“ Chiropractic ” A rationale approach to common neuromusculoskeletal disorders The objective of...

“Chiropractic” A rationale approach to common neuromusculoskeletal disorders

The objective of the lecture is to advance the knowledge base of medical professionals and paraprofessionals, nurses, case managers, and others concerning the chiropractic approach to back pain and disability. We will explore the following issues:

TABLE OF CONTENTS

1. Soft Tissue2. Chronic Pain3. Etiology of Pain 4. Spinal Manipulation5. Whiplash6. Recurrent Nature of Pain7. Dysfunction8. Drug Issues9. Diagnostic Accuracy10. Costs11. Summary/Quiz

“Chiropractic” A rationale approach to common neuromusculoskeletal disorders

Our goal is to create a common understanding of the issues facing an injured patient. The information will be valuable to treating physicians, case managers, employers and managed care personnel, to name just a few. This program is an effort to facilitate greater cooperation between the medical and chiropractic disciplines for the good of the patients we serve, in addition to providing quality information to third party payor personnel, often less informed by virtue of their education and training.

Goals of Care

Old School: Reduce pain

New Paradigm:

1. Minimize Pain

2. Decrease Reliance on drugs

3. Restore, maximize, and maintain function

4. Keep the patient working.

The Problem:

Old perceptions about goals of care still exist and are not consistent with the current literature. (i.e., symptoms vs. function)

Standard medical care (i.e.. Drugs) is often

ineffective and dangerous when taken long term or in combination with other drugs or alcohol (ex. Tylenol and liver failure).

Soft Tissue Healing

A Review of the Literature

Do All Soft Tissue Injuries Heal Within 6-8 Weeks?

A Review of the Scientific Literature

Croft, McFarland, et alBMJ 1998

"We should stop characterizing low back pain in terms of a multiplicity of acute problems, most of which get better, and a small number of chronic long term problems. Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences.”

Saal JA, MD. Spine 1997;22(14):1545-1552

The major premise used in the managed care system for the primary care of LBP is based upon the assumption that 90% of patients improve in 6-12 weeks. However, a natural history study by Von Korff found that approximately 60% will recur. In a study of BP in primary care, Von Korff and Saunders found that 60% to 75% improve within the first month, 33% report intermittent or persistent pain at one year, and 20% of patients describe substantial limitations at one year.

Croft, McFarland, et al. BJM 1998

“These figures do not fit with the claim that 90% of episodes of LBP end in

complete recovery.”

Frank, MD. BMJournal 1993; April 3:901-9.

Review of a study in which 373 patients less than 40 years old, with their first onset of back pain, are followed for 10 years. 89% had recurrences and only 33% had no lost time form work from future back problems. Strategies to manage low back pain must be long term and preventive. [Emphasis added.]

Waddel, MD. JMPT 1995;18(9):590-596

Traditional teaching is that 90% of LBP attacks recover within six weeks, but recent natural history studies suggest that this is overly optimistic and over-emphasizes RTW. It now seems that 50% of attacks settle within 4 weeks, but 15-20% have some symptoms for at least 1 year. 70% of patients who have acute back pain will suffer 3 or more recurrences. 20% will continue to have some back symptoms over long periods of their lives.

Jayson, MD, FRCP. Spine 1997;22(10):1053-1056.

At 3 months, only approximately 27% were completely better, 28% improved, 30% had no change, and 14% were worse or much worse. It may well be that in the many studies of acute low back pain, there has been very carefully selected clinical material so that only those patients with acute pain of recent onset and no other confounding factors were included, with the result that these studies do not reflect what actually happens in practice.

Waddell, MD. The Chiropractic Report 1993; July:1-6

Bed Rest: should die as soon as it can. Physical Therapy: There is no adequate evidence of effectiveness. Spinal manipulation: one of two treatments of proven value. Early active exercise: Is the other treatment supported by good evidence. Relief of pain and restoration of function must occur at the same time.Failure to restore function means any pain relief will be temporary andreinforces chronic pain. In the management of occupational back pain,the chiropractic profession is leading the way. The problem is weaknessand loss of function, not disease.

Bronfort. DC et al. JMPT 1996; 19(9): 570-582

…compared the efficacy of five weeks of: (1) spinal manipulation (SM) with trunk strengthening exercises (TSE); (2) SM combined with trunk stretching exercises; and (3) NSAIDs with TSE all followed by 6 weeks of supervised exercise alone.

For the management of chronic low back pain, trunk exercise in combination with spinal manipulation or NSAIDs seems beneficial and worthwhile.

Weisel, MD. Backletter 1996; 11(7): 84 Back pain is a recurrent illness.

Carey’s study emphasizes that BP is typically recurrent and sometimes disabling – in a substantial minority.

Kuritzky, MD. Physician and Sports Medicine 1997;25(1):56-64

97% of BP seen by primary care physicians is mechanical in origin. There is something wrong with the muscles, ligaments, or connective tissues.

Haldeman, DC, PhD, MD. Spine 1990;15(7):718-723.

The pathology model cannot explain back pain ordisability. It is not possible to look at pathology anddetermine the symptoms a patient may be suffering.It also is not possible to look at a patient with back

painwith no neurologic deficits and determine the nature ofthe pathology. About 30% of asymptomatic subjectsshow abnormalities in the lumbar spine by myelogram,CT and MRI. There is a large percent of symptomaticpatients with severe complaints in whom testing fails

toreveal any structural lesion.

Jensen, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. NEJM

1994;331(2)July 14:69-73

98 people: only 36% had a normal disc at all levels. 52% bulge at least one level 27% protrusion 1% extrusion 38% had abnormality at more than one level

Summary: Finding may be frequently coincidental

Liebenson, DC, Oslance. Rehabilitation of the Spine. Williams and Wilkins, Baltimore.

1996:73.

80% of patients have no identifiable structural pathology and require treatment based on evaluation of functional deficits.

Overemphasis on treatment of structural pathology results in a failure to identify or focus on functional loses and work demands. [Emphasis added.]

Croft P, Macfarland GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of Low Back Pain in General Practice: a

Prospective Study British Medical Journal 1998;316:1356-

1359

Low-back pain is aptly redefined as "a chronic problem with an untidy pattern of grumbling symptoms," with only 25% of patients consulting about the problem reporting full recovery 12 months later. Instead, most patients appear to be enduring their pain but not telling their primary care physician about it.

In fact, after seeing the results, the authors made the following statement:

"By three months after the index consultation with their general practitioner, only a minority of patients with low back pain had recovered. However, most patients with low-back, pain did not return to their doctor about their pain within three months of their initial consultation, and only 8% continued to consult for more than three months."

Croft P, et al. BMJ 1998;316:1356-1359

The authors found that consulting a doctor is not a direct measure of the presence of pain and disability. While patients may stop consulting their doctor, the vast majority will still have some pain and disability 12 months later. Therefore, the authors concluded:

Croft P, et al. BMJ 1998;316:1356-1359

"We should stop characterizing low back pain in terms of a multiplicity of acute problems, most of which get better, and a small number of chronic long term problems. Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences. This takes account of two consistent observations about low back pain: firstly, a previous episode of low back pain is the strongest risk factor for a new episode, and secondly, by the age of 30 years almost half the population will have experience a substantive episode of low back pain. These figures simply do not fit with claims that 90% of episodes of low back pain end in complete recovery."

Holm, in The Cervical Spine, Lippincott, 1989, p. 440

“Follow-up roentgenograms taken an average of 7 years after

injury in one series of patients without prior roentgenographic evidence of disc disease indicated that 39% had developed degenerative disc disease at one or more disc levels since injury. It was pointed out that available evidence indicated an expected incidence of 6% degenerative change in a population with this mean age of 30 years. Thus, it appeared that the injury had started the slow process of disc degeneration.”

“In another follow-up study of patients with similar injuries but with preexisting degenerative changes in the neck it was observed that after an average of 7 years 39% had residual symptoms, and roentgenographic evidence of new degenerative change at another level occurred in 55%.”

Symptoms vs. Function

As a result of these and other studies there has been a shift in thinking away from the traditional "symptom" approach, towards contemporary thinking of "function".

For many patients with recurrent back pain, staying functional is a "process" more so than a "result" based on a predictable healing time or average.

Summary

Since 1956…dozens of studies

“Natural Healing Time”……Myth

Mechanical Back Pain…predominant issue

Restoration and maintenance of “function” is critical

Chronic Pain


Meade Study: BMJ 1990

A British ten year study concluded that chiropractic treatment was significantly more effective, particularly with patients with chronic and severe pain

Bronfort, DC et al. JMPT 1996

“For the management of chronic back pain, trunk exercise in combination with manipulation or NSAIDs seems beneficial and worthwhile.”

Giles LG, Muller R. JMPT 1999

Study compared spinal manipulation, needle acupuncture, and NSAIDs for the treatment of chronic back pain.

After 30 days, spinal manipulation was the only intervention to achieve statistically significant improvement.

Intervention by way of acupuncture or NSAIDs did not result in significant improvements in any of the outcome measures.

Manual Medicine 1986

CMT is both subjectively and objectively, more effective at relieving low back pain than a manual placebo treatment.

SPINE 1997 Maurits W. van Tulder, et al

“…strong evidence for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short term results.”

Additionally, the study found that no single therapeutic intervention was demonstrated to be effective in the treatment of chronic LBP.

SPINE 1995 Triano, McGregor, et al

“There appears to be clinical value to treatment according to a defined plan using manipulation even in low back pain exceeding 7 weeks’ duration”

Summary

The benefit of chiropractic manipulation (in addition to exercise) over single intervention treatments like acupuncture, exercise, and NSAIDs for patients with chronic pain syndromes is clear and supported by scientific study.

Manipulation is certainly the safest and most effective treatment to keep a spine functional and the chronic pain patient employed.

“Passive” or “No lasting therapeutic Benefit” or “Non-Curative” or “Palliative”

What treatment can survive a requirement suggesting that treatment must provide curative or long lasting therapeutic benefit? ANSWER: NONE!

Chiropractic or Osteopathic manipulation Drugs Physical Therapy (electric stim, ultrasound, ice, heat, etc.) Massage Epidural injections Facet Injections Physical Rehabilitation Exercises Patient Education NSAIDs Surgery

Criteria: Minimal requirements to qualify

for Chronic Pain Management.

1. Unable to attain pre-accident status; attained maximal therapeutic benefit; recovered with residual soft tissue damage

2. Therapeutic withdrawal attempted3. Unable to maintain improvement4. Minimal tx recommended5. Dx & Tx alternatives considered6. Home management recommended

Goals of Chiropractic Spinal

Manipulation for Chronic Pain

1. Pain Relief2. Improve Fx3. Decrease Reliance on drugs4. Keep the patient employed

Etiology of Chronic Pain


Pain

Mechanics

Nocireception

Small Diameter

Slow: .5-2 mps

“C” afferent

Free / Naked Receptor

Hot Water

Mechanoreception(proprioception)

Large Diameter

Fast: 120 mps

1a or 1b afferent

Encapsulated Receptor

Muscle spindleGTO

GT like Rufini, etc

Cold Water

Mooney, MD. J. Musculoskeletal Medicine 1995; Oct:33-39.

Common acute back pain is due to chemical abnormalities created by soft tissue tear. The tear represents a mechanical disruption, which is usually microscopic. X-rays demonstrate no changes before and after an acute back injury.

Vert Mooney, MD: Spine, 1986 Dallas, TX.

“In summary, what is the answer to the question of where is the pain coming from in the chronic low-back pain patient? I believe its source, ultimately, is in the disc. Basic studies and clinical experience suggest that mechanical therapy is the most rational approach to relief of this painful condition.”

Lee et al: Spine 1995

“Anatomically the disc is richly innervated at the periphery and outer layers of the annulus by the branches of the sinu-vertebral nerves and sympathetic nerves.”

“Pathological conditions confined within the disc property were the most probable sources of pain.

Derby MD, Spine 1996;21:1744,1745

“Although muscle pain and tissue hyperalgesia may be an integral part of chronic cervical pain after whiplash injuries, such pain may be better explained as a secondary reflex reaction to injury of segmental supporting structures.”

* Zygapophysial Joint Pain

Bogduk: 1999 Saal 1996 Spine 1997

“Neuropathic lesions such as nerve root compression causing radicular pain are extraordinarily uncommon in the spine…In most back pain, the mechanism involved is the stimulation of nerve endings in the affected structure. Nerve root compression is

in no way involved.”

Bogduk, MD: Newcastle Bone and Joint Institute,

Point of View

“The study of Kaneoka et al now fills a critical gap in the story of cervical facet pain. It provides the missing biomechanical link. Theirs is the most significant advance in the biomechanics of whiplash since the pioneering studies of Severy et al in 1955.”

