Thursday, December 17, 2009

Attention Fellow Chiropractors - It's time to forget the "old school", read this and finally understand Why What You Do Works...

This is reprinted from Dynamic Chiropractic Magazine and once you understand it, proves to be a really powerful article and should provoke the desire to learn more. Many of our chiropractic brethren continue to cling to the old chiropractic vitalistic theories and fail to keep their eyes open for the actual physiology behind how and why chiropractic works. There's no question that chiropractic works....and it works beutifully at that, BUT the question is why does it work?

Read this article by one of the great minds of our profession and you'll begin to understand.

Subluxation and the Nervous SystemBy David Seaman, DC, MS, DABCN

Subluxation remains a topic of heated contention, as does its relationship to the nervous system. Some still view the subluxation as a "bone out of place" that is returned to its proper position with an adjustment. That this view persists is somewhat surprising when we consider that back in 1967, Len Faye first introduced the dynamic subluxation complex to his students at the Anglo-European College of Chiropractic, in Bournemouth, England, and then to us here in the United States in the late 1970s and early 1980s. Faye described the subluxation complex as a joint that hypomobility, myopathological changes in spinal musculature, histopathology of spinal structures, inflammation, and related neurological dysfunction termed "neuropathophysiology."

Joint Complex Innervation
To understand the neuropathophysiology of subluxation, we need to be aware of the innervation of the spinal joint complex. Nociceptors and mechanoreceptors are the primary sensory receptors that innervate joint structures, including synovia, joint capsules, bone, ligaments, tendons, muscles, and blood vessels. The predominant receptor is the nociceptor. More than 90 percent of joint innervation is nociceptive, originally determined by animal studies,1 then confirmed in studies with human spinal joint capsules. (2) In short, there is a paucity of mechanoreceptor innervation of the joint capsule, and an abundance of nociceptive innervation, which should seemingly lead our profession to dig deeply into the nature of nociception. There seems to be less nociceptive innervation of muscles; we have about an equal balance of nociceptive and mechanoreceptive receptors, (3) which means that nociceptive innervation of muscles is still significant.

Clearly, the afferent innervation of the spinal joint complex favors nociceptive receptors. At this point, readers should appreciate that nociceptors are not pain receptors and that nociception does not equate with pain. This misinterpretation is common throughout the extent of health care professions, as texts such as Guyton's Physiology use "pain receptor" and "nociceptor" interchangeably.

Different nerve fiber types are associated with nociceptors and mechanoreceptors, and nerve fibers are classified in two fashions. There is an alphabetical classification, which includes A, B, and C fibers that correspond to both afferent and efferent fibers. There is also a Roman numeral classification system, reserved exclusively for afferent fibers, designated as group I, II, III, and IV fibers, afferents, or units. These classification systems tend to make comprehending the nature of nerve fibers more difficult than it should be.

The best way to view this is from the perspective of fiber size. Generally speaking, there are A-alpha, A-beta, A-gamma, A-delta, B and C fibers, differentiated by their size, with A-alpha the largest and the C fibers being the smallest. Depending on their place of origin, A, B and C fibers can be afferent or efferent. Nociceptive afferents, for example, are either A-delta or C fibers; when these fibers leave peripheral tissues with which to travel to the spinal cord, we know that they are nociceptive. So far, so good, right?

The confusion often begins when the overlap between the alphabetical and numerical system is presented. All we need to know at this point is that A-delta afferents equate to group III units, and C fibers equate to group IV units. Practically speaking, this means that joints are predominately innervated by A-delta/group I fibers and C/group IV fibers. Actually, C-fibers/group IV units are the predominant afferent fibers that leave joints.
When we consider joint innervation for the purpose of understanding the neurology of subluxation, we need to know that C-fibers or group IV afferents are the primary nerve fibers that innervate spinal joints. Stated again, joints are innervated predominantly by C-fibers/group IV afferents.

Compared with nociceptors, significantly fewer mechanoreceptive afferents leave our joints. A-alpha fibers equate with Group Ia and Ib afferents, while A-beta fibers equate to group II units. Significantly more group I and group II units innervate muscle compared to joints.
This heavy concentration of nociceptive fibers in joints suggests that we are basically built to experience joint pain, which bears itself clinically when we consider that most people experience back or neck pain during their lives. Whenever asked why back pain is so common, we should state the simple truth: our spinal joints are densely populated with nerve receptors that sense tissue injury and inflammation, i.e., nociceptors.

Subluxation Neurology
The above description of fiber types can be found in most anatomy, neurology and physiology texts. What we don't read in such texts is that spinal dysfunction/subluxation will influence the activity of the various fiber types. Nociceptors are activated by tissue injury and the chemical mediators that cause inflammation, while mechanoreceptors are stimulated by normal movements. Accordingly, spinal injury is likely to increase the firing of nociceptors however, the activity of mechanoreceptors is likely to be reduced because with injury, inflammation, nociception and pain, there will be less movement afforded to the injured joint and therefore, less mechanoreceptor activation. The outcome of this pattern of receptor activity associated with the subluxation complex will be discussed in future columns. Suffice it to say that increased nociception and reduced mechanoreception can cause pain, visceral symptoms, problems with motor control and proprioception, or no symptoms at all. (4) The important point to appreciate now is that the subluxation complex will alter the firing of spinal tissue nociceptors and mechanoreceptors, and this will lead to various symptoms that we often encounter in the clinical setting that respond to chiropractic care. So, when we think about subluxation, the subluxation complex, or joint dysfunction, we need to think about receptors and afferent fibers.

