Transcript Dynamic Chiropractic June 26, 2000 Volume 18

“Chiropractic”
A rationale approach to common
neuromusculoskeletal disorders
The objective of the lecture is to
advance the knowledge base of medical
professionals and paraprofessionals,
nurses, case managers, and others
concerning the chiropractic approach to
back pain and disability. We will
explore the following issues:
TABLE OF CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Soft Tissue
Chronic Pain
Etiology of Pain
Spinal Manipulation
Whiplash
Recurrent Nature of Pain
Dysfunction
Drug Issues
Diagnostic Accuracy
Costs
Summary/Quiz
“Chiropractic”
A rationale approach to common
neuromusculoskeletal disorders
Our goal is to create a common understanding of the
issues facing an injured patient. The information will
be valuable to treating physicians, case managers,
employers and managed care personnel, to name
just a few. This program is an effort to facilitate
greater cooperation between the medical and
chiropractic disciplines for the good of the patients
we serve, in addition to providing quality information
to third party payor personnel, often less informed by
virtue of their education and training.
Goals of Care
Old School:
Reduce pain
New Paradigm:
1.
2.
3.
4.
Minimize Pain
Decrease Reliance on drugs
Restore, maximize, and maintain function
Keep the patient working.
The Problem:
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Old perceptions about goals of care still exist
and are not consistent with the current
literature. (i.e., symptoms vs. function)
Standard medical care (i.e.. Drugs) is often
ineffective and dangerous when taken long
term or in combination with other drugs or
alcohol (ex. Tylenol and liver failure).
Soft Tissue Healing
A Review of the Literature
Do All Soft Tissue Injuries Heal
Within 6-8 Weeks?
A Review of the Scientific Literature
Croft, McFarland, et al
BMJ 1998
"We should stop characterizing low back pain in terms
of a multiplicity of acute problems, most of which get
better, and a small number of chronic long term
problems. Low back pain should be
viewed as a chronic problem with an
untidy pattern of grumbling symptoms
and periods of relative freedom from pain and
disability interspersed with acute episodes,
exacerbations, and recurrences.”
Saal JA, MD. Spine 1997;22(14):1545-1552
The major premise used in the managed care system
for the primary care of LBP is based upon the
assumption that 90% of patients improve in 6-12
weeks. However, a natural history study by Von
Korff found that approximately 60% will recur. In a
study of BP in primary care, Von Korff and Saunders
found that 60% to 75% improve within the first
month, 33% report intermittent or persistent pain at
one year, and 20% of patients describe substantial
limitations at one year.
Croft, McFarland, et al. BJM 1998
“These figures do not fit with the claim that
90% of episodes of LBP end in complete
recovery.”
Frank, MD. BMJournal 1993; April 3:901-9.

Review of a study in which 373 patients less than 40
years old, with their first onset of back pain, are
followed for 10 years. 89% had recurrences and
only 33% had no lost time form work from future
back problems. Strategies to manage low back
pain must be long term and preventive.
[Emphasis added.]
Waddel, MD. JMPT 1995;18(9):590-596
Traditional teaching is that 90% of LBP attacks
recover within six weeks, but recent natural history
studies suggest that this is overly optimistic and
over-emphasizes RTW. It now seems that 50% of
attacks settle within 4 weeks, but 15-20% have some
symptoms for at least 1 year. 70% of patients who
have acute back pain will suffer 3 or more
recurrences. 20% will continue to have some back
symptoms over long periods of their lives.
Jayson, MD, FRCP. Spine 1997;22(10):1053-1056.
At 3 months, only approximately 27% were completely
better, 28% improved, 30% had no change, and 14%
were worse or much worse. It may well be that in the
many studies of acute low back pain, there has been
very carefully selected clinical material so that only
those patients with acute pain of recent onset and no
other confounding factors were included, with the result
that these studies do not reflect what actually happens
in practice.
Waddell, MD. The Chiropractic Report 1993;
July:1-6
Bed Rest: should die as soon as it can.
Physical Therapy: There is no adequate evidence of effectiveness.
Spinal manipulation: one of two treatments of proven value.
Early active exercise: Is the other treatment supported by good evidence.
Relief of pain and restoration of function must occur at the same time.
Failure to restore function means any pain relief will be temporary and
reinforces chronic pain. In the management of occupational back pain,
the chiropractic profession is leading the way. The problem is weakness
and loss of function, not disease.
Bronfort. DC et al. JMPT 1996; 19(9): 570-582
…compared the efficacy of five weeks of: (1) spinal
manipulation (SM) with trunk strengthening exercises
(TSE); (2) SM combined with trunk stretching
exercises; and (3) NSAIDs with TSE all followed by 6
weeks of supervised exercise alone.
For the management of chronic low back pain,
trunk exercise in combination with spinal
manipulation or NSAIDs seems beneficial and
worthwhile.
Weisel, MD. Backletter 1996; 11(7): 84 Back pain
is a recurrent illness.
Carey’s study emphasizes that BP is typically
recurrent and sometimes disabling – in a
substantial minority.
Kuritzky, MD. Physician and Sports Medicine
1997;25(1):56-64
97% of BP seen by primary care physicians is
mechanical in origin. There is something
wrong with the muscles, ligaments, or
connective tissues.
Haldeman, DC, PhD, MD. Spine 1990;15(7):718-723.
The pathology model cannot explain back pain or
disability. It is not possible to look at pathology and
determine the symptoms a patient may be suffering.
It also is not possible to look at a patient with back pain
with no neurologic deficits and determine the nature of
the pathology. About 30% of asymptomatic subjects
show abnormalities in the lumbar spine by myelogram,
CT and MRI. There is a large percent of symptomatic
patients with severe complaints in whom testing fails to
reveal any structural lesion.
Jensen, et al. Magnetic resonance imaging of the lumbar
spine in people without back pain. NEJM 1994;331(2)July
14:69-73
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98 people: only 36% had a normal disc at all levels.
52% bulge at least one level
27% protrusion
1% extrusion
38% had abnormality at more than one level
Summary: Finding may be frequently coincidental
Liebenson, DC, Oslance. Rehabilitation of the
Spine. Williams and Wilkins, Baltimore. 1996:73.
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80% of patients have no identifiable structural
pathology and require treatment based on evaluation
of functional deficits.
Overemphasis on treatment of structural
pathology results in a failure to identify or
focus on functional loses and work demands.
[Emphasis added.]
Croft P, Macfarland GJ, Papageorgiou AC, Thomas E, Silman AJ.
Outcome of Low Back Pain in General Practice: a Prospective Study
British Medical Journal 1998;316:1356-1359
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Low-back pain is aptly redefined as "a chronic problem with an untidy
pattern of grumbling symptoms," with only 25% of patients consulting
about the problem reporting full recovery 12 months later. Instead,
most patients appear to be enduring their pain but not telling their
primary care physician about it.
In fact, after seeing the results, the authors made the following
statement:
"By three months after the index consultation with their general
practitioner, only a minority of patients with low back pain had
recovered. However, most patients with low-back, pain did not return
to their doctor about their pain within three months of their initial
consultation, and only 8% continued to consult for more than three
months."
Croft P, et al. BMJ 1998;316:1356-1359

The authors found that consulting a doctor is not a
direct measure of the presence of pain and disability.
While patients may stop consulting their doctor, the
vast majority will still have some pain and disability
12 months later. Therefore, the authors concluded:
Croft P, et al. BMJ 1998;316:1356-1359

"We should stop characterizing low back pain in terms of a
multiplicity of acute problems, most of which get better, and a
small number of chronic long term problems. Low back pain
should be viewed as a chronic problem with an untidy pattern of
grumbling symptoms and periods of relative freedom from pain
and disability interspersed with acute episodes, exacerbations,
and recurrences.
This takes account of two consistent
observations about low back pain: firstly, a previous episode of
low back pain is the strongest risk factor for a new episode, and
secondly, by the age of 30 years almost half the population will
have experience a substantive episode of low back pain. These
figures simply do not fit with claims that 90% of
episodes of low back pain end in complete recovery."
Holm, in The Cervical Spine, Lippincott, 1989, p. 440

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“Follow-up roentgenograms taken an average of 7 years after injury in
one series of patients without prior roentgenographic evidence of disc
disease indicated that 39% had developed degenerative disc disease at
one or more disc levels since injury. It was pointed out that available
evidence indicated an expected incidence of 6% degenerative change
in a population with this mean age of 30 years. Thus, it appeared that
the injury had started the slow process of disc degeneration.”
“In another follow-up study of patients with similar injuries but with
preexisting degenerative changes in the neck it was observed that after
an average of 7 years 39% had residual symptoms, and
roentgenographic evidence of new degenerative change at another
level occurred in 55%.”
Symptoms vs. Function
As a result of these and other studies there has been
a shift in thinking away from the traditional
"symptom" approach, towards contemporary thinking
of "function".
For many patients with recurrent back pain, staying
functional is a "process" more so than a "result"
based on a predictable healing time or average.
Summary

Since 1956…dozens of studies

“Natural Healing Time”……Myth

Mechanical Back Pain…predominant issue

Restoration and maintenance of “function” is critical
Chronic Pain
A Review of the Literature
Meade Study: BMJ 1990

A British ten year study concluded that
chiropractic treatment was significantly
more effective, particularly with patients
with chronic and severe pain
Bronfort, DC et al. JMPT 1996
“For the management of chronic back
pain, trunk exercise in combination with
manipulation or NSAIDs seems
beneficial and worthwhile.”
Giles LG, Muller R. JMPT 1999
Study compared spinal manipulation, needle
acupuncture, and NSAIDs for the treatment of
chronic back pain.
After 30 days, spinal manipulation was the only
intervention to achieve statistically significant
improvement.
Intervention by way of acupuncture or NSAIDs did
not result in significant improvements in any of the
outcome measures.
Manual Medicine 1986
CMT is both subjectively and objectively,
more effective at relieving low back pain than
a manual placebo treatment.
SPINE 1997 Maurits W. van Tulder, et al

“…strong evidence for the effectiveness of
manipulation, back schools, and exercise therapy
for chronic low back pain, especially for short term
results.”

Additionally, the study found that no single
therapeutic intervention was demonstrated to be
effective in the treatment of chronic LBP.
SPINE 1995 Triano, McGregor, et al
“There appears to be clinical value to
treatment according to a defined plan using
manipulation even in low back pain exceeding
7 weeks’ duration”
Summary


