Author: Superadmin

Diathermy as a Supplement for Chiropractic Care

More than half of all adults will experience back pain in their lifetime [1,3], spurring the development and implementation of various techniques in chiropractic care. These may involve “pharmacological interventions, physical exercise, and modalities including electrotherapy, cold, and heat therapy” [3]. While each of these techniques may be prescribed on its own [2], some research suggests that there is greater efficacy when the therapy involved is multidisciplinary [6]. One popular supplement for chiropractic care is diathermy, “a therapeutic treatment most commonly prescribed for muscle and joint conditions, [which] uses a high-frequency electric current to stimulate heat generation within body tissues” [4]. The heat generated by diathermy is believed to help increase blood flow, mitigate pain, improve flexibility, and accelerate the healing process of damaged tissue [1,4,6].   

The three main types of diathermy are shortwave, microwave, and ultrasound [4]. Shortwave diathermy produces heat through electromagnetic energy, either pulsed or continuous [4]. Said to help reduce inflammation, shortwave diathermy is typically used in patients experiencing pain or muscle spasms caused by conditions such as kidney stones, osteoarthritis, sprains, and strains [4, 5]. Microwave diathermy, however, uses electromagnetic waves in the microwave range to generate heat. Because it does not penetrate as deeply as shortwave diathermy, though, it is often applied to more superficial areas of the body, since it warms tissue evenly without heating the skin [2,4]. Conversely, ultrasound diathermy is used more for deep tissue, generating heat through sound waves, which vibrate the tissue and, in turn, promote blood flow to the targeted area [4]. It may be prescribed to patients presenting with musculoskeletal sprains, joint contractures or adhesions, and muscle spasms [4]. 

“For ultrasound diathermy,” as described in a Healthline article, “the therapist applies a gel to the affected area of your body, [then] moves a wand continuously over the affected area” [6]. Shortwave and microwave diathermy, on the other hand, do not require gel, but instead are typically administered through electrodes placed over the affected area [6]. Sometimes a towel is placed between the electrodes and the skin to avoid direct contact [6].  

In a study examining the efficacy of diathermy treatment in patients with chronic low back pain (CLBP), Durmas et al. found that microwave diathermy combined with physical exercise was beneficial. However, they determined it was not superior to exercise alone [3]. Research performed by Ahmed et al., highlighted several studies that showed significant improvements in patients receiving shortwave diathermy treatment for CLBP and neck pain, concluding that “shortwave diathermy is an effective modality in the treatment of the patients with chronic low back pain” [1]. They also found that deep heat was more effective than superficial heat for the treatment of CLBP [1]. Similarly, a study done by Zati et al. determined that deep heating therapy, through medium-frequency (450–1000 KHz) waves diathermy, appears to be effective in patients with nonspecific CLBP, and thus suggested that it could be a positive addition to a patient’s therapeutic regimen.  

The research conducted by Andrade et al. aimed to observe the efficacy of microwave diathermy in patients presenting with nonspecific neck pain. Despite the rising popularity of microwave diathermy, their study suggests that it “provides no additional benefit to a treatment regimen of chronic neck pain that already involves other treatment approaches (e.g., exercise, TENS)” [2]. While they, like others, add that more research is needed to better understand the efficacy and benefits of diathermy treatment as an independent modality [2,4], most studies seem to suggest that it could potentially be a useful supplement for chiropractic care.  

References 

1.  Ahmed, M. S., Shakoor, M. A., et al. (2009). Evaluation of the Effects of Shortwave Diathermy in Patients With Chronic Low Back  Pain. Bangladesh Medical Research Council Bulletin, 35(1), 18–20. DOI: 10.3329/bmrcb.v35i1.2320 

2. Andrade Ortega, J. A., Cerón Fernández, E., et al. (2014). Microwave Diathermy for Treating Nonspecific Chronic Neck Pain: A Randomized Controlled Trial. The Spine Journal, 14(8), 1712–1721. DOI: 10.1016/j.spinee.2013.10.025 

3. Durmus, D., Ulus, Y. et al. (2014). Does Microwave Diathermy Have an Effect on Clinical Parameters in Chronic Low Back Pain? A Randomized Controlled Trial. Journal of Back & Musculoskeletal Rehabilitation, 27(4), 435–443. DOI: 10.3233/BMR-140464 

4. Giorgi, A. “Diathermy.” Healthline. (2017). www.healthline.com/health/diathermy 

5. Wu, C.-L., Yu, K.-L., et al. (2009). The Application of Infrared Thermography in the Assessment of Patients with Coccygodynia Before and After Manual Therapy Combined with Diathermy. Journal of Manipulative and Physiological Therapeutics, 32(4), 287–293. DOI: 10.1016/j.jmpt.2009.03.002 

6. Zati, A., Cavazzuti, L., et al. (2018). Deep Heating Therapy via MF Radiowaves v. Superficial Heating Therapy in the Treatment of Nonspecific Chronic Low Back Pain: A Double Blind Randomized Trial. Journal of Back & Musculoskeletal Rehabilitation, 31(5), 963–971. DOI: 10.3233/BMR-170944 

Back and Spine Health in Desk Jobs

Back pain is one of the most common reasons for people to see a doctor or miss work [1]. Symptoms can range in intensity, affect people of all ages, and be caused by a variety of factors, including scoliosis, sprains, traumatic injuries, degenerative diseases, consistent poor posture, and inactivity [1,2]. In particular, the National Institute of Neurological Disorders and Stroke identifies extended periods of working at a desk as a risk factor for back pain [1]. Though “preventing all back pain may not be possible,” Dr. Daniel Park states that certain behaviors “help reduce our risk” [3]. These behaviors are related to the increasingly sedentary and inactive lifestyle of many Americans, which is “linked to approximately $117 billion in annual health care costs and about 10 percent of premature mortality” [4]. A major contributor to these trends is the prevalence of office jobs. Working at a desk can have significant effects on overall back and spine health. 

