Disclosures can be found in Additional Information at the end of the article
Background
Case reports and case control studies have suggested an association between chiropractic neck manipulation and cervical artery dissection (CAD), but a causal relationship has not been established. We evaluated the evidence related to this topic by performing a systematic review and meta-analysis of published data on chiropractic manipulation and CAD.
Methods
Search terms were entered into standard search engines in a systematic fashion. The articles were reviewed by study authors, graded independently for class of evidence, and combined in a meta-analysis. The total body of evidence was evaluated according to GRADE criteria.
Results
Our search yielded 253 articles. We identified two class II and four class III studies. There were no discrepancies among article ratings (i.e., kappa=1). The meta-analysis revealed a small association between chiropractic care and dissection (OR 1.74, 95% CI 1.26-2.41). The quality of the body of evidence according to GRADE criteria was “very low.”
Conclusions
The quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. Our analysis shows a small association between chiropractic neck manipulation and cervical artery dissection. This relationship may be explained by the high risk of bias and confounding in the available studies, and in particular by the known association of neck pain with CAD and with chiropractic manipulation. There is no convincing evidence to support a causal link between chiropractic manipulation and CAD. Belief in a causal link may have significant negative consequences such as numerous episodes of litigation.
� Copyright 2016
Church et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article
Church E W, Sieg E P, Zalatimo O, et al. (February 16, 2016) Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus 8(2): e498. DOI 10.7759/cureus.498
Neck pain is a common complaint in physicians� and chiropractors� offices. Data from the Centers for Disease Control and from national surveys document 10.2 million ambulatory care visits for a neck problem in 2001 and 2002. By comparison, there were 11 million office-based visits for ischemic heart disease [1]. Many patients with neck pain seek chiropractic care and undergo cervical manipulation. As many as 12% of North Americans receive chiropractic care every year, and a majority of these are treated with spinal manipulation [2].
In contrast to the frequency of neck pain and chiropractic treatments, spontaneous cervical artery dissection (CAD) is rare. The annual incidence of internal carotid artery dissection has been estimated at 2.5�3 per 100,000 patients and that of vertebral artery dissection at 1�1.5 per 100,000 [3]. Stroke occurs in a small proportion of those with CAD, and its true incidence is difficult to estimate. Overall, dissection accounts for two percent of all ischemic strokes [4].
Case reports and case series of cervical dissection following manipulation have been published. Despite their rarity, these cases are frequently publicized for several reasons. Patients are often young and otherwise in good health. Dissection accounts for 10�25% of ischemic strokes in young and middle aged patients [4]. If dissection is caused by cervical manipulation it is potentially a preventable condition. Recent reports, including case control studies, have suggested an association between chiropractic neck manipulation and cervical dissection [5- 10]. Notably, a recent study from the American Heart Association evaluated the available evidence and concluded such an association exists [11]. This report did not include a meta- analysis, nor did it seek to classify studies and grade the body of evidence. We sought to examine the strength of evidence related to this question by performing a systematic review, meta-analysis, and evaluation of the body of evidence as a whole.
Materials & Methods
Search terms �chiropract*,� �spinal manipulation,� �carotid artery dissection,� �vertebral artery dissection,� and �stroke� were included in the search. We used the Medline and Cochrane databases. We additionally reviewed references of key articles for completeness. A librarian with expertise in systematic review was consulted throughout the search process.
Two study authors independently reviewed all articles (EC, ES). They selected any applicable studies for evaluation based on pre-specified inclusion and exclusion criteria. We included only human trials examining patients with carotid or vertebrobasilar artery dissection and recent chiropractic neck manipulation. We excluded non-English language studies. The articles were independently graded using the classification of evidence scheme adopted by the American Academy of Neurology [12-14]. A third author (MG) arbitrated any discrepancies in the class- of-evidence ratings for the included studies.
Data from all class II and III studies were included in a meta-analysis. A second meta-analysis excluding class III studies was also performed. The inverse variance method and a fixed effects model were employed. Additionally, we report results using a variable effects model. The analyses were performed using RevMan 5.3 software from the Cochrane Informatics and Knowledge Management Department. We did not compose a protocol for our review, although PRISMA and MOOSE methodologies were used throughout [15-16].
We evaluated the total body of evidence for quality using the GRADE system [17-20]. A final GRADE designation was achieved by consensus after discussions involving all study authors as recommended by GRADE guidelines. This system is designed to assess the total body of evidence rather than individual studies. The criteria include study design, risk of bias, inconsistency, indirectness, imprecision, publication bias, effect size, dose response, and all plausible residual confounding. Four possible final designations are specified: high, moderate,�low, and very low quality.
Results
Results of the systematic review
Our search strategy yielded 253 articles. Seventy-seven were judged by all reviewers to be non- relevant. Four articles were judged to be class III studies, and two were rated class II. There were no discrepancies between the independent ratings (i.e., kappa=1). Studies rated class III or higher are listed in Table 1. Figure 1 outlines our process of selecting studies for inclusion in the meta-analysis.
Meta-Analysis
Combined data from class II and III studies suggests an association between dissection and chiropractic care, OR 1.74, 95% CI 1.26-2.41 (Figure 2). The result was similar using a random effects model, OR 4.05, 95% CI 1.27-12.91. We did not include the study by Rothwell et al. because it describes a subset of patients in the study by Cassidy et al. [5,8]. There was considerable heterogeneity among the studies (I2=84%).
We repeated the meta-analysis excluding class III studies. The combined effect size was again indicative of a small association between dissection and chiropractic care, OR 3.17, 95% CI 1.30-7.74). The result was identical when using a random effects model.
Class II Studies
Smith et al. used a retrospective case control design, combining databases from two academic stroke centers to identify cases of arterial dissection [9]. They found 51 cases and 100 controls. Exposure to spinal manipulative therapy (SMT) was assessed by mail survey. The authors reported an association between SMT and VBA (P = .032). In multivariate analysis, chiropractor care within 30 days was associated with VBA, even when adjusting for neck pain or headache (OR 6.6, 95% CI 1.4-30). While this study controlled for possible confounders such as neck pain, there were several limitations. Head and neck pain as well as chiropractor visit were assessed in a retrospective fashion by mail survey, very possibly introducing both recall and survivor bias. The reason for reporting to the chiropractor (e.g., trauma) was not assessed. Further, there was significant variability among diagnostic procedures, which may reflect increased motivation by physicians to rule out dissection in patients with a history of SMT. Such motivation could result in interviewer bias.
Dittrich et al. compared 47 patients with CAD to a control group with stroke due to etiologies other than dissection [6]. They assessed for risk factors using a face-to-face interview with blinding. These authors found no association between any individual risk factor and CAD, including cervical manipulative therapy. They blame the small sample size for the negative result, and they point out that cumulative analysis of all mechanical risk factors <24 hours prior to symptom onset showed an association (P = .01). This study is subject to recall bias.
Class III Studies
Rothwell et al. used a retrospective case control design to test for an association between chiropractic manipulation and vertebrobasilar accidents (VBA) [8]. They reviewed Ontario hospital records for admissions for VBA from 1993�1998. There were 582 cases and 2328 matching controls. The authors report an association between VBA and visit to a chiropractor within one week (OR 5.03, 95% CI 1.32-43.87), but this was only true for young patients (<45 years). This study represented the first attempt to delineate the association between chiropractic manipulation and extremely rare VBA with controls. Limitations included requisite use of ICD-9 codes to identify cases and associated classification bias, as well as potential unmeasured confounders (e.g., neck pain).
In 2008, Cassidy et al. set out to address the problem of neck pain possibly confounding the association between chiropractic care and VBA [5]. Again using a retrospective case control design, they included all residents of Ontario over a period of 9 years (1993�2002, 109,020,875 person years of observation). They identified 818 VBA strokes resulting in hospitalization and randomly selected age and sex matched controls. Next, they examined ambulatory encounters with chiropractors and primary care physicians (PCPs) in the one year preceding the stroke, limited to cervical manipulation, neck pain, and headache. Associations between chiropractor visit and VBA versus PCP visits and VBA were compared. Indeed, there were associations between both chiropractor visit and VBA (<45yrs OR 1.37, 95% CI 1.04-1.91), and PCP visit and VBA (<45 yrs OR 1.34, 95% CI .94-1.87; >45 yrs and OR 1.53, 95% CI 1.36-1.67). The association for chiropractor visit was not greater than for PCP visit. This data was interpreted as evidence that a confounder such as neck pain may account for the association between chiropractor visit and VBA. This study was subject to many of the same limitations as previous efforts. Canadian health records would not reveal whether a patient with cervical complaints underwent cervical manipulation, and the researchers could not review each chart for imaging confirming dissection. Additionally, the incidence of comorbidities (e.g., hypertension, heart disease,�diabetes) was significantly higher among cases as compared to controls, and we are concerned that these differences were non-random.
In another case control study, Thomas et al. compared the records of 47 patients with confirmed or suspected vertebral or internal carotid artery dissection with 43 controls [10]. They limited their analysis to young patients defined as <55 years. These authors report a significant association between dissection and recent head or neck trauma (OR 23.51, 95% CI 5.71-96.89) as well as neck manual therapy (OR 1.67, 95% CI 1.43-112.0). An inconsistent standard for case ascertainment (a significant number of patients lacked radiographic confirmation of dissection) and lack of blinding weaken this study.
