Maruti Ram Gudavalli

Background: This commentary describes perspectives from workshop attendees at a North American educational conference on the chiropractic profession and its relationship with whole health. Whole Health is a paradigm shift within healthcare settings and funding agencies in the United States that utilizes a systems framework to transform healthcare. Whole health frameworks emphasize biopsychosocial well-being as defined by individuals, families, and communities, and leverages interprofessional, team-based approaches to promote well-being, disease prevention, and restoration of health. Main body: Two separate, 60-minute workshop sessions were convened at the 2025 Association of Chiropractic Colleges Education Conference and Research Agenda Conference to discuss whole health and chiropractic. Attendees ( n = 105) included chiropractic academicians, researchers, practitioners, students, and organizational leaders from institutions largely based in the United States. Participants in 14 small groups discussed (1) ways the chiropractic profession aligns with whole health, and (2) how chiropractors can contribute to whole health in clinical practice and healthcare education. Notes taken by group scribes were collected from each workshop and generated 401 distinct comments. Thematic analysis with an inductive approach was used to group and define key topics that emerged from the data. Aspects of the chiropractic profession were described as historically being aligned with whole health for its foundational philosophy in innate healing and resilience, and for espousing person-centeredness and patient values. Themes describing the future contribution of chiropractic to whole health include evidence-based practice; communication and advocacy; integration into the broader healthcare system; and forward-facing education. There was overlap between past and future when considering holism; therapeutic alliance and patient empowerment for self-care; direct access; therapeutic conservatism; preventive health and lifestyle medicine; and longitudinal care. Conclusions: The whole health paradigm presents an opportunity for chiropractors to be recognized contributors within multidisciplinary teams, using their expertise to aid chronic disease prevention, patient empowerment, and health care delivery innovations. Continued education and training, policy changes, and further research are required for the chiropractic profession to best serve patients and provide value within a whole health framework.

Accurate measurement of spinal metrics is critical for diagnosing and treating spinal disorders. However, discrepancies between X-ray and ultrasound imaging data pose a challenge in standardizing clinical assessments. This study introduces a novel methodology that combines geometric scaling factors and extrapolation techniques to align spinal metrics from X-ray and ultrasound modalities. Data were collected from fifteen healthy adult volunteers (8 males, 7 females) aged from early adulthood to middle age, all without a history of low back pain, who underwent a standardized chiropractic traction protocol. X-ray imaging was performed pre-procedure, and ultrasound imaging was conducted both pre-procedure and during the procedure at the L3–L4, L4–L5, and L5–S1 levels under graded traction forces (1.8 kg, 3.6 kg, 5.4 kg, and 11.3 kg). Extrapolation methods were applied to standardize measurements across pre- and during-procedure conditions. Significant findings include consistent increases in spinal metrics, such as height and area, indicating positive elongation and flexibility under progressive weights. The integration of these methods bridges the gap between static and real-time imaging data, potentially enhancing diagnostic accuracy and leads to clinical relevance. This proof-of-concept study lays the groundwork for developing standardized spinal imaging protocols and adapting the methodology to broader imaging applications for improved patient outcomes.

Objective: The objective of this study was to quantitatively determine intervertebral motions and changes in the intervertebral foramen (IVF) area, height, and width in the lumbar spine during the application of a chiropractic procedure. Methods: Eight unembalmed cadavers (five male and three female, age range 43–87 years) were procured for these experiments. Infrared light emitting markers were attached to L4, L5, and sacrum using metal rods to track the three-dimensional motion using the OPTOTRAK system. Five 4-sec cycles of flexion–distraction were performed over a 20-sec period by three clinicians. Vertebral movement data were collected using the marker data in three dimensions and the IVF by digitizing the IVF and computing the changes in area, height, and width. Vertebral motions were computed using three-dimensional kinematics in flexion, lateral bending, twisting, axial traction, and by digitizing the IVF contours; the dimensional changes in terms of height, length, and width were computed. Results: The flexion–distraction procedure created vertebral motions. Mean and standard deviation (SD) values of movements at L4–L5 were (1) 4.2° (0.78) in flexion and mean and SD values of vertebral separations were 1.10 (0.20) mm, respectively. Mean and SD values of vertebral movements at L5–S1 were 3.68° (0.69) in flexion and mean and SD values of vertebral separations were 0.80 (0.15) mm, respectively. Clinicians have created similar movements. Increases were observed in IVF dimensions in terms of area, height, and width at the L4–L5 and L5–S1. Mean and SD values of IVF changes in area, height, and width at L4–L5 were 21.12 (3.87)%, 12.13 (1.89)%, and 5.12 (1.88)%, respectively. Mean and SD values of IVF changes in area, height, and width at L5–S1 were 18.02 (2.97)%, 8.11 (1.68)%, and 4.11 (1.40)%, respectively. Conclusions: Intervertebral motions and IVF dimensional increases were noticed during the flexion–distraction procedure.

