Neck Problems

Neck Problems (50)

US Chiropractic Directory Presents:

Neck Problems

Neck problems are one of the most prevalent issues that people worldwide suffer. Neck pain has been called torticollis, stiff neck and a host of other names, however to the public, it is literally a "pain in the neck." Chiropractic has been safely and effectively helping patents with pain in the neck for over 100 years and The US Chiropractic Directory has create a forum of information combining the entire healthcare and scientific community to bring the public evidenced and researched based answers on how and why chiropractic works to help those with neck pain/problems.

Necessary Use of Initial X-Rays in Chiropractic



By Mark Studin DC, FASBE(c), DAAPM

Anthony Onorato DC, MBA


Reference: Studin M., Onorato A. (2023) Fact Sheet: Necessary Use of Initial X-Rays in Chiropractic, Dynamic Chiropractor, 42(03)


Public Health Risks


X-Ray Safety: There are ZERO negative effects of diagnostic X-rays in chiropractic offices. Radiation exposure to a patient in plain x-ray examinations of the spine involves an estimated 0.2, 1.0, and 1.5 mSv for the cervical, thoracic, and lumbar regions, respectively.[1] Among humans, there is no evidence of a carcinogenic effect for acute irradiation at doses less than 100 mSv and for protracted irradiation at doses less than 500 mSv.[2] The American College of Radiology, in their February 2020 ACR Appropriateness Criteria, reported, "Adverse health outcomes for radiation doses below 100 mSv are not shown by the evidence."[3] In chiropractic practice, it would require 500 cervical x-rays, 100 thoracic x-rays, or 67 lumbar x-rays in a single encounter to realize an adverse effect. It would take 5 times those levels over a protracted time; however, neither of these circumstances occurs in chiropractic practices as the safe use of radiation is inherent to our doctoral training regarding the number of necessary x-rays.


General Public Health Risk of NOT Taking X-Rays: The American Association of Physicians in Medicine reported, "Predictions of hypothetical cancer incidence and deaths in patient populations exposed to such low doses are highly speculative and should be discouraged. These predictions are harmful because they lead to sensationalistic articles in the public media that cause some patients and parents to refuse medical imaging procedures, placing them at substantial risk by not receiving the clinical benefits of the prescribed procedures."[4]


The Necessity of X-Ray in Chiropractic Practice: Chiropractic delivery modes are very diversified and state-dependent. Some choose an exercise model, while others use soft tissue work, joint mobilizations, arthrokinematic or kinesiological procedures, or high velocity, low amplitude thrusts (HVLAT, also known as a spinal adjustment or spinal manipulation). The combined effects of genetic inheritance, aging, and loading history can influence the strength of spinal tissues to such an extent that it is difficult to specify the likely strength of an individual’s spine. The risk of injury depends on tissue weakness as much as peak loading.[5]For the practitioners that consider every model but an HVLAT, there is little risk for the patient as minimal forces are being utilized. However, in an HVLAT, there are measurable forces with peak amplitudes that are generally tolerated in healthy spines. However, with injured spines, this can potentially be harmful if the force is not applied in the correct direction.[6]


As evidence in the literature has evolved over time, the direction and magnitude of spinal biomechanical pathology (misalignments), in conjunction with connective tissue pathology, have been defined.[7],[8] In some instances, those biomechanical lesions can cause serious injury to the spinal cord and must be identified before treatment begins.[9]


Significant Public Health Risk of Waiting 6 Weeks or a “Red Flag” to X-Ray: For the chiropractic practitioner that utilizes a lawful HVLAT procedure in their practice, whose outcome is evidenced to reduce opiate use by 64%[10] and realize a 313% lower disability outcome vs. physical therapy treatment[11], utilizing methods with poor reliability to determine care is not in the patient’s interest and is at the core of every state board’s responsibility. Seffinger et al., Troyanovich et al., and Bialosky et al. reported that palpation for position and movement faults had demonstrated poor reliability, suggesting an inability to determine a specific area requiring manual therapy accurately.[12],[13],[14]


Given that the majority of palpatory tests studied, regardless of the study conditions, demonstrated low reliability and invalid or unreliable and should not be used to arrive at a diagnosis, plan treatment, or assess progress.12 In contrast, the reliability of X-rays in morphology, measurements, and biomechanics, has been determined accurate and reproducible in both chiropractic and medical specialty.[15] The reliability of an x-ray is excellent for all parameters. It suggests that this valid and reliable information on accuracy should be used when assessing and interpreting a change in the cervical spine.[16]


For the HVLAT practitioner, treating for 6 weeks without evidence-based validity in diagnosis would be forcing a doctor to “guess” on formulating a prognosis and treatment plan and increase the risk to the patient. A “Red Flag” x-ray policy (evidence of fracture, tumor, or infection) is commonsense to any licensed provider. However, to apply the 6-week or red-flag “gatekeeper rule” for x-rays equally to chiropractic and medicine, as suggested by academicians and a minority, but influential political policymakers[17],[18] for the HVLAT practitioner is ignoring the evidence and potentially putting the public at risk. To underscore the necessity, the American College of Radiology Appropriateness Criteria 2021 lists in Variant 6 “low back pain with or without radiculopathy,” initial imaging of radiography of the lumbar spine; “Usually Appropriate.[19]


The Chiropractic Council for Education, under “META-COMPETENCY 1 – ASSESSMENT & DIAGNOSIS” (D), states, “Perform and utilize diagnostic studies and consultations when appropriate, inclusive of imaging, clinical laboratory, and specialized testing procedures, to obtain objective clinical data.” Most state scope parameters are consistent with the Federal Guidelines on imaging. Currently, x-ray procedures are being taught in every CCE-accredited program, and the Doctor of Chiropractic has the right, based upon a clinical decision for their treatment path, to take x-rays. This should not change. Carriers should not use political guidelines to limit the use of initial x-rays, nor should chiropractic colleges be allowed to limit the training on X-rays. This will increase the risk to the public.



[1]Mettler FA, Huda W, Yoshizumi TT, Mahesh M (2008) Effective doses in radiology and diagnostic nuclear medicine: A catalog Radiology 248: 254-263.

[2] Tubiana, M., Feinendegen, L. E., Yang, C., & Kaminski, J. M. (2009). The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology251(1), 13-22


[4] American Association of Physicists in Medicine. Position statement of the American Association of Physicists in Medicine. Radiation risks from medical imaging procedures. December 2011. http://www.aapm. org/.

[5] Adams, Michael A., and Patricia Dolan. "Spine biomechanics." Journal of biomechanics 38.10 (2005): 1972-1983.

[6] Lopes, Mark A., Roger R. Coleman, and Edward J. Cremata. "Radiography and Clinical Decision-Making in Chiropractic." Dose-Response 19.4 (2021): 15593258211044844.

[7] Steilen, D., Hauser, R., Woldin, B., & Sawyer, S. (2014). Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal, 8, 326.

[8] Lee, Derek J., and Beth A. Winkelstein. "The failure response of the human cervical facet capsular ligament during facet joint retraction." Journal of Biomechanics 45.14 (2012): 2325-2329

[9] Yang, Sun Y., et al. "A review of the diagnosis and treatment of atlantoaxial dislocations." Global spine journal 4.3 (2014): 197-210.

[10] Corcoran, Kelsey L., et al. "Association between chiropractic use and opioid receipt among patients with spinal pain: a systematic review and meta-analysis." Pain Medicine 21.2 (2020): e139-e145

[11] Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation27(3), 382-392

[12] Seffinger, Michael A., et al. "Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature." Spine 29.19 (2004): E413-E425.

[13] Troyanovich, Stephan J., Deed E. Harrison, and Donald D. Harrison. "Motion palpation: It's time to accept the evidence." Journal of Manipulative & Physiological Therapeutics 22.3 (1999): 186-191.

[14] Bialosky, Joel E., et al. "The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model." Manual therapy 14.5 (2009): 531-538.

[15] Fedorak, C., Ashworth, N., Marshall, J., & Paull, H. (2003). Reliability of the visual assessment of cervical and lumbar lordosis: how good are we? Spine28(16), 1857-1859.

[16] Marques, Catarina, et al. "Accuracy and reliability of X-ray measurements in the cervical spine." Asian spine journal 14.2 (2020): 169





Dr. Mark Studin is an Adjunct Associate Professor at the University of Bridgeport School for Chiropractic teaching advanced imaging and triaging chronic and acute patients, and an Adjunct Post-Doctoral Professor at Cleveland University-Kansas City College of Chiropractic. He is also a Clinical Instructor for the State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education. Dr. Studin consults for doctors of chiropractic, medical primary care providers and specialists, and teaching hospitals nationally. He can be reached at or 631-786-4253. TAP HERE for his CV

Dr. Anthony Onorato is the associate director of clinical education at the University of Bridgeport, School of Chiropractic. He is supervising attending physician for all clinical services. He is also an associate professor of clinical sciences at Bridgeport and currently teaches physical diagnosis. Dr. Onorato was the associate dean of chiropractic at the U of B College of Chiropractic, for 20 years. He directed the entire academic program and was responsible for the initial and continued accreditation of the program by the Council on Chiropractic Education (CCE) during his tenure. He also was a counselor for the CCE.


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Wednesday, 01 February 2023 14:41

Frequency Protocols with Initial Chiropractic Care

Written by

Frequency Protocols with Initial Chiropractic Care

By Mark Studin DC, FASBE(c), DAAPM

Anthony Onorato DC, MBA

Reference: Studin M., Onorato A., (2023) Frequency Protocols with Initial Chiropractic Care, American Chiropractor, 45 (3)



Determining a treatment plan cannot be a one-size-fits-all but must be a starting point to care. An evidence-based model should be considered and was defined by Sackett et al. (1992)[1] that included a doctor's clinical experience, the patient's feedback, and the evidence in scientific literature. Over the years, additional parameters have been added to Sackett's original model giving all in healthcare a direction for "published and yet unpublished" parameters in developing an effective treatment path.[2],[3],[4]


A Chiropractor's scope of practice can be diverse and is state dependent. Scope diversity is evidenced by Massachusetts' definition of "Correcting subluxations/segmental and somatic dysfunction or treating illnesses, injuries, conditions or disorders"[5] and New York, which states "detecting and correcting by manual or mechanical means structural imbalance, distortion, or subluxations in the human body for the purpose of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column."[6] Despite the diversity, a commonality in all state boards is allowing a doctor of chiropractic to treat neck and back pain with mechanical etiology.


Singh, Andersson, and Watkins-Castillo (2019) reported, "Lumbar/low back pain and cervical/neck pain are among the most common medical conditions requiring medical care and affecting an individual's ability to work and manage the daily activities of life. Back pain is the most common physical condition for patients visiting their doctor. In any given year, 12% and 14% of the United States adult population age 18 and older visit their physician with complaints of back pain. The number of physician visits has increased steadily over the years. In 2013, more than 57.1 million patients visited a physician complaining of back pain, compared to 50.6 million in 2010.[7]


Eklund et al. (2019) reported, [Non-Specific] "LBP is not only a societal problem, it also has profound impacts on an individual level with both psychological and social consequences. The condition is still poorly managed clinically, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Since over 90% of LBP cases have no underlying spinal pathology or other specific disease-causing their pain (i.e., no structural diagnosis can be made), the target for clinical intervention in non-specific LBP cannot be identified from a biomedical perspective."[8]


Conversely, Ndetan et al. reported that over 96% of survey respondents with spine-related problems said the use of chiropractic manipulation stated they were helped with their spinal-related condition. Comparing these statistics to medicine, which persists in diagnosing 90-95% as non-specific low back and unable to identify the cause of the pain, with significant evidence of a perpetual failed care path, chiropractic has superior outcomes.[9]


To realize a 96% positive outcome for back pain, protocols must be in place in clinical practice that is consistent in academia and clinical practice. These protocols must be in a "Best Practice Model" (as explained herein), consistent with other healing disciplines in creating protocols or standards.


