Chiropractic: What is it good for? Current Topics in Chiropractic - - PowerPoint PPT Presentation

Current Topics in Chiropractic David Folweiler, DC Folweiler Chiropractic

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Chiropractic: What is it good for?

Outline For Tonight’s Presentation

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 Chiropractic Characteristics  Rationale for Manipulation  Rationale for instrument-assisted soft tissue manipulation

(Graston)

 Clinical Evidence for Manipulation  Case Studies  Indications for Chiropractic  Questions and Answers

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Chiropractic Characteristics

 70,000 active DC licenses  19 chiropractic schools  1000+ hrs training in manipulation  Emphasis on spine & neuro-musculoskeletal conditions  94% of manipulations in US

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Presenting Complaints

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Etiology of Patient Conditions

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Chiropractic Evaluation

 History  Physical examination

 Neurologic  Orthopedic  Chiropractic structural (i.e. posture, joint motion/position)  Functional (i.e. wall angel, squat, lunge, single leg balance)

 Imaging

 Plain film radiography  Advanced imaging

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Chiropractic Management

 Spinal and extremity

manipulation

 Soft tissue techniques

 Graston  Nimmo (ischemic pressure)  Stretching

 NMS rehabilitation

 Exercise  Core stability  Active care

 Referral or co-management  Advice

 Healthy lifestyle  Nutrition  Postural  Ergonomic  Reassurance  Exercise

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Chiropractic Treatment

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Manipulation/Adjustments

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Why Manipulate?

 Rat Joint Dysfunction Model

 Mechanical fixation causes degenerative changes of facet joints

(osteophytes, articular cartilage pitting & remodeling, and adhesions) in as little as 1 week



Cramer GD, Fournier JT, Henderson CN, Wolcott CC. Degenerative changes following spinal fixation in a small animal model. J Manipulative Physiol Ther 2004;27(3):141-54.

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Osteophyte Formation

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Induced Hypomobility

 Surgically placed fixation devices

in rats

 Hypomobility for 8, 12, or 16

weeks, L4-6

 Number and size of adhesions

were measured



Zygapophyseal Joint Adhesions After Induced Hypomobility. Cramer GD et al. J Manipulative Physiol Ther 2010;33:508-518

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Adhesions After Induced Hypomobility

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Normal Z- joints w/ + w/o synovial fold Small adhesion Medium adhesion Large adhesion

Results of Induced Hypomobility

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Gapping of Zygapophyseal Joints

 64 healthy chiropractic students randomized into 4 groups:



Cramer GD - The Effects of Side-Posture Positioning and Spinal Adjusting on the Lumbar Z Joints; Spine Volume 27, Number 22, pp 2459–2466

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Side-Posture Adjustment for Group 3

 Performed between the two scans

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Second Scan for Groups 1 and 3

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MRI Scans

 Upper row is first and

second MRIs of control group

 Lower row is pre- and

post-adjustment for group 3

 Note gapping in left z-

joint, likely caused by cavitation of synovial fluid

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Greatest Gapping

 Greatest gapping occurred in adjusted subjects

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Effect of Instrument-Assisted STM

 51 rats had surgically induced bilateral MCL tears  7 controls with no intervention  After one week

 31 treated 3x/wk x 3 wks  20 treated 3x/wk x 10 wks  Only left MCL treated

 Treated ligaments were 43.1%

stronger, 39.7% stiffer, and could absorb 57.1% more energy before failure at 4 weeks



Loghmani, MT et al; Instrument-Assisted Cross-Fiber Massage Accelerates Knee Ligament Healing; J Orthop Sports Phys Ther 2009;39(7):506-514.

