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John A.M. Taylor, DC, DACBRProfessor & Coordinator of Diagnostic ImagingD’Youville CollegeDoctor of Chiropractic Program
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Your impression?
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Profession Characteristics (USA)
Chiropractic (DC) Osteopathy (DO) 70,000 active DC
licenses 19 chiropractic
schools 1000+ hrs
manipulation & MSK More emphasis on
spine & MSK 94% of manipulations
53,000 practicing DOs 25 osteopathic
schools 200+ hrs
manipulation & MSK More emphasis on
primary medical care 4% of manipulations
NBCE Practice Analysis, 2010NBCE Practice Analysis, 2010DYC curriculum, 2010DYC curriculum, 2010Shekelle et al, 1991Shekelle et al, 1991
Pickett HR, Jonas CE: Overview of Pickett HR, Jonas CE: Overview of Osteopathic Manipulative Osteopathic Manipulative PrinciplesPrinciples
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Original Theory of Chiropractic (1895)
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Current Theories of Spinal Manipulation
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Current Theories of Spinal Manipulation
Flynn 2006; Pickar 2002Flynn 2006; Pickar 2002
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Current Theories of Spinal Manipulation
Manipulation Changing Muscle Function
Brenner AK et al, 2007Brenner AK et al, 2007
http://www.cure-back-pain.org/
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Presenting Complaints
NBCE 2010NBCE 2010
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Etiology of Patient Conditions
NBCE 2010NBCE 2010
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D’Youville College Doctor of Chiropractic Program
Began 2003 30 graduates to date 3 year BS degree (50) 4 year DC degree (95) 1 year internship Chiropractic health centers
Campus (downtown) Community (Main & Hertel)
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D’Youville College Doctor of Chiropractic Program
200+ credit hours 4,600 clock hours Emphasis on:
Integrative care Active care > passive care Evidence – based Patient – centered Problem – focused Neuromusculoskeletal
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Accreditation
http://www.cce-http://www.cce-usa.org/usa.org/
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Steps Leading to Chiropractic Practice
http://www.nbce.org/http://www.nbce.org/
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First year
http://www.nbce.org/http://www.nbce.org/
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Second year
http://www.nbce.org/http://www.nbce.org/
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Third year
http://www.nbce.org/http://www.nbce.org/
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Fourth year
Clinic internship I Clinic internship II Clinic externship Clinical rotations Research project or thesis Part IV NBCE
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National Certification Board
http://www.nbce.org/http://www.nbce.org/
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What to Expect
Diagnosis Treatment/Management
History Physical examination
Neurologic Orthopedic Chiropractic structural
Special studies Radiography Advanced imaging Laboratory tests Nerve conduction tests
Manipulation Soft tissue techniques
Graston ART Nimmo
NMS rehabilitation Exercise Core stability Active care
Referral or co-management
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What to Expect
Treatment/Management cont’d
Advice Healthy lifestyle Nutrition Postural Ergonomic Positive attitude Exercise
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Chiropractic Approach to Back PainB. DIFFERENTIAL DIAGNOSIS Mechanical pain?
Sprain Strain Joint restriction
Pathologic pain? Tumor Infection Fracture
Mechanical Manipulation Soft tissue therapy Rehabilitation
Pathologic Imaging Referral Co-management.
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The Purpose of Tests
SCREENING TEST
© www.merck.com/pubs/mmanual© www.merck.com/pubs/mmanual
DIAGNOSTIC TEST
High specificity only in high risk population
Not useful for screening low risk groups
More expensive
More invasive
Haas M, Taylor JAM, Gillette RG. Haas M, Taylor JAM, Gillette RG. JMPTJMPT 1999;22(4):254-9. 1999;22(4):254-9.
Adam’s Test
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Back Pain Plus: Fever Unexplained weight loss History of cancer Neurologic deficit Alcohol or injection drug abuse Age over 50 Significant trauma Failure to improve with usual care.
Deyo RA, et al. Deyo RA, et al. N Engl J MedN Engl J Med, 344:5, 2001, 344:5, 2001..
Indications for Radiography
Suggestive of Systemic Disease, Pathology or TraumaSuggestive of Systemic Disease, Pathology or Trauma
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Mechanical LBP (97% of all LBP)
Idiopathic--sprain/strain 70% Degeneration 10% Disc herniation 4% Osteoporosis with comp fracture
4% Spondylolisthesis 2% Traumatic fracture <1% Congenital (scoliosis, kyphosis)
<1%
Deyo RA, Weinstein JN. Low Back Pain. Deyo RA, Weinstein JN. Low Back Pain. N Engl J MedN Engl J Med 2001; 344(5). 2001; 344(5).