A baseline protocol is a reasonable approach to care based on an initial evaluation. An ophthalmologist, faced with a clinical finding of macular degeneration, would consider a treatment, fluorescein angiography (FA)-guided reduced-fluence photodynamic therapy (PDT), as an accepted protocol.[10] If a patient presents to the emergency room with an occlusive stroke, the protocol is a tissue plasminogen activator (r-tPA) within 4 hours.[11] A patient with worsening symptoms of gait abnormalities, weakness, and sensory changes and diagnosed with cervical spondylotic myelopathy with minimal symptoms without hard evidence of gait disturbance or pathologic reflexes warrants nonoperative treatment. Still, patients with demonstrable myelopathy and spinal cord compression are candidates for operative intervention.[12] This is an accepted protocol depending on all the factors the physician observes and documents. Orthodontists, as a treatment protocol to move teeth create a force-induced tissue strain to create alterations in vascularity.[13]

 The four sample protocols above are in different medical specialties, and each specialty has its protocol. Chiropractic is no different. Having "predetermined protocols" is what we call a "standard of care" and a diagnostic or treatment regimen to follow. Our predecessors, having treated millions in a Best Practice model, have already determined the standards of care which is in the public interest. Every healthcare profession has a regimen of diagnosis and care, and they call them "predetermined protocols."

As the evidence evolves in every healing discipline, so do treatment protocols, with large enough cohorts to further confirm the efficacy of care. In determining the necessity of initial x-rays, the American College of Radiology (2021) deemed initial imaging of radiography of the lumbar spine, with or without radiculopathy, usually appropriate,[14] removing any controversy on standards of care.

Whalen et al. (2019) reported an appropriate standard of care is "multimodal treatment, inclusive of a chiropractic spinal adjustment (manipulation) for 3X (three times) per week for four weeks in the acute and chronic patient. Treatment may be initially provided more frequently and tapered as the patient improves. Continuing treatment should be predicated on the demonstration of improvement in functional capacity and not only temporary reduction in subjective complaints. A small population of patients with chronic pain with more complex problems may require ongoing care after a plateau in subjective and functional status has been reached. Patients with severe pain (numeric rating scale >7 of 10) and findings consistent with moderate to severe functional limitations may warrant daily treatment for up to 1 week to manage pain and improve function… Patients with more complex presentations, significant comorbidities, chronic neck associated disorders or whiplash associated disorders may require longer periods to demonstrate subjective, objective, or functional improvement."[15]


Globe et al. (2019) reported, "After an initial course of treatment has been concluded, a detailed or focused reevaluation should be performed. The purpose of this reevaluation is to determine whether the patient has made a clinically meaningful improvement. A determination of the necessity for additional treatment should be based on the response to the initial trial of care and the likelihood that additional gains can be achieved."[16] Despite numerous guidelines covering the spectrum of care, a clinical evaluation is the most accurate determinant for future care. This is an academic standard taught in CCE-accredited chiropractic colleges and is why timely reevaluations are performed during ongoing care.


Regardless of the semantics, protocols or predetermined treatment plans are an essential part of a standard of care that protects the public in a Best-Practice Model. The concern is when those protocols are not followed without specific clinical findings confirming an alternative course of care.


Dr. Mark Studin is an Adjunct Assistant Professor of Chiropractic, University of Bridgeport, College of Chiropractic, an Adjunct Post Graduate Faculty, Cleveland University-Kansas City, College of Chiropractic, an Adjunct Professor, Division of Clinical Sciences, Texas Chiropractic College and a Clinical Instructor, The State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Office of Continuing Medical Education. He can be reached at or at 631-786-4253


Dr. Anthony Onorato is currently the associate director of clinical education at the University of Bridgeport School of Chiropractic. He is supervising the attending physician for all clinical services. He is an associate professor of clinical sciences at Bridgeport and currently teaches physical diagnosis. Dr. Onorato was the associate dean of chiropractic at the University of Bridgeport, College of Chiropractic, for 20 years. He directed the entire academic program and was responsible for the initial and continued accreditation of the program by the Chiropractic Council on Education during his tenure. He also was a counselor for the Council on Chiropractic Education, the accrediting agency for all chiropractic programs recognized by the US Department of Education.


[1] Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., &  Richardson, W. S. (1996). Evidence-based medicine: What it is and what it isn’t. British Medical Journal, 312, 71–72. doi: https://doi. org/10.1136/bmj.312.7023.71

[2] Hayes, B. K., & Chen, T. H. (2008). Clinical expertise and reasoning with uncertain categories. Psychonomic Bulletin Review, 15, 5, 1002–1007. doi: 10.3758/PBR.15.5.1002

[3] Satterfield, J. M., Spring, B., Brownson, R. C., Mullen, E. J., Newhouse, R. P., Walker, B. B., & Whitlock, E. (2009). Toward a transdisciplinary model of evidence-based practice. Milbank Quarterly, 87, 368–390

[4] Cierpiałkowska, Lidia, et al. "Evidence-based assessment in a transtheoretical and paradigmatic approach." Current Issues in Personality Psychology 5.3 (2017): 153-162.




[8] Eklund, Andreas, et al. "Expectations influence treatment outcomes in patients with low back pain. A secondary analysis of data from a randomized clinical trial." European Journal of Pain 23.7 (2019): 1378-1389.

[9] Ndetan, H., et al. "Chiropractic Care for Spine Conditions: Analysis of National Health Interview Survey." Journal of Health Care and Research 2020.2 (2020): 105

[10] Koytak, A., Bayraktar, H., & Ozdemir, H. (2020). Fluorescein angiography as a primary guide for reduced-fluence photodynamic therapy for the treatment of chronic central serous chorioretinopathy. International Ophthalmology, 1-7.

[11] Ying, A., Cheng, Y., Lin, Y., Yu, J., Wu, X., & Lin, Y. (2020). Dynamic increase in neutrophil levels predicts parenchymal hemorrhage and function outcome of ischemic stroke with r-tPA thrombolysis. Neurological Sciences, 1-9

[12]Emery, S. E. (2001). Cervical spondylotic myelopathy: diagnosis and treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons9(6), 376-388

[13] Planning, O. T. (2001). Congenitally missing maxillary lateral incisors and orthodontic treatment considerations for the single-tooth implant. J can dent assoc67, 25-8


[15] Whalen, Wayne, et al. "Best-practice recommendations for chiropractic management of patients with neck pain." Journal of Manipulative and Physiological Therapeutics 42.9 (2019): 635-650.

[16] Globe, G., Farabaugh, R. J., Hawk, C., Morris, C. E., Baker, G., Whalen, W. M., ... & Augat, T. (2016). Clinical practice guideline: chiropractic care for low back pain. Journal of manipulative and physiological therapeutics39(1), 1-22.

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Wednesday, 01 February 2023 14:20

Addictionology, Back Pain and Chiropractic

Written by


Addictionology, Back pain, and chiropractic

Mark Studin DC, FASBE(c), DAAPM

Paolo Coppola MD, FACEP

Reference: Studin M., Coppola P., (2023) Addictionology, Back Pain and Chiropractic, Dynamic Chiropractor (41) 2, 53-55

According to the National Institutes of Health, “Unhealthy substance use, and addiction is the nation’s largest preventable health problem, yet only about 10% of patients receive treatment for it. This new subspecialty is important in helping eliminate the personal and public health consequences and the stigma associated with addiction by reinforcing that it is a preventable, treatable disease and by providing patients with access to credentialed physicians. Addiction Medicine (ADM) is now a recognized physician subspecialty of the American Board of Medical Specialties.”1

Back pain is the leading cause of disability worldwide, where ~37% of the population is affected by low back pain.2 Acute low back pain (LBP), if unresolved, is considered chronic if it persists for more than 3 months and is experienced by 70-80% of adults in their lifetime.3 85% -90% of patients with chronic low back pain (CLBP) have pain that cannot be determined from a definitive pathoanatomic structure and therefore termed “non-specific.”4 Non-specific LBP in an overall setting (acute and chronic) is defined as LBP with no attributable known cause and represents 90% - 95% of cases.5

Of those 85% - 90% of CLBP patients and upwards of 95% for all cases, they arise from acute low back pain with no definitive pathoanatomic cause (mechanical spine pain with no fracture, tumor, infection, or herniation). Of these acute patients, medical primary care providers prescribe LBP patients opiates in 24.4%, urgent care facilities in 40.8%, and emergency room physicians in 43.1% of cases.6

Of the 95% non-specific back pain, the literature has provided extensive evidence of the etiology when describing the genesis of spinal pain. Spinal meniscoids impingements, which are intra-articular folds of the synovial membrane, provide evidence of a pathoanatomical source of pain.7 In acute and chronic settings, there is a direct activation of nociceptor afferents where the sensitization and de-sensitization of pro- and anti-inflammatory mediators may modulate spinal pain. There is also central sensitization with widespread issues of mechanical pain sensitivity originating in the disc, facet, joint capsules, and ligaments.8

A chiropractic spinal adjustment (manipulation) inhibits neck and back pain through segmental and peripheral mechanisms regulating the inflammatory response.9 The meniscoid entrapment, which created pain, also creates a “tractioning” effect on the zygapophyseal joint capsule (mechanoreceptors), further leading to central sensitization. A chiropractic high velocity, low amplitude thrust/adjustment (HVLAT) stretches the joint, providing “joint gapping” and the “treatment of choice” for meniscoid entrapment, and reduces the pain created by the biomechanical pathology.10

In 2018 it was reported that average annual charges per person for filling opioid prescriptions were 74% lower among chiropractic patients compared with other forms of treatment. For clinical services provided at office visits for low back pain, average annual charges per person were 78% lower among chiropractic patients compared with other forms of treatment. The likelihood of a prescription for an opiate analgesic was 55% lower among chiropractic patients compared with other forms of treatment.11 In 2020, the prevalence of chiropractic care among patients with spinal pain varied between 11.3% and 51.3%. The proportion of patients receiving an opioid prescription was lower for chiropractic users compared with other forms of treatment. Chiropractic patients had 64% lower odds of receiving an opioid prescription compared with other forms of treatment.

In 2016, it was reported that medical care ended spinal-related compensation 12% longer than chiropractic, and physical therapy care required 239% more time to end full compensation than chiropractic. Medical care also required 20% more time, and physical therapy 313% more time versus chiropractic care regarding partial compensation.12

Despite the evidence in the literature, prominent medical establishments such as the Mayo Clinic still list chiropractic as an alternative footnote after listing physical therapy, drugs (including antidepressants and narcotics), surgery, implanted nerve stimulators, a radiofrequency neurotomy (surgery), steroid injections, all of which did nothing as primary treatment modalities. Herein lies part of the societal problem of dependence and the necessity for creating an addiction specialist.13

However, with the advent of an addiction specialist, they have understood and searched for a solution to the underlying cause of the fifth most prevalent reason for visiting a US doctor, low back pain.14 Addiction specialists are searching for the eradication of the cause of the pain that has led to opiate use initially, and chiropractic outcomes have warranted inclusion into their treatment plans for the management of substance addiction. The challenge that addiction specialists must overcome with using chiropractic is coverage issues where Medicaid and Workers’ Compensation systems place unrealistic roadblocks. These systems, in every state, offer full coverage for services that realize 64% higher opiate use and a 313% increase in disability yet still prevent patients from receiving “evidence-based care” that prevents opiate addiction.

Despite these outcomes, money is being drained from our healthcare system, lives are being severely disrupted, and people are dying unnecessarily.

