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Chiropractors Score Highest in Musculoskeletal Conditions Tests

Chiropractors Score Highest in Musculoskeletal Conditions Tests

According to Wikipedia: The musculoskeletal system (also known as the locomotor system) is an organ system that gives animals (including humans) the ability to move using the muscular and skeletal systems. The musculoskeletal system provides form, support, stability, and movement to the body. It is made up of the body’s bones (the skeleton), muscles, cartilage, tendons, ligaments, joints, and other connective tissue that supports and binds tissues and organs together. The musculoskeletal system’s primary functions include supporting the body, allowing motion, and protecting vital organs. The skeletal portion of the system serves as the main storage system for calcium and phosphorus and contains critical components of the hematopoietic system.

Musculoskeletal conditions range from neck, mid and low back pain to certain type of headaches and arm and leg pain. Most sports injuries are musculoskeletal in nature as well and most degenerative conditions (arthritis) that prevents the use of an limb over time. If it has to do with moving, lifting, sitting or carrying, it is usually a musculoskeletal condition responsible for the inability to perform that action, or have pain with completing the task related to movement.

In a recent article written by Humphreys, Sulkowski, McIntyre, Kasiban, and Patrick (2007), they stated, “In the United States, approximately 10% to 25% of all visits to primary care medical doctors are for MSK [musculoskeletal] complaints, making it one of the most common reasons for consulting a physician…Specifically, it has been estimated that less than 5% of the undergraduate and graduate medical curriculum in the United States and 2.26% in Canadian medical schools is devoted to MSK medicine” (p. 44).

Musculoskeletal complaints have a major impact on the healthcare system and although many patients believe that traditional providers are highly trained, recent publications relating to basic competency have shown otherwise. For example, the authors cited another study stating, “A study by Childs et al on the physical therapists’ knowledge in managing MSK conditions found that only 21% of students working on their master’s degree in physical therapy and 25% of students working on their doctorate degree in physical therapy achieved a passing mark on the BCE [Basic Competency Evaluation]” (Humphreys et al., 2007, p. 45).

The authors reported, “The objective of this study was to examine the cognitive (knowledge) competency of final-year chiropractic students in MSK [musculoskeletal] medicine” (Humphreys et al., 2007, p. 45). “The typical chiropractic curriculum consists of 4800 hours of education composed of courses in the biological sciences (ie, anatomy, embryology, histology, microbiology, pathology, laboratory diagnosis, biochemistry, nutrition, and psychology), chiropractic sciences, and clinical sciences (ie, clinical diagnosis, neurodiagnosis, orthorheumatology, radiology, and psychology). As the diagnosis, treatment, and management of MSK disorders are the primary focus of the undergraduate curriculum as well as future clinical practice, it seems logical that chiropractic graduates should possess competence in basic MSK medicine” (Humphreys et al., 2007, p. 45).

The following results were published in this paper for the Basic Competency Examination and various professions that are in the front line of the diagnosis and treatment of musculoskeletal conditions. In Table 2 on page 47, the following results were shown when the passing score was established at 73% or greater:

Recent medical graduates (18%), medical students, residents, and staff physicians (20.7%), osteopathic students (29.6%) physical therapy (MSc level, 21%), physical therapy (doctorate level, 26%), chiropractic students (51.5%).

In Table 2 on page 47, the following results were show when the passing score was established at 70% or greater.

Recent medical graduates (22%), medical students, residents, and staff physicians (NA), osteopathic students (33%) physical therapy (MSc level, NA), physical therapy (doctorate level, NA), chiropractic students (64.7%).

Although many professions offer significant training in musculoskeletal conditions, chiropractors, based upon their training and outcomes in comparative studies are shown to be highly competent in caring for musculoskeletal conditions. It is therefore in the public’s best interest to consider chiropractic as a “first-line” treatment option or the primary care for “all things musculoskeletal.”

Reference:

1. Human Musculoskeletal System, Retrieved from: http://en.wikipedia.org/wiki/Musculoskeletal_system

2. Humphreys, B. K., Sulkowski, A., McIntyre, K., Kasiban, M., & Patrick, A. N. (2007). An examination of musculoskeletal cognitive competency in chiropractic interns. Journal of Manipulative and Physiological Therapeutics, 30(1), 44-49.


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Chiropractors Save Over $13B to Federal and Private Insurers

Chiropractors Save Over $13B to Federal and Private Insurers

It was reported by Doheny in 2006 that migraine headaches cost U.S. employers more than $24 billion annually, including direct health care costs and indirect expenses such as absenteeism. Doheny goes on to report that according to Michael Staufacker, director of program development for StayWell Health Management in St. Paul, Minnesota, “The programs are so few and far between because many companies ‘don’t perceive it as a priority’” (p. 10).

