Upcoming interview with Dr. Katie de Luca. Katie de Luca is a post-doctoral research fellow in the Department of Chiropractic at Macquarie University. She is a chiropractor in clinical practice, however her research focuses on the epidemiology and management of musculoskeletal conditions, with expertise in the elderly. In 2016 she was awarded her PhD from the University of Newcastle, School of Medicine and Public Health. Her thesis explored the experience of pain in women with arthritis, and resulted in substantial contributions to fields of rheumatology, pain and ageing research. She has 25 peer-reviewed journal publications and more than 50 conference presentations, which includes several invited keynote presentations on back pain in the elderly. These have been at regional, national and international conferences in gerontology, pain, public health and chiropractic forums. She is on the editorial boards of Chiropractic and Manual Therapies and JMPT, and peer-reviews for another 13 journals. Please comment below if you have any questions for us during the interview. I might choose some of them for our conversation.
I wanted to share the latest episodes of the podcast with you all. Fascinating research ahead. Hope you enjoy. I’d love to hear your feedback. Also, did you know that we are on YouTube?
037- Interdisciplinary Care and Strategies to Incorporate Evidence Into Practice With Dr. Robert Vining
In this episode, Dr. Robert Vining and I discuss his involvement in chiropractic research at a specialty hospital in New Hampshire, low back pain classification and strategies on how to implement evidence into practice. Dr. Vining is an Associate Professor and Research Clinic Director at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic. […]
Dr. Peter McCarthy and I discuss his varied research in the profession from spine function to dysfunction and multidisciplinary teamwork.
Dean Smith, DC, PhD
In this upcoming interview, John M. Mayer, DC, PhD, CCRP, FACSM will discuss his extensive clinical and research experience in occupational health, wellness, and therapeutic exercise. Dr. Mayer has led teams on numerous clinical trials across the country on various aspects of wellness, clinical management, and prevention funded through federal, state, industry, and foundation sources, including the largest single financial commitment by the US Department of Homeland Security on low back injury prevention in firefighters. Please comment below if you have any questions for us during the interview. I might choose some of them for our conversation.
In this upcoming interview, Alice Kongsted, DC, PhD will discuss how the bio-medical/structural approach to back pain has failed and we need to implement a behavioural approach to back pain much more in practice. She will discuss the recommendation of active, non-pharmacological treatments that support self-management. Dr. Kongsted was part of the Lancet Low Back Pain Series Working Group that published three papers in March 2018 to call for worldwide recognition of the disability associated with back pain and the need for prioritizing this globally growing problem. Please comment below if you have any questions for us during the interview. I might choose some of them for our conversation.
There is a growing trend of chiropractic use in adults. In a recent survey of US adults who used chiropractic services, back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being. Most of the survey respondents reported consulting a chiropractor for general wellness or disease prevention (43.3%), to improve their energy (16.3%), or to improve athletic or sports performance (15.4%). Many reported positive outcomes of chiropractic utilization agreeing that such care had helped them to improve overall health and make them feel better (66.9%), to sleep better (41.9%), and to reduce stress or to relax (40.2%). Almost half of all adults surveyed (47.9%) felt that chiropractic was very important for maintaining health and well-being, and another 30% felt it was somewhat important.
Reference: Adams J, Peng W, Cramer H, Sundberg T, Moore C, Amorin-Woods L, Sibbritt D, Lauche R. The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey. Spine (Phila Pa 1976). 2017 Dec 1;42(23):1810-1816.
In this update, I will summarize key points from recent scientific literature regarding the practice of chiropractic, patient profiles, utilization rates, chiropractic assessment and care methods. Much of the information comes from the excellent work of Beliveau et al (2017) who did a scoping review and used 337 articles from across the globe. I have provided references to other key papers also.
Chiropractors practice in over 100 countries. There are 90 existing national chiropractic associations across the world. Chiropractic has become one of the most commonly used health professions in the United States and Europe. A substantial proportion of US adults utilize chiropractic services and report associated positive outcomes for overall well-being and/or specific health problems for which concurrent conventional care was common (1). Chiropractors provide a significant amount of care for patients with many health conditions including low back and neck pain. The profession is a major participant in the health care expenditures of the United States and Denmark. As an example, here in the United States in 2015, chiropractors provided 18.6 million clinical services under Medicare and overall spending for chiropractic services was estimated at USD $12.5 billion (Beliveau et al, 2017).
According to the American Chiropractic Association (2), there are 77,000 chiropractors in the United States with roughly another 3,000 chiropractors that work in academic and management roles. There are approximately 10,000 chiropractic students in 18 nationally accredited, chiropractic doctoral programs across the United States with 2,500 chiropractors entering the work environment each year. Estimates indicate that chiropractors treat more than 35 million Americans (adults and children) annually. Chiropractors are designated as physician-level providers in the vast majority of states and the federal Medicare program. The essential services provided by chiropractors are also available in federal health delivery systems, including those administered by Medicaid, the U.S. Departments of Veterans Affairs (VA) and Defense, Federal Employees Health Benefits Program, Federal Workers’ Compensation, and all state workers’ compensation programs. Chiropractic is currently offered at 75 VA facilities and 66 military hospitals/clinics.
