Validating Chiropractic Collection of research articles on Chiropractic

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Table of Contents Introduction Restoring Function - 3 Difficulty Diagnosing the Cause of Back Pain – Mechanical Back Pain - 4 Role Manipulation in Mechanical Back Pain - 8 Deconditioning Syndrome - 9 Fear-Avoidance Behavior - 9 Negative Effects of Bed rest - 10 Biomedical Model of Disease - 11 Errors in Medicine - 12 Relative Risk of NSAIDs & Cervical Spinal Adjustment - 14 Proprioception, Dizziness, the Cervical Spine and Spinal Adjustment - 20 Medical Management, Prescription Drugs, Surgery – Risks - 22 Medical Models, Patient Centered Care – Outcomes Assessment - 30 Outcome Measures - 33 Grading Outcome Measures General Health, Function, Prevention & low back pain - 37 Aging Baby Boomers, Increased Musculoskeletal Disability, Future Trends, Increased Need for Chiropractic Care - 40 Increased Use of Complimentary & Alternative Medicine & Chiropractic Care - 44 Chiropractic Cost Effectiveness and as Primary Care - 50 Chiropractic and Wellness Care - 54 Athletic Ambassadors for Chiropractic Care - 55 Stress, Need for Chiropractic & the Musculoskeletal System - 57 Chiropractic and Medical Education - 58 Common Characteristics of Discs & Articular Cartilage - 59 Chiropractic and Athletic Ability - 60 Chiropractic Research Agenda - 62 Back Problems and Imaging - 62 Common Acute Mechanical Back Pain & Soft Tissue Subfailure Injuries - 65 Types of Diagnoses of Back Pain - 68 The Recurrent Nature of Back Pain - 70 Chiropractic vs Medical Care for chronic low back pain - 77 Chronic Musculoskeletal Dysfunction - 79 Multifidi, Back Stabilizers and chronic low back pain - 81 Static Back Endurance Test - 84 Strengthening Multifidi & Reducing Future Back Pain - 86 Strengthening Abdominal Muscles - 87 Use of Fitballs - 87 Manipulation and Exercise - 89 Preventive Exercise - 91 Massage vs Acupuncture for chronic low back pain - 93 Surgery & Denervation Atrophy - 93 Chiropractic, Chronic Whiplash, Reduced ROM & Headache - 95 Somatic Referred Pain - 105 Somatovisceral Connections - 106 Recent & Important Clinical Studies - 109 Whiplash, Chronicity and Chiropractic Care - 119 Chiropractic & Infantile Colic - 121 2

Agency for Health Care Policy & Research Guidelines: Acute Low Back Problems in Adults 114 The Role of Exercise in Chiropractic Management - 130 Recommendations for Referral for Chiropractic Care - 132 Chiropractic Management and Ear Infections - 134 Chiropractic and Neurology - 136 Neurology and the Cervical Spine - 143 Neurology and Chiropractic: Subluxation, Joint Complex Dysfunction, Dysafferentiation and Adjustment Causes of Disturbed Proprioception - 147 Neuroplasticity – Learning in the Nervous System - 150 Articular Neurology and Chiropractic Adjustments - 155 Restoring Function, Pain Relief, Goals of Care - 157 Segmental Control of Nociception - 167 Tissue Injury and Repair - 169 Inflammatory Cascade, NSAIDs, COX2 Inhibitors - 170 Degeneration - 175 Tissue Overload Leads to Tissue Injury - 175 Sensitization - 175 Mechanisms resulting in Chronic Pain - 182 Fibromyalgia & Chiropractic Care - 183 Stages of Tissue Repair - 187 Discal and Cartilage Nutrition - 190 Effects of Immobility on Articular Structures - 190 Effects of Motion on Articular Structures - 191 Goals of Care - 191 Documenting Chiropractic: objective vs subjective measures - 194 Physical Impairment Disability - 204 Benefits of patient self-rated information - 208 Mercy Center guidelines - 208 Key to Abbreviations An Explanation of the Use of Outcome Measures - 213 Pediatric and Children - 211 Neurogenic inflammation - 231

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Introduction: chiropractic Philosophy & Science Role of chiropractic Philosophy – A Doctrine of Strongly Held Beliefs: Provides chiropractors with a sense of Purpose, Vision, an Overview: timeless Wisdom. 1. Health comes from within 2. Health is a natural condition of the body 3. Chiropractic cares for people not treat diseases. 4. It helps improve health & restore internal resistance to disease not treat external causes of disease. 5. The patient is the center of care not a disease or symptoms 6. Health is multidimensional not just physical 7. Some things are not measurable 8. Science only acknowledges what it can quantify. It is materialistic. 9. The wisdom inherent in the body is capable of maintaining the body in health if there is no interference in its functioning 10. Ultimate responsibility for health is the patient’s 11. The doctor’s role is to unleash the natural healing power within 12. A shift away from disease to wellness care Passive Care: Interventions that a patient passively receives (massage, physical therapy modalities, heat, cold, etc., mobilization, adjustments, pain meds, surgery, etc) Active Care: care in which the patient actively participates: stretching strengthening, endurance exercises, cardiovascular fitness, stress reduction, weight loss, etc. Active care becomes essential in patient tending toward chronicity (>3 months). Helps reduce complications of prolonged passive care: 1) patient dependency & 2) passive coping, 3) overutilization, 4) chronicity.

Restoring Function Teasell, MD & Harth, MD. Spine 1996; 21(7): 844-847. The failure of the medical model in relieving the pain suffering & disability of chronic low back pain has led to a gradual switch in management strategy characterized by the functional restoration approach. The focus is no longer on diagnosis or treatment but on maximizing functional abilities. Waddell G, MD. The Back Pain Revolution. Churchill & Livingstone 1998. Figure 5-9: Back disability is increasing at the rate of 14 times the rate of population growth. Saal, MD. Spine 1997; 22(14):1545-1552. Presidential Address to the North American Spine Society. We must remind ourselves that our care must be centered around patients’ needs & desires. We must listen to our patients and understand their motivations for obtaining care. . .We must adopt the principle of improving patient function as our new paradigm. Improving patient function must be the credo of care. Fordyce, PhD. Clin Orthop & Related Research 1997; 336:47-51. Changing Models of Care. The physician’s mission is not as a repair mechanic but as a performance promoter. Chapman-Smith, D. LLB. The Paris Paradigm of chiropractic. chiropractic Report 2001; 15(4): 1-3, 6-8. At the 6th biennial Congress of the World Federation of chiropractic (WFC) (May 22-28, 2001, attended by more than 750 DCs from 42 countries), Gordon Waddell, MD given a special award for outstanding lifetime contribution to the international growth and acceptance of the chiropractic profession. Dr. Waddell pioneered the biopsychosocial model of spinal pain and was a chief architect of the US and UK back pain guidelines. He has spoken at 3 WFC Congresses & has defended unfair criticism of the chiropractic profession in many 4

interprofessional settings including the pages of the British Medical Journal. WFC Congress adopted the Association of chiropractic College’s (ACC) 1996 Paradigm of chiropractic on May 23, 2001 by the Assembly (with delegates representing 48 countries including every national chiropractic association in the world with over 20 members) based on a motion jointly proposed by ACA & ICA, establishing an international consensus on fundamental principles of education & practice, creating a common ground for all DCs, their associations & colleges. ACC represents all 17 accredited colleges in Canada & US. It developed a foundation for a profession-wide shared vision. ACC Board of Directors is comprised of the presidents of all colleges representing all perspectives. In July 1996 the ACC’s Paradigm of chiropractic was unanimously agreed upon by all presidents. In 1999 the Congress of chiropractic State Assoc (COCSA) called a US Leadership Conference including reps from ACA, ICA, CCE, Federation of Chiropractic Licensing Boards, FCER, NBCE. The ACC Paradigm was unanimously accepted as a unifying vision of chiropractic in the US. This position was ratified by the ACA & ICA Boards which both submitted the ACC Paradigm to the WFC. The ACC Paradigm now assumes major significance because it has been adopted internationally as an appropriate guide to the development of chiropractic education & practice & the role of the DC w/I health care. ACC Paradigm of chiropractic: chiropractic is a health care discipline which emphasizes the inherent recuperative power of the body to heal itself without the use of drugs or surgery. The practice of chiropractic focuses on the relationship between structure (primarily the spine) & function (as coordinated by the nervous system) & how that relationship affects the preservation & restoration of health. In addition, doctors of chiropractic recognize the value & responsibility of working in cooperation with other health care practitioners when in the best interest of the patient. The ACC continues to foster a unique, distinct chiropractic profession that serves as a health care discipline for all. The ACC advocates a profession that generates, develops, & utilizes the highest level of evidence possible in the provision of effective, prudent, & cost conscious patient evaluation & care. Purpose: The purpose of chiropractic is to optimize health. Principle: The body’s innate recuperative power is affected by & integrated through the nervous system. Practice: The practice of chiropractic includes establishing a diagnosis , facilitating neurological & biomechanical integrity through appropriate chiropractic case management, & promoting health. Foundation: The foundation of chiropractic includes philosophy, science, art, knowledge, and clinical experience. Impacts: The chiropractic paradigm directly influences the following: education; research; health care policy and leadership; relationships with other health care providers; professional stature; public awareness and perceptions; & patient health through quality care. The Subluxation: chiropractic is concerned with the preservation & restoration of health, & focuses particular attention on the subluxation. A subluxation is a complex of functional &/or structural &/or pathological articular changes that compromise neural integrity & may influence organ system function & general health. A subluxation is evaluated, diagnosed, & managed through the use of chiropractic procedures based on the best available rational & empirical evidence. Difficulty Diagnosing the Cause of Back Pain – Nonspecific & Mechanical Back Pain Bigos, MD. Acute low back pain in Adults. Agency for Health Care Policy & Research, Dec 1994: 8. Different disciplines use a variety of diagnosis that suggest a cause for low back pain . However, these labels are often unreliable. Even after an extensive work-up, only about 15% of patients can be given a definitive diagnosis. Lawrence RC, MPH et al. Arthritis & Rheumatism 1998; 41(5): 778-799. Low back pain is extremely common & will affect most adults at some time. About half of adults have low back pain in any given year. The precise etiology is unclear, but we presume that most episodes are related to muscle & ligament injuries & bony or disc degenerative changes but definitive 5

diagnosis is usually impossible. Up to 85% of patients cannot be given a definitive diagnosis because of the weak association among back symptoms , pathologic changes, & imaging results. Devo RA, MD, MPH. Scientific American 1998; August: 48-53. BP may be a symptoms of serious underlying diseases such as cancer, bone infection, or rare forms of arthritis. Fortunately, such critical causes are extremely rare. About 98% of BP patients suffer from injury, usually temporary, to the muscles, ligament aments, bones or discs. Up to 85% of patients with low back pain are left w/o a definite diagnosis . Most patients can’t recall a specific incident that brought on their suffering, & heavy lifting or injuries, though risk factors, do not account for most episodes. BP often seems just to happen & the medical community has, by no means, reached a consensus as to the causes of garden-variety cases. If patients are confused, they are not alone. Hadler MD, Carey MD. JAMA 2000; 248(21): 2780-1. The findings of Wassell et al. (JAMA, 200; 284: 2727-2732) suggest that back belts should be viewed as no more than an option in apparel. There is little direct evidence that most back pain stems from a discrete injury or repetitive trauma. There is little direct evidence that most back pain stems from a discrete injury or repetitive trauma. Regional musculoskeletal disorders afflict otherwise well, working-age adults who have had no physical exposure unusual for them. Back pain seldom results from a fall, direct impact or extraordinary physical demands. Wiesel, S, MD. Are individuals with back pain at heightened risk of permanent spinal injury? Backletter 2002; 17(1): 1, 8-10. The injury model of low back pain – routine BP is attributable to a discrete injury. Many researchers believe that the injury model itself is flawed & outmoded. Most BP cannot be attributed to any specific injured structure. BP typically does not have any obvious traumatic precedent. Devo, MD, MPH, Weinstein, osteopath. Low back pain. NEJM. 2001; 344(5): 363-369. 85% of patients with low back pain cannot be given a precise pathoanatomical diagnosis. The assoc between symptoms and imaging results is weak. Risk factors include heavy lifting, poor conditioning, although low back pain is common in subjects w/o these risk factors. Because a precise anatomical diagnosis is elusive, the diagnostic evaluation is often frustrating. For patients with nonspecific low back pain a precise pathoanatomical diagnosis is often impossible. Bogduk, N. MD., PhD. What’s in a name? The labeling of back pain. Med J of Australia. 2000; 173 (October 16): 400-401. In “The Taxonomy of Pain,” the taxonomy subcommittee of the International Assoc for the Study of Pain (IASP) wrestled with the diagnosis of spinal pain. It recognized that many diagnosis labels were illegitimate, inappropriate, or fanciful & stipulated strict criteria to be satisfied if a particular diagnosis label was to be used to ensure consistent & accountable use of terms. However, often, the criteria could not be satisfied using history & exam alone, or even conventional investigations. In effect, the exercise established that it was essentially impossible to render any conventional or traditional diagnosis for low back pain . The means to do so were not available, reliable, nor valid. The subcommittee argued that the only intellectually & clinically honest diagnosis for most cases of low back pain was “lumbar spinal pain of unknown or uncertain origin.” This label is cumbersome. Despite its accuracy & honesty, the term conveys the sense that the doctor does not know what is going on. Facet joint pain & discogenic pain can not be diagnosis clinically. Some labels are simply wrong & can have deleterious effects. “Degenerative disc disease” conveys to patients that they are disintegrating, which they are not. 6

Devo, MD, MPH. Diagnosis of low back pain . Arch Intern Med 2002; 162 (July 8): 1444-1447. In most low back pain patients, the precise cause remains unclear. Anatomic abnormalities can be readily identified by imaging studies, but most of these are common in healthy subjects . This seems to be equally true for myelography, CT, mechanoreceptors. Often, these abnormalities result from age-related degenerative changes, which begin to appear even in early adulthood & are in some way analogous to gray hair & wrinkles. The high prevalence of anatomic abnormalities such as herniated discs, bulging discs, & annular tears among “normal” asymptomatic subjects in the absence of symptoms suggests that making causal inferences is often hazardous because many findings in symptomatic people may be coincidental. In the absence of corresponding clinical findings from history & PE, these anatomic derangements seem to be irrelevant & inconsequential. Thus, finding a cause for low back pain is often difficult or impossible. Borenstein, MD et al. The value of mechanoreceptor I of the lumbar spine to predict low back pain in asymptomatic subjects: a 7 year follow-up study. J Bone Joint Surg Am 2001; 83-A (9): 1306-11. In 1989, 67 subjects (ave 35 years) w/o a history of BP had mechanoreceptor I of the lumbar spine. 31% of subjects had an abnormality of a disc or spinal canal (herniation, protrusion, extrusion, free fragment, stenosis, disc bulge, disc degeneration). Study investigates whether mechanoreceptor I findings predicted development of low back pain in asymptomatic subjects . The 1989 & a repeat mechanoreceptor, 7 years later of 31 subjects , were read by 2 neuroradiologists & an orthopedist spine surgeon. Results: Of 50 subjects (ave 43.6 years) followed 7 years later, 42% (21 subjects ) developed low back pain < including 12 subjects with normal scans. Findings on mechanoreceptor I did not predict the development or duration of low back pain . Example: 5 of 6 subjects with herniation on mechanoreceptor in 1989 had repeat mechanoreceptor. Over 7 years, only 1 of the 5 had radiating pain longer than 2 wks. Findings discovered by mechanoreceptor can only confirm the clinical suspicions of the clinician. Treatment should not be based solely upon mechanoreceptor abnormalities in the absence of clinical indicators. Wiesel S, MD. Biochemical diagnosis. Backletter 1998:13(8):85, 94. One of the greatest problems in contemporary spine care is diagnostic imprecision. Despite space age imaging capabilities, it is usually impossible to conclusively determine the tissue source of a patient’s pain. Devo, MD, MPH, Weinstein, Osteopath. Low back pain. NEJM. 2001; 344(5): 363-369. Early or frequent use of imaging (plain films, mechanoreceptor I, CT) is discouraged because disc & other abnormalities are common among asymptomatic adults. Degenerated, bulging, & herniated discs are frequently accidental findings, even among patients with low back pain & may mislead to overdiagnosis, anxiety, dependence on medical care, conviction about the presence of disease & unnecessary test or treatments. Sequential mechanoreceptor studies reveal that the herniated portion of the disc tends to regress with time, with partial or complete resolution in 2/3 of cases after 6 months. Ito T et al. Spine 2001; 26(6): 648-51 & Postacchini F. Lumbar disc herniation. Spine 2001; 26(6): 601. patients with uncontained lumbar disc herniation (UDH) – (one that has breached the annulus) can be treatment w/o surgery if they can tolerate their symptoms for the 1st 2 months. The body’s defense system attacks & absorbs uncontained disc herniations, leading to early radiographic & clinical resolution. Prospective study – all these orthopedic surgeons’ patients with symptoms disc herniations underwent conservative care for at least 8 wks – except with cauda equina syndrome, severe motor weakness. This protocol reduced disc surgery rate by almost 50%. None of the patients who waited at least 8 wks had an uncontained disc herniation 7

at surgery. Findings provide further evidence that uncontained disc herniations often resolve quickly. In most patients with an extruded & sequestered herniation, the symptoms & the herniation itself disappear in a few wks to a few months. Unable to accurately differentiate contained from uncontained on mechanoreceptor. Waddell G, MD. The Back Pain Revolution. Churchill Livingstone 1998. We do not really understand the cause of most back pain & there is often very little relation between any physical pathology and the associated pain & disability. We often regard BP as an injury, but most episodes occur spontaneously with normal everyday activities. Our high tech investigations for spinal diseases tell us very little about simple backache. In BP we often cannot find the cause or even the exact source of pain. If BP becomes chronic, patients soon realize that we do not know what is wrong. Textbooks present diagnosis as a choice between a number of diseases. They give long lists of diseases which cause backache, but they are all rare. Simple backache is at the end of the list, almost an afterthought, & a diagnosis by exclusion (P. 137). BP is a problem to Drs & therapists because they cannot diagnose any definite disease or offer any real cure, so they are unsure & uncomfortable when dealing with BP. Finding a painful site does not diagnose the pathology. The various structures at one segmental level are closely linked, share common innervation & function together. So even when we localize pain to one level, that may not tell us which of the structures at that level is the cause of the problem. Kuritzsky, MD. Physician & Sports Medicine 1997; 25(1): 56-64. Bend your index finger backward until it’s intensely painful. A biopsy of the finger won’t reveal a tumor, infection or any identifiable lesion, because there is none. But releasing the finger & letting it return to its “position of comfort” will allow the pain to subside. We need to reorient ourselves to think about low back pain in a similar way – functionally instead of pathoanatomically. Rather than focusing on discovering the pathoanatomic disturbance leading to dysfunction, clinicians should strive to restore correct posture & normal productivity. 97% of BP seen by primary care physicians is mechanical in origin – there’s something wrong with the muscles, ligaments, or connective tissues. Most patients with BP don’t have ruptured discs, but it’s notorious, partly because imaging studies dramatically overestimate the frequency. I want practitioners to understand that surgery is a last resort. If we prescribe mobilization & allow sufficient time, with rare exception, people will get better. I didn’t know this when I experienced my own BP. I’ve addressed literally thousands of primary care physicians & they all tell me the same thing: They didn’t know it either. Devo, MD, MPH, Weinstein, osteopath . NEJM. 2001; 344(5): 363-369. Differential diagnosis of low back pain : Mechanical Back Pain: 97% (refers to anatomical or functional abnormality w/o ligament, neoplastic, or inflammatory disease.) Mechanical low back pain or leg pain: lumbar strain, sprain (70%): DJD of discs & facets (10%); Herniated disc (4%); Spinal Stenosis (3%); Osteoporotic compression Fx (4%); Spondylolisthesis (2%); Traumatic Fx (/=2 months NSAIDs: On average 1 in 1,200 patients taking NSAIDs for at least 2 months will die from gastroduodenal complications who would not have died had they not taken NSAIDs. That is 833 deaths per million patients who use NSAIDs for 2 months or more. This is 3332 times more deaths per million than from cervical spinal manipulation ! Beneliyahu DJ. Chiropractic management and manipulative therapy for MRI documented cervical disk herniation. J Manipulative Physiol Ther. 1994 Mar-Apr;17(3):177-85. OBJECTIVE: This case study reports on three cases of patients with documented cervical disk herniations, who responded to chiropractic management and manipulative therapy. CLINICAL FEATURES: Three patients complaining of neck pain with radiation of pain and tingling into the upper extremities had positive magnetic resonance imaging scans consistent with cervical disk herniations. They also had positive neurophysiologic testing with positive thermography scans and electrodiagnostic studies. INTERVENTION AND OUTCOME: The patients were 16

prescribed a treatment regimen consisting of chiropractic management including bracing, physiotherapy, cervical manipulative procedures, traction and exercises. The patients responded well to care as evidence by posttreatment MRI, electrodiagnostic studies, clinical exam findings and thermography scan findings. CONCLUSION: Patients with and without nerve root compression secondary to cervical disk herniation can and do respond well to chiropractic care. Chiropractic management of this condition can and should be employed prior to more invasive treatment. Van Tulder, PhD et al. NSAIDs for low back pain : A systematic review within the framework of the Cochrane collaboration back review group. Spine 2000; 25:2501-13. NSAIDs are the most frequently prescribed medications worldwide and are widely used for low back pain . This review of 51 trials (6057 patients) of NSAIDs in treatment of nonspecific low back pain (acute =/12 wks) with or without radiation found global improvement after 1 week was 1.24 with NSAIDs indicating a small effect in favor of NSAIDs compared to a placebo. 4 studies reported on chronic low back pain . Evidence could not be provided on the effectiveness of NSAIDs in managing chronic low back pain . Sufficient evidence on chronic low back pain is still lacking. 2 studies found no differences between NSAIDs & PT or spinal manipulation to manage acute low back pain . Thus, there is moderate evidence that NSAIDs are not more effective than PT or spinal manipulation for acute low back pain. There’s conflicting evidence that NSAIDs are more effective than bed rest for acute low back pain & conflicting evidence that NSAIDs are more effective than acetaminophen/paracetamol for acute low back pain . There’s moderate evidence that NSAIDs are not more effective than other drugs for acute low back pain . Plaugher, DC. Textbook of Clinical chiropractic. Williams & Wilkins 1993:309. Haldeman S, MD, PhD et al. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 1999; 24(8):785-794. The potential risk of vertebrobasil artery dissection after spinal manipulation is reported to be somewhere between one in 400,000 to one in 1.3 million spinal manipulation sessions. In the absence of a definitive trial, the current understanding of the exact mechanism & risk factors for vertebrobasilar artery dissection must be considered no more than speculation. Vertebrobasilar artery dissection after neck movement, trauma, or manipulation should be considered a rare, random, unpredictable complication assoc with these activities. Malpractice: Without conscientious care and record keeping, you could lose it all. JACA 1999;36(9):6-15. “We would have to study manipulation over generations before we had a large enough sample size of incidents to use scientifically. As a result, we have to use databases of preexisting cases where people claim they have been hurt. The results show patients with serious complications number between one in 500,000 to 1 in 4 million, depending on the research cited.” John Triano, DC, PhD. Terrett A, DC. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation. Nociceptor MIC 2001. Age distribution of 255 cases of post- spinal manipulation stroke. 1934-1999. Average age: Males 39.5; females 37.1. Often the words chiropractic &/or chiropractor have been used in publications to describe any practitioner of manual therapy regardless of the training of the practitioner. The 1999 J Neurology report on 10 cases in an article titled “Stroke following chiropractic manipulation of the cervical spine.” These chiropractic maneuvers were performed by 7 orthopedists, one PT & 2 health practitioners who cannot be accurately identified (no DCs). In the text of the article the words “chiropractic manipulation” were used 14 times, “chiropractic manipulations” eight times, “chiropractic 17

maneuver” twice, “chiropractic cervical spine manipulation” once, & “chiropractic cervical spine manipulations” once. Age & gender distribution indicates no greater risk in any age range. The increased number of accidents reported in the 30 to 45 year age group appears to reflect the age group most likely to seek spinal manipulation . Patients’ age & the presence or absence of degenerative or vascular changes don’t seem important in assessing a patient’s risk. Exact age & gender are known for 233 of 255 (91.4%) of patients. Males (n=101; 43.3%) age 7-87 with an average of 39.5. Females (n=132; 56.6%) ages 20-74 with an average 37.1. Reflects the greater number of female patients in chiropractic offices. Studies of chiropractic patients reveal male 40.7% to female 59.3% and 44.8% to 55.2%. Patients who suffer VBS (vertebrobasilar stroke) after neck spinal manipulation generally are young healthy adults, have an uneventful medical history, have none or only a few of the stroke risk factors, cannot be identified a priori by clinical or radiologic exam & women do not appear to be at greater risk. Terrett A, DC. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation. Nociceptor MIC 2001. In the 65 year period 1934-1999, there are only 37 cases of death known to have occurred in the world, from all different types of spinal manipulation practitioners, with only 19 being related to DCs or chiropractic manipulation. Some may already have a stroke in evolution, & therefore had an identical outcome even if they had not consulted a DC. Yet MDs often portray DCs as a serious risk to the public. While it may be argued that years ago there may have been an element of under-reporting, this is now less likely with increased awareness, & claims experience indicates that significant injury will nearly always lead to litigation. Licht, P. MD, PhD. Vertebral artery blood flow during chiropractic treatment of the cervical column. PhD. Thesis. Odense University, Denmark 2000: 63. Cervical manipulation is used millions of times each year to treat neck pain & headache. Patient satisfaction is high compared to what General Practitioners achieve. Reports on serious complications following cervical manipulation are extremely rare. It is estimated that CVAs occur in one in 400,000 to one in 3 million cervical spinal manipulations. In comparison, the risk assoc with several generally accepted pain relieving procedures in hospitals is much higher (coronary artery bypass grafting: mortality 1.2%, & serious complications >7%, or hip arthroplasty: mortality 1-2%). Even cosmetic procedure like liposuction has a mortality rate of 1 in 13,000. Therefore, one can hardly accuse cervical spinal manipulation of being a risky procedure as long as there is a relevant indication for its use. It may even be tempting to speculate that the widespread fear of cervical manipulation among MDs could be a political issue rather than a clinical one. Haldeman, DC, MD, PhD, Carey, DC. Arterial dissections following cervical manipulation: the chiropractic experience. Can Med Assoc J 2001; 165(7):95-6. Review of malpractice data from the Canadian Chiropractic Protective Assoc (CCPA) to evaluate all claims of stroke following chiropractic care for 10 years between 1988 & 1997. The diagnosis by the treating neurologist was obtained. Results suggested that @ 134.5 million cervical manipulations were performed by DCs covered by CCPCA during this period. There were 43 cases of neurological symptoms following cervical manipulation over 10 years. Of these, 20 were minor & not diagnosis as a stroke. 23 cases of stroke or vertebral artery dissection following cervical manipulation were reported. There are over 4500 DCs in Canada. The likelihood that a DC will be made aware of an arterial dissection following cervical manipulation is approx 1:8.06 million office visits, 1:5.85 million cervical manipulations, 1:1430 chiropractic years & 1:48 chiropractic careers. This is significant less than estimates of 1:500,000 – 1 million cervical manipulations based on surveys of neurologists. It’s probable that the experience of DCs does not reflect all dissections that occur following cervical manipulation. 18

Haldeman, S., DC, MD, PhD, et al. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy. Spine 2002; 27(1):49-55. A review of 64 unpublished medicolegal records with extensive documentation describing cerebrovascular ischemia (CVI) after cervical spinal manipulation . This is the largest case series of CVI associated with cervical spinal manipulation . The next largest was only 10 cases. These 64 cases were referred to a Haldeman for review over 16 years from the United States & Canada. The study was unable to identify factors from the history & P.E. that would assist in isolating patients at risk of CVI after cervical spinal manipulation . CVI after spinal manipulation appears to be unpredictable & should be considered an inherent, idiosyncratic, rare complication of cervical spinal manipulation . It’s assumed CVI may be avoided by screening patients thru history and head & neck positioning to evaluate patency of the vertebral arteries. In 27 cases, DC described screening before spinal manipulation with patient’s neck in ext/rot. None of these patients showed adverse responses to this screening test. Current frequency estimates vary from 1 in 400,000-500,000 to 1 in 3.85 million. Most CVAs occur in patients 30-50 years. There is no evidence that older patients at risk for atherosclerotic vascular ischemia are more likely to incur complications from spinal manipulation . None of the arteriographs in 64 cases showed the presence of arteriosclerotic plaquing. Therefore, the widely accepted risk factors for arteriosclerotic & thrombotic strokes probably do not apply; screening for bruits, hypertension, DM, smoking, to identify patients at risk for arteriosclerotic strokes does not appear to be of any benefit in determining the likelihood that a patient may be at risk for a stroke after spinal manipulation . Of 64 cases, 2 resulted in death & neither showed a pathology in the vertebral arteries on autopsy. One patient had a hemangioma of the venous plexus in the pons which hemorrhaged and the other had a ruptured berry aneurysm. None of the dissections resulted in death. Only 2 cases resulted from dissection of the internal carotid artery. Only 5 cases of carotid artery dissection are found in English lit. The current data on screening before spinal manipulation by placing the head/neck in extension/rotation suggest that this test is not capable of screening out patients at risk, is consistent with recent studies showing that rot/ext of the neck in vivo may not significantly reduce vert artery flow. Most dissections occur in the absence of Cspinal manipulation , spontaneously or after trivial trauma or common daily mov’ts of the neck, such as backing out of a driveway, painting the ceiling, playing tennis, sneezing, or yoga. Suggestions that there may be an inherited arterial defect in the cerebral arteries that makes some people prone to cerebral artery dissection may hold the answer for these seemingly random CVAs after spinal manipulation . Rosner, PhD. Response to PBS. Advance (FCER) 2002; 23(1):4, 30-32. Risk of deaths from the use of medicines such as NSAIDs or from surgery to treat many of the same conditions as those managed by chiropractors is 400 to 700 times greater; yet warnings about the use of these particular options were not mentioned by anyone in your program. Rates of spontaneous arterial dissections have been reported annually to be 1.5-3 per 100,000, substantially larger than most rates of severe strokes associated with [let alone caused by] cervical manipulation. Shievink WT, et al. Recurrent spontaneous cervical-artery dissection. NEJM 1994; 330: 393-397. Shievink WT, et al. Internal carotid artery dissection in a community: Rochester, Minnesota, 1987-1992. Stroke 1993; 24: 1678-1680. Giroud M, et al. Incidence of internal carotid artery dissection in the community of Dijon [Letter]. J Neur Neurosurgical Psychiatry 1994; 57:1443. Symons, DC, Leonard, Herzog, PhD. Internal forces sustained by the vertebral artery during spinal manipulation T. JMPT; 2002 25(8): 504-10. Study quantifies strains & forces sustained by the vertebral artery (VA) during spinal manipulation in 6 Vas from unembalmed cadavers. The cephalad (C0-C1) loop Vas were exposed & instrumented with a pair of piezoelectric ultrasonographic crystals. Strains were recorded during ROM, vertebrobasilar functional maneuvers, & during several spinal manipulation s. Vas were then strained on a materials 19

testing machine until mechanical failure (first point at which the elongation of the VA produced a decrease in force). Results: spinal manipulation on contralateral side of cervical spine resulted in an average strain of 6.2% +/- 1.3% to the cephalad loop of the VA – similar to or lower than the strains recorded during vertebrobasilar functional maneuvers & ROM. Failure testing: VAs could be stretched to 139% to 162% of their resting length before mechanical failure occurred. Therefore the strains sustained by the VA during spinal manipulation represent about one ninth of the strain at mechanical failure. Conclusions: spinal manipulation resulted in strains to the VA almost an order of magnitude lower than the strains required to mechanically disrupt it. Under normal circumstances, a typical High velocity low amplitude spinal manipulation thrust is very unlikely to mechanically disrupt the VA. Norris, MD et al. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. Canadian Med Assoc J 2000; 16(1): 38-40. Based on a survey of 38 Canadian neurologists: Stroke due to neck manipulation occurred in 28% (21/74) of our cases. . .there is little doubt that chiropractic neck manipulation can result in dissection of the carotid or vertebral arteries leading to stroke. DCs should inform all patients about possible serious complications. Information Bulletin from the Inquest on the death of Ms. Lewis 2002: Dr. Norris invited Dr. Murray Katz to speak on chiropractic stroke to a hospital medical staff. After the talk Dr. Norris agreed that Dr. Katz’s presentation was “unfair, unprofessional & completely unscientific” but he did nothing to stop it. In January 2001 Dr. Norris prepared a medical/legal report for the inquest which connected Ms. Lewis’ stroke to a chiropractic adjustment. He testified that he couldn’t recall what information he used in reaching his opinion. Dr. Norris conceded that he had never reviewed Ms. Lewis’ medical records & knew nothing of her medical history when he wrote his opinion. He agreed that seeing her medical records would be important to coming to a conclusion. Licht, MD, Christensen DC, MD., Hoilund-Carlsen MD, D musculoskeletal c, Is there a role for premanipulative testing before cervical manipulation? JMPT 2000; 23(3):175-179. Study at a university hospital vascular lab of vertebral artery blood flow in 20 patients with a positive premanipulative test for contraindication to spinal manipulation referred by DCs in Denmark. Flow velocities were measured in both vertebral arteries by color duplex sonography. 5 patients were excluded because symptoms were not reproduced in the vascular exam. In 15 patients with symptoms (vertigo, blurred or double vision, nausea, hemicranial paresthesia) no significant difference in peak flow velocity or time averaged mean flow velocity with different head positions was found. 19 of 21 DCs surveyed would treatment a patient with a positive premanipuulative test if the vascular exam was normal. 8 of the patients with a positive premanipulative test were treated without complications. 7 are now symptom free & 2 have improved symptoms . The remaining 8 patients refused manip & continue to have the same symptoms . Conclusion: A positive premanipulative test is not an absolute contraindication to cervical spinal manipulation . If the test is positive & reproducible, patients should be referred for a duplex exam of the vertebral artery flow. If the duplex flow is normal, the patient should be eligible for cervical spinal manipulation despite the positive premanipulative test. Controversy exists about the sensitivity & specificity of premanipulative tests. Studies indicate a test may be negative, despite occlusion of the vert artery, & CVAs may occur despite a negative test. Functional tests of the vertebral arteries include: Barre-Leiou’s sign test, Geroge’s cerebrovascular craniocervical functional test, Maigne’s test, Hautant’s test, Underberg’s test, Hallpike maneuver, & deKleyn’s or Wallenberg’s tests. All are variations of the same theme: extreme rotation & extension of the head to provoke cerebral ischemia during positional change of the cervical spine. A test is positive if it provokes S&S of vertebrobasilar insufficiency (nystagmus, vertigo, dizziness, tinnitus, visual blurring, nausea or faintness). In this study there was no significant difference in either peak flow or time-averaged mean flow velocity in the 20

various head positions. Results suggest that a positive test is seldom assoc with changes in vert artery blood flow & that a positive deKleyn’s test should not be considered an absolute contraindication to cervical spinal manipulation . Terrett A, DC. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation. nociceptorMIC 2001. Functional vascular tests are not a reliable indicator or predictor of VBI (vertebrobasilar ischemia). The tests have problems with false positive results, & often following spinal manipulation to the neck &/or other spinal regions, the positive result cannot be reproduced. Functional vascular tests have problems with false negative results. The absence of a positive functional test cannot be absolutely interpreted to mean that there is no underlying arteriopathic process. In all but the most grossly pathological or highly susceptible cases, these tests will give a false negative result & a false sense of security to the practitioner. It makes no sense to subject patients to a screening test that is invalid & gives the practitioner a false sense of security regarding the degree of risk for spinal manipulation . This can only lead to the conclusion that the tests should be abandoned, for clinical & medicolegal purposes, & should not be used for non-clinical risk management reasons. There is no evidence that suggests positive results have any correlation with future VBS if spinal manipulation is used. Current testing procedures are not able to predict susceptibility to VBS. Proprioception, Dizziness, the Cervical Spine and Spinal Adjustment Licht, MD, Christensen DC, MD, Hoilund-Carlsen MD, D musculoskeletal c, Is there a role for premanipulative testing before cervical manipulation? JMPT 2000;23(3):175-179. Other conditions may be responsible for the symptoms evoked by a premanipulative test. Neck proprioceptors involved in postural adjustment, are closely related to vestibular function. The proprioceptors are the joint receptors of the first 3 upper cervical vert. A positive premanipulative test could be from proprioceptor dysfunction, resulting in “cervical vertigo” by way of their projections to the vestibular nucleus. This presents a dilemma – the very symptoms that contraindicate therapy may most likely be relieved by the treatment they exclude. Patients in this study who were treatment got relief which favors an explanation of this kind & suggests that a positive deKleyn’s test should generally not be considered a contraindication to spinal manipulation . Norre. Vertigo & the Cervical Spine. Medica Physica 1986; 9:183-194. Vertigo results from a disturbance in sensory input from vestibular apparatus, eyes, & proprioceptors (especially of the neck) which renders the pattern abnormal & dysharmonic. The dysfunction of one sensor makes its signal contradictory to that of the others resulting in a Sensory Mismatch. Neck proprioceptors have a sensory function equivalent to vestibular function. Stimulation of neck proprioceptors produce the same ocular reflexes as does the vestibular system: Cervico-ocular Reflex. Hinoki, MD. Vertigo post-Whiplash due to over excitation of cervical proprioceptors. Acta Otolaryng 1988; Suppl 419:9-29. As a result of tissue injury & inflammation there is overexcitation of cervical & lumbar proprioceptors. Their abnormal input produces dysregulation of the CNS. This is a TRIGGER – TARGET effect. In 68.4% of patients there is increased disequilibrium due to pulsed stimulation or saline injections applied to injured neck muscles which was reduced by a cervical collar. Nelson CF et al. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. J Manipulative Physiol Ther. 1998 Oct;21(8):511-9. 21

BACKGROUND: Migraine headache affects approximately 11 million adults in the United States. Spinal manipulation is a common alternative therapy for headaches, but its efficacy compared with standard medical therapies is unknown. OBJECTIVE: To measure the relative efficacy of amitriptyline, spinal manipulation and the combination of both therapies for the prophylaxis of migraine headache. DESIGN: A prospective, randomized, parallel-group comparison. After a 4-wk baseline period, patients were randomly assigned to 8 wk of treatment, after which there was a 4-wk follow-up period. SETTING: Chiropractic college outpatient clinic. PARTICIPANTS: A total of 218 patients with the diagnosis of migraine headache. INTERVENTIONS: An 8-wk course of therapy with spinal manipulation, amitriptyline or a combination of the two treatments. MAIN OUTCOME MEASURES: A headache index score derived from a daily headache pain diary during the last 4 wk of treatment and during the 4-wk follow-up period. RESULTS: Clinically important improvement was observed in both primary and secondary outcomes in all three study groups over time. The reduction in headache index scores during treatment compared with baseline was 49% for amitriptyline, 40% for spinal manipulation and 41% for the combined group; p = .66. During the posttreatment follow-up period the reduction from baseline was 24% for amitriptyline, 42% for spinal manipulation and 25% for the combined group; p = .05. CONCLUSION:There was no advantage to combining amitriptyline and spinal manipulation for the treatment of migraine headache. Spinal manipulation seemed to be as effective as a well-established and efficacious treatment (amitriptyline), and on the basis of a benign side effects profile, it should be considered a treatment option for patients with frequent migraine headaches. Heikkila. Scand J Rehab 1996; 28:133-138. Study of kinesthetic sensibility in 14 whiplash patients ( motor vehicle accident 2-3 years before) vs 34 healthy subjects & the effects of a rehab program. subjects were tested in terms of head repositioning accuracy. All patients had pain & decreased ROM immediately after injury & persistent neck symptoms . Whiplash patients were significant less precise in repositioning their heads but this improved after 5 wks of rehab. Cervicocephalic kinesthesia is probably linked to sensory info from muscular & articular proprioceptor. A flexion-extension injury results in proprioceptor dysfunction either by lesioning or functional impairment of muscular & articular receptors, or by alteration in afferent integration & tuning. Heikkila, MD, Wengren, MD, PhD. Arch Phys Med Rehabil 1998;79:1089-1094. The nociceptor-interneuron-motor neuron connection in the spinal cord may contribute to increased muscle tension. With increased muscle tension & sensitized muscle spindles, the increased sensitivity may give rise to erroneous proprioceptor signaling, esp if spindles in different neck muscles or on different sides of the neck are unequally sensitized. Erroneous cervical proprioceptor info converges in the CNS with vestibular & visual signals, with a consequent feeling of dizziness or unsteadiness caused by distorted mental representation of body orientation & by a misinterpreted relation to surroundings. Rogers, DC. MPHT 1997;20(2):80-85. Effects of spinal manipulation on cervical kinesthesia in patients with chronic neck pain. Study of spinal manipulation vs stretching exercise’s effect on pain & head repositioning in 20 patients with chronic neck pain in a randomized controlled trial. ½ of patients received 6 treatments of high-velocity, low amplitude cervical spinal manipulation & ½ got stretching of upper thoracic muscles 2 sessions daily. Results: spinal manipulation patients had a mean reduction in VAS scores of 44% & a 41% improvement in head repositioning skill. Stretching patients had a 9% reduction in VAS & a 12% improvement in head repositioning scores. Conclusion: Results suggest a possible effect of spinal manipulation on proprioceptor in patients with chronic neck pain. Limits: Small sample size, lack of blinding of examiner. 22

Heikkila, MD, PhD et al. Effects of Acupuncture, Cervical Manipulation and NSAID Therapy on Dizziness and Impaired Head Repositioning of Suspected Cervical Origin, Man Ther 2000;5:151-157. 14 patients with chronic (>3 mo) dizziness/vertigo of suspected cervical origin were given in random order: 1) acupuncture – 3 treatment within 2 weeks, 2) cervical spinal manipulation – 3 treatment within 2 weeks, 3) no therapy, and 4) NSAID-percutan applied 23X/day over sore muscles in neck/shoulders for 1 week to evaluate their effect on kinesthetic sensibility, dizziness/vertigo and pain. Outcomes were based on effects of each treatment on 1) cervical kinesthetic performance, 2) vertigo, 3) pain & 4) active cervical ROM. Results were compared with 39 controls. Spinal manipulation was the only treatment to diminish the duration of dizziness/vertigo complaints in the past 7 days (before 4.5 & after treatment 2.2) & increase cervical ROM. Both acupuncture & spinal manipulation reduce dizziness/vertigo & positively effect head repositioning. NSAID-percutan application & acupuncture alleviated pain. Results suggest spinal manipulation may impact most efficiently on the complex process of proprioceptor & dizziness of cervical origin. Symptoms of cervical vertigo are caused disturbed proprioceptor input from the neck. Erroneous cervical proprioceptor info converges in the CNS with vestibular & visual signals, affecting perception of body, orientation & the relation to the surroundings, which may be misinterpreted, resulting in a feeling of dizziness of unsteadiness. Disturbed kinesthetic sensitivity may contribute to functional instability of joints & susceptibility to reinjury, chronic pain & DJD. Removal of abnl afferent input from joints may improve proprioceptor & motor response. Conclusion: Results suggest that spinal manipulation may be most effective in influencing the complex process of proprioceptor sensibility & dizziness of cervical origin. Medical Management, Prescription Drugs, Surgery – Risks, Marketing, Manipulation Classen DC, Pestonik SL, Evans RS, et al: Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA 1997;277(4):301 ADVERSE DRUG REACTIONS FOUND TO BE RESPONSIBLE FOR LOSS OF LIVES AND BILLIONS OF DOLLARS IN ADDED HEALTH CARE COSTS... Chiropractic has always advocated drug free health care and it seems, with good reason! In the past few years a number of studies, concerning the effects that adverse prescription drug reactions have on patients and on the health care industry, have been published. These studies reveal some disturbing facts about health care in The United States. For example, it is estimated that adverse prescription drug reactions increase the risk of death to a patient approximately 2 times. In fact, it is estimated that as many as 140,000 people die every year from adverse prescription drug reactions! In addition, in The United States alone, the ill effects of adverse prescription drug reactions and the deaths that they cause cost an estimated $136 billion dollars per year in added health care costs. That figure is more than what it costs for all the cardiovascular care or diabetes care in The United States per year. If you suffer from an adverse prescription drug reaction you are likely to have to stay in the hospital for 2 to 5 more days at an added cost of $3000 to $5000 dollars! This knowledge, though shocking, is not new. As far back as 20 years ago, it was known that approximately 30% of hospitalized patients experience an adverse prescription drug reaction. In fact, it was estimated back then that 1 in every 300 hospital patients suffer a fatal reaction to prescibed medication. Lasser, MD, MPH, et al. Timing of New Black Box Warnings and Withdrawals for Prescription Medications. JAMA; 2002; 287(17):2215-2220. Of 548 new chemical entities approved from 1975-1999, 56 (1f0.2%) acquired a new black box warning, (problems that may lead to death or serious injury, are required by FDA to be in a prominent box). 16 new drugs were withdrawn 23

from the market (a 4% probability of being withdrawn). Half of withdrawals occurred within 2 years of the drug’s introduction. Many serious adverse drug reactions (ADRs) are discovered only after a drug has been on the market for years. Why? FDA drug trials are often underpowered to detect ADRs & have limited follow-up. Despite limited knowledge about the safety of new drugs, their market uptake & sales volume may be explosive. The pharmaceutical industry promotes the early use of new drugs & influences Drs’ adoption of such drugs. Directto-consumer drug advertising generates a high volume of new drug prescriptions. Drug firms rush new drugs to market because of concerns about patent life, a desire to mold prescribing habits before the market entry of competitors, & hopes for brisk sales to encourage investors & increase stock prices. patient exposure to new drugs with unknown toxic effects may be extensive. Nearly 20 million patients in the U.S. took at least 1 of 5 drugs withdrawn from the market between September 1997 & 1998. 7 drugs approved since 1993 & later withdrawn are reported to contribute to 1002 deaths. Clinicians should avoid using new drugs when older, similarly efficacious agents are available. Patients who must use new drugs should be informed of the drug’s limited experience and safety record, & be observed for toxicity. Conclusions: Serious ADRs commonly emerge after FDA approval. The safety of new agents cannot be known with certainty until a drug has been on the market for many years. Moynihan, R. et al. Selling sickness: the pharmaceutical industry and disease mongering. BMJ; 2002 324 (April 13): 886-897. Moynihan, R. et al. Selling sickness: the pharmaceutical industry & disease mongering. BMJ; 2002; 324 (April 13): 886-91. Pharmaceutical companies are actively involved in sponsoring the definition of diseases & promoting them to prescribers & consumers. Ostensibly engaged in raising public awareness about undiagnosed & undertreated problems, these disease awareness campaigns are linked to companies’ marketing strategies to expand markets for new pharmaceutical products. Drug companies are engaged in invisible, unregulated attempts to change public perceptions about health & illness in order to widen markets for new drugs. The social construction of illness is being replaced by the corporate construction of disease. A key strategy is to target the news media with stories designed to create fears about the condition or disease & draw attention to the latest treatment. Company sponsored advisory boards supply “independent experts” for these stories. Public relations companies provide media outlets with the positive spin about the latest “breakthrough” medications. Drug companies sponsor meetings where a disease is being defined, fund studies of therapies, & develop close financial ties with leading researchers. They fund patient support groups, disease foundations, & advertising campaigns on both drugs & disease targeted at MDs & sponsor media awards with lucrative prizes to journalists who write about the disease. The promotional focus on chemical solutions for complex problems takes attention away from a variety of modestly effective non-pharmacological strategies, such as dietary supplements, smoking cessation 7 exercise which are played down or ignored. Irritable Bowel Syndrome (IBS) – long considered a common functional disorder is currently experiencing a global makeover. With the arrival of new drugs, the manufacturers seek to change the way the world thinks about IBS. It is currently being reframed as a serious disease attracting a label & a drug. The authors acquired a confidential document which describes a 3 year “medical education program” to create a new perception of IBS as a “credible, common & concrete disease” & establish in the minds of Drs that it is a significant & discrete disease state. Patients also need to be convinced that “IBS is a common & recognized medical disorder.” The educational program is part of the marketing strategy of GlaxoSmithKline’s drug Lotronex. First they set up an “Advisory Board” comprised of a key opinion leaders from each state of Australia to provide advice on the “current opinion in gastroenterology & on opportunities for shaping it.” The need is to establish a market & convince the “specialist market” that the condition is a “serious & credible disease.” Advertorials in medical journals featuring interviews with members of the company’s expert advisory board is invaluable in “reassuring General Practitioners that the material they receive is clinically valid.” 24

Other groups to be targeted include pharmacists, nurses, patients. Although billed as a medical education plan, the document is clearly part of the Lotronex marketing strategy. Also noted is that “ proprioceptor & media activities are crucial to a well rounded campaign particularly in the area of consumer awareness.” The conflict of interest is obvious. The drug company’s primary interest is shaping public opinion about IBS in a way that will maximize sales of its medication. In this case the campaign was stopped because of the withdrawal of Lotronex from the market after reports to the FDA of serious & sometimes fatal adverse reactions. Pharmaceutical Marketing: How to establish a need & create desire to prescribe. Risk factors being conceptualized as diseases: Osteoporosis (3.8 vs 2.1). High cholesterol: lowering top normal range: Lipitor, Zocor. Nuovo, MD et al. Reporting number needed to treatment & absolute risk reduction in randomized controlled trials. JAMA, 2002; 287 (21):813-4. Wiesel, MD. Backletter; 2002 17(10): 109, 11822. Med journals permit authors to present new treatment s in a misleading fashion. They allow statistics that paint findings in a maximally positive ligament ht to ensure maximal impact in the mass media. A review of studies had a 9% reduction in VAS & a 12% improvement in head repositioning scores. Conclusion: Results suggest a possible effect of spinal manipulation on proprioceptor in patients with chronic neck pain. Limits: Small sample size, lack of blinding of examiner. Heikkila MD, PhD. Et al. Effects of Acupuncture, Cervical Manipulation and NSAID Therapy on Dizziness and Impaired Head Repositioning of Suspected Cervical Origin, Man Ther 2000;5:151-157. 14 patients with chronic (>3 mo) dizziness/vertigo of suspected cervical origin were given in random order: 1 acupuncture – 3 treated within 2 weeks, 2) cervical spinal manipulation – 3 treated within 2 weeks, 3) no therapy, and 4) NSAID-percutan applied 23X/day over sore muscles in neck/shoulders for 1 week to evaluate their effect on kinesthetic sensibility, dizziness/vertigo and pain. Outcomes were based on effects of each treatment on 1) cervical kinesthetic performance, 2) vertigo, 3) pain & 4) active cervical ROM. Results were compared with 39 controls. spinal manipulation was the only treatment to diminish the duration of dizziness/vertigo complaints in the past 7 days (before 4.5 & after treatment 2.2) & increase cervical ROM. Both acupuncture & spinal manipulation reduce dizziness/vertigo & positively effect head repositioning. NSAID-percutan applications & acupuncture alleviated pain. Results suggest spinal manipulation may impact most efficiently on the complex process of proprioceptor & dizziness of cervical origin. symptoms of cervical vertigo are caused disturbed proprioceptor input from the neck. Erroneous cervical proprioceptor info converges in the CNS with vestibular & visual signals, affecting perception of body, orientation & the relation to the surroundings, which may be misinterpreted, resulting in a feeling of dizziness of unsteadiness. Disturbed kinesthetic sensitivity may contribute to functional instability of joints & susceptibility to reinjury, chronic pain & DJD. Removal of abnl afferent input from joints may improve proprioceptor & motor response. Conclusion: Results suggest that spinal manipulation may be most effective in influencing the complex process of proprioceptor sensibility & dizziness of cervical origin. Nuovo, MD et al. Reporting number needed to treatment & absolute risk reduction in randomized controlled trials. JAMA, 2002; 287(21):813-4. Wiesel, MD. Backletter; 2002 17(10): 109, 11822. Med journals permit authors to present new treatment s in a misleading fashion. They allow statistics that paint findings in a maximally positive ligament ht to ensure maximal impact in the mass media. A review of studies published in NEJM, JAMA, BMJ, The Lancet, & Ann Intern Med found in the vast majority, only the most favorable statistic – relative risk reduction (proportion of baseline risk removed by treatment) was used when reporting 25

results. Of 359 articles only 5 reported on the “number needed to treat” (number of patients who must be treated to prevent one adverse event) & only 18 portrayed the results in terms of “absolute risk reduction” (proportion of patients who are spared an adverse outcome by the treatment). Journals need to improve reporting of randomized controlled trials & enable readers to better interpret results. There are allegations that drug companies have oversold the benefits of osteoporosis meds by overemphasizing measures of relative risk reduction – ignoring absolute risk reduction & number needed to treat. A 1998 study found 2.1% of women with low bone density treatment with alendronate (Fosamax) developed vert Fx vs 3.8% treatment with a placebo. This is a 44% reduction in relative risk. The authors stated: “Alendronate reduced risk of vert Fx by about half.” This got splashy media coverage. Results are much less impressive in terms of absolute risk reduction: only 1.7%. In terms of the number needed to treat: 60 women had to be treated with alendronate for 4 years to prevent a single vert Fx. In women with higher ranges of bone density, 363 would have taken alendronate for 4 years to prevent a single silent Fx. Among women in the osteoporotic range, 35 would have had to take alendronate for 4 years to prevent a single Fx. Ex: at 1 year follow-up , raloxifene (Evista) decreased the risk of new vertebral Fx by 68%. Sounds impressive, but, very few women in either group had vert Fx: 0.08% of subjects in placebo group & 0.03% in raloxifene group . The absolute risk reduction was 0.05%. An absolute risk reduction of one half of 1% sounds a lot less impressive than a relative risk reduction of 68%. The authors didn’t state the number needed to treat: 200 women would have had to take 60 mg/day of raloxifene for a year to prevent a single vertebral Fx. Gorman C, Park A. The truth about hormones. Time 2002; July 22:32-39. Fletcher, MD, MSc, Colditzh, MD, DrPH. Failure of Estrogen Plus Progestin Therapy for Prevention. JAMA; 2002 28(3), July 17. Hormone replacement therapy (HRT) for aging women began around 1966. More than 40% of all women in the US start some form of HRT in their menopause years & many continue well into their 70s & 80s. Treatment was based on observational studies which showed that women on HRT lived longer with fewer health problems (lower cholesterol, less heart attacks & strokes). However, when reviewing all the data for guidelines on HRT for the American College of Physicians, it was realized that the data wasn’t definitive and the Women’s Health Initiative (WHI) was initiated. This involved randomized controlled trials enrolling >160,000 women including >16,000 healthy 50-79 year olds to study estrogen & progestin: Prempro by Wyeth Pharmaceuticals. 8,506 taking HRT & 8,102 taking placebo. The 8 year study was stopped 3 year early because of dangers associated with HRT: increased risk of blood clots in the legs & lungs, heart attacks & breast cancer. HRT increase in breast cancer: 26%; increase in heart disease: 29%; increase in strokes: 41%; increase in pulmonary embolism; 113%; decreased hip Fx: 34%; decreased colon cancer: 37%. Moseley, MD, et al. A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. NEJM 2002; 347: 81-88. Arthroscopy is the most commonly performed type of orthopedistedistpedic surgery & the knee is by far the most common joint on which it is performed. A randomized, placebo-controlled trial to evaluate the efficacy of arthroscopy for osteoarthritis (OA) of the knee. Patients with knee OA were randomly assigned to receive 1) arthroscopic debridement, 2) arthroscopic lavage, or 3) placebo surgery (skin incisions & simulated debridement w/o insertion of the arthroscope). patients & assessors were blinded to the treatment assignment. Outcomes assessed 2 & 6 weeks, 3, 6, 12, 18 & 24 months. 3 pain, 2 function scales &u an objective test of walking & stair climbing. 165 patients completed the trial. Results: At no point did either of the intervention groups report less pain or better function than the placebo group. Knee-Specific Pain Scale were similar in placebo, lavage, & debridement groups at one & two years. Differences between placebo group & intervention groups exclude any clinically meaningful difference. Conclusion: outcomes after arthroscopic lavage or debridement were no better than those after a placebo procedure. At no point did either 26

arthroscopic intervention group have either greater pain relief greater improvement in function than the placebo group. Indeed, objectively measured walking & stair climbing were poorer in the debridement group than the placebo group at 2 weeks & at 1 year & showed a trend toward worse functioning at 2 years. More than 650,000 arthroscopic lavage or debridement procedures are performed each year at a cost of roughly $5000 each. There is no evidence that arthroscopy cures or arrests OA. If the efficacy of arthroscopic lavage or debridement in OA patients of the knee is no greater than that of placebo surgery, the billions of dollars spent on such procedures annually might be put to better use. Barry, P. Drug industry spends huge sums guarding prices. AARP Bulletin; 2002 (May): 3, 13, 14, 15. The drug industry wages its battles with money. The sheer volume of their expenditures gives drug makers so much weight, they are able to thwart legislation they don’t like. The industry’s expenditures in Washington in 1999-2000 was documented by an investigation by Public Citizen which revealed the drug industry spent $177 million lobbying members of Congress & $20 million on campaign contributions – more than any other industry. The industry employed 625 lobbyists, more than 1 for each member of Congress & paid each lobbyist on average>$12,000/month. Critics say this perpetuates the high cost of drugs. The pharmaceutical industry’s influence concerns lawmakers. “The amount of money they spend & the number of lobbyists they hire is really a problem in a democracy,” says Tom Allen, D-Maine. The drug industry disagrees. “I’d say we are actively participating in the democratic process,” responds a spokesman for the Pharmaceutical Research & Manufacturers of America (PhaRMA), its trade group. The industries’ major issues: lobby for: bills maintaining & extending patent rights, bills shortening approval time for new drugs. Lobby against bills encouraging the use of generics to curb costs, bills allowing drugs to be imported from Canada. For years the pharmaceutical industry has been, by far, the richest industry in America. This year’s Fortune 500 list it had an average 18.5% profit margin, more than 4X that of all other industries. Economic analysis shows that the drug industry makes large profits way above the average 13% of revenue it spends on R&D. It spends an average of 35% on advertising & administration including lobbying costs. Zoellner, T. America’s other drug problem. Men’s Health 2001; Oct: 118-123. The AMA supplies pharmaceutical manufacturers with the “physician’s master file,” a database that contains detailed biographies of member MDs as well as their individual DEA (drug enforcement agency) numbers. Combine an MDs DEA number with the prescription records that drug companies purchase from pharmacies & suddenly you’re looking at every medication an MD is prescribing. Last year sales of the physician’s master file to drug companies made the AMA an estimated $20 million. Wiesel, S., MD. Multimillion dollar treatments. Backletter; 2002 17(7): 84, Vioxx (Merck) & Celebrex (Pharmacia) are the most heavily promoted treatment s for BP in history. In 2000 Merck spent $161 million promoting Vioxx & Pharmacia $78 million for Celebrex. Pepsi spent $125 million advertising Pepsi & Budweiser spent $146 million for beer. (NoFreeLunch.org). There are currently about 80,000 drug reps in the US. The drug industry gave out $7.2 billion in free samples in 2000. Free samples are a strong selling point. Older NSAIDs are no longer available in sample packets. The marketing system is promoting more expensive care. Elder, MD, et al. A cyclooxygenase-2 inhibitor impairs ligament healing in the rat. Am J Sports Med 2001; 29(6): 801-5. Study used surgical transection of medial collateral ligament aments of 50 rats as a model for acute ligament ament injuries to investigate the effects of Celebrex (celecoxib) on ligament healing. Post-op, half the rates were given celecoxib for first 6 days of recovery, others were not. At 14 days after the operation, both injured & uninjured medial collateral ligament aments were mechanically tested to failure in tension. The strength of 27

celecoxib-treated injured ligaments was 32% less than that of untreated injured ligaments. In addition, the energy absorbed to failure was 41% less & stiffness was 21!% less than I n untreated injured ligaments. This is the first study to deal with the effects of COX-2 inhibitors on soft tissue healing. Our results suggest that caution should be used when prescribing COX-2 inhibitors for the treatment of human ligament injuries. Wiesel, S., MD. Cox-2s and Bone Healing. Backletter; 2002 17(7): 73, 82, 83. Editorial in J Bone & Mineral Research suggests MDs stop using Cox-2 inhibitors & other NSAIDs for patients undergoing bony healing (spine surgery, stress or spine Fx, receiving dental implants, or joint arthroplasty) because new animal studies suggest these meds inhibit bone formation. Vioxx & Celebrex had a particularly negative impact on bone formation. It’s not clear whether older patients with low bone density & history of Fx should also avoid Cox-2 inhibitors & NSAIDs. Study: NSAIDs delayed healing of femoral Fx in rats & Cox-2 inhibitors appeared to prevent nl healing altogether. Cox-2 inhibitors can stop nl fracture healing & induce the formation of incomplete unions & nonunions. (Simon et al Cyclooxygenase-2 function is essential for bone fracture healing. J Bone & Mineral Res 2002; 17(6):963-76). Created femoral Fxs in 253 rats. Group 1: no meds, Group 2: indomethacin, Group 3: Celebrex (at nl dose) & Group 4: Vioxx (at 4X nl dose). Results: Indomethacin group healed, but healing delayed: 25% to 50%. No rats treatment with Celebrex exhibited complete healing. Conclusion: Celebrex at nl daily dose delayed & inhibited bony healing. Vioxx at higher dose (4X) completely inhibited bony healing. Wiesel, MD. Are drug companies shading the truth about Cox-2 inhibitors? Backletter 2001; 16(12): 136-7. The FDA arthritis advisory committee reports Vioxx & Celebrex provide no more effective analgesia than older NSAIDs. Celebrex is comparable in efficacy to naproxen. Vioxx is comparable to ibuprofen or diclofenac. GI safety profile of Celebrex is no better than ibuprofen or diclofenac. “There is not a proven clinically important safety advantage in upper GI events globally.” Vioxx has a significantly lower cumulative incidence of GI perforations, ulcers, & bleeds compared to naproxen (2.08% & 4.49%). But, FDA has not eased its GI warning on the Vioxx label. Cardiovascular safety: (CLASS trial), patients taking Celebrex & those taking diclofenac & ibuprofen had a virtually identical incidence of cardiovascular events (@1%). Patients on Vioxx (VIGOR trial) had a 4 to 5 fold increase in myocardial infarctions compared to patients on naproxen & more than twice as many serious CV events overall (2.5% vs 1.1%). Mukherjee, D et al. Risk of cardiovascular events associated with selective COX-2 inhibitors. JAMA 2001; 286(8):954-9. A lit search on the use of COX-2 inhibitors published between 1998 & 2001 yielded 2 major randomized trials, the Vioxx Gastrointestinal Outcomes Research Study (VIGOR: 8076 patients) & the Celecoxib Long-term Arthritis Safety Study (CLASS: 8059 patients), & 2 smaller trials with approximately 1000 patients each. Results from VIGOR showed that the relative risk of developing a thrombotic cardiovascular event (myocardial infarction, unstable angina, cardiac thrombus, cardiac arrest, sudden death, ischemic stroke, and TIA) with rofecoxib compared with naproxen was 2.38. There was no significant difference in cardiovascular events between celecoxib & NSAIDs in CLASS. The myocardial infarction rates for COX-2 inhibitors in both VIGOR and CLASS were significantly higher than in the placebo group of a recent meta-analysis of 23,407 patients. The data raise a cautionary flag about the risk of cardiovascular events with COX-2 inhibitors. Growth in Prescription Drug Sales – 1998 (nacds.org/news/releases/retail.html). For the first time, retail sales of prescription drugs will exceed $100 billion, according to projections released by the National Association of Chain Drug Stores (NACDS) which estimates year end sales for 1998 will reach $102 billion, an increase of 15% over 1997. Additionally, sales of over-thecounter meds in chain pharmacies will reach over $28 billion, an increase of >10% over sales in 28

1997. NACDS also announced projected increases in the total number of prescriptions dispensed by retail pharmacies for 1998 will reach nearly 2.8 billion, an increase of 6% from 1997. NACD subjects projects continuing growth in prescription volume will lead to nearly 4 billion dispensed by 2005. Wiesel S, MD. Drug Ads, Consumer Wrath. Backletter 1999; 14(2):24. HCFA predicts that expenditures on prescription drugs will almost triple between 1996 & 2007 – from $62 billion in 1996 to $171 billion in 2007. Direct-to-consumer advertising is expected to play a significant role in that growth. A November 1998 press release from a pharmaceutical consulting firm that drug companies spent more than $722 million on Direct-to-Consumer advertising in the first 6 months of 1998 alone. Over half of the MDs surveyed said patients were requesting increasingly more drugs that were advertised directly to them. Lurie, MD, MPH, Wolfe, MD. FDA Medical Officers (Mos) report lower standards permit dangerous drug approvals. 1998, Dec. 2. After criticism from the drug industry that the drug approval process was too slow, the US Congress passed the Prescription Drug User Fee Act in 1992 which authorized drug companies to pay fees to the FDA so it could hire more months– MDs responsible for coordinating the reviews of New Drug Applications by FDA employees, to speed up the review of new drugs. One result: larger numbers of drugs are now being approved. In 1995, 28 new drugs were approved, similar to previous years, in 1996, 53 new drugs were approved & 39 more new drugs were approved in 1997. In 1997 Congress passed the FDA Modernization Act, which permits drug approval based on a single clinical trial (instead of two). It also included mechanisms for speeding FDA review. A survey of FDA months in Sept/Oct 1998 found that many say the safety & efficacy standards for approving new drugs have been lowered in the past few years, allowing many drugs to be approved which should not have been. The study was conducted following the setting of 2 all time FDA records. First, the largest number of drugs ever approved in any 2-year period (92 in 1996 & ’97). Second, a record 3 new prescription drugs were banned in a 12 month period because they were too dangerous to be allowed to stay on the market. For all 3: (1) dexfenfluramine (Redux – 3/98). (2) mibefradil (Posicor – 6/98) & (3) bromfenac (Duract – 10/98) – data available prior to approval raised significant safety concerns. 19 months identified 27 new drugs in the past 3 years that they reviewed & thought should not have been approved but were. 17 months described the current standards as “lower” or “much lower” than in the past. 1 month stated: “My feeling, after more than 20 years at FDA, is that unless drugs cannot be shown to kill patients outright then they will be approved with revised labeling & box warning.” 34 months stated that the pressure on them to approve new drugs was “somewhat greater” or “much greater” compared to prior to 1995. Inappropriate pressure from Congress, drug companies, & senior FDA employees create an atmosphere in which the likelihood of drug approval is maximized & takes the form of 1) Inappropriate phone calls, 2) Pressure to withhold data or personal opinions unfavorable to a drug from FDA Advisory Committees, & 3) Pressure from supervisors to change their opinion in the direction of approving the drug. Stolberg, SG. The Boom in Medications Brings Rise in Fatal Risks. New York Times 1999; June 3. Doctors are having a difficult time keeping abreast of FDA warnings about possible risks. “There are just so many new drugs available,” says Dr. Kenneth W. Kizer, Under Secretary for health in the Depart of Veterans Affairs, “And keeping current with the information that goes with each drug has become almost impossible.” FDA officials are convinced the danger is growing. FDA, long criticized as moving too slowly on drug applications, is now approving products at a record-setting pace. More prescriptions are being written not only because there are more drugs but also because the population is aging; elderly people take more than 1/3 of all drugs that are prescribed. 29

Consumer-Direct Broadcast Advertisements. Draft Guidance for industry. 1997 August. The Federal Food, Drug, & Cosmetic Act requires that manufacturers advertising prescription ( treatment (prescription)) drugs disclose information about the product’s uses & risks. For treatment (prescription) drugs, the Act requires broadcast ads to contain “information in brief summary relating to side effects, contraindications, & effectiveness.” Ads broadcast through television, radio, or phone systems must disclose the product’s major risks. This is called the “major statement” which conveys the product’s most important risk information I n consumer friendly language. Sponsors of broadcast ads may present a brief summary or, may make “adequate provision. . .for dissemination of the package labeling in connection with the broadcast presentation” via toll free phone number, web page, print ads. The major statement, together with adequate provision for dissemination of the product’s labeling, provide the information disclosure required for broadcast advertisements. The Nat’l Inst for Health Care Management Res & Ed Foundation. Factors affecting the growth of prescription drug expenditures 1999; July 9. Spending on treatment (prescription) drugs increased twice as fast as national care health spending from 1992 & ’97 (>11% growth per year vs 5.5%). 1997-1998 growth rate will exceed 18%: a $42.7 billion (84%) increase in retail drug expenditures between 1993 ($50.6 billion) & 1998 ($93.4 billion). Spending growth is concentrated in the heavily advertised drugs. Antihistamines: such as Claritin*, Zyrtec*, Allegra* increased by 612% between ’93 & ’98 (these 3 drugs accounted for 90% of sales for treatment (prescription) antihistamines.) Antidepressants such as Prozac*, Zoloft & Paxil increased by 240%; Cholesterol reducing drugs such as Lipitor, Zocor* & Pracachol* increased by 194%; Anti-ulcerant drugs such as Prilosec*, Prevacid, & Pepcid increased by 71%. When newer products are introduced & heavily marketed, they tend to rapidly dominate sales in their class. Direct to consumer (DTC) spending increased >20X from $55.3 million in ’91 to over $1.3 billion in ’98 & projected to increase another 54% in ’99 reaching $2 billion. Patients are becoming more likely to ask for treatment (prescription) drugs by brand name. A 1998 survey found 53% of MDs reported an increase in brand name requests, up 30% from mid-97 before TV ads. When patients ask a MD for a specific treatment (prescription) drug, evidence indicates that the Dr is likely to honor such requests. A ’97 study found that 73% of consumers said their MD accommodated their request for a specific drug. Requests for Claritin were honored 86% of the time. Worldwide R & D expenditures increased >12X from $2 billion in 1980 to $24 billion in 1999. Pharm Res & Manufact Assoc (PhRMA) reports 316 new drugs are under development to treatment cancer, 87 to treat cardiovascular diseases, 93 to treat other chronic problems such as arthritis, osteoporosis, DM & asthma, & 17 to treat Alzheimer’s. Advances in genetic research will increase the number of targets for drug intervention exponentially in just a few years. There are 500 known targets for drug intervention & is expected to increase the number of potential targets to at least 3,000 & perhaps as many as 10,000. The single largest market for treatment (prescription) drugs is aging baby boomers. 54 to 64 age group will expand by 59% between 98 & 2010. Drugs used by middle age & elderly are expensive & often treatment conditions (HBP, cholesterol, DMD, arthritis) which require a steady regimen throughout the patient’s life.

