{"id":10776,"date":"2023-01-11T16:19:10","date_gmt":"2023-01-11T21:19:10","guid":{"rendered":"https:\/\/torontoneckandbackpain.com\/?p=10776"},"modified":"2023-01-11T16:19:10","modified_gmt":"2023-01-11T21:19:10","slug":"disc-herniation-and-chiropractic","status":"publish","type":"post","link":"https:\/\/torontoneckandbackpain.com\/newsite\/disc-herniation-and-chiropractic\/","title":{"rendered":"Disc Herniation and Chiropractic"},"content":{"rendered":"

This article is a reprint from a blog post at dkchiroblog.com<\/a> that is relatively long and in-depth when it comes to disc herniation and chiropractic care. While opinions abound in healthcare in many regards, each case is unique and should be considered on an individual basis. Herniated discs are no exception.<\/p>\n

This articles stands to demonstrate that manual therapies can be effectively applied in cases of herniated discs in order to avoid the need for more invasive treatments whenever possible. It does not stand to negate the value of any treatment when and if appropriate.<\/p>\n

It may not be the casual read you were looking for, however if you or someone you know is suffering from a herniated disc, the article will provide some insight on the benefits of chiropractic care for a herniated disc.<\/p>\n

A Review of Concepts and Evidence<\/strong><\/h4>\n

Let’s begin with the mainstay of chiropractic care, the adjustment.<\/p>\n

Manipulation of the joints of the lumbar spine usually involves some degree of segmental rotation. Historically, lumbar spine manipulations that are primarily rotational in nature are discouraged because it is assumed that such maneuvers are associated with an increased risk of injury to the annulus of the intervertebral disc. Such an annular disc injury would increase the risk for disc herniation and compressive neuropathy (radiculopathy), a problem that may require a surgical management.<\/p>\n

The traditional caution pertaining to rotational manipulations to the low back is based upon an understanding of the anatomy of the annulus of the disc. The collagen fibers that comprise the annulus of the disc are arranged in layers, and each layer is crossed in opposite directions.<\/p>\n

During disc rotational movements, half of the annular collagen fibers become tense, and the other half become lax. Therefore it is argued that rotational stress applied to the annulus of the disc is resisted by only half of the annular collagen fibers, the half that become tense. It is argued that the disc is operating at only half strength during rotationally applied stress, increasing its vulnerability to injury, herniation, compressive radiculopathy and surgical intervention.<\/p>\n

Despite these arguments, there is evidence that the lumbar disc cannot be injured by rotational manipulations, and that rotational manipulations are safe when applied by an appropriately trained provider.<\/p>\n

In 1981, a study was published in the journal\u00a0Spine<\/em>, titled:<\/p>\n

The Relevance of Torsion to the<\/strong>
\nMechanical Derangement of the Lumbar Spine<\/strong><\/h5>\n

The authors of this study observed the mechanics of applied rotational stresses that were applied to the lumbar spine discs of cadavers. They noted that the limit of lumbar spinal segmental rotation was not created by the disc, but rather by the facet joint. During rotational stress, the compression facet is the first structure to yield at the limit of torsion, and this occurs after about 1-2\u00b0 of rotation. The authors state:<\/p>\n

\u201cMuch greater angles are required to damage the intervertebral disc, so torsion seems unimportant in the etiology of disc degeneration and prolapse.\u201d<\/strong><\/p>\n

\u201cBecause of the protection offered by the compression facet, the intervertebral disc is subjected to relatively small stresses and strains in the physiologic range of torsion. By the time the facets are damaged, the disc is rotated only about one-third to one-tenth of its maximum angle and is bearing a small fraction of the torque required to rupture it.\u201d<\/strong><\/p>\n

\u201cExcept in cases of extreme trauma and as a sequel to crushing of the apophyseal joints, axial rotation can play no major part in the mechanical derangement of the intervertebral disc in life.\u201d<\/strong><\/p>\n

Two years later, in 1983, the same group published an updated cadaver studies in journal\u00a0Spine<\/em>, titled:<\/p>\n

The Mechanical Function of the Lumbar Apophyseal Joints<\/strong><\/h5>\n

Based upon their experiments, the authors concluded that the facet joints \u201cprevent excessive movement from damaging the discs: the posterior annulus is protected in torsion by the facet surfaces and in flexion by the capsular ligaments.\u201d They note that the facets only allow at most 2\u00b0 of rotation, and also note that the disc will completely recover from all rotational stresses that are less then 3\u00b0. The authors state:<\/p>\n

\u201cIn flexion, as in torsion, the apophyseal joints protect the intervertebral disc.\u201d<\/strong><\/p>\n