* Facet Joint pain

Bogduk et al: Pain 1993

Both a symptomatic disc and a symptomatic zygapophysial joint were identified in the same segment in 41% of the patients.

The paper demonstrated that chronic pain is articular, not myofascial.

Bogduk: Spine 1992

Cervical zygapophysial joint pain is not rare, and is worthy of further consideration not just in research but in clinical practice.

Bogduk: Spine 1988

Joint blocks in 24 pts

The high yield of positive responders in this study probably reflects the propensity of patients with ZJ syndromes to gravitate to a pain clinic when this condition is not recognized in conventional clinical practice.

Holm, in The Cervical Spine, Lippincott, 1989

“Follow-up roentgenograms taken an average of 7 years after injury in one series of patients without prior roentgenographic evidence of disc disease indicated that 39% had developed degenerative disc disease at one or more disc levels since injury.

….after an average of 7 years 39% had residual symptoms

Lord: Spine: Sept. 1993

Postmortem studies of victims of MVAs reveal that zygapophyseal joint injuries are common, being present in 86% of necks examined. The lesions include capsular tears, ruptures of meniscoids, intraarticual hemorrhage, and small fractures.”

Khan, Cook, Gargan, and Bannister: A Symptomatic Classification of Whiplash Injury and the Implications for Treatment. The Journal of Orthopaedic Medicine 1999.

Results: Organic pain causes psychological stress, not the result of it!

Halldor Jonsson et al: Spine

Conclusions: Follow-up surgery on the chronic patients showed a high incidence of discoligamentous injuries in whiplash-type distortions.

“Pain can originate both from the ganglion and the richly innervated annulus fibrosis and also from the facet joints causing both local and referred pain.”

Nachmeson, MD: Spine 1976

“Although practically all anatomic structures in the region of the motion segment have their proponents in the etiology discussion, the lower intervertebral disc most likely causes the pain.”

Bogduk: Spine 1988The Innervation of the Cervical Intervetrebral Discs

…cervical sinuvertebral nerves…upward course in vertebral canal, supplying the disc…

“These anatomical findings provide the hitherto missing substrate for primary disc pain and the pain of provocation discography.”

Bogduk: Spine 1983The Innervation of the Lumbar Spine

IVD innervated posteriorly by the sinuvertebral nerve but laterally by branches of the ventral rami and grey rami communicates.

PLL…SVN Lumbar musculature

Bogduk: J Anat 1981

Anterior longitudinal ligament is innervated by the recurrent branches of the rami communicates.

Barnsley et al: Spine 1995The prevalence of chronic cervical zygapophysial joint pain

after whiplash.

Conclusion: In this population [chronic neck pain], cervical zygapophysial joint pain was the most common source of chronic neck pain after whiplash.

Barnsley et al: NEJM 1994“…Corticosteriods for chronic pain..”

Results: Less than half the patients reported relief of pain for more than one week, and less than one in five pts reported relief for more than one month, irrespective of the treatment received.

Conclusion: Intraarticular injection of betamethasone is not effective….

Barnsley et al: NEJM 1994“…Corticosteriods for chronic pain..”

“…the pts who derived a benefit from either treatment may have had a condition that was improved by the stretching of the joint capsule during the intraarticular injection, irrespective of what was injected.”

Chronic disabling low back pain syndrome caused by internal disc derangements. The results of disc excision

and posterior lumbar interbody fusion.

Lee, Vessa, Lee, Spine 1995 Feb. 1;20(3):356-61

“Anatomically the disc is richly innervated at the periphery and outer layers of the annulus by the branches of the sinu-vertebral nerves and sympathetic nerves.”

“Pathological conditions confined within the disc property were the most probable sources of pain. These pathologic conditions may include nuclear degeneration, annular tear, and biochemical ground substance degradation. The possible pain mechanism is stimulation of nociceptors within the disc by mechanical sources (abnormal local stress/strain), biochemical sources (various endogenous nonneurogenic or neurogenic chemical products), or both.”

1999 Paper by Bogduk, MD, PhD

Saal JA. 1996 North American Spine Society Presidential Address, Spine 1997;22(14):1545-1552

“Neuropathic lesions such as nerve root compression causing radicular pain are extraordinarily uncommon in the spine…In most back pain, the mechanism involved is the stimulation of nerve endings in the affected structure. Nerve root compression is in no way involved.”

Literature Review by Haldeman, DC, MD, PhD\Liebenson C. Rehabilitation of the Spine. Wms. & Wilkins,

Baltimore 1996: 13-43.

“There has been no evidence that a change in the relation of adjacent vertebrae of the type commonly described in the chiropractic literature can result in nerve root or spinal cord compression.”

Haldeman

Spinal Manipulation


Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal

Manipulation. Spine July 15, 2003; 28(14):1490-1502

Design: RCT, 115 patients, public hospitals multidisciplinary spinal pain unit. Evaluated at 2, 5, and 9 weeks. Manipulation performed by DCs with 18 adjustments or less. Drugs used; Celebrex, Vioxx, paracetamol. Average duration of spine pain was 8.3 years for the manipulation group.

Results: The highest proportion of early (asymptomatic status)

recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%).

Conclusions: The consistency of the results provides

evidence that in patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication.

““Chiropractic Maintenance CareChiropractic Maintenance Care””

Journal of Manipulative and Physiological Therapeutics,23(1), January 2000, pp. 10-19

·

Study Design: 65 years +, “health promotion and prevention services” for at least 5 years @ min. of 4/yr. o 16.95 visits to DC/yr vs. 4.76 visits/yr to MD.

Chiropractic Maintenance Care


Results: DC avg. only $3,106 which is 31% lower of the national average healthcare costs for the same age group. DC avg is lower than the national avg. for US citizensOf all ages, which was $3,510. Pts. Receiving maintenance DC spent an avg. of $1,723 for hospitalizations. The per capita expenditures for Medicare hospitalization was $5,121 or 51% of the total cost of health care services.

Chiropractic Maintenance Care


Conclusions: • DC visits 2x vs. MDs, but 50% reduction in # of MD visits.

•Therefore, DC treatment “replaces”, not compliments, MD care. • Extreme differences in Hospitalization costs. • “Total annual cost of health care services for the patient

receiving MC was conservatively 1/3 of the expense made

by US citizens of the same age.”

What Are The Negative Effects of Joint What Are The Negative Effects of Joint Immobilization?Immobilization?

Liebenson C: Pathogenesis of Chronic Back Pain. JMPT

15:303, 1992

Joints Shrinks joint capsules Increases compressive loading Leads to joint contracture Increases synthesis rate of glycosaminoglycans Increase in periarticular fibrosis Irreversible changes after 8 weeks of immobilization Ligament Lowers failure or yield point Decreased thickness of collagen fibers



15:303, 1992(cont’d)

Disk Biochemistry · Decreases oxygen· Decreases glucose· Decreases sulfate· Increases lactate concentration· Decreases proteoglycan content

Bone · Decreases bone density· Eburnation



15:303, 1992(cont’d)

Muscle Decreased thickening of collagen fibers Decreased oxidative potential Decreased muscle mass Decreased sarcomeres Decreased cross-sectional area Decreased mitochondrial content Increased connective tissue fibrosis Type 1 muscle atrophy Type 2 muscle atrophy 20% loss of muscle strength per week



15:303, 1992(cont’d)

Cardiopulmonary

Increased maximal heart rate Decreased VO2 max Decreased plasma volume

What Are The Positive Effects of Spinal Manipulation and Joint Mobility?

Nelson, DC. Top Clin Chiro 1994;1(4):20-29.

Stretching of abnormally tight tissues (passive forcing)

Increased range of motion Selective tearing of adhesions without

damaging healthy tissue Stimulation of wound healing Improved edema removal due to pumping

action of movement Removal of waste products & chemical

mediators of pain Increased fluid flows, discal & cartilage nutrition



Reduction of the pain-spasm cycle Increase of mechanoreceptive input due to

increased motion Close the “gate” to the central transmission of

pain Regeneration of functional tissue & less scarring Improved rate & endpoint of tissue healing Movement is a specific stimulus for collagen

production Movement increases cellular metabolism &

protein synthesis



Improved ligament strength Improved matrix organization Proper alignment of new collagen Normalize proprioceptive patterns from joints

& muscles Normalize coordinated complimentary motor

programs

J. David Cassidy and William H. Kirkaldy-Willis, Managing Low Back Pain, Chapter 17 pg. 287-288,

Can. Fam. Physician Vol. 31: March 1985

“A manipulation or lumbar intervertebral joint adjustment is a passive manual maneuver during which the three-joint complex is suddenly carried beyond the normal physiological range of movement without exceeding the boundaries of anatomical integrity.

The usual characteristic is a thrust-a brief, sudden, and carefully administered “impulsion” that is given at the end of the normal passive range of movement. It is usually accompanied by a cracking noise.”

J. David Cassidy and William H. Kirkaldy-Willis, Managing Low Back Pain, Chapter 17 pg. 287-288, Can. Fam. Physician Vol. 31:

March 1985(cont’d)

Four zones: (1) active movement (2) passive movement (3) paraphysiological zone (4) pathological zone

Two barriers : (1) elastic barrier- overcome by the thrust without damage to the joint structures (2) limit of anatomical integrity-which cannot be surpassed without injuring ligaments and capsule

Note: Versus mobilization, only manipulation can influence all joint ranges: active, passive, and paraphysiological joint play.

Exercise? Is it a cure-all?

Several studies compared McKenzie (exercises) protocols with spinal manipulation.

Wiesel, MD (Cherkin, PhD) McKenzie Protocol versus Chiropractic Care for LBP. Backletter 1995:10(11):121, 130, 131.

And

Wiesel, MD. (Cherkin, PhD) Mckenzie versus Manipulation. Back letter 1996;11(12)Dec: 133, 139.

Exercise

“McKenzie and spinal manipulation were equivalent in symptoms, function, disability, and satisfaction, and were superior to booklet in terms of symptoms and satisfaction. However, McKenzie did not reduce recurrences or long-term utilization of health care.”

In other words, exercise is no cure in and of itself for the treatment of low back pain.

Bronfort. DC et al. JMPT 1996; 19(9): 570-582

This was a randomized controlled study with a one year follow-up in 174 chronic low back pain patients (age 20-60) that compared the efficacy of five weeks of: (1) spinal manipulation (SM) with trunk strengthening exercises (TSE); (2) SM combined with trunk stretching exercises; and (3) NSAIDs with TSE all followed by 6 weeks of supervised exercise alone.

Bronfort. DC et al. JMPT 1996; 19(9): 570-582 (cont’d)

Results: Outcomes at 5 and 11 weeks revealed no significant group differences. Continuance of exercise during the follow-up year, regardless of the type of treatment, was associated with a better outcome.

Conclusion: All three treatment regimens were

associated with similar and clinically important improvement over time and the treatment was considered superior to the expected natural history of long-standing chronic low back pain. For the management of chronic low back pain, trunk exercise in combination with spinal manipulation or NSAIDs seems beneficial and worthwhile.

Osteopathic Methods and the Great Flu Pandemic of 1917-1918 JAOA May 2000 Vol. 100 No. 5 Pg 309

Killed 10-20 Million Killed 1.5 x more in 6 months than in

the entire WWI. Death Rate 0.5% for pts treated by DOs

vs. 6% for pts treated by MDs

Pneumonia DO < 10% vs. MD 33% Osteopathic methods highly effective

JAOA May 2000Great Flu Pandemic of 1917-1918

“The best defense against disease and infection remains health.” “Optimal health is the result of the optimization of function of each individual.” “Osteopathic care….excellent preventativetreatment.”

Dabbs, D.C. and Lauretti, D.C., A Risk Assesment of Cervical Manipulation vs. NSAIDs for the Treatment of Neck Pain. Journal of Manipulative and Physiological Therapeutics. Vol. 18, number 8 Oct. 1995; 18:530-6.

“The best evidence indicates that cervical manipulation for neck pain is much safer than the use of NSAIDs, by as much as a factor of several hundred times. There is no evidence that indicates NSAID use is any more effective than cervical manipulation for neck pain.”

Death rate for NSAID-associated GI problems at 0.04% per yr amoung OA patients receiving NSAIDs, or 3,200 deaths in the US per year.

He (Brandt) also noted that there are several animal

studies and human clinical studies that have actually implicated NSAIDs in the acceleration of joint destruction.

