An Open Letter to our Medical friends.

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In the past year, many trusted medical establishments including the FDA (1), CDC (2), Joint Commission (3,4), JAMA (5), and The American College of Physicians/ Annals of Internal Medicine (6) have encouraged medical providers to prescribe spinal manipulation as a first line treatment for acute, subacute, and chronic low back pain.

Most recently, The Lancet echoed that endorsement, and provided a unique perspective:

The reduced emphasis on pharmacological care recommends nonpharmacological care as the first treatment option and reserves pharmacological care for patients for whom nonpharmacological care has not worked. These guidelines endorse the use of exercise and a range of other non- pharmacological therapies, including massage, spinal manipulation, and acupuncture.

Gaps between evidence and practice exist, with limited use of recommended first- line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence. (7)

Unfortunately, personal experience skews our perception of each other’s merit, i.e., we primarily see each other’s failures since the successes don’t need to seek additional care. Regardless of our professional degree, we all have failed cases mixed into our many clinical successes. We must not lose sight of the evidence supporting each other’s overwhelming proven value for a given diagnosis. If we judge each other by our successes rather than our failures, we will work toward an integrated model where the patient wins. Together, we will help more patients than either working alone.

We are honored for the opportunity to co-manage your patients.

 

References
1. FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain. May 2017. Accessed on May 12, 2017
2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain- United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49.
3. The Official Newsletter of The Joint Commission. Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals. July 2017 Volume 37 Number 7. Ahead of print in
2018 Comprehensive Accreditation Manual for Hospitals.
4. Joint Commission Online. Revision to Pain Management Standards. http://www.jointcommission.org/assets/1/23/jconline_november_12_14.pdf
5. Paige NM, Miake-Lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain; Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460.
6. Qaseem A, et al. for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.
7. Foster, Nadine EBuchbinder, Rachelle et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet, Published Online March 21, 2018 http://dx.doi.org/10.1016/ S0140-6736(18)30489-6

How do Chiropractic adjustments help my neck pain?

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We all know what it’s like to have neck pain—whether it’s after a long drive, pinching the phone between the head and shoulder, star-gazing, or from talking to someone who is seated off to the side. There are many causes of neck pain, but the question of the month is, how do chiropractic adjustments help neck pain? Let’s take a look!

Chiropractic, when broken down into its fundamental Greek derivatives, means “hand” (cheir) and “action” (praxis). The technique most often associated with chiropractic is spinal manipulation where a “high velocity, low amplitude” thrust is applied to specific vertebrae in the spine, which does several things: 1) It restores mobility in an area with restricted movement; 2) It stimulates the sensory “neuroreceptors” in joint capsules, which has a muscle relaxing reflex effect; 3) It can affect surrounding neurological structures in certain parts of the spine such as the parasympathetic (cranial & sacral regions) and sympathetic (mid-back) nervous systems, which can have beneficial effects on the digestive system, cardiovascular system, and other body systems not typically thought about when seeking chiropractic care.

Joint manipulation is not new, as it can be traced back to as early as 400 BCE. The profession of chiropractic began in the later 1800s and has grown in popularity ever since. There is now an overwhelming body of evidence that supports spinal manipulation as both a safe and highly effective treatment for neck and back pain, headaches, and many other maladies.

It’s important to note that there are many different types of manual therapies that chiropractors utilize when caring for neck pain patients. There are “low-velocity, low amplitude” or non-thrust techniques that do NOT produce the “crack” that is frequently associated with chiropractic adjustments. The term “mobilization” is often used when referencing these non-thrust methods, and this often incorporates a combination of manual traction (pulling of the neck), left to right and front to back “gliding” movements usually starting lightly and gradually increasing the pressure as tolerated. In many cases, a doctor of chiropractic may utilize a combination of manipulation and mobilization as well as “trigger point therapy” (applying sustained pressure over tight “knots” in muscles), depending on a patient’s needs.

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Chiropractic’s Many Benefits

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In 2010, Dr. Gert Bronfort published a pinnacle report that reviewed studies published up to 2009 and identified 26 categories of conditions for which there is evidence that manual therapies (including spinal manipulation, mobilization, and massage) are beneficial. These 26 categories included thirteen musculoskeletal (MSK) conditions (like low back and neck pain), four types of chronic headache, and nine non-MSK conditions (like infantile colic).

In 2014, the 2010 study was “updated” by Dr. Christine Clar and five colleagues from the Warwick Medical School in the United Kingdom using the same methodologies. They concentrated on the conditions that resulted in a “negative” or an “inconclusive” result in 2010 and either confirmed, updated, or added a new category based on the results of newer research.

After reviewing 25,539 studies, other conditions such as shoulder rotator cuff disorder, cervicogenic headache, and other types of headaches were added to the list. They also added a large number of non-MSK conditions they had not previously considered, of which most were rated ‘inconclusive.’

The 2014 study pointed out the continued need for more high-quality research on many conditions, but it shed light on a significant number of conditions not previously reported in the 2010 study such as TMD (jaw pain), myofascial pain syndrome, active upper trapezius trigger points and neck pain, carpal tunnel syndrome, tennis elbow, shoulder disorders, nerve and muscle pain in the shoulder, plantar fasciitis, arthritis with and without angulation of the great toe (big toe), and many more!

