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Association between chiropractic and allopathic classroom hours of neuroscience with patterns of diagnosis for patients with headaches and migraines in the US between 1994 and 2014.

ABSTRACT: Previous studies have investigated the relationship between medical knowledge of migraine headaches and diagnosis patterns; however, the author is unaware of any studies on the association between classroom hours of neuroscience and diagnosis patterns for headaches and migraines.

OBJECTIVE: This study compared the correlation between chiropractic and allopathic classroom hours of neuroscience in relation to patterns of diagnosis for patients with headaches or migraines.

METHODS: For chiropractic training in the treatment of migraines, chiropractic classroom hours of neuroanatomy and neurophysiology were measured by performing a search of the chiropractic school catalogs using those words. Neuroscience classroom hours after chiropractic or medical school were not accounted for in this study.

For allopathic patterns of diagnosis for patients with migraine headaches, an inclusion and exclusion criteria was performed. Only studies between 1994 and 2014 measuring the percentage of patients receiving a diagnosis of migraine by their physician were included using a search of the pubmed and google scholar electronic database using the words: patterns, migraine, diagnosis, united states, chronic, population, medical.

RESULTS: Chiropractors receive twice the amount of neuroscience hours (neuroanatomy and neurophysiology) compared to allopathic doctors (182/86).

Neuroanatomy alone, for chiropractors, is higher than the overall hours of neuroscience for allopathic doctors (106/79). 76.5% of chiropractors gave a non-subluxation based diagnosis to patients with headaches compared to 44.6% of patients with migraines that were given a diagnosis of migraine or chronic migraine by an allopathic physician.

CONCLUSION: In this study, classroom hours of neuroscience had a positive correlation with patterns of diagnosis in patients with headaches and migraines for both chiropractic and allopathic physicians.

INTRODUCTION

Migraine is an episodic headache disorder associated with various combinations of neurologic, gastrointestinal, and autonomic symptoms. Gastrointestinal disturbances including nausea, vomiting, abdominal cramps, or diarrhea are almost universal. Sensory hyperexcitability manifested by photophobia, phonophobia, and osmophobia are frequently experienced. (1)

The condition of migraine was selected because of the evidence of chiropractic treatment efficiency for patients with migraine headaches. In 2001, Bronfort, et al, conducted a systematic review of nine randomized controlled trials involving 683 patients with chronic headache. The study found that there is moderate evidence that spinal manipulative therapy (SMT) has short-term efficacy similar to amitriptyline in the prophylactic treatment of migraine. This study also concluded that SMT has an effect comparable to commonly used firstline prophylactic prescription medications for migraine headache. (2) In 2011, Bryans et al, conducted a literature review of 21 articles and found that for migraine, spinal manipulation and multimodal multidisciplinary interventions including massage are recommended for management of patients with episodic or chronic migraine. (3) Finally in 2011, Chaibi et al, conducted a literature review of randomized controlled trials and found that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally efficient as propranolol and topiramate in the prophylactic management of migraine. (4)

One survey of 633 chiropractors in 2003 conducted by McDonald, et al, found that 89.3% of chiropractors had good clinical outcomes when performing spinal manipulative therapy to patients with migraine headaches. (5) Another survey in 2008, conducted by Bigal, et al, involved 520 patients with chronic migraine and 9,494 patients with episodic migraine and found that 25.7% of patients seek a chiropractor for the treatment of migraine headaches compared to 24.6% of patients who seek a neurologist for the same condition. This same study found that only 48% of patients with chronic migraines were satisfied with their acute treatments. (6)

Two studies were identified as evaluating the number of neuroscience hours dedicated to headaches as inadequate in allopathic schools. In 2005, Gallagher, et al, conducted a study measuring headache education which involved surveys sent to all allopathic and osteopathic medical schools, 200 family medicine residencies, and all 126 neurology residencies. Response rates were 35% to 40%. This study concluded that undergraduate medical education in headache is limited. Despite medical schools perceiving their training as adequate, both neurology and family practice residency program directors believe entering residents are inadequately prepared in headache upon entering the program. (7) Also in 2005, Kominemi, et al, conducted a study involving ninety-five medical institutions including 75 Chairs and 44 residency training directors. This study found that only 29% agreed or strongly agreed that headache diagnosis and management is adequately taught. (8)

