SPINAL CARE 2000 SYMPOSIUM

CLEVELAND CLINIC MAR30, 2000

Bernard S. Burton, DC CCN

 Chiropractic Management of Low Back Pain.

HISTORICAL APPLICATION OF MANIPULATION:

             Recorded history of manipulative therapy extends back to the days of Hippocrates.  Orthodox and folk practitioners in Europe and the Middle East wrote on the usefulness of manipulation for treatment of acute low back pain and spinal curvatures.  Early manipulation involved Succession from a ladder while hanging by the patients’ feet.  According to Elizabeth Lomax in (1) Hippocrates disapproved of this approach due to its overuse and instead preferred extension with pressure exerted in the prone position on a wooden table.  Sometimes wood was applied as a lever to aid in the treatment.

In the mid 1700’s Nicholas Andry founded the term “orthopaedia” from the Greek roots orthos (meaning straight) and paidos (child) was termed with the implication that many of the deformities of adolescence and adult life originate in childhood.  His use however along with his contemporaries included rest, corsets, exercise and posture.  He was not an advocate of manipulation.  Percival Pott (1) stated that spinal problems were more common than suspected.  Treatment was by rest and local discharge by the use of issues.  Manipulation and extension was considered useless and dangerous.

Dr. Edward Harrison  in the late 18^th century became a big proponent of manipulation after spending a couple of decades in Lincolnshire  a county known for it’s numerous bonesetters. In 1821 he wrote a series of articles title “observations respecting the nature and origin of the common species of disorders of the spine: with critical remarks on the opinions of former writers on the disease.”  He attacked the views of Pott and expressed his own opinion, which was that the true cause of spinal complaints is in the connecting ligaments “which seem to have lost part of their power of holding the bones together.” His treatment consisted of manipulation (and probably friction based upon other treatments at that time).  One account was daily manipulations for 3 weeks.

There was some discourse since the doctrine of vertebral luxation and use of manipulation was considered taboo.  The Medico-Chirurgical Review  was very critical of Dr. Harrison.  He ended up being charged with practicing medicine without a license. In court, he defended himself by saying was actually practicing surgery instead. Even though untrue the jury found in his favor.  He continued to practice until his death in 1838.

Other supporters of Harrison advocated manipulation, such as Andrew Dods in 1824 and W. J. Little in 1868. Wharton Hood of Lancet in 1871 stated “I was most astonished, and often no less mortified at the number and variety of instances in which the manipulations I have endeavored to describe were followed by almost immediate cure”.

Spinal irritation became a new clinical entity and became more popular noted in 1871 “Treatise on Diseases of the Nervous system” These spinal irritations were thought to manifest as “mania, vertigo, amblyopia, nervous fevers, cough dyspnoea, pleuritis, colic, vomiting, disorders of menstruation, hysteria, asthma, and diabetes.  Diagnosis was based on tenderness of appropriate vertebra.  Treatment consisted of application of irritants, such as blisters, leeches, and cauteries to the tender dorsal points (Note: the area they denote is along the bladder acupuncture meridian which, today, is stimulated by needles, electricity, microcurrent, heat, and lasers in acupuncture, and chiropractic adjustments which supply the mechanical force.)

There seems to be much historical controversy in the orthopedic profession.  Watson-Jones has written there is no place for manipulation in orthopedic practice.  Wiles has published that manipulation should always be tried before any operation is undertaken.  According to John Mennell (1) “Recently I asked an orthopedic surgeon in charge of a large residency training program what he really thought about manipulation.  I did not say “spinal manipulation” yet that is how he heard my question.  Paraphrasing his reply he said “ I use it. I twist people around and I really don’t know what I am doing, but it is surprising how often it works.”

“Few of you will enter into practice today without having the so-called “bone-setter” as a competitor…. Learn then to imitate what is good and avoid what is bad in the practice of bone-setters… It is advisable to learn from one’s opponent.”  Sir James Paget late 19^th century.

From this comment, it appears that historically there has not just been controversy, but an adversarial relationship between manipulators and the medical profession.

Chiropractic is the 2^nd largest health care profession in the US and the only one whose focus is on spinal manipulation.  My goal is to demonstrate that we are capable of a high level of visceral diagnosis, able to determine when to refer, very qualified in neuromuscular problems, able to determine contraindication to adjustments, able to pick an approach to treating the spine which is the most effective and least risky. We typically see the patient more often so we are able be more accurate in our diagnosis.   To be a good chiropractor is a lifelong pursuit of excellence.

