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Chiropractic Practice, Patient Characteristics and Reasons for Seeking Care – An Update

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)

References:

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.

2. https://www.acatoday.org/Patients/Why-Choose-Chiropractic/Key-Facts

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.

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Low Recurrence Rate of Low Back Pain After Chiropractic Care

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.

 

 

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Nondrug and Nonsurgical Treatment of Shoulder Conditions

shoulder pain manual therapyShoulder 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.

Bottom line:

  • 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.

 

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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.

 

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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.

 

 

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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.

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Episode

056- Issues with Measurement in Science and Clinical Practice – Dr. Samuel Howarth

Dr. Samuel Howarth

Dr. Samuel Howarth is an Associate Professor, Director of Human Performance Research and the McMorland Family Research Chair in Mechanobiology at the Canadian Memorial Chiropractic College. He also holds adjunct positions at Ontario Tech University, University of Toronto, University of Guelph and Memorial University of Newfoundland. Dr. Howarth obtained his PhD in kinesiology from the University of Waterloo in 2011, focusing on biomechanics and more specifically related to the spine. His current research is directed toward biomechanical analysis of human movement focusing on functional tasks used in daily life and clinical practice. A fundamental component of this work, and scientific inquiry in general, is measurement and data handling. Once a topic primarily relevant to researchers, the proliferation of low-cost sensors capable of providing clinicians with a seemingly unimaginable amount data extends the conversation on the acquisition and interpretation of measurements to the clinical environment.

Please see Dr. Samuel Howarth’s research profile at researchgate.net and check out his google scholar page also.  Further information and links to his research can be found at the Canadian Memorial Chiropractic College website.

Below are the articles Dr. Samuel Howarth and I discuss in this episode:

1.
Investigator analytic repeatability of two new intervertebral motion biomarkers for chronic, nonspecific low back pain in a cohort of healthy controls.
To D, Breen A, Breen A, Mior S, Howarth SJ.
Chiropr Man Therap. 2020 Nov 24;28(1):62. doi: 10.1186/s12998-020-00350-5.
PMID: 33228737 Free PMC article.
2.
Does manual therapy affect functional and biomechanical outcomes of a sit-to-stand task in a population with low back pain? A preliminary analysis.
Carpino G, Tran S, Currie S, Enebo B, Davidson BS, Howarth SJ.
Chiropr Man Therap. 2020 Jan 24;28(1):5. doi: 10.1186/s12998-019-0290-7. eCollection 2020.
PMID: 31998472 Free PMC article.
3.
Grant C, Beach TAC, Hogg-Johnson, Chivers M, Howarth SJ. 
Meas Phys Educ Exerc Sci. 2019 Dec 24;24(1):81-92. doi: 10.1080/1091367X.2019.1707680
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054- Drs. Chris Malaya and Josh Haworth Discuss Motor Control, Posture and Chiropractic

Drs. Christopher Malaya and Joshua Haworth

Drs. Chris Malaya and Josh Haworth discuss motor control, posture and chiropractic research in this episode. Dr. Chris Malaya is a research associate at Parker University in Dallas, Texas. He graduated from Parker in 2018 with a Doctorate in Chiropractic and is currently pursuing a PhD in Motor Control from the University of Houston. His current research interests are in sensorimotor integration, postural control and adaptation, as well as the neural mechanisms of manual manipulation. His overall goal is to help expand the foundational mechanisms and practical applications of manual joint manipulation as it relates to movement and neural rehabilitation.

Dr. Josh Haworth’s research focuses on the mechanisms responsible for the integration of sensorimotor information in the production of human behavior. He uses eye-tracking combined with motion capture and posturographic measures to identify motor strategies used during daily tasks like upright standing, walking, and interpersonal communication. Extensions of this work include the identification of early indicators of clinical disorders and the production of novel therapeutic modalities. He has many active collaborations with colleagues in fields including chiropractic science and pediatric rehabilitation technology. He is focused to better understand the development of motor and social-cognitive skills in children with, and without, autism. 

View Dr. Christopher Malaya’s research at Parker University and researchgate.net and Dr. Josh Haworth’s research at Oakland University and researchgate.net.

Below are the studies that Drs. Chris Malaya and Josh Haworth discuss in this interview.

