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Spondylolisthesis and Chiropractic Care

November 27th, 2011 Brian Starry, D.C. No comments

Spondylolisthesis pronounced (spon-dee-low-liss-thesis) is a condition of the spine where one vertebral body segment slides forward in relation to the one below. There has been some recent buzz about this condition, but it is nothing new.  Chiropractors have been treating this for many years with great success, and having this myself and experiencing great results with treatment, I can attest to the benefits of Chiropractic care.

Dynamic Chiropractic – November 20, 2005, Vol. 23, Issue 24

Spondylolisthesis and Chiropractic Care
By Kim Christensen, DC, DACRB, CCSP, CSCS

Although much has been written in the health care literature regarding spondylolisthesis, the clinical decisions required for management remain challenging. This condition, which affects adolescent athletes, adults, and the geriatric population, is not necessarily associated with a pars defect and has a wide range of treatment options – from bracing to spinal manipulation to fusion surgery. So, what is the best and most effective treatment for chiropractic patients with a spondylolisthesis? How can we go beyond symptomatic care to provide long-term support for the spine with spondylolisthesis?

What, Where, Why

Traditionally, spondylolisthesis is defined as an anterior displacement of a vertebral body in relation to the segment immediately below.1 There are several types of spondylolistheses, with the most common being spondylolysis of the pars interarticularis, occurring in the young, and degenerative, which occurs in older patients.2 The vast majority of spondylolistheses are found in the lower lumbar region, with rare occurrences in other spinal regions.

We now understand that most spondylolistheses seen before the age of 50 are due to a break in the pars that occurred during childhood or adolescence (often during athletic activities requiring lumbar extension). When seen after the age of 50, a degenerative cause becomes more likely.

Categorical Classification

Classifying spondylolisthesis from a clinical viewpoint is very helpful. One system describes four classical presentations: recent spondylolytic spondylolisthesis (RSS); pre-existing spondylolytic spondylolisthesis – stable (PSS-S); pre-existing spondylolytic spondylolisthesis – unstable (PSS-U); and degenerative spondylolisthesis (DS).3 By placing each patient in one of these four categories, clinical decision-making is simplified and effective treatment can be provided. Another useful approach is the use of an algorithm to assist in determining imaging and treatment options.4

Response to Chiropractic Care

The primarily young athletes who comprise the RSS group have an active stress fracture of the pars, and benefit most from avoidance of hyperextension. Activity restrictions and use of a rigid lumbosacral brace often will produce a successful outcome.5 The most common type of spondylolisthesis seen in chiropractic offices is the stable pre-existing type (PSS-S).

Response to chiropractic care is often excellent. Studies have shown that when a spondylolisthesis is found in an adult, specific side-posture manipulations to the dysfunctional joints are quite effective, and that the prognosis is not significantly different from other patients.6 These researchers reported that the spinal segments most commonly needing adjustment were the ones above or below the spondylolisthetic segment, as well as the sacroiliac joints. Flexion-distraction also has been found to be a successful treatment method, as long as the patient does not demonstrate instability (PSS-U); in unstable patients, the treatment provided little benefit.7

Improving Stability and Control

An important approach to the treatment of patients with spondylolisthesis is to strengthen and re-coordinate the deep support muscles of the lumbar spine. An attempt is made to improve the dynamic stability and segmental control of the spine. These muscles include the multifidus muscles and the internal oblique and transverses abdominus muscles.8 Exercises to train the co-contraction patterns of these muscles often are called “spinal stabilization” exercises. Specific maneuvers include: posterior pelvic tilt; lower abdominal hollowing; and abdominal bracing.

The exercises are started non-weight-bearing while lying supine and/or prone, and then progress to quadruped (on all fours) if the position does not worsen symptoms, and finally to upright sitting and standing positions. They are described as low-resistance, isometric exercises whose focus is on precision of performance and re-learning of function. A 10-week program of supervised exercise sessions designed to progressively incorporate these postures into daily activities was found to reduce back pain and disability levels significantly over more than two years in subjects with spondylolisthesis.9

Postural Correction

Many patients with spondylolisthesis develop postural asymmetries over time. One important factor in treatment is the correction of any loss of the normal upright alignment of the pelvis and spine. While there is no standard “spondylo posture,” it is not unusual to see a change in pelvic alignment (often a forward-flexed pelvis) or in lumbar spinal curve. The lumbar changes can be either a hyperlordosis or (in some cases) a lack of normal lumbar lordosis. Patients will need to be shown corrective exercises specific for the postural imbalances they have developed.

