Efficacy and Adverse Effects of Chiropractic Treatment for Migraines

 

By Mark Studin

William J. Owens

A report on the scientific literature

When considering care for migraines, there are a myriad of considerations; efficacy of treatment, costs to sufferers and insurers and the socioeconomic impact to individuals, business and families of those who suffer. When considering there are co-morbidities that must be considered in the quest for a “best-outcome,” avoiding any potential side effects, both with pharmacological and non-pharmacological care paths are critical. Chaibi, Benth, Tuchin and Bjorn (2017) reported “Manual-therapy [chiropractic spinal adjustments] is a non-pharmacological prophylactic treatment option that appears to have a similar effect as the drug topiramate on migraine frequency, migraine duration, migraine intensity and medicine consumption.” (pg. 66) Although previous reports indicate that chiropractic was upwards of 57% more effective (see ensuing comments), for this report, we are going to focus on the side effects of treatment, as efficacy has already been established.

Studin and Owens (2011) reported, “Nelson, Suter, Casha, du Plessis and Hurlbert (1998) reported on randomized clinical trials that took place over an 8-week course. The results showed there was minor statistical differences in outcomes for improvement during the trial period for chiropractic care and for amatriptyline and over-the-counter medications for treating migraine headaches. It was also reported that there was no statistical benefit in combining therapies. However, the major factor is that in the post-treatment follow-up period, chiropractic was 57% more effective in the reduction of headaches than drug therapy. In addition, it was reported that, with the drug group, "...58% experienced medication side effects important enough to report them. In the amatriptyline group, 10% of the subjects had to withdraw from the study because of intolerable side effects. Side effects in the SMT (Spinal Manipulative Therapy) group were much more benign, infrequent, mild and transitory. None required withdrawal from the study (Nelson et al., 1998, p. 511).

Using the 57% increased effectiveness that chiropractic has over drug therapy (leaving out the overlap that chiropractic could help without drugs) and the $24,000,000,000 ($24 billion) Americans pay for headaches and migraines, the savings would result in $13,680,000,000. back in the insurers, the public's and the government's pockets. In addition, if chiropractic reduced the necessity for emergency room visits by 57%, then the ED doctors could focus on what their primary purpose is, to save lives in urgent scenarios.”

Retrieved from: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=533:headaches-and-migraines-chiropractic-saves-federal-and-private-insurers-13-680-000-000-and-resolves-many-issues-facing-emergency-rooms-today&Itemid=320

 

Studin and Owens (2011) also reported, “Bryans, et. al. (2011) confirmed Nelson's findings and reported that spinal manipulation (adjusting) is recommended for patients with episodic or chronic migraines with or without aura and patients with cervicogenic headaches. This follow-up study is not a comparison or comment on the use of drugs. It simply demonstrates that chiropractic is a viable solution for many and can save the government and private industry billions in expenditures both in health care coverage, loss of productivity and avoidance of absenteeism in industry creating a new level of cost as sequella to headaches.” Retrieved from: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=533:headaches-and-migraines-chiropractic-saves-federal-and-private-insurers-13-680-000-000-and-resolves-many-issues-facing-emergency-rooms-today&Itemid=320

 

Chaibi, Benth, Tuchin and Bjorn (2017) reported,The results of the current study and previous CSMT (chiropractic spinal manipulative therapy) studies suggest that AEs are usually mild and transient, and severe and serious AEs (adverse effects) are rare (Tuchin, 2012; Cassidy et al., 2008, 2016). These findings are in accordance with the World Health Organization guidelines on basic training and safety in CSMT, which has considered it to be an efficient and safe treatment modality (WHO, 2005). AEs in migraine prophylactic pharmacological RCTs (random control trials) are common (Jackson et al., 2015). The risk for AEs during manual-therapy appears also, to be substantially lower than the risk accepted in any medical context for both acute and prophylactic migraine medication (Jackson et al., 2015; Ferrari et al., 2001). Non-pharmacological management also has the advantage of no pharmacological interactions/AEs because such therapies are usually mild and have a transient characteristic, whereas pharmacological AEs tend to be continuous.” (pg. 70)

Mackenzie, Phillips, and Lurie (2015) reported on the safety in general for chiropractic patients and based their study on 6,669,603 subjects and after the unqualified subjects had been removed from the study, the total patient number accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified”(Whedon et al., 2015, p. 5). This study supersedes all the rhetoric about chiropractic and stroke and renders an outcome assessment to help guide the triage pattern of mechanical spine patients.

When considering the outcomes for chiropractic care vs. drug therapy and the safety for migraine sufferers and all other types of chiropractic patients in a large population study, chiropractic should be considered the first option for both referrals from medical primary care providers and the first treatment option for the public. This validates the common-sense approach to healthcare of “drugless first, drugs second and surgery last.” Too often, society for issues that are not germane to this argument, rely on dogma for healthcare solutions often a large risk to themselves and the results affect the entire socio-economics of that person’s life.

References:

  1. Chaibi, A., Benth, J. Š., Tuchin, P. J., & Russell, M. B. (2017). Adverse events in a chiropractic spinal manipulative therapy single-blinded, placebo, randomized controlled trial for migraineurs. Musculoskeletal Science and Practice29, 66-71.
  2. Studin M., Owens W., (2010) Headaches and Migraines: Chiropractic Saves Federal and Private Insurers $13,680,000,000 and Resolves Many Issues Facing Emergency Rooms Today
  3. Nelson, C. F., Bronfort, G., Evans, R., Boline, P., Goldsmith, C., & Anderson, A. V. (1998). The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative & Physiological Therapeutics, 21(8), 511-519.
  4. Studin M., Owens W., (2010) Headaches & Migraines: Chiropractic vs. Medicine Effectiveness and Safety, Retrieved from: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=533:headaches-and-migraines-chiropractic-saves-federal-and-private-insurers-13-680-000-000-and-resolves-many-issues-facing-emergency-rooms-today&Itemid=320
  5. Bryans,
  6. Doheny, K. (2006). Recognizing the financial pain of migraines. Workforce Management, 85
  1. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270.

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Chiropractic Improves Neck Pain in a Military Veteran Population & Lowers the Need for Opiates

 

By Mark Studin

William Owens

 

A Report on the Scientific Literature

 

According to the American Academy of Pain Medicine, neck pain accounts for 15% of commonly reported pain conditions. Sinnott, Dally, Trafton, Goulet and Wagner (2017) reported:

 

Neck and back pain problems are pervasive and associated with chronic pain, disability and high healthcare utilization. Among adults 60% to 80% will experience back pain and 20% to 70% will experience neck pain that interferes with their daily activities during their lifetime. At any given time, 15% to 20% of adults will report having back pain and 10% to 20% will report neck pain symptoms. The vast majority of back and neck pain complaints are characterized in the literature as non-specific and self-limiting.” (pg. 1) 

 

The last sentence above describes why back and neck pain has contributed significantly to the opioid crisis and why our population, after decades still suffers from back and neck problems that have perpetuated. Mechanical lesions of the spine are not “self-limiting” and are not “non-specific.” They are well-defined and based upon Wolff’s Law (known since the 1800’s) don’t go away. Allopathy (Medicine) has purely focused on the pain and has vastly ignored the underlying cause of the neuro-bio-mechanical cause of the pain. 

 

Corcoran, Dunn, Green, Formolo and Beehler (2018) reported that musculoskeletal problems as the leading cause of morbidity for female veterans and females are more prone to experience neck pain than men. In addition, there has been a 400% increase in opioid overdoes deaths in females since 1999 compared to 265% for men and as a result, the Veterans Health Administration has utilized chiropractic as a non-pharmacological treatment option for musculoskeletal pain. Neck pain has also comprised of 24.3% of musculoskeletal complaints referred to chiropractors. 

 

Corcoran et. Al. also reported with chiropractic care, based upon a numeric rating scale (NRS) and the Neck Bournemouth Questionnaire (NBQ) scores, the NRS improved by 45% and the NBQ improved by 38%, with approximately 65% exceeding the minimum clinically important difference of 30%. A previous study of male veterans revealed a 42.9% for NSC and a 33.1 improvement for NBQ; statistics similar to female veterans. 

 

Although this is a very positive outcome that has helped many veterans, the percentages do not reflect what the authors have found in their clinical practices. These authors of this article (Studin and Owens) reported that for decades, cervical pain has been eradicated in 90 and 95% of the cases treated in our practices. The question begs itself, why is the population of veterans showing statistics less than half? 

 

Corcoran, et. Al. (2018) reported how the chiropractic treatment was delivered in their study:

 

The type of manual therapy varied among patients and among visits, but typically included spinal manipulative therapy (SMT), spinal mobilization, flexion – distraction therapy, and or myofascial release. SMT was operatively defined as a manipulative procedure involving the application of a high - velocity, low – ample to thrust the cervical spine. Spinal mobilization was defined as a form of manually assisted passive motion involving repetitive joint oscillations typically at the end of joint playing without application of a high- velocity, low – ample to thrust. Flexion – distraction therapy is a gentle form of a loaded spinal manipulation involving traction components along with manual pressure applied to the neck in a prone position. Myofascial release was defined as manual pressure applied to various muscles on the static state or all undergoing passive lengthening.

 

The above paragraph explains why the possible disparity in outcomes as Corcoran et. Al  do not reflect the ratios of who received high-velocity low-amplitude chiropractic spinal adjustment vs. the other therapies. When considering the other modalities; mobilization, flexion distraction therapy and myofascial release we must equate that to the outcomes physical therapist realize when treating spine as those are their primary reported treatment modalities. The following paragraphs indicate why spine care delivered by physical therapist is inferior to a chiropractic spinal adjustment, which equates to only a portion of the referenced chiropractic treatment modalities cited in the Corcoran Et. Al. The following citations conclude why these modalities provide inferior results compared to the high-velocity, low-amplitude chiropractic spinal adjustment that was exclusively used by the authors and rendered significantly higher positive outcome.


Studin and Owens (2017) reported the following:

Groeneweg et al. (2017) also stated:

This pragmatic RCT [randomized control trial] in 181 patients with non-specific neck pain (>2 weeks and <1 year) found no statistically significant overall differences in primary and secondary outcomes between the MTU (manual Therapy University) group and PT group. The results at 7 weeks and 1 year showed no statistically and clinically significant differences. The assumption was that MTU was more effective based on the theoretical principles of mobilization of the chain of skeletal and movement-related joint functions of the spine, pelvis and extremities, and preferred movement pattern in the execution of a task or action by an individual, but that was not confirmed compared with standard care (PT). (pg. 8)

Mafi, McCarthy and Davis (2013) reported on medical and physical therapy back pain treatment from 1999 through 2010 representing 440,000,000 visits and revealed an increase of opiates from 19% to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the costs for managing low back pain patients (not correcting anything, just managing it) has reached $106,000,000,000 ($86,000,000,000 in health care costs and $20,000,000,000 in lost productivity).

Cifuentes et al. (2011) started by stating:

Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used. (p. 396). The authors concluded by stating: “After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (Cifuentes et al., 2011, p. 404).

Mafi, McCarthy and Davis (2013) stated:

Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005...In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period, use of recommended treatments would increase and use of non-recommended treatments would decrease. (p. 1574)

(http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320)

The above paragraph has accurately described the problem with allopathic “politics” and “care-paths who have continued to report medical “dogma” and have ignored the scientific literature results of chiropractic vs. physical therapy.

Mafi, McCarthy and Davis (2013) concluded:

Despite self-reported overwhelming evidence where there were 440,000,000 visits and $106,000,000,000 in failed expenditures, they hypothesized that increased utilization for recommended treatment would increase. The recommended treatment, as outlined in the opening two comments of this article, doesn’t work and physical therapy is a constant verifying a “perpetually failed pathway” for mechanical spine pain. (p. 1574)


(http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320)

Despite the disparity in statistics, the literature is clear chiropractic renders successful out comes for both male and females, and the spine is not discriminatory for veterans versus non-veterans and offers a successful solution in lieu of the utilization of opiates for musculoskeletal spinal issues. In addition, the labels “non-specific” and “self – limiting” are inaccurate and have been placed by providers with no training in the biomechanics of spine care. Chiropractors has been trained in spinal biomechanics for over 100 years and currently there are advanced courses in spinal biomechanical engineering, of which many chiropractors have concluded. 

References:

  1. AAPM facts and figures on pain, the American Academy of pain medicine (2018), retrieved from: http://www.painmed.org/patientcenter/facts_on_pain.aspx#common
  2. Sinnott P., Dally S., Trafton J., Goulet J. and Wagner T. (2017) Trends in diagnosis of painful neck and back conditions, 2002 to 2011, Medicine, 96 (20), pgs. 1-6
  3. Corcoran K., Dunn A., Green B., Formolo L., and Beehler G. (2018) Changes in Female Veterans’ Neck Pain Following Chiropractic Care at a Hospital for Veterans, Complimentary Therapies in Clinical Practice 30, pgs. 91-95
  4. Studin M., Owens W., (2017) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine, Part 5 of 5, Retrieved from: http://www.uschirodirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320

 

 

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Chiropractic and Prescriptive Rights

Should Chiropractors Be Allowed to Prescribe Drugs?

