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In the November 11th, 1998 issue of the Journal of the American Medical Association, (JAMA), David Eisenberg, M.D. published his long awaited follow up study on the use of "Alternative Medicine" in the United States. Several years earlier, Dr. Eisenberg published his initial study that rocked the medical community with his findings of how many people were actually going to what he termed "Alternative Providers".
From inside the medical profession, any other health care profession was known as an alternative. However, the numbers from the Eisenberg study quickly showed that chiropractic and other non-medical forms of health care are not "alternative" in the public's eye.
This new study, conducted in 1997, illustrated some astounding facts and figures.
- Americans spent $27 billion out-of-pocket for alternative therapies in 1997.
- Four out of 10 people used alternative healthcare in 1997.
- Visits to alternative health care providers (mostly chiropractors) increased by almost 50% from 1990.
- The number of visits to alternative health care providers (629 million) exceeded visits to medical providers (only 386 million) visits in 1997 alone.
- Less than 40% of patients tell their medical doctors that they seek alternative therapies.
Researchers also found that 42% of the alternative care was for existing illness while 58% was used for prevention and wellness. These numbers look good for the chiropractic profession, which has built its health care delivery future on wellness. "Many people initially enter the chiropractor's office for a health problem. But many then stay there for the wellness benefits chiropractic has to offer", says Robert Braile, D.C. President of the International Chiropractor Association.
Study shows more people using "alternative" health care.
According to an article in the May 20 issue of The Journal of the American Medical Association (JAMA), more people are turning toward what JAMA terms "Alternative Medicine". Traditionally, chiropractors do not use the term "Alternative Medicine" when referring to the profession of chiropractic, since chiropractic is a drugless natural approach to health. But it is interesting to note how the medical profession views chiropractic and other health approaches they term "alternative".
The article says, "Research both in the United States and abroad suggests that significant numbers of people are involved with various forms of alternative medicine. However, the reasons for such use are, at present, poorly understood. Along with being more educated and reporting poorer health status, the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life." According to John A. Astin, Ph.D., a researcher at Stanford University's School of Medicine in Palo Alto, California who surveyed 1,035 randomly selected people, "Alternative medicine users tend to hold a philosophical orientation toward health that can be described as holistic and are more likely to have had some type of transformational experience that changed their world view in a significant way."
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When patients seek chiropractic care, the focus is on improving ALL aspects of health, not just the presenting complaint of back or neck pain. The “Triangle of Health” is represented by an equilateral triangle where one side represents structure (something that chiropractic SPECIFICALLY manages), chemical (where we look closely at diet and nutrition), and emotional (which includes anxiety, depression, and/or poor coping strategies). If ANY one side of the triangle gets out of balance, it directly affects the other two sides. The goal is to find balance in this triangle of health. So, how does smoking fit into this picture? Let’s take a look!
Tobacco smoking is currently THE LARGEST cause of preventable deaths in the world, as smokers can expect to live seven-to-ten years less and have a three-times greater chance of a premature death than non-smokers, not to mention the poor quality of life with all the co-morbid conditions associated with smoking like COPD, emphysema, asthma, heart disease, and many more!
Many body systems are adversely affected by smoking, and the musculoskeletal system is no exception. Most conscientious surgeons will refuse to perform spine surgical fusions on smokers since the failure rate increases significantly (up to 20%) when compared with non-smokers. It has also been reported that smoking is associated with numerous post-surgical complications and associated costs.
There are many reasons why smoking “stinks” including direct toxic effects of nicotine on the cells that make and break down bone, indirect actions on hormones (adrenal and sex hormones especially), problems with calcium absorption, potential reductions in blood vessel oxygen supply, and more! Smoking may also hasten the onset or aggravate the progression of rheumatoid arthritis and back pain. What about the muscles and tendons? As chiropractors, we treat MANY sprains and strains of the spine and extremities, and negative side effects from smoking have been found in these types of injuries as well.
For example, in rotator cuff (RC) tendonitis of the shoulder, experts note the following: interference with tendon and ligament healing; open and arthroscopic RC repairs found larger tears in those in heavy smokers and smaller tears in those that smoked less (a dose-dependent relationship); a longer the history of heavy smoking increases an individual’s risk of developing a rotator cuff tear AND the degree of injury (a time-dose relationship); smokers also had a 7.5 times higher risk of biceps tendon tears; a greater risk of non-union of fractures and poor union of joint replacements; a reduced blood supply to healing tissues; increased chances for infection due to poor blood supply plus decreased overall immune response; and increased bone death (osteonecrosis) risk.
Not only does smoking increase the occurrence of lung cancer, chronic bronchitis, and coronary heart disease, but it also causes MANY conditions that interfere with longevity, and more importantly, quality of life!
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In the nervous system, there are three primary areas that regulate our balance: the cerebellum (located in the back of the brain), the dorsal columns (located in the back of the spinal cord), and the inner ear (the “vestibular” part of our cranial nerve VIII). There are also small, microscopic “proprioceptors” or mechanical receptors located in our joint capsules, muscles, and tendons that relay information to the brain and work hard to keep us upright when we walk, run, and play!
