What does an adjustment do?

Adjustment is the conglomerate term Chiropractors use to describe a set of modalities (treatment tools).  They vary enormously from so called 'low-force' techniques to the traditional HVLA adjustment (High Velocity Low Amplitude (short distance)).  In the hands of a clinician who is trained and experienced at knowing not just what but when and how to apply it these approaches can be very effective for various neuromusculoskeletal disorders.

Sometimes people will ask "what does it do".

Here's a list of some effects which have been observed during neuroscience research (courtesy of Matthew Long CDI)

• Engages mechanoreceptors to open mechanically gated ion channels and initiate a current flow into the largest and fastest primary afferent neurons.
• Uses a rapid lengthening of muscle to activate the dynamic components of the muscle spindle receptor to fire 1A afferents at a high frequency in order to modulate central neurology (greater than 200 Hz).  
• Alters the gain on the muscle spindle system to change muscle tone via the action of gamma motor neurons that innervate the intrafusal muscle fibres.
• Produces a ‘novel’ blend of sensory input that alters the state of the dorsal horn and shapes the responsiveness of spinal cord neurons to future inputs.
• Induces plastic changes in neural circuits via long-term potentiation and depression, depending upon the type of circuit i.e. manipulation can produce long-term depression of the projection neurons of the pain pathways.
• Alters the genetic responses in spinal cord neurons and those in the higher centres.
• Produces a propagated response in neurons in the ipsilateral cerebellum.
• Alters the frequency of firing of lower motor neurons to produce a change in muscle tone, joint stability, position and motion.

Doug Scown

PAIN is reliable in an unreliable way

The guys at The University of South Australia have put a great deal of work into the study of chronic pain.

Acute pain (as we might experience when we step on a nail or twist an ankle) is straight forward.  Do this - get that.  But what about pain which persists?  And what about pain which comes and goes or changes it's nature and location?  Confused?  Welcome to the world of chronic pain and the way it colours injury and dysfunction.

Health professionals still overwhelmingly deal with pain as if it were acute and something was damaged or broken.  Patients who present with continuing pain are told that their nerves are still healing or perhaps they have re injured the injury.  Is this accurate?

Chiropractors tend to see people with chronic or long term complaints.  Their problem often began yrs before but in the early stages their pain and dysfunction was brief and self limiting.  Furthermore it was aggravated by specific things, usually an awkward movement such as lifting and twisting.  Recently though the patient reports that their pain came from "nowhere".  "I slept wrong", "It just went out and now it's not going away".  In short their brief, self limiting problem has become chronic, 'unstable' and aggravated by trivial movements.  Additionally the pain has changed. It was sharper and "here".  Now it's sometimes sharp, often a dull ache or burning and it's spreading.  It feels like it could just "go" on me.

The patient has developed chronic pain.  The brain learns and changes through repetition and the repetition of pain can do interesting things with a plastic or moldable neurology.  Pain itself is a complex experience suffice to say it's important to pin down what originally triggered the problem (the disc, joint, bone, distortion - the diagnosis) and what may have led to it weakening (usually a combination of injury, sensation disturbance, lifestyle and of course genetics/epigenetics).

Ref   Apkarian et al. (2004) Chronic back pain

Do backs 'go out'

Can your back 'go out'?

The old model for SPINE (which is still used a great deal) was 'bone out of place'.  It made sense.  Hard bone, soft nerve, ouch.  Then someone applies a force to a joint, it may feel better and (particularly if we hear a pop) we connect the dots.

"My bone was out, it hurts, it's pinched a nerve, I heard it pop back in, now it feels better = bone out of place."  It feels like this, it sounds plausible and to cap it off even health practitioners (and specialists) still believe this to be true.  And if they don't they are not sure how else to explain it.

The trouble with this theory was this - there was never any evidence for it.  Short of fracture and dislocation there is NO evidence that we can put a displaced joint 'back in'.

So what on earth is happening? 

The model is now multifaceted and the research supports that MOST changes are due to neurophysiological changes (changes in the nervous system when physical modalities are applied (exercise, joint manipulation, etc) .  A big one is normal proprioception or 'joint position sense' which can be disrupted by injury, lack of use and pain.  Even if we ignore all of the other effects this deficit in the brains ability to properly sense and therefore control and protect the spine is reduced.

Physically based treatments aim to 'leverage' or target these deficits thus improving this innate body function.

The following research from the Physiotherapy profession illustrates the failure of the 'bone out of place' model to explain the effects we see.

http://www.pain-ed.com/wp-content/uploads/2013/08/SIJ-pelvis-In-Touch-Beales-OSullivan.pdf

Is a 'muscle spasm' just a muscle spasm?

We are all quite familiar with muscle cramps following exertion or perhaps associated with conditions of the blood vessels but what about those acute and often painful spasms of the back muscles?  What is happening here and why do they seem to affect the spinal muscles so much?  Why for example do we not feel the same thing in the arm or leg?

More importantly is 'muscle spasm' a valid diagnosis or is it a sign of something else?

Most of our brain and nervous system is built for one purpose - PROTECTION - and the structures of the spine are some of the most sensitive to errors and injury, so much so that even trivial injury can invoke significant pain and muscular guarding.  Muscle spasm is in effect a protective behaviour.  Something is triggering it.

Muscle spasm due to simple joint strain is common and self limiting however a history of repeated episodes is more complex.  Why do they keep recurring?  Why are they becoming resistant to conventional treatment?  What is going on?

 Meniscoid extrapment, Chronic facet synovitis, disc herniation, degenerative spondylolisthesis, cervical dystonia and other syndromes can all cause a tightening of the spinal muscles.

In short muscle spasm is a non specific symptom.  If it keeps coming back it requires a diagnosis.

