Chiropractic is a natural means by which to optimize your health by restoring proper joint motion and thus nervous system function. Growing in popularity and being adopted by many professions, spinal manipulation has been substantiated in the last few decades by reproduced randomized controlled trials that regard it as a primary means to help alleviate the following conditions.
- Acute (<12 days) and chronic (>12 weeks low back and neck pain
- Herniated or bulged lumbar and cervical discs with adjunctive positional rehabilitation
- Muscular and migraine headaches
- Temporomandibular joint disorders (jaw pain or grinding of the teeth)
- Degenerative arthritis and other inflammatory spinal conditions
- Rib, shoulder, and hip pain
*Note that this is by no means an exhaustive list of conditions treated, also that manipulative therapy is not exclusive to only the joints of the spinal column.
Most of the information below is in reference to the spine and this in part is due to spinal (low back and neck) pain being the most common complaint in healthcare today, and also that is where the majority of research on joint manipulation has been conducted. Our goal at Chiro Strong STL is to properly screen in and out patients that have been shown to respond to manipulative therapy and maintain their function before the condition negatively affects their overall movement function. Those who need additional treatment will be co-managed through our medical partnership program in order to provide the most effective and reasonable treatment for each individuals condition. Every patient’s complaint is unique and requires thorough investigation and treatment. Schedule your appointment today to see how chiropractic manipulation can help your condition or continue reading for further information on manipulative therapies.
In order to better understand how we can help you with spinal manipulation we need to talk about some basic anatomy, physiology, and neurology. Don’t be intimidated by these terms because we are going to break it down so it is very understandable for you. If you have any questions beyond what is covered here be sure to let us know.
Let’s get started with some basic movement terminology first.
When we talk about motion of the spine we use the term coupled motion. Coupled motion refers to the anatomical motion that any particular joint in your body allows. Certainly this is around all three axis of rotation, X, Y, and Z but limited in certain motions depending on the level in the spine. This is genetically predetermined for the most part and should be relatively the same between individuals. For example, when you bend your ear to your shoulder you have the tendency for your chin to move towards your chest. The opposite happens in your low back when you flex to the side your low belly moves toward the ceiling. This is based on the orientation of the facet joints at the top and bottom of each vertebral body which will be covered more below.
The next term you need to understand used in regards to spinal motion is segmental motion. Segmental motion refers to movement of a vertebral body and the discs above and below with their attached vertebrae. The importance of these terms is the realization that you cannot simply move one vertebrae without effecting both the ones above and below it. As most of you already know, you have a disc shaped structure between each vertebrae connecting them and providing the fulcrum of motion as well as a primary load sharing structure. Also connecting each motion segment is many spinal ligaments, muscles, and most importantly for manipulative therapy the facet joint capsular ligaments.
This certainly is not the exact configuration of all your spinal joints however gives you a decent understanding of basic spinal anatomy without all the nit picky details. The importance of mentioning coupled motion is to emphasize how it effects your overall global spinal movement. So lets say that you have lost motion in a motion segment or two in your low back, what happens? Since you now understand a bit about coupled motion we can say that the remaining 23 vertebral bodies and their coupled motion are now altered in some abnormal way. As you can see this leads to abnormal spinal loading, excessive ligamentous and muscle tensile strain, and overall poor movement efficiency. Put yourself in the most awkward position you can think of and hold it there for fifteen minutes then try to stand up and walk efficiently. It can’t be done until you’ve done it for a few minutes then things ease up a bit but this is only 15 minutes of one position. Think about the most commonly held position you put your body in every day.
The #1 reason for a loss of segmental motion in our spine is due to our repetitive lifestyles which do not prioritize sufficient movement throughout our day. The fact we all fall victim to gravity overtime due to lifestyle choices is no secret and the cause of countless medical problems beyond spinal de-conditioning, and this certainly needs to be addressed.
The next important thing we need to teach our patients is the importance of the nervous systems relationship to spinal motion. We all have learned how we sense things in or environment through nerve endings in our skin, muscles and ligaments. The important concept here is the innervation of your facet joint capsules. The complexity of this structural and functional relationship is incredibly complicated and changing rapidly so we will keep it simple enough for you to understand with some interesting facts along the way.
