Safety of Chiropractic Care - Neck Manipulation

The efficacy of spinal manipulative therapy (SMT) has been a topic of research for more than 20 years now and has subsequently been recognized as such in at least four countries which has led to increased integration of chiropractors into mainstream healthcare.[1] This greater predominance has led to questions regarding the possibility of complications due to SMT, especially with respect to manipulation of the cervical spine (neck).

This was never more prevalent than after two tragic events following chiropractic care in Canada in the 1990s which spurred rabid media attention and an adamant stance by the neurology community to avoid cervical manipulation as a treatment for neck pain.[2] These events have no less been the provocative factor for the publication of several case reports in which chiropractors have been incorrectly identified as the practitioner responsible for injuries related to SMT.[3] This fact is inescapable when reviewing two articles published in the Journal of Neurology where the authors cite 46 cases involving stroke and/or vertebral artery dissection due to “chiropractic manipulation”. Truth be told only FOUR (4) of the cases involved chiropractors the remaining 42 cases (91%) of injury due to cervical manipulation were induced by 25 -orthopedists, 6 -physical therapists, 1 -neurologist, 2 -Primary Care Physicians, 1 -homeopath, 2 -“health practitioners”, and the rest “remained unreported”.[4][5][6] Admittedly there is inherent risk, albeit minimal, associated with neck manipulation but all forms of therapeutic intervention come with risk and some are far greater than SMT.

 Take for instance the most common “quick fix” for musculoskeletal pain, non-steroidal anti-inflammatories [NSAIDs] (i.e. Advil, Aleve, Motrin, Tylenol). Medical studies published during the 1990s found that hospitalizations due to gastrointestinal complications from NSAIDs range from 32,000 - 103,000 while NSAID related deaths average out at 9,850 ANNUALLY in the United States alone![7][8][9] In fact the Food and Drug Administration reports that the largest cause of drug overdose in the United States is acetaminophen (Tylenol) which by itself is responsible for 56,000 emergency room visits, 2,600 hospitalizations, and 458 deaths due to acute liver failure EVERY YEAR![10] The one-year risks of experiencing complications due to prolonged NSAID use are simply staggering: [11]

Severe gastrointestinal bleeding:

            - Adults younger than 45 = 1 in 2,100

            - Adults older than 75 = 1 in 110

Death:

            - Adults younger than 45 = 1 in 12,353

            - Adults older than 75 = 1 in 647

These non-prescription pain relievers have become an accepted form of musculoskeletal pain relief yet their catastrophic effects have never been as scrutinized as spinal manipulative therapy which has been scientifically proven to be more effective in relieving neck pain and headache[12] with statistically infinitesimal risk of serious adverse reaction.

A population based study published in Neurology in 2006 discovered that over a 16 year period (1987-2003) the incidence rate of  strokes due to arterial dissection (ICAD and VAD) affected only 0.97 - 1.72 residents per 100,000 annually within the defined community (Olmsted County, MN).[13] These findings regarded the population in general since reliable epidemiological data was not available. A subsequent population-based case control and case-crossover study conducted by members of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders was published in SPINE in 2008 which investigated the association between chiropractic care and stroke due to arterial dissection and compared it to primary care physician (PCP) treatment for the same issue.[14] This study examined ALL residents of Ontario (109,020,875 person years), Canada’s most populous province over a nine (9) year period (1993-2002). The researchers found only 818 cases of stroke due to arterial dissection that met the study’s inclusion/exclusion criteria. Overall, 4.4% (n=36) of the cases had visited a chiropractor and 51.0% (417) had only visited a PCP 30 days prior to hospital admission for stroke related to arterial dissection. It should be noted  though that of the 36 cases noted above, only 16 cases (2.0%) were exclusively chiropractic visits 20 (2.4%) had visited both a chiropractor and PCP with the remaining 365 cases having consulted no one for care prior to hospitalization due to stroke. In the end the researchers came to the following conclusions:

            - Stroke due to arterial dissection within the population is a RARE EVENT.

- Of the 453 cases that did consult either a chiropractor or PCP prior to hospitalization, the chief complaint upon presentation was neck pain and headache. The researchers concluded that this similarity was due to an arterial dissection IN PROGRESS which led these patients to seek relief of their pain.

- There is an association between chiropractic care and arterial dissection-related stroke within residents under the age of 45 but chiropractic care DOES NOT exhibit any excess risk of eliciting a stroke.

- There is an association in PCP care and arterial dissection-related stroke in ALL AGE GROUPS.

