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Cervical Spine in Post Concussion Syndrome

postconcussionsyndromeMuch is known about the injury mechanisms of concussion injuries in the acute phase, but there is little evidence to support many of the theories regarding postconcussion syndrome (PCS).  A potential, and very treatable, cause of this chronic condition is cervical spine dysfunction due to co-existing whiplash-type injury.  Based on previously established tissue injury thresholds, acceleration/deceleration of the head and neck sufficient to cause traumatic brain injury is also likely to cause  injury to the joints and soft tissues of the neck. It has also been well established that injury and/or dysfunction of the cervical spine can result in numerous signs and symptoms synonymous with concussion, including headaches, dizziness, cognitive as well as visual dysfunction.  Given our current level of evidence, skilled, manual therapy-related assessment and rehabilitation of cervical spine dysfunction should be considered for chronic symptoms following concussion injuries.

http://www.ncbi.nlm.nih.gov/pubmed/26138797

 

Chiropractic Manipulation Versus Usual Medical Care for Acute and Subacute Low Back Pain

33609004_sLow back pain (LBP) is an extremely common presenting complaint that occurs in greater than 80% of people. Chiropractors care for patients who have no symptoms and those who have symptoms.   Research has demonstrated that chiropractic care in addition to standard medical care improves pain and disability scores, and in another study a subgroup of patients with acute nonspecific LBP – spinal manipulation was significantly better than nonsteroidal anti-inflammatory drug diclofenac and clinically superior to placebo (Spine 2013; 38:540-548).  The study reviewed here sought to compare the effectiveness of manual thrust manipulation (MTM) and manual assisted manipulation (MAM), to usual medical care (UMC) for the treatment of acute and subacute LBP.

This study was a prospective, randomized controlled trial evaluating the comparative effectiveness of manual and mechanical spinal manipulation to usual medical care for the treatment of acute and subacute LBP.  Participants were at least 18 years old and had a new LBP episode within the previous 3 months.  They also were required to have a minimum level of self-rated pain of 3 out of 10 and minimum disability rating of 20 out of 100. Exclusions included: chronic LBP (greater than 3 months duration), previous treatment for the current episode, radicular signs/symptoms, contraindications to SMT, current use of prescription pain medicine.

Participants and treating clinicians were not blinded to treatment allocation but the principal investigator was blinded to treatment assignment and had no interaction with participants.

The study interventions consisted of:

  1. Manual thrust manipulation (MTM) – high velocity low amplitude thrust delivered by a chiropractor to the lower thoracic, lumbar and SI joints in the side posture position as deemed necessary
  1. Mechanical-assisted manipulation (MAM) – certified Activator Methods chiropractor delivered MAM in the prone position to the lower thoracic, lumbar and SI joints as deemed necessary
  1. Usual medical care (UMC) – participants were seen by a board certified physical medicine and rehabilitation medical doctor and prescribed over the counter analgesic and NSAID medications, given advice to stay active and avoid bed rest

All groups had a 4 week course of care.  All groups received an educational booklet describing proper posture and movements during activities of daily living. Both manipulation groups had 8 visits (2 per week x 4 wks).  The UMC group had 3 visits (initial, at 2 weeks and at 4 weeks).  Following the 4 week assessment, participants were free to pursue rehabilitation or manipulation.

The primary outcome was the Oswestry LBP Disability Index (OSW).  Pain intensity ratings were also collected. Outcomes were assessed at baseline, 4 weeks, 3 months and 6 months.  Participants with at least 30% or 50% reductions in an outcome measure were considered to be ‘responders’ and had moderate or substantial improvement respectively.

Results and Conclusions:

  • Manual thrust manipulation by a chiropractor led to greater short term reductions in self-reported pain and disability than manual assisted manipulation (Activator) or usual medical care by a physical medicine and rehabilitation specialist
  • The benefits seen at the end of 4 weeks of care were no longer statistically significant at 3 or 6 months
  • MTM should be considered as an effective short term treatment option for patients with acute and subacute LBP
  • Significantly more patients in the MTM group achieved moderate or substantial reductions in disability and pain scores
  • These results contradict assumptions of therapeutic similarity between manual thrust and mechanical-assisted manipulation

Reference: Schneider M, Haas M, Glick R, Stevans J, Landsittel D. Comparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: a randomized clinical trial. Spine (Phila Pa 1976). 2015 Feb 15;40(4):209-17.

