Tuesday, March 10, 2015

Keeping an Open Mind

This following article is borrowed from Matthew Long (Chiropractic Development International)

The twin worlds of health care and education tend to be conservative places. New ideas are treated with scepticism, whilst entrenched dogma often persists without question. Although this culture makes it hard for new and valid ideas to take hold, it also serves to prevent dangerous, costly and unethical practices from gaining traction. However, this situation really only works if we can keep an open mind.

Over the past month I have read two interesting papers that caused me to question some assumptions I had held - specifically about the notion of 
visceral manipulation. On first glance the concept of moving one’s internal organs for some therapeutic effect seems far-fetched. Indeed, every rationale proposed thus far for visceral manipulation has, for me at least, not satisfied the first hurdle of even being biologically plausible. There are just too many unproven assumptions about the supposed dysfunction occurring, the reliability of palpatory methods, and the efficacy of the treatment. Apparently the goal of such treatment is "to encourage the normal mobility, tone and motion of the viscera and their connective tissues. These gentle manipulations can potentially improve the functioning of individual organs, the systems the organs function within, and the structural integrity of the entire body" (1). While such notions are admirable, they are not backed up by the quality of evidence one would hope might exist to support a revolutionary new treatment.

But does this mean that visceral manipulation is entirely without merit? Perhaps not. A recent study in the 
European Journal of Pain suggests that the use of visceral manipulation might be useful in the long-term management of lower back pain (2). While the short-term benefits weren't obvious, those undergoing visceral techniques did show benefit over a longer duration, prompting the authors to suggest that, "It is possible that, with continuing visceral nociceptive input, control patients experienced greater rates of recurrences of LBP compared with the visceral manipulation group."

This isn't the only study to find clinically meaningful benefits to visceral manipulation. A paper by McSweeney 
et al in 2012 examined the immediate effects of sigmoid colon manipulation on pressure pain thresholds in the lumbar spine (3). In this study,
"Pressure pain thresholds were measured at the L1 paraspinal musculature and 1st dorsal interossei before and after osteopathic visceral mobilisation of the sigmoid colon. The results demonstrated a statistically significant improvement in pressure pain thresholds immediately after the intervention (P < 0.001). This effect was not observed to be systemic, affecting only the L1 paraspinal musculature. This novel study provides new experimental evidence that visceral manual therapy can produce immediate hypoalgesia in somatic structures segmentally related to the organ being mobilised, in asymptomatic subjects."
So it just might be that such techniques are clinically useful. But what of the theories used to guide their application and explain their action? Unfortunately there is a paucity of sound research to underpin the biological construct of 'abnormal visceral motion', or the reliability of methods used to detect this phenomenon. Most of the available literature originates from our osteopathic colleagues, but the explanations given tend to remain abstract in nature and devoid of concrete facts or ideas. Attempts have been made to measure kidney mobility using diagnostic ultrasound (4), but whether the differing patterns of motion represent a true 'abnormality', or just normal human variation remains to be seen. However, is a motion-based model of organ dysfunction actually necessary to support the use of visceral manipulation? Could it be that the existing theories are completely wrong, yet the treatment itself might be useful for some other reason?

