Joseph C. Pigg, D.C. - Chiropractor In Campbell, CA USA

How man

y chiropractic treatments are enough?
by Dr. Joseph Pigg, D.C.

This is usually the number two question after "Can you help me with my problem?". Previously chiropractors relied on a combination of their own personal results for various conditions and a basic knowledge of healing times for injuries. There is some disagreement within the profession as far as specific protocols for how often and for how long someone needs to come in.

But in 2004, M. Hass, D.C. and Groupp, PhD published an exciting study in the Journal of Spine 4(5): 574-83 showing results from a randomized clinical trial on this very issue.

They took people with long time lower back pain and put them into several groups. One group received spinal manipulation and the other received spinal manipulation plus passive modalities (heat/ice, ultrasound, electric muscle stimulation, etc...) Each group got different amounts of care. 1, 2, 3, or 4 visits per week over a period of 3 weeks.

There was not much difference between the people getting chiropractic treatment 1 or 2 times per week, but a big jump in pain improvement for the people in the 3-4 times per week groups. This suggests that more chiropractic treatments may be required to reach the optimal benefit.

There are cases where the patient is able to get away with less visits when the doctor can clearly see that a quicker recovery is expected.

Too often, I am reluctant to recommend a large number of treatments because I anticipate the patient may not comply with the recommendations due to scheduling difficulties, financial barriers, or lack of motivation. And sadly, many HMO insurance plans and Kaiser only allow 5 visits for an episode of pain in spite of the fact that research like this clearly shows the most benefit came from approximately 9-12 treatments. As a doctor in practice, it is great to have this research to support my recommendations. It is what we call "Evidence Based Practice". Meaning that we don't make random recommendations or suggest numbers of treatments because they might be nice sounding numbers, but rather based on research and clinical trials that show evidence of a real benefit following a certain protocol.

There are some patients that I have been working with for a long time who are seen very seldom where we aren't getting the results we want and we try a 2-3 week period of very frequent adjustments to "move it up a notch". In almost every case, there has been a drastic improvement during this trial period and it makes the future maintenance care much easier.

If you are one of my patients and think you might benefit from a temporary increase in care, call or email me and let's talk about whether you would be a good candidate for more aggressive care.

The story is always the same. “Doc, I went to bed fine, but when I woke up I couldn’t turn my head, I had to use my hands to lift my head up this morning, and I feel like I’ve been hit by a truck!”

This is typical of a condition called “Torticollis”. One type of torticollis is “Congenital Torticollis” that occurs in infants and young children. But we will be discussing “Adult or Acquired Torticollis”.

Symptoms
In the majority of the cases, a person wakes up with a stiff and painful neck and sharp pain when trying to turn or tilt towards one side. If you had this condition and looked at yourself in the mirror, you might even see that your head is slightly turned, tilted, or even shifted to one side. For example, you might have pain on the right side of your neck and are tilted and turned slightly towards the left. In this case, turning or tilting your head right would cause excruciating sharp pain and looking up would be painful as well.

What causes it?
Many cases of this condition occur for no known cause, however there are several well known factors that may be related.

Sleeping with the window open:
This occurs most often in the hot summer months when people go to sleep with their window open for air circulation. But then around 4am when the temperature drops the neck muscles stiffen and cramp and lead to a change in the neck reflexes that don’t allow the tight muscles to loosen later.

Sleeping in an awkward position:
Whether you’re over-tired or have had a little too much alcohol, sometimes people will get their head or neck into a position from which they don’t move for several hours. The worst is when people sleep on their stomach and turn their head 90 degrees towards one direction so they can breathe, but also sleeping without a pillow or a shallow pillow can cause it. In the latter case, the neck is tilted too sharply towards the bed. For example, a person sleeping on their left with too shallow a pillow might have the joints on the left side of the neck jam or freeze in place while the muscles and other soft tissues on the right side of the neck are over-lengthened. It can also occur when one sleeps on their back on too many pillows causing their neck to be overly flexed during the night.