Hoving et al. A Randomized Controlled Trial of Manual Therapy. Ann Intern Med. 2002;136:713-722. Manual Therapy, Physical Therapy, or Continue Care by a General Practitioner for Patients with Neck Pain, A

Randomized, Controlled Trial., Pages 713-722

Intervention: 6 weeks of manual therapy (specific mobilization techniques) once per week, physical therapy (exercise therapy) twice per week, or continued care by a general practitioner (analgesics, counseling, and education).

“Conclusion: In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.”

Adjustments Don’t Have to Make Noise to Work. Archives of Physical Medicine and Rehabilitation – July 2003;84:1057-60.

“There is no relationship between an audible pop during SI region manipulation and improvement in ROM, pain, or disability in individuals with non-radicular LBP. Additionally, the occurrence of a pop did not improve the odds of a dramatic improvement with manipulation treatment.”

Doctors of Chiropractic More Qualified Than Osteopaths, PTs and MDs in Spinal Manipulation/Adjustment, According to American Chiropractic Association.

Arlington, Va., Nov. 4 /PRNewswire

* A survey of osteopathic schools found that most schools generally offer

spinal manipulation/adjustment only on an elective basis. * No manipulation/adjustment training is given or available for M.D.s

in medical school curricula. * One study queried 10 physical therapy schools -- none taught spinal manipulation/adjustment.

"Individuals with less training and expertise than doctors of chiropractic may provide outcomes that are less than optimal, and can pose unnecessary health and safety risks and possible complications for patients," the policy statement reads.

Osteopathic Manipulation No Better Than Sham Therapy for Chronic Back Pain. Spine: July 8, 2003.

July 8, 2003 — Osteopathic manipulation is no better than sham therapy for chronic nonspecific low back pain, according to the results of a randomized trial published in the July issue of Spine.

However, both osteopathic and sham manipulation were more effective than no therapy.

Efficacy of spinal manipulative therapy for low back pain of less than three months' duration. JMPT November/December 2003. Volume 26 .

Number 9. Review of the literature. Ferreira et al.

Conclusions: Spinal manipulative therapy produces slightly better outcomes than placebo therapy, no treatment, massage, and short wave therapy for nonspecific low back pain of less than 3 months duration. Spinal manipulative therapy, exercise, usual physiotherapy, and medical care appear to produce similar outcomes in the first 4 weeks of treatment.

The Journal of Neurological and Orthopaedic Medicine and Surgery. An article entitled, Effective Management of Spinal Pain in 200 Patients Evaluated for Manipulation

Under Anesthesia Volume 17,No 1, 1998.

"In completing this study, the authors found that a multidisciplinary approach to evaluation and treatment offers patient benefits above and beyond that which can be obtained through the individual providers working alone.

It is our intention to proceed with studies of a more specific design as this present work has demonstrated positive results and no complications."

The New England Journal of Medicine 1999;341:1426-1431, 1465-1467.

Osteopaths equal MDs at relieving chronic back pain NEW YORK, Nov 03 (Reuters Health) -- Manual therapy by an osteopath is as effective at relieving chronic lower back pain as traditional medical care, according to a report in the November 4th issue of The New England Journal of Medicine. Results of a study from Chicago researchers showed patients who received osteopathic therapy for subacute low back pain received fewer drugs and needed less physical therapy than those treated with standard care.

Reminder: DC’s provide 94% of all manipulation performed. RAND.

Randomized Osteopathic Manipulation Study (ROMANS): Pragmatic Trial for Spinal Pain in Primary Care. Wilkinson C, et al. Family

Practice 2003. Dec;20(6):662-9

CONCLUSION: A primary care osteopathy clinic improved short-term physical and longer term psychological outcomes, at little extra cost. Rigorous multicentre studies are now needed to assess the generalizability of this approach.

Reminder: DC’s provide 94% of all manipulation performed. RAND.

Spinal manipulation effective for low back pain. Strickland. The Journal of family practice.; 2003

Dec;52(12) p925 - 929

Spinal manipulation, usual care with analgesics, physical therapy, exercises, and "back school" all provide similar results when used for treatment of both acute and chronic low back pain. Clinicians may wish to treat patients with low back pain themselves or refer them for chiropractic care, physical therapy, or back schools. This decision should be based on patient preferences after reviewing relative risks and benefits.

A recent systematic review of alternative therapies for low back pain reported similar effects from spinal manipulation and massage therapy. The effectiveness of acupuncture in the management of low back pain remains unclear.

Bronfort et al. Trunk Exercise Combined with Spinal Manipulation or NSAID Therapy for Chronic Low Back Pain:

A Randomized, Observer-Blinded Trial. JMPT. Vol. 19. Number 9. Nov/Dec. 1996.

Results: There seemed to be a sustained reduction in medication use at the 1-year follow-up in the SMT/TSE group.

Continuance of exercise during the follow-up year, regardless of type, was associated with a better outcome.

Conclusion: For the management of CLBP, trunk exercise in combination with SMT or NSAID therapy seemed to be beneficial and worthwhile.

Cox et al. Distraction Manipulation Reduction of an L5-S1 Disk Herniation . Journal of Manipulative and

Physiological Therapeutics Volume 16, Number 5, June, 1993

Conclusions: Chiropractic distraction manipulation is an effective treatment of lumbar disk herniation, if the chiropractor is observant during its administration for patient tolerance to manipulation under distraction and any signs of neurological deficit demanding other types of care.

BenEliyahu et al. Magnetic Resonance Imaging and Clinical Follow-up: Study of 27 Patients Receiving Chiropractic Care for

Cervical and Lumbar Disc Herniations. JMPT. Volume 19, Number 9, November/December, 1996

Results: Clinically, 80% of the patients studied had a good clinical outcome with post-care visual analog scores under 2 and resolution of abnormal clinical examination findings. Anatomically, after repeat MRI scans, 63% of the patients studied revealed a reduced size or completely resorbed disc herniation. There was a statistically significant association (p, .005) between the clinical and MRI follow-up results. Seventy-eight percent of the patients were able to return to work in their pre-disability occupations.

Conclusion: This prospective case series suggest that chiropractic care may be a safe and helpful modality for the treatment of cervical and lumbar disc herniations. A random, controlled, clinical trial is called for to further substantiate the role of chiropractic care for the non-operative clinical management of intervertebral disc herniation.

Cassidy et al. Side Posture Manipulation for Lumbar Intervertebral Disk Herniation. JMPT. Volume 16,

Number 2, February, 1993

Conclusions: The treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective.

Cassidy et al. Cont’d

Points of Interest: Normal disks withstood an average of 22.6 degrees of rotation before failure,

while the degenerated disks withstood an average of 14.3 degrees. When disk failure occurred, it presented as peripheral annular tears and not

herniation or prolapse. Posterior facet joints of the intact lumbar motion segment allow only a small

range of rotation at the lower levels. Therefore torsional failure of the lumbar disk first requires fracture of the

posterior joints, which can then result in peripheral annular tears. Bottom line: The bony architecture of the lumbar spine prevents excess

rotation that would have damaged the peripheral annular fibers. Therefore it remains unlikely that side posture spinal manipulation would damage a disk.

Waagen et al. Short term trial of chiropractic adjustments for the relief of chronic low back pain. Manual Medicine (1986) 2:63-67

After two weeks of treatments the experimental patients as a group exhibited significant overall pain relief (+2.3), whereas improvement of patients in the control group was not significant (+0.6).

Troyanovich et al. JMPT. Vol. 21, Number 1, January 1998.

Structural Rehabilitation of the Spine and Posture: Rationale for Treatment Beyond the Resolution of Symptoms.

Conclusion: Because mechanical loading of the neuromusculoskeletal tissues plays a vital role in influencing proper growth and repair, chiropractic rehabilitative care should focus on the normalization/minimization of aberrant stresses and strains acting on spinal tissues.

Manipulation alone cannot restore body postures or improve an altered sagittal spinal curve. Therefore, postural chiropractic adjustments, active exercises and stretches, resting spinal blocking procedures, extension traction, and ergonomic education are deemed necessary for maximal spinal rehabilitation.

Wiberg et al. The Short-term Effect of Spinal Manipulation in the

Treatment of Infantile Colic: A randomized Controlled Clinical Trial with a Blinded Observer. Journal of Manipulative and

Physiological Therapeutics Volume 22, Number 8, October 1999.

Results: By trial days 4 to 7, hours of crying were reduced by 1 hour in the dimethicone group compared with 2.4 hours in the manipulation group (P=.04). On days 8 through 11, crying was reduced by 1 hour for the dimethicone group, whereas crying in the manipulation group was reduced by 2.7 hours (P=.004). From trial day 5 onward the manipulation group did significantly better than the dimethicone group.

Conclusion: Spinal manipulation is effective in relieving infantile colic.

Reed et al. Chiropractic Management of Primary Nocturnal Enuresis.

JMPT, Volume 17, Number 9, November/December, 1994

Results: The post-treatment mean wet night frequency of 7.6 nights/2 wk for the treatment group was significantly less than its baseline mean wet night frequency of 9.1 nights/2 wk (p = 0.05). For the control group, there was practically no change (12.1 to 12.2 nights/2 wk) in the mean wet night frequency from the baseline to the post-treatment………

Twenty-five percent of the treatment-group children had 50% or more reduction in the wet night frequency from baseline to post-treatment while none among the control group had such reduction.

Conclusion: Results of the present study strongly suggest the effectiveness of chiropractic treatment for primary nocturnal enuresis.

Croft et al. Outcome of low back pain in general practice: a prospective study. BMJ Volume 316; 2 May 1998.

Conclusions: The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months.

However most will still be experiencing low back pain and related disability one year after

consultation.

Shekelle et al. Congruence between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and

Appropriateness Criteria in North America. Annals of Internal Medicine, 1 July 1998. 129:9-17.

Conclusions: The proportion of chiropractic spinalmanipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care.

However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased.

Mooney. Why Exercise for Low Back Pain? Activity Reverses Biochemical Changes Caused by Injury. The Journal of Musculoskeletal Medicine. October 1995.

Selected statements:

There is no evidence that a diagnosis-or even the presence or absence of a neurologic deficit-can predict the duration or outcome of a back problem.

Concerning exercise and AHCPR Guidelines: The guidelines are nonspecific and contain no rationale.

In all other soft-tissue injuries, progressive physical activity evacuates extracellular, extravascular fluid. This justifies the recommendation of early mobility for injured tissues. The early motion should be gentle but progressive, with the expectation that gradually increasing stresses will facilitate healing.

Koes, et al. A Randomized Clinical Trial of Manual Therapy and Physiotherapy for Persistent Back and Neck Complaints:

Subgroup Analysis and Relationship Between Outcome Measures. JMPT; 16:211-219; 1993.

Results: Greater improvement in the main complaint was associated with manual therapy than with physiotherapy for patients with back problems of 1 year’s duration or longer. For patients younger than age 40 years, improvement was also greater with manual therapy than with physiotherapy.

Conclusion: Manual therapy appears to yield better results than physiotherapy in patients with chronic conditions, and in patients younger than age 40 years.

Davis. Chronic Cervical Spine Pain Treated With Manipulation Under Anesthesia.

Journal of the Neuromusculoskeletal System. Fall 1996 Vol. 4, No. 3.

The results suggest that manipulation under anesthesia may be beneficial in patients with chronic pain that effects work or activities of daily living and in patients with cervical segmental dysfunction, fibrosis, myofascitis, or cervicogenic headaches.

Licciardone et al. Osteopathic Manipulative Treatment for Chronic Low Back Pain. Spine. 2003;28:1355-1362.

Conclusion: Osteopathic Manipulative Treatment (OMT) and sham manipulation, both appear to provide some benefits when used in addition to usual care for the treatment of chronic nonspecific LBP.

It remains unclear whether the benefits of OMT can be attributed to the manipulative techniques themselves or whether they are related to other aspects of OMT, such as range of motion activities or time spent interacting with the patient, which may represent placebo effects.

Scholten-Peeters, et al. Clinical Practice Guideline for the Physiotherapy of Patients with Whiplash-Associated Disorders.

Spine Vol. 27, Number 4, pp. 412-422, 2002.

Conclusions: Scientific evidence for the diagnosis and physiotherapeutic management of whiplash is sparse; therefore, consensus is used in different parts of the guideline.

The guideline reflects the current state of knowledge of the effective and appropriate physiotherapy in whiplash patients. More and better research is necessary to validate this guideline in the future.

Vernon et al. Spinal Manipulation and Headaches of Cervical Origin.

Journal of Manipulative and Physiological Therapeutics, Volume 12,

Number 6, December, 1989.

