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The organisation of the stress response, and its relevance to chiropractors: a commentary
Katie Hardy1 and Henry Pollard1,2
1 ONE Research Foundation, Encinitas California, USA
2 Macquarie Injury Management Group, c/o PO Box 448, Cronulla NSW, 2230, Australia
author email corresponding author email
Chiropractic & Osteopathy 2006, 14:25doi:10.1186/1746-1340-14-25
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Neuromuscular disorders
Predictable disorders such as low back pain, tension headache and even rheumatoid arthritis may be a result of repeated activation of postural musculature during chronic flight-or-flight responses [88]. Jacobson [89] first argued that proprioceptive impulses could be found in conditions of high musculoskeletal tension. It was hypothesized that if such tension was combined with high levels of sympathetic activity, it could contribute to anxiety reactions. Krantz et al. [90] investigated different physiological responses to stress, as well as surface electromyography of the trapezius muscle. They found significant association between sympathetic arousal and electromyography activity, which is of importance when understanding the relation between musculoskeletal disorders and stressful situations. This is of particular interest in the treatment of work-related pain disorders in psychosocial stress syndromes as they may cause the development of pain disorders [91,92]. Therefore, chiropractors may require additional interventions to manage all aspects of chronic pain syndromes presenting to them. Combined psychological and manual interventions may provide the most appropriate healing of chronic conditions of the musculoskeletal neurohormonal systems commonly associated with chronic stress and disease. Further research is needed on the physiological and psychological effects of stress and its manifestation on the musculoskeletal system, as well as the effects of manipulative treatment on physiological and psychological functions. Emphasis should be given to the potential measurement of the stress response on various bodily systems after the application of manipulative therapy in normal and disease states.
Relevance to chiropractic
Chiropractors treat conditions of a neuromusculoskeletal and non-neuromusculoskeletal nature [93]. The majority of conditions treated by chiropractors are neuromusculoskeletal [94]. Much controversy exists about the role of chiropractic in the management of the non-neuromusculoskeletal conditions [95]. These non-neuromusculoskeletal conditions are sometimes referred to as "type O" conditions and the neuromusculoskeletal conditions are sometimes referred to as "type M" conditions. To justify the relevance of the management of the "type O" condition, the chiropractic profession has usually cited the presence of the somatovisceral and viscerosomatic reflexes as being integral to both the cause and potentially the management of the "type O" disorder [96,97]. Despite this dependence on the existence of these reflexes to justify a philosophical approach to management, little evidence exists to warrant the continued support of this justification.
The literature supports the existence of somatovisceral and viscerosomatic reflexes [98-100], but there is little or no evidence to support the notion that the spinal derangements (often referred to as subluxations by chiropractors) can cause prolonged aberrant discharge of these reflexes. Equally unsupported in the literature is the notion that the prolonged activation of these reflexes will manifest into pathological state of tissues, and most relevantly, that the application of spinal manipulative therapy can alter the prolonged reflex discharge or be associated with a reversal of the pathological degeneration of the affected reflexes or tissues [101,102]. The evidence that has been amassed is largely anecdotal or case report based [102-104] and it has attracted much intra disciplinary debate [102,105,106] because of its frequent association with certain approaches to management (largely described as being traditional or "philosophical" in nature).
Traumatic stress of a physical nature is known to manifest in changes to limbic, memory and other relevant stress centres in the brain including the hypothalamus and pituitary [107]. Whilst still controversial in management and diagnosis [108] conditions such as post traumatic stress disorder may be the linking mechanism for the manifestation of psychosocial variables often noted by chronic pain researchers [109-113]. If this supposition is true, would a purely mechanistic treatment approach be appropriate for its cost effective management?
Despite prolonged debate, very little consideration has been given to other potential mechanisms (and solutions) for the presence (and resolution) of the "type O" condition. A recent review has detailed that the somatovisceral reflex is a short term effect (millisecond to seconds in duration) when compared to supraspinal influences on the spinal cord which can be weeks to months in duration [102]. The review reasoned that the chiropractic profession should consider supraspinal factors in the generation and management of chronic pain states [102]. This conclusion is particularly pertinent on the now known association of psychosocial variables in chronic pain and disease [102], and the fact that many of the conditions treated by chiropractors whether type O or M are of a chronic nature [95]. However, the call to look at non-spinal non mechanical aspects of management has not been well received by the profession to date as evidenced by the continued predominantly mechanistic approach to management.
Chronic pain is associated with stress [114]. It is a matter of fact that stress can affect multiple systems within the body [115], including the neuromusculoskeletal system ("type M" disorders) [101] and the non-neuromusculoskletal systems ("type O" disorders) [101].
As with all homeostatic function, individual functions often have an optimum range of function outside of which function is decreased or becomes pathological. Thus, it is plausible that too little or too much of a particular function may be detrimental to the optimal function of the organism. Chronic stress is associated with abnormal organ function and the presence of disease [116,117]. Removal of stress has been shown to rehabilitate stress induced disease [118]. Can the chiropractic treatment (spinal manipulative therapy or adjustment) reduce stress levels as a potential mechanism for improvement of the "type M" or "type O" disorders? Are the newer techniques such as neuroemotional technique [119] that incorporate elements of cognitive/behavioural principles, Pavlovian conditioning and repetition compulsion with spinal manipulative therapy effective in altering stress associated with stress related disorder? Is any potential reduction associated with peripheral or supraspinal mechanisms of action? Can the profession adapt to its primarily mechanistic paradigm to truly incorporate the biopsychosocial model of disease first proposed by Engel in the 1970's [120].
