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Chiropractic Treatment for Disc Injuries – Current research



Chiropractic treatment for Disc injuries and Sciatica

Chiropractic treatment has over the years become more established as a mainstream treatment for neuro-musculoskeletal problems, particularly lower back pain.

Chiropractic now forms part of the recommended treatment in national guidelines for the treatment of back pain (Waddell et al 1999, CSAG 2001) and recent guidelines from the National Institute for Health and Clinical Excellence (NICE 2009).

The main reason for this is the increasing emergence of research in relation to chiropractic treatment.

There is however, controversy over chiropractic manipulation as a treatment in patients with disc injuries despite the existence of research to prove its effectiveness, and very little evidence that it is harmful.

Several uncontrolled descriptive studies have shown that approximately 50 to 80% of patients with lumbar disc herniations (LDH) benefit from side-posture manipulation (Henderson 1952, Mensor 1955, Christman 1964, Kuo 1987, Cassidy 1993) and one controlled study by Nwuga (1982) showed that lumbar side posture rotational manipulation was superior to heat, exercise and postural education, conventional physiotherapy, and also, BenEliyahu (1996) who did a clinical study of 27 patients with both lumbar and cervical disc herniation with very positive results.

These studies might have had little impact due to their research methodology, but a more recent randomised controlled study (RCT) published in Spine (Santilli et al 2006) showed that manipulation was significantly better than placebo, and another RCT by Snelling (2006) showed that manipulation was better than traction in patients with lumbar disc injuries.

The study by Santilli (2006) was a randomised controlled trial that compared manipulation performed by chiropractors to a sham manipulation. It found that after a 30 day treatment programme, a higher proportion of people were free of local or radiating pain after active spinal manipulation than after sham manipulation.

These studies has ‘tipped the scale’ in a couple of research reviews to rate the evidence of chiropractic manipulation for disc herniation as “favourable" by Bromfort et al (2010) and as “likely to be beneficial" by Jordan et al (2008).

Coincidentally, the BMJ Evidence report by Jordan et al (2008) rated all pharmaceutical therapy as of “unknown effectiveness" and specifically non-steroidal anti-inflammatory medication (NSAID’s) as “unlikely to be beneficial".


So why is there still such controversy?

It is possibly because of the lack of understanding of what chiropractic manipulation entails. It is often believed that manipulation is excessively forceful and violent, but that is not the case.

There is also a belief that side posture manipulation will damage the disc and spinal joints. Again, that is not the case. Spinal manipulation performed by chiropractor is a very controlled and specific procedure.

Spinal manipulation is considered extremely safe if performed by a qualified, proficient practitioner.

A systematic review and risk assessment by Oliphant (2004) estimated that the risk of causing further disc herniation or cauda equina syndrome by spinal manipulation is one in 3.7 million manipulations!

This should be compared to adverse reactions from other interventions like Spinal surgery and taking NSAID’s, which carry a much higher risks of serious complications.


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How do disc injuries occur?

Two basic mechanisms for lumbar disc herniations have been suggested (Adams & Hutton 1981, 1982 and 1985); 1. Acute hyperflexion loading of the disc and; 2. cumulative trauma leading to a gradual prolapse.

The latter, which is suggested to be the more common mechanism, is due to repetitive or prolonged loading by for instance sitting and bending.

The bending mechanism as the cause of a disc herniation has further been supported by experimental studies by McGill et al.

It has been demonstrated that sitting and forward flexion increases the intra discal pressure more compared to rotation, especially the stress on the posterior annulus, which is the most common location for the disc herniation to occur (Adams & Hutton 1982).

It is important to note that experimental studies on healthy tissues has shown that it is extremely difficult to cause traumatic rupture of the nucleus even if an artificial track is created by cutting the annulus. The biochemical and biophysical properties of the nucleus need to be altered to make it possible (internal disc degradation), a likely cause of internal disc degradation is traumatic compression injuries causing end plate fracture exposing the nucleus to the circulation initiating the degeneration of the nucleus and leading to internal disc disruption (Bogduk 1990).

