Spinal manipulation biochemical

Biochemical Markers of Pain Perception and Stress Response Following Spinal Manipulation

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

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

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

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

Results

Neurotensin (NT)

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

Orexin A

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

Oxytocin

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

Cortisol

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


Discussion

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

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

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


Key Points

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

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

EBP and Literature Searching for the Busy Chiropractor

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

Dr. André Bussières

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

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

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

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

Dr. Bussières Appointments:

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

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

Research Interests:

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

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

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

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

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

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
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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. Dean Smith – The Importance of an Evidence Based Practice

Dean Smith, DC, PhDChiropractors, how do you take all of the current chiropractic research and develop an effective evidence based practice strategy? I will be joining Dr. Stu Hoffman and ChiroSecure next Tuesday, June 21st for The Importance of an Evidence Based Practice.

At this event you will learn:

  • What is an Evidence Based Practice?
  • The Importance of an Evidence Based Practice
  • Barriers to the Evidence Based Practice

Dr. Dean Smith is a practicing chiropractor and has published over 40 peer reviewed scientific articles and conference publications.  Dr. Smith will be presenting what leading chiropractic researchers are saying about their own research (from the chiropractic science podcast).  We will also discuss strategies to incorporate the latest science into your practice.

So mark your calendars for the following:

WHO SHOULD ATTEND:  All chiropractors, associates and staff

WHEN: Tuesday, June 21st, 2016, 2:00 PM EST

WHERE: http://www.chirosecure.com/live/

LENGTH: 30 to 40 minutes

HOW TO SIGN-UP: JUST SHOW UP NO OPT-IN

COST TO ATTEND: NONE, COURTESY OF CHIROSECURE*

REPLAY: For ChiroSecure Concierge Members

PLEASE NOTE: We will be providing valuable notes to every attendee of the Live Event.

CHIROSECURE CONCIERGE SERVICE: Sign up for our Concierge Service and we will automatically send you the video replay, the notes and the transcripts for all our Live Events without ever having to show up again. http://www.chirosecure.com/concierge-service/

*Supporting the Chiropractic community for over 25 years,  ChiroSecure’s Live Events educate and support you, the practitioner, by making sure you have the information you need to protect you, your practice and your future.

 

 

Chiropractic and Immediate Pain Relief

18448850_xxlThe application of spinal manipulative therapy (SMT) is a cost-effective and widely recognized manual intervention used by a variety of health care professionals in the management of musculoskeletal pain. A growing body of scientific evidence supports the use of SMT for the treatment of a broad range of musculoskeletal disorders citing short-term antinociceptive (pain-relieving) effects and restoration of normal joint mechanics.

Last year, about this time, I wrote about a systematic review that found spinal manipulation therapy (SMT) has a pain reducing effect as measured by pressure pain thresholds (PPT).  Additionally, the effect of SMT on pain reduction was statistically significant at remote locations (for example, adjusting the neck yielded reduction in pain at the elbow).

A new study has emerged in the scientific literature that advances our understanding of the topic (Srbely et al, 2013).  The authors note that although the pathophysiology of myofascial pain syndrome (MPS) is still unclear, research suggests that myofascial trigger points (MTPs) play an fundamental role in the generation and clinical manifestation of MPS.  However, it is currently unknown if the antinociceptive effects of SMT in myofascial tissues are manifest predominantly via regional or general mechanisms, or a combination of both. A study was needed to specifically investigate the hypothesis that SMT evokes robust antinociceptive effects in MTPs preferentially located within neurosegmentally linked myofascial tissues.

Srbely et al conducted the study through the University of Guelph.  The study was a single session, single blinded, randomized controlled intervention.  The primary inclusion criterion was the presence of a clinically identifiable MTP locus (active or latent) within the right infraspinatus and right gluteus medius muscles.  The primary diagnostic criterion used to clinically identify the trigger point locus was ‘a palpable hyperirritable nodule nested within a taut band of skeletal muscle; sustained ischemic pressure over the trigger point locus elicited a dull achy regional pain or discomfort.’  Exclusion criteria encompassed conditions that would affect normal somatosensory processing.

Thirty-six participants qualified for the study and were randomly assigned to test or control groups.  Two chiropractors saw participants at an urban outpatient clinic. One chiropractor performed the history, exam and manipulations while the other chiropractor (blinded to treatment allocation) detected the trigger points and measured all PPTs. The primary outcome was PPT values from infraspinatus and gluteus medius muscles.  The infraspinatus was chosen due to its innervation from the manipulated segment (C5-6). The gluteus medius acted as a regional control point (L4-S1 innervation).

