reduction in frequency and severity of erectile ... in frequency and severity of erectile...

Reduction in Frequency and Severity of Erectile Dysfunction and Chronic Low Back Pain in a 53-year-old Male Utilizing the Gonstead Technique: A Case Study

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Introduction

Erectile Dysfunction

Erectile dysfunction (ED) is defined as a man’s inability to

attain or sustain an erection satisfactory for sexual

intercourse.1 A man that has never experienced normal erectile

function is said to have primary ED. One that previously had

normal function, but now does not, is said to have secondary

ED. Primary ED is rare, and almost always due to psychologic

factors or clinically obvious anatomic abnormalities.1

Secondary ED is much more common and is most likely

organic in origin (>90% of cases).1

Anatomists and physiologists describe the penile erection

process as a sensitive and complex neurovascular event that

requires proper functioning and interaction of three

physiological systems: the CNS, the peripheral nervous

system, and the penile arterial and trabecular smooth muscles.2

Due to this necessary interaction, damage to even one of these

systems can jeopardize proper erectile function. This damage

can occur as a result of underlying chronic conditions such as

chronic pain, depression, diabetes, kidney disease, an

overactive corpus cavernosum, vascular disease and hormonal

abnormalities.3-6 It may also occur as a result of post-surgical

damage, pelvic trauma, peripheral neuropathy and spinal cord

injury.7,8 Lifestyle choices such as smoking, poor diet and lack

of physical activity are also thought to play a role in ED.7

These factors are typically categorized as vasculogenic,

psychogenic, neurogenic, myogenic or hormonal.9 Studies

indicate that up to 40% of men between the ages of 40 and 70

have experienced ED in some form, making it one of

Abstract Objective: To record the improvements seen in a 53-year-old male patient with

a history of erectile dysfunction and chronic low back pain.

Clinical Features: The man first presented for chiropractic care with a chief

complaint of low back pain. He had a twenty-year history of low back pain and

erectile dysfunction, disclosing only the low back pain initially. Examination

revealed the presence of vertebral and pelvic subluxations.

Interventions and Outcomes: Each visit included the use of instrumentation,

static palpation, motion palpation, and visualization to accurately determine

when and where subluxations were present. Chiropractic adjustments utilizing

Gonstead methodology were performed whenever corrections were found

necessary. After eight weeks of care (12 adjustments) the patient was pain-free

and able to exercise comfortably. He continued care for a chronic lumbar

subluxation and was able to experience improved erectile function as well.

Conclusion: Chiropractic adjustments utilizing Gonstead methodology has been

shown to effectively reduce the effects of vertebral subluxation. This has

allowed the patient to live without chronic pain and experience improved erectile

function.

Key Words: Gonstead, chiropractic, subluxation, adjustment, spinal

manipulation, erection, erectile dysfunction, sexual function

Howard Hadley, BA, DC1

Harry Hadley, BA, DC1 1. Private Practice of

Chiropractic, Rochester, NY

Case Study

Erectile Dysfunction A. Vertebral Subluxation Res. December 5, 2016 137

the most common chronic male disorders today.7,10 In 2000,

the Unites States spent nearly $330 million on medical care

associated with ED; a substantial” increase from the $185

million spent in 1994.11 Global monitoring of this growing

prevalence indicates that by 2025 nearly 322 million men will

experience erectile dysfunction; 170 million more than in

1995.3

The standard medical treatments for ED include the use of oral

phosphodiesterase type 5 (PDE-5) inhibitors, intraurethral and

intracavernous prostaglandin E1 formulations, injectable

phetolamine and papaverine, and testosterone preparations.7

Several articles have been written describing the effects of

chiropractic care on organ function (including the heart12,

digestive system13, and reproductive system14), but no

publications were found involving ED specifically.

Low Back Pain

Low back pain (LBP) is “rarely well defined,” and is often

used to describe any pain located below the 12th ribs all the

way down to the gluteal folds (bilaterally or unilaterally),15

According to the British Medical Center, LBP is one of the

most commonly reported complaints in developing countries

today, with an estimated prevalence of 75-84%.15 LBP is the

leading cause of activity limitations seen in people under 45,

as well as the third most common reason for surgery.16 In the

United States alone, over $100 billion is spent each year on

the treatment of LBP.17

Recent attempts have been made to improve the specificity of

LBP, suggesting that the “low back” be broken down into five

smaller areas: left lateral lumbar, lumbar immediate paraspinal

area, right lateral lumbar area, left gluteal area and right

gluteal area. Of those with point-prevalent pain, paraspinal

pain is the most commonly reported (75.6%).15 LBP is

considered acute if it has lasted less than two months, and

chronic if it has lasted more than two months.18

Causes of low back pain are divided into three categories:

mechanical, non-mechanical and referred.18 Mechanical

causes include sprains, strains, spondylosis (disk, annulus

and/or facet), compression fractures, traumatic fracture and

spinal alignment disorders. Non-mechanical LBP is seen with

malignancy, infection, inflammatory spondyloarthropathy,

osteochondrosis and Paget’s disease. Referred pain can be the

result of pelvic disease, renal disease, aortic aneurysm or

gastrointestinal disease. Mechanically induced pain is shown

to be the most common cause of LBP.18

The African Journal for Physical, Health Education,

Recreation and Dance recommends “that treatment should not

focus primarily on pain, but rather on the consequences of

pain and a loss of function, physical inactivity and being

absent from work.”19 Standard medical treatment of LBP

includes pharmaceutical therapy, facet joint injections, soft

tissue injections, transcutaneous electrical nerve stimulations,

and surgical alterations to the bony and/or soft tissue

structures. Chiropractic has become an increasingly popular

alternative for the treatment of mechanical LBP. An article by

Geanopulos, et al in 2002 stated that 49 percent of all visits to

a doctor for LBP were made to a chiropractor.16

Vertebral Subluxation:

The word “subluxation” is not exclusive to chiropractic, and

has been used since the late 1600’s to mean “a dislocation or

putting out of joint.”20 The chiropractic profession (founded in

1895) has used the term “vertebral subluxation” to describe a

“displaced” vertebra, putting “pressure on nerves” and causing

“abnormal function.”20 A traditional chiropractic description of

this spinal articular and neurological derangement from the

body’s norm implies its pervasive and common nature in the

population.21 Such a subluxation could be caused by

something as simple as shoveling dirt or vacuuming the

carpet.21

A subluxation, as described in the Gonstead chiropractic texts,

is a “spinal lesion which produces an inflammatory reaction at

the contact site of a protruded intervertebral disc and a

compressed nerve.”22 The potential for this to happen is a

direct result of the design and purpose of the human spine.

