Chiropractic When (Why) to Refer. The Communication Gap. Confronting The Communication Gap Between Conventional And Alternative Medicine: A Survey Of Physicians. 19% of the physicians responding reported personally using manipulation.
The Communication Gap • Confronting The Communication Gap Between Conventional And Alternative Medicine: A Survey Of Physicians. • 19% of the physicians responding reported personally using manipulation. • Of these practitioners, 83% stated that they found it beneficial. • Ironically, only 32% of those using alternative therapies felt that their personal use was adequate to gauge the effectiveness of a particular therapy. • Crook RD, Jarjoura D, Polen A, Ruecki GW. Altern Ther health med, 1999; 5:61-66.
Acute LBP in Adults • Clinical Practice Guidelines, Number 14, Rockville, Maryland: US Dept Of Health and Human Services, Public Health Service, AHCPR, 1994. Bigos S, Bower O, et al. • Most effective physical method is manipulation • Muscle relaxants were no more effective than NSAIDs • No demonstrable benefit to combining w/NSAIDs • Opioids no more effective than safer analgesics
Spinal Proprioception • Human facets contain mechanoreceptors that detect motion and distortion and provide proprioception and protective information to the CNS regarding joint function and position. • Spinal proprioception may play a role in protective muscular reflexes that prevent injury or facilitate healing. • Mclain RF, MD, Pickar JG, DC PhD. Spine 1998; 21(2): 168-173.
Mechanoreceptors • The mechanoreceptors in ligaments & joint capsules influence gamma-motor neurons and modulate activity and joint stabilization. • Failure or destruction of MRs’ ability to provide feedback contributes to unpredictable “giving way” and may result in DJD and muscle atrophy. • Nyland, Med, PT, ATC. JOSPT 1994; 19(1): 2-11.
Proprioceptors • Proprioceptors provide postural & kinesthetic sensation to the sensory regions of the cerebral cortex allowing the brain to make informed decisions for effective motor programs. • Afferent input enables motor program changes based on information provided by changes in body position. • Nyland, Med, PT, ATC. JOSPT 1994; 19(1): 2-11.
Proprioceptors • Articular proprioceptors respond primarily to the extremes rather than to the mid-ranges of joint motion. • They may initiate protective muscular reflexes important in preventing joint degeneration & instability. • McLain MD. Spine 1994; 19(5): 495-501.
Altered Mechanoreception • Altered mechanoreception has a direct effect on reflex activity of muscle crossing the joint. • Joint deafferentation may accelerate degenerative changes. • Disturbance of articular innervations may play a role in the development of degenerative diseases and joint dysfunction. • McLain MD. Spine 1994; 19(5): 495-501
Interdependence • An injured joint is likely to cause persistently disturbed sensory feedback to the CNS and therefore existing motor programs have to be modified. • Sensory receptors in the joint can influence muscle tone. • This produces an interdependence between biomechanical & neurological mechanisms. • Johansson (Dept Physio), Neuro-orthopedic 1990; 9:1-23.
Chiropractic normalizes proprioception & spinal fine motor tuning which effect neurological mechanisms.
Chiropractic Office Visit • Past Medical History: R/O pathology. • Differential Diagnosis • Physical Examination – Vital Signs, Orthopedic and Neurological Testing. • Postural Imbalances, Muscular Dysfunction and Abnormalities of Joint Movement. • Outcomes Assessment Tools (Pain Drawings & Visual Analogue Scales) to document progress.
Rehab Without Adjustments • Rehab must not be solely based on symptom relief. • It must address more than pain. Rehab must be oriented towards restoration of function, not just relief of symptoms. • The patient has a functional disability after an injury and until it is addressed, these functional changes will persist.
Effects fine motor tuning and results in improved sensorimotor function Enhanced kinesthetic perception, agility, and balance Increased range & symmetry of motion Improved joint stability Better coordination & balance of muscle tone More symmetrical load distribution, less localized biomechanical stress Improved control,coordination Optimized peak performance Reduced risk of injury & degeneration Normalizing Proprioception
Common Assumptions • About spine pain: • Over 80% of spine pain is acute and less than 20% is chronic. • The majority of spine pain is self limiting, resolving in 6-8 weeks. • Both assumptions are false.
