Frank M. |

Health Coaching: A Model That Makes Sense for Chiropractic

May 13, 2011 By Frank M.

By Guy Riekeman, DC, President, Life University

As anyone who has ever raised a teenager knows all too well, telling someone to do something because it’s “good for them” can feel like so much wasted breath. Chiropractors also can find themselves winded from exhorting (encouraging, cajoling, threatening, nagging, etc.) patients to persist with their programs of care and enhance their overall well-being with more frequent chiropractic visits, better nutrition, more sleep, stress management and exercise.

Recent health care trends and research are supporting what you may have already suspected from years in practice: Simply telling people what to do often does not lead to them actually doing it. Showing them how and leading them through it stands a much better chance of working.

Patient Education vs. Coaching

Traditional patient education – loading people up with facts and figures and sending them home with a stack of brochures to tackle on their own – often doesn’t empower patients with the true understanding and skills they’ll need to persist and succeed with a health care regimen. Health coaching leaves less to chance. A health coaching approach provides a more interactive consultation model whereby the coach and patient work together to map out care plans. The coach proactively monitors progress, provides counseling and new strategies for navigating through rough patches, and holds the patient accountable to agreed-upon goals.

Embraced today as a way to both improve health and lower costs, health coaches, also known as wellness coaches, help people set and meet health goals, overcome health-related obstacles and aid patients in setting up support systems. Many patients today expect a personalized model of care organized around their unique needs and want to explore a wide variety of options. A health coach (much like an athletic coach or personal trainer) walks the road with patients, helping them actually apply information to everyday life and aiding them in removing and minimizing setbacks along the way.

Health coaches are also particularly helpful in guiding people through information overload. The Internet is a great resource for researching health-related questions, but it can also present patients with more data and/or highly conflicted data that is difficult to turn into useful insights. Health coaches can guide people toward trusted resources and help them evaluate a broad range of care options.

Health coaches work with people one-on-one in person, over the phone or online, or with a small group of individuals who share similar concerns or health goals. Health coaching can help people in a broad range of situations, but is often especially valuable to people who have difficulty understanding their care plans, lack motivation or discipline, or require a personalized plan established especially for their needs.

Better Results

There is growing research showing better outcomes with the use of health coaches rather than traditional patient education. The Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services completed a study in 2008 in which high-risk chronic disease patients at the Dartmouth-Hitchcock Clinic were assigned health coaches. The coaches, integrated into the clinic’s primary care practices, provided evidence-based information to patients by telephone, during office visits, and in group class settings, with the goals of improving patient self-management skills, better preparing patients for their physician office visits, encouraging physician-patient communication and engaging patients in their care plans.

The coaching program attracted more patients than the clinic’s typical, outsourced disease management program, with 77 percent of potential participants enrolling compared to the group’s usual 7-13 percent enrollment rate. In addition, the readmission rate of the targeted patient group dropped from 15.6 percent to 13.7 percent and saved the Centers for Medicare and Medicaid Services $2.7 million while meeting quality measures of those organizations.

But research is also finding that serving as an effective health coach requires a broad range of skills. In “Integrating a Health Coach Into Primary Care: Reflections From the Penn State Ambulatory Research Network,” published in the Annals of Family Medicine, researchers found health coaches were often confronted with myriad issues in patients’ lives and needed strong grounding in counseling skills. The study involved lay health coaches in assisting obese adults with weight loss. Although the model led to nearly 50 percent of patients initiating behavior changes in eating habits and physical activity, the health coaches sometimes struggled with how best to address patients’ complex psychosocial issues.

Implications for Chiropractic

As a profession, chiropractic has long struggled with how to best educate patients and the general public to help them understand the pervasive and long-term value of ongoing chiropractic care. And each of us has strived in our offices to increase compliance among patients in maintaining office appointments and following through with improved lifestyle behaviors.

Chiropractors need the techniques of an effective health coach within their own skill sets and consider “hiring” and “training” those skills within their office staff members. How much more impact might we have as individual practitioners and a profession if we effectively coached people toward better health choices and the vitalistic chiropractic lifestyle? A coach can serve as a facilitator and mentor, helping people take responsibility for their own health, completely in harmony with the chiropractic view of true health care.

The job title is relatively new, but a growing number of organizations have begun utilizing health coaches to help patients manage chronic conditions, improve overall health and reduce costs. Recently advertised positions include a wellness consultant for Humana Inc., a health education professional for Health Fitness Corporation, a health coach for Johns Hopkins Healthcare LLC, and lifestyle health coaches for WellCorp.

Let’s not let this opportunity pass chiropractic by or see this wellness-oriented practice subsumed within the disease care paradigm. Coaching people toward a fuller expression of their optimum performance and health dovetails beautifully with chiropractic practice.

Throughout chiropractic’s history, we’ve focused on helping people reach more of their inborn potential for true health. The use of health coaches and coaching strategies provides another vehicle for chiropractors to help people reach their peak performance goals.

Life University recently introduced a Bachelor of Science in Health Coaching for individuals who want to pursue a career in the field and for chiropractic students interested in a health coaching foundation for their undergraduate studies. Core courses are provided in nutrition, exercise science and psychology, as well as a clinical practicum and optional business minor.

Dr. Guy F. Riekeman, president of Life University in Marietta, Ga., has held leadership positions in chiropractic education essentially since his graduation from Palmer College of Chiropractic in 1972. He was appointed vice president of Sherman College in 1975 and has served as president of all three Palmer campuses and as chancellor of the Palmer Chiropractic University System. In 2006, he was elected to the board of directors of the Council on Chiropractic Education.

Filed Under: chiropractic

Cervicogenic Headache Revisited

May 9, 2011 By Frank M.

Thanks to: The Chiropractic Report for access to this article!

September 2010 Vol. 24 No. 5

Editor: David Chapman-Smith LL.B. (Hons.)

“In my experience, cervical migraine is the type of headache most frequently seen in general practice and also the type most frequently misinterpreted. It is usually erroneously diagnosed as classical migraine, tension headache, vascular headache. . . . Such patients have usually received an inadequate treatment and have often become neurotic and drug-dependent”.

Frykholm, neurosurgeon, Sweden (1972) [1]

“Manipulation is effective in patients with cervicogenic headache”.

Duke University Evidence-Based Practice Center, USA (2001) [2]

A. Introduction

Headache is one of the most frequent reasons people seek medical advice and is the primary complaint of about 10% of chiropractic patients [3,4]. Headaches may have a ‘sinister’ cause, such as accidental injury, a space-occupying lesion in the brain or other disease process. In that case they are secondary headaches. However the great majority of headaches are ‘benign’, not linked to any specific injury or disease, and are known as primary headaches.

Benign does not mean mild – symptoms may be frequent and severe. The three most common types of primary headaches are migraine, tension-type headache (TT H) and cervicogenic headache (CGH) [5]. Back in the 1960s the various categories of primary headache were thought to be distinct. That thinking still influences much clinical practice and public perception. However by 1988, when the International Headache Society (IHS) published a new classification of headaches [6] it was known:

The diagnosis and classification of primary headaches were extremely confusing and difficult areas. A headache may have various causes – genetic, neurological, biomechanical, vascular, physiological, environmental (e.g. certain foods and drink). New findings were casting doubt on the peripheral nervous system as the main source of pain. The “most fundamental problem”, noted the IHS, was that there was “a complete absence of laboratory tests which can be used as diagnostic criteria for any of the primary headache forms”.
There was a continuum between what had been thought to be separate types of headache – migraine could convert to chronic TT H, episodic TT H could
convert to chronic headache.
Movement abnormalities or dysfunctions in the cervical spine were a significant contributing factor to primary headaches. Where patients met the diagnostic criteria for migraine or TT H they might also have cervicogenic headache (CGH – headache born in the cervical spine).

Figure 1 gives the IHS criteria for CGH.

Figure 1. IHS Classification – Cervicogenic Headache (1988)

11.2.1 Cervical spine

Diagnostic criteria:

A. Pain localized to neck and occipital region. May project to forehead, orbital region, temples, vertex or ears.

B. Pain is precipitated or aggravated by neck movements or sustained neck posture.

C. At least one of the following:

1. Resistance to or limitation of passive neck movements

2. Changes in neck muscle contour, texture, tone or response to active and passive stretching and contraction

3. Abnormal tenderness of neck muscles

D. Radiological examination reveals at least one of the following:

1. Movement abnormalities in flexion/extension

2. Abnormal posture

3. Fractures, congenital abnormalities, bone tumours, rheumatoid arthritis or other distinct pathology (not spondylosis or osteochondrosis)

Comment: Cervical headaches are associated with movement abnormalities in cervical intervertebral segments. The disorder may be located in the joints or ligaments. The abnormal movement may occur in any component of intervertebral movement, and is manifest during either active or passive examination of the movement.

The 1972 quote from Frykholm that opens this article speaks to this diagnostic confusion and unfortunately remains valid in general practice today. [2]. While there is still much to learn there has been a wealth of new research since the early 1990s. With respect to CGH:

(a) Anatomical Basis. In 1995 Hack et al., dental researchers at the University of Maryland in Baltimore, presented new evidence of bridges of connective
tissue between the posterior muscles and the pain-sensitive dura (myodural bridges) in the upper cervical spine that gave a much stronger anatomical basis for CGH [7]. See Figure 2 for details. These and other connective tissue and ligamentous bridges were confirmed by subsequent studies and surgeries.

(b) Definition. CGH, rather narrowly defined by the IHS as in Figure 1, received a wider definition from the North American Cervicogenic Headache Society (NAC HS), a multidisciplinary society promoting the study of CGH:

“Referred pain perceived in any region of the head caused by a primary noceceptive source in the musculoskeletal tissues innervated by cervical nerves”.

(c) Research. A systematic review from the respected Duke University Evidence-Based Practice Center in 2001 summarized the research evidence to that time concerning the safety and effectiveness of various physical and behavioral treatments for CGH and TT H. It found that, even on the narrow definition given by the IHS, CGH was one of the most common forms of headache, similar in prevalence to migraine, and that the one physical or behavioral treatment with proven effectiveness was manipulation. Manipulation had two distinct advantages over use of medication – first it targeted the source of pain rather than control of symptoms, and second it was safe with fewer side effects. With respect to TT H, the effectiveness of manipulation was “less clear” because there were only three randomized controlled trials (RCTs), none with a placebo or non-treatment group.

However the trials suggested effectiveness. The largest, by Boline et al. in the US, reported that chiropractic manipulation was superior to amitriptyline in terms of reduced headache frequency and severity [8]. How can manipulation be effective for patients with TT H? That question highlights
the diagnostic and classification difficulties. Some patients diagnosed as having TT H, because they do not fall within the IHS definition of CGH
– perhaps because they have no neck pain or headache provoked by neck movements, nonetheless have spinal joint dysfunctions – also known as subluxation in chiropractic practice.

When these mechanical restrictions are corrected with manipulation, associated muscle tension is resolved. In 2002, the year following the Duke University review, Spine published the first physiotherapy trial of manipulative therapy for patients with CGH. This also reported effectiveness.

Read the complete FULL TEXT Article

This is really a moot conversation, because when they updated the ICD-9 codes last year, they did not bother creating any listing(s) for cervicogenic headache.

There are many more like this at the:
Headache and Chiropractic Page

References:

1 Frykholm R. (1972) Cervical Migraine: The Clinical Picture. In: Hirsch C, Zotterman Y, eds. Cervical Pain. Oxford England: Pergammon Press,
13-16.

2 McCrory DC , Penzien DB et al. (2001)
Evidence report: Behavioral and Physical Treatments for Tension-Type and Cervicogenic Headache
Des Moines, Iowa, Foundation for Chiropractic Education and Research.

3 Kelner M, Hall O, Coulter I (1980) Chiropractors, Do They Help. Fitzhenry and Whiteside, Toronto (Canada).

4 Straton RG, Sweeney J, Grandage J (1990). Review of the Relationship of Chiropractic Services to the Public Health System in Western Australia.
Health Department of Western Australia, Perth, Australia.