Basic neuroanatomy 101 starts with a few basic principles. Your brain, brainstem, and spinal cord located inside the skull and spinal canal are the anatomical units of the central nervous system (CNS). Any related structures which branch off of the CNS are considered to be in the peripheral nervous system (PNS). The peripheral nerves, with some exceptions, have both a motor (output) and sensory (input) component which are connected to the brain by spinal tracts which reside in your spinal cord. These are like spinal cord highways which consist of myelinated axons carrying neural impulses (information). If we talk about sensory input (bodily sensations) for a moment we will break down the sensations we experience into hot/cold, vibration, discriminative touch, crude touch, two point discrimination, proprioception (joint position), and pain. The last two being the most important for our discussion on manipulative therapies.
We now need to break down pain, which is also termed nociception (an abnormal sensation which is unpleasant), into sharp and dull for a more full understanding. Nociception as a sensation is percieved by free nerve endings which have been classified as nociceptive free nerve endingsdesigned to detect pending damage. These endings can be stimulated in response to mechanical as well as chemical damage. Sharp pain sensations that are easily localized are carried by larger, faster, A-Delta nerve fibers in the spinothalamic tract which terminates in your brain (this means you can tell where the pain is coming from). The perception of dull pain that is not easily discriminated or localized is carried by smaller and slower c- nerve fibers in the spinoreticulothalamic tract which does not reach the brain (this means you cannot accurately detect where the pain is coming from). The important thing to note about the different fiber types and size of these pathways is that the larger nerve fibers override the sensation of the small nerve fibers. This is of paramount importance and requires an example. Lets say that you have a dull, achy pain in your neck and soon after you get a paper cut on your finger. The nervous system prioritizes your pain sensations and assumes the more dangerous and life threatening pain is coming from your finger and you quickly forget about the pain in your neck. This will come into play and discussed more below but to sum up, nociceptors are usually activated by high-intensity stimulation, which can detect actual or potential tissue damage resulting in the “unpleasant sensory and emotional experience” defined as pain.
- Some research cites some two hundred and forty-eight receptors, nerve endings containing substance P and CGRP on the outside part of the facet joint capsules in the neck which is suspected to be a major pain generator in whiplash-related disorders and chronic neck pain patients.
Next we will discuss the sensation of mechanoreception, which is also known as proprioception. These synonymous terms are used to describe nerve endings that serve the function of detecting tissue displacement in tendons, ligaments, joint capsules, and muscle spindles. In short, your bodies position in space both during movement and when your not moving. The nerve fibers that carry proprioception are also large, fast, classified as Ia, Ib, and II fibers and have a direct influence on nociceptors through neural reflexes which we will only briefly cover here. There are multiple pathways which carry proprioception and this certainly emphasize its importance in normal function. The different proprioceptive fiber classification is beyond this discussion as well but the thing you want to take away is the fact that proprioception has the capacity, just like fast pain fibers to override c-fiber pain. This also is paramount to understand and another example is in order. Subconsciously when you got that same paper cut as above you immediately start rubbing your finger with your other hand. The reason for doing this is your bodies ability to know that mechanoreception can inhibit pain. So to sum up, proprioceptors are stimulated through joint motion stimulating internal (muscle contraction) and external (massaging, clothing etc) tissue displacement which also inhibits pain.
It is pivotal for patients to understand these basic principles in order to understand how manipulative therapy affects the body. The big take away point from the neuroanatomy crash coarse is that both joint movement and sharp pain inhibit dull and achey pain.
Next we are going to move on to the anatomy of the facet joints. This image to the right gives the important anatomical structures of the synovial joints in your body, which includes the facet joints. A synovial joint consists of a two articulating surfaces covered in hyaline cartilage, a meniscus or disc between the two surfaces which dissipates forces, a synovial membrane surrounding the joint which is filled with synovial fluid, a fat pad, a neuro-vascular bundle, and adjoining muscle and ligament attachments. Each vertebrae has at least 4 synovial joints, 2 on top and 2 on bottom, and more if you are in the thoracic spine which includes four extra joints for your ribs. The reason this is important for you to understand is to realize how many joints have the potential to be a pain generating structure.
The facet joints are like any other tissue in the body in respect to following the principle, use it or lose it. With both disuse or overuse, the facet joints can become excessively restricted (lack of movement) or excessively mobile (acute trauma leading to stretch or low level repetitive motion). It has been recently recognized that facet-joint capsules can undergo high strain during repetitive spinal loading and certainly with acute trauma of high intensity (whiplash type injury). Either one of these scenarios creates abnormal coupled motion throughout the spinal kinetic chain and leads to the creation of additional locations of abnormal motion above or below the involved motion segment.
