John A.M. Taylor, DC, DACBRProfessor & Coordinator of Diagnostic ImagingD’Youville CollegeDoctor of Chiropractic Program

Your impression?

Profession Characteristics (USA)

Chiropractic (DC) Osteopathy (DO) 70,000 active DC

licenses 19 chiropractic

schools 1000+ hrs

manipulation & MSK More emphasis on

spine & MSK 94% of manipulations

53,000 practicing DOs 25 osteopathic

schools 200+ hrs

manipulation & MSK More emphasis on

primary medical care 4% of manipulations

NBCE Practice Analysis, 2010NBCE Practice Analysis, 2010DYC curriculum, 2010DYC curriculum, 2010Shekelle et al, 1991Shekelle et al, 1991

Pickett HR, Jonas CE: Overview of Pickett HR, Jonas CE: Overview of Osteopathic Manipulative Osteopathic Manipulative PrinciplesPrinciples

Original Theory of Chiropractic (1895)

Current Theories of Spinal Manipulation

Current Theories of Spinal Manipulation

Flynn 2006; Pickar 2002Flynn 2006; Pickar 2002

Current Theories of Spinal Manipulation

Manipulation Changing Muscle Function

Brenner AK et al, 2007Brenner AK et al, 2007

http://www.cure-back-pain.org/

Presenting Complaints

NBCE 2010NBCE 2010

Etiology of Patient Conditions

NBCE 2010NBCE 2010

D’Youville College Doctor of Chiropractic Program

Began 2003 30 graduates to date 3 year BS degree (50) 4 year DC degree (95) 1 year internship Chiropractic health centers

Campus (downtown) Community (Main & Hertel)

D’Youville College Doctor of Chiropractic Program

200+ credit hours 4,600 clock hours Emphasis on:

Integrative care Active care > passive care Evidence – based Patient – centered Problem – focused Neuromusculoskeletal

Accreditation

http://www.cce-http://www.cce-usa.org/usa.org/

Steps Leading to Chiropractic Practice

http://www.nbce.org/http://www.nbce.org/

First year

http://www.nbce.org/http://www.nbce.org/

Second year

http://www.nbce.org/http://www.nbce.org/

Third year

http://www.nbce.org/http://www.nbce.org/

Fourth year

Clinic internship I Clinic internship II Clinic externship Clinical rotations Research project or thesis Part IV NBCE

National Certification Board

http://www.nbce.org/http://www.nbce.org/

What to Expect

Diagnosis Treatment/Management

History Physical examination

Neurologic Orthopedic Chiropractic structural

Special studies Radiography Advanced imaging Laboratory tests Nerve conduction tests

Manipulation Soft tissue techniques

Graston ART Nimmo

NMS rehabilitation Exercise Core stability Active care

Referral or co-management

What to Expect

Treatment/Management cont’d

Advice Healthy lifestyle Nutrition Postural Ergonomic Positive attitude Exercise

Chiropractic Approach to Back PainB. DIFFERENTIAL DIAGNOSIS Mechanical pain?

Sprain Strain Joint restriction

Pathologic pain? Tumor Infection Fracture

Mechanical Manipulation Soft tissue therapy Rehabilitation

Pathologic Imaging Referral Co-management.

The Purpose of Tests

SCREENING TEST

© www.merck.com/pubs/mmanual© www.merck.com/pubs/mmanual

DIAGNOSTIC TEST

High specificity only in high risk population

Not useful for screening low risk groups

More expensive

More invasive

Haas M, Taylor JAM, Gillette RG. Haas M, Taylor JAM, Gillette RG. JMPTJMPT 1999;22(4):254-9. 1999;22(4):254-9.

Adam’s Test

Back Pain Plus: Fever Unexplained weight loss History of cancer Neurologic deficit Alcohol or injection drug abuse Age over 50 Significant trauma Failure to improve with usual care.

Deyo RA, et al. Deyo RA, et al. N Engl J MedN Engl J Med, 344:5, 2001, 344:5, 2001..

Indications for Radiography

Suggestive of Systemic Disease, Pathology or TraumaSuggestive of Systemic Disease, Pathology or Trauma

Mechanical LBP (97% of all LBP)

Idiopathic--sprain/strain 70% Degeneration 10% Disc herniation 4% Osteoporosis with comp fracture

4% Spondylolisthesis 2% Traumatic fracture <1% Congenital (scoliosis, kyphosis)

<1%

Deyo RA, Weinstein JN. Low Back Pain. Deyo RA, Weinstein JN. Low Back Pain. N Engl J MedN Engl J Med 2001; 344(5). 2001; 344(5).

Nonmechanical LBP (1% of all LBP)

Neoplasm .7% Inflammatory arthritis .3% Infection .01% Scheuermann’s ? Paget’s disease ?