5 Nilsson-Grunnet N (2002) Epidemiology of Headache. Eur J Chiropr (49):33-5.

6 Classification and Diagnostic Criteria for Headache Disorder, Cranial Neuralgias and Facial Pain. (1988) IHS Classification Committee, Cephalalgia
8 Suppl 7:1-93.

7 Hack GD, Koritzer RT et al. (1995)
Anatomic Relation Between the Rectus Capitis Posterior Minor Muscle and the Dura Mater.
Spine 20(23):2482-2486.

8 Boline P, Kassak K, Bronfort G, Nelson C, Anderson A (1995)
Spinal Manipulation vs Amitriptyline for the Treatment of Chronic Tension-Type Headaches.
J Manipulative Physiol Ther 1995 (Mar); 18 (3): 148–154.

9 Jull G, Trott P et al. (2002)
A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache.
SPINE (Phila Pa 1976) 2002 (Sep 1); 27 (17): 1835—1843.

10 Sjaastad O, Fredriksson TA (2000) Cervicogenic Headache; Criteria, Classificatin and Epidemiology
Clin Exp Rheumatol 18(Suppl 19):S3-6.

11 Haas M, Spegman A et al. (2010)
Dose Response and Efficacy of Spinal Manipulation for Chronic Cervicogenic Headache: A Pilot Randomized Controlled Trial
Spine J. 2010 (Feb); 10 (2): 117–128

12 Astin JA (1998) Why Patients Use Alternative Medicine: Results of a National Study.
JAMA 279:1548-53.

13 Eisenberg DM, David RB et al. (1998)
Trends in Alternative Medicine Use in the United States, from 1990 to 1997: Results of a Follow-up National Survey
JAMA 1998 (Nov 11); 280 (18): 1569–1575

14 Peterson DH, Bergmann TF (2002) Chiropractic Technique: Principles and Practice. 2nd ed St. Louis, MO: Mosby.

15 Weingarten S, Kleinman M, Elperin L, Larson E (1992) The Effectiveness of Cerebral Imaging in the Diagnosis of Chronic Headaches.
Arch Intern Med 152:2457-2462.

16 Granella F et al. (1987) Drug Abuse In Chronic Headache: A Clinico-epidemiologic Study.
Cephalalgia 7:15-19.

Filed Under: chiropractic, Research

Reflections on the Opportunity of a Lifetime:Interview with Lance Cohen, DC

May 4, 2011 By Frank M.

SOURCE: Health Insights Today

Interview by Daniel Redwood, DC

Dr. Lance Cohen on the job at the
National Naval Medical Center in Bethesda.

Lance Cohen, a 2009 graduate of Cleveland Chiropractic College–Los Angeles (CCCLA), was the first chiropractic student to participate in one of the most prestigious health care fellowships in the nation, at the National Naval Medical Center (NNMC) in Bethesda, MD.

A second generation chiropractor (his father is CCCLA alumnus Dr. Nathan Cohen), Dr. Cohen had the opportunity to work under Dr. Bill Morgan at NNMC, providing care for injured veterans (many of them from the conflicts in Iraq and Afghanistan) at the nation’s premier tertiary care hospital. This experience afforded him unparalleled learning opportunities, which he describes in this Health Insights Today interview. Dr. Cohen now practices in Tahoe City and La Jolla, California.

What first kindled your interest in chiropractic?

My father was a chiropractor for nearly 3 years prior to my birth; chiropractic has always been part of my life. I was one of those kids whose mother received chiropractic care while she was carrying me and I received my first adjustment shortly thereafter. Throughout my younger years I was very active and played lots of sports, so I very quickly became aware of the benefits that chiropractic offered. I clearly remember seeing how grateful my father’s patients were for the improved quality that chiropractic afforded them. That was the deciding factor for me. I remember being about 5 or 6 years old; some children wanted to be firemen, astronauts, or maybe the president of the United States, and I knew that I wanted to be a chiropractor. I wanted to someday be able to emulate my father’s ability to assist others in regaining their health and improving their quality of life.

What is the procedure for determining which chiropractic student is chosen for the fellowship at National Naval Medical Center, Bethesda?

This is a question that I asked many times prior to applying for the program, a question which I still do not know the answer to. I know that the process differs from school to school with regards to candidate selection. After that I’m not sure how the final decision is reached. At Cleveland we were making it up as we went, because the college had never submitted a candidate for consideration. It was my understanding that the program had not been established previously at the college and there had not been a student demand for it in previous years.

That all changed when I made it my mission to create the student demand for the program after hearing one of Dr. Morgan’s interns speak about the program at the National Chiropractic Legislative Conference in Washington, DC. I wasn’t even sure if I wanted to apply for the program, but my father had graduated from CCCLA in 1980 and I felt a great deal of pride as a legacy at the college. I thought that the college was obligated to offer programs like this to students in order to provide a competitive product in today’s market of education. That is when I brought the issue up with Dr. Cleveland III (the college’s President), Dr. Globe (then the Dean/Provost), and Dr. Henry (Clinic Director).

Drs. William Morgan (l.) and Lance Cohen (r.),
with canine companion at the National
Naval Medical Center

The process of establishing the agreement between the Navy and the college was not easy and took over a year from when I brought up the project. I was unrelenting, steadfast and committed to seeing this project through even if I was not going to participate in it. I was convinced that someone at our college (either in Kansas City or Los Angeles) should have the opportunity to at least apply. I was very fortunate to have such a hard working team of faculty and staff at the school; if it wasn’t for their dedication and help this project would have never been brought to fruition.

What were your emotions when you first received word that you had been chosen?

I was in the intern lounge of the college clinic catching up on some paperwork while waiting for a new patient, who was late and I later learned didn’t show up for their appointment, when my mobile phone began to vibrate in my pocket. As I picked it up I didn’t recognize the number or even the area code. I answered the call and to my surprise Dr. Morgan was on the other end. My initial thoughts were that he wanted to ask me some questions about my application. After exchanging salutations and some small talk he asked if I was okay. I responded that I was, and apparently he could sense the surprise and bewilderment in my voice over the phone line.

He then proceeded to tell me that I was highly qualified and that I had studied under some of the greats in our profession and he hoped that I would not be disappointed while working with him at Bethesda. He offered me the position if I wanted to accept and he wanted to know how soon I could begin. I almost fell out of my chair, literally. I am sure that I will not be able to adequately put into words how I felt at that moment, but it was the shock and realization that I had achieved a goal that I had been working for tirelessly for several years. Immediately after that I was overcome with the excitement of the unknown. I knew that my future would have in store some truly incredible experiences during this program, but I couldn’t even begin to remotely conceive what they might be.

What advice would you offer to current students who are considering applying for this fellowship at NNMC?

Talk to your administration and faculty early on in your student career, find out about the program and see if it is something that you would be interested in. Declare your intentions early. This is not the sort of program that you sign up for a couple months in advance. Interns and fellows are usually selected 6 months prior to their start date. Contact interns or fellows who are currently at NNMC and talk to them about their experience, build rapport with Dr. Morgan or Dr. Kearney (both are chiropractors at NNMC). Make arrangements to visit the chiropractic clinic at NNMC. An opportune time to do this is while attending the National Chiropractic Legislative Conference.

Most importantly, be active during your student career, get involved with student associations and organizations, become a leader and actively seek mentorship. Dr. Morgan is not looking to mentor chiropractic students who are going to just go out and be successful. Success in practice should be expected. He is looking to mentor students who will leave NNMC and use what they have learned to change the world, change the way in which chiropractic is integrated and utilized in health care on a national or international level.

Please describe a typical day when you were at NNMC.

During my time at NNMC I would see patients in the chiropractic clinic Monday, Wednesday, and Friday. Typical clinic hours were from 0730 to 1600 hours. Tuesdays and Thursdays I would be on rotations either at NNMC or at Walter Reed Army Medical Center (WRAMC) while Dr. Morgan was staffing the health care clinic at the US Capitol. The hours for my hospital rotations were variable and dependent on the schedule of the respective department that I was assigned to. Some days I would report as early as 0400 hours in order to scrub in on a surgery and there were days when I stayed as late as 2000 hours helping out in the postsurgical wards.

On Wednesday afternoons Dr. Morgan and I would travel to Annapolis to the United States Naval Academy in order to care for the Naval Academy football team and some of the other athletes. This was a very memorable experience. I admired seeing the heart the Naval Academy football team displayed. Most always, their opponents were taller and outweighed them due to military height and weight regulations. The Midshipmen would compensate for this by superior physical conditioning, speed, and determination or heart. It was really a privilege to be a small part of that program.

What did you find most satisfying about your fellowship?

The most satisfying part of the internship was having the honor and privilege to be part of the team that administered care to the brave men and women who have sacrificed so much for our great nation. It was also a great honor to represent the chiropractic profession at the world’s most advanced tertiary care facility. Every time I interacted with another health care provider, legislator, or key government leader I took into account that my actions, interactions and responses were not only viewed as my own but were on behalf of the profession that I was there representing. Most of these people have not had much experience with chiropractors in a professional/clinical setting and I was there to dazzle them. I wanted to be able to answer the questions asked in rounds that the other fellows, residents, intern and med students fell silent on, and many times I did.

What surprised you most while you were there?

I was taken aback by the patients at the hospital and their families, who maintained such positive attitudes during the course of their treatment at the hospital. Some of these brave young men and women suffered what I would consider beyond devastating battle injuries, and through it all they kept hope and maintained high morale and the unrelenting desire to fight a new battle, the battle toward their recovery. This was testament to the undying, unrelenting American spirit upon which our country was founded.

What was the most difficult part of your work there?

The most difficult part of the experience was leaving. I really enjoyed my time at NNMC under the tutelage of Dr. Morgan and some of the country’s finest health care providers. During my time there, I didn’t even think about the difficulty of my charge because I was focused on doing the best job that I was capable of doing. There were long hours and challenges to overcome, yet every night I would find myself lying in bed just before falling asleep reflecting on how incredible and horizon-expanding that particular day had been. This occurred every night that I was at Bethesda.

Looking back, were there things you learned at Bethesda that you would have been unlikely to learn elsewhere?

I could write tomes on this question. Nearly a year after the completion of my time at Bethesda, I am still realizing the extent of what I learned during my time at NNMC. Conservatively, I would venture to say that I gained experiences during my fellowship that one could go several careers or lifetimes without accumulating. The vastness of the experience and knowledge available was unparalleled and I am certain that there is no program that even comes close to offering such experiences.

During your stay in Washington, were there aspects of life there (people you met, places you visited) that were meaningful for you, aside from your work at NNMC?

With regards to the people that I met during my time in Washington, by far the most interesting were people that I met at the hospital. I very much enjoyed hearing their stories. I took some time to visit many of the museums, national monuments and the White House. The most memorable of these was my tour to the top of the Washington Monument and a visit to Mount Vernon, George Washington’s estate.

How well are the chiropractors at NNMC integrated into the overall staff structure? Is there a spirit of cooperation and collaboration?

There are two staff chiropractors at NNMC, Dr. Morgan and Dr. Kearney, and at any given time each of them usually has one intern. There is usually some overlap time to aid in the training process. In the history of the program there have been only two fellows, including myself.

I feel that the chiropractic department is well integrated into the hospital. It is my opinion that this is a result of Dr. Morgan’s effort as the department head seeking out and building relationships with other providers in the hospital who refer patients to the chiropractic clinic. There is, of course, some room for improvement as there is always a constant flow of new providers, some of whom are not yet familiar with chiropractic and are hesitant to refer patients to the service. In the military, every patient is assigned to a Primary Care Manager (PCM). These doctors act as central hubs and coordinate the patient’s care. In order for a patient to see any specialist, including a chiropractor, the patient has to go through their PCM. Likewise, if a specialist wants to refer the patient to another specialty, the provider will communicate that to the PCM and the PCM will make the referral. This system may seem a bit convoluted but is helpful in tracking the overall care of a particular patient.

