Chiropractic And Pain

Chiropractic And PainStephen M. Perle, D.C., M.S. Professor Of Clinical SciencesUniversity Of BridgeportCollege Of Chiropractic 1What Experiences Do You Have About Chiropractic?Your impression?

23/3/093Prcis History of chiropracticWhat is chiropractic care?Systematic reviews on clinical effectivenessResearch on mechanism of spinal manipulation3History Of ChiropracticThe MTV Version43/3/095

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10What is chiropractic?113/3/0912Anachronistic Chiropractic TheoryBone Out Of Place

123/3/0913Nonsurgical Spine SpecialistPrimary intervention is spinal manipulationSpinal rehabilitation/ stabilization exercisesPhysiological therapeuticsSoft tissue mobilization

133/3/0914Levels Of Evidence: Not All Hands Are Of Equal Value

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153/3/0916Mechanical Neck Pain HeadacheNeither SMT nor mobilization (MOB) were effective alone or in combination with PTSMT or MOB with exercise is effectiveGross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine. 2004 Jul 15;29(14):1541-8.

163/3/0917Neck PainBone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders359 invasive and noninvasive intervention articles deemed relevant170 (47%) were accepted as scientifically admissible139 of these related to noninvasive interventions Manipulation or mobilization effective for WADNeck pain

Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15;33(4 Suppl):S123-52.173/3/0918Chronic/Recurrent HeadacheProphylactic treatment of chronic tension-type headacheAmitriptyline more effective than SMT during treatmentSMT is superior in short term after cessation of both treatmentsProphylactic treatment of migraine headacheSMT may be an effective treatment option short-term effect similar to amitriptylineEpisodic tension-type headacheAdding SMT to massage is not effective

Bronfort G, Nilsson N, Haas M, Evans R, goldsmith C, Assendelft W, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane database Syst rev. 2004;3:cd001878183/3/0919Chronic/Recurrent HeadacheProphylactic treatment of cervicogenic headacheSMT is effective in the short and long term when compared toNo treatmentMassage or placebo SMTPost-traumatic headacheMOB is more effective in the short term than cold packsBronfort G, Nilsson N, Haas M, Evans R, goldsmith C, Assendelft W, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane database Syst rev. 2004;3:cd001878

193/3/0920Carpal Tunnel SyndromeCarpal bone MOB significantly improved symptoms after three weeksHowever, only one studyO'Connor D, Marshall S, Massy-Westropp Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003;(1):CD003219.203/3/0921Low Back Pain31 studies 5,202 participants met inclusion criteriaAcute LBPModerate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used PTChronic LBPModerate evidence that SMT has an effect similar NSAIDSMT/MOB is effective in the short term when compared with placebo and GP care, and in the long term compared to physical therapyLimited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term.

Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J. 2004 May-Jun;4(3):335-56.213/3/0922New Review on Chronic LBPPreponderance of the evidence for efficacy & estimated very low risk of serious adverse events support SMT & MOB as viable options for treatment of CLBPSMT and MOB at least as effective as other efficacious & commonly used interventionsBronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J. 2008 Jan-Feb;8(1):213-25.3/3/0923Nocturnal EnuresisWeak evidence supports the use of chiropractic Single small trial (31 treatment & 15 control group) Better than sham manipulation

Glazener CM, Evans JH, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev. 2005(2):CD005230.23Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis.J Manipulative Physiol Ther. 1994 Nov-Dec;17(9):596-6003/3/0924Primary Or Secondary DysmenorrheaNo evidence of effectiveness of SMTMore research needed

Proctor ML, Hing W, Johnson TC, Murphy PA. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2001(4):CD002119.243/3/0925AsthmaNo evidence of effectiveness of SMTMore research neededCurrent RCT in Australia n=1000Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev. 2005(2):CD001002.

25Science Of Spinal Manipulation263/3/0927Interarticular AdhesionsRat Joint Dysfunction (Subluxation) Model

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):141-54.273/3/0928Manipulation Breaks AdhesionsManipulation may increase flexibility of a motion segmentSingle case with sophisticated assessment of motion segment stiffness

Kawchuk G, Herzog W. Preliminary evidence of changes in tissue stiffness following spinal manipulation. In: International Conference on Spinal Manipulation; 1996: FCER; 1996. p. 18.283/3/0929Manipulation Breaks AdhesionsManipulation gaps the Z-jointCramer GD, Gregerson DM, Knudsen JT, Hubbard BB, Ustas LM, Cantu JA. The effects of side-posture positioning and spinal adjusting on the lumbar Z joints: a randomized controlled trial with sixty-four subjects. Spine 2002;27(22):2459-66.293/3/0930Altered Muscle Firing PatternTransversus abdominis activated (diaphragm & pelvic mm) 30 ms prior to arm or leg movementsIn LBP patients transversus abdominis activated 30 ms after arm or leg movements

Hodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. J Spinal Disord 1998;11(1):46-56.

303/3/0931Response to SMTPickar & Wheeler 2001, JMPT 24(1):2-11

313/3/0932Muscle Spindle Response To SMT

323/3/0933GTO Response To SMT

333/3/0934Manipulation Changing Muscle FunctionBrenner AK, et al. Improved activation of lumbar multifidus following spinal manipulation: a case report applying rehabilitative ultrasound imaging. J Orthop Sports Phys Ther. 2007 Oct;37(10):613-9.

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3/3/0937Restoration Of Firing PatternGill NW, Teyhen DS, Lee IE. Improved contraction of the transversus abdominis immediately following spinal manipulation: a case study using real-time ultrasound imaging. Man Ther. 2007 Aug;12(3):280-5.

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Effects On Pain & Pain Processing393/3/0940Manipulations Effects On CNS In Pain ModulationManipulation of the knee resulted in analgesia of induced hyperalgesia of the paw of a ratUsed selective neurotransmitter blocksManipulation activates descending inhibitory pathways using serotonin and noradrenaline403/3/0941Suggested Analgesic MechanismAuthors suggest that manipulation stimulatesLateral periaquaductal gray (PAG)Rostral Ventral Medulla (RVM)Dorsolateral ponsPart of the descending analgesia system

Skyba DA et al. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain. 2003 Nov;106(1-2):159-68.413/3/0942

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433/3/0944Stroke & Cervical ManipulationSmall risk of stroke following chiropractic visitsRisk of stroke after chiropractic visit = risk of stroke after medical visitPeople with prodrome of stroke seek careCassidy JD, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176-83.44What questions do you have?

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