Archive for June, 2017

Complementary and Alternative Medicine Use in the US Adult Low Back Pain Population

Complementary and Alternative Medicine Use in the US Adult Low Back Pain Population. Global Advances in Health and Medicine January 2016; Vol. 5; No. 1; pp. 69-78


Neha Ghildayal, Pamela Jo Johnson, MPH, PhD, Roni L. Evans, DC, MS, PhD, and Mary Jo Kreitzer, PhD, RN.

The data for this article was from the 2012 National Health Interview Survey (NHIS), which is the most current nationally representative data available on CAM

health practices. Data was collected on 34,525 adults. “A major strength of this study was that it used a large, nationally representative survey of the US adult population with LBP and included a comprehensive list of CAM therapies.”



1) “A key goal of healthcare for patients with chronic back pain is to maximize their functional status so that they are able to carry out activities of daily living.”

2) “Many people suffering from LBP have found conventional medical treatments to be ineffective and unreliable for treating their pain. Therefore, due to

dissatisfaction with conventional treatments for LBP, individuals suffering from LBP are increasingly turning to complementary and alternative medicine (CAM) to find relief.”

3) Low back pain (LBP):

• Costs the United States healthcare system about $100 billion a year.

• Resulting in over 150 million lost workdays per year and $16 billion annually

in lost productivity in the US.

• More than 80% of adults in the US will experience it at some point during

their lifetime.

• Is a major cause of functional limitations and disability:

•• are 3 times more likely to have limited functional ability

•• are more than 4 times likely to experience serious psychological distress

• “People with back pain suffer from worse physical and mental health than

people without back pain.”

4) “A growing body of evidence supports the use of CAM for improving back pain outcomes, with back pain being the most common condition for which patients

use CAM.”

5) “Overall, chiropractic manipulation was the most prevalent CAM therapy used within the LBP population.” [Important]

6) “The majority of respondents (58.1%) who used CAM in the past year forback pain perceived a ‘great deal’ of benefit.”

7) “For people with severe LBP, turning to CAM may seem a better alternative due to its more conservative, noninvasive nature as compared to more conventional medical treatments such as epidural steroid injections, surgeries, and prescriptive medications—all which may carry higher risks than CAM treatments.”

8) Also, “those with severe pain may have exhausted all other possibilities and may be looking for any possibility of relief” and as such seek CAM approaches.

9) People may also seek CAM because of it low associated treatment risks.

10) “CAM therapies are becoming an increasingly important component of care for people with LBP.”

11) Over 40% of the US population used some form of CAM in the past year, with higher use reported among those with back pain.

12) The most popular therapies used in the LBP population included herbal therapies, chiropractic manipulation, and massage.

13) “The majority of the LBP population used CAM specifically to treat back pain, and most adults who used CAM for back pain perceived a great deal of benefit.”

14) “CAM use appears to be an important and growing part of healthcare for the back pain population.”



Limitations from this study include that the authors did not distinguish between acute and chronic back pain patients, which would undoubtedly influence the

percentages of perceived benefits from the various approaches. Chiropractic remains the leader of outpatient management choices for CAM for LBP, with an extremely high patient satisfaction rate; yet only 15% of those with LBP are using chiropractic.

Surprisingly, acupuncture is only being used by 2% of those with low back pain. An important aspect of this study (mentioned but not quantified) is that all of the CAM approaches are extremely safe, with a very low risk of adverse occurrences. Lastly, a mentioned but underemphasized aspect of this study is that many who chose to use CAM do so because traditional approaches to the management of their back pain was ineffective.

[Most chiropractors do not consider chiropractic to be “alternative” or “complementary” to medical practice, but rather a scientifically proven, non-drug, and non-surgical approach to healthcare problems, including musculoskeletal pain].

Glucose Metabolic Changes in the Brain and Muscles of Patients with Nonspecific Neck Pain Treated by Spinal Manipulation Therapy

Glucose Metabolic Changes in the Brain and Muscles of Patients with Nonspecific Neck Pain Treated by Spinal Manipulation Therapy:

A [18F] FDG PET Study {a radioactive glucose PET scan study}. Evidence-Based Complementary and Alternative Medicine Volume 2017

 The study has four important findings:

  • The brain is affected by chiropractic adjusting
  • Chiropractic adjusting inhibits pain
  • Chiropractic adjusting inhibits muscle tone, improving ranges of motion
  • Chiropractic adjusting inhibits sympathetic tone, a key influence on immunity and other factors in systemic wellness


PET (positron emission tomography) scan is a powerful neuroimaging technique to investigate neuronal activity in the human brain and muscles.