Although the spinal nerve travels through the intervertebral foramen, it is rare for a bone-on-nerve subluxation to occur. There has to be significant facet hypertrophy or disc collapse, not a common encounter in clinical practice; perhaps 1 percent of the population with back pain suffer with this problem.(5) When such neurocompression does exist, surgery and/or heavy medication is often the choice of care.

What makes the bone-on-nerve subluxation popular is that we can visualize the spinal nerve in books and cadaver specimens; however, we cannot see nociceptors or mechanoreceptors. For us humans, it is far easier to believe something that we see, compared with something that is invisible to the naked eye. Despite this tendency, we must understand that spinal joints and muscles have a massive nociceptive and mechanoreceptive innervation pattern that is profoundly influenced by the subluxation complex. While not visible, they are the reason patients come to our offices.

1. Hanesch U, Heppleman B, Messlinger K, Schmidt RF. Nociception in normal and arthritic joints: structural and functional aspects. In Willis WD. Ed. Hyperalgesia and Allodynia. New York: Raven Press; 1992:p.81-1062. McLain RF. Mechanoreceptor endings in human cervical facet joints. Spine 1994;19:495-501.
3. Burt AM. Textbook of Neuroanatomy. Philadelphia: WB Saunders; 1993:p.311.4. Seaman DS, Winterstein JF. Dysafferentation, a novel term to describe the neuropathophysiological effects of joint complex dysfunction: A look at likely mechanisms of symptom generation. J Manip Physiol Ther 1998;21:267-80.5. Seaman DR, Cleveland C. Spinal pain syndromes: nociceptive, neuropathic, and psychologic mechanisms. J Manip Physio Ther 1999;22:458-72.David Seaman, DC Port Orange, Florida

A BIG THANK YOU goes out to Dr. Seamans for his continued dedication to our profession, continued research and his commitment to teaching us everything he knows.

'nuff said

Dr. T


Dr. Narson is a 2-term past president of the Florida Chiropractic Association’s Council on Sports Injuries, Physical Fitness & Rehabilitation and was honored as the recipient of the coveted Chiropractic Sports Physician of the Year Award in 1999-2000. He practices in Miami Beach, Florida at the Miami Beach Family & Sports Chiropractic Center; A Facility for Natural Sports Medicine.

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Friday, December 4, 2009

Tiger Woods: Who's At Fault???

As a physician that takes care of athletes I felt I needed to weigh in on this issue of Tiger Woods, the car crash and the infidelity with his wife.

The media's money line continues to be about his "fall from grace as a role model". Well, he hasn't fallen from grace with me as a role model because for me, I only looked towards Tiger as a role model for my golf game. And, for my golf game, he remains the best role model on planet Earth.

It was nice to think he was so clean cut, neat, tidy and beyond reproach in other aspects of his life. That would have made for the whole package. But whose fault is it if we as citizens and especially we as parents to help our children choose their role models specifically for the achievements they've made and not for their entire existence.

I love sports medicine because I love competition, I love sports and it helps me stay connected with my younger years as an athlete. Sometimes I marvel in what athletes can do, the time and dedication they put into their sport, but that's typically where it ends.

My role model for my marriage are two sets of people that I've known for quite a long time. My parents and my grandparents. I've seen my parents go through relationship ups and downs and now they are in their 45Th year. My grandparents were married for 64 1/2 years until my grandpa Ben died when he was 90. My grandmother just passed earlier this year at 99. But nearly 65 years of a solid relationship. Wow, that's to be admired and modeled.

I use my parents and grandparent as role models for marriage and parenting along with some others. Neither my dad or grandfather played golf, so I think I'll stick with advice from Tiger about my swing.

Be we as people, as parents...and those of you in traditional media must stop putting sports figures and entertainers on these high pedestals. They may be good at their chosen craft, but it doesn't make them role models for all aspects of life. I don't think anyone is.

Babe Ruth was great with a baseball bat. But I don't take advice living a clean life from his life's example. However "The Babe" was extremely generous when it came to orphaned children and that is something people could learn from.

It's not the athlete that has to learn, it's us. Pick and choose your role models for their expertise, not in Toto. Otherwise, eventually, you'll be disappointed, but I won't.

I would hope people are more true to the people in their lives, but,'s their life.

If Tiger chooses to take a Mulligan on this, I'm sure it will cost him dearly and I wish him the best in his personal life.

But I'll still be analyzing his swing and his golf game just the same because in the game of Golf, he's the best. But with relationships, I look to my grandparents, my parents and my wife.

'nuff said.

Dr. T

Dr. Narson is a 2-term past president of the Florida Chiropractic Association’s Council on Sports Injuries, Physical Fitness & Rehabilitation and was honored as the recipient of the coveted Chiropractic Sports Physician of the Year Award in 1999-2000. He practices in Miami Beach, Florida at the Miami Beach Family & Sports Chiropractic Center; A Facility for Natural Sports Medicine.