Steadman Hawkins Sports Medicine Lecture Series: Chiropractic (2006)

Joel Dekanich Joel Dekanich DC, DACBSP, EMT, CSCSDC, DACBSP, EMT, CSCS

Mark Pitcher DC, MScMark Pitcher DC, MSc

Chiropractic Treatment:Chiropractic Treatment:Everything you wanted to know but was afraid to askEverything you wanted to know but was afraid to ask

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www.markjpitcher.comwww.markjpitcher.com

Objectives: Objectives:

1.1. Review manipulation and chiropractic origins Review manipulation and chiropractic origins

2.2. Explain the variation in chiropractic treatment and philosophies Explain the variation in chiropractic treatment and philosophies

3.3. Chiropractic TrainingChiropractic Training

4.4. Explain treatment rationaleExplain treatment rationale



Objectives:Objectives:

5.5. Understand the mechanics and physiology of spinal Understand the mechanics and physiology of spinal manipulationmanipulation

6.6. Briefly explore risk vs. benefitBriefly explore risk vs. benefit

7.7. Discuss best available evidence & clinical predictor Discuss best available evidence & clinical predictor rulesrules



ChiropracticChiropractic

……a profession that uses an array of manual a profession that uses an array of manual therapies and modalities, but primarily spinal therapies and modalities, but primarily spinal manipulation, for the correction and rehabilitation of manipulation, for the correction and rehabilitation of the neuromusculoskeletal problems.the neuromusculoskeletal problems.

Spinal ManipulationSpinal Manipulation Spinal manipulation:Spinal manipulation:

Depicted in cave Depicted in cave drawings (14,500 BC)drawings (14,500 BC)

Ancient china (2700 BC)Ancient china (2700 BC) Hippocrates (470 BC)Hippocrates (470 BC) Bonesetters (1800’s)Bonesetters (1800’s) Osteopaths (late 1800’s)Osteopaths (late 1800’s) Chiropractors 1895Chiropractors 1895

Historical PerspectiveHistorical Perspective

Spinal ManipulationSpinal Manipulation


Spinal manipulation:Spinal manipulation: Depicted in cave Depicted in cave

drawings (14,500 BC)drawings (14,500 BC) Ancient china (2700 BC)Ancient china (2700 BC) Hippocrates (470 BC)Hippocrates (470 BC) Bonesetters (1800’s)Bonesetters (1800’s) Osteopaths (late 1800’s)Osteopaths (late 1800’s) Chiropractors 1895Chiropractors 1895

ChiropracticChiropractic Chiropractic, as a profession, was Chiropractic, as a profession, was

founded by D.D Palmer in 1895.founded by D.D Palmer in 1895.

Palmer believed that spinal Palmer believed that spinal misalignments put pressure on misalignments put pressure on nerves, and could result in nerves, and could result in disease. disease.

Used a spinal “adjustment” to Used a spinal “adjustment” to correct these misalignments.correct these misalignments.



95% of spinal manipulation in the United 95% of spinal manipulation in the United States is done by chiropractors States is done by chiropractors

(Shekelle and Brook 1991)(Shekelle and Brook 1991)

TodayToday:: ChiropractorsChiropractors OsteopathsOsteopaths Physical TherapistsPhysical Therapists Medical Doctors Medical Doctors (Mostly in Eastern Europe)(Mostly in Eastern Europe)


Why is there variability in how Why is there variability in how chiropractors practice?chiropractors practice?

Variability in TreatmentVariability in Treatment

Chiropractic Chiropractic Wide spectrum of practice styles and belief systems.

Alternative Evidence Based

Many chiropractors hold the tenants of the Palmer’s original chiropractic theory. (Biggs et al. 2002)

A vitalistic versus a mechanistic philosophy flourished in the early 1900’s as chiropractic attempted to distance itself from Medicine and Allopathy in general.

Others in the chiropractic profession lean towards a more a research based and evidence driven practice.

Diversity of PracticeDiversity of PracticeVariability in TreatmentVariability in Treatment

What training do chiropractors have?What training do chiropractors have?

Chiropractic TrainingChiropractic Training

ChiropracticChiropractic TrainingTraining

Depending on the state, two or more years of undergraduate study or a Bachelor’s degree is required with basic pre-medical curriculum.

Complete a 5 year program in one of the accredited programs in the U.S. or Canada.

Complete 4 different national board examinations and additional state requirements.

Many D.C.’s complete additional postgraduate training in sports medicine, rehabilitation, orthopedics, radiology, neurology, and other areas.

Assessment and treatment Assessment and treatment

Rationale for Chiropractic TreatmentRationale for Chiropractic Treatment



Assessment: History Examination

Orthopaedic and Neurological Tests Functional Motion palpationF

Functional DiagnosisFunctional Diagnosis

TreatmentsTreatments Modalities Facilitated stretching (PIR/PNF) Taping and bracing Exercise therapy Mobilization Manipulation



Probably any abnormal loading conditions (including overload and immobilization) can produce tissue trauma and/or adaptive changes that may result in disc degeneration. (Stokes 2004)

Joint fixation (hypomobility) results in time-dependent degenerative changes of the Z joints. (Cramer 2004)

Vast majority of patients seek chiropractic care for musculoskeletal injuries: (Coulter et al. 2002)

Work related injuries Sports injuries Postural or repetitive or cumulative trauma.