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Histological Sections

(A) noninjured knee medial collateral ligament (MCL) in a cage-control animal, (B) scar region in a nontreated MCL at 4 weeks following injury, (C) scar region in an instrument-assisted cross-fiber massage (IACFM)-treated MCL at 4 weeks following injury, (D) scar region in a nontreated MCL at 12 weeks following injury, and (E) scar region in an IACFM-treated MCL at 12 weeks following injury. Black arrows indicate fibroblasts aligned parallel to the collagen fibrils in a noninjured ligament. White arrows indicate scar region in injured ligaments. 22

Electron Microscopic Sections

(A) intact knee medial collateral ligament (MCL) in a control animal, (B) non-treated MCL at 4 weeks following injury, and (C) instrument-assisted cross-fiber massage (IACFM)-treated MCL at 4 weeks following injury. Note the close appearance of the IACFM-treated ligament (C) to the non-injured ligament from a control animal (A). Also, note the large amount of surrounding granulation tissue in the non-treated, but injured ligament (C) relative to the other 2 ligaments. 23

Clinical Evidence about Manipulation

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Hierarchy of Evidence

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Acute and Subacute Low Back Pain

 Strong evidence supports the use of spinal manipulation to

reduce symptoms and improve function.

 Chiropractic management of low back pain and low back-related leg

complaints: a literature synthesis.

 Part of the Council on Chiropractic Guidelines & Practice Parameters

(CCGPP) 2008

 Reviewed 887 source papers



Lawrence DJ et al J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):659-74. [(CCGPP) 2008]

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Acute and Subacute Low Back Pain

 Good evidence that the use of exercise in conjunction with

manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence.



CCGPP 2008

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LBP & Radiating Leg Pain

 Fair evidence for the use of manipulation for patients with

LBP and radiating leg pain, sciatica, or radiculopathy

 Manipulation in combination with other common forms of

therapy may be of clinical value.



CCGPP 2008

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Chronic LBP

 Strong evidence supports the use of spinal

manipulation/mobilization to reduce symptoms and improve function.



CCGPP 2008

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Manipulation & Mobilization Effective for:

 Whiplash associated disorders (WAD)  Neck pain



Hurwitz EL et al. 2008

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Systematic Review of Randomized Controlled Trials

 13 musculoskeletal conditions  4 types of chronic headache  9 non- musculoskeletal conditions  49 relevant systematic reviews  16 evidence-based guidelines  46 additional RCTs



Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3.

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Manipulation is effective for:

 Low back pain – acute, subacute, and chronic  Headaches – migraines and cervicogenic  Cervicogenic dizziness  Neck pain – acute, subacute, and chronic  Shoulder pain



Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3.

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Manipulation and exercise is effective for:

 Knee and hip osteoarthritis  Plantar fasciosis  Lateral epicondylosis



Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3.

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Evidence is inconclusive, but favorable for SMT/mobilization in adults for:

 Sciatica/radiating leg pain  Coccydynia  Thoracic pain  Shoulder pain  Carpal tunnel syndrome  Ankle sprains  Knee OA  Lateral epicondylosis  TMD



Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3.

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Dose Response

 Cervicogenic headaches (at least 5 cervicogenic HAs per

month for a minimum of 3 months)

 4 week trial, n=24  1, 3, or 4 treatments per week.  Higher frequency associated with better outcomes for HAs



Dose Response For Chiropractic Care Of Chronic Cervicogenic Headache And Associated Neck Pain: A Randomized Pilot Study - Mitchell Haas, et al J Manipulative Physiol Ther 2004;27:547–553

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TX Frequency Effect on Head Pain

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10 20 30 40 50 60 0 weeks 4 weeks 12 weeks 1 TX/week 3 TXs/week 4 TXs/week

treatment ends

TX Frequency Effect on HA Disability

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5 10 15 20 25 30 35 40 45 50 0 weeks 4 weeks 12 weeks 1 TX/week 3 TXs/week 4 TXs/week treatment ends

TX Frequency on Cervicogenic HAs

 Outcome was dose dependent  “Findings suggest the benefit of 9 to 12 visits over 3 weeks

for the treatment of HA/neck pain and disability. A larger number of visits than 12 in 3 weeks may be required for maximum relief and durability of outcomes.”