This brings me to the second intriguing paper that I reviewed in recent weeks, entitled "
You May Need a Nerve to Treat Pain - The Neurobiological Rationale for Vagal Nerve Activation in Pain Management" (5). In this article De Couck and colleagues reviewed the role of the vagus nerve in modulating pain signals, discussing five distinct mechanisms by which it exerts inhibitory effects upon the pain experience. They wrote,
"The vagus nerve may play an important role in pain modulation by inhibiting inflammation, oxidative stress, and sympathetic activity, and possibly by inducing a brain activation pattern that may be incongruent with the brain matrix of pain. Finally, vagal activation may mediate or work in synergism with the effects of the opioid system in pain modulation. All these mechanisms are thought to influence neuronal hyperexcitability, culminating in the perception of less pain. For all the above neurobiological reasons, it seems justified to increase vagal nerve activity to reduce pain as this targets all 5 mechanisms with 1 intervention. This hypothesis is supported by experimental studies on animals and preliminary intervention trials on humans."
The vagus nerve has been used experimentally to influence pain in a variety of fashions. Simple deep breathing will augment vagal activity and has been shown to reduce pain, while electrical stimulators have been trialled in both implantable and transcutaneous forms (6). In each case, it appears that vagal stimulation influences central pain processing, rather than peripheral nociceptor activity. Could it therefore be that visceral manipulation, as performed by chiropractors and osteopaths, serves as a novel form of vagal stimulation? We might therefore suggest that the established theories of visceral manipulation as a tool for improving organ mobility be revised in light of more biologically plausible mechanisms. Perhaps the true value of visceral manipulation lies in its ability to increase vagal inhibition of pain, leading to widespread suppression of nociception from multiple sources? If this is so, then it would require the active proponents of visceral manipulation to update their understanding and refine their message. But will this happen easily?

At this point I should point out that I am not trying to single out the supporters of visceral manipulation for criticism. Indeed, the pretext of this article is to 
maintain an open mind, and I have found the topic to be one that lends itself to this exercise very well. So often the field of biological science is challenged to redefine its theories when new evidence comes to light, and we must learn to walk a balanced line of judgment. Unfortunately, this can be difficult once we have become emotionally invested in a practice or an idea. When presented with new information that conflicts with our long-held beliefs it is both easy and natural to dismiss it out of hand. Cognitive change can be costly, both in terms of mental effort and the possible impact upon our established patterns of practice. According to Chris Mooney in "The Science of Why We Don’t Believe Science” (7), it can be extremely hard to convince others of new ideas simply by presenting them with evidence and argument. Indeed, often this can have the opposite effect.
"...an array of new discoveries in psychology and neuroscience has further demonstrated how our preexisting beliefs, far more than any new facts, can skew our thoughts and even color what we consider our most dispassionate and logical conclusions. This tendency toward so-called “motivated reasoning” helps explain why we find groups so polarized over matters where the evidence is so unequivocal...

The theory of motivated reasoning builds on a key insight of modern neuroscience: Reasoning is actually suffused with emotion (or what researchers often call “affect”). Not only are the two inseparable, but our positive or negative feelings about people, things, and ideas arise much more rapidly than our conscious thoughts, in a matter of milliseconds - fast enough to detect with an EEG device, but long before we’re aware of it. That shouldn’t be surprising: Evolution required us to react very quickly to stimuli in our environment. It’s a “basic human survival skill,” explains political scientist Arthur Lupia of the University of Michigan. We push threatening information away; we pull friendly information close. We apply fight-or-flight reflexes not only to predators, but to data itself..."

'We apply fight-or-flight reflexes not only to predators, but to data itself.'
"In other words, when we think we’re reasoning, we may instead be rationalizing. Or to use an analogy offered by University of Virginia psychologist Jonathan Haidt: We may think we’re being scientists, but we’re actually being lawyers. Our “reasoning” is a means to a predetermined end - winning our “case” - and is shot through with biases. They include “confirmation bias,” in which we give greater heed to evidence and arguments that bolster our beliefs, and “disconfirmation bias,” in which we expend disproportionate energy trying to debunk or refute views and arguments that we find uncongenial."
So faced with new ideas it seems very 'human' to resist the cognitive burden of change. However, change we must if we wish to remain up-to-date and relevant as a profession. I would suggest that there are two distinct personality types that we need to consider when reflecting upon the subject of keeping an open mind.
1. The traditional 'scientist' type, who remains cynical until there is an overwhelming body of accepted evidence. These individuals use their faith in science to resist change.

