Toward Theory Driven : The Science of Subluxation Robert A. Leach, DC, MS, FICC, CHES • Author, The Chiropractic Theories • Certified Health Education Specialist • Private Practice since 1979, Starkville, Mississippi Copyright 2020 by Robert A. Leach Further Reading…

The textbook for this program is available through the Parker Chiropractic College bookstore, via Amazon, or your local bookseller.

2/5/2020 I. Subluxation: Philosophy/Dogma vs Philosophy/Theory Driven Will we adopt a questioning philosophy, informed by evidence, that drives our practices?

2/5/2020 Do you ever stop to ponder professional and clinical questions?

●Is there scientific evidence for subluxation, or should we abandon the term?

●Does theory (aka “the story”) matter?

●Which is more important: research of theory or outcomes? How to know what works?

How do you know if one technique is better or works better than another? Would you buy a used car without a test drive? Would you feel better about paying more if you could drive it to your mechanic to check it out? Do you read about computers or cars and crash and mileage tests before you buy? Why should the public buy chiropractic that is untested? Why should a chiropractor buy a technique or a subluxation detection system that is untested? These and similar questions should arouse the chiropractor toward a lifetime of learning that will benefit her or his patients and practice. Best of Times: Theory Informs Practice, Improves Outcomes Iridology Misalignment Myelopathy II. Disproven and Short leg deficiency Untested “Silent” Chiropractic complex Theories Surrogate testing Technique system processes and testing III. Promising Evidence Informed Spinal Manipulation Theories Today The First Subluxation Hypothesis: Fixation

•A simple subluxated vertebra differs from a normal vertebra only in its field of motion and the center of its field of motion; because of its being subluxated, its various positions of rest are differently located than when it was a normal vertebra . . . its field of motion may be too great in some directions and too small in others. (Smith, Langworthy, Paxson, Modernized Chiropractic, 1906). NINDS Description: Search Key Words/ #Pubmed hits: Fixation h. spinal dysfunction, 367; spine manipulation stiffness, 124; manipulable spinal lesion, 11; 1975 NINDS chiropractic spine compliance,29 Conference Immob. Deg. h. inflammation spine pain, 1,454; immobilization Hypotheses degeneration, 342 Seeing promising Neurodystrophy h. psychoneuroimmunology 2,571; inflammation spine pain, 1,454 ; subsequent study: neurodystrophy,27 Subluxation h. forward head posture, 792; spinal dysfunction, 367; chiropractic subluxation, 218 Somatoautonomic Reflex h. autonomic nervous system spinal manipulation, 96; neuroplasticity spinal manipulation, 47; visceral responses to spinal manipulation, 10 Axoplasmic aberration Neuroplasticity Additional Facilitation BioPsychoSocial Hypotheses Forward head Segmental dysfunction tilt/postural Vertebrobasilar Relating to Immobilization insufficiency degeneration Wellness Modern Inflammation Chiropractic Instability Minimum Theory: Mimicry Inflammation affecting Zygapophyseal Joints Patterson-Steinmetz Model

•Spinal Learning is the facilitation hypothesis based on the following facts: A) a small lesion in the cerebellum of an anesthetized animal causes the limbs on one side to actively flex and remain in that position (top). B) Immediate severance of spinal cord at T7 results in paralysis of the hind limb (middle). C) If the hind limb flexion is allowed to remain for even 45 minutes, it becomes “learned” by the spine and remains despite section of the cord (bottom). Contemporary summary of afferent pool for the alpha motor neuron, showing significant contributions from spinal interneuron pool whose inputs include projections received from corticospinal tract. Front Hum Neurosci. 2013:7:85. Neuroimmune Hypothesis Begins in 1950s with Hans Selye, M.D., Ph.D.’s Hypothesis: Localized Adaptation to Stress Questions: •Could Selye’s observations apply to spinal lesions? •Could inflammation trigger fixation, facilitation, and have somatoautonomic and somatovisceral effects? ATTENUATION EFFECT OF SPINAL MANIPULATION ON NEUROPATHIC AND POSTOPERATIVE PAIN THROUGH ACTIVATING ENDOGENOUS ANTIINFLAMMATORY CYTOKINE INTERLEUKIN 10 IN RAT SPINAL CORD