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Nonmechanical LBP (1% of all LBP)
Neoplasm .7% Inflammatory arthritis .3% Infection .01% Scheuermann’s ? Paget’s disease ?
Deyo RA, Weinstein JN. Low Back Pain. Deyo RA, Weinstein JN. Low Back Pain. N Engl J MedN Engl J Med 2001; 344(5). 2001; 344(5).
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Pelvic disease Renal disease Aortic aneurysm Gastrointestinal disease
Visceral Disease Resulting in LBP (2% of all LBP)
Deyo RA, Weinstein JN. Low Back Pain. Deyo RA, Weinstein JN. Low Back Pain. N Engl J MedN Engl J Med 2001; 344(5). 2001; 344(5).
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Computed Tomography
INDICATIONS
Spinal stenosis
Bone disease
Joint disease
Complex trauma
Complex anomalies
Disc disease when MR contraindicated
Taylor, Resnick, Advances in Chiropractic © 1994 Mosby
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Computed Tomography
Taylor, Resnick, Advances in Chiropractic © 1994 Mosby
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Magnetic Resonance Imaging
INDICATIONS
Disc disease
Joint disease
Bone marrow
Direct soft tissue visualization
Taylor, Resnick, Advances in Chiropractic © 1994 Mosby
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Aneurysmal bone cystAneurysmal bone cyst
Taylor, Resnick, Advances in Chiropractic © 1994 Mosby
Magnetic Resonance Imaging
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Bone Mineral Density ScansImportant Risk Factors Age ≥50
BMI or weight (<19 kg/m2 or <57 kg); Ethnic group or race (white or Asian); Menopause before age 45; Loss height (>4 cm); History of corticosteroid Tx; History of fragility fracture after age 45 of one
of the following sites: hip, rib, wrist;
Bussiere, et al, 2008Bussiere, et al, 2008
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BMD: WHO Classification
Normal bone density: +1 to -1 Osteopenia: -1 to -2.5 (low bone
density)
Osteoporosis: -2.5 or lower
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Radionuclide Imaging (Bone Scan)
INDICATIONSINDICATIONS Sensitive screen for pathology
Skeletal distribution
Metastatic disease
Radiation
Non-specific
Time-consuming
LIMITATIONSLIMITATIONS
Taylor, Resnick, Advances in Chiropractic © 1994 MosbyTaylor, Resnick, Advances in Chiropractic © 1994 Mosby
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http://www.ccgpp.org/documents.htmhttp://www.ccgpp.org/documents.htm
Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP)
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Spinal Manipulation Research
Acute and subacute low back pain (LBP)
Strong evidence supports the use of spinal manipulation to reduce symptoms and improve function.
CCGPP 2008CCGPP 2008
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Spinal Manipulation Research
Combined exercise and manipulation
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 2008CCGPP 2008
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Spinal Manipulation Research
LBP & radiating leg pain, sciatica, or radiculopathy
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.
Lawrence, DL, et al. CCGPP, 2008Lawrence, DL, et al. CCGPP, 2008
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Spinal Manipulation Research
Cases with high severity of symptoms
May benefit by referral for co-management of symptoms with medication
CCGPP 2008CCGPP 2008
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Spinal Manipulation Research
Chronic LBP
Strong evidence supports the use of spinal manipulation/mobilization to reduce symptoms and improve function.
CCGPP 2008CCGPP 2008
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Spinal Manipulation Research
Neck Pain
Manipulation & mobilization effective for: Whiplash associated disorders (WAD) Neck pain
Hurwitz EL et al. Hurwitz EL et al. 20082008
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Systematic Reviews of Randomized Controlled Trials
Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3. http://www.chiroandosteo.com/content/18/1/3
13 MSK conditions 4 types of chronic headache 9 non-MSK conditions 49 relevant systematic reviews 16 evidence-based guidelines 46 additional RCTs
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SMT/mobilization is effective in adults for:
Low back pain Acute Subacute Chronic
Cervicogenic Headache Dizzyness
Thoracic SMT/mobiliz for neck pain Acute Subacute
Extremities several conditions
Bronfort G et al. Bronfort G et al. 20102010
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Evidence is inconclusive in SMT/mobilization in adults for:
Cervical SMT alone for neck pain for any duration
Midback pain Sciatica Tension-type
headache
Coccydynia TMJ disorders Fibromyalgia Premenstrual
syndrome Pneumonia (older
adults)
Bronfort G et al. Bronfort G et al. 20102010
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SMT/mobilization is not effective in adults for:
Asthma Dysmenorrhea Stage 1
hypertension (added to antihypertensive diet)
Bronfort G et al. Bronfort G et al. 20102010
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Evidence is inconclusive in SMT/mobilization in children for: Otitis media Enuresis Infantile colic
Bronfort G et al. Bronfort G et al. 20102010
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Safety of Chiropractic Manipulation
Randomized controlled trial from 1966-2007
Most adverse events that could be attributed to spinal manipulation were benign and transitory;
However, the data were deemed insufficient to assess their actual prevalence in the general population
NBCE 2010NBCE 2010
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Side Effects & Risks of Chiropractic Manipulation
MINOR (common)
Short term soreness Temporary increase in pain Similar to starting exercise programMAJOR (extremely rare)
Disc herniation Cauda equina 1:1 million to 1:100 million
NBCE 2010NBCE 2010
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Vertebrobasilar Artery StrokeRetrospective Surveys of Incidence
Swiss Society of Manual Medicine (1985)
1 in 40,000 (slight neurologic complication)
1 in 400,000 (important complication) Based on recall: uncontrolled study
Danish Chiropractic Association (1996)
1 in 1.3 million cervical adjustments.