It therefore seems unlikely that a rotational manipulation will cause a disc herniation (Adams & Hutton 1981). In fact, Cassidy et al (1993) showed a reduction in the disc herniation or no change at all after using rotational manipulation.

So, if the disc herniation doesn’t change size why does the patient get better?


The herniation versus inflammation

Several investigations have indicated that the size of the herniation does not correlate to the symptoms (Cassidy 1993) and approximately 25% of asymptomatic subjects have been shown to have evidence of disc herniations (Wiesel 1984, Boden et al 1990 and Jensen et al 1994).

So how can that be?

The nucleus is avascular, as such, it has been shown that if it gets in contact with the body’s normal immune mechanism an auto immune inflammatory reaction will result (Naylor 1976, Cassidy 1993).

The inflammation around the nerve root would cause pain, sciatica. If the herniation is large enough and the pressure on the nerve root is high enough it may reduce axonal flow and cause neurological deficit.

This would indicate that the inflammatory process is more important in producing symptoms than the direct mechanical compression of the nerve root.

The nerve roots are particularly susceptible to the consequences of venous compression because they lack lymphatics (Bogduk and Twomey 1987).


So how can Pain be controlled Naturally?

There are three main pain relief mechanisms in place, which can modulate the pain:

1. Ergoreceptors located in the skeletal muscles which when stimulated by either hard pressure, stretching or acupuncture, lead to relaxation and increased range of movement leading to increased proprioceptor input and by acting on the pain gate theory reduces pain.

2. The pain gate theory, is that proprioceptive input to the spinal cord is competing with nociceptive input. It has been shown that proprioceptive input from deeper tissues, ie. facet joints, has a more long lasting (tonic) effect on pain reduction than stimulation to more superficial tissues like the skin and muscles (Gatterman 1995).

3. The descending noxious inhibitory control system from the periaqueductal grey matter of the mid brain projects onto the nucleus raphe magnus in the medulla, it descends and synapses in the dorsal horn in lamina I and II. The descending fibres synapse directly onto nociceptive tract neurons and inhibitory inter neurones that contain enkephaline. This descending system has input from the reticular formation, the limbic system and hypothalamus. Analgesia can be produced by administration of opiates into the CNS and by prolonged exercise, which has been shown to increase enkephaline levels in the CNS (Dahlin 1992).


Conclusion

There is currently good evidence in the literature that chiropractic manipulation is beneficial for patients with disc herniations.

It appears to be more effective than sham manipulation, placebo, traction or rest and pain medication, even injections and nerve root blocks (Santilli et al 2006 and Snelling 2006, Jordan et al 2008).

Chiropractic manipulation for disc herniations is safe according to Oliphant (2004). He estimates the risk for causing a further disc herniation or serious complications such as cauda equina syndrome to be one in 3.7 million.

Delay in treatment and unnecessary increased duration of symptoms tends to have a negative impact on the prognosis, therefore early treatment is imperative (NICE 2009).

The ‘wait and see’ approach has been pointed out as being the wrong approach when it comes to back pain generally (Waddell et al 1999 and NICE 2009).

It might be even more detrimental in cases with nerve root compromise because compression of vascular structures within the nerve leading to hypertension within the nerve and intra-neural fibrosis, this may lead to irreversible damage.

To just prescribe pain- and anti-inflammatory medication, and advocate rest for 6-8 weeks followed by a neurosurgical or orthopaedic opinion does not appear to be in the patient’s best interest.

A combination of chiropractic manipulation with the right exercise rehabilitation programme to improve the function, and added psychological and pharmacological support would be an evidence-based, patient-centered, multi-diciplinary treatment that might well be in the patients best interest.


For enquiries please call:

Chiropractic Care

Milton Keynes: 01908 307075
Northampton: 01604 460200
Aylesbury: 01296 489231


Read more about Chiropractic and Disc Injuries.

Read more about Chiropractic and Sciatica.

REFERENCES

Adams MA, Hutton WC. The relevance of torsion to the mechanical derangement of the lumbar spine. Spine 1981; 6:241-8.

