An interview with Arthur Croft, D.C.

Dr. Croft is the Founding Director of the Spine Research Institute of San Diego. He has been actively engaged in whiplash research for the past twenty-five years and has co-authored a best-selling textbook on whiplash (Whiplash Injuries: the Cervical Acceleration/Deceleration Syndrome, 3rd edition, 2002) and temporomandibular joint disorders (Whiplash and Temporomandibular Disorders: an Interdisciplinary Approach to Case Management), along with several other books, textbook chapters, and over 320 professional papers. He was the original developer of the now widely used whiplash (WAD) grading system, as well as the widely adopted treatment guidelines. Dr. Croft wrote and produced the Emmy-nominated video Whiplash, and the most recent human subjects crash test DVD’s, Machine vs. Man I and II and is the only chiropractic physician to conduct ongoing, full scale human volunteer crash testing.

Dr. Croft is a biomechanist, a trauma epidemiologist, and chiropractic orthopaedist and lectures extensively in the United States and abroad. He serves on the editorial boards of several professional peer-reviewed chiropractic, medical, and engineering journals, including Spine, Archives of Physical Medicine and Rehabilitation, SAE, JMPT, DC Tracts, Journal of Musculoskeletal Pain, Chiropractic Technique, and is a senior editor of the Journal of Whiplash-Related Disorders. He has served as faculty of University of California, San Diego, Southern California University of Health Sciences, Western States Chiropractic College, and New York Chiropractic College. In addition to his own research, Dr. Croft has contributed to several research steering committees and has participated in RAND projects, including the cervical spine manipulation study, and has served as a grant reviewer for the Foundation for Chiropractic Education and Research and the National Institutes of Health. Dr. Croft is also a certified accident reconstructionist (NUTI). He currently serves as a panelist on the International Whiplash Task Force. Dr. Croft’s focus is public health and injury prevention and he is very close to receiving his PhD in epidemiology.

In an interview with The American Chiropractor (TAC), Dr. Croft shares some of the wisdom his studies have distilled.

TAC:   Dr. Croft, please tell our readers a bit about some of the things you have been able to discover regarding whiplash through research.

Croft:   Most of the discoveries concerning the whiplash phenomenon have come from the eight years of human subject crash testing we’ve done at the Spine Research Institute of San Diego. In many cases, our findings have been new and innovative and, in other cases, they have served to support or extend previous research or theory. We’ve found, for example, that occupant kinematics and biomechanics is much more complicated than previously thought and that smaller persons and larger persons have very different responses. [1] A small female will experience two to four times the head linear acceleration as a larger male in the same crash. The male, however, will experience greater rearward bending.

We’ve compared frontal and rear impact collisions under identical crash conditions. [2-3] We’ve tested the standard crash test dummy (HYBRID III) and the newer, biofidelic rear impact dummies (RID2 and BioRID II). In all cases, this was the first research to actually compare human and dummy responses on a validation platform under the same crash conditions. [8-9]

We’ve evaluated Saab’s antiwhiplash seat in a direct comparison to standard car seats. We’re the only group, to date, that has followed up with long-term surveillance of crash test volunteers using digital incliniometry, algometry, and multiple upright MRI with flexion and extension.

Unlike reports from some crash testing, we’ve documented injuries in about 30 percent of volunteers. We’ve also evaluated some standard accident reconstruction methodologies, such as the momentum/energy/restitution (MER) method and shown that it is not uniformly reliable. [6] We’ve evaluated event data recorders (EDR)—the car’s black box that records acceleration during a crash—and compared it to a gold standard data from highly sophisticated and calibrated accelerometers. Its accuracy turns out to be nonlinear, falling off at lower crash speeds. We’ve shown that 45 percent of all chronic cervical spine pain is likely the result of motor vehicle crash injury. [12] These are just some highlights of the many results and findings we’ve gained from crash testing. And then we’ve done some population-based studies [10-11] and clinical studies as well. [13]

TAC:   How do you feel the chiropractic profession is prepared to deal with CAD-type injuries?

Croft:   To be frank, most chiropractors don’t have much formal training in whiplash traumatology because the curriculum in our schools doesn’t include it. I recognized this in my first year of practice and, while filling in the gaps in my knowledge, the idea of the whiplash textbook came to life. The first edition came out in 1988 and Whiplash Injuries: the Cervical Acceleration/Deceleration Syndrome is now in its third edition. The educational shortfall, of course, has also led to my seminar series and we provide chiropractic students with a large discount. The problem seems to be that the schools are under pressure to satisfy CCE core requirements on the one hand, and maintain their competitive edge on the other. Adding optional curriculum only extends the duration of the program and makes the school less competitive with other schools. So it is unlikely that students will get more than a lecture or two on whiplash in the future. That’s about all I got at Los Angeles Chiropractic College.