Engelter et al. evaluated data from the Cervical Artery Dissection and Ischemic Stroke Patients (CADISP) consortium, identifying 966 patients with CAD, 651 with stroke attributable to another cause, and 280 healthy controls [7]. The CADISP study involved both prospectively and retrospectively collected data at multiple centers in several countries. They assessed for prior cervical trauma within one month using questionnaires administered during clinic visits. Cervical manipulation therapy was more common for CAD versus stroke from another cause (OR 12.1, CI 4.37-33.2). The report notes that an association between any trauma and CAD was present even when restricting the analysis to prospectively recruited patients. However, in patients to whom the questionnaire was administered after dissection, recall bias may have been at work whether or not the patient was enrolled prospectively. Indeed, the frequency of prior cervical trauma in this study was substantially higher than previous reports (40% versus 12-34%). Additional weaknesses include a highly heterogeneous standard for case definition and no clear masking procedures.
Body Of Evidence Quality (GRADE Rating)
Having performed a systematic review and rated articles according to their individual strengths and weaknesses, we graded the overall body of evidence using the system proposed by Guyatt et al. [17-20]. The GRADE approach to rating quality of evidence proposes four categories that are applied to a body of evidence: high, moderate, low, and very low. In the setting of systematic review, a particular rating reflects the extent of confidence that the estimates of effect are correct. The GRADE approach begins with study design and sequentially examines features with the potential to enhance or diminish confidence in the meta-analytic estimate of effect size.
Our final assessment of the quality of the body of evidence using these criteria was very low. The initial rating based on study design was low (observational studies). Given the controversial nature of this topic and the legal ramifications of results, there is certainly potential for bias (-1 serious). However, blinding in the Class II studies mitigated this risk to some extent. Inconsistency and imprecision did not lower our rating. Because the body of evidence is derived from measures of association, the rating was lowered for indirectness (-1 serious). Publication bias is less likely because of the impact of a negative result in this case. The funnel plot from our meta-analysis was inconclusive with regard to possible publication bias because of the small number of studies included but suggested a deficit in the publication of small negative trials. There was not a large effect size, and currently there is no evidence for a dose response gradient. Moreover, the most worrisome potential confounder (neck pain) would increase rather than reduce the hypothesized effect.
Discussion
The results of our systematic review and meta-analysis suggest a small association between chiropractic care and CAD. There are no class I studies addressing this issue, and this conclusion is based on five class II and III studies. Scrutiny of the quality of the body of data�using the GRADE criteria revealed that it fell within the �very low� category. We found no evidence for a causal link between chiropractic care and CAD. This is a significant finding because belief in a causal link is not uncommon, and such a belief may have significant adverse effects such as numerous episodes of litigation.
The studies included in our meta-analysis share several common weaknesses. Two of the five studies used health administrative databases, and since conclusions depend on accurate ICD coding, this technique for case ascertainment may introduce misclassification bias. It is not possible to account for the type of spinal manipulation that may have been used. Retrospective collection of data is also a potential weakness and may introduce recall bias when a survey or interview was used. Moreover, patients arriving at a hospital complaining of neck pain and describing a recent visit to a chiropractor may be subject to a more rigorous evaluation for CAD (interviewer bias). Another potential source of interviewer bias was lack of blinding in the class III studies. Further, we noted substantial variability among diagnostic procedures performed. All of these weaknesses affect the reliability of the available evidence and are not �corrected� by performing a meta-analysis.
Perhaps the greatest threat to the reliability of any conclusions drawn from these data is that together they describe a correlation but not a causal relationship, and any unmeasured variable is a potential confounder. The most likely potential confounder in this case is neck pain. Patients with neck pain are more likely to have CAD (80% of patients with CAD report neck pain or headache) [21], and they are more likely to visit a chiropractor than patients without neck pain (Figure 3). Several of the studies identified in our systematic review provide suggestive evidence that neck pain is a confounder of the apparent association between chiropractic neck manipulation and CAD. For example, in Engelter et al. patients with CAD and prior cervical trauma (e.g., cervical manipulation therapy) were more likely to present with neck pain but less often with stroke than those with CAD and no prior cervical trauma (58% vs. 43% for trauma and 61% vs. 69% for stroke) [7]. If patients with CAD without neurological symptoms came to medical attention, it was probably because of pain. Patients with neck pain would also be more likely to visit a chiropractor than those without neck pain.
Cassidy et al. hypothesized that, although an association between chiropractor visits and vertebrobasilar artery stroke is present, it may be fully explained by neck pain and headache [5]. These authors reviewed 818 patients with vertebrobasilar artery strokes hospitalized in a population of 100 million person-years. They compared chiropractor and PCP visits in this population and reported no significant difference between these associations. For patients under 45 years of age, each chiropractor visit in the previous month increased the risk of stroke (OR 1.37, 95% CI 1.04-1.91), but each PCP visit in the previous month increased the risk in a nearly identical manner (<45 yrs OR 1.34, 95% CI .94-1.87; >45 yrs and OR 1.53, 95% CI 1.36- 1.67). The authors conclude that, since patients with vertebrobasilar stroke were as likely to visit a PCP as they were to visit a chiropractor, these visits were likely due to pain from an existing dissection.
Cervical artery dissection is a rare event, creating a significant challenge for those who wish to understand it. A prospective, randomized study design is best suited to control for confounders, but given the infrequency of dissection, performing such a study would be logistically and also ethically challenging. Sir Austin Bradford Hill famously addressed the problem of assigning causation to an association with the application of nine tests [22]. These criteria include strength, consistency, specificity, temporality, biological gradient, plausibility, coherence, experimental evidence, and analogy. The specific tests and our assessment for the association between cervical manipulation and CAD are summarized in Table 2. In our appraisal, this association clearly passes only one test, it fails four, and the remaining four are equivocal due to absence of relevant data [23]. Further, a 2013 assessment of the quality of reports of cervical arterial dissection following cervical spinal manipulation similarly found lacking data to support a causal relationship [24].
In spite of the very weak data supporting an association between chiropractic neck manipulation and CAD, and even more modest data supporting a causal association, such a relationship is assumed by many clinicians. In fact, this idea seems to enjoy the status of medical dogma. Excellent peer reviewed publications frequently contain statements asserting a causal relationship between cervical manipulation and CAD [4,25,26]. We suggest that physicians should exercise caution in ascribing causation to associations in the absence of adequate and reliable data. Medical history offers many examples of relationships that were initially falsely assumed to be causal [27], and the relationship between CAD and chiropractic neck manipulation may need to be added to this list.
Conclusions
Our systematic review revealed that the quality of the published literature on the relationship between chiropractic manipulation and CAD is very low. A meta-analysis of available data shows a small association between chiropractic neck manipulation and CAD. We uncovered evidence for considerable risk of bias and confounding in the available studies. In particular, the known association of neck pain both with cervical artery dissection and with chiropractic manipulation may explain the relationship between manipulation and CAD. There is no convincing evidence to support a causal link, and unfounded belief in causation may have dire consequences.
Additional Information
Disclosures
Conflicts of interest: The authors have declared that no conflicts of interest exist.
Acknowledgements
The authors wish to thank Elaine Dean, MLS, of the Penn State Hershey Medical Center George T. Harrell Health Sciences Library, for her assistance with the systematic review.
References
1. Riddle DL, Schappert SM: Volume and characteristics of inpatient and ambulatory medical care for neck pain in the United States: data from three national surveys. Spine. 2007, 32:132�140.
2. Hurwitz EL, Chiang LM: A comparative analysis of chiropractic and general practitioner patients in North America: findings from the joint Canada/United States survey of health, 2002-03. BMC Health Serv Res. 2006, 6:49. 10.1186/1472-6963-6-49
3. Micheli S, Paciaroni M, Corea F, et al.: Cervical artery dissection: emerging risk factors . Open Neurol J. 2010, 4:50�55. 10.2174/1874205X01004010050
4. Schievink WI: Spontaneous dissection of the carotid and vertebral arteries . N Engl J Med. 2001, 344:898�906. 10.1056/NEJM200103223441206
5. Cassidy JD, Boyle E, C�t� PDC, et al.: Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008, 33:176�183.10.1097/BRS.0b013e3181644600
6. Dittrich R, Rohsbach D, Heidbreder A, et al.: Mild mechanical traumas are possible risk factors for cervical artery dissection. Cerebrovasc Dis. 2007, 23:275�281. 10.1159/000098327
7. Engelter ST, Grond-Ginsbach C, Metso TM, et al.: Cervical artery dissection: trauma and other potential mechanical trigger events. Neurology. 2013, 80:1950�1957.10.1212/WNL.0b013e318293e2eb
8. Rothwell DM, Bondy SJ, Williams JI: Chiropractic manipulation and stroke: a population based case-control study. Stroke. 2001, 32:1054-1060.
9. Smith WS, Johnston SC, Skalabrin EJ, et al.: Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003, 60:1424-1428.10. Thomas LC, Rivett DA, Attia JR, et al.: Risk factors and clinical features of craniocervical arterial dissection. Man Ther. 2011, 16:351�356. 10.1016/j.math.2010.12.008
11. Biller J, Sacco RL, Albuquerque FC, et al.: Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014, 45:3155�3174.10.1161/STR.0000000000000016
12. AAN (American Academy of Neurology): Clinical Practice Guideline Process Manual. Gronseth GS, Woodroffe LM, Getchius TSD (ed): AAN (American Academy of Neurology), St Paul, MN; 2011.