• This animal-based study showed that spinal manipulation reduced neuropathic pain due to intervertebral foramen compression. • Spinal manipulation reduced postoperative pain after relief of nerve compression. • Spinal manipulation reduced neural inflammation and nociceptive neural hyperexcitability. • Spinal manipulation increased endogenous anti-inflammatory cytokine IL-10 in the spinal cord. -J Manipulative Physiol Ther 2016;39:42-53 Good vs Bad Stress and Brain Aging

Figure 4. Adaptation of McEwen model of good versus bad stress, showing dose response of increasing amounts and frequency of adrenal steroids in response to acute stressors having initially beneficial effects such as facilitation of long-term potentiation and memory. Cell. 2014 Nov 6;159(4):727-37. doi: 10.1016/j.cell.2014.10.035. Neuronal plasticity: beyond the critical period. Hübener M1, Bonhoeffer T2.

Neuronal plasticity in the brain is greatly enhanced during critical periods early in life and was long thought to be rather limited thereafter. Studies in primary sensory areas of the neocortex have revealed a substantial degree of plasticity in the mature brain, too. Often, plasticity in the adult neocortex lies dormant but can be reactivated by modifications of sensory input or sensory-motor interactions, which alter the level and pattern of activity in cortical circuits. Such interventions, potentially in combination with drugs targeting molecular brakes on plasticity present in the adult brain, might help recovery of function in the injured or diseased brain. Reorganization in Secondary Somatosensory Cortex in Chronic Low Back Pain Patients

Results. Nonpainful PA pressure revealed no cortical reorganization in S1. In contrast, the extent of S2 activation in the CLBP group was significantly reduced in both hemispheres. In the control group, a somatotopy was identified for the lumbar vertebrae between L1 and L3, respectively, and L5 in S2 of the right hemisphere. Most importantly, a blurring of the somatotopic representation of the lumbar spine in S2 was observed in the patient group. Conclusion. Together, these maladaptive changes suggest a reorganization of higher-order processing for sensory information in CLBP patients that might have implications for a decreased sensory acuity, also related to body perception and subsequent altered functioning of the lumbar spine. -SPINE Volume 41, Number 11, pp E667–E673, 2016 Somatosensory evoked potentials show plastic changes following a novel motor training task with the thumb D. Andrew a, H. Haavik b, E. Dancey a, P. Yielder a, B. Murphy a,⇑

a University of Ontario Institute of Technology, Faculty of Health Sciences, 2000 Simcoe Street North, Oshawa, Ont. L1H 7K4, Canada bNew Zealand College of Chiropractic, Centre for Chiropractic Research, 6 Harrison Road Mt Wellington, P.O. Box 112-044 Newmarket, Auckland 1149, New Zealand

Objective: Accumulating evidence indicates that plastic changes can be maladaptive in nature, resulting in movement and neurological disorders. The aim of this study was to further the understanding of these neurophysiological changes in sensorimotor integration (SMI) using somatosensory evoked potentials (SEPs) and concurrent performance changes following a repetitive typing task. Effects of 12 Weeks of Chiropractic Care on Central Integration of Dual Somatosensory Input in Chronic Pain Patients: A Preliminary Study

The observations in 6 subjects revealed that 12 weeks of chiropractic care improved suppression of SEPs evoked by dual upper limb nerve stimulation at the level of the motor cortex, premotor areas, and/or subcortical areas such as basal ganglia and/or thalamus. It is possible that these findings explain one of the mechanisms by which chiropractic care improves function and reduces pain for chronic pain patients. -J Manipulative Physiol Ther 2017;40:127-138 Manipulation of Dysfunctional Spinal Joints Affects Sensorimotor Integration in the Prefrontal Cortex: A Brain Source Localization Study

Results: SM decreased the N30 amplitude by 16.9 ± 31.3% (푃 = 0.02), while no differences were seen following the control intervention (푃 = 0.4). Brain sourcemodeling revealed a 4-source model but only the prefrontal source showed reduced activity by 20.2±12.2% (푃 = 0.03) following SM. Conclusion. A single session of spinal manipulation of dysfunctional segments in subclinical pain patients alters somatosensory processing at the cortical level, particularly within the prefrontal cortex. - Neural Plasticity 2016 Impact of Spinal Manipulation on Cortical Drive to Upper and Lower Limb Muscles Heidi Haavik 1,*, Imran Khan Niazi 1,2, Mads Jochumsen 2, Diane Sherwin 3, Stanley Flavel 1 and Kemal S. Türker 4

