who is in charge? Lise Hestbk DC, PhD Childrens musculoskeletal - PowerPoint PPT Presentation

Children’s musculoskeletal health – who is in charge? Lise Hestbæk DC, PhD

Children’s musculoskeletal health – who is in charge? Extensive public health issue Reliable and trustworthy profession Recommended and safe treatment

Now (2018) • 5 year education at Danish university Then (1990) integrated with medicine • Clinical training in hospitals and in private Educated in the UK or USA • clinics ” Quackery Act ” • • Chiropractic legislation • Private liability insurance Chiropractic patients covered by Danish • • No chiropractors employed National Patient Insurance, no fault outside of private practice • Many chiropractors involved in hospitals, Little or no inter- professional • multidisciplinary MSK rehabilitation centers, integration radiology departments, regional health administration, national task forces, national No research activity, no • guideline committees etc. chiropractors with PhDs Danish chiropractors are leading • Unimployment • researchers in the field of musculoskeletal health, both nationally and internationally 4% of the chiropractors have a PhD degree • Full employment, cannot meet demand •

Courage and political leadership Substantial and sustained funding for research and postgraduate education Partnerships and commitment

Foundation for Chiropractic Research and Postgraduate Education 6.2% Foundation for Chiropractic Research and Postgraduate Education 9.5% ~ 5.6 mill CAD/year

Foundation for Chiropractic Research and Postgraduate Education

Substantial and sustained funding for research and postgraduate education

Nordic Institute of Chiropractic and Clinical Biomechanics (NIKKB) Continued Professional Education Research Quality insurance and Imaging

NIKKB: general strengths • The profession has accepted responsibility to do research • Flat and small organisational structure • Short distance from decision to action • Economically rooted in the profession • Focus on end user • Bridge-building between academia and practice • Close dialogue with users

Dept. of Sports Science and Clinical Biomechanics, Faculty of Health, University of Southern Denmark

Danish Chiropractic Education 3 years 2 years 1 year Chiropractor Internship M.Sc. B.Sc. Admittance

Clinical Education o Spine Centre of Southern Denmark • Largest rheumatological department • 20,000 new pts per year • Many different units – Rheumatology, orthopaedic, imaging etc. • Broad sprectum of MSK problems • Part of a multidisciplinary team o Internships in other departments • Orthopaedic department • Rheumatological department o Internship in private chiropractic practice

≈ 1 yr differential diagnosis - From healthy to sick ≈ 1 yr skills training - MSK diagnosis - Palpation - Diagnostic imaging 1 + 2 - Clinical biomechanics - Diagnosis 1+2+3 - spinal column - Neurology - extremities - General diagnosis - Theoretical biomechanics - Orthopaedics - Health psychology and ethics - Rheumatology - Exercise thearpy - Extremity diagnostics - Sports injuries - Pharmacology - Radiography - Clinic internships ≈ 1 yr academics - Introductory research project ≈ 2 yrs biomedicine - Theory of science - Cellular mech. - Research methods - Physiology - Bachelor thesis - Biochem. - Masters dissertation - Anatomy - Immunology ≈ 1 yr internships - Internal organs - Internship A - etc … - Elective internships Chiropractor - Internship B - Internship C Professional manipulator

≈ 1 yr differential diagnosis - From healthy to sick ≈ 1 yr skills training - MSK diagnosis - Palpation - Diagnostic imaging 1 + 2 - Clinical biomechanics - Diagnosis 1+2+3 - spinal column - Neurology - extremities - General diagnosis - Theoretical biomechanics - Orthopaedics - Health psychology and ethics - Rheumatology - Exercise thearpy - Extremity diagnostics - Sports injuries - Pharmacology - Radiography - Clinic internships ≈ 1 yr internships - Internship A ≈ 2 yrs biomedicine - Elective internships - Cellular mech. - Internship B - Physiology - Internship C - Biochem. - Anatomy ≈ 1 yr academics - Immunology - Introductory research project - Internal organs - Theory of science - etc … - Research methods - Bachelor thesis Chiropractor - Masters dissertation Differential diagnostician Leader and administrator Musculoskeletal expert Health promoter Communicator Professional Academic Collaborator

Clinical and epidemiological peer-reviewed publications dealing with back pain from Denmark 1995-2012 Increase due to non-medical researchers 70 60 50 40 30 20 10 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year Anna Sofie Hosbond, Dorte Odgaard 2012

