Question
QUESTION: Hey there Gerald. Im a 29 year old man who has been seeing my local chiropractor for about 6 months. I went to see him complaining of a really sore neck and sinus problems. Initially I saw him once a week because I couldn't afford twice a week. However recently I've been going twice a week for about 7 weeks as he claims  stage 1 misalignment requires this frequency. When I was seeing him once a week I felt great immediately and up until the next treatment. However now that i'm seeing him twice a week it seems I feel great for the first two days then it gets sore on the third. Is this a common occurrence? Is it because the  frequency of these visits causes my back and neck to try harder in reverting back to its original position? And if so will it go away over time? And secondly I am prone to bouts of sinusitis, which causes me to have facial pain. Could the way I tilt my head affect my posture or do you think its unrelated. Sometimes I think my sinusitis may be product of long term sub-laxation. Thank you for taking time out to address my query.

treatment is causing my back and neck to  my back and neck are my back and neck are trying to revert back to its original position and the effect will go away over time?  andresist the treatment.  Initially I felt great for the length of time between

ANSWER: Christopher,

Thanks for your question.

A 1999 clinical survey published in the journal Laryngoscope (Krouse JH, Krouse HJ. Patient use of traditional and complementary therapies in treating rhinosinusitis before consulting an otolaryngologist) found that patients employ both traditional and complementary therapies before seeking the care of an otolaryngologist for symptoms of allergic disease and sinusitis. Their findings suggest that despite aggressive and surgical therapy, many patients continued to remain symptomatic.

In 2005, a study published in the Journal of Manipulative and Physiological Therapeutics (Leboeuf-Yde et al. Self-reported nonmusculoskeletal responses to chiropractic intervention: a multinations survey) found that a minority of patients with self-reported nonmusculoskeletal symptoms (including sinus problems)report definite improvement after chiropractic care, and very few report definite worsening.

That said, chronic sinusitis that does not respond to a conservative treatment approach should be evaluated and treated by the appropriate health care practitioner. A chronic infection would need to be treated with medical intervention. It is doubtful that chronic sinusitis is the result of long-term joint dysfunction in the neck, as there is no clear correlation between the two that has been established in the medical literature. Moreover, I would not consider chiropractic manipulation to be an appropriate primary treatment for sinusitis due to the paucity of evidence supporting its efficacy.

Some chiropractors advocate frequent treatments to correct abnormal spinal curves. I am not aware of any evidence to show that this proprietary technique approach results in an improved state of health. In particular, I share the concern of critics of this approach regarding repetitive x-rays of the spine to show improvement or progress. I believe that the risks of over-exposure to ionizing radiation outweigh the benefit of quantifying curvature change.

Your neck pain may be a result of being over-manipulated. In a 2004 study published in the Journal of Manipulative and Physiological Therapeutics (Hurwitz et al. Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study), the authors stated increased stiffness, soreness, or pain following a thrust joint manipulation of the neck was more likely than if non-thrust joint mobilization.

Additionally, other possible causes of neck pain include disc bulge or herniation, or muscular problems. You might be better off with non-forceful joint mobilization or soft tissue manipulation.

Postural stress also plays a role in many cases of chronic neck or back pain. The Alexander Technique Workbook (2011 edition) by Richard Brennan is an excellent resource for learning how to improve your posture to reduce musculoskeletal stress.

Whenever a patient fails to achieve desired outcomes within a reasonable time period, or when symptoms change or worsen, it would be prudent for the treating clinician to re-examine his or her approach to the patient's care. Additional testing or a referral to another specialist may be helpful options.

I hope that this helps to answer your questions.


---------- FOLLOW-UP ----------

QUESTION: Dear Gerald thanks so much for taking the time to answer my question. Just a quick follow-up. The main reason for adjustments is not my sinuses but supposed proof of a misalignment gleamed from an x-ray. I am 100% certain now that my sinus problems stem from smoking and dairy allergies. However just wanted to know if you thought 8 weeks of twice weekly treatments constituted 'a reasonable time period' as my chiropractor believes my misalignment as developed over a few year. Apparently it requires this 'intensive period' and then the 'rebuilding phase' which is once weekly for who knows....

Answer
Christopher,

Thank you again for your follow-up question.

