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Science, Art, and Philosophy of Chiropractic


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Chronic Pain and the Brain

Written by: Brooke Preston-Chiropractic Intern at Zen Chiropractic Inc. DBA Zen Healing Center

Most of us are totally different people today than we were five years ago. Why is that? Today, we’re going to dive in and talk about a concept known as neuroplasticity.

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What is neuroplasticity?
Neuroplasticity is the idea that the brain and nervous system (neuro) can remodel(plasticity) itself to reflect the experiences we have in our daily lives(5). This means that our nervous system can learn, which is an important concept.
An example of neuroplasticity in our bodies would be our motor (voluntary muscle control and coordination) development. We definitely don’t have the same motor function as when we were babies. We’ve learned to roll over, crawl, sit, stand, walk, and even do more complex things such as type, play sports, write, and play musical instruments.

How does neuroplasticity work?
Think about a set of railroad tracks(5). You’re born with a specific set of railroad tracks. These railroad tracks get messages from Grand Central Station, which in this case refers to your brain. As you learn to do new things- whether they are physical or mental, you lay down new railroad tracks. Some of these tracks get used a lot- they’re heavily developed and polished.

Various-Railroad-Tracks-Many-Directions2-e1438628029405
Change happens through a process called long-term potentiation or LTP or long-term depression or LTD. LTP and LTD function similar to a dimmer switch. LTP is when you’re turning up the dimmer switch and LTD is when you’re turning down the dimmer switch. The lights are still on, but in one scenario more light is shining than the other.

light-bulb-and-dimmer-switch

What is Long-Term Potentiation (LTP)?
LTP is a pathway that is being stimulated or turned on. Think of it like positive feedback. The more you get, the more you want. So the more a railroad track is used, the more you want to use it and the easier it becomes to use. You polish it, and it becomes well traveled.

Structure of a typical chemical synapse. neurotransmitter release mechanisms
You have messengers in your body called neurons that help the brain and body communicate using chemical substances called neurotransmitters. The more a pathway is stimulated, the more neurotransmitter is produced. What does this mean? Think of it in this way: the more a railroad track is used, more cargo can be transported along its path.

If you’re more economically minded, a principle similar to this is the law of supply and demand. The more a consumer (your body) uses something (a pathway) then the more of that product (the neurotransmitter) needs to be produced.

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What is Long-Term Depression (LTD)?
LTD is the result of a pathway that isn’t being stimulated and is being muted or turned off. Think of it in the sense “if you don’t use it, you lose it”. The less a railroad track is used, the harder it becomes to access that pathway. It’s still available, but not as readily available. It’s like the rickety old mineshaft railway with old abandoned carts everywhere. It could be restored to its former glory, but it’s going to take a lot of work and practice. These tracks are harder to utilize.

Neuroplasticity and pain.. is it good or bad?

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In normal development, the nervous system uses pain as a warning sign. Think about it like using a smoke alarm. Just like that alarm, pain is telling us “Something is wrong, fix it!” This is known as eudynia or “good” pain. This system is used as security against threats like injury, infection, and tumor. In some people, though, this wiring somehow gets mixed up and a system that once worked to protect the body produces long-term effects. The pain tracks are getting an increasing amount of cargo and are being utilized more often. This is known as maldynia or “bad” pain.

What are examples of conditions that may be caused by maldynia?
Some examples of dysfunctional neuroplasticity include when our bodies rewire themselves for pain like was discussed in the last point. Specific examples of conditions include limbically augmented pain syndrome, fibromyalgia, phantom pain, complex regional pain syndrome, visceral (organ) pain, headache, and postsurgical pain.

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What does this have to do with chiropractic?

Premise 1: Chronic pain and altered movement

Recent papers have shown that in patients with a history of long-term or recurring neck pain and/or stiffness, episodes of short-term pain with injury may be what induce long-term changes in the brain. Basically, the wrong train track is being laid down, and this disrupts how the brain processes sensation and carries out motor function. If this change in how your body moves is not corrected, long-term altered movement occurs and new train tracks continue to develop and be polished. These new train tracks tell the brain that this is the body’s new normal function and the short term protection that was previously discussed becomes a long-term problem.
The representations of muscles near a site of pain are altered in both the sensory and motor areas of the brain and these areas of the brain are then reorganized to show the new normal. The extent of change is correlated with the level of motor function and/or deficit.