Much of the public perceive headaches and migraines as normal occurrences. For example, a patient will enter a doctor’s office and report they get normal headaches, not realizing that pain is never a normal occurrence. Symons, Shinde and Gilles (2008) highlighted a statement from iasp-pain.org saying that pain is “‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage'” (p. 277). As a result of the public not taking many types of headaches as potential serious problems, they let the condition linger and that can lead to negative sequella.

According to Munakata, Hazard, Serrano, Klingman, Rupnow, Tierce, Reed and Lipton (2009) “…neuroimaging studies have provided compelling evidence that suggests progressive brain changes in persons with migraines…migraine frequency is associated with posterior circulation infarcts and diffuse white-matter lesions…Welch et al. showed that impairments in iron homeostasis in periaqueductal grey areas that were associated with migraine duration and chronic daily headache” (Munakata et al., 2009, p. 499).

Munakata et al. also reported that the economic impact of migraines in both direct healthcare costs and indirect costs of absenteeism is a huge economic burden. The direct cost of migraines ranges from $127 to $7,089 per and the indirect cost due to absenteeism ranges from $709 to $4,453 per victim, making migraines an economic burden to the individual, the insurer, the employer with absenteeism and increased benefits paid and local, state and federal entities who will experience a lowered tax base from lost wages. It was also reported that between 2005 and 2006 there were 1,729,555 physician office visits, 186,603 advanced imaging procedures, 59,589 other diagnostic procedures, and 22,168 hospital days with a primary diagnosis of migraine or headache; all of which are paid by private or public insurers or out of the pockets of individuals. In short, the costs are staggering and a burden to the economy.

Friedman, Feldon, Holloway and Fisher (2009) reported that acute headaches account for 5% of emergency department (ED) visits in hospitals. In addition, they also reported that “…the ED environment that may also contribute to unsatisfactory treatment response include limited physician contact time that may preclude a detailed history, overuse of ED by patients with substance abuse problems, the need for rapid triage, the competing distraction of patients with life-threatening conditions, and directives (or lack thereof) for care dictated by the referring physician…Thus, the treatment of migraine patients in the ED appears to be suboptimal and the high rate of recurrent headache may be attributed to underutilization of relatively ‘migraine specific’ treatment” (Friedman et al., 2009, p. 1164).

Nelson, Suter, Casha, du Plessis and Hurlbert (1998) reported on randomized clinical trials that took place over an 8-week course. The results showed there was minor statistical differences in outcomes for improvement during the trial period for chiropractic care and for amatriptyline and over-the-counter medications for treating migraine headaches. It was also reported that there was no statistical benefit in combining therapies. However, the major factor is that in the post-treatment follow-up period, chiropractic was 57% more effective in the reduction of headaches than drug therapy. In addition, it was reported that, with the drug group, “…58% experienced medication side effects important enough to report them. In the amatriptyline group, 10% of the subjects had to withdraw from the study because of intolerable side effects. Side effects in the SMT (Spinal Manipulative Therapy) group were much more benign, infrequent, mild and transitory. None required withdrawal from the study (Nelson et al., 1998, p. 511). Although this study was conducted 13 years ago, a more current study by Chaibi, Tuchin and Russell (2011) reported that that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine, supporting the previous findings. Although more research is desperately needed, the above conclusions give the public clear directions with migraines and headaches.

Using the 57% increased effectiveness that chiropractic has over drug therapy (leaving out the overlap that chiropractic could help without drugs) and the $24,000,000,000 ($24 billion) Americans pay for headaches and migraines, the savings would result in $13,680,000,000. back in the insurers, the public’s and the government’s pockets. In addition, if chiropractic reduced the necessity for emergency room visits by 57%, then the ED doctors could focus on what their primary purpose is, to save lives in urgent scenarios.

Chiropractic offers solutions to the federal government, local government, public and private insurance companies, eases the burden on emergency rooms and prevents unnecessary side effects of drugs that are not clinically indicated, with a more viable and proven drugless solution. Although much more research is desperately needed to explore the benefits of chiropractic with migraines and headaches, the research that is available clearly reports that chiropractic offers immediate solutions. These solutions will add to the economy of local, state and federal governments by increasing the tax base and productivity in the marketplace as a result of keeping workers at work and circulating money into local economies with increased paychecks at the end of the year and productivity avoiding absenteeism. The research is conclusive and chiropractic has solutions to many of the economic and societal problems in the United States and worldwide.

References:

1. Doheny, K. (2006). Recognizing the financial pain of migraines. Workforce Management, 85(16), 10-12.

2. Symons, F. J., Shinde, S. K., & Gilles, E. (2008). Perspectives on pain and intellectual disability. Journal of Intellectual Disability Research, 52(Pt 4), 275-286.

3. Munakata, J., Hazard, E., Serrano, D., Klingman, D., Rupnow, M. F. T., Tierce, J., Reed, M., & Lipton, R. (2009). Economic burden of transformed migraine: Results from the American Migraine Prevalence and Prevention (AMPP) Study. Headache, 49(4), 498-508.

