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January 2006, Vol. 16, No. 1
Table of Contents
CBP® Non-Profit Matches Dr. Bill Harris' $25,000 Research Grant • Counter Point Round III • Dr Deed Harrison is the Most Published Chiropractor in the Index Medicus • Flawed Thinking • It's Don's Opinion • JCCA Publishes CBP® Structural Rehab Protocol • More Studies to Confirm the Validity and Reliability of PosturePrint™ • Thriving in the New Health Care Marketplace • Organic Chiropractic • Patient Education • Point Round III • The Purpose Driven Practice • Radiation Hormesis • Research Corner • Subluxation Update • System Failure • Ten New Year's Resolutions for Your Practice • Chiropractic: A Useful Component of Traumatic Brain Injury Rehabiitation • Triano is a Chiropractic Pariah •
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Subluxation Update
by Daniel J. Murphy, DC, FACO,
Vice President of ICA
Dan Murphy graduated magna cum laude from Western States Chiropractic College in 1978, and has more than 20 years of practice experience. He received Diplomat status in Chiropractic Orthopedics in 1986. Since 1982, Dr. Murphy has served part-time as undergraduate faculty at Life Chiropractic College West, currently teaching classes to seniors in the management of spinal disorders.
Dr. Murphy is on the post-graduate faculty of several chiropractic colleges. His post-graduate continuing education classes include “Whiplash and Spinal Trauma” and “Pain Neurology.” Dr. Murphy is the coordinator of a year-long certification program in “Chiropractic Spinal Trauma,” now (2000) in its twelfth year of being offered. This year, the program is being offered through the International Chiropractors Association of California. He has taught more than 700 post-graduate continuing education seminars.
Dr. Murphy is a contributing author to the book Motor Vehicle Collision Injuries, published by Aspen, 1996; and to the book Pediatric Chiropractic, published by Williams & Wilkins, 1998. He writes a quarterly column in the Journal of Clinical Chiropractic.
In 1987, 1991 and 1995 Dr. Murphy received the Post-graduate Educator of the Year award, given by the International Chiropractic Association. In 1997, he received The Carl S. Cleveland, Jr., Educator of the Year award, given by the International Chiropractic Association of California.
In 2005, Grimm, Cunningham, and Burke1 noted:
“One of the central hypotheses of traditional chiropractic is that dysfunction of somatic structures, chiefly the musculoskeletal components of the human vertebral column, may have significant impact on regulation of the nervous system, specifically the autonomic nervous system, and hence influence visceral function and health.”
Three recent articles support the chiropractic concept (as stated above) that postural distortions, spinal positional distortions, and segmental neurological integrity influence an individuals systemic health, well being, and their pain profile. These articles and related concepts are reviewed here.
Summary of an Original Article:
Glassman, Steven D. MD; Bridwell, Keith MD; Dimar, John R. MD; Horton, William MD; Berven, Sigurd MD; Schwab, Frank MD. The Impact of Positive Sagittal Balance in Adult Spinal Deformity. Spine Volume 30(18), September 15, 2005 pp. 2024-2029
This study involved 752 adult patients. Their systemic health status was determined using three assessment measures (The Scoliosis Research Society patient questionnaire, MOS short form-12, and Oswestry Disability Index).
The patients were then x-rayed with lateral full-spine radiographs. The center of the C7 vertebral body was marked on the radiograph and a plum line was dropped past the sacrum. The plum line was measured as to where it fell with respect to the posterior superior sacral base. When the plum line fell anterior to the posterior superior sacral base, it was labeled as a “positive sagittal balance” and when it fell posterior, it was labeled as a “negative sagittal balance.” These authors carefully measured the sagittal postural balance using full-spine lateral radiographs, noting that their protocols are “reproducible.”
Subsequently, statistical correlation between radiographic parameters and health status measures were performed and reported.
The following points were made:
• There is a deterioration of health status with progressive forward head / body sagittal balance.
• All measures of health status showed significantly poorer scores as C7 plumb line deviation increased forward of the sacrum.
• Even minor forward head / body sagittal balance is detrimental.
• The severity of symptoms increases in a linear fashion with progressive increase of forward head / body sagittal imbalance.
• There was clear evidence of increased pain and decreased function as the magnitude of forward head / body sagittal balance increased.
My favorite quotes from the article are:
“All measures of health status showed significantly poorer scores as C7 plumb line deviation increased [forward head / body].”
“There was a high degree of correlation between positive sagittal balance and adverse health status scores, for physical health composite score and pain domain.”
