ChiropracticWhen (Why) to Refer

The Communication GapConfronting The Communication Gap Confronting The Communication Gap Between Conventional And Alternative Between Conventional And Alternative Medicine: A Survey Of Physicians. Medicine: A Survey Of Physicians. 19% of the physicians responding reported 19% of the physicians responding reported personally using manipulation. personally using manipulation. Of these practitioners, 83% stated that they Of these practitioners, 83% stated that they found it beneficial. found it beneficial. Ironically, only 32% of those using Ironically, only 32% of those using alternative therapies felt that their personal alternative therapies felt that their personal use was adequate to gauge the use was adequate to gauge the effectiveness of a particular therapy. effectiveness of a particular therapy. Crook RD, Jarjoura D, Polen A, Ruecki GW. Crook RD, Jarjoura D, Polen A, Ruecki GW. Altern Ther health med, 1999; 5:61-66.Altern Ther health med, 1999; 5:61-66.

Traditional Medical Treatment

Acute LBP in AdultsClinical Practice Guidelines, Number 14, Clinical Practice Guidelines, Number 14, Rockville, Maryland: US Dept Of Health and Rockville, Maryland: US Dept Of Health and Human Services, Public Health Service, Human Services, Public Health Service, AHCPR, 1994. Bigos S, Bower O, et al. AHCPR, 1994. Bigos S, Bower O, et al. Most effective physical method is Most effective physical method is manipulation manipulation Muscle relaxants were no more effective Muscle relaxants were no more effective than NSAIDsthan NSAIDsNo demonstrable benefit to combining No demonstrable benefit to combining w/NSAIDsw/NSAIDsOpioids no more effective than safer Opioids no more effective than safer analgesicsanalgesics

A Review Of Biomechanics

Spinal ProprioceptionHuman facets contain mechanoreceptors Human facets contain mechanoreceptors that detect motion and distortion and that detect motion and distortion and provide proprioception and protective provide proprioception and protective information to the CNS regarding joint information to the CNS regarding joint function and position. function and position.

Spinal proprioception may play a role in Spinal proprioception may play a role in protective muscular reflexes that prevent protective muscular reflexes that prevent injury or facilitate healing. injury or facilitate healing.

Mclain RF, MD, Pickar JG, DC PhD. Mclain RF, MD, Pickar JG, DC PhD. Spine 1998; 21(2): 168-173. Spine 1998; 21(2): 168-173.

MechanoreceptorsThe mechanoreceptors in ligaments The mechanoreceptors in ligaments & joint capsules influence gamma-& joint capsules influence gamma-motor neurons and modulate motor neurons and modulate activity and joint stabilization. activity and joint stabilization. Failure or destruction of MRs’ Failure or destruction of MRs’ ability to provide feedback ability to provide feedback contributes to unpredictable contributes to unpredictable “giving way” and may result in DJD “giving way” and may result in DJD and muscle atrophy. and muscle atrophy. Nyland, Med, PT, ATC. JOSPT 1994; Nyland, Med, PT, ATC. JOSPT 1994; 19(1): 2-11.19(1): 2-11.

ProprioceptorsProprioceptors provide postural & Proprioceptors provide postural & kinesthetic sensation to the sensory kinesthetic sensation to the sensory regions of the cerebral cortex regions of the cerebral cortex allowing the brain to make informed allowing the brain to make informed decisions for effective motor decisions for effective motor programs. programs. Afferent input enables motor program Afferent input enables motor program changes based on information changes based on information provided by changes in body position. provided by changes in body position. Nyland, Med, PT, ATC. JOSPT 1994; Nyland, Med, PT, ATC. JOSPT 1994; 19(1): 2-11.19(1): 2-11.

ProprioceptorsArticular proprioceptors respond Articular proprioceptors respond primarily to the extremes rather than primarily to the extremes rather than to the mid-ranges of joint motion. to the mid-ranges of joint motion.

They may initiate protective muscular They may initiate protective muscular reflexes important in preventing joint reflexes important in preventing joint degeneration & instability. degeneration & instability.

