How to confidently communicate the science of chiropracticIntroductory Workshop

Dr Heidi HaavikDG Melbourne 22nd February 2014

PhD, PG Dip, BSc (chiro), Bsc (physiology)

Director of Research, New Zealand College of Chiropractic

Adjunct Professor, Master of Health Sciences Program, University of Ontario Institute of Technology

World Federation of Chiropractic Research Council member

My background

1999 University of Auckland, BSc, Physiology 1999 Chiropractic degree from NZCC 2000 Private chiropractic practice 2003 University of Auckland, PG Dip (Science) 2006 Director of Research, NZCC 2007 Editorial board Journal of Chiropractic Education 2008 PhD University of Auckland 2009 Editorial board member of JMPT 2011 World Federation of Chiropractic Research Council 2011 Associate Graduate Faculty Member, UOIT 2014 Adjunct Professor, Master of Health Sciences

Program, University of Ontario Institute of Technology, Ontario, Canada.

My background

15 national and international research awards ½ million dollars in national and international research grants Developed, course-coordinated and lectured in Neuroscience,

Research Methodology, Visceral Physiology, Professional Development, etc.

Co supervised 5 MSc students and 1 PhD student Authored 23 peer reviewed research manuscripts 51 peer reviewed abstracts presented 40 invited or keynote presentations in NZ, Australia, Europe and

USA

Chiropractic, Research & Neuroscience business for 14 years

Heidi’s Vision

A world of people expressing optimal potential

Heidi’s mission

Run a ridiculously successful and Vitalistic International Centre for Chiropractic Research

Heidi’s why

To allow more people access to chiropractic care through he power of cutting edge top quality research about mechanisms

Heidi’s role

1. Facilitate research2. Mentor researchers3. Inform / teach4. Raise funds

Purpose of Today

That you can confidently talk about the science of chiropractic

AIM: Confident Communication!

Knowing what you can and cannot say about the science of chiropractic

10

Outline for the day

Where are you at now?– Where do you want to get to?– How I can best help you

The Brain 101 The big picture - chiropractic Science 101 How to talk about specific studies

heidi.haavik@nzchiro.co.nz

heidihaavik.com

• Written for the public

• Describes in easy to understand language what happens when we adjust a VS

heidi.haavik@nzchiro.co.nz

Where are you at now?

In pairs (one being the chiro, the other the patient) each take turns explaining:

What a subluxation is

How chiropractic care works

How did that go?

Where you confident?

Do you know if your ‘story’ has scientific backing?

The big picture

In a nutshell

What is a subluxation?

How does chiropractic care work?

A subluxation is.....

“a central segmental motor control problem”

Which means that the central nervous system is notcontrolling the movement pattern of the spinalsegment as it should, which alters the stretching ofthe paraspinal muscles which changes the input to thebrain which impacts how it processes otherinformation

So that it can accurately perceive what is going on and respond

appropriately

which in turn improves the communication between your brain,

the body and the environment

Chiropractic is a healing art that improves the health and function of

the spine

Wisdom vs Knowledge

When talking about the chiro-relevant scientific studies:

1. This is what they did

2. This is what they found

3. This is what that possible means to you

4. BUT..... (mention limitations with study for you patient)

My potential role

Help you communicate about the key neuroscience concepts vital to understand how chiro care likely works

Help you to understand and communicate about the chiropractic relevant neuroscience research

To patients, the public, and to other health care providers

Help you to understand and communicate about the chiropractic relevant neuroscience research specific to particular groups

Sports, paediatric, asymptomatic,

What I can help you with

Various topics:

Research and science

Difference between different research methods

Evidence based practice

Sensorimotor integration

Mulitimodal integration

Neural plasticity

Inner body schema – inner brain reality

How the brain works

Various topics

Functional role of paraspinal muscles

Segmental movement research and biomechanics

Sensory chiro research

SMI chiro research

Motor control chiro research

Functional outcomes chiro research

Clinical chiro research

Props to use to explain each topic

Props are helpful!!

