How to confidently communicate the science of chiropractic

1. How to confidently communicate
the science of chiropractic
Introductory Workshop
Dr Heidi Haavik
DG Melbourne 22nd February 2014
PhD, PG Dip, BSc (chiro), Bsc (physiology)
Director of Research, New Zealand College of Chiropractic
Adjunct Professor, Master of Health Sciences Program, University of Ontario Institute of Technology
World Federation of Chiropractic Research Council member

2. My background
 1999 University of Auckland, BSc, Physiology
 1999 Chiropractic degree from NZCC
 2000 Private chiropractic practice
 2003 University of Auckland, PG Dip (Science)
 2006 Director of Research, NZCC
 2007 Editorial board Journal of Chiropractic Education
 2008 PhD University of Auckland
 2009 Editorial board member of JMPT
 2011 World Federation of Chiropractic Research Council
 2011 Associate Graduate Faculty Member, UOIT
 2014 Adjunct Professor, Master of Health Sciences
Program, University of Ontario Institute of
Technology, Ontario, Canada.

3. My background
 15 national and international research awards
 ½ million dollars in national and international research grants
 Developed, course-coordinated and lectured in Neuroscience,
Research Methodology, Visceral Physiology, Professional
Development, etc.
 Co supervised 5 MSc students and 1 PhD student
 Authored 23 peer reviewed research manuscripts
 51 peer reviewed abstracts presented
 40 invited or keynote presentations in NZ, Australia, Europe and
USA
 Chiropractic, Research & Neuroscience business for 14 years

4. Heidi’s Vision
 A world of people expressing optimal
potential

5. Heidi’s mission
 Run a ridiculously successful and
Vitalistic International Centre for
Chiropractic Research

6. Heidi’s why
 To allow more people access to
chiropractic care through he
power of cutting edge top quality
research about mechanisms

7. Heidi’s role
1. Facilitate research
2. Mentor researchers
3. Inform / teach
4. Raise funds

8. Purpose of Today
That you can confidently talk
about the science of chiropractic

9. AIM: Confident Communication!
 Knowing what you can and cannot say
about the science of chiropractic

10. 10

12. Outline for the day
 Where are you at now?
– Where do you want to get to?
– How I can best help you
 The Brain 101
 The big picture - chiropractic
 Science 101
 How to talk about specific
studies

13. heidi.haavik@nzchiro.co.nz

14. heidihaavik.com
• Written for the public
• Describes in easy to
understand language
what happens when we
adjust a VS

15. heidi.haavik@nzchiro.co.nz

16. Where are you at now?

17. In pairs (one being the chiro, the other
the patient) each take turns explaining:
 What a subluxation is
 How chiropractic care works

18. How did that go?
Where you
confident?
Do you know if your
‘story’ has scientific
backing?

19. The big
picture
In a nutshell
What is a subluxation?
How does chiropractic
care work?

20. A subluxation is.....
“a central segmental
motor control problem”
Which means that the central nervous system is not
controlling the movement pattern of the spinal
segment as it should, which alters the stretching of
the paraspinal muscles which changes the input to the
brain which impacts how it processes other
information

21. So that it can accurately perceive
what is going on and respond
appropriately
which in turn improves the
communication between your brain,
the body and the environment
Chiropractic is a healing art that
improves the health and function of
the spine

23. Wisdom vs Knowledge

24. 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)

25. My potential role
 Help you communicate about the key neuroscience concepts
vital to understand how chiro care likely works
 Help you to understand and communicate about the
chiropractic relevant neuroscience research
 To patients, the public, and to other health care providers
 Help you to understand and communicate about the
chiropractic relevant neuroscience research specific to
particular groups
 Sports, paediatric, asymptomatic,

26. What I can help you with
Various topics:
 Research and science
 Difference between different research methods
 Evidence based practice
 Sensorimotor integration
 Mulitimodal integration
 Neural plasticity
 Inner body schema – inner brain reality
 How the brain works

27. Various topics
 Functional role of paraspinal muscles
 Segmental movement research and biomechanics
 Sensory chiro research
 SMI chiro research
 Motor control chiro research
 Functional outcomes chiro research
 Clinical chiro research
 Props to use to explain each topic

28. Props are helpful!!
• Simple tests you can do in your office
• Poster for the Office to help explain mechanisms
• Office brochures explaining mechanisms
• A book for the patient (fully referenced)

29. Office Poster

30. Patient pamphlet

32. The Brain & CNS 101

34. 34

35. The Matrix

36. Principles of Neural Science by Eric R. Kandel,
James H. Schwartz, and Thomas M. Jessell.
Elsevier, 2000, 4th Ed, Ch 33, p. 654
 “IN THE PRECEDING PART of this book we
considered how the brain 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 the motor
programs responsible for purposeful
movement.”
This is SENSORI-MOTOR-INTEGRATION
This is MULTI-MODAL-INTEGRATION

