Update on Spinal-Visceral Relationships: The Nucleus Intermedius

Dan Murphy, DC—

Private Practice of Chiropractic;
Diplomate American Board of Chiropractic Orthopedist;
Faculty Life Chiropractic College West;
Vice President ICA 2003-2009;

ICA Chiropractor of the Year 2009

The intermedius nucleus of the medulla: A potential site for the integration of cervical information and the generation of autonomic responses.

Edwards IJ, et al. Journal of Chemical Neuroanatomy November 2009, 38, pp. 166–175.

KEY POINTS FROM DAN MURPHY

1) The intermedius nucleus of the medulla (InM) [nucleus intermedius] receives afferent information from:

a) The neck musculature

b) The vestibular nuclei

2) The nucleus intermedius sends monosynaptic projections to the nucleus of the solitary tract (NTS)

3) The nucleus intermedius integrates information from the head and neck and relays this information on to the nucleus of the solitary tract where suitable autonomic responses are generated.

4) The nucleus intermedius also communicates with the hypoglossal nucleus to influence movements of the tongue and upper airways.

5) Outputs from the nucleus intermedius to the nucleus tractus solitarius and hypoglossal nucleus suggest a role in the co-ordination of tongue movements and autonomic responses to changes in posture. [Very Important: the nucleus intermedius co-ordinates autonomic responses to postural changes]

6) The nucleus intermedius has a spinal cord component called the “central cervical nucleus” or the “medullary portion of the central cervical nucleus” or the “intercalated nucleus” or the “nucleus intercalatus of Staderini.”

7) The spinal cord component of the nucleus intermedius (central cervical nucleus) is “located lateral to the central canal at the border of the dorsal and ventral horns.”

8) Sensory fibers from the upper cervical dorsal root ganglion (DRG) directly enter the nucleus intermedius. [Very Important]

9) Sensory nerves from the suboccipital muscles, the sternocleidomastoid muscle and the longus capitis muscle project to the nucleus intermedius via the upper cervical spine dorsal root ganglion. [Very Important: the sensory projections from these muscles are mechanoreceptors and proprioceptors; alterations of mechanical afferent input from these muscles alters the input to the nucleus intermedius, then to the nucleus tractus solitatius and to subsequent autonomic responses]

10) “These projections from the cervical DRG to the nucleus intermedius have been proposed to be proprioceptive, which suggests that activity within the nucleus intermedius is heavily influenced by the position of the head relative to the trunk.” [Very Important]

11) “Chemical or electrical stimulation of the nucleus intermedius causes monosynaptic excitatory and inhibitory postsynaptic potentials in the nucleus of the solitary tract (NTS).”

12) The authors suggest that the greatest influence of the nucleus intermedius is to the “autonomic circuits relating to the cardiovascular system.”

13) Nucleus intermedius neurones are “under the influence of information arising from the neck region, in particular the dorsal neck muscles.”

14) One of the functions of the nucleus intermedius is to elicit autonomic responses to movements of the head to complement those triggered by the vestibular system.

15) The vestibular system regulates cardiovascular autonomic (sympathetic) responses to head movements.

16) Innocuous mechanical stimulation of the neck of humans that does not activate the vestibular system evokes changes in heart rate and blood pressure, perhaps through the nucleus intermedius. [This is like saying that altered mechanical afferent input from the neck {innocuous mechanical stimulation} subsequent to the chiropractic subluxation alters the neurological influence to the nucleus intermedius, in turn influencing the autonomic control of heart rate and blood pressure. Recall that the study in the Journal of Human Hypertension, March 2007, showed that specific upper cervical chiropractic adjustments (NUCCA) significantly reduced blood pressure, and the outcomes remained stable during an 8 week follow-up period]

17) Low threshold stimulation of the nerves entering the C1 and C2 DRG can elicits changes in the activity of both sympathetic and respiratory nerves. [Very Important: supports chiropractic adjustments influencing sympathetic neurology]

18) Proprioceptive information can play a role in modulating the autonomic nervous system. [Very Important: this is a central theme to chiropractic clinical approaches to many non-musculoskeletal syndromes]

19) “Neurones in the nucleus intermedius are under the influence of sensory afferent information arising from the neck region.” [Very Important]

20) The nucleus intermedius receives afferent input from the vestibular nuclei. [Important because the vestibular nucleus also receives monosynaptic inputs from upper cervical spine afferents]

21) Upper cervical DRG afferent fibers project to the nucleus intermedius, and these fibers are “proprio- and mechano-ceptive afferents” and not nociceptors. [This is very important because it implies that non-painful aberrant mechanical afferent input from the upper cervical spine can alter autonomic function. In the study from the Journal of Human Hypertension, March 2007, which showed a significant reduction of blood pressure with specific upper cervical chiropractic adjustments, the authors noted that none of the patients were suffering from neck or back pain]

22) The authors suggest the primary afferents influencing the nucleus intermedius are from the upper cervical muscles “adding weight to the theory that the nucleus intermedius is under the influence of cervical muscles.”

23) “Changes in the positioning of the head relative to the trunk, or sensory information arising from the neck musculature, have been clinically implicated in the control of heart rate and blood pressure.” [Very Important: the upper cervical chiropractic subluxation is a change in the “positioning of the head relative to the trunk, or sensory information arising from the neck musculature”]

24) “The nucleus intermedius acts to integrate information from both the neck musculature and the vestibular system before relaying this information on to the nucleus tractus solitarius.”

25) This pathway from the neck musculature to the nucleus tractus solitarius might be behind the “changes in heart rate and blood pressure observed following upper cervical chiropractic manipulations and autonomic disturbances observed in whiplash patients.” [Very Important: these authors acknowledge the ability of upper cervical chiropractic adjustments to influence heart rate and blood pressure, both autonomic functions]

26) “The nucleus intermedius neurones are strongly targeted by afferent fibres projecting via the upper cervical DRG,” and this “information can manifest as changes in autonomic variables.”