The spine, and back in general, is a complex system of 33 vertebrae, intervertebral discs that help absorb shock, ligaments, tendons, muscles, and nerves [1]. Maintaining the strength of the overall system and minimizing asymmetry is important for physical function. For example, weak core muscles weaken the back overall and also may drive forward slouching. A study in the European Spine Journal found that “slump posture” while using a computer or watching TV were associated with chronic low back pain [5]. In fact, the Occupational Safety and Health Administration has published recommendations for office workstations, such as using desk chairs that adequately support the back and positioning the computer monitor, keyboard, and desk at natural positions [6]. 

When seeking medical advice for back health, diagnosing the condition(s) underlying back pain usually involve a comprehensive medical history, physical exam, and occasionally further tests. However, it is not always possible to determine the cause, and pain that does not stem from a straightforward, acute injury may be more complicated to treat [1]. Such situations require a gradual approach, starting with less invasive and cost-effective treatments and only moving on to more aggressive options if needed. Self-management strategies include exercises to strengthen core muscles, which can balance out extended periods of relative inactivity in a desk job. Acupuncture, transcutaneous electrical nerve stimulation, and chiropractic spinal manipulation and mobilization can often provide relief; research demonstrates that chiropractic care is beneficial for chronic low back pain. Surgery, a more advanced care option, is not always successful, may involve long recovery time, and involves significant risks [1]. 

Prevention and proactive management of back health are critical for those who work at desks or in other sedentary jobs. Many work-related injuries are “caused or aggravated by stressors such as … awkward posture” [1]. The Mayo Clinic recommends workers to “pay attention to posture”, “modify repetitive tasks”, and “listen to your body” [2]. It is important to regularly strengthen muscles through exercise; maintain a healthy weight, as an imbalance between body weight and strength “puts added pressure on your spine and lower back”; use ergonomic equipment; periodically move and stretch to relieve tension; and maintain proper posture [1-3]. Dr. Park adds, “Make sure your working surface is the proper height so you don’t have to lean forward,” and, “Once an hour, stand and stretch” [4]. 

Back pain is a common condition that can impair daily activities and quality of life. Back and spine health is damaged by poor posture, inactivity, and muscle loss, all of which are common in desk jobs. 

References 

1. Office of Communications and Public Liaison. “Low Back Pain Fact Sheet,” (2020). National Institute of Neurological Disorders and Stroke, Disorders, Patient & Caregiver Education, Fact Sheets. Available: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet 

2. Mayo Clinic Staff. “Back pain at work: Preventing pain and injury,” (2019). Mayo Clinic, Health Lifestyle, Adult Health. Available: https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/back-pain/art-20044526 

3. Park DK. “Preventing Back Pain at Work and at Home,” (2017). American Academy of Orthopaedic Surgeons, OrthoInfo, Staying Healthy. Available: https://orthoinfo.aaos.org/en/staying-healthy/preventing-back-pain-at-work-and-at-home/ 

4. Olson RD, Piercy KL, Troiano RP, et al. “Physical Activity Guidelines for Americans,” (2018). U.S. Department of Health and Human Services. Available: https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf 

5. Filho NM, Coutinho ES, & e Silva GA. “Association between home posture habits and low back pain in high school adolescents,” (2015). European Spine Journal. Available: https://doi.org/10.1007/s00586-014-3571-9 

6. Occupational Safety and Health Administration. “Workstation components,” (n.d.). U.S. Department of Labor, Occupational Safety and Health Administration, Computer Workstations eTools. Available: https://www.osha.gov/SLTC/etools/computerworkstations/components_chair.html 

The Role of Asymmetry in Back Pain

Asymmetry in body dimensions is not the exception but the norm for humans, and random deviations from perfect symmetry are to be expected (Einas, 2004). Depending on the type and degree of asymmetry, however, some individuals may develop spinal conditions that cause back pain and require intervention. Kyphosis, scoliosis, and spinal stenosis are three common conditions involving abnormal curvature of the spine. Other factors that researchers have found to contribute to lower back pain include asymmetry of the lower limbs, such as discrepancy in leg length (Einas, 2004).  

Back conditions can be either acute or chronic. Acute back pain, such as that resulting from sprains, strains, and spasms, is short-term and tends to resolve with self-care within a few days, weeks, or months. Chronic back pain, on the other hand, is pain that continues for longer than 12 weeks and is more difficult to treat. An estimated 20.4 percent of all adults experience chronic back pain (Dahlhamer et al., 2016) and about 20 percent of acute cases develop into chronic issues (NINDS, 2020). While chronic low back pain is sometimes successfully treated, it may persist in some patients despite medical and surgical treatment.  

Kyphosis is a forward rounding, or “hunching”, of the upper back that most often occurs in older women. Though mild kyphosis may not be a cause for concern, severe cases can affect the lungs, nerve roots, tissues, and other internal organs, in which case surgery may be needed to permanently join two or more vertebrae and reduce the degree of curvature (Cleveland Clinic, 2020). Though osteoporosis-related factors and degenerative diseases of the muscles are primary causes, hyperkyphosis may be induced by a variety other factors such as habitual poor posture (Wendy et al., 2010). 