One major study prior to 1994, recognized a high percentage of undiagnosed patients with migraine headaches by their allopathic physician. In 1992, Lipton, et al, conducted a study of 20,468 patients with migraine headaches and found that 41 % of females and 29% of males with migraines reported having been diagnosed by a physician. Of the undiagnosed subjects, 80% experienced at least some headache-related disability. (9) In 2003, Blumenthal, et al, conducted a study where 95% of the 57 patients met the International Headache Society diagnostic criteria for migraine. Emergency department physicians, however, diagnosed only 32% of the patients with migraine. All 57 patients reported that after discharge they had to rest or sleep and were unable to return to normal function. 60% of patients still had a headache 24 hours after discharge from the emergency department. (10)

The purpose of this study is to simply compare the classroom hours of neuroscience between chiropractors and allopathic doctors in relation to patterns of diagnosis for patients with headaches or migraines.

METHODS

For chiropractic training in the treatment of migraines, chiropractic classroom hours of neuroanatomy and neurophysiology were measured by performing a search of the chiropractic school catalogs using those words. Neuroscience classroom hours after chiropractic or medical school were not accounted for in this study.

For allopathic training, three published studies were used to evaluate classroom hours of neuroscience. (11, 12, 13)

For chiropractic patterns of diagnosis for patients with migraine headaches, an inclusion and exclusion criteria was performed. Only the job analysis of chiropractic publications conducted by the national board of chiropractic examiners between 1994 and 2014 was included.

For allopathic patterns of diagnosis for patients with migraine headaches, an inclusion and exclusion criteria was performed. Only studies between 1994 and 2014 measuring the percentage of patients receiving a diagnosis of migraine by their physician were included, using a search of the pubmed and google scholar electronic database.

RESULTS

Chiropractors receive twice the amount of neuroscience hours (neuroanatomy and neurophysiology) compared to allopathic doctors (182/86). Neuroanatomy alone, for chiropractors is higher than the overall hours of neuroscience for allopathic doctors (106/79).

For chiropractic diagnosis practice patterns, 2 survey analyses measuring the ability of chiropractors to provide a non-subluxation diagnosis to headaches was evaluated.

The Job Analysis of Chiropractic conducted by the National Board of Chiropractic Examiners for the years 2000 and 2005 was included.

The two studies had a sample population of chiropractors of 5,344 which is equivalent to 12% of the 44,400 chiropractors currently practicing in the US according to the bureau of labor statistics. According to the two studies, an average of 76.5% of chiropractors gave a non-subluxation based diagnosis to patients with headaches.

For allopathic diagnosis practice patterns, 5 studies measuring the ability of allopathic doctors to diagnose was evaluated. The five studies had a total sample population of patients of 25,020 which is equivalent to 2.3% of the 1.1 million patients who received anti-migraine medication in the US in 2011 according to the IMS Institute's report The Use of Medicines in the United States: Review of 2011. According to the 5 studies, an average of 44.6% of patients with migraines were given a diagnosis of migraine or chronic migraine by an allopathic physician.

DISCUSSION

The plausibility of a correlation between classroom hours of neuroscience and patterns of diagnosis for patients with headaches and migraines was discussed in the introduction. Another plausible explanation for the positive correlation between classroom hours of neuroscience and patterns of diagnosis is the positive correlation between increased classroom hours of neuroscience and increased recognition of neurological conditions among allopathic students. In the year 2000, Resnick, et al, conducted a study involving two groups of 18 medical students.

Students enrolled in the pilot neuroscience course performed significantly better on the examination than those who had completed the standard neurology course. Striking improvements were noted in the recognition and management of head injury, hydrocephalus, and radiculopathy. (14)

Based on the findings of this study, classroom hours of neuroanatomy alone for chiropractors with 106 hours is greater than the overall hours of microscopic anatomy for allopathic physicians which was 79, 73 and 72 hours in 2002, 2009 and 2012 respectively. (11, 1213) Moreover, classroom hours of neuroanatomy alone for chiropractors with 106 hours was similar to the average overall hours of gross anatomy for allopathic physicians which was 167, 149 and 147 hours in 2002, 2009 and 2012 respectively. (11, 12, 13)

Research evaluating the anatomy knowledge of surgery residents is warranted to assess if the residents have proper knowledge in gross anatomy.