The problems of Personal Injury today are more convoluted than they were in the past. Insurers have made it progressively more challenging for doctors and lawyers over the past two decades, and physicians and lawyers have generally followed one of two paths: either they continue to do the same old thing year after year until they seemed to be swamped at every turn, or they attempt to keep pace with the rapidly evolving strategies. The first group eventually has given up, while the second group is actually able to pick up the slack from the first group. I remember that, in the early 1980’s, we just sent in our bills and we got paid. We wrote narrative reports in cases where there were lawsuits and they seemed to be sufficient, even though—speaking, at least, for myself—I had no idea what I was doing and would probably be mortified to read those reports now.

The world is much more sophisticated today. Not only has an entire new literature developed, but the insurance industry has developed a number of very successful tactics to defeat claims made against them.

TAC:   Can you give us some examples of these new tactics?

Croft:   Chief among them is the MIST defense. This arose out of an Allstate program which was devised by a large consulting firm in the 1990’s. It stands for minor injury, soft tissue. It’s been so successful for Allstate that most major auto insurers have followed suit in one way or another. The chief tactics are to “delay, deny, and defend.”

The way it works is this: When a claim is made against the insurer and the property damage of the claimant’s vehicle is under $1000, the case is automatically “segmented” to the special investigative unit (SIU). This is the fraud investigative arm, so it is a serious issue and can later result in a complaint being filed with the state board of examiners and even trials in front of administrative law judges. The insurers consider this a “soft fraud,” meaning that it is not an outright insurance fraud, but a situation in which medical charges and claimed injuries are excessive or overstated. The end result, however, is that the insurer will use this as a pretext to deny billing.

SIU investigators may call the patient and request an interview. They will ask what the doctor did on various appointments. Usually, patients can rarely verbalize their office visit in detail and usually answer, “I don’t remember.” This will be interpreted to mean that nothing was done—more evidence of fraud.

If there is an attorney on the case, I would advise patients to refer these calls from investigators to the attorney. The most important take-home point from this is that we investigated the correlation between crash damage and three possible outcome parameters: (1) acute injury risk, (2) injury severity, and (3) long-term symptoms. In this meta-analysis of all medical and engineering literature going back to 1970, we found only four relevant studies and they did not support the notion that one could gauge any of these parameters from crash severity. [5] This paper is available as a free download (go to www.medscimonit.com and search under author for “croft”) and should be in the possession of every physician and attorney working within this arena, because it shows, once and for all, that this MIST segmentation policy is not scientifically or empirically based. Instead, it is an arbitrary, cost-saving device for the insurer which is deceptive and entirely bereft of an evidentiary foundation.

The reason it works so well is because low velocity crashes that produce minimal property damage do look trivial to most lay people who see only a photo of the car’s bumper, so the defense can effectively rely on the jurors’ intuition. We produced DVD’s of real crash test footage which more dramatically illustrate what happens in these MIST cases, but most jurors will never get to see these.

Ultimately, to be successful in PI today, DC’s need to have embraced the latest literature. They need to understand crash mechanics, occupant kinematics, and the numerous strategies applied in these cases. Otherwise, they—and their patients—will more likely fall prey to the more robust tactics employed by the defense.

But, let me be clear about one thing: In nearly every case, the defense case is almost entirely based on junk science, innuendo, reliance on faulty “common sense,” and outright deception. If you know how to deal with it, it dissolves like smoke in the wind.

TAC:   Do you have a particular stance with relation to videofluoroscopy?

Croft:   I have been an advocate of videofluoroscopy (VF) since the early 1980’s. It can provide information about the spine that cannot be obtained by other methods. In demonstrating certain types of pathology, therefore, it is unique as a modality.

Having said that, the scant amount of research to date is disappointing. My colleagues and I did some research years ago [4,7] but, as an orthopaedist, I felt that radiologists should be the ones to carry on with that kind of work. Oddly, though, radiologists, with some exceptions, have turned a blind eye to VF, and many appear to be outwardly hostile to it.

I think it is crucial that this profession develop a training and licensing infrastructure for VF. We should also develop a best practices guidelines with respect to indications for it, how it should be performed, and what it should cost. Currently, none of this infrastructure exists. It is also crucial that we invest in more research, beginning with the collection of normative data.

TAC:   What is it about CAD that has captured your imagination and led to the vast database of information that you have been able to accumulate?

Croft:   That’s simple. This is a huge public health problem today in all parts of the world. Every year, in the U.S., three million people are injured this way. Of these, about half will be left with permanent residua and half a million will become disabled to some degree. It has an annual comprehensive cost (i.e., the total cost including lost wages, medical, legal, etc.) of $43 billion, which is about what we spend on diabetes. But, unlike diabetes, whiplash injuries are largely preventable, without resorting to expensive lifelong interventions and dramatic lifestyle changes.

We are interested in ways to (1) prevent crashes, (2) improve crashworthiness to reduce injuries in collisions that are unavoidable, and (3) make treatment more efficacious. All of these are exciting vistas and all of them are being actively and aggressively researched right now. This is, in fact, one of the fastest growing areas of investigation in both medicine and engineering and I am involved in both fields, so “captured” is a very apt term. But I can certainly say that I love my work.

TAC:   Are you currently seeing patients?

