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chiropractic neck pain whiplash
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The Treatment of Neck Pain–Associated Disorders and Whiplash-Associated Disorders

chiropractic neck pain whiplashA clinical practice guideline on the management of neck pain–associated disorders (NADs) and whiplash-associated disorders (WADs) was recently developed and replaces existing chiropractic guidelines on these topics (Bussières, Stewart et al, 2016). The Guideline Development Group of the Canadian Chiropractic Guideline Initiative (CCGI) conducted the updated guidelines. They considered recently published systematic reviews on NAD and WAD from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Below is a brief summary of the guidelines.  Please refer to the numerous links in this blog post to gain access to the original paper and the full guidelines which are freely available.

Neck pain and its associated disorders (NAD), including headache and radiating pain into the arm and upper back, are common. These disorders often result in significant social, psychological, and economic burden.  Neck pain is a common reason for people to seek chiropractic care.

Motor vehicle collisions most commonly are associated with neck pain related to whiplash-associated disorders (WADs). Whiplash-associated disorders also affect the daily functioning of our patients in terms of considerable pain, suffering, disability, and costs.  Whiplash-associated disorders are defined as an injury to the neck that occurs with sudden acceleration or deceleration of the head and neck relative to other body parts.  Symptoms of WADs commonly include headache, stiffness, shoulder and back pain, numbness, dizziness, sleeping difficulties, fatigue, and cognitive deficits.

The 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders recommended that all types of neck pain, including WADs, be included under the classification of NAD.  The 4 grades of NAD are:

  • I – No signs or symptoms suggestive of major structural pathology and no or minor interference with activities of daily living
  • II – No signs or symptoms of major structural pathology, but major interference with activities of daily living
  • III – No signs or symptoms of major structural pathology, but presence of neurologic signs such as decreased deep tendon reflexes, weakness or sensory deficits
  • IV – Signs or symptoms of major structural pathology (e.g., fracture, tumor, infection)

After searching and synthesizing the latest scientific literature on these topics, the guideline committee provided their recommendations.  Below is the summary of the recommendations.  The full guideline and accompanying documents are available from the CCGI website at www.chiroguidelines.org. There are excellent resources for practitioners and patients available from this website including exercise videos and forms.

Global summary of recommendations: A multimodal approach including manual therapy, self-management advice and exercise is an effective treatment strategy for both recent onset and persistent neck pain and whiplash associated disorders.

A) Summary of Recommendations for Grades I-III Neck Pain and Associated Disorders (NAD)

  • For recent-onset (0-3 months) neck pain grades I-II, based on patient preference and practitioner experience we suggest offering advice with:
    • multimodal care;
    • manipulation or mobilization;
    • Range of motion home exercises or multimodal manual therapy.
  • For recent-onset (0-3 months) neck pain grade III, based on patient preference and practitioner experience we suggest offering advice with:
    • supervised graded strengthening exercises.
  • For persistent (>3 months) neck pain grades I-II, based on patient preference and practitioner experience we suggest offering advice with:
    • multimodal care or stress self-management;
    • multimodal care or advice alone;
    • manipulation in conjunction with soft tissue therapy;
    • supervised yoga; supervised group exercise; supervised strengthening exercises or home exercises;
    • mixed supervised and unsupervised high-intensity strength training or advice alone for workers with persistent neck and shoulder pain;
    • high dose massage.
  • For persistent (>3 months) neck pain grade III, based on patient preference and practitioner experience we suggest offering advice with:
    • multimodal care or advice alone;
    • mixed supervised and unsupervised high-intensity strength training or advice alone for workers with persistent neck and shoulder pain.

B) Summary of Recommendations for Grade I-III Whiplash and Associated Disorders (WAD)

  • For recent onset (0-3 months) whiplash grades I-III, based on patient preference and practitioner experience we suggest offering advice with:
    • multimodal care.
  • For persistent (>3 months) whiplash grades I-II, based on patient preference and practitioner experience we suggest offering advice with:
    • supervised exercise or advice alone.

Source: Bussières AE, Stewart G, Al-Zoubi F et al. The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. J Manipulative Physiol Ther. 2016 Oct;39(8):523-564.

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Increase in Cortical Drive Following Spinal Manipulation


Chiropractic care is commonly thought to have a beneficial effect on the functioning of the human body by affecting the nervous system. Evidence indicates that chiropractic adjustments result in plastic changes in sensorimotor integration within the central nervous system in human participants, particularly within the prefrontal cortex. Adjustments appear to alter the net excitability of the low-threshold motor units, increase cortical drive, and prevent fatigue (see this blog).  This same group of researchers have more recently found an increase cortical drive to upper and lower extremity muscles following manipulation as measured by motor evoked potential. The researchers suggested the effects were due to descending cortical drive and could not be explained by changes at the level of the spinal cord (although they can’t rule that out completely).  Two experiments were conducted.  In experiment one, transcranial magnetic stimulation input–output (TMS I/O) curves for an upper limb muscle (abductor pollicus brevis; APB) were recorded, along with F waves prior to and after either spinal manipulation or a control intervention for the same subjects on two different days. During these two separate days, lower limb TMS I/O curves and movement related cortical potentials (MRCPs) were recorded from tibialis anterior muscle (TA) before and after spinal manipulation. Spinal manipulation resulted in a 54.5% ± 93.1% increase in maximum motor evoked potential (MEPmax) for APB and a 44.6% ± 69.6% increase in MEPmax for TA. 
They conclude that “Spinal manipulation may therefore be indicated for the patients who have lost tonus of their muscle and or are recovering from muscle degrading dysfunctions such as stroke or orthopaedic operations. These results may also be of interest to sports performers. We suggest these findings should be followed up in the relevant populations.”

Reference: Haavik H, Niazi IK, Jochumsen M, Sherwin D, Flavel S, Türker KS. Impact of Spinal Manipulation on Cortical Drive to Upper and Lower Limb Muscles. Brain Sci. 2016 Dec 23;7(1).