ABSTRACT: The role of the cervical spine in headache remains controversial. Often confused as tension or common migraine headache, headaches arising from the neck pose a diagnostic and therapeutic challenge.

Recent writers addressing this issue, including Bogduk (2-4), Edmeads (50, Farina et al. (6) and Sjaastad and his colleagues (7-9), have added much to our current understanding. However, even these authors appear to have included only a small portion of the supportive literature in their reports, leaving a diminished sense of the historical attention and the current clinical importance of this category of headaches.

Quon et al. Lumbar Intervertebral Disc Herniation: Treatment byRotational Manipulation. Journal of Manipulative and

PhysiologicalTherapeutics, Volume 12, Number 3, June, 1989.

Although caution must be exercised in interpreting single case studies, this paper describes a patient who presented with an L4-L5 disc herniation. The size of the lesion revealed by CT examination was so great that one would not expect a favorable response to conservative measures.

However, the patient was rendered pain-free within 2 weeks by daily manipulations.

The enormous size of the disc herniation did not seem to influence the clinical result. Had a trial of conservative therapy not been prescribed, he may well have undergone an unnecessary surgical procedure. Furthermore, a repeat CT scan, 4 months after the initial episode, showed no change in the size or position of the disc herniation.

Maigne et al. Highlighting of Intervertebral Movements and Variations of Intradiskal Pressure During Lumbar Spine

Manipulation: A Feasability Study. JMPT Vol. 23, Number 8, October 2000.

Even though this study was a limited one on cadavers, it has important implications:

- Spinal manipulation is capable of lowering intradiscal pressure, a phenomenon thought to improve related symptoms.

- This pressure change theory is consistent with outcome studies that have examined manipulation in the treatment of symptomatic disc herniation.

- Vertebral movement can be demonstrated during manipulation.

- The effect of this movement is to redistribute or normalize intradiscal pressure, not to result in a different resting position of the vertebra.

- Future work on the motion/position aspect of manipulation should look at temporary positional changes during the manipulation, not before and after position.

Maigne et al. Cont’d

Conclusion: Lumbar spinal manipulations have a biomechanical effect on the IVD, producing a brief but marked change in intradiskal pressure. This effect, which differs slightly with the different types of manipulation studied, is the consequence of movements of the adjacent vertebrae.

Whiplash: Research and Case Management

Presented by: Ronald J. Farabaugh, D.C.

Principle #1:

The three pillars of LOSRIC:

Accident reconstruction: weak science.

Body kinematics: strong science. Risk Factors: strong science.

Documentation

Principle #2:

The threshold of injury is approximately 5 mph delta V.

However, every human being is unique.

The threshold of vehicle damage is 2-3x that of injury potential.

Principle #3:

The use of daily activities to describe the forces experienced in a traffic collision is invalid.

Principle #4:

Property damage is not a reliableindicator of injury potential.

Principle #5:

Minimal vehicle damage cannot be used

to determine that a collision was lowspeed or low impact.

Principle #6:

Bumper standards pertain to minimum change in velocity, not maximum.

Principle #7:

Acceleration of the head is much more important than the acceleration of the vehicle, delta V, speed, or vehicle damage, when determining injury potential.

Accident reconstruction is a very inexact science.

Principle #8:

Accident reconstruction based on photographs is woefully inadequate.

Principle #9:

Injuries and fatalities occur in collisions with little, or no, property damage.

Principle #10:

It is imperative for the attorneys to set up the Chiropractic physician as the expert.

It is imperative for the attorneys to develop the proper foundation for the soft tissue case!

It is imperative for the DC to document well, treat effectively, and keep costs reasonable.

Principle #11:Paradoxic Relationship

Due to the elastic nature of LOSRIC, the apparent paradox of the inverse relationship between property damage and injury potential is a real one.

Previous attempts to correlate these factors have failed to show a relationship

Low Speed Rear Impact Collision

A review of miscellaneous literature….

French Study: Foret-Bruno et al

8000 + crashes and 15,000 occupants 27% of occupants in rear-end collisions

sustained cervical injuries, compared to 10% and 8% in frontal and side impacts.

7% of all crashes = rear end Women injured in 42 % and men 21% Delta V below 9.3 mph = injury rate 36% Delta V above 9.3 mph = only 20%

Thomas et al

The largest clustering of rear impact crashes is between a delta V of 9.3 and 12.4 mph,

About 70% occur at a delta V of less than 15.5 mph.

American Studies

States et al: Reported an injury risk of 38% in consecutive series of 691 rear impacts.

Kihlberg: 26% of exposed motorists were injured when seat backs did not fail; 19% when failure occurs.

American Studies

Chapline et al: Largest category of injury crashes = no

damage In these 38% of females and 19% of

males had symptoms. When damage rated as “minor”, these

percentages were 54% and 34%.

Japanese Studies

Ono and Kanno: 50% of car crashes result in neck injury, increasing every year.

95% of crash injuries are scaled AIS I Of these 80% concentrated in the neck 95% of these neck injuries are CAD

injuries 15-20% of victims have prolonged

symptoms

Australian Study: Dolinis

Two risk factors identified as independent risk factors for injury.

1. A history of prior neck injury (4.5x more likely to be injured)

2. Female gender (2x more likely to be injured than a man)

U.S. Study

Records from 11 police agencies 1995-1997

Risk: 45% of females S/S of neck pain 28% of males drivers 43% of females and 31% males also had

low back pain.

Overall Risk Estimate

Based on studies and data, Croft estimates that between 30% and 60% of real world car occupants exposed to LOSRIC of > 2.5 mph delta V sustain some degree of injury ranging from very short lived to disabling.

CAD Related Chronic Pain Rear impact injuries carry a worse

prognosis than either side or frontal impact injuries.

On average 30-50% of the patients in these studies had not recovered completely at follow-up—about 10% rating their problem as disabling or severe.

Latest Data

A surprising 45% of the American population with chronic neck pain attributes it to a MVC. (6.2% of population)

Low Speed Crashes Most modern vehicles can withstand

crash speeds of up to 8-10 mph, and often higher, without sustaining appreciable damage.

Resulting delta V = 6-5 to 8 mph. Threshold for soft tissue injury in

the neck of a healthy adult male is a delta V of 2.5 to 5 mph.

Vehicle can withstand crash velocities nearly 2x the injury threshold.

Nikolai Bogduk, MD, Department of Anatomy and Musculoskeletal Medicine, University of Newcastle, Newcastle Bone and Joint Institute,

Point of View

“Whiplash-associated disorders have lacked credibility. Opponents in the past have cited lack of evidence of a lesion in patients with symptoms, lack of successful treatment, and lack of a biomechanical link between symptoms and the alleged injury.”

Bogduk (cont’d)

“The study of Kaneoka et al now fills a critical gap in the story of cervical facet pain. It provides the missing biomechanical link. Theirs is the most significant advance in the biomechanics of whiplash since the pioneering studies of Severy et al in 1955.”

Bogduk (cont’d)

“The critical observation is that in whiplash the lower cervical segments undergo sagittal rotation about an abnormally high instantaneous axis of rotation. As a result, there is no translation; there is only rotation. As the vertebra spins, its anterior elements separate from, while the posterior elements crunch into, the vertebra below.

This mechanism predicts that the resultant lesions should be tears of the anterior annulus and fractures of the zygapophysial joints or contusions of their meniscoids. These are the very lesions seen at postmortem.”

(Clearly, this is an important article. Nikolai Bogduk believes that this is the most important biomechanical research on whiplash in 44 years.)

Pettersson, K; Hildingsson, C; Toolanen, G; Fagerlund, M; Bjornebrink, J Disc Pathology After Whiplash Injury: A Prospective Magnetic Resonance Imaging and Clinical Investigation. Spine 1997 Feb. 22 (3) pp. 283-8

ABSTRACT: Study Design: This study was used to evaluate the relationship between magnetic resonance imaging finding and clinical findings after whiplash injury.

Objectives: To identify initial soft-tissue damage after whiplash injury, the development of disc pathology, and the relationship of disc pathology to clinical findings.

Disc Pathology After Whiplash Injury: A Prospective Magnetic Resonance Imaging and Clinical Investigation. Spine 1997 Feb. 22 (3) pp. 283-8

Results: The authors found 13 patients (33%) with disc herniations with medullary (six cases) or dura (seven cases) impingement over the 2-year follow-up period. At the follow-up examination all patients with medullary impingement had persistent or increased symptoms, and three of 27 patients (11%) with no or slight changes on magnetic resonance imaging had persistent symptoms. No ligament injuries were diagnosed.

Disc Pathology After Whiplash Injury: A Prospective Magnetic Resonance Imaging and Clinical Investigation. Spine 1997 Feb. 22 (3) pp. 283-8

Conclusion: Although disc pathology seems to be one contributing factor in the development of chronic symptoms after whiplash injury, it may be unnecessary to examine these patients in the acute phase with magnetic resonance imaging; correlating initial symptoms and signs to magnetic resonance imaging findings is difficult because of the relatively high proportion of false-positive results. Magnetic resonance imaging is indicated later in the course of treatment in patients with persistent arm pain, neurologic deficits, or clinical signs of nerve root compression to diagnose disc herniations requiring surgery.

Lord, in Spine: State of the Art Reviews: Cervical Flexion-Extension/Whiplash Injuries, Hanley and Belfus, Sept. 1993, p. 362

“In studies in which experimental animals or cadavers have been subjected to whiplash motion, injuries to the cervical zygapophyseal joints are among the most common and most consistent lesion produced. The lesions include tears of the joint capsules, intraarticular hemorrhage and impaction fractures.”

“Postmortem studies of victims of MVAs reveal that zygapophyseal joint injuries are common, being present in 86% of necks examined. The lesions include capsular tears, ruptures of meniscoids, intraarticual hemorrhage, and small fractures.”

Woodward, Cook, et al. (1996). “Chiropractic Treatment of Chronic Whiplash.” Injury 27 (9): 643-5

“The accumulated literature suggests that 43% of patients will suffer long-term symptoms following ‘whiplash’ injury. If patients are still symptomatic after 3 months then there is almost a 90% chance that they will remain so. No conventional treatment has proven to be effective in these established chronic cases.”

“The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic ‘whiplash’ injury.”

Following the chiropractic treatment, 93% of the

patients had improved.

A Symptomatic Classification of Whiplash Injury and the Implications for Treatment. Khan, Cook, Gargan, and Bannister, University Department of Orthopaedic Surgery, Bristol, UK. The Journal of Orthopaedic Medicine 21[1]1999.

Objective: To determine which patients with chronic whiplash will benefit from chiropractic treatment.

93 patients, 68 female. Conclusion: Whiplash injuries are common. Chiropractic is the only

proven effective treatment in chronic cases. Our study enables patients to be classified at initial assessment in order to target those patients who will benefit from such treatment.

57% make full recovery. Resolution of symptoms will have occurred within 2 years of injury. 8% will remain disabled by their symptoms.

Khan, Cook, Gargan, and Bannister, University Department of Orthopaedic Surgery, Bristol, UK. The Journal of Orthopaedic

Medicine 21[1]1999. (cont’d)

Non-responders do exist. Defining characteristics include: full

range of motion in association with neck pain, bizarre symptoms, female sex and ongoing litigation.

McNab, found that symptoms persist in 45% of patients two

years after settlement of litigation. Watkinson et al, found significantly higher frequency of

degenerative changes on radiological examination of patients who have sustained soft tissue injuries than in a controlled population, place more emphasis on the organic basis of symptoms.

Khan, Cook, Gargan, and Bannister, University Department of Orthopaedic Surgery, Bristol, UK. The Journal of Orthopaedic

Medicine 21[1]1999. (cont’d)

Whilst other studies have suggested that neurological signs (Group 2) have a poorer prognosis, this was not the case amongst our patients. Indeed, such patients showed the greatest improvement in disability grade.

Group 1: Neck pain, restricted ROM, no

neurological deficit. Group 2: Neurological symptoms, neck pain,

restricted motion. Group 3: Severe neck pain, full ROM, no

neurological symptoms.

Results: Organic pain causes psychological stress, not the result of it!

Vert Mooney, MD, Spine, 12(8), 1987 754-759, Presedential address of the International Society for the Study of the Lumbar Spine. May 29-June 2, 1986 Dallas, TX.

“Physical activity seems to be a source of increase of endorphins”, which greatly reduce the perception and neurotransmission of painful stimuli.

In adulthood, mucopolysaccharide production is switched to chondroitin sulfate B and keratosulfate production, both of which bind less water which adversely affects primarily the nucleus.

“Mechanical activity has a great deal to do with the exchange of water and oxygen concentration in the disc.”

