Chiropractic case studies

This is something we definately don't try here at C1 Chiropractic Health Centre. 

Medicine-assisted Manipulation is defined as manipulation of the spine after any type of anaesthesia or analgesia.  The most common form of this is manipulation under anaesthesia (MUA).

 
In the journal of the North American Spine Society there is a comprehensive review of ‘Chronic low-back pain’ and evidence for and against the numerous methods of managing patients with this condition including MUA.

 

Currently there are several influential clinical guidelines about this sort of stuff such as the Ontario Workers’ Safety and Insurance Board of Canada’s guidelines and in Europe the European Back Pain Guidelines which are all available online.  In the UK the British Medical Research council sponsored the BEAM Trial which has shown “convincingly that both manipulation alone and manipulation followed by exercise provide cost-effective additions to best care (for low-back pain patients) in general practice”

 

The editors are critical of what they call a supermarket response to low-back care where patients are offered a range of untested treatments (with over 200 different forms of care available in the USA) and even those with the most evidence, such as chiropractic still have questions that must be asked.  Every year there appeared to be more treatments available with strong and commercial advocates with generally limited scientific evidence. 

 

However, this review is different with each form of management being tackled by another health care expert, so the review of manipulation under anaesthesia is done by chiropractors. 

 

In this review it demonstrated that there was little evidence supporting or refuting the value of MUA – not a single quality RCT and only a few published cases.  The authors conclude that these is insufficient research to make any conclusions and yet the thing still continues – remarkable really

 

These reviews are available on:

www.science-direct.com/science/journal/15299430

click on Vol.8 Issue 1.

 

 “Chronic low-back pain -

The single most expensive cause of pain and disability in working age adults”

The Spine Journal (2008) 8 (1):1-278

 

In the journal of the North American Spine Society there is a comprehensive review of ‘Chronic low-back pain’ and evidence for and against the numerous methods of managing patients with this condition.

 

Currently there are several influential clinical guidelines about this sort of stuff such as the Ontario Workers’ Safety and Insurance Board of Canada’s guidelines and in Europe the European Back Pain Guidelines which are all available online.  In the UK the British Medical Research Council sponsored the BEAM Trial which has shown “convincingly that both manipulation alone and manipulation followed by exercise provide cost-effective additions to best care (for low-back pain patients) in general practice”

 

However this review is different with each form of management being tackled by another health care expert, so the review of manipulation under anaesthesia is done by chiropractors.  The editors are critical of what they call a supermarket response to low-back care where patients are offered a range of untested treatments (with over 200 different forms of care available in the USA) and even those with the most evidence, such as chiropractic still have questions that must be asked.  Every year there appear to be more treatments available with strong and commercial advocates but with generally limited scientific evidence. 

 

This does present a problem because the gold standard would be high-quality randomized controlled trails (RCT) but the cost of conducting these is, as the report states, “beyond the realm of possibility”.  So, we are left using evidence-informed care rather than evidence-based care.  Though there are more randomized controlled trails examining chiropractic care than any other chronic low-back intervention. 

 

The best available evidence today is not materially different from the recommendations in the Practice Guidelines on Acute Low-Back Pain in Adults published in the US by the Agency for Health Care Policy and Research (AHCPR) in 1994.  The reviews support the findings of this work and add that “a reasonable approach to CLBP would include education strategies, exercise, simple analgesics, a brief course of manual therapy in the form of spinal manipulation, mobilization or massage, and possibly acupuncture”.  And, tellingly, that these treatments should be preferred to more complex or invasive approaches.

 

These reviews are available, free, on www.science-direct.com/science/journal/15299430 and click on Vol.8 Issue 1.

 

The one covering chiropractic is really useful.  It has a history of chiropractic, a description of the examination and treatments in practice today and is seen as being an excellent authority for all concerning chiropractic especially referring medical doctors.  A couple of telling lines:

 

“Spinal manipulative therapy (SMT) or spinal mobilization is superior to usual medical care for patient improvement”

 

“For pain reduction “SMT with strengthening exercises is similar to prescription NSAIDs with exercise in both the short-term and long-term”

 

High-dose SMT is superior to low-dose SMT "for pain reduction in the short term”

 

And from the 9 trials where there were patients with chronic and acute low-back pain the evidence was good that:

 

SMT is superior to usual medical care alone

 

SMT/MOB is superior to physical therapy and to home exercise in the long-term

 

Now this is a change from the old approach where it was recognised that chiropractic was effective in treating acute low-back pain as this now demonstrates that chiropractic is effective in treating chronic as well as acute low-back pain.

 

One of the key advantages of SMT over drug and surgery lies in respect to harm.  The review noted that the only likely side effects of SMT are minor, temporary and typically do not interfere with activities of daily living – a major advantage over spinal surgery I'd argue.