 

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Spinal Manipulation Alters Somatosensory Processing in the Prefrontal Cortex

adobestock_49611047Over 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 et al) has hypothesized that the articular 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.

Investigators utilizing techniques such as transcranial magnetic stimulation and somatosensory evoked electroencephalographic (EEG) potentials have suggested that neuroplastic changes occur in the brain (e.g. primary sensory cortex, primary motor cortex, prefrontal cortex, basal ganglia, and cerebellum).  Inducing and recording somatosensory evoked potentials (SEPs) is emerging in scientific literature relating to spinal manipulation (SM). There is evidence to support that SEPs are able to elucidate differences in cortical activity associated with SM. Studies with only a few recording EEG electrodes allow investigation of evoked potential amplitudes and latencies and have shown changes in the N30 somatosensory evoked potential (SEP) amplitudes following spinal manipulation.  The N30 response from the frontal lobe peak reflects sensory integration.

With recent advances in the spatial resolution of EEG, it is becoming possible to better anatomically localize the signal.  With this study, the authors aimed to utilize brain electrical source analysis to explore which brain sources are responsible for changes in N30 amplitude following a single session of spinal manipulation.

Nineteen young (average age 26 years) subclinical pain volunteers were included in the study. Subclinical pain (SCP) refers to recurrent spinal ache, pain, or stiffness for which the subject had not sought treatment. Subjects were excluded if they had: no evidence of spinal dysfunction, they were in current pain, they had sought previous treatment for their spinal issues, or they had contraindications to receiving spinal manipulation. The EEG signals were recorded with the Neuroscan System from 62 scalp electrodes using the extended 10-20 system montage. Supine subjects received electrical stimulations applied to the median nerve at the right wrist to evoke SEPs. Two trials of 1000 pulses were given in each session: one trial before treatment (control or chiropractic) and one trial after the treatment.

The entire spine and both sacroiliac joints were assessed for segmental dysfunction and adjusted where they were deemed necessary by an experienced chiropractor. Assessment for dysfunction included tenderness to palpation of the relevant joints, restricted intersegmental range of motion, asymmetric muscle tension, and any abnormal or blocked joint play and end-feel of the joints. The control (sham) involved one of the investigators (not a chiropractor) simulating a chiropractic treatment session. This included passive and active movements of the subject’s head, spine, and body, similar to what was done by the chiropractor who provided the actual chiropractic treatment.

Results:

  • SEPs were successfully recorded in all subjects
  • the majority of subjects were able to correctly guess which intervention group they were in (SM or sham)
  • there was a significant post-intervention difference between the two groups – specifically the N30 amplitude was reduced in the spinal manipulation group following the treatment, while it remained stable in the control group
  • source localization indicated that the prefrontal cortex tended to have the highest strength during the time interval between 20 and 60 ms
  • source strength analysis revealed that chiropractic treatment reduced the strength of the prefrontal source, while all the other strengths remained stable

Key Points:

  • Results from this study confirmed that spinal manipulation of dysfunctional spinal segments reduces the N30 SEP peak amplitude and demonstrated that this change is taking place in the prefrontal cortex
  • This suggests that, at least in part, the mechanisms by which spinal manipulation improves performance are due to a change in function at the prefrontal cortex
  • It is possible that the mechanisms behind pain relief following spinal manipulation in low level pain patients are due to improved sensorimotor integration and appropriate motor control, as this is the key function of the prefrontal cortex

Source: Lelic D, Niazi IK, Holt K, Jochumsen M, Dremstrup K, Yielder P, Murphy B, Drewes AM, Haavik H. Manipulation of Dysfunctional Spinal Joints Affects Sensorimotor Integration in the Prefrontal Cortex: A Brain Source Localization Study. Neural Plast. 2016;2016:3704964.

 

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.

 

 

 

 

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Brain Activity Following Chiropractic Manipulation

35856944_sResearch on chiropractic spinal manipulation (CSM) has been conducted extensively worldwide, and its efficacy on musculoskeletal symptoms has been well documented.  Previous studies have documented potential relationships between spinal dysfunction and the autonomic nervous system and that chiropractic treatment affects the autonomic nervous system. The authors of this study hypothesized that CSM might induce metabolic changes in brain regions associated with autonomic nervous system functions as assessed with positron emission tomography (PET).  Positron emission tomography is a nuclear medicine imaging technique that allows quantification of cellular and molecular processes in humans such as cerebral glucose metabolism which is thought to reflect regional neuronal activities.

Participants were men between the ages of 20-40 who had neck pain and shoulder stiffness.

A crossover study design was used such that subjects served as their own controls to compare their resting brain activity to their brain activity following chiropractic manipulation.  Half of the participants completed the control condition first while the other half completed the chiropractic condition first.  The participants came back sometime between 1 and 6 weeks later to complete their remainder condition.  Chiropractic consisted of a single Activator Methods assessment and treatment session by a chiropractor lasting 20 minutes.  The control condition consisted of 20 minutes of rest.  Immediately after each condition, 18F-labeled fluorodeoxyglucose (FDG) was injected.  FDG is an excellent imaging marker of brain metabolism (glucose consumption).  PET scanning followed administration of FDG.

Additional outcome measures included pain (VAS), Stress Response Scale (SRS-18) and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), trapezius muscle tone, and salivary amylase.

Results of the PET image analysis showed statistically significant changes in regional cerebral metabolism between rest and treatment conditions.  With chiropractic treatment, increased glucose metabolism was observed in the inferior prefrontal cortex, anterior cingulate cortex,  middle temporal gyrus; decreased glucose metabolism was observed in the cerebellar vermis and visual association cortex.  Reduced metabolism in the cerebellar vermis may be related to reductions is pain, mental stress, muscle tone and sympathetic tone.  Activation of the anterior cingulated cortex and inferior prefrontal cortex may arise from sympathetic relaxation.

The mean SRS-18 and EORTC QLQ-C30 scores were significantly lower in the treatment condition indicating improved stress response and improved quality of life. Mean VAS pain score comparison was significantly improved with treatment.  Additionally, measurement of trapezius muscle tone and salivary amylase showed significant reduction with chiropractic suggesting improved sympathetic relaxation.

