Improvement of GERD Following Chiropractic Care: A Case Study and Selective Review of Literature __________________________________________________________________________________________ ________________________________________________________________________________________________________ Introduction Gastroesophageal reflux is a condition in which the stomach contents flow back up into the esophagus. When reflux becomes long lasting or chronic (more than twice a week for a few weeks) this is a sign of gastroesophageal reflux disease (GERD). 1 The most common symptoms associated with GERD are heartburn, acidic taste in mouth, and regurgitation. Some lesser common symptoms include chest pain, chronic cough, recurrent laryngitis, and subglottic stenosis. 2-3 Heidelbaugh et al estimate that 44% of the US population suffer from heartburn or gastroesophageal reflux symptoms at least once per month, 14% suffer weekly, and 7% have symptoms daily. 3 Jarosz et al explain the pathophysiology behind GERD as, most commonly, “transient relaxation” of the lower esophageal sphincter (LES), increased intra- abdominal pressure resulting in breach of the LES, medication use (primarily calcium channel blockers), and hiatal hernia. 2 There is currently no gold-standard for the diagnosis of GERD. When the classic symptoms of heartburn and acid regurgitation are present a diagnosis can be made with high specificity but low sensitivity. The accepted standard is 24-hr pH monitoring that has 70%-96% sensitivity and specificity ratings, however, false-positives and false-negatives are possible. 3 Treatment of GERD is typically patient directed in mild to moderate cases through the use of over-the-counter antacids. When symptoms are more severe or frequent medical opinion Abstract Objective: This case report will describe the management of a patient with gastroesophageal reflux disease (GERD) by means of Gonstead chiropractic care. Clinical Features: A 37-year-old male presented with a two-year history of GERD, mid-thoracic pain, as well as cervical and thoracic vertebral subluxations. Lateral radiographs of the thoracic spine revealed intervertebral osteochondrosis at the mid-thoracic vertebrae. Intervention and Outcome: High velocity, low amplitude (HVLA) spinal adjustments were utilized (Gonstead technique). The patient received 12 adjustments over the span of 3.5 months that consisted primarily of HVLA adjustments to specific cervical and thoracic vertebrae. The patient experienced a reduction in frequency of GERD symptoms and vertebral subluxations following the introduction of Gonstead chiropractic care. The patient was able to maintain a care-free diet and remain asymptomatic. Conclusions: A patient suffering from GERD had successful management under Gonstead chiropractic care. The patient reported both quality of mental and physical health as improved and is currently satisfied with his condition. This case study helps validate that further research for chiropractic adjustments and its benefits to those suffering from GERD is warranted. Key Words: Chiropractic, Subluxation, Gonstead, Adjustment, Spinal Manipulation, Heartburn, GERD, Dyspepsia, Acid Reflux Jonathan Madill, D.C. 1 1. Private Practice of Chiropractic, Johnson City, TN Case Study GERD A. Vertebral Subluxation Res. July 11, 2016 53
Transcript
Improvement of GERD Following Chiropractic Care: A Case Study and Selective Review of Literature __________________________________________________________________________________________
Gastroesophageal reflux is a condition in which the stomach
contents flow back up into the esophagus. When reflux
becomes long lasting or chronic (more than twice a week for a
few weeks) this is a sign of gastroesophageal reflux disease
(GERD).1 The most common symptoms associated with
GERD are heartburn, acidic taste in mouth, and regurgitation.
Some lesser common symptoms include chest pain, chronic
cough, recurrent laryngitis, and subglottic stenosis.2-3
Heidelbaugh et al estimate that 44% of the US population
suffer from heartburn or gastroesophageal reflux symptoms at
least once per month, 14% suffer weekly, and 7% have
symptoms daily.3 Jarosz et al explain the pathophysiology
behind GERD as, most commonly, “transient relaxation” of
the lower esophageal sphincter (LES), increased intra-
abdominal pressure resulting in breach of the LES, medication
use (primarily calcium channel blockers), and hiatal hernia.2
There is currently no gold-standard for the diagnosis of
GERD. When the classic symptoms of heartburn and acid
regurgitation are present a diagnosis can be made with high
specificity but low sensitivity. The accepted standard is 24-hr
pH monitoring that has 70%-96% sensitivity and specificity
ratings, however, false-positives and false-negatives are
possible.3
Treatment of GERD is typically patient directed in mild to
moderate cases through the use of over-the-counter antacids.
