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

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

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

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

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

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

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

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

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

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

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

Results:

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

Key Findings:

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

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

 

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

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Chiropractic Adjustments Reduce Fatigue and Increase Neural Drive

ChiropracticOver the last decade, research has demonstrated that spinal manipulation can change various aspects of nervous system function, including muscle reflexes, cognitive processing, reaction time, and the speed at which the brain processes information. One research group from New Zealand (Haavik et al) has hypothesized that the joint dysfunction part of the chiropractic clinical construct, the vertebral subluxation, results in altered afferent input to the central nervous system (CNS) that modifies the way in which the CNS processes and integrates all subsequent sensory input. This processing (i.e., sensorimotor integration) is a central nervous system (CNS) function that appears most vulnerable to altered inputs.

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

This new study reported here sought to investigate possible neural plastic changes with spinal manipulation by measuring H-reflexes and V-waves.  The H-reflex is an electrically evoked response that operates via the same neuronal circuitry as stretch reflexes.  The H (Hoffmann) reflex may be useful to assess motoneuron excitability in vivo while also reflecting presynaptic inhibition of Ia afferent synapses.  The so-called V-wave, which is an electrophysiological variant of the H-reflex, can be recorded during maximal voluntary motor contractions. The elicited V-wave response may be used to reflect the level of efferent neural drive from spinal α-motoneurons during maximal voluntary contraction (MVC).

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

Methods:

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

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

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

Results:

  • the threshold to elicit the H-reflex significantly decreased by 8.5% in the spinal manipulation group
  • the SEMGs showed a significant drop in the power spectrum after controls but there was no fatigue demonstrated in the power spectrum after spinal manipulation
  • for study 1: maximal voluntary contraction as determined by SEMG increased significantly by 59.5% after spinal manipulation and decreased significantly by 13.3% after control
  • for study 2: maximal voluntary contraction increased significantly by 16.1% after spinal manipulation and decreased significantly by 11.4% after control
  • the V-wave amplitude (V/Mmax ratio) increased significantly by 45% after spinal manipulation and reduced significantly by 23% after control

Key Points

  • this study is the first to indicate that chiropractic adjustments can induce significant changes in the net excitability for the low-threshold motor units/and or alters the synaptic efficacy of the Ia synapse
  • the improvements in maximal voluntary contraction following spinal manipulation are likely attributed to the increased descending drive and/or modulation in afferents
  • spinal manipulation prevents fatigue
  • these results suggest that spinal manipulation may be indicated as part of the treatment for the patients who have lost tonus of their muscle and/or are recovering from muscle dysfunction such as stroke or orthopedic operations
  • these findings will also be of interest to athletes and perhaps the general public

 

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

 

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

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

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

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Is Chiropractic Useful For Dizziness and Balance?

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.

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Chiropractic and Midwifery Improve Breastfeeding Rates

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

 

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Happy 120th Birthday Chiropractic!

chiropractic birthday DDCelebrate the founder of chiropractic today, Sept. 18.  Chiropractic’s first adjustment is recognized each year as Chiropractic Founder’s Day. On this day in 1895 (120 years ago), Dr. Daniel David Palmer gave the first chiropractic adjustment. Chiropractic focuses on the relationship between the body’s main structures – the skeleton, the muscles and the nerves – and the patient’s health.  There is substantial evidence supporting the safety and effectiveness of chiropractic treatment for patients seen in chiropractic practice.  Share the word of chiropractic today.

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

33609004_sLow 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.   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.

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).  Pain intensity ratings were also collected. Outcomes were assessed at baseline, 4 weeks, 3 months and 6 months.  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 and Conclusions:

  • 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 were 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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Chiropractic Has Lowest Total Costs for Low Back Problems in a Major Self-Insured Workforce

Low Back PainStatistics tell us that up to 84% of the general population will report low back pain (LBP) symptoms at some point during their lifetime.  This leads employers seeking to maximize the ratio of outcomes achieved relative to costs incurred (ie, value) for the investments that they are making in their employees. Previous research has found that patients receiving chiropractic care have been found to record lower associations of probability of disability recurrence than patients of physicians and physical therapists.  Given these findings, the authors of this newly published article sought 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. Results of the study were that care congruent with 10 of 11 guidelines was linked to lower total costs. Of the five patterns of care, complex medical management reported the highest guideline-incongruent use of imaging, surgeries, and medications and had the highest health care costs.  On the other hand, chiropractic reported the lowest rates of guideline-incongruent use of imaging, surgeries, and medications and had the lowest health care costs.

