topicofthemonthjanuary2007

Case Report:

A 54-year-old African American male patient suffered from low back pain and hypertensive disease. The patient has been under medical care for essential hypertension for 5 years and has been under antihypertensive drugs since to control both his systolic and diastolic pressures. Pharmacological interventions included Syniprol and Iniziode.

At presentation for chiropractic care, his blood pressure was 150/90mmHg in his right and left arm. All subsequent blood pressure measurements utilized the sphygmomanometer cuff and stetscope.

A comprehensive examination, including full series x-rays, static and motion palpation of the spine, postural analysis, orthopedic exams, and ranges of motion (ROM) of the cervical and lumbar were performed on August 2005. Upon posture analysis the subject was found to have 2cm high right shoulder. The subject had no pain upon ROM

And none of the orthopedic tests were found to be positive.

Static and motion palpation of the patient’s spine revealed tenderness and hypertonicity at C1-C3, T6, L4-L5 and right ilium. Plain film radiography showed L5/S1 facet imbrication, hyperlordotic lumbar curve and hypolordotic cervical curve.

On August 5, 2005, patient began a chiropractic care, which consisted of short lever specific contact adjustments utilizing Thompson drop table at motion segments of the cervical, thoracic and lumbar spine. Patient was given a 2 times a week schedule and was advised to eat more fruits and vegetables, low sodium and eliminate fatty foods and exercise 2-3 times/week for at least 30 minutes (walk, treadmill, stationary bike, etc.). Before and after each adjustment the patient’s blood pressure was closely monitored (Figure 1). After every adjustment, both systolic and diastolic values appeared to fall, as illustrated in Figure 1.

The patient was re-assessed on September 2005, his low back pain completely resolved and his blood pressure continued to decrease after every adjustment. The patient also had his medications reduced by his medical physician during his routine checkup in December.

Week one

Right arm Left arm

Pre-adjustment

150/92mmHg

150/91mmHg

Post-adjustment 145/88mmHg

146/87mmHg

Week two

Pre-adjustment

149/90mmHg

148/90mmHg

Post-adjustment 146/87mmHg

146/86mmHg

Week three

Pre-adjustment

144/89mmHg

143/89mmHg

Post-adjustment 135/82/mmHg 133/81mHg

Figure 1: Pre and post systolic and diastolic blood pressure mm Hg.

Discussion:

The clinical results of this case study illustrate the need for controlled investigations into the area of hypertension and chiropractic management. As follows is a critical review of the literature in understanding whether chiropractic has therapeutic effects in managing hypertensive patients.

However, before an in-depth discussion of chiropractic and hypertension can ensue, the physiological control mechanism of normal blood pressure must be addressed and understood. To maintain homeostasis of any kind we must have an afferent system, control center and an efferent system working together as a unit. In the case of blood pressure control, the arterial and cardiac baroreceptors carry afferent information, which monitor and modulate arterial pressure and sympathetic tone. On the other hand, sympathetic and parasympathetic neurons act as the control centers which make the appropriate efferent response to maintain proper blood pressure. However, patients with hypertension their arterial baroreceptors have been found to have high-pressure threshold and reduced sensitivity to pressure increases, thus, resulting in a decreased afferent input to the central nervous system and increased sympathetic activity – i.e. lose of homeostasis {1}

Several studies in the literature have observed the effectiveness of chiropractic in the management of hypertension. For instance, Plaugher and Bachman {3} studied the effects of chiropractic adjustments on blood pressure in a 38-year-old hypertensive male.

In this study, the patient received specific short lever arm adjustments, and in the course of the treatment Plaugher and Bachman concluded that the patient’s need for hypertensive drugs was reduced and eventually withdrawn by his medical physician. Thus, Plaugher and Bachman concluded that specific short lever arm adjustments can cause hypotensive effects in medicated hypertensive patients. Although, case reports have high limitations of validity in comparison to randomized clinical trials, we can still conclude from this study and our case study that chiropractic care has an effect on blood pressure, and hence, chiropractors need to closely monitor the patient’s blood pressure especially those receiving antihypertensive drugs.

Furthermore, McKnight and DeBoer {4} studied the effects of spinal manipulation on blood pressure in 53 normotensive patients. In this preliminary study, the experimental group received a single cervical chair adjustment and had their blood pressure measured before and after the adjustment. The authors observed that both the systolic and diastolic were significantly lower in the experimental group but not the control group. They also stated that substantial pre and post-adjustment changes were observed in every patient with values greater than 130/90mmHg prior to the adjustment. Therefore, supporting our conclusion that chiropractic adjustment could have a beneficial therapeutic effect in hypertensive patients, however, further controlled research studies are needed in this field.One small scale clinical trial using activator method also demonstrated the benefits of chiropractic management in high blood pressure {5}. In this study the manipulative intervention was confined to the mid-thoracic spine (T1-T5). Both systolic and diastolic values were significantly reduced. No significant changes were observed in the placebo or control group.

Clinical investigators have not only attempted to demonstrate the benefits of chiropractic management in hypertensive subjects, but they have attempted to correlate

regions of spinal facilitations in these subjects. For instance, Tran and Kirby and Miller {6} have stated that upper cervical adjustments (especially occiput-atlas level) may have the greatest influence in blood pressure regulation. The argument put forth to support this statement by the authors is that the occiput-atlas region has the greatest effect on the largest of the sympathetic trunk ganglia, the superior cervical – i.e. a structure known to have an influence on blood pressure directly or indirectly {6}. Although Tran et al. have observed that upper cervical segmental facilitation plays an important role in hypertensive subjects, Crawford et al. (7) in their review of the literature, cite two other spinal regions that appear to be related to hypertension. They are the upper thoracic region (particularly T2-T3), and the lower thoracic (T11-T12).

Although in our case study segmental facilitations were not correlated with the reduction of the patient’s blood pressure, this can be further studied to determine whether one area or the combination of many areas of the spine have the greatest influence in blood pressure regulation.

Conclusion:

After an in-depth review of the literature one can conclude that most patients with hypertensive disease may benefit from regular chiropractic care. In our case, the reduction of the patient’s both systolic and diastolic pressures post-adjustment has proven that chiropractic adjustments can cause hypotensive effects. Hence, it is advised that all hypertensive subjects who undergo chiropractic care have their blood pressure closely monitored pre and post-adjustment and medications adjusted, if necessary, by their medical physician.

One question raised by this case study concerns the long-term efficacy of the observed treatment effect. In other words, while chiropractic adjustments appear to be effective in producing temporary reduction in blood pressure immediately after treatment, the effect of such treatment in reducing blood pressure over a period of days, months or even years is unknown, and thus warrants further investigation.

In conclusion, the potential contribution of spinal manipulative therapy in the management of hypertension is greatly significant and must not be taken too lightly.

One day spinal adjustments may prove to be more effective than hypotensive drugs in correcting or modifying blood pressure. Hence, in the words of Hood: “I am convinced that there is a cause for the 28,800,000 Americans who have hypertension from an unknown origin. I am also convinced that many of the 3,200,000 cases of secondary high blood pressure are misdiagnosed and would benefit greatly from this form of treatment” {8}.