When symptoms are more severe or frequent medical opinion
Abstract Objective: This case report will describe the management of a patient with gastroesophageal reflux disease (GERD) by means of Gonstead chiropractic care. Clinical Features: A 37-year-old male presented with a two-year history of GERD, mid-thoracic pain, as well as cervical and thoracic vertebral subluxations. Lateral radiographs of the thoracic spine revealed intervertebral osteochondrosis at the mid-thoracic vertebrae. Intervention and Outcome: High velocity, low amplitude (HVLA) spinal adjustments were utilized (Gonstead technique). The patient received 12 adjustments over the span of 3.5 months that consisted primarily of HVLA adjustments to specific cervical and thoracic vertebrae. The patient experienced a reduction in frequency of GERD symptoms and vertebral subluxations following the introduction of Gonstead chiropractic care. The patient was able to maintain a care-free diet and remain asymptomatic. Conclusions: A patient suffering from GERD had successful management under Gonstead chiropractic care. The patient reported both quality of mental and physical health as improved and is currently satisfied with his condition. This case study helps validate that further research for chiropractic adjustments and its benefits to those suffering from GERD is warranted. Key Words: Chiropractic, Subluxation, Gonstead, Adjustment, Spinal Manipulation, Heartburn, GERD, Dyspepsia, Acid Reflux
Jonathan Madill, D.C.1 1. Private Practice of
Chiropractic, Johnson City, TN
Case Study
GERD A. Vertebral Subluxation Res. July 11, 2016 53
is warranted proton pump inhibitors (PPI) have emerged as the
gold-standard by medical doctors.4 This is due to randomized
controlled trials that proved PPIs to be more effective than
both histamine type-2 receptors antagonists (H2Ras) and
placebo.2 Even though these are accepted safe methods of
treatment they are only designed to create temporary relief of
symptoms.4 Lifestyle modifications are suggested as well
although there is currently no supporting evidence. In a
clinical trial for alternative treatment, Dickman et al showed
that including acupuncture with a typical PPI dosage had
further benefits then PPI alone or a double-dose PPI regimen.5
Hayden et al found that only 3.8% of the population utilized
alternative medicine, herbal medicine mostly, for GERD-
related symptoms.6
The purpose of this paper is to add evidence to the alternative
treatment of GERD by reporting on the successful
management of GERD by chiropractic adjustments without
dietary or lifestyle adjustments.
Case Report
Patient History
A 35-year-old male presented with a two-year history of
GERD associated with mid-back pain. The patient’s
symptoms were made worse by awkward postural movements,
twisting motions of the thorax, left side lying with left arm
extended above head, large meals, fried foods, spicy foods,
and alcohol. He stated he had symptoms of heartburn, acid
rising feeling, headache, tooth/jaw ache, cough and dizziness
associated with the mid-thoracic pain. The patient was
diagnosed with GERD by his family practitioner and
prescribed Prilosec (q.d). It should be noted that the patient
maintained a vegan diet during this period consisting mostly
of lentils, beans, rice, quinoa, oats, vegetables, fruit and water.
The patient stated that OTC antacids did not work effectively
and made him feel “weird”; at this time he sought out
alternative treatment.
Prior to undergoing our care he saw two different
chiropractors over a 10 month period who utilized Diversified
technique for a total of 35 adjustments. He noted relief after
each adjustment for approximately one week at a time, no
longer needed his medications, and was able to introduce meat
and alcohol back into his diet without setting off reflux
symptoms. At times, an awkward movement would cause
back pain and set-off GERD symptoms (“very quickly”)
requiring an adjustment in between his scheduled times. His
stress levels were rated low, 2/10 on a daily level (scale from
0-10 with 0 being no stress and 10 being maximum stress).