Chronic LBP • When patients presented to primary care for an episode of acute LBP were surveyed 1 year later, 75% had pain in the past month. • Von Korf, PhD. Spine 1993: • Patients with LBP receiving primary care typically have recurrent LBP; evidence is increasing that patients are more likely to have chronic phases of LBP than was previously believed. • Available evidence does not support the effectiveness of med treatments for long term control of chronic and recurrent pain for most patients with LBP • Von Korf, PhD. Ann. Int Med 1994; 121: 187-195
Chronic LBP • Wahlgren, MD Pain, 1997; 73: 213-221 • One Year Follow-up Of First Onset of LBP • Croft, BMJ 1998; 1316-1359 Outcome of LBP in General Practice: A Prospective Study • Finding 72% and 75% respectively reported more back pain at one year. • More likely than not that once pain begins, it is a chronic problem of exacerbation and remission.
Trauma • Regional musculoskeletal disorders afflict otherwise well, working age adults who have had no physical exposure unusual for them. • There is little direct evidence that most back pain stems from a discrete or repetitive trauma. • Back pain seldom results from a fall, direct impact or extraordinary physical demands. • Hadler MD, Carey MD. JAMA 2000: 2780-1.
A Fluctuating Course • One of the main characteristics of BP is that it often runs a fluctuating course. • An isolated acute attack with no previous history and complete recovery is rare. • The most important feature of chronic pain is not its duration but its impact on the patient’s life. • Waddell G. Md. The back pain revolution. Churchill Livingston 1998: 35.
Epidemic Of The Century • Musculoskeletal disorders are becoming the “Epidemic Of The Century”. • They are the leading cause of disability in the 6th decade of life • Yelin. EH, Trupin LS Sebesta DS. Transitions on employment, morbidity, and disability among persons ages 51-61 with musculoskeletal and non-musculoskeletal conditions in the US, 1992-1994. Arthritis rheum, 1999; 42:769-779. .
Anatomical Basis • There are no scientific data that sustain the belief that muscles may be a source of chronic pain. • On the other hand, controlled studies have shown how common discogenic pain and zygapophyseal joint pain are. • Bogduk. N MD, PhD. JMPT 1995; 18: 603-5. The anatomical basis for spinal pain syndromes.
Lumbar Paraspinal Muscles • The lumbar paraspinal muscles show histological evidence of atrophy and “selective” atrophy of the multifidus muscle at the lower levels in chronic LBP Pts vs controls. • Danneels LV, CT Images of Trunk Muscles in Chronic LBP Pts & Healthy Control Subjects. Eur Spine J, 2000; 9:266-272.
Paraspinal Muscle Spindles • The Role of Paraspinal Muscle Spindles in Lumbosacral Position Sense in Individuals With and Without Low Back Pain. • Brumagne S, et al Spine 2000; 25-989-994. Repositioning Error In Low Back Pain Controls 1.6 degrees Low Back Pain Subjects 4.3 degrees (p<0.0001)
Medical Treatment • Traditional medical treatmentuses NSAID’s to reduce symptoms and inflammation rather then normalizing mechanoreceptors and proprioception.
Complications • Singh G, Triadafilpoulos G. J Rheumatol, 1999; 26 Suppl 26: 18-24. Epidemiology of NSAID Induced Gastrointestinal Complications. • This data was drawn from the Arthritis, Rheumatism, and Aging Medical Information System (ARMIS). • This system is a prospective observational cohort study that collects data on subjects w chronic disease. • This data represents 36,000 pts seen at 17 centers in the US & Canada, 12,000 of which have either RA or OA.
Complications Relative Risk of Hospitalization for Serious GI Complications OA patients using NSAIDs 2.51X (vs non-users) RA patients using NSAIDs 6.77X (vs non-users)
Complications NSAIDs Complication National Incidence Estimates Per Year GI Hospitalizations GI Death Rate RA patients using NSAIDs 1/77 1/455 OA patients using NSAIDs 1/143 1/909
Complications • These numbers calculate out to 16,000 deaths in the US each year from NSAIDs use for “arthritis” patients. • One of the greatest driving forces in NSAIDs use for many musculoskeletal conditions is “they’re cheap / easy”. • The authors state that there are over 103,000 of these complications per year at an average cost of $15,000 to $20,000 each. • This would put the conservative estimate of only the hospitalizations at over $2 billion.