2. The front-line clinican, who may view the greater scientific community with scepticism and as having an overly pessimistic view of the realities of clinical practice. These individuals use their lack of faith in science to resist change.
Obviously there are many other personality types who lie in between these polar opposites, but it is these two stereotypes who probably have the most difficult time keeping an open mind. To quote George Bernard Shaw, "The reasonable man adapts himself to the conditions that surround him... The unreasonable man adapts surrounding conditions to himself... All progress depends on the unreasonable man."

But why should we even care? Does it really matter if clinicians still explain their treatment rationales using ideas that are somewhat outdated?

I would suggest that it 
does matter, because in health care at least, truth is preferable to fiction. As our understanding improves, so does our capacity to target our treatment better. Furthermore, the long-term future of the chiropractic profession is one that will increasingly become intertwined with other health professionals and third-party payers, all of whom need to understand chiropractic through contemporary neuroscience theory. It is my contention that much of the clinical practice of chiropractors is uniquely helpful to our patients, but it just might not work for the reasons that we've traditionally thought. As long as we maintain an open mind we can retain the practical usefulness of our techniques, while upgrading the theories supporting their application.
Something to think about...Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)

1. http://www.barralinstitute.com/about/vm.php
2. Panagopoulos, J., Hancock, M. J., Ferreira, P., Hush, J., & Petocz, P. (2014). 
Does the addition of visceral manipulation alter outcomes for patients with low back pain? A randomized placebo controlled trial. European Journal of Pain, n/a–n/a. doi:10.1002/ejp.614
3. McSweeney, T. P., Thomson, O. P., & Johnston, R. (2012). 
The immediate effects of sigmoid colon manipulation on pressure pain thresholds in the lumbar spine. Journal of Bodywork and Movement Therapies, 16 (4), 416–423. doi:10.1016/j.jbmt.2012.02.004
4.Tozzi, P., Bongiorno, D., & Vitturini, C. (2012). 
Low back pain and kidney mobility: local osteopathic fascial manipulation decreases pain perception and improves renal mobility. Journal of Bodywork and Movement Therapies, 16(3), 381–391. doi:10.1016/j.jbmt.2012.02.001
5. De Couck, M., Nijs, J., & Gidron, Y. (2014). 
You May Need a Nerve to Treat Pain. The Clinical Journal of Pain, 30 (12), 1099–1105. doi:10.1097/AJP.0000000000000071
6. Busch, V., Zeman, F., Heckel, A., Menne, F., Ellrich, J., & Eichhammer, P. (2013). 
The effect of transcutaneous vagus nerve stimulation on pain perception – An experimental study. Brain Stimulation, 6 (2), 202–209. doi:10.1016/j.brs.2012.04.006
7. Mooney, Chris. 
The Science of Why We Don’t Believe Science. https://medium.com/mother-jones/the-science-of-why-we-dont-believe-science-adfa0d026a7e?goal=0_9f67e23487-a5da358f4e-97580213

Thursday, August 7, 2014

Can Spinal Manipulation Reduce Pain and Stress?

For years chiropractors observed curious responses in patients.  Not only did people often feel 'better' following treatment with often sudden reductions in pain, they would also express feelings of well being (even euphoria) and 'clear headedness' as well as being able to move more freely and this often appeared to be more prevalent following cervical or neck manipulation.
How so?

So far there have been 8 recorded neurological effects of spinal manipulation many of which 'fire' impulses into the very busy and electrically sensitive brain stem where many of our body functions are housed and where our outer 'self' is represented by the brain.  The release of hormones is a knock on effect and although how long these effects last is still a question we also understand that with repetition of such treatments positive 'plastic' brain changes occur, principally in the way the brain 'maps' the body's movements and sensations.  It is fascinating and useful information to communicate with patients that the targeted and gentle input of spine movement affects more than just 'sore backs'. It appears that it may influence the way we perceive our world.