“The fluid content of the disc can be changed by mechanical

activity, and the fluid content is largely bound to the proteoglycans, especially of the nucleus.”

Vert Mooney, MD, Spine, 12(8), 1987 754-759, Presedential address of the International Society for the Study of the Lumbar Spine. May 29-June 2, 1986 Dallas, TX. (cont’d)

“In summary, what is the answer to the question of where is the pain coming from in the chronic low-back pain patient? I believe its source, ultimately, is in the disc. Basic studies and clinical experience suggest that mechanical therapy is the most rational approach to relief of this painful condition.”

“Prolonged rest and passive physical therapy modalities no longer have a place in the treatment of the chronic problem.”

Chronic Cervical Zygapophysial Joint Pain After Whiplash: A Placebo-Controlled Prevalence Study. Derby MD, Spine 1996;21:1744,1745 (August 1, 1999)

“This study reveals a single symptomatic segment in 26 of 31 patients completing the study in which the C2-3 joint is the most common cause of upper cervical pain referral and headache and the C5-6 joint is the most common source of lower cervical axial pain and referred arm pain.”

“Although muscle pain and tissue hyperalgesia may be an integral part of chronic cervical pain after whiplash injuries, such pain may be better explained as a secondary reflex

reaction to injury of segmental supporting structures.”

Acute Injuries to Cervical Joints. An Autopsy study of Neck Sprain. Taylor, Twomey, Spine 1993, July;18(9):1115-22

A comparative study of cervical spines from 16 subjects who died of major trauma and 16 control subjects who died of natural causes, showed clefts in the cartilage plates of the intervertebral discs in 15 of 16 spines from the trauma victims.

It is suggested that disc “rim lesions” could cause the pain experienced by patients with neck sprain.

Acute Injuries to Cervical Joints. An Autopsy study of Neck Sprain. Taylor, Twomey, Spine 1993, July;18(9):1115-22 (cont’d)

“Neck sprain without fracture poses a difficult diagnostic problem because soft-tissue injuries are not usually demonstrable by using standard radiography. This adds to a patient’s distress, because there is no objective display of an injury to account for the pain. Such patients are often regarded as having a psychosomatic illness with little organic basis.”

“A substantial proportion of neck sprains remain symptomatic for

more than 2 years with little or no evidence of organic disease.”

“There is good evidence that disc splits (rim lesions) near the endplate

persist for 6-18 months or more without healing and their presence is associated with early disc degeneration.”

“The clefts are only visible on extension films and the pain

distribution suggests that the discs involved may be responsible for the symptoms.”

Acute Injuries to Cervical Joints. An Autopsy study of Neck Sprain. Taylor, Twomey, Spine 1993, July;18(9):1115-22 (cont’d)

Conclusion: “Clinical studies show that rim lesions and traumatic

herniations are demonstrable in survivors of motor vehicle trauma, in the absence of vertebral fractures. Such lesions would cause acute pain at the time of the injury and would be likely to progress to early disc degeneration, with extension of the clefts and vascularization within the clefts.”

“The disc may degenerate because the clefts separate the

center of the disc from its source of nutrition in the vessels of the vertebral marrow and the outer annulus. These degenerative changes would also be likely to contribute to chronic pain and dysfunction of the cervical spine.”

Vehicle Damage vs. Injury Potential Article

Is there a valid correlation between vehicle damage and the probability

of injury?

Answer: NO!!

Callier, 1981

“A collision, when the offending car moves at a rate as slow as seven (7) mph can cause severe tissue damage and injury.

Taken from Croft seminars: (Module 4, Section two-Cervical Spine References)

Mcnab, 1982

3.7 to 5 mph rear-end impact, which subjects the cervical spine to as much as 4.5 G-forces, constitutes the threshold for mild cervical strain injury.

Mcnab, 1982

“The amount of damage sustained by the car bears little relationship to the force applied.”

The Spine, Saudners, 1982, p. 648

Ameis 1986: Canadian Family Physician, September, 1986

“Each accident must be analyzed in its own right. Auto speed and damage are not reliable parameters.”

Cervical Whiplash: Considerations in the Rehabilitation of Cervical Myofascial Injury.

Hirsh, et al 1988

In an 8-mph rear-end collision, a 2 G-force of acceleration of the vehicle may result in a 5G-force acceleration of the occiput and head. “The amount of damage to the automobile may bear little relationship to the forces applied to the cervical spine and to the injury sustained by the cervical spine.” Whiplash Syndrome, Orthopedic Clinics of North America, October 1988. p. 791.

Navin, Macnab, et al. 1989

“The experimental results indicate that some vehicles can withstand a reasonably high speed impact without significant structural damage. The resulting occupant motions….. dangerous acceleration up to speeds greater than that of the vehicle.” An Investigation into Vehicle and Occupant Response Subjected to Low-Speed Rear Impacts.

Emori, 1990

“…neck extension becomes almost 60 degrees which is a potential danger limit of whiplash, at collision speed as low as 2.5 km/h.”

SAE, Feb, 1990, p.108.

McConnell, et al 1993

The crash tests study concluded that Delta Vs of 5 mph was the probable threshold for cervical injury.

Smith, J. 1993“The absence or presence of vehicle damage is not a reliable indicator of injury potential in rear impacts. Based upon the principle of conservation of energy, any energy which does not go into damaging the vehicle must be converted into kinetic energy, the source of injuries.”

“The Physics, Biomechanics, and Statistics of Automobile Rear Impact Collisions.”

Trial Talk: 10-14.

Smith, J. 1993 (cont’d)

“Since kinetic energy is the source of injury to vehicle occupants, it is obvious that the bumper standards have the effect of reducing vehicle damage while increasing the probability of personal injury in rear end impacts.”

Ono, et al 1997At impact speeds of 2.5, 3.7, and 5 mph C5-6 compressive loading and bending movement was found along with sudden extension causing compression in the facet joint, rather than gliding. There was more injurious compression in the facet joints during extension even before the head hits/strikes that seat’s head restraint.

Brault, et al 1998

Recent crash testing produced injuries in 29% and 38% in 2.5 and 5 mph, respectively in Delta Vs, low speed rear impact collisions.

Significant Facts

There is no relevant science that equates injury potential to vehicle damage.

No accident reconstructionist can predict an individual’s INJURY THRESHOLD.

The presence of an injury is best determined by the examining physician and is based on the CORRELATION between history, examination, x-ray and other diagnostic tests.

No MD, DC, DO or other medical professional was ever educated to consult an accident reconstructionist to determine the presence or absence of injury.

Significant Facts

Strong research exists correlating RISK FACTORS and injury potential.

Strong research exists demonstrating that chronic pain is often the result of Low Speed Rear Impact Collisions (LOSRIC).

The “6-8 week natural healing time” is a myth that should forever be abandoned.

“No Crash-No Cash” is a concept that should be forever abandoned.

Review of Risk Factors

Acute Risk Factors: 18

Late or “Chronic” Risk Factors: 20

Sneeze Article

“The “G” forces of an ordinary sneeze is greater than that experienced in a LOSRIC, yet people sneeze everyday and don’t get hurt. How do you explain that?”

Sneeze AnalogyAllen; Iain Weir-Jones; P Eng, et al. (1994).

“Acceleration perturbations of daily living; A comparison to “whiplash’”. Spine: 1994 19(11): 1285-92.

8 healthy volunteers subjected them to daily activities, none of

which caused any hint of injury.

Allen Paper-ADL1. Looking to the left,2. Unexpected startle by discharge of a starter pistol behind the

subject,3. Standing up suddenly from a kitchen chair,4. Passively dropping the head backwards as if falling asleep from a

seated position,5. Routine sitting into a kitchen chair from standing,6. Sneeze from sniffing pepper into nostrils,7. A simulated cough,8. An unexpected bump against the left shoulder as would occur in

a crowd,9. An anticipated hardy slap on the back greeting,10. Kicked hard from behind while sitting in a wheeled office chair,11. Hopping off a 20 cm (8 inch) step and land on both feet,12. Plopping backwards into a low-backed office chair.

Response to Allen Paper1. Artifact movement 2. No two persons are alike, and no two crashes

are alike. 3. The forces applied to the body are not the

same for different individuals who appear to perform similarly.

4. This study was limited in the number of volunteers. The full spectrum of the population, with a presumed wide variance in physical and psychological profiles, was not tested.

Response to Allen Paper5. The authors did not consider the influence of

“awareness factor” during their two highest peak average measured accelerations of 10.1 G (plop in chair) and 8.1 G (hop off step).

6. The authors did not take into account other well researched risk factors associated with LOSRIC, and compare them to common activities like a sneeze.

7. The applied forces in a LOSRIC are external. The force generated during a sneeze is internal.

Response to Allen Paper8. A short list of risk factors important to consider

in LOSRICs that were not considered by the authors include:

Poor head geometry (1, 2) Rear impact versus frontal impact collision (3, 4, 5, 6) Front versus rear seat position (7) Out of position occupant (8, 9) Height, mass, or age of patient (10, 11, 12, 13) Injury threshold of patient (14) Position of head rest (15) Mass of bullet vehicle versus mass of target vehicle (16) Non-failure of seat back and influence of head rest (17) Pre-existing conditions (18)

Litigation Neurosis: Is it real?

See article

The Neurological Basis for Chronic Pain

Two important studies…

Spine 2004; 29(2):182-188 Characterization of Acute Whiplash-Associated Disorders. Sterling, PhD, et al.

Conclusions.

Acute whiplash subjects with higher levels of pain and disability were distinguished by sensory hypersensitivity to a variety of stimuli, suggestive of central nervous system sensitization occurring soon after injury.

These responses occurred independently of psychological distress. These findings may be important for the differential diagnosis of acute whiplash injury and could be one reason why those with higher initial pain and disability demonstrate a poorer outcome.

Evidence for spinal cord hypersensitivity in chronic pain after whiplash injury and in fibromyalgia. Banic B, et al. Pain; 2004 Jan;107(1-2) p7 - 15

Patients with chronic pain after whiplash injury and fibromyalgia patients display exaggerated pain after sensory stimulation. Because evident tissue damage is usually lacking, this exaggerated pain perception could be explained by hyperexcitability of the central nervous system.

We provide evidence for spinal cord hyperexcitability in patients with chronic pain after whiplash injury and in fibromyalgia patients. This can cause exaggerated pain following low intensity nociceptive or innocuous peripheral stimulation. Spinal hypersensitivity may explain, at least in part, pain in the absence of detectable tissue damage.

Lecture Summary

The biomechanics of a motor vehicle accident (whiplash) may cause injury to the disc and facet joints; therefore these structures are the most probable source for irritation causing chronic whiplash pain.

An appreciable amount of chronic pain afferents synapse in the limbic cortex, causing an abnormal psychological profile. The abnormal profile can only be helped by successful treatment of the chronic spinal pain.

The best treatment for the disc and facet soft-tissue

injuries are early, persistent, controlled motion of the injured tissues.

Lecture Summary(cont’d)

Self directed controlled motion of injured extremity joints is possible because the muscles that cross those joints are primarily under the control of the voluntary motor cortex.

Self directed controlled motion of injured spinal joints is NOT possible because the muscles that move the individual segments are not under the primary control of the voluntary motor cortex, but rather controlled primarily through the vestibular spinal tracts (descending medial longitudinal fasciculus), which is non-voluntary.

Injury to the spinal discs and facet joints causes a non-

voluntary contraction of the non-voluntary segmental movers (primarily the multifidus) at the level of injury and for several segments above and below the level of injury.


This non-voluntary contraction locks the motor unit into a certain parameter of position and reduced movement.

This reduction of movement:

Opens the pain gait. Impairs the “disc pump” which:

Accelerates disc degeneration Makes the disc more acidic which increases the firing of

disc nocireceptors. Alters the quality of the synovial fluid which:

Reduces its nutrient value, which accelerates posterior joint arthrosis and pain.


Chiropractic Adjustments: Segmentally fire high threshold mechanoreceptors that di-

synaptically inhibit tone in the segmental movers, which improves segmental spinal motion and position.

This controlled movement allows the injured tissues to heal better and quicker.

This controlled movement improves the fluid exchanges of the

disc and synovial fluid, which reduces pain and joint degeneration.

This controlled movement initiates a neurological sequence of

events that causes pain inhibition (closes the pain gait).

Recurrent Nature of Pain


Frank, MD. British Medical Journal 1993; April 3:901-9.

Review of a study in which 373 patients less than 40 years old, with their first onset of back pain, are followed for 10 years. 89% had recurrences and only 33% had no lost time form work from future back problems. Strategies to manage low back pain must be long term and preventive.

