When looking at the spine from the front it should be straight. The function and health of the spine is at its optimum when there is no lateral deviation from the front. This concept is well-reviewed by James Oschman, PhD (1):
In contrast, when the spine is viewed from the side, optimum health and function requires 3 distinct spinal curves (2):
1) Cervical Lordosis
2) Thoracic Kyphosis
3) Lumbar Lordosis
We are going to focus on the importance of cervical lordosis.
The loss of the cervical lordosis can be categorized into 3 groups:
1) Hypolordosis: is a loss of the normal curve in the neck.
2) Military: is a complete loss of the curve resulting in a straight cervical spine.
3) Kyphosis: is a complete reversal of the normal curve in the neck.
Loss of the normal neck curve is associated with a number of nerve and muscle problems. The primary problems fall into five categories:
1) Muscle strain and the consequent Myofascial Pain Syndromes.
2) Acceleration of Osteoarthritis in the neck and upper back.
3) Spinal Cord Tethering.
4) Spinal Cord Demyelination.
5) Vertebral Artery blood flow compromise.
1)Muscle strain and the consequent Myofascial Pain Syndromes.
Loss of the normal curve of the neck leads to the head being displaced forward on the spinal column. To prevent you falling onto your face, the muscles at the back of the neck and rib cage will contract to maintain balance (3). The constant muscle contraction results in pain, chronic inflammation, muscle tissue fibrosis and disability (3). The term given to this sequence of events is - "myofascial pain syndrome" (4, 5, 6).
If the head weighs 10 lbs. and the loss of neck curve pushes the head’s center of gravity forward by 3 inches, the required counter-balancing muscle contraction would be 30 lbs. (10 lbs. X 3 inches):
In these cases, although muscle therapy such as massage is helpful, it is not a long-term solution. The best solution is improvement of the neck curve, reducing lever-arm stress and allowing the counterbalancing muscles to relax.
2) Acceleration of Osteoarthritis in the neck and upper back.
Loss of normal neck curve not only pushes the head forward resulting in counterbalancing muscle contraction, it also significantly increases the load placed on the the discs and facet joints (7, 8). This starts and accelerates degenerative disc and joint disease in the cervical spine, commonly known as osteoarthritis (9, 10).
The acceleration of the osteoarthritis is most pronounced when there is a reversal of the normal neck curve. This is called a kyphosis (11, 12).
3) Spinal Cord Tethering.
With loss of cervical lordosis there is a stretching of the spinal cord (7). Chronic elongation leading to tethering of the spinal cord can result in both spinal nerve dysfunction and spinal cord vascular compromise (13, 14). These can result in both autonomic and musculoskeletal symptoms.
4) Spinal Cord Demyelination.
An important research study was published in the prestigious journal "Spine" in 2005 detailing cervical spine kyphosis and demyelination of the spinal cord (15).
This study showed that cervical spine kyphosis leads to compression of the anterior blood supply to the spinal cord, resulting in spinal cord demyelination. The demyelination was greatest at the apex of the kyphotic deformity in the neck. Blood Angiography studies showed a decrease in the density of the capillary networks at the compressed spinal cord due to the neck kyphosis.
As the kyphotic angle in the neck increased, these changes in the blood supply to the area became more marked, especially in the ventral side of the spinal cord that was directly exposed to mechanical compression.
The Anterior Spinal Artery is the main blood supply to the neurons of the anterior and lateral spinal cord.
Reversal of the normal neck curve (kyphosis) compresses the front of the spinal cord against the discs and spinal bones.
5) Vertebral Artery Blood Flow Compromise.
The vertebral artery carrys blood, nutrients and oxygen to the brainstem. There is evidence that loss of the normal cervical curve (lordosis) results in reduced blood flow from the heart, through the vertebral artery into the brain stem. This can negatively effect the normal functioning of the cranial nerves and other vital functions.
An important article on this topic was published in the journal "Medical Science Monitor" in 2016, titled: Decreased Vertebral Artery Hemodynamics in Patients with Loss of Cervical Lordosis (16).
The authors evaluated the blood flow of the vertebral arteries of patients with loss of their normal neck curve and compared it to control subjects without loss of their cervical lordosis.
30 patients with loss of cervical lordosis and 30 carefully matched controls were assessed with Doppler Ultrasonography. Vertebral artery hemodynamics were statistically compared between the patient group and control group. The cervical lordosis was assessed on X-ray using the posterior tangent method.
The authors state: “The normal cervical spine has a lordotic curve. Abnormalities of this natural curvature, such as loss of cervical lordosis or cervical kyphosis, are associated with pain, disability, and poor health-related quality of life.”
“Loss of cervical lordosis causes disrupted biomechanics, triggering a degenerative process in the cervical spine.”
“The present study revealed a significant association between loss of cervical lordosis and decreased vertebral artery hemodynamics, including diameter, flow volume, and peak systolic velocity.”
When the cervical curve is lost, the vertebral arteries “are also in danger of being stretched or compressed.”
“The results of this study indicate that loss of cervical lordosis is associated with decreased vertebral artery values in lumen diameter, flow volume, and peak systolic velocity.”
This article increases the awareness of the negative impact of loss of the normal curve in the neck. It also highlights the importance of correcting cervical lordosis.
Balmoral Spine Clinic Belfast focuses on the assessment and treatment of spinal pain, including pain and associated symptoms resulting from a loss of cervical lordosis. The most accurate assessment of spinal alignment is with X-rays.