1.Immediate impact of extremity manipulation on dual task performance: a randomized, crossover clinical trial.Malaya CA, Haworth J, Pohlman KA, Smith DL.Chiropr Man Therap. 2021 Feb 5;29(1):6. doi: 10.1186/s12998-021-00366-5.PMID: 33541378 Free PMC article.
2.Impact of Extremity Manipulation on Postural Sway Characteristics: A Preliminary, Randomized Crossover Study.Malaya CA, Haworth J, Pohlman KA, Powell C, Smith DL.J Manipulative Physiol Ther. 2020 Jun;43(5):457-468. doi: 10.1016/j.jmpt.2019.02.014. Epub 2020 Aug 14.PMID: 32800642
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053- Dr. Joyce Miller and Evidence Based Chiropractic Care for Infants

Dr. Joyce Miller

Dr. Joyce Miller, semi-retired, is a guest paediatrics researcher at AECC University College, Bournemouth, England. She previously worked full-time as Lead Tutor for MSc Musculoskeletal Health of Paediatrics, undergrad paediatrics and evidence based clinical practice at AECC University College. An Associate Professor, she pioneered the busy infant and child practice in the teaching clinic approximately 25 years ago at AECC.  She is a busy researcher and has authored more than 80 articles published in peer reviewed journals and conducted over 180 seminars world-wide.  She was a certified Brazelton neonate examiner, awarded from Cambridge University and a diplomat of the Royal College Paediatrics and Child Health Nutrition Programme and a fellow of the Royal College of Chiropractors and British Chiropractic Association.  Along with Bournemouth University’s midwifery team from the School of Health and Social Care, in 2013 has developed an AECC-BU breastfeeding clinic located on the University Campus. This is an inter-disciplinary clinic where midwives and chiropractors (and students) manage difficult feeding cases together and learn together. She focuses on the care of the neonate and infants, obtaining her PhD in musculoskeletal health of the infant in 2013. She has undergraduate degrees in education and psychology and a post-graduate diplomate in chiropractic orthopaedics. She authored the book, Evidence Based Chiropractic Care for Infants in 2019, co-edits Journal Clinical Chiropractic Pediatrics and continues to mentor graduate students.

View Dr. Miller’s research on researchgate.com.

Here is a link to purchase Dr. Miller’s book, from the publisher and from Amazon.

Evidence Based Chiropractic Care for Infants

Here are the articles we discuss in this episode:

1.
Maternal Report of Outcomes of Chiropractic Care for Infants.
Miller JE, Hanson HA, Hiew M, Lo Tiap Kwong DS, Mok Z, Tee YH.
J Manipulative Physiol Ther. 2019 Mar-Apr;42(3):167-176. doi: 10.1016/j.jmpt.2018.10.005. Epub 2019 Apr 25.
PMID: 31029467
2.
Long-term effects of infant colic: a survey comparison of chiropractic treatment and nontreatment groups.
Miller JE, Phillips HL.
J Manipulative Physiol Ther. 2009 Oct;32(8):635-8. doi: 10.1016/j.jmpt.2009.08.017.
PMID: 19836599
3.
Efficacy of chiropractic manual therapy on infant colic: a pragmatic single-blind, randomized controlled trial.
Miller JE, Newell D, Bolton JE.
J Manipulative Physiol Ther. 2012 Oct;35(8):600-7. doi: 10.1016/j.jmpt.2012.09.010.
PMID: 23158465 Clinical Trial.
4.
 Risks and rewards of early musculoskeletal assessment: An evidence-based case report
Joyce Miller, Marcella Fontana, Karin Jernlås, Henny Olofsson, Ida Verwijst.
British Journal of Midwifery VOL. 21, NO. 10. https://doi.org/10.12968/bjom.2013.21.10.736

View another chiropractic pediatric podcast episode.

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052- Dr. Ken Weber Discusses Advanced MRI Techniques, Pain & Manual Therapy

Dr. Ken Weber

Dr. Ken Weber and I discuss his research pursuits which involve: 1) developing imaging modalities that are more sensitive and specific to the pathology, providing more diagnostic, prognostic, and predictive information; 2) providing more quantitative information to the clinician; and 3) using these measures to better understand the nervous system and how it functions, the neurophysiology of pain, how treatments work, and why certain treatments work for some patients but not for others. Dr. Ken Weber is an Instructor in the Department of Anesthesia, Perioperative and Pain Medicine at Stanford University. He obtained his Doctor of Chiropractic from Palmer College of Chiropractic Florida in 2009 and then completed a PhD in neuroscience at Northwestern University in 2016, specializing in movement and rehabilitation science. Ken’s research intersects clinical pain research and advanced MRI techniques with an emphasis on brain, spinal cord, and musculoskeletal imaging. His research aims to better understand the neural and musculoskeletal changes underlying clinical pain conditions, the mechanisms of treatments, and predictors for recovery. Ken is currently supported by a K23 Mentored Patient-Oriented Research Career Development Award from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health. His previous funding has included the National Center for Complementary and Integrative Health, the National Institute on Drug Abuse, and the NCMIC Foundation, Inc.

