The Science of Adjusting the Spine

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1 The Science of Adjusting the Spine Heidi Haavik BSc (chiropractic), PhD Columbus, Ohio, October 2016

2 Aisha Strand Mads Nibe Stausholm Thomas Momme Christensen Thomas Lykke Christiansen Marianne Enggaard Mette Vandborg Lauridsen Astrid Clausen Nørgaard Danielle Andrew Andreas Egmose Collaborators Bernadette Muphy Kemal Türker Imran Khan Niazi Kelly Holt Diane Sherwin Stanley Flavel Kim Dremstrup Julian Daligadu Paul Yielder Julianne Baarbe Jenny Kruger Jens Duehr Steve Holmes Mat Kingett Stefan Calder Mads Jochusen Asger Agard Jensen Marko Niemeier Duy Thien Van Asbjørn Drews Dina Lelic Ernest Kamavuako Vivian Schlupp

3 Dr William Charles Lawson Palmer Graduate 1924

8 Spinal function & dysfunction

9 Spinal physiology

10 Spinal physiology

11 Spinal physiology

12 Physiologically speaking a central segmental motor control problem That influences how accurately the BRAIN can perceive what is going on in the rest of the body, and the environment around it

13 Chiropractic care improves the health and function of the spine which in turn helps clear up the communication between your brain, the body and the environment So that it can accurately perceive what is going on and respond appropriately

15 Resources for you!

16 50% discount on memberships for you for next 48 hours!!!

17 HEALTHY PATHOLOGY Physiology vs Pathology NON-SYMPTOMATIC, BUT NOT HEALTHY e.g. sub clinical pain

E.g. Low back pain & injury Differences in proprioception do exist between subjects with back dysfunction and normal subjects (Georgy, Asian Spine J.

19 E.g. Low back pain & injury Differences in proprioception do exist between subjects with back dysfunction and normal subjects (Georgy, Asian Spine J Dec; 5(4): ; Laird et al BMC Musculoskeletal Disorders 2014, 15:229) LBP patients less likely to be able to feed forward activate core ab muscles (Marshall & Murphy. J Electromyogr Kinesiol Oct;20(5):833-9; Hodges &Richardson, Arch Phys Med Rehabil Sep;80(9): ) Altered motor control of spine/trunk muscles in LBP (Gotze et al Clin Biomech (Bristol, Avon) Mar;30(3):290-5;) Delayed trunk muscle reflex responses significantly increases the odds of sustaining a low back injury (Cholewicki et al Spine (Phila Pa 1976) Dec 1;30(23): ) LBP is complex and multi-faceted with psycho-social as well as NMS components

20 Bone out of place, squashing a nerve

21 We adjust BRAINS Know that adjusting someone s spine impacts their brain and thus the way it perceives what goes on in the body and the environment around it, which impacts how the brain controls the body

22 What does the research show? Adjusting the spine has lead to: SEP changes at cortical level Improved proprioception in arms and legs Change cortical drive to muscles Increased strength Prevention of fatigue Changes in cortical processing of vision & sound Taking faster step Changes in prefrontal cortex processing etc

23 Sub-clinical Spinal Pain 1-4 Intermittent pain, ache, tension, or stiffness of spine Not yet sought treatment for it NO pain on day of experimental testing

24 Avoid confounding presence of pain

Haavik H, Niazi IK, Holt K & Murphy B, (2016). The effects of 12 weeks of chiropractic care on central integration of dual somatosensory input: A pilot study.

"Manipulation of Dysfunctional Spinal Joints Affects Sensorimotor Integration in the Prefrontal Cortex: A Brain Source Localization Study." Neural Plast 2016: 3704964. Haavik Taylor H and Murphy B.