Medical Models, Patient Centered Care – Outcomes Assessment Hawkins, PhD. T J of Mind-Body Health 1994; 10(1): 55-56. According to the Biomedical Model, disease is associated with changes at the microscopic level. This approach tends to ignore other significant factors associated with health & illness such as patients’ attitude toward their work, health & disease. Such influences are dismissed or ignored because they don’t fit within the biomedical model. This model doesn’t account for the psychological state of the patient, the healing potential of caring & empathy, or the relationship between the patient & provider. Such factors are not seriously considered & have no part in the biomedical model. This 30

helps explain the dehumanization & depersonalization in orthopedic medicine which places the disease rather than the patient at the center of its focus. Jamison, MD, PhD, EdD. J Chiropractic Humanities 1994; 4(1):26-35. The biomedical model is flawed because it is etiologically limited. It conceptualizes pathogenesis exclusively in terms of molecular biology & ignores the human role & social conditions of disease. The model inherently depersonalizes the doctor-patient relationship because the individual patient’s perspective, experience of illness is dismissed as irrelevant to diagnosis & management. Marketos SG, MD, Skiadas PK, MD. Spine 1999; 24(11):1159-1163. Advances in technology have changed the whole construction & philosophy of medicine. Interest has shifted from clinical evaluation of the patient to the interpretation of sophisticated procedures. This attitude tends to alienate physicians from the patient. Overspecialization has also contributed to broadening the gap between physician and patient. Fragmentation of medicine has created physicians who regard the patient as a disordered mechanism rather than a psychosomatic entity. . .Clinical medicine has been sidestepped by medical technology. There is a feeling that biomedical technology has ignored the psychosociologic aspect, treating the patient more or less as a disease, not as a unique human entity resulting in depersonalization and a lost sense of the patient’s individuality. What we want our patients to know: Chiropractic acknowledges & cares for the whole person. The Patient is the Center of Care: 1. His or her function, 2. Well being, 3. Quality of life, 4. General health and 5. Structural integrity – not a disease or symptoms. Gatterman, MA, DC, EdD. Med. J Alternative Complementary Med 1995; 1(4):371-386. The medical reductionists narrow field of vision delays treatment until the pathological process can be identified. The holistic providers strive to improve function & enhance the body’s own curative effort, its inherent capacity to heal. Wilson, MD, MSc, Cleary, PhD. JAMA 1995; 273(1):59-65. Health Related Quality of Life (HRQL) model or functional status model: focuses on dimensions of functioning & overall well being. Research is to find ways to accurately measure complex behaviors & feelings. HRLQ includes: 1. Physical functioning, 2. .Role functioning, 3. Mental health, 4. General health, 5. Vitality (energy/fatigue) levels, 6. Pain, 7. Cognitive functioning. An introduction to the Health Outcomes Institute’s outcomes management system 1993 15. We don’t know enough about how medical interventions affect patients’ lives &, therefore, are unable to appraise the true value of health services. Information must be obtained from patients to learn about function & quality of life following treatment. Patients judge the effectiveness of care by its impact on their lives. They want to know whether the treatment will relieve pain, improve their ability to see, hear, walk, or function in other ways. Providers have not taken these outcomes seriously enough. To understand the true effects of health care, information must be obtained from patients to learn about function & quality of life following treatment. Hufford, PhD. Alternatives Therapies 1995; 1(1): 53-61. Illness is the experience of being sick – the impact of disease on the patient’s perceived quality of life. Illness is what concerns sick people most. Patients’ problems are not bad laboratory values, anomalous CTs, nor abnormal findings on orthopedic or neurological exams. Their problems are pain, loss of function, & suffering. Illness is profoundly personal, & no one has better access to its central features than the sick person. Consumer changes in medicine are due to the perception that experts often omit 31

from decision making crucial factors available only to the patient. An MD has expertise to predict probable outcomes of treatment & risks, but, only patients can say what effect treatment has on their illness, on their quality of life. When the authority of patients to speak about their illness is ignored, medicine is extended beyond physicians’ expertise. Such authority is not legitimate. Objectivity of data, the freedom from the influence of emotions & personal bias includes observations that are quantitative & can be made by mechanical instruments. This is the basis for the preference of signs over symptoms. It has contributed to a sharp focus on physiological pathology to describe sickness & the effectiveness of treatment. Objectivity can be a very useful value in investigation, but when it excludes the subjective dimension of sickness it becomes pernicious. Lewis, MD, Amini, MD, Lannon, MD. A General Theory of Love. NY: Random House; 2000: 80-2, 220-3. In adults subjected to prolonged separation, their bodies respond to the loss: cardiovascular function, hormone levels, & immune processes are disturbed. Illness or death often follows the end of a marriage or the loss of a spouse. One study found that social isolation tripled the death rate following a heart attack. Another, that group psychotherapy doubled the postsurgical lifespan of women with breast cancer. A third noted that leukemia patients with strong social supports had 2 year survival rates more than twice that of those who lacked them. Dozens of studies demonstrate that solitary people have a vastly increased rate of premature death from all causes – they are 3 to 5 times likelier to die than people with ties to a caring spouse, family or community. However, connectedness is not a drug or an operation, that makes it nearly invisible to Western medicine. The prevailing medical paradigm has no capacity to incorporate the concept that a relationship is a physiological process, as real & as potent as any pill or surgical procedure. In medicine there has been a distancing of doctors from human affairs. The first half of the twentieth century brought antibiotics, vaccines, X-rays, anesthesia. The age ushered in was also one of estrangement from patients. The paradox of Western medicine has been the coexistence of technical excellence with unpopularity. Americans receive the world’s most advanced treatments, yet patients complain fiercely – Drs don’t listen, they are cold & busy technocrats. What Drs once knew, but cast aside for technology is that patients come looking for both expert & healer. Illness arouses the ancient attachment machinery; it awakens a limbic need. When they go to the doctor, patients hope not only for the correct diagnosis, the appropriate remedy, they also want someone who connects with them. They wish for a warm hand on their shoulder and the security of speaking with one who has been through this before. Western medicine dismissed these tools of healing as expendable hand-holding, a luxury that busy schedules could not permit. "Bedside manner” became a cursory interchange thought mildly reassuring but inessential, particularly when compared to the real science of pathophysiology. Medicine lost sight of this truth: attachment is physiology. Good Drs have always known that the relationship heals. Western medicine embraced effective machines and ceded its historic soul. In 1994 in The Lancet, a proposal advocated teaching acting techniques to medical students to provide physicians with the means to feign concern for patients since their incapacity to care is too embarrassingly evident. Here, our Drs endeavor, without irony or shame, to pass off a good relationship as a kind of performance art that be conveniently faked. Their proposal aptly captures the emptiness at the core of Western medicine. Patients sense the limbic void in American medicine & have deserted en masse. Even while traditional medicine has rejected emotional aspects of healing, multiple groups sprang up to accommodate them: chiropractors, acupuncturists, masseuses, & others. Alternative healers proliferate in response to the demand for a context of relatedness. These limbically wiser settings are friendlier to emotional needs – they involve regular contact with someone who participates in close listening, and often, the ancient reassurance of laying on hands.

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Yeomans, S. DC, FACO. Manual: Quantitative Functional Capacity evaluation: 2000. Interest in functional testing & outcomes assessment (OAs) is growing because physicians, Ins companies, medico-legal reviewers & Managed Care Organizations are demanding a way to objectify pt status & document pt progress during the course of care. OAs are emerging as the tools for measuring treatment effectiveness regardless of treatment methods utilized. OAs are concerned with objectifying patient status & showing pt progress over time in order to: 1) Validate patient’s subjective complaint & improvement (pain diagram, VAS); 2) Document functional loss & progress; 3) Document changes in activities of daily living; 4) Documenting psychosocial status; Documenting time off of work (days off work). OAs help establish objective baselines & show progress. Functional tests are concerned with isolating key functional deficits which in turn drive therapeutic planning & clinical decision making. Yeomans, S., D.C. The Clinical Application of Outcomes Assessment. Stamford, CT, Appleton & Lange; 2000. Hurwitz EL, DC, PhD et al. Am Jj Public Health 1998; 88 (5):771-776. The number of DCs & the percent of the population using chiropractic have approximately doubled during the past 15 to 20 years. There has been a 2 fold increase in the use of chiropractic services & this mirrors the increase in number of DCs as well. A random sample of 1,916 patient records from 131 DC offices for completed treatment episodes from 5 US sites & 1 Canadian site for pt consultation between Jan 1, 1985 & Dec 31, 1991 were evaluated. 1310 pt records were low back pain & 606 were patients with other conditions. 68% of those who sought care were for low back pain while 32% were for other reasons including: 40% reported complaints of the face or neck, 19% had symptoms of extremities, 7.5% had headache . Non- musculoskeletal conditions such as migraine headache, otitis media & asthma accounted for fewer than 1% of the diagnosis. Grumbach, MD, Coffman, MPP. JAMA 1998; 280(9):825-826. For most of the 20th Century, MDs have enjoyed a privileged position in US society. This “professional sovereignty” was buttressed by regulations that shielded p physicians from competitors, restricting opportunities for others to practice medicine. Physicians exercised considerable latitude in setting their own fees & in practicing medicine with minimal external oversight. But managed care is ending this golden era by imposing fee schedules, authorizing clinical decisions & restricting practice opportunities. Between 1992 & 1997 there was a 2 to 4 fold increase in the annual number of grads of neck pain, CNM, & PA programs & a doubling or more of grads from chiropractic & acupuncture schools. Many welcome an expanded role for NPCs, arguing that restrictive practice laws functioned more as protectionism for a physician guild than as protection for patients against unqualified providers. Patients will benefit from wider options in health care & competition may drive down prices for services. Institute for Alternative Futures. The Future of chiropractic: Optimizing Health Gains 1998. Funded by a grant from NCMIC & administered by FCER. There is dramatic growth among alternative providers. Acupuncturists will swell from 10,000 to 24,000 by 2010. DCs will nearly double from 55,000 to 103,000 by 2010. Currently 15% of DCs are underemployed. This expansion comes at a time when experts forecast massive surpluses of conventional providers: >100,000 or more MDs, 200,000 or more nurses, 40,000 pharmacists by 2010. Alternative providers could face tremendous increased competition from these provider populations. In this environment all health professionals will face significant challenges. The ability to be financially successful will be more challenging. A critical question: will CAA schools, including chiropractic colleges, “overshoot” & produce surpluses, as medical, nursing & pharmacy schools are thought to be doing now? The profession faces the serious possibility that by 2010, DCs may 33

experience underemployment or unemployment. If the figures are accurate, the chiropractic profession might be well advised to reduce the number of new graduates, & soon. Outcome Measures Anderson, MD. Spine letter 1994; 1(2):1-3, 8. Outcomes research: you attempt to determine if what you are providing the pt is beneficial or not. The focus has shifted to the patient: Is the pt satisfied with the operation? Is the patient'’ functional ability normalized? Thru outcomes research we are determining how helpful a procedure or program has been to the patient. Nelson BW, MD et al. Arch of Phys Med Rehabil 1999; 80(Jan):20-25. Cost of lumbar laminectomy: $30,300; cost of lumbar fusion: $62,300; cost of cervical laminectomy: $20,750; cost of cervical fusion: $43,100. Devo, MD, MPH et al. Spine 1998; 23(18):2003-2013. Measurements of patient outcomes of low back pain has been a vexing problem. In an effort to achieve objectivity, physiologic measures such as ROM & muscle strength were widely used, but such measures are only weakly associated with outcomes more relevant to patients such as symptom relief, daily functioning, & work status. The appropriate dimensions of outcomes for low back pain include: 1) Symptoms, 2) Functional Status, 3) Overall Well-being, 4) Work Disability a. Charting. Today, Must Quantify & Document: 1) Severity of patient’s condition at initial presentation including: a) Disability/Loss of function & activities of daily living; b) Pain intensity & distribution; c) Positive orthopedistedist/neuro & imaging findings; d) Range of motion; 2) Benefit of care to date; 3) Need for additional care. Most Widely recommended Outcomes Measures: Disability scales (Activities of Daily Living Scales): Oswestry, Roland-Morris, Neck Disability Index. Pain Drawing & Quadruple Pain scale (using visual analog vs numerical rating scale). A new disability measure: Functional Rating Index. Feise, DC, Menke, musculoskeletal , DC. Functional Rating index: a new valid and reliable instrument to measure the magnitude of clinical change in spinal conditions. Spine 2001; 26(1):78-87. Health Status questionnaires: SF-36 or Rand 36 or SF-12. Physical Impairment: anatomic or pathologic abnormality leading to loss of normal bodily ability. Disability (aka Functional Impairment): diminished capacity for everyday activities & gainful employment. Waddell, MD. Clin Ortho 1987;;221:271-273. The basic grading of the Oswestry Disability Index and the Neck Disability Index: have the patient follow the directions to check the box in each section that most closely describes them. Each section has 6 boxes. The upper box in each section indicates no disability and is worth “0” points, The next box indicates minimal disability and is worth “1” point The next box indicates mild disability and is worth “2” points The next box indicates moderate disability and is worth “3” points The next box indicates severe disability and is worth “4” points The last box indicates complete disability and is worth “5” points 34

Add up the scores of each of the 10 sections to get the “raw” score. Multiply the “raw” score by 2 to get the percent disability score. The highest possible raw score is 50 and when multiplied by 2 equals 100% functional disability. Take the patient’s percent disability score and apply it to the following grading scales: Oswestry Disability Index: (see Fairbank. Physiotherapy 1981; 66(8):271-3. Hudson-Cook. In Roland, Jenner (eds). Back pain new approaches to rehabilitation & education. Manchester Univ Press, Manchester 1989: 187-204). Scoring: 0-5% none, 6-20% mild, 21-40% moderate, 41-60% severe, 61-80% crippled, 81-100 bed-bound or exaggerating Neck Disability Index (see Vernon, Mior. JMPT 1991;14(7):409-15). Scoring: 0-8% none, 1028% mild, 30-48% moderate, 50-68% severe, >70% complete. For the Roland-Morris Activity Scale have the patient follow the directions. Add up the selections that are checked and subject them to the grading scale below. (Roland, Morris. Spine 1983; 8(2):144-50. A raw score of over 14 of 24 is associated with a poor prognosis: 0-5 minimal, 6-10 moderate, 11-14 severe, 15-19 crippled, 20-24 bed bound or exaggerating Frequency of Use for Outcome Assessment: The patient should complete disability scales, pain drawings, & pain scales at baseline (initial visit), once a week for acute patients & at least once a month for chronic patients. Some researchers suggest every other week for chronic patients. Others also recommend completing the forms at the time of flare-ups & at the time of discharge. Others suggest following up patients at 2 wks, 4 wks, 6 wks or 8 wks to see if the pt is maintaining his/her benefit or is unable to maintain therapeutic gains and may therefore need supportive care including supervised exercise. Roland, MA, MRCS, Fairbank, FRCP. The Roland-Morris Disability Questionnaire and the Oswestry Disability questionnaire. Spine 2000; 25(24):3115-24. The authors recommend use of the Oswestry in BP patients who are likely to have persistent severe disability & the RolandMorris in patients who have relatively little disability. However, for most pt groups, both instruments function satisfactorily in groups with severe disability The Roland is a short & simple method of self-rated physical function in BP patients. The ease of use makes it suitable for following the progress of patients & for combining with other measures of function. The Oswestry is also an effective method of measuring disability in BP patients with a wide range of severity & causes. Both instruments have stood the test of time & have been used in many countries. Both perform as well as most other currently available instruments & better than some. The Roland may be better suited to settings win which patients have mild to moderate disability & the Oswestry to situations in which patients have persistent severe disability. Pietrobon, R., MD, R. R. Coeytaux, MD, et al. Standard scales for measurement of functional outcome for cervical pain or dysfunction: a systematic review. Spine; 2002 27(5): 515-22. The concept of functional measurement differs considerably from the traditional measurement of clinical signs & symptoms. Instead of focusing on signs & symptoms used for diagnostic purposes, functional scales measure the impact of a disease on the performance of activities of daily living. Assessment of the impact a traumatic injury or degenerative condition has on a patient’s life is necessary for p roper follow-up to evaluate pt progress & outcomes. A systematic review to evaluate standard scales for assessing neck pain or dysfunction was done. 5 standard scales were found: The Neck Disability Index (NDI) has been revalidated the most times in different study populations. It has accumulated the most evidence to show that its psychometric characteristics should remain stable in different settings. 35

Okie, S. Pain Measurement comes into focus. Washington Post 2001; Jan 14. The Herald, Bay Area Living – 3. The practice of measuring pain as a vital sign is about to become the norm in American hospitals. Under new rules that went into effect Jan. 1, 2001, by the Joint Commission on accreditation of Health Care Organizations (JCAHO), which accredits @80% of the nation’s hospitals, hospitals & other health care facilities now must regularly monitor & manage pain in all patients or risk losing accreditation. Advocates for people with cancer & dying have long argued that MDs too often ignore or undertreat pain, contributing to unnecessary suffering. The new standards require that pain must be regularly assessed & managed in all patients both with acute & chronic conditions. Standards apply to @5,000 hospitals & 12,000 other medical facilities accredited by JCAHO (nursing homes, HMOs, etc.). Facilities will be required to employ consistent pain rating scales that patients can understand & use. Mantyselka, P., et al. Patients’ vs General Practitioners’ assessments of pain intensity in primary care with non-cancer pain. Brit J Gen Pract; 2001; 51: 995-997. 28 General Practitioners & 730 of their patients in Finland rated perceived pain levels using a 100 mm VAS. 57% of the patients suffered from musculoskeletal pain & 1/5 had chronic pain. Results: There’s poor concordance between MDs & patients’ ratings of pain intensity. Patients rated their pain higher than their MDs in chronic pain cases, although not in nonchronic pain cases. The most severe pain cases showed the greatest differences between pt & MD. There is a considerable nonconcordance between General Practitioners & patients’ assessments of pain intensity. Physician underestimation of pain may be one reason that patients with musculoskeletal pain may be less satisfied with treatment than other patients. Authors recommend the use of VAS or other pain rating scales to improve clinician awareness of pt pain levels. Nelson, DSc. Med Care 1990;28(12):1111-1126. A goal of clinical practice is to preserve the patient’s function & quality of life. The emphasis has expanded from focusing primarily on the biological function of separate organ systems to encompass global, physical & social function. Hawk, DC, PhD et al. JMPT 1997; 20(2):73-79. 18 women with CPP (non-cyclic pelvic pain persisting longer than 3 mo) given 6 wks of flexion/distraction & trigger point by DCs at Palmer. Outcomes: Pain Disability Index (PDI), VAS for pain, RAND-36 Health Survey & Back Depression Inventory (BDI) at baseline & at 6 wks: Results: Mean improvement on PDI was 13 points; on VAS was 4.0 cm, & BDI was 6.1 points – all stat significant. All 8 subscales of the RAND-36 Health Survey increased post-intervention, largest increases in role function limitations because of physical problems (45.8%), emotional problems (44.4%) & pain (40.6%). Conclusion: chiropractic treatment had positive short-term effects. Results will be used to design an randomized controlled trial. Ware JE, Jr., PhD. Spine Letter 1997; 4(12):4-6 (an interview). SF-36 is increasingly used by payers as a scorecard on outcomes. It is a Generic (general) Health Assm’t Questionnaire that has been tested in .100 different medical & psychological conditions. It only takes 5-10 min & evaluates different domains of health – Mental & Social factors – that are important, no matter what the disease condition. There are 2 principle types of outcomes: 1) Disease specific measures (Oswestry, Roland Morris, Neck Disability Index); 2) Generic measures. Disease specific evaluates whether the specific desired effects of treatment are being achieved & allow one to compare the burden of different diseases & the benefits of different treatments to better understand what conditions account for the most morbidity & which treatment s are the most effective in restoring people to nl functioning.

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Petersen D. Colleges begin multi-site clinical trial on pelvic pain in women. Dyn chiro 1999; 17(10):37. Dr. Cheryl Hawk of Palmer Center for chiropractic Res will direct a multi-site study to investigate the use of chiropractic manipulation for pelvic pain. National, Northwestern & Palmer are collecting data to test the hypothesis that chiropractic manipulation reduces CPP in women. The Study “Multi-Site Pilot of chiropractic for Chronic Pelvic Pain” will refine protocols leading to a full scale randomized controlled trial. The preliminary study will last 1 year with each college studying 20 patients & is funded by CCCR (Constorial Center for chiropractic Res) with more funds from nociceptor maximum medical improvement C. CPP affects 15% of women & accounts for @ 15% of hysterectomies & 40% of laparoscopies in the US. CPP is typically unresponsive to medical care. Outpatient care costs @ $2.8 billion (excluding surg & hospitalization) with lost work days contributing another $555.3 million. Jay TC, DC et al. A chiropractic service arrangement for musculoskeletal complaints in industry: a pilot study. Occup. Med. 1998:48(6):389-395. Followed 32 workers with low back 919 patients) & neck complaints (13 patients) attending a chiropractic service. Used 5 outcome measures over a 1 month& 6 month follow-up . 1) pain (VAS), 2) disability (FLP), 3) quality of life (SF-36), 4) perceived benefit & 5) satisfaction with care. 57% of the patients were chronic (>3 mo). The effect sizes were large for pain & for 7 out of 8 dimensions of the SF-36 at 6 month follow-up , although not for disability (FLP). High levels of satisfaction & perceived improvement were reported & sickness costs to the companies fell.. Satisfaction with Care: 6 month suggests less complete satisfaction than 1 mo, but both have very high levels & no one reported dissatisfaction. Treatment: between 15% & 26% of patients had no treatment after 1 month& utilization dropped by @ 2/5 between 1 & 6 mo. Mean number of treatment /mo over 6 months was 3.23 for neck/arm & 5.32 for back/leg. Taylor SJ, musculoskeletal c et al. Responsiveness of common outcome measures for patients with low back pain. Spine 1999; 24(17):1805-1812. Patrick et al found the SF-36 general health scale to be unresponsive & theorized that patients do not regard back pain as an aspect of their general health. Their findings are reproduced in the current study, except for patients classified as significantly worse. This may indicate that patients perceived their low back pain as an aspect of their general health status only when their symptoms or function had deteriorated.

General Health, Function, Prevention, and low back pain Croft P, MD. Et al. Spine 1999;24(15):1556-1561. 2,715 adults free of current low back pain completed a survey on current pain, weight & height, nonoccupational physical activities (cycling, gardening, walking, etc & overall health.) New episodes of low back pain were documented over 12 mo. Results: poor general health was the strongest predictor of new episodes of low back pain ; 34% of men & 37% of women reported new episodes of low back pain . Self-rated low levels of physical activity were not consistently assoc with low back pain , nor were specific nonoccupational physical activity. Poor physical health is a legitimate risk factor for new episodes of low back pain. Johansson SE, Sundquist J Int J Epidemiol 1999;28(6):1073-80. Swedish study of how lifestyle factors evaluated in 1980-1981 & again in 1988-1989 influence self-reported health status in a sample of 3,843 adults, (25-74 years). 85% of subjects in the first interview participated in the 2nd in 1988-1989. Results: Physical inactivity, being a current or former smoker and obesity (women only) were strong risk factors for poor health. Smoking, physically inactive and obese women had about a ten times higher risk of poor health status than non-smoking, physically active, and normal-weight women. The corresponding risk for men was about five times higher. Physically active, but smoking and obese individuals showed only moderately increased risks for 37

poor health status. Those who were physically inactive in 1980-1981, but did exercise in 19881989, improved their health. Continuing to smoke or being physically inactive or having hypertension at both points in time were associated with higher ratios for all-cause mortality (1.6, 1.9 and 1.8, respectively). Conclusions: Physical activity protects against poor health irrespective of an increased BMI and smoking. The major findings are the long-standing benefits of physical activity and not smoking. Brill, et al. Med & Science in Sports & Exercise 2000; 32(2):412-416. Study of the association of muscular strength & endurance with the development of functional limitations in 3,069 M & 589 F (30-82 years) evaluated for strength between 1980 & 1989. Subjects had to be healthy & have no history of MI, stroke, DM, HBP, Ca or arthritis. A strength index (0-6) was calculated using age & sex specifics based on 1) bench press, 2) leg press, & 3) sit-up tests. subjects scoring 5 or 6 were categorized in the high strength group . Functional health status was assessed by a questionnaire about the ability to perform ligament ht, moderate, & strenuous recreational, household, daily living & personal care tasks. Results: at 5 year follow-up , 7% of men & 12% of women reported at least one functional limitation. The odds of reporting functional limitations at follow-up in the high strength group in men was 0.56 & in women was 0.54 relative to those with lower levels of strength. Conclusions: maintenance of strength throughout the lifespan may reduce the prevalence of functional limitation. Hassmen et al. Physical exercise and psychological well-being: a population study in Finland. Prev Med 2000;30(1):17-25. Regular physical exercise is a positive health behavior having physiological benefits. It may have psychological benefits. This study explores the association between physical exercise frequency and measures of psychological well-being in 3403 subjects ( subjects ) (1856 F & 1547 M) in Finland between 25 and 64 years. subjects answered questions on exercise habits & perceived health & fitness, as well as, the Beck Depression Inventory, the State-Trait Anger Scale, the Cynical Distrust Scale, and the Sense of Coherence inventory. Results suggest that subjects who exercised at least 2 to 3X/wk experienced significantly less depression, anger, cynical distrust, and stress than those exercising less frequently or not at all. Regular exercisers also perceived their health and fitness to be better than less frequent exercisers did. Those who exercised at least 2X/wk reported higher levels of a sense of coherence and a stronger feeling of social integration. Results indicate a consistent association between enhanced psychological well-being, measured by a variety of psychological inventories & regular physical exercise. Maruta MD, et al. Optimists vs pessimists: survival rate among medical patients over a 30 year period. Mayo Clin proc 2000; 75:140-143. Study examines how people explain life events as a risk factor for early death, using scores from the Optimism-Pessimism Scale of the MMPI. 839 Patients completed the MMPI between 1962 & 1965. 30 years later, the vital status of these patients was ascertained. Results: Of the 839 patients, (529 F & 310 M) 124 were classified as optimistic, 518 as mixed, & 197 as pessimistic. Follow-up was done for 723 patients 29 years later. A statistically significant increase on the Optimism-Pessimism Scale (more pessimistic) was associated with a 19% increase in the risk of mortality. Conclusion: A pessimistic way of explaining life events, as measured by the Optimism-Pessimism Scale of the MMPI, is significantly associated with mortality. Manga P, PhD, Angus D, PhD. 1998:1-70. Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes and achieving equitable access to health services. 4 out of 5 chiropractic patients have had their problems for more than 6 months & have typically had medical &/or PT before their visit to the DC. The evidence 38

is that chiropractic services should be frontline services for many NMS disorders rather than the default system of care when all else fails, as it seems to be for many patients. Gordon, MD. Am Fam Phys 1996; Nov 15: 2205-2212. Since Eisenberg’s article, the use of alternative medical has most likely increased to more than 40% of the US population. Patients use alternative therapies because they want providers who will take the time to listen & understand them & deal with their personal life as well as their pathology. They believe alternative providers will meet these needs. Not only do family MDs need to understand alternative treatments, they need to develop a reliable network of referrals. It’s important to begin to integrate aspects of alternative medicine into family practice: mind-body intervention, exercise, diet & nutrition complement any MD’s work. Alternative treatments change Dr-pt relationships to a more collaborative one, allowing patients to reap rewards of feeling more in control of their own lives. Peterson. Dyn chiro 1998;16(7):1, 44. Palmer College will headquarter research consortium. NIH co-funds program. The Consortial Center for chiropractic Research is the 11th specialty research center funded by NIH’s OAM – an historical achievement for the chiropractic profession. Tom Harkin (senator from Iowa): “this center will bring recognition to the chiropractic profession at a nat’l level. The Federal Government spends $13 billion on medical research in nat’l. institutions. It is important that the federal government also spends money on chiropractic research & we will continue to try to increase the funding.” This is one of the biggest legislative victories this profession has ever had,” says Palmer’s exec director of institutional advancement. “It not just the funding. It’s the first time the NIH will be spending its money on an ongoing basis to recognize the value & significance of chiropractic.” II. U.S. News & World Report 2000; April 10:82. Harvard Medical School in 199 received $587.2 million in grants from the National Institute of Health (NIH). Rosner AL, PhD. Dyn chiro 1998; 16(23): 19, 22. The current annual budget of the OCAM is $20 million while that of NIH, as a whole, is $11 billion. The fraction of the NIH budget devoted to complementary & alternative medicine is less than two-tenths of one percent. As a former director of the OCAM suggested, “obviously the government must believe in complementary & alternative medicine research because they have provided homeopathic doses of money to work with.” Elder Nancy C, MD, MSPH et al. Arch Fam Med 1997;6 (March/April): 181-184. Use of alternative health care by family practice patients. 1113 family practice patients from 4 practices in Portland, Oregon were asked if they used alternative health care. 50% (57/113) had or were using some form. Chiropractic was used most: 42%, next massage: 32%, herbal meds: 30%, megavitamins 24%, meditation 21%. Homeopathy, naturopathy & acupuncture were each used by 10%. Only 53% had told their MD. There was no difference in the patients who used alternative medicine attributable to gender, education, finances, age, race. Why did patients use alternative care? 30% responded “to prevent illness or injuries,” 44% for “wellness,” 79% for specific health problems including 36% for BP, 18% for headache , 11% for neck pain & musculoskeletal problems. 36% were seeing their MD for the same problem; 50% of PTs didn’t use alternative care because they weren’t interested in 54%. 2 (4%) patients believed alternative medical was unscientific, another 2 or 4% didn’t believe in it. 18% were satisfied with MD care, 7% because it wasn’t covered by Ins & they couldn’t afford it. Blais, PhD et al. Canadian J Public Health 1997;8(3):159-162. Evaluated characteristics of users (n = 169) & non-users (n = 169) of alternative medicine in Quebec. Most frequent use were 39

among the 30 to 44 year age group , more likely to be working, have a higher education & higher income. Users had more good health habits, better overall health & fewer incapacities, but more chronic conditions. Users made fewer visits than non-users to General Practitioners & specialists in the short term (2 wks) & to generalists in the long term (1 year). The diagnosis for which patients consulted alternative medical providers: 56% with musculoskeletal & connective tissue. All other diagnosis groups were no more than 8% of cases. Users made 40% fewer medical visits in the year surveyed. This may represent substantial savings, but doesn’t account for the cost of alternative care. It’s possible that some medical visits were avoided & money was saved by consulting with less expensive alternative providers. Conclusion: Users of alternative medical are relatively socially advantaged, well-off, better educated & younger adults who are in better health than non-users. They generally consume less medical care. Micozzi, MS, MD, PhD. Complementary Care: When is it appropriate? Who will provide it? Annals of Internal Med 1998; 129(1):65-66. In 1994 Agency for Health Care Policy & Research made history concluding that spinal manipulation is the most effective & cost-effective treatment for acute low back pain & that spinal manipulation hastens recovery. At the same time, Agency for Health Care Policy & Research concluded that various traditional methods: bed rest, traction, PT & pharmaceutical therapies were less effective than spinal manipulation & cautioned against lumbar surgery except in the most severe cases. Most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief & functional improv’t. One might conclude that for acute low back pain not caused by Fx, tumor, infection, or cauda equina syndrome, spinal manipulation is the treatment of choice. Adherence to these guidelines could substantially increase the numbers of patients referred for spinal manipulation . DCs provide 94% of spinal manipulation . Agency for Health Care Policy & Research is developing new guidelines for the use of chiropractic manipulation in chronic headache. FCER & the Consortial Center are supporting other studies. Chiropractic is clearly the largest complementary health care force in the US. It is also the most “professionalized” with licensure in all 50 states, educational accreditation standards, continuing ed requirements & active research & investigation. We must foster the development of training, research & clinical protocols to support integration of complementary medicine. When all is said and done, what works will no longer be called mainstream or complementary – it will just be called good medicine. Cherkin, PhD, Mootz, DC. Synopsis, research priorities, & policy issues. In Adams, DC et al. Chiropractic in the United States: Training, Practice and Research. Agency for Health Care Policy & Research, Rockville, Maryland 1997; Chapter XII: 117-130. By 2010, there will be >100,000 practicing DCs in the US. The Agency for Health Care Policy & Research guidelines, appropriateness criteria for the use of spinal manipulation for low back pain, neck pain & headache developed by multidisciplinary expert panels have legitimized the use of spinal manipulation as a relatively safe & effective treatment for BP. The chiropractic profession has begun to resemble the more mainstream health care professions in many respects. The metamorphosis from fringe to mainstream is not quite complete but appears inevitable. The main question is no longer, “Will DCs enter the mainstream of health care?” but “What role will DCs play in the health care system tomorrow?” Aging Baby Boomers, Increased Musculoskeletal Problems, Disability, Future Trends and Increased Need for Chiropractic Care Badley, PhD, Crotty, MD. An international comparison of the estimated effect of the aging of the population on the major cause of disablement, musculoskeletal disorders. J Rheumatol 1995; 22(10):1934-40. The world’s population is aging. This will be one of the most important 40

influences on the health of the population & the need for health care services in the coming decades and will result in a disproportionate increase in the number of people with chronic disabling disorders. This is a global process – a reduction in mortality has resulted in a concomitant increase in disability & chronic conditions. Musculoskeletal (MS) disorders are, by a wide margin, the most frequent cause of physical disability in developed countries. Musculoskeletal disability & its 2 major subgroups, arthritis & back disorders will increase over the years 1985, 2000, 2010 & 2020. Estimates for 1985 US, adults with musculoskeletal disability: 9,777,000. Estimates for 2020 US, adults with musculoskeletal disability: 15,474,000. Percent change in total population: 28.3%. Percent change in number with musculoskeletal disability: 58.3%. For arthritis in US in for 2020 percent change 64.9%. Back Disorders in US for 2020: 4,606,000; percent change 52%. Bolen, PhD. Prevalence of Self-Reported Arthritis or Chronic Joint Symptoms Among Adults – United States, 2001. Morbid Mort Wkly 2002; 51(42):948-950. Arthritis & rheumatic conditions comprise the leading cause of disability among adults in the United States. This is expected to increase as the U.S. population ages. In 2001, questions about arthritis & chronic joint symptoms (CJS) were asked of adults in every state. Findings indicate that the estimated prevalence of arthritis/CJS was 33.0% among adults, representing approximately 69.9 million lives, including 10.6%(22.4 million) of the adult population with physician-diagnosed arthritis. Prevalence increased with age. Women had higher prevalence than men. Other higher prevalence groups were persons who hadn’t completed high school, the physically inactive, and those who were obese. Increased efforts, including early diagnosis and appropriate clinical and self-management are needed to reduce the impact of arthritis and CJS. Leopold, E. World getting older and few nations can cope. United Nations, Mar 28, 2002. Second World Assembly on Aging in Madrid from April 8-12. The figures are startling: Globally, in the next 50 years, the number of people above 60 years of age will nearly quadruple, growing from about 600 million to almost 2 billion people. Today, one in every 10 persons is 60 years or older but by 2050, one out of every 5 people will be an older person. In France, it took 115 years, 1865 to 1980, for the proportion of older persons to double from 7% to 17%. But developing nations are expected to see the older population increase by 200% to 300% over only 35 years. Today the median age for the world is 26 years. By 2050, the average world age is expected to have increased to 36 years. Dr. Robert Butler, founding director of the US National Institute on Aging, calls the aging phenomenon “the most significant population shift in history.” Thiel, S. Newsweek 2002; September 16: 34R-34X. The demographics are clear & irreversible. Two thirds of all senior citizens who’ve ever lived are alive today. The number of people born between 1990 & 1995 was only about half as large as the number born between 1970 & 1975. This year the average Japanese turned 42 years old. In the USA this will happen around 2070. In 2012, 3 in 10 in Japan will be over 60. Yelin EH, PhD et al. Transitions in employment, morbidity, & disability among persons aged 51-61 with musculoskeletal & non- musculoskeletal conditions in the US, 1992-1994. Arthritis & Rheumatism 1999; 42(4):769-79. A national survey of 8739 people found that painful musculoskeletal (MS) conditions in middle age are normal. musculoskeletal conditions affected about 2/3 (62.4% & 70.5%) of persons aged 51-61 & accounted for all but 10% of those with disabilities. These conditions exact a heavy disability toll. More than 40% of persons with musculoskeletal conditions reported disability, which was almost 90% of all persons with disability in this age group. musculoskeletal conditions were defined as self-perceived arthritis, rheumatism, or problems of the back or feet. Questions were designed to detect chronic 41

ailments, not transient (episodic) ones, but persistent ones, that have lasted or are expected to last. Edmond, MPH, PT, Felson, MD, MPH. Prevalence of Back Symptoms in Elders. J Rheum 2000; 27(1):220-225. 1307 seniors (ages 68-100) were asked about Back symptoms . Back symptoms (pain, aching or stiffness) in past year occurred in 48.6% overall (52.7% F; 41.6% M). Back symptoms on most days occurred in 22.3%. low back pain was more prevalent than mid or upper back. (25.6% F; 16.5% M). Age didn’t affect the prevalence of back symptoms in this elderly cohort. Conclusion: Back symptoms are highly prevalent among the elderly, although among elders, they do not increase in prevalence with age. Back symptoms are more common in women than in men. Elliot AM, et al. The epidemiology of chronic pain in the community. Lancet 1999;354 (Oct 9):1248-1252. Study of the prevalence of chronic pain: “pain or discomfort, that persisted continuously or intermittently for longer than 3 mo.” A random sample of 5036 patients, (25 years & over), from 29 general practices in Scotland sent a questionnaire (Q)> Findings: 3605 Qs completed. 50.4% reported chronic pain, equivalent to 46.5% of the general population. Most common complaints: 576 (16%) reported BP; 560 (15.8%) reported arthritis & accounted for a third of all complaints. Next was injury, angina, women’s problems. 48.7% of subjects had the least severe grade of pain & 15.8%, the most severe grade. Chronic pain is a major problem & associated with older age, sex, living in rented council accommodations, employment & being retired or unable to work. March, LM et al. Musculoskeletal disability among elderly people in the community. MJA 1998; 168 (May 4): 439-442. A survey in Sydney of 1527 residents (622 M & 905 F) 65 years & over to determine the prevalence of disability among elderly people. Arthritis & rheumatism were the leading long term conditions in the 3 age groups (65-74, 75-84 & 85 years & over). The back, neck & knees were the most common sites of pain & stiffness. Difficulty with performing activities of daily living increases markedly with age. 23.4% of women & 24.3% of men reported regularly taking NSAIDs. Conclusion: Arthritis & rheumatism were the most prevalent chronic conditions among elderly people in the community, & were significantly associated with difficulty performing activities of daily living. Butler, R. MD. Time 2001; January 29: G4. Older Americans take an average of 4.5 prescription & 2 nonprescription drugs daily. McNeil J, Binette J. Prevalence of Disabilities and Associated Health Conditions Among Adults – United States, 1999. Morbidity and Mortality Weekly Report 2001; 50:120-125. The U.S. Bureau of the Census and CDC analyzed data from the 1996 Survey of Income and Program Participation (SIPP) – a stratified sample of the U.S. population. subjects were interviewed 12 times in 4 years. In late 1999 data was collected during interviews w/ subjects in 36,700 households. The analysis focused on 53,636 adults aged >18 years. In 1999, 44 million (22%) adults reported having a disability – 24% among women & 20% among men. Those with disabilities comprised persons reporting difficulty with activities of daily living, selected functional activities like climbing a flight of stairs, walking 3 city blocks, or lifting/carrying 10 lbs. Or limitation in the ability to work around the house or at a job or business. 93.4% of adults with disabilities reported the main health condition associated with their disability: 17.5% had arthritis & rheumatism, 16.5% had back or spine problems, & 7.8% had heart trouble/hardening of the arteries. Of the total percentage of disabilities, 63% occurred among working adults (aged 8 – 64 years). The age-specific prevalence rate of disability was the highest among respondents aged >65. 42

Institute for Alternative Futures. BABY BOOMERS become dominant & then retire, policies that strengthen individual freedoms & responsibilities will become more prominent. These demographic trends will favor the growth of self-care, prevention & wellness. 77 million baby boomers are now taking political power & are characterized as idealists in their desire to place individuals over institutions. They believe in individuals assuming greater responsibility for their health & financing more of their care. A health care paradigm emphasizing self-care, prevention & wellness will join & to some extent supplant today’s treatment-focused model. The long era of Dr. as unquestioned authority is coming to an end. Dissatisfaction with providers, concerns over MC & innovations in health & information technology are shaping a new breed of health care consumer. Lay people can educate themselves & conduct informed comparison shopping of treatment & providers. By 2010, the movement for better accountability & outcome measures – originally impelled by large health care buyers will have raised consumer awareness & knowledge by another order of magnitude. Consumers in our focus groups shared a high level of dissatisfaction with allopathic medicine, viewing MDs as too expensive, having uncertain outcomes, neglecting patients’ overall health & well-being & having a low touch impersonal approach. Health Maintenance Organizations especially were characterized as too impersonal & their Drs failing to spend enough time with patients. HMOs’ assembly line approach to medicine is one of the chief reasons many Americans are using some form of CAA & have begun looking at alternative providers for their health needs. Executive Summary”: “New” Health Care Consumer. Institute for the future. 1999. People with the sophistication that comes with information technologies are growing from 25% of the population 20 years ago to 45% today. By 2005 they will constitute 52% & will impact on the purchase & delivery of health care services. These consumers want to be involved in the choices related to their health care. They are more active, more engaged, demand superior, personalized customer service. These consumers are hungry for information about health & their health care. They will shift the perception of patients from passive recipients of medical care to active consumers of health services. This includes a cultural shift in the relationship between patients & physicians that “pops the God bubble” that once surrounded MDs. The growth of accessible & inexpensive sources of info about health care will accelerate the move toward consumer-driven health care. Institute for the Future 1998: There will be 35 million Americans 65 & older by the year 2000 and 70 million by the year 2030. Smart, T. Not acting their age. U.S. News & World Report 2001; June 4, 54-60. The first of the 78 million baby boomers (born between 1946 ^ 1964) turn 55 this year. This healthy, wealthy, & wise band of “zoomers” is charging toward retirement. Demographers anticipate the boomer generation will rewrite what it means to be a senior citizen. Boomers make up almost 1/3 of the US population. Beginning in 2000, boomers started turning 50 at a rate of just under 10,000/day. Already, more than 14 million boomers are 50 & up. It is a well educated crowd: nearly 90% graduated high school, & more than ¼ have at least a bachelor’s degree. More than ¾ own their own homes, & 73% have some investments. Special Report: Health for Life. Newsweek 2002; Dec 2: 45-75. Cherkin, Herman, Eisenberg. Beyond the Backache: 56. Spinal manipulation, most often performed by chiropractors, is the most popular alternative therapy for back pain in this country and has been the focus of extensive research. Studies have found that manipulative therapy is modestly helpful for back pain, but not necessarily more helpful than some types of physical therapy. .A typical course of 5 to 10 treatments can cost $200 - $500, but chiropractic care often receives at least partial Ins coverage. 43

Manipulation in the lower back is generally considered a very low risk procedure. Chiropractic care for acute low back pain is the first complementary & alternative medicine treatment listed as “likely safe and effective.” Greenwald J. Elder care: making the right choice. Time 1999; Aug 30: 52-56. The widening flood of Americans into later life guarantees that elder care will be a 21st Century growth industry. The market which was $86 billion in 1996 is expected to reach $490 billion by 2030. That potential is attracting such big developers as the Hyatt Corp & Marriott International hotel operators. Hansen JP, MD, musculoskeletal PH, Futch DB, DC, MPS. HMO Practice 1997; 11(1):39-42. Utilization of chiropractic services was assessed in the membership of Group Health Cooperative of South Central Wisconsin in 1933 & 1994. A sample of 500 members using chiropractic services (38.2% responded) was surveyed about satisfaction. A total of 5.1% & 5.3% of members used the services in 1993 & 94. Highest utilization was among women aged 35 to 45 with rates of 9.5% & 9.9%. Satisfaction levels were high in all areas with a 95.8% indicating overall satisfaction with chiropractic care & services.

Increased Use of Complementary & Alternative Medicine & Chiropractic Care The Landmark Report on Public Perceptions of Alternative Care. Sacramento. CA, Jan 27, 1998. A nationwide phone survey of 1500 interviews in November 1997 found Americans embrace alternative care. (chiropractic, acupuncture, Massage). 42% of adults in the US used some type of alternative care in the past year & many report a likelihood of future usage. 45% of adults say they’d pay more in order to have access to alternative care. 67% believe availability of alternative care is important when choosing a health plan. The survey confirms a persistent, rapidly evolving trend & suggests a growing awareness of these types of therapies as viable health care options. Chiropractic & acupuncture have the greatest name recognition among the general public. The Landmark Report on Public Perceptions of Alternative Care. Sacramento. CA, Jan 27, 1998. The most prevalent types of alternative care used in the past year are herbal therapy (17%) & chiropractic (16%). People say they are most likely to use massage (80%), vitamins (80%), herbal (75%), & chiropractic (73%) in the future. 40% of adults say their attitudes toward alternative care have become more positive in the last 5 years because they have learned more about it or have had a favorable experience with it. 74% using alternative care use it along with traditional health care. LA Times 1998; Sunday, Aug 30: A1, A12, A13. LA Times Poll in California April 4-9, 1998. 32% of the sample of adults in California used chiro in the past year. Hawk, DC, PhD, Long. J Rural Health 1999; 15:233-239. This study evaluates sociodemographic predictors of chiro use in Illinois, Iowa, Minnesota, Missouri, Nebraska, South Dakota & Wisconsin. Data from 1,511 respondents to a 1994 population survey by U of Iowa School of Social Science Institute were analyzed. Overall, 15.1% of respondents had used chiropractic within the last year, most often for low back pain (57%). chiropractic use was less likely in African Americans, Hispanics & Asians than whites, less likely by nonrural than rural residents. 42.7% of workers with low back pain reported using chiropractic & use increased with age. >90% of complaints related to N musculoskeletal S system (back, neck, head, general spinal, extremities), 6% were for health maintenance, 3% non-N musculoskeletal conditions (asthma, allergies, ulcers).

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Astin JA, PhD. Why patients use alternative medicine. JAMA 1998:279(19):1548-1553. Survey of 1035 randomly selected subjects to determine reasons and frequency of using alternative health care. 40% of respondents reported using some form of alternative health care in the past year. The top 4 treatment categories were chiropractic (15.7%), lifestyle diet (8%), exercise/movement (7.2%) & relaxation (6.9%). The top 5 of 26 health problems listed were: 1) back pain (19.7%), 2) allergies (16.6%), 3) sprains/muscle strains 915.7%), 4) digestive problems (14.5%), 5) lung problems (13%). The most frequent noted benefits of the use of alternative health care. “I get relief for my symptoms, the pain or discomfort is less or goes away. I feel better.” “The treatment works better for my particular health problem than standard medicine’s treatment.” “The treatment promotes health rather than just focusing on illness.” Petersen Report to Congress on chiropractic in the military. Dyn chiro 2000; 18(9):1-44. How satisfied are you with improvement in your condition (4 wk survey): chiropractic: Excellent 81.5%, somewhat 13.8%, Poor 4.6%; Traditional: Excellent 55.6%, somewhat 22.9, Poor 21.5; How satisfied are you with the practitioner'’ willingness to spend time with you: chiropractor Excellent 93.7, somewhat 5.0, Poor 1.2; Traditional: 77.5; 16.4; 6.1; How satisfied are you with the explanation of your treatment: chiropractic Excellent 5.1, Somewhat 3.9, Poor 0.9, Traditional 81.1, 13.6, 5.3; What best describes you today: chiropractic not restricted 48.5, somewhat 44.1, very restricted 7.4; Traditional 32.1, 50.0, 17.9; What is your current level of activity: chiropractic Not restricted 73.4, Somewhat 19.2, Very Restricted 7.4; traditional 52.9, 29.4, 17.7; Do your problems limit your performance: chiropractic No 73.2, Somewhat 17.3, Yes 9.5; Traditional 53.5, 25.9, 20.9; I feel better now: chiropractic Strongly agree 78.5, Somewhat 14.6, Strongly disagree 6.9; Traditional 49.2, 22.0, 28.8; I had good results from the treatment: chiropractic Strongly agree 82.9, somewhat 12.6, Strongly disagree 4.6; traditional 50.7, 24.8, 24.6. Petersen. Dyn chiro 2000; 18(24):1, 44, 45. Active Duty Military Personnel Guaranteed Access to Permanent chiropractic Benefit. The Congress passed legislation mandating that chiropractic care be made available to all active duty personnel in the U.S. armed forces. The Fiscal Year 2001 Defense Authorization Act (H. R. 4205) is to become law once signed by President Clinton, (to occur within a matter of days). ACA Chairman, Dr. J. Michael Flynn stated, “For the first time, all active duty military personnel will be guaranteed access to a permanent chiropractic benefit. We have achieved inclusion on a broad scope basis, & have avoided a very narrow, Medicare-like-benefit.” The act requires access to chiropractic services “which includes, at a minimum, care for NMS conditions typical among military personnel on active duty.” 4205 requires full implementation of the benefit be phased in over a five-year period, in all three service branches of the military. When completed, all active duty personnel in the US & overseas are to have access to the chiropractic benefit. The act further requires that DoD to develop by March of 2001, a full “implementation plan” to ensure the benefit is adequately provided. The legislation requires that the DoD consult with the chiropractic representatives serving on the chiropractic Health Care Demonstration Project’s (CHCDP) Oversight Advisory Committee regarding the phase-in plan. The legislation could result in the commissioning of DCs as officers in the military. DoD conducted a “pilot program” to demonstrate the “feasibility and advisability” of integrating chiropractic into military health care which resulted in chiropractic being offered on a test basis at 13 military treatment facilities in the U.S. In March 2000 the DoD released a final report on the pilot program which clearly demonstrated: 1) higher levels of patient satisfaction with chiropractic vs. traditional medical care; 2) superior outcomes for patient receiving chiropractic; 3) fewer hospital stays resulting from chiropractic; & 4) significant improvements in military “readiness” due to chiropractic vs. traditional care because of a large reduction in lost duty time. Despite the positive results of the pilot study, the DoD opposed integration of chiropractic into the DoD health care system citing a 45

high-dollar “cost estimate” for adding chiropractic as a benefit. However, a separate cost analysis developed by the chiropractic members of the CHCDP Oversight Advisory Committee concluded that the integration of chiropractic care into the military would produce a net savings of $25 million/year for the DoD, and Congress was persuaded to mandate the inclusion of the chiropractic benefit over DoD’s objection. PR Newswire. President Bush Signs Historic chiropractic Veterans Legislation Into Law. Jan 24, 2002. President Bush signed legislation (Jan 23, 2002) mandating the establishment of a permanent chiropractic benefit within the Department of Veterans Affairs (DVA) health care system. “This profession has been fighting to make this law a reality for 65 years. It is just tremendous to finally see it happen,” said ACA Chairman James Edwards, DC. The law, (DVA Health Care Programs Enhancement Act of 2001), passed by the Senate on Dec 20, 2001, authorizes the hiring of DCs in the DVA health system, sets a broad scope if chiropractice, & allows the chiropractic profession to oversee the development & implementation of the new benefit through and ”advisory committee,” partially composed of reps of the chiropractic profession. The agreement is similar to legislative language that became law last year requiring the DoD to establish a permanent chiropractic benefit for active duty military personnel. The measure was championed by a strong bi-partisan coalition led by Senate Majority leader Tom Daschle (D-SD), House Veterans Committee Chairman Chris Smith (R-NJ). Key provisions of the new law include: Immediate phase-in of the program. Designation of at least one DVA medical center in each geographic service area to provide chiropractic services. Scope of chiropractic services “shall include a variety of chiropractic care & services for neuromusculoskeletal conditions, including subluxation complex.” Dissemination of educational materials on chiropractic to primary care teams “for the purpose of familiarizing such providers with the benefits of chiropractic care & services.” Establishment of a chiropractic advisory committee to advise the Secretary on protocols governing referral to DCs, direct access to chiropractic, scope of chiropractic, etc. The chiropractic profession’s task is to ensure that the DVA properly & expeditiously moves forward to implement this law. Petersen. Intersurvey 2000. Dyn chiro 2000; 18(16): 1, 48 Internet survey of 1,148 subjects in 2000. 38% of American adults have tried Herbs, 37% have tried chiropractic, 35% have tried Massage. 44% of those who tried chiropractic found it extremely helpful & 48% found it somewhat helpful. Crock RD, MD et al. alternative Ther 1999;5(2):61-66. Questionnaire responses from 107 internists & family practitioners in Stark County, Ohio about alternative therapies. Younger MDs were somewhat more familiar with, saw more benefit from & were more accepting of alternative therapies than older MDs. Primary Care Providers were consistently more positive than specialists who were less tolerant & were less familiar with & saw less benefit from alternative therapies. Eisenberg DM, MD et al. Trends in alternative medicine use in the United States, 1990-1997: JAMA 1998; 280: 1569-1575. Nat’l survey of 2055 subjects measures utilization of alternative care in US between 1990 & 1997. Use of at least 1 of 16 alternative therapies in previous year increased from 33.8% (22 million) in 1990 to 42.1% (39 million) in 1997. Percent of users who actually saw alternative providers increased from 36.3% to 46.3%. Alternative therapies were used most frequently fro chronic conditions (back problems, anxiety, depression & headache). There was a 47.3% increase in total visits to all US primary care physicians by @ 243 million visits. Expenditures for alternative professional services increased 45.2% between ’90 & ’97 estimated at $21.2 billion in ’97, with at least $12.2 billion paid out-of-pocket. Total out-ofpocket expenditures relating to alternative therapies was @ $27 billion, comparable with the 46

1997 out-of-pocket expenditures for all US physician services. In 1997, 5 therapies had a majority of users consulting a practitioner: chiropractic, massage, hypnosis, biofeedback & acupuncture. Unsupervised use is the usual method of use for all other alternative therapies. Increases in use of alternative therapies for medical conditions occurred for back problems, allergies, arthritis, & digestive problems. The highest condition-specific rates of alternative care use in 1997 were: neck (57%) & back (47.6%) problems. In ’90, s19.9% seeing an MD for a medical condition also used alternative therapy. This increased to 31.8% in ’97. For subjects ages 35 to 45 in ’97 it is estimated that 1 of every 2 persons used at least 1 alternative therapy. In ’97, 42% of all alternative therapies used were exclusively attributed to treatment of existing illness, whereas 58% were used, at least in part, to “prevent future illness from occurring or to maintain health & vitality.” In ’97, 11% had seen a DC with a mean number of 9.8 visits for an estimated total in the US of 191,886,000 visits. Haldeman S, DC. MD, PhD et al. Spine 1999; 24(8): 785-794. There are an estimated 250 million office visits to chiropractors in the United States each year. Eisenberg, MD et al. Perceptions about Complementary Therapies Relative to Conventional Therapies among Adults Who Use Both. Ann Intern Med. 2001;135:344-351. National survey of 2055 adults. 1802 (87%) saw an MD in past year. 831 (45%) of these used complementary & alternative medicine in past year, & 411 (23%) saw a complementary & alternative medicine provider in past year. Only 21% of complementary & alternative medicine users agreed with the statement, “Alternative therapies are superior to conventional therapies,” & 79% of respondents agreed that “Using both conventional & alternative therapies is better than using either one alone for your problems.” Only 15% said they saw a complementary & alternative medicine provider first, s18.5% saw both at the same time & 51.2% saw an MD first. Asked about relative helpfulness for 10 of the most commonly reported medical conditions among users of both medical & complementary & alternative medicine for each condition. Relative helpfulness for 10 of the most commonly reported medical conditions among 411 users of both medical & complementary & alternative medicine for each condition. Med Conditions Back conditions Allergies Fatigue Arthritis Headaches Neck Conditions High Blood Pressure Strains or Sprains Lung Conditions Digestive Conditions

Conventional Better % 12.4 22.7 9.4 25.9 19.0 6.4 57.0 7.8 25.9 34.5

CAM & better % 46.1 29.9 41.3 44.8 39.1 61.0 0 22.5 23.5 25.9

Of the 411 who saw both provider types, the percent who perceived “total” or “a lot of” confidence in their complementary & alternative medicine provider was similar to the percent who perceived the same in their MD. (81% & 77% respectively). Among 831 who saw MD & used complementary & alternative medicine, 63% didn’t disclose use. The data contrasts with previous editorials that the high prevalence of complementary & alternative medicine in U.S. largely represents a rejection of orthopedic medicine. We found that complementary & alternative medicine was perceived to be more helpful for chronic, disabling conditions such as headache, neck & back conditions. Adults typically seek services of their MD first. Many adults 47

believe that their MD will not understand their use of complementary & alternative medicine, but 700,000 members who will have the option of having one of AMI’s DCs as their Primary Care Provider. This new model ahs achieved significant savings while maintaining a high level of patient care & satisfaction. Sarnat, MD says they offer an emerging product, a second generation plan integrating complementary & alternative medicine & traditional care. “From Primary Care Provider DCs on up, our plan is a team effort – there’s ongoing dialogue & coordination among all MD specialists, hospitals, home care, etc. Because the project exists within an HMO, a closed loop, every visit & expenditure for lab work & hospital stay can be tracked. The focus is to publish the data of preventive med. What happens when you front-load the system & perhaps increase your expenditures up front by utilizing more true preventions, such as frequent visits to the Primary Care Provider DC? It that happens, what does the data show? We’ve been running for almost 10 mo, & we’ve seen significant savings overall in a health care system. We are probably going to approach 50% savings overall – of hospital utilizations, pharmaceutical costs & diagnostic & laboratory costs. Granted it’s preliminary, & only a small number of members tracked over the course of a year, but it’s still a very significant finding.

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Zechman J. CEO of Alternative Medicine Incorporated, letter dated September 20, 2000: This data is derived from 18 months of consecutive patient care from January 1, 1999 through July 1, 2000. The data is based on 5,000 member months and is compared to normative Chicago IPA performance. AMI has decreased hospital admissions by 80%. AMI has reduced outpatient procedures & surgeries by 85%. AMI has decreased pharmaceutical utilization by 56%. AMI patient satisfaction scores approached 100% while normative scores averaged approximately 60%. Petersen, D. DCs as primary care providers. Interview with James Zechman, Part 1. Dyn chiro 2001; 19(4): 1, 43-46. Upon enrolling in AMI, patients must choose a Primary Care Provider. They can choose one of our DCs. A maximum medical improvement is the only HMO in the US where it is mandatory for the pt to be seen within the 1st 3 months of enrolling. The average number of visits patients make to AMI’s Primary Care Providers is one every 2 to 3 wks. This is a contrast to the allopathic model, where the national average number of visits in an HMO to allopathic Primary Care Provider is one every 16 months. How well can that practitioner know that patient? IF you are visiting your MD only once every 16 months, with minimal or nonexistent prevention & wellness benefits, the cause is a medical crisis. Waiting to see an MD until disease is present adds costly tests, procedures & pharmaceuticals to the health care bill that could have been avoided through a strong integrated preventive care program. Unlimited chiropractic assessment & treatment ; acupuncture, analysis of nutrition, exercise & diet, & nonpharmacological means are readily available without restrictions or referral. Sarnat, Robert, MD. Personal correspondence. 10-26-01. Data is now available on 653 patients using AMI 1999 thru October 1, 2001, representing 12,000 member months. Our clinical outcomes represent a dramatic improvement over HMO normative data. Hospital admissions reduced by 56.8%. Hospital days reduced by 73.2%. Average length of stay reduced by 32%. Outpatient surgical cases reduced by 67.8%. Pharmaceutical usage reduced by 52.8%. AMI’s cost saving on non-pharmaceutical component was 66.7% for 1999; 88.1% for 2001. Patient satisfaction consistently rated above network normative values 100% for 1999; 89% for 2000; 91% for 2001. Coulter, PhD et al. Chiropractic & Care for the Elderly. Top Clin Chiro 1996; 3(2):46-55. A study of 414 elderly adults (average age 80 years), 23 use chiropractic care. AT baseline DC patients were similar to the general sample except they were an average of 2 years younger (79.2 vs 81.3 years). DC users were more likely to do strenuous levels of exercise. DC users were less likely to report their health status as fair or poor (13% vs 32.2%). More DC users rated their health as good to excellent (87% vs 67.8%). DC users were less likely to report having arthritis (43.5% vs 65.7%). At 3 years follow-up, DC users were less likely to have used a nursing home (95.7% had not in the 3 years vs 52.4%). For hospitalizations 73.9% of DC users had not been hospitalized in the 3 years vs 52.4% for the non-DC group. DC patients represent a self-selected group, so no causality can be implied by these results, they can only be interpreted as being associated with, not an outcome of, chiropractic intervention. The independent effect of DC care cannot be assessed with much certainty. Rupert , R, DC. Maintenance care: health promotion services administered to US chiro patients aged 65 and older, Part II. JMPT 2000;23(1):10-19. Health promotion & prevention services by DCs are known as maintenance care (MC). Study investigates chiropractic patients 65 years & over (ave 72.9) who have had long-term (min 5 years; ave 16.49 years) chiropractic MC with a minimum of 4 visits/year. Patients were from 73 DCs in 6 USA locations. Assessments: SF-36D, health habits, health care expenditures, frequency of health provider use & perceived value of Chiropractic MC. Results: DCs used not only spinal manipulation but also recommended 51

stretching exercises (68.2%), aerobic exercise (55.6%), dietary advice (45.3%), & other prevention strategies, including vitamins & relaxation. patients reported making only half the annual number of visits to MDs (4.76 per year ) compared with the national ave of 9 for age 65 & over. chiropractic MC appears to replace medical management. The annual number of chiropractic MC visits was 16.95/ year bringing the total number of physician contacts to 21.7 MD & DC visits/ year, more than double the national ave. Lower depression scores (16.6% in DC patients vs 89%) were found compared to seniors in a previous study. There was a signif correlation between the reduced use of nonprescription drugs & the number of years of MC. Expenditures for 65 & over is estimated to be $10,041 annually. Total annual health care cost assoc with subjects 65 & over receiving MC was $3,106. This is lower than the ave health care costs for US citizens of all ages in 1994, which was $3510. MC patients in this study spent only 31% of the national ave for health services for their age group . The greatest difference was in hospital charges. patients receiving MC ave spending only $1723 for hospital care vs $5121. Reduced costs of nursing care was also found. The reduced need for hospital & nursing home was previously reported by Coulter et al (1996). 95.8% of the chiropractic patients surveyed believe their chiropractic MC was either considerably or extremely valuable. Because of the study’s design limitations, it is not possible to establish a causal relationship between MC care & differences in health expenses. Correlations do not confirm that a cause & effect relationship exists. ACA. Utilization, Costs, and Effects of chiropractic Care on Medicare Program Costs. ACA Today 2001:3. Study commissioned by ACA & completed in June 2001 by Muse & Associates is the first study to compare global, per capita Medicare expenditures of chiropractic patients receiving care in the Medicare program. Data is from Medicare’s Standard Analytical Files for 199 (most recent available cost data). The executive summary states: Results strongly suggest that chiropractic care significantly reduces per beneficiary costs to the Medicare program. Chiropractic services could play a role in reducing costs of Medicare reform &/or a new prescription drug benefit. The study found: 1. Beneficiaries who received chiropractic care had lower ave. 2. Medicare payments for all Medicare services than those who did not: $4,426 vs. $8,103. 3. Averaged fewer Medicare claims than those who did not; had lower ave Medicare payments per claim than those who did not. Results will be used to bolster legislative efforts to expand the availability of chiropractic care in Medicare & expand chiropractic related services that Medicare would reimburse to all services that they are authorized to provide under state law. Chiropractic patients’ Freedom of Choice Act (H. R. 902). Moran M. Am Med News 1998; March 9: 7. More physicians are employees. Employed physicians are growing in numbers in a health care system in which it is increasingly difficult to be your own boss. This is a finding of the AMA’s 1997 Socioeconomic Monitoring System survey released last month. The survey confirms a trend toward choosing salaried positions, esp among MDs 30 to 40 years old. It is a demographic shift of profound importance. The survey findings reflect several long-term trends – the growth of managed care, increasing numbers of MDs who are employees & growth in practice expenses that are continuing to exert a downward pressure on MD income over time. The proportion of MDs who are employed rose to 38.8% in 1997 compared with 38.1% in 1996 & a 3% increase in number of employed MDs in 1995. Proportion of self-employed MDs dropped from 57.7% in 1996 to 56.6% in 1997. Kassirer JP, MD. Doctor discontent. NEJM 1998; 339(21) Nov 19: 1543-1544. Many American MDs are unhappy with the quality of their professional lives. This is due to 1) frustrations in their attempts to deliver ideal care, 2) restrictions on their personal time, 3) financial incentives that strain their professional principles, & 4) loss of control over their clinical decisions are major issues. Physicians’ time is increasingly consumed by paperwork they view as intrusive & 52

valueless, by meetings devoted to expanding clinical reporting requirements, by the need to seek permission to use resources, by complex business activities forced on them by the fragmented health care system. To maintain their incomes, many may not only work longer hours, but fit many more patients into their already crowded schedules. Many Drs are disturbed about the limitations on their capacity to make independent clinical decisions & their inability to refer patients to the appropriate specialists or prescribe the optimal drug. Incentives that reward them for spending less money on patient care create wrenching ethical dilemmas. Incentive arrangements create an intolerable threat to physicians’ integrity if they are strong enough to tempt Drs to shun sick patients. While the cost of care increases insurers are reducing physicians’ fees, sometimes abruptly & without warning. Payment delays, denials of claims, & the expense of complying with ever more complex & demanding regulations contribute to the problem. Some argue that Drs will eventually adapt & with political pressure, MC will serve patients & physicians better. Others believe that we are dealing with a generational transition & that, as older physicians bow out & are replaced by younger physicians who have never known any other mode of practice, the anguish within the profession will slowly abate. The new physicians will grow accustomed to the more restrictive system, the new incentives, the lower standard of living. Many young physicians seem content with a more favorable lifestyle, fewer days on call, more job security & a lower income. Many physicians are dismayed. Some are frankly morose. The complaints seem more widespread & more strident now. One thing we know, disgruntled, cranky Drs are not likely to provide outstanding medical care. Payers, insurers & legislators must recognize this predicament & stop pretending that Dr discontent doesn’t matter. 3 Classes of Physicians. Hansen, DC, Bougie, DC. Top Clin chiro 1998; 5(4): 31-43. Old-timers: began practice in 1985 or earlier & remember the “good old days’ of the 1960’s, 70s & early 80s when you could count on receiving 100 cents on a dollar billed with few exceptions. Drs were the “cultural authority” on health care then. DCs who began practice between 1985 & 1995. Entered a world with the early elements of reform, regulation, cost controls, competition & accountability – the beginning of “mother may I” medicine. It was common for health care bills to be discounted by 15 to 20%, or capitated fee arrangements. The pendulum of cultural authority is swinging away from physicians to those that manage the business side of health care. Clinicians fresh out of school (graduated 1995 to present) enter a world of variation & ever-changing reimbursement strategies – the realm of corporate medicine. Now, providers are lucky to get 55 to 65 cents on a dollar billed for their services, that is if it has been deemed appropriate, & after a period of time for the approval process. New Drs need to get credentialed into the majority of MC plans if there is any chance to be a part of the health economy. The pendulum of cultural authority is very much parked in the business side of health care. Cherkin, PhD, Mootz, DC. chiropractic’s Identity Crises. Synopsis, research priorities, & policy issues. In Adams, DC et al. Chiropractic in the United States: Training, Practice and Research. Agency for Health Care Policy & Research. 1997; Chap XII: 117-130. Some DCs attempt to prevent recurrences of a problem & the development of other illnesses, or to enhance general health. It’s important to research if chiropractic can prevent recurrences of musculoskeletal problems, prevent illness, or enhance health. Most patient seek chiropractic for musculoskeletal problems, primarily low back pain . But chiropractic has positioned itself not only as an alternative source of health care, but as a separate profession with a distinct health care philosophy. This has created an identity crisis within chiropractic. The profession is unclear about whether it is a comprehensive, holistic alternative to medical or a clearly defined musculoskeletal subspecialty. DC practices include characteristics consistent with primary care: they are directly accessed, frequently coordinate care with other providers, obtain special studies, 53

develop continuing relationships with patients & emphasize prevention strategies. But DCs don’t offer a comprehensive array of medical treatment strategies. Limitations of clinical training in multidisciplinary settings, scope of practice, & comprehensiveness of services by DCs need to be overcome before those outside the profession will be comfortable with the idea of DCs as Primary Care Providers. The musculoskeletal specialist view of DCs poses a hazard for chiropractic. Because treatment of musculoskeletal problems is provided by PTs & OTs by referral from MDs, there’s concern that DCs may be viewed as a duplication of existing medical management options. But, given that >90% of billable manipulation is provided by DCs an argument can be made that they provide a unique service. The chiropractic profession needs to clarify its role & strive to ensure that both training & practice are consistent with that vision. The profession needs to establish a credible & supportable clinical identity. Marketing & patient education should focus on prevention, wellness, rapid resolution of disorders, & self-reliance for common health problems. III.

Chiropractic and Wellness Care Eisenberg DM, Davis RB, Ettner SL, et al. MORE AND MORE SEEK ALTERNATIVE HEALTH CARE...In November 1998, the Journal of the American Medical Association (JAMA) published a study that found that more and more people are seeking the services of alternative health care practitioners. In fact, the number of visits to alternative health carepractitioners is now close to 2 times the amount of visits to traditional primary care practitioners. One of the authors of this studyoffered an explanation for this finding in a separate paper, published in Archives of Internal Medicine in November 1998. He states,"Chiropractic finds its voice exactly where biomedicine becomes inarticulate. Too often, biomedicine fails to affirm a patient's chronic pain. Patients think their experience is brushed aside by a physician who treats it as unjustified, unfounded, orannoying, attitudes that heighten a patient's anguish and intensify suffering. ..." Ebrall. DC, PhD (c). Chiro J Aust 1994;24(3):106-112. Medicine has maintained its dominance by promoting the view that only one legitimate health care paradigm exists. But medical treatment is more correctly viewed as disease care, not health care. It is a disease oriented service. Primary medical care’s emphasis is on the treatment of defined illnesses. Coulter, PhD. J Canadian Chiro Assoc 1993; 37(2):997-103. The present health care system is too illness dominated. Wellness is a way of life, an integrated enjoyable approach to living that emphasizes the importance of achieving harmony in all parts of the person, mind, body, & spirit. It is a lifestyle that creates the greatest potential for personal well being. More than an absence of illness, it is a balance among all of the aspects of the person. Phillips, DC, DACBR, PhD. J Chiro Humanities 1994;4(1):20-25. Holism is the balanced integration of the individual in all aspects & levels of being: body, mind, & spirit. It involves recognizing the mental, social, spiritual & physical aspects of the individual & their importance to health. The purpose of care is to restore the whole person & not to treat isolated symptoms or diseases. When the patient is the center of care there is an emphasis on understanding the personal & human aspects of health & illness as opposed to only the biological effects. Coulter, PhD. I Lawrence DJ, DC (ed). Advances in Chiropractic, Vol. 3 Mosby; 1996: 431446. The goal of chiropractic is correction of dysfunction with relief of pain, restoration of function & enhancement of well-being. The role of the DC is health promotion. Chiropractic 54

offers holistic, personalized, conservative care, using low risk procedures. The concern is for the whole person, not the limb or the case. DCs make patients aware of their personal role & responsibility in maintaining their health. Chiropractic is cooperative care – patients participate as partners in enhancing of their health. The holistic, wellness model has contributed very directly to the flourishing of chiropractic. Chiropractic’s ability to promote itself in the health care market & with MCs will in part be determined by its wellness & structure-function-based approach. What is missing is good outcome studies of wellness chiropractic care, but the state of measuring health related quality of life is now such that this should be possible. Coulter, PhD. J Can chiro Assoc 1993;37(2):97-103. In Medicine the focus is on symptoms & specific etiologies. The concept of disease has supplanted that of wellness. Meador CK, MD. The Last Well Person. New Eng J Med 1994; Feb s10:440-441. Clinical medicine can only say, with the methods we used we found none of the diseases we looked for. If the behavior of M.D.s & the public continues unabated, eventually every well person will be labeled sick. Institute for the Future. A forecast of health and health care in American. The future beyond 2005. Funded by The Robert Wood Johnson Foundation Nov 1998. The biomedical definition of health as “the absence of disease” has provided the framework of modern medicine. The curative model which narrowly focuses on the goal of curse, the eradication of the cause of a disease has predominated. However, other goals are important as well: 1) Restoring functional capacity, 2) relieving suffering, 3) Preventing illness, injury & untimely death, & 4) Promoting health. Medicine has defined health I n the narrow meaning of disease according to this curative, biomedical model. Perhaps an obsession with disease has unintentionally relegated health to a position of secondary importance. The health care delivery system is organized & financed based on the assumption that its central task is to use biomedical interventions to provide care for people facing acute episodes of illness. The view of health should be expanded to encompass mental, social, & spiritual well-being. This expanded view moves beyond attention only on disease to incorporate that concept of salutogenesis: the generation & maintenance of health. Led by health-conscious seniors & baby boomers, the medical establishment is confronting a mandate to move beyond the curative model to become engaged in preserving health & preventing illness & disease. Their needs unmet in biomedicine, millions of Americans flock to alternative practitioners in growing numbers.