A topic not mentioned in this study is patient persistence and efficiency of anti-migraine medications. In 2012, Jackson, et al, conducted a meta-analysis of published systematic reviews between 1966 and 2012 and found no significant association between use of botulinum toxin A and reduction in the number of episodic migraine. (15) In 2014, Messah, et al, conducted a literature review ot 380 studies and found that the proportion of patients that remained persistent, up to six refills of index triptan, ranged from 3.2% to 12.6% and the proportion of patients that never refilled their index triptan ranged from 38% to 65.8%. This literature review also found that several studies reported the 1-year probability of discontinuation among a general group of triptan users (not limited to treatment of naive patients) to be between 30% and 60%. (16)

Finally in 2014, Hepp, et al, conducted a literature review from 1966 to 2014 of 33 studies and found pooled persistence from RCTs on propranolol, amitriptyline, and topiramate (n = 19) which showed rates of 77%, 55%, and 57%, respectively, at 16-26 weeks. Adverse events were the most common reason for discontinuation cited (24% for topiramate and 17% for amitriptyline). (17)

Regarding safety of anti-migraine medications, an article written by Parsekyan in the year 2000 listed among other possible adverse side effects the following: Bradycardia and bronchospasm for propanolol; seizures and tremors for amitryptyline; tremors, ataxia and hepatotoxicity for valproic acid; hypotension and peripheral edema for verapamil and erosive gastritis and peptic ulceration for NSAIDS. Furthermore, an article written by Demaagd in the year 2008 listed among other side effects the following: Tingling of extremities and chest discomfort for ergots and paresthesia, asthenia and transient increase in blood pressure for triptans.

The association between cervical adjustments and stroke has been unsubstantiated. An article written by Ernst in 2007 suggested that there was an association between neck adjustments and stroke. A replication to this article in 2012 written by Peter Tuchin concluded the following: "The review of the 32 papers discussed by Ernst found numerous errors or inconsistencies from the original case reports and case series. These errors included alteration of the age or sex of the patient, and omission or misrepresentation of the long term response of the patient to the adverse event. Other errors included incorrectly assigning spinal manipulation therapy (SMT) as chiropractic treatment when it had been reported in the original paper as delivered by a non-chiropractic provider (e.g. Physician)." (18)

In 2008, a study by Cassidy found that there were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke. The study concluded that the increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. The study found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care. (19)

CONCLUSION

In this study, classroom hours of neuroscience had a positive correlation with patterns of diagnosis in patients with headaches and migraines for both chiropractic and allopathic physicians. The higher number of classroom hours of neuroscience was associated with a majority of chiropractors giving a non-subluxation diagnosis for headaches.

Similarly, the lower number of classroom hours of neuroscience for allopathic doctors during medical school was associated with a percentage below 50% of patients with migraines that were given such diagnosis by their allopathic physician. Since this is an observational study, causal inference is not claimed. Further research with other cohort groups is indicated to confirm these findings.

[TABLE 6 OMITTED]

References

(1.) Silberstein SD. Migraine symptoms: results of a survey of self-reported migraineurs. Headache. 1995; 35(7): 387-96.

(2.) Bronfort G, Assendelft WJ, Evans R, Haas M, BouterL. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther. 2001; 24(7): 457-66

(3.) Bryans R, Descarreaux M, Duranleau M, et al. Evidence-based guidelines for the chiropractic treatment of adults with headache. J Manipulative Physiol Ther. 2011; 34(5): 274-89

(4.) Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraine: a systematic review. J Headache Pain. 2011; 12(2): 127-33.

(5.) William P. McDonald (Other Contributor). How Chiropractors Think and Practice, The Survey of North American Chiropractors. Institute for Social Research Ohio Northern University; 2003.

(6.) Bigal ME, Serrano D, Reed M, Lipton RB. Chronic migraine in the population: burden, diagnosis, and satisfaction with treatment. Neurology. 2008; 71(8): 559-66.

(7.) Gallagher RM, Alam R, Shah S, Mueller L, Rogers JJ. Headache in medical education: medical schools, neurology and family practice residencies. Headache. 2005; 45(7): 866-73.

(8.) Kommineni M, Finkel AG. Teaching headache in America: survey of neurology chairs and residency directors. Headache. 2005; 45(7): 862-5.

(9.) Lipton RB, Stewart WF, Celentano DD, Reed ML. Undiagnosed migraine headaches. A comparison of symptom-based and reported physician diagnosis. Arch Intern Med. 1992; 152(6): 1273-8.

(10.) Blumenthal HJ, Weisz MA, Kelly KM, Mayer RL, Blonsky J. Treatment of primary headache in the emergency department. Headache. 2003; 43(10): 1026-31.

