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Based on the most recent and comprehensive systematic reviews, there is moderate evidence of short-term efficacy for spinal manipulation in the treatment of both acute and chronic low back pain. There is insufficient data available to draw conclusions regarding the efficacy for lumbar radiculopathy. The evidence is also not conclusive for the long-term efficacy of spinal manipulation for any type of low back pain.
BACKGROUND: Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological condition. The efficacy of medical treatments such as nonsteroidal anti-inflammatories (NSAIDs) or oral contraceptive pills (OCPs) is considerable, however the failure rate can still be as high as 20-25% and there are also a number of associated adverse effects. Many women are thus seeking alternatives to conventional medicine. One popular treatment modality is spinal manipulation therapy. There are several rationales for the use of musculoskeletal manipulation to treat dysmenorrhoea. The parasympathetic and sympathetic pelvic nerve pathways are closely associated with the spinal vertebrae, in particular the 2nd-4th sacral segments and the 10th thoracic to the 2nd lumbar segments. One hypothesis is that mechanical dysfunction in these vertebrae causes decreased spinal mobility. This could affect the sympathetic nerve supply to the blood vessels supplying the pelvic viscera, leading to dysmenorrhoea as a result of vasoconstriction. Manipulation of these vertebrae increases spinal mobility and may improve pelvic blood supply through an influence on the autonomic nerve supply to the blood vessels. Another hypothesis is that dysmenorrhoea is referred pain arising from musculoskeletal structures that share the same pelvic nerve pathways. The character of pain from musculoskeletal dysfunction can be very similar to gynecological pain and can present as cyclic pain as it can also be altered by hormonal influences associated with menstruation. OBJECTIVES: To determine the safety and efficacy of spinal manipulative interventions for the treatment of primary or secondary dysmenorrhoea when compared to each other, placebo, no treatment, or other medical treatment. SEARCH STRATEGY: Electronic searches of the Cochrane Menstrual Disorders and Subfertility Group specialised register of controlled trials, CCTR, MEDLINE, EMBASE, CINAHL, Bio extracts, Psyclit and SPORTDiscus were performed to identify relevant randomised controlled trials (RCTs). The Cochrane Complementary Medicine Field's Register of controlled trials (CISCOM) was also searched. Attempts were also made to identify trials from the National Research Register, the Clinical Trial Register and the citation lists of review articles and included trials. In most cases, the first or corresponding author of each included trial was contacted for additional information. SELECTION CRITERIA: Any RCTs including spinal manipulative interventions (e.g. chiropractic, osteopathy or manipulative physiotherapy) vs each other, placebo, no treatment, or other medical treatment were considered. Exclusion criteria were: mild or infrequent dysmenorrhoea or dysmenorrhoea from an IUD. DATA COLLECTION AND ANALYSIS: Five RCTs were identified that fulfilled the inclusion criteria for this review. Four trials involving high velocity, low amplitude manipulation (HVLA), and one involving the Toftness manipulation technique were included. Quality assessment and data extraction were performed independently by two reviewers. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Data unsuitable for meta-analysis were reported as descriptive data and were also included for discussion. The outcome measures were pain relief or pain intensity (dichotomous, visual analogue scales, descriptive) and adverse effects. MAIN RESULTS: Results from the four trials of high velocity, low amplitude manipulation suggest that the technique was no more effective than sham manipulation for the treatment of dysmenorrhoea, although it was possibly more effective than no treatment. Three of the smaller trials indicated a difference in favour of HVLA, however the one trial with an adequate sample size found no difference between HVLA and sham treatment. There was no difference in adverse effects experienced by participants in the HVLA or sham treatment. The Toftness technique was shown to be more effective than sham treatment by one small trial, but no strong conclusions could be made due to the small size of the trial and other methodological considerations. REVIEWER'S CONCLUSIONS: Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea. There is no greater risk of adverse effects with spinal manipulation than there is with sham manipulation.
STUDY DESIGN: A prospective, cohort study of patients with nonradicular low back pain referred to physical therapy. OBJECTIVE: Develop a clinical prediction rule for identifying patients with low back pain who improve with spinal manipulation. SUMMARY OF BACKGROUND DATA: Development of clinical prediction rules for classifying patients with low back pain who are likely to respond to a particular intervention, such as manipulation, would improve clinical decision-making and research. METHODS: Patients with nonradicular low back pain underwent a standardized examination and then underwent a standardized spinal manipulation treatment program. Success with treatment was determined using percent change in disability scores over three sessions and served as the reference standard for determining the accuracy of examination variables. Examination variables were first analyzed for univariate accuracy in predicting success and then combined into a multivariate clinical prediction rule. RESULTS: Seventy-one patients participated. Thirty-two had success with the manipulation intervention. A clinical prediction rule with five variables (symptom duration, fear-avoidance beliefs, lumbar hypomobility, hip internal rotation range of motion, and no symptoms distal to the knee) was identified. The presence of four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%. CONCLUSION: It appears that patients with low back pain likely to respond to manipulation can be accurately identified before treatment.