What is it?

 

Seen standing upright from the side someone with perfect posture would have an imaginary centre of gravity line running from just in front of their ear hole through the slight bump on the top-middle of their shoulder.  Normally, the centre of gravity of their head is slightly forward of this line so that a very slight muscle tone is required to keep the head looking forward.  This tone may act to prevent sudden uncontrolled movements of the head, or lolling (you will have personal experienced of this if you have ever fallen asleep sitting up where your head will fall forwards and your inactive muscles suddenly crank up into action and you jerk upright again).  

         

What you get in anterior head carriage is the centre of gravity of the head moving a significant distance forward of the correct centre of gravity line.  In some cases I have seen this has been up to 6cm forward of the correct line. 

 

The problem is spectacularly and increasingly prevalent because of what we do in our lives and, I suspect, is set to get worse and worse as the Wii generation grow up.  It is easy to spot, just go and stand next to someone and look to see if their ear hole is forward of the mid-shoulder line.  I suspect you’ll be surprised how prevent it is, in fact I think if you did a statistical analysis of your friends it would be the statistical norm, but still wrong, posture.

 

How does it occur?

 

The key cause is computer use, especially laptops.  Carrying heavy bags or back packs, lazy posture and telly time with little or no exercise also don’t help but it is the eight hours a day for 30 years that really does the trick especially if it starts when you are young – say in your teens.  Computer work keeps you in a static position (usually a forward curved position as well) for long periods of time, which is why getting up and moving around every 15-20 minutes will help.

 

Backpacks also do it by increasing the overall load on the spine as well as by focusing that extra load onto the shoulders, which is where the major muscles that attach to the back of the skull originate, so putting a much larger strain onto the mechanism of anterior head carriage than the weight of the load would indicate.

 

The other place it I have seen it is in young girls who are tall and they are trying to height hide, though this is getting less common as they don’t fret about it as much as they used to. 

 

What’s the problem with it?

 

The way you achieve anterior head carriage is by straightening your cervical spine from C2 to C7 and in some extreme cases I have even seen reverse curving in the neck. 

 

In terms of skeletal problems this means that you are removing the elegant shock absorbing cervical curve and turning the neck into a column which transfers the weight of the head straight down the neck through the discs and the posterior facets leading to disc damage and facet injury.  This also places the cervical facets in an abnormal position which means they are far more likely to sustain injury.  It is rare for a patient to present at the clinic with non-traumatic acute posterior facet syndrome (you know the sort of thing – the “I don’t know what I did but I woke up like this” cricked neck complaint) who has not got significant anterior head carriage.  Also with anterior head carriage the posterior fibres of the disc annulus get stretched which increases the risk of posterior disc rupture, protrusion or bulge and the subsequent events associated with these grim conditions.

 

In neurological terms a straight cervical spine means that your spinal cord, and therefore nearly every nerve in your body, is physically straightened.  Now, nerves are designed to take this stretch as you look down but only for a short time and there are some interesting studies out there showing the changed anatomy of the spinal cord in a chronic anterior head carriage patient.  Stretched nerves have been shown to function less effectively and their axoplasmic flow is reduced.  I don’t suspect that there is a great deal of tolerance built into the human system. 

 

From the perspective of upper cervical care, when your head and neck are no longer in proper alignment to each other, your muscles have to pick up the slack of supporting your head.  This results in a higher muscle tone in your neck and upper back leading to trigger points in the Traps and Lev Scap muscles.  If you think of the force your muscles have to develop to keep your head from pivoting round your low-cervical vertebrae and smashing into your keyboard you can see why your low-cervical vertebrae suffer.  It is similar to the trick of trying to hold a plank up by the thin end – fine when it’s well balanced but once it comes away from the centre of gravity it takes masses of muscle power to keep it there – it’s all to do with levers.  No wonder people have shoulder trigger points that never seem to resolve; the underlying problem hasn’t been resolved and the outcome will remain the same.

 

The result is neck and upper back pain, restricted cervical biomechanics and all the physiological changes that would be associated with an abnormally functioning neck and upper spine. 

 

Now in some people I have seen there are no problems at all but in others there have been a raft of neck pain, headaches, upper body fatigue, sleep disorders and the rest.  And I would be willing to bet that more than a few people have been mistakenly diagnosed with migraine head ache or tension headache who, in reality, have anterior head carriage and tragic cervical biomechanics.

 

Cure

 

Prevention would be good.  Then if that fails adjust the spine to improve the biomechanics, soft tissue work to help the muscles cope and then some cervical spine stretches to combat the anterior head carriage posture adopted at work.

 

Just typing this up is making my neck hurt!