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Foundations of

Chiropractic Practice:
Updating Ourselves by
Dr. John J. Triano.
CP 2203 FLIP CLASS
Dr. Simon Wang

Part 1

Part 1 - 2 minutes each


Take 2 minutes each to discuss with a partner what you got from part 1 of Dr.

Trianos talk

How is treating a patient like going


through the scientific method?
Come up with a hypothesis, then do an experiment with your patient

(orthopaedic test, treatment), then check your results (re-evaluate your


patient).

Why should we study the


mechanisms of manual therapy?
IF you dont know how it works, we dont know
how it helps people
How to optimize results (promoting appropriate use of manual therapy
Who does the treatment work best for (target population)
No point on doing more RCTs if you dont know mechanism
RCTs are having a decreased return on investment (ROI)

What do we tell the patient we


do?
Normalize and optimized function
Health care discipline that focuses on prevention of disease and maintenance

and improvement of health related to mechanical disorders, specifically


Musckuloseklteal system

W treat aberrations of health and wellbeing that either are caused by or

manifest as mechanical problems.

Where is our entry to health?


Where do chiropractors fit in?
Normalization of movement

Part 2
View only section
Any thoughts or comments?

Part 3

Part 3 - 2 minutes each


Take 2 minutes each to discuss with a partner what you got from part 3 of Dr.

Trianos talk

Fill in the dysfunctional


movement model

Dysfunctional Movement: Local and Remote


Dashed lines represent assumed pathways.
Local Effects

Overload event

6. Local tissue
stress
concentration

1. Cortex:
Volitional task
commands
7.

2. Cerebellar
&?
Coordination

Remote
Effects

Asynchronous
proprioceptiv
e &
nociceptive
bombardment

9.

3. Spinal Cord:
Asynchronous
feedforward/feedbac
k neuromotor control
3a. Motor,
sensory,
autonomic
responses.
3b. Neurohumoral
responses

Copyright JTriano DC, PhD January 2016


Draft

Pain, swelling,
cytokine
release

4. Asynchronous
intrinsic & extrinsic
spinal muscle
stabilizers

5.
Asynchronous
motion

How did Hartman in 2014 demonstrate the


connection between mechanotransduction and
mechanotransduction disease? What
experiment did he do?
Hartman loaded a spinal unit in multiple directions and measured the

changes in chemical messengers, based on different loading

They found applied load (I.e. facet gapping versus compression) dictated

production changes (pro-inflammatory and catabolic loss, respectively)

Hartman RA. MECHANOBIOLOGY OF COMPLEX LOADING IN FUNCTIONAL


SPINAL UNITS. PhD Thesis 2014 University of Pittsburgh
The objective of this study was to determine the effect of spinal F/E on
catabolism and inflammation simultaneously in all types of spinal tissue
AF, NP, FC, and LFin viable FSUs.

14

What did the studies by Drs. Stephen Injeyan and Julieta


Teodorczyk-Injeyan on SMTs effects on chemical
mediators (immunoregulatory, pro-inflammatory, antiinflamatory) in LBP patients find, regarding acute and
chronic LBP group responses?
Acute and chronic LBP patients have different chemical mediator response to

SMT

Demography, pain and functional outcomes


Asymptomatic
(n=20)

Acute
(n=15)

Chronic
(n=19)

Age

32
(22-45)

41
(23-48)

45
(26-59)

Gender
(m/f)

14/6

11/4

10/9

VAS 1

__

6.1

5.2

VAS 2

__

2.4

2.7

OS 1

__

51

27.6

OS 2

__

13

17

VAS: 10 point visual analogue scale


OS: Oswestry (%)

Effect of SMT on the production of pro-inflammatory


mediators

*
*

*
* P<0.05

Effect of SMT on the production of anti-inflammatory mediators

Effect of SMT on the production of immunoregulatory


mediators
*

* P<0.05

Part 4

Part 4 - 1 minute each


Take 1 minute each to discuss with a partner what you got from part 4 of Dr.

Trianos talk

What 3 levels of the dysfunctional


movement model does manual
therapy act, based on the current
evidence?
1. Local tissue stress concentration
2. Asynchronous proprioceptive and nociceptive bombardment
3. Black box between CNS and spinal cord (changes in pain (DIPM) and motor

Dysfunctional
Movement:
Overload
event
1. Cortex:
Volitional task
commands

6. Local tissue
stress
concentration

2. Cerebellar
& brainstem
Modulation

7.
Asynchronous
proprioceptive
& nociceptive
bombardment

9.

3. Spinal Cord:
Asynchronous
feedforward/feedback
neuromotor control

3a. Motor, sensory,


autonomic responses.

Pain, swelling,
cytokine release

4. Asynchronous

intrinsic &
extrinsic spinal
muscle stabilizers

5.
Asynchronous
motion

Part 5

Part 4 - 1 minute each


Take 1 minute each to discuss with a partner what you got from part 5 of Dr.

Trianos talk

Does technique
(applications
characterisitcs)
matter?
Yes, all the following have been shown to matter in muscle and afferent signal

response.
Preload

Preload positioning
Peak force amplitude
Rate of rise in force (speed)

Do chiropractors use too much


force during cervical SMT?
No
ROM of neck from flexion to extension causes 200N (at extension)
SMT of cervical spine causes 90N

Cervical HVLA Force


amplitudes

Neck loads during movement

LH Force Magnitude +/- S.E.


90
80
70
60

Newtons

50
40
30
20
10
0
-10
-20

Force matters!
1 Second

Triano PhD Thesis, University of Michigan 1998


Anderst et al. Subject-Specific Inverse Dynamics of the Head and Cervical Spine During in Vivo
Dynamic Flexion-Extension. J Biom Eng 2013

Individual work

Please grow your portfolio


Reflection assignment:

1. Please take some time and reflect on this class discussion

2. Answer this question in plain language (for your patient):


Why has my back pain not improved on its own?
Use the dysfunctional movement model as the basis for you explanation
Also add this to your portfolio:

3. All pre-work questions & answers

4. All class discussion notes (this lecture will be re-posted on KIRO)


Please submit your link via KIRO assignments by February 2nd, 2017
This will account for 5% of your grade.

Questions or
comments?