Pran Manga Ph.D. et al. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain. Ontario Ministry of Health 1993
This government funded report found:
"On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by Chiropractors is shown to be more effective than alternative treatments for low back pain." "There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management."
"There should be a shift in policy to encourage and prefer Chiropractic services for most patients with low-back pain." "A very good case can be made for making Chiropractors the gatekeepers for management of low-back pain."
Key Study Concepts:
The Manga Report represents the biggest and most extensive government initiated and funded review of the literature regarding the treatment of Low Back Pain in history.
The reason for the report was rising costs of healthcare. The main focus was on back pain and back pain related disability, and the lack of evidence for many commonly used treatments.
The study concluded:
"In our view, the constellation of the evidence of:
(1) the effectiveness and cost-effectiveness of Chiropractic management of low-back pain.
(2) the untested, questionable or harmful nature of many current Medical therapies.
(3) the economic efficiency of Chiropractic care for low-back pain compared with medical care.
(4) the safety of Chiropractic care.
(5) the higher satisfaction levels expressed by patients of Chiropractors, together offers an overwhelming case in favour of much greater use of Chiropractic services in the management of low-back pain.
Key Study Points:
Chiropractic has been found, by the most comprehensive independent, government initiated, government funded report in history, to be the most evidence-based, most effective, most cost-effective, safest option for patients with back pain that also produces the highest level of patient satisfaction.
If you are in the Belfast area and want to be helped with back pain - please contact our office on
028 9600 9075
Research Shows Spinal Issues Don't Recover Without Proper Care.
Itz, C.J. et al. (2013) Clinical course of non-specific low back pain: A systematic review of prospective cohort studies set in primary care. European Journal of Pain (17): 5-15
"The findings of this review indicate that the assumption that spontaneous recovery occurs in a large majority of low back pain patients is not justified. There should be more focus on intensive follow-up of patients who have not recovered within the first 3 months."
"The findings in this review are in stark contrast with current recommendations and guidelines for the treatment of patients with non-specific LBP, which are based on the assumption that in a large majority of patients spontaneous recovery occurs."
It is illogical to wait for back pain to just go away or to use medication to numb it. Similar to waiting for tooth pain to go away or to use pills to numb tooth pain.
If you are serious about recovering your health and function you need to address the cause of your back pain. You need to "fix the spinal cavities"; not simply try to numb the pain that its causing.
Ignoring the issue does not resolve it. Even if the pain temporarily goes away, the unresolved problem is still lurking in the tooth or spine. Unresolved issues get worse over time not better.
Important Take Home Points:
Evidence-based Chiropractors have always emphasized the fact that it is important to identify and address the cause of spinal pain.it is both illogical and unscientific to cover up the symptoms rather than fix problems and restore the patient's health and function.
The Chiropractic Research:
An important study illustrating the value of Chiropractic care for chronic low back pain patients was carried out at the University of Saskatchewan's Hospital Orthopedics Department by Dr. Kirkaldy-Willis, a world-renowned Orthopedic Surgeon. 300 subjects in the study were “totally disabled” by lower back pain, with pain present for an average of 7 years. All had gone through intensive, unsuccessful Medical treatment before participating in the study.
After 2 to 3 weeks of Chiropractic treatment, more than 80% of the patients had good to excellent results, reporting substantially increased mobility and decreased pain. After Chiropractic treatment, more than 70% were improved so much that they no longer suffered from work restrictions. Follow-up's a year later demonstrated that the changes after Chiropractic treatment were long-lasting. Even those with a narrowed spinal canal, generally considered the most challenging cases, showed a notable improvement.
Senna, M.K. and Machaly, S.A. (2011) "Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?" Spine. Aug 15;36(18):1427-37.
"This study confirms previous reports showing that spinal manipulation is an effective modality in chronic non-specific LBP especially for short-term effects as the disability and pain scores in our study are significantly reduced in the short-term evaluation - but not in long-term - when compared with the sham manipulation."
Oswestry Disability Score: "At the 4-month and 7-month evaluation the mean disability scores gradually elevated back toward the pretreatment level in the non-maintained SMT group. However disability score in the maintained SMT group continue improving."
