these spine pain patients.

As a consequence of the effectiveness and safety of chiropractic care for spine pain patients, more and more practice guidelines are advocating for the use of spinal manipulation as the initial intervention for the management of spinal pain syndromes (2, 3, 4, 5). Yet, pharmaceuticals continue to have a substantial influence in the management of pain as a consequence of financial influence, marketing, and control of publication and education (6).

The theme of this publication is to review credible studies comparing chiropractic care (specific line-of drive spinal manipulation) to these commonly prescribed drugs:

• Acetaminophen (best known brand name is Tylenol)
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Opioids
• Benzodiazepine
• Gabapentin

Acetaminophen

Acetaminophen (paracetamol) is a pain reliever found in many products. In the United States, the best-known brand name for acetaminophen is Tylenol.

In 2017, the European Journal of Pain published a study titled (7):

Clinical Practice Guidelines for the Noninvasive Management of Low Back Pain

The authors performed an extensive search of 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, and paracetamol [acetaminophen] or NSAIDs as first-line treatments.”

“However, the endorsement of paracetamol [acetaminophen] for acute low back pain is challenged by a recent high-quality randomized controlled trial and systematic review; therefore, guidelines need updating.”

The use of acetaminophen has fallen into disfavor in the treatment of low back pain as a consequence of a number of published studies. As an example, in 2014, the journal Lancet published a study titled (8):

Efficacy of Paracetamol for Acute Low-Back Pain:
A Double-Blind, Randomised Controlled Trial

In this multicenter trial, patients with acute low-back pain were followed for 3 months. The authors note:

Guidelines for acute low-back pain universally recommend paracetamol [acetaminophen] as the first-line analgesic; “No direct evidence supports this universal recommendation.”

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

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

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

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

 In 2015, a study was published in the British Medical Journal titled (9):

Efficacy and Safety of Paracetamol for Spinal Pain and Osteoarthritis:
Systematic Review and Meta-Analysis of Randomised Placebo Controlled Trials

The authors performed a systematic review and meta-analysis of randomized controlled trials found in multiple medical databases. The evidence presented in the article is considered to be of “high quality.” These authors note:

“[Our results confirm the] conclusion that paracetamol does not deliver a clinically important benefit for spinal pain and osteoarthritis.”

“There was ‘high quality’ evidence that paracetamol is ineffective for reducing pain intensity and disability or improving quality of life in the short term in people with low back pain.” 

“Paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis.”

“Our results therefore provide an argument to reconsider the endorsement of paracetamol in clinical practice guidelines for low back pain and hip or knee osteoarthritis.”

Nonsteroidal Anti-inflammatory Drugs

Nonsteroidal Anti-inflammatory Drugs (NSAIDs) are the most commonly used category of drugs for the treatment of pain, including low back pain. They are available over-the-counter and/or by prescription. Common category/brand names for NSAIDs include aspirin, ibuprofen, Motrin, Naprosyn, etc.

In 2003, a study was published in the journal Spine titled (10):

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

The spinal manipulation was performed by chiropractors (2 visits per week). The acupuncture was performed by experienced acupuncturists (2 visits per week). The drugs used were prescription NSAIDs (daily use).

The study involved 115 patients. The primary assessment tools used were the Oswestry Back Pain Disability Index, the Neck Disability Index, the Short-Form-36 Health Survey questionnaire, and a visual analog scale for pain intensity. The clinical trial lasted for 9 weeks.

The proportion of primary care patients with uncomplicated spinal pain who have poor outcomes is higher than generally recognized. Adverse reactions to NSAIDs are well documented, including gastrointestinal toxicity, which is “one of the most common serious adverse drug events in the industrialized world.” There is “insufficient evidence for the use of NSAIDs to manage chronic low back pain.” The authors made these conclusions:

“The highest proportion of asymptomatic patients before or at the week 9 assessment was found in the manipulation group followed by the acupuncture group and the medication group.” 

“Manipulation yielded the best results over all the main outcome measures.”

“Medication apparently did not achieve a marked improvement in chronic spinal pain and caused adverse reactions in 6.1% of the patients. The adverse symptoms disappeared once medication was stopped.”

“In summary, the significance of the study is that for chronic spinal pain syndromes, it appears that spinal manipulation provided the best overall short-term results, despite the fact that the spinal manipulation group had experienced the longest pretreatment duration of pain.”

The authors of this study (10) published a 1 year long-term follow-up in 2005. It appeared in the Journal of Manipulative and Physiological Therapeutics, titled (11).

Long-Term Follow-up of a Randomized Clinical Trial  Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes

The authors concluded:

“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.”

“Medication apparently did not achieve an improvement in chronic spinal pain.”

Opioids

In 2017, the United States’ problem with opiates/opioids was quantified in the journal Annals of Internal Medicine in a study titled (12):

Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults

This survey used 51,200 adult subjects. The authors found:

• 8 million (37.8%) U.S. civilian, non-institutionalized adults used prescription opioids.
• 5 million adults misused opiate drugs (12.5%).

The authors note that the numbers they present underrepresented the opioid problem because they did not include an assessment of groups that are likely to take and to abuse these drugs, including homeless persons who were not living in shelters, active-duty military personnel, and anyone in jail or other institutions.

The first randomized controlled trial to evaluate opioids for chronic pain was published in 2018, long after the magnitude and seriousness of the opioid crisis was recognized by all players. It was published in the Journal of the American Medical Association, titled (13):

Effect of Opioid vs Non-opioid Medications on Pain-Related Function in Patients with Chronic Back Pain or Hip or Knee Osteoarthritis Pain:

This study involved 234 subjects. The authors state:

“Rising rates of opioid overdose deaths have raised questions about prescribing opioids for chronic pain management.”

“Because of the risk for serious harm without sufficient evidence for benefits, current guidelines discourage opioid prescribing for chronic pain.”

“Studies have found that treatment with long-term opioid therapy is associated with poor pain outcomes, greater functional impairment, and lower return to work rates.”

“Treatment with opioids was not superior to treatment with non-opioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”

In 2023, a study published in the journal The Lancet, titled (14):

Opioid Analgesia for Acute Back Pain and Neck Pain (the OPAL Trial):
A Randomised Placebo-controlled Trial

This is the first placebo controlled randomized controlled trial looking at opioids for acute spinal pain. The study involved 151 participants in the opioid group and 159 in the placebo group. The authors found that being prescribed an opioid for acute spinal pain actually increased the patient’s pain at both the 26- and 52-week follow-up assessment. In other words, not only did the opioid not work, it actually worsened the patient’s pain in the long term. The authors made these observations:

“Low back pain and neck pain are very prevalent, with low back pain being the largest contributor to years lived with disability globally, and neck pain being the fourth largest.”

“Opioid analgesics are commonly used for acute low back pain and neck pain, but supporting efficacy data are scarce.”

“The use of opioids for the management of acute low back pain and neck pain is not supported by direct and robust evidence.”

“This study found there was no benefit of an opioid compared with placebo in people receiving guideline care for acute non-specific low back pain or neck pain.”

“Our findings say that not only are opioids not going to benefit individuals with back and neck pain, but they might also cause worse outcomes even after short-term judicious use.”

“Our findings show that even judicious, short-term use of an opioid conferred no benefits in pain reduction and led to a small increase in pain at the medium-term and long-term compared with placebo.”

“There is no evidence that opioids should be prescribed for people with acute non-specific low back pain or neck pain.”

“Opioids should not be recommended for acute non-specific low back pain or neck pain given that we found no significant difference in pain severity compared with placebo.”

These authors explain that clinical practice guidelines for physicians that advocate for the judicious use of opioids for acute spinal pain syndromes are erroneous and that they should be changed. They note that their study shows no benefit, risks of harms, risks of misuse, and increased risk of long-term pain. As such, they support a shift in the focus of practice guideline for spinal pain management from pharmacological to non-pharmacological treatments. These non-pharmacological treatments endorse spinal manipulation.

In 2018, a study was published in The Journal of Alternative and Complementary Medicine, titled (15):

Association Between Utilization of Chiropractic Services  for Treatment of Low-Back Pain and Use of Prescription Opioids

The authors analyzed the health insurance claims of 6,868 low back pain subjects, noting:

“There is little evidence that opioids improve chronic pain, function, or quality of life.”

“Among U.S. adults prescribed opioids, 59% reported having back pain.”

“The adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower for recipients of services provided by doctors of chiropractic compared with non-recipients.”

“Pain management services provided by doctors of chiropractic may allow patients to use lower or less frequent doses of opioids, leading to lower costs and reduced risk of adverse effects.”  

“Pain relief resulting from services delivered by doctors of chiropractic may allow patients to use lower or less frequent doses of opioids, leading to reduced risk of adverse effects.”

Also, in 2018, the journal Pain Medicine published a study titled (16):

Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs [VA] Chiropractic Care

The authors are from Yale School of Medicine, School of Medicine Boston University, and University of Massachusetts Medical School. The VA began providing chiropractic services on-site in 2004 and has expanded implementation each year thereafter. In the VA, chiropractic patients are seen overwhelmingly for low back and/or neck musculoskeletal pain conditions. The authors note:

“Apart from the potential to reduce pain and improve function in patients with musculoskeletal conditions, chiropractic care may have an impact on opioid use in such patients.”

“Chiropractic care is more likely to be a replacement for, rather than an addition to, opioid therapy for chronic musculoskeletal pain conditions in the VA.”

In 2019, a study was published in the journal BMJ Open titled (17): 

Observational Retrospective Study of the Initial Healthcare Provider for New-onset Low Back Pain with Early and Long-term Opioid Use

The authors examined the association of initial conservative therapy provider treatment (chiropractors, acupuncturists, physical therapists) on opioid use in a national sample (216,504) of individuals with a new-onset low back pain. The most frequent initial conservative provider seen was a chiropractor. The authors note:

“For early opioid use, patients initially visiting chiropractors had 90% decreased odds [of early opioid use].”