Scoliosis is a lateral, rather than forward, curvature of the spine into an “S” or “C” shape. It most often occurs at a young age just before or during puberty, and while most cases are mild, some adolescents develop spinal deformities that increase in severity as they grow. Though the causes of scoliosis are still not entirely known, one prominent hypothesis is that changes during the growth process in the womb contribute to scoliosis present at birth. In older children and adolescents, scoliosis may be brought about by diseases such as cerebral palsy and muscular dystrophy (Janicki et al, 2007). In adults, osteoporosis and forms of arthritis can weaken the spine, leading to misalignment and potentially scoliosis. More recently, researchers have identified, through a defect in CHD7, a genetic link to scoliosis in cases where there is no other definite cause (Washington University in St. Louis, 2007). Further steps in understanding the genetic basis of the condition may allow doctors to identify those who are predisposed and intervene before the deformity develops. 

Unlike scoliosis, which generally appears in children, spinal stenosis usually occurs later in life as the vertebrae change with age. It is characterized by a narrowing of the spine that subsequently puts pressure on the spinal cord or nerves, causing pain or weakness in the back, neck, or shoulders. Though most cases of spinal stenosis produce bilateral symptoms, asymmetrical pressure on nerves can result in symptoms being more severe on one side of the body (Munakomi, 2020). Primary causes of spinal stenosis include osteoarthritis of the spine and spondylosis, a type of arthritis spurred by repetitive stress. Injuries, tumors, and other diseases may also be causes. Additional factors that contribute to stenosis of the spinal canal include lumbar disc degeneration and asymmetrical disc bulging, which occurs when the soft center of a disc between the bones that make up the vertebrae pushes through the exterior casing.  

Though back asymmetries can often be treated with surgery or noninvasive methods such as chiropractic and physical therapy, other cases are more difficult to treat and tend to result in chronic pain. It is important to realize, however, that the persistence of pain does not necessarily mean there is a medically serious underlying cause (NINDS, 2020). Oftentimes, simple changes to one’s diet, lifestyle, and stress management may help alleviate a variety of back-related symptoms. 

References 

Al-Eisa E, et al. “Fluctuating Asymmetry and Low Back Pain.” Evolution and Human Behavior, Volume 25, Issue 1, 2004, 31-37, ISSN 1090-5138, http://www.sciencedirect.com/science/article/pii/S1090513803000813. 

Dahlhamer J, Lucas J, Zelaya, C, et al. “Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016.” Center for Disease Control and Prevention (MMWR Morbidity and Mortality Weekly Report), 2018, 67:1001–1006, https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm. 

Janicki J, Alman B. “Scoliosis: Review of Diagnosis and Treatment.” Paediatrics & Child Health, 2007, vol. 12,9: 771-6, https://www.sciencedaily.com/releases/2007/06/070614100445.htm. 

Katzman W, et al. “Age-Related Hyperkyphosis: Its Causes, Consequences, and Management.” The Journal of Orthopaedic and Sports Physical Therapy, 2010, vol. 40,6: 352-60, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907357/. 

“Low Back Pain Fact Sheet”. National Institute of Neurological Disorders and Stroke (NINDS), 2020, No. 20-NS-5161, https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet. 

Munakomi S, Foris LA, Varacallo M. “Spinal Stenosis and Neurogenic Claudication.” StatPearls, 2020. https://www.ncbi.nlm.nih.gov/books/NBK430872/. 

“Spondylolisthesis.” Cleveland Clinic, 2020, https://my.clevelandclinic.org/health/diseases/10302-spondylolisthesis. 

Washington University in St. Louis. “First Gene Linked To Scoliosis Identified.” ScienceDaily, 15 June 2007, www.sciencedaily.com/releases/2007/06/070614100445.htm. 

Soft Tissue Chiropractic Techniques for Migraines

Headaches affect nearly half of all adults in their lifetime [7]. Migraine headaches account for 69% of all primary headaches, which are defined by the International Headache Society as headaches “in which the pain is caused by independent pathologic mechanisms” [7]. An estimated 15% of people worldwide are said to have one-year prevalence of migraine [1,3], making it “19th among all causes of years lived with disability,” according to the World Health Organization, and the seventh highest cause of disability in a study performed by the Global Burden of Disease [1].  Chiropractic techniques are an effective treatment for migraine.

As explained by Espí-López et al., migraine is considered a neurovascular disorder, originating “in the sensory fibers that convey pain signals from intracranial and extracranial blood vessels” [5]. Factors resulting in migraine sometime include “changes in atmospheric pressure, intake of certain foods, certain drugs, psychological factors, sleep disturbance, or stress” [5]. While multiple medications have been shown to help treat migraine (e.g., Amitriptyline), their many unwanted side-effects (fatigue, dizziness, low blood pressure, depression, and renal damage) [7] “has led to a growing demand for nonpharmacological prophylactic treatments to reduce the frequency of migraine” [1]. 

One nonpharmacological approach to migraine treatment is through chiropractic care. In fact, in a study performed in 2011 by Bryans et al., headache was listed as the third most common reason for patients seeking chiropractic care in North America [3]. Various studies find spinal manipulation therapy, in which “an examiner applies a manual force to a spinal joint to move the joint near its end range of motion” [8], as being equally effective for migraine treatment as Amitriptyline, but without the unwanted side-effects [2,3,6,7,8]. Occipital decompression, a chiropractic technique that involves “using the fingertips to manually stretch the paraspinal tissues at the base of the occiput,” has also been shown to help manage pain and discomfort from migraine [6].  