We use a number of techniques to improve and/or restore the cervical spine lordosis. There are numerous studies in the PubMed Database indicating that Chiropractic can improve and even reverse cervical kyphosis. Our typical treatment procedures involve combinations of specific Chiropractic adjustments and extension traction exercises (17, 18, 19, 20, 21, 22, 23, 24, 25).
1) Oschman J; Energy Medicine, The Scientific Basis; Chruchill Livingstone; 2000.
2) Kapandji IA; The Physiology of the Joints; Volume Three, The Trunk and the Vertebral Column; Churchill Livingstone; 1974.
3) Cailliet R; Soft Tissue Pain and Disability; 3rd Edition; FA Davis Company; 1996.
4) Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual; New York: Williams & Wilkins, 1983.
5) Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual: THE LOWER EXTREMITIES; New York: Williams & Wilkins, 1992.
6) Simons D, Travell J; Travell & Simons’, Myofascial pain and dysfunction, the trigger point manual: Volume 1, Upper Half of Body; Baltimore: Williams & Wilkins, 1999.
7) White AA, Panjabi MM; Clinical Biomechanics of the Spine, Second Edition; Lippincott; 1990.
8) Cailliet R; Low Back Pain Syndrome, 4th edition; FA Davis Company; 1981.
9) Garstang SV, Stitik SP; Osteoarthritis; Epidemiology, Risk Factors, and Pathophysiology; American Journal of Physical Medicine and Rehabilitation; November 2006; Vol. 85, No. 11; pp. S2-S11.
10) Ruch W; Atlas of Common Subluxations of the Human Spine and Pelvis, Second Edition; Life West Press; 2014.
11) Uchida K, Nakajima H, Sato R, Yayama T, Mwaka ES, Kobayashi S, Baba H; Cervical Spondylotic Myelopathy Associated with Kyphosis or Sagittal Sigmoid Alignment: Outcome after Anterior or Posterior Decompression; Journal of Neurosurgery: Spine; November 2009; Vol. 11; pp. 521-528.
12) Grosso M, Hwang R, Mroz T, Benzel, Steinmetz M; Relationship between degree of focal kyphosis correction and neurological outcomes for patients undergoing cervical deformity correction surgery; Journal of Neurosurgery: Spine; June 18, 2013; Vol. 18; No. 6; pp. 537-544.
13) Breig A; Adverse Mechanical Tension in the Central Nervous System; Almqvist and Wiksell; 1978.
14) Wing PC, Tsang IK, Susak L, Gagnon F, Gagnon R, Potts JE; Back Pain and Spinal Changes in Microgravity; Orthopedic Clinics of North America; April 1991; Vol. 22; No. 2; pp. 255-262.
15) Shimizu K, Nakamura M, Nishikawa Y, Hijikata S, Chiba K, Toyama Y; Spinal Kyphosis Causes Demyelination and Neuronal Loss in the Spinal Cord: A New Model of Kyphotic Deformity; Spine; November 2005; Vol. 30; No. 21; pp. 2388-2392.
16) Bulut MD, Alpayci M, Şenkoy E, Bora A, Yazmalar L, Yavuz A, Gulşen I; Decreased Vertebral Artery Hemodynamics in Patients with Loss of Cervical Lordosis; Medical Science Monitor; February 15, 2016; Vol. 22; pp. 495-500
17) Leach RA. An evaluation of the effect of chiropractic manipulative therapy on hypolordosis of the cervical spine. J Manipulative Physiol Ther. 1983 Mar;6(1):17-23.
18) Harrison DD, Jackson BL, Troyanovich S, Robertson G, de George D, Barker WF. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study. Journal of Manipulative and Physiological Therapeutics; September 1994; Vol. 17; No. 7; pp. 454-64.
19) Troyanovich SJ, Harrison DE, Harrison DD. Structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther. 1998 Jan;21(1):37-50.
20) Harrison DE, Harrison, DD, Haas JW. CBP Structural Rehabilitation of the Cervical Spine, 2002.
21) Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial. Arch Phys Med Rehabil. 2002 Apr;83(4):447-53.
22)Morningstar MW, Strauchman MN, Weeks DA. Spinal manipulation and anterior headweighting for the correction of forward head posture and cervical hypolordosis: A pilot study. J Chiropr Med. 2003 Spring;2(2):51-4.
23) Harrison DE, Harrison DD, Betz JJ, Janik TJ, Holland B, Colloca CJ, Haas JW. Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial. J Manipulative Physiol Ther. 2003 Mar-Apr;26(3):139-51.
24) Ferrantelli JR, Harrison DE, Harrison DD, Stewart D. Conservative treatment of a patient with previously unresponsive whiplash-associated disorders using clinical biomechanics of posture rehabilitation methods. J Manipulative Physiol Ther. 2005 Mar-Apr;28(3):e1-8.
25)Oakley PA, Harrison DD, Harrison DE, Haas JW. Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP) publications. J Can Chiropr Assoc. 200
A Disc lesion means a disruption of the annular fibers and displacement of nuclear material in the intervertebral disc. This can lead to symptoms of inflammation and chemical irritation of the nerve or true compression of the nerve roots. Expected symptoms include pain, loss of sensation and numbness or weakness in the area of the body the effected nerve supplies
Lumbar disc lesion begins with repetitive disc strain which leads to disc herniation and ends in disc degeneration. Multiple factors contribute to the development of lumbar disc herniations. A very important systematic review and meta-analysis published in 2017 of more than 1700 patient cases determined that patients with a reduction of the normal curve in their lower back have significantly higher levels of lumbar disc herniation and lower back pain (1).