"SMT is effective for the treatment of chronic non-specific LBP. To obtain long-term benefit, this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy."
This was a prospective single blinded placebo controlled study. That means this is a VERY high quality study.
Subjects were randomly assigned to their groups (no bias), there was a control to remove, as much as possible, the chance that improvements were from placebo, and assessments of improvement were performed by a blinded examiner (meaning the examiner did not know which group the patient was from - ie whether the patient had or had not been treated).
"Sixty patients, with chronic, non-specific LBP lasting at least 6 months, were randomized to receive either (1) 12 treatments of sham SMT over a 1-month period, (2) 12 treatments, consisting of SMT over a 1-month period, but no treatments for the subsequent 9 months, or (3) 12 treatments over a 1-month period, along with "maintenance spinal manipulation" every 2 weeks for the following 9 months."
"To determine any difference among therapies, we measured pain and disability scores, generic health status, and back-specific patient satisfaction at baseline and at 1, 4, 7, and 10 month intervals."
The outcome measures were Oswestry, Visual Analog Scale (VAS) for pain, SF-36 to measure quality of life, Patient Self Evaluation of Improvement, and Mobility tests.
"Patients in the second and third groups experienced significantly lower pain and disability scores than first group at the end of 1-month period (P = 0.0027 and 0.0029, respectively)."
"However, only the third group that was given spinal manipulations (SM) during the follow-up period showed more improvement in pain and disability scores at the 10-month evaluation."
"In the non-maintained SMT group, however, the mean pain and disability scores returned back near to their pretreatment level."
"At the 4 and 7-month evaluation the mean pain score gradually elevated back toward the pretreatment level in the non-maintained spinal manipulation therapy group. However, pain score in the maintained spinal manipulation therapy group continued improving."
"Spinal Manipulation Therapy is effective for the treatment of chronic low back pain. To obtain long-term benefit, this study suggests maintenance spinal manipulation after the initial intensive manipulative therapy."
Spinal mobility, spinal comfort, and spine-related functional ability and quality of life all showed the exact same trend; the group that received maintenance care not only maintained but increased mobility, comfort, function, and quality of life as time under maintenance care progressed over the 10 months.
The group that did not receive maintenance care not only failed to improve, they actually lost the improvements they had made during the first month.
MAIN CLINICAL GEM
For the first time we have peer-reviewed evidence from a well designed study that shows a maintenance chiropractic care program consisting of care every 2 weeks for up to 10 months not only prevents relapse and a waste of initial investment, it pays dividends in continued improvements!
Lower back pain can be localised to only the low back area or the pain can travel down the leg also. Localised lower back pain is often less complicated and usually has a more favourable prognosis for complete recovery. During your Chiropractic consultation, a large portion of the history and examination is focused on this differentiation between back pain and leg pain. This week's article aims to explain the different types of leg pain that can occur with different lower back conditions.
We’ve all heard the word “sciatica”. It is loosely used to describe everything from lower back pain coming from the facet joints in the back, from the sacroiliac joints, from the muscles of the low back, and even from compressed nerves caused by a ruptured disc in the lumbar spine.
For the sake of accurcy, the term “sciatica” should really only be used when the sciatic nerve is being compressed. The sciatic nerve is comprised of five nerves (L4, L5, S1, S2, S3) that come from the spine and sacrum and join to form one large nerve called the sciatic nerve. True sciatica occurs when any one of the five small nerves or the larger sciatic nerve itself becomes irritated or compressed. There are many causes for this irritation, such as a lumbar disc herniation, a mal-positioned vertebra aka "a spondylolisthesis", pressure from an arthritic bone spur growing off the vertebrae where the nerve exits aka “spinal stenosis”.
"Pseudosciatica" is caused by compression of the sciatic nerve by the piriformis muscle where the nerve passes under the buttocks. Other “pseudosciatica” causes include pain referred from the facet joints of the lower back which the patient often describes as a deep ache felt inside the leg.
Some direct trauma, like a bruise to the buttocks from a fall or pinching the nerve during an injection into the buttock area, can also trigger “sciatica.”