“Initial visits to chiropractors or physical therapists is associated with substantially decreased early and long-term use of opioids.”

In 2020, a study was published in the journal Pain Medicine titled (18):

Association Between Chiropractic Use and  Opioid Receipt Among Patients with Spinal Pain

The authors are from Yale School of Medicine. This meta-analysis used 62,624 patients from 6 chiropractic studies. The authors note:

“Chiropractors predominantly manage spinal conditions, with back conditions being the most common reason to seek chiropractic care.”

“The main finding of the review was that all included studies demonstrated a negative association between use of chiropractic care and opioid prescription receipt.”

“Chiropractic users had 64% lower odds of receiving an opioid prescription than nonusers.”

In 2020, a study was published in the journal Pain Medicine titled (19):

Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain

The objective of this study was to evaluate the impact of chiropractic utilization upon use of prescription opioids among 101,221 patients with spinal pain. The authors note:

“Among patients with spinal pain disorders, for recipients of chiropractic care, the risk of filling a prescription for an opioid analgesic over a six-year period was reduced by half, as compared with non-recipients.”

“[There is] accumulating evidence for increased utilization of chiropractic services as an upstream strategy for reducing dependence upon prescription opioid medications.”

In 2022, a study was published in the Journal of Chiropractic Medicine, titled (20):

Associations Between Early Chiropractic Care and Physical Therapy on Subsequent Opioid Use Among Persons with Low Back Pain

This study assessed 40,929 patients with low back pain, noting:

“The use of chiropractic care within 30 days of LBP diagnosis was associated with diminished use of opioids in the short term and, in particular, the long term, in which the risk of long-term opioid use was almost cut in half.”

“Chiropractic care was associated with substantial reduction in likelihood of any opioid use and long-term opioid use [by 44%].”

Also, in 2022, a study was published in the journal Chiropractic & Manual Therapies, titled (21):

Association Between Chiropractic Care and Use of Prescription Opioids Among Older Medicare Beneficiaries with Spinal Pain

This retrospective observational study examined 55,949 Medicare beneficiaries diagnosed with spinal pain. The authors noted:

“The adjusted risk of filling an opioid prescription within 365 days of first office visit was 56% lower among [chiropractic] recipients as compared to nonrecipients.”

Among early recipients of chiropractic care, the reduction of filling an opioid prescription was 62% lower as compared to non-recipients.

“Among older Medicare beneficiaries with spinal pain, use of chiropractic care is associated with significantly lower risk of filling an opioid prescription.”

Benzodiazepine

In 2022, a study was published in the journal BMJ Open, titled (22):

Association Between Chiropractic Spinal Manipulative Therapy and Benzodiazepine Prescription in Patients with Radicular Low Back Pain

Benzodiazepines (BZDs) are a class of medication that are increasingly prescribed for patients with low back pain (LBP). They are particularly commonly used in patients with radicular LBP (rLBP).

This was the first study to examine the association between chiropractic spinal manipulative therapy (CSMT) and subsequent benzodiazepine prescription. There were 9,206 patients in each cohort with a mean age of 38 years (range 18-49 years). Outcomes were measured at 3, 6, and 12 months. The authors’ initial hypothesis was that adults receiving chiropractic care for new diagnosis of radicular LBP would have reduced odds of receiving a benzodiazepine drug. The authors made these observations:

• The number of physician visits during which BZDs were prescribed for back pain in the USA more than tripled from 2003 to 2015.
• In a 2018 survey, 27% of low back pain patients reported being recommended BZDs by a medical doctor in the previous 12 months.
• “Adverse effects of BZDs include sedation, addiction and increased risk of suicide.”
• “There is an increased risk of fatal, accidental overdose with concurrent use of BZDs and opioids.”
• BZDs are a risk factor for motor vehicle collisions, falls and associated injuries, which may be explained by BZD-related psychomotor, balance, and cognitive impairment.
• “Although BZDs are increasingly prescribed for LBP, there is no strong evidence supporting their use for this condition.”

Pertaining to chiropractic care, the authors noted:

• “Chiropractors are portal-of-entry providers that treat a variety of musculoskeletal conditions, the most common of which is LBP.”
• Chiropractors use non-drug treatments for patients with rLBP.
• The most common treatment chiropractors employ is spinal manipulative therapy (SMT), which involves high-velocity, low-amplitude thrust, and low-force non-thrust or mobilization.
• “In a 2019 survey, U.S. chiropractors reported managing radiculopathy at least once per week.”
• “SMT may relax hypertonic (abnormally tight) muscles, or release adhesions surrounding the lumbar disc or facet joints, leading to improved range of motion in those with rLBP.”
• “Systematic reviews have found evidence supporting [SMT] treatment for acute, chronic and radicular LBP, while documenting its safety.”

Pertaining to Clinical Practice Guidelines (CPGs), the authors note:

• “Insufficient evidence supporting the efficacy of BZDs for LBP and the risk of serious adverse events has led clinical practice guidelines to discourage their use for this condition.”
• “Recent CPGs from the National Institute for Health and Care Excellence (2020), Veterans Affairs/Department of Defense (2019), Global Spine Care Initiative (2018) and Belgian Health Care Knowledge Centre (2017) recommended against prescribing BZDs for LBP while those of the Am. College of Physicians (2017) concluded there was insufficient evidence for their effectiveness in acute or subacute LBP.”

The authors made these conclusions:

• “This study identified a significant reduction in odds of BZD prescription over 3-month, 6-month and 12-month follow-up windows in adults initiating care for rLBP with CSMT.”
• “These results reinforce the use of CSMT as a first-line non-pharmacological option for adults with rLBP.”
• “These findings suggest that receiving CSMT for newly diagnosed rLBP is associated with reduced odds of receiving a benzodiazepine prescription during follow-up.”

Gabapentin

In 2023, a study was published in the journal BMJ Open, titled (23):

Association Between Chiropractic Spinal Manipulation and Gabapentin Prescription in Adults with Radicular Low Back Pain

This study was the first to examine the association between chiropractic spinal manipulative therapy (CSMT) and the likelihood of gabapentin prescription among patients with radicular low back pain (rLBP). Study participants were adults aged 18–49 who were having their first episode of rLBP diagnosis. Eligible patients were from 77 healthcare organizations:

• There were 1,635 patients in the CSMT cohort.
• There were 1,635 patients in the gabapentin cohort.

Low back and neck pain account for the leading cause of medical expenditures in the U.S. The U.S. has the leading prevalence of low back pain in the world. Radicular low back pain (rLBP) involves a nerve root lesion and has symptoms that radiate into the ipsilateral lower extremity.

• “Gabapentin has been used off-label to treat neuropathic symptoms of LBP, namely rLBP.”
• “Systematic reviews in 2018 and 2022 demonstrated clear evidence of lack of its effectiveness [gabapentin] for rLBP.” (emphasis added)
• There is growing evidence of risks associated with gabapentin use, including abuse, misuse, dependence, and withdrawal. Other deleterious adverse effects of gabapentin include somnolence (excessive sleepiness), dizziness, ataxia, fatigue, and new-onset asthenic (weakness or lack of energy) symptoms.
• “Several clinical practice guidelines do not recommend gabapentin for the treatment of LBP or rLBP, including those of the American Family Physician.”
• “Despite the paucity of evidence, and in contrast to clinical guideline recommendations, gabapentin continues to be commonly prescribed for LBP.”

Pertaining to chiropractic, the authors made these observations:

• “Chiropractors are portal-of-entry providers in the USA who frequently treat spinal disorders.”
• “While US chiropractors are portal-of-entry providers, they do not prescribe medications, including gabapentin.”
• When treating rLBP, chiropractors use “spinal manipulative therapy (CSMT), a hands-on treatment directed to the joints of the spine.”
• CSMT is supported by systematic reviews and recommended by clinical practice guidelines for the treatment of LBP and rLBP.

The authors made these conclusions:

• “After matching, odds of gabapentin prescription over the 1-year follow-up were significantly lower in the CSMT cohort compared with the cohort receiving usual medical care,” by 47%.
• “These real-world findings support our hypothesis that adults initially receiving CSMT for rLBP have reduced odds of receiving a gabapentin prescription over a 1-year follow-up period.”
• “Our findings are consistent with some authors’ recommendations that patients with LBP/rLBP should initiate treatment with non-pharmacological providers such as chiropractors.”

Summary

The studies reviewed here share a central theme: acetaminophen, NSAIDs, opioids, benzodiazepine, and gabapentin do not work well for pain control. Yet, providers and patients often do not understand this. Doctors routinely prescribe these drugs for pain, and patients willingly take them. In addition to not working very well, long-term use is associated with many harmful side effects.

These studies also show that chiropractic care for spine pain syndromes is effective, safe, and is associated with meaningful reductions in the use of these pharmacological products, ultimately avoiding harmful side effects.