Commonly treat such conditions such as: Back and Neck pain Headaches Sprains and Strains Disc injury

Treatment RationaleTreatment Rationale


Mechanical and Neuromuscular Treatment Goals:

Increase segmental range of motion Reduce muscle spasm Decrease articular pain Short term activation of skeletal muscle


Goals of Spinal Manipulation

Decreased Segmental Range of MotionDecreased Segmental Range of Motion Barrier concept (Bourdillon, et al. 1992)Barrier concept (Bourdillon, et al. 1992) Elastic and anatomic barriers (Greenman 1989)Elastic and anatomic barriers (Greenman 1989)

Passive ROMPassive ROM

Active ROMActive ROM

Elastic barrier

Paraphysiological Paraphysiological SpaceSpace



Manipulation vs. MobilizationManipulation vs. Mobilization

Manipulation Usually a single application Preload force Force Profile:

Higher Magnitude ForceShorter delivery timeHigher Velocity (~100-300ms)

Manipulation vs. MobilizationManipulation vs. Mobilization

Mobilization Single or multiple applications +/- Preload force Force Profile:

Lower Magnitude of Force

Variable delivery time

Variable Velocity

Force Magnitudes with ManipulationForce Magnitudes with Manipulation

TreatmentTreatment

Region Preload (N) Peak Contact Force (N) Study

SI 88 328 Herzog 2000

Lumbar Spine ? 384-515 Triano and Shultz 1997

Thoracic Spine 23.8

310

238

1044

Herzog 2001

Kirstukas et al. 1999

Cervical Spine 27 107 Herzog 2000

Spinal Manipulative Therapy (SMT) is a therapeutic tool where a high velocity, low

amplitude thrust is directed to a joint to restore its segmental range of motion.

Effects of spinal manipulation: Increased range of motion (Whittingham 2001, Nilsson 1996) Increased functional capacity (Meade 1995, Shekelle 1992) Mechanical and Neuromuscular effects (Herzog 1996).


Mechanisms of Manipulation:

Changes associated with spinal manipulation are thought to arise from:

Release of entrapped synovial tissues

Stretching and breaking of adhesions

Dynamic stretching of musculature and myofascial tissues.

(Evans 2002)


Neuromuscular EffectsNeuromuscular Effects

Mechanical Effects:

Increased active (Wittingham 2001) and passive (Nilsson

1996) ranges of motion.

Increased intersegmental motion. (Yeomans 1992)

Gapping of zygapophyseal joints on MRI post-manipulation. (Cramer 2000)


The effect of manipulation of a normal joint:

Initial separation of 1.8 mm is due to the thickness of the cartilages

The separation increases gradually to a tension of 8 kg

At this point, the surfaces jump to a separation of 4.7 mm and an ‘audible’ is heard

Gapping of the jointGapping of the joint


The effect of manipulation of a normal joint:

Increasing tension to 18kg produces a further joint separation up to 5.4 mm

On reduction of tension, the joint surface separation is approx. 2 mm, a distance slightly more than the initial separation of 1.8 mm.

Mechanical EffectsMechanical Effects


CavitationCavitation

When forces associated with manipulation separates joint surfaces beyond the elastic barrier, gases normally dissolved in solution are pulled out of solution creating a cavitation.

The cavitation rapidly distends the joint capsule creating a “snap”, or “pop”


Neuromuscular EffectsNeuromuscular Effects

Neuromuscular Effects:

Attenuation of motoneuronal discharge. (Dishman et al.1998, Dishman and Bulbulian 2000 )

Decreased muscle inhibition.(Suter et al.1999, Suter et al.2000)

Increased EMG activity after manipulation. ***(Keller and Colloca 2000)

Inhibition of muscle hypertonicity. *** (Herzog, et al. 1999, Lehman et al. 2001)


RiskRisk

Risk / Benefit RatioRisk / Benefit Ratio

Can this happen as a result of chiropractic neck treatment (adjustments/SMT)?

If so, what is the mechanism?

What’s the temporal relationship between stroke and cervical manipulation?

Is treatment causal? Is treatment contributory? Is treatment coincidental?

Can it be predicted, prevented or screened for?

CVACVA Cerebrovascular accidentCerebrovascular accident

RiskRisk

Disc Injury

Risk of spinal manipulation to clinically worsen disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million.

(Oliphant 2004)

RiskRisk

Evidenced Based?Evidenced Based?

How Evidence Based is Chiropractic?How Evidence Based is Chiropractic?QQ

Evidence Based ChiropracticEvidence Based Chiropractic

Effectiveness Bronfort et al. 2004 Assendelft et al. 2004 Horris et al. 2004 Assendelft et al. 1996 Mead et al. 1995 Meade, et al. 1991 Shekelle, et al. 1991

Cost-Effectiveness Nelson et al 2005 UK Beam RCT 2004 Cherkin et al 2003 Stano and Smith 1996 Manga, et al.1993, Ebrall 1992

Evidence BasedEvidence Based

Clinical Prediction Rules Clinical Outcomes are improved when subgrouping

is used to guide treatment decision-making. (Brennan 2006)

Clinical Prediction Rules help accurately identify patients most likely to best respond to spinal manipulative therapy. (Flynn et al. 2002)

1. Duration >16 days, 2. FABQ <19, 3. Lumbar hypomobility, 4. No Symptoms distal to Knee 5. Internal rotation of at least one f-a joint of <35°

Clinical Prediction RulesClinical Prediction Rules

SummarySummary

SummarySummary



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Steadman Hawkins Sports Medicine Lecture Series: Chiropractic (2006)

Health & Medicine

Transcript of Steadman Hawkins Sports Medicine Lecture Series: Chiropractic (2006)