Please Read If Considering Injections Or Back Surgery

Do not let this person confuse you! It would seem that he is a dc (chiroprator) not an md although he has not made that clear! He has also given unscientific and misleading advice in other posts!

Surgery for low back and other orthopedic problems should always be the last resort! As with any surgery there are potential side effects and risks including increased pain, no relief of pain and other more serious side effects. Surgery does work for some people and should be a decision that you and your dr make.

The information Dr. Scotti gave about cortisone is very interesting and mostly true. However, most people who get cort injections for orthopedic problems get local injections. These are not put in the blood stream and do not have a significant systemic effects. They really only affect the local area and most people do not get any side effects from them. If you get too many injections in the same location it can weaken the tendons and ligaments in the area but that takes several injections. Injection can be very helpful and give lasting pain relief (yrs) in some cases. Like anything, including surgery, chiropractic care, medication, physical therapy, ect.. Injection do not help everyone!

You really need to go back and do some research as I feel you are doing a great diservice to this forum. I am a chiropractor, have a doctorate, and if you check you will find we take as many hours, and many of the same courses. I choose not to be a medical doctor as I feel your scientific approach is very limited. You rant about scientific research, I put the research up for people to view, and you say its ""mostly true". You come off here like you are the know all authority and have put nothing up to show your claims. I will not continue to waste my time going back and forth with you like this. Infact, I read through your post about the patient who had ringing in the ear. You had suggested it was due to the trigeminal nerve, guess what? You were wrong its cranial nerve 8. Cortisone will have systemic effects on your body.. It weakens the immune system, and in longer term use causes decreases in bone density. You don't know what you are talking about and should not be giving your opinion as fact... Please anyone that is reading this forum please do a google search on steriod injections before taking them, and see what the contraindications are. She is not the authority and should not be taken seriously...

""""you said""""
surgery for low back and other orthopedic problems should always be the last resort! As with any surgery there are potential side effects and risks including increased pain, no relief of pain and other more serious side effects. Surgery does work for some people and should be a decision that you and your dr make. "

I said the same thing check my post

First I am not here promoting myself as a dr or even as a health care professional. By calling yourself Dr. People are going to assume that your opinion must be based on evidence and science. However from what I have read of your posts it often is not! The format of this forum is to assume that these people are not medical professionals unless they claim other wise (which I have not)

the evidence you gave about cortisone was very interesting and I thank you for it! However, from what you wrote (unless I missed something which is possible) it seems like these studies were mostly done on ingested steroids. The affect on the body of steroids taken as a pill is much much different than when it is injected. Yes, it is remotely possible a person may get mild systemic effects from injected cortisone but I have never herd of a case of diabetes, gastrointestinal problems or any other problem you talked about caused by local injections! If you know of any case studies describing this please give me the reference. I agree 100 percent with you if we are talking about pills. But injections have primarily a local effect and only minimal amounts of the hormone are absorbed into the blood stream. Even so, with the amount they inject, 1,2,3 or even a few more injections are not going to cause a big problem for the majority of people. And injections are not for everyone however can be helpful. I am not pushing surgery or injection, I just don't think they are always bad!


I am not challenging the validity of the chiropractic profession. I know that you are educated at a doctoral level and I know you feel your education is at par with an md. However, when chiropractors try to convince people that spinal manipulation helps the body deal with organ disorders it is very upsetting to me. I do not feel that allopathic medicine is perfect but it does, in theory, strive to find truth and not mislead pts.
I am not an all knowing authority and never claimed to be an apologize if I came across that way. I just don't like to see people taken advantage of with what I and the medical community feel are false claims. I have not supplied any evidence because my point is, there is no evidence that supports what you are saying. You are making the claims, you should provide the evidence!


In regards to my other posts about the ear ringing. You are right it could very well be a problem with the signal transmission from the ear structures to the brain. It could also be a central nervous system problem. If you review your anatomy you will see that the chorda tympani nerve (which is a branch of the trigeminal n) innervates the muscles that attach to the conduction bones of the inner ear. It is by this mechanism that trigeminal n disorders can cause ear ringing!

"cortisone will have systemic effects on your body.. It weakens the immune system, and in longer term use causes decreases in bone density"

yes it will do all these things when it is long term use of ingested steroids. I do not know any physician (md) who uses local steroid injections long term (meaning several injections week after week, month after month) a trial of 2-3 injections is not long term use and has min side effects, if all contraindications are ruled out.