The benefit of chiropractic manipulation (in
addition to exercise) over single intervention
treatments like acupuncture, exercise, and
NSAIDs for patients with chronic pain
syndromes is clear and supported by scientific
study.
Manipulation is certainly the safest and most
effective treatment to keep a spine functional
and the chronic pain patient employed.
“Passive” or “No lasting therapeutic Benefit” or
“Non-Curative” or “Palliative”
What treatment can survive a requirement suggesting that treatment must
provide curative or long lasting therapeutic benefit? ANSWER: NONE!
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Chiropractic or Osteopathic manipulation
Drugs
Physical Therapy (electric stim, ultrasound, ice, heat, etc.)
Massage
Epidural injections
Facet Injections
Physical Rehabilitation
Exercises
Patient Education
NSAIDs
Surgery
Criteria: Minimal requirements to qualify for
Chronic Pain Management.
1.
2.
3.
4.
5.
6.
Unable to attain pre-accident status; attained
maximal therapeutic benefit; recovered with
residual soft tissue damage
Therapeutic withdrawal attempted
Unable to maintain improvement
Minimal tx recommended
Dx & Tx alternatives considered
Home management recommended
Goals of Chiropractic Spinal Manipulation
for Chronic Pain
1.
2.
3.
4.
Pain Relief
Improve Fx
Decrease Reliance on drugs
Keep the patient employed
Etiology of Chronic Pain
A Review of the Literature
Pain
Mechanics
Nocireception
Mechanoreception
(proprioception)
Small Diameter
Large Diameter
Slow: .5-2 mps
Fast: 120 mps
“C” afferent
1a or 1b afferent
Free / Naked Receptor
Encapsulated Receptor
Muscle spindle
GTO
GT like
Rufini, etc
Hot Water
Cold Water
Mooney, MD. J. Musculoskeletal Medicine 1995;
Oct:33-39.
Common acute back pain is due to chemical
abnormalities created by soft tissue tear. The
tear represents a mechanical disruption,
which is usually microscopic.
X-rays
demonstrate no changes before and after an
acute back injury.
Vert Mooney, MD: Spine, 1986 Dallas, TX.
“In summary, what is the answer to the question of
where is the pain coming from in the chronic lowback pain patient? I believe its source, ultimately, is
in the disc. Basic studies and clinical experience
suggest that mechanical therapy is the most rational
approach to relief of this painful condition.”
Lee et al: Spine 1995
“Anatomically the
disc is richly innervated at the
periphery and outer layers of the annulus by the
branches of the sinu-vertebral nerves and
sympathetic nerves.”
“Pathological conditions confined within the disc
property were the most probable sources of pain.
Derby MD, Spine 1996;21:1744,1745
“Although muscle pain and tissue hyperalgesia may
be an integral part of chronic cervical pain after
whiplash injuries, such pain may be better explained
as a secondary reflex reaction to injury of segmental
supporting structures.”
* Zygapophysial Joint Pain
Bogduk: 1999 Saal 1996 Spine 1997
“Neuropathic lesions such as nerve root compression
causing radicular pain are extraordinarily uncommon
in the spine…In most back pain, the mechanism
involved is the stimulation of nerve endings in
the affected structure. Nerve root compression is in
no way involved.”
Bogduk, MD: Newcastle Bone and Joint Institute, Point
of View
“The study of Kaneoka et al now fills a critical gap in
the story of cervical facet pain. It provides the
missing biomechanical link. Theirs is the most
significant advance in the biomechanics of whiplash
since the pioneering studies of Severy et al in 1955.”
* Facet Joint pain
Bogduk et al: Pain 1993
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Both a symptomatic disc and a symptomatic
zygapophysial joint were identified in the same
segment in 41% of the patients.
The paper demonstrated that chronic pain is
articular, not myofascial.
Bogduk: Spine 1992
Cervical zygapophysial joint pain is not
rare, and is worthy of further consideration
not just in research but in clinical practice.
Bogduk: Spine 1988
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Joint blocks in 24 pts
The high yield of positive responders in this study
probably reflects the propensity of patients with ZJ
syndromes to gravitate to a pain clinic when this
condition is not recognized in conventional clinical
practice.
Holm, in The Cervical Spine, Lippincott, 1989
“Follow-up roentgenograms taken an average of 7
years after injury in one series of patients without
prior roentgenographic evidence of disc disease
indicated that 39% had developed degenerative
disc disease at one or more disc levels since
injury.
….after an average of 7 years 39% had residual
symptoms
Lord: Spine: Sept. 1993
Postmortem studies of victims of MVAs reveal that
zygapophyseal joint injuries are common, being
present in 86% of necks examined. The lesions
include capsular tears, ruptures of meniscoids,
intraarticual hemorrhage, and small fractures.”
Khan, Cook, Gargan, and Bannister: A Symptomatic Classification
of Whiplash Injury and the Implications for Treatment. The Journal
of Orthopaedic Medicine 1999.
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Results: Organic pain causes
psychological stress, not the result of it!
Halldor Jonsson et al: Spine
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Conclusions: Follow-up surgery on the chronic
patients showed a high incidence of
discoligamentous injuries in whiplash-type
distortions.
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“Pain can originate both from the ganglion and the
richly innervated annulus fibrosis and also from the
facet joints causing both local and referred pain.”
Nachmeson, MD: Spine 1976
“Although practically all anatomic structures in the
region of the motion segment have their proponents
in the etiology discussion, the lower intervertebral
disc most likely causes the pain.”
Bogduk: Spine 1988
The Innervation of the Cervical Intervetrebral Discs
…cervical sinuvertebral nerves…upward
course in vertebral canal, supplying the
disc…
“These anatomical findings provide the hitherto
missing substrate for primary disc pain and
the pain of provocation discography.”
Bogduk: Spine 1983
The Innervation of the Lumbar Spine
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IVD innervated posteriorly by the sinuvertebral nerve
but laterally by branches of the ventral rami and grey
rami communicates.
PLL…SVN
Lumbar musculature
Bogduk: J Anat 1981
Anterior longitudinal ligament is innervated
by the recurrent branches of the rami
communicates.
Barnsley et al: Spine 1995
The prevalence of chronic cervical zygapophysial joint pain after
whiplash.
Conclusion: In this population [chronic
neck pain], cervical zygapophysial joint
pain was the most common source of chronic
neck pain after whiplash.
Barnsley et al: NEJM 1994
“…Corticosteriods for chronic pain..”
Results: Less than half the patients reported relief of
pain for more than one week, and less than one in
five pts reported relief for more than one month,
irrespective of the treatment received.
Conclusion: Intraarticular injection of betamethasone is
not effective….
Barnsley et al: NEJM 1994
“…Corticosteriods for chronic pain..”
“…the pts who derived a benefit from either
treatment may have had a condition that was
improved by the stretching of the joint
capsule during the intraarticular injection,
irrespective of what was injected.”
Chronic disabling low back pain syndrome caused by internal disc
derangements. The results of disc excision and posterior lumbar
interbody fusion.
Lee, Vessa, Lee, Spine 1995 Feb. 1;20(3):356-61

“Anatomically the disc is richly innervated at the periphery and
outer layers of the annulus by the branches of the sinuvertebral nerves and sympathetic nerves.”
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“Pathological conditions confined within the disc property were
the most probable sources of pain. These pathologic conditions
may include nuclear degeneration, annular tear, and
biochemical ground substance degradation. The possible pain
mechanism is stimulation of nociceptors within the disc by
mechanical sources (abnormal local stress/strain), biochemical
sources (various endogenous nonneurogenic or neurogenic
chemical products), or both.”
1999 Paper by Bogduk, MD, PhD
Saal JA. 1996 North American Spine Society Presidential Address, Spine
1997;22(14):1545-1552
“Neuropathic lesions such as nerve root compression
causing radicular pain are extraordinarily uncommon
in the spine…In most back pain, the mechanism
involved is the stimulation of nerve endings in the
affected structure. Nerve root compression is in no
way involved.”
Literature Review by Haldeman, DC, MD, PhD\
Liebenson C. Rehabilitation of the Spine. Wms. & Wilkins,
Baltimore 1996: 13-43.
“There has been no evidence that a change in the
relation of adjacent vertebrae of the type commonly
described in the chiropractic literature can result in
nerve root or spinal cord compression.”
Haldeman
Spinal Manipulation
A Review of the Literature
Chronic Spinal Pain: A Randomized Clinical Trial Comparing
Medication, Acupuncture, and Spinal Manipulation. Spine July 15,
2003; 28(14):1490-1502
Design: RCT, 115 patients, public hospitals multidisciplinary spinal pain
unit. Evaluated at 2, 5, and 9 weeks. Manipulation performed by DCs
with 18 adjustments or less. Drugs used; Celebrex, Vioxx,
paracetamol. Average duration of spine pain was 8.3 years for the
manipulation group.
Results: The highest proportion of early (asymptomatic status) recovery
was found for manipulation (27.3%), followed by acupuncture (9.4%)
and medication (5%).
Conclusions: The consistency of the results provides evidence that
in patients with chronic spinal pain, manipulation, if not
contraindicated, results in greater short-term improvement
than acupuncture or medication.
“Chiropractic Maintenance Care”
Journal of Manipulative and Physiological Therapeutics,
23(1), January 2000, pp. 10-19
·
Study Design: 65 years +, “health promotion and
prevention services” for at least 5 years @ min. of
4/yr.
o
16.95 visits to DC/yr vs. 4.76 visits/yr to MD.
Chiropractic Maintenance Care
Journal of Manipulative and Physiological Therapeutics,
23(1), January 2000, pp. 10-19
Results:
DC avg. only $3,106 which is 31% lower of the national average healthcare costs
for the same age group.
DC avg is lower than the national avg. for US citizens
Of all ages, which was $3,510.
Pts. Receiving maintenance DC spent an avg. of $1,723 for hospitalizations.
The per capita expenditures for Medicare hospitalization was $5,121 or 51% of
the total cost of health care services.
Chiropractic Maintenance Care
Journal of Manipulative and Physiological Therapeutics,
23(1), January 2000, pp. 10-19
Conclusions:
• DC visits 2x vs. MDs, but 50% reduction in # of MD visits.
•Therefore, DC treatment “replaces”, not compliments, MD care.
• Extreme differences in Hospitalization costs.
• “Total annual cost of health care services for the patient
receiving MC was conservatively 1/3 of the expense made
by US citizens of the same age.”
What Are The Negative Effects of Joint Immobilization?
Liebenson C: Pathogenesis of Chronic Back Pain. JMPT 15:303,
1992
Joints
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Shrinks joint capsules
Increases compressive loading
Leads to joint contracture
Increases synthesis rate of glycosaminoglycans
Increase in periarticular fibrosis
Irreversible changes after 8 weeks of immobilization
Ligament
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Lowers failure or yield point
Decreased thickness of collagen fibers
What Are The Negative Effects of Joint Immobilization?
Liebenson C: Pathogenesis of Chronic Back Pain. JMPT 15:303,
1992
(cont’d)
Disk Biochemistry
·
·
·
·
·
Decreases oxygen
Decreases glucose
Decreases sulfate
Increases lactate concentration
Decreases proteoglycan content
Bone
·
·
Decreases bone density
Eburnation
What Are The Negative Effects of Joint Immobilization?
Liebenson C: Pathogenesis of Chronic Back Pain. JMPT 15:303,
1992
(cont’d)
Muscle
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Decreased thickening of collagen fibers
Decreased oxidative potential
Decreased muscle mass
Decreased sarcomeres
Decreased cross-sectional area
Decreased mitochondrial content
Increased connective tissue fibrosis
Type 1 muscle atrophy
Type 2 muscle atrophy
20% loss of muscle strength per week
What Are The Negative Effects of Joint Immobilization?
Liebenson C: Pathogenesis of Chronic Back Pain. JMPT 15:303,
1992
(cont’d)
Cardiopulmonary
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Increased maximal heart rate
Decreased VO2 max
Decreased plasma volume
What Are The Positive Effects of Spinal Manipulation and
Joint Mobility?
Nelson, DC. Top Clin Chiro 1994;1(4):20-29.
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Stretching of abnormally tight tissues (passive
forcing)
Increased range of motion
Selective tearing of adhesions without damaging
healthy tissue
Stimulation of wound healing
Improved edema removal due to pumping action of
movement
Removal of waste products & chemical mediators of
pain
Increased fluid flows, discal & cartilage nutrition
What Are The Positive Effects of Spinal Manipulation and
Joint Mobility?
Nelson, DC. Top Clin Chiro 1994;1(4):20-29.
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Reduction of the pain-spasm cycle
Increase of mechanoreceptive input due to increased
motion
Close the “gate” to the central transmission of pain
Regeneration of functional tissue & less scarring
Improved rate & endpoint of tissue healing
Movement is a specific stimulus for collagen
production
Movement increases cellular metabolism & protein
synthesis
What Are The Positive Effects of Spinal Manipulation and
Joint Mobility?
Nelson, DC. Top Clin Chiro 1994;1(4):20-29.
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Improved ligament strength
Improved matrix organization
Proper alignment of new collagen
Normalize proprioceptive patterns from joints &
muscles
Normalize coordinated complimentary motor
programs
J. David Cassidy and William H. Kirkaldy-Willis, Managing
Low Back Pain, Chapter 17 pg. 287-288, Can. Fam.
Physician Vol. 31: March 1985
“A manipulation or lumbar intervertebral joint adjustment is a
passive manual maneuver during which the three-joint complex
is suddenly carried beyond the normal physiological range of
movement without exceeding the boundaries of anatomical
integrity.
The usual characteristic is a thrust-a brief, sudden, and carefully
administered “impulsion” that is given at the end of the normal
passive range of movement. It is usually accompanied by a
cracking noise.”
J. David Cassidy and William H. Kirkaldy-Willis, Managing Low Back Pain,
Chapter 17 pg. 287-288, Can. Fam. Physician Vol. 31: March 1985
(cont’d)
Four zones: (1) active movement (2) passive movement
(3) paraphysiological zone (4) pathological zone
Two barriers : (1) elastic barrier- overcome by the thrust without
damage to the joint structures (2) limit of anatomical integritywhich cannot be surpassed without injuring ligaments and
capsule
Note: Versus mobilization, only manipulation can influence
all joint ranges: active, passive, and paraphysiological
joint play.
Exercise? Is it a cure-all?
Several studies compared McKenzie (exercises) protocols with
spinal manipulation.
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Wiesel, MD (Cherkin, PhD) McKenzie Protocol versus
Chiropractic Care for LBP. Backletter
1995:10(11):121, 130, 131.
And
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Wiesel, MD. (Cherkin, PhD) Mckenzie versus
Manipulation. Back letter 1996;11(12)Dec: 133, 139.
Exercise
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“McKenzie and spinal manipulation were equivalent
in symptoms, function, disability, and satisfaction,
and were superior to booklet in terms of symptoms
and satisfaction. However, McKenzie did not reduce
recurrences or long-term utilization of health care.”
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In other words, exercise is no cure in and of itself for
the treatment of low back pain.
Bronfort. DC et al. JMPT 1996; 19(9): 570-582

This was a randomized controlled study with a one
year follow-up in 174 chronic low back pain patients
(age 20-60) that compared the efficacy of five weeks
of: (1) spinal manipulation (SM) with trunk
strengthening exercises (TSE); (2) SM combined with
trunk stretching exercises; and (3) NSAIDs with TSE
all followed by 6 weeks of supervised exercise alone.
Bronfort. DC et al. JMPT 1996; 19(9): 570-582
(cont’d)
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Results: Outcomes at 5 and 11 weeks revealed no significant
group differences. Continuance of exercise during the followup year, regardless of the type of treatment, was associated
with a better outcome.
Conclusion: All three treatment regimens were associated with
similar and clinically important improvement over time and the
treatment was considered superior to the expected natural
history of long-standing chronic low back pain.
For the
management of chronic low back pain, trunk exercise in
combination with spinal manipulation or NSAIDs seems
beneficial and worthwhile.
Osteopathic Methods and the Great Flu Pandemic of 1917-1918
JAOA May 2000 Vol. 100 No. 5 Pg 309





Killed 10-20 Million
Killed 1.5 x more in 6 months than in the
entire WWI.
Death Rate 0.5% for pts treated by DOs vs.
6% for
pts treated by MDs
Pneumonia DO < 10% vs. MD 33%
Osteopathic methods highly effective
JAOA May 2000
Great Flu Pandemic of 1917-1918
“The best defense against disease and infection
remains health.”
“Optimal health is the result of the optimization of
function of each individual.”
“Osteopathic care….excellent preventative
treatment.”
Dabbs, D.C. and Lauretti, D.C., A Risk Assesment of Cervical
Manipulation vs. NSAIDs for the Treatment of Neck Pain. Journal
of Manipulative and Physiological Therapeutics. Vol. 18, number 8
Oct. 1995; 18:530-6.



