Business To Business Fact Sheet
1. Chiropractic Education:Summary of Course Hours for Doctor of Chiropractic - NYCC
• Anatomy 585 hours
• Biochemistry 75 hours
• Physiopathology 345 hours
• Microbiology and Public Health 120 hours
• Diagnosis 525 hours
• Diagnostic Imaging 270 hours
• Clinical Laboratory 75 hours
• Associated Studies 165 hours
• Chiropractic Philosophy 135 hours
• Chiropractic Technique 615 hours
• Ancillary Therapeutic Procedures 90 hours
• Clinical Practice Issues 75 hours
• Clinical Experience and Outpatient Services 1,320 hours
• Total Core hours 4,380 hours
• Elective Courses 225 hours
Total 4,620 hours
2. Education to receive a Diplomate in Rehabilitation:
300 hour postgraduate program - basically one week-end/month for 3 years
Course material includes:
(detail list of Delphi topics on acrb.org website)
3. Testing to receive a Chiropractic License:
National Board examinations Part I, II, III & IV
Note: individual states have different requirements.
4. Testing to receive a Diplomate in Rehabilitation
a. 3 written 100 question exams at the end of every 100 hour segment
b. a comprehensive oral examination at the completion of all 300 hours and
all 3 written tests
also required is a publishable scientific paper on a rehab topic that is approved by the Board.
5. The essential difference in a DACRB is not only knowledge, our training includes active learning of how to apply the advanced diagnostic, soft tissue and treatment techniques as well as cardio, proprioceptive, and muscle co-ordination, facilitation, flexibility, strength, power and speed rehabilitative base-lines and treatment. Simply put, we are more knowledgeable and more skilled.
6. The treatment end goal of the DACRB is different than that of the average chiro. All too often the average chiro’s goal is to foster dependency and create a life-time patient. The DACRB’s goal is to find and correct the true underlying causes, empower the patient with self care exercises and to release them from care. This treatment approach is called “active care”. The patient is included in their treatment – giving patient’s control over their healing process is especially important with chronic pain patients.
By addressing underlying causative issues like poor posture while sitting at a computer or driving, poor patterns of lifting and bending, in-coordination in movement, muscle weakness, poor cardio-vascular fitness, poor balance and general deconditioning – the patient has an opportunity to get better and to maintain a home program that keeps them better. It is empowering to the patient and cost-effective.
7. Treatment with a DACRB may include passive care therapies such as manipulation, mobilization, a variety of soft tissue techniques, acupuncture, ultra-sound, muscle stim, tens …this is especially true in the acute phase of care, but the focus is always on reactivating the patient as soon as possible. The difference is that a DACRB’s choice of treatment is generally evidence based and progressive.
This means that the DACRB studies the literature and makes decisions based on evidence that is reported in research studies. Our treatment is cutting edge and research based.
8. Treatment is also progressive. What this means is that treatment changes as the patient improves. Treatment is based on the phase of care: Acute, Sub-acute and Chronic. As the patient improves, their treatment changes accordingly. As will be discussed later, active care is especially encouraged in chronic patients.
Treatment is also based on the needs and goals of the patient. A fifty five year old sedentary office worker will not have the same rehab treatment plan as a 25 year old delivery person whose job requires lifting 100 lb boxes off the floor. The patient’s end goal of treatment is based on the demands of their ADL’s (activitites of daily living) and the patient’s goals (to play 18 holes of golf, lift a 30 lb grandchild or take a kickboxing class)
In some traditional chiro offices not only will the same patient receive the same treatment for their entire program of care – every patient receives the same full spine adjustment, every time. There is no progression; there is no addressing of posture, function, movement, fitness or deconditioning. The patient is dependant on the chiro to fix them. Great for the doc, not so great for the patient.
9. DACRB’s are trained to evaluate yellow flags and psycho-social issues. It is 3% that incur 97% of all health care costs. Training in identifying and properly treating this population is the most cost-effective measure that can be taken.