 

Reference: Tashiro M, Ogura T, Masud M, Watanuki S, Shibuya K, Yamaguchi K, Itoh M, Fukuda H, Yanai K. Cerebral metabolic changes in men after chiropractic spinal manipulation for neck pain. Altern Ther Health Med. 2011 Nov-Dec;17(6):12-7.

 

 

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

1005989_highIn a recent study, manual 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.

Low 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.  Chiropractic has been used as a treatment for those with lower back pain but evidence is mixed with some reviews finding no advantage of chiropractic spinal manipulation therapy (SMT) compared to other treatments while some guidelines find moderate effectiveness of chiropractic care for back pain.  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.

Methods:

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) and this index provides a valid and reliable way to assess functional impairment.  Pain intensity ratings were also collected using the mean of current pain, worst pain in 24 hours and average pain during last week.  Outcomes were assessed at baseline, 4 weeks, 3 months and 6 months. Other outcomes were physical examination, fear avoidance questionnaire, and treatment credibility-expectation questionnaire.

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:

  • No adverse events were reported

Longitudinal Analysis:

  • For disability, no statistically significant differences were found between groups
  • For pain, MTM yielded lower pain scores compared to MAM and UMC
  • For pain, there were no significant differences between MAM and UMC

Responder Analysis:

  • 76% of MTM group achieved at least 30% reduction in disability compared with about 50% of MAM and 50% of the UMC groups (MAM not significantly different from UMC)
  • 50% of MTM group achieved at least a 50% reduction compared with 16% of the MAM and 39% of the UMC groups (MAM was significantly worse than UMC in this outcome)
  • 94% of MTM achieved greater than 30% reduction in pain compared with 69% of MAM and 56% of UMC
  • 76% of MTM achieved greater than 50% reduction in pain compared to 47% of MAM and 41% of UMC (MAM not significantly different from UMC)

Key Points:

  • 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 was 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.

Hip Osteoarthritis – Improvements in Pain and Disability with Care Provided by a Chiropractor

Hip ArthritisChiropractic care holds potential value for the treatment of a variety of limb conditions.  For patients with osteoarthritis (OA) of the hip, a combined intervention of manual therapy provided by a chiropractor and patient education was more effective than a minimal control intervention.

A recent article by Poulsen et al (2013) contributes to our understanding of the literature regarding chiropractic and lower extremity conditions – particularly hip osteoarthritis. Hip osteoarthritis (OA) is a common joint disease and when symptomatic can have significant impact on regular daily activities.  Recently, hip OA has been linked to higher mortality rates.  In end stage hip OA, joint replacement surgery is an appropriate and cost-effective treatment but a long-term cohort study has documented that only 20% of patients with radiographic hip OA have had surgery 11-28 years after the initial diagnosis.  Therefore, non-surgical interventions with documented effectiveness become essential for patients who do not need, or choose not to have surgery.

Although guidelines recommend patient education (PE) programs as a core intervention, systematic reviews are contradictory in conclusions regarding their effectiveness on pain and function in hip OA. Manual therapy (MT) has been proposed as an adjunct intervention to exercise for patients with hip OA but evidence is based on a single randomized clinical trial (RCT).  The authors of the current study realized this gap in the literature and decided to investigate the effectiveness of a patient education (PE) program with or without the added effect of manual therapy (MT) compared to a minimal control intervention (MCI).

The design of this study was a single-center proof-of-principle three-arm parallel group RCT.  Inclusion criteria were: Unilateral hip pain >3 months’ duration, age 40-80 years, radiographic hip OA defined as minimal joint space width (JSW) measurement <2.00 mm or a side difference in minimal JSW >10%, and, ability to speak and read Danish.  The study took place at the Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Denmark.

During the first 2 months of recruitment, 3 exclusion criteria were added to the original criteria: patients who had had MT within the previous twelve months; patients who rated their pain severity as 1 or 2 on the numerical rating scale (NRS); patients with polyarthritis.

The 3 groups in the study were: 1) MCI; 2) PE; 3) PE + MT.

For the MCI group, a nurse provided written advice on a home stretching program derived from the PE program together with 5-10-min instruction.

The PE group, originally termed ‘Hip School’ was taught by a physiotherapist with 11 years experience. The PE program included two individual sessions and three group sessions.

In the combined PE and MT group, manual therapy was administered by a chiropractor with 20 years of clinical experience. MT was scheduled twice a week for the 6-week intervention period and treatment was individualized to each patient depending on examination findings. MT consisted of: trigger point release therapy (TPPR), muscular stretching by muscle energy technique (MET) and joint manipulation.

The primary outcome was pain severity rated on an 11-box NRS, measured after 6 weeks of intervention. Patients were asked to rate the worst pain experienced during the previous week. Secondary outcome measures were the Hip Disability and Osteoarthritis Outcome Score (HOOS) ranging from 0-100, worst to best; patients’ perceived global effect of interventions, percentage in each group having classified themselves as improved; passive hip range of motion (ROM); use of pain medication at 12 months and hip replacement surgery within the 12 month follow-up period.

Results:

  • A total of 111 patients were included in the analyses at the primary end point at 6 weeks
  • In the combined group (PE + MT), a clinically relevant reduction in pain severity compared to the MCI of 1.90 points was achieved
  • Effect size (Cohen’s d) for the PE + MT minus the MCI was 0.92 (large effect)
  • The number of patients in each group experiencing pain reduction of at least 25% from baseline to 6 weeks was PE = 8, PE +MT = 21 and MCI = 7
  • Number needed to treat for PE + MT was 3
  • No difference was found between the PE and MCI groups
  • At 12 months, not including patients receiving hip surgery the statistically significant difference favoring PE + MT was maintained
  • All HOOS (pain, symptoms, ADLs, Sport/Rec, QOL) subscales demonstrated clinically relevant and statistically significant superiority, p < 0.05 for the PE + MT group when compared to the MCI group
  • Mean differences between PE and MCI were small (range 4 to 1) and not statistically significant, p > 0.05
  • Effect sizes for HOOS subscales for PE + MT minus MCI ranged between 0.75 and 1.08
  • No changes in hip ROM noted between groups

Key Findings:

  • For primary care patients with OA of the hip, a combined intervention of manual therapy provided by a chiropractor and patient education was more effective than a minimal control intervention
  • Note that patient education alone was not superior to the minimal control intervention

So, what does this study tell us?  This trial demonstrated clinical and statistically significant improvements in pain, symptoms and disability for a combined intervention consisting of manual therapy provided by a chiropractor and patient education when compared to a minimal control intervention including home stretching.

