Clinical ManagementAn

Introduction to ChiropracticJeffrey McKinley, DC,

CCSP

2700 B.C. 1500 B.C. Ancient Chinese and Greek writings mention spinal manipulation and the

maneuvering of the lower extremities to ease low

back pain.

Hippocrates 460 to 357

B.C. “Get knowledge of the spine, for this is

the requisite for many diseases.”

D.D. Palmer

1895 – Beginning date of modern day chiropractic

history

David Robertson, M.D.Professor, Departments of Medicine, Pharmacology and NeurologyMember, Division of Clinical PharmacologyDirector, Clinical Research CenterDirector, Medical Scientist Training Program

Profile:This laboratory aims to identify mechanisms of autonomic neurodegenerative disease processes and develop improved treatments for them. Over the years, we have explored how the brain exerts control over the nervous system and how abnormalities in this regulation can lead to disease. These studies resulted in the identification of the previously unrecognized disorders, dopamine-ß-hydroxylase deficiency and baroreflex failure

•Biomechanics

•Structure

•Function

Vertebral

Subluxation

Complex

Doctors of Doctors of ChiropracticChiropractic

Assess and Manage PatientsAssess and Manage PatientsPatient historyPatient historyPhysical examination – orthopedic & Physical examination – orthopedic & neurologicalneurologicalDiagnostic testing – x-ray, CT, MRI, labDiagnostic testing – x-ray, CT, MRI, labDiagnosisDiagnosisTreatment plan – manipulative therapy, Treatment plan – manipulative therapy, physical therapy, counsel lifestyle physical therapy, counsel lifestyle changes, nutritionchanges, nutrition

Current EducationCurrent Education

Three years of pre-Three years of pre-chiropracticchiropractic

4.5 years of 4.5 years of professional educationprofessional education

16 USDE accredited 16 USDE accredited schools in USschools in US

Chiropractic Student Hours Class Description Medical Student Hours

520 Anatomy 508

420 Physiology 326

271 Pathology 335

300 Chemistry 325

114 Bacteriology 130

370 Diagnosis 374

320 Neurology 112

217 X-Ray 148

65 Psychiatry 144

65 Obstetrics & Gynecology 198

225 Orthopedics 156

2,887 Total Hours 2,756

1,598 Specialty  Courses 1,492

4,485 Entire Total Hours 4,248

Primary Healthcare Provider

Licensed in all 50 states

Post Graduate Education

Family Practice

Clinical Neurology

Sports Chiropractic

Nutrition

Industrial Consulting

Applied Chiro Sciences

Orthopedics

Pediatrics

Rehabilitation

Radiology

Government InquiriesGovernment Inquiries

Similar inquiries with similar Similar inquiries with similar findingsfindings Sweden – 1987Sweden – 1987

Measures to improve cooperation Measures to improve cooperation between chiropractors, MDs, and PTs between chiropractors, MDs, and PTs are vital to the interest of the publicare vital to the interest of the public

Canada - 1993Canada - 1993 United Kingdom – 2 reports in the United Kingdom – 2 reports in the

last 10 yearslast 10 years

Government InquiriesGovernment Inquiries

Australia – Medicare Benefits Australia – Medicare Benefits ReviewReview 19841984 Review by committee – less weightReview by committee – less weight Recommended full funding in Recommended full funding in

hospitals and other health hospitals and other health institutionsinstitutions

Government InquiriesGovernment Inquiries

New Zealand – by judicial hearingNew Zealand – by judicial hearing 1978-19791978-1979 Glowing report on chiropractic careGlowing report on chiropractic care Highly cost effective treatment for Highly cost effective treatment for

spine related conditionsspine related conditions Procedures very safeProcedures very safe Deficiencies were caused by medical Deficiencies were caused by medical

boycottboycott

Conditions Treated Conditions Treated

Spine pain – neck, mid back and Spine pain – neck, mid back and low backlow back

Musculoskeletal pain – Musculoskeletal pain – fibromyalgia, chronic fatigue fibromyalgia, chronic fatigue

Headache – migraine and tensionHeadache – migraine and tension Peripheral joint painPeripheral joint pain Sports injuriesSports injuries

Back PainBack Pain

Uses manipulation to Uses manipulation to improve function of spinal improve function of spinal segmentssegments

Therapy to reduce spasm Therapy to reduce spasm and swellingand swelling

Exercises to improve Exercises to improve movement patternsmovement patterns

Postural and nutritional Postural and nutritional counselingcounseling

ManipulationManipulation

Improves spinal functionImproves spinal function Reduces intradiscal pressureReduces intradiscal pressure Reduces nerve root pressureReduces nerve root pressure Reduces spasticity of paraspinal Reduces spasticity of paraspinal

musclesmuscles Has CNS and peripheral nerve Has CNS and peripheral nerve

effectseffects

Lower Back PainLower Back Pain

Most common Most common condition treated condition treated by D.C.sby D.C.s

Spinal Spinal manipulation is the manipulation is the most researched most researched treatment for LBPtreatment for LBP

Effectiveness of Effectiveness of SMT for LBPSMT for LBPAssendelft WJ, Morton SC, Yu EI, Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal Suttorp MJ, Shekelle PG. Spinal

manipulative therapy for low back pain. manipulative therapy for low back pain. A meta-analysis of effectiveness relative A meta-analysis of effectiveness relative

to other therapies. Ann Intern Med to other therapies. Ann Intern Med 2003;138(11):871-81.2003;138(11):871-81.