The primary function of the vertebral column is the

“protection and support” of the spinal cord.22 Similar to the

skull protecting the brain, the vertebral segments offer

“osseous housing for protection of its delicate neural

contents.”22 Unlike the skull, however, the spine is also

flexible enough to allow one to bend and rotate appropriately.

This additional function is made possible by the spine’s

segmentation into twenty-four vertebral units. In an attempt to

reduce the impact of this flexibility on the spines ability to

protect and support the spinal cord, each vertebra is connected

to the ones above and below by “strong restraining

ligaments.22 Specifically, the most important of these

ligaments are the intervertebral discs.22 The discs are intended

to provide flexibility to the spine while at the same time

maintaining the adjacent vertebrae within allowable limits of

displacement.22 A disc’s ability to perform this complex task

is dependent upon the integrity of its anatomical components.

It is proposed that as long as the annulus fibers are intact…the

vertebral bodies will be able to retain their proper

relationships.22 Two vertebrae are in an optimal relationship

when “the perimeters of the bodies are in line, and the vertical

distance between the opposing surfaces of the vertebral bodies

is the same at all points.22

If two segments are found to be aligned properly and the disc

between them healthy enough to maintain that relationship, the

area is not subluxated. A subluxated segment does not meet

these requirements, and is the product of trauma to the spine

(either macro-trauma or repetitive micro-trauma) that damages

the anatomical structures of the disc and initiates the sequence

of events which result in nerve dysfunction. The process is

described in a Gonstead textbook as:22

1) Trauma misaligns the vertebra, shifting it into a

sustained position.

2) The shifting vertebral body compresses the disc

and exerts pressure on the nucleus. Since the

nucleus has a high water content, and is

noncompressible, it is forced against the

annulus.

3) The annulus fibers are stretched beyond their

elastic limit by the bulging nucleus, resulting in

damaged or deranged fibers.

138 A. Vertebral Subluxation Res. December 5, 2016 Erectile Dysfunction

4) Tissue damage induces an inflammatory

reaction. Intracellular edematous fluid infuses

the disc, causing it to expand and protrude.

5) Protrusion of the disc produces compression

upon neural structure within the neural canal or

in the intervertebral foramen.

6) The nerve pressure thereby produced results in

nerve dysfunction.

It is said, therefore, that a subluxation is a disorder of the disc,

and that unless the misaligned vertebral segments are

repositioned appropriately, the disc usually progresses through

worsening degrees of degeneration (evident when analyzing

the condition of the disc space from the appropriate lateral

radiograph).22

It is also important to consider that when a vertebra is

subluxated, it is unable to move appropriately on top of its

disc. The disc itself will have changed shape due to the

displaced nucleus, most significantly in the direction of

nucleus displacement (such that a nucleus protruded to the left

and laterally will make it more difficult to perform left lateral

flexion).22 Further immobilization will result from infiltration

of the disc by edematous fluid, such that the fluid should be

regarded as a stabilizing mechanism, attempting to protect the

injured joint from further misalignment. Adhesions within the

joints will also develop if the subluxation is allowed to

become chronic (uncorrected). These adhesions are the result

of “dehydrated and shrunken tissues” which bind together and

reduce vertebral body motion. Every vertebra that is

subluxated loses its normal motion and is simultaneously

regarded as a fixation. 22

In the 2003 Gonstead text by Cox, a recent (acute) subluxation

will commonly demonstrate pain, swelling and tenderness

upon examination.23 A chronic subluxation, however, may

demonstrate none of these findings. This is due to the eventual

tissue numbness occurring over time as a protective

mechanism. A chronic subluxation will often also result in

“excessive wear and tear on the involved disc. 23

A summary of the short and long-term effects of subluxation

can be found in a 1996 article by Kent.20 It explains that:

1) Progressing degeneration occurs with abnormal

spinal mechanics: This phenomenon is thought to

begin with damage to the intervertebral discs, and

progress to changes in the vertebrae and the

contiguous soft tissue structures. This can then result

in pressure on the spinal cord, due to degenerative

changes causing canal stenosis (disc protrusion,

ligamentum flavum hypertrophy/corrugation, and or

osteophytosis). Foraminal stenosis may also occur

secondary to arthritic changes or disc protrusions.

This degeneration is thought to be the product of

pathomechanics and torsional stress placed on the

involved structures, as well as aging.

2) Sensitivity of spinal nerve roots to compression

increases the likelihood of neurological

consequences: Nerve root compression has been

shown to develop following reduction of foramina

diameter (as seen in disc protrusions or

osteophytosis). Spinal nerve roots may be especially

sensitive to mechanical effects due to their lack of

perineum and funicular plexus formations. It is

important to note that compressed nerve roots can

exist without the presence of pain. Studies have

shown that pressure as low as 10 mm Hg can produce

a significant conduction block in a spinal nerve root.

Maintaining that pressure for 15 or 30 minutes

resulted in a 40% or 50% reduction in action

potentials respectively. Fortunately, the body can

often make a full recovery once low levels of

pressure (10 mm Hg) are removed. As levels of

pressure increase, however, the chances of a

complete recovery are reduced.

3) Sensitivity of the vascular supply to the spinal nerve

roots increases likelihood of dysfunction: Venous

function can be compromised with even less pressure

(5-10 mmHg) than required for nerves. In addition to

the effects of reduced blood flow, the resulting

retrograde venous stasis can also increase the

pressure on other intraforaminal structures. Individual

radicular arteries are also considered vulnerable to

dysfunction as they are without collateral pathways

for backup.