27) The nucleus intermedius “plays a role in the generation of autonomic responses to movements of the head,” especially as it is monosynaptically connected with the nucleus tractus solitarius.

COMMENTS FROM DAN MURPHY

This is a very important article for chiropractors. It explains the neuroanatomical relationship between upper cervical spine subluxation (a mechanical problem) and visceral autonomic neurology. The authors use chiropractic adjustments of the upper cervical spine influencing cardiac function as support for their neuroanatomical findings. This study supports the 115 years of clinical observations of chiropractors. It shows the “biological plausibility” of the influence of chiropractic adjustments on non-musculoskeletal syndromes.

Chiropractic BioPhysics, Dan Murphy, DC, Neurology

Custom Foot Orthotics: Are they really Custom?

Stuart Currie DC,

Director of Research, Sole Supports.

www.solesupports.com

When is a custom foot orthotic not a custom foot orthotic? Practitioners prescribing these devices need to know. The word “custom” is often used in the foot orthotic industry and critical thought as to its meaning is warranted for the astute practitioner. We are bombarded in both the public and professional domains with advertisements and claims for the “Custom Foot Orthotic”. As the American physicist and Nobel Prize winner Richard Feynman once said, “For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.”

There are two main considerations when determining the level of custom that an orthotic provides: (1) How it is casted, and (2) how that cast is manufactured. What will become clear very quickly is that the notion of “custom” is not entirely black or white, but a scale ranging from completely prefabricated devices, to “best fit” devices pulled from a library of molds or feet, to truly custom devices based on a model of the foot in a corrected position.

To start, let us review a description of the casting process for a custom-made orthotic:“The cast is taken in a position that minimizes mechanical anomalies by either improving foot alignment or accommodating foot alignment when necessary. A three dimensional mold of the foot is necessary in order to fabricate a truly custom-made orthotic”.¹Any provider dispensing a custom foot orthotic, therefore, must know how they intend to influence the foot’s alignment (or posture). The biomechanical goals and how they can be achieved through a cast of the foot are crucial to a custom prescription and have been outlined in a previous AJCC article.² In order to attain a corrected position with an orthotic device it must be achieved in the cast and then communicated to the lab. A cast that is taken in full weight-bearing therefore, would have to be altered by the lab in some way to achieve correction of any mechanical abnormalities. Because this is performed using assumptions, this type of alteration lessens the custom properties of the doctor’s prescription.

Any discussion of casting as it relates to a custom orthotic needs to address the issue of digital casting and manufacturing methods. There exists significant confusion as to the efficacy of the digital methods used today. A digital impression of the foot may have utility in conjunction with a proper physical assessment in at- risk populations such as diabetics and those diagnosed with rheumatoid arthritis.³ However, two dimensional data alone cannot provide exact information for the third dimension in order to manufacture a custom-made foot orthotic. So while there is no inherent flaw in the digital technology itself, it is incapable of providing the data needed for a custom-made orthotic. From the Pedorthic Association of Canada on casting technique: “Casting does not include taking an imprint on an ink pad or forceplate”¹.

Accurate vertical dimensions of a foot cannot be predicted from footprints or measurements of the plantar surface area. In one study only 27% of the vertical arch height could be estimated by plantar surface data⁴, so using this data alone would negate roughly three-quarters of the clinical picture. This is not a confidence level most would be comfortable with for the manufacture of a custom device. I have heard the analogy worded this way: Estimating arch height from plantar pressure data is akin to trying to draw the skyline of a city using only the weights of the buildings.

FIGURE 1. True custom-made foot orthotics are fabricated from a 3D volumetric model of the patient’s foot that duplicates its unique plantar anatomy in a corrected position, to which raw materials are molded to create the orthotic.

The Prescription Foot Orthotic Laboratory Association (PFOLA) differentiates between two types of orthotic manufacture. Those that use anatomical models and those which use extrapolated models. This second type of model is a digital model that “approximates” a person’s anatomy using mathematical models to extrapolate pressure, temperature or light data.⁵ A third type of manufacturing with an even less custom process uses a library of pre-made orthotic shells choosing a “best fit” approach to the cast in question; sometimes the criteria can be as vague as foot length or size.

The above information helps us draw a distinction between “customized” and “custom-made”. A customized orthotic uses an extrapolated model or a library of shells in the manufacturing process, while a custom-made orthotic uses anatomical three-dimensional data from the patient’s foot.

When trying to determine if your orthotic company makes custom-made or customized orthotics, ask yourself this question: How does the lab determine the three dimensional height of the corrected arch? If you are not providing it in your cast then there must be a lab extrapolation. Other variables that increase the custom properties of an orthotic include the patient’s weight, the patient’s foot flexibility, and the patient’s activity levels.

There is no secret to the process of manufacturing a truly custom-made device. Your lab should be forthcoming with any and all information concerning the manufacture of the devices you prescribe. As a doctor it is your responsibility to provide the most custom orthotic to your patients, after all, the diagnosis and treatment of patients is a custom business.

Reference List

(1) Pedorthic Assoc. of Canada. www.pedorthics.ca. Internet Comm.

(2) Currie S.J. AJCC 2009;19(4):4,26.

(3) Randolph AL, Arch Phys Med Rehabil 2000 May;81(5):573-8.

(4) McPoil T. J Am Podiatr Med Assoc 2006;96(6):489-94.

(5) PFOLA. www.pfola.org. Internet Comm.

