<ul><li>Joel Dekanich  DC, DACBSP, EMT, CSCS </li></ul><ul><li>Mark Pitcher DC, MSc </li></ul>Chiropractic Treatment: Ever...
Objectives:  <ul><li>Review manipulation and chiropractic origins  </li></ul><ul><li>Explain the variation in chiropractic...
Objectives: <ul><li>Understand the mechanics and physiology of spinal manipulation </li></ul><ul><li>Briefly explore risk ...
Chiropractic <ul><li>… a profession that uses an array of manual therapies and modalities, but primarily spinal manipulati...
Spinal Manipulation <ul><li>Spinal manipulation: </li></ul><ul><ul><li>Depicted in cave drawings (14,500 BC) </li></ul></u...
Spinal Manipulation Historical Perspective <ul><li>Spinal manipulation: </li></ul><ul><ul><li>Depicted in cave drawings (1...
Spinal Manipulation Historical Perspective <ul><li>Spinal manipulation: </li></ul><ul><ul><li>Depicted in cave drawings (1...
Spinal Manipulation Historical Perspective <ul><li>Spinal manipulation: </li></ul><ul><ul><li>Depicted in cave drawings (1...
Spinal Manipulation Historical Perspective <ul><li>Spinal manipulation: </li></ul><ul><ul><li>Depicted in cave drawings (1...
Chiropractic <ul><li>Chiropractic, as a profession, was founded by D.D Palmer in 1895. </li></ul><ul><li>Palmer believed t...
Spinal Manipulation <ul><li>Today : </li></ul><ul><ul><li>Chiropractors </li></ul></ul><ul><ul><li>Osteopaths </li></ul></...
Why is there variability in how chiropractors practice? Variability in Treatment
Chiropractic  <ul><li>Wide spectrum of practice styles and belief systems.  </li></ul><ul><ul><li>Alternative     Evidenc...
What training do chiropractors have? Chiropractic Training
Chiropractic   Training <ul><li>Depending on the state, two or more years of undergraduate  </li></ul><ul><li>study or a B...
Assessment and treatment  Rationale for Chiropractic Treatment
<ul><li>Assessment: </li></ul><ul><ul><li>History  </li></ul></ul><ul><ul><li>Examination </li></ul></ul><ul><ul><ul><li>O...
<ul><li>Probably any abnormal loading conditions (including overload and immobilization) can produce tissue trauma and/or ...
<ul><li>Vast majority of patients seek chiropractic care for musculoskeletal injuries :  (Coulter et al. 2002)   </li></ul...
<ul><li>Mechanical and Neuromuscular Treatment Goals: </li></ul><ul><ul><li>Increase segmental range of motion  </li></ul>...
<ul><li>Decreased Segmental Range of Motion </li></ul><ul><ul><li>Barrier concept (Bourdillon, et al. 1992) </li></ul></ul...
Manipulation vs. Mobilization <ul><li>Manipulation </li></ul><ul><ul><li>Usually a single application </li></ul></ul><ul><...
Force Magnitudes with Manipulation Treatment Herzog 2001 Kirstukas et al. 1999 238 1044 23.8 310 Thoracic Spine Herzog 200...
<ul><li>Spinal Manipulative Therapy  (SMT)   </li></ul><ul><li>is a therapeutic tool where a high velocity, low  amplitude...
<ul><li>Changes associated with spinal manipulation are thought to arise from:   </li></ul><ul><ul><li>Release of entrappe...
<ul><li>Mechanical Effects: </li></ul><ul><li>Increased active   (Wittingham 2001)   and passive   (Nilsson 1996)   ranges...
<ul><li>The effect of manipulation of a normal joint: </li></ul><ul><li>Initial separation of 1.8 mm is due to the thickne...
<ul><li>The effect of manipulation of a normal joint: </li></ul><ul><li>Increasing tension to 18kg produces a further join...
<ul><li>When forces associated with manipulation separates joint surfaces beyond the elastic barrier, gases normally disso...