I’d also like to point out that Ken was recently selected to be part of the CARL (Chiropractic Academy for Research Leadership) program. 

View Dr. Weber‘s research at researchgate.net.

Here are some of the papers we discuss in this episode.

1. Machine Learning for the Prediction of Cervical Spondylotic Myelopathy: A Post Hoc Pilot Study of 28 Participants.
  Hopkins BS, Weber KA 2nd, Kesavabhotla K, Paliwal M, Cantrell DR, Smith ZA.
  World Neurosurg. 2019 Jul;127:e436-e442. doi: 10.1016/j.wneu.2019.03.165. Epub 2019 Mar 25.
  PMID: 30922901 [PubMed – indexed for MEDLINE]
  Similar articles
2. Are Magnetic Resonance Imaging Technologies Crucial to Our Understanding of Spinal Conditions?
  Crawford RJ, Fortin M, Weber KA 2nd, Smith A, Elliott JM.
  J Orthop Sports Phys Ther. 2019 May;49(5):320-329. doi: 10.2519/jospt.2019.8793. Epub 2019 Mar 26.
  PMID: 30913967 [PubMed – in process]
  Similar articles
3. Lateral Corticospinal Tract Damage Correlates With Motor Output in Incomplete Spinal Cord Injury.
  Smith AC, Weber KA 2nd, O’Dell DR, Parrish TB, Wasielewski M, Elliott JM.
  Arch Phys Med Rehabil. 2018 Apr;99(4):660-666. doi: 10.1016/j.apmr.2017.10.002. Epub 2017 Oct 26.
  PMID: 29107041 [PubMed – indexed for MEDLINE] Free PMC Article
  Similar articles
4. Evidence for decreased Neurologic Pain Signature activation following thoracic spinal manipulation in healthy volunteers and participants with neck pain.
  Weber Ii KA, Wager TD, Mackey S, Elliott JM, Liu WC, Sparks CL.
  Neuroimage Clin. 2019;24:102042. doi: 10.1016/j.nicl.2019.102042. Epub 2019 Oct 18.
  PMID: 31670070 [PubMed – in process] Free PMC Article
  Similar articles
5. Deep Learning Convolutional Neural Networks for the Automatic Quantification of Muscle Fat Infiltration Following Whiplash Injury.
  Weber KA, Smith AC, Wasielewski M, Eghtesad K, Upadhyayula PA, Wintermark M, Hastie TJ, Parrish TB, Mackey S, Elliott JM.
  Sci Rep. 2019 May 28;9(1):7973. doi: 10.1038/s41598-019-44416-8.
  PMID: 31138878 [PubMed – in process] Free PMC Article
  Similar articles
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051- Dr. William Reed Discusses Mechanisms of Spinal Manual Therapy

Dr. William Reed is an Associate Professor in the School of Health Professions, Department of Physical Therapy at University of Alabama at Birmingham. He is the director of the Mechanisms of Spinal Manual Therapy Laboratory. His research is directed towards determining the peripheral and central mechanisms of spinal manipulation (manual therapy) for the treatment of musculoskeletal pain.  He is also the Interim Co-Director of the PhD program in Rehabilitation Science at the University of Alabama at Birmingham. Here we discuss some of Dr. William Reed’s research starting with his introduction to research as a chiropractic student in 1994 then we’ll discuss his work with Dr. Joel Pickar, his K01 award topic, and progressing to his latest line of research on characterization of a rat LBP model and spinal mobilization mechanisms. 

See more of Dr. Reed’s research at researchgate.net.