http://www.ncbi.nlm.nih.gov/pubmed/24854253

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Episode

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: MFunabashi@cmcc.ca

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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042- J. David Cassidy, DC, PhD, DrMedSc Discusses Stroke, Concussion, Neck Pain, Whiplash and Epidemiology

Listen as Dr. Cassidy and I discuss his career in chiropractic, research, and hear his thoughts on a variety of important issues including the powerful role of psychosocial factors on health.  Dr. Cassidy is a Professor of Epidemiology and Health Policy at the Dalla Lana School of Public Health at the University of Toronto. He is also an Adjunct Globalization Professor at the Faculty of Health at the University of Southern Denmark. He began his career as a chiropractor (CMCC 1975) and later obtained graduate degrees in Surgery (MSc University of Saskatchewan), Pathology (PhD University of Saskatchewan) and Injury Epidemiology (DrMedSc Karolinska Institute, Sweden). His past appointments include Assistant Professor of Surgery and Rehabilitation Medicine at the University of Saskatchewan (1994-1999), Associate Professor of Public Health and Medicine at the University of Alberta (2000-2003), Senior Scientist at the Toronto Western Hospital Research Institute (2003-2017) and Professor of Sport Science and Clinical Biomechanics at the University of Southern Denmark (2011-2016).

His research focus is injury epidemiology, neurotrauma, musculoskeletal disorders and evidence-based health care and policy. He has published over 300 research papers and chapters in textbooks over his career, including papers in the New England Journal of Medicine, the British Medical Journal, Annals of Internal Medicine, JAMA Psychiatry and the Archives of Physical and Rehabilitation Medicine to name a few. He is particularly interested in the psychosocial determinants of injury recovery and long-term consequences of injury.

View Dr. Cassidy’s research at researchgate.net.

We talked about a lot of research articles, too many to list in the show notes.  You can see a listing of Dr. Cassidy’s research at pubmed.com.

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041- Spinal Pain in the Elderly and Chiropractic with Dr. Katie de Luca

Dr. de Luca and I discuss her research on spinal pain in the elderly and chiropractic. Katie de Luca is a post-doctoral research fellow in the Department of Chiropractic at Macquarie University. She is a chiropractor in clinical practice, however her research focuses on the epidemiology and management of musculoskeletal conditions, with expertise in the elderly. In 2016 she was awarded her PhD from the University of Newcastle, School of Medicine and Public Health. Her thesis explored the experience of pain in women with arthritis, and resulted in substantial contributions to the fields of rheumatology, pain and ageing research. She has 25 peer-reviewed journal publications and more than 50 conference presentations, which includes several invited keynote presentations on back pain in the elderly. These have been at regional, national and international conferences in gerontology, pain, public health and chiropractic forums. She is on the editorial boards of Chiropractic and Manual Therapies and JMPT, and peer-reviews for another 13 journals. She has received several large competitive grants, most recently being awarded in excess of $400,00 in an industry led grant from the Australia Chiropractors Association to perform a longitudinal study on back pain in older Australians who present to a chiropractor for treatment of their low back pain. She has won many research prizes, including 1st prize at the World Federation of Chiropractic Biennial Conference in Washington DC (March, 2017). She is actively on the board for the Chiropractic Australia Research Foundation, and is the Research Chair for Sports Chiropractic Australia. She is one of only 13 CARL Fellows, a group which she is privileged to be a part of. She hopes to be a leading chiropractic researcher on spinal pain in the elderly.

View Dr. de Luca’s research at researchgate.net.