Athletic Ambassadors for Chiropractic Care Deters, Dc. (Ed). Muscle & Fitness 1995; Nov. Arnold Schwarzenegger: “We are a perfect team. The world of fitness and the world of chiropractic.” Barry Bonds – A True Champion. Palmer, A, DC, CCST. Dyn chiro 2001; 19(22): 1, 46, 50. 73 Homers!!! For the first time a major league player has requested that a DC be available to him in every city on the team’s schedule. Barry Bonds: “I think it should be mandatory to see a chiropractor and massage therapist.” Panter J. Barry Bonds: The Most Valuable Player. Today’s chiropractic 1997; May/June: 60-6. “I go to Dr. Athens on a regular basis. By getting adjusted once a week, I feel I can sustain my career a lot longer. Athens adjusts ¾ of the team. I’m happy we have chiropractic services at the park, I don’t think few would ever go without it.” Panter. Barry Bonds: The Most Valuable Player. Today’s chiropractic 1997; May/June: 60-66. “I go to Dr. Athens on a regular basis. By getting adjusted once a week, I feel I can sustain my 55

career a lot longer. Athens adjusts ¾ of the team. I’m happy we have chiropractic services at the park, I don’t think we would ever go without it.” Navratilova, Martina’s Column: Natural Health. Conde Nast Woman’s Sports 1998; March 1998: 60-61. A chiropractor was instrumental in putting my body back together. Since then I’ve visited the chiropractor many times for a variety of problems & solutions. As Americans become more aware of the need for preventive medicine, alternative therapies will play a bigger role in our lives. After all, people like what works. Cowboys’ Smith still runs ahead of time. Body maintenance key to longevity for backfield star. USA Today 1998; Oct 16: 17C. Smith will head to his DC for several hours of bone realignment. “I started doing this on a regular basis 4 or 5 years ago. I believe what I’m doing is what’s helping me go on. I’ve become a big, big believer in servicing my body & making sure it is lined up properly & functioning the way it’s supposed to on Sundays.” Stechschulte P. Bill Romanowski: The Wall Behind the Line. Today’s Chiropractic 1999; Sept/Oct: 68-73. NFL Pro Bowl 1997 &1999. On the winning team in four super bowls. At age 33 has new 5 year, $32.2 million contract + $4.2 million signing bonus. “I spent a couple of days with Craig Buhler, DC (full time team DC for the Utah Jazz). To me, he is just amazing on what he can do for the body.” Denver Broncos just hired two new team DCs this year – Dr. J.T. Anderson & Dr. Dan Hill. Filson, DC. JACA 2000; 37(5):22, 23. Ralph Filson, DC, a professor at Logan, is the team DC for the St. Louis Rams and Cardinals. He has worked with Mark McGwire since 1997. “Mark is very positive about chiropractic & knows how important it is to him. The big thing is preventive care to keep him in shape.” In August 1999, Dr. Filson’s work with the Cardinals led to his being named team DC for the Rams. His reputation was so strong with the Cardinals that the head Rams orthopedist said he didn’t need Dr. Filson’s CV. “We have all the information we need on you. We just want you.” It was unbelievable, says Dr. Filson. Armstrong, Lance. Advantage 2000;23(3). Dr. Jeff Spencer was a sprint cyclist on the 1972 U.S. Olympic team & has worked closely with Lance Armstrong for the past 2 years. P. Diddy Runs NYC Marathon, Raises $2 Million, Thanks Chiropractic "Mr. Combs decided to run the NYC Marathon only two months before the event," said Dr. DeMann. "He had a number of physical ailments prior to the race and used chiropractic extensively to prepare for the race. This included treatment of his back, neck and knees." "We decided to take an aggressive approach to treating and combating muscle fatigue so that he could continue his rigorous training sessions," noted Dr. Demann. "The combination of chiropractic joint manipulation and vertebral axial decompression therapy has kept Sean on his feet and on course for completing the marathon." Joe Montana signs on as official spokesperson for chiropractic. J CA Chiropractic Assoc 2001; 26(2) 10. Joe Montana, holder of 4 Superbowl rings, 3 Superbowl MVPs & 1990 Player of the Year has agreed to become spokesperson for chiropractic in California. Joe & his entire family continue to use chiropractic to help maintain an optimum healthy & active lifestyle. Joe has always been a supporter of chiropractic. Lennox Lewis. World Heavyweight Boxing Champion & Dr. Denny D. Dunler 56

Evander Holyfield. Chiropractic Products. July 2001:14. Whole Body Healing & Health Maintenance. The Alliance for chiropractic Progress: A Partnership of ACA, ICA, ACC 1998. DCs are extensively trained in the healing sciences & in many areas receive more intensive training than MDs, especially regarding the spine. Because chiropractic education centers on health, not disease, DCs carefully evaluate lifestyle issues including nutrition, exercise & stress. Chiropractic offers a natural, hands on approach. The human body has an innate self-healing ability & seeks balance. The nervous system plays a major role in maintaining that balance. Problems in our spines & other joints interfere with proper functioning of the nervous system & diminishes our body’s health. DCs bring the body into balance so nerve & skeletal systems can function properly. 90% of all people who go to DCs say their care was effective.

Stress, Need for Chiropractic & the Musculoskeletal System Jamison, MB, BCh, PhD, EdD. JMPT 1999;22(6):395-398. Study of the stress perceptions of chiropractic patients. patients were allocated to 1 of 4 group s: 1) acute, 2) chronic biomechanical, 3) fibromyalgia, or 4) maintenance care. patients given a questionnaire to rate their levels of stress with respect to emotional, cognitive, & physical function. Results: Of 138 patients from 1 of 10 chiropractic clinics, >30% regarded themselves as moderately to severely stressed, & over 50% felt that stress had a moderate or greater effect on their current problem. 71% of patients felt it would be helpful if their chiropractic care included strategies to help them cope with stress, & 44% were interested in taking a self-development program to enhance their stress management skills. Conclusion: Many chiropractic patients perceive they are moderately or severely stressed. Interventions that reduce stress, or the patient’s perception of being stressed, may be valid, non-specific clinical interventions. It may be timely for DCs to actively contemplate including stress management routinely in their clinical care protocols. Psychosocial factors are among the best predictors of whether acute pain will become chronic. Marras, PhD et al. the influence of psychosocial stress, gender, and personality on mechanical loading of the lumbar spine. Spine 2000; 25(23):3045-54. The effects of psychosocial stress on muscle activity and spinal loading were evaluated to determine the influence of psychosocial stress, gender, and personality traits on the functioning & loading of the spine. 25 asymptomatic subjects (15 M, 10 F) (no low back pain for at least 1 year ) performed sagittally symmetric lifts of 13.6kg mass under stressful and nonstressful conditions. Trunk muscle activity in 10 muscles & spinal loads in 3 dimensions were measured, as well as anxiety, blood pressure & heart rate to verify level of stress response. A personality & an anxiety inventory were given. Blood pressure confirmed reactions to stress. Psychosocial stress was assoc with muscle activity increases in the erector spinae, internal oblique, & external oblique indicating an increase in coactivation & spinal loading (increased spine compression & lateral shear) in response to stress. Differences in muscle coactivation accounted for these stress reactions. Psychosocially stressful environments solicited more muscular coactivity in people with certain personality traits (introversion & intuition) with increased spine loading, making them more susceptible to spine loading increases and suspected low back disorder risk. Psychosocial stress increases spinal loading thru alterations in muscle coactivity & trunk kinematics resulting in increased compressive loads & lateral shear. Effects of psychosocial stress may be under represented because results are only for short-term responses. The impact of long-term exposure to stress may increase coactivation more & result in more permanent changes in the neuromuscular system. Because people with different personality traits respond to psychosocial stress differently, a physical task may be stressful for one personality type & increase risk of injury but 57

in another. The study shows for the first time, that there is a potential biomechanical pathway associated with psychosocial stress resulting in increases in muscle coactivity & spine loading. Chapman-Smith. Chiropractic Report 1999;13(2): 1, 4, 5. A poll commissioned by Canadian Chiropractic Assoc was done in November 1998 on a sample of 1,515 adults, 1 month after a woman died of a stroke after a chiropractic treatment to assess the impact of the media blitz. Lack of knowledge of the educational qualifications of DCs was a much greater impediment to non-users to see a DC than risk of harm. 15% of respondents have been to a DC in past 6 months, up from 11% in 1994/95 – with a high in the Western provinces of 22%, 16% in Ontario & a low of 3% in Atlantic Canada. 53% were non-users: principal reasons – I believe I have no need (75%) & I don’t see any benefits (16%). 90% agree that chiropractic treatment is good for certain people & 71% that chiropractic treatments are safe. 29% thought chiropractic was not safe: 22% said because treatment can be dangerous. Almost equally strong reasons were “DCs are not qualified” (20%) “I have heard of bad experiences” (18%), “I don’t believe in chiropractic (18%). The survey tested the impact of specific statements made to respondents & showed that the message most likely to improve opinions of DCs was “DCs are highly trained professionals” (37%). This had almost twice the power of any other message including ‘there are minimal risks associated with chiropractic treatment .” (23%). The main message DCs need to give the public relates to their education, qualifications & professional standing. Any communication campaign should have an educational focus “promoting positive info” rather than negative info @ risk rates. The goal should be “to enhance public opinion about the chiropractic profession. . .not necessarily to sell people on starting to use chiropractic.”

Chiropractic and Medical Education Coulter I, PhD et al. A comparative study of chiropractic and medical education. Alternative therapies 1998;4(5):64-75. Average GPA for entrance at Med College 3.56, at chiropractic 2.90. Ave min of 100.94 semester hrs for Med for chiropractic 64.06 hrs. Curriculum of 3 chiropractic & 3 medical schools (CA, TX, IA): chiropractic total 4800 hrs, Med total of 4667 hrs, but with additional 3 years of graduate education to meet requirements for practice. Largest difference is in clinical clerkship: Med 3467 hrs, chiropractic 1405 hrs. But, chiropractic students take 1975 hrs in chiropractic clinical sciences combined with clerkship total 3380. In med, clinical sciences are combined with clinical clerkship totaling 3467. Basic Sciences: DCs taught additional 290 hrs of basic sciences (29% of curriculum) in medical (26%). Same basic sciences courses: Same number of hrs of Microbiology (ave: 120 hrs); chiropractic teaches more hrs in Pathology (205 vs 162); More anatomy & phys in chiropractic: 570 hrs in Anatomy (40%), Phys 205 hrs (21%) in Med: 368 hrs Anatomy (31%) & 142 hrs Phys (12%). Clinical clerkships/internships: 3467 (74%) medical vs 1405 (29%) chiropractic. But 44% to 50% of chiropractic program is dedicated to chiropractic clinical sciences which have no equivalent in med. Combining chiropractic clin sci with clinical clerkships comes to 3380 in chiropractic school. Medical students receive twice the number of hours in clinical experience but 1000 fewer hours in lectures & labs. Clinical experience doesn’t include medical residency after grad, if residency is included clin experience becomes 5227 hrs vs 1405 for chiropractic.

Wellness, Active Care, Restoring Function Institute for Alternative Futures 1998. Health care is moving from its focus on medical care to lifestyle factors. This new focus will increasingly favor prevention & treatment approaches, with certain core components: nutritional, physical, psychological & spiritual. Complementary & alternative medicine more often than conventional health care, includes or reinforces these components of care. Consumers seeking prevention & wellness often go beyond what medical 58

care or coverage provides. This “wellness demand” now accounts for a significant part of some CAAs workloads. For DCs, an estimated 14% to 35% of all current visits are routine maintenance or wellness visits not related to a specific problem. DCs should broaden what they do: combining intelligent information focusing on lifestyle with touch & assertive coaching emphasizing wellness. Chiropractic needs a shared vision of the profession, in the context of creating optimal health gains. The national chiropractic organizations should cooperate to develop a unified vision for the profession that helps it unite around the highest shared values. Chiropractic needs to champion health promotion. We need to document the effectiveness of wellness visits. An important focus should be performance enhancement & proactive wellness services. Barovick H. Burning Off the Years. Time Magazine 2001:G1-3. Health Care Dimensions, which sells and administers a senior-fitness program called Silver sneakers, has taken the lead and signed up 13 major HMOs from Florida to Oregon to fully cover the cost of 500,000 Medicareeligible members who attend fitness clubs that teach Silver Sneakers. “We’ve shown that covering club dues is a relatively inexpensive investment with a huge return: senior fitness is not a fad, it’s the future.” Marcus, M. Shaping up under a watchful eye. Hospital-based gyms offer medical expertise. U. S. News & World Report 2001; June 4: 70. In the 1970s there were only 4 health clubs affiliated with hospitals, but hospital-based fitness facilities have grown to more than 1,000 serving more than a million middle-age or older people. Filling a niche between physical therapy centers & health clubs, they are meant for people with recent illnesses or chronic conditions like diabetes or arthritis. They contain the usual exercise equipment, but all have nurses, exercise physiologists, & MDs to design fitness plans & monitor progress. Common Characteristics Shared by Discs and Articular Cartilage. 1) Occur in weight bearing joints and are subjected to repetitive load bearing. 2) Are viscoelastic/deformable structures: a) Deform under loading; b) Exhibit creep deformation in response to sustained loads. 3) Are avascular. Blood vessels would be disrupted under the loads they would be subjected to if they supplied disc & cartilage. Mooney, Vert, MD. Backstrong.com; 2001. Neither the disc’s nucleus nor annulus have their own blood supply so all the cells living in this tissue must gain nutrition by diffusion to keep alive. These cells make the collagen and proteoglycans that give tissue resilience. Because there are less cells in the disc compared to tissues anywhere else in the body, it is very slow to repair. Even worse, it is very easy for these relatively few cells to be cut off from their supply of nutrition due to local swelling or barriers for diffusion. That is one of the major reasons why recurrent back pain is so common. Discs cannot repair themselves very well. Because the disc does not have its own blood supply, it’s nutrition must be achieved by the disc swelling up with water and having it squeezed out with physical activities – like a sponge that soaks up water which then can be squeezed out. Thus we see that physical activity is really the pump for exchange of fluid in the disc. Important in achieving a healthy back is to provide a mechanism to improve disc hydration. Physical activity which creates a pumping force is the mechanism by which exchange of fluid within the discs occur. This is best achieved by loading and unloading the lumbar spine. Repeated cycling from flexion to extension, and extension to flexion, should achieve the appropriate hydration.

Chiropractic and Athletic Ability 59

Lauro A. Mouch B Chiropractic effects on athletic ability: The Journal of Chiropractic Research and Clinical Investigation. 1991; 6: 84-87 Fifty athletes were tested. They were divided into two groups. One group received chiropractic adjustments, the other served as controls. Eleven tests were used to measure aspects of athletic ability including: agility, balance, kinesthetic perception, power, and reaction time. After 6 weeks, the control group exhibited minor improvement in eight of the 11 tests while the chiropractic group improved significantly in all 11 tests. In a hand reaction test measuring the speed of reaction with the hand in response to a visual stimulus, the control group exhibited less than a 1% response while the chiropractic group exhibited more than an 18% response after 6 weeks. After 12 weeks the chiropractic group exhibited more than 30% improvement. Lauro, DC. Chiro: J Chiro Res & Cain Invest 1991;6(4):84-87. Evaluated the effect of spinal manipulation on athletic ability in a group of 50 completely asymptomatic athletes. Result: In randomized trial, the control group improved overall 4.5% at 6 wks. 8 of 11 test scores improved, 3 declined. Significant improvement occurred in only 2 of 11 tests. In the adjusted group all 11 test scores improved, none declined. At 6 weeks overall improvement was 10.57% or 2.35 times better than control group. 20 of 24 athletes were adjusted an additional 6 weeks and were 16.7% better than at baseline at that point. Chiropractic quantitatively improved agility, balance, speed reaction time, kinesthetic perception, & power. How? I. Identify & correct altered biomechanical patterns of activity which if not corrected leads to: a) decreased mechanical efficiency, b) increased energy expenditure; c) decreased performance, d) altered load distribution, e) increased risk of injury. Normalize proprioception & fine motor tuning. Schwartzbauer J, DC, Schwartzbauer M, DC, Hart J, DC, Zhang J, MD, PhD. J Vert Sublux Res 1997;1(4):33-39. Assessed changes in athletic performance & physiological measures in a randomized controlled trial of 21 male university baseball players free of injury (9 in spinal manipulation group, 12 in control group), during & after upper cervical adjustment. Evaluated 1) vertical jump, 2) broad jump – specified, 3) standing broad jump, & 4) muscle strength, 5) blood pressure, 6) pulse rate, 7) microcirculation (nail bed capillary counts) & 8) treadmill stress test. Subjects tested at baseline, 5 & 14 weeks follow-up. Results: Significant improvement at 14 weeks in muscle strength, long jump distance in adjustment groups. Adjustment group also showed improvement in capoillary counts at 5 & 14 weeks. Trends in performance in other measures were accompanied by either moderate or large effect sizes within both groups. Adjustment group revealed decreases in resting blood pressure & pulse rate following tread mill activity. These same measures showed increases in the control group. Watson. J. Sports Med & Physical Fitness 1995;35(4):289-294. 52 high level soccer/rugby players followed 2 years to assess relationship between injuries & body mechanics by using photographs with prints on a metric grid to detect asymmetries of shoulder, back, trunk & lower limbs. All injuries were recorded & mechanical associations were noted. The most common deviations of mechanics: 1) excess lumbar lordosis, 2) kyphosis, 3) shoulder asymmetry, 4) sway back, 5) scoliosis, 6) abducted scapulae, 7) rib hymp, 8) deviations of foot mechanics, 9) knee interspaces. Injuries sustained: 27 Subjects had muscle strains of lower limb, 24 had 33 back injuries, 14 had knee, 17 had ankle injuries, 12 of 52 Subjects had no injuries within the 24 month, 10 subjects had 1 type of injury, 13 subjects had 2 types of injuries, 7 subjects had 3 types, 10 subjects had all 4 types. The incidence of injury was linked to body mechanics defects associated with the site of injury. Subjects who had more than 2 types of injury had signif lower scores for lordosis, sway back & knee interspace & lower mean scores for the 15 aspects of body mechanics. Study indicates a relationship between deviations of body mechanics & occurrence of sports injuries. Results suggest that intervention programs to improve body mechanics might help reduce the incidence of injuries in footballers who regularly compete at a high level. 60

Hawk C, DC, PhD. Should chiropractic be a “wellness” profession? Top Clin Chiro 2000;7(1):23-26. Chiro has emerged as the most popular & well documented complementary & alternative medicine profession. This allows the health care industry to finally see a niche for chiropractic & enhances the profession’s acceptability. The central tenet of chiropractic – that the body has a natural healing capacity – is the perfect paradigm for the complementary & alternative medicine revolution. Medicine, built on the principle that invasive procedures are needed to counteract what the body is doing, has to stretch to accommodate the concept of selfhealing. Chiropractic, however, was built on the concept of the wisdom of the body. Other chiropractic tenets: the importance of function in relation to structure rather than a focus on a single ‘disease’ entity is well suited to the growing emphasis in health related quality of life, in which how well a person can carry out his daily functions is more important than a diagnosis of disease. The egalitarian partnership of DC & their patients is much more in keeping with the new emphasis on health care ‘partnerships’ between practitioner & patient, as opposed to the dominant patriarchal model of doctor-patient interaction. DCs offer the option of a well-trained, knowledgeable, caring physician who believes in the wisdom of the body & the attitude that the body can heal itself. DCs have the skills to know how to support the body’s functional integrity. In addition to basic beliefs which are congruent with principles of prevention & wellness, chiropractic has emphasized important aspects of prevention & wellness care. Exercise & physical activity are emphasized in chiropractic more than in medical & they are established components of effective disease prevention & health promotion programs. Diet & nutrition are also traditional components of chiropractic care. Avoidance of drugs, toxic substances, & environmental pollutants are frequently recommended as part of chiropractic care. These positions are entirely congruent with prevention & wellness practice & many chiropractic patients consider chiropractic care to be wellness promoting. Challenges to a prevention & wellness position for chiropractic: there are substantive gaps in chiropractic’s expertise that must be addressed if DCs wish to responsibly assume such a position in the future. Chiropractic education hasn’t emphasized public health or epidemiology, the areas from which prevention methods evolved. Chiropractic has focused on a single physical cause of disease rather than the biopsychosocial model. Most DCs don’t routinely perform or refer patients for screening & prophylaxis procedures. Until the profession gets up to speed on current prevention & health promotion practices, it would be wise to speak very cautiously, if at all, about being a wellness profession. Chiropractic clinical training rarely emphasizes the importance of interdisciplinary collaboration. Chiropractic training hasn’t prepared DCs to form alliances with public health departments, the repository of community’s store of prevention & health promotion info & public ed programs. DCs commonly believe that continued chiropractic adjustments prevent disease & promote wellness. Unfortunately, this claim remains to be substantiated by a convincing body of evidence. Maintenance care to date remains unsupported as a factor in wellness. Adequate investigation to test such a hypothesis has not yet been done. Evidence for any disease-preventing or health-promoting effects of chiropractic care is scarce -- & evidence will be an increasingly key factor in the future for acceptance & reimbursement. If the profession decides to make a commitment to wellness, DCs adequately trained in existing prevention & health promotion knowledge & skills – DCs need to develop wellness teams serving patients’ health needs rather than treat their diseases or alleviating symptoms. DCs belief in the body’s inherent capacity assisted by hands on care to correct imbalances of the nervous system & the large body of knowledge of prevention gleaned from the public health arena could make a powerful combination. It remains to the profession to be willing to put them together & put them to use. Chiropractic’s Research Agenda should focus on research that evaluates the effectiveness of regular care (preventive/wellness care) – Does it improve patient function & health related 61

quality of life? Does it reduce recurrences of previous health problems? Does it reduce the development of new health problems? Does it reduce future loss time from work? Does it reduce the use of future medical/hospital services? Back Problems, Imaging, reliability of Clinical Indications for Spinal Manipulation 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 is also 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 & MRI. There is a large percent of symptomatic patients with severe complaints in whom testing fails to reveal any structural lesion. Wiesel, MD. Spine 1984;9(6):49-51. 52 asymp subjects had CT scans. In the 20-39 year age group 19.5% had herniated disc; those 40 & older 50% had abnormal readings: herniations, spinal stenosis, ankylosis, etc. Jensen. Dept. Rehab. Med, U Wa. New England J Med 1994; 331(2) July 14:669-73: Found a high prevalence of abnormalities in lumbar spine in 98 people without back pain. (Average age 42.3 years). Only 36% had a normal disc at all lumbar levels. 52% without symptoms had a bulge at at least one disc, 27% had a protrusion, 1% had an extrusion. 64% of people without back pain had an abnormality, 38% had them at more than 1 level. 67% of the 27 people 50 years or older had multiple abnormalities compared with 27% of the 71 younger people. About half had a bulge & a quarter had at least one protrusion. Given the high prevalence of back pain, the discovery of a bulge or protrusion on MRI in people with low back pain may frequently be coincidental. Abnormalities of lumbars by MRI can be meaningless if considered in isolation. Stadnik et al. Radiology 1998; 206:49-55. MRI study of lumbar disc abnormalities in 36 asymptomatic volunteers (18 with no history of back pain, 18 with previous back pain). Anular tears are common in patients with back pain, but are also common in asymptomatic subjects. Since these findings are so common in pain free subjects, their association with symptoms seems dubious. Disc extrusion, nerve root compression & tears interrupting the annulus – PLL interface weren’t found in any asymptomatic subjects & may be correlated with symptoms. Disc degeneration was extremely common and associated with increasing age. There was no difference in the prevalence of disc degeneration in subjects with & without a history of back pain. Bogduk, N, MD, PhD. ABS Newsletter 1998; Spring: 6-7: Spondylosis occurs naturally with age & does not correlate significantly with pain. You can tell how old a patient is from the radiograph, but you cannot tell even if they have pain, let alone where the pain is coming from! Schultz GD, DC. Bassano JM, DC. Is radiography appropriate for detecting subluxations. Top Clin Chiro 1997;4(1):1-8. Measurement errors of radiographic variables 1) Poor definition of anatomic measuring points, 2) magnification and/or distortion, 3) Variations in location of lines of mensuration intra- & inter-examiner, 4) Changes in patient position/repositioning. These combined factors may produce an error amounting to 50% of measured values. Literature evaluation of upper C-sp show much lower error measurements. Error margins often exceed the actual measured values or the magnitude of change expected with spinal manipulation, rendering the procedure of dubious reliability. Positional changes pre- & post-treatment of less than 3 mm 62

or 4-5 degrees are difficult to attribute to therapy given the positional effect of cumulative error on multiple measurements. It is likely that most of the misalignments proclaimed to be sublux on radiographs are smaller than these error limits, & therefore one cannot rely upon their actual existence radiographically. The magnitude of post-adjustment change is often well within the range of generally accepted error, invalidating conclusions drawn from this study. French, DC, MPH et al. Reliability of chiropractic methods commonly used to detect manipulable lesions in patients with chronic low back pain. JMPT 2000;23:231-8. Study to assess intra- & interexaminer reliability of spinal diagnosis methods commonly used by DCs including 1) visual postural analysis, 2) pain description by the patient, 3) plain static erect lumbar spine x-rays, 4) leg length discrepancy, 5) neurologic tests, 6) motion palpation, 7) static palpation, 8) orthopedic tests & ROM. 4 DCs examined each of the 10 patients on 2 occasions. On the 2nd day, each of the 4 DCs examined 9 other patients on 2 occasions. Commonly used chiropractic diagnostic methods in patients with chronic mechanical low back pain to detect manipulable lesions in thoracic, lumbar spine, & SI joints are not reproducible either by the same examiners on different occasions or by different examiners on the same occasion. On the basis of the results of this study, the use of these exam techniques in combination to detect manipulable lesions should not be seen by practitioners to provide reliable information concerning where to direct a manipulative procedure. Hestoek, DC, Leboeuf-Yde, DC, MPH, PhD. Are chiropractic tests for the lumbo-pelvic spine reliable and valid? A systematic critical literature review. JMPT 2000;23:258-75. A systematic review of the literature (1976-1995) about the intra- & interexaminer reliability & validity of chiropractic tests to determine the need for spinal manipulation of the lumbo-pelvic spine including: Static Palpation; Palpation for pain; Palpation for muscle tension; Palpation for misalignment; Motion palpation; Leg length inequality; Visual inspection; SOT; Applied Kinesiology. Results: Only studies on palpation for pain had consistently acceptable reliability. Studies of motion palpation, leg length inequality & most of the sacro-ocipital technique had mixed findings. Visual inspection had consistently unacceptable agreement. Palpation for muscle tension & palpation for misalignment had only been investigated once each, both with poor agreement. Documentation of applied kinesiology was not available. None of these tests had been sufficiently evaluated & none except palpation for pain had consistently acceptable results. Conclusion: the detection of the manipulative lesion in the lumbopelvic spine depends on valid & reliable tests. Thus far no manual or visual tests have been identified that fulfill minimal criteria of consistent reliability & validity. Until such tests have been established, the presence of the manipulative lesion remains hypothetical. Surely, it is time that an expert panel designs a series of acceptable study protocols for different types of study designs. Procedures found to be useless should be excluded from our clinical repertoire & useful tests should be promoted at undergraduate & graduate levels. Feise, DD. Reliability of chiropractic methods commonly used to detect manipulable lesions in patients with chronic low back pain. JMPT 2001;24:145. Studies concerning chiropractic analysis to identify dysfunctional vertebral lesions that the tests commonly used by DCs to detect manipulable lesions provide little reliability or validity. Of what value is a test with little reliability or validity? If a test is unreliable, test results might change without the patient’s condition really changing. If a test is invalid, it might have questionable sensitivity & be unable to find the condition it purports to find. In light of these findings, there is no doubt that the chiropractic profession must tackle the problems surrounding the detection of “manipulable lesions.” A jury of researchers needs to define this term, design reliable & valid tests, & establish precise standards for using those tests – and the sooner the better. 63

Lehman, G. J. Clinical considerations in the use of surface electromyography. JMPT; 2002 25(5):293-9. The validity & applicability of erector spinae EMG use in clinical practice is questionable. Study in chronic low back pain patients compares paraspinal muscle EMGs for bilateral asymmetry in segments exhibiting pain vs segments not exhibiting pain during quiet stance. Results: During quiet stance no differences were found in bilateral asymmetry between painful and nonpainful motion segments. Conclusion: bilateral asymmetry may not be a definitive indicator of dysfunction. In terms of amplitude asymmetry, problematic spinal segments are no more asymmetrical than pain-free segments in a population with low back pain. It is important to note that smaller segmental muscles are not measured by the electrodes since electrode pick-up depth is 1 cm. Because of this anatomical limit, it may be impossible to detect segmental dysfunction (ie: discriminating L4 for L5) with surface or scanning EMG. This study questions the validity of using a simple static posture (stance) to identify muscle dysfunction. Weisel, MD. Backletter 1996;11(8):89. Problems with Imaging. Unfortunately, specialized imaging is a two-edged sword. It allows the accurate visualization of clinically important pathology, but also highlights vast numbers of clinically irrelevant asymptomatic abnormalities. Devo RA, MD, MPH. Low back pain. Scientific American 1998; August: 48-53. Multiple x-ray studies determined that many spine abnormalities were as common in asymptomatic people as in those with pain. X-rays can be quite misleading. Medical experts hoped that improved diagnosis imaging such as CT & MRI would make possible more precise diagnoses for most back pain patients. This promise has been illusory. On x-ray studies, alarming abnormalities are found in pain-free people. Even the best imaging tests fail to identify simple muscle spasm or injured ligament probably responsible for pain in a substantial % of back pain patients. Schellhas, MD. Spine 1996;21(3):300-312. Study compared MR & Discography findings in asymptomatic & chronic head/neck pain sufferers. 27 of 31 discs that appeared normal on mechanoreceptor had anular tears. Mechanoreceptor does not reliably detect anular defects & cannot be relied on either to identify painful cervical discs or rule out anular lesions. Cervical disc anular tears often escape mechanoreceptor detection. MR cannot reliably identify sources of discogenic pain. Wiesel S, MD. Perils of disc puncture. Backletter 1997;12(8):96 (Presented at ISSLS). New study on puncture of 60 canine lumbar IVDs with an 18 gauge needle to see whether the punctured disc heals & prevents leakage of nuclear material. Re-examined the dogs at 1, 2, 3, & 6 months. Results: Neither the inner nor outer annulus healed in any of the dogs & nuclear material leaked into the puncture tract in each disc. 39% of discs had subligamentous extrusions, 17% had transligamentous extrusions & 7% had a sequestration – total of 63%. Conclude: Disc puncture, including discography should not be viewed as a benign procedure. Jonsson MD. J Spinal Disorders 1991;4(3):251-263. Study of cervical spine of 22 patients who died of fatal skull fractures in motor vehicle accidents. X-rays were evaluated by an expert orthopedic radiologist. Then specimens were cryosectioned & all injuries recorded. Only 1 of 10 gross ligamentous disruptions were even suspected on X-rays. 198 lesions were missed: 77 facet joint & ligamentum flavum injuries, 77 uncovertebral & 22 disc lesions. All spines were injured. Multilevel soft-tissue injuries were common. Very few injuries were detected or even suspected on radiograms. The vast majority were 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 fail to show many fractures; they show virtually no soft-tissue lesions. 64

Common Acute Mechanical Back Pain & Soft Tissue Subfailure Injuries Mooney, MD. J Musculoskeletal Medicine 1995; Oct: 33-39. Common acute back pain is due to chemical abnormalities created by a soft tissue tear. The tear represents a mechanical disruption which is usually microscopic. X-rays demonstrate no changes before & after an acute back injury. Soft tissue tears are associated with edema & swelling. Distention of innervated tissue creates pain. In soft tissue injuries progressive physical activity evacuates extracellular & extravascular fluid. This justifies the recommendation of early mobility for injured tissues. Subfailure Injury. DeLeo, PhD, Winnem, PhD. Physiology of Chronic Spinal Pain Syndromes. Spine 2002; 27(22):2526-37. Spinal tissue (disc, muscle, etc) or nerve root injury sets into play the synthesis and release of numerous inflammatory mediators that not only induce inflammation and edema, but also sensitize nociceptors & recruit new nociceptors to enhance the pain. Mediators include: bradykinin, substance P, histamine, 5-HT (serotonin), glutamate, Acetylcholine, ATP, cholecystokinin, eicosanoids (PGE2, PG12, LKB4). Drezner, MD, Herring, MD. Managing Low Back Pain. Steps to optimize function and hasten return to activity. Phys & Sports Med 2001;29(8). Back strains or sprains imply some degree of muscle stretching or microscopic tearing of the muscle fibers &/or ligaments. Pain results fro mechanical or chemical irritation of nociceptor nerve fibers. Precise identification of the anatomic pain generator is difficult. Local tenderness & muscle spasm, limited ROM, & normal neuro exam are the usual findings. Radiating pain is unusual, & walking & sitting are generally uncomfortable but not unbearable. Panjaabi, PhD. Simulation of whiplash trauma using whole cervical spine specimens. Spine 1998;23(1):17-24. 84% of all neck injuries are classified as low severity soft tissue injuries & result mainly from low velocity impact collisions. Soft tissue whiplash injuries include interspinous ligament tears disc rupture, strains of cervicocapital joint complex, ligament flavum rupture, disruption of facet joints, overstretching of anterior muscles & have been documented during surgery. The majority of whiplash patients do not undergo surgery & their soft tissue injuries remain undetected. Only severe injuries that show complete ruptures are documented. Incomplete or subfailure injuries of ligaments are seldom noted. Soft tissue injuries associated with whiplash often are not visualized on routine radiographs or CT scans. Even at surgery, the view of the surgeon is limited to the operating field & only soft tissues that are completely torn/avulsed are documented. Less severe injuries & those away from the site of surgical exposure are not seen. The soft tissue in low velocity impact such as whiplash is seldom torn completely. Most likely it is stretched beyond its elastic limit, resulting in an incomplete injury. Davis, Charles, DC. Chronic pain/dysfunction in whiplash-associated disorders. JMPT 2001; 24(1):44-51. The soft tissue in whiplash injury is seldom torn completely; instead, it is most likely stretched beyond its elastic limit, the result being an incomplete injury. This subfailure injury can significantly alter the tissue’s mechanical properties. Microscopic collagen fiber failure begins at 3% to 5% strain. Strain greater than 7% to 8% may result in the ligament’s undergoing plastic deformation & cause the load carrying capacity to be lost even when the ligaments appear macroscopically intact. Yoganandan, PhD et al. .whiplash injury determination with conventional spine imaging and cryomicrotomy. Spine 2001;26(22):2443-8. Soft tissue injuries to the cervical spine were produced in 4 intact human cadavers that underwent single whiplash acceleration (3.3g or 4.5g) loading via a whole-body sled to replicate injuries from whiplash. Pre & post-test X-ray, CT & 65

cryomicrotomy were used to visualize injuries. Results: X-rays identified the least lesions (1 in 2 specimens). Ct identified 3 lesions in 2 specimens, but trauma was not readily apparent to all soft tissues of the cervical spine. Cryomicrotomy sections identified 17 structural alterations in 4 specimens to the lower cervical spine including stretch & tear of the ligamentum flavum, annulus disruption, anterior longitudinal ligament rupture, and facet joint compromise with tear of capsular ligaments. Conclusions: results clearly indicate that whiplash acceleration can induce soft tissue & ligament alterations to the C-spine. Pathologic changes assist in the explanation of pain arising from this injury. CT is better than X-ray, but subtle, clinically relevant injuries may be left undiagnosed with either technique. Cryomicrotomy offers a procedure to understand soft tissue-related injuries to the cervical anatomy due to whiplash. Recognition of these injuries advances the knowledge of the whiplash disorder. In whiplash, often the severity of impact is considered to be of low magnitude & doesn’t induce bony damage (Fx & subluxations). Radiographs are routinely assessed as normal. Thus, the injury does not lend itself to objective identification by traditional imaging methods. Cryomicrotomy showed abnormalities in all specimens’ anterior & posterior columns – frequently confined to the lower spine, often at C5-6 & attributed to extension injury. A-P sliding of facet joints associated with pinching, shear & capsular strains may compromise joint integrity. This can be painful because facet joints are rich in nociceptors which can be excited by motions exceeding physiologic limits. The study shows evidence for potential neck pain secondary to abnl motions in these soft tissues. The more occult whiplash associated injuries are less understood than Fx & subluxations. Lack of objective radiographic findings has often led to the dismissal of patients’ symptoms. Recent acknowledgement that whiplash associated injuries do occur has led to the acceptance of patients’ pain. The study clearly shows that structural alterations occur to the head-neck complex as a result of whiplash & that these alterations are not seen on routine X-rays & CT. These findings help define the injuries & potential sources of pain (caused by structural abnormalities) in whiplash. A better understanding of these injuries will allow better treatment. Rosomoff HL, MD et al. Chronic low back pain. J Back & Musculoskeletal Rehab 1997;9:201208. As far back as 1944 a study cited no objective findings in 80% of low back pain patients, meaning no neurological deficit. 99% of low back pain patients don’t have neurologic deficits, but have major subjective complaints for which objectivity must be sought. Many texts depict low back pain as being due to herniated disc. Nothing is further from the truth. Nerve root compression or radiculopathy is not the usual source of pain, but rather it is a chemical reaction. A chemical reaction occurs with herniated discs, degenerative discs, stenosis & arthritic joints. Chemically, the proteoglycans in the disc or joints degrade to a material which acts like a foreign body. The foreign body induces inflammation derived from the arachidonic cascade which sensitizes nociceptors & lowers their threshold. It is not nerve root compression as everyone has been taught. Seaman DC, Cleveland DC. J Manipulative Physiol Ther 1999;22(7):458-72. Bogduk, MD, PhD, states that neuropathic lesions such as nerve root compression causing radicular pain are extraordinarily uncommon in the spine. Nerve root compression is inconsistent with the clinical features of the majority of cervical pain syndromes & accounts for only a very specific proportion of cases. For root compression to be deemed the cause of back pain it must be accompanied by other features: numbness, weakness or paresthesia. In the absence of such features, it is difficult to maintain that root compression is the cause. 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. Haldeman, DC, MD, PhD. Neurologic effects of the adjustment. JMPT 2000;23(2):112-114. Nerve compression model of subluxation – the primary effect of the adjustment is to correct 66

subluxations – an abnl biomechanical relation among vertebrae that can cause compression of spinal nerve roots & interference with normal nerve root function resulting in pain or other symptoms. 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. There is also minimal evidence that the adjustment of a subluxations or manipulation of any spinal lesion can result in reduction of nerve root compression. It is therefore still not possible to consider the relief of nerve compression an established effect of the adjustment. Nygaard OP, MD, Mellgren SI, MD, PhD. Spine 1998;23(3):348-353. Compression alone doesn’t independently cause pain. Some degree of inflammation & irritation of the nerve root must exist to produce symptoms of sciatica. Inflammatory mediators leak from the disc, reach the epidural space & can penetrate the dura & the root sheath affecting nerve roots at adjacent levels on both sides which are not directly compressed. The concentration of these inflammatory mediators is highest in the area of disc herniation & the compressed root with nerve roots at adjacent levels & on the asymptomatic side being less affected. Coppes MH, MD et al. Spine 1997;22(20):2342-2350. Innervation of painful lumbar disc. It is unlikely that discogenic pain is merely generated by mechanical irritation of sensory nociceptor terminals. Chemical stimuli in degen discs have been reported to play a substantial role. A wide variety of substances with the ability to excite or increase the excitability of primary sensory neurons have been reported in the interstitial fluid of the disc. These include PG E, histaminelike substances, potassium ions, lactic acid, & several polypeptide amines. The dorsal root ganglion (DRG) serves as a warehouse for all kinds of peptides & is very likely to have a painmodulating function around each motion segment. Igarashi, MD et al. Exogenous tumor necrosis factor-alpha mimics nucleus pulposus-induced neuropathology. Spine 2000;25(23):2875-80. Nucleus pulposus (NP) applied to spinal nerve roots produces a breakdown in nerve structure, function, & pain. Herniated NP tissue is rich in tumor necrosis factor a (TNF-a) which appears to trigger destructive reactions associated with disc herniations. TNF-a applied directly to nerve roots & DRG in rats vs saline was assessed at 3, 5, 7, 10, 14 days. TNF-a produced profound neuropathological changes & behavioral deficits which exactly mimicked the neuropathology associated with neck pain applied to N roots. Within 24 hours there was signif endoneural edema, myelin splitting, macrophage & Schwann cell activation, & some axonal degeneration. The pathology progressed over time – myelin splitting progressed to frank demyelination with Wallerian degen & upregulation of fibroblasts which causes an increase in TNF-a, so the body’s response to injury, appears to set off a cycle of further injury & nerve degeneration. Davis, DC. JNMS 1996;4(3):102-115. Imaging studies are useful in ruling out herniation or foraminal encroachment, but generally do not demonstrate the source of pain which usually resides in soft tissues. Plain-film radiograms fail to show many fractures & show little of soft tissue lesions, therefore, they are usually not helpful in determining the origin of pain.

Types of Diagnoses of Back Pain Devo MD, MPH, Phillips, MD, MPH. Spine 196;21(24):2826-2832. Types of back pain seen by primary care MDs: Non-specific back pain: 76%; Herniated Disc: 3%; Spinal Stenosis: 2%; Degenerated Disc: 10% (another form of non-specific back pain); Other Pathologies: 9%. 86% of back pain is from soft tissues innervated by multiple segmental levels. 67

McCulloch, MD. Spine 1996;21(24S):45S-56S. Lumbar disc herniations (LDH) are common: about 1% of general population per year. More than 90% of LDH improve with conservative care. Approximately 2-4% of patients with LDH have indications for surgical intervention. Surgery results in less pain for 4-5 weeks than conservative care. Whether a patient chooses surgery is unlikely to effect long-term outcome of sciatica. The decision to operate usually depends on the patient’s preference rather than necessity. Persson, RPT, MSc, Carlsson, MD, PhD, Carlsson, PhD. Spine 1997;22(7):751-758. Treatments for Cervical Radicular Pain. Randomized controlled trial of cervical collar, physical therapy, or surgical treatment in 81 patients with long-lasting (.3 months) cervical radicular pain (nerve root compressed by spondylitic encroachment with or without a bulging disc confirmed by MR or CT). There are no controlled trials comparing surgical with nonsurgical treatment in patients with cervical radicular pain. Outcomes: pain (VAS), function (SIP) & mood (Mood Adjective Check List) at 14-16 weeks, and after a further 12 month (15-16 months from start of treatment). Results: at baseline the groups were similar. At 14-16 weeks, surgery group reported less pain (VAS) & like the physical therapy group better function (SIP) than the C-collar group. At 12 months, patients treated with surgery, physical therapy, or C-collar were no different in terms of pain, function & mood. Results don’t differ from the natural course of this cervical disorder. It appears such simple treatment as a collar or possibly even no treatment is as effective in the long run as physical therapy or surgery. The effect of physical therapy in treatment patients with cervical radicular pain has not been scientifically evaluated. Some authors believe surgery should be considered in patients with persistent pain for 3 months in spite of nonsurgical treatment. The current study cannot support that indication for surgery. Saal JA, MD. Spine 1997;22(14):1545-1552. In the 1980s, with the growth of advanced imaging, new surgical techniques & a surge of subspecialty trained spine surgeons, spine care began to flourish & surgery rates went through the roof, increasing by over 110%. Many patients who failed surgery were labeled as having psychological problems & told their surgery was a success, but the reason they didn’t get better was due to their psyche. During this period, structural intervention was considered the only worthwhile intervention. Patients were often left on their own after surgery, being told that all that could be done had been done & they would have to learn to live with their condition. Exercise & physical rehabilitation were felt to be useless by most surgeons. Structure not function was the paradigm of the era. Data began to accumulate that nonsurgical treatment such as rehab & exercise could improve patient function even without addressing the structural abnormality. Some centers developed multidisciplinary teams to deal with chronic back pain, but, too often, the team recommended more surgery to correct the last surgery. The structural fix-it paradigm still prevailed. If disc excision didn’t work, the patient could have a fusion, if the fusion didn’t work, the patient could have a fusionrevision surg with hardware & interbody grafts. If this failed, the hardware could be removed. Some surgeons even began to specialize in explants – the removal of the hardware that someone else had put in. The merry-go-round seemed endless, a self-perpetuating industry. All the players seemed happy, except the patients, & business was good. But the public began to become m ore wary of back surgery & patient satisfaction with most specialists dealing with back pain plummeted. Bigos, MD; Davis, BS. JOSPT 1996;24(4)Oct: 192-207. The Agency for Health Care Policy & Research defined low back pain 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. Rest, medications & surgery don’t build or maintain activity tolerance. They may support activities or exercises needed to build a comfortable activity tolerance, but they cannot replace the conditioning process. Don’t let patients confuse 68

recommendations to be more comfortable (pain relief) with conditioning, which is the real treatment for an activity limitation. Saal, MD. Spine 1995;20(16):1821-1827. our approach to management of lumbar disorders relates etiology of pain to discrete structural abnormalities of the spine. However, structural changes do not necessarily predict levels of pain or disability. Experience indicates that removal or correction of structural abnormalities may fail to cure and may even worsen painful conditions. Waddell, MD, et al. Clinical guidelines for the Management of Acute Low Back Pain. Royal College of General Practitioners 1996:26. Red Flags for Possible Serious Spinal Pathology. Age of onset 55 years; Violent trauma; Constant progressive, non-mechanical pain; Thoracic pain; Past medical History of Carcinoma; systemic Steroids; drug abuse; HIV; Systemically unwell; Weight Loss; Persisting severe restriction of lumbar flexion; Widespread neurology; Structural Deformity. Simple Backache – Mechanical Origin: Presentation between ages 20 – 55: Lumbosacral region, buttocks & thighs; Pain of mechanical nature; varies with physical activity; Varies with time; Patient well; Prognosis good: 90% recover from acute attacks in 6 weeks. Nerve Root Pain: 1. Unilateral leg pain worse than lower back pain; Pain generally radiates to foot or toes; 2. Numbness & paresthesia in the same distribution; 3. Nerve irritation signs: Reduced straight leg raise which reproduces leg pain; 4. Motor, sensory or reflex change limited to one nerve root; 5. Prognosis reasonable: 50% recover from acute attack within 6 weeks. Risk Factors for Chronicity: Previous history of low back pain; Total work loss due to low back pain in 12 months; Radiating leg pain; Reduced straight leg raise; Signs of Nerve Root involvement; reduced trunk muscle strength & endurance; Poor Physical Fitness; Self-rated poor health; Heavy Smoking; Psychological distress & depressive symptoms; Disproportionate illness behavior; Low job satisfaction; Personal problems – alcohol, marital, financial; Adversarial medicolegal proceedings. Cauda Equina Syndrome: Difficulty with micturition, Loss of anal sphincter tone or fecal incontinence, Saddle anesthesia about the anus, perineum or genitals, Widespread or progressive motor weakness in legs or gait disturbance, Sensory level. Manipulation. Waddell, MD et al. .Clinical guidelines for the Management of Acute Low Back Pain. RCGP 1996:15. There are 36 randomized controlled trials of spinal manipulation for low back pain. 19 report positive results & 5 more, positive results in subgroups. There is very little evidence available on spinal manipulation in patients with nerve root pain. Within the first 6 weeks of acute or recurrent low back pain, spinal manipulation provides better short-term improvement in pain, activity levels & higher patient satisfaction than other treatments with which it has been compared. There is no firm evidence that it’s possible to select which patients will respond or what kind of spinal manipulation is most effective. The evidence is inconclusive as to whether spinal manipulation for low back pain of >6 weeks duration provides clinically signif improvement in outcomes compared with other treatments. There is conflicting evidence from randomized controlled trials & lit reviews on the effectiveness of spinal manipulation in chronic low back pain. Risks of spinal manipulation for low back pain are very low if carried out by a trained practitioner. Spinal manipulation should not be used in patients with severe or progressive neuro deficits in view of rare but serious risk of neuro complication. Recommendation: Consider spinal manipulation within the first 6 weeks for patients who need additional help with pain relief or who are failing to return to nl activities: within the first 6 weeks of onset, spinal manipulation can provide short-term improvement in pain & activity levels & higher patient satisfaction. Evidence is inconclusive that spinal manipulation produces 69

clinically significant improvement in chronic low back pain. Risks of spinal manipulation are very low in skilled hands. Back Exercises: Waddell, MD et al. Clinical guidelines for the Management of Acute Low Back Pain. RCGP 1996:15. There are now 28 randomized controlled trials of specific back exercises for low back pain but many are of poor quality. Based on the evidence it is doubtful that specific back exercises produce clinically signif improvement in acute low back pain or that it is possible to select which patients will respond to which exercises. McKenzie exercises may produce some short-term symptom improvement in acute low back pain. There is some evidence that exercise programs & reconditioning can improve pain & functional levels in patients with chronic low back pain. There are strong theoretical arguments for exercises & reconditioning by 6 weeks rather than later. Waddell G. MD. The Back Pain Revolution. Churchill Livingstone 1998:35. One of the main characteristics of back pain is that it often runs a fluctuating or recurring course. An isolated acute attack with no previous history & complete recovery is rare. Each attack or episode of health care may be against a background of recurrent attacks or persisting minor symptoms. The most important feature of chronic pain is not its duration but its impact on the patient’s life. The Recurrent Nature of Back Pain Frank, MD. Brit Med J 1993; April 3:901-9. Reviews a study in which 373 Patients under 40 years old, with their first onset of back pain are followed for 10 years. 89% had recurrences & only 33% had no lost time from work from future back problems. Strategies to manage low back pain must be long term & preventive. Waddell, MD. JMPT 1995;18(9):590-596. Traditional teaching is that 90% of low back pain attacks recover within 6 weeks, but recent natural history studies suggest that this is overly optimistic & overemphasizes return to work. 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% of patients with low back pain will continue to have some back symptoms over long periods of their lives. LB disability affects @ 3-6% of the population each year. Back symptoms are the most common cause of disability for people under the age of 45. Benefits for low back pain in Britain are rising more quickly than for any other cause of chronic incapacity. McGorry RW, MSBE, PT et al. The relation between pain intensity, disability, and the episodic nature of chronic and recurrent low back pain. Spine 2000;25(7):834-841. Two thirds of the people who have had back pain in the past can be expected to have some symptoms every year. Wiesel, MD. Backletter 2002;17(1):1, 8-10. The universe of back pain sufferers in the US exceeds 100 million people every year. Jayson, MD, FRCP. Spine 1997;22(10):1053-1056. Does back pain recover spontaneously? There have been many studies of the natural history of back pain demonstrating the high natural remission rate of acute episodes, with approximately 90% resolving within 6 weeks. Whether this reflects what happens in practice is in some doubt. In our own studies of whole populations in primary care, we found the prognosis was not nearly as good. At 3 months, only approximately 27% were completely better, 28% improved, 30% had no change, & 14% were worse or much worse. It may be well that in the many studies of acute back pain, there has been very carefully selected patients, so that only those patients with acute pain of recent onset & no 70

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 MC system for the primary care of low back pain is based upon the assumption that 90% of patients improve in 6 to 12 weeks. However, a natural history study by Von Korff found that approximately 60% will recur. In a study of back pain in primary care, Von Korff & Saunders found that 60% to 75% improve within the first month, 33% report intermittent or persistent pain at one year, & 20% of patients describe substantial limitations at 1 year. The premise for the Agency for Health Care Policy & research guidelines & MC for back pain is not valid. Von Korff, PhD. Spine 1993;18(7):855-62. 83% of 1200 consecutive back patients had onset of symptoms >6 months, only 17% had onset of symptoms within past 6 months. After conservative medical treatment at an Health Maintenance Organization at 1 year follow-up only 21% of those whose pain began within past 6 months & only 12% of those with pain which began before that time were pain free. Von Korff, PhD. Ann Intern Med 1994;121:187-195. More patients than expected had a chronic phase of back pain during the 2 year follow-up. 44% were in a chronic phase (90 or more days of back pain in 6 months) at either 1 or 2 year follow-up. Patients with back pain receiving primary care typically have recurrent back pain & evidence is increasing that patients are more likely to have chronic phases of back pain than was previously believed. Available evidence doesn’t support the effectiveness of med treatments for long-term control of chronic & recurrent pain for most patients with back pain. Unfortunately, health care providers receive less training & have fewer incentives to provide info & teach self-care skills than to order diagnostic studies, medically prescribed palliative care & surgery of unknown efficacy & high cost. Important goals are to teach patients self-care that minimizes recurrence & reduce the need for future medical interventions. The success & failure of treatment should be rated according to their capacity to affect recurrences. Von Korff, PhD. Spine 1994;19(18S):2041S-2046S. It is widely believed that back pain (BP) typically runs an acute course. This is the basis for emphasizing reassurance & short-term palliative treatment (prescriptions) (pain meds & bed rest). The belief is that pain typically resolves with healing of muscle strain or other soft-tissue injury. The course of back pain is highly variable, occurring in transient, recurrent & chronic phases. Recent longitudinal studies suggest that back pain is typically a recurrent condition & that chronic phases occur more often than previously believed. For back pain, which often runs an episodic course, studies that assess only short-term resolution of an initial episode provide inadequate information regarding clinical course. Longterm pain outcomes are better assessed by variables such as: 1. the level of functional impairment, 2. the average level of back pain intensity, 3. the number of days of back pain during a defined time interval. Reporting only short-term outcomes of back pain, which are often favorable, for a condition that often runs a recurrent course may be misleading. Long-term outcomes appear less favorable because recurrences are common. Back pain is typically recurrent and more often chronic than usually believed. Mooney, MD. J Musculoskeletal Med 1995; Oct: 33-39. Most soft tissue injuries heal spontaneously within 6 weeks if there is not total disruption & instability. Failure to heal within 6 weeks is probably due to poor blood supply, insufficient stimulus to repair or uncontrolled 71

mechanical stresses exceeding the tolerance of the healing tissues. Tissues which fail to heal over 6 to 8 weeks probably will not heal itself & should be considered a chronic injury. Kannus, MD, PhD. Phys & Sportsmed 2000;28(3):55-63. Approximately 6 to 8 weeks postinjury, the new collagen fibers can withstand near normal stress, although final maturation of tendon & ligamentous tissue may take as long as 6 to 12 months. Lawrence, MPH et al (NIH National Institute of Arthritis & Musculoskeletal & Skins Diseases). Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis & Rheumatism 1998; 41(5):778-99. Back pain is pervasively common, about half of adults have back pain in any given year. The usual course is rapid improvement, but 510% develop persistent back symptoms. Back pain tends to relapse – most patients will experience multiple episodes. The usual natural history is one of recurrence. About 15% report low back pain lasting longer than 2 weeks in the past year. Persistent pain, (>3-5 months) occurred in 5-10% of patients with back pain. Only 1.6% report back pain with sciatica of >2 weeks at some time in their lives & 1% report being told they had a slipped or ruptured disc in any given year. Lifetime prevalence of being told a patient had a ruptured disc was 2.21%. Among working ages (20-64 years) >26 million in the United States have frequent low back pain. Ages 65 & older almost 6 million have frequent low back pain. Skargren E, RPT, PhD et al. 1-year follow-up comparing cost & effectiveness of chiropractic and physical therapy in management for back pain. Spine 1998; 23(17):1875-1884. A randomized trial of 2323 patients with back pain & neck pain visiting a General Practitioner were allocated to chiropractic or physical therapy to compare outcomes & costs in Sweden. Follow-up was done at 12 months. Outcome measures were changes in 1) Oswestry scores, 2) Pain intensity, & 3) General health, 4) Recurrence rates & 5) Direct & indirect costs. Results: No differences were detected in health improvement, costs, or recurrence rate between the 2 groups. According to Oswestry score, chiropractic was more favorable for patients with a current pain episode of less than 2 weeks & physical therapy for patients with a current episode of >1 month. Nearly 60% of patients in both chiropractic & physical therapy reported 2 or more recurrences within 1 year. Mean number of treatments sessions was 4.9 for DCs & 6.4 for patients. Conclusions: Effectiveness & costs of chiropractic or physical therapy as primary treatment were similar for the total population, but there were some differences in subgroups. Back problems often recurred & additional health care was common. Implications: Treatment policy & clinical decisions must consider that back pain & neck pain are often recurrent. Recurrences: nearly 60% of both groups reported 2 or more recurrences & another 12% in the chiropractic group & 15% in the physical therapy group reported continual pain. These rates are in line with those in previous studies: Despite reported improvements, a high proportion of patients still experience pain after 1 year. The studies suggest that back pain is typically a recurrent condition. The results suggest that the prognosis of back pain over time may be somewhat less favorable than in other reports. Croft PR, MD et al. BMJ 1998;36:1356-1359. Outcome of low back pain in general practice. 463 patients saw a general practitioner (GPs) for low back pain in a 12 month period. Patients hadn’t seen their general practitioner for low back pain in past 3 months & had a new episode of low back pain. 59% of patients agreed to be followed by nurses & interviewed within 1 week of their first visit, at 3 & 12 months to determine the outcome of the low back pain episode based on pain & disability scales. 59% of 463 patients saw their general practitioner only once in the 6 months after 1st visit. 32% of patients did consult again, but only within the first 3 months & only 8% of patients had visits for >3 months. By 3 months only a minority of low back pain patients recover & there was little increase in the percent who recovered by 12 months, emphasizing the 72

recurrent & persistent nature of low back pain. Findings are in sharp contrast to the assumption that 90% of low back pain in primary care resolves within 1 month. Many patients seeing general practitioners for the 1st visit for an episode of back pain had symptoms for 1 month or more. Although symptoms improve, most still have pain or disability 12 months later but, are no longer seeing their MD. Only 25% have fully recovered 12 months later. We should stop characterizing low back pain as multiple acute problems, & a small number of chronic, long term problems. Low back pain is a chronic problem with an untidy pattern of symptoms & periods of relative freedom from pain & disability interspersed with acute episodes, exacerbations & recurrences. A previous episode of low back pain is the strongest risk factor for a new episode. By age of 30 almost half the population have had 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. Miedema, MD et al. Chronicity of back problems during working life. Spine 1998; 23(18):20212029. Follow-up after 7 years in 444 patients who consulted their general practitioners for a new episode of back pain in 1987. Results: Chronic back problems developed in 28% of patients. These patients reported more pain, higher levels of medical resource consumption, worse health outcomes, & lower labor force participation. Van Tulder concluded that once low back pain has persisted longer than 3 months, recovery is unlikely. Factors associated with chronicity: 1) Previous episodes of back pain (before 1987-88), 2) Severe pain in 1991 & 3) Disability score in 1991. Conclusions: Even after a follow-up of 7 years, the proportion of patients with chronic back problems was high. Reis S, MD et al. A new look at low back complaints in primary care. J Family Practice 1999, 48(4):299-303. A study of the natural history of a new episode of low back pain (no low back pain in past month & no functional limitation for 2 months). Care was based on customary patterns of diagnosis, treatment, & referral in consecutive patients presenting at primary care family practice clinics in Israel. 219 (92%) Subjects completed the study. Results: Most MDs recommended meds (80%) & bed rest (64%). 20% referred for physical therapy, 14% to other paramed or altern providers (DCs, massage), surgical referral in 0.8%. During the 2 months after the initial visit, low back pain severity lessened for the vast majority of patients, as they shifted from more severe pain to milder pain. Functional limitation also improved. However, only a minority of subjects reported total recovery. At 2 months follow-up, complete pain relief was noted for 37% (77) of patients & only 25% (55) reported no functional limitation. Conclusions: Patients displayed a relatively benign natural history of low back pain. Pain is likely to improve but not disappear, functional status is likely to improve, but significant limitation may persist in a significant minority. Return to work is almost certain, in spite of the persistence of signif pain & functional limitation. The study confirms the new paradigm of low back pain: that pain does not disappear completely for most patients, & yet they continue to work. It indicates that looking at low back pain’s clinical course as either acute or chronic is an oversimplification. Carey, MD. Spine 2000; 25(1):115-120. Once disabling symptoms are present for 3 months, the majority of patients will begin a career of impairment that affects almost all aspects of their lives says Carey, MD. (presented at Society of Gen Internal Med in SF 1999). Functional disability at 1 month was a strong predictor of chronicity. Lack of functional recovery at 1 month appeared to be the best early predictor of long-term impairment. More than half of those who were impaired at 4 weeks were impaired at 22 months. Patients who had intractable back pain for 3 months had even worse outcomes. 2/3 of patients who had continuous symptoms at 3 months had functionally disabling symptoms at 22 months.

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Schiottz-Christensen B, et al. Long-term prognosis of ALBP in patients seen in general practice. Family Practice 1999; 16(3):223-232. A prospective longitudinal study in Denmark of patients with acute low back pain. Patients (18-60 years), consulting their general practitioner due to an episode of low back pain lasting < 2 weeks. Patients could have no low back pain in previous 6 months. Outcome (sick leave, pain & functional or complete recovery were measured at 1, 6 & 12 mo.) Functional recovery: the ability to manage ordinary Activities of Daily Living; Complete recovery: feeling of well-being with regard to low back problems. Results: 503 patients were followed-up. 50% of patients on sick leave returned to work within 8 days; at 1 year, only 2% remained on sick leave. At 1 year, 45% of patients continued to complain of low back pain. Factors most associated with poor long-term low back pain outcome were 1) severity of low back pain at inclusion, 2) assessments by the general practitioner of susceptibility to develop chronic low back pain & 3) a history of low back pain having caused previous sick leave. Conclusions: Low back pain in general practice has a good prognosis with regard to sick leave, but a high proportion of patients continue to complain of low back pain. Even though nearly all the patients had returned to work at 1 month, 16% did not consider themselves functionally recovered. This figure declined to 8% at 12 months. At follow-up at 6 & 12 months, 53% and 46% of the patients did not consider themselves completely recovered. At year, about 50% continued to complain of discomfort, indicating that an acute episode of low back pain causing a visit to a general practitioner is followed by a longer period with low-grade disability than previously expected. Although work loss is well-defined & often-used outcome, it is too insensitive for use as a comprehensive single outcome in studies of low back pain. @ 15% of patients were on sick leave between follow-ups, indicating a recurrent pain pattern. One reason for the low predictive value of the history of the index episode & the traditional PE may be that this set of diagnostic procedures was developed mainly in hospitals to identify surgical patients with lumbar disc herniation. In general practice, however, the vast majority of patients have unspecified low back pain, only 2 patients of 503 had an operation for lumbar disc herniation in this study. It is therefore not surprising that the predictive powers of the various tests differ between the 2 populations. Ferguson, S. A., W. S. Marras, et al. Longitudinal quantitative measures of the natural course of low back pain recovery. Spine 2000;25(15):1950-6. A study with evaluation every 2 weeks for 3 months to quantify acute low back pain recovery in 32 low back pain subjects with no radicular symptoms 916 occupational and 16 nonoccupational) based on 1) work status, 2) Pain, 3) Activities of Daily Living, 4) Trunk Kinematics (Objective & validated functional performance) – measuring ROM, flexion & extension velocity, flexion & extension acceleration from each plane as well as twisting positions at 0 deg, 15 deg, & 30 deg clockwise & counterclockwise. The trunk kinematic provides a quantitative measure of recovery, comparable to the traditional symptoms & Activities of Daily Living, but independent of the subjective impression of the patient or MD. Results: Most patients continued to work during the acute low back pain episode. Return to Work underestimated the percent of subjects impaired compared to all other outcomes. Pain, Activities of Daily Living, & trunk kinematics all showed similar patterns of recovery for 0 to 12 weeks. At 14 weeks, functional performance recovery lagged behind. Both pain & Activities of Daily Living indicated that 80% of the population was recovered, functional performance indicated the figure to be 68%. Conclusion: Use of several outcome measures may lead to a better understanding of low back pain recovery or residual impairment & may minimize risk of recurrent injury. Findings indicate that people continue to work although subjective symptoms & objective functional performance measures show them to be impaired. Return to work may be a misleading outcome. This study’s results clearly denote that return to work is a misleading indicator of impairment. It’s hypothesized that lost time is a function of psychosocial factors, physical job demands, etc & not of functional performance, symptoms, or Activities of Daily Living. The correlation between work status & the other 3 major outcomes were all weak, 74

indicating that work status recovery is independent of workers’ functional performance, symptoms or Activities of Daily Living. Phillips, PhD, Grant. Behav Res Ther 1991;29(5):435-441. 117 patients with their first episode of acute low back pain or neck pain (without discal or neural signs) assessed at onset, 3 months & 6 months. At 3 months 43.9% still had pain. At 6 months 40.2% still had pain & were considered chronic. Most pain decrease occurred in the first 3 months. In this study of acute back pain, 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. It is believed only 10-15% of patients with acute back pain will continue to report it after a 6 week healing period. At 6 months in this study only 57.6% were free of pain. This suggests a much slower recovery period than had been considered & a much larger number of people who are vulnerable to persisting pain. Wahlgren DR et al. Pain 1997;73:213-221. 76 men with their first episode of low back pain (of 6-10 weeks duration – subacute back pain) were assessed at 2, 6, & 12 months following onset of pain. All patients received standard orthopedic care. At both 6 & 12 months after onset of pain, most of the men (78% at 6 months, 72% at 12 months) continued to experience pain. Many also had marked disability at 6 months (26%) & at 12 months (14%). Only 20% of the sample had fully resolved at 6 months & 22% by 12 months. Follow-up found greater improvement in the first 2-6 months & relative stability but unimproved during the 6-12 month interval. The clinical course of the first onset of back pain may be prolonged for many patients. Outcomes of subacute, first onset back pain for many subjects may be unfavorable; Despite a trend towards improvement, only about 1 in 5 fully resolved on all symptoms by 12 months. Long lived difficulties are common for those who enter a subacute phase. Whereas traditional biomedical approaches indicate that time alone may be a curative factor, pain-related effects such as functional deficits & distress may extend beyond healing of tissue damage. Interventions to help patient regain function might help prevent excessive physical deconditioning. Emphasizing early physical reactivation may also reduce distress associated with pain & loss of function. Wiesel MD. Fourth International Forum for Primary Care Research on Low Back Pain. Backletter 2000; 15(5): 42, 52, 53, 58. Back pain as seen in a primary care setting is not the acute, self-limited condition it was once thought to be. It is more typically a recurrent or chronic symptom that erupts periodically over the course of a lifetime. Given the recurrence rate of low back pain, the distinctions among acute, subacute, & chronic low back pain are becoming increasingly fuzzy. There is scant evidence that any form of medical treatment can alter the natural history of this condition long-term. The general goal for health care providers is enlightened, cost-effective management & not a heroic cure. Borkan, PhD, Van Tulder, PhD, et al. Advances in the field of low back pain in primary care. A report from the Fourth International Forum. Spine; 2002 27(5): E128-132. Low back pain is not easily classified as either an acute, self-limited condition or a chronic, unremitting ailment. It is more typically a recurrent or intermittent syndrome that erupts periodically over the course of a lifetime. Low back pain, once thought to afflict people of middle years, is extremely common from teenage years into old age. Only a small portion of sufferers slide from acute or recurrent symptoms to chronic disability & heavy utilization of healthcare. The concept of low back pain has undergone a dramatic shift in the dominant paradigm. Until 10 years ago, low back pain was considered purely biomechanical & involved looking for anatomic damage & finding ways of fixing it. This approach hasn’t worked. The inadequacy of this model & management led to a radical shift – from thinking about low back pain as a biomedical “injury” to viewing it as a multifactorial biopsychosocial pain syndrome. The shift may be summarized as a change from 75

viewing low back pain as a “curable” acute bioanatomic problem to a manageable biopsychosocial recurrent complaint. Low back pain is a functional disturbance rather than a signal of structural damage. There are doubts that any form of medical treatment can alter the natural history of this condition over the long-term. Waxman, MPH et al. Low back pain in the community. Spine 2000;25(16):2085-2090. A questionnaire was sent to adults (25 to 64 years) in Bradford, England in 1994. 1455 respondents were surveyed again in 1997. Results: One third of subjects reported no lifetime low back pain. 2/3 report significant low back pain at some time. Of those who reported lifetime low back pain, 42% reported persistent annual low back pain, 18% reported a first episode in 1997 & 40% reported intermittent low back pain. The likelihood of having had low back pain increased signif with age. Those who reported a new case of low back pain in 1997 were signif more likely to be younger & were most likely to report acute low back pain with very little disability. Those with persistent low back pain were signif more likely to report some disability. Evidence of effective treatments affecting the long-term course of low back pain was not found. Researchers now recognize the difficulty in categorizing low back pain. Although it appears that most episodes are self-limiting, previous low back pain episodes are a strong predictor of future episodes. Low back pain is a mutable problem. It is often intermittent, fluctuating, & recurrent and changes throughout life. 2/3 of low back pain cases were in a state of flux, moving into & out of low back pain-free periods. 1/3 reported persistent annual low back pain from 1994-1997, but half of these were acute at each time point. This infers that although low back pain may become persistent in the middle years, episodes may be short lived. Those experiencing their first episode of low back pain tend to recover more quickly & completely than those who have had a previous episode. Among those with persistent low back pain there is a 50% increase in the number reporting problems with Activities of daily living. Low back pain is a mutable problem. New episodes, which tend to be acute with little disability, blend into longer more disabling episodes as time progresses. Most persistent disabling low back pain is preceded by episodes that, although they may resolve completely, may also increase in severity & duration.

Chiropractic vs Medical Care for Chronic Low Back Pain Coulter, PhD et al. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine 2002; 27(3):298-298. A random sample of 1275 chiropractic patients from 131 DC offices at 6 locations to identify patients’ reasons for chiropractic care, health status, attitudes, beliefs, & satisfaction. Study compared data from patients, DCs & medical patients. Results: >70% of patients listed back & neck problems as the reason they sought chiropractic care. 94% of DC patients went for musculoskeletal problems. Chiropractic patients had signif worse health status on all SF-36 scales than a matched general population sample. Roland-Morris scores for chiropractic back pain patients were similar to values reported for medical back pain patients. Compared with medical back pain patients, chiropractic back pain patients had signif worse mental health scores. Health attitudes & beliefs of DCs & their patients were similar. Chiropractic patients were very satisfied with their care – average: 87.4%. Conclusion: Findings don’t support surveys of DCs that non-NMS conditions are commonly treated. Patients seek chiropractic care almost exclusively for musculoskeletal symptoms. DCs and their patients share a similar belief system. Stano, PhD, et al. Chiropractic and medical care costs of low back care: results from a practicebased observational study. Am J Managed Care; 2002 8:802-809. Study of 111 MDs & 60 DCs compares 1 year cost for 2263 acute low back pain & chronic low back pain patients treated by MDs & DCs. Data included billing, charts, provider & patient questionnaires, patient health status, pain, disability, & socioeconomic characteristics. Medical patients prescription drug costs 76

were included. Results: Direct office costs for 1920 DC patients & 952 MD patients over a 1 year period were relatively small. 43% of chiropractic patients & 57% of medical patients incurred costs of 6 weeks) in 309 MD patients from 111 MD practices & 526 DC patients from 51 DC practices. 84.5% of MD Patients & 89.4% of DC Patients had a previous history of back pain. MD patients were younger & had lower incomes; their baseline pain (54.2 vs 47.7) & 77

disability (49.7 vs 38.3) were slightly greater. MD patients also had more pain radiating below the knee (40.3% vs 28.4%). MD patients had ¼ as many visits as DC patients. Meds were prescribed for 80% of MD patients; spinal manipulation was given to 84% of patients. Most patients had recurrences: MD patients 59.3%; DC patients 76.4%. 34.1% of MD patients & 12.7% of DC patients reported 12 months of continuous pain. Just 6.7% of MD patients & 10.9% of DC patients reported only a single index episode during the year. Conclusions: Chronic Low back pain is persistent and difficult to treat for both provider types. Current research on the course of low back pain suggests that patients whose pain is not completely resolved at 6 months or s1 year is considerably higher than previously thought. Our findings are consistent with this new understanding. A very high proportion of low back pain patients are still reporting low back problems 1 year after enrollment, and the proportion reporting long bouts of continuous pain is not trivial. Nviendo J, PhD et al. Pain, Disability, & Satisfaction Outcomes & Predictors of Outcomes. JMPT 2001;24(7):433-9. Despite improvement in low back pain, persistence of this condition is apparent: only 20% patients reported being completely pain free at 1 year & only 12% had the absence of any disability. At 1 year 39% of MD patients & 18% of DC patients reported pain or disability scores of at least 40%. There is a significant advantage for DC care over MD care for patients with pain below the knee. For patients back pain only or with pain above the knee the differences were unremarkable. In terms of patient satisfaction there is a sharp contrast favoring chiropractic apparent on all 10 questions. Greatest differences found in patients’ confidence that treatment was working (36% vs 74%) & that they would choose the same provider type for future low back pain (61% vs 83%).

Dr listening time adequate Dr understood patient’s concerns Dr agreed pain was real Dr confident in diagnosis Dr confident treatment will work Dr comfortable treating low back pain Patient given sufficient info Patient knew how to care for back Patient confident treatment was working Future care: choose same type of Dr

% MD Patient 64 60 78 66 61 68 40 51 36 61

% DC Patient 90 90 94 92 89 92 73 82 74 83

Nviendo, PhD et al. A descriptive study of medical and chiropractic patients with chronic low back pain & sciatica. JMPT 2001; 24(9):543-51. 121 MD patients & 157 DC patients chronic low back pain patients with radiating pain below the knee were follow-up for 1 year. There was a long-term advantage for DC patients over MD patients. Exercise plans & self-care education were more frequently employed by DCs than MDs. The motivational component of health behavior may be enhanced by health care providers, leading to greater patient self-efficacy for initiating & maintaining positive health behaviors. DC patients had greater self-efficacy motivation (61% greater than MD patients). MD patients were far more likely to choose bed rest. The chiropractic encounter may enhance Patients’ self-efficacy motivation, leading to better coping abilities & better pain & disability outcomes. Greater self-efficacy may lead to improvement in coping abilities. DC patients may have reported better pain & disability because they were better able to cope. DC patients reported greater confidence in themselves in dealing 78

with their low back pain. Patient self-efficacy is a predictor of good treatment responses in chronic low back pain. Hertzman-Miller, R. PhD et al. Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: results from the UCLA low back pain study. Am J Public Health; 2002 92 (10): 1628-33. Study of differences in patient satisfaction I n 681 low back pain patients randomized to chiropractic (341 patients) vs medical care (340 patients) in a Managed Care Organization. 4 treatment groups: 1) med care, 2) med care with physical therapy, 3) DC care, 4) DC care with physical modalities. Satisfaction scores after 4 weeks of follow-up were compared. Results: Visit duration, level of confidence in treatment, changes in pain & disability at 2 weeks were similar in both groups, but, mean satisfaction for chiropractic patients was 15% better than for medical patients. The amount of self-care advice & treatment explanation received was positively associated with satisfaction. Chiropractic patients reported receiving more self-care advice & had more visits. Difference in satisfaction nearly disappeared if MD patients received self-care advice & an explanation of their treatment. Both self-care advice & explanation of treatment had strong effects on patient satisfaction. Among patients receiving little or no self-care advice, DC patients were more satisfied with their provider. Conclusions: Advice & information to low back pain patients increases satisfaction with the provider & accounts for much of the difference between chiropractic & medical patients’ satisfaction.