Conditions that can result in balance problems include, but are not limited to, BPPV (Benign Paroxysmal Positional Vertigo), spinal stenosis (narrowing of the spinal canal where our spinal cord is located), dorsal column disease, cerebellar lesions, and/or circulation loss into the back of the brain.
Other conditions associated with light headedness include low or high blood pressure, hydration, medications, postural or orthostatic hypotension, diabetes, endocrine disorders, hyperventilation, heart conditions, and vasovagal syncope. However, issues with BPPV/inner ear are the most common reported cause of dizziness. Emergency actions should be exercised when dizziness is associated with chest pain, shortness of breath, or palpitations. If eating helps resolve the dizziness, blood testing for hypoglycemia is appropriate.
If confusion, memory lapses, changes in speech, facial droop, weakness on one side of the body, or acute headache occur, these could be signs of a stroke or a brain bleed or tumor and should be quickly evaluated. If ANY of these signs or symptoms is present, we will refer you to the appropriate specialty for further evaluation.
The upper cervical spine has also been found to affect balance, and it’s a primary area of treatment that we as chiropractors focus on when patients complain about balance dysfunction. Unique to this upper cervical region is the fact that the nucleus of cranial nerve V (the trigeminal nerve) extends down the spinal canal to the C2 level and adjustments in this region can have significant benefits for several other conditions, including trigeminal nerve problems as well as BPPV (inner ear dysfunction such as dizziness) where small crystals dislodge from the ampulla of the semicircular canal and interfere with the flow of fluid inside the canal with resulting dizziness. Adjustments and the BPPV exercises (Epley’s and / or Brandt-Daroff) significantly benefit this cause of dizziness. You can depend on our evaluation to determine if chiropractic is the right choice in managing your balance disturbance!
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The Importance of Understanding the Relationship Between Vehicle Crush and Patient Injury
The headline and front-page photographs were stunning and unbelievable. On Saturday, November 22, 2014, the front page of the San Francisco Chronicle newspaper led with this headline (1):
11-Story Plummet: What Onlookers Saw
“The first inkling that office workers scurrying along Montgomery Street had that something was wrong came when they looked up to see a blue blur falling from the sky. Some thought it was debris—but then it got closer, and the crowd began to scream and scatter. It was a man, plummeting 11 stories towards them.”
“With a thump and a crash of shattering glass, the middle – aged window washer smashed into a moving car just after 10 a.m. Friday morning. He lay wincing and miraculously alive …on the crumpled roof of a green Toyota Camry.”
Peter Melton, from the California Department of Industrial Relations, noted:
“It seems pretty clear the cushioning of the car he fell onto kept him alive.”
The universe and our world are under the control of the principles of math, physics, chemistry, etc. The principles of inertia have likewise always been with us, but they were not officially acknowledged through publication until Isaac Newton wrote, in the year 1687, the book Mathematical Principles of Natural Philosophy.
Inertia is the resistance of a physical object to any change in its state of motion or rest. As often stated, an object in motion will remain in motion unless an outside force acts upon that object. Likewise, an object at rest will remain at rest unless an outside force acts upon that object.
When the laws of inertia are applied to a whiplash injury, it is quickly pointed out that different parts of a single object can have different inertias, depending upon how the object’s mass is distributed. Specifically the human body (a single object) can have different inertias between the trunk and the head. In a rear-end motor vehicle collision, the struck vehicle, its seat, and trunk of the occupant are quickly propelled forward, while the head, having its own inertial mass, will remain at rest. The head remains still, while the body is moved forward, under the head. This gives the appearance that the head is extending upon the trunk, the so-called “hyperextension” phase of a rear-end motor vehicle collision.
Hyperextension As Trunk Is Pushed Under Head
Under these circumstances, the most vulnerable body part to injury is not the trunk nor the head, but rather the part of the body that balances these two larger inertial masses to each other, the neck. Because of the large inertial masses of the trunk and the head, the neck is historically very vulnerable to “inertial injury.” In this context, an “inertial injury” means that there is no direct blow or contact injury to the neck.
A horrible example of a neck inertial injury is the injury sustained in “shaken baby syndrome.” The violent shaking of the baby’s trunk causes the baby’s head to inertially “bounce” on the neck, often leading to catastrophic neck injuries. The neck and spinal cord can sustain horrific injuries, even though there is no direct blow to the head or neck of the child; these are inertial injuries.
Cervical spine (neck) inertial injuries caused by motor vehicle collisions are the rule, and their occurrence is not controversial. Yet, because there are many pain-producing tissues in the neck (discs, facet capsules, ligaments, muscles, tendons, nerves, bone, skin, etc.), research has been conducted to determine if there is one particular tissue in the neck that might be responsible for the predominance of whiplash mechanism induced cervical spine inertial injury pain. Alas, one such tissue has been identified. It is the facet joint capsular ligaments (2, 3, 4, 5, 6, 7, 8). In fact, in 2002, Nikolai Bogduk, MD, PhD, states of the Uhrenholt study (4) in the following, attached, Point Of View:
This study has “harvested the best available evidence concerning the possible pathology of whiplash.”
