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Arthritis and Chiropractic: Whats the Evidence?

Posted on 19. Sep, 2018 by in Learn, Research

 Arthritis and Chiropractic Care: is there any evidence for a Manual Functional Approach?

Joseph J Ierano BSc DC BCAO

Doctor of Chiropractic

 

The literature, whilst relatively scarce regarding chiropractic and arthritis treatment, contains many studies that examine chiropractic care of the patient with arthritis and support the notion that all arthritides are not a contraindication to chiropractic care. This is a very brief discussion about a subject not commonly exposed to the public: that chiropractic many present, for many people, especially the elderly and the young, who are more susceptible to drug interactions or damage, a viable solution to relief of the common non-specific joint and arthritic pain.

 

We shall consider the common Osteoarthritis, not medical conditions such as Rheumatoid Arthritis (RA), Juvenile RA, Psoriatic Arthropathies and/or the multitude of systemic manifestations of joint inflammation.

 

A Global Burden

So what is the number one condition in humans that causes the most suffering? Is it Heart disease? Cancer? Well they rate highly, yes. But Low Back Pain is worse.

 

Here is what the World Health Organisation (WHO)[1]state on their web site:

 

Key facts

  • Musculoskeletal conditions are the second largest contributor to disability worldwide, with low back pain being the single leading cause of disability globally.
  • Musculoskeletal conditions and injuries are not just conditions of older age– they are relevant across the life-course. Between one in three and one in five people live with a painful and disabling musculoskeletal condition.
  • Musculoskeletal conditions significantly limit mobility and dexterity, leading to early retirement from work, reduced accumulated wealthand reduced ability to participate in social roles.
  • The greatestproportion of persistent pain conditions is accounted for by musculoskeletal conditions.
  • Highly prevalent among multi-morbidity health states, musculoskeletal conditions are prevalent in one third to one half of multi-morbidity presentations, and very commonly linked with depression 

(emphasis mine)

Pain and spinal degeneration

Please note the distinction between the terms “chiropractic care” and “manipulation”. Not all chiropractic visits consist solely of manipulation. As far as the existence of arthritis in the spine, or more properly termed Osteoarthritis (OA), or Degenerative Disc Disease (DDD), we shall briefly cite several studies.

 

A study published in the Journal of Neuroimaging in 1991 showed that in patients without low back pain undergoing MRI, 39% of this normal group had evidence of DDD.[2]A New England Journal of Medicine Article in 1994 found similar results.  It demonstrated that of 98 subjects without low back pain, 52% had DDD on MRI.[3]This can be found in the thoracic spine (upper back) in the Journal of Bone and Joint Surgery in 1995.  Thoracic MRI’s were performed in 90 asymptomatic adults. 73% of these patients had DDD at least one level.[4]This also goes for the cervical spine[5]with prevalence of DDD increasing with age. There are no studies that determine that DDD is always a painful condition that correlates with symptoms.

 

Therefore, we may assume that the DDD creates a situation where other functional problems eventuate, such as the case where arthritic joints or degenerative discs move abnormally predisposing them to injury.[6]

                     

Do the Young get Back Pain?

Many studies show that back pain exists in adolescents and the young. More alarmingly a recent study in The Journal of Public Health[7]showed:

 

Two large, independent samples show adolescents that experience back pain more frequently are also more likely to smoke, drink alcohol and report feelings of anxiety and depression. Pain appears to be part of the picture of general health risk in adolescents.

 

Do we give more medicine and drugs to these groups? How do we deal with such shocking associations of what was commonly thought of as an older person’s ordeal?

 

Medical research says Chiropractic helps arthritis

Medical researchers Fiechtner and Brodeur[8]state clearly that arthritic conditions may benefit from chiropractic, with reflexive muscular function being normalised during spinal manipulation:

 

Manipulation is practiced primarily by chiropractors and osteopaths and is one of the most commonly utilized alternative treatments for rheumatic diseases… Manipulation has been shown to decrease joint pain and normalize function. The mechanisms of action, however, are not well understood. Current theories propose an imbalance of muscle activity is a source of pain that manipulation can relieve through reflexive actions. Such muscle imbalances would exacerbate rheumatic and arthritic conditions, suggesting that manipulation may be an important therapy that is appropriate for early conservative care as part of a comprehensive treatment program.