1. About the Addiction Medicine Specialties (2018), Retrieved from:
2. Gevers-Montoro, Carlos, et al. "Chiropractic spinal manipulation prevents secondary hyperalgesia induced by topical capsaicin in healthy individuals." Frontiers in Pain Research (2021): 33.
3. Paolucci, Teresa, et al. "Chronic low back pain and postural rehabilitation exercise: a literature review." Journal of pain research 12 (2019): 95.
4. Tagliaferri, Scott D., et al. "Domains of chronic low back pain and assessing treatment effectiveness: a clinical perspective." Pain Practice 20.2 (2020): 211-225.
5. Oliveira, Crystian B., et al. "Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview." European Spine Journal 27.11 (2018): 2791-2803.
6. Azad, Tej D., et al. "Initial provider specialty is associated with long-term opiate use in patients with newly diagnosed low back and lower extremity pain." Spine 44.3 (2019): 211-218.
7. Farrell, S.F., et al. “Cervical spine meniscoids: an update on their morphological characteristics and potential clinical significance.” European Spine Journal (2017) 26:939–947
8. Gevers‐Montoro, Carlos, et al. "Neurophysiological mechanisms of chiropractic spinal manipulation for spine pain." European Journal of Pain 25.7 (2021): 1429-1448.
9. Ibid
10. Evans, David W. "Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories." Journal of manipulative and physiological therapeutics 25.4 (2002): 251-262.
11. Whedon, James M., et al. "Association between utilization of chiropractic services for treatment of low-back pain and use of prescription opioids." The Journal of Alternative and Complementary Medicine 24.6 (2018): 552-556.
12. Corcoran, Kelsey L., et al. "Association between chiropractic use and opioid receipt among patients with spinal pain: a systematic review and meta-analysis." Pain Medicine 21.2 (2020): e139-e145.
13. Back Pain (2021) Mayo Clinic, retrieved from
14. Urits, Ivan, et al. "Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment." Current pain and headache reports 23.3 (2019): 1-10.

 Studin picture
Dr. Mark Studin is a chiropractor who graduated from New York Chiropractic College in 1981. He is currently an Adjunct Associate Professor of Chiropractor at the University of Bridgeport, College of Chiropractic, and an Adjunct Professor at Cleveland University Kansas City, College of Chiropractic.
Dr. Studin is also a clinical instructor for The State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education, where he teaches numerous courses related to trauma and patient management.

Dr. Coppola simultaneously earned a Bachelor of Science in mathematics at New York University and a Bachelor of Engineering at The Cooper Union in New York in 1990. He completed his medical degree at The Mount Sinai School of Medicine in New York. 
He completed his residency in emergency medicine at the Johns Hopkins Hospital in Baltimore, Maryland. To better serve the diverse communities in New York City, Dr. Coppola is multilingual and speaks English and Italian fluently. He is board-certified in addiction medicine by the

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The Legal and Appropriate Use of X-Ray in Chiropractic


To Consider the American Chiropractic Association's “Choose Wisely” X-Ray Recommendations is a Potential Public Risk

 Mark Studin

William J. Owens

Noah Herbert

[to view any of the author's credentials, please click on their name]


NOTE: After the references is visual evidence of why x-ray should not be limited in chiropractic

Let’s be very clear on who determines the appropriateness and necessity of chiropractic clinical practice including x-ray, it is the state licensure boards of Alabama, Alaska, Arizona, Arkansas, California and all the rest to the 50th state alphabetically through Wyoming. These authors are perplexed as to why a political organization, the American Chiropractic Association (ACA), has deliberately inserted itself between the practicing doctor of chiropractic and their individual state licensure boards which has quickly delivered its negative effects by limiting the diagnostic tools and reimbursement of chiropractors nationally. Additionally, instead of working towards and supporting increased access to chiropractic care they are consuming limited financial and personnel resources and those of other political organizations by pushing an agenda crafted by a distinct minority of the profession. This is despite our state licensure boards laws and regulations that already regulate the appropriate utilization of x-ray in chiropractic.

To think that this doesn’t have a far-reaching negative effect on your practice and reimbursement is Pollyannaish, as these authors predicted in their 2017 article “Should Chiropractic Follow the American Chiropractic Association/American Board of Internal Medicine’s Recommendation on X-Ray? (1), because it has already happened and will continue to happen. To further outline the gravity of the issue and lend objective evidence that the American Chiropractic Association is now cause for limitation of your services and reimbursement, ACA President R. Ray Tuck in an official ACA capacity, wrote to Blue Cross Blue Shield of Illinois the following letter on July 31, 2018:

“I write to you on behalf of the American Chiropractic Association ("ACA") in connection with the above-referenced coverage policy recently adopted by your company. We note that the coverage policy references a "Choosing Wisely" article entitled ‘Five Things Physicians and Patients Should Question and utilizes portions of the article as coverage standards. 

Permit me to bring to your attention the following disclaimer appearing on the ‘Choosing Wisely’ web page: 

‘Note: Choosing Wisely recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversation about what is an appropriate and necessary treatment. As each patient situation is unique, providers and patients should use the recommendations as guidelines to determine an appropriate treatment plan together.’ (emphasis added) 

Conveying information not intended or designed to be coverage standards as such, while at the same time attributing such standards to this association, conveys an unfair and false impression. This action also, in our view, constitutes a violation of the Illinois Unfair Claims Practices Act by knowingly misrepresenting relevant facts relating to coverage issues (215 ILCS 5/154.6(a)). 

We, therefore, would request your company's immediate attention to this matter and the withdrawal of all coverage standards derived from the ‘Choosing Wisely’ article from the Chiropractic Services coverage policy.”

To review the American Chiropractic Association’s Choosing Wisely guidelines that were released in 2017, especially in regard to how they relate to imaging our patients in a clinical setting, they state “Do not obtain spinal imaging for patients with acute low-back pain during the six (6) weeks after onset in the absence of red flags.” (2) This controversial recommendation was adopted in conjunction with the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports.

The ACA has continued to support their position by writing articles in support of their own internal decision. Christine Goertz DC, Ph.D. wrote in an article titled Choosing Wisely X-ray Recommendations Reflect Evolving Evidence, Accepted Standards: “This recommendation is not only on ACA’s Choosing Wisely® list; a similar item is also included on the lists of seven other organizations. This includes, among others, the American College of Emergency Physicians, the North American Spine Society and the American College of Physicians. It's also one of the performance measures established by the Centers for Medicare and Medicaid (CMS) under the MIPS Program. Thus, it is a widely accepted standard.” It should be noted, while the three groups that Dr. Goertz cited above, the American College of Emergency Physicians, the North American Spine Society and the American College of Physicians, are all held in high regard, we have to examine this fact at a deeper academic level. Regarding the North American Spine Society, their recommendations specifically state they “Do not recommend advanced imaging (MRI) of the spine within the first six weeks in patients with non-specific acute low back pain in the absence of red flags.” Their recommendations do not include x-ray. (3)The American College of Physicians, as an organization, represent internal medicine physicians and while we recognize they are focused on the diagnosis and management of systemic disease, they do not have advanced training in musculoskeletal or biomechanical spine diagnosis and are not trained as spine specialists.

Dr. John Edwards, a neurosurgeon from Provo, Utah wrote:

December 1, 2018 

Dear Dr. Studin, 

I would like to commend you for the work you have done to integrate chiropractic into higher education, medical research, and the medical community. 

Over the past few years in my neurosurgical practice, I have understood more and more the value of biomechanical testing and treatment as the foundation for spinal care. I have discovered what you have known for years-biomechanical failures in the spine do not respond nearly as well to narcotics, steroids, injections, and surgery, as they do to chiropractic spinal adjusting. 

Plain x-ray of the spine is the foundation of biomechanical diagnosing and biomechanical treatment, and supplemented with MRI as needed, enables the chiropractor as a primary spinal provider to triage patient care and initiate treatment as clinically indicated. 

I think it is appropriate for the American Board of Internal Medicine to limit the frequency with which their providers are ordering diagnostic spinal tests, but inappropriate to hold this same standard to chiropractors. Internists generally know little about how to diagnose and treat spinal conditions. However, as a well-trained chiropractor, you understand when to order these tests. You can interpret them. You have validated, low cost, low-risk interventions that you can implement for treatment. 

I hope the biomechanically trained chiropractor will be valued, validated, and viewed as the most important primary care spinal provider in the future. In our low access, high cost, high-risk health care system, the high access, low cost, low-risk management chiropractors can provide should be embraced by the entire medical community.

Although state licensure boards have spoken loudly in their historical support of doctors of chiropractic having the right to take x-rays within their lawful scope of practice, let’s examine the list of other organizations that have no such x-ray recommendation like the ACA has adopted. These groups are arguably in a better position to provide recommendations as they relate to and represent doctors with advanced training in spinal care and diagnosis. This list includes the American Academy of Orthopedic Surgeons, the American Academy of Physical Medicine and Rehabilitation, the North American Spine Society, the American College of Radiology, the American College of Surgeons, the American Medical Society for Sports Medicine, the American Society for Clinical Pathology, and the American Society of Clinical Oncology. These organizations have far more experience when dealing with x-rays and how they relate to treating patients for spine pain particularly in the diagnosis of spinal disorders. The ACA should have consulted with these groups before providing their recommendations for the Choosing Wisely program. Instead they sided with organizations consisting of non-spine specialties while choosing to ignore those with advanced training.

Plain film radiographs are clinically indicated to both asses anatomical (space occupying lesion, fracture, tumor or infection) and biomechanical pathology directed by thorough clinical evaluation. In the absence of an anatomical source of pathology and spine pain, associated it is critical that aberrant biomechanical motion is assessed. These paradoxical biomechanical diagnoses indicate failure of the surrounding spinal ligaments and/or tendons demonstrating the mechanical source of the ensuing nociceptive, mechanoreceptive and proprioceptive neuropathological cascade. Fedorak, Ashworth, Marshall, and Paull (2003) reported: “This study has shown that the visual assessment of cervical and lumbar lordosis is unreliable. This tool only has fair intra-rater reliability and poor interrater reliability. Visual assessment of spinal posture was previously shown to be inaccurate, and this study has demonstrated that is reliability is poor.” (4). In contrast, the reliability of x-ray in morphology, measurements, and biomechanics has been determined accurate and reproducible. Additionally, Ohara, Miyamoto, Naganawa, Matsumoto, and Shimzu (2006) reported, “Assessment of the sagittal alignment of the spine is important in both clinical and research settings… and it is known that the alignment affects the distribution of the load on the intervertebral discs”(5)

In a recent informal survey of 400 doctors of chiropractic nationally returning 152 responses asking “Does the clinical use of x-rays changes either your diagnosis, prognosis or treatment plan?” Out of 152 respondents, 98.42% of those surveyed, used x-rays in their clinical practices that changed either the diagnosis, prognosis and/or treatment plan for their patients. X-rays, and being able to visualize the biomechanical pathology in the absence of anatomical pathology, is vital to the chiropractic physician and the outcomes of their patients.

Some organizations, such as the American Association of Neurological Surgeons, have published recommendations stating, “Do not obtain spinal imaging for patients with acute “non-specific” low-back pain during the six (6) weeks after onset in the absence of red flags.” (6) Let us examine the term non-specific low back pain and how it relates to the clinical assessment of other professions outside chiropractic. Non-specific low back pain is low back pain without a known anatomical cause, meaning without structural pathology. Simply because there is no anatomical pathology present doesn’t mean the pain is “non-specific.”   Doctors of chiropractic have long known the cause of non-specific low back pain, it has gone by various names, neuro-biomechanical lesions, biomechanical lesions, subluxation, vertebral subluxation complex, and spinal fixation.

Gedin et. Al (2018) reported, “it has been estimated that the vast majority of back pain cases is of non-specific origin. (7) The concept of simply focusing on the anatomical component of spine pain patients would render chiropractic no different than any other health profession. When focusing on the “non-specific” nature of spine pain, the focus must be on the biomechanical pathological component since the anatomical correlation is missing or does not correlate. The direction of care should be to the biomechanical compensation and individual motor units of the spine with a particular focus on spinal function and balance. Previous literature has verified that the supposition that “non-specific” is synonymous with “unobjectifiable” is erroneous since definite biomechanical changes in the motor units of the spine cause alterations of spinal balance, therefore resulting in “very specific” biomechanical pathology causing pain syndromes.

Panjabi in 1992, who had led the laboratory-based research into biomechanical spine pain, presented a detailed work explaining how the biomechanical systems within the human spine react to the external environment, how it can become dysfunctional and cause pain. He stated “Presented here is the conceptual basis for the assertion that the spinal stabilizing system consists of three subsystems, the vertebrae, discs, and ligaments constitute the passive subsystem, all muscles and tendons surrounding the spinal column that can apply forces to the spinal column constitute the active subsystem and finally, the nerves and central nervous system comprise the neural subsystem, which determines the requirements for spinal stability by monitoring the various trans­ducer signals [of the nervous system] and directs the active subsystem to provide the needed stability.” He goes on to state, “A dysfunction of a component of any one of the subsystems may lead to one or more of the following three possibilities, an immediate response from other subsys­tems to successfully compensate, a long-term adaptation response of one or more subsystems or an injury to one or more components of any subsystem.” (8)


Panjabi continues, “It is conceptualized that the first response results in normal function, the second results in normal function but with an altered spinal stabilizing system, and the third leads to overall system dysfunction, producing, for example, low back pain. In situations where additional loads or complex postures are anticipated, the neural control unit may alter the muscle recruitment strategy, with the temporary goal of enhancing the spine stability beyond the normal requirements.” (8) Panjabi’s laboratory is where the idea of biomechanical compensation was conceptualized and proven.