4) Biomechanical dysfunction results in altered

nociception and/or mechanoreception: “The

intervertebral motion segment is richly endowed by

nociceptive and mechanoreceptive structures. As a

consequence, biomechanical dysfunction may result

in an alteration in normal nociception and/or

mechanoreception.”20 The discs themselves have

multiple sources of innervation and the ligaments

attached to the spine house mechanoreceptors and

other neural tissues. Facet joints also house

mechanoreceptors and nociceptive nerve endings,

which “proves that these tissues are monitored by the

central nervous system and implies that neural input

from the facets is important to proprioception and

pain sensation.” Abnormal afferent inputs to the

CNS, as a result of biomechanical dysfunction, may

result in dysponesis.

5) Neural dysfunction is stressful to the body tissues:

Vertebral subluxations are associated with

“exaggerated sympathetic activity as well as

exaggerated paraspinal muscle tone.” Increased

sympathetic tone is thought to alter organ and tissue

responses to hormones, infectious agents, and blood

components. “Correcting the specific vertebral

subluxation cause is paramount to restoring normal

afferent input to the CNS, and allowing the body to

correctly perceive itself and its environment.”20

The vertebral subluxation and chiropractic care have been

routinely presented to the public as a mere cause and

respective solution to low back pain. However, the potential

benefits of chiropractic care are clearly much grander once the

structures and dysfunctions associated with a subluxation are

fully considered. As the body of information concerning

vertebral subluxation continues to grow, so too will the

chiropractors’ ability to justify and clarify their involvement in

their patients’ various improvements. It is the goal of this

paper to add to that body of information, and present a

situation not yet published in the literature. This is done in

hopes of inspiring further research concerning chiropractic,


subluxation correction, and its ability to provide benefit to

those with erectile dysfunction.

Gonstead Technique:

This case was managed using the Gonstead system of analysis

and adjusting protocols. The goal of the Gonstead system is to

enable the chiropractor to “give the right adjustment at the

right place and at the right time.”24 To do this, a variety of

different diagnostic procedures are used, at the discretion of

the chiropractor, to meet the unique needs of the patient.

These procedures include taking a thorough patient history, a

general physical examination, visual inspection, static and

motion palpation, static and dynamic (stress) radiography, and

instrumentation (primarily thermography).24 While the

majority of these tools are not individually unique to the

Gonstead technique, the concept of using most, if not all, of

these examination procedures routinely to assist in the

identification of subluxated motion segments and the weighing

of the relative values of each test is what sets Gonstead apart

from other chiropractic techniques.

To accurately identify the “right place” to adjust, an order of

importance must be considered when interpreting different

diagnostic procedures. This order is such that: instrumentation

is considered most heavily in the analysis, followed by digital

palpation, motion palpation, visual analysis and then X-ray.24

The unique use of instrumentation in the Gonstead technique

involves a dual-probed thermometric instrument called the

ETS-6 Nervoscope. The tool consists of two groups of

termocouples in series with a microvoltmeter. Each of the two

input detectors (Figure 1) contains a group of thermocouples

so that bilateral paraspinal temperatures can be measured

simultaneously. Paraspinal temperatures are compared using a

full-spine “canning method, monitoring for voltmeter pointer

deflections toward the detector receiving the greater amount of

heat.22 The scanning method is performed such that the

probes are held in perpendicular contact with the skin surface

with sufficient pressure to prevent air gaps forming at the

skin/thermocouple interface.25 The tool is then moved in a

caudocephalad gliding motion from T2 to C0 and in a

cephalocaudal gliding motion from T2 to S2.25 The needle will

show a deflection in proportion to the difference in

temperature at the two input detectors.22 The nervoscope is

considered to be a temperature differential recording

instrument and is meant to be used at every visit.22

A temperature differential (TD) is considered significant if an

abrupt ‘over and back’ needle movement is seen over a one

spinal segment distance during the scan.25 The location of the

TD is considered to be specifically associated with the

functional spinal unit underlying it due to the segmental nature

of the spinal nerves, the posterior primary rami, and

autonomic connections present at the individual spinal

levels.25 It is important to note that the relationship of the

readings locations to the bony landmarks is mildly variable

from patient to patient.25 The main factors that influence this

variability include the state of the sagittal curves and the

presence of a scoliotic curve.25 Because of this, a table was

provided by Plaugher to best interpret temperature differential

readings and their corresponding segmental levels (Figure 2).25

Thermographic findings are largely accepted as resulting from

changes in underlying blood vascularity and are a probable

connection to nervous system phenomena related to

subluxation. The two main mechanisms thought responsible

for these blood vessel changes involve substance P release in

response to dorsal sensory nerve stimulation and sympathetic

nervous system activity. Traditionally, preganglionic cell

bodies were thought to be confined to the thoracic and upper

lumbar levels, however, preganglionic sympathetic cell bodies

have been identified at all levels of the spinal cord.25

Review of the Literature

A brief review of literature was performed on the topic of low

back pain and chiropractic. Galileo, PubMed and McCoy

Press were utilized. A search was done on Galileo for “low

back pain chiropractic” limiting options to scholarly journals

only, from 2000 to 2015. This produced 102 articles.

PubMed was used next, searching for "low back pain

chiropractic" in the last five years, concerning humans. This

produced 132 articles. The final search for “low back pain

chiropractic” (without quotation marks) was done without

other filters using McCoy Press, which produced 81 articles.