Current knowledge regarding biomechanical in vivo deep tissue measures related to spinal manipulation remain somewhat limited. More in vivo animal studies are needed to better understand the effects viscoelastic tissue properties (i.e., dampening) have on applied spinal manipulation forces. This new knowledge may eventually help to determine whether positive clinical outcomes are associated with particular force thresholds reaching superficial and/or deep spinal tissues. A computer-controlled feedback motor and a modified Activator V device with a dynamic load cell attached were used to deliver thrust spinal manipulations at various magnitudes to the L7 spinous process in deeply anesthetized animals. Miniature pressure catheters (Millar SPR-1000) were inserted unilaterally into superficial and deep multifidi muscles. Measurements of applied mechanical forces and superficial/deep multifidi intramuscular pressure changes were recorded during spinal manipulations delivered in vivo. Manipulative forces and net changes in intramuscular pressures reaching deep spinal tissues are greatly diminished by viscoelastic properties of in vivo tissues, which could have possible clinical safety and/or mechanistic implications.

Objective: The study objective was to quantify the changes in intradiscal pressure (IDP) during the application of a chiropractic procedure known as the Cox flexion-distraction technique. Materials and Methods: Pressure sensors were inserted into lumbar intervertebral discs of eight unembalmed cadavers (five male and three female, age range 43–75 years). Five 4-second cycles of flexion distraction were performed for a 20-sec period. Pressure data were collected while the discs were in an unpressurized state as well as a pressurized state (with water). The pressure data were collected during three separate applications of the flexion-distraction procedure with transducers inserted into the L2-L3, L3-L4, and L4-L5 intervertebral discs. The mean pressure values were documented before, during (in the distracted position), and after the treatment procedure (calculated). Pressure differences were compared using the paired t-test for significance in pressure changes from initial prone position to distracted treatment position. Results: The IDPs significantly decreased in both pressurized and unpressurized discs at all studied disc levels. The average IDP decreases in unpressurized discs were as follows: 5.6 kPa at L2-L3, 20.6 kPa at L3-L4, and 22.0 kPa at L4-L5. The IDP decrease range in pressurized-in-the-initial-prone-position discs were as follows: 17.8 kPa at L2-L3, 35.2 kPa at L3-L4, and 122.0 kPa at L4-L5. Conclusions: IDP was found to decrease during the flexion-distraction procedure, which is consistent with the hypothesis that this procedure may be able to draw a protruded nucleus pulposus back toward the intervertebral disc's center and allow for the nutrients flow into the disc.

Background: The intervertebral disc is a known back pain generator and is frequently the focus of spinal manipulative therapy evaluation and treatment. The majority of our current knowledge regarding intradiscal pressure (IDP) changes related to spinal manual therapy involves cadaveric studies with their inherent limitations. Additional in vivo animal models are needed to investigate intervertebral disc physiological and molecular mechanisms related to spinal manipulation and spinal mobilization treatment for low back disorders. Methods: Miniature pressure catheters (Millar SPR-1000) were inserted into either the L4-L5 or L5-L6 intervertebral disc of 3 deeply anesthetized adult cats (Oct 2012-May 2013). Changes in IDP were recorded during delivery of instrument-assisted spinal manipulation (Activator V® and Pulstar®) and motorized spinal flexion with/without manual spinous process contact. Results: Motorized flexion of 30° without spinous contact decreased IDP of the L4-L5 disc by ~ 2.9 kPa, while physical contact of the L4 spinous process decreased IDP an additional ~ 1.4 kPa. Motorized flexion of 25° with L5 physical contact in a separate animal decreased IDP of the L5-L6 disc by ~ 1.0 kPa. Pulstar® impulses (setting 1–3) increased IDP of L4-L5 and L5-L6 intervertebral discs by ~ 2.5 to 3.0 kPa. Activator V® (setting 1–4) impulses increased L4-L5 IDP to a similar degree. Net changes in IDP amplitudes remained fairly consistent across settings on both devices regardless of device setting suggesting that viscoelastic properties of in vivo spinal tissues greatly dampen superficially applied manipulative forces prior to reaching deep back structures such as the intervertebral disc. Conclusions: This study marks the first time that feline in vivo changes in IDP have been reported using clinically available instrument-assisted spinal manipulation devices and/or spinal mobilization procedures. The results of this pilot study indicate that a feline model can be used to investigate IDP changes related to spinal manual therapy mechanisms as well as the diminution of these spinal manipulative forces due to viscoelastic properties of the surrounding spinal tissues. Additional investigation of IDP changes is warranted in this and/or other in vivo animal models to provide better insights into the physiological effects and mechanisms of spinal manual therapy at the intervertebral disc level.