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Chiropractic Adjustments Reduce Fatigue and Increase Neural Drive

chiropractic adjustmentOver the last decade, research has demonstrated that spinal manipulation can change various aspects of nervous system function, including muscle reflexes, cognitive processing, reaction time, and the speed at which the brain processes information. One research group from New Zealand (Haavik Taylor et al) has hypothesized that the joint dysfunction part of the chiropractic clinical construct, the vertebral subluxation, results in altered afferent input to the central nervous system (CNS) that modifies the way in which the CNS processes and integrates all subsequent sensory input. This processing (i.e., sensorimotor integration) is a central nervous system (CNS) function that appears most vulnerable to altered inputs.  Many studies show that chiropractic adjustments result in changes to sensorimotor integration within the central nervous system.

A new study sought to investigate possible neural plastic changes with spinal manipulation by measuring H-reflexes and V-waves.  The H-reflex is an electrically evoked response that operates via the same neuronal circuitry as stretch reflexes.  The H (Hoffmann) reflex may be useful to assess motoneuron excitability in vivo while also reflecting presynaptic inhibition of Ia afferent synapses.  The so-called V-wave, which is an electrophysiological variant of the H-reflex, can be recorded during maximal voluntary motor contractions. The elicited V-wave response may be used to reflect the level of efferent neural drive from spinal α-motoneurons during maximal voluntary contraction (MVC).

Results of the study:

  • the threshold to elicit the H-reflex significantly decreased by 8.5% in the spinal manipulation group
  • the SEMGs showed a significant drop in the power spectrum after controls but there was no fatigue demonstrated in the power spectrum after spinal manipulation
  • for study 1: maximal voluntary contraction as determined by SEMG increased significantly by 59.5% after spinal manipulation and decreased significantly by 13.3% after control
  • for study 2: maximal voluntary contraction increased significantly by 16.1% after spinal manipulation and decreased significantly by 11.4% after control
  • the V-wave amplitude (V/Mmax ratio) increased significantly by 45% after spinal manipulation and reduced significantly by 23% after control

Key Points

  • This study is the first to indicate that chiropractic adjustments can induce significant changes in the net excitability for the low-threshold motor units/and or alters the synaptic efficacy of the Ia synapse
  • the improvements in maximal voluntary contraction following spinal manipulation are likely attributed to the increased descending drive and/or modulation in afferents
  • spinal manipulation prevents fatigue
  • these results suggest that spinal manipulation may be indicated as part of the treatment for the patients who have lost tonus of their muscle and/or are recovering from muscle dysfunction such as stroke or orthopedic operations
  • These findings will also be of interest to athletes and perhaps the general public

 

Dr. Bernadette Murphy

Chiropractic Neurophysiology with Dr. Bernadette Murphy

Dr. Bernadette Murphy
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Listen to this great interview with Dr. Bernadette Murphy. This is an interview that all chiropractors and students will want to listen to! We talk about many interesting concepts such as the current state of neurophysiology research within chiropractic, neural adaptation in humans and the role of chiropractic adjustments in aiding the re-establishment of appropriate neuromuscular connections, how a chiropractic adjustment works and much more.  She is at the forefront of research regarding the neurophysiology of chiropractic.  Dr. Murphy graduated from Queens University in 1985 and the Canadian Memorial Chiropractic College in 1989 before moving to New Zealand where she completed her MSc (1992) and PhD (1998) in Human Neurophysiology at the University of Auckland. She was a fulltime faculty member in the Department of Sport and Exercise Science from 1999-2007, where she established an MSc in Exercise Rehabilitation.  In January 2008, she returned to Canada and took on the role of Head of Kinesiology in the Faculty of Health Sciences at the University of Ontario Institute of Technology (UOIT).  She is the Director of the Human Neurophysiology and Rehabilitation Laboratory. The overall theme of her research is neural adaptation in humans and the role of physical interventions such as spinal manipulation and exercise in aiding the re-establishment of appropriate neuromuscular connections.  She has previously been awarded the World Federation of Chiropractic best scientific paper award (1995) and 3rd prize in 2007; the New Zealand Chiropractor of the year (2004) and the 2010 Ontario Chiropractic Association award for most significant contributions to research.  She has supervised numerous award winning Masters and PhD students and received significant research funding in New Zealand, Australia and Canada.

