How to confidently communicate the science of chiropractic
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How to confidently communicate the science of chiropracticIntroductory Workshop
Dr Heidi HaavikDG Melbourne 22nd February 2014
PhD, PG Dip, BSc (chiro), Bsc (physiology)
Director of Research, New Zealand College of Chiropractic
Adjunct Professor, Master of Health Sciences Program, University of Ontario Institute of Technology
World Federation of Chiropractic Research Council member
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My background
1999 University of Auckland, BSc, Physiology 1999 Chiropractic degree from NZCC 2000 Private chiropractic practice 2003 University of Auckland, PG Dip (Science) 2006 Director of Research, NZCC 2007 Editorial board Journal of Chiropractic Education 2008 PhD University of Auckland 2009 Editorial board member of JMPT 2011 World Federation of Chiropractic Research Council 2011 Associate Graduate Faculty Member, UOIT 2014 Adjunct Professor, Master of Health Sciences
Program, University of Ontario Institute of Technology, Ontario, Canada.
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My background
15 national and international research awards ½ million dollars in national and international research grants Developed, course-coordinated and lectured in Neuroscience,
Research Methodology, Visceral Physiology, Professional Development, etc.
Co supervised 5 MSc students and 1 PhD student Authored 23 peer reviewed research manuscripts 51 peer reviewed abstracts presented 40 invited or keynote presentations in NZ, Australia, Europe and
USA
Chiropractic, Research & Neuroscience business for 14 years
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Heidi’s Vision Board
A world of people expressing optimal potential
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Heidi’s Mission
Run a ridiculously successful and VitalisticInternational Centre for Chiropractic Research
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Heidi’s WhyTo allow more people access to chiropractic care through he power of cutting edge top quality research about mechanisms
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Heidi’s Role
1. Facilitate research2. Mentor researchers3. Inform / teach4. Raise funds
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Purpose of Today
That you can confidently talk about the science of chiropractic
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AIM: Confident Communication!
Knowing what you can and cannot say about the science of chiropractic
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Outline for the day
Where are you at now?– Where do you want to get to?– How I can best help you
The Brain 101 The big picture - chiropractic Science 101 How to talk about specific studies
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heidihaavik.com
• Written for the public
• Describes in easy to understand language what happens when we adjust a VS
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Where are you at now?
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In pairs (one being the chiro, the other the patient) each take turns explaining:
What a subluxation is
How chiropractic care works
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How did that go?
Where you confident?
Do you know if your ‘story’ has scientific backing?
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The big picture
In a nutshell
What is a subluxation?
How does chiropractic care work?
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A subluxation is.....
“a central segmental motor control problem”
Which means that the central nervous system is notcontrolling the movement pattern of the spinalsegment as it should, which alters the stretching ofthe paraspinal muscles which changes the input to thebrain which impacts how it processes otherinformation
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So that it can accurately perceive what is going on and respond
appropriately
which in turn improves the communication between your brain,
the body and the environment
Chiropractic is a healing art that improves the health and function of
the spine
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Wisdom vs Knowledge
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When talking about the chiro-relevant scientific studies:
1. This is what they did
2. This is what they found
3. This is what that possible means to you
4. BUT..... (mention limitations with study for you patient)
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My potential role
Help you communicate about the key neuroscience concepts vital to understand how chiro care likely works
Help you to understand and communicate about the chiropractic relevant neuroscience research
To patients, the public, and to other health care providers
Help you to understand and communicate about the chiropractic relevant neuroscience research specific to particular groups
Sports, paediatric, asymptomatic,
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What I can help you with
Various topics:
Research and science
Difference between different research methods
Evidence based practice
Sensorimotor integration
Mulitimodal integration
Neural plasticity
Inner body schema – inner brain reality
How the brain works
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Various topics
Functional role of paraspinal muscles
Segmental movement research and biomechanics
Sensory chiro research
SMI chiro research
Motor control chiro research
Functional outcomes chiro research
Clinical chiro research
Props to use to explain each topic
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Props are helpful!!
