Category Archives: Chiropractic Research

When an Old Injury Turns Into Chronic Pain

pain_cloudThe brain is constantly changing through a process called neuroplasticity. When you have an injury it sends signals of pain to the brain. Because of injury or pain you change the way you move. This can cause changes in the sensorimotor portions of the brain. These changes can persist beyond the initial injury repair and can disrupt sensorimotor re-integration (the healing process of the nerve patterns). This may explain why you may limp even after a leg injury has healed or why you have chronic pain from an old injury that healed years ago. Because of this process joint dysfunction/subluxations can contribute to the chronicity of injuries.

Medically these conditions are called allodynia or hyperalgesia. These are when the brain is reporting the wrong feedback to the body (pain with light touch, or tingling sensation when nothing is really going on). You see your brain has a sense that you may not be aware of. Beyond your touch, taste, smell, hearing and sight you have a sense is called proprioception. It’s the ability of your body to sense where any part of it is in space even without the other senses. This sense comes from all the afferent signals that your muscle spindle fibers, Golgi tendon organs, etc… send to the brain. Vertebral subluxation is a state of altered afferent input which can lead to maladaptive central plastic changes that over time can lead to further dysfunction. In other words interference in the path of communication is like playing that game telephone, and the signal that the body sends is not what the brain gets or visa versa. This interference does affect all communication that comes through the area. So, if you have a bad knee and a bad back the brain may not know how the knee is doing even after it has healed because the back problem interfered. Because these subluxations can contribute to these conditions fixing subluxations can also contribute to resolving them.

Chiropractic care improves the health and function of the spine, so that it can accurately perceive what is going on and respond appropriately which in turn helps clear up the communication between your brain, the body and the environment. When the communication lines are open for a long enough period of time then the chronic pain patterns have a chance to resolve.

Additional Research on the topic:

Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders?

Cervical spine manipulation alters sensorimotor integration

The role of spinal manipulation in addressing disordered sensorimotor integration and altered motor control.

 

Ankylosing Spondylitis

Ankylosing Spondylitis (AS) is in the category of less common diseases that you may not know that your chiropractor can treat.  Don’t worry, you probably don’t have it.  Recently the topic came up and I promised to create a post to provide some basic information on the topic of AS.

AS RibbonFirst let me cover what it is.  AS is an inflammatory disease and can be classified as a type of arthritis.  It causes pain in joints and bones, particularly in the spine with the most common complaint being the low back.  In the most severe cases it can cause bones to fuse together.  It is much less common than your typical  osteoarthritis and is also harder to diagnose because of the similarity of its symptoms to so many other conditions.  When you walk into a doctor’s office complaining of low back pain, they won’t jump to the conclusion that you have AS.

Your chiropractor can diagnose AS using a combination of your health and family history, blood tests and radiologic tests, but they won’t usually go hunting for this condition.  It is more often found after other things are ruled out or discovered incidentally with X-rays for other conditions.  This is a sexist disease usually affecting men, but that doesn’t mean that women can’t have it.  AS is also not an illness that comes on late in life.  It usually makes its self known before the age of 35.  The cause of AS is unknown still, but is likely genetic, meaning that it runs in families.  As with most diseases whose causes are unknown there is no known cure yet.  There are however treatments.

Most medical treatments for AS focus on management of pain and symptoms, but there are some medications that have been found to slow the progress of the disease.  Your chiropractor should be able to help you manage or reduce your symptoms as well as slow down the progression of the disease without medication.  As always he should also keep in close contact with your other providers that may be treating you, most likely your  rheumatologist, and together they should come up with a plan of action specific to you.

Image by Cienpies Design http://www.cienpies.net

Image by Cienpies Design http://www.cienpies.net

The treatment with the best results for AS is improving your range of motion and flexibility with exercise, diet, and joint mobilization.  You can do much of it on your own at home with guidance from your provider.  Your chiropractor should already be using these tools to treat any low back pain, but they will be even more important if you have AS.  Your chiropractor may or may not adjust your spine depending on your condition, but managing your care does not require manipulation if you don’t want it.