4. Friedman, D., Feldon, S., Holloway, R., & Fisher, S. (2009). Utilization, diagnosis, treatment and cost of migraine treatment in the emergency department. Headache, 49(8),1163-1173.

5. Nelson, C. F., Bronfort, G., Evans, R., Boline, P., Goldsmith, C., & Anderson, A. V. (1998). The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative & Physiological Therapeutics, 21(8), 511-519.

6. Chaibi, A., Tuchin, P. J., & Russell, M.B. (2011). Manual therapies for migraine: A systematic review. The Journal of Headache and Pain, 12(2), 127-133.


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Increased Immunity Linked to Chiropractic Care

Increased Immunity Linked to Chiropractic Care

From the public’s perspective, we all want to be well and not sick. During the winter months we fear the flu and colds and according to American Public Media (2016) we spend over $40 billion dollars annually just to feel better. Whether that number is accurate, underinflated or overinflated, we can all agree that as a society we spend a significant amount of money just to feel better and not to actually be better. The new buzzword over the last decade has been “wellness” and even hospitals are touting to focus on wellness although most MD’s who staff those hospitals have little to no training in wellness vs. disease care.

Personally, I welcome those highly trained MD’s who focus on disease care and our society desperately needs every one of them who is helping to successfully treat sick patients. However, medicine has failed at the “wellness game” and we are starting to see “functional medicine” practitioners who use holistic measures such as vitamins, herb, minerals and other natural means and most are not doctors of medicine, but practitioners who understand that wellness does not necessitate the use of pharmaceuticals. The goal of wellness is to increase our immune system to increase our immunity to various viruses and bacterial causing diseases in part of an overall health plan.

According to Wikipedia (2016) “In biology,immunity is the balanced state of having adequate biological defenses to fighting infection,disease, or other unwanted biological invasion, while having adequatetoleranceto avoidallergy, andautoimmune diseases. It is the capability of the body to resist harmfulmicroorganismsorvirusesfrom entering it. Immunity involves both specific and nonspecific components. The nonspecific components act either as barriers or as eliminators of wide range of pathogens irrespective of antigenic specificity. Other components of theimmune systemadapt themselves to each new disease encountered and are able to generate pathogen-specific immunity.” (https://en.wikipedia.org/wiki/Immunity_(medical)

According to Jeffries (1991) “The relationship between adrenocortical function and immunity is a complex one. In addition to the well-known detrimental effects of large, pharmacologic dosages of glucocorticoids upon the immune process, there is impressive evidence that physiologic amounts of cortisol, the chief glucocorticoid normally produced by the human adrenal cortex, is necessary for the development and maintenance of normal immunity.” Although many scholarly articles explain the connection between cortisol and the immune system, The Adrenal Fatigue Solution (2016) articulates it well “The hormones produced by your adrenal glands, particularly the stress hormone cortisol, play an important role in regulating your immune system. If your cortisol levels go too low or too high, this can lead to regular infections, chronic inflammation, autoimmune diseases or allergies. Maintaining a balanced level of cortisol is an important part of staying healthy.” (http://adrenalfatiguesolution.com/immune-system/)

One of cortisol’s many functions is to reduce inflammation. When your body encounters a pathogen, the immune system responds by quickly attacking it. This causes inflammation, which is often a good thing (it means the immune system is working). In those with healthy immune and endocrine systems, cortisol works to moderate the inflammation caused by an immune system response, but it does not completely eliminate it.”

Research done at the University of Madrid Medical School in Madrid Spain and the Department of Health Sciences at the University of Jaen Spain, Plaza-Manzano (2014) and fellow researchers found a link between immunity and chiropractic care. They were studying manipulation, or what chiropractors do when we adjust our patients and the cause for eradication of pain. They concluded that certain neuropeptides, or transmitters in the brain increase when our patients get adjusted. The specific neurotransmitter is called cortisol and according to Smith and Vale (2006) “The principal effectors of the stress response are localized in the paraventricular nucleus (PVN) of the hypothalamus, the anterior lobe of the pituitary gland, and the adrenal gland. This collection of structures is commonly referred to as the hypothalamic-pituitary-adrenal (HPA) axis…In addition to the HPA axis, several other structures play important roles in the regulation of adaptive responses to stress. These include brain stem noradrenergic neurons, sympathetic adrenomedullary circuits, and parasympathetic systems” (pgs. 383-384) . Smith and Vale also reported that balanced cortisol is important in the maintenance of the immune system.

It was reported that post-chiropractic adjustment (high velocity, low amplitude spinal manipulation: SM), at 2 hours after the intervention, an increase was found only in the cervical SM group when compared with pre-intervention levels… the cervical SM group showed a significant increase in cortisol plasma concentration immediately post-intervention compared with baseline values” (Plaza-Manzano et al. 2014, p. 235). This verifies that chiropractic care has a direct link to the cortisol-immunity connection through the neuro-endocrine reaction.