Individuals with a preponderance of “yellow flags” are at heightened risk for developing chronic symptoms and disability (26, 53, 110, 165, 201, 202), and thus require a carefully mapped out management strategy. The strength of the association between “yellow flags” and spinal pain syndromes is reinforced by the prospective studies involving asymptomatic individuals which have shown that they predict both future acute episodes (133) and who will become chronic (240). Importantly, there is preliminary evidence that psycho-social illness behavior can be improved merely by active rehabilitation alone without a structured cognitive-behavioral component (152).
According to Vlaeyen (259) fear-avoidance behavior leads to deconditioning in the following manner:
Negative views about pain (i.e. viewing it as a threat rather than an annoyance) and its causes lead to catastrophization
Fear and anxiety in turn lead to the tendency to avoid the perceived threat.
Activities of daily living become restricted
Psycho-physical reactivity (sympathetic activation, ↑muscle tension) occurs when activities are encountered which are perceived as harmful.
Fearful patients become hypervigilent since they cognitively put increased attention on possible sources of pain.
Since avoidance behaviors are anticipatory they are self-perpetuated since the individual rarely comes into contact with the actual (non-harmful) consequences of the feared situation.
“Guarded movements” such as an impaired flexion - relaxation phenomenon are correlated with fear-avoidance beliefs NOT actual pain (267)
Anxious patients predict pain earlier during the performance of physical tasks such as ROM or straight leg raise tests (34,37,119,120)
Long standing avoidance of physical activity leads to the “disuse syndrome” or deconditioning syndrome affecting both musculoskeletal and cardiovascular systems
Teaching patients what they can do for themselves is an essential part of caring for the person who is suffering with pain. A simple technique for getting a patient to become active in their own rehabilitation program is to shift them from being pain avoiders to pain managers (25,212).
*****We have the permission of Dr. Craig Liebenson to use the information and bibliography from his book Rehabilitation of the Spine 2nd Edition. Please be sure to reference Dr. Liebenson when using any of the information that follows in italics as I have taken it all from Chapter one of his book.
10. Rather than focusing merely on pathology and symptoms the emphasis in a
rehabilitative approach is on recovery and reactivation.
This is very important because research has proven a significant amount of false positives in imaging studies. If fact, structural findings such as arthritic changes or disc herniations have proven to be incidental findings – NOT the cause of the patient’s pain or their problem.
To clear up the confusion it is important to understand the difference between a structural and functional approach of evaluation and treatment. Orthopedists traditionally have a structural approach. They order tests that evaluate the structure of the area in question – X-ray, MRI, CT. They look for a structural explanation for a patient’s pain and basically treat by either medicating or changing the structure – ie performing surgery.
A functional approach looks to how the system works. Quality of movement, habits, condition of the tissues, and psycho-social issues are all factored in.
Pain is a multi-dimensional issue that simply cannot be treated successfully if only the structural component is addressed.
The patient-centered reactivation approach is focused on the patient’s dysfunction and distress rather than various signs of often coincidental structural pathology or the patient’s subjective symptoms. A paradigm shift from a traditional biomedical model to a biopsychosocial one has taken firm hold in the spine field. The biopsychosocial approach teaches us that the old adage “let pain be your guide” can actually reinforce illness behavior such as fear-avoidance behavior. The more modern report of findings reassures patients that they do not have a disease (tumor, infection, and fracture) and that staying active will actually speed recovery. Learning that pain does not always warn of impending harm or damage can empower patients to remain active, avoid disability, and prevent the transition from acute to chronic pain.
Table 1-7 Common Denominators of Successful Care for Chronic Patients (from 102)
• Thorough physical and functional examination performed
• Report of findings given
• Emphasis on self-care
• Reduce any unfounded fear or anxiety about pain
• Crystal clear recommendations about activities/exercise
• Avoidance of excessive “high tech” testing or bed rest prescription
11. Traditional Chiropractic tends to emphasis passive care (what the doctor does to the patient),
where in rehab active care and patient participation are emphasized.