- Currently there exists no valid screening procedure to identify the risk of stroke in a person presenting with neck pain and/or headache.

The substantive nature of this data is enlightening but in no way exhausts the need for further investigation into this rare yet life altering event. A collaborative effort between chiropractors and neurologists during future research is needed in order to derive a feasible screening method and eliminate the confusing and conflicting information currently being given to patients regarding the treatment of neck pain and headache.

---

[1] Haldeman, Scott, Paul Carey, Murray Townsend, and Costa Papadopoulos. "Arterial Dissections following Cervical Manipulation the Chiropractic Experience." Canadian Medical Association Journal 165.7 (2001): 905-06. Print.

[2] Cassidy, David, Eleanor Boyle, Pierre Cote, Helen He, Sheilah Hogg-Johnson, Frank L. Silver, and Susan J. Bondy. "Risk of Vertebrobasilar Stroke and Chiropractic Care." Spine 33.4S (2008): 000. Print.

[3] Terrett, AG. "Misuse of the Literature by Medical Authors in Discussing Spinal Manipulative Therapy Injury." Journal of Manipulative and Physiological Therapeutics 18.4 (1995): 203-10. Print.

[4] Murphy, Donald. “Primary Spine Practitioner Training Session III: Putting it all Together.” Community Spine Pathway Training. Burgundy Basin Inn, Rochester. 3&4 May 2014. Lecture.

[5] Hufnagel, A., Alexander Hammers, Paul-Walter Schonle, Klaus-Dieter Bohm, and Georg Leonhardt. "Stroke following Chiropractic Manipulation of the Cervical Spine." Journal of Neurology 246(8) (1999): 683-88. Print.

[6] Reuter, U., M. Hamling, I. Kavuk, K. M. Einhaupl, and E. Schielke. "Vertebral Artery Dissections after Chiropractic Neck Manipulation in Germany over Three Years." Journal of Neurology 253(6) (2006): 724-30. Print.

[7] Risser, Amanda, Deirdre Donovan, John Heintzman, and Tanya Page. "NSAID Prescribing Precautions." American Family Physician 80.12 (2009): 1371-378. American Academy of Family Physicians. American Family Physician, 15 Dec. 2009. Web. 08 May 2014. <http://www.aafp.org/afp/2009/1215/p1371.html#afp20091215p1371-b13>.

[8] Wolfe, Micheal, David Lichtenstein, and Gurkirpal Singh. "Gastrointestinal Toxicity of Nonsteroidal Anti-inflammatory Drugs." New England Journal of Medicine 340;24 (1999): 1888-899. Print.

[9] Tarone RE, Blot WJ, McLaughlin JK. Nonselective non-aspirin nonsteroidal anti-inflammatory drugs and gastrointestinal bleeding. Am J Ther. 2004;11(1):17–25.

[10] June 29-30, 2009: Joint Meeting of the Drug Safety and Risk Management Advisory Committee with the Anesthetic and Life Support Drugs Advisory Committee and the Nonprescription Drugs Advisory Committee: Meeting Announcement http://www.fda.gov/AdvisoryCommittees/Calendar/ucm143083.htm).

[11] Blower AL, Brooks A, Fenn GC, et al. Emergency admissions for upper gastrointestinal disease and their relation to NSAID use. Aliment Pharm Ther. 1997;11(2):283–291.

[12] Association, American Chiropractic. "Benefits and Risks of Neck Pain Treatments." Acatoday.org. American Chiropractic Association, n.d. Web. 13 May 2014. <http://www.acatoday.org/pdf/Benefits_Risks_Neck_Pain_Treatments.pdf>.

[13] Lee, VH, Brown RD Jr, Mandrekar JN, et al. Incidence and outcome of cervical artery dissection: a population-based study. Neurology 2006;67: 1809-12

[14]Cassidy, David, Eleanor Boyle, Pierre Cote, Helen He, Sheilah Hogg-Johnson, Frank L. Silver, and Susan J. Bondy. "Risk of Vertebrobasilar Stroke and Chiropractic Care." Spine 33.4S (2008): 000. Print.

A Best Evidence Synthesis Regarding the Classification and Treatment of Neck Pain

Endorsed by the United Nations on 30 November 1999 and officially launched on 13 January 2000 at the headquarters of the World Health Organization in Geneva, Switzerland the Bone and Joint Decade (BJD) is an international group of healthcare professionals that address the substantial effect that bone and joint disorders have on society, the healthcare system, and the individual. The goal of the BJD is to “improve the health- related quality of life for people with musculoskeletal disorders throughout the world by raising awareness and promoting positive actions to combat the suffering and costs to society associated with musculoskeletal disorders”.[1] This patient centered organization’s motivation has been the establishment of initiatives capable of delivering best-evidence multi-disciplinary healthcare on a global scale.