 

By Mark Studin DC, FASBE(C), DAAPM, DAAMLP

 

Citation: Studin M. (2018) Chiropractic and Prescriptive Rights; Should Chiropractors be Allowed to Prescribe Drugs? American Chiropractor, 40 (3) 16, 17, 18, 19

 

As the rhetoric and legislative agendas escalate nationally on chiropractic and pharmaceutical prescriptive rights, as a profession, we need to take pause and consider the long-term effects of our actions. The question is, “Are we responsibly evolving or are we creating a problem that could put chiropractic back decades in utilization?” Please understand that this argument is totally devoid of any philosophy or beliefs in chiropractic principles or results; it is purely focused on increasing the utilization and business of every chiropractic practice in the country for the betterment of our patients.

 

Based upon an informal, but lengthy poll of many in our profession, one of the core reasons for wanting to add prescriptive rights is to help increase utilization at the practice level. The majority believe that if we could prescribe even non-narcotics, then patients would stay in our offices vs. seeking medical care for pain relief and a pro forma prescription to physical therapy with a resultant decrease in utilization of our offices. Unfortunately, that has been the national trend for far too long.

 

The question begs, “Are prescriptive rights the solution for both the chiropractic profession and our society? Over the last decade, I have been focused on increasing the level of clinical excellence of the practicing chiropractor, which has nothing to do with technique, philosophy or documentation. The level of clinical excellence has been centered on patient management, including accurately diagnosing, prognosing and triaging patients. The reason, medicine focuses on patient diagnosis and management and chiropractic has historically focused on treatment, too often bypassing rendering a thorough and conclusive diagnosis prior to rendering care. Therefore, my areas of focus are MRI spine interpretation, spinal biomechanical engineering, accident engineering, spinal trauma pathology and diagnosing spinal issues beyond subluxation.

 

 

Why concern ourselves with the medical community? The answer, quite simply, is that medical utilization is over 95% nationally and chiropractic is well below 10% and has been eroding steadily over the last decade. IF chiropractic can “tap” into that 95% and have every medical doctor in the nation consider chiropractic as the first choice for mechanical spine issues (excluding fracture tumor or infection), then we will rapidly change the culture of our society and resolve our utilization challenges rapidly. This is called “primary spine care.”

 

Over the last 10 years, I have been teaching in both chiropractic and medical academia and have cooperatively created courses in chiropractic in the above genres. As a result, the doctors who have taken these courses are getting the exact same level of education as many of our medical counterparts. The results, we are now functioning at a “peer” level that has garnered respect NOT because we get people well without drugs. That respect is because we understand spine at an extremely high level, often more so than our medical counterparts and they find themselves consulting with us on many of their more challenging cases looking for solutions. In turn, they also have been referring us many of their mechanical spine cases to manage because many medical doctors realize they are poorly equipped with nothing but drugs that are often too often addictive or end up with surgery as the only other option.

 

The primary care medical providers, medical specialists and emergency rooms that we work with nationally have expressed their gratitude for helping these patients by redirecting their care to the properly credentialed chiropractor and preventing further opiate abuse and/or the side effects of non-narcotics as well. The way they thank us is in the form of a perpetual streams of referrals. A case in point was in Cedar Park, Texas, where one of our doctors, 8 years into practice, sat with an orthopedic surgeon and discussed MRI spine interpretation. After a 1-hour conversation, the surgeon said to the doctor, “I love chiropractic; I just couldn’t find a smart enough chiropractor to trust with my referrals until now. Your knowledge of spine and MRI is equal to mine and from here forward, you will get all of my non-surgical referrals!” That doctor left with 8 referrals instantly and 1 year later has had a steady stem of referrals   . I could share similar stories from Dayton, Ohio, Buffalo, New York, America Fork, Utah, Denver, Colorado, Fair Lawn, New Jersey and dozens of other locations across the United States. The formula is working; it is reproducible and is purely based upon clinical excellence beyond adjusting!

 

 

As a note, many get angry with our chiropractic colleges for not teaching us enough…Remember, our chiropractic colleges are charged with giving us the basics to get started and they do an outstanding job in that role. I applaud them and so should you in the form of donations to their research departments. In medicine, it is no different, they get a basic education and THEN go back to school to become specialized. What you do with YOUR career after graduation is on YOU.

 

 

We now have hospital emergency departments nationally reaching out to our doctors purely based upon their curricula vitae’s (CVs) because the doctors in our program are trained in what needs to be on their CVs with the resultant knowledge base behind those credentials. AND…for clarity (unlike my former beliefs), letters after your DC are not as important as the specific citations or credentials in your CV.

 

Utilization

 

Having been involved politically at the national and state levels for quite some time, I can say with a great degree of certainty that very little healthcare legislation (chiropractic falls under this category) in this country at either level gets passed without the blessing of the medical community. By attempting to add prescriptive rights to our scope, we will be threatening the utilization of medicine on a national scale and it will potentially close many of those doors that are currently opening at a rapid rate. The medical schools and research departments that have opened their doors to chiropractic (us) have done so primarily as a possible solution to the opiate epidemic in our country and we cannot be “Pollyannaish” and say we only want to prescribe non-narcotics. It has been clearly documented that this is a well-established “gateway” to addictive narcotics as when non-narcotics fail to offer relief, those patients need something else. Chiropractic care is that “something else” for mechanical spine pain, which is in the top 10 diagnoses for both emergency rooms and primary care medical providers who often have no solution other than drugs or surgery. Medicine’s only other historical care path with regards to mechanical spine diagnosis and management is physical therapy, which renders significantly inferior outcomes for spine vs. chiropractic based upon recent literature (a topic for another article) and one where far too many patients have ended up in pain management (narcotics) as the final solution.

 

 

Currently, our profession is at a cross-road on the prescriptive rights issue and if taken, could turn out to be a “very slippery slope” that could further erode our utilization and lead to increased iatrogenic issues in our society. I empathize with those doctors clinging to hope for a “quick fix” for their individual practices. However, as outlined above, there are viable solutions for every practice in the nation with none involving “get rich quick” paradigms. As I also consult many medical providers at various levels and I can report that their prescription pads are not making them wealthy, should they practice ethically. Their utilization and income increases as they get better at what they do and in chiropractic, we are no different.

 

 

Although our paradigm for increased utilization is working through increasing our clinical excellence, we are just starting to see this happen on a larger scale and the only way to have that upward spiral go faster, is if more chiropractors realize that the only way up is though academia and a strategic plan behind your new level of clinical excellence. So please hurry because your local medical community is waiting for you with that 95% to refer.

 


 

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Chiropractic Reduces Opioid Use by 55% in Low Back Pain

 

By Mark Studin

William J. Owens

 

A report on the scientific literature  

 

In the United States, of the adults who were prescribed opioids, 59% reported back pain.1 According to Statistia, the percentage of adults in the United States in 2015 with low back pain was 29.1% (https://www.statista.com/statistics/684597/adults-prone-to-selected-symptoms-us/)  and in 2017 that number was 49% for all back-pain sufferers reporting symptoms (https://www.statista.com/statistics/188852/adults-in-the-us-with-low-back-pain-since-1997/).

 

Peterson ET. AL. (2012) reported:

 

[The] Prevalence of low back pain is stated to be between 15% and 30%, the 1-year period prevalence between 15% and 45%, and a life-time prevalence of 50% to 80%” (pg. 525). 

 

While acute pain is a normal (author’s note: pain is never normal) short-lived unpleasant sensation triggered in the nervous system to alert you to possible injury with a reflexive desire to avoid additional injury, chronic pain is different. Chronic pain persists and fundamentally changes the patient’s interaction with their environment. In chronic pain it is well documented that aberrant signals keep firing in the nervous system for weeks, months, even years. (http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm)

Baliki Et. AL. (2008) stated

 

Pain is considered chronic when it lasts longer than 6 months after the healing of the original injury. Chronic pain patients suffer from more than pain, they experience depression, anxiety, sleep disturbances and decision-making abnormalities that also significantly diminish their quality of life (pg. 1398).

 

 

Chronic pain patients also have shown to have changes in brain function in sufferers with Alzheimer’ disease, depression, schizophrenia and attention deficit hyperactivity disorder giving further insight into disease states. In addition, chronic pain has a cause and effect on the morphology of the spinal cord and the brain resulting in a process termed “linear shrinkage”, which has been suggested to cause ancillary negative neurological sequella.  

 

Apkarian Et. Al. (2004) reported that “Ten percent of adults suffer from severe chronic pain. Back problems constitute 25% of all disabling occupational injuries and are the fifth most common reason for visits to the clinic; in 85% of such conditions, no definitive diagnosis can be made.” (pg. 10410) 

 

Whedon, Toler, Goel and Kazal (2018) reported the following:

 

One in 5 patients with noncancer pain or pain related diagnosis is prescribed opioids in office-based setting… primary care clinicians account for 50% of opioid prescriptions (Pg. 1). 1 day of opioid exposure carries a 6% chance of being on opioids 1year later, increasing to 13.5% by 8 days and 29.9% by 31 days. Among drug overdoses in the United States in 2014, 28,647, 61% involved an opioid. Opioids were involved in 75% of pharmaceutical deaths in 2010 and in 2015 over 22,000 deaths involved in prescription opioids were recorded-an increase of 19,000 deaths over the previous year (pg. 2).

 

 

Perhaps a portion of this phenomena is related to the training of medical primary care providers regarding musculoskeletal conditions. Studin and Owens reported (2016):

 

Day Et. Al. (2007) reported that only 26% of fourth year Harvard medical students had a cognitive mastery of physical medicine (pg. 452). Schmale (2005) reported “Incoming interns at the University of Pennsylvania took an exam of musculoskeletal aptitude and competence, which was validated by a survey of more than 100 orthopaedic program chairpersons across the country. Eighty-two percent of students tested failed to show basic competency. Perhaps the poor knowledge base resulted from inadequate and disproportionately low numbers of hours devoted to musculoskeletal medicine education during the undergraduate medical school years. Less than 1⁄2 of 122 US medical schools require a preclinical course in musculoskeletal medicine, less than 1⁄4 require a clinical course, and nearly 1⁄2 have no required preclinical or clinical course. In Canadian medical schools, just more than 2% of curricular time is spent on musculoskeletal medicine, despite the fact that approximately 20% of primary care practice is devoted to the care of patients with musculoskeletal problems. Various authors have described shortcomings in medical student training in fracture care, arthritis and rheumatology, and basic physical examination of the musculoskeletal system (pg. 251).  

 

With continued evidence of lack of musculoskeletal medicine and a subsequent deficiency of training in spine care, particularly of biomechanical orientation, the question becomes which profession has the educational basis, training and clinical competence to manage these cases?  Let’s take a closer look at chiropractic education as a comparison. Fundamental to the training of Doctor of Chiropractic according to the American Chiropractic Association is 4,820 hours (compared to 3,398 for physical therapy and 4,670 to medicine) and receive a thorough knowledge of anatomy and physiology. As a result, all accredited Doctor of Chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. So important to practice are these courses that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education requires a curriculum which enables students to be “proficient in neuromusculoskeletal evaluation, treatment and management.” In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. As a result, students are afforded the opportunity to practice utilizing this basic science information for many hours prior to beginning clinical services in their internship.

 

http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=320

 

Whedon, Toler, Goel and Kazal (2018) continued:

 

Recently published clinical guidelines from the American College of Physicians recommended nonpharmacological treatment is the first – line approach to treating back pain, with consideration of opioids only is the last treatment option or if other options present substantial harm to the patient. Recent systematic review and meta-analysis found that for treatment of acute low back pain, spinal manipulation provides a clinical benefit equivalent to that of an NSAID’s, with no evidence of serious harm. Spinal manipulation is also shown to be an effective treatment option for chronic low back pain (pg. 2).

 

A retrospective claims study of 165,569 adults found that utilization of chiropractic services delivered by Doctor of Chiropractic was associated with reduced use of opioids. More recently, it was reported that the supply chiropractors as well as spending on spinal manipulative therapy is inversely correlated with opioid prescriptions in younger Medicare beneficiaries. This finding suggests that increased availability and utilization of services delivered by Doctor of Chiropractic could lead to reductions in opioid prescriptions. It has been reported that services delivered by Doctor of Chiropractic may improve health behaviors and reduced use of prescription drugs… Pain management services provided by Doctor of Chiropractic may allow patients use lower less frequent doses of opioids, leading to lower costs and reduce risk of adverse effects loops getting together (pg. 2).

