Journalof Manipulativeand PhysiologicalThernpeutics Volume 22' Number3' March/April 1999 0161-1754/99/$8.

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Rationalefor Assessing the Effectsof ManipulativeTherapyon AutonomicTone by Analysisof Heart RateVariability

Ale.t !v!. Eingorn. Dca and GeorgeJ. Mtths. DCb

ABSTRACT

Background: For more than 100years,chiropractorshaveasserted that overall healthcan be improvedthroughthe useof spinalmahipulative therapy.The autonomicnervoussys- ( tern is known to control and regulate all involuntaryphysiologic activitiesby controlling the activities of the internal organs, glands, and circulation. Recent studies document a potential relationship betweenthe verte. bral subluxationcomplex,autonomictone, and car. 'diac function. Objective: This discussionreviews how it is possibleto use heartrate variability analysisto calculatea quantitativeindexof autonomicfunction, which accuratelyreflects the sympathetic and parasympathetic toneandthe sympathovagal balance. Discussion: The technique of heartrateanalysisknownasheart rate variability could be extremelyusefulin assessment of treat-

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ment outcomes in clinical chiropractic practice. At present, heart rate variability is in widespread use in the fields of neurology, cardiology, psychology, psychophysiology, obstetrics, anesthesiology, and psychiatry. Conclusion:Further studies in this area may lead to a better understanding of the effects of spinal manipulation on (I) the general health of an individual, (2) an individual's susceptibility to lowered immunity and recuperative capacity, and (3) conditions that lie are outside the scope of musculoskeletal therapeutics and more in line with

classical chiropractic concepts. This can also contribute to a better-informed interprofessional cooperation between allopathic and chiropractic health care providers. (J Manipulative Physiol Ther 1999;22:161-5) KeyIndexing Terms:Autonomic Nervous System: Vagus Nerve; Chiropractic Manipulation

INTRODUCTION

For more than 100 years, chiropractors have asserted that overall health can be improved through the use of spinal manipulative therapy (SMT).1-4 This concept is integral to traditional chiropractic philosophy and is continuously alluded to in numerous anecdotal accounts.l.4.SThe autonomic nervous system (ANS) is known to control and regulate all involuntary physiologic activities by controlling the activities of the internal organs, glands, and circulation.6-s Recent studies document a potential relationship between the vertebral subluxation complex, autonomic tone, and cardiac function.S.9-11 In addition, in the osteopathic literature manipulation has been shown to have an effect on the ANS, specifically on lowering blood pressure in hypertensive individuals and positively affecting the fibrinolytic system.12 The same study showed that SMT produced an insignificant effect in normotensive individuals. Another study iridicated that autonomic neurovascular changes seem to bccur with suboccipital dermatomyotonic stimulation as measured with digital strain gauge plethysmography. 13

Walko and Janouschek14showed thennographic cooling after manipulative therapy of a patient with cervicothoracic pain. Grayson15discussed the case of a patient displaying a postmanipula~ve decrease in sympathetic output. Furthermore, spinal joint dysfunction has been shown to affect cardiac function,9.1o and the somatovisceral autonomic reflex system.11.16-19 Satol9 has shown that noxious stimulation can result in an increase in reflex somatocardiac sympathetic activity. Stimulation of vertebral joints produces a decreasein both heart rate and blood pressure.ISThe quality and direction of influence of SMT and ANS activity may depend on the specific spinal level that is manipulated.1oOn the other hand, the brain stem oscillators of the central autonomic network are integral to the modulation of autonomic output!1 and Sato's work indicates that the cardiac reflex response to somatic stimulation demonstrates a strong segmental organization that is suppressedby supraspinal structures}1.23 Therefore the mechanism by which manipulation may affect autonomic function must also consider possible suprasegmentaleffects.
DISCUSSION

"Researchassociate,New York Chiropractic College, Seneca Falls, NewYork. bAssistant professorof clinical services,University of Bridgeport Collegeof Chiropractic,Bridgeport,Connecticut. Submit reprint requests to: Alex M. Eingom, DC, Better Health Chiropractic,PC, 825 Seventh Ave, NewYork, NY 10019. PapersubmittedMay 21, 1998;in revisedfonn July 8, 1998.