Waddel, MD. JMPT 1995;18(9):590-596

“Traditional teaching is that 90% of LBP attacks recover within six weeks, but recent natural history studies suggest that this is overly optimistic and over-emphasizes RTW. It now seems that 50% of attacks settle within 4 weeks, but 15-20% have some symptoms for at least 1 year. 70% of patients who have acute back pain will suffer 3 or more recurrences. 20% will continue to have some back symptoms over long periods of their lives.”

Jayson, MD, FRCP. Spine 1997;22(10):1053-1056.

“At 3 months, only approximately 27% were completely better, 28% improved, 30% had no change, and 14% were worse or much worse. It may well be that in the many studies of acute low back pain, there has been very carefully selected clinical material so that only those patients with acute pain of recent onset and no other confounding factors were included, with the result that these studies do not reflect what actually happens in practice.”

Saal JA, MD. Spine 1997;22(14):1545-1552

“The major premise used in the managed care system for the primary care of LBP is based upon the assumption that 90% of patients improve in 6-12 weeks. However, a natural history study by Von Korff found that approximately 60% will recur. In a study of BP in primary care, Von Korff and Saunders found that 60% to 75% improve within the first month, 33% report intermittent or persistent pain at one year, and 20% of patients describe substantial limitations at one year. The premise for the AHCPR guidelines and Managed Care for back pain is not valid. [Emphasis added.]”

Waddell, MD. The Chiropractic Report 1993; July:1-6

“Traditional medical treatment according to the disease model has failed. Bed Rest: should die as soon as it can. Avoid bed rest if possible. Physical Therapy: There is no adequate evidence of effectiveness. Spinal manipulation: one of two treatments of proven value. The last 10 years produced a lot of solid scientific evidence to support the value of manipulation. Early active exercise: Is the other treatment supported by good evidence”.

“Relief of pain and restoration of function must occur at the

same time. Failure to restore function means any pain relief will be temporary and reinforces chronic pain. In the management of occupational back pain, the chiropractic profession is leading the way. The problem is weakness and loss of function, not disease.”

Kuritzky, MD. Physician and Sports Medicine 1997;25(1):56-64

“97% of BP seen by primary care physicians is mechanical in origin. There is something wrong with the muscles, ligaments, or connective tissues. Most patients with low back pain do not have ruptured discs, but it is notorious, partly because imaging studies dramatically overestimate the frequency.”

Eisenberg, MD. Annals of Internal Medicine 1997;127(1):61-69.

“More than 70% of patients who used alternative therapy never mentioned it to their MDs.”

Like the British study, this research demonstrated that even though patients no longer consult their medical provider, it does not mean that the problem has resolved. The myth of "natural healing time" must be reconsidered given the extended nature of pain and the fact that patients continue to seek out the advice of other providers when the primary care giver does not successfully treat the condition.

Cowley. Going Mainstream. Newsweek 1995;June 26:56-57.

“There is a growing awareness among health insurers that patients seeking unconventional care represent a huge potential market and that alternative care does not cost the insurer very much. As one managed care executive said, "3 visits to a DC are a lot less expensive than an MRI or back surgery.”

Concerning chronic pain, it makes a lot more sense to treat a

patient with a periodic chiropractic adjustment than to allow the condition to degenerate to the point of requiring dangerous medication (impairing function, thus productivity at work) or surgery. Many times, daily exercise and self-management are not enough to control a chronic back problem.


“The pathology model cannot explain back pain or disability. It is not possible to look at pathology and determine the symptoms a patient may be suffering. It also is not possible to look at a patient with back pain with no neurologic deficits and determine the nature of the pathology. About 30% of asymptomatic subjects show abnormalities in the lumbar spine by myelogram, CT and MRI. There is a large percent of symptomatic patients with severe complaints in whom testing fails to reveal any structural lesion.”

A study by Jensen, which appeared in the New England Journal of Medicine 1994;331(2)July 14:69-73, produced similar results

Summary…

As a result of these and other studies there has been a shift in thinking away from the traditional "symptom" approach, towards contemporary thinking of "function". For many patients with recurrent back pain, staying functional is a "process" more so than a "result" based on a predictable healing time or average.

Jonsson MD. Journal of Spinal Disorders 1991;4(3):251-263.

Study of cervical spine of 22 patients who died of fatal skull fractures in MVAs. X-rays were evaluated by an expert orthopedic radiologist. Only 1 of 10 gross ligamentous disruptions were even suspected on X-rays. 198 lesions were missed. Multilevel soft-tissue injuries were common. Very few injuries were detected or even suspected on radiograms. The vast majority was not recognized. Plain radiograms cannot detect soft-tissue lesions unless they are associated with vertebral body malalignment. Conclusions: the majority of lesions are soft-tissue injuries. Plain radiograms show virtually no soft-tissue lesions.

Side note:As a result of these types of studies, it has become apparent that a

thorough physical examination is more important, in combination with functional assessments, than traditional diagnostic evaluations to determine the presence or absence of soft-tissue injuries.

Liebenson, DC, Oslance. Rehabilitation of the Spine. Williams and Wilkins, Baltimore. 1996:73.

“80% of patients have no identifiable structural pathology and require treatment based on evaluation of functional deficits. In the majority of cases, patients have soft tissue injuries and functional changes are the only objective findings on which to base treatment and judge progress. Outcomes assessments including objective functional tests give the third party payers, patients and doctors a way to measure progress over time, and evaluate the prescribed treatment. Overemphasis on treatment of structural pathology results in a failure to identify or focus on functional loses and work demands. [Emphasis added.]”

The Recurrent Nature of Back Pain

In other words, the reduction of pain alone is not an accurate indicator of the need for additional treatment. There has been a shift away from treatment based only on pain relief to treatment based on the desire to improve function and return to the patient to the original form of employment. The improvement of function in a person with a "complicated" soft tissue injury in combination with a physically demanding job is an ongoing process more so than an endpoint based on pain reduction alone.


“Common acute back pain is due to chemical abnormalities created by soft tissue tear. The tear represents a mechanical disruption, which is usually microscopic. X-rays demonstrate no changes before and after an acute back injury.”

Again, function is more important in the evaluation and treatment of

back pain than structural pathology. A "negative" x-ray has limited value in the determination of medical necessity since one cannot evaluate "function" from an x-ray. Similar findings concerning other imaging findings was also demonstrated in a paper by Davis, DC. JNMS 1996;4(3):102-115.

In general, imaging studies are not useful in determining the origin of

pain. However, they are a useful diagnostic tool used in the detection of structural deformities or pathology, which may prevent the application of appropriate manipulative procedures.

Eisenberg, Kessler, Foster, Norlock, Calkins, Delbanco. Special Article: Unconventional Medicine in the United States. NEJM Jan.

28, 1993

34% reported using at least one unconventional therapy in the past year Highest use by non-black persons from 25-49 years of age who had relatively

more education and higher incomes. The majority used unconventional therapy for chronic care 1990 Americans made 425 million visits to providers of unconventional care. This number exceeds the number of visits to all U.S. primary care physicians

(388 million). 1990 expenditures for unconventional therapies $13.7 billion, 75% of which

was out-of-pocket. This figure is comparable to the $12.8 billion spent out-of-pocket annually for

all hospitalizations in the U.S.

Question: When tissues have healed, shouldn’t pain be gone and function restored?

Wahlgren DR et al. Pain 1997;73:213-221.

Question: When tissues have healed, shouldn’t pain be gone and function restored?

Wahlgren DR et al. Pain 1997;73:213-221. “Whereas traditional biomedical approaches indicate that time alone

may be a curative factor, pain-related effects such as functional deficits and distress may extend beyond healing of tissue damage”

Phillips HC, Grant L Behav Res Ther 1991;29 (5):435-441 “The recovery process was found to be considerably longer than was

expected and than would be predicted from the course of physical healing of soft tissue damage…This suggests a much slower recovery period than had been considered and a much larger number of people who are vulnerable to persisting pain.”

Tissue Repair and Rehabilitation

Herring S Med & Science in Sports & Exercise 1990;22 (4):453-456.

“ The tissue may repair and remodel, but concomitant changes in function-strength, strength balance, flexibility, and proprioception occur. The signs and symptoms of injury abate but these functional deficits persist…

The rehabilitation process is not over when the

symptoms disappear. Rehabilitation must not be solely based on symptom relief. It must address more than pain. The athlete has a functional disability after an injury, and, until that is addressed these functional changes will persist.”

Findings and Outcome in Whiplash-Type Neck Distortions:

Halldor Jonsson, Kristina Cesarini, Bo Sahlstedt, Wolfgang Rauschning, Spine, Vol. 19, No. 24, pp 2733-2743

Authors assessed the clinical and imaging findings and late outcome in 50 patients with whiplash-type neck distortions.

Neck pain persisted in 24 patients; radiating pain developed within 6 weeks in 19

patients. Conclusions: Follow-up surgery on the chronic patients showed a high

incidence of discoligamentous injuries in whiplash-type distortions. “Patients with whiplash-type neck distortions inflicted in car collisions tend to

develop progressive neck pain and stiffness during the first days after the accident.”

“These symptoms can persist over years and may become bizarre and

disabling and ensue cumbersome and costly insurance litigations.” “A significant increase in cervical spine injuries has been reported after the

introduction of seat belts.”

Halldor Jonsson, Kristina Cesarini, Bo Sahlstedt, Wolfgang Rauschning, Spine, Vol. 19, No. 24, pp 2733-2743

(cont’d)

“Traumatic cartilaginous endplate separations may explain why the two young patients with extensive posterior soft tissue injuries had normal disc signals on magnetic resonance imaging. Because the discs are structurally intact in these avulsion injuries, they may generate normal signals on magnetic resonance.”

“Pain can originate both from the ganglion and the richly

innervated annulus fibrosis and also from the facet joints causing both local and referred pain.”

The most likely source of radicular symptoms is perineural

scarring. Therefore, patients with neck distortions after traffic accidents should be mobilized early within the limits of pain to prevent scar transformation of hidden injuries.

Dysfunction…

A review of the literature

Dynamic Chiropractic June 26, 2000 Volume 18, Number 14

“Goals of Care: Minimize Pain and

Maximize Function”

Author

Malik Slosberg, DC, MS, Professor, Life Chiropractic College West.

“Dysfunction”

Malik Slosberg, DC, MS, Professor. Goals of Care: Minimize pain and Maximize Function. Dynamic Chiropractic June 26, 2000

Volume 18, Number 14. Pages 8,12,42

Dysfunction may become self-perpetuating….One of the common criticisms of the diagnosis of soft tissue sprain and strain is that such an injury is normally followed by healing.

Symptoms should settle over the expected tissue healing time.

However, if the problem is dysfunction, then symptoms can persist for as long as dysfunction continues. Dysfunction may be self-sustaining, so symptoms may persist indefinitely.

“Dysfunction”

Mayer TG. Neurologic Clinics of North America 1999; 17 (1): 131-147

“The majority of injuries to the low back involve soft tissue or discs with sprains and strains of musculoligamentous tissues, which have a relatively brief healing period. When healing is temporally complete, but biomechanically imperfect, leading to permanent impairment or supporting elements, chronic pain disability may follow.”

If tissues are allowed to heal without functional

restoration, chronic disability can occur.

“Dysfunction”

Ameis A. Can Fam Physician 1986;32 (Sept) : 1871-76.

Ameis explains that, “As time passes, the rehabilitative program should

become progressively more active…Patients invariably expect treatment to result in pain-free status. Instead, it should be stressed that recovery of function is the primary goal.”

The restoration of function, so that a patient has an

adequate capacity to tolerate activities of daily living and work tasks, is the single most important goal of care.

“Dysfunction”

Bigos SJ, Davis, GE. JOSPT 1996;24 (4) Oct: 192-207.

“The Agency for Health Care Policy and Research

defined low back problems not as pain but activity intolerance due to back symptoms. The actual treatment relates to regaining activity tolerance. Controlling symptoms supports, not replaces, the true treatment. Don’t let patients confuse recommendations to be more comfortable (pain relief) with conditioning, which is the real treatment for an activity limitation.”

“Dysfunction”Abenhaim L, et al. Spine 2000; 25(4S):8S.

The primary conclusion of the recent Report of the International Paris Task Force on Back Pain, states:

“Individuals who have back pain reduce their

activity…The longer they reduce their activity, the greater the risk of the conditioning becoming chronic. The prevailing management approach to the treatment of back pain considers a return to normal activities to be a more important goal than pain relief.”