“There was clear evidence of increased pain and decreased function as the magnitude of positive sagittal balance [forward head / body] increased.”
“This study shows that although even mildly positive sagittal balance is somewhat detrimental, severity of symptoms increases in a linear fashion with progressive sagittal imbalance [forward head / body].”
In my view, this article is very important. It is published in SPINE, the scientific communities most prestigious orthopedic journal. All 5 authors are medical physicians, they are exposing patients to upright full-spine radiographs, making postural measurements in units of millimeters, and using the measurements in evaluating systemic health and pain. The authors note that the radiographic measurements are “reproducible.” This article gives important support to traditional chiropractic thinking, analysis, and management of patients.
Summary of An Original Article:
Shimizu, Kentaro MD; Nakamura, Masaya MD; Nishikawa, Yuji MD; Hijikata, Sadahisa MD; Chiba, Kazuhiro MD; Toyama, Yoshiaki MD. Spinal Kyphosis Causes Demyelination and Neuronal Loss in the Spinal Cord: A New Model of Kyphotic Deformity.
Spine; Volume 30(21), November 1, 2005 pp. 2388-2392
These authors surgically created kyphotic deformities of the cervical spine of birds and histologically evaluated the effects of kyphotic chronic compression on the cervical spinal cord. The magnitude of the kyphotic deformity was measured with lateral cervical x-rays.
The results of this study showed that kyphotic deformity of the cervical spine caused compression and flattening of the spinal cord, creating mechanical compression to the neurons and compression to the vascular supplies to the spinal cord. The greater the kyphotic deformity, the more the spinal cord compression and ischemia. The compression was greatest at the apex of the kyphotic deformity.
The histologic changes noted in this study were demyelination of the anterior funiculus as well as neuronal loss and atrophy of the anterior horn (lamina IX) were observed. With time, the demyelination extended to the lateral and then eventually to the posterior funiculus. Again, angiography revealed a decrease of the vascular distribution at the ventral side of the compressed spinal cord. These authors state that the histologic changes documented are associated with the continuous mechanical compression and vascular changes in the spinal cord. They note:
“Taking these results together, demyelination of the compressed white matter due to kyphotic deformity progressed in the order of anterior, lateral, and posterior funiculus.”
As the “kyphosis progressed, an increase in the degree of flattening of the spinal cord and histologic changes, including the loss of anterior horn cells and demyelination of the anterior funiculus, were observed.”
The spinal cord histologic changes noted in this study are probably the results of both mechanical compression of the neurons as well as mechanical compression of the blood vessels creating vascular disturbances.
This study was done on birds, not humans. This type of research requires the animal to lose its life, so this type or research cannot be done on humans. However, birds are bipeds and try to maintain their head parallel to the ground, as do humans. Other studies have established the mechanical similarity of the human and bird nervous systems. These authors state, “It is known that the spinal cord vascular system of birds resembles that of humans.” Consequently, the histologic changes noted in this study are applicable to humans.
Several chiropractic techniques, including Chiropractic Biophysics® have stressed the adverseness of cervical kyphosis on spinal cord neurons and spinal cord blood supply. This influences systemic health and is related to demyelinating diseases such as multiple sclerosis. Chiropractic Biophysics® has also stressed the importance of efforts to restore cervical lordosis. The patient video by chiropractor Tommy Dandrea on the treatment of multiple sclerosis patients with cervical curve restoration is remarkable.
Summary of an Original Article:
Panjabi, MM, A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. European Spine Journal, July 27, 2005
This article is perhaps the most significant single article published to date on the musculoskeletal aspects of the subluxation. Dr. Panjabi is from the Department of Orthopaedics and Rehabilitation, Yale University School of Medicine. He is the world’s most published human biomechanical researcher, with 263 published articles to his credit to date. In this article, he presents a “A new hypothesis, based upon the concept that subfailure injuries of ligaments (spinal ligaments, disc annulus and facet capsules) may cause chronic back pain due to muscle control dysfunction.” His hypothesis has the following sequential steps:
1) Single trauma or cumulative microtrauma causes subfailure injuries of the ligaments and embedded mechanoreceptors.
2) The injured mechanoreceptors generate corrupted transducer signals, which lead to corrupted muscle response pattern produced by the neuromuscular control unit.
3) Muscle coordination and individual muscle force characteristics, i.e. onset, magnitude, and shut-off, are disrupted.
4) This results in abnormal stresses and strains in the ligaments, mechanoreceptors and muscles, and excessive loading of the facet joints.