I was very impressed by how patients were co-managed in the multidisciplinary setting of NNMC. One day I was on rotations in the outpatient physical therapy department and the therapist that I was shadowing performed an exam on a patient who we discovered to have what seemed to be a classic presentation of an S1 radiculopathy. She then asked me to examine the patient so that she could see how a chiropractic exam would differ. Most of what we did was very similar with the exception of the motion palpation and some additional neurologic and orthopedic tests that I performed.

The physical therapist and I both agreed on the diagnosis and both agreed that the patient’s L5 vertebra was fixated. The only main difference was that I was able to determine what particular ranges of motion the L5 segment was limited in. After that the physical therapist laid out the exercises that she recommended that the patient do and asked me if I would do anything else to treat the patient. I was surprised that to learn that the exercises were no different than what I was taught in school and then I said that if I were treating the patient, I would adjust the L5 segment to restore normal motion. At this point she said, “Let’s head across the hall to the chiropractic clinic.” I performed the chiropractic adjustment and we sent the patient on his way. I had never seen this sort of collaboration between physical therapists and chiropractors.

The chiropractic clinic had very close ties with the neurosurgery clinic. Many times they would schedule a patient for surgery and then refer them to us. If the patient was able to show improvement from chiropractic care prior to the surgical date, then they would cancel the surgery. I really enjoyed working with the neurosurgeons in co-managing difficult cases. Members of the chiropractic clinic regularly attended the neurosurgery morning report.

Did you have an opportunity to meet and to work with medical and other students who also had fellowship at NNMC?

I had the privilege to work with a number of med students, PT students, residents, interns and fellows. I felt that I was well received by the majority of the abovementioned personnel, especially in physical therapy clinic a the pain clinic. I still keep in touch with some of these connections.

What are you doing these days and what are your plans for the future?

After completing my time at NNMC, I took a month long road trip back to the West Coast with my best friend, logging about 5000 miles (60 of which were spent backpacking through Utah). After reaching San Diego, I entered practice with my father, Dr. Nathan E. Cohen. He and I currently work together out of our offices in Tahoe City and La Jolla, CA. With regards to plans for the future, my short term plans include creating a lot of change to our practice. I have been pushing our team to develop greater branding; we are in the process of converting to an electronic health record system and improving our business practices while still striving to provide world class care to our patients. My intermediate and long term goals include working with college and professional level athletics programs and establishing chiropractic care within local hospitals here in the San Diego area.

Daniel Redwood, DC, the interviewer, is a Professor at Cleveland Chiropractic College–Kansas City. He is the Editor-in-Chief of Health Insights Today and The Daily HIT, and serves on the editorial boards of the Journal of the American Chiropractic Association, Journal of Alternative and Complementary Medicine, and Topics in Integrative Healthcare.

Filed Under: chiropractic, News

DEEP THOUGHTS: The Joy of Life

May 2, 2011 By Frank M.

“This is the joy of life, the being used up for a purpose recognized by yourself as a mighty one: being a force of nature instead of a feverish, selfish little clod of ailments and grievances, complaining that the world will not devote itself to making you happy.

I am of the opinion that my life belongs to the community, and as long as I live, it is my privilege to do for it whatever I can.

I want to be thoroughly used up when I die, for the harder I work, the more I live. Life is no “brief candle” to me. It is sort of a splendid torch which I have got hold of for a moment, and I want to make it burn as brightly as possible before handing it on to future generations.”

~ George Bernard Shaw

If you enjoyed this, then visit
The THOUGHT for Today Page

Filed Under: chiropractic

The Issue That Just Won’t Go AwayVaccines and Autism: A New Scientific Review

May 2, 2011 By Frank M.

SOURCE: CBS News Investigates

By Sharyl Attkisson

For all those who’ve declared the autism-vaccine debate over – a new scientific review begs to differ. It considers a host of peer-reviewed, published theories that show possible connections between vaccines and autism.

The article in the Journal of Immunotoxicology is entitled “Theoretical aspects of autism: Causes–A review.” [1] The author is Helen Ratajczak, surprisingly herself a former senior scientist at a pharmaceutical firm. Ratajczak did what nobody else apparently has bothered to do: she reviewed the body of published science since autism was first described in 1943. Not just one theory suggested by research such as the role of MMR shots, or the mercury preservative thimerosal; but all of them.

Ratajczak’s article states, in part, that “Documented causes of autism include genetic mutations and/or deletions, viral infections, and encephalitis following vaccination [emphasis added]. Therefore, autism is the result of genetic defects and/or inflammation of the brain.”

The article goes on to discuss many potential vaccine-related culprits, including the increasing number of vaccines given in a short period of time. “What I have published is highly concentrated on hypersensitivity, Ratajczak told us in an interview, “the body’s immune system being thrown out of balance.”

University of Pennsylvania’s Dr. Brian Strom, who has served on Institute of Medicine panels advising the government on vaccine safety says the prevailing medical opinion is that vaccines are scientifically linked to encephalopathy (brain damage), but not scientifically linked to autism. As for Ratajczak’s review, he told us he doesn’t find it remarkable. “This is a review of theories. Science is based on facts. To draw conclusions on effects of an exposure on people, you need data on people. The data on people do not support that there is a relationship. As such, any speculation about an explanation for a (non-existing) relationship is irrelevant.”

Ratajczak also looks at a factor that hasn’t been widely discussed: human DNA contained in vaccines. That’s right, human DNA. Ratajczak reports that about the same time vaccine makers took most thimerosal out of most vaccines (with the exception of flu shots which still widely contain thimerosal), they began making some vaccines using human tissue. Ratajczak says human tissue is currently used in 23 vaccines. She discusses the increase in autism incidences corresponding with the introduction of human DNA to MMR vaccine, and suggests the two could be linked. Ratajczak also says an additional increased spike in autism occurred in 1995 when chicken pox vaccine was grown in human fetal tissue.

Why could human DNA potentially cause brain damage? The way Ratajczak explained it to me: “Because it’s human DNA and recipients are humans, there’s homologous recombinaltion tiniker. That DNA is incorporated into the host DNA. Now it’s changed, altered self and body kills it. Where is this most expressed? The neurons of the brain. Now you have body killing the brain cells and it’s an ongoing inflammation. It doesn’t stop, it continues through the life of that individual.”

Dr. Strom said he was unaware that human DNA was contained in vaccines but told us, “It does not matter…Even if human DNA were then found in vaccines, it does not mean that they cause autism.” Ratajczak agrees that nobody has proven DNA causes autism; but argues nobody has shown the opposite, and scientifically, the case is still open.

A number of independent scientists have said they’ve been subjected to orchestrated campaigns to discredit them when their research exposed vaccine safety issues, especially if it veered into the topic of autism. We asked Ratajczak how she came to research the controversial topic. She told us that for years while working in the pharmaceutical industry, she was restricted as to what she was allowed to publish. “I’m retired now,” she told CBS News. “I can write what I want.”

We wanted to see if the CDC wished to challenge Ratajczak’s review, since many government officials and scientists have implied that theories linking vaccines to autism have been disproven, and Ratajczak states that research shows otherwise. CDC officials told us that “comprehensive review by CDC…would take quite a bit of time.” In the meantime, CDC provided these links:

Interagency Autism Coordination Committee: http://iacc.hhs.gov

Overview of all CDC surveillance and epi work: http://www.cdc.gov/ncbddd/autism/research.html

CDC study on risk factors and causes: http://www.cdc.gov/ncbddd/autism/seed.html

REFERENCES:

1. Theoretical Aspects of Autism: Causes– A Review
J Immunotoxicol. 2011 (Jan-Mar); 8 (1): 68-79

2. Theoretical Aspects of Autism: Biomarkers– A Review
J Immunotoxicol. 2011 (Jan-Mar); 8 (1): 80-94

Filed Under: chiropractic

Immune Responses to Spinal Manipulation

May 1, 2011 By Frank M.

SOURCE: Dynamic Chiropractic ~ May 6, 2011

There are more articles like this in our:
Chiropractic and Immune Function Page

By Malik Slosberg, DC, MS

For many years, chiropractors have observed in their own practices that their patients sometimes demonstrate improvements of complaints related to immune problems: the disappearance or lessening of allergy symptoms, quicker recovery from or less frequent and severe colds and other respiratory infections, and so on.

In the scientific literature, there have been occasional case reports that corroborate such findings, but no sound evidence to really document their veracity. These clinical observations remain suspended in that grey area unsubstantiated by scientific data to confirm their validity. Significant limitations of changes attributed to spinal manipulation in individual patients include
1) there is never a control group;
2) there is no blinding;
3) the improvement may simply be due to time;
4) they may be a nonspecific effect of care and attention;
5) it may be a regression to the mean; or
6) the result may be due to something other than spinal manipulation.

In some large studies, it has been found that chiropractic care for nonmusculoskeletal conditions is only weakly to moderately successful, but rarely harmful. [1-2] The most recent and thorough systematic literature review found that the evidence for effectiveness of spinal manipulation was inconclusive for nonmusculoskeletal conditions. [3]

Despite the lack of evidence of clinical effectiveness for nonmusculoskeletal conditions, a series of recent studies from several international research groups is systematically building the case that spinal manipulation appears to reduce the production of pro-inflammatory cytokines and increase the blood levels of immunoregulatory cytokines. Cytokines are small cell-signaling protein molecules that are secreted by numerous cells of the immune system and are a category of signaling molecules used extensively in intercellular communication.

The accumulation of data from these studies suggests that a possible benefit of spinal manipulation is related to neuroimmunological effects. Of course, this is an exciting proposition for clinicians who have seen such changes in their own patients. Let’s review some of the research exploring the connections between spinal manipulation and functional changes in the immune system.

Early Research on Manipulation and the Immune System

Research in the 1990s laid the groundwork for the more recent papers published in the past five years. Brennan, et al., [4] published a paper demonstrating that upper thoracic spinal manipulation resulted in markers indicating significant increased phagocytic activity of neutrophils and monocytes compared to a sham manipulation or soft-tissue treatment. The findings suggest that a certain force threshold was needed to elicit the response.

In a second study, Brennan, et al., [5] concluded that their data suggests spinal manipulation, which generates a force over a certain threshold, elicits viscerosomatic responses that affect both neutrophils and mononuclear cells phagocytic activity, at least over the short term. And in a very small 1994 study, [6] the study authors concluded that upper cervical adjustments increased CD4 “helper” T-cell counts, which initiate the body’s response to viruses in HIV-positive subjects, by 48 percent over the six-month duration of the study.

Neural immunoregulation: Communication Between the Immune and Nervous Systems

These earlier papers have now been followed-up by a series of recent studies within the past five years. Teodorczyk-Injeyan, et al., [7] described the interplay between the nervous system and immune system as neural immunoregulation. The authors note that immune homeostasis is based on the reciprocal communication between the immune and the nervous systems executed by the actions of cytokines and neurotransmitters. In addition, the paper explains the close association of autonomic nerve terminals with macrophages and lymphocytes, which facilitates a chemically mediated transmission between nerves and immune cells.

This research group has published a series of papers that explores the relationship of spinal manipulation, spinoautonomic reflexes and their influence on activity of cells involved in immune and/or inflammatory responses. These interconnections may have great clinical relevance because studies [8] on the pathophysiology of discogenic low back pain, sciatica, and ligamentous tissue damage-related pain [9] reveal that the production of pro-inflammatory mediators, such as tumor necrosis factor alpha (TNF-a) and interleukin-1 beta (IL-1ß), are major factors in the genesis of pain and functional changes in neural activity. Furthermore, studies of the hypoalgesic effects of spinal manipulation have already been reported in the literature, suggesting that an anti-inflammatory mechanism might be activated by spinal manipulation. [10-11] Recent clinical studies have shown that chemical blockage of TNF-a is highly effective in reducing sciatic pain. [12]

Reduced Pro-Inflammatory Cytokines After Spinal Manipulation

In the first of their studies, the authors report that a single bilateral hypothenar upper-thoracic HVLA thrust resulted in the reduction of in vitro inflammatory cytokines, TNF-a and IL-1ß in blood samples activated with lipopolysaccharide taken before, 20 minutes and two hours after spinal manipulation. TNF-a and IL-1ß significantly declined in asymptomatic subjects assigned to manipulation with cavitation/audible, whereas in the sham and control groups, TNF-a and IL-1ß levels increased significantly after exposure to lipopolysaccharide.