Function vs. Pain Relief

Saal JA. 1996 North American Spine Society Presidential Address, Spine 1997;22(14):1545-15

“We must adopt the principle of improving patient function as our new paradigm…Improving patient function must be the credo of care.”

Saal

Waddell, G. The Chiropractic Report 1993; July:1-6.

“Failure to restore function means any pain relief will be temporary and reinforces chronic pain.”

Waddell, MD.

Owens, MS, DC; Top Clin Chiro 2000; 7(1):74-79.

Preventive Care

Degeneration of tissues is thought to occur in areas of disturbed kinematics, which can eventually lead to arthritic changes of not addressed. Evaluation should be focused on areas of dysfunction in order to correct before symptoms occur. In this case, chiropractic care is indicated whether symptoms are present, or not.

Waddell G. The Back Pain Revolution Churchill Livingstone 1998;145

Residual dysfunctions that can frequently persist long after tissues are healed if the dysfunctions which occur with tissue damage are not identified and corrected:

(1) Abnormalities of joint movement A. Limited movement B. Hypermobility C. Abnormal patterns of movement (2) Acute joint locking (3) Muscle fatigue, weakness, tension, shortening, stretching. (4) Reflex muscle spasm

Waddell G. The Back Pain Revolution Churchill Livingstone 1998;145 (cont’d)

(5) Connective tissue (fascia, ligs, joint capsule, muscle)a. Adhesionsb. Scarringc. Trigger pointsd. Fibrositis

(6) Neuromuscular incoordination: muscle imbalance(7) Abnormal patterns of movement(8) Altered proprioceptor and nocireceptor input and

neurophysiologic processing.

Drug Issues

Miscellaneous Literature

Gurkirpal Singh, George Triadafilopoulos, Epidmiology of NSAID induced gastrointestinal complications. J. Rheumatol 1999, Apr;26

Suppl 56:18-24. Department of Medicine, Division of Immunology, Stanford University School of Medicine, Palo Alto,

California 94304, USA.

NSAIDs are one of the most commonly used classes of medications worldwide. 30 million people take NSAIDs daily. GI complications are the most prevalent category of adverse drug reactions. Patients with arthritis are the most frequent users, therefore at greater risk.

NSAID related deaths among patients with RA and OA are even more startling. It is conservatively estimated that 16,500 NSAID-related deaths occur in these patients every year in the US.

15th most common cause of death in the US. Stats DO NOT include nonarthritis indications.

Wolfe, M.D., Lichtenstein, M.D., Singh, M.D.Gastrointestinal Toxicity of Nonsteroidal Anti-inflammatory Drugs.

The New England Journal of Medicine, June 17, 1999, Review Article, Medical Progress.

113 References.

NSAID agents constitute one of the world’s most widely used classes of drugs, with more than 70 million prescriptions and more than 30 billion over-the-counter tablets sold annually in the US.

“Although the annual mortality rate is low, it must be emphasized that

because a large number of patients are exposed to NSAIDs often for extended periods of time, the risk over a lifetime is substantial.”

Hospitalization due to GI complications 103,000/yr. Estimated cost

$15,000 to $20,000 per hospitalization. Annual cost exceeds $2 Billion.

“It has been estimated conservatively that 16,500 NSAID-related deaths occur among patients with RA and OA every year in the US.”

Wolfe, M.D., Lichtenstein, M.D., Singh, M.D.Gastrointestinal Toxicity of Nonsteroidal Anti-inflammatory Drugs.

The New England Journal of Medicine, June 17, 1999, Review Article, Medical Progress. (cont’d)

Doses of aspirin as low as 30 mg are sufficient to suppress prostaglandin synthesis in the gastric mucosa initiating gastric-duodenal mucosal injury, resulting in the release of oxygen-derived free radicals.

Peptic ulcers-gastroduodenal hemorrhage-perforation-death! Acetaminophen is nontoxic to the GI mucosa, however, recall that

acetaminophen is a leading cause of end-stage renal disease. Cox-2 inhibitors will hopefully have a reduced capacity to cause injury to

the gastroduodenal mucosa. However, Cox-2 inhibitors are also known to cause defects in renal

function, alter the regulation of bone resorption, impair female reproductive physiology, and increase the rate of thrombotic events in patients with increase risk for cardiovascular disease.

Dabbs, D.C. and Lauretti, D.C., A Risk Assesment of Cervical Manipulation vs. NSAIDs for the Treatment of Neck

Pain. Journal of Manipulative and Physiological Therapeutics. Vol. 18, number 8 Oct. 1995; 18:530-6.

“The best evidence indicates that cervical manipulation for neck pain is much safer than the use of NSAIDs, by as much as a factor of several hundred times. There is no evidence that indicates NSAID use is any more effective than cervical manipulation for neck pain.”

Death rate for NSAID-associated GI problems at 0.04% per yr among OA patients receiving NSAIDs, or 3,200 deaths in the US per year.

He (Brandt) also noted that there are several animal

studies and human clinical studies that have actually implicated NSAIDs in the acceleration of joint destruction.

OxyContin

U.S. News and World Report, July 2, 2001 “Not an appropriate use”, “Did the makers

of OxyContin push too hard?” Virginia residents filed a $5.3 billion class

action lawsuit that alleges Pharma also failed to disclose the drug’s risks, setting off a wave of OxyContin addiction and abuse.

Associated deaths jumped 93% between 1997 and 1998.

DEA reported 291 deaths in just 6 states.

NUTLEY, N.J. (July 15) - Mother's little helper is not so little anymore.

Valium, the drug that revolutionized the treatment of anxiety and became a cultural icon, is 40 years old this year.

Invented by chemist Leo Sternbach Approved for use in 1963, became the country's

most prescribed drug from 1969 to 1982. The Roche Group, Hoffman-La Roche's

parent, sold nearly 2.3 billion pills stamped with the trademark ``V'' at its 1978 peak.

Baycol-Cholesterol drug

The Columbus Dispatch, August 9, 2001 “Bayer pulls medicine tied to 31

U.S.Deaths” Baycol has been linked to significantly more

fatal cases than its competitors, Dr. John Jenkins of the FDA

Other drugs include Lescol, Lipitor, Mevacor, Pravachol, Zocor

Baycol-Cholesterol drug

“Every statin has been linked to very rare reports of the muscle side effect called rhabdomyolysis.”

Baycol is the 12th prescription drug taken off the market since 1997.

Allergy Pills Overused

Study out of OSU, reported in Columbus Dispatch, Monday, April 9, 2001

Of 246 North Carolina residents taking prescription antihistamines, blood tests showed 65 percent didn’t have allergies.

Skill testing unreliable vs. Blood tests

“Side Effects: As Drug-Sales Teams Multiply, Some Doctors Shut Them Out”

Wall Street Journal, 6-13-03 “’Arms Race’ by Pfizer, Rivals Boost Pill Prices

and Ire, But No One Dares Retreat.” “Free Tacos and Piles of Bextra” 90,000 drug industry reps $12 Billion spent on sales force $2.76 billon on consumer drug ads. Result: Prescriptions up 14% to $161 Billion

spent on drugs in 2002!!!!

Unnecessary Mastectomies

BMJ March 4, 2000 1997 pathologist Professor Kemnitz made

numerous false positive diagnoses of breast cancer.

300 women suffered mastectomies Professor Kemnitz committed suicide, set

himself on fire and destroyed evidence in his lab.

Wall street journal,4/22/03 Page 1, section dSaying No to the Knife...

Apparently, research now shows that surgery for back problems, gum disease, hernias, sinus problems, and injured kidneys, to name a few, are not necessary much of the time.

And the effects of the surgery are apparently often worse than the condition treated.

Antibiotics and Breast Cancer

February 17, 2004 JAMA

The longer that women took the drugs, and the more prescriptions they took, the greater their risk of breast cancer.

Aspirin in Gastric Ulcer

76 year old women NEJM Levy MD, Vol. 343 Number 12 400 mg. Etodolac 2x/day for RA 1 tablet of enteric-coated aspirin / day 1 mg. of warfarin sodium per day Endoscopy revealed aspirin tablet intact with

an ulcer of gastric antrum.

Continuous Low-Level Heat Wrap Therapy Provides More Efficacy Than Ibuprofen and Acetaminophen for Acute Low Back Pain

Scott F. Nadler, DO, et al. SPINE 2002;27:1012-1017

Conclusion. Continuous low-level heat wrap therapy was superior to both acetaminophen and ibuprofen for treating low back pain.

Diagnostic Test Accuracy


Cervical Discogenic Pain. Prospective Correlation of MRI and Discography in Asymptomatic Subjects and Pain Sufferers.

Schellhas, Smith, Gundry, and Pollei, Spine 1996 Feb. 1;21(3):300-11; Discussion by James Zucherman, 311-12.

Methods:

Ten lifelong asymptomatic subjects and 10 nonlitigious chronic neck/head pain patients underwent discography at C3-C4 and C6-C7 after magnetic resonance imaging. Disc morphology and provoked responses were recorded at each level studied.

Results: In the pain patients, 11 discs appeared normal at MRI and 10 of

these proved to have anular tears discographically. Discographically normal discs were never painful in either

groups.

Cervical Discogenic Pain. Spine 1996 Feb. 1;21(3):300-11; Discussion by James Zucherman, 311-12.

(cont’d)

Conclusion: Significant cervical disc annular tears often

escape magnetic resonance imaging detection, and MRI cannot reliably identify the source(s) of cervical discogenic pain.

Jensen, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. NEJM

1994;331(2)July 14:69-73

98 people: only 36% had a normal disc at all levels. 52% bulge at least one level 27% protrusion 1% extrusion 38% had abnormality at more than one level

Summary: Finding may be frequently coincidental

“But the x-ray is negative! How can there be an injury?”

Question: Are diagnostic tests such as x-ray, MRI, EEG, EMG, etc, reliable indicators for the potential for injury?

Answer: NO


The pathology model cannot explain back pain or disability. It is not possible to look at pathology and determine the symptoms a patient may be suffering. It also is not possible to look at a patient with back pain with no neurologic deficits and determine the nature of the pathology. About 30% of asymptomatic subjects show abnormalities in the lumbar spine by myelogram, CT and MRI. There is a large percent of symptomatic patients with severe complaints in whom testing fails to reveal any structural lesion.

Wickstrom et al….

Experiments produced tears of the ALL so severe that they were often seen in conjunction with avulsions of the disc of vertebrae (rim lesions).

Yet, they were not seen on radiographs

MRI…(1) Goldberg et al. (2) Davis et al. Visualization of ALL

Jonsson MD. Journal of Spinal Disorders 1991;4(3):251-263.

Study of cervical spine of 22 patients who died of fatal skull fractures in MVAs. X-rays were evaluated by an expert orthopedic radiologist. Only 1 of 10 gross ligamentous disruptions were even suspected on X-rays. 198 lesions were missed. Multilevel soft-tissue injuries were common. Very few injuries were detected or even suspected on radiograms. The vast majority was not recognized. Plain radiograms cannot detect soft-tissue lesions unless they are associated with vertebral body malalignment. Conclusions: the majority of lesions are soft-tissue injuries. Plain radiograms show virtually no soft-tissue lesions.

Side note:As a result of these types of studies, it has become apparent that a

thorough physical examination is more important, in combination with functional assessments, than traditional diagnostic evaluations to determine the presence or absence of soft-tissue injuries.

Liebenson, DC, Oslance. Rehabilitation of the Spine. Williams and Wilkins, Baltimore. 1996:73.

“80% of patients have no identifiable structural pathology and require treatment based on evaluation of functional deficits. In the majority of cases, patients have soft tissue injuries and functional changes are the only objective findings on which to base treatment and judge progress. Outcomes assessments including objective functional tests give the third party payers, patients and doctors a way to measure progress over time, and evaluate the prescribed treatment. Overemphasis on treatment of structural pathology results in a failure to identify or focus on functional loses and work demands. [Emphasis added.]”


“Common acute back pain is due to chemical abnormalities created by soft tissue tear. The tear represents a mechanical disruption, which is usually microscopic. X-rays demonstrate no changes before and after an acute back injury.”

Again, function is more important in the evaluation and treatment of

back pain than structural pathology. A "negative" x-ray has limited value in the determination of medical necessity since one cannot evaluate "function" from an x-ray. Similar findings concerning other imaging findings was also demonstrated in a paper by Davis, DC. JNMS 1996;4(3):102-115.

In general, imaging studies are not useful in determining the origin of

pain. However, they are a useful diagnostic tool used in the detection of structural deformities or pathology, which may prevent the application of appropriate manipulative procedures.

Jarvik et al. Rapid Magnetic Resonance Imaging vs Radiographs for Patients with Low Back Pain. JAMA

2003;289:2810-2818.