In my opinion, the treatment schedule recommended by the chiropractor you described is an arbitrary time period. You have been treated for 6 months for the same problem, which in my opinion is excessive, particularly as you have more recently suffered from increased neck symptoms.

Spinal "misalignment" is an outdated concept. Bones don't slip out place. Muscles move bones, and more specifically, skeletal muscles move the skeleton.

Many (but not all) chiropractors focus on a static x-ray image and use numerous terms to describe various stages of degeneration (i.e., as "phases" or "stages"), which really are nonsensical terms without any practical clinical usefulness.

Radiologists, in contrast, characterize degenerative changes evidenced on x-ray, MRI, or CT images as mild, moderate or severe. This is a much more useful way to describe how bad structural integrity appears on an image. In general, the more severe the degree of degenerative change, the more chronic the symptoms tend to be.

Chiropractors can't reverse degenerative changes of the spine with manipulation or adjustments. There is no evidence to show that manipulation can event slow or halt the progression of degenerative change.

Many (but not all) chiropractors believe that they can improve posture with long-term manipulation/adjustments. I tell my patients that if this was really true, I would expect older chiropractors who have received spinal adjustments over many decades to have some of the best examples of perfect human posture on the planet, but when I attend chiropractic conferences and continuing education classes, I see chiropractors in their 60s, 70s, or 80s (or even much younger) with some of the worst postures and bent-over spines I've ever come across, and I doubt they have had repeat x-rays taken every 8 weeks over their lifetime of receiving chiropractic adjustments to show their "progress".

The best evidence of which I am aware supports the use of chiropractic manipulation of the spine for short-term periods for certain musculoskeletal conditions. Having said that, there is always the case in which an individual patient finds that in their particular case, they may benefit from longer-term (and usually periodic) treatments on a symptomatic basis (that is, they receive treatment when they have pain).

There is no evidence to show that treating a non-symptomatic patient imparts any health benefit.

In general, (non-evidence-based) chiropractors refer to these arbitrary treatment schedules as "maintenance care".  

It also runs contrary to common sense as well as evidence-based guidelines to continue to treat a patient who fails to show improvement within a reasonable time period with the same treatments. What constitutes a reasonable time period? That depends upon the diagnosis of the patient, the severity of their condition, the objective findings obtained during examination or diagnostic imaging, the patient's overall health condition, and the patient's compliance with appropriate advice and recommendations by a competent health care professional as well as the patient's overall lifestyle (example: a severely overweight smoker with a poor diet and poor posture with chronic low back pain who maintains a sedentary lifestyle can hardly expect to experience optimum results from chiropractic manipulation/adjustments regardless of how many treatments they receive without making some lifestyle, diet, and exercise improvements).

A 2008 paper published in the journal Chiropractic and Manipulative Therapies ( Leboeuf-Yde and Hestb鎘. Maintenance care in chiropractic ?what do we know?) stated that:

"Back problems are often recurring or chronic. It is therefore not surprising that chiropractors wish to prevent their return or reduce their impact. This is often attempted with a long-term treatment strategy, commonly called maintenance care. However, some aspects of maintenance care are considered controversial. It is therefore relevant to investigate the scientific evidence forming the basis for its use.

There is no evidence-based definition of maintenance care and the indications for and nature of its use remains to be clearly stated. It is likely that many chiropractors believe in the usefulness of maintenance care but it seems to be less well accepted by their patients. The prevalence with which maintenance care is used has not been established. Efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown. Therefore, our conclusion is identical to that of a similar review published in 1996, namely that maintenance care is not well researched and that it needs to be investigated from several angles before the method is subjected to a multi-centre trial."

One additional point: The Australian physical therapist Robin McKenzie published an excellent book written for patients entitled Treat Your Own Neck. I highly recommend it for detailed information on how to actively use self-help techniques.

If you continue to experience problems, I'd recommend an additional opinion with another health care provider to make sure that there isn't something else contributing to your symptoms. Smoking certainly adds to the problem by dehydrating discs and advancing degenerative disc and joint disease, increasing the risk of disc herniation, increasing the rate of bone demineralization, increasing the level of pain-producing inflammation, and retarding the natural healing process.

I hope that this helps to answer your question.