“The best evidence indicates that cervical manipulation for neck
pain is much safer than the use of NSAIDs, by as much as a
factor of several hundred times. There is no evidence that
indicates NSAID use is any more effective than cervical
manipulation for neck pain.”
Death rate for NSAID-associated GI problems at 0.04% per yr
amoung OA patients receiving NSAIDs, or 3,200 deaths in the
US per year.
He (Brandt) also noted that there are several animal studies and
human clinical studies that have actually implicated NSAIDs in
the acceleration of joint destruction.
Hoving et al. A Randomized Controlled Trial of Manual Therapy. Ann Intern Med.
2002;136:713-722. Manual Therapy, Physical Therapy, or Continue Care by a
General Practitioner for Patients with Neck Pain, A Randomized, Controlled Trial.,
Pages 713-722
Intervention: 6 weeks of manual therapy (specific mobilization
techniques) once per week, physical therapy (exercise therapy)
twice per week, or continued care by a general practitioner
(analgesics, counseling, and education).
“Conclusion: In daily practice, manual therapy is a favorable
treatment option for patients with neck pain compared with
physical therapy or continued care by a general practitioner.”
Adjustments Don’t Have to Make Noise to Work. Archives of Physical
Medicine and Rehabilitation – July 2003;84:1057-60.
“There is no relationship between an audible pop during
SI region manipulation and improvement in ROM,
pain, or disability in individuals with non-radicular
LBP. Additionally, the occurrence of a pop did not
improve the odds of a dramatic improvement with
manipulation treatment.”
Doctors of Chiropractic More Qualified Than Osteopaths, PTs and
MDs in Spinal Manipulation/Adjustment, According to American
Chiropractic Association. Arlington, Va., Nov. 4 /PRNewswire
* A survey of osteopathic schools found that most schools generally offer
spinal manipulation/adjustment only on an elective basis.
* No manipulation/adjustment training is given or available for M.D.s in
medical school curricula.
* One study queried 10 physical therapy schools -- none taught spinal
manipulation/adjustment.
"Individuals with less training and expertise than doctors of chiropractic
may provide outcomes that are less than optimal, and can pose
unnecessary health and safety risks and possible complications for
patients," the policy statement reads.
Osteopathic Manipulation No Better Than Sham Therapy for
Chronic Back Pain. Spine: July 8, 2003.
July 8, 2003 — Osteopathic manipulation is no better
than sham therapy for chronic nonspecific low back
pain, according to the results of a randomized trial
published in the July issue of Spine.
However, both osteopathic and sham manipulation
were more effective than no therapy.
Efficacy of spinal manipulative therapy for low back pain of less than
three months' duration. JMPT November/December 2003. Volume 26 .
Number 9. Review of the literature. Ferreira et al.
Conclusions: Spinal manipulative therapy produces slightly
better outcomes than placebo therapy, no treatment, massage,
and short wave therapy for nonspecific low back pain of less
than 3 months duration. Spinal manipulative therapy, exercise,
usual physiotherapy, and medical care appear to produce
similar outcomes in the first 4 weeks of treatment.
The Journal of Neurological and Orthopaedic Medicine and
Surgery. An article entitled, Effective Management of Spinal Pain
in 200 Patients Evaluated for Manipulation Under Anesthesia
Volume 17,No 1, 1998.
"In completing this study, the authors found that a
multidisciplinary approach to evaluation and
treatment offers patient benefits above and beyond
that which can be obtained through the individual
providers working alone.
It is our intention to proceed with studies of a more
specific design as this present work has
demonstrated positive results and no complications."
The New England Journal of Medicine
1999;341:1426-1431, 1465-1467.
Osteopaths equal MDs at relieving chronic back pain
NEW YORK, Nov 03 (Reuters Health) -- Manual therapy
by an osteopath is as effective at relieving chronic lower
back pain as traditional medical care, according to a report in
the November 4th issue of The New England Journal of
Medicine.
Results of a study from Chicago researchers showed
patients who received osteopathic therapy for subacute low
back pain received fewer drugs and needed less physical
therapy than those treated with standard care.
Reminder: DC’s provide 94% of all manipulation performed. RAND.
Randomized Osteopathic Manipulation Study (ROMANS): Pragmatic
Trial for Spinal Pain in Primary Care. Wilkinson C, et al. Family
Practice 2003. Dec;20(6):662-9
CONCLUSION: A primary care osteopathy clinic improved shortterm physical and longer term psychological outcomes, at little
extra cost. Rigorous multicentre studies are now needed to
assess the generalizability of this approach.
Reminder: DC’s provide 94% of all manipulation performed.
RAND.
Spinal manipulation effective for low back pain. Strickland. The
Journal of family practice.; 2003 Dec;52(12) p925 - 929
Spinal manipulation, usual care with analgesics, physical therapy,
exercises, and "back school" all provide similar results when
used for treatment of both acute and chronic low back pain.
Clinicians may wish to treat patients with low back pain
themselves or refer them for chiropractic care, physical
therapy, or back schools. This decision should be based on
patient preferences after reviewing relative risks and benefits.
A recent systematic review of alternative therapies for low back
pain reported similar effects from spinal manipulation and
massage therapy. The effectiveness of acupuncture in the
management of low back pain remains unclear.
Bronfort et al. Trunk Exercise Combined with Spinal Manipulation
or NSAID Therapy for Chronic Low Back Pain: A Randomized,
Observer-Blinded Trial. JMPT. Vol. 19. Number 9. Nov/Dec. 1996.
Results: There seemed to be a sustained reduction in medication
use at the 1-year follow-up in the SMT/TSE group.
Continuance of exercise during the follow-up year, regardless of
type, was associated with a better outcome.
Conclusion: For the management of CLBP, trunk exercise in
combination with SMT or NSAID therapy seemed to be
beneficial and worthwhile.
Cox et al. Distraction Manipulation Reduction of an L5-S1 Disk
Herniation . Journal of Manipulative and Physiological
Therapeutics Volume 16, Number 5, June, 1993
Conclusions: Chiropractic distraction manipulation is
an effective treatment of lumbar disk herniation, if
the chiropractor is observant during its administration
for patient tolerance to manipulation under
distraction and any signs of neurological deficit
demanding other types of care.
BenEliyahu et al. Magnetic Resonance Imaging and Clinical Follow-up:
Study of 27 Patients Receiving Chiropractic Care for Cervical and Lumbar
Disc Herniations. JMPT. Volume 19, Number 9, November/December,
1996
Results: Clinically, 80% of the patients studied had a good clinical
outcome with post-care visual analog scores under 2 and resolution of
abnormal clinical examination findings. Anatomically, after repeat MRI
scans, 63% of the patients studied revealed a reduced size or
completely resorbed disc herniation. There was a statistically
significant association (p, .005) between the clinical and MRI follow-up
results. Seventy-eight percent of the patients were able to return to
work in their pre-disability occupations.
Conclusion: This prospective case series suggest that chiropractic care
may be a safe and helpful modality for the treatment of cervical and
lumbar disc herniations. A random, controlled, clinical trial is called for
to further substantiate the role of chiropractic care for the nonoperative clinical management of intervertebral disc herniation.
Cassidy et al. Side Posture Manipulation for Lumbar
Intervertebral Disk Herniation. JMPT. Volume 16, Number 2,
February, 1993
Conclusions: The treatment of lumbar intervertebral
disk herniation by side posture manipulation is both
safe and effective.
Cassidy et al. Cont’d
Points of Interest:
q
Normal disks withstood an average of 22.6 degrees of rotation before failure,
while the degenerated disks withstood an average of 14.3 degrees.
q
When disk failure occurred, it presented as peripheral annular tears and not
herniation or prolapse.
q
Posterior facet joints of the intact lumbar motion segment allow only a small
range of rotation at the lower levels.
q
Therefore torsional failure of the lumbar disk first requires fracture of the
posterior joints, which can then result in peripheral annular tears.
q
Bottom line: The bony architecture of the lumbar spine prevents excess
rotation that would have damaged the peripheral annular fibers. Therefore it
remains unlikely that side posture spinal manipulation would damage a disk.
Waagen et al. Short term trial of chiropractic adjustments for the
relief of chronic low back pain. Manual Medicine (1986) 2:63-67
After two weeks of treatments the experimental
patients as a group exhibited significant overall pain
relief (+2.3), whereas improvement of patients in the
control group was not significant (+0.6).
Troyanovich et al. JMPT. Vol. 21, Number 1, January 1998. Structural
Rehabilitation of the Spine and Posture: Rationale for Treatment Beyond
the Resolution of Symptoms.
Conclusion: Because mechanical loading of the
neuromusculoskeletal tissues plays a vital role in influencing
proper growth and repair, chiropractic rehabilitative care should
focus on the normalization/minimization of aberrant stresses
and strains acting on spinal tissues.
Manipulation alone cannot restore body postures or improve an
altered sagittal spinal curve. Therefore, postural chiropractic
adjustments, active exercises and stretches, resting spinal
blocking procedures, extension traction, and ergonomic
education are deemed necessary for maximal spinal
rehabilitation.
Wiberg et al. The Short-term Effect of Spinal Manipulation in the
Treatment of Infantile Colic: A randomized Controlled Clinical Trial with a
Blinded Observer. Journal of Manipulative and Physiological Therapeutics
Volume 22, Number 8, October 1999.


Results: By trial days 4 to 7, hours of crying were reduced by
1 hour in the dimethicone group compared with 2.4 hours in the
manipulation group (P=.04). On days 8 through 11, crying was
reduced by 1 hour for the dimethicone group, whereas crying in
the manipulation group was reduced by 2.7 hours (P=.004).
From trial day 5 onward the manipulation group did significantly
better than the dimethicone group.
Conclusion: Spinal manipulation is effective in relieving
infantile colic.
Reed et al. Chiropractic Management of Primary Nocturnal Enuresis.
JMPT, Volume 17, Number 9, November/December, 1994
Results: The post-treatment mean wet night frequency of 7.6 nights/2
wk for the treatment group was significantly less than its baseline
mean wet night frequency of 9.1 nights/2 wk (p = 0.05). For the
control group, there was practically no change (12.1 to 12.2 nights/2
wk) in the mean wet night frequency from the baseline to the posttreatment………
Twenty-five percent of the treatment-group children had 50% or more
reduction in the wet night frequency from baseline to post-treatment
while none among the control group had such reduction.
Conclusion: Results of the present study strongly suggest the
effectiveness of chiropractic treatment for primary nocturnal enuresis.
Croft et al. Outcome of low back pain in general practice: a
prospective study. BMJ Volume 316; 2 May 1998.
Conclusions: The results are consistent with the
interpretation that 90% of patients with low back
pain in primary care will have stopped consulting with
symptoms within three months.
However most will still be experiencing low back pain
and related disability one year after consultation.
Shekelle et al. Congruence between Decisions To Initiate Chiropractic
Spinal Manipulation for Low Back Pain and Appropriateness Criteria in
North America. Annals of Internal Medicine, 1 July 1998. 129:9-17.
Conclusions: The proportion of chiropractic spinalmanipulation
judged to be congruent with appropriateness criteria is similar
to proportions previously described for medical procedures;
thus, the findings provide some reassurance about the
appropriate application of chiropractic care.
However, more than one quarter of patients were treated for
indications that were judged inappropriate. The number of
inappropriate decisions to use chiropractic spinal manipulation
should be decreased.
Mooney. Why Exercise for Low Back Pain? Activity Reverses
Biochemical Changes Caused by Injury. The Journal of
Musculoskeletal Medicine. October 1995.
Selected statements:
There is no evidence that a diagnosis-or even the presence or absence of a
neurologic deficit-can predict the duration or outcome of a back problem.
Concerning exercise and AHCPR Guidelines: The guidelines are nonspecific and
contain no rationale.
In all other soft-tissue injuries, progressive physical activity evacuates extracellular,
extravascular fluid. This justifies the recommendation of early mobility for
injured tissues. The early motion should be gentle but progressive, with the
expectation that gradually increasing stresses will facilitate healing.
Koes, et al. A Randomized Clinical Trial of Manual Therapy and
Physiotherapy for Persistent Back and Neck Complaints: Subgroup
Analysis and Relationship Between Outcome Measures. JMPT; 16:211219; 1993.
Results: Greater improvement in the main complaint was
associated with manual therapy than with physiotherapy for
patients with back problems of 1 year’s duration or longer. For
patients younger than age 40 years, improvement was also
greater with manual therapy than with physiotherapy.
Conclusion: Manual therapy appears to yield better results than
physiotherapy in patients with chronic conditions, and in
patients younger than age 40 years.
Davis. Chronic Cervical Spine Pain Treated With Manipulation Under
Anesthesia.
Journal of the Neuromusculoskeletal System. Fall 1996 Vol. 4, No. 3.
The results suggest that manipulation under
anesthesia may be beneficial in patients with
chronic pain that effects work or activities of
daily living and in patients with cervical
segmental dysfunction, fibrosis, myofascitis,
or cervicogenic headaches.
Licciardone et al. Osteopathic Manipulative Treatment for Chronic
Low Back Pain. Spine. 2003;28:1355-1362.
Conclusion: Osteopathic Manipulative Treatment (OMT) and
sham manipulation, both appear to provide some benefits when
used in addition to usual care for the treatment of chronic
nonspecific LBP.
It remains unclear whether the benefits of OMT can be attributed
to the manipulative techniques themselves or whether they are
related to other aspects of OMT, such as range of motion
activities or time spent interacting with the patient, which may
represent placebo effects.
Scholten-Peeters, et al. Clinical Practice Guideline for the Physiotherapy
of Patients with Whiplash-Associated Disorders. Spine Vol. 27, Number 4,
pp. 412-422, 2002.
Conclusions: Scientific evidence for the diagnosis and
physiotherapeutic management of whiplash is sparse; therefore,
consensus is used in different parts of the guideline.
The guideline reflects the current state of knowledge of the
effective and appropriate physiotherapy in whiplash patients.
More and better research is necessary to validate this guideline
in the future.
Vernon et al. Spinal Manipulation and Headaches of Cervical Origin.
Journal of Manipulative and Physiological Therapeutics, Volume 12,
Number 6, December, 1989.
ABSTRACT: The role of the cervical spine in headache remains
controversial. Often confused as tension or common migraine
headache, headaches arising from the neck pose a diagnostic and
therapeutic challenge.
Recent writers addressing this issue, including Bogduk (2-4), Edmeads
(50, Farina et al. (6) and Sjaastad and his colleagues (7-9), have
added much to our current understanding. However, even these
authors appear to have included only a small portion of the supportive
literature in their reports, leaving a diminished sense of the historical
attention and the current clinical importance of this category of
headaches.
Quon et al. Lumbar Intervertebral Disc Herniation: Treatment by
Rotational Manipulation. Journal of Manipulative and Physiological
Therapeutics, Volume 12, Number 3, June, 1989.
Although caution must be exercised in interpreting single case studies, this
paper describes a patient who presented with an L4-L5 disc herniation.
The size of the lesion revealed by CT examination was so great that
one would not expect a favorable response to conservative measures.
However, the patient was rendered pain-free within 2 weeks by daily
manipulations.
The enormous size of the disc herniation did not seem to influence the
clinical result. Had a trial of conservative therapy not been prescribed,
he may well have undergone an unnecessary surgical procedure.
Furthermore, a repeat CT scan, 4 months after the initial episode,
showed no change in the size or position of the disc herniation.
Maigne et al. Highlighting of Intervertebral Movements and Variations of
Intradiskal Pressure During Lumbar Spine Manipulation: A Feasability
Study. JMPT Vol. 23, Number 8, October 2000.
Even though this study was a limited one on cadavers, it has important implications:
- Spinal manipulation is capable of lowering intradiscal pressure, a phenomenon
thought to improve related symptoms.
- This pressure change theory is consistent with outcome studies that have
examined manipulation in the treatment of symptomatic disc herniation.
- Vertebral movement can be demonstrated during manipulation.
- The effect of this movement is to redistribute or normalize intradiscal pressure,
not to result in a different resting position of the vertebra.
- Future work on the motion/position aspect of manipulation should look at
temporary positional changes during the manipulation, not before and after
position.
Maigne et al. Cont’d
Conclusion: Lumbar spinal manipulations have a
biomechanical effect on the IVD, producing a brief
but marked change in intradiskal pressure. This
effect, which differs slightly with the different types
of manipulation studied, is the consequence of
movements of the adjacent vertebrae.
Whiplash: Research and Case
Management
Presented by:
Ronald J. Farabaugh, D.C.
Principle #1:
The three pillars of LOSRIC:

Accident reconstruction: weak science.
Body kinematics: strong science.
Risk Factors: strong science.

Documentation


Principle #2:
The threshold of injury is approximately
5 mph delta V.
However, every human being is unique.
The threshold of vehicle damage is 2-3x
that of injury potential.
Principle #3:
The use of daily activities to describe
the forces experienced in a traffic
collision is invalid.
Principle #4:
Property damage is not a reliable
indicator of injury potential.
Principle #5:
Minimal vehicle damage cannot be used
to determine that a collision was low
speed or low impact.
Principle #6:
Bumper standards pertain to minimum
change in velocity, not maximum.
Principle #7:
Acceleration of the head is much more
important than the acceleration of the
vehicle, delta V, speed, or vehicle damage,
when determining injury potential.
Accident reconstruction is a very inexact
science.
Principle #8:
Accident reconstruction based on
photographs is woefully inadequate.
Principle #9:
Injuries and fatalities occur in collisions
with little, or no, property damage.
Principle #10:
It is imperative for the attorneys to set up the
Chiropractic physician as the expert.
It is imperative for the attorneys to develop the
proper foundation for the soft tissue case!
It is imperative for the DC to document well,
treat effectively, and keep costs reasonable.
Principle #11:
Paradoxic Relationship
Due to the elastic nature of LOSRIC, the
apparent paradox of the inverse
relationship between property damage
and injury potential is a real one.
Previous attempts to correlate these
factors have failed to show a
relationship
Low Speed Rear Impact
Collision
A review of miscellaneous literature….
French Study: Foret-Bruno et al






8000 + crashes and 15,000 occupants
27% of occupants in rear-end collisions sustained
cervical injuries, compared to 10% and 8% in frontal
and side impacts.
7% of all crashes = rear end
Women injured in 42 % and men 21%
Delta V below 9.3 mph = injury rate 36%
Delta V above 9.3 mph = only 20%
Thomas et al


The largest clustering of rear impact crashes
is between a delta V of 9.3 and 12.4 mph,
About 70% occur at a delta V of less than
15.5 mph.
American Studies


States et al: Reported an injury risk of 38%
in consecutive series of 691 rear impacts.
Kihlberg: 26% of exposed motorists were
injured when seat backs did not fail; 19%
when failure occurs.
American Studies
Chapline et al:
 Largest category of injury crashes = no
damage
 In these 38% of females and 19% of males
had symptoms.
 When damage rated as “minor”, these
percentages were 54% and 34%.
Japanese Studies
Ono and Kanno: 50% of car crashes result in
neck injury, increasing every year.
 95% of crash injuries are scaled AIS I
 Of these 80% concentrated in the neck
 95% of these neck injuries are CAD injuries

15-20% of victims have prolonged
symptoms
Australian Study: Dolinis
Two risk factors identified as independent risk
factors for injury.
1.
2.
A history of prior neck injury (4.5x more
likely to be injured)
Female gender (2x more likely to be injured
than a man)
U.S. Study




Records from 11 police agencies 1995-1997
Risk: 45% of females S/S of neck pain
28% of males drivers
43% of females and 31% males also had low
back pain.
Overall Risk Estimate

Based on studies and data, Croft estimates
that between 30% and 60% of real world car
occupants exposed to LOSRIC of > 2.5 mph
delta V sustain some degree of injury ranging
from very short lived to disabling.
CAD Related Chronic Pain


Rear impact injuries carry a worse prognosis
than either side or frontal impact injuries.
On average 30-50% of the patients in these
studies had not recovered completely at
follow-up—about 10% rating their problem as
disabling or severe.
Latest Data
A surprising 45% of the American
population with chronic neck pain
attributes it to a MVC. (6.2% of
population)
Low Speed Crashes




Most modern vehicles can withstand crash
speeds of up to 8-10 mph, and often higher,
without sustaining appreciable damage.
Resulting delta V = 6-5 to 8 mph.
Threshold for soft tissue injury in the
neck of a healthy adult male is a delta V
of 2.5 to 5 mph.
Vehicle can withstand crash velocities nearly
2x the injury threshold.
Nikolai Bogduk, MD, Department of Anatomy and Musculoskeletal Medicine,
University of Newcastle, Newcastle Bone and Joint Institute, Point of View

“Whiplash-associated disorders have lacked
credibility. Opponents in the past have cited lack of
evidence of a lesion in patients with symptoms, lack
of successful treatment, and lack of a biomechanical
link between symptoms and the alleged injury.”
Bogduk (cont’d)

“The study of Kaneoka et al now fills a critical gap in
the story of cervical facet pain. It provides the
missing biomechanical link. Theirs is the most
significant advance in the biomechanics of whiplash
since the pioneering studies of Severy et al in 1955.”
Bogduk (cont’d)
“The critical observation is that in whiplash the lower cervical
segments undergo sagittal rotation about an abnormally high
instantaneous axis of rotation. As a result, there is no
translation; there is only rotation. As the vertebra spins, its
anterior elements separate from, while the posterior elements
crunch into, the vertebra below.
This mechanism predicts that the resultant lesions should be tears
of the anterior annulus and fractures of the zygapophysial joints
or contusions of their meniscoids. These are the very lesions
seen at postmortem.”
(Clearly, this is an important article. Nikolai Bogduk believes that
this is the most important biomechanical research on whiplash
in 44 years.)
Pettersson, K; Hildingsson, C; Toolanen, G; Fagerlund, M; Bjornebrink, J
Disc Pathology After Whiplash Injury: A Prospective Magnetic Resonance
Imaging and Clinical Investigation. Spine 1997 Feb. 22 (3) pp. 283-8


ABSTRACT: Study Design: This study was used to evaluate the
relationship between magnetic resonance imaging finding and
clinical findings after whiplash injury.
Objectives: To identify initial soft-tissue damage after whiplash
injury, the development of disc pathology, and the relationship
of disc pathology to clinical findings.
Disc Pathology After Whiplash Injury: A Prospective Magnetic Resonance
Imaging and Clinical Investigation. Spine 1997 Feb. 22 (3) pp. 283-8

Results: The authors found 13 patients (33%) with disc
herniations with medullary (six cases) or dura (seven cases)
impingement over the 2-year follow-up period. At the follow-up
examination all patients with medullary impingement had
persistent or increased symptoms, and three of 27 patients
(11%) with no or slight changes on magnetic resonance
imaging had persistent symptoms. No ligament injuries were
diagnosed.
Disc Pathology After Whiplash Injury: A Prospective Magnetic Resonance
Imaging and Clinical Investigation. Spine 1997 Feb. 22 (3) pp. 283-8

Conclusion: Although disc pathology seems to be
one contributing factor in the development of chronic
symptoms after whiplash injury, it may be
unnecessary to examine these patients in the acute
phase with magnetic resonance imaging; correlating
initial symptoms and signs to magnetic resonance
imaging findings is difficult because of the relatively
high proportion of false-positive results. Magnetic
resonance imaging is indicated later in the course of
treatment in patients with persistent arm pain,
neurologic deficits, or clinical signs of nerve root
compression to diagnose disc herniations requiring
surgery.
Lord, in Spine: State of the Art Reviews: Cervical FlexionExtension/Whiplash Injuries, Hanley and Belfus, Sept. 1993, p. 362


“In studies in which experimental animals or cadavers have
been subjected to whiplash motion, injuries to the cervical
zygapophyseal joints are among the most common and most
consistent lesion produced. The lesions include tears of the
joint capsules, intraarticular hemorrhage and impaction
fractures.”
“Postmortem studies of victims of MVAs reveal that
zygapophyseal joint injuries are common, being present in 86%
of necks examined. The lesions include capsular tears, ruptures
of meniscoids, intraarticual hemorrhage, and small fractures.”
Woodward, Cook, et al. (1996). “Chiropractic Treatment
of Chronic Whiplash.” Injury 27 (9): 643-5

“The accumulated literature suggests that 43% of patients will
suffer long-term symptoms following ‘whiplash’ injury. If
patients are still symptomatic after 3 months then there is
almost a 90% chance that they will remain so. No conventional
treatment has proven to be effective in these established
chronic cases.”


“The results of this retrospective study would suggest that
benefits can occur in over 90% of patients undergoing
chiropractic treatment for chronic ‘whiplash’ injury.”
Following the chiropractic treatment, 93% of the patients had
improved.
A Symptomatic Classification of Whiplash Injury and the Implications for
Treatment. Khan, Cook, Gargan, and Bannister, University Department of
Orthopaedic Surgery, Bristol, UK. The Journal of Orthopaedic Medicine
21[1]1999.



Objective: To determine which patients with chronic whiplash will
benefit from chiropractic treatment.
93 patients, 68 female.
Conclusion: Whiplash injuries are common. Chiropractic is the only
proven effective treatment in chronic cases. Our study enables
patients to be classified at initial assessment in order to target those
patients who will benefit from such treatment.

57% make full recovery.

Resolution of symptoms will have occurred within 2 years of injury.

8% will remain disabled by their symptoms.
Khan, Cook, Gargan, and Bannister, University Department of Orthopaedic
Surgery, Bristol, UK. The Journal of Orthopaedic Medicine 21[1]1999.
(cont’d)



Non-responders do exist. Defining characteristics include: full range of
motion in association with neck pain, bizarre symptoms, female sex
and ongoing litigation.
McNab, found that symptoms persist in 45% of patients two years after
settlement of litigation.
Watkinson et al, found significantly higher frequency of degenerative
changes on radiological examination of patients who have sustained
soft tissue injuries than in a controlled population, place more
emphasis on the organic basis of symptoms.
Khan, Cook, Gargan, and Bannister, University Department of Orthopaedic
Surgery, Bristol, UK. The Journal of Orthopaedic Medicine 21[1]1999.
(cont’d)
Whilst other studies have suggested that neurological signs (Group 2)
have a poorer prognosis, this was not the case amongst our patients.
Indeed, such patients showed the greatest improvement in disability
grade.
Group 1: Neck pain, restricted ROM, no
neurological deficit.
Group 2:
Neurological symptoms, neck pain,
restricted motion.
Group 3:
Severe neck pain, full ROM, no
neurological symptoms.
Results: Organic pain causes psychological stress, not the result of it!
Vert Mooney, MD, Spine, 12(8), 1987 754-759, Presedential
address of the International Society for the Study of the Lumbar
Spine. May 29-June 2, 1986 Dallas, TX.




