Chiropractic News

Back Clinic Chiropractic News. El Paso, TX. Chiropractor, Dr. Alex Jimenez brings various chiropractic news articles dealing with the latest in adjustment techniques, technology, and medical discoveries. It is the third-largest area of medicine today. The word chiropractic comes from Greek meaning treatment by hand, which is exactly what chiropractors do they use their hands to manipulate the body and promote healing and wellness. A doctor of chiropractic (DC), chiropractor or chiropractic physician, is a health professional who is trained to diagnose and treat disorders of the musculoskeletal and nervous systems. Chiropractors treat patients of all ages, infants, children, and adults. They believe in a traditional (non-surgical) hands-on method of treating these disorders.

The chiropractic philosophy is dependent on the following belief statements: All bodily functions are connected as well as the healing process requires the entire body. A healthy nervous system, especially the spine, is an important factor in a healthy body. The spinal cord carries advice throughout the body and is accountable for many bodily functions including voluntary movements (such as walking) and involuntary functions (like respiration). When the systems of the body are in equilibrium, it is called homeostasis. Disorders of the bones, muscles, and nerves increase the risk of disorder along with other health problems and can disrupt homeostasis. When body systems are in harmony, the human anatomy gets the extraordinary ability to keep well-being and heal itself. For answers to any questions you may have please call Dr. Alexander Jimenez at 915-850-0900

Vertebrobasilar Stroke, Chiropractic Care & Risks

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic, Chiropractic News, Health, Physical Rehabilitation

Results Of A Population-Based Case-Control & Case-Crossover Study

J. David Cassidy, DC, PhD, DrMedSc,*�� Eleanor Boyle, PhD,* Pierre Co�te ?, DC, PhD,*�� Yaohua He, MD, PhD,* Sheilah Hogg-Johnson, PhD,�� Frank L. Silver, MD, FRCPC, and Susan J. Bondy, PhD�

SPINE Volume 33, Number 4S, pp S176 �S183 �2008, Lippincott Williams & Wilkins

Neck pain is a common problem associated with consid- erable comorbidity, disability, and cost to society.1�5 In North America, the clinical management of back pain is provided mainly by medical physicians, physi- cal therapists and chiropractors.6 Approximately 12% of American and Canadian adults seek chiropractic care annually and 80% of these visits result in spinal manipulation.7,8 When compared to those seeking medical care for back pain, Canadian chiropractic pa- tients tend to be younger and have higher socioeco- nomic status and fewer health problems.6,8 In On- tario, the average number of chiropractic visits per episode of care was 10 (median 6) in 1985 through 1991.7 Several systematic reviews and our best- evidence synthesis suggest that manual therapy can benefit neck pain, but the trials are too small to eval- uate the risk of rare complications.9 �13

Two deaths in Canada from vertebral artery dissection and stroke following chiropractic care in the 1990s attracted much media attention and a call by some neurologists to avoid neck manipulation for acute neck pain.14 There have been many published case reports linking neck manipulation to vertebral artery dissection15�and stroke.�The prevailing theory is that extension�and/or rotation of the neck can damage the vertebral artery, particularly within the foramen transversarium at the C1�C2 level. Activities leading to sudden or sustained rotation and extension of the neck have been implicated, included motor vehicle collision, shoulder checking while driving, sports, lifting, working over- head, falls, sneezing, and coughing.16 However, most cases of extracranial vertebral arterial dissection are thought to occur spontaneously, and other factors such as connective tissue disorders, migraine, hyper- tension, infection, levels of plasma homocysteine, vessel abnormalities, atherosclerosis, central venous�catherization, cervical spine surgery, cervical percutaneous nerve blocks, radiation therapy and diagnostic cerebral angiography have been identified as possible risk factors.17�21

The true incidence of vertebrobasilar dissection is un- known, since many cases are probably asymptomatic, or the dissection produces mild symptoms.22 Confirming the diagnosis requires a high index of suspicion and good vascular imaging. The cases that are most likely to be diagnosed are those that result in stroke.19,22 Ischemic stroke occurs when a thrombus develops intraluminally and embolizes to more distal arteries, or less commonly, when the dissection extends distally into the intracranial vertebral artery, obliterating branching vessels.22 The best incidence estimate comes from Olmstead county, where vertebral artery dissection causing stroke affected 0.97 residents per 100,000 population between 1987 and 2003.23

To date there have been two case-control studies of stroke following neck manipulation. Rothwell et al used Ontario health data to compare 582 cases of VBA stroke to 2328 age and sex-matched controls.24 For those aged 45 years, cases were five times more likely than con- trols to have visited a chiropractor within 1 week of VBA stroke. Smith et al studied 51 patients with cervical ar- tery dissection and ischemic stroke or transient ischemic attack (TIA) and compared them to 100 control patients suffering from other strokes not caused by dissections.25 Cases and controls came from two academic stroke cen- ters in the United States and were matched on age and sex. They found no significant association between neck manipulation and ischemic stroke or TIA. However, a subgroup analysis showed that the 25 cases with verte- bral artery dissection were six times more likely to have consulted a chiropractor within 30 days before their stroke than the controls.

Finally, because patients with vertebrobasilar artery dissection commonly present with headache and neck pain,23 it is possible that patients seek chiropractic care for these symptoms and that the subsequent VBA stroke occurs spontaneously, implying that the associ- ation between chiropractic care and VBA stroke is not causal.23,26 Since patients also seek medical care for headache and neck pain, any association between pri- mary care physician (PCP) visits and VBA stroke could be attributed to seeking care for the symptoms of verte- bral artery dissection.

The purpose of this study is to investigate the association between chiropractic care and VBA stroke and compare it to the association between recent PCP care and VBA stroke using two epidemiological designs. Evidence that chiropractic care increases the risk of VBA stroke would be present if the measured association between chiropractic visits and VBA stroke exceeds the association between PCP visits and VBA strokes.

Study Design

We undertook population-based case-control and case- crossover studies. Both designs use the same cases. In the case- control design, we sampled independent control subjects from the same source population as the cases. In the case-crossover design, cases served as their own controls, by sampling control periods before the study exposures.27 This design is most appropriate when a brief exposure (e.g., chiropractic care) causes a transient change in risk (i.e., hazard period) of a rare-onset disease (e.g., VBA stroke). It is well suited to our research questions, since within person comparisons control for unmeasured risk factors by design, rather than by statistical modeling.28 �30 Thus the advantage over the case control design is better control of confounding.

Source Population

The source population included all residents of Ontario (109,020,875 person-years of observation over 9 years) covered by the publicly funded Ontario Health Insurance Plan (OHIP). Available utilization data included hospitalizations with diagnostic coding, and practitioner (physician and chiropractic) utilization as documented by fee-for-service billings accompanied by diagnostic coding. We used two data sources: (1) the Discharge Abstract Database (DAD) from the Canadian Institute for Health Information, which captures hospital separations and ICD codes, and (2) the OHIP Databases for services provided by physicians and chiropractors. These data- bases can be linked from April 1992 onward.

Cases

We included all incident vertebrobasilar occlusion and stenosis strokes (ICD-9433.0 and 433.2) resulting in an acute care hospital admission from April 1, 1993 to March 31, 2002. Codes were chosen in consultation with stroke experts and an epidemiologist who participated in a similar past study (SB).24 Cases that had an acute care hospital admission for any type of stroke (ICD-9433.0, 433.2, 434, 436, 433.1, 433.3, 433.8, 433.9, 430, 431, 432, and 437.1), transient cerebral ischemia (ICD- 9435) or late effects of cerebrovascular diseases (ICD-9438) before their VBA stroke admission or since April 1, 1991 were excluded. Cases residing in long-term care facilities were also excluded. The index date was defined as the hospital admission date for the VBA stroke.

Controls

For the case-control study, four age and sex-matched controls were randomly selected from the Registered Persons Database, which contains a listing of all health card numbers for Ontario. Controls were excluded if they previously had a stroke or were residing in a long-term care facility.