In the past some practitioners would recommend not seeing a chiropractor for AS because possible risks were unknown.  No studies have found increased risk to people with AS when treated with chiropractic manipulation, and recent research indicated benefits even at the late stages of the disease.  While most of the research is focused on finding a cure to AS here’s a link to an excellent case study of improvement with chiropractic management of AS.

Scientific Studies Interpreted

JMPT

Journal of Manipulative and Physiological Therapeutics

Since the dawn of modern science answers to life’s questions have been sought through studies.  I highly recommend research and physicians using research to the advantage of their patients.  I encourage patients to stay informed through reading research.  In life, online, and even the media you hear things like, “oh it’s true, they’ve done studies.”  I’m not sure who “they” are and whatever study is being referred to probably didn’t mean what you thought it did.

ACA

American Chiropractic Association

Chiropractic, for good or bad, has been forced into research by the well-meaning movement of evidence based medicine.  This movement, as with most things, falls short when strictly applied to every scenario.  There are always too many exceptions.  One of the most well-known, and a great read, is a farcical review article discussing, “parachute use to prevent death and major trauma related to gravitational challenge.”  This article was actually published in the British Medical Journal in 2003.  It inferred that because there was no research studies to show the efficacy of parachute use that their use should be discontinued as a preventative health care measure.

ICL

Index to Chiropractic Literature

The truth is that most studies are either to vague or to specific or too something to be applied directly in real life situations.  They all have flaws and weaknesses.  Even the gold standard Double Blind Randomized Controlled Trial is not perfect.  Most of the good studies admit and disclose their bias so that readers can take that into consideration when determining usefulness.  If you don’t understand research bias don’t worry there are entire college courses dedicated to the topic, if you want to learn more you can begin here  Google results: research bias.

To make things simple for you, there is no perfect study because people are not perfect.   This principle becomes utterly clear in online debates that usually end in name calling and any truth lost to both parties.

Chiro.org

The Chiropractic Resource Organization

I often cite research on my blog, and sometimes people agree and sometimes they disagree with the research.  You are welcome to do so.  I highly recommend reading research for truth.  The best RCT can be useless and the anectdotal single case study may hold the answer to the problem you face.  Don’t discount evidence of any kind.  Read it for truth and accept the research for what it is, one possible view of a whole situation.

Menier’s Disease: New Research

Patients doing their own research on conditions occationally bring me something that they find interesting to get my opinion.  This recently happened with an article on MÉNIÈRE’S DISEASE AND JOINT INJURY.  The full title is “The Potential Role of Joint Injury and Eustachian Tube Dysfunction in the Genesis of Secondary Ménière’s DiseaseI thought I’d just share that review with you.

Meniere’s Disease is a disorder of the inner ear causing many different symptoms from vertigo to ringing in the ears to hearing loss.  The article really seems to be just an idea that the authors have been pondering and sought to find evidence to back up their idea.  Not very scientific in my opinion.  What they’ve really done is see if there is any validity to their hypothesis so that they can do further studies.

The ear has 3 sections, inner, middle, and outer.  The inner ear is sealed off and in your skull and is what does all of the work you might associate with the ear, hearing and balance.  The middle ear is simply a cavity with facilities to allow the outer ear to “talk” to the inner ear and is drained by the eustachian tube into the back of your throat.  The middle ear is usually where ear “infections” occur.  The eustation tube becomes blocked and can’t drain the middle ear so fluid builds up or an infection may grow.  If this occurs frequently, medical doctors sometimes, (instead of fixing the tube that your body has) insert additional tubes that drain to your outer ear.

The bones in your neck join the skull right behind your ear.  If you put your finger right there you feel a soft spot between the bump of your skull your jaw and your ear.  Those are the joints that the article talks about, the upper cervical spine and the TMJ.  The close proximity has always caused people to justify a relationship between those joints and the ear. Neurologically there has been no direct connection found that I’m aware of. These authors are proposing an indirect nerve connection in order to explain why TMJ or neck injuries can lead to Menier’s disease. 