25 Haavik H, Niazi IK, Holt K & Murphy B, (2016). The effects of 12 weeks of chiropractic care on central integration of dual somatosensory input: A pilot study. Journal of Manipulative and Physiological Therapeutics; In press. Lelic, D., I. K. Niazi, K. Holt, M. Jochumsen, K. Dremstrup, P. Yielder, B. Murphy, A. M. Drewes and H. Haavik (2016). "Manipulation of Dysfunctional Spinal Joints Affects Sensorimotor Integration in the Prefrontal Cortex: A Brain Source Localization Study." Neural Plast 2016: Haavik Taylor H and Murphy B. (2010). Association of Chiropractic Colleges Research Agenda Conference 2008 Award Winning Paper (1 st Prize Basic Science Category): Altered Central Integration of Dual Somatosensory Input Following Cervical Spine Manipulation. Journal of Manipulative and Physiological Therapeutics, 33(3): Haavik Taylor H and Murphy B. (2010). Association of Chiropractic Colleges Research Agenda Conference 2009 Award Winning Paper: The effects of spinal manipulation on central integration of dual somatosensory input observed after motor training: A crossover study. Journal of Manipulative and Physiological Therapeutics, 33(4): Haavik-Taylor, H. & Murphy, B.A. (2007) Cervical spine manipulation alters sensorimotor integration: A somatosensory evoked potential study Clinical Neurophysiology, 118 (2):

28 Amplitude ( mv) Haavik-Taylor & Murphy (2007) Cervical spine manipulation alters sensorimotor integration: A somatosensory evoked potential study. Clinical Neurophysiology; 118(2): p Pre/post cervical adjustments 5 Pre-manipulation average 0-10 min post-manipulation pre b post x Pre Adjustment min post-manipulation post y min post-manipulation post z 2 Post Adjustment Time (ms) -3-4

30 M + U MU

31 A B C

32 6 4 MU Baseline MU Post 2w CTRL MU Post 12w Chiro AFTER 12 weeks of Chiro care!!

33 Pain Now VAS scores Pain Last week VAS scores Series1 Series2 Series3 Series4 Series5 Series6 Series7 0.0 Baseline 12 weeks Baseline 12 weeks

34 Lelic D, Niazi IK, Murphy B, Jochumsen M & Dremstrup K, Drewes AM. & Haavik H (2016) Reorganization of brain networks in subclinical pain patients following spinal manipulation. Neural Plasticity; in press

36 Pre/Post Control Intervention

37 Pre/post single chiro session

39 How do you talk about it? Brain changes have been shown 4 times in different studies!! The last time was all done in a Medical Professors Lab all data was collected and analysed by his staff This is solid scientific proof that when we adjust the spine we change brain function! And these changes appear to be occurring particularly in the pre-frontal cortex

40 So what does that mean? Chiropractic adjustments of subluxations changes pre-frontal cortex function by 20%!!! Pre-frontal Cortex is main structure responsible for Executive function i.e. the coordinated operation of various neural systems and is essential for achieving any particular goal. This requires: planning a sequence of subtasks to accomplish a goal focusing attention on relevant information inhibiting irrelevant distractors being able to switch attention between tasks monitoring memory initiation of activity responding to stimuli

41 Pain is likely modulated in top-down manner with key involvement of PFC We propose that the DLPFC exerts active control on pain perception by modulating corticosubcortical and corticocortical pathways. Lorenz et al (2003) Brain: 126(5):

42 It explains previous research findings! A change in prefrontal activity following chiropractic care may therefore explain and/or link some of the varied improvements in neural function previously observed in the literature, such as: improved joint position sense error (Haavik & Murphy 2011; Holt et al 2016) Improved brain reaction time on mental rotation task (Kelly et al 2000) Changes in cortical processing (Haavik-Taylor & Murphy 2007; Haavik & Murphy 2010a; 2010b) Changes in cortical sensorimotor integration (Haavik-Taylor & Murphy 2007; Haavik-Taylor & Murphy 2008; Haavik & Murphy 2010a; 2010b) Altered reflex excitability (Herzog et al 1999; Murphy et al 1995; Suter et al 1999, Suter et al 2000) Altered motor control (Niazi et al 2015; Marshall & Murphy 2006; Haavik-Taylor & Murphy 2008) Increased lower limb muscle strength (Niazi et al 2015; Hillermann et al 2006)

43 A collectively funded study exploring the effects of chiropractic spinal adjustments on cortical and clinical function in victims of stroke

44 Stroke Study in Pakistan 50% increase in strength in affected leg!!! This is most likely cortical drive changes (70% V wave increase) Still to analyze whole head EEG, source localization