• Simple tests you can do in your office

• Poster for the Office to help explain mechanisms

• Office brochures explaining mechanisms

• A book for the patient (fully referenced)

Office Poster

Patient pamphlet

The Brain & CNS 101

34

The Matrix

Principles of Neural Science by Eric R. Kandel, James H. Schwartz, and Thomas M. Jessell. Elsevier, 2000, 4th Ed, Ch 33, p. 654

“IN THE PRECEDING PART of this book we considered how the brain constructs internal representations of the world by integrating information from the different sensory systems.

These sensory representations are the framework in which the motor systems plan, coordinate, and execute the motor programs responsible for purposeful movement.”

This is SENSORI-MOTOR-INTEGRATION

This is MULTI-MODAL-INTEGRATION

In pairs, take turns explaining to each other the following concepts:

Multimodal integration and the inner brain reality

Sensorimotor integration and its importance for accurate purposeful movements

How did that go?

Where you confident?

Did any questions arise?

The inner brain realityis it always accurate?

Phantom limb pain

Moseley GL, Olthof N, Venema A, Don S, Wijers M, Gallace A, Spence C. 2008. Psychologically induced cooling of a specific body part caused by the illusory ownership of an artificial counterpart Proc Nat Acad Sci USA; 105(35):13169-73. Copyright (2008) National Academy of Sciences, U.S.A.

Central filtering of info

Sensory information in the central nervous system is processed in stages, in the sequential relay nuclei of the spinal cord, brain stem, thalamus, and cerebral cortex. Each of these processing stations brings together sensory inputs from adjacent receptors and—using networks of inhibitory neurons—transforms the information to emphasize the strongest signals.

Kandel, Schwartz, and Jessell, 2000, p.428

“We are continuously exposed to stimulation across our senses; some of which is relevant to the task at hand but most of which is not. The ability to isolate and process appropriate sensory stimulation whilst inhibiting irrelevant stimulation is essential in order to achieve our goals in a timely and efficient manner. However as we age it is thought that the inhibition of irrelevant information becomes more difficult such that available sensory information is processed more extensively.”

(Setti et al 2011, Experimental Brain Research, 209;p.379)

Brain fills in the gaps and/or alters your reality based on past expectations, surrounding information and intentions.

““Ceoinsdr the anmzaig pweor of the hmuan biran. It dseno’t metatr in wahtoredr the lrttees in a wrod are, the olny tihng taht is iproamtnt is the frsitand lsat ltetres are in the rghit pclae. The rset can be a tatol mses and you can sitll raed it wuhotit a plboerm. Azanimg huh?”

Morning Tea

9.35 – 10.20

Video clip – TEDxAdelaide - Lorimer Moseley -Why Things Hurt:

http://www.youtube.com/watch?v=gwd-wLdIHjs

Pain and Plasticity

“We can mess with that”

48

Blind spot testing

Neural plasticity

Neural Plasticity

“Many important behaviors are learned. Indeed, we are who we are largely because of what we learn and what we remember. We learn the motor skills that allow us to master our environment, and we learn languages that enable us to communicate what we have learned, thereby transmitting cultures that can be maintained over generations. But not all learning is beneficial. Learning also produces dysfunctional behaviors, and these behaviors can, in the extreme, constitute psychological disorders.”

Kandel, Schwartz, and Jessell, 2000, p.1228

Maladaptive vs Adaptive Plasticity

Maladaptive vs Adaptive Plasticity

Symptoms don’t just appear out of thin air

Neuroscience concepts covered:

CSN, PNS, neurons, synapses, networks Internal representations

– Internal body schema– Inner Matrix

Problems with false internal body schema– Phantom limb pain, tinnitus, and on smaller

scale Central filtering Brain filling in the gaps (blind spot) Neural plasticity (good and bad) Sensorimotor integration and movement control

The connection between the neuroscience and chiropractic!