In 2011, a retrospective case series was published by the

Journal of Rehabilitation Research & Development (JRRD)

assessing the clinical outcomes associated with chiropractic

management for veterans with low back pain.26 In it, 171

cases of veterans who saw a chiropractor for a chief complaint

of LBP were considered. The typical course of care included

once or twice a week treatments, with a mean number of

treatments per case of 8.7 (ranging from 2-26). These

treatments were such that 95.3% received flexion distraction,

39.8% received high-velocity, low amplitude spinal

manipulative therapy, and 19.3% received spinal mobilization

without high-velocity thrust. The Numeric Rating Scale

(NRS) and the Back Bournemouth Questionnaire (BBQ) were

used as outcome measures, with a minimum clinically

important difference (MCID) set at 30% improvement from

baseline for both assessment forms. Their treatments resulted

in an NRS mean raw score improvement of 37.4% change

from baseline, with 60.2% of patients meeting or exceeding

the MCID. The BBQ mean raw showed a 34.6%

improvement from baseline, with 53.8% of all patients

meeting or exceeding the MCID. This indicates that the mean

percentages of clinical improvements were “statistically

significant and clinically meaningful for both the NRS and

BBQ.”26

The Journal of Manipulative and Physiological Therapeutics

came out with a preliminary study in 2004 investigating the

efficacy of preventive spinal manipulation for chronic LBP

and other related disabilities. Two groups of fifteen patients

with chronic low back pain were formed (LBP-1 and LBP-2)

such that neither knew the other existed. The LBP-1 group

was given an initial baseline evaluation and told to come back

in four weeks for a second evaluation (this month was used as

a control to examine the effects of time on pain and disability).

After these four weeks they were placed on a twelve-week

schedule of three chiropractic treatments per week. Once

these twelve weeks were up, the LBP-1 group was released

from care. The LBP-2 group did not receive the initial one-

month waiting period. They instead began with the twelve-


week schedule of three chiropractic treatments per week.

After that series was over, they were seen once every three

weeks for the remainder of the ten-month experiment for

“maintenance treatments.”27 Each group had their pain levels

assessed using the Oswestry disability index and a visual

analogue scale (VAS) at the initial examination, before the

first treatment, and then daily. Spinal manipulations were

limited to side-posture manipulation of the lumbar and

sacroiliac joints.27

The study showed several interesting things. First, that after

one month without intervention, the control group had seen no

improvement in pain or disability scores. This suggested that

any changes seen were in fact due to chiropractic intervention,

not time alone. The research also showed that pain and

disability scores related to chronic LBP conditions were

significantly reduced after the twelve weeks of chiropractic

care. And finally, both groups were seen to maintain their

improved VAS pain scores for the remainder of the ten

months, but disability scores returned to their pre-treatment

levels in the LBP-1 group (no maintenance treatments) while

the LBP-2 group (maintenance treatment group) was able to

retain their improved post-treatment levels. This is extremely

important, as it indicates a benefit to long-term, maintenance

type care, even once a reduction in pain has been achieved.27

A recent (2009) publication in the Journal of Vertebral

Subluxation Research describes a growing trend in US

insurance companies and managed care organizations to insist

that LBP should be resolved in six to twelve visits.28 The

article’s objective was to determine the validity of such

claims. Doing so involved an analysis of sixty-five

randomized control trials (RCTs) involving low back pain and

spinal manipulative therapy (not necessarily performed by

chiropractors). The results were compiled to show that the

average patients studied received 8.4 visits and experienced

less than a 43% improvement in pain intensity. When a

similar search was done considering only the 26 RCTs where

chiropractors performed the SMT, the average number of

visits was increased to 9.6, with patients showing an average

of 47% decrease in pain intensity. Further evaluation was

done of the 7 RCTs involving over 10 visits, resulting in an

average of 16 visits with a 54.3% improvement in pain

intensity. The article goes on to say that none of these

numbers support the idea that six to twelve visits is enough to

completely resolve low back pain, and that “assuming a

reasonable mathematical constant dose response…estimates of

twenty-six to thirty-six visits” would be more appropriate

when determining what should be required for “completely

resolving and stabilizing low back pain with SMT.” 28 They

also stress the importance of patient individuality and initial

condition, meaning some patients may have their symptoms

decrease faster than average and others will recover more

slowly than average.28

Several case reports involving patients who presented to the

chiropractor with LBP describe other dysfunctions improving

also after subluxation correction. Geanopulos et al. published

a case report in 2015 describing a 44-year-old man with a two-

year history of chronic low back pain and hip pain,

unmanaged depression, and congenital hemochromatosis.16

The patient had slipped and fallen six months before

presenting to the office, which had caused an exacerbation in

his pain. Subluxations were found at the C5, C6, C7, L4, L5

and S1 vertebrae. The patient was seen three times each week

for the first three months of care, once each week for the next

month, and once the following month (for a total of 34 visits).

Each time the chiropractor applied the Diversified technique

(manual high-velocity, low-force adjustments) to correct the

subluxations found. After the first five weeks of care, the

patient reported significant improvement in his low back pain

and radicular pain, and was able to ambulate without pain.16

Another case report, written by Fedorchuk, et al. in 2010,

involves a 24-year-old soldier with LBP and urinary

urgency.29 The patient had been experiencing LBP for the past

year and a half, with insidious onset. The pain was an “achy,

sharp pain” that started in both sacroiliac joints and radiated

into the “front groin.” Severe pain was also felt over the third

lumbar vertebra. The urinary incontinence had existed for two

years, began insidiously and involved bouts of urinary urgency

approximately 12-15 times per day, producing only a few

ounces of urine each time. Chiropractic analysis (static

palpation, motion palpation, and radiographic findings)

indicated subluxation of the L3 vertebra. Diversified

technique was applied (such that high-velocity, low-amplitude

adjustments were performed using a specific contact) to the

subluxated L3 vertebra only. The patient was adjusted once

each week for the first three weeks. After the third week, the

patient’s urinary urgency had decreased from 12-15 times per

day to 3-4 times per day, and his low back pain had decreased

significantly. The patient continued to be seen regularly by

the chiropractor (once every three weeks) and maintained a

normal urinary pattern up until the time of the article’s

publication.29

Schwanz et al. published a case study involving a 29-year-old

female with a two-week history of lower back pain and left leg

pain.30 In her initial examination she also revealed an eight-

year history of infertility. Gonstead analysis (involving

nervoscope instrumentation, static palpation, motion

palpation, visualization, and full spine X-rays) revealed a

sacral subluxation. Side-lying adjustments were performed on

a pelvic bench using a base posterior push move on the

posterior sacrum. This was the only segment adjusted. The

patient was seen once a week for a total of eight visits. After

the first visit, the low back pain had decreased significantly

and swelling had decreased 50%. Nineteen days after her first

adjustment, the patient reported a positive Early Pregnancy

Test (+EPT), which was later confirmed by the obstetrician. 30

A similar case study was written by Lombardi et al. in 2015,

documenting a 27-year-old female who presented to the

chiropractor with moderate bilateral low back pain that she

had suffered with for years.31 She had also been diagnosed

with infertility five months prior, which her doctors associated

with “anovula due to infrequent menstruation.” Her medical

doctors had prescribed several medications, including:

Clomid, estradiol, prenatal DHA, and ethinyl estradiol. Her

past history of trauma included two car accident, a four-

wheeler accident, and an emergency C-section for her first

child. Examinations revealed subluxations at the C2, C4, T7,

L4 and L5 spinal levels. The patient was seen three times a

week for the first eight weeks, two times a week for the next

ten weeks and once a week thereafter. She was adjusted using

mirror image, high velocity, low amplitude, and low force


procedures (combining “Thompson drops and Diversified

adjustment”). After ten weeks of care (19 adjustments) the

patient reported a significant decrease in her chief complaints,

including the conception of her second child.31

Case Report

This case report will be divided into two sections, such that

the first section will describe a patient’s chronic low back pain

improvements following eight weeks of chiropractic care.

The second section will describe that same patient when he

returned to chiropractic care five years later, this time noticing

a connection between subluxation correction and improved

erectile function.

Section 1 - Patient History:

A 47-year-old Caucasian male sign language interpreter first

presented to the chiropractor with right-sided low back

pain. The man had been experiencing “on and off” low back

pain for the past 25 years and had awoken that morning to a

new “flare-up.” The patient had spent the night before

clearing his driveway of snow and was now in a high level of

pain. No more than a mild level of discomfort and soreness

was felt while clearing the driveway, and he did not remember

any one motion or action being especially traumatic. The pain

was now preventing him from walking or lying down

comfortably.

The patient had recently begun playing racquetball and had

started taking weekly (sometimes biweekly) aerobics classes.

Height and weight were recorded at 5 feet 11 inches and 250

pounds. The patient was allergic to penicillin, had a history of

high blood pressure, and a 19-year 3-packs-a-day history of

cigarette smoking that he had quit eight years prior. Family

history included high blood pressure, diabetes, heart disease,

and skin cancer. Medication use reported at that time included

a daily dosage of unspecified high blood pressure medication.

The patient had been seeing another chiropractor 2-3 times a

week for the past year to manage his chronic LBP, and was

looking for a second opinion. The patient’s reasons for care

were: he wanted a reduction in the severity and frequency of

his pain, and he wanted to be well enough to keep playing

racquetball 1-2 times a week.

Nothing about erectile dysfunction was mentioned at this time.

Section 1 – Exam Findings:

In the patient’s initial evaluation, the chiropractor employed

break analysis using a dual-probed thermometric instrument

(ETS-6 Nervoscope). Nervoscope instrumentation revealed

significant deflection at the lumbosacral junction. These

findings, along with the patient’s chief complaint, led the

remainder of the analysis to be focused on the pelvis and

lumbar spine. Orthopedic, neurological and range-of-motion

testing revealed a positive Bechterew’s test on the right

(causing right-sided LBP to radiate down the right leg), a

decreased Achilles reflex on the right, and an inability to

perform lumbar flexion without increasing pain in the right

sacroiliac (SI) joint. Digital palpation revealed point

tenderness over the right SI joint, significant edema at the

superior portion of the right SI joint, and right-sided

paraspinal hypertonicity. Motion palpation of the lumbar

spine and pelvis was performed, confirming a fixation of the

right SI joint. No x-rays were taken at this time due to the

congruency of all other findings and a lack of recent instances

of macrotrauma.

These findings led to a diagnosis of right SI joint subluxation

with resulting myalgia.

Section 1 - Intervention:

After the initial examination, the patient’s right SI joint was

adjusted in the side-lying position, utilizing an acetabula ridge

contact point on a Gonstead pelvic bench (Figure 3). This was

the only adjustment performed that day. The patient was

instructed to apply ice regularly, and to walk as much as

possible to encourage motion in the joint.

The patient was seen one more time in the first week of care,

three times in the second week, twice a week in the third and

fourth weeks, once a week in the fifth and sixth weeks, and

one more time in the eighth week. Each time he presented to

the office, a similar use of instrumentation, static palpation,

motion palpation and visualization were used to ensure where

and when adjustments should be delivered. All twelve visits

resulted in similar adjustments to the right SI joint. No other

segments were addressed at this time due to the chronicity of

the pain and the results of the analysis.

Section 1 - Outcomes:

In his first-ever visit to the office, the patient had a history of

chronic low back pain and wanted a reduction in the severity

and frequency of his pain. He also wanted to be able to stay

well long enough to keep playing racquetball 1-2 times a

week.

With these as his goals, the patient visited the chiropractor a

total of twelve times over the course of six weeks. By the

fourth visit/adjustment, the patient had noticed improvements

in his LBP, but still had moments of “come and go pain” that

made walking comfortably sometimes a challenge. On the

fifth visit the patient explained that the pain had improved

from a sharp severe pain to a more tolerable dull achy pain. By

the tenth visit, the patient reported feeling much “looser,” with

a significant reduction in pain (with only the occasional

“twinge”). On the eleventh visit he was excited to report that

his four-year-old daughter had jumped out of her bunk bed

and he was able to catch her without any pain. By his twelfth

he said he was “feeling good” and was ready to get back to

playing racquetball. His pain had decreased, he was back to

doing what he loved, so he decided not to continue with care.

This reduction in pain made it possible for him to increase his

daily activity level and exercises comfortably. He was also

able to maintain a level of comfort high enough not to “need”

the chiropractor again for five years.

