I am excited for the opportunity to discuss chiropractic research with Drs. Peterson and Humphreys in the near future. Cynthia Peterson, RN, DC, DACBR, M.Med.Ed. has worked as a chiropractic radiologist, researcher and educator in 4 countries. She retired from her positions as Professor and researcher, Radiology Department, Orthopaedic University hospital Balgrist and Professor, Chiropractic Medicine Programme, University of Zürich in 2017. She is currently a Visiting Professor for the Chiropractic Department in the Faculty of Health at the University of Johannesburg, South Africa and is the Quality Assurance Consultant for the European Council on Chiropractic Education. Barry Kim Humphreys, BSc, DC, PhD, is Professor Emeritus, Faculty of Medicine, University of Zurich. He retired in July 2017, after 9 years as the first Professor for Chiropractic Medicine in Switzerland. During this time, Professor Humphreys was responsible for the development and accreditations of the chiropractic education program, research portfolio and teaching clinic within the university, medical faculty and teaching hospital. He has been active in research including chiropractic clinical outcome studies for back and neck pain, functional MRI studies of chronic pain patients and back pain in various gravitational environments (parabolic flight). Please comment below if you have any questions for us during the interview. I might choose some of them for our conversation.
A clinical practice guideline on the management of neck pain–associated disorders (NADs) and whiplash-associated disorders (WADs) was recently developed and replaces existing chiropractic guidelines on these topics (Bussières, Stewart et al, 2016). The Guideline Development Group of the Canadian Chiropractic Guideline Initiative (CCGI) conducted the updated guidelines. They considered recently published systematic reviews on NAD and WAD from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Below is a brief summary of the guidelines. Please refer to the numerous links in this blog post to gain access to the original paper and the full guidelines which are freely available.
Neck pain and its associated disorders (NAD), including headache and radiating pain into the arm and upper back, are common. These disorders often result in significant social, psychological, and economic burden. Neck pain is a common reason for people to seek chiropractic care.
Motor vehicle collisions most commonly are associated with neck pain related to whiplash-associated disorders (WADs). Whiplash-associated disorders also affect the daily functioning of our patients in terms of considerable pain, suffering, disability, and costs. Whiplash-associated disorders are defined as an injury to the neck that occurs with sudden acceleration or deceleration of the head and neck relative to other body parts. Symptoms of WADs commonly include headache, stiffness, shoulder and back pain, numbness, dizziness, sleeping difficulties, fatigue, and cognitive deficits.
The 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders recommended that all types of neck pain, including WADs, be included under the classification of NAD. The 4 grades of NAD are:
- I – No signs or symptoms suggestive of major structural pathology and no or minor interference with activities of daily living
- II – No signs or symptoms of major structural pathology, but major interference with activities of daily living
- III – No signs or symptoms of major structural pathology, but presence of neurologic signs such as decreased deep tendon reflexes, weakness or sensory deficits
- IV – Signs or symptoms of major structural pathology (e.g., fracture, tumor, infection)
After searching and synthesizing the latest scientific literature on these topics, the guideline committee provided their recommendations. Below is the summary of the recommendations. The full guideline and accompanying documents are available from the CCGI website at www.chiroguidelines.org. There are excellent resources for practitioners and patients available from this website including exercise videos and forms.
Global summary of recommendations: A multimodal approach including manual therapy, self-management advice and exercise is an effective treatment strategy for both recent onset and persistent neck pain and whiplash associated disorders.
A) Summary of Recommendations for Grades I-III Neck Pain and Associated Disorders (NAD)
- For recent-onset (0-3 months) neck pain grades I-II, based on patient preference and practitioner experience we suggest offering advice with:
- multimodal care;
- manipulation or mobilization;
- Range of motion home exercises or multimodal manual therapy.
- For recent-onset (0-3 months) neck pain grade III, based on patient preference and practitioner experience we suggest offering advice with:
- supervised graded strengthening exercises.
- For persistent (>3 months) neck pain grades I-II, based on patient preference and practitioner experience we suggest offering advice with:
- multimodal care or stress self-management;
- multimodal care or advice alone;
- manipulation in conjunction with soft tissue therapy;
- supervised yoga; supervised group exercise; supervised strengthening exercises or home exercises;
- mixed supervised and unsupervised high-intensity strength training or advice alone for workers with persistent neck and shoulder pain;
- high dose massage.
- For persistent (>3 months) neck pain grade III, based on patient preference and practitioner experience we suggest offering advice with:
- multimodal care or advice alone;
- mixed supervised and unsupervised high-intensity strength training or advice alone for workers with persistent neck and shoulder pain.
B) Summary of Recommendations for Grade I-III Whiplash and Associated Disorders (WAD)
- For recent onset (0-3 months) whiplash grades I-III, based on patient preference and practitioner experience we suggest offering advice with:
- multimodal care.