Deyo RA, Weinstein JN. Low Back Pain. Deyo RA, Weinstein JN. Low Back Pain. N Engl J MedN Engl J Med 2001; 344(5). 2001; 344(5).

Pelvic disease Renal disease Aortic aneurysm Gastrointestinal disease

Visceral Disease Resulting in LBP (2% of all LBP)

Deyo RA, Weinstein JN. Low Back Pain. Deyo RA, Weinstein JN. Low Back Pain. N Engl J MedN Engl J Med 2001; 344(5). 2001; 344(5).

Computed Tomography

INDICATIONS

Spinal stenosis

Bone disease

Joint disease

Complex trauma

Complex anomalies

Disc disease when MR contraindicated

Taylor, Resnick, Advances in Chiropractic © 1994 Mosby

Computed Tomography

Taylor, Resnick, Advances in Chiropractic © 1994 Mosby

Magnetic Resonance Imaging

INDICATIONS

Disc disease

Joint disease

Bone marrow

Direct soft tissue visualization

Taylor, Resnick, Advances in Chiropractic © 1994 Mosby

Aneurysmal bone cystAneurysmal bone cyst

Taylor, Resnick, Advances in Chiropractic © 1994 Mosby

Magnetic Resonance Imaging

Bone Mineral Density ScansImportant Risk Factors Age ≥50

BMI or weight (<19 kg/m2 or <57 kg); Ethnic group or race (white or Asian); Menopause before age 45; Loss height (>4 cm); History of corticosteroid Tx; History of fragility fracture after age 45 of one

of the following sites: hip, rib, wrist;

Bussiere, et al, 2008Bussiere, et al, 2008

BMD: WHO Classification

Normal bone density: +1 to -1 Osteopenia: -1 to -2.5 (low bone

density)

Osteoporosis: -2.5 or lower

Radionuclide Imaging (Bone Scan)

INDICATIONSINDICATIONS Sensitive screen for pathology

Skeletal distribution

Metastatic disease

Radiation

Non-specific

Time-consuming

LIMITATIONSLIMITATIONS

Taylor, Resnick, Advances in Chiropractic © 1994 MosbyTaylor, Resnick, Advances in Chiropractic © 1994 Mosby

http://www.ccgpp.org/documents.htmhttp://www.ccgpp.org/documents.htm

Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP)

Spinal Manipulation Research

Acute and subacute low back pain (LBP)

Strong evidence supports the use of spinal manipulation to reduce symptoms and improve function.

CCGPP 2008CCGPP 2008

Spinal Manipulation Research

Combined exercise and manipulation

Good evidence that the use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence.

CCGPP 2008CCGPP 2008

Spinal Manipulation Research

LBP & radiating leg pain, sciatica, or radiculopathy

Fair evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy

Manipulation in combination with other common forms of therapy may be of clinical value.

Lawrence, DL, et al. CCGPP, 2008Lawrence, DL, et al. CCGPP, 2008

Spinal Manipulation Research

Cases with high severity of symptoms

May benefit by referral for co-management of symptoms with medication

CCGPP 2008CCGPP 2008

Spinal Manipulation Research

Chronic LBP

Strong evidence supports the use of spinal manipulation/mobilization to reduce symptoms and improve function.

CCGPP 2008CCGPP 2008

Spinal Manipulation Research

Neck Pain

Manipulation & mobilization effective for: Whiplash associated disorders (WAD) Neck pain

Hurwitz EL et al. Hurwitz EL et al. 20082008

Systematic Reviews of Randomized Controlled Trials

Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3. http://www.chiroandosteo.com/content/18/1/3

13 MSK conditions 4 types of chronic headache 9 non-MSK conditions 49 relevant systematic reviews 16 evidence-based guidelines 46 additional RCTs

SMT/mobilization is effective in adults for:

Low back pain Acute Subacute Chronic

Cervicogenic Headache Dizzyness

Thoracic SMT/mobiliz for neck pain Acute Subacute

Extremities several conditions

Bronfort G et al. Bronfort G et al. 20102010

Evidence is inconclusive in SMT/mobilization in adults for:

Cervical SMT alone for neck pain for any duration

Midback pain Sciatica Tension-type

headache

Coccydynia TMJ disorders Fibromyalgia Premenstrual

syndrome Pneumonia (older

adults)

Bronfort G et al. Bronfort G et al. 20102010

SMT/mobilization is not effective in adults for:

Asthma Dysmenorrhea Stage 1

hypertension (added to antihypertensive diet)

Bronfort G et al. Bronfort G et al. 20102010

Evidence is inconclusive in SMT/mobilization in children for: Otitis media Enuresis Infantile colic