• Simple tests you can do in your office
• Poster for the Office to help explain mechanisms
• Office brochures explaining mechanisms
• A book for the patient (fully referenced)
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Office Poster
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Patient pamphlet
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The Brain & CNS 101
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CHIROPRACTIC ALTERS THE MATRIX OF YOUR BRAIN!
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Principles of Neural Science by Eric R. Kandel, James H. Schwartz, and Thomas M. Jessell. Elsevier, 2000, 4th Ed, Ch 33, p. 654
“IN THE PRECEDING PART of this book we considered how the brain constructs internal representations of the world by integrating information from the different sensory systems.
These sensory representations are the framework in which the motor systems plan, coordinate, and execute the motor programs responsible for purposeful movement.”
This is SENSORI-MOTOR-INTEGRATION
This is MULTI-MODAL-INTEGRATION
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In pairs, take turns explaining to each other the following concepts:
Multimodal integration and the inner brain reality
Sensorimotor integration and its importance for accurate purposeful movements
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How did that go?
Where you confident?
Did any questions arise?
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The inner brain realityis it always accurate?
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Phantom limb pain
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Moseley GL, Olthof N, Venema A, Don S, Wijers M, Gallace A, Spence C. 2008. Psychologically induced cooling of a specific body part caused by the illusory ownership of an artificial counterpart Proc Nat Acad Sci USA; 105(35):13169-73. Copyright (2008) National Academy of Sciences, U.S.A.
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Central filtering of info
Sensory information in the central nervous system is processed in stages, in the sequential relay nuclei of the spinal cord, brain stem, thalamus, and cerebral cortex. Each of these processing stations brings together sensory inputs from adjacent receptors and—using networks of inhibitory neurons—transforms the information to emphasize the strongest signals.
Kandel, Schwartz, and Jessell, 2000, p.428
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“We are continuously exposed to stimulation across our senses; some of which is relevant to the task at hand but most of which is not. The ability to isolate and process appropriate sensory stimulation whilst inhibiting irrelevant stimulation is essential in order to achieve our goals in a timely and efficient manner. However as we age it is thought that the inhibition of irrelevant information becomes more difficult such that available sensory information is processed more extensively.”
(Setti et al 2011, Experimental Brain Research, 209;p.379)
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Brain fills in the gaps and/or alters your reality based on past expectations, surrounding information and intentions.
““Ceoinsdr the anmzaig pweor of the hmuan biran. It dseno’t metatr in wahtoredr the lrttees in a wrod are, the olny tihng taht is iproamtnt is the frsitand lsat ltetres are in the rghit pclae. The rset can be a tatol mses and you can sitll raed it wuhotit a plboerm. Azanimg huh?”
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Morning Tea
9.35 – 10.20
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Video clip – TEDxAdelaide - Lorimer Moseley -Why Things Hurt:
http://www.youtube.com/watch?v=gwd-wLdIHjs
Pain and Plasticity
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“We can mess with that”
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Blind spot testing
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Neural plasticity
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Neural Plasticity
“Many important behaviors are learned. Indeed, we are who we are largely because of what we learn and what we remember. We learn the motor skills that allow us to master our environment, and we learn languages that enable us to communicate what we have learned, thereby transmitting cultures that can be maintained over generations. But not all learning is beneficial. Learning also produces dysfunctional behaviors, and these behaviors can, in the extreme, constitute psychological disorders.”
Kandel, Schwartz, and Jessell, 2000, p.1228
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Maladaptive vs Adaptive Plasticity
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Maladaptive vs Adaptive Plasticity
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Symptoms don’t just appear out of thin air
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Sensorimotor integration
Feed-forward control systems
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Neuroscience concepts covered:
CSN, PNS, neurons, synapses, networks Internal representations
– Internal body schema– Inner Matrix
Problems with false internal body schema– Phantom limb pain, tinnitus, and on smaller
scale Central filtering Brain filling in the gaps (blind spot) Neural plasticity (good and bad) Sensorimotor integration and movement control
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The connection between the neuroscience and chiropractic!