 

Reference: Poulsen E, Hartvigsen J, Christensen HW, Roos EM, Vach W, Overgaard S. Patient education with or without manual therapy compared to a control group in patients  with osteoarthritis of the hip. A proof-of-principle three-arm parallel group randomized clinical trial. Osteoarthritis Cartilage. 2013 Oct;21(10):1494-503.

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Chiropractic Adjustments Reduce Fatigue and Increase Neural Drive

ChiropracticOver 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 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. Do these changes correlate with beneficial clinical outcomes?  That is not completely determined yet. It is also not clear whether the changes seen after adjustments are due to the correction of vertebral subluxation, therefore normalizing aberrant afferent input to the CNS, or are they merely due to afferent influx associated with the thrusting into the spine? These questions remain to be answered. The level of CNS involvement and the exact mechanisms underlying these neural adaptations following chiropractic adjustments remain unclear.

This new study reported here 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).

While several previous studies have shown a decrease in the H-reflex indicating a transient attenuation of motoneuronal activity of the lumbosacral spine in both asymptomatic subjects and low back pain patients, new advances in data collection and processing have occurred since then. The purpose of this study was to take advantage of these recent technical and methodological discoveries related to the H-reflex and V-waves and explore what effect, if any, spinal manipulation of vertebral subluxations will have on them.

Methods:

Two studies were included in the paper.  All participants were men, between the ages of 18 and 40 and were required to have evidence of spinal dysfunction and a previous history of subclinical pain, but absence of degenerative conditions of the spine or known contraindications to spinal manipulation.  Instrumentation included: 1) surface EMG to record the (SEMG) activity of the soleus muscle (SOL) of the right leg; 2) electrical stimulation producing the H-, M-, and V-waves of the SOL muscle by stimulation of the tibial nerve and; 3) force recordings performed using a strain gauge attached to a custom-made ankle brace, while the subject performed maximum voluntary ankle dorsiflexion contractions.

During study one, ten subjects attended two sessions each, the control and the experimental (spinal manipulation) session. A second study was added wherein a group of eight participants attended two more sessions each, where only force was measured. The order of these sessions were randomized and at least 1 week separated the sessions.  All experiments were performed on the right leg, while the volunteers comfortably lay prone on a massage table with their right leg firmly strapped to the table with Velcro.  The following measures were collected pre and post interventions: SEMG signals during MVC; H-and M-recruitment curves; H-reflex area under curve normalized to Mmax (Harea/Mmax), H-reflex threshold, V-wave normalized to Mmax (V/Mmax), M-wave slope, H-reflex slope and the mean power frequency (MPF) of a fast Fourier transform (FFT) of the SEMG during MVC.

The entire spine and sacroiliac joints were assessed for segmental dysfunction (vertebral subluxation) and adjusted where deemed necessary by a registered chiropractor with at least 10-years clinical experience using high-velocity, low-amplitude techniques.  The control condition involved passive and active movements of the subject’s head, spine, and body into the manipulation setup positions but without performing the adjustment.

Results:

  • 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

 

Reference: Niazi IK, Türker KS, Flavel S, Kinget M, Duehr J, Haavik H. Changes in H-reflex and V-waves following spinal manipulation. Exp Brain Res. 2015 Apr;233(4):1165-73. doi: 10.1007/s00221-014-4193-5. Epub 2015 Jan 13. PubMed

 

We’re not ‘just treating’ back and neck pain

WorldSpineChiropracticWe’re not ‘just treating’ back and neck pain!  We are reducing the leading global burden of disease! Low back pain causes more global disability than any other condition.  Neck pain is the 4th leading cause of global disability.

Reference: Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G, Smith E, Vos T, Barendregt J, Murray C, Burstein R, Buchbinder R. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014 Jun;73(6):968-74.

Podcast

Dr. Martin Descarreaux

021- Learning to Adjust and Neuromuscular Responses to Manipulation with Martin Descarreaux, DC, PhD

Dr. Martin Descarreaux and I discuss his research regarding learning to perform chiropractic adjustments, neuromuscular responses following spinal manipulation and several other studies.  Dr. Descarreaux graduated from the UQTR’s first cohort of the chiropractic program in 1998, and completed a PhD in kinesiology at the Université Laval 6 years later. He is now a full professor in the Human Kinetics Department (UQTR), and an invited professor and researcher at the Institut Franco-Européen de Chiropraxie, in Paris and Toulouse. His current research projects involve the characterization of the neurophysiological and biomechanical effects of spinal manipulation, the various effects of pain and pain-related psychological components on trunk neuromuscular strategies, as well as spinal manipulation learning, as can attest the numerous articles he has published on these topics. Over the years, he has developed several strategies to better integrate motor learning principles, which have been shared with students, professors and those responsible for clinical training within chiropractic teaching institutions not only in Canada, but also in Europe. His work in this specific area has contributed to the characterization of the adjustment learning sequence, and showed the importance of augmented feedback in the technical training of future chiropractors. He is currently the Director of graduate studies in human kinetics and director of the Groupe de recherche sur les affections neuromusculosquelettiques at UQTR.

Take a look at Dr. Descarreaux’s publications at researchgate.