REFERENCES

1. Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
2. Chou R, Huffman LH; Non-pharmacologic Therapies for Acute and Chronic Low Back Pain; Annals of Internal Medicine; October 2007; Vol. 147; No. 7, pp. 492-504.
3. Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, DC, Whalen WM, Walters S, Kaeser M, Dehen M, 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.
4. 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; February 2017; Vol. 21; No.; pp. 201-216.
5. 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. 116; Np. 7; pp. 514-530.
6. Abramson J; Sickening: How Big Pharma Broke American Health and How We Can Repair It; Mariner Books; 2022
7. Wong JJ, Cote P, Sutton DA, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer HM, Carroll LJ, Stern PJ, Ameis A, Southerst D, Mior S, Stupar M, Varatharajan T, Taylor-Vaisey A; Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration; European Journal of Pain; February 2017; Vol. 21; No. 2; pp. 201-216.
8. Williams CM, Maher CG, Latimer J, McLachlan AJ, Mark J Hancock MJ, Day RO, Lin CW; Efficacy of paracetamol for acute low-back pain: A double-blind, randomised controlled trial; Lancet; November 1, 2014; Vol. 384; pp. 1586-1596.
9. Machado GC, Maher CG, Ferreira PH, Pinheiro BM, Lin CW, Day RO, McLachlan AJ, Ferreira ML; Efficacy and safety of paracetamol for spinal pain and osteoarthritis: Systematic review and meta-analysis of randomised placebo controlled trials; British Medical Journal; March 31, 2015; Vol. 350; Article h1225.
10. Giles LGF, Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine; July 15, 2003; Vol. 28; No. 14; pp. 1490-1502.
11. Muller R, Giles LGF; Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes; Journal of Manipulative and Physiological Therapeutics; January 2005; Vol. 28; No. 1; pp. 3-11.
12. Han B, Wilson M. Compton WM, Blanco C, Crane E, Lee J, Jones CM; Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health; Annals of Internal Medicine; September 2017; Vol. 167; No. 5; pp. 293-301.
13. Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S; Effect of Opioid vs Non-opioid Medications on Pain-Related Function in Patients with Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial; Journal of the American Medical Association; March 6, 2018; Vol. 319; No. 9; pp. 872-882.
14. Jones CMP, Day RO, Koes BW, Latimer J, Maher CG, McLachlan AJ, Billot L, Shan S, Lin CWC; Opioid Analgesia for Acute Back Pain and Neck Pain (the OPAL Trial): A Randomised Placebo-controlled Trial; Lancet; July 22, 2023; Vol. 402; pp. 304-312.
15. Whedon JM, Toler AWJ, Goehl JM, Kazal LA; Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain and Use of Prescription Opioids; The Journal of Alternative and Complementary Medicine; June 2018; Vol. 24; No. 4; pp. 552-556.
16. Lisi AJ, Corcoran KL, DeRycke EC, Bastian LA, Becker WC and 11 more; Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care; Pain Medicine; September 1, 2018; Vol. 19; Supplemental; pp. S54–S60.
17. Kazis LE, Ameli O, Rothendler J, Garrity B, Cabral H, McDonough C, Carey K, Stein M, Sanghavi D, Elton D, Fritz J, Saper R; Observational Retrospective Study of the Initial Healthcare Provider for New-onset Low Back Pain with Early and Long-term Opioid Use; BMJ Open; September 2019; Vol. 9; No. 9; e028633.
18. Corcoran KL, Bastian LA, Gunderson CG, Steffens C, Brackett A, Lisi AJ; Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis; Pain Medicine; February 1, 2020; Vol. 21; No. 2; pp. e139-e145.
19. Whedon JM, Toler AWJ, Kazal LA, Bezdjian S, Goehl JM, Greenstein J; Impact of Chiropractic Care on Use of Prescription Opioids in Patients with Spinal Pain; Pain Medicine; December 25, 2020; Vol. 21; No. 12; pp. 3567-3573.
20. Acharya M, Chopram D, Smith AM, Fritz JM, Martin BC; Associations Between Early Chiropractic Care and Physical Therapy on Subsequent Opioid Use Among Persons with Low Back Pain in Arkansas; Journal of Chiropractic Medicine; June 2022; Vol. 21; pp. 67-76.
21. Whedon JM, Uptmor S, Toler AJW, Bezdjian S, MacKenzie TA, Kazal LA; Association Between Chiropractic Care and Use of Prescription Opioids Among Older Medicare Beneficiaries with Spinal Pain: A Retrospective Observational Study; Chiropractic & Manual Therapies; January 31, 2022; Vol. 30; No. 1.
22. Trager RJ, Cupler ZA, DeLano KJ, Perez JA, Dusek JA; Association Between Chiropractic Spinal Manipulative Therapy and Benzodiazepine Prescription in Patients with Radicular Low Back Pain: A Retrospective Cohort Study Using Real-world Data from the USA; BMJ Open; June 13, 2022; Vol. 12; No. 6; Article e058769.
23. Trager RJ, Cupler ZA, Srinivasan R, Casselberry RM, Perez JA, Dusek JA; Association Between Chiropractic Spinal Manipulation and Gabapentin Prescription in Adults with Radicular Low Back Pain: Retrospective Cohort Study Using US Data; BMJ Open; July 21, 2023; Vol. 13; No. 7; e073258.

“Manipulation” and “Chiropractic” are not Synonyms

Background

Joint Manipulation

Joint manipulation is the applying of a force to a joint that helps that joint move better. It is classically associated with an audible sound. All people, trained and untrained, are capable of manipulating joints and eliciting an audible sound.

Manipulation is a lay term. It is often used synonymously with the word chiropractic. Yet, importantly, chiropractors technically do not manipulate joints. Chiropractors adjust joints.

Joint Adjustment

Manipulation implies the movement of a joint to the point of creating an audible sound, but the line-of-drive and the control of the amplitude (distance) is not precise. In contrast, the term for manipulation that has a specific line-of-drive direction and control of the amplitude is adjustment. Chiropractors deliver spinal adjustments, not manipulation. The mastery of spinal adjusting takes years of study, training, and practice. After completing college with a biological curriculum, the educational requirements to be a chiropractor take an additional 4 academic years at an accredited chiropractic college. The point is that chiropractors are extensively trained in the science and art of specific line-of-drive manipulation, or what would properly be called the chiropractic adjustment.

There are 18 chiropractic colleges in the United States and many more throughout the world (1). Some of the chiropractic colleges are universities that grant academic degrees in addition to the Doctor of Chiropractic degree (DC). Others only grant Doctor of Chiropractic degrees.

Beginning in the 1970s, chiropractic education became accredited through the United States Department of Education via the Council for Chiropractic Education (1): All 18 of the chiropractic colleges in the United States are accredited by the Council for Chiropractic Education.

In the United States, the licensure of chiropractors is controlled by the individual states, and all 50 U.S. states officially license chiropractors, allowing them to practice with their Doctor of Chiropractic degree (DC). Chiropractors are considered to be primary portal health care providers, which means (in part) that the public may choose chiropractic care without requiring a referral from another health care provider.

As a result of their education and examination procedures, chiropractors are legally allowed to provide a number of services to their patients. These include physical therapy, exercise, tissue work, dietary advice, use of supplements, the taking of and the interpretation of x-rays, etc. The central core of chiropractic clinical practice is the use of mechanical care, and the primary form of mechanical care is specific line-of-drive manipulation (the chiropractic adjustment).

A typical chiropractic visit involves an assessment of posture and joint motion (possibly with the use of x-rays), helping the chiropractor assess the manner in which his/her patient exists and functions mechanically in a gravity environment. Abnormal findings are usually treated mechanically and primarily with the use of the chiropractic adjustment.

Chiropractors are extensively trained to be mechanical providers of care. Ninety-three percent of patients who chose to initially see a chiropractor do so for spinal pain complaints (2). Satisfaction among patients with these complaints is exceptionally high (2).

•••

Joint movement is divided into three categories (3, 4, 5, 6, 7):

• Active Motion
• Passive Motion
• Periarticular Paraphysiological Space Motion

Active Motion

Active motion is the type of motion joints experience when people move any part of their body. It requires active contraction of our muscles. Active motion is the typical motion joints experience when people engage in the activities of normal life (showering, dressing, preparing meals, driving, working, shopping, etc.) and exercise.

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

Passive Motion

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

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

At the end of the passive range of motion, another “barrier” is encountered. This is called the elastic barrier. Movement beyond the elastic barrier is not only beneficial, it is often critically required. It is also difficult to appropriately achieve without training. Noted orthopedic surgeon WH Kirkaldy-Willis states (6):

Periarticular Paraphysiological Space Motion

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

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

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

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

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

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

Misuse of the Word Chiropractic

Defamation is any false information that harms the reputation of a person, business, or organization. With this definition, the purposeful misuse of the word “chiropractic” would potentially defame all chiropractors and the entire chiropractic profession.

The misuse of the word “chiropractic” in medical publications is not new; it is a decades-long problem. It is documented that when both the professional and lay press ascribe a manipulative injury to the vertebral artery that they apply the words “chiropractic” and “manipulation” as being synonymous; they are not. Many people “manipulate” and yet they are not trained and licensed chiropractors.

An early whistleblower on this abuse of the chiropractic profession is researcher Alan Terrett from Australia. Dr. Terrett has shown that often, in the literature, when an untrained person manipulates a patient and causes an injury, the literature inappropriately labels the manipulator as being a chiropractor (8). The list of discovered manipulators included:

A Blind Masseur
An Indian Barber
A Wife
A Kung-Fu Practitioner
Self-Manipulation
A Medical Doctor
An Osteopath
A Naturopath
A Physical Therapist

Dr. Terrett states:

“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.”

•••

Another noted pioneer of the misuse and abuse of the word “chiropractor” in medical literature is Adrian Wenban. Dr. Wenban is presently the principal of the Barcelona College of Chiropractic. He holds a B.Sc. (Anatomy), a B.App.Sc. (Chiropractic), a M.Med.Sc. (Clinical Epidemiology) and a P.Gr.Cert. (Medical Education). He has worked in 5 different countries. In 2006, Dr. Wenban published a study titled (9):

Inappropriate Use of the Title ‘Chiropractor’ and Term ‘Chiropractic Manipulation’  in the Peer-reviewed Biomedical Literature

This publication by Dr. Wenban was based on a review of the literature using PubMed, identifying allegations of injury caused by chiropractic cervical spine manipulation. Dr. Wenban contacted the lead authors of these publications to confirm or rule out chiropractic participation. He notes:

“… authors suggest the care provider was a chiropractor and that each patient received chiropractic manipulation of the cervical spine prior to developing symptoms suggestive of traumatic injury.”