National Clinical Guidelines, DK, 2016-2018 Non-surgical Non-surgical treatment of treatment of lumbar Newly developed cervical Newly developed radiculopathy neck pain radiculopathy low back pain Diagnosis Non- Pathology and Lumbar surgical of the treatment stenosis treatment meniscus in of specific after the knee shoulder alloplasty complaints

National Clinical Guidelines, DK, 2016-2018 Non-surgical Non-surgical treatment of treatment of lumbar cervical Newly developed Newly developed radiculopathy radiculopathy neck pain low back pain Diagnosis Hip Pathology and arthrosis of the Lumbar treatment meniscus in stenosis of specific the knee shoulder complaints

1 20 Back Pain 40 Rank Neck Pain Osteoarthritis 60 80 Age

Trajectories of LBP in adults Dunn et al. Am J Epidemiol 163:754-761, 2006.

Trajectories of LBP, 11-14 y.o.a. Cluster 3: Late Dunn et al. Pain 152:66-73, 2011

Trajectories of LBP, 11-14 y.o.a. 1,3% 4% 4% Cluster 3: Late 2% 10% 78% Dunn et al. Pain 152:66-73, 2011

The ususal suspects: Physical activity/screen time: o Conflicting evidence, probably U-shaped o Spinal pain episodes lead to decreased physical activity/sports participation Strength, flexibility, posture: o No association Backpacks/schoolbags: o No association

General comorbidity > 400.000 schoolchildren from the worldwide ‘ HealthBehaviour in Schoolaged Children ’ survey Swain 2014

Psychological and social factors 45,371 Danish 11-12 year olds from the Danish National Birth Cohort. Spinal pain in one Stress level (SiC) or more regions OR* ( 95% CI) No stress 1 (Ref.) Medium stress 2.19 (2.08-2.30) High stress 4.73 (4.28-5.23) *Adjusted for the child’s gender, age, and maternal educational level at child age 7. Stallknecht 2017

1 o Prevention (public health) Consider MSK health as part of a general health pattern rather than a discrete entity. Target public arenas, i.e. schools and preschools rather than individuals ( avoid stigmatism ) Encourage PA in general, better education of PE teachers, include knowledge of the MSK system in school curriculums ( increase awareness, avoid fear of pain/movement )

2 o Prevention (clinical) Increased focus on patient education Integrate!

Danish research projects Pediatric MSK health (involving chiropractors) • Epidemiological studies • Randomized controlled trials

The Danish Twin Registry The Young Cohort: Born 1972 and 1982 LBP-questions from 1994 9.600 individuals Representative of the general population with regard to mortality and morbidity

The Danish Twin Registry Genetic and familial influences Long-term course Comorbidity Social factors Birth factors

Danish National Birth Cohort Interview, Postal E-mail Pregnant Email Interview, questionnaire questionnaire women questionnaire child 18 child 6 months recruited child 18 yoa months child 7 yoa child 11 yoa 100.000 children 45.000 children

Danish National Birth Cohort Infantile colic and otitis media Screentime Stress/wellbeing Motorskills PhD, University of Copenhagen (public health) o A life-course approach to spinal pain etiology and prevention (LifeSpine): Familial determinants for back and neck pain in childhood

The SPACE Study Outdoor Active TeenFitness Playspots areas, public Transport schools 1200 children, aged 11-13 in 2010 with follow-up in 2012

The SPACE Study Spinal pain prevalence, frequency, intensity and change over time Spinal pain in relation to physical activity, overweight and psychosocial factors

The CHAMPS study DK (Childhood Health, Activity and Motor Performance School Study) Tanner Dexa scan Tanner Tanner Motor capacity, Motor capacity, Motor capacity, 1200 Fitness, Fitness, Fitness, children Anthropometry, Anthropometry, Anthropometry, included Beighton Beighton Beighton Marts Sept. Sept. Sept. Marts Marts 2014 2012 2013 2011 2012 2013 Accelerometer Accelerometer Accelerometer Weekly SMS, telephone interviews, examinations Intervention (manipulation for spinal pain) 2½ years

The CHAMPS Study DK LBP patterns and prevalence from age 6 to 15 LBP and physical activity Optimizing physical performance Prevalence and patterns of extremity complaints