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Spinal manipulation biochemicalSpinal manipulation (SM) can improve function and reduce spinal disability.  SM also provides pain relief for many disorders such as back pain and neck pain.   Pain induces changes in both the central and peripheral nervous systems.  The mechanisms by which SM alters musculoskeletal pain are still not completely known.  Current evidence however suggests that SM is associated with neurophysiological responses including rapid hypoalgesia with simultaneous sympathetic and motor system excitation.  Animal studies have shown that analgesia provided by joint mobilization involves serotonin and noradrenaline receptors in the spinal cord.

A new investigation sought to determine the response of several other biochemical markers of pain and stress to SM.  Specifically, three neuropeptides (neurotensin, oxytocin, orexin A) and a glucorticoid hormone (cortisol) were studied.  The authors note that the neuropeptides have been associated with hypoalgesia and pain modulation and that cortisol plays an analgesic role in the stress response.  Recent theories have suggested that chronic pain could be partially maintained in a facilitated state due to maladaptive responses in the presence of recurrent stressful situations.  To date there is a lack of studies analyzing these specific biomarkers in relation to SM.

The purpose of this study was to determine the effect of cervical or thoracic manipulation on neurotensin (NT), oxytocin, orexin A, and cortisol levels.  Experimenters examined both spinal regions because they thought there may be a difference in anti-nociceptive effect between the cervical spine and thoracic spine.

Participants included graduate students from Spain.  All subjects were asymptomatic and were excluded if there was a contraindication to manipulation, history of whiplash or surgery, pain in the last month, SM in the last 2 months.  Thirty asymptomatic subjects were randomly divided into 3 groups: cervical manipulation (n = 10), thoracic manipulation (n = 10), and non-manipulation (control) (n = 10).  Although it is not explicitly stated in the article, I presume the manipulations were performed by physical therapists since the lead authors were PT’s.  Manipulations consisted of supine ‘anterior’ thoracic spine manipulations, and rotary type cervical manipulations.  Blood samples were extracted before, immediately after, and 2 hours after each intervention by way of venipuncture of the cephalic vein. Neurotensin, oxytocin, and orexin A were determined in plasma using enzyme-linked immuno assay. Cortisol was measured by microparticulate enzyme immuno assay in serum samples.

Results

Neurotensin (NT)

  • Statistically significant increases in neurotensin occurred in both the thoracic and cervical manipulation groups compared to controls post-intervention with the greatest increase occurring immediately following manipulation
  • Cervical spine manipulation produced a slightly larger increase in neurotensin

Orexin A

  • No statistically significant changes were noted in orexin A levels following treatment

Oxytocin

  • Statistically significant increases in oxytocin occurred in both the thoracic and cervical manipulation groups compared to controls post-intervention with the greatest increase occurring immediately following manipulation
  • Cervical spine manipulation produced a significantly larger increase in oxytocin compared to thoracic manipulation

Cortisol

  • A significant increase in cortisol occurred in the cervical manipulation group compared to controls and the thoracic manipulation group immediately post-intervention
  • However, a significant decrease in cortisol was found at 2 hrs post intervention in the thoracic SM group compared with pre-intervention values
  • A non-significant decrease in cortisol was found also found at 2 hrs post intervention in the cervical SM group compared with pre-intervention values


Discussion

NT is an endogenous peptide with broad spectrum of central and peripheral activities, including modulation of pain signal transmission and perception. NT behaves as a neurotransmitter in the brain and as a hormone in the gut.  Because of its association with a wide variety of neurotransmitters, NT has been implicated in the pathophysiology of several CNS disorders such as schizophrenia, drug abuse, Parkinson’s disease (PD), pain, central control of blood pressure, eating disorders, as well as, cancer and inflammation. Note that the antinociceptive effects of NT are independent from opioid antinociception.

Increased oxytocin following SM could be partly responsible for the analgesic effect linked to manual therapy techniques due to the activation of descending pain-inhibitory pathways.

Cortisol is a potent anti-inflammatory that functions to mobilize glucose reserves for energy and modulate inflammation. Ultimately, a prolonged or exaggerated stress response may perpetuate cortisol dysfunction, widespread inflammation, and pain.  SM in this study led to an immediate increase in cortisol followed by a significant 2 hour decrease in levels with thoracic manipulation and a decrease in 2 hr levels with cervical manipulation.


Key Points

  • SM can modify several biochemical markers of pain and stress
  • These findings suggest that descending inhibitory pathway mechanisms may be involved in the physiological effects that follow SM
  • The effect size for the cervical manipulation group was larger than that for the thoracic manipulation group suggesting an increase in the activation of the possible descending inhibitory pathway mechanisms after cervical manipulation compared to thoracic manipulation

Reference: Plaza-Manzano G, Molina-Ortega F, Lomas-Vega R, Martínez-Amat A, Achalandabaso A, Hita-Contreras F. Changes in biochemical markers of pain perception and stress response after spinal manipulation. J Orthop Sports Phys Ther. 2014 Apr;44(4):231-9.