 

Although chiropractic has been clinically reporting for over 100 years positive outcomes for a vast array of conditions inclusive of low back pain the American Medical Association (AMA) has been a significant opponent historically. Although the AMA’s position has been well chronicled through lawsuits such as Wilk v. American Medical Association, 895 F.2d 352 (7th Cir. 1990)

(https://openjurist.org/895/f2d/352/wilk-dc-dc-dc-dc-v-american-medical-association-a-wilk-dc-w-dc-b-dc-b-dc), in 2017 it appears they have reversed their position. In the August 2017 Journal of the American Medical Association’s “Clinical Guideline Synopsis for Treatment of Low Back Pain” under the heading MAJOR RECOMMENDATIONS, spinal manipulation is recommended as a first – line therapy, with a strong recommendation. As the AMA did not list Chiropractic specifically and based upon clinical guidelines of other highly regarded medical institutions such as the Cleveland Clinic and the Mayo Clinic, physical therapy is probably high on their list as first-line of referral for spinal manipulation (This is a  topic for another article and nomenclature utilized by chiropractic). When considering the treatment of mechanical spine issues comparatively between chiropractic and physical therapy the outcomes are overwhelmingly in chiropractic’s favor as reported by Studin and Owens (2017)

 

Mafi, McCarthy and Davis (2013) reported on medical and physical therapy back pain treatment from 1999 through 2010 representing 440,000,000 visits and revealed an increase of opiates from 19% to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the costs for managing low back pain patients (not correcting anything, just managing it) has reached $106,000,000,000 ($86,000,000,000 in health care costs and $20,000,000,000 in lost productivity). 

 

Mafi, McCarthy and Davis (2013) stated:

Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005...In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period, use of recommended treatments would increase and use of non-recommended treatments would decrease. (p. 1574)

 

The above paragraph has accurately described the problem with allopathic “politics” and “care-paths.” Despite self-reported overwhelming evidence of chiropractic vs. physical therapy outcomes for spine, where there were 440,000,000 visits and $106,000,000,000 in failed expenditures, they hypothesized that increased utilization for recommended treatment would increase. The recommended treatment, as outlined in the opening two comments of this article, doesn’t work and physical therapy is a constant verifying a “perpetually failed pathway” for mechanical spine pain.

 

http://uschiropracticdirectory.com/index.php?option.com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320

 

Whedon, Toler, Goel and Kazal (2018) reported the concluded:

In 2013, average annual charges per person for filling opioid prescriptions were 74% lower among recipients compared with non-recipients (author’s note: recipients are referring to those patients receiving chiropractic care). For clinical services provided at office visits for low back pain, average annual charges per person in 2013 were 78% lower among recipients compared with non-recipients. The authors have similar between – Cohort differences in charges in 2014: annual charges per person were 70% lower with opioid prescriptions and 71% lower for clinical services among recipients compared with nonrecipients. The Adjusted likelihood find prescription for the opiate analgesic in 2014 was 55% lower among recipients compared with nonrecipients.

 

…the Adjusted likelihood of filling a prescription opioid analgesic was 55% lower for recipients of services provided by Doctor of Chiropractic compared with non-recipients (pg. 4)

 

The above reports evidenced based outcomes verifying chiropractic must be considered as the first-line of referrals, or Primary Spine Care Providers for mechanical spine diagnosis (no fracture, tumor or infection). The evidence also reveals that chiropractic outcomes exceed those of physical therapy and medicine for mechanical spine diagnosis. Unfortunately, it has taken 10,000’s of opioid related deaths to bring chiropractic to the forefront and start to eradicate the medical dogma against chiropractic and consider chiropractic as the 1st referral option for spine.

 

 References:

 

  1. Hudson, Teresa J., Edlund, Mark J., Steffick, Diane E., Tripathi, Shanti P., Sullivan, Mark D. (2008) Epidemiology of Regular Prescribed Opioid Use: Results from a National, Population-Based Survey Journal of Pain and Symptom Management, 2008, Vol.36(3), pp.280-288
  2. Percentage of adults in the U.S. with low back pain from 1997 to 2015 (2018) retrieved from:https://www.statista.com/statistics/188852/adults-in-the-us-with-low-back-pain-since-1997/
  3. Percentage of adults in the U.S. who were prone to select symptoms as of 2017 (2018), Retrieved from: https://www.statista.com/statistics/684597/adults-prone-to-selected-symptoms-us/
  4. Whedon J., Toler A., Goehl J., Kazal L. (2018), Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Use of Opioids, The Journal of Alternative and Complementary Medicine, 2018 Feb 22. doi: 10.1089/acm.2017.0131. [Epub ahead of print]
  5. Treatment of Low Back Pain, Wenger H., Cifu A., (2017) Treatment of Low Back Pain, Journal of the American Medical Association, 318 (8) pages 743-744
  6. Studin M., Owens. W., (2016), Chiropractic vs. Medicine: Who is Most Cost Effective and Renders Better Outcomes for Spine? Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=320
  7. Whedon J., Toler A., Goehl J., Kazal L. (2018), Association Between Utilization of Chiropractic Services for Treatment of Low Back Pain and Use of Opioids, The Journal of Alternative and Complementary Medicine, 2018 Feb 22. doi: 10.1089/acm.2017.0131. [Epub ahead of print]
  8. Treatment of Low Back Pain, Wenger H., Cifu A., (2017) Treatment of Low Back Pain, Journal of the American Medical Association, 318 (8) pages 743-744
  9. Studin M., Owens. W., (2016), Chiropractic vs. Medicine: Who is Most Cost Effective and Renders Better Outcomes for Spine? Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=320
  10. Wilk vs. American Medical Association, Retrieved from: https://openjurist.org/895/f2d/352/wilk-dc-dc-dc-dc-v-american-medical-association-a-wilk-dc-w-dc-b-dc-b-dc
  11. Studin M., Owens. W., (2017), The Mechanism of the Chiropractic Spinal Adjustment /Manipulation: Chiropractic vs. Physical Therapy for Spine, Part 5 of a 5 Part series (2017) Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=758:chiropractic-vs-medicine-who-is-more-cost-effective-renders-better-outcomes-for-spine&Itemid=32

 

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Case Report: Establishing the Efficacy for Trauma Trained Chiropractors as Primary Spine Care Physicians

Donald A. Capoferri, D.C., DAAMLP

Abstract: The objective of this case report is to explore the use of chiropractic and chiropractors as a primary spine care specialty and the efficacy of early referral to a properly trained and credentialed chiropractor. Diagnostic studies included physical examination, radiographic examinations, cervical, thoracic, and lumbar spine MRI studies and brain MRI study.  Treatments included non-surgical axial decompression and low-level laser treatments. Once a clinical examination and diagnosis was formed, a favorable prognosis was expected. With appropriate chiropractic management, the outcome proved excellent in pain reduction and had minimal effect on the numbness and weakness of the patient’s left upper and lower extremities.

Key Words: Disc herniation, syringomyelia, multiple sclerosis, disc bulge, demyelination.

Introduction: On 8/23/2017, a 49-year-old female presented for examination and treatment of chronic left sided lumbar spine pain that began on 8/1/1983 after a slip and fall incident. The pain was described as sharp, burning, and deep with radiation into the back of the left leg with an 8 out of 10 on the VAS (visual analog scale) scale, worsening since its onset.

Other Presenting Concerns: The patient also presented with sub-acute chest pain with radiation into the left upper arm.  She described the pain as 8 out of 10 and has stayed the same since 7/1/2017 and is of unknown origin. The patient also reported numbness and tingling of the left lower extremity since 7/1/2017 of unknown origin.  The final reported complaint was numbness and tingling of the left lower arm since 7/1/2017 that seems to start in the left upper back and shoulder and travels to the left lower arm rated at 8/10 on the VAS scale.  The reported symptoms have made sleeping and staying asleep, bending over, using a computer, and concentrating very difficult.

Prior Treatments: Medical care including orthopedic specialist, neurology with prescription medications, chiropractic care, and physical therapy.

Past Medical History: The patient’s past history includes use of prescription and over the counter medications. Surgical history includes tonsils and adenoids in 2008, wisdom tooth extraction in 1990, partial hysterectomy in 2002 and C-section in 1998.  The family health history includes Alzheimer’s disease, anemia, arthritis, diabetes, heart disease, and high blood pressure.

Clinical Findings: The patient presents as a 49-year-old female of average build, clean and neat and well groomed. The vitals are: Height: 61 inches, Weight: 168 lbs, Pulse: 74 bpm, BP: 168/117 mm/Hg in left arm. The patient’s appearance is visibly uncomfortable and restless.

Physical Findings:  Palpation of the paraspinal musculature revealed moderate to severe spasms on the left neck, upper thoracic, and lumbosacral regions.  Orthopedic testing produced pain and dizziness with foraminal compression. Upper thoracic pain with Soto Hall’s test and Sternal compression produced pain on the left anterior chest. Percussion test produced pain in the upper thoracic spine.

Neurologic Testing: Diminished right patella reflex and 3/5 weakness of the left deltoid muscle group and left hamstring muscle group with hypersensitivity to light touch along the C6, C8, T1, L3, L4 and L5 dermatomes were the only positive neurologic findings.  All other tests are within normal limits. Digital muscle testing was ordered following up on the initial manual findings of muscle weakness.  The results were profound left sided deficits in the upper and lower extremities; deltoids 35% weaker than right side, left biceps 68% weaker than right, left triceps 26% weaker than right, wrist extensors 47% weaker than right.  The left hamstring group was 25% weaker than right, left quadriceps 40% weaker than right, left anterior tibialis 44% weaker than right.

Radiographic Findings: I personally reviewed cervical spine and thoracic spine x-rays taken on 8/14/17 and found the following: A severe loss of the cervical lordosis, translation of C3 on C4, C4 on C5 in extension.  T3 is laterally flexed on T4 with body rotations to the left of T3, T4, and T5. A bifid spinous is noted of C6. Mild posterior osteophyte is noted on C3 and C4.  Lumbar x-rays taken on 8/23/2017 revealed pelvic unleveling with right inferiority, anteriority of L5 on S1, an inferior Schmoral’s node on L5 and mild demineralization, disc degeneration and joint degeneration of the lumbar spine.  Moderate to severe foraminal encroachment of L4/L5, L5/S1 is noted. 

MRI findings by radiologist:

Cervical spine:  MRI taken at 2.5 mm slice thickness, with gradient echo and STIR studies revealed C4-C5 right paracentral herniated disc measuring 2 x 3 mm not indenting the cord.  A small syrinx of the cord is noted at level of C6-C7 interspace and extending above and below for a total of 15mm in length and 2mm in width. (Fig. 1A) (3)

Thoracic Spine:  MRI taken at 3.0 mm slice thickness, angled to the disc with STIR and T2 axial views revealed a T4-T5 central protrusion measuring 2 x 4 mm in size in the midline.

Lumbar Spine:  MRI taken at 3.0 mm slice thickness, angled to the disc with STIR and T2 Axial views. L5/S1 demonstrates a central disc herniation with annular tear measuring 3x 6 mm indenting the epidural space and very mildly touching the thecal sac.

I personally reviewed the MRI studies and my impression is as follows:

Cervical spine also demonstrated a C3-C4 disc bulge compressing the thecal sac and deforming the normal shape of the cord by altered CSF pressure. (Fig. 1B) (1).  C5-C6 demonstrates a central protrusion with annular tear compressing the ventral cord in the midline by altered CSF pressure. 

In addition to the radiologist findings, the thoracic study demonstrated significant facet arthritis at the level of T10 that indents the thecal sac and compresses the left posterolateral aspect of the cord. (Fig. 2.) In addition to the radiologist’s findings, I reviewed the lumbar spine and reported an L4-L5 left asymmetric bulge with compression of the left aspect of the thecal sac. (1)

MRI Discussion: After review of the clinical examination findings, the patient’s subjective complaints and the X-ray and MRI imaging studies, the findings were reported to the patient.  I subsequently ordered a brain MRI since I did find an adequate explanation of the left sided sensation and motor deficits. The brain MRI demonstrates a right frontal/parietal subcortical white matter demyelinating lesion in T2/FLAIR images. (Fig 3).

 Fig. 1A: Shows a demyelination of the central cord assessed as a syrinx by radiologist

Fig. 1B:  C3-C4 disc bulge, thecal sac compression, deforming the cord shape and apparent CSF in the central canal of the cord.

Fig. 2:  T10 left facet arthritis indenting the thecal sac and compressing the left posterolateral cord.

Fig. 3:  T2/FLAIR shows left frontal / parietal area of demyelination

Diagnostic Impression: When arriving at a diagnosis all objective findings along with subjective complaints should be considered.  When I considered the profound left sided sensory and motor deficits, the clinical findings and the imaging findings I referred the patient to a neurologist for evaluation of late onset multiple sclerosis. (3) The patient consulted the lead Neurologist in the M.S. Department at Shepard Center in Atlanta who confirmed the diagnosis.