Past history showed no tobacco or recreational drug use, and
no previous surgeries, accidents or hospitalizations. A review
of systems disclosed no further issues.
Examination
Physical examination exposed the following information.
Initial instrumentation, utilizing the ETS-6 Nervoscope,
revealed “breaks” at C7, T6, and T11 vertebrae with the most
serious deflections at C7 and T6 (≥0.5°C).
Motion palpation in the lower cervical and mid-thoracic
regions found motion restrictions in flexion and left rotation at
C7 along with spinous tenderness; flexion and right rotation
restrictions at T6 along with marked spinous tenderness. T11
was found to be within normal limits of intersegmental motion
despite spinous tenderness upon palpation.
AP and lateral thoracic radiographs were obtained. Typical
Gonstead protocol is to take 14x36” Full Spine films but due
to recent cervical radiographs only thoracic films were
ordered. C7 was found to be posterior and inferior (extension
malposition) in relation to T1 as demonstrated after analysis of
the previously taken lateral cervical film. The lateral thoracic
film (Fig. 1) showed significant decrease in disc space with
concomitant bony proliferation at the T8-T9 level indicating
intervertebral osteochondrosis at this level. The T5 vertebra
was found to be posterior and superior (extension malposition)
in relation to T6. The AP thoracic radiograph (Fig. 2)
portrayed a left list measuring 7.4°, apex at T5, with
associated right lateral flexion malposition at this level.
Intervention and Outcome
The patient was switched to the Gonstead method of analysis
for vertebral subluxation correction. This consisted of static
palpation, motion palpation, x-ray analysis, and
instrumentation at each visit to determine the presence of
vertebral subluxation and when present, a specific high
velocity, low amplitude thrust would be administered. The
thrust favors a posterior-anterior line of drive and avoids
rotational vectors while simultaneously avoiding thrusts into
hypermobile compensations.7
The instrumentation device used was an ETS-6 Nervoscope, a
dual-probe thermometric instrument. Two input detectors lead
into a micro-voltmeter in which the voltmeter needle is drawn
to the side of greater temperature when gliding down each side
of a patient’s spine. The amount of needle deflection is
directly proportional to paraspinal temperature difference.8 A
“break” in thermography is suggestive of local autonomic
nervous system dysfunction or local changes due to
inflammation and the resultant production of heat.7
On the patient’s first visit, clinical indications of vertebral
subluxations were found at C7 and T5. These findings were
supported by x-ray analysis and were found to be fixated in a
posterior, right rotation and posterior, left rotation
misalignment respectively (referenced to vertebral body). The
C7 subluxation was corrected using a Gonstead cervical chair
movement. For this correction the patient is seated in a chair
with legs slightly extended (feet still resting on floor), hands
open and supinated on patient’s lap. This patient placement is
used to aid in the relaxation of the posterior cervical
musculature. A specific contact using the distal, lateral tuft of
the intern’s right index finger on the patient’s right C7/T1
zygapophyseal joint was taken before a thrust in the posterior-
anterior, inferior-superior, and lateral-medial direction was
given following the disc plane line of the C7/T1 intervertebral
disc. The T5 subluxation was corrected using a Lloyd Galaxy
Stationary table, thoracic piece released to allow the spine to
go into extension, and the patient lying in the prone position.
A contact was made with the left hand (specifically the fleshy
54 A. Vertebral Subluxation Res. July 11, 2016 GERD
pisiform region) over the left transverse process of T5 with
intern standing on the patient’s left. A thrust was delivered in
the posterior-anterior, inferior-superior, and lateral-medial
direction once again following the disc plane line of the T5/T6
intervertebral disc. This exact adjusting procedure was carried
out in its entirety or by a cervical or thoracic correction alone,
depending on subjective and objective findings, during each
patient visit.