People with migraine disorder often show postural deficiencies and complain of tension and pain in the neck muscles associated with myofascial trigger points (MTrPs) [7]. In turn, researchers believe MTrPs contribute to the prevalence of migraine headaches [7]. Current non-pharmacological methods for mitigating MTrPs in patients with migraine include laser therapy, needling therapies (such as acupuncture), and soft tissue techniques [7,8]. Although soft tissue techniques focusing on MTrPs have been said to effectively treat migraine [7], the study performed by Espí-López et al. saw greater efficacy when they were combined with suboccipital soft tissue inhibition [5]. Several studies also examine the use of osteopathic therapy, such as soft tissue massage of the paraspinal tissues, for migraine relief [3,6]. One study cites that “the use of 8 osteopathic sessions over a 6-month period significantly reduced the use of drugs, pain, and disability” among patients with migraine [4].   

Research has demonstrated that soft tissue chiropractic techniques can indeed improve the quality of life for patients suffering from migraine and are an effective and safe alternative to pharmacological intervention. This is a promising research avenue to pursue in developing guidelines for headache prevention and treatment. 

References 

  1. Amons, A. L., Castien, R. F., van der Wouden, et al. (2019). Manual Therapy as a Prophylactic Treatment for Migraine: Design of a Randomized Controlled Trial. Trials, 20(1), 1–9. doi:10.1186/s13063-019-3937-8  
  1. Biondi, D. M. (2005). Physical Treatments for Headache: A Structured Review Headache, 6, 738. doi:10.1111/j.1526-4610.2005.05141.x  
  1. Bryans, R., Descarreaux, M., Duranleau, M., et al. (n.d.). (2011). Evidence-Based Guidelines for the Chiropractic Treatment of Adults with Headache. Journal of Manipulative and Physiological Therapeutics, 34(5), 274–289. doi:10.1016/j.jmpt.2011.04.008  
  1. Cerritelli, F., Emanuele, C., Rina, G. L., Gabriella, M., Marcello, D. V., & Luca, M.. (n.d.). Is osteopathic manipulative treatment effective in migraine? International Journal of Osteopathic Medicine, 16(1), e15–e16. doi:10.1016/j.ijosm.2013.01.008  
  1. Espí-López, G.-V., Ruescas-Nicolau, M.-A., Nova-Redondo, C., et al. (2018). Effect of Soft Tissue Techniques on Headache Impact, Disability, and Quality of Life in Migraine Sufferers: A Pilot Study. Journal of Alternative & Complementary Medicine, 24(11), 1099–1107. doi:10.1089/acm.2018.0048  
  1. Keays, A. C., Neher, J. O., & Safranek, S. (2008). Is Osteopathic Manipulation Effective for Headaches? Journal of Family Practice, 57(3), 190–191. PMID:18321458  
  1. Rezaeian, T., Mosallanezhad, Z., Ahmadi, M. et al. (n.d.). The Impact of Soft Tissue Techniques in the Management of Migraine Headache: A Randomized Controlled Trial. Journal of Chiropractic Medicine, 18(4), 243–252. doi:10.1016/j.jcm.2019.12.001  
  1. Smith, M. S., Olivas, J., & Smith, K. (2019). Manipulative Therapies: What Works. American Family Physician, 99(4), 248–252. PMID:30763049 

The Activator Method for Spinal Mobilization

The Activator Method for spinal mobilization is a well-established chiropractic technique for alleviating bodily discomforts which specifically stem from spinal or pelvic misalignment. Using the Activator Method is a common practice in the U.S. and internationally— for example, it is also prevalent in Canada and Australia.[1]According to the National Board of Chiropractic Examiners, around fifty percent of all practicing chiropractors in the U.S. currently use or have used this method.[2]

The Activator Method is utilized to treat a number of common ailments, including pain in the neck, back, and lower extremities. The Activator is a hand-held, spring-loaded machine that applies repetitive force to a selected area of the spine. While other spinal mobilization techniques involve the application of a high-velocity, low-amplitude (HVLA) thrust, the Activator provides a gentler pulse that is less likely to erroneously compromise joint positioning. It is consistent in its magnitude of force (approximately 0.3 Joules) and generally is operated at a frequency of approximately 3 milliseconds. 

There are a few ways in which a chiropractor may evaluate the ideal site for application. One method of assessment is a leg length evaluation, based on the theory that disparities in length between the two legs are telling of pelvic or spinal misalignments. This method is relatively contentious, given the lack of randomized clinical trials supporting its validity. Generally, static or dynamic spinal palpation is sufficient to determine where the Activator should be put to use.

Though quality studies on the long-term benefits of chiropractic methods are generally scarce, there is a non-negligible body of research supporting the use of the Activator Method for treating pain and misalignment. One study showed that the Activator Method was just as effective as other methods of spinal mobilization as far as long-term improvements in disability and pain in patients with sub-acute non-specific neck pain.[3] Another study found that HVLA spinal mobilization and the Activator Method both resulted in statistically significant improvements in pain and disability in the treatment of cervical spine dysfunction both after therapy and in a one month follow-up.[4] Therefore, while research supports that the Activator Method of spinal mobilization is generally effective at improving disability index and pain ratings, it may not necessarily be more effective than other methods of spinal mobilization.  

[1] Huggins T, Boras AL, Gleberzon BJ, et al. Clinical effectiveness of the activator adjusting instrument in the management of musculoskeletal disorders: a systematic review of the literature. Journal of the Canadian Chiropractic Association 2012;56(1):49-57.

[2] National Board of Chiropractic Examiners. Job Analysis of Chiropractic 2005: A project report, survey analysis, and summary of the practice of chiropractic within the United States. Greeley, CO. January 2005.

[3] Gemmell, H., Miller, P. Relative effectiveness and adverse effects of cervical manipulation, mobilisation and the activator instrument in patients with sub-acute non-specific neck pain: results from a stopped randomised trial . Chiropr Man Therap 18, 20 (2010). https://doi.org/10.1186/1746-1340-18-20

[4] Wood TG, Colloca CJ, Matthews R. A pilot randomized clinical trial on the relative effect of instrumental (MFMA) versus manual (HVLA) manipulation in the treatment of cervical spine dysfunction. J Manipulative Physiol Ther. 2001 May;24(4):260-71. https://doi.org/10.1067/mmt.2001.114365. PMID: 11353937.