The paper’s conclusion states that manipulation-related down-regulation of inflammatory-type responses occurred via an unknown central mechanism. These findings suggest that a single thoracic manipulation effectively ameliorates the physiological responses of blood cells to an inflammatory stimulus and that spinovisceral reflex effects may alter the functional activity of cells in the immune and/or inflammatory systems. Based on these findings, the paper notes that spinal manipulation is likely to present a noninvasive and efficacious alternative to drug therapies for reducing inflammation and resultant pain.

A 2009 paper from the Hungarian National Institute for Rheumatology and Physiotherapy [13] reported a dramatic and significant reduction in both debilitating cervicogenic headaches (before treatment 3-6 times a week lasting a total of 31-36 hours a week), neck stiffness and TNF-a after manual therapy in two women who suffered post-whiplash, MRI-documented C4-5 disc herniation.

Previous trials of conservative care (analgesic infusions, physical therapy) had failed. Both patients, after a neurological consult, were recommended to have a discectomy, but both opted for a trial of manual therapy (two times a week for 4-8 weeks) first. After manual therapy, surgery was unnecessary because both women became headache-free with a normal range of cervical motion. In addition, both patients experienced a dramatic reduction in TNF-a (reduced by more than half). [13]

The medical researchers conclude that pro-inflammatory substances secreted by the nucleus pulposus are likely involved in symp-tomatic disc herniation. In addition, TNF-a, interleukin-1ß and interleukin-10 may be involved in the pathogenesis of migraine at-tacks. After restoring spinal segmental motion and reducing pathologic mechanical irritation/compression, TNF-a levels were mark-edly reduced and symptoms were eliminated. In 2010, Roy, [14] et al., followed up these two studies by evaluating pre- and post-intervention measures from blood samples detecting pro-inflammatory cytokines interleukin 6 (IL-6) and C-reactive protein (CRP) after a series of nine chiropractic manipulations from T12-L5 using the an adjusting instrument and related protocol in 10 chronic low back pain patients and 10 healthy subjects. Once again, the introduction notes that low back pain is often associated with an inflammatory process and increased production of several pro-inflammatory cytokines including IL-6 and CRP. IL-6 is the main mediator of the acute phase of pro-inflammatory cytokines and results in a marked increase in liver cell synthesis of CRP.

This trial found that a series of nine thoracic manipulations resulted in a reduction of both IL-6 and CRP; that is, a normalization response. Both IL-6 and CRP levels were reduced toward the values in the healthy subjects. IL-6 and CRP were elevated in chronic LBP patients pre-intervention, but post-intervention differences were smaller, suggesting that nine manipulations are capable of attenuating the inflammatory response. The authors opine that it is plausible the inflammatory process was being reversed in those who received the adjustments.

Immunoregulation, Interleukin 2 and Spinal Manipulation

Another related avenue of research on neural immunoregulation evaluates the effects of spinal manipulation on the production of interleukin 2 (IL-2) – an immunoregulatory (not pro-inflammatory) cytokine and signaling molecule, instrumental in the body’s response to microbial infection and for the body’s ability to discriminate between foreign (non-self) and self. IL-2 is a pivotal cytokine in T-cell-dependent immune responses and plays a major role in the development, maintenance and survival of regulatory T cells. Thus, it is of critical importance in induction and sustenance of immune tolerance.

Seventy-six asymptomatic subjects [15] were randomized to receive an upper thoracic manipulation with cavitation or without cavitation, or were included in a control group. All subjects had their blood drawn before, 20 minutes and two hours after the intervention. Production of IL-2 in mononuclear cell cultures was activated with staphylococcal protein A (SPA). Induced secretion of IL-2 increased significantly in manipulation with and without cavitation. The paper concludes that in vitro T lymphocyte response to a SPA stimulus became enhanced after spinal manipulation. Therefore, this effect may be independent of joint cavitation/audible. This finding suggests manipulation may influence IL-2 immune-regulated biological responses.

In 2010, Teodorczyk-Injeyan, et al., [16] continued with this research on induction and regulation of immune responses related to interactions between the immune and nervous systems mediated by actions of neurotransmitters and immunoregulatory cytokines. To this end, the researchers followed the subjects from the previous study to determine if the increased production of interleukin-2 as a result of a single thoracic manipulation is associated with increased antibody synthesis from monocytes.

The paper reports that there were indeed significantly increased synthesis of immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies induced in cultures of peripheral blood mononuclear cells in subjects who received thoracic manipulation, particularly in those who had an associated cavitation. The paper concludes that antibody synthesis (IgG and IgM) induced by interleukin-2 can be, at least temporarily, increased after manipulation. This is additional direct evidence that thoracic manipulation may influence interleukin-2 immune-regulated biological responses.

The Take-Home Message

The studies described above demonstrate an accumulation of evidence that indicates spinal manipulation may influence the immune system’s response to various stimuli. Three of the studies suggest that manipulation consistently reduced the production of pro-inflammatory mediators associated with tissue damage and pain from articular structures. Two studies provide evidence that manipulation consistently reduced the production of pro-inflammatory mediators associated with tissue damage and pain from articular structures. Two studies provide evidence that manipulation may induce and enhance production of the immunoregulatory cytokine IL-2 and the production of immunoglobulins as well.

We must acknowledge that these results are preliminary because most are performed on asymptomatic subjects and the duration of the effects so far have only been demonstrated to be short-lived. Nevertheless, this research opens the door to further exploration of the possible neuroimmunoregulatory effects of spinal manipulation and confirms what many of us have observed in practice: Adjustments reduce pain and inflammation, and may improve immunoregulatory function.

References

1. Leboeuf-Yde C, et al. Self-reported nonmusculoskeletal responses to chiropractic intervention: a multination survey.
JMPT, 2005;28(5):294-302.

2. Leboeuf-Yde C, et al. The types and frequencies of improved nonmusculoskeletal symptoms reported after chiropractic SMT.
JMPT, 1999;22(9):559-64.

3. Bronfort G, Haas M, Evans R, Leiniger B, Triano J. Effectiveness of manual therapies: the UK evidence report.
Chiropr Osteopat, 2010;18:3.

4. Brennan PC, et al. Enhanced Phagocytic Cell Respiratory Burst Induced by Spinal Manipulation: Potential Role of Substance P
J Manipulative Physiol Ther 1991 (Sep); 14 (7): 399–408.

5. Brennan PC, et al. Enhanced Neutrophil Respiratory Burst as a Biological Marker for Manipulation Forces: Duration of the Effect and Association with Substance P and Tumor Necrosis Factor
J Manipulative Physiol Ther 1992 (Feb); 15 (2): 83–89

6. Selano JL. The Effects of Specific Upper Cervical Adjustments on the CD4 Counts of HIV Positive Patients
Chiro Res J 1994; 3 (1): 32–39

7. Teodorczyk-Injeyan JA, et al. Spinal Manipulative Therapy Reduces Inflammatory Cytokines but Not Substance P Production in Normal Subjects
J Manipulative Physiol Ther 2006 (Jan); 29 (1): 14–21

8. Fiorentino PM, Tallents RH, Miller J-nH. Spinal interleukin-1B in a mouse model of arthritis and joint pain.
Arthritis Rheum, 2008;58:3100-9.

9. King K, Davidson B, Zhou BE, Lu Y, Solomonow M. High magnitude cyclic load triggers inflammatory response in lumbar ligaments.
Clin Biomech, 2009;25:792-98.

10. Terrett Ac VH. Manipulation and pain tolerance.
Am J Phy Med, 1984;63:217-25.

11. Giles LG, Muller R. Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation
Spine 2003 (Jul 15); 28 (14): 1490–1502

12. Mohammadian P, Gonsalves A, Tsai C, Hummel T, Carpenter T. Areas of capsaicin-induced secondary hyperalgesia and allodynia are reduced by a single chiropractic adjustment: a preliminary study.
J Manipulative Physiol Ther. 2004 (Jul); 27 (6): 381-7

13. Omos G, MD, et al. Reduction in high blood TNF-a levels after manipulative therapy in 2 cervicogenic headache patients.
J Manipulative Physiol Ther. 2009 (Sep); 32 (7): 586-91

14. Roy RA, Boucher JP, Comtois AS. Inflammatory response following a short-term course of chiropractic treatment in subjects with and without chronic low back pain.
Journal of Chiropractic Medicine, 2010 (Sep);9 (3): 107-114.

15. Teodorczyk-Injeyan JA, Injeyan HS, McGregor M, et al. Enhancement of in vitro interleukin-2 production in normal subjects following a single spinal manipulative treatment. Chiropr Osteopat, 2008;16:5.

16. Teodorczyk-Injeyan JA, et al. Interleukin-2 regulated in vitro antibody production following a single spinal manipulative treatment in normal subjects.
Chiropr Osteopat, 2010;18:26.

Dr. Malik Slosberg, a 1981 valedictorian of Life Chiropractic College, has been in private practice for 25 years. He also holds a master’s of science degree (clinical counseling) from California State University, Hayward and a physician’s assistant degree from Dartmouth College. Dr. Slosberg has served on the postgraduate faculty of 10 chiropractic colleges and is currently a professor at Life Chiropractic College West.

Dr. Slosberg lectures throughout the United States and internationally. He has also written numerous articles that have been published in chiropractic journals, and produced educational materials including videos, wall charts and patient handouts used by many chiropractic colleges and thousands of chiropractors throughout the world.

Dr. Slosberg is a founding board member of the National Institute of Chiropractic Research, a funding agency for chiropractic research.

Filed Under: chiropractic, Research

Who’s Asleep Over at MedScape?

April 27, 2011 By Frank M.

In general, I find the reporting at MedScape to be top notch, but I have significant problems with their 4-20-11 essay titled: “The Potential Complications of Chiropractic Therapy”.

Answer this question:

If I sneeze, and there is a car accident across the street,
have we discovered the *cause* of car accidents?

The scientific method would propose that we sneeze a hundred times, and count the car accidents.

That’s how you begin to determine if there is an actual relationship between one event (like drinking milk) and it’s potential consequences (like developing cancer).

The Bone and Joint Decade Task Force was appointed by the World Health Organization (WHO) to look at the causes of, and treatments for neck pain, and after years of review, they published their results in the prestigious Spine Journal. One of the most relevant articles (to this conversation) was titled:

“Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-based Case-control and Case-crossover Study”
Spine 2008 (Feb 15); 33 (4 Suppl): S176–183

CONCLUSION: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke.

This Blog (and our website in general) has published regularly on this topic:

WARNING: Conducting an Orchestra Can Cause Vertebral Artery Dissection and Stroke
http://www.chiro.org/wordpress/?p=5005

If Not Chiropractic Care, Then What’s Your Alternative?
http://www.chiro.org/wordpress/?p=3671

Do You Still Beat Your Wife?
http://www.chiro.org/wordpress/?p=3658

Chiropractic and Stroke Incidence
http://www.chiro.org/wordpress/?p=1769

Respected Researcher Validates Chiropractic Standard of Care and Safety
http://www.chiro.org/wordpress/?p=1721

We also have access to an interview with the author himself:

Podcast Interview with J. David Cassidy: No Increased Risk of Stroke With Chiropractic
http://www.chiro.org/wordpress/?p=4963

This interview, with author, researcher and epidemiologist J David Cassidy, DC, DrMedSc, PhD, should quell the fears of even the most vehement critics who would normally carry on on by mis-quoting, ignoring, or twisting the existing scientific literature to suit their pre-conceived notions and biases.