18F-labeled fluorodeoxyglucose (FDG) is a radioactive analogue of glucose, and is an excellent imaging marker of brain glucose consumption (brain metabolic activity).


A PET scan can visualize brain metabolic changes induced by spinal manipulative therapy (SMT). The aim of this study was to investigate changes in brain and muscle glucose metabolism using positron emission tomography with fluorodeoxyglucose.


Twenty-one male volunteers were recruited for the present study. Spinal manipulative therapy (SMT) was applied using an Activator in accordance with the Activator Methods protocols. The Activator applied impulses to specific vertebrae or joints. “SMT was performed on the subject in a prone position without movements such as cervical rotation, lateral flexion, and extension, in order to prevent the muscular FDG uptake due to muscle contractions during the therapeutic procedure. SMT was carried out on the whole spine, the scapulae, the ilium, and the sacrum, as necessary for each subject. The mean number of SMT adjusted sites was 8 per subject.”


Glucose metabolism of the brain and skeletal muscles was measured. Also measured was salivary amylase levels as an index of autonomic nervous system (ANS) activity, muscle tension, and subjective pain intensity. “Other measurements indicated relaxation of cervical muscle tension, decrease in salivary amylase level (suppression of sympathetic nerve activity), and pain relief after SMT.” “SMT on all subjects was performed by the same Chiropractor, who was an advanced practitioner of Activator Methods.”


 1) Spinal manipulation therapy (SMT) has “been applied mainly to musculoskeletal problems such as neck pain or low back pain.”

2) Previous studies have shown that “SMT has beneficial clinical effects, including pain relief and reduction of blood pressure.”

3) “The intensity of subjective pain was evaluated using a 0–10 visual analog scale (VAS) before and after SMT in the treatment condition.”

4) “Cervical muscle tension was measured bilaterally at the superior part of the trapezius muscle using a tissue hardness meter.”

5) “Salivary amylase levels were measured for each subject using an amylase monitor to evaluate changes in autonomic nervous system (ANS) function.”

6) “Salivary 𝛼-amylase levels correspond to plasma norepinephrine levels and are utilized as an accessible measure of sympathetic nervous reactivity in stress research, with lower levels indicating lower activity.”

7) “We observed multiple changes in brain activity after SMT.”

8) “The findings of the present study demonstrate how stimuli to the mechanoreceptors of the joints and skin during SMT are processed in the brain.”

9) “Brain processing after SMT may lead to physiological relaxation via a decrease in sympathetic nerve activity.” [Key Point]

10) “Comparisons of VAS pain scores in the treatment condition revealed a significant decrease after SMT.”

11) “Cervical muscle tension was significantly reduced bilaterally after SMT.” “Our results suggest that stimulation of joints during SMT induced relaxation of reflexive muscle tension.”

12) “Salivary amylase level decreased significantly after SMT.”

Changes Following Spinal Manipulation

-Visual Analogue Pain, VAS, Significantly Reduced By About 65%

-Muscle Tension Significantly Reduced

-Salivary Amylase (as an indicator of norepinephrine sympathetic tone)Significantly Reduced

-Cingulate Cortex (part of the limbic system)emotions, learning, memory

-Increased Cerebellar Vermis (spinal proprioception)posture/movement, emotions Increased

-Somatosensory Cortex (pain perception/localization)Reduced

-Prefrontal Cortex (executive function) personality, planning, decision making, moderating social behavior Reduced

13) The Cerebellar Vermis:

  • “The Cerebellar Vermis receives somatic sensory information from the spinal cord and via the vestibulospinal tract or reticular nuclei of the brainstem through the spinal cord, connecting indirectly or directly with motor cells on the ventral horn. These systems control involuntary muscular tension and reflexes.”
  • The cerebellum has many roles in non-motor functions.
  • “The cerebellum is also thought to have a functional role as an integrator of multiple effector systems, including affective processing, pain modulation, and sensorimotor processing.”
  • The Cerebellar Vermis is activated during mental recall of emotional personal episodes in humans. 14) “Our assessment of body responses in this study showed relaxation of muscle tension and decreased salivary amylase levels—phenomena that are associated with reduced sympathetic nerve activity.”[Key Point]

14) SMT stimuli to the joints may result in “decreased sympathetic nerve activity.” [Key Point]

15) These authors believe that the relaxation of muscle tone documented in this study occur as a consequence of two mechanisms:

  • Inhibition of sympathetic autonomic nervous activity
  • Improvement of the range of joint movement

16) “We observed that SMT stimulus induced physical responses such as muscle tension relaxation, pain relief, and reduced amylase secretion.”