Spinal manipulation resulted in a 54.5% +/- 93.1% increase in maximum motor evoked potential (MEPmax) for APB and a 44.6% +/- 69.6% increase in MEPmax for TA. For the MRCP data following spinal manipulation there were significant difference for amplitude of early bereitschafts-potential (EBP), late bereitschafts potential (LBP) and also for peak negativity (PN). The results of this study show that spinal manipulation leads to changes in cortical excitability, as measured by significantly larger MEPmax for TMS induced input–output curves for both an upper and lower limb muscle, and with larger amplitudes of MRCP component post manipulation. Establishing a theoretical basis for research in musculoskeletal epidemiology: a proposal for the use of biopsychosocial theory in investigations of back pain and smoking Bart N. Green DC, MSEd, Claire D. Johnson DC, MSEd J Chiropr Hum 2013 Biological • Age, sex • Genes • Physiologic responses Social • Interpersonal Vector relations Host Environ • Social support ment • Socioeconomic Agent status Psychological • Mental health • Emotions • Beliefs Fig 2. Biopsychosocial theory relates how various factors may interrelate to affect physical and mental health. Genetic/markers of inflammation in saliva predict pain and Oswestry disability and correlate with severity/extent of adjacent disc degeneration 9 years after fusion in a prospective genetic association study. -Omair et al BMC Musc Dis 2013:14;105 “The inflammatory genes tested in the present study are interestingly also involved in the modulation of pain. They regulate the production of cytokines that may contribute to LBP by inducing growth of nerve and vascular elements [47,48]. IL18 induced synthesis of tumor necrosis factor-alpha (TNF α) has also been proposed to play a role in discogenic pain [49]. MMP3 and IL1A have been associated with neuropathic pain and sensitization of nocireceptors [18,24].” IV. How to have a Theory Driven, Science Informed Practice Tomorrow “If it isn’t documented, it hasn’t been done” is an adage that is frequently heard in the health care Why Evidence setting. -”Evaluation and Informed? Management Services Guide.” GPO, Centers for Why Medicare and Medicaid, ICN: 006764 July 2009. Documentation? Why Theory Driven Chiropractic?

•Without philosophy, a profession is like a ship without a rudder •Without testable theory, a profession is like a runner without a course •Without documentation of our practices and research, a profession does not get their claims paid Documentation is too much work, why not just a cash practice?

●What if no chiropractors accepted patients with Medicare, Medicaid for the poor, worker or service disabilities?

●What if no chiropractors were willing to work at VA or military facilities?

●With integrative care & Medicare parity on the horizon, will we embrace change? Practice Guidelines? Phooey, who wants 'em? Who needs 'em?

●“I don't want anyone telling ME what they think chiropractic is!”

BEST PRACTICES RECOMMENDATIONS FOR CHIROPRACTIC CARE FOR INFANTS, CHILDREN, AND ADOLESCENTS: RESULTS OF A CONSENSUS PROCESS Cheryl Hawk, DC, PhD,a Michael Schneider, DC, PhD,b Randy J. Ferrance, DC, MD,c Elise Hewitt, DC,d,e,f Meghan Van Loon, DC, PT,g,h and Lora Tanis, DCi,j ABSTRACT Objective: There has been much discussion about the role of chiropractic care in the evaluation, management, and treatment of pediatric patients. To date, no specific guidelines have been adopted that address this issue from an evidence based perspective. Previous systematic reviews of the chiropractic literature concluded that there is not yet a substantial body of high quality evidence from which to develop standard clinical guidelines. The purpose of this project was to develop recommendations on “best practices” related primarily to the evaluation and spinal manipulation aspects of pediatric chiropractic care; nonmanipulative therapies were not addressed in detail. Methods: Based on both clinical experience and the results of an extensive literature search, a set of seed documents was Range of Motion, Motion Palpation, Pain Provocation Testing

•Nansel’s Experiments: •Rotation restriction ameliorated by upper CS adjustment on side of restriction •Lateral bending restriction ameliorated by lower CS adjustment on side of restriction Pressure Pain Thresholds...