McLain MD. Spine 1994; 19(5): 495-McLain MD. Spine 1994; 19(5): 495-501.501.

Altered MechanoreceptionAltered mechanoreception has a Altered mechanoreception has a direct effect on reflex activity of direct effect on reflex activity of muscle crossing the joint. muscle crossing the joint. Joint deafferentation may accelerate Joint deafferentation may accelerate degenerative changes. degenerative changes. Disturbance of articular innervations Disturbance of articular innervations may play a role in the development may play a role in the development of degenerative diseases and joint of degenerative diseases and joint dysfunction. dysfunction. McLain MD. Spine 1994; 19(5): 495-McLain MD. Spine 1994; 19(5): 495-501501

InterdependenceAn injured joint is likely to cause An injured joint is likely to cause persistently disturbed sensory feedback persistently disturbed sensory feedback to the CNS and therefore existing motor to the CNS and therefore existing motor programs have to be modified.programs have to be modified.

Sensory receptors in the joint can Sensory receptors in the joint can influence muscle tone. influence muscle tone.

This produces an interdependence This produces an interdependence between biomechanical & neurological between biomechanical & neurological mechanisms. mechanisms.

Johansson (Dept Physio), Neuro-Johansson (Dept Physio), Neuro-orthopedic 1990; 9:1-23.orthopedic 1990; 9:1-23.

Chiropractic normalizes proprioception & spinal fine motor tuning which

effect neurological mechanisms.

Chiropractic Office VisitPast Medical History: R/O pathology. Past Medical History: R/O pathology. Differential DiagnosisDifferential DiagnosisPhysical Examination – Vital Signs, Physical Examination – Vital Signs, Orthopedic and Neurological Testing.Orthopedic and Neurological Testing.Postural Imbalances, Muscular Postural Imbalances, Muscular Dysfunction and Abnormalities of Dysfunction and Abnormalities of Joint Movement.Joint Movement.Outcomes Assessment Tools (Pain Outcomes Assessment Tools (Pain Drawings & Visual Analogue Scales) Drawings & Visual Analogue Scales) to document progress.to document progress.

A chiropractic adjustment effects spinal joint movement and nerve tissue

Rehab Without Adjustments

Rehab must not be solely based on Rehab must not be solely based on symptom relief. symptom relief.

It must address more than pain. It must address more than pain. Rehab must be oriented towards Rehab must be oriented towards restoration of function, not just restoration of function, not just relief of symptoms. relief of symptoms.

The patient has a functional The patient has a functional disability after an injury and until it disability after an injury and until it is addressed, these functional is addressed, these functional changes will persist. changes will persist.

Normalizing ProprioceptionEffects fine motor Effects fine motor tuning and results in tuning and results in improved sensorimotor improved sensorimotor functionfunction

Enhanced kinesthetic Enhanced kinesthetic perception, agility, and perception, agility, and balancebalance

Increased range & Increased range & symmetry of motionsymmetry of motion

Improved joint stabilityImproved joint stability

Better coordination & Better coordination & balance of muscle tonebalance of muscle tone

More symmetrical load More symmetrical load distribution, less distribution, less localized localized biomechanical stressbiomechanical stress

Improved Improved control,coordinationcontrol,coordination

Optimized peak Optimized peak performanceperformance

Reduced risk of injury Reduced risk of injury & degeneration & degeneration

Low Back Pain

Common Assumptions

About spine pain: About spine pain:

Over 80% of spine pain is acute Over 80% of spine pain is acute and less than 20% is chronic.and less than 20% is chronic.

The majority of spine pain is self The majority of spine pain is self limiting, resolving in 6-8 weeks.limiting, resolving in 6-8 weeks.

Both assumptions are false.Both assumptions are false.