17) “Neural inputs evoked by SMT stimuli via various receptors in muscles, tendons, and joints may ascend to the somatosensory areas of the brain through the medial lemniscal system. “

18) “In summary, we observed metabolic changes in the brain and skeletal muscles, as well as reductions in subjective pain, muscle tension, and salivary amylase, after SMT intervention. These results may be associated with reduced sympathetic nerve activity,” suggesting that SMT induces sympathetic inhibition (“relaxation”).

20) “The brain response to SMT may reflect the psychophysiological relaxation that accompanies reduced sympathetic nerve activity.”


This study used the most sophisticated technology to date to assess the affects of chiropractic spinal adjusting:

  • Changes in radioactive glucose metabolism as measured with a PET scan in both the brain and in muscles
  • Changes in muscle tone
  • Improvement in pain using a VAS
  • Changes in sympathetic nervous system production and release of norepinephrine (sympathetic tone)


Akie Inami, Takeshi Ogura, Shoichi Watanuki, Mehedi Masud, Katsuhiko Shibuya,Masayasu Miyake, Rin Matsuda, Kotaro Hiraoka, Masatoshi Itoh, Arlan W. Fuhr,Kazuhiko Yanai, Manabu Tashiro:Takeshi Ogura is a chiropractor.Arlan Fuhr is a chiropractor and owner of Activator Methods International, Ltd.

This study was done at Tohoku University Graduate School of Medicine, Sendai, Japan, along with the Division of Cyclotron Nuclear Medicine at Tohoku University. This article has 47 references.




What You Need to Know About Vaping

By Bart N. Green, DC, MSEd, PhD, Kevin Rose, DC, MPH and Claire Johnson, DC, MSEd, PhD

Editor’s Note: This article has been modified from the original, which was directed toward a professional (doctor) audience.

Smoking can be harmful in so many ways. Not only are there a multitude of negative health consequences from smoking, but recent research even shows a connection between smoking and back pain.1 Thus, any aid that can help people stop smoking is of interest. However, what happens if the aid causes new problems? The health impact, use and safety of electronic cigarettes (e-cigarettes) are still under investigation. We offer a brief overview on this important public health issue.

1. What Is Vaping?

When someone smokes traditional cigarettes, they inhale the smoke of burning tobacco. However, someone using an electronic device, such as an electronic cigarette, inhales vaporized chemical liquids – thus the term vaping.

The liquids in e-cigarettes often contain nicotine or other drugs, as well as scents or flavors to increase the pleasure of the experience. E-cigarettes are now the most commonly used smoking product by U.S. youth2 and the number of users continues to rise.

2. What Are the Arguments in Favor of Vaping?

Vaping is considered an option to reduce the harmful effects of traditional tobacco cigarette smoking and as an aid to help people quit. The thought is that e-cigarettes might help someone step down to lower levels of addictive substances (e.g., nicotine) and reduce the amount of carcinogens inhaled. Some studies have shown the use of e-cigarettes may help some people to reduce or stop smoking.3

3. What Are the Potential Harms of Vaping?

Although e-cigarettes do not use burning tobacco, they still contain harmful substances. Issues with vaping include:

  • Intake of vaporized substances in e-cigarettes may be harmful.4-6
  • E-cigarettes have vapors that can include formaldehyde, acetaldehyde and metal nanoparticles.7
  • E-cigarette devices could potentially be used to intake illegal or other potentially harmful drugs,8  such as synthetic drugs or cannabis.9-10
  • Secondhand vapors are harmful to those who are exposed.4-5
  • There is potential harm with short-term use, although the effects of long-term use on health are unknown.
  • Targeting minors with bright colors and candy flavors, and re-establishing the culture that smoking is “cool” or “safe,” may entice youth to start or continue smoking.
  • The potential exists for physical danger from e-cigarettes (e.g., explosions and burns).

4. What Can You Do to Learn More?

In addition to speaking with your doctor, helpful resources on e-cigarettes include the following:

  • The U.S. Surgeon General has a “Know the Risks” fact sheet on youth and e-cigarettes.
  • The American Heart Association has a fact sheet on e-cigarettes and public health.
  • The Centers for Disease Control and Prevention (CD) has a website with information for patients.
  • The American Lung Association has a statement on e-cigarettes.
  • The American Public Health Association has a policy statement on the regulation of e-cigarettes.

