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Cerebral metabolic changes in men after chiropractic spinal manipulation for neck pain

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Chiropractic spinal manipulation (CSM) is an alternative treatment for back pain. The autonomic nervous system is often involved in spinal dysfunction. Although studies on the effects of CSM have been performed, no chiropractic study has examined regional cerebral metabolism using positron emission tomography (PET). The aim of the present study was to investigate the effects of CSM on brain responses in terms of cerebral glucose metabolic changes measured by [18F]fluorodeoxyglucose positron emission tomography (FDG-PET). Twelve male volunteers were recruited. Brain PET scanning was performed twice on each participant, at resting and after CSM. Questionnaires were used for subjective evaluations. A visual analogue scale (VAS) was rated by participants before and after chiropractic treatment, and muscle tone and salivary amylase were measured. Increased glucose metabolism was observed in the inferior prefrontal cortex, anterior cingulated cortex, and middle temporal gyrus, and decreased glucose metabolism was found in the cerebellar vermis and visual association cortex, in the treatment condition (P < .001). Comparisons of questionnaires indicated a lower stress level and better quality of life in the treatment condition. A significantly lower VAS was noted after CSM. Cervical muscle tone and salivary amylase were decreased after CSM. Conclusion The results of this study suggest that CSM affects regional cerebral glucose metabolism related to sympathetic relaxation and pain reduction.
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Takeshi Ogura, DC, PhD, is a research fellow in the Division of
Cyclotron Nuclear Medicine, Cyclotron and Radioisotope
Center, Tohoku University, Sendai, Japan, and a director at the
Japan Chiropractic Doctor College, Sendai. Manabu Tashiro,
MD, PhD, is an associate professor and a chief nuclear medicine
physician; Mehedi Masud, MD, PhD, is a research fellow;
Shoichi Watanuki is a radiological technologist in the
Division of Cyclotron Nuclear Medicine, Cyclotron and
Radioisotope Center. Masatoshi Itoh,
MD, PhD, is a specially-
approved visiting professor in the Division of Cyclotron
Nuclear Medicine, Cyclotron and Radioisotope Center, and a
director at Sendai Medical Imaging Clinic, Sendai, Japan.
Keiichiro Yamaguchi, MD, PhD, is a visiting professor in the
Division of Cyclotron Nuclear Medicine, Cyclotron and
Radioisotope Center, and a director at the Advanced Image
Medical Center, Sendai Welfare Hospital. Katsuhiko Shibuya,
MS, is a researcher and Kazuhiko Yanai, MD, PhD, is a profes-
sor in the Department of Pharmacology, Graduate School of
Medicine, Tohoku University. Hiroshi Fukuda, MD, PhD, is a
professor at the Department of Radiology and Nuclear
Medicine, the Institute of Development, Aging and Cancer,
Tohoku University.
Corresponding Author: Manabu Tashiro, MD, PhD
E-mail: mtashiro@cyric.tohoku.ac.jp
C
hiropractic spinal manipulation (CSM) is an alterna-
tive treatment for ailments such as neck, back, and
lower back pain. For >100 years, chiropractors have
asserted that overall health can be improved through
spinal manipulative therapy.
1-5
Research on CSM has
been extensively performed worldwide, and its efcacy on musculo-
skeletal symptoms has been well documented. The autonomic ner-
vous system has been invoked in constructing mechanisms that
account for the effect of spinal dysfunction.
6
Previous studies docu-
mented a potential relationship between the vertebral subluxation
complex and the function of the autonomic nervous system.
1,6-13
These studies mainly discussed the autonomic effects on cardiovas-
cular function in relation to CSM.
9,11-13
A recent study using heart
rate variability analysis documented that chiropractic adjustment
affects the autonomic nervous system.
13
However, literature search
showed no study using positron emission tomography (PET) to
examine regional cerebral metabolic changes related to autonomic
responses resulting from CSM.
Only one available neuroimaging study on CSM using single
photon emission computed tomography (SPECT) indicated
decreased regional cerebral blood ow in the left cerebellum related
to adverse reactions after treatment.
14
Since this study focused on
the adverse reactions, the brain effects and the clinical effects of
CSM have remained unknown. Recent chiropractic research docu-
mented the need for a functional neuroimaging study regarding the
effects of spinal manipulation for deeper understanding of the neu-
Cerebral Metabolic Changes After Chiropractic Treatment
Cerebral Metabolic Changes in Men After
Chiropractic Spinal Manipulation for Neck Pain
Takeshi Ogura, DC, PhD; Manabu Tashiro, MD, PhD; Mehedi Masud, MD, PhD; Shoichi Watanuki; Katsuhiko Shibuya, MS;
Keiichiro Yamaguchi, MD, PhD; Masatoshi Itoh, MD, PhD; Hiroshi Fukuda, MD, PhD; Kazuhiko Yanai, MD, PhD
original research
Abstract
Background Chiropractic spinal manipulation (CSM) is an
alternative treatment for back pain. The autonomic nervous
system is often involved in spinal dysfunction. Although stud-
ies on the effects of CSM have been performed, no chiropractic
study has examined regional cerebral metabolism using posi-
tron emission tomography (PET).
Objective • The aim of the present study was to investigate the
effects of CSM on brain responses in terms of cerebral glucose
metabolic changes measured by [
18
F]uorodeoxyglucose posi-
tron emission tomography (FDG-PET).
Methods Twelve male volunteers were recruited. Brain PET
scanning was performed twice on each participant, at resting
and after CSM. Questionnaires were used for subjective evalua-
tions. A visual analogue scale (VAS) was rated by participants
before and after chiropractic treatment, and muscle tone and
salivary amylase were measured.
Results Increased glucose metabolism was observed in the
inferior prefrontal cortex, anterior cingulated cortex, and mid-
dle temporal gyrus, and decreased glucose metabolism was
found in the cerebellar vermis and visual association cortex, in
the treatment condition (P < .001). Comparisons of question-
naires indicated a lower stress level and better quality of life in
the treatment condition. A signicantly lower VAS was noted
after CSM. Cervical muscle tone and salivary amylase were
decreased after CSM.