13. French J, Gronseth G: Lost in a jungle of evidence: we need a compass . Neurology. 2008, 71:1634�1638. 10.1212/01.wnl.0000336533.19610.1b 2016 Church et al. Cureus 8(2): e498. DOI 10.7759/cureus.498 10 of 11
14. Gross RA, Johnston KC: Levels of evidence: taking Neurology� to the next level . Neurology. 2009, 72:8�10. 10.1212/01.wnl.0000342200.58823.6a
15. Moher D, Liberati A, Tetzlaff J, et al.: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009, 6:e1000097. Accessed: January 23, 2016: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000097. 10.1371/journal.pmed.1000097
16. Stroup DF, Berlin JA, Morton SC, et al.: Meta-analysis of observational studies inepidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA. 2000, 283:2008-2012.
17. Guyatt G, Oxman AD, Akl EA, et al.: GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011, 64:383�394. 10.1016/j.jclinepi.2010.04.026
18. Guyatt GH, Oxman AD, Kunz R, et al.: GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol. 2011, 64:395�400. 10.1016/j.jclinepi.2010.09.012
19. Balshem H, Helfand M, Sch�nemann HJ, et al.: GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011, 64:401�406. 10.1016/j.jclinepi.2010.07.015
20. The Cochrane Collaboration: Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0). Higgins JPT, Green S (ed): The Cochrane Collaboration, 2011.
21. Lee VH, Brown RD Jr, Mandrekar JN, et al.: Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006, 67:1809-1812.
22. Hill AB: The environment and disease: association or causation?. Proc R Soc Med. 1965, 58:295�300.
23. Herzog W, Leonard TR, Symons B, et al.: Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012, 22:740�746. 10.1016/j.jelekin.2012.03.005
24. Wynd S, Estaway M, Vohra S, Kawchuk G: The quality of reports on cervical arterial dissection following cervical spinal manipulation. PLOS ONE. 2013, 8:e59170. Accessed: February 8, 2016: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0059170. 10.1371/journal.pone.0059170
25. Albuquerque FC, Hu YC, Dashti SR, et al.: Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg. 2011, 115:1197�1205. 10.3171/2011.8.JNS111212
26. Debette S, Leys D: Cervical-artery dissections: predisposing factors, diagnosis, and outcome . Lancet Neurol. 2009, 8:668�678. 10.1016/S1474-4422(09)70084-5
27. Artenstein AW: The discovery of viruses: advancing science and medicine by challenging dogma. Int J Infect Dis. 2012, 16:e470�e473. 10.1016/j.ijid.2012.03.005
Ephraim W. Church 1 , Emily P. Sieg 1 , Omar Zalatimo 1 , Namath S. Hussain 1 , Michael Glantz 1 , Robert E. Harbaugh 1
1. Department of Neurosurgery, Penn State Hershey Medical Center
Corresponding author: Ephraim W. Church, [email protected]
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
1. Borghouts JA, Koes BW, Vondeling H, et al. Cost-of-illness of neck pain in The Netherlands in 1996. Pain 1999;80:629�36.
2. Co�te� P, Cassidy JD, Carroll L. The Saskatchewan Health and Back PainSurvey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine 1998;23:1689�98.
3. Co�te� P, Cassidy JD, Carroll L. The factors associated with neck pain and its related disability in the Saskatchewan population. Spine 2000;25:1109�17.
4. Co�te� P, Cassidy JD, Carroll L. Is a lifetime history of neck injury in a trafficcollision associated with prevalent neck pain, headache and depressive symptomatology? Accid Anal Prev 2000;32:151�9.
5. Co�te� P, Cassidy JD, Carroll LJ, et al. The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain 2004; 112:267�73.
6. Co�te� P, Cassidy JD, Carroll L. The treatment of neck and low back pain: who seeks care? who goes where? Med Care 2001;39:956�67.
7. Hurwitz EL, Coulter ID, Adams AH, et al. Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health1998;88:771�6.
8. Hurwitz EL, Chiang LM. A comparative analysis of chiropractic and general practitioner patients in North America: findings from the jointCanada/United States Survey of Health, 2002�03. BMC Health Serv Res 2006;6:49.
9. Aker PD, Gross AR, Goldsmith CH, et al. Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ 1996; 313:1291�6.
10. Gross AR, Kay T, Hondras M, et al. Manual therapy for mechanical neckdisorders: a systematic review. Man Ther 2002;7:131�49.
11. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 1996;21:1746�59.
12. McClune T, Burton AK, Waddell G. Whiplash associated disorders: a review of the literature to guide patient information and advice. Emerg Med J 2002;19:499�506.
13. Peeters GG, Verhagen AP, de Bie RA, et al. The efficacy of conservative treatment in patients with whiplash injury: a systematic review of clinical trials. Spine 2001;26:E64�E73.
14. Norris JW, Beletsky V, Nadareishvili ZG. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ 2000;163:38�40.
15. Ernst E. Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995�2001. Med J Aust 2002;176:376�80.
16. Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neckmovements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 1999;24:785�94.
17. Rubinstein SM, Peerdeman SM, van Tulder MW, et al. A systematic reviewof the risk factors for cervical artery dissection. Stroke 2005;36:1575�80.
18. Inamasu J, Guiot BH. Iatrogenic vertebral artery injury. Acta Neurol Scand 2005;112:349�57.
19. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001;344:898�906.
20. D�Anglejan-Chatillon J, Ribeiro V, Mas JL, et al. Migraine�a risk factor for dissection of cervical arteries. Headache 1989;29:560�1.
21. Pezzini A, Caso V, Zanferrari C, et al. Arterial hypertension as risk factor for spontaneous cervical artery dissection. A case-control study. J Neurol Neurosurg Psychiatry 2006;77:95�7.
22. Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med 2005;352: 2618�26.
23. Lee VH, Brown RD Jr, Mandrekar JN, et al. Incidence and outcome of cervical artery dissection: a population-based study. Neurology 2006;67: 1809�12.
24. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke 2001;32:1054�60.
25. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology 2003;60: 1424�8.
26. Arnold M, Bousser MG, Fahrni G, et al. Vertebral artery dissection: presenting findings and predictors of outcome. Stroke 2006;37:2499�503.
27. Maclure M. The case-crossover design: a method for studying transient effects on the risk of acute events. Am J Epidemiol 1991;133:144�53.
28. Kelman CW, Kortt MA, Becker NG, et al. Deep vein thrombosis and air travel: record linkage study. BMJ 2003;327:1072.
29. Mittleman MA, Maclure M, Tofler GH, et al. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators.
N Engl J Med 1993;329:1677�83.
30. Redelmeier DA, Tibshirani RJ. Association between cellular-telephone calls and motor vehicle collisions. N Engl J Med 1997;336:453�8.
31. Janes H, Sheppard L, Lumley T. Overlap bias in the case-crossover design, with application to air pollution exposures. Stat Med 2005;24:285�300.
32. Janes H, Sheppard L, Lumley T. Case-crossover analyses of air pollution exposure data: referent selection strategies and their implications for bias. Epidemiology 2005;16:717�26.
33. Efron B, Tibshirani RJ. An Introduction to the Bootstrap. New York: Chapmanand Hall/CRC, 1993.
34. STATA/SE [computer program]. College Station, Tex: Stata Corp, 2006.
35. Liu L, Reeder B, Shuaib A, et al. Validity of stroke diagnosis on hospital discharge records in Saskatchewan, Canada: implications for stroke surveillance. Cerebrovasc Dis 1999;9:224�30.
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.
38. van der Velde G, Hogg-Johnson S, Bayoumi A, et al. Identifying the best treatment among common non-surgical neck pain treatments: a decision analysis. Spine 2008;33(Suppl):S184�S191.
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: [email protected]
Title: Abatement of radiculopathy clinical signs and symptoms after chiropractic treatment in an older patient with trauma induced posterolateral disc herniation, superimposed on an underlying disc bulge.
Abstract: Objective: To examine the concomitant clinical diagnosis of a lumbar disc bulge and lumbar disc herniation at the same spinal level, in an older traumatically injured patient with radicular symptoms. Diagnostic studies include physical examination, including orthopedic and neurological examination, lumbar MRI without contrast, and plain film x-rays. Treatments included low force instrument adjusting without manual manipulation, diversified chiropractic manipulation, flexion-distraction treatment, intersegmental traction, electric muscle stimulation, ice, heat and massage/trigger point therapy. The patient�s outcome was very good and resulted in complete abatement of initial L5 paresthesia and radiating symptoms into the left leg, although mild lower back pain remained upon discharge from active treatment.
Introduction: A 63 year old, 6� 0�, 193lbs., male was seen for a chief complaint of lower back pain radiating into the left leg with numbness in the dorsum of the left foot which started immediately following a motor vehicle accident with a frontal impact. During the collision, he reported his right knee struck the dashboard and his head struck the ceiling of his vehicle causing him to briefly lose consciousness. The patient additionally reported immediate neck and right knee pain. He was taken via ambulance to the hospital where he was evaluated, x-rayed, given medications and released the same day. He was unable to work as a bailiff in a courthouse due to worsening pain and after 3 days sought treatment in my office.
The patient noted that prior to the accident he did not have any physical limitations and that he played soccer weekly. He was observed to have a trim, fit build. He reported no prior motor vehicle accidents or other serious injury. He reported no previous neck or lower back pain and denied the use of alcohol, tobacco and illicit drugs.
