Chiropractic + Naturopathic Doctor • December 2016 • Roundup

TORONTO – Canada needs a comprehensive national strategy to curb rampant overprescribing of opioids and to reduce escalating numbers of deaths caused by overdoses of the powerful narcotics, addiction experts say.

Writing in a recent edition of the Canadian Medical Association Journal, Dr. Benedikt Fischer of the Centre for Addiction and Mental Health (CAMH) and co-authors say an estimated 2,000 Canadians died from opioid overdoses in 2015, and many provinces are on track for an even higher number of deaths in 2016.

“It’s a real public health disaster,” Fischer said in an interview. “Over the last 10 years, we’re looking at somewhere between 10,000 and 20,000 dead people in Canada just from opioid overdoses alone.”

In a separate report, the Toronto centre urged Ottawa to launch a review of all prescription painkillers sold in Canada and said highdose opioid medications should be pulled from the market.

Worldwide, Canadians are the second-highest consumers of prescription opioids like oxycodone, hydromorphone and fentanyl, after the U.S.

“We have hundreds of thousands of people now who are dependent on these drugs because of misuse or overprescribing or excessive exposure,” said Fischer, laying the blame on the medical system that sees too many physicians prescribing the drugs for chronic pain, when research “clearly shows” it is not efficacious for that kind of pain and can actually do harm.

Medical evidence suggests opioids should be restricted to patients with acute pain, such as that related to cancer or following surgery, and should be given in limited doses and for a short duration to prevent dependence, as well as accidental overdoses.

But instead of focusing on overprescribing – the major driver of opioid misuse and abuse – Fischer said governments and the medical system have instead tinkered with downstream effects, such as increasing access to naloxone, a drug that can reverse an opioid overdose, and treatment of dependency with another medication called suboxone.

While Ontario has delisted Oxycontin on its provincial drug benefit program, that move merely shifted the problem to other prescription opioids like morphine and fentanyl patches, said Fischer.

However, the Ontario government announced in July it would remove those highdose opioids from its insurance plan next year, except for patients requiring the medications for palliative care.

“Regulators and authorities have been watching this problem not just unfold but grow and get worse and worse, and didn’t really take effective action,” said Fischer.

“It is late – but not too late – to move toward reducing the toll of opioid overuse and abuse in Canada,” Fischer said.

DOCTORS are warning about vitamin D again, and it’s not the “we need more” news you might expect. Instead, they say there’s too much needless testing and too many people taking too many pills for a problem that few people truly have.

Misunderstandings about the recommended amount of vitamin D have led to misinterpretation of blood tests and many people thinking they need more than they really do, some experts who helped set the levels write in the New England Journal of Medicine.

Correctly interpreted, less than six per cent of Americans aged one to 70 are deficient and only 13 per cent are in danger of not getting enough.

That’s concerning, “but these levels of deficiency do not constitute a pandemic,” the authors write. Yet people may think there is one.

Blood tests for vitamin D levels – not advised unless a problem like bone loss is suspected – are soaring. Under Medicare, there was an 83-fold increase from 2000 to 2010, to 8.7 million tests last year, at $40 apiece. It’s Medicare’s fifth most common test, just after cholesterol levels and ahead of blood sugar, urinary tract infections and prostate cancer screening.

Vitamin D pill use also grew, from five per cent of Americans in 1999 to 19 per cent in 2012.

That may be due to many reports suggesting harm from too little of “the sunshine vitamin.”

The bottom line, experts say: Get 600 to 800 units a day from food or supplements and skip the blood test unless you have special risk factors.

Many of the doctors and volunteers who attend chiropractic mission trips abroad and briefly leave their comfortable lives in North America discover that the needs of the people they serve are far greater and more desperate than they realized. This has certainly been the case for thousands of volunteers who have been traveling to the Dominican Republic, one of the regular international countries ChiroMission serves.

ChiroMission is a not-for-profit organization headquartered in Forest Lake, Minn., that has been conducting outreach in poor communities since 2001. It is also dedicated to providing, teaching and spreading the good news about chiropractic to the world, helping improve health outcomes in communities.