I would like to leave you with a last and seemingly unrelated statement. Our research team felt it is important to add this at the end since many of our critics negatively portray the safety of chiropractic care. This statement shall put that to rest leaving only personal biases left standing. Whedon, Mackenzie, Phillips, and Lurie(2015) based their study on 6,669,603 subjects and after the unqualified subjects had been removed from the study, the total patient number accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified”(Whedon et al., 2015, p. 5). This study supersedes all the rhetoric about chiropractic and stroke and renders an outcome assessment to help guide the triage pattern of mechanical spine patients.

References:

  1. The Cost of the Common Cold, American Public Media (2016), Retrieved from: http://www.marketplace.org/2011/01/21/life/cost-common-cold
  2. Immunity (2016) Retrieved from: https://en.wikipedia.org/wiki/Immunity_(medical)
  3. Jeffries W., (1991) Cortisol and Immunity, Medical Hypothesis, 34, 198-208
  4. Adrenal Fatigue and Your Immune System (2016). Retrieved from: http://adrenalfatiguesolution.com/immune-system/
  5. Plaza-Manzano, G., Molina-Ortega, F., Lomas-Vega, R., Martinez-Amat, A., Achalandabaso, A., & Hita-Contreras, F. (2014). Changes in biochemical markers of pain perception and stress response after spinal manipulation. Journal of Orthopedic and Sports Physical Therapy, 44(4), 231-239.
  6. Smith, S. M., & Vale, W. W. (2006). The role of hypothalamic-pituitary-adrenal axis neuroendocrine response to stress. Dialogue in Clinical Neuroscience, 8(4), 383-395.
  7. Whedon, J. M., Mackenzie, T. A., Phillips, R. B., & Lurie, J. D. (2015). Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66-69 years. Spine, 40(4), 264-270.


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Chiropractic Care Better Than Medical Care for Acute and Sub-Acute Low Back Pain

Chiropractic Care Better Than Medical Care for Acute and Sub-Acute Low Back Pain

By any standard, back pain is one of the most prevalent disabilities plaguing our population. According to Block, 2014, over 100 million Americans experience chronic pain with common painful conditions including back pain, neck pain, headaches/migraines, and arthritis, in addition to other painful conditions such as diabetic peripheral neuropathy, etc… In a large study in 2010, 30.7% of over 27,000 U.S. respondents reported an experience of chronic, recurrent pain of at least a 6-month duration. Half of the respondents with chronic pain noted daily symptoms, with 32% characterizing their pain as severe (≥7 on a scale ranging from 0 to 10). Chronic pain has a broad impact on emotional well-being and health-related quality of life, sleep quality, and social/recreational function. (pg. 1)

According to Schneider et al., 2015 “low back pain is among the most common medical elements an important public health issue. Approximately 50% of the United States working – age adults experience low back pain each year with a quarter of US adults reported in episode back pain in the previous three months. Back pain is the most common cause of disability for persons younger than 45 years old and one of the most common reasons for office visits to primary care physicians in the United States as well as Europe and Australia.” (pg. 2009)

In chiropractic, although chiropractic’s scope is significantly beyond back pain, based upon the sheer volume of low back pain sufferers, there simply aren’t enough chiropractors to manage this “epidemic sized” condition. In addition, chiropractors as a profession do not want to be labeled as solely “low back pain doctors.” Although the authors firmly agree, we also must acknowledge while treating mechanical spine pain (no fracture, tumor or infection) that the formal health care system has fallen short and in its effort, has contributed to the opiate epidemic.  Healthcare in the United States has had a myopic focus on “anatomical” sources of spine pain such as herniated disc and degenerative disc disease while ignoring the impact that faulty biomechanics have on spine pain and disability.  When it comes to the biomechanics of the spine, it is the responsibility of the chiropractic profession, based upon training and outcomes to lead the nation in its diagnosis, management and treatment.  When we consider both anatomical and biomechanical spine conditions are significant contributors to the spine pain and disability epidemic in the United States, we must understand its full impact and the standard healthcare system’s (allopathic) inability to manage the biomechanical side.

Block, 2014 continued “In addition to the pervasive personal suffering associated with this disease, chronic pain (author’s note: where low back pain is one of the most significant contributors) has a substantial negative financial impact on the economy. Direct office visits, diagnostic testing, hospital care, and pharmacy costs are only a portion of the picture, with combined medical and pharmacy costs averaging $5,000 annually per individual. Chronic pain results in a significant economic burden on the healthcare system, with estimated costs ranging from $560 to $635 billion 2010 dollars, more than the annual cost of other priority health conditions including cardiovascular disease, cancer, and diabetes. Moreover, the estimated annual costs of the workplace impact of pain range from $299 to $335 billion from absenteeism and reduced productivity.” (pgs. 1-2) These statistics help us to understand that “management” of spine pain is a critical component of cost reduction since the costliest portion of healthcare services is when a patient enters the system.  Continued mismanagement of mechanical spine pain causes patients to move in and out of disability status. That reentry is what drives up cost, chiropractic is the 3rdlargest health profession in the United States and the largest with the education to lead the diagnosis and management of mechanical spine pain.

