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

 

BackacheManaging and controlling health care expenditures is a top priority.  Multiple comorbidities in the aging population has become more prevalent likely because of the extended lifespan experienced in the U.S. over the last few decades.  It is estimated that more than sixty percent of Americans over age 65 have multiple chronic conditions, and twenty-three percent of Medicare beneficiaries have 5 or more chronic conditions.

Patients with chronic low back pain (cLBP) have been thought to present to our offices with high prevalence of psychological, somatoform, and musculoskeletal comorbidity. The persistence of LBP may contribute to the development of these disorders and comorbidities have also been associated with poor outcome of LBP. Additionally, patients with comorbidities present with worse physical and psychosocial functioning, poorer response to treatment, and higher rates of health care utilization than other patients suffering from LBP.

The care of individuals with chronic conditions is estimated to account for 78% of US healthcare spending, and Medicare beneficiaries with more than 1 chronic condition account for 95% of all Medicare spending.  Not surprisingly, those with more than 5 chronic conditions account for 66% of Medicare spending. The probability that patients will use expensive health care such as hospital care increases substantially when there are comorbidities.

The rising prevalence of low back pain (LBP) among Medicare beneficiaries, the growing costs of its treatment, and the high use and costs of prescription drugs suggest an essential need to identify suitable, cost-effective, non-drug, non-surgical treatments for older patients with LBP.

Most LBP in older adults can be managed non-surgically.  Randomized controlled clinical trials have shown that chiropractic manipulative treatment (CMT) is an effective, conservative treatment option for LBP. With this in mind, the authors wanted to explore whether older Medicare fee-for service beneficiaries with an episode of LBP and multiple comorbidities who obtained CMT during their episode had lower costs than those who did not.

Methods:

This study was an observational, retrospective study that used Medicare fee-for-service data from 2006 to 2012 to identify older (aged 66 to 99) patients who had a discrete episode of cLBP.  The episode was defined as lasting at least 90 days and was preceded and followed by 180 days in which no LBP diagnosis was noted.  Additionally, each patient also had an additional musculoskeletal disorder diagnosis and a mental health disorder. If a patient had multiple episodes during the study period, only the first episode was included in the analysis.

The study included 4 groups of patients who used: 1) only CMT; 2) conventional medical care followed by CMT; 3) CMT followed by conventional medical care; and 4) only conventional medical care.

For these 4 treatment groups, the authors used un-weighted and propensity-score weighted inflation- and price-adjusted Medicare Part A, B, and D reimbursements during the episode.  Propensity scoring is a powerful tool to strengthen causal inferences drawn from observational studies. Propensity scoring helps in selecting similar patient groups for comparison. Medicare Part A covers hospital, skilled nursing facility, home health and hospice care expenditures. Medicare Part B covers doctors’ services and other outpatient expenditures; and Medicare Part D covers prescription medications. Particular attention was given to Part B reimbursements for chiropractic care, psychiatric care, physical therapy care, and spinal manipulation therapy (SMT) provided by doctors of osteopathy (DOs) as well as to Part D reimbursements for pain medications.

The study also looked at rate of spine surgery within 1 year of the end of the episode as well as compound rates of growth for price and inflation-adjusted Medicare expenditures. In addition, the study examined expenditures for psychiatric visits and pain medications.

Results:

  • Medicare reimbursements during the cLBP treatment episode were lowest for patients who used CMT alone
  • CMT only patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode
  • Costs were greatest for patients receiving medical care alone
  • Patients who used only CMT had the lowest annual growth rates in almost all Medicare expenditure categories
  • Patients who used only CMT had the lowest Part A and Part B expenditures per episode day, although there was no indication of lower psychiatric or pain medication expenditures associated with CMT

Key Points:

  • Among older, multiply-comorbid Medicare beneficiaries with a chronic low back pain episode, chiropractic manipulative treatment was associated with lower overall episode costs and lower episode costs per day
  • Use of CMT was associated with lower total Part A and Part D Medicare cost growth for multiply-comorbid patients with chronic low back pain episodes over the course of the study period
  • The authors found overall Medicare cost-savings associated with use of chiropractic care
  • There was no evidence of lower psychiatric or pain medication expenditures associated with CMT

Source: Weeks WB, Leininger B, Whedon JM, Lurie JD, Tosteson TD, Swenson R, O’Malley AJ, Goertz CM. The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities. J Manipulative Physiol Ther. 2016 Feb 19. pii: S0161-4754(16)00007-5. doi: 10.1016/j.jmpt.2016.01.006.

back pain chiropractic

Up to 84% of the general population has been found to report low back pain (LBP) symptoms at some point during their lifetime.  Another staggering fact is that low back pain is the leading cause of disability worldwide affecting nearly one in ten people. Not surprisingly then, back pain is the second most common symptom-related reason for clinician visits in the United States.

The costs for spinal conditions continue to rise. Consider that back pain has substantial recurrence rates that may affect 40% to 50% of patients within 6 months and 70% within 12 months.  Current evidence suggests that the natural history of LBP is alike chronic conditions such as asthma, marked by chronic mild symptoms and periodic exacerbations. These developments have highlighted that LBP is a priority for employers focusing on workforce health and productivity (H&P).  Employers are seeking to maximize the ratio of outcomes achieved relative to costs incurred (ie, value) for the investments that they are making in their employees.  Furthermore, employers are in the unique position of being able to determine what treatments actually cost and how effective they are in their workforce.

The authors of this article point out that previous research has found that patients receiving chiropractic care have lower associations of probability of disability recurrence than patients of physicians and physical therapists.  They also state that early use of magnetic resonance imaging (MRI) has been linked to prolonged disability, higher costs, and greater use of surgery without evidence of benefit on health and function.

The goals of this study were to assess the cost outcomes of treatment approaches to care for back problems in a major self-insured workforce, using published guidelines to focus on low back pain.

—The study involved a retrospective time series analysis of tracked episodes of three types of ICD-9 code–identified back problems (n = 14,787) during 2001 to 2009 from a Fortune 500 company.

—The sample consisted of back pain episodes stratified into 3 groups:
#1: LBP (low back pain) with neurologic findings  (LBP/neuro) (n=1837)
#2: LBP with no neurologic findings (LBP/nonneuro) (n=8569)
#3: Other back (n=4381)

Of all employees, 39.4% of employees had at least one back pain episode and many had multiple episodes of LBP.  Total costs (direct/indirect) per employee were calculated per year.

Results indicated that 5 overall episode treatment patterns emerged (overall sample percentage in parentheses):

  1. Information and Advice (TalkInfo): simple office visits, lab tests, emergency department or hospital visits, talk therapy, or visits involving imaging (59%).
  2. Complex Medical Management (Complex MM): visits for nerve blocks, surgeries, or comparable procedures. Any ties with other categories went to this category (2%).
  3. Chiropractic (Chiro): number of visits to a chiropractor was greater than 1 and comprised the plurality or greater of procedures. This included cases involving manipulation billed as PT if the manipulation occurred on the same day (11%).
  4. Physical therapy (PT): number of visits to a PT was greater than 1 and comprised the plurality or greater of procedures. Physical therapy by itself (no chiropractor) sometimes included devices or other palliative treatments (11%).
  5. Dabble: at most one visit for physician, chiropractic, or PT care, or at most one visit to two or more of these categories (17%).

—The chiropractic group had the lowest prescription medication rates, least costs per episode of low back pain, and least guideline-incongruent use of medications and imaging.  —The chiropractic group also was the least likely to receive complex medical procedures like surgeries. —Complex medical management costs were greater than 4 times more expensive for an episode of low back pain (over 3 years) with neurological findings than chiropractic care ($6983.82 vs $28,231.5).  —Physical therapy costs were more than double per episode of low back pain (over 3 years) with neurological findings compared with chiropractic care ($6983.82 vs $17,193.92). —Similar cost savings in favor of chiropractic were found for an episode of low back pain (over 3 years) without neurological findings (chiropractic care = $6768.43, complex medical management = $29,344.25, physical therapy = $13,448.82).

