As you may already know, Dr. Joseph Evans, founder of PulStar, published his new research on the cause and consequences of neuromusculoskeletal pain in the Chiropractic Journal of Australia in January. Read Dr. Evan’s study as published in the Chiropractic Journal of Australia, or Click here to see the original post on the subject.
If you still have questions, join the discussion.
Last month, we received a great question about Dr. Evan’s calcium pump research from someone we are calling “Dr. S,” and it made us realize that other DCs could also be looking for more information. Scroll down to read Dr. S’s question and Dr. Evan’s response. Then, if you would still like to know more, feel free to post in the comments section at the very bottom of the page. Dr. Evans would be happy to discuss his theory with you.
Dr. S: “I am only one doctor and realize the insignificance of my opinion. I am writing in the hopes that, if you see my concerns as valid, you will address them in a mass email so that any other doctors with my same questions might also be helped to understand your theory. This way we can see how it relates to the PulStar and to your nutrition line. I read your paper. I can see how it would relate to nutrition if true. However, if this was the main cause of nonspecific pain, why does manual manipulation of the tissues work so well. How do the multitude of manual manipulation techniques out there turn the calcium pumps back on (which I am assuming Is what would be required to deal with these muscle contractions via your theory). This is the main thing that keeps me from believing this theory. On the other hand the older established theories like pain gating seem to explain this phenomenon very well. I think your theory can have major implications if true so I am asking if you would please fill in the blanks for me (I don’t want to miss the boat on this if it is true).
Dr. Evans: Before I respond, lets review a few facts and concepts that led me to formulate the theory.
The first and perhaps most important fact may be the relative recentness of the concepts of calcium transport. When I mention the Calcium Pump in the context of muscle relaxation to a chiropractor, the typical response is to the effect “Oh yeah, I remember that”! The truth is that most of us have never heard of the calcium pump if we have not studied physiology in the last 15 years! That is because the concept of calcium transport across cellular membranes did not exist as recently as 15 or so years ago. This appears to be a result of the dominance of the sodium/potassium transport phenomena that was discovered using experimental preparations of squid and mollusk neurons that do not exhibit calcium transport at all. So the calcium pump is a “brand new” concept to deal with and explain what, if any, relationship it may have to back pain. Before muscle relaxation was identified as an active process dependent on the calcium pump, muscle relaxation was described vaguely as a passive response to the contraction of the antagonist muscle. Since my theory is so new, it has not been tested experimentally. One of the reasons for publishing the theory is to encourage such testing through the development of hypotheses related to the predictions of the theory. Now to the questions. One common response runs along these lines; “Why do we need yet another theory when older more established theories like pain gating seem to explain why the multitude of manual manipulation techniques out there seem to work so well?”
There are really two parts to this question, the first is “Why do we need a new theory?
I agree, there are currently at least 100 “named” techniques of chiropractic which implies at least one hundred theories that are invoked by the founders of each technique. So I agree that there are already too many theories. Robert Leach, in his book “Theories of Chiropractic” describes ten theories of manual manipulation only two of which account for the origin of pain. Both require some form of trauma to the muscle to initiate the pain. On the other hand, no theory treats directly with the case of pain that has no apparent cause i.e. “atraumatic” pain. So while there are a plethora of theories, none of them directly address the case of atraumatic pain, which may be the majority of neuromusculoskeletal pain addressed by clinicians.
The second question is; “Doesn’t the Gate Theory explain why a multiple of manual techniques seem to work so well?”
Well, yes, it does. If the origin of the patient’s pain is due to an increase in nociception, say due to trauma, then applying proprioception in the form of manual therapy of almost any type would be expected to restore the balance between proprioception and nociceptive input to the spinal cord, at least temporarily relieving the patient’s pain. The opposite is also the case, where the pain is due to a lack of proprioceptive input, applying proprioception in the form of manual therapy of almost any type would be expected to restore the balance between proprioception and nociceptive input to the spinal cord, again, at least temporarily relieving the patient’s pain. What about the case when we encounter both conditions simultaneously such as a disk bulge where the protruding matter causes nerve irritation (nociceptive input) and the contact between the nerve and the bulge blocks proprioceptive input from the leg? Again, applying proprioception in the form of manual therapy of almost any type would be expected to restore the balance between proprioception and nociceptive input to the spinal cord, at least temporarily relieving the patient’s pain. So, in one sense, we have the best of both worlds, based on application of the Gate Theory of Pain the application of manual therapy would be expected reduce or eliminate pain no matter what the cause. I believe that the Gate Theory provides a reasonable explanation for the apparent effectiveness of all of our many techniques of manipulation. Unfortunately, the theory gives little guidance with respect to the improvement of any technique. While the Gate Theory appears to be valid, it is not much of a guide to improvement of techniques since any technique that applies proprioception should work to relieve pain. The Gate Theory itself doesn’t deal with the origin of pain in the sense of “What is causing this persons pain?” So while the Gate Theory is useful in understanding the potential reasons for the sensation of pain, it is not helpful beyond that because predicting that proprioception should help, it gives no prediction of any changes to therapy aside from doing what we are already doing. So, after a close study of the Gate Theory, I introduced the idea that the lack of proprioception can result in the sensation of pain as well as the universal? Belief that an excess of nociception caused the perception of pain.
So I looked for a physiologic mechanism to identify a possible underlying cause of lack of proprioception and found the calcium pump.
I then combined my new insight that a cause of pain sensation that was overlooked in the literature with a newly discovered means of muscle relaxation which gives a much deeper insight into the phenomena which is giving rise to the reduction in proprioception. And, until my paper the concept that a lack of proprioception was perceived as pain was not in the lexicon. My theory, while allowing for nociception resulting from buckling, muscle damage due to overuse etc. is the only theory that deals with the lack of proprioception as an underlying cause of pain. Once I had realized that the lack of proprioception could result in the perception of pain, I started to search for a plausible physiologic mechanism that would result in a reduction in proprioception and found one in the calcium pump. Now, understanding of the calcium pump and its failure mechanisms may offer a route to possible improvement of manual therapies. For example, the operation of the calcium pump is dependent on the availability of ATP. It has recently been shown that mechanical stimulation results in the synthesis of ATP. So, in addition to providing proprioceptive stimulation to the spinal cord to relieve pain, manual therapy may also stimulate the production of ATP sufficiently to allow the muscle to relax, removing the original cause of pain. In fact in the last thirty years it has been observed that not only does manual therapy stimulate the production of ATP but that electrical stimulation, light stimulation, needling, the application of heat all stimulate the synthesis of ATP. In fact, one might ask “What manual therapy or modality doesn’t stimulate the synthesis of ATP? Seems to me that a reasonable proposition might be that the effectiveness of manual manipulation might well be increased by combining two or more known techniques that stimulate the synthesis of ATP under the assumption that each technique may have slightly different results in the magnitude and or timing of ATP synthesis. Lots of speculation here and I don’t mean to restrict the possibilities for improvement to optimizing the synthesis alone since there are other as yet unexplored mechanisms that might be used for technique improvement.
So Dr. S, did I answer any of your questions?
Thanks for the opportunity,
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