Fourth Edition t his is the fourth in a series of articles that will share various concepts of research with doctors in clinical practice. This one relates to chiropractic care of nonmusculoskeletal conditions. to better understand the nature of chiropractic care for nonmusculoskeletal conditions, it is important to become familiar with the concept of "risk benefit ratios" and how viscerosomatic and somatovisceral interactions tend to be complex and nondiscrete. the lack of a clear understanding of how chiropractic care affects nonmusculoskeletal conditions is a challenge our profession will The chiropractic profession has been attempting to study which subset of patients with nonmusculoskeletal conditions might respond to chiropractic care. While there is a paucity of published literature relating to the chiropractic treatment of nonmusculoskeletal conditions'1, our colleges still seem to find that both student interns" and clinicians" have an interest in the treatment of these visceral related conditions. Nonmusculoskeletal conditions may be affected by visceral related referred pain patterns associated with the: (1) convergence of visceral and somatic affcrcnts at or near the spinal cord''. (2) dorsal spinal column1", and (3) cerebral nuclei and the brain stem". Sato notes that some somatovisccral rcilcxcs "have propriospinal and scgmcntal cliaracteristics. while others have supraspinal and generalized characteristics in their reflex nature12." He postulates that "somatovisccral rcllcx responses may be functioning during spinal manipulative therapy... 12" Budgcll also suggests that there is a ncurophysiologic rationale for the concept tliat aberrant stimulation of spinal or paraspinal structures leads to segmentally organized rcllcx responses of the autonomic nervous system, affecting visceral function1-'. Risk Benefit Ratio The term "risk benefit ratio" can be used to help us better understand the complex nature of chiropractic treating nonmus-culoskelctal conditions. It simply means. "What is the risk of an intervention or no intervention versus its possible benefit?" As the chiropractic profession participates within the nonmuscu-loskelctal care arena, we would need to show that chiropractic care is a low risk intervention. "Watching and waiting" or no care is not an option for some patients. In addition, chiropractic care may indeed offer some benefit. Being able to discern when patients with these conditions need to be referred for emergency care or interdisciplinary cotreatment is essential for responsible practitioners treating nonniusculoskclctal cases. Treatment Becomes Part of the Diagnosis Evidence-based care of nonmusculoskclctal conditions treated by chiropractic is slowly emerging. Due to the complex and diffuse nature of visccrosomatic and somatovisccral referred pain interactions, it is possible that chiropractic care could be seen as a relatively low-risk intervention, particularly if the cost is reasonable. If chiropractors arc going to use treatment and the patients response as means to develop a diagnosis, then the treatment should be safe and show some response in at least two to four weeks. The challenge for chiropractors in this arena is presenting a rationale for care, utilizing care for a limited period, and then making the proper referral to an allied healthcare provider if the patient's response docs not show improvement within that time period. The following are some studies from the SOT Research Conferences that help illustrate how chiropractic care might play a role in the treatment of patients presenting with nonmusculoskclctal conditions. Pediatric Nonmusculoskeletal Retrospective Survey14 Introduction: For the purposes of this retrospective survey, all parents of children treated (2000-07) in a clinic by the same clinician (n=127) were sent a questionnaire. The questionnaires were part of a standard practice of this office for follow up. patient control, and management. 65/127 parents responded from this standard follow up outreach, and 37/65 of those were treated for nonmusculoskclctal presentations. In all of the cases, active chiropractic care consisted of sacro occipital technique and cranial pediatric treatments. Methods/Results: Of the 37 (17 male. 20 female) nonmusculoskclctal pediatric patients, five were treated for immune function, seven for developmental delays/dysfunction, nine for birth trauma, one for seizure activity, four for learning problems, three for endocrine problems, three for migraines, two for gastrointestinal issues, two forfussincss/agitation/anxicty. and one for cnurcsis. 36 of the 37 patients, per their parent, reported improvement of their child's nonmusculoskclctal condition that appeared related to the chiropractic intervention Implication: Since it docs appear from this patient survey that nonmusculoskclctal conditions may benefit from SOT and cranial adjustivc techniques, there is a greater need to investigate whether certain children with nonmusculoskclctal presentations may be candidates for chiropractic care. With its low risk options, chiropractic care may offer an option for parents who feel the need to do "something" for their child. Chiropractic care may help children with nonmusculoskctctal presentations and offer their parents' confidence that they will be properly referred to allied health practitioners if a condition remains unresponsive. Adolescent Incontinence Case Study15 Introduction: A 13-ycar-old female presented with a prior history that included sprained right and left ankles, attention deficit disorder (ADD. inattentive type), and