Over 90% of disc lesions occur at L4/5 or L5/S1, with the latter being most prevalent (2). The lumbar disc damage is accompanied by an inflammatory reaction capable of producing a “chemical radiculopathy”. Large disc disruption can lead to disc herniation or bulging resulting in mechanical compression of nearby nerves.
Other risk factors associated with the development of disc herniations include: a sedentary lifestyle, long periods of driving, long term smoking, previous full-term pregnancy, increased body mass index, and a tall stature (3).
Disc herniation is most likely to occur in the 40-50 years old age group and the condition is very uncommon in children (4). Approximately 35-45% of adults will experience lumbar disc lesions at some point in their lifetime and the condition is more common in men (5).
The presentation to the Chiropractor's office for lumbar disc herniations really depends on the degree of neurologic involvement. Disc lesions with no mechanical compression may present with only local discomfort and pain, or we may see pain that radiates into the buttock or upper leg.
Disc bulges with mechanical compression of a nerve can present with all of the above symptoms but also with decreased muscle strength and abnormal reflexes. Referred pain into the limbs is described by the patient as sharp and sometimes accompanied with pins/needles or altered sensation. As a Chiropractor our job is to rule out "Red Flags" such as Cauda Equina where the patient will present with numbness or altered sensation in the saddle area, they may also report loss of bowel or bladder function and this is deemed a medical emergency situation and the patient will likely require immediate surgery.
Disc herniation with limb pain can be successfully managed via conservative Chiropractic treatment (6). In fact, the majority of disc herniations will reduce over time without the need of surgery. (7,8) . The goal of conservative Chiropractic management is to centralize symptoms, reduce pain and inflammation in the area, decrease mechanical compression of the nerve and improve functional core stability.
McMorland reported that the main technique carried out by the Chiropractor produced results equal to surgical decompression in 60% of lumbar disc lesion patients who had failed earlier medical management. He concluded: “Patients with symptomatic lumbar disc herniation should consider spinal manipulation before surgery" (9). An other study of 148 patients demonstrated significant and lasting improvement in all outcome measures (with no adverse events) when spinal manipulation was applied to the level of the disc lesion (10). Chiropractic patients with disc herniation who undergo spinal manipulation at the level of disc involvement demonstrate a significant decrease in radicular symptoms (pain in the limbs) (11).
A study of 1271 lower back pain patients determined that patients with related leg pain and signs of nerve root involvement will have a worse prognosis than patients with low back pain only. Chiropractic clinical outcomes with low back pain are very impressive.
After two weeks of treatment, patients with local lower back pain only - 77% had improved.
Patients with lower back pain and pain above the knee - 72 % improved after just 2 weeks.
Average outcomes for Chiropractic patients, regardless of the location of pain were significantly better than those who sought treatment from their GP’s at 2 weeks (74% improved vs 36% improved), 3 months (82% improved vs. 60% improved), and 12 months (73% improved vs. 54% improved). (12)
1.The relationships between low back pain and lumbar lordosis: a systematic review and meta-analysis. Chun, Se-Woong et al. The Spine Journal , Volume 17 , Issue 8 , 1180 - 1191
2. Frymoyer JW. Back pain and sciatica. N Engl J Med 1988;318: 291-300.
3. Nachemson AL: Prevention of chronic back pain. The orthopaedic challenge for the 80's. Bull Hosp Jt Dis Orthop Inst 44:1-15, 1984.
4. Hoffman HJ: Childhood and adolescent lumbar pain: differential diagnosis and management. Clin Neurosurg 1980; 27:553-576.
5. Hurwitz EL, Shekelle P. Epidemiology of low back syndromes. In: Morris CE, editor. Low back syndromes: integrated clinical management. New York: McGraw-Hill; 2006. p. 83-118.
6. Saal JA, Saal JS: Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy an outcome study. Spine 1989; 14:431-436
7. Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015 Feb;29(2):184-95.
8. Zhong M, Liu JT, Jiang H, Mo W, Yu PF, Li XC, Xue RR. Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician. 2017;20(1):E45–E52.
9. McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ.
Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study . J Manipulative Physiol Ther. 2010 Oct;33(8):576-84. doi: 10.1016/j.jmpt.2010.08.013
10. Serafin Leemann, Cynthia K. Peterson, Christof Schmid, Bernard Anklin, and B. Kim Humphreys. 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. JMPT 01/2014; DOI:10.1016/j.jmpt.2013.12.011.
11. Ehrler M, Peterson C Leemann S et al. Symptomatic, MRI Confirmed, Lumbar Disc Herniations: A Comparison of Outcomes Depending on the Type and Anatomical Axial Location of the Hernia in Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulation. JMPT Mar-April 2016, Volume 39, Issue 3, Pages 192–199.
12. Hartvigsen L. et al. Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain. BMC Musculoskeletal Disorders 2017, 18:133
The "Pain Gate Theory" has been accepted as a viable explanation for the benefits of Chiropractic treatment.
Canadian orthopedic surgeon WH Kirkaldy-Willis, MD (1)notes :
“Spinal manipulation is essentially an assisted passive motion applied to the spinal joints.”
Since 1965, Melzack and Wall's proposed Pain Gate Theory has “withstood rigorous scientific scrutiny.”
“The transmission of pain can be impeded by increased proprioceptive input.” Pain is increased by “lack of proprioceptive input.” This is why it is so important to regain early movement in joints after an injury.
The facet joints in the spine are densely populated with mechanoreceptors. How Chiropractic works is by increasing proprioceptive input in the form of spinal adjustments to decrease the central transmission of pain from adjacent spinal structures by closing the "Pain Gate".