Therapeutic Focus and Assessment: At the report of findings it was explained to the patient that she did have spinal findings that were treatable and that did contribute to her pain.  It was further explained that the care provided is not expected to affect the symptoms that are caused by the M.S. condition.  An 8-week course of non-surgical axial decompression was completed, aimed at reduction of the C3-C4, C4-C5, C5-6, L4-L5 and L5-S1 disc displacements.  At discharge, the patient reported a 90% reduction of spine pain and improvements of the left sided upper and lower extremity weaknesses. She was discharged into the care of her neurologist at that time.

Discussion: Properly trained chiropractors are the perfect fit to be the primary spine care provider. Our education includes extensive training in identifying biomechanical and anatomical lesions of the spine in order to arrive at an accurate diagnosis, prognosis and treatment plan.  This includes proper triage to other healthcare providers. 

In this case the patient presented with a biomechanical issue, disc herniation and degeneration, with facet arthritis, but also with a significant non-spinal pathology that was identified properly and referred appropriately. 

Numerous other physicians and chiropractors evaluated this patient, all of whom treated the obvious without finding the underlying cause of her numbness and weakness, which may have delayed necessary care. A Doctor of Chiropractic, who is well trained and credentialed as a Primary Spine Care physician knows to look beyond the obvious, taking all findings and patient subjective complaints into consideration in order to obtain a proper diagnosis, prognosis, and appropriate plan of treatment for each patient.

  • All identifying information has been removed from this report
  • There is no conflicts of interest in producing this report

References:

1. Fardon DF, Williams AL, Dohring EJ, Murtagh FR, Gabriel Rothman SL, Sze GK. Nomenclature 2.0 for Disc PathologySpine J. 2014 Nov 1;14 (11):2525-45.doi: 10.1016/j.spinee.2014.04.022. Epub 2014 Apr 24. 

2. Schippling S. Neurodegener Dis Manag.  MRI for multiple sclerosis diagnosis and prognosis. 2017 Nov;7(6s):27-29.  doi: 10.2217/nmt-2017-0038

3. Pillich D, El Refaee E, Mueller JU, Safwat A, Schroeder HWS, Baldauf J.  Syringomyelia associated with cervical spondylotic myelopathy causing canal stenosis. A rare association.

Neurol Neurochir Pol. 2017 Nov - Dec; 51(6): 471-475. doi: 10.1016/j.pjnns.2017.08.002.Epub 2017 Aug 14.

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Chiropractic

Primary Spine Care

A mandatory “future trend” for chiropractic success that has already begun

By Mark Studin

William J. Owens

Primary Spine Care has been proven in the market place as chiropractic’s future and the instrument to increase our utilization. Primary Spine Care simply means that the chiropractor is the first referral option for mechanical spine issues short of fracture, tumor or infection. After 10 years of development and 4 years of market testing, this paradigm has been released nationally and has far exceeded our expectations based upon the dramatic increased utilization of chiropractic services nationwide from private practice to hospitals.   If you are committed to being “the best-of-the-best” through clinical excellence, you can still create a leadership position in your community for both you and your practice with not losing sight that this is happening, with you or without you, and if you are not out in front you will potentially be forever behind. 

Insurers are scrambling to “corner the market” using the lure of primary spine care.  In the end, this is just another plan to further limit your reimbursements; it is “managed care in sheep’s clothing”. Hospitals are also devising primary spine care schemes to dupe you into becoming one of their devoted “minions” into a 1-way referral pattern; with you referring into THIER system while avoiding referring into YOURS. Chiropractic academia is also struggling to catch the primary spine care trend, while their true mandate is to prepare our future doctors of chiropractic to pass national and state boards.  Our politicians and political organizations have realized they are also significantly behind this trend and are reaching “inward” in a hope for someone within the organization to try to take a leadership position. Although our political organizations are vocally touting their ability to grow chiropractic, we can see historically the opposite is true.  Our profession has thought leading with politics was the answer and that path would finally deliver chiropractic into the mainstream, however, based upon published evidence, that approach has proven to deliver relatively stagnant growth as reported by Adams et. Al (2017).  Adams states chiropractic utilization to be 8.4% of the population. It was also reported that 35.2% of the United States population takes over the counter drugs and 23.2% takes prescription medications for the same conditions that respond favorably to chiropractic care. The disparity in utilization of drugs vs. chiropractic care underscores that our global approach to the promotion of chiropractic care is failing, and it can no longer be “business as usual.”

One of the fastest growing trends in healthcare today, is defining who should be considered a “Primary Spine Care Practitioner.” There is a myriad of factors to consider and the timing, based upon a “Best Practice/Evidence Based  Models” (consisting of the scientific literature, patient feedback/expectations and the doctors experience) is perfect for chiropractic to take its place as the leading profession in this critically important niche.  As a society, we are failing to provide adequate spine care.  One of the issues that inevitably occurs when there is a trend catching everyone’s attention, is the rise of the “fly by night, get rich quick, self-proclaimed gurus” that cut corners behind the scenes, but gives you the perception that they are true leaders.  Our profession has a significant history of this occurring, particularly in the managed care arena and we are seeing it starting to happen within the contemporary Primary Spine Care Practitioner trend.  We wanted to provide insight on what is occurring from our unique position, which combines both chiropractic and medical academia and clinical practice.  We would like to outline the critical factors to consider so you can prepare to effectively participate and leverage this important trend in healthcare to your private practice.  The end result; increase utilization (you are busier).

The following should be considered a guide to your path to success in Primary Spine Care and WHO to participate WITH and WHO to AVOID.

TRACK RECORD OF SUCCESS

One of the most important aspects of evaluating a Primary Spine Care training program, or even taking advice at the academic, political or consulting end is determining whether the program and its instructors are coming from a position of success.  Do they present with a proven track record or are they are simply capturing a trend and experimenting with you and your practice?  Consider the reality television show The Shark Tank, a show which has billionaire investors investigating companies that want them to invest in their products or services. The Sharks have a simple rule, which is an underlying theme of the show, what has the “wannabe” business PRODUCED in revenue or success PRIOR to a Shark considering investing their personal money? If the answer is little or none, then the Shark passes since speculation rarely leads to profit. Too many Primary Spine Care “guru’s” promote a pathway to success, but have not achieved any significant level of expertise or track record in filling offices in a profitable scenario. These are the groups that have so called “friends” on the inside and at first glance seems impressive, but as you dig deeper into their past successes they come up empty.  It is important to not enter a training program that needs YOU to grow, that is a recipe for failure, frustration and no return on your investment.  We suggest asking how many chiropractors are currently in the program and how may referrals they have to date in their system [most do not keep track for obvious reasons] and GET references.  Facts are facts and not rhetoric and no matter how “sexy” a program appears, it means nothing if it doesn’t work.  This is the difference between an experimental process and a real program achieving real results.  Don’t be the experiment.

CHIROPRACTIC FIRST

Secondly, we want to caution you to make sure every Primary Spine Care program is putting chiropractic first.  We suggest asking if the program is chiropractic centric or does it concurrently invite physical therapists as Co-Primary Spine Care Providers?  It has long been discussed and demonstrated [CLICK HERE FOR VERIFICATION] that the scientific literature has concluded that chiropractic care for spine is superior to that of physical therapy at many levels including pain management and in the reduction of recurrent disability. 

Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) reported:

The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation. These differences raise concerns regarding the useof physiotherapists as gatekeepers for the worker’s compensation system. (pg. 388)

Programs that include physical therapy are brining chiropractic down to a level that will not ensure your success as the outcomes are far less effective than a chiropractic spinal adjustment as evidenced in the paragraph above. Physical therapy has its place in spine care, but not first. It is our experience that a program who offers both chiropractic and physical therapy as primary spine care will do this to ensure the profit of the program and NOT YOU. We also firmly believe this creates a public healthcare risk by supporting poorer outcomes, which feed the current opiate epidemic by mismanaging mechanical spine patients. In the end, this will create a perception that chiropractic and physical therapy are equal.  Nothing could be farther from the truth and nothing could be more dangerous to the public and your long-term success.  Only consider a Primary Spine Care program that is chiropractic only.

MANAGED CARE IN DISGUISE

This is one of the most negative aspects of the current Primary Spine Care trend and one that we see happening more and more each week. There are groups in our profession that are promoting the Primary Spine Care concept not to help chiropractic, but to “sell” chiropractic to insurance carriers or hospitals under the umbrella of third party administrators or managed care. This type of focus is NOT in the best interest of chiropractic and does not have your practice’s best interests in mind or the chiropractic profession (for verification, see all the current managed care models that allow 8 or 10 visits at a severely reduced fee, where most have chiropractors controlling your practice and paycheck).  Insurance carriers are not ignorant, they realize the benefits of using chiropractic care and coverage is expanding in these plans, however there are those in our profession that continue to insert themselves between hardworking chiropractors and the insurance carriers.  This is a veiled attempt to create a “network” of doctors that they can sell to the highest bidder.  These “middle men” even promise doctors in their group a steady stream of patients, but in the end, it is an empty promise or worse… you get a lot of patients at such a reduced rate that paying your bills is challenging.  Don’t let this happen to you and your practice. Enriching others at the expense of your practice and your family is not a recipe for success.  We suggest reviewing ALL the directors of ALL programs you are considering and if there is ANY indication that they had consulted with insurance carriers, worked for managed care companies or are significant players in the independent examination world…RUN.  Many are now getting astute and realizing that chiropractors have been taken advantage of for too long, so they leave these things off their CV or Resume.  We suggest searching GOOGLE and Social Media, many have digital trail and an employment track record that can be uncovered.  This is occurring faster and more obviously than previously thought…don’t be taken advantage of, consider WHY the program was created and to whom the money flows. 

HOSPITAL ILLUSIONS

One of the more “sexy” portions of working as a Primary Spine Care Provider is the hospital component.  Since doctors of chiropractic have historically worked outside of the mainstream health system, it continues to be relatively rare for DCs to be included in hospital groups.  Fortunately, hospitals are working with doctors of chiropractic more than ever before, however many of the chiropractors that are leading the way are simply being taken advantage of by the system.  Most chiropractors don’t know it is occurring, while hospitals are “selling” YOU on perceived success in breaking into their system.  In the end, it is just a house of cards and will do nothing to move you or your practice forward.  When working with the hospitals as a Primary Spine Care Provider, the point is that THEY REFER TO YOU as the first option for mechanical spine issues. If the hospital is excited to receive referrals FROM you instead of referring TO you…RUN.  Hospitals not referring to chiropractic as a first choice for spine is NOT a Primary Spine Care Program, it is an enrichment program for the hospital and the consultant that is promoting or selling the program.  Caveat Emptor!!! Do your homework first and do not fall into the trap of being put on a list, having access to doctors in the hospital and having an open line of communication with doctors you refer to… you already have that! A true Primary Spine Care Program ALREADY has established, or will give you the pathway for referrals INTO YOUR office.   Anything other than that is to suck you into the hospital system to get your referrals. Never lose sight that chiropractic is big business for many hospitals and they will do anything to get your business and not give an inch to allow you a piece of theirs. The tide is turning with many hospitals bringing chiropractic on staff, changing by-laws to create chiropractic inclusion into their system and realizing that the best business model is the chiropractor as the first referral option and keep everything else in-house.   Make sure you are creating or entering the right system, a REAL Primary Spine Care Program will teach you that and show you how it has been done in other areas of the country.

ACADEMIC AND CLINCIAL BASIS

In the chiropractic world, there are two places that a program can evolve FROM and two places that it is governed BY.  The program can evolve FROM either an Academic or a Clinical perspective and it can be governed BY either Academics or Politics.  These are very important points to consider.  First, when a program is buried in Academics, although it may be perceived as having state of the art information, it is often built and run from predominantly a theoretical perspective.  This is a prime example of a “it looks good on paper” program, which has not had any real measure of clinical success in the marketplace.  Secondly, when a program is developed and run by clinicians there is often a narrow-sited approach that is missing what the literature provides and not understanding the trends in the industry.  Many times, the clinicians are lacking significant post-graduate training on MRI, Spinal Biomechanical Engineering and triage protocols which ultimately will make the program ineffective or focus on one aspect too heavily. This is at the expense and ultimately the success of your practice. Another alarming trend is when politics drives the process. It is our observation over the last 4 decades that politics typically drives patients and income to those who are in control of the political process and their “friends.” Typically, the rest of the profession, no matter how hard they try, work or get better, simply can’t participate as the system has been designed for so few. In addition, politics in our profession has been controlling too much and has crossed the lines too often in our academic process; they should support academia, not lead it . The “politics first” approach has lead us to an 8.4% utilization in the United States when failing spine care is epidemic nationally and with so many patients suffering, all chiropractic offices should be on a waiting list.