Traditionally, autonomictone hasbeenassessed approximately, on the basisof subjectivedata suchas pupil dilatation!4.2S distal skin in temperature!O heartrate, andsympathoadrenergicbiochemical criteria such as blood levels of adrenaline, noradrenaline, andcorticosteroids.26-29 The heart rhythm electrocardiographicR-to-R interval (RR) haslong beenconsidered to be indicativeof cardiova-

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Manipulation and Autonomic Tone Ein8o~

~
Fig I. Methodofdetennining the RR interval rhythmogram.(CourtesyofHeart Rhythm Instruments, Inc.

gal activity.3o Heart rate variability (HRV) is an analysis technique that examines these beat-to-beat oscillations in heart rate. This analysis is targeted at what was formerly considered electrocardiographic "noise..'31Through the use of mathematical analysis, the oscillations can be broken into a series of periodic components consisting of various frequency ranges.31-35 The earliest clinical use of HRV was in obstetrics as a marker for fetal distress.36 At present, HRV is in widespread use in the fields of neurology, cardiology, psychology, psychophysiology, obstetrics, anesthesiology, and psychiatry.36 Thus the qualitative analysis of the spectral components inherent within the heart rate is an accepted means of examining the functioning of the sympathetic and parasympathetic divisions of the ANS, which is known to reflect the health status of the individual.32-40 HRV's usefulness in predicting risks and in early detection of an abnormal physiologic state has been documented in the literature.38.4o Likewise, the Framingham Heart Study indicates that ambulatory monitoring of HRV in elderly subjects offers prognostic information beyond that of traditional evaluation methods in relation to mortality risk.41 It should also be noted that the normal heart dynamics, as reflected by HRV analysis, indicate the absence of a disease process and thus the presence of good health.32-35 Integral to any HRV analysis is the collection of a heart rate rhythmogram by means of an electrocardiogram so that the inherent beat-to-beat oscillations, as measured by consecutive RR intervals (Fig 1), can be readily examined. For accurate interpretation of this electrocardiogram tachogram, any ectopic beats or signal interference within the collected cardiac rhythm data must be removed before performing !be.various methods of statistical analysis on the data. // In 1996, Malik and the task force on HRV42 published a thorough review of HRV in the journal Circula!{on. The article described in detail the measurement methods and proposed standards for HRV analysis. The article also reviews the known physiologic interpretation of HRV data with an eye toward clinical application. Malik et al42 discussed the use of two methods of HRV recording and analysis to standardize physiologic and clinical studies: long-duration recordings of 24 hours that use time domain statistical~

analysis, and short-duration recordings of 5 minutes that use frequency domain statistical analysis. Time domain analysis of HRV is based on calculation of the beat-to-beat interval measurements between adjacent QRS complexes, tenned the nonnal-to-nonnal (NN) interval with the usual electrocardiogram reference being the RR.36.42 A statistical variable that can be applied to time domain HRV data is the standard deviation of the NN intervals. The significance of the result of the standard deviation of the NN interval analysis lies in that it is equal to the total power of the spectral analysis and is therefore an estimate of the overall HRV. Another time domain method of statistical analysis is therefore an estimate of the overall HRV. Another time domain method of statistical analysis is the standard deviation of the average NN intervals. This measurement estimates the long-term or low-frequency (LF) variations within the heart rate data. Yet another time domain statistical analysis is the ror.mean square of the standard deviation of successive NN intervals. This measurement estimates the short-term or high-frequency (HF) variations within the heart rate data. Geometric methods are also useful for analysis of time domain HRV data. The density distribution histogram of NN intervals can be appraised with the HRV triangular index, which is also an estimate of the total power of the overall HRV.36.42 Frequency domain analysis of the tachogram yields an estimate of the power spectral density, which reflects how power, or variance, distributes as a function of frequency. Power spectral density can be calculated by either parametric or nonparametric methods. The nonparametric methods are simpler and faster, and usually use a fast Fourier transfonn. The fast Fourier transfonn analysis quantifies the proportion of one frequency relative to that of another frequency within a signal.3D The parametric methods yield smoother spectral components with easily identifiable central frequencies of the LF and HF components and provide an accurate estimation of power spectral density even on a small number of samples. Short-duration frequency domain recordings yield very low frequency, LF, and HF spectral components, whereas long-duration recordings yield an additional ultra low frequency component along with the verY low freQuen-~