This focus was evident with establishment of The Task Force on Neck Pain and Its Associated Disorders in 2000. This fifty (50) member Task Force, with members from nine (9) countries, and representing nineteen (19) clinical and scientific disciplines/specialties was mandated with the task of publishing a report outlining the best current evidence regarding the risk and prognosis of neck pain, its assessment/diagnosis, and the effectiveness and safety of invasive and non-invasive treatment methods for neck pain. During this process they were to also identify problems with the current literature so that future studies could be developed. The goal of this seven year project was to empower the public, especially individuals who suffer from neck pain or at risk of developing it. This collaborative effort that included eight (8) universities in four (4) countries and eleven (11) professional organizations who were nonfinancial sponsors produced a document that has changed approaches and views regarding neck pain as well as its prevention, diagnosis, treatment, and management.[2]

Below is the roster of the 13-member Scientific Secretariat who conducted the screening process of 31,878 research citations on neck pain of which 1,203 articles were found to be relevant. 46% (552) of those were found to be “scientifically admissible” for utilization in this synthesis of best-evidence. Aside from this, various other members of the Task Force also conducted four (4) original research projects during its seven year tenure, two that examined vertebrobasilar stroke, one that compared the outcomes of various forms of neck pain treatment, and another that examined work absenteeism due to neck pain.

As Primary Spine Practitioners, the doctors at Life in Motion Chiropractic and Wellness have found this study to be an invaluable guideline for providing our patients with or triaging them to the most effective treatment available for their neck pain.

Eugene J. Carragee, MD, FACS	Linda Carroll, PhD
J. David Cassidy, DC, PhD, DrMedSc	Pierre Côté, DC, PhD
Stephen W. Greenhalgh, MA, MLIS	Jaime Guzman, MD, MSc, FRCP(C)
Scott Haldeman, DC, MD, PhD, FRCP(C)	Sheilah Hogg-Johnson, PhD
Lena Holm, DrMedSc	Eric L. Hurwitz, DC, PhD
Margareta Nordin, PT, DrMedSc, CIE	Paul Peloso, MD, MSc, FRCP(C)
Gabrielle van der Velde, DC, PhD (Candidate) “In other words, one finds much more information than any individual clinician would be able to find, download, print, read, and digest/assimilate should he/she be devoted to such tasks full-time for years. More specifically, the fact that not only whiplash and nontraumatic disorders but also headaches, arm pain, and generalized symptoms of cervical origin are included in the review is a major strength of this work. Similarly, it’s very useful having both nonsurgical and surgical treatments in the same publication. Moreover, grading treatments according to the likelihood of helpfulness; reporting on prognostic factors and using “suspected etiology” to evaluate treatments are some other examples of the clinical orientation and practicality of this report.” Federico Balagué MD Department of Rheumatology, Physical Medicine and Rehabilitation, Hôpital Fribourgeois – Freiburger Spital Site de Fribourg – Freiburg, Freiburg, Germany Service de Rhumatologie, Médecine Physique et Rééducation, 1708, Fribourg, Switzerland

---

[1] "Background & Goals." THE BONE AND JOINT DECADE. World Health Organization, 13 Jan. 2000. Web. 25 Apr. 2014. <http://bjdonline.org/home/bjd-goals/>.

[2] Haldeman, Scott, Linda Carroll, David Cassidy, Jon Schubert, and Ake Nygren. "The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders - Executive Summary." SPINE 33.4S (2008): S5-S7. Print.

Integrative Care for Headache Pain

Headache has been a bane of humankind for centuries and one of the most common conditions that affects the nervous system. The universally accepted premise is that pain sensitive components of the head and neck are what elicit headache.[1] It is estimated that 47% of adults will experience a headache at least once within the next year.[2]

In 1988, the International Headache Society (IHS) devised a uniform system for classifying headaches which has unequivocally aided headache research. However, the clinical application of this system is limited due to its length, intricate detail, contradictory elements, and lack of real-world observation and data.[3] In fact the World Health Organization admits that many people have their headaches inaccurately diagnosed by their health-care provider.[1] An understandable fact when primary care physicians (PCP) only receive an average of four hours of instruction on headache disorders while in medical school.[1]
This statistic in no way indicates incompetence, just inadequate training with regard to headache. A comprehensible fact given the other more fatal pathologies a PCP must learn about on an intricate level.