By the Chiropractor applying a stretch into the facet joint capsule, the aim is to fire capsular mechanoreceptors which will “inhibit facilitated motoneuron pools” which are responsible for the muscle spasms that commonly accompany low back pain.
Mechanoreceptors are considered the most important source of the “non-nociceptive” afferents that control pain. Therefore improving their function closes the pain gate and in turn reduces pain.
The increased muscle spasm that often accompanies spinal pain also reduces spinal motion and results in opening the pain gate and in turn increasing the patients pain.
Our muscles become a key player in chronic spinal pain conditions because of overlapping feedback loops:
1) Pain leads to increased muscle tone.
2) Increased muscle tone leads to more inflammation and more pain.
3) An increase in muscle tone reduces joint range of motion.
4) Reduced range of motion leads to reduced mechanoreception.
5) Reduced joint mechanoreception opens the pain gate.
6) The “open” pain gate leads to more pain and further increased muscle tone (again, a feedback loop).
This feedback loop mechanism was eloquently reviewed by Yale’s Manohar Panjabi, PhD (2):
The theoretical basis for Panjabi’s model was based on the animal studies carried out by Aage Indhal, MD, and colleagues from Norway (3). The studies clearly showed the relationship between spine pain and contraction of the segmental muscles, leading to reduced movement of that region of the spine.
Indahl was also able to show that by stimulating the mechanoreceptors of the facet joint they could inhibit the spinal cord reflex to the spinal muscles causing the spasm and also decrease pain.
Dr. Indahl’s experiments and Dr. Panjabi’s models are perfect matches to how Chiropractic spinal adjusting works.
Raymond Brodeur is a Chiropractor and Engineer working at Michigan State University (4). Dr. Brodeur’s basic premise is that the cavitation ( popping noise) associated with the audible adjusting of a spinal segment has sufficient speed to fire off high-threshold mechanoreceptors,decreasing muscle spasm and improving joint motion.
The primary research by Orthopedic Surgeon WH Kirkaldy-Willis, MD was clearly able to show that Chiropractic spinal adjusting was capable of decreasing both muscle spasm and pain (1). Dr. Kirkaldy-Willis used 283 patients with chronic, severe, treatment resistant low back pain and documented that Chiropractic spinal adjusting was able to fix the condition in 81% of the patients.
Dr. Kirkaldy-Willis’ explanation for the observed improvement in clinical status was the firing of facet capsule mechanoreceptors, which decreases muscle spasm and closes the pain gate.
1) Kirkaldy-Willis WH; Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985, Vol. 31, pp. 535-540.
2) Panjabi MM; A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction; Eur Spine J. 2006 May;15(5):668-76.
3) Indahl A, Kaigle A, Reikerås O, Holm S; Electromyographic response of the porcine multifidus musculature after nerve stimulation; Spine (Phila Pa 1976). 1995 Dec 15;20(24):2652-8.
4) Brodeur R; The audible release associated with joint manipulation; J Manipulative Physiol Ther. 1995 Mar-Apr;18(3):155-64.
Leg length inequality and a pelivis that is not level is a common cause of low back pain.
The biomechanics of the lower back is closely linked to the biomechanics of the foot, leg, and pelvis.
Doctors may be tempted to only focus on the back with their back pain patients, however oftentimes the stresses in these tissues are caused by biomechanical problems in the feet, knees or pelvis. Failure to address biomechanical problems in these areas often results in poor clinical outcomes and the patient fearing the problem will never get better.
Successful management of low back issues requires full assessment of biomechanical problems of the lower extremities and pelvis because they are linked through the kinetic chain effecting posture and ambulation.
The first large research study into leg length issues was carried out over 70 years ago
In 1946, Lieutenant Colonel Weaver A. Rush and Captain Howard A. Steiner of the X-ray Department of the Regional Station Hospital of Fort Leonard Wood, Missouri, took standing lumbosacral X-rays on 1,000 soldiers for the specific purpose of measuring differences in their leg lengths and to determine if inequality of leg length was a factor in the incidence of back pain. Their research was published in the American Journal of Roentgenology and Radium Therapy and is titled 1): A Study of Lower Extremity Length Inequality.
23% of the soldiers had legs of equal length.
77% of the soldiers had unequal length of their legs.
No difference was noticed in limb shortness between the left and right legs and the average shortening was slightly more than 7 mm.
Importantly, the authors noted that the short leg was associated with a tilt of the pelvis and a scoliosis.
The Authors noted: “It was a general consistent observation that the degree of scoliosis was proportionate to the degree of pelvic tilt. An individual who has a shortened leg will have to compensate completely if he intends to hold the upper portion of his body erect or in the midsagittal plane.”
They also noted:
"Leg length differences exceeding 5 mm were associated with the greatest low back pain or disability, and therefore 5 mm is labeled as being a “marked difference.”
“For this reason, it is our opinion that the existence of such a condition [a short leg exceeding 5 mm] is significant from the standpoint of symptomatology and disability.”
Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual:
In these books, Drs. Travell and Simons discuss difficult cases caused by structural deficiencies, the most common of which were:
A difference in the length of the lower limbs.
A long second metatarsal or a short first metatarsal.
It has been documented since 1946 that around three quarters of the population have unequal leg lengths and that about a third of people have leg length differences that can perpetuate trigger points (2). As a general rule, the sacrum is lower on the side of the short leg. The spine initially tilts towards the short leg, then compensates back to the midline as a consequence of chronic contraction of the quadratus lumborum muscle. Dr. Travell states the resulting trigger points in the quadratus lumborum muscle are a very common but frequently overlooked cause of chronic low back pain (3).