Chiropractic BioPhysics, Shoe Lift, SoleSupports

Tocotrienols – The Sleeper Nutrients

Dr. Lynn Toohey, Ph.D, Nutrition

Colorado State University in Ft. Collins, CO

Research Consultant NutriWest

The word “tocotrienols” doesn’t exactly roll off the tongue. This 5 syllable word describes the lesser known players of the vitamin E molecule. Many people think that alpha tocopherol is vitamin E, but that is incorrect. Alpha tocopherol is just the portion of vitamin E that has been used in most of the clinical trials existing in the research.

The synthetic variety, DL alpha tocopherol, was used in these studies, instead of the natural form, D alpha tocopherol. When you couple this with the fact that alpha tocopherol was not given with the other synergistic members of the molecule in these studies, it is no wonder that “bad press” occasionally comes out about “vitamin E”, even though vitamin E was not studied. Using alpha tocopherol alone may actually interfere with the action of the other parts of the molecule.

There are many who believe that studies done with just the alpha tocopherol portion of the vitamin E would have been much more efficacious if the studies had taken advantage of the properties, both synergistic and stand-alone characteristics, that the tocotrienols possess.

“Disappointments with outcomes-based clinical studies testing the efficacy of alpha tocopherol need to be handled with caution and prudence recognizing the untapped opportunities offered by the other forms of natural vitamin E”¹

While alpha tocopherol has cornered much of the press in recent years, the alpha, beta, gamma and delta tocotrienols are very important parts of the vitamin E molecule. As we have seen, it has been suggested that the vitamin E research done only with the alpha tocopherol portion of vitamin E (and the synthetic DL variety at that) does not do justice to the properties of the vitamin.

Besides the fact that the tocotrienols balance the alpha tocopherol portion of the vitamin E molecule and work in synergy with it, tocotrienol research demonstrates that the tocotrienols have many health benefits over and above that of alpha tocopherol alone. The tocotrienols have emerged as vitamin E moieties with functions in health and disease that are clearly distinct from that of alpha tocopherol, and properties that are synergistic with alpha tocopherol. There are many instances where the tocotrienols surpass the tocopherols in potency and performance; neuroprotection is one of those areas.

Tocotrienols and Neuroprotection:

Tocotrienols have been called a “potent neuroprotective form of natural vitamin E”² , and have been named “potent neuroprotective agents against stroke”³ Another study confirms the neuroprotective qualities of the tocotrienols, and reports that “tocotrienol protects against stroke-associated brain damage”, and that “taken orally, tocotrienols are bioavailable to all vital organs” (Sen CK, et al. 2007)

Significant protection from mercury-induced neuronal cell death has been observed with both tocopherols and tocotrienols. Even though tocopherols were effective, researchers observed that tocotrienols are multi-fold more potent than tocopherols in protecting brain neuronal cells against mercury neurotoxicity, and that it only took a micro-molar concentration of tocotrienols (but not tocopherols) to show complete protection by an antioxidant mechanism. “These results suggested that oxidative events may contribute to methyl mercury (MeHg) toxicity in isolated cerebellar granule neurons, and that tocotrienols are potent supplements for pharmacological protection of the developing brain exposed to MeHg”⁴

Tocotrienols and the Heart:

Several studies suggest that the tocotrienols are very cardioprotective. One study even rated the tocotrienols as to their cardioprotective power, and found that, “The gamma-isoform of tocotrienol was the most cardioprotective of all the isomers followed by the alpha- and delta-isoforms” (Das S, et al. 2008.)

“Tocotrienols attenuate myocardial ischemia-reperfusion injury, atherosclerosis, and reduced ventricular arrythmias”, in addition to the fact that “tocotrienol-mediated cardioprotection is also achieved through the preconditioning-like effect, the best yet devised method of cardioprotection”⁵

Additionally, while it is known that high dose (1200 IUs or more) of alpha tocopherol may have adverse effects on blood pressure because it lowers the levels of synergistic components like tocotrienols, the tocotrienols appear to have a favorable effect on blood pressure.⁶

Tocotrienols and Cholesterol:

Another area in which the tocotrienols seem to outperform the tocopherols is that of cholesterol. Natural methods of tackling cholesterol are constantly being sought, and the tocotrienols are making headlines in this arena too. Additionally, the tocotrienols provide antioxidant protection of the cholesterol that many believe to be more important than lowering the quantity of cholesterol. The tocotrienols have been shown to reduce Total cholesterol; reduce LDL (the bad) cholesterol (over 40% in some studies; 90% in cell studies!); reduce triglycerides; reduce Apo B; improve the HDL profile; and increase coenzyme Q 10 levels (up to 300% in vitro!)^7,8

Another study reported that tocotrienols “possess potent antioxidant, anticancer, and cholesterol lowering activities”, and they additionally reported that they possess potent anti-inflammatory activity, probably by inhibiting substances like cox 2 and NF-kappaB expression.⁹

Summary

The tocotrienols are powerful substances, and they work together synergistically to accomplish all the benefits described in the literature. It is clear that the more they are researched (and the more that people learn how to pronounce the tricky name), the more we will learn about the sleeper nutrients called tocotrienols.

References

1. Sen CK, et al. Tocotrienols in health and disease: the other half of the natural vitamin E family. Mol Aspects Med. 2007 Oct-Dec;28(5-6):692-728.

2. Sen CK, Khanna S, Roy S. Tocotrienol: the natural vitamin E to defend the nervous system? Ann N Y Acad Sci. 2004 Dec;1031:127-42.

3. Das S, et al. Cardioprotection with palm oil tocotrienols: comparision of different isomers. Am J Physiol Heart Circ Physiol. 2008 Feb;294(2):H970-8.

4. Shichiri M, et al. Protection of cerebellar granule cells by tocopherols and tocotrienols against methylmercury toxicity. Brain Res. 2007 Nov 28;1182:106-15.