- For persistent (>3 months) whiplash grades I-II, based on patient preference and practitioner experience we suggest offering advice with:
- supervised exercise or advice alone.
Source: Bussières AE, Stewart G, Al-Zoubi F et al. The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. J Manipulative Physiol Ther. 2016 Oct;39(8):523-564.
We’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.
New scientific evidence on the effectiveness of manual therapies, passive physical modalities, and acupuncture was assessed in a recent systematic review. This update of the Neck Pain Task Force suggests that mobilization, manipulation, and clinical massage are effective interventions for neck pain. Conversely, they found that electroacupuncture, strain-counterstrain, relaxation massage, and other modalities such as heat, cold, diathermy, hydrotherapy, ultrasound are not effective.
Drs. Cindy Peterson and Kim Humphreys join me to talk about cervical and lumbar disc herniation comparative effectiveness studies involving spinal manipulation compared to nerve root injections. We also discuss spinal manipulation for neck pain with and without dizziness as well as for chronic low back pain.
Cynthia Peterson, RN, DC, DACBR, M.Med.Ed. has worked as a chiropractic radiologist, researcher and educator in 4 countries. She retired from her positions as Professor and researcher, Radiology Department, Orthopaedic University hospital Balgrist and Professor, Chiropractic Medicine Programme, University of Zürich in 2017. Dr. Peterson has published numerous research studies in many journals including ‘Spine’, European Spine Journal, ‘American Journal of Roentgenology’, ‘JMPT’ and ‘Skeletal Radiology’. She is currently a Visiting Professor for the Chiropractic Department in the Faculty of Health at the University of Johannesburg, South Africa and is the Quality Assurance Consultant for the European Council on Chiropractic Education.
Barry Kim Humphreys, BSc, DC, PhD, is Professor Emeritus, Faculty of Medicine, University of Zurich. He retired in July 2017, after 9 years as the first Professor for Chiropractic Medicine in Switzerland. During this time, Professor Humphreys was responsible for the development and accreditations of the chiropractic education program, research portfolio and teaching clinic within the university, medical faculty and teaching hospital. Professor Humphreys is a graduate of the University of British Columbia (BSc), Canadian Memorial Chiropractic College (DC), and the University of Southampton, UK (PhD). He has been Academic Dean, Anglo-European College of Chiropractic, Dean of Graduate Education and Research, CMCC and Professor, Chiropractic Medicine, University of Zurich. He has been active in research including chiropractic clinical outcome studies for back and neck pain, functional MRI studies of chronic pain patients and back pain in various gravitational environments (parabolic flight).
View all of the podcast episodes at chiropracticscience.com
Here are the articles we discuss in this episode:
|1.||Symptomatic, Magnetic Resonance Imaging-Confirmed Cervical Disk Herniation Patients: A Comparative-Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either Imaging-Guided Indirect Cervical Nerve Root Injections or Spinal Manipulative Therapy.|
|Peterson CK, Pfirrmann CW, Hodler J, Leemann S, Schmid C, Anklin B, Humphreys BK.|
|J Manipulative Physiol Ther. 2016 Mar-Apr;39(3):210-7. doi: 10.1016/j.jmpt.2016.02.004. Epub 2016 Mar 31.|
|PMID: 27040033 [PubMed – indexed for MEDLINE]|
|2.||Symptomatic magnetic resonance imaging-confirmed lumbar disk herniation patients: a comparative effectiveness prospective observational study of 2 age- and sex-matched cohorts treated with either high-velocity, low-amplitude spinal manipulative therapy or imaging-guided lumbar nerve root injections.|
|Peterson CK, Leemann S, Lechmann M, Pfirrmann CW, Hodler J, Humphreys BK.|
|J Manipulative Physiol Ther. 2013 May;36(4):218-25. doi: 10.1016/j.jmpt.2013.04.005. Epub 2013 May 22.|
|PMID: 23706678 [PubMed – indexed for MEDLINE]|
|3.||Comparison of outcomes in neck pain patients with and without dizziness undergoing chiropractic treatment: a prospective cohort study with 6 month follow-up.|
|Humphreys BK, Peterson C.|
|Chiropr Man Therap. 2013 Jan 7;21(1):3. doi: 10.1186/2045-709X-21-3.|
|PMID: 23295018 [PubMed] Free PMC Article|
|4.||An observational study on trajectories and outcomes of chronic low back pain patients referred from a spine surgery division for chiropractic treatment.|
|Wirth B, Riner F, Peterson C, Humphreys BK, Farshad M, Becker S, Schweinhardt P.|
|Chiropr Man Therap. 2019 Feb 5;27:6. doi: 10.1186/s12998-018-0225-8. eCollection 2019.|
|PMID: 30766664 [PubMed – indexed for MEDLINE] Free PMC Article|
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.