\u201cThe function of the lumbar apophyseal joints is to allow limited movement between vertebrae and to protect the discs from shear forces, excessive flexion, and axial rotation.\u201d<\/strong><\/p>\n

In 1995, a third updated article was published by this group and published in the journal\u00a0Clinical Biomechanics<\/em>, titled:<\/p>\n

Recent Advances in Lumbar Spinal Mechanics<\/strong>
\nand their Clinical Significance<\/strong><\/h5>\n

Once again, these authors note that rotational loading of the lumbar spinal motor unit will always damage the facet joints \u201clong before the disc.\u201d If the facet joints are removed, rotational forces will damage the disc if subjected to rotational loads between 10-20\u00b0.<\/p>\n

Despite the supposition that lumbar spinal manipulation, and especially primary rotational manipulation, may injure the intervertebral disc, these cadaver biomechanical studies indicate that such injuries are not biomechanically possible.<\/p>\n

\"Disc
Lumbar (low back) disc herniation, causing low back pain and sciatica<\/figcaption><\/figure>\n

Can Rotational Manipulation Help Patients<\/strong>
\nwith Proven Lumbar Disc Herniation?<\/strong><\/h4>\n

There is evidence that lumbar spine rotational manipulations are effective in the treatment of low back pain, including the management of disc herniation.<\/p>\n

In 1954, there was a study in the Instructional Course Lectures of the\u00a0American Academy of Orthopedic Surgeons<\/em>, titled:<\/p>\n

Conservative Treatment of Intervertebral Disk Lesions<\/strong><\/h5>\n

The author advocates the use of conservative treatment, including spinal manipulation, for patients suffering with low back disc herniations. He states:<\/p>\n

\u201cThe conservative management of lumbar disk lesions should be given careful consideration because no patient should be considered for surgical treatment without first having failed to respond to an adequate program of conservative treatment.\u201d<\/strong><\/h6>\n

\u201cFrom what is known about the pathology of lumbar disk lesions, it would seem that the ideal form of conservative treatment would theoretically be a manipulative closed reduction of the displaced disk material.\u201d<\/strong><\/p>\n

\u201cWe limit the use of manipulation almost entirely to those patients who do not seem to be responding well to non-manipulative conservative treatment and who are anxious to have something else done short of operative intervention.\u201d<\/strong><\/p>\n

\u201cThe patient lies on his side on the edge of the table facing the surgeon and the leg that is up is allowed to drop over the side of the table, tending to swing the up-side of the pelvis forward. The arm that is up is allowed to drop back behind the patient, tending to pull the shoulder back. The surgeon then places one hand on the patient\u2019s shoulder and his opposite forearm on the patient\u2019s iliac crest. Simultaneously, the shoulder is thrust suddenly back, rotating the torso in one direction while the iliac crest is thrust down and forward, rotating the pelvis in the opposite direction. This gives the lumbar spine a twist that frequently causes an audible and palpable crunch. This procedure is then repeated with the patient on his other side. The patient is then turned on his back and his hips and knees are hyperflexed sufficiently to forcibly flex the lumbar spine which tends to open up the disk spaces posteriorly.\u201d<\/strong><\/p>\n

The manipulation described here is rotational in nature, using the term \u201ctwist.\u201d<\/p>\n

    \n
  • \u2022\u2022\u2022\u2022<\/li>\n<\/ul>\n
    \"Man
    Back Pain and Sciatica are common chiropractic treatment conditions.<\/figcaption><\/figure>\n

    In 1969, a study was published in the\u00a0British Medical Journal<\/em>, titled:<\/p>\n

    Reduction of Lumbar Disc Prolapse by Manipulation<\/strong><\/h5>\n

    These authors evaluated a number of patients that presented with an acute onset of low back and buttock pain that did not respond to rest. Diagnostic epidurography showed a clinically relevant small disc protrusion, along with antalgia and positive lumbar spine nerve stretch tests.<\/p>\n

    These patients were treated with long-lever rotation manipulations of the lumbar spine, using the shoulder and iliac crest as levers. These lumbar spine manipulations were clearly accompanied with a thrust maneuver. The manipulations were repeated until abnormal symptoms and signs had disappeared. Following the manipulations there was resolution of signs, symptoms, antalgia, and reduction in the size of the protrusions. The authors state:<\/p>\n

    \u201cManipulation of the lumbar spine has been used as an empirical treatment of low backache since antiquity. The persistence and popularity of this type of treatment was based on the clinical impression that it is beneficial.\u201d<\/strong><\/p>\n

    \u201cThe lumbar spine was rotated away from the painful side to the limit of its range, the buttock or thigh of the painful side being used as a lever; a firm additional thrust was made in the same direction. This manoeuver was repeated until abnormal symptoms and signs had disappeared, progress being assessed by repeated examination.\u201d<\/strong><\/p>\n