When we consider how a program is governed, the options are either academia or politics and as stated above, politics should support academia, not drive it and the success of a Primary Spine Care program is a perfect example. Politics cannot drive it, there must be a mix of significant post-doctoral (graduate level) formal training and a long history of success in this paradigm.

It can no longer be business as usual, your success and future depend on it.

THE SOLUTION

The perfect solution is a blend of meaningful post-doctoral (graduate level) formal training and clinical practice with a track record of success. Politics as previously stated is there to support the process, not drive the process.  Historically the old way of doing things is not working based upon the 8.4% of our current utilization. Investigate the qualifications and experience of who you are listening to and who you choose to follow, and a blend of academia and successful clinical experiences is the perfect solution. This can be verified by demanding to inspect the Curriculum Vitae of all involved and then scour both Google and social media as previously suggested.     

After 10 years of researching the infrastructure of primary spine care and 4 years of market testing in figuring out HOW to make it work in every chiropractic office in the world, we have ALREADY gotten 711,434 (as of 1-26-2018) referrals INTO chiropractic practices in 47 states from lawyers, primary care medical providers, medical specialists, urgent care centers and emergency room. I also want to report, that this number is an approximate, where the actual number is significantly higher, but that is all we can safely verify. It is this number that would make the “Sharks” happy because it already works, and YOU are not the market research or the EXPERIMENT. It was done with your clinical excellence, a best practice model inclusive of the literature and a business plan that includes medical primary care providers, medical specialists, urgent care centers, hospital emergency rooms and lawyers.

Right now, you are still at the beginning of this “Wave” [or future trend] and you do not have to change how you treat your patients, how you adjust or whether you believe in subluxation or purely a pain model. All you HAVE to do is work within your lawful scope of practice as set forth by your state and get smarter with a business plan to educate your referral sources, so THEY RUN AFTER YOU. Truthfully, that is the easiest part.

References:

  1. Adams, J., Peng, W., Cramer, H., Sundberg, T., Moore, C., Amorin-Woods, L., & Lauche, R. (2017). The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey. Spine42(23), 1810-1816.
  2. Studin M., Owens W. (2016) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine, Retrieved from: http://uschiropracticdirectory.com/index.php?option=com_k2&view=item&id=822:the-mechanism-of-the-chiropractic-spinal-adjustment-manipulation-chiropractic-vs-physical-therapy-for-spine-part-5-of-a-5-part-series&Itemid=320
  3. Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation27(3), 382-392.
 

Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport College of Chiropractic, an Adjunct Professor at Cleveland University-Kansas City College of Chiropractic, an Adjunct Professor of Clinical Sciences at Texas Chiropractic College and a Graduate Medical Clinical Presenter for the State of New York at Buffalo, Jacobs School of Medicine for post-doctoral education, teaching MRI spine interpretation, spinal biomechanical engineering and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www.DoctorsPIProgram.com), teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally and studies trends in healthcare on a national scale (www.TeachDoctors.com). He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it.">This email address is being protected from spambots. You need JavaScript enabled to view it. or at 631-786-4253. 

 

Dr. Bill Owens is presently in private practice in Buffalo NY and generates the majority of his new patient referrals directly from the primary care medical community.  He is an Associate Adjunct Professor at the State University of New York at Buffalo Jacobs School of Medicine, an Adjunct Professor at Cleveland University-Kansas City College of Chiropractic, an Adjunct Assistant Professor of Clinical Sciences at the University of Bridgeport, College of Chiropractic and an Adjunct Professor of Clinical Sciences at Texas Chiropractic College.  He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it. or www.mdreferralprogram.com or 716-228-3847  

 

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Friday, 29 December 2017 17:24

Chiropractic Verified as Primary Spine Care Providers

Written by

Chiropractic Verified as

 Primary Spine Care Providers

By Mark Studin

William J. Owens

A report on the scientific literature 

 

Primary Spine care simply means being the first referral option for spine care in instances other than fracture, tumor or infection. Having a chiropractic degree is paramount and the first step in the process, but one must not forget that any doctoral training, no matter the specialty (i.e. medicine, dentistry, podiatry, etc.) is the start of a provider’s educational journey and what we do with that training is up to the doctor in clinical practice. Erwin, Korpela and Jones (2013) stated “The function of the PSCP (Primary Spine Care Provider) could easily be assumed by chiropractic, but this window of opportunity may be limited. If chiropractic does not seek to evolve, what role does chiropractic have left to perform.” (Pg. 289)

 

Although these authors agree that chiropractors in clinical practice can assume the role as PSCP’s in the healthcare system, we strongly disagree with the direction suggested by Erwin, Korpela and Jones. The solution is not to prescribe more drugs in an “already over-drugged society,” the solution is being able to manage the patient in a collaborative environment on a peer level being “expert” on common healthcare issues. The underlying tenant is that there is no drug for a mechanical problem, it is with that initial focus that allows chiropractic to assume a role that no other profession can accomplish.  True PSCP management includes being able to accurately diagnose/triage patients and the ability to use and understand MRI is a prime example. Herzog, Elgart, Flanders and Moley (2017) reported a 43.6% error rate of general radiologists inaccurately reporting the morphology of the intervertebral disc. This underscores that when a doctor of chiropractic relies on the MRI report without understanding how to interpret the image and clinically correlate the findings to the patient’s symptoms, there is close to a 50% error rate in rendering an accurate diagnosis, prognosis and treatment plan.  A PSCP must have a complete and independent diagnostic scope of practice in order to fill a useful and clinically significant role.

 

To use an example in a current and modern setting, a doctor of chiropractic in Cedar Park, Texas was granted a “brief 10-minutes” to meet with an orthopedic surgeon. During that short meeting the chiropractor, an 8-year graduate spoke solely and specifically of his MRI slice thickness protocols and his MRI interpretation training which is cross-credentialed in both chiropractic and medical academia. One hour later [the meeting continued well past the initial “10-minutes” suggested], the orthopedic surgeon said, “I respect chiropractic, but have very little respect for the level of training of chiropractors in our region.” This 8-year graduate walked out with 8 referrals instantly and now 1 year later, has been getting referrals weekly. That is very definition of Primary Spine Care, the orthopedic surgeon trusts the chiropractor’s ability to manage and diagnose patients and now is “off-loading” the non-surgical patients to someone that can effectively manage that case.  It is because of this specific advanced training that the chiropractor is successful.

 

In a second recent example, in Utah, a chiropractor decided that his post-doctoral training should be focused on spinal trauma care and triage, including more specifically, MRI Spine Interpretation, Spinal Trauma Pathology, Spinal Biomechanical Engineering and Stroke Evaluation. As a result, a hospital system that has over 900 auto accident cases monthly in 5 local hospitals reached out to him to manage their spine cases (all of them).  This was based purely on his curriculum vitae and the inherent credentials and knowledge base from his continued education training in the above courses. Since then, Brigham Young University’s Athletic Department and the PGA (Professional Golf Association) have both sought his services. Please don’t overlook the fact THEY ran after him to be their first option for spine; that is Primary Spine Care and credentials matter.

 

 

Thirdly, in Buffalo NY, 5 teaching hospitals refer exclusively to one chiropractor’s office and their emergency rooms refers close to 60 spine patients per month to him with that number growing steadily. This past week, the neurosurgical department just informed this doctor that their 23 neurosurgeons will be referring their non-surgical cases to this office and will be directing many of their referral sources to START with this doctor to screen for surgery and let him decide who to refer for surgical consultation. That is Primary Spine Care.

 

 

Although individual reporting does not make a trend in the profession, these are not isolated cases, and this is NOW THE TREND in chiropractic we are seeing nationally, there are similar stories in most states. None of the successes involve adding drugs as a tool of the chiropractic, however in every case becoming smarter in spine care was mandatory.  In all cases it is a properly trained doctor of chiropractic that is leading Primary Spine Care alongside medical specialty and primary care in a collaborative environment as peers, when clinically indicated. 

 

 

Most of the Primary Spine Care “equation” is verifying chiropractic care as the “best choice” for the “first referral”.  That is being achieved though peer-reviewed outcome based studies and involves all phases of care starting with initial pain management to corrective spine care and finally when required, health maintenance care for cases that need non-opioid and non-surgical long-term management. Historically and all too frequently in current medicine, either medical management or physical therapy is considered for mechanical spine issues as the first treatment of choice. Cleveland Clinic, one of the better-known centers of medical excellence currently posted the following regarding the treatment of back pain; “These patients may be best served through prompt access to care from physical therapists or nurse practitioners as entry-level providers. When pain persists beyond four to six weeks, the care path defines when referral to spine or pain specialists, spine surgeons or behavioral health providers is indicated.” (https://consultqd.clevelandclinic. org/2014/11/sticking-with-proven-practices-for-low-back-pain/) The Mayo Clinic Staff (2017) also reported: “Physical therapy is the cornerstone of back pain treatment.”

 

When considering the best option for Primary Spine Care, we should consider “what” type of provider renders the best outcomes in population based studies and has the autonomy to manage the case independent of primary care and medical specialty.   Based upon population based studies, both the Cleveland and Mayo clinics got it wrong as their opinions are not based upon contemporary literature and appear to be rooted in “age-old biases.”  Their suggested care paths are similar to prior care paths that perhaps have led to the long-term mismanagement of mechanical spine pain that has in part, contributed to the opioid crisis.  

 

Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) in a population based study of 5511 injured workers in Ontario Canada as reported by the Workplace Safety and Insurance Board, a governmental agency reported a comparison of outcomes for back pain among patients seen by three types of providers: medical physicians, chiropractors and physical therapists. The found “The type of first healthcare provider was a significant predictor of the duration of the first episode of compensation only during the first 5 months of compensation. When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of a second episode of financial compensation.” (pg.392) and These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.” (pg. 382)

 

Blanchette, Rivard, Dionne, Hogg-Johnson and Steenstra (2017) continued, “The cohort study of American workers with back pain conducted by Turner et al. found that the first healthcare provider was one of the main predictors of work disability after a year. In accordance with our findings, workers who first sought chiropractic care were less likely to be work-disabled after 1 year compared with workers who first sought other types of medical care… We did not retrieve any study that directly compared physiotherapy care with other types of first healthcare providers in the context of occupational back pain, probably because most workers’ compensation systems still require a referral for physiotherapy. However, a study comparing primary physiotherapy care with usual emergency department care concluded that physiotherapy care leads to a prolonged time before patients return to their usual activities.” (pg. 389)

 

Cifuentes, Willets and Wasiak (2011) stated that chiropractic care during the health maintenance care period resulted in: 

The study concluded that chiropractic care during the disability episode resulted in:

24% Decrease in disability duration of first episode compared to physical therapy

250% Decrease in disability duration of first episode compared to medical physician's care

5.9% Decrease in opioid (narcotic) use during maintenance care with physical therapy care

30.3% Decrease in opioid (narcotic) use during maintenance care with medical physician's care

32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care

 

Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating,“After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP (low back pain) who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type(pg. 404). 

The above studies continue to verify chiropractic as a better “first option” for spine and that resolves the “what provider is best” question by using an Evidence Based approach.  The “who is best” within that subset is what type of chiropractor is better suited to lead in Primary Spine Care is evident. As an example, although every medical doctor is licensed to do open heart surgery not all are trained and credentialed. Would you want a psychiatrist performing the procedure? The answer should be “they are licensed, but not qualified through training.” The same holds true for contemporary chiropractic and every chiropractor has the same opportunity. We are all held to a “continuing education standard” and are all required to seek post-doctoral training to maintain our licenses. There are a significant number of courses, both live and through enduring materials (online) to enable every chiropractor on the planet to attain the level of education mandated by the “referral sources” to be considered Primary Spine Care Providers. 

Let’s not be Pollyannaish not to think that chiropractic can be successful in increasing utilization independent of the medical community and even the legal community for personal injury cases. As mentioned previously, the medical community DOES NOT CARE about your treatment approach, what they do care about is the “risk” of you missing a diagnosis.  They need to trust you based on your training, and the do NOT care about what technique you use.  What you do in your offices is up to you just like a pain management MD or a surgeon, remember, it’s how you triage and manage your patients that is the ultimate arbiter in having them consider you as the first option for spine care. Once you have responsibly secured the referral, based upon your clinical excellence, you get to independently decide the best course of care for your patient.  Then it is business as usual during the treatment phase of care because results were never, and are not an issue in chiropractic. 

