Chiropractic + Naturopathic Doctor • February 2018 • Roundup

A new study has revealed that chiropractic care is improving low-back pain among female veterans, according to the American Chiropractic Association (ACA). Female veterans are one of the fastest growing populations receiving treatment through the Veterans Administration (VA) health care system in the U.S.

Published in the Journal of Manipulative and Physiological Therapeutics, the study’s authors note that musculoskeletal conditions such as back pain are the most common ailments among female veterans. They also report that female veterans on average access VA medical care more frequently than male veterans, have a higher outpatient cost per patient and have a higher rate of service- connected disability.

“Although further research is warranted,” the study says, “chiropractic care may be of value in contributing to the pain management needs of this unique patient population.”

Chiropractic services are one of the conservative (non-drug) treatment options for pain offered in the VA. They are available at half of the major VA medical facilities in the United States.

Efforts to expand chiropractic services to American veterans recently gained new momentum in Congress. Rep. Julia Brownley (DCA), ranking member of the Veterans Subcommittee on Health, and Rep. Lucille Roybal-Allard (D-CA), have joined forces to broaden the range of services and care options available to veterans by supporting the Chiropractic Care Available to All Veterans Act (H.R. 103). The bill – supported by several major veterans groups – would require chiropractic services to be offered at all U.S. Department of Veterans Affairs medical centers and codify chiropractic care as a standard benefit for veterans using VA health care. There is a bipartisan companion bill in the Senate (S. 609).

“Chiropractic’s non-drug, non-addictive and noninvasive approach to pain management can help alleviate disabling pain and improve function,” said ACA president David Herd, DC. “That’s why chiropractors are an important part of the health care team in the VA.”

Chiropractors focus on disorders of the musculoskeletal system, most often treating complaints such as back pain, neck pain, pain in the joints of the arms or legs and headaches.

Widely known for their expertise in spinal manipulation, chiropractors are also trained to recommend therapeutic and rehabilitative exercises, and to provide dietary and lifestyle counseling.

Muscle paralysis rapidly causes inflammation in nearby bone marrow, which may promote the formation of large cells that break down bone, said a new study published in the American Journal of Physiology – Cell Physiology.

Researchers from the University of Washington, Seattle, studied mice whose calf muscles were exposed to botulinum toxin A (BTxA), a protein that causes temporary muscle weakness and paralysis. Researchers found that calf paralysis caused inflammation in the marrow of the adjacent tibia. This inflammation was associated with an increase in the size of cells that break down bone tissue that occurred three days after BTxA exposure. Breakdown of bone that is not replaced with new tissue results in osteopenia.

Reduced bone mass is prevalent in older adults but also often affects people paralyzed by spinal cord injury.

The findings of this study may have important implications for treating people with paralysis.

“The identification of an acute inflammatory cascade in bone marrow leading to the formation of giant osteoclasts has potential to reveal novel therapeutic strategies for mitigating paralysis-induced bone loss following neuromuscular trauma,” the researchers wrote.

VANCOUVER – People who live with chronic pain need options beyond prescription opioids, and it’s up to the British Columbia government to provide more services, said the head of a group supporting patients and their families.

“There has really been a lack of any appropriate response to chronic pain in our province and in our country,” said Maria Hudspith, executive director of Pain BC.

Beside painkillers, patients must have access to physical therapy and psychological support but wait lists stretch from one to three years at the few specialized pain clinics in the province, she said.

“We’ve seen this overreliance on the prescription pad as the only tool in the toolbox,” Hudspith said. “Some people may become dependent on the medication in order to function and some of those people may become addicted.”

One in five people in B.C. lives with pain that can be relentless and crippling but she said some communities have no specialized health-care providers for patients who need intervention after an injury or surgery, for example.

A lack of dedicated pain services means patients make more doctors’ visits and may require more surgeries, resulting in high health-care costs and poor quality of life, Hudspith said.

“There’s a growing recognition that this is a huge problem that is really, in many ways, at the root of a lot of issues that we’re seeing.”

Hudspith said Pain BC has been in discussions with the provincial government to expand services.

Neither the Ministry of Mental Health and Addictions or the Health Ministry could provide any information when contacted for comment.

In June 2016, B.C. doctors became the first in Canada to face mandatory standards for prescribing opioids and other addictive medications. At the time, the College of Physicians and Surgeons replaced guidelines offering only recommendations with legal standards that allowed for consequences, such as complaint hearings and disciplinary action.

Following the introduction of the standards, some doctors began weaning or cutting patients off pain medication. Hudspith said that has left people suffering, especially if they don’t have access to other options for pain relief.

“We have documented cases of people who are no longer able to work, they’ve maxed out their sick time, they’re contemplating going on disability,” she said.

While the college’s policy intended to minimize the effects of opioid in the midst of an overdose crisis, overdoses have “continued like a runaway train,” she said.

“There are people who have said to us or have said to their physicians or MLAs (members of the legislature) that they are going to the street and buying opioids through the illicit market despite the risk,” she said.

The society has been working with the province’s medical association to create educational material for doctors, but Hudspith said “robust mentoring” is crucial so doctors and other clinicians can build their skills to provide evidence- based care for people who suffer from chronic pain

“Chronic pain is a very misunderstood condition. The approach needs to be very different from other chronic conditions that are very well understood.”