History of Chiropractic:

Chiropractic is 105 years old.  The history of Chiropractic requires mention of  Dr. D.D. Palmer the founder,  Dr. B.J Palmer, the developer, Dr. Logan, Dr. Dejarnette, Dr. Gonstead, Dr. Arlan Fuhr, Dr. George Goodheart. Dr. Grostic. Dr Gillet, Dr. Thompson, Dr. Cox, and the hundreds of Chiropractors who perform and performed clinical research in their practices to evolve a methods of treatment which consists of 100’s of different techniques* designed to restore joint and nerve function and whose ultimate goal is to optimize health.  From its early inception, nutrition played an integral part, and we have been on the forefront of clinical nutrition.

*(A technique is the method of determining when an adjustment is needed, how to treat it, and when you are finished.)

Chiropractic.

Definition: (Fla. Statute 460.403. 3a,b,& c)

a) “Practice of chiropractic” means a noncombative principle and practice consisting of the science of the adjustment, manipulation, and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that are interfering with the normal generation, transmission, and expression of nerve impulse between the brain, organs, and tissue cells of the body, thereby causing disease, and adjusted, manipulated, or treated, thus restoring the normal flow of nerve impulse which produces normal function and consequent health.”

b) Any chiropractic physician who has complied with the provisions of this chapter may examine, analyze, and diagnose the human living body and its diseases by the use of any physical, chemical, electrical, or thermal method; use the X-ray for diagnosing; phlebotomize in compliance with paragraph (f); and analysis taught in any school of chiropractic.

c) Chiropractic physicians my adjust manipulate, or treat the human body by manual, mechanical, electrical, or natural methods; by the use of physical means or physiotherapy, including light, heat, water, or exercise; by the use of acupuncture; or by the administration of foods, food concentrates, food extracts, and proprietary drugs and may apply first aid and hygiene, but chiropractic physicians are expressly prohibited from prescribing or administering to any person any legend drug, from performing any surgery except as stated herein, or from practicing obstetrics.

Subluxation:

The subluxation is the clinical entity associated with chiropractic.  The antiquated premise has been termed the “Garden Hose” theory or nerve compression hypothesis.   More elaborate descriptions have been described in the literature (1).  The most recent and most complete definition is that of the Subluxation Complex (2), noted below.

Subluxation tends to Pathophysiology, which tends to Pathology.

Axiom – Correction of a subluxation restores normal physiologic processes and the reversible pathology reverses.

Subluxation – A complex clinical entity comprising one or more of the following.

1. Neuropathophysiology

2. Kinesiopathology

3. Myopathology

4. Histopathology

5. Biochemical Changes

CHIROPRACTIC TRAINING

The Chiropractic curriculum is accredited by the CCE (Council on Chiropractic Education) typically consists of 5 academic years. Courses consist of classroom and laboratory work in basic sciences such as anatomy, physiology, and biochemistry; chiropractic courses on theory, treatment, and diagnostic procedures; and chiropractic clinic for practical experience.

CHIROPRACTORS initial visit

Like allopathic physicians, when a patient presents into our offices, the primary focus is on differential diagnosis to determine if this patient requires immediate referral to an appropriate physician, co-managed with an appropriate physician, or treated in-house.

The initial visit includes, elaboration of chief complaint, a thorough history of present illness, past medical history, review of systems, past family social history, inspection,

and examination.

A typical examination can include, visceral examination (if necessary), vital signs, extremity evaluation.  The examination always includes an orthopedic, neurologic, and chiropractic exams.  The orthopedic exam includes inspection, palpation, percussion, range of motion, posture analysis, and orthopedic tests.  A neurologic exam consists of 

mental status, cranial nerves, motor function, muscle testing, reflexes, cerebellar function, and sensory function.

Diagnostic imaging may be necessary which can include plain film X-ray, (usually weight bearing), videoflouroscopy ( for joint movement), MRI for soft tissue, disc problems or fractures if software enhancements are employed.  CT and bone scans are recommended, if necessary.  Laboratory testing may also be prescribed.  It is important to note that on many of these more complicated cases the average chiropractor would prefer to co-manage if the proper referral system were in order.