18448850_xxlThe application of spinal manipulative therapy (SMT) is a cost-effective and widely recognized manual intervention used by a variety of health care professionals in the management of musculoskeletal pain. A growing body of scientific evidence supports the use of SMT for the treatment of a broad range of musculoskeletal disorders citing short-term antinociceptive (pain-relieving) effects and restoration of normal joint mechanics.

Last year, about this time, I wrote about a systematic review that found spinal manipulation therapy (SMT) has a pain reducing effect as measured by pressure pain thresholds (PPT).  Additionally, the effect of SMT on pain reduction was statistically significant at remote locations (for example, adjusting the neck yielded reduction in pain at the elbow).

A new study has emerged in the scientific literature that advances our understanding of the topic (Srbely et al, 2013).  The authors note that although the pathophysiology of myofascial pain syndrome (MPS) is still unclear, research suggests that myofascial trigger points (MTPs) play an fundamental role in the generation and clinical manifestation of MPS.  However, it is currently unknown if the antinociceptive effects of SMT in myofascial tissues are manifest predominantly via regional or general mechanisms, or a combination of both. A study was needed to specifically investigate the hypothesis that SMT evokes robust antinociceptive effects in MTPs preferentially located within neurosegmentally linked myofascial tissues.

Srbely et al conducted the study through the University of Guelph.  The study was a single session, single blinded, randomized controlled intervention.  The primary inclusion criterion was the presence of a clinically identifiable MTP locus (active or latent) within the right infraspinatus and right gluteus medius muscles.  The primary diagnostic criterion used to clinically identify the trigger point locus was ‘a palpable hyperirritable nodule nested within a taut band of skeletal muscle; sustained ischemic pressure over the trigger point locus elicited a dull achy regional pain or discomfort.’  Exclusion criteria encompassed conditions that would affect normal somatosensory processing.

Thirty-six participants qualified for the study and were randomly assigned to test or control groups.  Two chiropractors saw participants at an urban outpatient clinic. One chiropractor performed the history, exam and manipulations while the other chiropractor (blinded to treatment allocation) detected the trigger points and measured all PPTs. The primary outcome was PPT values from infraspinatus and gluteus medius muscles.  The infraspinatus was chosen due to its innervation from the manipulated segment (C5-6). The gluteus medius acted as a regional control point (L4-S1 innervation).

PPT was measured with a force gauge (Newtons) over the trigger point locus (infraspinatus, gluteus medius) and was defined as the force necessary to elicit the onset of a deep dull achy local discomfort and/or referred pain. Measurements were taken at 1,5, 10, and 15 minutes postintervention.  In order to specifically compare regional antinociceptive effects between intervention groups, the authors also calculated the PPT difference (PPTdiff) between infraspinatus and gluteus medius trigger points at each time interval within each participant. Participants received a rotary type manipulation to the C5-6 segment in a supine posture.   Additionally, a drop piece mechanism was used to aid in the high velocity low amplitude thrust.  Control participants received a sham manipulation.  The sham consisted of rotating the neck of the participant, supporting the neck of the participant with the clinician’s forearm under the headpiece and a thrust of the forearm into the headpiece.  It is noted that the contact hand did not thrust and did not create ‘a real manipulation’ of any segment.

Results:

  • there was a significantly increased PPT threshold for infraspinatus trigger points in treated participants compared to controls at all time intervals beyond baseline
  • there was a significantly increased PPT threshold for infraspinatus compared to gluteus medius before and after manipulation at all time intervals beyond baseline
  • no significant differences in PPT scores were observed at any time interval when comparing test gluteus medius, control infraspinatus, and control gluteus medius groups
  • there were significant increases in PPTdiff in the test group vs controls at all time intervals beyond baseline

Key Findings:

  • This study suggests that SMT evokes statistically significant short-term increases in PPT in segmentally related myofascial tissues in young adults
  • Decreased pressure sensitivity (increased PPT score) was observed at all time intervals beyond baseline within neurologically linked infraspinatus muscle after real, but not sham, manipulation
  • The peak antinociceptive effect was measured as a 36% decrease in pressure sensitivity from baseline values and was recorded at 5 minutes postSMT

So, what does this study tell us?  It suggests that SMT evokes robust regional antinociceptive effects in myofascial tissues.  It also provides important evidence to support further research into the potential benefit and role of SMT in the management of chronic widespread pain syndromes  including myofascial pain, and fibromyalgia.

