In October, the Canadian Memorial Chiropractic College (CMCC) held a two-day research symposium and colloquium in Toronto, where our mostaccomplished researchers presented their latest work. An eager group offield practitioners, students and faculty enjoyed CMCC’s hospitalityfor the event, where an abundance of research in a variety of areas –all of which can have an impact on the way we care for our patients –was presented!
In October, the Canadian Memorial Chiropractic College (CMCC) held a two-day research symposium and colloquium in Toronto, where our most accomplished researchers presented their latest work. An eager group of field practitioners, students and faculty enjoyed CMCC’s hospitality for the event, where an abundance of research in a variety of areas – all of which can have an impact on the way we care for our patients – was presented! The task of summarizing the information from both days in one short article is daunting, if not impossible. I will focus on the first day of the conference, which was titled: “Managing Patient Health: Pain and Beyond.” This broad title suggests a variety of potential topics, which was exactly what attendees enjoyed.
Dr. John J. Triano, dean of graduate education and research programs at CMCC, welcomed the group and introduced the main concept for the day – a series of presentations covering a variety of topics with the unified goal of helping us understand and address pain clinically, all in the larger context of improving the overall health of our patients.
Each presentation was roughly 45 minutes in length. I will try to capture some of the highlights for those who were unable to attend.
PATIENTS’ CLINICAL PROFILES – DR. SILVANO MIOR
- Dr. Mior discussed our current understanding of neck and back pain patient profiles from an epidemiological perspective.
- We know neck and back pain is the most common problem encountered in clinical practice, increasing to more than $60 billion in direct expenses in the United States.
- Despite this increased spending, there has not been an improvement in health status or outcomes.
- The majority of patients who seek care from chiropractors: have pain with no or some limited movement (most commonly musculoskeletal in nature), live in urban centres, have higher education, are between 25 and 54 years of age (less than 10 per cent are children), and are in excellent general health (compared to those who visit physiotherapists).
- The utilization rate for chiropractic in Canada varies by province, but has remained relatively stable for quite some time (approximately 12 per cent).
NUTRITIONAL AND FUNCTIONAL APPROACHES TO MANAGING HEALTH – DR. HEATHER TICK
- Dr. Tick discussed the concept of functional medicine as it relates to illness medicine and wellness paradigms.
- The role of stress in the development and proliferation of pain syndromes was explored in relation to the concepts of homeostasis and allostasis (maintaining a system through change).
- A functional medicine approach includes:
- environmental inputs – nutrition, micronutrients
- immune balance and inflammation
- gastrointestinal health
- structural imbalance
- energy production and oxidative stress
- hormone and neuroendocrine imbalance
- detoxification and biotransformation
- stress, spirituality and the mind-body connection.
FASCIAL MECHANISMS OF PAIN – DR. JOHN J. TRIANO
- Fascia permeates the body, surrounds organs, muscles, bones and nerve fibres.
- It varies in density, layering patterns and biomechanical properties.
- It is responsible for regional force distribution and likely global movement patterns (via the conceptual fascial “trains”).
- Muscles don’t just “pull”; they expand or flatten to help modulate the moment arm for their enveloping fascia.
- Fascia and other connective tissue cell membranes contain receptors that respond to stretch, mechanical loads, deformation, shear stress, etc.
- The effect of common clinical interventions such as exercise, manipulation and acupuncture on fascia are not completely understood, but studies are underway in many of these areas.
EVIDENCE FOR ALTERED CENTRAL PROCESSING – DR. BERNADETTE MURPHY
- “Neural plasticity” equals any lasting modulation to the function of the central nervous system (CNS) and:
- can include changes to synaptic connections or changes in “circuitry”
- can be adaptive or maladaptive (for example, altered sensory processing from a repetitive strain injury).
- Joint dysfunction may play a role in afferent functions, sensorimotor integration and motor control problems – these concepts are currently under study.
- A variety of neurophysiological measurements are currently being used to study the effects of spinal manipulation on the central nervous system – somatosensory evoked potentials, EMG, transcranial magnetic stimulation, feed forward activation.