Section 2 - Patient History:

Five years later, the patient returned to the office with what

felt like the start of a new “flare-up” in low back pain. His last


experience in the office had reduced his chronic LBP

significantly, which was allowing him to live a much more

active lifestyle — playing racquetball 2-3 times a week,

bicycling 2-3 times a week, taking aerobics classes 1-2 times a

week, and eating a “healthier diet.” He had lost nearly fifty

pounds of body weight and was determined not to let his

activities become limited again by LBP. This right-sided low

back pain had started the week before while playing

racquetball. He came in four times over the next six weeks

before taking another four months off from care. When he

returned he had bilateral cervical pain that traveled into the

base of his occiput. It had begun the night before after using

improper form and excessive straining during his workout.

His low back was said to feel “not-right,” although not

especially painful.

Due to the sensitive nature of sexual health, it is quite

common for patients to avoid discussing things they feel are

private with their health care providers.16, 32 This is true for the

patient in this study as well. It was several years before he

decided to share his experiences with ED with the

chiropractor.

Follow-up questions revealed the patient had first begun

noticing signs of ED at the age of 22. He was soon after

diagnosed with ED by his medical doctor and had been treated

with a variety of the standard medical prescriptions since then

(with varying results). In an attempt to effectively record the

patient’s experiences with ED since being under chiropractic

care, the International Index of Erectile Function (IIEF)

Questionnaire and a Johns Hopkins, ED-specific questionnaire

were given. With the intention of providing a pre-

chiropractic-care reference point, a non-traditional,

retrospective IIEF was also completed. This retrospective

analysis revealed a mild to moderate classification in the area

of erectile dysfunction (21/30 versus the 25.8/30 average), and

normal/average scores in the areas of orgasmic function,

sexual desire, intercourse satisfaction, and overall

satisfaction.33,34

This prompted a conversation in which the patient was able to

recall two major, previously unmentioned, spinal traumas

involving his lumbar spine. At age 16, while playing sandlot

football (no pads), one specific tackle landed him flat on his

back and left him in so much pain he couldn’t move. He did

not seek medical help and instead remained in bed, unable to

move due to pain, for a full week. After that week the pain

had decreased enough that he could tolerate movement, and he

resumed his daily activities. At age 20, he injured his low back

again while working on a delivery truck. While holding

several heavy boxes (approximately fifty pounds), he jumped

down from the truck bed to the ground three feet below,

causing an “explosion” of pain in the low back that sent him

immediately to his knees in pain. This time he did see his

medical doctor. Muscle relaxers (unspecified) were

prescribed, which allowed him to tolerate the pain well

enough to resume his daily activities. No further care was

provided and no follow-up appointments were made with that

doctor.

His past treatments included prescriptions for Viagra and

Cialis (Cialis preferred), which worked to his satisfaction. He

had been previously prescribed 20mg of Cialis on an as-

needed basis (which he preferred), but was now taking 2mg

daily. Positive risk factors for ED include regular bike riding,

a past history of smoking, a past history of recreation alcohol

usage, and the two significant spinal injuries (as mentioned

above). The patient had never had his testosterone levels

measured, never had any penile injections performed, never

had any penile blood flow studies performed, and never had

his erections tested during sleeping.

Section 2 – Exam Findings:

The chiropractor employed break analysis using an ETS-6

Nervoscope. Nervoscope instrumentation revealed significant

deflections in the upper cervical spine, as well as in the lower

lumbar spine. These findings, along with the patient’s chief

complaints, led the remainder of the analysis to be focused on

the cervical and lumbar spine. Digital palpation revealed point

tenderness, edema, and muscular hypertonicity at the levels of

L5 and C1. Motion palpation of the cervical and lumbar spine

was performed, confirming fixations at both L5 and C1. No x-

rays were taken at this time due to the congruency of all other

findings and a lack of recent instances of macrotrauma.

These findings led to a diagnosis of vertebral subluxation at

L5 and C1 with associated myalgia.

After another four months off from care, the chiropractor

employed break analysis using an ETS-6 Nervoscope.

Nervoscope instrumentation revealed significant deflections in

the lower cervical spine, as well as in the lower lumbar spine.

These findings, along with the patient’s chief complaints, led

the remainder of the analysis to be focused on the cervical and

lumbar spine. Digital palpation revealed point tenderness,

edema, and muscular hypertonicity at the levels of L5 and C6.

Motion palpation of the cervical and lumbar spine was

performed, confirming fixations at both L5 and C6. No x-rays

were taken at this time due to the congruency of all other

findings and the lack of recent macrotrauma.

These findings led to a diagnosis of vertebral subluxation at

L5 and C6 with associated myalgia.

Three years later, the patient confessed to the chiropractor that

his now routine visits to the office, years after experiencing a

resolution of his chronic low back pain, were due to an

increase in erectile function that he associated with the

reduction of vertebral subluxation. In an attempt to better

observe the condition of his lumbar spine and pelvis and more

appropriately understand this phenomenon, standard 14”x17”

lumbar and pelvic X-rays were taken.

X-ray analysis revealed the following: on the lateral lumbar

projection (Figure 4), anterolisthesis of the L4 vertebra with

resulting intervertebral osteoarthritis is seen, as well as a

posterior loss of disc height at the L5-S1 level, limbus bone

formation in the anterior L1-L2 disc space, and an anterior-

posterior osteophyte formation off the L4 vertebral body.

Anterior to posterior (AP) lumbar and pelvis views (Figures 5

and 6) show normal bony and soft tissue findings. It is noted

that sacrum and both ilia are “very well-balanced” and show

no signs of leg-length inequality.

Due to the relative posteriority of L5, the well-balanced pelvis,


and the entirety of the patient history, the X-rays confirmed

the presence of the chronic L5 subluxation.

Section 2 - Intervention:

On the patient’s first visits back, a side-lying L5 adjustment

was performed, using a spinous process contact on a Gonstead

pelvic bench. A seated C1 adjustment was also delivered,

using a transverse process contact in a Gonstead cervical

chair. The patient was told to remain active. He was seen one

more time the following week, once in the fourth week, and

once in the sixth week, for a total of 4 visits. Each time he

presented to the office, a similar use of instrumentation, static

palpation, motion palpation, and visualization were used to

ensure where and when adjustments should be delivered. The

first three appointments required similar L5 and C1

adjustments and post-adjustment instruction. On the fourth

appointment (6th week) only L5 required adjusting. His pain

had decreased significantly after the completion of the sixth

week and the patient once again removed himself from care.