When I said: "surgery for low back and other orthopedic problems should always be the last resort! As with any surgery there are potential side effects and risks including increased pain, no relief of pain and other more serious side effects. Surgery does work for some people and should be a decision that you and your dr make. "

i was aware that you also stated this. My point was, it is risky, it should not be taken lightly, there may not be positive results and it is necessary and the proper treatment in some cases.

Sometimes all else fails, including adjustments, meds, physical therapy and prayer. In these cases surgery can be a saving grace

some interesting links for the skeptical consumer:
http://newsok.Com/?Video#
http://www.G eocities.Com/healthbase/chirolinks.Html
http://www.Pbs .Org/saf/1210/video/watchonline.Htm

you have to type the above inks in by hand or cut and paste them. For some reason just cliking on them does not work!

Mpt, I appreciate your last post and respect your opinion.

Below is joint injection research. I have attached arrows to some points I found interesting about the effects of cortisone injections.
Please note table 2
caused by corticosteroid agent
acceleration of septic joint
subcutaneous fat atrophy (<1%), particularly if injection is <5 mm beneath skin surface
fistulous tract formation
steroid flare with pain 6 to 12 hr after injection (2% to 5%)
exacerbation of diabetes (rare)
osteoporosis (high doses over long period)
cartilage damage, particularly in weight-bearing joints
tendon rupture (<1%)
facial flushing (<1%)
transient paresis of injected extremity (rare)
asymptomatic pericapsular calcification (43%)
adverse gastrointestinal effects
mood alterations
fluid retention
menstrual irregularities
allergic or hypersensitivity reactions



basics of joint injection
general techniques and tips for safe, effective use
sami f. Rifat, md; james l. Moeller, md

vol 109 / no 1 / january 2001 / postgraduate medicine



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cme learning objectives

to understand the indications and contraindications for basic joint and soft-tissue aspiration and injection
to review the basic techniques for performing these procedures
to learn what supplies, equipment, and medications are required for these techniques
the authors disclose no financial interests in this article.



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this page is best viewed with a browser that supports tables.

A related article, on site-specific techniques of joint injection, will appear in an upcoming issue.

Tenth in a series of articles on office procedures in primary care.

Preview: primary care physicians may use joint and soft-tissue aspiration and injection to diagnose and treat a variety of painful musculoskeletal conditions successfully in an office setting. The procedure usually is well tolerated and produces few adverse effects. In this article, the first of two on aspiration and injection techniques, drs rifat and moeller discuss indications, contraindications, and general guidelines for use. The second article, which focuses on specific techniques at 12 common sites, will appear in an upcoming issue.
Rifat sf, moeller jl. Basics of joint injection: general techniques and tips for safe, effective use. Postgrad med 2001;109(1):157-166



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safe, effective joint and soft-tissue aspiration and injection techniques are relatively easy to master. Primary care physicians who know the techniques and pertinent anatomy should be able to perform many of these procedures. If a physician is uncomfortable performing any of them, referral is appropriate.

Potential complications
indications for and contraindications to joint and soft-tissue aspiration and injection in musculoskeletal conditions are outlined in table 1. Generally, these procedures are safe and produce few adverse effects. complications can be caused by the medication being injected (table 2) and the injection itself. All injectable medications have both local and systemic effects; the larger the dose, the greater the systemic effect.

Table 1. Indications for and contraindications to joint and soft-tissue aspiration and injection
indications
therapeutic

provide pain relief
deliver pharmacologic agents
diagnostic
obtain fluid for analysis
differentiate between local and referred joint or soft-tissue pain
contraindications
broken skin over injection site
overlying skin showing signs of cellulitis
patient known to have bacteremia
patient takes blood thinner or has major clotting disorder


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table 2. Major complications of joint and soft-tissue aspiration and injection
caused by injection
bleeding (rare)
infection (1 in 10,000) (5)
joint injury (incidence unknown): avoid by aspirating slowly and not moving needle side to side in joint

caused by corticosteroid agent
acceleration of septic joint
subcutaneous fat atrophy (<1%), particularly if injection is <5 mm beneath skin surface
fistulous tract formation
steroid flare with pain 6 to 12 hr after injection (2% to 5%)
exacerbation of diabetes (rare)
osteoporosis (high doses over long period)
cartilage damage, particularly in weight-bearing joints
tendon rupture (<1%)
facial flushing (<1%)
transient paresis of injected extremity (rare)
asymptomatic pericapsular calcification (43%)
adverse gastrointestinal effects
mood alterations
fluid retention
menstrual irregularities
allergic or hypersensitivity reactions