5. Das S, et al. Tocotrienols in cardioprotection. Vitam Horm. 2007;76:419-33.

6. Rasool AHet al. Arterial compliance and vitamin E blood levels with a self emulsifying preparation of tocotrienol rich vitamin E. Arch Pharm Res. 2008 Sep;31(9):1212-7.

7. Qureshi, AA. et al. Dose-dependent suppression of serum cholesterol by tocotrienol-rich fraction (TRF25) of rice bran in hypercholesterolemic humans. Atherosclerosis. 2002 Mar;161(1):199-207;

8. Bentinger M, et al. Polyisoprenoid epoxides stimulate the biosynthesis of coenzyme Q and inhibit cholesterol synthesis. J Biol Chem. 2008 May 23;283(21):14645-53.

9. Wu SJ, et al. Tocotrienol-rich fraction of palm oil exhibits anti-inflammatory property by suppressing the expression of inflammatory mediators in human monocytic cells. Mol Nutr Food Res. 2008 52(8):921-9.

Chiropractic BioPhysics, Nutriwest

Advertising and Patience Make Patients

Lisa Holmes, MBA, MHA

Lisa Holmes is president of Holmes & Co., a health-care-specialty marketing communications firm.

We live in an “I want it now” culture. Patience may still be a virtue, but it’s an increasingly uncommon one. Look at correspondence: letters gave way to faxes, which were pushed aside by e-mails, which lost ground to instant messaging. Now “tweets” seem to be the order of the day. We send someone a question or request, then teeter on the edge of a panic attack if the response is not immediate.

Like it or not, this “want it now” attitude affects all of us to some degree. And it bleeds into every area of our lives, including business.

And advertising.

Many people in business, unfamiliar with advertising and its ways, expect to place an ad and instantly be overwhelmed with customers. Unfortunately, it doesn’t work like that. At least not often.

That said, advertising does work. It remains an important tool in building a business. But it takes purpose. Planning. Proficiency. Persistence. And patience.

Look at it from the consumer’s perspective (which is essential anytime you’re talking about advertising). Every one of us (we’re all consumers) is exposed to thousands—literally—of commercial messages of one kind or another every day. Online, on signs and billboards, on television and radio, in newspapers and magazines—in short, on almost any surface our eyes encounter.

Add to all this clutter the fact that we’re busy. We’ve got more important things on our mind than paying attention to everyone who’s trying to sell us something. So, the chance of any single advertising message being noticed—let alone paid attention to and remembered—are infinitesimal.

Overcoming those barriers is possible. Let’s start with the basics. In preparing advertising strategies for our clients (all of whom are in health care, by the way), we start with three basic questions: Who are we talking to? What do we want them to believe? Why should they believe us?

Simple questions, but the answers aren’t always simple or easily arrived at. Often, we rely on market research, but not always. Critical thinking and simple logic can work, too.

Knowing “who” you’re talking to is crucial, not only in devising your appeal, but also in developing you voice and selecting the advertising media that will carry your message. And “who” may not be who you think. For instance, we know that when it comes to health-care decisions, women either make or are the primary influence in those decisions some 80% of the time.

“What” you want prospects to believe simplifies and clarifies your sales message. For example, the new advertising campaign for whiplash treatment available to all CBP-trained chiropractors seeks to persuade people that CBP techniques can provide relief from whiplash pain even when other treatments fail.

But consumers are skeptical. They know you’re trying to sell them something, and they won’t believe what you say just because you say so. So, you have to support your sales message with convincing proof—facts, figures, endorsements, and the like.

Now that you’ve answered all the questions and used the answers to create effective advertisements (which often requires professional help), patience comes into play. Repeated exposure is necessary. Years ago—long before the clutter we face today—research found a prospect must be exposed to a message seven times before being noticed. More often to make an impression. Still more often to be remembered.

But, like chiropractic, advertising works. And the better the advertising, the better it works. Ad campaigns create awareness of you and your practice, which is the first step in attracting new patients. After all, they can’t come to you if they don’t know about you.

Put advertising to work for your practice. The CBP whiplash campaign might be a good place to start. Start now.

And be patient. The patients will come.

Chiropractic BioPhysics

#1 Biggest Mistake in Patient Management: “MAKING STATEMENTS AND NOT ASKING QUESTIONS.”

Fred DiDomenico, DC

Practice Coach and Mentor

Drfred1@msn.com

Almost ALL new patients come into our clinics with a pain relief intention and perspective. As corrective care chiropractors, our core value in practice is to influence their thinking and inspire them to desire life changing spinal corrective programs so they may live up to their full potential in life without the progressive, degenerative health conditions resulting from a subluxated posture. Our challenge is we figuratively and literally have 5 minutes on Day #1 to make a powerful impression that can shift their perspective and captivate their attention so we can inspire their INTENTION. In order to fulfill this purpose we MUST create a shift in our communication from making statements to asking questions so the patient does not reabsorb themselves back into their fast paced, subluxated life after leaving our office. This is a great responsibility, not to be taken lightly, and is a much greater responsibility than the average doctor treating for pain relief. In fact, it is our calling.

In order to create accelerated influence, we must change from teaching information on subluxation, to asking questions guiding the patient through their own thought process, revealing their emotional impression while increasing their understanding of the effect a subluxated posture is having on the most important aspect of their lives. Questions create influence because they bring a person through their own thought process that helps them derive their own conclusions. When they answer, “yes,” to a question that brings them into agreement with the truths and principles of a subluxated posture and the effects it is having on their body, you have just accelerated their learning rate, created more impression which has allowed them to make your care THEIR IDEA. “When They say it, they believe it.”

