Chiropractic Dose-Response Relationship and Public Health with Dr. Mitch Haas

dr-mitch-haasDr. Mitch Haas and I discuss the dose-response relationship between chiropractic and health outcomes as well as chiropractors in public health. Dr. Haas has been an integral member of the research division at the University of Western States (UWS) since joining the faculty in 1987. He is now the associate vice president of research at UWS. Dr. Haas also serves as an adjunct associate professor in the neurology department at Oregon Health & Science University (OHSU). Dr. Haas has been either principal investigator or co-investigator on more than 30 extramurally funded grants bringing more than $7 million in research funding to UWS. In 1994, he was a co-investigator on the first federal research grant ever awarded to a chiropractic college.

Dr. Haas has since become the principal investigator (PI) for a number of large federal grants awarded by the U.S. Department of Health and Human Services (U.S.D.H.H.S.) Health and Resources Services Administration and the National Center for Complementary and Alternative Medicine at the National Institutes of Health. These collaborative projects with OHSU and other institutions were designed to evaluate pain and disability outcomes and cost-effectiveness of chiropractic and medical treatment for low back pain, a chronic pain self-management program in the elderly, the relationship of the number of chiropractic treatments with health outcomes for low back pain and headaches and care of low back pain in adolescents.

Dr. Haas has been active in state and national public health associations. He was the founding chair of the Chiropractic Healthcare Section of the American Public Health Association (APHA) and has since served as chair of the APHA Intersection Council, a governing councilor, member of the APHA Executive Board and chair of the APHA Bylaws Committee. He was also the 2007 president of the Oregon Public Health Association (OPHA).

Check out Dr. Mitch Haas’s publications on researchgate.

Here are the articles we discuss in this podcast episode:

1. Dose-response of spinal manipulation for cervicogenic headache: study protocol for a randomized controlled trial.
Hanson L, Haas M, Bronfort G, Vavrek D, Schulz C, Leininger B, Evans R, Takaki L, Neradilek M.
Chiropr Man Therap. 2016 Jun 8;24:23. doi: 10.1186/s12998-016-0105-z.
PMID: 27280016 [PubMed] Free PMC Article
Similar articles
2. Dose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial.
Haas M, Vavrek D, Peterson D, Polissar N, Neradilek MB.
Spine J. 2014 Jul 1;14(7):1106-16. doi: 10.1016/j.spinee.2013.07.468.
PMID: 24139233 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
3. Cost analysis related to dose-response of spinal manipulative therapy for chronic low back pain: outcomes from a randomized controlled trial.
Vavrek DA, Sharma R, Haas M.
J Manipulative Physiol Ther. 2014 Jun;37(5):300-11. doi: 10.1016/j.jmpt.2014.03.002.
PMID: 24928639 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
4. A path analysis of the effects of the doctor-patient encounter and expectancy in an open-label randomized trial of spinal manipulation for the care of low back pain.
Haas M, Vavrek D, Neradilek MB, Polissar N.
BMC Complement Altern Med. 2014 Jan 13;14:16. doi: 10.1186/1472-6882-14-16.
PMID: 24410959 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles

 

Update on the Magnitude and Time Course of Low Back Pain

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The high prevalence of low-back pain (LBP) has been highlighted for many years, but until recently, awareness of its influence on the population was inadequate. The results of the Global Burden of Disease (GBD) Projects 2010 have informed us that the leading cause of disability (as measured by years lived with disability) worldwide is low back pain.  Additionally, musculoskeletal conditions as a whole are the second greatest cause of disability globally according to a report by international experts, published in The Lancet on December 15th, 2012.  In the first comprehensive study of the worldwide impact of all diseases and risk factors, musculoskeletal (MSK) conditions such as arthritis and back pain affect over 1.7 billion people worldwide, and have the fourth greatest impact on the overall health of the world population, considering both death and disability.  This burden has increased by 45% over the last 20 years and will continue to do so unless action is taken.  This landmark study of the global burden of all diseases provides indisputable evidence that musculoskeletal conditions are an enormous and emerging problem in all parts of the world and need to be given the same priority for policy and resources as other major conditions like cancer, mental health and cardiovascular disease.

With the knowledge that LBP is the number one cause of disability in the world, it is unfortunate that little is known about the detailed course, and trajectory, of LBP.  Until recently LBP was believed to be a self-limiting condition, similar to the common cold. However, research in the past two decades has shown that LBP is actually a recurrent condition that could be likened to a more chronic condition such as asthma.  In this regard, we are starting to look at LBP as not seen as a single entity, but rather to the LBP condition which can be regarded as a chain of LBP episodes.  So, we need to view LBP (and maybe all types of spine pain) as having a lifelong course – perhaps with different etiology and modifying factors as life progresses, but always existing as an underlying ‘trait’.