Of note is that the complex medical management approach recorded the highest rates of prescription fills for opiods, other pain medications, SSRI/SNRI/tricyclics, and anxiolytics/sedatives/hypnotics.  The PT group had the highest rates for NSAIDs, muscle relaxant, and oral steroids.

Reference: Tracking low back problems in a major self-insured workforce: toward improvement in the patient’s journey. Allen H, Wright M, Craig T, Mardekian J, Cheung R, Sanchez R, et al.  J Occup Environ Med. 2014;56(6):604-20.

 

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.

42184199_sDizziness and imbalance are amongst the most common complaints in older people, and are a growing public health concern since they put older people at a significantly higher risk of falling. A recent study explored the role of chiropractic in the treatment of dizziness/balance disorders through analysis of data from the 2008 National Health Interview Survey (the only year that included a subset of questions about balance and dizziness).  Questions were asked about dizziness, balance and  accompanying health conditions as well as their perceived causes and effects of the dizziness or balance problem. The survey data queried whether people were helped by a variety of practitioners, including chiropractors.   Balance or dizziness problems were reported by 11% of all respondents.  The reported prevalence was 35% for those aged 65 or older.  The authors found that although a small proportion (4.2%) sought chiropractic care for balance and dizziness, those who did were very likely to report that it had helped (OR, 1.73). For those in whom the cause of their balance or dizziness problem was head or neck trauma, the odds ratio for perceiving that they had been helped by a chiropractor was 9.5, compared with OR 0.53 for medical physicians. For those respondents aged 65 years and older, and for those reporting the cause of their balance and dizziness were trauma or neurological or musculoskeletal issues, the OR was even higher (OR, 13.78).

Reference:
Ndetan H, Hawk C, Sekhon VK, Chiusano M. The Role of Chiropractic Care in the Treatment of Dizziness or Balance Disorders: Analysis of National Health Interview Survey Data. J Evid Based Complementary Altern Med. 2016 Apr;21(2):138-42. doi: 10.1177/2156587215604974. Epub 2015 Sep 11. PubMed PMID: 26362851.

Low Back Chiropractic AdjustmentMost low back pain in older adults can be managed non-surgically.  Randomized controlled clinical trials have shown that chiropractic manipulative treatment (CMT) is an effective, conservative treatment option for LBP. With this in mind, the authors of a new analysis wanted to explore whether older Medicare fee-for service beneficiaries with an episode of LBP and multiple comorbidities who obtained CMT during their episode had lower costs than those who did not.

This study was an observational, retrospective study that used Medicare fee-for-service data from 2006 to 2012 to identify older (aged 66 to 99) patients who had a discrete episode of cLBP.  The study included 4 groups of patients who used: 1) only CMT; 2) conventional medical care followed by CMT; 3) CMT followed by conventional medical care; and 4) only conventional medical care.

For these 4 treatment groups, the authors used un-weighted and propensity-score weighted inflation- and price-adjusted Medicare Part A, B, and D reimbursements during the episode.  Propensity scoring is a powerful tool to strengthen causal inferences drawn from observational studies. Propensity scoring helps in selecting similar patient groups for comparison. Medicare Part A covers hospital, skilled nursing facility, home health and hospice care expenditures. Medicare Part B covers doctors’ services and other outpatient expenditures; and Medicare Part D covers prescription medications. Particular attention was given to Part B reimbursements for chiropractic care, psychiatric care, physical therapy care, and spinal manipulation therapy (SMT) provided by doctors of osteopathy (DOs) as well as to Part D reimbursements for pain medications.