When you make statements, they feel they MUST conform to your idea, which they may not agree with. As you all may have experienced, they don’t always agree with you and/or your ideas. When they don’t agree you will hear, “I want to get another opinion,” “I don’t have time,” “I can’t afford it right now,” etc.

Their answers to your carefully and intentionally directed questions confirm in their mind they are speaking truth. When your question directly applies to their individual emotional condition weakening their life and emotional priorities, they will take action NOW, almost the moment they answer your question because it is THEIR DECISION.

Your job is to recognize their objection, handle it directly with a question that brings them closer to the thought process you are attempting to teach and inspire. You can create a question that shifts their thoughts and brings new understanding in one sentence from you, and a one word answer by them. Your ability to influence their decisions and behavior now instills self empowerment. This is coaching. Elite Coaching is a “coaching” system and is HIGLY EFFECTIVE for spinal rehab practices.

Our responsibility is to empower patients to take responsibility for their lives and their condition. When they derive conclusions regarding their life and health from the energy of empowerment, they are inspired to go above and beyond their normal efforts to become or do something that may be atypical of previous behavior with any other doctor or chiropractor. Empowering patients to complete a spinal rehabilitative program will require energy and effort that many have not exhibited in their past. To reap the benefits of a healthy lifestyle through spinal correction, they must dig deep inside themselves with unbridled inspiration. All of us have that inspiration innately inside us. Many have not taken the opportunities in life to unleash their deepest passions. We have that responsibility to help each person find that which may have remained dormant and bring out their divine inspiration to reach and be their best. As corrective care chiropractors, we can help them achieve this level of inspiration. In fact, it is our responsibility, purpose and mission.

Inspire EVERY patient to be their best. Help them find their own individual emotional commitment for a healthy life through spinal correction by asking them specific questions taking them through the thought process and accelerate their understanding and inspiration to be their best.

“I had a new patient come to me from another chiropractor around the corner who recommended a program for 70 visits for $1700.00 for corrective care. He left his office rejecting his care. After taking him through the Elite Coaching communication systems and learning how to ask the right questions, he payed me $5000.00 for 41 visits. The patient told me he trusted me more as he wrote the check. Most importantly, I know we will correct his spine.”

Dr. A. G., Miami FL.

Chiropractic BioPhysics, Elite Coaching

Evidence Based Chiropractic from a Modern Practical Practice Perspective

Len Siskin, DC

Promote Chiropractic,

Co-Chair ICA Best Practices

A friend emailed me an article recently where I learned that one in four Britain chiropractors are currently under investigation for allegedly making misleading claims about being able to help a list of named medical conditions in their advertisements. (http://www.guardian.co.uk/science/2010/mar/01/simon-singh-libel-case-chiropractors) Another friend sent an email with an article written by chiropractors, paid for by the UK General Chiropractic Council (GCC) and published in, “Chiropractic and Osteopathy” which reviews chiropractic research.²⁷

Problematically, the Bronfort et al²⁷ paper leans heavily on Level I Randomized Clinical Control Studies (RCT’s) particularly from the past 5 years. After having read the article, I have to commend the authors for the scope of dimension they looked at which includes the use of a research grading system, and consideration of various clinical guidelines as well as 46 RCT’s considering twenty six named medical conditions which chiropractors historically claim to have helped in clinical practice. The authors mention that RCT’s are the highest quality of clinical research, and respected critics of the RCT acknowledge that with the level of controls used to measure the effectiveness of a procedure, they may not commonly represent typical clinical scenarios in an everyday chiropractic or healthcare practice.

If a person were to research data-searching-algorithms for modern computers, it would be foolish to look at the information published 30 or 50 years ago when computers either didn’t exist or took entire buildings to do what most mobile phones can do now in a fraction of a second. In contrast we still use laws of physics established hundreds and sometimes thousands of years ago as these are established universal laws. In the case of human physiology and the benefits and effectiveness of the chiropractic adjustment, it seems that neither has really changed much since the inception of our great profession. See the contemporary best Practices Document of the International Chiropractors Association (http://www.icabestpractices.org/) which can be found in the National Guideline Clearinghouse (http://ngc.gov/).

The best practices database shows greater than 80% of chiropractic research consists of Level IV studies, which are mostly case studies or case series without controls. Looking primarily at RCT’s and reviews of the literature as well as a list of professional guidelines may not represent what the research actually has to show. How does this influence the findings published in the Chiropractic and Osteopathy²⁷ article mentioned above? How would policymakers view chiropractic any differently given more detail on this information? The authors should be applauded for discussing the importance of several clinically relevant factors. These include:

1. Doctor experience and the importance of understanding factors such as the high safety value in chiropractic risk assessment

2. The cost effectiveness of chiropractic treatment as compared to other available modalities to help the named conditions

3. The importance of patient education and the patient’s right to choose the type of care which may be best for them, when properly informed about the potential risks, benefits, and known research outcomes related to their individual clinical picture.

So many research efforts in healthcare have focused on co-morbid factors in healing and treatment, it would have been nice to have seen a discussion on some of these co-morbid factors here, and how the existing research might incorporate an awareness of such clinical complexities which prolong the healing process, complicate the healing of patients, and influence the crafting of a care plan under a given treatment modality. Simply typing, “co-morbid influences on healing”, into Google yields 63,100 hits which are predominantly reflective of clinical research on topics relevant to crafting treatment guidelines. These considerations are accounted for in the ICA Best Practices document which takes all chiropractic treatment research into consideration without exclusion so long as the research was original clinical research and not research reviews or meta-analysis.