5) Due to inherently poor healing of spinal ligaments, accelerated degeneration of disc and facet joints may occur.
6) The abnormal conditions may persist, and, over time, may lead to chronic back pain via inflammation of neural tissues.
Dr. Panjabi notes that the process begins with “abnormal mechanics of the spine” that causes aberrant mechanical afferent input into the spinal cord. The abnormal mechanics has two causes:
1) Degenerative changes of the spinal column
2) Injury of the spinal ligaments, from a single trauma event or from repetitive aberrant motion microtrauma over a period of time.
Dr. Panjabi states:
“The role played by the injury to the mechanoreceptors embedded in the ligaments of the spinal column has not been explored by any hypothesis.”
This, of course, is completely untrue. Some of you have been attending my classes for nearly 30 years, and this is the key component to my hypothesis of subluxation and whiplash injury. Many others in chiropractic have taught and written about the same mechanoreceptor driven mechanism.
Dr. Panjabi further notes that the tissue source for the mechanoreceptors is spinal column ligaments, facet capsules and the disc annulus. This is very important in understanding whiplash injuries as studies continue to support that the primary injury in whiplash is to the facet capsules and annulus of the disc. He also notes that injured muscles heal relatively quickly due to abundant blood supply and are not the main cause of chronic back pain; ligament injuries heal poorly and therefore lead to tissue degeneration over time; “Thus, the ligament injuries are more likely to be the major cause of the chronic back pain.”
These subfailure ligament injuries may heal with scar tissue over time, resulting in long-term or permanent mechanoreception.
Dr. Panjabi’s hypothesis of subfailure ligamentous injury initiating aberrant afferent mechanical input into the spinal cord, ultimately resulting in chronic back pain is particularly relevant with respects to two recent studies:
1) The 2001 article in the British Medical Journal by Macfarlane that notes that chronic pain causes a statistacally significant increase in death from cancer.2
2) The 2004 article in the Journal of Neuroscience by Vania Apkarian that notes that chronic back pain is associated with greatly accelerated atrophy of the brain.3
This is all extremely important in light of the articles that document that chiropractic spinal adjustments are more effective in treating chronic spinal pain when compared to medication, exercise, and needle acupuncture.4, 5, 6, 7, 8, 9, 10, 11
Finally, this article is extremely important for those in our profession who are evaluating the existence of the chiropractic subluxation.
References
1) David R. Grimm, Brian M. Cunningham, Jeanmarie R. Burke, Autonomic Nervous System Function Among Individuals With Acute Musculoskeletal Injury, Journal of Manipulative and Physiological Therapeutics, January 2005, Volume 28, Number 1.
2) Gary J Macfarlane, John McBeth, Alan J Silman. Widespread body pain and mortality: prospective population based study BMJ 2001;323:662 (22 September).
3) Vania Apkarian, Yamaya Sosa, Sreepadma Sonty, Robert M. Levy, R. Norman Harden, Todd B. Parrish, and Darren R. Gitelman. Chronic Back Pain Is Associated with Decreased Prefrontal and Thalamic Gray Matter Density. The Journal of Neuroscience, November 17, 2004, 24(46):10410-10415.
4) WH Kirkaldy-Willis and JD Cassidy, Spinal manipulation in the treatment of low back pain, Canadian Family Physician, Vol. 31, March 1985, pp536-40.
5) TW Meade, S Dyer, W Browne, J Townsend, AO Frank. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal, June 2, 1990;300: 1431-7.
6) The Lancet, Chiropractors and low back pain, July 28, 1990, p. 220.
7) TW Meade, S Dyer, W Browne, AO Frank. Randomised comparison of chiropractic for low back pain: results from extended follow up. British Medical Journal, August 5, 1995;311: 349-51.
8) Woodward MN, Cook JC, Gargan MF, Bannister GC. Chiropractic treatment of chronic ‘whiplash’ injuries. Injury. 1996 Nov;27(9):643-5.
9) S Khan, J Cook, M Gargan, G Bannister. A symptomatic classification of whiplash injury and the implications for treatment. Journal of orthopaedic Medicine 21(1) 1999:22-5.
10) Lynton GF Giles and Reinhold Muller, Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation, Spine, July 15, 2003; 28(14): 1490-1502.
11) Reinhold Muller, PhD, Lynton G.F. Giles, DC, PhD, Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes, Journal of Manipulative and Physiological Therapeutics, January 2005, Volume 28, Number 1.
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