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sperle33
12-10-1998, 03:28 PM
I will ignore those comments that Dr. Swanepoel directed to Neil Tuttle
as I believe I have already dealt with those issues.

M Swanepoel wrote:
> Come on, all
> you chiropracters out there, does spinal manipulation:

In case your spell checker does not know, there are only two acceptable
forms of the name of the professional or profession: chiropractor and
chiropractic, respectively. Neither chiropracter nor chiropractice are
appropriate.

> 1 Cure muscular inflammation?

No but I have a question for you. What condition that one typically has
present to our offices would you describe as muscular inflammation? I
am only aware of inflammation in a muscle as a typical patient
presentation as a *normal* sequella to a muscular strain or as part of
delayed onset muscle soreness (DOMS). Since inflammation is a normal
part of healing from a injury I am curious to know:

1. Why should one want to "cure" it?
2. What condition typically causes muscular inflammation and is a cause
for common patient presentations? And how does it manifest itself
mechanically?

> 2 Cure torn paraspinal musles?
> 3 Cure torn spinal ligaments?
> 4 Cure torn facet joint capsules?
> 5 Cure a tear in the annulus fibrosus and IV disk prolapse?
> 6 Remove osteophytes impinging on nerve roots?
> 7 Cure marginal fractures of the facet joints?
> 8 Cure vertebral endplate fractures?
> 9 Permanently cure intervertebral subluxation by arresting age-related fibrosis
> of the nucleus pulposus and the concomitant dehydration?
> 10 Cure congential malformations of the spine?
> 11 Cure facet joint osteoarthrosis and subsequent arthrodesis?
> 12 Cure metastases of malignant cancers?
> 13 Cure primary spinal cancers?
> 14 Permanently cure L5/S1 spondylolisthesis?
> 15 Cure bacterial spinal infections, such as tuberculous spines?
> 16 Cure HLA 27-related disorders, ankylosing spondylitis and
> scoliosis?
> 17 Cure spinal vascular restrictions?

To your remaining conditions I would submit to you that the chiropractic
profession has not claimed that we have significant impact on these in
many many years and in fact consider a few of these to be
contraindications to manipulation in general or to the effected motion
segment.

I would submit that manipulation may be effective in a total treatment
program for the following conditions.

> 2 Cure torn paraspinal musles?
> 3 Cure torn spinal ligaments?
> 4 Cure torn facet joint capsules?

The rationale is that loss of joint motion in supr and subjacent motion
segments should increase loads on the injured motion segments. Thereby
exacerbating the injury. As noted in my previous posting, a member of
this list Dr. Greg Kawchuk, has published preliminary evidence that
manipulation produces dramatic increases in segmental flexibility.(1)
This was done with a device that he has shown is both valid and
reliable.(2)

In a motion segment that has a restriction of its range of motion as a
result of injury, manipulation by restoring motion to that spinal
segment could accelerate healing of that motion segment. Support for
this concept is found in the literature that shows the benefits of
motion on the healing of ligaments.(3-5) (I know there are more
references but I am only using ones where I have read the actual paper.)

I am well aware that these are purely deductive theoretical concepts
that do need to be tested in an appropriate animal model. I would love
to produce the literature that supports this concept but the lack of
substantial government funding for chiropractic research in the past has
significantly retarded the growth of our science. The newly created
National Center for Complementary and Alternative Medicine we hope will
help accelerate that growth.

> 5 Cure a tear in the annulus fibrosus and IV disk prolapse?

There is literature to document that manipulation may be effective in
treating patients with the symptoms of and the imaging to document disk
herniation. Although the manipulation may not actually have any impact
on the disk prolapse.(6-28) Further it should be kept in mind that a
large percentage of people who demonstrate discal abnormalities on MRI
are asymptomatic.(29-33) As such, those annular tears or disk prolapses
may in reality be clinically insignificant incidental findings in
patients with symptoms from mechanical causes that are amenable to
chiropractic manipulation and not people who suffer with clinically
significant disk problems. Although within the population of patients
treated in the studies cited above there may actually be patients with
clinically significant disk problems.

> 11 Cure facet joint osteoarthrosis and subsequent arthrodesis?

Osteoarthrosis is an interesting case. One experimental animal model is
immobilization and since Kawchuk has found that manipulation improves
the flexibility of a motion segment it is conceivable that manipulation
might be an effective treatment for osteoarthosis and might then prevent
subsequent arthrodesis. Again this is a construct that awaits
validation. A documented case of arthrodesis secondary to
osteoarthrosis or any other cause is, of course, a contraindication to
manipulation of the effected motion segment.