 

Here are the articles we discuss in this interview:

1. Qualitative insights into the experience of pain in older Australian women with arthritis.
de Luca K, Parkinson L, Hunter S, Byles JE.
Australas J Ageing. 2018 Sep;37(3):210-216. doi: 10.1111/ajag.12557. Epub 2018 Jun 26.
PMID: 29947165 [PubMed – in process]
Similar articles
2. The Relationship Between Spinal Pain and Comorbidity: A Cross-sectional Analysis of 579 Community-Dwelling, Older Australian Women.
de Luca KE, Parkinson L, Haldeman S, Byles JE, Blyth F.
J Manipulative Physiol Ther. 2017 Sep;40(7):459-466. doi: 10.1016/j.jmpt.2017.06.004. Epub 2017 Oct 13.
PMID: 29037787 [PubMed – indexed for MEDLINE]
Similar articles
3. Three subgroups of pain profiles identified in 227 women with arthritis: a latent class analysis.
de Luca K, Parkinson L, Downie A, Blyth F, Byles J.
Clin Rheumatol. 2017 Mar;36(3):625-634. doi: 10.1007/s10067-016-3343-5. Epub 2016 Jul 6.
PMID: 27383742 [PubMed – indexed for MEDLINE]
Similar articles
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040- Dr. Anthony Lisi Discusses Chiropractic Practice and Research in the VA

In this episode, Dr. Anthony Lisi and I discuss the state of chiropractic practice and research in the US Veterans Health Administration. Dr. Anthony Lisi is the Chiropractic Program Director for the US Veterans Health Administration, overseeing all national programmatic issues related to the integration of chiropractic clinical services, education and research. He is also an Associate Research Scientist at the Yale Center for Medical Informatics, Yale University School of Medicine.

He has authored numerous peer-reviewed publications on topics including low back pain management, spinal manipulation, interprofessional education, and chiropractic services. Dr. Lisi received the American Chiropractic Associations’ 2015 Academician of the Year award, and the 2017 Chiropractor of the Year award.

See Dr. Lisi’s research profile at researchgate.net.

Below are the articles we discuss in this episode:

1. Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care.
Lisi AJ, Corcoran KL, DeRycke EC, Bastian LA, Becker WC, Edmond SN, Goertz CM, Goulet JL, Haskell SG, Higgins DM, Kawecki T, Kerns RD, Mattocks K, Ramsey C, Ruser CB, Brandt CA.
Pain Med. 2018 Sep 1;19(suppl_1):S54-S60. doi: 10.1093/pm/pny114.
PMID: 30203014 [PubMed – in process]
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2. Trends in the Use and Characteristics of Chiropractic Services in the Department of Veterans Affairs.
Lisi AJ, Brandt CA.
J Manipulative Physiol Ther. 2016 Jun;39(5):381-6. doi: 10.1016/j.jmpt.2016.04.005.
PMID: 27288324 [PubMed – indexed for MEDLINE]
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3. Chiropractic Integration into Private Sector Medical Facilities: A Multisite Qualitative Case Study.
Lisi AJ, Salsbury SA, Twist EJ, Goertz CM.
J Altern Complement Med. 2018 Aug;24(8):792-800. doi: 10.1089/acm.2018.0218. Epub 2018 Jul 17.
PMID: 30016118 [PubMed – indexed for MEDLINE]
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4. Variations in the implementation and characteristics of chiropractic services in VA.
Lisi AJ, Khorsan R, Smith MM, Mittman BS.
Med Care. 2014 Dec;52(12 Suppl 5):S97-104. doi: 10.1097/MLR.0000000000000235.
PMID: 25397831 [PubMed – indexed for MEDLINE]
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5. Use of Department of Veterans Affairs administrative data to identify veterans with acute low back pain: a pilot study.
Lisi AJ, Burgo-Black AL, Kawecki T, Brandt CA, Goulet JL.
Spine (Phila Pa 1976). 2014 Jun 15;39(14):1151-6. doi: 10.1097/BRS.0000000000000350.
PMID: 24732845 [PubMed – indexed for MEDLINE]
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039- Inflammation of Peripheral Nerves, Chiropractic Principles, Manual Therapies and More with Dr. Geoffrey Bove

Geoffrey Bove, DC, PhD, and I discuss his research regarding inflammation within peripheral nerves, chiropractic principles, manual therapies, repetitive motion disorders and much more.  Dr. Bove is a graduate of Hampshire College, Canadian Memorial Chiropractic College, and the University of North Carolina, Chapel Hill.  He is currently a professor at the University of New England, in Biddeford Maine (USA).  Dr. Bove’s research has focused on the effect of inflammation on small diameter axons within peripheral nerves, a topic directed by founding chiropractic principles.  He also studies the effects of manual therapies on common painful conditions, such as repetitive motion disorders and postoperative visceral adhesions.