The credibility of these injuries is enhanced because different lines of investigation, using totally independent methods, point to the same conclusion. “This constitutes convergent validity.”
“In the case of whiplash, postmortem studies, biomechanics studies, and clinical studies converge.”
“Postmortem studies point to lesions in the zygapophysial [facet] joints.”
“Biomechanical studies show how these joints can be injured to produce the lesions seen at mortem.”
“Clinical studies have shown that zygapophysial [facet] joint pain is common in patients with chronic neck pain after whiplash.”
“All three lines of investigation point to the same culprit,” the facet joint.
Chiropractic spinal adjusting (manipulation) affects the facet joints. As described by Canadian Orthopedic Surgeon and Professor, William Kirkaldy-Willis, MD (9):
“Spinal manipulation is essentially an assisted passive motion applied to the spinal apophyseal [facet] and sacroiliac joints.”
There are mechanical neurophysiological explanations as to how spinal manipulation inhibits pain. The most accepted of these involve the use of the Gate Theory by Ronald Melzack and Patrick Wall (10, 11), established more than 50 years ago. This Gate Theory has survived the test of time (12). As described by R. Kirkaldy-Willis (9):
Melzack and Wall proposed the Gate Theory of Pain in 1965, and this theory has “withstood rigorous scientific scrutiny.”
“The central transmission of pain can be blocked by increased proprioceptive input.” Pain is facilitated by “lack of proprioceptive input.” This is why it is important for “early mobilization to control pain after musculoskeletal injury.”
The facet capsules are densely populated with mechanoreceptors. “Increased proprioceptive input in the form of spinal mobility tends to decrease the central transmission of pain from adjacent spinal structures by closing the gate. Any therapy which induces motion into articular structures will help inhibit pain transmission by this means.”
A number of important studies have documented the remarkable benefit of cervical spine (neck) joint manipulation (adjustment) for neck pain including for chronic whiplash mechanism neck pain. A few such studies include these (13, 14, 15, 16):
In 1996, the journal Injury published a study titled (13):
Chiropractic treatment of chronic ‘whiplash’ injuries
The authors of this study are from the University Department of Orthopaedic Surgery, Bristol, UK. The authors retrospectively evaluated the effects of chiropractic in a group of 28 patients who had been referred with chronic ‘whiplash’ syndrome. The 28 chronic whiplash patients in this study were treated by a chiropractor using “specific spinal manipulation, proprioceptive neuromuscular facilitation, and cryotherapy.” The treatment was evaluated by an independent orthopedic surgeon, M. Woodward, who was blinded as to the treatment. The results showed that following chiropractic treatment, 93% of the patients had improved. The authors stated:
“The results of this retrospective study would suggest that benefits can occur in over 90% of patients undergoing chiropractic treatment for chronic whiplash injury.”
In 1999, a second article pertaining to the chiropractic management of chronic whiplash appeared in the Journal of Orthopedic Medicine, and is titled (14):
A symptomatic classification of whiplash injury and the implications for treatment
In this study, the authors retrospectively evaluated 93 consecutive patients seen in chiropractic clinics for chronic whiplash symptoms. All patients underwent spinal manipulation, a high velocity, low amplitude thrust to a specific vertebral segment by a licensed chiropractor. These authors made the following points and conclusions:
“Conventional treatment of patients with whiplash symptoms is disappointing.”
“In chronic cases, no conventional treatment has proved successful.”
“Chiropractic is the only proven effective treatment in chronic [whiplash] cases.”
“Our results confirm the efficacy of chiropractic, with 69 of our 93 patients (74%) improving following treatment.”
“The results from this study provide further evidence that chiropractic is an effective treatment for chronic whiplash symptoms.”
In 2002, physical therapist Jan Hoving and colleagues published a randomized clinical trial in the treatment of acute neck pain involving physician care v. exercise v. manual manipulative therapy. The article was published in the Annals of Internal Medicine and titled (15):
Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain A Randomized, Controlled Trial
In this study, “Manual Therapy” was defined as:
“Orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities.”
These authors made the following points and conclusions:
“At 7 weeks, the success rates were 68.3% for manual therapy, 50.8% for physical therapy, and 35.9% for continued [physician] care.”
“Manual therapy scored consistently better than the other two interventions on most outcome measures.”
“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.”
“Primary care physicians should consider manual therapy when treating patients with neck pain.”
“The success rates for manual therapy were statistically significantly higher than those for physical therapy.”
“Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued [physician] care.”
“In our study, mobilization, the passive component of the manual therapy strategy, formed the main contrast with physical therapy or continued care and was considered to be the most effective component.”