The patient was scheduled to be seen once per week with re-
assessments every 45 days. The first adjustment was tolerated
well by the patient. Due to lack of symptomatology the
patient was not adjusted again for 2 ½ weeks. He presented
again with 1/10 mid-back pain (on a scale from 0-10 with 0
being no pain and 10 being excruciating pain) and a slight
sensation of reflux. Patient was adjusted and noted relief of
reflux sensation after one day. He presented for care a week
later and there were no clinical indications for a thoracic
adjustment and patient was asymptomatic for GERD, a
cervical subluxation (C7) was found and corrected. Before his
next visit the patient stated his dog leaped on his neck causing
an evasive maneuver that “tweaked” his back, created mid-
thoracic pain rated at 2-3/10 and slight sensation of heartburn.
A thoracic subluxation was found then corrected.
The patient was seen on a regular weekly schedule for
adjustments seven times with relief of symptoms for an
average of one week at a time. There was a four-week break in
care and the patient noted no major heartburn issues during
this time. He shared that he felt his back “go out” during a
workout after his previous adjustment but the heartburn
sensation did not follow which was atypical as this would
have normally caused symptoms of GERD to onset quickly.
The patient received two adjustments (a week apart) that
relieved current, mild reflux symptoms. Over the final four
visits, spanning the course of six weeks, the patient noted zero
instances of heartburn, reflux or similar. The cervical spine
was adjusted solely twice, thoracic spine adjusted solely once,
and both were adjusted once over the last four visits. In total,
the patient received 12 adjustments in 3.5 months. The patient
was compliant with his care schedule.
At the time of this writing the patient had not been under
chiropractic care since that final adjustment (a time frame of
approximately three months). He stated that currently and
while under care he was able to eat whatever pleased him.
This includes large meals, spicy food, and alcohol (primarily
beer and liquor). The patient was asked to fill out a GERD
Impact Scale form (GERD-IS) and a GERD Health related
Quality of Life form (GERD-HROL) both in retrospect to
receiving chiropractic care and currently after completion of
care (Table 1 & 2 respectively).9-10 The GERD-IS showed
improvement in all categories from “often” before beginning
care to “never” or “sometimes” after completion of care. The
GERD-HROL originally ranged from 3-5/5 (mostly 4-5/5) and
showed that the patient was on OTC antacids (Prilosec as
prescribed by family physician) and dissatisfied with current
condition. After completion of care the patient scored this
same assessment 0/5 in all categories, is now satisfied with
current condition, and is no longer taking OTC antacids. See
the tables 1 & 2 below for a complete breakdown.
Discussion
Review of Literature
A literature search in the Index for Chiropractic Literature for
full text, peer reviewed articles containing the keyword
“GERD” revealed a total of 13 results and “dyspepsia” found
10 articles. A search in the journals contained within McCoy
Press for keyword “GERD” found 7 results and “reflux” found
27 results. Many of these articles from both sources included
the care of children and per the case report presented of a
middle-aged male were irrelevant to the topic at hand.
Therefore, only those articles containing individuals over the
age of 18 (typical age skeletal maturity) were included in the
review of literature.
Lerner and Lerner reported on the case of a 51-year-old
female suffering from GERD. The patient had seen multiple
providers in the past and was on Advair for asthma and Zegrid
for the GERD. The patient was determined to have postural
abnormalities, spinal osteoarthritis, asthma, scoliosis and
multiple vertebral subluxations. The chiropractors utilized
Pettibon and Diversified adjusting techniques and saw the
patient a total of 105 visits to date. A healing diet was also
incorporated involving removal of grains (except for rolled
steal oats), and sugars; after a period of 9 months fruits and
select grains were allowed back into her diet. After 12 visits
the patient reported a decrease in pain levels throughout her
body and was able to reduce the frequency of her GERD
medication to every other day. Eventually she was able to stop
taking the Zegrid entirely.11
Young et al in a letter to the editor wrote in regards to a pilot
study involving chiropractic care for the intervention of
chronic adult dyspepsia. It was a cohort study involving a
single practitioner and a convenience sample of 83 subjects.
There complaints were pain of digestive origin in central chest
or epigastric region of more than two years in duration. The
practitioner utilized spinal manipulation therapy and soft
tissue techniques, the names of which were not mentioned.