(11.) Drake RL, Lowrie DJ, Prewitt CM. Survey of gross anatomy, microscopic anatomy, neuroscience, and embryology courses in medical school curricula in the United States. Anat Rec. 2002; 269(2): 118-22.

(12.) Drake RL, Mcbride JM, Lachman N, Pawlina W. Medical education in the anatomical sciences: the winds of change continue to blow. Anat Sci Educ. 2009; 2(6): 253-9.

(13.) Drake RL, Mcbride JM, Pawlina W. An update on the status of anatomical sciences education in United States medical schools. Anat Sci Educ. 2014; 7(4): 321-5.

(14.) Resnick DK, Ramirez LF. Neuroscience education of undergraduate medical students. Part II: outcome improvement. J Neurosurg. 2000; 92(4): 642-5.

(15.) Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis. JAMA. 2012; 307(16): 1736-45.

(16.) Messali AJ, Yang M, Gillard P, et al. Treatment persistence and switching in triptan users: a systematic literature review. Headache. 2014; 54(7): 1120-30.

(17.) Hepp Z, Bloudek LM, Varon SF. Systematic review of migraine prophylaxis adherence and persistence. J Manag Care Pharm. 2014; 20(l): 22-33.

(18.) Tuchin P. A replication of the study 'Adverse effects of spinal manipulation: a systematic review'. Chiropr Man Therap. 2012; 20(1): 30.

(19.) Cassidy JD, Boyle E, Cote P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008; 33(4 Suppl): S176-83.

(20.) Cleveland chiropractic college. Kansas City 2012-2013 Catalog http://www.cleveland.edu/media/cms_page_media/128/catalog2012.pdf

(21.) Life University 2013-2014 Academic Catalog http://www.life.edu/attachments/article/123/college-of-chiropractic-section11.pdf

(22.) Life Chiropractic College West. Catalog and Student handbook 2013-2015 http://lifewest.edu/wp-content/documents/lccw-catalog.pdf

(23.) Logan College of Chiropractic University programs. Academic catalog 2012-2013 http://www.logan.edu/mm/files/Academics/Academic-Catalog-2012.pdf

(24.) National University of Health sciences. Bulletin 2013-2014 https://www.nuhs.edu/extras/docs/Bulletin_2013-2014.pdf

(25.) Palmer College of Chiropractic 2013-2014 Catalog http://www.palmer.edu/uploadedFiles/Pages/Marketing/Publications/Official_College_Documents/palmer_catalog.pdf

(26.) Sherman College of Chiropractic. Catalog 2013 http://www.shermancollege.net/intranet/ACADEM/college-catalog/Catalog-current.pdf?_ga=l.227948443.707802404.1408562641

(27.) Texas chiropractic college. 2013-2014 Catalog and handbook http://www.txchiro.edu/dc-program/curriculum

(28.) University of Western States. Catalog 2013-2014 https://www.uws.edu/wp-content/uploads/2013/11/UWS-Catalog-2013-14.pdf

(29.) Mark G. Christensen. Job Analysis of Chiropractic 2000, A Project Report, Survey Analysis, and Summary of the Practice of Chiropractic Within the United States. NATIONAL BOARD OF CHIROPRACTIC EXAMINERS; 2000

(30.) Examiners NB, Kollasch MW. Job Analysis of Chiropractic 2005, A Project Report, Survey Analysis, and Summary of the Practice of Chiropractic Within the United States. NATIONAL BOARD OF CHIROPRACTIC EXAMINERS; 2005.

(31.) Lipton RB, Stewart WF, Simon D. Medical consultation for migraine: results from the American Migraine Study. Headache. 1998; 38(2): 87-96.

(32.) Lipton RB, Diamond S, Reed M, Diamond ML, Stewart WF. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache. 2001; 41(7): 638-45

(33.) Lipton RB, Scher Al, Steiner TJ, et al. Patterns of health care utilization for migraine in England and in the United States. Neurology. 2003; 60(3): 441-8.

