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 abnormalities1-5, 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.
This6-7 ‘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 lifetime17-20. 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 shown22-24. 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 injuries26-32.
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
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