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Rh ythm StrIp

a)

b)

Fig 2. A, Representative RR interval HRV rhythmogram. B, Spectral function of the HRV rhythmogram. (Courtesyof Heart RateInstruments. Inc.)

cy, LF, and HF spectral bands. So far, only the LF and HF spectrum up to the respiratory frequency of about 0.3 Hz, the HF spectral component is considered to be a combinaspectral components produce useful data.42 Many of the time and frequency domain analysis methods tion of both the vagal and sympathetic activity. In contrast, yield results that strongly correlate with each other.42 This is the LF spectral component with a peak of about 0.1 Hz is of clinical significance because the frequency domain mea- considered to be representative of bursts of sympathetic vasomotor activity.31.42 As noted earlier, the interpretation of sures are easier to perform and are more practical in a clinical setting becausethey do not require the 24-hour recording the very low frequency and the ultra low frequency spectral components of HRV is still unclear. Therefore analysis of duration of the time domain methods. The different spectral components of HRV reflect the beat- ~he HF and LF spectral bands layered within the compound to-beat modulation of various oscillators on the sinus node of HRV waveform provides an indication of changes in the It should also be noted that in the heart. The sympathetic and vagal efferent activity is a sympathovagal balance.31.42.43 product of both the central nervous system oscillators of the addition to frequency, the amplitude of the spectral function vasomotor and the respiratory centers and the peripheral os- should also be considered when analyzing the sympathovacillations of the arterial pressure and the respiratory motion. gal interaction.43 It is therefore possible to use HRV analysis to calculate a The heart rate and blood pressure waves that are coupled to the respiratory frequency are termed Traube-Hering waves quantitative index of autonomic function that accurately and have a peak period of about 0.3 HZ.31ThI1 waves that are reflects the sympathetic and parasympathetic tone, as well as In conjunction with this nonrespiratory frequency coupled waves are called Mayer- the sympathovagal balance.31.44.4S the orthostatic test has been shown to be a reliable method of waves and consist of slower frequencies between O.O~~d 0.15 Hz, with a peak period of about 0.1 HZ.30.31 Thjlrefore ANS provocation with predictable normal results.46.47 An HRV reflects the state and function of the central osFillators, orthostatic stress test is used to produce a vasodilatory stimperipheral responsesto the central autonomic drive;6y means ulus. A simple slow upright tilt from a supine position to 80 of sympathetic and vagal efferent activity, humoral factors, degrees or 90 degreesover a minimal period of 10 to 20 seconds can be used to elicit an orthostatic response.42.48 In and the state of the sinus node itself.3O.42 some patients with adrenergic failure, a routine tilt test will The HF component of the HRV compound waveform (Fig 2) can be abolished by a cholinergic blockade with atropine, not elicit presyncope or an orthostatic drop response. Four leaving only the LF component with a peak of about 0.1 Hz. additional methods of orthostatic challenge are sublingual This remaining LF component can then be abolished with a trinitroglycerin, postexercise tilt, lower body negative pressympathetic blockade by propranolol.36 Although the vagal sure, and a prolonged tilt.48 In addition, some patients will efferent activity is the major contributor to the entire HF exhibit an orthostatic responseafter a meal or a warm bath.48