Here are the links to the articles we discussed in this interview:

1. Effects of practice variability on spinal manipulation learning.
Marchand AA, Mendoza L, Dugas C, Descarreaux M, Pagé I.
J Chiropr Educ. 2017 Jan 25. doi: 10.7899/JCE-16-8. [Epub ahead of print]
PMID: 28121458 [PubMed – as supplied by publisher]
Similar articles
2. Influence of Lumbar Muscle Fatigue on Trunk Adaptations during Sudden External Perturbations.
Abboud J, Nougarou F, Lardon A, Dugas C, Descarreaux M.
Front Hum Neurosci. 2016 Nov 14;10:576.
PMID: 27895569 [PubMed – in process] Free PMC Article
Similar articles
3. Physiological and Psychological Predictors of Short-Term Disability in Workers with a History of Low Back Pain: A Longitudinal Study.
Dubois JD, Cantin V, Piché M, Descarreaux M.
PLoS One. 2016 Oct 26;11(10):e0165478. doi: 10.1371/journal.pone.0165478.
PMID: 27783666 [PubMed – in process] Free PMC Article
Similar articles
4. Neuromechanical response to spinal manipulation therapy: effects of a constant rate of force application.
Nougarou F, Pagé I, Loranger M, Dugas C, Descarreaux M.
BMC Complement Altern Med. 2016 Jun 2;16:161. doi: 10.1186/s12906-016-1153-6.
PMID: 27249939 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
5. Systematic Augmented Feedback and Dependency in Spinal Manipulation Learning: a Randomized Comparative Study.
Lardon A, Cheron C, Pagé I, Dugas C, Descarreaux M.
J Manipulative Physiol Ther. 2016 Mar-Apr;39(3):185-91. doi: 10.1016/j.jmpt.2016.02.002.
PMID: 27016338 [PubMed – in process]
Similar articles
6. Effects of a prehabilitation program on patients’ recovery following spinal stenosis surgery: study protocol for a randomized controlled trial.
Marchand AA, Suitner M, O’Shaughnessy J, Châtillon CÉ, Cantin V, Descarreaux M.
Trials. 2015 Oct 27;16:483. doi: 10.1186/s13063-015-1009-2.
PMID: 26507388 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
Dr. Michele Maiers

020- Patient Perspectives, Integrative Care and Health Policy with Dr. Michele Maiers

Dr. Michele Maiers

Dr. Michele Maiers and I discuss the patient perspective in chiropractic clinical trials, integrative care and  leveraging research to inform health care policy.

“We’re drowning in information and starving for knowledge.”   ~Rutherford Rogers

This axiom aptly characterizes how many see research as it relates to health care delivery.  Dr. Maiers’ professional goal is to facilitate the pragmatic use of research to both inform clinical practice and shape public health policy. Her research has focused on clinical trials that answer practical questions, including, are patient outcomes improved with co-management by different provider types? Is short term treatment or long term management a better approach for chronic musculoskeletal conditions? What aspects of care matter most to patients? It is essential that the information gained in these and other studies is translated into knowledge that improves patient care, policy guidelines, access and reimbursement. Dr. Maiers is excited about her work because she believes in the capacity for integrative and complementary professions to be a positive force to improving the landscape of health care.  When not at work, she enjoys traveling, reading, running and baking pies.

See Dr. Maiers publications on researchgate.

Here are the links to the articles we discussed in this interview:

1. What do patients value about spinal manipulation and home exercise for back-related leg pain? A qualitative study within a controlled clinical trial.
Maiers M, Hondras MA, Salsbury SA, Bronfort G, Evans R.
Man Ther. 2016 Dec;26:183-191. doi: 10.1016/j.math.2016.09.008.
PMID: 27705840 [PubMed – in process]
Similar articles
2. Adverse events among seniors receiving spinal manipulation and exercise in a randomized clinical trial.
Maiers M, Evans R, Hartvigsen J, Schulz C, Bronfort G.
Man Ther. 2015 Apr;20(2):335-41. doi: 10.1016/j.math.2014.10.003.
PMID: 25454683 [PubMed – indexed for MEDLINE]
Similar articles
3. Perceived value of spinal manipulative therapy and exercise among seniors with chronic neck pain: a mixed methods study.
Maiers M, Vihstadt C, Hanson L, Evans R.
J Rehabil Med. 2014 Nov;46(10):1022-8. doi: 10.2340/16501977-1876.
PMID: 25258045 [PubMed – indexed for MEDLINE] Free Article
Similar articles
4. Spinal manipulative therapy and exercise for seniors with chronic neck pain.
Maiers M, Bronfort G, Evans R, Hartvigsen J, Svendsen K, Bracha Y, Schulz C, Schulz K, Grimm R.
Spine J. 2014 Sep 1;14(9):1879-89. doi: 10.1016/j.spinee.2013.10.035.
PMID: 24225010 [PubMed – indexed for MEDLINE]
Similar articles
5. Integrative care for the management of low back pain: use of a clinical care pathway.
Maiers MJ, Westrom KK, Legendre CG, Bronfort G.
BMC Health Serv Res. 2010 Oct 29;10:298. doi: 10.1186/1472-6963-10-298.
PMID: 21034483 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
Dr. Alan Breen

019- Spine Dynamics, Spine Control and Chiropractic with Dr. Alan Breen

Alan BreenDr. Alan Breen and I discuss spine dynamics and spine control along with quantitative fluoroscopy in chiropractic research and practice. Dr. Alan Breen graduated from the Canadian Memorial Chiropractic College in 1967, then travelled in North America, Australia and Europe before starting a part time teaching post at the Anglo-European College of Chiropractic (AECC) in Bournemouth UK in 1971, he established a practice in Salisbury in 1974, which continues. In 1986 Dr. Breen became Director of Research at AECC and focussed on musculoskeletal research and epidemiology, encouraging staff to undertake doctoral studies. In 1999 he became director of a new musculoskeletal research institute – the Institute for Musculoskeletal Research and Clinical Implementation, where he continues to work. Dr. Breen is also Professor of Musculoskeletal Research in the Faculty of Science and Technology at Bournemouth University.