The Stroke and Chiropractic Page has been online since early 1996, compiling the literature which documents how chiropractic care has been mis-labeled as the “proximal event” in reported cases of vertebral artery injury.

Most telling is Terrett’s seminal work Misuse of the Literature by Medical Authors in Discussing Spinal Manipulative Therapy Injury, which clearly demonstrates that many of the reported injuries ascribed to chiropractic actually occurred following care provided by MDs, PTs and even hair-dressers, even though the authors of those works knew the truth. Where I come from, that’s called bald-faced lying, not *misuse*.

The unadorned FACT is that there is ZERO scientific evidence that a chiropractic adjustment has EVER *caused* a stroke. None.

I hope the Editors at MedScape will publish a retraction and apology, while explaining how and why they missed mentioning the results published by the Spinal Task Force.

Filed Under: chiropractic, News

The Evidence-based Rap, orWhat’s Wrong With My Pain Meds?

April 23, 2011 By Frank M.

Editorial Commentary:

Based on: “A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain ”
Eur Spine J. 2011 (Jan); 20 (1): 40–50 ~ FULL TEXT

OK, maybe this isn’t a genuine Rap, and I’m not rhyming-Simon, but somebody needs to bust-a-cap on the pain-med industry, because they hold themselves to a much lower standard than they expect my profession to maintain.

Fortunately (and, to the rescue) comes this study from the Dutch Institute for Health Care Improvement. They actually busted the cap, by deciding to explore “the effectiveness of pharmacological interventions [i.e., non-steroid anti-inflammatory drugs (NSAIDs), muscle relaxants, antidepressants, and opioids] for non-specific chronic low-back pain (LBP)”.

I say Bravo, because these drugs are medicine’s sole conservative approach for managing LBP. This Blog has previously published numerous (and recent) studies suggesting that chiropractic management for low back pain is orders of magnitude more effective for pain relief, and is also significantly more cost-effective than standard medical management. [1-8]

Now this study comes along challenging the benefits and effectiveness of medicine’s reliance on drug treatments for pain management. The Iatrogenic Injury Page [9] clearly documents the dangers associated with these drugs (primarily death). This current study reviewed 17 randomized controlled trials for pain treatments: NSAIDs (n = 4), antidepressants (n = 5), and opioids (n = 8). No studies were found for muscle relaxants.

They concluded that NSAIDs and opioids “seem to lead to a somewhat higher relief in pain on the short term, as compared to placebo” (aka no treatment at all!), “in patients with non-specific chronic low back pain and that both types of medication show more adverse effects than placebo”. (What an elegant understatement that is!)

Review of the Iatrogenic Injury Page reveals that thousand die ever year from the use of NSAIDs for simple pain relief, and overdose deaths from prescribed opiates has doubled in the last 2 decades. [10] And yet we don’t see the headlines screaming about how this medicine is killing patients by the tens of thousands. Who is asleep at the wheel?
When will the madness stop???

The current healthcare debate has brought up basic questions about how medicine should work. On one hand we have the medical establishment with its enormous cadre of M.D.s, medical schools, big pharma, and incredibly expensive hospital care. On the other we have the semi-condoned field of alternative medicine that attracts millions of patients a year and embraces literally thousands of treatment modalities not taught in medical school.

One side, mainstream medicine, promotes the notion that it alone should be considered “real” medicine, but more and more this claim is being exposed as an officially sanctioned myth. When scientific minds turn to tackling the complex business of healing the sick, they simultaneously warn us that it’s dangerous and foolish to look at integrative medicine, complementary and alternative medicine, or God forbid, indigenous medicine for answers. Because these other modalities are enormously popular, mainstream medicine has made a few grudging concessions to the placebo effect, natural herbal remedies, and acupuncture over the years. But M.D.s are still taught that other approaches are risky and inferior to their own training; they insist, year after year, that all we need are science-based procedures and the huge spectrum of drugs upon which modern medicine depends. [11] And now, even that claim is eroding.

REFERENCES:

1. New LBP Study Reveals Chiropractic Is Superior to PT and MD Care
Chiro.Org Blog ~ 3-17-2011

2. Chiropractic Cost-Effectiveness
Chiro.Org Blog ~ 3-16-2011

3. Chiropractic Goes To The Hospital
Chiro.Org Blog ~ 3-06-2011

4. Chiropractic Treatment of Workers’ Compensation Claimants in the State of Texas
Chiro.Org Blog ~ 2-24-2011

5. New Study Confirms That Maintenance Care Delivers!
Chiro.Org Blog ~ 1-26-2011

6. Primary Care MDs Decline Training In Pain Management
Chiro.Org Blog ~ 1-20-2011

7. The Cost-Effectiveness of Chiropractic Page

8. Patient Satisfaction With Chiropractic Page

9. The Iatrogenic Injury Page

10. Painkiller Deaths Double in Ontario
Chiro.Org Blog ~ 12-08-2009

11. The Mythology Of Evidence-Based Medicine
Chiro.Org Blog ~ 2-25-2011

Filed Under: chiropractic, Research

Happy Easter from Chiro.Org!

April 22, 2011 By Frank M.

Filed Under: chiropractic

Landmark Legislation Passes In The Texas Senate

April 20, 2011 By Frank M.

SOURCE: Texas Journal of Chiropractic

The Texas Chiropractic Association reports that on Thursday, April 14, 2011, the Texas Senate passed Senate Bill 1001. Says the Texas Chiropractic Association:

“This landmark legislation is significant for two reasons: It allows chiropractors to form professional associations with medical doctors, and it ensures that chiropractors will be treated fairly by insurance companies that decide to cover services that can legally be provided by chiropractors and other types of practitioners. …We have been trying to pass this type of legislation for more than 20 years.”

The Senate Journal reflects that “Senator Carona offered the following amendment to the bill”: These amendments include:

“A COLLABORATION BETWEEN PHYSICIANS AND CHIROPRACTORS. a person licensed under Subtitle B, Title 3, and a person licensed under Chapter 201 are authorized to: (1) collaborate with each other in providing services to a client ….”

Title 3 is the Health Professions portion of the Occupations Code.
Subtitle B relates to Physicians.
Chapter 201 of Subtitle C relates to Chiropractors.

“ASSOCIATIONS. (a) a person licensed under Subtitle B, Title 3, and a person licensed under Chapter 201 of this code may form a partnership, professional association, or professional limited liability company according to the requirements of this section and any other applicable law.

(b) When persons licensed under Chapter 201 of this code form a professional entity with persons licensed under Subtitle B, Title 3 of this code, as provided by this section, the authority of each practitioner is limited by that practitioner’s scope of practice, and a practitioner may not exercise control over another practitioner’s clinical authority granted by the other practitioner’s license, either through agreements, bylaws, directives, financial incentives, or other arrangements that would assert control over treatment decisions made by the practitioner.

(c) The state agencies exercising regulatory control over professions to which this section applies continue to exercise regulatory authority over their respective licenses.

(d) A person licensed under Subtitle B, Title 3 of this code, who forms a professional entity under this section shall report the formation of the entity and any material change in agreements, bylaws, directives, financial incentives, or other arrangements related to the operation of the entity to the Texas Medical Board no later than the 30th day after the entity is formed or the material change is made.”

“If physical modalities and procedures are covered services under a health benefit plan and within the scope of the license of a chiropractor and one or more other type of practitioner, a health benefit issuer may not: (1) deny payment or reimbursement for physical modalities and procedures provided by a chiropractor if: (A) the chiropractor provides the modalities and procedures in strict compliance with laws and rules relating to a chiropractor’s license; and (B) the health benefit plan issuer allows payment or reimbursement for the same physical modalities and procedures performed by another type of practitioner; (2) make payment or reimbursement for particular covered physical modalities and procedures within the scope of a chiropractor’s practice contingent on treatment or examination by a practitioner that is not a chiropractor; or (3) establish other limitations on the provision of covered physical modalities and procedures that would prohibit a covered person from seeking the covered physical modalities and procedures from a chiropractor to the same extent that the covered person may obtain covered physical modalities and procedures from another type of practitioner.”

The amendment was adopted, the Senate Journal reports, with “all members … deemed to have voted ‘Yea’” with the exception of one absent-excused Senator. The bill passed to the third reading by a vote of 30 yeas and 0 nays. On final reading the bill passed the Senate 30 to 0 with one senator excused-absent.

The TCA reports that “Dallas state Sen. John Carona deserves our thanks and praise for successfully guiding SB 1001 through the Senate. … SB 1001 now goes to the Texas House, where it must also be approved.”

Review the text of the final Senate Bill 1001

The House is noted as having received the bill from the Senate on April 15, 2011.

Filed Under: chiropractic, News

Advising on Prevention in Chiropractic: A Look at Public Health Promotion

April 19, 2011 By Frank M.

Advising on Prevention in Chiropractic:
A Look at Public Health Promotion and Health Behavior Theory Used in Clinical Education Settings

SOURCE: Topics in Integrative Health Care 2011: 2 (1)

There are more articles like this at the:
Health Promotion & Wellness Page

Harrison Ndetan, M.Sc., MPH, DrPH, Michael Ramcharan, DC, Marion Willard Evans, Jr., DC, PhD, MCHES, CWP

The Abstract:

Chiropractic care is among the more commonly used Complementary and Alternative Medical (CAM) therapies. Spinal co-morbidities include many of the most common causes of premature death and disability. Health promotion and disease prevention have been used in the profession and taught in educational settings but not yet fully embraced in usual practice. This manuscript reviews areas in which health promotion has been emphasized in chiropractic education along with instances in which health behavior theories (HBTs) have been applied. Chiropractic clinical and educational programs should consider application of HBTs to move clinicians and interns forward regarding better advising roles with patients related to prevention and health promotion.

Introduction

The actual causes of death in the United States include many chronic diseases that are attributable to modifiable behavioral risk factors such as tobacco use, physical inactivity or sedentary lifestyle, alcohol consumption, poor nutrition or eating habits. [1] An increased emphasis on prevention, health promotion (HP), and education has been recommended for decades but has failed to reduce many of the threats related to premature morbidity and mortality. [2,3] Complementary and alternative medicine (CAM) use has also increased; in many cases aimed at chronic disease management. [4-7]

Chiropractic care is one of the most frequently used professional CAM health care systems in the U.S. [4,5,7] Musculoskeletal conditions such as low back and neck pain, which are among the most common reasons patients visit medical physicians in the U.S., [8] are also among the conditions most frequently treated with chiropractic care. [7-9] The relative efficacy and cost effectiveness of chiropractic and medical care have emerged as important issues in the broader debate on evidence-based healthcare. [10,11]

Chiropractors and health promotion

Chiropractic principles claim to emphasize wellness, prevention and, to a certain degree, health promotion. In addition, chiropractors report providing a substantial portion of prevention and wellness-based care in the U.S. [12-14] Several studies have investigated whether doctors of chiropractic (DCs) perform HP and most report some health educational activities in practice. [14,15] However, the question as to whether chiropractic care influences modifiable risk behavior is largely unanswered, especially from the perspective of the patients.

The Job Analysis of Chiropractic, 2005 reported that the percentage of patients receiving some HP advice ranged from 40% receiving advice on disease prevention to 65% on general physical fitness and exercise. [13] Interestingly, a study by Jamison in Australia gives some indication as to the type of health information DCs are most comfortable providing from a self-reported, self-efficacy perspective. [16] It should be noted that self-efficacy is simply the feeling one can replicate the behavior desired such as advising adequately in this case. Her study suggests that DCs are very comfortable with giving advice on exercise, for instance, but much less comfortable with advice on other “wellness” topics. While 91% said they felt comfortable giving advice on exercise, only 13% felt comfortable giving advice on alcohol use and only 12% regarding substance abuse.