National and international guidelines include chiropractic (spinal manipulation) for low back pain (LBP) and neck pain. A short summary (3-4) of recent guidelines include:
- For acute and chronic LBP, a review of clinical practice guidelines (CPGs) on the noninvasive management of LBP and 3 national CPGs published since 2016 in the United States (Agency for Healthcare Research and Quality [AHRQ] comparative effectiveness review [CER]), the UK (National Institute for Care Excellence [NICE]), and Denmark (Denmark National Guideline) recommend considering manual therapy, including SMT, mobilization, or soft tissue techniques such as massage
- An additional CPG, by the American College of Physicians (ACP), recommends clinicians select nonpharmacologic treatment for acute and chronic LBP (superficial heat, massage, acupuncture, and SMT) before pharmacologic treatment options
Chiropractic utilization rates
- Across the world, 52 studies (Beliveau et al, 2017) have found the median 12-month use of chiropractic services was 9.1% and lifetime utilization was 22.2%
- In Canada and the United States there has been an increased 12 month utilization rate from 10% to 11.7% and from 7.2% to 10.7% respectively from the 1980’s until 2015
Who delivers spinal manipulation?
- Among the 8.5% of US adults who reported receiving manipulation, 97.6% saw chiropractors according to the 2012 National Health Interview Survey (5)
Reasons for seeing a chiropractor
- For the general population, the most common reasons for seeking care from a chiropractor included: low back pain (49.7%), neck pain (22.5%), extremity problem (10%), wellness/maintenance (7.5%), hip pain (7%), headache (5.5%)
- For the pediatric population, the most common reasons for seeking care from a chiropractor included: musculoskeletal conditions (44%), excessive crying (19.8%), neurologic conditions (17.9%), gastrointestinal conditions (17.5%), ear/nose/throat conditions (8.3%) and infection (7%) (Beliveau et al, 2017)
Profile of chiropractic patients
- People who sought chiropractic care were more likely to be female with a median age of 43.4 years
- 3% of the chiropractic patient population were employed, and a smaller proportion were either retired, unemployed, or students
- People with disabilities constituted only 1.4% of chiropractic patients (Beliveau et al, 2017)
Types of chiropractic assessments used in practice
- The most common assessment methods included: static palpation (89.3%), motion palpation (86.5%), spinal examination (79.5%), orthopedic examination (71.8%), neurological examination (64.6%) (Beliveau et al, 2017)
Types of chiropractic treatment provided
- Across the globe, spinal manipulation (79.3%), soft-tissue therapy (35.1%), formal patient education (31.3%), nutritional supplements (30.9%), exercise instruction/prescription (26%)
- Interestingly the NBCE (National Board of Chiropractic Examiners) found that in the US: 98.8% of chiropractors provide ergonomic/postural advice, 98.5% of chiropractors provide physical fitness/exercise promotion and 97% of chiropractors provide nutritional/dietary recommendations (Beliveau et al, 2017)
Main Source: Beliveau PJH, Wong JJ, Sutton DA et al. The chiropractic profession: a scoping review of utilization rates, reasons for seeking care, patient profiles, and care provided. Chiropr Man Therap. 2017 Nov 22;25:35.
1. Adams J, Peng W, Cramer H, Sundberg T, Moore C, Amorin-Woods L, Sibbritt D, Lauche R. The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey. Spine (Phila Pa 1976). 2017 Dec 1;42(23):1810-1816.
3. Wong JJ, Côté P, Sutton DA, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain 2016;21(2):201-16.
4. Bussières AE, Gauthier CA, Fournier G, Descarreaux M. Spinal manipulative therapy for low back pain-time for an update. Can Fam Physician. 2017 Sep;63(9):669-672.
5. Forte ML, Maiers M. Functional Limitations in Adults Who Utilize Chiropractic or Osteopathic Manipulation in the United States: Analysis of the 2012 National Health Interview Survey. J Manipulative Physiol Ther. 2017 Nov -Dec;40(9):668-675.
Today, we celebrate the birthday of the chiropractic profession, Sept. 18. Chiropractic’s first adjustment is recognized each year as Chiropractic Founder’s Day. On this day in 1895 (122 years ago), Dr. Daniel David Palmer gave the first chiropractic adjustment. Chiropractic is a health profession concerned with the assessment, care and prevention of disorders of the musculoskeletal system and the effects of these disorders on the nervous system and general health.
