Altered sensorimotor integration with cervical spine manipulation
From: Journal of Manipulative and Physiological Therapeutics. 2008 Feb;31(2):115-26
Investigating changes in the intrinsic inhibitory and facilitatory interactions within the sensorimotor cortex subsequent to a single session of neck manipulation of the cervical spine using single and paired pulse transcranial magnetic stimulation protocols.
Twelve subjects with a history of reoccurring neck pain participated in this study. Short interval intracortical inhibition, short interval intracortical facilitation, motor evoked potentials, and cortical silent periods were recorded from the abductor pollicis brevis and the extensor indices proprios muscles of the dominant limb after single and paired pulse transcranial magnetic stimulation of the contralateral motor cortex. The experimental measures were recorded before and after spinal manipulation of dysfunctional cervical joints, and on a different day after passive head movement. To assess spinal excitability, F wave persistence and amplitudes were recorded after median nerve stimulation at the wrist.
After neck manipulations, there was an increase in short interval intracortical facilitation, a decrease in short interval intracortical inhibition, and a shortening of the cortical silent periods in abductor pollicis brevis. The opposite effect was observed in extensor indices proprios, with a decrease in short interval intracortical facilitation and a lengthening of the cortical silent periods. No motor evoked potentials or F wave response alterations were observed, and no changes were observed after the control condition.
Spinal manipulation of dysfunctional cervical joints in the neck may alter specific central corticomotor facilitatory and inhibitory neural processing and cortical motor control of 2 upper limb muscles in a muscle specific manner. This suggests that spinal manipulation may alter sensorimotor integration. These findings may help elucidate mechanisms responsible for the effective relief of pain and restoration of functional ability documented after spinal manipulation.
The Refractory Period of the Audible “Crack” After Lumbar Manipulation
From: Journal of Manipulative and Physiological Therapeutics Volume 31, Issue 3, March 2008, Pages 199-203
This study evaluates if side posture lumbar manipulation frequently used in chiropractic treatment of lower back pain is associated with a refractory period of the audible “crack” or popping sound of a joint and if so, to quantify this refractory period across subjects.
Three subjects were exposed to multiple “baseline” side posture manipulations until no further audible cracks or popping of the jointswere recorded. “Test-refractory period” manipulations were administered after a set time (ie, potential refractory period) at which point the number of audible cracks was recorded. The refractory period was declared when a minimum of 50% of the baseline audible “cracks” had recovered during the test lower back manipulations. The study design included 2 clinicians who performed side posture lumbar manipulation on asymptomatic subjects ranging from 38 to 49 years of age.
The refractory period was 40 minutes for subject A, 70 minutes for subject B, and 95 minutes for subject C. The average refractory period across subjects was 68.33 minutes. The audible “crack” recovery was maintained for the remaining test days once the refractory period had been met.
The audible “crack” heard during side posture lumbar manipulation is believed to originate from the zygapophyseal joints. This is supported by the presence of a refractory period and by the number of audible “cracks” found per manipulation.
Altered Sensorimotor Integration With Cervical Spine Manipulation
From: Journal of Manipulative and Physiological Therapeutics. Volume 31, Issue 2, February 2008, Pages 115-126
Investigating changes in the intrinsic inhibitory and facilitatory interactions within the sensorimotor cortex subsequent to a single session of cervical spine manipulation using single and paired pulse transcranial magnetic stimulation protocols.
Twelve subjects with a history of reoccurring neck pain participated in this study. Short interval intracortical inhibition, short interval intracortical facilitation (SICF), motor evoked potentials, and cortical silent periods (CSPs) were recorded from the abductor pollicis brevis and the extensor indices proprios muscles of the dominant limb after single and paired pulse transcranial magnetic stimulation of the contralateral motor cortex. The experimental measures were recorded before and after spinal manipulation of dysfunctional cervical joints, and on a different day after passive head movement. To assess spinal excitability, F wave persistence and amplitudes were recorded after median nerve stimulation at the wrist.
After cervical manipulations, there was an increase in SICF, a decrease in short interval intracortical inhibition, and a shortening of the CSP in abductor pollicis brevis. The opposite effect was observed in extensor indices proprios, with a decrease in SICF and a lengthening of the CSP. No motor evoked potentials or F wave response alterations were observed, and no changes were observed after the control condition.