Last September ChiroMission teamed up with Dreamweaver International’s Gear for Goals sports project to bring the largest, single delivery of baseball equipment to the Antero Mota Baseball League in Puerta Plata, Dominican Republic.

The goal of the project was to bring 1,000 lbs. Of new and used sports equipment, which participating doctors collected from their patients. The sports gears were provided to the baseball program during a planned tournament that ChiroMission, Gear for Goals and Antero Mota hosted together.

Dreamweaver’s executive director Dr. Warren Bruhl wanted to add to this outreach to see if ChiroMission could help Antero Mota build a bathroom on their baseball field. For over four decades, the local baseball program has struggled to just supply enough equipment for the youth to fuel their baseball dreams of stardom, and has been unable to organize and collect enough money to build a restroom for players and spectators. As a result, some of the players end up literally urinating on the wall or in a ditch at the corner of the baseball fields.

Bruhl and ChiroMission leaders, Dr. Jason Gerard and Jeff Cobelli, wanted to try something new and see if they could help them solve this problem. They asked the local coaches to price the donated equipment for sale and then offer it to parents and other coaches. In turn, all the money raised would be donated back to the Antero Mota program to build the bathroom.

Not only did the community respond, they were thankful to be able to purchase the baseball equipment in lieu of receiving it for free. They appreciated the partnership to co-create a way they could build the bathroom and give their youth the equipment required to fuel their talent.

In just one day, chiropractors and coaches raised more money than was ever raised in 30 years combined.

Since 2012, Bruhl, a Chicago area chiropractor, has been executive director for Dreamweaver International and the leader for the charity’s sport project Gear for Goals. The mission of Gear for Goals is to bring hope and opportunity to the one billion children living in poverty around the world. One out of every two children still lives in poverty. Their opportunity for an education and meaningful purpose is often bleak. But hope is tangible and there are some signs of positive change, especially when sports development is part of the programming.

Working with compassionate partner charities, churches and volunteers, Gear for Goals has provided sports gear to over 550,000 children in 30 countries. Gear for Goals and ChiroMission have been teaming up over the past four years and helping nearly 50,000 children in the Dominican Republic alone.

ChiroMission president, Dr. Jason Gerard, appreciates the value of a partnership and recognizes the needs of the people are immense. When we can come together with other charities and local leaders, we have a much better chance of making lasting change for the community, he said.

IF YOU’RE ANGRY or upset, you might want to simmer down before heading out for an intense run or gym workout. A Canadian study ties heavy exertion while stressed or mad to a tripled risk of having a heart attack within an hour.

New research led by the Population Health Research Institute at McMaster University in Hamilton, Ont., suggests there may be better or worse times to exercise, and that extremes can trigger harm.

The study was published in the American Heart Association journal Circulation last October.

Barry Jacobs, a psychologist at the Crozer-Keystone Health System in suburban Philadelphia and an American Heart Association volunteer, said the study is further evidence of the connection between mind and body.

“When you’re angry, that’s not the time to go out and chop a stack of wood,” said Jacobs, who was not involved in the study.

Earlier studies have looked at anger and exertion as heart attack triggers, but most were small or in one country, or included few women or minorities. The new study involved 12,461 people suffering a first heart attack in 52 countries. Their average age was 58 and three-fourths were men.

They answered a survey about whether they were angry or upset, or had heavy exertion, in the hour before their heart attack or during the same time period the previous day. That way researchers could compare risk at different times in the same people and the effect of these potential heart attack triggers.

Being angry or upset doubled the risk of suffering heart attack symptoms within an hour; heavy physical exertion did the same. Having both at the same time more than tripled the risk for a heart attack.

The risk was greatest between 6 p. m. and midnight, and was independent of other factors such as smoking, high blood pressure or obesity.

Big caveats: Patients reported their own stress or anger, and people who just had a heart attack may be more prone to recall or think they suffered one of these triggers than they otherwise might have been. Also, strenuous exertion is whatever the patient perceives it to be – for some people that could be climbing stairs and for others, running a marathon.

The study also is observational, so it cannot prove cause and effect. But it’s likely to be the best kind of information available – it’s not possible to randomly assign people to be angry and exercise, then see how many have heart attacks.

“This is a large enough sample size that we can put stock in the findings,” Jacobs said.