Dr. Travell stated that the solution was a heel lift for the short leg, these are commonly applied using orthotics in modern clinics
This concept of a pronated foot lowering the pelvis on the same side, altering lumbar spine biomechanics has been confirmed in more recent publications, including sports medicine reference books authored by podiatrists (4).
Another cause for the increased occurence of low back pain in individuals with an anatomical short leg is that it can also cause counter-rotational stress at the L5-S1 intervertebral disc. This phenomenon was best described by Ora Friberg, MD, from Finland. Dr. Friberg published his findings in 1987 in the journal Clinical Biomechanics, titled (5): The Statics of Postural Pelvic Tilt Scoliosis;A Radiographic Study on 288 Consecutive Chronic LBP Patients
The intervertebral disc has two components. The center of the disc is called the Nucleus Pulposus, or simply nucleus. The nucleus is mostly water and functions as a ball bearing, allowing the vertebrae to bend and twist.
In this study by Friberg, standing X-rays of the pelvis and lumbar spine in 288 consecutive patients with chronic low back pain and in 366 asymptomatic controls were taken. The findings showed that 73% of the patients assessed had more than 5mm difference in leg length. The incidence of leg length inequality in lower back pain patients was twice as much as the patients with no pain (controls).
Friberg emphasized the counter-rotational stresses on the L5-S1 disc: "These “significant” counter-rotational stresses primarily affect the L5-S1 intervertebral disc. The consequences of these counter-rotational stresses at L5 are accelerated disc degeneration and degradation, back pain and sciatica."
A recent (2016) study pertaining to the biomechanical consequences of an anatomical short leg was published in the Journal of Craniovertebral Junction Spine and titled (6): Inequality in Leg Length is Important for the understanding of the pathophysiology of Lumbar Disc Herniation.
The researchers studied 39 subjects with leg length inequality and low back pain and 43 controls to note the differences in occurrence of disc herniation between between the two groups. They found that leg length inequality causes spinal joint load assymetry, accelerating disc degeneration and disc herniation. They also suggested that poor low back disc surgical outcomes may be linked to the abnormal spinal loads caused by leg length inequality, They state:
“Inequality in leg length may lead to abnormal transmission of load across the endplates leading degeneration of the lumbar spine and the disc space.”
“Patients with chronic lower back pain have minor balance defects. Inequality in leg length is important for understanding of reasons behind lumbar disc degeneration and herniation.”
This year (2017), a very important article was published in the Archives of Physical Medicine and Rehabilitation, titled (7): Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial.
The aim of this study was to investigate how shoe orthotics with or without Chiropractic treatment for chronic low back pain compared to no treatment at all. This was a randomized controlled trial (three groups) that involved 225 adults with symptomatic low back pain of 3 months or longer:
Group 1:"Orthotics Group" received custom-made shoe orthotics only.
Group 2: "Plus Group" received custom-made orthotics plus Chiropractic treatment.
Group 3: "Wait Group" received no care.
Both pain levels and disability were assessed at 6 weeks and 12 weeks, and then after an additional 3, 6, and 12 months. These authors note:
“The best results were in the Orthotics Plus Chiropractic group in which 70% had a decrease in pain and 56% a decrease in disability of 30% or more compared to baseline.”
“This large-scale clinical trial show that LBP and disability were significantly improved after six weeks of orthotics care compared to a wait-list control, and that the addition of chiropractic care with the orthotics demonstrated a significant improvement in the disability scores compared to orthotics alone.”
“Foot and leg length dysfunction must not be overlooked as a contributing factor in treating lower back pain.”
Rush WA, Steiner HA; A Study of Lower Extremity Length Inequality; American Journal of Roentgenology and Radium Therapy; Vol. 51; No. 5; November 1946; pp. 616-623.
Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual: THE LOWER EXTREMITIES; New York: Williams & Wilkins, 1992.
Simons D, Travell J; Travell & Simons’, Myofascial pain and dysfunction, the trigger point manual: Volume 1, Upper Half of Body; Baltimore: Williams & Wilkins, 1999.
Subotnick SI; Sports Medicine of the Lower Extremity; Churchill Livingstone; 1989.
Friberg O; The statics of postural pelvic tilt scoliosis; a radiographic study on 288 consecutive chronic LBP patients; Clinical Biomechanics; Vol. 2; No. 4; November 1987; pp. 211-219.
Balik SM, Kanat A, Erkut A, Ozdemir B, Batcik OE; Inequality in Leg Length is Important for the Understanding of the Pathophysiology of Lumbar Disc Herniation; Journal of Craniovertebral Junction Spine April-June 2016; Vol. 7; No. 2; pp. 87-90.
Cambron JA, Dexheimer JM, Duarte M, Freels S; Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial; Archives of Physical Medicine and Rehabilitation; April 29, 2017. [Epub]
A recent Danish study of 1271 patients with lower back pain concluded that patients with lower back and leg pain will have a worse prognosis than patients with lower back pain alone.
The outcomes of the first 2 weeks of Chiropractic treatment varied depending on how far the pain had initially spread down the leg.
Lower back pain only - (77% of patients improved after 2 weeks of Chiropractic)
Lower back pain + pain above the knee - (72 % improved after 2 weeks of Chiropractic)
Lower back pain + pain below the knee - (61% improved after 2 weeks of Chiropractic)
Lower back pain + positive nerve tension test (SLR) or abnormal neuro findings - (40% improved after 2 weeks of Chiropractic)
As expected, average outcomes for Chiropractic patients, regardless of pain location were significantly better than those of patients who were only under the care of their GP’s.