Nutrition in Chiropractic Care

Chiropractors comprise an essential part of the American healthcare system. With more than 70,000 practitioners, chiropractors1 form the third largest primary healthcare profession and the largest non-allopathic healthcare profession.2 Chiropractors practice an integrative system of medicine that incorporates the diagnosis and manipulation of misaligned joints, particularly in the spine, which often negatively affect the rest of the body.3 Traditionally, this involves performing adjustments – specific, controlled forces applied to misaligned joints – to restore proper function and mobility.  

Chiropractic, however, adopts a holistic lens to treat musculoskeletal concerns. As primary care providers, chiropractors participate in the diagnosis, treatment, and prevention of general health issues too, particularly as they relate to musculoskeletal disorders.4 Therefore, chiropractors also perform soft-tissue therapies, provide lifestyle advice, prescribe exercise regimens, and nutritionally counsel their patients.3  

Nutrition, specifically, serves as a cornerstone of general health and preventative medicine. As holistic health professionals, chiropractors hold a unique position to implement nutritional changes.5 Further, chiropractors treat various conditions and disorders that often benefit from dietary recommendations.1 For example, substantial research suggests that certain dietary changes may reduce systemic inflammation. These diets, therefore, may alleviate pain in inflammatory conditions like rheumatoid arthritis, osteoarthritis, and scoliosis, all of which chiropractors often treat.7 Similarly, research suggests that tryptophan and vitamin C deficiencies are correlated with the development of scoliosis, and that vitamin B6 may aid in scoliosis prevention.8–10   

In 2009, the National Board of Chiropractic Examiners reported that approximately 94% of chiropractors in the United States provide nutritional or dietary services for their patients.11 Similarly, in a 2001 study, most chiropractors incorporated nutrition counseling into their practice; yet only half of this sample felt they received adequate nutrition education from their chiropractic college.2 Chiropractors appear split on this issue – 44% and 42% of this 2001 sample disagreed and agreed with, respectively, the following statement: “Chiropractors are able to address all nutritional concerns and do not require the service of a dietitian or nutritional specialist.”2 Unsurprisingly, the average chiropractor in this same sample received eighty-four hours of postgraduate nutrition instruction to supplement their initial education.2 65% of chiropractors in a 2007 study also felt their chiropractic education did not prepare them adequately to counsel their patients on nutrition in-depth.5 Most chiropractic colleges offer two nutrition courses – give or take – in their core curricula.12,2  

Practitioners use various methods to assess their patients’ nutritional wellbeing. At the initial patient examination, a 2018 study reported that chiropractors frequently appraised patients’ nutritional wellbeing through questions about medications, nutritional supplements, smoking, alcohol, self-perception of health, and physical appearance.6 Chiropractors used dietary assessment, waist-to-hip ratio, and laboratory measures less frequently to evaluate nutritional wellbeing.6 Research suggests that chiropractors most often provide nutritional guidance via the prescription of vitamins or nutritional supplements to their patients.2,5,6,15 Chiropractors also typically discuss healthy nutrition choices, offer recipe suggestions, and recommend sources of nutrition information.6 These resources include general health books and magazines, nutrition brochures, practice newsletters, and scientific or professional journals and newsletters.6  

Time and education constraints likely contribute to the type of nutritional guidance chiropractors offer. Many chiropractors wish for more nutrition education during their chiropractic college and postgraduate education.5 Furthermore, busy practices also lend themselves to nutritional guidance that requires less time per patient, such as the dissemination of nutritional information and supplements.5 In addition, the reimbursement policies of health insurance and managed care plans potentially affect the time that chiropractors devote to nutrition counseling.11 

References

  1. Key Facts. American Chiropractic Association https://www.acatoday.org/News-Publications/Newsroom/Key-Facts. 
  2. Smith, D. L. & Spillman, D. M. A survey of chiropractors’ use of nutrition in private practice. J. Chiropr. Humanit. 10, 93–98 (2001). 
  3. What is Chiropractic? https://www.palmer.edu/about-us/what-is-chiropractic/. 
  4. Goncalves, G., Le Scanff, C. & Leboeuf-Yde, C. Primary prevention in chiropractic practice: a systematic review. Chiropr. Man. Ther. 25, (2017). 
  5. Holtzman, D. & Burke, J. Nutritional counseling in the chiropractic practice: a survey of New York practitioners. J. Chiropr. Med. 6, 27–31 (2007). 
  6. Lee, M. K., Amorin-Woods, L., Cascioli, V. & Adams, J. The use of nutritional guidance within chiropractic patient management: a survey of 333 chiropractors from the ACORN practice-based research network. Chiropr. Man. Ther. 26, (2018). 
  7. Seaman, D. R. The diet-induced proinflammatory state: a cause of chronic pain and other degenerative diseases? J. Manipulative Physiol. Ther. 25, 168–179 (2002). 
  8. Silverstone, A. M. & Hammell, L. Spinal deformities in farmed Atlantic salmon. Can. Vet. J. 43, 782–784 (2002). 
  9. Worthington, V. & Shambaugh, P. Nutrition as an environmental factor in the etiology of idiopathic scoliosis. J. Manipulative Physiol. Ther. 16, 169–173 (1993). 
  10. Pompeiano, O., Manzoni, D. & Miele, F. Pineal gland hormone and idiopathic scoliosis: possible effect of melatonin on sleep-related postural mechanisms. Arch. Ital. Biol. 140, 129–158 (2002). 
  11. Christensen, M., Kollasch, M. & Hyland, J. Chapter 9: Professional Functions and Treatment Procedures. in Practice Analysis of Chiropractic 2010 (National Board of Chiropractic Examiners, 2009). 
  12. Christensen, M. G. et al. Job analysis of chiropractic. 18 (2005). 
  13. Chiropractic Curriculum Organization and Design for Life University. Life University. A World Leader in Holistic Health and Chiropractic Education. https://www.life.edu/academic-pages/chiropractic-program/chiropractic-curriculum/. 
  14. Doctor of Chiropractic degree program course curriculum. Parker University. https://www.parker.edu/doctor-of-chiropractic-curriculum/. 
  15. Stuber, K., Bruno, P., Kristmanson, K. & Ali, Z. Dietary supplement recommendations by Saskatchewan chiropractors: results of an online survey. Chiropr. Man. Ther. 21, 11 (2013). 