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corticosteroids have their own risks, including the much-discussed corticosteroid-associated tendon rupture (1). The risk of tendon rupture is quite low, but the ramifications can be significant (2). Therefore, direct tendon injection should be avoided. In our opinion, corticosteroid injections in and around the achilles and patellar tendons are not recommended. The potential for cartilage injury with corticosteroid injection also is cause for concern (1). For this reason, we recommend no more than three injections per location per year. Practically speaking, if three injections do not provide relief, it is unlikely that more injections will.

Supplies

The understanding that the spine is somehow involved in health and wellness as well as the practice of using manual manipulation as a source of healing dates back to the time of the ancient greek philosophers. In fact, hippocrates once said, "get knowledge of the spine, for this is the requisite for many diseases".
Modern chiropractic, however, marks its beginnings in the late 1800s when daniel david palmer, a self-educated teacher and healer, performed the first spinal manipulation on a patient. That patient was harvey lillard, a janitor who worked in palmer's building. Lillard was nearly totally deaf, and mentioned to palmer that he lost his hearing many years ago when he was bending over and felt a "pop" in his upper back. Palmer, who was a practitioner of magnet therapy (a common therapy of the time) was quite knowledgeable in anatomy and very interested in how the spine interacts with the rest of the body's systems. He felt strongly that the two events - the "popping" in lillard's back and his deafness - must somehow be related. He examined lillard's spine and found that one of his vertebra was misaligned. After applying slight pressure, palmer returned lillard's vertebra to the correct position and an amazing event occurred - lillard's hearing was restored! This procedure has become known as a chiropractic adjustment.
Palmer soon discovered that spinal adjustments could correct misaligned vertebra, eliminate nerve interference and relieve patients' pain. These misaligned vertebrae have been classified as chiropractic subluxations (versus allopathic subluxations). He began to use these "hand treatments" to treat a variety of ailments including sciatica, migraine headaches, stomach complaints, epilepsy and heart trouble. In 1898, he opened the palmer school & infirmary of chiropractic and began teaching his chiropractic techniques to others.
The medical community did not immediately embrace palmer's chiropractic theories and techniques. The called him a "quack" and refused to acknowledge his accomplishments. At one point, palmer was even indicted for practicing medicine without a license and spent time in jail for his offense.
While d. D. Palmer did not live to see his discoveries become accepted by the medical community, his son b.J. Palmer carried on his father's devotion and advanced the practice of chiropractic by getting it recognized as a licensed profession and establishing the palmer school of chiropractic in davenport, iowa, one of the premier chiropractic college in the united states.
Today, chiropractors are licensed in every state with over 50,000 practicing chiropractors in this country alone. Chiropractic continues to gain wide acceptance by the medical, legal, and patient communities through is record of beneficial results and ongoing research. There is even an area of veterinary medicine that utilizes chiropractic techniques to treat animals.
While the practice of chiropractic has come a long way since it's beginnings, its basic philosophies remain the same: the nervous system is involved in all bodily functions and a healthy nervous system, particularly a healthy spine, is one of the major keys to wellness. Disorders of the bones and muscles can cause interference in this delicate communications system and increases the risk of disease and other health problems. Only by diagnosing and eliminating this interference, can health be restored.

