Chiropractic: What is it good for? Current Topics in Chiropractic - PowerPoint PPT Presentation

Chiropractic: What is it good for? Current Topics in Chiropractic David Folweiler, DC Folweiler Chiropractic 1

Outline For Tonight’s Presentation  Chiropractic Characteristics  Rationale for Manipulation  Rationale for instrument-assisted soft tissue manipulation (Graston)  Clinical Evidence for Manipulation  Case Studies  Indications for Chiropractic  Questions and Answers 2

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Chiropractic Characteristics  70,000 active DC licenses  19 chiropractic schools  1000+ hrs training in manipulation  Emphasis on spine & neuro-musculoskeletal conditions  94% of manipulations in US 4

Presenting Complaints 5

Etiology of Patient Conditions 6

Chiropractic Evaluation  History  Physical examination  Neurologic  Orthopedic  Chiropractic structural (i.e. posture, joint motion/position)  Functional (i.e. wall angel, squat, lunge, single leg balance)  Imaging  Plain film radiography  Advanced imaging 7

Chiropractic Management  Spinal and extremity  Referral or co-management manipulation  Advice  Soft tissue techniques  Healthy lifestyle  Graston  Nutrition  Nimmo (ischemic pressure)  Postural  Stretching  Ergonomic  NMS rehabilitation  Reassurance  Exercise  Exercise  Core stability  Active care 8

Chiropractic Treatment 9

Manipulation/Adjustments 10

Why Manipulate?  Rat Joint Dysfunction Model  Mechanical fixation causes degenerative changes of facet joints (osteophytes, articular cartilage pitting & remodeling, and adhesions) in as little as 1 week Cramer GD, Fournier JT, Henderson CN, Wolcott CC. Degenerative changes following spinal fixation in a small animal model.  J Manipulative Physiol Ther 2004;27(3):141-54. 11

Osteophyte Formation 12

Induced Hypomobility  Surgically placed fixation devices in rats  Hypomobility for 8, 12, or 16 weeks, L4-6  Number and size of adhesions were measured Zygapophyseal Joint Adhesions After Induced Hypomobility. Cramer  GD et al. J Manipulative Physiol Ther 2010;33:508-518 13

Adhesions After Induced Hypomobility Small adhesion Normal Z- Medium joints w/ + adhesion w/o synovial fold Large adhesion 14

Results of Induced Hypomobility 15

Gapping of Zygapophyseal Joints  64 healthy chiropractic students randomized into 4 groups: Cramer GD - The Effects of Side-Posture Positioning and Spinal Adjusting on the Lumbar Z Joints; Spine Volume 27, Number  22, pp 2459 – 2466 16

Side-Posture Adjustment for Group 3  Performed between the two scans 17

Second Scan for Groups 1 and 3 18

MRI Scans  Upper row is first and second MRIs of control group  Lower row is pre- and post-adjustment for group 3  Note gapping in left z- joint, likely caused by cavitation of synovial fluid 19

Greatest Gapping  Greatest gapping occurred in adjusted subjects 20

Effect of Instrument-Assisted STM  51 rats had surgically induced bilateral MCL tears  7 controls with no intervention  After one week  31 treated 3x/wk x 3 wks  20 treated 3x/wk x 10 wks  Only left MCL treated  Treated ligaments were 43.1% stronger, 39.7% stiffer, and could absorb 57.1% more energy before failure at 4 weeks Loghmani, MT et al; Instrument-Assisted Cross-Fiber Massage Accelerates Knee Ligament Healing; J Orthop Sports  Phys Ther 2009;39(7):506-514. 21

Histological Sections (A) noninjured knee medial collateral ligament (MCL) in a cage-control animal, (B) scar region in a nontreated MCL at 4 weeks following injury, (C) scar region in an instrument-assisted cross-fiber massage (IACFM)-treated MCL at 4 weeks following injury, (D) scar region in a nontreated MCL at 12 weeks following injury, and (E) scar region in an IACFM-treated MCL at 12 weeks following injury. Black arrows indicate fibroblasts aligned parallel to the collagen fibrils in a noninjured ligament. White arrows indicate scar region in injured ligaments. 22