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Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients
From: Journal of Human Hypertension (2007), 1–6
It is well known that achievement of blood pressure goals in more than 70% of hypertensive individuals requires two or more antihypertensive agents. Based on the most recent NHANES 1999– 2000 data, blood pressure control in the US has not improved significantly. Moreover, many people have searched for alternative methods for lowering arterial pressure.
Since the early 1940s, a small cadre of chiropractic specialists have foregone typical ‘full-spine manipulations’, limiting their practice to precise, delicate manual alignment of a single vertebra, C-1 or Atlas; these practitioners make up the National Upper- Cervical Chiropractic Association (NUCCA). Unlike other vertebrae, which interlock one to the next, the Atlas relies solely upon soft tissue (muscles and ligaments) to maintain alignment; therefore, the Atlas is uniquely vulnerable to displacement. Displacement of C-1 is pain free and thus, remains undiagnosed and untreated, whereas health-related consequences are attributed to other aetiologies.
Minor misalignment of the Atlas vertebra can potentially injure, impair, compress and/or compromise brainstem neural pathways. The relationship between hypertension and presence of circulatory abnormalities in the area around the Atlas vertebra and posterior fossa of the brain has been known for more than 40 years. Studies by Jannetta et al. note arterial compression of the left lateral medulla oblongata by looping arteries of the base of the brain in 51 of 53 hypertensive patients who underwent left retromastoid craniectomy and microvascular decompression for unrelated cranial nerve dysfunctions. Such compression was not present in normotensive patients. Treatment by vascular decompression of the medulla was performed in 42 of the 53 patients and amelioration of hypertension was noted in 76%.6 Moreover, studies to clarify the mechanism by which decompression of the left rostral ventrolateral medulla relieves neurogenic hypertension are summarized in a review. It is clear from these studies that a sub-population of hypertensive patients improved their blood pressure after microvascular decompression.
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Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study
From: Spine. 33(4S) Supplement:S176-S183, February 15, 2008
Study Design. Population-based, case-control and case-crossover study.
Objective. To investigate associations between chiropractic visits and vertebrobasilar artery (VBA) stroke and to contrast this with primary care physician (PCP) visits and VBA stroke.
Summary of Background Data. Chiropractic care is popular for neck pain and headache, but may increase the risk for VBA dissection and stroke. Neck pain and headache are common symptoms of VBA dissection, which commonly precedes VBA stroke.
Methods. Cases included eligible incident VBA strokes admitted to Ontario hospitals from April 1, 1993 to March 31, 2002. Four controls were age and gender matched to each case. Case and control exposures to chiropractors and PCPs were determined from health billing records in the year before the stroke date. In the case-crossover analysis, cases acted as their own controls.
Results. There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke.
Conclusion. VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.
Predictors of adverse events following chiropractic care for patients with neck pain
From: Journal of Manipulative and Physiological Therapeutics. 2008 Feb;31(2):94-103.
Neck pain is a common and costly complaint in Western society. Studies of neck pain have suggested that manipulation is an effective therapy, particularly when combined with exercise. However, as with other interventions, such as nonsteroidal
anti-inflammatory drug use, cervical manipulation is not without side effects. Although the rare cases of stroke after cervical manipulation are well documented, there is much less known about the more common adverse, but benign events.
Previous observational studies have described the type, frequency, duration, and intensity of adverse events after manipulative treatment of the neck and/or back, but much less is known about the predictors of these events. Only one of these studies has specifically examined cervical manipulation by chiropractors, which found headache and neck disability to be significantly associated with an adverse event. Given this, it remains to be verified whether these or other socio-demographic and/or clinical factors can be identified which are predictive of adverse events after treatment to the neck by chiropractors.
OBJECTIVE: This study examines which variables may predict adverse events in subjects undergoing chiropractic treatment for neck pain.
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Chiropractic: A Critical Evaluation.
From: Journal of Pain and Symptom Management 2008 Feb 13.