Maintenance and Support

Patients with spondylolisthesis should be taught to perform a general fitness exercise program for the lumbar support muscles on a once-a-week basis. A general and usual recommendation for maintenance exercising is a series of exercises using heavy-duty elastic tubing. These isotonic resistance exercises, performed in an upright (seated) position, will activate all of the stabilizing and major mobility muscles of the lumbar spine.

Another important consideration for long-term support of the spondylolisthetic spine is the use of custom-made orthotics. Since many of these patients have low or absent arches in their feet, the additional support from a pair of custom-made orthotics frequently is necessary. In fact, lower-extremity misalignments such as leg-length discrepancies and pronation problems are often are associated with chronic pelvic and low back symptoms.10

References

Yochum TR, Rowe LJ, eds. Essentials of Skeletal Radiology, 2nd ed. Baltimore: Williams & Wilkins; 1996:327.
Souza TA. Differential Diagnosis for the Chiropractor. Gaithersburg, MD: Aspen Pubs; 1997:132.
Hyland JK. Clinical classification of spondylolisthesis. J Am Chiro Assoc 1993;30(8):67-71.
Yochum TR et al. Natural history of spondylolysis and spondylolisthesis. In: Yochum TR, Rowe LJ, eds. Essentials of Skeletal Radiology, 2nd ed. Baltimore: Williams & Wilkins; 1996:365-367.
Blanda J, Bethem D, Moats W, Lew M. Defects of pars interarticularis in athletes: a protocol for nonoperative treatment. J Spinal Disorders 1993;5:406-411.
Mierau D, Cassidy JD, McGregor M, Kirkaldy-Willis WH. A comparison of the effectiveness of spinal manipulative therapy for low back patients with and without spondylolisthesis. J Manip Physiol Therap 1987;10:49-55.
Cox JM. Chiropractic adjustment results correlated with spondylolisthesis instability. J Man Med 1991;6:67-72.
Richardson C, Jull G. Muscle control-pain control. What exercises would you prescribe? Man Therapy 1995;1:2-10.
O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercises in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;2:2959-2967.
Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Therap 1988;11:373-379.
Kim Christensen, DC, DACRB, CCSP, CSCS
Director, Chiropractic Rehabilitation and Wellness Program
PeaceHealth Hospital
Longview, Washington
kchristensen@peacehealth.org

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Click here for more information about Kim Christensen, DC, DACRB, CCSP, CSCS.

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Chiropractic and 911.

September 5th, 2011 Brian Starry, D.C. No comments
Dynamic Chiropractic – September 9, 2011, Vol. 29, Issue 19
Where Were You When the World Stopped Turning?
On the 10-year anniversary of the World Trade Center disaster, Richard Gorgo Jr., DC, recalls his volunteer experience at Ground Zero.
By Richard Gorgo Jr., DC
More than 100 doctors of chiropractic participated in relief efforts following the Sept. 11, 2001 terrorist attacks that left 2,753 dead – including 343 firefighters, 60 police officers and eight paramedics / emergency medical technicians – and far more than the New York City skyline forever altered. Dr. Richard Gorgo Jr. was one of those DCs who selflessly donated his time, skill and compassion during that surreal, yet all-too-real moment in history. This is his remarkable story. Where were you when the world stopped turning? For Dr. Gorgo, who volunteered for more than three months following that infamous day, the answer is Ground Zero.
Where were you when the world stopped turning? The famous Alan Jackson song with that very title, composed only days after the terrorist attacks that brought down the Twin Towers, still creates an emptiness in the pit of my stomach and hollows my spirit. The chilling lyrics remind me so much of those days. Hard to believe it’s been 10 years; 10 tumultuous years. None of our lives has been the same since that day. It seems as if everyone has a story about it. This is mine, as myopic as it may seem.
While I sit here attempting to type, my hands are already cramping, a lasting symptom of an illness that plagues so many of us who worked at the World Trade Center site. (I should talk about it a little in case there are any volunteers who read this who have not been diagnosed properly or treated, but my battle with this illness is a subject for another day.)
As I mull through a box full of memories hidden for a decade in my basement, I see NYPD, FDNY, and Urban Search and Rescue badges and hats. (A common practice for fire departments and other service teams around the country is to exchange shirts or patches. It’s a way of saying “thank you” and accepting you into their family.) I pick up a children’s book called September 12th given to me by a schoolteacher, letters from children, letters from friends, signed T-shirts, hardhats and more. I’m completely overwhelmed. How do I express all these memories? How do I put all of this to paper? Every object I touch means something, has a story and brings back memories.
What part of all this do I keep private? What part of it needs to be heard? How much is needed to tell the story? I don’t know. I can tell you that it hurts to dig through this stuff; that the emotions are suppressed, just under the surface; that they are never gone. I can’t imagine how our veterans must feel, because I have seen nothing like they have and yet I’m trembling as I touch this stuff. I pick up my hardhat, unused since 2001; it still fits pretty well, as do the different respirators we were given to wear (at least we were supposed to wear them).
Some of the many signed T-shirts in Dr. Gorgo’s collection of memories. This story isn’t just about me, though, although it’s my story. The reason I want to tell it is because of the kind, generous and compassionate people who became part of my life and whose lives I became a part of. This story is about chiropractic; it is about how important a role we played in helping begin the healing of our nation.
Who am I, you may ask? Officially, I’m nobody. I woke up as you did in on the morning of Sept. 11, 2001, gathered up my paperwork and headed off to my accountant’s office. I checked in with his secretary and asked her what movie was playing on the television. She told me it was no movie, and at that moment the second plane hit. It’s the first time I’ve felt the kind of fear that comes when you realize things happen completely beyond your control.
I immediately called my mother to see if she’d heard from my sister, who lived in New York City at the time. I tried to contact my sister and other family members in New York City. Then I knew I had to do something. I left my accountant’s office and began the approximately three-hour trip to New York City (I practiced in Parkesburg, Pa., back then), calling some friends along the way. But I was turned away at the Holland Tunnel and returned home disheartened.
The next day, one of my staff members invited me to church. “They’re going to pray for America,” she said. While we were praying for the country, the congregation also prayed that I would be able to make it safely and effectively into New York City. That night, I packed up all the medical supplies I could find, including my chiropractic table and all the towels, bed clothing and pillows I could get my hands on. My best friend from New Jersey offered to drive up with me.