STUDY DESIGN: Double-blind, randomized, placebo-controlled trial. OBJECTIVES: To evaluate the effect of manual endplay assessment on neck pain and stiffness outcomes in neck pain patients receiving spinal manipulation. SUMMARY OF THE BACKGROUND DATA: There have been no studies on the efficacy of palpation used as an indicator for manipulation in the management of back and neck pain. METHODS: Neck pain patients (n = 104) were randomly assigned to two groups. The study group received manipulation targeted to individual cervical vertebrae according to endplay restriction noted by the examining clinician. The control group received manipulation determined by sham, computer-generated examination findings; endplay examination was ignored and served as a placebo assessment. Treatment was rendered on a single occasion by a chiropractor. Outcomes were neck pain and stiffness assessed before and after manipulation and at least 5 hours following treatment. RESULTS: The study and control groups showed clinically important improvement in neck pain and stiffness. However, there were no clinically important or statistically significant differences between the study and control groups in terms of pain or stiffness outcomes. Findings were robust across patient, complaint, and treatment characteristics. CONCLUSIONS: Endplay assessment in and of itself did not contribute to the same-day pain and stiffness relief observed in neck pain patients receiving spinal manipulation. The impact on a longer course of treatment remains to be investigated. The data suggest that pain modulation may not be limited to mechanisms associated with manipulation of putative motion restrictions.
OBJECTIVES: To provide preliminary information on whether a regimen of 30 chiropractic treatments that combines ischemic compression and spinal manipulation effectively reduces the intensity of pain, sleep disturbance, and fatigue associated with fibromyalgia. In addition, to study the dose-response relation and identify the baseline characteristics that may serve as predictors of outcome. DESIGN: Subjects were assessed with self-administered questionnaires taken at baseline, after 15 and 30 treatments, and 1 month after the end of the treatment trial. SETTING: Private practice. METHODS: Participating subjects were adult members of a regional Fibromyalgia Association. Participating subjects had fibromyalgia for more than 3 months. They received 30 treatments including ischemic compression and spinal manipulation. The 3 outcomes being evaluated were pain intensity, fatigue level, and sleep quality. A minimum 50 improvement in pain intensity from baseline to the end of the treatment trial was needed to include the patient in the respondent category. RESULTS: Fifteen women (mean age 51.1 years) completed the trial. A total of 9 (60) patients were classified as respondents. A statistically significant lessening of pain intensity and corresponding improvement in quality of sleep and fatigue level were observed after 15 and 30 treatments. After 30 treatments, the respondents showed an average lessening of 77.2 (standard deviation = 12.3) in pain intensity and an improvement of 63.5 (standard deviation = 31.6) in sleep quality and 74.8 (standard deviation = 23. 1) in fatigue level. The improvement in the 3 outcome measures was maintained after 1 month without treatment. Subjects with less than 35 improvement after 15 treatments did not show a satisfactory response after 30 treatments. A trend, determined as not statistically significant, suggests that older subjects with severe and more chronic pain and a greater number of tender points respond more poorly to treatment. CONCLUSION: This study suggests a potential role for chiropractic care in the management of fibromyalgia. A randomized clinical trial should be conducted to test this hypothesis.
BACKGROUND CONTEXT: Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain. PURPOSE: To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB. STUDY DESIGN: RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated pain, disability, global improvement and recovery time). METHODS: Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized trials were identified by a comprehensive search of computerized and bibliographic literature databases up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Forty-three RCTs met the admissibility criteria for evidence. RESULTS: Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes in the short and long term when compared with placebo and with other treatments, such as McKenzie therapy, medical care, management by physical therapists, soft tissue treatment and back school. Acute NP: There are few studies, and the evidence is currently inconclusive. Chronic NP: There is moderate evidence that SMT/MOB is superior to general practitioner management for short-term pain reduction but that SMT offers at most similar pain relief to high-technology rehabilitative exercise in the short and long term. Mix of acute and chronic NP: The overall evidence is not clear. There is moderate evidence that MOB is superior to physical therapy and family physician care, and similar to SMT in both the short and long term. There is limited evidence that SMT, in both the short and long term, is inferior to physical therapy. CONCLUSIONS: Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.