REFERENCES:

 

  1. Erwin, W. M., Korpela, A. P., & Jones, R. C. (2013). Chiropractors as primary spine care providers: precedents and essential measures. The Journal of the Canadian Chiropractic Association, 57(4), 285.
  2. Herzog, R., Elgort, D. R., Flanders, A. E., & Moley, P. J. (2017). Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. The Spine Journal, 17(4), 554-561.
  3. Cleveland Clinic. (2017). Sticking with proven practices for low back pain, Introducing: Cleveland Clinic’s Spine Care Path. Retrieved from https://consultqd.clevelandclinic.org/2014/ 11/sticking-with-proven-practices-for-low-back-pain/
  4. Mayo Clinic Staff. (2017). Treatments and drugs. Diseases and Conditions, Back Pain, Retrieved from:http://www.mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797
  5. Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation27(3), 382-392.
  6. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine53(4), 396-404.

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The Mechanism of the Chiropractic

Spinal Adjustment/Manipulation:

Chiropractic vs. Physical Therapy for Spine

 

Part 5 of a 5 Part Series

By: Mark Studin

William J. Owens

 

 

Reference: Studin M., Owens W., (2017) The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine, Part 5 of 5, American Chiropractor 39 (12) pgs. 20, 22, 24, 26, 28, 30, 31

 

A report on the scientific literature  

 

According to the Cleveland Clinic (2017):

 

The Cleveland Clinic Spine Care Path is a process-based tool designed for integration in the electronic medical record (EMR) to guide clinical work flow and help providers make evidence-based guidelines operational. 

 

The care path was developed by Cleveland Clinic’s Center for Spine Health with input from Department of Pain Management staff like Dr. Berenger. One goal was to match appropriate treatments and providers to patients at various points along the care continuum for low back pain.

 

We know acute back pain is common and often resolves with simple therapy or even no therapy,” Dr. Berenger says. “For patients without red flags, imaging is rarely required.” 

 

These patients may be best served through prompt access to care from physical therapists or nurse practitioners as entry-level providers. When pain persists beyond four to six weeks, the care path defines when referral to spine or pain specialists, spine surgeons or behavioral health providers is indicated. (https://consultqd.clevelandclinic. org/2014/11/sticking-with-proven-practices-for-low-back-pain/)

According to the Mayo Clinic Staff (2017):

 

Most acute back pain gets better with a few weeks of home treatment. Over-the-counter pain relievers and the use of heat or ice might be all you need. Bed rest isn't recommended. 

 

Continue your activities as much as you can tolerate. Try light activity, such as walking and activities of daily living. Stop activity that increases pain, but don't avoid activity out of fear of pain. If home treatments aren't working after several weeks, your doctor might suggest stronger medications or other therapies. (http://www.mayoclinic. org/diseases-conditions/back-pain/basics/treatment/con-20020797

 

The Mayo Clinic Staff (2017) continued:

 

Physical therapy is the cornerstone of back pain treatment. A physical therapist can apply a variety of treatments, such as heat, ultrasound, electrical stimulation and muscle-release techniques, to your back muscles and soft tissues to reduce pain.As pain improves, the therapist can teach you exercises that can increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques can help prevent pain from returning. (http://www. mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797)

 

The above 2 scenarios are consistent with contemporary care paths for medicine regarding back pain. High velocity-low amplitude chiropractic spinal adjustments are not part of any medical institution’s care plan (to the current knowledge of the authors) despite the following compelling literature.

Coronado et al. (2012) reported:

 

Reductions in pain sensitivity, or hypoalgesia, following SMT [defined by the author as high velocity-low amplitude adjustment or a spinal adjustment] may be indicative of a mechanism related to the modulation of afferent input or central nervous system processing of pain. (p. 752)

 

Coronado et al. (2012) further asked the question:

 

…was whether SMT [defined by the author as high velocity-low amplitude or a spinal adjustment] elicits a general response on pain sensitivity or whether the response is specific to the area where SMT is applied. For example, changes in pain sensitivity over the cervical facets following a cervical spine SMT would indicate a local and specific effect while changes in pain sensitivity in the lumbar facets following a cervical spine SMT would suggest a general effect. We observed a favorable change for increased PPT [pressure pain threshold] when measured at remote anatomical sites and a similar, but non-significant change at local anatomical sites. These findings lend support to a possible general effect of SMT beyond the effect expected at the local region of SMT application. (p. 762)

Reed, Pickar, Sozio, and Long (2014) reported:

 

…forms of manual therapy have been clinically shown to increase mechanical pressure pain thresholds (i.e., decrease sensitivity) in both symptomatic and asymptomatic subjects. Cervical spinal manipulation has been shown to result in unilateral as well as bilateral mechanical hypoalgesia. Compared with no manual therapy, oscillatory spinal manual therapy at T12 and L4 produced significantly higher paraspinal pain thresholds at T6, L1, and L3 in individuals with rheumatoid arthritis. The immediate and widespread hypoalgesia associated with manual therapy treatments has been attributed to alterations in peripheral and/or central pain processing including activation of descending pain inhibitory systems. 

 

Increasing evidence from animal models suggests that manual therapy activates the central nervous system and, in so doing, affects areas well beyond those being treated. (p. 277)

 

With regards to manual therapy versus physical therapy, this is where the phrase, “caveat emperor” should be used as the concept is misleading. Groeneweg et al. (2017) compared manual and physical therapies, recruiting 17 manual therapists and 27 physical therapists. The training of the manual therapists was from Manual Therapy University and were predominantly physical therapists who spent 3 years studying manual therapy. 

Groeneweg et al. (2017) reported:

 

The manual therapist performs per protocol repeated passive joint movements with low velocity and intensity and high accuracy in different positions of the patient (sitting, supine and side-lying). The rhythm of the movements is slow (approximately 30 cycles/min) and the movements are repeated about six times. Treatment is in general painless. Passive joint movements are performed in a combination of rolling and sliding, or rocking and gliding (or swinging and sliding) in the joint, based on the arthrokinematic and osteokinematic principles of intra-articular movements. Passive movements are performed over the entire range of motion within the physiological range of motion of joints, whereby the curvature of the articular surface is followed, with manual forces directed to the joints/specific spinal level. Physiological joint range of motion is carefully respected. Traction, oscillation and high-velocity movements are not applied. In all patients, based on the assessment protocols, all joints of the spine, pelvis and extremities are mobilized in specific directions. (p. 3)

Groeneweg et al. (2017) also stated:

 

This pragmatic RCT [randomized control trial] in 181 patients with non-specific neck pain (>2 weeks and <1 year) found no statistically significant overall differences in primary and secondary outcomes between the MTU group and PT group. The results at 7 weeks and 1 year showed no statistically and clinically significant differences. The assumption was that MTU was more effective based on the theoretical principles of mobilization of the chain of skeletal and movement-related joint functions of the spine, pelvis and extremities, and preferred movement pattern in the execution of a task or action by an individual, but that was not confirmed compared with standard care (PT). (pg. 8)

 

The above article strongly confirms why language is important when describing the chiropractic spinal adjustment. Too many “lump together” all manual therapies and claim the effectiveness, or lack thereof, based on studies as the one above confirms. The article compared physical therapy to physical therapists who have gone for advanced education in what they already do in low-amplitude repetitive movements using “arthrokinematic and osteokinematic principles of intra-articular movements” meaning very specific per the anatomy. The outcome confirmed there is no difference between manual therapy and physical therapy because they are the same according to the description in the research. However, these therapies do not provide what chiropractic offers, although many hastily consider manual therapy and chiropractic care to be the same. Substance P is perhaps the most compelling evidence of why a chiropractic spinal adjustment should be considered the “first choice” for spinal care.

Evans (2002) reported:

 

In a series of studies, Brennan et al. investigated the effect of spinal HVLAT manipulation causing cavitation ("sufficient to produce an auditory release or palpable joint movement") on cells of the immune system. They found that a single manipulation to either the thoracic or lumbar spine resulted in a short-term priming of polymorphonuclear neutrophils to respond to an in vitro particulate challenge with an enhanced respiratory burst (RB) as measured by chemiluminescence in subjects with and without symptoms. The enhanced RB was accompanied by a two-fold rise in plasma levels of the neuropeptide substance P (SP).

 

SP is an 11-amino acid polypeptide and is one of a group of neuropeptides known as tachykinins. These are peptides that are produced in the dorsal root ganglion (DRG)  and released by the slow-conducting, unmyelinated C-polymodal nociceptors in a process known as an "axon reflex." They are released into peripheral tissues from the peripheral terminals of the C-fibers. modulating the inflammatory process by "neurogenic inflammation.” They are also released from the central terminals of the nociceptors into the dorsal horn of the spinal cord, where they modulate pain processing and spinal cord reflex activity.

 

This neurophysiologic effect of spinal HVLAT manipulation seems to be force threshold-dependent. The threshold was found to lie somewhere between 450N and 500N for the thoracic spine and 400N for the lumbar spine. When compared with data from biomechanical studies of spinal manipulation, these forces would be sufficient to cause cavitation. The "SP" studies used "sham manipulation" as a control, consisting of a "low-velocity light-force thrust to the selected segment." rather like a mobilization. This illustrates that zygapophyseal HVLAT manipulations that cause cavitation produce physiological effects, not demonstrable by electromyography, that are totally different fi-om effects created by zygapophyseal manipulations that do not cause cavitation. (p. 255-256)

According to Hartford-Wright, Lewis, Vink and Ghabriel (2014):

 

Substance P (SP) is a neuropeptide released from the endings of sensory nerve fibers and preferentially binds to the NK1 receptor. It has a widespread distribution throughout the nervous system, where it is implicated in a variety of functions including neurogenic inflammation, nausea, depression and pain transmission as well as in a number of neurological diseases, including CNS tumors. (p. 85)

Low velocity manipulation, no matter how well it follows “arthrokinematic and osteokinematic principles of intra-articular movements,” will not effectuate the release of Substance P, only a chiropractic spinal adjustment with cavitation will do that. When considering the results of a chiropractic spinal adjustment, disability is a critical indicator with regards to the effectiveness of treatment outcomes.

Cifuentes, Willets and Wasiak (2011) compared different treatments of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability after a 15-day absence and return to disability. Anyone with less than a 15-day absence was excluded from the study. Please note that we kept disability outcomes for all reported treatment and did not limit this to physical therapy. However, the statistic for physical therapy is significant.

 

The Cifuentes, Willets and Wasiak (2011) study concluded that chiropractic care during the health maintenance care period resulted in:

The study concluded that chiropractic care during the disability episode resulted in:

24% Decrease in disability duration of first episode compared to physical therapy

250% Decrease in disability duration of first episode compared to medical physician's care

5.9% Decrease in opioid (narcotic) use during maintenance care with physical therapy care

30.3% Decrease in opioid (narcotic) use during maintenance care with medical physician's care

32% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

21% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care

 

Cifuentes et al. (2011) started by stating, “Given that chiropractors are proponents of health maintenance care...patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used” (p. 396). The authors concluded by stating, “After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type” (Cifuentes et al., 2011, p. 404).

 

Given that physical therapy has been the primary portal for mechanical spine issues (not fractures, tumors or infection) coupled with the contemporary opiate addiction and mortality issues, a different path must be sought as a matter of public safety. The only avenue for both medical primary care providers and specialists other than surgery is pain management in the form of opiates and that doesn’t resolve any issues, it only creates new addiction issues. Mechanical spine pain is one of the most common diagnoses.

 

According to Block (2014): 

 

Over 100 million Americans experience chronic pain with common painful conditions including back pain, neck pain, headaches/migraines, and arthritis, in addition to other painful conditions such as diabetic peripheral neuropathy, etc... In a large study in 2010, 30.7% of over 27,000 U.S. respondents reported an experience of chronic, recurrent pain of at least a 6-month duration. Half of the respondents with chronic pain noted daily symptoms, with 32% characterizing their pain as severe (≥7 on a scale ranging from 0 to 10). Chronic pain has a broad impact on emotional well-being and health-related quality of life, sleep quality, and social/recreational function. (p. 1)

 

Mafi, McCarthy and Davis (2013) reported on medical and physical therapy back pain treatment from 1999 through 2010 representing 440,000,000 visits and revealed an increase of opiates from 19% to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the costs for managing low back pain patients (not correcting anything, just managing it) has reached $106,000,000,000 ($86,000,000,000 in health care costs and $20,000,000,000 in lost productivity).

 

 

Mafi, McCarthy and Davis (2013) stated:

 

Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005...In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period, use of recommended treatments would increase and use of non-recommended treatments would decrease. (p. 1574)

 

The above paragraph has accurately described the problem with allopathic “politics” and “care-paths.” Despite self-reported overwhelming evidence where there were 440,000,000 visits and $106,000,000,000 in failed expenditures, they hypothesized that increased utilization for recommended treatment would increase. The recommended treatment, as outlined in the opening two comments of this article, doesn’t work and physical therapy is a constant verifying a “perpetually failed pathway” for mechanical spine pain.