Posture-and-Your-Brain

Premise 2: Pain changes your brain
We’ve talked a lot about train tracks in how your body learns, but it turns out that your brain, Grand Central Station, is changed by pain input as well.
One paper concluded that pain can alter activation of the neurons in brain regions associated with the central processing of pain and showed that chronic pain can actually lead to reorganization of the brain(6, 7). This was shown as a reduction in grey matter in patients with chronic low back pain(8). The grey matter is the area that houses the neurons. When we talked about neurons earlier we talked about them as messengers and they were the cargo containers. Fewer cargo containers mean less communication between the brain and body or between different areas of the brain. Unfortunately, the areas that are losing communication are those that decrease and stop pain sensation, so this actually makes the patient more sensitive to pain.

Differences in the “resting” brain have also been documented. This means that brain activity may be different in patients with chronic back pain even when the brain is not processing painful inputs. Significant impairments in memory, language skills, mental flexibility, deficits in cognitive function, and changes in decision-making have been noted in chronic back pain patients.

Chiropractic adjustments have been found to improve how the brain processes sensation and motor information

Research has shown that chiropractic adjustments in the neck can change the processing of sensation and movement within the brain. This contributes to pain relief and restoration of functional ability. The authors conclude that spinal manipulation of dysfunctional joints may modify transmission in neuronal circuits not only at a spinal level but in the brain as well. Imaging was used to draw these conclusions.
Research showed that after a single chiropractic adjustment to dysfunctional neck joints, improved sensory responses in the brain occurred in patients with recurring neck pain and stiffness. Their results indicate an improvement in discrimination and filtering of sensory information from the upper limb for at least 20 minutes after the adjustment.
In addition, the study concludes that these results are not simply due to altered input to the brain from balance, changes in muscle or changes in skin sensors as a result of the chiropractor’s touch or due to movement of the patient’s head because no changes were found after passive neck movement. This implies that results are likely specific to the delivery of the high-velocity, low-amplitude thrust of a chiropractic adjustment. (2,3,4)

(1) Boudreau SA, Farina D, Falla D. The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Manual Ther, 2010:1-5. Epub ahead of print.

(2) Haavik-Taylor H, Murphy B. Cervical spine manipulation alters sensorimotor integration: a somatosensory evoked potential study. Clin Neurophysiol, 2007;118:391-402.

(3) Haavik-Taylor H, Murphy B. Altered sensorimotor integration with cervical spine manipulation. JMPT, 2008;31:115-26.

(4) Haavik-Taylor H, Murphy B. ACC-RAC Award Winning Paper. Altered central integration of dual somatosensory input after cervical spine manipulation. JMPT, 2010;33:178-88.

(5) Ray, AA. Treatment of Chronic Pain by Integrative Approaches: The American Academy of Pain Medicine Textbook on Patient Management. Springer. 2015. P52 ISBN: 978-1-4939-1820-1

(6) Strutton P, Theodorou S, Catley M, et al. Corticospinal excitability in patients with chronic low back pain. J Spinal Disord Tech, 2005;18:420-4.

(7) Tsao H, Galea M, Hodges P, et al. Driving plasticity in the motor cortex in recurrent low back pain. Eur J Pain, 2010;14:832-9.

(8) Wand BM, et al. Cortical changes in chronic low back pain: current state of the art and implications for clinical practice. Manual Therapy, 2010:1-6. Epub ahead of print.

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Guide to Whiplash Injury

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No one asks for a whiplash injury-they are nearly always a surprise and rarely the fault of the victim. But they are very common. In fact, over 1 million rear-end collisions occur every year in the U.S. Most cases of whiplash are minor and heal within a few weeks with the proper care. Unfortunately, a small number of patients, about 20-30% with whiplash cases, becomes chronic and lead to long-term discomfort. Whiplash consists of some classic symptoms. Sometimes these symptoms occur immediately after the crash and other times they may take weeks or even months to appear. Common symptoms are the following:

  • A headache
  • Neck Pain
  • Dizziness
  • Shoulder Pain
  • Jaw Pain
  • Arm Pain

Many people might think that they only had a minor car accident that was with speed of only 5-10 mph.

Dr. Cailliet stated:

“Simulated impacts have been studied extensively and essentially confirm that a low-speed impact with minimal or no damage to the impacted vehicle can and does cause significant musculoskeletal injury to the drivers or occupant’s head and neck.”

Dr. Macnab reported in his article, “Acceleration Extension Injuries of the Cervical Spine,” said:

“Acceleration depends on the force applied and the inertia of the vehicle that has been struck. The force is dependent upon the weight and speed of the striking vehicle so that a streetcar traveling at 3 mph can apply as much force and initiate the same degree of acceleration as a compact car traveling at 40 mph.”

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The key to recovering quickly from your whiplash injury is to understand how this happened. It is hard to sort out the truth from the myth about whiplash. This guide is to help you understand how you were injured and how to get well again.

