Irritable bowel syndrome and spinal manipulation: a case report
Irritable bowel syndrome and spinal manipulation: a case report
ABSTRACT. This is a case study of a 25-year-old woman with chronic irritable bowel syndrome. The patient was treated by a chiropractor using spinal manipulation. The patient's symptoms were quickly alleviated during the course of treatment. A number of mechanisms for this phenomenon are suggested.
KEY WORDS: Irritable Bowel Syndrome -- Spinal manipulation -- Chiropractic
THE EFFECT OF SPINAL MANIPULATION upon visceral dysfunction is a source of controversy in the scientific world. "Where's the research?" is the battle cry of many skeptics. A common problem of the gastrointestinal system, affecting 15-20% of adults, is irritable bowel syndrome [ 1]. Also known as mucous colitis and nervous bowel [ 2], this condition is defined as "abnormally increased motility of the small and the large intestine, generally associated with stress" [ 3]. The symptoms include cramp-like abdominal pain, which is often relieved by belching or moving the bowels. There is frequently constipation or diarrhea. Some patients will also have ulcer-type symptoms such as heartburn or upper abdominal indigestion [ 4].
The exact mechanism of irritable bowel syndrome is not fully understood, but according to Christensen, irritable bowel syndrome may be caused by a variety of factors, including psychological and neurological disorders, abnormalities of the small intestines, and sensory abnormalities [ 5]. Accarino et al. concluded that "Patients with irritable bowel syndrome show selective hypersensitivity of intestinal mechanosensitive pathways associated with a non-specific, probably central dysfunction of viscerosomatic referral" [ 6].
The purpose of this case report is to point out the possible relationship between spinal manipulation and relief of irritable bowel syndrome and to suggest a few possible mechanisms for this palliative effect.
A 25-year-old woman presented in December 1993 with a complaint of intestinal pain and diarrhea. The patient said that the pain began in 1988 and that it was a sharp, deep pain lasting about 10 minutes, followed by diarrhea. She further explained that the problem was most noticeable during times of stress and occurred one to two times per week. The patient also stated that she had been treated previously by a medical doctor for this condition in France. Her doctor prescribed Spasfon (fluoroglucinal) to reduce smooth muscle contraction and Carbosylane (dimethicone with activated charcoal).
A complete physical exam was performed, which ruled out organic disease as a cause of these symptoms. This patient's lab results were unremarkable and her blood pressure, pulse, and respiration were all within normal ranges. Upon visual examination, the patient had a right head tilt and right low ear. Her right shoulder, scapula and hip also appeared to be low. The patient was found to have a positive Adam sign, which reveals a possible functional scoliosis. A positive Jackson's test on the left of C7 indicated possible foraminal encroachment. She also had a positive Derifield test on the left leg, which perhaps indicated an unlevel pelvis. Radiographic analysis revealed a slight dextrorotary thoracolumbar scoliosis, with the apex at T12. The treating physician developed a working diagnosis of chronic irritable bowel syndrome and a treatment plan as follows: adjust indicated areas twice per week for 3 weeks, then reevaluate. Treatments were to begin after the holidays.
When the patient was treated for the first time, the physician observed fixations at C1, T1, T9, and L1. The T1, T9, and L1 segments were manipulated with the patient in a prone position. The thrusts were directed posterior-to-anterior with contacts on the transverse processes of T1 and T9 and on the mammillary process of L1. The C1 segment was manipulated with the patient supine. The thrust was directed posterior-to-anterior and slightly right-to-left with a contact on the right transverse process of C1. The patient returned 2 days later and stated that she had not experienced any diarrhea since her first treatment. Her spine was manipulated again and she returned the next week and claimed she still had not experienced any diarrhea. The patient then continued treatments approximately once a month to insure that the fixations, as outlined above, were no longer a problem. She had not complained of any of her previous bowel symptoms.
There are a number of mechanisms that one might cite to explain a link between the vertebral column and the gastrointestinal system. Mayer explains that the
changes in the threshold and/or gain of the viscerosensory system (peripheral and/or central) will provide a distorted representation of the triggering event (contraction, distention, inflammation) or even worse, can provide unpleasant or inappropriate sensory experiences in the absence of any physiological or pathophysiological event [ 7].
Accarino et al. further offer "that the small bowel in patients with irritable bowel syndrome is affected by a selective hypersensitivity to mechanical but not to electrical stimuli, suggesting a specific dysfunction of mechanosensitive afferents" [ 6]. Wiles revealed that "manipulation to the first cervical vertebra was associated with an increase in the basic gastric tone" [ 8]. It was also noted that "efferent activity of the gastric vagi was responsible for the gastric motility facilitation" [ 8]. The vagus nerves pass just posterior to each transverse process of C1. These nerves supply the stomach and other visceral organs with parasympathetic innervation. It is possible that if an adjustment to C1 can relieve irritation of a vagus nerve, then gastric and bowel motility may be restored to its normal state and, thereby, the symptoms of irritable bowel syndrome may be relieved.
Many chiropractors have noted successful treatment of irritable bowel syndrome while adjusting the lumbar spine, especially L1 and L2 segments. This may be effective because the nerve supply emanating from these segments innervates the colon via the inferior mesenteric ganglion [ 9]. If these nerves are irritated or compressed because of vertebral dysfunction or malposition, then abnormal colonic activity could occur. Thus, manipulating these segments may theoretically relieve the facilitation response, resulting in normal bowel activity.
Stress has been strongly associated with irritable bowel syndrome [ 9]. Another possible theoretical mechanism for symptomatic relief may be simply that spinal manipulation relaxes the patient and therefore attenuates some of the stress, leading to a lessening of symptoms.
This case exhibits a possible link between spinal manipulation and relief of the symptoms of irritable bowel syndrome. There are many possible mechanisms that could account for this link between the nervous system and visceral dysfunction. Three possible mechanisms that may cause symptoms of irritable bowel syndrome include a fixation at C1 affecting the vagus nerve, a fixation at L1/L2 affecting their emanating nerves, or life stresses affecting the bodily function. The fact that some cases of this disease may be treated successfully through chiropractic care is worthy of further evaluation.
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8. Wiles MR. Observations on the effects of upper cervical manipulations on the electrogastrogram: a preliminary report. J Manipulative Physiol Ther 1980;1:226-9
9. Lawrence DJ. Fundamentals of chiropractic diagnosis and management. Baltimore: Williams & Wilkins, 1991: 197
The National College of Chiropractic.
By Trevor Wagner; Julie Owen and Earl Malone