The results showed an improvement in the average severity of
symptoms in 59 of the 83 subjects. 24 had no change, and 0
subjects complained of worsening symptoms. Further, in
regards to frequency, 69 reported a reduction and the
remaining 14 reported no change. When it came to medication
types, 37 patients reported the downgrade of class and/or style
of drug use, 45 reported no change in drug use, and one
patient upgrade from antacids to PPI. The authors believe the
study to show that chiropractic management can have a highly
significant positive impact on GERD symptoms.12
Hains et al published a preliminary study on the effects of
chiropractic spinal manipulative therapy (SMT) and ischemic
compression to the upper two quadrants of the abdomen for
treatment of GERD. The study contained 62 subjects ranging
from 20-60 years of age with mild to severe symptoms of
GERD. They were divided into three groups consisting of a
SMT group, ischemic group, and a combination of both
modalities group. The patients were asked to report changes in
GERD using a self-rating questionnaire regarding severity of
symptoms and another regarding affect on social activities.
The patients took these questionnaires after 10 treatments, 20
treatments, 1-month follow-up, and at a 6-month follow up.
GERD A. Vertebral Subluxation Res. July 11, 2016 55
The results showed that 39% of the combination group
reported improvement after 10 treatments, 66% after 20
treatments, 73% at the 1 month follow up, and 57% at the 6-
month follow up. The SMT group had improvement in 39%
after 10 treatments, 40% after 20 treatments, 38% at the 1-
month follow up and 71% after an additional 20 treatments
consisting of ischemic compression. The ischemic
compression group reported an improvement of symptoms in
44% after 10 treatments, 65% after 20 treatments, 63% at 1-
month follow up, and 67% at 6-month follow up. The authors
concluded that both SMT and ischemic compression were
found to be beneficial to those suffering with GERD, however,
ischemic compression alone was more effective than SMT
alone.13
A case of a 41-year-old female with chronic gastroesophageal
reflux by Fedorchuk and Bernard was reported. The patient
was also suffering from mid-back pain and vertebral
subluxations. HVLA Diversified adjustments and
Chiropractic Biophysics (CBP) were utilized for treatment. At
home exercises of extension traction were assigned.
Furthermore, the Antigen Leukocyte Cellular Antibody Test
(ALCAT) procedure and dietary plan was introduced to the
patient. After a year of care the GERD symptoms and mid-
back pain had reduced from daily to once per week. She
introduced the ALCAT diet and eliminated all foods in the
minimal to severe sensitivity categories. Over the following 6
months while getting adjusted once per week she reported a
complete resolution of GERD symptoms as well as mid-back
pain. The patient’s shod-form 36 showed a 56% improvement
in quality of life since she began chiropractic care. A
detrimental factor to this case study was a reported motor
vehicle accident involving the patient shortly after beginning
care, this could be a mitigating factor to the length of time for
complete resolution to occur. This report helps show that
further research into chiropractic and GERD is warranted.14
Intervention
Motion palpation is highly utilized in the Gonstead system of
analysis to assess for end-feel range of intersegmental motion
to help determine a level of vertebral fixation. In the hierarchy
of the technique, motion palpation is third after
instrumentation (thermography) and digital palpation for
determining the “right place” to adjust.7
Lakhani et al performed a randomized control trial to help
determine the specificity, sensitivity, and etiologic fraction (%
of cases with end-feel improvement [EFI] attributable to
SMT). Their blinded, randomized-placebo pilot trial consisted
of 20 symptomatic and 10 asymptomatic patients from a
chiropractic teaching clinic. The placebo utilized was detuned
ultrasound and treatment was SMT. The results showed that,
for symptomatic patients, motion palpation to determine end-
feel improvement after SMT had an etiologic fraction of 78%,
sensitivity of 90%, and specificity of 80%. For the
asymptomatic group the etiologic fraction was 40%,
sensitivity 100%, and specificity 40%. They concluded that,
especially for symptomatic patients, motion palpation appears
to be a responsive assessment tool for determining whether
perceived lack of motion prior to therapy is improved after
SMT.15 Another study performed by Cooperstein et al showed
an increased examiner concordance than what previous studies