Contents
Clinical Findings After Treatment
Lasague�s, Braggard�s and Kemps orthopedic testing was positive on the left and lumbar motion was decreased approximately 60% collectively. Lasague�s and Braggard�s revealed an increase in radiating pain into the left leg and Kemps was positive bilaterally for pain into the left lower extremity. These orthopedic tests were positive indicating nerve root irritation. Dermatomal evaluation revealed a decreased sensation in the dorsum of the left foot representing the L5 dermatome. Motor evaluation revealed a weakness when attempting to walk on the heel of the left foot and weakness of the left extensor hallicus longus muscle, again indicating possible L5 nerve root compromise. Lumbar x-rays revealed a severe decrease of the normal lumbar lordosis, mild L3-L4 spondylosis (arthritis) and a posterior misalignment of L4 in relation to L5. The patient�s review of systems, surgical and family history were all unremarkable as reported.
Therapeutic Focus and Assessment: A non-contrast lumbar spine MRI was ordered immediately with 2 mm slice thickness and no gap in between slices on a 1.5 Tesla machine for optimal visualization of pathology due to the clinical presentation of left L5 nerve root compression. Lumbar MRI�s revealed a L4-L5 broad-based left posterolateral disc herniation superimposed on an underlying disc bulge with severe left lateral recess narrowing, compressing the descending left L5 nerve root.
Note: the findings of a disc bulge AND disc herniation at the same spinal level do not contradict each other. Patients often have an underlying disc bulge (degenerative thinning of the outer fibers (annulus) of the disc causing �bulging�). When subject to trauma, a focal displacement of disc material through a tear in the annular fibers, disc herniation, then occurs through the thinned annulus of the bulging disc. Further, a bulging disc is actually more likely to herniate with trauma due to the thinning of the annulus than a normal healthy disc.
��������� Definition �Bulging disc: A disc in which the contour of the outer anulus extends, or appears to extend, in the horizontal (axial) plane beyond the edges of the disc space, over greater than 50% (180 degrees) of the circumference of the disc and usually less than 3mm beyond the edges of the vertebral body apophyses. (Ref. 2)
��������� Definition – Herniated disc: Localized displacement of disc material beyond the normal margins of the intervertebral disc space. (Ref. 2)
Again, the key distinction is the localized (aka focal displacement) of disc material that differentiates a herniated disc from a bulging disc. Or stated this way,�The bulging disk is defined as a disk that extends diffusely beyond the adjacent vertebral body margins in all directions� (Ref. 1)
Follow-up and Outcomes After Chiropractic
Upon discovery of a L4-L5 posterolateral disc herniation compressing the left L5 nerve root finding on MRI evaluation, the patient was referred for neurologic consult. The neurologist diagnosed a left L4-L5 radiculopathy after a positive lower extremity EMG/NCV study was performed.
Radiculopathy is a general term used to describe any disease of the nerve roots. In this case, the cause of the radiculopathy was a traumatically induced lumbar posterolateral disc herniation.
Definition � Radiculopathy: Sometimes referred to as a pinched nerve, it refers to compressionof the nerve root – the part of a nerve between vertebrae. This compression causes pain to beperceived in areas to which the nerve leads.(Ref. 3)
The patient underwent approximately 5 months of active chiropractic treatment after which an ordered gap in treatment of approximately 7 weeks occurred. After the gap in treatment, the patient reported they continued to experience no remaining radicular symptoms and re-evaluation showed no remaining clinical findings consistent with radiculopathy. However, the patient did report continuing to experience mild, intermittent lower back pain.
DISCUSSION: It is appropriate to immediately order MRI imaging in patients with a history of trauma leading to sudden onset of obvious clinical signs and symptoms of radiculopathy to ascertain an accurate diagnosis, prognosis and treatment plan. Is it important to understand the difference between herniated and bulging disc findings on MRI evaluation and that herniation can and does occur after a pre-existing disc bulge at the same spinal level. The patient in this case experienced immediate onset of radicular symptoms after trauma and was promptly evaluated with a lumbar MRI. The lumbar MRI confirmed a disc herniation compressing the left L5 nerve root as well as an underlying disc bulge.� EMG testing confirmed the radiculopathy diagnosis at L4-L5 on the left. Chiropractic treatment resulted in a very favorable outcome aided by an accurate diagnosis.
SUMMARY: Lumbar posterolateral disc herniation (interestingly, the most common type of disc herniation � Ref. 4) can affect a lumbar nerve root, causing radiculopathy. Further, �The stress of annulus circumference is higher at the posterolateral region than that of other regions of annulus circumference� � (Ref. 5). I report a case of a healthy 64 year old male who presented with lower back pain radiating into the left leg with no relevant personal or family history or previous trauma, after a front impact collision while driving in which his right knee struck the dashboard. The patient showed immediate clinical signs and symptoms of lumbar disc herniation and left L5 radiculopathy. A lumbar MRI without contrast was ordered immediately and revealed a L4-L5 left posterolateral disc herniation superimposed on an underlying disc bulge, compressing the left L5 nerve root. Subsequent EMG testing confirmed a left L4-L5 radiculopathy. The diagnosis of herniation and disc bulge does not mean the herniation was pre-existing, as bulging discs are a risk factor for disc herniation due to a thinner, weaker annulus. The patient’s history of no previous trauma and sudden onset of lower back pain radiating into the left leg, confirm the traumatic cause of the posterolateral disc herniation. Conservative chiropractic treatment was effective at eliminating all radicular signs and symptoms, even after an approximate 2 month gap in active treatment. Chiropractic care has been shown to be both safe and effective in treating patients with disc herniation and accompanying radicular symptoms. (Ref. 6, 7, 8, that can be reviewed for further study and investigation)
Informed consent: The patient provided a signed informed consent.
Competing Interests: There are no competing interests writing this case report.
De-Identification: All patient related data has been removed from this case report.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
References:
Milette PC. The proper terminology for reporting lumbar intervertebral disk disorders. AJNR Am J Neuroradiol 1997;18:1859-66.
David F. Fardon, MD, Alan L. Williams, MD, Edward J. Dohring, MD. Lumbar disc nomenclature: version 2.0 Recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. The Spine Journal 14 (2014) 2525�2545
Gopalakrishnan N1, Nadhamuni K2, Karthikeyan T3 Categorization of Pathology Causing Low Back Pain using Magnetic Resonance Imaging (MRI) J ClinDiagn Res. 2015 Jan;9(1):TC17-20.
Guo LX, Teo EC. Influence prediction of injury and vibration on adjacent components of spine using finite element methods. J Spinal Disord Tech. 2006 Apr;19(2):118-24.
Leeman S., Peterson C., Schmid C., Anklin B., Humphreys B., (2014) Outcomes of Acute and Chronic Patients With Magnetic Resonance Imaging-Confirmed Symptomatic Lumbar Disc Herniations Receiving High-Velocity, Low Amplitude, Spinal Manipulation Therapy: A Prospective Observational Cohort Study With One-Year Follow Up, Journal of Manipulative and Physiological Therapeutics, 37 (3)155-63
McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiscectomy for sciatica? A propective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33
Whedon, J. M., Mackenzie, T.A., Phillips, R.B., & Lurie, J.D. (2014). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69. Spine, �(Epub ahead of print) 1-33.
Additional Topics: Chiropractic Helps Patients Avoid Back Surgery
Back pain is a common symptom which affects or will affect a majority of the population at least once throughout their lifetime. While most back pain cases may resolve on their own, some instances of the pain and discomfort can be attributed to more serious spinal conditions. Fortunately, a variety of treatment options are available for patients before considering spinal surgical interventions. Chiropractic care is a safe and effective, alternative treatment option which helps carefully restore the original health of the spine, reducing or eliminating spinal misalignment which may be causing back pain.
Title: The Efficacy of Chiropractic Adjustments in the care of Migraine Headache with patients presenting with cervical disc bulge.
Abstract: Objective: To explore the efficacy of chiropractic adjustments, and non-surgical spinal decompression in the treatment of cervical spine disc conditions presenting as neck pain, migraine headache, dizziness and visual disturbances. Diagnostic studies included physical examination, computer aided range of motion, orthopedic and neurological examinations, plain film x-ray studies, brain MRI, cervical spine MRI examinations.� Treatments included specific spinal adjustments, low level laser therapy and spinal decompression.� The patient�s outcome proved excellent in reduction of neck pain, headache severity and frequency as well as elimination of dizziness and visual disturbances.
Introduction: On 11/19/13 a 37-year-old female presented for examination and treatment of neck pain, migraine headaches with associated dizziness and visual disturbances.� The patient denies and recent injuries.
Contents
Presenting Concerns of Research Study
The patient reports neck pain in the cervical occipital region as a 4 on the Verbal Analog Scale of 0 meaning the complete absence of pain and 10 being unbearable pain.� The duration of the current symptom picture is 2 years and 1 month.� The patient further reports episodic migraine headaches starting at the upper cervical region and progressing into her occipital area.� These episodes are accompanied by dizziness and visual disturbances described as kaleidoscope vision.� At the time of the initial consultation these episodes were occurring 2-3 times per week.� The patient reports being afraid to drive her car due to concerns about headache onset.� The patient reports past consultations with her medical doctor who diagnosed her with vertigo and previous chiropractic care without results.� The records from both consultations were reviewed personally.
Clinical Findings:��The patient presents with complaints of neck pain, headaches, dizziness and visual disturbances of 2 years duration.� The patient is a 37-year-old female who is a mother of 2.� The ages are 16 and 3.
Her vital signs are:
Height – 5 ft. 0 inches
Weight – 130 lbs.