Chronic Musculoskeletal Dysfunction Devo, R. MD, Weinstein, DO. Low back pain. NEJM. 2001;344(5):363-369. Cross-sectional studies of nonspecific low back pain, which best reflect primary care, suggest that 1/3 of patients are substantially improved at 1 week & 2/3 at 7 weeks. Recurrences are common, affecting 40% of patients within 6 months. Most recurrences are not disabling, but the emerging picture is that of a chronic problem with intermittent exacerbations, analogous to asthma, rather than an acute disease that can be cured. Waddell G. MD. The Back Pain Revolution. Churchill Livingstone 1998: 151-151. One of the common criticisms of the diagnosis of soft tissue sprain or 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 self-sustaining, so symptoms may persist indefinitely. Another important implication: Because dysfunction does not involve any permanent change, it is always reversible. Even if dysfunction & symptoms may persist indefinitely, there is always the potential for recovery by restoring normal function. Waddell G, MD. The Back Pain Revolution. Churchill Livingstone 1998: 145. Musculoskeletal Dysfunction. Abnormalities of Posture; abnormalities of joint movement: Limited movement; Hypermobility; Abnormal Patterns of Movement; acute joint locking. Muscle: Fatigue; Weakness; tension, stress/anxiety; Shortening, stretching; reflex muscle spasm. Connective tissue (fascia, ligaments, joint capsule, muscle): Adhesions, scarring; Trigger points; Fibrositis. Musculoskeletal Dysfunction: Neuromuscular Incoordination: Muscle imbalance; Abnormal patterns of movement; Altered proprioceptor and nociceptor input and neurophysiologic processing. Mayer TG, MD. Neurologic clinics of North America 1999; 17(1):131-147. The majority of injuries to the low back involve soft tissues or discs with sprains and strains of musculoligamentous tissues, which have a relatively brief healing period. When healing is 79

temporally complete, but biomechanically imperfect, leading to permanent impairment of supporting elements, chronic disability may follow. Kannus, MD, PhD. Immobilization or early mobilization after an acute soft tissue injury? Phys & Sportsmed 2000;28(3):55-63. Inflammation and pain result in voluntary inhibition of muscle activity across the affected joint.

Al-Obaidi, PhD, PT et al. The role of anticipation and fear of pain in the persistence of avoidance behavior in patients with chronic low back pain. Spine 2000;25(9):1126-1131. 63 chronic low back pain patients, 20 to 56 years of age performed maximum voluntary isometric contraction of lumbar extensors to measure spinal isometric strength using a Medex lumbar extension machine. VAS for anticipation of pain & actual pain experienced during contraction, Fear-Avoidance Belief questionnaire, & Disability Belief questionnaire were measured. Results: Anticipation of pain and fear-avoidance belief about physical activity significantly predict reductions in spinal isometric strength. True pain experienced during the testing & the Disability Belief questionnaire were not related. Conclusions: results strongly support the hypothesis that spinal physical capacity in chronicity is not explained solely by the sensory perception of pain. The anticipation of pain and the fear-avoidance belief about physical activities were the strongest predictors of reductions in physical performance. Dreyer, MD, Boden, MD. Spine 1998;23 (24):2746-2754. 1 year prevalence rate for neck & shoulder pain is 16% - 18%. Most musculoskeletal conditions resulting in neck pain respond quickly to treatment & heal without sequella. Automotive-associated neck disorders may be more refractory with 20% - 70% of patients still experiencing pain 6 months after the original injury. 10 years after the onset of neck pain, 79% of patients have improved but only 43% are pain free, & 32% have persistent, moderate to severe pain. Multifidi, Back Stabilizers and Chronic Low Back Pain Lee, J-H, MD et al. Spine 199;24(1):54-57. Study investigates trunk muscle weakness as a risk factor for low back pain in asymptomatic subjects. 67 Subjects (mean age 17) with no history or treatment for low back pain. Trunk muscle strength was measured isokinetically for trunk extension & flexion & torso rotation. Peak torques & agonist/antagonist ratios were calculated. Subjects were followed for 5 years to determine the incidence of low back pain (defined as back pain leading to work absence &/or requiring medical attention). Results: 18 subjects developed low back pain during the 5 years. There were no differences between non-low back pain & low back pain groups regarding age, height, weight, peak torque values, or left rotation/right rotation ratio. However, the extension/flexion ratio of the low back pain demonstrated significantly lower values than that of the non-low back pain group. Conclusion: the imbalance of trunk muscle strength – lower extensor muscle strength than flexor muscle strength, is a risk factor of low back pain incidence. Lee J-H, et al. trunk muscle imbalance as a risk factor of the incidence of low back pain: a 5 year prospective study. JNMS 1999;7(3):997-101. 5 year study finds trunk muscle weakness is a risk factor in the incidence of low back pain. 140 asymp subjects (ages 13 to 49) who had never been treated for low back pain had trunk muscle strength measured isokinetically to evaluate peak torque of ext, flex, right rot & left rot & agonist/antagonist ratios (E/F & L/R) ratios. Subjects were followed 5 years. Low back pain subjects: M (32%) & F (40%). There were no differences between the non-low back pain & low back pain groups in age, height & weight, peak torque 80

values & L/R ratios. However, E/F ratio of the low back pain group showed signif lower value than the non-low back pain group. Lower extensor than flexor muscle strength may be a risk factor in the incidence of low back pain. Cohen, MD, Rainville, MD. Aggressive Exercise as Treatment for Chronic Low Back Pain. Sports Med; 2002; 32(1):75-82. Studies show that chronic low back pain patients have deficits in trunk strength. The loss of extensor strength is much greater than that of flexor strength. The normal extensor to flexor strength ratio is 1.2 to 1.5, & in chronic low back pain patients it has been documented to be less than 1.0. Leggett SM, Mooney VM, et al. Restorative exercise for clinical low back pain. Spine 1999;24(9):889-898. Treatment of 412 patients with chronic low back pain at 2 centers using the same treatment protocols. Outcomes: specific strength testing, SF-36, & self-appraisal of improvement at intake, discharge, and 1-year follow-up, & reuse of health care services after discharge. Results: response during the program and at 1-year follow-up was similar at the 2 centers. Because of the extreme reuse of the health care system for chronic low back pain, the authors believe reuse is the most important evaluation of efficacy. The most important finding from the study is the low reuse of the health care system by patients who’d completed the progressive strengthening program: reuse rate of 10% & 12% at 1 year at the 2 centers. Results were as effective in worker’s comp as in private insurance cases. A study 1995 on 269 patients with chronic low back pain >3 months found the reuse of health care system was 73.1% & 10.4% of the patients had undergone surgery. Another study found at follow-up that 55% had need for medical care. This study found that a program designed to restore functional deficits rather than manage pain has an excellent opportunity to provide effective care unrelated to medical diagnoses. In chronic low back pain, lumbar extensors are likely to be deficient. Multifidi are the muscles most used in lumbar extension. A study noted that fatty infiltration in the lumbar extensors of patients with chronic low back pain was higher than that in healthy subjects. The same findings were noted by others using CT who found the more severe the back pain, the greater the atrophy in the lumbar extensor muscles. EMGs demonstrated that the amplitude of EMG signals in the extensors is considerably less than nl in chronic low back pain. Lumbar flexors function normally in with patients with low back pain, but the extensors do not. There’s considerable evidence to focus the recovery program for chronic low back pain specifically at lumbar extensors with equipment that isolates this musculature & provides progressive, restorative strengthening exercise. Richardson, PhD, Bphty, Jull, Pphty, GradDipManipTher, et al. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. Edinburgh, Churchill Livingstone 1999:22, 25. The multifidus (MF) is the most medial lumbar muscle. The muscle has 5 separate bands which stem from SPs & laminae of lumbars. The deepest & shortest fascicle arises from the vertebral lamina (laminar fibers) & inserts into the mamillary processes of the vert 2 levels below with L5 fibers inserting onto the sacrum. The other fascicles arise from the SP & are longer. Some of the deepest MF fibers attach to the capsules of the facet joints. The MF has a unique segmental arrangement & the capacity for fine control of movements of individual lumbar vert. The MF is segmentally innervated by the medial branch of the dorsal ramus. Each nerve innervates only the fascicles that arise from that vert indicating a direct relationship between a segment & its MF. The segmental MF can control a segment to match the applied load. MF muscle bulk increases caudally from L2 to S1. The MF is the largest muscle spanning the lumbosacral junction. In contrast, the cross-sectional area of the lumbar longissimus & iliocostalis decreases on progression caudally. The large size of the MF at the lumbosacral joint compared with the lumbar erector spinae suggests that the MF is the most capable of providing support at this level. It is the L4-5, L5-S1 segments that have the highest incidence of pathology 81

in low back pain. The MF has a close relationship to the facet joints & by controlling the sliding movement of the facets, controls the distribution of stresses & loading on the vertebral joints. THe MF is the only muscle that’s primary function is to protect the vertebral joints. Moseley, BappSc, Hodges, PhD, Gandevia, DSc. Deep :& superficial fibers of lumbar MF are differentially active during voluntary arm mov’ts. Spine; 2002;27(2):E29-36. The deep & superficial fibers of the MF are controlled differently during arm movements that challenge the stability of the spine. The superficial fibers of the MF exhibit direction-specific activity to match the direction of reactive forces caused by limb movement to reduce the displacement of the center of mass. In contrast, the deep MF & transverse abdominis (TrA) are not influenced by the direction of movement and contribute to control of spine stiffness. The deep MF is used to control intersegmental motion & minimize intervertebral shear & torsion. Ebenbichler, et al. Sensory-motor control of the lower back: implications for rehabilitation. Med Sci S ports Exerc 2001; 33(11): 1889-98. Stabilizing function of the trunk muscles is especially important in the Neutral zone where the spine is least stiff – range of displacement around the mid position of the segment/joint, where little resistance is offered by passive spinal restraints. MF contributes nearly 70% of the stiffness resulting from muscle contraction inn the neutral zone of the lumbar spine. Any injury or dysfunction of the MF will directly affect lumbar segmental stability. Hodges, PhD, Richardson, PhD. Arch Phys Med Rehab 1999; 80(Sept): 1005-1012. Study of trunk muscle coordination in subjects with & without a history of low back pain (mean duration of 8.3 years)> All subjects were pain free at the time of testing. Results: Low back pain subjects failed to recruit transverse abdominus (TrA) or internal obliques (IO) in advance of fast limb mov’t & no abdominal muscle activity was recorded in most intermediate speed trials. Findings indicate that preparatory spinal control is altered with low back pain. Low back pain subjects have altered recruitment of trunk muscles which may provide inadequate protection of spinal structures from injury. Precise recruitment of the trunk muscles is essential to protect the spine. In the neutral position minimal restraint is provided by passive structures (ligaments & joint capsules) & stability is dependent on the contraction of surrounding muscles. Changes in muscular control of the trunk with a history of low back pain may expose spinal structures to increased risk of microtrauma & injury. Increased stress on the passive structures may result from decreased muscular stabilization. Results provide evidence that coordination of the trunk muscles is altered in subjects with a history of low back pain even without pain so they may be at greater risk of reinjury due to inadequate muscular stabilization of the spine. Jull, PT, PhD, Richardson, PT, PhD. Motor control problems in patients with spinal pain. JMPT 2000;23(2):115-117. Traditional exercise programs focus on strength, endurance, & functional capacity – beneficial in deconditioned patients, increasing general muscular support of the spine. However, recent research suggests motor control is a key impairment rather than loss of strength. Links are emerging between low back pain & motor control deficits in the local muscle system – transverse abdominis (TrA) & multifidus (MF). These muscles lose their nl anticipatory function in low back pain patients, exhibiting delays in activation & loss of their nl preprogrammed function for support. MF reacts by inhibition at a segmental level in acute episodes of low back pain. Segmental stabilization training is aimed at controlling pain, protecting & supporting the spinal segment from reinjury by re-establishing & enhancing muscle control – to improve motor control & restore nl synergistic function between local & global muscle systems. The focus is on retraining co-contraction of the TrA & MF. During retraining, these muscles are activated cognitively, as independently as possible from global muscles. Contractions are practiced repeatedly with the aim of restoring the muscles automatic stabilization function. 82

Kader, MD et al. Correlation between the MRI changes in the lumbar multifidus muscles and leg pain. Clinical Radiology 2000; 55:145-149. MRIs of 78 back pain patients (17-72 years) with or without leg pain were analyzed for lumbar multifidus (MF) atrophy, disc degen & N root compression. MF atrophy was present in 80% of patients with low back pain & was bilateral in most cases & at L4/L5 & L5/S1 levels together. Muscle atrophy was more common in older patients and females. The correlation between MF atrophy & leg pain was signif. Atrophy of MF may explain referred leg pain in the absence of other MR abnormalities & should be assessed in MRIs of lumbar spine. MF are innervated unisegmentally by the medial branch of the dorsal ramus. MF wasting may be caused by the Lumbar Dorsal Ramus Syndrome: low back pain with referred leg pain induced by irritation to structures innervated by the dorsal ramus nerve, (facet joints, MFs, interspinous ligaments, or by myofascial injury) due to acute or chronic trauma which initiates myofascial pain, spasm & ischemia. This triggers a self-sustained vicious cycle that promotes muscle atrophy. Kang, Y.-M., PhD et al. Electrophysiologic evidence for an intersegmental reflex pathway between lumbar paraspinal tissues. Spine 2002; 27: E56-63. Sensory (afferent) impulses conveyed by the medial branch of the dorsal ramus reflexly alter motor (efferent) activity of medial branches at least one to two vertebral segments away. This provides evidence that the medial branch of the dorsal ramus underlies reports that mechanical stimuli (like spinal manipulation) initiate reflex interactions between lumbar medial paraspinal tissues. The presence of reflex pathways between adjacent lumbar segments probably helps contribute to segmental coordination during movement & may provide the neural substrate proposed to understand the effects of spinal manipulation. Sensory stimuli from the most medial paraspinal tissues may reflexly alter motor (efferent) activity to an adjacent lumbar segment & could contribute to biomechanical changes associated with chronic low back pain & lumbar muscle spasm. Parkkola, R. and M. Kormano. Lumbar disc and back muscle degeneration on MRI. J Spinal Disord 1992; 5(1):86-92. Lumbar discs & paraspinal muscles in 74 healthy subjects (19 to 74 years) were evaluated with MRI. Degeneration of both discs & muscles increased with age. Muscle degeneration is as common as disc degeneration in the lumbar area. The amount of fat within the back muscles correlated with age; older subjects had more fat within & around the back muscles than younger ones. Danneels LA et al. CT imaging of trunk muscles in chronic low back pain patients & healthy control subjects. Eur Spine J 2000;9:266-72. A study of 32 chronic low back pain patients (ave 9.16 years) & 23 controls. Muscle cross-sectional size (CSA) was evaluated from CT images. Only CSA of MF at the lower end-plate of L4 was found to be statistically smaller in low back pain patients. After onset of papin, a combination of reflex inhibition & substitution patterns of other trunk muscles may work together & cause selective atrophy of the MF. Since the MF is important for lumbar segmental stability, the MF atrophy may permit spinal instability & be a reason for the high recurrence rate of in chronic low back pain. The selective atrophy of the MF in chronic low back pain patients was unilateral & isolated to one level. This suggests that wasting was not generalized disuse atrophy but spinal reflex inhibition. MF recovery didn’t occur spontaneously on remission of pain. In subacute & chronic stages a combination of reflex inhibition & changes in coordination of trunk muscles work together to produce atrophy. Many studies highlight the importance of the MF to provide dynamic control. Wasting of the MF may permit lumbar segmental instability, predisposing to further damage. This may explain the progressive nature of symptoms & disability exhibited by many chronic low back pain patients. Results suggest that a selective training of the stabilizing muscular system could be meaningful in the prevention & rehab of chronic low back pain. 83

Static Back Endurance Test Luoto, BM., Heliovaara, MD. Static back endurance and the risk of low-back pain. Clin Biomechanics 1995;10(6):323-324. Spinal physical capacity & static back endurance were studied for their prediction of first-time experience of low back pain. Of a total of 126 subjects without low back pa in, 33 developed low back pain during a 1 year follow-up. The static back endurance test was found to be the only physical capacity measurement that indicated an increased risk of low back pain. Adjusted for age, sex, & occupation, the risk of a new episode of low back pain in those with poor performance on static back endurance test was 3.4X that of those with medium or good performance. Payne et al. Health-Related Fitness, Physical Activity, and History of Back Pain. Can J Appl Physio 2000;25(4):235-249. Study of 233 M & 287 F (118 M, 220 F with no history of back pain; 45 M, 67 F with history of back pain) to evaluate 1) trunk flexion, 2) abdominal muscular endurance, 3) back extensor endurance, 4) physical activity, & 5) waist girth & their relationship to back pain. Subjects with back pain at the time of testing were eliminated. The best discriminators between no history & a history of back pain were back extensor endurance, physical activity participation in both sexes & waist girth in females. Back extensor endurance is a very good predictor of back health. Results substantiate the usefulness of back extensor endurance to differentiate levels of back health in apparently healthy M & F. Moreau, DC, MSEd, et al. Isometric Back Extension Endurance Tests: A Review of the Literature. JMPT 2001;24:110-122. A lit review of isometric back extension endurance tests identified 6 different types of tests. Normative databases are established for the Sorensen test and 2 others. The Sorensen test is probably the most clinically useful: it is easy to perform, requires no special equipment, and enjoys the most support from the literature. The Sorensen test may be of value when used as a screening tool in subjects with a history of severe low back pain. The Sorensen method enjoys abundant positive support in the literature; this test seems to be a valid, reliable, and useful outcome measure for tracking changes in isometric extension endurance capacity in the clinical setting. Mean extensor endurance time for healthy M & F ranges from 77.76 to 129 sec. On average women have longer extension times than men. Low back pain patients mean endurance time range is 39.55 to 54.5 sec. Latimer, PhD et al. The reliability & validity of the Biering-Sorensen test in asymptomatic subjects and subjects reporting current or previous nonspecific low back pain. Spine 1999; 24(20):2085-9. The Biering-Sorensen test provides reliable measures of holding time in subjects with current or previous nonspecific (NS) low back pain & in asymp subjects. The test can discriminate between subjects with and without low back pain. The test is simple to perform & uses inexpensive equipment. Of all the muscle performance tests in clinical use, few have been evaluated this extensively, and none have performed as well on these criteria. It is therefore a very useful clinical test. Sjolie, MSc, Lungren, PhD. The significance of high lumbar mobility and low lumbar strength for current and future low back pain in adolescents. Spine 2001; 26(23):2629-36. In 88 adolescents (ave 14.7 years) low back pain was assessed by questionnaire as low back pain or discomfort in the past year. Lumbar mobility & strength J(static back endurance) were evaluated. Follow-up was 3 years later. Low back pain was highly associated with low lumbar extension strength & high lumbar mobility-extension strength ratios. Low lumbar extension strength & high lumbar sagittal mobility-extension strength ratios predicted low back pain at 3 year followup. Findings support that insufficient strength & stability in the low back are important factors 84

for both concurrent & future low back pain. Juvenile low back pain is associated with low lumbar extension strength & low lumbar extension-flexion strength ratio. A reduction in strength by 2 minutes (out of max of 4 min on the static back endurance test – ave 3.2 min) increased the odds 4X for concurrent & future low back pain. The findings support the association between low back pain & poor stability. Lack of stability may be the results of poor functions of trunk muscles & inefficient neuromuscular control. Reduced function in deep abdominal & lumbar extension muscles may be associated with low back pain. Low strength increases greatly in significance if combined with large mobility. Low strength & high mobility—strength ratios may mirror a lack of ability to keep the low back stable. A practical implication of the results may be an emphasis on training for low back strength & stability in adolescents. Nourbaksh, PT, PhD, Arab, PT MSc. Relationship between mechanical factors and the incidence of low back pain. JOSPT 2002;32(9):447-460. Study investigates the association among mechanical factors & occurrence of low back pain. 600 subjects categorized in 4 groups 1) asymp men; 2) asymp women; 3) men with low back pain; 4) women with low back pain. (each: #150, 43 years). Measured 17 physical characteristics & the association with low back pain: Back extensor endurance & length; Length of ilioposas, abdominal muscle, hip adductor, hip flexor, hamstrings, gastrosoleus; Strength of hip flexor, extensor, abductor, adductor, abdominal muscle; pelvic tilt, foot arch. Results: Endurance of back extensor muscles had the highest assoc with low back pain of all factors. Length of back extensor muscles, strength of hip flexors, hip adductors, & abdominal muscles also had a signif assoc with low back pain. Conclusion: Endurance of back extensor muscles has the highest assoc with low back pain. Other studies also show a decrease in back extensors muscle endurance in chronic low back pain patients. Factors including size of lumbar lordosis, pelvic tilt, leg length discrepancy, & length of abdominal, hamstrings, & ilioposas muscles are not associated with low back pain. EMG studies indicate paraspinal muscles in low back pain patients have a faster fatigue rate. Fatigued muscles have longer response times & decreased ability to tolerate sudden loads. Excessive, uncontrolled loads may induce strain on the facet joints & other passive structures resulting in low back pain. Studies show that improvement of erector spinae endurance is important in preventing & treating low back pain. Improved symptoms may be due to enhanced muscle endurance & coordination between the trunk flexor & extensor muscles. Strengthening Multifidi & Reducing Future Back Pain Danneels et al. Effects of 3 different training modalities on the cross sectional area of the lumbar multifidus muscle in patients with chronic low back pain. Br J Sports Med 2001; 35(3):186-191. To determine whether MF atrophy can be reversed & the effect of different exercise programs on the cross sectional area (CSA) of the lumbar multifidus (MF) in 59 chronic low back pain patients. Patients were randomly assigned to one of 3 programs: Group 1 (19 subjects) 10 weeks of stabilization training; Group 2 (20 subjects) 10 weeks of stabilization combined with dynamic resistance training; Group 3 (20 subjects) 10 weeks of stabilization combined with dynamicstatic resistance training. Before and after 10 weeks of training, MF CSAs were measured from CT images at 3 different levels (upper end plate of L3 and L4, and lower end plate of L4). Results: The CSA of the multifidus muscle was significantly increased at all levels after training in group 3. In contrast, no significant differences were found in groups 1 and 2. General stabilization & dynamic intensive lumbar resistance training have no significant effect on the CSA of the lumbar MF in chronic low back pain patients. The static holding component between the concentric and eccentric phase was found to be critical in inducing muscle hypertrophy. Treatment consisting of stabilization training combined with an intensive lumbar dynamic-static strengthening program seems the most appropriate method of restoring the size of the multifidus muscle. Eccentric muscle contractions seem to be essential to obtain optimal hypertrophy in 85

response to resistance training & a combined dynamic-static training mode has been recommended in order to recruit as many motor units as possible. To increase muscle mass, an intensive strengthening program is necessary in addition to stabilization training. In chronic low back pain, recovery of MF may be hampered by changed recruitment patterns, so that other muscles are active & substitute. People with sedentary lifestyles do not expose their back muscles to work loads high enough to stimulate type II fibers. Type II fibers (fast twitch) of MF recover as a result of intensive exercise. Training with maximal & submaximal effort may reverse the selective atrophy of type II fibers in the MF. Carpenter et al. Low back strengthening for the prevention and treatment of low back pain. Med Sci Sports Exerc 1999; 31(1):18-24. Over the past 30 years therapeutic approaches to back rehab have focused upon passive care for symptom relief. Recent spine rehab programs use active reconditioning centered around low back strengthening to restore normal musculoskeletal function. Chronic low back pain patients participating in isolated lumbar extension progressive resistance exercise (PRE) programs demonstrate significant reductions in pain and symptoms associated with improved muscle strength, endurance, and joint mobility. Isolated lumbar extension exercise elicits the most favorable improvements in low back strength, muscle crosssectional area, and vertebral bone mineral density. These improvements occur with a low training volume of 1 set of 8 to 15 repetitions performed to volitional fatigue one time per week. Improvements occur 1) independent of diagnosis, 2) are long-lasting, and 3) result in less reutilization of the health care system than other more passive treatments. Low back strengthening shows promise for the reduction of industrial back injuries and associated costs. Graves, PhD et al. arch Phys Med Rehab 1994:75:210-15. Training without pelvic stabilization resulted in no improvement in strength of lumbar extensors. Training with pelvic stabilization showed significant improvement in lumbar extensor strength. The magnitude of improvement in the fully extended ROM was 120% at full extension to 42% at full flexion. This demonstrates the unique potential of the lumbar muscles to adapt to specific resistive exercise. Research suggests that large strength increases in the isolated lumbar extensor muscles are due to the fact that these muscles are initially very weak. Because lumbar extensors are rarely isolated during normal daily activities, they seldom encounter an overload stimulus required to gain strength. These muscles are weak before training because they exist in a state of chronic disuse. Trained lumbar extensors have a greater strength & would be able to handle greater external loads & be more resistant to fatigue.

Strengthening Abdominal Muscles Vera-Garcia, Phys Ther 2000;80(6):564-9. Performing curl-up exercises on labile surfaces increased abdominal muscle activity. For curl-up on a stable surface, rectus abdominis muscle activity was 21% of max voluntary contraction (MVC) & external oblique muscle activity was 5% of MVC; for curl-up with the upper torso on a labile ball, rectus abdominis muscle activity was 35% of MVC and external oblique muscle activity was 10% of MVC. Increases in external oblique muscle activity were larger than those of other abdominal muscles. Performing curlups on labile surfaces changes both the level of muscle activity and the way that the muscles coactivate to stabilize the spine and the whole body. This finding suggest a much higher demand on the motor control system, which may be desirable for specific stages in a rehabilitation program. Strey, K. Ab-solutely no other way. San Diego Magazine; 2001:35. Study sponsored by the American Council on Exercise (ACE), from the Biomechanics Lab at SDSU, monitored muscle activity using EMG to compare 13 of the most common abdominal exercises & ranked them 86

from most to least effective. According to Peter Francis, PhD (director of the Biomechanics Lab at SDSU) the 1st ranked was the bicycle maneuver, 2nd was the captain’s chair, 3rd was crunches on exercise ball. Even though the use of the exercise ball came in third, Francis highly recommended using an exercise ball because it requires balance and continuous use of muscles. U.S. Department of Labor: Bureau of Labor Statistics. 2001 National Occupational Employment & Wage Estimates. Chiropractic – Mean income: $76,870. median income (50th percentile): $68,420. Use of Fitballs to Enhance Balance, Proprioception, Endurance & Motor Control. PosnerMayer J, PT, editor. Orthopedic, Sports Medicine, & Fitness Exercises using the Swiss Ball; 1995. Excellent resource for prescribing exercises utilizing the Swiss (Gym) Ball. Jemmett, R., PT. Spinal Stabilization. The New Science of Back Pain. Halifax, Canada, RMJ Fitness & Rehabilitation Consultants. 2001. The Deep Layer consists of vertebrae, discs, ligaments, & a series of muscles which run from one vertebrae to the next. Deep layer performs 2 functions: 1) Helping to stabilize the spinal column. Ligaments serve to limit the size of the bending & rotating motions and limit motion only at the end ROM. Ligaments prevent the vert from moving too far in any direction. 2) providing the CNS with information about the exact position of every joint & vertebrae in the spine. Discs, small muscles (intertransversarii & interspinales) ligaments of the deep layer are well innervated & have the ability to sense changes in the position of the many joints of the spine & send this postural information to the CNS. The CNS is extremely dependent on this postural information when attempting to effectively organize & use the various muscles which make the spine work. CNS needs a steady stream of accurate information about the relative position of all our joints if it is going to successfully coordinate paraspinal muscles. We are beginning to understand the significance of the positionsensing function of the deep layer. The body uses muscles to control the small coupled & translation motions. To control them, the nervous system needs to know what motions are occurring. Discs, ligaments, & small muscles of the spine contain receptors which send this positional information to the nervous system. Every split second, discs, ligaments, small muscles at every joint send this positional information to the nervous system so it can know where the different parts of the body are relative to each other. With this information, the nervous system can activate the correct muscles to create a certain movement or prevent excess movement. When the small coupled and translations of the spine are not kept under precise control, injury may occur. Therefore, developing a highly tuned positional sense is a first step to rehabilitation or prevention. Stabilization training requires the use of position & movement sense much more than standard exercises. Previous exercise approaches for back pain & sports conditioning ignored position sense training. The Middle Layer consists of four key muscles that provide the bulk of stability required to keep the lower back working effectively. Two are back muscles: multifidus & the quadratus lumborum & two are abdominal muscles: internal oblique & transverses abdominis. These muscles provide dynamic stabilization of the spine, preventing excessive motion at spinal joints. Until recently we failed to appreciate the importance of the middle layer muscles in this activity, thinking that the ligaments did all the work of stabilizing the spine. We now know that the ligaments only provide stability at the extreme end ROM. It is the middle layer muscles which are responsible for the majority of the stabilization required to keep the back functioning properly. A complicated set of muscle activations must take place in order to maintain spinal stability while we use our extremities. The body preactivates the middle layer muscles before virtually any form of movement. This braces or stabilizes the spine so that movements of the limbs occurs efficiently & without disturbing the overall sense of balance. If this core is unstable, the arms & legs will have to work harder to accomplish a given task. The trunk, functioning as the foundation from which our arms & legs operate must be stable to allow 87

the limbs to work at optimal efficiency. If the spine is not well stabilized some part of the body may eventually become injured. Rehab has been going about stabilization training the wrong way. The focus on the large power muscles of the trunk has left many patients & athletes physically unprepared. The Outer Layer of large, thick, long muscles can create large amounts of power & create bodily movements. They are collectively known as the erector spinae muscles (iliocostalis, longisiumus, spinalis). Two abdominal muscles, the external oblique & the rectus abdominis are also components. Standard Sizes for Fitballs Patient Height 5’ – 5’7” 5’8” – 6’2” 6’3” – 6’9”

Size – CM 55cm 65cm 75cm

Size – Inches 22” 26” 30”

To Order Fitballs (available in black & pearl colors), Posner-Mayer work book for prescribing exercises, doctor videos, patient videos, exercise progress charts: Call (925) 426-1137. $25 per ball includes hand held pump & wall chart of basic exercises. For orders of 6 balls or more $24 per ball, orders of 12 or more $23 per ball. McPartland, DO, Brodeur, DC, PhD, Hallgren, PhD. JMPT 1997;20(1):24-29. Study of relationship between Chronic Neck Pain (CNP > 3 months); Somatic dysfunction (tender, asymmetry, restriction, tissue texture); Suboccipital muscle atrophy on MRI in 7 patients vs 7 normal subjects (average age 39). MRI showed atrophy of rectus capitus posterior major & minor muscles including fatty infiltration. Conclusions: Findings suggest a relationship between CNP, somatic dysfunction, muscle atrophy & standing balance. Propose a cycle of chronic somatic dysfunction, resulting in muscle atrophy, which reduces PR output from atrophied muscles. The lack of PR inhibition of pain in the dorsal horn results in chronic pain & a loss of balance. Axen, PhD et al. Progressive resistance neck exercises using a compressible ball coupled with an air pressure gauge. JOSPT 1992; 16(6):275-9. Study compares healthy men performing 3 sets of 10 repetitions of cervical flexion, extension, & lateral flexion (3 to 5 sessions per week for 4-7 weeks) using the Nexerciser while maintaining pressure at 60-80% of maximum voluntary pressure (MVP) vs a control group who did not exercise. Results: progressive resistance neck exercises, facilitated by a compressible ball coupled with an air pressure gauge, can markedly increase neck muscle strength & consistently reduced asymmetries of lateral flexion force. Subjects in the control group demonstrated no increased force or reduction of asymmetry. The exercise group’s increases in MVP for flexion, extension, & lateral flex & decreases in lateral force imbalance could be attributed entirely to effects of the training program. The amount of gain in neck muscle strength in the study was greater than for similar protocols for biceps & much greater than for the diaphragm. Findings suggest that neck muscles respond to strength training more readily than these other muscles. Neck muscle strength training may be important for injury prevention & rehabilitation. Gains of 156% in flexion strength, 162% in extension strength, & 173% in lateral flexion strength. The Interactive Spine – Chiropractic Edition by Primal Pictures (primalpictures.com): CDROM of anatomical illustrations, cadaver sections, pathology, MRI, examination, conditions, with explanations and videos of treatment, rehabilitation, neurological & orthopedic evaluation. Also offer CD-ROMs of Hand & Wrist, Foot & Ankle, Shoulder & Elbow, Hip, Knee. For more information call (925) 426-1137. 88

Manipulation and Exercise Morton, PT, M Hth Sc. Manipulation in the treatment of acute low back pain. J Manual & Manip Ther 1999;7(4):182-189. Prospective study of 29 patients with acute low back pain (4 weeks or less) randomized to 2 treatment groups: Group 1) 15 subjects receive spinal manipulation & stabilization exercises (to contract multifidi & improve co-contractions between multifidi & abdominal muscles); 2) 14 subjects receive stabilization exercise program alone. Patients got spinal manipulation two times per week for total of 8 treatments. Post-treatment assessment performed weekly for 4 weeks, then without further spinal manipulation but continuing exercise program at 2 months & 3 months. Outcomes: ROM, Roland, VAS taken at initial visit, at the end of each week, at 2 and 3 months. Results: Significant differences between groups appear at 1 week for pain & ROM & at 4 weeks for disability. All 3 outcomes increase further with time. Acute low back pain patients who receive spinal manipulation + exercise program improve to a greater extent than patients who receive the exercise program alone. At 3 months, group 1 (spinal manipulation & exercise group) had a mean disability score on the Roland 90.3% less than exercise alone group. 11 of 15 patients in Group 1 had no disability at 3 months vs only 1 in 14 in Group II (exercise alone). At 3 months Group 1 had a mean pair score 100% less than Group II. None of the 15 patients in group 1 had pain at the end of 3 months, vs 13 of 14 in group still had pain. At 3 months, group 1 had mean ROM 46.44% more than group II. Conclusions: Patients who receive spinal manipulation & exercise for acute low back pain will improve more & faster than patients who receive exercises alone. The difference between the groups appears early. Spinal manipulation also appears to be cost-effective. Bronfort DC, PhD et al. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine 2001;26:788-99. After a 1-week baseline, 191 patients with chronic mechanical neck pain were randomized to 11 weeks of treatment with follow-up at 5 weeks, 11 weeks, 3, 6 & 12 months to compare efficacy of 20 one hour sessions of spinal manipulation alone, spinal manipulation + low tech exercise, or MedX(high-tech exercise). Patients randomized to receive: 1) Spinal manipulation only: by 1 of 9 DCs, High velocity low amplitude to Cervical & Thoracic spine & light soft tissue massage & then 45 minutes of detuned microcurrent after spinal manipulation to control for similar time per visit. 2) Spinal manipulation + exercise: spinal manipulation by 1 of 9 DCs to Cervical & Thoracic spine + light soft tissue massage & low tech exercise: 45 minute supervised sessions of progressive strengthening for neck & upper body proceeded by short aerobic warm up & light stretch. Upper body strengthening includes push-ups, dumbbell weights of 2 to 10 lbs. Cervical strengthening exercises with weight attachments to headgear (1.25 – 10 lbs). 3) MedX Exercise: one on one supervision by physical therapist. Sessions begin with stretching, upper body strengthening, & 15-20 minute aerobic stationary bike. Dynamic progressive resistance exercises on MedX cervical extension & rotation machines to isolate C-rotators & extensors. All patients in all groups were instructed to use a home exercise program of resistive extension, flexion & rotation exercises with rubber tubing device. Outcomes: patient rated neck pain, disability, functional health status (SF-36), global improvement, satisfaction with care, & medication use. ROM, muscle strength, & endurance assessed by examiners blinded to patients’ treatment assignment. Results: after 11 weeks: patient rated outcomes: all 3 groups improved. No significant differences between groups in terms of pain, neck disability, general health, improvement, except for satisfaction with care which was signif higher for spinal manipulation + exercise than for spinal manipulation alone. In terms of neck performance at least twice as much improvement in spinal manipulation/exercise as in spinal manipulation on all measures including ROM. Spinal manipulation/exercise showed greater improvement in flex endurance & flex strength than MedX. MedX showed higher gains than spinal manipulation in most measures with flex the exception. Long term outcomes: Tendency in short term for the 2 exercise groups to perform 89

better continued throughout 1 follow-up year & resulted in signif group differences of medium effect size & are clinically important, especially between the spinal manipulation/exercise vs spinal manipulation group. Spinal Manipulation/exercise patient satisfaction was superior to both MedX & spinal manipulation. Spinal manipulation/exercise was superior to spinal manipulation alone in terms of pain, satisfaction & improvement & MedX was superior to spinal manipulation in terms of pain. Conclusion: with exception of patient satisfaction for which spinal manipulation/exercise was superior to spinal manipulation al one, no clinically important group differences were observed at 11 weeks. During the follow-up year, there was a cumulative advantage for both spinal manipulation/exercise & MedX exercise compared to spinal manipulation. Both exercise groups showed very similar improvements in all outcomes, but spinal manipulation/exercise reported greater satisfaction with care. The use of strengthening exercise whether in combination with spinal manipulation or in the form of high-tech MedX program appears to be more beneficial to patients with chronic neck pain than spinal manipulation alone. Spinal manipulation/exercise patient satisfaction was superior to both MedX & spinal manipulation. Spinal manipulation/exercise was superior to spinal manipulation alone in terms of pain, satisfaction & overall improvement & MedX was superior to spinal manipulation in terms of pain. Swenson R, DC, MD, PhD. Point of View. Spine 2001;26:798-799. Bronfort et al’s study is a very well designed & conducted randomized controlled trial. When pain ratings are considered, there is a relative benefit for neck exercise alone or neck exercise combined with spinal manipulation as compared with treatment using spinal manipulation alone. This effect was identifiable for months after treatment, arguing that exercises should be incorporated as a regular part of treatment for patients with chronic neck pain. Evans, DC, MS, Bronfort, DC, PhD, et al. 2 year follow-up of a randomized clinical trial of spinal manipulation & two types of exercise for patients with chronic neck pain. Spine; 2002 27(21):2383-9. 145 chronic neck pain patients were evaluated at all follow-ups over two years (3, 6, 12 & 24 months) after treatment. A signif difference in pain was observed in favor of the 2 exercise groups. Spinal manipulation + exercise was superior to both Med & spinal manipulation in terms of patient satisfaction. No signif differences were found for neck disability, general health status, improvement, & OTC medication use, although the trend favored the two exercise groups. Results demonstrate an advantage of spinal manipulation + low tech rehab exercise & MedX rehab exercise vs spinal manipulation alone over 2 years in terms of pain reduction & are similar to those at 1 year follow-up. Results suggest treatment including supervised rehab exercise should be considered for chronic neck pain. Drezner, MD, Herring, MD. Managing Low Back Pain. Steps to optimize function and hasten return to activity. Phys & Sports Med 2001; 29(8). Spinal Manipulation should always be used with other appropriate rehab components. Protracted passive treatment places the patient in a dependent role & becomes counter productive to establishing functional independence. The high recurrence rate & functional changes that occur in chronic low back pain warrant attempts to maximize rehabilitation. The overall goal is to restore nl function & promote safe & independent return to activity. Implementing a long-term maintenance program is important in preventing recurrence. Thus rehab should continue beyond the resolution of symptoms & return to sport. Preventive Exercise Hides JA, PhD, et al. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 2001;26:E243-8. A randomized controlled trial with 1-year and 3-year followup to evaluate a short-term exercise program’s long-term effect on recurrence sin acute, first90

episode low back pain patients. An initial episode of acute low back pain is known to resolve spontaneously in the short-term in the majority of cases. However, the recurrence rate is staggeringly high ranging from 60% to 86% in various studies. 39 acute, first-episode low back pain patients ( 4 weeks. In 1999 we had 16 randomized controlled trials that showed that activity & exercise are essential for the recovery of nonacute, nonspecific low back pain. How much more evidence do the health care professional community, the industrial community, & the social security community need to be convinced? Massage vs Acupuncture for Chronic Low Back Pain Cherkin, PhD, Eisenberg, MD et al. Randomzied trial comparing traditional acupuncture, therapeutic massage, and self-care education for chronic low back pain. Arch Intern Med 2001, 161 (8): 1081-8. 262 patients (20 to 70 years) with chronic low back pain were randomized to receive 1) acupuncture (n = 94), 2) therapeutic massage (n = 78), or 3) self-care educational materials (n = 90). Up to 10 massage or acupuncture visits were permitted over 10 weeks. Symptoms (0-10 scale) & dysfunction (0-23 scale) were assessed. Follow-up for 95% of patients after 4, 10, and 52 weeks. Results: at 10 weeks, massage was superior to self-care on the symptom scale (3.41 vs 4.71), & disability scale (5.88 vs 8.92). Massage was also superior to acupuncture on disability scale (5.89 vs 8.25). After 1 year, massage was not better than self-care but was better than acupuncture (Symptom scale: 3.08 vs 4.74) & dysfunction scale: (6.29 vs 8.21). Massage group used the least medications & had lowest costs of subsequent care. Conclusions: Massage was effective for chronic low back pain providing long-lasting benefits. Acupuncture was relatively ineffective. Massage may be an effective alternative to conventional medical care for chronic low back pain. Surgery & Denervation Atrophy Sihvonen T et al. Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine 1993; 18 (5): 575-581. 13 of 15 patient suffering from severe postoperative failed back syndrome (FBS) after laminectomies had dorsal ramus lesions in one or more segments & local paraspinal muscle atrophy. Disturbed back muscle innervation & loss of muscular support leads to disability & increased biomechanical strain & may be an important cause of failed back syndrome. Operative techniques can cause iatrogenic lesions of dorsal rami & innervation failure of low back muscles. Striking denervation atrophy of low back muscles can occur leading to loss of functional muscle support & to disturbed segmental mobility & further increased biomechanical strain & disability. In addition, muscles in unoperated levels seemed more atrophied probably due to disuse. Low back surgery can cause severe lesions (slight partial denervation may be much more general) to back muscle innervation & denervation atrophy in back muscles. Bigos, MD. Agency for Health Care Policy & Research Guidelines. 1994. Patient Guide: Even a lot of back pain doesn’t by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back pain. Devo, R. M. and J. D. Weinstein. Low back pain. NEJM. 2001; 344(5): 363-369. There is no evidence from clinical trials or cohort studies that surgery is effective for patients who have low back pain unless they have sciatica, pseudoclaudication, or spondylolisthesis. In the absence of cauda equina syndrome or progressive neurologic deficit, patients with suspected herniated disc should be treated nonsurgically for at least a month. Multiple surgical procedures are rarely helpful.

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Gejo R, MD et al. Serial changes in trunk muscle performance after posterior lumbar surgery. Spine 1999; 24(10): 1023-1028. Study to evaluate the influence of surgically-related back muscle injury on postop trunk muscle performance & low back pain. Patients divided into: 1) Short retraction time (< 80 min) & 2) Long (> 80 min): evaluated before surg at 3 & 6 month follow-up post surg. Injury was estimated by MRI & trunk muscle strength. Results: Back muscle injury was directly related to the muscle retraction time during surg. The damage to the multifidi was more severe & recovery of extensor muscle strength was delayed in the longretraction time group. In addition, the incidence of postop low back pain was higher in the longretraction time group. Conclusions: Postop trunk muscle performance is dependent on muscle retraction time. It is beneficial to shorten the retraction time to minimize back muscle injury & subsequent postop low back pain. Loupasis, MD. Seven to 20 year outcome of lumbar discectomy. Spine 1999; 24 (22): 23132317. A retrospective study to assess the effects surgery for lumbar disc herniation over an extended period of time. 109 patients with surgically documented herniated lumbar disc were follow-up at a mean of 12.2 years by a mailed self-report questionnaire which asked about pain relief, satisfaction with results, analgesics, activity level, work capacity, & reoperations. Results: The long-term results were satisfactory in 64% of patients. Of the 101 patients, 28% still complained of signif back pain or leg pain. Reoperation rate was 7.3% (8 patients). Conclusions: The long-term results of standard lumbar discectomy are not very satisfying. More than 1/3 of patients had unsatisfactory results & more than one quarter complained of signif residual pain. Female gender was predictive of a poor outcome. About 50% of women had an unsatisfactory result with only 25% of the men with unfavorable outcome. Jobs requiring signif physical strenuousness predispose to an unfavorable outcome. Hence, only patients with light occupational activity fare best. Only 19% of these had unsatisfactory results compared with 64% of those who did heavy manual work. Dreyfuss, MD et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 2000; 25 (10): 1270-1277. 15 chronic low back pain patients whose pain was relieved by diagnostic medial branch blocks of the lumbar facet joints underwent lumbar medial branch radiofrequency neurotomy to coagulate the nerve along 8-10 mm of its length. Patients were evaluated before & at 6 weeks, 3, 6 & 12 months after surgery. Results: 60% of patients had at least 90% relief of pain at 12 months, & 87% had at least 60% relief. Relief was associated with denervation of the multifidus (MF) in those segments in which the medial branches had been coagulated. Conclusions: Lumbar medial branch neurotomy is effective in reducing pain in patients selected on the bases of controlled diagnosis blocks. Denervation was achieved in all patients, all of whom obtained some degree of relief. In 11 of 15 subjects, based on EMG there was denervation in every segmental MF muscle that pertained to the targeted nerves. The relief of pain is concordant with the demonstration of postoperative denervation in the respective bands of MF. Leboeuf-Yde, C, DC, MPH, PhD, Kyvik KO, MD, PhD. Spine 1998; 23(2): 228-234. Study of >29,00 people ages 12 to 41 about lifetime, one year, & one day prevalence of low back pain. There is a rapid increase in low back pain in early adolescence (earlier in girls than boys), possibly at the time of puberty. Low back pain is common in subjects as young as their late teens. Approx 50% of girls aged 18 years, boys aged 20 experienced some low back pain, & half of girls aged 21, boys aged 22 had low back pain in the preceding year. The low back pain today reached 10% for women (20 years) & men (age 25). The pattern of reporting low back pain for the preceding year (presence & total number of days with low back pain) remained stable after the age of 19. Because low back pain has an early onset, we should research its causes & prevention in nonadults. Studies of chronicity & recurrence should focus on young subjects 94

because the pattern of reporting low back pain becomes established at an early age & remains the same throughout adult years. Chiropractic, Chronic Whiplash, Reduced Range of Motion, and Headaches (Cervicogenic, Tension-type, Migraine) Journal of Orthopaedic Medicine Study Indicates That Chiropractic Is "...Only Proven Method" For Chronic Whiplash Symptoms... Journal of Orthopaedic Medicine 1999;21:22-25. The Journal of Orthopaedic Medicine published a study recently that concluded that chiropractic is the "...only proven method" for patients suffering chronic whiplash symptoms. In fact, the authors of the study reported that 74% of the patients in their study improved after chiropractic adjustments. The authors stated that their results, "...confirm the efficacy of chiropractic" - a previous study, done by Woodward et al. and published in Injury, which found that 93% of chronic whiplash suffers improve with chiropractic). The authors went on to say that, "The results of this study provide further evidence that chiropractic is an effective treatment for chronic whiplash symptoms." Dall’Alba, Bphty et al. Cervical Range of Motion Discriminates Between Asymptomatic Persons and Those With Whiplash. Spine 2001; 26(19): 2090-94. A comparative study of cervical ROM in 89 asymptomatic subjects & 114 chronic whiplash patients (3 months – 2 years). ROM was measured in 3D with a computerized, electromagnetic, motion-tracking device. Results. ROM was reduced in all primary movements in patients with persistent whiplashassociated disorder. Sagittal plane movements were proportionally the most affected. On the basis of ROM, age, and gender, 90.3% of study participants could be correctly categorized as asymptomatic or as having whiplash. ROM was capable of discriminating between asymptomatic persons and those with persistent whiplash-associated disorders. Sjaastad, MD, PhD et al (On behalf of The Cervicogenic Headache International Study Group). Cervicogenic headache: Diagnostic Criteria. Headache 1998;38:442-445. Major Criteria of Cervicogenic headache (in order of importance): Neck involvement a) Precipitation of head pain occurring by 1) neck movement &/or sustained awkward head positioning &/or 2) external pressure over the upper cervical or occipital region on the symptom side b) Restriction of ROM in the neck c) Ipsilateral neck, shoulder, or arm pain of vague nonradicular nature, or occasionally radicular-type arm pain. Confirmed by diagnosis anesthetic blockades (scientific works) Unilateral head pain, without sideshift (with severe pain it may cross the midline). Moderate-severe, nonthrobbing, & nonlancinating pain, fluctuating or continous pain usually starting in the neck. Not infrequent occurrence of head or indirect neck trauma by history, usually of only medium severity. Sjaastad, MD, PhD, Fredriksen, MD. PhD. Cervicogenic headache: Criteria, Classification & Epidem. Clin Exper Rheum. 2000; 2 (Suppl 19): S3-6. Particularly unfortunately may be a non-tolerated position of the head/neck during sleep. When the patient finally wakes up, the triggering event may already have passed the point of no return, since the patient has been unable to notice the initial warning during sleep. These are unilateral headaches (not strictly one-sided, but the pain dominates on one side) starting in the neck & “spreading” forwards. There are signs pertaining to the neck, such as reduced cervical ROM, mechanical precipitation mechanisms & ipsilateral shoulder/arm sensation or pain. CHIROPRACTIC ADJUSTMENTS HIGHLY EFFECTIVE FOR PATIENTS WITH CHRONIC WHIPLASH SYMPTOMS... Injury 1996;27(9):643. The results of a recent study 95

conducted on 28 patients who suffer from chronic whiplash symptoms was published in Injury Magazine. Of the 28 patients, 93% showed improvements after receiving Chiropractic Adjustments. The study reported that 43% of those who experience a whiplash trauma will suffer from long term symptoms which do not respond to conventional treatments. Whittingham, DC, PhD, Nilsson, DC, MD, PhD. Active range of motion in the cervical spine increases after spinal manipulation (toggle recoil). JMPT 2001; 24(9): 552-5. Blinded randomized controlled trial of the changes in active cervical ROM after cervical spinal manipulation in 105 patients with cervicogenic headache. After 3 week baseline observation period (phase 1), subjects randomized into 2 groups. Phase 2 – Group 2 received spinal manipulation (toggle recoil), group 1 received a sham spinal manipulation. Phase 3, group 1 received toggle & group 2 – no treatment. Phase 4, group 2 received sham spinal manipulation & group 1 received no treatment. After each phase, active cervical ROM was measured with a strap on head goniometer by 2 blinded examiners. Results: After receiving spinal manipulation, active cervical ROM increased signif in group 2 vs group 1. The difference between the treatment groups disappeared after group 1 received spinal manipulation. Conclusion: Cervical spinal manipulation increases active ROM. McCrory, MD, MHSc et al. Evidence Report: Behavioral and Physical Treatments for Tensiontype and Cervicogenic Headache. 2001 (Executive Summary at www.fcer.org). Duke University Evidence-based Practice Center Center for Clinical Health Policy Research. A systematic review by expert epidemiologists & clinicians affiliated with a very respected research center of behavioral & physical interventions for treatment of headache: Behavioral: 1) relaxation training, 2) biofeedback training & 3) cognitive-behavioral (or stress-management). Physical Treatments: acupuncture, cervical spinal manipulation & physical therapy. These treatments are primarily aimed at headache prevention rather than alleviation of symptoms once an attack has begun. A recent population study, using diagnostic criteria of the International Headache Society (HIS), found that 17.8% of subjects with frequent headache 95 days per month) had the criteria for cervicogenic headache, equivalent to a prevalence of 2.5% in the general population. Cervical spinal manipulation was associated with improvement in headache outcomes in 2 trials involving patients with neck pain &/or neck dysfunction & headache. Spinal manipulation appeared to result in immediate improvement in headache severity when used to treat episodes of cervicogenic headache compared with a placebo group. When compared to soft-tissue therapies (massage), spinal manipulation resulted in sustained improvement in headache frequency & severity. However, in patients without a neck pain/dysfunction component to their headache – patients with episodic or chronic tension-type headache – the effectiveness of cervical spinal manipulation was less clear. No placebo or no treatment control studies of spinal manipulation have been done in these populations. In a trial among patients with episodic tension-type headache, spinal manipulation conferred no extra benefit when added to a soft-tissue therapy (deep friction massage). In another trial of patients with tension-type headache, amitriptyline was significantly better than spinal manipulation at reducing headache severity during 6-week treatment period; there was no significant difference between the 2 treatments for headache frequency during the same period. Interpretation of results is difficult because all patients received the same relatively low dose of amitryptyline (30 mg). Despite the same dose of amitriptyline adverse effects were much more common with amitriptyline (82% of patients) than with manipulation (4%). During the 4-week period after treatments ceased, patients who had spinal manipulation were significantly better than those who took amitriptyline for both headache frequency & severity. The return to near-baseline values for headache outcomes in the amitriptyline group contrasts with a sustained reduction in headache frequency & severity in those who received spinal manipulation. 96

Nilsson, DC, MD et al. JMPT 1997; 20(5): 326-330. Study of the effect spinal manipulation on cervicogenic headache (CH) in a prospective, randomized controlled trial in 53 patients with frequent headache criteria for cervicogenic headache. All subjects were aged 20 to 60; had >/= 5 days/month of headache for at least 3 months; no prior spinal manipulation of C-spine; no effect with migraine meds, occipital headache location; patients could identify neck movements or postures that precipitate/aggravate headache; patients exhibited decrease passive ROM; patients kept a headache diary for 1 week before treatment. 28 patients received spinal manipulation 2X/week for 3 weeks. 25 patients received low-level laser in the upper C-sp (placebo) & deep friction massage (including trigger pts) in the lower cervical/upper thoracic region 2X/week for 3 weeks. Results: 1. Use of analgesics decreased by 36% in spinal manipulation group but was unchanged in the soft-tissue group. 2. Number of headache hours/day decreased by 69% in spinal manipulation group compared with 37% in soft tissue group. 3. Headache intensity per episode decreased by 36% in spinal manipulation group vs 17%. Conclusion: Spinal manipulation has a signif positive effect in cases of cervicogenic headache. CH accounts for some 15-20% of all recurrent headache. Nelson CF, DC et al. JMPT 1998; 21(8): 511-519. Study of the relative efficacy of amitriptyline, spinal manipulation & a combination of both therapies for the prophylaxis of migraine headache in a prospective, randomized trial of 218 patients with the diagnosis of migraine headache. After 4 week baseline period, patients were assigned to 8 weeks of treatment & a 4 week follow-up. Results: Improvement was observed in both primary & secondary outcomes in all 3 study groups. The reduction in headache scores during treatment compared with baseline was 49% for amitriptyline, 40% for spinal manipulation & 41% for the combined group. During follow-up, the reduction from baseline was 24% for amitriptyline, 42% for spinal manipulation & 255 for the combined group. Conclusion: There’s no advantage to combining amitriptyline & spinal manipulation for treatment of migraine headache. Spinal manipulation was as effective as a wellestablished & efficacious treatment (amitriptyline), & on the basis of a benign side effects profile, it should be considered a treatment option for patients with frequent migraine headaches. Tuchin P, DC, et al. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. JMPT 2000; 23(2): 91-95. Assesses efficacy of chiropractic spinal manipulation in treatment of 127 chronic migraine patients (average age 38; average duration 18.1 years) in a 6 month randomized controlled trial in 3 stages: 2 month pre-treatment; 2 months of treatment (diversified, max of 16 treatments or a placebo group getting detuned interferential current), & 2 month post-treatment. Results: Mean number of migraines reduced from 7.6 to 4.1/month in the spinal manipulation group (46% reduction in frequency). Greatest improvement was in med use (54% reduction). Also 36% reduction in duration & 34% reduction in disability. A signif number of patients reduce their med use to zero by the end of the 6 month trial. The average response of the spinal manipulation group showed signif improvement in migraine frequency, duration, disability, & meds use. 22% of subjects reported >90% reduction of migraines as a consequence of the 2 month spinal manipulation. Another 49% more subjects reported signif improvement in the morbidity of each episode. 59% of spinal manipulation treatment patients reported no neck pain after 2 months of spinal manipulation. 22% reported sl pain, 13% mild & 8% moderate pain. Highest responses were signif reduction in photo phobia (90%), nausea (89%) & needing a quiet, dark area in reaction to pain (83%), lowest responses were reduction in aura (33%) & vomiting (52%). Conclusion: Results support previous findings showing that some people report signif improvement in migraines after chiropractic spinal manipulation. Vernon, DC. JMPT 1995; 18(9):611-617. The sustained benefit with spinal manipulation may indicate a correction of some underlying disorder responsible for the headaches. Given that amitriptyline is a standard therapy for chronic tension headaches the finding that spinal 97

manipulation provides comparable relief should compel everyone’s attention. It is now indisputable that afferent connections from the upper cervical joints have an enormous capacity to create referred head & facial pain as well as muscle dysfunction in the cranio-vertebral region. Hoving, PhD, Koes, PhD, et al. Manual Therapy, Physical Therapy, or Continued Care by a general Practitioner for Patients with Neck Pain. Ann Intern Med. 2002; 136(10): 713-722. 183 patients with =/>2 weeks of nonspecific neck pain randomized to receive: 1) manual therapy (MT) x 6 weeks (specific mobilization techniques) 1x/week; 2) physical therapy (exercise therapy) 2x/week; or 3) continued care by a general practitioner (analgesics, counseling, and education). Outcomes (3 & 7 weeks): treatment successful if patient reported “completely recovered” or “much improved” on a 6 point scale. Physical dysfunction, pain intensity, & disability also measured. Results: At 7 weeks, success rates were 68.3% for manual therapy, 50.8% for physical therapy, & 35.9% for continued care. Differences favored MT > Physical therapy & physical therapy > general practitioner. Success rate at 7 weeks was twice as high for MT vs continued care. ROM improved more for MT or physical therapy than continued care. General health perception showed signif difference in favor of MT vs continued care or physical therapy. Manual therapy patients had fewer absences from work than physical therapy or general practitioner patients. There were signif differences in pain intensity with manual therapy vs continued care or physical therapy. Disability scores also favored manual therapy. Physical therapy scored better than continued general practitioner care on some outcomes but differences were small. In everyday practice, for every 3 patients referred for manual therapy & every 7 for physical therapy, 1 additional patient will completely recover within 7 weeks than would have recovered after continued general practitioner care. Conclusion: Manual therapy is favorable treatment option for neck pain patients vs physical therapy or continued general practitioner care. Manual Therapy (MT): included techniques by Cyriax, Kaltenborn, Maitland, Mennel: use of passive movements to help restore nl spinal function: “hands-on” muscular mobilization to improve soft tissue function, specific joint mobilization techniques (low-velocity passive movements within or at the limit of joint ROM. High velocity low amplitude spinal manipulation was not included) to improve overall joint function & decrease restrictions, & coordination or stabilization techniques to improve postural control, coordination, & movement patterns by using the stabilizing cervical musculature. Sessions: 1 per week for maximum of 6 weeks. Physical Therapy (PT): Combined treatments but active exercises was the strategy to improve strength, ROM, postural exercises, stretching, relaxation exercises, & functional exercises. Manual traction, stretching, massage, interferential current or heat could precede exercise, but specific manual mobilization techniques not included. 30 minute treatment sessions, 2X/week with a maximum of 12 treatments. Continued care by General Practitioner: Including advice on prognosis, self-care, advice on ergonomics (size of pillow, work position) & encouragement to await further recovery. Also an educational booklet with advice & exercises. Meds: paracetamol or NSAIDs. 10 min follow-up visits scheduled every 2 weeks were optional. Jull, PT, PhD, et al. Randomized Controlled Trial of Exercise & Manipulative Therapy for Cervicogenic Headache. Spine; 2002 27(17): 1835-1843. Randomized Controlled trial for cervicogenic headache (CHA) in 200 patients with follow-up at 7 weeks, 3, 6, & 12 months to determine effectiveness of manipulative therapy (MT) (Maitland type includes low-velocity cervical joint mobilization [passive, rhythmical joint movements] & high-velocity manipulation), exercise therapy (ExT) emphasizing motor control rather than strength (low-load endurance exercises to train muscle control of the cervicoscapular region) or a combination of both (MT & ExT) vs a control group. Patients received 8 to 12 visits over 6 weeks. Outcomes: headache frequency, intensity, duration, Northwick Park Neck Pain Index, medication use, Patient satisfaction, pain or neck movement, upper cervical joint tenderness, craniocervical flexion muscle test, & posture measures. Results: Both MT & ExT signif reduced CHA frequency, 98

intensity, neck pain & benefits were maintained at 12 month follow-up. Effect sizes were at least moderate & clinically relevant. 72% of patients in MT, ExT or Combined groups achieved reductions of 50% or more in headache frequency at 12 month follow-up, with 42% reporting 80% to 100% relief at 12 months, indicating clinically relevant results. Combined MT + ExT were not superior to either treatment alone except for duration of headache, but 10% more patients gained relief which is clinically significant. Thus, it could be argued that MT & ExT should be used in combination for CHA to ensure optimal effects are gained across all outcomes over the long term. Martelletti, MD. JNMS 1995; 3(4): 182-187. Criteria for Cervicogenic Headache: 1) sidelocked head pain; 2) symptom of neck involvement: 2A) Attack provocating factors: either/or 2B.) Neck movement and/or sustained, awkward positioning of the neck; 2C.) Mechanical pressure towards ipsilat upper post neck region, or occipital region; 3) Ipsilat neck/shoulder/arm pain, 4) Reduced kinetic range in C-sp 5) Typical pain characteristics: either/or 5A) Nonclustering pain episodes of varying duration (or fluctuating, continuous pain); 5B) Moderate, nonthrobbing pain, originating in the neck, spreading forward; 6) Female preponderance (M: F = 1:4); 7) Frequent history of head/neck trauma. 36 patients were treated with spinal manipulation 3X/week for 4 weeks using Diversified. Patients were allowed to take analgesics or antiinflammatory drugs to assess the effect of spinal manipulation on pain & on total amount of daily analgesics. Pain intensity was recorded in daily headache diary, duration of headache in hours, amounts of analgesics or anti-inflammatory. Results: There was a progressive decrease in total pain index (TPI) as well as drug consumption index (DCI). The declines of both began immediately after the start of spinal manipulation & remained signif lowered even during the 4 week follow-up. Chapman-Smith, JD. The formation of the North American Cervicogenic Headache Society (NACHS). Chiropractic Report 1996; 10(5): 1, 6. NACHS established in Sept 1995 has a multidisciplinary board. The President is Peter Rothbard, MD, anesthesiologist & pain management specialist who frequently refers patients with headache for chiropractic care. Board members include Howard Vernon, DC & Scott Haldeman, DC, MD, PhD & Nikolai Bogduk, MD, PhD. An anatomical & physiological explanation for cervicogenic headache has been clearly established. Most headachologists are neurologists & don’t have the skills or desire to examine & investigate the neck. We feel that it is very important to study how neck pathology can cause headaches so this information becomes integrated into the mainstream of headache etiology & treatment. We are therefore starting NACHS. Cervicogenic headache defined: referred pain perceived in any region of the head caused by a primary nociceptive source in the musculoskeletal tissues innervated by cervical nerves. Bogduk, MD, PhD. JMPT 1992;15(1):67-70. Cervicogenic headache: Pain perceived as arising in the head, but whose actual source lies not in the head but in the C-spine. The trigeminocervical nucleus (cells in the upper 3 cervical segments) receive trigeminal & cervical peripheral input. The basis of cervicogenic headache is the convergence within the trigeminocervical nucleus. In the absence of other sensory information, second order neurons that receive both trigeminal & cervical input have no means of determining whether they are activated by trigeminal or cervical afferents. If a second order neuron that is accustomed to a trigeminal input receives noxious input from an unaccustomed cervical source, the brain relying on familiarity with the more accustomed input interprets the pain as arising from the trigeminal field & not the neck. Cervicogenic headache felt in the occiput, is due to convergence between the deep cervical nociceptor axons & axons that innervate the occipit occur. Interneurons of the trigeminocervical nucleus have extensive receptive fields that encompass both the field of the trigeminal N & the fields of the first 3 cervical Ns. These neurons have central connections that 99

are poorly organized somatotopically. Information relayed by them is interpreted as arising from anywhere within the peripheral (trigeminocervical) receptive field. Due to the convergence between trigeminal & first 3 cervical spine N afferents, the possible sources of cervicogenic headache are any structures innervated by C2-C3 Ns. Distribution of C1-C3 Spinal Nerves: 1) C1-C3 Ventral rami: atlanto-occipital joint, lat atlantoaxial joint, longus capitus, longus cervicis, recius capitis ant, rectus capitus lateralis, trapezius & SCM (both receive motor supply from spinal accessory N but their sensory supply is cervical), dura mater of post fossa, vert artery. C13 ventral rami communicate with 10th & 12th cranial Ns which innervate the posterior cranial fossa & inferior surface of the tentorium cerebelli. 2) C1-C3 Sinuvertebral Nerves: median atlantoaxial joint, transverse ligaments, alar ligaments, dura mater of spinal cord, dura mater of clivus, C2-3 intervertebral disc. 3) C1-C32 DORSAL RAMI: C2-3, C3-4 facet joints, suboccipital muscles, semispinalis capitus, semispinalis cervicus, multifidi, longissiums capitus, splenius capitus. Pathology: cervicogenic headache can arise from any of the above sources. Conclusion: The actual prevalence of cervicogenic headache is unknowon, but there is the prospect that a large proportion of patients diagnosed with tension headache may be suffering from cervicogenic headache. Pikus, MD & Phillips, MD. Headache; 1995; Nov/Dec: 621-629. Cervicogenic headache is associated with unilateral head pain without side-shift (all 27 patients had occipital or suboccipital pain, 80% also have parietotemporal pain. 69% had retro-orbital pain, 37% had frontal pain). When pain is severe it can cross the midline. Pain is usually moderate, infrequently throbbing, may become excruciating. Most frequently pain starts in the upper neck or posterior craniocervical jct with spread to the vertex, frontal. Temporal or retro-orbital regions. Patients have S & S of neck problems. Pain may be triggered by neck movements and/or awkward positioning. ROM may be decreased. Pressure of craniocervical jct may induce pain. Common to also have ipsilateral arm and/or shoulder pain. Symptoms of autonomic dysfunction such as nausea, vomiting, periocular or fascial edema or flushing is common. Many patients have history of trauma to head or neck. Involvement is most commonly of C2, but C1 & C3 are commonly involved. The anatomical origin of pain impulses arriving at the dorsolateral cervical cord is likely to be a relay area for pain from many cranial vessels. This area also receives input from cervical roots which can be misconstrued. Thus, a form of referred pain links cervical pathology to headache. Pearce, MD. Cephalgia 1995; 15:463-469. The neuro-anatomical basis for cervicogenic headache is thought to be the convergence in the trigeminocervical nucleus between pain afferents from the field of the trigeminal nerve & the receptive fields of C1-3. Structures innervated by C1-3 can cause cervicogenic headache. Pain may arise in muscle, jts, & ligaments but also from dura, posterior fossa S & vert arteries. Input from joints or C1-3 roots may activate trigeminal sensory nerve fibers in the brainstem. This may trigger efferents through the facial nerve to the greater petrosal nerve which innervates autonomic pathways in the cranial vessels & may explain a throbbing vascular type of pain. The fibers from C2 innervate the occiput & may be the origin of occipital headache. Zwart, J-A, MD. Headache 1997; Jan: 6-11. Neck Mobility in Different Headaches. Assessed neck mobility in 90 patients with headache disorders: 28 had migraine (MI), 34 tension-type headache (TH), 28 cervicogenic headache (CH) & compared the findings with those in 51 controls. Criteria for Cervicogenic headache. Unilat headache without sideshift. Attack provoked by neck movements or pressure. Ipsilateral nonradicular shoulder/arm pain. Positive blockade effect of greater occipital nerve. No significant radiological abnormalities have been found in patients with cervicogenic headache. Reduced neck mobility is a major criteria for the diagnosis of CH. 100