Croft:   I see patients in consultation. In some cases, I simply review records and render reports. I do a lot of international work in this manner. In other cases, patients come to California to see me for an examination. They come mostly from the U.S.

I serve as an expert in cases large and small. I think my input is unique, because I can provide an opinion not only as a physician, but also as an epidemiologist, crash test researcher, and biomechanist. Wearing all of these hats means I can provide a sort of polymath opinion for the price of a single expert, while simultaneously obviating the problems of internal disagreement among multiple experts!

TAC:   What is the most common problem you see among chiropractors today?

Croft:   A lack of cohesion and a failure to understand that the old “separate but equal” philosophy is no longer viable. Most chiropractors don’t seem to recognize that we won’t be able to legislatively insulate ourselves from extinction. Many have been falsely buoyed by the Wilke’s case. This merely changed the game plan of chiropractic’s enemies. The erosion of our influence and scope is evident in many states, including California. With a stroke of his pen, long-time chiropractic friend and now Governor Arnold Schwarzenegger sharply limited our place in the workers’ compensation system.

The healthcare world now demands verification and validation. We have not been very responsive in that context. Nor have we been effective in policing our own ranks. Meanwhile, PT’s have been more active in research and now have doctorate (DPT) level programs. They will be looking to have autonomy and to practice manipulation and, if the insurers see them as being more tractable than DC’s have been, watch for a change in reimbursement practices that will favor DPT’s. And the profession won’t be able to sue its way out.

We are also seeing changes in the use of non-physicians—a change also driven by insurers’ profit goals. In many cases now, when patients have surgery, the assistant surgeon is a physician’s assistant (PA) rather than a surgeon. Will there be a corollary in chiropractic?

TAC:   What is the biggest problem or challenge you see in the chiropractic profession today?

Croft:   The biggest challenge is to face the research/validation/cohesion problem mentioned earlier. If the members of this profession would donate just $100 per year to a research fund, we could really accomplish something big. Little science shops like mine have always—with some exceptions—been self-funded. We simply don’t have the budget for really big projects. But that’s what the profession desperately needs.

TAC:   Do you have any recommended marketing strategies that chiropractors can do to attract new patients and/or to keep current patients?

Croft:   Yes. We developed a program called Auto Safety Facts that is designed to provide physicians with the tools to go out to their communities and educate the public in critically important safety issues like head restraint geometry, seat belts, airbags, child protection systems, etc. It is not about chiropractic — it is about safety. Of course, it is also useful in the clinic. Our doctors have had surprisingly good success with it. And, best of all, they are probably actually saving lives and preventing serious injuries in the process. This is the kind of positive PR the profession really needs.

You may contact Dr. Croft at drcroft@san.rr.com, www.srisd.com or by calling the Spine Research Institute of San Diego at 1-619-423-9867.

REFERENCES:

1.   Croft A, Freeman M. The Neck Injury Criterion (NIC): future considerations. 44th Annual Proceedings of the Association for the Advancement of Automotive Medicine. Chicago, IL, 2000:519-21.

2.   Croft A, Haneline M, Freeman M. Differential Occupant Kinematics and Forces Between Frontal and Rear Automobile Impacts at Low Speed: Evidence for a Differential Injury Risk. International Research Council on the Biomechanics of Impact (IRCOBI), International Conference, Munich, German, September 18-20 2002:365-6.

3.   Croft A, Haneline M, Freeman M. Low speed frontal crashes and low speed rear crashes: is there a differential risk for injury? . 46th Annual Proceedings of the Association for the Advancement of Automotive Medicine. Tempe, AZ., 2002:79-91.

4.   Croft A, Young D. Videofluoroscopy: a sampling of chiropractic radiologist’s opinions.
Topics Diagn Radiology Adv Imag 1994;2:4-10.

5.   Croft AC, Freeman MD. Correlating crash severity with injury risk, injury severity, and long-term symptoms in low velocity motor vehicle collisions.
Med Sci Monit 2005;11:RA316-21.

6.   Croft AC, Haneline MT, Freeman MD. Automobile crash reconstruction in low speed rear impact crashes utilizing a momentum, energy, and restitution (MER) method. International Congress on Whiplash-Associated Disorders. Berne, Switzerland, 2001:28.

7.   Croft AC, Krage JS, Pate D, et al. Videofluoroscopy of cervical spine trauma-an interinterpreter reliability study.
J Manip Physio Ther 1994;17:20-4.

8.   Croft AC, Philippens MMGM. The RID2 biofidelic rear impact dummy: A pilot study using human subjects in low speed rear impact full scale crash tests.
Accid Anal Prev 2007;39:340-6.

9.   Croft AC, Philippens MMGM. The RID2 biofidelic rear impact dummy: a validation study using human subject in low speed rear impact full scale crash tests. Neck injury criteria (NIC). 2006 SAE World Congress. Detroit, MI: SAE, 2006.

10.   Freeman M, Croft A, Centeno C. Fatal head injury cases in a rural Oregon county. . Proceedings of the 19th World Congress of the International Traffic Medicine Association. Budapest, Hungary, 2003.