When researchers have looked at the non-benign, and non self-limiting nature of the condition, three large groups of LBP patients emerge: 1): those without LBP; 2) those who experience it on and off and; 3) those who have it most of the time. It is pretty clear that definite recovery with no recurrences does not appear to be common, although to date, we do not know how these patterns develop over the course of a lifetime. People with LBP will not necessarily seek care, but a person who consults a chiropractor for an episode of LBP is likely to feel better fairly quickly. In light of these findings, clinicians should observe and convey information about episodes within the context of a longer-term pain trajectory, to provide patients with a realistic view of the problem. The authors of the recent trajectories of low back pain article referenced herein suggest that effective short-term treatment strategies, pain management and activity maintenance as well as secondary and tertiary prevention should be high on the clinical agenda. ‘Management rather than cure’ might be a helpful catch phrase, similar to the well-known recommendation of ‘don’t worry – keep active’ (Axén and Leboeuf-Yde, 2013).

Given the shift in attention of LBP to view it as a chronic condition, researchers and clinicians are putting more emphasis on investigating LBP throughout the life course.  What is emerging from this life course investigation is that similar factors (e.g., genetics, parental factors, psychological factors, injury, physical activity, comorbidity) are associated with the pain at different times. There appears to be strong evidence for the links between back pain, pain at other locations (e.g., shoulder) and other health problems. This evidence leads to the potential conclusion that vulnerability for long-term back pain develops at an early age, likely in childhood, and influences the occurrence of, and recovery from, episodes of back pain (Dunn et al, 2013).

Furthermore, results of a recent meta-analysis of LBP in children and adolescents indicates higher prevalence rates of LBP in the most recent studies suggesting that this a problem that is increasing in this young population (Calvo-Muñoz et al, 2013). As a consequence, more attention should be devoted to develop and apply prevention programs and early detection programs for young children in order to reverse this tendency.

Key Points

  • The leading cause of disability worldwide is low back pain
  • Evidence is mounting that classifying low back pain as acute, subacute and chronic is no longer helpful
  • Many individuals experience multiple episodes of back pain with the first episode occurring early in life
  • LBP is now being thought of as a potentially chronic health condition in its own right

References:

1. Vos T et al.Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec 15;380(9859):2163-96.

2.Axén I, Leboeuf-Yde C. Trajectories of low back pain. Best Pract Res Clin Rheumatol. 2013 Oct;27(5):601-12.

3. Dunn KM, Hestbaek L, Cassidy JD. Low back pain across the life course. Best Pract Res Clin Rheumatol. 2013 Oct;27(5):591-600.

4. Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr. 2013 Jan 26;13:14.

Back Pain During Pregnancy and Chiropractic Care

adobestock_69723890Low back pain is one of the most common and often disabling problems in pregnancy. The prevalence of pregnancy related low back pain (PLBP) or pelvic girdle pain (PGP) is 20% to 90% with most studies reporting more than 50% prevalence. —PGP is almost 2x more common than lumbar pain. —25% of all postpartum women suffer from PGP and/or PLBP.

A 2014 prospective, cohort, outcomes study involving 115 pregnant women with low back or pelvic pain participated in the study.  Baseline numerical rating scale (NRS) of pain intensity and Oswestry Low Back Pain Disability Index questionnaire data were collected.  In addition, The patient’s global impression of change (PGIC) (primary outcome), NRS, and Oswestry data (secondary outcomes) were collected at 1 week, 1 and 3 months after the first treatment.  Then, at 6 months and 1 year the PGIC and NRS scores were collected again. PGIC responses of ‘better’ or ‘much better’ were categorized as ‘improved’. Chiropractic treatment was pragmatic and left to the discretion of the treating clinician.

Results:

  • 52% of 115 recruited patients ‘improved’ at 1 week, 70% at 1 month, 85% at 3 months, 90% at 6 months and 88% at 1 year.
  • There were significant reductions in NRS and Oswestry scores
  • Patients with more prior LBP episodes had higher 1 year NRS scores

Most pregnant patients with low back or pelvic pain undergoing chiropractic treatment reported clinically relevant improvement at all time points.

Reference: Peterson CK, Mühlemann D, Humphreys BK. Outcomes of pregnant patients with low back pain undergoing chiropractic treatment: a prospective cohort study with short term, medium term and 1 year follow up. Chiropr Man Therap. 2014 Apr 1;22(1):15.

 

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Chiropractic and Infant Colic

adobestock_42898239Infantile colic is one of the significant challenges of parenthood.  It is one of the common reasons for pediatrician visits during the child’s first 3 months of life. Infantile colic is a prevalent and distressing condition for which there is no proven standard therapy, which motivates parents to seek alternatives.  It is defined as paroxysms of crying lasting more than 3 hours a day, occurring more than 3 days in any week for 3 weeks (aka rule of 3) in a healthy baby aged 2 weeks to 4 months. Colic remains a poorly understood phenomenon affecting up to 30% of babies, with underlying organic causes of excessive crying accounting for less than 5% of cases.  Laboratory tests and radiological examinations are unnecessary if the infant is gaining weight normally and has a normal physical examination.