Paraspinal Muscles act as CNS sensors

Spinal muscle afferents are important for the brain sensory integration of other afferent input

Uthaikhup et al 2006. The influence of neck pain on sensorimotor function in the elderly Archives of Gerontology and Geriatrics; 55 p.667

Spinal adjustments

Appropriate joint movement

Appropriate spinal information sent to

brain and CNS

Appropriate processing and

integrationby brain and CSN

Better control of the spine

and body

The specific research hypothesis

Spinal adjustments

Abnormal SomatosensoryFiltering & processing

Altered function (pain and disability)

Altered sensorimotor

integration

Altered motor control

Altered afferent

input

SubluxationAppropriate

Joint movement

Normalafferent

input

Appropriate SomatosensoryFiltering & processing Appropriate

sensorimotor integration

Accurate motor control

Good function

What evidence is there for this model?

Abnormal Somatosensory

Processing

Altered function (pain and disability)

Altered sensorimotor

integration

Altered motor control

Altered afferent

input

Subluxation

Marshall & Murphy, 2006Murphy et al, 2009; 2010

Haavik & Murphy 2012b

What evidence is there for this model?

Spinal manipulation

Abnormal Somatosensory

Processing

Altered function (pain and disability)

Altered sensorimotor

integration

Altered motor control

Altered afferent

input

Joint dysfunction

AppropriateJoint

movement

Appropriateafferent

input

Appropriate Somatosensory

Processing Appropriatesensorimotor

integration

Accuratemotor control

Good function

Marshall & Murphy, 2006Murphy et al, 2009; 2010

Haavik & Murphy 2012b

67

Amplitu

de

Time

Signal

Background noise

Amplitu

de

Time

Aberrant spinal movement

Can mean that the brain may not be fully aware of what is going on in your spine, which appears to influence how it controls the rest of the body

– Growing body of research supports this!

May impact the accuracy of our Matrix

– Theory, but with some evidence that suggests this

Spinal function impacts integration of sensory information

Growing body of research supports this!

This could lead to accidents, the develop pain and dysfunction, syndromes, conditions, etc.

So that it can accurately perceive what is going on and respond

appropriately

which in turn helps clear up the communication between your brain,

the body and the environment

Chiropractic care improves the health and function of the spine

A subluxation is.....

“a central segmental motor control problem”

Which means that the central nervous system is notcontrolling the movement patter of the spinal segmentas it should, which alters the stretching of theparaspinal muscles which changes the input to thebrain which impacts how it processes otherinformation

7 essential components

1. Neuroplasticity - Good or Bad

2. Inner brain reality / body schema

3. Subconscious processing

4. Brain fill in the gaps & filters info

5. Paraspinal muscles are SENSORS

6. What happens when a segment is not moving properly

7. What happens when we adjust these

Self Test!

See if you can remember the key essential components to explain the effects of an adjustment !

7 essential components

1. Neuroplasticity - Good or Bad

2. Inner brain reality / body schema

3. Subconscious processing

4. Brain fill in the gaps & filters info

5. Paraspinal muscles are SENSORS

6. What happens when a segment is not moving properly

7. What happens when we adjust these

Take 10 minutes to plan your 10 min talk about the mechanisms of chiropractic care for a patient’s Report of Findings. Include the following components and use SIMPLE examples

1. Neuroplasticity - Good or Bad

2. Inner brain reality / body schema

3. Subconscious processing

4. Brain fill in the gaps & filters afferent info

5. Paraspinal muscles are SENSORS

6. What happens when a segment does not move properly

7. What happens when we adjust these segments

Include in your the plan the use of Office Poster & Pamphlet!

Name: __________Components:

Tick if discussed

Tick if simple example included:

Note what may have been missed:

Specific Notes:

Neuroplasticity – Can be good and bad

Inner brain reality /  body schema

Subconscious processing

Brain fill in the gaps & filters afferent info

Paraspinal muscles are SENSORS

What happens if spinal segments don’t move properly

What happens when we adjust these segments

Use of Poster

Use of Pamphlet

In groups of 3 Practice the talk! One be the Chiro One the patient One take notes and provide feedback

Rotate so everyone gets to try being the chiropractor.