Move it or lose it. Why stress is good.

Explanations of joint pathology, the reasons why it may have developed and what can be done about it can become complex and difficult to understand.  In particular information relating to the structure and function of biological systems is continually mounting.  Much of the time we tell patients that in the end it boils down to a lack of complex movement.  In days past 'overdoing it' led to injury and trouble but is that what happens most of the time?

The phrase 'move it or lose it' is old and I suspect it's been around in some form for thousands of years.  We observe what happens when we don't move.  We become weak and flaccid, our balance deteriorates and there is evidence that even our automatic functions (such as blood pressure) which are neurologically controlled become disordered and dysfunctional. 

Neuroscience is now mapping out the mechanisms whereby we break down due to a LACK of stress.


https://www.facebook.com/NeuroscienceAndPainScienceForMovementProfessionals

Coenzyme Q 10

This "Vitamin Like" substance (https://en.wikipedia.org/wiki/Coenzyme_Q10) is rapidly gaining attention for it's positive effects on a range of metabolic disorders including the neurological condition migraine.

We are now typically recommending that migraineurs trial 150-300mg per day to improve cellular function and reduce the tendency of the brain cells to easily fatigue and increase the risk of triggering the symptoms of migraine (which can include any of a combination of  head pain, extreme fatigue, cognitive changes, nausea, visual hallucination, gut disturbance, etc.).  Again it should be emphasised that migraine is NOT simply a headache and has been reclassified as a genetically based neurological condition.  This is a vital distinction to make otherwise we treat symptoms rather than manage the condition (it is also why no two migraineurs experience exactly the same symptoms)

But about Co Q 10 itself.  What is it and how might it help? http://www.drweil.com/drw/u/ART03367/Coenzyme-Q10-CoQ10.html

As afr as brains are concerned it is one of the chemicals which allows neurons to do their job efficiently and it is the hallmark of a migraine brain to be inefficient at processing sensory information (significantly the inhibition of 'pain').  As a result of this genetically influenced trait any sensation (food, light, heat, fatigue, stress, disturbed sleep, a sore back and neck (so called somatic pain) can become a 'trigger' and why many substrates (CoQ10, Vit D, magnesium, folate, etc) can effectively increase the brains resilience and reduce the symptoms of migraine.

D Scown

Looking into the brain

Our understanding of pain has transformed largely because we can now look into the brain and observe what is going on there when the body appears to hurt.

Neuroscience (including advanced imaging where we can see nerve and brain activity in real time) has opened a window where none existed before.  We can actually see the behaviour or activitiy of the brain when a person is thinking, emoting, in chronic pain, acute pain, moving, imagining, crying, etc.  In the past we saw outward human behaviour but couldn't see brain activity so our ideas and theories were based on an understanding that the brain was static and hard wired; kind of an innert computer like machine.  Coupled with that is the fact that the various health professions and their specialties tend to view human function from different perspectives. Furthermore some problems result in various signs and symptoms of apparently somatic (or in body) aches and pains but defy a single diagnosis.

Fibromyalgia is one such condition which is often diagnosed when an individual has chronic diffuse musculoskeletal pain.  That patient is also likely to see a gut specialist for gut sensitivity, a Neurologist for head and face pain, their psychologist for cognitive symptoms such as 'feeling muzzy or foggy' and the GP for any of the above.  And of course they may see a chiropractor or physiotherapist for 'aches and pains'  While it's certainly possible for any one individual to be suffering from multiple maladies it is most likely that there is a systemic or widespread cause which manifests in a variety of ways.  Confusing?

Eric Kandel (who won a Nobel for neural science) describes pain as an emotional reaction to sensation and also as a complex behaviour.  This is quite different from the old idea that a brain is like a computer hence the title of a recent book 'The brain that changes itself'.  If we want to race that marathon we train.  Why?  When we stress our bodies they can adapt and become stronger however if we do too much too soon we can overdo it, break down and accumulate injuries.  Because we all have a unique set of genes we are all slightly more and less predisposed to certain problems.  It turns out that the brain can do the same thing.  It can respond to stress by developing better coping mechanisms or respond to too much stress by becoming dysfunctional.

Fibromyalgia is characterised by combinations of diffuse musculoskeletal pain often including head ache and TMJ or jaw pain, gut sensitivity, cognitive difficulties (feeling dull or fuzzy in the head) and psychological or emotional lability.  So what used to happen to people in the past when we understood pain to be purely due to serious pathology (say infection or blood disorder) injury or scarring OR a psychosomatic issue (all in your head)?

Tests often come back negative.  This is good when we're trying to pin point a diagnosis.  Then we read the scientific literature which says a few things about FM

1.  There appears to be a familial (genetic) predisposition.  A first level relative is 8 times more likely to develop similar symptoms.
2. Symptoms seem triggered by the environment (often a combination of severe or sustained emotional stress coupled with musculoskeletal injury (more often injury to the axial skeleton (spine and pelvis) and trunk)
3. Dysfunction in the HPA (hypothalamopituitary axis) and ANS (autonomic nervous system)
4. Impaired pain and sensory processing
5. Cognitive, behavioural and psychological impairments.

In effect the brain becomes 'globally' sensitive so any structure of the body can begin to hurt even though there may be little, even no actual structural injury.

Depressingly much of the freely available information regarding FM will say that there is no cure.  It's important to understand the nature of FM - It is not a disease with a cure rather a genetically linked predisposition to brain sensitivity.  Furthermore because we now understand the brain to be plastic or changeable it is theoretically possible to reverse some of these changes.

So FM can be complex and difficult to manage and although it does respond slowly and less predictably than other simple joint and muscle problems it can respond well over time.