(courtesy of Michael Rieger/FEMA): An inside view of the first floor of the Jacob Javit Center.

An inside view of the first floor of the Jacob Javit Center. We drove 2 1/2 hours and wound up again at the entrance to the Holland Tunnel. This time, instead of turning around, I pulled my window to the side of the police officer on duty. (You have to know how dangerous this is at a time when no one knows who the enemy is.) I told the officer I was a doctor and that I was there to help. He was kind enough to direct me to the Jacob Javits Center [on 34th Street, approximately 4 miles from where the Twin Towers had stood]. I can remember how eerie it was driving through that tunnel alone, with no other cars on the road. Anyone who lives in New York City can tell you that never happens.
When I pulled up in front of the Jacob Javits Center, a tall man in fatigues asked me, “Are you the chiropractor?” Stunned, I said, “Oh, yes, I am,” but in my mind I was wondering how he knew I was coming. Later, I found out that he was likely waiting for Dr. John Albaneze, who arrived a few hours after me. The doctor who greeted me was Dr. Hernando Garzon, chief medical officer for FEMA; he and his staff helped us unload our vehicle. They set us up upstairs at the Jacob Javits Center and told us that most of the FEMA search-and-rescue workers would return about 7 a.m.
At this point, a lot of my memory is a blur. (I apologize if I leave anyone out or get anything incorrect; after all, it’s been 10 years.) The Javits Center was full of search-and-rescue teams that were still pouring in from all around the country and even from around the world. Then the patients started coming, Dr. Albaneze showed up and we worked through the night. I remember Mick Sacco, the friend I’d brought with me, running back and forth between the FEMA search-and-rescue workers and the news media, expressing the needs of the different teams. It was astonishing how quickly those needs were met. I think it was something like 3 a.m. when he put a call out over the air for blowdryers to dry the search-and-rescue dogs. Some hair supply place brought them right over; that’s just how it was. People just gave.

"The Pile" - the twisted remains of the Twin Towers and surrounding structures that fell on Sept. 11.