OBJECTIVE: Recent experimental evidence demonstrating neuronal/synaptic plasticity and, in particular, long-term potentiation (LTP) and long-term depression (LTD) in spinal neurons is reviewed. The implications of these studies for possible mechanistic explanations of low back pain and its remediation by spinal manipulative therapy (SMT) are explored. Brief descriptions of LTP and LTD and elaboration of the key roles of calcium, glutamate, and glutamate receptors in LTP/LTD are provided as separate appendices. DATA SOURCES: The referenced articles regarding LTP/LTD in spinal cord neurons and neuronal plasticity, in general, were identified from accumulated review of the neuroscience literature. Publications cited from chiropractic sources relevant to central neuronal plasticity and LTP/LTD were identified using the Index to Chiropractic Literature and informal review. STUDY SELECTION: Experimental studies examining LTP/LTD mechanisms in spinal neurons and more general references useful as an introduction to central neuronal plasticity and LTP/LTD are included.Data Extraction Experimental evidence presented in this review has been previously published and illustrates neuronal plasticity from an animal model for low back pain. DATA SYNTHESIS: Both in vitro and in vivo evidence identifying LTP and LTD in dorsal horn nociceptive neurons is reviewed. Of special interest are studies showing LTP in response to intense noxious stimulation and reports that Adelta-mechanosensitive afferent activation can reverse an existing LTP condition in dorsal horn neurons. CONCLUSIONS: The potential involvement of LTP in low back pain is discussed and a role for LTD in spinal manipulative therapy is proposed. The need for future studies is identified in the areas of spatial and temporal changes in symptomatology post-SMT of the low back; combining, sequencing, and comparing several therapeutic approaches; and demonstrating LTD in spinal cord neurons post-SMT-like stimulation.
Thumb pain is a common complaint of physical therapists. The purpose of this study was to investigate the prevalence, presentation, and techniques associated with aggravation of thumb pain in physical therapists practicing spinal manipulative therapy and the management strategies used to deal with pain. A survey was sent to members of Musculoskeletal Physiotherapy Australia. Data were collected from subjects who had completed postgraduate study in manipulative physical therapy. Of the 155 subjects who responded, 83% complained of pain in their thumbs aggravated by performing manipulative therapy techniques in the preceding year (2000). The most common presentation of pain included mild pain (3.8/10) at the metacarpophalangeal joint, with multiple, short-lived episodes. Techniques most commonly responsible for aggravation of symptoms were unilateral (87%) and central posteroanterior glides (85%). Most subjects (74%) changed their choice of treatment technique to alleviate symptoms. Suggestions are made about the safe alignment of the thumb during performance of spinal manipulative therapy techniques.
PURPOSE: To study whether a 3-wk series of spinal manipulation has any lasting effect on passive cervical range of motion. DESIGN: Randomized, controlled trial with a blind observer. SETTING: Ambulatory outpatient facility in an independent National Health Service funded chiropractic research institution. PARTICIPANTS: Thirty-nine headache sufferers who, on entering the study, displayed objectively decreased passive cervical range of motion. These subjects were recruited from 400 headache sufferers who responded to newspaper advertisements. INTERVENTION: Half of the group received high-velocity, low-amplitude cervical manipulation twice a week for 3 wk. The other half received low-level laser in the upper cervical region and deep friction massage in the lower cervical/upper thoracic region, also twice a week for 3 wk. MAIN OUTCOME MEASURE: Goniometrically assessed passive range of motion of the cervical spine. RESULTS: Although passive cervical range of motion increased in both groups during the trial period, there were no statistically significant differences between the two groups 1 wk after the last treatment. CONCLUSION: It seems that any changes in passive range of motion after spinal manipulation are of a temporary nature.
The literature has produced sufficient evidence to suggest that spinal manipulation may be more effective than standard medical care in the management of painful musculoskeletal conditions; most notably that of low back pain. However, much of the research has been severely criticized because of poor methodological design characteristics, the incorporation of systematic bias and the increased likelihood of making serious beta errors. This review identifies the essential components which distinguish 'good' clinical research and critically appraises the nearly four dozen clinical trials of spinal manipulation which have been published to date. It was observed that only the randomized control clinical trials demonstrated sufficient rigor to adequately control the data collection and analysis but agreement about the clinically relevant outcomes of manipulative therapy still have not been consistently demonstrated.