“… the principal researcher revealed that the care provider was not a chiropractor.”

“In the case series, which involved twenty relevant cases, the principal researcher conceded that the term chiropractor had been inappropriately used and that his case series did not relate to chiropractors who had undergone appropriate formal training.”

“The results of this year-long prospective review suggest that the words ‘chiropractor’ and ‘chiropractic manipulation’ are often used inappropriately by European biomedical researchers when reporting apparent associations between cervical spine manipulation and symptoms suggestive of traumatic injury.”

“In those cases, reported here, the spurious use of terminology seems to have passed through the peer-review process without correction.”

“These findings provide further preliminary evidence, beyond that already provided by Terrett, that the inappropriate use of the title ‘chiropractor’ and term ‘chiropractic manipulation’ may be a significant source of over-reporting of the link between the care provided by chiropractors and injury.”

•••

On February 1, 2024, an epub appeared in the American Journal of Forensic Medicine and Pathology, titled (10):

Self-Chiropractic Cervical Spinal Manipulation Resulting in Fatal Vertebral Artery Dissection

It appears that the authors, editors, and publisher of this article have defamed the chiropractic profession. In this sad case, chiropractic had nothing to do with it and hence should not have been mentioned in the article, let alone in the title of the article. When an untrained lay person self-manipulates her own neck causing her own death, and the published journal article titles the event “self-chiropractic cervical manipulation,” it is blatantly false and defames chiropractors and the entire chiropractic profession. Furthermore, it biases the healthcare community, healthcare practitioners, patients, and the legal system against the chiropractic profession. This should cast shame on the authors, editors, and publisher of this article.

This case involves a 43-year old woman who had a significant history of long-standing hypertension and headaches. She also had a past history of laying down with her neck on the top step of a staircase and self-manipulation of her neck which would afford her headache relief. It should be stressed that she was not a chiropractor and no chiropractors were present.

On this last day of performing this self-manipulation, she experienced a worsening of headache, then vomiting, then she went unresponsive. She was transported to the emergency department where she was pronounced deceased.

At autopsy, a dissection of the right vertebral artery was identified. Additionally, a histologic examination revealed underlying chronic vascular hypertensive degenerative changes. The autopsy report concluded:

“The cause of death was determined to be vertebral artery dissection because of the injury sustained during self-chiropractic maneuver.”

The authors also add:

“The vertebral artery is potentially more prone to damage from the mechanical effects of hypertension, and an increased susceptibility of the vertebral artery to other triggering conditions (eg, minor trauma) can result from chronic hypertension.”

“In [this] case, the history of hypertensive-range blood pressure readings (suspected to represent systemic essential hypertension) may have contributed to the propensity for vascular dissection.”

Despite the blatant misuse of the word “chiropractic” in this article, there are potential lessons, including:

• Lay manipulation of the cervical spine would typically target the atlas-axis articulation. This would potentially affect the V3 portion of the vertebral artery in extension and rotation, which is the anatomical site that theoretically would be most vulnerable to a traumatic dissection. It should be noted that trained chiropractors are aware of this theory and are trained not to do the extension-rotation-thrust maneuver of the atlas-axis articulation.
• The histopathological findings in this study suggest that chronic hypertension can lead to hypertensive vascular changes in the central nervous system vasculature, increasing the risk of cerebral vascular events. Due diligence might include taking the patient’s blood pressure and modifying adjustive techniques as deemed appropriate on patients with a history of uncontrolled chronic hypertension.

Incidence

The incidence of vertebral dissection in the society, unrelated to chiropractic care, is 1-1.5/100,000 persons yearly (11).

In 2001, a study was published in the Canadian Medical Association Journal and titled (12):

Arterial Dissections Following Cervical Manipulation:
The Chiropractic Experience

The lead author, Scott Haldeman, is a historic and contemporary giant in the chiropractic profession. His list of accomplishments includes a chiropractic degree (DC), a medical degree (MD), a PhD, and a DSc. Dr. Haldeman is a clinical professor of neurology at the University of California, Irvine.

The authors of this study reviewed all malpractice data from the Canadian Chiropractic Protective Association to evaluate all claims of stroke following chiropractic care over a 10-year period of time. This data was compared with the number of cervical manipulations performed each year by chiropractors covered by the Canadian Chiropractic Protective Association.

The authors note that there were more than 4,500 licensed chiropractors in Canada during the study period. These chiropractors performed approximately 134.5 million cervical manipulations during the 10-year assessment period, or approximately 13.45 million cervical manipulations per year. They observed 23 cases of stroke or vertebral artery dissection following cervical manipulation reported during this 10-year period, or 2.3 cases per year. An analysis of these numbers revealed:

• 1 event per 8.06 million chiropractic office visits
• 1 event per 5.85 million chiropractic cervical manipulations
• 1 event per 1,430 chiropractic practice years
• 1 event per 48 chiropractic practice careers

The authors concluded:

“[These numbers are] significantly less than the estimates of 1 per 500,000–1 million cervical manipulations calculated from surveys of neurologists.”

It is important to emphasize:

• The incidence of vertebral dissection in society, unrelated to chiropractic care, is 1-1.5/100,000 persons yearly.
• The incidence of vertebral artery dissection associated with chiropractic cervical adjustments is 1 per 5.85 million chiropractic cervical adjustments.
• A chiropractor would have to be in clinical practice for 1,430 years to be statistically associated to a single vascular event.

Biomechanical Studies
Walter Herzog and the University of Calgary

Walter Herzog, PhD, is a Professor of Kinesiology and Director of the Human Performance Lab at the University of Calgary. He has more than 1,000 published scientific studies. His lab at the University of Calgary has done more primary research pertaining to vertebral artery injury as related to the chiropractic adjustment than any other facility globally. In 2012, his group published (13):

Vertebral Artery Strains During High-speed, Low Amplitude Cervical Spinal Manipulation

This study presented the first ever data on the mechanics between C1/C2 during cervical manipulation performed by chiropractic clinicians. 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.”

“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.”

In 2023, Dr. Herzog and colleagues from the University of Zürich, and the University of Calgary published a follow-up study titled (14):

Vertebral Arteries Do Not Experience Tensile Force During Manual Cervical Spine Manipulation Applied to Human Cadavers

These authors note:

“Certain cervical spine manipulations are associated with neck extension and rotation, leading to suggestions that these interventions stretch the vertebral artery (VA), thereby causing tissue damage.” 

“Population-based studies suggest that there is no causal link between cervical spine manipulation and VA damage/stroke, rather there is a temporal (time) link.”

“In previous studies, the effects of cervical spine manipulation (using cervical spine extension and rotation and delivered at the end-range of segmental movement) delivered by chiropractors on the VA of cadaveric donors have been reported.”  

“[These studies have] concluded that arterial length changes experienced during cervical spine manipulation were almost an order of magnitude lower than the length changes required to mechanically disrupt the artery and thus, a single typical manipulative thrust was unlikely to mechanically disrupt the artery.”

The findings of these authors include:

“No segment of the VA was ever stretched during cervical spine manipulation, but merely elongated (some of the natural slack of the VA was taken up).”

“[Of the 518 cervical spine manipulations applied in this study, the length change during the manipulative thrust] never came close to the failure length changes.”

These authors concluded:

“During cervical spine manipulations (using cervical spine extension and rotation), arterial length changes remained below that slack length, suggesting that VA elongated but were not stretched during the manipulation.”

“The VA was slack in its resting, in-situ length and required an average of 33.5% elongation prior to first force occurrence, suggesting that the VA is not stretched during cervical spinal manipulation, but merely some of the slack naturally present is taken up during the procedure.”

“The results of this study, in conjunction with previously published results that VA length changes during spinal manipulation are about half of those experienced during normally achievable head and neck movements, suggest that the VA cannot be mechanically damaged by elongation that occurs during cervical spinal manipulation (using cervical spine extension and rotation).”

“Our analysis revealed that the VA is never stretched during any of the cervical spine manipulations, thus any force felt by a clinician must originate from structures other than the VA.”

“At peak lengths during cervical spine manipulation (using cervical spine extension and rotation), longitudinal VA length changes remained below that slack length, suggesting that VA elongated but were not stretched during the intervention.”

Chiropractic Safety

Two recent (2022 and 2023) large studies have specifically looked at the incidence of adverse events caused by trained medical doctors and chiropractors performing spinal adjustments (specific line-of-drive manipulations). These studies involved 345,789 individual patients and 3,642,389 spinal adjustments (15, 16). The incidence of vascular injuries/events was zero. This study supports the incidence numbers cited by Haldeman above (12).

•••

Chiropractic care is in a unique position. These last two robust studies document the extreme safety of chiropractic care. When a patient fails to respond to chiropractic care, medical referral is standardly done by chiropractors with the intention of benefiting the patient with the best of both approaches to healthcare. With education, medical professionals will hopefully appreciate that many biases against the chiropractic profession exist as a consequence of the literature’s misuse of the word “chiropractic.”