Handedness – R
Blood Pressure – L – 107 systolic and 78 diastolic
Radial Pulse – 75 BPM
The patient�s Review of Systems and Family History were unremarkable.
Palpation/Spasm/Tissue changes:� The patient was evaluated by palpation and observation with the following findings: Bilateral cervical spine spasms rated at +2 in the cervical-occipital region.� Orthopedic testing was unremarkable.� Range of motion examination revealed mildly decreased left lateral flexion, moderately decreased flexion, right lateral flexion and extension. No pain was produced during range of motion examination.
Neurological Examination: Biceps, Triceps and Brachioradialis reflexes were rated at a +2 bilaterally.� Sensory examination revealed normal sensation bilaterally for dermatomes C-5 through T1.� Motor/Muscle testing revealed 5 out of 5 bilaterally for Deltoids, Biceps, and Triceps, Forearm and Intrinsic Hand muscles.
Radiographic findings: reversal of the cervical curve with altered C5/C6 disc space is noted. (Fig. 1, (A) (B) A small osteophyte is observed on the posterior inferior body of C5.� Flexion malposition of C5 is also noted.� (Fig. 1, (B).
Fig. 1,� (A), (B) show loss of the cervical lordosis, flexion malposition of C5, partial collapse of C5/6 anterior disc space.
Fig. 1. (B) shows upon magnification a small posterior-inferior osteophyte.
Fig. 2,� (A), (B) shows in T2 MRI images (A) is Sagittal and (B) is Axial a
C5/6 central disc herniation contacting the ventral cord.
Diagnostic Focus and Assessment:�Diagnoses considered are: Brain Tumor, Cervical Disc Displacement, and Cervical-cranial syndrome.� A brain MRI was ordered and produced normal findings.� Diagnostic reasoning included the C5/C6 disc/osteophyte complex and the encroachment into the ventral aspect of the central canal and contact with the cervical spinal cord. (1)�Peter�J. Tuchin, GradDipChiro, DipOHS, Henry Pollard, GradDipChiro, GradDipAppSc, Rod Bonillo, DC, DO.� Received 29 June 1999.��Another consideration was the treatment schedule because the patient lives 60 miles west of the clinic and 2 treatments was the ordered therapeutic schedule.
Therapeutic Focus and Assessment:��Assessment of the cervical spine MRI both sagittal and axial views of the C5/C6 and C6/C7 segmental levels revealed adequate space between the cervical cord and posterior vertebral elements.� It was determined that conservative management of this patient was appropriate.� Therapeutic focus was reducing the pressure of the C5/C6 disc/osteophyte complex on the ventral cord.� Promoting healing of damaged nerve tissue and restoring more favorable position and motion of vertebral segments C5/C6.� The modalities used to treat this patient were:
1.�����Specific Spinal Adjustments: utilizing a Sigma Precision Adjusting Instrument to introduce a percussive force of 20 lbs. with a maximum of impact number of 50.
2.�����Spinal Decompression: A Hill Spinal Decompression table was utilized with 8 lbs. of pull maximum and a cycle of 5 minute at maximum and 5 minutes at reduction to 50% over a 25 minutes treatment session.� The patient completed 18 sessions in total.
3.�����Low Level Laser Therapy was used to promote healing on a cellular level using a Dynatron Solaris system.� Treatments consisted of 30 seconds of exposure to an 860-nanometer beam at C5/C6 and C6/C7 levels.
Follow-up and Outcomes
The patient�s compliance to the treatment schedule as rated at 9 of 10.� Completion of the recommended 18 treatments required 1 week longer than anticipated.� For personal reasons the patient missed 2 treatment sessions but made them up by adding a week to the estimated completion date. Upon discharge examination the patient reports her neck pain on the Verbal Analog Scale a 2 of 10 with 0 being the complete absence of pain and 10 being the worst pain imaginable. She further reported her headaches as a 1 on the Verbal Analog Scale.� Both symptoms were constant since 10/01/11.� This is duration of 25 months prior to her first visit. Her symptoms of dizziness and visual disturbances have been absent since 12/13/13.
Discussion:�Headaches and Migraine Headaches are a big health problem. It has been estimated that 47% of the adult population have headache at least once within last year in general.��More than 90% of sufferers are unable to work or function normally during their migraine. American employers lose more than $13 billion each year as a result of 113 million lost workdays due to migraine. (2)�Schwartz BS1, Stewart WF, Lipton RB. J Occup Environ Med. 1997 Apr; 39(4): 320-7.
This case report is very limited because it represents the experience and clinical findings for just 1 patient. However a study of the references included with this report as well as reports by care providers as well as testimonials from patients indicates that more study should be invested in the relationship of the cervical spine, its structures and biomechanics during the diagnostic workup on headache and migraine patients.
Informed Consent:�The patient provided a signed informed consent.
Competing Interests:�There are no competing interests writing of this case report.
De-Identification:�All the patient�s related data has been removed from this case report.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .�
References:
1. Schwartz BS1, Stewart WF, Lipton RB.
J Occup Environ Med. 1997 Apr; 39(4): 320-7.
Lost workdays and decreased work effectiveness associated with headache in the workplace.
2. Vernon, H., Humphreys, K., & Hagino, C. (2007). Chronic mechanical neck�pain in adults treated by manual therapy: A systematic review of change scores in randomized clinical trials,�Journal of Manipulative and Physiological Therapeutics, 30(3), 215-227.
3.�Peter J. Tuchin, GradDipChiro, DipOHS, Henry Pollard, GradDipChiro, GradDipAppSc, Rod Bonillo, DC, DO.� Received 29 June 1999
A randomized controlled trial of chiropractic spinal manipulative therapy for migraine?
4.Mark Studin DC, FASBE (C), DAAPM, DAAMLP, William J. Owens DC, DAAMLP Chronic Neck Pain and Chiropractic. A Comparative Study with Massage Therapy.
5.�D�Antoni AV, Croft AC. Prevalence of Herniated Intervertebral Discs of the Cervical Spine in Asymptomatic Subjects Using MRI Scans: A Qualitative Systemic Review. Journal of Whiplash & Related Disorders 2006; 5(1):5-13.
6.��Murphy, D. R., Hurwitz, E. L., & McGovern, E. E. (2009).�A nonsurgical approach to the management of patients with lumbar radiculopathy secondary to herniated disk: A prospective observational cohort study with follow-up.�Journal of Manipulative and Physiological Therapeutics, 32(9), 723-733.
Additional Topics: Chiropractic Helps Patients Avoid Back Surgery
Back pain is a common symptom which affects or will affect a majority of the population at least once throughout their lifetime. While most back pain cases may resolve on their own, some instances of the pain and discomfort can be attributed to more serious spinal conditions. Fortunately, a variety of treatment options are available for patients before considering spinal surgical interventions. Chiropractic care is a safe and effective, alternative treatment option which helps carefully restore the original health of the spine, reducing or eliminating spinal misalignment which may be causing back pain.
Title: Spinal Adjustments are Safe in the Presence of Herniated disc with the Absence of Cord Compression
Abstract: The objective was to explore the use of MRI to increase the efficacy and safeness of adjusting the cervical spine in the presence of a disc herniation when there is no evidence of cord compression on MRI.
Introduction: A 30 year old male patient presented to the office on 1/8/14 with injuries from a motor vehicle accident. The motor vehicle accident had occurred 3 weeks prior to his first visit. The patient was the restrained front seat passenger. The car he was travelling in struck another car and the patient�s car was flipped over onto its roof. While the car remained on its roof the patient was able to crawl out and awaited medical attention. The patient was taken by ambulance to the hospital where he was examined and testing was ordered. The patient had multiple CT scans of the head and X-rays of the cervical and lumbar. The CT of the head revealed a nasal fracture and the patient underwent immediate surgery to repair his broken nose.
Contents
Safe and Effective Chiropractic Adjustment Study
The patient presented three weeks post-accident with persistent and progressive daily occipital headaches, neck pain into the shoulders bilaterally, upper back pain and lower back pain that radiates into the legs and down into the feet bilaterally. He has swelling at the left anterior knee and bandages around the right elbow and two black eyes.
The patient states that he was having difficulty with regular activities of daily living including walking for more than 15-20 minutes, long periods of standing, more than an hour of sitting, any bending or lifting and any regular daily chores. The patient also states he was having difficulty getting a restful night�s sleep due to the pain. The patient�s visual analog scale rating was 10 out of 10.
History: The patient denied any prior history of neck or back pain. No reported prior injuries or traumas.
Objective Findings: An examination was performed and revealed the following:
Range of Motion:
Cervical Motion Studies:
Flexion: Normal=60 Exam- 25 with pain with spasm
Extension: Normal=50 Exam- 20 with pain with spasm
Left Rotation: Normal=80 Exam- 35 with pain with spasm
Right Rotation: Normal=80 Exam- 35 with pain with spasm
Left Lat. Flex: Norma=-40 Exam- 15 with pain with spasm
Right Lat. Flex: Normal=40 Exam- 15 with pain with spasm
Dorsal-Lumbar Motion Studies:
Flexion: Normal=90 Exam- 35 with pain with spasm
Extension: Normal=30 Exam- 10 with pain with spasm
Left Rotation: Normal=30 Exam- 10 with pain with spasm
Right Rotation: Normal=30 Exam- 5 with pain with spasm
Left Lat. Flex: Normal=20 Exam- 5 with pain with spasm
Right Lat. Flex: Normal=20 Exam- 5 with pain with spasm
Orthopedic Testing
The orthopedic testing revealed the following positive orthopedic tests in the cervical spine: Valsalva�s indicating the presence of a disc at L4-S1 and the lower cervical region, foraminal compression indicating radicular pain in the lower cervical region, Jackson�s compression , shoulder depressor and cervical distraction all indicating pain in the lower cervical region. The lumbar testing revealed a positive Soto-Hall with pain at the L4-S1 level, Kemps positive with pain from L4-S1, Straight Leg raiser with pain at 60 degrees, Milgram�s with pain at the L5-S1 level, Lewin�s with pain at L5-S1, and Nachlas eliciting pain in the L5-S1 region.