Chiropractic science is growing rapidly. Chiropractic care is commonly used to treat musculoskeletal conditions and has been endorsed by clinical practice guidelines as being evidence-based and cost-effective for the treatment of patients with spinal conditions such as back pain, neck pain and headaches. Chiropractic does not involve the use of drugs or surgery. You do not need a referral from another doctor in order to see a chiropractor. Doctors of Chiropractic (DCs) – often referred to as chiropractors or chiropractic physicians are well known for their expertise in spinal health and well-being. One of the most common and well known therapeutic procedures performed by doctors of chiropractic are “chiropractic adjustments” (frequently referred to as “spinal manipulation”). Patient satisfaction with chiropractic care is high :). There is substantial evidence supporting the safety and effectiveness of chiropractic treatment for patients seen in chiropractic practice. Share the word of chiropractic today.
There was a low recurrence rate (using a stringent definition of recurrence) in a large population of patients with low back pain (LBP) up to 1 year after chiropractic care. However, the vast majority of patients were not pain free after 1 year. This is the conclusion of a recent observational study published in the Journal of Manipulative and Physiological Therapeutics.
Patients in the study were located in Switzerland. Seven hundred and twenty-two patients with LBP (375 male) completed the Numeric Rating Scale for pain (NRS) and the Oswestry Disability Index (ODI) before chiropractic treatment and 1, 3, 6, and 12 months later (ODI up to 3 months). Patients were then categorized based on pain rating scores into “fast recovery,” “slow recovery,” “recurrent,” “chronic,” and “others.”
Based on these pain ratings, 13.4% of the patients were categorized as recurrent. The recurrent pattern significantly differed from fast recovery in duration of complaint. The duration of complaint before treatment was the main predictor for recurrence. Specifically, a subacute duration, defined in the present study as longer than 14 days, significantly increased the odds for an unfavorable course of LBP, which is of clinical relevance.
Reference: Knecht C, Humphreys BK, Wirth B. An Observational Study on Recurrences of Low
Back Pain During the First 12 Months After Chiropractic Treatment. J Manipulative
Physiol Ther. 2017 Jul – Aug;40(6):427-433.
Shoulder pain is one of the most common musculoskeletal disorders. The lifetime prevalence is estimated to be in the range of 6.7–66.7%. Shoulder pain and stiffness may reduce family life or social life functions as well as reduce productive activities. It also has a strong statistical correlation with somatizing tendency and poor mental health. There are many cases of shoulder pain that have not improved over time, remain persistent, or occur repeatedly. The prognosis becomes poorer the longer the illness is present. A review of the effectiveness of conservative nondrug, nonsurgical interventions, either alone or in combination, for conditions of the shoulder was published in the Journal of Manipulative and Physiological Therapeutics in June, 2017. Shoulder conditions addressed in the article were shoulder impingement syndrome (SIS), rotator cuff-associated disorders (RCs), adhesive capsulitis (AC), and nonspecific shoulder pain. Eligibility criteria for the scientific studies included randomized controlled trials (RCTs), systematic reviews, or meta-analyses. Treatments included nondrug, nonsurgical procedures. Results indicated low- to moderate-quality evidence supporting the use of manual therapies for all 4 shoulder conditions. Exercise, particularly combined with physical therapy protocols, was beneficial for SIS and AC. For SIS, moderate evidence supported several passive modalities. For RC, physical therapy protocols were found beneficial but not superior to surgery in the long term. Moderate evidence supported extracorporeal shockwave therapy for calcific tendinitis RC. Low-level laser was the only modality for which there was moderate evidence supporting its use for all 4 conditions.
- Manual therapy is beneficial for common shoulder conditions.
- Low-level laser therapy is beneficial for common shoulder conditions.
- Exercise protocols are beneficial for SIS and AC.
A 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.
- 045- Dr. Martha Funabashi Discusses the Biomechanics and Safety of Spinal Manipulation May 2, 2019
- 044- Dr. Sidney Rubinstein Discusses Chronic Low Back Pain, Spinal Manipulation and Systematic Reviews February 24, 2019
- 043- Dr. Geoff Outerbridge Discusses World Spine Care and the Global Spine Care Initiative January 22, 2019
- 042- J. David Cassidy, DC, PhD, DrMedSc Discusses Stroke, Concussion, Neck Pain, Whiplash and Epidemiology December 4, 2018
- 041- Spinal Pain in the Elderly and Chiropractic with Dr. Katie de Luca November 15, 2018
- 040- Dr. Anthony Lisi Discusses Chiropractic Practice and Research in the VA October 18, 2018
- 039- Inflammation of Peripheral Nerves, Chiropractic Principles, Manual Therapies and More with Dr. Geoffrey Bove October 4, 2018
- 038- Chiropractic, Opioids, Adverse Drug Events, and Medicare with Dr. James Whedon August 23, 2018
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