Conclusion • The results of this study suggest that CSM affects
regional cerebral glucose metabolism related to sympathetic
relaxation and pain reduction. (Altern Ther Health Med.
2011;17(6):12-17.)
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Cerebral Metabolic Changes After Chiropractic Treatment
rophysiological effects of CSM.
15
Thus, we hypothesized that one
CSM might induce metabolic increase or decrease (activation or deac-
tivation) in the brain regions associated with autonomic nervous
functions in response to CSM intervention: the limbic and paralimbic
regions such as prefrontal cortex, orbitofrontal cortex, cingulate
gyrus, striatum and thalamus, cerebellum, and brain stem.
Functional neuroimaging techniques are powerful tools to
investigate neuronal activity in the human brain.
15
The PET scan
has been used for measuring regional cerebral blood flow and
regional cerebral metabolic rate using radiolabeled molecules,
which are either injected intravenously or continuously inhaled by
the participant.
15-21
In the research setting, functional neuroimaging
has been used in studies of acute brain activation, and for this pur-
pose, functional magnetic resonance imaging (fMRI) has replaced
PET with [
15
O]H
2
O because of its preferred spatial resolution, avoid-
ance of radioactive materials, and operating cost per investiga-
tion.
15,18,19
However, PET with
18
F-labeled uorodeoxyglucose (FDG)
has been regarded as an excellent imaging marker of brain metabol-
ic activity (glucose consumption).
20
The molecule FDG, a radioac-
tive analogue of glucose, is trapped metabolically into activated cells
in the brain and can be substantially used for evaluating physiologi-
cal and biomechanical functions in vivo.
21
Initially, this technique
was used in healthy volunteers who performed a natural running
task in upright posture.
22
Later, this technique was applied to daily
movement
23
and alternative therapy such as aromatherapy.
24
An
important advantage of the FDG technique is that the regional
brain activity during 30 minutes after injection is averaged and
recorded based on the biochemical property of “metabolic trap-
ping,”
21
where the phases for FDG uptake and for PET measure-
ment can be separated (Figure 1). Another advantage of this
technique is low radiation exposure achieved by a sensitive 3-dimen-
sional data acquisition mode.
21
We hypothesized that a CSM treatment might induce meta-
bolic increase or decrease (activation or deactivation) in the brain
regions associated with autonomic nervous functions in response to
CSM intervention: the limbic and paralimbic regions such as pre-
frontal cortex, orbitofrontal cortex, cingulate gyrus, striatum and
thalamus, cerebellum, and brain stem. The aim of the present study
was to investigate the effects of CSM on brain responses in terms of
cerebral glucose metabolic changes using PET and FDG. In addi-
tion, we evaluated the relation between the results of PET investiga-
tion and the changes in autonomic function and pain intensity
induced by chiropractic treatment.
METHODS
Participants and Materials
Volunteer men with cervical pain and shoulder stiffness were
recruited after researchers placed a poster on the campus of Tohoku
University. Included were men aged 20 to 40 years with cervical
pain and shoulder stiffness who did not receive any kind of manipu-
lative treatment for ≥1 month before the experiment. Exclusion cri-
teria were (1) the presence of disc problems such as disc herniation
or signicant disc degeneration and (2) any other physical or men-
tal disorders or medication that might affect brain function or per-
fusion. After giving informed consent, all 15 candidates were rst
assigned for MRI examination of the cervical region, and 3 partici-
pants with disc problems were excluded from the study. Medical
screening was performed to conrm absence of any disorders or
medication that might affect brain function. Therefore, 12 men
volunteers aged 21 to 40 years (mean age ± SD, 28 ± 7 y) were
included in the study. Women were not included because of the
higher risk of radiation exposure to the ovary and the physiologi-
cal uctuation of the brain activity associated with the menstrual
cycle. The present study protocol was approved by the Ethics
Committee of Tohoku University Graduate School of Medicine,
Sendai, Japan (No. 2008-115).
The present study was conducted in crossover study design, in
which each participant was examined twice (once in the “treat-
ment” and the other time in the “control[“resting”] conditions) to
compare resting regional brain activity in the 2 conditions (Figure
1). In the treatment condition, participants received a single CSM
intervention including a CMS diagnostic procedure (in total 20
minutes). Shortly after the CSM treatment, FDG-containing saline
solution was injected into the participant through the left antecu-
bital vein (37 MBq) in a quiet, dimly lit room. Participants were
asked to sit in a relaxed manner with their eyes closed for 30 min-
utes before the scan. The brain scan was initiated 30 minutes after
the FDG injection using a PET scanner (SET2400W, Shimadzu Inc,
Kyoto, Japan). The PET scan covered the entire brain in 1 scan, tak-
Diagram demonstrating the present protocol. In the treatment or
control (resting, no treatment) condition,
18
F-labelled
uorodeoxyglucose (FDG) was injected shortly after the chiropractic
treatment or resting period. Additional measurements such as muscle
stiffness, salivary amylase, and subjective feelings were made before
and after the treatment or resting period. The duration of 30 minutes
after FDG injection is FDG uptake time in the resting state. Positron
Emission Tomography (PET) scanning started 30 minutes after FDG
injection and continued for 20 minutes. In the treatment condition,
FDG was injected shortly after the treatment. Additional
measurements such as muscle stiffness, salivary amylase, and
subjective feeling were conducted before and after the treatment. The
duration of 30 minutes following FDG injection is FDG uptake time in
the resting state. PET scanning started 30 minutes after FDG injection
and following 20 minutes.