For the case crossover study, four control periods were randomly chosen from the year before the VBA stroke date, using a time-stratified approach.31 The year was divided into disjoint strata with 2 week periods between the strata. For the 1 month hazard period, the disjoint strata were separated by 1 month periods and the five remaining control periods were used in the analyses. We randomly sampled disjoint strata because chiropractic care is often delivered in episodes, and this strategy eliminates overlap bias and bias associated with time trends in the exposure.32

Exposures

All reimbursed ambulatory encounters with chiropractors and PCPs were extracted for the one-year period before the index date from the OHIP database. Neck-related chiropractic visits were identified using diagnostic codes: C01�C06, cervical and cervicothoracic subluxation; C13�C15, multiple site subluxation; C30, cervical sprain/strain; C40, cervical neuritis/ neuralgia; C44, arm neuritis/neuralgia; C50, brachial radiculitis; C51, cervical radiculitis; and C60, headache. For PCP visits, we included community medicine physicians if they submitted ambulatory fee codes to OHIP. Fee codes for group therapy and signing forms were excluded. Headache or neck pain- related PCP visits were identified using the diagnostic codes: ICD-9307, tension headaches; 346, migraine headaches; 722, intervertebral disc disorders; 780, headache, except tension headache and migraine; 729, fibrositis, myositis and muscular rheumatism; and 847, whiplash, sprain/strain and other traumas associated with neck (These codes include other diagnoses, and we list only those relevant to neck pain or headache). There is no limit on the number of reimbursed PCP visits per year. However, there are limits chiropractors, but less than 15% of patients surpass them.24

Statistical Analysis

Conditional logistic regression was used to estimate the asso- ciation between VBA stroke after chiropractor and PCP visits. Separate models were built using different a priori specified hazard periods, stratified by age ( 45 years and 45 years) and by visits with or without head and neck pain related diag- nostic codes. For the chiropractic analysis, the index date was included in the hazard period, since chiropractic treatment might cause immediate stroke and patients would not normally consult a chiropractor after having a stroke. However, the in- dex day was excluded from the PCP analysis, since patients might consult these physicians after experiencing a stroke. We tested different hazard periods, including 1 day, 3 days, 1 week, 2 weeks, and 1 month before the index date. Exposure occurred if any chiropractic or PCP visits were recorded during the des- ignated hazard periods.

We also measured the effect of cumulative numbers of chiropractic and PCP visits in the month before the index date by computing the odds ratio for each incremental visit. These estimates were similarly stratified by age and by diagnostic codes related to headache and/or neck pain. Finally, we conducted analyses to determine if our results were sensitive to chiropractic and PCP visits related to neck complaints and headaches. We report our results as odds ratios (OR) and 95% confidence intervals. Confidence intervals were estimated by accelerated bias corrected bootstraps with 2000 replications using the variance co-variance method.33 All statistical analyses were per- formed using STATA/SE version 9.2.34

Results

A total of 818 VBA strokes met our inclusion/exclusion criteria over the 9 year inception period. Of the 3272 matched control subjects, 31 were excluded because of prior stroke, one had died before the index date and 76 were receiving long-term care. Thus, 3164 control subjects were matched to the cases. The mean age of cases and controls was 63 years at the index date and 63% were male. Cases had a higher proportion of comorbid conditions (Table 1). Of the 818 stroke cases, 337�(41.2%) were coded as basilar occlusion and stenosis, 443 (54.2%) as vertebral occlusion and stenosis and 38 (4.7%) had both codes.

Overall, 4% of cases and controls had visited a chiropractor within 30 days of the index date, while 53% of cases and 30% of controls had visited a PCP within that time (Table 2). For those under 45 years of age, 8 cases (7.8%) had consulted a chiropractor within 7 days of the index date, compared to 14 (3.4%) of controls. For PCPs, 25 cases (24.5%) under 45 years of age had a consultation within 7 days of the index date, com- pared to 27 (6.6%) of controls. With respect to the number of visits within 1 month of the index date, 7.8% of cases under the age of 45 years had three or more chiropractic visits, whereas 5.9% had three or more PCP visits (Table 2).

The case control and case crossover analyses gave similar results. (Tables 3�7) Age modified the effect of chiropractic visits on the risk of VBA stroke. For those under 45 years of age, there was an increased association between chiropractic visits and VBA stroke regardless of the hazard period. For those 45 years of age and older, there was no association. Each chiropractic visit in the month before the index date was associated with an in- creased risk of VBA stroke in those under 45 years of age (OR 1.37; 95% CI 1.04�1.91 from the case crossover analysis) (Table 7). We were not able to estimate boot- strap confidence intervals in some cases because of sparse data.

Similarly, we found that visiting a PCP in the month before the index date was associated with an increased risk of VBA stroke regardless of the hazard period, or the age of the subject. Each PCP visit in the month before the stroke was associated with an increased risk of VBA stroke both in those under 45 years of age (OR 1.34; 95% CI 0.94 �1.87 from the case crossover analysis) and 45 years and older (OR 1.52; 95% CI 1.36�1.67 from the case crossover analysis) (Table 7).

Our results were sensitive to chiropractic and PCP visits related to neck complaints and headaches, and we observed sharp increases in the associations when restricting the analyses to these visits (Tables 3�7). Overall,�these associations were more pronounced in the PCP analyses. However, the data are sparse, and we were unable to compute bootstrap confidence intervals in many cases.

Discussion

Our study advances knowledge about the association between chiropractic care and VBA stroke in two respects. First, our case control results agree with past case control studies that found an association between chiropractic care and vertebral artery dissection and VBA stroke.24,25 Second, our case crossover results confirm these findings using a stronger research design with better control of confounding variables. The case-crossover design controls for time independent confounding factors, both known and unknown, which could affect the risk of VBA stroke. This is important since smoking, obesity, undiagnosed hypertension, some connective tis- sue disorders and other important risk factors for dissection and VBA stroke are unlikely to be recorded in ad- ministrative databases.

We also found strong associations between PCP visits and subsequent VBA stroke. A plausible explanation for this is that patients with head and neck pain due to vertebral artery dissection seek care for these symptoms, which precede more than 80% of VBA strokes.23 Since it�is unlikely that PCPs cause stroke while caring for these patients, we can assume that the observed association between recent PCP care and VBA stroke represents the background risk associated with patients seeking care for dissection-related symptoms leading to VBA stroke. Be- cause the association between chiropractic visits and VBA stroke is not greater than the association between PCP visits and VBA stroke, there is no excess risk of VBA stroke from chiropractic care.

Our study has several strengths and limitations. The study base includes an entire population over a 9-year period representing 109,020,875 person-years of observation. Despite this, we found only 818 VBA strokes, which limited our ability to compute some estimates and bootstrap confidence intervals. In particular, our age stratified analyses are based on small numbers of ex- posed cases and controls (Table 2). Further stratification by diagnostic codes for headache and neck pain related visits imposed even greater difficulty with these estimates. However, there are few databases that can link�incident VBA strokes with chiropractic and PCP visits in a large enough population to undertake a study of such a rare event.

A major limitation of using health administrative data are misclassification bias, and the possibility of bias in assignment of VBA-related diagnoses, which has previously been raised in this context.24 Liu et al have shown that ICD-9 hospital discharge codes for stroke have a poor positive predictive value when compared to chart review.35 Furthermore, not all VBA strokes are secondary to vertebral artery dissection and administrative databases do not provide the clinical detail to determine the specific cause. To investigate this bias, we did a sensitivity analysis using different positive predictive values for stroke diagnosis (ranging from 0.2 to 0.8). Assuming non differential misclassification of chiropractic and PCP cases, our analysis showed attenuation of the estimates towards the null with lower positive predictive values, but the conclusions did not change (i.e., associations remained positive and significant�data not shown). The�reliability and validity of the codes to classify headache and cervical visits to chiropractors and PCPs is not known.