Traditionally in medicine the advice has been bed rest, muscle relaxant and heat – today
research has proven that manipulation, ice and graduated activity are far more effective.
Activity has been shown to be effective for preventing or treating many of the most common chronic ailments in our society today (77). In particular, active care or patient reactivation plays a decisive role in the modern management of disorders of the cardiovascular and locomotor systems (75, 94, 95, 161, 183, 189, 195, 200, 201). From simple, uncomplicated reactivation advice to comprehensive, multidisciplinary rehabilitation the goal is to restore function. The functional goal is an essential hinge for guiding clinicians in the decision-making process. Biomechanical, neurophysiological, psycho-social and biochemical rationales exist for the benefits of active care. However, the most important justification for making reactivation a primary focus of care is that patients in pain tend to accept the adage “let pain be your guide” with the result being they decondition as a result of their pain.
Excessive immobilization interferes with the healing, coping, and recovery process. Thus, health care professionals are being urged by each successive international guideline on spinal disorders to first perform a diagnostic triage to rule out “red flags” of rare but serious disease, and then to reassure patients of the benign nature of their back pain and the safety and value of gradually resuming activities (2,25,38,94,148,217)
The evidence in favor of reactivation for spine patients is strong. Reactivation advice to resume near normal activities is both safe and effective for acute low back pain (LBP) patients (148). Similarly, early activation has been found to be effective for neck pain following a whiplash injury (18,166,213). Deconditioning normally accompanies acute LBP and its prevention has been shown to reduce recurrence rates (82, 83, 234). Active therapies involving such diverse exercise methods as cognitive-behavioral, stabilization, and strengthening have demonstrated their effectiveness for subacute and chronic LBP (11, 58-60, 83, 94, 95, 113, 128, 150, 190). Therefore, at each phase of the acute to chronic pain continuum patient reactivation has been shown to play a fundamental role.
Active care adheres to biochemical principles by advising patients to avoid the debilitation of bed rest and inactivity while encouraging them regarding both the safety and value of resuming activities with simple biomechanical modifications. Pain and tissue healing are related to metabolic and nutritional issues. The disc is a relatively hypovascular tissue which contributes to its poor healing ability (87). In fact, some pain treatments such as epidural injections while they clearly de-inflame the nerve root and initially reduce pain, have recently been shown to cause a rebound pain later, perhaps as a result of interfering with the body’s natural resorption process for the herniated disc (106). Resorption or regression of herniated discs – even in large disc herniations - is a common finding and is consistent with the normal process of tissue repair and remodeling (28,29,107,116,172,203). Further evidence for this is the finding that macrophages are present in high concentration with disc herniations (72,78,93). Inactivity slows the recovery process since the disc is dependent on diffusion for its nutrition.
12. Research has shown several simple functional tests can determine if a patient is more likely to suffer with back pain. And even more importantly, testing can determine if a patient is fully recovered and ready to return to work after an injury. Here is a summary of the recent research:
(It is important to note that every one of these factors is addressed in a rehabilitative evaluation and treatment program and NOT in a traditional Chiropractic approach.)
a. The back extensors should be slightly stronger than the abs – 1.3-1
b. There should not be a delayed reaction time of the muscles
c. There should be good co-ordination of back and abdominal muscles and the
ability to activate and isolate the low abdominal muscles.
d. Underactivity of agonists and overactivity of synergists was able to discriminate pain patients with 88% accuracy.
e. Decreased endurance of the trunk extensors has not only been shown to correlate with pain, but prospectively to predict recurrences as well as first time onset of episodes in healthy individuals
Decreased endurance of the deep neck flexors has been correlated with chronic neck pain and headaches.
f. Poor balance has been related to LBP and also prospectively correlated with future LBP
g. Bed rest for more than 2-3 days can foster deconditioning and is not advised.
a. A reduced ratio of trunk extensor to flexor strength/endurance discriminates between LBP patients and control subjects. The normal ratio is approximately 1.3:1 with the extensors being stronger (158). Mayer and colleagues demonstrated that patients chronically disabled with LBP frequently had a decreased trunk extensor/flexor strength ratio and that a comprehensive, multidisciplinary functional restoration program (including an emphasis on trunk extensor training) successfully returned many of these individuals to work. (161)
b. Altered reaction times of muscles have been correlated with LBP. Wilder showed that slow reaction time, decreased peak output, and increased after discharges when irregular load is handled is typical of LBP subjects (272). Following treatment the reactions improved. Sitting was shown to disturb these variables and a brief walking break to improve them again.