History of an unusual activity the day before:
Many times a person will report that they had done an activity outside of their normal routine the day before they woke up with the neck pain. Examples are people who are packing and moving homes, gardening, watching TV or a movie with their head turned one direction for the whole time, or beginning a new exercise in the gym. They don’t usually feel any problem the day of, but wake up feeling it the next morning.

What’s going on inside my neck? – Catch 22
In this type of Torticollis, one or more of the small joints along the back side of the neck called “facet joints” become jammed or locked. The small supportive muscles of the neck that are usually controlled by unconscious reflexes (the muscles you don’t even know you have until you have this condition) contract and hold the joint in a protective manner so as to avoid what it “thinks” is further damage to the joint. There is a swelling reaction around the joint as well. It is the swelling and the prolonged contraction that cause the pain. Here’s the catch. The joint can’t move normally because the muscles are holding their position, but the muscles won’t loosen because they feel the joint out of position.

Can it be treated?
Over the counter drugs such as ibuprofen or acetaminophen can temporarily help the pain and swelling. In severe prolonged cases, injections into the joint are sometimes used. However, most cases are self-limiting and do not require such drastic treatments. An average case of adult torticollis usually lasts from 4 to 7 days. Many people have to take a few days off work because they can’t drive or because the pain is too severe while working. X-rays are sometimes taken, but in typical non-serious cases, x-rays do not show the cause of the torticollis.

Conservative treatment:
Physical therapy employs a technique called Neuromuscular re-education in which proprioceptive neurofacilitation (P.N.F.) is used. After a therapist performs passive range of motion (ROM) in the pain-free range, they then use these longer named techniques which basically involve gentle isometric contraction into or away from the side of pain. The treatment reproduces the pain because it in effect “re-sets” the normal muscle reflexes much in the way that a computer can be “re-booted” when something goes wrong. Other helpful modalities may involve ice, heat, ultrasound, electric muscle stim., and traction.

Is chiropractic safe for treating this condition?
All of the above helps address the muscular reflex and spasm part of the condition, however the deeper joint issue should also be addressed. A chiropractor can help with this, however, it is very difficult to receive an adjustment (even if you’re already used to getting adjusted by a chiropractor on normal days) unless the physiotherapy involving resetting of the muscle reflexes and range of motion is done first. Otherwise, the tendency of the muscles will be to fight the adjustment.
In my own practice, I spend the majority of the time first performing these physiotherapies and then preposition the head in several different positions to see which would be the most comfortable for an adjustment. If there is no position possible without sharp pain, then I either use a light force adjusting tool (Activator) or don’t adjust the person at all at that time. When a patient is able to handle an adjustment, there is usually a sharp pain followed by instant relief and a relaxed feeling in the muscles. However, the muscles usually try to follow their newly learned habit and retighten over a few hours, but to a lesser degree. It is not uncommon for someone with this condition to come in for treatment in the morning, and then return for a follow up the same day in the evening. Typically after 3-4 treatments, the joint moves well enough to allow the muscles to calm down on their own and the person is able to function more normally.

Without treatment, torticollis usually will resolve on it’s own in 5-7 days. With proper conservative treatment, the majority of the condition usually resolves in 2-3 days. There is commonly left over soreness for about 1 week, but 90% of the motion with no sharp pain. It is crucial not to repeat sleeping in the wrong position again during this recovery phase.

Warning: If your neck is extremely stiff in every direction or you have lightning shock-like pains down your entire spine and especially if you have an accompanying fever and/or nausea/vomiting, you should seek immediate medical attention as you may be suffering from meningitis or some other severe life threatening neurologic condition. If you are not sure, call 911 or an advice nurse at your nearest hospital to discuss the symptoms. Rare cases of adult torticollis can also be related to fracture, tumor, or infection.

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2011

How Many Chiropractic treatments are enough?

The results are in. More IS better.

Neck Pain from "Sleeping Wrong"

Adult Torticollis- Neck pain from "sleeping wrong"

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