REFERENCES

1. cce-usa.org; accessed March 23, 2024.
2. Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey; December 1, 2017; Spine; Vol. 42; No. 23; pp. 1810–1816.
3. Sandoz R; Some Physical Mechanisms and Effects of Spinal Adjustment; Annals of the Swiss Chiropractic Association; 1976; Vol. 6; pp. 91-141.
4. Haldeman S; Modern Developments in the Principles and Practice of Chiropractic; Appleton-Century-Crofts; New York; 1980.
5. Kirkaldy-Willis WH; Managing Low Back Pain; Churchill Livingston; (1983 & 1988).
6. Kirkaldy-Willis, WH, Cassidy JD; Spinal Manipulation in the Treatment of Low-Back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-40.
7. Fischgrund JS; Neck Pain, Monograph 27; American Academy of Orthopaedic Surgeons; 2004.
8. Terrett AG; Misuse of the literature by medical authors in discussing spinal manipulative therapy injury; Journal of Manipulative and Physiological Therapeutics; May 1995; Vol. 18; No. 4; pp. 203-210.
9. 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; No. 16.
10. Fink C, Bryce CH, Knight LD; Self-Chiropractic Cervical Spinal Manipulation Resulting in Fatal Vertebral Artery Dissection: A Case Report and Review of the Literature; American Journal of Forensic Medicine and Pathology; February 1, 2024; Epub
11. Kwan-Woong Park, Jong-Sun Park, Sun-Chul Hwang, Soo-Bin Im, Won-Han Shin, Bum-Tae Kim; Vertebral Artery Dissection: Natural History, Clinical Features and Therapeutic Considerations; Journal of the Korean Neurosurgical Society; September 2008; Vol. 44; No. 3; pp. 109–115.
12. Haldeman S, Carey P, Townsend M, Papadopoulos C; Arterial Dissections Following Cervical Manipulation: The Chiropractic Experience; Canadian Medical Association Journal; October 2, 2001; Vol. 165; No. 7; pp. 905-906.
13. 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.
14. Gorrell LM, Sawatsky A, Edwards WB, Herzog W; Vertebral Arteries do Not Experience Tensile Force During Manual Cervical Spine Manipulation Applied to Human Cadavers; Journal of Manual & Manipulative Therapy; August 2023; Vol. 31; No. 4; pp. 261-269.
15. Kim S, Kim G, Kim H, Park J, Lee J, and nine more; Safety of Chuna Manipulation Therapy in 289,953 Patients with Musculoskeletal Disorders: A Retrospective Study; Healthcare; February 2, 2022; Vol. 10; No. 2; Article 294.
16. Chu E, Trager RJ, Lee L, Niazi IK; A Retrospective Analysis of the Incidence of Severe Adverse Events Among Recipients of Chiropractic Spinal Manipulative Therapy; Scientific Reports; January 23, 2023; Vol. 13; No. 1; Article 1254.

C. Chan Gunn, MD, is a Clinical Professor at the Multidisciplinary Pain Center at the University of Washington Medical School, Seattle, Washington. Dr. Gunn describes three categories of pain, which are quite useful for the following discussion (1). These three categories are:

1)      Nociception Pain

In this category of pain, there is no tissue damage, and therefore no inflammation. This is the type of pain one would experience if someone stepped on your toe; one would have pain but no tissue damage or inflammation. This type of pain does not require a healthcare provider to diagnose the cause of the pain. The cause of the pain is obvious: someone is standing on your toe.

Likewise, this type of pain does not require healthcare provider treatment. The treatment is obvious: get the person’s foot off your toe. The patient self-treats.

With this type of pain, once the person’s foot is off your toe, you experience immediate and lasting relief. The prognosis is excellent.

This is the type of pain that most patients (and insurance companies) hope they are experiencing, hoping for instant relief. Sadly, this type of pain rarely makes it into a doctor’s office because it is self-diagnosed and treated.

2)      Algogenic or Inflammatory Pain

Instead of someone stepping on your toe, they smacked your toe with a hammer. Even though the hammer is no longer actually on your toe, your toe still hurts. The hammer added something to the equation: trauma, tissue damage, and inflammation. This disruption of the tissues and blood vessels by the trauma produces and releases inflammatory chemicals that are often collectively called algogenic exudates.

The inflammatory algogenic chemicals alter the thresholds of the nociceptive afferent system, increasing the pain electrical signal to the brain. Instant relief for this type of pain is not possible. The pain subsides as inflammation resolves and the nociceptive afferents system becomes sub-threshold.

Individuals suffering from this type of pain often go to healthcare providers for relief. Treatment often involves anti-inflammatory efforts (controlled motion, drugs, omega-3s, ice, electrical modalities, low–level laser therapy, etc.) and efforts to accelerate healing (low-level laser therapy). Depending upon the degree of tissue injury and a myriad of individual unique characteristics, response can last days, week, or months.

Importantly, for the chiropractic profession, there is credible evidence that mechanically-based interventions, including spinal adjusting, can disperse the accumulation of inflammatory chemicals, reducing that person’s pain. This is particularly well documented when the source of the pain is the patient’s intervertebral disc (2).

Since the intervertebral disc is avascular, only improved motion can disperse the inflammatory chemicals. Spinal adjusting improves spinal motion, and improved spinal motion disperses the accumulation of the inflammatory chemicals. This model was profiled by Vert Mooney, MD, in his Presidential Address International Society for the Study of the Lumbar Spine (2). Dr. Mooney states:

“Mechanical events can be translated into chemical events related to pain.”

“The fluid content of the disk can be changed by mechanical activity.”

“Mechanical activity has a great deal to do with the exchange of water and oxygen concentration [in the disc].”  

“Research substantiates the view that unchanging posture, as a result of constant pressure such as standing, sitting or lying, leads to an interruption of pressure-dependent transfer of liquid. Actually, the human intervertebral disk lives because of movement.”

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

“Prolonged rest and passive physical therapy modalities no longer have a place in the treatment of the chronic problem.”

As noted with the hammer analogy, inflammatory pain subsides as the injured tissues heal. Without controversy, injured tissues heal in three distinct steps, as follows (3, 4, 5, 6, 7, 8):

Once again, quite important to the chiropractic profession and their patients, these phases of healing and the concomitant pain are greatly benefited from controlled motion (9, 10, 11, 12, 13, 14, 15, 16, 17, 18). This would include chiropractic adjusting (19, 20, 21).

3)      Neuropathic Pain

This category of pain is pain caused from injury and damage of the nerve itself. Neuropathic pain has the potential to become chronic and debilitating. Neuropathic pain affects approximately 3–17% of the chronic pain population in the world (22).

Important for this discussion, neuropathic pain includes compressive neuropathology.

Compressive Neuropathology

Compressive neuropathology:

• Peripheral compressive neuropathology, also known as compressive neuropathy.

An example of compressive neuropathy is carpal tunnel syndrome. The median nerve is compressed at the wrist.

• Nerve root compressive neuropathology, also known as compressive radiculopathy.

Between every spinal segmental level there is a spinal nerve root.

In compressive radiculopathy, the spinal nerve root is compressed at the level of exit from the spinal column.

In the neck, the spinal nerve root extends down the shoulder and into the arm(s).

In the low back, the spinal root extends down the pelvis and into the leg(s).

When a spinal nerve root is compressed (radiculopathy), it generates symptoms (pain, numbness, tingling, hypersensitivity, burning, achiness, etc.) and/or functional disturbances (weakness, atrophy, etc.) in the arm(s) and/or leg(s).

Compressive radiculopathy is the most concerning clinical syndrome seen in chiropractic clinical practice. This is because excessive or prolonged compression may lead to death of some of the nerve fibers resulting in permanent functional impairments. The most common cause of nerve root compression is herniation of the intervertebral disc.

Spinal manipulation and chiropractic care have a long history in the management of discogenic compressive radiculopathy. However, these patients often require longer treatment duration and more frequent chiropractic visits. To understand the magnitude of the compression, chiropractors often make use of diagnostic imaging, such as x-rays, MRI, CT, etc.

Statistically, compressive radiculopathy is rare, being found in less than 10% of chiropractic clinical practice patients (20). Sometimes, patients suffering from compressive radiculopathy will require a surgical decompression. Chiropractors are trained to monitor patient progress for any symptoms or signs that might benefit from or require a surgical consultation.

Review of Selected Studies

For decades, numerous studies have shown that spinal adjusting is appropriate and usually successful in the management of compressive radiculopathy.

In 1954, an article was published in the Instructional Course Lectures of the American Academy of Orthopedic Surgeons, titled (23):

Conservative Treatment of Intervertebral Disk Lesions

The author states:

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

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

In 1969, a study was published in the British Medical Journal, titled (24):

Reduction of Lumbar Disc Prolapse by Manipulation

 The patients in this study presented with an acute onset of low back and buttock pain that did not respond to rest. Diagnostic epidurography showed a clinically relevant small disc protrusion, along with antalgia and positive lumbar spine nerve stretch tests. These patients were then treated with rotation manipulations of the lumbar spine, accompanied with a thrust maneuver. The manipulations were repeated until abnormal symptoms and signs had disappeared. Following the manipulations there was resolution of signs, symptoms, antalgia, and reduction in the size of the protrusions. The authors state:

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

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

Also, in 1969, a study was published in the Australian Journal of Physiotherapy, titled (25):

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

The author compared the effectiveness of heat/massage/exercise to spinal manipulation in the treatment of 184 patients that were grouped according to the presentation of back and leg pain. The further the sciatic pain radiated down the leg, the greater the benefit of spinal manipulation. This study was reviewed in the 1990 book, Clinical Biomechanics of the Spine, which stated (26):

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

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

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

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

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

 In 1977, the third edition of Orthopaedics, Principles and Their Applications was published. This reference book includes a section pertaining to the protruded disc with compressive radiculopathy, titled (27):

“Treatment of Intervertebral Disc Herniation with Manipulation”

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

In 1987, a study was published in the journal Clinical Orthopedics and Related Research, titled (28):

Treatment of Lumbar Intervertebral Disc Protrusions by Manipulation

This study involved 517 patients with protruded lumbar discs with compressive radiculopathy who were treated with manipulation. Eighty-four percent of the patients achieved a successful outcome and only 9% did not respond. The authors stated:

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

“Most protruded discs may be manipulated.”