At 2 weeks (74% improved with Chiropractic vs 36% improved with GP).
At 3 months (82% improved with Chiropractic vs. 60% improved with GP).
Hartvigsen L, Hestbaek L, Lebouef-Yde C, Vach W, Kongsted A. Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain. BMC Musculoskeletal Disorders. 2017;18:133. doi:10.1186/s12891-017-1495-3.
The medical definition of a migraine headache is (1):
The headache must last between 4 to 72 hours.
The headache is associated with either nausea / vomiting / phonophobia / photophobia.
The headache must be characterized by two of the following four symptoms: throbbing pulsile quality; unilateral location; moderate or severe degree of pain; made worse by physical activity.
A diagnosis of Migraine is formed when these characteristics are present:
-Pain involves half of the head.
-An aura is present.
-Associated gastro-intestinal symptoms.
-There is phonophobia and or photophobia.
-Pain is aggravated by the Valsalva maneuver and or by the "head-low position".
-The migraines can be triggered by: The menstrual cycle; Oversleeping; Fasting; Alcohol; Tyramine-containing foods (meats that are pickled/aged/smoked/fermented/most pork; chocolate; and fermented foods.
-Migraine relief occurs with sleep.
Nikoli Bogduk, MD, PhD, is one of the World's leading Musculoskeletal researchers.
Dr. Bogduk’s expertise in clinical anatomy includes headaches. A literature search using the words “Bogduk + Headache” finds 25 separate citations. One of his most important contributions to the study of understanding headaches appeared in the scientific journal Biomedicine and Pharmacotherapy. The article is titled (2): "Anatomy and Physiology of Headache".
In this review, Bogduk notes that “all headaches are mediated by the trigeminocervical nucleus.”
This means that all headaches, including migraines, synapse in the upper aspect of the neck, in an area called the trigeminocervical nucleus. The trigeminocervical nucleus is housed in the brainstem and the upper cervical spinal cord.
Upper cervical spine afferents to a second-order neuron that also receives trigeminal input may be a source of the electrical signal that is interpreted as headache in the brain, including migraine headache. Therefore structures that are innervated by C1/C2/C3, can cause headaches including migraine. Irritation or inflammation of structures supplied by C1/C2/C3 can all cause headaches. Such structures include:
The Dura mater.
Anterior and posterior upper cervical and cervical occipital muscles.
C1/2/3 cervical joints.
Vertebral and Carotid arteries.
Transverse and Alar ligaments.
The Trapezius muscle.
The Sternocleidomastoid muscle.
In 2017, researchers from Akershus University Hospital, Oslo, Norway, and the Department of Chiropractic, Macquarie University, NSW, Australia, published a study in the journal Musculoskeletal Science and Practice titled (3):
Adverse Events in a Chiropractic Spinal Manipulative Therapy: A Single-blinded, Placebo, Randomized Controlled Trial for Migraineurs
The authors note that migraines are a common challenge, and pharmacological management is often the first treatment of choice. However these drugs can have serious and undesirable side effects. In contrast, manual-therapy carried out by Chiropractors appears to have a similar effect as common drugs on migraine frequency, migraine duration, and migraine intensity.
70 migrainers were randomized to chiropractic manipulation (Gonstead full-spine adjusting) or a placebo, with 12 intervention sessions over three months. The subjects in this study were randomly placed into three groups:
An active spinal manipulation group, using Gonstead technique: “Active treatment consisted of chiropractic spinal manipulation using the Gonstead method.
A placebo manipulation group, receiving sham manipulation: “The placebo intervention consisted of sham manipulation, i.e., a broad non-specific contact approach via a low-velocity, low-amplitude sham push manoeuvre in a non-intentional and nontherapeutic directional line.
A control group, using usual pharmacological management: “The control group continued their usual pharmacological management without receiving manual intervention.”
The participants were interviewed and physically assessed by a Chiropractor, “including meticulous investigation of the spinal column.” They also received a full spine X-rays. The subjects attended treatments over 12 weeks with follow-up at 3, 6 and 12 months post-treatment. The authors concluded:
This study “showed significant differences between the Chiropractic spinal manipulation group and the control group [drug group] at all post-treatment time points.”
“These findings are in accordance with the World Health Organization guidelines on basic training and safety in chiropractic spinal manipulation, which is considered to be an efficient and safe treatment modality (WHO, 2005).” (4)
Non-pharmacological management of migraine has the advantage of having mild and transient adverse events, “whereas pharmacological adverse events tend to be continuous.”
“Chiropractic spinal manipulation applying the Gonstead technique appears to be safe for the management of migraine headache and presents few mild and transient adverse events.”
The group being treated by the chiropractor had the best long-term results.
These studies explain what essentially every chiropractor has observed:
Improvement of the mechanical function of the upper cervical spine with spinal manipulation is an effective and safe treatment for patients suffering from migraine headache.
The presented data here suggests that manipulation actually addresses the cause of the migraine headache; in contrast, it appears that taking drugs is nothing more than temporary pain control with no improvement to the causative pathophysiology of migraine headache.
1) Jones HR, MD; Netter’s Neurology; 2005.
2) Bogduk N; Anatomy and Physiology of Headache; Biomedicine and Pharmacotherapy; 1995, Vol. 49, No. 10, 435-445.