The most common symptoms of sciatica include: leg pain, buttocks pain, low back pain and foot or leg numbness and tingling. If the nerve compression is there for a long enough time, muscle weakness and wasting can occur. This weakness is noted during the Chiropractic examination by the Patient struggling to stand up on their tip toes leading to a limp when walking.
In the examination, your Doctor may raise your straightened leg and if the sciatic nerve is compressed, then a sharp pain can occur. If the pain occurs between 30 and 70° of elevation, this indicates a positive test for sciatica.
Testing the lower limb reflexes and skin sensation with a sharp object can give your Chiropractor clues where the is nerve damage is occuring.
The good news for patients in Belfast is that Chiropractic techniques can resolve this problem, thus helping you to avoid unnecessary surgery or the nasty side effects of prescription medication! So, check with your Doctor of Chiropractic first, before consulting the surgeon.
When low back pain strikes, we often think it’s a brand new problem. But why did coughing, twisting, or doing the hoovering cause injury this time? These are activities we normally do every day.
What is the problem this time?
The problem is caused by joint dysfunction. This is often a ligament or muscle problem that occurs by tiny micro-traumas repeated over many years, or sometimes a traumatic event such as car accidents or falls.
The ligaments can stretch or the muscles tighten, causing the joints and vertebrae in your spine to become displaced or stuck. This can irritate the delicate nerve fibers in the area. The body will usually find a way to compensate to take the pressure off that area over the next few days or weeks. The pain that accompanies this injury eventually lessens and sometimes goes away all on its own.
But has the problem really gone away?
Usually its still there in the background, because when ligaments or muscles are damaged, the repair mechanism involves the laying down of of scar tissue in the damaged area. Scar tissue is less elastic than the original tissue and this makes the joint vulnerable to re-injury. Oftentimes it impairs the normal motion of the spinal bones.
The Doctor of Chiropractic examines for this type of joint strain/sprain using a technique called motion palpation. They are looking for tenderness and swelling in the area. Sometimes x-rays are needed to see the directions the vertebrae have moved or whether they are moving at all. These specific analyses tell them the vulnerable joint directions and how the bones in the spine need to be repositioned to promote normal movement and good alignment.
When joint movements are faulty in the spine, it can lead to premature degeneration of the bones and discs and early arthritis in the area.
This may be why an everyday task such as hoovering the floor can flare up your back so easily. You may be performing the task with good posture but with faulty mechanics in the spine, a painful episode of back pain is a possible result.
Sometimes, the discs in the spine are so damaged that a simple cough or sneeze can lead to cause severe pain.
When these simple tasks seem to trip you up, there is likely an underlying problem that needs to be addressed and treated.
If you have been suffering with symptoms similar to this, please call our Belfast clinic to book an appointment with the Chiropractor.
There is a commonly held clinical belief that 90% of all low back pain episodes spontaneously self-resolve within a 60 day period.
It would appear that this commonly held “fact” may not be “factual” at all.
Possibly the most authoritative textbook of the 1970’s “Clinical Biomechanics of the Spine” was the main contributor to the 60 day self healing belief. An important comment was made on page 424 of the book.
“There are few diseases [low back pain] in which one is assured improvement of 70% of the patients 3 weeks and 90% of the patients in two months, regardless of the type of treatment employed.”
Firstly we need to ask where is this statement derived?
Reference J Dixon; Progress and Problems in Back Pain Research; Rheumatology and Rehabilitation; Volume 12, Number 4; November 1973; Pages 165-175.
Surprisingly the reference is not a scientific study at all. The reference is actually from a paper read at the Annual Meeting of the British Association for Rheumatology and Rehabilitation, London, March 1973.” (p. 165)
The first two sentences of the article are as follows:
“It is a great honor to be invited to talk to my own Medical School, but I am not noted for my contribution to back pain research nor for my startling observations into the biochemistry of the human intervertebral disc. My only contribution has been to show that patients with non-specific back pain more often do better in a rabbit-wool body belt than in a rigid spinal corset which they are more frequently prescribed.” (p. 165)
It is quite obvious, from Dixon’s own opening statement, he is not an expert on back pain, nor is he a back pain researcher of any kind.