Changes in Biochemical Markers of Pain Perception and Stress Response After Spinal Manipulation

Address correspondence to Dr Fidel Hita-Contreras, Department of Health Sciences (B-3/272). Universidad de Jaén. Campus Las Lagunillas s/n, 23071 Jaén, Spain. E-mail: 
Published: Journal of Orthopaedic & Sports Physical Therapy, 2014, Volume: 44 Issue: 4 Pages: 231-239 doi:10.2519/jospt.2014.4996
Study Design
Controlled, repeated-measures, single-blind randomized study.

To determine the effect of cervical or thoracic manipulation on neurotensin, oxytocin, orexin A, and cortisol levels.

Previous studies have researched the effect of spinal manipulation on pain modulation and/or range of movement. However, there is little knowledge of the biochemical process that supports the antinociceptive effect of spinal manipulation.

Thirty asymptomatic subjects were randomly divided into 3 groups: cervical manipulation (n = 10), thoracic manipulation (n = 10), and nonmanipulation (control) (n = 10). Blood samples were extracted before, immediately after, and 2 hours after each intervention. Neurotensin, oxytocin, and orexin A were determined in plasma using enzyme-linked immuno assay. Cortisol was measured by microparticulate enzyme immuno assay in serum samples.

Immediately after the intervention, significantly higher values of neurotensin (P<.05) and oxytocin (P<.001) levels were observed with both cervical and thoracic manipulation, whereas cortisol concentration was increased only in the cervical manipulation group (P<.05). No changes were detected for orexin A levels. Two hours after the intervention, no significant differences were observed in between-group analysis.

The mechanical stimulus provided by spinal manipulation triggers an increase in neurotensin, oxytocin, and cortisol blood levels. Data suggest that the initial capability of the tissues to tolerate mechanical deformation affects the capacity of these tissues to produce an induction of neuropeptide expression. J Orthop Sports Phys Ther 2014;44(4):231–239. Epub 22 January 2014. doi:10.2519/jospt.2014.4996

Thursday, July 10, 2014

What's the Best Diet?

We are what we eat. Literally. All of the parts of your body are entirely dependant upon what you poked into the hole in the middle of your face coupled with whatever activity and genetic influences you inherited.

We are made of what we eat - made of it.

You can calorie count but it's boring and psychologically depressing, no one wants to accept that they are actively depriving themselves of fun stuff so I suggest take a long term view and stick to simple rules and basics (you can add detail as you like (or not)):-

1.  Avoid 'White' Stuff. Read Tim Ferris Slow carb Diet.  You can get as elaborate as you like with tweaking (like using cinnamon, water, timing your meals with exercise, etc) but in essence FAT is NOT an issue.  If you want to know what 'simple carbs' are then read Ferris lists but understand this - during most of human evolutionary history quick energy foods were hard to get hold of so we have a biology which, when presented with sugar, bread, pasta, rice, pasta, bread, corn flakes, sugar, etc on what has become a simple carb conveyor belt of hell our body will latch onto it pronto and do what? Does it stay a carb? No. It turns it into FAT - it get's stored by your body 'just in case' it's the last meal for a while (as it must have been in out not so distant past).

Is this oversimplified? Except for rare cases that's pretty much it and it's been the thrust behind the Paleo Diet Fad which to some has become a lifestyle.  Due to human variability we don't all respond exactly the same way to this diet.  Personally if I don't eat ANY 'white' stuff I can eat like a horse and drop 5kg in 2 weeks.  As soon as I eat chocolate and ice cream or just lots of cereal (obvious simple sugary things) I can put 5kg back on in the same time.  If I eat or don't eat fat it makes little difference.  If you eat fat AND sugar together all hell breaks loose. Females hold onto fat easier (sorry, talk to your creator) so you wont experience (nor should you) such dramatic short term changes if you are female.