To date, several randomized trials examining chiropractic care for children with colic have been reported, and although these trials demonstrate some reduction in crying, weaknesses in study methodologies have limited the evidence they provide.  Based on these previous studies, there is some but not definitive evidence to make a recommendation of manual therapy for the excessively crying baby.

The purpose of this study was to try to address methodological weaknesses in the scientific literature by conducting a single-blind, randomized controlled trial comparing chiropractic manual therapy with no treatment and to determine whether parents’ knowledge of treatment biases their report of change in infant crying.

Infants with unexplained persistent crying (colic) verified by a baseline crying diary of 3 days or more and presenting to the Anglo-European College of Chiropractic were included in the study. Other inclusion criteria included: patients had to be younger than 8 weeks, born at a gestational age of 37 weeks or later, and had a birth weight of 2500 grams or more and show no signs of other conditions or illness.  One hundred and four infants participated.

Parents completed a questionnaire (baseline) and their child was then randomized to 1 of 3 groups.  In 2 of the 3 groups, infants received treatment, and in the third, no treatment was administered.  For one of the treatment groups, the parent was able to observe the treatment and knew that the infant was being treated.  Parents in the other two groups were seated behind a screen and could not observe their child. Therefore, parents in these two groups were ‘blind’ as to whether their infant received treatment or not.  To be clear, the 3 groups were: (i) infant treated/parent aware, (ii) infant treated/parent unaware (blinded), and (iii) infant not treated/parent unaware (blinded).

Chiropractic care was delivered by a chiropractic intern and involved low force tactile pressure to spinal joints and paraspinal muscles where dysfunction was noted on palpation. The manual therapy, estimated at 2 N of force, was given at the area of involvement without rotation of the spine. Treatment duration lasted up to 10 days, and the number of treatments during this period were influenced by examination findings and parent reports. Treatment was stopped if parents reported their infant was symptom-free. Infants in the blinded groups were placed by the parent on the examination table and then parents sat behind a screen that blinded observation. Patients in the no-treatment group were not touched by the intern and/or clinician.

Outcome measures included crying time as assessed by a 24 hour crying diary ending either 10 days after baseline or at discharge – whichever was sooner.  Crying time was extracted from the diaries.  A global improvement scale (GIS) was completed at either 10 days or discharge by parents and assessed their ratings of change since baseline (e.g., worse to much improvement).

Key findings of this study were:

  • Compared with baseline, by day 10, there was a significant decrease in crying time -44.4%,  51.2%, and 18.6% in the treatment groups ([Blinded] and [Not Blinded]) and the no-treatment group, respectively
  • In parents blinded to treatment allocation, using 2 or less hours of crying per day to determine a clinically significant improvement in crying time, the increased odds of improvement in treated infants compared with those not receiving treatment were statistically significant at day 8 (adjusted odds ratio [OR], 8.1) and at day 10 (adjusted OR, 11.8)
  • There was a similar greater odds of improvement with treatment compared with no treatment using the global improvement scale
  • The number needed to treat was 3 (indicating that 3 infants need to be treated to gain one additional improvement in crying time over no treatment)

In summary, this study found that excessively crying infants were at least 5 times less likely to cry if they were treated with chiropractic manual therapy than if they were not treated.  Infants who were treated were equally likely to improve, whether the parents were blinded to treatment or not.

Reference:  Miller JE, Newell D, Bolton JE. Efficacy of chiropractic manual therapy on infant colic: a pragmatic single-blind, randomized controlled trial. J Manipulative Physiol Ther. 2012 Oct;35(8):600-7.

 

 

 

 

Chiropractic Science Delivers the Evidence with Convenience (and It’s Free)

ChiropracticScienceLogo1American chiropractors are very similar to chiropractors in other countries, as well as other health professionals in terms of their favorable attitudes towards evidence based practice (EBP) (1-2). The purpose of EBP is to promote effective chiropractic practice and enhance public health. Evidence based practice incorporates the best research evidence with individual clinical expertise and patient choice/values (3). There are however several limitations and barriers to implementing EBP that chiropractors express such as lack of research relevance, lack of time and insufficient skills for locating and appraising research (1). It is important to note that these same obstacles are also encountered by other professions including medicine and nursing.

In a recent survey, very few DCs indicated that computer, internet, or database access were barriers to their uptake of EBP (1). Since chiropractors are interested in implementing EBP, these findings underscore the importance of providing clinicians with training in EBP skills, particularly through online resources. It is likely that comprehensive and multi-faceted approaches that take into account all the relevant levels affecting EBP will likely be needed to integrate research into practice (1).