Traction Therapy for Chronic Neck Injuries

Chronic neck pain is a common ailment that can arise from injuries and other underlying conditions. In 2014, it was estimated that the annual healthcare burden of neck and back pain was upwards of 315 billion USD.[1] Cervical traction therapy is a common technique used by both physical therapists and chiropractors for reducing chronic neck pain and improving range of motion. Depending on both patient and therapist preference, neck traction can be performed either continuously or intermittently with small breaks for rest in between. The practice is typically supplemented by other therapeutic techniques, such as deep tissue massage or electrical stimulation. 

Cervical traction uses either weights or pulleys to gently stretch the head away from the body, therefore relieving tension in neck muscles and gently separating the vertebrae. Neck support during traction has been shown to lessen tension in the posterior annulus fibers and ligaments at the C4-C6 levels. It is therefore recommended to include neck support in clinical practice to avoid further injury and aid soft tissue protection.[2] Research has not yet identified the specific mechanism by which neck traction therapy is effective, however it is generally believed to work by easing pressure on the intervertebral discs.

Though traction therapy is safe for most patients, patients with vascular problems in the neck are at a higher risk for experiencing complications. No pain should be experienced at any point throughout or after the procedure.

The majority of research on the effectiveness of neck traction therapy has been within the past five years. A 2017 meta-analysis showed significantly decreased pain immediately after treatment in patients who underwent cervical traction as compared to placebo.[3] The research on long-term effects and changes in neck disability index scores is more contentious. Studies and meta-analyses generally show a subtle long-term improvement in neck pain and function; however, whether or not this improvement can be considered significant varies.[4],[5] Research suggests that traction therapy should instead be used to complement and enhance the effects of other established therapeutic techniques, such as neural mobilization or transcutaneous electrical nerve stimulation.[6]

References

[1] Low Back and Neck Pain [Online]. BMUS: The Burden of Musculoskeletal Diseases in the United States. https://www.boneandjointburden.org/fourth-edition/iia0/low-back-and-neck-pain [21 Sep. 2020].

[2] Wang K, Wang H, Deng Z, Li Z, Zhan H, Niu W. Cervical traction therapy with and without neck support: A finite element analysis. Musculoskelet Sci Pract. 2017;28:1-9. doi:10.1016/j.msksp.2017.01.005.

[3] Yang JD, Tam KW, Huang TW, Huang SW, Liou TH, Chen HC. Intermittent Cervical Traction for Treating Neck Pain, Spine: July 1, 2017 July 1;41(13):959-965. doi:10.1097/BRS.0000000000001948.

[4] Graham N, Gross A, Goldsmith CH, et al. Mechanical traction for neck pain with or without radiculopathy. Cochrane Database Syst Rev. 2008 July 16;(3):CD006408. doi:10.1002/14651858.CD006408.pub2

[5] Fritz JM, Thackeray A, Brennan GP, Childs JD. Exercise Only, Exercise With Mechanical Traction, or Exercise With Over-Door Traction for Patients With Cervical Radiculopathy, With or Without Consideration of Status on a Previously Described Subgrouping Rule: A Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy 44: 45–57, 2014.

[6] Savva C, Korakakis V, Efstathiou M, Karagiannis C. Cervical Traction combined with Neural Mobilization for patients with cervical radiculopathy: A randomized controlled trial. Journal of Bodywork and Movement Therapies. 2020. doi:10.1016/j.jbmt.2020.08.019.

Overview of High-Velocity, Low-Amplitude (HVLA) Spinal Mobilization Techniques

High velocity, low-amplitude (HVLA) spinal mobilization is one of the most popular chiropractic methods for addressing both lower and middle back pain. An evidence report compiled in 2010 by Bronfot et al. noted that spinal mobilization was also effective in adults for migraine, cervicogenic dizziness, and neck pain.[1]There are three schools of technique of HVLA spinal mobilization, as described below:

  1. Diversified technique: The most common of the three HVLA methodologies, a diversified technique is generally used to restore full range of motion to restricted joints. One short, high-velocity thrust is applied to the joint of interest to create an unlocking effect. Multiple adjustments can be made in a single appointment if more than one joint is restricted. Manipulation of patient body positioning may be necessary to allow for the ideal angle and leverage for diversified HVLA. 
  2. Palmer-Gonstead adjustment: The Palmer-Gonstead adjustment is similar to the diversified technique in both duration and magnitude of force, but places greater emphasis on isolating an exact spinal location for ideal joint adjustment. Location can be determined through palpation (both with motion and static), visualization, instrumentation, and X-ray analysis. A wide variety of specially-designed tables, chairs, and other equipment are employed to alter body configuration and create optimal angles for spinal adjustment. 
  3. Drop technique: Also known as the Thompson Terminal Point technique, the drop technique focuses specifically on facilitating the movement of the restricted joint during HVLA mobilization. Patients are placed on specialized tables that have the ability to drop a short distance during the physician’s or chiropractor’s thrust. Occasionally, the drop of the table along is sufficient to free the restricted joint. The drop technique is often used as a complement to the diversified technique.