Panjabi’s evidence summarized in the above work is the basis for the underlying mechanics of spine pain that does NOT correlate well to anatomical findings. Anatomical findings are fracture, tumor or infection and allopathy has labeled anything else inaccurately “non-specific.” This concept and approach to spine care continue to maintain a dogmatic perspective in both clinical decision making, provider reimbursement and all too often, the literature, despite compelling evidence to the contrary.


A recent study by Scheer et al. (2016) reports a biomechanical assessment of the spine as critical to spine care including spine surgery. This concept was originally presented at the 2015 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves. The authors state “The cervical spine plays a pivotal role in influencing adjacent and global spinal alignment as compensatory changes occur to maintain horizontal gaze. Concomitant cervical positive sagittal alignment (loss of cervical lordosis) in adult patients with a thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach minimal clinically important difference at 2-year follow-up compared with patients without cervical deformity.” (9) Here we see additional evidence that spinal biomechanical modeling has an effect even in the presence of severe anatomical pathology requiring surgical intervention. In this case, it was even in an adjacent spinal region to the surgical site!

The scientific literature and certainly the surgical community is showing that thorough biomechanical assessment of the patient is a critical component to spine care, particularly in the complex spine pain patient. Without x-rays, the doctor is simply guessing.

One of the primary caveats stated in the ACA’s Choosing Wisely suggestions to not take spinal x-rays is the patient’s exposure to ionizing radiation. Patients routinely ask us about the radiation effects of x-rays, therefore it is imperative that we look at the facts, not the deceptive rhetoric that is so often quoted. According to a recent article from April 2018 by Harvard Health Publishing at Harvard Medical School titled Radiation Risk from Medical Imaging, they state that the average effective dose of a lumbar x-ray is 1.5 mSv. (10) According to the Radiological Society of North America in an article published April 2009 titled The Linear No-Threshold Relationship Is Inconsistent with Radiation Biologic and Experimental Data, they state “Among humans, there is no evidence of a carcinogenic effect for acute irradiation at doses less than 100 mSv and for protracted irradiation at doses less than 500 mSv.” They go on to state “There are potent defenses against the carcinogenic effects of ionizing radiation. Their efficacy is much higher for low doses and dose rates; this is incompatible with the LNT (linear no-threshold) model but is consistent with current models of carcinogenesis.” (11) As one can clearly see, the ionizing radiation effects of taking a set of lumbar x-rays is well below the minimum dosage to have a carcinogenic effect.

The following is a sampling of responses received by the Academy of Chiropractic, these responses were received from an informal survey of doctors of chiropractic nationwide. The instructions were to send over x-rays demonstrating ONLY ANATOMICAL PATHOLOGY and a brief history taken in their offices, many of which showed significant anatomical pathology in the absence of “red flags.” These responses underscore why the options for doctors of chiropractic should not be limited by politics, but instead should be driven by clinical assessment and scientific data. This myopic vision will create a public health risk and is integral in creating an accurate diagnosis, prognosis and treatment plan for our patients particularly in those patients with spine pain not specific to an anatomical lesion. As responsible doctors of chiropractic, we and the profession urge the American Chiropractic Association not to amend it's policy on Choose Wisely, but to rescind its x-ray “suggestions” in any and all formats. Furthermore, terminate all efforts in recommending anything other than each doctor follow their scope of practice in their respective states regarding the utilization of x-ray in clinical practice and the care of their patients. The chiropractic profession needs a strong political advocate and the American Chiropractic Association has historically been a major component in successfully filiing that need, however we need a powerful voice to unite us and not create further division within our profession or waste our valuable and limited resources. 

NOTE: Below the references is visual evidence of why x-ray should not be limited in chiropractic


  1. (
  2. (
  3. (
  4. Fedorak, C., Ashworth, N., Marshall, J., & Paull, H. (2003). Reliability of the visual assessment of cervical and lumbar lordosis: how good are we?.Spine,28
  5. Ohara, A., Miyamoto, K., Naganawa, T., Matsumoto, K., & Shimizu, K. (2006). Reliabilities of and correlations among five standard methods of assessing the sagittal alignment of the cervical spine.Spine,31
  6. []
  7. Gedin, F., Dansk, V., Egmar, A. C., Sundberg, T., & Burström, K. (2018). Patient-reported improvements of pain, disability and health-related quality of life following chiropractic care for back pain–A national observational study in Sweden.Journal of Bodywork and Movement Therapies.
  8. Panjabi, M. M. (1992). The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement.Journal of spinal disorders,5, 383-383.
  9. Scheer, J. K., Passias, P. G., Sorocean, A. M., Boniello, A. J., Mundis, G. M., Klineberg, E., ... & Shaffrey, C. I. (2016). Association between preoperative cervical sagittal deformity and inferior outcomes at 2-year follow-up in patients with adult thoracolumbar deformity: analysis of 182 patients: Presented at the 2015 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves.Journal of Neurosurgery: Spine,24
  10. (
  11. Tubiana, M., Feinendegen, L. E., Yang, C., & Kaminski, J. M. (2009). The linear no-threshold relationship is inconsistent with radiation biologic and experimental data.Radiolog 



NOTE: The following does not comment or reflect biomechanical pathology or the negative sequela of having it go undiagnosed. That is a topic for a separate article.  


The following is a sampling of responses we received from a survey of doctors nationwide 3 days prior to this publishing of this article. The instructions were to send over x-rays for ONLY ANATOMICAL PATHOLGY and a brief history taken in their office within the last 3 months. These responses underscore why the utilization for chiropractors should not be limited as it will create a public health risk and is integral in creating an accurate diagnosis, prognosis and treatment plan for our patients.  As responsible doctors of chiropractic we and the profession urge the American Chiropractic Association to terminate all efforts in recommending anything other than each doctor follow their scope of practice in their respective states regarding the utilization of x-ray in clinical practice. 

Abdominal Aortic Aneurysm


Compression Fracture

Compression Fracture LateralCompression Fracture AP

17 year old male with chronic mid back pain from high school wrestling.  Found a compression fracture.


Patient presented upper lumbar pain, adamant that he was cancer free, no problems whatsoever, had been cleared by PCP and oncologist in past, just "needed an adjustment" and was actually rather angry that I would not perform adjustment or treat the day of his exam. 

C2 Dens Fracture

Dens Fracture APDens Fracture Lat

This patient is a 25-year-old female with a history of a roll-over accident 10 years ago and recurrent neck pain. During history she said "I think they said something about a neck fracture".

Lumbar Transverse Process Fracture

TP Fracture2TP Fracture1

Lung Mass

Lung Mass

This patient was referred by an ENT/Facial Plastic Surgeon for evaluation of TMJ/Neck pain. The patient had the mass surgically removed. 


Spondylolisthesis 2Spondylolisthesis 4Spondylolisthesis 1

Patient was experiencing lower extremity radicular pain.  Saw a PT 6 times and a DC 6 times with no relief.  Then came to me.  I found the Spondylolisthesis.  He is doing great without any symptoms now.

L5 Metastatic Cancer

L5 enlarged spinous processL5 bone Cancer

Onset of low back pain and sciatica. X-ray revealed enlargement of L5 spinous process. Patient was reluctant to get MRI.  And then I had to fight with insurance carrier to get it authorized. But the x-rays revealed a problem. MRI confirmed metastatic lesion L5-S1 and posterior elements of L5.

Anterior Cervical Discectomy and Fusion


Patient came in complaining of neck pain. Never once stated a prior neck surgery in either the paperwork or when asking about past surgeries. 

Congenital Fused Vertebra

Congenital Fused Cervical LatCongenital Fused Cervcial AP

C2 Dens Instability

Dens 3Dens 2

54 year old male delivery driver, acute on chronic onset of low back pain constant 7/10 and neck pain intermittent 5/10 for years.  Seen by numerous chiropractors and medical doctors for 30+ years, taking medication for psoriasis.  Patient stated that he did not need x-rays just an adjustment and he would be on his way.  After x-rays I told the patient go to Kaiser and see a neurosurgeon, I refused to treat and showed him the instability.  He protested and said "you are just a f_ _ _ing chiropractor and I have seen many medical doctors over the years and no one has told me anything like I might need surgery. I called him later that day and he did go to Kaiser hospital and was seen immediately a spine specialist.


Ankylosing Spondylitis




Thoracic Compression Fracture


Comp Fx


56 year old male lifting heavy coffee table 1 week prior, mid back pain acute. No insurance, did not want to spend the money on x-rays. No significant health history.


Lumbar Anterolisthesis of L3


IMG 3836IMG 3873-2 


Spinal Fusion from T1-L3




Cervical Fracture



I was asked by an attorney to review a case of a 16 year old female with persistent headaches and neck pain with bilateral paresthesia in her left and right hands. He said he doesn't think she has much of a case. She was involved in a side collision with a pickup truck with a plow in a 30 mph zone. She was evaluated with CT of head and X-rays of neck and back and released by Children's hospital the same day. She has undergone a year of physical therapy for cervicalgia and neurologist for post traumatic headaches. She has 6 degrees of active extension with pain and 48 degrees of active flexion with pain. So I asked for the hospital records including copies of diagnostic imaging for my review. The cervical spine imaging report stated: "unremarkable cervical radiograph without evidence of acute osseous abnormalities." Well I have attached the lateral view for you, which I must strongly disagree with and contacted the radiologist regarding. He asked me at first why I was reviewing the films. I stole your line and said "real doctor's read their own films, would you want a surgeon doing surgery on you without looking at the films." The reply was "good point." He also agreed to write the addendum. I then advised the attorney of my findings and the text message said, "HOLY S!@#! WOW that makes so much sense."



17 year old female presented with lower back pain after baton twirling practice. No trauma. Spondylolysis of L4 most visible on the right posterior oblique.

Multiple Myeloma

Multiple Myeloma2Multiple Myeloma

Note multiple pathologic compression fractures and lysis of right ischial tuberosity. Turned out to be multiple myeloma, Stage 4. L3 is post vertebroplasty.

Lumbar Scoliosis

AP L3LL 3 

Cervical Fusion

Cervical Fusion LatCervical Fusion AP


Xrays Lspine

Lung Mass 





68 year old male with severe low back and right leg pain. Radiographs exhibit dextrocurvature, severe degeneration and a grade1-2 spondylolisthesis.

Compression Fracture 


Cervical Mass

Cervical MassCervical Mass2Cervcial Mass3

Kidney Stones

Screen Shot 2018-07-09 at 12.07.00 PMScreen Shot 2018-07-09 at 12.07.20 PMScreen Shot 2018-07-09 at 12.07.39 PM


AC Joint Separation

Screen Shot 2018-04-17 at 6.27.46 PMScreen Shot 2018-04-17 at 6.28.14 PM

Baastrup's Disease 

Screen Shot 2018-05-15 at 10.42.45 AM

Coccyx Fracture

Coccyx FX 4-2018

Atlantoaxial Instability 

Screen Shot 2018-11-07 at 4.32.47 PMScreen Shot 2018-11-07 at 4.33.31 PMUnknown




Aortic Aneursym

IMG 4491

Pelvic Fracture

Screen Shot 2018-10-30 at 4.55.45 PMScreen Shot 2018-10-30 at 4.55.17 PM


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Increased Chiropractic Visit Frequency Renders Better Outcomes

By: Mark Studin DC

Reference: Studin M., (2022) Increased Chiropractic Visit Frequency Renders Better Outcomes, Chiropractic Economics, 68 (15) pgs. 24, 26-27

It has been well-established that chiropractic renders positive outcomes for mechanical spine pain. DeVochet et. Al (2005) reported that 87% of chiropractic patients reported improvement. Leeman et. Al (2014) reported that 95% of chronic pain patients reported improvement. Shokri et. Al (2018) reported that 95% of sacroiliac joints, a primary pain generator in low back pain improved with manipulation (chiropractic spinal adjustments or CSA). Yang et. Al (2022) verified through functional MRI (fMRI), that immediate changes in the brain involving pain, and emotional and cognitive changes were achieved using spinal manipulation (CSA) and reported further diminishing chronic low back pain in all patients.