The cartilagenous surfaces of your joints lack blood supply and thus depend solely on the diffusion of oxygen and nutrients from synovial fluid. Movement of your joints creates the pressure necessary to drive synovium into cartilage. Joint mobility = joint health!!
Because your facet capsules are highly innervated with nociceptors and mechanoreceptors, motion is necessary to maintain the balance of firing between small and large diameter fibers. Remember from what you have learned already, an acute type of trauma and strain would cause firing of A-Delta fibers which would be detected as sharp pain. Low level repetitive motion disorders or lack of motion over time would fire c-fibers and be detected as dull and achey pain. Movement with proper coupled motion in all planes would promote type Ia, Ib, and II mechanoreceptive fibers to fire and inhibit pain. This actually happens all day long without you noticing until the scale tips towards the side of not moving as often as we should. In fact there is a mechanism termed central sensitization which recognizes the increased pain sensitivity in the spinal cord as a direct reflexion of an imbalance of these pain and mechanoreceptive pathways.
Lets now use some current literature to list what has been implicated in facet joint pain:
Facet joints can become impinged – This is when the meniscus or the fat pad become abnormally stuck within the joint causing abnormal movement and pain.
Facet joint capsules can undergo strain injuries – This strain is similar to other tissues in your body from overload beyond the elastic limit in an acute or chronic injury.
Synovial fold pinching – This is the synovial membrane becoming pinched between the two bony surfaces when it should be maintained around the periphery.
Inflammation in the joint – This is due to a preceding injury which leads to decreased thresholds of nerve endings in the facet capsules as well as elevated baseline discharge rates.
Abnormal joint mechanics as the result of pain causing muscle firing pattern dysfunction.
You have come along way by now and probably have some question’s about the things you have heard about chiropractic. Lets address some of those now…
I have heard that my spine might be crooked, and are you going to make it straight again? Unfortunately, as good as this sounds is not the case in respect to what we do. Chiropractor’s traditionally thought they literally were relocating displaced bones back into proper position in relation to adjacent vertebrae to create spinal symmetry, thus promoting overall health. Now we realize through research that the spine is consistently asymmetric from person to person in regards to its bony configuration. It is argued that some of this could be developmental, however the more likely scenario is that genetics play the more significant role. Chiropractic’s effects actually are the response of the surrounding soft tissues to mechanical deformation. The bones really are just good places to contact with our hands in order to deliver a quick impulse into your tissues.
I think I have a pinched nerve in my back which is the cause of my pain? It was also traditionally thought in chiropractic that vertebral body displacement or subluxation could displace the spine enough to put pressure on peripheral nerves. We now know this is not the case with the exception of certain pathological conditions such as disc herniations, vertebral body bone spurs, central canal or IVF narrowing (all usually from degenerative changes), and ligament calcification as seen with certain inflammatory spinal conditions. Statistically speaking these conditions are by far less frequent than the most common source of spinal pain, which non-specific in nature.
So you don’t know exactly what the cause of my back pain is? The trouble with spinal pain is that clinicians of all types have great difficulty establishing the underlying cause. Only about 15% of patients receive a definitive diagnosis, even with advanced imaging, which is often unnecessary. Often times it is impossible to reach that diagnosis clinically and most people get better anyways with the current treatments. The goal Chiro Strong STL is to assist in the pain control of our patient’s through manipulation and other modalities while we utilize our rehabilitation expertise to promote better overall movement for our patients.
So I have heard that a chiropractor manipulating my neck will cause a stroke? This is a very serious topic which must be discussed at length. The public and medical community at large have been largely uninformed in regards to this relationship. Chiropractor’s are at fault as well for taking a defensive approach instead of educating the public at large. We dedicated an entire page to this discussion and you can find that here.
Now you have some background, lets talk about what spinal manipulative therapy consists of
Manipulative therapy involves the skillful use of passive movement designed to maintain or restore pain-free movement of the musculoskeletal system and decrease disability. Manipulation involves a high velocity thrust of small amplitude performed at the limit of available movement.