11.   Freeman MD, Croft AC, Nicodemus CN, et al. Significant spinal injury resulting from low-level accelerations: a case series of roller coaster injuries.
Arch Phys Med Rehabil 2005;86:2126-30.

12.   Freeman MD, Croft AC, Rossignol AM, et al. Chronic neck pain and whiplash: a case-control study of the relationship between acute whiplash injuries and chronic neck pain.
Pain Res Manag 2006;11:79-83.

September 2010 Vol. 24 No. 5

Editor: David Chapman-Smith LL.B. (Hons.)

“In my experience, cervical migraine is the type of headache most frequently seen in general practice and also the type most frequently misinterpreted. It is usually erroneously diagnosed as classical migraine, tension headache, vascular headache. . . . Such patients have usually received an inadequate treatment and have often become neurotic and drug-dependent”.

Frykholm, neurosurgeon, Sweden (1972) [1]

“Manipulation is effective in patients with cervicogenic headache”.

Duke University Evidence-Based Practice Center, USA (2001) [2]

A. Introduction

Headache is one of the most frequent reasons people seek medical advice and is the primary complaint of about 10% of chiropractic patients [3,4]. Headaches may have a ‘sinister’ cause, such as accidental injury, a space-occupying lesion in the brain or other disease process. In that case they are secondary headaches. However the great majority of headaches are ‘benign’, not linked to any specific injury or disease, and are known as primary headaches.

Benign does not mean mild – symptoms may be frequent and severe. The three most common types of primary headaches are migraine, tension-type headache (TT H) and cervicogenic headache (CGH) [5]. Back in the 1960s the various categories of primary headache were thought to be distinct. That thinking still influences much clinical practice and public perception. However by 1988, when the International Headache Society (IHS) published a new classification of headaches [6] it was known:

• The diagnosis and classification of primary headaches were extremely confusing and difficult areas. A headache may have various causes – genetic, neurological, biomechanical, vascular, physiological, environmental (e.g. certain foods and drink). New findings were casting doubt on the peripheral nervous system as the main source of pain. The “most fundamental problem”, noted the IHS, was that there was “a complete absence of laboratory tests which can be used as diagnostic criteria for any of the primary headache forms”.

• There was a continuum between what had been thought to be separate types of headache – migraine could convert to chronic TT H, episodic TT H could
  convert to chronic headache.

• Movement abnormalities or dysfunctions in the cervical spine were a significant contributing factor to primary headaches. Where patients met the diagnostic criteria for migraine or TT H they might also have cervicogenic headache (CGH – headache born in the cervical spine).

Figure 1 gives the IHS criteria for CGH.

The 1972 quote from Frykholm that opens this article speaks to this diagnostic confusion and unfortunately remains valid in general practice today. [2]. While there is still much to learn there has been a wealth of new research since the early 1990s. With respect to CGH:

(a) Anatomical Basis. In 1995 Hack et al., dental researchers at the University of Maryland in Baltimore, presented new evidence of bridges of connective
tissue between the posterior muscles and the pain-sensitive dura (myodural bridges) in the upper cervical spine that gave a much stronger anatomical basis for CGH [7]. See Figure 2 for details. These and other connective tissue and ligamentous bridges were confirmed by subsequent studies and surgeries.

(b) Definition. CGH, rather narrowly defined by the IHS as in Figure 1, received a wider definition from the North American Cervicogenic Headache Society (NAC HS), a multidisciplinary society promoting the study of CGH:

“Referred pain perceived in any region of the head caused by a primary noceceptive source in the musculoskeletal tissues innervated by cervical nerves”.

(c) Research. A systematic review from the respected Duke University Evidence-Based Practice Center in 2001 summarized the research evidence to that time concerning the safety and effectiveness of various physical and behavioral treatments for CGH and TT H. It found that, even on the narrow definition given by the IHS, CGH was one of the most common forms of headache, similar in prevalence to migraine, and that the one physical or behavioral treatment with proven effectiveness was manipulation. Manipulation had two distinct advantages over use of medication – first it targeted the source of pain rather than control of symptoms, and second it was safe with fewer side effects. With respect to TT H, the effectiveness of manipulation was “less clear” because there were only three randomized controlled trials (RCTs), none with a placebo or non-treatment group.

However the trials suggested effectiveness. The largest, by Boline et al. in the US, reported that chiropractic manipulation was superior to amitriptyline in terms of reduced headache frequency and severity [8]. How can manipulation be effective for patients with TT H? That question highlights
the diagnostic and classification difficulties. Some patients diagnosed as having TT H, because they do not fall within the IHS definition of CGH
– perhaps because they have no neck pain or headache provoked by neck movements, nonetheless have spinal joint dysfunctions – also known as subluxation in chiropractic practice.

When these mechanical restrictions are corrected with manipulation, associated muscle tension is resolved. In 2002, the year following the Duke University review, Spine published the first physiotherapy trial of manipulative therapy for patients with CGH. This also reported effectiveness.

Read the complete FULL TEXT Article

This is really a moot conversation, because when they updated the ICD-9 codes last year, they did not bother creating any listing(s) for cervicogenic headache.