SIMULATION TESTS FOR CERVICAL NONORGANIC SIGNS: A STUDY OF FACE VALIDITY Howard Vernon, DC, PhD,a Dan Proctor, DC,b Dianna Bakalovski, DC,c and Jesse Moretond ABSTRACT Objectives: The purpose of this study was to develop and determine the face validity of additional cervical nonorganic simulation tests. Methods: Four simulation tests were either selected from the literature or newly designed: simulated sitting trunk/ shoulder rotation (SR; test no. 1), active vs passive cervical rotation (CR; test no. 2), Libman's test (LT; test no. 3) of pressure over the mastoid process, and side-lying passive shoulder abduction (SA; test no. 4). Three groups, 1 without neck pain (n = 44) and 2 with neck pain (n = 43 and 27), were formed. Outcome measures consisted of questions on provocation of pain (Yes/No) and appropriateness (Yes/No) as well as measurements of cervical rotation (goniometric) and pressure pain threshold (pressure algometer). Group test responses were evaluated and scored. A threshold of acceptance was established at 80% agreement for face validity. Ranges of rotation and pressure threshold values were analyzed with the Student t test. Results: In nonneck pain subjects, all 4 tests were rated as nonpainful and 3 were rated as “appropriate” for neck pain examination (not SR). In neck pain subjects, this test and SA were rated as nonpainful, whereas LT was rated as painful in 26% of subjects. Only CR and LT were rated as “appropriate.” In neck pain subjects, passive rotations exceeded actives by 10% to 14% (P = .000). On a second round of testing with a slightly modified method, SR and SA achieved acceptable “appropriateness.” Conclusions: Once 2 tests were slightly modified, all 4 tests were found to have acceptable face validity. Further research into the reliability of these tests as well as into the combinations of these tests is warranted. (J Manipulative Physiol Ther 2010;33:20-28) Key Indexing Terms: Neck Pain; Psychology; Psychometrics; Chiropractic Segmental Assessments

•Motion Palpation and Pain Provocation tests •Motion Studies (imaging at end ranges) •Static Palpation or instrumented tests (algometry) for Tenderness •Static Palpation or Instrumented tests of Compliance •Ultrasound, and Other Measures Regional Assessments

•Algometry (muscle specific) •Functional Strength Assessments •Passive and Active Range of Motion •Surface Electromyography •Thermography •Other Tests of Regional Dysfunction Are “hard” outcome measures really hard? Imaging of the Spine in Motion: •Cineroentgenography and Videofluoroscopy •Stress X-rays •Motion Studies after CMT •Surface EMG (sEMG) Flexion/Relaxation response US Agency for Healthcare Policy and Research? The correlation of radiographic findings and patient symptomatology in cervical degenerative joint disease: a cross-sectional study Rudy et al Chiropr Man Ther 2015:23;9

• “Conclusion: The results of this study indicate that clinical symptoms such as pain level, headaches, shoulder referral • and hand radiculopathy or numbness are not reliably correlated with radiographic findings of degenerative joint disease in the cervical spine. A small increase in diagnostic accuracy between the presence of neck stiffness and all forms of cervical degenerative joint disease is shown, however, this increase is not at the level expected to change clinical practice.” Role of Research in Refining Theory and Informing Practice What is the goal and how do we score?

●Subluxation? Then study mediator variables like PPTs.

●Biological effects? Then study analog variables like arousal levels.

●Clinical outcomes? Then study outcome variables like VAS, NDI or Oswestry. Evidence in the Era of Documentation: Finding Legitimate Research of Chiropractic •For the chiropractor, two key resources are the National Library of Medicine’s MEDLINE www.pubmed.gov •And MANTIS (formerly CHIROLARS, for Chiropractic Literature and Retrieval System) at www.healthindex.com Evidence Based? Which Technique is Best? What if we don’t presently know the answer to this question in every case? Governments provide licenses to practitioners in all U.S. states to support quality, standardization, and protect the public from providers who lack proper education, cannot provide evidence of continuing education, or fail to properly safeguard their patients. Why Guidelines for Patients, government and 3rd party payors expect that minimum standards will be met in providing Healthcare quality services, before payments are rendered. Chiropractors?