Electron Microscopic Sections (A) intact knee medial collateral ligament (MCL) in a control animal, (B) non-treated MCL at 4 weeks following injury, and (C) instrument-assisted cross-fiber massage (IACFM)-treated MCL at 4 weeks following injury. Note the close appearance of the IACFM-treated ligament (C) to the non-injured ligament from a control animal (A). Also, note the large amount of surrounding granulation tissue in the non-treated, but injured ligament (C) relative to the other 2 ligaments. 23

Clinical Evidence about Manipulation 24

Hierarchy of Evidence 25

Acute and Subacute Low Back Pain  Strong evidence supports the use of spinal manipulation to reduce symptoms and improve function.  Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis.  Part of the Council on Chiropractic Guidelines & Practice Parameters (CCGPP) 2008  Reviewed 887 source papers Lawrence DJ et al J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):659-74. [(CCGPP) 2008]  26

Acute and Subacute Low Back Pain  Good evidence that the use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. CCGPP 2008  27

LBP & Radiating Leg Pain  Fair evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy  Manipulation in combination with other common forms of therapy may be of clinical value. CCGPP 2008  28

Chronic LBP  Strong evidence supports the use of spinal manipulation/mobilization to reduce symptoms and improve function. CCGPP 2008  29

Manipulation & Mobilization Effective for:  Whiplash associated disorders (WAD)  Neck pain Hurwitz EL et al. 2008  30

Systematic Review of Randomized Controlled Trials  13 musculoskeletal conditions  4 types of chronic headache  9 non- musculoskeletal conditions  49 relevant systematic reviews  16 evidence-based guidelines  46 additional RCTs Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3.  31

Manipulation is effective for:  Low back pain – acute, subacute, and chronic  Headaches – migraines and cervicogenic  Cervicogenic dizziness  Neck pain – acute, subacute, and chronic  Shoulder pain Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3.  32

Manipulation and exercise is effective for:  Knee and hip osteoarthritis  Plantar fasciosis  Lateral epicondylosis Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3.  33

Evidence is inconclusive, but favorable for SMT/mobilization in adults for:  Sciatica/radiating leg pain  Coccydynia  Thoracic pain  Shoulder pain  Carpal tunnel syndrome  Ankle sprains  Knee OA  Lateral epicondylosis  TMD Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3.  34

Dose Response  Cervicogenic headaches (at least 5 cervicogenic HAs per month for a minimum of 3 months)  4 week trial, n=24  1, 3, or 4 treatments per week.  Higher frequency associated with better outcomes for HAs Dose Response For Chiropractic Care Of Chronic Cervicogenic Headache And Associated Neck Pain: A Randomized Pilot  Study - Mitchell Haas, et al J Manipulative Physiol Ther 2004;27:547 – 553 35

TX Frequency Effect on Head Pain 60 50 40 1 TX/week 30 3 TXs/week 4 TXs/week 20 treatment ends 10 0 0 weeks 4 weeks 12 weeks 36

TX Frequency Effect on HA Disability 50 45 40 35 30 1 TX/week 25 3 TXs/week 20 4 TXs/week 15 10 treatment ends 5 0 0 weeks 4 weeks 12 weeks 37

TX Frequency on Cervicogenic HAs  Outcome was dose dependent  “Findings suggest the benefit of 9 to 12 visits over 3 weeks for the treatment of HA/neck pain and disability. A larger number of visits than 12 in 3 weeks may be required for maximum relief and durability of outcomes.” Dose Response For Chiropractic Care Of Chronic Cervicogenic Headache And Associated Neck Pain: A Randomized Pilot  Study - Mitchell Haas, et al J Manipulative Physiol Ther 2004;27:547 – 553 38

Dose Response for Cervicogenic HAs  Eighty subjects randomized to receive either light massage (LM) or manipulation (SMT)  SMT was limited to cervical and upper thoracic spine  LM was performed for 5 minutes following 5 minutes of moist heat  Patients were treated once or twice per week for 8 weeks Haas M et al; Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: a pilot randomized  controlled trial; The Spine Journal 10 (2010) 117 – 128 39

Adjusted Mean Cervicogenic HA Pain treatment ends 40

Adjusted Mean Number of Cervicogenic HAs treatment ends 41

Dose Response for Cervicogenic HAs  Results show less dose dependence than pilot  Limitations: only 1 or 2 treatments per week, higher frequencies not tested  Blinding not possible for subject or doctor 42