There are many more like this at the:
Headache and Chiropractic Page

References:

1 Frykholm R. (1972) Cervical Migraine: The Clinical Picture. In: Hirsch C, Zotterman Y, eds. Cervical Pain. Oxford England: Pergammon Press,
13-16.

2 McCrory DC , Penzien DB et al. (2001)
Evidence report: Behavioral and Physical Treatments for Tension-Type and Cervicogenic Headache
Des Moines, Iowa, Foundation for Chiropractic Education and Research.

3 Kelner M, Hall O, Coulter I (1980) Chiropractors, Do They Help. Fitzhenry and Whiteside, Toronto (Canada).

4 Straton RG, Sweeney J, Grandage J (1990). Review of the Relationship of Chiropractic Services to the Public Health System in Western Australia.
Health Department of Western Australia, Perth, Australia.

5 Nilsson-Grunnet N (2002) Epidemiology of Headache. Eur J Chiropr (49):33-5.

6 Classification and Diagnostic Criteria for Headache Disorder, Cranial Neuralgias and Facial Pain. (1988) IHS Classification Committee, Cephalalgia
8 Suppl 7:1-93.

7 Hack GD, Koritzer RT et al. (1995)
Anatomic Relation Between the Rectus Capitis Posterior Minor Muscle and the Dura Mater.
Spine 20(23):2482-2486.

8 Boline P, Kassak K, Bronfort G, Nelson C, Anderson A (1995)
Spinal Manipulation vs Amitriptyline for the Treatment of Chronic Tension-Type Headaches.
J Manipulative Physiol Ther 1995 (Mar); 18 (3): 148–154.

9 Jull G, Trott P et al. (2002)
A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache.
SPINE (Phila Pa 1976) 2002 (Sep 1); 27 (17): 1835—1843.

10 Sjaastad O, Fredriksson TA (2000) Cervicogenic Headache; Criteria, Classificatin and Epidemiology
Clin Exp Rheumatol 18(Suppl 19):S3-6.

11 Haas M, Spegman A et al. (2010)
Dose Response and Efficacy of Spinal Manipulation for Chronic Cervicogenic Headache: A Pilot Randomized Controlled Trial
Spine J. 2010 (Feb); 10 (2): 117–128

12 Astin JA (1998) Why Patients Use Alternative Medicine: Results of a National Study.
JAMA 279:1548-53.

13 Eisenberg DM, David RB et al. (1998)
Trends in Alternative Medicine Use in the United States, from 1990 to 1997: Results of a Follow-up National Survey
JAMA 1998 (Nov 11); 280 (18): 1569–1575

14 Peterson DH, Bergmann TF (2002) Chiropractic Technique: Principles and Practice. 2nd ed St. Louis, MO: Mosby.

15 Weingarten S, Kleinman M, Elperin L, Larson E (1992) The Effectiveness of Cerebral Imaging in the Diagnosis of Chronic Headaches.
Arch Intern Med 152:2457-2462.

By Malik Slosberg, DC, MS

For many years, chiropractors have observed in their own practices that their patients sometimes demonstrate improvements of complaints related to immune problems: the disappearance or lessening of allergy symptoms, quicker recovery from or less frequent and severe colds and other respiratory infections, and so on.

In the scientific literature, there have been occasional case reports that corroborate such findings, but no sound evidence to really document their veracity. These clinical observations remain suspended in that grey area unsubstantiated by scientific data to confirm their validity. Significant limitations of changes attributed to spinal manipulation in individual patients include
1) there is never a control group;
2) there is no blinding;
3) the improvement may simply be due to time;
4) they may be a nonspecific effect of care and attention;
5) it may be a regression to the mean; or
6) the result may be due to something other than spinal manipulation.

In some large studies, it has been found that chiropractic care for nonmusculoskeletal conditions is only weakly to moderately successful, but rarely harmful. [1-2] The most recent and thorough systematic literature review found that the evidence for effectiveness of spinal manipulation was inconclusive for nonmusculoskeletal conditions. [3]

Despite the lack of evidence of clinical effectiveness for nonmusculoskeletal conditions, a series of recent studies from several international research groups is systematically building the case that spinal manipulation appears to reduce the production of pro-inflammatory cytokines and increase the blood levels of immunoregulatory cytokines. Cytokines are small cell-signaling protein molecules that are secreted by numerous cells of the immune system and are a category of signaling molecules used extensively in intercellular communication.

The accumulation of data from these studies suggests that a possible benefit of spinal manipulation is related to neuroimmunological effects. Of course, this is an exciting proposition for clinicians who have seen such changes in their own patients. Let’s review some of the research exploring the connections between spinal manipulation and functional changes in the immune system.

Early Research on Manipulation and the Immune System

Research in the 1990s laid the groundwork for the more recent papers published in the past five years. Brennan, et al., [4] published a paper demonstrating that upper thoracic spinal manipulation resulted in markers indicating significant increased phagocytic activity of neutrophils and monocytes compared to a sham manipulation or soft-tissue treatment. The findings suggest that a certain force threshold was needed to elicit the response.