When we compare who is better educated to manage mechanical back pain cases, we also must conclude as a result, who is better educated to successfully treat those cases based upon outcomes. In this comparison, we will consider the education of chiropractic vs. traditional musculoskeletal education and competency as well as treatment outcomes.

In a recent article written by Humphreys, Sulkowski, McIntyre, Kasiban, and Patrick (2007), they stated, “In the United States, approximately 10% to 25% of all visits to primary care medical doctors are for MSK [musculoskeletal] complaints, making it one of the most common reasons for consulting a physician…Specifically, it has been estimated that less than 5% of the undergraduate and graduate medical curriculum in the United States and 2.26% in Canadian medical schools is devoted to MSK medicine” (p. 44).

Musculoskeletal complaints have a major impact on the healthcare system and although many patients believe that traditional providers are highly trained, recent publications relating to basic competency have shown otherwise.  For example, the authors cited another study stating, Humphreys et al., 2007 continues by stating, “A study by Childs et alon the physical therapists’ knowledge in managing MSK conditions found that only 21% of students working on their master’s degree in physical therapy and 25% of students working on their doctorate degree in physical therapy achieved a passing mark on the BCE [Basic Competency Evaluation]” (p. 45).

The authors continued by reporting, “The objective of this study was to examine the cognitive (knowledge) competency of final-year chiropractic students in MSK [musculoskeletal] medicine” (p. 45).  “The typical chiropractic curriculum consists of 4,800 hours of education composed of courses in the biological sciences (i.e., anatomy, embryology, histology, microbiology, pathology, laboratory diagnosis, biochemistry, nutrition, and psychology), chiropractic sciences, and clinical sciences (i.e., clinical diagnosis, neurodiagnostic, ortho-rheumatology, radiology, and psychology).  As the diagnosis, treatment, and management of MSK disorders are the primary focus of the undergraduate curriculum as well as future clinical practice, it seems logical that chiropractic graduates should possess competence in basic MSK medicine” (Humphreys et al., 2007, p. 45).

The following results were published in this paper for the Basic Competency Examination and various professions that are in the front line of the diagnosis and treatment of musculoskeletal conditions.  In Table 2 on page 47, the following results were shown when the passing score was established at 73% or greater:

Recent medical graduates (18%), medical students, residents, and staff physicians (20.7%), osteopathic students (29.6%) physical therapy (MSc level, 21%), physical therapy (doctorate level, 26%), chiropractic students (51.5%).

In Table 2 on page 47, the following results were show when the passing score was established at 70% or greater.

Recent medical graduates (22%), medical students, residents, and staff physicians (NA), osteopathic students (33%) physical therapy (MSc level, NA), physical therapy (doctorate level, NA), chiropractic students (64.7%).

According to Frank Zolli DC, former Dean at the University of Bridgeport, College of Chiropractic, “Fundamental to the training of doctors of chiropractic is 4,820 hours (compared to 3,398 for physical therapy and 4,670 to medicine) and students receive a thorough knowledge of anatomy and physiology. As a result, all accredited doctor of chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. It is so important to practice these courses that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education, requires a curriculum which enables students to be proficient in neuromusculoskeletal evaluation, treatment and management. In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. To qualify for licensure, graduates of chiropractic programs must pass a series of examinations administered by the National Board of Chiropractic Examiners (NBCE) in 4 separate parts including clinical evaluations. It is therefore mandatory for a chiropractor to know the structure and function of the human body,  the study of neuromuscular and biomechanics is weaved throughout the fabric of chiropractic education.” As a result, the doctor of chiropractic has an expertise in the diagnosis and management of biomechanical musculoskeletal disorders that the traditional health care system is lacking. Chiropractic offers significant insight where traditional health care has no answers.

When it comes to direct influence of the chiropractic adjustment on spine pain patients, a 2005 study by DeVocht, Pickar, & Wilder concluded through objective electrodiagnostic studies (neurological testing) that 87% of chiropractic patients exhibited decreased muscle spasms. This study validates the reasoning behind why people with severe muscle spasms in the low back respond well to chiropractic care which in turn is shown to prevent future problems and disabilities. It also dictates that care should not be delayed or ignored due to a risk of complications. This study renders evidence that chiropractic spinal adjusting provides a direct nervous system and physiologic response to the human body.

In a recently published case study and literature review in the New England Journal of Medicine, Deyo and Mirza (2016) had published a case study and literature review on the diagnosis and treatment of lumbar disc herniation with sciatica. What is useful in this publication is the review of the literature in basic, easy to use format highlighting the most common treatments associated in lumbar disc herniation with sciatica.