The articles we discuss in this episode include:

1.
Chiropractic management of primary nocturnal enuresis.
Reed WR, Beavers S, Reddy SK, Kern G.
J Manipulative Physiol Ther. 1994 Nov-Dec;17(9):596-600.
PMID: 7884329 Clinical Trial.
2.
Relationship between Biomechanical Characteristics of Spinal Manipulation and Neural Responses in an Animal Model: Effect of Linear Control of Thrust Displacement versus Force, Thrust Amplitude, Thrust Duration, and Thrust Rate.
Reed WR, Cao DY, Long CR, Kawchuk GN, Pickar JG.
Evid Based Complement Alternat Med. 2013;2013:492039. doi: 10.1155/2013/492039. Epub 2013 Jan 20.
PMID: 23401713 Free PMC article.
3.
Paraspinal Muscle Spindle Response to Intervertebral Fixation and Segmental Thrust Level During Spinal Manipulation in an Animal Model.
Reed WR, Pickar JG.
Spine (Phila Pa 1976). 2015 Jul 1;40(13):E752-9. doi: 10.1097/BRS.0000000000000915.
PMID: 25856263 Free PMC article.
4.
Neural responses to the mechanical characteristics of high velocity, low amplitude spinal manipulation: Effect of specific contact site.
Reed WR, Long CR, Kawchuk GN, Pickar JG.
Man Ther. 2015 Dec;20(6):797-804. doi: 10.1016/j.math.2015.03.008. Epub 2015 Mar 27.
PMID: 25841562 Free PMC article.
5.
Spinal Mobilization Prevents NGF-Induced Trunk Mechanical Hyperalgesia and Attenuates Expression of CGRP.
Reed WR, Little JW, Lima CR, Sorge RE, Yarar-Fisher C, Eraslan M, Hurt CP, Ness TJ, Gu JG, Martins DF, Li P.
Front Neurosci. 2020 Apr 30;14:385. doi: 10.3389/fnins.2020.00385. eCollection 2020.
PMID: 32425750 Free PMC article.

 

Check out related chiropractic science podcasts on neurophysiology and the brain.

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049- Veterinary Chiropractic, Horses and Research with Dr. Kevin Haussler

Dr. Kevin Haussler, DVM, DC, PhD

Kevin Haussler, DVM, DC, PhD and I discuss his research regarding chiropractic and horses.  In particular we discuss four themes in this interview: 1) How chiropractic techniques can be applied to horses; 2) How do you know you are making a difference (objective outcome measures)?; 3) Effects of mobilization versus manipulation in horses; 4)Controlled clinical trials in horses with acute versus chronic back pain.

Dr. Haussler graduated from The Ohio State University, College of Veterinary Medicine in 1988 and completed a small animal internship in Sacramento, CA.  To further his training in the conservative management of spinal-related disorders, he pursued human training at Palmer College of Chiropractic-West and completed a veterinary chiropractic certification program in 1993.  He attended the University of California-Davis to attain a PhD focusing on spinal pathology and pelvic biomechanics in Thoroughbred racehorses.  Post-doctorate training involved evaluation of in-vivo spinal kinematics in horses at Cornell University.  While at Cornell, he directed the newly formed Integrative Medicine Service which provided chiropractic, acupuncture and physical therapy services to both small and large animals.  Currently, he is an Associate Professor at the Orthopaedic Research Center at Colorado State University and is involved in teaching, clinical duties, and research into the objective assessment of musculoskeletal pain, spinal dysfunction and the application of physical therapy and rehabilitation. Dr. Haussler is a charter diplomate of the American College of Veterinary Sports Medicine and Rehabilitation and is currently a course instructor for the Equine Rehabilitation Certification course co-branded by the University of Tennessee and Colorado State University.

View Dr. Haussler’s research at researchgate.net

Below are the articles we discuss in this interview.

1. Haussler KK. Review of Manual Therapy Techniques in Equine Practice. Journal of Equine Veterinary Science. 2009;29(12):849-69.
2. Haussler KK, Erb HN. Pressure algometry for the detection of induced back pain in horses: a preliminary study. Equine Vet J. 2006;38(1):76-81.
3. Haussler KK, Hill AE, Puttlitz CM, McIlwraith CW. Effects of vertebral mobilization and manipulation on kinematics of the thoracolumbar region. Am J Vet Res. 2007;68(5):508-16.
4. Haussler KK, Manchon PT, Donnell JR, Frisbie DD. Effects of Low-Level Laser Therapy and Chiropractic Care on Back Pain in Quarter Horses. Journal of Equine Veterinary Science. 2020;86:102891.
5. Sullivan KA, Hill AE, Haussler KK. The effects of chiropractic, massage and phenylbutazone on spinal mechanical nociceptive thresholds in horses without clinical signs. Equine Vet J. 2008;40(1):14-20.