Visit Dr. Bove’s research gate profile.

Here are the links to Dr. Bove’s articles we discuss in this interview:

 

1. Time course of ongoing activity during neuritis and following axonal transport disruption.
Satkeviciute I, Goodwin G, Bove GM, Dilley A.
J Neurophysiol. 2018 May 1;119(5):1993-2000. doi: 10.1152/jn.00882.2017. Epub 2018 Feb 21.
PMID: 29465329 [PubMed – in process]
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2. Group IV nociceptors develop axonal chemical sensitivity during neuritis and following treatment of the sciatic nerve with vinblastine.
Govea RM, Barbe MF, Bove GM.
J Neurophysiol. 2017 Oct 1;118(4):2103-2109. doi: 10.1152/jn.00395.2017. Epub 2017 Jul 12.
PMID: 28701542 [PubMed – indexed for MEDLINE] Free PMC Article
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3. Attenuation of postoperative adhesions using a modeled manual therapy.
Bove GM, Chapelle SL, Hanlon KE, Diamond MP, Mokler DJ.
PLoS One. 2017 Jun 2;12(6):e0178407. doi: 10.1371/journal.pone.0178407. eCollection 2017.
PMID: 28574997 [PubMed – indexed for MEDLINE] Free PMC Article
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4. A model for radiating leg pain of endometriosis.
Bove GM.
J Bodyw Mov Ther. 2016 Oct;20(4):931-936. doi: 10.1016/j.jbmt.2016.04.013. Epub 2016 Apr 14.
PMID: 27814877 [PubMed – indexed for MEDLINE] Free PMC Article
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5. A Novel Method for Evaluating Postoperative Adhesions in Rats.
Bove GM, Chapelle SL, Boyle E, Mokler DJ, Hartvigsen J.
J Invest Surg. 2017 Apr;30(2):88-94. doi: 10.1080/08941939.2016.1229367. Epub 2016 Oct 3.
PMID: 27690703 [PubMed – indexed for MEDLINE]
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6. Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury.
Bove GM, Harris MY, Zhao H, Barbe MF.
J Neurol Sci. 2016 Feb 15;361:168-80. doi: 10.1016/j.jns.2015.12.029. Epub 2015 Dec 24.
PMID: 26810536 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
7. Disruption of fast axonal transport in the rat induces behavioral changes consistent with neuropathic pain.
Dilley A, Richards N, Pulman KG, Bove GM.
J Pain. 2013 Nov;14(11):1437-49. doi: 10.1016/j.jpain.2013.07.005. Epub 2013 Sep 12.
PMID: 24035352 [PubMed – indexed for MEDLINE]
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8. Focal nerve inflammation induces neuronal signs consistent with symptoms of early complex regional pain syndromes.
Bove GM.
Exp Neurol. 2009 Sep;219(1):223-7. doi: 10.1016/j.expneurol.2009.05.024. Epub 2009 May 27.
PMID: 19477176 [PubMed – indexed for MEDLINE]
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9. Inflammation induces ectopic mechanical sensitivity in axons of nociceptors innervating deep tissues.
Bove GM, Ransil BJ, Lin HC, Leem JG.
J Neurophysiol. 2003 Sep;90(3):1949-55. Epub 2003 Apr 30.
PMID: 12724363 [PubMed – indexed for MEDLINE] Free Article
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10. Disruption of axoplasmic transport induces mechanical sensitivity in intact rat C-fibre nociceptor axons.
Dilley A, Bove GM.
J Physiol. 2008 Jan 15;586(2):593-604. Epub 2007 Nov 15.
PMID: 18006580 [PubMed – indexed for MEDLINE] Free PMC Article
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038- Chiropractic, Opioids, Adverse Drug Events, and Medicare with Dr. James Whedon