 

 

Chiropractic offers an evidence-based approach in developing an “outcome based “care path for mechanical spine pain. Although this article discusses pain, chiropractic offers more than simply pain management, however this discussion is limited to mechanical spine pain. Therefore, with chiropractic as the “first option” or “Primary Spine Care” focusing on the biomechanical pathological instability, the underlying cause of the pain can be addressed, leaving no further need to manage an issue that has been simply fixed.

 

 

References

1. Cleveland Clinic. (2017). Sticking with proven practices for low back pain, Introducing: Cleveland Clinic’s Spine Care Path. Retrieved from https://consultqd.clevelandclinic.org/2014/ 11/sticking-with-proven-practices-for-low-back-pain/

2. Mayo Clinic Staff. (2017). Treatments and drugs. Diseases and Conditions, Back Pain, Retrieved from: http://www.mayoclinic.org/diseases-conditions/back-pain/basics/treatment/con-20020797

3. Coronado, R. A., Gay, C. W., Bialosky, J. E., Carnaby, G. D., Bishop, M. D., & George, S. Z. (2012). Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis. Journal of Electromyography Kinesiology, 22(5), 752-767.

4. Reed, W. R., Pickar, J. G., Sozio, R. S., & Long, C. R. (2014). Effect of spinal manipulation thrust magnitude on trunk mechanical activation thresholds of lateral thalamic neurons. Journal of Manipulative and Physiological Therapeutics, 37(5), 277-286.

5. Groeneweg, R., van Assen, L., Kropman, H., Leopold, H., Mulder, J., Smits-Engelsman, B. C., ... & van Tulder, M. W. (2017). Manual therapy compared with physical therapy in patients with non-specific neck pain: a randomized controlled trial. Chiropractic & Manual Therapies25(12), 1-12.

6. Evans, D. W. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics, 25(4), 251-262.

7. Harford-Wright, E., Lewis, K. M., Vink, R., & Ghabriel, M. N. (2014). Evaluating the role of substance P in the growth of brain tumors. Neuroscience261, 85-94.

8. Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine53(4), 396-404.

9. Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine173(17), 1573-1581.

Dr. Mark Studin is an Adjunct Associate Professor of Chiropractic at the University of Bridgeport College of Chiropractic, an Adjunct Post Graduate Faculty of Cleveland University - Kansas City, College of Chiropractic, an Adjunct Professor of Clinical Sciences at Texas Chiropractic College and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post-doctoral education, teaching MRI spine interpretation, spinal biomechanical engineering and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www.DoctorsPIProgram.com), teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally and studies trends in healthcare on a national scale (www.TeachDoctors.com). He can be reached at www.teachchiros.com or at 631-786-4253.

 

 

Dr. Bill Owens is presently in private practice in Buffalo and Rochester NY and generates the majority of his new patient referrals directly from the primary care medical community.  He is an Associate Adjunct Professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences, an Adjunct Post Graduate Faculty of Cleveland University - Kansas City, College of Chiropractic, an Adjunct Assistant Professor of Clinical Sciences at the University of Bridgeport, College of Chiropractic and an Adjunct Professor of Clinical Sciences at Texas Chiropractic College.  He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at www.mdreferralprogram.com or 716-228-3847  

 

 

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Chiropractic & Central Afferent Inhibition:

A Chiropractic Care Path & Mechanism for Chronic Pain, Tremors, Spatial and Inhibitory Distortion

 

By Mark Studin

William J. Owens

Michael Barone

A report on the scientific literature 

 

Although it is unusual in the literature to place a disclaimer in the beginning of an article, we want to ensure that our reporting is not inflammatory since the foundation of this article was written with the following limitation in our primary literary source, Haavik, Niazi, Holt and Murphy (2017) reported:

 

This study was not designed to test the efficacy of chiropractic care for treating chronic pain; therefore, conclusions about efficacy cannot be drawn from our findings. The study did not include randomization with an adequate control group, thus limiting the interpretations that can be made about the changes in pain observed in the trial. Causation cannot be claimed. (pg. 135)

 

Although Haavik, et al. reported limitations in their study, the results cannot be overlooked or minimized, particularly when those results match what doctors working within a “Best Practice Model” (the patient and doctor feedback component) have been reporting for decades. Additionally, in the clinical setting, this information provides direction to practitioners searching for answers although the mechanisms are not yet fully understood. Results often don’t mandate detailed knowledge of the mechanism and that is the primary reason why both “evidenced based” and “best practice” models must be embraced and combined (pure literature results with doctor and patient feedback or experiences) as a matter of public health.

 

When we consider central afferent neurological input, the inability to inhibit those signals leads to sensorimotor disturbances that are found in the chronicity of many chronic pain conditions, essential tremors, dystonia and other central spatial and temporal mismatches. In addition, we must consider to the long-term negative sequalae of those conditions, such as brain shrinkage.

 

Baliki, Geha, Apkarian and Chialvo (2008) reported:

 

Recent studies have demonstrated that chronic pain harms cortical areas unrelated to pain, long-term pain alters the functional connectivity of cortical regions known to be active at rest, i.e., the components of the “default mode network” (DMN). This DMN is marked by balanced positive and negative correlations between activity in component brain regions. In several disorders, however this balance is disrupted. Studying with fMRI [functional MRI] a group of chronic back pain patients and healthy controls while executing a simple visual attention task, we discovered that chronic back pain patients, despite performing the task equally well as controls, displayed reduced deactivation in several key default mode network regions. These findings demonstrate that chronic pain has a widespread impact on overall brain function, and suggest that disruptions of the default mode network may underlie the cognitive and behavioral impairments accompanying chronic pain.” (pg. 1398)

 

“The existence of a resting state in which the brain remained active in an organized manner, is called the ‘default mode of brain function. The regions exhibiting a decrease in activity during task performance are the component members of the “default-mode network” (DMN), which in concerted action maintain the brain resting state. Recent studies have already demonstrated that the brain default mode network is disrupted in autism, Alzheimer’ disease, depression, schizophrenia and attention deficit hyperactivity disorder, suggesting that the study of brain resting activity can be useful to understand disease states as well as potentially provide diagnostic information.”  (pg. 1398)

 

This is important since for the first time we are starting to see a published correlation between spinal function, chronic pain and central nervous system changes.  This is what our founders have observed yet were unable to prove.

 

“Thus, the alterations in the patient’s brain at ‘rest’ can result in a different default mode network organization. In turn, potential changes in the default-mode network activity could be related to symptoms (other than pain) commonly exhibited by chronic pain patients, including depression and anxiety, sleep disturbances, and decision-making abnormalities, which also significantly diminish their quality of life… chronic pain patients display a dramatic alteration in several key default-mode network regions, suggesting that chronic pain has a widespread impact on overall brain function” (pg. 1398)

 

This information is pointing to the fact that a doctor of chiropractic should be involved in the triage and treatment of these patients and part of a long-term spinal care program. 

 

Baliki Et. Al (2008) continued “Consistent with extensive earlier work examining visuospatial attention tasks, dominant activations were located in posterior parietal and lateral prefrontal cortices, whereas deactivations occurred mainly within Pre-Frontal Cortex and Posterior Cingulate/Cuneate Cortexes. Although activations in chronic back pain patients’ and controls’ brains were similar, chronic back pain patients exhibited significantly less deactivations than healthy subjects in Pre-Frontal Cortex, amygdala, and Posterior Cingulate/Cuneate Cortexes.  The focus was on identifying differences in the way chronic back pain patients’ brains process information not related to pain. This is the first study demonstrating that chronic back pain patients exhibit severe alterations in the functional connectivity between brain regions implicated in the default mode network. It seems that enduring pain for a long time affects brain function in response to even minimally demanding attention tasks completely unrelated to pain. Furthermore, the fact that the observed task performance, compared with healthy subjects, is unaffected, whereas the brain activity is dramatically different, raises the question of how other behaviors are impaired by the altered brain activity” (pg. 1399).

 

“However, the disruption of functional connectivity observed here with increased chronic back pain duration may be related to the earlier observation of brain atrophy increasing with pain duration also in chronic back pain patients. Patient’s exhibit increased pre-frontal cortex activity in relation to spontaneous pain, in addition to dorsolateral prefrontal cortex atrophy. Therefore, the decreased deactivations described here may be related to the dorsolateral pre-frontal cortex /pre-frontal cortex mutual inhibitory interactions perturbed with time. If that is the case, it will support the idea of a plastic, time-dependent, reorganization of the brain as patients continue to suffer from chronic back pain. Mechanistically, the early stages of this cortical reorganization may be driven by peripheral and spinal cord events, such as those that have been documented in animal models of chronic pain, whereas later events may be related to coping strategies necessary for living with unrelenting pain. It is important to recognize that transient but repetitive functional alterations can lead to more permanent changes. Accordingly, long term interference with normal activity may eventually initiate plastic changes that could alter irreversibly the stability and subsequently the conformation of the resting state networks” (pg. 1401).

 

Essential Tremors which, according to Wikipedia

 

Essential tremor (ET, also referred to as benign tremor, familial tremor, or idiopathic tremor) is the most common movement disorder; its cause is unknown. It typically involves a tremor of the arms, hands or fingers but sometimes involving the head, vocal cords or other body parts during voluntary movements such as eating and writing.[1] It is distinct from Parkinson's disease—and often misdiagnosed as such—although some individuals have both conditions. Essential tremor is commonly described as an action tremor (i.e., it intensifies when one tries to use the affected muscles) or postural tremor (i.e., present with sustained muscle tone) rather than a resting tremor, such as is seen in Parkinson’s, which is usually not included among its symptoms. (https://en.wikipedia.org/wiki/Essential_tremor)

 

Restuccia, Valeriani, Barba, Le Pera, Bentivoglio, Albanese and Tonali (2003) reported:

 

...our present data seem to indicate that somatomotor cortical areas play an important role in generating ET. This finding can be important in the future understanding of its pathophysiologic mechanisms, as well as in its management. (pg. 127)

 

This study suggests that somatosensory cortical areas plays an important role, therefore the afferents “feeding” that region is critical in normalizing function of the cortex a that region. Another negative sequela of aberrant input.

When we consider one potential etiology of maladaptive plastic changes in the brain that can cause chronic pain, essential tremors, brain shrinkage and a host of other maladies, regulatory control of the impulses must be considered and interfered with. The lack of gating (inhibition) will lead to an overflow of impulses and crate a negative cascade that can lead to chronic and often permanent changes. Haavik, Niazi, Holt and Murphy (2017) reported:

 

Thus, distorted sensory information is thought to disturb SMI (sensorimotor integration) and impair accurate motor control. In normal circumstances, 2 inputs that engage the sensory system have a reciprocally inhibitory action that gates the total amount of signal at all central levels, spatially and temporally limiting the amount of input engaging the CNS. This is thought to prevent sensory “overflow.” The defective gating may cause an input-output mismatch in specific motor programs, and such mismatches in motor programs may in themselves lead to production of distorted sensory information and issue of less than ideal motor commands. In this way, the chronicity of the problem can be maintained via a self-perpetuating mechanism. The reduced frontal N30 SEP (somatosensory evoked potential) peak ratio observed in the current study after 12 weeks of chiropractic care may reflect a normalization of pain-induced central maladaptive plastic changes and may reflect one mechanism for the improvement of functional ability reported following chiropractic adjustment or manipulation. (pg. 134)

 

The N30 ratio change represented on average a 37.4% decrease following the 12 weeks of chiropractic care. The N30 MU (median-ulnar) amplitude changes following chiropractic care represented an 18.0% decrease in amplitude compared with baseline (pg. 131) Alongside this change in the N30 SEP ratio, the subjects reported a decrease in both current pain and average pain over the last week. A control period of 2 weeks of no intervention resulted in no significant changes in any SEP peak ratio. (pg. 134)

 

When considering care paths for this population of patients, the following was reported by Haavik, Niazi, Holt and Murphy (2017) reported:

 

The 2-week control period, during which no intervention was applied, was followed by a 12-week chiropractic care intervention. During the 12 weeks of chiropractic care, the chiropractor assessed and treated the subject as she would any other chronic pain patient. The participating chiropractor (H.H., with 7 years clinical experience) assessed the spine for segmental dysfunction using tenderness on palpation and passive intervertebral and global motion of the spine. Other treatments included as part of chiropractic care were exercises, peripheral joint adjustments/manipulations, soft tissue therapy, and pain education if deemed by the chiropractor to be appropriate based on history and examination. The chiropractic adjustment/manipulation was the delivery of a high-velocity, low-amplitude thrust to dysfunctional spinal segments. (pgs. 129-130)

 

The changes observed conclude (with the aforementioned disclaimer that more research is needed) that chiropractic is a verifiable treatment option. Haavik, Niazi, Holt and Murphy (2017) continued:

 