Little research has been done to compare the relative efficacy of these techniques to each other; however, preliminary findings suggest they may perform similarly.[2] Regardless, it has been found that overall, successful HVLA spinal mobilization results in significantly superior patient outcomes as compared to placebos,[3] and should be considered a useful method for treating a variety of back-related issues.

References

[1] Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. 2010 Feb 25;18:3. doi:10.1186/1746-1340-18-3. PMID: 20184717; PMCID: PMC2841070.

[2] Cao DY, Reed WR, Long CR, Kawchuk GN, Pickar JG. Effects of thrust amplitude and duration of high-velocity, low-amplitude spinal manipulation on lumbar muscle spindle responses to vertebral position and movement. J Manipulative Physiol Ther. 2013;36(2):68-77. doi:10.1016/j.jmpt.2013.01.004.

[3] von Heymann WJ, Schloemer P, Timm J, Muehlbauer B. Spinal high-velocity low amplitude manipulation in acute nonspecific low back pain: a double-blinded randomized controlled trial in comparison with diclofenac and placebo. Spine (Phila Pa 1976). 2013 Apr 1;38(7):540-8. doi:10.1097/BRS.0b013e318275d09c. PMID: 23026869.

Cauda Equina Syndrome (CES): Causes, Symptoms and Treatments

Low back pain is one of the most prevalent chronic conditions world-wide, affecting adults as young as 18, and worsens with age [4]. Typical interventions for alleviating low back pain involve adjustments in life-style factors such as workload, social support, and physical therapy, with very rare cases requiring admission to an emergency room [2]. However, severe back pain can also be a symptom of a lesser known or misdiagnosed condition [3][4]. For instance, Cauda Equina Syndrome (CES) is a rare condition that typically requires immediate surgical treatment in order to avoid serious excretory complications (incontinence) and permanent nerve damage [5][7]. 

The cauda equina, Latin for “horse’s tail”, is a bundle of spinal nerve roots originating near the distal end of the spinal cord that send and receive nerve impulses to pelvic organs and lower limbs [3][4][7]. Damage to the cauda equina can result in sudden and severe symptoms that disrupt motor and sensory functions of the lower extremities, bladder and bowels [3][5]. Typically, this damage arises from compression and inflammation of the nerve roots, caused by a herniated disc in the lumbar region [3][7]. Common causes of a lumbar disc herniation include excessive pressure from loading or strain from sudden twisting movements [6]. Other causes include but are not limited to spinal infections and inflammation, lumbar spine trauma, spinal lesions and tumors, lumbar spinal stenosis, and spinal hemorrhages [5][7]. 

The severity of symptoms varies depending on the degree of compression and number of nerves injured [5][6]. For some patients, the onset of cauda equina symptoms can develop within 24 hours (acute onset) or over weeks and months (gradual onset) [5]. Typical symptomatic indicators of CES include severe low back pain, weakness, tingling, or sharp, hot pain in one or both legs and/or “saddle region” (groin, buttocks, genitals, upper thighs), recent onset of bladder and bowel dysfunction and/or incontinence, and loss of reflexes in the lower extremities [3-7]. Patients are typically classified into two categories: CES-R (urinary retention) and CES-I (an incomplete syndrome) [4]. In addition to a diagnostic screening with an MRI, Gardner et al. suggests implementation of a trigone sensitivity test in order to discern “genuine” neurological deficits of bladder retention [4].

As mentioned above, CES usually requires immediate hospitalization and prompt decompression surgery in order to reduce the symptoms of neurological dysfunction and avoid incontinence and permanent paralysis [3][4]. As with most neurological conditions, the sooner the diagnosis and subsequent treatment, the better the chance of recovery with minimal lasting neurological damage [1][4][5]. Ideally, CES is treated early within 24 to 48 hours for the best chance of complete sensory recovery [1][4]. However, surgery does not necessarily eradicate the possibility of irreversible outcomes [6]. It is important to note that the rarity and variability of CES contributes to misdiagnosis and delay of treatment, contributing to its “prominent position in the medico-legal field” [4]. While attention of CES has increased in the medical field, it is crucial for patients and doctors to be informed and aware of this rare syndrome.

References

1. Bečulić, H., Skomorac, R., Jusić, A., Alić, F., Imamović, M., Mekić-Abazović, A., Efendić, A., Brkić, H., & Denjalić, A. (2016). Impact of timing on surgical outcome in patients with cauda equina syndrome caused by lumbar disc herniation. Medicinski Glasnik : official publication of the Medical Association of Zenica-Doboj Canton, Bosnia and Herzegovina, 13(2), 136–141. https://doi.org/10.17392/861-16

2. Buruck, G., Tomaschek, A., Wendsche, J., Ochsmann, E., & Dörfel, D. (2019). Psychosocial areas of work life and chronic low back pain: a systematic review and meta-analysis. BMC musculoskeletal disorders, 20(1), 480. https://doi.org/10.1186/s12891-019-2826-3

3. Cauda Equina Syndrome. American Association of Neurological Surgeons.https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Cauda-Equina-Syndrome

4. Gardner, A., Gardner, E., & Morley, T. (2011). Cauda equina syndrome: a review of the current clinical and medico-legal position. European Spine Journal: official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 20(5), 690–697. https://doi.org/10.1007/s00586-010-1668-3