“Physical activity seems to be a source of increase of endorphins”,
which greatly reduce the perception and neurotransmission of painful
stimuli.
In adulthood, mucopolysaccharide production is switched to chondroitin
sulfate B and keratosulfate production, both of which bind less water
which adversely affects primarily the nucleus.
“Mechanical activity has a great deal to do with the exchange of water
and oxygen concentration in the disc.”
“The fluid content of the disc can be changed by mechanical activity,
and the fluid content is largely bound to the proteoglycans, especially
of the nucleus.”
Vert Mooney, MD, Spine, 12(8), 1987 754-759, Presedential
address of the International Society for the Study of the Lumbar
Spine. May 29-June 2, 1986 Dallas, TX. (cont’d)


“In summary, what is the answer to the question of
where is the pain coming from in the chronic lowback pain patient? I believe its source, ultimately, is
in the disc. Basic studies and clinical experience
suggest that mechanical therapy is the most rational
approach to relief of this painful condition.”
“Prolonged rest and passive physical therapy
modalities no longer have a place in the treatment of
the chronic problem.”
Chronic Cervical Zygapophysial Joint Pain After Whiplash:
A Placebo-Controlled Prevalence Study.
Derby MD, Spine 1996;21:1744,1745 (August 1, 1999)


“This study reveals a single symptomatic segment in 26 of 31
patients completing the study in which the C2-3 joint is the
most common cause of upper cervical pain referral and
headache and the C5-6 joint is the most common source of
lower cervical axial pain and referred arm pain.”
“Although muscle pain and tissue hyperalgesia may be an
integral part of chronic cervical pain after whiplash injuries, such
pain may be better explained as a secondary reflex reaction to
injury of segmental supporting structures.”
Acute Injuries to Cervical Joints. An Autopsy study of Neck Sprain.
Taylor, Twomey, Spine 1993, July;18(9):1115-22
A comparative study of cervical spines from 16 subjects
who died of major trauma and 16 control subjects
who died of natural causes, showed clefts in the
cartilage plates of the intervertebral discs in 15 of 16
spines from the trauma victims.
It is suggested that disc “rim lesions” could
cause the pain experienced by patients with
neck sprain.
Acute Injuries to Cervical Joints. An Autopsy study of Neck Sprain.
Taylor, Twomey, Spine 1993, July;18(9):1115-22 (cont’d)
“Neck sprain without fracture poses a difficult diagnostic problem
because soft-tissue injuries are not usually demonstrable by using
standard radiography. This adds to a patient’s distress, because there
is no objective display of an injury to account for the pain. Such
patients are often regarded as having a psychosomatic illness with
little organic basis.”
“A substantial proportion of neck sprains remain symptomatic for more
than 2 years with little or no evidence of organic disease.”
“There is good evidence that disc splits (rim lesions) near the endplate persist for 618 months or more without healing and their presence is associated with early
disc degeneration.”
“The clefts are only visible on extension films and the pain distribution
suggests that the discs involved may be responsible for the
symptoms.”
Acute Injuries to Cervical Joints. An Autopsy study of Neck Sprain.
Taylor, Twomey, Spine 1993, July;18(9):1115-22 (cont’d)
Conclusion:
“Clinical studies show that rim lesions and traumatic herniations
are demonstrable in survivors of motor vehicle trauma, in the
absence of vertebral fractures. Such lesions would cause acute
pain at the time of the injury and would be likely to progress to
early disc degeneration, with extension of the clefts and
vascularization within the clefts.”
“The disc may degenerate because the clefts separate the center
of the disc from its source of nutrition in the vessels of the
vertebral marrow and the outer annulus. These degenerative
changes would also be likely to contribute to chronic pain and
dysfunction of the cervical spine.”
Vehicle Damage vs. Injury
Potential Article
Is there a valid correlation between
vehicle damage and the probability of
injury?
Answer: NO!!
Callier, 1981
“A collision, when the offending car
moves at a rate as slow as seven (7)
mph can cause severe tissue damage
and injury.
Taken from Croft seminars:
(Module 4, Section two-Cervical Spine References)
Mcnab, 1982
3.7 to 5 mph rear-end impact, which
subjects the cervical spine to as much
as 4.5 G-forces, constitutes the
threshold for mild cervical strain injury.
Mcnab, 1982
“The amount of damage sustained by
the car bears little relationship to the
force applied.”
The Spine, Saudners, 1982, p. 648
Ameis 1986: Canadian Family Physician,
September, 1986
“Each accident must be analyzed in its
own right. Auto speed and damage are
not reliable parameters.”
Cervical Whiplash: Considerations in
the Rehabilitation of Cervical Myofascial
Injury.
Hirsh, et al 1988
In an 8-mph rear-end collision, a 2 G-force of
acceleration of the vehicle may result in a 5Gforce acceleration of the occiput and head.
“The amount of damage to the automobile
may bear little relationship to the forces
applied to the cervical spine and to the injury
sustained by the cervical spine.”
Whiplash Syndrome, Orthopedic Clinics of North America,
October 1988. p. 791.
Navin, Macnab, et al. 1989
“The experimental results indicate that some
vehicles can withstand a reasonably high
speed impact without significant structural
damage. The resulting occupant motions…..
dangerous acceleration up to speeds greater
than that of the vehicle.”
An Investigation into Vehicle and Occupant Response
Subjected to Low-Speed Rear Impacts.
Emori, 1990
“…neck extension becomes almost 60
degrees which is a potential danger
limit of whiplash, at collision speed as
low as 2.5 km/h.”
SAE, Feb, 1990, p.108.
McConnell, et al 1993
The crash tests study concluded that
Delta Vs of 5 mph was the probable
threshold for cervical injury.
Smith, J. 1993
“The absence or presence of vehicle damage
is not a reliable indicator of injury potential in
rear impacts. Based upon the principle of
conservation of energy, any energy which
does not go into damaging the vehicle must
be converted into kinetic energy, the source
of injuries.”
“The Physics, Biomechanics, and Statistics of
Automobile Rear Impact Collisions.”
Trial Talk: 10-14.
Smith, J. 1993 (cont’d)
“Since kinetic energy is the source of
injury to vehicle occupants, it is obvious
that the bumper standards have the
effect of reducing vehicle damage while
increasing the probability of personal
injury in rear end impacts.”
Ono, et al 1997
At impact speeds of 2.5, 3.7, and 5
mph C5-6 compressive loading and
bending movement was found along
with sudden extension causing
compression in the facet joint, rather
than gliding. There was more injurious
compression in the facet joints during
extension even before the head
hits/strikes that seat’s head restraint.
Brault, et al 1998
Recent crash testing produced injuries
in 29% and 38% in 2.5 and 5 mph,
respectively in Delta Vs, low speed rear
impact collisions.
Significant Facts




There is no relevant science that equates injury
potential to vehicle damage.
No accident reconstructionist can predict an
individual’s INJURY THRESHOLD.
The presence of an injury is best determined by the
examining physician and is based on the
CORRELATION between history, examination, x-ray
and other diagnostic tests.
No MD, DC, DO or other medical professional was
ever educated to consult an accident
reconstructionist to determine the presence or
absence of injury.
Significant Facts




Strong research exists correlating RISK FACTORS and
injury potential.
Strong research exists demonstrating that chronic
pain is often the result of Low Speed Rear Impact
Collisions (LOSRIC).
The “6-8 week natural healing time” is a myth that
should forever be abandoned.
“No Crash-No Cash” is a concept that should be
forever abandoned.
Review of Risk Factors
Acute Risk Factors:
Late or “Chronic” Risk Factors:
20
18
Sneeze Article
“The “G” forces of an ordinary sneeze is
greater than that experienced in a
LOSRIC, yet people sneeze everyday
and don’t get hurt. How do you explain
that?”
Sneeze Analogy
Allen; Iain Weir-Jones; P Eng, et al. (1994).
“Acceleration perturbations of daily living; A
comparison to “whiplash’”. Spine: 1994
19(11): 1285-92.
 8 healthy volunteers
 subjected them to daily activities, none of which
caused any hint of injury.
Allen Paper-ADL
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Looking to the left,
Unexpected startle by discharge of a starter pistol behind the subject,
Standing up suddenly from a kitchen chair,
Passively dropping the head backwards as if falling asleep from a
seated position,
Routine sitting into a kitchen chair from standing,
Sneeze from sniffing pepper into nostrils,
A simulated cough,
An unexpected bump against the left shoulder as would occur in a
crowd,
An anticipated hardy slap on the back greeting,
Kicked hard from behind while sitting in a wheeled office chair,
Hopping off a 20 cm (8 inch) step and land on both feet,
Plopping backwards into a low-backed office chair.
Response to Allen Paper
1.
2.
3.
4.
Artifact movement
No two persons are alike, and no two crashes are
alike.
The forces applied to the body are not the same for
different individuals who appear to perform
similarly.
This study was limited in the number of volunteers.
The full spectrum of the population, with a
presumed wide variance in physical and
psychological profiles, was not tested.
Response to Allen Paper
5.
6.
7.
The authors did not consider the influence
of “awareness factor” during their two
highest peak average measured
accelerations of 10.1 G (plop in chair) and
8.1 G (hop off step).
The authors did not take into account other
well researched risk factors associated with
LOSRIC, and compare them to common
activities like a sneeze.
The applied forces in a LOSRIC are external.
The force generated during a sneeze is
internal.
Response to Allen Paper
8.
A short list of risk factors important to consider in
LOSRICs that were not considered by the authors
include:










Poor head geometry (1, 2)
Rear impact versus frontal impact collision (3, 4, 5, 6)
Front versus rear seat position (7)
Out of position occupant (8, 9)
Height, mass, or age of patient (10, 11, 12, 13)
Injury threshold of patient (14)
Position of head rest (15)
Mass of bullet vehicle versus mass of target vehicle (16)
Non-failure of seat back and influence of head rest (17)
Pre-existing conditions (18)
Litigation Neurosis: Is it real?
See article
The Neurological Basis for Chronic Pain
Two important studies…
Spine 2004; 29(2):182-188 Characterization of Acute
Whiplash-Associated Disorders. Sterling, PhD, et al.
Conclusions.
Acute whiplash subjects with higher levels of pain and disability
were distinguished by sensory hypersensitivity to a variety of
stimuli, suggestive of central nervous system sensitization
occurring soon after injury.
These responses occurred independently of psychological distress.
These findings may be important for the differential diagnosis of
acute whiplash injury and could be one reason why those with
higher initial pain and disability demonstrate a poorer outcome.
Evidence for spinal cord hypersensitivity in chronic pain
after whiplash injury and in fibromyalgia. Banic B, et al.
Pain; 2004 Jan;107(1-2) p7 - 15
Patients with chronic pain after whiplash injury and fibromyalgia
patients display exaggerated pain after sensory stimulation.
Because evident tissue damage is usually lacking, this
exaggerated pain perception could be explained by
hyperexcitability of the central nervous system.
We provide evidence for spinal cord hyperexcitability in patients with
chronic pain after whiplash injury and in fibromyalgia patients. This
can cause exaggerated pain following low intensity nociceptive or
innocuous peripheral stimulation. Spinal hypersensitivity may
explain, at least in part, pain in the absence of detectable tissue
damage.
Lecture Summary



The biomechanics of a motor vehicle accident (whiplash) may
cause injury to the disc and facet joints; therefore these
structures are the most probable source for irritation causing
chronic whiplash pain.
An appreciable amount of chronic pain afferents synapse in the
limbic cortex, causing an abnormal psychological profile. The
abnormal profile can only be helped by successful treatment of
the chronic spinal pain.
The best treatment for the disc and facet soft-tissue injuries are
early, persistent, controlled motion of the injured tissues.
Lecture Summary
(cont’d)



Self directed controlled motion of injured extremity joints is
possible because the muscles that cross those joints are
primarily under the control of the voluntary motor cortex.
Self directed controlled motion of injured spinal joints is NOT
possible because the muscles that move the individual segments
are not under the primary control of the voluntary motor cortex,
but rather controlled primarily through the vestibular spinal
tracts (descending medial longitudinal fasciculus), which is nonvoluntary.
Injury to the spinal discs and facet joints causes a nonvoluntary contraction of the non-voluntary segmental movers
(primarily the multifidus) at the level of injury and for several
segments above and below the level of injury.
Lecture Summary
(cont’d)
This non-voluntary contraction locks the motor unit into a certain
parameter of position and reduced movement.
This reduction of movement:


Opens the pain gait.
Impairs the “disc pump” which:



Accelerates disc degeneration
Makes the disc more acidic which increases the firing of disc
nocireceptors.
Alters the quality of the synovial fluid which:

Reduces its nutrient value, which accelerates posterior joint
arthrosis and pain.
Lecture Summary
(cont’d)
Chiropractic Adjustments:




Segmentally fire high threshold mechanoreceptors that di-synaptically
inhibit tone in the segmental movers, which improves segmental spinal
motion and position.
This controlled movement allows the injured tissues to heal better and
quicker.
This controlled movement improves the fluid exchanges of the disc and
synovial fluid, which reduces pain and joint degeneration.
This controlled movement initiates a neurological sequence of events
that causes pain inhibition (closes the pain gait).
Recurrent Nature of Pain
A Review of the Literature
Frank, MD. British Medical Journal 1993; April 3:901-9.
Review of a study in which 373 patients less than 40
years old, with their first onset of back pain, are
followed for 10 years. 89% had recurrences and
only 33% had no lost time form work from future
back problems. Strategies to manage low back
pain must be long term and preventive.
Waddel, MD. JMPT 1995;18(9):590-596
“Traditional teaching is that 90% of LBP attacks recover
within six weeks, but recent natural history studies
suggest that this is overly optimistic and overemphasizes RTW. It now seems that 50% of attacks
settle within 4 weeks, but 15-20% have some
symptoms for at least 1 year. 70% of patients who
have acute back pain will suffer 3 or more
recurrences. 20% will continue to have some back
symptoms over long periods of their lives.”
Jayson, MD, FRCP. Spine 1997;22(10):1053-1056.
“At 3 months, only approximately 27% were completely
better, 28% improved, 30% had no change, and
14% were worse or much worse. It may well be that
in the many studies of acute low back pain, there has
been very carefully selected clinical material so that
only those patients with acute pain of recent onset
and no other confounding factors were included, with
the result that these studies do not reflect what
actually happens in practice.”
Saal JA, MD. Spine 1997;22(14):1545-1552
“The major premise used in the managed care system
for the primary care of LBP is based upon the
assumption that 90% of patients improve in 6-12
weeks. However, a natural history study by Von
Korff found that approximately 60% will recur. In a
study of BP in primary care, Von Korff and Saunders
found that 60% to 75% improve within the first
month, 33% report intermittent or persistent pain at
one year, and 20% of patients describe substantial
limitations at one year. The premise for the
AHCPR guidelines and Managed Care for back
pain is not valid. [Emphasis added.]”
Waddell, MD. The Chiropractic Report 1993; July:1-6
“Traditional medical treatment according to the disease model has
failed. Bed Rest: should die as soon as it can. Avoid bed rest if
possible. Physical Therapy: There is no adequate evidence of
effectiveness. Spinal manipulation: one of two treatments of
proven value. The last 10 years produced a lot of solid scientific
evidence to support the value of manipulation. Early active
exercise: Is the other treatment supported by good evidence”.
“Relief of pain and restoration of function must occur at the same
time. Failure to restore function means any pain relief will be
temporary and reinforces chronic pain. In the management of
occupational back pain, the chiropractic profession is leading the
way. The problem is weakness and loss of function, not
disease.”
Kuritzky, MD. Physician and Sports Medicine 1997;25(1):56-64
“97% of BP seen by primary care physicians is
mechanical in origin. There is something wrong with
the muscles, ligaments, or connective tissues. Most
patients with low back pain do not have ruptured
discs, but it is notorious, partly because imaging
studies dramatically overestimate the frequency.”
Eisenberg, MD. Annals of Internal Medicine 1997;127(1):61-69.
“More than 70% of patients who used alternative therapy never
mentioned it to their MDs.”
Like the British study, this research demonstrated that even though
patients no longer consult their medical provider, it does not
mean that the problem has resolved. The myth of "natural
healing time" must be reconsidered given the extended nature
of pain and the fact that patients continue to seek out the
advice of other providers when the primary care giver does not
successfully treat the condition.
Cowley. Going Mainstream. Newsweek 1995;June 26:56-57.
“There is a growing awareness among health insurers that patients
seeking unconventional care represent a huge potential market
and that alternative care does not cost the insurer very much.
As one managed care executive said, "3 visits to a DC are a lot
less expensive than an MRI or back surgery.”
Concerning chronic pain, it makes a lot more sense to treat a
patient with a periodic chiropractic adjustment than to allow the
condition to degenerate to the point of requiring dangerous
medication (impairing function, thus productivity at work) or
surgery. Many times, daily exercise and self-management are
not enough to control a chronic back problem.
Haldeman, DC, PhD, MD. Spine 1990;15(7):718-723.
“The pathology model cannot explain back pain or disability. It is
not possible to look at pathology and determine the symptoms a
patient may be suffering. It also is not possible to look at a
patient with back pain with no neurologic deficits and determine
the nature of the pathology. About 30% of asymptomatic
subjects show abnormalities in the lumbar spine by myelogram,
CT and MRI. There is a large percent of symptomatic patients
with severe complaints in whom testing fails to reveal any
structural lesion.”
A study by Jensen, which appeared in the New England
Journal of Medicine 1994;331(2)July 14:69-73,
produced similar results
Summary…
As a result of these and other studies there has been a
shift in thinking away from the traditional "symptom"
approach, towards contemporary thinking of
"function". For many patients with recurrent back
pain, staying functional is a "process" more so than a
"result" based on a predictable healing time or
average.
Jonsson MD. Journal of Spinal Disorders 1991;4(3):251-263.
Study of cervical spine of 22 patients who died of fatal skull fractures in
MVAs. X-rays were evaluated by an expert orthopedic radiologist.
Only 1 of 10 gross ligamentous disruptions were even suspected on Xrays. 198 lesions were missed. Multilevel soft-tissue injuries were
common. Very few injuries were detected or even suspected on
radiograms. The vast majority was not recognized. Plain radiograms
cannot detect soft-tissue lesions unless they are associated with
vertebral body malalignment. Conclusions: the majority of lesions are
soft-tissue injuries. Plain radiograms show virtually no soft-tissue
lesions.
Side note:
As a result of these types of studies, it has become apparent that a
thorough physical examination is more important, in combination with
functional assessments, than traditional diagnostic evaluations to
determine the presence or absence of soft-tissue injuries.
Liebenson, DC, Oslance. Rehabilitation of the Spine. Williams and
Wilkins, Baltimore. 1996:73.
“80% of patients have no identifiable structural pathology and
require treatment based on evaluation of functional deficits. In
the majority of cases, patients have soft tissue injuries and
functional changes are the only objective findings on which to
base treatment and judge progress. Outcomes assessments
including objective functional tests give the third party payers,
patients and doctors a way to measure progress over time, and
evaluate the prescribed treatment.
Overemphasis on
treatment of structural pathology results in a failure to
identify or focus on functional loses and work demands.
[Emphasis added.]”
The Recurrent Nature of Back Pain
In other words, the reduction of pain alone is not an
accurate indicator of the need for additional
treatment. There has been a shift away from
treatment based only on pain relief to treatment
based on the desire to improve function and return to
the patient to the original form of employment. The
improvement of function in a person with a
"complicated" soft tissue injury in combination with a
physically demanding job is an ongoing process more
so than an endpoint based on pain reduction alone.
Mooney, MD. J. Musculoskeletal Medicine 1995; Oct:33-39.
“Common acute back pain is due to chemical abnormalities created by soft
tissue tear. The tear represents a mechanical disruption, which is
usually microscopic. X-rays demonstrate no changes before and after
an acute back injury.”
Again, function is more important in the evaluation and treatment of back
pain than structural pathology. A "negative" x-ray has limited value in
the determination of medical necessity since one cannot evaluate
"function" from an x-ray. Similar findings concerning other imaging
findings was also demonstrated in a paper by Davis, DC. JNMS
1996;4(3):102-115.
In general, imaging studies are not useful in determining the origin of
pain. However, they are a useful diagnostic tool used in the detection
of structural deformities or pathology, which may prevent the
application of appropriate manipulative procedures.
Eisenberg, Kessler, Foster, Norlock, Calkins, Delbanco. Special Article:
Unconventional Medicine in the United States. NEJM Jan. 28, 1993
34% reported using at least one unconventional therapy in the past year
Highest use by non-black persons from 25-49 years of age who had relatively more
education and higher incomes.
The majority used unconventional therapy for chronic care
1990 Americans made 425 million visits to providers of unconventional care.
This number exceeds the number of visits to all U.S. primary care physicians (388
million).
1990 expenditures for unconventional therapies $13.7 billion, 75% of which was
out-of-pocket.
This figure is comparable to the $12.8 billion spent out-of-pocket annually for all
hospitalizations in the U.S.
Question: When tissues have healed, shouldn’t pain be gone and
function restored?
Wahlgren DR et al. Pain 1997;73:213-221.
Question: When tissues have healed, shouldn’t pain be gone and function
restored?
Wahlgren DR et al. Pain 1997;73:213-221.
“Whereas traditional biomedical approaches indicate that time alone may
be a curative factor, pain-related effects such as functional deficits and
distress may extend beyond healing of tissue damage”
Phillips HC, Grant L Behav Res Ther 1991;29 (5):435-441
“The recovery process was found to be considerably longer than was
expected and than would be predicted from the course of physical
healing of soft tissue damage…This suggests a much slower recovery
period than had been considered and a much larger number of people
who are vulnerable to persisting pain.”
Tissue Repair and Rehabilitation
Herring S Med & Science in Sports & Exercise 1990;22 (4):453-456.
“ The tissue may repair and remodel, but concomitant
changes in function-strength, strength balance,
flexibility, and proprioception occur. The signs and
symptoms of injury abate but these functional deficits
persist…
The rehabilitation process is not over when the
symptoms disappear. Rehabilitation must not be
solely based on symptom relief. It must address
more than pain. The athlete has a functional
disability after an injury, and, until that is addressed
these functional changes will persist.”
Findings and Outcome in Whiplash-Type Neck Distortions:
Halldor Jonsson, Kristina Cesarini, Bo Sahlstedt, Wolfgang
Rauschning, Spine, Vol. 19, No. 24, pp 2733-2743
Authors assessed the clinical and imaging findings and late outcome in 50 patients
with whiplash-type neck distortions.
Neck pain persisted in 24 patients; radiating pain developed within 6 weeks in 19
patients.
Conclusions: Follow-up surgery on the chronic patients showed a high
incidence of discoligamentous injuries in whiplash-type distortions.
“Patients with whiplash-type neck distortions inflicted in car collisions tend to
develop progressive neck pain and stiffness during the first days after the
accident.”
“These symptoms can persist over years and may become bizarre and
disabling and ensue cumbersome and costly insurance litigations.”
“A significant increase in cervical spine injuries has been reported after the
introduction of seat belts.”
Halldor Jonsson, Kristina Cesarini, Bo Sahlstedt, Wolfgang
Rauschning, Spine, Vol. 19, No. 24, pp 2733-2743
(cont’d)
“Traumatic cartilaginous endplate separations may explain why the two
young patients with extensive posterior soft tissue injuries had normal
disc signals on magnetic resonance imaging. Because the discs are
structurally intact in these avulsion injuries, they may
generate normal signals on magnetic resonance.”
“Pain can originate both from the ganglion and the richly innervated
annulus fibrosis and also from the facet joints causing both local and
referred pain.”
The most likely source of radicular symptoms is perineural
scarring. Therefore, patients with neck distortions after traffic
accidents should be mobilized early within the limits of pain to
prevent scar transformation of hidden injuries.
Dysfunction…
A review of the literature
Dynamic Chiropractic
June 26, 2000 Volume 18, Number 14
“Goals of Care: Minimize Pain and
Maximize Function”
Author
Malik Slosberg, DC, MS, Professor, Life
Chiropractic College West.
“Dysfunction”
Malik Slosberg, DC, MS, Professor. Goals of Care: Minimize pain and
Maximize Function. Dynamic Chiropractic June 26, 2000 Volume 18,
Number 14. Pages 8,12,42
Dysfunction may become self-perpetuating….One of the common
criticisms of the diagnosis of soft tissue sprain and strain is that
such an injury is normally followed by healing.
Symptoms should settle over the expected tissue healing time.
However, if the problem is dysfunction, then symptoms can persist for
as long as dysfunction continues. Dysfunction may be selfsustaining, so symptoms may persist indefinitely.
“Dysfunction”
Mayer TG. Neurologic Clinics of North America 1999; 17 (1): 131-147
“The majority of injuries to the low back involve soft
tissue or discs with sprains and strains of
musculoligamentous tissues, which have a relatively
brief healing period. When healing is temporally
complete, but biomechanically imperfect, leading to
permanent impairment or supporting elements,
chronic pain disability may follow.”
If tissues are allowed to heal without functional
restoration, chronic disability can occur.
“Dysfunction”
Ameis A. Can Fam Physician 1986;32 (Sept) : 1871-76.
Ameis explains that,
“As time passes, the rehabilitative program should
become progressively more active…Patients
invariably expect treatment to result in pain-free
status. Instead, it should be stressed that recovery
of function is the primary goal.”
The restoration of function, so that a patient has an
adequate capacity to tolerate activities of daily living
and work tasks, is the single most important goal of
care.
“Dysfunction”
Bigos SJ, Davis, GE. JOSPT 1996;24 (4) Oct: 192-207.
“The Agency for Health Care Policy and Research
defined low back problems not as pain but activity
intolerance due to back symptoms. The actual
treatment relates to regaining activity tolerance.
Controlling symptoms supports, not replaces, the true
treatment. Don’t let patients confuse
recommendations to be more comfortable (pain
relief) with conditioning, which is the real treatment
for an activity limitation.”
“Dysfunction”
Abenhaim L, et al. Spine 2000; 25(4S):8S.
The primary conclusion of the recent Report of the
International Paris Task Force on Back Pain, states:
“Individuals who have back pain reduce their
activity…The longer they reduce their activity, the
greater the risk of the conditioning becoming chronic.
The prevailing management approach to the
treatment of back pain considers a return to normal
activities to be a more important goal than pain
relief.”
Function vs. Pain Relief
Saal JA. 1996 North American Spine Society Presidential
Address, Spine 1997;22(14):1545-15