In 2012, Gert Bronfort, DC, PhD, and colleagues from Northwestern Health Science University, published a study in the Annals of Internal Medicine, titled (16):
Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain A Randomized Trial
This study sought to determine the relative efficacy of spinal manipulation therapy (SMT), medication, and home exercise with advice (HEA) for acute and subacute neck pain in both the short and long term. This was a randomized, controlled trial using 272 subjects aged 18 to 65 years who had nonspecific neck pain for 2 to 12 weeks. The intervention was 12 weeks of SMT, medication, or HEA.
The primary measurement outcome was participant-rated pain, measured at 2, 4, 8, 12, 26, and 52 weeks after randomization. Secondary measures were self-reported disability, global improvement, medication use, satisfaction, general health status (Short Form-36 Health Survey physical and mental health scales), and adverse events. The main conclusion from these authors is:
“For [neck] pain, SMT had a statistically significant advantage over medication after 8, 12, 26, and 52 weeks.”
“For participants with acute and subacute neck pain, SMT was more effective than medication in both the short and long term. However, a few instructional sessions of HEA resulted in similar outcomes at most time points.”
“Our results suggest that SMT and HEA both constitute viable treatment options for managing acute and subacute mechanical neck pain.”
This study clearly shows the superiority of chiropractic spinal manipulation over pharmacologic management of patients suffering from acute and subacute neck pain. However, the findings that chiropractic spinal manipulation and home exercise with advice (HEA) achieved similar results on these patients requires discussion.
The printed words in the article suggest that chiropractic spinal adjusting and home exercise/advice are essentially equal in the management of acute and subacute neck pain. Yet, a careful review of the measured markers presented in the article show that chiropractic adjustments were nearly always superior to those from home exercise/advice. As examples, nine markers are listed for “Portion With Absolute Reduction In Pain”: spinal adjusting was superior in 8 of 9 of the listed markers. Six markers are listed for “Pain Score”: spinal adjusting was superior in 5 of the 6 markers listed.
Additionally, a careful review of the charts presented in the article show that during the randomization, nearly twice as many of the chiropractic group (29.7%) had trauma initiated neck pain compared to the home exercise/advice group (16.5%). Trauma triggered neck pain is always more difficult to manage in both the short and long term as compared to non-trauma triggered neck pain. It appears that the chiropractors had a “tougher” patient draw as compared to the home exercise /advice group. This finding was not discussed in the text of the article.
Although the article states several times that the chiropractic adjustments were given over a period of 12 weeks, the actual range of adjustments was 2-23 with a mean of 15.3. This is slightly more than 1 adjustment per week for 12 weeks. In contrast, the home exercise/advice group was seen only 1 or 2 times, but instructed to do neck exercises at home daily. The exercises consisted of 7 isolated maneuvers that required 3 different positions: sitting, supine head supported, and supine head unsupported. Each maneuver required 10 repetitions, and the patient was instructed to repeat all of the maneuvers 6-8 times per day. Performing the exercise maneuvers as prescribed takes approximately 10 minutes per session. As such, the authors are advocating that patients with acute/subacute neck pain exercise 60-80 minutes per day. This is both impractical and unrealistic.
Back to the “Protection of Crush”
Can a patient involved in a vehicle-to-vehicle collision sustain a crushing type of injury? Yes, of course. However, outside of the emergency department, such injuries are quite rare. Rather, chiropractors primarily treat whiplash inertial injuries, as noted above.
The inertial injuries sustained by the occupant of a struck motor vehicle is dependent upon the rate of struck vehicle acceleration, and distance such vehicle moved (17). Consequently, anything that reduces the forward acceleration of the struck vehicle will reduce inertial injuries to the occupants of that vehicle. Interestingly, one factor that reduces the acceleration of the struck vehicle is the “crushing” of that vehicle.
World-class pole vaulters routinely clear a bar that is approximately 20 feet high.
What goes up must come down. To protect the athlete, the landing pit is constructed of foam. Imagine what the consequences would be if the landing pit were made of concrete; the landing athlete would no doubt be injured.
The foam in the landing pit protects the athlete because it “crushes” when the athlete lands on it. It is precisely this crushing that dissipates the energy from the falling athlete, protecting her/him from injury. In contrast, concrete would not crush and disperse the energy, and the athlete would be injured.
These injury-sparing principles apply to motor vehicle collisions. When a struck vehicle crushes, it dispersed energy that otherwise would accelerate the vehicle, increasing occupant inertial injuries. This concept has been recognized for decades and is often published. As an example, in 1982, Ian MacNab, MD, succinctly states (17):
“The amount of damage sustained by the car bears little relationship to the force applied. To take an extreme example: If the car was stuck in concrete, the damage sustained [crush] might be very great but the occupants would not be injured because the car could not move forward, whereas, on ice, the damage to the car could be slight but the injuries sustained might be severe because of the rapid accelerations permitted.”
The point is that vehicle “crush” is protective of the occupant because it dispersed energy that would otherwise increase the vehicle’s acceleration. In the opening story, the crushing of the roof of the falling window washer was certainly responsible for saving his life. Of course, this all changes if the vehicle is crushed so severely that the occupant also sustains a “crushing” injury.