When the patient returned four months later, instrumentation,

static palpation, motion palpation, and visualization indicated

a C6 subluxation, which was adjusted in the seated position in

a Gonstead cervical chair (Figure 7). A subluxation was also

detected at L5, which was corrected using a single hand

contact on a Gonstead knee-chest table (Figure 8). The patient

returned two more times that week, both times receiving a

similar L5 adjustment using the knee-chest table. The

following week the patient came in two times, receiving two

similar lumbar adjustments and one similar cervical

adjustment.

Over the next three years the patient would be seen 321 times.

Each time he presented to the office, a similar use of

instrumentation, static palpation, motion palpation, and

visualization were used to ensure where and when adjustments

should be delivered. The results were such that, 225 times

(70.1%) an L5 subluxation was detected and adjusted (almost

always on a Gonstead knee-chest table using a spinous

contact). On 81 (25.2%) of these visits the patient was

determined to be free from subluxations, and no adjustments

were performed. Only 15 visits (4.7%) resulted in the

identification and correction of subluxations that did not

include L5. The areas adjusted in these instances were: the

right SI joint (one time), C1 (four times), T10 (3 times), T7 (3

times), C5 (one time), T8 (2 times), and T9 (1 time). (Figures

9 and 10).

Section 2 - Outcomes:

This patient has a particularly interesting set of outcomes, due

to the magnitude of the unforeseen benefits provided by the

correction of vertebral subluxation. The patient’s goals in this

section were initially very similar to his goals from the

previous section: reduce low back pain, and feel good enough

to return to his normal exercise routine. The patient improved

significantly in only 4 visits this time (6 weeks), and he

decided not to continue with care.

The difference this time, though, was that he injured his neck

four months later lifting weights at the gym and came back to

the chiropractor for care. The first two weeks back called for

adjustments to the L5 and C6 segments such that L5 was

adjusted five times total and C6 was adjusted two times. The

patient returned two more times that week, both times

receiving a similar L5 adjustment using the knee-chest table.

It was around this time that the patient believes he first noticed

a connection between the correction of his subluxations

(especially those at L5) and an improvement in erectile

function. He remembers it as such because it was at this point

that he started coming in to have his spine checked for

subluxations twice a week, on average, for the remainder of

the next three years. With the exception of two minor traumas

(pulled hard on a locked door, fell off his bike) the patient

remained under care with the primary goal of maintaining an

improved level of erectile function.

When asked now to reflect on these initial experiences, he

explained that once his chronic sacroiliac pain had gone away

and the chiropractor was able to focus on his L5 subluxation,

”for a short time after receiving an adjustment it is much

easier and highly more likely that (he) will attain and maintain

a strong erection.” The patient also commented that, while he

does still take a daily dosage of Cialis, and he has lost a

considerable amount of body weight, “improvements from L5

adjustments seem consistent and independent of all the other

variables.” He also found it important to mention that the

most effective of any of the pharmaceuticals prescribed to him

was a 20mg dose of Cialis that he was allowed to take on an

as-needed basis. This would provide him with, at best, a 36-

hour window of improved function. Replication of such

improvement had not been seen under his new prescription

(2mg of Cialis daily). Viagra had also been prescribed, but “it

didn’t work that well.” A chiropractic adjustment to a

subluxated L5, however, typically resulted in a 2-3 day period

without erectile dysfunction. In the three years after he

noticed improved erectile function, the longest he went

without being checked for subluxations was three weeks. The

highest number of consecutive visits where no spinal segments

were subluxated was three (which happened on five separate

occasions).

When asked if he would continue to utilize weekly

chiropractic care, after quite thoroughly testing its effect on

his dysfunction, he replied that “of course” he will. This

sentiment is due in part to the improvements in erectile

function, and also in part because it has helped him maintain a

high level of physical activity without the fear of his chronic

low back pain returning.

To better quantify this improvement, a traditional IIEF was

given to the patient and it was compared to the retrospective

IIEF given previously. His original, below-average score of

21/30 in the area of erectile function had improved to a 25/30

(a score now in the mild range, only one point away from

being considered “no erectile dysfunction”).34

Discussion

The case first described a patient with acute right low back

pain, sustained while shoveling snow. The man went to the

chiropractor the very next day and an acute right SI

subluxation was diagnosed and adjusted. Twelve adjustments

(total) and eight weeks later, the patient had improved to a


point where all of his goals were met and he felt comfortable

discontinuing care.

At first read, this section may seem somewhat irrelevant

(especially to ED). However, it is the first example of how

well that individual’s body was able to heal when subluxations

were corrected promptly. The patient made all of his

scheduled appointments, he was compliant with the

recommendations given, and he got better quickly.

When the patient returned 5 years later with acute neck pain

(from an injury the day before at the gym), an acute C6

subluxation was diagnosed and adjusted. He received five C6

adjustments (total) over the next five weeks, and three C6

adjustments over the following six weeks.

This example involves a different area of the spine, and a man

now five years older. Still, the patient’s potential for rapid

recovery following the correction of vertebral subluxation is

observed.

Why, then, is there such a difference in the ability at the L5

level to make a similarly impressive recovery? Logic would

suggest that, if this chronic L5 subluxation is, and has been, a

contributing factor to the patient’s loss of function, then it

would have to have existed either as long as, or longer than the

dysfunction itself.

Since the patient was 22-years-old when he first experienced

ED, a high level of suspicion is placed on the two instances of

lumbar spinal trauma (experienced at ages 16 and 20). Either

or both of these events could be easily credited with enough

abnormal strain on the low back to cause a subluxation.