It is also possible that patients presenting to hospital with neurologic symptoms who have recently seen a chiropractor might be subjected to a more vigorous diagnostic workup focused on VBA stroke (i.e., differential misclassification).36 In this case, the predictive values of the stroke codes would be greater for cases that had seen a chiropractor and our results would underestimate the association between PCP care and VBA stroke.

A major strength of our study is that exposures were measured independently of case definition and handled identically across cases and controls. However, there was some overlap between chiropractic care and PCP care. In the month before their stroke, only 16 (2.0%) of our cases had seen only a chiropractor, while 20 (2.4%) had seen both a chiropractor and PCP, and 417 (51.0%) had�just seen only a PCP. We were not able to run a subgroup analysis on the small number of cases that just saw a chiropractor. However, subgroup analysis on the PCP cases (n 782) that did not visit a chiropractors during the 1 month before their stroke did not change the conclusions (data not shown).

Our results should be interpreted cautiously and placed into clinical perspective. We have not ruled out neck manipulation as a potential cause of some VBA strokes. On the other hand, it is unlikely to be a major cause of these rare events. Our results suggest that the association between chiropractic care and VBA stroke found in previous studies is likely explained by present- ing symptoms attributable to vertebral artery dissection. It might also be possible that chiropractic manipulation, or even simple range of motion examination by any practitioner, could result in a thromboembolic event in a patient with a pre-existing vertebral dissection. Unfortunately, there is no acceptable screening procedure to identify patients with neck pain at risk of VBA stroke.37 These events are so rare and difficult to diagnose that future studies would need to be multi-centered and have unbiased ascertainment of all potential exposures. Given our current state of knowledge, the decision of how to treat patients with neck pain and/or headache should be driven by effectiveness and patient preference.38

Conclusion

Our population-based case-control and case-crossover study shows an association between chiropractic visits and VBA strokes. However, we found a similar association between primary care physician visits and VBA stroke. This suggests that patients with undiagnosed vertebral artery dissection are seeking clinical care for head- ache and neck pain before having a VBA stroke.

Acknowledgments

The authors acknowledge the members of the Decade of the Bone and Joint 2000 �2010 Task Force on Neck Pain and its Associate Disorders for advice about de- signing this study. In particular, they acknowledge the help of Drs. Hal Morgenstern, Eric Hurwitz, Scott Haldeman, Linda Carroll, Gabrielle van der Velde, Lena Holm, Paul Peloso, Margareta Nordin, Jaime Guzman, Eugene Carragee, Rachid Salmi, Alexander Grier, and Mr. Jon Schubert.

References
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36. Boyle E, Co�te� P, Grier AR, et al. Examining vertebrobasilar artery stroke in two Canadian provinces. Spine, in press.
37. Co�te� P, Kreitz BG, Cassidy JD, et al. The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis. J Manip Physiol Therap 1996;159�64.
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Key words: vertebrobasilar stroke, case control stud- ies, case crossover studies, chiropractic, primary care, complications, neck pain. Spine 2008;33:S176�S183

From the *Centre of Research Expertise for Improved Disability Outcomes (CREIDO), University Health Network Rehabilitation Solutions, Toronto Western Hospital, and the Division of Heath Care and Outcomes Research, Toronto Western Research Institute, Toronto, ON, Canada; �Department of Public Health Sciences, Management and Evaluation, University of Toronto, Toronto, ON, Canada; �Department of Health Policy, Management and Evalua- tion, University of Toronto, Toronto, ON, Canada; �Institute for Work & Health, Toronto, ON, Canada; �University Health Net- work Stroke Program, Toronto Western Hospital, Toronto, ON, Canada; and Division of Neurology, Department of Medicine, Fac- ulty of Medicine, University of Toronto, Toronto, ON, Canada. Supported by Ontario Ministry of Health and Long-term Care. P.C. is supported by the Canadian Institute of Health Research through a New Investigator Award. S.H.-J. is supported by the Institute for Work & Health and the Workplace Safety and Insurance Board of Ontario. The opinions, results, and conclusions are those of the authors and no endorsement by the Ministry is intended or should be inferred.

The manuscript submitted does not contain information about medical device(s)/drug(s).
University Health Network Research Ethics Board Approval number 05-0533-AE.

Address correspondence and reprint requests to J. David Cassidy, DC, PhD, DrMedSc, Toronto Western Hospital, Fell 4-114, 399 Bathurst Street, Toronto, ON, Canada M5T 2S8; E-mail: dcassidy@uhnresearch.ca

How To Become A Chiropractor

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic, Chiropractic News, Physical Rehabilitation

How to Become A Chiropractor

Name: El Paso Back Clinic | Spine Specialists - El Paso, TX
Price range: $$

A chiropractor is a doctor who specializes in musculoskeletal and nervous system problems. It is the belief of the chiropractic community that problems in these areas can cause adverse health issues, including lowered resistance to disease, illness, and injury.

Chiropractors manipulate the spine to realign spinal joints in their patients. By doing so, patients are expected to experience optimum health without the assistance of drugs or surgery. Instead, chiropractors expect the body will heal itself once the spine and spinal joints are in proper alignment. Additionally, chiropractors consider and address other lifestyle factors which are commonly recognized as significantly affecting health such as diet, rest, exercise, heredity, and environmental factors. They also make other recommendations for changes which are expected to improve the patient�s overall health.

Chiropractors perform many of the same tasks as other general and specialty doctors. Patient health histories are gathered, physical, neurological, and orthopedic examinations are performed, and various laboratory tests, x-rays, and diagnostic imaging tools are used to diagnose and analyze the patient�s condition. Other forms of treatment may be used or recommended by the chiropractor including ultrasound, massage, heat, water, acupuncture, or electric currents. Prescription drugs and surgery are not part of the services provided by chiropractors. Chiropractors may recommend patients to see other doctors or specialists to address health issues or concerns outside of their area of expertise. Some chiropractors choose to specialize in a certain type of practice, such as orthopedics, neurology, sports injuries, internal disorders, diagnostic imaging, or pediatrics.
The Bureau of Labor Statistics predicts a job growth increase of 17% in the chiropractic field over the next seven years. An increasing public interest in alternative healthcare methods is beneficial to the chiropractic field. The public is seeking healthy living options which do not include prescription medicines or surgery; instead, a substantial number of people are searching for solutions which emphasize healthy lifestyles. The non-invasive procedures provided by chiropractors in answer to their patients health issues and concerns appeals to the segment of the public looking for these types of answers.

SELECTING THE RIGHT CHIROPRACTIC COLLEGE

Chiropractor students should select a college which offers a strong science degree or pre-medical program. Some colleges may have an affiliation with chiropractic training schools, which all future chiropractors must successfully complete. Research chiropractic schools to determine which one you are most interested in attending; this will help you to determine if the school is linked to any of the colleges you are considering. Courses in biology, chemistry, and physics will be important to individuals looking to work in a medical field. Electives may be concentrated in health, fitness, and nutrition. Students should, if given the opportunity, study topics and courses related to kinesiology and sports medicine. Courses in psychology and sociology will also help students to gain a more comprehensive understanding of people and society, better preparing them to serve the public. Additionally, business courses ensure that future professionals understand how to successfully manage a business in the complex healthcare field, as medical professionals must understand finances, medical insurance processing, business laws, business practices, business ethics, and medical records maintenance.