To see other chiropractic research on mobilization and manipulation here.

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048- Drs. Imran Niazi and Kelly Holt Discuss Chiropractic, Neuroplasticity and Falls

Drs. Imran Niazi and Kelly Holt

Drs. Imran Niazi and Kelly Holt discuss with me their research on chiropractic, falls risk, and neuroplasticity in various populations. Imran Khan Niazi received his B.Sc. degree in Electrical engineering (specialisation: Biomedical Engineering) from the Riphah International University, Islamabad, Pakistan, in 2005, and his  Masters in biomedical engineering from University & FH Luebeck, Luebeck, Germany in 2009. Later he got his PhD under the supervision of Prof. Dario Farina from Center of sensory-motor interaction, Health Science Technology Department, University of Aalborg, Aalborg, Denmark in 2012. After working as a postdoc for a year, he moved to New Zealand in 2013, where he is currently working as Senior Research Fellow at New Zealand College of Chiropractic. He has an adjunct position in Aalborg University, Denmark and Auckland University of Technology, New Zealand.

Dr. Niazi is interested in studying and understanding the altered mechanism of motor control and learning in neurological disorder to develop various technologies that can enhance the QOL of these patients. He has successfully co-supervised 4 PhD and 31 master thesis and currently has 4 active PhD students. He has authored 46 peer-reviewed journal papers and 82 conference papers (proceedings and extended abstracts including). His work has been cited more than 1100 times, and have an h-index of 16 according to google scholar. Over the last ten year, he has received funding worth around US $ 1.5 million from various sources. He is currently working as a review editor for Frontiers in Robotics and AI (Biomedical Robotics) and reviewer for more than 25 engineering/neuroscience journals.

Dr. Kelly Holt was a member of the 1998 inaugural graduating class of the New Zealand College of Chiropractic. Besides his chiropractic degree he also holds a Bachelor of Science majoring in physiology and a PhD in Health Science from the University of Auckland. His PhD focused on the effects of chiropractic care on sensorimotor function and falls risk in older adults. He has published work in a number of peer reviewed journals that investigated the effects of chiropractic care on nervous system function and the reliability of vertebral subluxation indicators and has won a number of international research awards. Kelly worked in private practice as a chiropractor for 10 years following graduation and has taught at the New Zealand College of Chiropractic since 2000 and is currently the Dean of Research at the College.   Kelly was named ‘Chiropractor of the Year’ by the New Zealand College of Chiropractic Alumni Association in 2012 and by the New Zealand Chiropractors’ Association in 2014.

View Dr. Imran Niazi’s research at researchgate.net and Dr. Kelly Holt’s research at researchgate.net.

In addition to Drs. Imran Niazi and Kelly Holt, you might also be interested in listening to the previous episode with Dr. Heidi Haavik, also from New Zealand College of Chiropractic discussing “brain adjustments”.

Below are the studies that we discuss in this interview.

1. The effects of a single session of chiropractic care on strength, cortical drive, and spinal excitability in stroke patients.
  Holt K, Niazi IK, Nedergaard RW, Duehr J, Amjad I, Shafique M, Anwar MN, Ndetan H, Turker KS, Haavik H.
  Sci Rep. 2019 Feb 25;9(1):2673. doi: 10.1038/s41598-019-39577-5.
  PMID: 30804399 [PubMed – in process] Free PMC Article
  Similar articles
2. The effects of a single session of spinal manipulation on strength and cortical drive in athletes.
  Christiansen TL, Niazi IK, Holt K, Nedergaard RW, Duehr J, Allen K, Marshall P, Türker KS, Hartvigsen J, Haavik H.
  Eur J Appl Physiol. 2018 Apr;118(4):737-749. doi: 10.1007/s00421-018-3799-x. Epub 2018 Jan 11.
  PMID: 29327170 [PubMed – indexed for MEDLINE] Free PMC Article
  Similar articles
3. Effectiveness of Chiropractic Care to Improve Sensorimotor Function Associated With Falls Risk in Older People: A Randomized Controlled Trial.
  Holt KR, Haavik H, Lee AC, Murphy B, Elley CR.
  J Manipulative Physiol Ther. 2016 May;39(4):267-78. doi: 10.1016/j.jmpt.2016.02.003. Epub 2016 Apr 2.
  PMID: 27050038 [PubMed – indexed for MEDLINE]
  Similar articles
4. Changes in H-reflex and V-waves following spinal manipulation.
  Niazi IK, Türker KS, Flavel S, Kinget M, Duehr J, Haavik H.
  Exp Brain Res. 2015 Apr;233(4):1165-73. doi: 10.1007/s00221-014-4193-5. Epub 2015 Jan 13.
  PMID: 25579661 [PubMed – indexed for MEDLINE]
  Similar articles
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046- Dr. Jeffrey Hebert Discusses Back Pain, Cardiovascular Disease, Sport Participation