“The Pile” – the twisted remains of the Twin Towers and surrounding structures that fell on Sept. 11. Throughout that night and the next morning, more chiropractors showed up, as did massage therapists and acupuncturists. On occasion I would ask Dr. Garzone when it would be alright for me to go down to “The Pile” – that’s what we called the smoking mass of twisted metal and remains. By the next evening, the Javits Center was fully stocked with chiropractors full of passion and desire to help.
At 7 p.m. that evening, I was given the go-ahead to work my way down through five checkpoints to The Pile. Just before I left, I remember seeing a U.S. marshal passed out on some folding chairs. She had been up for over 40 hours. I remember handing her a pillow.
At the first checkpoint, NYPD-manned, no one wanted to hear from me. One officer noticed my frustration. Yolanda Gutierrez was her name. Already up for more than 24 hours, she sat me down, called back to FEMA and was able to verify my clearance. While this was happening, a very kind woman had filled the Jeep Cherokee I was driving with trays upon trays of food she had cooked out on the sidewalk. She begged me to bring it to the men working.
The next few checkpoints were manned by U.S. marshals and went smoothly. The checkpoint with the military police was a different story. By this time, the smoke from the pile had mixed with the lights, creating an eerie fog. Our only identification at this moment was our driver’s license with a sticker placed on it by FEMA. That’s it, just a silly colored circular sticker placed over the driver’s license. After the MP removed his weapon from my face, my friend and I explained our purpose and our clearance. The MP grumbled that our IDs were subpar, but after a thorough searching, he reluctantly let us through.
Search-and-rescue dogs like this one were also recipients of chiropractic care. Photos courtesy of Andrea Booher/FEMA.

Search-and-rescue dogs like this one were also recipients of chiropractic care. Photos courtesy of Andrea Booher/FEMA.

Search-and-rescue dogs like this one were also recipients of chiropractic care. Photos courtesy of Andrea Booher/FEMA. It was well after midnight by the time we made it through all the checkpoints. Our first impression was the smell; oh, how I will never forget that smell. Beyond that, our inability to see due to the thick smoke and all the different uniforms rushing around created a sensation that was unreal. We always said it felt like we were on a movie set where King Kong was battling Godzilla in Manhattan.
We parked in front of St. Peter’s Church on the corner of Church and Vesey. The Salvation Army had already set up a canteen – essentially a cafeteria – and was stacking supplies on the church steps. Later, it would be the Salvation Army that helped us and fed us and clothed us. I carried what few supplies I had left and my portable chiropractic table into the church. I was happy to see that the Salvation Army had already set up a medical supply on the church pews. I set my table up between the pews and noticed how eerie the altar looked. It was covered in at least an inch of dust/ash. Later, there would be a book on the altar that many signed and left behind their fear, hurt, fatigue and memories.
I remember walking in that dust; it looked like we were on the surface of the moon. I was later told that the church had been completely locked and sealed during the towers’ collapse, yet great amounts of dust still made it in. Mick and I ran outside to see who we could help. We had no hardhats and no masks, so the Salvation Army supplied us. As we walked up Church Street, we came to the St. Paul’s Church graveyard. There isn’t enough room in this story to describe how, little by little, your eye catches glances of things and over time begins to make them out; how surreal everything seems. I remember horizontal blinds in the trees, which had been knocked over, and how everything was covered in dust. Along the fence were small tents and a Salvation Army canteen. There were large overhead lights that gave everything a odd, movie-like feel.
From left: NYPD Officer Gail Imhauser, Dr. Gorgo and Dr. Heidi Yudelowitz at the 2002 memorial service at Ground Zero.

From left: NYPD Officer Gail Imhauser, Dr. Gorgo and Dr. Heidi Yudelowitz at the 2002 memorial service at Ground Zero.

From left: NYPD Officer Gail Imhauser, Dr. Gorgo and Dr. Heidi Yudelowitz at the 2002 memorial service at Ground Zero. The attitude at the site can’t be emphasized enough. It was solemn yet busy, but with an air of hope. There was no smiling, no emotion; just work – and you dared not have a camera. I saw a news cameraman trying to sneak around and they picked him up and threw him out of the site. This was not a place of discovery, journalism or interest; not then. This was the place where so many of these people had lost someone. These men lost brothers and sisters. They were working nonstop for days. The FDNY is a fraternity that you can’t describe. They had one thing on their minds: rescue whoever could be saved. They stuck together like a pack of vicious wolves and protected the lives, integrity and honor of their own.
As we walked, we walked lightly, making sure to hide our natural intrigue. We could see the damage to building five by this point; the exterior facade of the building was warped and twisted, and all the glass was gone. It was here that I would later meet Officer Gail Imhauser. She was a transit cop who told me of her plight and how she had been saved by a brave fireman. Gail, along with many others, ran inside building five to take cover from the falling debris. She told me the dust was so aggressive that although she squeezed her eyes, nose and mouth shut and covered her face, she still choked on a ball of dust that lodged in the back of her throat. The fireman who had taken cover with her and some of his fellow firefighters used their axes to break them out of the building and ultimately saved their lives.
Over time, Gail and I would become good friends, and she would lead many people to our makeshift clinics for chiropractic care. She would also give me a call and ask me to meet her and some fellow police officers who were not allowed to take a break or even remove their bulletproof vests. She would have me meet them in building lobbies, alleyways and even dining halls to receive treatment.
Prior to 9/11, Officer Gail was not a chiropractic patient. But in the aftermath of 9/11, she saw the results chiropractic provided firsthand and wanted her colleagues to experience the benefits of chiropractic care. I have a miniature version of her badge here in my hand right now as I write this. I’m thankful for her friendship and the hundreds of other friends and heroes I met.
Dr. Gorgo’s site identification, similar to that required of other DCs providing chiropractic care at GZ. As Mick and I kept walking to our right, the remains of building seven could be seen down the alleyway. We were able to make it within 50 yards of the Millennium Hotel, and it was from this vantage point that we could make out the facade of WTC building 2 through the smoke. A portion of the remains was stuck in the ground like a lawn dart; later, Officer Gail would inform me that it had pierced the ground more than 60 feet, and if I remember correctly, penetrated into one of the train tunnels.
Dr. Gorgo's site identification, similar to that required of other DCs providing chiropractic care at GZ.