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Perhaps two of the most elegant examples of autonomic assessment with HRV were the presentations of Lipsitz et al49and Pruvot et aI,50in which the relationship between the parasympathetic and the sympathetic nervous systems in normal subjects and those subjects with vasovagal syncope were studied by using the orthostatic test to provide provocation to the ANS. These studies revealed that patients with vasovagal syncope have an increase in parasympathetic tone on oI1hostatic provocation as reflected in an elevation of HF components of the HRV analysis. Various general physiologic correlations have been noted in relation to HRV. Spectral analysis of HRV indicates a prevalent increase in LF during a 90-degree tilt, standing, mental stress, moderate exercise, moderate hypotension, physical activity, and occlusion of the coronary or common carotid arteries and is generally higher during the day. An increase in the HF component is seen as the result of controlled respiration, a cold stimulus to the face, rotational stimuli, and is generally increased at night.42 Pathologic reduction in HRV has been noted in relation to myocardial infarction, diabetic neuropathy, cardiac transplantation, myocardial dysfunction, tetraplegia, and in the identification of individuals with the possibility of increased risk of sudden cardiac death.42.51 In the clinical setting HRV analysis must be used in conjunction with other clinical assessment modalities when determining the specific diagnosis of a patient's condition. It is not a replacement for existing clinical evaluation methods. However, as noted earlier, ceI1ain trends in HRV fluctuations are an accurate means for predicting and identifying the presence of a serious disorder by a method independent of the patient's anecdotal report as to how he or she may be doing. As such, it is a valuable and practical modality for aiding the clinical decision-making process.42
CONCLUSION

ACKNOWLEDGMENTS

We would like to expressour thanks to Dr Alexander Riftine of Heart Rhythm Instruments, Inc; Dr Anthony Rosnerof the Foundationfor Chiropractic Education and Research; and Mary Ellen Bowen and Krystyna Kossarska of the University of BridgeportWahlstromLibrary.
REFERENCES 1. Palmer DD. Textbook of the science, art and philosophy of chiropractic. Portland (OR): Portland Printing House 1910. p. 117,408. 2. Palmer DD. The chiropractor. Los Angeles: Beacon Light Printing Company; 1914. 3. Leach The chiropractic theories: synopsis1986. of scientific rese " RA. . 2nd ed. Baltimore: William &a Wilkins; 4. Wardwe WI. Chiropractic: History and evolution of a new profession St. Louis: Mosby; 1992. 5. Gatterma MI. Foundations of chiropractic: subluxation. St. ouis: sby; 1995. p. 12, 150-68. 6. Haratl Y, Machkhas H. Spinal cord and peripheral nervous system. In: Low PA, editor. Clinical autonomic disorders. 2nd ed. Philadelphia: Lippincott-Raven Publishers; 1997. p. 25-45. 7. Guyton AC. Basic neuroscience: anatomy and physiology. 2nd ed. Philadelphia: WB Saunders: 1991. p. 273-82. 8. Kandel ER, Schwartz JH, Jessell TM. Principles of neural science. 3rd ed. Norwalk (CT): Appleton and Lange; 1991. p. 761-8. 9. Jarmel MA. Possible role of spinal joint dysfunction on the genesis of sudden cardiac death. J Manipulative Physiol Ther 1989;12:469- 77. 10. Jarmel M, Zatkin J. Improvement of cardiac autonomic regulation following spinal manipulative therapy. Chiropractic Foundation Conference Proceedings; 1995 JuI6-8; Washington (DC). 11. Slosberg M. Effects of altered afferent articular input on sensation, proprioception, muscle tone and sympathetic reflex responses. J Manipulative PhysiolTher 1988;11:181-9. 12. Celander E, Koenig AJ, Celander DR. Effect of osteopathic manipulative therapy on autonomic tone as evidenced by blood pressure changes and activity of the fibrinolytic system. J Am Osteopath Assoc 1968;67:1037-8. 13. Purdy WR, Frank JJ, Oliver B. Suboccipital dermatomyotomic stimulation and digital blood flow. J Am Osteopath Assoc 1996;96:285-9. 14. lIalko EJ, Janouschek C. Effects of osteopathic manipulative treatment in patients with cervicothoracic pain: pilot study using thermography. J Am Osteopath Assoc 1994;94:135-41. 15. Grayson MF. Horner's syndrome after manipulation of neck. BMJ 1987;295:1381-2. 16. Korr 1M. The neurobiologic mechanisms in manipulative therapy. New York: Plenum Press; 1977. 17. Giles LGF. Paraspinal autonomic ganglion distortion due to vertebral body osteophytosis: a cause of vertebrogenic autonomic syndromes? J Manipulative Physiol Ther 1992;15:551-5. 18. Sato A. The reflex effects of spinal somatic nerve stimulation on visceral function. J Manipulative Physiol Ther 1992;15:57-61. 19. Sato A. Somatovisceral reflexes. J Manipulative Physiol Ther 1995;18:597-602. 20. Harris W, Wagnon RI. The effects of chiropractic adjustments on distal skin temperature. J Manipulative Physiol Ther 1987;10:57-60. 21. Benarroch EE. The central autonomic network. In: Low PA, editor. Clinical autonomic disorders. 2nd ed. Philadelphia: Lippincott-Raven Publishers; 1997. p. 17-23. 22. Atsuko H, Hideo 0, Akio S, et al. Somatocardiovascular reflexes in anesthetized rats with the central nervous system intact or acutely spinalized at the cervical level. Neurosci Res 1995;
???q7-~n~