Even though Dr. Dixon is the most often end reference of the natural history of back pain, a review of Dixon’s article finds that he actually quotes another article as well J Fry; Advisory Services Colloquia; “Back Pain and Soft Tissue Rheumatism”; Advisory Services (Clinical & General) Ltd., London; Number 1; 1972; Page 8
Dr. Fry’s contribution to the colloquium includes the following:
In an average GP practice each year 125 patients could be expected for soft tissue rheumatism or acute back pain.
“Of these 125 patients, 50 would be likely to be suffering from acute back pain and 25 from acute neck pain.”
“44% of the patients with acute low back pain lost their symptoms in less than one week and 82% in less than 4 weeks.”
Dr. Fry makes it abundantly clear that these numbers are from a retrospective review of his general practitioner practice of acute low back pain patients.
Dr. Fry provides no information regarding how he evaluated his patients and their progress or lack there of. Equally he fails to discuss how many patients he used to establish these statistics.
A more recent group of researchers, led by professor Peter Croft published in the British Medical Journal, actually took the time to evaluate the statistics on the natural history of low back pain that are frequently attributed to Dixon, and they unequivocally show Dixon’s statistics to be false.
Here is the review of the Croft Group article, the results speaks for themselves:
“Outcome of low back pain in general practice: a prospective study; British Medical Journal; May 2, 1998; Vol. 316, pp. 1356-1359; Peter R Croft, Gary J Macfarlane, Ann C Papageorgiou, Elaine Thomas, Alan J Silman”
KEY MESSAGES FROM AUTHORS:
1) It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month.
2) While 90% of subjects consulting the GP pactice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and related disability.
3) Only 25% of the patients who consulted about low back pain had fully recovered 12 months later.
KEY POINTS FROM THIS ARTICLE INCLUDE:
1)This prospective study of 463 patients with an acute episode of low back pain agrees with numerous other studies that indicate that approximately 90% of such patients will stop consulting their doctor about their back within three months. In this study the number was actually 92%.
2)However, this study is adamant that NOT seeing a doctor for a back problem does NOT mean that the back problem has resolved. This study showed that 75% of the patients with a new episode of low back pain have continued pain and disability a year later, even though most are not continuing to go to the doctor.
3)The belief that “90% of episodes of low back pain seen in general practice resolve within one month” is false, and based primarily upon one flawed study published in 1973 by Dixon. [As noted above, Dixon is NOT a study, and should not be referred to as such.]
4)It is generally believed that most low back pain episodes will be “short lived and that ’80-90% of attacks of low back pain recover in about six weeks, irrespective of the administration or type of treatment.'” This belief is untrue, false.
5)Many patients seeing their general practitioner for the first time with an episode of back pain will still have pain or disability 12 months later but not be consulting their doctor about it. [Very Important]
6)Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences.
7)90% of episodes of low back pain DO NOT end in complete recovery within a few months.
If you are part of the 92% with back pain that hasn't got better by itself, please contact our Belfast clinic to see if Chiropractic can help you.
Around 80% of people will suffer from back pain at some point in their lives. If it lasts for more than 3 months it is considered chronic back pain and can have a devastating effect on their overall quality of life.
Since back pain is usually multifactoral, there are some tips that can be used to ease the pain alongside Chiropractic treatment.
A 2017 study showed that simply taking adequate vitamin D supplementation produced significant benefits to those patients suffering with chronic lower back pain.
In the study, 68 patients with chronic lower back pain and low vitamin D levels were given an oral dose of 60,000 iu of vitamin D3 every week for 8 weeks.
The data showed that not only did the patient's vitamin D levels improve, but the participants also had a significant improvement in pain and disability throughout the course of the treament.
The authors concluded that Vitamin D supplementation can have a significant effect on the pain and disabilty of those suffering with chronic back pain.
Up to 75% of teens and adults have suboptimal levels of Vitamin D. Recent research has shown that vitamin D deficiency may be a risk factor for diseases such as cancer, depression, heart disase and diabetes.
Chiropractors frequently use supplementation and diet advice to help reduce the pain levels of our patients in Belfast.
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)
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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.