The above outcomes are all related to pain and do not consider the biomechanical changes in the spine that are necessary to “normalize” the pain generators. These pain generators make up the mechanoreceptors and Nociceptors. They are compromised of Pacinian Corpuscles, Ruffini Corpuscles, Golgi Ligament Organs, and the Nociceptors found in the joint capsule and on the facets. The fMRI changes reported by Yang et. Al (2022) are a direct result of a CSA causing afferent innervation, as reported by Coronado (2012) from the mechanoreceptors and nociceptors into the lateral horn. According to Montero et. Al (2021), these evoke central sensitization with both primary and secondary hypoalgesia.

The pain mechanisms are a result of biomechanical failures and neurological compromise as described herein, which are a result of joint capsule (ligamentous) subfailures. Holsgrove et. Al (2016) reported “Any disruption to the various hard and soft tissue structures of the facet joint has the capacity to elicit pain. The facet capsule and synovial folds are innervated by nociceptive and mechanoreceptive afferents. Pain can result from direct damage of nociceptors but can also be produced indirectly through damage to the mechanoreceptors, which alters feedback and increases neck instability, leading to pain in muscles and/or from muscular contractions.” (Pg. 1)

Chronic pain indicates a persistent biomechanical failure and a constant firing of the nociceptors and mechanoreceptors to the central nervous system. Chronic neck and low back pain as reported by Herman et. Al (2021) “usually cannot be cured, but it can be managed.” (Pg. E62) Medicine has for too long, has tried to apply a pharmacological solution to a mechanical problem, with poor outcomes. Cifuentes et. Al (2011) reported that medical management of mechanical spine pain had a 250% increase in disability duration vs. chiropractic care and Herman et. Al (2021) reported that if patients didn’t receive chiropractic care, their pain would have been double.

It was reported by Herman et. Al that 30-60% of patients in the United States with chronic low back pain have seen a chiropractor creating an easy “pool” of people to study. Herman et. Al’s results of studying 2024 patients indicate that more frequent visits (greater than once weekly) over a 3-month period rendered better outcomes. The study also found that adding complementary therapy (i.e., massage, etc.) rendered better functional improvement. It was also found that the more significant the pain initially, the more frequent chiropractic care per week rendered better outcomes.

According to Shokri et. Al. (2018), “compared to common treatments for lumbar disc herniation   chiropractic care is 37,000 to 148,000 times safer than non-steroidal anti-inflammatory drugs and 55,000 to 444,000 times safer than surgery.” Whedon, Mackenzie, Phillips, and Lurie (2015) reported on the safety in general of chiropractic patients and based their study on 6,669,603 subjects after the unqualified subjects had been removed from the study, total patient number accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified” (Whedon et al., 2015, p. 5). This study supersedes all the rhetoric about chiropractic and stroke and renders an outcome assessment to help guide the triage pattern of mechanical spine patients.

Chiropractic is safe, creates a mechanical solution for biomechanical pathology, and renders better outcomes when used as clinically indicated. Should the medical community and insurers read the evidence in the literature, chiropractic isn’t the best “first choice” for mechanical spine pain, it should be the ONLY first choice. There are tools in the industry (i.e., Symverta) that render demonstrative guidance to DCs on where and when to adjust, and when MMI has been attained. These demonstrative tools also give evidence of the biomechanical changes made with a CSA. It is tools like this and others that will help “bridge the knowledge gap” to bring chiropractic to the forefront as a Primary Spine Care Provider.


  1. DeVocht, J. W., Pickar, J. G., & Wilder, D. G. (2005). Spinal manipulation alters electromyographic activity of paraspinal muscles: A descriptive study. Journal of Manipulative and Physiologic Therapeutics, 28(7), 465-471.
  2. Leeman, S., Peterson, C., Schmid, C., Anklin, B., Humphrys, K. (2014). Outcomes of acute and chronic patients with magnetic resonance imaging-confirmed symptomatic lumbar disc herniations receiving high-velocity, low-amplitude, spinal manipulative therapy: A prospective observational cohort study with one year follow up. Journal (3), 155-163
  3. Shokri, Esmaeil, et al. "Spinal manipulation in the treatment of patients with MRI-confirmed lumbar disc herniation and sacroiliac joint hypomobility: a quasi-experimental study." Chiropractic & Manual Therapies 26.1 (2018): 1-7
  4. Yang, Yu-Chan, et al. "The Changes of Brain Function After Spinal Manipulation Therapy in Patients with Chronic Low Back Pain: A Rest BOLD fMRI Study." Neuropsychiatric Disease and Treatment 18 (2022): 187.
  5. Coronado R., Gay C., Bialosky J., Carnaby G., Bishop M., George S., (2012) Changes in Pain Sensitivity following Spinal Manipulation: a Systematic Review and Meta-Analysis, Journal of Electromyography Kinesiology, 22(5) 752-767
  6. Gevers‐Montoro, Carlos, et al. "Neurophysiological mechanisms of chiropractic spinal manipulation for spine pain." European Journal of Pain 25.7 (2021): 1429-1448.
  7. Holsgrove T, Jaumard N., Zhu N., Stiansen N., Welch W., Winkelstein B., (2016) Upper Cervical Spine Loading Simulating a Dynamic Low-Speed Collision Significantly Increases the Risk of Pain Compared to Quasi-Static Loading With Equivalent Neck Kinematics, Journal of Biomechanical Engineering, 138 / 121006: 1-10
  8. Herman, Patricia M., et al. "Visit frequency and outcomes for patients using ongoing chiropractic care for chronic low-back and neck pain: An observational longitudinal study." Pain physician 24.1 (2021): E61.
  9. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine53(4), 396-404
  10. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270

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Thursday, 02 April 2020 20:32

Chiropractic Practice During the COVID-19 Pandemic

Written by

Chiropractic Practice

During the COVID-19 Pandemic


By Mark Studin


In a conversation with Jonathan Epstein, an epidemiologist at the EcoHealth Alliance in New York who has traveled the globe in studying zoonotic viruses—those that can jump from animals to people, and was part of the research team in China’s Guandong Province that discovered bats were the natural reservoir for SARS, I now understand that the current COVID-19 strain is related to SARS and MERS, two other recently emergent zoonotic coronaviruses. These viruses live in certain bat species and have co-evolved with bats for the entire span of human civilization. Dr. Epstein explained, “These viruses are made up of RNA and can mutate quickly, making them promiscuous. Often, when a virus jumps from its natural host (e.g. bats) to a new host (e.g. people) it can cause disease. A virus that transmits easily and doesn’t readily kill its host has the best chance to survive in nature.”


A German study published just as a few weeks ago revealed that the coronavirus is an outstanding “shedder” and seeks to leave its host once it replicates. It searches mucosal exists, even our breath well before the host is experiencing symptoms.[1] The New Yorker Magazine reported, “Outside a host, in parasitical purgatory, a virus is inert, not quite alive, but not dead, either. It was found that the virus can linger on copper for four hours, on a piece of cardboard for twenty-four hours, and on plastic or stainless steel for as long as three days. They also found that the virus can survive, for three hours, floating through the air, transmitted by the tiny respiratory droplets as an infected person exhales, sneezes, or coughs out.”[2]


Living in New York, at the epicenter of this crisis and now self-isolated for 17 days, this is eerily reminiscent of 9-11 to many New Yorkers where we know someone infected, and someone knows someone who has lost their life. We live in fear for friends and families who are “hospital-based first responders,” and most everyone wants to be part of the solution. The Long Island Expressway dubbed the “longest parking lot in the world” is perpetually empty, and the largest railway commuter system on the planet hardly has a passenger. We are also fearful of others in our nation due to political “misinformation” because we are in the epicenter living and witnessing the truth through ourselves, family, and friends with confirmation through local media.



Where does that leave our profession?


I have spent the last two weeks becoming an expert on infectious disease prevention in chiropractic offices, telemedicine, home-based treatments, acquiring feedback from patients, risk management, coding, preserving referral sources, managing finances, and labor/employment laws. I have been teaching doctors how to prepare for “opening day” that will come sooner than you think and a host of other things chiropractic would have never considered.


For those who have chosen to stay open, the patient’s car in the parking lot has become the new waiting room, where one person at a time is allowed in the office for treatment. Most staff has been furloughed, leaving only the doctor and essential treating staff with hand and treatment table sanitizing between every patient. A mask for the doctor is strongly advised due to the “breath” transmission of this virus. If you treat a patient that has been diagnosed with Covid-19, you and your staff are then mandated by your state’s department of health to self-isolate for 15 days.



For those who have closed, telemedicine has become a necessity, and the Federal Government has relaxed its HIPAA rules, practicing over state line rule and others. Carriers have added chiropractic telemedicine services, and many have waived co-pays and deductibles because these are billable events. There have been recent E-Codes added by the AMA to create clarity in billing telemedicine codes. You should consider using modifier “95” [telemedicine services], and place of service “02” [telemedicine]. These are predominantly timed services involving patient management and have specific documentation requirements to consider.



If you would like to learn more about coding and other COVID-19 issues, I am providing a link for a 40-minute Webinar I created for the profession to help clarify these issues [there is no cost]:


There is lots of money in the system right now with the Federal Bail-Out, but be careful not to borrow what you don’t need and start with your local bank. They have the Federally backed money that includes some type of forgiveness in the Payroll Protection Program (PPP). I have also been told by many on Wall Street that inflation is not far away. Should you have a variable rate, or high-interest loan on any property, now is the time to refinance with interest rates low. Be financially smart.



Patient communication is paramount now. You do not want to see yourself re-starting your practice from “ground-zero” because you neglected to engage them during this mandatory isolation time. If you regularly have telemedicine visits, that is great; if not, ensure you touch base with them periodically via telephone to “check on them.” The same goes for lawyers and MD’s that you have referral relationships with, communicate with them. We have instituted regular academic programs for lawyers and MD‘s to keep them engaged with our doctors at a very high level. Opening day is coming sooner than you think, and the referral sources will remember you, if you made that extra effort.


What you do with your time is critical. I urge every chiropractor in the nation to get better academically. Take as many online post-doctoral courses as you can. I don’t care if your state allows online courses or not. Market research has proven over the last decade; the more credentials a doctor of chiropractic has, the more they can help their patients, the more referral they get, and the financial bottom line goes up. Cleaning your garage with your extra free time is admirable, but elevating your knowledge will help the multitudes in your community, yourself included.



Should you open if you have the opportunity or not? That is a personal question for you to answer. For me, I want to be part of the solution, and today is day 17 of being self-isolated, where I work long days and sleepless nights in being creative to ensure that I am prepared for opening day.




[1] Woelfel, R., Corman, V. M., Guggemos, W., Seilmaier, M., Zange, S., Mueller, M. A., ... & Bleicker, T. (2020). Clinical presentation and virological assessment of hospitalized cases of coronavirus disease 2019 in a travel-associated transmission cluster. medRxiv.


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Wednesday, 19 February 2020 14:07

Chiropractic Co-Management of Pre & Post-Spine Surgical Cases

Written by

Chiropractic Co-Management of Pre & Post-Spine Surgical Cases


By: Matt Erickson DC, FSBT


Ashraf Ragab, MD, Orthopedic Spine Surgeon



Reference: Erickson M., Studin M., Ragag A. (2019) Chiropractic Co-Management of Pre and Post-Surgical Cases, American Chiropractor 41(9), 34, 36,38-40


A report on the scientific literature




When a patient presents in a chiropractic office and has clinical signs of either radiculopathy (nerve root compression) at the neural canal or central canal regions or any myelopathic findings (cord compression with ensuing neurological deficit distal to the level of the lesion), immediate referral for an MRI should be considered. Based upon your clinical findings, triage then ensues as a result of creating a clinically driven diagnosis, prognosis and treatment plan. In a smaller percentage of cases, it will be discovered that the patient has a condition that requires a referral to a spine surgeon or a pain management provider. Regardless of where the patient is directed, having the patient fully worked up (examination, x-rays and advanced imaging) before the referral takes place is an important aspect of what the Doctor of Chiropractic can and should do and is within the lawful scope of practice within all 50 states and the United States territories.