    \u201cRotation manipulations apply torsion stress throughout the lumbar spine. If the posterior longitudinal ligament and the annulus fibrosus are intact, some of this torsion force would tend to exert a centripetal force, reducing prolapsed or bulging disc material.\u201d<\/strong><\/p>\n

    \u201cThe results of this study suggest that small disc protrusions were present in patients presenting with lumbago and that the protrusions were diminished in size when their symptoms had been relieved by manipulations.\u201d<\/strong><\/p>\n

    These authors concluded \u201cit seems likely that the reduction effect [of the disc protrusion] is due to the manipulating thrust used.\u201d<\/strong><\/h6>\n

    This article clearly describes the manipulations used as \u201cforceful,\u201d \u201cthrust,\u201d and \u201crotation.\u201d Their explanation for the successful treatment was credited to a reduction in the size of the disc protrusion from the rotational component of the manipulation: rotation tightens up intact aspects of the annular ring, pulling the nuclear protrusion towards the center and away from the nervous system.<\/p>\n

      \n
    • \u2022\u2022\u2022\u2022<\/li>\n<\/ul>\n

      Another study was published in 1969 in the\u00a0Australian Journal of Physiotherapy<\/em>, titled:<\/p>\n

      Low Back Pain and Pain Resulting from Lumbar Spine Conditions:<\/strong>
      \nA Comparison of Treatment Results<\/strong><\/h5>\n

      The author compared the effectiveness of heat\/massage\/exercise to spinal manipulation in the treatment of 184 patients that were grouped according to the presentation of back and leg pain. His results were clearly summarized in White and Panjabi\u2019s\u00a0Clinical Biomechanics of the Spine<\/em>, in 1990. Drs. White and Panjabi state:<\/p>\n

      \u201cA well-designed, well executed, and well-analyzed study.\u201d<\/strong><\/p>\n

      In the group with central low back pain only, \u201cthe results were acceptable in 83% for both treatments. However, they were achieved with spinal manipulation using about one-half the number of treatments that were needed for heat, massage, and exercise.\u201d<\/strong><\/p>\n

      In the group with pain radiating into the buttock, \u201cthe results were slightly better with manipulation, and again they were achieved with about half as many treatments.\u201d<\/strong><\/p>\n

      In the groups with pain radiation to the knee and\/or to the foot, \u201cthe manipulation therapy was statistically significantly better,\u201d and in the group with pain radiating to the foot, \u201cthe manipulative therapy is significantly better.\u201d<\/strong><\/p>\n

      \u201cThis study certainly supports the efficacy of spinal manipulative therapy in comparison with heat, massage, and exercise. The results (80 \u2013 95% satisfactory) are impressive in comparison with any form of therapy.\u201d<\/strong><\/h6>\n

      It is usual for pain that travels further down an extremity to be associated with greater compression, or a larger disc protrusion. In this study, manipulation worked excellently in patients with leg pain radiation.<\/p>\n

        \n
      • \u2022\u2022\u2022\u2022<\/li>\n<\/ul>\n

        In 1977, the third edition of\u00a0Orthopaedics, Principles and Their Applications<\/em>\u00a0was published. The author, Samuel Turek, MD (d. 1986), was a Clinical Professor, Department of Orthopedics and Rehabilitation at the University of Miami School of Medicine. His text encompasses 1,574 pages. In the section pertaining to the protruded disc, Dr. Turek states:<\/p>\n

        Treatment of Intervertebral Disc Herniation With Manipulation<\/strong><\/h5>\n

        \u201cManipulation. Some orthopaedic surgeons practice manipulation in an effort at repositioning the disc. This treatment is regarded as controversial and a form of quackery by many men. However, the author has attempted the maneuver in patients who did not respond to bed rest and were regarded as candidates for surgery. Occasionally, the results were dramatic.<\/strong><\/p>\n

        Technique. The patient lies on his side on the edge of the table facing the surgeon, and the uppermost leg is allowed to drop forward over the edge of the table, carrying forward that side of the pelvis. The uppermost arm is placed backward behind the patient, pulling the shoulder back. The surgeon places one hand on the shoulder and the other on the iliac crest and twists the torso by pushing the shoulder backward and the iliac crest forward. The maneuver is sudden and forceful and frequently is associated with an audible and palpable crunching sound in the lower back. When this is felt, the relief of pain is usually immediate. The maneuver is repeated with the patient on the opposite side.\u201d<\/strong><\/p>\n

        The manipulation maneuver described by Dr. Turek is the classic description of the rotational manipulation of the lumbar spine. His comments are in the aspect of his book pertaining to the treatment of the protruded lumbar intervertebral disc.<\/p>\n