Chronic LBPWhen patients presented to primary care for an When patients presented to primary care for an episode of acute LBP were surveyed 1 year later, episode of acute LBP were surveyed 1 year later, 75% had pain in the past month. 75% had pain in the past month. Von Korf, PhD. Spine 1993:Von Korf, PhD. Spine 1993:Patients with LBP receiving primary care Patients with LBP receiving primary care typically have recurrent LBP; evidence is typically have recurrent LBP; evidence is increasing that patients are more likely to have increasing that patients are more likely to have chronic phases of LBP than was previously chronic phases of LBP than was previously believed. believed. Available evidence does not support the Available evidence does not support the effectiveness of med treatments for long term effectiveness of med treatments for long term control of chronic and recurrent pain for most control of chronic and recurrent pain for most patients with LBP patients with LBP Von Korf, PhD. Ann. Int Med 1994; 121: 187-195 Von Korf, PhD. Ann. Int Med 1994; 121: 187-195

Chronic LBPWahlgren, MD Pain, 1997; 73: 213-221 Wahlgren, MD Pain, 1997; 73: 213-221

One Year Follow-up Of First Onset of LBPOne Year Follow-up Of First Onset of LBP

Croft, BMJ 1998; 1316-1359 Outcome of Croft, BMJ 1998; 1316-1359 Outcome of LBP in General Practice: A Prospective LBP in General Practice: A Prospective StudyStudy

Finding 72% and 75% respectively Finding 72% and 75% respectively reported more back pain at one year. reported more back pain at one year.

More likely than not that once pain More likely than not that once pain begins, it is a chronic problem of begins, it is a chronic problem of exacerbation and remission.exacerbation and remission.

TraumaRegional musculoskeletal disorders afflict Regional musculoskeletal disorders afflict otherwise well, working age adults who otherwise well, working age adults who have had no physical exposure unusual for have had no physical exposure unusual for them. them.

There is little direct evidence that most There is little direct evidence that most back pain stems from a discrete or back pain stems from a discrete or repetitive trauma. repetitive trauma.

Back pain seldom results from a fall, direct Back pain seldom results from a fall, direct impact or extraordinary physical demands. impact or extraordinary physical demands.

Hadler MD, Carey MD. JAMA 2000: 2780-1.Hadler MD, Carey MD. JAMA 2000: 2780-1.

A Fluctuating CourseOne of the main characteristics of BP is One of the main characteristics of BP is that it often runs a fluctuating course. that it often runs a fluctuating course.

An isolated acute attack with no previous An isolated acute attack with no previous history and complete recovery is rare. history and complete recovery is rare.

The most important feature of chronic The most important feature of chronic pain is not its duration but its impact on pain is not its duration but its impact on the patient’s life. the patient’s life.

Waddell G. Md. The back pain revolution. Waddell G. Md. The back pain revolution. Churchill Livingston 1998: 35. Churchill Livingston 1998: 35.

Epidemic Of The CenturyMusculoskeletal disorders are becoming Musculoskeletal disorders are becoming the “Epidemic Of The Century”. the “Epidemic Of The Century”.

They are the leading cause of disability in They are the leading cause of disability in the 6th decade of lifethe 6th decade of life

Yelin. EH, Trupin LS Sebesta DS. Yelin. EH, Trupin LS Sebesta DS. Transitions on employment, morbidity, Transitions on employment, morbidity, and disability among persons ages 51-61 and disability among persons ages 51-61 with musculoskeletal and non-with musculoskeletal and non-musculoskeletal conditions in the US, musculoskeletal conditions in the US, 1992-1994. Arthritis rheum, 1999; 1992-1994. Arthritis rheum, 1999; 42:769-779. 42:769-779.

.

Anatomical BasisThere are no scientific data that There are no scientific data that sustain the belief that muscles may be sustain the belief that muscles may be a source of chronic pain. a source of chronic pain.

On the other hand, controlled studies On the other hand, controlled studies have shown how common discogenic have shown how common discogenic pain and zygapophyseal joint pain are. pain and zygapophyseal joint pain are.

Bogduk. N MD, PhD. JMPT 1995; 18: Bogduk. N MD, PhD. JMPT 1995; 18: 603-5. The anatomical basis for spinal 603-5. The anatomical basis for spinal pain syndromes. pain syndromes.