 

Dr. Smith and Dr. Murphy at University of Ontario Institute of Technology

 Dr. Murphy and Dr. Smith at University of Ontario Institute of Technology

 

Dr. Katie Pohlman

Chiropractic Pediatric Research with Dr. Katherine Pohlman

Dr. Katherine Pohlman, Katie PohlmanListen to my chiropractic research interview with Dr. Katherine Pohlman.  Dr. Pohlman is a graduate student with the Department of Pediatrics. She earned a BSc in Biology from The Ohio State University and a Doctor of Chiropractic and MSc in Clinical Research both from the Palmer College of Chiropractic. In addition to her education, Dr. Pohlman has also had the opportunity to be the lead clinical project manager for several US federally funded clinical trials, including the largest trial in chiropractic history conducted in active-duty military personnel and a CIHR-funded team grant. Her overall goal is to become an independent clinician scientist investigating the safety and effectiveness and complementary and alternative medicines, especially chiropractic care, for use among the pediatric population.

We discuss several of the articles below:

1. Practice patterns of doctors of chiropractic with a pediatric diplomate: a cross-sectional survey.
Pohlman KA, Hondras MA, Long CR, Haan AG.
BMC Complement Altern Med. 2010 Jun 14;10:26. doi: 10.1186/1472-6882-10-26.
PMID: 20546582 [PubMed – indexed for MEDLINE] Free PMC Article
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2. Otitis media and spinal manipulative therapy: a literature review.
Pohlman KA, Holton-Brown MS.
J Chiropr Med. 2012 Sep;11(3):160-9. doi: 10.1016/j.jcm.2012.05.006.
PMID: 23449823 [PubMed] Free PMC Article
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3. Study protocol for patient response to spinal manipulation – a prospective observational clinical trial on physiological and patient-centered outcomes in patients with chronic low back pain.
Xia T, Wilder DG, Gudavalli MR, DeVocht JW, Vining RD, Pohlman KA, Kawchuk GN, Long CR, Goertz CM.
BMC Complement Altern Med. 2014 Aug 8;14:292. doi: 10.1186/1472-6882-14-292.
PMID: 25106673 [PubMed – indexed for MEDLINE] Free PMC Article
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4. Barriers to Implementing a Reporting and Learning Patient Safety System: Pediatric Chiropractic Perspective.
Pohlman KA, Carroll L, Hartling L, Tsuyuki RT, Vohra S.
J Evid Based Complementary Altern Med. 2016 Apr;21(2):105-9. doi: 10.1177/2156587215609191.
PMID: 26438719 [PubMed – indexed for MEDLINE]
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5. Core Competencies of the Certified Pediatric Doctor of Chiropractic: Results of a Delphi Consensus Process.
Hewitt E, Hestbaek L, Pohlman KA.
J Evid Based Complementary Altern Med. 2016 Apr;21(2):110-4. doi: 10.1177/2156587215622769.
PMID: 26739669 [PubMed – indexed for MEDLINE]
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Risk of Injury Following Visits to Health Professionals

Aging ChiropracticThere are physiologic changes associated with aging. There are also health conditions that occur more commonly with advancing age. These changes and conditions increase an older adult’s vulnerability to injuries. A recent study investigated risk of injury to Medicare beneficiaries with an office visit for a neuromusculoskeletal problem to chiropractors and primary care physicians.  Specifically, investigators looked at the risk of injury within 7 days of those treated by chiropractic spinal manipulation vs. those evaluated by a primary care physician.  Results showed that risk of injury to the head, neck or trunk within 7 days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician.

Chiropractic Research with Dr. Gregory Cramer

Gregory Cramer, DC, PhDListen to my chiropractic research interview with Gregory Cramer, D.C., Ph.D.   Dr. Cramer graduated from The National College of Chiropractic [now National University of Health Sciences (NUHS)] in 1979 and was in clinical practice for five years with his father, David Cramer, DC, before pursuing a career in research and teaching. He received his Ph.D. in Basic Medical Sciences (Anatomy) in 1987 from The Medical College of Ohio at Toledo (now University of Toledo College of Medicine and Life Sciences) and then began teaching and conducting research at NUHS, where he is currently Professor and Dean of Research. He is interested in human and animal research designed to determine the mechanisms of action of spinal manipulation, promoting evidence-based/informed CAM practice, and CAM “disciplines research.” He has worked on over two dozen federally and privately funded research projects related to these goals. He has received several awards for research, including the 2005 American Chiropractic Association Researcher of the Year Award, and has published over 150 abstracts, papers, and book chapters. He is co-author of a text entitled, “Clinical Anatomy of the Spine, Spinal Cord, and ANS,” the third edition of which was published in 2013.