FIGURE 1
Treatment
condition
treatment FDG uptake time (rest) PET scanning
0 min 20 25 55 75
FDG injection
additional
measurements
additional
measurements
Control
condition
resting FDG uptake time (rest) PET scanning
0 min 20 25 55 75
FDG injection
additional
measurements
additional
measurements
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Cerebral Metabolic Changes After Chiropractic Treatment
FIGURE 2
Regional activation (left) and deactivation (right) after chiropractic spinal manipulation. Brain regions showing a metabolic increase (left) and a
metabolic decrease (right) in the treatment condition. Both images show results of voxel-by-voxel comparison of regional cerebral glucose metabolic
images using statistical parametric mapping (SPM) (height threshold: P < .001, extent threshold: 10 voxel minimum).
ing 10 minutes for the emission scan and another 5 minutes for the
transmission scan for tissue attenuation correction (Figure 1). In the
scan for the control condition, FDG was injected into the partici-
pant after a 20 minute resting phase instead of CSM intervention;
the scanning procedure following was identical to that for the treat-
ment condition (Figure 1). The radiation exposure from 1 PET scan
in this study was estimated at approximately 0.9 mSv; this was com-
parable to the exposure from a chest radiograph (0.4 mSv per test)
and less than annual environmental exposure (2.4 mSv).
21
The order of the 2 scans—that is, “control–treatment” and
“treatment–control”—was counterbalanced to minimize an order
effect.” Order effect occurs because study participants tend to feel
psychophysiological stress more in the rst scan than in subsequent
scans. Therefore, the protocol was prepared to minimize this order-
associated effect. As a result, the rst scan was performed in the
treatment condition in half of the participants and vice versa. The
interval between the rst and second scans was ≥1 week to elimi-
nate residual effects of treatment; the interval between conditions
(scans) ranged from 1 to 6 weeks (mean interval ± SD, 22 ± 13 d).
The CSM was performed by the same chiropractor, an advanced
prociency-rated doctor of activator methods.
Questionnaires were used for subjective evaluation.
Participants were requested to answer questions related to the
Stress Response Scale (SRS-18) and European Organization for
Research and Treatment of Cancer Quality of Life Questionnaire-
Core 30 (EORTC QLQ-C30) immediately after the CSM treatment
and before FDG injection. Results of SRS-18 and EORTC QLQ-C30
were examined using Wilcoxon signed-rank test for statistical analy-
sis. In addition, intensity of subjective pain sensation was evaluated
using a visual analogue scale (VAS) (0, no pain; 10, maximum possi-
ble pain) before and after CSM intervention. Wilcoxon signed-rank
test was performed for analysis of the VAS results, as well. Cervical
muscle tone was measured bilaterally at the superior part of the tra-
pezius muscle (Muscle Meter PEK 1, Imoto Inc, Kyoto, Japan).
Salivary amylase was determined (Amylase Monitor, Nipro Inc,
Osaka, Japan) as a measure of changes in autonomic nervous sys-
tem function. The measurements of muscle tone and salivary amy-
lase were performed before and after the 20-minute treatment or
resting phase (Figure 1). Paired t tests were performed on measure-
ments of muscle tone and salivary amylase to determine differences
in before and after measurements between the resting and treat-
ment conditions.
18
F-labelled Fluorodeoxyglucose Positron Emission Tomography
The PET brain images were analyzed to identify regional
changes in glucose metabolic rate using a software package
Statistical Parametric Mapping 2 (SPM2, Functional Imaging
Laboratory, London, United Kingdom).
25,26
Positional errors
between the two scans were corrected for each participant, using
the realignment function of the SPM2. The FDG brain template
(Montreal Neurological Institute, McGill University, Canada)
25
was
used for anatomical standardization (spatial normalization) of the
PET images by applying linear and nonlinear transformations,
which minimized the intersubject differences in gyral and function-
al anatomy. The size of each voxel is converted into 2 mm (for x, y,
and z axes) in the normalized image. The normalized data were
smoothed using isotropic Gaussian kernel of 12 mm (for x, y, and z
axes) to increase the signal-to-noise ratio by suppressing high fre-
quency noise in the images.
Voxel-by-voxel analysis (such as Statistical Parametric
Mapping) is the standard tool for detecting regional changes in
radioactivity levels in certain brain regions. The most popular con-
trast in these studies has been to contrast “resting” with “task or
stimulus.” For statistical analysis, all voxel values were normalized
to an arbitrary global mean value of 50 mg/100 mL/min by analysis
of covariance to exclude the effects of intersubject variability in
global cerebral glucose metabolism. A paired t test was applied to
each voxel; only voxel clusters were maintained with voxels corre-
sponding to P < .001 in a single test (height threshold for voxel val-
ues) in 2 ways.
26
Usually, statistically significant voxels tend to
appear in a group since each neural substructure has a certain vol-
ume in human brain (eg anterior cingulate cortex). The size of the
voxels group (cluster size) is described by the number of voxels
showing statistical signicance together. Based on the fact that each
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Cerebral Metabolic Changes After Chiropractic Treatment
neural substructure has a certain volume, a very small cluster with
just a few voxels is not physiological and often produced by noises
in images. Thus, an extent threshold for the voxel cluster size is
additionally dened (10 to 50 voxels minimum).
26
The statistical
signicance of a regional metabolic change was given in z scores.
The z score value was the difference between the treatment and con-
trol group mean values, divided by standard deviation of the control
values [(Mean
treatment
-Mean
control
)/SD
control
]. Empirically in Statistical
Parametric Mapping analysis, a z score higher than 3.0 (approxi-
mately corresponding to P < .001) was considered statistically signif-
icant. The location of each statistical peak was identied based on a
coplanar stereotaxic atlas of the human brain.
27
In the stereotaxic
atlas, the location of statistical peak is described in x,y,z axes of the
stereotaxic coordinates of the standardized human brain space.
Each location is also classied into a brain area called Brodmann’s
area (BA) dened by its histological similarity that also suggests
functional similarity.
27
Statistically signicant areas were superim-
posed on the standard MRI brain template images (Figure 2).