 

Recent research published in JAMA by Goertz & Long et al[9]also points to benefit of chiropractic within medical management also.

 

Chiropractic care, when added to usual medical care, resulted in moderate short-term improvements in low back pain intensity and disability in active-duty military personnel. This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for low back pain, as currently recommended in existing guidelines

 

Drug dangers

Other authors[10]have evaluatedthe rationale behind the most commonly used treatments of osteoarthritis, including nonsteroidal anti-inflammatory drugs (NSAIDs), and to assess more effective conservative treatment options. In conclusion they state:

 

The rationales for using NSAIDs in the treatment of osteoarthritis is controversial and openly contested. Given the detrimental effects of NSAIDs on joints and other organs, their use should be discouraged and their classification as a first choice conservative treatment should be abolished. A truly effective and conservative approach to the treatment of osteoarthritis should include chiropractic manipulation, essential nutrient supplementation, exogenous administration of glucosamine sulfate and rehabilitative stretches and exercises to maintain joint function.

 

Even more so now, the class of drugs that are ‘Opioids’ are in serious question, from becoming a leading cause of death to serious overdose. Australian researchers Mathieson and de Luca have both shown problems in ineffectual drug treatments for back pain, and impact of ageing on chronic back pain, which may create greater need for safer non-drug treatments.

 

De Luca and Ferreira stated[11]:

 

Spinal pain in older people is a global health problem; the physical and personal impact of spinal [sic] directly threatens efforts to support healthy ageing.

 

Mathieson et al stated[12]:

 

However, the evidence for the efficacy and safety of anticonvulsants in low back and lumbar radicular pain is unclear and can be resolved only by high-quality evidence produced from placebo-controlled trials

 

Which also reflects the paucity of evidence for many drugs against placebo: the phenomenon of getting better by just believing in the treatment.

 

 

“Alternative” therapies widely used by arthritis sufferers

Use of chiropractic is a prominent part of the medical literature, and commonly praised. Saag, from the Department of Internal Medicine, University of Iowa College of Medicine, wrote:

 

Advances in rheumatologic arthritis health services research continue to be of interest to clinical rheumatologists and arthritis researchers interested in healthcare delivery and policy. New therapeutic programs have been proposed to better coordinate efforts between generalists and specialists. Many arthritis patients also seek alterative therapies. Of these, chiropractic care is one of the most common nontraditional therapies.Chiropractic management appears to be as cost-effective as traditional back care in certain settings.[13](Italics mine)

 

Surgery for Disc Degeneration

To date, not one placebo controlled study exists testing whether spinal decompression surgery is actually worthwhile – and yet thousands upon thousands of low back disc surgeries have been done.  Placebo controlled studies have been done on the shoulder and the knee, to find that these surgeries are useless and dangerously expose patients to risk. That is not to say that joint replacements, where indicated, are very successful. But merely doing arthroscopies and minor procedures on knees and upper limb has become the exception, not the rule.

 

A recent study ruled out even paracetamol in the effective treatment of back pain in a dramatic turn around[14], then it was “retracted”. What is the public to believe? Whatever works, is what often happens.

 

What’s left?

 

Millions turn to chiropractic care. We know that even just exercise is more effective than many medical treatments.

 

Safety of chiropractic care

Manipulation of the spine carries with it inherent risks. University trained Chiropractic, which incorporates spinal adjustment and manipulation, is relatively safe and carries a minuscule risk when compared to medical treatment. In an Australian government paper, “Complications of medical/surgical care is, quite shockingly, rated as the fourth greatest cost to the community. Greater than superficial injuries, contusion, burns, poisoning, toxicity, and internal crushing injury.”[15]We question the notion that chiropractic care is categorised as a high-risk procedure for arthritis patients.