Your Spine: How it is built

Your spine supports your body weight, aids in movement, and serves as a passageway for your spinal cord and nervous system. The spine is made up of 24-26 vertebrae, that are individually designed for specific roles. Each vertebra is separated by a tough disc that cushions the bones and allows flexibility and movement. The spine as a whole, with many bones and disc, is capable of very large motions. But each individual joint by itself allows only a few degrees of movement.

Neck Movements

The neck is the most flexible part of the spine. It allows your head to move in practically any direction. But, its flexibility also makes it the area of the spine that is most vulnerable to injury.

In addition to the disc for flexibility and movement of the cervical spine (neck region) also has what is the known as the facet joint. The facet joint is the part of each neck vertebrae, and it allows the bones to glide smoothly over each other. All of these neck facet joints moving together making it possible for the head to nod forward or backward. In a typical segment of the neck region, the spine has 4 facet joints and two-disc joints.

How Collisions can hurt your body:

The bottom line on whiplash is this: your body was not designed for the abnormal motions that occur during a collision. Normally when your head moves forward and backward, all of the vertebrae participate equally and safely in the motion. Whiplash, however, is not normal motion. During a collision, which takes place in a split second, your head is thrown backward so forcibly and quickly that your body does not even have a chance to respond. As we mentioned earlier, the facet joints allow smooth, controlled forward and backward movement motion of the head and neck. And each joint moves equally to aid this motion.

Different Phases of Whiplash Motion:

Watching each spinal segment in a live human being during a whiplash type collision is not an easy task. What these scientists did was to subject a volunteer to a simulated rear-end collision, while videotaping the spinal motion with x-ray video camera at very high speeds (about 500 frames per second). Whiplash injuries occur in about a tenth of a second so that the entire occupant motion would take up just three frames with a regular video camera with a rate of 30 frames per second.

These researchers found that the smooth motions that they saw when looking at the overall motion during whiplash were much more complex when they examined and analyzed the motions of individual segments.

The Whiplash motion looks like the following:

Phase 1: Upright spine before collisionnormal-cervical-curve1

Phase 2: Immediately after the impact, the car seat pushes the torso forward while the head remains stationary. At the same time, the torso “ramps” up the seat, compressing the cervical spine.

cervical-spine-lateral2

Phase 3: Torso is accelerated by the vehicle seat and may start to ramp up the seat. The lower neck is then pulled forward by the accelerated torso/seat. The head rotates and extends rapidly rearward hyper-extending the neck. The vehicle seat begins to spring forward, and torso continues to accelerate forward.

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Phase 4: The spine forms an S-shaped curve before the musculature of the neck has a chance to react. This S-shape curve results in bending and damaging ligaments in several of the spinal segments.motor-accident-2

Head and torso are accelerated forward. The neck is “whipped” forward rotating and hyper-flexing the neck forward. The head accelerates due to neck motion and moves ahead of the seat back.

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The latest study on this issue shows that the joint capsule and disc undergoes excessive stress in just a few segments of the spine. So much stress that the joint capsules and disc can be torn or the cartilage of the joint itself can be “pinched,” resulting in tissue damage and pain.

Why your body is in pain?

All of the most common symptoms of whiplash can be traced either directly or indirectly to the trauma in your neck that you experience the auto injury. There are 5 major types of injury that whiplash can cause, these are muscle, ligament/tendons, nerve, facet joint injury, and fractures.