Recent analyses of the National Health Interview Survey indicated that respondents who reported seeing a DC and not a medical physician (MD) in a period of 12 months were more likely to report “heavy drinking” compared to those seeing only an MD [17] and very few stated that they had been advised by their doctors on diet change and weight loss even when they were overweight or obese. However, when advised by either a MD or DC, a majority reported an attempt at compliance. [18] Previous investigation indicates that U.S. medical and chiropractic curricula are deficient in training their students on advising roles in HP, especially smoking cessation. [19-22] HP and health education have been emphasized for years in the field of chiropractic, [15,22-28] but studies do not indicate a wide adoption of HP activities in the profession. [17,18,29-31] However, topics covered recently do include areas such as fall prevention, [32,33] balance, [34-38] domestic violence prevention [39,40] and screening for adverse drug events. [41]

The need for health promotion practice in chiropractic care

The American Chiropractic Association and the Association of Chiropractic Colleges have position statements that encourage HP and preventive efforts related to wellness. [42,43] This is important, since so many acute neck and back pain patients consult DCs and because a minority of medical patients report having been counseled on health-related behavioral change. [44,45] Further, patients who develop chronic spine problems tend to have a higher prevalence of co-morbid health conditions than the general public in aggregate. [46-48] In addition to those indications that spinal patients may need more emphasis on general preventive care, numerous agencies, researchers, and accrediting bodies have called for more prevention and HP education emphasis within the practice of health care delivery. [13,19, 46-48] Limiting morbidity and disability from back conditions is also a focus area under Healthy People guidelines. [3]

According to the Council on Chiropractic Education (CCE):

“Health promotion includes general strategies to enhance quality of life, prevent disease, trauma and illness including ergonomics, psychosocial supports, exercise, diet and nutrition including lifestyle counseling and health screening…” [49]

In January 2006, this new CCE standard for the delivery of HP and wellness went into effect at America’s chiropractic colleges. This included demonstration of the ability to determine how lifestyle, behavior, and other factors affect the wellness of the patient and the demonstration of skills, knowledge, and ability to communicate needs regarding required changes in lifestyle that will be conducive toward better health. [49]

The aim of this report was to review the literature for papers that stressed the use of health promotion, with or without health behavior theories (HBT), and to assess the literature on advising prevention in the chiropractic clinical educational setting. In addition, this report emphasizes the various HBTs and outlines how they may assist in promoting better advising behaviors among clinicians and interns in the clinical education setting.

Methods

The authors searched the literature using PubMed, Google Scholar, ChiroAccess, as well as their personal literature files and reference tracking. Search terms included “chiropractic and health promotion” and “chiropractic and prevention.” The authors restricted the review to papers that included an emphasis on health promotion in the clinical education setting or that used HBT to frame an intervention or educational program.

Results

Only a few studies could be identified within the chiropractic literature documenting HBT-based interventions to improve the practitioner’s behavior towards health promotion. However, additional papers emphasized the need to apply HBT in practice ranging from patient communications [50-52] to promoting health advocacy [53] through use of Ecological Theory (ET), [54] which posits multi-factorial cause for most health problems including social and environmental constructs.

Notable non-theory publications

In 2003 Hawk and colleagues [28] pre and post-tested students’ familiarity with and intention to use key HP concepts, resources, and practice techniques following an educational intervention. The goal of their study was to implement and evaluate a model course on “wellness concepts” for chiropractic students that emphasized national goals and evidence-based practices for HP and prevention. The study was conducted at a chiropractic college and employed teaching methods that included traditional lecture discussions and experiential activities, centered on the Healthy People 2010 objectives. The investigators noted significant increases in students’ self-reported familiarity on key HP concepts. Although slight increases in intent were noted during the education process, statistically significant differences were rare from pre to post intervention evaluations because a majority of the students had predetermined they would use HP at baseline. This study did not attempt to evaluate the actual practice of HP by the students. The authors suggested that didactic methods of teaching HP be integrated into the clinical education, as well as an emphasis on practical application of HP in chiropractic clinical practice.

Hawk and Evans assessed 9 teaching clinics on smoking cessation advising and intake paperwork related to assessment of patient smoking status. [55] Although they assessed for provider cues to take action, they did not mention HBT. Gordon and colleagues proposed a pilot program to focus chiropractors on advising on tobacco cessation. [56] They mention barriers to this process as well as readiness to quit smoking as constructs, but do not specifically cite or mention HBTs.

Killinger proposed HP for older Americans engaged in chiropractic care [57] and although no HBTs were mentioned, she suggested the need for enabling and reinforcing factors as well as the need for the doctor to “cue” patients to take action; both of which are integral parts of HBTs. Globe and colleagues performed two chart reviews to assess the effect of a model program in public health on advising rates. [30-31] Although they did not report measurable differences, and did not mention specific HBTs, they do mention the need to frame messages toward the positive when recommending behavior changes.

Ndetan and colleagues performed random chart reviews at two teaching clinics after the CCE standard went into effect and found some HP activities but noted a fragmented system of recording them and serious gaps in delivery of HP delivery, often indicating patients at risk receiving no HP advice at all on a given visit. [58]

Terre and colleagues authored a selective review of the empirical literature on family violence. [39] This paper discussed integrating the screening and detection of family violence with chiropractic training. The authors held that there is a clear need to translate the didactics of family violence into the clinical setting but made no attempt to design any interventions in this regard. Mertz and a team of investigators assessed various scoliosis screening programs for their use of planning theories or change theories but found none that relied on either of those. [59] Borody and Till reported on a new course on HP modeled after an online course on public health at the Canadian Memorial Chiropractic College. [60] The investigators surveyed students’ perceptions and motivation to study and apply course content in clinical settings before and after the implementation of the new online model course. Their report indicated significant improvements in perceived relevance of HP to chiropractic practice and motivation to learn the material as a foundation for clinical practice. In the short term, the students embraced changes made to the content and delivery of the course based on the online course model, but no mention of HBT is noted.

In 2008 Rose and Ayad published a study on the factors associated with changes in knowledge and attitude toward public health concepts among chiropractic college students enrolled in a community health class. [61] Although this was not an interventional study targeting the HP behavior of chiropractic students, it assessed factors associated with an intervention that was already in place. The intervention was a second-year chiropractic college course in community health. The authors noted that the course had a positive impact on students’ knowledge of and attitudes towards HP and public health concepts, while also eliminating the eminent disparities in these views across gender, race, age, political inclinations and religious beliefs that existed at baseline (before the course was given). However, the investigators noted a certain degree of stigmatization regarding immunization and recommended that additional educational strategies were needed to ensure changes in future practice behavior, particularly in the area of opposing necessary, routine vaccinations. In 2009 Johnson and Green described how DCs could view public health, wellness and prevention within the context of practice by applying best-practices in the clinical setting. [62]

Theory-driven chiropractic interventions

The literature related to the application of health behavior theories in improving the chiropractors’ or chiropractic interns’ behavior regarding HP practice is sparse. Table 1 lists papers or interventions that have utilized specific HBTs. Evans and colleagues published two papers in 2005 and 2006 [63-64] that reported on a theory-based intervention to increase intern and staff advising on smoking cessation at one teaching clinic. In their study, they used methods driven by evidence-based health behavior theories in planning an education campaign (intervention) aimed at improving the behavior of chiropractic interns towards advising their patients on smoking cessation. The overall goal of the study was to move interns from possible lack of awareness related to the need to advise patients, to awareness, agreement with the need to advise, and adopting this as practice, then adhering to smoking cessation counseling as a new behavior. The study was based on Pathman-PRECEDE theoretical framework [65] which, in turn, was constructed after the Green and Krueter’s PRECEDE-PROCEED model. [66] The model was applied in an educational campaign, with focus on identifying the predisposing, reinforcing, and enabling, factors for the new advising behaviors. In this study, Evans and colleagues identified factors that would aid the facilitation and focused on moving interns toward adoption within the PRECEDE-PROCEED model, which was also centered on winning the support of key college stakeholders such as the college president, the clinic chief-of-staff, and the director of research. Their interventions led to the change of vision of the college to include a wellness orientation and the college later became a smoke-free campus.

Table 1. HBT Utilized in Chiropractic Education or Research

Author(s)	Aim of Intervention	Theory or Constructs Cited	Outcome
Evans ⁵⁰	Increase awareness of HBTs with DCs	Message-framing, TTM	N/A
Evans ⁵¹	Increase awareness of HBTs with DCs	HBM, TTM, SLT, ET	N/A
Evans ⁵²	Increase awareness of HBTs with DCs	TTM, Cues to action	N/A
Mertz, Thompson, Green, Wyatt, Akagi ⁵⁹	Assess scoliosis interventions for presence of planning or HBTs	PRECEDE-PROCEED, HBM	No use of HBT noted in review
Hawk, Baird ¹⁹	Pilot project on tobacco advising with DC as audience	Advised doctor cue to action(HBM, SLT)	Advising and doctor cue to action feasible
Hawk, Evans ²²	Assess intake paperwork, patient population for advice given on tobacco cessation, information given in 9 teaching clinics	Assessed doctor cue to action (HBM, SLT)	Fragmented system of record keeping, low level of advising, information
Evans, Hawk, Strasser ⁶²	Education campaign to increase advising and information given to patients on smoking cessation	HBM, SLT, ET	Increased advising rates, increased among of information from pre/post
Evans, Hawk, Boyd ⁶³	Education campaign to increase advising and information given to patients on smoking cessation	As above (Describes intervention in more detail)	As above
Evans, Breshears ⁶⁸	Assessed barriers, knowledge, attitudes toward hand hygiene and table surface sanitizing in teaching clinics	HBM, SLT, ET	N/A
Shearere, Bhandari ⁴⁰	Cross-sectional survey on intimate partner violence	Assessed attitudes, knowledge, beliefs	N/A
Evans, Williams, Perko ⁵³	Increase awareness of advocacy role of DCs	ET	N/A
Evans, Ndetan, Williams ⁷⁰	Cross-sectional survey of future intentions of interns on use of HP in practice	TRA	High level of behavioral intent to use HP in practice
Evans, Ramcharan, Ndetan, et al. ⁷²	Education campaign to increase hand hygiene and table surface sanitizing in 2 teaching clinics	HBM, SLT, ET	Increased observed and reported hand /surface hygiene
Gordon, Istvan, Haas ⁵⁶	Pilot study to increase advising on tobacco by DCs	Doctor cue to action, readiness to change assessed	Patients reported some compliance in pilot
Ndetan, Evans, Lo et al. ⁵⁸	Assessed two teaching clinics for advising on HP by retrospective file review	Assessed intern or staff doctors cues to action	Low levels of cues to action
Leach and Yates⁷⁴	To have DCs encourage better diet and soccer participation by area youths	SLT	Pilot project-could be effective, nutrition knowledge increased

This study applied two health behavior theories within the PRECEDE-PROCEED planning model, and constructs of Bandura’s Social Learning Theory were applied in addressing the self-efficacy of the interns. [67] The theory’s construct of “cue to action” was also emphasized regarding the interns’ ability as health care providers to get their patient to quit smoking as was vicarious learning from staff clinicians who were to model the advisory role behavior.

The second theoretical model they considered as essential to their smoking cessation educational campaign project was the Trans-Theoretical Model (TTM), developed by Prochaska and DiClemente. [68] This model makes reference to 5 stages of susceptibility to health behavior change (stages of change): the pre-contemplation (no idea or intention of changing a behavior); contemplation (actively considering making a change in behavior, perhaps thinking about where to begin); preparation (taking steps to prepare for change); action (taken some action such as date setting, discussing intentions with others, etc); and maintenance (maintaining a new behavior for at least 6 months). The study employed materials and delivery methods developed according to constructs of these health behavior principles. Materials were of two broad classes: instructional materials for interns including an hour Power Point lecture given by the principal investigator; 3″ X 5″ card guiding interns through engagement of patients using the Surgeon General’s 5-A’s; a chart stamp for clinic supervising doctors to track smoking cessation advising done by interns and; informational materials for their patients (campaign buttons for the intern’s clinic jacket, posters placed in each treatment of report room of the outpatient clinic from the CDC, brochure rack at the clinic check-out desk to provide quick and easy access to brochures for patients and resource directory of cessation programs available in the Dallas/Ft. Worth Metroplex). Key to the campaign were the Surgeon General’s 5-A’s which instructed the interns to “ask” all patients about smoking status; “advise” all patients to quit smoking; “assess their willingness to make a quit attempt”; “assist” in any patient cessation effort; and “arrange for follow-up” and set a date to check on the patient. This campaign was a one month campaign and pre-post campaign evaluation of interns advising role on smoking cessation increased by 25% as noted in the literature.

