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Dr Heidi Haavik Melbourne Presentation

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How to confidently communicate the science of chiropractic

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Dr Heidi Haavik Melbourne Presentation

  1. 1. How to confidently communicate the science of chiropractic Introductory Workshop Dr Heidi Haavik DG 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
  2. 2. 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.
  3. 3. 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
  4. 4. Heidi’s Vision  A world of people expressing optimal potential
  5. 5. Heidi’s mission  Run a ridiculously successful and Vitalistic International Centre for Chiropractic Research
  6. 6. Heidi’s why  To allow more people access to chiropractic care through he power of cutting edge top quality research about mechanisms
  7. 7. Heidi’s role 1. Facilitate research 2. Mentor researchers 3. Inform / teach 4. Raise funds
  8. 8. Purpose of Today That you can confidently talk about the science of chiropractic
  9. 9. AIM: Confident Communication!  Knowing what you can and cannot say about the science of chiropractic
  10. 10. 10
  11. 11. 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
  12. 12. heidi.haavik@nzchiro.co.nz
  13. 13. heidihaavik.com • Written for the public • Describes in easy to understand language what happens when we adjust a VS
  14. 14. heidi.haavik@nzchiro.co.nz
  15. 15. Where are you at now?
  16. 16. In pairs (one being the chiro, the other the patient) each take turns explaining:  What a subluxation is  How chiropractic care works
  17. 17. How did that go? Where you confident? Do you know if your ‘story’ has scientific backing?
  18. 18. The big picture In a nutshell What is a subluxation? How does chiropractic care work?
  19. 19. A subluxation is..... “a central segmental motor control problem” Which means that the central nervous system is not controlling the movement pattern of the spinal segment as it should, which alters the stretching of the paraspinal muscles which changes the input to the brain which impacts how it processes other information
  20. 20. 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
  21. 21. Wisdom vs Knowledge
  22. 22. 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)
  23. 23. 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,
  24. 24. 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
  25. 25. 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
  26. 26. 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)
  27. 27. Office Poster
  28. 28. Patient pamphlet
  29. 29. The Brain & CNS 101
  30. 30. 34
  31. 31. The Matrix
  32. 32. 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
  33. 33. 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
  34. 34. How did that go? Where you confident? Did any questions arise?
  35. 35. The inner brain reality is it always accurate?
  36. 36. Phantom limb pain
  37. 37. 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.
  38. 38. 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
  39. 39. “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)
  40. 40. 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 waht oredr the lrttees in a wrod are, the olny tihng taht is iproamtnt is the frsit and 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?”
  41. 41. Morning Tea  9.35 – 10.20
  42. 42. Video clip – TEDxAdelaide - Lorimer Moseley - Why Things Hurt: http://www.youtube.com/watch?v=gwd-wLdIHjs Pain and Plasticity
  43. 43. “We can mess with that”
  44. 44. 48
  45. 45. Blind spot testing
  46. 46. Neural plasticity
  47. 47. 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
  48. 48. Maladaptive vs Adaptive Plasticity
  49. 49. Maladaptive vs Adaptive Plasticity
  50. 50. Symptoms don’t just appear out of thin air
  51. 51. 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
  52. 52. The connection between the neuroscience and chiropractic!
  53. 53. Paraspinal Muscles act as CNS sensors
  54. 54. 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
  55. 55. Spinal adjustments Appropriate joint movement Appropriate spinal information sent to brain and CNS Appropriate processing and integration by brain and CSN Better control of the spine and body
  56. 56. The specific research hypothesis Spinal adjustments Abnormal Somatosensory Filtering & processing Altered function (pain and disability) Altered sensorimotor integration Altered motor control Altered afferent input Subluxation Appropriate Joint movement Normal afferent input Appropriate Somatosensory Filtering & processing Appropriate sensorimotor integration Accurate motor control Good function
  57. 57. 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, 2006 Murphy et al, 2009; 2010 Haavik & Murphy 2012b
  58. 58. 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 Appropriate Joint movement Appropriate afferent input Appropriate Somatosensory Processing Appropriate sensorimotor integration Accurate motor control Good function Marshall & Murphy, 2006 Murphy et al, 2009; 2010 Haavik & Murphy 2012b
  59. 59. 67
  60. 60. Amplitude Time Signal Background  noise
  61. 61. Amplitude Time
  62. 62. 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.
  63. 63. 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
  64. 64. A subluxation is..... “a central segmental motor control problem” Which means that the central nervous system is not controlling the movement patter of the spinal segment as it should, which alters the stretching of the paraspinal muscles which changes the input to the brain which impacts how it processes other information
  65. 65. 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
  66. 66. Self Test! See if you can remember the key essential components to explain the effects of an adjustment !
  67. 67. 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
  68. 68. 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!
  69. 69. 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
  70. 70. 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
  71. 71. Lunch  12.30-1.45
  72. 72. Recap of Morning Session Questions?
  73. 73. Review and you will remember 70% more!
  74. 74. How did practical go? Where you confident? What were you less confident about? What did you not remember ? Biggest gaps in understanding/knowledge?
  75. 75. 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
  76. 76. 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
  77. 77. Science & Research 101
  78. 78. Evidence Informed Practice Improved patient outcomes! Patients own values and expectation
  79. 79. Overall Working Model Narrow down to testable question Test with scientific method Interpret your results
  80. 80. Clinical research Basic Science Research
  81. 81. The floor-plan research methodology analogy
  82. 82. Basic Science Qualitative researchClinical Trials RCTs Case reports Copyright ©Dr Heidi Haavik 2014
  83. 83. Systematic Reviews Editorials, Expert Opinion Randomised Controlled Trials Cohort Studies Case-control Studies Case Series, Case Reports The hierarchy of evidence
  84. 84. 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?
  85. 85. 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?
  86. 86. 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?
  87. 87. Simple balance testing in the Office Copyright ©Dr Heidi Haavik 2014 Copyright ©Dr Heidi Haavik 2014
  88. 88. Scrambled sentence & Blind spot testing Blind spot test and instructions in your booklet
  89. 89. Square Illusion
  90. 90. 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?
  91. 91. How did that go? Share with another pair how it went What was easy? What was hard? Where you confident?
  92. 92. Afternoon Tea  3.00 – 3.45
  93. 93. Lets get stuck into some studies
  94. 94. 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)
  95. 95. 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)
  96. 96. 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
  97. 97. Feedforward Activation (Marshall & Murphy. J Manipulative Physiol Ther 2006;29:196-202) (Govorko,MScThesis,2007,p.106)
  98. 98. (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
  99. 99. 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
  100. 100. 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?
  101. 101. How did that go? Share with another pair how it went What was easy? What was hard? Where you confident?
  102. 102. (Award winning poster at 2009 WFC; Award winning paper at ACC RAC 2010) Haavik & Murphy, 2011, JMPT; 34:88-97 Copyright ©Dr Heidi Haavik 2014
  103. 103. 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
  104. 104. 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?
  105. 105. How did that go? Share with another pair how it went What was easy? What was hard? Where you confident?
  106. 106. Feedback Please
  107. 107. 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?

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