Dose Response For Chiropractic Care Of Chronic Cervicogenic Headache And Associated Neck Pain: A Randomized Pilot Study - Mitchell Haas, et al J Manipulative Physiol Ther 2004;27:547–553

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Dose Response for Cervicogenic HAs

 Eighty subjects randomized to receive either light massage

(LM) or manipulation (SMT)

 SMT was limited to cervical and upper thoracic spine  LM was performed for 5 minutes following 5 minutes of

moist heat

 Patients were treated once or twice per week for 8 weeks



Haas M et al; Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: a pilot randomized controlled trial; The Spine Journal 10 (2010) 117–128

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Adjusted Mean Cervicogenic HA Pain

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treatment ends

Adjusted Mean Number of Cervicogenic HAs

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treatment ends

Dose Response for Cervicogenic HAs

 Results show less dose dependence than pilot  Limitations: only 1 or 2 treatments per week, higher

frequencies not tested

 Blinding not possible for subject or doctor

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Lower Disability

 Prospective study of 1885 injured Washington State workers  First provider seen was a strong predictor of work disability

at 1 year, chiropractors had OR of 0.41 [95% CI 0.24-0.70]

 Possible selection bias, chiropractors may see less significant

pathology

 Future RCT for first provider?



Turner JA et al; Early Predictors of Chronic Work Disability: A Prospective, Population-Based Study of Workers With Back Injuries; Spine 2008; 33 (25): 2809–2818

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Side Effects and Risks of Manipulation

 4712 treatments on 1058 new patients by 102 Norwegian

chiropractors

 55% had at least one reaction

 Local discomfort (53%) (similar to starting new exercise)  Headache (12%)  Tiredness (11%)  Radiating discomfort (10%)

 74% of reactions lasted < 24 hours  No reports of serious complications



Frequency and characteristics of side effects of spinal manipulative therapy. Senstad O, Leboeuf-Yde C, Borchgrevink C. Spine (Phila Pa 1976). 1997 Feb 15;22(4):435-40; discussion 440-1.

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Side Effects and Risks of Manipulation

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local discomfort, 53% headache, 12% tiredness, 11% radiating discomfort, 10% dizziness, 5% nausea, 4% hot skin, 2%

• ther,

2%

Risk Associated with Chiropractic Treatment of Lumbar Disk Herniations

 Systematic review  Estimate of risk < 1 in 3.7 million  “Disk prolapse could occur only in an already fissured and

fragmented disk”



Oliphant D - J Manipulative Physiol Ther 2004;27:197-210

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Stroke and Manipulation

 Very rare event  818 vertebrobasilar artery (VBA) strokes admitted to

Ontario hospitals over 9 years with 4x age and gender matched controls (109,020,875 person-years of observation)

 > 45 y/o, no increased association between chiropractic

visits and VBA stroke

 < 45 y/o, three times more likely to see a chiropractor or a

PCP before their stroke than controls



Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based, Case-Control and Case-Crossover Study. Cassidy JD et al. J Manipulative Physiol Ther. 2009 Feb;32(2 Suppl):S201-8.

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Stroke and Manipulation

 PCP or DC visit before stroke likely due to patients with

headache and neck pain from VBA dissection seeking care before their stroke

 No evidence of excess risk of VBA stroke associated

chiropractic care compared to primary care



Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based, Case-Control and Case-Crossover Study. Cassidy JD et al. J Manipulative Physiol Ther. 2009 Feb;32(2 Suppl):S201-8.

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Case studies

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25 y/o Computer Sales Clerk

 Left gluteal pain with radiation below the knee, x 2 weeks  ↑ pain with Valsalva, denies paresthesia  Exam: limps, slouches (flexion) in chair, neurologically

intact, except generalized partial loss of light touch in LLE, negative SLR with dorsiflexion and Valsalva, unlevel pelvis, fixations in L-spine, negative hip testing, hypertonic and tender g. max.

 DX: suspected disk herniation  TX: spinal manipulation, extension and spinal stabilization

exercises, taught spine sparing strategies

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25 y/o Computer Sales Clerk

 Results: near complete relief in four visits, then exacerbated

by lifting heavier objects at work, is recovering again

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58 y/o Grandmother with Heel Pain

 Heel feels “bruised”  Pain starts after a few steps, worsens as day progresses  Walking is limited due to pain  Exam: T&T plantar muscles, tender heel fat pad, joint

restrictions in the subtalar joint and navicular

 DX: plantar fasciosis  TX: Graston instrument-assisted soft tissue mobilization,

2x/week decreasing to once per 2 weeks, home stretch

 Results: no pain or limitation in walking after 12 visits

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Graston Technique

 Short duration (1 minute maximum)  Break up fibrosis/adhesions (can be felt

through tool)