Furthermore, the ICA Best Practices document utilizes a research grading system extremely similar to that used in the Chiropractic and Osteopathy paper discussed here. Common factors on the note of co-morbidity would be things like obesity, smoking or a history of smoking, history of multiple physical traumas, life stressors like divorce, debt, family health issues, etc. It is unfortunate the chiropractic profession does not have the money or funding of the pharmaceutical industry where entire multinational corporations are dedicated solely to performing randomized clinical control trials for the pharmaceutical products. What the chiropractic profession has the most of is simply Level IV evidence.

The ICA Best Practices Guidelines draws information from approximately 1500 research papers showing positive benefit from chiropractic care on over 330 named medical conditions. In their paper, Bronfort et. al. came up with 26 named medical conditions which have been reported to receive help from chiropractic intervention. When crafting the ICA Best Practices Guidelines, all original research papers since the beginning of chiropractic time were summarized and questions were answered about findings by unpaid practicing chiropractor volunteers. Only after the data was entered was a search done to learn what conditions received help from chiropractic according to the existing research. That search yielded a list of over 330 healthcare conditions shown to receive help from chiropractic intervention.

As a comparison below I have made a table of conditions listed By Bronfort et. al. and a comparison table for similar conditions listed in the ICA Best practices Guidelines document. The only condition not listed by the Best practices Document was, ‘Myofascial Pain Syndrome’, which was analyzed specially for this paper as indicated below for comparison and evaluation purposes. Also included in the table is a ranking of where each condition listed by Bronfort et. al. falls in terms of research power in the ICA Best practices list of conditions helped by chiropractic. This reflects a progression from high to lower quality evidence shown by already existing research. I included headache in the list but think it is important to note names of conditions as reported by research have changed over the years. For example, 8 of 670 pubmed.gov hits for, ‘cervicogenic headache’, were before 1961. Thirty Four of 140 papers summarized by ICA BPG were prior to 1961 on this topic. The research indicates headaches and even cervicogenic headache have existed and been researched well before the past 5 years no less the past 5 decades.

In Evidence based healthcare, research is used to indicate the truth about making the best possible clinical decision and in providing the best truth in informing patients of their treatment options. When the research is under-represented or misrepresented it is a detriment to the consumer of healthcare. It is important to understand which treatment modalities have existed for many years (like spinal manipulation) and which are more recent (like cold laser or disc decompression traction). Spinal manipulation simply has not changed much at all over many years time. Most chiropractic techniques used today are the same or extremely similar to what was used nearly a century ago. The difference is in the way we understand what chiropractic does to help consumers heal, advancements in information insuring consumer safety, and in the depth of insight to the dangers of not instituting chiropractic treatment for those who could benefit from it.

In the below table, rank refers to the point score as dictated by the rating generated by the best practices database and where each condition falls in the pool of available research performed in chiropractic since the beginning of time through approximately the middle of 2008. Approximately 338 conditions were identified as having research done on chiropractic treatment where there was a benefit shown. For more details or to check numbered references, please go to www.ICA Bestpractices.org. Level’s I-IV represent types of research performed where Level I is an RCT and Level IV is an observational study like a case study. ‘R^*’, indicates the grading system used in the ICA Best Practices Guidelines which is similar to that used by Bronfort et al.²⁷ as discussed above.

**Myofascial Pain Syndrome (inclusive)-- Medline search indicates this terminology is modern and historically this vague description has also been referred to as Fibrositis or muscular rheumatism; Fibropathic Syndromes… Data searches intermingle this condition with fibromyalgia as well. The numbers here reflect a search of the ICA Best practices Database for all these conditions except for fibromyalgia. Myofascial Pain Syndrome was not included in the list of over 330 conditions shown to receive help under chiropractic care by published clinical chiropractic research. It was investigated solely for demonstration in this paper.

***Myofascial Pain Syndrome (Strict) refers to a search of the exact phrase, “Myofascial Pain Syndrome” in the ICA Best Practices Database and the found results. Note, on the grading scale, omitting the scope of the research changes the grade of evidence found from an, ‘A’, to a, ‘C’.

**** These references are specific to this paper and do not correlate with ICA Best practices Guidelines References. No rank was assigned as this was not included in the ICA best practices Guidelines symptom list.

Chiropractic BioPhysics, ICA Best Practices Chiropractic Guidelines

Newly Published Guidelines to Save Chiropractic in Europe?

Dr. Joe Betz, B.S., D.C

ICA Board Member,

Idaho Chiropractic Association

CBP Fellow & Instructor

Here we go again! Findings from an “extensive” review of the “literature”¹ conclude that spinal manipulation is only effective for the following conditions:

· low back pain;

· migraine and cervicogenic headache;

· cervicogenic dizziness;

· several extremity joint conditions;

· neck pain (only using thoracic manipulation)

Cervical manipulation alone for neck pain of any duration, manipulation for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, and over 300 other health conditions was either found to be not effective, or was ignored in the review.

This group, which I assume is presenting themselves as “coming to the rescue” of the Chiropractors in Europe, also supports the findings of the equally maligned (and, in my opinion, poorly performed and biased) “Red Flag Only” X-ray Guidelines put out by Bussieres et al.¹ This guideline intended to limit the use of X-ray in Chiropractic practice. However, it is flawed due to the fact that it is based upon the findings of the medical profession on their utilization of X-ray for musculoskeletal conditions. Frontline management by MD’s for low back pain, for example, is the utilization of medication. Of course X-rays are not warranted in this type of management. However the Chiropractic “Red Flag Only” guidelines by Bussieres et al.¹ attempt to loosely apply these MD protocols to the practice of Chiropractic. Obviously, the practice of Chiropractic with mechanical force application to the spine as the primary treatment intervention, should be quite different in its radiography utilization needs, applications, outcomes, indications and contra-indications, etc.