CHIROPRACTIC SCHOOLS

Students must attend chiropractic college in order to enter the profession. Upon completion of the program, students will have earned a doctorate in chiropractic medicine. The Council on Chiropractic Education, or CCE, is the nationally recognized accrediting agency by the United States Secretary of Education which regulates the quality of the curriculum offered at chiropractic colleges. Currently there are 15 CCE accredited chiropractic institutions in the United States. These include, as listed on the CCE website:

- Cleveland University Kansas City: Overland Park, KS
- D�Youville College Doctor of Chiropractic: Buffalo, NY
- Life University College of Chiropractic: Marietta, GA
- Life Chiropractic College West: Hayward, CA
- Logan College of Chiropractic: Chesterfield, MO
- Southern California University of Health Sciences: Whittier, CA
- National University of Health Sciences: Lombard, IL and Pinellas Park, FL
- New York Chiropractic College: Seneca Falls, NY
- Northwestern College of Chiropractic: Bloomington, MN
- Palmer College of Chiropractic: Davenport, IA; San Jose, CA; and Port Orange, FL
- Parker College Of Chiropractic: Dallas, TX
- Sherman College Of Chiropractic: Spartanburg, SC
- Texas Chiropractic College: Pasadena, TX
- University of Bridgeport College of Chiropractic: Bridgeport, CT
- University of Western States College of Chiropractic: Portland, OR

Students attend chiropractic college for four years. During this time, students are taught the scientific and academic skills and knowledge required to become experts in the field of chiropractic medicine. The final year is spent in practice, performing the functions of a chiropractic doctor under the supervision of an experienced professional. The curriculum includes intensive study of neuromusculoskeletal conditions, nutritional and holistic health, specialized and focused curriculum in areas of acupuncture and oriental medicine, applied nutrition, and various other disciplines. Students will complete extensive course hours in diagnosis, biochemistry, anatomy, chiropractic technique, and philosophy and ancillary therapeutic procedures.

TAKING THE NATIONAL BOARD EXAM

The National Board Exam for chiropractors is administered by the NBCE. The test is given twice each year. The exam consists of three parts. Part one is 110 multiple choice questions relating to general anatomy, spinal anatomy, physiology, chemistry, pathology, microbiology, and public health. The second part also consists of 110 multiple choice questions, but in the areas of general diagnosis, neuromusculoskeletal diagnosis, diagnostic imaging, and principles of chiropractic, chiropractic practice, and associated clinical sciences. Part three of the test consists of another 110 multiple choice questions and 10 case vignettes covering the areas of diagnosis or clinical impression, clinical laboratory and special studies examination, chiropractic techniques, case management, physical examination, case history, and roentgenologic examination. Each part of the test is timed. Additional specialized testing is offered for applicants who choose to pursue an area of specialization.

LICENSING FOR CHIROPRACTORS

After successful completion of an accredited chiropractic program, graduates will need to obtain a license to practice in their resident state or the state in which they intend to practice. State licensure regulations may vary from state to state. It is important to research your state�s regulations prior to completion of the doctor of chiropractic program to ensure all conditions are met. The Federation of Chiropractic Licensing Boards is a nonprofit organization which provides a link to the licensure information in all states. Locate information for each state through this directory.
The information provided includes licensing fees, renewal requirements, national board testing requirements, security and criminal check requirements, additional certification requirements, continuing education, and malpractice insurance requirements. A link to each state licensing board is also provided.

CONTINUING EDUCATION FOR CHIROPRACTORS

The chiropractic field is experiencing an increase in advancements in technology and knowledge through research and academic exploration. Changing regulations are also an area in which chiropractic doctors will need to remain current. Each state maintains their own continuing education requirements upon which licensing will be contingent. Twenty-four credit hours of continuing education every two years is a common requirement. All programs must be board approved and conducted by approved colleges or chiropractic associations or organizations. Check with your state licensing board to determine if the program has been approved prior to enrollment.

PRACTICING AS A CHIROPRACTOR

After obtaining a doctorate and passing the licensing examination, a new chiropractor has many options ahead of them. Most chiropractors will end up working solo or in a group practice, with about one in three being self-employed. A small group will work in hospitals or physicians� offices. The median pay for Chiropractors in 2016 was $67,520, with the lowest 10 percent earning less than $32,380, and the highest earning more than $141,030. Chiropractors can further increase their salary by building up a strong client base and developing their own practice. Many times, chiropractors will work in the evening or on weekends to accommodate their patients.

DAY TO DAY PRACTICE

Chiropractors will spend a lot of time on their feet as they examine and treat patients. Some of the most important qualities that a chiropractor can have include decision-making, detail-oriented, dexterity, empathy, and interpersonal skills. If the chiropractor is operating his or her own practice, the ability to manage a staff of employees like secretaries and nurses is vital to the success of the practice. An understanding of the current healthcare system is also important, as that will determine what kind of payments a chiropractor may be able to receive, unless they work in a cash-only system. More information can be found in the Occupational Outlook Handbook provided by the BLS.

CHIROPRACTIC SPECIALTIES AND CERTIFICATIONS

Another way for chiropractors to increase their annual earnings or skills would be to specialize in one or more areas. Specializations can help a chiropractor better diagnose and treat chronic illnesses, sports injuries, and/or complex occupational injuries. The American Chiropractic Association and American Board of Chiropractic Specialties (ABCS) lists 14 specialties and provides guidance to maintain standards of chiropractic certification. These include, as listed on the American Chiropractic Association website:

Certifying Body or Bodies	Certification	Description
American Chiropractic Board of RadiologyDiplomate (DACBR)	Chiropractic Diagnostic Imaging (DACBR) Specialist	Has additional training in interpreting diagnostic imaging results such as x-rays, CT scans, MRIs, and ultrasounds.
American Chiropractic Rehabilitation BoardDiplomate (DACRB)	Chiropractic Physiotherapy and Rehabilitation (DACRB) Specialist	Has had extensive postgraduate training in physiologic therapeutics and rehabilitation to better treat injuries that may have resulted from an accident or a sports injury.
American Chiropractic Rehabilitation BoardDiplomate (DACRB)	Chiropractic Acupuncture (DABCA) Specialist	Treats a wide variety of health conditions that include all body systems and tissues, and focuses special attention on the relationship between the spine, nervous system, and the meridian system.
American Clinical Board of NutritionDiplomate (DACBN) OR Chiropractic Board of Clinical NutritionDiplomate (DCBCN)	Chiropractic Nutrition (DACBN/CBCN) Specialist	Is trained to encourage and promote a more advanced knowledge and use of nutrition in the practice of chiropractic for the maintenance of health and the prevention of disease.
American Board of Chiropractic InternistsDiplomate (DABCI)	Chiropractic Diagnosis and Management of Internal Disorders (DABCI) Specialist	Is trained as a holistic primary care physician specializing in modern medical diagnosis, functional medicine, and natural therapeutics.
Academy of Chiropractic Orthopedists Fellow (FACO)	Chiropractic Orthopedist (DACO/DABCO) Specialist	Has special knowledge of both the normal function and diseases of the bones, joints, capsules, discs, muscles, ligaments, and tendons, as well as their complete neurological components, referred organ systems and contiguous tissues, and is able to diagnose and treat the conditions related to them.
American Chiropractic Neurology BoardDiplomate (DACNB) and sub-specialties: American Chiropractic Academy of Neurology Diplomate (DACAN) American Board of Chiropractic Neurology Diplomate (DABCN) American Board of Electrodiagnostic Specialties Fellow (FABES) American College of Functional Neurology Fellow (FAFCN) American Board of Vestibular Rehabilitation Fellow (FABVR) American Board of Childhood Developmental Disorders Fellow (FABCDD) American Board of Brain Injury & Rehabilitation Fellow (FABBIR) American Board of Neurochemistry & Nutrition Fellow (FABNN)	Chiropractic Clinical Neurologist (DACAN/DACNB) Specialist	Is a DC specially trained in the clinical evaluation and treatment of conditions involving the central and peripheral nervous systems.
American Board of Forensic ProfessionalsDiplomate (DABFP)	Diplomate of the American Board of Forensic Professionals (DABFP)	Performs an orderly analysis, investigation, inquiry, test, inspection, and examination in an attempt to obtain the facts of a case, from which to form an expert opinion.
American Chiropractic Board of Sports Physicians Diplomate (DACBSP) OR Certified Chiropractic Sports Physician (CCSP)	Chiropractic Sports Physician (CCSP/DACBSP) Specialist	Is trained in chiropractic sports medicine and exercise science in order to treat sports injuries, enhance athletic performance, and promote physical fitness.
American Chiropractic Board of Occupational Health Diplomate (DACBOH)	Chiropractic Occupational Health (DACBOH) Specialist	A DC trained in health care diagnosis and treatment choices for workplace neuromusculoskeletal injuries who is able to provide a broad range of work-related injury and illness prevention services for employee populations.
American Board of Chiropractic AcupunctureDiplomate (DABCA)	Diplomate of the American Board of Chiropractic Acupuncture (DABCA)	Dedicated to promoting high standards of competence and preserving the integrity of using acupuncture as an adjunct therapy to chiropractic treatment.
American Board of Chiropractic Pediatrics	Diplomate in Clinical Chiropractic Pediatrics (DICCP)	Support members who take care of children in their chiropractic practices, and to promote the acceptance and advancement of pediatric chiropractic care.