Debrief after each round about what worked well and what did not

Lunch

12.30-1.45

Recap of Morning Session

Questions?

Review and you will remember 70% more!

How did practical go?

Where you confident?

What were you less confident about?

What did you not remember ?

Biggest gaps in understanding/knowledge?

Neuroscience concepts covered:

CSN, PNS, neurons, synapses, networks Internal representations

– Internal body schema– Inner Matrix

Problems with false internal body schema– Phantom limb pain, tinnitus, and on smaller

scale Central filtering Brain filling in the gaps (blind spot) Neural plasticity (good and bad) Sensorimotor integration and movement control

Link between neuro to chiro concepts covered:

Functional role of paraspinal muscles The muscle spindle Where spindle info goes How spindle info impacts brain function Descending brain control of ...... everything The research model Effects of VS (too much or too little movement)

– Signal to noise ratio– Working in the dark

Science & Research 101

Evidence Informed Practice

Improved patient

outcomes!

Patients own values and expectation

Overall Working Model

Narrow down to testable question

Test with scientific method

Interpret your results

Clinical research

Basic Science

Research

The floor-plan research methodology analogy

Basic Science

Qualitative researchClinical TrialsRCTs

Case reports

Copyright ©Dr Heidi Haavik 2014

Systematic Reviews

Editorials, Expert Opinion

Randomised Controlled Trials

Cohort Studies

Case-control Studies

Case Series, Case Reports

The hierarchy of evidence

Turn to your neighbour and explain the difference between basic science and clinical science and answer the following:

1. How can you tell the difference between basic science and clinical science? What evidence do each provide?

2. Can you think of some difficulties scientist have when doing research into the subluxations and effects of adjusting them?

3. What is the key difficulty when trying to do clinical science with a chiropractic intervention?

4. What is the benefit to you with good chiropractic basic science?

5. What is the benefit to you with positive chiropractic clinical science?

2. Issues for scientists wishing to explore the subluxation and the effects of the adjustment

An intervention is supposed to be properly defined and repeatable

– What is a subluxation?

– How do you find one?

– Can you find them reliably?

– What is the spinal manipulation / adjustment intervention?

– Can it be repeated in a reliable manner?

3. What is the key difficulty when trying to do clinical science with a chiropractic intervention?

Clinical research is about the effects of an intervention on a particular condition

So what (conditions) does chiropractic treat?

Simple balance testing in the Office

Copyright ©Dr Heidi Haavik 2014 Copyright ©Dr Heidi Haavik 2014

Scrambled sentence & Blind spot testing

Blind spot test and instructions in your booklet

Square Illusion

In groups of 3 practice these tests on each other (patient, chiro, assessor)

Square A and Square B illusion

Blind spot testing

Scrambled sentence

Rhomberg’s testing

Assessor: how are they communicating this, do they seem confident, can they answer questions, are they using their new knowledge?

How did that go?

Share with another pair how it went

What was easy?

What was hard?

Where you confident?

Afternoon Tea

3.00 – 3.45

Lets get stuck into some studies

Clinical research

Read and be able to discuss the RCTs and reviews that demonstrate spinal manipulation is as good as anything else out there for

– Back pain (E.g. UK BEAM study 2004 BMJ; LBP Brontfort et al 2008; AM-LBP - Bishop et al 2010)

– Neck pain (Haldeman S, Carroll L et al. (2008) The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders; Executive Summary, Spine 33(4S):S5-S7)

– Headaches (See review in The chiropractic report Sept 2010)

Clinical research

And that chiro patient satisfaction is MUCH better than other care (See review in The chiropractic report Jan 2007)

And we are more cost effective (See review in The chiropractic report Nov 2009)