Assendelft et al – Meta-Assendelft et al – Meta-analysis analysis ““Conclusion: There is no evidence that Conclusion: There is no evidence that

spinal manipulative therapy is superior to spinal manipulative therapy is superior to other standard treatments for patients other standard treatments for patients with acute or chronic low back pain”with acute or chronic low back pain”

Other standard treatments:Other standard treatments: General practitioner careGeneral practitioner care AnalgesicsAnalgesics Physical therapyPhysical therapy ExercisesExercises Back schoolBack school

Conclusion is valid Conclusion is valid However, a biased statementHowever, a biased statement Actual finding SMT = other Actual finding SMT = other

treatmentstreatments Thus, SMT an effective alternative Thus, SMT an effective alternative

for patient’s who desire CAMfor patient’s who desire CAM

Assendelft et al – Meta-Assendelft et al – Meta-analysis analysis

Why People Choose CAMWhy People Choose CAM

““Largely because they find these Largely because they find these health care alternatives to be more health care alternatives to be more congruent with their own values, congruent with their own values, beliefs, and philosophical beliefs, and philosophical orientations toward health and life.”orientations toward health and life.”

Astin JA. Why patients use alternative Astin JA. Why patients use alternative medicine: Results of a national study. medicine: Results of a national study. JAMA 1998;279(19):1548-53.JAMA 1998;279(19):1548-53.

Nyiendo, Joanne, Mitchell Haas, and Peter Goodwin. 2000, Nyiendo, Joanne, Mitchell Haas, and Peter Goodwin. 2000, “Patient Characteristics, Practice Activities, and one-month “Patient Characteristics, Practice Activities, and one-month Out Comes for Chronic, Recurrent Low-Back Pain Treated by Out Comes for Chronic, Recurrent Low-Back Pain Treated by Chiropractors and Family Medicine Physicians: A Practice-Chiropractors and Family Medicine Physicians: A Practice-based Feasibility Study.” based Feasibility Study.” Journal of Manipulative and Journal of Manipulative and Physiological Therapeutics Physiological Therapeutics 23, no. 4: 239-245.23, no. 4: 239-245.

… … the chiropractic patients showed a the chiropractic patients showed a five times greater improvement than five times greater improvement than that of the medical patients on the that of the medical patients on the Visual Analogue Scale, with the Visual Analogue Scale, with the chiropractic patients also reporting chiropractic patients also reporting better results in diminished pain. better results in diminished pain. Likewise, 90% of the chiropractic Likewise, 90% of the chiropractic patients claimed satisfaction with their patients claimed satisfaction with their care, while only 52% of the medical care, while only 52% of the medical patients reported the same.patients reported the same.

Giles, Lynton G. F. and Reinhold Muller. 2003, “Chronic Giles, Lynton G. F. and Reinhold Muller. 2003, “Chronic Spinal Pain: A Randomized Clinical Trial Comparing Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation.” Medication, Acupuncture, and Spinal Manipulation.” Spine Spine 28, no. 14: 1490-1502.28, no. 14: 1490-1502.

……manipulation patients experienced the manipulation patients experienced the greatest short-term benefits, in spite of greatest short-term benefits, in spite of the fact that they had the longest pre-the fact that they had the longest pre-treatment duration of pain (8.3 years treatment duration of pain (8.3 years ave), yet 27% recovered in a nine-week ave), yet 27% recovered in a nine-week period or less. Overall results of the period or less. Overall results of the study showed that 47% of chiropractic study showed that 47% of chiropractic patients improved, while only 18% and patients improved, while only 18% and 15% improved in the medication and 15% improved in the medication and acupuncture groups respectively.acupuncture groups respectively.

Niemisto, L., T. Lahtinen-Suopanki, P. Rissanen, K. A. Niemisto, L., T. Lahtinen-Suopanki, P. Rissanen, K. A. Lindgren, S. Sarna, and H, Hurri. 2003, “A randomized Trial Lindgren, S. Sarna, and H, Hurri. 2003, “A randomized Trial of Combines Manipulation, Stabilizing Exercises, and of Combines Manipulation, Stabilizing Exercises, and Physician Consultation Compared to Physician Consultation Physician Consultation Compared to Physician Consultation Alone for Chronic Low Back Pain.” Alone for Chronic Low Back Pain.” SpineSpine 28, no. 19;2185-2191 28, no. 19;2185-2191

… … manipulative therapy is superior manipulative therapy is superior to consultation alone and that short, to consultation alone and that short, specific treatments may change the specific treatments may change the course of chronic low-back pain.course of chronic low-back pain.