Dr. Breen published the first epidemiology paper by a chiropractor in a medical journal in 1977 then built a collaboration that resulted in a trial by the Medical Research Council in the UK. This was published in 1991 and had a positive outcome for chiropractors. His PhD project, which was completed in 1991, involved the invention of Quantitative Fluoroscopy, a technology that measures inter-vertebral motion in living subjects and which has now entered clinical use. He is a former member of the World Federation of Chiropractic’s Research Council.

Here is the link to Dr. Alan Breen’s website at the Institute for Musculoskeletal Research and Clinical Implementation.

To view Dr. Breen’s research publications please visit researchgate.

Here are the links to the articles we discussed in this interview:

1. Relationships between Paraspinal Muscle Activity and Lumbar Inter-Vertebral Range of Motion.
du Rose A, Breen A.
Healthcare (Basel). 2016 Jan 5;4(1). pii: E4. doi: 10.3390/healthcare4010004.
PMID: 27417592 [PubMed] Free PMC Article
Similar articles
2. Proportional lumbar spine inter-vertebral motion patterns: a comparison of patients with chronic, non-specific low back pain and healthy controls.
Mellor FE, Thomas PW, Thompson P, Breen AC.
Eur Spine J. 2014 Oct;23(10):2059-67. doi: 10.1007/s00586-014-3273-3.
PMID: 24676852 [PubMed – indexed for MEDLINE]
Similar articles
3. Does inter-vertebral range of motion increase after spinal manipulation? A prospective cohort study.
Branney J, Breen AC.
Chiropr Man Therap. 2014 Jul 1;22:24. doi: 10.1186/s12998-014-0024-9.
PMID: 25035795 [PubMed] Free PMC Article
Similar articles
4. Measurement of intervertebral motion using quantitative fluoroscopy: report of an international forum and proposal for use in the assessment of degenerative disc disease in the lumbar spine.
Breen AC, Teyhen DS, Mellor FE, Breen AC, Wong KW, Deitz A.
Adv Orthop. 2012;2012:802350. doi: 10.1155/2012/802350.
PMID: 22666606 [PubMed] Free PMC Article
Similar articles

 

018- 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

 

017- 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

 

Dr. William Weeks

015- 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
Similar articles
Dr. Jan Hartvigsen

014- Evidence Based Practice with Jan Hartvigsen, DC, PhD

Dr. Hartvigsen and I discuss some important issues facing the profession including: 1) What is Evidence Based Practice?; 2) How do we build chiropractic’s academic capacity (and what are the barriers)?; 3) The Chiropractic Profession in the Mainstream; 4) How can we get the research out to chiropractors and the public?; 5) Musculoskeletal health in the context of general health; 6) The current situation in Australia (pediatric chiropractic).

Professor Hartvigsen is Full Professor and Head of Research at the Department of Sports Science and Clinical Biomechanics at the Faculty of Health, University of Southern Denmark (SDU). He is also leading the Graduate Program for Physical Activity and Musculoskeletal Health and is co-founder of the Center for Muscle and Joint Health. He has published 136 scientific publications (67 in the past five years) including 26 systematic reviews, 13 editorials and commentaries and 10 book chapters and commissioned reports. His h-index is 26 and his work has received 1806 citations in the past five years. He has published as lead and senior author in leading general and musculoskeletal specialty journals such as BMJ, Spine, Pain, Osteoarthritis and Cartilage and Archives of Physical Medicine and Rehabilitation.

Invited Keynote Presentations:

Jan Hartvigsen has given 104 keynotes or invited presentations at meetings and multidisciplinary conferences in the fields of chiropractic, physiotherapy, back pain, and orthopaedics. Noticeably he has been invited to speak at the Forum for Research on Back Pain in Primary Care, World Congress on Low Back and Pelvic Pain (2x), World federation of Chiropractic Biennial Conference (4x), Forum on Manual Medicine, and The Nordic Congress on Musculoskeletal Physiotherapy and Musculoskeletal Medicine.

Research:

Jan Hartvigsen has received research support from numerous sources including from The Danish Regions 2001-2015, European Chiropractors Union 2012, Ontario Neurotrauma Foundation 2012, IMK General Foundation 2006-2015, Danish League Against Rheumatism 2011, Danish Agency for Science, Technology, and Innovation 2008, Danish Enterprise and Construction Authority 2008, Danish Board of Health 2005, Health Ressources and Service Administration (USA) 2009-2012. In total he has received over 50 million DKK in research support as lead or co-applicant since 2005.

Jan Hartvigsen has supervised 70+ MSc students during thesis work. He has completed supervision of 13 PhD students and is currently supervising 6 PhD students.

Prof Hartvigsen has peer reviewed 200+ manuscripts for 38 scientific journals including BMJ, Annals of Internal Medicine, Pain, Brain, and Annals of Rheumatic Diseases. He has reviewed submissions for 17 international conferences since 2007. He has reviewed grant applications from 13 agencies since 2005 including Canadian Institutes for Health Research, National Institutes for Health Research (UK), Arthritis Research UK, The BUPA Foundation (UK), WorkSafe BC (Canada), and The Wellcome Trust (UK). He has been examiner on 13 PhD theses in Denmark, Norway, Sweden, UK, Canada, Holland and Australia. Jan Hartvigsen has evaluated candidates for scientific positions at University of Sydney (AU), MacQuarie University (AU), Curtin University (AU), Keele University (UK), University of Toronto (Canada), University of Alberta (Canada), and all major Danish universities.