In summary,empirical and early quantitative evidence suggestSMT may have an effect on a patient's autonomic tone by modulationof the centralcontrol mechanisms governing suchphysiologicprocesses. InasmuchasHRV analysis currently appearsto be reliable and accuratemethodof ANS assessment andbecause no publishedresearch is in the current literature that directly correlatesANS assessment through HRV with either generalor specific SMT, we suggestthat further studiesin this field may significantly~ontribute to a betterunderstanding of the effectsof SMT n (I) the generalhealth of an individual, (2) an individu 's susceptibility to lowered immunity and recuperativec pacity, and (3) conditions that lie outside the scope of musculoskeletal therapeuticsand are more in line with lassical chiropractic concepts. It may also contribute to more informed interprofessional understanding and enhanced cooperation betweenboth allopathicand chiropractichealth care providers.This includes the possibleeffectivenessof manipulativeintervention in nonmusculoskeletal disorders, asreflectedin the effectsof therapeutic modulationof autonomic tone.

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23. SatoA. Neural mechanisms of autonomicresponses elicited by somatic sensorystimulation. Neurosci Behav Physiol 1997; 27(5):610-21. 24. Briggs L, Boone WR. Effects of chiropractic adjustmenton changes in pupillary diameter:a model for evaluatingsomatovisceralresponse. J ManipulativePhysiolTher 1988;11: 181-9. 25. VandertopWP, de Vries WB, NotermansNC, Tulleken CAF, Gispen WHo Beneficial effect of an ACTH4-9 analogueon experimentallyinduceddiabeticautonomicneuropathyin the eye of the rate under generalanaesthesia. J Auton Nerv Syst 1995;51 :49-57. 26. Woo MA, StevensonWG, Moser DK, Middlekrauf HR. Complexheartrate variability andserumnorepinephrine levels in patients with advancedheart failure. J Am CoIl Cardiol 1994;23:565-9. 27. aka H, Mochio S, SatoK, et al. Spectralanalyses of R-R interval andsystolic blood pressure in diabeticautonomicneuropathy. JAuton Nerv Syst 1995;52:203-11. -~ 28. Ikuta Y, Simoda 0, Kano T. Quantitative assessment of the autonomicnervoussystemactivities during atropine induced bradycardiaby heartrate spectralanalysis.J Auton Nerv Syst 1995;52:71-6. 29. WarnerMR. Time-courseand frequencydependence of sympathetic stimulation evokedinhibition of vagal effects at the sinusnode.J Auton Nerv Syst 1995;52:23-33. 30. NovakV, NovakP,Low PA.Time frequencyanalysisof cardiovascularfunction andits clinical applications. In: Low PA, editor. Clinical autonomic disorders. 2nd ed. Philadelphia: Lippincott-Raven Publishers;1997.p. 323-48. 3 I. Karemaker JM. Analysis of blood pressure and heartrate variability: Theoreticalconsiderations. In: Low PA, editor.Clinical autonomicdisorders.2nd ed. Philadelphia:Lippincott-Raven Publishers;1997.p. 309-22. 32. GoldbergerAL. Fractalsand the heart. Konink linjke NederlandsevanWetenschappen 1990;93:409-18. 33. GoldbergerAL, Rigney DR. Suddendeath is not chaos. In: KrasnerS, editor. The ubiquity of chaos.Vol. 3. Washington: AAAS Press;1990.p. 23-34. 34. Goldberger AL. Fractalelectrodynamics of the heartbeat. Ann Acad Sci 1990;591:402-9. 35. GoldbergerAL, Rignery DR, West BJ. Chaosand fractals in humanphysiology.Sci Am 1990;262(2):43-9. 36. FreemanR. Noninvasiveevaluationof heart rate variability: the time domain.In: Low PA,editor.Clinical autonomicdisorders.2nd ed. Philadelphia: Lippincott-Raven Publishers;1997. p. 297, 298,307. 37. MolgraadH, HenllansenK, Bjerregaard. Spectralcomponents of short-tenll R-R interval variability in healthy subjects and effectsof risk factors.Eur HeartJ 1994;15:1174-83. 38. Itoh H, TakedaK, Tanaka M, et al. Youngborderlinehypertensives are hyperreactiveto mental arithmetic stress:spectral analyses of R-R intervals.J Auton Nerv Syst 1995;~4: 155-62.