Among those patients referred to the spine surgeon, some will not require or be a candidate for surgery. This is an area where a Doctor of Chiropractic especially with post-graduate training in Primary Spine Care and spinal biomechanical engineering, can be a big help to the surgeon by ensuring that a higher portion of the referred patients presents with the condition that likely requires the surgeon’s services. By triaging those patients who more likely needs the spine surgeon or pain management doctor’s services, it allows the specialist to save time on screening patients in the clinic who do not need their services and instead, it allows them to spend more time performing medically necessary spine-related procedures which allows patients to be taken care of more efficiently.


In the event a patient does not require surgery, unless there is a contraindication to correcting a patient’s neuro-musculo-biomechanical failure leading to structural imbalance, the Doctor of Chiropractic can co-manage the patient with the pain management provider. For the pain management provider, they may recommend various pain management procedures like a spinal epidural injection, a medial branch block or a facet injection. And given that pain management providers don’t focus on spinal biomechanics, but the Doctor of Chiropractic does, for most patients, this collaborative approach is ideal for better patient outcomes.


Surgical Considerations


In patients who do require surgery, the treatment plan can be as simple as the referral to the spine surgeon. This however brings the question, “What is the Doctor of Chiropractic’s role in managing patients before and after surgery?”


In some cases, immediate surgery may be required. This would be the case where the patient has a spinal cord injury like myelomalacia-which is regarded as softening of the spinal cord due to damaged neural tissue that fills in with a glial scar.   A glial scar, according to Silver and Miller (2004, February) “consists predominately of reactive astrocytes [star-shaped glial cells-cells without neurons, in the brain or spinal cord] and proteoglycans [molecules made of sugar and proteins]” (p. 146). Further, myelomalacia forms with pressure on the spinal cord which may be due to biomechanical failure and ensuing cord pressure in post-trauma cases. Immediate surgery may also be required with a disc extrusion (a type of disc herniation) which presents with myelopathic findings (ensuing neurological deficit distal to the site of the spinal cord lesion following trauma) and in patients with an advanced nerve root compression leading to pain, numbness, tingling and weakness into the upper or lower extremity at the level the nerve root has been compressed.


In other patients however, while surgery may be indicated, the Doctor of Chiropractic can work to improve the patient’s biomechanical balance before surgical intervention. This is another area a Primary Spine Care trained Doctor of Chiropractic has the additional post-graduate training to co-manage this type of case. Regardless, these considerations must be coordinated with the spine surgeon if surgery is required. Sagittally balancing the spine for better patient surgical outcomesas reported by Makhni, Shillingfor, Latatta Hyun and Kim (2018), “Adult spinal deformity with sagittal imbalance is associated with significant pain, disability, as well as directly and negatively influence health-related quality of life scores. The spine surgeon has to understand the whole global and regional alignment changes after sagittal imbalance to address the multiplanar deformity. Restoration of global alignment and minimization of complications through various surgical options can successfully improve the pain and function of spinal deformity patients” (pp. 176-177).


Importance of Sagittal Balance


Sagittally balancing the lumbar spine is further supported in an article published on related to lectures on the outcomes of lumbar spine surgery about sagittal balance, Hu (2016, para 3) reported, “Surgical outcomes for spine surgery are improved when spinal, pelvic and hip alignment is considered in both degenerate and deformity cases, and how we better understand these will help us better improve outcomes for our patients” (


Hu (2016) also reported, “Sagittal imbalance in a patient can negatively affect the outcomes of a surgical procedure. But, how extensive the surgery required is to correct the imbalance must be carefully considered for the individual patient” (para. 4). r. LeHuec (2016) added, “Sagittal balance is an active phenomenon for patients. “The best course of action is to strive to achieve sagittal balance in patients” (para. 8).



In a study by Tang, Scheer, Smith, Deviren, Bess, Hart, Lafage, Shaffrey, Schwab and Ames (2015) regarding the thoracolumbar spine sagittal balance, the authors concluded, “Our findings demonstrate that, similar to the thoracolumbar spine, the severity of disability increase with positive sagittal malalignment following surgical reconstruction” (p. S21).


Finally, in an article by Yeh, Lee, Chen, Yu, Liu, Peng, Wang, and Wu, (2018) they concluded, “The results of this study support previous findings that functional outcomes are closely associated with sagittal radiographic parameters in the patients with the degenerative thoracolumbar spinal disease who received long-segment fusion. The achievement of global and regional sagittal alignment balance is a crucial factor for improved postoperative functional outcomes” (p. 1361).


Post-Surgical Management

According to a publication titled “A Detailed Guide to Your Surgery and The Recovery Process by the Johns Hopkins Spine Service (n.d., p. 16), “Walking is the best activity you can do for the first 6 weeks after surgery. Further, there will be “restrictions for the first 6 weeks after surgery,” the patient should “avoid twisting and bending” and avoid lifting, pushing or pulling objects greater than 5 lbs” (


From the Johns Hopkins publication (n.d.), patients are advised to call the surgeon’s office to make a 6-week follow-up appointment. At that appointment, x-rays will be performed to evaluate how the surgical area is healing. If everything checks out, “patients may be given a handout of lower back exercises to begin at home.” Patients may also be provided a prescription for outpatient physical therapy, but that is dependent upon the patient’s recovery (p. 24).


When physical therapy begins, the goal is to gradually improve strength, flexibility and endurance. The patient may also receive help with activities of daily living like gate training (learning how to walk properly again). However, while beneficial, physical therapy is limited in that a physical therapist does not focus diagnosing and correcting the spinal biomechanics. Further, a physical therapist is not licensed to manage the patients on a physician level. This is where the Doctor of Chiropractic is needed as part of the long-term recovery solution.


Following the initial 6-week evaluation, according to Hayeri and Tehranzadeh (2009, para. 21), “Evaluation of the postoperative spine usually begins with conventional radiographs in AP and lateral projections. It usually takes 6 to 9 months for a solid bone fusion to be established radiographically.”  Hayeri and Tehranzadeh (2009, para. 20) also reported, “Postoperative imaging plays an important role in the assessment of fusion and bone formation. It is also helpful to detect instrument failure and other suspected complications. It is necessary to compare current images with previous studies to identify any subtle changes and disease progression” (


Hayeri and Tehranzadeh (2009) added, Currently, computed tomography (CT) with multiplanar reconstruction (MPR) is considered the modality of choice for imaging bony details and assessing osseous formation and hardware position despite artifact formation.” (para. 22).



It is important to understand, patients don’t need to wait 6-9 months to start treatment with the Doctor of Chiropractic. About 6 weeks following surgery, if the patient is healed enough to begin physical therapy, the patient should be able to tolerate gentle mechanical corrections above and below the level of the surgical fusion. However, the patient will need to first be cleared to do so by the surgeon. Doing this can help in the patient’s recovery process and prepare the patients spine for a more comprehensive correction process once the patient is cleared. It can also help to shorten the time needed for correction.


The Doctor of Chiropractic (trained in Primary Spine Care) therefore, can take on a critical and important role in the management of patients before and after spine surgery. Further, unlike the physical therapist, the Doctor of Chiropractic having physician class status, is licensed to fully diagnose, manage and treat biomechanical pathology of the spine when indicated.


Primary Spine Care


Despite this, not all Chiropractic Doctors have additional post-graduate training or experience to manage complex spine cases. This is no different than a Medical Doctor having just completed medical school not being able to function in the capacity of a specialist short of residency and/or a fellowship program.


One solution that provides the Doctor of Chiropractic with the additional training and experience to manage complex spine cases is an extensive post-graduate training program in Primary Spine Care as previously discussed. Currently, there is a growing body of Chiropractic Doctors through an extensive post-graduate program offered through the Academy of Chiropractic, that are becoming qualified in Primary Spine Care that is well prepared to take on the role in managing patients with complex spine related issues (


The concept of the Doctor of Chiropractic taking on the role of a Primary Spine Care provider was discussed in an article by Erwin, Korpela and Jones (2013). The stated, “Chiropractors have the potential to address a substantial portion of spinal disorders; however the utilization rate of chiropractic services has remained low and largely unchanged for decades. Other health care professions such as podiatry/chiropody, physiotherapy and naturopathy have successfully gained public and professional trust, increases in the scope of practice and distinct niche positions within mainstream health care. Due to the overwhelming burden of spine care upon the health care system, the establishment of a ‘primary spine care provider’ may be a worthwhile niche position to create for society’s needs. Chiropractors could fulfill this role, but not without first reviewing and improving its approach to the management of spinal disorders” (p. 285).



In conclusion, the Doctor of Chiropractic has the foundational training to diagnose, manage and treat patients when indicated both before and after spinal surgery. However, with additional post-graduate training in Primary Spine Care, the Doctor of Chiropractic can obtain the necessary skills to manage more complex spine conditions which include coordinating care with the spine surgeon, pain management doctors and even a patient’s primary care doctor. With the current opioid crisis in the United States, there is a need for a front-line provider to lead in the management of non-surgical spine care and the Doctor of Chiropractic as a licensed physician is positioned to take on that role especially with additional training in Primary Spine Care.




  1. Silver Jerry and Miller Jared H. (2004, February). Regeneration Beyond the Glial Scar. Nature Publishing Group, Volume 5, 146-156. Retrieved from
  2. Makhni Melvin C., MD, MBA, Shillingford, Jamal, N. MD, Laratta, Joseph, L. MD, Hyun, Seung-Jae, MD, PhD and Kim Yongjung, J., MD. (2018). Restoration of Sagittal Balance in Spinal Deformity. Journal of Korean Neurosurgery Society, 61(2), 167-179.
  3. Serena S. Hu, MD, Jean Charles LeHuec, MD, PhD and J.N. Alastair Gibson, MD, FRCS(Ed), FRCS(Tr &Orth), MFSTEd. (2016 Jan/Feb). “Proper sagittal balance may correlate with better surgical outcomes.” Retrieved from
  4. Jessica A. Tang, BS Justin K. Scheer, BS, Justin S. Smith, MD, PhD, Vedat Deviren, MD, Shay Bess, MD, Robert A. Hart, MD, Virginie Lafage, PhD Christopher I. Shaffrey, MD, Frank Schwab, MD and Christopher P. Ames, MD. (2015). The Impact of Standing Regional Cervical Sagittal Alignment on Outcomes in Posterior Cervical Fusion Surgery. Neurosurgery 76, S14-S21.
  5. Kuang-Ting Yeh, MD, PhD, Ru-Ping Lee, RN, PhD, Ing-Ho Chen, MD, Tzai-Chiu Yu, MD, Kuan-Lin Liu, MD, PhD, Cheng-Huan Peng, MD, Jen-Hung Wang, MD, and Wen-Tien Wu, MD, PhD. (2018). Correlation of Functional Outcomes and Sagittal Alignment After Long Instrumented Fusion for Degenerative Thoracolumbar Spinal Disease. Spine, 43(19), 1355-1362.
  6. Johns Hopkins. (n.d., pp. 1-36). “A Detailed Guide to Your Surgery and The Recovery Process. Retrieved from (
  7. Hayeri Mohammad Reza, MD, Tehranzadeh Jamshid, MD. (August 6, 2009). “Diagnostic imaging of spinal fusion and complications.” Retrieved from
  8. Studin Mark, D.C., Primary Spine Care Qualified, “What is Primary Spine Care?” Retrieved from
  9. W. Mark Erwin, DC, PhD, A. Pauliina Korpela, BSc and Robert C. Jones. (2013) Chiropractors as Primary Spine Care Providers: precedents and essential measures, Journal of the Canadian Chiropractic Association, 57(4), 285-291.