had suggested in regards to motion palpation of the cervical
spine.16
Instrumentation has been used by chiropractors almost since
its inception by BJ Palmer. Dossa Evans, in 1924, introduced
the Neurocalometer and it is widely used throughout many
techniques still prominent today in varying forms17. The
Gonstead-system utilizes a surface thermography instrument,
similar to the Neurocalometer, known as a Nervoscope. It is
said that practitioners utilizing Gonstead technique use
instrumentation to determine the “right time” to adjust as it
confirms nerve interference and if there is no pressure on the
nerve than an adjustment is not necessary.7
Owens et al studied the reliability of skin temperature
scanning between practitioners and found that the intra class
correlation (ICC) coefficient ranged from 0.918 to 0.975. The
intra-examiner reliability found from the study was higher as
the coefficient ranged from 0.953 to 0.984. The authors state
that changes seen in thermal scans, when performed properly,
were most likely due to physiological change and not
equipment fault.18
McCoy et al found similar results in a more recent study using
a different commercially available infrared scanner.19 Diakow
et al looked for the correlation between thermography and
spinal dysfunction. Their results found that the highest
correlation between thermography and fixation was 64.7% and
that most thermographic abnormalities found were
hyperthermic. In a few instances when hypothermic
abnormalities were found they were adjacent to hyperthermic
regions. The authors concluded that there is convincing
evidence of thermography providing objective verification of
segmental dysfunction.20
McCoy performed a review of literature that included the
clinical meaningfulness of thermography. He discovered
several studies by Hart that compared thermal scans to health
perception (utilizing SF-12) and a decreased perception in
mental and physical health with higher thermal pattern
calculator (TPC) results. Further, it was uncovered that
osteopaths are studying the effect of thermography and found
that temperature imbalances in the spine are correlated to a
lower quality of life.21-23
The adjusting style associated with the Gonstead system was
created by Clarence Gonstead who developed the technique
over his entire lifetime. He was known to work 6+ days per
week for 16 hours or more per day. He was highly respected
and known for creating many instruments, the knee-chest
table, and developing the “disc concept” utilized by many
chiropractors. In the Gonstead system, a subluxation is defined
as a vertebral misalignment that causes nerve interference, and
more specifically, the misalignment of the facets (causing
nerve interference) is directly caused by misalignment of the
intervertebral disc. The adjusting maneuvers are HVLA
thrusts focusing mainly on the posterior-anterior line of
correction while avoiding rotational thrusts. The thrust is
delivered to move a vertebral bone to a more normal position
and that a single, solid sound is evidence of a better
adjustment over the “rattle” typically heard with
manipulation.7 Currently, approximately 59% of chiropractors
utilize Gonstead techniques in one form or another.24
56 A. Vertebral Subluxation Res. July 11, 2016 GERD
Conclusion
A 35-year-old male presented for care with mid-back pain and
gastroesophageal reflux disease. The patient suffered with
these symptoms almost daily and was taking Prilosec to
control condition. He received 10 months of Diversified
chiropractic care and obtained temporary results of
approximately one week at a time and was able to control
condition without medication. After commencement of
Gonstead chiropractic care the patient noted length of relief of
symptoms to increase. In 3.5 months and 12 adjustments the
patient had resolution of GERD symptoms and improvement
in quality of life. As of the time of this writing the patient has
not been under the care of any health provider and is still
asymptomatic.
The limitation of this case report is that it was a single subject
study. This study is unique in that lifestyle or dietary changes
were not incorporated as part of the treatment plan. The study
also points to the importance of specific chiropractic care. It
serves as evidence to chiropractic care for visceral and
somatovisceral conditions not typically treated through an
alternative means. Further research is warranted consisting of
observational studies, randomized control trials, and double
blind studies. This would help show the relevance of
chiropractic care and the potential successful management of
GERD.
References
1. National Digestive Diseases Information Clearinghouse.