OBJECTIVE: To determine whether spinal manipulative therapy (SMT) is an independent risk factor for cervical artery dissection. METHODS: Using a nested case-control design, the authors reviewed all patients under age 60 with cervical arterial dissection (n = 151) and ischemic stroke or TIA from between 1995 and 2000 at two academic stroke centers. Controls (n = 306) were selected to match cases by sex and within age strata. Cases and controls were solicited by mail, and respondents were interviewed using a structured questionnaire. The medical records of interviewed patients were reviewed by two blinded neurologists to confirm that the patient had stroke or TIA and to determine whether there was evidence of arterial dissection. RESULTS: After interview and blinded chart review, 51 patients with dissection (mean age 41 +/- 10 years; 59% female) and 100 control patients (44 +/- 9 years; 58% female) were studied. In univariate analysis, patients with dissection were more likely to have had SMT within 30 days (14% vs 3%, p = 0.032), to have had neck or head pain preceding stroke or TIA (76% vs 40%, p < 0.001), and to be current consumers of alcohol (76% vs 57%, p = 0.021). In multivariate analysis, vertebral artery dissections were independently associated with SMT within 30 days (OR 6.62, 95% CI 1.4 to 30) and pain before stroke/TIA (OR 3.76, 95% CI 1.3 to 11). CONCLUSIONS: This case-controlled study of the influence of SMT and cervical arterial dissection shows that SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain. Patients undergoing SMT should be consented for risk of stroke or vascular injury from the procedure. A significant increase in neck pain following spinal manipulative therapy warrants immediate medical evaluation.
The practice of chiropractic has been regulated in the State of Delaware since 1937. Since that time, the battle lines in the state between medicine and chiropractic have been drawn. This war has existed on both the political and clinical fronts, and although it has always been believed by the chiropractic profession that once the "scientific evidence" of the benefit of chiropractic was proven, the war would end. This has not occurred to the extent believed. Even with its 1980 victory over the AMA, chiropractic has still been unable to achieve full acceptance as a clinical discipline among other professions. Many hospitals in this country have opened their doors to DCs. This by and large, has solely been for economic reasons and not as a recognition of the clinical benefit of manipulation. There is, however, a growing population of primary care physicians and researchers suggesting the benefit of manipulation for low back pain as well as suggesting that increased cooperation between MDs and DCs could be of extreme benefit to the patient population at large. This group continues to be in the minority. However, with increased knowledge of the benefits of spinal manipulation and the scientific evidence that now exists to support its efficacy, it is now believed that this interprofessional referral pattern will increase. In addition, many managed care programs now require primary care physicians to determine the necessity for referral to a chiropractor, thus causing a need for the primary physician to have some knowledge of spinal manipulation. This paper is presented to inform the physician community of Delaware of some of the evidence pointing to the efficacy of spinal manipulation as a treatment for low back pain.
BACKGROUND: The effect of osteopathic manual therapy (i.e., spinal manipulation) in patients with chronic and subchronic back pain is largely unknown, and its use in such patients is controversial. Nevertheless, manual therapy is a frequently used method of treatment in this group of patients. METHODS: We performed a randomized, controlled trial that involved patients who had had back pain for at least three weeks but less than six months. We screened 1193 patients; 178 were found to be eligible and were randomly assigned to treatment groups; 23 of these patients subsequently dropped out of the study. The patients were treated either with one or more standard medical therapies (72 patients) or with osteopathic manual therapy (83 patients). We used a variety of outcome measures, including scores on the Roland-Morris and Oswestry questionnaires, a visual-analogue pain scale, and measurements of range of motion and straight-leg raising, to assess the results of treatment over a 12-week period. RESULTS: Patients in both groups improved during the 12 weeks. There was no statistically significant difference between the two groups in any of the primary outcome measures. The osteopathic-treatment group required significantly less medication (analgesics, antiinflammatory agents, and muscle relaxants) (P< 0.001) and used less physical therapy (0.2 percent vs. 2.6 percent, P<0.05). More than 90 percent of the patients in both groups were satisfied with their care. CONCLUSIONS: Osteopathic manual care and standard medical care had similar clinical results in patients with subacute low back pain. However, the use of medication was greater with standard care.