Regarding the chiropractic adjustment, the authors stated “A randomized trial of chiropractic manipulation for sub-acute or chronic “back-related leg pain” (without confirmation of nerve-root compression on MRI) showed that manipulation [author’s note: Chiropractic spinal adjustment]  was more effective than home exercise with respect to pain relief at 12 weeks (by a mean 1-point decrease on a pain-intensity scale on which scores ranged from 0 to 10, with higher scores indicating greater severity of pain) but not at 1 year. This is important since early intervention of chiropractic care will reduce early dependency on pain medication. In addition, a randomized trial involving patients who had acute sciatica with MRI-confirmed disk protrusion showed that at 6 months, significantly more patients who underwent chiropractic manipulation had an absence of pain than did those who underwent sham manipulation (55% vs. 20%).  Neurologic complications in the lumbar spine, including worsened disk herniation or the cauda equina syndrome, have been reported anecdotally, but they appear to be extremely rare.” (pg 1768)

In relationship to counseling versus supervised exercise, the authors reported,“A systematic review of five randomized trials showed that patients who participated in supervised exercise had greater short-term pain relief than patients who received counseling alone, but this reduction in pain was small and these patients did not have a long-term benefit with respect to reduced pain or disability.” (pg. 1768)

Concerning oral steroids, the paper reported“Randomized trials show no significant advantage of systemic glucocorticoid (steroid) therapy over placebo with respect to pain relief or reduced rates of subsequent surgical intervention, and they show little, if any, advantage with respect to improvement in physical function.” (pg. 1767)

The authors commented on opioid medication by stating,“Data from randomized trials to support the use of opioids in patients with sciatica are lacking.   Systematic reviews suggest that opioids have slight short-term benefits with respect to reduced back pain.  Convincing evidence of benefits of long-term use is lacking, and there is growing concern regarding serious long-term adverse effects such as fractures and opioid overdose and abuse.” (pg. 1767)

Focusing on spinal injection therapy the paper continues by reporting, “A systematic review showed that patients with radiculopathy who received epidural glucocorticoid injections had slightly better pain relief (by 7.5 points on a 100-point scale) and functional improvement at 2 weeks than patients who received placebo. There were no significant advantages at later follow-up and no effect on long-term rates of surgery.” (pg. 1768)

This report serves as a nice general guideline for the primary care [conservative] management of lumbar disc herniation with sciatica.  We see that in addition to any anatomical correction there is a positive response to biomechanical interventions for which the properly trained and credentialed chiropractor is an important provider.

Cifuentes et al., 2011 stated, “Given that chiropractors are proponents of health maintenance care, we hypothesize that patients with work-related LBP [low back pain] who are treated by chiropractors would have a lower risk of recurrent disability because this specific approach would be used.Conversely, similar patients treated by other providers would have higher recurrence rates because the general approach did not include maintaining health, which is a key component to prevent recurrence” (Cifuentes, Willetts, & Wasiak, 2011, p. 396).

This research is unique and comprehensive in that it tracked injured workers’ compensation patients in multiple states and it reviewed claims dated between January 1, 2006 and December 31, 2006 including 894 cases out of a pool of 11,420 claims of non-specific low back pain cases.  (The states were chosen because the patients had the ability to select their doctors on their own and were not mandated a provider.)

Relating to the results, the authors report, “In our study, after controlling for demographics and severity indicators, the likelihood of recurrent disability due to LBP for recipients of services during the health maintenance care period by all other provider groups was consistently worse when compared with recipients of health maintenance care by chiropractors. Care from chiropractors during the disability episode (“curative”), during the health maintenance period (main exposure variable, “preventative”), and the combination of both (curative and preventive) was associated with lower disability recurrence HRs” (p. 403). This article validates chiropractic’s role in the prevention of the recurrence of back pain in patients with chronic spine disorders.

When analyzing why, the reasons are evident and based upon the literature. A chiropractic spinal adjustment reduces verifiable bio-neuro-mechanical failures (commonly known as vertebral subluxation in our profession) at the spinal level.  Non-steroidal anti-inflammatory drugs do not and there is no “spontaneous recovery,” only less pain with the underlying biomechanical failures persisting awaiting Wollf’s law to adversely remodel the spine leading to certain increased permanent disability over time. Therefore, if “literature based outcomes” “ruled the day” (as they should in a reasonable world void of politics and financial interest) at the legislative and reimbursement levels, then we would be a healthier society and spend far less money while avoiding unnecessary side effects and increasing the potential for significantly greater disabilities in the future.