37. In pairs, take turns explaining to each
other the following concepts:
 Multimodal integration and the
inner brain reality
 Sensorimotor integration and its
importance for accurate purposeful
movements

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

39. The inner brain reality
is it always accurate?

40. Phantom limb pain

41. Moseley GL, Olthof N, Venema A, Don S, Wijers M, Gallace A, Spence C. 2008.
Psychologically induced cooling of a specific body part caused by the illusory ownership of an
artificial counterpart Proc Nat Acad Sci USA; 105(35):13169-73. Copyright (2008) National
Academy of Sciences, U.S.A.

42. Central filtering of info
Sensory information in the central nervous
system is processed in stages, in the
sequential relay nuclei of the spinal cord, brain
stem, thalamus, and cerebral cortex. Each of
these processing stations brings together
sensory inputs from adjacent receptors and—
using networks of inhibitory neurons—
transforms the information to emphasize the
strongest signals.
Kandel, Schwartz, and Jessell, 2000, p.428

43. “We are continuously exposed to stimulation across
our senses; some of which is relevant to the task at
hand but most of which is not. The ability to isolate
and process appropriate sensory stimulation whilst
inhibiting irrelevant stimulation is essential in order to
achieve our goals in a timely and efficient manner.
However as we age it is thought that the inhibition of
irrelevant information becomes more difficult such
that available sensory information is processed more
extensively.”
(Setti et al 2011, Experimental Brain Research, 209;p.379)

44. Brain fills in the gaps and/or alters your
reality based on past expectations,
surrounding information and intentions.
““Ceoinsdr the anmzaig pweor of the
hmuan biran. It dseno’t metatr in waht
oredr the lrttees in a wrod are, the
olny tihng taht is iproamtnt is the frsit
and lsat ltetres are in the rghit pclae.
The rset can be a tatol mses and you
can sitll raed it wuhotit a plboerm.
Azanimg huh?”

45. Morning Tea
 9.35 – 10.20

46. Video clip – TEDxAdelaide - Lorimer Moseley -
Why Things Hurt:
http://www.youtube.com/watch?v=gwd-wLdIHjs
Pain and Plasticity

47. “We can mess with that”

48. 48

49. Blind spot testing

50. Neural plasticity

51. Neural Plasticity
“Many important behaviors are learned. Indeed, we
are who we are largely because of what we learn and
what we remember. We learn the motor skills that
allow us to master our environment, and we learn
languages that enable us to communicate what we
have learned, thereby transmitting cultures that can
be maintained over generations. But not all learning is
beneficial. Learning also produces dysfunctional
behaviors, and these behaviors can, in the extreme,
constitute psychological disorders.”
Kandel, Schwartz, and Jessell, 2000, p.1228

52. Maladaptive vs Adaptive Plasticity

53. Maladaptive vs Adaptive Plasticity

55. Symptoms don’t just appear out of thin air

57. Neuroscience concepts covered:
 CSN, PNS, neurons, synapses, networks
 Internal representations
– Internal body schema
– Inner Matrix
 Problems with false internal body schema
– Phantom limb pain, tinnitus, and on smaller
scale
 Central filtering
 Brain filling in the gaps (blind spot)
 Neural plasticity (good and bad)
 Sensorimotor integration and movement control

58. The connection
between the
neuroscience and
chiropractic!

59. Paraspinal Muscles act as CNS sensors

61. Spinal muscle afferents are important
for the brain sensory integration of other
afferent input
Uthaikhup et al 2006. The influence of neck pain on sensorimotor function
in the elderly Archives of Gerontology and Geriatrics; 55 p.667

62. Spinal
adjustments
Appropriate
joint movement
Appropriate spinal
information sent to
brain and CNS
Appropriate
processing and
integration
by brain and CSN
Better control
of the spine
and body

63. The specific research hypothesis
Spinal
adjustments
Abnormal
Somatosensory
Filtering & processing
Altered function
(pain and disability)
Altered
sensorimotor
integration
Altered
motor control
Altered
afferent
input
Subluxation
Appropriate
Joint
movement
Normal
afferent
input
Appropriate
Somatosensory
Filtering & processing
Appropriate
sensorimotor
integration
Accurate
motor control
Good function

64. What evidence is there for this model?
Abnormal
Somatosensory
Processing
Altered function
(pain and disability)
Altered
sensorimotor
integration
Altered
motor control
Altered
afferent
input
Subluxation
Marshall & Murphy, 2006
Murphy et al, 2009; 2010
Haavik & Murphy 2012b

