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