What medical doctors say about chiropractic
chiropractic treatment for a variety of neuromusculoskeletal conditions is gaining wider acceptance among the medical profession. Because students of chiropractic spend significantly more time studying the spine than do medical students, many medical doctors recognize the value of chiropractors as the appropriate source for diagnosis of and first line of treatment for functional disorders of the entire musculoskeletal system.
Medical doctors now categorize chiropractic manipulation with the highest rating: "generally accepted, well-established and widely used." spine, 1991. North american spine society.
"a majority of family physicians (in washington) admitted having encouraged patients to see a chiropractor, and two-thirds indicated a desire to learn more about what chiropractors do." the journal of family practice, 1992. "family physicians and chiropractors: what's best for the patient?" " our trial showed that chiropractic is a very effective treatment, more effective than conventional hospital outpatient treatment for low-back pain ... Particularly in patients ... Who have severe problems." t. W. Meade, m.D.
"the only difference that I can see is that the patients at john f. Kennedy get chiropractic manipulations. And in my experience, the patients at j.F.K. Almost without fail get out of the hospital in a week. At lutheran, it usually takes, oh, not uncommonly, 14 days." per frietag, m.D., an orthopedic surgeon, on why he prefers to admit his patients with back pain to john f. Kennedy hospital, which has staff chiropractors, rather than lutheran general, which does not have staff chiropractors. Manipulative medicine is no longer a taboo topic." norton hadler, m.D., self-described "cantankerous doctor who would have never dealt with manipulation in the past," professor of rheumatology, university of north carolina medical school at chapel hill, time magazine, 1991.
"ten years ago if you practiced manipulation ... You couldn't get published and were never invited to meetings. Now I can't keep up with the invitations." neurologist scott haldeman. M.D., d.C. New york times. 1991.
Material © healthy spine used by permission

Yes manipulation is a respected treatment for some musculo-skeletal disorders! Many practitioners use it and have done research on it! But again it is not considered an acceptable treatment for visceral (organ) disorders by mainstream medicine!


You talk about the side effects of injections but have not mentioned any of the potential side effects of manipulation. Adjustments are not completely safe and can lead to serious injury and even death. Death is rare, but no one really knows how many strokes are caused each year by adjustments.

Do you let pts exercise their right to informed consent? If so, every time you adjust a person's neck you should inform then that there is a small chance this technique could cause a stroke and leave then with permanent damage or worst case result in death.

A stroke is a very real possibly and it should be up to the pt to decide if they want to take that risk. I can imagine that people would think twice about cervical manipulations, especially upper
cervical rotation adjustments, if you gave them this information!

Its starting to really annoy me that again you are expressing your opinion, or what you have heard, or believe. If I had not taken the time to respond to your last post, you would have mislead people to believe that "chiropractic adjustments are not safe". Infact, if you do read the reseach below, you will find only 1 in almost 4 million people are effected adversely.... Again, I will provide the information for people to make an educated decision.. Here it is, more research, the top where I have numbered are key points, and below is the actual research. Please note #5 on my list as it is important for the person reading to believe that there are other techniques available then the "thrust" type


1)spinal manipulation has been reviewed in meta-analysis published as early as 1991, showing a clear benefit for low back pain.

2)manipulation relieves cervicogenic headache and is comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine.8 meta-analysis of five randomized controlled trials showed that there was a statistically significant reduction in neck pain using a visual analogue scale.9

3)risks
since 1925, there have been approximately 275 cases of adverse events reported with cervical spine manipulation.10,11,12,13 it has been suggested by some that there is an under-reporting of adverse events.

4)the estimated risk of adverse outcome following cervical spine manipulation ranges from one in 400,000 to one in 3.85 million manipulations.16, 17, 18, 19

5)the estimated risk of major impairment following cervical spine manipulation is 6.39 per 10 million manipulations.20 most of the reported cases of adverse outcome have involved “thrust” or “high velocity/ low amplitude” types of manipulation.



Print article: 8 ½x11
print complete issue: 8 ½x11

cervical spine manipulation
risk/benefit analysis

evidence behind the safety and benefit of cervical spine manipulation is explored.

By ken johnson, do and george pasquarello, do, faao

recently there has been an increasing concern about the safety of cervical spine manipulation specifically, this concern has centered on devastating negative outcomes such as stroke.

Benefits
spinal manipulation has been reviewed in meta-analysis published as early as 1991, showing a clear benefit for low back pain.1 there is less available information in the literature about manipulation in regards to neck pain and headache, but the evidence does show benefit.2, 3, 4, 5, 6 there have been at least 12 randomized controlled trials of manipulative treatment of neck pain.