3.  Willpower.  Noooooooo!  When presented with the truth of our biology our first reaction is to ignore it, pray, and continue on our merry path to weight gain and metabolic breakdown.  Old habits die hard so it does take mental effort to walk back into Coles and choose differently.  We're like robots really, so ingrained is our cultures approval of stuff which just isn't good for us. "But it's LOW FAT!"  This was my wife's mantra for years and no amount of reason made any difference so one day I said "Don't listen to me, just look at the label and ask yourself how many spoonfuls of sugar are in that."

4.  Cheat Day!!  Yay!  To offset the mental breakdown you are about to have by forcing yourself to change habits, there is the cheat day.  One, even two days (if you're active) a week of eating whatever the hell you want and not feeling like a diet leper makes such a difference and not just because it's a mental health day.  If you've been a good boy or girl the other 5 days your body will react to the 'starvation' of simple carbs by lowering your BMR (Basal Metabolic Rate).

This means that your survival mechanisms will slow you down to conserve resources - you don't want that.

BMR is the rate your body burns calories while you are doing nothing.  Our body evolved to survive so if it senses that it's being somehow deprived it will down regulate.  This is often why people diet, loose weight, then plateau, get frustrated then break diet and go back to the chocolate Isle at Woolies. The injection of fast food one day a week tricks your body into maintaining it's BMR.

5. What about exercise?  Go to the other post.  Strictly speaking you don't have to exercise to lose weight but of course it can help.  Also if you are active you have to inject some simple carbs into the routine otherwise you hit an energy wall and fall over.  Ferris goes into that.

7.  Body loves a Shock!  Anything new or 'novel' gets noticed by our organism (us).  Abrupt changes force adaptation.  Sorry to sound morbid but if you want to kill Granny (or a pet) just prevent her from moving and feed her the same dull, white diet.  Again we evolved to engage with different situations and we thrive when challenged.  Food is no different hence the restriction/binge nature of this approach can work quite well.


Doug Scown

Wednesday, July 9, 2014

What's the Best Exercise?


This will be a post I will continually update.  Why?  There is no 'best' but there are certainly some principles which remain, some which die because they're just wrong, some which survive because they're wrong but popular and the biggest group, the stuff which we just don't know about yet.  I'll refer to us as organisms a lot because 'brain-body' is cumbersome and they work together.

Hang Your Hat

The HYH category are things which we understand quite well, things we understand quite well.

1. Humans evolved as movement based organisms (movement has been described as nutrition for your brain).  If you deprive them of movement, they weaken and become increasingly susceptible to injury even without even trying. The 'best' movement is walking because it's easy and we're made for it.  Walking (and movement generally) works best if it's done for at least 1/2 an hour or more each day and movement has all sorts of benefits - it improves posture, inhibits pain, clears your head, improves mood, slows brain shrink (doesn't make you smarter but keeps you less dumber) and makes you more attractive (true).

2. We love complex movement, novel movement.  Complex movement requires complex brain firing and brains love 'novel' things so every now and then vary your movement. It's also why we suspect that Tai Chi, Pilates and dancing are very useful for chronic pain and general well being because they challenge the brain.

3. Exercise is for your brain, less for your body.  The brain controls the body so although every problem combines an 'in' body or tissue problem the effect of disease or dysfunction is as much a brain issue as a body issue.  It's a chicken - egg paradox. In reality our entire body is quite seamless from a development point of view even though we can separate it into organ systems.

4. The organism is highly adaptable - bouts of High Intensity (HIT - high intensity training) force the organism to shift.  Athletes have been doing this for centuries.  It's simple, effective and allows you to eat more (yum!). Weights once or twice a week can do this but it has to be difficult.  Short, heavy, simple (one or a few exercises) workouts (which of course anyone can be trained for) do it.  It's not for everyone but if you like it, do it.

That's it for now.  Anyone is welcome to suggest alterations.  I'll keep 'eating' to another post.



Enter the Matrix

The following link is for the eggheads.


It's great fun to be able to use the word 'matrix' at work and still remain credible and within the realm of science but what on earth does it have to do with the spine?