In a second study, Brennan, et al., [5] concluded that their data suggests spinal manipulation, which generates a force over a certain threshold, elicits viscerosomatic responses that affect both neutrophils and mononuclear cells phagocytic activity, at least over the short term. And in a very small 1994 study, [6] the study authors concluded that upper cervical adjustments increased CD4 “helper” T-cell counts, which initiate the body’s response to viruses in HIV-positive subjects, by 48 percent over the six-month duration of the study.

Neural immunoregulation: Communication Between the Immune and Nervous Systems

These earlier papers have now been followed-up by a series of recent studies within the past five years. Teodorczyk-Injeyan, et al., [7] described the interplay between the nervous system and immune system as neural immunoregulation. The authors note that immune homeostasis is based on the reciprocal communication between the immune and the nervous systems executed by the actions of cytokines and neurotransmitters. In addition, the paper explains the close association of autonomic nerve terminals with macrophages and lymphocytes, which facilitates a chemically mediated transmission between nerves and immune cells.

This research group has published a series of papers that explores the relationship of spinal manipulation, spinoautonomic reflexes and their influence on activity of cells involved in immune and/or inflammatory responses. These interconnections may have great clinical relevance because studies [8] on the pathophysiology of discogenic low back pain, sciatica, and ligamentous tissue damage-related pain [9] reveal that the production of pro-inflammatory mediators, such as tumor necrosis factor alpha (TNF-a) and interleukin-1 beta (IL-1ß), are major factors in the genesis of pain and functional changes in neural activity. Furthermore, studies of the hypoalgesic effects of spinal manipulation have already been reported in the literature, suggesting that an anti-inflammatory mechanism might be activated by spinal manipulation. [10-11] Recent clinical studies have shown that chemical blockage of TNF-a is highly effective in reducing sciatic pain. [12]

Reduced Pro-Inflammatory Cytokines After Spinal Manipulation

In the first of their studies, the authors report that a single bilateral hypothenar upper-thoracic HVLA thrust resulted in the reduction of in vitro inflammatory cytokines, TNF-a and IL-1ß in blood samples activated with lipopolysaccharide taken before, 20 minutes and two hours after spinal manipulation. TNF-a and IL-1ß significantly declined in asymptomatic subjects assigned to manipulation with cavitation/audible, whereas in the sham and control groups, TNF-a and IL-1ß levels increased significantly after exposure to lipopolysaccharide.

The paper’s conclusion states that manipulation-related down-regulation of inflammatory-type responses occurred via an unknown central mechanism. These findings suggest that a single thoracic manipulation effectively ameliorates the physiological responses of blood cells to an inflammatory stimulus and that spinovisceral reflex effects may alter the functional activity of cells in the immune and/or inflammatory systems. Based on these findings, the paper notes that spinal manipulation is likely to present a noninvasive and efficacious alternative to drug therapies for reducing inflammation and resultant pain.

A 2009 paper from the Hungarian National Institute for Rheumatology and Physiotherapy [13] reported a dramatic and significant reduction in both debilitating cervicogenic headaches (before treatment 3-6 times a week lasting a total of 31-36 hours a week), neck stiffness and TNF-a after manual therapy in two women who suffered post-whiplash, MRI-documented C4-5 disc herniation.

Previous trials of conservative care (analgesic infusions, physical therapy) had failed. Both patients, after a neurological consult, were recommended to have a discectomy, but both opted for a trial of manual therapy (two times a week for 4-8 weeks) first. After manual therapy, surgery was unnecessary because both women became headache-free with a normal range of cervical motion. In addition, both patients experienced a dramatic reduction in TNF-a (reduced by more than half). [13]

The medical researchers conclude that pro-inflammatory substances secreted by the nucleus pulposus are likely involved in symp-tomatic disc herniation. In addition, TNF-a, interleukin-1ß and interleukin-10 may be involved in the pathogenesis of migraine at-tacks. After restoring spinal segmental motion and reducing pathologic mechanical irritation/compression, TNF-a levels were mark-edly reduced and symptoms were eliminated. In 2010, Roy, [14] et al., followed up these two studies by evaluating pre- and post-intervention measures from blood samples detecting pro-inflammatory cytokines interleukin 6 (IL-6) and C-reactive protein (CRP) after a series of nine chiropractic manipulations from T12-L5 using the an adjusting instrument and related protocol in 10 chronic low back pain patients and 10 healthy subjects. Once again, the introduction notes that low back pain is often associated with an inflammatory process and increased production of several pro-inflammatory cytokines including IL-6 and CRP. IL-6 is the main mediator of the acute phase of pro-inflammatory cytokines and results in a marked increase in liver cell synthesis of CRP.

This trial found that a series of nine thoracic manipulations resulted in a reduction of both IL-6 and CRP; that is, a normalization response. Both IL-6 and CRP levels were reduced toward the values in the healthy subjects. IL-6 and CRP were elevated in chronic LBP patients pre-intervention, but post-intervention differences were smaller, suggesting that nine manipulations are capable of attenuating the inflammatory response. The authors opine that it is plausible the inflammatory process was being reversed in those who received the adjustments.