Reference: Srbely JZ, Vernon H, Lee D, Polgar M. Immediate effects of spinal manipulative therapy on regional antinociceptive effects in myofascial tissues in healthy young adults. J Manipulative Physiol Ther. 2013 Jul-Aug;36(6):333-41.

 

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.

Aging ChiropracticThere are physiologic changes associated with aging. There are also health conditions that occur more commonly with advancing age. These changes and conditions increase an older adult’s vulnerability to injuries. A recent study investigated risk of injury to Medicare beneficiaries with an office visit for a neuromusculoskeletal problem to chiropractors and primary care physicians.  Specifically, investigators looked at the risk of injury within 7 days of those treated by chiropractic spinal manipulation vs. those evaluated by a primary care physician.  Results showed that risk of injury to the head, neck or trunk within 7 days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician.

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

Podcast

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
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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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Ian Coulter, PhD, is a senior health policy analyst at the RAND Corporation, where he holds the Samueli Institute Chair in Policy for Integrative Medicine. He is a full professor in the School of Dentistry, UCLA, in the Division of Public Health and Community Dentistry; a professor at the Pardee RAND Graduate School; and a research professor at the Southern California University of Health Sciences.

Dr. Coulter has published over 200 articles, chapters and books. He is the past Vice President for Integrative Medicine at the Samueli Institute.  He has had numerous grants from NIH and the DoD. For the past 20 years he has taught ethics and research ethics at UCLA and to various professional bodies throughout the United States. He currently teaches Professional Ethics/Research Ethics in the Pediatric Dentist Residency Program at the UCLA School of Dentistry.

Dr. Coulter was born in New Zealand and holds degrees in sociology from the University of Canterbury (B.A., M.A. Honors) and the London School of Economics & Political Science (Ph.D.) and an honorary doctorate in humanities from the Southern California University of Health Sciences. He was a Pew Fellow at the RAND/ University of California at Los Angeles, Center for Health Policy Study from which he received a certificate in health policy analysis. Additional qualifications include a diploma in educational management from the Institute of Educational Management, Harvard University. He is also a past President of the Canadian Memorial Chiropractic College.

And…more specifically regarding his research that relates to this interview, Dr. Coulter was an author of the recent JAMA article on adding chiropractic care to usual medical care, and lead author on the recent Spine Journal systematic review on spinal manipulation and chronic LBP. In addition, he is currently lead investigator of the CERC project (funded at over $8 million) to investigate chiropractors and their patients for Clinician Based Appropriateness, Outcomes Based Appropriateness, Patient Preferences Appropriateness and Resource Utilization Based Appropriateness.

View Dr. Coulter’s RAND page here.

How to cite this episode:
Smith DL. Chiropractic Science: Dr. Ian Coulter Discusses Research in JAMA, Appropriateness and Contextual Factors in Chiropractic Care [internet]. Eaton, Ohio; July 10, 2018. Podcast: 1:19:47. Available from: https://chiropracticscience.com/podcast/driancoulter/

Research discussed in this episode with Dr. Coulter include:

Goertz CM, Long CR, Vining RD, Pohlman KA, Walter J, Coulter I. Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back PainA Comparative Effectiveness Clinical Trial. JAMA Network Open. 2018;1(1):e180105. 

Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Suttorp Booth M, Herman PM. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J. 2018 May;18(5):866-879. 

Dr. Carolina Kolberg and I discuss her research dealing with the effect of chiropractic care on oxidative stress blood markers. Dr. Kolberg has a degree in chiropractic from the Anhembi Morumbi University in São Paulo, Brazil (2004), and she completed her Masters (2009) and PhD (2013) in Biological Sciences: Physiology at the Federal University of Rio Grande do Sul (UFRGS). Her research interests include the neurophysiology of pain and physiological effects of chiropractic treatment. Dr. Kolberg’s thesis on oxidative stress blood markers in patients with chronic back or neck pain treated with high-velocity and low-amplitude manipulation support the hypothesis that HVLA spinal manipulation leads to an antioxidant effect which, in turn, could be related to the analgesic response. Being the first chiropractor graduated in Brazil with a PhD, her goal is to promote the interest of Brazilians’ young chiropractors in research.

Dr. Kolberg is a member of the Research Committee of the WFC, is the Chair of the Research Committee of the Latin American Federation of Chiropractic (FLAQ) and a member of the editorial board of the Journal Coluna/Columna (ISSN 1808-1851), the official scientific publication of the Brazilian Spine Society and affiliated Societies. Dr. Kolberg is active in clinical practice; she is a Physiology professor at the University Center of the Serra Gaúcha (FSG) in the south of Brazil and is an associate researcher at the Neurobiology group from the Federal University of Rio Grande do Sul.