(34.) Diamond S, Bigal ME, Silberstein S, Loder E, Reed M, Lipton RB. Patterns of diagnosis and acute and preventive treatment for migraine in the United States: results from the American Migraine Prevalence and Prevention study. Headache. 2007; 47(3): 355-63.

by: Adrian Isaza, DC, DACBN
TABLE 1 NUMBER OF CHIROPRACTIC CLASSROOM HOURS OF NEUROSCIENCE
(NEUROANATOMY)

CHIROPRACTIC SCHOOLS                NEUROANATOMY HOURS
(12 out of 18 schools represented)

Cleveland Chiropractic College.
Kansas (20)                         Neuroanatomy = 90
Life College (21)                   Neuroanatomy CNS = 55 + Neuroanatomy
                                    PNS=55 Total = l10
Life Chiropractic college West
(22)                                Peripheral neuroanatomy=44 + central
                                    neuroanatomy/lab = 44 Total = 88
Logan College of Chiropractic (23)  Neuroanatomy = 90
National College of Chiropractic
x 2 (24)                            Neuroanatomy = 90
Palmer College Davenport   (25)     Neuroanatomy 1,2 = 150
Palmer College Florida (25)         Basic neuroanatomy = 84 Advanced
                                    neuroanatomy = 84 Total = 168
Palmer College West campus (25)     Neuroanatomy = 48
Sherman College (26)                Neuroanatomy 1,2 = 168 Total = 168
Texas Chiropractic College (27)     Neuroanatomy = 75
Western States chiropractic (28)    Neuroanatomy = 88
AVERAGE                                           106

TABLE 2 NUMBER OF CHIROPRACTIC CLASSROOM HOURS OF NEUROSCIENCE
(NEUROPHYSIOLOGY)

CHIROPRACTIC SCHOOLS (4 out of 18 schools
represented)                                 NEUROPHYSIOLOGY HOURS

Cleveland Chiropractic College. Kansas (20)  Neurophysiology = 60
National College of Chiropractic (24)        Neurophysiology = 60
Palmer College Davenport (25)                Neurophysiology 1,2,3 = 120
Western states chiropractic (28)             Neurophysiology = 66
AVERAGE                                                        76

TABLE 3 TOTAL NUMBER OF CLASSROOM HOURS OF NEUROSCIENCE

CLASSROOM HOURS                      CHIROPRACTIC SCHOOLS

Neuroanatomy (see table 1)            106
Neurophysiology (see table 2)          76
Total neuroscience hours (table 1 +   182
Tabel 2 and (ll)(12)(13)
TOTAL/AVERAGE                         182

CLASSROOM HOURS                      ALLOPATHIC SCHOOLS

Neuroanatomy (see table 1)
Neurophysiology (see table 2)
Total neuroscience hours (table 1 +  2002: 96
Tabel 2 and (ll)(12)(13)             2009: 79
                                     2012: 83
TOTAL/AVERAGE                              86

TABLE 4 PATTERNS OF HEADACHE DIAGNOSIS FOR CHIROPRACTORS

STUDY                                      CONDITION



National board of Chiropractic examiners.  Headaches
Job analysis of chiropractic 2000 (29)
National board of Chiropractic examiners.  Headaches
Job analysis of chiropractic 2005 (30)
TOTAL/AVERAGE

STUDY                                      PERCENT OF CHIROPRACTORS WHO
                                           PROVIDED A NON-SUBLUXATION
                                           DIAGNOSIS OF HEADACHE

National board of Chiropractic examiners.  76.1%
Job analysis of chiropractic 2000 (29)
National board of Chiropractic examiners.  76.9%
Job analysis of chiropractic 2005 (30)
TOTAL/AVERAGE                              76.5%

STUDY                                      SAMPLE SIZE



National board of Chiropractic examiners.  3,177 Chiropractors
Job analysis of chiropractic 2000 (29)
National board of Chiropractic examiners.  2,167 Chiropractors
Job analysis of chiropractic 2005 (30)
TOTAL/AVERAGE                              5,344 Chiropractors

TABLE 5 PATTERNS OF MIGRAINE DIAGNOSIS FOR ALLOPATHIC DOCTORS

STUDY                     CONDITION  PERCENT OF PATIENTS DIAGNOSED WITH
                                     MIGRAINE OR CHRONIC MIGRAINE

Lipton, etal, 1998(31)    Migraine   42.4%
Lipton, etal, 2001(32)    Migraine   48%
Lipton, et al, 2003(33)   Migraine   56%
Diamond, et al, 2007(34)  Migraine   56.2%
Bigal, et al, 2008(6)     Migraine   20.2%
TOTAL/AVERAGE                        44.6%

STUDY                       SAMPLE SIZE


Lipton, etal, 1998(31)       1,720 patients
Lipton, etal, 2001(32)       3,577 patients
Lipton, et al, 2003(33)        235 patients
Diamond, et al, 2007(34)    18,968 patients
Bigal, et al, 2008(6)          520 patients
TOTAL/AVERAGE               25,020 patients
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Date:Sep 1, 2015
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