The study’s findings also are biologically plausible. Emotional stress and exertion can raise blood pressure and heart rate, change the flow of blood in the vessels and reduce the heart’s blood supply, said the study leader, Dr. Andrew Smyth of McMaster University. In an artery already clogged with plaque, a trigger could block blood flow and lead to a heart attack.

“From a practical perspective, there will be times when exposure to such extremes is unavoidable,” Smyth said.

“We continue to advise regular physical activity for all, including those who use exercise to relieve stress,” but people should not go beyond their usual routine at such times, he said.

CHICAGO – Millions of people take opioids for chronic back pain, but many of them get limited relief while experiencing side effects and worrying about the stigma associated with taking them, suggests research presented at the Anesthesiology 2016 annual meeting.

More than 100 million people in the United States suffer from chronic pain, and those with chronic low back pain are more likely than patients with other types of pain to be prescribed opioids. Unfortunately, these medications are addictive and can cause side effects.

“Patients are increasingly aware that opioids are problematic, but don’t know there are alternative treatment options,” said Dr. Asokumar Buvanendran, lead author of the study, director of orthopedic anesthesia and vice-chair for research at Rush University, Chicago, and vice-chair of the American Society of Anesthesiologists Committee on Pain Medicine.

“While some patients may benefit from opioids for severe pain for a few days after an injury, physicians need to wean their patients off them and use multimodal therapies instead,” Buvanendran added.

In the study, 2,030 people with low back pain completed a survey about treatment. Nearly half (941) were currently taking opioids. When asked how successful the opioids were at relieving their pain, only 13 per cent said “very successful.” The most common answer – given by 44 per cent – was “somewhat successful” and 31 per cent said “moderately successful.” Twelve per cent said “not successful.”

Seventy-five per cent of the respondents said they experienced side effects including constipation (65 per cent), sleepiness (37 per cent), cognitive issues (32 per cent) and dependence (29 per cent).

Respondents also had concerns about the stigma associated with taking opioids. Forty-one per cent said they felt judged for using opioids. While 68 per cent of the patients had also been treated with antidepressants, only 19 per cent felt a stigma from using those.

A major pharmaceutical company recently agreed to disclose in its promotional material that narcotic painkillers carry serious risk of addiction and not to promote opioids for unapproved, “off-label” uses, such as long-term back pain. Researchers also note a lack of solid studies on the effectiveness of opioids in treating back pain beyond 12 weeks.

It’s never too late to reap the benefits of exercise, and that includes older adults with arthritis and other muscle and joint conditions, according to a study. Researchers at Hospital for Special Surgery (HSS) found that a low-impact exercise program in senior centers in New York City’s Chinatown and Flushing, Queens communities helped decrease pain, improve mobility and enhance quality of life for many participants.

The study, titled, “Effects of a Culturally Tailored Low-Impact Exercise Program for Chinese Older Adults in NYC,” was presented at the American Public Health Association annual meeting on November 1st in Denver.

According to the Centers for Disease Control and Prevention, Asian seniors had the highest rate of physical inactivity (defined as no physical activity beyond basic daily life activities), 29 per cent of them lived in poverty, and 75 per cent had limited English language proficiency in 2012. In addition, Chinese Americans were less likely to seek health care because of cost and language and cultural barriers.

“In 2011, HSS developed the Asian Community Bone Health Initiative, a culturally- tailored low-impact exercise program aimed at improving musculoskeletal health in the underserved Chinese older adult community,” said Minlun (Demi) Wu, research coordinator, Department of Public & Patient Education at Hospital for Special Surgery.

“Joints will often stiffen if not used, and muscles will weaken if not exercised. Our bodies are meant to move, and inactivity leads to weakness and stiffness, and joints with arthritis often worsen with inactivity,” said Dr. Theodore Fields, director, Rheumatology Faculty Practice Plan at HSS.

The exercise classes, which were free and open to community members, took place once a week for eight weeks. Participants performed chair and floor mat exercises using stretch bands and other gentle exercises. Certified bilingual instructors made the sessions culturally relevant by integrating Chinese breathing techniques and meditation into the program.