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50 y/o Chocolate Maker with Shoulder Pain

 Right shoulder pain for several years  “dull ache” near AC joint, crepitus, limited ROM  Exam: pain with ext and horizontal add, (-) ortho tests,

elevated right shoulder, ant head, hyperkyhotic, rounded shoulders, loss of intersegmental motion in c/t spine, ↓ inferior glide GH, tender AC jt., T+T c/t p-s, teres minor, serratus ant

 TX: 2x/wk (x 3wks) manipulation of spine and shoulder,

TPT to mm., foam roll mobilization of t-sp in ext

 Results: ↓ pain, ↑mobility, improved posture

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Thoracic Extension Mobilization

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45 y/o MMA Instructor with Whiplash

 Referred in by Seroussi  MVC 2 months prior, frontal impact  Transported to ED with HA & vomiting  HAs, suboccipital, refer to temporal region  Neck, MB and LBP  Exam: well developed, ↓ROM w/pain, intact neuro  X-rays: loss of c-spine lordosis, mild DISH at C2-3

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45 y/o MMA Instructor with Whiplash

 DX: acceleration/deceleration trauma (strain/sprain),

cervicogenic/post-traumatic HA, post-concussive syndrome

 TX: 3x/wk manipulation, referred for massage, co-

treatment here (meds & IMS), acupuncture

 Results: slow, steady improvement until second MVC four

months later and third six weeks after that

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59 y/o Teacher with Left Knee Pain

 Sedentary, obese  “ache” in left knee, ant & post, started as LBP  Co-morbidity - diabetic peripheral neuropathy  Two prior episodes of sciatica  Less pain with initiating walking  Fatigues with longer walking

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59 y/o Teacher Exam

 Gait is unsteady, stance is wide  Minor’s signs on rising  LE pain with lumbar flexion and LLF  Delayed R DTRs, absent on L  (+) heel walk on L, unsteady tandem gait  SLR to 70° on L, popliteal pain with dorsiflexion  Sensation symmetric  4/5 L EHL, knee ext & flex, dorsiflexors

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59 y/o Teacher DX & TX

 DX: sciatica 2° to disk/spinal pathology  Trial of TX: 5 TXs of manipulation, stretching (hip ext rot),

and flexion/distraction

 Results: ↓↓ pain, centralization, but weakness persisted  MRI @ CDI: foraminal stenosis and bulging at most levels,

CSF effacement, “tortuous, redundant cauda equina”

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59 y/o Teacher MRI

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59 y/o Teacher

 Conservative care reduced and centralized his pain, but failed

to improve his weakness

 Referred to neurosurgeon – had laminectomy and

diskectomy at L3-4 and L4-5 on left

 Results: no pain, increased strength ~ 4 weeks post-surgery,

lost to follow-up since

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Indications for Chiropractic Care

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Indications for Chiropractic Care

 Neck, mid-back, low back, sacroiliac pain w/ or w/o rads  Whiplash associated disorders (WAD)  Cervicogenic headaches/dizziness/dysequlibrium  Migraine headaches  Radiculopathy/herniated disk(s)/sciatica  Tendinopathy/-oses (tennis elbow, plantar fasciosis, etc.)  Temporomandibular disorder (TMD)  Neurogenic thoracic outlet syndrome (TOS)  Chest wall/rib pain  Sports injuries

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Relative Indications for Chiropractic

 Centrally mediated pain  Fibromyalgia (perhaps better with gentler techniques)  Inflammatory arthritis (not during acute inflammatory state)  Coccydynia  Joint instability  Compression fractures/marked osteoporosis

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Contraindications for Chiropractic

 Metastatic cancer  Septic arthritis  Fracture (at least until stable)

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Credits*

 John Taylor, DC, DACBR  Michael Neely, DC  Stephen M. Perle, DC

*(I stole their ideas and slides)

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Q & A

David Folweiler, DC • Folweiler Chiropractic 10564 Fifth Ave NE #202, Seattle, WA 98125 206-523-3855 • drdave@folweiler.com

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