Some of the benefits shown include relief of acute neck pain, improvement in pain as measured by validated instruments in sub-acute and chronic pain compared with muscle relaxants or usual medical care. There is also short-term relief from tension type headaches.7 manipulation relieves cervicogenic headache and is comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine.8 meta-analysis of five randomized controlled trials showed that there was a statistically significant reduction in neck pain using a visual analogue scale.9

risks
since 1925, there have been approximately 275 cases of adverse events reported with cervical spine manipulation.10,11,12,13 it has been suggested by some that there is an under-reporting of adverse events.10 a conservative estimate of the number of cervical manipulations per year is approximately 33 million and may be as high as 193 million in the us and canada. 14, 15 the estimated risk of adverse outcome following cervical spine manipulation ranges from one in 400,000 to one in 3.85 million manipulations.16, 17, 18, 19

the estimated risk of major impairment following cervical spine manipulation is 6.39 per 10 million manipulations.20 most of the reported cases of adverse outcome have involved “thrust” or “high velocity/ low amplitude” types of manipulation.11 however, the risk of vertebrobasilar artery stroke from manipulation is less than the risk of a spontaneous vertebrobasilar artery stroke.7

a concern has been raised by a recent report that vertebrobasilar artery stroke following cervical spine manipulation is unpredictable.10 this report is biased because all of the cases were involved in litigation. The nature of litigation can lead to inaccurate reporting by patient or provider.

However, it did conclude that vertebrobasilar artery stroke following cervical spine manipulation is “idiosyncratic and rare.” further review of this data showed that 25 percent of the cases presented with sudden onset of new and unusual headache and neck pain often associated with other neurologic symptoms that may have represented a dissection in progress.21

in direct contrast to this concern of unpredictability, another recent report states that cervical spine manipulation may worsen preexisting cervical disc herniation or even cause cervical disc herniation. This report describes complications such as radiculopathy, myelopathy, and vertebral artery compression by a lateral cervical disc herniation.12 the authors concluded that the incidence of these types of complications could be lessened by rigorous adherence to published exclusion criteria for cervical spine manipulation.12

manipulative treatment for neck pain is much safer than the use of nsaids, which are the most commonly prescribed medications for neck pain. Research in the united kingdom has shown nsaids will cause 12,000 emergency admissions and 2,500 deaths per year.22 the annual cost of gi tract complications in the us is estimated at $3.9 billion, with at least 2,600 deaths and up to 20,000 hospitalizations per year.23, 24

provocative tests
provocative tests such as the dekline test have been studied in animals and humans. This test and others like it were found to be unreliable for demonstrating reproducibility of ischemia or risk of injuring the vertebral artery.25, 26, 27, 28, 29, 30

risk factors
vertebrobasilar artery stroke accounts for 1.3 in 1000 cases of stroke, making this a rare event. The most common risk factors for vertebrobasilar artery stroke are migraine, hypertension, oral contraceptive use and smoking.31

a study done in 1999 reviewing 367 cases of vertebrobasilar artery stroke reported from 1966-1993 showed 115 cases related to cervical spine manipulation; 167 were spontaneous, 58 from trivial trauma and 37 from major trauma.31

complications from cervical spine manipulation most often occur in patients who have had prior manipulation uneventfully and without obvious risk factors for vertebrobasilar artery stroke.7 “most vertebrobasilar artery dissections occur in the absence of cervical manipulation, either spontaneously or after trivial trauma or common daily movements of the neck, such as backing out of the driveway, painting the ceiling, playing tennis, sneezing, or engaging in yoga exercises.”10 in some cases manipulation may not be the primary insult causing the dissection, but an aggravating factor or coincidental event.21

it has been proposed that thrust techniques using a combination of hyperextension, rotation and traction of the upper cervical spine will place the patient at greatest risk of injuring the vertebral artery. In a retrospective review of 64 medical legal cases, information on the type of manipulation was available in 39 (61 percent) of the cases. 51 percent involved rotation, with the remaining 49 percent representing a variety of positions including lateral flexion, traction and isolated cases of non-force or neutral position thrusts. Only 15 percent had any form of extension.21

conclusion
manipulation of the cervical spine is a safe and effective treatment. As with all medical procedures, practitioners should be provided with sufficient information so they are advised of the potential risks and benefits.


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ken johnson, do is the osteopathic dme, aoa fp residency director for the emmc in bangor, maine. He is certified in special proficiency in osteopathic manipulative medicine (cspomm) family practice and omt.

George pasquarello, do, faao is an associate professor of osteopathic manipulative medicine at the unecom. He is certified by the aobspomm and practices in maine and rhode island.