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

In 1989, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (29):

Lumbar Intervertebral Disc Herniation:
Treatment by Rotational Manipulation

This was a case study of a patient with an “enormous central herniation lumbar disc” who underwent a course of side posture manipulation. The patient improved considerably with only 2 weeks of treatment. The authors state:

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

In 1993, a “Review of the Literature” was published in the Journal of Manipulative and Physiological Therapeutics, titled (30):

Side Posture Manipulation for Lumbar Intervertebral Disk Herniation

The authors state:

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

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

In 1995, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (31):

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

The authors retrospectively reviewed the outcomes of 59 consecutive patients complaining of low back and radiating leg pain, and were clinically diagnosed as having a lumbar spine disk herniation with compressive radiculopathy: 90% of these patients reported improvement of their complaint after chiropractic manipulation. The authors state:

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

In 2006, a study was published in The Spine Journal, titled (32):

Chiropractic Manipulation in the Treatment of Acute Back Pain and Sciatica with Disc Protrusion:
A Randomized Double-blind Clinical Trial of Active and Simulated Spinal Manipulations

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

“At the end of follow-up a significant difference was present between active and simulated manipulations in the percentage of cases becoming pain-free.”

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

“No adverse events were reported.”

In 2010, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (33):

Manipulation or Microdiskectomy for Sciatica?
A Prospective Randomized Clinical Study

Forty consecutive consenting patients with lumbar disc herniation and radiculopathy who failed at least 3 months of nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture, were randomized to either surgical microdiskectomy or standardized chiropractic spinal manipulation. The authors state:

“Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention…. Patients with symptomatic lumbar disk herniation failing medical management should consider spinal manipulation followed by surgery if warranted.”

In 2014, a study was published in the Annals of Internal Medicine, titled (34):

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

This study included 192 patients who were suffering from back-related leg pain for at least 4 weeks. The authors state:

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

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

 Also in 2014, a study was published in the Journal of Manipulative and Physiological Therapeutics, titled (35):

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

The purpose of this study was to document outcomes of patients with confirmed, symptomatic lumbar disc herniations and compressive radiculopathy that were treated with chiropractic side posture high-velocity, low-amplitude, spinal manipulation to the level of the disc herniation. The authors state:

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

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

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

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

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

In 2021, a study was published in the American Journal of Medicine titled (36):

Spinal Manipulation for Subacute and Chronic Lumbar Radiculopathy

The objective of this study was to evaluate the efficacy of spinal manipulation for the management of subacute and/or chronic lumbar radiculopathy. Forty-four patients, with unilateral radicular low back pain lasting more than 4 weeks, were randomly allocated to a treatment group  (manipulation + physiotherapy) and a control group (physiotherapy only). The authors state:

“Spinal manipulation improves the results of physiotherapy over a period of 3 months for patients with subacute or chronic lumbar radiculopathy.”

“Minimum side effects, ease of administration, and patient satisfaction are the expected benefits of manipulation.”

In 2022, a study was published in the BMJ Open, titled (37):

Association Between Chiropractic Spinal Manipulation and Lumbar Discectomy in Adults with Lumbar Disc Herniation and Radiculopathy

The authors assessed matched cohorts of 5,785 patients with a mean age of 37 years. They note that it is common for patients with lumbar disc herniations and compressive radiculopathy to receive chiropractic care or undergo surgery to remove herniated disc material, a procedure called discectomy. Prior studies have found that patients who initiate care for low back pain with a chiropractor have significantly reduced odds of having discectomy.

In this study, the relative odds for discectomy were significantly reduced in the chiropractic cohort compared with the cohort receiving other care over 1-year (by 69%) and 2-year follow-up (by 77%). This study shows that patients initially receiving chiropractic care for lumbar disc herniation with radiculopathy have reduced odds of discectomy over 1-year and 2-year follow-up.

Conclusions

It is understood that some patients suffering from discogenic compressive radiculopathy (neuropathic pain syndrome) will require some form of decompressive spinal surgery. The studies presented here support that prior to surgery, spinal manipulation should be tried in an effort to avoid surgery. Spinal manipulation, especially by those expertly trained (chiropractors), is safe and often very effective. Chiropractors are also trained to monitor patient progress for any symptoms or signs that might benefit from a surgical consultation.

REFERENCES:

1. Gunn CC; The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin; Churchill Livingston; 1996.
2. Mooney V; Where Is the Pain Coming From?; Spine; October 1987; Vol. 12; No. 8; pp. 754-759.
3. Oakes BW; Acute Soft Tissue Injuries; Nature and Management; Australian Family Physician; July 1981; Vol. 10; Supplement 7; pp. 3-16.
4. Roy S, Irvin R; Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation; Prentice-Hall, Inc; 1983.
5. Frank C, Amiel D, Woo S, Akeson W; Normal ligament Properties and Ligament Healing; Clinical Orthopedics and Related Research; June 1985.
6. Kellett J; Acute soft tissue injuries-a review of the literature; Medicine and Science of Sports and Exercise; American College of Sports Medicine; October 1986; Vol. 18; No.5; pp. 489-500.
7. Woo S, Buckwalter J; Injury and Repair of the Musculoskeletal Soft Tissues; American Academy of Orthopaedic Surgeons; 1988.
8. Cohen IK, Diegelmann RF, Robert F, Lindbald WJ; Wound Healing, Biochemical & Clinical Aspects; WB Saunders; 1992.
9. Stearns ML; Studies on development of connective tissue in transparent chambers in rabbit’s ear; American Journal of Anatomy; Vol. 67; 1940; p. 55.
10. Cyriax, J; Orthopaedic Medicine, Diagnosis of Soft Tissue Lesions; Bailliere Tindall; Vol. 1; 1982.
11. Salter R; Continuous Passive Motion, A Biological Concept for the Healing and Regeneration of Articular Cartilage, Ligaments, and Tendons; From Origination to Research to Clinical Applications; Williams and Wilkins; 1993.
12. Buckwalter J; Effects of Early Motion on Healing of Musculoskeletal Tissues; Hand Clinics; Vol. 12; No. 1; February 1996.
13. Hildebrand K, Frank C; Scar Formation and Ligament Healing; Canadian Journal of Surgery; December 1998; Vol. 41; No. 6; pp. 425-429.
14. Kannus P; Immobilization or Early Mobilization After an Acute Soft-Tissue Injury?; The Physician And Sports Medicine; March, 2000; Vol. 26; No 3; pp. 55-63.
15. Hildebrand KA, Gallant-Behm CL, Kydd AS, Hart DA; The Basics of Soft Tissue Healing and General Factors that Influence Such Healing; Sports Medicine Arthroscopic Review September 2005; Vol. 13; No. 3; pp. 136–144.
16. Walsh W; Orthopedic Biology and Medicine; Repair and Regeneration of Ligaments, Tendons, and Joint Capsule; Orthopedic Research Laboratory; University of New South Wales, Sydney, Australia; Humana Press; 2006.
17. Schleip R; Fascia; The Tensional Network of the Human Body; The Scientific and Clinical Applications in Manual and Movement Therapy; Churchill Livingstone; 2012.
18. Hauser RE, Dolan EE, Phillips HJ, Newlin AC, Moore RE, Woldin BA; Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics; The Open Rehabilitation Journal; 2013; No. 6; pp. 1-20.
19. Haldeman S; Modern Developments in the Principles and Practice of Chiropractic; Appleton-Century-Crofts; New York; 1980.
20. Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
21. Fishgrund JS; Neck Pain; American Academy of Orthopedic Surgeons; 2004.
22. van Hecke O, Austin SK, Khan RA, Smith BH, Torrance N; Neuropathic Pain in the General Population: A Systematic Review of Epidemiological Studies; Pain; April 2014; Vol. 155; No. 4; pp. 654–662.
23. Ramsey RH; Conservative Treatment of Intervertebral Disk Lesions; American Academy of Orthopedic Surgeons; Instructional Course Lectures; Vol. 11; 1954; pp. 118-120.
24. Mathews JA and Yates DAH; Reduction of Lumbar Disc Prolapse by Manipulation; British Medical Journal; September 20, 1969; No. 3; pp. 696-697.
25. 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.
26. White AA, Panjabi MM; Clinical Biomechanics of the Spine; Second edition; JB Lippincott Company; 1990.
27. Turek S; Orthopaedics, Principles and Their Applications; JB Lippincott Company; 1977; page 1335.
28. Kuo PP, Loh ZC; Treatment of Lumbar Intervertebral Disc Protrusions by Manipulation; Clinical Orthopedics and Related Research; February 1987; No. 215; pp. 47-55.
29. Quon JA, Cassidy JD, O’Connor SM, Kirkaldy-Willis WH; Lumbar intervertebral disc herniation: treatment by rotational manipulation; Journal of Manipulative and Physiological Therapeutics; June 1989; Vol. 12; No. 3; pp. 220-227.
30. Cassidy JD, Thiel HW, Kirkaldy-Willis WH; Side posture manipulation for lumbar intervertebral disk herniation; Journal of Manipulative and Physiological Therapeutics; February 1993; Vol. 16; No. 2; pp. 96-103.
31. Stern PJ, Côté P, Cassidy JD; A series of consecutive cases of low back pain with radiating leg pain treated by chiropractors; Journal of Manipulative and Physiological Therapeutics; Jul-Aug 1995; Vol. 18; No. 6; pp. 335-342.
32. Santilli V, Beghi E, Finucci S; Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: A randomized double-blind clinical trial of active and simulated spinal manipulations; The Spine Journal; March-April 2006; Vol. 6; No. 2; pp. 131–137.
33. McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ; Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study; Journal of Manipulative and Physiological Therapeutics; October 2010; Vol. 33; No. 8; pp. 576-584.
34. Bronfort G, Hondras M, Schulz CA, Evans RL, Long CR, Grimm R; Spinal Manipulation and Home Exercise With Advice for Subacute and Chronic Back-Related Leg Pain: A Trial With Adaptive Allocation; Annals of Internal Medicine; September 16, 2014; Vol. 161; No. 6; pp. 381-391.
35. Leemann S, Peterson CK, Schmid C, Anklin B, Humphreys BK; Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging–Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study with One-Year Follow-Up; Journal of Manipulative and Physiological Therapeutics; March/April 2014; Vol. 37; No. 3; pp. 155-163.
36. Ghasabmahaleh SH, Rezasoltani Z, Dadarkhah A, Hamidipanah S, Mofrad RK, Sharif Najafi S; Spinal Manipulation for Subacute and Chronic Lumbar Radiculopathy: A Randomized Controlled Trial; The American Journal of Medicine; January 2021; Vol. 134; No. 1; pp. 135−141.
37. Trager RJ, Daniels CJ, Perez JA, Casselberry RM, Dusek JA: Association Between Chiropractic Spinal Manipulation and Lumbar Discectomy in Adults with Lumbar Disc Herniation and Radiculopathy: Retrospective Cohort Study Using United States’ Data; BMJ Open; December 16, 2022; Vol. 12; No. 12; Article e068262.