Dr. James Whedon

In this episode, Dr. James Whedon and I discuss his research on chiropractic, opioids, adverse events, risk of injury, medicare, and much more.  For instance, his research found the likelihood of filling a prescription for an opioid analgesic was significantly lower for recipients of services delivered by doctors of chiropractic compared with nonrecipients.  Dr. Jim Whedon is Director of Health Services Research at Southern California University of Health Sciences and adjunct instructor at The Dartmouth Institute for Health Policy and Clinical Practice. He holds a DC degree from Logan College and an MS from Dartmouth College. He has authored 33 peer reviewed publications. He is advisor to the Project for Integrative Health and the Triple Aim, co-chair of the research working group of The Academic Consortium for Integrative Health, charter member of the Academy of Integrative Health & Medicine, and recipient of the Jerome F. McAndrews DC Memorial Research Fund Award from NCMIC Foundation.

Dr. Jim Whedon is a national award-winning, NIH-funded clinical and health services investigator with interests in trauma, integrative medicine, spinal disorders and Medicare health policy. Experience in clinical database development and medical editing. IRB and editorial advisory board member. Licensed chiropractic physician with 25 years clinical experience. Faculty appointment with Geisel School of Medicine at Dartmouth.

Much of his research has focused upon geographic variations in access to chiropractic services under Medicare. He conducts observational research using claims and registry data.

Dr. Whedon’s long-term research goals are to improve access to health services that people need and want, and to improve quality through systematic care of acute problems and conservative upstream care of chronic problems. He has a particular interest in helping to improve access to care for vulnerable populations.

He is also a member of the Advisory Team, Project for Integrative Health and the Triple Aim, and of the Research Working Group, Academic Consortium for Complementary and Alternative Health Care (ACCAHC).

See Dr. Whedon’s list of publications on researchgate.net.

How to cite this episode:
Smith DL. Chiropractic Science: Chiropractic, Opioids, Adverse Drug Events, and Medicare with Dr. James Whedon [internet]. Eaton, Ohio; Aug 23, 2018. Podcast: 1:05:21. Available from: https://chiropracticscience.com/podcast/drjameswhedon/

Below is a list of the articles Dr. Whedon discusses in this episode:

1. Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Risk of Adverse Drug Events.
Whedon JM, Toler AWJ, Goehl JM, Kazal LA.
J Manipulative Physiol Ther. 2018 Jun;41(5):383-388. doi: 10.1016/j.jmpt.2018.01.004. Epub 2018 May 26.
PMID: 29843912 [PubMed – in process]
Similar articles
2. Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain and Use of Prescription Opioids.
Whedon JM, Toler AWJ, Goehl JM, Kazal LA.
J Altern Complement Med. 2018 Jun;24(6):552-556. doi: 10.1089/acm.2017.0131. Epub 2018 Feb 22.
PMID: 29470104 [PubMed – indexed for MEDLINE]
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3. Relevance of Quality Measurement to Integrative Healthcare in the United States.
Whedon JM, Punzo M, Dehen R, Menard MB, Fogel D, Olejownik J.
J Altern Complement Med. 2016 Nov;22(11):853-858. Epub 2016 Sep 23.
PMID: 27660896 [PubMed – indexed for MEDLINE]
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4. The Association Between Use of Chiropractic Care and Costs of Care Among Older Medicare Patients With Chronic Low Back Pain and Multiple Comorbidities.
Weeks WB, Leininger B, Whedon JM, Lurie JD, Tosteson TD, Swenson R, O’Malley AJ, Goertz CM.
J Manipulative Physiol Ther. 2016 Feb;39(2):63-75.e1-2. doi: 10.1016/j.jmpt.2016.01.006. Epub 2016 Feb 19.
PMID: 26907615 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
5. Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66 to 99 years.
Whedon JM, Mackenzie TA, Phillips RB, Lurie JD.
Spine (Phila Pa 1976). 2015 Feb 15;40(4):264-70. doi: 10.1097/BRS.0000000000000725.
PMID: 25494315 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
6. Risk of stroke after chiropractic spinal manipulation in medicare B beneficiaries aged 66 to 99 years with neck pain.
Whedon JM, Song Y, Mackenzie TA, Phillips RB, Lukovits TG, Lurie JD.
J Manipulative Physiol Ther. 2015 Feb;38(2):93-101. doi: 10.1016/j.jmpt.2014.12.001. Epub 2015 Jan 14.
PMID: 25596875 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
7. Comparing Propensity Score Methods for Creating Comparable Cohorts of Chiropractic Users and Nonusers in Older, Multiply Comorbid Medicare Patients With Chronic Low Back Pain.
Weeks WB, Tosteson TD, Whedon JM, Leininger B, Lurie JD, Swenson R, Goertz CM, O’Malley AJ.
J Manipulative Physiol Ther. 2015 Nov-Dec;38(9):620-8. doi: 10.1016/j.jmpt.2015.10.005. Epub 2015 Nov 5.
PMID: 26547763 [PubMed – indexed for MEDLINE] Free PMC Article
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037- Interdisciplinary Care and Strategies to Incorporate Evidence Into Practice With Dr. Robert Vining