This does, however, lead one to theorize that the prescribed drug treatments utilized to combat headache pain may be improperly applied due to the many coinciding aspects of migraine and tension-type [4] headaches. Therefore these analgesics provide no lasting relief to the patient and out of their frustration to feel better easily leads to the development of a medication-overuse headache (MOH).[5]

An integrative approach to headache pain is the most logical way to manage this epidemic given the reasons and biologic elements that contribute to it. According to the research, especially in the case of migraine and tension-type headaches, this may be the most successful strategy to help patients overcome their headache pain.

Since the principal causative factor of headache is spine related, wouldn’t it make sense to have a physician who is specifically trained in spine related disorders be the hub of the diagnostic, management and treatment of headache pain. The doctors at Life in Motion Chiropractic and Wellness are trained Primary Spine Practitioners who can deferentially diagnosis, rule out serious pathology, and provide evidence-based management for the majority of headache patients while also integrating that care with their already established healthcare providers.

---

[1] Swenson, Rand and Grunnet-Nilsson, N. 2005. The Management of Headache. In: Haldeman, Scott, et        al, eds. Principles and Practice of Chiropractic. New York: McGraw-Hill, pp. 999-1011

[2] "Headache Disorders." WHO. Ed. WHO Media Center. World Health Organization,
         Oct. 2012. Web. 12 Mar. 2014.

[3] McKenzie, Robin, Stephen May. The Cervical & Thoracic Spine – Mechanical Diagnosis & Therapy.
            Raumati Beach: Spinal Publications New Zealand Ltd, 2006. Print.

[4] Most common type of primary headache. Its mechanism may be stress-related or associated with musculoskeletal problems in the neck. [World Health Organization]

[5] Most common type of secondary headache. [World Health Organization]

An Alternative to Pharmacologic Treatment of Headache Pain - Making the Case for Primary Spine Practitioner Care

Discusses that hazards of over the counter/prescription medication use for the treatment of headache pain and offers a drug-free and evidence-based alternative that may help you overcome your headaches ALL TOGETHER. This video provides research that substantially makes the case for Primary Spine Practitioner treatment of headache pain.

Preventing Shoulder Injury

The human shoulder is designed to provide a great deal of mobility. 

It can assume up to as many as 1,600 positions. However, in order to provide this function it is dependent upon an integrated system of ligaments, muscles, and tendons for support.

Very similar to a golf ball sitting on a tee, the rounded end of the upper arm moves within the scooped out socket of the shoulder blade. But, unlike the golf ball, the head of the arm must remain in a confined space and still move freely. Pain occurs when excessive demands are placed on the stabilizing structures (muscles, ligaments, joint capsule) of the shoulder, especially when placed at higher angles of flexion (forward elevation >90°) and/or extremeabduction (sideward elevation). Studies have shown that shoulder pain in the general population of some countries has been reported to be as high as 50%.

Here are some ways to prevent you from becoming part of this statistic:

• Stretchand strengthen regularly. The stronger and more flexible the joints are, the more readily they will be able to withstand impact or repetitive forces.
• When lifting: face the object, keep the back as straight as possible, and use the legs for lifting power.
• Do not reach to place or retrieve heavy objects stored up high or behind other objects (i.e. briefcase/purse in the back seat of your car). Position your body carefully and use a stable platform/step stool for elevated objects.
• Do not “yank” on an object. Think about the task at hand and if too heavy or precarious, get help!
• For seated tasks, use a supportive chair, particularly one with adjustable arm rests and seat. Position the body so that your buttocks are back as far as possible, adjust the seat so that the hips and knees are maintained at 90°-110°, and adjust the arm rests so that the shoulder can hang naturally and the elbows are 90°-110° to the keyboard.
• Take posture breaks and stretch for 5-10 minutes every hour.
• Know when you need rest and relaxation during non-working hours and maintain good physical condition to avoid strains and sprains.

Preventing Back Injury

The spine is literally a mechanical device and when we sit, stand, lift, or bend it obeys the orders we give it and assumes the position we place it in. Ergonomics is the science of obtaining a correct match between the human body, work-related tasks, and work tools both at home and on the job. When we do not perform activities of daily living correctly, slow innocent changes occur to the support structures of our body. Physical warnings (i.e. pain) begin to intensify and become exacerbated by repetitive activities, sustained postures, and other factors such as bodily reaction/bending, reaching, or twisting. 