These specialty �degrees� are given by their corresponding boards, which also maintain the level of expected qualifications and standards of excellency.

Chiropractic Can Tune Up The Brain

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic News

New studies in neuroscience suggest chiropractic care affects much more than back and neck pain. Celeste McGovern investigates an emerging body of evidence that spinal manipulation also improves your brain.

Imagine a convention that mixes cutting-edge natural health seminars with a surfer dude�s attitude, a revivalist�s enthusiasm and a good measure of live rock-�n-roll. That�s the California Jam, which took place in Costa Mesa in January. Billed as �the biggest health, wellness and chiropractic event on the planet�, it�s an annual meeting of thousands of unapologetically alternative practitioners who mill about three floors of exhibitions, sampling detox juices, protein snacks, �bulletproof� coffee and vitamins.

There�s a buzz about urine tests for metabolites; people are talking cellular detoxification and energy-balancing therapies, and they�re trading spinal adjustments on a row of tables. Inside the auditorium, a roster of headliner speakers takes the stage for two days, but one of the biggest ticket draws this year was a relatively unknown figure: neurophysiologist and chiropractor Heidi Haavik, who is pioneering a whole new field of research into what happens to a person�s brain when a chiropractor adjusts their spine.

�There is so much more to chiropractic care than back and neck pain, and headaches,� enthuses Haavik, who studied neuroscience after graduating from the New Zealand College of Chiropractic and is now focusing on research.

Up to now, there�s been a gulf between the available published research and the practice. A handful of studies have shown that chiropractic works only modestly�yet substantially better than drugs�at nipping neck and back pain,1 and may help with migraine,2 and even mysteriously lower blood pressure3 which, for 40 years, has been linked to joint dysfunction in the neck.

But the research is hardly enough to support its position as the most popular alternative medical treatment for more than a century, used by 30 million people in the US alone each year.

�Haavik�s research may finally explain scientifically the amazing results chiropractors have in clinical practice,� says Ross McDonald, a practising chiropractor and President of the Scottish Chiropractic Association.

The neuroscience studies explore the underlying mechanism of those results�how the spine and central nervous system (CNS) are interconnected and �talk� to each other, and how dysfunction in the spine can affect health and well-being.

One of Haavik�s studies, published this year in the journal Brain Sciences, looked at the effect of chiropractic adjustments in 28 patients with �subclinical� pain�those with a history of intermittent back or neck ache or stiffness for which they were never treated�but who were in pain the day of the experiment. On examination, all had tender spots and restricted joint movement in their spines.

Compared with �sham� adjustments, chiropractic spinal adjustments of these people induced significantly greater brain activity, or �cortical excitability� (which has to do with neuro-electrical signals produced when brain or peripheral muscles are stimulated), as measured by transcranial magnetic stimulation (TMS), which uses magnetic fields to stimulate nerve cells in the brain, as well as arm and leg muscle strength.

Increases in muscle strength have proved to be driven by brain activity resulting from spinal manipulation, and not by any changes made to the spinal cord itself. This offers a host of possibilities for, say, recovering muscle strength after nervous-system injuries. As the study concluded, �spinal manipulation may therefore be indicated� for patients who have lost muscle tone, or are recovering from a stroke or from orthopedic surgery that affects the muscles. It may even be of interest to athletes who participate in sports.4

These findings have confirmed a 2015 study which showed that, following a full-spine chiropractic adjustment session, voluntary leg muscle strength in study participants increased by 16 per cent, while electrical activity readings from the measured muscle increased by nearly 60 per cent. But most spectacularly, the researchers (from the Centre for Chiropractic Research in New Zealand) discovered a 45 per cent increase in the reflex pathway �drive� from the brain to muscle (an indicator of the ability of the brain to activate it). By contrast, the control participants who underwent the sham adjustment actually lost strength and brain drive to the measured muscle.5

This same Auckland-based team, led by Haavik and two colleagues are now embarking on some groundbreaking research involving brain-body communication in stroke patients.6 A preliminary study had tested the effect of a single chiropractic adjustment on 12 stroke patients, and found that it increased leg muscle strength by an average of 64 per cent and brain drive to the limb by more than 50 per cent. In contrast, both measurements fell after the sham adjustments in the controls.

Ordinarily, you wouldn�t expect to see muscles gain in strength after being asked to repeatedly resist something because muscles become fatigued. Now, that we have the technology to objectively measure an increase in muscle strength after an intervention, Haavik says, these results suggest that�chiropractic care is not only preventing fatigue, but making [muscles] even more efficient at producing force�.

The potential results of the new study could have a significant impact on the role of chiropractic care in people who have reduced muscle function as a result of stroke, she says.

Injury Risk

One interesting recent study by Haavik and her colleagues looked specifically at the impact of chiropractic on the risk of falls among older people.7

Falling is a significant cause of death, injury and health decline in the elderly, with about 30-40 per cent of older adults who still live independently suffering from at least one fall each year or more as they age.

In this randomized controlled trial, half of the group of 60 community-dwelling people, aged over 65 and living in Auckland, received 12 weeks of chiropractic care (two visits per week), while the other half received the �usual care�, which didn�t include seeing a chiropractor.

The patients were tested on their proprioception (in this case, their awareness of where their ankle joint was positioned), postural stability and ability to process �multi-sensory� information�a sound-induced flash illusion test, using flashing lights and beeps. This test is used to screen for fall risk, as it measures how well people can process two different kinds of stimuli at a time.8 The participants were also given a sensorimotor function test, which measured their ability to move their feet in response to a panel that suddenly lit up on the floor, plus a questionnaire based on their self-perceived health-related quality of life.

Over the 12 weeks of the study, the group receiving chiropractic care showed significant improvement in ankle joint position sense, meaning their brains may have become more accurately aware of what was going on in their feet; they were also able to react and move their foot onto the illuminated panel on the floor more quickly than before the chiropractic care. These improvements were not seen in the control group.

The chiropractic patients were 13 per cent better able to accurately report the correct number of flashes with the corresponding number of beeps�meaning they had lowered their risk for falls.

What�s more, at the end of the study, the participants who had received the chiropractic care reported a 2.4-fold increased improvement in the quality-of-life questionnaire compared with the controls.7

Your Plastic Brain

Haavik is now trying to explain how chiropractic achieves all this, and why restoration of proper movement is able to so profoundly affect the brain and overall health.

The CNS�the brain and spinal cord�and all the nerves beyond the CNS (the peripheral nervous system, or PNS) is a complex network comprising as many as 10 billion nerve cells (also called �neurons�) and 60 trillion synapses�tiny little junctions between neurons that mediate the �talk� across highly specialized neural circuits via chemicals called �neurotransmitters�. Indeed, nerves feed out of each segment of the spine like strands of spaghetti, and facilitate communication back and forth with various regions of the body.

Everything we do�from our basic motor reflexes to our capacity to experience abstract thoughts and feelings�relies on the precision of the computational processes performed by these CNS and PNS neural circuits. They, in turn, depend on having healthy excitatory and inhibitory systems.

A neuron gets �excited� when it�s �talked to� loudly enough, or stimulated, and this sends an electrical message down one of the neuron�s extensions (called �axons�), so allowing it to talk to another nerve cell by releasing more neurotransmitters at the synapses.

