Segmental To Brain Based Thinking – Where Are You And Your Practice At?

Traditionally, chiropractic has been built on a model of segmental subluxation assessment and correction with local impacts and views of possible global affects on the central nervous system and overall health. The structural or biomechanical paradigm of segmental subluxation assessment is not without its challenges. For example, why do assessment findings often poorly correlate with pain and dysfunction? Why are there many patients with damage to musculoskeletal structures but are asymptomatic? Why do some people heal quickly with acute injury, whilst others develop chronic pain and neuromusculoskeletal injury? Finally, why do many patients have persistent sensory abnormalities^1-5, like chronic pain, in the absence of any tissue or structural dysfunction?

Something else is going on! There needs to be an expansion of thinking to explore neurophysiological processes and neuroplasticity within the central nervous system that can better explain many of the presenting conditions for which patients seek our help. As a profession, it’s time we embrace contemporary clinical neuroscience and shift our attention away from a biomechanical only model of spinal care, to one that is a ‘spinal control’ model. By doing so, we acknowledge the involvement of the brain, both from its contribution to the condition, but also as a means of assessment and therapeutic options.

This^6-7 ‘brain-centric’ shift is both exciting and necessary for Chiropractic in the future. Patient-centred care, along with evidence-based practice in clinical neuroscience is a great foundation in which chiropractic can strengthen and unite.

We’re fortunate that Australian Spinal Research Foundation is supporting research in this area of brain-body connection and how Chiropractic can influence it ^8-10. A simple review of their funded research projects over the last 10 years is a testament to this focus.

The scope of chiropractic practice ought to be a blend of the brain and spine with musculoskeletal system. From ankle sprains to migraine, spinal pain syndromes to vertigo or poor balance, the literature is now supporting the brain’s contribution to the cause and the management of many of these commonly presenting neuromusculoskeletal conditions ^11-16. As a profession, it’s important we don’t get left behind!

How do we connect the two – the peripheral system and central system? Neuroplasticity, refer to changes in structure, function, and organisation within the nervous system that represents a dynamic, response to its environment throughout one’s lifetime^17-20. These neuroplastic changes are in response to internal cognitive stressors and external stressors such as motor learning and peripheral sensory stimulation¹⁷. Neuroplasticity is the method by which the brain encodes new experiences, learns, and develops new behaviours. Neuroplastic changes associated within the scope of chronic musculoskeletal disorders have been demonstrated at many different layers of the nervous system. E.g. peripheral nervous system and spinal cord, brain stem, sensorimotor areas, and mesolimbic and prefrontal areas of the cortex.

Let’s explore one key area of neuro rehabilitation that chiropractors can use. Research is now pointing to vestibular dysfunction as having an associated influence on musculoskeletal conditions which many chiropractors encounter in their practice. One notable example is scoliosis. Hitier et al ²¹ showed that adolescents with idiopathic scoliosis (AIS) exhibit morphological vestibular asymmetry. Since the vestibular system influences the vestibulospinal pathway, the hypothalamus, and the cerebellum, the study suggested that the vestibular system is a possible cause of morphological, hormonal and neurosensory anomalies observed in AIS. Moreover, they suggested that simple lateral semicircular canal MRI measurement could be used for early detection of AIS, selection of children for close follow-up, and initiation of preventive treatment before spinal deformity occurs.

Other studies have linked scoliosis with altered vestibular, balance and oculomotor function, however a link of causality has yet to be shown^22-24. An interesting study by Pialasse et al ²⁵, shows that stimulating the vestibular system using neuromodulation via galvanic vestibular stimulation, improved balance in patients with idiopathic scoliosis. Additionally, together with other sensorimotor components, vestibular based therapies i.e. Vestibular Rehabilitative Therapy (VRT) are showing promise in the management of other musculoskeletal conditions like osteoarthritis and peripheral joint injuries^26-32.

There is growing support showing VRT could help cervicogenic disorders, based on the sensorimotor connection between the cervical joint system, the vestibular system and the oculomotor system. The work of Trelevan, Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control³³ discusses how cervical afferents are known to be involved in the cervico-collic reflex, the cervico-ocular reflex and the tonic neck reflex, which work in conjunction with other reflexes influenced by visual and vestibular systems to stabilise the head, the eyes and posture.

Additionally, the work by Haavik and Murphy³⁴ showed that asymptomatic people with a history of recurring neck pain, stiffness, or ache have reduced elbow joint position sense (proprioception) accuracy compared to those with no history of any neck complaints. Spinal manipulation (adjustments) delivered to dysfunctional cervical segments in people with subclinical neck pain improved upper limb JPS accuracy in this group. These findings support the concept that neck joint dysfunction can impair the way proprioceptive input from the upper limb is processed and provides evidence that this can be improved by cervical spine manipulation.