Immunoregulation, Interleukin 2 and Spinal Manipulation

Another related avenue of research on neural immunoregulation evaluates the effects of spinal manipulation on the production of interleukin 2 (IL-2) – an immunoregulatory (not pro-inflammatory) cytokine and signaling molecule, instrumental in the body’s response to microbial infection and for the body’s ability to discriminate between foreign (non-self) and self. IL-2 is a pivotal cytokine in T-cell-dependent immune responses and plays a major role in the development, maintenance and survival of regulatory T cells. Thus, it is of critical importance in induction and sustenance of immune tolerance.

Seventy-six asymptomatic subjects [15] were randomized to receive an upper thoracic manipulation with cavitation or without cavitation, or were included in a control group. All subjects had their blood drawn before, 20 minutes and two hours after the intervention. Production of IL-2 in mononuclear cell cultures was activated with staphylococcal protein A (SPA). Induced secretion of IL-2 increased significantly in manipulation with and without cavitation. The paper concludes that in vitro T lymphocyte response to a SPA stimulus became enhanced after spinal manipulation. Therefore, this effect may be independent of joint cavitation/audible. This finding suggests manipulation may influence IL-2 immune-regulated biological responses.

In 2010, Teodorczyk-Injeyan, et al., [16] continued with this research on induction and regulation of immune responses related to interactions between the immune and nervous systems mediated by actions of neurotransmitters and immunoregulatory cytokines. To this end, the researchers followed the subjects from the previous study to determine if the increased production of interleukin-2 as a result of a single thoracic manipulation is associated with increased antibody synthesis from monocytes.

The paper reports that there were indeed significantly increased synthesis of immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies induced in cultures of peripheral blood mononuclear cells in subjects who received thoracic manipulation, particularly in those who had an associated cavitation. The paper concludes that antibody synthesis (IgG and IgM) induced by interleukin-2 can be, at least temporarily, increased after manipulation. This is additional direct evidence that thoracic manipulation may influence interleukin-2 immune-regulated biological responses.

The Take-Home Message

The studies described above demonstrate an accumulation of evidence that indicates spinal manipulation may influence the immune system’s response to various stimuli. Three of the studies suggest that manipulation consistently reduced the production of pro-inflammatory mediators associated with tissue damage and pain from articular structures. Two studies provide evidence that manipulation consistently reduced the production of pro-inflammatory mediators associated with tissue damage and pain from articular structures. Two studies provide evidence that manipulation may induce and enhance production of the immunoregulatory cytokine IL-2 and the production of immunoglobulins as well.

We must acknowledge that these results are preliminary because most are performed on asymptomatic subjects and the duration of the effects so far have only been demonstrated to be short-lived. Nevertheless, this research opens the door to further exploration of the possible neuroimmunoregulatory effects of spinal manipulation and confirms what many of us have observed in practice: Adjustments reduce pain and inflammation, and may improve immunoregulatory function.

References

1.   Leboeuf-Yde C, et al. Self-reported nonmusculoskeletal responses to chiropractic intervention: a multination survey.
JMPT, 2005;28(5):294-302.

2.   Leboeuf-Yde C, et al. The types and frequencies of improved nonmusculoskeletal symptoms reported after chiropractic SMT.
JMPT, 1999;22(9):559-64.

3.   Bronfort G, Haas M, Evans R, Leiniger B, Triano J. Effectiveness of manual therapies: the UK evidence report.
Chiropr Osteopat, 2010;18:3.

4.   Brennan PC, et al. Enhanced Phagocytic Cell Respiratory Burst Induced by Spinal Manipulation: Potential Role of Substance P
J Manipulative Physiol Ther 1991 (Sep); 14 (7): 399–408.

5.   Brennan PC, et al. Enhanced Neutrophil Respiratory Burst as a Biological Marker for Manipulation Forces: Duration of the Effect and Association with Substance P and Tumor Necrosis Factor
J Manipulative Physiol Ther 1992 (Feb); 15 (2): 83–89

6.   Selano JL. The Effects of Specific Upper Cervical Adjustments on the CD4 Counts of HIV Positive Patients
Chiro Res J 1994; 3 (1): 32–39

7.   Teodorczyk-Injeyan JA, et al. Spinal Manipulative Therapy Reduces Inflammatory Cytokines but Not Substance P Production in Normal Subjects
J Manipulative Physiol Ther 2006 (Jan); 29 (1): 14–21

8.   Fiorentino PM, Tallents RH, Miller J-nH. Spinal interleukin-1B in a mouse model of arthritis and joint pain.
Arthritis Rheum, 2008;58:3100-9.

9.   King K, Davidson B, Zhou BE, Lu Y, Solomonow M. High magnitude cyclic load triggers inflammatory response in lumbar ligaments.
Clin Biomech, 2009;25:792-98.