<ul><li>Neuromuscular Effects: </li></ul><ul><ul><li>Attenuation of motoneuronal discharge.  (Dishman et al.1998, Dishman ...
Risk / Benefit Ratio Risk
<ul><li>Can this happen as a result of chiropractic neck treatment (adjustments/SMT)?  </li></ul><ul><ul><li>If so, what i...
Disc Injury <ul><li>Risk of spinal manipulation to clinically worsen disk herniation or CES in a patient presenting with L...
Evidenced Based? How Evidence Based is Chiropractic? Q
Evidence Based Chiropractic <ul><li>Effectiveness  </li></ul><ul><ul><ul><li>Bronfort et al. 2004 Assendelft et al. 2004 <...
Clinical Prediction Rules <ul><li>Clinical Outcomes are improved when subgrouping is used to guide treatment decision-maki...
Summary Summary www.vailhealth.com www.markjpitcher.com
Questions? www.vailhealth.com www.markjpitcher.com
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Steadman Hawkins Sports Medicine Lecture Series: Chiropractic (2006)

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This is a lecture presented to the Steadman Hawkins Sports Medicine Foundation's Orthopedic Lecture Series a few years back.

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  • Chiropractors certainly did not INVENT manipulation, but they did hone it into a well crafted art and more recently subjected it to scientific scrutiny. Spinal Manipulation predates chiropractic. Palmer “WESTERNIZED IT”
  • Coulter I, et al. Patients using chiropractors in North America: Who are they, and why are they in chiropractic care? Spine 2002; 27(3):291-298.
  • 328 newton = 74 pound-force
  • Manipulative Physiol Ther. 2002 May;25(4):251-62. Related Articles, Links   Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories. Evans DW . British School of Osteopathy, London, United Kingdom. OBJECTIVES: When the clinical efficacy of spinal manipulative treatment for spinal pain has been assessed, high-velocity low-amplitude thrust (HVLAT) manipulation and mobilization have been regarded as clinical interventions giving identical and equivalent biologic effects. The objective of this review is to critically discuss previous theories and research of spinal HVLAT manipulation, highlighting reported neurophysiologic effects that seem to be uniquely associated with cavitation of synovial fluid. DATA SOURCE: The biomedical literature was searched for research and reviews on spinal manipulation. MEDLINE and EMBASE databases were used to help find relevant articles. STUDY SELECTION: All articles relevant to the objectives were selected. DATA EXTRACTION: All available data were used. DATA SYNTHESIS: The main hypotheses for lesions that respond to HVLAT manipulation were critically discussed: (1) release of entrapped synovial folds or plica, (2) relaxation of hypertonic muscle by sudden stretching, (3) disruption of articular or periarticular adhesions, and (4) unbuckling of motion segments that have undergone disproportionate displacements. RESULTS: There appear to be 2 separate modes of action from zygapophyseal HVLAT manipulation. Intra-articular &amp;quot;mechanical&amp;quot; effects of zygapophyseal HVLAT manipulation seem to be absolutely separate from and irrelevant to the occurrence of reported &amp;quot;neurophysiologic&amp;quot; effects. Cavitation should not be an absolute requirement for the mechanical effects to occur but may be a reliable indicator for successful joint gapping. CONCLUSIONS: It is hoped that identification of these unique neurophysiologic effects will provide enough theoretical reason for HVLAT manipulation and mobilization to be assessed independently as
