CF 102: Headaches and the Neck, Absolute Contraindications, More Maintenance Care
Today we’re going to talk about new information on how working on the neck could help headaches of all kinds. Who woulda thunk it? We’ll talk about absolute contraindications to spinal manipulative therapy. Do you remember them all? I’ll give you a refresher to be sure. We’ll wrap up the episode with another paper on maintenance care. Is it evidence-based?
But first, here’s that sweet sweet bumper music
OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around.
We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers.
Welcome, I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.
If you haven’t yet I have a few things you should do.
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You have sauntered into Episode #102
Now if you missed last week’s episode, it was episode #101 and it covered 9 characteristics that make up a good chiropractor, make sure you don’t miss that info. Put that one on your listen-to list muy pronto, mi amigo.
On the personal end of things that whole DACO thing you’ve heard me talk about since June of 2018…..well, I got word last week that I passed the part II exam. That also happens to be the FINAL exam I’ll have you know which means……yes, it means I’m now officially a Diplomate or Fellow of the International Academy of Neuromusculoskeletal Medicine.
It turns out that we can choose whether to go by Diplomate or Fellow and I choose Fellow. So, when it comes to adding alphabet soup to the end of my signature, I now get to add FIANM(us).
Besides graduating with a doctorate, this is the biggest thing I’ve done and I can’t really express how excited I am to join the amazing group of doctors in this specialization.
Did you know that only 2% of chiropractors go on to specialize? We really really need to change that. I want to be honest here: the hours were absolutely, 100%, without a single doubt one of the most enjoyable and most rewarding things I’ve done. WAaaaaayyyy better than chiropractic school.
The course was current with research. It was smart. It was professionally done. It was just amazing.
The testing process……welll…..that was a different story for me. I felt that the material in Part I was just irrelevant to the course. In fact, had little to nothing to do with what we learned. BUT – the good news is that they’ve created a new test now and it should be more relevant.
Part II was amazing, imaginative, and well-put together and conducted. But, I believe there were doctors making the questions that had never undergone the current course load so, once again, there were questions that were a bit random and just seemed out of place to a person that had all of those hours.
Again, the good news is that they are consistently adding updated questions and I have no doubt they will get more and more focused in regard to what was actually covered in the course.
So, I in short, doctors should undertake this Diplomate. The hours are so rewarding. You literally cover a topic in the course and then it shows up in your clinic. It’s scary as hell how that works.
The testing part is cumbersome and clunky but they’re working on lining it out. Even if that part didn’t get any smoother or any better, it is still 100% absolutely worth every dime spent and every hour spent achieving the goal.
Trust me, I’d tell you straight up if it weren’t. If you have the money, do it. Don’t give me that excuse about time. I didn’t have time either. I just made time. I did it while I watched football. I did it with coffee on Saturday and Sunday mornings. I took off early on Tuesdays just to study. It can be done and YOU can do it.
Send me an email at email@example.com if I can help point you in the right direction and get you started. I’d be happy to help you.
More chiropractors need to specialize. Just think about it.
My Dad…..well….If you listened to previous episodes, you know he had a stroke a couple of weeks ago. I can’t tell you how emotionally challenging this has been. To work and still get out there to spend time every day…..it’s a process and it’s a commitment.
But that’s it. He’s my Dad and I’m committed to being there to help and do whatever I can to help him get restored to whatever level we can get.
We are both guitar players so I brought my guitar up to the rehab facility last night and played for him for a while. We are both sculptors. We make bronzes. Check riverhorseart.com and we have a Facebook page as well.
So, I bought him some new sculpting tools and some clay and took them up to him today at lunch. He can only use is dominant hand, his right hand, but he was pretty excited. He started sculpting before I even left.
Fingers crossed that we see some improvement in a hurry. Thank you to each of you that sent me emails and messages through Facebook offering prayers and good wishes. I value each of them as much as I value you. Thank you.
Before we dive into the reason we’re here, it’s good to support the people that support you don’t you think? Well, ChiroUp certainly supports evidence-based practices.
If you don’t take advantage of this deal, I just think you might be crazy.
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You can be confident that your patients are getting the best possible care, because the reports are populated based on what the literature recommends and isn’t that re-assuring? All of that work has been done FOR you.
There are more than 1000 providers worldwide using ChiroUp to empower their treatments, patients, & practice – Including myself! **Short testimony**
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Let’s start with absolute contraindications shall we? This comes from the WHO Guidelines(Sweaney J 2004). That’s right the World Health Organization. The actual name of the document is WHO guidelines on basic training and safety in chiropractic.