Dr. Robert Vining

In this episode, Dr. Robert Vining and I discuss his involvement in chiropractic research at a specialty hospital in New Hampshire, low back pain classification and strategies on how to implement evidence into practice. Dr. Vining is an Associate Professor and Research Clinic Director at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic. Beginning in private practice in Pennsylvania, he eventually transitioned to the role of clinician/educator, teaching courses in clinical biomechanics at Cleveland Chiropractic College (now Cleveland University), and serving as a teaching clinic director at Logan College of Chiropractic. More recently, Dr. Robert Vining has taken on the role of clinician/scientist, serving as a co-investigator on 11 federally funded clinical studies including those conducted within Veterans Affairs and the US Department of Defense health systems. He was also co-principal investigator on a series of privately funded research projects focused on integrating chiropractic care into a rehabilitation specialty hospital. Dr. Vining is a lead or co-author on over 30 peer reviewed scientific journal articles, 2 book chapters, and numerous other publications related to chiropractic care, musculoskeletal diagnosis, and translating research evidence into clinical practice.

You can view Dr. Vining’s research articles at researchgate.

How to cite this episode:
Smith DL. Chiropractic Science: Interdisciplinary Care and Strategies to Incorporate Evidence Into Practice With Dr. Robert Vining [internet]. Eaton, Ohio; Aug 7, 2018. Podcast: 1:21:13. Available from: https://chiropracticscience.com/podcast/drrobertvining/

1. “Be good, communicate, and collaborate”: a qualitative analysis of stakeholder perspectives on adding a chiropractor to the multidisciplinary rehabilitation team.
Salsbury SA, Vining RD, Gosselin D, Goertz CM.
Chiropr Man Therap. 2018 Jun 22;26:29. doi: 10.1186/s12998-018-0200-4. eCollection 2018.
PMID: 29977521 [PubMed – in process] Free PMC Article
Similar articles
2. Patients receiving chiropractic care in a neurorehabilitation hospital: a descriptive study.
Vining RD, Salsbury SA, Cooley WC, Gosselin D, Corber L, Goertz CM.
J Multidiscip Healthc. 2018 May 3;11:223-231. doi: 10.2147/JMDH.S159618. eCollection 2018.
PMID: 29760552 [PubMed] Free PMC Article
Similar articles
3. Interdisciplinary rehabilitation for a patient with incomplete cervical spinal cord injury and multimorbidity: A case report.
Vining RD, Gosselin DM, Thurmond J, Case K, Bruch FR.
Medicine (Baltimore). 2017 Aug;96(34):e7837. doi: 10.1097/MD.0000000000007837.
PMID: 28834891 [PubMed – indexed for MEDLINE] Free PMC Article
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4. An evidence-based diagnostic classification system for low back pain.
Vining R, Potocki E, Seidman M, Morgenthal AP.
J Can Chiropr Assoc. 2013 Sep;57(3):189-204.
PMID: 23997245 [PubMed] Free PMC Article
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036- From Spine Function to Dysfunction and Multidisciplinary Teamwork With Dr. Peter McCarthy