  • Purported relationship to cervical SMT ranges by orders of magnitude 1 : 20,000 manipulations (Schievink) 1 : 1,000,000 (RAND) 1 : 400,000 cervical manipulations (the Swiss Survey) 1 : 414,000 cervical manipulations using rotation techniques (Dutch Study) 1 : 5,850,000 cervical manipulations (CCPA study)
  • All types of acute care hospitals across the U.S. are becoming increasingly involved in offering CAM services. Hospitals appear to be responding to consumer demand”. (Clement 2006)
  • Steadman Hawkins Sports Medicine Lecture Series: Chiropractic (2006)

    1. 1. <ul><li>Joel Dekanich DC, DACBSP, EMT, CSCS </li></ul><ul><li>Mark Pitcher DC, MSc </li></ul>Chiropractic Treatment: Everything you wanted to know but was afraid to ask www.vailhealth.com www.markjpitcher.com
    2. 2. Objectives: <ul><li>Review manipulation and chiropractic origins </li></ul><ul><li>Explain the variation in chiropractic treatment and philosophies </li></ul><ul><li>Chiropractic Training </li></ul><ul><li>Explain treatment rationale </li></ul>www.vailhealth.com www.markjpitcher.com
    3. 3. Objectives: <ul><li>Understand the mechanics and physiology of spinal manipulation </li></ul><ul><li>Briefly explore risk vs. benefit </li></ul><ul><li>Discuss best available evidence & clinical predictor rules </li></ul>www.vailhealth.com www.markjpitcher.com
    4. 4. Chiropractic <ul><li>… a profession that uses an array of manual therapies and modalities, but primarily spinal manipulation, for the correction and rehabilitation of the neuromusculoskeletal problems. </li></ul>
    5. 5. Spinal Manipulation <ul><li>Spinal manipulation: </li></ul><ul><ul><li>Depicted in cave drawings (14,500 BC) </li></ul></ul><ul><ul><li>Ancient china (2700 BC) </li></ul></ul><ul><ul><li>Hippocrates (470 BC) </li></ul></ul><ul><ul><li>Bonesetters (1800’s) </li></ul></ul><ul><ul><li>Osteopaths (late 1800’s) </li></ul></ul><ul><ul><li>Chiropractors 1895 </li></ul></ul>Historical Perspective
    6. 6. Spinal Manipulation Historical Perspective <ul><li>Spinal manipulation: </li></ul><ul><ul><li>Depicted in cave drawings (14,500 BC) </li></ul></ul><ul><ul><li>Ancient china (2700 BC) </li></ul></ul><ul><ul><li>Hippocrates (470 BC) </li></ul></ul><ul><ul><li>Bonesetters (1800’s) </li></ul></ul><ul><ul><li>Osteopaths (late 1800’s) </li></ul></ul><ul><ul><li>Chiropractors 1895 </li></ul></ul>
    7. 7. Spinal Manipulation Historical Perspective <ul><li>Spinal manipulation: </li></ul><ul><ul><li>Depicted in cave drawings (14,500 BC) </li></ul></ul><ul><ul><li>Ancient china (2700 BC) </li></ul></ul><ul><ul><li>Hippocrates (470 BC) </li></ul></ul><ul><ul><li>Bonesetters (1800’s) </li></ul></ul><ul><ul><li>Osteopaths (late 1800’s) </li></ul></ul><ul><ul><li>Chiropractors 1895 </li></ul></ul>
    8. 8. Spinal Manipulation Historical Perspective <ul><li>Spinal manipulation: </li></ul><ul><ul><li>Depicted in cave drawings (14,500 BC) </li></ul></ul><ul><ul><li>Ancient china (2700 BC) </li></ul></ul><ul><ul><li>Hippocrates (470 BC) </li></ul></ul><ul><ul><li>Bonesetters (1800’s) </li></ul></ul><ul><ul><li>Osteopaths (late 1800’s) </li></ul></ul><ul><ul><li>Chiropractors 1895 </li></ul></ul>
    9. 9. Spinal Manipulation Historical Perspective <ul><li>Spinal manipulation: </li></ul><ul><ul><li>Depicted in cave drawings (14,500 BC) </li></ul></ul><ul><ul><li>Ancient china (2700 BC) </li></ul></ul><ul><ul><li>Hippocrates (470 BC) </li></ul></ul><ul><ul><li>Bonesetters (1800’s) </li></ul></ul><ul><ul><li>Osteopaths (late 1800’s) </li></ul></ul><ul><ul><li>Chiropractors 1895 </li></ul></ul>