From a chiropractic perspective their hypothesis also implies the reverse, that patients with Menier’s Disease might benefit from chiropractic management.  To be determined…

Informed Consent

In Connecticut there is a debate over chiropractic and the topic of informed consent.  (News Article) The debate is not over whether there should be informed consent.  In fact, in the United States, informed consent is already mandatory for all health care providers.  Informed consent is supported by chiropractors.  It is in the best interest of our patients .  No!  This debate is over whether chiropractors should be forced to inform every patient of a risk of stroke.

There are many problems with this.

CAUTION: there are risks to drinking water!

The most obvious is that chiropractic is not known to cause stroke.  The only evidence even remotely related does not show that it causes stroke, but that there is an association.  The same association that exists with medical doctors (oh, and hair dressers).  So if it’s not known to cause it why would you force chiropractors to inform people of the risk.  I think I know the reason.

If it is required for chiropractors then it should also be required of all health care practitioners that have equivalent risks. Can you imagine walking into every doctor’s office and having to sign a paper that says that if you came to that office to see them for neck, head or upper back pain there is a possibility you could have a stroke after seeing this doctor. Either no one would go to doctors for those conditions or it would become so prevalent that the warning would become like the boy who cried wolf, useless.

Another problem is the actual risk level that we are talking about. The risk of having a stroke after seeing a chiropractor is somewhere in the region of 30-300 times less likely than you dying in a lightning strike.  Should I have to also warn my patients that they may aspirate  and die from that water I recommended they drink.

Defining what must be included in informed consent adds loopholes for dishonest people and destroys the purpose of informed consent, that of an honest and open conversation between a doctor and a patient.  Please doctors share the likely and serious risks with your patients.  Inform them, by all means.  Don’t get ridiculous.

A New Baby

I have to pause my normal posting to announce that my wonderful wife has given birth to our 4th daughter.  There were no complications and things went well.  Both mom and baby are beautiful and healthy.  Some of the training we receive in chiropractic college I never plan to use as a chiropractor.  This is one of those things.  I never plan to deliver a baby for anyone else, but I am happy to have been able to deliver all four of my little girls.  If I didn’t feel outnumbered before this picture will show you how lopsided our family is now.  family

Because this is a professional health care site I would like to include a report on an experiment that we attempted during this labor.  Many of you reading this will be familiar with E-stim or TENS.  I posted about it a few posts back (link).  I posted there that this modality was not used during pregnancy because there was no research to support or contraindicate it’s use.  There are however studies indicating possible benefits to mothers in labor.  The findings are interesting, and the application is safe and has been used successfully for over 30 years in Europe.  I have asked my wife to write up her feelings on using the TENS unit during this labor.  I’ll not bias you with my observations, but I will post her comments as soon as she gets the time to write them, though I must warn you she’s a much more engaging writer than I am.  In the meantime here is a great though dry article on the use of this modality during labor.

Accepted Therapies – What Research?

In a review of research on the topic of evidence it was reported that about 75-85% of all medical treatments are evidence based.  In this review, evidence based included non-experimental evidence most often reported to mean unanimity among physicians that there was convincing non-experimental evidence.  Only about 30-40% of all treatments in these studies were based on Randomized Controlled Trials (RCTs).  Here is another similar review with citations.

There are levels of quality in evidence. RCTs are currently held as the gold standard of evidence, but some treatments don’t lend themselves to testing in this manner or are common sense.  Even in RCTs there are always outliers that don’t conform.  If we could do an RCT for every treatment that would be great, but we can’t.  Evidence based treatment relies on doctors to make the best decisions based on all the evidence available to them at the time.  So I’d say that 85% of medical treatments are based on evidence and a judgment call. That, is good.

There does seem to be a double standard in this area of discussion.  When it comes to traditional medicine the levels of accepted evidence are understood.  When it comes to complimentary and alternative treatments (CAM) anything less than an RCT is refused as evidence.  Because of this bias chiropractic has been forced to prove it’s self by performing RCTs.  And research has now found about 68% of all chiropractic procedures are backed by RCTs.  Compared to 30-40% of medical treatments.  That is also good.

I appreciate having good research to support my profession.  I’d really like to stop hearing that chiropractic is not founded in evidence, but that may not happen.  On a slight tangent, and to give you a thought provoking sampling, here are a few common treatments that either have limited evidence or research that actually finds that they don’t help.