“We must adopt the principle of improving
patient function as our new
paradigm…Improving patient function must
be the credo of care.”
Saal
Waddell, G. The Chiropractic Report 1993; July:1-6.
“Failure to restore function means any pain relief will be
temporary and reinforces chronic pain.”
Waddell, MD.
Owens, MS, DC; Top Clin Chiro 2000; 7(1):74-79.
Preventive Care

Degeneration of tissues is thought to occur in areas
of disturbed kinematics, which can eventually lead to
arthritic changes of not addressed. Evaluation should
be focused on areas of dysfunction in order to correct
before symptoms occur. In this case, chiropractic
care is indicated whether symptoms are present, or
not.
Waddell G. The Back Pain Revolution Churchill Livingstone
1998;145
Residual dysfunctions that can frequently persist long after tissues are
healed if the dysfunctions which occur with tissue damage are not
identified and corrected:
(1) Abnormalities of joint movement
A. Limited movement
B. Hypermobility
C. Abnormal patterns of movement
(2) Acute joint locking
(3) Muscle fatigue, weakness, tension, shortening, stretching.
(4) Reflex muscle spasm
Waddell G. The Back Pain Revolution Churchill Livingstone
1998;145 (cont’d)
(5) Connective tissue (fascia, ligs, joint capsule, muscle)
a. Adhesions
b. Scarring
c. Trigger points
d. Fibrositis
(6) Neuromuscular incoordination: muscle imbalance
(7) Abnormal patterns of movement
(8) Altered proprioceptor and nocireceptor input and neurophysiologic
processing.
Drug Issues
Miscellaneous Literature
Gurkirpal Singh, George Triadafilopoulos, Epidmiology of NSAID induced
gastrointestinal complications. J. Rheumatol 1999, Apr;26 Suppl 56:18-24.
Department of Medicine, Division of Immunology, Stanford University
School of Medicine, Palo Alto, California 94304, USA.


NSAIDs are one of the most commonly used classes of
medications worldwide. 30 million people take NSAIDs daily.
GI complications are the most prevalent category of adverse
drug reactions. Patients with arthritis are the most frequent
users, therefore at greater risk.
NSAID related deaths among patients with RA and OA are even
more startling. It is conservatively estimated that 16,500
NSAID-related deaths occur in these patients every year
in the US.

15th most common cause of death in the US.

Stats DO NOT include nonarthritis indications.
Wolfe, M.D., Lichtenstein, M.D., Singh, M.D.
Gastrointestinal Toxicity of Nonsteroidal Anti-inflammatory Drugs. The
New England Journal of Medicine, June 17, 1999, Review Article, Medical
Progress.





113 References.
NSAID agents constitute one of the world’s most widely used classes of drugs,
with more than 70 million prescriptions and more than 30 billion over-thecounter tablets sold annually in the US.
“Although the annual mortality rate is low, it must be emphasized that because
a large number of patients are exposed to NSAIDs often for extended periods of
time, the risk over a lifetime is substantial.”
Hospitalization due to GI complications 103,000/yr. Estimated cost $15,000 to
$20,000 per hospitalization. Annual cost exceeds $2 Billion.
“It has been estimated conservatively that 16,500 NSAID-related
deaths occur among patients with RA and OA every year in the US.”
Wolfe, M.D., Lichtenstein, M.D., Singh, M.D.
Gastrointestinal Toxicity of Nonsteroidal Anti-inflammatory Drugs. The
New England Journal of Medicine, June 17, 1999, Review Article, Medical
Progress. (cont’d)





Doses of aspirin as low as 30 mg are sufficient to suppress prostaglandin
synthesis in the gastric mucosa initiating gastric-duodenal mucosal injury,
resulting in the release of oxygen-derived free radicals.
Peptic ulcers-gastroduodenal hemorrhage-perforation-death!
Acetaminophen is nontoxic to the GI mucosa, however, recall that
acetaminophen is a leading cause of end-stage renal disease.
Cox-2 inhibitors will hopefully have a reduced capacity to cause injury to the
gastroduodenal mucosa.
However, Cox-2 inhibitors are also known to cause defects in renal function,
alter the regulation of bone resorption, impair female reproductive physiology,
and increase the rate of thrombotic events in patients with increase risk for
cardiovascular disease.
Dabbs, D.C. and Lauretti, D.C., A Risk Assesment of Cervical
Manipulation vs. NSAIDs for the Treatment of Neck Pain. Journal of
Manipulative and Physiological Therapeutics. Vol. 18, number 8
Oct. 1995; 18:530-6.



“The best evidence indicates that cervical manipulation for neck
pain is much safer than the use of NSAIDs, by as much as a
factor of several hundred times. There is no evidence that
indicates NSAID use is any more effective than cervical
manipulation for neck pain.”
Death rate for NSAID-associated GI problems at 0.04% per yr
among OA patients receiving NSAIDs, or 3,200 deaths in the US
per year.
He (Brandt) also noted that there are several animal studies and
human clinical studies that have actually implicated NSAIDs in
the acceleration of joint destruction.
OxyContin





U.S. News and World Report, July 2, 2001
“Not an appropriate use”, “Did the makers of
OxyContin push too hard?”
Virginia residents filed a $5.3 billion class action
lawsuit that alleges Pharma also failed to disclose the
drug’s risks, setting off a wave of OxyContin
addiction and abuse.
Associated deaths jumped 93% between 1997 and
1998.
DEA reported 291 deaths in just 6 states.
NUTLEY, N.J. (July 15) - Mother's little
helper is not so little anymore.




Valium, the drug that revolutionized the treatment of
anxiety and became a cultural icon, is 40 years old
this year.
Invented by chemist Leo Sternbach
Approved for use in 1963, became the country's most
prescribed drug from 1969 to 1982.
The Roche Group, Hoffman-La Roche's parent,
sold nearly 2.3 billion pills stamped with the
trademark ``V'' at its 1978 peak.
Baycol-Cholesterol drug




The Columbus Dispatch, August 9, 2001
“Bayer pulls medicine tied to 31 U.S.Deaths”
Baycol has been linked to significantly more fatal
cases than its competitors, Dr. John Jenkins of the
FDA
Other drugs include Lescol, Lipitor, Mevacor,
Pravachol, Zocor
Baycol-Cholesterol drug


“Every statin has been linked to very rare reports of
the muscle side effect called rhabdomyolysis.”
Baycol is the 12th prescription drug taken off the
market since 1997.
Allergy Pills Overused



Study out of OSU, reported in Columbus Dispatch,
Monday, April 9, 2001
Of 246 North Carolina residents taking prescription
antihistamines, blood tests showed 65 percent didn’t
have allergies.
Skill testing unreliable vs. Blood tests
“Side Effects: As Drug-Sales Teams Multiply, Some
Doctors Shut Them Out”







Wall Street Journal, 6-13-03
“’Arms Race’ by Pfizer, Rivals Boost Pill Prices and
Ire, But No One Dares Retreat.”
“Free Tacos and Piles of Bextra”
90,000 drug industry reps
$12 Billion spent on sales force
$2.76 billon on consumer drug ads.
Result: Prescriptions up 14% to $161 Billion spent on
drugs in 2002!!!!
Unnecessary Mastectomies




BMJ March 4, 2000
1997 pathologist Professor Kemnitz made numerous
false positive diagnoses of breast cancer.
300 women suffered mastectomies
Professor Kemnitz committed suicide, set himself on
fire and destroyed evidence in
his lab.
Wall street journal,4/22/03 Page 1, section d
Saying No to the Knife...


Apparently, research now shows that surgery for
back problems, gum disease, hernias, sinus
problems, and injured kidneys, to name a few, are
not necessary much of the time.
And the effects of the surgery are apparently often
worse than the condition treated.
Antibiotics and Breast Cancer
February 17, 2004 JAMA
The longer that women took the drugs, and the more
prescriptions they took, the greater their risk of
breast cancer.
Aspirin in Gastric Ulcer

76 year old women

NEJM Levy MD, Vol. 343 Number 12




400 mg. Etodolac 2x/day for RA
1 tablet of enteric-coated aspirin / day
1 mg. of warfarin sodium per day
Endoscopy revealed aspirin tablet intact with an ulcer
of gastric antrum.
Continuous Low-Level Heat Wrap Therapy Provides More Efficacy Than
Ibuprofen and Acetaminophen for Acute Low Back Pain
Scott F. Nadler, DO, et al. SPINE 2002;27:1012-1017
Conclusion. Continuous low-level heat
wrap therapy was superior to both
acetaminophen and ibuprofen for
treating low back pain.
Diagnostic Test Accuracy
A Review of the Literature
Cervical Discogenic Pain. Prospective Correlation of MRI and Discography
in Asymptomatic Subjects and Pain Sufferers. Schellhas, Smith, Gundry,
and Pollei, Spine 1996 Feb. 1;21(3):300-11; Discussion by James
Zucherman, 311-12.
Methods:

Ten lifelong asymptomatic subjects and 10 nonlitigious chronic
neck/head pain patients underwent discography at C3-C4 and C6-C7
after magnetic resonance imaging. Disc morphology and provoked
responses were recorded at each level studied.
Results:


In the pain patients, 11 discs appeared normal at MRI and 10 of these
proved to have anular tears discographically.
Discographically normal discs were never painful in either groups.
Cervical Discogenic Pain. Spine 1996 Feb. 1;21(3):300-11; Discussion by
James Zucherman, 311-12.
(cont’d)
Conclusion:

Significant cervical disc annular tears often escape
magnetic resonance imaging detection, and MRI cannot
reliably identify the source(s) of cervical discogenic
pain.
Jensen, et al. Magnetic resonance imaging of the lumbar
spine in people without back pain. NEJM 1994;331(2)July
14:69-73





98 people: only 36% had a normal disc at all levels.
52% bulge at least one level
27% protrusion
1% extrusion
38% had abnormality at more than one level
Summary: Finding may be frequently coincidental
“But the x-ray is negative! How can
there be an injury?”
Question: Are diagnostic tests such as x-ray,
MRI, EEG, EMG, etc, reliable indicators for the
potential for injury?
Answer: NO
Haldeman, DC, PhD, MD. Spine
1990;15(7):718-723.
The pathology model cannot explain back pain or
disability. It is not possible to look at pathology and
determine the symptoms a patient may be suffering.
It also is not possible to look at a patient with back
pain with no neurologic deficits and determine the
nature of the pathology.
About 30% of
asymptomatic subjects show abnormalities in the
lumbar spine by myelogram, CT and MRI. There is a
large percent of symptomatic patients with severe
complaints in whom testing fails to reveal any
structural lesion.
Wickstrom et al….



Experiments produced tears of the ALL so severe that
they were often seen in conjunction with avulsions of
the disc of vertebrae (rim lesions).
Yet, they were not seen on radiographs
MRI…(1) Goldberg et al. (2) Davis et al. Visualization
of ALL
Jonsson MD. Journal of Spinal Disorders 1991;4(3):251-263.
Study of cervical spine of 22 patients who died of fatal skull fractures in
MVAs. X-rays were evaluated by an expert orthopedic radiologist.
Only 1 of 10 gross ligamentous disruptions were even suspected on Xrays. 198 lesions were missed. Multilevel soft-tissue injuries were
common. Very few injuries were detected or even suspected on
radiograms. The vast majority was not recognized. Plain radiograms
cannot detect soft-tissue lesions unless they are associated with
vertebral body malalignment. Conclusions: the majority of lesions are
soft-tissue injuries. Plain radiograms show virtually no soft-tissue
lesions.
Side note:
As a result of these types of studies, it has become apparent that a
thorough physical examination is more important, in combination with
functional assessments, than traditional diagnostic evaluations to
determine the presence or absence of soft-tissue injuries.
Liebenson, DC, Oslance. Rehabilitation of the Spine. Williams and
Wilkins, Baltimore. 1996:73.
“80% of patients have no identifiable structural pathology and
require treatment based on evaluation of functional deficits. In
the majority of cases, patients have soft tissue injuries and
functional changes are the only objective findings on which to
base treatment and judge progress. Outcomes assessments
including objective functional tests give the third party payers,
patients and doctors a way to measure progress over time, and
evaluate the prescribed treatment.
Overemphasis on
treatment of structural pathology results in a failure to
identify or focus on functional loses and work demands.
[Emphasis added.]”
Mooney, MD. J. Musculoskeletal Medicine 1995; Oct:33-39.
“Common acute back pain is due to chemical abnormalities created by soft
tissue tear. The tear represents a mechanical disruption, which is
usually microscopic. X-rays demonstrate no changes before and after
an acute back injury.”
Again, function is more important in the evaluation and treatment of back
pain than structural pathology. A "negative" x-ray has limited value in
the determination of medical necessity since one cannot evaluate
"function" from an x-ray. Similar findings concerning other imaging
findings was also demonstrated in a paper by Davis, DC. JNMS
1996;4(3):102-115.
In general, imaging studies are not useful in determining the origin of
pain. However, they are a useful diagnostic tool used in the detection
of structural deformities or pathology, which may prevent the
application of appropriate manipulative procedures.
Jarvik et al. Rapid Magnetic Resonance Imaging vs Radiographs
for Patients with Low Back Pain. JAMA 2003;289:2810-2818.
Conclusion: Rapid MRIs and radiographs resulted in nearly
identical outcomes for primary care patients with low back pain.
Although physicians and patients preferred the rapid MRI,
substituting rapid MRI for radiographic evaluations in the
primary care setting may offer little additional benefit to
patients and may increase the costs of care because of the
increased number of spine operations that patients are likely to
undergo.
Symptoms vs. Function
As a result of these and other studies there has been a
shift in thinking away from the traditional "symptom"
approach, towards contemporary thinking of
"function".
For many patients with recurrent back pain, staying
functional is a "process" more so than a "result"
based on a predictable healing time or average.
Chiropractic
Cost Related Literature and
Information
Cost Issues
What is the financial impact of
Chiropractic Healthcare? What is
the impact of medical errors and
drug shadow costs?
Research…
oldies but goodies!
A review of past literature.
Topic: Bed Rest
Waddell. A New Clinical Model for the Treatment of Low-Back
Pain. Spine. 1987;12:632-644