Evans and Breshears [69] tested interns’ attitudes toward hand hygiene and table sanitizing using the Health Belief Model (HBM) [70] to identify barriers to this practice and looked at peer attitudes and knowledge based on ET. [54] Evans, Ndetan and Williams assessed intentions of chiropractic interns regarding use of HP in practice. [71] They applied the Theory of Reasoned Action (TRA) [72] assessing the intentions on use of HP in practice and identify attitudes, beliefs, and other influencing factors of graduating interns along with their feelings about how wellness and HP education was being delivered in a chiropractic college. Constructs of the TRA served to frame 20 survey questions that helped determine what factors in the educational experience of the students might influence use of HP in their future practice. TRA explores health behaviors in relation to intentions, beliefs, and attitudes. It suggests that an essential determinant of behavior is an individual’s behavioral intention. The theory proposes that behavioral action is determined by intentions with an individual’s intention to perform a behavior determined by attitude towards the behavior and normative beliefs.

Evans and a team of researchers at two college campuses pre- and post-tested an education campaign aimed at increasing compliance on hand hygiene and treatment table surface sanitizing utilizing components of the HBM, ET and SLT. [73] This campaign increased both observed and self-reported compliance levels.

A project by Leach and Yates aimed at clinical education could be applied in the education of DCs or in the field. [74] This program applied SLT to develop a model of better nutrition advice and encouragement of physical activity through soccer for combating obesity and overweight in youths. They applied the specific constructs of observational learning, behavioral capability and enhancement of self-efficacy from SLT.

Discussion

The role of theory in planning health interventions

Effective HP and public health intervention programs can have dramatic effects not only on people but on the entire health care system, especially in this era of persistent health care crises (increased mortality/morbidity and burgeoning cost). This can assist patients in maintaining and improving health, reducing disease risks, and managing chronic illnesses which in turn can help reduce health care cost. Such programs have the potential to impact well-being and self-sufficiency at different levels: individuals, families, organizations, and/or communities. [75] Many existing programs target the patient population directly but studies that focus on changing the behavior of health care providers appear to be less common. Yet, these are equally important especially since HP has not been fully embraced by US health care delivery system. It is important to note that not all health programs and initiatives achieve the desired outcomes. A clear understanding of targeted health behaviors and the environmental context in which they occur is crucial. Interventions (planning, implementation, and monitoring) that are theory-driven are likely to be more successful compared to those developed without considerations of a theoretical perspective. [75]

Using theory as a foundation for program planning and development is consistent with the current emphasis on using evidence-based interventions in public health, behavioral medicine, and preventive medicine. Theory presents a systematic way of understanding events or situations and can be applied to a broad variety of situations. Health behavior and health promotion theories (conceptual or theoretical frameworks) draw upon various disciplines, such as psychology, sociology, anthropology, consumer behavior, and marketing. [75] This diversity in perspectives gives planners the tools for moving beyond intuition to design and evaluate health behavior/interventions based on understanding of behavior and help them identify the most suitable target audiences, methods for fostering change, and outcomes for evaluation. Theory can also help to explain the dynamics of health behaviors, including processes for changing them, and the influences of the many forces that affect health behaviors, including social and physical environments. Apart from explaining “why,” “what,” and “how” health problems should be addressed, health theories also help identify which indicators should be monitored and measured during program evaluation.

The success and effectiveness of many interventions depend on using theories and strategies that are appropriate to a situation. Because there is a plethora of health explanatory and change theories, deciding how well a theory or model “fits” a particular situation/issue is usually challenging and requires care and deliberation. In addition to working knowledge of specific theories, familiarity with how they have been applied in the past may also be insightful. Investigators or practitioners who use theory develop a nuanced understanding of realistic program outcomes that drives the planning process.

Extent of application of health behavior theory in changing/assessing HP behavior of future chiropractors

Problems, behaviors, populations, cultures, and contexts of public health practice are broad and varied. As such, no single theory dominates health education and promotion. In the education campaign to improve the cigarette cessation advising role (behavior) of chiropractic interns, Evans and colleagues [63,64] used the PRECEDE-PROCEED model. [66] PRECEDE-PROCEED is not a model aimed at changing individual behavior but rather a planning model that allows health educators and others design effective communications or health promotion efforts in a community. The design by Evans and colleagues is an eloquent testimony of putting theory and practice together by applying both planning and HBTs. The PRECEDE-PROCEED planning model offers a framework for identifying intervention strategies to address factors that are linked to a specific outcome of interest such as a major health risk in a community. It helps develop an intervention program step by step, integrating perhaps multiple theories to explain and address a health problem. Typical steps would include epidemiological, behavioral, educational, environmental, organizational, administrative and policy diagnoses or assessments. A central feature of a comprehensive planning model such as this is resource acquisition and identification of problem-specific scenarios. This was a big part of the design by Evans et al, as the investigators identified that institutional policies, including stakeholders (college president, research director and clinic chief-o-staff) as well as sources of funding were major challenges and marshaled initial efforts in overcoming these perceived barriers. They combined two behavior change theories for greater impact and use them as bases for evaluation.

Bandura’s Social Learning Theory [67] was used to develop a set of assumptions that centered on self-efficacy of the interns as well as the premise of cue-to-action. They went on to test and adjust these while adding more assumptions through the application of the TTM. To a larger extent this was a well designed theory-driven intervention and the result did not only elicit positive behavior changes among the interns but also enacted a policy (a smoke free campus). Although the theory was not mentioned by name, they certainly applied some aspects of the HBM [70] (which also contained the constructs of self-efficacy and the cue-to-action in addition to some constructs on perceived threat and benefits) to their intervention. The overall goal of that project was to move interns from possible lack of awareness to awareness and agreement that they should be advising patients, adopting this as practice, and adhering to smoking cessation counseling as a new behavior. Although TTM which they applied would offer explanations for stages of change it does not guarantee linear changes along a continuum. TTM acknowledges people may experience recidivism. A possible alternative model to this that offers theoretical bases to directly explore and evaluate the stages of change addressed in the study goal is the Stages of the Precaution Adoption Process Model. [76] This model specifies seven distinct stages in the journey from lack of awareness (a focus of the intervention) to adoption and/or maintenance of a behavior.

Another avenue to explore that has been considered to have significant impact in changing behavior is motivational interviewing (MI). [77] This method attempts to get the patient to contemplate the reasoning behind a needed behavior change and to move them toward self-motivated action through guided, empathetic dialogue.

In the theory-driven evaluation of behavioral intention the TRA was reasonably applied as an explanatory theory. It offered explanations on how behavioral intention determines a behavior and how attitudes towards a behavior, subjective norms, and perceived behavioral control influence behavioral intentions. While this model validly explains how the causal web of beliefs, attitudes, and intentions drive behavior there is still a missing piece in the pie: how the presence or lack of enabling, predisposing or reinforcing factors that may make it easier or more difficult to perform the behavior affects perceived behavioral control which can drive behavioral intentions. This missing piece could be addressed by a potential extension of this model to including the Theory of Planned Behavior, [78] especially as it assumes that factors such as culture and social environment influence certain behaviors (an assumption that is implicit in this study). A planning model such as PRECEDE-PROCEED would also aid in filling in those gaps as well.

Non-medical providers and other CAM providers interact with patients on a more frequent basis than physicians and may be more likely to advise positive behavior changes. [79] This aspect of patient care should not be underestimated when helping patients move toward reductions in risky health behaviors.

Conclusion

Included in the health care responsibilities of primary contact practitioners is the requirement that they serve as a relevant information source for their patients when it comes to reducing health risks. Chiropractors may effectively achieve disease intervention and prevention by participating in the health education of their patients. Clinicians should teach and model this educating and advising role. In line with chiropractic philosophy, their perspective should be holistic. In order to minimize intrusion upon the practice of their clinical expertise, health education tools are recommended for use by these practitioners with an HP conscience. Chiropractic has traditionally regarded itself a wellness profession. As prevention and a wellness model of care can be postulated to predict the future growth of this profession, the development of a wellness ethos acceptable within conventional health care is desirable. Thus, there is urgent need to prepare future DCs (current interns) for the role of advising prevention. Emphasis should be placed on providing interns with HP techniques, skills, self-efficacy, and motivation in an effort to prepare them for the challenge of interfacing with an increasingly evidence-based health care system.

Chiropractic researchers or program planners may derive benefits from the application of health behavior theories in designing interventions targeting healthy behavior. In applying theories or adopting models that have been successful in other settings the concept of targeting a population based on shared characteristics or risks and tailoring change messages for improved health outcomes should be seriously considered.

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48. Zhu K, Devine A, Dick IM, Prince RL. Association of back pain frequency with mortality, coronary heart events, mobility and quality of life in elderly women. Spine 2007;32:2010-2018.

49. Council on Chiropractic Education, Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status, January 2006. Scottsdale, AZ: The Council on Chiropractic Education. 2006: 45-47.

50. Evans M. Communicating your health message to patients. J Amer Chiropr Assoc 2004;41(4) 20-23.

51. Evans M. The abc’s of health promotion and disease prevention in chiropractic practice. J Chiropr Med 2003; 2:107-110.

52. Evans M. Health theory and chiropractic practice: what makes your patients tick? J Amer Chiropr Assoc 2003;40(6):42-44.

53. Evans M, Williams, RD, Perko M. Public health advocacy and chiropractic: a guide to helping your community reach its health objectives. J Chiropr Med. 2008;7:71-77.

54. McLeroy KR, Bibeau D, Stecker A, Glanz K. An ecological perspective on health promotion programs. Health Ed Qtrl 1988;15:35-377.

55. Hawk C, Evans M. Does chiropractic clinical training address tobacco use? J Amer Chiropr Assoc 2005; 42(3) 6-13.

56. Gordon JS, Istvan J, Haas M. Tobacco cessation via doctors of chiropractic: results of a feasibility study. Nic Tob Res 2010;12:305-308.

57. Killinger L. Promoting health and wellness in the older patients: chiropractors and the Healthy People 2010 objectives. Top Clin Chiropr 2001:8(4);58-63.

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59. Mertz TA, Thompson MA, Greene L, Wyatt LA, Akagi CG. Adolescent idiopathic scoliosis screening for school, community, and clinical health promotion practice utilizing the PRECEDE-PROCEED model. Chiropr Osteopat 2005,13:25. [ Full-Text Link ]

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61. Rose KA, Ayad S. Factors associated with changes in knowledge and attitude towards public health concepts among chiropractic college students enrolled in a community health class. J Chiropr Educ 2008;22(2):127-37.

62. Johnson C, Green BN. Public health, wellness, prevention and health promotion: considering the role of chiropractic and determinants of health. J Manipulative Physiol Ther 2009;32(6):405-412.

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69. Evans M, Breshears J. Attitudes and behaviors of chiropractic college students on hand sanitizing and treatment table disinfection: results of a pilot survey and focus group. J Am Chiropr Assoc 2007;44(4): 13-23.

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71. Evans M., Ndetan, H., Williams, R. Intentions of chiropractic interns regarding use of health promotion in practice: applying Theory of Reasoned Action to identify attitudes, beliefs and influencing factors. J. Chiro Educ. 2009; 23(1):17-27.

72. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ. Prentice Hall, 1980.

73. Evans M, Ramcharan M, Ndetan H, Floyd R. et al. Hand hygiene and treatment table sanitizing in chiropractic teaching institutions: results of an education intervention to increase compliance. J Manipulative Physiol Ther 2009, 32:469-476.