  1. Muscle Injury:
    • Most whiplash pain involves muscle tissue since it is the easiest to damage in a collision. During the impact, the muscles in your neck are stretched beyond what they normally experience. Muscle damage is accompanied by swelling and tenderness of the muscles in the neck and shoulders. Fortunately, muscle injuries heal quickly and usually don’t require extensive lengthy treatment.
  2. Ligament/Tendon Injury:whiplash-injury-recovery
    • Now a new study has looked more closely at what happens to the neck, but this time by studying the anterior ligaments of the spine. Previous studies have shown that some patients experience injuries to the anterior longitudinal ligament (ALL) after whiplash. This new report by leading whiplash researchers used a sophisticated mathematical analysis (based upon experimental anatomical and crash data) to see what happens to the ALL during a crash.The ALL runs along the front of the human neck, providing stability for the vertebrae of the spine. The added hypermobility may lead to spinal disorders such as early degeneration of the connected intervertebral disc or vertebrae. In addition, segmental hypermobility can lead to long-term instability. Catastrophic failure of the ALL in a whiplash injury will almost inevitably result in simultaneous injury to the intervertebral disc requiring Chiropractic intervention with specific and scientific analysis to prevent further damage and degeneration.
  3. Nerve Injury:
    • Just as muscles, ligaments/tendons are stretched during rapid motion of whiplash, so our nerves. Most nerves are able to handle such motion. But if your head is turned, head restraint wasn’t adjusted properly, having neck instability, to begin with, a nerve can be damaged and stretched too far or pinched. Nerve injuries can be slightly more difficult to heal than muscle and ligament damage. Nerves that are trapped by misalignment of the vertebra require chiropractic adjustments to restore normal functional capacity.
  4. Facet Joint Injury:
    • Facet joint injury can show itself in a variety of ways. Pain in the area of the joint is the most common symptom. Facet damage can also result in pain that is felt elsewhere in the body. Shoulder and arm pain are common whiplash complaints that may be related to facet joint injury.        Healing of joint damage can be more difficult for many reasons. First, the joint itself does not have a good supply of blood, which makes it hard for the tissues to heal. Secondly, the constant motion of the joint and swelling can irritate the injury. Thirdly, misalignment of the vertebra called subluxation is the culprit cause of this problem causing loss of motion in a damaged vertebra in the lower neck area and creating too much instability in the upper neck.
  5. Fractures:PE-SpinalFractures_Figure2b
    •  Fractures in the neck may also occur during motor vehicle accidents when the head is violently jerked either backward or forwards. The most common type of spine fracture is a vertebral body compression fracture. Sudden downward force shatters and collapses the body of the vertebrae. If the force is great enough, it may send bone fragments into the spinal canal, called a burst fracture. Abnormal slipping and rubbing motions can cause pain and damage the spinal nerves or spinal cord. Stable fractures can usually be treated with bracing and rest. Unstable fractures usually require surgery to realign the bones and prevent spinal cord or nerve injury.when more pressure is put on a bone than it can stand, it will break. People affected by osteoporosis, tumors, and certain forms of cancer that weaken bone are prone to vertebral compression fractures (VCF). The fracture appears as a wedge-shaped collapse of the vertebra.

Effective Healing Methods:

The goal of healing and stability is to help the damaged tissues from the injury. This may take time, depending upon the extent of the damage.

First, it’s very important that you stay active and continue to keep your daily activities. Don’t take excessive time off work or recreation, as this can make it harder for you to get back into the daily lifestyle. The more you make an effort to stay active, the easier it will be for you if you have a legal case later on.

Chiropractic with Whiplash:

Chiropractors work to correct the biomechanical problem causing the symptoms related to whiplash. An approach that will only emphasize on pain or other symptoms will not correct the problem. One report examined 10,382 articles on a neck injury and found traditional techniques for whiplash (collars, injections, ultrasound, medication) were largely ineffective. Several studies point to the success of chiropractic for whiplash sufferers. One found 26% were completely pain-free after chiropractic intervention and the other 74% were significantly improved. Another found 93% improvement.

Patients who undergo chiropractic care are found to have the natural curve of their necks restored, whereas patients who do not undergo chiropractic care tend to be left with a straightened or even reverse curve in their neck. Through research from the Cervical Spine Research Society conducted by Dr. Hohl, he has been shown that after an average of 7 years post-auto accident, an acceleration of degenerative disc disease following whiplash injuries occurred. By that amount of time, auto insurance will not cover the damage of auto injury.

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Dr. Gonstead’s Experience with Whiplash

According to Dr. Gonstead, whiplash usually causes a lower neck problem, but the gonstead and spinemajor problem is often the upper neck problem. He often found damage in the front of the neck bone in the case where a lower neck problem is involved. When there is a very bad whiplash case, he often saw atrophy of the thumb muscles and they couldn’t bring the thumb and index finger together. Dr. Gonstead always wanted to adjust the whiplash as early as possible after the accident. Dr. Gonstead used soft collars for TV and driving purposes if they couldn’t hold up their neck and also make sure that after the Chiropractic adjustment the neck will heal in the best posture as possible. Dr. Gonstead stated that traction for whiplash is to be avoided along with cervical collar. Ice will help reduce the sensation of pain but heat will make the muscle inflammation worse and increase the pain. Typically whiplash damages start to degenerate after 6 months of stagnant lack of care to the spine.

In the Future:

When the whiplash injury is cared for with Chiropractic adjustments, the whiplash will stabilize and heal properly with a series of Chiropractic adjustments. There will be no fear of reoccurring symptoms, a progression of degeneration, and less medical bills to pay for in the future. Not just any Chiropractic adjustment will do. The Chiropractor has to be specific, objective, and creating a future plan of how to keep their spine strong and stable. Dr. Gonstead had the most experience with all kinds of whiplash injuries and his Chiropractic system has been tested throughout time. There are all kinds of whiplash injuries that involve the muscles, ligaments, nerves, and bones so finding a good Chiropractor is very important and if they perform Chiropractic adjustment like Dr. Gonstead.