Neurological Testing
The neurological exam revealed bilateral upper extremity tingling and numbness into the shoulder on the left and down the right arm into the hand. The lower extremity revealed tingling and numbness into the gluteal�s bilaterally with left sided radicular pain in to the leg into left foot. The pinwheel revealed hypoesthesia at C7 bilaterally and L5 bilaterally dermatome level. The patient was unable to perform the heel-toe walk
The chiropractic motion palpation and static palpation exam revealed findings at C 1,2 , 5, 6, 7 and T 2,3,4,9, 10 and L 3,4,5 as well as the sacrum.
X-Ray Result Study
The hospital had cervical x-rays and a CT of the head on the day of the accident. Thoracic and lumbar studies were needed as a result of the positive testing and the patients history and complaints The x-ray studies revealed a reversed cervical curve and misalignment of the C1,2,5,6,7 and the lumbar studies revealed a mild IVF encroachment at L5-S1 with rotations at L3,4,5.
The results of the exam were reviewed. The patient�s positive orthopedic testing, neurological deficits coupled with the decreased range of motion and positive chiropractic motion and static palpation indicated the necessity to order both cervical[1]and lumbar[2] MRI�s4.
MRI Results
The MRI images were personally reviewed. The cervical MRI revealed a right paracentral disc herniation at the level of C5-6 with impingement on the anterior thecal sac. There is also a C6-7 disc bulge impinging on the anterior thecal sac. The lumbar MRI revealed an L5-S1 disc herniation. There are disc bulges at from L2-L4.
CERVICAL MRI STUDIES
LUMBAR MRI IMAGES
Safe and Effective Treatment Plan
After reviewing the history, examination, prior testing, x-rays, MRI�s and DOBI care paths3 it was determined that chiropractic adjustments6 wereclinically indicated
The patient was placed on a treatment plan of spinal manipulation with modalities including intersegmental traction, electric muscle stimulation and moist heat. Diversified technique was used to adjust the subluxation diagnosed levels of C1,2,5,6,7 and L3,4,5. Although there were herniated and bulging discs present in the cervical and lumbar spine there was no cord compression. Therefore; there was no contraindication to performing a spinal adjustment. As long as there is enough space between the cord and the herniation or bulge then it is generally safe to adjust.5
The patient responded quite favorably to the spinal adjustments and therapies over the course of 6 months of treatments. Initially, the patient was seen three times a week for the first 90 days. The patient demonstrated subjective and objective improvement and his care plan was adjusted accordingly and reduced to two visits per week for the next 90 days of care. His range of motion returned to 90% of normal:
Range of Motion:
Cervical Motion Studies:
Flexion: Normal=60 Exam- 55 with no pain
Extension: Normal=50 Exam- 40 with mild tenderness
Left Rotation: Normal=80 Exam- 75 with mild tenderness
Right Rotation: Normal=80 Exam- 75 with mild tenderness
Left Lat. Flex: Norma=-40 Exam- 35 with no pain
Right Lat. Flex: Normal=40 Exam- 35 with no pain
Dorsal-Lumbar Motion Studies:
Flexion: Normal=90 Exam- 80 with tenderness
Extension: Normal=30 Exam- 25 with tenderness
Left Rotation: Normal=30 Exam- 25 with no pain
Right Rotation: Normal=30 Exam- 25 with no pain
Left Lat. Flex: Normal=20 Exam- 20 with no pain
Right Lat. Flex: Normal=20 Exam- 20 with no pain
The patient had decreased spasm, decreased pain, increased ability to perform ADL�s and his sleep had returned to normal. The patient states that he was no longer having the same difficulties with regular activities of daily living. He was now able to walk for 45 minutes to 1 hour before the lower back pain flared up, he is able to stand for 1-2 hours before the lower back pain begins, he is able to sit for an hour or more before the lower back pain flares up. When the patient bends or lifts he has learned to use his core and lifts less than 20-30 pounds to avoid exacerbating his low back. The patient also states he was no longer having difficulty getting a restful night�s sleep. The patient�s visual analog scale rating was 3 out of 10.
Conclusion
The patient presented 3 weeks post trauma with cervical and lumbar pain as well as headaches. The symptoms were progressing and the pain was radiating into the upper and lower extremities. The history and exam indicated the presence of a herniated disc in the lower lumbar and cervical region. Cervical and lumbar MRI�s were ordered to identify the presence of the herniated disc as well as to determine whether or not the patient should be adjusted. The MRI results of both the cervical and lumbar MRI revealed herniated discs, however, because these discs were not causing cord compression it was safe to adjust the cervical and lumbar spine5.
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.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
References
New England Journal of Medicine; Cervical MRI, July 28, 2005, Carette S. and Fehlings M.G.,N Engl J Med 2005; 353:392-399MRI for the lumbar disc, March 14 2013, el Barzouhi A., Vleggeert-Lankamp C.L.A.M., Lycklama � Nijeholt G.J., et al., N Engl J Med 2013; 368:999-1000 http://www.state.nj.us/dobi/pipinfo/carepat1.htm -16.7KB
New England Journal of Medicine; Cervical-Disk HerniationN Engl J Med 1998; 339:852-853September 17, 1998DOI: 10.1056/NEJM199809173391219
Is It Safe to Adjust the Cervical Spine in the Presence of a Herniated Disc? By Donald Murphy, DC, DACAN, Dynamic Chiropractic, June 12, 2000, Vol. 18, Issue 13
Treatment Options for a Herniated Disc; Spine-Health, Article written by:John P. Revord, MD
Additional Topics: Chiropractic Helps Patients Avoid Back Surgery
Back pain is a common symptom which affects or will affect a majority of the population at least once throughout their lifetime. While most back pain cases may resolve on their own, some instances of the pain and discomfort can be attributed to more serious spinal conditions. Fortunately, a variety of treatment options are available for patients before considering spinal surgical interventions. Chiropractic care is a safe and effective, alternative treatment option which helps carefully restore the original health of the spine, reducing or eliminating spinal misalignment which may be causing back pain.
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:
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:
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.
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.
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.
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.
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.
Is trained in chiropractic sports medicine and exercise science in order to treat sports injuries, enhance athletic performance, and promote physical fitness.
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.
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.
IRVING, Texas � Anthony Rotich (Cross Country) was announced as one of the 14 recipients of the Jim Castaneda Postgraduate Scholarship Award, announced by the league office on Tuesday afternoon.
The conference annually awards the $4,000 Postgraduate Scholarships to graduates as selected by the C-USA Faculty Athletics Representatives and approved by the Board of Directors.
Rotich, a civil engineer major and mathematics minor, graduated from UTEP as a three-time C-USA All-American honoree and a four-time C-USA Commissioner�s Academic Honor Roll recipient. The Kenya native was a four-time NCAA Champion and an 11-time Mountain Region Athlete of the Year. He was named the 2014 C-USA Cross Country Athlete of the Year.
Rotich is applying to UTEP�s College of Engineering � Construction Management.
Check Also
Emmanuel Korir has been named a semifinalist for college track and field�s highest individual honor, �
Acupuncture is a safe and effective alternative to pain medications for some emergency room patients, a new study reports.
“While acupuncture is widely used by practitioners in community settings for treating pain, it is rarely used in hospital emergency departments,” said study lead investigator Marc Cohen. He is a professor in the School of Health and Biomedical Sciences at RMIT University in Melbourne, Australia.
The study — billed as the world’s largest randomized, controlled trial of acupuncture in the emergency department — included 528 patients.
The study participants were seen at four Australian emergency departments for acute low back pain, migraines or ankle sprains. Patients who said their level of pain was at least 4 on a 10-point scale received one of three treatments: acupuncture alone; acupuncture with painkillers; or painkillers alone.
One hour after treatment, less than 40 percent of all patients had significant pain reduction, meaning at least a 2-point decline on the 10-point scale. More than 80 percent still had a pain rating of at least 4, the findings showed.
But two days later, most patients were satisfied. Overall, nearly 83 percent of acupuncture-only patients said they would probably or definitely repeat their treatment, compared with about 81 percent in the combined group, and 78 percent who took painkillers alone.
“Emergency nurses and doctors need a variety of pain-relieving options when treating patients, given the concerns around opioids such as morphine, which carry the risk of addiction when used long-term,” Cohen said in a university news release.
The study results suggest acupuncture would be especially beneficial for patients who can’t use standard pain-relieving drugs because of other medical conditions, Cohen added.
But he noted that more research is needed because some patients remained in pain no matter what treatment they received.
The study was published June 18 in the Medical Journal of Australia.
Chiropractor, Dr. Alexander Jimenez examines the role of biomechanics in medial tibial stress syndrome…
Medial tibial stress syndrome (MTSS � commonly known as shin splints) is not medically serious, yet can suddenly side- line an otherwise healthy athlete. Roughly five percent of all athletic injuries are diagnosed as MTSS(1).