Bronfort G et al. Bronfort G et al. 20102010

Safety of Chiropractic Manipulation

Randomized controlled trial from 1966-2007

Most adverse events that could be attributed to spinal manipulation were benign and transitory;

However, the data were deemed insufficient to assess their actual prevalence in the general population

NBCE 2010NBCE 2010

Side Effects & Risks of Chiropractic Manipulation

MINOR (common)

Short term soreness Temporary increase in pain Similar to starting exercise programMAJOR (extremely rare)

Disc herniation Cauda equina 1:1 million to 1:100 million

NBCE 2010NBCE 2010

Vertebrobasilar Artery StrokeRetrospective Surveys of Incidence

Swiss Society of Manual Medicine (1985)

1 in 40,000 (slight neurologic complication)

1 in 400,000 (important complication) Based on recall: uncontrolled study

Danish Chiropractic Association (1996)

1 in 1.3 million cervical adjustments.

Murphy D, 2010Murphy D, 2010

Vertebrobasilar Artery Stroke

109,020,875 person-years Observation over a period of nine years 818 patients with VADS 3164 controls without stroke.

Cassidy JD, et al. 2008

Vertebrobasilar Artery Stroke

VBAS is a rare event in the population

Association between VBAS & DC visits in those under 45

Association between VBAS & PCP visits in all age groups

No evidence of excess risk of VBAS associated with chiropractic careCassidy JD, et al. 2008Cassidy JD, et al. 2008

Vertebrobasilar Artery Stroke

“The increased risk of VBAS associated with chiropractic and physician visits is likely explained by patients with VBAS-related neck pain and headache consulting both chiropractors and PCPs before their VBA stroke”

Cassidy JD, et al. 2008Cassidy JD, et al. 2008

Patient Satisfaction Studies

Chronic LBP Chiropractic Medical

Better or much better after 1 month 56% 13%

Worse or much worse after 1 month

14% 35%

Nyiendo et al, 2000Nyiendo et al, 2000

Patient Satisfaction Studies

“There is a growing body of research that documents patient satisfaction with the manner, care, and explanations of treatment by doctors of chiropractic”

Coulter I, 2000Coulter I, 2000

Patient Satisfaction StudiesDepartment of Defense Chiropractic Healthcare Demonstration Project

“Participants who received chiropractic care strongly agree that they had good treatment results compared to those who received medical care”

More satisfaction with DC’s willingness to:

spend time with them explanations of treatments health condition improvements Birch & Davis, 2000Birch & Davis, 2000

Patient Satisfaction StudiesMedicare Demonstration Project 2005-2007

Satisfaction with DC care 10-point scale 10 56% >8 87% Moderate or complete relief

Chiropractic: 60% Other health

professionals: 11%Stason et al, 2010Stason et al, 2010

References1. National Board of Chiropractic Examiners http://www.nbce.org/

2. Council on Chiropractic Education http://www.cce-usa.org/

3. Hurwitz EL et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15;33(4 Suppl):S123-52. http://www.ccgpp.org/documents.htm

4. Lawrence DJ, et al. Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis. J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):659-74. http://www.ccgpp.org/documents.htm

5. Globe GA, et al. Chiropractic management of low back disorders: report from a consensus process. Council on Chiropractic Guidelines and Practice Parameters. J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):651-8. http://www.ccgpp.org/documents.htm

References (cont’d)

6. Bussières AE, Peterson C, Taylor JAM. Diagnostic imaging practice guidelines for adult musculoskeletal complaints: An evidence-based approach:

Introduction: J Manip Phys Therap 2007;30(9):617-83. Part 1: Lower Extremity Disorders. J Manip Phys Therap 2007;30(9):684-717.Part 2: Upper Extremity Disorders. J Manip Phys Therap 2008;31(1):2-32. Part 3: Spinal Disorders. J Manip Phys Therap 2008;31(1):33-88.http://www.sciencedirect.com/science/journal/01614754

7. Cassidy JD, et al. Risk of vertebrobasilar stroke and chiropractic care: Results of a population-based case-control and case-crossover study. Eur Spine J 2008 ; 17 (Suppl I) S176-S183.

8. Murphy D. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession?. Chiropractic & Osteopathy 2010; 18:22.

References (cont’d)

9. Bronfort et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy 2010, 18:3. http://www.chiroandosteo.com/content/18/1/3

10. Bishop PB et al. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. The Spine Journal 2010 (In press).

Acknowledgements

Stephen Perle, DC John Ventura, DC Warren Jahn, DC Michael Hubka, DC West Hartford Group

Contact Information

John A.M. Taylor, DC, DACBR

taylorj@dyc.edu

Cell: 716-548-6343

D’Youville College Chiropractic Health Center

2900 Main Street

Buffalo, NY

716-923-4375