RESULTS
The FDG-PET analysis revealed changes in regional cerebral
metabolism between resting and treatment (P < .001). In the treat-
ment condition, increased glucose metabolism was observed in the
inferior prefrontal cortex (BA 47), anterior cingulate cortex (BA 32),
and middle temporal gyrus (BA 21); decreased glucose metabolism
was observed in the cerebellar vermis and visual association cortex
(BA 19) (Table 1).
Results of subjective measures revealed signicant differences
between the resting and treatment conditions. The mean SRS-18
score was signicantly lower in the treatment than the resting con-
dition (Table 2). The mean EORTC QLQ-C30 score was also signi-
cantly lower in the treatment than resting condition (Table 2).
Comparisons of mean VAS showed that pain was significantly
improved after treatment (Table 2). Measurements of cervical mus-
cle tone showed signicant improvements from the resting to treat-
ment conditions (Table 2). A signicant decrease in mean salivary
amylase was observed after chiropractic treatment (Table 2).
DISCUSSION
In the present study, participants had cervical pain at the time
of the examination as commonly experienced by many chiropractic
patients. Psychological stress may be a cause of cervical pain, and
diagnosis and management of cervical pain routinely includes psy-
chological stress management
28-33
because psychological stress
Anatomical Coordinates Brodmanns Cluster z score
Region x, y, z (mm) Area (BA) Size
Activation IPC 54 24 -8 47 19 3.82
MTG -48 -36 0 21 30 3.73
ACC 22 24 38 32 10 3.48
Deactivation CV 4 -42 -18 121 4.62
VAC 4 -90 24 19 46 3.64
TABLE 1 Activation/Deactivation Areas After Chiropractic
Spinal Manipulation in Men
(n=12)
The table indicates results of voxel-by-voxel analysis using statistical
parametric mapping 2 (SPM2). Regions of statistically signicant
activation and deactivation are demonstrated. The location of these
statistic peaks in each regions is described by the x, y, and z
coordinates in stereotaxic standard brain space and by the
Brodmann’s area. Cluster size indicates the number of voxels in each
region showing statistical signicance simultaneously. The z score
indicates statistical signicance if it is >3.0, corresponding to P < .001
(without corrections for multiple comparisons).
Abbreviations: IPC, inferior prefrontal cortex; MTG, middle temporal
gyrus; ACC, anterior cingulate cortex; CV, cerebellar vermis; VAC,
visual association cortex.
Data reported as mean ± SD. Abbreviations: SRS-18, Stress Response Scale-18; EORTC QLQ-C30, European Organization for Research and Treatment
of Cancer Quality of Life Questionnaire-Core 30; VAS, visual analogue scale
Muscle tone—differences between before and after measurements: Right: resting, 0.5 ± 2.9 mm; treatment, 6.1 ± 4.3 mm; P < .005. Left: resting,
1.1 ± 1.8 mm; treatment, 5.1 ± 2.5 mm; P < .001.
Salivary amylase: differences between the means of the before and after measurements: resting, -10.8 ± 19.5 KIU/L; treatment, 7.5 ± 17.0 KIU/L; P < .05.
Resting Treatment P Value
SRS-18 10.4 ± 8.3 5.2 ± 5.3 .003
EORTC QLQ-C30 45.1 ± 8.8 42.0 ± 8.8 =.016
Before After Before After
VAS 3.6 ± 1.7 1.1 ± 1.1 <.001
Muscle tone (mm)
Right 56.8 ± 3.3 56.3 ± 3.7 57.3 ± 4.4 51.1 ± 4.8 <.002
Left 58.8 ± 2.4 57.8 ± 3.0 58.8 ± 3.7 53.7 ± 3.5 <.001
Salivary amylase (KIU/L) 32.3 ± 29.8 43.1 ± 36.9 27.0 ± 19.2 19.5 ± 12.4 <.04
TABLE 2 Results of Questionnaires and Measurements in Subjects Having Chiropractic Spinal Manipulation
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Cerebral Metabolic Changes After Chiropractic Treatment
causes sympathetic activation.
34-36
Therefore, it is possible to com-
pare autonomic function in the resting and treatment conditions in
patients who have cervical pain. However, the usefulness of CSM for
cervical pain is controversial because of possible adverse reactions of
cervical adjustment, including a signicant increase in neck pain and
stiffness and occasional headaches or radiating pain.
37,38
Therefore, we
selected Activator Methods as the treatment procedure in the present
study. Activator Methods are a form of research-based spinal manipu-
lative therapy
39
in which high-velocity and relatively low force–impact
instruments known as Activator Adjusting Instruments are used.
40
Activator Adjusting Instruments are in use by >50% chiropractic prac-
titioners.
40,41
In addition, investigations on Activator Adjusting
Instruments have been performed because of safety concerns related
to general cervical manipulation
39,40,42,43
; in one study, Activator
Adjusting Instruments maximized therapeutic effects and benets
and decreased the risk of iatrogenic injury.
40
In previous studies aiming at scientific examination of the
autonomic effects of CSM intervention, cardiovascular function and
subjective feeling had been the main outcome measures.
10,12-14
However, it would be useful to examine the status of regional brain
activity immediately after the CSM intervention. We rst applied
the FDG technique for a long-term activation study in healthy vol-
unteers;
21-24
the regional brain activity during 30 minutes after FDG
injection was averaged and recorded based on the biochemical
property of “metabolic trapping.”
21
In the present study, the region-
al metabolic changes in the limbic and paralimbic regions, cerebel-
lum, and brain stem were expected.
In the present PET investigation, the most signicant change
was detected in the cerebellar vermis, which was deactivated in the
treatment condition compared to the resting condition. The cere-
bellar vermis may be important in pain perception. Neuroimaging
studies have shown a pattern in cerebellar activation during the
pain response.
44-46
Glucose metabolic changes have been noted in
the cerebella of 13 of 18 patients suffering regional pain syndrome,
47
and other authors have noted a similar activation pattern in the cer-
ebellum.