In this episode, Dr. Jeff Hebert discusses back pain in young people, the link between back pain, health behavior and cardiovascular disease & sport participation as a health intervention. Jeff Hebert, DC, PhD is a Professor and the CCRF/NBHRF Chair of Musculoskeletal Health Research at the University of New Brunswick, as well as an Adjunct Professor at Murdoch University in Australia. Jeff’s career to date includes 18 years of experience in faculty, clinical, and administrative positions in Canada, the United States, and Australia.  Most recently, he was the Associate Dean (Research) in Murdoch University’s School of Psychology and Exercise Science. Previous appointments include positions as a Senior Lecturer of Rehabilitation Science (Murdoch University) and Assistant Professor of Neurosurgery (University of Utah). He has earned a Bachelor’s degree in Psychology (University of Denver) as well as a Doctorate in Chiropractic (Palmer College) and PhD in Exercise Science (University of Utah). He serves as an Associate Editor for the journal Chiropractic & Manual Therapies. Before pursuing an academic career, Jeff worked as an outpatient and hospital-based clinician in multidisciplinary environments including as pain medicine, sports medicine, and spine surgery.

View Dr. Hebert’s research publications at researchgate.net.

Here are the articles that we discussed in this episode of the chiropractic science podcast.

1. Pubertal development and growth are prospectively associated with spinal pain in young people (CHAMPS study-DK).
  Hebert JJ, Leboeuf-Yde C, Franz C, Lardon A, Hestbæk L, Manson N, Wedderkopp N.
  Eur Spine J. 2019 Feb 11. doi: 10.1007/s00586-019-05905-6. [Epub ahead of print]
  PMID: 30740638 [PubMed – as supplied by publisher]
  Similar articles
2. The relationship of lumbar multifidus muscle morphology to previous, current, and future low back pain: a 9-year population-based prospective cohort study.
  Hebert JJ, Kjaer P, Fritz JM, Walker BF.
  Spine (Phila Pa 1976). 2014 Aug 1;39(17):1417-25. doi: 10.1097/BRS.0000000000000424.
  PMID: 24859576 [PubMed – indexed for MEDLINE]
  Similar articles
3. Physical activity is prospectively associated with spinal pain in children (CHAMPS Study-DK).
  Franz C, Møller NC, Korsholm L, Jespersen E, Hebert JJ, Wedderkopp N.
  Sci Rep. 2017 Sep 14;7(1):11598. doi: 10.1038/s41598-017-11762-4.
  PMID: 28912463 [PubMed – in process] Free PMC Article
  Similar articles
4. The Prospective Association of Organized Sports Participation With Cardiovascular Disease Risk in Children (the CHAMPS Study-DK).
  Hebert JJ, Klakk H, Møller NC, Grøntved A, Andersen LB, Wedderkopp N.
  Mayo Clin Proc. 2017 Jan;92(1):57-65. doi: 10.1016/j.mayocp.2016.08.013. Epub 2016 Nov 16.
  PMID: 27865444 [PubMed – indexed for MEDLINE]
  Similar articles
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045- Dr. Martha Funabashi Discusses the Biomechanics and Safety of Spinal Manipulation

Martha Funabashi, is a PhD currently working as a clinical research scientist at CMCC. She is also a CARL fellow and the co-lead study coordinator of SafetyNET – an international and multidisciplinary research team to support patient safety among spinal manipulative therapy (SMT) providers. Martha has a Bachelor’s Degree in Physiotherapy and a Master’s Degree in Neuroscience from the University of Sao Paulo – Brazil. She completed her PhD in Rehabilitation Sciences at the University of Alberta under the supervision of Dr. Greg Kawchuk and her post-doctoral fellowship also at the University of Alberta with Dr. Sunita Vohra. Martha’s research interests and passion are on the SMT’s biomechanics, underlying mechanisms, force-time characterization and its safety aspects. Martha has 26 peer-reviewed scientific journal publications, over 40 conference presentations and is on the editorial boards for peer review journals, such as Chiropractic and Manual Therapies. Martha has won research prizes, including the New Investigator Award at the World Federation of Chiropractic Conference 2017 and works in collaboration with emerging and well-known researchers around the world.