Such talk happens all the time as input comes in from our external senses (eyes, ears, mouth, nose and touch), as well as through an inner �map� of the location of our muscles and joints in three-dimensional space relative to each other (proprioception), as the brain carries out its decisions and functions.

Contrary to decades of scientific dogma, a recent wave of research has shown that the brain is actually highly adaptable to its ever-changing environment throughout life. It does this by keeping an up-to-date tab on its sensory inputs and its internal map of the self. This ability to adapt is known as �neural plasticity�.

Haavik likens the plasticity of the CNS to the subtle changes in the bed in a flowing stream. �You can never really step into the same river twice; the water, stones and silt of the riverbed are constantly changing,� she says. Likewise, your brain is changing with every thought and every execution, and is in a constant state of flux.

In fact, she believes her research demonstrates that vertebral subluxations (dysfunctional spinal segments; see box, page 33) lead to a breakdown in the way the brain perceives and controls the movement of the spine. And this spinal dysfunction doesn�t just affect how the brain then perceives and controls the spine, but also how it perceives and controls other parts of the body as well.

When the brain gets even slightly wrong information, it builds a faulty map that can impede neural signaling as effectively as damped sensory input�like wearing a blindfold or losing the sense of taste. And that translates to faulty functioning.

Chronic pain and neurodegenerative disorders have been linked to these faulty perceptions by the plastic brain.9 �Pain and conditions with other symptoms don�t necessarily happen all of a sudden for no reason. They can slowly develop without your awareness, a bit like a thousand straws on a camel�s back before it breaks,� says Haavik. �Only when the last straw is added do you feel the effect.�

Haavik�s team hypothesizes that spinal adjustments that restore normal movement also restore more normal data input from the spine to the brain. This, in turn, allows the spinal cord, brain stem and brain to process any incoming information more coherently.

�We believe this to be the mechanisms by which adjustments of vertebral subluxations can improve nervous system function, as observed daily in chiropractic practices all around the world.�

While the New Zealand researchers are reluctant to speculate on immunity, an emerging body of research is demonstrating the interconnectedness of both the nervous and immune systems too. An entirely new lymphatic system in the brain was only discovered in 2015 by a team of researchers at the University of Virginia,10 which highlights how limited our understanding of the brain, and the effect of the nervous system on global health, still is. It also raises further questions about how improving one system can lead to improvement in the other�and so perhaps why some people experience benefits to their immune-mediated disease with chiropractic manipulations.

�What is becoming clear is that chiropractic care seems to impact our brain�s inner reality by restoring the proper processing and integration of sensory information, which alters the way our brain controls our body,� says Haavik.

�It�s so exciting to see that there are other possible ways now to explain the effects of chiropractic that are actually congruent with current neuroscience,� she adds. �It�s actually more profound and powerful than we could have ever thought.�

The Many Faces Of Chiropractic

There are two schools of thought in chiropractic: the �mechanics�, who claim it should be absorbed into mainstream medicine as a standardized treatment for back and neck pain; and the �vitalists�, who believe that the treatment is much more far-reaching, as they�ve seen it help cases of fatigue, joint pain, migraines, allergies, asthma, bedwetting and even infertility.

The latter philosophy is radically different from the current medical paradigm. �The body has an innate ability to heal, provided there is no interference,� says Gilles LaMarche, vice president of professional relations at Life University in Atlanta, Georgia, the world�s largest chiropractic college. �It is self-developing, self-maintaining and self-healing.�

In this vitalistic view of chiropractic, when you get an infection or scrape your knee, the best practitioner merely assists the body in getting on with its own spontaneous and spectacular business of healing itself.

The chiropractor�s job, as vitalists see it, is to remove any interference in the body at the level of the spine, which they consider central.

�Conventional medicine doesn�t interpret symptoms as we interpret symptoms,� explains LaMarche from his end of chiropractic.

He sees fever, for instance, as one of the body�s natural mechanisms to fight infection: raising the body�s temperature kills bacteria and viruses, and facilitates other immune functions.

�Many doctors see fever as bad, as something to reduce,� he says, �and they give Tylenol [paracetamol], not considering it as a toxin that is actually going to stay in the liver and therefore interfere with healing and health.�

How Chiropractic Changes The Brain

So what�s going on in the brain after a chiropractic adjustment that could be increasing muscle strength in stroke patients? As a 2016 study from Aalborg University Hospital in Denmark demonstrated, a single chiropractic adjustment helps to improve something called �somatosensory integration� (when the brain receives accurate sensory input, so allowing it to properly organize and execute subsequent behaviors).1

Such a change mostly happens in the prefrontal cortex, that part of the brain known to be a key player in executive functions. It�s a sort of command control centre, integrating and coordinating the multiple neural inputs from a constantly changing environment to solve problems and achieve goals.

�Chiropractic care, by treating the joint dysfunction, appears to change processing by the prefrontal cortex,� the authors conclude.

So, while some chiropractors (and their patients) may have thought their adjustments were making changes locally and directly from the spine, in fact, the change is apparently effected indirectly by being sent to �central command� (the brain), then redirected back down neuronal chains to give the perception of reduced pain as well as other benefits.

�This suggests that chiropractic care may, as well, have benefits that exceed simply reducing pain or improving muscle function and may explain some claims regarding this made by chiropractors,� the study researchers say.

These claims include the ability of adjustments to increase muscle strength and core stability, improve reaction time and proprioception (your awareness of your body�s position in space), and so reduce the risk of injury.

What Is A Subluxation?

In 1895 in Iowa, the founder of chiropractic, Daniel David Palmer, claimed to have restored the hearing of deaf janitor Harvey Lillard by adjusting the part of his spine that Palmer could feel was �out of alignment�.

From this, he devised a theory that �misaligned� or �out-of-place� spinal segments interfere with proper nerve function, and that �adjusting� these segments back to their normal position relieves pressure on the nerves and restores neural function.

Chiropractors assess spines for areas where some of the small muscles that attach to the individual vertebrae have become tight due to injury, hunching over mobile phones and computers, or simply overuse. When these tight muscles cause the vertebrae�the small bones that make up the spine�to twist, certain parts of the bones can protrude and feel �misaligned� or �stuck�. Chiropractors call it a vertebral �subluxation� or �joint restriction�.

�It is more that a bone is functioning or moving in a less than ideal way�in a manner that is not �normal� for the body,� says Heidi Haavik.

And chiropractors counter this abnormality by �adjusting� it. �We don�t really put bones back in place when we adjust the spine,� she explains. The aim of the short, quick movements of chiropractic adjustments to the spine are to restore its natural range of movement.

How To Find A Good Chiropractor

All chiropractors must attend a licensed chiropractic college or university, and undergo at least four years of training in anatomy, neurology, physiology, radiology, pathology, clinical diagnostics and clinical nutrition, as well as physiotherapy and chiropractic techniques.

In the UK, chiropractors must pass a national exam to ensure competency. It is illegal to practice without first registering with the General Chiropractic Council.

Apart from these legal requirements, chiropractors have a broad range of approaches, specialities and techniques. Make sure to choose a chiropractor who:

��Meets your particular needs. Some chiropractors take a biomechanical approach, or treat a narrow range of conditions and only see people when they have a problem, like pain, while others take a �wellness� approach and treat people to prevent problems. Many chiropractors have special areas of focus: sports injuries, pregnancy, children, or even functional medicine, testing for metabolic deficiencies such as low vitamin D levels and prescribing supplements.

� Has a good reputation. It�s worth considering if other people have had good results.

� Talks with you at no cost to discuss your needs and their skills and services, and employs techniques that suit you. Some chiropractors use manual adjustments only, while others use devices like drop-tables�examination tables that move when the chiropractor adjusts so the impulse is delivered by the release-action of the table�and activators�hand-held tools that resemble a tire-pressure gauge and are spring-activated to deliver small and precisely controlled impulses to areas like the cervical (neck) spine. Some may also be trained in techniques like acupuncture, dry needling (acupuncture needles are inserted in muscle tissue to stimulate the release of �trigger points�, where muscles have gone into spasm) and active release technique (ART), which also targets contractions of muscles, ligaments and tendons to reduce joint stress.