PPT was measured with a force gauge (Newtons) over the trigger point locus (infraspinatus, gluteus medius) and was defined as the force necessary to elicit the onset of a deep dull achy local discomfort and/or referred pain. Measurements were taken at 1,5, 10, and 15 minutes postintervention.  In order to specifically compare regional antinociceptive effects between intervention groups, the authors also calculated the PPT difference (PPTdiff) between infraspinatus and gluteus medius trigger points at each time interval within each participant. Participants received a rotary type manipulation to the C5-6 segment in a supine posture.   Additionally, a drop piece mechanism was used to aid in the high velocity low amplitude thrust.  Control participants received a sham manipulation.  The sham consisted of rotating the neck of the participant, supporting the neck of the participant with the clinician’s forearm under the headpiece and a thrust of the forearm into the headpiece.  It is noted that the contact hand did not thrust and did not create ‘a real manipulation’ of any segment.

Results:

  • there was a significantly increased PPT threshold for infraspinatus trigger points in treated participants compared to controls at all time intervals beyond baseline
  • there was a significantly increased PPT threshold for infraspinatus compared to gluteus medius before and after manipulation at all time intervals beyond baseline
  • no significant differences in PPT scores were observed at any time interval when comparing test gluteus medius, control infraspinatus, and control gluteus medius groups
  • there were significant increases in PPTdiff in the test group vs controls at all time intervals beyond baseline

Key Findings:

  • This study suggests that SMT evokes statistically significant short-term increases in PPT in segmentally related myofascial tissues in young adults
  • Decreased pressure sensitivity (increased PPT score) was observed at all time intervals beyond baseline within neurologically linked infraspinatus muscle after real, but not sham, manipulation
  • The peak antinociceptive effect was measured as a 36% decrease in pressure sensitivity from baseline values and was recorded at 5 minutes postSMT

So, what does this study tell us?  It suggests that SMT evokes robust regional antinociceptive effects in myofascial tissues.  It also provides important evidence to support further research into the potential benefit and role of SMT in the management of chronic widespread pain syndromes  including myofascial pain, and fibromyalgia.

Reference: Srbely JZ, Vernon H, Lee D, Polgar M. Immediate effects of spinal manipulative therapy on regional antinociceptive effects in myofascial tissues in healthy young adults. J Manipulative Physiol Ther. 2013 Jul-Aug;36(6):333-41.

 

Chiropractic and Routine Obstetric Care

pregnantMusculoskeletal pain in pregnant women is common and is frequently viewed as short-lived and temporary.  Most women report either low back pain (LBP) or pelvic pain (PP) during pregnancy and up to 40% of patients report pain during the 18 months after delivery.  Pelvic pain in pregnant women is a health care challenge in which moderate and severe pain develops rather early and has important implications for society.  These pain syndromes increase sick leave and impair general level of function during pregnancy.

Previous research has evaluated different treatments to reduce morbidity in women with LBP and/or PP during pregnancy including prescription exercise, manual manipulation, education, acupuncture, and pelvic belts amongst others.

The authors of this study conducted a prospective, randomized, masked clinical trial (including 169 women) to test the hypothesis that a multimodal approach (MOM) involving a chiropractor including manual therapy, exercise, and education for LBP/PP in pregnant women is superior to standard obstetric care (STOB) for reducing pain, impairment, and disability in the antepartum period.

Patients from this study were recruited from 3 university affiliated practices (Washington University, St. Louis, MO).  Patients were between 15-45 years old with a single fetus from 24-28 weeks’ gestation.  Patients were evaluated by their obstetric provider for LBP, PP or both.  Exclusion criteria included acute inflammatory disease, acute infectious disease, chronic back pain for greater than 8 weeks before pregnancy, a mental health disorder, back pain from visceral disease, ongoing treatment for previous back pain, peripheral vascular disease, substance abuse, or litigation pending from back pain.

A single, masked chiropractic specialist conducted the baseline evaluation (BE) with eligible volunteers before randomization.  Randomization of subjects across to the STOB group or the STOB plus multimodal musculoskeletal and obstetric treatment (MOM) group was achieved across all 3 sites.

Subjective and objective measures were collected at baseline evaluation (24-28 weeks’ gestation) with follow-up at 33 weeks’ gestation. Three questionnaires including the numerical rating scale, Quebec task force disability questionnaire (QDQ) and personal pain history (PPH) were obtained.  Physical assessments included the straight leg raise (SLR), posterior PP provocation test, active SLR, and long dorsal ligament test.

Patients in the both the STOB and MOM groups selected their own obstetric provider.   In addition to obstetric care, the MOM group had weekly visits with a chiropractor until 33 weeks’ gestation who provided education, manual therapy, and lower back and pelvic stabilization exercises.  Patients were reassured the pain experienced was not likely pathologic and that activation of joints and muscle through exercise would likely improve symptoms and signs without posing risk to the patient or her fetus.  Joint mobilization involved gently moving hypomobile joints in their restricted directions to help restore proper range of motion.  The gluteus maximus, gluteus medius, quadratus lumborum, abdominal wall, and intrinsic spine muscles were targeted in the quadruped, supine, or side-lying positions.