Teaching:

He has extensive teaching experience in the areas of research methodology, biostatistics, clinical examination and treatment of spine problems, and epidemiology. He has been responsible for establishing and coordinating courses in all of these areas.

www.sdu.dk/staff/jhartvigsen

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

Links to Articles mentioned in the podcast:

1. Beyond the spine: a new clinical research priority.
Donovan J, Cassidy JD, Cancelliere C, Poulsen E, Stochkendahl MJ, Kilsgaard J, Blanchette MA, Hartvigsen J.
J Can Chiropr Assoc. 2015 Mar;59(1):6-12.
PMID: 25729080 [PubMed] Free PMC Article
Similar articles
2. Is it all about a pain in the back?
Hartvigsen J, Natvig B, Ferreira M.
Best Pract Res Clin Rheumatol. 2013 Oct;27(5):613-23. doi: 10.1016/j.berh.2013.09.008. Review.
PMID: 24315143 [PubMed – indexed for MEDLINE]
Similar articles
3. Musculoskeletal disorders and work disability.
Hartvigsen J.
Pain. 2013 Oct;154(10):1904-5. doi: 10.1016/j.pain.2013.06.036. Review. No abstract available.
PMID: 23810853 [PubMed – indexed for MEDLINE]
Similar articles

 

Dr. Kent Stuber

013- Patient Centered Chiropractic Care with Dr. Kent Stuber

Dr. Kent StuberDr. Kent Stuber discusses his research interests, his role as editor of the Journal of the Canadian Chiropractic Association and how chiropractors can get involved in research. Kent Stuber has been in practice in Calgary, Alberta, Canada for nearly 14 years. He did his chiropractic training at CMCC. He completed a Master of Science degree in Health and Social Care Research from the University of Sheffield in 2008. He is currently a MPhil/PhD student at the University of South Wales, studying patient-centeredness in chiropractic.

Kent is an Adjunct Professor in CMCC’s Division of Graduate Education and Research. He has published over 30 articles in over a dozen different peer-reviewed scientific journals. His research interests include patient-centered care, sports injuries, spinal stenosis, the psychometric properties and use of orthopaedic testing, as well as the treatment of pregnancy-related musculoskeletal conditions.

Kent is a member of the International Task Force on Diagnosis and Management of Lumbar Spinal Stenosis as well as the Guideline Implementation Group (GIG) of the Canadian Chiropractic Association’s Clinical Practice Guideline Initiative. In July 2015, Kent became the fifth Editor-in-Chief of the Journal of the Canadian Chiropractic Association, a peer-reviewed journal now in its 60th year of publication.

Dr. Stuber was born and raised in Calgary. He obtained a Bachelor of Science degree in Cellular, Molecular & Microbial Biology from the University of Calgary before moving to Toronto where he graduated Magna Cum Laude with Clinic Honours from the Canadian Memorial Chiropractic College (CMCC) in 2002.  Dr. Stuber’s post graduate education courses have included Graston Technique®, Active Release Techniques®, Kinesiotaping, Low-Tech Lumbar Spinal Stabilization Training, Managing Neck Pain Conditions, Evaluation and Management of Neck and Arm Pain, courses from the Titleist Performance Institute, and Taping and Support Techniques for Sports Practitioners.  You can visit Dr. Stuber’s practice at: http://www.momentumhealth.ca.

Visit the Journal of the Canadian Chiropractic Association.  The Journal of the Canadian Chiropractic Association (JCCA) is the official, peer reviewed, quarterly research publication of the Canadian Chiropractic Association (CCA). Published since 1957 and searchable from 1986 on this site and from 1978 in PubMed, the JCCA publishes research papers, commentaries and editorials relevant to the practice of chiropractic.

View Dr. Stuber’s publications on researchgate.com.

Here are the articles we discuss during the interview:

1. Assessing patient-centered care in patients with chronic health conditions attending chiropractic practice: protocol for a mixed-methods study.
Stuber KJ, Langweiler M, Mior S, McCarthy PW.
Chiropr Man Therap. 2016 May 9;24:15. doi: 10.1186/s12998-016-0095-x.
PMID: 27162609 [PubMed] Free PMC Article
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2. ISSLS Prize Winner: Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study.
Tomkins-Lane C, Melloh M, Lurie J, Smuck M, Battié MC, Freeman B, Samartzis D, Hu R, Barz T, Stuber K, Schneider M, Haig A, Schizas C, Cheung JP, Mannion AF, Staub L, Comer C, Macedo L, Ahn SH, Takahashi K, Sandella D.
Spine (Phila Pa 1976). 2016 Aug 1;41(15):1239-46. doi: 10.1097/BRS.0000000000001476.
PMID: 26839989 [PubMed – in process]
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3. Chiropractic treatment of lumbar spinal stenosis: a review of the literature.
Stuber K, Sajko S, Kristmanson K.
J Chiropr Med. 2009 Jun;8(2):77-85. doi: 10.1016/j.jcm.2009.02.001.
PMID: 19646390 [PubMed] Free PMC Article
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4. Core stability exercises for low back pain in athletes: a systematic review of the literature.
Stuber KJ, Bruno P, Sajko S, Hayden JA.
Clin J Sport Med. 2014 Nov;24(6):448-56. doi: 10.1097/JSM.0000000000000081. Review.
PMID: 24662572 [PubMed – indexed for MEDLINE]
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5. Chiropractic treatment of pregnancy-related low back pain: a systematic review of the evidence.
Stuber KJ, Smith DL.
J Manipulative Physiol Ther. 2008 Jul-Aug;31(6):447-54. doi: 10.1016/j.jmpt.2008.06.009. Review.
PMID: 18722200 [PubMed – indexed for MEDLINE]
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6. The treatment experience of patients with low back pain during pregnancy and their chiropractors: a qualitative study.
Sadr S, Pourkiani-Allah-Abad N, Stuber KJ.
Chiropr Man Therap. 2012 Oct 9;20(1):32. doi: 10.1186/2045-709X-20-32.
PMID: 23046615 [PubMed] Free PMC Article
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Dr. Cheryl Hawk

