August 31, 2012

How can a Chiropractor help you?

How can Chiropractors help you?

Chiropractors focus on diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on nervous system function and general health.

Whilst concentrating on the spine and its mechanics, Chiropractors take a thorough medical and complaint history before moving on to a focused examination, undertaking further diagnostic tests, including radiology if indicated.

Once completed, an appropriate and safe treatment plan best suited to provide symptomatic relief and maximise biomechanical function is explained to the patient prior to commencement of treatment.

How do disc injuries occur?

Two basic mechanisms for lumbar disc herniations have been suggested (Adams & Hutton 1981, 1982 and 1985): acute hyperflexion loading of the disc, and cumulative trauma leading to a gradual prolapse. The latter, which is suggested to be the more common mechanism, occurs through repetitive or prolonged loading by, for instance, sitting and bending.

It has been demonstrated that sitting and forward flexion increases the intra-discal pressure to a greater extent than rotation, placing particular stress on the posterior annulus which is the most common location for the disc herniation to occur (Adams & Hutton 1982).

Experimental studies on healthy tissues have shown that it is extremely difficult to cause traumatic rupture of the nucleus pulposus even if an artificial track is created by cutting the annulus. The biochemical and biophysical properties of the nucleus pulposus need to be altered to make it possible i.e. internal disc degradation. A likely cause of internal disc degradation is traumatic compression injury causing end plate fracture and exposing the nucleus pulposus to the circulation. This initiates the degeneration of the nucleus pulposus leading to internal disc disruption (Bogduk 1990).

The roles of herniation and inflammation

Several investigations have indicated that the size if the herniation does not correlate with 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; Jensen et al 1994). This is explained by the fact that the nucleus pulposus is avascular but if it becomes exposed to the body’s normal immune mechanism, an autoimmune inflammatory reaction may result (Naylor 1976, Cassidy 1993). It is this inflammation around the nerve root that is likely to cause the sciatic pain. If the herniation is large enough and the pressure on the nerve root is high enough, axonal flow may be reduced and cause neurological deficit; the nerve roots are particularly susceptible to the consequences of venous compression because they lack lymphatics (Bogduk and Twomey 1987).

Treatment interventions

Jordan et al (2008) systematically reviewed the evidence for common interventions used to treat symptomatic herniated lumbar disc including drug treatments, spinal manipulation and surgery. They concluded that:

  • There is little evidence to suggest that drug treatments are effective in treating herniated disc. NSAIDS and cytokine inhibitors do not seem to improve symptoms of sciatica caused by disc herniation.

 

  • Spinal manipulation is more effective at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion compared to any other treatment recommendations.

 

Role of chiropractic care in the management of disc herniation

Effectiveness

It is noted that compared with sham treatment, active chiropractic spinal manipulation is more effective at six months at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion.

Safety

On the basis that it is extremely difficult to cause traumatic rupture of the nucleus pulposus in experimental studies and that rotational force increases discal pressure to a lesser extent than forward flexion upon sitting/bending, it seems unlikely that a rotational manipulation will cause disc herniation (Adams & Hutton 1981). Cassidy et al (1993) showed a reduction in the disc herniation or no change at all following rotational manipulation of patients with existing lumbar intervertebral disc herniation. Oliphant (2004) estimated the risk of causing a further disc herniation or serious complications such as cauda equina syndrome to be extremely low at one in 3.7 million, although it was unclear whether the populations studied included surgical candidates.

Conclusion

A combination of spinal manipulation with suitable exercise rehabilitation to improve function, is an evidence-based approach for primary care patients with symptomatic herniated lumbar disc.

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.

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.

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

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,

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

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.

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.

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.