Cramer GD, DC, PhD. Top Clin Chiro 1998; 5(1): 1-10. Anatomy of the cervical spine with respect to head pain. The spinal nucleus of the trigeminal nerve is intermixed with the dorsal horn of the upper 2 to 3 cervical spinal cord segments. This region receives nociceptor (pain) input from the upper 3 cervical cord segments as well & is frequently described as the trigeminocervical nucleus. Many upper cervical dorsal horn neurons in this region receive afferents from both nerves of the upper cervical segments & the trigeminal nerve which serves as the neuro-anatomical basis for referring head pain to the neck & neck pain to the anterior head. The Trigeminal Nerve supplies the majority of pain generators of the head including Custaneous areas of the face, TMJ, Cornea, Nasal mucosa, teeth & gums, Oral mucosa & anter 2/3 of the tongue, Paranasal sinus, Intracranial blood vessels- dural arteries, superior sagittal sinus, large vessels of the brain including superior cerebellar, rostal basilar, middle cerebral & portions of the circle of Willis, extracranial vessels: superficial temporal artery, middle meningeal artery. Sessle BJ, BDS, MDS, PhD. Top Clin Chiro 1998; 5(1):36-8. The majority of interneurons transmitting pain in the trigeminocervical nucleus can be excited by peripheral afferents supplying craniofacial muscles, the TMJ, cutaneous or mucosal noxious stimuli. These interneurons receive nociceptor input from both deep & superficial structures & therefore contribute to poor localization, pain spread & referral from deep tissues. About 50% of these neurons can also be excited by cervical afferents supplying superficial or deep structures in the neck – a mechanism contributing to pain spread & referral between craniofacial & cervical tissues. Because these interneurons can be excited by multiple inputs they can become sensitized (exhibit increased excitability to input). These neuroplastic changes in NC interneurons & in associated altered jaw muscle output pathways may be involved in the development of conditions that manifest pain & neuromuscular changes including TMJ & cervical disorders. Rook, MD. In Cassvan et al (ed). Cumulative trauma disorders. Butterworth-Heinemann 1997: 31-42. There is convergence of nociceptor information from head & neck structures onto 2nd order neuron pain transmission cells in the nucleus caudalis. In the neck, nociceptor information from cervical structures or irritated occipital nerves (C1-C3) travel into the upper spinal cord portion of the nucleus caudalis. Nociceptor impulses from cranial structures are transmitted to the brain stem nucleus caudalis. There is extensive convergence of neural input from neck & jaw musculature onto 2nd order pain transmission cells in the nucleus caudalis. Over time the convergence of noxious impulses may sensitive 2nd order pain transmission cells which activate pain pathways to the thalamus. Before this pathway reaches the thalamus, neural connections at the midbrain raphe nuclei stimulate ascending the serotonergic system to cererbral blood vessels, releasing serotonin which may underlie the vascular abnormalities in migraine headaches. Serotonin released from the ascending system binds to receptors on nerve terminals of C & A delta fibers surrounding the cerebral blood vessels & trigeminal vascular system. Binding of serotonin causes release of neurotransmitters including sub P, CGRP, & other neuropeptides which interact with the blood vessel wall producing dilatation, plasma extravasation, & sterile inflam. Sub P increases vascular permeability & dilates cerebral blood vessels. Sub P activates macrophages to synthesize thromboxanes, activate lymphocytes & at high concentrations to degranulate mast cells & release histamine resulting in local inflam. These pain producing substances cause nociceptor impulses along trigeminal N fibers to 2nd order pain neurons in the nucleus caudalis perpetuating this cycle. Decreasing nociceptive input to the nucleus caudalis via physical modalities & meds aimed at decreasing noxious input from TMJ, cervical muscles, occipital Ns, & facial structures may prove helpful. Decreasing supraspinal influences that may up-regulate the nucleus caudalis projection neurons. Psychotherapeutic techniques & meds aimed at treating depression, tension, anxiety. Meds that prevent thte release of serotonin and/or 101

block the effect of serotonin at cerebral blood vessels have proven effective in treatment of vascular headache. Ergot, tricyclic antidepressants, propranolol, verapamil, Imitrex. Otte A et al. PET & SPECT in whiplash syndrome. J Neurol Neurosurg Psychiatry 1997; 63: 368-372. This study evaluates perfusion & glucose metabolism in the whiplash brain. Using SPECT & PET, 6 patients with whiplash & 12 controls were evaluated. IN patients there was significant bilateral hypometabolism & hopoperfusion in the parieto-occipital regions. Stimulation of pain sensitive afferences of the trigeminal system has widespread effects on local vasoactive peptides & the cranial vascular system. Hence, our hypothesis is that parieto-occipital hypometabolism may be caused by activation of nociceptor afferences from the upper cervical spine. This study indicates abnormalities in glucose metabolism in the whiplash brain. Brain injury in whiplash patients may be under reported, as CT or MRI showed normal brain findings in all investigated patients. Most of patients complained of nonspecific symptoms such as concentration & memory disturbances, which are often seen in other brain disorders as well. It could be that the parietio-occipital region of hypoperfusion & glucose hypo-metabolism is the “substrate” of some of the cognitive disturbances in some patients after whiplash injury of the neck. Terrett, DC. Cerebral dysfunction: a theory to explain some of the effects of chiropractic manipulation. Chiro tech 1993; 5(4): 168-173. Brian Hibernation: a decrease in cerebral blood flow (CBF) may cause parts of the brain to “hibernate.” Blood flow is too low for completely normal functioning but not low enough to cause irreversible tissue damage. Cells remain alive but function has ceased. If CBF is restored, function resumes. If spinal manipulation can reactivate hibernating cerebral neurons the implications are enormous. Need to measure CBF pre & post spinal manipulation, etc. Zhang studied 114 subjects who had improved vision postspinal manipulation. He measured CBF in 18 subjects & showed it was greatly improved postspinal manipulation. 2 MDs (Milne (GP) & Gorman (opthalmologist)) have used spinal manipulation for headache & visual problems & often noted relief of other symptoms like tiredness, dizziness. Milne proposed arterial insufficiency to the brain caused many common disorders which could be relieved with spinal manipulation. They propose that restriction in CBF can occur because vertebrae that guide the vertebral arteries to the brain are misaligned or malfunctioning creating stress & constricting the lumens. If CBF falls below a critical level, the cells remain alive but don’t function. This state can persist indefinitely. As ischemia increases the number of functioning cerebral cells decreases & the disability becomes more severe. This cerebral arterial insufficiency causes no loss of core brain function but affects sophisticated brain functions (concentration, peripheral vision, mood, emotion). It requires more active brain function to be happy, have a good memory, perform complicated physical & mental tasks, to be articulate, etc. These disabilities are often ignored because they are not pathologic nor detectable on X-ray, CT, blood work, etc., don’t respond to usual treatment. They propose that cervical spinal manipulation by restoring alignment/function increases CBF & functioning. Gorman reported on 12 patients with visual disorders who had spinal manipulation. 4 opthalmologists examined the patients pre & post spinal manipulation. In all cases the vision improved (either visual field or acuity). Also noted were nonvisual improvements: headaches, less tired, feeling better, more alert etc. Licht, P. MD, PhD. Vertebral artery blood flow during chiropractic treatment of the cervical column. PhD Thesis. Odense University, Denmark 2000: 67. Cervical manipulation had a modest effect on vertebral artery volume blood flow, median maximal increase of 20%, in pigs which increased for 20-40 sec & then returned to baseline values. We measured flow velocity & volume blood flow in the human vertebral artery by non-invasive color-duplex technique before & after spinal manipulation & found no change. A short live defect similar to these experimental 102

findings could have passed undetected in the human study because we measured flow velocity only twice, immediately before & 3 minutes after spinal manipulation. However, we assumed that flow changes of similar magnitude as in the pig study would not be of clinical relevance. Kelly DD, Murphy DC, PhD, Backhouse DC. JMPT 2000; 23(4): 246-251. Study uses a mental rotation reaction time test to measure spinal manipulation effects on cortical processing to see if cortical processing, measured by response time is altered by spinal manipulation. Mental rotation reaction time tests require subjects to judge if an object is in its normal orientation or its mirror image. The task is complex when images are presented at varied angles. Reaction time increases as the angular disparity increases, suggesting that subjects mentally rotate the object into its normal position before responding. This requires more cortical processing than a simple recognition test & has a longer central processing component. Rotation reaction time may demonstrate the effects of interventions that affect cortical processing vs peripheral neuromuscular changes that affect movement time. 36 chiropractic students with upper cervical subluxations (based on static & motion palpation) were randomized. 18 subjects in (experimental group) received a toggle recoil upper cervical adjustment & 18 controls rested for 2 minutes & then were retested. Subjects responded “N” for normal or “B” for backward when presented with the capital letter “R” in either normal or mirror-reversed orientation, both randomly presented at angles of 0 deg, 45 deg, 90 deg, 135 deg, 225 deg, 270 deg, & 315 deg for 80 stimulus presentations. The reaction time was compared to evaluate the change in cognitive processing. Results: The average decrease in reaction times in the experimental group was 98 ms, a 14.9% improvement, whereas the average decrease in the control group was 58 ms, a 8.0% improvement. Results demonstrate a signif improvement for both groups. The reaction time improvement of the experimental group was signif greater than that of the control group. A decrease in reaction time occurred in both groups, but the significantly greater improvement in reaction time for the experimental group suggests that the upper cervical adjustment may have resulted in an effect on cognitive function beyond that of a learning effect alone. Conclusion: Study demonstrates a signif improv’t. in cognitive function, as measured by an improved reaction time to a mental rotation task after upper cervical adjustments. More research is needed to investigate the mechanism of these effects. Hides JA, PhD et al. Multifidus muscle recovery is not automatic after resolution of acute, firstepisode low back pain. Spine 1996;21(23):2763-2769. 39 patients with first episode unilateral acute low back pain & unilat, segmental inhibition of the multifidus muscle (identified by diagnostic ultrasound) were randomized to 1) a control (pain meds) or 2) Treatment group (meds & exercise) to evaluate the effectiveness of localized exercise to improve multifidi’s stabilizing role. Inhibition of multifidus occurs with acute, first episode low back pain & pathologic changes in this muscle are linked with poor outcome & recurrence of symptoms. Results: Multifidi muscle recovery was not spontaneous on remission of painful symptoms in control group (pain meds only). Muscle recovery was more rapid & more complete in patients in exercise group muscular. Conclusions: Lack of localized, muscle support may be a reason for the high recurrence rate of low back pain following an initial episode. Patients with acute low back pain in this study whose pain had resolved had resumed a normal level of activity, but it is possible that they did so with a predisposition to further injury & recurrence of low back pain. Multifidus recovery from inhibition associated with first episode low back pain doesn’t occur automatically with resolution of pain & disability. Even when functional levels of activity returned to nl (at 10 weeks follow-up), muscle size did not return to nl. This may be one factor that contributes to the high recurrence rate of low back pain after an episode of low back pain – a high proportion of patients may have a deficit in their lumbar muscular stabilizing capacity despite their lack of pain. 103

Richardson, PhD, Bphyt et al. Therapeutic Exercise for Spinal Stabilization in Low Back Pain. Scientific Basis and Clinical Approach. Churchill Livingstone 1999: 74. Despite relief of pain and return to activities of daily living, patients in control group displayed decreased MF which persisted to the 10 week follow-up. Persistence of segmental MF inhibition, still evident at 10 week follow-up in the control group, exposed the injured segment to decreased muscle support & a predisposition to further injury. 1 year results showed only 30% of subjects who performed exercises suffered recurrences of low back pain vs 80% of subjects in the control group. The rapidity of onset & localized distribution of the decrease in muscle size suggest that disuse atrophy was not the cause. The most likely mechanism is reflex inhibition which was still seen after resolution of pain in the control group patients. Possible mechanism for the selective inhibition of the MF at the affected level – it is sensory innervation of the injured joint or structure which is the crucial element in reflex inhibition. It has been suggested that input from the joint is processed & modulated in the spinal cord to produce an effect in specific muscles which act on the joint in question. The parts of MF crossing the affected segmental level seem to be the specific parts of the muscle which are affected by reflex inhibition. Waddell, MD. In Weinstein, Wiesel (eds). The Lumbar Spine. Saunders 1990: 38-56. Disc surgery has survived the test of time; at least 70 to 80% of carefully selected patients experience relief. Such dramatic surgical success, unfortunately, apply to only some 1% of patients with low back disorders. Our failure is in the remaining 99% of patients with simple backache, for whom, despite new investigations & all our treatments, the problem has become progressively worse. In most patients with simple backache, we cannot identify any definite pathologic condition or even the anatomic source of pain. Somatic Referred Pain Cramer, DC, PhD, Darby, PhD. Top Clin Chiro 1996; 3(3): 1-8. Somatic Referred Pain: Pain of somatic origin felt distant to the structure generating it. It is poorly localized. Why? Pain input is dispersed by ascending & descending several segments within fibers that make up the tract of Lissauer before synapsing with interneurons. Pain input entering from several different spinal cord segments converges on the same interneurons receiving input from different somatic regions. Dispersal of afferents onto different second order neurons in combination with the convergence of several different afferents onto a single second order neuron decrease the ability of the CNS to localize nociception. This type of dispersal & convergence is also found at the 2nd synapse along the pain pathway in the thalamus which transmits impulses to the postcentral gyrus of the cerebral cortex. The region of the back is represented on a small area of the Sensory Homonculus of the cortex. This may also contribute to poor localization of pain of spinal origin. In addition, the same ascending pain pathways carry pain input from cutaneous areas. Therefore, when these tracts are stimulated, the cerebral cortex may interpret impulses as originating from a cutaneous region. Cramer GD, DC, PhD. Anatomy of the cervical spine with respect to head pain. Top Clin Chiro 1998; 5(1): 1-10. The region of the sensory homunculus related to the neck is very small & is very closely related to the posterior region of the head (suboccipital & occipital regions). There is a great deal of overlap which helps explain the broad referral of neck pain to the posterior head. Somatovisceral Connections Patterson, PhD. J Canadian Chiro Assoc 1992;36(2) June 107-8. With inflam the number of active joint receptors increases dramatically, perhaps by a factor of 10. There are potent effects 104

of such a dramatic increase in input to the cord & higher centers of the CNS in terms of spinal reflex function & long-term excitability, as well as the interactions between somatic sensory inputs & autonomic outflows from the cord. Up to 80% of spinal interneurons which receive input from somatic afferents also receive input from visceral afferents. Thus a tremendous increase in somatic input could not help but disrupt normal autonomic outflow patterns, disrupting nl body function & homeostasis. Nansel, PhD. Somatic-Visceral Mimicry syndromes. JMPT 1995; 18(62):379-397. Nociceptive afferents from deep somatic structures converge on the same central neuronal pools as do the afferent fibers transmitting noxious stimulation from regionally related visceral structures. Both of these afferent inputs can result in S&S that may be indistinguishable with respect to their somatic vs visceral etiologies. Somatic dysfunction can often mimic symptoms of visceral disease & be mistaken for it, & is supported by an impressive amount of both experimental & clinical data. Nansel, PhD, Szlazak, DC. JMPT 1997; 20(3): 219-224. There isn’t any scientific evidence for the existence of a segmental, neuronally mediated somatovisceral disease mechanism. The evidence doesn’t support the view that autonomic nerves have the capability for inducing tissue pathology in any of their innervated organs. Nor, is there the slightest clinical evidence that patients with broken necks or broken backs or patients with entire hips or shoulders blown apart by shotgun blasts or patients with mechanical neck or low back dysfunction go on to develop higher incidences of any segmentally or regionally related internal organ disease. We fail to comprehend the evolutionary advantage of an “innate” neuronal reflex mechanism by which an inflamed facet joint or a subluxated L5 vert would initiate a set of maladaptive, segmentally directed reflex responses that would orchestrate various disease processes in the prostate, appendix or colon. Overwhelming evidence leaves little doubt that dysfunction involving deep somatic structures can often produce signs & symptoms which mimic (rather than cause) internal organ disease. Whether or not spinal manipulation is an effective strategy for managing any internal organ disease, the phenomenon of somatic visceral simulation is a separate issue to be dealt with clinically. What is at issue is for how much longer, the chiropractic profession will continue to embrace its “nerve interference” theories in spite of the glaring inconsistencies they impose on the current scientific knowledge base. Leboeuf-Yde DC, PhD, et al. The types and frequencies of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulative therapy. JMPT 1999;22(9):559-564. Retrospective study of the frequency & types of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulation obtained through standardized interviews of 1504 chiropractic patients on return visit within 2 weeks of previous treatment. Study done in private practices of 87 Swedish DCs. Outcome: Self-reported improved nonmusculoskeletal (non-MS) symptoms. Results: At least 1 improved non-MS Symptom was reported after the previous treatment (342 of 1504) in 23% of cases. 26% were related to airway passages (usually: easier to breathe); 25% were related to the digestive system (improved function); 14% were under eyes/vision (usually improved vision), & 14% under heart/circulation. The number of spinal areas treatment was associated with the number of reactions. Patients treated in only 1 area, 15% reported a non-MS response; 2 areas – 22%, 3 areas – 32%, 4 areas – 35%. None of the patients had sought care primarily for non-MS conditions & Swedish DCs do not emphasize non-MS benefits of care. All benefits are reported by patients & none have objective verification to confirm their veracity. Whether the link between treatment and reaction is causal or not cannot be shown. The occurrence of reported reactions increased with the number of areas treated with about twice as many in those treatment in 4 areas than in only 1. Findings warrant further investigation. 105

Waddell G, MD. The Back Pain Revolution. Churchill Livingstone 1998. Finding a painful site does not diagnose the pathology. The various structures at one segmental level are closely linked, share common innervation & function together. So even when we localize pain to one level, that may not tell us which of the structures at that level is the cause of the problem. Bigos, MD. Acute Low Back Pain in Adults. Agency for Health Care Policy & Research, Dec 1994: 8. Different clinical disciplines use a variety of diagnoses that suggest a cause for low back pain. However, these labels are often unreliable for categorizing causes of acute low back pain. Even after an extensive workup, only @ 15% of patients can be given a definitive diagnosis. The panel classified low back pain into 3 descriptive clinical categories: 1. Potentially serious conditions: A) spinal tumors, B) infection, C) fracture, D) cauda equina syndrome 2. Sciatica: back-related lower limb symptoms suggesting nerve root compromise. 3. Nonspecific back symptoms: symptoms occurring primarily in the back that suggest neither nerve root compromise nor serious underlying condition Initial assessment for acute low back pain focuses on the detection of “Red Flags”: indicators of serious spinal or nonspinal pathology: A) For Fracture: Major trauma, minor trauma in older or potentially osteoporotic patients; B) Possible Tumor or Infection: age over 50 or under 20, history of cancer, symptoms: recent fever or chills or unexplained weight loss. Risk factors for spinal infection: IV drug use, recent bacterial infection, immunosuppression. Pain worsens when supine, severe nighttime pain. C) Possible Cauda Equina Syndrome: saddle anesthesia, recent onset of bladder or bowel dysfunction, severe or progressive neuro deficit in lower limb; on PE: laxity of anal sphincter, perianal/perineal sensory loss, major motor weakness of quads, ankle plantar flexors, evertors & dorsiflexors The Benefits of Adjustments: Once DCs rule out serious pathologies such as fractures, infections, tumors & cauda equina syndrome as the federal guidelines suggest), we know the patient is in good hands because all the mechanical tissues of the back including: Muscles, Ligaments, Joint Capsules, & Discs – Respond to & heal well if we adjust them. Because adjusting restors motion & overcomes abnormal restrictive barriers. This helps: 1. Restore motion – both symmetry & ROM; 2. Normalize biomechanics & load distribution; 3. Pump out waste products & edematous fluid; 4. Improves nutrition to discs & articular cartilage; 5. Relax tight muscles; 6. Normalize proprioception – position sense & kinesthesia; 7. Stimulate sensorymotor reflexes which improve dynamic muscular stabilization of joints; 8. Accelerate healing – because movement: A. Increases metaboilic rate; B. Increases collagen & protein production; 9. Improves the alignment of new connective tissue. Wiesel, MD. Backletter 1994; 9(4): 37, 38, 44. Surgery rates vary dramatically. Studies find up to 9X differences in fusion surgery rates among different regions of US. 12X differences in back surgery rates between cities 200 miles apart in New England. 17X variations between counties in Washington state. There is no scientific evidence that higher surgery rates are doing patients any good. Most forms of spine surgery haven’t been subjected to systemic scientific assessment. There is little evidence that they provide long term benefit in low back pain. Managed Care Organizations are projecting spine surgeon staffing levels that would strict the availability of surgery substantially. Depending on the course of health care reform, a large number of orthopedic surgeons may have to change fields or treat far fewer patients.

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Bigos, MD. Agency for Health Care Policy & Research Guidelines. Patient Guide: Even a lot of back pain doesn’t by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back pain. Davis, MD. Spine 1994; 19(10): 1117-1124. Surgery rates have been increasing dramatically. Cervical fusion 1979-81: 22,000/year; 1988-90: 48,000/year. Lumbar fusion 1979-81: 18,000/year; 1988-90: 38,000/year. Franklin, MD. Spine 1994; 19(17):1897-1904. Work comp study of 388 patients who had lumbar fusions had 2 year post surgery follow-up. Overall 68% were disabled & 23% required further lumbar surgery. Most patients (67.7%) reported that back pain was worse & overall quality of life (55.8%) was no better or worse than before surgery. Wiesel, MD. Backletter 1994; 9(12):133, 142. study found 68% of surgical candidates with discogenic low back pain who didn’t have surgery were substantially better 3 years later. These outcomes appear as good or better than those reported by surgery for this condition. Discogenic low back pain has a favorable natural history in patients who don’t have significant psychological problems. Very few studies of fusion surgery for back pain show a success rate as high as 68%. Wiesel, MD. Backletter 1994; 9(5):51. Many cases of neck (NP) defy accurate diagnosis, given our current diagnosis capabilities. It is fair to say, says Nikolai Bogduk, that imaging & clinical tests for neck pain are useless. All common tests for neck pain produce substantial levels of false-positive results. Roughly a third of imaging tests reveal asymptomatic abnormalities. Physical maneuvers are imprecise at best. Uncontrolled facet joint blocks lead to false-positive results in up to 35% of patients. Cervical discography also produces high levels of false positives. Bigos, MD. Acute Low Back Problems in Adults. Clinical Practice Guidelines. December 1994; 67-81. To order: (80) 358-9295. Special studies: Tests to Provide Anatomic Definition: Abnormal findings on anatomic studies such as CT, MRI, myelography & discography may be misleading if not corroborated with evidence of physiologic abnormality from the history, physical exam or physiologic tests. One problem with imaging studies: in many patients there is an inability to find any defects. Another problem is a lack of a “gold standard” in determining if an anatomic defect seen on imaging tests is actually the cause of symptoms. Anatomic abnormalities such as degenerative changes & bulging & herniated discs, are found to increase with aging in subjects asymptomatic for low back pain. Plain film X-rays: Degeneration: IN all studies reviewed, degenerative changes were noted in some subjects with no history of low back pain whereas subjects with back pain showed no degen changes. Some studies found no signif difference in prevalence of degenerative changes between these groups. These studies support the idea that degen changes of the spine are not by themselves a cause of back pain. In fact, many authors suggest that degen changes of the spine are merely signs of aging of the back. Furthermore, degen changes were seen more commonly with increasing age for both those with and those without a history of low back pain. Other findings in patients with acute low back pain included transitional vert, spina bifida occulta, increased or decreased lordosis, mild or moderate scoliosis, spondylolysis & DJD. These findings were reported in similar frequency for subjects without symptoms, subjects reporting back injury claim & for subjects disabled for > 6 months. This confirms that multiple studies have questioned both the use of L-radiographs for pre-employment screening & the diagnosis signif of many radiologic findings. Summary: plain lumbar x-rays are useful in detecting or 107

defining spinal fxs, but alone don’t rule in or out tumors or infections suspected by other findings. Plain films are rarely useful in evaluating or guiding treatment of adult acute low back pain in the absence of red flags. Plain films aren’t effective or diagnosing lumbar nerve root impingement of herniated disc or spinal stenosis or for R/O cancer or infection. The use of Lfilms for spinal degen, congenital abnormalities, spondylolysis, listehsis or scoliosis very rarely adds useful clinical info. Only 1 of 2,500 x-rays detects something not suspected on med history & PE that has an impact on patient care. Waddell MD. Bailliere’s Clinical Rheumatology 1992; 6(3): 523-557. The success of modern medicine has been the treatment of serious spinal pathologies. These conditions fit the disease model. The failure of medicine is in the treatment of common non-specific back pain which doesn’t fit the model. If back disability is a result of physiological impairment rather than structural pathology, then the disease model is either appropriate nor effective. Many diseases have been proposed to be the structural basis of low back pain, but no firm evidence that any is the common basis. Yet we search relentlessly for such structural pathology. Many specialists involved in the treatment of back disorders are inappropriate for the majority of patients with low back pain. Orthopedic surgeons with a primary interest in fixable structural problems should not dominate research, treatment & teaching of low back pain. Rheumatologists with a primary interest in inflammatory arthropathies or any other medical specialists constrained by the disease model are equally unsuitable. The main responsibility for management of most low back pain should pass to primary care MDs, Dos, DCs, PTs to rehabilitate rather than medicalize. Recent & Important Clinical Studies: Meade, MD. Br Med J 1990; June 2: 1431-37. Long term benefit (6 week, 6 month, 1 & 2 years) of short term care (10 visits maximum) DC vs MD for low back pain in terms of reduction of disability. Chiropractic more effectively reduced disability. Percent of DC patients who had time loss from work in the 2nd year of study: 21%; MD patients: 35%. Meade, MD. Br Med J 1995; 311: 349-351. 3 year follow-up of 741 patients with low back pain randomized to receive either DC or hospital based outpatient care. Results: Mean Oswestry scores at 3 years represents a 29% greater improvement in patients treated by DCs. The absolute improvement was 14.1 in DCs & 10.9 in hospital patients. Patients with short current episodes, a previous history of back pain, & initial high Oswestry scores derived the most benefit from DCs. The proportion of patients at 3 years who thought their allocated trial treatment had helped their back pain was higher among patients referred to DCs. The substantial benefit of DC treatment in terms of pain is evident early on & then persists throughout the trial. Shekelle, MD, PhD. The Backletter 1994; 9 (6): 61- 62, 68. The evidence on spinal manipulation is much better than for most other back treatments. I think of the treatments that have been tested for acute low back pain, spinal manipulation has probably done the best. There are new treatments that need to be tested and they need it against spinal manipulation to see if they perform better. Spinal manipulation, based on its performance in studies to date, deserves a prominent role in future research on back pain treatment. The North American Spine Society. Spine 1991; 16(10):1161-67. Chiropractic given their highest rating: Procedure Category 1: Generally accepted, well established, widely used. Recommended for up to 3-4 months, within a 1 month optimum. Reinstitution is warranted if there is a flare-up. Also states that prolonged bed rest is detrimental to recovery.

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Twomey, PhD, PT. Physical Therapy 1992; 72(12): 885-892. prolonged rest or avoidance of activity increases duration & severity of back pain. Despite this evidence, bed rest, analgesics, corsets & avoidance of physical activity are still the most commonly prescribed medical treatments. Twomey, PhD, PT. Spine 1995; 20(5): 615-619. Bed rest & analgesics remain the treatment prescribed most by MDs for low back pain despite lack of evidence. Prolonged rest or avoidance of exercise are associated with an increase in the duration & severity of back pain. All elements of the musculoskeletal system (MS) react adversely to inactivity, resulting in weakness & loss of tissue. Prolonged inactivity leads to a loss of muscle bulk, reduction of bone density, reduced ROM, strength, & endurance. The MS system including the spine demands the loading & stress of exercise & movement. Waddell, MD et al. Bed Rest. In Clinical Guidelines for the Management of Acute Low Back Pain 1996: 12, 22. There are now 9 randomized controlled trials of bed rest for acute or recurrent low back pain with or without leg pain. These show consistently that bed rest is not effective. Some patients may initially be confined to bed as a consequence of their pain but this should not be considered as a treatment. Short periods of bed rest are used to treat disc prolapse, but there is little evidence that this is effective. For acute low back pain bed rest for 2-7 days is worse than placebo or ordinary activity. Prolonged bed rest may lead to debilitation, chronic disability & increasing difficulty in rehab. Koes, PhD. JMPT 1992; 15(1):16-23. 256 Subjects with back of neck pain of at least 6 weeks, randomly assigned to 1) physiotherapy (PT), 2) manual therapy, 3) Treatment by MD (general practitioner), 4) placebo. Results; improvement in physical functioning was greatest in manual treatment group at 3, 6, 12 weeks follow-up. Manual treatment had fastest & largest improvement. Number of treatments was only 5.4 versus 14.7 for physiotherapy which had the second best results. Changes in ROM were small & inconsistent. Koes, PhD. JMPT 1993; 16(4): 211-219. At 12 month follow-up, better results were noted for manual treatment than physiotherapy or other groups, especially in chronic patients (symptoms > 1 year) & in patients younger than 40 years old. Koes, PhD, Assendelft, MD. Spine 1996; 21 (24): 2860-2873. An updated review of randomized controlled trials of spinal manipulation for low back pain. Update of 1991 review of randomized controlled trials of spinal manipulation for low back pain. 8 new randomized controlled trials since 1990. Each study’s methodological quality was assessed & scored. Outcomes were noted for acute (< 6 weeks), chronic (> 6 weeks) or mixed groups of patients. Results: 36 randomized controlled trials reviewed. In general, studies are of poor quality. 19 trials (53%) report better results for spinal manipulation than reference treatment (SWD, massage, exercises, analgesics, or placebo). 5 trials report better results in subgroups only. In 10 trials spinal manipulation did no better than reference treatment. Only 16 studies include outcomes of =/> 3 months. 6 report long-term benefits of spinal manipulation. 10 did not. Acute low back pain: (< 6 weeks) 12 Trials of spinal manipulation alone or in combination with other treatments vs reference treatments. 5 had positive results, 4 negative, 3 had positive in a subgroup only. Chronic low back pain: (> 6 weeks) 8 trials – 5 had positive results, 2 negative, 1 had no conclusion. Mixed Populations: 12 trials – 8 reported positive results, 1 negative, & in 1 no conclusion. Placebo Comparisons: 11 trials of spinal manipulation vs a placebo treatment (detuned SWD, sham spinal manipulation). 7 had positive results, 1 positive only in a subgroup & 3 negative studies. Included acute & chronic conditions. Spinal Manipulation is the most frequently studied intervention in randomized controlled trials for low back pain. Results 109

indicate that spinal manipulation is not consistently better than other therapeutic approaches. Most trials report only short-term effects. Long-term effects (>3 months) are seldom reported. 2 of 8 trials since 1990 report long-term results. 10 of 16 trials reporting long-term had negative results – indicates that long-term efficacy remains doubtful. Conclusion: Efficacy of spinal manipulation for acute low back pain has not been convincingly demonstrated with sound randomized controlled trials. There’s at least as much evidence in favor of spinal manipulation for chronic low back pain. However, efficacy of spinal manipulation has not been established for either. There are indications that spinal manipulation might be effective in some subgroups but we’re unable to identify which patients might benefit most. Meeker, DC, MPH. Spine 1996; 21(24):2873. Koes & Assendelft are too cautious. In all the studies on spinal manipulation, not once has the comparison treatment done better. 3 metaanalyses reached different conclusions. 2 government practice parameters consensus methods came to different conclusions. The grading scheme implies better trials are routine in medicine but such is not the case. The article doesn’t note that data on all other treatments for back pain are poorer or even nonexistent. No other treatment for back pain has been evaluated in more clinical trials than spinal manipulation. If estimates from meta-analyses are close, spinal manipulation has @ a 30% advantage over treatments with which it has been compared. NSAIDs, another treatment recommended by Agency for Health Care Policy & Research, have about the same effect size, but have greater health risks. Assendelft, MD, PhD, Koes, PhD et al. The effectiveness for chiropractic for treatment of low back pain. JMPT 1996; 19(8): 499-507. To determine the effectiveness of chiropractic treatment for patients with low back pain, a systematic review of the literature to identify randomized controlled trials on chiropractic was done & methodological quality was assessed independently by 2 reviewers. Results: 8 randomized controlled trials were identified. All randomized controlled trials had serious flaws in their design, execution & reporting. The review did not provide convincing evidence for the effectiveness of chiropractic for acute or chronic low back pain. Conclusions: There is a need for correctly executed trials. Guidelines for uniform execution & reporting of randomized controlled trials should be established. Cherkin, PhD et al. A comparison of physical therapy, chiropractic manipulation, & an educational booklet for treatment of patients with low back pain. NEJM 1998;339(15):10211029. Randomly assigned 321 adults with low back pain persisting 7 days or more after a primary care visit to: 1) McKenzie method of physical therapy, 2) chiropractic spinal manipulation, or 3) educational booklet. Patients with sciatica were excluded. Physical Therapy or Spinal Manipulation for 1 month (number of visits determined by the provider, limited to a max of 9 visits); follow-up at 1 week, 1 month, 1 & 2 years. Bothersomeness of symptoms 7 dysfunction were measured. Results: Chiropractic group (average 6.9 adjustments) had less severe symptoms than the booklet group at 4 weeks (P = 0.02) & there was a trend toward less severe symptoms in the physical therapy group (average 4.5 visits). But, the differences were small & not significant after adjustments for their non-normal distribution. Differences in dysfunction among groups were small & approached signif only at 1 year, with greater dysfunction in the booklet group than in the other 2 groups. For all outcomes, there were no signif differences between the physical therapy & chiropractic groups & no significant differences among the groups in 1) the number of days of reduced activity, 2) missed work or 3) in recurrences of back pain. 75% of subjects in physical therapy & chiropractic groups rated their care as very good or excellent, as compared with 30% of subjects in the booklet group. Over 2 years, the mean costs of care were $437 for the physical therapy group, $429 for the chiropractic group, & $153 for the booklet group. Approximately 60% of patients had >2 previous episodes of back pain @ 50% at 1 year & 70% in 2nd year of all groups had recurrences. Conclusions: For 110

patients with low back pain, the McKenzie method & chiropractic spinal manipulation had similar effects & costs, & patients receiving these treatments had only marginally better outcomes than patients who got an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question. Balon J, Aker PD, et al. A comparison of active and simulated chiropractic manipulation as adjunctive treatment of childhood asthma. NEJM 1998; 339 (15):1013-1020. Randomized trial of chiropractic spinal manipulation for children with mild/moderate asthma. After 3 week baseline, 91 kids with symptoms of asthma despite usual meds were randomized to active or simulated chiropractic spinal manipulation for 4 months. None had previously received chiropractic care. Each child was treated by 1 of 11 DCs. Primary outcome: change in peak expiratory flow (PEF), in the morning, before the use of a bronchodilator, at 2 & 4 months. Adjustment received: 20 to 36. Results: 80 children’s outcomes (38 in active – treatment & 42 in simulated-treatment group) were evaluated. There were small increases (7 to 12 liters per minute) in PEF in both treatment groups, with no signif differences between groups. Symptoms of asthma & use of beta-agonists decreased and the quality of life increased in both groups, with no signif differences between groups. There were no signif changes in spirometric measures or airway responsiveness. Conclusions: In children with mild/moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit. Shekelle P, MD, PhD. What role for chiropractic in health care? NEJM 1998; 339 (15): Chiropractic is becoming more mainstream. Spinal manipulation is the treatment that is used most often & is the method most identified with chiropractic. Chiropractic often includes advice about exercise, nutrition & lifestyle. That spinal manipulation is a somewhat effective symptom therapy for some patients with acute low back pain is, I believe, no longer in dispute. Cherkin’s new study confirms this: Low back pain patients assigned to chiropractic spinal manipulation had a small, marginally signif improvement in symptoms at 4 weeks as compared an educational booklet. What’s in dispute is the efficacy of spinal manipulation in relation to other therapies. Cherkin found no appreciable difference in outcomes between chiropractic spinal manipulation & McKenzie method. Cost-effectiveness of chiropractic relative to other care is also controversial. Cherkin found chiropractic & McKenzie patients incurred about $280 more in costs over 2 years than patients who got an educational booklet. Indirect costs, are unlikely to differ since 1) the numbers of days of reduced activity, 2) days in bed, & 3) days of work lost were similar in all 3 groups. The recurrence rate & the percent of patients who sought care for back pain were similar among groups, casting doubt on the hypothesis that either chiropractic or McKenzie method saves money by reducing the rate of relapse. I conclude that chiropractic for low back pain costs more than the usual supportive med care delivered by Health Management Organizations. Whether the small symptom benefit & the enhanced patient satisfaction are worth this costs is debatable. Before we judge too harshly, remember that many med interventions paid for by insurance companies provide equally small benefits or even none at all. There is evidence from randomized trials that spinal manipulation may be effective for some patients with neck pain. But, efficacy & cost effectiveness of spinal manipulation relative to other therapies has not been established. MDs generally oppose spinal manipulation for treatment of non-MS disorders such as hypertension, asthma, OM, despite numerous case reports of improvement, there is a paucity of data from randomized controlled trials. Balon concluded that the addition of chiropractic spinal manipulation to medical treatment had no effect on the control of childhood asthma. Patients who seek chiropractic for asthma or other non-MS conditions accounts for less than 1% of all patients visits to DCs. There is little evidence to support the value of spinal manipulation for non-MS conditions. It is currently inappropriate to consider chiropractic as a broad-based alternative to traditional medical care. But, for some MS conditions, chiropractic 111

does provide some benefit to some patients. The challenge is to demonstrate that DCs can achieve this benefit at a cost that patients or health insurers are willing to bear. Feather, Felicity. ACA Statement – NEJM study. 10/8/98. Cherkin’s study is the latest but not the most in depth or valid study on low back pain conducted in recent years. The study compares McKenzie method & chiropractic spinal manipulation. McKenzie is often incorporated into some forms of chiropractic treatment. All 3 methods, spinal manipulation, stretching & patient education are important aspects of chiropractic treatment & it is reasonable to expect less favorable outcomes by using only one of these important treatments. Chiropractic treatment isn’t restricted to spinal manipulation. The treatment period was limited to no more than 9 visits. Each patient is different & the course of treatment should be tailored to each patient. 9 or less visits may be adequate, but in other cases > 9 might be needed depending on the clinical presentation. Limitations of the patient pool Excluded were patients with sciatica, prior back surgery, work comp claims, previous chiropractic or physical therapy. Other recent studies found that DCs are experts in the treatment of low back pain. A plethora of research exists demonstrating chiropractic’s efficacy & cost effectiveness. The 1994 Agency for Health Care Policy & Research expert panel concluded that spinal manipulation is recommended & effective form of initial treatment for acute low back pain in adults. RAND corp determined that spinal manipulation is an appropriate treatment for acute low back pain & 94% of all manipulations are performed by DCs. A 1993 study funded by the Ontarior Ministry of Health found chiropractic spinal manipulation was the most effective & efficacious care of low back pain. 1995 study in BMJ supported chiropractic long-term effectiveness in treating low back pain, finding that improvement in all patients at 3 years was @ 29% more in those treated by DCs than in those treated by hospitals. A study in March 1996 Am J Managed Care concluded that managed chiropractic is an extremely promising method of treatment for acute back & acute neck discomfort & recommended its wider application by the managed care industry. Tye, L. Reports rekindle medical debate. MDs challenging alternative care. Boston Globe 1998; Oct 11: A01. Chiropractic may have been the immediate target of last week’s stinging critiques in the NEJM, but it’s the broader empire of alternative medicine that the journal & its allies in mainstream med really are after. Such a campaign wouldn’t have been surprising when mainstream & alt med were openly at war. But this comes in what seemed an era of detent, in which “complementary” practitioners practice alongside of traditional MDs. Last week’s articles make clear that the cease-fire has ceased as the journal, for the 2nd time in a month, attacked alternative medicine for allegedly failing to back its claims of healing power. The intense reaction suggests that rather than embracing an alliance between mainstream & alternative approaches, many MDs had bottled up their grievances & were waiting for the right moment to vent them. “We’ve been giving alt medicine a free ride,” says Dr. Marcia Angell, NEJM exec editor. “MDs wer4e leaning over backwards not to alienate their patients. But they won’t alienate patients by leveling with them, by telling them the truth that there’s very little scientific proof that supports altern med.” Dr. James Gordon, former chair of the advisory council to OAM at NIH views it differently: “The editors of NEJM seem to see themselves functioning not as scientists but as guardians of orthodoxy.” The relationship between mainstream & alt med has been mostly distrustful. MDs saw altern healers as peddling unproven arts that unfairly raised patients’ hopes & raided their pocketbooks. Altern providers saw MDs as promoting toxic & expensive conventional treatments & unwilling to consider remedies used for centuries in other parts of the world. Since Eisenberg’s study there’s been a slow building of bridges. But not everyone bought the new alliance. Many MDs complained, generally in private for fear of alienating their patients. Some strident responses stem partly from legitimate concerns by MDs over the lack of evidence that alt treatments work. “You’re seeing scientific methods applied to evaluating therapies, many of which are basically the placebo effect, & those methods 112

demonstrate that it is the placebo effect,” says Tom Delbanco, MD, coauthor on the 1993 Eisenberg study. Some medical backlash is self-interest. Squeezed by MC, MDs worry that more dollars are going to altern providers. There is journalistic competition between the NEJM & its archival, JAMA. NEJM’s recent focus on alt med was motivated partly by a desire to upstage JAMA which announced plans a year ago to make alt med the centerpiece of an issue due next in Nov 1998. NEJM critiques of alt med are almost certain to continue because they bring into the open simmering issues within the med community. Angell says the recent articles generated a record response in letters & the recent studies on alt treatments are “The tip of the iceberg. . .Finally the scientific community is beginning to mobilize themselves & conduct rigorous studies on these issues.” John Eisenberg, MD, head of The Agency for Health Care Policy & Research notes, “The alt med group have to recognize the rules of evidence used in science to establish what ought to be done for patients. The traditional scientific community must understand there are outcomes & processes of care that patients value. We are starting to measure what patients see as important rather than what laboratory tests show.” Boye G, DC, PhD, Nilsson N, DC, MD, PhD. Spinal manipulation in the treatment of episodic tension-type headache. JAMA 1998;280:1576-1579. 19 week randomized controlled trial to determine effects of spinal manipulation on adults with episodic tension-type headache, 26 M & 49 W (20-59 years) with the diagnosis of episodic tension-type headache were randomized into 2 groups, group 1) received soft tissue therapy & spinal manipulation. Group 2) received soft tissue therapy & a placebo laser treatment (control group). All subjects got 8 treatments over 4 weeks performed by the same DC. Outcomes: 1) Daily hours of headache, 2) pain intensity per episode, 3) daily analgesic use (recorded in diaries). Results: No signif differences between spinal manipulation & control groups in any of the 3 outcomes. By week 7, both groups had signif reductions in 1) Mean daily headache hours (spinal manipulation: from 2.8 to 1.5 hours); (control group: from 3.4 to 1.9 hours); 2) Number of analgesics per day (spinal manipulation: from 0.66 to 0.38); (control group: from 0.82 to 0.59). Changes were maintained through the observation period. Headache pain intensity was unchanged for the duration of the trial. Conclusion: As an isolated intervention, spinal manipulation doesn’t seem to have a positive effect on episodic tension-type headache. Agency for Health Care Policy & Research Guideline #14: Acute Low Back Problems in Adults. Dec 8, 1994. Spinal manipulation: manual therapy for symptomatic relief and functional improvement of the back. Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal manipulation. Spitzer, MD, MPH. Spine 1995; 20 (8S):1S-73S. Quebec Task Force on Whiplash-associated Disorders (WAD). Task Force Consensus: The short-term use of NSAIDs & analgesics, spinal manipulation & mobilization by trained persons & active exercises are useful in Grade II & III WAD, but prolonged use of C-collars, rest or inactivity probably prolongs disability. Early return to usual activities should be encouraged. Van Tulder, PhD et al. Spine 1997; 22(18): 2128-2156. Spinal Manipulation for Acute Low Back Pain (< 6 weeks): 16 randomized controlled trials on spinal manipulation, only 2 were of high quality. 12 trials including the 2 high quality randomized controlled trials reported positive results & 4 trials negative results. There is limited evidence that spinal manipulation is more effective than a placebo treatment for acute low back pain. There is no evidence that spinal manipulation is more effective than other physiotherapeutic applications (massage, SWD, exercises) or drug therapy (analgesics, NSAIDs) for acute low back pain because of contradictory results. Conservative treatment of acute and nonspecific low back pain. A review of randomized controlled trials of common interventions. Spinal manipulation for chronic low 113

back pain: (>12 weeks): 2 high quality & 7 low quality randomized controlled trials. 6 trials including the 2 high quality randomized controlled trials reported positive results, 2 trials reported negative results & in one trial, no clear conclusion was drawn. There is strong evidence that spinal manipulation is more effective than a placebo treatment for chronic low back pain. There is moderate evidence that spinal manipulation is more effective for chronic low back pain than usual care by a general practitioner, bed rest, analgesics & massage. Cherkin, PhD. Presentation at the 4th International forum for Primary Care research on Low Back Pain. Backletter 2000; 15 (5): 50, 57. There have been 40 randomized trials on spinal manipulation for low back pain & even more literature reviews. There is a consensus, based on research, that lumbar spinal manipulation is a reasonably safe procedure for low back pain & has a modestly beneficial effect, at least on pain. There is still controversy as to whether these effects are greater for patients with acute or chronic pain. There is little evidence that spinal manipulation alters long-term back pain outcomes. The effects tend to be short term. There is no strong evidence of any subsequent decrease in medical utilization or cost. I don’t think there is any need for further studies on spinal manipulation for low back pain. However, there have not been any major studies of spinal manipulation for sciatica. Giles, DC, PhD, Muller, PhD. JMPT 1999; 22(6):376-381. Study of 77 patients at a specialized spinal pain syndrome outpatient unit at Townsville General Hospital, Queensland, Australia. Compares 1) Acupuncture (6 treatments in 3-4 week period), 2) NSAIDs: Tenoxicam with Rantiidine (3-4 weeks) & 3) Spinal manipulation (6 treatments in 3-4 week period) for managing chronic (>13 weeks duration) spinal pain syndromes (low back, thoracics, neck) in a prospective, randomized assessed clinical pilot trial. Outcomes: changes in measures at 4 weeks vs initial visit in scores of 1) Oswestry, 2) NDI, 3) VAS of local pain intensity. Results: After a median of 30 days, consistently, over all outcomes, spinal manipulation was the only intervention which achieved statistically significant improvements: a reduction of 30.7% on the Oswestry scale; 2) an improvement of 25% on the NDI, & 3) reductions on the VAS of 50% for low back pain & 46% for upper back pain & 33% for neck pain (all signif). Neither of the other interventions showed any signif improvement on any of the outcome measures. Conclusions: spinal manipulation results in greater improvement than acupuncture & medicine. The most remarkable feature of the results is the absolute consistency; over all outcome measures, the manipulation group displayed the most substantial improvements that were uniformly found to be signif. In the 2 other intervention groups, not a single signif improvement could be found in any of the outcome measures. Breen DC et al. Communication between general and manipulative practitioners. Complementary Therapies in Medicine 2000; 8: 8-14. A survey of 86 MDs in England found that general practitioners preferred referring to physical therapists for manipulation rather than DCs or osteopaths because they felt they had a better understanding of the treatment involved. Chiropractic & osteopathy terminologies were considered more confusing than physical therapy terminology. 60% of the MDs surveyed thought that Fixation was a confusing term; 67% thought Adjustment was confusing; & 42% thought Subluxation was confusing. The use of professional jargon can be a barrier to effective communication. Terms which can be misunderstood due to differences in interpretation are damaging to good communication. The medical definition of subluxation is a partial dislocation of a joint. .This is quite different from the chiropractic meaning which frequently is referring to abnl motion of a joint. Findings reinforce the message that all jargon should be avoided in correspondence. A number of MDs commented that the biggest problem was knowing whether they meant the same thing as the manipulative practitioner when interpreting these words. 114

Del Mar C, MD et al. BMJ 1997; 314: 526-9. A lit search for randomized controlled trials using antibiotics to treat acute otitis media (OM) found only 6 studies of children. The number of randomized controlled trials is small for such a common condition. There is a deficiency of research on this subject. Findings: 60% of children treated with placebo were pain free within 24 hours of presentation. Only 14% of children in control group still had pain 2-7 days after presentation. In these children initial use of antibiotics will reduce pain & contralat OM by a reduction of about 40%. This is equivalent to an absolute benefit of 5.6% fewer children experiencing pain by 2 to 7 days after presentation. Thus, 17 children must be treated at first presentation to prevent one child experiencing pain after 2 to 7 days. Conclusions: Many MDs may be disinclined to use antibiotics at first presentation of OM for so little benefit. Antibiotics had no influence on subsequent attacks of OM or deafness at 1 month. Antibiotics were associated with a near doubling of the risk of vomiting, diarrhea or rashes. Symptoms of OM consist mainly of pain & systemic illness. In 80% of children this is limited to 24 hours duration. Tulberg T, MD, PhD et al. Spine 1998; 23 (10): 1124-28. What are we doing? A rotengen stereophotogrammetric analysis (RSA) was performed before & after manip in 10 standing patients with SI joint dysfunction to see if manip can influence the position between the ilium & sacrum & if positional SI joint tests are valid. Many manual therapists claim good clinical results are a result of a reduction of subluxations. Patients had 12 SI tests (positional tests, functional tests, pain provocation tests). 3 clinicians had to agree that at least 10 of the 12 tests were positive to have the diagnosis of SI joint dysfunction. The positive tests must be normalized after manipulation. RSA is a well documented method for demonstrating minor 3-D movements calculated by computerized mathematical algorithms. It uses two 40 degree angulated roentgen tubes, a reference plate & a calibration device with indicators at known positions are placed between the patient & the film plate. By computed data processing, 3-D translations & rotations of the ilium in relation to the sacrum induced by manip were calculated. Manip: high velocity, low amplitude thrust on the inferior lat angle of the apex of the sacrum followed by mobilization, muscle energy technique, & another high velocity thrust. Results: In none of the 10 patients did manip alter the position of the sacrum in relation to the ilium on RSA, although positional test results changed from positive before manip to nl after. Conclusion: Manip of the SI joint normalized different types of clinical tests but there was no altered position of the SI joint according to RSA. Therefore, the positional test results were not valid & didn’t provide a valid description of SI position. Results neither disprove nor prove possible beneficial clinical effects of manip of the SI joint. Because the positive effects are not a result of a reduction of subluxation, further studies of the effects of manip should focus on the soft tissue response. Cassidy JD, DC, PhD. Point of view. Spine 1998;23(10):1129. Tulberg’s study shows no evidence that manip alters the position of the SI joint. There is no credible evidence that small displacements (subluxations) of the SI joint are responsible for low back pain, yet, the tradition of SI displacement as a cause of low back pain remains strong in some professional circles. Spinal manipulation providers often claim exact specificity in the direction of their corrective thrusts applied to displaced SI joints. Yet, there is no evidence that the SI joint can be repositioned. There is a plethora of proposed mechanisms for how manip exerts its effect but little convincing research to support them. It seems unlikely that the reduction of subluxations occurs after manip. This study adds evidence to refute this hypothesis. Most providers of manip now believe that manip exerts its effect through reflex mechanisms on pain, muscle tension & joint mobility. There is some basic science research support, yet we have no definitive answers yet.

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Seaman D, DC, DABCN, MS. JMPT 1999; 22(1):46-47. With joint hypomobility & the loss of normal movement, mechanoreceptor firing will be suboptimal or decreased. The evidence supports the concept that reduced mechanoreceptor is associated with joint complex dysfunction. Boline, DC. JMPT 1995; 18(3):148-15. Randomized trial compares effectiveness of spinal manipulation and amitriptyline for chronic tension-type headache (HA) using 2 groups. Study has 2 week baseline period, 6 week treatment period & 4 week post-treatment follow-up period. 150 patients between 18 – 70 years with diagnosis of tension-type headache of at least 3 months at a frequency of at least 1X/week. Results: During the 6 week treatment period, both groups improved at very similar rates in all primary outcomes. In relation to baseline values at 4 weeks after cessation of treatment, the spinal manipulation group showed a reduction of 32% in headache intensity, 42% in headache frequency, 30% in over-the-counter medicine usage & an improvement of 16% in functional health status (SF-36). The amitriptyline group showed no improvement or a slight worsening from baseline values in the same major 4 outcome measures. All group differences at 4 weeks after cessation of treatment were statistically significant. SIDE EFFECTS: Of the patients who finished the study 46 (82.1%) in amitriptyline group reported side effects including drowsiness, dry mouth, & weight gain. In the spinal manipulation group 3 patients (4.3%) reported neck soreness & stiffness. CONCLUSIONS: Spinal manipulation is an effective treatment for tension headache. Amitriptyline was slightly more effective in reducing pain at the end of the treatment period but was associated with more side effects. 4 weeks after cessation of treatment, patients who got spinal manipulation had sustained their therapeutic benefit in all major outcomes. The patients who got amitriptyline reverted to baseline values. The sustained benefit associated with spinal manipulation seemed to result in a decreased need for over-the-counter meds. Gibbons, DO, DM-Smed, et al. Short-term effects of cervical manipulation on edge light pupil cycle time: a pilot study. JMPT 2000;23(7):465-469. Edge light pupil cycle time (ELPCT) is a light reflex of the eyes that has been shown to be a measurable constant, unaffected by visual acuity, refractive error, eye color, pupil size, or sex. The reflex is controlled through the autonomic nervous system (ANS). Study investigates the effects of a C1-2 High velocity low amplitude spinal manipulation on ELPCT in a randomized pilot study without a control group in 13 men without eye disease or central or ANS pathology. Subjects had ELPCT measured before & after a high velocity low amplitude rotary thrust to the C1-2 joint on the left (N = 6) & right ( N = 7). Results: spinal manipulation of the C1-2 joint can produce a signif measurable difference between manip before & after ELPCT, with ELPCT becoming signif faster after spinal manipulation. Although there is not agreement among researchers in the balance of the parasymp & symp activity that control the ELPCT, there is agreement that alterations in ELPCT do reflect changes within the ANS. The study found the high velocity low amplitude thrust applied to C1-2 produced a signif effect on the autonomically mediated ELPCT (P = .002). Results suggest there may be an interrelation between somatic & autonomic function & that autonomic function might be altered by manual intervention. This is a preliminary study with a small sample & no control group. Caution should be exercised in interpretation/extrapolation of the results. Moore KL, MD, Noble SL, Pharm D. Drug treatment of migraine: Part 1. Acute therapy & drugrebound headache. Am Fam Physician 1997; 56 (8) Nov 15:2039-2048. Release of vasoactive substances (sub P, CGRP, neurokinin A) from trigeminal nerve fibers induce a sterile inflammatory reaction around the blood vessels of the dura & pia. This “neurogenic inflammation” may be accompanied by vasodilation & is triggered by impulses originating in the caudal trigeminal nucleus. Abortive agents for migraine such as sumatriptan (Imitrex), dihydroergotamine (DHE 45) & ergotamine can reverse neurogenic inflammation by interactions with specific serotonin receptors. Stimulation of inhibitory (5-HT 1) serotonin receptors can turn 116

off neurogenic inflammation, whereas activation of the excitatory (5-HT 2) serotonin receptors lead to migraine. Many meds used for migraine prophylaxis work by blocking 5-HT2 receptors. Lu J, MD, MS, Ebraheim NA, MD. Spine 1998; 23(6): 649-652. Anatomic considerations of C2 Nerve root ganglion. Dissection of dorsal root ganglion (DRG) of C2 nerve root found that the DRG are all proximally placed & occupy most of the foramen & may render the C2 DRG vulnerable to entrapment. C2 ganglia occupy 76% of the foramen height. All C2 DRGs are confined within foramens between the arch of atlas & the lamina of axis. Trauma with extreme rotation/extension (ie whiplash) at the C1-2 joint has the potential to crush the C2 ganglion between the arch of atlas & the lamina of axis and may be implicated in cervicogenic headache. Many patients with cervicogenic headache have a history of motor vehicle accidents & head or neck trauma typical whiplash. C1-2 arthrosis may directly Irritate the C2 N root & ganglion causing occipital neuralgia. Cervicogenic headache may occur as the result of displacement, abnl movements or arthritic changes in the C1-2 joint compromising the C2 ganglion & N root. During combined rotation with extension (whiplash) the post arch of atlas & the superior articular process of axis approximate & contact C2 ganglion. Histologic studies of C2 ganglion show morphologic changes: proliferation of connective tissue in the endoneurium & the ganglion itself, signs of myelin damage & axonal degeneration. Compression or entrapment of the C2 ganglion involves fibers that contribute to the greater occipital nerve. Hack GD, DDS et al. 1998 Medical and Health Annual. Encyclopedia Brittanica, Inc. Chicago 1997: 18-29. In 1995, Hack et al found that the RCPM (rectus capitis posterior minor) muscle extends from the occiput to the posterior arch of atlas & connects via a bridge of connective tissue to the spinal dura. This connection may resist inward folding of the dura which may compromise CSF flow when the neck si extended. Can abnormal tension in the RCPM result in increased tension in the dura & play a role in headache? The dura is extremely sensitive & tension on it during surgery is felt as headache. The muscle-dura connection may transmit forces from neck muscles to the pain sensitive dura. Researchers postulate headache pain may be produced by neck structures. This is accepted by DCs, & osteopaths who perform spinal manipulation in the C-spine. A recent literature relates headaches to injury or pathology of the neck. Studies suggest that spinal manipulation, massage & biofeedback directed at the neck are valuable for managing tension headaches. Spinal manipulation for headache is based on dysfunction in neck muscles contributing to head pain. In the US more than 90% of spinal manipulations are performed by DCs. The muscle-dura connection may represent an anatomic basis for the effectiveness of spinal manipulation which may decrease muscle tension & reduce pain by reducing the forces exerted on the dura via the RCPM. Hack et al have now identified another muscle-dura connection between C1 & C2 involving – the Rectus Capitis Posterior Major & Oblique Capitis Inferior muscles. A role in headache pain is hypothesized as the mechanics of these 2 anatomic structures appear to be similar. McPartland, DO, MS, Brodeur, DC, PhD. J Bodywork & Movement Therapies. 1999;Jan 3035. RCPM dysfunction causes reflex muscles activity in other cervical & jaw muscles & may also cause indirect irritation to the pain sensitive dura resulting in chronic headaches. Dural tension & irritation may ascend directly into the posterior cranial fossa via the falx cerebelli or involve the spinal cord via the second denticulate ligament. Chronic dysfunction of the RCPM may lead to persistent mechanical irritation to the dura & chronic reflexive activity of other cervical & jaw muscles. Injury to the RCPM may irritate the C1 nerve. Chronic C1 irritation may refer pain to the neck & face via C1 connections to C2 & CN 5. Whiplash, Chronicity and Chiropractic Care 117

Murphy D, DC, DABCO. Whiplash biomechanics update. Am J Clin Chiro 1999;9 (3):24-25. During rear end collision the head remains stationary due to its inertia. Since the occupant’s upper back is in contact with the vehicle’s seat, as the vehicle moves forward during the collision the C-spine begins to extend from the lower C-spine. The upper C-sp & occiput are the last to extend. Because of the time lag to extend the upper C-sp during rear-end collision, the C-sp will initially form an “S” configuration with the upper spine in flexion while the lower spine extends. In whiplash, the neck initially forms an S-shaped curvature with lower C-hyperextension & upper flexion which they identify as the injury stage for lower C-joints. The lower cervical extension is actually significant segmental hyperextension consistently exceeding the physiological limits of rotation in extension. The soft tissue, in low velocity impact like whiplash is seldom torn completely. More likely, it is stretched beyond its elastic limit, resulting in incomplete injury. Many whiplash victims subjected to less severe injury, have incomplete soft tissue injuries not readily visualized even by MRI. These patients don’t undergo surgery, so , these soft tissue injuries go under-detected & unidentified. Whiplash patients suffer pain, disability & degenerative changes for many years. Panjabi et al in 1998 speculate that symptoms, especially long-term symptoms, may be due to incomplete soft tissue injuries that may not easily heal. In these sub-failure injuries, soft tissues are not completely torn, but become stretched beyond their elastic limit & constitutes functional injury to the spine. The results will help clinicians direct their attention to the soft tissue injuries in whiplash patients. The results point to lower levels of the C-sp as potential injury sites, esp for low energy rear-end impacts. At higher impact, the upper levels of the C-spine are also prone to injury. Kaneoka K et al. Motion analysis of cervical vert during whiplash loading. Spine 1999; 24(8):763-769. Bogduk N, MD, PhD, DSc. Point of view. Spine 1999;24 (8):770. Studies show that facet injuries are common in fatal motor vehicle accidents. They also show that these injuries are undetectable on plain radiographs. Studies also show that facet joint pain is very common in patients with chronic whiplash & that the assoc psychologic distress disappears when pain is relieved & provides the missing biomechanical link between symptoms & mechanism of injury. This is the most significant advance in the biomechanics of whiplash since the pioneering studies of 1955. As a result, we no longer rely on inference or speculation; we have a direct demonstration of the mechanism of injury in whiplash. The study demonstrates in live human volunteers that in whiplash the lower cervical segments undergo sagittal rotation about an abnormally high IAR. 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 vert below. .This mechanism predicts that the resultant lesions should be tears of the anterior annulus & fx of the facet apophysial joints or contusions of their menisocids. These are the very lesions seen at postmortem. This & previous studies indicate the threshold for symptom injury is approximately 8 kmph (4.96 mph). When subjected to such impact volunteers develop symptoms, but they last a day or two to less than a week. It seems reasonable to expect that patients subject to impacts 4 & 8 times as great could develop lasting injuries & symptoms. Croft DC, MS, MPH, Whiplash Injury: the current model. JACA 2000; 37(7):32-42. In CAD – cervical acceleration/deceleration injury, the occupant’s head rises above head restraint during impact – ramping – due to a gliding up the seat back (as much as 3.5”) & a temporary straightening of the thoracic & cervical spine. The restraint then acts as a fulcrum intensifying the injury. Hyperextension of the lower cervical segments occurs within the first 200 msec & may occur before the head contacts the head restraint. Backset – the distance between the head & the head restraint at the moment of impact. More than 2 inches renders even a well positioned restraint nearly useless. The model of CAD has changed: 1) global (regional) hyperextension is 118

neither necessary as an injury mechanism, nor is it common. Intersegmental hyperextension is more likely a key factor. Early in the crash, within 100 msec after impact, the spine takes on an s-shape with the lower segments in the range of hyperextension, while the upper segments are flexed. This is the point of maximal injury potential. In no cases did global (regional) hyperextension occur. The global neck motion never exceeds the nl ROM, thus gross hyperextension does not occur. Injury can, & often does occur well within the nl ROM. Even the most severe lesions seen at autopsy are often not visible on plain film or MRI. Woodward, MD et al. Injury 1996; 27(9):643-645. The literature suggests 43% of whiplash patients suffer long-term symptoms. If pts are symptomatic after 3 months then there’s almost a 90% chance they will remain so. No conventional treatment has proven effective in chronic cases. Methods: 28 patients randomly selected from chiropractic referrals for chronic whiplash. The severity of patients’ symptoms before & after treatment was assessed independently by a DC & an orthopedist in a structured phone interview. Patients were divided into 4 groups: Group A: symptom free; Group B: mild nuisance symptoms, no pain-killers or interference with work or leisure; Group C: intrusive symptoms that handicap work & leisure & caused frequent analgesic use. Group D severely disabled, had lost jobs, repeatedly sought med advice & continually used analgesics. Chiropractic care included spinal manipulation, PNF & cryotherapy. 28 symptomatic whiplash patients (mean 39 years) all had medical care but remained symptomatic. Treatments included anti-inflammatories, soft collars & physical therapy. Patients referred for chiropractic treatment at an average of 15.5 months after injury. 22 (79%) were referred by their solicitors, others by friends, relatives or self-referrals – none was referred by an MD. Symptoms included neck pain, stiffness, headache, shoulder, arm & back pain. At the time of referral 27 of 28 patients were Group C or Group D. Results: Following chiropractic treatment 26 (93%) of patients had improved; 16 by one symptomatic group & 10 by 2 symptomatic groups. This improvement was independent of whether assessed by orthopod or DC. In the group that had improved, 17 had stopped treatment at time of assessment; symptoms had recurred to a minor degree in 4 (24%) of these patients. Results of this retrospective study suggest that benefits with chiropractic care can occur in over 90% of patients undergoing chiropractic treatment for chronic whiplash. The encouraging results from this retrospective study merit a prospective randomized controlled trial to compared conventional treatment with chiropractic in chronic whiplash injury. Khan, Cook, Gargan, Bannister. J Orthop Med 1999;21(1):22-25. Retrospective review by phone interviews of 93 consecutive patients seen in a chiropractic clinic. Patients were referred after a mean of 12.7 months from injury. Patients underwent a mean of 19.3 treatments over a period of 4.1 months. There were 3 categories of patients:Group 1 – Patients with isolated neck pain associated with restricted neck ROM. Group 2 – Patients with neuro symptoms or signs associated with a restricted ROM. Group 3 – Patients who described severe neck pain but had full ROM of the neck. Patients in this group often described an unusual group of symptoms with a bizarre, non-dermatomal pain distribution. Gargan & Bannister classification of whiplash symptoms: Grade A – absent; Grade B – nuisance; Grade C – intrusive; Grade D – disabling. Groups 1 & 2 both improved following chiropractic manipulation, but Group 3 showed no signif improvement. Conclusion: Results provide further evidence that chiropractic is effective for chronic whiplash symptoms. However, the identification of a group of patients who fail to respond highlights the need for a careful history & PE before beginning treatment. Chiropractic is the only proven effective treatment in chronic cases. Spitzer, MD, MPH. Quebec Task Force on Whiplash-associated Disorders (WAD). 1995; 20(8S):1S-73S. A review of original research & consensus recommendations: C-strain can occur with forces as low as 119

2.7-3.6 MPH. Grade 0: No neck complaints, no physical signs; Grade I: Neck pain, stiffness or tenderness, no physical signs; Grade II: Neck complaints & musculoskeletal signs (decreased ROM, point tenderness); Grade III: Neck complaints & neurological signs (decreased deep tendon reflexes, weakness, sensory deficits); Grade IV: Neck complaints & fx or dislocation. Treatment of WAD: Most treatment currently used haven’t been evaluated in a scientifically rigorous manner & are unproven. This includes: C-pillows, postural alignment training, acupuncture, spray & stretch, TENS, ultrasound, laser, diathermy, heat, ice, massage, epidural or intrathecal injections, muscle relaxants, & psychosocial interventions. Treatments evaluated in scientifically rigorous manner show little or no evidence of efficacy. This includes C-soft collars, steroid injec of facet joints, pulsed electromagnetic treatment, magnetic necklace, & subcutaneous water injec. Use of soft C-collar beyond 72 hours probably prolongs disability in WAD. Promotion of Activity Interventions such as mobilization, manipulation & exercise in combination with analgesics or NSAIDs are effective on a time-limited bases. Prescribed rest is seldom indicated & should always be limited to short duration. Task Force consensus: Is that use of NSAIDs & analgesics, short-term manip & mobilization by trained persons & active exercises are useful in Grade II & III WAD, but prolonged use of C-collars, rest or inactivity probably prolongs disability. Early return to usual activities should be encouraged.

Chiropractic & Infantile Colic Wiberg DC, Nonrdsteen, DC, Nilsson DC, MD, PhD. The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled clinical trial with a blinded observer. JMPT 1999; 22(8): 517-522. Definition of Infantile Colic: unexplainable & uncontrollable crying in babies from 0 to 3 months, >3 hours/day, > 3 days/week for 3 weeks or more, usually in the afternoon & evening hours. 50 infants seen by the health visitor nurses, who fulfilled the diagnostic criteria for infantile colic in Denmark. One group (#25) received spinal manipulation for 2 weeks (3 to 5 sessions) based on restricted movement, manipulated with specific light pressure with fingertips until nl mobility was found in the involved segments. The other group (#25) treated with the drug dimethicone for 2 weeks. Outcome: Changes in daily hours of crying as registered in a colic diary. Parents kept a 1 week baseline diary. Kids then randomly assigned. At end of 1 week & at end of 2 weeks, blinded visiting nurses administered the infantile colic behavior profile. Parents continued with the diary for the 2 weeks of care. The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled clinical trial with a blinded observer. 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 spinal manipulation group. On days 8 through 11, crying was reduced by 1 hour for the dimethicone group, and by 2.7 hours in the spinal manipulation group. From trial day 5 onward, the spinal manipulation group did significantly better than the dimethicone group. Conclusions: Spinal manipulation is effective in relieving infantile colic. When results were compared with those of the only other trial on spinal manipulation for infantile colic (Klougart et al. JMPT 1989;21(4):281-8) we see the results were virtually identical. In the previous trial, mean daily hours with colic was reduced by 66% on day 12 of the trial, & in this trial there was a reduction of 67% on day 12, whereas the dimethicone group only had a reduction in daily hours with colic of 38% on day 12. These similarities strengthen the conclusion that a positive effect of spinal manipulation exists in the treatment of infantile colic. Wiberg et al. Compared with dimethicone, 2 weeks of spinal manipulation reduced infantile colic behavior at 4-11 days after initial treatment. Evidence-Based Nursing 2000;3(2):12. A new review notes that there were no dropouts in the spinal manipulation group but 9 in the dimethicone group. The reason for all 9 dropouts was worsening of the infants’ symptoms. By excluding data on these more severe cases, the colic behavior in the dimethicone group appears 120

better than it actually was. Despite this bias, the spinal manipulation group still scored significantly better. Treatment of infantile colic is important because it can lead to serious consequences such as abuse & family disruption. Preliminary evidence indicates a potential benefit of spinal manipulation in the treatment of infantile colic. Lee, BSE, Li, MD, Kemper MD, MPH. Chiropractic care for children. Arch Ped & Adoles Med 2000;154(April):401-407. Survey of 150 DCs in Boston area to evaluate pediatric care. 90 (60%) of DCs responded (65% M, 35% F). Technique use: diversified 62%, activator (40%), SOT (37%). DCs averaged 122 visits/week & 13 (11%) were children/adolescents. For kids, 305 of DCs actively recommend immunizations, 7% recommend against them, 63% make no recommendations. Number of children visiting DCs is increasing. In 1997, ACA reported that kids were 10% of chiropractic patients. This amounts to @ 20 million ped chiropractic visits annually. An estimated 410,000 ped chiropractic visits in Boston area in 1997. Extrapolating to US, approx 30 million ped visits were made in US in 1997 – a 50% increase in ped visits over 4 years, reflecting growth in number of DCs. The expected doubling of DCs in the next 10 years is likely to lead to additional ped visits to DCs. Considering the fees & frequency of visits, the costs, our estimate is that @ $1 billion was spent on ped chiropractic in 1998, $510 million paid out-of-pocket. Bronfort, DC et al. JMPT 1996; 19(9):570-582. Randomized controlled trial with 1 year followup in 174 chronic low back pain patients (age 20-60) compared the efficacy of 5 weeks of 1) spinal manipulation combined with trunk strengthening exercise (TSE); 2) Spinal manipulation combined with trunk stretching exercises; 3) NSAID with TSE, all followed by 6 weeks of supervised exercise alone. OUTCOMES: Patient-rated low back pain, disability, & functional health status at 5 & 11 weeks. RESULTS: Outcomes at 5 & 11 weeks revealed no signif group differences. Continuance of exercise during the follow-up year, regardless of type was assoc with a better outcome. CONCLUSION: All 3 treatment regimens was assoc with similar & clinically important improvement over time that was considered superior to the expected natural history of long-standing chronic low back pain. For management of chronic low back pain, trunk exercise in combination with spinal manipulation or NSAIDs seem beneficial & worthwhile. Carey, MD, MPH. Costs & Outcomes of acute low back pain in North Carolina. New Eng J Med 1995;Oct. 5:913-917. Study of 1633 acute low back pain patients (symptoms < 10 weeks) treated by Primary Care MDs, DCs, Orthopods, Managed Care. Patients in all groups had similar degrees of pain & loss of function (Roland-Morris) at onset. Patients re-evaluated at 2, 4, 8, 12, & 24 weeks. Most patients improved rapidly with a median improvement of 8 & a mean of 16 days. Only 5% hadn’t functionally recovered at 6 months. No significant differences in recovery rates among the patients treated by different provider types. Costs of outpatient care were highest for Orthopods & DCs. DCs had the most visits. Patients who saw DCs had a much higher satisfaction rating. Weisel, MD. Backletter 1996; 11(7):84. Back pain is a recurrent illness. Carey’s study emphasizes that back pain is typically recurrent & sometimes disabling – in a substantial minority. Patients made a functional recovery from acute back pain at 6 month follow-up. Carey reinterviewed patients 16 months after the 6 month follow-up. Over the 16 months, 42% of patients had at leas tone spell of any increased or recurring back pain. 28% had a spell of functionally disabling pain. None of the provider groups seemed to have any advantage over the others in reducing the risk of recurrence (presented at annual meeting of the Society of General Internal Med in Washington, DC 1996, as yet unpublished).