As a practitioner as well as a researcher, I realize the importance and barriers of translating research into practice. I have also begun to realize how I can give back to the profession. Some of you may recognize my On Target research summaries.  Others may be familiar with my chiropractic science podcast.  While there may be many ways to tackle the evidence-practice gap, one convenient educational method is a podcast. This is one of the ways that I have been utilizing to help get chiropractic research out to the masses. For those not familiar, a podcast describes audio and/or video files that can be downloaded and played on a personal computer or mobile device.

Podcast is the term commonly used to refer to a series of digital media files that are released periodically and can be subscribed to using an RSS (Really Simple Syndication) feed. This means of digital delivery is what makes podcasting different from other means of accessing media files over the internet.  Of course one can still download the audio and/or video files that makeup a podcast.  The automatically downloaded files can be stored locally on a computer or other device (such as your mobile phone) ready for offline use, providing simple and convenient access to regular releases.

Podcasting has been used successfully in teaching and learning in many different student groups (4-5). In theory podcasts provide educational content in a format that is convenient and available 24 hours a day and can be accessed whenever and wherever the learner chooses (4-5). Learners have the ability to replay a podcast as many times as they wish in order to improve understanding. In addition, podcasting offers the ability to embed additional content from researchers or clinicians to help make links between theoretical concepts and practice.

While many chiropractic podcasts exist, chiropractic science (CS) is the only podcast that exclusively interviews chiropractic researchers about the science of chiropractic. CS publicizes and disseminates chiropractic research. Hear about chiropractic research from the authors in plain English, not through the media, nor a middleman. Think about recent media coverage concerning the evidence of chiropractic in magazines or online.  While reports of chiropractic studies in the media may be very good (or very poor), some things get lost in translation.  By interviewing the chiropractic experts that are actually doing the research, you’ll get the information direct – the way the author intended it.

Making scientific findings available to the public is an important part of the research process.  Publicizing these interviews passes on the benefits of chiropractic research to other researchers, chiropractors in practice as well as practitioners from other disciplines and the wider community. In addition to publicizing the interviews, other goals of the podcast are to encourage collaboration of researchers to promote future high quality chiropractic research as well as to motivate and assist practitioners and students alike to pursue research careers in chiropractic science!

Why Chiropractic Science?

  • There is a lot of excellent chiropractic research published by top scientists in the field that deserve our attention
  • Incorporating the latest evidence into your practice of chiropractic is good for everyone
  • Reduce the evidence – practice gap and promote knowledge translation from the chiropractic research laboratory to the clinic
  • Engage clinicians in evidence based practice in a fun, easy to access manner
  • Learn from the experts and gain confidence in your knowledge and communications with others about chiropractic
  • A chiropractic resource for students, doctors and patients

Feedback about Chiropractic Science

  • “It has been such an inspiration to listen to all the greats in the world of chiropractic research”
  • “It has certainly made an impact on my practice and gives me a tremendous amount of certainty in what we do as chiropractors”
  • “I find the information profoundly motivating”
  • “It is difficult to read and interpret journal articles for a seasoned chiropractor. This saves time and hearing it explained from your colleagues themselves in language that I can communicate with my patients is invaluable”
  • “I am humbled by the sacrifice, hard work and accomplishments of all the researchers you have interviewed”
  • “Being in practice for many years, I am weary of ideologically biased forums when 21st Century chiropractic can have and bring it all; evidence and practice based science WITH a strong philosophical foundation. Highest accolades to Dr. Dean Smith for his untiring success at bringing the bar, raising colleagues and conversations together to articulate just how pertinent chiropractic is in contemporary health care”

In short, CS is starting to achieve what it set out to do, but this just the beginning. I am humbled by the feedback I have received from chiropractors about the podcast and am looking forward to interviewing as many chiropractic researchers as possible.  If you haven’t listened to the podcast, check them out.  If you like what you hear, please leave a great review on iTunes. This will help position CS as a leading health podcast – enlightening the masses about the evidence of chiropractic.  Listen to the podcast on iTunes or download the files directly to your device from chiropracticscience.com.  Enjoy and share with everyone.

References:

  1. Schneider MJ, Evans R, Haas M, Leach M, Hawk C, Long C, Cramer GD, Walters O, Vihstadt C, Terhorst L. US chiropractors’ attitudes, skills and use of evidence-based practice: A cross-sectional national survey. Chiropr Man Therap. 2015 May 4;23:16.
  2. Alcantara J, Leach MJ. Chiropractic Attitudes and Utilization of Evidence-Based Practice: The Use of the EBASE Questionnaire. Explore (NY). 2015 Sep-Oct;11(5):367-76.
  3. Lefebvre R, Peterson D, Haas M. Evidence-Based Practice and Chiropractic Care. J Evid Based Complementary Altern Med. 2012 Dec 28;18(1):75-79.
  4. Burke S, Cody W. Podcasting in undergraduate nursing programs. Nurse Educ. 2014 Sep-Oct;39(5):256-9.
  5. Strickland K, Gray C, Hill G. The use of podcasts to enhance research-teaching linkages in undergraduate nursing students. Nurse Educ Pract. 2012 Jul;12(4):210-4.