Spinal manipulation is similar to stretching your joints with a few exceptions. The big difference between mobilization (stretching) and manipulation (quick thrust maneuver) is that manipulation delivers a quick dynamic thrust which atypically activates group III proprioceptors which also evokes a high-frequency discharge in both muscle spindles and GTO afferents at local and distal locations. Passive movements as employed with stretching do not usually evoke such simultaneous responses from these 2 proprioceptor types. This is important for a couple reasons, spinal manipulation provides more proprioceptive input to inhibit pain and also high velocity thrust stimulates a type of receptor called the pacinian corpuscle. This particular nerve ending has been shown to temporarily deliver and inhibitory impulse to the conjoining muscle spindles allowing muscles to relax and reduce overall tension.
Lets see what the some recent literature says about manipulative therapies:
Pain threshold and tolerance levels increase after spinal manipulation. In addition, spinal manipulation both increases the excitability of motor pathways in the spinal cord and depresses the inflow of sensory information from muscle spindles.
Spinal manipulation increases the synovial space of the lumbar facet joints by up to 0.7 mm. The increased space lasts beyond the duration of the manipulation itself and the neurologic responses to manipulation are thought to be responsible largely for its effects.
There is evidence in favor of central facilitation (increased intensity and frequency) of pain from stimulation of spinal structures and that manipulation of the spine changes cutaneous (skin) and muscular pain thresholds, and also releases endorphins (your bodies natural pain medication).
Multiple studies have demonstrated manipulation of the spine in conjunction with prescriptive rehabilitation to be superior to medication, surgery, and manipulation or rehabilitation alone.
Patients that were given spinal manipulations during the study follow-up period showed more improvement in pain and disability scores at the 10-month evaluation. In the non maintained spinal manipulation group, however, the mean pain and disability scores returned back near to their pretreatment level.
77% of patients with neck pain exhibited an abnormally located instantaneous center of rotation at least at one level in their neck. (p<0.001).
Manipulative therapy for the shoulder girdle in addition to usual medical care accelerates recovery of shoulder symptoms.
To date, the place that manipulative therapy fills in the healthcare system according to the literature is the detection and maintenance of abnormal spinal coupled motion that is assessed through functional movement and motion palpation. As a therapeutic tool to inhibit pain while patients learn to rehabilitate their nervous and musculoskeletal system through active therapy. Sometimes patients need additional therapies outside our clinic or are not candidates for manipulation. In order to best serve patients interests, we accept that as fact and properly co-manage when indicated. Integrative medicine is all about getting the right patient, to the right doctor, at the right time, and that is our goal at Chiro Strong STL.
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2. Lynton G. F. Giles, DC, PhD,*† and Reinhold Muller, PhD. Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation. SPINE Volume 28, Number 14, pp 1490–1503 ©2003
3. Wolfgang J. von Heymann, Dr. Med,* Patrick Schloemer, Dipl. Math,† Juergen Timm, Dr. RER, NAT, PhD,† and Bernd Muehlbauer, Dr. Med*. 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 Volume 38, Number 7, pp 540–548 ©2013
4. Paul S. Sung, PT, DHSc, PhD,*† Yu-Ming Kang, PhD,* and Joel G. Pickar, DC, PhD*†. Effect of Spinal Manipulation Duration on Low Threshold Mechanoreceptors in Lumbar Paraspinal Muscles: A Preliminary Report. SPINE Volume 30, Number 1, pp 115–122 ©2004
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6. BY CHAOYANG CHEN, MD, YING LU, PHD, SRINIVASU KALLAKURI, MS, AJIT PATWARDHAN, MD, AND JOHN M. CAVANAUGH, MD, Distribution of A-δ and C-Fiber Receptors in the Cervical Facet Joint Capsule and Their Response to Stretch. COPYRIGHT © 2006 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED
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8. Gert J.D. Bergman, MSc; Jan C. Winters, PhD, MD; Klaas H. Groenier, MSc; Jan J.M. Pool; Betty Meyboom-de Jong, PhD, MD; Klaas Postema, PhD, MD; and Geert J.M.G. van der Heijden, PhD. Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain: A randomized controlled trial. 21 September 2004 Annals of Internal Medicine Volume 141 • Number 64
9. JOHN M. CAVANAUGH, MD, YING LU, MS, CHAOYANG CHEN, MD, AND SRINIVASU KALLAKURI, MS. Pain Generation in Lumbar and Cervical Facet Joints. The Journal of Bone and Joint surgery, 2006