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Paraspinal Muscles act as CNS sensors
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MUSCLE SPINDLESExtra-fusal fibres
Intra-fusal fibres
α- motor neurone
γ- motor neurone
Type 1a & II afferents
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Spinal muscle afferents are important for the brain sensory integration of other afferent input
Uthaikhup et al 2006. The influence of neck pain on sensorimotor function in the elderly Archives of Gerontology and Geriatrics; 55 p.667
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Spinal adjustments
Appropriate joint movement
Appropriate spinal information sent to
brain and CNS
Appropriate processing and
integrationby brain and CSN
Better control of the spine
and body
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The specific research hypothesis
Spinal adjustments
Abnormal SomatosensoryFiltering & processing
Altered function (pain and disability)
Altered sensorimotor
integration
Altered motor control
Altered afferent
input
SubluxationAppropriate
Joint movement
Normalafferent
input
Appropriate SomatosensoryFiltering & processing Appropriate
sensorimotor integration
Accurate motor control
Good function
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What evidence is there for this model?
Abnormal Somatosensory
Processing
Altered function (pain and disability)
Altered sensorimotor
integration
Altered motor control
Altered afferent
input
Subluxation
Marshall & Murphy, 2006Murphy et al, 2009; 2010
Haavik & Murphy 2012b
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What evidence is there for this model?
Spinal manipulation
Abnormal Somatosensory
Processing
Altered function (pain and disability)
Altered sensorimotor
integration
Altered motor control
Altered afferent
input
Joint dysfunction
AppropriateJoint
movement
Appropriateafferent
input
Appropriate Somatosensory
Processing Appropriatesensorimotor
integration
Accuratemotor control
Good function
Marshall & Murphy, 2006Murphy et al, 2009; 2010
Haavik & Murphy 2012b
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Signal to noise ratio problem!
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Amplitu
de
Time
Signal
Background noise
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Amplitu
de
Time
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Aberrant spinal movement
Can mean that the brain may not be fully aware of what is going on in your spine, which appears to influence how it controls the rest of the body
– Growing body of research supports this!
May impact the accuracy of our Matrix
– Theory, but with some evidence that suggests this
Spinal function impacts integration of sensory information
Growing body of research supports this!
This could lead to accidents, the develop pain and dysfunction, syndromes, conditions, etc.
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So that it can accurately perceive what is going on and respond
appropriately
which in turn helps clear up the communication between your brain,
the body and the environment
Chiropractic care improves the health and function of the spine
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A subluxation is.....
“a central segmental motor control problem”
Which means that the central nervous system is notcontrolling the movement patter of the spinal segmentas it should, which alters the stretching of theparaspinal muscles which changes the input to thebrain which impacts how it processes otherinformation
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7 essential components
1. Neuroplasticity - Good or Bad
2. Inner brain reality / body schema
3. Subconscious processing
4. Brain fill in the gaps & filters info
5. Paraspinal muscles are SENSORS
6. What happens when a segment is not moving properly
7. What happens when we adjust these
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Self Test!
See if you can remember the key essential components to explain the effects of an adjustment !
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7 essential components
1. Neuroplasticity - Good or Bad
2. Inner brain reality / body schema
3. Subconscious processing
4. Brain fill in the gaps & filters info
5. Paraspinal muscles are SENSORS
6. What happens when a segment is not moving properly
7. What happens when we adjust these
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Take 10 minutes to plan your 10 min talk about the mechanisms of chiropractic care for a patient’s Report of Findings. Include the following components and use SIMPLE examples
1. Neuroplasticity - Good or Bad
2. Inner brain reality / body schema
3. Subconscious processing
4. Brain fill in the gaps & filters afferent info
5. Paraspinal muscles are SENSORS
6. What happens when a segment does not move properly
7. What happens when we adjust these segments
Include in your the plan the use of Office Poster & Pamphlet!