Little scientific or clinical evidence supports the value
of bed rest.
Only four controlled studies
Bed rest is the most harmful treatment ever devised
and a potent cause of iatrogenic disease.
Topic: Bed Rest
AHCPR. Lee. Publication No. 95-0643; December 1994, pp. 2.
Extended bed rest could be harmful. Resting in bed
for more than 4 days can weaken muscles and bones
and delay recovery.
RAND Study
Shekelle, et al. “The Appropriateness of Spinal Manipulation for
Low Back Pain: Indication and Ratings by a Multidisciplinary
Expert Panel.” 1991; RAND/UCLA Monograph No. R-4025/2CCR/FCER.
“Spinal manipulation is the most commonly used conservative treatment
for back pain supported by the most research evidence of effectiveness
in terms of early results and long-term effectiveness.”
2/3 of patient visits were to chiropractic providers for a total cost
of $2.4 billion in 1988. Conversely, 1/3 of the visits for back
pain were to medical providers (MD) for a total cost of $8
billion.
94% of manipulation is performed by doctors of chiropractic.
AHCPR
Acute Low Back Problems in Adults: Assessment and Treatment
Proven Initial Care: Patient education, patient comfort
(NSAIDs), and SPINAL MANIPULATION.
Unproven Therapies: Traction, physical modalities
(massage, diathermy, US, cutaneous laser,
biofeedback, TENS, acupuncture, trigger point
injections, facet injections, steroid or lidocaine
injections, shoe lifts, exercise machines, stretching.
Harmful treatment: Best Rest.
Utah Study
Jarvis, et al. Cost per Case Comparison of Back Injury Claims of
Chiropractic Versus Medical Management for Conditions with
Identical Diagnostic Codes. Journal of Occupational Medicine.
1991; Vol. 33, No. 8, Aug., pp. 847-851.
In 3,062 separate cases:


Chiropractic care took an active
approach with 8 times more visits.
Medical care took a passive approach
prescribing medication and rest.
Utah Study
(cont’d)
Conclusion:




Chiropractic care was 73% more cost-effective per
case.
The average distribution cost per office visit was 67%
less for chiropractic than for the medical office visit.
Patients seeing doctors of chiropractic were able to
return to work 10 times sooner than those under
medical care.
For the total data set, cost for care was significantly
more for medical claims—Compensation costs were
ten-fold less for chiropractic claims.
Australian Study
Ebrall. Mechanical Low Back Pain: A Comparison of Medical and
Chiropractic Management Within the Victorian WorkCare Scheme.
Chiropractic Journal of Australia. 1992; Vol. 22, No. 2, June pp.
47-53




Compensation days with Chiropractic management
are ¼ the days of claims with medical management.
The “occurrence of chronicity” was greater with
medical management (6 fold greater progression to
chronicity-11.6% to 1.9%).
Cost of claims: $2,038 Medical/$963 Chiropractic.
Average compensation payment is 4 times greater
with medical management.
Australian Study
(cont’d)
Conclusion: Financial and social savings could
be maximized by:


Increased participation rate by DCs in the WorkCare.
Increased early referral from medical doctors to
Chiropractic doctors.
British Study
Meade, et al. Low Back Pain of Mechanical Origin. Randomized
Comparison of Chiropractic and Hospital Outpatient Treatment.
BMJ. 1990; Vol. 303, No. 6737. June pp. 1431-1437


10 year multicenter trial.
Conclusion:




Chiropractic treatment was significantly more effective,
particularly with patients with chronic and severe pain.
Results were long-term throughout the two-year follow up
period.
The potential economic, resources, and policy implications of
the results were extensive.
Patients treated by Chiropractors…almost certainly
fared considerably better and maintained their
improvement for at least two years.
Canadian Study
Manga et al. The Effectiveness and Cost Effectiveness of
Chiropractic Management of Low-Back Pain. Manga Report to
Ontario Ministry of Health. August, 1993.
Conclusions: The “Constellation of evidence” demonstrates:





The treatment effectiveness and cost effectiveness of
Chiropractic care.
The untested, questionable, or harmful nature of
many current medical therapies.
The economic efficiency of Chiropractic care versus
medical care.
The safety of Chiropractic.
Higher patient satisfaction.
Canadian Study
Manga (cont’d)
Summary:
There should be a shift in policy to encourage the
utilization of chiropractic services for most patients
with back pain…
A very good case can be made for making chiropractors
the gatekeepers for management of low-back pain
the worker’ compensation system.
Virginia Study
Schifrin. Mandated Health Insurance Coverage for Chiropractic
Treatment: An Economic Assessment with Implications for the
Commonwealth of Virginia. January, 1992



“By every test of cost-effectiveness, the general
weight of evidence shows that Chiropractic provides
important therapeutic benefits at economical costs.”
“These benefits are achieved with minimal, even
negligible, impact on the costs of health insurance.”
“Chiropractic services are widely used and
appreciated by a growing segment of Americans.”
2nd Virginia Study
Dean, et al. “A Comparison of the Cost of Chiropractors versus
Alternative Medical Practitioners.” Virginia Chiropractic
Association. January 1992.



“Chiropractors see their patients more frequently but
have lower overall costs for most of the conditions
considered.”
“Chiropractic care requires fewer referrals for
specialists and outside procedures.”
“If Chiropractic care is insured to the same extent as
other specialties, it may result in a decrease in overall
treatment costs for neuro-musculoskeletal
conditions.”
Medstat Project
Stano et al. MEDSTAT Data Base Review. The Journal of
American Health Policy. 1992; Vol. 2 #6.
Conclusions:


Plans which have limited or no chiropractic coverage
have the highest total costs per patient.
Broader coverage of chiropractic services results in
dramatically lower health care cost as follows:
35% lower hospital admission rates.
42% lower inpatient payments.
23% lower total health care costs.
US General Accounting Office
“Access to Health Insurance: State Efforts to Assist Small
Business.” GAO-92-90; May 1992; pg. 33

“Mandates determined not to add significantly to the
cost of health insurance include services for in-vitro
fertilization, acupuncture, and cleft palate, as well as
services provided by Chiropractors and home health
nurses. It is these low cost mandates, however that
are often cited by the business community as
examples of the added wasteful expense mandates
cause for business.”
Journal of American Health Policy
Stano et al. “The Growing Role of Chiropractic in Health Care
Delivery.” Journal of American Health Policy. 1992 Nov-Dec. pp.
39-45.


“Plans which do not cover Chiropractic have the
highest payments per patient.”
“Increased availability of demonstrated cost-effective
alternatives would increase access and would reduce
costs.”
Journal of Family Practice
Cherkin et al. “Family Physicians, Chiropractors, and Back Pain.”
The Journal of Family Practice. 1992; Vol. 35, No. 5, pp. 551-555

Chiropractic doctors are well-trained
and well-accepted by both patients and
insurers.
Western Journal of Medicine
Cherkin et al. “Patient Evaluation of Low Back Pain Care from
Family Physicians and Chiropractors.” Western Journal of
Medicine. 1989; Vol. 150, No. 3, March pp. 351-355.
Conclusion:



Chiropractic doctors were highly rated compared to
medical doctors in critical patient care areas for the
treatment of low back pain.
Patients gave DCs a 3:1 advantage in five important
areas of patient satisfaction.
Chiropractic patients reported quicker recoveries.
British Medical Journal
Smith. “Where is the Wisdom? The Poverty of Medical Evidence.”
BMJ. 1991; Vol. 303, October pp. 798-799.
“Only about 15% of medical
interventions are supported by valid
medical evidence…Many treatments
have never been assessed at all.”
Recent studies…
A review of the literature.
“DC’s as Primary Care Providers”
(Interview with James Zechman, Part 1, condensed summary)
Editor’s note: In the December 1, 1999 issue, we
interviewed the CEO of Alternative Medicine, Inc.
(AMI), James Zechman. AMI had contracted with
Blue Cross/ Blue Shield of Illinois, the state’s largest
managed care plan, to give its more than 700.000
enrolled members the option of having AMI’s
chiropractors as their primary care physicians.
The following interview highlights were reported in the
February 12, 2001issue of Dynamic Chiropractic.
Zeckman (cont’d)
Our theory was to accurately test a preventive health
care system based on a non-pharmaceutical/nonsurgical entry point.
We have no limit on the number of visits, treatments or
procedure. Anything which takes place within the
doctor’s own office is unencumbered.
Zeckman (cont’d)


Waiting to see a physician until disease is present adds costly
tests, procedures and pharmaceuticals to health care bill that
could have been avoided through a strong and integrated
preventive care program.
We believe this is the only rational choice: to create a true
prevention-based health care system as opposed to after-thefact disease care system. It is this system of truly integrated
medicine that precludes the need for restrictive guidelines and
disruptive oversight of chiropractic care. We believe once you
identify quality- the rest takes care of itself.
Zeckman…The Results

Compared to normative values in the greater Chicago area for all
other allopathic IPA’s our network has reduced hospitalizations by
approximately 60 percent over a 24-month consecutive period.

We have reduced outpatient surgery and procedures by
approximately 85 percent over a 24- month consecutive period.

We have reduced pharmaceutical usage by approximately 56 percent
over a 24-month consecutive period.

Of interest to note is that we have no C-section deliveries over a twoyear period, as compared to a network average of over 22 percent.
Zeckman…Conclusion


AMI’s primary care chiropractors are showing
the world what the profession has always
believed since its inception:
Chiropractic has an ability to impact a
person’s health in a very profound manner.
Mosley, Cohen, DC, Arnold, MD. American Journal of
Managed Care 1996;2:280-282.
Retrospective study of patients at an independent
physician model HMO in Louisiana evaluating cost of
care for acute low back pain or neck pain for patients
who sought chiropractic care or other treatment. Also
looked at surgical rates, use of diagnostic imaging (MR
and CT) and patient satisfaction on claims paid Oct. 1,
1994 – Oct. 1, 1995.
Mosley, Cohen, DC, Arnold, MD. American Journal of
Managed Care 1996;2:280-282.
Results: Cost of care for BP and NP was substantially lower for DC
patients than non-DC patients.
Use of prescription drugs and
diagnostic imaging were significantly greater in non-DC group
whereas surgical rates and patient satisfaction were nearly identical.
Conclusion: DC care outcomes are equal to those of non-DC care at
substantially lower costs. MD patients got 2x as many prescriptions.
Study demonstrates that DC services were well integrated in an HMO
and has proven satisfactory to patients and providers as well as costeffective for BP and NP. The system offered self-referral for DC
services.
Mosley, Cohen, DC, Arnold, MD. American Journal of
Managed Care 1996;2:280-282.
If half of the patients treated by traditional care received DC
care, annual savings would have exceeded $215,000. We
recommend its wider application by the managed care
industry and physician community. [Emphasis Added.]
Muse Study\Medicare
The Muse study compared the most recently available
CMC Medicare cost and utilization data for those
beneficiaries that received chiropractic care versus
those beneficiaries that only received traditional
medical care. The Muse study found that the
global per capita Medicare expenditures for
chiropractic patients were significantly lower
than the same costs for non-chiropractic
patients.
Muse Study\Medicare
(cont’d)
The Muse study concluded,
"Chiropractic care significantly reduces per
beneficiary costs to the Medicare program. The
results of the study suggests that chiropractic
services could play a role in reducing costs
Medicare reform and/or a new prescription
drug benefit."
Questions…
What is the tissue source of chronic spine pain?
Answer: The Disc, The Facet Capsule
What tissues are primarily affected by chiropractic spinal
adjustments?
Answer: The Disc, The Facet Capsule

The perception of pain is dependent upon the balance of
activity between the pain afferents and the mechanical
afferents. True or false?
Answer: True!
Nolte, 1999
Questions……
What is the common thread between swimming,
using a rocking chair, and chiropractic joint adjusting?
Answer:
They all increase the firing of large diameter joint
and muscle mechanoreceptors.
In terms of the prevention of chronic spine pain
and disability, what is the most important to consider?
a)
b)
c)
Pain relief
Tissue Repair
Restoration of function
(Correct Answer!)
Copyright Protection Statement
The material in this packet is under copyright
protection and may not be reproduced in any format
without the expressed written consent of Dr. Ronald
J. Farabaugh.
© Copyright. 2011. All Rights Reserved.