Listen as Dr. Pierre Côté and I discuss his involvement in hugely impactful research on stroke, lumbar disc herniations and neck pain. He provides chiropractors with key information that helps de-mystify these topics. Pierre Côté DC, PhD is an epidemiologist. In 2013, he was awarded the prestigious Canada Research Chair in Disability Prevention and Rehabilitation from the Canadian Government. He is currently an Associate Professor in the Faculty of Health Sciences at the University of Ontario Institute of Technology, director of the UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation and an Associate Professor in the Dalla Lana School of Public Health at the University of Toronto. Dr. Côté graduated from the Canadian Memorial Chiropractic College in 1989. In 1996, he obtained a Master’s Degree in Surgery from the University of Saskatchewan. He completed his PhD in epidemiology at the University of Toronto in 2002. In 2003, he received a New Investigator Award from the Canadian Institutes of Health Research.
Dr. Côté was a member of the scientific secretariat of the 2000-2010 Bone and Joint Task Force on Neck Pain and its Associated Disorders; a large international collaboration aimed at synthesizing the scientific evidence on the problem of neck pain. In 2010, he reviewed and proposed modifications to the definition of catastrophic impairment related to traffic collision for the Financial Services Commission of Ontario. More recently in 2012, he was mandated by the Government of Ontario to develop evidence- based Clinical Practice Guidelines for the management of traffic injuries. He submitted his report on the management of Common Traffic injuries to the Ontario Government in 2015. Dr. Côté’s research focuses on understanding the etiology, prognosis and evidence-based management of musculoskeletal pain and disability and mental health. Dr. Côté has published more than 200 scientific papers in prestigious peer-reviewed journals such as the New England Journal of Medicine, the Annals of Internal Medicine, Pain and the American Journal of Epidemiology. His 2017 Google Scholar h-index is 56 and it is 48 according to Scopus.
You can find a listing of Dr. Côté’s research at researchgate.
Below are the articles we discuss in this interview:
|1.||Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study.|
|Hincapié CA, Tomlinson GA, Côté P, Rampersaud YR, Jadad AR, Cassidy JD.|
|Eur Spine J. 2017 Oct 16. doi: 10.1007/s00586-017-5325-y. [Epub ahead of print]|
|PMID: 29038870 [PubMed – as supplied by publisher]|
|2.||Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study.|
|Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ.|
|Spine (Phila Pa 1976). 2008 Feb 15;33(4 Suppl):S176-83. doi: 10.1097/BRS.0b013e3181644600. Erratum in: Spine (Phila Pa 1976). 2010 Mar 1;35(5):595.|
|PMID: 18204390 [PubMed – indexed for MEDLINE]|
|3.||Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.|
|Côté P, Wong JJ, Sutton D, Shearer HM, Mior S, Randhawa K, Ameis A, Carroll LJ, Nordin M, Yu H, Lindsay GM, Southerst D, Varatharajan S, Jacobs C, Stupar M, Taylor-Vaisey A, van der Velde G, Gross DP, Brison RJ, Paulden M, Ammendolia C, David Cassidy J, Loisel P, Marshall S, Bohay RN, Stapleton J, Lacerte M, Krahn M, Salhany R.|
|Eur Spine J. 2016 Jul;25(7):2000-22. doi: 10.1007/s00586-016-4467-7. Epub 2016 Mar 16. Review.|
|PMID: 26984876 [PubMed – in process]|
|4.||The annual incidence and course of neck pain in the general population: a population-based cohort study.|
|Côté P, Cassidy JD, Carroll LJ, Kristman V.|
|Pain. 2004 Dec;112(3):267-73.|
|PMID: 15561381 [PubMed – indexed for MEDLINE]|
- 048- Drs. Imran Niazi and Kelly Holt Discuss Chiropractic, Neuroplasticity and Falls August 22, 2019
- 047- Drs. Cindy Peterson and Kim Humphreys Discuss Disc Herniations, Neck Pain, Dizziness and Chronic Low Back Pain August 10, 2019
- 046- Dr. Jeffrey Hebert Discusses Back Pain, Cardiovascular Disease, Sport Participation May 30, 2019
- 045- Dr. Martha Funabashi Discusses the Biomechanics and Safety of Spinal Manipulation May 2, 2019
- 044- Dr. Sidney Rubinstein Discusses Chronic Low Back Pain, Spinal Manipulation and Systematic Reviews February 24, 2019
- 043- Dr. Geoff Outerbridge Discusses World Spine Care and the Global Spine Care Initiative January 22, 2019
- 042- J. David Cassidy, DC, PhD, DrMedSc Discusses Stroke, Concussion, Neck Pain, Whiplash and Epidemiology December 4, 2018
- 041- Spinal Pain in the Elderly and Chiropractic with Dr. Katie de Luca November 15, 2018
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