3) Chaibi A, Benth JS, Tuchin PJ, Russell MB; Adverse Events in a Chiropractic Spinal Manipulative Therapy Single-blinded, Placebo, Randomized Controlled Trial for Migraineurs; Musculoskeletal Science and Practice ; March 2017; Vol. 29; pp. 66-71.
4) WHO, 2005. Guidelines on Basic Training and Safety in Chiropractic. World Health Organization, Switzerland.
Here’s a sampling of 14 studies that we used to update protocols this week. Some studies describe new concepts, while others simply reinforce our current understanding and provide additional support for evidence-based chiropractic practice.
1. A systematic review of 26 studies strongly supports the existence of a soft tissue connection between the upper cervical muscles (rectus capitis posterior minor, the rectus capitis posterior major, and the obliquus capitis inferior) and the spinal cord dura. This connection has pathophysiological and therapeutic implications that may help explain the beneficial effect of manual therapy on craniocervical disorders, i.e. cervicogenic headache, cervicogenic vertigo, etc.
PalomequeDel-Cerro L, et al. A systematic review of the soft-tissue connections between neck muscles and dura mater: The myodural bridge. Spine (Phila Pa 1976).2017 Jan 1;42(1):49-54.
2. “Mobilization, (cervical & thoracic) manipulation, and clinical massage are effective interventions for the management of neck pain. Electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective.”
Wong JJ, et al. Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplashassociated disorders or neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa collaboration. Spine J. 2016 Dec;16(12):1598-1630
3. In older adults with chronic neck pain, incorporating spinal manipulation decreases overall societal costs 5% and results in greater improvements in pain and disability when compared to a home exercise program alone. Furthermore, adding spinal manipulation to a home exercise program resulted in 47% lower costs compared to supervised rehabilitation.
Leininger B, et al. Cost-effectiveness of spinal manipulative therapy, supervised exercise, and home exercise for older adults with chronic neck pain. Spine J. 2016 Nov;16(11):1292-1304.
4. Regarding patients with myofascial neck and shoulder pain, a randomized clinical trial found that 4 sessions of either dry needling or manual pressure resulted in significant short and long-term improvements in pain and stiffness. Dry needling was not shown to be more effective than manual pressure in the treatment of myofascial neck and shoulder pain.
Meulemeester KE, et al. Comparing Trigger point dry needling and manual pressure technique for the management of myofascial neck/shoulder pain: A randomized clinical trial. De J Manipulative Physiol Ther. 2017 Jan;40(1):11-20.
5. In patients with cervical radiculopathy, cervical manipulation provides immediate pain relief.
Thoomes EJ. Effectiveness of manual therapy for cervical radiculopathy, a review. Chiropr Man Therap. 2016 Dec 9;24:45.
6. Spinal manipulation leads to changes in cortical excitability and motor control of both upper and lower limb muscles. This is particularly encouraging for providers treating athletic populations or muscle degrading dyfunctions (i.e. stroke).
Haavik H, et al. Impact of spinal manipulation on cortical drive to upper and lower limb muscles. 2016 Dec 23;7(1).
7. In a group of 104 migraine patients, cervical spine manipulation resulted in significantly decreased headache intensity and duration with no significant adverse effects. Patients undergoing SMT also noted a reduction in frequency, however not significantly different as compared to participants in prescription medication and placebo control groups.
Chaibi A, Benth JŠ, Tuchin PJ, Russell MB. Chiropractic spinal manipulative therapy for migraine: a three-armed, single-blinded, placebo, randomized controlled trial. Eur J Neurol. 2017 Jan;24(1):143-153.
8. Patients with Shoulder Anterior Impingement Syndrome show positive outcomes to upper thoracic manipulation.
Kardouni JR, Shaffer SW, Pidcoe PE, Finucane SD, Cheatham SA, Michener LA. Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: a randomized controlled study. Man Ther. 2015;20:540–46.View ArticlePubMedGoogle Scholar
9. Obese patients are less likely to show improvement from LBP treatment regardless of the care they receive.
Ewald SC, Hurwitz EL, Kizhakkeveettil A. The effect of obesity on treatment outcomes for low back pain. Chiropr Man Therap. 2016 Dec 12;24:48.
10. An analysis of over 5000 LBP workers compensation clams showed that patients who chose a chiropractor over an MD or PT as their first healthcare provider typically had:
o a mixed-manual job (i.e. skilled or semi-skilled occupation)
o longer employment tenure
o higher income
o a smaller residential community (<500,000)
Blanchette MA, Rivard M, Dionne CE, Hogg-Johnson S, Steenstra I. Workers’ characteristics associated with the type of healthcare provider first seen for occupational back pain. BMC Musculoskelet Disord. 2016 Oct 18;17(1):428.
11. Patients with LBP have impaired lumbar proprioception compared to controls.
Tong MH, et al. Is there a relationship between lumbar proprioception and low back pain? A systematic review with meta-analysis. Arch Phys Med Rehabil. 2017 Jan;98(1):120-136.e2.
12. A systematic review showed no significant long-term effect for surgery compared to physical activity based interventions for leg and back pain from lumbar disc herniation. The same study found that surgery provided long-term benefit for local and radicular complaints in appropriate stenosis and spondlyolisthesis patients.
Fernandez M, et al. Surgery or physical activity in the management of sciatica: a systematic review and meta-analysis. Eur Spine J. 2016 Nov;25(11):3495-3512.
13. A systematic review concluded that manual therapy and exercise therapy are beneficial for people with hip osteoarthritis in terms of reduced pain, improved physical function and improved quality of life. In particular, exercise therapy provided short-term as well as long-term benefits.