Chiropractic was defined by D.D. Palmer as “a science of healing without drugs”. About 60,000 chiropractors currently practice in North America, and, worldwide, billions are spent each year for their services. This article attempts to critically evaluate chiropractic. The specific topics include the history of chiropractic; the internal conflicts within the profession; the concepts of chiropractic, particularly those of subluxation and spinal manipulation; chiropractic practice and research; and the efficacy, safety, and cost of chiropractic. A narrative review of selected articles from the published chiropractic literature was performed. For the assessment of efficacy, safety, and cost, the evaluation relied on previously published systematic reviews. Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today. Currently, there are two types of chiropractors: those religiously adhering to the gospel of its founding fathers and those open to change. The core concepts of chiropractic, subluxation, and spinal manipulation, are not based on sound science. Back and neck pain are the domains of chiropractic but many chiropractors treat conditions other than musculoskeletal problems. With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition. Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.
Typical anti-chiropractic propaganda while promoting the same treatments through physical therapy and medical doctors.
Chiropractic management of intractable chronic whiplash syndrome
From: Clinical Chiropractic (2004) 7, 16—23
Hyperflexion extension injuries are common and often result in neck and low back pain. As a neuromusculoskeletal complaint, chiropractors, as primary healthcare clinicians, are increasingly providing treatment in such cases. In the case described, a 22-year-old female presented 3 years after a whiplash type injury complaining of chronic neck pain and stiffness and frontal headaches. The neck pain had commenced 24 h after a road traffic accident (RTA) and had remained severe for 2 weeks, during which time a soft collar was worn. The neck pain and stiffness had persisted and had worsened in the 6 months leading up to presentation. In addition, frontal headaches had also developed.
This case demonstrates that chronic whiplash injury patients can respond well to appropriate conservative management, even in the presence of poor prognostic indicators. The management protocol in this case consisted of chiropractic spinal manipulative therapy, soft tissue work and post-isometric relaxation (PIR) techniques to address biomechanical somatic dysfunction. In addition, active rehabilitation exercises, self-stretches and proprioceptive exercises were utilised to address postural and muscle imbalance. On the seventh treatment, the patient reported no neck pain, no headaches and unrestricted cervical spine range of motion. At 4 months follow-up, the patient continued to be free of headaches and neck stiffness and reported only mild, intermittent neck pain. This case demonstrates the use of chiropractic management of chronic whiplash type injuries. However, more high-quality evidence is required to support the use of chiropractic care for chronic and, indeed, acute whiplash cases.
The Quebec Task Force classification of Whiplash-Associated Disorders Grade Signs and symptoms:
- Grade 0 No complaint of pain or discomfort. No physical sign(s) of injury
- Grade 1 Neck complaint of pain, stiffness or tenderness only. No physical sign(s) of injury
- Grade 2 Neck complaint of pain, stiffness or tenderness and physical, musculoskeletal sign(s) of injury such as point tenderness or decreased range of motion
- Grade 3 Neck complaint of pain, stiffness or tenderness and neurological sign(s) or injury
- Grade 4 Neck complaint of pain, stiffness or tenderness and fracture or dislocation
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Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain
From: Ann Intern Med. 2002;136:713-722.
Background: Neck pain is a common problem in the general population, with point prevalences between 10% and 15%. It is most common at approximately 50 years of age and is more common in women than in men. Neck pain can be severely disabling and costly, and little is known about its clinical course. Limited range of motion and a subjective feeling of stiffness may accompany neck pain, which is often precipitated or aggravated by neck movements or sustained neck postures. Headache, brachialgia, dizziness, and other signs and symptoms may also be present in combination with neck pain. Although history taking and diagnostic examination can suggest a potential cause, in most cases the pathologic basis for neck pain is unclear and the pain is labeled nonspecific.
Objective: To determine the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner. Conservative treatment methods that are frequently used in general practice include analgesics, rest, or referral to a physical therapist or manual therapist. Physical therapy may include passive treatment, such as massage, interferential current, or heat applications, and active treatment, such as exercise therapies. Physical therapists can specialize in passive manual or hands on techniques, including mobilization or manipulation (high-velocity thrust techniques), also referred to as manual therapy. According to the International Federation of Orthopedic Manipulative Therapies, “Orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities”. (more…)