Low back pain is a predominant specter in our society and nearly 80% of adults will experience it at some point in their lives. Here are some tips that my just keep you from becoming part of this statisti

• Stretch and strengthen your back regularly.
• Utilize good posture at all times. This means keeping the ear lobe lined up with the shoulder, shoulder with the hip, and hip with the ankle.
• Use your body in ways that reduce stress on your back. GOOD BODY MECHANICS!!

      
       - Sitting:

• Don’t sit in the same position for more than an hour. Change positions every 30 minutes.
• If your job requires sitting, utilize an adjustable chair that maintains the normal curve of your back. If necessary use a lumbar pillow or roll for added support.
• Keep your feet flat on the floor or footrest.
• Keep the top of your computer screen at eye level.

     
       - Lifting

• The spine was designed with three curves that contribute to its strength and stability. Keeping your head level reduces stress on your back while lifting.
• Reduce the force on your spine by holding objects close to your body. Remember, whether you feel it or not, gravity is always there and holding a load away from the body can increase its weight by 10 TIMES!
• The neck was designed to turn and bend in multiple directions to allow us to take in life from all angles. However, the low back was not, so when lifting don’t twist, shuffle your feet to turn keeping your nose between your toes. 

Spine Health Program Overview

A compelling argument could be made that the most inefficient and ineffective area of health care is spine pain management. Nationally, direct costs of spine care have gone up six to eight times over the last 20 years accompanied by an even more dramatic increase in indirect costs (lost work days, decreased productivity). The bottom line: we are putting significantly more money into spine care, with worse outcomes.

The Spine Care Program offered by Lifetime Health Medical Group and Excellus BlueCross BlueShield is designed to address this issue. The program is based on a spine care pathway created by Spine Care Partners© and currently being implemented in hospital systems, ACOs and PCMHs as well as privately operated PCP and specialty groups.

The core of the program is an evidence-based, patient centered spine pathway based on a biopsychosocial model of care. Strong emphasis is put on patient choice, education and motivation in self-care. Educational websites, applications and specific self-care tools are being developed to support these patient directed efforts. Care is co-ordinated by a Primary Spine Practitioner (PSP), a licensed health care provider (i.e. physician, physical therapist, chiropractor, nurse practitioner). The PSP is trained in the pathway and necessary diagnostic, treatment and communication skill sets to effectively manage most cases by treating 85+% of spine patients and triage the rest to appropriate care.

PSPs are the hub of the diagnostic, management and treatment wheel. Relational care concepts create the infrastructure of the PSP/patient interactions, using validated psychosocial questionnaires and motivational interviewing techniques to more accurately access the ‘whole person’ impact of the spine condition and modify treatment and language used to motivate patients to fully participate in their own recovery and future management.

Another unique element of the program is the use of a multidisciplinary team of spine care providers to provide fast, effective quality patient care. The team seamlessly interacts to deliver a virtual value add, process driven model of spine care. Team members are identified through data, experience and peer recommendation. As “fast track” providers, they ensure pre-screened patients access to services within one-two business days, allowing quicker access to second level providers than can be acquired through a typical PCP/specialist interaction. This, in turn, allows ‘teachable moments’ between PSPs and PCPs, outline alternative and evidence based options to early or non-evidence based use of surgeons, injections, imaging and opioids. Evidence-supported shared decision making tools are discussed with patients with each pathway provider encountered. These concepts are supported by employer and community based public spine health initiatives, when possible.

Our spine program quality goals are aimed at better value through optimizing patient provider match, invoking process to the full spectrum of spine care (adding efficiencies via pathway adherence), and identifying psychosocial issues or early signs of perpetuating factors. We then align patient specific resources to address these early indicators of possible chronicity. We are early in our program, but our 'fast track' neurosurgeons enjoy the higher quality surgical patients they are seeing. We feel the timing of surgical intervention is often sub-optimal (too early, too late...) and these front end efficiencies help to right size the timing and the care.

Using data collection tools to examine episodes of care will allow us to monitor cost shifting and overall spine care costs. Strict outcome and patient satisfaction data will allow us to derive value measures to the individual practitioner or provider group level. Quality of life data and spinal registries are on the horizon.

We are evolving the program to a community-wide Spine Care Program to improve clinical outcomes (function, quality of life), the patient experience (patient satisfaction, patient directed outcome measures), and guide appropriate utilization of healthcare resources related to spine care (high value care).

For questions, research articles, or additional information, please contact: Brian Justice brian.justice@excellus.com