45 % Chnage in Force % change In V wave Normalised to Mmax V wave Preliminary Data N=12-60 Intervention CTRL Intervention Absolute Force CTRL

46 % Change Preliminary Data Intervention CTRL Intervention CTRL Intervention CTRL H-Threshold s50 slope

47 Stroke Study in Pakistan WE NEED YOUR HELP!!! 100,000 NZD and We can follow up with high density EMG

48 Workshop A How to use relevant scientific research in practice in an appropriate way Workshop B How to communicate the science of the chiropractic adjustments

49 Workshop A How to how to use relevant scientific research in practice in an appropriate way Heidi Haavik BSc (chiropractic), PhD Columbus, Ohio, October, 2016

50 Science & Research 101

51 51

52 Evidence Informed Practice Improved patient outcomes! Patients own values and expectation

53 Overall Working Model Narrow down to testable question Test with scientific method Interpret your results

54 Clinical research Basic Science Research

55 Clinical Trials RCTs Qualitative research Basic Science Case reports

56 Clinical research Basic Science Research

57 Turn to your neighbour and explain the difference between basic science and clinical science and answer the following: 1. How can you tell the difference between basic science and clinical science? What evidence do each provide? 2. Can you think of some difficulties scientist may have when doing research into exploring the effects of adjusting the spine? 3. What is the key difficulty when trying to do clinical science with a chiropractic intervention? 4. What is the benefit to you with good chiropractic basic science? 5. What is the benefit to you with positive chiropractic clinical science?

58 2. Can you think of some difficulties scientist may have when doing research into exploring the effects of adjusting the spine? An intervention is supposed to be properly defined and repeatable How do we define what we adjust? What do we call it? How do you find them? Can you find them reliably? What is the spinal manipulation / adjustment intervention? How does it work? Can it be repeated in a reliable manner?

59 3. What is the key difficulty when trying to do clinical science with a chiropractic intervention? Clinical research is about the effects of an intervention on a particular condition So what (conditions) does chiropractic treat?

60 How to thrive in an evidence informed world

61 Steps involved in following best available research evidence Searching the Literature Search engines Key word strategies Evaluating the literature Strengths and weaknesses of different methodologies Hierarchy of evidence Translating the evidence Simplifying key findings Translating meaning to patient language

62 Haavik Research Membership Public Animations 15 in total to date New one every month Science Gems topic lit reviews Critiqued Key studies looked closely at what you can claim what you cannot claim (and why) Public and Other heath care professional talks Watch me give talk as much as you like Downloadable scripts Downloadable power points Downloadable reference list Practice marketing for topic reviews Posters / pamphlets on the various topics Fully referenced website/facebook/social media material you can trust Ongoing updates as new literature becomes available

63 Resources for you!

64 50% discount on memberships for you for next 48 hours!!!

65 When talking about the chiro-relevant scientific studies: 1. This is what they did 2. This is what they found 3. This is what that possible means to you 4. BUT... (mention limitations with study for you patient)

66 Wisdom vs Knowledge

68 When talking about the chiro-relevant scientific studies: 1. This is what they did 2. This is what they found 3. This is what that possible means to you 4. BUT... (mention limitations with study for you patient)

70 In pairs describe to each other: What did they do? Describe the experimental methodology including i) (subject number and) subject population, ii) intervention(s) used and i ii) name the neurophysiological technique used to record the dependant measures and state clearly what the dependant variables were. what did they find in this study? (i.e. Describe what the study results were) Describe how this could be relevant to a patient in your clinic What are possible limitations of this research?

71 (Govorko, MSc Thesis, 2007, p.106) Feedforward Activation (Marshall & Murphy. J Manipulative Physiol Ther 2006;29: )

72 (Marshall & Murphy. J Manipulative Physiol Ther 2006;29: ) 17/90 impaired FFA Pre Adjustments 13/17 retested 6 month later Post Adjustments 38% improvement in FFA times after SI adjustments

73 Clinical Scenario 1- active daughter A woman has come to see you because of her teenage daughter She plays netball, and you notice she has bad posture, but she professes to be fine and not needing chiro care Plus she has been told by her best friends mum that there is no evidence for chiropractic and she should not get manipulated by one. Plus she thinks she is fine, as has no pain Except when you ask a few questions she falls into category of Subclinical pain because she does get a sore neck when studies at the computer for a long time and stiffness and ache in her shoulders.