39. lnohue K, Ogata H, Hayano J, Miyake S, Kamada T, Kuno M, et al. Assessment of autonomic function in traumatic quadriplegic and paraplegic patients by spectral analysis of heart rate variability. J Auton Nerv Syst 1995:54:225-34. 40. Furlan R, Piazza S, Belivacqua M, Turiel M, Norbiato G, Lombardi F, et al. Pure autonomic failure: complex abnormalities in the neural mechanisms regulating the cardiovascular system. J Auton Nerv Syst 1995;51:223-35. 41. Tsuji H, et al. Reduced heart rate variability and mortality in an elderly cohort: the Framingham Heart Study. Circulation 1994;90:878-83. 42. Malik M, et al. Heart rate variability: standards of measurement, physiological interpretation, and clinical use. Circulation 1996;93:1043-65. 43. Montano N, et al. Power spectrum analysis of heart rate variability to assessthe changes in sympathovagal balance during

addedorthostatictilt. Circulation 1994;90:1826-31. 44. K in EM, Riftine AD, et al. Application of automated systems for ssessing the functional states of the humanorganism, Part 1: nalysisof indicesof the functionalstates of persons in var. us professions (white-and blue-collar workers). Human Physiology. Acad Sciences USSR 1991;17(1):126-31. 45. Kazin EM, Riftine AD, et al. Automatedsystems for the complex evalliation of the health and adaptive reservesof the human body. Human Physiology. Acad Sciences USSR 1990;16(3):94-9. 46. SneddonJF, CounihanAJ, Bashiry, HaywoodGA, Ward DE, CammAJ. Assessment of autonomicfunction in patientswith neurally mediatedsyncope: augmented cardiopulmonary baroreceptor responsesto graded orthostatic stress.J Am Coil CardioI1993;21:1193-8. 47. Shakespeare CF, Katritsis D, CrowtherA, CooperIC, Coltari JD, Webb-Peploe MM. Differencesin autonomicnerve function in patients with silent and symptomatic myocardial ischemia.Br HeartJ 1994;71 :22-9. 48. Low PA. Laboratoryevaluation of autonomicfunction.In: Low PA, editor.Clinical autonomicdisorders. 2nd ed. Philadelphia: Lippincott-RavenPublishers;1997.p. 179-208. 49. Lipsitz LA, Mietus J, Moody GB, GoldbergerAL. Spectral characteristics of heartrate variability before and during postural tilt: relations to aging and risk of syncope.Circulation 1990;81:1803-10. 50. Pruvot E, Vibe K, VesinJM, SchlapferJ, FromerM, KappenbergerJ. Autonomic imbalanceassessed by heartrate variability analysisin vasovagal syncope.PACEPacingClin ElectrophysioI1994;17:2201-6. 51. Jarmel ME. Identifying and treating apparentlyhealthy individuals at increased risk for suddencardiacdeath.Chiropract FamPract 1992;17(3):1-9.