The incidence increases in specific populations, accounting for 13-20% of injuries in runners and up to 35% in military recruits(1,2). MTSS is defined as pain along the posterior-medial border of the lower half of the tibia, which is present during exercise and (usually) diminishes during rest. Athletes identify the lower front half of the leg or shin as the location of discomfort. Palpation along the medial tibia usually reproduces the pain.
Contents
Causes Of MTSS
There are two main hypothesized causes for MTSS. The first is that contracting leg�muscles place a repeated strain upon the medial portion of the tibia, inducing periostitis � inflammation of the periosteal outer layer of bone. While the pain of a shin splint is felt along the anterior leg, the muscles that arise from this area are the posterior calf muscles (see figure 1). The tibialis posterior, flexor digitorum longus, and the soleus all arise from the posterior- medial aspect of the proximal half of the tibia. Therefore, the traction force from these muscles on the tibia is unlikely to be the cause of the pain typically felt on the distal portion of the leg.
A variation of this tension theory is that the deep crural fascia (DCF) � the though- connective tissue that surrounds the deep posterior compartment muscles of the leg � pulls excessively on the tibia, again causing trauma to the bone. Researchers at�the University of Honolulu examined a single leg from five male and 11 female adult cadavers. They confirmed that in these specimens, the muscles of the posterior compartment originated above the portion of the leg that is typically painful in MTSS, and the DCF indeed attached along the entire length of the medial tibia(3).
Doctors at the Swedish Medical Centre in Seattle, Washington wondered if, given the anatomy, could the tension from the posterior calf muscles produce a related strain on the tibia at the insertion of the DCF, and thus be the mechanism of injury(4)?
In a descriptive laboratory pilot study of three fresh cadaver specimens, they found that strain at the insertion site of the DCF along the medial tibia progressed linearly as tension increased in the posterior leg muscles. This confirmed that a mechanism for a tension-induced injury at the medial tibia is plausible. However, studies of bone periosteum in MTSS patients have yet to find inflammatory markers consistently enough to confirm the periostitis theory(5).
Tibial Bowing
The second causation theory for MTSS is that repetitive or excessive loading causes a bone-stress reaction in the tibia. The tibia, unable to adequately bear the load, bends during weight bearing. The overload results in micro damage within the bone, and not just along the outer layer. When the repetitive loading outpaces the bone�s ability to repair, localized osteopenia can result. Thus, some consider a tibial stress fracture to be the result of a continuum of bone stress reactions that include MTSS(1).
Magnetic resonance imaging (MRI) of the symptomatic leg often shows bone�marrow edema, periosteal lifting, and areas of increased bony resorption in patients with MTSS(1,5). This supports the bone- stress reaction theory. Magnetic resonance imaging of an athlete with a clinical presentation of MTSS can also help rule out other causes of lower leg pain such as tibial stress fracture, deep posterior compartment syndrome, and popliteal artery entrapment syndrome.
Risk Factors For MTSS
While the aetiology of MTSS is still theoretical, the risk factors for athletes developing it are well determined. A large navicular drop, as determined by the navicular drop test (NDT), significantly correlates with a diagnosis of MTSS(2,5). The NDT measures the difference in height position of the navicular bone, from a neutral subtalar joint position in supported non-weight bearing, to full weight bearing (see figures 2 and 3). The NDT is an indication of the degree of arch collapse during weight bearing. An excursion of more than 10 mm is considered excessive and a significant risk factor for the development of MTSS(5).
Research suggests that athletes with MTSS are found more likely to be female, have a higher BMI, less running experience, and a previous history of MTSS(2,5). Running kinematics for females can differ from males and fit a pattern that is known to leave them vulnerable to anterior cruciate ligament tears and patellofemoral pain syndrome(5). This same biomechanical pattern may also predispose females to MTSS. Hormonal considerations and low bone density are possibly contributing factors in increasing the risk of MTSS in the female athlete as well.
A higher BMI in an athlete likely indicates they have more muscle mass rather than they are overweight. The end result, however, is the same in that the legs bear a significantly heavy load. It is thought that in these instances, the bone growth�stimulated by the tibial bowing may not progress rapidly enough, and injury to the bone occurs. Therefore, those with a higher BMI may need to progress their training programs more slowly, to allow for adaptation.
Those with less running experience are more likely to make training errors (often identified by the athlete) as the catalyst for MTSS. These include increasing distance�too rapidly, changing terrain, overtraining, poor equipment (shoes), etc. Inexperience may also lead the athlete to return to activity too soon, thus accounting for the higher prevalence of MTSS in those who had suffered MTSS previously. Full recovery from MTSS can take anywhere from six to ten months, and if the cause of injury was not rectified or the athlete returns to training too soon, the chances are good the pain will return(5).
Biomechanical Considerations
The NDT is used as a measurable indication of foot pronation. Pronation is a tri-planar movement comprised of eversion at the hind foot, abduction of the forefoot, and dorsiflexion of the ankle. Pronation is a normal movement, and essential in walking and running. When the foot strikes the ground at the initial contact phase of running, the foot begins to pronate and the joints of the foot assume a loose-packed position. This flexibility helps the foot absorb ground reaction forces (see figure 4).
During the loading response phase, the foot further pronates, reaching peak pronation by around 40% of stance phase(6). In mid stance, the foot moves out of pronation and back to a neutral position. During terminal stance, the foot supinates, moving the joints into a closed packed position and creating a rigid lever arm from which to generate the forces for toe off.
Beginning with the loading response phase and throughout the remainder of the single leg stance phase of running, the hip is stabilized, extended, abducted and externally rotated by the concentric contraction of the hip muscles of the stance�leg (the gluteals, piriformis, obturator internus, superior gemellus and inferior gemellus). Weakness or fatigue in any of these muscles can result in internal rotation of the femur, adduction of the knee, internal rotation of the tibia, and over-pronation (see figure 5). Overpronation therefore, can be a result of muscle weakness or fatigue. If this is the case, the athlete may have a quite normal NDT, and yet when the hip muscles don�t function as needed, can overpronate.
In a runner who has significant over pronation, the foot may continue to pronate into mid stance, resulting in a�delayed supination response, and thus less power generation at toe off. The athlete may attempt two biomechanical fixes here that could contribute to the development of MTSS. Firstly, the tibialis posterior will strain to prevent the over pronation. This can add tension to the DCF and strain the medial tibia. Secondly, the gastroc-soleus complex will contract more forcefully at toe off to improve the power generation. Again, the increased force within these muscle groups can theoretically add tension to the medial tibia through the DCF and possibly irritate the periosteum.
Evaluating The Injured Athlete
Knowing that over pronation is one of the leading risk factors for MTSS, start your evaluation at the ground and work your way up. First, perform the NDT, noting if the difference is more than 10mm. Analyze the athlete�s running gait on a treadmill, preferably when the muscles are fatigued, as at the end of a training run. Even with a normal NDT, you may see evidence of over pronation in running (see figure 6).
Next evaluate the knee. Is it adducted? Notice if the hip is level or if either hip is more than 5 degrees from level. These are indications that there is likely weakness at the hip. Traditional muscle testing may not reveal the weakness; therefore, functional muscle testing is required.
Observe the athlete perform a one-legged squat with arms in and arms overhead. Does the hip drop, the knee adduct and the foot pronate? Test the strength of hip abductors in side lying, with hip in neutral, extended, and flexed, keeping the knee straight (see figure 7). Test all three positions with hip rotated in neutral, and at end ranges of external and internal rotation. Test hip extension in prone with the knee straight and bent, in all three positions of hip rotation: external, neutral and internal. The position where you find the weakness is where you should begin strengthening activities.
Treat The kinetic Chain
If there is weakness in the hip, begin by having the athlete perform isometric exercises in the position of weakness. For instance, if you find weakness in hip abduction with extension, then begin isolated isometrics in this position. Not until the muscles consistently fire isometrically in this position for three to five sets of 10 to 20 seconds should you add movement. Once the athlete achieves this level, begin concentric contractions, in that same position, against gravity. Some examples are unilateral bridging and side lying abduction. Eccentric contractions should follow, and then sport specific drills.
Keep in mind if there are other biomechanical compensations, they must also be addressed. If the tibialis posterior is also weak, begin strengthening there. If the calf muscles are tight, initiate a stretching program. Utilise whatever modalities might be helpful. Lastly, consider a stabilising shoe if the ligaments in the foot are over stretched. Using a stabilising shoe for a short time during rehabilitation can�be helpful in cuing the athlete to adopt new movement patterns.
Conclusion
The best way to prevent shin pain from MTSS is to decrease the athlete�s risk factors. Ideally, each athlete should have a basic running gait analysis and proper shoe fitting. Include hip strengthening in functional positions such as unilateral stance as part of the strengthening program. Pair inexperienced athletes with a more experienced mentor to ensure proper training, use of equipment, and investigation of pain at onset. They may be more likely to tell a teammate they are feeling pain than a coach or trainer. Progress the running schedule of heavier athletes more slowly to allow adaptation of the bone. Ensure that athletes fully rehabilitate before returning to play because the chances of recurrence of MTSS are high.
References
1. Am J Sports Med. 2015 Jun;43(6):1538-47
2. Br J Sports Med. 2015 Mar;49(6):362-9
3. Med Sci Sports Exerc. 2009;41(11):1991-1996
4. J Am Podiatr Med Assoc. 2007 Jan;97(1):31-6
5. J Sports Med. 2013;4:229-41
6. Gait and Posture. 1998;7:77�95
Title: The Utilization of Long Term Care for Herniated Lumbar Discs with Chiropractic for the Management of Mechanical Spine Pain.