Patients and payors expect that unsubstantiated claims will not be made in advertising or in person regarding services that will be provided. What are trade journals? Can I get an article published if I am selling Critical something? What am I selling? How does science inform guideline Thinking Skills? development? Trade Journals versus Science Journals? How are Professional What are science journals? What is peer review? What is financial Guidelines disclosure? Might there still be conflicts Developed? of interests between scientists and institutions? How can proper professional guideline development hurt or help practitioners? Can we test chiropractic theories? Can we test chiropractic theories? Health and Wellness: Counseling regarding exercise, tobacco cessation, stress management, nutrition? The Mediterranean Diet as an exampe?

www.Oldwayspt.org www.mayoclinic.com www.webmd.com Secondly, being overweight seems to influence the MRI findings at the SIJs as well as the spinal MRI findings, because the prevalence of being overweight was significantly lower in patients with no or few MRI findings compared with the subgroups with spinal degeneration and/or SIJ findings, regardless of age and gender.

a 0–100 scale) [37]. SIJ involvement may cause greater disability compared with These results indicate that patients with spinal involvement due to the SIJ MRI findings are more disabled, with biomechanical involvement of the SIJs in be causally related to the presence of the between-group difference gait and weight-bearing functions. severe axial MRI findings and approximating the threshold that Because the prevalence of being subsequent back pain-related activity patients rate in this secondary care overweight also varied across the MRI limitation. setting as important (minimal clinical subgroups and was highest in people importance difference of 9 on with the most severe MRI findings, both spinal and SIJ, being overweight could Are we familiar with national healthcare goals, and do we act as community advocates for health? Do we speak with our patients regarding their weight and encourage them to stay active, and give them other options like cognitive or behavioral approaches or referrals for group support? Harvard Study on Adult Development+ George Vaillant, MD 80 year longitudinal study; predictors at age 50 that you will be Alive and Well, as opposed to Sad, Dead or Disabled by age 75: a) smoker b) alcoholism c) sedentary/inactive d) overweight e) stable marriage f) coping behaviors +Aging Well, 2008. The Future of Chiropractic

●Chiropractic in the 2010 Affordable Care Act (section 2706 not expected to be in Republican reconcilliation package)

●Chiropractic in the military and VA system

●Chiropractic involvement with Public Health and PHS

●NIH funding of chiropractic research The National Prevention Strategy, Office of the Surgeon General (June 16, 2011) National Prevention Strategy 2011, page 22:

“Evidence-based complementary and focuses on individualizing treatments, treating the whole person, promoting self-care and self-healing, and recognizing the spiritual nature of each individual, according to individual preferences.73 Complementary and alternative therapies for back and neck pain (e.g., , massage, and spinal manipulation) can reduce pain and disability.74” An evidence basis for full coverage of chiropractic in Medicare? • Older people reporting spinal pain have 13% increased risk of mortality per year lived. However, this association is not likely to be causal, with the relevant Spinal Pain confounders contributing to this Associated relationship. Thus, pain in the spine may be part of a pattern of with All poor health, which increases mortality risk in the older Cause population. Mortality - European J Pain 2017 May;21(5):938-948 • Specific ACEs (e.g., verbal and sexual abuse, parental psychopathology, and early parental loss) were associated with the painful medical conditions. Baseline measures of depression, When Emotional bipolar disorder, and posttraumatic stress disorder were also associated with the number Pain Becomes of painful medical conditions. Anxiety and mood Physical: Adverse disorders were found to partially mediate the ACEs-painful medical conditions relationship. We Childhood determined through mediation analyses that ACEs were linked to an increase in anxiety and Experiences, Pain, mood disorders, which, in turn, were associated and the Role of with an increase in the number of painful Mood and Anxiety medical conditions. • Dysregulation of the hypothalamic-pituitary- Disorders adrenal stress response and the theory of reserve capacity are reviewed to integrate our findings of the complex relationships. -J Clin Psychol. 2017 Mar 22. • The Future of Chiropractic Practice, Evidence Informed, Theory Driven: th ●After her 5 adjustment in 3 weeks, the senior immediately proclaims that she can hear in her left ear for the first time in a couple of years? What hypothesis/mechanism would you use to explain this outcome?

●Someone at church read that some chiropractors treat infants with colic, and he questions how could they possibly benefit from chiropractic? What hypothesis/mechanism would you use to explain this outcome?

●A patient denies any more R sciatic pain after a month of chiropractic, but notices left hip pain has returned that she had for years before the sciatica. Why?