Peter McCarthy, PhD

Dr. Peter McCarthy and I discuss his varied research in the profession from spine function to dysfunction and multidisciplinary teamwork. Professor Peter McCarthy PhD (Full Professor of clinical technology, University of South Wales, UK) has been involved in the education of chiropractors for 30 years. He obtained his PhD in neurophysiology from the University of St Andrews (1986) and worked in various institutes around the world. He first joined the AECC in 1989, moving in 1998 to the University of Glamorgan to help Susan King create and consolidate the first University based chiropractic course in the UK: later becoming the Welsh Institute of Chiropractic. Holding a couple of patents, Peter has been awarded honorary fellowships, from the BCA, RCC and EAC, and research awards from the National Back Pain Association and British Association for Sport and Exercise Medicine, amongst others; even being part of a team that won a National design award. He has successfully supervised PhD students from a wide range of professions across medicine, including 4 chiropractors. Although his research publication profile appears eclectic, it is tied together by his overarching interest in sensory neurophysiology. He has studied the innervation of spinal structures, factors that affect cervical spine function and also performed RCTs of therapies on chronic back pain. More recently, he has been looking at measuring the sensory factors that can help predict relative discomfort when sitting or lying as well as developing a multidisciplinary team interested in studying neck function changes in sport and developing ways of reducing the impact these changes can have.

A link to Dr. McCarthy’s researchgate profile is found here.

How to cite this episode:
Smith DL. Chiropractic Science: From Spine Function to Dysfunction and Multidisciplinary Teamwork With Dr. Peter McCarthy [internet]. Eaton, Ohio; Aug 1, 2018. Podcast: 59:14. Available from: https://chiropracticscience.com/podcast/drpetermccarthy/

Below is a list of some of the articles we discuss in this interview.

1. A pilot study assessing patient-centred care in patients with chronic health conditions attending chiropractic practice.
Stuber KJ, Langweiler M, Mior S, McCarthy PW.
Complement Ther Med. 2018 Aug;39:1-7. doi: 10.1016/j.ctim.2018.05.006. Epub 2018 May 18.
PMID: 30012379 [PubMed – in process]
Similar articles
2. Modelling the effect of electrode displacement on transcranial direct current stimulation (tDCS).
Ramaraju S, Roula MA, McCarthy PW.
J Neural Eng. 2018 Feb;15(1):016019. doi: 10.1088/1741-2552/aa8d8a.
PMID: 28925375 [PubMed – in process]
Similar articles
3. Effect of Anodal-tDCS on Event-Related Potentials: A Controlled Study.
Izzidien A, Ramaraju S, Roula MA, McCarthy PW.
Biomed Res Int. 2016;2016:1584947. Epub 2016 Nov 10.
PMID: 27957487 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
4. The factors and motivations behind United Kingdom chiropractic professional association membership: a survey of the Welsh Institute of Chiropractic Alumni.
Wotherspoon SE, McCarthy PW.
Chiropr Man Therap. 2016 Sep 12;24(1):35. doi: 10.1186/s12998-016-0115-x. eCollection 2016.
PMID: 27621800 [PubMed] Free PMC Article
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5. Assessing patient-centered care in patients with chronic health conditions attending chiropractic practice: protocol for a mixed-methods study.
Stuber KJ, Langweiler M, Mior S, McCarthy PW.
Chiropr Man Therap. 2016 May 9;24:15. doi: 10.1186/s12998-016-0095-x. eCollection 2016.
PMID: 27162609 [PubMed] Free PMC Article
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6. Wearing American Football helmets increases cervicocephalic kinaesthetic awareness in “elite” American Football players but not controls.
McCarthy PW, Hume PJ, Heusch AI, Lark SD.
Chiropr Man Therap. 2015 Nov 16;23:32. doi: 10.1186/s12998-015-0077-4. eCollection 2015.
PMID: 26576266 [PubMed] Free PMC Article
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7. Survey based investigation into general practitioner referral patterns for spinal manipulative therapy.
Kier A, George M, McCarthy PW.
Chiropr Man Therap. 2013 May 29;21:16. doi: 10.1186/2045-709X-21-16. eCollection 2013.
PMID: 23718217 [PubMed] Free PMC Article
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