Almost everything it seems.

Most problems felt in the body are triggered in the body however, how they feel, particularly when these conditions become chronic, is due to what is happening up inside the head, in the matrix.

The crowning achievement of biology in the 20th century was the mapping of the human genome.  It has allowed us to forge ahead at an even greater rate with our understanding of life, both how individual organisms function (and dysfunction), and how we all appeared to evolve.  It begins to reveal the why of the inherent, and unwanted, faultiness of ourselves but it also reveals it's wonder.  We are not even a single organism but a collection of billions most of which are not even 'human' and without which we could not survive.  We are not even constant.  In 7 years time we may see a slightly more wrinkled version of our self in the mirror but it will be a facsimile, most of those billions of cells having divided, died and replaced, giving you the illusion of continuity.

No wonder our reality verges on science fantasy and has been so difficult to understand.  Even highly esteemed scientists and thinkers get befuddled by the brain.

Nevertheless the average 10 year old grasps concepts which even Einstein was unaware of.  We were not the only humans on earth just the ones which have survived so far.  The universe is not static but expanding.  Black holes are real and consciousness, despite many of us not wanting it to be so, appears to be a final fluid function of the universes most complex piece of biology.  The brain.

In the developing embryo the beginnings of the central nervous system precedes all other structures, so, while the end product may appear to be a collection of disparate pieces, the body as a whole is a continuous, effectively homogeneous collective.  In fact biologists explain that we are not so much a single complex organism but a complex arrangement of billions of separate cells which have learnt, over billions of years, via the effects of physics and chemistry to arrange themselves into patterns which work.

And what of this Matrix - the brain map?

Well, we can see our limbs move but we cannot see our brain.  It's role and functions are counter intuitive.  You cannot feel it but feel with it, we cannot see it but see with it, we cannot move it but move with it.  We cannot even study it without using it to study itself.  It's no wonder that it's enigmatic nature is the source of considerable confusion, and the stubborn refusal to admit, that despite thousands of years of introspection and hundreds of years of science, what we perceive appears to be the projection of an organ weighing about 1.3kg.

Surely our seemingly unlimited subjective reality, our marvellously creative human imagination with which we make our world and experience it, surely it is greater than this.  But consider it's parts as science has revealed and is continuing to reveal - it is comprised of 100 billion neurons, each with hundreds, thousands of interconnections, each with a plastic, fluid nature.  The result is a moldable neural network of such complexity that it defies all rational mathematical numbers yet it is definable nonetheless as a product of these things.  Despite the considerable achievements of many of history's introspective traditions, none of them escaped the burden of superstition.  We can barely begin to understand reality without first understanding how the brain works and admitting that this is where we sit.  All other explanations are, for the present, just ideas.

Many fear that by reducing the study of the brain to it's constituent parts we will destroy the wonder of it.  In the film 'The Matrix', what neo experiences is the product of the machines.  In the same manner our attachment to our subjective experience as 'real' including our ideas and cherished beliefs does not often accord with reality.  This is why science has become such an essential tool, a way of thinking, with which we've been able to begin to poke our way through our cloak of ignorance about how things work.

We're afraid I think of damaging our awe and wonder.  We don't want to know what's around the next corner because it may not be as grand as what we've imagined.  But who imagined the nebula, the sheer unimaginable size of the universe, the speed of light, the roundness of the planet, the sun as a star, matter as the products of stars, the brain as the seat of our senses then our subjective reality, the fluid nature of the brain in response to experience?  The risk of knowing far outweighs the so called bliss of ignorance.  As a child I gazed up at the moon and considered how it could just be there without apparent support.  That was enough for me.