This paper has been adopted by the aao board of governors as an official position paper.

References:

shekelle, p, adams, a, et al. Spinal manipulation for low-back pain. Annals of internal medicine 1992;117(7): 590-98.
Koes, bw, bouter, lm, et al. The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints, a randomized clinical trial. Spine 1992;17(1):28-35.
Koes, b, bouter, l, et al. Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up. Bmj 1992;304:601-5.
Koes bw, bouter lm van marmeren h, et al. A randomized clinical trial of manual therapy and physiotherapy for persistent neck and back complaints: sub-group analysis and relationship between outcome measures. J manipulative physio ther 1993;16:211-9.
Cassidy jd, lopes aa, yong-hing k. The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine: a randomized controlled trial. J manipulative physio ther 1992;15:570-5.
Jensen ok, nielsen ff, vosmar l. An open study comparing manual therapy with the use of cold packs in the treatment of posttraumatic headache. Cephalgia 1990;10:241-50.
Hurwitz el, aker pd, adams ah, meeker wc, et al. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 1996;21(15):1746-56 .
Bronfort g, assendelft wj, evans r, haas m, bouter. Efficacy of spinal manipulation for chronic headache: a systematic review. J of manip & physio ther 2001;27(7):457-66.
Gross ar, aker pd, goldsmith ch, peloso p. Conservative management of mechanical neck disorders. A systematic overview and meta-analysis. Online j curr clin trials. 1996; doc no 200-201.
Haldeman s, kohlbeck fj and mcgregor m. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation: a review of 64 cases after cervical spine manipulation therapy. Spine 2002;27:49-55.
Assendelft wjj, bouter lm and knipschild pg. Complications of spinal manipulation: a comprehensive review of the literature. J fam pract 1996;42:475-480.
Malone dg, baldwin ng, tomecek fj, boxell cm, et al. Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice. Neurosurg focus 13(6), 2002.
Vick da, mckay c, zengerle cr. The safety of manipulative treatment: review of the literature from 1925 to 1993. Jaoa 1996;96(2):113-5.
Haldeman s, carey p, townsend m, papadopoulos c. Arterial dissection following cervical manipulation. The chiropractic experience. Cmaj 2001;165:905-6.
Hurwitz el, coulter id, adams ah, genovese bj, shekelle pg. Use of chiropractic services from 1985 through 1991 in the united states and canada. Am j public health 1998;88:771-6.
Jenson et al. Complications of cervical manipulation, general forensic
science1987 ;32(4) :1089-1094.
Koss rw. Quality assurance monitoring of osteopathic manipulative treatment. Jaoa 1990;90(5):427-433.
Dvorak j, orelli f. How dangerous is manipulation to the cervical spine? Case report and results of a survey. Manual med 1985;2:1-4.
Carey p. A report on the occurrence of cerebral vascular accidents in chiropractic practice. J can chiropract assoc 1993;37:104-6.
Coulter id, hurwitz el, adams ah, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa monica ca: rand, 1996.
Haldeman s, kohlbeck fj, mcgregor. Stroke, cerebral artery dissection, and cervical spine manipulative therapy. J of neurol 2002;249:1098-1104.
Blower al, brooks a, fenn cg et al. Emergency admissions for upper gastrointestinal disease and their relation to nsaids use. Alimart. Pharmacology ther, 1997, 11:283-91.
Fries jf, miller sr, spitz pw, williams ca, hubert hb, bloch da. Toward an epidemiology of gastropathy associated with nonsteroidal anti-inflammatory drug use. Gastroenterology. 1989;96:647-655.
Bloom bs. Direct medical costs of disease and gastrointestinal side effects during treatment for arthritis. Am j med 1988;84(suppl 2a):20-24.
Licht pb et. Al. Vertebral artery flow and cervical manipulation: an experimental study. J manipulative physiol ther 1999;sep; 22(7):431-5.
Cote p, kreitz bg, cassidy jd, et al. The validity of extension-rotation tests as a clinical screening procedure before neck manipulation: a secondary analysis. J manipulative physio yher 1996;19:159-64.
Refshauge km. Rotation: a valid premanipulative dizziness test? Does it predict safe
manipulation? J manipulative physio ther 1994;17:15-19.
Stevens a. A functional doppler sonography of the vertebral artery and some considerations about manual techniques. J manual med 1991;6:102-5.
Theil h, wallace k, donat j, et al. Effect of various head and neck positions on vertebral artery blood flow. Clin biomech 1994;9:105-10.
Weingart jr, bischoff hp. Doppler sonography of the vertebral artery with regard to head positions appropriate to manual medicine. J manual medicine 1992;6:62-5.
Haldeman s, kohlbeck fj, mcgregor m. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation: spine 1999;24:785-94.