10.   Terrett Ac VH. Manipulation and pain tolerance.
Am J Phy Med, 1984;63:217-25.

11.   Giles LG, Muller R. Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation
Spine 2003 (Jul 15); 28 (14): 1490–1502

12.   Mohammadian P, Gonsalves A, Tsai C, Hummel T, Carpenter T. Areas of capsaicin-induced secondary hyperalgesia and allodynia are reduced by a single chiropractic adjustment: a preliminary study.
J Manipulative Physiol Ther. 2004 (Jul); 27 (6): 381-7

13.   Omos G, MD, et al. Reduction in high blood TNF-a levels after manipulative therapy in 2 cervicogenic headache patients.
J Manipulative Physiol Ther. 2009 (Sep); 32 (7): 586-91

14.   Roy RA, Boucher JP, Comtois AS. Inflammatory response following a short-term course of chiropractic treatment in subjects with and without chronic low back pain.
Journal of Chiropractic Medicine, 2010 (Sep);9 (3): 107-114.

15.   Teodorczyk-Injeyan JA, Injeyan HS, McGregor M, et al. Enhancement of in vitro interleukin-2 production in normal subjects following a single spinal manipulative treatment. Chiropr Osteopat, 2008;16:5.

Based on: “A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain ”
Eur Spine J. 2011 (Jan); 20 (1): 40–50 ~ FULL TEXT

OK, maybe this isn’t a genuine Rap, and I’m not rhyming-Simon, but somebody needs to bust-a-cap on the pain-med industry, because they hold themselves to a much lower standard than they expect my profession to maintain.

Fortunately (and, to the rescue) comes this study from the Dutch Institute for Health Care Improvement. They actually busted the cap, by deciding to explore “the effectiveness of pharmacological interventions [i.e., non-steroid anti-inflammatory drugs (NSAIDs), muscle relaxants, antidepressants, and opioids] for non-specific chronic low-back pain (LBP)”.

I say Bravo, because these drugs are medicine’s sole conservative approach for managing LBP. This Blog has previously published numerous (and recent) studies suggesting that chiropractic management for low back pain is orders of magnitude more effective for pain relief, and is also significantly more cost-effective than standard medical management. [1-8]

Now this study comes along challenging the benefits and effectiveness of medicine’s reliance on drug treatments for pain management. The Iatrogenic Injury Page [9] clearly documents the dangers associated with these drugs (primarily death). This current study reviewed 17 randomized controlled trials for pain treatments: NSAIDs (n = 4), antidepressants (n = 5), and opioids (n = 8). No studies were found for muscle relaxants.

They concluded that NSAIDs and opioids “seem to lead to a somewhat higher relief in pain on the short term, as compared to placebo” (aka no treatment at all!), “in patients with non-specific chronic low back pain and that both types of medication show more adverse effects than placebo”. (What an elegant understatement that is!)

Review of the Iatrogenic Injury Page reveals that thousand die ever year from the use of NSAIDs for simple pain relief, and overdose deaths from prescribed opiates has doubled in the last 2 decades. [10] And yet we don’t see the headlines screaming about how this medicine is killing patients by the tens of thousands. Who is asleep at the wheel?
When will the madness stop???

The current healthcare debate has brought up basic questions about how medicine should work. On one hand we have the medical establishment with its enormous cadre of M.D.s, medical schools, big pharma, and incredibly expensive hospital care. On the other we have the semi-condoned field of alternative medicine that attracts millions of patients a year and embraces literally thousands of treatment modalities not taught in medical school.

One side, mainstream medicine, promotes the notion that it alone should be considered “real” medicine, but more and more this claim is being exposed as an officially sanctioned myth. When scientific minds turn to tackling the complex business of healing the sick, they simultaneously warn us that it’s dangerous and foolish to look at integrative medicine, complementary and alternative medicine, or God forbid, indigenous medicine for answers. Because these other modalities are enormously popular, mainstream medicine has made a few grudging concessions to the placebo effect, natural herbal remedies, and acupuncture over the years. But M.D.s are still taught that other approaches are risky and inferior to their own training; they insist, year after year, that all we need are science-based procedures and the huge spectrum of drugs upon which modern medicine depends. [11] And now, even that claim is eroding.

REFERENCES:

1. New LBP Study Reveals Chiropractic Is Superior to PT and MD Care
Chiro.Org Blog ~ 3-17-2011

2. Chiropractic Cost-Effectiveness
Chiro.Org Blog ~ 3-16-2011

3. Chiropractic Goes To The Hospital
Chiro.Org Blog ~ 3-06-2011

4. Chiropractic Treatment of Workers’ Compensation Claimants in the State of Texas
Chiro.Org Blog ~ 2-24-2011

5. New Study Confirms That Maintenance Care Delivers!
Chiro.Org Blog ~ 1-26-2011

6. Primary Care MDs Decline Training In Pain Management
Chiro.Org Blog ~ 1-20-2011

7. The Cost-Effectiveness of Chiropractic Page

8. Patient Satisfaction With Chiropractic Page

9. The Iatrogenic Injury Page

10. Painkiller Deaths Double in Ontario
Chiro.Org Blog ~ 12-08-2009