Wednesday, June 4, 2014

Chiropractic Diagnosis and the Elephant in The Room

The following comes courtesy of Dr Matt Long at CDI (Clinical Development International).
The Diagnostic Imperative
September 03, 2013 by Dr Matthew D. Long
Since its inception the chiropractic profession has had an uneasy relationship the word 'diagnosis'. While there were strong historical reasons for this, largely based upon establishing a separate and distinct lexicon to avoid being jailed for practicing medicine without a license (1), there remains an undercurrent of concern about the word itself.

What are the implications of using this word? For one thing, a diagnosis allows us to understand the
extent and character of a condition. We can then choose our management wisely, even if our clinical application remains focussed upon the chiropractic adjustment. After all, if I know that the patient in front of me has an annular tear then I might approach the delivery of an adjustment differently to that of someone suffering from a facet synovitis or meniscoid extrapment. How would the presence of a disc protrusion alter my decision-making? Or an extrusion? Or a sequestration? How would such knowledge alter my approach and improve patient safety and outcomes?
Because it should.
The recent discovery that vertebral body degeneration visible on MRI (type I Modic changes) may actually be due to an infection of Propionibacterium acnes from the mouth (2,3) further clarifies the importance of diagnostic specificity. If we know that such degeneration might actually be infectious in nature it significantly changes management.

We should also bear in mind that even if we limit our descriptors to the word 'subluxation' to quantify a spinal problem, we are
still making a diagnosis. We are attaching a label to a patient and deciding to intervene based upon it. However, a term like ‘subluxation’ leaves out the very important element of the tissue in lesion - and it is the connective tissues of the spine that must ultimately bear the forces that we wish to impart with our adjustments. After all, the bones of the spine are nothing more than levers that we use to stretch connective tissues and fire the receptors embedded within. It makes sense that we understand the nature of the tissues that we interact with. A subluxation is a model. It is a representation of various functional aberrancies in the spine, but like all models it is an approximation. An accurate diagnosis gives us clarification.

Making a rigorous diagnosis also grants us a
What is the chance of resolution of a grade 3 lumbar nerve root compression? How much time have you got to try out your conservative management before you close the window of recovery forever and condemn the patient to a life of chronic pain? 1 month? 3 months? 6 months? Would identifying the at-risk patient early make a difference? Absolutely.

Diagnosis gives us clarity. It also gives us a place in the health care system. The world does not need better therapists. It needs better problem solvers. It needs better clinicians. It needs better diagnosticians.

Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)

1. Keating, Joseph C Jnr. B.J. of Davenport: The early years of chiropractic. Davenport, IA: Association for the History of Chiropractic; 1997.
2. Albert, H. B., Lambert, P., Rollason, J., Sorensen, J. S., Worthington, T., Pedersen, M. B., et al. (2013).
Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? European spine journal, 22(4), 690–696. doi:10.1007/s00586-013-2674-z
3. Albert, H. B., Sorensen, J. S., Christensen, B. S., & Manniche, C. (2013).
Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy. European spine journal, 22(4), 697–707. doi:10.1007/s00586-013-2675-y

Sunday, March 23, 2014

BPPV revisited

A while back I wrote about Benign Paroxysmal Positional Vertigo or BPPV for short. It is a condition which although not life threatening is common, profoundly disturbing, often anxiety producing and inadequately treated. A sense of balance is fundamental to normal day to day activity and this problem doesn't just make you feel 'off' as many spinal problems can do. BPPV is a sudden and disturbing spinning sensation (most often associated with movement such as rolling over in bed) accompanied by nausea, sweating and anxiety and visual disturbance. Futhermore even once an attack has passed the experience is such that most people remain highly anxious or hypervigilant. This in itself is a normal response by the brain which has evolved to force you to pay particular attention to sensations which may threaten your survival and falling over is a main one. Think of the times your pesky brother sneaked up on you at lovers leap. Now magnify that sensation of threat, add in a manic childs roundabout and you have BPPV.

Fortunately it's diagnosis is easily confirmed and 90% respond well to treatment. In contrast is Menieres disease which is currently thought to be due to a disturbance in the fluid of the inner ear (endolymph).