References:

  1. Block, C. K. (2014). Examining neuropsychological sequelae of chronic pain and the effect of immediate-release oral opioid analgesics (Order No. 3591607). Available from ProQuest Dissertations & Theses Global. (1433965816). Retrieved from http://search.proquest.com/docview/1433965816?accountid=1416
  1. Humphreys, B. K., Sulkowski, A., McIntyre, K., Kasiban, M., & Patrick, A. N. (2007). An examination of musculoskeletal cognitive competency in chiropractic interns. Journal of Manipulative and Physiological Therapeutics, 30(1), 44-49.
  2. Deyo, R. A., & Mirza, S. K. (2016). Herniated Lumbar Intervertebral Disk. New England Journal of Medicine374(18), 1763-1772.
  3. Cifuentes, M., Willetts, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
  1. Schmale, G. A. (2005). More evidence of educational inadequacies in musculoskeletal medicine. Clinical Orthopaedics and Related Research, 437, 251-259.
  2. DeVocht, J. W., Pickar, J. G., & Wilder, D. G. (2005). Spinal manipulation alters electromyographic activity of paraspinal muscles: A descriptive study. Journal of Manipulative and Physiologic Therapeutics, 28(7), 465-471.
  3. Goldberg, H., Firtch, W., Tyburski, M., Pressman, A., Ackerson, L., Hamilton, L., Avins, A. L. (2015). Oral steroids for acute radiculopathy due to a herniated lumbar disk: A randomized clinical trial.Journal of the American Medical Association (JAMA), 313(19), 1915-1923.


Downtown’s Healthcare – Web Media – Man Running 4

Chiropractors Treating Mechanical Spine Failure and Failed Back Surgery

Chiropractors Treating Mechanical Spine Failure and Failed Back Surgery

The latest CDC statistics show that in 2012, 54 out of 100 people had self-reported musculoskeletal conditions.  By way of comparison, that is six times more than self-reported cases of cancer, double that of respiratory disease and one-third more than circulatory disorders.  If we extrapolate that to a more current population in the United States of 321 million, that equates to 173 million people reporting musculoskeletal problems in 2012.  Many of these are spine patients who suffer long-term without any type of biomechanical assessment or functional case management.

In 2013, Itz, Geurts, van Kleef, and Nelemans reported, “Non-specific low back pain [LBP] is a relatively common and recurrent condition with major medical and economic implications for which today there is no effective cure” (p. 5).  The idea that spinal pain has a “natural history” resulting in a true resolution of symptoms is a myth and the concept that spine pain should only be treated in the acute phase for a few visits has no support in the literature.  We don’t address cardiovascular disease in this manner, i.e. wait until you have a heart attack to treat, we don’t follow this procedure with dentistry, i.e. wait until you need a root canal to treat, and we certainly don’t handle metabolic disorders such as diabetes in this way, i.e. wait until you have diabetic ulcers or advanced vascular disease to treat.  Why does healthcare fall short with spinal conditions in spite of the compelling literature that states the opposite in treatment outcomes?

The front lines of medical care for spine-related pain is typically the prescription of pain medication, particularly at the emergency care level, and then if that doesn’t work, a referral is made to physical therapy. If physical therapy is unsuccessful, the final referral is to a surgeon.  If the surgeon does not intervene with surgery, then the diagnosis becomes “non-specific back pain” and the patient is given stronger medication since there is nothing the surgeon can do.  In those surgical interventions that result in persistent pain, a commonly reported problem, there is an ICD-10 diagnosis for failed spine surgery, M96.1

A recent article Ordia and Vaisman (2011) described this syndrome a bit further stating the following, “We propose that these terms [post laminectomy syndrome or failed back syndrome] should be replaced with Post-surgical Spine Syndrome (PSSS)” (p. 132).  They continued by reporting, “The incidence of PSSS may be reduced by a meticulous neurological examination and careful patient selection.  The facet and sacroiliac joints should always be examined, particularly when the pain is predominantly in the lower back, or when it radiates only to the thigh or groin and not below the knee” (Orida & Vaisman, 2011, p. 132). The authors finally stated, “Adherence to these simple guidelines can result in a significant reduction in the pain and suffering, as also the enormous financial cost of PSSS” (Orida & Vaisman, 2011, p. 132).  What they are referring to is a careful distinction between an “anatomical” versus a “biomechanical” cause of the spine pain.

According to Mulholland (2008), “[Surgery] Spinal fusion became what has been termed the “gold standard” for the treatment of mechanical low back pain, yet there was no scientific basis for this” (p. 619). He continued, “However whilst that fusion [surgery] may be very effective in stopping movement, it was deficient in relation to load transfer” (Mulholland, 2008, p. 623). He concluded, “The concept of instability as a cause of back pain is a myth. The clinical results of any procedure that allows abnormal disc loading to continue are unpredictable” (Mulholland, 2008, p. 624).  Simply put, surgery does not correct the underlying biomechanical failure or the cause of the pain.