74 How did that go? Share with another pair how it went What was easy? What was hard? Where you confident?

75 Example 1 What did they do? Describe the experimental methodology including Ninety young asymptomatic males (Those with delayed feed forward activation (FFA) of their abdominal muscles in response to rapid arm lifting) received a sacroiliac adjustment (i.e. experimental intervention) The subjects were assessed for the FFA using surface EMG over their deep abdominal muscles in relation to rapid upper limb movements. Describe what the study results were (i.e. what did they find in this study) Seventeen (18.9%) of 90 subjects met the criteria of impaired FFA. Thirteen of 17 were available to be re-measured at 6-month follow-up. The intraclass correlation coefficient for FFA at this time was greater than 0.70 for all movement directions. There was a significant improvement (38.4%) in FFA times for this group when remeasured immediately after the sacroiliac joint manipulation.

76 Example 1 Describe how this could be relevant to a patient in your clinic young healthy males in practice, even if they dont have symptoms may be at risk for developing low back injuries if they cannot appropriately reflexively activate their core muscles (Cholowicky 2005) and that chiropractic appears to improve the ability of the CNS to reflexively activate core muscles in a FFA manner. Limitations of study You are a woman, the study was only on men We dont know how long the effects last, was only one pre/post

78 In pairs describe to each other: What did they do? Describe the experimental methodology including i) (subject number and) subject population, ii) intervention(s) used and i ii) name the neurophysiological technique used to record the dependant measures and state clearly what the dependant variables were. what did they find in this study? (i.e. Describe what the study results were) Describe how this could be relevant to a patient in your clinic What are possible limitations of this research?

79 (Award winning poster at 2009 WFC; Award winning paper at ACC RAC 2010) 25 SCNP 18 healthy controls Haavik & Murphy, 2011, JMPT; 34:88-97

80 Comparison study Healthy better than SCP group

81 Pre/post adjustment And Pre/Post 5 min res

82 Clinical Scenario 2 Clumsy Woman A 50 year old woman comes to see you She has neck pain You also notice she is very clumsy, knocking her elbow on the doorframe into your office room, tripping on her feet and putting things on desk that miss desk and fall to floor.

83 How did that go? Share with another pair how it went What was easy? What was hard? Where you confident?

84 Example 2 What did they do? Describe the experimental methodology including Twenty-five subjects with sub clinical neck pain and 18 healthy control participants took part in this pre-post experimental study. The intervention was adjusting subluxations and a setup control in the sub clinical neck pain patients and five minutes of rest for the healthy control subjects. They used an electrogoniometer to measure elbow joint position sense (absolute, constant, and variable errors) (ie. This was the dependant variables). Describe what the study results were (i.e. what did they find in this study) At baseline, the control group was significantly better at reproducing the elbow target angle. The SCNP group's absolute error significantly improved after the cervical adjustments The control group participants' JPS accuracy was worse after the control intervention

85 Example 2 Describe how this could be relevant to a patient in your clinic It might mean that if patients are a bit clumsy, like subbing their tow often or knocking their elbow in the door frame unintentionally that adjusting their spine might help improve their proprioceptive accuracy. Limitations of study You are a older than the individuals in this particular study, although there is an study done in 65 + year olds done with anckle JPS and they improved significantly over a four week period We dont know how long the effects last, was only one pre/post The ankle study showed effects of 12 weeks chiro care, but no follow up done

86 Workshop B How to communicate about the science of the chiropractic adjustments Heidi Haavik BSc (chiropractic), PhD Columbus, Ohio, October 2016

87 Where are you at now?

88 In pairs (one being the chiro, the other the patient) each take turns explaining: How do you explain that a part of the spine needs to be adjusted? How do you explain how chiropractic care works?