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Wiesel MD. Backletter 1997;12(6):63. Carey examined the impact, over 12 months, of a 2 day intensive training on manual therapy skills on a group of 30 family physicians & internists. Confidence in the ability to treat back pain increased substantially. 15% of MDs felt well prepared to treat low back pain prior to the course & 67% at 1 year. 90% felt comfortable explaining the rationale of spinal manipulation to their patients. The MDs didn’t perform many spinal manipulations as a result of the course – treating roughly one new patient per month with spinal manipulation. The program seemed to build bridges between MDs & DCs. Prior to training 17% of MDs said they frequently or occasionally suggested referral to DCs. 47% did so at 1 year after training. Mushinski. Stat Bulletin 1995; April/May:26-35. Average hospital charges for medical & surgical treatment of back problems. 1993. Among 3480 patients treated surgically & insured by MetLife the average cost was $13,990. Among the 2,539 patients hospitalized but non-surgically treated the average cost was $7,120. Johnson, MSc., Bootman, PhD. Drug-related morbidity and mortality. A cost-of-illness model. Arch Intern Med 1995; 155 (Oct 9): 1949-1956. Drug-related morbidity & mortality was estimated to cost $76.6 billion in the ambulatory setting in U.S. The largest cost was drug-related hospitalizations: 8.76 million admissions at a cost of $47.4 billion/year --- 62% of total cost. This represents 28.2% of the total 31.1 million admissions in 1993. Admissions to long-term care facilities is the 2nd largest cost with 3.15 million admissions at a cost of $14.4 billion. Visits to doctors for drug related problems exceeds 115 million costing @ $7.5 billion. This is 17.3% of all physician office visits of the almost 760 million annually. Drug-related morbidity and mortality. A cost-of-illness model. An additional 76.3 million prescriptions is needed to resolve treatment failures & drug related problems at a cost of $1.93 billion & is 8.2% of all treatment in 1992. A total of 930.5 million prescriptions/year. Emergency room visits due to drug-related problems is 18.9% of @ 89.8 million visits in 1992. CONCLUSIONS: the cost of drug-related problems in ambulatory care in U.S. is considerable & should be considered in health policy decisions with regard to pharmaceutical benefits. Bates, MD et al. JAMA 1997; 277 (4): 307-311. The costs of adverse drug events in hospitalized patients. Study of resource utilization associated with adverse drug events (ADE) in a sample of 4108 admissions to 11 medical & surgical units in 2 hospitals over 6 months. Results: there were 190 ADEs of which 60 were preventable. The estimated post-event costs attributable to an ADE were $2595 for all ADEs & $4685 for preventable ADEs. These estimates are conservative & don’t include the costs of injuries to patients or malpractice costs. If ADEs & associated costs are representative of the nation’s hospitals, the total hospital costs of ADEs occurring during hospitalization would be {text is missing from original}. Phillips DP et al. Increase in US medication-error deaths between 1983 & 1993. The Lancet 1998; 351 (Feb 28):643-644. Between 1983 & 1993 the number of Americans who died from Medication Errors (ME) rose sharply & the trend appears to be continuing. From the most recent data, fatal ME increased 260% overall, but among outpatients, the jump in such deaths was 850%. “Deaths officially ascribed to medical errors may represent only the tip of the iceberg,” said Phillips of The University of California at San Diego because many such fatalities probably are not listed that way on death certificates. During the decade evaluated, the number of outpatient encounters jumped 75% while the number of days Americans spent in hospitals fell 21%. The largest jump in outpatient ME involved deaths due to anesthesia drugs, suggesting that the tremendous growth in outpatient surg may be one part of the problem. Outpatient fatalities from ME jumped from 172 in 1983 to 1,459 in 1993, a nearly 9-fold increase. The increase in 122

medication related deaths can’t be explained by the number of drugs prescribed which has risen only 39% in the decade while med fatalities jumped 257%. Carey, MD, MPH. Spine 1996; 21(3): 339-344. In more than 4,445 households: 11.5% of adults had severe low back pain in 1 year (functionally disabling). 7.6% had acute severe low back pain (< 3 months). Symptoms were more common in younger patients than in those >60 years (8.5% vs 5%). 39% of patients sought health care. More prolonged pain, severe pain 7 sciatica were associated with seeking care. 13% saw DCs, 24% MDs, 2% other providers. Patients viewing DC treatment as helpful vs MD treatment: 99% vs 80%. Patients satisfied with DC treatment vs MD treatment: 96% vs 84%. DC vs MD patients who sought treatment from another provider: 14% vs 27%. Use of DCs is so common that one hesitates to use the terms alternative or nonstandard. Shekelle, MD, PhD. Med Care 1995;33(8):842-850. Evidence continues to accumulate that DCs are more popular than MDs with their back pain patients. Of 1020 episodes of back pain care made by 686 patients encompassing 8825 visits, DCs were the primary providers for 40% of episodes. DCs were the first provider in 1/3 of all patients who sought back pain care & @ 10% of patients initially seeing other providers switch to a DC to receive the majority of their back pain care. DCs remain a greater percent of their patients who have a subsequent episode of back pain care than do other providers. DCs retained 92% of their patients for a second episode. General practitioners retained 75%. Osteopaths retained 75%. Orthopedists retained 50%. Internists retained 22%. Other professions retained 40%. The new message in this study is the degree to which DCs retain their patients. With a 92% retention rate, DCs seem to be extremely popular with their patients. This is compatible with previous research @ patient satisfaction with DCs. Wiesel, MD. Will the utilization of chiropractic increase? Backletter 1996; 11(3):36. Given the popularity of DCs with their patients & the depth of scientific evidence in favor of spinal manipulation, it will be interesting to see if DCs begin to take a larger share of the back pain market. Currently, about 30% of people use DCs. If DCs make inroads into the other 70% of the population there could be an explosive growth of chiropractic services. Carey, Benedict. Back Magic. Health 1998; May/June: 108-112. DCs were once dismissed as crackpots. Now even MDs call them your back’s best hope. DCs have not only shaken the carnival barker stereotype, in recent years they have transcended mere acceptability to become as much a part of mainstream medicine as tongue depressors. DCs are being added to hospitals, Health Maintenance Organizations, are widely reimbursed by Medicare & Medicaid, work comp & private insurers. This embrace is partly a matter of economics. Average costs for a back pain patient to see a DC are @ 1/10 of the costs for seeing an MD. “I courted Jay Triano longer than I courted my wife,” says founder of the Texas Back Institute, Ralph Rashbaum. Last year some 20 million back pain sufferers visited a DC – a throng that by 2010 is expected to double in size. In the first weeks of pain chiropractic quickens recovery. But if pain hasn’t diminished in a month, more adjustments don’t seem to help. Then it’s probably time to give an MD a shot at the problem. In other words, the surgeons at TBI are still very busy handling accident victims & chronic spinal pain or fractures. But, in striking change, they see themselves as doctors of last resort. Back crackers, like John Triano, are emerging as the bearers of conservative care. “The wonderful thing is that you get a response right away. If it works, great. If there’s no improvement after 2 or 3 visits, well, at least you know it’s not working. And the risk is almost zero. We have wonderful surgeons at TBI & we’re certainly not going to lose any of them. But we’ve just hired 2 more DCs. I think that tells you which direction we’re headed.” 123

Saal JA, MD. Spine 1997; 22(14):1545-1552. Analysis of spine care delivery system in the US reveals two parallel systems. The first is the traditional medical model, serving 60% of the market. This model has relied upon bed rest, hospitalization, drugs & surgery. The second is the chiropractic model servicing approx 40% of the spine market. Petersen. Dyn chiro 1997; 15(4): Feb 10:1,8. The WHO establishes official relations with chiropractic profession. In the Jan 1997 meeting in Switzerland, the World Health Organization (WHO) granted official status to the World Federation of Chiropractic (WFC) as an affiliated nongovernmental organization (NGO). WFC is funded by national chiropractic association members worldwide. Its goals are to promote increased international acceptance & utilization of chiropractic services. WHO recognition is extremely important for legalization & development of chiropractic in many countries. The recognition resulted from strong support of NGOs such as International Council of Nurses, World Fed of Neurology & World Fed of Health Associations. This represents a new level of acceptance & recognition of the chiropractic profession. Wiesel, MD. Chiropractic continues to grow. Backletter 1997;12(5):60. The chiropractic profession continues to grow in popularity worldwide. It is now the third largest primary health care profession in the western world after medicine & dentistry. There are approx 50,000 DCs in US, 10,000 in Japan, 5000 in Canada, 2500 in Australia, 1000 in UK, 100 to 500 in Belgium, Denmark, France, Italy, Norway, Sweden, Switzerland, NZ, So Africa & the Netherlands. There are smaller numbers in other European countries, Asia, Africa, the Middle East, & So America. Mosley, Cohen, DC, Arnold, MD. Am J Man Care 1996; 2:280-282. Retrospective study of patients at an independent physician model HMO in Louisiana evaluating cost of care for back acute (BP) or neck pain (NP) for patients who sought chiropractic care (N = 121) or other treatment (N = 1,838). Also looked at surgical rates, use of diagnostic imaging (MR & CT) & patient satisfaction on claims paid Oct. 1, 1994 – Oct. 1, 1995. Results: cost of care for back pain & neck pain was substantially lower for DC patients than non-DC patients ($539 vs $774). Use of prescription drugs & diagnostic imaging (4.9% vs. 16.5%) were signif greater in non-DC group whereas surgical rates & patient satisfaction were nearly identical. (94% satisfaction in both groups). Conclusion: DC care has 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 & have proven satisfactory to patients & providers as well as cost-effective for back pain & neck pain. The system offered self-referral for DC services. If half of the patients treated by traditional care received DC care, annual savings would have exceeded $215,000. We believe that managed DC care is an extremely promising method of treating acute back pain & neck pain. We recommend its wider application by the managed care industry & physician community. Petersen D. Dyn Chiro 1998; 16(10):1, 7. West Virginia gets new comprehensive law to protect chiropractic practice. In March 1998, W Va. Legislature passed a bill to amend the state’s chiropractic act: “No person may perform or authorize a spinal manipulation without having received a minimum of 400 hours of classroom instruction in spinal manipulation & 800 hours of supervised clinical training at a facility where spinal manipulation is a primary method of treatment. Qualified DCs may use physical therapy devices. DCs may use any instrument or procedure for diagnosis provided the DC is trained to perform the procedures thru a chiropractic college. A licensed DC is competent to testify before the courts as an expert witness. An IME physician must have a W VA chiropractic license. The bill assures a strong legal foundation for chiropractic & gives the state chiropractic board administrative & disciplinary powers. By requiring 1200 hours of training in spinal manipulation, the state is protecting the public & DCs 124

from the unqualified intrusion of MDs, osteopaths, & physical therapists who take weekend adjusting seminars. The law is a blueprint for other states to assure & protect the practice of chiropractic. Triano, DC, MA. Spine 1995;20(8):948-955. Randomized trial of patients with untreated low back pain lasting >7 weeks. Groups: 1) spinal manipulation – side posture, 2) spinal manipulation sham, 3) back education program (BEP). PRIMARY OUTCOMES: Self-report pain (VAS) & activity tolerance (Oswestry). Patients assessed at enrollment, at 2 weeks of treatment & 2 weeks without treatment. RESULTS: 170 patients completed study with a mean of 10.5 visits. Greater improvement was noted in pain & activity tolerance in spinal manipulation group. Immediate benefit from pain relief continued to accrue after spinal manipulation even for the last encounter at the end of the 2-week treatment interval. CONCLUSION: There appears to be clinical value to treatment according to a defined plan using spinal manipulation even in low back pain > 7 weeks. Heigh, MD. Postgraduate Med 1994;96(6): 63-6. The prevalence of ulcers in patients taking NSAIDs ranges from 10% to 30%. In the Aspirin for Myocardial Infarction Trial risk of hospital admission for duodenal ulcer was 10.7X > in aspirin vs. placebo patients. Gastric ulcers develop in 26% of patients who take aspirin regularly. Patients who take NSAIDs for a total of 30 or fewer days had the highest risk. Most gastroduodenal injury occurs during the first several weeks of treatment. Tamblyn R, PhD et al. Ann Intern Med 1997;127:429-438. 70 million prescriptions for NSAIDs per year in the US. Use of NSAIDs accounts for about 7,600 deaths & 76,000 hospitalizations in the US. Almost all deaths from NSAID related GI side effects occur in the elderly. In the 1980s, MDs were advised to avoid prescribing NSAIDs to elderly. In 1990, however, an estimated 58% of women & 53% of men 65 years of age or older in Quebec were prescribed NSAIDs! Surveys in the US & Britain indicate that 4% to 42% of MDs are unaware of the side effects of these drugs. Patients 60 to 69 have a 3-fold increase in relative risk for serious GI side effects relative to those 25 to 49. Those with a history of peptic ulcer dis have a 6-fold increase in risk. Low doses are recommended because the relative risk for serious GI side effects increases from 2.8 with half the standard dose to 8.0 with the highest dose. Manga P, PhD. Angus D, PhD. Univ of Ottawa 1998. Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes & improving the public’s access to cost-effective health services. There is considerable empirical support for the cost-effectiveness & safety of chiropractic management of musculoskeletal disorders. Doubling the proportion of the Ontario public from 10% to 20% will lead to direct annual savings of $348 million to the Ontario health care system, indirect saving of $1.85 billion per year through sharply reduced levels of short & long-term disability & compensation. The only 2 studies that do not show significantly better cost-effectiveness for chiropractic services (by Shekelle & Carey) are by medical researchers not economists & have significant design problems. Smith M, DC, PhD, Stano M, PhD. JMPT 1997;20(1):5-12. Analysis of payments & outcomes for recurrent episodes for 9 common lumbar & low back conditions treated by DCs vs MDs from 2 years of Ins claims data. 7077 patients with 9314 episodes of care. 8018 episodes of care initiated by DCs or MDs. 1215 patients had recurrent episodes. Total Ins payments were 1.6 times greater for MD treatment episodes. For recurrent episodes DCs retain more patients. Patients who cross over between provider types for multiple episodes are more likely to return to DCs suggesting that chronic, recurrent low back cases may gravitate to DCs over time. Chronic low back pain patients tend to shift over time to DCs. In patients who had 3 episodes of back 125

pain, MD patients exposed to a DC in an intervening episode were 23 times more likely not to return to an MD than an MD patient not exposed to a DC. Coulter, PhD et al. The Appropriateness of Manipulation & Mobilization of the Cervical Spine. RAND 1996: Table 6, page 36 Complications resulting from Treatments of the Cervical Spine per million applications. 1) spinal manipulation – CVA & other complications: 1.46, Major impairment: 0.639, Death 0.268 2) Cervical spinal surgery – Neurologic complications 15,600, Death 6,900; 3) NSAIDs – Serious GI complications 3,200>65 years, 390 age 60 regularly take meds for chronic pain (arthritis & low back pain). NSAIDs are more widely used by seniors than any other type of prescription meds. An alarming 13% using NSAIDs also reported an ulcer. 25% taking prescription NSAIDs reported side effects. 60% using NSAIDs said they took them for 6 months or more, in spite of warnings that risk for serious GI complications increases 4 fold after 6 months of use. Seniors taking non-prescription NSAIDs used them daily for an average of 5 years despite labels cautioning against >10 days of use. “The serious side effects of NSAIDs result in 200,000 hospitalizations & 20,000 deaths annually,” says Thomas Schnitzer, MD, rheumatologist & geriatrician at Northwestern U. Treatment cost for NSAID induced side effects is $3 billion/year. Senstad, DC, Leboef-Yde, DC, MPH, PhD, Borchgrevink, MD. Spine 1997;22(4): 435-440. Unpleasant Side Effects after spinal Manipulation. Prospective survey of the frequency & characteristics of unpleasant side effects after spinal manipulation. Based on data from 4712 treatments of 1058 new patients by 102 Norwegian DCs. 55% of patients had an unpleasant effect within the first 6 visits. ¼ of all treatments over the first 7 visits will result in at least one reaction. Less than 1/5 of reactions arise within 10 min of treatment, suggesting that the spinal manipulation itself is rarely painful. Reactions are short, with symptoms usually disappearing on the day of their appearance. Radiating discomfort is reported significantly most-often to be severe & to last the longest. 89% of patients didn’t curtail their activities of daily living. Common & benign reactions follow a distinct pattern & can be considered “normal.” Hurwitz, DC, PhD et al. Spine 1996;21(15):1746-1760. Scientific Paper of RAND study of Appropriateness of Spinal Manipulation & Mobilization (MO) of the Cervical Spine. Of 1457 articles identified only 67 were used. Much more high quality research is needed before more definitive recommendations can be made. Conclusions: 1) MO is probably of at least short-term benefit for patients with acute neck pain; 2) Spinal manipulation is probably slightly more effective than MO or physical therapy for some patients with subacute or chronic neck pain. All three treatments are probably superior to usual medical care; 3) spinal manipulation and/or MO 126

may be beneficial for muscle tension headaches; 4) MO results in fewer complications than does spinal manipulation. Baker B. Family Practice News 1996; June 1: 14. Spinal manipulation vs Acetaminophen for Chronic Neck Pain. Study at University of Colorado of patients with chronic neck pain of minimum of 12 weeks and an average of 10 years. 35 patients in spinal manipulation group saw a Dc 12 visits over 6 weeks. 34 patients in med group got acetaminophen 4X/daily & saw a nurse 12 visits over 6 weeks to control for personal attention. Both groups told to exercise & use a heating pad. At end of 6 weeks patients in spinal manipulation group reported signif improvement in neck pain & function, and showed trends toward better ROM & strength. Patients in med group showed no real change. Long-term follow-up is underway. Bigos, MD et al. Acute Low Back Problems in Adults. Clinical Practice Guidelines No. 14. Agency for Health Care Policy & Research, December 1994. (800) 358-9295. AHCPR (The Agency for Health Care Policy & Research) was established to enhance the quality, appropriateness, & effectiveness of health care services within The Agency for Health Care Policy & Research, the guidelines were developed by an independent multidisciplinary panel of 23 clinicians and experts using extensive literature searches and critical reviews to evaluate empirical evidence & outcomes. The recommendations are based on the scientific lit. When the lit is incomplete or inconsistent, recommendations based on the judgment of panel members and consultants was used. Intent: to change the paradigm of focusing care exclusively on the pain of low back pain to one of helping patients improve their activity tolerance. Goal is to help patients recovery normal activity tolerance & avoid the development of low back disability. Spinal Manipulation: manual therapy for symptomatic relief & functional improvement of the back. Abstract Assessment & treatment of adults with Acute Low Back Problems (ALBP): activity limitations due to symptoms in the low back &/or back-related leg symptoms of less than 3 months. In the absence of red flags neither routine nor special testing is required in the first month of symptoms for either sciatica or nonspecific back pain. Most of these patients will recover spontaneously from their activity limitations within 1 month. The principal conclusions: 1) The initial assessment for acute low back pain focuses on the detection of “Red Flags” indicators of serious spinal or nonspinal pathology: A) For Fracture: Major trauma, minor trauma in older or potentially osteoporotic patients; B) Possible Tumor or Infection: age over 50 or under 20, history of cancer, symps: recent fever or chills or unexplained weight loss. Risk factors for spinal infection: IV drug use, recent bacterial infection, immunosuppression. Pain worsens when supine, severe nighttime pain. C) Possible Cauda Equina Syndrome: saddle anesthesia, recent onset of bladder or bowel dysfunction, severe or progressive neuro deficit in lower limb; on PE: laxity of anal sphincter, perianal/perineal sensory loss, major motor weakness of quads, ankle plantar flexors, evertors & dorsiflexors. 2) 3) 4)

In the absence of red flags, imaging studies & further testing of patients are not usually helpful during the first 4 weeks of low back pain Relief of discomfort can be accomplished most safely with nonprescription medication &/or spinal manipulation While some activity modification may be necessary during the acute phase, bed rest > 4 days is not helpful & may further debilitate the patient. 127

5) 6) 7) 8) 9)

10) 11)

Low-stress aerobic activities can be safely started in the first 2 weeks of symptoms to help avoid debilitation; exercises to condition trunk muscles are delayed at least 2 weeks. Patients recovering from acute low back pain are encouraged to return to work or normal daily activities as soon as possible If low back pain persists, further evaluation may be indicated Patients with sciatica may recover more slowly, but further evaluation can also be safely delayed Within the first 3 months of low back pain only patients with evidence of serious spinal pathology or severe, debilitating symptoms of sciatica & physiologic evidence of specific nerve root compromise corroborated on imaging studies can be expected to benefit from surgery With or without surgery, 80% of patients with sciatica recover eventually Nonphysical factors (psychological or socioeconomic problems) may be addressed in the context of discussing reasonable expectations for recovery

The panel found no evidence of benefit from the application of physical agents & modalities such as ice, heat, massage, traction, ultrasound, cutaneous laser treatment, TENS, & biofeedback. Self-application of heat or cold may be taught to patients who choose such options to provide temporary relief of symptoms. Evidence doesn’t support the use of trigger point, ligamentous & facet joint injections, needle acupuncture, or dry needling as treatment for acute back pain. Chapman-Smith, JD. Chiro Report 1996;10(4) July:1,6. Agency for Health Care Policy & Research’s annual budget of $163 million has been slashed to $3 million. This is the price for offending the big boys. When the acute back pain guidelines recommended against many common medical treatments & in favor of spinal manipulation, those whose incomes & positions were threatened (orthopods & equipment suppliers) lobbied to prevent publication. Pharmaceutical manufacturers were in disbelief seeing recommendations against the use of prescription drugs for most patients. Opponents caused a 12 month delay. The Agency for Health Care Policy & Research headache panel has completed its final draft, but recommends the use of prescription drugs be tempered & non-drug management like spinal manipulation for headaches from the C-spine is appropriate for many patients has caused the pharmaceutical world to be too uncomfortable. The result, its headache guideline – even though in final draft form after years of work – will not be published – the headache project is dead. Hillyer, DC. Manipulation in the Curricula of Chiropractic, Osteopathic, Physical Therapy & Medical Schools. FCER 1995:1-14. RAND: 94% of spinal manipulation done by DCs. Remainder is by general practitioners, orthopedic surgeons, physical therapists. What are the educational qualifications of each? Reviewed the catalogs of at least 10 schools from each category to determine class hours of training to learn manipulation. Chiropractic colleges average more than 500 hours of class time devoted to spinal manipulation. Osteopath colleges have @ 128 hours, Med schools & Physical Therapy have none. The Role of Exercise in Chiropractic Management: Ameis, MD. Can Fam Physician 1986;32(Sept):1871-76. As time passes the rehabilitative program should become progressively more active. Physicians can help by being directive & specific in allowing resumption of activity. Excessive rest & precaution within the first 4 weeks is counter-productive & assures a passive attitude toward recovery. There is little justification for a formal physiotherapy program extending beyond the 4th month. Attendance is mostly for pain control. The effectiveness of the modalities does not extend more than a few hours post 128

treatment. The risk of dependency increases markedly. Patients invariably expect treatment to result in pain-free status. Instead, it should be stressed that recovery of function is the primary goal. Unfortunately, in chiropractic the goals often fail to include restoration of specific & general fitness, a failing which may foster passivity & dependence. More progressive DCs emphasize recovery of activity, diet & exercise while tapering the attendance in keeping with the improving clinical picture. Doctors should provide steady pressure on the patient to maximize the recovery by actively & aggressively responding to & managing the pain impairments & secondary inactivity related weight gain & deconditioning. Cady, MD. J Occupat Med 1979;21(4):269-272. Prospective study of 1652 fire fighters. Initial evaluation of endurance, strength, flexibility, timing, coordination. Divided into 3 fitness groups & followed for 3 years. Who developed back injuries: least fit group: 7.1%, mid-fit group: 3.2%; most fit group: 0.8%. Conclusion: physical fitness & conditioning are preventive of back injuries. The passive structures of the back are most likely to be injured when exposed to forces beyond muscular control. Bigos, MD, et al. Acute Low Back Problems in Adults. Clinical Practice Guidelines. December 1994:57. Early Goals of Exercise Program in Patients with Acute Low Back Pain 1. Prevent debilitation due to inactivity 2. Improve activity tolerance 3. Return patients to their highest level of functioning as soon as possible Bigos, MD. Acute Low Back Problems in Adults. Clinical Practice Guidelines. Quick Reference Guide Number 14. December 1994:22. Improving Physical Conditioning through an incrementally increased Exercise Program. 1. Goal is to build activity tolerance & overcome individual limitations due to back symptoms. 2. At this point in treatment, symptom control methods are only an adjunct to making prescribed exercises more tolerable. 3. Begin with low stress aerobic activities to improve general stamina (walking, biking, swimming, & eventually jogging) 4. Exercises to condition specific trunk muscles can be added a few weeks after [onset]. The back muscles may need to be in better condition than before the problem occurred. Otherwise the back may continue to be painful & easily irritated by even mild activity. 5. Finally, specific training to perform activities required at home or work can begin. The objective of this program is to increase the patient’s tolerance in carrying out actual daily duties. Agency for Health Care Policy & Research Guidelines: 152-3: The goal is to try to prevent back problems from returning, or if they do return, being severe. Success will depend on 2 factors: 1) The condition of your protective muscles, 2) The activities you ask your back to tolerate. Ignoring either of these factors usually means more back problems. Out-of-condition protective muscle tires easily. Regular activity is essential to obtain the conditioning effect to protect your back. Both your level of physical conditioning & the stresses you put on your back will determine how often you will have problems & how severe they become. Cherkin, PhD. West J Med 1989; 150(3):351-355. Patients’ response to management of low back pain by MD vs DC: Much greater patient satisfaction with DCs: 66% vs 22%. Much greater satisfaction with the information provided by DCs. Less days of disability: DC Patients 10.8, MD’s 39.7. 129

Finestone, MD, Conter, PhD. Lancet 1994; Sept 17: 801-2. USA Today 1994; Sept 16-18:1A. Acting classes should be taught in med school, so MDs can at least pretend that they are concerned about their patients. Cherkin, PhD. West J Med 1988; 149(4): 475-80. Beliefs of MDs & DCs about managing low back pain: MDs more frustrated by back patients, less well trained, don’t think they can do much to stop acute from becoming chronic. Cherkin, PhD. Am J Pub Health 1989;79(5):636-7. MDs attitude toward DCs: the more they know about chiropractic the more likely they will view it positively. Younger MDs are more open than older ones. Cherkin, PhD. J Fam Practice 1992;35(5):505-6: DCs well trained, effective & safe for low back pain. MDs should get to know DCs in their area & consider referral of patients with low back pain. Borkan, MD. Referrals for alternative therapies. J Family Practice 1994; 39(6): 545-550. MD referrals were most often based on: 1. Patients’ request for referral to alternative treatment, 2. Patients’ cultural beliefs; 3. Failure of conventional treatment (patients’ lack of response). 4. The belief that patients have nonorganic or psychological disease. Primary Care MDs referred 2.33 times more often than other medical specialties. The most common referral is for spinal manipulation Callahan, MA. The chiropractor as a primary care health provider in rural, health professional shortage areas of the USA. FCER 1994: Types of health care providers referring patients to DCs: Family practitioners: 69.2%; orthopedists 18.8%, neurologists: 11.2%. Hart, PhD. Spine 1995; 20(1):11-19. Low back pain is the 5th most common reason for MD office visits: 1) hypertension, 2) pregnancy care & complications, 3) general med exam, 4) acute upper respiratory infection, 5) low back pain. Market share by specialty of back problem visits: MD family practice or general practice: 30.4%; General internal med: 14.1%; Osteopath family or general practice: 11.1%. Total seen by generalists = 55.6%; Orthopods: 24.9%. Cherkin, PhD. Spine 1995; 20(1) 1-10. Physician perceptions of the effectiveness of nonsurgical treatments for acute back pain: physical therapy: 81%; Strict bed rest for > 3 days: 72%; Spinal manipulation: 3a6%. For chronic low back pain: Physical therapy: 93%; multidisciplinary pain program 75%, TENS 74%; spinal manipulation: 35%. Less than 3% of MDs would have recommended spinal manipulation for any of their acute back pain, sciatica, of chronic low back pain. Published Recommendations for Referral for Chiropractic Care Curtis, MD, Bove, DC, PhD. T J Family Practice 1992; 35 (5):551-555. Guidelines for identifying a competent chiropractor: 1) Treats mainly musculoskeletal disorders with spinal manipulation; 2) Doesn’t do routine x-rays on every patient; 3) Doesn’t extend duration of treatment unnecessarily; 4) Writes a response to a referral & outlines evaluation & therapy; 5) Doesn’t charge “front end” lump sum for whole treatment program; 6) Graduated from CCE accredited school; 7) Willing to have MD visit office to observe treatment; 8) good feedback from patients on care given. CLINICAL PROFILES APPROPRIATE FOR MANIPULATION PROBLEM DURATION OF TREATMENT 130

Acute low back pain (3 months)

3-5 treatment, max of 10 before re-eval Unclear 3 treatments/week for up to 8 weeks before re-eval

Summary: In terms of return to normal function & patient satisfaction chiropractic seems to be of value. A favorable response to spinal manipulation is good sign that treatment may help again. Article supported in part by The Agency for Health Care Policy & Research. Shekelle, MD, PhD. Spine 1994; 19(7):858-86. Clinical Characteristics of Patients most likely to benefit from Spinal Manipulation: 1. Acute Low Back Pain (3 months duration): a) No contraindications on L-S radiographs & CT/MRI; b) NO lower limb neurologic findings; c) No sciatic nerve irritation; d) No ongoing biomechanical or psychosocial stress. REFERRAL FOR SPINAL MANIPULATION? For patients particularly with uncomplicated acute low back pain with symptoms prolonged >1 or 2 weeks or poorly controlled with mild analgesics, a therapeutic trial of spinal manipulation may be suggested. Over 90% of all claims for reimbursement are by DCs. Best method of referral is to contact the doctor & ask him to explain the approach to diagnosis & treatment of patients with low back pain. Select a clinician who has reasonable judgement & practices within the boundaries of acceptable care. Be wary of doctors who make extravagant claims of efficacy or encourage prolonged courses of spinal manipulation. Ebrall, dC, PhD © Workers Compensation studies: Chiro J Australia 1992; 22(2): 47-53. Only ½ the injured workers treated by DCs required comp days and of those who needed comp days, they required only 1/3 as many as patients treated by MDs. There was 6 times less progression to chronicity with DC vs MD care in this match sample of 1996 subjects. See also: Johnson-Iowa, Wolk-Fla, Nyiendo-Oregon, Greenwood-W Va, Jarvis-Utah. Yates, DC. JMPT 1988;11(6):484-488. Chiropractic decreased Blood Pressure; systole 14.7mmHg, Diastole 13mmHg, 5 minute post adjustment. Brennan, PhD. JMPT 1991; 14(7):399-408; 1992; 15(2):83-9. Adjustment increases in respiratory burst in phagocytes in order to engulf and destroy invasive organisms. Chiropractic influences the immune system, a somatovisceral effect. Yeomans, DC. JMPT 1992; 15(2):106-114. Chiropractic increases intersegmental motion of restricted cervical joints & reduces excess motion of adjacent hypermobile joints. Schifrin, PhD; Dean, PHD & Schmidt, PhD. Studies in Virginia. Order from FCER 1 (800) 622-6309. Cost of DC care accounts for only 1% of all insurance billings. It is cost effective with high patient satisfaction. Reviews all clinical trials. Stano, PhD. ACA J Chiro; March; 41-5; J Am Health Policy 1992; Nov/Dec:39-45; JMPT 1993; 16(5):291-9; JNMS 1993; 1(2):64-8. Chiropractic care is a substitute for more expensive medical, particularly a substitute for inpatient hospitalization, surgery, medications. Average cost 131

of care for neuromuscular diagnoses if just have MD care averaged $1138 higher (30% higher). Has data base of 360,000 patients including 91,000 who have received DC care. Manga, PhD. Report for the Ontario Ministry of Health: Order from FCER 1 (800) 622-6309. Potential savings of many hundreds of dollars annually if there is a switch in management of back care from MDs to DCs. DC care is safer, more effective, reduces both disability and chronicity. Chiropractic reduces the spiraling of health care costs which occurs in the medical system. For every dollar paid to a DC there is an additional 25 cents generated in additional costs. For every dollar paid to the primary MD there are an additional $4-$5 generated. Kokjohn, DC. JMPT 1992; 15(5):279-285. Chiropractic reduces back pain, abdominal pain & menstrual distress & may be a safe non-pharmacological alternative to management of primary dysmenorrhea. Pikalov MD, PhD, Kharin, MD. Use of spinal manipulative therapy in the treatment of duodenal ulcer; a pilot study. JMPT 1994; 17(5): 310-313. Spinal manipulative therapy achieved clinical remission with full epithelialization of cicatrisation in all 11 subjects in the spinal manipulative therapy group. Under the same conditions of patient age and size of defect, the spinal manipulative therapy group had pain relief after 1-9 (average of 3.8) days & clinical remission an average of 10 days earlier than traditional medical care. This was statistically significant at p < .001. Patients with the same dimensions of ulcerous defect were relieved sooner with spinal manipulative therapy. The data suggest that spinal manipulative therapy is adequate to ameliorate the pathogenesis & to reduce the clinical symptoms of ulcer with greater success than traditional medical care. Pick, DC. JMPT 1994; 17(3): 168-173. In a 42 year old asymptomatic male, an MRI was done, first, without manipulative pressure. A second MRI was performed while firm pressure was applied through the contacts toward the opposing contact point. Results from the second MRI demonstrated that the pressure affects the structure of the brain & supports the theory of suture mobility. There were changes on the second MRI in the shape of the corpus callosum, fornix, the lateral ventricle, angular surface of the central lobule & inferior colliculi. Structural alterations deep within the brain can be produced to a gross visual level by the application of external cranial manipulative force. This suggests that altering the volume of flow of CSF & blood through cranial manipulation may lead to alteration of neuron function.

Chiropractic Management and Ear Infections Froehle, DC. JMPT 1996; 19(3):169-177. Chiropractic & Ear Infections in Children: Retrospective study of 46 children all 5 or less years old with S&S of ear discomfort/ear infection. Treatment: All children treated by a single DC using Activator with some SOT blocking & modified AK for 3 X/week for 1 week, 2X/week for 1 week, then 1X/week. Regimen ended with improvement. Treatment focused primarily on C-sp & occiput. OUTCOMES: Based on parental observation: child has no fever, no signs of ear pain, is asymp or child seemed asymp to DC or parent stated that child’s MD judged the child improved. RESULTS: 93% of all episodes improved, 75% in 10 days or less; 43% with only 1 or 2 treatments. Young age, no history of antibiotoic use, initial episode (vs recurrent) & designation of an episode as discomfort rather than infection were associated with improvement with fewest treatments. LIMITS OF STUDY 1) retrospective, 2) small sample size, 3) little data available on the natural history, 4) lack of objective diagnostic criteria, 5) lack of objective outcome measures, 6) lack of control group. CONCLUSION: limitation of medical intervention 132

(antibiotics or tympanostomy tubes) & the addition of chiropractic care may decrease the symptoms of ear infection in young children. Fysh, DC. Chronic recurrent otitis media. J Clin Chiro Ped 1996; 1(2): 66-78. Restricted lymphatic drainage from the middle ear plays a major part in the establishment of chronic recurrent infections. Lymphatic drainage depends on its flow on adequate muscle activity/contractions, arterial pulsations & external compression of body tissues. If a child has a subluxations the misalignment or fixation may cause nerve irritation sufficient to cause hypertonicity of neck muscles which can restrict lymph drainage from the head through the deep cervical lymph ducts. Most children with chronic suppurative otitis media have been treated with at least several courses of antibiotics so fluid in the middle ear is likely sterile. The presence of this sterile serous fluid in the middle ear cavity at a temp of 98.6 deg F provides an ideal medium for the proliferation of bacterial or viral organisms which make their way up the Eustachian tube. If organisms are able to proliferate in the residual middle ear fluid then acute suppurative otitis media results. Peet, DC. Chiro Pediatrics 1996; 2(2): 8-10. Research suggest that otitis media may be caused by improper drainage of the deep cervical lymphatics. Reduced drainage causes a reduction in the lymphatic outflow from the Eustachian tubes so fluid builds up in the inner ear making it an inviting environment for bacteria & viruses. Improper drainage may be caused by increased muscle tone or spasm coupled with a child’s already small drainage system. The drainage system must pass under the cervical musculature before emptying into the superior vena cava. Physical motion due to muscular contractions, arterial pulsations & passive movement pumps the lymph through the system. Increased motion increases the lymph flow, whereas lack of movement restricts the flow of lymph. Subluxations may produce muscle spasms which constrict & pool the lymphatic drainage. Fallon Joan M, DC. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media. J Clin Chiro Ped 1997;2(2): 167-183. Del Mar C, MD et al. BMJ 1997;314:526-9. A lit search for randomized controlled trials using antibiotics to treat acute otitis media (OM) found only 6 studies of children. The number of randomized controlled trials is small for such a common condition. There is a deficiency of research on this subject. Findings: 60% of children treated with placebo were pain free within 24 hours of presentation. Only 14% of children in control group still had pain 2-7 days after presentation. In these children initial use of antibiotics will reduce pain & contralat OM by a reduction of about 40%. This is equivalent to an absolute benefit of 5.6% fewer children experiencing pain by 2 to 7 days after presentation. Thus, 17 children must be treated at first presentation to prevent one child experiencing pain after 2 to 7 days. Conclusions: Many MDs may be disinclined to use antibiotics at first presentation of OM for so little benefit. Antibiotics had no influence on subsequent attacks of OM or deafness at 1 month. Antibiotics were associated with a near doubling of the risk of vomiting, diarrhea or rashes. Symptoms of OM consist mainly of pain & systemic illness. In 80% of children this is limited to 24 hours duration. Froom J et al. BMJ 1997; 315: 98-102. Antimicrobials for acute otitis media? A review. A multinational review of antimicrobials found that otitis media is the most common reason for outpatient antimicrobial use in the US. About 30% of children under age 3 receive microbial treatment for acute ear ache each year. No study found large differences between placebo & antimicrobials groups & concluded that the benefit of routine antimicrobials for otitis media is unproved. Little evidence exists that routine treatment is effective for preventing mastoiditis & 133

meningitis. In the 9 country study, antimicrobials did not improve outcome at 2 months & no differences in rates of recovery were found for either 1) type of antimicrobial or 2) duration. We conclude that existing research offers no compelling evidence that children with acute otitis media routinely given antimicrobials have shorter duration of symptoms, fewer recurrences, or better long-term outcomes than those who do not receive them. Antimicrobial use in children with otitis media results in the emergence of resistant organisms that cause otitis media. More than 80% of children with acute otitis media recover without antimicrobials. Clinicians should immediately reconsider routine use of antimicrobials for children with otitis media & consider treating symptoms with analgesics & observation for lack of improvement. Increasing worldwide resistance of bacteria to antimicrobial drugs is causing a crises manifested by higher morbidity, mortality & costs. Winters et al. BMJ 1997;314 (May 3): 1320-1325. Compares efficacy of physical therapy, manipulation & corticosteroid injections for treating patients with shoulder complaints in a randomized single blind study in the Netherlands. 172 divided into 2 diagnosis groups: 1) synovial group (n = 114) & 2) shoulder girdle group (n = 58). Patients in shoulder girdle group were randomized to manip or physical therapy. Patients in synovial group were randomized to corticosteroid injections, manip or physical therapy. Main outcomes were duration of shoulder c/o. Results: In shoulder girdle group duration of c/o was signif shorter after manip than physical therapy. The number of patients reporting failure was less with manipulation. In synovial group duration of c/o was shortest after corticosteroid injection. Drop out due to treatment failure was low in injec group (17%) & high in manip (59%) & physical therapy (51%) groups. Conclusions: For shoulder girdle disorders manip seems to be the preferred treatment for synovial disorders, corticosteroid injection seems to be the best treatment. Vicenzino B et al. Pain 1996;68:69-74. Effects of cervical spinal manipulation on the pain and dysfunction of lateral epicondylitis. 15 patients with lateral epicondylitis (LE) & elbow pain for a mean of 8 months had a reduction of 53.4% in the neurodynamic test; 35.3% in pain-free grip strength, 43.1% in pressure pain threshold at baseline as compared to their unaffected side. The patients had a high prevalence of hypomobility in the lower C-spine. Each patient received one of the 3 interventions per day (spinal manipulation, placebo or control) & all 3 in a randomized sequence over 3 days. Both patients & assessors were blinded. Outcome measures were determined immediately before & after each inervention. Pain (VAS) was also assessed at 24 hours. Patients & assessors were blinded as to which group patients were in. Spinal manipulation was as contralateral lateral glide (CLG) at C5-6 with the affected arm maintained in a position predetermined at the initial exam involving combinations of shoulder abduction, internal rotation & occasionally elbow extension. One had of the therapist depressed the scapula while the other cradled the occiput & neck above C5, 6. A grade III passive lateral glide movement was applied by the hand cradling the neck & occiput. Results: A signif effect was found for Uppler limb Tension Test (ULTT), Pain-free Grip (PFG) & Pressure Pain threshold (PPT) & 24 hour pain scores. The study demonstrates a clear & immediate hypoalgesic effect of spinal manipulation (CLG) in patients with LE at a site removed from the site of the treatment application. Nansel, PhD. JMPT 1989;12(6):419-27. Randomized controlled trial indicates cervical adjustment improved symmetry & ROM in asymptomatic subjects with cervical lat flexion differences > 10 deg. Seemann, PhD. Chiro Res J 1993;2(3): 33-38. Post adjustment improvement in symmetry of load distribution as measured by dual scales after 12 weeks of care: 12.84 lbs to 3.67 lbs. 134

Herzog, PhD. JMPT 1991;14(2): 104-9. Post-adjustment improvement in the biomechanics of walking. Chiropractic quantitatively improved the symmetry of load distribution so that patients were indistinguishable from a normal population. Cassidy, DC, PhD. JMPT 1992; 15(9): 570-75. Adjustments increased cervical ROM & reduced pain more effectively than did mobilization. The mechanism by which spinal manipulation works is not certain. There is no evidence that it reduces subluxations or that minor positional misalignments are of clinical significance. It is more likely that spinal manipulation exerts a reflex effect on pain & muscle tension. Mechanical stimulation of joint capsule proprioceptors & muscle spindles can result in reflex inhibition of pain, reflex muscle relaxation & improved mobility. Chiropractic treatment of otitis media with effusion: a case report and literature review of the epidemiological risk factors that predispose towards the condition and that influence the outcome of chiropractic treatment Clinical Chiropractic Volume 7, Issue 4 , December 2004, Pages 168-173 Abstract Objective: Comparison of the risk factors identified in one patient and the outcome of treatment, with the epidemiological risk factors identified in the literature that predispose to otitis media with effusion that can potentially influence the outcome of chiropractic treatment. The aim of this case study is to focus practitioners when taking a case history, in order to aid an individual prognosis and treatment plan for each patient. Clinical features: A 31/2-year-old boy presented to a chiropractic clinic with a 10-month history of continuous discharge with a distinctive smell emanating from both his ears. Upon a routine 3-year checkup for his hearing, 4 months prior to consultation, a slight hearing deficit had been identified. This was being reviewed in 2 months’ time with consideration for myringotomy and tympanostomic tube insertion. Cervical and thoracic segmental dysequilibrium was found on static motion palpation, suggesting the presence of a chiropractic vertebral subluxation complex at these levels. Intervention and outcome: The patient was treated 4 times using cervical paediatric adjusting. Activator technique was applied to the thoracic region. Discharge from the ears disappeared immediately after the first visit. An improvement in hearing was identified at a hearing test 3 months after cessation of chiropractic care. Consequently, myringotomy and tympanostomic tube insertion was considered inappropriate. The patient now uses oil drops to prevent cerruminum accumulation. At 6 years old, he has had no further recurrences of OME and no speech or hearing problems are apparent. Conclusion: Of the risk factors identified with the onset of otitis media with effusion, this patient exhibited the following: premature birth, breech presentation, low birth weight, time spent in intensive care, exclusive formula feeding, day care attendance and 2 or 3 recurrent episodes of ear infection for which antibiotics were prescribed. Despite these factors, the patient made rapid symptomatic improvement in a single treatment.

Chiropractic and Neurology Wyke, MD. Aspects of manipulative therapy 1985. 67-71: Proprioception provides 1) conscious awareness of joint position (Position Sense) and awareness of movement in space (Kinesthesia). 2) Feedback from mechanoreceptors exerts unconscious, continuous reflex effects on muscle tone and balance, through the gamma-motoneuron loop, to provide dynamic stabilization of joints. Swinkels Annette, MSc, Dolan Patricia, PhD. Spine 1998; 23(5): 590-597. Proprioception (PR) describes sensations generated within the body that contribute to awareness of the relative orientation of body parts, at rest & in motion and are fundamental to control of human movement. Recent work suggests that position & movement sense may be impaired in the presence of joint disease. Consequently, an improvement in proprioceptors is considered by many as an essential part of rehabilitation. 135

Sharpless, SK: Susceptibility of spinal roots to compression block. NINCDS Monograph 15, DHEW publication (NIH) 76-998,1975, pp155-61. STUDIES REVEAL EFFECTS OF SPINAL NERVE ROOT COMPRESSION... In 1975 Seth Sharpless, a researcher at The University of Colorado, did a study on the effects of compression at the level of the nerve root. His finding was that only 8-10mmHg of pressure can have profound effects and result in significant conduction block in the nerve root. The weight of a dime on the back of your hand equals about 8-10mmHg of pressure. Sharpless's finding was confirmed in a 1995 study that found that when a bundle of nerves known as the cauda equina, (these nerves resemble a horse's tail as they emanate from the low back and tail bone regions), were compressed at their nerve roots at only 10mmHg pressure it resulted in decreased action potentials. In 1992 B.L. Rydevik, a research scientist, found that it took only 5-10mmHg of pressure at the nerve root to interfere with the supply of nutrition to the nerve root. Finally, M. Hause, another researcher, found that pain is not neccesarily present when nerve roots are compressed. Hause's study also found that with compression there were mechanical changes, circulatory changes, production of inflamatory agents which will produce pain, and disturbed cerebral spinal flow. What the findings of this research mean to you is that, if you have a subluxation in your spine, it can be responsible for the pain you may or may not feel, and the dysfunction you are experiencing. When a vertebra is misaligned it can cause the nerve root to experience increased pressure which in turn can cause you to suffer from all that these researchers found. Swinkels MSc, Dolan PhD. Spine 2000;25(1):98-105. Proprioceptor has 2 components: position sense (awareness of the relative orientation of body parts in space & movement sense (kinesthesia) – the perception of velocity & acceleration. Afferent inputs from joint tissues, muscles, skin, eyes, & vestibular apparatus all contribute to proprioceptor. Ligamentous & capsular afferents are most active at the limits of joint movement, input from muscle spindles provides the primary source of joint position sense over most of the physiologic range. Position sense in healthy subjects is accurate to within a few degrees, but may be impaired by pathology. Movement of one vertebra relative to another will produce the most strain in small intersegmental muscles (richly endowed with muscles spindles) & ligaments. Gill, MSc, Callaghan, Mphil. Spine 1998;23(3):371-377. Dynamic stability requires more than adequate force generated by muscles. The force must be properly coordinated, occurring at precise points in a movement. An exact balance must exist between agonist & antagonist muscle groups. If a patient bends in 2 different ways, the sequence & timing of contractions of various agonists & antagonists will be different. Normal proprioception is thought to be essential for this muscular coordination. Cornefjord, Michael MD et al Spine. 22(9):946-957, May 1, 1997. A Model for Chronic Nerve Root Compression Studies: Presentation of a Porcine Model for Controlled, Slow-Onset Compression With Analyses of Anatomic Aspects, Compression Onset Rate, and Morphologic and Neurophysiologic Effects. Abstract: Study Design. Compression onset rate, anatomic aspects, and morphologic and neurophysiologic effects in spinal nerve roots were studied in a nerve root compression model in pigs. Objectives. To analyze the compression onset rate by measuring the gradual reduction of the inner diameter of the constrictor, the motor nerve conduction velocity by electromyography, the morphologic changes by light microscopy, and the gross and vascular anatomy by dissection and ink injections, respectively, in a model for experimental chronic nerve root compression. Summary of Background Data. Chronic nerve root compression is recognized to be related to back pain syndromes, including sciatica. Various aspects of morphologic and physiologic changes have been studied previously in models for 136

acute compression and chronic nerve root irritation, but a controlled, graded chronic nerve root compression model has not been described.Methods. An ameroid constrictor was applied around a spinal nerve root just cranial to the dorsal root ganglion. The inner diameter of this constrictor gradually becomes reduced. After 1 week or 4 weeks, electromyographic measurements were performed, and tissue samples were harvested for histologic analyses. The gross and vascular anatomy of the pigs' spinal nerve roots were studied by dissection and ink injections. Results. There was a statistically significant decrease in the nerve conduction velocity in compressed compared with noncompressed spinal nerve roots after 1 week and after 4 weeks. The ameroid constrictors induced nerve fiber damage, endoneural hyperemia, bleeding, and inflammation at the compression zone. There was often a severe reduction in the number of myelinated fibers after 4 weeks. Conclusion. A model for controlled, chronic, partial nerve root injury using a gradual compression-onset constrictor is presented. This model allows for induction of a controlled graded chronic nerve root injury and can be used for research on basic pathophysiologic mechanisms and on the effects of various interventions on nerve root injury development. Lam SS-K. MphySt et al. Lumbar spine kinesthesia in patients with low back pain. J Orth & Sports PT 1999;29(5):294-299. Kinesthetic awareness is an important sense for controlling human movement & is required for coordinating trunk muscles during movement. Guyton, MD. 1991 text: Mechanoreceptors: detect mechanical deformation. Proprioceptive sensations have to do with the physical state of the body, including position sensations, tendon & muscle sensations, pressure sensations from the bottom of the feet & sensation of equilibrium. They include: Static position sense: conscious orientation of the different parts of the body with respect to each other. Rate of movement sense also known as kinesthesia or dynamic proprioception. Seaman, DC, MS, DABCN. JMPT 1997;20(4):279-284. Proprioception is a conscious processing of mechanoreceptive input. Proprioception refers to conscious awareness of body position & body movement. Proprioception is a conscious cortical experience & not a peripheral sensory phenomenon. It cannot occur if cortical centers are not intact. Lephart, PhD et al. Am J Sports Med 1997;25(2): 130-137. Articular structures like ligaments not only provide mechanical restraint but also provide neurologic feedback that directly mediates reflex muscular stabilization about the joint, providing dynamic joint stability. Jiang, MB, PhD et al. Spine 1997;22(1):17-25. Joint receptors contribute to 1) the coordination of muscle tone around joints & 2) provide neurologic feedback to enhance joint stability. Spinal ligaments, like those around knee joints, are richly innervated, responsive to mechanical stimulation & provide proprioceptor feedback that mediates reflex muscular stabilization about the joint, providing dynamic joint stability – part of a neurologic protective mechanism. Stretching ligaments stimulates mechanoreceptors & the production of Fos protein. Synaptic transmission to interneurons & neural nuclei activates production of Fos protein & can be used to trace sensory & functional pathways in the CNS. In chickens, a transverse ligament at T3-4 was repeatedly stim by a mechanical load. Fos production was assessed using a fluorescence microscope. RESULTS: Mechanical stim of a transverse ligament led to a widespread barrage of neuronal activity in sensory areas of the CNS. Results strongly support that spinal ligaments contribute to muscle coordination around joints increasing joint stability. Stretching a spinal ligament resulted in massive & widespread neuro input from several levels of the spinal cord & suggest a reflex response to muscles designed to maintain adjacent vertebrae in close alignment & prevent the joints from being damaged. The involvement of higher brain centers suggests a 137

central involvement of reflex activity in response to the sensory information to maintain general balance & an upright posture. Scoliosis may be related to misperception of info associated with local motor reflex activity of the spinal cord or central reflex activity in the brain. Evidence suggests a primary defect of posture, proprioceptor, or equilibrium control is responsible for production of the spinal curvature in scoliosis. Lephart PhD, ATC et al. Am J Sports Med 1997;25(2):130-137. Proprioceptive neuromuscular control influences 3 levels of motor activation in the CNS. 1) Spinal Reflexes provide reflex muscular stabilization of joints – Dynamic Stabilization. 2) Brainstem Motor Control integrates input from joint mechanoreceptors, vestibular centers & visual input to maintain posture & balance. 3) Highest levels of CNS function – provides cognitive awareness of body position & kinesthesia needed for control of voluntary movements. Encouraging maximum afferent discharge to these levels of the CNS must be the goal in stimulating joint & muscle receptors. The abnormal sequencing of muscle firing can cause asynchronous neuromuscular activation patterns that may predispose articulations to overuse trauma. Loss of normal synchronization of firing patterns can alter joint kinematics resulting in repetitive microtrauma. O’Sullivan, Twomey, PhD, Allison, PhD. J Man & Manip Therapy 1997;5(1):20-26. Muscular dysfunction in the presence of low back pain does not so much affect the strength of trunk muscles, but influences the patterns of trunk muscle co-activation & recruitment. When a muscle is weakened there may be shifts in the pattern of motor activity, enabling synergistic muscles to generate the forces required for functional tasks – muscle substitution. Low back pain results not only in changes to levels of trunk muscle activity, but also to the patterns of recruitment & activation between different trunk synergists during movement. Chronic low back pain often results in changes to the neural control system, affecting timing of patterns of cocontraction, balance, reflex & righting responses. Altered mechanoreceptive & proprioceptive input into the neural system can result in disruption to patterns of muscle activation, leaving the person biomechanically vulnerable to further rinjury or increased chronicity. Hodges, PhD, Richardson, PhD. Arch Phys Med Rehab 1999; 80 (Sept): 1005-1012. Study of trunk muscle coordination (abdominal & back extensors) in subjects with & without a history of low back pain with of upper limb movement. Subjects with a history of low back pain had history of an insidious onset of at least 18 months duration for which they had sought care & lost a minimum of 3 work days. Subjects had at least 1 episode of back pain per year or semicontinuous back pain. Mean duration of symptoms was 8.3 years. Subjects were pain free at the time of testing. Results: Early activation of transverse abdominals (TrA) & internal obliques (IO) occurred in the majority of trials in the control group with movement. Subjects with history of low back pain failed to recruit TrA or IO in advance of limb movement with fast movement, & no activity of the abdominal muscles was recorded in the majority of intermediate speed trials. Findings indicate that the mechanism of preparatory spinal control is altered in people with low back pain for movement. Subjects with a history of low back pain have altered recruitment of trunk muscles in response to voluntary tasks. Because of the instability of the spine, these changes in recruitment may indicate inadequate protection of spinal structures from injury. Precise temporal & spatial recruitment of the trunk muscles is essential to protect the spine. In the neutral position minimal restraint is provided by passive structures & stability of spinal segments is dependent on the contraction of surrounding muscles. .Changes in muscular control of the trunk in subjects with a history of low back pain may potentially expose spinal structures to increased risk of microtrauma & injury. Increased stress on the passive structures may result from decreased muscle system spinal stabilization. Results provide evidence that coordination of the trunk muscles is altered in subjects with a history of low back pain when they are without 138

pain. A person with a history of low back pain without current symptoms may be at greater risk of reinjury because of inadequate muscular stabilization of the spine. Radebold, MD et al. Spine 2000;25(8):947-54. A quick-release method during isometric trunk exertions (flex, ext, & lat bend) was used to study the muscle response patterns in 17 chronic low back pain patients & 17 controls to evaluate how low back pain patients react to sudden load release by an electromagnet & EMGs from 12 trunk muscles were recorded. The time delay between the magnet release and the shut-off or switch-on of muscle activity (reaction time) was compared between low back pain patients & controls. A delay in erector spinae reaction time after sudden loading has been observed in low back pain patients. Results: For controls a shut-off of agonistic muscles (53 ms) occurred before the switch-on of antagonist muscles (70 ms). Low back pain patients exhibited a pattern of co-contraction, with agonists remaining active while antagonists switched on. Low back pain patients had longer reaction times for muscles shutting off & switching on. Conclusions: Low back pain patients had a signif different muscle response pattern with sudden load release. The differences may be a predisposing factor to low back injuries or a compensation mechanism to stabilize the lumbar spine. Injuries & chronic mechanical derangement in the osteoligamentous structure reduce spine stability. To maintain a nl level of stability, trunk muscles must compensate by altering their typical activation pattern. Neuromuscular control of the spinal system is extremely complex. An adequate response to sudden loading depends not only on sufficient muscle force but also on correct muscle recruitment & timing patterns to assure mechanical stability. Hodges & Richardson found a delayed response of the transverse abdominis in low back pain patients indicating a deficit in motor control & an insufficient muscular stabilization of the trunk. Altered recruitment patterns in trunk muscles may be necessary to compensate for & stabilize the mechanically disturbed lumbar spine. The hypothesis is that soft tissue injuries in low back pain patients may have an effect on the response of nociceptors & proprioceptors. Previous soft tissue injuries may have irreversibly damaged proprioceptors, & therefore an adequate fast reflex response to sudden loading may not be possible. A delay in responses time must be compensated for by an altered recruitment pattern. The continued contraction of agonist & antagonistic muscle groups similar to muscle spasms in low back pain group may promote an increase in joint stability & serve as a successful compensation mechanism to protect them from the pain & lumbar spine instability.

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Jull Mphty, Richardson, Bphty, Phd. Motor control problems in patients with spinal pain. JMPT 2000;23(2):115-117. Traditional exercise programs focus on strength, endurance, & functional capacity training – beneficial in deconditioned patients, increasing general muscular support of the spine. Recent research suggests that a key impairment in the muscle system is one of motor control rather than of only strength. Such impairments need to be addressed before or in conjunction with more general exercise programs. Links are now emerging between low back pain & motor control deficits in muscles of the local system, notably the transverse abdominis & lumbar multifidus. These muscles appear to lose their nl anticipatory function in patients with low back pain, exhibiting delays in activation & loss of their nl preprogrammed function for support. In low back pain patients, the transverse abdominis demonstrates phasic rather than tonic activity required for its supporting function. Lumbar multifidus has been shown to react by inhibition at a segmental level in acute episodes of low back pain. Segmental stabilization training is aimed at controlling pain, protecting & supporting the spinal segment from reinjury by re-establishing & enhancing muscle control – to improve motor control & restore nl synergistic function between local & global muscle systems. The focus is on retraining the cocontraction of the transverses abdominus & lumbar multifidus. During the retraining process, these local muscles are activated cognitively, as independently as possible from the global muscles. Contractions are practiced repeatedly with the aim of restoring the muscles automatic stabilization function. Ghez C. The Control of Movement. In Kandel ER, Schwartz JH, Jessell TM (eds). Principles of Neural Science 3d edition. NY. Elsevier 1991; Chap 35:534-547. Local interneurons main branches are confined to the same or adjacent spinal segments & in the medial intermediate zone project bilaterally to motor nuclei that control axial muscles. Propriospinal neurons main axon branches terminate in distant spinal segments, running up & down the cord, terminating on interneurons & on motor nuclei located several segments away. Axon of medial propriospinal neurons are longer & may extend the entire length of the spinal cord. This pattern of organization allows the axial muscles, innervated by many spinal segments to be coordinated. Kandel, Schwartz, Jessell. Principles of Neural Science; 4th Ed, 2000: 667-8. Axons of the propriospinal neurons course up & down the white matter of the spinal cord & terminate on interneurons & motor neurons located several segments away. Axons of medial propriospinal neurons run have long axons that branch extensively, some axons extend the entire length of the spinal cord to coordinate movements of the neck & pelvis. This organization allows axial muscles, innervated from many spinal segments, to be coordinated easily during postural adjustments. Guyton, MD. Medical Physiology 1991: 591. Propriospinal Tracts: More than half of all nerve fibers ascending & descending in the spinal cord are propriospinal fibers which run from one segment to another providing pathways for multisegmental reflexes. Ghez C. In Kandel ER, Schwartz JH, Jessel TM (eds). Principles of Neural Science 3d edition. NY. Elsevier 1991; Chap 35: 596-607. Postural responses are triggered by 3 types of sensory inputs: 1) muscle proprioceptors, 2) Vestibular receptors, 3) Visual inputs. Bending the neck 7 turning the head evoke reflexes in neck muscles (cervicocollic reflexes), axial & limb muscles (cervicospinal reflexes). Spindles in neck muscles & receptors in joints of upper cervical vert are responsible. By exciting interneurons & long propriospinal neurons, vestibular & neck reflexes produce complex patterns of facilitation & inhibition in motor neurons innervating axial muscles of the neck & back.

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Nansel, PhD et al. JMPT 1993;16(2):91-95. Changes in cervical afferent proprioceptor input entering the CNS can induce postural changes in the trunk & lower extremity muscles. These “tonic neck reflexes” are mediated through changes in activities of descending & ascending intersegmental spinal pathways, altering activities of motoneurons at spinal levels often some distance away from the entry level of afferent proprioceptor input. On head rotation, asymmetric proprioceptor signals from cervical facet joints & muscles enter the spinal cord intra & intersegmental reflex pathways & orchestrate appropriate movement patterns. Intersegmental reflex pathways carry descending impulses to lumbosacral levels of the cord which modulate activities of motoneurons coordinating contractions of various muscle groups of the lower extremities. Afferent input from 1) the labyrinths to the vestibular nuclei, 2) input from the retina of the eye, & 3) from proprioceptors in joint capsules & muscles, particularly those of the neck, are known to participate in the maintenance of static & dynamic equilibrium & spatial orientation. A significant proportion of proprioceptor info entering the CNS at spinal levels may exert direct influences on motoneurons by means of purely spinal intersegmental pathways not requiring a participation by higher brain stem centers. In this study lower cervical (C7) adjustments caused a decrease in lumbar muscle tone. Pollard, DC, MS, Ward, PhD. The effect of upper cervical or sacroiliac manipulation on hip flexion ROM. JMPT 1998; 21(9):611-616. Study compares the effectiveness of an upper cervical manip & a manip of the SI joint for increasing hip ROM in 52 subjects (18 to 34 years) by using a reliable hand held digital electrogonimometer using a SLR before & after the treatment. 3 groups of subjects: 1) received cervical spinal manipulation; 2) SI spinal manipulation (side posture), & 3) sham (digital pressure on the mastoid process). Results: The 2 spinal manipulation treatments resulted in increased flexion ROM at the hip, but only the upper cervical spinal manipulation increased hip flexion ROM significantly. Spinal manipulation of the neck may affect hip ROM & indicates the existence of a link between C-spine & the lower extremity. A study by same authors found that hip flexion ROM could be improved after a stretch to the hamstring or a stretch to the suboccipital muscles & the cervical stretch effect was greater than the effect of the locally applied stretch on hip ROM changes. Findings lend support to DCs that emphasize a role of upper cervical treatment on the function of sites removed from the spine, that upper cervical spinal manipulation can affect extraspinal function. Potential mechanisms: Tonic Neck Reflexes: Result may be due to a change in muscle spindle output of the suboccipital muscles, causing reflex proprioceptor changes to centers controlling posture. This is supported by animal studies. It is likely that lower limb flexion has resulted from stimulation of the suboccipital muscles & joint capsules associated with a cervical spinal manipulation of the area. It is possible that these effects may manifest in other regions of the spine. As all muscles under consideration are postural in nature, it is highly probable that all would be affected by such reflex activity. This is the first study to demonstrate improvement in an objective ROM measure of peripheral joint function after a single cervical spinal manipulation. The study suggests a link between the neck & hip exists & the link can be affected by cervical spinal manipulation. A potential reflex action of spinal manipulation on long loop reflexes has been suggested as a possible mechanism for increased hip flex. Patterson, PhD. Somatic Dysfunction in Osteopathic Medicine. The Role of Subluxation in Chiropractic. FCER 1997: 26-31. Various areas of the Musculoskeletal System are extensively & richly innervated with mechanoreceptors, especially around the spinal column which seems to operate as one vast proprioceptive organ. Nyland, Med, PT, ATC. JOSPT 1994; 19(1):2-11. The mechanoreceptors in ligaments & joint capsules influence gamma-motoneurons & modulate muscle activity & joint stabilization. Failure or destruction ofmechanoreceptors’ ability to provide feedback contributes to 141

unpredictable “giving way” and may result in progressive degenerative changes of joints & muscle atrophy. Proprioceptors provide postural & kinesthetic sensation to the sensory regions of the cerebral cortex allowing the brain to make inforomed decisions for effective motor programs. Afferent input enables motor program changes based on information provided by changes in body position. Dietz (Dept Neurology & Neurophys). Physio Reviews 1992; 72(1):33-69. Afferent input influences central motor programs. Proprioceptor input from muscles and joints is required to adjust the motor program by modulating muscle EMG activity. Freeman, MD & Wyke, MD. Brit J Surgb 19967;54(12):990-1001. Articular mechanoreceptors along with descending projections from the brain stem reticular system help determine the coordination & degree of gamma-motoneuron activity in muscles working a joint. Mechanoreceptors directly influence segmental & intersegfmental reflex coordination of muscles. Indirectly, they exert ocntrol thru supra-segmental projections to brain stem, cerebellum & cortex. Yeung MS Survey on Ankle Sprains. Br J Sp Med 1994;28(2):112-116. Previous studies found 67.3% of football players & 70% of basketball players had sprained ankles. 26.5% of athletes surveyed had a history of one ankle sprain, 51.5% had a history of 2 to 4, & 22% had a history of 5 or more ankle sprains.

Neurology and the Cervical Spine Abrahams, (Dept Physio). In Garlick D (ed). Proprioception, posture, & emotion. Committee in Postgraduate Medical Education, Kensington, NSW, Aust; 1982: The evidence that the neck plays a critical role in posture is overwhelming. Muscle receptors may be of great importance in sensing joint position. A characteristic of neck muscles is an abundance of muscle spindles. The spindle density in large muscles of the neck range from 46-106/gm, among the highest of anywhere. High spindle density is characteristic of muscle executing fine motor control. The abundance of afferent information may not only be due to fine motor control. Polysynaptic pathways from neck muscle afferents to neck motorneurons are powerful. Afferents leaving neck muscles can exert profound effects on hind limb motorneuron excitability. The neck structures are unusually rich in receptors. Small muscles close to the cervical vertebrae may have up to 500 muscle spindles/gm, a density almost 100 times as great as some muscles of locomotion & 5 times greater than the large dorsal neck muscles which are regarded as spindle rich. These deep structures play an important role in reflexes & maintenance of posture & provide precise information with respect to position. Guyton, MD. Textbook of medical physiology (9th ed). WB Saunders, Phila 1996; 714. The vestibular apparatus detects the orientation & movement only of the head. Therefore, it is essential that the nervous centers also receive appropriate information depicting the orientation of the head with respect to the body. This information is transmitted from the proprioceptors of the neck & body directly into the vestibular & reticular nuclei of the brain stem & also indirectly by way of the cerebellum. By far the most important proprioceptive information needed for the maintenance of equilibrium is that derived from the joint receptors of the neck. McLain RF, MD, Pickar JG, DC, PhD. Spine 1998; 21(2): 168-173. Human facets contain mechanoreceptors that detect motion & distortion and provide proprioceptor & protective information to the CNS regarding joint function & position. Spinal proprioceptor may play a role in modulating protective muscular reflexes (PMRs) that prevent injury or facilitate healing. 142

Cervical facets have a more consistent pattern of mechanoreceptor innervation & a greater density of receptors per capsule than the thoracic or lumbar spine suggesting that proprioceptor function in the thoracic & lumbar spine is less refined &, perhaps, less critical. The predominance of receptors in the cervical s pine is consistent with its greater mobility & the need for coordinated muscle control for posture & for accurate positioning & protection of the head in space. The paucity of receptors in the thoracic spine is consistent with the limited motion & intrinsic stability of the thoracic cage. Receptor complexes may work in concert to provide proprioception, modulate protective muscular reflexes (PMRs) & signal potential tissue damage in the face of excessive movement. Wyke, MD. Neurology of Cervical Joints. Physiotherapy 1979;65(3): 72-76. Electrical or mechanical stimulation of 1 C3-C4 facet joint results in a coordinated pattern of motor responses in all 4 extremities including rectus & bicep femoris, biceps & tripceps brachia. Grillner, MD, PhD. Scientific American 1996; Jan: 64-69. Neural Networks for Locomotion. Neural networks governing specific, often repeated motions are called Central Pattern Generators. They can execute a particular action over & over again without need for conscious effort. The circuits for walking, running & some protective reflexes aren’t located in the brain but reside in the spinal cord. The essential neural patterns for locomotion are generated completely within the spinal cord. The brain controls these circuits by a simple control signal from an area of the brain which can generate intricate patterns involving large numbers of muscles in the trunk & limbs by activating pattern generators for locomotion housed within the spinal cord. Although the brain stem issues the overall command to walk, it delegates the task of coordinating muscle movements to local teams of neurons which process incoming sensory data & adjust their own behavior accordingly. Radanov, MD. Cognitive deficits post-cervical soft tissue injury. Spine 1992:17(2):127-131. In whiplash, functional brain stem disturbance was reported without morphologic lesions in any part of the brain. It was noted that cognitive impairment & reduced speed of information processing disappeared with the use of cervical collar or infiltration of deep neck muscles with local anesthetic. A reflex influence of proprioceptors can lead to functional brain stem disturbances. Galm R et al. Vertigo in patients with cervical spine dysfunction. Eur Spine J 1998; 7: 55-58. 50 patients with dizziness & previous ENT & neuro exams excluding causes in their fields followed a program of physical therapy & follow-up at 2 weeks & 12 weeks. All patients received a manual med exam to diagnose segmental C-spine dysfunction, which if present, was treated with manual therapy consisting of mobilizing techniques without impulse & manipulation with high velocity impulse. All patients got physical therapy for 3 months & had follow-up at 2 weeks & at 12 weeks. Results: All 50 patients had dizziness/vertigo. 31 of 50 patients had signs of dysfunctions of the upper C-spine & received manual therapy, 19 didn’t. At 2 weeks follow-up, 16 of 31 patients with signs of dysfunction had significant improvement of vertigo. 4 more patients had temporary improvement but later had recurrence. At 3 months 24 of 31 patients with signs of upper cervical dysfunction (77.4%) reported lasting improvements of vertigo & 5 had complete relief. 7 patients had no improvement. In the 19 patients who had no signs of upper cervical dysfunction, 8 showed improvement of vertigo after 2 weeks of physical therapy. At 3 months, only 5 (26.3%) had an improvement of vertigo, the other 14 had no improvement. Improvement of vertigo was more frequent in patients with signs of dysfunction (77.4 vs 26.3%). Physical therapy is more likely to succeed in reducing vertigo if patients have upper cervical dysfunction that is successfully resolved by manual medicine prior to physical therapy. The authors regard the C-spine dysfunction as the principal cause of these patients’ vertigo. 143

Loudon, PhD, PT et al. Ability to reproduce head position after whiplash. Spine 1997; 22(8):865-8668. 11 symptoms whiplash patients (within the past 2 years but > 3 months) & 11 age-matched asymp controls tried to reproduce various positions of the cervical spine: 30 & 50 degrees of rotation & 20 degrees of lat bending left & right using a CROM. “Neutral” position was also assessed. Results: Whiplash patients were less accurate in reproducing the angles. Average differences in whiplash patients was 5.01 vs 1.75 degrees in controls. Whiplash patients possess an inaccurate perception of head position secondary to their injury. Injury of mechanoreceptors in the C-spine with whiplash has profound effects on postural reflexes. With pain & muscle inflam there’s inhibition of gama-motoneuron discharge & information from muscle spindles is inaccurate, altering proprioceptor sensibility. Whiplash patients also had an impaired ability to reproduce a neutral head position. Whiplash patients may have proprioceptor deficits that do not allow them to accurately calculate head position. Coordination activities & proprioceptor retraining can have positive effects on kinesthetic awareness after injury. Rehab after whiplash should focus not only on ROM & strength but on postural awareness. Fitz-Ritson, DC. Cervicogenic Vertigo. JMPT 1991;14(3):193-198. In 112 post-whiplash patients with cervicogenic vertigo 90% were symptom free by 18 adjustments. Patients with upper cervical problems improved the fastest. Goals of care: to normalize motor function and afferent input. All 11 patients who only improved slightly or not at all had their injury 21-43 months earlier. Disturbances in cervical soft tissues may be important in producing vertigo due to the potency of their disturbed afferent input. Fitz-Ritson, DC. JMPT 1995; 18(1):21-24. Phasic exercises including rapid eye-head-neck-arm movements can benefit patients with chronic cervical injuries. Patients with >12 weeks post whiplash who had been treated with spinal manipulation & rehab exercises but still suffered pain/soreness/stiffness were randomized into 2 groups. Group 1 had spinal manipulation & rehab exercises; Group 2 had spinal manipulation & phasic exercises. Both groups were treated 4X/week for 8 weeks. Results: Group 1 improved by 7.4%; group 2 by 48.3% on the Neck disability index. Field et al. J Back & Musculoskel rehab 1997; 8:199-207. The effect of back injury on ability to replicate a posture. 16 back injured subjects (injured 4 months to 6 years previously) & 16 aged matched controls were asked to reproduce a target standing posture. Subjects were blindfolded. After back injury subjects may develop an inaccurate perception of body position. Improved accuracy was statistically significant in injured group after rehab but still not as accurate as controls. Neurology and Chiropractic: Subluxation, Joint Complex Dysfunction, Dysafferentiation and Adjustment Cavanaugh JM et al, Mechanisms of low back pain: a neurophysiologic and neuroanatomic study. Clin Orthop. 1997 Feb;(335):166-80.Idiopathic low back pain has confounded health care practitioners for decades. The cellular and neural mechanisms that lead to facet pain, discogenic pain, and sciatica are not well understood. To help elucidate these mechanisms, anesthetized New Zealand white rabbits were used in a series of neurophysiologic and neuroanatomic studies. These studies showed the following evidence in support of facet pain: an extensive distribution of small nerve fibers and endings in the lumbar facet joint, nerves containing substance P, high threshold mechanoreceptors in the facet joint capsule, and sensitization and excitation of nerves in facet joint and surrounding muscle when the nerves were exposed to inflammatory or algesic chemicals. Evidence for pain of disc origin included an extensive distribution of small nerve 144

fibers and free nerve endings in the superficial annulus of the disc and small fibers and free nerve endings in adjacent longitudinal ligaments. Possible mechanisms of sciatica included vigorous and long lasting excitatory discharges when dorsal root ganglia were subjected to moderate pressure, excitation of dorsal root fibers when the ganglia were exposed to autologous nucleus pulposus, and excitation and loss of nerve function in nerve roots exposed to phospholipase A2.