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

Here are the research articles we discussed in this episode:

1. Peripheral oxidative stress blood markers in patients with chronic back or neck pain treated with high-velocity, low-amplitude manipulation.
Kolberg C, Horst A, Moraes MS, Duarte FC, Riffel AP, Scheid T, Kolberg A, Partata WA.
J Manipulative Physiol Ther. 2015 Feb;38(2):119-29. doi: 10.1016/j.jmpt.2014.11.003. Epub 2014 Dec 5.
PMID: 25487299 [PubMed – indexed for MEDLINE] Free Article
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2. Effect of high-velocity, low-amplitude treatment on superoxide dismutase and glutathione peroxidase activities in erythrocytes from men with neck pain.
Kolberg C, Horst A, Moraes MS, Kolberg A, Belló-Klein A, Partata WA.
J Manipulative Physiol Ther. 2012 May;35(4):295-300. doi: 10.1016/j.jmpt.2012.04.010.
PMID: 22632589 [PubMed – indexed for MEDLINE]
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3. Effects of high-velocity, low-amplitude manipulation on catalase activity in men with neck pain.
Kolberg C, Horst A, Kolberg A, Belló-Klein A, Partata WA.
J Manipulative Physiol Ther. 2010 May;33(4):300-7. doi: 10.1016/j.jmpt.2010.03.002.
PMID: 20534317 [PubMed – indexed for MEDLINE]
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dr-mitch-haasDr. Mitch Haas and I discuss the dose-response relationship between chiropractic and health outcomes as well as chiropractors in public health. Dr. Haas has been an integral member of the research division at the University of Western States (UWS) since joining the faculty in 1987. He is now the associate vice president of research at UWS. Dr. Haas also serves as an adjunct associate professor in the neurology department at Oregon Health & Science University (OHSU). Dr. Haas has been either principal investigator or co-investigator on more than 30 extramurally funded grants bringing more than $7 million in research funding to UWS. In 1994, he was a co-investigator on the first federal research grant ever awarded to a chiropractic college.

Dr. Haas has since become the principal investigator (PI) for a number of large federal grants awarded by the U.S. Department of Health and Human Services (U.S.D.H.H.S.) Health and Resources Services Administration and the National Center for Complementary and Alternative Medicine at the National Institutes of Health. These collaborative projects with OHSU and other institutions were designed to evaluate pain and disability outcomes and cost-effectiveness of chiropractic and medical treatment for low back pain, a chronic pain self-management program in the elderly, the relationship of the number of chiropractic treatments with health outcomes for low back pain and headaches and care of low back pain in adolescents.

Dr. Haas has been active in state and national public health associations. He was the founding chair of the Chiropractic Healthcare Section of the American Public Health Association (APHA) and has since served as chair of the APHA Intersection Council, a governing councilor, member of the APHA Executive Board and chair of the APHA Bylaws Committee. He was also the 2007 president of the Oregon Public Health Association (OPHA).

Check out Dr. Mitch Haas’s publications on researchgate.

Here are the articles we discuss in this podcast episode:

1. Dose-response of spinal manipulation for cervicogenic headache: study protocol for a randomized controlled trial.
Hanson L, Haas M, Bronfort G, Vavrek D, Schulz C, Leininger B, Evans R, Takaki L, Neradilek M.
Chiropr Man Therap. 2016 Jun 8;24:23. doi: 10.1186/s12998-016-0105-z.
PMID: 27280016 [PubMed] Free PMC Article
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2. Dose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial.
Haas M, Vavrek D, Peterson D, Polissar N, Neradilek MB.
Spine J. 2014 Jul 1;14(7):1106-16. doi: 10.1016/j.spinee.2013.07.468.
PMID: 24139233 [PubMed – indexed for MEDLINE] Free PMC Article
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3. Cost analysis related to dose-response of spinal manipulative therapy for chronic low back pain: outcomes from a randomized controlled trial.
Vavrek DA, Sharma R, Haas M.
J Manipulative Physiol Ther. 2014 Jun;37(5):300-11. doi: 10.1016/j.jmpt.2014.03.002.
PMID: 24928639 [PubMed – indexed for MEDLINE] Free PMC Article
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4. A path analysis of the effects of the doctor-patient encounter and expectancy in an open-label randomized trial of spinal manipulation for the care of low back pain.
Haas M, Vavrek D, Neradilek MB, Polissar N.
BMC Complement Altern Med. 2014 Jan 13;14:16. doi: 10.1186/1472-6882-14-16.
PMID: 24410959 [PubMed – indexed for MEDLINE] Free PMC Article
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