47,48
In the present study, all participants had neck pain at
the time of the experiment, and the results of VAS indicated a signif-
icantly lower value after CSM. Thus, deactivation of the cerebellar
vermis in this study may be related to pain reduction in the partici-
pants. The cerebellar vermis is also concerned with mental stress.
Painful heat activates the anterior cerebellum around the vermis,
and a sensory cue that anticipates the painful stimulation results in
activation of the posterior cerebellar vermis.
45,46
In addition, the cer-
ebellar vermis is involved with the autonomic nervous system.
Previous studies have suggested that the cerebellum is involved in
the regulation of autonomic responses in aversive condition-
ing.
44,49,50
Removal of the cerebellum impairs performance of auto-
nomic functions including salivary, cardiac, and respiratory
conditioning.
44,49,50
These effects on aversive conditioning can be
localized to the cerebellar vermis.
44
Stimulation of the cerebellar ver-
mis, not the hemispheres, inhibits vasomotor tone previously
increased by peripheral stimulation.
44,51
Thus, deactivation of the
cerebellar vermis in the present study may have been related to a
decrease in sympathetic tone. Mental stress causes sympathetic acti-
vation,
34-36
and stress-related disorders are frequently accompanied
by increased sympathetic activity and muscle tone.
34
Some studies
have shown that chronic activation of the sympathetic nervous sys-
tem in chronic stress facilitates tonic and painful muscle contrac-
tions, as has been suggested for chronic tension-type headaches and
work-related myalgia.
34,52,53
In the present study, measurement of
muscle tone indicated a signicantly lower value after CSM at which
point the cerebellar vermis was deactivated. Therefore, we suggest
that deactivation of the cerebellar vermis may be preceded by
decreases in sympathetic tone, muscle tone, and pain.
The anterior cingulate cortex, inferior prefrontal cortex, and
middle temporal gyrus were activated in the treatment condition in
the present study. The cingulate cortex is involved in the generation
of autonomic responses,
34,54,55
and performance of relaxation tasks
may elicit maximal activation in the anterior cingulate region.
56
This
region of the limbic cortex has been implicated in cognitive and
emotional processing and as part of the midline attentional system
that involves the dorsolateral prefrontal cortex.
56-58
The lateral pre-
frontal regions are deactivated during various cognitive tasks com-
pared to resting.
59-63
It is possible that the lateral prefrontal regions
are activated during the relaxed condition. Activation of the inferior
prefrontal cortex in the treatment condition may indicate a relax-
ation effect. Thus, the results of the present study suggest that acti-
vation of the anterior cingulate cortex and inferior prefrontal cortex
may arise from sympathetic relaxation.
Measurement of salivary amylase in the present study revealed
signicantly lower values after CSM and increased values in the rest-
ing condition. Salivary measures have become increasingly impor-
tant in psychoneuroendocrinological research on stress.
64
A
parameter of salivary measures thought to reflect stress-related
changes in the body is the salivary enzyme alpha-amylase.
64-68
Authors
have documented an increase in salivary amylase in people undergo-
ing psychological stress.
64,65
Thus, it is possible that a decrease in sali-
vary amylase is observed in people in a relaxed condition. Regarding
the results of PET analysis, the reduction in salivary amylase in the
present treatment condition may be related to activated areas and
deactivated areas may be related to sympathetic relaxation.
The limitations of this study include the limited number of partici-
pants and absence of a control group, though many clinical PET studies
have been done without control groups based on test-retest reproduc-
ibility.
69
Furthermore, some of the results in this study are based on sub-
jective evaluations of the participants. An additional limitation is that
the chiropractic treatment was performed by a single practitioner.
Another disadvantage of this technique would be radiation exposure,
though the exposure was as low as reasonably achievable.
CONCLUSION
In summary, the present study demonstrated sympathetic
relaxation and corresponding regional brain metabolic changes, as
well as reduced muscle tone and decreased pain intensity following
a chiropractic spinal manipulation. FDG-PET seems to be a very
promising tool for elucidating the underlying mechanism of clinical
effects of the chiropractic treatment. Further neuroimaging studies
are needed to support the results because the number of partici-
pants was small in the present study.
Acknowledgements
Authors would like to thank Kazuko Takeda, of the Department
ALTERNATIVE THERAPIES, nov/dec 2011, VOL. 17, NO. 6 17
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Cerebral Metabolic Changes After Chiropractic Treatment
of Cyclotron Nuclear Medicine, Cyclotron and Radioisotope Center,
Tohoku University, for her technical support on this study. The
authors also would like to thank the Japan Chiropractic Doctor
College for its contribution of funding to this study.
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... 15 of the 23 studies were dealing with a healthy population. In the other articles, the included subjects were dealing with craniofascial pain and temporomandibular dysfunction (TMD) [19], hypertensive and normotensive blood pressure [8], lumbar pain vs. pain free [20], acute cervical pain vs. pain free [21], lumbar pain, cervical pain or headache [22], acute back pain [23], cervical pain and stiffness [24] and certain symptomatic region [25]. ...
... Globally, a wide range of techniques was used. The following treatment techniques were investigated: mobilization of the cervical spine [19][20][21], posterior/anterior mobilization of the thoracic spine [28], mobilization of the lumbar spine [23], soft tissue techniques in the cervical spine region [24,25], HVLAT techniques in the thoracic spine [6,15,26], HVLAT techniques in the lumbar spine [23,[26][27][28], HVLAT techniques in the cervical spine [6,26,[28][29][30][31][32] and a rib raise technique [7]. ...
... The studied population ranged in size from 1 in the single case study [25] and 10 in a pilot study [16] to 539 in a clinical multi-centre study [22]. Treatment A wide range of measurements can be used to demonstrate changes in the ANS through heart rate variability (HRV) [14,15,23] (quantitative marker for changes in the vegetative nervous system [33]), heart frequency, blood pressure [23], breathing rate [17], edge light pupil effect [32], distal skin conductance/skin temperature [20,21,25], and also through changes in the immune [24] and endocrine system [6,7]. ...