Other studies that support this “crushing” principle include:
• In 1986, the Journal of Musculoskeletal Medicine publish a study titled (18):
Objective Findings for the Diagnosis “Whiplash”
The amount of damage to the automobile bears little relationship to the force applied to the cervical spine of the occupants. The acceleration of the occupant’s head depends upon the force imparted, the moment of inertia of the struck vehicle, and the amount of collapse of force dissemination by the crumpling [crushing] of the vehicle.
• In 1989, the journal of the Society of Automotive Engineers, published a study titled (19):
Whiplash in Low Speed Vehicle Collisions
“…experimental results indicate that some vehicles can withstand a reasonable high speed impact without significant structural damage [crush]. The resulting occupant motions are marked by a lag interval, followed by a potentially dangerous acceleration up to speeds greater that of the vehicle.
As the vehicle becomes stiffer [less crush], the vehicle damage costs are reduced as less permanent deformation takes place. However, the occupant experiences a more violent ride which increases the potential for injury.
…the average acceleration experienced by the occupant in the elastic [no crush] vehicle would be approximately twice that of the plastic [crushed] vehicle. This theory implies that vehicles which do not sustain damage [crush] in low speed impacts can produce correspondingly higher dynamic loadings on their occupants than those which plastically deform under the same of more severe impact conditions.”
• In 1993, the journal Trial Talk published a study titled (20):
The Physics, Biomechanics and Statistics of Automobile Rear Impact Collisions
“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 [crushing] the vehicle must be converted into kinetic energy, the source of injuries.”
• In 1997, the journal of the Society of Automotive Engineers published a study titled (21):
Lack of Relationship Between Vehicle Damage and Occupant Injury
Using a mathematical analysis and examples from a pole vaulter and high performance racing car crashes, this article explains vehicle crush actually reduces injury to occupants. The author notes that racing cars are designed with state-of-the-art crash engineering. When racing cars are in a collision, they appear to almost shed their body structure and crush in almost every direction. This design is to dissipate energy in a collision and reduce injurious peak G forces to the occupant. The results are very low driver injury rates, even though the collisions involve very high speeds.
“… the body of the racing car is sacrificed to prevent driver injury or death.”
• In 2005, the Journal of Neurology, Neurosurgery, and Psychiatry published a study titled (22):
Whiplash Following Rear-end Collisions: A Prospective Cohort Study
“It is surprising that it has not been possible to relate estimated striking speeds to early whiplash or to any measure of neck pain severity either early on or at 1 year.”
In this study, driving a large car and being struck increased the risk of neck pain. This “seems counterintuitive.” “Large cars are less likely to deform [crush] and therefore more of the energy of the collision was transmitted to the occupants.”
- Although it is counter-intuitive, vehicle crushing actually protects vehicle occupants from inertial injuries. This is important because inertial injuries are the most common injury seen in clinical practice. In contrast, lack of vehicle damage can occur in the presence of significant vehicle acceleration and accompanying inertial injury to the vehicle’s occupants.
- The primary inertial injury sustained in those who experience vehicle-to-vehicle collisions is to the facet joint capsules of the cervical spinal joints.
- Chiropractic spinal adjusting is proven to be effective in the majority of patients with facet joint injuries and pain syndromes.
On December 6, 2014, the newspaper San Francisco Chronicle published an update on the clinical status of the window-washer (23). The article noted that the 58 year-old man had plunged 130 feet and had fractured his pelvis and his right arm, but that he did not suffer any major head injury. He is breathing on his own and he is talking. The man who was driving the vehicle the window-washer fell on said:
“God wanted me to be there just at the moment the poor man fell.”
Absent landing on a passing vehicle and crushing its roof, the window-washer would not have survived.
The Chiropractic Impact Report™ is a monthly publication by myself, Dan Murphy, DC. I am a 1978 graduate of Western States Chiropractic College in Portland, OR. I have managed about 10,000 whiplash-injury cases. In the past 32 years, I have taught more than 500 12-hour post graduate continuing education classes pertaining to whiplash and spinal trauma, including 21 years of coordinating a year-long certification program in spine trauma, certified through the International Chiropractic Association. Additionally, I am board certified in chiropractic orthopedics (DABCO), and I am on the faculty at Life Chiropractic College West in Hayward, CA (28 years).
The purpose of The Chiropractic Impact Report™ is to keep you updated as to relevant academic concepts pertaining to whiplash-injured patients. The hope is that the information is useful in terms of enhanced understanding, as well as helping the personal injury attorney deal with insurance claim adjusters and adverse medical experts.
The chiropractor sending you this Report is well versed and trained in these concepts, and can be a valuable asset in personal injury cases in terms of both academics and treatment. Additionally, these expert chiropractors have access to a monthly phone consultation with me to discuss any pertinent issues that they may be facing on a particular case. I hope that you find this Report and the referring chiropractor a valuable resource.
Daniel J. Murphy DC, DABCO
- Aleaziz H, Gagan K; 11-story plummet: what onlookers saw; San Francisco Chronicle; November 22, 2014, A1 and A9.