I literally never knew this existed until I saw it in a Facebook group last week. Some kind hearted individual shared it. I can’t recall whether it was the Forward Thinking Chiropractic Alliance group or if it was the Evidence Based Chiropractic group. Either way, I found it interesting and here we are.
I’m going to leave a link to the document at this point in the show notes so just go to chiropracticforward.com and episode 102. You’ll find it and you’ll be happy.
If we go down to page 21, we find a list of Absolute contraindications to spinal manipulative therapy. Many of them, you already know but let’s just stroll through them for a refresher just in case.
1. anomalies such as dens hypoplasia, unstable os odontoideum, etc.
2. acute fracture
3. spinal cord tumor
4. acute infection such as osteomyelitis, septic discitis, and tuberculosis of the spine
5. meningeal tumor
7. malignancy of the spine
8. frank disc herniation with accompanying signs of progressive
9. basilar invagination of the upper cervical spine
10. Arnold‐Chiari malformation of the upper cervical spine
11. dislocation of a vertebra
12. aggressive types of benign tumors, such as an aneurysmal bone cyst, giant cell tumor, osteoblastoma, or osteoid osteoma
13. internal fixation/stabilization devices – metal hardware such as after a surgical fusion
14. neoplastic disease of muscle or other soft tissue
15. positive Kernig’s or Lhermitte’s signs – these are orthopedic meningitis signs. Go look up Kernig’s and Lhermitte’s if you don’t know them please.
16. congenital, generalized hypermobility – Are you using the Beighton Scale for hyper mobility? Are you adjusting chronic pain, hyper mobile people? Sometimes, even if they like the popping sounds, that’s not best. Sometimes, strengthening and support exercises are better than mobilizing joints that are already too mobile.
17. signs or patterns of instability
19. hydrocephalus of unknown etiology
20. diastematomyelia – a congenital disorder in which a part of the spinal cord is split, usually at the level of the upper lumbar vertebra. Fortunately, we almost never see this.
21. cauda equina syndrome – I caught one not long ago in my office. A new patient who had been to the ER 3 times already and they never even took the time to do any imaging. A young guy in his 30’s on a walker, difficulty controlling bowel and bladder function, saddle anesthesia. I told him to go directly back to the ER and tell them you are concerned you are suffering from cauda equina and tell them you have saddle anesthesia.
As soon as he did that, boom, imaging, and emergency surgery. He says I saved his life. While that’s not true specifically, it sure as hell feels good to hear.
Alright. I hope you enjoyed that brief refresher and it gave you a little food for thought. You can go to the show notes and get the document or just go to get the list if you like.
This one is pretty cool. It’s called “A neuroscience perspective of physical treatment of headache and neck pain,” by Rene Castien and Willem De Hertogh and published in Front Neurology in March of 2019(Castien R 2019).
This one is probably going to tell you what you instinctively already knew but it’s going to lay some scienc-ing in on the top there for you.
Just like a warm blanket, a layer of scienc-ing is all warm and fuzzy and makes you feel good. Can’t get enough of scienc-ing can we?
OK, we know that the most prevalent headache is tension type headache. In fact, about 40% of those presenting in your clinic are TTH. Not migraine, not cervicogenic…..TTH. In fact, only about 10% of the headaches that present to your office are actually migraines. That’s not very many is it?
Which is a good thing because migraine is more of an issue in the brainstem – in the descending pain inhibitory complex. In the words of Dr. Anthony Nicholson and Dr. Matthew Long from the CDI coursework – The experience of head pain requires activation of the trigeminal nucleus. After all, this is where the neurons that sense the head and neck are located.
Adjustments don’t always knock out a migraine issue right? It’s wired into the brain. However, adjustments tend to show more success when we’re dealing with a TTH.
Now, the TTH is also an issue with impaired inhibition. It’s on the same spectrum….the same continuum as is migraine. Migraine way off to the right and TTH way off to the left. But there’s a lot of middle ground in there where their symptoms can overlap into each other a bit.
But, in general, we are able to be more effective with TTH than we are with migraine.
They mention in this paper that physical treatment is a frequently applied treatment for headaches. They say that although physical treatment is often applied to the neck, the neurophysiological background…..how it works or helps…..is unclear.
So, the authors had the goal of taking more recent knowledge from neuroscience and enhancing clinical reasoning in using physical treatment for headaches and to understand why it’s so common for headaches and neck pain to exist together so oftenly.
Some of the highlight quotes from this article are as follows:
“Headache (migraine, tension-type headache, cervicogenic headache), neck pain, and cervical musculoskeletal dysfunctions seem to be related in case-control studies, although the strength, significance and explanation of this relation varies per type of headache.”