A recent study by Leinonen utililzing similar methods as Wilder reported that there was a slower reaction time to anticipated, sudden loading in patients with sciatica than in healthy controls (126). This was theorized as due to an impairment in the patient’s central processing of information. It was concluded that chronic sciatica can impair lumbar feed-forward control.
Radebold and colleagues also found that a motor control signature discriminates LBP patients from asymptomatics - namely a slow reaction time, increased muscle activation, and slow relaxation of muscles following unexpected perturbations (33,204,205).
With voluntary upper or lower limb movements <TXT>A delayed activation of the transverse abdominus muscle during arm or leg movements has been found to distinguish LBP patients from asymptomatic individuals (85, 86). A rehabilitation program designed to improve this dysfunction has been shown to be effective for chronic LBP patients (190).
To external visual stimuli <TXT>Reaction times to visual stimuli have been shown to be slower in chronic LBP patients than in asymptomatic individuals (143,144,236).
c. Incoordination <TXT>Incoordination is correlated with LBP. Paarnianpour showed that a loss of control of the center of rotation during resisted trunk movements in the sagittal plane occured in LBP patients, but not in normals (193). Increases in rotation and side bending and a decrease in sagittal motion occurred during the resisted movement. Similarly, Grabiner reported that asymetric muscle output during isokinetic resisted trunk extension did not reduce torque production, but was abnormal (65).
O’Sullivan found that an increased ratio of rectus abdominus to transverse abdominus/oblique abdominal activation is correlated with LBP (190). Control subjects were able to preferentially activate the internal oblique and transverse abdominus muscles without significant rectus abdominus activation while LBP patients could not do this. Individuals who automatically perform a trunk curl fast instead of slow also showed a greater ratio of rectus abdominus to transverse abdominus/oblique abdominal activation (191).
d. Edgerton found that an altered muscle activation ratio of synergist spinal muscles during a variety of motor tasks was common in chronic neck pain patients after whiplash injury (44). Underactivity of agonists and overactivity of synergists was able to discriminate pain patients with 88% accuracy. He stated, “The nervous system apparently can detect a reduced capacity to generate force from a specific muscle or group of muscles and compensate by recruiting more motoneurons. This compensation can be made by recruiting motor units from an uninjured area of the muscle or from other muscles capable of performing the same tasks…” Nedherhand found that a decreased ability to relax the upper trapezius muscles during static tasks and following exercise distinguished between chronic Whiplash Associate Disorder (WAD) classification II patients and healthy control subjects (181).
Jull has shown that a cranio-cervical flexion test can differentiate both chronic headache and chronic neck pain post-whiplash patients from asymptomatic individuals (100,101). During the test patients showed overactivation of the superficial neck muscles (sternocleidomastoid), an inability to hold a constant pressure with the head against a pressure sensor at all test levels, and an inability to target higher pressure levels (26-30mmHg) (230). Individuals with mild or moderate/severe pain and disability had significant overactivity of the superficial neck muscles during the flexion test at 1 month (230). This persisted at 3 months regardless of whether or not pain persisted (230). Treatment directed at improving cranio-cervical flexion has recently been shown to achieve lasting results both in terms of improved function and reduced symptoms
e. Endurance has been shown to correlate with LBP. Decreased endurance of the tunk extensors has not only been shown to correlate with pain (13,124,184), but prospectively to predict recurrences (13) as well as first time onset of episodes in healthy individuals (88,142). Some studies have disputed that this test correlates with low back trouble (238). The test, if performed in the manner described by Biering-Sorensen, has been shown to be reliable in various populations – asymptomatic (124), symptomatic (175), and those with a past history of LBP (124). One study claimed the test was unreliable, but a small sample (12 subjects) and a different procedure utilizing a Roman Chair was utilized (160).