The study also looked at rate of spine surgery within 1 year of the end of the episode as well as compound rates of growth for price and inflation-adjusted Medicare expenditures. In addition, the study examined expenditures for psychiatric visits and pain medications.

Results:

  • Medicare reimbursements during the cLBP treatment episode were lowest for patients who used CMT alone
  • CMT only patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode
  • Costs were greatest for patients receiving medical care alone
  • Patients who used only CMT had the lowest annual growth rates in almost all Medicare expenditure categories
  • Patients who used only CMT had the lowest Part A and Part B expenditures per episode day, although there was no indication of lower psychiatric or pain medication expenditures associated with CMT

Key Points:

  • Among older, multiply-comorbid Medicare beneficiaries with a chronic low back pain episode, chiropractic manipulative treatment was associated with lower overall episode costs and lower episode costs per day
  • Use of CMT was associated with lower total Part A and Part D Medicare cost growth for multiply-comorbid patients with chronic low back pain episodes over the course of the study period
  • The authors found overall Medicare cost-savings associated with use of chiropractic care
  • There was no evidence of lower psychiatric or pain medication expenditures associated with CMT

Reference:

Weeks WB, Leininger B, Whedon JM, Lurie JD, Tosteson TD, Swenson R, O’Malley AJ, Goertz CM. The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities. J Manipulative Physiol Ther. 2016 Feb 19. pii: S0161-4754(16)00007-5.

12394403_sWith so many people taking prescription medication, there is a distinct possibility that the side effects of such medications may be responsible for the symptoms for which patients seek chiropractic care.  In a recent study in Australia, 549 prescription medications were used by 330 patients.  A total of 104 individual medications were identified of which 69 listed headache as a potential side effect of their use. Fifty-seven patients who sought care for the treatment of headache were using medication which may produce headache as a side effect of its use.  There is a need for chiropractors to be aware of the side effects of prescribed medication their patients may be taking. This is the case not only because of the potential for adverse interaction between treatments, but because symptoms produced by prescribed medication may be responsible for the patient’s clinical presentation.

http://www.ncbi.nlm.nih.gov/pubmed/26850807

 

A recent study incorporated a clinic of midwives and chiropractors to care for suboptimal feeding through a multidisciplinary approach. Suboptimal breastfeeding is a recognized problem among mothers and health care professionals worldwide. The aim was to assess the impact of care and education on breastfeeding and maternal satisfaction after attending the multidisciplinary clinic. On follow-up, 93% of mothers reported an improvement in feeding as well as satisfaction with the care provided. Prior to treatment, 26% of the infants were exclusively breastfed. At the follow-up survey, 86% of mothers reported exclusive breastfeeding. The relative risk ratio for exclusive breastfeeding after attending the multidisciplinary clinic was 3.6  The results from this study demonstrate high maternal satisfaction and improved breastfeeding rates associated with attending the chiropractic and midwifery clinic.

http://www.ncbi.nlm.nih.gov/pubmed/26763046

 

42136910_s (1)New scientific evidence on the effectiveness of manual therapies, passive physical modalities, and acupuncture was assessed in a recent systematic review. This update of the Neck Pain Task Force suggests that mobilization, manipulation, and clinical massage are effective interventions for neck pain. Conversely, they found that electroacupuncture, strain-counterstrain, relaxation massage, and other modalities such as heat, cold, diathermy, hydrotherapy, ultrasound are not effective.

http://www.ncbi.nlm.nih.gov/pubmed/26707074

Dr. Dean Smith will be hosting a podcast interview with Dr. Steven Passmore this Thursday, September 24th at 2 pm (EST).

Passmore Headshot 2012Steven Passmore, DC, PhD.  Dr. Passmore is Assistant Professor in the Faculty of Kinesiology & Recreation Management at the University of Manitoba. 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.  We will discuss Dr. Passmore’s chiropractic and performance related research. To hear the podcast live, go to chirocredit.com/chiropracticscience and login for instructions (Not a member? Create an account for free).