    10. 10. Chiropractic <ul><li>Chiropractic, as a profession, was founded by D.D Palmer in 1895. </li></ul><ul><li>Palmer believed that spinal misalignments put pressure on nerves, and could result in disease. </li></ul><ul><li>Used a spinal “adjustment” to correct these misalignments. </li></ul>Historical Perspective
    11. 11. Spinal Manipulation <ul><li>Today : </li></ul><ul><ul><li>Chiropractors </li></ul></ul><ul><ul><li>Osteopaths </li></ul></ul><ul><ul><li>Physical Therapists </li></ul></ul><ul><ul><li>Medical Doctors (Mostly in Eastern Europe) </li></ul></ul>95% of spinal manipulation in the United States is done by chiropractors (Shekelle and Brook 1991) Historical Perspective
    12. 12. Why is there variability in how chiropractors practice? Variability in Treatment
    13. 13. Chiropractic <ul><li>Wide spectrum of practice styles and belief systems. </li></ul><ul><ul><li>Alternative  Evidence Based </li></ul></ul><ul><li>Many chiropractors hold the tenants of the Palmer’s original chiropractic theory. (Biggs et al. 2002) </li></ul><ul><li>A vitalistic versus a mechanistic philosophy flourished in the early 1900’s as chiropractic attempted to distance itself from Medicine and Allopathy in general. </li></ul><ul><li>Others in the chiropractic profession lean towards a more a research based and evidence driven practice. </li></ul>Diversity of Practice Variability in Treatment
    14. 14. What training do chiropractors have? Chiropractic Training
    15. 15. Chiropractic Training <ul><li>Depending on the state, two or more years of undergraduate </li></ul><ul><li>study or a Bachelor’s degree is required with basic pre-medical curriculum. </li></ul><ul><li>Complete a 5 year program in one of the accredited programs in the U.S. or Canada. </li></ul><ul><li>Complete 4 different national board examinations and additional state requirements. </li></ul><ul><li>Many D.C.’s complete additional postgraduate training in sports medicine, rehabilitation, orthopedics, radiology, neurology, and other areas. </li></ul>
    16. 16. Assessment and treatment Rationale for Chiropractic Treatment
    17. 17. <ul><li>Assessment: </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Examination </li></ul></ul><ul><ul><ul><li>Orthopaedic and Neurological Tests </li></ul></ul></ul><ul><ul><ul><li>Functional Motion palpationF </li></ul></ul></ul><ul><li>Functional Diagnosis </li></ul><ul><li>Treatments </li></ul><ul><ul><li>Modalities </li></ul></ul><ul><ul><li>Facilitated stretching (PIR/PNF) </li></ul></ul><ul><ul><li>Taping and bracing </li></ul></ul><ul><ul><li>Exercise therapy </li></ul></ul><ul><ul><li>Mobilization </li></ul></ul><ul><ul><li>Manipulation </li></ul></ul>Assessment and treatment Rationale for Chiropractic Treatment
    18. 18. <ul><li>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) </li></ul><ul><li>Joint fixation (hypomobility) results in time-dependent degenerative changes of the Z joints. (Cramer 2004) </li></ul>Assessment and treatment Rationale for Chiropractic Treatment
    19. 19. <ul><li>Vast majority of patients seek chiropractic care for musculoskeletal injuries : (Coulter et al. 2002) </li></ul><ul><ul><li>Work related injuries </li></ul></ul><ul><ul><li>Sports injuries </li></ul></ul><ul><ul><li>Postural or repetitive or cumulative trauma. </li></ul></ul><ul><li>Commonly treat such conditions such as: </li></ul><ul><ul><li>Back and Neck pain </li></ul></ul><ul><ul><li>Headaches </li></ul></ul><ul><ul><li>Sprains and Strains </li></ul></ul><ul><ul><li>Disc injury </li></ul></ul>Rationale for Chiropractic Treatment Treatment Rationale