DIFFERENTIATING PAIN: SPINAL-SOMATIC REFERRAL MECHANISMS – DR. HOWARD VERNON
- Pain research has typically focused on cutaneous pain, or pain stimuli in peripheral tissues.
- Recently, there is increasing work in delineating the unique characteristics of deep pain mechanisms, both somatic and visceral – spinal pain is of special interest.
- Spinal pain of mechanical origin demonstrates important differences from peripheral tissue mechanisms:
- primary afferents display prominent divergence when they enter the grey matter of the spinal cord (cranial and caudal secondary zones – multisegmental innervation)
- lumbar dorsal horn neurons receive input from afferents throughout the lumbar spine, including somatic and visceral inputs
- deep spinal inputs display more pronounced laminar termination in the spinal cord.
- In summary, back pain is more like visceral pain than extremity pain.
- Our understanding is increasing but further research is required.
SOMATIC PAIN FROM INTERNAL DISORDERS – DR. BRIAN BUDGELL
- Dr. Budgell discussed some common theories that are used to explain visceral referred pain.
- There are several good hypotheses that are incomplete at this time.
- Central projection of noxious stimuli involves numerous spinal cord tracts, including: spinothalamic, spinoreticular and spinomesencephalic.
- A general theory is that afferent input beyond a certain threshold creates dysfunction in sensory processing.
- No single current theory can account for various factors surrounding referred pain, including:
- the delayed onset of referred pain
- topographical evolution of referred pain
- non-segmental referred pain.
IDENTIFYING SUBGROUPS OF PATIENTS WITH LOW BACK PAIN – DR. JEFFREY HEBERT
- Dr. Hebert discussed the evolution and development of the Clinical Prediction Rule for low back pain (LPB) assessment and management.
- LBP is not a homogenous condition, yet it is often studied as such, leading to inconclusive results on a variety of treatment interventions.
- Treating all LBP with one intervention is analogous to treating all causes of chest pain with a drug meant only for acid reflux.
- It is now apparent that subgroups of LBP patients exist that will respond differently to various treatment interventions.
- The specific subgroups that have been identified based on historical and physical examination findings include:
- stabilization exercise
- specific exercise
CHIROPRACTIC FOR NON-MUSCULOSKELETAL CONDITIONS – DR. CHERYL HAWK
Dr. Hawk summarized a study that reviewed the literature on chiropractic care for non-musculoskeletal conditions.
17 RCTs were included on manual procedures (not just chiropractic) for the following conditions: asthma, hypertension, vertigo, infantile colic, otitis media, dysmenorrhea, nocturnal enuresis, pneumonia, phobia, jet lag. (The results of this study were reviewed in Research Review Corner in the May 2008 – Volume 13, No. 3 – of Canadian Chiropractor magazine.)
In addition to these presentations, Dr. Michael Schneider added an interesting case study presentation and review of occult upper cervical instability, while Dr. Carlo Amendolia presented the key note speech during dinner, updating attendees on the state of the literature and the clinical approach to two conditions: ankylosing spondylitis and lumbar spinal stenosis.
As you can see, the Saturday session was packed with useful information and an attempt at reviewing it all can merely scratch the surface – for this reason, I encourage all of you to attend future research symposia at CMCC. Chiropractors who pursue research dedicate their lives to our discipline through their work, and their passion for knowledge and improving patient outcomes is exemplary. Their research will ensure our continuing success and improve our profession. They truly deserve our admiration and gratitude.
The present and future of chiropractic research is very bright! •
Dr. Shawn Thistle is the founder and president of Research Review Service Inc., an online, subscription-based service designed to help busy practitioners to integrate current, relevant scientific evidence into their practice. Shawn graduated from CMCC and holds an Honours Degree in Kinesiology from McMaster University. He also holds a certificate in Contemporary Medical Acupuncture from McMaster University, and is a Certified Active Release Techniques (ART®) Provider. For more information about the Research Review Service, visit www.researchreviewservice.com .
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