> I beg chiropracters to answer these questions, to prove that their
> manipulations do not exacerbate matters in most, and to
> provide the supporting references.

There is no literature that I know of that shows that manipulation is
deleterious to joints. Watson (34-37) has suggested that cavitation
(cracking) of joints is harmful. Watson notes that the energy released
during joint cavitation is 0.07 mJ/mm3 and that threshold of energy
hyaline cartilage can before injury results is 1.0 mJ/mm3. Therefore
the energy involved in cavitation of a joint is below the threshold for
injury and thus should be safe. Watson hypothesizes that the damage to
the cartilage is due to the additive effects of repeated caviation.(35)
However, studies by Castellanos (38) and Swezey, (39) have found that
habitual knuckle crackers do not have a higher risk for joint
degeneration. The importance of this, in the current discussion is that
studies have shown that the noise generated by knuckle cracking and
spinal manipulation are similar, suggesting that these are similar
processes mechanically.(40, 41)

I have previously discussed the fact that the literature shows us that
catastrophic complications to manipulation are exceedingly rare. A
review and assessment can be found in Dabbs and Lauretti.(42)

> The only condition that I know of that may be "cured" by chiropractic
> manipulation, and this is unproven, is nipping of facet joint villi
> between the articulating surfaces.

I am interested in seeing a reference for this. For I was unaware that
this existed.

> Spinal traction provides temporary
> relief of compressive spinal conditions, and provides temporary
> stabilization of most spinal fractures - your local paramedics
> know and apply this from day to day.

Although many chiropractors use traction (I for one do not) but it is
not the core therapeutic method used by the profession. Manipulation is.

> It is a pointless waste of time to list all the papers which have examined
> spinal motion, although I have already sent lists of references to a
> few people who actually wished to see the scientific evidence.
> Having examined the facet joints, I believe (no, I am certain!) that
> vigorous rotational movements of vertebrae seriously damage the
> articular cartilage, which is usually soft and in a state of "bad
> repair" anyway. (Swanepoel MW, Adams LM, and Smeathers JE, Human
> lumbar apophyseal joint damage and intervertebral disc degeneration,
> Ann Rheum Dis, 1995, 54, 182-188).

What literature do you have to support the knowledge, of which you are
certain, that "vigorous rotational moments of vertebrae seriously damage
the articular cartilage.?" I do realize that Watson's literature
search which produced the absorbed energy injury threshold may be in
healthy cartilage and thus Dr. Swanepoel's assertion that manipulation
will injure cartilage that is already in "bad repair" may be correct.
But this requires evidence from appropriately constructed studies. I
hold you to the same high standard you would like to hold me to.
However, I do accept that this is as reasonable a theoretical construct
as those I have proposed. It should be tested. (See below)

Further, I would like to get a reprint of your paper but having access
at this time to just your abstract, I quote:

"The predominantly peripheral location of fibrillation of both superior
and inferior surfaces may be associated with inadequate mechanical
conditioning of marginal joint areas. Disc degeneration cannot be the
initial cause of apophyseal fibrillation in most specimens. The study
indicates a need for regular spinal exercise, starting at a young age."

Given your findings and those of Kawchuk it would appear that you should
be supporting the regular manipulation of joints to improve their
mobility and thus improve their "mechanical conditioning." Maybe a
decrease in segmental flexibility is the precipitating event for the
degeneration of the apophyseal joint.

You have proposed a study (below) I propose one too. In a small animal
model create a device that will reliably produce a loss of in a spinal
motion segment. Then see if this results in joint degeneration. If so,
then so prepare animals and then remove the devices after there is joint
degeneration. Have one group undergo manipulation, one group undergo
sham manipulation (control for the effect of touching) and one group
serve as controls. Then determine if there is a different effect on the
cartilage. This should tell us if the manipulation is beneficial to the
health of the cartilage (my belief) or detrimental (your belief). Do
you want to collaborate on this?

> The role of the lumbar
> facet joints is to prevent significant intervertebral rotation, and
> to act against this by applying vigorous rotational impulses from
> without the body, is folly. (I would support gentle twisting
> exercises with an extended spine, however, as a means of
> strengthening these joints and their cartilage.)