We discuss several of the articles below:

 

1. Correctly identify practitioners and put adverse events of spinal manipulation into perspective.
Cramer GD, Smith DL.
Orthop Rev (Pavia). 2014 Mar 4;6(1):5248. doi: 10.4081/or.2014.5248. No abstract available.
PMID: 24744843 [PubMed] Free PMC Article
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2. Magnetic resonance imaging zygapophyseal joint space changes (gapping) in low back pain patients following spinal manipulation and side-posture positioning: a randomized controlled mechanisms trial with blinding.
Cramer GD, Cambron J, Cantu JA, Dexheimer JM, Pocius JD, Gregerson D, Fergus M, McKinnis R, Grieve TJ.
J Manipulative Physiol Ther. 2013 May;36(4):203-17. doi: 10.1016/j.jmpt.2013.04.003.
PMID: 23648055 [PubMed – indexed for MEDLINE] Free PMC Article
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3. Quantification of cavitation and gapping of lumbar zygapophyseal joints during spinal manipulative therapy.
Cramer GD, Ross K, Raju PK, Cambron J, Cantu JA, Bora P, Dexheimer JM, McKinnis R, Habeck AR, Selby S, Pocius JD, Gregerson D.
J Manipulative Physiol Ther. 2012 Oct;35(8):614-21. doi: 10.1016/j.jmpt.2012.06.007.
PMID: 22902194 [PubMed – indexed for MEDLINE] Free PMC Article
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4. Spinal Manipulation is Not an Emerging Risk Factor for Stroke Nor is it Major Head/Neck Trauma. Don’t Just Read the Abstract!
Smith DL, Cramer GD.
Open Neurol J. 2011;5:46-7. doi: 10.2174/1874205X01105010046. No abstract available.
PMID: 21687558 [PubMed] Free PMC Article
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5. Zygapophyseal joint adhesions after induced hypomobility.
Cramer GD, Henderson CN, Little JW, Daley C, Grieve TJ.
J Manipulative Physiol Ther. 2010 Sep;33(7):508-18. doi: 10.1016/j.jmpt.2010.08.002.
PMID: 20937429 [PubMed – indexed for MEDLINE]
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6. Introducing the external link model for studying spine fixation and misalignment: part 2, Biomechanical features.
Henderson CN, Cramer GD, Zhang Q, DeVocht JW, Fournier JT.
J Manipulative Physiol Ther. 2007 May;30(4):279-94.
PMID: 17509437 [PubMed – indexed for MEDLINE]
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7. Introducing the external link model for studying spine fixation and misalignment: part 1–need, rationale, and applications.
Henderson CN, Cramer GD, Zhang Q, DeVocht JW, Fournier JT.
J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):239-45. Review.
PMID: 17416279 [PubMed – indexed for MEDLINE]
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8. Introducing the external link model for studying spine fixation and misalignment: current procedures, costs, and failure rates.
Henderson CN, Cramer GD, Zhang Q, DeVocht JW, Sozio RS, Fournier JT.
J Manipulative Physiol Ther. 2009 May;32(4):294-302. doi: 10.1016/j.jmpt.2009.03.005.
PMID: 19447266 [PubMed – indexed for MEDLINE]
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Chiropractic Has Lowest Total Costs for Low Back Problems in a Major Self-Insured Workforce

Low Back PainStatistics tell us that up to 84% of the general population will report low back pain (LBP) symptoms at some point during their lifetime.  This leads employers seeking to maximize the ratio of outcomes achieved relative to costs incurred (ie, value) for the investments that they are making in their employees. Previous research has found that patients receiving chiropractic care have been found to record lower associations of probability of disability recurrence than patients of physicians and physical therapists.  Given these findings, the authors of this newly published article sought to assess the cost outcomes of treatment approaches to care for back problems in a major self-insured workforce, using published guidelines to focus on low back pain. Results of the study were that care congruent with 10 of 11 guidelines was linked to lower total costs. Of the five patterns of care, complex medical management reported the highest guideline-incongruent use of imaging, surgeries, and medications and had the highest health care costs.  On the other hand, chiropractic reported the lowest rates of guideline-incongruent use of imaging, surgeries, and medications and had the lowest health care costs.

http://www.ncbi.nlm.nih.gov/pubmed/24854253