Combining Spinal Injections with Chiropractic Adjustments: A Chiropractor’s Perspective

By Brian Renner, D.C.

     B.J. Palmer, a chiropractic pioneer once said "Team work is important. Even a banana gets skinned when it leaves the bunch."  It comes particularly to mind right now in regards to a recent discussion I had with a local spine interventionist. He was discussing with me his preference to work with chiropractors in the area to help bring difficult patients out of what seems to be a “plateau” in the course of their treatment. The interventionist lamented over what he perceived to be a lack of coordination between the two specialties and how, by working together, some patients can get the most out of chiropractic care.  Over the past several decades, chiropractic medicine has gained much recognition in its effectiveness in treating spinal pain. In fact, some would say that chiropractors have evolved as the current day primary care providers for spinal pain. The field of interventional pain management has also blossomed, similarly to chiropractic care.  However, most patients come to pain management at the end of chiropractic care, when they plateau.  Perhaps, now that these two fields have matured, it’s time to consider how they might best intersect to serve patients; in other words, team work.

     Spinal injections consisting of epidural steroid and facet injections have been shown to be effective in treating back pain (1; 2). Research suggests that collaborative efforts of combining spinal injections with chiropractic adjustments may be beneficial in cases of chronic low back pain patients that have plateaued in their progress. According to Nelson et al, the use of epidural spinal injection and spinal manipulation together offers promise and “should be considered in patients who do not respond to conventional forms of care.” (3) Why might this show promise? Is it simply because the injection causes pain relief? Does it make it easier for the patient to accept the adjustment? Does it allow the patient to move with more normal movement patterns and better accept rehabilitative exercises? Actually, all of the above appear to be reasons contributing to this conclusion.

      Injectional therapy may help some chiropractic patients better receive adjustments and tolerate prescribed exercises.  I will probably always remember the drills we did in school which developed our speed at delivering the thrust for the adjustment. For a patient in pain, being controlled and quick at delivering the thrust is paramount. In fact, not only does it seem to contribute to the patient’s comfort, but it may “comprise part of the mechanism contributing to this intervention’s physiologic effects.” (4) The findings in this study suggest that the quicker the thrust, the more effective it may be. How much easier would it be to deliver a quick thrust to a spinal vertebra if the patient is not in pain? Maybe that’s actually a contributing factor to some patients’ roadblock to recovery. By utilizing injectional therapy in our plateaued patients, we could likely get through the patient’s muscle guarding and pain receptors to deliver a better adjustment.  In addition, the patient may also be more likely to perform the exercises prescribed in order to facilitate the rehabilitation process. In fact, this may actually be one of the big ways that injections help spine pain patients improve. (5)

     Injectional therapy is complementary to the anti-inflammatory effects of chiropractic manipulation. A study done in 2006 demonstrated a significant reduction in severity and duration of IVF and DRG inflammation using Activator adjustments. (6) In some patients though, injury mediated inflammation may become chronic.  What kind of outcome could we see in recoveries of these patients by combining injections, which are anti-inflammatory, as well as high-speed adjustments, which have also shown to be anti-inflammatory?  From a purely mechanistic point of view, a combined approach might well be promising.

     While little research has been done to specifically analyze the potential benefits of combining spinal injections with spinal adjustments it seems likely that some groups of patients could greatly benefit from spinal injections in combination with chiropractic care.  This would most likely benefit the patient who has reached a plateau in their chiropractic regimen and has become chronic.  Such use of injectional therapy would be in keeping with the current standard of referring patients for injections only after a lack of improvement in conservative care.  Importantly, such patients would not “fail” chiropractic care if injectional therapy returned the patient to a successful chiropractic regimen. Though the intersection of pain management and chiropractic care may not be exactly what Palmer had in mind when he discussed teamwork in the chiropractic community, the potential benefit of such team work is undeniable.

(1)    T.L. Shulte, T.A. Pietila, J. Heidenreich, M. Brock, R. Stendel. (2006). Injection therapy of lumbar facet syndrome: a prospective study. Acta Neuroshirurgica, 148(11):1165-1172

(2)    Buchner, Matthias MD; Zeifang, Felix MD; Brocai, Dario R.C. PhD; Schiltenwolf, Marcus MD. (2000). Epidural Corticosteroid Injection in the Conservative Management of Sciatica. Clinical Orthopaedics & Related Research, 375:149-156

(3)    Nelson L., Aspegren D., & Bova C. (1997). The use of epidural steroid injection and manipulation on patients with chronic low back pain. Journal of Manipulative and Physiological Therapeutics, 20(4):263-266

(4)    Sung, Paul S. PT, DHSc, PhD; Kang, Yu-Ming PhD; Pickar, Joel G. DC, PhD. (2005). Effect of Spinal Manipulation Duration on Low Threshold Mechanoreceptors in Lumbar Paraspinal Muscles: A Preliminary Report. Spine, 30(1):115-122

(5)    Robert F. McLain, MD; Leonardo Kapural, MD, Nagy A. Mekhail, MD, PhD. (2005). Epidural steroid therapy for back and leg pain: mechanisms of action and efficacy. The Spine Journal, 5(2):191-201

(6)    Xue-Jun Song, MD, PhD; Qiang Gan, MS; Jun-Li Cao, MD; Zheng-BejWang, MD; Ronald L. Rupert, DC, MS. (2006). Spinal Manipulation Reduces Pain and Hyperalgesia After Lumbar Intervertebral Foramen Inflammation in the Rat. Journal of Manipulative and Physiological Therapeutics, 29(1):5-13