Dr. Dean Smith is founder of chiropractic science – dedicated to publicizing and disseminating chiropractic research through podcast interviews with the experts that are doing the research.  Listen to free chiropracticscience.com interviews on iTunes.  Dr. Smith is also a clinical professor at Miami University in Oxford, Ohio.  He has a practice of chiropractic in Eaton, Ohio.

Chiropractic and Response Time, EMG and TMD with James DeVocht, DC, PhD

DeVocht (061205)James DeVocht, DC, PhD and I discuss research regarding the effect of chiropractic care on special operations forces reaction and response times, the biomechanical aspects of chiropractic care on patients, the cervical flexion-relaxation phenomenon and chiropractic treatment of temporomandibular disorders.

Dr. James DeVocht is an associate professor in the Palmer Center for Chiropractic Research at Palmer College of Chiropractic. He has a BS in physics (Brigham Young University, 1972), a DC (Palmer College of Chiropractic, 1983), a MS in mechanical engineering, with emphasis in biomedical engineering (Michigan Technological University, 1992), and a PhD in biomedical engineering (University of Iowa, 1996). He was in private practice in New Mexico (1984-1985). He has spent 11 years on active duty as an officer in the US Army, including 2 years as a research physicist. For the last 19 years he has been a research scientist at Palmer and is going to retire this year.

He has been a peer reviewer for several journals including Clinical Biomechanics, Journal of Electromyography and Kinesiology, and Journal of Manipulative and Physiological Therapeutics (JMPT). He has also been an examiner of the PhD thesis of a research student at Macquarie University, Australia. His research interests include the use of electromyography (EMG) to quantify the effect of chiropractic treatment, descriptive studies of chiropractic adjustments, and chiropractic treatment of temporomandibular disorders.

Here is a link to Dr. DeVocht’s publications on researchgate.

Articles Discussed in the Podcast:

1. Novel Electromyographic Protocols Using Axial Rotation and Cervical Flexion-Relaxation for the Assessment of Subjects With Neck Pain: A Feasibility Study.
DeVocht JW, Gudavalli K, Gudavalli MR, Xia T.
J Chiropr Med. 2016 Jun;15(2):102-11. doi: 10.1016/j.jcm.2016.04.013.
PMID: 27330512 [PubMed] Free PMC Article
Similar articles
2. A pilot study of a chiropractic intervention for management of chronic myofascial temporomandibular disorder.
DeVocht JW, Goertz CM, Hondras MA, Long CR, Schaeffer W, Thomann L, Spector M, Stanford CM.
J Am Dent Assoc. 2013;144(10):1154-63.
PMID: 24080932 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
3. Chiropractic treatment of temporomandibular disorders using the activator adjusting instrument and protocol.
DeVocht JW, Schaeffer W, Lawrence DJ.
Altern Ther Health Med. 2005 Nov-Dec;11(6):70-3.
PMID: 16320863 [PubMed – indexed for MEDLINE]
Similar articles
4. Spinal manipulation alters electromyographic activity of paraspinal muscles: a descriptive study.
DeVocht JW, Pickar JG, Wilder DG.
J Manipulative Physiol Ther. 2005 Sep;28(7):465-71.
PMID: 16182019 [PubMed – indexed for MEDLINE]
Similar articles
5. Experimental validation of a finite element model of the temporomandibular joint.
Devocht JW, Goel VK, Zeitler DL, Lew D.
J Oral Maxillofac Surg. 2001 Jul;59(7):775-8.
PMID: 11429739 [PubMed – indexed for MEDLINE]
Similar articles

 

Spinal manipulation biochemical

Biochemical Markers of Pain Perception and Stress Response Following Spinal Manipulation

Spinal manipulation biochemicalSpinal manipulation (SM) can improve function and reduce spinal disability.  SM also provides pain relief for many disorders such as back pain and neck pain.   Pain induces changes in both the central and peripheral nervous systems.  The mechanisms by which SM alters musculoskeletal pain are still not completely known.  Current evidence however suggests that SM is associated with neurophysiological responses including rapid hypoalgesia with simultaneous sympathetic and motor system excitation.  Animal studies have shown that analgesia provided by joint mobilization involves serotonin and noradrenaline receptors in the spinal cord.