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Name: __________Components:
Tick if discussed
Tick if simple example included:
Note what may have been missed:
Specific Notes:
Neuroplasticity – Can be good and bad
Inner brain reality / body schema
Subconscious processing
Brain fill in the gaps & filters afferent info
Paraspinal muscles are SENSORS
What happens if spinal segments don’t move properly
What happens when we adjust these segments
Use of Poster
Use of Pamphlet
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In groups of 3 Practice the talk! One be the Chiro One the patient One take notes and provide feedback
Rotate so everyone gets to try being the chiropractor.
Debrief after each round about what worked well and what did not
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Lunch
12.30-1.45
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Recap of Morning Session
Questions?
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Review and you will remember 70% more!
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How did practical go?
Where you confident?
What were you less confident about?
What did you not remember ?
Biggest gaps in understanding/knowledge?
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Neuroscience concepts covered:
CSN, PNS, neurons, synapses, networks Internal representations
– Internal body schema– Inner Matrix
Problems with false internal body schema– Phantom limb pain, tinnitus, and on smaller
scale Central filtering Brain filling in the gaps (blind spot) Neural plasticity (good and bad) Sensorimotor integration and movement control
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Link between neuro to chiro concepts covered:
Functional role of paraspinal muscles The muscle spindle Where spindle info goes How spindle info impacts brain function Descending brain control of ...... everything The research model Effects of VS (too much or too little movement)
– Signal to noise ratio– Working in the dark
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Science & Research 101
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Evidence Informed Practice
Improved patient
outcomes!
Patients own values and expectation
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Overall Working Model
Narrow down to testable question
Test with scientific method
Interpret your results
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Clinical research
Basic Science
Research
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The floor-plan research methodology analogy
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Basic Science
Qualitative researchClinical TrialsRCTs
Case reports
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Systematic Reviews
Editorials, Expert Opinion
Randomised Controlled Trials
Cohort Studies
Case-control Studies
Case Series, Case Reports
The hierarchy of evidence
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Turn to your neighbour and explain the difference between basic science and clinical science and answer the following:
1. How can you tell the difference between basic science and clinical science? What evidence do each provide?
2. Can you think of some difficulties scientist have when doing research into the subluxations and effects of adjusting them?
3. What is the key difficulty when trying to do clinical science with a chiropractic intervention?
4. What is the benefit to you with good chiropractic basic science?
5. What is the benefit to you with positive chiropractic clinical science?
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2. Issues for scientists wishing to explore the subluxation and the effects of the adjustment
An intervention is supposed to be properly defined and repeatable
– What is a subluxation?
– How do you find one?
– Can you find them reliably?
– What is the spinal manipulation / adjustment intervention?
– Can it be repeated in a reliable manner?
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3. What is the key difficulty when trying to do clinical science with a chiropractic intervention?
Clinical research is about the effects of an intervention on a particular condition
So what (conditions) does chiropractic treat?
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Simple balance testing in the Office
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Scrambled sentence & Blind spot testing
Blind spot test and instructions in your booklet
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Square Illusion
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In groups of 3 practice these tests on each other (patient, chiro, assessor)
Square A and Square B illusion
Blind spot testing
Scrambled sentence
Rhomberg’s testing
Assessor: how are they communicating this, do they seem confident, can they answer questions, are they using their new knowledge?
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How did that go?
Share with another pair how it went
What was easy?
What was hard?
Where you confident?