011- Health Promotion, Wellness and Chiropractic Guidelines with Dr. Cheryl Hawk

Cheryl-Hawk-thumbnailIn this episode Cheryl Hawk, DC, PhD, CHES discusses chiropractic maintenance vs. wellness care, various chiropractic guidelines on low back pain, health promotion and pediatric care as well as her two new books. Dr. Cheryl Hawk is an author of over 100 publications in peer-reviewed scientific journals. She has designed and taught courses on wellness and health promotion to health professions students and in post-graduate education. She has also collaborated on the design and implementation of an online wellness certification program for health professionals, with Will Evans, DC, PhD, MCHES, and Michael Perko, PhD, CHES, FAAHE, offered by the National Wellness Institute. She received her Doctor of Chiropractic degree in 1976 from the National University of Health Sciences and practiced full-time for 12 years. In 1991, she earned a PhD in Preventive Medicine from the University of Iowa and also became a Certified Health Education Specialist (CHES). She is the author, with Will Evans, DC, PhD, MCHES, of Health Promotion and Wellness: An Evidence-Based Guide to Clinical Preventive Services. She is currently co-chair of the Research Working Group of the Academic Consortium for Complementary and Alternative Health Care. She has been named “Researcher of the Year” by both the American Chiropractic Association (2003) and the Foundation for Chiropractic Education and Research (2005). Her areas of interest are health promotion and prevention, practice-based research and health services research.

And…Dr. Hawk is also working on two upcoming books, Evidence-based Chiropractic Practice and Careers in Chiropractic. Although they won’t be published until 2017, there’s never been anything like it for chiropractic. This will be 2 entire volumes written NOT for chiropractors, but for potential patients, other providers, and potential chiropractic students!

As mentioned in the interview,  please find a link to the link to the CCGPP/Clinical Compass website and materials at http://clinicalcompass.org/

After CCGPP teams with specific skills review and rate all information gathered from multiple databases (synthesis), this information is then translated into easily usable tools (the “Chiropractic Clinical Compass©”). The synthesis is not the Compass©, it is merely an evidence stratification for the most common conditions seen by chiropractic doctors. CCGPP recognizes that information in this format is difficult to digest and implement. To assist comprehension and ease of application, the synthesis will be translated for use in the treatment room via a DIER (Dissemination, Implementation, Evaluation, and Revision) process (see Powerpoint presentation on the Introduction page of this website for more details on this process). This process will ultimately produce the Chiropractic Clinical Compass©. In addition, in today’s ever-changing health care environment, the literature synthesis can be used for many purposes and CCGPP is flexible and responsive to rapidly changing trends and needs.

The goals of CCGPP/Clinical Compass are:

  • To promote the improvement of the quality of chiropractic services and of the professional reputation of doctors of chiropractic
  • To promote the intellectual, academic, and clinical integrity of chiropractic practice
  • To promote the intellectual, academic, and clinical integrity of practice guidelines and PR

Please support CCGPP/Clinical Compass by donations at http://clinicalcompass.org/donate

For a list of Dr. Hawk’s scientific publications please click here.

Here is a list of the publications we discuss during this interview:

1. The Role of Chiropractic Care in the Treatment of Dizziness or Balance Disorders: Analysis of National Health Interview Survey Data.
Ndetan H, Hawk C, Sekhon VK, Chiusano M.
J Evid Based Complementary Altern Med. 2016 Apr;21(2):138-42. doi: 10.1177/2156587215604974.
PMID: 26362851 [PubMed – indexed for MEDLINE]
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2. Consensus process to develop a best-practice document on the role of chiropractic care in health promotion, disease prevention, and wellness.
Hawk C, Schneider M, Evans MW Jr, Redwood D.
J Manipulative Physiol Ther. 2012 Sep;35(7):556-67. doi: 10.1016/j.jmpt.2012.05.002.
PMID: 22742964 [PubMed – indexed for MEDLINE]
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3. Chiropractic and public health: current state and future vision.
Johnson C, Baird R, Dougherty PE, Globe G, Green BN, Haneline M, Hawk C, Injeyan HS, Killinger L, Kopansky-Giles D, Lisi AJ, Mior SA, Smith M.
J Manipulative Physiol Ther. 2008 Jul-Aug;31(6):397-410. doi: 10.1016/j.jmpt.2008.07.001.
PMID: 18722194 [PubMed – indexed for MEDLINE]
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4. A framework for chiropractic training in clinical preventive services.
Hawk C, Evans MW Jr.
Chiropr Man Therap. 2013 Aug 20;21(1):28. doi: 10.1186/2045-709X-21-28.
PMID: 23962353 [PubMed] Free PMC Article
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5. Clinical Practice Guideline: Chiropractic Care for Low Back Pain.
Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen WM, Walters S, Kaeser M, Dehen M, Augat T.
J Manipulative Physiol Ther. 2016 Jan;39(1):1-22. doi: 10.1016/j.jmpt.2015.10.006.
PMID: 26804581 [PubMed – indexed for MEDLINE]
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6. Best Practices for Chiropractic Care of Children: A Consensus Update.
Hawk C, Schneider MJ, Vallone S, Hewitt EG.
J Manipulative Physiol Ther. 2016 Mar-Apr;39(3):158-68. doi: 10.1016/j.jmpt.2016.02.015.
PMID: 27040034 [PubMed – in process] Free Article
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Dr. Steven Passmore

005- Human Performance with Dr. Steven Passmore

Passmore Headshot 2012

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Listen to Dr. Dean Smith interview Dr. Passmore regarding the science relating chiropractic to human performance. Dr. Passmore is Assistant Professor in the Faculty of Kinesiology & Recreation Management at the University of Manitoba.  He also holds adjunct appointments in the College of Rehabilitation Sciences at the University of Manitoba, the Research Department at New York Chiropractic College, and the University of Ontario Institute of Technology.  His expertise deals with human perceptual learning and motor control.  Dr. Passmore utilizes his theoretical and applied background in perceptual motor behaviour to explore performance-based outcome measures in an attempt to objectively determine population characteristics, movement outcomes and sustainability of interventions.  Dr. Passmore practiced as a chiropractor in the Buffalo Veterans Affairs Medical Center (2007-09), and is currently in practice in Manitoba. He has held competitive grants from the Canadian Institutes for Health Research (CIHR), the Worker’s Compensation Board of Manitoba (WCB), Research Manitoba (RM), the Manitoba Medical Service Foundation (MMSF), and the Alexander Gibson Fund.