Dr. Alex Jimenez, doctor of chiropractic, focuses on the diagnosis, treatment and prevention of a variety of injuries and conditions associated with the musculoskeletal and nervous systems, utilizing several chiropractic methods and techniques. The following procedures may be similar to his own but can differ according to the specific issue and complications by which the individual is diagnosed.
Abstract: To explore the utilization of chiropractic treatment consisting of spinal adjusting, axial traction, electrical muscle stimulation, and core stabilization exercise for the management of mechanical spine pain. Diagnostic studies included physical examination, orthopedic and neurological examinations, and lumbar spine MRI. The patient reports long-term success in reducing pain levels and increasing functionality by having the ability to perform activities of daily living (ADL�s) without frequent flare-ups which he reported of prior to undergoing chiropractic treatment.
Introduction: On 2/6/2015, a 49 year old male certified nursing assistant, presented for consultation and examination due to a work injury which occurred on 11/12/2001. The patient stated he sustained a lifting injury that resulted in severe low back pain. He stated that he was under the care of a pain management interventionist receiving epidural injections in his lumbar spine on an ongoing basis since the injury occurred. He added that the injections helped him to cope with the elevated pain levels he experienced on a frequent basis. The patient had previously received chiropractic and physical therapy for his injury and reported that the therapies did help him when he was actively treating. He informed it had been over 3 years since he last treated with chiropractic or physical therapy.
Contents
Chiropractic Back Pain Management
The patient presented to my office on 2/6/2015 with a chief complaint of lumbar pain. He rated the discomfort as a 7 on a visual analog scale of 10 with 10 being the worst and the pain was noted as being constant (76-100% of the time). The onset of pain was a result of the work injury described above. He reported that the pain would aggravate by activities which required excessive or repetitive bending, lifting, and pulling. He stated he experienced flare-up episodes 4-6 times a month depending on the type of activities he was involved with. The quality of the discomfort was described as aching, gnawing, sharp, shooting, and painful and was noted as being the worst at the end of the day. He stated that when his pain levels were elevated, it would limit his ability of getting a good night sleep. The patient further noted he was experiencing numbness and tingling in both legs and his right foot.
Prior History:
The patient denied any prior or subsequent low back injuries and/or traumas.
Clinical Findings:
The patient was 5 feet 10 inches and weighed 230 pounds. His sitting blood pressure was 132/86 and his radial pulse was 74 BPM. The patient�s Review of Systems and Family History were unremarkable.
An evaluation and management exam was performed. The exam consisted of visual assessment of range of motion, manual muscle tests, deep tendon reflexes, digital and motion palpation, and other neurological and orthopedic tests. Palpation revealed areas of spasm, hypertonicity, asymmetry, and end point tenderness indicative of subluxation at T12, L2, and L4. Palpation of the lumbar muscles revealed moderate to severe muscle spasms in the left piriformis, right piriformis, right sacrospinalis, right gluteus maximus, right erector spinae, right quadratus lumborum and right iliacus. He presented with postural deviations that were found using a plumb line assessment showing short right leg (pelvic deficiency), head tilted to the left, high left shoulder and high right hip. Point tenderness was notably present along the midline of the spine at the L4 and L5 level.
Manual, subjectively rated strength tests were performed on some of the major muscle groups of the lower extremities, based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed., 2001. A rating scale of five to zero was used, with five representing normal muscle strength. A muscle strength loss of the lower extremities indicates a neurological facilitation resulting from dysfunction in the lumbar spine. Grade 4 muscle weakness was noted on the right extensor hallicus longus.
Dermatomal sensation was decreased at L4 on the right and decreased at L5 on the right.
Reflex testing was completed and was diminished: 0/+2 on the right patella and +1/+2 on the left patella. The following lumbar orthopedic examinations were performed and found to be positive: Ely’s on the right, Hibb’s on the right, Iliac compression test and Bragard’s on the right.
Lumbar Range of Motion tested with Dual Inclinometers:
Range of Motion Normal Examination % Deficit
Flexion
90
40
56
Extension
25
10
60
Left Lateral Flexion
40
20
50
Right Lateral Flexion
40
15
62
Left Rotation
35
25
29
Right Rotation
35
20
43
Flexion and left lateral bending were painful at end range. The patient�s limitation to bend is corroborated by the persistent spasticity of lack of motion eliciting pain upon exertion in the lumbar spine.
MRI Results
The MRI images were personally reviewed. The lumbar MRI performed on 9/29/2014 revealed anterior positioning of the L4 vertebral body with respect to L5 with a right L4-L5 protrusion compromising the right neural foramen. There is a central herniation at the L5-S1 disc.
Fig. 1, (A), (B), (C) shows in T2 MRI images (A) is Sagittal and (B) is Axial at L4-L5 and (C) is Axial at L5-S1
Fig. 1 (A) Sagital
Fig. 1 (B) T2 Axial at L4-L5
Fig. 1 (C) T2 Axial at L5-S1
After reviewing the history, physical and neurological examination, and MRI�s it was determined that chiropractic treatment was medically indicated and warranted. Frequency of treatment was determined 1 time a week.
The patient was placed on a treatment plan consisting of high velocity low amplitude chiropractic adjustments, axial traction, electrical muscle stimulation, and core stabilization exercise. The patient responded in favorable fashion to the chiropractic treatment over a 6 month period. The patient demonstrated subjective and objective improvement and his care plan was reduced to one time every two weeks to manage and modulate pain levels associated with his permanent condition.
On follow-up re-evaluation approximately 9 months after starting supportive treatment the patient showed improvement in range of motion testing.
Lumbar Range of Motion was tested with Dual Inclinometers:
Range of Motion Normal Examination % Deficit
Flexion
90
70
13
Extension
25
20
20
Left Lateral Flexion
40
35
12
Right Lateral Flexion
40
30
25
Left Rotation
35
30
15
Right Rotation
35
25
29
The patient also reported a reduction in pain levels rating the low back discomfort as a4 on a scale of 10 with 10 being the worst and the pain was noted as beingintermittent 25 to 50% of the time. Decreased muscle spasm in the lumbar paraspinal muscles was noted as well as better symmetry and tonicity. The patient reported the ability of getting a better night sleep and waking up in the morning with less rigidity and achiness. He stated he was able to perform his work duties and activities of daily living with less flare-ups and exacerbations occurring only 1-2 times a month. The core training exercises we worked on have helped stabilize the patient�s spine and protected it from reinjuring the already injured tissues.
Conclusion of Research Study
Chiropractic care has been shown to be both safe and effective in treating patients with disc herniation and accompanying radicular symptoms1-4. Spinal chiropractic adjustive therapy has been proven to modulate pain6. This patient presented with chronic low back pain sequela to an injury that occurred over 13 years ago. The patient had prior success in reduction of pain when he was treating with chiropractic in the past then discontinued treatment. The patient has been treating with pain management intervention since the injury occurred and it has helped him reduce his pain but has done minimal for him from a functional and mechanical standpoint. The history and exam indicated the presence of 2 herniated discs in the lumbar spine. Lumbar MRI�s were ordered prior to being evaluated and the images were viewed to establish an accurate diagnosis, prognosis, and treatment plan. Long term chiropractic treatment has been utilized successfully in this case study to reduce pain levels and restore the patient�s functional capacity of performing activities of daily living and work duties with less flare ups and exacerbations of low back pain.
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.
The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss options on the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Leeman S., Peterson C., Schmid C., Anklin B., Humphryes B., (2014) Outcomes of Acute and Chronic Patients with Magnetic Resonance Imaging-Confirmed Symptomatic Lumbar Disc Herniation Receiving High-Velocity, Low Amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One-Year Follow Up, Journal of Manipulative and Physiological Therapeutics, 37 (3) 155-163
Hahne AJ, Ford JJ, McMeeken JM, “Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review,”Spine35 (11): E488�504 (2010).
Rubinstein SM, van Middelkoop M, et. al, “Spinal manipulative therapy for chronic low-back pain,”Cochrane Database Syst Rev(2): CD008112. doi:10.1002/14651858.CD008112.pub2. PMID 21328304.
Hoiriis, K. T., Pfleger, B., McDuffie, F. C., Cotsonis, G., Elsangak, O., Hinson, R. & Verzosa, G. T. (2004). A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. Journal of Manipulative and Physiological Therapeutics, 27(6), 388-398.
Coronado, R. A., Gay, C. W., Bialosky, J. E., Carnaby, G. D., Bishop, M. D., & George, S. Z. (2012).Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis. Manuscript in preparation.
Whedon, J. M., Mackenzie, T.A., Phillips, R.B., & Lurie, J.D. (2014). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69. Spine, (Epub ahead of print) 1-33.
Additional Topics: Recovering from Auto Injuries
After being involved in an automobile accident, many victims frequently report neck or back pain due to damage, injury or aggravated conditions resulting from the incident. There’s a variety of treatments available to treat some of the most common auto injuries, including alternative treatment options. Conservative care, for instance, is a treatment approach which doesn’t involve surgical interventions. Chiropractic care is a safe and effective treatment options which focuses on naturally restoring the original dignity of the spine after an individual suffered an automobile accident injury.
IFM's Find A Practitioner tool is the largest referral network in Functional Medicine, created to help patients locate Functional Medicine practitioners anywhere in the world. IFM Certified Practitioners are listed first in the search results, given their extensive education in Functional Medicine