A new investigation sought to determine the response of several other biochemical markers of pain and stress to SM.  Specifically, three neuropeptides (neurotensin, oxytocin, orexin A) and a glucorticoid hormone (cortisol) were studied.  The authors note that the neuropeptides have been associated with hypoalgesia and pain modulation and that cortisol plays an analgesic role in the stress response.  Recent theories have suggested that chronic pain could be partially maintained in a facilitated state due to maladaptive responses in the presence of recurrent stressful situations.  To date there is a lack of studies analyzing these specific biomarkers in relation to SM.

The purpose of this study was to determine the effect of cervical or thoracic manipulation on neurotensin (NT), oxytocin, orexin A, and cortisol levels.  Experimenters examined both spinal regions because they thought there may be a difference in anti-nociceptive effect between the cervical spine and thoracic spine.

Participants included graduate students from Spain.  All subjects were asymptomatic and were excluded if there was a contraindication to manipulation, history of whiplash or surgery, pain in the last month, SM in the last 2 months.  Thirty asymptomatic subjects were randomly divided into 3 groups: cervical manipulation (n = 10), thoracic manipulation (n = 10), and non-manipulation (control) (n = 10).  Although it is not explicitly stated in the article, I presume the manipulations were performed by physical therapists since the lead authors were PT’s.  Manipulations consisted of supine ‘anterior’ thoracic spine manipulations, and rotary type cervical manipulations.  Blood samples were extracted before, immediately after, and 2 hours after each intervention by way of venipuncture of the cephalic vein. Neurotensin, oxytocin, and orexin A were determined in plasma using enzyme-linked immuno assay. Cortisol was measured by microparticulate enzyme immuno assay in serum samples.

Results

Neurotensin (NT)

  • Statistically significant increases in neurotensin occurred in both the thoracic and cervical manipulation groups compared to controls post-intervention with the greatest increase occurring immediately following manipulation
  • Cervical spine manipulation produced a slightly larger increase in neurotensin

Orexin A

  • No statistically significant changes were noted in orexin A levels following treatment

Oxytocin

  • Statistically significant increases in oxytocin occurred in both the thoracic and cervical manipulation groups compared to controls post-intervention with the greatest increase occurring immediately following manipulation
  • Cervical spine manipulation produced a significantly larger increase in oxytocin compared to thoracic manipulation

Cortisol

  • A significant increase in cortisol occurred in the cervical manipulation group compared to controls and the thoracic manipulation group immediately post-intervention
  • However, a significant decrease in cortisol was found at 2 hrs post intervention in the thoracic SM group compared with pre-intervention values
  • A non-significant decrease in cortisol was found also found at 2 hrs post intervention in the cervical SM group compared with pre-intervention values


Discussion

NT is an endogenous peptide with broad spectrum of central and peripheral activities, including modulation of pain signal transmission and perception. NT behaves as a neurotransmitter in the brain and as a hormone in the gut.  Because of its association with a wide variety of neurotransmitters, NT has been implicated in the pathophysiology of several CNS disorders such as schizophrenia, drug abuse, Parkinson’s disease (PD), pain, central control of blood pressure, eating disorders, as well as, cancer and inflammation. Note that the antinociceptive effects of NT are independent from opioid antinociception.

Increased oxytocin following SM could be partly responsible for the analgesic effect linked to manual therapy techniques due to the activation of descending pain-inhibitory pathways.

Cortisol is a potent anti-inflammatory that functions to mobilize glucose reserves for energy and modulate inflammation. Ultimately, a prolonged or exaggerated stress response may perpetuate cortisol dysfunction, widespread inflammation, and pain.  SM in this study led to an immediate increase in cortisol followed by a significant 2 hour decrease in levels with thoracic manipulation and a decrease in 2 hr levels with cervical manipulation.


Key Points

  • SM can modify several biochemical markers of pain and stress
  • These findings suggest that descending inhibitory pathway mechanisms may be involved in the physiological effects that follow SM
  • The effect size for the cervical manipulation group was larger than that for the thoracic manipulation group suggesting an increase in the activation of the possible descending inhibitory pathway mechanisms after cervical manipulation compared to thoracic manipulation

Reference: Plaza-Manzano G, Molina-Ortega F, Lomas-Vega R, Martínez-Amat A, Achalandabaso A, Hita-Contreras F. Changes in biochemical markers of pain perception and stress response after spinal manipulation. J Orthop Sports Phys Ther. 2014 Apr;44(4):231-9.

EBP and Literature Searching for the Busy Chiropractor

Learn the basics about Evidence Based Practice for chiropractors and some quick strategies to search the scientific literature regarding chiropractic.  Watch in HD for the best viewing experience.

Dr. André Bussières

Chiropractic Research Utilization and Knowledge Translation with André Bussières, DC, PhD

Dr. BussieresIn this podcast episode, André Bussières DC, PhD and I discuss topics such as: research utilization and knowledge translation in chiropractic (the Know-Do gap) as well as professional behaviour change, and the Canadian Chiropractic Guideline Initiative.