When a biomechanical assessment is lacking, the patient’s pain persists and allopathic medicine is focused on “managing the pain” vs. correcting the underlying biomechanical lesion/pathology/imbalance, the medication of choice at this point in care has been opioid analgesics.  Back in 2011, the CDC reported, “Sales of OPR quadrupled between 1999 and 2010. Enough OPR were prescribed last year [2010] to medicate every American adult with a standard pain treatment dose of 5 mg of hydrocodone (Vicodin and others) taken every 4 hours for a month” (p. 1489).  That was 6 years ago, which was when people began to feel that treating musculoskeletal pain with narcotics was trending in the wrong direction.  Now, in 2016, we can see there is a problem of epidemic proportions to the point that MDs are changing how they refer spine patients for diagnosis and treatment.

Dowell, Haegerich, and Chou (2016), along with the CDC, published updated guidelines relating to the prescription of opioid medication:

Opioid pain medication use presents serious risks, including overdose and opioid use disorder. From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States. In the past decade, while the death rates for the top leading causes of death such as heart disease and cancer have decreased substantially, the death rate associated with opioid pain medication has increased markedly.

…a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain and followed for up to 13 years revealed that one in 550 patients died from opioid-related overdose at a median of 2.6 years from their first opioid prescription, and one in 32 patients who escalated to opioid dosages >200 morphine milligram equivalents (MME) died from opioid-related overdose. (p. 2)

Clearly, there needs to be a nationwide standard for the process by which patients with spine pain are handled, including academic and clinical leadership on spinal biomechanics.  The only profession that is poised to accomplish such a task is chiropractic.

In a recent study by Houweling et al. (2015), the authors reported, “The purpose of this study was to identify differences in outcomes, patient satisfaction, and related health care costs in spinal, hip, and shoulder pain patients who initiated care with medical doctors (MDs) vs those who initiated care with doctors of chiropractic (DCs) in Switzerland” (p. 477). This is an important study which continually demonstrates maintaining access to chiropractic care, for both acute and chronic pain is critical.  We can also see from current utilization statistics that chiropractic care is underutilized on a major scale.  The authors also state, “Although patients may be comanaged with other medical colleagues or paramedical providers (eg, physiotherapists), treatment for the same complaint may vary according to the type of first-contact provider. For instance, MDs tend to use medication, including analgesics, muscle relaxants, and anti-inflammatory agents, for the treatment of acute nonspecific spinal pain, whereas DCs favor spinal manipulative therapy as the primary treatment for this condition” (Houweling et al., 2015, p. 478).  The continue by stating “This study showed that spinal, hip, and shoulder pain patients had modestly higher pain relief and satisfaction with care at lower overall cost if they initiated care with DCs, when compared with those who initiated care with MDs” (Houweling et al., 2015, p. 480).  Overall, when taking cost into consideration, “Mean total spinal, hip, and shoulder pain-related health care costs per patient during the 4-month study period were approximately 40% lower in patients initially consulting DCs compared with those initially consulting MDs” (Houweling et al., 2015, p. 481).  The authors concluded, “The findings of this study support first-contact care provided by DCs as an alternative to first-contact care provided by MDs for a select number of musculoskeletal conditions” (Houweling et al., 2015, p. 481).

Bases on the literature and outcome studies, backed up with 121 years of doctors of chiropractic and their patients’ testimonies, the time has never been better for the chiropractic profession to move into treating the 93% of the population that is not under care. Chiropractic must be moved from the accepted standard of biomechanical processes in the laboratory to the standard of care for spine beyond fracture, tumor or infection across all professions, inclusive of physical therapy. The outcomes overwhelmingly support that anything less perpetuates the epidemic of failed back treatments.

References

1. Centers for Disease Control and Prevention. (2015). National hospital discharge survey. Retrieved from: http://www.cdc.gov/nchs/nhds.htm

2. United States Census Bureau. (n.d.). Quick facts, United States. Retrieved from https://www.census.gov/quickfacts/

3. Itz, C. J., Geurts, J. W., van Kleef, M., & Nelemans, P. (2013). Clinical course of non‐specific low back pain: A systematic review of prospective cohort studies set in primary care. European Journal of Pain17(1), 5-15.

4. Ordia, J., & Julien Vaisman. (2011). Post-surgical spine syndrome. Surgical Neurology International, 2, 132.

5. Mulholland, R. C. (2008). The myth of lumbar instability: The importance of abnormal loading as a cause of low back pain. European Spine Journal, 17(5), 619-625.

6. Centers for Disease Control and Prevention. (2011). Vital signs: Overdoses of prescription opioid pain relievers – United States, 1999–2008. Morbidity and Mortality Weekly Report60(43), 1487-1492.

7. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain – United States, 2016. JAMA315(15), 1624-1645.

8. Houweling, T. A., Braga, A. V., Hausheer, T., Vogelsang, M., Peterson, C., & Humphreys, B. K. (2015). First-contact care with a medical vs chiropractic provider after consultation with a swiss telemedicine provider: Comparison of outcomes, patient satisfaction, and health care costs in spinal, hip, and shoulder pain patients. Journal of Manipulative and Physiological Therapeutics38(7), 477-483.