The changes observed in dual SEP ratios after several weeks of chiropractic care in a chronic pain population suggest that this treatment option may improve gating of peripheral afferent input to the brain, thus improving impaired SMI in cortical motor areas and improving processing of motor programs. Impaired SMI and defective motor programming is known to be present in various chronic pain populations and is implicated in the clinical symptomatology. We know from the literature that in normal circumstances, afferent input to the motor system leads to finely tuned activation of neural elements and ultimately results in the correct execution of movement. Multiple experimental and clinical studies have confirmed the importance of sensory feedback to the motor system. Thus, distorted sensory information is thought to disturb SMI and impair accurate motor control. In normal circumstances, 2 inputs that engage the sensory system have a reciprocally inhibitory action that gates the total amount of signal at all central levels, spatially and temporally limiting the amount of input engaging the CNS. This is thought to prevent sensory “overflow.” The defective gating may cause an input-output mismatch in specific motor programs, and such mismatches in motor programs may in themselves lead to production of distorted sensory information and issue of less than ideal motor commands. In this way, the chronicity of the problem can be maintained via a self-perpetuating mechanism. The reduced frontal N30 SEP peak ratio observed in the current study after 12 weeks of chiropractic care may reflect a normalization of pain-induced central maladaptive plastic changes and may reflect one mechanism for the improvement of functional ability reported following chiropractic adjustment or manipulation. (pgs. 134-135)

 

Haavik, Niazi, Holt and Murphy (2017) concluded:

 

After the 12 weeks of chiropractic care, when he was also feeling better symptomatically, this was reversed, and all of his MU traces for all SEP peak complexes were smaller in amplitude than his M + U trace, indicating a greater level of central reciprocal inhibition was occurring… Thus, if sensory “overflow” occurs, then incomplete processing of this incoming signal may occur in the brain, resulting in its perceiving not only excessive, but also spatially distorted information. (pg. 135)

 

The N9 SEP peak (the “N” is a location for electrodes) reflects the afferent signal over the brachial plexus before it enters the CNS, and thus can be used to ensure that the incoming signal is consistent before and after an intervention. Furthermore, these experiments demonstrated that the subjects' N30 SEP peak ratios decreased significantly after a single chiropractic manipulation of the cervical spine. As the N30 SEP peak is thought to reflect early cortical SMI, the authors argued that their results suggest that the subject's SMI networks' ability to suppress the dual input after the adjustment was increased. The N30 SEP peak ratios remained decreased even after repeating the 20-minute repetitive thumb abduction task. This suggested that the treatment effects appear to have altered the way in which each subject's CNS responded to the repetitive thumb typing task.

 

When considering treating chronic pain, dystonia, essential tremor or any other type of patient where there are spatial (distorted or excessive afferent) input issues, the above care path (treatment plan) should be considered. By not completed a complete treatment protocol might expose your patient to a chronic issue that may become permanent if the maladaptive cortical changes persist over time. Since there are no timetables for how long a patient can withstand for the issue to become permanent and there is an indexed peer reviewed suggestion of correction, that must be adhered as a minimum until further evidence suggests otherwise. In addition, no two patients are alike and the treatment plan should be guided with a full clinical reevaluation and consider performing that examination every 30 days of active care considering all facets, both history and clinical.

 

 

References:

  1. Haavik, H., Niazi, I. K., Holt, K., & Murphy, B. (2017). Effects of 12 Weeks of Chiropractic Care on Central Integration of Dual Somatosensory Input in Chronic Pain Patients: A Preliminary Study. Journal of manipulative and physiological therapeutics40(3), 127-138.
  2. Restuccia, D., Valeriani, M., Barba, C., Le Pera, D., Bentivoglio, A., Albanese, A. & Tonali, P. (2003). Abnormal gating of somatosensory inputs in essential tremor. Clinical neurophysiology114(1), 120-129.
  3. Baliki N., Geha P., Apkarian A., Chialvo D., (2008) Beyond Feeling: Chronic Pain Hurts the Brain, disrupting the Default-Mode Network Dynamics, Journal of Neurosciences 28(6) 1398-1403
  4. Essential Tremor (2017) retrieved from: https://en.wikipedia.org/wiki/Essential_tremor

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Chronic Pain and Chiropractic:

A 12-Week Solution & Necessity for Care

 

By Mark Studin

William J. Owens

A report on the scientific literature and commentary 

 

 

How long should a patient be under chiropractic care? This has been the struggle for many in the insurance industry, the legal community, licensure boards and a “hot topic” politically. There are the CCGPP [Council on Chiropractic Guidelines and Practice Parameters], the Croft Guidelines, Best Practice for Chiropractic Care for Older Adults, Best Practices Recommendations for Chiropractic Care for Infants, Children and Adolescents, Chiropractic Practice Guidelines: Chiropractic Care for Low Back Pain. These are just some of the chiropractic industry’s guidelines, then you must consider the insurance industry’s care paths where most are hidden behind statements like “medical necessity” and “eligible charges.” Those are “buzz phrases” indicating they have a guideline, but most will neither publish or make them available to the providers, their insured or the public claiming proprietary information giving them a legal basis for the secrecy.

 

 

Aetna, as an example lists specifics for care and then goes further to limit a significant number of techniques, procedures and diagnostics claiming they are “experimental.” Although Medicare considers chiropractic a covered service they limit treatment arbitrarily according based upon significant feedback from many in the profession.  Workers Compensation Boards have guidelines that are either legislated or created based upon a case law judge’s opinion which include arguments from the defense to support limiting care.  At best, that is an arbitrary process based upon rhetoric or legislation that is too often ignorant of the scientific literature resulting in serious imposed limits in scope of treatment as we see in California, New York and many other states.

 

 

Although the guideline landscape is expansive, these authors choose to rely on a hybrid of both “Best Practice” and “Evidenced Based” method in the development of treatment plans. Both have a strong place in clinical practice, academic settings, the courts and third-party reimbursement systems.

 

Best Practice is defined as “a method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark. In addition, a best practice can evolve to become better as improvements are discovered. Best practice is considered by some as a businessbuzzword, used to describe the process of developing and following a standard way of doing things that multiple organizations can use" (Best Practice, http://en.wikipedia.org/ wiki/Best practice).

 

These are certain procedures in healthcare that are taught in schools, internships and residencies and are considered the “standard” by which care is expected to follow. These practices are based on clinical experience and rely heavily on time-tested approaches, that is how a profession evolves and grows.  Surprisingly, most of the best medical practice care paths are not published in the peer-reviewed indexed literature. This is due to many factors, but the most obvious are applications of financial resources and grants to “new” discoveries and the simple fact that the clinical arena is well positioned to monitor and adjust these practices in a timely manner allowing practitioners to keep pace with the literature that follows. In recent times, although it has been talked about for decades, there is another parameter that exists and although focuses on best practices, there is a strong reliance on published studies, aka “evidence”, as the main driver of whether a procedure is approved and reimbursed. This is extremely problematic to healthcare outcomes.

Evidence-based practice(EBP) is an interdisciplinary approach to clinical practice that has been gaining ground following its formal introduction in 1992. It started inmedicineasevidence-based medicine (EBM) and spread to other fields such as dentistry, nursing, psychology,

education, library and information science and other fields. Its basic principles are that all practical decisions made should be based on three important criteria.  First, they must be based on the practicing provider’s clinical experience, secondly, they should be based on published research studies and thirdly should consider the patients expectations.

 

"Evidence-based behavioral practice(EBBP) entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. This is done in a manner that is compatible with the environmental and organizational context. Evidence is comprised of research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses" (Evidence-Based Practice, http://en.wikipedia.org/wiki/Evidence-based_practice).

 

This highly-debated topic of evidence-based vs. best practice has valid issues on each side, but putting them together as a hybrid would allow them to thrive in both a healthcare delivery and reimbursement system; therefore, all sides would win. This would allow advances in healthcare to save more lives, increase the quality of life and at the same time, offer enough safeguards to prevent abuse to payors. A one-sided approach would tip the scales to favor either the provider/patients or the payors which, in the end, results in distrust and conflict.

Evidence-based medicine proponents argue that it would eliminate waste and reduce costs while providing patients with the most up-to-date care available. Those against this concept argue that reliance on evidence-based care would eliminate many procedures that fall under the best medical practice parameters and remove the clinical decision making and professional experience from the equation. They feel what would be left is denial of good therapies and the stifling of innovation since the process of establishing a research study, following its participants and publishing those findings can take many years not to mention poor study design or research bias can have both a profound effect on the evidence provided and severely delay the final publication. This delay would eventually cost either lives or severely diminish the quality of life for those who could have been helped during the research and publication processes.

Haavik, Niazi, Holt and Murphy (2017) reported:

 

Post hoc tests using the Bonferroni correction revealed significant mean differences in N30 MU amp (P = .049) and N30 MU to M + U ratio data (P = .001) during the chiropractic intervention, but no significant changes were observed during the control period (P = .1 for N30 MU amp and P = .3 for N30 MU to M + U ratio data). The effect size for the change in N30 MU amp was 0.61, and for the N30 MU to M + U ratio it was 0.66. The N30 ratio change represented on average a 37.4% decrease following the 12 weeks of chiropractic care. The N30 MU amplitude changes following chiropractic care represented an 18.0% decrease in amplitude compared with baseline. (Pg 131)

 

These results were based upon a limited study, but validates that a chiropractic spinal adjustment modulated aberrant afferent input by 37.4% in median and ulnar nerve rations and 18% in median and ulnar nerve amplitudes.

 

The authors went on to report:

 

The purpose of this preliminary study was to assess whether the dual SEP technique is sensitive enough to measure changes in cortical intrinsic inhibitory interactions in patients with chronic neck pain after a 12-week period of chiropractic care and, if so, whether any such changes related to changes in symptomatology. (pg. 128)

 

This was tested to determine if inhibitory innervation was affected specifically by a chiropractic spinal adjustment and the outcomes conclusively, against a 2-week control period of the same test subjects confirmed these results.

Haavik, Niazi, Holt and Murphy (2017) went on to describe the 12 weeks of chiropractic care that realized these results:

 

The chiropractic care plan was pragmatic and generally consisted of 2 to 3 visits per week for the first 2 to 3 weeks. Frequency was reduced based on clinical findings and patient symptomatology. By the end of the 12-week period, participants were seen once or twice a week. No requirements were placed on the treating chiropractor, other than including chiropractic adjustment or manipulation during treatment; thus, the care plan was designed in conjunction with patient preferences and was based on the patients’ history, symptoms, wishes, and time availability as well as the clinician’s clinical experience and knowledge. (pg. 130)

 

Although the length of care in this study does not render a specific guideline, it does validate that it takes time to realize changes in the mechanics of the spine and the human nervous system.  The results are consistent with the “Best Practice Model” and the authors 57 years of combined experience and results. Twelve weeks of care is a conservative and reasonable time frame since we are observing and considering that cerebral neuroplastic changes are a direct and verifiable result of a chiropractic spinal adjustment. Less than 12 weeks of chiropractic spinal adjusting has not been evidenced to make these reported changes, therefore we must consider this threshold for care.Concurrently, what we see is that less treatment time does not allow the connective tissue to help the spine as one contiguous organ system to remodel to a homeostatic state (a conversation for a different paper).

 

Chiropractic care for chronic pain patients requires a both a combination of Best Practice and Evidenced Based models as the literature is now verifying that a chiropractic spinal adjustment is an effective care path and 12 weeks is a minimum to see neuroplastic changes.  Clinically speaking however, to confirm the optimum care path for this particular population of patients, continuation of care should be based on re-evaluations every 30-days and should continue as clinical sign and symptoms persist and there is evidence that the patient is benefiting both in the short and long term.   Additionally, no significant improvement over the first 12 weeks should be considered acceptable as neuroplastic changes are a process. Although these authors have rarely personally experienced a lack of significant neuro-biomechanical changes over that time period, it is a clinical decision that must be derived by the treating provider in a “Best Practice Model” and not a 3rd party.

 

References:

  1. Aetna Chiropractic Services (2017) Retrieved from: http://www.aetna.com/cpb/medical/data/100_199/0107.html
  2. https://www.medicare.gov/coverage/chiropractic-services.html
  3. Best Practice. (n.d.). In Wikipedia. Retrieved January 3, 2012, from http://en.wikipedia.org/wiki/Best_practice
  4. Evidence-Based Practice. (n.d.). In Wikipedia. Retrieved January 3, 2012, from http://en.wikipedia.org/wiki/Evidence-based_practice
  5. Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996) Evidence based medicine: What it is and what it isn't. British Medical Journal, 312(7023), 71-72.
  6. Haavik, H., Niazi, I. K., Holt, K., & Murphy, B. (2017). Effects of 12 Weeks of Chiropractic Care on Central Integration of Dual Somatosensory Input in Chronic Pain Patients: A Preliminary Study. Journal of manipulative and physiological therapeutics40(3), 127-138.

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