b'ComplianceLEGAL NUTRITIONCouncilANJC Leadership ANJC Leadership LEGAL EASE NUTRITION REHAB Council Executive Directors UPDATE LEGAL Q&A CHIROASSISTINSURANCE Update INSURANCE Update Legislative UpdateWho Responds Best toTECHNIQUE CouncilSpinal Manipulation?By Dr. David GraberChair, Council on Technique and Clinical ExcellenceNot every patientinformation to calculate the bodysone week. For patients with chronic MedicareQ&Aresponds the same tocurrent position.pain (>12 weeks symptoms), those chiropractic adjust- Atrophy of the multifidus muscle isOUR HEALTHreporting improvement in one month ments or high velocity,found in patients with back pain,had a six-times greater improvement low-amplitude (HVLA)lumbar radiculopathy, and lumbarat three months compared to those spinal manipulationdegenerative kyphosis. There isunimproved at one month. Acute low (SMT). That fact isincreased fat infiltration visualized onback pain patients respond better obvious. Are there certain variablesMRI to the multifidus muscle in thosethan chronic low back pain patients. which will allow us to predict who ispatients with lumbar radiculopathy,Low back pain patients respond better more likely to respond to SMT? Well,lumbar degenerative kyphosis, andif at least one hip has more than 35 there are some evidence-based patientdecreased lumbar range of motion. degrees of internal rotation. The main characteristics that can predict who willpredictors of improvement in patients respond better than others. Below areMinimal Facet Joint Degeneration: Inwith thoracic spine pain were a greater several factors found in the research onlumbar spine back pain patients, SMTdecrease in both pain intensity and patient responsiveness characteristicsresponders tended to have a lowertenderness.to SMT. Using these, we can makeprevalence of severely degenerated better prognoses for the patientsfacets than non-responders accordingFor cervical spine manipulation, the under our care. to a 2019 study. MR imaging studiespresenting symptoms of neck pain, Spinal Segmental Stiffness:also found that SMT respondersshoulder, arm pain, reduced neck, Researchers have found that patientswere also characterized by significantshoulder, arm movement, stiffness, with at least one hypomobile vertebralincreases in post-SMT apparentheadache, upper, mid-back segment, or spinal segmental stiffnessdiffusion coefficient (ADC) values atpain, and none or one presenting beyond normal respond better todiscs associated with painful segmentssymptom have been found to be HVLA thrust manipulation. Further, theidentified by palpation. Curiously, theresignificant predictors for an immediate thrust SMT improved pre-SMT spinalwas no significant difference in otherimprovement. segmental stiffness, while non-thrustspinal degenerative features found onPatients with chronic and acute low manipulation did not. Interestingly, thisMR imaging, such as Modic changes. back pain reporting that they were included both global stiffness (stiffnessMore Localized Symptoms: Patientsmuch better or better on the of the underlying tissues throughoutwith lumbar pain and no symptomsPatient Global Impression of Change the measurement) and terminalextending distal to the knee have beenscale at one week after the first stiffness (stiffness at the measurementshown to be better responders to SMT.chiropractic visit were four to five times end point).Patients with cervical pain with referralmore likely to be improved at both Multifidus Activation: Decreased acti- proximal to the shoulder or those withone and three months compared with vation and recruitment of the multifidicervical spondylosis without radicu- patients who were not improved atmuscles is a common feature in spinallopathy have been shown to respondone week.segmental dysfunction. Those patientsbetter to SMT. For headaches, thePoor Responder Characteristics: with increased multifidus thickness andabsence of light-headedness indicatedPatients who respond poorly to SMT activation sustained over a one-weekhigher odds of reduction in headachemost often have one or more factors follow-up period after SMT have beenfrequency in the long term.as the reason: Inappropriate technique shown to be good responders. SMTShorter Duration of Symptoms: Spinalapplied, poorly executed technique, activates the multifidus muscle withpain symptom duration of less thanunsuitable patient selected, and/or the lasting effects in these patients. 30 days for the cervical spine, and 16condition was not appropriate for the The multifidus is distinctive for thedays for the lumbar spine have a bettertechnique or treatment. unusually high number of muscleimmediate response to SMT.spindles it contains. Muscle spindlesEarly Symptomatic Response to SMT:David Graber, DC, CCSP, is the are sensory receptors in muscles thatAcute neck pain patients (<4 weekschairperson of the ANJC Council on detect changes in the length of thesymptoms) that reported improvementTechnique and Clinical Excellence.muscle and report this informationin one week have shown a three-timesHe maintains a private practice in back to the central nervous system.greater improvement at three monthsParsippany, NJ. He can be reached at:The central nervous system uses thecompared with those unimproved atDrDavidGraber@gmail.com.www.njchiropractors.com I 17'