“It is a great challenge for clinicians and researchers to develop effective treatment strategies for headache targeted on modulation of cervical afferent input in order to decrease the excitability of first- to second order neurons at the level of the TCC. Experimental studies of the neurophysiological effect of physical treatment and randomized clinical trial on this topic are scarce and urgently warranted. Meanwhile, there is no standard recipe for physical treatment on the neck for different types of headache. But clinicians may be encouraged by recent evidence and new insights on headache and neck pain and may use this knowledge in clinical reasoning to provide a tailored and evidence based neuro-physiological approach for patients with headache and neck pain.”
“The relation between brainstem nuclei and the (upper) neck and trigeminal nerve has to be incorporated in development of physical treatment for headache targeted at the cervical spine, especially the upper cervical region.
According to the ‘gate-control’ hypothesis, the relative high amount of proprioceptive muscular input from the upper cervical segments particularly C1-3….. to the central nervous system may alter nociceptive input.
Stimulation of proprioceptive input by active exercises for neck muscles may decrease the excitability of second order neurons at the trigemino-cervical complex and activation of the supraspinal diffuse noxious inhibitory control system by stimulation of myofascial fibers through manual pressure techniques at the upper cervical spine can be of added value.”
Pretty cool stuff. Physical treatment is effective for different kinds of headache through the trigemino-cervical complex via proprioceptive stimulation of the upper cervical region.
You’re welcome. This is something covered extensively in the coursework we did for our Neuromusculoskeletal Fellowship/Diplomate.
Like I said, it’s absolutely worth going through the course.
Our last paper here is paper #3 in the last year on Chiropractic Maintenance. It’s called, “Chiropractic maintenance care – what’s new? A systematic review of the literature”. It was published in Chiropractic and Manual Therapies and authored by Iben Axen, Lise Hestbaek, and Charlotte Leboeuf-Yde in November 2019(Axen I 2019) – Hot steamin’ greasy plate of enchiladas here.
If you notice the name Iben Axen, then you will remember he is the one that authored the paper on how a patient’s improvement in the first visit or two can really help you know how they will do through the course of the treatment. He’s pretty active in research and we appreciate him here at the Chiropractic Forward Podcast.
Why They Did It
Here’s why they did this one: knowing that maintenance care is an age old tradition with chiropractors, and knowing that systematic reviews in ’96 and in /08 both found evidence lacking for maintenance care, and then considering Andreas Eklund’s Nordic papers on maintenance care recently (we’ve covered them both here), these authors decided it was time to review the newest evidence on the matter.
How They Did It
Knowledge of chiropractic Maintenance Care has advanced. There is reasonable consensus among chiropractors on what Maintenance Care is, how it should be used, and its indications. Presently, Maintenance Care can be considered an evidence-based method to perform secondary or tertiary prevention in patients with previous episodes of low back pain, who report a good outcome from the initial treatments. However, these results should not be interpreted as an indication for Maintenance Care on all patients, who receive chiropractic treatment.
You know it feels good when a paper can conclusively say ‘presently, maintenance care can be considered an evidence-based method.” It reminds me of Jim Carrey in the Ace Ventura movies saying, “Can you feel that? Huh?” Lol.
Good stuff there. I love slapping people with research. It’s a warm feeling going down kind of like Bailey’s and coffee. You know what I’m saying.
- Be smart and know your absolute contraindications
- Treating the neck for headaches is evidence-based
- Chiropractic maintenance is evidence-based
Speaking of evidence-based, make sure you go to chiropracticforward.com and go to the store link to check out our evidence-based brochures and posters. You’ll like them.
I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment instead of chemical treatments like pills and shots.
When compared to the traditional medical model, research and clinical experience show us that patients can get good to excellent results for headaches, neck pain, back pain, and joint pain just to name just a few.
It’s safe and cost-effective. It can decrease surgeries & disability and we normally do it through conservative, non-surgical means with minimal hassle to the patient.
And, if the patient develops a “preventative” mindset going forward from initial recovery, we can likely keep it that way while raising the general, overall level of health of the patient!
Patients should have the guarantee of having the best treatment offering the least harm. When it comes to non-complicated musculoskeletal complaints….
Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show or tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on iTunes and other podcast services. Y’all know how this works by now so help if you don’t mind taking a few seconds to do so.
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We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.
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About the Author & Host
Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger
- Axen I, H. L., Leboeuf-Yde C, (2019). “Chiropractic maintenance care – what’s new? A systematic review of the literature.” Chiropr Man Therap 27(63).
- Castien R, D. H. W. (2019). “A Neuroscience Perspective of Physical Treatment of Headache and Neck Pain.” Front Neurol 10: 276.
- Sweaney J (2004). WHO guidlines on basic training and safety in chiropractic. WHO: 44.