Decreased endurance of the deep neck flexors has been correlated with chronic neck pain and headaches (10,221,243,268).
f. Balance Ability: Balance deficits have been demonstrated to be related to LBP (30,145,238, 176). Byl showed that excessive anterior to posterior body sway on an unstable surface or poor single leg standing balance ability is correlated with LBP (30). Mok has shown that when compared with age and gender matched pain-free controls, study participants with LBP had poorer balance (176). Poor balance was also prospectively correlated with future LBP by Takala (238).
g. Bed Rest -Of all the traditional treatment methods none has fared worse than bed rest.
Deyo performed a controlled clinical trial which compared 2 days of bed rest against 2
weeks and concluded that not only was 2 days of bed rest as effective as 2 weeks, but the
negative effects of prolonged immobilization were also limited (41). A Cochrane
Collaboration review concluded that bed rest (74):has no positive effect for LBP
may have slightly harmful effects yields no improvement with 7 days over 2-3 days in LBP or sciatica
The Paris Task Force on Back Pain recommended that “bed rest should neither be enforced nor prescribed, but may be authorized if pain indicates it (1). If authorized, it should be of as short a duration as possible and should be intermittent rather than continuous. After 3 days of bed rest, patients must be strongly encouraged to progressively resume their activities.” The Danish guidelines concurred suggesting that bed rest can be considered a pain relieving measure for 1-2 days for severe pain (38).
When recommended for severe pain it should be made clear that brief bed rest is as a consequence of the pain, but not a treatment for the pain (217).
What follows is a summary of some evidence comparing active care to “tincture of time” or other modalities for the treatment of spine related conditions. The most common criteria for recovery are symptom reduction and return to work. But, other criteria such as satisfaction, health care utilization, activity intolerances, and distress have also been applied. Active care includes a variety of approches from basic advice to stay active to supervised machine-based exercise routines.
13. Acute Phase (first 4-6 weeks) - Advice to Stay Active is proven effective:
Information and advice emphasizing the value of fitness and the safety of resuming activities Achieved superior outcomes to advice which reinforced rest, activity restrictions and the notion that the spine was injured or damaged (arthritis, herniated disc) (25). Reassuring workers and encouraging resumption of ordinary activities was superior to medication, bed rest or mobilization exercises (148). Little et al. recently demonstrated that educational advice which encourages early exercise (not just advice to stay active) or endorsement by a physician of a self-management booklet has been shown to increase patient satisfaction and function while reducing pain (137).
Studies evaluating behavioral strategies have also shown substantial improvements with early active care approaches. Early behavior modification through exercise reduced disability 1 year later than in the control group (50). An 8 fold reduction in the risk of becoming chronic was achieved from information designed to reduce fear and anxiety and provide self-care advice (129). A recent randomized, controlled trial verified the results of these early studies (134).
14. Many of the most popular treatments for acute LBP lack evidence of effectiveness.
The recent Danish guidelines (38) (p60) state, “One of the greatest errors in the treatment of LBP in this century has been the unquestioned usage of passive treatments, often-times initiated when spontaneous recovery has already begun.” Passive modalities such as electrical muscle stimulation were recommended only as optional. Such passive modalities may engender higher levels of patient satisfaction, but they have not been demonstrated to improve outcomes related to recovery (89). Thus, similar to taking x-rays, patients may like it but since it doesn’t improve outcomes better patient education about appropriate management techniques for acute LBP are needed (47,98,111).