Dr. Funabashi’s email is: [email protected]

See Dr. Funabashi’s publications at researchgate.net.

Here is a list of the articles Dr. Funabashi and I discussed on the podcast.

1. SafetyNET Community-based patient safety initiatives: development and application of a Patient Safety and Quality Improvement Survey.
  Funabashi M, Pohlman KA, Mior S, O’Beirne M, Westaway M, De Carvalho D, El-Bayoumi M, Haig B, Wade DJ, Thiel HW, Cassidy JD, Hurwitz E, Kawchuk GN, Vohra S.
  J Can Chiropr Assoc. 2018 Dec;62(3):130-142.
  PMID: 30662067 [PubMed] Free PMC Article
  Similar articles
2. Tissue loading created during spinal manipulation in comparison to loading created by passive spinal movements.
  Funabashi M, Kawchuk GN, Vette AH, Goldsmith P, Prasad N.
  Sci Rep. 2016 Dec 1;6:38107. doi: 10.1038/srep38107.
  PMID: 27905508 [PubMed – indexed for MEDLINE] Free PMC Article
  Similar articles
3. Does the application site of spinal manipulative therapy alter spinal tissues loading?
  Funabashi M, Nougarou F, Descarreaux M, Prasad N, Kawchuk GN.
  Spine J. 2018 Jun;18(6):1041-1052. doi: 10.1016/j.spinee.2018.01.008. Epub 2018 Jan 31.
  PMID: 29355792 [PubMed – indexed for MEDLINE]
  Similar articles
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044- Dr. Sidney Rubinstein Discusses Chronic Low Back Pain, Spinal Manipulation and Systematic Reviews

Dr. Rubinstein and I discuss his latest paper that will appear soon in the British Medical Journal regarding his systematic review of spinal manipulative therapy and chronic low back pain. Sidney Rubinstein is an associate professor at the VU University, Amsterdam and adjunct research professor at Southern California University of Health Sciences (SCUHS). He is also a registered epidemiologist in the Netherlands. He has more than 60 publications in international peer-reviewed journals, including three systematic reviews in the Cochrane Library.

His research focuses on effectiveness and cost-effectiveness of interventions in musculoskeletal disorders. His broader goals are to lessen the burden of neck and low-back pain to society by providing high-quality scientific evidence. The projects that he currently supervises are strongly embedded in clinical practice, including the PTED trial, Warrior Trial, an IPD (individual patient data) meta-analysis on spinal manipulative therapy for chronic low-back pain and a large, international observational study in chiropractic care in the elderly (BACE-C cohort study).

One of his passions lies in systematic reviews and meta-analysis as these types of overviews represent a crucial link in the practice of evidence-based health care. He is actively involved in conducting and supervising these reviews, including a position on the Associate Editorial Board of the Cochrane Back and Neck Review Group.  His reviews are quite diverse. One of the more recent Cochrane reviews focused on complications of trocar types for laparoscopic surgery, while another has examined the effectiveness of exercise for acute low back pain. An update of the Cochrane review on the effect of spinal manipulative therapy for chronic low-back has been accepted by the BMJ and should be published soon.

Dr. Rubinstein currently supervises 5 PhD students as well as MSc students, and teaches methodology of systematic reviews and meta-analyses at various levels, including BSc, MSc and PhD students. One chiropractor has received his PhD under Sidney’s supervision, while others are completing theirs.

Here is a link to Dr. Rubinstein’s research at researchgate.net.

Here is a link to Dr. Rubinstein’s page at Vrije Universiteit Amsterdam

The article we discuss in this episode is available now at https://www.bmj.com/content/364/bmj.l689

Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l689 (Published 13 March 2019) Cite this as: BMJ 2019;364:l689

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