Chiropractic Exam

•  Posture

• Range of Motion

• Static Palpation

• Motion Palpation

• X-ray for mensuration and functional evaluation

• Instrumentation

• Synthesis

• Diagnosis

  • Medical Diagnosis

  • Chiropractic Diagnosis

• Referral vs. Treat

Purpose of Diagnosis:

Whatever the health field, the diagnosis determines the course of treatment.  In medicine, cervicalgia and lumbalgia which means neck and low back pain, would, by their definition, be treated with pain relievers.  In chiropractic, lumbalgia may be caused by; misalignment of L5 on S1, hypermobile SI joints, fixation of a lumbar vertebra, or piriformis involvement.  The chiropractic diagnosis may be: body right L5, CAT II Right, L3-L4 fixation, or piriformis syndrome.  Therefore without a functional diagnosis a treatment approach is difficult. Given below are examples of Medical Diagnoses and Chiropractic Diagnoses.

  Medical Diagnoses:

Sciatica, Facet syndrome, sacroiliitis, lumbar discitis, piriformis syndrome, bursitis, tendonitis, Tumor (Benign + Malignant), infection, arthritis (OA, rheumatoid, nonrheumatoid variants, enteropathic) Referred pain from viscera are examples of a medical diagnosis.

  Chiropractic Diagnoses:

Chiropractic Diagnoses for low back pain are based upon function, examples are:

Ligamentous: Fixation of L5 - C1 in any of the up to 8 joints per vertebra, fixation of sacroiliac joints, symphysis pubis, aberrant movement of any of the above, subluxation, sacral segment subluxation, sacral misalignment, pelvic misalignment, hypermobility of sacroiliac joint, Category II, & III in SOT, and iliolumbar ligament contacture.

Muscular: weakness of quadratus lumborum, piriformis-contracted or elongated, gluteus maximus, minimus, psoas, hamstrings, abdominals,

Misaligment, weakness or functional problem distal to pain:

Hip, knee, ankle, foot, either side and spinal lesion and thoracic, cervical, or cranial regions.

Treatment may consist of:

1) Manipulation varying velocity, force, direction, torque, directly to the lesion or distal through reflex points or along muscular attachments, traction and distraction.  

2)  Muscle approaches such as trigger point and strain-counter strain.

3) Energy approaches such as Acupuncture

4)  Nutritional approaches specific to the complaint (symptom approach) or to the organ system (holistic approach)

5)      Craniopathy

6)      Massage

7)      Physical therapy modalities such as EMS, US, Trigger point US, Microcurrent, Cryotherapy, and heat

Chiropractic use of Physiotherapy

Frequently physiotherapy is applied with the chiropractic treatment.  PT was firmly established at the National College of Chiropractic 1914.  A chiropractic traction couch patented in 1914. (5) The table below shows the Modalities related to the Physiologic Stages involved in Healing.(5).

I.                    Stage of Hyperemia or Active Congestion

1.      Ice packs: vasoconstrictive effects

2.      Galvanism: vasoconstrictive, hardening of tissue effects.

3.      Pulsed Ultrasound: dispersing effects; increased membrane permeability effects.

4.      Rest, with possible support; prevents irritation and further injury.

II.                 Stage of Passive Congestion

1.      Alternating hot and cold applications, preferably in a 3:1 ratio every few hours: revulsive effects

2.      Light massage, particularly effleurage: revulsive effects

3.      Passive manipulation: effects of revulsion, maintenance of muscle tone, freeing of coagulates and possibly early adhesions.

4.      Mild range of motion exercise: effects same as 3.

5.      Alternating current stimulation, of a surging nature: effects same as 3.

6.      Ultrasound: increase in gaseous exchange, dispersion of fluids, liquefaction of gels, and increased membrane permeability effects.

III.               Stage of Consolidation and/or Formation of Fibrinous Coagulant

1.      Local moderate heat, preferably of a moist nature: mild vasodilation, increased membrane permeability effect.

2.      Moderate active exercise: revulsive effects, freeing of coagulant and early adhesions, maintenance of tone, and ligamentous and muscular integrity effects.

3.      Motorized alternating traction: effects same as 2.

4.      Moderate range of motion manipulation: effects same as 2.

5.      Ultrasound: hyperemia, liquefaction of gels, dispersion of gases and fluids, increased membrane permeability, and tissue-softening effects.