Key findings of this study were:

  • the MOM group (involving chiropractor) had a significant reduction in pain on 7 indices (NRS, QDQ, SLR(left), active SLR, long dorsal ligament test, PPH – leg and shoulders)
  • the STOB group had a significant increase in pain on 5 indices and only 1 improvement (PPH -leg)
  • The MOM group reported significantly less trouble sleeping at 33 weeks’ gestation than the STOB group
  • No adverse events were reported in either group

In summary, including chiropractic interventions with standard obstetric care for low back and pelvic pain in mid pregnancy benefits patients more than standard obstetric care alone. The benefits derived are both subjective and objective. Patients perceived less pain and disability and an overall global improvement in daily activities. Their physical examinations revealed improved range of motion, stability, and less irritation at the lumbar and pelvic joints.

Reference:

George JW, Skaggs CD, Thompson PA, Nelson DM, Gavard JA, Gross GA. A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. Am J Obstet Gynecol. 2013 Apr;208(4):295.e1-7.

 

 

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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Musculoskeletal Chest Pain and the Cost-Effectiveness of Chiropractic Care

chestpain1Chest pain is a common presentation to health care practitioners, and requires careful and often urgent assessment. Although it is critical to rule out potentially life-threatening conditions, in the general practice/primary care setting, musculoskeletal conditions are the most common causes of chest pain (1). The evidence suggests a prevalence in the general practice population of from 20.6%to 46.6%. By contrast, musculoskeletal conditions were diagnosed in only 6.2% of patients presenting to the emergency department (1).  An attack of acute chest pain can have many causes, not all of which are critical.  Once serious pathology such as myocardial infarction (heart attack) has been ruled out, these patients are often discharged from the emergency department (ED) with the diagnosis of undifferentiated chest pain, i.e. chest pain of unknown origin (2). An often over-looked cause of acute undifferentiated chest pain is pain from the neck and mid back (thoracic spine), creating a sub-category of this condition often called ‘musculoskeletal chest pain’.

A recent Danish randomized controlled trial by Dr. Stochkendahl, a chiropractor and PhD clinical researcher compared chiropractic care, including spinal manipulation of the thoracic and/or cervical spine to the normal self-management program for patients presenting to a University Hospital with acute musculoskeletal chest pain (3, 4) The study results demonstrated improvement in self-perceived chest pain and less pain intensity in favor of chiropractic care. In addition, patients receiving chiropractic care reported significantly less thoracic spine and shoulder-arm pain. This study suggested that chiropractic care could help speed recovery for patients with acute musculoskeletal chest pain presenting to the emergency department.

A study that just came out in 2016 has examined the cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain (5). An interesting finding is that patients with non-specific chest pain feel equally or more disabled than patients with cardiac chest pain and are a major burden on healthcare resources. This new study found that in terms of health-related quality of life, primary care in the form of chiropractic care has similar effectiveness as self-management in patients with musculoskeletal chest pain. For patients with musculoskeletal chest pain, community-based chiropractic care is more cost-effective than self-management as it is associated with fewer hospital admissions and lower healthcare costs (5).

 

References:

1: Winzenberg T, Jones G, Callisaya M. Musculoskeletal chest wall pain. Aust Fam Physician. 2015 Aug;44(8):540-4. PubMed PMID: 26510139.

2: Donovan J, Cassidy JD, Cancelliere C, Poulsen E, Stochkendahl MJ, Kilsgaard J, Blanchette MA, Hartvigsen J. Beyond the spine: a new clinical research priority.  J Can Chiropr Assoc. 2015 Mar;59(1):6-12. PubMed PMID: 25729080; PubMed Central PMCID: PMC4319449.

3: Stochkendahl MJ, Christensen HW, Vach W, Høilund-Carlsen PF, Haghfelt T, Hartvigsen J. Chiropractic treatment vs self-management in patients with acute chest pain: a randomized controlled trial of patients without acute coronary syndrome. J Manipulative Physiol Ther. 2012 Jan;35(1):7-17. doi: 10.1016/j.jmpt.2010.11.004. Epub 2011 Dec 19. PubMed PMID: 22185955.

4: Christensen HW, Vach W, Gichangi A, Manniche C, Haghfelt T, Høilund-Carlsen PF. Manual therapy for patients with stable angina pectoris: a nonrandomized open prospective trial. J Manipulative Physiol Ther. 2005 Nov-Dec;28(9):654-61. PubMed PMID: 16326234.

5: Stochkendahl MJ, Sørensen J, Vach W, Christensen HW, Høilund-Carlsen PF, Hartvigsen J. Cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain. Open Heart. 2016 May 4;3(1):e000334. doi: 10.1136/openhrt-2015-000334. eCollection 2016. PubMed PMID: 27175285.