Stress as a mechanism of system wide disease
It seems reasonable to examine physiological systems involved in the processing of symptoms such as pain in the many conditions reported to be managed by chiropractic intervention strategies. Whilst the somatoviseral reflex has been used as an example of a possible mechanism for the cause and management of these conditions, the scope of conditions that cannot be addressed by this mechanism is still large. We contend that a higher centre system impacting on the spinal cord could better explain the diversity of conditions.
In doing so, a consideration should be given to the role of psychosocial variables resulting from the stress of various events including trauma [121]. Findings from animal studies have interestingly suggested that hormones of the HPA axis, pain-processing pathways, and autonomic nervous system may be underlying peripheral as well as central substrates of chronic pain and broad system dysfunction [122,123]. Traumatic physical or psychological stress can have enduring impact on functioning of these systems, and chiropractors manage conditions incorporating elements of these systems [124]. An impaired HPA axis could serve as a physiological mechanism of medically unexplained symptoms as well as function as a mediator between psychological distress and observed symptoms [125].
Chiropractic management of non-musculoskeletal conditions
Chiropractic management strategies have been used to manage or co-manage a number of non-musculoskleletal, non-malignant conditions. The pubmed database was searched in June of 2006 with the terms "chiropractic" and "case" and returned more than 589 hits. Of these, more than 40 related to non-musculoskeletal care. Some examples included: Ehlers-Danlos syndrome [126], gastroesophageal reflux [127], cervical spinal cord compression[128], congestive heart failure [129], asthma [130], cervical dystonia [131], ulnar tunnel syndrome [132] and myaesthenia gravis [133]. Unfortunately more examples of complications were returned in the pubmed database with this search string than there were examples of non-musculoskeletal treatment. The ratio appeared to be at least 3 to one.
By contrast, 416 hits were returned from the same search string on the Index to Chiropractic Literature database (ICL). There appeared to be fewer reports of negative outcomes, and the scope of the reports appeared just as broad as that presented on the Pubmed databases. Some examples include: otitis media [134], post polio syndrome [135], urinary incontinence [136], Dejerine-Roussy syndrome [137] and infantile colic [138].
It appears that the two databases present very different perspectives based on the content of their contributing journals, one (Pubmed) largely a medical database and the other largely chiropractic (ICL). This differential may explain and or reflect the different perspectives that chiropractors hold with regard to the management of non-musculoskeletal conditions when compared with their medical counterparts.
As mentioned previously, chiropractic often postulates the somatovisceral reflex as being the vehicle for the changes noted in the above conditions [101]. However, less speculation is given to the potential role of supraspinal or cortical processes in the etiology and management of such conditions. As a large body of research currently supports the role of psychosocial variables in the generation and maintenance of disease [139-145], chiropractic should look to this research to potentially explain some of the clinical observations being made and recorded in the journals.
A review by Siegrist and Marmot discusses psychosocial variables as causative, aggravating, and perpetuating factors for the stress response, as well as stress implicating elevated psychosocial variables [146]. The stress response has been associated with the propagation of numerous disorders including: dermatological [147], cardiovascular [148,149], diabetic [150], Hepatic [151], immune [152], thyroid [153], gastrointestinal [154,155], reproductive [156-158], renal [159], metabolic [160], rheumatic [161] and musculoskeletal [162,163].
Future studies could utilize a randomized controlled trial design and measure variables such as: self reported levels of pain, disability, anxiety, depression, as well as objective blood and urine based measures of stress including: proinflammatory cytokines (TNF-alpha, IL-1, IL-6, IL-8, IL-18) [121,164,165] and anti inflammatory cytokines such as IL-4 and IL-10 [122,165,166]. These tests could be cross-referenced to the expression of collagen expressed in the inflammatory reaction frequently associated with chronic disease. Research designs such as the above would provide information on the effect of chiropractic management on subjective variables of pain as well as objective measures of stress and provide insight into the mechanism of action. It is only with similar studies can the association of stress be investigated thoroughly and its relevance to chiropractic measured accurately.
Conclusion
Sufficient evidence exists to consider stress and its mechanism, in the generation of diseases often seen by chiropractors. To date little investigation of this potential mechanism of disease and treatment has been conducted by the chiropractic profession. In a time when peak chiropractic organizations are calling for a mind-body approach to the management of chronic musculoskeletal and non – musculoskeletal disease [165], due consideration of the body of neurobiological evidence that supports the broadening of the operating paradigm within chiropractic seems warranted. Despite the call for a broadening of approaches and the embrace of such approaches by groups within chiropractic, it appears the threat to the dominant paradigm appears too great for most to adapt. The profession should consider more closely the emerging areas of study such as psychoneuroimmunology and how the development of that literature actually supports a broadening of the dominant mechanistic paradigm to reflect recent advances in science.
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