- Bogduk N, Aprill C. On the nature of neck pain, discography and cervical zygapophysial joint blocks; Pain; August 1993;54(2):213-7.
- Kaneoka K, Ono K, Inami S, Hayashi K; Motion analysis of cervical vertebrae during whiplash loading. Spine. 1999 Apr 15;24(8):763-9.
- Uhrenholt L, Grunet-Nilsson N, Hartvigsen J; Cervical spine lesions after road traffic accidents: a systematic review; Spine;2002 Sep 1;27(17):1934-41.
- Pearson AM, Ivancic, Ito S, Panjabi MM; Facet joint kinematics and injury mechanisms during simulated whiplash; Spine; 2004 Feb. 15; 29(4):390-7.
- Barnsley L, Lord SM, Wallis BJ, Bogduk N; The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine. 1995 Jan 1;20(1):20-5.
- Lord SM, Barnsley L, Wallis BJ, Bogduk N; Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study;
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Total Health Spending
Health Care as
Growth in Total Spending
In 2012 (the most recently available data), approximately 44% of the United States costs of Health Care were paid by government (Federal and State) agencies. This would amount to approximately $1.23 trillion.
This escalation in Health Care spending, especially by government agencies, has mandated an approach for cost containment, hopefully without compromising the quality of health care. The contemporary approach in this effort is called “Evidenced-Based Medicine.”
Evidence Based Medicine has been around for centuries, but its proponents have become increasingly organized in the 1990s. As an example, in 1996, the British Medical Journal published an editorial titled (2):
Evidence Based Medicine: What it is and What it isn’t
This article describes Evidence Based Medicine as:
“Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”
The accepted delivery of healthcare in the United States is increasingly becoming “Evidence Based.” A necessary component for the implementation of Evidence Based Medicine is the development and use of Clinical Practice Guidelines. As stated in the journal Health Affairs in 2005 (3):
“One common implementation of Evidence Based Medicine involves the use of clinical practice guidelines during medical decision making to encourage effective care.”
Evidence Based Medicine is not without criticism. A common criticism is that practice guidelines take the “doctoring” out of being a doctor. Doctors are increasingly being judged by Evidence Based Practice Guidelines. Doctors were (are) often questioned about their treatment approach to a particular patient when the approach varied from Evidence Based Practice Guidelines. Again, in 2005, the journal Health Affairs published a study titled (3) The Promises And Pitfalls Of Evidence-Based Medicine, which states:
“While advocates welcome the stronger scientific foundation of such guidelines, critics fear that they will lead to ‘cookbook medicine’.”
Another criticism of Evidence Based Practice Guidelines is that sometimes, “evidence” will “slip through the cracks.” As an example, apparently Evidence Based Practice Guidelines pertaining to the management of Low Back Pain, worldwide, advocate the use of the drug acetaminophen (the primary ingredient in Tylenol) as the first line treatment for acute low back pain. Astonishingly, this advice had never been subjected to the “gold standard” of evidence, the “double-blind, randomized controlled clinical trial.” Such a trial was completed last year, and published (November 1, 2014) in the journal The Lancet, and titled (4):
Efficacy of Paracetamol [Tylenol] for Acute Low-back Pain:
A Double-blind, Randomised Controlled Trial
The authors for this study are from the Sydney Medical School, Sydney, Australia. The study was a multicenter, double-blind, randomized, placebo controlled trial involving 1,652 patients with acute low-back pain. The authors made the following points:
- Low-back pain is the leading cause of disability worldwide.
- Guidelines for acute low-back pain universally recommend paracetamol [Tylenol] as the first-line analgesic; No direct evidence supports this universal recommendation.
- Regular paracetamol is the recommended first-line analgesic for acute low-back pain; however, no high-quality evidence supports this recommendation.
- There was no difference between treatment groups for time to recovery in this study.
“Our findings suggest that regular or as-needed dosing with paracetamol does not affect recovery time compared with placebo in low-back pain, and question the universal endorsement of paracetamol in this patient group.”
“Although guidelines endorse paracetamol for acute low-back pain, this recommendation is based on scarce evidence.”
“Neither regular nor as-needed paracetamol improved recovery time or pain intensity, disability, function, global change in symptoms, sleep, or quality of life at any stage during a 3- month follow up.”
The results of this study “suggest that simple analgesics such as paracetamol might not be of primary importance in the management of acute low-back pain, and the universal recommendation in clinical practice guidelines to provide paracetamol as a first-line treatment should be reconsidered.”
“Our results convey the need to reconsider the universal endorsement of paracetamol in clinical practice guidelines as first-line care for low-back pain.”
A follow-up Comment made in The Lancet pertaining to this study stated (5):
“Do patients with acute low-back pain need paracetamol?”
The findings of the Paracetamol for Low-Back Pain Study, show that paracetamol was not more effective than placebo in patients with acute low-back pain.
“In a well-designed and large clinical trial in Australia, 1652 patients with acute low-back pain were randomly assigned to receive paracetamol in regular doses, paracetamol as needed, or placebo.” The investigators reported no differences in the primary outcome (time to recovery) in any of the groups.