The non-MSK conditions that Dr. Clar and her team found that are in need of further high-quality studies include: asthma, cervicogenic dizziness, hypertension, infantile colic, enuresis, pneumonia/respiratory disorders, dysmenorrhoea, and PMS.  “NEW” categories include: ADHD/learning disorders, cancer care, cerebral palsy, chronic fatigue, chronic pelvic pain, cystic fibrosis, gastrointestinal, menopause, Parkinson’s disease, pregnancy and neonatal and post-natal care, rehabilitation, and peripheral arterial disease.

Obviously, these two studies have taken the quest of determining the current “science” behind many of the claims that doctors of chiropractic have made for many conditions HEAD ON. This is a VERY important step in the right direction so we as healthcare professionals can tell our patients which conditions are likely or not likely to respond to this form of care based on research!

Low speed collision; what happens?

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You may have heard the comment, “If there’s no damage to the car, then there’s no injury.” Unfortunately, that does not always seem to be the case.

There are MANY factors that affect the dynamics of a collision and whether or not injury occurs. A short list includes: vehicle type and design, speed, angle of collision, momentum, acceleration factors, friction, kinetic and potential energy, height, weight, muscle mass, seat back angle and spring, head position upon impact, etc.

Consider Sir Isaac Newton’s Third Law of Motion: “For every action there is an equal and opposite reaction.” This law applies to a car accident at any speed. Using the analogy of hitting a pool ball into the corner pocket straight on, when the cue ball stops, its momentum is transferred to the target ball which accelerates at the same speed…hopefully into the corner pocket!

This example is not quite the same as an automobile collision because the energy transfer is very efficient due in part to the two pool balls not deforming (crushing or breaking) on impact with one another. If either ball did deform, more energy absorption would occur and the acceleration of the second ball would be lower.

In fact, in the United States, vehicle bumpers are tested at 2.5 mph with impact equipment of similar mass with the test vehicle’s brakes disengaged and the transmission in neutral. National Highway Transportation Highway Safety Administration (NHTSA) vehicle safety standards demand that no damage should occur to the car in this scenario.

However, energy transfer occurs very quickly and with a greater amount of force when there is no vehicle deformation (damage). As a result, a greater amount of energy (described as G-force) is directly transferred to the occupants inside the vehicle—increasing the risk of injury. A 1997 Society of Automobile Engineers article provided an example in which the same 25 mph (12 m/s) collision resulted in a five-times greater force on the occupants of the vehicle when the crush distance of the impact fell from 1 meter to .2 meters.

So be aware that even low-speed impacts can still place quite a bit of force on your body, even if the bumper of your car doesn’t have a scratch on it.

Is my Shoulder Pain a SITS Tear?

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One of the most common causes of shoulder pain is a rotator cuff (RC) tear. To determine just how common this is, one study looked at a population of 683 people regardless of whether or not they had shoulder complaints. There were 229 males and 454 females for a total of 1,366 shoulders. (The participants’ average age was 58 years, ranging from 22 to 87 years old.)

The research team found 20.7% had full thickness rotator cuff tears. Of those with shoulder pain, only 36% had tears found on ultrasound. Of those without shoulder pain, 17% also had tears! Risk factors for an increased for tearing of the rotator cuff include a history of trauma, the dominant arm (ie your right arm if you’re right handed), and increasing age.

In a review of radiologic studies of 2,553 shoulders, researchers found full-thickness rotator cuff tears in 11.75% and partial thickness tears in 18.49% of the subjects for a total of 30.24% having some degree of tearing. In this group, about 40% of tears were found in pain-free shoulders. The researchers concluded that rotator cuff tears are common and frequently asymptomatic.

Both of these studies support the necessity to FIRST consider the patient’s clinical presentation and then correlate that with the imaging results. In other words, the presence of a RC tear on an image (usually MRI or ultrasound) does NOT necessarily mean there is pain (and vise versa)!

So what other things could be causing the shoulder pain? There are many: impingement, tendonitis, bursitis, muscle strain, capsular (and other ligament) sprain, frozen shoulder, and osteoarthritis (the “wearing out” type). Also, rheumatoid arthritis, lupus, polymyalgia rheumatica and other autoimmune types of “arthropathies,” fibromyalgia, a herniated cervical disk, shoulder dislocations, whiplash injuries, and more!

Most importantly, we must NOT forget to include referred pain to the shoulder from an impaired heart (such as coronary heart disease or heart attack), lung, liver, or gall bladder as these problems commonly refer pain to the shoulder and may represent a MEDICAL EMERGENCY!

Is your foot causing your knee pain?

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Due to bipedal locomotion (walking around on two legs), foot and ankle problems have the potential to affect EVERYTHING above the feet—even the knees!

When analyzing the way we walk (also known as our gait), we find when the heel strike takes place, the heel and foot motion causes “supination” or the rolling OUT of the ankle. As the unloaded leg begins to swing forwards, there is a quick transition to pronation where the heel and ankle roll inwards and the medial longitudinal arch (MLA) of the foot flattens and pronates NORMALLY!