89 How did that go? Where you confident? Do you know if your story has scientific backing?

90 a central segmental motor control problem That influences how accurately the BRAIN can perceive what is going on in the rest of the body, and the environment around it

91 Chiropractic care improves the health and function of the spine which in turn helps clear up the communication between your brain, the body and the environment So that it can accurately perceive what is going on and respond appropriately

96 Neural plasticity

97 Maladaptive vs Adaptive Plasticity

98 Maladaptive vs Adaptive Plasticity

100 In pairs, take turns explaining to each other the following concepts: Neural Plasticity How this can be good AND bad thing

101 Chiropractic alters the Matrix of your brain! 101

102 Your Reality temperature Proprioception & kinestesia Pain Balance Chemoreceptors 102 Plus LOTS of additional background processing 102

103 Principles of Neural Science by Eric R. Kandel, James H. Schwartz, and Thomas M. Jessell. Elsevier, 2000, 4 th Ed, Ch 33, p. 654 IN THE PRECEDING PART of this book we considered how This the brain is MULTI-MODAL-INTEGRATION constructs internal representations of the world by integrating information from the different sensory systems. These sensory representations are the framework in which the motor systems plan, coordinate, and execute This the is SENSORI-MOTOR-INTEGRATION motor programs responsible for purposeful movement.

104 Patient pamphlet

105

106 In pairs, take turns explaining to each other the following concepts: Multimodal integration and the inner brain reality Subconscious/background processing and that the brain can fill in the blacks/gaps Sensorimotor integration and its importance for accurate purposeful movements

107 How did that go? Where you confident? Did any questions arise?

108 The connection between the neuroscience and chiropractic!

109 The functional role of paraspinal muscles They act as CNS sensors!

110 MUSCLE SPINDLES Intra-fusal fibres Extra-fusal fibres Type 1a & II afferents α- motor neurone γ- motor neurone

111 Talking about the subluxation to patients

112

113 7 essential components 1. Three key spinal functions (move, stiffen, reflex response) 2. Neuroplasticity - Good or Bad 3. Inner brain reality / body schema not always accurate 4. Subconscious processing - Brain fill in the gaps 5. Paraspinal muscles are SENSORS 6. What happens when a segment is not moving properly 7. What happens when we adjust these

114 See if you can remember the key essential components to explain the effects of an adjustment! Self Test!

115 7 essential components 1. Three key spinal functions 2. Neuroplasticity - Good or Bad 3. Inner brain reality not always accurate 4. Subconscious processing - Brain fill in the gaps 5. Paraspinal muscles are SENSORS 6. What happens when a segment is not moving properly 7. What happens when we adjust these

116

117 Take 10 minutes to plan your 10 min talk about the mechanisms of chiropractic care. Include the following components and use SIMPLE examples 1. Three key spinal functions 2. Neuroplasticity - Good or Bad 3. Inner brain reality / body schema not always accurate 4. Subconscious processing - Brain fill in the gaps 5. Paraspinal muscles are SENSORS 6. What happens when a segment is not moving properly 7. What happens when we adjust these Include in your the plan the use of Office Poster & Pamphlet!

118 Name: Components: Tick if discussed Tick if simple example included: Note what may have been missed: Specific Notes: Neuroplasticity Can be good and bad Inner brain reality / body schema Subconscious processing Brain fill in the gaps & filters afferent info Paraspinal muscles are SENSORS What happens if spinal segments don t move properly What happens when we adjust these segments Use of Poster Use of Pamphlet

119 In groups of 2 Practice the talk! One be the Chiro One the patient and take notes and provide feedback Rotate so both gets to try being the chiropractor. Debrief after each round about what worked well and what did not

120 How did practical go? Where you confident? What were you less confident about? What did you not remember? Biggest gaps in understanding/knowledge?

121 Resources for you!

122 50% discount on memberships for you for next 48 hours!!!

12/12/2016. A novel approach to unite the profession by bringing the science and philosophy together

12/12/2016. A novel approach to unite the profession by bringing the science and philosophy together A novel approach to unite the profession by bringing the science and philosophy together Heidi Haavik BSc (chiropractic), PhD COCSA, Phoenix, Arizona, Nov 2016 http://therealitycheck.com/cocsa 1 Basic