Murphy D, 2010Murphy D, 2010
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Vertebrobasilar Artery Stroke
109,020,875 person-years Observation over a period of nine years 818 patients with VADS 3164 controls without stroke.
Cassidy JD, et al. 2008
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Vertebrobasilar Artery Stroke
VBAS is a rare event in the population
Association between VBAS & DC visits in those under 45
Association between VBAS & PCP visits in all age groups
No evidence of excess risk of VBAS associated with chiropractic careCassidy JD, et al. 2008Cassidy JD, et al. 2008
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Vertebrobasilar Artery Stroke
“The increased risk of VBAS associated with chiropractic and physician visits is likely explained by patients with VBAS-related neck pain and headache consulting both chiropractors and PCPs before their VBA stroke”
Cassidy JD, et al. 2008Cassidy JD, et al. 2008
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Patient Satisfaction Studies
Chronic LBP Chiropractic Medical
Better or much better after 1 month 56% 13%
Worse or much worse after 1 month
14% 35%
Nyiendo et al, 2000Nyiendo et al, 2000
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Patient Satisfaction Studies
“There is a growing body of research that documents patient satisfaction with the manner, care, and explanations of treatment by doctors of chiropractic”
Coulter I, 2000Coulter I, 2000
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Patient Satisfaction StudiesDepartment of Defense Chiropractic Healthcare Demonstration Project
“Participants who received chiropractic care strongly agree that they had good treatment results compared to those who received medical care”
More satisfaction with DC’s willingness to:
spend time with them explanations of treatments health condition improvements Birch & Davis, 2000Birch & Davis, 2000
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Patient Satisfaction StudiesMedicare Demonstration Project 2005-2007
Satisfaction with DC care 10-point scale 10 56% >8 87% Moderate or complete relief
Chiropractic: 60% Other health
professionals: 11%Stason et al, 2010Stason et al, 2010
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References1. National Board of Chiropractic Examiners http://www.nbce.org/
2. Council on Chiropractic Education http://www.cce-usa.org/
3. Hurwitz EL 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. http://www.ccgpp.org/documents.htm
4. Lawrence DJ, et al. Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis. J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):659-74. http://www.ccgpp.org/documents.htm
5. Globe GA, et al. Chiropractic management of low back disorders: report from a consensus process. Council on Chiropractic Guidelines and Practice Parameters. J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):651-8. http://www.ccgpp.org/documents.htm
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References (cont’d)
6. Bussières AE, Peterson C, Taylor JAM. Diagnostic imaging practice guidelines for adult musculoskeletal complaints: An evidence-based approach:
Introduction: J Manip Phys Therap 2007;30(9):617-83. Part 1: Lower Extremity Disorders. J Manip Phys Therap 2007;30(9):684-717.Part 2: Upper Extremity Disorders. J Manip Phys Therap 2008;31(1):2-32. Part 3: Spinal Disorders. J Manip Phys Therap 2008;31(1):33-88.http://www.sciencedirect.com/science/journal/01614754
7. Cassidy JD, et al. Risk of vertebrobasilar stroke and chiropractic care: Results of a population-based case-control and case-crossover study. Eur Spine J 2008 ; 17 (Suppl I) S176-S183.
8. Murphy D. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession?. Chiropractic & Osteopathy 2010; 18:22.
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References (cont’d)
9. Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3. http://www.chiroandosteo.com/content/18/1/3
10. Bishop PB et al. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. The Spine Journal 2010 (In press).
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Acknowledgements
Stephen Perle, DC John Ventura, DC Warren Jahn, DC Michael Hubka, DC West Hartford Group
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Contact Information
John A.M. Taylor, DC, DACBR
Cell: 716-548-6343
D’Youville College Chiropractic Health Center
2900 Main Street
Buffalo, NY
716-923-4375