5. So, Is Vaping Good or Bad?

Although vaping is touted as an aid for smoking cessation to help those who are addicted to tobacco, this does not mean vaping is harmless. Harms may be experienced by the person vaping, as well as those who are inhaling the vapors secondhand. The best thing for your health is to refrain from smoking at all – electronic or tobacco.


  1. Green BN, Johnson CD, Snodgrass J, et al. Association between smoking and back pain in a cross-section of adult Americans. Cureus, 2016 Sep 26;8(9):e806.
  2. Singh T, Kennedy S, Marynak K, et al. Characteristics of electronic cigarette use among middle and high school students – United States, 2015. MMWR Morb Mortal Wkly Rep, 2016 Dec 30;65(5051):1425-1429.
  3. Hartmann-Boyce J, McRobbie H, Bullen C, et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev, 2016 Sep 14;9:CD010216.
  4. Pankow JF, Kim K, McWhirter KJ, et al. Benzene formation in electronic cigarettes. PLoS One, 2017 Mar 8;12(3).
  5. Hess IM, Lachireddy K, Capon A. A systematic review of the health risks from passive exposure to electronic cigarette vapour. Public Health Res Pract, 2016 Apr 15;26(2).
  6. Kaisar MA, Prasad S, Liles T, Cucullo L. A decade of e-cigarettes: limited research and unresolved safety concerns. Toxicology, 2016 Jul 15;365:67-75.
  7. Drug Facts: Electronic Cigarettes (e-Cigarettes). Washington, DC: National Institutes of Health, National Institute on Drug Abuse, May 2016.
  8. Blundell MS, Dargan PI, Wood DM. The dark cloud of recreational drugs and vaping. QJM, 2017 Mar 9.
  9. Giroud C, de Cesare M, Berthet A, et al. E-cigarettes: a review of new trends in cannabis use. Int J Environ Res Public Health, 2015 Aug 21;12(8):9988-10008.
  10. Budney AJ, Sargent JD, Lee DC. Vaping cannabis (marijuana): parallel concerns to e-cigs? Addiction, 2015 Nov;110(11):1699-704.

Bart Green, DC, MSEd, PhD, is a full-time corporate health chiropractor; a part-time faculty member at National University of Health Sciences; and a member of the APHA-CHC. He has extensive experience working in interdisciplinary pain management teams for patients with chronic non-cancer pain.

Kevin Rose, DC, MPH, is a public health professor at the Southern California University of Health Sciences and a diplomate of the American Board of Chiropractic Orthopedists.

Claire Johnson, DC, MSEd, PhD, is a professor at National University of Health Sciences and editor in chief of JMPT, the Journal of Chiropractic Medicine and the Journal of Chiropractic Humanities. She also serves as the communications chair for the APHA-CHC.

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Osteopathic Manipulative Treatment Improves Heart Surgery Outcomes: A Randomized Controlled Trial Annals of Thoracic Surgery

(The Society of Thoracic Surgeons)


January 18, 2017; Vol. 16 [epub]

Vittorio Racca, MD, Bruno Bordoni, MS, Paolo Castiglioni, PhD, Maddalena Modica, MS, Maurizio Ferratini, MD


Cardiology Rehabilitation Center and Biomedical Technology Department, Santa


Maria Nascente Institute-IRCCS, Don C. Gnocchi Foundation, Milan, Italy

The aim of this study was to assess whether osteopathic manipulative treatment


(OMT) contributes to post heart surgical sternal pain relief and “improves

postoperative outcomes.”


Eighty post-sternotomy patients were randomly allocated to receive a standard ,cardiorespiratory rehabilitation program alone (control group) or standard cardiorespiratory rehabilitation with spinal manipulation. Pain intensity and respiratory functional capacity were quantified by the Visual Analogue Scale score and by a standardized breathing test, at the start and end of rehabilitation.




1) “Controlling sternal pain after heart surgery is important to reduce the risk of postoperative complications, but pain is often undertreated because of contraindications and side effects of analgesic drugs.” Postoperative pain

“diminishes patients’ ability to cooperate, delays recovery and may lead to worse outcomes.”

2) “Inadequately controlled postoperative pain negatively affects the immune system, wound healing, and pulmonary function.”

3) Pain can “activate the sympathetic system, increasing demands on cardiac function and favoring cardiac complications such as tachycardia, arrhythmia, or myocardial ischemia.”

4) “Uncontrolled postoperative pain is often responsible for neurologic

complications, episodes of delirium, and other acute confusional states with a multifactorial pathogenesis.”