Conclusion: Rapid MRIs and radiographs resulted in nearly identical outcomes for primary care patients with low back pain. Although physicians and patients preferred the rapid MRI, substituting rapid MRI for radiographic evaluations in the primary care setting may offer little additional benefit to patients and may increase the costs of care because of the increased number of spine operations that patients are likely to undergo.

Symptoms vs. Function

As a result of these and other studies there has been a shift in thinking away from the traditional "symptom" approach, towards contemporary thinking of "function".

For many patients with recurrent back pain, staying functional is a "process" more so than a "result" based on a predictable healing time or average.

Chiropractic

Cost Related Literature and Information

Cost Issues

What is the financial impact of Chiropractic Healthcare?

What is the impact of medical errors and drug shadow

costs?

Research…oldies but goodies!

A review of past literature.

Topic: Bed RestWaddell. A New Clinical Model for the Treatment of Low-

Back Pain. Spine. 1987;12:632-644

Little scientific or clinical evidence supports the value of bed rest.

Only four controlled studies

Bed rest is the most harmful treatment ever devised and a potent cause of iatrogenic disease.

Topic: Bed Rest

AHCPR. Lee. Publication No. 95-0643; December 1994, pp. 2.

Extended bed rest could be harmful. Resting in bed for more than 4 days can weaken muscles and bones and delay recovery.

RAND StudyShekelle, et al. “The Appropriateness of Spinal

Manipulation for Low Back Pain: Indication and Ratings by a Multidisciplinary Expert Panel.” 1991; RAND/UCLA

Monograph No. R-4025/2-CCR/FCER.

“Spinal manipulation is the most commonly used conservative treatment for back pain supported by the most research evidence of effectiveness in terms of early results and long-term effectiveness.”

2/3 of patient visits were to chiropractic providers for a total cost of $2.4 billion in 1988. Conversely, 1/3 of the visits for back pain were to medical providers (MD) for a total cost of $8 billion.

94% of manipulation is performed by doctors of chiropractic.

AHCPRAcute Low Back Problems in Adults: Assessment and

Treatment

Proven Initial Care: Patient education, patient comfort (NSAIDs), and SPINAL MANIPULATION.

Unproven Therapies: Traction, physical modalities (massage, diathermy, US, cutaneous laser, biofeedback, TENS, acupuncture, trigger point injections, facet injections, steroid or lidocaine injections, shoe lifts, exercise machines, stretching.

Harmful treatment: Best Rest.

Utah StudyJarvis, et al. Cost per Case Comparison of Back Injury

Claims of Chiropractic Versus Medical Management for Conditions with Identical Diagnostic Codes. Journal of

Occupational Medicine. 1991; Vol. 33, No. 8, Aug., pp. 847-851.

In 3,062 separate cases:

Chiropractic care took an active approach with 8 times more visits.

Medical care took a passive approach prescribing medication and rest.

Utah Study(cont’d)

Conclusion: Chiropractic care was 73% more cost-effective per

case. The average distribution cost per office visit was

67% less for chiropractic than for the medical office visit.

Patients seeing doctors of chiropractic were able to return to work 10 times sooner than those under medical care.

For the total data set, cost for care was significantly more for medical claims—Compensation costs were ten-fold less for chiropractic claims.

Australian StudyEbrall. Mechanical Low Back Pain: A Comparison of Medical and Chiropractic Management Within the

Victorian WorkCare Scheme. Chiropractic Journal of Australia. 1992; Vol. 22, No. 2, June pp. 47-53

Compensation days with Chiropractic management are ¼ the days of claims with medical management.

The “occurrence of chronicity” was greater with medical management (6 fold greater progression to chronicity-11.6% to 1.9%).

Cost of claims: $2,038 Medical/$963 Chiropractic.

Average compensation payment is 4 times greater with medical management.

Australian Study(cont’d)

Conclusion: Financial and social savings could be maximized by:

Increased participation rate by DCs in the WorkCare.

Increased early referral from medical doctors to Chiropractic doctors.

British StudyMeade, et al. Low Back Pain of Mechanical Origin.

Randomized Comparison of Chiropractic and Hospital Outpatient Treatment. BMJ. 1990; Vol. 303, No. 6737.

June pp. 1431-1437

10 year multicenter trial. Conclusion:

Chiropractic treatment was significantly more effective, particularly with patients with chronic and severe pain.

Results were long-term throughout the two-year follow up period.

The potential economic, resources, and policy implications of the results were extensive.

Patients treated by Chiropractors…almost certainly fared considerably better and maintained their improvement for at least two years.

Canadian StudyManga et al. The Effectiveness and Cost Effectiveness of

Chiropractic Management of Low-Back Pain. Manga Report to Ontario Ministry of Health. August, 1993.

Conclusions: The “Constellation of evidence” demonstrates:

The treatment effectiveness and cost effectiveness of Chiropractic care.

The untested, questionable, or harmful nature of many current medical therapies.

The economic efficiency of Chiropractic care versus medical care.

The safety of Chiropractic. Higher patient satisfaction.

Canadian StudyManga (cont’d)

Summary:

There should be a shift in policy to encourage the utilization of chiropractic services for most patients with back pain…

A very good case can be made for making chiropractors the gatekeepers for management of low-back pain the worker’ compensation system.

Virginia StudySchifrin. Mandated Health Insurance Coverage for

Chiropractic Treatment: An Economic Assessment with Implications for the Commonwealth of Virginia. January,

1992

“By every test of cost-effectiveness, the general weight of evidence shows that Chiropractic provides important therapeutic benefits at economical costs.”

“These benefits are achieved with minimal, even negligible, impact on the costs of health insurance.”

“Chiropractic services are widely used and appreciated by a growing segment of Americans.”

2nd Virginia StudyDean, et al. “A Comparison of the Cost of Chiropractors

versus Alternative Medical Practitioners.” Virginia Chiropractic Association. January 1992.

“Chiropractors see their patients more frequently but have lower overall costs for most of the conditions considered.”

“Chiropractic care requires fewer referrals for specialists and outside procedures.”

“If Chiropractic care is insured to the same extent as other specialties, it may result in a decrease in overall treatment costs for neuro-musculoskeletal conditions.”

Medstat ProjectStano et al. MEDSTAT Data Base Review. The Journal of

American Health Policy. 1992; Vol. 2 #6.

Conclusions:

Plans which have limited or no chiropractic coverage have the highest total costs per patient.

Broader coverage of chiropractic services results in dramatically lower health care cost as follows:

35% lower hospital admission rates.42% lower inpatient payments.23% lower total health care costs.

US General Accounting Office“Access to Health Insurance: State Efforts to Assist Small

Business.” GAO-92-90; May 1992; pg. 33

“Mandates determined not to add significantly to the cost of health insurance include services for in-vitro fertilization, acupuncture, and cleft palate, as well as services provided by Chiropractors and home health nurses. It is these low cost mandates, however that are often cited by the business community as examples of the added wasteful expense mandates cause for business.”

Journal of American Health PolicyStano et al. “The Growing Role of Chiropractic in Health Care Delivery.” Journal of American Health Policy. 1992

Nov-Dec. pp. 39-45.

“Plans which do not cover Chiropractic have the highest payments per patient.”

“Increased availability of demonstrated cost-effective alternatives would increase access and would reduce costs.”

Journal of Family PracticeCherkin et al. “Family Physicians, Chiropractors, and Back Pain.” The Journal of Family Practice. 1992; Vol. 35, No.

5, pp. 551-555

Chiropractic doctors are well-trained and well-accepted by both patients and insurers.

Western Journal of MedicineCherkin et al. “Patient Evaluation of Low Back Pain Care

from Family Physicians and Chiropractors.” Western Journal of Medicine. 1989; Vol. 150, No. 3, March pp. 351-

355.

Conclusion:

Chiropractic doctors were highly rated compared to medical doctors in critical patient care areas for the treatment of low back pain.

Patients gave DCs a 3:1 advantage in five important areas of patient satisfaction.

Chiropractic patients reported quicker recoveries.

British Medical JournalSmith. “Where is the Wisdom? The Poverty of Medical Evidence.” BMJ. 1991; Vol. 303, October pp. 798-799.

“Only about 15% of medical

interventions are supported by valid medical evidence…Many treatments have never been assessed at all.”

Recent studies…

A review of the literature.

“DC’s as Primary Care Providers”

(Interview with James Zechman, Part 1, condensed summary)

Editor’s note: In the December 1, 1999 issue, we interviewed the CEO of Alternative Medicine, Inc. (AMI), James Zechman. AMI had contracted with Blue Cross/ Blue Shield of Illinois, the state’s largest managed care plan, to give its more than 700.000 enrolled members the option of having AMI’s chiropractors as their primary care physicians.

The following interview highlights were reported in the February 12, 2001issue of Dynamic Chiropractic.

Zeckman (cont’d)

Our theory was to accurately test a preventive health care system based on a non-pharmaceutical/non-surgical entry point.

We have no limit on the number of visits, treatments or procedure. Anything which takes place within the doctor’s own office is unencumbered.

Zeckman (cont’d) Waiting to see a physician until disease is present adds

costly tests, procedures and pharmaceuticals to health care bill that could have been avoided through a strong and integrated preventive care program.

We believe this is the only rational choice: to create a true prevention-based health care system as opposed to after-the-fact disease care system. It is this system of truly integrated medicine that precludes the need for restrictive guidelines and disruptive oversight of chiropractic care. We believe once you identify quality- the rest takes care of itself.

Zeckman…The Results

Compared to normative values in the greater Chicago area for all other allopathic IPA’s our network has reduced hospitalizations by approximately 60 percent over a 24-month consecutive period.

We have reduced outpatient surgery and procedures by approximately 85 percent over a 24- month consecutive period.

We have reduced pharmaceutical usage by approximately 56 percent over a 24-month consecutive period.

Of interest to note is that we have no C-section deliveries over a two-year period, as compared to a network average of over 22 percent.

Zeckman…Conclusion

AMI’s primary care chiropractors are showing the world what the profession has always believed since its inception:

Chiropractic has an ability to impact a person’s health in a very profound manner.

Mosley, Cohen, DC, Arnold, MD. American Journal of Managed Care 1996;2:280-282.

Retrospective study of patients at an independent physician model HMO in Louisiana evaluating cost of care for acute low back pain or neck pain for patients who sought chiropractic care or other treatment. Also looked at surgical rates, use of diagnostic imaging (MR and CT) and patient satisfaction on claims paid Oct. 1, 1994 – Oct. 1, 1995.


Results: Cost of care for BP and NP was substantially lower for DC patients than non-DC patients. Use of prescription drugs and diagnostic imaging were significantly greater in non-DC group whereas surgical rates and patient satisfaction were nearly identical.

Conclusion: DC care outcomes are equal to those of non-DC care at substantially lower costs. MD patients got 2x as many prescriptions. Study demonstrates that DC services were well integrated in an HMO and has proven satisfactory to patients and providers as well as cost-effective for BP and NP. The system offered self-referral for DC services.


If half of the patients treated by traditional care received DC care, annual savings would have exceeded $215,000. We recommend its wider application by the managed care industry and physician community. [Emphasis Added.]

Muse Study\Medicare

The Muse study compared the most recently

available CMC Medicare cost and utilization data for those beneficiaries that received chiropractic care versus those beneficiaries that only received traditional medical care. The Muse study found that the global per capita Medicare expenditures for chiropractic patients were significantly lower than the same costs for non-chiropractic patients.

Muse Study\Medicare(cont’d)

The Muse study concluded,

"Chiropractic care significantly reduces per beneficiary costs to the Medicare program. The results of the study suggests that chiropractic services could play a role in reducing costs Medicare reform and/or a new prescription drug benefit."

Questions…

What is the tissue source of chronic spine pain?

Answer: The Disc, The Facet Capsule

What tissues are primarily affected by chiropractic spinal adjustments?

Answer: The Disc, The Facet Capsule

The perception of pain is dependent upon the balance of activity between the pain afferents and the mechanical afferents. True or false?

Answer: True! Nolte, 1999

Questions……

What is the common thread between swimming, using a rocking chair, and chiropractic joint adjusting?

Answer: They all increase the firing of large diameter joint and muscle mechanoreceptors.

In terms of the prevention of chronic spine pain and disability, what is the most important to

consider?

a) Pain reliefb) Tissue Repair

c) Restoration of function (Correct Answer!)

Copyright Protection Statement The material in this packet is under copyright protection and may not be reproduced in any format without the expressed written consent of Dr. Ronald J. Farabaugh. © Copyright. 2011. All Rights Reserved.

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