“Nor were differences recorded in secondary outcomes (eg, pain intensity, disability, symptom change, and function) between the three study groups.”
“This study is the first randomised clinical trial to assess paracetamol versus placebo for patients with acute low-back pain, and its results could have a substantial effect on the management of patients with low-back pain. Worldwide, national clinical guidelines recommend paracetamol as the first choice for prescribed analgesics for acute low-back pain.”
Evidence Based Guidelines for the chiropractic management of spinal problems began in 1992 with the publication of Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference (6). These Guidelines are often referred to as the “Mercy Guidelines,” named after the location of the conference, the Mercy Conference Center in Burlingame, CA.
In 1989, the United States federal government established the Agency for Health Care Policy and Research. At that time the message was clear – either the health professions developed their own guidelines or third parties would impose them. The task of attempting to do something for the chiropractic profession was taken up by the Congress of Chiropractic State Associations or COCSA. Through a slow and detailed process, 35 chiropractors participated in developing a consensus document on chiropractic quality assurance and parameters of practice. The group had broad support from chiropractic colleges and organizations.
Despite being 23 years old, the Mercy Guidelines set the stage for more contemporary guidelines. The Mercy Guidelines make the following statements:
- “These recommendations do not give a ‘cookbook’ approach to the duration of care or number of treatments.”
- “They are NOT designed as a prescriptive or cookbook procedure for determining the absolute frequency and duration of treatment/care for any specific case.”
- “Note: statistical descriptions of treatment frequency such as mean/median/mode, should NOT be used as a standard to judge care administered to an INDIVIDUAL patient.”
Today, there are a number of guidelines for the management of spinal problems, including the recent, comprehensive, and authoritative Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain that was published in the October 2007 issue of the journal Annals of Internal Medicine. An extensive panel of qualified experts constructed these clinical practice guidelines. These experts performed a review of the literature on the topic and then graded the validity of each study. The literature search for this guideline included studies from MEDLINE (1966 through November 2006), the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and EMBASE. This project was commissioned as a joint effort of the American College of Physicians and the American Pain Society. The specific document pertaining to the chiropractic profession is titled (7):
Non-pharmacologic Therapies for Acute and Chronic Low Back Pain:
A Review of the Evidence for an American Pain Society
And American College of Physicians Clinical Practice Guideline
This article is probably the most comprehensive review of the literature concerning non-drug therapies used in the treatment of low back pain. It was prepared for the American Pain Society and the American College of Physicians Clinical Practice Guideline. These authors note that there are many non-pharmacologic therapies available for treatment of low back pain. They therefore assessed the benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain). This article has 188 references.
Importantly, the Co-chairs and members of the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel included one chiropractor, Donald R. Murphy, DC, DACAN.
The following chart summarizes the guideline’s recommendations for the treatment of acute, sub-acute, and chronic low back pain. Importantly, the only treatment approved for all three stages of low back pain is spinal manipulation.
The Following Chart Summarizes The Treatment Benefit For Low Back Pain
|Low-Level Laser Therapy||no||no||yes|
A central theme in Evidence Based Guidelines is that treatment should be reasonable and necessary. To establish that treatment is reasonable and necessary, the treating clinician should be using measurement outcomes.
Measurement Outcomes measure the health status of a patient before treatment, and then again after treatment (or a series of treatments) is/are performed. If the post treatment measurement outcome shows improvement, it is classically interpreted that the treatment was both reasonable and necessary. When measurement outcomes stop improving, it means that the patient’s clinical status has reached maximum improvement, or that a different clinical approach may be warranted.
There are literally hundreds of measurement outcomes available for health care providers. Each discipline of health care has developed recognized measurement outcomes that best serve their disciplines and patient’s needs. Chiropractors and other musculoskeletal disciplines often use the same measurement outcomes. These same measurement outcomes are often used in musculoskeletal research. For example, note:
- The number one ranked musculoskeletal journal in the world is the journal Spine. Spine is the official journal of publication for the world’s top thirteen orthopedic societies. In 2003, Spine published a study using the “gold standard” randomized clinical trial, comparing the benefits of prescription non-steroidal anti-inflammatory drugs (NSAIDs) to needle acupuncture to chiropractic spinal manipulation (adjusting) in patients suffering from chronic back and neck pain (8).
- The study evaluated patient progress using standard and accepted measurement outcomes:
- Oswestry Back Pain Disability Index (ODI)
- Neck Disability Index (NDI)
- Visual analog scales (VAS)
- Using these measurement outcomes, it was shown that needle acupuncture was twice as effective than the drugs in improving the patient’s pain and disability. Chiropractic spinal adjusting was better than five times more effective than the drugs. Also, importantly, only those receiving chiropractic spinal adjusting showed a long-term clinical benefit at the one-year follow-up assessment (9).