Article
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Objective: The objective of this systematic review was to evaluate the effectiveness of an osteopathic treatment on the autonomic nervous system (ANS). For this purpose, published primary studies were analysed and critically evaluated. Method: To generate this review, 15 electronic databases were systematically searched for studies. Randomized clinical controlled trials (RCT) and clinical controlled trials (CCT) are included in the review and evaluated with appropriate assessment tools (Downs and Black Checklist and the checklist from Kienle and Kiene). Results: 23 published studies (10 RCT, 1 clinic multi-centre study, 1 CCT, 5 randomized cross-over studies, 5 randomized pilot studies and 1 single case study) are included in this review. The studies were evaluated with the assessment tools according to their quality. 3 studies are graded as high quality, 11 as moderate and 8 as low-quality studies. Conclusion: The included published studies represent a good level of evidence. Due to a small number of subjects and no follow-ups, the methodological quality is rated as moderate. A significant change on the ANS was shown in studies including High-Velocity Low-Amplitude Techniques (HVLAT). No statement could be drawn in studies in which they used cranial osteopathic techniques due to the lack of methodological quality. A significant change on the ANS is shown in the treatment of the suboccipital region. In studies which evaluated the effectiveness of mobilization in the cervical and thoracic region, no statement could be displayed due to a low level of evidence. None of the findings in these studies have given statements if ANS activation takes place in the sympathetic or parasympathetic system.
... All articles reported an ethics approval from an ethics committee or from a review board, with or without an identification number of the application and approval. As for conflict of interest, 11 studies declared to have none [8, 9, 14-16, 18, 21, 22, 24, 26, 28], whereas the issue of conflict was not mentioned at all in the others [17,19,20,23,25,27,29]. ...
... Most of the included articles investigated high-velocity low-amplitude SM, whereas three investigated instrumentally or mechanically assisted techniques. The area where SM was provided varied across studies to include all areas of the spine, whereas one study did not indicate where [19]. In most of them SM was provided 'where deemed necessary'. ...
... The outcome measures and measurement tools used in the selected studies are briefly described in Additional file 3. In two studies, outcomes were assessed only after intervention or control, presumably for ethical reasons [8,19]. As can be seen in Tables 1, 2 and 3, in all other studies outcomes were assessed before and after intervention at various time points. ...
Article
Full-text available
Background: A recent hypothesis purports that spinal manipulation may cause changes at a brain level. Functional Neurology, a mainly chiropractic approach, promotes the use of spinal manipulation to improve 'brain function' as if it were a proven construct. No systematic review has been performed to investigate how well founded this hypothesis is. Objective: To investigate whether spinal manipulation has an effect on 'brain function' that is associated with any clinical benefits. Method: In this systematic review, the literature was searched in PubMed, Embase, and PEDro (final search February 2018). We included randomized or non-randomized controlled studies, in which spinal manipulation was performed to any region of the spine, applied on either symptomatic or asymptomatic humans, and compared to a sham or to another type of control. The outcome measures had to be stated as direct or proxy markers of 'brain function'. Articles were reviewed blindly by at least two reviewers, using a quality checklist designed for the specific needs of the review. Studies were classified as of 'acceptable', 'medium', or 'low' methodological quality. Results were reported in relation to (i) control intervention (sham, 'inactive control', or 'another physical stimulus') and (ii) study subjects (healthy, symptomatic, or with spinal pain" subjects/spinal pain"), taking into account the quality. Only results obtained from between-group or between-intervention comparisons were considered in the final analysis. Results: Eighteen of 1514 articles were included. Studies were generally of 'low' or 'medium' methodological quality, most comparing spinal manipulation to a control other than a sham. Thirteen out of the 18 studies could be included in the final analysis. Transitory effects of different types of 'brain function' were reported in the three studies comparing spinal manipulation to sham (but of uncertain credibility), in "subclinical neck/spinal pain" subjects or in symptomatic subjects. None of these three studies, of 'medium' or 'acceptable' quality, investigated whether the neurophysiological effects reported were associated with clinical benefits. The remaining 10 studies, generally of 'low' or 'medium' quality, compared spinal manipulation to 'inactive control' or 'another physical stimulus' and similarly reported significant between-group differences but inconsistently. Conclusion: The available evidence suggests that changes occur in 'brain function' in response to spinal manipulation but are inconsistent across and - sometimes - within studies. The clinical relevance of these changes is unknown. It is therefore premature to promote the use of spinal manipulation as a treatment to improve 'brain function'.
... 6 Estudios de neuroimagen han demostrado este fenómeno. 39,40 Tashiro et al. fueron los primeros en realizar un estudio de neuroimagen funcional mediante PET para valorar los cambios producidos en el metabolismo cerebral relacionados con la respuesta del SNA tras la manipulación espinal cervical, así como los cambios en la intensidad del dolor tras el tratamiento. Observaron que el cambio más significativo se produjo en la desactivación del vermis cerebeloso tras el tratamiento, en comparación con el estado de reposo. ...
... También se ha observado que tras la MV se produce una activación del córtex prefrontal inferior y el córtex cingulado anterior que puede deberse a una relajación simpática. 39 En el trabajo de Sparks et al., 40 mediante RMN funcional, se estudió la activación supraespinal en respuesta a un estímulo nocivo, antes y después de una manipulación torácica. Observaron una menor activación en el córtex cingulado anterior y en el córtex insular, correlacionando esta última con una disminución significativa en la percepción del dolor. ...