To more properly review all the aspects of this specific L5

subluxation, the five traditional components of vertebral

subluxation35 will be used, as described by Flesia:

1) Component 1 – Spinal Kinesiopathology –

spinal pathomechanics, including alignment

and motion irregularities

2) Component 2 –

Neuropathophysiology/Neuropathology –

compressed or facilitated nerve tissue

3) Component 3 – Myopathology –

muscle spasm, muscle weakness/ atrophy

4) Component 4 – Histopathology –

inflammation, edema and swelling of tissue,

usually local to the traumatized area

5) Component 5 – Pathophysiology/Pathology –

pathophysiologic and pathoanatomical

changes due to Components 1-4 (usually seen

locally as degeneration), fibrous tissue and/or

erosion (locally and peripherally) as a loss of

global homeostasis.

When a subluxation first occurs, that joint is

immediately and simultaneously subject to the

effects of the first four components of

subluxation.35 Excessive force (like that produced

by jumping off a truck while weighted) can create

hypermobility in a joint initially, and fixations in a

joint if left uncared for. Chronically hypomobile

joints become increasingly vulnerable to fibrosis,

which eventually leads to degeneration and

remodeling of the involved structures. These local

changes place increased stress on the joints above

and below the dysfunction, which can result in

compensation/adaptions that affect the entire

biomechanics of the spine.35

The next three components of subluxation (myopathology,

neuropathophysiology/ neuropathology, and histopathology)

produce long-term spasm, long-term hypotonicity and atrophy,

nerve damage at the site of subluxation, retention of abnormal

spinal functions, and deteriorating whole body homestasis.35

The final component, Pathophysiology/Pathology, is the point

when the presence of vertebral subluxation “becomes a

clinical reality.”35 Once this has been reached, “significant

deterioration of the global and local homeostatic function in

the form of spinal degeneration and loss of the normal health

index” occurs.

This leads us back to the idea that the L5 subluxation is a

long-standing injury. After the two injuries to his lumbar

spine that were left untreated, it reached the stage of

pathophysiology/pathology. This also implies that, unlike his

other injuries that cleared up fairly quickly, this is a chronic

issue. This idea was also supported when X-rays were taken of

the lumbar spine for further analysis. The bony and soft tissue

changes were evidence of long standing dysfunction.

The role of vertebral subluxation in the development of

erectile dysfunction is not well supported by the current body

of literature. To best understand and defend this connection,

one must instead turn to the literature available on normal

penis anatomy, the pathophysiology of erectile dysfunction,

normal lumbar anatomy, the role of the lumbar spine in

erectile function, the effects of subluxation(s) on other

reproductive or autonomic functions, the effects of

subluxation(s) on the secondary systems necessary for erectile

function, the role of subluxation in low back pain and, in turn,

low back pain’s role in ED.

One of the more relevant articles describes a three-year-old

with painful priapism that showed improvement under

Gonstead-type chiropractic care.36 While priapism is quite

different than ED in presentation, the role of subluxation

correction and its effect on the male reproductive system is a

rarity in the literature. The child had been suffering for over

three weeks with erections lasting 22-23 hours a day. A

nervoscope was used to perform break analysis, and motion

palpation was used to confirm joint restriction. After one

cervical (C1) and one sacral (S2) adjustment, the mother

reported that the child was having only 1-2 erections per day,

for less than an hour each. Following this third visit, no more

erection problems were noted by the patient’s mother.

Another correlation between the lumbar spine and erectile

function comes in the discussion of disc herniation in the

lumbar spine and its effect on sexual dysfunction. In a case

report done by the International Medical Society of

Paraplegia, a 30-year-old male patient with a “2 month history

of low back pain” sustained said injury “while lifting an 18

kilogram garbage container.”37 After sustaining this injury, he


also complained of symptoms of erectile dysfunction as well

as experiencing “two episodes of urinary incontinence.”37 MRI

revealed disc herniation at L4/L5. At a follow-up visit three

weeks later, where the disc herniation had greatly reduced, he

“had no further episodes of sphincteric dysfunction,” and the

“erectile dysfunction had somewhat improved.”37 In a similar

study, it was concluded that “paralysis of the sphincter and

sexual dysfunction are possible in patients with lumbar L5-S1

disc disease.”38

The Scandinavian Journal of Urology and Nephrology

published a case report in which a 35-year-old lost proper

erectile function after falling off a horse at age 18.

Similarities can be found in the age of onset, the location of

the lumbar injury (L5-S1 disc protrusion), and the presentation

following trauma (the man landed on his buttocks and was

unable to sit for 3 weeks due to pain). A bilateral archotomia

was performed, followed by disc incision and emptying from

both sides. After 15 days he reported a strong erection, and on

a follow-up 10 years later he was still functioning properly.39

Conclusion

This case describes a patient with a long-standing history of

low back pain and erectile dysfunction. There are no

publications available at this time that describe the effects of

vertebral subluxation on erectile function. One limitation of

this study is that the results described are only of one man, and

are therefore hard to apply globally. Also, no MRI studies

were available to properly evaluate disc condition. It is, the

goal of this study to inspire future research, especially

research concerning young men with a new occurrence of ED,

and less chronic subluxations. These studies should be paid

for and conducted by the various chiropractic colleges of the

world, as they are the institutions tasked with providing

knowledge and resources to the next generation of

chiropractors. This would, in turn, provide all chiropractors

with a more significant resource for reference and would help

to improve the public’s awareness of chiropractic’s role in

maintaining proper body function.

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protrusion. Scand J Urol Nephrol. 2008 Feb; 42(1): 91.


Figures

Figure 1 - ETS-6 Nervoscope (dual-probed thermometric instrument)

Figure 2 – Corresponding segmental levels for temperature differentials while using an ETS-6 Nervoscope


Figure 3 – Gonstead Pelvic Bench

Figure 4 – Lateral Lumbar X-ray


Figure 5 – AP Lumbar X-ray

Figure 6 – AP Pelvis X-ray


Figure 7 – Gonstead Cervical Chair

Figure 8 – Gonstead Knee-Chest Table


Figure 9 – Adjustment schedule

Figure 10 – Adjustment schedule


reduction in frequency and severity of erectile ... in frequency and severity of erectile...

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