Dr. André Bussières is an Assistant Professor at the School of Physical and Occupational Therapy and an Associate Member, Department of Epidemiology, Biostatistics and Occupational Health at McGill University. He is a professor in the Chiropractic Department at l’Université du Québec à Trois-Rivières. He has clinical training in nursing (U. Montreal, 1987) and chiropractic (CMCC, 1991), and completed an MSc in Kinesiology (UQTR, 2008), and a PhD in Population Health (U. Ottawa, 2012). He was in private practice between 1993 and 2007. He is a Fellow of the College of Chiropractic Scientists (Canada), and serves as an Associate Editor of the Journal of the Canadian Chiropractic Association and BMC Health Service Research, and is an Editorial Board member of Chiropractic & Manual Therapies.

He holds a Canadian Chiropractic Research Foundation (CCRF) Professorship in Rehabilitation Epidemiology (McGill University) and leads the Canadian Chiropractic Guideline Initiative. His research interest focuses on clinical practice guidelines development and uptake to improve patient care and health outcome, knowledge synthesis, implementation research and professional behaviour change.

Dr. Bussières Appointments:

  • Assistant Professor, McGill’s School of Physical and Occupational Therapy
  • Cross-appointment: Department of Epidemiology and Biostatistics
  • Professeur (régulier), Département Chiropratique, Université du Québec à Trois-Rivières (UQTR)

Education: BSc (Nursing) Université de Montréal; DC, Canadian Memorial Chiropractic College, Toronto; Fellowship in Clinical Sciences, Toronto; MSc (Kinesiology) Université du Québec à Trois-Rivières; PhD (Population Health) University of Ottawa.

Research Interests:

Dr. Bussières’ research focuses on clinical practice guideline development and uptake to improve process of care and patient outcome, knowledge synthesis, implementation research and professional behaviour change, and musculoskeletal disorders.

Dr. Bussières website at McGill University:
https://www.mcgill.ca/spot/our-faculty/bussieres

Canadian Chiropractic Guideline Initiative:
http://chiroguidelines.org

Links to articles by Dr. Bussières mentioned in the podcast:

1. Evidence-based practice, research utilization, and knowledge translation in chiropractic: a scoping review.
Bussières AE, Al Zoubi F, Stuber K, French SD, Boruff J, Corrigan J, Thomas A.
BMC Complement Altern Med. 2016 Jul 13;16:216. doi: 10.1186/s12906-016-1175-0. Review.
PMID: 27412625 [PubMed – indexed for MEDLINE] Free PMC Article
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2. Self-reported attitudes, skills and use of evidence-based practice among Canadian doctors of chiropractic: a national survey.
Bussières AE, Terhorst L, Leach M, Stuber K, Evans R, Schneider MJ.
J Can Chiropr Assoc. 2015 Dec;59(4):332-48.
PMID: 26816412 [PubMed] Free PMC Article
Similar articles
3. Fast tracking the design of theory-based KT interventions through a consensus process.
Bussières AE, Al Zoubi F, Quon JA, Ahmed S, Thomas A, Stuber K, Sajko S, French S; Members of Canadian Chiropractic Guideline Initiative..
Implement Sci. 2015 Feb 11;10:18. doi: 10.1186/s13012-015-0213-5.
PMID: 25880218 [PubMed – indexed for MEDLINE] Free PMC Article
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4. The Canadian Chiropractic Guideline Initiative: progress to date.
Bussières A.
J Can Chiropr Assoc. 2014 Sep;58(3):215-9. No abstract available.
PMID: 25202149 [PubMed] Free PMC Article
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Dr. William Weeks

Chiropractic and Value in Spine Care with William Weeks, MD, PhD, MBA

weeks_dr. william_thumbnailWilliam Weeks MD, PhD, MBA and I discuss topics such as: how doctors of chiropractic supply health care services, how patients use such services, and how best to integrate chiropractic with other health care providers; health care delivery science; value in spine care and; opioid overuse in back pain. Dr. Weeks is Professor of Psychiatry and of Community and Family Medicine at The Geisel School of Medicine at Dartmouth. There, he works at The Dartmouth Institute for Health Policy and Clinical Practice as a Senior Research Scientist, where he teaches in Masters programs and conducts research on health economics, healthcare value, the complementary and alternative medicine market, and geographic variation in health services utilization in France.  Dr. Weeks has published over 150 peer-reviewed manuscripts examining economic and business aspects of health care services utilization and delivery, physicians’ return on educational investment, health care delivery science, and healthcare value. He received his MD from the University of Texas Medical Branch at Galveston, his MBA from Columbia University, and his PhD in Economics from the Aix-Marseille School of Economics and Management. Dr. Weeks has been honored with the 2009 National Rural Health Association Outstanding Researcher Award and the 2016 Jerome F McAndrews award for excellence in research from the National Chiropractic Mutual Insurance Corporation Group. During 2016, Dr. Weeks holds the Fulbright-Toqueville Distinguished Chair at Aix-Marseille University.