� Carries out a thorough assessment before beginning treatment. A medical history and physical exam should be done to rule out conditions that need further referral or should not be treated by chiropractic. A chiropractor is trained to perform and read X-rays, which are sometimes required, but only if they meet standardized criteria.

� Gives you clear outcome measures to gauge improvement, such as less pain or an overall improved sense of wellbeing.

� Gives you enough time and attention. The best practitioner is also a coach or partner who can help you achieve your best state of health. Only choose someone who truly supports you.

Source: �Celeste McGovern

MRI To Evaluate Lumbar Posterior Ligament Complex Post Trauma

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic News

The importance of Magnetic Resonance Imaging to evaluate the integrity of the lumbar posterior ligament complex post trauma.

Abstract: Posterior ligamentous complex(PLC), consisting of the supraspinous ligament, interspinous ligament, ligamentum flavum, and the facet joint capsules is thought to contribute significantly to the stability of the lumbar spine. There has been much debate on whether Magnetic Resonance Imaging(MRI) is specific and sensitive in diagnosing pathology to the PLC. The objective is to determine the necessity of MRI imaging for evaluating the integrity of the lumbar posterior ligament complex post trauma.

Key Words: Magnetic Resonance Imaging(MRI), interspinous ligament, posterior ligament complex, low back pain, ligament laxity, electromyography, impairment rating

A 41-year-old male, presented to my office for an examination with complaints of low back pain with numbness, tingling and weakness into the left lower extremity after he was the restraint driver in a motor vehicle collision approximately three and a half months� post trauma.�He�rated the pain as a�3/10 on a visual analog scale with 10/10 being the worst and the pain and noted the pain as being�present most of the time.� He stated that he was on pain killers daily and this helped manage his daily activities. Without pain killers his pain levels are rated 8/10 being present most of the time. The pain killers stated by the patient are Oxycodone and Naproxen.
He�reported that the pain would be aggravated by activities which required excessive standing, repetitive bending, and lifting. He further noted that in the morning the pain was increased and his left leg would be numb and weak for about the first hour.

The patient stated that his care to date had been managed by a pain management clinic and that he had minimal improvement with treatment which has included physical therapy and massage therapy. He reported the pain clinic next recommended steroid injections which he refused. He states there has been was no imaging ordered and that an Electromyography(EMG) had been performed. He was told the test was negative for pathology.

Prior History: No significant medical history was reported.
Clinical Findings:�The patient is 6�0� and weighs 210 lbs.

Physical Exam Findings:

Cervical Spine:
Cervical spine range of motion is full and unrestricted. Maximum cervical compression is negative. Motor and other regional sensory exam are unremarkable at this time.

Thoracic Spine:
Palpation of the thoracic spine region reveals taught and tender fibers in the area of the bilateral upper and mid thoracic musculature. Thoracic spine range of motion is restricted in flexion, extension, bilateral lateral flexion, and bilateral rotation. Regional motor and sensory exam are unremarkable at this time.

Lumbar Spine:
Palpation of the lumbosacral spine region reveals taught and tender fibers in the area of the lumbar paraspinal musculature. Lumbar spine range of motion is limited in flexion, extension, bilateral lateral flexion and bilateral rotation. Extension restriction is due to pain and spasm. Straight leg raise causes pain at approximately 50 degrees when testing either side in the left low back. There is no radicular symptomatology down the leg. Kemp�s maneuver recreates pain in the L4 region on the left. No radicular symptoms are noted. The patient is able to heel and toe walk. Regional motor and sensory exam is unremarkable at this time other than L4, L5 and S1 dermatomes having decreased sensation with light touch.

Muscle testing of the upper and lower extremities was tested at a 5/5 with the exception of the left quadricep tested at a 4/5.� The patient�s deep tendon reflexes of the upper and lower extremities were tested including triceps, biceps, brachioradialis, patella, and Achilles and all were tested at 2+ bilaterally except the left patellar reflex was 1+.

RANGES OF MOTION EVALUATION

All range of motions are based on the�American Medical Association�s Guides to the Evaluation of Permanent Impairment, 5^th�Edition¹�and performed by a dual inclinometer for the lumbar spine.

�� Range of Motion��Normal�� Examination�� % Deficit

Flexion	60	48	20
Extension	25	12	52
Left Lateral Flexion	25	16	36
Right Lateral Flexion	25	18	28

An MRI was ordered to rule out gross pathology.

Imaging:

�

A lumbar MRI reveals;
1)�� Mild disc bulges at T11-T12, T12-L1, L1-L2 and L5-S1
2)�� Low disc signals indicative of disc desiccation at T11-T12, T12-L1, L1-L2, L2-L3, L3-L4 and L4-L5
3)�� Retrolisthesis of 2mm at L3-L4
4)�� Mild ligamentous hypertrophy at L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1
5)�� L4-L5 has a Grade 1-2 tear of the interspinous ligament with mild inflammation
6)�� L5-S1 has a Grade 1 interspinous ligament tear with mild inflammation

After reviewing the MRI I ordered lumbar x-rays to rule out ligament laxity.

X-RAY STUDIES

Lumbar x-rays reveal the following:
1)�� Left lateral tilt
2)�� Retrolisthesis at L1 of 3mm
3)�� Retrolisthesis at L2 of 3mm
4)�� Combined excessive translation of 4mm of L1 during flexion-extension
5)�� Combined excessive translation of 4mm of L2 during flexion-extension
6)�� Excessive translation of L3 in extension posteriorly of 2.5mm
7)�� Decreased disc space at L5-S1

Chiropractic care was initiated. The patient was placed on an initial care plan of 2-3x/week for 3 months and then a recommended break in care for one month so the patient could be evaluated for permanency while he was not care dependent.

At maximum medical improvement, he had continued low back pain rated 4/10, continued numbness and tingling into his left leg and left quadricep weakness rated 4/5. He does not need pain killers for pain management anymore. He continues chiropractic care every two weeks to manage his symptoms.

Conclusion:
In this specific case, pathology to the posterior ligament complex diagnosed on MRI lead to the x-ray finding of excessive translation at L1-L2 and L2-L3. The patient was given a permanent impairment rating of 22% based on my interpretation of the American Medical Association�s Guides to the Evaluation of Permanent Impairment, 5^th�Edition¹. The interspinous ligament tears at the L4-L5 and L5-S1 level would not have been diagnosed without the MRI.

There has been much debate on whether MRI imaging has a role in evaluating lumbar PLC. MRI is a powerful diagnostic tool that can provide important clinical information regarding the condition of the PLC. Useful sequences for spinal MRI in trauma include sagittal and axial T1-weighted images, T2-weighted FSE, fat-saturated T2-weighted FSE, and STIR sequences to highlight bone edema.²�Ligamentous injuries are best identified on T2-weighted images with fat saturation because the ligaments are thin and bonded on either side by fat, which can appear as hyperintense on both T1 and T2 images.³�T1-weighted images are inadequate in isolation for identifying ligamentous injuries.^4�

The diagnostic accuracy for MRI was reported for both supraspinous ligament and interspinous ligament injury with a sensitivity of 89.4% and 98.5%, respectively, and a specificity of 92.3% and 87.2% in 35 patients.⁵
For patients with persistent symptoms after trauma an MRI may be indicated to evaluate posterior ligamentous complex integrity.

Competing Interests:� There are no competing interests in the writing of this case report.

De-Identification: All of the patient�s data has been removed from this case.