All perceptions (e.g., hot, cold, loud, bright, smelly, hard, soft, sour, sweet, pain, etc.) are cortical, meaning perceived in the brain. All pain is perceived in the brain (1).

Pain perception is brought to the brain by nerves. Structures that do not have a nerve supply (like articular hyaline cartilage, fingernail) cannot send the pain signal to the brain. All structures that do have a nerve supply can initiate a pain signal and send it to the brain.

The pain signal is an electrical phenomenon. As an analogy, the pain “wire” for the electrical signal is the neuron.

The pain “wire” (neuron) has specific parts that are important to this discussion:

The Pain Receptor

The receptor is found at the end of the sensory neuron. This includes soft tissues (ligament, muscles, skin, fascia, intervertebral disc, etc.). It also includes hard tissues (bone).

The receptor has the ability to take an environmental stress and convert it to an electrical signal.

Soft tissue injuries, inflammations, and/or irritations can initiate the pain electrical signal at the receptor, and the receptor will propagate the electrical signal along the axon to the brain where the signal is perceived.

The Axon

As noted above, the primary responsibility of the axon is to propagate the electrical signal from the receptor to the brain.

There is an important exception to this, which will be explained later in this publication.

The Brain

Also, as noted above, it is the brain that perceives the pain electrical signal that is delivered to it by the axon.

Soft Tissue Injury and Repair

When watching sports, like the Super Bowl, one will observe numerous injuries. The sportscasters will often tell their audience the reason why a number of a team’s top players are not in the game, detailing the injuries that the absent player is recovering from. It is rare for these injuries to be fractures, or what is referred to as hard tissue injury. The majority of these injuries are considered to be a soft tissue injury.

Soft tissues include ligaments, muscles, skin, fascia, intervertebral disc, etc. Essentially, all injuries that are not to the bone are considered to be a soft tissue injury. Technically, an injury to the nerve itself is a soft tissue injury. However, important for this discussion, an injury to the nerve itself will not be considered to be a soft tissue injury. This discussion will consider a nerve injury to be in a separate category of injury called neuropathic injury.

Injured soft tissues heal in three distinct phases (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12):

• Phase 1:     the acute inflammatory phase
• Phase 2:     the repair or proliferation phase
• Phase 3:     remodeling phase

Phase 1: The Acute Inflammatory or Reaction Phase

This phase of healing lasts up to about 72 hours. It is characterized by vasodilation, immune system activation of phagocytosis by macrophages to remove debris, and the release of prostaglandins and other inflammatory molecules.

The inflammatory chemicals play a prominent role in pain production, the increase in capillary permeability, and swelling.

The wound is hypoxic because the blood vessels have been disrupted, but immune system macrophages perform their phagocytosis duties anaerobically.

Phase 2: The Repair or Regeneration Phase

This phase begins at about 48 hours and continues for approximately 6 to 8 weeks. This phase is characterized by the synthesis and deposition of collagen, which literally glues the margins of the healing breach together.

The collagen that is deposited in this phase is not fully oriented in the direction of tensile strength. Rather, it is laid down in an irregular, non-physiological pattern.

Phase 3: The Remodeling Phase

This phase may last up to “12 months or more” (12). The remodeling phase is mostly influenced and controlled through the use of controlled motion. This is an important clinical application for chiropractors who use controlled motion as a benefit of joint manipulation (specific and controlled line-of-drive motion). This point is emphasized in the following publications:

••••

(6)

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

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

“Following this acute inflammatory phase and largely guided by the pain response of the patient, early mobilization is commenced, based upon the premise that the stress of movement on repairing collagen is largely responsible for the orientation and tensile strength of the tendons and ligaments.”

“The goal of stressing repairing tissues with controlled motion is to induce adaptive response of functionally stronger connective tissues.”

“Collagen fiber growth and realignment can be stimulated by early tensile loading of muscle, tendon, and ligament.”

••••

(10)

“The large scar tissue mass gradually remodels, likely under the influence of the mechanical environment.”

“Maturation of the scar tissue requires mechanical loading to continue the remodeling phase of healing.”

“Normal connective tissues that function in a mechanically active environment (actually most tissues) subscribe to the ‘use it or lose it’ paradigm of tissue integrity.”

“Increased loading leads to adaptation, whereas decreased loading below a threshold leads to atrophy.”

“Mechanobiology is likely important in the healing outcome in tissues such as ligaments, tendons, and related tissues. That is, depriving healing ligaments of mechanical loading likely has a detrimental impact on healing outcome.”

••••

(11)

“For [the] collagen network to attain an almost identical construction of the original tissue, the tissue in this phase of wound healing must be confronted with its normal physiological stress.”

“An important task for the therapist is to apply gradually increasing levels of force without causing pain, in order to promote the healing and regeneration processes and in this way restore mobility and stability.”

Most healed soft tissue injuries are asymptomatic. However, it is universally accepted that the healed tissue is weaker than the pre-injured tissue. Consequently, acute flare-ups of pain or exacerbations of pain and/or spasm often occur as a consequence of increased use or stress of the once injured but now healed tissues. Good early treatment improves the quality and timing of soft tissue injury. Best early treatment appears to include ice and early controlled motion. This would include chiropractic care involving adjusting of the injured joints.

•••••••••

Problem Solving

A common and legitimate question is “Why do some soft tissue injuries take a prolonged period of time to heal?” It is a reality: some patients do not recover as expected and/or take a longer period of time to become maximumly improved. This question is asked by all parties involved: the patient, doctors, chiropractors, insurance companies, claims adjusters, health plan administrators, lawyers, courts, family and friends, etc. The answer may be right in front of all involved. It has been described in the scientific literature for decades:

Neuropathic Pain Syndrome

The prior discussion pertained to soft tissue injuries that cause inflammations and/or irritations to the nerve receptors. These nerve receptors reside within those tissues. As mentioned above, technically, neuropathic pain is a soft tissue injury. But in contrast to other soft tissue injuries, the consequences and prognosis for neuropathic injury are far more difficult and less optimistic.

Simply stated, neuropathic pain is pain caused from injury, damage, or dysfunction of the nerve itself. Neuropathic pain is distinct from the pain caused by soft tissue injury. Neuropathic pain tends to become chronic and debilitating. “Neuropathic pain affects approximately 3–17% of the chronic pain population in the world” (13).

There are several Clinical Questionnaires to help establish the presence and clinical outcomes for neuropathic pain. An example of a popular one, the DN-4, is included on page 10 of this publication.

Most musculoskeletal practitioners are unfamiliar with the concept of neuropathic pain. Yet, a search of the U.S. National Library of Medicine, using the PUBMED search engine and the words “neuropathic pain,” identifies 56,609 citations (as of February 6, 2024). The oldest of these publications appeared in the 1930s. In 2015, the International Association for the Study of Pain (IASP) declared that year to be the “global year against neuropathic pain” (14).

Typical neuropathic pain categories include:

• Lumbosacral radiculopathy
• Piriformis sciatica
• Carpal tunnel syndrome
• Cervical radiculopathy
• Neurogenic thoracic outlet syndrome
• Chemotherapy-induced peripheral neuropathy
• Spinal cord injury
• Diabetic polyneuropathy
• Post stroke pain
• Chronic inflammatory demyelinating polyneuropathy
• Entrapment neuropathy
• Trigeminal neuralgia

Several of these are rarely or never seen in chiropractic clinical practice (chemotherapy-induced peripheral neuropathy, spinal cord injury, diabetic polyneuropathy, post stroke pain, demyelinating polyneuropathy).

In contrast, some of these are quite common in chiropractic clinical practice and often successfully resolved or acceptably improved with chiropractic care, including spinal adjusting (lumbosacral radiculopathy, piriformis sciatica, cervical radiculopathy, neurogenic thoracic outlet syndrome, carpal tunnel syndrome, entrapment neuropathy, trigeminal neuralgia). The radiculopathy neuropathic pain syndromes are particularly relevant to the chiropractic community because the nerve roots exit between the spinal vertebrae. Disc pathology, facet injury, uncinate joint injury, and spinal arthrosis and/or spondylosis all have the ability to injure, inflame, and/or irritate the adjacent nerve root axions.

A subjective hallmark of neuropathic pain has the patient complaining of multiple characteristics. These might include burning, painful cold, electric shocks, tingling, pins and needles, numbness, itching, etc. No two patients are exactly alike. Each patient will present uniquely different.

The clinical assessment of neuropathic pain syndrome is not a simple task. Credible studies on the topic of neuropathic pain syndrome often use similar but often somewhat different questionnaires to determine the presence of neuropathic pain syndrome (15, 16). A representative example of a commonly used questionnaire is attached at the end of this publication.