Lumbar Paraspinal Muscles

The lumbar paraspinal muscles show The lumbar paraspinal muscles show histological evidence of atrophy and histological evidence of atrophy and “selective” atrophy of the multifidus “selective” atrophy of the multifidus muscle at the lower levels in chronic muscle at the lower levels in chronic LBP Pts vs controls. LBP Pts vs controls.

Danneels LV, CT Images of Trunk Danneels LV, CT Images of Trunk Muscles in Chronic LBP Pts & Muscles in Chronic LBP Pts & Healthy Control Subjects. Eur Spine Healthy Control Subjects. Eur Spine J, 2000; 9:266-272. J, 2000; 9:266-272.

Paraspinal Muscle SpindlesThe Role of Paraspinal Muscle Spindles in The Role of Paraspinal Muscle Spindles in Lumbosacral Position Sense in Individuals Lumbosacral Position Sense in Individuals With and Without Low Back Pain. With and Without Low Back Pain.

Brumagne S, et al Spine 2000; 25-989-Brumagne S, et al Spine 2000; 25-989-994. 994.

Repositioning Error In Low Back Pain

Controls

Low Back Pain Subjects

1.6 degrees

4.3 degrees (p<0.0001)

Medical Risks

Medical Treatment

Traditional medical treatmentTraditional medical treatmentuses NSAID’s to reduce uses NSAID’s to reduce symptoms and inflammation symptoms and inflammation rather then normalizing rather then normalizing mechanoreceptors and mechanoreceptors and proprioception.proprioception.

ComplicationsSingh G, Triadafilpoulos G. J Rheumatol, Singh G, Triadafilpoulos G. J Rheumatol, 1999; 26 Suppl 26: 18-24. Epidemiology 1999; 26 Suppl 26: 18-24. Epidemiology of NSAID Induced Gastrointestinal of NSAID Induced Gastrointestinal Complications.Complications.This data was drawn from the Arthritis, This data was drawn from the Arthritis, Rheumatism, and Aging Medical Rheumatism, and Aging Medical Information System (ARMIS). Information System (ARMIS). This system is a prospective observational This system is a prospective observational cohort study that collects data on subjects cohort study that collects data on subjects w chronic disease. w chronic disease. This data represents 36,000 pts seen at 17 This data represents 36,000 pts seen at 17 centers in the US & Canada, 12,000 of centers in the US & Canada, 12,000 of which have either RA or OA. which have either RA or OA.

Relative Risk of Hospitalization for Serious GI Complications

OA patients using NSAIDs

RA patients using NSAIDs

2.51X (vs non-users)

6.77X (vs non-users)

Complications

NSAIDs Complication

National Incidence Estimates Per Year

GI Hospitalizations

GI Death Rate

RA patients using NSAIDs

OA patients using NSAIDs

1/77 1/455

1/143 1/909

Complications

ComplicationsThese numbers calculate out to 16,000 These numbers calculate out to 16,000 deaths in the US each year from NSAIDs deaths in the US each year from NSAIDs use for “arthritis” patients. use for “arthritis” patients.

One of the greatest driving forces in One of the greatest driving forces in NSAIDs use for many musculoskeletal NSAIDs use for many musculoskeletal conditions is “they’re cheap / easy”. conditions is “they’re cheap / easy”.

The authors state that there are over The authors state that there are over 103,000 of these complications per year at 103,000 of these complications per year at an average cost of $15,000 to $20,000 an average cost of $15,000 to $20,000 each. each.

This would put the conservative estimate of This would put the conservative estimate of only the hospitalizations at over $2 billion.only the hospitalizations at over $2 billion.

Congestive Heart FailurePage J, Henry D. Archives of Int Med, Page J, Henry D. Archives of Int Med, 2000; 160:777-784. Consumption of 2000; 160:777-784. Consumption of NSAIDs and the Development of NSAIDs and the Development of Congestive Heart Failure in Elderly Congestive Heart Failure in Elderly Patients. Patients.

Term the relationship between NSAID use Term the relationship between NSAID use and CHF, “An unrecognized public health and CHF, “An unrecognized public health problem”. problem”.