During the transition from supination to pronation, the flattening of the MLA acts like a spring to propel us forwards followed by the “toe off”, the last phase, as we push off with our big toe and the cycle starts with the other leg. However, if you watch people walk from behind, you will see MANY ankles roll inwards too much. This is call “hyperpronation” and that is NOT NORMAL!

So at what point does this normal pronation become hyperpronation? The answer is NOT black and white, as there is no specific “cut-off” point but rather, a range of abnormal. Hence, we use the terms mild, moderate, and severe hyperpronation to describe the variance or the degrees of abnormality.  Hyperpronation can lead to the development of bunions and foot/ankle instability that can cause and/or contribute to knee, hip, pelvis, and spinal problems—even neck and head complaints can result (the “domino effect”)!

One study looked at the incidence of hyperpronation in 50 subjects who had an anterior cruciate ligament (ACL) rupture vs. 50 without a history of knee / ACL injury. They found the ACL-injured subjects had greater pronation than the noninjured subjects suggesting that the presence of hyperpronation increases the risk of ACL injury.

Doctors of chiropractic are trained to evaluate and treat knee conditions of all kinds. Often this may include prescribing exercises or utilizing foot orthotics in an effort to restore the biomechanics of the foot, which can have positive effects not only on the knees but also further up the body.

Meditation and Chiropractic

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With growing evidence that meditation has significant health benefits, a 2016 study by a team of researchers from the United States, Spain, and France sought to explain how and why meditation actually works.

The study investigated the difference between “mindful meditation” in a group of experienced meditators vs. “quiet non-meditative activity” in a group of untrained control subjects. After eight hours of mindfulness practice, the meditation group showed a range of genetic and molecular differences, which in turn correlated with faster physical recovery from a stressful situation.

According to researchers, this is the first time a study has documented a rapid alteration in gene expression within meditating subjects. Interestingly, the researchers observed these changes in the SAME genes that anti-inflammatory and pain-killing drugs target! Thus, they speculate that mindful-based training may benefit patients with inflammatory conditions! This and prior studies have prompted the American Heart Association to endorse meditation as an effective cardiac preventative intervention.

Meditation has been found to be helpful for many conditions including stress management, lowering high blood pressure, heart disease, and depression. You can incorporate meditation into your life with three simple meditation exercises! The initial advice is “…go slow and be compassionate and gentle with yourself.” Your mind will try to wander (called our “default mode”) which consumes about half of our day, so try to focus (called “focus mode”)!

1)  WALKING MEDITATION: At a slow to medium pace, focus on your feet. Notice how your heel hits the ground and then feel the roll of your foot followed by the big toe pushing off prior to the swing phase. Feel for stones under the foot and other interesting sensations. If your mind starts to wander (default mode), gently bring your attention back to your foot (focus mode). You WILL get better with practice, and you’ll soon find it much easier to “focus” during stressful situations!

2)  NOVEL EXPERIENCES: It’s much easier to lose focus on the people you see everyday vs. those seen only one time a month. The next time you arrive home from work, pretend you haven’t seen your spouse/friend in 30 days. Give them your undivided attention. Then, try this on co-workers and other people you see every day. Believe me, they WILL notice a difference!

3)  GRATITUDE EXERCISES: When you’re not in their presence, focus on a person’s face and send them a “silent gratitude” for being in your life. Try this on family members, friends, co-workers, and others!

When Teens Get Headaches

In 2016, researchers at Curtin University in Perth examined the seated posture and health data of 1,108 17-year olds in an effort to determine if any particular posture increased the risk of headaches/neck pain among late adolescents.

Among four posture subgroups—upright, intermediate, slumped thorax, and forward head—the researchers observed the following: participants who were slumped in their thoracic spine (mid-back region) and had their head forward when they sat were at higher odds of having mild, moderate, or severe depression; participants classified as having a more upright posture exercised more frequently, females were more likely to sit more upright than males; those who were overweight were more likely to sit with a forward neck posture; and taller people were more likely to sit upright.

While they found biopsychosocial factors like exercise frequency, depression, and body mass index (BMI) ARE associated with headaches and neck pain, their data did not suggest any one particular posture increased the risk of neck pain or headaches more than any other posture among the teenagers involved in the study.

This is noteworthy as studies with adults do indicate the risk for neck pain and headaches is greater in individuals with poor neck posture. In particular, postures such as forward head carriage, pinching a phone between the ear and shoulder, and prolonged neck/head rotation outside of neutral can all increase the risk of cervical disorders. This suggests that in younger bodies, the cause of neck pain and headaches may be multifactoral and not limited to just poor posture and that treatment must address all issues that may increase one’s risk for neck pain/headaches in order to reach a desired outcome.

The good news is that chiropractic has long embraced the biopsychosocial model of healthcare, looking at ALL factors that affect back and neck pain and quality of life. Through patient education, spinal manipulation, mobilization, exercise training, the use of modalities, and more, chiropractors can greatly help those struggling with neck pain and headaches!