She cited Project Echo, a mentoring program in Ontario, as a way to care for patients with chronic pain as doctors get guidance on specific challenges from a team of experts.

Serena Patterson, a psychologist in Comox, B.C., said she has suffered with fibromyalgia for 30 years and also developed migraines before starting to see clients with chronic pain, many of whom suffer from depression, shame and stigma.

Some people go from doctor to doctor for years to get help for conditions that remain undiagnosed while they’re denied longterm disability and unable to work or afford private therapists, she said.

Publicly funded clinics with a variety of experts who work together, including nurses and other health-care providers offering physical, occupational, massage and psychological therapy, would serve patients most effectively, Patterson said.

“We have a medical system that is geared toward fixing acute problems but does a terrible job with chronic pain.”

Opioids have been the mainstay of treatment for moderate to severe pain for decades. The challenge is that their effects on patients vary tremendously. Current attempts to prevent opioid-use disorder focus mainly on reining in prescription practices, which is problematic.

A researcher from Florida Atlantic University’s Charles E. Schmidt College of Medicine has received a five-year, $4 million grant from the National Institutes of Health to help solve the “onesize- fits-all” approach to prescribing opioids for chronic pain. Because of the high heritability, finding the genetic predictors of prescription opioid-use disorder is more critical than ever. Little data currently exists on clinical characteristics and genetic variants that confer risk for opioid-use disorder.

In a novel study, Janet Robishaw, professor and chair in the Department of Biomedical Science in FAU’s College of Medicine, and colleagues from Geisinger Health System and the University of Pennsylvania, are assessing clinical and genetic characteristics of a large patient cohort suffering from chronic musculoskeletal pain and receiving prescription opioids. As part of the DiscovEHR project, they have leveraged data from Geisinger’s central biorepository and electronic health record database to conduct large-scale genomics research and phenotype development.

With this information, this multidisciplinary team will derive a clinical and genetic profile of prescription opioid-use disorder and use this knowledge to develop an “addiction risk score.” Findings from this study will be key for identifying those who are at low-risk for opioid-use disorder from those who are at high-risk, and who need additional counseling and access to other treatment options.

“The overall goal of this project is figuring out if there is a unique genetic signature of patients who are most susceptible to addiction,” said Robishaw. “In the first part of our study, we are looking at the clinical characteristics of these patients to understand the cause of their pain and how prescription opioids are affecting their outcomes.”

As part of this initial process, the investigative team composed of Robishaw, Dr. Wade Berrettini, Karl E. Rickels professor of psychiatry at the University of Pennsylvania, and Vanessa Troiani, assistant professor at Geisinger, are administering questionnaires that will give them additional information on the patients’ pain phenotype as well as whether or not they’re showing symptoms of prescription opioid-use disorder. It will take about two years to analyze the data to divide the patient population into cases and controls to complete a genome-wide association study, which is the second part of the research project.

The genome-wide association study will help the researchers determine if there is a particular subset of genes and genetic variants that are influencing susceptibility to becoming addicted to prescription opioids. Once they are able to generate the hypothesis that a genetic variant is responsible for increasing risk, the next steps for research will involve functional studies on those top associations to prove causation.

“There is an urgent need to develop clinical, genetic and neural characteristics of patients who are at moderate- to high-risk of becoming addicted to prescription opioids,” said Dr. Phillip Boiselle, dean of FAU’s College of Medicine. “The National Institutes of Health grant awarded to Dr. Robishaw and her collaborators will help them to identify the genetic factors that increase the risk of addiction in patients, which then become targets for new drug development.”

The investigative team stresses the importance of using a multipronged approach to addressing this national crisis, which should involve research, education and engaging patients so that they understand their susceptibility to risks and empower them in their health care decisions.

“Prescription opioid-use disorder is a lifelong problem that requires a thoughtful approach that is not going to be solved just by curtailing prescriptions of these narcotics,” said Robishaw. “We have to employ more rigorous prescribing practices and provide alternative treatments for moderate to severe pain that don’t involve opioids. And, we need to improve access to medication-assisted therapy for those patients already dependent on prescription opioids.”

Smoking may increase the risk of musculoskeletal injuries among people in the military, said a new study published in the Medicine & Science in Sports & Exercise journal by the American College of Sports Medicine. The authors reviewed and analyzed the literature on the impact of cigarette smoking on lower-extremity overuse injuries in military training.

“Tobacco use is common among military personnel, as is musculoskeletal injury during training. In a review of the literature on musculoskeletal injuries, there was mixed evidence on the role of smoking as a risk factor,” the authors wrote.

The review showed men and women who smoked had an increased risk of injury: 31 per cent higher among men, and 23 per cent higher among women.

The study concluded that smoking is a “moderate risk factor” for musculoskeletal injury and may account for a meaningful proportion of injuries among men and women due to the high prevalence of smoking and injury in the military. Although enlistees are not allowed to smoke during basic training, their risk of injury remains high, indicating that smokers may remain at increased risk for medium- to long-term duration.

The investigators also found that those who smoked more had a higher risk of injury than those who smoked less. Among the heaviest smokers, the risk was increased 84 per cent in men and 56 per cent in women.

While this study was limited to military personnel, adult smokers in the general population who participate in exercise training also may be at moderate risk for overuse injuries, the ACSM said.