The burden of illness resulting from The burden of illness resulting from NSAID-related CHF may exceed that NSAID-related CHF may exceed that resulting from GI tract damage”resulting from GI tract damage”

Risk of Hospitalization with CHF Following NSAID Use

Risk relative to non-users

All NSAID users

NSAID users with CV history

2.1X

10.5X

Congestive Heart Failure

Chiropractic Risks

Cost-effective & SafeThere is considerable empirical support There is considerable empirical support for the cost-effectiveness & safety of for the cost-effectiveness & safety of chiropractic management of chiropractic management of musculoskeletal disorders. musculoskeletal disorders.

The only two studies that do not show The only two studies that do not show significantly better cost-effectiveness (by significantly better cost-effectiveness (by Shekelle & Carey) are by medical Shekelle & Carey) are by medical researchers not economists & have researchers not economists & have significant design problems. significant design problems.

Manga P, PhD. Angus D PhD. Univ of Manga P, PhD. Angus D PhD. Univ of Ottawa.Ottawa.

Vertebrobasilar arteryVertebrobasilar artery dissection after Vertebrobasilar artery dissection after neck movement, trauma, or manipulation neck movement, trauma, or manipulation should be considered a rare, random, should be considered a rare, random, unpredictable complication associated unpredictable complication associated with these activities. with these activities.

Haldeman S, MD, PhD. Spine 1999; 24(8): Haldeman S, MD, PhD. Spine 1999; 24(8): 785-794. Risk Factors and Precipitating 785-794. Risk Factors and Precipitating Neck Movements Causing Vertebrobasilar Neck Movements Causing Vertebrobasilar Artery Dissection After Cervical Trauma Artery Dissection After Cervical Trauma and Spinal Manipulation. and Spinal Manipulation.

Clinical TrailsA few randomized clinical trails A few randomized clinical trails examining the use of SMT for patients examining the use of SMT for patients with radiculopathy have been with radiculopathy have been reported and suggested favorable reported and suggested favorable outcomes compared to other outcomes compared to other treatments. treatments.

Bronfort G, Haldeman S. Sem Spine Bronfort G, Haldeman S. Sem Spine Surg, 1999; 11; 97-103. Spinal Surg, 1999; 11; 97-103. Spinal Manipulation in Patients with Lumbar Manipulation in Patients with Lumbar Disc Disease.Disc Disease.

Clinical Trails ConcludeThree randomized trails examining Three randomized trails examining spinal manipulation for radiculopathy spinal manipulation for radiculopathy all found it to be superior to the all found it to be superior to the comparative treatment.comparative treatment.Several prospective case series have Several prospective case series have suggested spinal manipulation to be suggested spinal manipulation to be effective in patients with effective in patients with radiculopathy.radiculopathy.The quality of these studies has been The quality of these studies has been poor leading to dismissal of the poor leading to dismissal of the results by most non-chiropractic results by most non-chiropractic experts.experts.

Clinical Trails ConcludeNot a single serious complication has Not a single serious complication has been reported in these trails that been reported in these trails that have involved over 2600 patients.have involved over 2600 patients.

““Current research, however, Current research, however, suggests that it (spinal manipulation suggests that it (spinal manipulation for radiculopathy) is of benefit and for radiculopathy) is of benefit and worthy of inclusion into a worthy of inclusion into a comprehensive spine management comprehensive spine management program”.program”.

Side Effects of SMTOver 4700 treatments with spinal Over 4700 treatments with spinal manipulation given to 1058 patients was manipulation given to 1058 patients was studied. studied.

There was not a single serious complication There was not a single serious complication and also none that resulted in secondary tx. and also none that resulted in secondary tx.

This number of treatments is well with in This number of treatments is well with in the range where GI complications would be the range where GI complications would be expected. expected.

Senstad O, et al. Spine 1997: 22: 435-441 Senstad O, et al. Spine 1997: 22: 435-441 Frequency and Characteristics of Side Frequency and Characteristics of Side Effects of Spinal Manipulative Therapy. Effects of Spinal Manipulative Therapy.

Neck Pain

The yearly prevalence of neck The yearly prevalence of neck pain is approximately 35% of pain is approximately 35% of the adult population and the adult population and approximately 15% have approximately 15% have chronic pain. chronic pain.

