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

Reliable and trustworthy profession Extensive public health issue Recommended and safe treatment

Children’s musculoskeletal health – who is in charge?

Then (1990)

• Educated in the UK or USA
• ”Quackery Act”
• Private liability insurance
• No chiropractors employed
• utside of private practice
• Little or no inter- professional

integration

• No research activity, no

chiropractors with PhDs

• Unimployment

Now (2018)

• 5 year education at Danish university

integrated with medicine

• Clinical training in hospitals and in private

clinics

• Chiropractic legislation
• Chiropractic patients covered by Danish

National Patient Insurance, no fault

• Many chiropractors involved in hospitals,

multidisciplinary MSK rehabilitation centers, radiology departments, regional health administration, national task forces, national guideline committees etc.

• Danish chiropractors are leading

researchers in the field of musculoskeletal health, both nationally and internationally

• 4% of the chiropractors have a PhD degree
• Full employment, cannot meet demand

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

9.5%

Foundation for Chiropractic Research and Postgraduate Education

6.2%

~ 5.6 mill CAD/year

Foundation for Chiropractic Research and Postgraduate Education

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 Quality insurance and Imaging Research

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

B.Sc. 3 years M.Sc. 2 years Internship

Chiropractor

1 year Admittance

Clinical Education

• 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
• Internships in other departments
• Orthopaedic department
• Rheumatological department
• Internship in private chiropractic practice

≈ 2 yrs biomedicine

• Cellular mech.
• Physiology
• Biochem.
• Anatomy
• Immunology
• Internal organs
• etc…

≈ 1 yr skills training

• Palpation
• Clinical biomechanics
• spinal column
• extremities
• Theoretical biomechanics
• Health psychology and ethics
• Exercise thearpy
• Sports injuries
• Radiography
• Clinic internships

≈ 1 yr differential diagnosis

• From healthy to sick
• MSK diagnosis
• Diagnostic imaging 1 + 2
• Diagnosis 1+2+3
• Neurology
• General diagnosis
• Orthopaedics
• Rheumatology
• Extremity diagnostics
• Pharmacology

≈ 1 yr academics

• Introductory research project
• Theory of science
• Research methods
• Bachelor thesis
• Masters dissertation

Professional manipulator Chiropractor ≈ 1 yr internships

• Internship A
• Elective internships
• Internship B
• Internship C

≈ 2 yrs biomedicine

• Cellular mech.
• Physiology
• Biochem.
• Anatomy
• Immunology
• Internal organs
• etc…

≈ 1 yr skills training

• Palpation
• Clinical biomechanics
• spinal column
• extremities
• Theoretical biomechanics
• Health psychology and ethics
• Exercise thearpy
• Sports injuries
• Radiography
• Clinic internships

≈ 1 yr differential diagnosis

• From healthy to sick
• MSK diagnosis
• Diagnostic imaging 1 + 2
• Diagnosis 1+2+3
• Neurology
• General diagnosis
• Orthopaedics
• Rheumatology
• Extremity diagnostics
• Pharmacology

≈ 1 yr academics

• Introductory research project
• Theory of science
• Research methods
• Bachelor thesis
• Masters dissertation

Chiropractor ≈ 1 yr internships

• Internship A
• Elective internships
• Internship B
• Internship C

Differential diagnostician Musculoskeletal expert Communicator Academic Collaborator Professional Health promoter Leader and administrator

Anna Sofie Hosbond, Dorte Odgaard 2012

Increase due to non-medical researchers

Clinical and epidemiological peer-reviewed publications dealing with back pain from Denmark 1995-2012

Newly developed low back pain Non-surgical treatment of lumbar radiculopathy Newly developed neck pain Non- surgical treatment after alloplasty Diagnosis and treatment

• f specific

shoulder complaints Non-surgical treatment of cervical radiculopathy Pathology

• f the

meniscus in the knee Lumbar stenosis

National Clinical Guidelines, DK, 2016-2018

National Clinical Guidelines, DK, 2016-2018

Non-surgical treatment of lumbar radiculopathy Hip arthrosis Diagnosis and treatment

• f specific

shoulder complaints Non-surgical treatment of cervical radiculopathy Pathology

• f the

meniscus in the knee Lumbar stenosis Newly developed low back pain Newly developed neck pain

1 20 40 60 80

Rank Age

Back Pain Neck Pain Osteoarthritis

Trajectories of LBP in adults

Dunn et al. Am J Epidemiol 163:754-761, 2006.