Article
Full-text available
Introduction. Although its neurophysiological effects have not been fully elucidated, current evidence suggests the clinical effectiveness of spinal manipulation. Different studies suggest that manual therapy induces changes in the autonomic nervous system (ANS). Recent studies showed that mobilization produced a sympatheticexcitatory effect. However, studies using thrust manipulation appeared to be less consistent in their results. Objectives. The main objective of this review was to evaluate whether spinal manipulation induces effects on the ANS. Another objective was to correlate the changes in the measured variables with the activation or inhibition of the sympathetic or parasympathetic nervous system and with the level of spinal manipulation. Materials and methods. We performed a literature search in the following databases: PubMed, PEDro, CINAHL and OVID, using the keywords «Manipulation, spinal» and «Autonomic Nervous System». The PEDro scale was used to assess the methodological quality. Results. Nine studies met the inclusion criteria. Six trials measured cardiovascular function indicators (blood pressure, heart rate, Heart Rate Variability). Three other trials measured the pupil reaction. In most studies, cervical or upper thoracic region was manipulated. Conclusions. Our review does not provide definitive evidence of the effects of spinal manipulation on the ANS. However, most studies observed the existence of autonomic effects by modifying parameters such as blood pressure or Heart Rate Variability after manipulation. Increased parasympathetic activation probably occurs after cervical and lumbar treatment and increased sympathetic activation after dorsal treatment.
... 6 Estudios de neuroimagen han demostrado este fenómeno. 39,40 Tashiro et al. fueron los primeros en realizar un estudio de neuroimagen funcional mediante PET para valorar los cambios producidos en el metabolismo cerebral relacionados con la respuesta del SNA tras la manipulación espinal cervical, así como los cambios en la intensidad del dolor tras el tratamiento. Observaron que el cambio más significativo se produjo en la desactivación del vermis cerebeloso tras el tratamiento, en comparación con el estado de reposo. ...
... También se ha observado que tras la MV se produce una activación del córtex prefrontal inferior y el córtex cingulado anterior que puede deberse a una relajación simpática. 39 En el trabajo de Sparks et al., 40 mediante RMN funcional, se estudió la activación supraespinal en respuesta a un estímulo nocivo, antes y después de una manipulación torácica. Observaron una menor activación en el córtex cingulado anterior y en el córtex insular, correlacionando esta última con una disminución significativa en la percepción del dolor. ...
... 27 In recent years, the research of analgesic mechanism in manipulation has gradually shifted from the pathological structural changes 28,29 to the changes of pain neural pathway. 30 As far as the current studies are concerned, SMT works mainly through intervention of pain signal uploading, central pain signal processing, and feedback and suppression of pain signal to affect the pain neural pathway. It had been noted that pain activated the emotion-related areas in the central nervous system, which made the descending pain expression contain emotional context. ...
Article
Full-text available
Objective: To investigate the changes of regional homogeneity (Reho) values before and after spinal manipulative therapy (SMT) in patients with chronic low back pain (CLBP) through rest blood-oxygen-level-dependent functional magnetic resonance imaging (BOLD fMRI). Methods: Patients with CLBP (Group 1, n = 20) and healthy control subjects (Group 2, n = 20) were recruited. The fMRI was performed three times in Group 1 before SMT (time point 1, TP1), after the first SMT (time point 2, TP2), after the sixth SMT (time point 3, TP3), and for one time in Group 2, which received no intervention. The clinical scales were finished in Group 1 every time before fMRI was performed. The Reho values were compared among Group 1 at different time points, and between Group 1 and Group 2. The correlation between Reho values with the statistical differences and the clinical scale scores were calculated. Results: The bilateral precuneus and right mid-frontal gyrus in Group 1 had different Reho values compared with Group 2 at TP1. The Reho values were increased in the left precuneus and decreased in the left superior frontal gyrus in Group 1 at TP2 compared with TP1. The Reho values were increased in the left postcentral gyrus and decreased in the left posterior cingulate cortex and the superior frontal gyrus in Group 1 at TP3 compared with TP1. The ReHo values of the left precuneus in Group 1 at TP1 were negatively correlated with the pain degree at TP1 and TP2 (r = -0.549, -0.453; p = 0.012, 0.045). The Reho values of the middle temporal gyrus in Group 1 at TP3 were negatively correlated with the changes of clinical scale scores between TP3 and TP1 (r = 0.454, 0.559; p = 0.044, 0.01). Conclusion: Patients with CLBP showed abnormal brain function activity, which was altered after SMT. The Reho values of the left precuneus could predict the immediate analgesic effect of SMT.
... For example, one central argument in FN is that joint manipulation has a powerful effect on the brain [9,39,57]. As some research has been conducted in this area [58][59][60][61], a review of the literature seems timely. ...
Thesis
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En France, les chiropracteurs sont autorisés à pratiquer des actes conservateurs, incluant la manipulation vertébrale, afin de prévenir ou de remédier à des troubles neuro-musculo-squelettiques. La profession apparaît toutefois composite, certains chiropracteurs proposant de prendre en charge également des troubles non-neuro-musculo-squelettiques, sur la base d’approches aux théories diverses.La Neurologie Fonctionnelle (NF) en constitue un exemple contemporain. Il s’agit d’une approche attractive, présentée comme scientifiquement fondée. Elle fait cependant l’objet de vives critiques, la qualifiant parfois de pseudoscience.Cette thèse a pour but de contribuer à une meilleure compréhension de ce qu’est la NF ainsi qu’à une meilleure connaissance des faits scientifiques pouvant la sous-tendre, plus particulièrement dans un contexte chiropratique. Pour ce faire, une scoping review et deux revues critiques de la littérature ont été réalisées.La scoping review a montré que la NF est une approche thérapeutique conservatrice qui compterait de nombreuses indications, notamment non-neuro-musculo-squelettiques. Les “neurologues fonctionnels” recourent à de multiples outils thérapeutiques, dont la manipulation vertébrale, dans le but de stimuler le système nerveux, particulièrement des zones du cerveau. En NF, de nombreux éléments de langage sont empruntés aux neurosciences et différentes procédures diagnostiques et différents outils thérapeutiques sont issus de la médecine conventionnnelle. L’ensemble que forme sa théorie et ses applications cliniques lui apparait cependant propre et peu plausible.A travers une revue critique d’articles obtenus via un journal spécialisé en NF, aucune évidence scientifique probante n’a été trouvée à propos du bénéfice ou effet de la NF. A l’issue d’une revue systématique critique de la littérature, aucune évidence montrant que la manipulation vertébrale a un effet clinique via un effet sur l’activité cérébrale n’a été trouvée.Ces travaux nous ont amené à conclure que la NF, utilisée dans un contexte chiropratique, relève probablement d’une pratique pseudoscientifique.