How would you define gentle? Triano (43) has measured the forces
generated by spinal manipulation in the lumbar spine. Peak forces of
495.5 N (142.5 95% CI) and peak moments 149.4 N (43.2 95% CI) applied
to the maxillary process were measured in vivo. In the cervical spine
peak forces of 99 to 140 N (mean 118 N) and in the thoracic spine 399 N
(sd=119 N) were measured by Herzog et al.(44) Gal et al (45) measured
mean peak force of 562N in the thoracic spine in an un-embalmed
post-rigor cadaver.

Concerning the fact that the lumbar facets function to restrict spinal
mobility, I understand that some patients present with segmental
instability and these subjects are probably not candidates for
manipulation of the effected joint. Again I submit they may be
candidates for manipulation of adjacent motion segments to decrease the
mechanical load on the unstable segment. However, in my clinical
experience most of the patients I have treated have a loss of range of
motion, both globally and segmentally. The segmental range of motion I
have assessed by motion palpation and by stress radiographs. Again, it
would appear that manipulation, that increases joint range of motion
would appear to be a reasonable treatment.

I have ignored the neurological discussion, this is the biomechanics
list.


> I suggest a controlled experiment is conducted in which about 200 patients
> suffering from non-specific (undiagnosed?) chronic back pain,
> (say one year after initial consultation),
> are divided into five groups. One group receives no treatment except
> bedrest, a second group is referred to orthopaedic consultants
> who apply placebo treatment, a third group is treated by qualified
> physiotherapists, a fourth group is treated by masseurs, and a fifth
> group is treated by chiropracters. As part of this study I suggest
> that the mental and pain states of each patient are assessed by psychiatrists
> before and after at least one treatment session, and that if possible some
> physiological measures of well-being are also measured - (pulse rates
> and blood pressures before and after treatment?)
>
> Further I suggest that the therapists are blind to the fact that they
> are participating in such a study. (Are those howls of protest I hear,
> carried by the wind?)

Ok this is a interesting idea. Of course you probably should start with
a literature search and read some of the hundreds of clinical studies
(of quite varied quality) that have already been conducted on
manipulation. (I can provide citations but shall not do so here.) One
suggestion is to take a look at the US Agency for Health Care Policy and
Research's Clinical Practice Guideline Number 14 AHCPR Publication No.
95-0642: December 1994: Acute Low Back Problems in Adults. You can read
this on-line by going to:

http://text.nlm.nih.gov/ftrs/pick?dbK=&ftrsK=37547&t=913352021&collect=ahcpr&advOpt=

and in the drop down menu entitled Clinical Practice Guidelines choose:
#14 Acute Low Back Problems in Adults (Clinic...

Finally, there is funding available for your study from the National
Center for Complimentary and Alternative Medicine of the National
Institutes of Health:
http://web.fie.com/htdoc/fed/nih/gen/any/proc/any/11069802.htm

Care to collaborate?

Finally, I present what I believe are some of the major areas in
biomechanics of manipulation that are drastically in need of research. I
know that this is not an exhaustive list. All we know regarding these
items is theory and we desprately need and want to replace theory with
good scientific evidence.

1. Biomechanical effects of manipulation on tissues and what tissues are
effected.
2. Effects of manipulation on IAR or HAR of spinal motion segments
3. Further research on the effects of manipulation on the mechanical
properties of the motion segment.
4. Biomechanical parameters of the manipulable lesion
5. Longevity of any mechanical effects (and physiological and
neurophysiological effects, for that matter).


References

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stiffness following spinal manipulation. In: International Conference on
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3. Almekinders LC, Baynes AJ, Bracey LW. An In Vitro Investigation Into
the Effects of Repetitive Motion and Nonsteroidal Antiinflammatory
Medication on Human Tendon Fibroblasts. Am J Sports Med
1995;23(1):119-23.
4. Almekinders LC, Banes AJ, Ballenger CA. Effects of Repetitive motion
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5. Reider B, Sathy M, Talkington J, Blyznak N, Kollias S. Treatment of
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--

__________________________________________________ ___________________
Stephen M. Perle, D.C. "A man who knows that
Assistant Professor of Clinical Sciences he is a fool is not
University of Bridgeport College of Chiropractic a great fool."
Bridgeport, CT 06601 Chuang Tzu
E-mail: perle@bridgeport.edu
http://www.bridgeport.edu/ubpage/chiro/
__________________________________________________ ___________________

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