Now back to the main issue at hand in this editorial. With regard to the scope of conditions effectively managed by the application of spinal manipulation, findings of “saviors” of Chiropractic in Europe do not surprise me to any extent. This is what they perpetuated in their CCGPP Guidelines.

However, it is the implications of this particular publication that is most disturbing. Some of you who pay attention to the events unfolding on one side of the world that invariably affect the profession on the other, are well aware of the ongoing situation in the United Kingdom between the British Chiropractic Association and the popular press, in particular a journalist named Simon Singh. Singh is being sued by the British Chiropractic Association for libel for an article he wrote critical of the chiropractic profession.

Singh has since teamed with a medical researcher and author known for being extremely critical of Chiropractic in recent years, and has blasted back at the profession resulting in a significant backlash. What has come into question is the scope of conditions for which Chiropractors should be allowed to claim success within their advertising and marketing materials. Specifically, advertising claims made by Chiropractors asserting benefits of Chiropractic care for non-musculoskeletal conditions have come under aggressive attack. This well-orchestrated effort has resulted in an onslaught of 600 board complaints against Chiropractors filed with the General Chiropractic Council (GCC), Europe’s centralized regulatory agency. This aggressive barrage of complaints equals a complaint against one out of four licensed Chiropractors in Europe. Obviously, these complaints were not filed against the Doctors of Chiropractic by their patients, but rather by disgruntled readers and supporters of Singh, most of whom one would assume had never been to a Chiropractor.

These publicly dramatized activities in Britain have moved the General Chiropractic Council (GCC), the UK-wide statutory body with regulatory powers, to commission a group of researchers to evaluate the evidence of manipulative and manual therapies for conditions. Unfortunately, many of the same researchers that did the horrid CCGPP documents, performed this review. Without much surprise, these individuals ONLY REVIEWED Randomized Clinical Trials (RCT’s) and systematic reviews of RCT’s. So again, as they did with the flawed CCGPP Low Back Pain document, they ignored 90% of the literature on the topic.² The GCC argues that only RCTs are appropriate to consider when determining what can be advertised by Chiropractors.

In my opinion, their findings, published in the journal Chiropractic and Osteopathy,³ work to shift the position of the BCA from defending Chiropractic as a healing profession that has 115 years of experience and published studies helping people with over 300 various conditions, to a glorified musculoskeletal therapist (of only selective regions of course). It is important to know that not all European associations have accepted these findings in Europe. Some groups maintain their position supporting Chiropractic and are adamantly opposed to the direction that these GCC commissioned researchers are driving the profession in Europe.

The International Chiropractors Association developed a COMPLETE Guideline that reviewed ALL levels of evidence, not the RCT exclusively. This guideline has been accepted for inclusion at the National Guideline Clearinghouse (NGC) a project by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The findings of this clinical practice guideline showed benefits of Chiropractic care for over 300 different health conditions using many different techniques. Chiropractic organizations in Europe who do not want Chiropractors to be reduced to a limited musculoskeletal pain therapists, should consult these documents. Many national and state associations from around the world have officially adopted these guidelines to support their position that Chiropractic is a health care profession, not a limited therapeutic musculoskeletal modality.

Whether you practice Chiropractic in Anytown, USA or some remote corner of Scotland, the ICA Guidelines are continuously being updated for the benefit of you and your patients. You can support this process by joining the ICA and purchasing a copy of the ICA Best Practices and PCCRP X-ray Guidelines. All proceeds go to future revision of the document. Call the ICA today 800-423-4690. While you sit on the sidelines, others are working to strip the purpose of Chiropractic out of the profession.

References

1. Bussieres AE, Taylor JA, Peterson C: Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther 2008, 31: 33-88.
2. ICA Committee’s Critique of CCGPP’s Best Practices: Chiropractic Management of Low Back Pain and Low Back Pain Related Leg Complaints. June 2006.
3. Bronfort G, Haas M, Evans R, Leiniger, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiro Osteopath 2010; 18(3): 1-113.

Chiropractic BioPhysics, Chiropractic Guidelines

New RCT Finds Vitamin D Prevents Influenza & Asthma Attacks in Children

Monday morning March 22, 2010, the American Journal of Clinical Nutrition published a multicenter, randomized, double-blind, placebo controlled trial of school children showing vitamin D3 prevents influenza. A secondary finding was that asthmatic children on placebo had six times more asthma attacks than did children on vitamin D3.

Over the course of 4 months, Urashima et al¹ compared the rate of incidence of influenza A diagnosis in 167 children using a nasopharyngeal swab. The children were randomized into 1 of 2 groups: Group 1 received 1200 IU/d of vitamin D(3) while Group 2 received a placebo. Only 10.8% of children receiving the Vitamin D(3) were found to have acquired Influenza A, whereas 18.6% of children in the placebo group acquired Influenza A; results were statistically significant. Also of importance, only 2 of the children with a diagnosis of asthma reported an attack whereas 12 children in the placebo group reported an asthmatic episode.

Key Take Home Points for Chiropractors and Their Patients

1. Vitamin D3 is a vital nutrient for immune system function, cardio-vascular function, and brain development and activity.^2,3

2. Vitamin D3 is produced naturally in humans by direct exposure of the skin to sunlight. In Winter and even other seasons, we do not expose our skin to adequate time periods of Sun light. ^2,3

3. It takes approximately 20 minutes per day of full body exposure (that means in the NUDE) to direct sunlight in order for your body to produce adequate levels of natural Vitamin D3. ^2,3

4. Thus, most Adults and Children need to supplement daily with Vitamin D3, especially in the winter months.

5. According to the results of Urashima et al.¹ vitamin D3 supplementation in school children may decrease the incidence of children developing signs and symptoms of the flu and may also decrease the rate of asthma attacks in asthmatic children.