5. Hoy, D., Bain, C., Williams, G., March, L., Brooks, P., Blyth, F., Woolf, A., Vos, T., & Buchbinder, R. (2012). A systematic review of the global prevalence of low back pain. Arthritis and Rheumatism, 64(6), 2028–2037. https://doi.org/10.1002/art.34347

6. Kapetanakis, S., Chaniotakis, C., Kazakos, C., & Papathanasiou, J. V. (2017). Cauda Equina Syndrome Due to Lumbar Disc Herniation: a Review of Literature. Folia Medica, 59(4), 377–386. https://doi.org/10.1515/folmed-2017-0038

7. Villavicencio, A. Cauda Equina Syndrome (2016). Cauda Equina Syndrome. Spine-Health. https://www.spine-health.com/conditions/lower-back-pain/cauda-equina-syndrome

Osteoarthritis: Causes, Symptoms, and Management

Osteoarthritis (OA) is the most common form of arthritis and the most common joint disorder in the United States, affecting approximately 1 in 7 adults [1]. OA is a disease that is caused and worsened by the continual inflammation of joint cartilage along with the surrounding bone and synovium [2] [3]. OA is caused primarily by joint injury and overuse, as these occurrences trigger the production of inflammatory mediators—such as cytokines and chemokines—in the synovium and chondrocytes (cartilage cells). During later stages of OA, cartilage fragments can fall into the synovium, exacerbating the process. Those who are older, obese, and work more physically demanding jobs are more likely to develop OA, as these factors all increase the use of or stress on joints. OA also disproportionately affects women; of those over the age of 60, women are almost twice as likely to develop the condition (18.0% of women over 60 versus 9.6% of men) [4]. OA can develop in any joint, but most commonly occurs in the knees, hips, hands, and spine.

Common symptoms of OA include joint pain, stiffness, swelling, decreased range of motion, and fatigue. This often results in intense discomfort during use, and can inhibit function of the joint, leading to an inability to walk if OA is present in the hip, knee, or foot. However, an individual’s level of pain or discomfort does not translate to the structural deterioration of the joint—thus, OA is often difficult to diagnose symptomatically, especially when pain is less present in its early stages [5]. OA has no cure; its end-stage involves the irreversible damage of joint cartilage, necessitating surgical joint replacement. As such, early diagnosis of OA—through an analysis of symptoms and X-ray or MRI screenings—is imperative for preventive treatment [6]. The presence of developing osteophytes (bone outgrowths), along with narrowing of joint space and deformity are indications of OA. 

Management of OA is largely dependent on the patient and severity. Mild OA can be managed through simple exercises that do not stress the joints, such as aerobics and light muscle-strengthening exercises [1] [7] [8]. Patients with obesity are often given weight loss suggestions, and almost all patients are suggested to attend self-management education courses, which are designed to instruct patients to adopt practices to mitigate daily pain and discomfort. These practices range from identifying unhealthy exercise habits to stress management techniques to improving sleep schedules and diet. Most of all, these courses aim to support patients with the emotional toll of OA, as deteriorating joint function often leads to frustration and depression [1] [4]. Simple analgesics assist patients with day-to-day activities and if needed, topical or oral NSAIDs (non-steroidal anti-inflammatory drugs) can also be prescribed [9]. Physiotherapy is also often recommended. In severe cases, supportive devices like crutches and canes or intra-articular corticosteroid injections may become necessary for function and, as previously stated, end-stage OA requires joint replacement. Although not empirically proven, alternative medicine methods—like acupuncture—have also been reported to improve OA symptoms. 

Hence, it is vital that those who are high-risk of developing OA consult medical professionals in a timely manner to catch symptoms before the OA develops and causes irreversible damage. Individuals who attribute mild joint pain or stiffness solely to the aging process may mistakenly overlook a developing case of OA. When diagnosed early, OA can be alleviated through proper self-management and exercise practices, leading to a superior quality of life. 

References

  1. Centers for Disease Control and Prevention (CDC). (2020). A National Public Health Agenda for Osteoarthritis: 2020 Update. https://www.cdc.gov/arthritis/docs/oaagenda2020.pdf
  2. Berenbaum, F. (2013). Osteoarthritis as an inflammatory disease (osteoarthritis is not osteoarthrosis!). Osteoarthritis and cartilage, 21(1), 16-21.
  3. Goldring, M. B., & Otero, M. (2011). Inflammation in osteoarthritis. Current opinion in rheumatology, 23(5), 471.
  4. Arthritis Foundation. (2019). Arthritis by the Numbers: Book of Trusted Facts & Figures.https://www.arthritis.org/getmedia/e1256607-fa87-4593-aa8a-8db4f291072a/2019-abtn-final-march-2019.pdf
  5. Glyn-Jones, S., Palmer, A. J. R., Agricola, R., Price, A. J., Vincent, T. L., Weinans, H., & Carr, A. J. (2015). Osteoarthritis. The Lancet, 386(9991), 376-387.
  6. Zhang, Y., & Jordan, J. M. (2010). Epidemiology of osteoarthritis. Clinics in geriatric medicine, 26(3), 355-369.
  7. Fransen, M., McConnell, S., Harmer, A. R., Van der Esch, M., Simic, M., & Bennell, K. L. (2015). Exercise for osteoarthritis of the knee. Cochrane database of systematic reviews, (1).
  8. Fransen, M., McConnell, S., Hernandez‐Molina, G., & Reichenbach, S. (2014). Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews, (4).
  9. Dieppe, P. A., & Lohmander, L. S. (2005). Pathogenesis and management of pain in osteoarthritis. The Lancet, 365(9463), 965-973.