    20. 20. <ul><li>Mechanical and Neuromuscular Treatment Goals: </li></ul><ul><ul><li>Increase segmental range of motion </li></ul></ul><ul><ul><li>Reduce muscle spasm </li></ul></ul><ul><ul><li>Decrease articular pain </li></ul></ul><ul><ul><li>Short term activation of skeletal muscle </li></ul></ul>Goals of Spinal Manipulation Spinal Manipulation
    21. 21. <ul><li>Decreased Segmental Range of Motion </li></ul><ul><ul><li>Barrier concept (Bourdillon, et al. 1992) </li></ul></ul><ul><ul><li>Elastic and anatomic barriers (Greenman 1989) </li></ul></ul>Spinal Manipulation Passive ROM Active ROM Elastic barrier Paraphysiological Space Spinal Manipulation
    22. 22. Manipulation vs. Mobilization <ul><li>Manipulation </li></ul><ul><ul><li>Usually a single application </li></ul></ul><ul><ul><li>Preload force </li></ul></ul><ul><ul><li>Force Profile : </li></ul></ul><ul><ul><ul><ul><li>Higher Magnitude Force </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Shorter delivery time </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Higher Velocity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>(~100-300ms) </li></ul></ul></ul></ul>Manipulation vs. Mobilization <ul><ul><li>Mobilization </li></ul></ul><ul><ul><li>Single or multiple applications </li></ul></ul><ul><ul><li>+/- Preload force </li></ul></ul><ul><ul><li>Force Profile: </li></ul></ul><ul><ul><ul><ul><li>Lower Magnitude of Force </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Variable delivery time </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Variable Velocity </li></ul></ul></ul></ul>
    23. 23. Force Magnitudes with Manipulation Treatment Herzog 2001 Kirstukas et al. 1999 238 1044 23.8 310 Thoracic Spine Herzog 2000 107 27 Cervical Spine Triano and Shultz 1997 384-515 ? Lumbar Spine Herzog 2000 328 88 SI Study Peak Contact Force (N) Preload (N) Region
    24. 24. <ul><li>Spinal Manipulative Therapy (SMT) </li></ul><ul><li>is a therapeutic tool where a high velocity, low amplitude thrust is directed to a joint to restore its segmental range of motion. </li></ul><ul><li>Effects of spinal manipulation: </li></ul><ul><ul><li>Increased range of motion (Whittingham 2001, Nilsson 1996) </li></ul></ul><ul><ul><li>Increased functional capacity (Meade 1995, Shekelle 1992) </li></ul></ul><ul><ul><li>Mechanical and Neuromuscular effects (Herzog 1996). </li></ul></ul>Mechanisms of Manipulation: Spinal Manipulation
    25. 25. <ul><li>Changes associated with spinal manipulation are thought to arise from: </li></ul><ul><ul><li>Release of entrapped synovial tissues </li></ul></ul><ul><ul><li>Stretching and breaking of adhesions </li></ul></ul><ul><ul><li>Dynamic stretching of musculature and myofascial tissues. </li></ul></ul><ul><ul><li>(Evans 2002) </li></ul></ul>Mechanisms of Manipulation:
    26. 26. <ul><li>Mechanical Effects: </li></ul><ul><li>Increased active (Wittingham 2001) and passive (Nilsson 1996) ranges of motion. </li></ul><ul><li>Increased intersegmental motion. (Yeomans 1992) </li></ul><ul><li>Gapping of zygapophyseal joints on MRI post-manipulation . (Cramer 2000) </li></ul>Mechanisms of Manipulation: Neuromuscular Effects
    27. 27. <ul><li>The effect of manipulation of a normal joint: </li></ul><ul><li>Initial separation of 1.8 mm is due to the thickness of the cartilages </li></ul><ul><li>The separation increases gradually to a tension of 8 kg </li></ul><ul><li>At this point, the surfaces jump to a separation of 4.7 mm and an ‘audible’ is heard </li></ul>Mechanisms of Manipulation: Gapping of the joint