The potential benefit of VRT for chiropractors is considerable, given the overlap of exercises into chiropractic care and the emphasis that chiropractors have on cervical assessment and management. Generally speaking, these exercises include balance and posture, cervical spine stability and oculomotor retraining. More specifically VRT exercises include general strengthening and flexibility exercises, voluntary eye movements and fixations (visual stabilization exercises), active head movements (recalibration of the VOR), active body movements (improvement of vestibulospinal regulation), substitution exercises for the use of various senses (particularly somatosensory cues) and vision, visual-dependency exercises, somatosensory dependence exercises, habituation exercises, education for using assistive devices, and safety awareness techniques to avoid falls.

The goals of VRT, and especially for postural stability, are to help patients to 1) learn to use stable visual references and surface somatosensory information for their primary postural sensory system, 2) use the remaining vestibular function, 3) identify efficient and effective alternative postural movement strategies, and 4) recover normal postural strategies³⁵.

Posture, stability and movements are carefully orchestrated via the interplay of various reflexes, most notably arising from the vestibular apparatus, oculomotor systems and spinal systems³⁶. With many common musculoskeletal and associated neurological concomitant conditions, like poor balance and dizziness, a product of a poor reflexive system, it’s imperative we consider a ‘top-down’ as well as a traditional ‘bottom-up’ approach in chiropractic care.

In summary, vestibular rehabilitative therapy has been shown to be effective not only for dizziness conditions, but also for other neuromusculoskeletal conditions including cervical spine disorders. Additionally, research and clinical guidelines are showing other effective neuro-rehabilitation based approaches that chiropractors can confidently use in their practice. These include exploration of cervical and lumbar proprioception with body awareness and dissociation, as well as the cerebellum. At an upcoming seminar Dr Carlo Rinaudo and Dr Paul Bergamo will present simple and effective tool kits for spinal control to help chiropractors in practice. The key goal will be to translate the research into usable bite sized forms into practice that will help you gain better results which is the cornerstone to success for all chiropractic practices.