Mpt, you will find this very interesting... Notice the section where it talks about cortisone injections and states "it is not intended for repeated use, however, due to its ability to cause degeneration of tissue over time."
i would agree that it is effective in pain relief but has more serious side effects then spinal adjustments. Also notice that there is a choice called glucosimine sulfate and chondroitin sulfate which are not prescribed drugs, so unlikely many md's would recommend them. They work to rebuild the cartilage, have antiimmflamatory properties, and safer for long term use. Thats why a chiropractor would suggets that... Oh, by the way, why don't you look up nasids and see what the long term effects are of those... Liver damage, kidney damage, ulcers, etc.


Osteoarthritis injuries - non-surgical treatment options

the injury: as the joint starts to wear out, the surface of the joint becomes irregular, and the muscle wastes away due to pain and disuse. Stiffness occurs due to inflammation and pain associated with movement.

Treatment options: in the earlier stages of osteoarthritis, rehabilitation may provide significant benefit. Rehabilitation for arthritis focuses on range of motion to the joint and strengthening the muscles around the joint. Exercises that are particularly beneficial are bicycling and swimming. Bicycling at high revolution and low resistance acts to lubricate the joint and smooth the joint surfaces as they rub together. At least 20 minutes a day on a stationary bicycle is recommended. Swimming allows exercise without bearing weight on the involved joint and is an excellent way to maintain muscle strength around the joint without causing irritation. Daily stretching is useful to maintain range of motion.

Modalities: use of ice is often helpful when the joint is particularly swollen or painful. Ice acts to decrease inflammation and swelling in the joint and acts as an analgesic by slowing nerve conduction in the pain fibers around the joint. Topical treatments may provide temporary relief as well. These are typically one of a variety of skin irritants such as menthol or caspacin (pepper!). These agents act to irritate and thus warm the skin around the painful joint. Relief occurs due to the warmth as well as the over stimulation of the local sensory nerves which temporarily distracts and overrides the pain fibers. Elastic braces or ace bandages provide some relief due to the added sense of stability and warmth. The pressure from the brace may also help to limit swelling.

Medication: the mainstay of medication treatment for degenerative arthritis is antiinflammatory medicine. The most commonly used category of these are called non steroidal antiinflammatory drugs (nsaid). This is to differentiate them from steroid antiinflammatory drugs which are very powerful, but have more side effects. The antiinflammatory drugs work to stop the natural chemical mediators of inflammation in the body. The uneven surfaces caused by degeneration of the joint cause an inflammatory reaction in the joint. Nsaid limit this secondary inflammation but do not affect the degeneration of the joint. They also act to relieve pain. The most common side effect is gastrointestinal upset.

Chondroprotective agents: there are currently several new methods for trying to protect and enhance cartilage function, either through injection or orally. The exact efficacy of these treatments is still being debated in the scientific community, but they are still being used extensively.

Injectable agents: hyaluronic acid: hyaluronic acid is a type of molecule that occurs naturally in the joint and is important in the structure and function of cartilage. It is a type of sugar (glycosaminoglycan) that acts as the backbone on which other important cartilage molecules (proteoglycans) aggregate. These aggregates combine with proteins (collagen) to make up the spongy resilient cartilage surface. Hyaluronic acid has recently been approved by the fda for injection into the joint. It is thought to act by providing additional lubrication, controlling permeability of the lining of the joint (synovium) and possibly by promoting further cartilage proteoglycan synthesis and function. Between 3 and 5 injections are given into the knee over a 1-2 week period. The majority of patients experience some relief of pain that can last between 6-12 months. The relief is temporary, however, and repeat injections or other treatments are often necessary.