Trajectories of LBP, 11-14 y.o.a.

Dunn et al. Pain 152:66-73, 2011 Cluster 3: Late

Dunn et al. Pain 152:66-73, 2011

1,3% 4% 4% 2% 10% 78%

Cluster 3: Late

Trajectories of LBP, 11-14 y.o.a.

The ususal suspects:

Physical activity/screen time:

• Conflicting evidence, probably U-shaped
• Spinal pain episodes lead to decreased physical

activity/sports participation

Strength, flexibility, posture:

• No association

Backpacks/schoolbags:

• 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.

Stress level (SiC) Spinal pain in one

• r more regions

OR* ( 95% CI) No stress Medium stress High stress 1 2.19 4.73 (Ref.) (2.08-2.30) (4.28-5.23)

Stallknecht 2017

*Adjusted for the child’s gender, age, and maternal educational level at child age 7.

1o 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)

2o 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

Pregnant women recruited Interview, child 6 months Interview, child 18 months Postal questionnaire child 7 yoa E-mail questionnaire child 11 yoa Email questionnaire child 18 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)

• A life-course approach to spinal pain etiology and

prevention (LifeSpine): Familial determinants for back and neck pain in childhood

The SPACE Study

Active Transport TeenFitness Playspots Outdoor areas, public 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,

• verweight and psychosocial factors

Intervention (manipulation for spinal pain) 2½ years Weekly SMS, telephone interviews, examinations

Sept. 2011 Marts 2012 Sept. 2012 Marts 2013 Sept. 2013 Marts 2014 Motor capacity, Fitness, Anthropometry, Beighton

Dexa scan Tanner Tanner Tanner

Accelerometer Motor capacity, Fitness, Anthropometry, Beighton Motor capacity, Fitness, Anthropometry, Beighton

The CHAMPS study DK

(Childhood Health, Activity and Motor Performance School Study)

Accelerometer Accelerometer

1200 children included

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

Intervention (training of motor skills) < 2½ years Bi-weekly SMS, telephone interviews, examinations

• Sept. - Dec

2016 Marts - June 2017 Marts - June 2018 Marts - June 2019 Test Test Test

The Motor skills in PreSchool Study

Test

850 children included

The MiPS study DK

Fine and gross motor skills Cognition Anthropometry Selfperceived physical competency Physical activity Movement patterns General well-being Language evaluation Academic performance

The MiPS study DK

Start Toe off Hang time Landing

Research projects Pediatric MSK health

• Epidemiological studies
• Randomized controlled trials

The CHAMPS Study DK

Age 12-15 LBP >2weeks Spinal manipulation in addition to gold standard care Weekly SMS track 6-132 weeks No difference in recurrences, duration or intensity GPE better in the manipulation group

The MiPS Study DK

Age 3-5 Attending public preschools ≥45 minutes of daily activities focusing on improvement of motor skills 1o outcome: motor competency after 18 months 2o outcomes: MSK problems, physical activity,

• verweight, general well- being, academic

competencies

Infantile colic, RCT

Age 3-14 weeks Crying > 3 hours, >3 days/week Manipulation versus none (parents leave the room) Four treatment over 2 weeks Diary during the two weeks of treatment

(and >3 days before)

Sept 2018: 160 randomized June 2019: end of inclusion

Headache, RCT

Age 7-14 Headache weekly for min. 6 months Manipulation versus sham Weekly SMS track 4 months Questionnaire after one year

• Sept. 2018: 161 randomized
• Dec. 2018: end of inclusion

DTR (10,000) 1994 DNBC (50,000) 1998/2009 SPACE (1200) 2010 CHAMPS (1200) 2011 Infantile Colic (200) 2015 MiPS (850) 2016 Headache (200) 2016 Age 0 3 6 9 12 15 18

Clear and unambiguous communication

Communication

Proportion of patients attending chiropractors in Denmark by age

0,00 5,00 10,00 15,00 20,00 25,00 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

0 yoa 1-2 yoa 3-17 yoa 18-25 yoa 26-64 yoa 65-79 yoa 80+ yoa

Reliable and trustworthy profession Extensive public health problem Recommended and safe treatment

Children’s musculoskeletal health – who is in charge?

0,00 5,00 10,00 15,00 20,00 25,00 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Chiropractor Differential diagnostician Musculoskeletal expert Communicator Academic Collaborator Professional Health promoter Leader and administrator

Thank You!

l.hestbaek@nikkb.dk