65. What evidence is there for this model?
Spinal
manipulation
Abnormal
Somatosensory
Processing
Altered function
(pain and disability)
Altered
sensorimotor
integration
Altered
motor control
Altered
afferent
input
Joint
dysfunction
Appropriate
Joint
movement
Appropriate
afferent
input
Appropriate
Somatosensory
Processing Appropriate
sensorimotor
integration
Accurate
motor control
Good function
Marshall & Murphy, 2006
Murphy et al, 2009; 2010
Haavik & Murphy 2012b

67. 67

68. Amplitude
Time
Signal
Background
noise

69. Amplitude
Time

70. Aberrant spinal movement
 Can mean that the brain may not be fully aware of what is
going on in your spine, which appears to influence how it
controls the rest of the body
– Growing body of research supports this!
 May impact the accuracy of our Matrix
– Theory, but with some evidence that suggests this
 Spinal function impacts integration of sensory information
 Growing body of research supports this!
 This could lead to accidents, the develop pain and
dysfunction, syndromes, conditions, etc.

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

72. A subluxation is.....
“a central segmental
motor control problem”
Which means that the central nervous system is not
controlling the movement patter of the spinal segment
as it should, which alters the stretching of the
paraspinal muscles which changes the input to the
brain which impacts how it processes other
information

73. 7 essential components
1. Neuroplasticity - Good or Bad
2. Inner brain reality / body schema
3. Subconscious processing
4. Brain fill in the gaps & filters info
5. Paraspinal muscles are SENSORS
6. What happens when a segment is not moving properly
7. What happens when we adjust these

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

75. 7 essential components
1. Neuroplasticity - Good or Bad
2. Inner brain reality / body schema
3. Subconscious processing
4. Brain fill in the gaps & filters info
5. Paraspinal muscles are SENSORS
6. What happens when a segment is not moving properly
7. What happens when we adjust these

76. Take 10 minutes to plan your 10 min talk about
the mechanisms of chiropractic care for a
patient’s Report of Findings. Include the
following components and use SIMPLE examples
1. Neuroplasticity - Good or Bad
2. Inner brain reality / body schema
3. Subconscious processing
4. Brain fill in the gaps & filters afferent info
5. Paraspinal muscles are SENSORS
6. What happens when a segment does not move
properly
7. What happens when we adjust these segments
Include in your the plan the use of Office Poster & Pamphlet!

77. 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

78. In groups of 3 Practice
the talk!
 One be the Chiro
 One the patient
 One take notes and provide feedback
 Rotate so everyone gets to try being
the chiropractor.
 Debrief after each round about what
worked well and what did not

79. Lunch
 12.30-1.45

80. Recap of Morning Session
Questions?

81. Review and you will
remember 70% more!

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

83. Neuroscience concepts covered:
 CSN, PNS, neurons, synapses, networks
 Internal representations
– Internal body schema
– Inner Matrix
 Problems with false internal body schema
– Phantom limb pain, tinnitus, and on smaller
scale
 Central filtering
 Brain filling in the gaps (blind spot)
 Neural plasticity (good and bad)
 Sensorimotor integration and movement control

84. Link between neuro to chiro concepts
covered:
 Functional role of paraspinal muscles
 The muscle spindle
 Where spindle info goes
 How spindle info impacts brain function
 Descending brain control of ...... everything
 The research model
 Effects of VS (too much or too little movement)
– Signal to noise ratio
– Working in the dark

85. Science & Research 101

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

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

88. Clinical
research
Basic
Science
Research

89. The floor-plan research
methodology analogy

90. Basic Science
Qualitative researchClinical Trials
RCTs
Case reports
Copyright ©Dr Heidi Haavik 2014

91. Systematic Reviews
Editorials, Expert Opinion
Randomised Controlled Trials
Cohort Studies
Case-control Studies
Case Series, Case Reports
The hierarchy
of evidence

92. 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 have when doing
research into the subluxations and effects of adjusting them?
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?

93. 2. Issues for scientists wishing to explore the
subluxation and the effects of the adjustment
 An intervention is supposed to be properly defined
and repeatable
– What is a subluxation?
– How do you find one?
– Can you find them reliably?
– What is the spinal manipulation / adjustment
intervention?
– Can it be repeated in a reliable manner?

94. 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?

95. Simple balance testing in the Office
Copyright ©Dr Heidi Haavik 2014 Copyright ©Dr Heidi Haavik 2014

96. Scrambled sentence & Blind spot
testing
Blind spot test
and instructions
in your booklet

97. Square Illusion

98. In groups of 3 practice these tests on
each other (patient, chiro, assessor)
 Square A and Square B illusion
 Blind spot testing
 Scrambled sentence
 Rhomberg’s testing
 Assessor: how are they communicating this, do
they seem confident, can they answer questions,
are they using their new knowledge?