Bovem, et al Spine Bovem, et al Spine 1994;19:1307-1309. Neck Pain 1994;19:1307-1309. Neck Pain in the General Population.in the General Population.

EvidenceNo evidence exists for most common No evidence exists for most common treatments of neck pain such as physical treatments of neck pain such as physical therapy modalities and all drug therapy modalities and all drug treatments. treatments.

Manipulation & mobilization have the most Manipulation & mobilization have the most trails examining its efficacy and the trails examining its efficacy and the greatest number of trails with positive greatest number of trails with positive outcomes.outcomes.

Florian T. J Back Musculoskeletal Florian T. J Back Musculoskeletal Rehabil,1991;1:55-66. Conservative Rehabil,1991;1:55-66. Conservative Treatment for Neck Pain: Distinguishing Treatment for Neck Pain: Distinguishing Useful from Useless Therapy. Useful from Useless Therapy.

Whiplash InjuryKahn S, Cook J, Gargan M Bannister G. Kahn S, Cook J, Gargan M Bannister G. J Orthopaedic Medicine,1999;21:22-25. J Orthopaedic Medicine,1999;21:22-25. A Symptomatic Classification of A Symptomatic Classification of Whiplash Injury & the Implications for Whiplash Injury & the Implications for Treatment.Treatment.Group 1. Neck pain / restricted ROM.Group 1. Neck pain / restricted ROM.Group 2. Additional neurological signs Group 2. Additional neurological signs and symptoms.and symptoms.Group 3. Significant reported pain, but Group 3. Significant reported pain, but full ROM.full ROM.

Group 1 Group 2 Group 3

Some Benefit

Asymptomatic

72% 94% 27%

24% 38% 0%

Results with Chiropractic Manipulation

The authors comment in their abstract that “Chiropractic is the only proven effective treatment in chronic cases (of whiplash)”.

Cervical Kinesthesia

Spinal manipulation resulted in a Spinal manipulation resulted in a 41% improvement in repositioning 41% improvement in repositioning error, while patients receiving error, while patients receiving active rehabilitation improved only active rehabilitation improved only 12 %. 12 %.

Rogers R. JMPT, 1997;20:80-85. Rogers R. JMPT, 1997;20:80-85. The Effects of Spinal Manipulation The Effects of Spinal Manipulation on Cervical Kinesthesia in Patients on Cervical Kinesthesia in Patients With Chronic Neck Pain.With Chronic Neck Pain.

Reduced Positioning ErrorThis study compared spinal This study compared spinal manipulation, acupuncture, and manipulation, acupuncture, and NSAIDs and found SMT & acupuncture NSAIDs and found SMT & acupuncture significantly reduced positioning significantly reduced positioning error, while NSAIDs did not. error, while NSAIDs did not. Heiklila H et al. Manual Therapy, Heiklila H et al. Manual Therapy, 2000; 5: 151-157. Effects of 2000; 5: 151-157. Effects of Acupuncture, Cervical Manipulation Acupuncture, Cervical Manipulation and NSAID Therapy on Dizziness and and NSAID Therapy on Dizziness and Impaired Head Repositioning Of Impaired Head Repositioning Of Suspected Cervical Origin: A Pilot Suspected Cervical Origin: A Pilot Study.Study.

In Summary

Chiropractic Adjustments to Chiropractic Adjustments to Spinal Joints Return Functional Spinal Joints Return Functional Biomechanics & Reduces Biomechanics & Reduces Reoccurrence of SymptomsReoccurrence of Symptoms

Chiropractic is SafeChiropractic is Safe

The OutcomeRefer your patients with postural Refer your patients with postural imbalances, acute and chronic imbalances, acute and chronic back, neck symptoms and lifestyle back, neck symptoms and lifestyle management issues. management issues.

You will help those patients get You will help those patients get better and they will love you for it. better and they will love you for it.

The chiropractor will keep you The chiropractor will keep you informed of their progress and informed of their progress and work with you as the primary care work with you as the primary care provider.provider.

ChiropracticWhen (Why) to Refer