Asymptomatic within 9 weeks
Another research example using measurement outcomes is a study published in the journal Public Library of Science ONE (PloS One) in 2011 (10). The authors, from Harvard’s Medical School, used Positron Emission Tomography (PET) imaging to assess residual inflammation on patients suffering from chronic whiplash injuries. The authors used standard measurement outcomes to assess the patient’s clinical status:
- Neck Disability Index (NDI)
- Visual analog scales (VAS)
The authors showed that chronic whiplash patients do have regions of chronic inflammation that are consistent with their complaints, and that matched normal controls do not have these inflammatory regions. They conclude that their findings support an anatomical basis for chronic whiplash pain.
Clinically, measurement outcomes are primarily used for two purposes:
- To show that the treatment given was reasonable and necessary.
- To determine when the patients clinical status has reached maximum improvement.
Essentially, if measurement outcomes show progressive improvement in a patient’s clinical status, it means that the treatment given was reasonable and necessary, and that continued treatment is warranted. Additional treatment is warranted as long as the patient’s clinical status continues to improve.
In contrast, if measurement outcomes no longer show improvement, it is often interpreted as meaning that the patient’s clinical status had reached maximum improvement, and additional scheduled treatment may not be warranted. As an example, California chronic pain specialist, Jerome Schofferman, MD, used standard measurement outcomes to determine the recovery rate of people injured in motor vehicle accidents (11). Patients were treated until they became pain free, or until they reached maximum improvement, as assessed with measurement outcomes. Maximum improvement was determined to be when there was no significant change in symptoms and measurement outcomes for approximately 8 weeks.
Interestingly, the mean duration of treatment was 29 weeks (7 months 1 week); the range of treatment was 8 weeks (2 months) to 108 weeks (2 years and 1 month).
Secondary reasons to use measurement outcomes include:
- To document long-term or permanent symptoms and/or disabilities for a particular patient.
- To help apportion treatment, residual symptoms and permanent disabilities.
Reading the literature and a number of practice guidelines, the most important measurement outcomes for chiropractors are these:
- Quantify the symptoms with the Visual Analog Scale (VAS).
- Use a standard Pain Drawing, ideally large enough for the patient to mark individual fingers and toes.
- The Oswestry Back Pain Disability Index (ODI).
- The Neck Disability Index (NDI).
- Samples of the Visual Analog Scale and Pain Drawing are attached.
- The frequency of the use of measurement outcomes is at the discretion of the treating doctor, but here are a few suggestions:
- All four of these should be used as a component of initial patient intake. The exception is that there is no need to do the Oswestry if the patient has no low back complaints, and there is no need to do the Neck Disability Index if the patient has no neck complaints.
- For patients under active care, these measurement outcomes should be completed at least once per month.
- For patients under maintenance care, these measurement outcomes should be completed at least once every 10-12 patient visits.
- At the discretion of the treating doctor, the Visual Analog Scale of the patient’s major symptoms may be done every visit.
- At the discretion of the treating doctor, the Pain Drawing may also be done every visit.
Measurement outcomes are now a standard component of contemporary clinical practice, including for chiropractors. Using measurement outcomes are an invaluable tool for the modern health care provider. Failure to use measurement outcomes invites criticism and conflict. Future health providers will be increasingly judged by their use of measurement outcomes and their results.
- Wilson KB; Health Care Costs 101: US Health Care Spending; California HealthCare Foundation; www.chcf.org.
- Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WE; Editorials: Evidence based medicine: what it is and what it isn’t; British Medical Journal; January 13, 1996; 312:71.
- Timmermans S, Mauck A; The Promises And Pitfalls Of Evidence-Based Medicine; Health Affairs; January 2005; Vol. 24; No. 1; pp. 18-28.
- Williams CM, Maher CG, Latimer J, McLachlan AJ, Hancock MJ, Day RO, Lin CW; Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014 Nov 1;384(9954):1586-96.
- Koes BW, Enthoven WT; Do patients with acute low-back pain need paracetamol?; The Lancet; July 24, 2014 (published online).
- Haldeman S, Chapman-Smith D, Peterson DM; Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference; Aspen publications; 1992.
- Chou R, Huffman LH; Non-pharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society And American College of Physicians Clinical Practice Guideline; Annals of Internal Medicine; October 2007, Volume 147, Number 7, pp. 492-504.
- Giles LGF, Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine July 15, 2003; 28(14):1490-1502.
- Muller R, Giles LGF; Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes; Journal of Manipulative and Physiological Therapeutics; January 2005, Vol. 28; No. 1; pp. 3-11.
- Linnman C, Appel L, Fredrikson M, Gordh T, Soderlund A, Langstrom B, Engler H; Elevated [11C]-D-Deprenyl Uptake in Chronic Whiplash Associated Disorder Suggests Persistent Musculoskeletal Inflammation; Public Library of Medicine (PLoS) ONE; April 6, 2011, Vol. 6 No. 4, pp. e19182.
- Schofferman J, Wasserman S; Successful treatment of low back pain and neck pain after a motor vehicle accident despite litigation; Spine; May 1, 1994;19(9):1007-10.
“Authored by Dan Murphy, D.C.. Published by ChiroTrust™ – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”
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