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

100. Afternoon Tea
 3.00 – 3.45

101. Lets get stuck into some studies

102. Clinical research
 Read and be able to discuss the RCTs and reviews
that demonstrate spinal manipulation is as good as
anything else out there for
– Back pain (E.g. UK BEAM study 2004 BMJ; LBP Brontfort et
al 2008; AM-LBP - Bishop et al 2010)
– Neck pain (Haldeman S, Carroll L et al. (2008) The Bone and
Joint Decade 2000-2010 Task Force on Neck Pain and Its
Associated Disorders; Executive Summary, Spine 33(4S):S5-S7)
– Headaches (See review in The chiropractic report Sept 2010)

103. Clinical research
 And that chiro patient satisfaction is MUCH better
than other care (See review in The chiropractic report Jan
2007)
 And we are more cost effective (See review in The
chiropractic report Nov 2009)
 And we are safe (Cassidy JD, Boyle, E, Cote et al. 2008 Risk of
Vertebrobasilar Stroke and Chiropractic Care: Results of a
Population-Based Case-Control and Case-Crossover Study, SPINE
33(4S): S176-183)
 There is even evidence for maintenance care for
low back pain (Senna MK, Machaly SA. 2011. Does Maintained
Spinal Manipulation Therapy for Chronic Non-Specific Low-Back Pain
Result in Better Long Term Outcome? SPINE)

104. In groups of 3 practice telling your
patient about the clinical research
there is about chiropractic
 See if you can turn the subject’s
attention from the clinical research to
the basic science research in simple
language

105. Feedforward Activation
(Marshall & Murphy. J Manipulative Physiol Ther 2006;29:196-202)
(Govorko,MScThesis,2007,p.106)

106. (Marshall & Murphy. J Manipulative Physiol Ther 2006;29:196-202)
Pre Adjustments
Post Adjustments
17/90 impaired FFA
13/17 retested
6 month later
38% improvement
in FFA times after
SI adjustments

107. Example 1
 This is what they did and this is what they found:
– They tested 90 healthy young male cricket players in their ability to feed-forward
activate their abdominal muscles - 19/90 could not
– Six months later 13/17 still could not
– One adjustment session – 40% improvement
 This is what this means to you
– You may not be able to feed forward activate your core abdominal muscles
– These are important low back support mechanism for you
– If you cannot you are basically causing mini low back whiplash each time you lift
your arm
– No symptoms in those guys, so you may not have felt it either – so can be why
your low back pain started.... You said you did not know why
– We know being unable to activate core muscles leads to LBP
 Caution/Limitations.......... ‘BUT...’
– You are a woman, the study was only on men
– We dont know how long the effects last, was only one pre/post

108. Practice this
 In groups of three (chiro, patient, assessor) practice telling a
patient about this study. Remember:
– What did they do
– What did they find
– What does this mean to your patient
– But....limitations of study
 Swap around so everyone has a go at being chiro
 Assessors: please provide feedback to chiropractor!
 Patient:
– create a story for the chiro (e.g. I’m a 48 female with LBP)
– And ask questions like – why did I get low back pain, I
had no injury, it just happened, why would chiropractic
work for me?

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

110. (Award winning poster at 2009 WFC; Award winning paper at ACC RAC 2010)
Haavik & Murphy, 2011,
JMPT; 34:88-97
Copyright ©Dr Heidi Haavik 2014

111. Example 2
 This is what they did and this is what they found:
– Twenty-five SCNP participants and 18 control participants were tested for their elbow
JPS before to see if SCNP participants JSP was worse than controls – and they were!
– The SCNP group then were retested after either SM or control intervention. SM
improved elbow JPS!!
 This is what this means to you
– If your brain is not fully aware of where your elbow is, it could be why you keep
knocking it in doorframes
– This study suggests that spinal function impacts how accurately your brain can
interpret propriocpetive information from your arms
 Caution/Limitations.......... ‘BUT...’
– 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 anckle study showed effects of 12 weeks chiro care, but no follow up done

112. Practice this
 In groups of three (chiro, patient, assessor) practice telling a
patient about this study. Remember:
– What did they do
– What did they find
– What does this mean to your patient
– But....limitations of study
 Swap around so everyone has a go at being chiro
 Assessors: please provide feedback to chiropractor!
 Patient:
– create a story for the chiro (e.g. I’m a 48 female with LBP)
– And as questions like – why did I get low back pain, i had
no injury, it just happened, why would chiropractic work
for me?

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

114. Feedback Please

115. Resources & further info:
 Intermediate model here next year
 My book www.heidihaavik.com
 CJA and JEK review articles – email me!!
 CAA online learning modules
 NZCA/CCR online learning modules
 Seminar series like this to be run in NZ
 And Australia?