A survey was distributed to participants before the classes started and again after they ended to evaluate pain, physical function, stiffness, fatigue, balance and other health indicators. A total of 256 adults completed the questionnaires between September 2011 and June 2016. Ninety-three per cent of participants were female, and 73 per cent were between 60 and 79 years of age.

“Overall, the program was very well-received,” said Wu. “After completing the classes, statistically significant differences were found in pain intensity, physical function, balance and confidence about exercising without making symptoms worse.”

Participants also reported significant improvements in the ability to perform activities of daily living, such as lifting or carrying groceries, climbing stairs, bending, kneeling, stooping, bathing and getting dressed.

“The study results are consistent with the experience of rheumatologists and with prior studies showing that exercise, even of mild degree, helps with pain,” said Fields. “Getting people up and moving does appear to help with mood, pain and overall functioning.”

Tai Chi, a low-impact mind-body exercise, can be as effective as neck exercises in relieving persistent neck pain, according to results of randomized controlled trial reported in The Journal of Pain, the peer-reviewed publication of the American Pain Society.

An international team of researchers investigated the efficacy of group Tai Chi compared with group neck exercises and no treatment to improve neck pain, disability and quality of life in groups of people with nonspecific chronic neck pain. They hypothesized that 12 weeks of Tai Chi would prove superior to no treatment for chronic neck pain. The study also explored whether Tai Chi was more and less effective than conventional neck exercises. One hundred fourteen subjects were enrolled in the trial.

“The study results showed that 12 weeks of Tai Chi was more effective than no treatment to improve pain, disability, quality of life and postural control in persons with chronic neck pain,” said Peter Wayne, co-author, founder of the Tree of Life Tai Chi Center, and assistant professor of medicine at Harvard Medical School. Tai Chi was neither superior nor inferior to 12 weeks of neck exercises, he added.

Tai Chi originated in China and involves integrated dynamic musculoskeletal breathing and meditation training. It often is used for health care purposes and evidence supports its potential to help people with back pain, rheumatologic disease and psychological disorders. No studies had been performed previously to determine Tai Chi’s benefits in relieving chronic neck pain.

MONTREAL – Equipping students with the knowledge and tools to be able to demonstrate the value of chiropractic in multidisciplinary health care teams will help in advancing the profession as primary spine care experts.

This was the point made by Winnipeg-based chiropractic researcher Dr. Steven Passmore at the recent Education Conference hosted by the World Federation of Chiropractic and the Association of Chiropractic Colleges.

“What if we can show our (chiropractic) students how to collect uniform clinical data on every patient that walks through the door?” Passmore said. “What if we taught our students to be able to use technology to set up a system to record prospective quality assurance data on their patients?”

Citing his experience at Mount Carmel Clinic in Winnipeg, Passmore said data collection is not as complicated as one might think.

Mount Carmel Clinic is a not-for-profit health-care centre serving low-income inner-city residents of Winnipeg. The centre includes a chiropractic clinic, which began as a pilot project in 2010, being run by one chiropractor on a part-time basis, Passmore explained.

Since the chiropractic clinic’s inception, Passmore has been capturing quality assurance data on all patients accessing chiropractic at Mount Carmel.

“We were using a spreadsheet to be able to track the identified patient data on who is being seen, how long they are being seen for, what their diagnoses were, what the course of care looks like for them, what their outcome measures were,” Passmore explained.

“It doesn’t cost a lot of money to be able to set something like that up. It’s really just a matter of trying to figure out what kind of quality assurance data you want to collect – and then you can use that data to understand what your clinic is actually doing and how patients are responding to the care that’s being offered.”

The data provided stakeholders a good picture of the clinical practice and patient care, particularly at the Mount Carmel chiropractic clinic – and enabled Passmore and other clinic advocates to make a business care for continued government funding for the chiropractic clinic beyond the pilot phase.

Passmore pointed out collecting clinical data can be an important initiative toward increasing evidence in chiropractic care, but it’s also something many clinicians are not necessarily doing.

“It doesn’t take a huge amount of expertise to be able to manage the data that’s being collected,” he said. “It’s a very powerful tool so my hope is that some of the people that were in the room today will be able to... make a decision about how to implement that kind of big data collection in their own facilities, in their own countries, in their own clinics, so that we can create a fairly large standardized database... to be able to, five years from now, look back and say, ‘We created data that was uniform in 15 different countries on hundreds of thousands of patients and these are the outcomes that we’ve seen.’”