Adams MA, Hutton WC. Prolapsed intervertebral disc - a hyperflexion injury. Spine 1982; 7:184-91.

Adams MA, Hutton WC. Gradual disc prolapse. Spine 1985; 10:524-31.

BenEliyahu D. Magnetic resonance imaging and clinical follow up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. JMPT 1996; 19,9.

Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg Am. 1990;72:403–408.

Bogduk N, Twomey LT, Clinical anatomy of the lumbar spine. Churchill Livingstone 1987.

Bogduk N. Pathology of lumbar disc pain. J Manual Medicine 1990; 5:72-79.

Bromfort G, Haas M, Evans R, Leininger B, Triano J, Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3.

Cassidy JD, Wedge JH. The epidemiology and natural history of low back pain and spinal degeneration. In: Kirkaldy-Willis WH, ed. Managing low back pain. New York: Churchill-Livingstone, 1988: 3-14.

Cassidy JD, Thiel HW, Kirkaldy-Willis WH (1993), Side Posture Manipulation for Lumbar Intervertebral Disk Herniation, J Manipulative Physiol Ther 16(2);96-103.

Clinical Standards Advisory Group (CSAG), Report on Back Pain, May 1994, HMSO, ISBN 0 11 321887 7.

Christman OD. Mittnacht A, Snook G. A study of the results following rotatory manipulation in th lumbar intervertebral disc syndrome. J Bone Joint Surg 1964; 46A:517-24.

Dahlin LB, Holm SH, Rydevik BL, Lundborg G. Physiology of nerve compression. Chapter 7 p.73-85 in Principles and Practice of Chiropractic. Haldeman 2nd Ed. 1992 Appleton & Lange.

Gatterman MI, Foundations of Chiropractic Subluxation, Mosby 1995.

Henderson RS. The treatment of lumbar intervertebral disc protrusion: an assessment of conservative measures. Br Med J 1952; 2:597-8.

Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331:69–73.

Jordan J, Konstantinou K, O’Dowd J. BMJ Clinical Evidence, Herniated lumbar disc, BMJ Publishing Group Ltd 2009. 2009;03:1118,

Kuo PP-F, Loh Z-C. Treatment of the lumbar intervertebral disc protrusions by manipulation. Clin Orthop 1987; 215:47-55.

Laderman JP. Accidents of spinal manipulation. Ann Swiss Chiro Assoc 1981; 7:161-208.

McGill S, et al

Mensor MC. Non-operative treatment, including manipulation, for lumbar intervertebral disc syndrome. J Bone Joint Surg 1955; 37A:925-36.

Naylor A (1976) Intervertebral disc prolapse: The biochemical and biophysical approach. Spine 1:108-114.

NICE (2009 ) National Institute for Health and Clinical Excellence Early management of persistent non-specific low back pain, MidCity Place, 71 High Holborn, London, WC1V 6NA; www.nice.org.uk.

Nwuga VCB. Relative Therapeutic efficacy of vertebral manipulation and conventional treatment in back pain management. Am J Phys Med 1982; 61:273-8.

Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk hernia- tions: a systematic review and risk assessment. J Manipulative Physiol Ther 2004;27:197–210.

RCGP 2001, Clinical Guide Lines for the Management of Acute Low Back Pain.

Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J 2006;6:131–137.

Snelling NJ., Spinal manipulation in patients with disc herniation: a critical review of risk and benefit. Int J Osteopath Med 2006;9:77–84.

Waddell G, McIntosh A, Hutchinson A, Feder G, Lewis M, (1999) Low Back Pain Evidence Review, London: Royal College of General Practitioners, Royal College of General Practitioners
, 14 Princes Gate, Hyde Park, London SW7 1PU.

Weisel SE, Tsourmas N ,Feffer HL, CItrin CM, Patronas N. A study of computer assisted tomography. The incidence of positive CT scans in an asymptomatic group of patients. Spine 1984: 9:549-51.


For enquiries please call:

Chiropractic Care

Milton Keynes: 01908 307075
Northampton: 01604 460200
Aylesbury: 01296 489231



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