This October, during National Chiropractic Health Month (NCHM), chiropractors around the country are promoting improved access to non-drug therapies and reminding people that chiropractic’s non-drug approach is on the frontline for pain management. In recognition of NCMH, Norman W. Kettner, DC (’80), DACBR, FICC, dean of research and professor emeritus of Logan’s Department of Radiology discusses the body of research he has conducted on the use of chiropractic for chronic pain management.
Q: Could you provide an overview of the research you have conducted on how chiropractic care impacts the use of opioids?
In collaboration with my research colleagues from Massachusetts General Hospital (MGH) and Harvard Medical School, we have sought to elucidate the altered brain structure and function precipitating and sustaining states of chronic pain in human clinical disorders such as carpal tunnel syndrome, chronic lower back pain, and lumbar radiculopathy. The use of opioids and other high risk pain medications has in part resulted from the complexity and convolutional mechanisms underlying the pathophysiology of chronic pain. The use of non-pharmacological pain management is currently emerging with evidence for safety and effectiveness when employed by chiropractic physicians. To this end, our functional neuroimaging studies on functional magnetic resonance imaging (fMRI), magnetic resonance imaging (MRI), positron emission tomography (PET), and magnetoencephalography (MEG) over the last 20 years have contributed to the understanding of maladaptive brain neuroplasticity in the pathophysiology of chronic pain.
In addition, much of our functional neuroimaging research targeted the brain mapping of areas and networks responding to chronic pain. Human brain mapping of non-pharmacological integrative interventions using electroacupuncture and more recently spinal manipulation has had direct clinical translations, both verifying putative mechanisms and extending our current knowledge, especially the role of cognitive- and emotion-related pain complicating the spectrum of chronic pain. This multidimensional perspective provided by functional neuroimaging has served to reinforce and highlight the value of the biopsychosocial model in patient care.
Q: Why is this area of study of interest to you?
My research interest in the disorder of chronic pain evolved with my knowledge of the anatomy, physiology and pathophysiology of the central nervous system (CNS). Simultaneously, it was my good fortune to have access to the explosion of the tools for functional neuroimaging in the CNS by virtue of the research collaboration with MGH’s Athinoula A. Martinos Center for Biomedical Imaging and Logan University.
Over the decades, the prevalence of chronic pain has only increased, suggesting clinical solutions related to pharmacological interventions have been limited, and safer approaches need to be in the care pathway for acute and chronic pain management.
Q: What have been some of your key findings over the course of your research?
Over two dozen publications describe the body of our research. My perspective of the critical advances would focus on the functional neuroimaging models of chronic pain that mapped maladaptive cortical neuroplasticity, which reverted to normal under the non-pharmacological interventions such as acupuncture and spinal manipulation as did most clinical measures in the model. The pathophysiology of activated neuroglial cells was also a striking finding as the first published MRI/PET model of human lumbar radiculopathy mapping glial activation.
Q: Is there anything you have discovered that has surprised you?
The most surprising discovery was finally realizing the enormous complexity of the mechanisms underlying the chronification of pain, or how acute pain becomes chronic. I had been raising that question and pondering on the related literature for a long time, along with many pain researchers. The key was to perceive the chronic patient as the summated and integrated response to the dynamic multidimensional role of CNS inputs arising from biological, psychological and social sources of variable proportions rendering each patient entirely unique. This awareness also mandated the need for holistic and integrative care in chronic pain.
Q: Do you have plans for any additional studies on the impact of chiropractic care on opioid use?
The study of chronic pain with non-pharmacological integrative interventions is a long-term research trajectory. More recently, we explored the integrative capacity of the autonomic nervous system, which when disrupted, may be associated with maladaptive cortical and brainstem neuroplasticity resulting in, for example, gastrointestinal pain and dysfunction known as functional gastric dyspepsia. I am particularly excited for the promise of this research, which employs multi-modal MRI combining functional neuroimaging of brain responses along with structural MRI characteristics of the visceral anatomy.
Q: How can chiropractic care reduce the chances of opioid dependence and improve pain outcomes?
There is a growing body of evidence reporting that the use of chiropractic care reduces the likelihood of opioid use. Chiropractic physicians utilize a range of interventions with analgesic impact on acute and chronic pain. However, the problem continues to be access to their care. Guidelines are published on the appropriate use of non-pharmacological pain management but may ignored at the level of primary care with potential risk for adverse patient outcomes.