... And there is corroborating research showing that chiropractic care can help improve the blood flow to the brain by removing these obstructions through chiropractic adjustments. [48][49][50] Another fluid that can be obstructed from entering or leaving the brain from subluxation is cerebrospinal fluid or CSF for short. CSF bathes the brain and spinal cord and it has been shown for example that some children with autism experience this obstruction. ...
... Twenty-four trials were selected for full-text read, among which 10 studies were excluded. [38][39][40][41][42][43][44][45][46][47] Reference lists of selected papers yielded 4 additional references and, therefore, 18 trials were included in this systematic review. The flow diagram is depicted in Figure 1. ...
Article
Full-text available
Objective: The purpose of this study was to systematically review the effects of spinal manipulative therapy (SMT) on autonomic nervous system (ANS)-mediated outcomes, in both symptomatic and healthy populations, and to assess the quality of evidence for the most prevalent outcomes with the Grading of Recommendations, Assessment, Development and Evaluation approach. Methods: PubMed, Cochrane Library, PEDro, Web of Science, and EMBASE were searched from their inception to March 2014. Randomized controlled trials involving SMT, such as mobilization and manipulation, that reported at least 1 outcome related to the ANS, with placebo, control groups, or other SMT techniques as comparators, with either healthy or symptomatic samples were included. The Physiotherapy Evidence Database scale and the Grading of Recommendations, Assessment, Development and Evaluation approach were used to assess risk of bias and the quality of evidence, respectively. Results: Eighteen trials were included in this systematic review. Passive accessory intervertebral mobilization produced sympathoexcitation independently of the treated region (cervical, thoracic, or lumbar spine); although sustained natural apophyseal glides did not influence the ANS, conflicting results were observed regarding manipulation techniques. The overall quality of evidence for all analyzed outcomes ranged from low to very low quality. Conclusion: There is evidence pointing toward the existence of sympathoexcitatory short-term effects following passive accessory intervertebral mobilization mobilizations, but not for sustained natural apophyseal glide mobilizations. There is conflicting evidence regarding the ability of manipulation to elicit sympathoexcitation. However, the low quality of the evidence precludes a definitive conclusion of such effects. Based on the current evidence, there is uncertainty regarding the true effect estimates of SMT on ANS-mediated outcomes.
... This study indicated that the application of manual techniques, i.e., post-isometric relaxation of tissues and elastic deformation of tissues, reduced anxiety in the respondents more effectively than Jacobson's progressive relaxation. Previous studies are consistent with these results, showing that different massage techniques significantly reduce the state of anxiety [26][27][28][29]. Ernst [30] noted that the use of massage can induce many psychological and somatic benefits, i.e., reduction in muscle tension, mood improvement, and increase in pain threshold, and it is often used to relieve symptoms of fatigue, stress, depression, and anger. ...
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OBJECTIVES The purpose of this study is to analyze the effect of changes in cervical alignment on balance ability, to correct cervical alignment, and to present effective interventional variables that can improve balance ability.METHODS Group 1 (Deformed cervical alignment group, n = 16) and Group 2 (Normal cervical alignment group, n = 16). The subjects measured their balance ability before and after treatment with chiropractic and shoulder flexibility exercises. Balance ability was measured by static balance and dynamic balance. For Group 1, chiropractic was treated once a week for 15 minutes, and shoulder flexibility exercise was treated three times a week for one hour. The pre- and post-measurement results of Group 1 were compared with Group 2, and differences among groups and groups were analyzed. The test method was tested with the Independent t-test and Paired t-test.RESULTS Group 1 showed a significant reduction (p<0.04) in the distance between the 7th cervical spine and gravity line, showing an improvement in cervical alignment. In the static equilibrium, the significant difference that was measured beforehand disappeared and the sum of deflection decreased. The dynamic balance did not disappear significantly but the balance ability improved as the sum of deflection decreased.CONCLUSIONS The cervical alignment deformation affects the balance ability. A combination of cervical alignment correction and exercise to increase the flexibility of the shoulder and neck muscles were performed. As a result, it was a factor in improving the static balance and dynamic balance ability of the left and right sides of the cervical spine.
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Background: The collective experience of the chiropractic profession is that aberrant stimulation at a particular level of the spine may elicit a segmentally organized response, which map manifest itself in dysfunction within organs receiving autonomic innervation at that level. This experience is at odds with classic views of neuroscientists about the potential for somatic stimulation of spinal structures to affect visceral function. Objective: To review recent findings from basic physiologic research about the effects of somatic stimulation of spinal structures on autonomic nervous system activity and the function of dependent organs. Data Source: Finding were drawn from a major recent review of the literature on the influences of somatic stimulation on autonomic function and from recent original physiologic studies concerning somatoautomatic and spinovisceral reflexes. Conclusions: Recent neuroscience research supports a neurophysiologic rationale for the concept that aberrant stimulation of spinal or paraspinal structures may lead to segmentally organized reflex responses of the automatic nervous system, which in turn may alter visceral function.
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Correction for ‘Spatial attention and neglect: parietal, frontal and cingulate contributions to the mental representation and attentional targeting of salient extrapersonal events’ by M.-M. Mesulam (Phil. Trans. R. Soc. Lond. B 354 , 1325–1346. (doi: [10.1098/rstb.1999.0482][1])). In the legend to figure 3 (p. 1332), the words left and right were mistakenly transposed. [1]: /lookup/doi/10.1098/rstb.1999.0482
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