In 1958, the Journal of the American Medical Association published a study titled (17):

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

The author, Beverly Hills neurosurgeon Emil Seletz, MD, states:

“The person’s body (in the car that is struck) continues to move forward, while the head, being hinged at the neck, snaps backwards. The average head weighs about 8 lbs., and the cervical vertebrae are very delicate; the force that is pushing the head backwards is even greater than believed, since the base of the neck acts as a fulcrum and the leverage is applied near the top of the head.”

“Therefore, the head snaps back with the equivalent of several tons of force—without any support, since ‘the muscular control of the neck is caught off guard.’”

“The end-result, with the neck in acute hyperextension, is a momentary posterior subluxation of the various joints with fleeting narrowing of the foramina, so that the nerve root is caught in a pinchers between the superior and inferior facets.”

This discussion, “the nerve root is caught in a pinchers between the superior and inferior facets,” presents a plausible argument for the etiology of neuropathic pain from whiplash mechanism injuries.

A recent publication (2022) in the journal Pain quantified the incidence of neuropathic pain following whiplash collisions in a study titled (18):

Nerve Pathology and Neuropathic Pain After Whiplash Injury:
A Systematic Review and Meta-Analysis

This study is quite large. It reviewed 54 studies reporting on 390,644 patients and 918 controls.

The authors note that about 50% of patients suffering from whiplash injuries will suffer from chronic pain. They note that an explanation for this high rate of chronicity is that the patients are suffering not from soft-tissue injury alone, but rather from neuropathic pain syndrome.

The authors note that the prevalence of neuropathic pain in these whiplash-injured subjects was 34% to 75%. They state:

“There is no clear understanding of the mechanisms causing persistent pain in patients with whiplash associated disorder (WAD).” 

“There is increasing evidence of nerve involvement and neuropathic pain in patients with chronic WAD.”

“Our systematic review including 54 studies in 390,644 patients suggests that after whiplash injury, a subset of people demonstrate signs of peripheral nerve injury and/or neuropathic pain.”

“Neuropathic pain is reported by a significant group of patients with WAD.”

“Our data suggest that nerve pathology and signs of neuropathic pain are present in a subset of patients after whiplash injury.”

The DN-4 Questionnaire Estimates the Probability of Neuropathic Pain

This questionnaire has been well validated in a number of studies and is considered to be one of the most suitable neuropathic pain screening tools for clinical use:

7 symptom items are scored by interviewing the patient.

3 items are scored by means of clinical examination.

The scores are added and a score of 4 or more out of 10 is suggestive of neuropathic pain. YES = 1 Point; NO = 0 Points; Patient’s Score_______

Interviewing the Patient

QUESTION 1: Does the pain have one or more of the following characteristics?

Burning	YES	NO
Painful Cold	YES	NO
Electric shocks	YES	NO

QUESTION 2: Is the pain associated with one or more of the following symptoms in the same area?

Tingling	YES	NO
Pins and needles	YES	NO
Numbness	YES	NO
Itching	YES	NO

Examination of the Patient

QUESTION 3: Is the pain located in an area where the physical examination may reveal one or more of the following characteristics?

Hypoesthesia to touch	YES	NO
Hypoesthesia to pinprick	YES	NO

QUESTION 4: In the painful area, can the pain be caused or increased by?

Brushing

YES

NO

Future Directions and Concepts

Cytokines are protein molecules that are produced by immune system cells. Cytokines can be pro-inflammatory or anti-inflammatory.

Interleukins are a category of cytokines. Like cytokines, interleukins can be either be pro-inflammatory or anti-inflammatory. Interleukins are abbreviated “IL.”

IL-27 and IL-10 are both anti-inflammatory cytokines. An important article pertaining to neuropathic pain was published in the journal Frontiers in Immunology in 2020, titled (19):

IL-27 Counteracts Neuropathic Pain Development
Through Induction of IL-10

These authors propose that, ideally, following axonal nerve injury, the immune system cells will increase production of anti-inflammatory cytokine IL-27. In turn, IL-27 will induce an increase in the anti-nociceptive cytokine IL-10, which inhibits neuropathic pain development following injury. The authors state:

“These results provided evidence that IL-27 is a cytokine produced after peripheral nerve injury that counteracts neuropathic pain development through induction of the antinociceptive cytokine IL-10.”

The authors conclude that interventions that increase IL-27 and IL-10 “could emerge as possible therapeutic approaches for the prevention of neuropathic pain development after peripheral nerve injury.”

This science and perspective has a lot of relevance for the chiropractic profession and for their patients suffering from neuropathic pain. In 2016, the World Federation of Chiropractic award winning paper was published in the Journal of Manipulative and Physiological Therapeutics, titled (20):

Attenuation Effect of Spinal Manipulation on Neuropathic and Postoperative Pain Through Activating Endogenous Anti-Inflammatory Cytokine Interleukin-10 in Rat Spinal Cord

Using animal models, these authors showed that repetitive spinal manipulative therapy “significantly reduced simulated neuropathic and postoperative pain, inhibited or reversed the neurochemical alterations, and increased the anti-inflammatory IL-10 in the spinal cord.” They concluded:

“These findings show that spinal manipulation may activate the endogenous anti-inflammatory cytokine IL-10 in the spinal cord and thus has the potential to alleviate neuropathic and postoperative pain.”

••••

The benefits of chiropractic care, including spinal adjusting, are unquestioned in the management of neuropathic pain syndromes, especially for spinal radiculopathy syndromes. Perhaps, this elevation of IL-10 following spinal adjusting is a plausible explanation.

REFERENCES

1. Ambron R; The Brain and Pain: Breakthroughs in Neuroscience; Columbia University Press; New York; 2022.
2. Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
3. Oakes BW; Acute Soft Tissue Injuries; Australian Family Physician; 1982; Vol. 10; No. 7; pp. 3-16.
4. Roy S, Irvin R; Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation; Prentice-Hall, Inc.; 1983.
5. Frank C, Amiel D, Woo S, Akeson W; Normal Ligament Properties and Ligament Healing; Clinical Orthopedics and Related Research; June 1985.
6. Kellett J; Acute Soft Tissue Injuries: A Review of the Literature; Medicine and Science of Sports and Exercise; American College of Sports Medicine; 1985; Vol. 18; No. 5; pp. 489-500.
7. Woo S (ed.); Injury and Repair of the Musculoskeletal Soft Tissues; American Academy of Orthopaedic Surgeons; 1988.
8. Cohen IK, Diegelmann RF, Lindbald WJ; Wound Healing, Biochemical & Clinical Aspects; WB Saunders, 1992.
9. Kannus P; Immobilization or Early Mobilization After an Acute Soft-Tissue Injury?; The Physician And Sports Medicine; March 2000; Vol. 26; No. 3; pp. 55-63.
10. Hildebrand KA, Gallant-Behm CL, Kydd AS, Hart DA; The Basics of Soft Tissue Healing and General Factors that Influence Such Healing; Sports Medicine Arthroscopic Review; September 2005; Vol. 13; No. 3; pp. 136–144.
11. Schleip R; Fascia: The Tensional Network of the Human Body; The Scientific and Clinical Applications in Manual and Movement Therapy; Churchill Livingstone; 2012.
12. Hauser RA, Dolan EE, Phillips HJ, Newlin AC, Moore RE, Woldin BA; Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics; The Open Rehabilitation Journal; 2013; No. 6; pp. 1-20.
13. van Hecke O, Austin SK, Khan RA, Smith BH, Torrance N; Neuropathic Pain in the General Population: A Systematic Review of Epidemiological Studies; Pain; April 2014; Vol. 155; No. 4; pp. 654–662
14. IASP; Global year against neuropathic pain. 2015; Available at: http://www.iasp-pain.org/GlobalYear/NeuropathicPain?navItemNumber5580.
15. Finnerup NB, Haroutounian S, Kamerman P, Baron R, Bennett DLH, Bouhassira D, Cruccu G, Freeman R, Hansson P, Nurmikko T, Raja SN, Rice ASC, Serra J, Smith BH, Treede RD, Jensen TS; Neuropathic Pain: An Updated Grading System for Research and Clinical Practice; Pain August 2016; Vol. 157; No. 8; pp. 1599–1606.
16. Madani SP, Abdolmaleki K, Ahadi T, Mansoori K, Raissi GR; Neuropathic Pain Symptom Inventory (NPSI) Questionnaire-Persian Version Can Differentiate Neuropathic from Non-Neuropathic Pain; Pain Management Nursing; February 2023; Vol. 24; No. 1; pp. 96-101.
17. Seletz E; Whiplash Injuries: Neurophysiological Basis for Pain and Methods Used for Rehabilitation; Journal of the American Medical Association; November 29, 1958; Vol. 168; No. 13; pp. 1750-1755.
18. Fundaun J, Kolski M, Baskozos G, Dilley A, Sterling M, Schmid AB; Nerve Pathology and Neuropathic Pain After Whiplash Injury: A Systematic Review and Meta-Analysis; Pain; July 1, 2022; Vol. 163; No. 7; pp. e789-e811
19. Fonseca MM, Davoli-Ferreira M, Santa-Cecília F, Guimarães RM, Oliveira FFB, Kusuda R, Ferreira DW, Alves-Filho JC, Cunha FQ, Cunha TM; IL-27 Counteracts Neuropathic Pain Development Through Induction of IL-10; Frontiers in Immunology; January 28, 2020; Vol. 10; Article 3059.
20. Song XJ, Huang ZJ, Song WB, Song XS, Fuhr AF, Rosner AL, Ndtan H, Rupert RL; Attenuation Effect of Spinal Manipulation on Neuropathic and Postoperative Pain Through Activating Endogenous Anti-Inflammatory Cytokine Interleukin-10 in Rat Spinal Cord; Journal of Manipulative and Physiological Therapeutics; January 2016; Vol. 39; No. 1; pp. 42-53.