    28. 28. <ul><li>The effect of manipulation of a normal joint: </li></ul><ul><li>Increasing tension to 18kg produces a further joint separation up to 5.4 mm </li></ul><ul><li>On reduction of tension, the joint surface separation is approx. 2 mm, a distance slightly more than the initial separation of 1.8 mm. </li></ul>Mechanisms of Manipulation: Mechanical Effects
    29. 29. <ul><li>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. </li></ul><ul><li>The cavitation rapidly distends the joint capsule creating a “snap”, or “pop” </li></ul>Mechanisms of Manipulation: Cavitation
    30. 30. <ul><li>Neuromuscular Effects: </li></ul><ul><ul><li>Attenuation of motoneuronal discharge. (Dishman et al.1998, Dishman and Bulbulian 2000 ) </li></ul></ul><ul><ul><li>Decreased muscle inhibition. (Suter et al.1999, Suter et al.2000) </li></ul></ul><ul><ul><li>Increased EMG activity after manipulation. *** (Keller and Colloca 2000) </li></ul></ul><ul><ul><li>Inhibition of muscle hypertonicity. *** (Herzog, et al. 1999, Lehman et al. 2001) </li></ul></ul>Mechanisms of Manipulation: Neuromuscular Effects
    31. 31. Risk / Benefit Ratio Risk
    32. 32. <ul><li>Can this happen as a result of chiropractic neck treatment (adjustments/SMT)? </li></ul><ul><ul><li>If so, what is the mechanism? </li></ul></ul><ul><li>What’s the temporal relationship between stroke and cervical manipulation? </li></ul><ul><ul><li>Is treatment causal? </li></ul></ul><ul><ul><li>Is treatment contributory? </li></ul></ul><ul><ul><li>Is treatment coincidental? </li></ul></ul><ul><li>Can it be predicted, prevented or screened for? </li></ul>CVA Cerebrovascular accident Risk
    33. 33. Disc Injury <ul><li>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. </li></ul><ul><li>(Oliphant 2004) </li></ul>Risk
    34. 34. Evidenced Based? How Evidence Based is Chiropractic? Q
    35. 35. Evidence Based Chiropractic <ul><li>Effectiveness </li></ul><ul><ul><ul><li>Bronfort et al. 2004 Assendelft et al. 2004 </li></ul></ul></ul><ul><ul><ul><li>Horris et al. 2004 Assendelft et al. 1996 </li></ul></ul></ul><ul><ul><ul><li>Mead et al. 1995 </li></ul></ul></ul><ul><ul><ul><li>Meade, et al. 1991 </li></ul></ul></ul><ul><ul><ul><li>Shekelle, et al. 1991 </li></ul></ul></ul><ul><li>Cost-Effectiveness </li></ul><ul><ul><ul><li>Nelson et al 2005 </li></ul></ul></ul><ul><ul><ul><li>UK Beam RCT 2004 Cherkin et al 2003 </li></ul></ul></ul><ul><ul><ul><li>Stano and Smith 1996 </li></ul></ul></ul><ul><ul><ul><li>Manga, et al.1993, </li></ul></ul></ul><ul><ul><ul><li>Ebrall 1992 </li></ul></ul></ul>Evidence Based
    36. 36. Clinical Prediction Rules <ul><li>Clinical Outcomes are improved when subgrouping is used to guide treatment decision-making . </li></ul><ul><li>(Brennan 2006) </li></ul><ul><li>Clinical Prediction Rules help accurately identify patients most likely to best respond to spinal manipulative therapy. (Flynn et al. 2002) </li></ul><ul><li>1. Duration >16 days, </li></ul><ul><li>2. FABQ <19, </li></ul><ul><li>3. Lumbar hypomobility, </li></ul><ul><li>4. No Symptoms distal to Knee </li></ul><ul><li>5. Internal rotation of at least one f-a joint of <35 ° </li></ul>Clinical Prediction Rules
    37. 37. Summary Summary www.vailhealth.com www.markjpitcher.com
    38. 38. Questions? www.vailhealth.com www.markjpitcher.com

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