Seaman DR, DC, MS, DABCN. JMPT 1997;20(9):634-644. Joint Complex Dysfunction has been described by DCs, physical therapists, MDs. All agree that reduced mobility promotes pathological changes in the structures that make up the joint complex & that pain, inflammation & stiffness are common manifestations of the lesion. Restoring mobility is often a primary objective of treatment. Muscle functional imbalances, such as tightening, shortening & trigger points are intimately associated with joint hypomobility/immobility & may be components of joint complex dysfunction. Muscles develop weakness or tightness in typical imbalance patterns which promote faulty movement patterns, an essential component of joint complex dysfunction. It is likely that joint complex dysfunction develops before pain is generated. Connective tissue, disc & muscle pathology (degen & atrophy) without any symptoms can exist in asympt & apparently healthy individuals. Muscles play a role in stabilizing the spinal column & muscle weakness may predispose the spine to injury. This suggests that the great majority of people suffer asymp joint complex dysfunction before spinal tissue injury generates pain. Once injury occurs, a new set of dynamics come into play, including inflam, nociception & pain, all of which promote joint immobility & further development of joint complex dysfunction, including increased formation & deposition of fibrous tissue which further reduces mobility & promotes joint complex dysfunction. Cavanaugh JM. Neural mechanisms of lumbar pain. Spine. 1995 Aug 15;20(16):1804-9. This article discusses neuroanatomic and neurophysiologic bases for low back pain. Evidence for the existence of pain generators in facet, disc, muscle, nerve roots, and dorsal root ganglia are discussed. Mechanisms that may explain the persistence of pain, including neurogenic and nonneurogenic inflammation and central sensitization, are also presented. Owens MS, DC. Theoretical constructs of vertebral subluxations as applied by chiropractic practitioners and researchers. Top Clin Chiro 2000;7(1): 74-79. Preventive subluxations care: Degeneration of tissues is thought to occur in areas of disturbed kinesmatics, which can eventually lead to arthritic changes in the joints or nerve involvement if the disturbance is not addressed. Care is focused on detecting areas of kinematic dysfunction & correcting them before symptoms arise. In this case, chiropractic care is indicated whether symptoms are present or not. Meeker, W. DC, MPH. Concepts germane to an evidence-based application of chiropractic theory. Top Clin Chiro 2000;7(1):67-73. Spinal manipulation & adjustments (Adj) have been studied for certain kinds of health outcomes, usually musculoskeletal pain & disability. In this regard, the concept of subluxations has been somewhat ignored. Few studies examine the effect of adjustments on subluxations directly, assuming that any improvements in health status as measured by pain & disability are an indirect indication that a “subluxations” was improved. This has yet to be directly tested, leaving the possibility that the concept of subluxations is relatively unimportant in the relationship between adjustments & health. In other words, there may be effects of adjustments on health that are independent of subluxations. This would have tremendous implications for chiropractic practice, let alone theory. 145

Chiropractic researchers set sights on the spine. J Am Chiro Assoc 2002; 39(1):9-15. It is an irony of chiropractic research that we have demonstrated the therapeutic effectiveness of what we do, but not the reality of the spinal lesion – the subluxations – that is the focus of our treatment approach. Seaman DR, DC, Winterstein JF, DC. JMPT 1998;21(4):267-280. Dysafferentiation is an imbalance in afferent input resulting in an increase of nociceptor input & reduction in mechanoreceptor input. Joint complex dysfunction influences both mechanoreceptors & nociceptors leading to excitation of nociceptors & reduced activity in Mrs. Reduced activity in mechanoreceptor system reduces the ability to inhibit pain in the spinal cord & may magnify symptoms due to nociceptor input. Mechanoreceptor input to the brainstem, cerebellum, thalamus & cortex plays a major role in equilibrium, PR, & motor control. Reduced mobility assoc with joint complex dysfunction may reduce mechanoreceptor activation & result in dysequilibrium, vertigo, faulty motor control. Brumagne et al. Spine 2000;25(8):989-94. Deficits in proprioceptor input may change perception. Deficits in proprioceptor may reorganize spinal motor reflexes so they no longer protect the spine from mechanical injury. Interventions that enhance proprioceptor acuity may aid in recovery 7 reduce the likelihood of recurrence of chronic low back pain. Rieman, PhD, ATC, Lephart, PhkD, ATC. The sensori-motor system, Part II: The role of proprioception in motor control and functional joint stability. J Athletic Training; 2002 37(1): 80-84. Proprioceptor is fundamental for sensorimotor control over joint stability. Proprioceptor is conveyed to all levels of the CNS & provides a unique sensory component to optimize motor control. Joint receptors, which are often damaged during articular injury, appear to be an important component of PR. Their role in influencing gamma motoneurons & supraspinal motor programs appears to be substantial. Critical to effective motor control is accurate sensory information. Adaptive motor programs are stimulated by sensory triggers. Three sensory sources (somatosensory, visual, vestibular) have specific unique roles that may not be compensated for by the other sensory sources. Before & during a motor command, the motor control system must consider the current & changing positions of the joints involved. PR best provides the needed segmental movement & position information to the motor control system to solve movement problems. Motor control undergoes constant review & modification based upon the analysis & integration of sensory input, motor commands, & movements. PR info stemming from joint & muscle receptors plays an integral role in this process. These actions represent neuromuscular control. PR is essential to maintaining both stability of the entire body (postural stability) & stability of individual segments (joint stability). Normal Sensory input (Somatosensory Input: Mechanoreception and Visual & Vestibular Input) leads to normal sensory processing (Perceptual Processing & Coordination of Motor Programs to Execute Movement) & results in normal motor output (Effective Motor Control & Movement Strategy). Abnormal sensory input (Nociception, Altered mechanoreceptor due to decreased ROM, Spasm, Swelling & Sensory Mismatch) can lead to abnormal central processing (Inability to Integrate Disturbed Input) & result in abnormal motor output (Spasm, restriction, Hypermobility, Increased Risk of Injury & Degeneration). CAUSES OF DISTURBED PROPRIOCEPTION: 1) tissue injury, 2) Inflammation, 3) Pain, 4) Loss of Motion, 5) Degeneration.

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Freeman, MD. Ankle Sprain. J Bone & Jt Surg 1965;47B(4):678-85. Forces strong enough to damage ligaments damage nerve fibers which have lower tensile strength. Results in partial joint deafferentation & functional instability. Wobble board exercises provide sensorimotor facilitation & improve balance & sensorimotor control. Ankle sprain not only damages the lateral ligaments but damages proprioceptor (PR) nerve fibers which run in the ligaments leading to partial joint deafferentation and instability. Muscles need PR input in order to perform in a coordinated fashion needed for joint stability. Lephart, Phd, ATC et al. Am J Sports Med 1997;25(1):130-137. Dynamic joint stabilization exercise performed with a wobble board to stimulate coactivation of shoulder muscles. Trauma to tissues that contain mechanoreceptors may result in partial deafferentation which can lead to proprioceptive deficits. Susceptibility to reinjury becomes more likely because of the decreased proprioceptive feedback. Deficits in neuromuscular reflex pathways may have a detrimental effect on the motor control system’s role as a protective mechanism to prevent acute joint injury. Parkhurst, MS, PT & Burnett, MS, PT. JOSPT 1994;19(5):282-295. Musculotendinous junction is the weakest link in the muscle-tendon unit. This region fails first when exposed to excess tension. This is the site of Golgi tendon organs & may expose them to structural derangement or denervation resulting in possible proprioceptive impairment. Intramuscular bleeding can lead to increased pressure & local tissue ischemia. The muscle spindle may be susceptible to these types of trauma. Muscle spindles may be susceptible to this type of trauma. Spindles surviving mechanical disruption, denervation & tenotomy have evidence of abnormal afferent impulses. This can alter proprioception. Lachman, MA, MD. Soft tissue injuries in sport. 2nd ed. London, Blackwell Scientific Publications 1994:12-31: Proprioceptors provide information at the conscious level about position & movement & subconsciously eliciting spinal reflexes that alter muscle action to control posture & prevent excessive deformation of joints & tissues. Its failure results in the loss of control of posture & complex movements. The end organs cease to function in the presence of inflammation or after prolonged immobilization of a joint. This loss of afferent input results in failure of postural reflexes so that the joint gives way, known as functional instability. When treating injuries involving structures around a joint it is very important to stimulate the proprioceptive endings from an early stage of treatment. This appears to prevent atrophy of some endings & probably also recruits resting proprioceptive organs in surrounding tissues. Pain causes 1. A distortion of body image in space. A painful body part occupies a much greater part of our perceptual awareness in space. 2. Pain can produce marked and involuntary changes in motor strategies to protect the painful body part. Nansel, PhD. The electrophysiologic consequences of early neurovascular compression. Top Clin Chiro 1999;6(4):1-5. Tactile discrimination, vibratory detection & position sense are transmitted primarily along thick myelinated A-beta fibers. Pain & temp are transmitted over much smaller, lightly myelinated A-delta (fast pain) & smaller unmyelinated C fibers (slow). The reason that the largest, myelinated nerve fibers are so sensitive to oxygen deprivation is that their relatively huge surface areas simply require a much higher ATP production rate & a much higher rate of 02 use. Because of their high metabolic demand, they are, by far, the first to feel the effects of a decrease in oxygen delivery which results in dysfunctional physiologic changes. Caranasos, MD, Israel, MD. Gait Disorders in the Elderly. Hospital Practice 1991;June 15:6794. mechanoreceptors in cervical facet joints provide major input regarding the position of the 147

head in relation to the body. With aging, mild defects impair mechanoreceptors function. Loss of proprioceptor can also involve the legs, especially with diabetes. With decreased proprioceptor, body positioning in space is impeded and the patient becomes reliant on vision to know the location of a limb. To compensate for loss of proprioception in the legs, the feet are kept wider apart than usual. Steps become irregular & uneven in length. As impairment increases the patient becomes unable to compensate. With severe loss of proprioception, the patient is rendered unable to get up from a chair or rise after a fall without assistance. Nies, Sinnott. Variations in balance & body sway in middle-aged adults. Subjects with healthy backs compared with subjects with low-back dysfunction. Spine 1991; 16(3): 325-30. In 45 middle aged adults, 20 with low back pain & 25 controls with healthy backs, balance responses (body sway) were measured under with computerized force plate stabilometry. Compared with controls, low back pain subjects demonstrated significantly greater postural sway, kept their center of force significantly more posterior, & were significantly less likely to be able to balance on one foot with eyes closed. Treatment of low back pain patients may require attention to postural alignment, strength, flexibility, joint stability, balance reactions, & postural strategies. Tjon, MA, Geurts, MD et al. Postural control in rheumatoid arthritis patients scheduled for total knee arthroplasty. Arch Phys Med Rehabil 2000; 81: 1489-93. Study of postural stability in 18 rheumatoid arthritis (RA) patients scheduled for total knee arthroplasty & 23 age matched controls evaluating anterior to posterior & lateral sway during quiet standing with 1) eyes open, 2) eyes closed, & 3) while performing an attention-demanding arithmetic task. RA patients with severe knee joint impairment have substantial postural instability & a high reliance on visual information (visual dependency) which suggests compensation for impaired sensory feedback from the lower limbs. There is ample evidence for an association between postural instability & an increased risk of falling. Visual dependency deteriorates patients safety even further in situations in which visual information is limited. Hassan, B. S. et al. Static postural sway, proprioceptor, & maximal voluntary quadriceps contraction in patients with knee osteoarthritis & nl controls. Ann Rheum Dis 2001;60(6):61128. 77 subjects (average age 63.4 years) with knee osteoarthritis (OA) & 63 healthy age matched controls with nl knees were evaluated for static postural sway, knee proprioceptor acuity & quadriceps strength. Results: patients with knee OA had increased postural sway especially with eyes closed, reduced proprioceptor acuity & weaker quadriceps. Subjects with knee OA have impaired proprioceptor. Studies of ligaments from OA knees show a marked reduction in the number of mechanoreceptors. Knee OA is also associated with a 50-60% reduction in max quadriceps torque possibly resulting from disuse atrophy & arthrogenic inhibition. Radebold, MD et al. Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic low back pain. Spine 2001; 26:724-30. Balance performance in unstable subjects sitting with eyes open & closed and EMG trunk muscle response from 12 major trunk muscles in response to a quick force release in 16 chronic low back pain patients & 14 controls. Results: chronic low back pain patients had poorer balance than controls especially with eyes closed. Lack of visual feedback seems to overburden impaired proprioceptor with postural control tasks. Low back pain patients have poor lumbar spine position sense. In the absence of visual feedback, the remaining sensory input systems were more challenged, which resulted in a more pronounced deficiency in postural control. Chronic low back pain patients also had delayed muscle response times to quick force release. A deficiency in proprioceptor may cause both a delayed muscle response & poor balance performance with low back pain. Injury causes localized proprioceptor deficits. Trunk muscles 148

& ligaments, the main dynamic stabilizers of the spine, may contain damaged proprioceptors in low back pain patients. Maintaining whole body balance is complex & involves interactions of the 3 major sensory input systems: Visual, Vestibular, Somatosensory. As well as precisely coordinated motor output from 3 levels of motor control: 1) Spinal reflexes which provide unconscious joint stability, uses proprioceptor input from joint proprioceptors, muscle spindles & GTOs; 2) Brain stem pathways which control motor programs involved with posture & balance, coordinates vestibular & visual input with proprioceptor input from joint receptors; 3) Cognitive programming for voluntary movements is based on stored central commands which can be voluntarily adjusted depending on sensory feedback. Seaman D, DC, DABCN, MS. JMPT 1999;22(1):46-47. Reduced muscle spindle reflex activity is common & is a cause of postural instability, particularly in the elderly. Movements during stance of elderly subjects indicate delayed postural reactions to stabilize the body before initiation of voluntary movements. Impaired reflex function in older subjects contributes to a greater instability during stance. It appears that muscle spindle reflex hypofunction is the norm for the average elderly individual & it is probably a similar case in those with musculoskeletal injuries & joint complex dysfunction. Sensory motor stimulation is seen as an important adjunct to spinal manipulation & is performed for enhancing sensory input, sensory motor integration & motor control. Wolf, PhD. J Am Geriatr Soc 1996; 44:489-497. 2 new studies find elderly patients taking Tai Chi improve their balance & reduce their number of falls. Tai Chi use slow graceful & precise body movements to improve both balance & body awareness. Study found 15 week program reduced their rate of falls by 47.5%. www.slosberg.com, website which has information about fitballs, upcoming seminars, products, order forms, recent publications and an excellent links page to many journals, health new updates, free medline, chiropractic and health care organizations and more. Lan C, et al. 12-month Tai Chi training in the elderly: its effect on health fitness. Med & Sci in Sports & Exerc 1998;30(3):345-351. Study of the effect of Tai Chi on health in 38 older community dwelling subjects (58 to 70 years). The Tai Chi group included 9 males & 11 females; the control group 9 males & 9 females. Tai Chi group practiced for 11.2 months, an average of 4.6 times per week. Exercise intensity was 52-63% of the heart range. Cardiorespiratory function, strength, flexibility, & percent of body fat were evaluated. Results: The male Tai Chi group showed 16.1% increase in VO2 max, 11 degree increase in thoracic/lumbar flexibility, 18.1% increase in muscle strength of knee extensor, & 15.4% increase of knee flexor. The fefmale Tai Chi group showed 21.3% increase in VO2 max, 8.8 degree increase in flexibility, 20.3% increase in muscle strength of knee extensor, & 15.9% increase of knee flexor. The control group showed no signif change in these variables. Conclusions: Results indicate that a 12 month Tai Chi program is effective for improving health fitness of the elderly.

Neuroplasticity – Learning in the Nervous System Liebenson, C, DC. Dyn Chiro 1998;16(20):36,40,41. Dynamic stabilization training requires some cortical effort, but once it is trained, a new motor program will form that will subcortically protect vulnerable joints from injury on a reflex, semi-automatic basis. To facilitate the formation of a new motor program, labile surfaces (balls, foam, platforms) are used as much as possible. By challenging balance, afferent pathways are spontaneously facilitated in a concentrated way. 149

Liebenson, DC. The state of the art – “Evidence-Based Care.” Dyn Chiro 2000; 18(25):22, 24, 25, 30-1. Muscles can work to either produce or control movement. Injury prevention depends more on movement control than strength. Two distinct muscle systems: One to produce movement – the superficial muscles are responsible for voluntary movement. The deep (intrinsic) muscles for maintaining joint stability (multifidi & transverse abdominus). The deep, intrinsic muscles are responsible for joint stability on an involuntary or subcortical basis. Edelman, MD, PhD, Tononi, MD, PhD. A Universe of Consciousness. Basic Books 2000: 5759. In the initial stages of learning a new skill, conscious control has to be exerted at every step, about every detail, in a process that is slow, laborious, & prone to error. But with practice, conscious control becomes superfluous & disappears. Our performance becomes automatic & fades from consciousness. With practice, new & specialized circuits may augment those already present (long-term changes in synaptic strength) in the areas involved, & performance becomes automatic, fast, easy, accurate & largely unconscious. Automatization suggests that conscious control is exerted only at critical junctures, when a definite choice or a plan has to be made. In between, unconscious routines are continuously triggered & executed, so that consciousness can float free of all those details & proceed to plan & make sense of the grand scheme of things. Carter, R. Mapping the Mind. Univ California Press, Berkeley 1998: 196. PET scans: areas in the prefrontal & temporal cortex are lit up when subject is concerned with making decisions & focusing attention in learning a word task. When the person has practiced the task & it has become routine these areas remained switched off. When the person is choosing new words the activity returns. Kandel E, MD. Cellular mechanisms of learning and the biological basis of individuality. In: Kandel E, editor. Principles of Neuroscience. 4th ed: McGraw Hill; 2000. p. 1247-1279. The molecular mechanisms of memory storage change the connectivity of neurons in the brain. Learning changes the effectiveness of the synaptic connections that make up the pathway mediating the behavior. Learning can lead to increases in synaptic strength & structural changes in sensory & motor neurons. At synapses involved in learning & memory storage, a relatively small amount of training can produce large & enduring changes in synaptic strength. Long-term changes require new protein synthesis which involves: 1) gene activation & expression, 2) new protein synthesis, & 3) growth of synaptic connections. The number of presynaptic terminals in the sensory neurons increases & may become twice as great in the long-term sensitization. Changes also occur in motor neurons – their dendrites grow to accommodate additional synaptic input. Long-term sensitization also involves facilitation of transmitter release at synapses. Longterm sensitization involves the synthesis of new proteins & leads to the growth of new synaptic connections. Specific enzymes translocate to the nucleus activating certain genes that encode proteins important for the growth of new synaptic connections. Connections of afferent & efferent pathways in the cortex can expand or retract depending on activity. Organizational changes probably occur throughout the somatic afferent pathways as well. All brains are uniquely modified by experience. Learning produces changes in the effectiveness of neural connections. LeDoux, J. PhD. Synaptic Self. How our brains become who we are. Viking 2002: 78-81. Neural activity drives the formation of new synapses & axon branches, as well as, provides cues that act to select & stabilize existing ones. Active axons branch & sprout new connections. Plasticity is accompanied by axon branching & new synapse formation following learning. Once this occurs, an action potential (AP) will be more effective in firing the postsynaptic cell because it activates more synapses on that cell. An important set of molecules are neurotrophins, which 150

promote the survival & growth of neurons. When an AP occurs in a postsynaptic cell, neurotrophins are released from the cell & diffuse backward across the synapse, where they are taken up by presynaptic terminals. Under the influence of neurotrophins, axon terminals branch& sprout new synaptic connections. Since only the presynaptic cells that were just active take up the molecules, only they sprout new connections. Activity thus induces growth, & the growth is restricted to the active terminals. Cell death is prevented if a presynaptic terminal receives a lifesustaining shot of neurotrophins from its postsynaptic partner. Sandkuhler J. Learning and memory in pain pathways. Pain 2000;88: 113-118. Contemporary terminology for models of cellular learning and memory. 1) Usedependent change in synaptic strength, 2) Synaptic plasticity, 3) Synaptic long-term plasticity in nociceptive systems, 4) Use-dependent long term potentiation of synaptic strength, 5) Injury induced hyperalgesia DeLeo, J. A. PhD, Winnem, PhD. Physiology of Chronic Spinal Pain syndromes. Spine; 2002; 27(22):2526-2537. In chronic pain that has extended beyond the period of normal tissue healing, a cascade of changes initiated by tissue or neural damage elicits a collection of synaptic, neurotransmitter, & modulatory events that mimics synaptic plasticity & remodeling similar to that seen in learning & memory. A large body of evidence indicates that sensitization in the CNS is largely responsible for the development of persistent pain states. Janda L, Vavrova M. In Liebenson C (ed). Rehabilitation of the spine. Baltimore, Williams & Wilkins 1996:319-328. The afferent system not only has an informative role, but also participates substantially in motor programming & motor system regulation. Therefore, proprioceptor stimulation (sensory motor stimulation) is stressed more & more. To prevent injury, fast reflex muscle contraction is needed to protect joints. It is possible to accelerate muscle contraction about twofold with increased proprioceptive flow & balance exercises. In sensory motor stimulation an attempt is made to facilitate the proprioceptor system & those circuits & pathways that play an important role in regulation of equilibrium & posture. Posner-Mayer, Joanne, P.T. Orthopedic, sports medicine, & fitness exercises using the (Swiss) Gymnic Ball. 1995. Besides improving strength & ROM, these exercises facilitate balance, coordination & muscle recruitment for trunk stability & posture control. This occurs through unconscious neuromotor programming that will carry over at a functional level, something that most exercises for specific muscle groups fail to do. These exercises have the potential range that allows the patient to continue improving beyond his or her preinjury or disability status. Balogun, PhD, PT. Physiotherapy Canada 1992;44(4):23-30. 6 week wobble board training in asymptomatic males. Eyes open balance increased 2012.2%. Eyes closed balance increased 58.8%. Findings: wobble board exercise can improve static balance. Taylor, MA, PT, Gunter, PhD, PT. In: Posner-Mayer J, PT, editor. Orthopedic, Sports Medicine, & Fitness Exercises using the Swiss Ball; 1995:5-18. The gym ball provides dynamic challenges that elicit protective & equilibrium reactions in response to movement. Not only is the strength of individual muscles increased, but each muscle is strengthened as part of a larger functional unit involved in the development of optimal timing & appropriate force to promote biologically sound & efficient movement. The dynamic nature of these exercises stimulates visual, vestibular, & somatosensory systems simultaneously & presents the opportunity to work on integration of multimodal sensory information which may be impaired in a wide range of conditions. Use of the ball elicits quick postural reactions made automatically, utilizing intrinsic sensory feedback & challenges patients, in a very unconscious way, to make reflex postural adjustments 151

reinforcing coordination between postural muscles which is useful in movement re-education following injury or trauma. Janda, V, MD. Sensory Motor Stimulation 1994. The goal of the exercise program is to achieve, as quickly as possible, an automatized control of the muscles responsible for maintenance of good posture & repeated movements such as gait. A goal is to increase the flow of stimuli from the peripheral structures of the musculoskeletal system & exteroreceptors of the skin to increase activation of the subcortical regulatory centers. Activation of the subcortical nervous system increases the fast, automatized activation of muscles with minimal cortical or voluntary control. The program is based on the concept of two stages of motor learning. In the first stage, proprioceptive & exteroceptive information from the periphery passes to the cerebellum where the primitive pattern is formulated & then to the sensory cortex & finally to the motor cortex where the pattern is refined. It is transmitted directly & by the subcortical centers along efferent pathways to the periphery & movement is accomplished. This stage of the motor learning process is tiring & requires cortical motor regulation & deep concentration. The goal of the program is to progress quickly to the second stage of motor control in which the cortex is protected & the decisive role in motor regulation is maintained by subcortical areas. This leads to a fast reflexive manner requiring less concentration. One means of facilitating the second stage of motor control is to increase the proprioceptive input. The facilitation of the 3 following areas is important: Proprioceptors of the sole of the feet; Exteroceptors of the skin; Activation of the neck muscles. The whole regimen attempts to provide in the subcortex, a basis for movement which is progressively elaborated by more complicated movements which demand increasing coordination, precision & skill acquisition. Vellas BJ, MD, PhD et al. JAGS 1997; 43:735-738. One leg balance: A predictor of injurious falls. Study of 316 healthy, community living older subjects (mean 73 years). At baseline 84.5% of subjects could perform one-leg balance for 5 seconds. Impairment on the test was associated with older age & gait abnormalities. Over 3-year follow-up, 71% (225) of subjects experienced a fall & 22% (70), an injurious fall. The only significant predictor of all falls was age > 73. But, impaired one-leg balance was the only signif predictor of injurious falls. Conclusion: One-leg balance is an easy test to do to predict injurious falls, but not all falls. Subjects who couldn’t stand on one leg for 5 seconds had 2.1 times the risk of an injurious fall over 3 years. Hurvitz MD, et al. Unipedal stance testing as an indicator of fall risk among older patients. Arch Phys Med Rehabil 2000;81:587-91. 53 ambulatory outpatients 50 years & older underwent 3 timed unipedal stance at a electroneuromyography lab. Unipedal stance time (UST) & fall history during the previous year were evaluated. Results: 20 subjects (38%) reported falling in the past year. Compared with subjects who had not fallen, those who fell had a signif shorter UST (9.6 seconds vs 31.3 seconds). An abnormal UST ( 7X the average price of older drugs in its category. At Costco’s Pharmacy for 30 pills of Ibuprophen (generoc Motrin): $5.99; Celebrex: $64.27; at Railey’s Pharmacy for 40 pills: Ibuprophen (generic Motrin): $10.09; Celebrex: $109.49. Schultz S. When drug costs sting, look for relief. US News & World Report 2001; June 4: 6970. Data from Rxaminer.com show sharp differences in monthly costs for prescription medications. High Cholesterol drugs – cost per month: Zocor .20mg tablet/once a day $301; Baycol 0.4mg tablet/once a day $130; Lipitor half 20mg tab/once a day $117; Arthritis drugs – cost per month: Celebrex 200mg tab/once a day $189; Mobic 7.5mg tab/once a day $157; Ibuprofen 800mg tab/3X a day $33; depression Drugs – cost per month: Prc 20mg/once a day $203; Celexa half 40mg tab/once a day $83; Nortriptyline 75mg cap/once a day $44. Pert CB, PhD. The Molecules of Emotion. NY, Scribner 1997. Prozac, Zoloft: antidepressant drugs are the ubiquitous medical solution to the epidemic of depression. The drugs work at the synapse, blocking reuptake of serotonin, allowing excess serotonin to flood the receptors. What is going on in other parts of the brain & body when these drugs are used? The intestines, for example, are loaded with serotonin receptors. What happens when these receptors get flooded with serotonin as a result of taking Prozac? It’s known that patients on Prozac often have GI disorders. What might be happening to cells in the immune system that also have these same receptors? Could this affect the ability of natural killer cells to attack mutated cells? No one’s doing research to explore these kind of effects. Certainly not pharmaceutical companies. Gibbs Nancy. Time 1998; Nov 30: 86-96. Childhood depression is common: about 3.4 million Americans under 18 are said to be seriously depressed. That’s a lot of potential consumers for Prozac, Zoloft, Paxil. In North America up to 800,000 antidepressant prescriptions were written for children last year. Eli Lilly is conducting clinical studies in under 18 & may have just the product for this booming new market: liquid Prozac flavored a tasty peppermint. LeFever. The extent of drug therapy for attention deficit-hyperactivity disorder among children in public schools. O e. a. (1999). Am J Public Health 89(9):359-364. Experts contend that 3-5% of US pediatric population suffers from ADD. NIH recognized the possible overdiagnosis and overtreatment of ADD may be an important public health issue. A study of 30,000 grade school students in 2 US cities (grades 2-5) evaluate the extent of med use for ADD. Results: The percent of students receiving ADD meds was similar in both cities (8% & 10%) – 2 to 3X higher than the expected rate of ADD. Meds were used 3 times more frequently on boys than girls & 2X more on white than black kids. By 5th grade, 18 – 20% of white boys were receiving meds.

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Ritalin Fraud: May 2000. (www.ritalinfraud.com). The law firm of Waters & Kraus is filing a class action lawsuit against Ciba Geigy Corporation, Novartis Pharmaceuticals Corporation, Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), and the American Psychiatric Association. Waters & Kraus’ usual practice concerns toxic exposure and cancer cases, but the pattern & practice of improper conduct on the part of the defendants in this case rivals that of the asbestos corporate defendants and tobacco companies in other cases. The allegations are based on fraud and conspiracy. From 1955 through 1995, the exclusive manufacturer/supplier of Ritalin in this country was defendant Ciba-Geigy. In 1996 Ciba merged with Sandoz to become Novartis Pharmaceuticals. Ciba/Novartis planned, conspired, and colluded to create, develop and promote the diagnosis of Attention Deficit Disorder (ADD) in a highly successful effort to increase the market for its product Ritalin. In addition, Ciba/Novartis took steps to promote and dramatically increase the sales of Ritalin by: 1. Actively promoting the concept that a significant percentage of children suffer from a “disease” which required narcotic treatment. 2. actively promoting Ritalin as the “drug of choice” to treat ADD. 3. Actively supporting groups such as CHADD financially so that they would promote increasing implementation of ADD diagnoses as well as directly increasing Ritalin sales; 4. Distributing misleading sales & promotional literature to parents, schools and others in a successful effort to further increase the number of diagnoses and persons prescribed Ritalin. CHADD received contributions from Ciba/Novartis for many years including $748,000 in the period 1991 to 1994 alone. CHADD deliberately made efforts to increase the sales & supply of Ritalin (methylphenidate) available in the USA & to reduce or eliminate laws and restrictions concerning its use in the USA all to the financial benefit of Ciba/Novartis. Ciba/Novartis made such financial contributions with the purpose of advertising and promoting sales of Ritalin – an internationally controlled substance. Ciba/Novartis has thus repeatedly violated Article 10 of the United Nations Convention on Psychotropic Substances. CHADD’s activities have led to significant increase in the amount of Ritalin taken by school children and directly resulted in enormous profits to Ciba/Novartis. Parents, the school districts and other interested parties are unaware that use of Ritalin can cause a significant number of health problems. In addition, it is not generally known that use of Ritalin precludes a child from every joining the U.S. military because Ritalin is a Class II controlled substance, along with morphine and other amphetamines. Landry, MD, PhD. Immunotherapy for cocaine addiction. Scientific American 1997; Feb: 4245. Attention Deficit Hyperactivity Disorder. Barkley, MA. PhD. Scientific American 1998; Sept: 66-71. Neurotransmitters released at a synapse stimulate the post-synaptic neuron to discharge. To prevent excessive signaling, the first neuron actively takes up the transmitter from the synaptic cleft. Ritalin acts by inhibiting the dopamine transporter, increasing the time that dopamine has to bind to its receptors on postsynaptic neurons. Cocaine interferes with this system by preventing transport proteins that carry dopamine from the synapse back into the presynaptic cell, so too much dopamine remains in the synapse. The excess dopamine stimulates the reward pathway & reinforces cocaine use. Zito, PhD et al. Trends in the prescribing of psychotropic medications to preschoolers. JAMA 2000; 283(8): 1025-1030. Psychotropic medications (stimulants, antidepressants & neuroleptics) prescribed for preschoolers (2 – 4 year olds) increased dramatically between 1991 & 1995. For some types of psychotropic drugs there was as much as a 3 fold increase in prescriptions in just 5 years! Thomas. Parents pressured to put kids on drugs. Courts, schools force Ritalin use. USA Today 2000; Aug 8: 1D, 10D. Public schools are accusing parents of child abuse when they balk at giving their kids drugs such as Ritalin, & judges are beginning to agree. Parents are medicating 172

their children for fear of having them hauled away by authorities. An Albany, NY couple put their 7 year old son back on Ritalin after the child’s school district called protective services, alleging child abuse, when the parents said they wanted to take their son off of Ritalin because of side effects (sleeplessness & loss of appetite). A family court ruled that the parents must continue medicating him for ADD. This case is the first pitting educators against parents that progressed to a judge’s ruling. Child protective services in Millbrook, NY visited a couple to check out anonymous allegations of “medical neglect” after they took their son off Ritalin & dexadrine because they made him withdrawn. With the introduction of Paxil the child began to hallucinate. There are similar cases in Boston. Often divorced parents disagree on medicating kids and judges have recently begun ruling in favor of parents who want to medicate. But should parents be forced to put their kids on drugs? “We as a society do the same thing with parents who don’t immunize their kids. The risk for severe ADD going untreated is not trivial.” Says a psychologist. The long-term effects of children taking stimulants have not been studied. About 3.8 million kids are diagnosed with ADD & at least 2 million are on medications for it. Slatyer, MD, PhD. Am J of Sports Med 1997; 25(4): 544-553. Piroxicam in acute ankle sprain. 364 Patients with acute ankle sprains were randomized to treatment with either piroxicam or placebo. Subjects treated with piroxicam had less pain, were able to resume training more rapidly (in 2.74 vs 8.57 days), & were found to have increased exercise endurance on resumption of activity. Nausea was the only side effect. Findings suggest that the early use of piroxicam saved money. Patients treated with piroxicam had greater instability, less ROM & increased swelling. It is possible that the analgesic effects of NSAIDs actually allow patients to resume activity prematurely, before there had been sufficient tissue healing to prevent further swelling & interference with healing that leads to increased instability & reduced ROM. Kibler, MD. Clinics in Sports Med 1995; 14(2): 447-457. repetitive overload injuries in soft tissues reveal many blood vessels & a large amount of unorganized fibrotic tissue – evidence of a failed healing response to chronic low grade injury. This immature tissue lacks the capacity to mature to beneficial tissue. The repair process has largely been turned off. The disorganized nature of the tissue shows that it cannot respond to normal biologic signals for repair & recovery, collagen orientation, or maturation – reflecting a process that characterizes a degenerative condition. These degenerative changes may be due to mechanical, tensile, vascular or hypoxic causes. The result is a cell incapable of making matrix of normal quality & quantity. Degeneration: A variation of repetitive strain syndrome in which there is a gradual accumulation of microdamage over an extended period of time. Damage is due to repetitive, high, localized biomechanical stress (force per unit area) as a result of poor or uneven load distribution in response to normal movement and load bearing over extended periods of time. Tissue fatigue limits are exceeded and damage accumulates more quickly than the body can repair it. This process is accelerated in abnormal tissues which have reduced biomechanical properties including a decreased ability to recover/regenerate after damage. Abnormal tissues may become injured by exposure to forces normally encountered in daily living, and because of their decreased mechanical properties, will be less able to tolerate the higher or more sustained forces that occur with more strenuous activities such as athletics. The same chemical mediators are released as occurs with macrotrauma and repetitive strain, but with degeneration only very small amounts are released over very prolonged periods of time because there is only a very small amount of tissue damage gradually occurring. If the amount of chemicals released are small enough, degeneration is painless. If slightly more is released, patients experience discomfort or achiness, minimal loss of function & subclinical inflammation. Clinical presentation is complicated by scar tissue, & bony changes, disc atrophy & other degenerative changes. 173

Buckwalter, MD, Lane Nancy E, MD. Am J Sports Med 1997; 25(6):873-881. Joint subluxation or incongruity prevent normal distribution of contact stress over the articular surface. These abnormalities increase peak stresses on some regions of the articular surface & decrease stresses on other regions. As a result, normal physical activities may produce damaging levels of peak contact stress in focal regions of the joint surface, leading to articular cartilage injury & joint degeneration. Bishop, Dc, PhD, MD. JMPT 1993; 16(5):300-305. If Joint mechanics are altered, the cells (chondrocytes & fibroblasts) responsible for biosynthesis of proteoglycans will be stimulated to change the composition of the extracellular matrix to produce connective tissue better suited for the new mechanical demands. In a joint that has been severely injured the connective tissue may change sufficiently to permanently alter the function of the joint & thus predispose to premature degeneration &/or further injury. By the same mechanism, maintaining normal joint mechanics may act to prevent premature degeneration &/or joint injury. Tissue Overload Leads to Tissue Injury Biomechanical insult: stretching, tearing, crushing, compression results in the breakage of molecular bonds and the release of chemical mediators. Chemical mediators – histamine, serotonin, bradykinin, substance P, prostaglandins, acids. Sub P & prostaglandins cause redness, swelling, induration, pain & sensitization: lowering the threshold of nociceptors so that they fire in response to innocuous normal movement & weight bearing. Sensitization Saal, MD. Spine 1995;20(16):1821-1827. Inflammation results in the release of algesic substances which cause sensitization of anular or peridiscal nociceptors & their threshold is lowered. Physical loading within the normal physiological range of the dics (e.g., sitting) will result in low back pain &/or extremity pain in the absence of radiculopathy. This neuronal activation results in ongoing generation of back or radicular pain from mechanical forces well within the physiological range of the tissues. Zimmerman in Jayson (ed). Back Pain, Painful Syndromes & Muscle Spasm 1989. Sheather-Reid RB, Cohen ML. Pain 1998; 75:341-347. Allodynia is defined as pain in response to a stimulus which is not tissue damaging. (Normal weight bearing & movement). Hyperalgesia is defined as increased pain in response to a normally painful stimulus. (Stimuli which are tissue damaging). Hyperalgesia is considered to reflect sensitization of afferent pathways peripherally or centrally. The question is whether this hyperalgesia is peripheral --- due to diseased or damaged tissue, or central. Seaman, DC, MS, DABCN. JMPT 1997;20(9):634-644. Sensitization may markedly increase discharges from articular nerves. With inflammation, individual afferents frequency of discharge sometimes increase more than 100 fold! Cavanaugh, MD. Spine 1995;20(16):1804-1809. Peripheral Sensitization. Peripheral nerve endings become sensitized by chemical mediators released during tissue damage & inflammation. Normal motion may become painful with neurogenic inflammation. Tissue damage can cause prolonged nociceptive excitation contributing to a cycle including muscle spasm & hyperalgesia which can lead to persistent pain. 174

When drug costs sting, look for relief. Schultz, Stacy. U.S. News & World Report 2001; June 4: 69-70. Siddall, MB, BS, PhD. Spine 1997;22(1): 98-104. Peripheral Sensitization. With tissue damage there is an inflammatory response including the release of intracellular contents from damaged cells & chemical mediators from inflammatory cells. These interactions result in the release of a “soup” of inflammatory mediators – K+, serotonin, bradykinin, sub P, histamine, etc. These chemicals act to sensitize nociceptors, after which low intensity stimulation causes pain. Tissue damage & inflammation also result in the expression of opiod receptors which may be activated by local release of endogenous opiods. Primary nociceptive afferents terminate in laminae I, II, & III of the dorsal horn on 3 types of interneurons: 1) Nociceptive specific projections neurons (spinothalamic tract neurons); 2) Wide Dynamic range interneurons which respond to noxious & innocuous input. 3) excitatory & inhibitory interneurons which can enhance or diminish responsiveness to peripheral sensory input. Liebenson, DC. Rehabilitation of the Spine. Baltimore, Williams & Wilkins 1996:13-43. With injury & inflammation, chemical mediators are released leading to pain & further compensatory muscular adaptations including increased tone in some muscle & reciprocal inhibition of others in order to avoid further failure or damage. These protective muscular reactions immobilize an injured area & are appropriate in the acute stage. If they become programmed in the form of new movement patterns, “Pain-Motor Programs,” stored in the CNS, they can lead to a chronic state. Consequences of Muscular Imbalance: 1. Altered joint mechanics/uneven load distribution; 2. Limited ROM & compensatory hypermobility, 3. Altered proprioception due to altered load bearing, tension, compression & stress on various tissues. 4. Impaired reciprocal inhibition, 5. Altered programming of movement patterns. Waddell G, MD. The Back Pain Revolution. Churchill Livingstone 1998; 147-148. Altered neuromuscular activity can result in hypersensitivity of joints to mechanical strain & movement. Normal movements may become painful. This leads to reprogramming of neuro-muscular control. The CNS “learns” new patterns of posture, locomotion & activities of daily living. These patterns of motor behavior become fixed & self-perpetuating. www.slosberg.com. Website which has information about fitballs, upcoming seminars, products, order forms, recent publications and an excellent links page to many journals, health new updates, free medline, chiropractic and health care organizations and more. Etiology of Symptoms with injury. Tissue Overload, acute or gradual, leads to tissue damage & the release of chemical mediators resulting in 1) Inflammation & swelling which restrict motion, 2) Pain & Increased sensitivity of pain endings which restricts motion, 3) Reflex Muscle Spasm – involuntary muscle guarding or splinting which restrict motion. These responses lead to the classic clinical symptoms of: Swelling, Pain, Muscle spasm, restriction of motion, & loss of normal function because normal movement & weight bearing are painful due to sensitization of nociceptors. Reuters. Canadian baby found frozen makes “miracle” recovery. 2001. Edmonton, Alberta, Feb 26 – A Canadian toddler wandered into sub-zero temperatures and became so frozen her heart stopped. Doctors said the 13-month-old Edmonton girl, who was clinically dead when she arrived at a hospital on Saturday, had no immediate indication of brain injury, although the extent of her frostbite wounds are still being determined. Medical officials expressed amazement 175

at the recovery. Her body temperature was 16 C (61 F) when paramedics reached her. The toddler crawled out of her mother’s bed and went outside in Edmonton’s –24 degree centigrade (-11 F) weather wearing only a diaper. The mother discovered her daughter hours later, lying curled in the snow of a neighbor’s backyard. Paramedics said the girl had no pulse when they arrived. She was described as being nearly “frozen solid.” Her heart may have been stopped for as long as two hours. Medical officials told reporters they theorize the extreme cold helped preserve the girl by reducing the need for oxygen in her brain at the same rate that her circulation slowed “down, down, down.” Cavanaugh, MD. Spine 1995; 20(16): 1804-1809. Central Sensitization. Tissue injury & inflammation causes a barrage of nociceptor input to the spinal cord & may sensitize neurons in the dorsal horn. Resulting in reduced thresholds, increased spontaneous discharge, increased response to afferent input & repeated stimulation, expansion of receptive fields, sensitizing agents (sub P, PGs, etc) released in the dorsal horn after noxious stimulation lead to central sensitization. Mechanical thresholds are reduced so stimulation from low threshold mechanoreceptors causes firing of pain signaling neurons in the dorsal horn. The expansion of receptive fields from the site of injury to adjacent noninjured tissue may be a mechanism for poor localization & referral of low back pain. Sessle BJ, BDS, MDS, PhD. Top Clin Chiro 1998; 5(1):36-38. Peripherally induced modulation of interneurons & motor neurons reflects the plasticity of the CNS & the effectiveness of deep nociceptor inputs in inducing neuroplastic changes reflective of central sensitization. These pathways are not “hard wired” but are plastic & subject to modification by peripheral input and sustained by the central neural changes. Sheather-Reid RB, Cohen ML. Pain 1998; 75: 341-347. Acute soft tissue injury resolves within weeks & can’t reasonably explain the chronicity of the symptoms in chronic neck pain patients. Initial or ongoing nociceptor insult may be sufficient to cause changes in dorsal horn neurons. A sufficient noxious barrage may induce central changes. Long term alterations to the central processor may become autonomous & independent of peripheral input. The evidence supports that central sensitization of nociceptor processing in response to an afferent barrage, acute or sustained, initiates the process & explains allodynia elicited from structurally normal tissues. This is neuropathic rather than peripheral pain, attributable to changes in function of the neural pathways themselves. Waddell G. The Back Pain Revolution. Churchill Livingstone 1998; 31-32. The CNS is not a set of rigid electrical circuits, but rather is plastic in nature. Chronic pain may involve functional changes in the nervous system. Tissue damage or inflammation can cause peripheral sensitization of nociceptors, so that normal stimuli produce pain. Sensory neurons become hyperexcitable & may produce central sensitization in the spinal cord & higher levels of the CNS. There may be abnormal electrical & chemical activity in the brain itself. The neural networks can change & be altered by neural activity over time. These changes may be lasting & can explain how pain may persist after the original peripheral stimulus has stopped. Chronic pain & disability often seem to become dissociated from the original physical problem. There may be little evidence of any remaining tissue damage or nociception. Chronic pain & disability seem to become self-sustaining & intractable to treatment. Continued attempts to treat tissue damage do not relieve symptoms. Chronic pain loses its biologic meaning & purpose & becomes counter-productive. We cannot understand or treat chronic back pain like the acute pain of tissue damage. Loeser JD, Melzack R. Pain: An overview. The Lancet 1999; 353: 176

1607-1609. Nociceptor function is altered by the inflammatory soup that characterizes a region of tissue injury. Research shows that huge nociceptor input can – thru excitatory toxic effects – permanently change spinal cord function & lead to chronic pain after an acute injury. The intensity of chronic pain frequently bears little or no relation to the extent of tissue injury or other pathology. It is not the duration that distinguishes acute from chronic pain, but the inability of the body to restore its physiological functions to normal homeostatic levels. The central & peripheral nervous systems are dynamic & modulated by tissue damage & by changes in the CNS & stress regulation systems that occur in response to such damage. Some of these modulations may persist & lead to chronic pain states. Bennett RM, MD. Emerging concepts in the neurobiology of chronic pain: evidence of abnormal sensory processing in fibromyalgia. May clin Proc 1999;74:3835-398. Prevention of central sensitization by adequate treatment of nociceptive pain, should be the foremost goal of acute pain management. Vernon, DC, Hu, PhD. Neuroplasticity of neck/craniofacial pain mechanisms: a review of basic science studies. JNMS 1999;7(2):51-64. With nerve injury neuroplastic changes may produce a long-term pain state. The critical element in preventing the development of these changes is early treatment. If nociceptor-induced pathophysiologic changes are permitted to develop fully, the changes may become permanent & refractory to treatment. The short-term pathophysiology converts to longer term pathophysiology with memory & permanent structural change. Bara-Jimenez W, MD et al. Abnormal somatosensory homounculus in dystonia of the hand. Ann Neurol 1998; 44: 828-831. repetitive peripheral sensory stimulation & movements induced plastic changes of the primary somatosensory cortex in animal studies. Plasticity-mediated cortical reorganizations in humans followed the alteration of afferent inputs. Reshaping of cortical representations demonstrates that subject-environment interactions affect organizational features of the somatosensory cortex. Plastic brain reorganization might not always be beneficial, possibly as a consequence of repetitive sensory input or maladaptive learning. Flor H et al. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Assessed reorganization of the primary somatosensory cortex in 10 chronic low back pain patients & 9 controls. Electric stimuli were applied to the left back & index finger at nonpainful & painful intensity. Magnetic fields were recorded from the contralateral hemisphere. The power of the magnetic field elicited by the painful stim in very chronic low back pain patients was elevated. The maximum activity in the primary somatosensory cortex shifted more medially in very chronic low back pain patients suggesting that chronic pain is accompanied by cortical reorganization. The data provide strong evidence of enhanced cortical reactivity in chronic pain states. Previous studies found pain-related plastic changes at the spinal level. This study extends them to the supraspinal level. The magnitude of the cortical response to tactile stim was positively related to chronicity. Findings confirm imaging studies suggesting strong involvement of the activity somatosensory cortex in the processing of pain. In addition to increased activity in the primary somatosensory cortex, the cortical representation of the back had shifted towards a more medial position in chronic low back pain patients suggesting not only enhanced reactivity but an expansion of the back representation into the neighboring (foot & leg) area. The enlarged cortical representation of chronic pain may contribute to the continuing experience of pain in chronic pain patients. Studies also show that extensive tactile stimulation or training lead to an expansion of the respective cortical area. We hypothesize that ongoing painful stim results in cortical reorganization due to excessive nociceptor barrage. The resulting expansion of the primary somatosensory cortex is specific to the site of pain & results in an exaggerated cortical response to tactile stimuli from the painful body region. 177

Grachev, MD et al. Abnormal brain chemistry in chronic back pain. Pain 2000;89:7-18. Study of chemistry changes in the brain of chronic low back pain patients using a magnetic resonance spectroscopy in 6 brain regions of 9 chronic low back pain patients & 11 nl controls. Patients were also evaluated for pain & anxiety. Chronic low back pain alters human brain chemistry. Reductions in N-acetyl aspartate & glucose were found in the dorsolateral prefrontal cortex & the interrelationship between chemicals within & across brain regions was abnormal. The study found direct evidence for brain chemical abnormalities in chronic low back pain & demonstrates that chronic pain is linked to a specific chemical network pattern as a result of long-term cortical reorganization. Findings may explain the low diagnostic value of structural imaging studies (MRI) of the spine in these patients. Local disc abnormalities may play a role in acute back pain but when the process becomes chronic more central mechanisms driven by or causing changes in brain chemistry may be more important. Decreases in N-acetyl aspartate have been documented in various conditions involving neuronal damage including stroke, MS, Alzheimer’s & other neurodegenerative disorders, suggesting a link between chronic pain and neuronal loss & degeneration. The abnl patterns of chemical connectivity shows a well-defined relationship to the perception of chronic pain indicating that the chemical network reflects the functional/perceptual state of the brain, linking neurochemistry to pain/anxiety perception. Results provide chemical evidence for chronic pain occurring in the prefrontal cortex which may disrupt other cognitive processing. Results provide direct evidence of abnl brain chemistry & chemical network in chronic low back pain, which may be a consequence of long-term neurotransmitter changes in chronic pain sufferers. Further studies are needed to determine whether these brain chemical abnormalities may be reversed following pain alleviation. The conclusion that chronic pain may be associated with neural degeneration needs further evaluation. Liepert, MD et al. Stroke 2000;31(6):1210-1216. Treatment-induced cortical reorganization after stroke in humans. In 13 stroke patients with an average duration of 4.9 years of hemiparesis received 12 days of constraint-induced movement therapy. Study used focal transcranial magnetic stimulation to map the cortical motor output area of a hand muscle on both sides before & after the therapy. Results: Before treatment, the cortical representation area of the affected hand muscle (abductor pollicis brevis) was signif smaller than the contralat side. After treatment, the muscle output area in the affected hemisphere was signif enlarged, corresponding to a greatly improved motor performance of the paretic limb. Shifts of the center of the output map in the affected hemisphere suggest the recruitment of adjacent brain areas. 6 months after treatment, motor performance remained at a high level, & cortical area sizes in the 2 hemispheres became almost identical, representing a return of the balance of excitability toward a normal condition. The complete reversal of the abnormally small excitable cortical area which had lasted for 4.9 years after a stroke took place in only 12 days of therapy. Conclusions: This is the first demonstration in humans of a long-term alteration in brain function associated with a therapyinduced improvement in the rehab of movement after neurological injury – use dependent cortical reorganization. Vernon H, DC. Neuroplasticity of neck/craniofacial pain mechanisms. JNMS 1999;7(2):51-54. 2 types of interneurons are involved in signaling pain, one exclusively – nociceptor specific cells (NS) – activated exclusively by high-intensity noxious stim & WDR (wide dynamic range) which respond to both noxious & non-noxious stimuli – convergent neurons. They can code stimulus intensity: Low rate of response to mechanoreceptors; high rate to painful stim. They receive inputs from a variety of tissue sources including: skin, viscera, muscles & joints. Rook, MD. In Cassvan et al (ed). Cumulative trauma disorders. Butterworth-Heinemann 1997; 17-30. Wide dynamic range neurons (WDRs) respond to both nociceptive & mechanoreceptive 178

afferents. They have large receptive fields & result in poorly localized pain. WDRs project up the paleospinothalamic tract to the medial thalamic nuclei. Neurons in this part of the thalamus have highly convergent input from large areas of the skin & deep tissues & no obvious topographic arrangement. 3d order thalamic cells project to the 1) frontal cortex, 2) limbic system & 3) reticular formation of the brain stem. Activity in this pathway leads to poorly localized pain with emotional connotations: 1) Depression, 2) Anxiety, 3) Sleep disturbances, & other features seen in chronic pain syndrome. This pathway, with its diffuse projections to the limbic system & to the frontal lobe subserves the affective-motivational aspects of pain. Ashburn, MA, MD, Staats PS, MD. Management of chronic pain. The Lancet 1999;353:18651869. The effect of chronic pain often profoundly affects the patient’s mood, personality, & social relationships. People with chronic pain typically experience concomitant depression, sleep disturbance, fatigue & decreased overall physical functioning. Pain is only one of the many issues that must be addressed in the management of patients with chronic pain. Interventions that target only nociception without addressing the patient’s depression & social stresses are unlikely to lead to long-term benefit. In most patients, chronic pain cannot be eradicated or cured. Thus, the goal of therapy is to control pain & to rehabilitate the patient so that they can function as well as possible. Fishbain Msc, MD. Chronic pain-associated depression: antecedent or consequence of chronic pain? A Review. The Clinical Journal of Pain 1997; 13:116-1137. A review of 191 studies found depression is more common in chronic pain patients (CPPs) than healthy subjects as a consequence of the presence of chronic pain. A predisposition to depression (a previous history) may increase the likelihood of depression in some CPPs. The neurochemical link between pain & depression lies with 2 neurotransmitters: Serotonin (5-HT) & Norepinephrine (NE). 5-HT plays a major role in depression: There is a reduction in 5-HT in postmortem brain tissue of depressed patients & reduced CSF fluid concentrations of 5-HT in depressed patients, especially suicidal patients. All drugs that selectively inhibit the reuptake of 5-HT are effective in the treatment of depression. Inhibition of 5-HT synthesis in treated depressed patients produces a rapid relapse. All currently available antidepressant treatment including electroconvulsive therapy (ECT) increase 5-HT neurotransmission. Norepinephrine (NE) also plays a role in depression. NE is reduced in CSF, plasma & urine in depressed patients. In the postmortem brain tissue from depressed patients there is increased beta-adrenergic receptor density possibly secondary to reduced synaptic availability of NE. All tricyclic antidepressants increase concentrations of NE & 5-HT in the synaptic cleft by blocking reuptake or inhibiting their metabolism. The descending pain control system that inhibits pain at the dorsal horn – utilizes both serotonin & NE. Many neurons of the descending pain control system in the medulla contain serotonin as their neurotransmitter & stim of the brain stem causes release of serotonin or NE at the level of the spinal cord. The depletion of serotonin increases painful responses. A functional NE system is necessary for 5-HT mediated analgesia. Pain may increase the turnover of serotonin reducing presynaptic 5-HT release in chronic pain patients just as in depressed patients leading to reduced activity of the pain descending control system, thus more pain. Antidepressant drugs can generate analgesia in CPPs due to a reversal of the reduction in presynaptic 5-HT release, increasing activity of the descending pain control system. If the turnover of serotonin is increased with pain, this could lead to depression. Kandel, Schwartz, Jessell. Principles of Neuroscience, 4th ed, 2000: 486. There are two descending pathways in the CNS to inhibit the central transmission of pain. One begins in the Periaqueductal Grey Region of the Midbrain & uses serotonin as the neurotransmitter to result in the release of met-enkephalin from the substantia gelatinosa (SG) in lamina two of the dorsal horn. The other inhibitory pathway originates in the Locus Ceruleus in the pons and uses 179

norepinephrine to result in the release of met-enkephalin as well. Both presynaptic nociceptor neurons & postsynaptic transmission neurons of the spinothalamic tract have receptor sites for met-enkephalin. Its release causes pre & postsynaptic inhibition of the central transmission of pain. SG cells can also be stimulated to release met-enkephalin in the dorsal horn due to increased mechanoreceptor input at the same or nearby segmental levels – helping to close the gate to the central transmission of pain. Fishbain, Msc, MD. Chronic pain-associated depression: antecedent or consequence of chronic pain? A review. The Clinical Journal of Pain 1997;113:116-137. A review of 191 studies found depression is more common in chronic pain patients (CPPs) than healthy subjects as a consequence of the presence of chronic pain. A predisposition to depression (a previous history) may increase the likelihood of depression in some CPPs. The neurochemical link between pain & depression lies with 2 neurotransmitters: Serotonin (5-HT) & Norepinephrine (NE). 5-HT plays a major role in depression: there is a reduction in 5-HT in postmortem brain tissue of depressed patients & reduced CSF fluid concentrations of 5-HT in depressed patients, especially suicidal patients. All drugs that selectively inhibit the reuptake of 5-HT are effective in the treatment of depression. Inhibition of 5-HT synthesis in treated depressed patients produces a rapid relapse. All currently available antidepressant treatment including electroconvulsive therapy (ECT) increase 5-HT neurotransmission. Norepinephrine (NE) also plays a role in depression. NE is reduced in CSF, plasma & urine in depressed patients. In the postmortem brain tissue from depressed patients there is increased beta-adrenergic receptor density possibly secondary to reduced synaptic availability of NE. All tricyclic antidepressants increase concentrations of NE & 5-HT in the synaptic cleft by blocking reuptake of inhibiting their metabolism. The descending pain control system that inhibits pain at the dorsal horn – utilizes both serotonin & NE. Many neurons of the descending pain control system in the medulla contain serotonin as their neurotransmitter & stim of the brain stem causes release of serotonin or NE at the level of the spinal cord. The depletion of serotonin increases painful responses. A functional NE system is necessary for 5-HT mediated analgesia. Pain may increase the turnover of serotonin reducing presynaptic 5-HT release in chronic pain patients just as in depressed patients leading to reduced activity of the pain descending control system, thus more pain. Antidepressant drugs can generate analgesia in CPPs due to a reversal of the reduction in presynaptic 5-HT release, increasing activity of the descending pain control system. If the turnover of serotonin is increased with pain, this could lead to depression. Vernon, DC. JMPT 1986;9(2):115-123. Mechanisms of Pain relief with Adjustments. Spinal manipulation stimulates mechanoreceptors to fire sending impulses up the dorsal columns exciting supraspinal mechanisms of pain control including 1) endorphin production via the hypothalamus-pituitary axis, 2) the central raphe to cause the descending inhibitory pathways to inhibit pain, 3) as well as segmental stimulation of met-enkephalin to close the gate to the central transmission of pain. Mechanisms Resulting In Chronic Pain: 1) Peripheral & Central Sensitization lead to neuropathic pain due to long-term changes in responsiveness of central neurologic pathways. 2) Biomechanically imperfect tissue healing results in permanent impairment of supporting elements & chronic disability may follow. 3) Dysfunction can cause pain without any structural damage. If the problem is dysfunction, symptoms can persist for as long as dysfunction continues. Dysfunction may be self-sustaining, so symptoms may persist indefinitely. Even if dysfunction & symptoms may persist, there is always the potential for recovery by restoring normal function.

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Meyers, MS. Use of neurotransmitter precursors for treatment of depression. Alternative Medicine Review 2000;5(1):64-71. Insufficient activity of the neurotransmistters serotonin & norepinephrine is a central element of the model of depression most widely held by neurobiologists today. Nearly all of the drugs used to treat depression appear to enhance neurotransmission in one or both of these systems. Serotonin production in the human brain can be increased two-fold by oral intake of L-tryptophan. Serotonin synthesis is dependent upon the availability of L-tryptophan & its immediate metabolite 5-HTP within the CNS. Therapeutic use of 5-HTP bypasses the conversion of L-tryptophan into 5-HTP, the rate limiting step in the synthesis of serotonin. 5-HTP easily crosses the blood-brain barrier & unlike L-tryptophan, doesn’t require a transport molecule to enter the CNS. L-tryptophan at a dose of 3 g/day was more effective than placebo, as effective as amitriptyline, produced fewer side effects & the response lasted as long as 3 months. Some reviewers weren’t convinced of L-tryptophan’s antidepressant efficacy in severe depression, but noted it may be more effective in moderate dysphoric states. In cases of mild to moderate depression, it seems reasonable to use neurotransmitter precursors, especially given their low degree of side effects & low costs. Woelk H. Comparison of St. John’s Wort & imipramine for treating depression. BMJ 2000;321:536-539. Randomized study of ST. John’s wort (Hypericum perforatum extract 250mg 2X/day for 6 weeks) in 157 subjects & imipramine (75mg 2X/day for 6 weeks) in 167 subjects (total = 325 patients) with mild to moderate depression. St. John’s Wort subjects’ mean scores on Hamilton depression scale decreased from 22.4 to 12.00. Imipramine subjects’ scores fell from 22.21 to 12.75. On the 7 point self assessments of global improvement completed by subjects (1 = very much improved & 7 = very much deteriorated) mean scores were 2.44 in St. John’s Wort group & 2.60 in imipramine group. Mean score on the anxiety-somatization subscale St. John’s wort group & 4.26 in imipramine group) indicated a signif advantage for St. John’s Wort. Scores on the tolerability scale were better for St. John’s wort than imipramiine. Adverse events occurred in 39% subjects taking St. John’s wort & 63% taking imipramine. 3% of subjects taking St. John’s wort withdrew due to adverse events vs 16% taking imipramine. Conclusions: St. John’s wort extract is therapeutically equivalent to imipramine in treating mild to moderate depression, but patients tolerate St. John’s wort better. Wiesel S. MD. Nutraceuticals to sweep spinen world. New study touts glucosamine for back pain. Backletter 2000;15(12):133, 140, 141. Researchers from Germany & Italy presented the 1st randomized trial that suggests oral glucosamine sulphate is an effective treatment for back pain related to osteoarthritis (OA) of the lumbar spine. As alredy well established in OA of the knee, glucosamine sulphate has a signif better symptomatic efficacy than placebo in controlling pain & movement limitation in lumbar spondyloarthrosis according to Klaus Foerster et al. This effect lasts on after treatment. The investigators conclude patieints who took glucosamine sulphate had a signif advantage over the placebo group based on investigator’s global judgment of an exam of p atients function (movement & ROM) & reported pain levels. 51.2% of glucosamine sulphate patients showed either definitely improved or improved symptoms vs 28% of placebo patients. Siddall, MB, BS, PhD. Spine 1997;22(1):98-104. With pain the CNS is not hard wired, but plastic. A barrage of nociceptive input results in changes to response properties of dorsal horn neurons. Sufficient noxious stimulation not only activates dorsal horn neurons but results in a progressive increase in neuronal activity which can result in: 1) Wind-Up; 2) Expansion of receptive fields; 3) Reduction in threshold so normal stimuli activates neurons that normally transmit painful input. Preemptive Analgesia – to reduce noxious input & minimize post-surgical sensitization. 181

Kramis, PhD, Roberts, PhD, Gillette, PhD. JOSPT 1996;24(4):255-267. Wide Dynamic Range Interneurons (WDRs) receive input from both nociceptors (NCs) & mechanoreceptors (MRs), but respond differently -- high frequency response to pain & low frequency to Mrs. But if painful input is intense enough & of long enough duration, this can sensitize WDRs so they now respond intensely to mechanoreceptor input & the brain interprets the input as painful. Central sensitization induced by prior painful input can persist even in the absence of ongoing painful input. Usually central sensitization is temporarily linked to painful input & decreases as pain activity decreases as tissues heal. An important question is to what extent central sensitization can become independent of ongoing painful input? Christensen. Med Trib Amer Pain Soc 1996; Dec 12. R. Dworkin, PhD, “If a patient has severe pain, you want to take it seriously & treat it aggressively. We can make chronic pain less likely by treating acute pain.” “The best way to forget previous pain is not to have learned it in the first place,” added Joel Katz, PhD, Assoc Dir of the acute pain research clinic at U of Toronto Hospital.

Fibromyalgia & Chiropractic Care Bendtsen, MD et al. Arthritis & Rheumatism 1997;40(1):98-102. Fibromyalgia & Central Sensitization. Nociception is qualitatively altered in patients with fibromyalgia, which strongly indicates that fibromyalgic pain, at least in part, is due to aberrant central pain mechanisms. Mechanoreceptors don’t normally mediate pain, but strong input from peripheral nociceptors can remodel the circuitry of the dorsal horn unmasking previously ineffective synapses & by forming novel synaptic contacts between mechanoreceptors & dorsal horn neurons that normally receive input from nociceptors. In this way mechanoreceptors can mediate pain. Pain perception is centrally disturbed in these patients. Increased rate of fibromyalgia after C-spine injury. Pillemer, MD et al. Arthritis & Rheumatism 1997;40(11):1928-1939. Substance P is an important nociceptive neurotransmitter & is elevated in the CSF of patients with FMS. Certain antinociceptive mediators like met-enkephalin are abnormally low in the CSF of FMS patients. There is also evidence of decreased availability of serotonin to down-regulate nociception in FMS. Findings suggest that chronic pain in FMS is associated with abnormalities indicative of altered CNS processing of nociceptive signals. Goldenberg DL, MD. Fibromyalgia syndrome a decade later. What we have learned. Arch Int Med 1999;159:777-783. Patients with FM have evidence of qualitatively altered nociception. The heightened pain response at tender points is now accepted to be a manifestation of altered CNS processing of nociceptive stimuli. Levels of substance P & abnormal antinociceptive peptides are elevated in the CSF of patients with FM. Brain imaging demonstrated lower regional cerebral blood flow to the thalamus & caudate nucleus. Decreased blood flow to these areas has been demonstrated in other chronic pain disorders. Russell, MD, PhD. Neurochemical pathogenesis of fibromyalgia syndrome. J Musculoskeletal Pain 1999;7(1/2):183-191. The most dramatic and consistent findings have been elevated levels of SP in CSF in FMS patients. Vacroy was the first to recognize that the concentration of SP was elevated (about 3 times normal) in the CSF of FMS patients. The findings have been reproduced in 3 other studies. Findings imply that CSF SP may be integrally related to changes in the severity of the pain. Higher CSF SP levels in FMS correlated with a decrease in regional cerebral blood flow within the caudate nucleus & thalamus. The concentration of met-enkephalin, which exerts an antinociceptive effect in the spinal cord was found to be signif decreased. The 182

widespread body pain & tenderness in FMS could result from central pain amplification by mediators of nociception. Abnormalities in FMS brain regional blood flow, neuroendocrine function, autonomic neural function, & intestinal motility could also relate to central neurotransmitter imbalance. In contrast with just a few years ago, when FMS patients were often viewed as healthy complainers without any exam findings, there are now criteria to aid in the diagnosis. Abnormalities in neurochemical mediators of CNS nociceptive function are consistent with patterns of clinical symptoms. The recognition of allodynia as a manifestation of abnl central nociceptor processing has changed the collective view of FMS. Ruda M, al e. Altered nociceptive neuronal circuits after neonatal peripheral inflammation. Science 2000; 289 (July 28):628-630. Nociceptive circuits are formed during embryonic & postnatal times when painful stimuli are normally absent or limited. Medical procedures for neonates involve tissue injury & pain for which long-term effects are unknown. The impact of neonatal tissue injury & pain on the development of nociceptor neuronal circuitry was studied in an animal model of persistent hind paw peripheral inflammation. As adults, these animals exhibited spinal neuronal circuits with increased input & segmental changes in nociceptor afferent axons & altered responses to sensory stimuli. This demonstrates that peripheral inflammation in the neonatal period in an immature has long-term consequences on nociceptor neuronal circuitry & may cause hyperexcitability. Sprouting of axons into new areas of the dorsal horn resulting from inflammation induced release of nerve growth factors (NGFs) was found. NGFs play a role in growth of central axon terminals. In neonates, wounding of the skin increases NGF levels at the site. Enhanced responsiveness of dorsal horn neurons may result in a permanent facilitated response to noxious stimulation due to the increased density of nociceptor axons to the dorsal horn or to altered connections & activity in neurons exposed to peripheral inflammation during the period of immature neuronal responses & reduced inhibitory control. Peripheral inflammation in the neonate can result in lasting & potentially detrimental alterations in nociceptor pathways. Heim CP, al e. Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA 2000;284(5):592-597. Early adverse experiences play a major role in the development of mood & anxiety disorders. Early-life stress results in a persistent sensitization of the hypothalamic-pituitary-adrenal axis to mild stress in adults contributing to vulnerability to psychopathological conditions. 49 women (18-45) with regular menses, no history or mania or psychosis, no substance abuse or eating disorder & on no hormonal & psychotropic meds were recruited into 4 groups: 1) subjects with no history of childhood abuse or psychiatric disorder (controls, N = 12); 2) Subjects diagnosis of current major depression who were sexually or physically abused as children (N = 13); 3) Subjects without current major depression who were sexually or physically abused as children (N = 14); 4) Subjects with diagnosis of current major depression & no history of childhood abuse (N = 10). Results: women with a history of childhood abuse & a current major depression exhibited a more than 6 fold greater ACTH response to stress than age-matched controls. Findings suggest that hypothalamic-pituitary-adrenal axis & autonomic nervous system hyperactivity is a persistent consequence of childhood abuse & may contribute to adult psychopathology. This is the first human study to report persistent changes in stress reactivity in adult survivors of early trauma. The findings are remarkably consistent with findings from lab animal studies. Buskila, MD et al. Arth & Rheum 1997;40(3):446-452. 102 patients with neck injury & 59 patients with leg fracture were assessed for the presence of fibromyalgia syndrome (FMS). A count of 18 tender points were conducted by palpation & tenderness thresholds were assessed. Results: FMS was diagnosed following neck injury in 21.6% of patients vs only 1.7% of patients with leg fracture. FMS was noted at a mean of 3.2 months after the trauma. Conclusions: FMS 183

was 13 times more frequent following neck injury than leg fracture. Findings suggest that neck injury may trigger the development of a localized pain syndrome (in the neck & chest area) that evolves into a diffuse musculoskeletal pain disorder – FMS. Findings suggest that some areas of the body are more susceptible than others. Johansen MD, et al. Generalized muscular hyperalgesia in chronic whiplash syndrome. Pain 1999;83:229-234. In 11 chronic whiplash patients & 11 matched controls the sensitivity over the infraspinatus, brachioradial & anterior tibialis muscles was assessed by pressure stim, pin-prick & cotton swab. Infusion of hypertonic saline into the infraspinatus & anterior tibialis was done to assess muscular sensibility & referred pain pattern. Results: Pressure pain thresholds were signif lower in patients vs controls in the infraspinatus; brachioradial & anterior tibialis. Infusion of hypertonic saline caused higher pain scores & larger patterns of referred pain in patients vs controls. Muscular hyperalgesia & larger referred pain areas were found in patients with chronic whiplash both within & outside the traumatized. Conclusions: Findings suggest a generalized central hyperexcitability in patients with chronic whiplash. This pain may be a neurogenic type of pain. Findings of muscular hyperalgesia to painful muscle stim not only in the neck & shoulder but also in the distant areas not associated with whiplash injury may be a manifestation of a generalized central hyperexcitability & support the hypothesis that central mechanisms are involved in chronic whiplash syndrome. Similar findings of widespread muscular hyperalgesia are reported in fibromyalgia (FMS) & indicates a role of central hyperexcitability in FMS. Blunt, DC et al. JMPT 1997; 20(6):389-399. Chiropractic management of fibromyalgia. Evaluated chiropractic management of fibromyalgia (FMS) using Oswestry, NDI, VAS, SLR & lumbar & cervical ROM as outcomes in a preliminary randomized controlled trial crossover trial in 21 rheumatology patients. Treatment consisted of 4 weeks of spinal manipulation, soft tissue therapy & passive stretching. Average number of treatments was s15.1. Control intervention consisted of chiropractic management withheld for 4 weeks with continuation of prescribed meds. Results: Chiropractic management clinically improved patient’s cervical & lumbar ROM, SLR & reported pain. Chiropractic management should be included in treating FMS patients in a multidisciplinary approach. A short course (4-8 weeks) may offer patients some pain relief, increased ROM in C & L-spines 7 in flexibility. Chiropractic seems to improve function & not just pain even in chronic FMS patients. But, chiropractic doesn’t offer a break-through for FMS. No significant change on Oswestry or NDI in 4 weeks. Manual therapy should facilitate FMS patients progression into a functional restoration program. FMS should be defocused from their pain & focused on improving function. Conclusion: Study suggests chiropractic management may be beneficial in treating FMS, specifically improving ROM, general flexibility & reported pain levels. Hains G, DC, Hains H, DC. Combined ischemic compression and spinal manipulation in the treatment of fibromyalgia. JMPT 2000;23(4):225-30. Study evaluates a regimen of 30 chiropractic treatments combining trigger point work (ischemic compression) & spinal manipulation in patients with chronic fibromyalgia (FM). 15 female subjects (average age 51.1 years, average duration of FM @ 10 years) were assessed by questionnaire at baseline, after 15 & 30 treatments & 1 month after the end of treatment. Pain intensity, fatigue, & sleep quality were assessed. Results: 9 (60%) patients responded (defined as at least 50% improvement in pain) – this was assoc with a corresponding improvement in quality of sleep & fatigue level after 15 & 30 treatments. After 30 treatments, respondents showed an ave lessening of 77.2% in pain intensity & 63.5% improvement in sleep quality & 74.8% in fatigue level. These improvements were maintained after 1 month without treatment. Subjects with 115 years, I witnessed 15 years, I witnessed for DC patients. 3 month risk of worsening was 40% < for DC patients. DC patients were 60% more likely to have their pain resolved after 3 months. DC patients were almost twice as likely to perceive their treatment to be successful after 3 months than MD patients & have 0 days of low back pain in the week preceding the 3 month evaluation. Findings concur with earlier studies that DC patients were more likely to be satisfied with their treatment. Liebenson, DC. Rehabilitation of the Spine. Wms & Wilkins, Baltimore. 1996: 13-43. A primary goal of care is to reduce disability. Improving function is the key to long-term pain relief. Patients have sacrificed different features of their lifestyle as a result of pain. These problems are key issues in patients’ lives. Whatever lifestyle changes they have made due to pain should be uncovered in their history. Restoring these activities is a critical goal of care. This personalizes your treatment & lets the patient know that you are genuinely concerned about their well-being. Takahashi MD, et al. Nerve root pressure in lumbar disc herniation. Spine 1999;24(19):20032006. The contact pressure between the nerve root & lumbar disc herniation (LDH) was measured & compared with clinical features in 34 patients with LDH during open discectomy surgery. Levels of pressure on the nerve root of LDH in clinical cases has never before been measured. Results: Nerve root pressure before discectomy varied from 7 to 256 mm Hg (mean 53.2 mm Hg). After discectomy the contact pressure was 0 mm Hg in all cases. There was no signif correlations between the magnitude of N root pressure & limits of straight leg raise, duration of symptoms, pain intensity or age. However, the magnitude of the pressure in patients with neurologic deficits & trunk list was signif higher than in the absence of these findings. Results suggest that the magnitude of N root pressure is not related to pain, but is related to neurologic deficits. Previous studies of N root pressure in vivo found the contact force between simulated LDH & deformed N root was @ 400 mm Hg. This study measured actual pressure in clinical cases. Pressures were measured after laminotomy with patients in a prone position. If the lamina & lig flavum were present the pressure would likely be higher. It is also expected that the pressure might increase b postural change. Critical pressure has been analyzed in experimental studies. Compression of 10mm Hg induced an acute reduction of intraneural microcirculation & impaired nutritional transport to the N roots. Total ischemia of a N root was induced at pressure levels close to the mean arterial pressure. Edema formation in N root was induced at 50 mm Hg for 2 minutes. There is an acute pressure threshold between 50 & 75 mm Hg for the occurrence of change in N root function. Waddell, MD et al. Clinical guidelines for the Management of Acute Low Back Pain. Royal College of General Practitioners 1996. Nerve Root Pain: 1.Unilateral leg pain worse than low back pain; Pain generally radiates to foot or toes; 2. Numbness & paresthesia in the same distribution; 3. Nerve irritation signs: Reduced straight leg raise which reproduces leg pain; 4. Motor, sensory or reflex change limited to one nerve root; 5. Prognosis reasonable: 50% recover from acute attack within 6 weeks. Vroomen MD, PhD, et al. Consistency of history taking and physical examination in patients with suspected lumbar nerve root involvement. Spine 2000; 25(1):91-97. Study investigates interobserver variability & the consistency of signs & symptoms of nerve root compression in 91 patients with radiating pain (sciatica) into the leg. Patients were independently assessed by a neurologist or resident. Results: The tests with the most reproducibility (high Kappa scores) were decreased muscle strength & sensory loss. The straight leg raise, crossed-straight leg raise, Braggard’s sign, & Naffziger’s sign were the most consistent nerve root tension signs (>0.66). Conclusions: For more consistent diagnosis the doctor should put more emphasis on: History of 204