15. Subacute Phase Reactivation and Exercise (from 4 – 12 weeks)
The subacute phase is the ideal time for both active and aggressive treatment (52,132,266). In cases of disability the return to work curve declines steeply between 6 and 20 weeks (227, 266). The longer patients with LBP are off work, the more difficult it is for them to return to work (227, 266). For this reason most guidelines recommend exercise therapy/fitness for LBP of greater than 6 weeks duration (38). In patients with subacute LBP light multidisciplinary treatment programs have been shown to be more effective than treatment as usual for return to work (73,94,95,128,138). A Cochrane Collaboration review concluded that there is moderate evidence that multidisciplinary rehabilitation is effective for subacute LBP (105).
Two studies found that either lay-led or professional-led instruction in self care and worry reduction were both successful in reducing back-related worry, fear-avoidance beliefs, pain severity and activity intolerances (173,260). A long term follow-up study led by Indahl focused on education designed to reduce fear (94, 95). Patients were informed that light activity would not injure the disc, but instead speed recovery. The return to work rate was double the control group. Hagen reported at 1 year follow-up that light activity, education about the benign nature of pain, and encouragement to stay active achieved a significantly greater return to work rate than those who received more traditional management (73). These studies utilized graded exposures which means that patients exercise included movements which were perceived as threatening by the patient. Loisel’s group demonstrated that a work site visit improved the success of the program (138,139).
A recent randomized, controlled trial of 160 LBP patients found that adding manual therapy to reactivation advice was shown to be superior to reactivation advice alone (68). Similarly, a pragmatic study of “best care” vs manipulation followed by exercise, exercise alone, or manipulation alone for 1334 subacute LBP patients in England was recently published (247). “Best care” involved giving advice to gradually resume near normal activities along with a copy of The Back Book. Relative to “best care” the manipulation followed by exercise group had the best patient outcomes (disability, pain, adverse back pain beliefs, and general physical health) at both 3 and 12 month follow-up, whereas the manipulation alone group was the most cost-effective (247, 248).
16. Chronic Phase Reactivation and Exercise (after 12 weeks)
A large number of well-controlled studies have shown that exercise is an effective treatment for chronic LBP. A Cochrane Collaboration review of exercise (257) concluded that, “…there is strong evidence (Level 1) that exercise therapy is more effective than usual care by a general practitioner for chronic low back pain.” Two recent studies strongly suggest that exercise has a long-term beneficial effect in the management of chronic LBP (83,234). Both studies utilized exercise programs which focused on training coordinated movements and included evaluation of results during a prolonged follow-up period.
O’Sullivan et al. showed that specific spine stabilization exercises achieved superior outcomes to isotonic exercises in chronic patients with spondylolysthesis (190). Manniche et al demonstrated that an isotonic regime emphasizing endurance training was successful in improving outcomes (150). In a large, randomized controlled clinical trial Timm showed that exercise was superior to passive care in treating failed back surgery patients (242). In this study a further comparison of exercise types showed that low-tech exercise (McKenzie and stabilization) was superior to high-technology exercise (isotonics & Cybex).
The McKenzie method was shown to be as effective as an isotonic strengthening program in a recent randomized, controlled trial of subacute and chronic patients (pain duration of at least 8 weeks) (199). The course of treatment was 8 weeks of supervised training. McKenzie was superior at a 2 month follow-up, but no differences were noted at 8 month follow-up.
The Quebec Whiplash Associated Disorders (WAD) guidelines recommended early, active intervention (including manipulation) (227) (see table 1-8).
Treatment following these guidelines has recently been shown to be much more effective than traditional passive based care (213). Clinically important symptoms at 6 months post-accident were present in only 10% of properly managed patients (early active intervention with submaximal movements identified by McKenzie evaluation) as compared with the greater than 50% of those given standard care (soft collar, initial rest, gradual mobilization).
Jull has recently demonstrated that a combination of manual therapy and exercise training which improves deep neck flexor function correlates with improved recovery in chronic neck pain patients following a whiplash injury (102).
Here is a complete list of references from Chapter One – I’m sure you will find points of interest that may be useful in addition to those referenced above.
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