References

1. Urashima M, Segawa T, Okazaki M, Kurihara M, Wada Y, Ida H. Randomized trial of vitamin D supplementation to prevent seasonal influenza A in schoolchildren. Am J Clin Nutr.2010 Mar 10.

2. Toohey L. Vitamin D: The versatile nutrient. American Journal Clinical Chiropractic 2010; 20(1):4 and 21.

3. Murphy DJ. Our schools, Autism, and Vitamin D. American Journal Clinical Chiropractic 2009; 19(2).

Chiropractic BioPhysics, Nutriwest

ICAC Guidelines for Whiplash Disorders Accepted at National Guidelines Clearinghouse

Charles G. Davis, DC, FICA, FICAC(H)

Ever get deposed and try to explain why the natural course of a whiplash injury may not be 6 weeks? The necessity and appropriateness of the treatment rendered? The medical reasonableness of the modalities utilized? The medical reasonability of the duration of treatment rendered?

The management guidelines for Whiplash Associated Disorders by the International Chiropractors Association of California has met the stringent criteria of the Federal Agency for Healthcare Research & Quality (AHRQ), and has been accepted for inclusion in the National Guidelines Clearinghouse (NGC), located at www.guidelines.gov. The NGC is a comprehensive database of evidence-based clinical practice guidelines and related documents produced by the Agency for Healthcare Research and Quality (AHRQ), in partnership with the American Medical Association and the American Association of Health Plans. The purpose of the NGC database is to provide health care professionals and providers access to objective, detailed information on clinical practice guidelines and to further the dissemination, implementation and use of those guidelines.

This guideline of Management of Whiplash Associated Disorders by the International Chiropractors Association of California provides integrated treatment guidelines for Whiplash Associated Disorders (WAD). These management guidelines for Whiplash Associated Disorders are evidence-based suggestions for appropriate care of patients seeking care. Recommendations are made for assessment along with time parameters, treatments, frequency & duration of treatment, staging and grades of injury, prognosis, criteria for discharge, and a variety of implementation tools, including a Pain Disability Questionnaire (PDQ), a Core Whiplash Outcome Measure, and an Impact of Event Scale.

While no guideline can replace the clinical decisions made by a practitioner in the course of caring for an individual patient’s health problem, the suggestions contain herein, are based on the best available published evidence. Any approach, by a practitioner, that is different from this ICAC-Management of Whiplash Disorders Guideline, does not necessarily mean that the approach in question was below the standard of care. However, any practitioner, who adopts a course of action different from this ICAC-Management of Whiplash Disorders Guideline, is advised to keep sufficient patient records to explain why such an action was undertaken.

Adherence to these ICAC-Management of Whiplash Disorders Guideline will assist the practitioner by allowing him/her to practice based on the most current scientific data available. Following the ICAC-Management of Whiplash Disorders Guideline, it is expected that the chiropractic practitioner will follow a reasonable course of action based on the best available knowledge. It is expected that with the assistance of the ICAC-Management of Whiplash Disorders Guideline, the practitioner will use the assessment and care suggested herein to deliver safe and effective care.

Main Participants in the guideline development included: Charles G. Davis, DC – Editor, Art Croft, DC, MS, MPH, FACO and Dan Murphy, DC, DABCO. However many other authors contributed to information, draft suggestions, critical reviews, and the final version of the document.

The nature of a science is that it is constantly evolving. Due to the variety, complexity, severity, and intricacy of human health conditions it is impossible to always determine the appropriate examination, appropriate diagnostic analyses, and to predict with absolute certainty the patient’s response to care. The ICAC-Management of Whiplash Disorders Guideline advances previous research and guidelines on this issue.

Copies are available from the ICA of California, 9700 Business Park Drive #305, Sacramento, CA 95827. 800-275-3515

Chiropractic BioPhysics, ICA Best Practices Chiropractic Guidelines, whiplash

CBP® NonProfit Research Update

CBP Research Presented at ACC-RAC 17

The research of CBP NonProfit, Inc. was represented at the seventeenth annual Association of Chiropractic Colleges Educational Conference-Research Agenda Conference held in Las Vegas, NV March 18-20. Dr. Paul Oakley represented himself and Dr. Deed Harrison’s case report featuring an MRI-documented complete resolution of an L4-5 disc herniation/sequestration after only 6-weeks of lumbar extension traction. The abstract is published in a special issue of The Journal of Chiropractic Education (Oakley P, Harrison DE. Lumbar extension traction and disc herniation/sequestration: A CBP case report. J Chiropr Educ: Spr 2010 (24:1): 136).

Berry Translation Traction to be Investigated by Dominican College, New York

In February of 2010, Dr. Bob Berry and Dr. Deed Harrison were contacted by the Department of Physical Therapy at Dominican College, New York. Two graduate students in the Doctorate of Physical Therapy program were inquiring as to the likelihood of acquiring a Berry Translation Traction Table and whether Dr. Berry and Dr. Harrison would be willing to assist in a research project. This research project is a requisite to be submitted-completed for partial fulfillment of the requirements for the Doctorate in Physical Therapy Degree at Dominican College.

The title of the project is: “Lateral Translational Traction to the Cervical Spine and its Reflection on Center of Gravity”; the main authors are Daniel Y. Lerner, SPT, Ailene M. Matusevich, SPT, and Project Advisors are: Michael Gallucci, EdD, Andrew McDonough, EdD, Deed Harrison, DC, Robert Berry, DC.

Drs. Berry and Harrison are excited about this project as it should further the understanding of translation traction intervention in chronic neck pain subjects. It is hoped that this project will aid in the determination of the effect of translation traction as a stand-alone intervention for correction of postural deformities in neck pain populations.

Chiropractic BioPhysics, Research