1) Pain on coughing-straining-sneezing, 2) A feeling of coldness in the legs, & 3) Urinary incontinence. Physical Exam to evaluate 1) Paresis, 2) Sensory loss, 3) Reflex changes, 4) Straight leg raise, & 5) Bragard’s sign provide the most consistent results. Street, PhD et al. Med Care 1994;32(7):732-744. Study of 58 prenatal patients found that patients had strong preferences for & were more satisfied if doctors ask about the patient’s perceptions of health in general & about physical dimensions of health status such as pain, vitality, role limitations due to physical functioning. The evaluation of med outcomes should expand beyond traditional standards & also assess PT HRQL. Patients thought it was important for MDs to ask about patients’ experiences with health & its effects on daily living. Patients’ satisfaction was greater the more MDs were perceived as having asked @ health status. Findings reveal that patients expect & want their doctors to show interest in the patient’s everyday experience with health, particularly as it relates to physical dimensions of health status. Vernon, DC. In Liebenson (ed). Rehabilitation of the Spine. Baltimore, Williams & Wilkins 1996: 57-71. Use as baseline to document severity on initial visit. Serial testing at appropriate intervals – weekly for acute conditions, biweekly for chronic cases – allows for ongoing evaluation of progress. Individual items can provide meaningful information on worst-case issues. Example: on Oswestry or NDI, any item scoring 4 or 5 represents a key issue in the patient’s life. Identifying items of high impairment allows for individualized goal setting. Beurskens. Spine 1995; 20(9):1017-1028. If improvement of function is a major goal, functional status should be used as an outcome measure. For disability assessment in low back pain, it may be useful to employ both the Roland & Oswestry because they complement each other. The Roland scored higher with lower disability than the Oswestry, reaching maximum first. The Roland seems more sensitive in detecting changes when patients have minor disabilities, but less sensitive with more severe disabilities. Verhoef, PhD et al. JMPT 1997;20(4): May: 235-240. Responsiveness of Oswestry & Roland to Chiropractic. Study changes from baseline to 6 weeks follow-up in terms of pain, functional ability & patient satisfaction with chiropractic care in 278 patients with back &/or neck pain from 13 chiropractic practices as measured by VAS, Oswestry, & NDI. Changes in pain & functional disability were most notable in patients reporting higher baseline levels. No signif improvement was found in patients whose initial level of pain or disability was mild. It is not clear how sensitive the Oswestry is in cases of minor disability. Hsieh suggested that the Oswestry is not as sensitive as the Roland-Morris in patients with minor disability. This might explain why signif changes weren’t found in these patients. Leclaire, MD et al. Spine 1997; 22(1):68-71. The sensitivity of the Oswestry and RolandMorris Functional Disability scales in patients with low back pain. Oswestry & Roland-Morris scores in 2 groups low back pain of different severity. Group 1: Patients with low back pain & clinical & EMG signs of radiculopathy; Group 2: patients with only mechanical low back pain. Conclusions: Both disability scales accurately discriminated between these 2 groups of patients. Patients with mild disabilities scored higher on the Roland-Morris. The Roland-Morris was more sensitive to changes in these patients. The Oswestry was more sensitive in patients with more severe disabilities. Benefits of patient self-related information: Disability Scales, VAS, Pain Drawings 1.document baseline severity 2.document quantifiable response to care 3.document appropriateness of care 205

4.document need for additional care 5.document if patient fails to respond & the need for re-evaluation of diagnosis and treatment plan 6.document maximum medical improvement: as long as DC can document that the patient is still responding they have not reached MMI. Jinkins, MD. Am J Roent 1989; 152:1277-1289. Posterior Ramus innervates facet joints, SI joints, interspinous ligaments, paraspinal muscles, vertebral bodies & arches, periosteum, fascia, tendons, aponeurosis. Recurrent Meningeal Nerve innervates outer posterior annulus, posterior longitudinal ligament, ligamentum flavum, anterior dura mater, epidural fat, blood vessels to vertebral bodies, part of periosteum to vertebrae. Responsive Outcome Measures 1. Can reliably detect subtle but significant clinical & health changes over time. 2. Correlates well with other valid measures of health status. 3. Can distinguish patients with mild, moderate & severe degrees of the same condition 4. Can distinguish between patients who have been given an effective treatment from those given a placebo 5. Can be reliably used to document the efficacy of health care Pain Intensity Scales: Visual analog scale, NRS-101 (numerical rating scale 101 data points) Pressure Pain Threshold Meter: Tissue Algometer. Ameis, MD. Can Fam Physician 1986;32 (Sept):1871-76. Patients invariably expect treatment to result in pain-free status. Instead, it should be stressed that recovery of function is the primary goal. Triano, J, DC, MA. JACA 1997; 34(10):30-38. Some DCs make the mistake of assuming that ongoing symptoms justify ongoing care. Not so. Ongoing symptoms, unexplained by mitigating factors & unaltered by the care given so far, may signal failed treatment & indicate that the max therapeutic benefit has already been achieved. Doctors who make this determination on their own initiative & move the patient on to another provider or to cessation of care, whenever appropriate, are much more likely to have repeat managed care business. Mercy Center Guidelines: Chapter 8: Frequency & Duration of Care: 118 1) Supportive Care: Treatment/care for patients having reached MMI, in whom periodic trials of therapeutic withdrawal fail to sustain previous therapeutic gains that would otherwise progressively deteriorate. Supportive care follow appropriate application of active and passive care. It is appropriate when rehabilitation and alternative care options including home-base self-care and life-style modification have been attempted. 2) Therapeutic Necessity: An impairment evidenced by recognized signs & symptoms indicating the likelihood of favorable response to treatment/care intervention. Freeman S, DC. Dyn Chiro 1998; 16(6): 13, 48. To a peer reviewer, “maintenance care” will result in an immediate determination that care is not reasonable or necessary. There is no quicker way to lose a peer review. The insurance carrier is not responsible for ongoing bills once a patient’s injury has achieved maximum therapeutic benefit (MTB or MMI). Unless a patient is continuing to make therapeutic gains, treatment is no longer indicated. Despite ongoing pain, 206

bills are no longer paid. Pain is not in & of itself an indication for continued care. Continued care is rarely reasonable or necessary if there is no objective benefit. Supportive care comes into play when a patient has achieved MTB. A patient whose condition continues to improve requires active treatment, while a resolved condition should prompt a release from care. Supportive care is only established under specific conditions predicated around the presence of a progressively deteriorating condition. Proof that a patient cannot sustain gains can only be demonstrated through periodic withdrawals from care, along with detailed documentation which clearly supports a subsequent regression in patient status. Many DCs don’t provide the documented evidence which supports their case. Documentation is paramount, esp since claims adjusters continually look for reasons to deny treatment. It is impossible for a 3rd party payer to grant such care when there is a lack of appropriate documentation. Patients who have reached MTB & been withdrawn from care should have specific notations made in their files, clearly delineating the end of treatment & the fact that a clinical withdrawal of care has been attempted. Then if the patient contacts the DC about increased problems, documentation from the file can be presented providing evidence of a condition that has deteriorated. This requires diligent note taking including objective assessment reflecting a deteriorating condition. The presentation of uncomplicated soft tissue injuries, without documented objective deficits, makes it difficult to argue for supportive care, regardless of the pain involved. In these cases, even better record keeping is required. DCs must spell out their rationale and treatment regimens in detail. They must clearly provide justification for their position, clarifying what & why they are treating. A good reviewer will see you are providing quality care. It’s up to you, as the DC to prove the case. Meeker, DC, MPH. The Chiropractic Report 1992;7(1):4. The above reports (Oswestry, Roland Morris, VAS, NDI) can be made to third party payers. Such a report, supported with questionnaire results & referenced to the scientific literature proving the acceptability of your methods, is not only valid & reliable – it is also impressive & hard to challenge. Objective demonstration of results is now imperative. There must be good outcomes data as an integral part of ongoing daily practice. Wallace, DC. Chiro: J Chiro Res & Clin Invest 1994; 9(1):19-23. Over 12 weeks, in 38 patients, chiropractic care 2X/week reduced pain scores (VAS: 56%, & pressure algometer: threshold increased 42.5%), disability (NDI: 58.8%) & increased cervical curve an average of 6 degrees. Non-organic physical signs (Waddell. Spine 1980; 5(2):117-125; Waddell in Jayson (ed). The Lumbar spine and back pain. Churchill-Livingstone 1992: 469-485) 1.superficial & non-organic deep tenderness 2.non-anatomical distribution of signs & symptoms 3.simulation tests: a) axial load; b) rotation 4.distraction tests 5.exaggerated emotional responses Hayes, PhD. Spine 1993;18(10):1254-1262. Nomogenic disorders: disorders in which complaints of pain & disability are maintained by expectations of major financial gain thru litigation. Non-organic signs could correctly classify 90% of cases. This is extremely costefficient way to determine if persistent pain are maintained by expectations of financial gain. Mercy Guidelines 1.Acute uncomplicated case (6 but 8 days duration before presenting may take 1.5X longer to recover, 2) Severe pain may take 2X longer to recover 3) 4 to 7 previous episodes may take 2X longer to recover 4) pre-existing conditions, underlying pathologies or anomalies may take 1.5 to 2X longer Factors competing with recovery: 1) biomechanical stress, 2) psychosocial stress, 3) poor compliance, 4) prolonged static stress, 5) reinjury exacerbation, 6) multilevel DJD, 7) spondylolisthesis, all may delay recovery & necessitate a need for additional care that may exceed the recommended guidelines for simple uncomplicated cases. Introduction to the Mercy Guidelines: xl. These recommendations do not give a “cookbook” approach to duration of care or number of treatments. The guidelines on these matters may be modified by multiple factors, including pre-existing conditions, re-injury or failure to comply with other aspects of management. These facts may explain why the guideline is exceeded & the care still considered appropriate in an individual case. Individual chiropractic practice should conform with the guidelines in general, & document reasons for continuing with manual procedures in the absence of anticipated improvement in specific cases. A problem only arises when the management of a specific case is outside the guidelines with no apparent reason. Adler, Esq & Giersch, Esq. Survival guide, chiropractic practice guidelines. 2nd ed. Chapter 8: 8-8 to 8-10. (206) 682-0300. Pre-existing conditions can be inactive/dormant (requiring no treatment) before the current injury or active/symptomatic requiring care before the current injury. Washington state law states that if there is no evidence that a pre-existing condition is causing pain or disability before trauma, then the “lighting up” of that condition makes the atfault party liable for all damages caused to the injured person. From a medical-legal perspective the proximate cause of the present symptoms is the recent trauma even though symptoms may worsen or healing take longer because of a pre-existing condition. If pre-existing condition is active, then apportionment is necessary. This relies on the “more probably true than not” standard. Standard means that it is more likely true than not (51% vs 49%) that current symptoms are related to the current condition by a certain percent. Base opinion on patients condition before vs after current problem. What restrictions of activity, frequency of doctor’s visits before vs after. Get old records. Have patient fill out disability scales as if before & after the accident. Compare old vs new films. Chapman-Smith, Esq. Chiro Report 1995; 9(2):1,7. Canadian court case: Lynch v T Halifax Ins Co in an Ontario Ins Commission Arbitration, Dec 20, 1994. Insurance Co. argued chiropractic care for 4 years post-accident was unnecessary passive care promoting dependency & refused to pay. Patient appealed. The decision was based on the distinction between supportive care & preventive/maintenance care as defined in chiropractic guidelines. Patient’s attorney held that care was supportive -- given to maintain improvement after MMI & was therapeutically necessary. The court accepted that the patient used chiropractic to manage chronic pain in order to remain fully fit for work & this was equivalent to the continuing use of meds for chronic pain. The choice of modality of treatment is the patient’s & his/her health care providers. The court rejected the argument that the ongoing supportive care promoted dependency because it 208

supplemented his self-care & kept him at work. The insurer was held liable for past & future supportive care. This is an important precedent & shows that chiropractic protocols of management can be successfully defended if a literature base is established using valid guidelines.

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Key to Abbreviations ABP – acute back pain MSAs – medical savings accounts adj – adjustment MVAs – motor vehicle accidents ADLs – activities of daily living NCs – nociceptors AHCPR – Agency for Health Care Policy & Research NP – neck pain ALBP – acute low back pain Orthos or orthops – orthopedists PCPs – Primary Care Providers CAM – complimentary & alternative medicine Chiro – chiropractic PRs – proprioceptors CLBP – chronic low back pain pt(s) – patient(s) Ctls – controls P.T. – physical therapy DOs – osteopaths RCT – randomized controlled trial DTRs – deep tendon reflexes RTW – return to work Dx – diagnosis Rx – treatment (prescription) FCLB – Federation of Chiropractic Licensing Boards SLR – straight leg raise F-U – follow-up SM – spinal manipulation GPs – General Practitioners Ss – subjects grp(s) – group(s) Sx—symptoms HA(s) – headaches t – the tt -- that HMOs – Health Maintenenance Organizations HVLA – High velocity low amplitude Tx(s) – treatment hx – history w – with ins – insurance wh – which IVD – intervertebral disc yr – year jts – joints LBP – low back pain lig(s) – ligament(s) MCOs – Managed Care Organizations med – medical mo(s) – month (s) MRs – mechanoreceptors MS – musculoskeletal MMI – maximum medical improvement

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An Explanation of the Use of Outcome Measures in order to Document Patient Severity, Benefit of Care and Need for Additional Care Disability indices, such as the Roland Morris Disability Index, the Oswestry Disability Index, and the Neck Disability Index, have all been reported to be established outcome measures in the Guidelines for Chiropractic Quality Assurance and Practice Parameters.0 They each have multiple randomized controlled trials published in the scientific literature documenting their clinical usefulness, responsiveness, reproducibility and validity. 0,3,4,5,6,7 In 1996 such outcomes measures were noted to be valid, reliable, responsive to clinical change and indispensable, as well as, more reproducible and responsive than traditional physical exam or radiographic measures of impairment0 . In 1998 some of the most renowned experts on low back pain in the world stated, “With regard to functional status the use of either the Roland Morris or the Oswestry is recommended. These are among the most widely used and well validated functional status questionnaires and both are highly acceptable.”9 Also in 1998 other experts noted, “the Roland-Morris and the Oswestry disability questionnaires are the most widely used scales for measuring back disability in back pain patients and both scales seem to be reliable, valid and responsive.”10 In 2000, a survey of 17,774 patients treated at specialty spine clinics found that back and neck pain patients perceived themselves to have greater functional impairment than typical patients with cancer, diabetes, congestive heart failure, myocardial infarction, & hypertension.11 An international task force on low back pain published findings in 2000 stated that a return to normal activities is a more important goal than pain relief.12 It is therefore essential for clinicians to use these highly recommended and sensitive outcomes to document patients disability, loss of function and response to care. Pain intensity scales, such as the Visual Analogue Scale and the Numerical Rating Scale, are also widely used as sensitive and reliable clinical indicators for the evaluation of patients’ pain intensity and changing degrees of pain over time and in response to treatment.13,14,15 Regular use of disability and pain scales are valuable clinical tools when evaluating patients with back or neck disability. They help document the severity of patients’ disability and papin at the time of their initial visit and changes in patients’ health status over time and in response to care. The quantification of patients’ response to care by the use of repeated evaluation of established outcome measures helps to document the efficacy of care and eliminate uncertainty or dispute concerning questions about the appropriateness and efficacy of prescribed treatment protocols.16,17,18 The physical examination, an essential part of patient evaluation, is designed specifically to detect physical impairment: anatomic or pathological abnormalities that lead to a loss of normal bodily ability and not disability: diminished capacity for everyday activities and gainful employment.19 The physical examination is not considered a sensitive or responsive means of quantifying significant but subtle changes of patients’ health status or disability over time.20,21,22 Many patients with significant back and/or neck disability have minimal or no localizing signs on physical exam.23 In such clinical cases, it is difficult to document efficacy of care by physical examination alone. These outcome measures were developed, through years of medical research, as responsive, reliable, and valid means of evaluating patient progress in such circumstances.24

Pediatrics and Children Holtrop DP. Resolution of suckling intolerance in a 6-month-old chiropractic patient. Manipulative Physiol Ther. 2000 Nov-Dec;23(9):615-8. OBJECTIVE: To discuss the management and resolution of suckling intolerance in a 6-monthold infant. CLINICAL FEATURES: A 6-month-old boy with a 4(1/2)-month history of aversion 211

to suckling was evaluated in a chiropractic office. Static and motion palpation and observation detected an abnormal inward dishing at the occipitoparietal junction, as well as upper cervical (C1-C2) asymmetry and fixation. These indicated the presence of cranial and upper cervical subluxations. INTERVENTION AND OUTCOME: The patient was treated 5 times through use of cranial adjusting; 4 of these visits included atlas (C1) adjustment. The suckling intolerance resolved immediately after the first office visit and did not return. CONCLUSION: It is possible that in the infant, a relationship between mechanical abnormalities of the cervicocranial junction and suckling dysfunction exists; further research in this area could be beneficial. Possible physiological etiologies of painful suckling are presented. Pistolese RA. Epilepsy and seizure disorders: a review of literature relative to chiropractic care of children. J Manipulative Physiol Ther. 2001 Mar-Apr;24(3):199-205. International Chiropractic Pediatric Association, Research Department, Stone Mountain, GA 30087-3414, USA.OBJECTIVE: To review the currently available literature regarding chiropractic care relative to patients with epilepsy, particular emphasis being placed on those who have epilepsy as children. DATA SOURCES: The Index to Chiropractic Literature was searched for the years 1980 through 1998 through use of the keywords epilepsy and seizure. The MANTIS database was searched for the years 1970 through 2000 through use of the Medical Subject Heading (MeSH) keywords chiropractic, epilepsy, seizure, and child/children. In addition, a MEDLINE search of the literature was performed for the years 1966 through 2000 through use of the same subject headings. RESULTS: The present study reviews 17 reports of pediatric epileptic patients receiving chiropractic care. Fourteen of the 17 patients were receiving anticonvulsive medications, which had proven unsuccessful in the management of the condition. Upper cervical care to correct vertebral subluxation was administered to 15 patients, and all reported positive outcomes as a result of chiropractic care. CONCLUSIONS: Chiropractic care may represent a nonpharmaceutical health care approach for pediatric epileptic patients. Current anecdotal evidence suggests that correction of upper cervical vertebral subluxation complex might be most beneficial. It is suggested that chiropractic care be further investigated regarding its role in the overall health care management of pediatric epileptic patients. Graham, RL and Pistolese RA. An impairment rating analysis of asthmatic children under chiropractic care. Journal of Vertebral Subluxation Research 1997: 1 (4): 1-8 Eighty one children under chiropractic care took part in this self-reported asthma related impairment study. The children were assessed before and two months after chiropractic care using an asthma impairment questionnaire. Significantly lower impairment rating scores (improvement) were reported for 90.1% of subjects 60 days after chiropractic care in comparison to their prechiropractic scores. In addition, 30.9% of the children voluntarily decreased their dosage of medication by an average of 66.5% while under chiropractic care. Twenty four of the patients who reported asthma attacks 30-days prior to the study had significantly decreased attacks by an average of 44.9%. Six different chiropractic techniques were used by the different chiropractors who participated in this study. Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. J Manipulative Physiol Ther. 1994 (Nov-Dec);17 (9): 596-600 This was a controlled clinical trial of 46 enuretic children that were placed under chiropractic care. The children were under care for a 10 week period preceded by and followed by a 2 week nontreatment period. Participants: Forty-six nocturnal enuretic children (31 treatment and 15 control group), from a group of 57 children initially included in the study, participated in the trial. Results:...25% 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. 212

The Webster Technique: A Chiropractic Technique with Obstetric Implications. J Manipulative Physiol Ther. 2002 Jul-Aug;25(6): E1-9 Objective: The purpose of this study is to survey members of the I.C.P.A. regarding their experiences with the Webster Technique. The Webster Technique is a chiropractic technique designed to relieve the musculoskeletal causes of intrauterine constraint, which lead to cesarean section. Results: 187 surveys were returned from 1,047 members of the I.C.P.A., Inc throughout the United States and Canada, constituting a return rate of 17.86%. One hundred twelve surveys were returned from which to derive data. Of the 112 responses, 102 resulted in resolution of the breech presentation while 10 remained unresolved. Conclusion: In this study the doctors surveyed reported a high proportion of success in relieving the musculoskeletal causes of intrauterine constraint with the Webster Technique (82%). When successful, the Webster Technique avoids the costs and/or risks of wither, ECV, cesarean section or vaginal trial of breech. In view of these findings the Webster Technique deserves serious consideration in the health care management of expectant mothers exhibiting adverse fetal presentation. Van Breda, WM and Van Breda JM A comparative study of the health status of children raised under the health care models of chiropractic and allopathic medicine. Journal of Chiropractic Research Summer 1989. Lower antibiotic use and lower incidence of disease, especially ear infections, was reported in the chiropractic children. If the "chiropractic" children did get measles, rubella or mumps it was reported that the diseases were quite mild compared to those exhibited by their classmates. Plaugher and Alcantara. Chiropractic Management of a Patient with Subluxations, Low Back Pain and Epileptic seizures. J Manipulative Physiol Ther. 1998 (Jul-Aug);21 (6): 410-418 This is a case study of a 21 year old female with a history since childhood of grand mal and petit mal seizures occurring every three hours. Examination revealed subluxation/dysfunction at L5S1, C6-C7 and C3-C4, retrolisthesis at L5, hypolordosis of the cervical spine and hyperextension at C6-C7. Gonstead care was administered and at a 1.5 year follow-up, "the patient reported her low back complaints had resolved and her seizures had decreased (period between seizures as great as 2 months.) The authors conclude, "Data suggests that epilepsies are common, with an incidence between 40 and 200 per 100,000 with an overall prevalence between 0.5-1.0% of the general population. When one considers the potential side effects of antiepileptic drugs, research into the effects of chiropractic care for patients with epilepsy should be initiated." Danbert RJ. Scoliosis: biomechanics and rationale for manipulative treatment. J Manipulative Physiol Ther. 1989 Feb;12(1):38-45 This paper discusses methods to biomechanically evaluate scoliosis. From a chiropractic point of view, an understanding of the biomechanics of scoliosis is of paramount importance. By understanding the pathogenesis, the chiropractic physician can apply a rational approach to outline a treatment regimen. Spinal curvatures in the median plane change during growth, and in normal children the thoracic kyphosis reduces in size between the ages of 8 to 14. However, the change occurs at different times for boys and girls. Since scoliosis is a lordotic problem, associating lateral curvatures with gender, age, and attitude of the thoracics during growth spurt may answer questions of a female disposition and a male tendency to Scheuermann's disease. Further, this paper evaluates the lateral curvatures of the spine concerning normal curve mechanics and idiopathic scoliosis. Mechanical stability is considered, applying engineering principals to understand buckling and critical loading. By examining the factors of spine slenderness, flexibility and strengths of the trunk muscles, and applying this understanding to curve mechanics-biomechanics of scoliosis, the chiropractor has a rationale for the treatment of mild lateral curves. 213

Biedermann H. J. Kinematic imbalances due to suboccipital strain in newborns. Manual Medicine 1992, 6:151-156. More than 600 babies (to date) have been treated for suboccipital strain. One hundred thirty-five infants who were available for follow-up was reviewed in this case series report. The suboccipital strain's main symptoms include torticollis, fever of unknown origin, loss of appetite and other symptoms of CNS disorders, swelling of one side of the facial soft tissues, asymmetric development of the skull, hips, crying when the mother tried to change the child's position, and extreme sensitivity of the neck to palpation. Most patients in the series required one to three adjustments before returning to normal. "Removal of suboccipital strain is the fastest and most effective way to treat the symptoms...one session is sufficient in most cases. Manipulation of the occipito-cervical region leads to the disappearance of problems...." Wood KW. Resolution of spasmodic dysphonia (focal laryngeal dystonia) via chiropractic manipulative management. Manipulative Physiol Ther. 1991 (Jul-Aug); 14 (6): 376-378 Author's abstract: This paper discusses the case of a 46 year old male suffering from spasmodic dysphonia, a chronic disorder involving hyperadduction of the vocal mechanism and resultant vocal arrest. Attention is paid to the innervation of the intrinsic laryngeal musculature and postulated mechanisms of irritation, which may be amenable to chiropractic. At the time, the patient went to the chiropractor he had been suffering from this condition for six months and had consulted with numerous specialists and two teaching hospitals with no improvement in his condition. The chiropractor learned that upper cervical pain and stiff-ness and suboccipital headache appeared along with the vocal problem. After two weeks of upper cervical adjustments (5 visits) patient' the condition cleared up. Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BMC Musculoskelet Disord. 2004 Sep 14;5(1):32 BACKGROUND: The combination of spinal manipulation and various physiotherapeutic procedures used to correct the curvatures associated with scoliosis have been largely unsuccessful. Typically, the goals of these procedures are often to relax, strengthen, or stretch musculotendinous and/or ligamentous structures. In this study, we investigate the possible benefits of combining spinal manipulation, positional traction, and neuromuscular reeducation in the treatment of idiopathic scoliosis. METHODS: A total of 22 patient files were selected to participate in the protocol. Of these, 19 met the study criterion required for analysis of treatment benefits. Anteroposterior radiographs were taken of each subject prior to treatment intervention and 4-6 weeks following the intervention. A Cobb angle was drawn and analyzed on each radiograph, so pre and post comparisons could be made. RESULTS: After 4-6 weeks of treatment, the treatment group averaged a 17 degrees reduction in their Cobb angle measurements. None of the patients' Cobb angles increased. A total of 3 subjects were dismissed from the study for noncompliance relating to home care instructions, leaving 19 subjects to be evaluated post-intervention. CONCLUSIONS: The combined use of spinal manipulation and postural therapy appeared to significantly reduce the severity of the Cobb angle in all 19 subjects. These results warrant further testing of this protocol.

The efficiency of spinal manipulation in otorhinolaryngology. A retrospective long-term study BACKGROUND: The vertebral genesis of many functional disorders in otorhinolaryngology, such as dizziness, hearing-impairment, ear-pressure, ear-pain, foreign body sensation in the throat and dysphonia, is suggested by the success of spinal manipulative therapy, particularly of the atlanto-occipital joint. Up to now, there are no retrospective investigations which show the duration of the therapeutic effect. METHODS: We examined 220 patients with cervical otorhinolaryngological disorders (100 patients with dizziness, 49 with hearing impairment, 47 with tinnitus and 24 with dysphonia) after cervical manipulation lasting more than 6 months. RESULTS AND CONCLUSIONS: The extraordinary satisfaction with the manipulative therapy in 82% of patients with dizziness (46% total relief, 36% high improvement) reflects the high efficiency of this manual therapy. In contrast to these results, only 10% of 214

patients with tinnitus showed an improvement (P30,000 Patients showed that iatrogenic disabling injury occurred in 3.7% of cases & 13% were fatal. Major suction lipectomy is considered to have a 217

low complication rate, despite a rate of fatal complications of 1 per 7,500 operations. The fear of CVAs seems greatly exaggerated in view of the higher rate of complications with many generally accepted medical Treatments. It is tempting to speculate that the widespread fear of cervical spinal manipulation within the medical profession is more a political than a factual issue. Haldeman, PhD, et al. Stroke, cerebral artery dissection, & cervical spine manipulation therapy. J Neurol 2002; 249 (8): 1098-104. A review of 64 medical legal cases of stroke temporally associated with cervical spinal manipulation was performed. Files included post stroke testing by neurologists, expert testimony, hospital & DC records, etc. 92% of cases presented with a history of head &/or neck pain. 25% (16) of cases presented with a sudden onset of new & unusual headache and neck pain often associated with neurological symptoms that may represent a dissection in progress. Strokes were noted following any form of standard cervical spinal manipulation including rotation, extension, lateral flexion, & non-force & neutral position spinal manipulation. Vertebrobasilar dissection should be considered a random & unpredictable complication of any neck movement including cervical spinal manipulation. The sudden onset of acute & unusual neck &/or head pain may represent a dissection in progress & be the reason a patient seeks spinal manipulation that then serves as the final insult to the vessel leading to ischemia. Herzog, PhD. Symons, DC, PhD. The mechanics of neck manipulation with special consideration of the vertebral artery. J Canadian Chiro Assoc 2002; 46(3): 134-6. Are people who receive spinal manipulation of neck at greater risk of VBA? The incidence rate appears to be 1 in several million, so any statistical approach has a miniscule statistical power, & a couple of “fluke accidents” that occur in a chiropractic clinic, but in reality have nothing to do with chiropractic treatment may produce a “statistical error” that may persist for years in a small community like Canada. When tackling the problem of mechanics of neck spinal manipulation we were surprised that there were no data on what actually happens mechanically to the vertebral artery during cervical spinal manipulation. Mechanical injury to the vertebral artery was accepted within the chiropractic community, as a very, very, very rare occurrence; but nevertheless accepted. And all this without a shred of scientific evidence about the mechanics of the vert artery during cervical spinal manipulation. For mechanical injury to occur, the forces (stresses) in the tissue must exceed the microstructural & macrostructural failure limits of the tissue. We investigated the forces (stresses) & elongations (strains) of the vert artery during nl mov’ts, diagnosis procedures, & High velocity low amplitude spinal manipulation & the corresponding failure forces & elongations. Vert artery elongations during C spinal manipulation are always well within the elongations observed within the nl ROM. Vert artery elongations during spinal manipulation are always much smaller than the elongations that cause first mechanical failure. For elongations observed during spinal manipulation, there are no measurable forces (stresses) acting on the vert artery. Conclusion: It seems highly unlikely that a spinal manipulation of the neck can cause mechanical injury to nl vert artery. A severe predisposition in a vertebral artery to stroke may produce a stroke when submitted to spinal manipulation. However, if that happens, then, based on our results, the accident would have also been triggered by any movement of the neck, for example, when turning the head while backing out of a driveway. We conclude from our results on the mechanics of the vertebral artery that stresses & strains of the vert artery during cervical spinal manipulation are well within the normal range experienced during everyday movements. Chapman-Smith, d. Lana Dale Lewis Inquest. – Evidence of Sackett, Herzog, & Upton. State Association Notes. www.ccachiropractic.org/media; 2002 (November 30): 1-5. Prof David 218

Sackett, founding chair of the Clinic in Epidemiology at Oxford Univ, England, known worldwide as the “father of evidence-based medicine,) gave evidence (Nov 18 to 20) to demonstrate that the SPONTADS (spontaneous vs traumatic artery dissections) study was invalid & meaningless in scientific terms. Media in many countries have quoted the SPONTADS study demonstrating that stoke following chiropractic spinal manipulation is frightening & more common than previously thought. SPONTADS was the work of the Canadian Stroke Consortium involving 60 neuros who were merely being asked whether Patients with vert artery dissection seen in their practices had been to a DC. There was no verification of what they reported. Under cross exam, Norris confessed they didn’t actually have one case that definitely linked vert artery dissection to chiropractic treatment. Sackett explained that Norris’s study was a case series – a weak retrospective review & couldn’t draw conclusions about cause & effect and was no value to the inquest & jury. Sackett described Norris as “incompetent” in scientific research & “scientifically irresponsible” in making claims in the media based on the this study. Sackett concluded that the Consortium’s study couldn’t tell the jury anything about the relationship between neck adjustment & stroke; Norris had publicly misrepresented the study & that Norris’ description of the study as retrospective & prospective was “scientifically nonsensical.” Sackett stated that Norris is “incompetent as a scientist in the study of causation.” “He is making claims for which he has no scientific value. . .he is wasting your time”. . .”I think he has contributed noting of scientific value. . .and has caused enormous confusion.” Prosser, Helen, et al. Influences on general practitioners’ decision to prescribe new drugs—the importance of who says what. Family Practice. 2003; 20(1): 61-68. Study to understand the factors that influence MDs use of new drugs. 107 general practitioners in England were interviewed. Topics included reasons for prescribing new drugs & sources of information used for each prescribed drug. Results. Most influential was the pharmaceutical representative. Hospital consultants & hospital prescribing was cited next. Patient request for a drug also influenced new drug uptake. Written information was of limited importance except for local guidelines. Important biomedical influences were the failure of current therapy and adverse effect profile. General practitioners were largely reactive & opportunistic recipients of new drug information, rarely reporting an active information search. The decision to initiate a new drug is heavily influenced by the pharmaceutical industry, hospital consultants and patients. The decision to adopt a new drug is clinched by personal clinical experience. Hagan, P. Drug firms have most effect on doc’s prescribing. Reutershealth.com 2003. General practitioners deciding whether to prescribe a new drug are more likely to rely on information supplied by the pharmaceutical firm that makes it than independent sources of evidence. Manufacturers’ sales reps have the greatest influence on family doctors’ prescribing habits, even though there is a strong risk their information is wrong. Findings sound a warning over the power that pharmaceutical companies exert on general practitioners. "This is disquieting since information from reps may be misleading, biased, contain inaccuracies that MDs fail to recognize. General practitioners relied heavily on the pharmaceutical industry as the major information source.” “Although general practitioners questioned the objectivity of the industry, they generally considered its information to be factually accurate, if selective. . . .70% of general practitioners who saw drug firm representatives regarded them as an expedient means of acquiring and processing drug information.” Only a small minority of family docs consult evidence-based sources before deciding what to prescribe. “Peer-reviewed journals influenced only 17 per cent of general practitioners, who cited lack of time, information overload, difficulty in interpretation, irrelevance. . .and the importance of clinical experience as constraints.” Wolsko, MD, MPH et al. Patterns and perceptions of care for treatment of back and neck pain: results of a national survey. Spine 2003; 28(3): 292-7. National survey of treatment for BP or 219

neck pain. Of 2055 adults, 644 (33%) reported back pain or neck pain in past year: 38%: low back pain only, 16%: neck pain or upper back pain only, 46% pain in >1 location. Of those with back pain or neck pain < 29% used complimentary & alternative medicine alone, 25% used both complimentary & alternative medicine & conventional, 12% only conventional, 34% used neither. Most commonly used complimentary & alternative medicine for back pain or neck pain was chiropractic (20%), massage (14%), relaxation techniques (12%). Of those with back pain or neck pain, 37% had seen a conventional provider, 54% had used complementary & alternative medicine. Chiropractic, massage, and relaxation techniques were rated as “very helpful” for back or neck pain among users (61%, 65%, and 43%, respectively), whereas conventional providers were rated as “very helpful” by only 27% of users. Nearly 1/3 of all complimentary & alternative medicine provider visits (203 million of 629 million) were made to treat back pain or neck pain. Back pain & neck pain were most commonly treated with complimentary & alternative medicine alone or a combination of complimentary & alternative medicine & conventional; use of conventional alone was infrequent (12%). For chiropractic mean number of visits 8.5/year. Sarnat, R. MD. President of Alternative Medicine Integration. Personal Communication. From Richard Sarnat, MD, President of AMI. January 2003. AMI network currently has approximately 175 DCs in 5 states. AMI offers unrestricted access to Patients and fee for service reimbursement to clinicians without capitation for core covered benefits. AMI just completed a prospective study from 1999 through 2002 gathering data on AMI Patients based on data from 20,000 member months. Case savings, on average are well over 50% for the same ICD 9 codes which were analyzed by blinded assessors vs a control group of over 200,000 member months. Findings: AMI patients had an increased rate of illness based on visits (not for routine screening). Increased mental health diagnosis @ 10X, orthopedic @ 3X, URI decreased @ 10X, HBP, DM, stroke decreased too. Mooney, V. MD. How to have a health back. Backstrong.com. 2003. With inflammation, swelling of the tissues results & aggravates nerves. Local swelling hurts because tissue is stretched. Thus, the goal of treatment in acute painful situations is to reduce swelling by increasing motion & improving fluid exchange. Connective tissue – fascia, ligaments, tendons – have a high density of fibers because they have to be very strong for their size, so there is very little room for blood vessels. Thus, the problem is limited nutrition to the cells. If connective tissue motion is diminished, fibers begin to glue together with cross-links resulting in stiffer tissue, which is no longer flexible and can tear when sudden overload occurs. To maintain the health of connective tissue, motion is necessary to maintain flexibility & elasticity. Motion can avoid the formation of cross-linking & enhance nutrition to the cells. Uhrenholt, L. DC, Niels Grunnet-Nilsson, DC, MD, PhD, et al. Cervical spine lesions after road traffic accidents. Spine; 2002 27(17): 1934-1941. A literature review to determine if occult pathoanatomical lesions in the C-spine of motor vehicle accident fatalities exist. Study identified 3 high quality studies which used cryomicrotomy & a control group. Subtle lesions found exclusively in motor vehicle accident fatalities & not in the control group included: Minor tears of the AF at the vertebral rim; Disc disruption with herniation; Avulsions & partial separation between the endplate & vertebrae; Articular cartilage microfractures; Hemarthrosis or capsular swelling or bruising; New vertebral Fxs; Bruising of synovial folds. Conclusions: Occult lesions in cervical discs & facet joints after fatal motor vehicle accidents exist. Present imaging methods, esp radiography, do not visualize these subtle lesions. Radiologic exam is very insensitive for detecting subtle spinal lesions. Jonsson et al found radiograms identified only 4 of 245 lesions found later at autopsy in 22 motor vehicle accident fatalities. Taylor & Twomey found that none of the lesions found at autopsy were identified at postmortem radiography in 16 patients. Taylor & Taylor found that postmortem radiologic exam of 58 patients failed to detect 199 (64.4%) of 220

309 lesions visible in sectioned specimens. A total of 3.5% of the minor lesions were missed. Nonlethal injuries in C-spine fatalities indicate what may occur if people are subjected to nonlethal forces. Nonfatal motor vehicle accidents may result in similar lesions. Negative clinical & radiologic exam do not prove the absence of pathoanatomical lesions. Mooney, V. MD. How to have a healthy back. Backstrong.com 2003. Lower back pain is the most common musculoskeletal disorder. Following heart disease and cancer, back pain represents the most costly medical problem in every industrialized society. No one dies of lower back pain & most people get over it. Unfortunately, most people do not stay over it. The reoccurrence of back pain is almost guaranteed. Mooney, V. MD. How to have a healthy back. Backstrong.com. 2003. There are small muscles in the low back that function in a unique manner to maintain lumbar lordosis. With pain, these small back muscles rapidly atrophy. Scientific studies confirm that they atrophy more quickly than any other muscle group when there is back injury. The muscle atrophy can remain after recovery from the lower back pain episode. When one has a back injury with recurrent pain, the nervous system inhibits muscle function. The inhibition may be greater than it needs to be, especially when pain is associated with anxiety & fear of re-injury. Inhibition can be diminished by aggressive physical training best accomplished when the muscles to be facilitated are isolated in some way so there is no substitution by other muscles. Bogduk, MD, PhD. Clinical anatomy of the lumbar spine & sacrum. NY, Churchill Livingstone 1997. 104-5. The intertransversarii & interspinales muscles act as large, proprioceptor transducers. Their value lies not in the force they can exert, but in the muscle spindles they contain. Placed close to the lumbar vertebral column, they can monitor movements of the column & provide feedback that influences the action of the surrounding muscles. Such a role has been suggested for the cervical intertransversarii, which contain a high density of muscle spindles. All unisegmental muscles of the vertebral column have 2 to 6 times the density of muscle spindles found in the longer, polysegmental muscles. This underscores the proprioceptor function of all short, small muscles of the body. Springen, K. Newsweek 2003; January 20:67-68. Core-strength training. . .fans swear that working the torso – from neck to lower back, including the abdomen & the back & hip muscles – stabilizes the spine, improves balance, prevents back injury. “If you want a tube of toothpaste to stand up taller, you squeeze it in the middle.” So pull your navel into your spine. . .recommends that people think of core training as “functional” training that will help them keep their torso erect so they’ll be better at sports and everyday activities. . .If you don’t have power in your spine and your trunk, you can’t throw hard, you can’t run fast.” Holm, Indhal, Solomonow. Sensorimotor control of the spine. J Electromyogr Kinesiol 2002; 12(3):219-34. The focus on the innervation of different spinal structures has led to a new understanding that they may play an important role in a complex regulating system. The functioning of the motor system is intimately related to that of the sensory system. Proper moment-to-moment functioning of the motor system depends on a continuous inflow of sensory neck pain which influences motor output in many ways at all levels of the motor system. Loadsensitive mechanoreceptors & GTOs in muscle & tendon provide proprioceptor info regarding tension levels, essential for controlling muscle tone &, thereby, joint stability. Neurologic feedback from passive structures (discs, ligaments, joint capsules) also provides sensory info needed to regulate muscle tension & stability in the lumbar spine. Recruitment of paraspinal muscles may be coordinated so that forces applied to the various structures are properly distributed so loading on the motion segments is optimal regardless of position. These muscle 221

actions provide different structures with the support needed to counteract detrimental forces & prevent injury. Overload on specific parts can, by high threshold nerve endings, be detected & inhibit muscle actions responsible for the increased loading & thereby prevent injury. Stimulation of receptors in the outer annulus or facet joint causes activation of paraspinal muscles not only at the same segmental level, but also on different levels, indicating a complex interaction necessary to stabilize different segments. A lesion in one location may alter muscle activation in other than the actual segment & also on the contralateral side. SI joint is well suited for detecting various loading patterns during locomotion. In man, the slanted position of the L5S1 motion segment & the relative position of the SI joint appear to be for load detection. The afferent neck pain from the SI joint receptors, as well as, mechanoreceptors in the disc & facet joints contribute to different degrees of muscle activation & may constitute an integral regulatory system. Changes in loading on the SI joints may result in altered activation of the stabilizing muscles (MF, glut max, quadratus) & play an important regulating function in stabilization & mov’t of the upper body during postural changes. Instability of a motion segment – the change in length & loading of the ligaments may result in altered firing patterns & changes in the coordination of the muscles. When decreased disc height as a result of degeneration, adaptation of the surrounding nerve endings may be less efficient & thus result in less optimal neuromuscular reflexes. Addendum #2: 2003 Laurethati, W. J., DC. Cerebral Vascular Accidents Associated with Cervical Manipulation: Another View. JACA; 2003 40(3):31, 36-38. Signs & Symptoms of vertebrobasilar insufficiency: 5 Ds And 2 Ns: 5 Ds: Dizziness, drop athatacks, Diplopia, Dysarthria, dysphagia, And: Ataxia (unsteadiness of gait or hemiparesis), 2 Ns: Nausea, Numbness of hemianesthesia. If a patient presents with any of these signs & symptoms consider possible vertebrobasilar insufficiency. Warning sign: sudden onset of severe pain in the side of neck &/or head or in occipital region, particularly if different from any pain the patient has had before. This may represent referred pain from an injury to the pain sensitive wall of the vert artery, & may herald the onset of a dissection. Patients may seek DC care for this type of pain. Many cases of VBA stroke are preceded by symptoms of headache or neck pain days or even weeks before the stroke is complete & represent referred pain from injury to the arterial wall. The “true stroke” might occur later, after an embolus forms at the site of trauma, breaks free, & lodges in the cerebral circulation. The patient may have been seeking the DC for treatment of symptoms that were actually a result of the developing arterial dissection. Brandt, Bronstein Cervical vertigo. J Neurol Neurosurg Psychiatry; 2001 71(1): 8-12. Neck afferent input is important in reflex control of muscle tone, head orientation, eye coordination, body posture & spatial orientation. Traumatic, degenerative, inflammatory or rheumatic diseases can alter upper cervical somatosensory input causing vertigo. Inflammation sensitizes muscle spindle receptors resulting in asymmetric somatosensory mismatch between vestibular & cervical inputs resulting in vertigo. Dizziness/unsteadiness of cervical origin can also be due to loss or inadequate stimulation of mechanoreceptors with cervical pain. Proprioceptor is mostly dependent on deep short intervertebral neck muscles which are extensively supplied with muscle spindles. Somatosensory cervical input converges with vestibular input to mediate multisensory control of orientation, gaze, & posture. Cervical vertigo may include symptoms of disorientation, postural imbalance, & ocular motor signs. Humphreys, Bolton. A cross-sectional study of the association between pain and disability in neck pain patients with dizziness of suspected cervical origin. J Whiplash & Related Disorders; 222

2002 1(2): 63-73. Cervicogenic dizziness & vertigo may arise from disturbed sensory input due dysfunctional joints & mechanoreceptors, esp with trauma and are common complaints: 80%-90% of whiplash patients report them. Of 180 neck pain patients recruited at a chiropractic college clinic, 40.57% had neck pain from trauma, 33.5% had dizziness. Neck pain patients with dizziness were signif more likely to have had trauma, have greater pain intensity, more disability, & a longer duration of pain. Women report dizziness more often than men & are more prone to neck complaints esp with trauma as a result of a smaller cross-sectional area of muscle mass & a decrease in forces generated to stabilize, support & protect the cervical spine. Women’s ligaments may be prone to greater injury & biomechanical stress due to reduced muscular support leading to pain & disability. Dysfunction or trauma to connective tissues (muscles & ligaments) rich in proprioceptors may lead to sensory impairment. Disturbed sensory input from neck proprioceptors is commonly responsible for cervicogenic dizziness due to dysfunction of the Somatosensory system of the neck. Treleaven, Jull, et al. Dizziness & unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med; 2003; 35(1): 36-43. Study regarding dizziness & unsteadiness to determine if they are related to cervical joint position error: the accuracy of returning to the natural head posture following extension and rotation. The procedure was performed by 102 subjects with persistent whiplash associated disorders (WAD) & 44 controls. Results: Subjects with chronic WAD had signif greater joint position error than controls. Within the whiplash group, those with dizziness had greater joint position error than those without dizziness & more neck pain. Dizziness may be due to direct damage to the cervical mechanoreceptors following trauma. The barrage of abnl afferent input can result from the sudden acceleration/deceleration forces placed on cervical structures &/or the effects of pain & inflammatory mediators on proprioceptor activity. Disturbances to the postural control system, including abnl cervical afferent input from damaged or functionally impaired neck joint & muscle receptors are the likely cause. Dizziness of cervical origin arises from abnormal afferent activity from the extensive neck muscle & joint proprioceptors which converge in the CNS with vestibular & visual signals confusing the postural control system. Results indicate the presence of deficits in cervical mechanoreceptor function in WAD. Between 12 & 40% WAD patients develop persistent problems. After pain, dizziness/unsteadiness are the next most frequent symptoms. Cervicogenic dizziness is exacerbated with neck movements or increased pain. 40-70% of persistent WAD patients have dizziness associated with reports of loss of balance & falls. Outcomes assessment-based chiropractic care. What & Why? JACA; 2003 40(4): 8-16. Outcomes-based care involves regular measurement of patient’s symptoms & functional capabilities using research-based outcomes tools – questionnaires (Qs) answered by the patient (self-reports) & physical performance tests. Outcomes assessment on the initial visit establishes baselines & helps setting goals. It’s critical to establish functional goals, then follow & document patient status & progress. Outcomes allow the DC to measure patient’s progress against his/her own baseline & against normative data. It’s frustrating to rely on orthopedic tests for measuring progress. Patients’ orthopedic findings may be normal, yet they continue to complain of pain. Outcome tools guide the DC as to patient progress. The 4 most useful types of questionnaires: General Health: used to measure effects of illness & care on general health, rather than more specific outcomes. Helpful when patients have multiple problems & to evaluate out the effects of treatment on patients’ health related quality of life (HRQL). Assessment of Pain: difficult to interpret, but often the key component driving a patient’s satisfaction with care. May include numerical & visual analogue scales to evaluate current, average, best, & worst pain, (quadruple pain scales) & pain drawings. Useful in malpractice cases; when drawings completed by patients show gradual improvement, but the patient is saying the DC injured him, it’s easy to prove 223

innocence in a frivolous case. Condition specific tools: Oswestry, Roland, carpal tunnel, dizziness, upper extremity & lower extremity. Useful for Musculoskeletal conditions. Psychosocial or Psychiatric Tools: including depression, anxiety, coping strategies (fear avoidance beliefs, passivity, dependence). Often the greatest barrier to recovery includes “yellow flags” – psychosocial factors that can prolong recovery. These tools identify patients at risk for prolonged recovery early in the course of care. The treatment plan can then emphasize the transition from passive to active care as early as possible so patients don’t become dependent. The importance of the psychosocial domain can’t be over emphasized – much of the health expense is caring for the few chronically disabled patients which these questionnaires help identify. These four domains are the strongest predictors of patient outcome. Newer tools to predict patients who may become chronic are “hybrid” questionnaires which combine several outcomes related questions from a variety of domains into a single brief questionnaires which is very practical. Yeomans uses the Bournelmouth Questionnaires released in 1999 for low back pain & in 2002 for neck pain. Both contain only 7 items graded 0 to 10. They’re easy & fast for patients to complete & score. They’re quite sensitive to change over time. These 2 tools cover lumbar & cervical condition-specific pain & psychometric domains in 1 Q. Objective outcomes are also available but not yet in widespread use. These tools clearly demonstrate deconditioning which is immediately appreciated by both the examiner & the patient. Use of objective outcome tools are helpful in determining patients functional status & setting long term goals. Often patients show much improvement on subjective outcomes tools, but at re-exam 1 month later, the same objective, functional tests show no change. For patients with recurring chronic low back pain, it’s important to try to implement a program to improve their functional status & take them beyond where they’ve been at their previous best since they’ve been plagued with a recurring condition for years. This is where objective measures, called physical performance tests are needed to measure aerobic capacity, strength, endurance, proprioceptor, ROM, & non-organic signs. These tests should replace most orthopedic tests in re-exam at 4th to 6th week. When pain & inflammation subside but the patient still complains of problems, it’s time for physical performance tests. Such exams can change treatment patterns ESP for longer-term care. Each abnormal test relates to a specific exercise or manual release treatment which represents a change from the previous passive spinal manipulation approach. Each patient is unique, functional status & progress must be individually assessed. Adopting the way re-exams are conducted promotes a transition from a passive to active care approach to case management. Nederhand, Hermens, et al. Chronic neck pain disability due to an acute whiplash injury. Pain; 2003 102(1-2): 63-71. The Neck Disability Index (NDI) has been shown to have a high degree of test-retest reliability, internal consistency, acceptable level of validity & is sensitive to severity levels & to changes in severity over time. Nelson, DC, musculoskeletal. Effects of inclusion of a chiropractic benefit on the utilization of health care resources in a managed care health plan. WFC 2003. A 4 year study using administrative claims data comparing 700,000 health plan members with chiropractic coverage to 1 million member w/o chiropractic coverage to evaluate the effects of chiropractic coverage on total health care costs, rate of utilization of specific high-cost procedures, cost of management of specific musculoskeletal conditions, & whether chiropractic care is used as a substitution care or add-on care in a managed care health plan. Results: Members with chiropractic coverage were younger (mean 33 vs 36) & less likely to have specific comorbid medical conditions (for 6; selected conditions) vs to those without chiropractic coverage. Total health care costs for members with chiropractic coverage was 12% lower than for those w/o coverage. In health plan members treatment for musculoskeletal conditions, total health care costs were 13% lower for those with chiropractic coverage. Cost of treating episodes of low back pain was 28% lower in those with chiropractic coverage. Back pain patients with chiropractic coverage had fewer 224

inpatient stays (9.3 vs 15.6 stays per 1000 patients). MRI rate was lower for back pain patients with chiropractic coverage (43.2 vs 68.9 MRIs per 1000 patients). Rate of low back surgery was lower (3.3 vs 4.8 per 100 patients.). Back pain patients with chiropractic coverage received fewer radiographs (17.5 vs 22.7 per 1000). Data also demonstrate that most chiropractic care is a substitution for medical care within the health plan. Conclusion: Inclusion of a chiropractic benefit in a managed care plan results in a reduction in overall utilization of health care resources & cost savings. If all 1.7 million members had chiropractic coverage the plan would have saved $47.5 million over 4 years. Cost reduction due to: 1. A favorable selection process; 2. A substitution effect of chiropractic for medical care; 3. Lower rates of use of high cost procedures; 4. Lower cost management of care episodes by DCs. van den Hoogen, Koes, PhD et al. On the course of low back pain in general practice: a one year follow up study. Ann Rheum Dis; 1998 57(1): 13-9. Dutch study investigates the course of low back pain in patients given usual medical treatment in general practice. 269 patients completed all follow-up questionnaires. Results: At 12 weeks 35% & at 1 year 10% of patients still suffered low back pain. Pain & disability diminished quickly after initial visit, & both stabilized at a lower level if low back pain didn’t completely disappear. Time to recovery for patients with more chronic low back pain (>7 weeks) was 4 weeks longer than for patients with more acute low back pain. 3 of 4 patients (76%) endured one or more relapses within a year. Median time to a relapse was 7 weeks, & its duration was about 6 weeks. Pain & disability were less severe during relapses. . .Conclusions: For most patients, the clinical course of low back pain in general practice clearly is less favorable than expected. It takes more than just a few weeks to recover, & relapses occur within a year in most cases. Relapse rates by far exceeded our expectations. 76% (3 of every 4 patients) endured one or more relapses. Our review of the lit did not reveal any data on the relapse rates of low back pain in general practice. The high relapse rate indicates that our concept of low back pain as an incidental & temporary problem may be false in many cases presented in general practice. Low back pain in many cases should be viewed as a recurrent illness. This implies that the treatment of low back pain should be changed accordingly. Therapeutic intervention may be highly valid if relapses are prevented. Hayden, DC, Mior, DC, Verhof, PhD. Evaluation of chiropractic management of pediatric patients with low back pain. J M physical therapy 203; 26(1): 1-8. A lit search revealed no published studies of conservative treatment of childhood low back pain. This Canadian study describes chiropractic management & outcomes of low back pain in 54 pediatric patients – ages of 4 & 18 years from 15 DCs offices (ave age 13.1 years – 57% male, 61% acute, 47% with acute sports-related onset; 24% with an episode duration >3 month). Almost 90% presented with mechanical low back pain. Patients managed with musculoskeletal but only 7.7% also received some form of active management. Results: Signif improvement seen in 62% on VAS & 87% a subjective scale (5 point Likert scale: 1 = worse, 2 = same, 3 = improved, 4 = much improved, 5 = resolved) within 6-week course of care. Patients with chronic low back pain were less likely to respond within median number of treatments. Conclusions: patients responded favorably to chiropractic management with no reported complications. Only 7.7% of patients were given active management strategies. Given the recommendation of activity & exercise in many published guidelines, we expected this management strategy to be more prevalent. This may be especially important given the finding that chronic patients were less likely to respond within the median number of follow-up visits. Findings suggest that there is a need to educate DCs regarding active patient management. Bogduk, MD, PhD. Clinical anatomy of the lumbar spine & sacrum. NY, Churchill Livingstone 1997: 105-8. The MF, the largest & most medial of the lumbar back muscles, consists of a repeating series of 5 overlapping fascicles which stem from the laminae & spinous process (SP) 225

of each lumbar vertebrae. The key feature of the MF is that its fascicles are arranged segmentally. Each lumbar vert is endowed with a group of fascicles that radiate from its SP anchoring it below to mamillary processes, the iliac crest & the sacrum. MF fibers are arranged so their principal action is focused on individual vertebrae. They act in concert on a single SP. All fascicles arising from the SP of a vertebrae are innervated by the medial branch of the dorsal ramus that issues from below that vertebrae. Thus, the muscles that directly act on a particular vertebral segment are innervated by the nerve of that segment. Lund, Donga, et al. The pain-adaptation model: a discussion of the relationship between chronic musculoskeletal pain and motor activity. Can J Physio Pharmacol; 1991 69(5): 683-94. A review of motor function in chronic musculoskeletal pain conditions (TMJ, tension headache, fibromyalgia, chronic low back pain, & postexercise muscle soreness) concludes that data do not support the commonly held view that the pain of these conditions is maintained by some form of tonic muscular hyperactivity. Instead, it is clear, in these conditions activity of agonist muscles is often reduced by pain, even when this does not arise from the muscle itself. Pain also causes small increases in the level of activity antagonists. As a consequence, force production, ROM, & velocity of movement of the affected body part are often reduced. To explain how such changes in the behavior come about, We propose a neurophysiological model based on the modulation of excitatory and inhibitory interneurons supplied by high-threshold sensory afferents (nociceptors) & suggest that the “dysfunction” that is characteristic of these types of chronic musculoskeletal pain is a normal protective adaptation, not a cause of pain. Nederhand, Hermens, et al. Chronic neck pain disability due to an acute whiplash injury. Pain; 2003 102(1-2): 63-71. Study of muscle activation patterns (SEMG) in the upper trapezius in 92 subjects with acute neck pain due to a motor vehicle accident (motor vehicle accident) follow-up at 1, 4, 8, 12 & 24 weeks. Results: In isometric & dynamic tasks patients with the worse neck pain & disability had the lowest levels of muscle activation. In subjects who develop future disability after motor vehicle accident, the acute stage is characterized by a reorganization of the muscular activation of neck & shoulder muscles, likely aimed at minimizing the use of painful muscles. patients with the highest pain disability had the greatest reduction in recruitment of upper traps during isometric & dynamic exercise. In the acute phase of WAD, painful traumatic injury does not initiate hyperactivity in the upper trap, nor is there a tendency to develop hyperactivity during the transition from acute to chronic neck pain disability 6 month after motor vehicle accident. Throughout this period there is decreased rather than increased muscle activation in the upper trap. Results suggest that the vicious cycle of pain & increased muscle activity reinforcing one another (pain spasm reflex), does not occur. The Pain Adaptation Model explains the reduced muscle activation levels seen during isometric & dynamic exercise. The model suggests that segmental nociceptors affect agonist & antagonist muscles in a reciprocal way. musculoskeletal injuries result in a decrease of muscle activity of painful muscles acting as agonists or of muscles surrounding a pain generator. Avoidance of painful movements results in a re-coordination of muscles with an increase of activity of agonists or synergists muscles. In acute whiplash, changes in activity of painful muscles may result from segmental & supraspinal inhibitory effects. Subjects may also develop a new synergy aimed at minimizing the use of the painful muscles during physical exercise. O’Sullivan. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine; 1997 22(24): 2959-67. randomized controlled trial of 42 chronic low back pain patients with lumbar instability (spondylolysis or spondylolisthesis) to determine the efficacy of a 10 week supervised specific stabilizing exercise program with daily home exercises. Patients were follow-up at 3, 6 & 30 month. Outcomes: McGill, Oswestry, lumbar & hip ROM, abdominal muscle recruitment 226

patterns. Exercise group: 10 week exercise program specifically training deep abdominal muscles (TA, IO)s, with coactivation of MF. Control Group: 10 week supervised by MDs – regular weekly general exercise: swimming, walking, gym work. 8 patients also supervised exercise & local pain relief via heat massage, ultrasound. 9 subjects did trunk curls regularly. Results: Specific exercise group showed a significant reduction in pain intensity & functional disability, which was maintained at a 30 month follow-up. Control group showed no significant changes. A “specific exercise” treatment approach appears more effective than other commonly prescribed conservative treatment in chronic low back pain patients with spondylolysis or spondylolisthesis. Aure, physical therapy, Nilsen, physical therapy, Vasseljen, PhD. Manual & exercise therapy in chronic low back pain patients. Spine 2003; 28(6): 525-31. Randomized controlled trial with 1year follow-up in Norway compares effects of manual therapy (MT) to exercise therapy (ET) in 49 chronic low back pain patients on 100% sick-leave (>8 weeks but 48 hrs. These complaints, Haldeman concludes comprise nothing more than classic complaints of patients exposed to any new treatment. Haldeman notes that although there are isolated cases of VBA dissection following neck spinal manipulation, none have shown conclusively that spinal manipulation has any direct relationship to an increased prevalence of stroke. Andrew Cole, MD, physiatrist/professor of rehab medicine at University of Washington said that spinal manipulation is most effective for short term pain relief for acute lower back pain, but has proven to provide modest relief in chronic low back pain patients. Overall, spinal manipulation has the advantage of reducing pain, decreasing medication, rapidly advancing 227

physical therapy & requiring fewer passive modalities. There is also a more rapid return to work & a decrease in cost & time involved with patient care. Zigler, MD, a surgeon at TBI agreed that spine surgeons who work with DCs are enhancing their patient care. “DCs work for us at TBI as screeners for surgical pathology. They can do the same work-up & send the patient who has already gone thru his conservative treatment & had all his diagnostic work done to the surgeon.” ==================================== Bekelman et al. Scope & impact of financial conflicts of interest in biomedical research. A systematic review. JAMA; 2003 289 (4); 454-465. A review of 1140 original studies to evaluate the impact of financial relationships among industry (pharmaceutical, biotechnology, biomaterials, etc), investigators, & academic institutions on biomedical research. Conclusions: financial relationships among industry, scientific investigators & academic institutions are pervasive. ¼ of biomedical investigators at academic institutions receive research funding from industry. Lead authors in 1 of every 3 articles published hold relevant financial interests. 2/3 of academic institutions hold equity in “start-up” businesses that sponsor research performed by their facility. Institutional ownership of equity carries the responsibility of business stewardship. Equity ownership creates a new revenue model for academic institutions inducing a dramatic increase in institutional medical entrepreneurialism, further blurring the lines between academic & commercial values. It is questionable whether institutions that stand to gain substantial benefits from research commercialization can still police themselves. Evidence suggests financial ties that intertwine industry, investigators, & academic institutions influence the research process. Strong & consistent evidence shows that industry-sponsored studies were 3.6 times more likely to reach conclusions that were favorable to the sponsor than non-industry studies. Industry sponsored research uses trial designs that favor positive results such as the use of placebo as the comparison treatment. There is also bias with the use of active controls. Evidence from NSAID & other randomized controlled trials reveals that inappropriate administration & dosing disparities decrease the effectiveness of active controls. Publication bias – positive results published more often than negative ones. A review of 61 industry sponsored randomized controlled trials of NSAIDs found that none of the studies reported a negative conclusion. Industry may also alter, obstruct, or even stop publication of negative studies. Bodenheimer, T. M. Uneasy Alliance. Clinical investigators and the pharmaceutical industry. NEJM; 2000 342(20); 1539-44. 70% of the money for clinical drug trials in the US come from industry rather than from NIH. Improving outcomes of drug studies: If a drug is tested in a healthier population (younger, w fewer coexisting conditions & w milder disease) than the population that will actually receive the drug, a trial may find the drug relieves symptom & creates fewer adverse effects than will actually be the case. A study found that only 2.1% of subjects in trials of NSAIDs were 65 years or older, even though these drugs are more commonly used & have a higher incidence of side effects on the elderly. If a new drug is compared with an insufficient dose of a competing one, the new drug will appear more effective. A review concluded that trials of NSAIDs always found the sponsoring company’s product superior or equal to the comparison product; in 48% of the trials, the dose of 5 sponsoring company’s drug was higher than that of the comparison drug. 30-50% of contracts submitted by companies have unacceptable publication clauses. 27% faculty researchers with industry funding experienced delays of more than 6 month in the publication of their study results. Results of substantial numbers of clinical trials are never published at all. A 1990 study of Synthroid found it to be no more effective than generics. The sponsoring company refused to allow the findings to be published; the contract stipulated that no information could be released without the consent of the manufacturer. An investigator found that a studied drug caused adverse reactions. He sent 228

his manuscript to the sponsoring company. The company vowed never to fund his work again & published a competing article with scant mention of the adverse effects. Friedman MA, MD et al. The safety of newly approved medicines. JAMA 1999; 2821:17281734 Clinical testing: 1994 international drug safety standard for a chronically administered drug used long-term to treatment a non-life threatening condition recommends that 1500 patients be exposed overall with 60 patients treatment for 6 months & 300 for 1 year. This is considered adequate to detect an adverse event occurring in 1 of every 300 to 500 patients. A drug tested in a few thousand people may be administered to several million within the first years of marketing. Limitations of US clinical testing: Trials may exclude certain patients: 1) elderly, 2) the very young, 3) those too sick, or 4) those taking certain other meds. Any special vulnerability to adverse events in these groups will be missed. Although drug labeling may warn about the lack of info in such patients, an MD may decide to treat the patient. Postmarketing surveillance & trials may be needed to define risks to subgroups, with long-term use, or when used with other meds. ADDENDUM 2004 Treatment of bipolar, seizure, and sleep disorders and migraine headaches utilizing a chiropractic technique. J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):E5 OBJECTIVE: To discuss the use of an upper cervical technique in the case of a 23-year-old male patient with rapid-cycling bipolar disorder, sleep disorder, seizure disorder, neck and back pain, and migraine headaches. CLINICAL FEATURES: The patient participated in a high school track meet at age 17, landing on his head from a height of 10 ft while attempting a pole vault. Prior to the accident, no health problems were reported. Following the accident, the patient developed numerous neurological disorders. Symptoms persisted over the next 6 years, during which time the patient sought treatment from many physicians and other health care practitioners. INTERVENTION AND OUTCOME: At initial examination, evidence of a subluxation stemming from the upper cervical spine was found through thermography and radiography. Chiropractic care using an upper cervical technique was administered to correct and stabilize the patient's upper neck injury. Assessments at baseline, 2 months, and 4 months were conducted by the patient's neurologist. After 1 month of care, the patient reported an absence of seizures and manic episodes and improved sleep patterns. After 4 months of care, seizures and manic episodes remained absent and migraine headaches were reduced from 3 per week to 2 per month. After 7 months of care, the patient reported the complete absence of symptoms. Eighteen months later, the patient remains asymptomatic. CONCLUSION: The onset of the symptoms following the patient's accident, the immediate reduction in symptoms correlating with the initiation of care, and the complete absence of all symptoms within 7 months of care suggest a link between the patient's headfirst fall, the upper cervical subluxation, and his neurological conditions. Further investigation into upper cervical trauma as a contributing factor to bipolar disorder, sleep disorder, seizure disorder, and migraine headaches should be pursued. The amelioration of symptoms in cervical spinal stenosis with spinal cord deformation through specific chiropractic manipulation: a case report with long-term follow-up. J Manipulative Physiol Ther. 2004 Jun;27(5):e7 OBJECTIVE: To describe the chiropractic management of a patient with paresthesia on the entire left side of her body and magnetic resonance imaging (MRI)-documented cervical spinal cord deformation secondary to cervical spinal stenosis. CLINICAL FEATURES: A 70-year-old special education teacher had neck pain, headaches, and burning paresthesia on the entire left side of her body. These symptoms developed within hours of being injured in a side-impact motor vehicle accident. Prior to her visit, she had been misdiagnosed with a cerebrovascular accident. INTERVENTION AND OUTCOMES: Additional diagnostic studies revealed that the patient was suffering from cervical spinal stenosis with spinal cord deformation. Two manipulative technique systems (Advanced Biostructural Therapy and Atlas Coccygeal Technique) unique to the chiropractic profession and based on the theory of relief of adverse mechanical neural tension were administered to the patient. This intervention provided complete relief of the patient's complaints. The patient remained symptom-free at long-term follow-up, 1 year postaccident. CONCLUSION: There is a paucity of published reports describing the treatment of cervical spinal stenosis through manipulative methods. Existing reports of the manipulative management of cervical spondylosis 229

suggest that traditional manual therapy is ineffective or even contraindicated. This case reports the excellent short-term and long-term response of a 70-year-old patient with MRI-documented cervical spinal stenosis and spinal cord deformation to less traditional, uniquely chiropractic manipulative techniques. This appears to be the first case (reported in the indexed literature) that describes the successful amelioration of the symptoms of cervical spinal stenosis through chiropractic manipulation. More research into the less traditional chiropractic systems of spinal manipulation should be undertaken.

Factors related to the inability of individuals with low back pain to improve with a spinal manipulation. Phys Ther. 2004 Feb;84(2):173-90. BACKGROUND AND PURPOSE: Although spinal manipulation is one of the few interventions for low back pain supported by evidence, it appears to be underutilized by physical therapists, possibly due to therapists' concerns that a patient may not benefit from the intervention. The purpose of this study was to identify factors that are associated with an inability to benefit from manipulation. SUBJECTS: Seventy-five people with nonradicular low back pain (mean age=37.6 years, SD=10.6, range=19-59; mean duration of symptoms=41.7 days, SD=54.7, range=1-252) participated. METHODS: Subjects underwent a standardized examination that included history-taking; self-reports of pain, disability, and fear-avoidance beliefs; measurement of lumbar and hip range of motion; and use of various tests. All subjects received a spinal manipulation intervention for a maximum of 2 sessions. Subjects who did not show greater than 5 points of improvement on the modified Oswestry Low Back Pain Disability Questionnaire were considered to have shown no improvement with the manipulation. Baseline variables were tested for univariate relationship with the outcome of the manipulation. Variables showing a univariate relationship were entered into a logistic regression equation, and adjusted odds ratios were calculated. RESULTS: Twenty subjects (28%) did not improve with manipulation. Six variables were identified as being related to inability to improve with manipulation: longer symptom duration, having symptoms in the buttock or leg, absence of lumbar hypomobility, less hip rotation range of motion, less discrepancy in left-to-right hip medial rotation range of motion, and a negative Gaenslen sign. The resulting logistic regression model explained 63% of the variance in manipulation outcome. DISCUSSION AND CONCLUSION: The majority of subjects improved with manipulation. Baseline variables could be identified that were predictive of which subjects would not improve. An evaluation of medical and chiropractic provider utilization and costs: treating injured workers in North Carolina. J Manipulative Physiol Ther. 2004 Sep;27(7):442-8 OBJECTIVE: To examine utilization, treatment costs, lost workdays, and compensation paid workers with musculoskeletal injuries treated by medical doctors (MDs) and doctors of chiropractic (DCs). DESIGN: Retrospective review of 96,627 claims between 1975 and 1994. RESULTS: Average cost of treatment, hospitalization, and compensation payments were higher for patients treated by MDs than for patients treated by DCs. Average number of lost workdays for patients treated by MDs was higher than for those treated by DCs. Combined care patients generated higher costs than patients treated by MDs or DCs alone. CONCLUSION: These data, with the acknowledged limitations of an insurance database, indicate lower treatment costs, less workdays lost, lower compensation payments, and lower utilization of ancillary medical services for patients treated by DCs. Despite the lower cost of chiropractic management, the use of chiropractic services in North Carolina appears very low. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. J Manipulative Physiol Ther. 2004 Jul-Aug;27(6):388-98 BACKGROUND: The adult lifetime incidence for low back pain is 75% to 85% in the United States. Investigating appropriate care has proven difficult, since, in general, acute pain subsides spontaneously and chronic pain is resistant to intervention. Subacute back pain has been rarely studied. OBJECTIVE: To compare the relative efficacy of chiropractic adjustments with muscle relaxants and placebo/sham for subacute low back pain. DESIGN: A randomized, double-blind clinical trial. METHODS: Subjects (N = 192) experiencing low back pain of 2 to 6 weeks' duration were randomly allocated to 3 groups with interventions applied over 2 weeks. Interventions were either chiropractic adjustments with placebo medicine, muscle relaxants with sham adjustments, or placebo medicine with sham adjustments. Visual Analog Scale for Pain, Oswestry Disability Questionnaire, and Modified Zung Depression Scale were assessed at baseline, 2 weeks, and 4 weeks. Schober's flexibility test, acetaminophen usage, and Global Impression of Severity Scale (GIS), a physician's clinical impression used as a secondary outcome, were 230

assessed at baseline and 2 weeks. RESULTS: Baseline values, except GIS, were similar for all groups. When all subjects completing the protocol were combined (N = 146), the data revealed pain, disability, depression, and GIS decreased significantly (P