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Afternoon Tea
3.00 – 3.45
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Lets get stuck into some studies
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Clinical research
Read and be able to discuss the RCTs and reviews that demonstrate spinal manipulation is as good as anything else out there for
– Back pain (E.g. UK BEAM study 2004 BMJ; LBP Brontfort et al 2008; AM-LBP - Bishop et al 2010)
– Neck pain (Haldeman S, Carroll L et al. (2008) The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders; Executive Summary, Spine 33(4S):S5-S7)
– Headaches (See review in The chiropractic report Sept 2010)
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Clinical research
And that chiro patient satisfaction is MUCH better than other care (See review in The chiropractic report Jan 2007)
And we are more cost effective (See review in The chiropractic report Nov 2009)
And we are safe (Cassidy JD, Boyle, E, Cote et al. 2008 Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study, SPINE 33(4S): S176-183)
There is even evidence for maintenance care for low back pain (Senna MK, Machaly SA. 2011. Does Maintained Spinal Manipulation Therapy for Chronic Non-Specific Low-Back Pain Result in Better Long Term Outcome? SPINE)
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In groups of 3 practice telling your patient about the clinical research there is about chiropractic
See if you can turn the subject’s attention from the clinical research to the basic science research in simple language
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Feedforward Activation(Marshall & Murphy. J Manipulative Physiol Ther 2006;29:196-202)
(Gov
orko
, MS
c Th
esis
, 200
7, p
.106
)
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(Marshall & Murphy. J Manipulative Physiol Ther 2006;29:196-202)
Pre Adjustments
Post Adjustments
17/90 impaired FFA
13/17 retested 6 month later
38% improvement in FFA times after SI adjustments
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Example 1
This is what they did and this is what they found:– They tested 90 healthy young male cricket players in their ability to feed-forward
activate their abdominal muscles - 19/90 could not– Six months later 13/17 still could not– One adjustment session – 40% improvement
This is what this means to you– You may not be able to feed forward activate your core abdominal muscles– These are important low back support mechanism for you– If you cannot you are basically causing mini low back whiplash each time you lift
your arm– No symptoms in those guys, so you may not have felt it either – so can be why
your low back pain started.... You said you did not know why – We know being unable to activate core muscles leads to LBP
Caution/Limitations.......... ‘BUT...’– You are a woman, the study was only on men– We dont know how long the effects last, was only one pre/post
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Practice this
In groups of three (chiro, patient, assessor) practice telling a patient about this study. Remember:– What did they do– What did they find– What does this mean to your patient– But....limitations of study
Swap around so everyone has a go at being chiro Assessors: please provide feedback to chiropractor! Patient:
– create a story for the chiro (e.g. I’m a 48 female with LBP)– And ask questions like – why did I get low back pain, I
had no injury, it just happened, why would chiropractic work for me?
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How did that go?
Share with another pair how it went
What was easy?
What was hard?
Where you confident?
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(Award winning poster at 2009 WFC; Award winning paper at ACC RAC 2010)
Haavik & Murphy, 2011, JMPT; 34:88-97
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Example 2
This is what they did and this is what they found:– Twenty-five SCNP participants and 18 control participants were tested for their elbow
JPS before to see if SCNP participants JSP was worse than controls – and they were!– The SCNP group then were retested after either SM or control intervention. SM
improved elbow JPS!!
This is what this means to you– If your brain is not fully aware of where your elbow is, it could be why you keep
knocking it in doorframes– This study suggests that spinal function impacts how accurately your brain can
interpret propriocpetive information from your arms
Caution/Limitations.......... ‘BUT...’– You are a older than the individuals in this particular study, although there is an study
done in 65 + year olds done with anckle JPS and they improved significantly over a four week period
– We dont know how long the effects last, was only one pre/post– The anckle study showed effects of 12 weeks chiro care, but no follow up done
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Practice this
In groups of three (chiro, patient, assessor) practice telling a patient about this study. Remember:– What did they do– What did they find– What does this mean to your patient– But....limitations of study
Swap around so everyone has a go at being chiro Assessors: please provide feedback to chiropractor! Patient:
– create a story for the chiro (e.g. I’m a 48 female with LBP)– And as questions like – why did I get low back pain, i had
no injury, it just happened, why would chiropractic work for me?
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How did that go?
Share with another pair how it went
What was easy?
What was hard?
Where you confident?
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Feedback Please
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Resources & further info:
Intermediate model here next year
My book www.heidihaavik.com
CJA and JEK review articles – email me!!
CAA online learning modules
NZCA/CCR online learning modules
Seminar series like this to be run in NZ
And Australia?