References:
1. Cocchiarella L., Anderson G. Guides to the Evaluation of Permanent Impairment, 5th Edition, Chicago IL, 2001 AMA Press.
2. Cohen, W.A., Giauque, A.P., Hallam, D.K., Linnau, K.F. and Mann, F.A., 2003. Evidence-based approach to use of MR imaging in acute spinal trauma.�European journal of radiology,�48(1), pp.49-60.
3. Terk, M.R., Hume-Neal, M., Fraipont, M., Ahmadi, J. and Colletti, P.M., 1997. Injury of the posterior ligament complex in patients with acute spinal trauma: evaluation by MR imaging.�AJR. American journal of roentgenology,�168(6), pp.1481-1486.
4. Saifuddin, A., Green, R. and White, J., 2003. Magnetic resonance imaging of the cervical ligaments in the absence of trauma.�Spine,�28(15), pp.1686-1691.
5. Haba H, Taneichi H, Kotani Y, et al. Diagnostic accuracy of magnetic resonance imaging for detecting posterior ligamentous complex injury associated with thoracic and lumbar fractures.�J Neurosurg. 2003; 99(1 Suppl):20-26.

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Is Pain The Only Reason to see an El Paso Chiropractor?

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic, Chiropractic News

Chiropractic treatment has been associated with pain relief ever since it became part of the public consciousness. If you have a sore back, shoulder, or neck you head to the chiropractor for an adjustment and all-natural pain relief. But is pain the only reason to see a El Paso chiropractor? �New studies from the Journal of the American Medical Association JAMA, have shed new light on why Chiropractic is a great first choice with back pain.

Drawn In By Pain

The main reason people make that first visit to see a El Paso chiropractor is because they are in pain. They may have a persistent headache, lower back pain, radiating pain from the neck, sore shoulders, knees, or some other type of pain. The common denominator is pain and the need for relief. Some patients will be trying out a chiropractor as a last resort after exhausting all conventional options, and others will be looking for chiropractic treatment right from the start.

Chiropractors are experts at adjusting spinal misalignments, which is a major cause of pain throughout the body. And while many patients are drawn in to see chiropractors in El Paso because of pain, they quickly discover there is a lot more to it than just pain relief.

A Host of Other Benefits

Chiropractic treatment has the potential to improve and eliminate scores of different health issues and related problems. Some health problems and other factors that you probably haven�t associated with chiropractic treatment before, include:

Ear Infections
Increased Range of Motion
Colic
PMS Symptoms
High Blood Pressure
Various Behavioral Issues
Improved Productivity
Improved Immunity
Stress Reduction
Decreased Need for Pain Medication
Improved Sleep Quality
More Comfortable Pregnancy
Allergy Relief

When you visit an El Paso chiropractor it is important to clearly detail why you are there and explain every health issue that has been plaguing you. Many patients don�t bother telling the chiropractor about certain health conditions because they feel chiropractic treatment is only effective for pain. Much of the time whatever you are experiencing is just a symptom of a more complex issue. Chiropractors are trained to treat causes, not just symptoms, so you may notice improvements in several different areas after treatment.

The goal of a chiropractic office is to create a comprehensive treatment plan that will restore your body back to its original balance. It might take only a few sessions, or it may take longer, but in the end you�ll be free of pain and you�ll feel like your old self. We are happy to help answer any questions that you might have.

Scope: In Texas, the scope of practice is limited to the treatment and diagnosis of musculo-skeletal system. �Texas statute and TBCE board rules define and interpret what a licensed chiropractor is allowed to do in Texas. Many chiropractors are trained to provide far more services to patients than a Texas license actually permits, but training does not drive scope. Each state has its specified scope. Specialty board training does not change Texas chiropractic�scope. Scope of Practice can only be changed by legislative action. For example, Texas Chiropractors cannot treat diseases or disorders, such as: diabetes, hypothyroidism, infertility, schizophrenia, Parkinson�s, colic, diarrhea, asthma or constipation.

Chiropractic Garners Positive Mainstream Media Coverage

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic, Chiropractic News

Chiropractic received a boost from some major national sources in recent months. Here�s a recap.

1. American College of Physicians issues new guideline for low-back pain treatment

The American College of Physicians (ACP) published a new low-back pain treatment guideline recommending first using non-invasive, non-drug treatments, including spinal manipulation, before resorting to drug therapies. The guideline was published Feb. 14, 2017 in the Annals of Internal Medicine. For more information, see the American Chiropractic Association news release on the guideline.

On May 1, 2017, the New York Times published an editorial by Aaron E. Carroll, M.D., that mentions the new guideline in a generally positive light. The article appeared in a major, mainstream publication read by millions of people. �Spinal manipulation�along with other less traditional therapies like heat, meditation and acupuncture�seems to be as effective as many other more medical therapies we prescribe, and as safe, if not safer,� he wrote.

Talking points on new ACP guideline:

The chiropractic profession has advocated for decades that conservative care choices such as chiropractic be the first line of treatment for low-back pain. Now, with this new guideline, the medical profession is recognizing the benefits of conservative care for this common problem.
Thanks to this guideline, it�s possible more medical doctors will choose to refer their patients with low-back pain to chiropractors.
The ACP guideline was adopted by the American Chiropractic Association, which also adopted the Clinical Compass guidelines on chiropractic for LBP at its HOD meeting in March.

2. Article�and editorial on spinal manipulation published in JAMA

The April 11, 2017, issue of the Journal of the American Medical Association (JAMA) featured the article �Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain.� This systematic review and meta-analysis found that of the 26 eligible RCTs identified, 15 RCTS (1,711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain. Twelve RCTs (1,381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function. One of the RCTs included in this analysis, �Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study,� was led by investigators at the Palmer Center for Chiropractic Research.

Additionally, an editorial by Richard A. Deyo, M.D., M.P.H., titled �The Role of Spinal Manipulation in the Treatment of Low Back Pain,� was published in the April 11 issue of JAMA. �If manipulation is at least as effective and as safe as conventional care, it may be an appropriate choice for some patients with uncomplicated acute low back pain,� Dr. Deyo wrote. �This is an area in which a well-informed patient�s decisions should count as much as a practitioner�s preference.�

A National Public Radio story on April 11 quoted Dr. Paul Shekelle, an internist with the West Los Angeles Veterans Affairs Medical Center and one of the study authors, as saying the JAMA study found patients undergoing spinal manipulation experienced a decline of one point in their pain rating. He added that the study also found spinal manipulation modestly improved function.

3. Article�and editorial on spinal manipulation published in JAMA

An article published April 4 in STAT News, a medical journal, discussed the ACP guideline and how it�s bolstering the cause of non-pharmaceutical pain control methods like chiropractic and acupuncture. Another article published May 10 in STAT News covered proposed FDA recommendations that physicians learn more about chiropractic, acupuncture and other drug-free pain treatments as therapies to help patients avoid prescription opioids.

4.�Article posted May 19 on Psychology Today website about new research on chiropractors helping people with low-back pain

This article, �The Evolving Evidence on Chiropractors for Low Back Pain,� covered the ACP guideline and its recommendation for conservative care first, as well as the Annals of Internal Medicine systematic review that found evidence spinal manipulation helps to reduce pain for people with chronic low-back pain. It concluded by saying, �On the whole, the evidence suggests that seeing a chiropractor can reduce pain levels and increase function for people with chronic low back pain.�

Can Impacting Spinal Health Affect Pediatric Well-Being? – Pediatric References

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Children, Chiropractic News

The Journal of Clinical Chiropractic Pediatrics (JCCP) is the official peer-reviewed journal of the ICA Council on Chiropractic Pediatrics. It is committed to publishing research, scientific and professional papers, literature reviews, case reports and clinical commentaries for chiropractors and other health care professionals interested in the treatment of the pregnant, postpartum and pediatric patient. Through the publication of these papers and the dissemination of this information, the JCCP seeks to encourage professional dialogue and awareness about chiropractic pediatric care to help enhance patient care and improve patient outcomes.

Editors: Sharon A. Vallone, DC., DICCP., Cheryl Hawk, DC, PhD.

We are hopeful that this venue will provide field clinicians interested in maternal health and pediatric chiropractic with current research, case reports and clinical commentary that they will find both useful and informative. �We invite you to submit your own research or scientific writing for consideration for publication in this journal.

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