Oral agents: glucosamine: glucosamine is one of the building blocks (aminomonosacharide) of the large sugar molecules that make up cartilage tissue. The body normally produces glucosamine from glucose, a basic nutritional sugar. Taking supplemental glucosamine provides the body with a 'prefab' ready source of this important cartilage building block, enhancing the joints ability to produce new cartilage tissue. Glucosamine may also have a mild antiinflammatory effect. The recommended dose is at least 1 gram daily, and there are no known side effects. The medication is obtainable without a prescription. It may take 2-3 months before the effects are detectable, so be patient!

Chondroitin sulfate: chondroitin sulfate is another type of molecule that contributes to the structure of cartilage. It is important in the binding of the spongy sugar aggregates to the structural protein framework which comprises cartilage. It is also thought to help inhibit some of the harmful enzymes that break down cartilage. A typical dose of chondroitin sulfate is 1000 mg/day. There are no known side effects.

Cortisone injections: cortisone is a type of steroid that is used for its powerful antiinflammatory properties. Cortisone is extremely effective and safe when used properly and in moderation. It is not intended for repeated use, however, due to its ability to cause degeneration of tissue over time. A single cortisone injection will often give relief of pain and swelling for 6 months to a year. Cortisone is often used for end stage arthritis in order to buy time until a joint replacement surgery becomes necessary.

The argument that chiropractors spend more time studying the spine and have just as many hours of study as an md is ludicrous. Mds participate in medical school = 4 years at 25-35 equiv. Class hours per week then engage in intensive study for typically 4-6 years in a residency program which entails 70-90 hours per week. To compare the education obtained via chiropractic vs. Allopathic medicine is absurd and demonstrates an intentional elevation of chiropractic to an educational status which is not justified based on hours of study. There is simply no possible comparison. However, chiropractic for musculoskeletal conditions is indeed becoming well accepted despite the gross underreporting of chiropractic injuries in the literature. In my area alone, I am treating one patient with a vertebral artery transsection which occurred during forceful chiropractic manipulation 18 months ago leaving him paralyzed and unconscious in the parking lot of the chiropractor and am treating approximately 10 more which have developed permanent deficits due to chiropractic manipulation, astonishly some of which were due to cervical manipulations performed by the chiropractor in the absence of previous symptoms. This type of sloppy shoddy work is what continues to fuel the firestorm about chiropractic. The other area in which chiropractic continues to defy logic and science is in the voodoo of treating multiple maladies such as asthma or bowel disorders through continuing adjustments.
That being said, I am a firm believer in chiropractic and have administered anesthesia for muga performed by chiropractors who are certified in the technique.
I think chiropractic and allopathic medicine can coexist quite nicely as long as both stick to science, not rely on reported statistics on injuries as being complete and avoiding extrapolating bad data to ridiculous degrees, and respecting what is proven.

I have ra and I have degenerative disc disease and for the past 18 months I have been having epidural injections in my lower back area. I have had a total of 26 injections over a period of 18 months, and I have been reading all these post dr scotti and ect... My personal advice to anyone out there do not ever and I repeat ever get ant injections in your back. I am in a painful situation now and my back is screwed up major from all those injections. My rhumy told me that it excelerated my arthritis. So take it from someone who knows, they are no good!!!!

I had a steroid injection in my back, lower facet joints as a diagnostic tool as nothing showed on mri scan. Ever since ive had pain down my left side. Since then my right side has been injected and ive got pain down my right side also. Caused by the injections.

Injections were done in my lower facet joints, have bad pain at injection sites and pain under my ribs.

Im only 24 and was fine before I had them done, albeit apart from the original pain I went in for that has now gone, im left with the after affects of these injections.

Any advise to steer people away form these the better

Sad stories here. I agree these pain shots and surgery are the last thing to do...

Before those you must check pelvis and sacroiliac joints. Sij blocks are very common problems. And if pelvis is not working correctly you will get problems to your spine. And if you operate on spine often the problems just get worse.

You should correct pelvis first! 80% of all people and almost all back pain patients have problems in pelvis causing the troubles to their spine: lordosis, spondylisthesis, scoliosis, degeneration, disc problems and many others... And that asymmetrical biomechanics is the cause of muscle spasms, weak deep muscles, etc.

I had subluxated sij since I was a child but no doctors understood to check it. Why? They just don't know it is possible to subluxate. Now I am fine, after 20 years of pains, because I finally found one who knew what was wrong with me and corrected it: sij subluxation. Very common disorder... And all the doctors said my pains are because of multiple disc herniations and degenerations.