5) “In addition to discomfort and suffering, pain may cause sleep deprivation, may delay return to normal functioning, and may have nociception-induced adverse effects on cardiovascular functioning and pulmonary morbidity.”

6) Pain intensity was measured using a 10-cm visual analogue scale (VAS)

ranging from “no pain at all” to “unbearable pain.”

7) The improvement in respiratory function was more marked in the

[manipulation] group. “The inspiratory volume was significantly greater in the [manipulation] group.”

8) “Hospitalization was significantly shorter in the [manipulation] group than in the control group (19.1 ± 4.8 versus 21.7 ± 6.3 days).”

9) “Anti-inflammatory drugs may impair renal function, interact with platelet

aggregation, and increase the risk of gastrointestinal damage and bleeding;

analgesic drugs have detrimental neurologic effects and negatively affect visceral motility; and opioids may decrease survival during in-hospital resuscitation and increase duration of hospitalization.”

10) The manipulation in this study began the day after being discharged from the surgery department, and was administered for 5 days.

11) At the end of rehabilitation:

  • The manipulation group had a lower Visual Analogue Scale score.
  • The manipulation group had higher mean inspiratory volume.
  • The manipulation group had shorter stays.


“At the end of the rehabilitation program, the reduction in perceived pain was more marked in the [manipulation] group and the VAS score was significantly lower in [manipulation] patients than in controls.”


13) “The combination of standard care with [manipulation] is effective in

inducing pain relief and functional recovery, and significantly improves the

management of patients after heart surgery with sternotomy.”

14) These authors reference articles that show spinal manipulation does the


  • “Intervenes in the process that transforms nociceptive information into the

subjective experience of pain.”

  • “Controls pain after abdominal surgery.”
  • “Facilitates recovery of functional ability after coronary artery bypass graft


  • “Improves cardiac function.”
  • “Reduces analgesia that patients with musculoskeletal problems need after

elective knee or hip arthroplasty.”

15) Of the patients who took pain medications, side effects occurred in

22.5%; these side effects included nausea, vomiting, dizziness, difficulty

concentrating, drowsiness, light-headedness, abdominal discomfort, constipation, dry mouth, itching, rash, and blurred vision.

16) Nonsteroidal anti-inflammatory drugs “may increase the risk of thrombotic cardiovascular events, including myocardial infarction, and of gastrointestinal bleeding.”

17) “Overuse of opioid analgesics induces side effects that can delay recovery and worsen the outcome.”

18) “This is the first randomized controlled trial evaluating the effect of OMT on both pain perception and functional outcomes after heart surgery.”

19) “The main results of our study are that OMT treatment decreases dramatically the level of perceived pain, and substantially improves the functional capacity in terms of inspiratory volumes.”

20) “We also observed a reduced hospitalization, on average by more than 2

days, in the OMT-treated group, that could be consequence of the improved

functional capacity.”

21) The gating mechanism of spinal manipulation would have an “analgesic effect, reducing somatic reactivity and muscle spasms.”

22) “The lower pain intensity in the OMT group at discharge suggests that OMT had a direct analgesic effect.” “The shorter duration of hospitalization

in the OMT group might suggest a more rapid functional improvement.”

23) “It can be hypothesized that the pain-relieving action of [manipulation]

enables lower doses of analgesic drugs.” “Our study suggests that [manipulation] may reduce the use of analgesic drugs, lowering the risk of adverse effects during rehabilitation programs.”

24) “The efficacy of [manipulation] on rehabilitation outcomes can therefore be summarized in terms of a more pronounced reduction in pain intensity and a greater improvement in rib cage mobility, both factors that might have played a role in shortening hospitalization.”

25) “Manipulative treatment is safe, free of side effects, and well

accepted by patients. Moreover, it is relatively inexpensive and only moderately time consuming. For these reasons, cardiac rehabilitation programs should include MT.”

26) Manipulation “should begin before the development of the respiratory

sequelae associated with reduced chest and diaphragm mobility.”

27) “We believe that adding [manipulation] to traditional care programs 1 week after surgery is neither too soon nor too late.”

28) These authors suggest that postoperative manipulation “can be expected to improve the quality of patient care and its cost efficiency, by leading to better and more rapid outcomes and by reducing morbidity.”




This amazing study supports that all post surgical patients should start spinal manipulation within 5 days of surgery, during the rehabilitation process. The benefits include:


  • Significantly reduced pain
  • Significantly improved function
  • Reduced hospital stay and it associated reduced costs
  • Avoidance of drugs and all the risks (complications and side effects)

associated with pharmacology

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