And we are safe (Cassidy JD, Boyle, E, Cote et al. 2008 Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study, SPINE 33(4S): S176-183)

There is even evidence for maintenance care for low back pain (Senna MK, Machaly SA. 2011. Does Maintained Spinal Manipulation Therapy for Chronic Non-Specific Low-Back Pain Result in Better Long Term Outcome? SPINE)

In groups of 3 practice telling your patient about the clinical research there is about chiropractic

See if you can turn the subject’s attention from the clinical research to the basic science research in simple language

Feedforward Activation(Marshall & Murphy. J Manipulative Physiol Ther 2006;29:196-202)

(Gov

orko

, MS

c Th

esis

, 200

7, p

.106

)

(Marshall & Murphy. J Manipulative Physiol Ther 2006;29:196-202)

Pre Adjustments

Post Adjustments

17/90 impaired FFA

13/17 retested 6 month later

38% improvement in FFA times after SI adjustments

Example 1

This is what they did and this is what they found:– They tested 90 healthy young male cricket players in their ability to feed-forward

activate their abdominal muscles - 19/90 could not– Six months later 13/17 still could not– One adjustment session – 40% improvement

This is what this means to you– You may not be able to feed forward activate your core abdominal muscles– These are important low back support mechanism for you– If you cannot you are basically causing mini low back whiplash each time you lift

your arm– No symptoms in those guys, so you may not have felt it either – so can be why

your low back pain started.... You said you did not know why – We know being unable to activate core muscles leads to LBP

Caution/Limitations.......... ‘BUT...’– You are a woman, the study was only on men– We dont know how long the effects last, was only one pre/post

Practice this

In groups of three (chiro, patient, assessor) practice telling a patient about this study. Remember:– What did they do– What did they find– What does this mean to your patient– But....limitations of study

Swap around so everyone has a go at being chiro Assessors: please provide feedback to chiropractor! Patient:

– create a story for the chiro (e.g. I’m a 48 female with LBP)– And ask questions like – why did I get low back pain, I

had no injury, it just happened, why would chiropractic work for me?

How did that go?

Share with another pair how it went

What was easy?

What was hard?

Where you confident?

(Award winning poster at 2009 WFC; Award winning paper at ACC RAC 2010)

Haavik & Murphy, 2011, JMPT; 34:88-97

Copyright ©Dr Heidi Haavik 2014

Example 2

This is what they did and this is what they found:– Twenty-five SCNP participants and 18 control participants were tested for their elbow

JPS before to see if SCNP participants JSP was worse than controls – and they were!– The SCNP group then were retested after either SM or control intervention. SM

improved elbow JPS!!

This is what this means to you– If your brain is not fully aware of where your elbow is, it could be why you keep

knocking it in doorframes– This study suggests that spinal function impacts how accurately your brain can

interpret propriocpetive information from your arms

Caution/Limitations.......... ‘BUT...’– You are a older than the individuals in this particular study, although there is an study

done in 65 + year olds done with anckle JPS and they improved significantly over a four week period

– We dont know how long the effects last, was only one pre/post– The anckle study showed effects of 12 weeks chiro care, but no follow up done

Practice this

In groups of three (chiro, patient, assessor) practice telling a patient about this study. Remember:– What did they do– What did they find– What does this mean to your patient– But....limitations of study

Swap around so everyone has a go at being chiro Assessors: please provide feedback to chiropractor! Patient:

– create a story for the chiro (e.g. I’m a 48 female with LBP)– And as questions like – why did I get low back pain, i had

no injury, it just happened, why would chiropractic work for me?

How did that go?

Share with another pair how it went

What was easy?

What was hard?

Where you confident?

Feedback Please

Resources & further info:

Intermediate model here next year

My book www.heidihaavik.com

CJA and JEK review articles – email me!!

CAA online learning modules

NZCA/CCR online learning modules

Seminar series like this to be run in NZ

And Australia?