Areas of Expertise:

Healthcare delivery science; healthcare value; health economics; physician incomes; the complementary and alternative medicine market

Awards:

2015-16 Fulbright-Tocqueville Distinguished Chair 2015-2016 at Aix-Marseille University
2009 Researcher of the Year, National Rural Health Association

Professional Achievements:

Consulting
•Provided strategic consultative services, partnering opportunities, to a variety of healthcare organizations
•Reviewed operations and provided strategic advice to Maine Medical Center, Dupont/Nemours Children’s Hospital, and Christiana Care around enhancing value, leveraging research efforts, and moving toward becoming an Accountable Care Organization
•Conducted analytics and provided strategic advice to Community Health Network of Washington around performance variation, identification of best practices, and the development of a comprehensive plan to improve quality and reduce costs.
•Provided consulting services and policy updates to Amerinet, a group purchasing organization around accountable care and organization of healthcare services.
•Provided on-site and distance quality improvement and research education followed by ongoing coaching teams at Eastern Maine Medical Center and Central Maine Medical Center.

Professor and Senior Research Scientist
•Wrote research proposals, obtained grant funding, conducted original research, and published findings
•For The High Value Healthcare Collaborative, a CMMI ($26.1 million) and member funded (approximately $2.5 million per year) effort to examine and leverage variation in care quantity, understand and reduce healthcare costs, and enhance value of care delivered across 15 US healthcare systems, with considerable work focused on bundled payments.
•On the performance of physician practices and medical groups in the United States, funded by Commonwealth Fund and Kaiser Foundation ($536,254)
•Examining the association between public reporting of quality of care on care quality in Wisconsin, funded by Commonwealth Fund ($295,889)
•On chiropractic and alternative medicine care markets in the US, funded by NIH, Bernard Osher Foundation, and National Chiropractic Medicine Insurance Corporation ($1,170,451).
•In an effort to examine and select patient safety indicators for emerging and developing countries, funded by WHO ($35,000)
•Between 1992 – 2008 obtained over $10 million in grant funding as PI or Co-PI while working within the VA system.

Core Faculty and Course Director
•Designed, developed, directed, and taught masters level courses
•Leveraging Data to Inform Decision Making, Dartmouth’s Master in Healthcare Delivery Science program. Provides methods for examining, understanding, and using data from a variety of sources to inform managerial decision-making. 50 students per year.
•Critical Issues in Health and Health Care, Geisel School of Medicine’s MS and MPH programs. Required survey course designed to provide a foundation in and overview of current healthcare issues. 60-70 students per year.
•Strategic and Financial Management of Health Care Organizations, Geisel School of Medicine’s MS and MPH programs. Provided an overview of managerial and financial accounting practices and strategic frameworks in order to prepare students for managerial roles in healthcare environments. 50-60 students per year. Required course for MPH.
•Financial Management for Non-Financial Managers, TDI’s Office for Professional Education and Outreach. Online course providing basic financial and managerial accounting practices in healthcare settings.

http://tdi.dartmouth.edu/faculty/william-weeks-md-mba

Discover more of Dr. Hartvigsen’s publications on researchgate.

Links to articles mentioned in the podcast:

1. Multistakeholder recommendations for improving value of spine care: Key themes from a roundtable discussion at the 2015 NASS Annual Meeting.
Weeks WB, Ventura J, Justice B, Hsu E, Milstein A.
Spine J. 2016 Jul;16(7):801-4. doi: 10.1016/j.spinee.2016.02.031. No abstract available.
PMID: 27045250 [PubMed – in process]
Similar articles
2. Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic and Opioid Use in Younger Medicare Beneficiaries.
Weeks WB, Goertz CM.
J Manipulative Physiol Ther. 2016 May;39(4):263-6. doi: 10.1016/j.jmpt.2016.02.016.
PMID: 27034107 [PubMed – in process] Free Article
Similar articles
3. Characteristics of US Adults Who Have Positive and Negative Perceptions of Doctors of Chiropractic and Chiropractic Care.
Weeks WB, Goertz CM, Meeker WC, Marchiori DM.
J Manipulative Physiol Ther. 2016 Mar-Apr;39(3):150-7. doi: 10.1016/j.jmpt.2016.02.001.
PMID: 26948180 [PubMed – in process] Free Article
Similar articles
4. The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities.
Weeks WB, Leininger B, Whedon JM, Lurie JD, Tosteson TD, Swenson R, O’Malley AJ, Goertz CM.
J Manipulative Physiol Ther. 2016 Feb;39(2):63-75.e1-2. doi: 10.1016/j.jmpt.2016.01.006.
PMID: 26907615 [PubMed – indexed for MEDLINE] Free PMC Article
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