Dr. Gorgo's site identification, similar to that required of other DCs providing chiropractic care at GZ.

Sometime in the early-morning hours while it was still dark, I noticed a passed-out fireman lying on an I-beam. Smoke was pouring out all around him. I shook him and told him I was a doctor. I asked him to come back with me to the makeshift clinic we had made in the church. He didn’t want anything to do with me; he did not want to be taken off the pile and away from his brothers, whose rescue alarms (known as PASS devices) we could hear going off underneath the wreckage.
I expressed to him that I was chiropractor and that I might be able to help him. I brought him back to the church, assessed and adjusted him. He got a burst of energy and thanked me. Later, he sent me hundreds of patients.
Before the 7 a.m. shift started at the Javits Center, I had adjusted well over 100 people. I would eventually see patients with injuries of all types including puncture wounds, impalements, and even two heart attacks.
If you read the stories on the Internet from other chiropractors who volunteered at Ground Zero, you know they were working nonstop as well. Together, we began what I have to say was the most effective broad-based and extensively used chiropractic-only health care emergency response in this nation’s history. On top of that, it was all volunteers! The patients simply did not want to go to the medical tents. It brings a smile to my face, and I hope to yours, knowing that we did it. The police, firefighters, U.S. marshals, military police, FEMA teams, city cleanup crews, transit authority workers, engineers, city council members, and on and on chose chiropractic care. I worked on that pile until Dec. 18, 2001, and have so many memories. I’m very proud to be a chiropractor.
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In part 2 of this article (Sept. 23 issue), Dr. Gorgo recounts how he was recruited by FEMA to credential and train chiropractic volutneers, and how together, they continued to make a difference in the lives of so many in the aftermath of Sept. 11.
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Dr. Richard Gorgo Jr. is a 1996 graduate of National College of Chiropractic. He maintained a practice in Parkesburg, Pa., at the time of the WTC terrorist attacks and now practices at Baltimore Family Chiropractic in Baltimore, Md.
Visit us at All Injury Rehab for more information and to set up an appointment.

Dr. Oz on Chiropractic Treatment

Source: http://texasjournalofchiropractic.eznuz.com/

It is REPORTED HERE that “The Dr. Oz Show (http://www.doctoroz.com/) aired a segment featuring the spine and the causes of back pain. Dr. Oz explained that 80% of people experiencing back pain could benefit from visiting a chiropractor and receiving a chiropractic adjustment to the spine.”

“Dr. Oz demonstrated how the spine getting out of alignment causes pressure on the discs and nerves, which in turn, causes pain. Dr. Oz said that even simple things such as sleeping wrong or getting groceries out of the car can force the spine out of alignment.”

“Dr. Oz explained that pain medications only mask the symptoms, but do not treat the underlying cause of back pain. He also said that a misaligned spine can result in a herniated disc which causes a lot of pain and takes quite a while to heal.”

“Chiropractors restore health by the manual realigning of joints, particularly the spine. After the adjustment was given, he explained to Dr. Oz that realignment of the spine reduces interference to the nervous system and lets the body heal itself.”

“Dr. Oz has praised the benefits of chiropractic treatment before on previous shows. The majority of chiropractic clinics offer spinal and joint adjustments, massage, electrical stimulation, acupuncture, heat, cold, and exercise prescription to reduce their client’s pain.”

More of Chiropractic on Dr. Oz here http://www.doctoroz.com/question?query=chiropractic

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