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No Evidence Exists Between

Chiropractic Care and Cervical Artery Dissection


Verified by a Study of 110 Million Person-Years

 Mark Studin DC

William J. Owens DC

John Edwards MD, Neurosurgeon

 A report on the scientific literature

Citation: Studin., Owens W., Edwards J. (2019) No Evidence Exists Between Chiropractic Care and Cervical Artery Dissection, The American Chiropractor 41(10) pgs. 28, 30-32 


Cervical artery dissection (CAD) is a major source of cervical ischemia in all ages, and can lead to various clinical symptoms such as neck pain, headache, Horner’s Syndrome (paresis of the eye) and cranial nerve palsy. An underlying arteriopathy, which is often genetically encoded, is believed to have a role in the development of CAD.1  There have been case studies and low-quality published literature that attempt to link chiropractic care and CAD. This type of reporting often reports dogma and as in this case, is devoid of high-quality standards of scientific examination and lacking a complete set of facts.2 

When considering CAD, both the internal carotid and vertebral arteries must be considered. Dissection of one or both can lead to serious complications but can also be asymptomatic. Thrombolytic stroke is typically in the old, while cervical artery dissection causes stroke in young and middle-aged patients. Only 1-2% of ischemic strokes are caused by CAD, but in younger patients, 10-25% are caused by CAD. The overall incidence of CAD is 2.3-5 patients per 100,000; the mean age is 44 years old. CAD is rare beyond 65 years old.3, 4 

Although headaches, migraine headaches, minor trauma, neck pain, and inflammatory and connective tissue diseases have been thought to play a role in CAD, patients with CAD (with or without trauma) likely have an underlying arteriopathy, an inflammatory process or structural instability of the arteries that lead to dissection. A biopsy-proven study, Cervical Artery Dissections: A Review, conducted by JJ Robertson and A. Koyfman in 2016, shows structural differences in the arterial walls of patients with spontaneous CAD and in patients who have sustained major trauma and a positive association with dissection and kinking and coiling of the internal carotid artery, which suggests an underlying predisposition.4 

In 2001-2002, the number of visits to medical primary care providers and chiropractors in the US and Canada was 10.2 million.  Visits to primary care providers accounted for 80% of the total, while visits to chiropractors accounted for 12%. 5 

The most prevalent diagnoses in chiropractic care involve neck and back pain. 5,6 And the most common treatment at a chiropractic office is a spinal high-velocity, low-amplitude manipulation, commonly known as a chiropractic spinal adjustment. 

A Meta-analysis of 253 articles on chiropractic care and cervical artery dissection by Church, et. Al.,3 3   showed that neck pain and headaches are found in approximately 80% of CAD patients.  Neck pain and headaches are also common symptoms in patients with cervical artery dissection.  They concluded,  “There is no convincing evidence to support a causal link between chiropractic manipulation and cervical arterial dissection.”  which is a correlation, but not causally related. The most prevalent co-founder is neck pain and that demographic typically visits a chiropractor. When you consider the association between chiropractic visits vs. medical primary care visits with patients who experienced a CAD, the utilization was similar, yet because chiropractors treat neck pain there appears to be a dogmatic conclusion that chiropractic is the causative factor for dissection despite the lack of evidence. 

The evidence, as determined by Church et. Al. is based upon the Grading Recommendation Assessment Development and Evaluation (GRADE) system of rating quality of evidence and grading strength in systematic reviews. Those reviews ranged from high quality of evidence to very low quality of evidence.7 

Church et. Al.3 found that the quality of the body of data using the GRADE criteria revealed that it fell within the “very low” category. Also, they found no evidence for a causal link between chiropractic care and CAD. Perhaps the greatest threat to the reliability of any conclusions drawn from these data is that together they describe a correlation but not a causal relationship, and any unmeasured variable is a potential confounder. As previously discussed, the most likely potential confounder in this case is neck pain with no causal evidence. 

Cassidy et al. (2008) studied the occurrence of vertebral basilar artery (VBA) stroke events in Ontario, Canada over nine years with a database representing almost 110 million person-years (12.2 million people, studied over 9 years, equals 110 million person-years).8 The purpose of this study was to investigate if the rates of VBA stroke, which is sometimes caused by CAD, were higher in patients treated by chiropractors than in those treated by medical primary care doctors. The premise was that if the rate of VBA stroke was higher with chiropractic care, then one could logically say there were a cause and effect relationship between chiropractic care and VBA strokes. 

The results were conclusive: There was no greater likelihood of a patient experiencing a stroke following a visit to his/her chiropractor than there was after a visit to his/her primary care physician. Cassidy et al wrote: 

“We found no evidence of excess risk of VBA stroke with associated chiropractic care compared to primary care.” Cassidy et al. concluded that overall, 4% of stroke patients had visited a chiropractor within 30 days of a stroke while 53% of stroke patients had visited their medical primary care providers within the same time frame. The authors suggest that because neck pain is a common symptom of CAD, patients visit their doctors with the onset of symptoms, prior to the development of a full-blown stroke scenario.  Because the association between VBA stroke and visits to both chiropractic and medical physicians is the same, there appears to be no increased risk of VBA stroke from chiropractic care. In fact, the incident of chiropractic vs. medical care was substantially lower in certain situations based upon the data.8




Cervical artery dissection occurs rarely, yet often creates significant adverse outcomes to patients. Unfortunately, there has been a bias in the medical community, incorrectly linking chiropractic care and CAD. But the evidence is mounting that there is no causal relationship between them. With literature bordering on dogma devoid of the facts in high-quality studies. 12.2 million people study over 9 years equaling 110 million person-years conclude no causal relationship doing chiropractic care and cervical artery dissection.




  1. Debette, S., & Leys, D. (2009). Cervical-artery dissections: predisposing factors, diagnosis, and outcome. The Lancet Neurology, 8(7), 668-678.
  2. Artenstein, A. W. (2012). The discovery of viruses: advancing science and medicine by challenging dogma. International Journal of Infectious Diseases, 16(7), e470-e473.
  3. Church, E. W., Sieg, E. P., Zalatimo, O., Hussain, N. S., Glantz, M., & Harbaugh, R. E. (2016). Systematic review and meta-analysis of chiropractic care and cervical artery dissection: no evidence for causation. Cureus, 8(2).
  4. Robertson J., Koyfman A., (2016). Cervical Artery Dissection: A Review, the Journal of Emergency Medicine, 51 (5, 508-515
  5. Riddle, D. L., & Schappert, S. M. (2007). Volume and characteristics of inpatient and ambulatory medical care for neck pain in the United States: data from three national surveys. Spine, 32(1), 132-140.
  6. Hurwitz, E. L., & Chiang, L. M. (2006). A comparative analysis of chiropractic and general practitioner patients in North America: findings from the joint Canada/United States Survey of Health, 2002–03. BMC Health Services Research, 6(1), 49.
  7. Guyatt, G., Oxman, A. D., Akl, E. A., Kunz, R., Vist, G., Brozek, J., ... & Jaeschke, R. (2011). GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. Journal of clinical epidemiology, 64(4), 383-394.
  8. Cassidy, J. D., Boyle, E., Côté, P., He, Y., Hogg-Johnson, S., Silver, F. L., & Bondy, S. J. (2008). Risk of vertebrobasilar stroke and chiropractic care: Results of a population-based case-control and case-crossover study. Spine,33(45), S176-S183.



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Chiropractors Reduce Costs by 40% if the 1st Option for Spine


DC’s Would Save the Healthcare System 1.86 Trillion Dollars Over 10 Years


By: Matt Erickson, DC, FSBT



A report on the scientific literature


Citation: Erickson M., Studin M (2019) Chiropractors Reduce Costs by 40% if the 1st Option for Spine, American Chiropractor 41(8) 38, 40-43




Currently, our country is facing a health care crisis not only with respect to the opioid epidemic, but also due the fact our health care costs in the US have skyrocketed out of control. According to Centers for Medicare and Medicaid Services (CMS), National Health Expense (NHE) fact sheet (2017), “NHE grew 3.9% to $3.5 trillion in 2017, or $10,739 per person, and accounted for 17.9% of Gross Domestic Product (GDP).” It was also predicted by CMS (2017) thatUnder current law, national health spending is projected to grow at an average rate of 5.5 percent per year for 2018-27 and to reach nearly $6.0 trillion by 2027”(



In a study from data primarily from 2013-2016, Papanicolas, Woskie and Jha (2018) reported, “The United States spends more per capita on health care than any other nation, substantially outpacing even other very high-income countries. However, despite its higher spending, the United States performs poorly in areas such as health care coverage and health outcomes” (p. 1025).


Papanicolas et al., (2018), also stated, “The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations. Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries” (p. 1038). Papanicolas et al., (2018), reported, “Ten high-income countries were selected for comparison” (p. 1025). The ten countries included, “the United Kingdom (consisting of England, Scotland, Wales, and Northern Ireland), Canada, Germany, Australia, Japan, Sweden, France, Denmark, the Netherlands, and Switzerland” (p. 1025).



Singh, Andersson and Watkins-Castillo (2019, para. 1) reported “Lumbar/low back pain and cervical/neck pain are among the most common medical conditions requiring medical care and affecting an individual’s ability to work and manage the daily activities of life. Back pain is the most common physical condition for which patients visit their doctor. In any given year, between 12% and 14% of the United States adult population age 18 and older visit their physician with complaints of back pain. The number of physician visits has increased steadily over the years. In 2013, more than 57.1 million patients visited a physician with a complaint of back pain, compared to 50.6 million in 2010. Also, an unknown number of patients visit a chiropractor or physical therapist for these complaints. Singh et. al (2019, para. 4) further reported, “The estimated annual direct medical cost for all persons with a back-related condition in 2014 dollars was an average of $315 billion per year across the years 2012-2014(


According to Cynthia Cox of the Kaiser Family Foundation (2017) reporting on data from 2013, The top five disease-based spending categories (ill-defined conditions, circulatory, musculoskeletal, respiratory, and endocrine) account for half of all medical services spending by disease category. Ill-defined conditions each represent about 13% of overall health spending by disease while circulatory, musculoskeletal, respiratory, and endocrine conditions represent 12%, 10%, 8%, and 7% respectively.” That is to say, musculoskeletal disease represents 10% of the health care expenditures” (


The above graphic is from the 2017 Peterson-Kaiser report, “How much does the U.S. spend to treat different disease?”



As neck and back pain in one of the most prevalent issues that present to primary care physician (PCP) offices, considering the current opioid crisis and the associated health care expenditure, particularly related to neck and back pain, this raises the question if Doctors of Chiropractic-who are licensed to manage spinal disorders and comprehensive training in spine care, can not only provide similar or better outcomes and greater or equivalent satisfaction among patients, but provide care in a more cost effective manner, as well as help to unburden the already overloaded primary care practices considering the trending shortage of PCPs in our health care delivery system?




In an article by Houweling, Braga, Hausheer, Vogelsang, Peterson and Humphreys (2015), the authors reported on first-contact care with a medical vs. a chiropractic provider after a consultation with a Swiss telemedicine provider. The study looked to compare outcomes, patients satisfisfaction and health care costs in spinal, hip and shoulder pain patients.


Houweling et al., (2019), reported that “Pain of musculoskeletal origin represents a major health problem worldwide. In a Swiss survey conducted in 2007, back pain was a commonly reported health problem, with 43% of the population experiencing this complaint over the course of a year. Of these, 33% reported that their symptoms led to reduced productivity at work. The burden of musculoskeletal conditions on the Swiss health care system is equally staggering, with health care expenditure resulting from this condition being estimated at 14 billion Swiss Francs (CHF) per year (US $14 billion) or 3.2% of the gross domestic product” (p. 478-479).



The study by Houweling et al., (2019), also showed that spinal, hip, and shoulder pain patients had modestly higher pain relief and satisfaction with care at lower overall cost if they initiated care with DCs, when compared with those who initiated care with MDs” (p. 480). Houweling et al., further added, “Although the differences in pain relief scores between groups were statistically significant, they were likely not of clinical significance.” (p. 480). Houweling et al., explained the reason for this was, “the extent of the differences in pain relief observed might be too small for patients to notice a clinically meaningful difference” (p. 480).