74. Leach RA, Yates JM. Nutrition and youth soccer for childhood overweight: a pilot novel chiropractic health education intervention. J Manipulative Physiol Ther 2008;31(6):434-441.

75. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice. 4th Ed. San Francisco, CA. Jossey-Bass, 2008.

76. Weinstein ND. The precaution adoption process. Health Psych 1988;7:355-386.

77. Miller WR, Rollnick S. Motivational interviewing: preparing people for change. 2nd Ed. New York, NY. The Guilford Press, 2002.

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Filed Under: chiropractic

Predictors For Success Of Spinal Manipulation For Neck Pain

April 19, 2011 By Frank M.

SOURCE: J Manipulative Physiol Ther. 2011 (Mar); 34 (3): 144–152

This newly published JMPT study attempted to identify those prognostic clinical factors that may potentially identify, a priori, patients with mechanical neck pain who are likely to experience a rapid and successful response to spinal manipulation of the cervical and thoracic spine.

Data from 81 subjects were included in the analysis, of which 50 had experienced a successful outcome (61.7%). Five variables were found to be associated with a positive response:

Initial pain intensity greater than 4.5 points
Cervical extension less than 46°
Hypomobility at T1 vertebra
A negative upper limb tension test [1]
Female sex

Interestingly, if 4 of 5 variables were present in a particular individual, the likelihood of success increased from the average success rate of 61.7% to a whopping 75.4%.

Although there are several limitations within this study, including the limited group size, and the lack of a comparative control group, this study is a sound first step towards developing a clinical prediction formula associated with a rapid and positive response to care.

Guidelines, and the more recent evidence-based care pathways were originally conceived as a method to inform clinicians and improve patient outcomes. There is no question that the excessive cost of American medical care needs to be reined in. There is also no question that third party payers in managed care have been ruthless in establishing rules and procedures based on financial targets, rather than reasonable patient care. Money that should be going to patient care is going to their bloated administration and the managed care owners. Crucial differences in the quality and success of care are being ignored.

In the field of spinal manipulation for example, there are fundamentally different levels of education and skill for different health professions utilizing spinal adjusting. This is apparent from trials such as:

Meade et al., where chiropractors received significantly superior results for back pain patients than did physical therapists, and

Carey et al., where medical doctors, given postgraduate training in spinal manipulation, proved unable to assess and treat back pain patients successfully.

Our website has published extensively about the vast gap between medical and chiropractic skill sets. That is especially evident in the management of low back pain.

You may also want to review our original Practice Guidelines Page and the newer, evidence-based “Best Practice” Initiative Page, because they reflect the evolution in thinking about improving patient care outcomes.

REFERENCES:

1. Upper Limb Neural Tension and Seated Slump Tests: The False Positive Rate among Healthy Young Adults without Cervical or Lumbar Symptoms
J Man Manip Ther. 2009; 17 (3): e104-105

A recent trial, involving healthy young adults with no history of cervical, lumbar, or peripheral symptoms, revealed a false-positive response of 86.9% in the ULNTT test at some point in the available range of elbow extension. Because of this finding, this JMPT study may have inadvertently ruled out some candidates who would have responded positively to manipulative care.

Filed Under: chiropractic, Research

Chiropractic Physicians Meet with Congress

April 15, 2011 By Frank M.

SOURCE: ACA News

As health care reform implementation begins, making the case for chiropractic inclusion on the federal and state levels remains a priority.

Nearly 500 chiropractic physicians, students and supporters converged on the nation’s capital Feb. 14-15 as part of the American Chiropractic Association’s 2011 National Chiropractic Legislative Conference (NCLC) with the Chiropractic Summit. Those in attendance listened to speeches from government leaders, received advocacy training and urged elected officials to support pro-chiropractic measures that seek to provide patients, veterans and active-duty military personnel with greater access to the essential services provided by chiropractic physicians.

While last year’s conference focused on the first phase of health care reform, congressional debate surrounding the Patient Protection and Affordable Care Act (PPACA), this year’s meeting concentrated on the next phase, implementation of the law.

Among the speakers this year, Iowa State Sen. Jack Hatch (D-Des Moines), a member of the White House Legislative Working Group on Health Care Reform, stressed that While the work being done on Capitol Hill to expand patient access to chiropractic care is vital to improving health care for all Americans, at this stage important work is also being done in every state capital. “This is both a challenge and an opportunity,” he said.

The meeting’s keynote speakers were Sen. Tom Harkin (D-Iowa) and Ret. Brig. Gen. Becky Halstead, spokesperson for the Foundation for Chiropractic Progress. Harkin, who was instrumental in the inclusion of the provider non-discrimination language in PPACA emphasized chiropractic’s role in transforming the U. S. health care delivery system.

“Patients want options, alternatives and noninvasive care,” said Harkin. “We need to keep moving forward, away from the current sick care system to a health care system. Chiropractic physicians must be a part of the health care team.”

Halstead, a fierce advocate for chiropractic care for our nation’s veterans and active-duty military talked about prescription drug addiction in the military as a result of widespread chronic pain. She cited a recent USA Today article about another general’s struggle with addiction and back pain, cautioning, “If it’s happening in leadership, it’s rampant at lower levels.” Halstead then shared her personal struggle with fibromyalgia and chronic pain, which was finally resolved through chiropractic care.“If I had had more access to sustained chiropractic care [when I was in active duty], I would probably still be in the military,” she said.

Also on behalf of the nation’s armed forces, Rep. Michael Rogers (R-Ala.) urged attendees to ask their congressional representatives to support H.R. 409, the Chiropractic Health Parity for Military Beneficiaries Act [1], which would require the Secretary of Defense to develop a plan to allow any beneficiary covered under TRICARE to select and have direct access to a chiropractic physician. Rogers recently re-introduced this legislation in the House of Representatives.

HHS Secretary Kathleen Sebelius addressed NCLC attendees in a Video message. Sebelius said that chiropractic care has been “proven to be effective care that is also cost-effective,” and that chiropractic physicians are a “vital part” of the U.S. health care system. Like Harkin, Sebelius called for an end to the current “sick care” system.

ACA President Rick McMichael, DC, told attendees, “This is about a transformation in health care. This is about our patients and the public we serve. We have a window of opportunity — right now — and we must rise to the challenge, take action and persist. Working together as one team with one voice and one message, we can, and we will, help improve health care for America.”

Following NCLC, Chiropractic Summit XII took place on Feb. 16. First convened in September 2007, the Chiropractic Summit represents leaders from more than 40 organizations within the profession who meet regularly to collaborate, seek solutions and support collective action to address challenges facing the profession. [2]

Each year NCLC is held in conjunction with an official business meeting of the ACA House of Delegates. Dr. McMichael presided over both meetings and opened each with praise for the profession for working together to address critical issues.

REFERENCES:

1. H.R.409 – Chiropractic Health Parity for Military Beneficiaries Act
http://www.opencongress.org/bill/112-h409/show

2. What Is the Chiropractic Summit?
Chiro.Org Blog Editorial ~ June 22, 2010
http://www.Chiro.Org/Wordpress/?p=3056

Filed Under: chiropractic, News

Just In Case You Don’t Believe Me…

April 12, 2011 By Frank M.

For those of you who want limited prescription rights, and believe that Medicine wishes you well, please review this abstract from an Editorial in the Texas Medicine Journal.

SOURCE: Texas Medicine Journal 2011 (Apr 1); 107 (4): 20-26

Medicine Under Attack

The Texas Medical Association is fending off attacks on the practice of medicine by nonphysician practitioners who want to expand their scope of practice and diagnose and treat patients without going to medical school. Most recently, TMA went to court to protect patients, filing another lawsuit against the Texas Board of Chiropractic Examiners.

I don’t know about you, but I think I hear war drums beating. Did you notice their subtle counter-attack? Not only do they want to deny you the right to prescribe, they also question your ability (and right) to diagnose. And the AMA is happy to fund State Associations who’d like to cause this kind of mischief. Isn’t that a normal reaction against those who poach on their scope of practice?

You may also want to read previous articles on this topic:

AMA’s “Contain and Eliminate” Tactics Are Alive and Well

UPDATE: Texas Judge Finally Rules on Diagnosis Issue

A Constitutional Challenge to DCs Diagnosing

Filed Under: chiropractic

Historic Grant for Palmer, Rand Corporation, and Samueli Institute To Study Chiropractic Care For Active-duty Military Personnel

April 8, 2011 By Frank M.

On Febuary 18, 2011 we reported that the Palmer Center for Chiropractic Research Received a $7.4 million Military Readiness Grant. Here’s an interesting update (4-09-2011) on the proposed study from Dynamic Chiropractic

On the Front Lines With Chiropractic Research

The Congressionally Directed Medical Research Program has awarded the Palmer Center for Chiropractic Research, the RAND Corporation and the Samueli Institute $7.4 million to conduct a four-year research project featuring members of the U.S. military as study subjects.

The primary area of study: the impact of chiropractic treatment on the military readiness of active-duty personnel. Dr. Christine Goertz, Palmer College of Chiropractic’s vice president for research and health policy, who serves as co-principal investigator of the project, summed up the importance of the award: “The three clinical trials to be conducted at six sites across the country under this grant represent the largest coordinated research effort to date within the chiropractic profession. In one of the trials, we will randomize 850 active-duty military personnel at four of the six sites. This represents the largest clinical trial effort to date evaluating chiropractic care.”

When interviewed by DC following the award announcement, Dr. Goertz shared more key details regarding this historic research project, including the primary study parameters and the potential impact positive results could have on the expansion of chiropractic in the military.

How / why did the Palmer Center for Chiropractic Research collaborate with the RAND Corporation and the Samueli Institute in proposing this research project?

We wanted a team that had the expertise and experience necessary to conduct this set of complex clinical trials and each of us brings something unique to the partnership. The PCCR has experience in the conduct of clinical trials in chiropractic, including a small pilot we finished at Ft. Bliss last year. RAND has deep experience in qualitative research and the management of DoD studies and the Samueli Institute is knowledgeable about DoD procedures and how to navigate effectively through the system when conducting research.

Please elaborate on the key study parameters, outcome measures, etc. (number of participants, recruitment measures, how each of the above organizations will participate).

The primary objectives of the main study are to 1) assess the effectiveness of chiropractic manipulative therapy (CMT) for pain management and improved function in active-duty service members with orthopedic injuries or disorders of the low back that do not require surgery; and 2) to assess the impact of a chiropractic intervention on smoking cessation. Two additional studies will assess the impact of CMT on strength, balance and likelihood of re-injury in Armed Forces with combat specialties and assess CMT’s effects on reflexes and reaction times in Special Operations Forces (SOF).

Palmer is responsible for the design and implementation of all three studies to be conducted. RAND is responsible for fiscal oversight of the entire grant, quality control, some qualitative analysis and statistical analysis. The Samueli Institute will work with RAND on quality control and qualitative analysis, as assisting in obtaining IRB and other military approvals.

As you mention, the impact of chiropractic care on smoking cessation is one of the areas of study – what was the rationale for including it in this particular project, and how will you evaluate its value / outcome?

The Military Program Announcement specifically called for a study on smoking cessation, so that was the rationale for including it in this particular project. We are working with Dr. Mitch Haas at Western States on this aspect of the study and will use a model for dissemination and evaluation that he and Dr. Judith Gordon have used in the past with chiropractic clinicians.

Do you believe these research findings will help propel widespread expansion of chiropractic services in the military (currently available at only 42 or so military facilities worldwide)?

I think that will depend on the results. What I do know is that the desired outcome of this research is to provide information to the DoD that allows them to make evidence-based decisions regarding the appropriate role for chiropractic care for our service members in the Armed Forces; and that the results from this collection of clinical trials will provide critical information regarding the health and mission-support benefits of chiropractic health care delivery for active-duty service members in the military.

Filed Under: chiropractic, News, Research

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Historic Grant for Palmer, Rand Corporation, and Samueli Institute To Study Chiropractic Care For Active-duty Military Personnel

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