the rare occasion of bed-wetting at age three and four (fully toilet trained at age two). The patient's major concern was incontinence that had worsened the summer prior to the office visit following a fall from a swing into a lake that caused her to land onto her back. Methods/Results: Examination and patient's presenting symptoms suggested a relationship between her incontinence (urgency) and a sacroiliac joint sprain (category two). Sacro occipital technique treatments, soft tissue balancing, and Carver techniques were used. While the patient still had some degree of incontinence during treatment, the incidence of incontinence and frequency of occurrences were significantly lessening. It was apparent to both the patient and her parent that there was a clear relationship between the reduced low back pain, second- an to the patient's category two resolution, and her decrease in incontinence and urgency. Conclusion: It is of interest to determine if the reduction of joint or body-related pains might also have a relationship with improvement of nonmusculoskclctal presentations. What needs to be determined is if this improvement of visceral function is related to cither balancing of sympathctic/parasympathctic nervous system function, improvement of visccrosomatic/ somato\ isccral rcllcx activity and reduction of inociccptivc signals crossing over to adjacent visceral affcrcnts. or mechanical musculoskclctal effect on adjacent visceral structures. Parents of children with difficult conditions, such as incontinence, often consider that doing nothing is not an option, yet they are concerned about medications and their side effects. It is possible that chiropractic care might fill a low-risk intermediate option between watching and waiting and beginning a medication program. Insulin Resistance Case Series16 Introduction: High plasma levels of insulin and glucose due to insulin resistance arc a major component of the metabolic syndrome. Metabolic syndrome is a group of risk factors that raises the risk for heart disease and other conditions, such as diabetes mellitus (DM) type 2 and stroke. Since some low-level evidence has found that chiropractic care may demonstrate some influence in nonmusculoskclctal interactions such as in DM individuals, this study was performed to analyze any possible influence of chiropractic treatment for patients with DM and insulin resistance. Methods/Results: Four patients with DM type 2 with insulin resistance were selected by an allopathic diabetes specialist to participate in this study. The treatment consisted of eight chiropractic office visits that incorporated adjustments to the spine and chiropractic manipulative reflex technique (CMRT) to balance viscerosomatic/somatovisccral autonomic reflexes. Laboratory blood tests were taken before and after the chiropractic adjustment on the second and eighth office visits. After the eighth office visit, the levels of insulin resistance, following cluropractic care, decreased significanth when compared to the levels prior to the chiropractic intervention. Implications: Further research is needed in this arena to determine which subset of patients and type of chiropractic care may achieve optimal results. Since the risk is high for the various types of medications utilized for insulin resistance, and not treating this condition may lead to serious sequelae, a low-risk trial of chiropractic care could be part of an early treatment regimen to determine if a patient with insulin resistance syndrome might be responsive to chiropractic care. There is much to learn about nonmusculoskclctal conditions that respond to chiropractic interventions. Which patients with nonmusculoskclctal presentations may respond to chiropractic adjusting, soft tissue visceral manipulative reflex care, nutritional or lifestyle counseling, and/or other low-risk chiropractic interventions? What would be a reasonable trial period to determine if chiropractic care may be assisting a nonmusculoskclctal patient? How can we assess a patient's response to care and know when and to whom it is appropriate to refer a patient that is not responding appropriately? While our chiropractic research community is attempting to answer these questions, it may be best for "patients in need" to receive a trial period of chiropractic care (two to four weeks) to determine if chiropractic care might be an option for their nonmusculoskclctal presentation. Since nonmusculoskclctal conditions arc multifactorial and complex, chiropractic care may not be an option for some patients and developing proper referral skills will be essential for optimal patient care. CharlesL Blum, DC is in private practice Santa Monica. California, director of research for Sacro Occipital Technique Organization - USA. adjunct research faculty at Cleveland Chiropractic College and teaches the Sacro Occipital Technicjtie (SOT} elective class at Palmer C hllege ofC liiropractic -West and Southern California University of Health Sciences. References: Ferrance RJ, Miller./. Chiropractic diagnosis and management of non-muscidoskeletal conditions in children and adolescents. Chiropr Osteopat. 2010.Jim 2; 18:14. Hawk C. Khorsan R, Lisi AJ, Ferrance RJ, Evans Mil'. Chiro practic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research. J Altern Complement Med. 2007Jun;13(5):491-5l2. Leboeuf-Yde CAxen I, AhlefeldtG, Lidefelt P. Rosenbaum A. T. The types and frequencies of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulative therapy. J Manip Physio Therap. 1999 Sov;22(9):559-64. 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