Written by Drs Carlo Rinaudo and Paul Bergamo

References

1. Stadnik TW, Lee RR, Coen HL, Neirynck E, Buisseret TS, Osteaux M. Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology. 1998;206:49–55.
2. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8:296–9.
3. Teresi L, Lufkin R, Reicher M, Moffit B, Vinuela F, Wilson G, et al. 
Asymptomatic degenerative disk disease and spondylosis of the cervical 
spine: MR imaging. Radiology. 1987;164:83–8.
4. Mazanec DJ, Benzel EC. Acute low back pain and radiculopathy: MR 
imaging findings and their prognostic role and effect on outcome. 
 2005;237:597–604.
5. Finan PH, Buenaver LF, Bounds SC, Hussain S, Park RJ, Haque UJ, et al. 
Discordance between pain and radiographic severity in knee osteoarthritis: findings from quantitative sensory testing of central sensitization. Arthritis Rheum. 2013;65:363–72.
6. Pelletier R, Higgins J, Bourbonnais D. Addressing Neuroplastic Changes in Distributed Areas of the Nervous System Associated With Chronic Musculoskeletal Disorders. Phys Ther. 2015 Nov;95(11):1582-91
7. Suzanne J. Snodgrass, Nicola R. Heneghan, Henry Tsao, Peter T. Stanwell, Darren A. Rivett, Paulette M. Van Vliet Recognising neuroplasticity in musculoskeletal rehabilitation: A basis for greater collaboration between musculoskeletal and neurological physiotherapists. Manual Therapy: December 2014 Volume 19, Issue 6, Pages 614–617
8. Haavik H,Murphy BA. Selective changes in cerebellar-cortical processing following motor training. Exp Brain Res. 2013 Dec;231(4):397-403 2013 Sep 25.
9. Daligadu J,Haavik H, Yielder PC, Baarbe J, Murphy B. Alterations in Cortical and Cerebellar Motor Processing in Subclinical Neck Pain Patients Following Spinal Manipulation Journal of Manipulative & Physiological Therapeutics , Volume 36 , Issue 8 , 527 – 537
10. Baarbé J¹,Yielder P, Daligadu J, Behbahani H, Haavik H, Murphy B. J A novel protocol to investigate motor training induced plasticity and sensorimotor integration in the cerebellum and motor cortex 2014 Feb;111(4):715-21.
11. Needle AR1, Palmer JA, Kesar TM, Binder-Macleod SA, Swanik CB Brains and Sprains: The Brain’s Role in Noncontact Anterior Cruciate Ligament Injuries. J Athl Train. 2015 Oct;50(10):1100-2
12. Needle AR, Palmer JA, Kesar TM, Binder-Macleod SA. Brain regulation of muscle tone in healthy and functionally unstable ankles. Swanik CB J Sport Rehabil. 2013 Aug;22(3):202-11
13. Pelletier R, Higgins J, Bourbonnais D.  Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? Musculoskelet Disord. 2015 Feb 12;16:25
14. Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008;51:S225–39.
15. Pascual-Leone A, Freitas C, Oberman L, Horvath JC, Halko M, Eldaief M, et al. Characterizing brain cortical plasticity and network dynamics across the age-span in health and disease with TMS-EEG and TMS-fMRI. Brain Topogr. 2011;24:302–15.
16. Sanes JN, Donoghue JP. Plasticity and primary motor cortex. Annu Rev Neurosci. 2000;23:393–415.
17. Boudreau SA, Farina D, Falla D. The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Man Ther. 2010;15:410–4.
18. Hitier, M., Hamon, M., Denise, P., Lacoudre, J., Thenint, M. A., Mallet, J. F., Moreau, S. and Quarck, G. (2015) Lateral semicircular canal asymmetry in idiopathic scoliosis: An early link between biomechanical, hormonal and neurosensory theories?’, PLoS ONE, 10(7).
19. Lion, A., Haumont, T., Gauchard, G. C., Wiener-Vacher, S. R., Lascombes, P. and Perrin, P. P. (2013) ‘Visuo-Oculomotor Deficiency at Early-Stage Idiopathic Scoliosis in Adolescent Girls’, Spine, 38(3), pp. 238–244.
20. Catanzariti, J.-F., Agnani, O., Guyot, M.-A., Wlodyka-Demaille, S., Khenioui, H. and Donze, C. (2014) ‘Literature review / Revue de la littérature Does adolescent idiopathic scoliosis relate to vestibular disorders? A systematic review’, Annals of Physical and Rehabilitation Medicine, 57, pp. 465–479.
21. Hawasli, A. H., Hullar, T. E. and Dorward, I. G. (2014) ‘Idiopathic scoliosis and the vestibular system’, European Spine Journal, pp. 227–233.
22. Pialasse, J.-P., Mercier, P., Descarreaux, M. and Simoneau, M. (2016) ‘Sensorimotor Control Impairment in Young Adults With Idiopathic Scoliosis Compared With Healthy Controls’. J Manipulative Physiol Ther.2016 Sep;39(7):473-9
23. Hubbard, T. J., Hicks-Little, C. and Cordova, M. (2009) ‘Mechanical and Sensorimotor Implications With Ankle Osteoarthritis’, Archives of Physical Medicine and Rehabilitation, 90(7), pp. 1136–1141.
24. Cheng, P.-F. (2008) ‘The effects of sensorimotor training on knee proprioception and function for patients with knee osteoarthritis: a preliminary report’, Clinical Rehabilitation, 22, pp. 448–457.
25. Lasker, D. M., Backous, D. D., Lysakowski, A., Davis, G. L. and Minor, L. B. (1999) ‘Horizontal vestibuloocular reflex evoked by high-acceleration rotations in the squirrel monkey. II. Responses after canal plugging.’, Journal of neurophysiology, 82(3), pp. 1271–85.
26. Solomonow, M. and Krogsgaard, M. (2001) ‘Sensorimotor control of knee stability. A review’, Scandinavian journal of medicine & science in sports, 11(2), pp. 64–80.
27. Hupperets, M. D. W., Verhagen, E. A. L. M. and van Mechelen, W. (2009) ‘Effect of sensorimotor training on morphological, neurophysiological and functional characteristics of the ankle: a critical review.’, Sports medicine (Auckland, N.Z.). Centre for Reviews and Dissemination (UK), 39(7), pp. 591–605.
28. Ahmed, A. F. (2011) ‘Effect of sensorimotor training on balance in elderly patients with knee osteoarthritis’, Journal of Advanced Research, 2, pp. 305–311.
29. Hagert, E. (2010) ‘Proprioception of the Wrist Joint: A Review of Current Concepts and Possible Implications on the Rehabilitation of the Wrist’, Journal of Hand Therapy, 23, pp. 2–17.
30. Treleaven, J. (2008) ‘Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control-Part 2: Case studies’, Manual Therapy, 13(3), pp. 266–275.
31. Haavik H, Murphy B. Subclinicalneck pain and the effects of cervical manipulation on elbow joint position sense
32. . J Manipulative Physiol Ther 2011;34:88-97
33. Han, B. I., Song, H. S. and Kim, J. S. (2011) ‘Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises.’, Journal of clinical neurology (Seoul, Korea), 7(4), pp. 184–96.
34. Morningstar, M. W., Pettibon, B. R., Schlappi, H., Schlappi, M. and Ireland, T. V ‘Reflex control of the spine and posture: a review of the literature from a chiropractic perspective’. Chiropr Osteopat.2005 Aug 9;13:16