With respect to patient satisfaction Houweling et al., (2019), reported, “The findings of this study pertaining to patient satisfaction were in line with previous research comparing chiropractic care to medical care for back pain, which found that chiropractic patients are typically more satisfied with the services received than medical patients” (p. 481). Houweling et al., added, “The Mean total spinal, hip, and shoulder pain-related health care costs per patient during the 4-month study period were approximately 40% lower in patients initially consulting DCs compared with those initially consulting MDs. The reason for this difference was a lower use of health care services other than first-contact care in patients initially consulting DCs compared with those initially consulting MDs” (p. 481).


Thus, Houweling et al., (2019) concluded, “The findings of this study support first-contact care provided by DCs as an alternative to first-contact care provided by MDs for a select number of musculoskeletal conditions” (p. 481). The authors also noted, “In addition to potentially reducing health care costs, direct access to chiropractic care may ease the workload on MDs, particularly in areas with poor medical coverage and hence enabling them to focus on complex cases. The minority of patients with complex health problems initially consulting a chiropractic provider would be referred to, or comanaged with, a medical provider to provide optimal care” (p. 481).




In conclusion, health care cost has skyrocketed out of control with the prediction the US expenditures will reach 6 trillion by 2027. Considering neck and back pain expenditures in between 2012-2014 averaged $315 billion annually and total health care costs in 2017 were $3.5 trillion, this means approximately 10% of health care expenditures annually are for neck and back pain which is supported by the Peterson-Kaiser Health Tracker System report. Moreover, considering the estimated health costs are predicted to be $6 trillion by 2027, if the expenditure for neck and back pain remained on par at 10% that means the cost of neck and back pain in would increase to around $600 billion over that time frame.


Considering in the Houweling et al., that by using doctors of chiropractic as a first-line provider for spine, hip and shoulder pain, it demonstrated a 40% reduction in costs, that means in 2027, if DCs were first-line providers, it is estimated this could save the health care delivery system $240 BILLION DOLLARS in one year alone (just for neck and back pain). If one considers the prediction of 5.5% annual expenditure increase, that means the estimated total expenditure for neck and back pain between 2018-2027 would be $4.65 trillion dollars. If having DCs as a first-line provider were to save 40% in costs, that would translate into saving $1.86 TRILLION DOLLARS. If that was applied to the predicted 2027 neck and back pain expenditure, that number would represent a 32% savings in that year. Given our skyrocketing health care costs, that would represent a significant savings!


Further, if we consider from the study, there was a modestly higher pain relief and ever greater patient satisfaction reported, when you factor in the predicted PCP shortage, having the ability for DCs to serve as a first-line provider, not only can it help unburden the already overloaded PCPs, but doing so would have a significant financial impact in lowering health care expenditures. All things considered, it is time our decision makers take a serious look at improving access to Doctors of Chiropractic so they may serve as first-line providers for the management of all spine and even hip and shoulder related disorders.




  1. “National Health Expenditure Fact Sheet” (2019, April 26). Centers for Medicare and Medicaid. Retrieved from
  2. Irene Papanicolas, Liana R. Woskie, Ashish K. Jha. (2018). Health Care Spending in the United States and Other High-Income Countries, Journal of the American Medical Association, 319(10), 1024-1039.
  3. Kern Singh, MD, Gunnar Andersson, MD, PhD and Sylvia I. Watkins-Castillo, PhD. (2019) United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States (BMUS), forthcoming. Rosemont, IL. Retrieved from
  4. Cox Cynthia. (2017, May 22). How much does the U.S. spend to treat different disease? Peterson-Kaiser Health Tracker System. Retrieved from
  5. Houweling, Braga, Hausheer, Vogelsang, Peterson and Humphreys. (2015). First-Contact Care with a Medical vs. Chiropractic Provider After Consultation with a Swell Telemedicine Provider: Comparison of Outcomes, Patient Satisfaction, and Health Care Costs in Spinal, Hip, and Shoulder Pain Patients. Journal of Manipulative and Physiological Therapeutics, 38(7), 477-483.

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The Chiropractic Adjustment Changes Brain Function


The Evidence of Increased Muscle Strength is Added to Pain Sensitivity and Autonomic Changes



William J. Owens DC, DAAMLP

Matt Erickson DC, FSBT


A report on the scientific literature


There is a growing body of evidence that a high-velocity, low-amplitude (HVLA) chiropractic spinal adjustment (CSA) has a significant influence on cortical (brain) and other central (cord) changes. This is significant as the evidence is now answering more questions on why has chiropractic has had such a profound effect on a myriad of conditions beyond back pain. Technology, including but not limited to functional MRI, NCV, EEG and sEMG renders demonstrable validation of the effect the chiropractic spinal adjustment has on changes in central function.


A chiropractic spinal manipulation/adjustment is a specific HVLA thrust maneuver designed to correct spinal patho-neuro-biomechanics (remove nerve irritation/interference, restore biomechanical balance), increases important proteins such as Substance P (Evans 2002) and makes plastic changes to the central nervous system. Conversely, a spinal manipulation as manual therapy or thrust joint manipulation (TJM) performed by physical therapists (PT’s) is a generalized non-specific low-velocity, low-amplitude of non-specific HVLA thrust maneuver of joints and connective tissue to improve motion and decrease muscle tension.



Essentially, the intent of TJM is in treating pain and dysfunction. That is not to say a non-specific manipulation will not help a patient. However, when spinal manipulation is not performed as a chiropractic based neuro-biomechanical corrective adjustment or from a salutogenic health management perspective, it is something else entirely. Therefore, spinal manipulation as a chiropractic adjustment delivered by a chiropractor is not synonymous with TJM, mobilization or spinal manipulation delivered by a PT.


Reed, Pickar, Sozio, and Long (2014) reported, “.forms of manual therapy have been clinically shown to increase mechanical pressure pain thresholds (i.e., decrease sensitivity) in both symptomatic and asymptomatic subjects. Cervical spinal manipulation (chiropractic HVLA) has been shown to result in unilateral as well as bilateral mechanical hypoalgesia. Compared with no manual therapy, oscillatory spinal manual therapy at T12 and L4 produced significantly higher paraspinal pain thresholds at T6, L1, and L3 in individuals with rheumatoid arthritis. The immediate and widespread hypoalgesia associated with manual therapy treatments has been attributed to alterations in peripheral and/or central pain processing including activation of descending pain inhibitory systems. Increasing evidence from animal models suggests that manual therapy activates the central nervous system and, in so doing, affects areas well beyond those being treated. (p. 277)


Reed et al. (2014) also reported, The finding that only the higher intensity manipulative stimulus (ie, 85% BW [body weight] vs 55% BW or control) decreased the mechanical sensitivity of lateral thalamic neurons to mechanical trunk stimulation coincides with other reports relating graded mechanical or electrical stimulus intensity to the magnitude of central inhibition. Several clinical studies indicate that spinal manipulation [chiropractic spinal adjustment] alters central processing of mechanical stimuli evidenced by increased pressure pain thresholds and decreased pain sensitivity in asymptomatic and symptomatic subjects following manipulation. (p. 282)


Daligadu, Haavik, Yielder, Baarbe, and Murphy (2013) reported, There is also evidence in the literature to suggest that muscle impairment occurs early in the history of onset of spinal complaints, and that such muscle impairment does not automatically resolve even when pain symptoms improve. This has led some authors to suggest that the deficits in proprioception and motor control, rather than the pain itself, may be the main factors defining the clinical picture and chronicity of various chronic pain conditions. Furthermore, recent evidence has demonstrated that spinal manipulation (CSA) can alter neuromuscular and proprioceptive function in patients with neck and back pain as well as in asymptomatic participants. For instance, cervical spine manipulation (CSA) has been shown to produce greater changes in pressure pain threshold in lateral epicondylalgia than thoracic manipulation; and in asymptomatic patients, lumbar spine manipulation (CSA) was found to significantly influence corticospinal and spinal reflex excitability. Interestingly, Soon et al did not find neurophysiological changes following mobilization on motor function and pressure pain threshold in asymptomatic individuals, perhaps suggesting that manipulation [chiropractic spinal adjustments], as distinct from mobilization, induces unique physiological changes. There is also accumulating evidence to suggest that chiropractic manipulation can result in changes to central nervous system function including reflex excitability, cognitive processing, sensory processing, and motor output. There is also evidence in SCNP [sub-clinical neck pain] individuals that chiropractic manipulation alters cortical somatosensory processing and elbow joint position sense. This evidence suggests that chiropractic manipulation may have a positive neuromodulatory effect on the central nervous system, and this may play a role in the effect it has in the treatment of neck pain. It is hoped improving our understanding of the neurophysiological mechanisms that may precede the development of chronic neck pain in individuals with sub-clinical neck pain (SCNP) will help provide a neurophysiological marker of altered sensory processing that could help determine if an individual is showing evidence of disordered sensorimotor integration and thus might benefit from early intervention to prevent the progression of SCNP into more long-term pain states.  (p. 528)


Christriansen, Niazi, Holt, Nedergaard, Duehr, Allen, Marshall, Turker and Haarvik (2018) discussed the effects of a single session of a chiropractic spinal manipulation (CSA) on strength and cortical drive. They studied the effects upwards of 60 minutes and further testing is needed to determine the long-term effects of the adjustment. They found in “blinded studies” that “the increased maximum voluntary contraction force lasted for 30 min and the corticospinal excitability increase persisted for at least 60 minutes.” (pg. 737)


Christiansen et. Al (2018) also reported, “The increased V-wave amplitudes observed in the current study possibly reflect an increased cortical drive in the corticospinal pathways and corresponding increased excitability of the MNs following SM found differences in the cortical drive in volleyball athletes competing at different levels, and argued that elite players had increased cortical drive correlating to their biomechanical performance. The absence of change in the H-reflex in the presence of the increased MVC along with increased V-waves suggests that it's possible that the change post manipulation occurred at supraspinal centers involving a cortical neural drive. The V-waves represent cortical drive. The absence of change in the H-reflex alone suggests that the spinal motor neurons and the excitability of the spindle primary afferent synapses on the spinal motor neurons did not change as a result of SM.” (pg. 745) The above paragraph indicates there is no input at the cord level as the H-Reflex exhibited no changes.



Increased motor function for a minimum of 60 minutes post-chiropractic spinal adjustment has far-reaching manifestations for a dichotomy of the population. Athletes at every level will benefit from increased motor function and patients suffering from either muscular or neuro-degenerative illnesses, such as Parkinson’s, Amyotrophic lateral sclerosis (ALS), Muscular Dystrophy and others will also potentially benefit. Although this article touched on PT manual therapy, low-velocity, low-amplitude or non-specific thrust joint manipulation; these forms of treatment do not render the outcomes a chiropractic spinal adjustment.


Christiansen et. Al (2018) concluded and perfectly positioned the effect of a chiropractic spinal adjustment and the effect on the brain, “this study supports a growing body of research that suggests chiropractic spinal manipulation’s main effect is neuroplastic in nature and affects corticospinal excitability. Changes in both cerebellum and prefrontal cortex function have been implicated post-spinal manipulation in previous research studies. The presence of mild, recurrent spinal dysfunction has been shown to be associated with maladaptive neural plastic changes, such as alterations in elbow joint position sense mental rotation ability, and even multisensory integration Furthermore, spinal manipulation of dysfunctional spinal segments has been shown to impact somatosensory processing, sensorimotor integration and motor control.” (pg. 746)




  1. Reed, W. R., Pickar, J. G., Sozio, R. S., & Long, C. R. (2014). Effect of spinal manipulation thrust magnitude on trunk mechanical activation thresholds of lateral thalamic neurons. Journal of Manipulative and Physiological Therapeutics, 37
  2. Daligadu, J., Haavik, H., Yielder, P. C., Baarbe, J., & Murphy, B. (2013). Alterations in cortical and cerebellar motor processing in subclinical neck pain patients following spinal manipulation. Journal of Manipulative and Physiological Therapeutics, 36.
  3. Christiansen, T. L., Niazi, I. K., Holt, K., Nedergaard, R. W., Duehr, J., Allen, K., ... & Haavik, H. (2018). The effects of a single session of spinal manipulation on strength and cortical drive in athletes. European journal of applied physiology118

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