Haas, M., B. Goldberg, M. Aickin, B. Ganger, and M. Attwood. 2004. Haas, M., B. Goldberg, M. Aickin, B. Ganger, and M. Attwood. 2004. “A Practice-Based Study of Patients with Acute and Chronic Low Back “A Practice-Based Study of Patients with Acute and Chronic Low Back Pain Attending Primary Care and Chiropractic Physicians: Two-week Pain Attending Primary Care and Chiropractic Physicians: Two-week to 48-month Follow-up.” to 48-month Follow-up.” Journal of Manipulative and Physiological Journal of Manipulative and Physiological Therapeutics Therapeutics 23,no. 4; 225-23023,no. 4; 225-230

The study demonstrated that VAS were The study demonstrated that VAS were lower for chronic low-back pain lower for chronic low-back pain chiropractic patients than for medical chiropractic patients than for medical patients. patients. Results were even greater for Results were even greater for patients with concurrent leg pain.patients with concurrent leg pain. Thus, Thus, the authors concluded that chiropractic the authors concluded that chiropractic patients with chronic and acute low-back patients with chronic and acute low-back pain experienced greater relief up to one pain experienced greater relief up to one year following treatment, and those with year following treatment, and those with chronic LBP showed a clinically chronic LBP showed a clinically important advantage in the short term.important advantage in the short term.

Conditions Treated Conditions Treated

Spine pain – neck, mid back and Spine pain – neck, mid back and low backlow back

Musculoskeletal pain – Musculoskeletal pain – fibromyalgia, chronic fatigue fibromyalgia, chronic fatigue

Headache – migraine and tensionHeadache – migraine and tension Peripheral joint painPeripheral joint pain Sports injuriesSports injuries

Nelson, Craig F., Gert Bronfort, Roni Evans, Pat Boline, Nelson, Craig F., Gert Bronfort, Roni Evans, Pat Boline, CharlieGoldsmith, and A.V. Anderson. 1998. “The Eddicacy of Spinal CharlieGoldsmith, and A.V. Anderson. 1998. “The Eddicacy of Spinal Manipultion, Amitriptyline and the Combination of Both Therapies for Manipultion, Amitriptyline and the Combination of Both Therapies for the Prophylaxis of Migraine Headache. the Prophylaxis of Migraine Headache. Journal of Manipulative Journal of Manipulative and Physiological Therapeuticsand Physiological Therapeutics 21,no. 8: 511-519. 21,no. 8: 511-519.

Spinal manipulation seemed to be as Spinal manipulation seemed to be as effective as a well-established and effective as a well-established and efficacious treatment (amitriptyline), efficacious treatment (amitriptyline), and on the basis of a benign side and on the basis of a benign side effects profile, should be considered effects profile, should be considered a treatment option for patients with a treatment option for patients with frequent migraine headaches.frequent migraine headaches.

McCrory, Douglas C., Donald B. Penzien, Vic Hasselblad, and McCrory, Douglas C., Donald B. Penzien, Vic Hasselblad, and Rebecca N. Gray. 2001. Behavioral and Physical Treatments Rebecca N. Gray. 2001. Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache.” Duke for Tension-type and Cervicogenic Headache.” Duke University Evidence-based Practice Center.University Evidence-based Practice Center.

… … SMT resulted in a 40% decrease in headache SMT resulted in a 40% decrease in headache severity compared to no change in rest period severity compared to no change in rest period groups. Also, when compared to soft-tissue groups. Also, when compared to soft-tissue therapy, SMT reduced headache frequency by therapy, SMT reduced headache frequency by 69% and severity by 36% compared to the 69% and severity by 36% compared to the repective soft-tissue reductions of 37% and repective soft-tissue reductions of 37% and 17%. SMT also showed better results than did 17%. SMT also showed better results than did the commonly practice amitriptyline. … 82% of the commonly practice amitriptyline. … 82% of amitriptyline patients reported adverse effects amitriptyline patients reported adverse effects from the drug, while only 4% of SMT patients from the drug, while only 4% of SMT patients reported adverse effects.reported adverse effects.

CHIROPRACTIC CHIROPRACTIC RESEARCH CHALLENGE?RESEARCH CHALLENGE?

““Remember, Ginger Rogers did everything Fred Astaire did, but Remember, Ginger Rogers did everything Fred Astaire did, but she did it back- wards and in high heels.” she did it back- wards and in high heels.”

--Faith WhittleseyFaith Whittlesey