Sampath KK, Mani R, Miyamori T, Tumilty S. The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: a systematic review and metaanalysis.. Clin Rehabil. 2016 Dec;30(12):1141-1155.
14. A randomized clinical trial found that in patients with knee osteoarthritis, Kinesio taping resulted in improvements in pain, ambulation, and ROM.
Kaya Mutlu E, Mustafaoglu R, Birinci T, Razak Ozdincler A. Does kinesio taping of the knee improve pain and functionality in patients with knee osteoarthritis?: A randomized controlled clinical trial. Am J Phys Med Rehabil. 2017 Jan;96(1):25-33.
2017 is shaping up as a great year for Chiropractic. In February, the American College of Physicians published a Clinical Practice Guideline recommending spinal manipulation for acute, sub-acute, and chronic LBP. (1) Last month JAMA published a systematic review of 26 randomized clinical trials that highlighted the safety and effectiveness of spinal manipulation for low back pain. (2)
Now, The FDA has published a Blueprint for Healthcare Providers designed to decrease the utilization of dangerous Opioid medication and increase provider’s awareness of safer, effective conservative options for musculoskeletal pain. (3) Among the FDA recommendations:
“A number of nonpharmacologic therapies are available that can play an important role in managing pain, particularly musculoskeletal pain and chronic pain: Specifically including Chiropractic.
Two prominent medical journals have told the medical community what Chiropractors and their patient have known for many years- Chiropractic Spinal Manipulation is safe and effective and should be the first choice for musculoskeletal pain. Now the FDA is advising all healthcare providers to learn more about these options and incorporate them into care plans.
1. Qaseem A, Wilt TJ, McLean RM, Forciea MA, for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. [Epub ahead of print 14 February 2017] 2. Paige NM, Miake-Lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain; Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460.
3. FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain. May 2017. Accessed from https://www.fda.gov/downloads/Drugs/NewsEvents/UCM557071.pdf on May 12, 2017
The hip is an extremely unique joint. The strength of the ligaments and muscles surrounding it, the way it works in weight bearing activities is unlike any other joint in the human body.
The hip joint is a synovial joint. It is a ball-in-socket joint that is made up of the femoral head and the acetabulum.
The intimate relationship between the hip and the surrounding joints means that each joint affects the next. For example - inward rolling of the foot and ankle results in a knocked knee, which can then shift the hip outwards. The pelvis will then drop down on that side, unlevelling the sacrum and the lower spine curves to compensate as the Brain's ultimate goal is keeping your eyes level.
When your hip hurts, your Doctor of Chiropractic will examine and treat the WHOLE lower kinetic chain—the Spine, Pelvis, Hip, Knee, Ankle and Foot —as ALL are so closely related to each other.
When it comes to managing you and your hip pain, be prepared for management of any of the following:
Ankle pronation: This is the inward rolling of the ankle often associated with a flat foot. When viewing someone with ankle pronation from behind, the angle from the Achilles tendon to the ground will lean inward when it normally should be perpendicular.
Knocked-knees: Ankle pronation can result in “knocked-knees” (genu valgus) which overloads or jams the outer knee joint, over-stretching the inner knee joint and ligaments. The knee cap (patella) then rides excessively hard on the outer surface of the femoral groove in which it glides as one bends and straightens their knee, causing knee cap pain.
Hip inward angulation (or coxa vera): As the knee shifts inward or knocks, the head of the femur moves outward, leaving the joint less stable. Leg length deficiency (LLD)—or a short leg—occurs when the pelvis drops on that side further destabilizing the lower kinetic chain.
Once ankle pronation is properly corrected with a rear foot post and the hind foot is repositioned back to neutral (if LLD persists) a heel lift can be placed under the foot orthotic to corrective this imbalance. ONLY then will the pelvis become level and stable so it can properly serve as a strong foundation for the spine the rest of the body to rest on!
We haven’t touched the subject of muscle imbalance, strengthening of commonly weak hip extensor muscles, or stretching of overly tight hip flexors and adductor muscles—topics for another day! The good news— as a Chiropractor in Belfast Dr Jonathan Rice DC MChiro can help!
Many scientific studies have been carried out on the benefits and efficacy of Chiropractic to treat back pain—so much so that many G.P’s frequently refer patients with back pain to Chiropractors for this service. But what about neck pain?
Although it’s taken longer to carry out the research, there is now substantial evidence to support that Chiropractic for neck pain is equally as effective as it is for low back pain in regards to improving quality of life, function and pain levels.
Multiple reviews and meta-analyses (studies that evaluate the research over a series of years) indicate that manipulation, mobilisation and exercise all work, but appear to give the best long-term benefits when used in combination with each other. This is what is provided to our patients at Balmoral Spine Clinic
In the acute and subacute stages of neck pain, studies show cervical manipulation is more effective than various combinations of pain killers, muscle relaxants, and nonsteroidal anti-inflammatory drugs (NSAIDs) for improving pain and function in both the short and intermediate term.
Studies show that thoracic or mid-back adjustments are also very helpful for patients with neck pain. Chiropractic approaches often include a combination of spinal manipulation, spinal mobilisation, manual cervical traction, deep tissue trigger point and active release forms of therapy.
As noted above, the inclusion of exercise yields the best long-term benefits, especially for chronic neck pain. There are many exercises your Doctor of Chiropractic can show you.
If you are suffering from neck pain call Balmoral Spine Clinic on 028 9600 9075 to see if we can help