6.      Sinusoidal current, surging or pulsating: effects same as 2.

IV.              Stage of Fibroblastic Activity and Fibrosis

1.      Deep heat, prolonged (e.g., diathermy): prolonged vasodilation, increased membrane permeability, increased chemical activity effects.

2.      Deep massage (e.g., petrissage or other soft-tissue manipulation): tends to break down fibrotic tissue and create more elasticity.

3.      Vigorous active exercise, preferably with slight traction or at lease without weight bearing: maintains muscle and ligamentous integrity, stretches fibrotic tissues, breaks adhesions, and creates greater elasticity.

4.      Motorized alternating traction: effects same as 3.

5.      Negative galvanism, particularly with an antisclerotic (e.g., potassium iodine): vasodilation, softening, liquefaction, and antisclerotic activity effects.

6.      Ultrasound: effects causing softening of tissues as previously mentioned.

7.      Active joint manipulation: reduction of muscular spasm, breaking of adhesions and fibrotic tissue, and restoration of physiologic motion effects.

CONTRAINDICATIONS TO MANIPULATION (4)

According to the Mercy Guidelines which was an initial united effort by the chiropractic profession to establish practice guidelines using accepted consensus methods in Jan 25-30, 1992.

The contraindication ratings for the below conditions had the highest level of consensus amongst the Mercy participants.  Note : there are no contraindications for low force adjusting in areas distant to the lesion.

Absolute contraindicated for high velocity thrust procedures in areas of involvement

Articular derangements:

1.      Acute rheumatoid, rheumatoid-like and nonspecific arthropathies including acute AS

2.      Acute fractures and dislocations; or healed fractures with signs of ligamentous rupture or instability.

3.      Unstable os odontiodium

Bone Weakening Destructive Disorders

1.      Active juvenile avascular necrosis, specifically (Perthes DX).

2.      Malignancies

3.      Infection of bone and joint

Neurological Disorders

1.      Acute Myelopathy or Acute Cauda Equina Syndrome.

Relative to Absolute contraindicated for high velocity thrust procedures in areas of involvement

Articular derangements:

1.      Spondylolysis and Spondylolisthesis with progressive slippage

2.      Articular hypermobility, and circumstances where the stability of a joint is uncertain.

Bone Weakening Destructive Disorders

1.      Demineralization of bone warrants caution

2.      Benign bone tumors may result in pathological fractures

Circulatory and Cardiovascular Disorders

1.      Vertebrobasilar insufficiency

2.      Significant aneurysm

3.      Anticoagulant therapy or certain blood dyscrasias has bleeding as a potential complication.

Not contraindicated for high velocity thrust procedures in areas of involvement

Articular derangements:

1.      Subacute or chronic AS and other chronic spondyloarthropathies with no signs of ligamentous integrity, anatomic subluxation, or ankylosis.

2.      DJD, OA, degenerative discopathy, and spondyloarthrosis.

3.      Spondylolysis and Spondylolisthesis without progressive slippage.

4.   Post surgical joints or segments with no evidence of instability

5.  Acute injuries of osseous and soft tissue may require modification of treatment

6.      Scoliosis

Conclusion:

The chiropractic approach is multifaceted and has developed somewhat independently from the medical profession; this has led to ignorance and mistrust between the professions.  The Journal of the American Medical Association has estimated that 40% of Americans have turned away from traditional drug usage in favor of incorporating natural alternatives. Establishing relationships between us will benefit the patient first and then ultimately ourselves.

References:

1)      The U.S. Department of Health, Education, and Welfare.: The research status of Spinal manipulative Therapy NINCDS Monograph No. 15, 1975. Pgs. 3-47

2)      John Faye and the Motion Palpation Institute. 1986 .: Motion Palpation and Chiropractic Technic 2^nd edition. R.C. Schafer, DC, FICC, and L.J. Faye, DC, FCCSS © Hon.

3)  Homewood A.E.; The Neurodynamics of the Vertebral Subluxation., 1977

4)  Proceedings of the Mercy Center Consensus Conference.; “ Guidelines for Chiropractic Quality Assurance and Practice Parameters,  Aspen Publication, 1993

5) Jaskoviak, P.A ; DC, FICC, R.C. Schafer, DC, FICC; Applied Physiotherapy, Practical Clinical Applications with Emphasis on the Management of Pain and Related Syndromes.; First Edition 1986. Pgs 3-14.