Congestive Heart Failure • Page J, Henry D. Archives of Int Med, 2000; 160:777-784. Consumption of NSAIDs and the Development of Congestive Heart Failure in Elderly Patients. • Term the relationship between NSAID use and CHF, “An unrecognized public health problem”. • The burden of illness resulting from NSAID-related CHF may exceed that resulting from GI tract damage”
Congestive Heart Failure Risk of Hospitalization with CHF Following NSAID Use Risk relative to non-users All NSAID users 2.1X NSAID users with CV history 10.5X
Cost-effective & Safe • There is considerable empirical support for the cost-effectiveness & safety of chiropractic management of musculoskeletal disorders. • The only two studies that do not show significantly better cost-effectiveness (by Shekelle & Carey) are by medical researchers not economists & have significant design problems. • Manga P, PhD. Angus D PhD. Univ of Ottawa.
Vertebrobasilar artery • Vertebrobasilar artery dissection after neck movement, trauma, or manipulation should be considered a rare, random, unpredictable complication associated with these activities. • Haldeman S, MD, PhD. Spine 1999; 24(8): 785-794. Risk Factors and Precipitating Neck Movements Causing Vertebrobasilar Artery Dissection After Cervical Trauma and Spinal Manipulation.
Clinical Trails • A few randomized clinical trails examining the use of SMT for patients with radiculopathy have been reported and suggested favorable outcomes compared to other treatments. • Bronfort G, Haldeman S. Sem Spine Surg, 1999; 11; 97-103. Spinal Manipulation in Patients with Lumbar Disc Disease.
Clinical Trails Conclude • Three randomized trails examining spinal manipulation for radiculopathy all found it to be superior to the comparative treatment. • Several prospective case series have suggested spinal manipulation to be effective in patients with radiculopathy. • The quality of these studies has been poor leading to dismissal of the results by most non-chiropractic experts.
Clinical Trails Conclude • Not a single serious complication has been reported in these trails that have involved over 2600 patients. • “Current research, however, suggests that it (spinal manipulation for radiculopathy) is of benefit and worthy of inclusion into a comprehensive spine management program”.
Side Effects of SMT • Over 4700 treatments with spinal manipulation given to 1058 patients was studied. • There was not a single serious complication and also none that resulted in secondary tx. • This number of treatments is well with in the range where GI complications would be expected. • Senstad O, et al. Spine 1997: 22: 435-441 Frequency and Characteristics of Side Effects of Spinal Manipulative Therapy.
Neck Pain • The yearly prevalence of neck pain is approximately 35% of the adult population and approximately 15% have chronic pain. • Bovem, et al Spine 1994;19:1307-1309. Neck Pain in the General Population.
Evidence • No evidence exists for most common treatments of neck pain such as physical therapy modalities and all drug treatments. • Manipulation & mobilization have the most trails examining its efficacy and the greatest number of trails with positive outcomes. • Florian T. J Back Musculoskeletal Rehabil,1991;1:55-66. Conservative Treatment for Neck Pain: Distinguishing Useful from Useless Therapy.
Whiplash Injury • Kahn S, Cook J, Gargan M Bannister G. J Orthopaedic Medicine,1999;21:22-25. • A Symptomatic Classification of Whiplash Injury & the Implications for Treatment. • Group 1. Neck pain / restricted ROM. • Group 2. Additional neurological signs and symptoms. • Group 3. Significant reported pain, but full ROM.
Results with Chiropractic Manipulation Group 1 Group 2 Group 3 Some Benefit 72% 94% 27% Asymptomatic 24% 38% 0% 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 41% improvement in repositioning error, while patients receiving active rehabilitation improved only 12 %. • Rogers R. JMPT, 1997;20:80-85. The Effects of Spinal Manipulation on Cervical Kinesthesia in Patients With Chronic Neck Pain.
Reduced Positioning Error • This study compared spinal manipulation, acupuncture, and NSAIDs and found SMT & acupuncture significantly reduced positioning error, while NSAIDs did not. • Heiklila H et al. Manual Therapy, 2000; 5: 151-157. Effects of Acupuncture, Cervical Manipulation and NSAID Therapy on Dizziness and Impaired Head Repositioning Of Suspected Cervical Origin: A Pilot Study.
In Summary • Chiropractic Adjustments to Spinal Joints Return Functional Biomechanics & Reduces Reoccurrence of Symptoms • Chiropractic is Safe
The Outcome • Refer your patients with postural imbalances, acute and chronic back, neck symptoms and lifestyle management issues. • You will help those patients get better and they will love you for it. • The chiropractor will keep you informed of their progress and work with you as the primary care provider.