Chiropractic And Pain

Stephen M. Perle, D.C., M.S. Professor Of Clinical SciencesUniversity Of BridgeportCollege Of Chiropractic

What Experiences Do You Have About Chiropractic?

Your impression?

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Précis History of chiropractic What is chiropractic care? Systematic reviews on clinical

effectiveness Research on mechanism of spinal

manipulation

History Of Chiropractic

The MTV Version

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What is chiropractic?

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Anachronistic Chiropractic Theory

Bone Out Of Place

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Nonsurgical Spine Specialist

Primary intervention is spinal manipulation

Spinal rehabilitation/ stabilization exercises

Physiological therapeutics

Soft tissue mobilization

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Levels Of Evidence: Not All Hands Are Of Equal

Value

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Mechanical Neck Pain Headache

Neither SMT nor mobilization (MOB) were effective alone or in combination with PT

SMT or MOB with exercise is effectiveGross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine. 2004 Jul 15;29(14):1541-8.

SC

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Neck Pain Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its

Associated Disorders 359 invasive and noninvasive intervention articles deemed relevant 170 (47%) were accepted as scientifically admissible 139 of these related to noninvasive interventions Manipulation or mobilization effective for

WAD Neck pain

Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15;33(4 Suppl):S123-52.

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Chronic/Recurrent Headache

Prophylactic treatment of chronic tension-type headache Amitriptyline more effective than SMT during treatment SMT is superior in short term after cessation of both treatments

Prophylactic treatment of migraine headache SMT may be an effective treatment option short-term effect

similar to amitriptyline Episodic tension-type headache

Adding SMT to massage is not effective

Bronfort G, Nilsson N, Haas M, Evans R, goldsmith C, Assendelft W, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane database Syst rev. 2004;3:cd001878

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Chronic/Recurrent Headache

Prophylactic treatment of cervicogenic headache SMT is effective in the short and long term when

compared to No treatment Massage or placebo SMT

Post-traumatic headache MOB is more effective in the short term than cold

packsBronfort G, Nilsson N, Haas M, Evans R, goldsmith C, Assendelft W, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane database Syst rev. 2004;3:cd001878

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Carpal Tunnel Syndrome Carpal bone MOB significantly improved

symptoms after three weeks However, only one study

O'Connor D, Marshall S, Massy-Westropp Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003;(1):CD003219.

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Low Back Pain 31 studies – 5,202 participants met inclusion criteria Acute LBP

Moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used PT

Chronic LBP Moderate evidence that SMT has an effect similar NSAID SMT/MOB is effective in the short term when compared with placebo and GP

care, and in the long term compared to physical therapy Limited to moderate evidence that SMT is better than physical therapy and home

back exercise in both the short and long term.

Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J. 2004 May-Jun;4(3):335-56.

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New Review on Chronic LBP

Preponderance of the evidence for efficacy & estimated very low risk of serious adverse events support SMT & MOB as viable options for treatment of CLBP

SMT and MOB at least as effective as other efficacious & commonly used interventionsBronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J. 2008 Jan-Feb;8(1):213-25.

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Nocturnal Enuresis Weak evidence supports the use of chiropractic

Single small trial (31 treatment & 15 control group) Better than sham manipulation

Glazener CM, Evans JH, Cheuk DK. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev. 2005(2):CD005230.

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Primary Or Secondary Dysmenorrhea

No evidence of effectiveness of SMT More research needed

Proctor ML, Hing W, Johnson TC, Murphy PA. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2001(4):CD002119.

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Asthma No evidence of effectiveness of SMT More research needed Current RCT in Australia n=1000

Hondras MA, Linde K, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev. 2005(2):CD001002.

Science Of Spinal Manipulation

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Interarticular AdhesionsRat Joint Dysfunction (Subluxation) Model

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.

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Manipulation Breaks Adhesions

Manipulation may increase flexibility of a motion segment

Single case with sophisticated assessment of motion segment stiffness

Kawchuk G, Herzog W. Preliminary evidence of changes in tissue stiffness following spinal manipulation. In: International Conference on Spinal Manipulation; 1996: FCER; 1996. p. 18.

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Manipulation Breaks Adhesions

Manipulation gaps the Z-jointCramer GD, Gregerson DM, Knudsen JT, Hubbard BB, Ustas LM, Cantu JA. The effects of side-posture positioning and spinal adjusting on the lumbar Z joints: a randomized controlled trial with sixty-four subjects. Spine 2002;27(22):2459-66.

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Altered Muscle Firing Pattern

Transversus abdominis activated (diaphragm & pelvic mm) 30 ms prior to arm or leg movements

In LBP patients transversus abdominis activated 30 ms after arm or leg movementsHodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. J Spinal Disord 1998;11(1):46-56.

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Response to SMTPickar & Wheeler 2001, JMPT 24(1):2-11

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Muscle Spindle Response To SMT

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GTO Response To SMT

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Manipulation Changing Muscle Function

Brenner AK, et al. Improved activation of lumbar multifidus following spinal manipulation: a case report applying rehabilitative ultrasound imaging. J Orthop Sports Phys Ther. 2007 Oct;37(10):613-9.

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Restoration Of Firing Pattern

Gill NW, Teyhen DS, Lee IE. Improved contraction of the transversus abdominis immediately following spinal manipulation: a case study using real-time ultrasound imaging. Man Ther. 2007 Aug;12(3):280-5.

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Effects On Pain & Pain Processing

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Manipulation’s Effects On CNS In Pain Modulation

Manipulation of the knee resulted in analgesia of induced hyperalgesia of the paw of a rat

Used selective neurotransmitter blocks Manipulation activates descending

inhibitory pathways using serotonin and noradrenaline

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Suggested Analgesic Mechanism

Authors suggest that manipulation stimulates Lateral periaquaductal gray (PAG)

Rostral Ventral Medulla (RVM) Dorsolateral pons

Part of the descending analgesia system

Skyba DA et al. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain. 2003 Nov;106(1-2):159-68.

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Stroke & Cervical Manipulation

Small risk of stroke following chiropractic visits Risk of stroke after chiropractic visit = risk of

stroke after medical visit People with prodrome of stroke seek care

Cassidy JD, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008 Feb 15;33(4 Suppl):S176-83.

What questions do you have?