Objective: High-velocity, low-amplitude spinal manipulation (HVLA-SM) may generate different therapeutic effects depending on force and duration characteristics. Variability among clinicians suggests training to target specific thrust duration and force levels is necessary to standardize dosing. This pilot study assessed an HVLA-SM training program using prescribed force and thrust characteristics. Methods: Over 4 weeks, chiropractors and students at a chiropractic college delivered thoracic region HVLA-SM to a prone mannequin in six training sessions, each 30 minutes in duration. Force plates embedded in a treatment table were used to measure force over time. Training goals were 350 and 550 Newtons (N) for peak force and ≤150 ms for thrust duration. Verbal and visual feedback was provided after each training thrust. Assessments included 10 consecutive thrusts for each force target without feedback. Mixed-model regression was used to analyze assessments measured before, immediately following, and 1, 4, and 8 weeks after training. Results: Error from peak force target, expressed as adjusted mean constant error (standard deviation), went from 107 N (127) at baseline, to 0.2 N (41) immediately after training, and 32 N (53) 8 weeks after training for the 350 N target, and 63 N (148), −6 N (58), and 9 N (87) for the 550 N target. Student median values met thrust duration target, but doctors' were >150 ms immediately after training. Conclusion: After participation in an HVLA-SM training program, participants more accurately delivered two prescribed peak forces, but accuracy decreased 1 week afterwards. Future HVLA-SM training research should include follow-up of 1 week or more to assess skill retention.

Low back pain (LBP) is a common cause of disability among U.S. military personnel. Approximately 20% of all diagnoses resulting in disability discharges are linked to back-related conditions. Because LBP can negatively influence trunk muscle strength, balance, and endurance, the military readiness of active-duty military personnel with LBP is potentially compromised. Chiropractic care may facilitate the strengthening of trunk muscles, the alteration of sensory and motor signaling, and a reduction in pain sensitivity, which may contribute to improving strength, balance, and endurance for individuals with LBP. This trial will assess the effects of chiropractic care on strength, balance, and endurance for active-duty military personnel with LBP. This randomized controlled trial will allocate 110 active-duty military service members aged 18–40 with non-surgical acute, subacute, or chronic LBP with pain severity of ≥2/10 within the past 24 h. All study procedures are conducted at a single military treatment facility within the continental United States. Participants are recruited through recruitment materials approved by the institutional review board, such as posters and flyers, as well as through provider referrals. Group assignment occurs through computer-generated random allocation to either the study intervention (chiropractic care) or the control group (waiting list) for a 4-week period. Chiropractic care consists primarily of spinal manipulation at a frequency and duration determined by a chiropractic practitioner. Strength, balance, and endurance outcomes are obtained at baseline and after 4 weeks. The primary outcome is a change between baseline and 4 weeks of peak isometric strength, which is measured by pulling on a bimanual handle in a semi-squat position. Secondary outcomes include balance time during a single-leg standing test and trunk muscle endurance with the Biering-Sorensen test. Patient-reported outcomes include pain severity, disability measured with the Roland Morris Disability Questionnaire, symptom bothersomeness, PROMIS-29, Fear Avoidance Beliefs Questionnaire, expectations of care, physical activity, and global improvement. This trial may help inform further research on biological mechanisms related to manual therapies employed by chiropractic practitioners. ClinicalTrials.gov, NCT02670148 Registered on 1 February 2016.

Spinal manipulation (SM) is used commonly for treating low back pain (LBP). Spinal stiffness is routinely assessed by clinicians performing SM. Flexion-relaxation ratio (FRR) was shown to distinguish between LBP and healthy populations. The primary objective of this study was to examine the association of these two physiological variables with patient-reported pain intensity and disability in adults with chronic LBP (>12 weeks) receiving SM. A single-arm trial provided 12 sessions of side-lying thrust SM in the lumbosacral region over 6 weeks. Inclusion criteria included 21–65 years old, Roland-Morris Disability Questionnaire (RMDQ) score ≥ 6 and numerical pain rating score ≥ 2. Spinal stiffness and FRR were assessed pre-treatment at baseline, after 2 weeks and after 6 weeks of treatment. Lumbar spine global stiffness (GS) were calculated from the force-displacement curves obtained using i) hand palpation, ii) a hand-held device, and iii) an automated indenter device. Lumbar FRR was assessed during trunk flexion-extension using surface electromyography. The primary outcomes were RMDQ and pain intensity measured by visual analog scale (VAS). Mixed-effects regression models were used to analyze the data. The mean age of the 82 participants was 45 years; 48% were female; and 84% reported LBP >1 year. The mean (standard deviation) baseline pain intensity and RMDQ were 46.1 (18.1) and 9.5 (4.3), respectively. The mean reduction (95% confidence interval) after 6 weeks in pain intensity and RMDQ were 20.1 mm (14.1 to 26.1) and 4.8 (3.7 to 5.8). There was a small change over time in the palpatory GS but not in the hand-held or automated GS, nor in FRR. The addition of each physiologic variable did not affect the model-estimated changes in VAS or RMDQ over time. There was no association seen between physiological variables and LBP intensity. Higher levels of hand-held GS at L3 and automated GS were significantly associated with higher levels of RMDQ (p = 0.02 and 0.03, respectively) and lower levels of flexion and extension FRR were significantly associated with higher levels of RMDQ (p = 0.02 and 0.008, respectively) across the 3 assessment time points. Improvement in pain and disability observed in study participants with chronic LBP was not associated with the measured GS or FRR. NCT01670292 on clinicaltrials.gov, August 2, 2012