This kind of data collection is what Dr. Michel Tetrault intends to pursue at several government- funded rural health clinics in California that he works with through the Chiropractic Community Health Alliances (CCHA).

“We realized, as much as there’s been a lot of talk about getting the research and the data out, we haven’t found the vehicle or haven’t found the funding for it. I am encouraged by the fact that it’s already been done in Manitoba and we can follow that portion of the template and replicate that,” Tetrault said.

The CCHA helps integrate chiropractic services in community health care safety net clinics, which provide health care for the underserved, low-income communities in California.

MONTREAL – Advocating for chiropractic to be “separate and distinct” does not mean chiropractors will be “isolated and alone.” This was the argument put forth by Dr. Gerard Clum during a panel session at the recent education conference in this city, hosted jointly by the World Federation of Chiropractic (WFC) and the Association of Chiropractic Colleges (ACC).

Clum stressed he supports the push for chiropractic integration in interprofessional health care, but believes it should happen while maintaining the chiropractic identity.

“If there is no distinction to what you do, then you have no ability to define what you bring to the marketplace,” Clum explained.

He noted other health care disciplines are already increasingly intent on being able to provide spinal health care, potentially threatening the distinct value proposition of chiropractors.

“Other disciplines would like to do what we do,” Clum pointed out. “We proved the value in the marketplace, now they want to do what we do. But they’re not interested in chiropractic; they just want to do what we do.”

While many agree that spinal health is not the only area of health care chiropractors can excel, it is where chiropractors are gaining ground, said Dr. William Morgan, president of Parker University.

Morgan, who also spoke at the conference panel, is a former chiropractor to the U. S. Capitol and clinician at Walter Reed National Military Centre. He spoke about his experiences working as a spine care expert in an interprofessional health care team.

He said by being active in a hospital setting – with access to more resources – chiropractors can demonstrate the benefits of conservative, non-drug patient care.

“If we try chiropractic before epidural injections, we would save billions of dollars,” noted Morgan, who also worked as White House chiropractor and team chiropractor for the United States Naval Academy football team.

Morgan outlined many of the benefits for chiropractors working as a team player in a hospital environment, such as having access to a big database of patient history and records allowing for better interprofessional collaboration, and the ability to “learn things that we would not have even researched as chiropractors.”

He maintained chiropractic should capitalize on its value proposition as musculoskeletal health experts to gain more ground in the integrated health care system.

Chiropractic’s strength is in “musculoskeletal pain, wellness and athletic enhancement,” he said. “We’ve made the breakthroughs and we should exploit them.”

Interprofessional education is also important in shaping new generations of chiropractors. In his presentation, Dr. Henrik Hein Lauridsen, head of chiropractic at University of Southern Denmark, outlined the curriculum for chiropractic students at his university, which is integrated at some level with medical students.

Lauridsen suggested some elements important for developing interprofessional education for chiropractic students.

“When we design the curriculum, make it congruent with university-based education,” he recommended. “Focus chiropractic education on evidence, critical thinking, team work and best practices.”

It’s also important, he added, that the “type of education you develop is actually aligned with how the actual health care system works.”

Northwestern Health Sciences University’s Dr. Michele Maiers was also on the panel and spoke about developing future generations of chiropractors who are innovators.

She said that while chiropractic students currently graduate with adequate clinical skills, oftentimes they do not have sufficient skills to be leaders in health care.

The chiropractic education system should enable its students to think and “act outside the box.”

“As expectations go beyond competent clinical care... our educational institutions need to prepare (students) for the changing demands of health care,” said Maiers, who is the executive director of innovations and research at Northwestern.

Maiers said education for the next generations of chiropractors should focus on: communication skills, professional engagement, fostering a spirit of innovation and contemporary leadership.

Chiropractic educators, she added, should “serve as advocates to champion our students to be the next leaders in health care.”

More than 160 chiropractors, educators, researchers and students attended the WFC/ACC Education Conference, which was held Oct. 29 to 22.