 

In contrast, in a paper entitled “Side-effects to chiropractic treatment: a prospective study”[16]looked at chiropractic iatrogenesis. They found that:

 

Reactions to spinal manipulation are common and benign. They typically arise and disappear shortly after treatment (usually gone the day after treatment). The most common reactions are local discomfort in the area of treatment (two-thirds of reactions), followed by pain in areas other than that of treatment, fatigue or headache (10%, respectively). Nausea, dizziness or “other” reactions are uncommonly reported (<5% of reactions)… Common and uncommon reactions to chiropractic spinal manipulation have been identified, are to a large degree foreseeable, and appear to be predominantly physiological in nature.

 

 

Conclusion

Chiropractic remains one of the safest procedures for the arthritic patient. Combined with exercise and other more specific regimes like Pilates and Tai Chi, relief can be gained.

 

Further research is needed to assess its mode of action and efficacy in the various forms of conditions commonly described as “arthritis”. Surgery needs to be subjected to placebo-controlled studies. Drugs are increasingly found to be high-risk or ineffective.

Chiropractic remains a worthy choice – even though it is far from being completely tested – as it remains relatively very safe.

 

REFERNCES:

[1]http://www.who.int/mediacentre/factsheets/musculoskeletal/en/

 

[2]Greenberg JO; Schnell RG. Magnetic resonance imaging of the lumbar spine in asymptomatic adults. J Neuroimaging 1991 Feb;1(1):2-7

[3]Jensen MC; Brant-Zawadzki MN; Obuchowski N; Modic MT; Malkasian D; Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 1994 Jul 14;331(2):69-73

 

[4]Wood KB; Garvey TA; Gundry C; Heithoff KB. Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals. J Bone Joint Surg Am 1995 Nov;77(11):1631-8

 

[5]Parfenchuck TA; Janssen ME. A correlation of cervical magnetic resonance imaging and discography/computed tomographic discograms.1994 Dec 15;19(24):2819-25

 

[6]Mimura M; Panjabi MM; Oxland TR; Crisco JJ; Yamamoto I; Vasavada A. Disc degeneration affects the multidirectional flexibility of the lumbar spine. Spine 1994 Jun 15;19(12):1371-80

 

[7]Back pain, mental health and substance use are associated in adolescents

S J Kamper  Z A Michaleff  P Campbell  K M Dunn T P Yamato  R K Hodder  J Wiggers C M Williams. Journal of Public Health, fdy129, https://doi.org/10.1093/pubmed/fdy129

 

[8]Fiechtner and Brodeur. Manual and manipulation techniques for rheumatic disease. Rheumatology Diseases Clinic of North America 2000 Feb: 26(1): 83-96.

 

[9]https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2680417

 

[10]Gottlieb MS. Conservative management of spinal osteoarthritis with glucosamine sulfate and chiropractic treatment. J Manipulative Physiol Ther. 1997 Jul-Aug;20(6):400-14

 

[11]https://www.bprclinrheum.com/article/S1521-6942(17)30016-5/fulltext

 

[12]http://www.cmaj.ca/content/190/26/E786

 

[13]Saag KG. Curr Opin Rheumatol. 1997 Mar; 9(2):118-25

 

[14]da Costa BR, Reichenbach S, Keller N, et al. Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis The Lancet. Published online March 17 2016

[15]Mathers C, Penm R. Health system costs of injury poisoning and musculoskeletal disorders in Australia 1993-4. 1999. Australian Institute of Health and Welfare. Canberra.

 

[16]Charlotte Leboeuf-Yde, DC, MPH, PhD, Bjorn Hennius, DC, Erik Rudberg, DC, Patrick Leufvenmark, DC and Marija Thunman, DC. Side-effects to chiropractic treatment: a prospective study. J Manipulative Physiol Ther 1997; 20:511-515.