OBJECTIVE: To quantify in vivo spinal motions and coupling patterns occurring in human subjects in response to mechanical force, manually assisted, short-lever spinal manipulative thrusts (SMTs) applied to varying vertebral contact points and utilizing various excursion (force) settings. METHODS: Triaxial accelerometers were attached to intraosseous pins rigidly fixed to the L1, L3, or L4 lumbar spinous process of 4 patients (2 male, 2 female) undergoing lumbar decompressive surgery. Lumbar spine acceleration responses were recorded during the application of 14 externally applied posteroanterior (PA) impulsive SMTs (4 force settings and 3 contact points) in each of the 4 subjects. Displacement time responses in the PA, axial (AX), and medial-lateral (ML) axes were obtained, as were intervertebral (L3-4) motion responses in 1 subject. Statistical analysis of the effects of facet joint (FJ) contact point and force magnitude on peak-to-peak displacements was performed. Motion coupling between the 3 coordinate axes of the vertebrae was examined using a least squares linear regression. RESULTS: SMT forces ranged from 30 N (lowest setting) to 150 N (maximum setting). Peak-to-peak ML, PA, and AX vertebral displacements increased significantly with increasing applied force. For thrusts delivered over the FJs, pronounced coupling was observed between all axes (AX-ML, AX-PA, PA-ML) (linear regression, R(2) = 0.35-0.52, P <.001), whereas only the AX and PA axes showed a significant degree of coupling for thrusts delivered to the spinous processes (SPs) (linear regression, R(2) = 0.82, P <.001). The ML and PA motion responses were significantly (P <.05) greater than the AX response for all SMT force settings. PA vertebral displacements decreased significantly (P <.05) when the FJ contact point was caudal to the pin compared with FJ contact cranial to the pin. FJ contact at the level of the pin produced significantly greater ML vertebral displacements in comparison with contact above and below the pin. SMTs over the spinous processes produced significantly (P <.05) greater PA and AX displacements in comparison with ML displacements. The combined ML, PA, and AX peak-to-peak displacements for the 4 force settings and 2 contact points ranged from 0.15 to 0.66 mm, 0.15 to 0.81 mm, and 0.07 to 0.45 mm, respectively. Intervertebral motions were of similar amplitude as the vertebral motions. CONCLUSIONS: In vivo kinematic measurements of the lumbar spine during the application of SMTs over the FJs and SPs corroborate previous spinous process measurements in human subjects. Our findings demonstrate that PA, ML, and AX spinal motions are coupled and dependent on applied force and contact point.
OBJECTIVE: To evaluate the effectiveness of spinal manipulative therapy (SMT) in the treatment of an internal organ disorder. DESIGN: Clinical trial. SETTING: Medical hospital. PATIENTS: Eleven adult men and women ranging in age from 18-44 yr with endoscopically confirmed diagnosis of ulcer disease took part in the study as an experimental group. The outcome of 24 cases of uncomplicated ulcerous disease treated by usual medical methods was analyzed as a control. INTERVENTIONS: The experimental group received spinal manipulative therapy (SMT) treatment from 5-22 days with a range of 3-14 procedures. The control group received traditional medical treatment (drug therapy and diet). The dietary regimen was standard for both groups. MEASUREMENTS: The effectiveness of the treatment was evaluated using clinical parameters and endoscopic examination performed weekly. MAIN RESULTS: The use of SMT resulted in pain relief after 1-9 (avg. 3.8) days and clinical remission an average of 10 days earlier than traditional care. CONCLUSIONS: Chiropractic practice often includes patients with gastrointestinal problems who report some relief of their symptoms after treatment; however, the physiological basis for these results has yet to be established. The normalization in segmental trophic innervation of the mucosal layer of the intestine, and positive reaction of the whole body, are under discussion as a possible mechanism for the treatment effect.
OBJECTIVE: To examine the differences in predefined biomechanical parameters of spinal manipulation using a single method common to the training of both novice and expert manipulators. DESIGN: Analytic Cohort Study. PARTICIPANTS: Fifteen novice manipulators and fifteen experienced physicians provided 2 applications of spinal manipulation therapy (SMT) to 15 healthy, male student volunteers. Assignment of volunteers was randomized, and the order of the first interaction with the manipulators was determined by coin toss and then inverted for the second. INTERVENTION: The bilateral transverse-thenar thoracic maneuver was selected from the diversified system of treatment to be used as the test procedure. Selection was guided by mechanical simplicity. SMT was applied at the physician's discretion to the region of T3-T10. Standard informed consent procedures were followed. MAIN OUTCOME MEASURES: Preload force, rise rate of thrust and thrust force were selected as prospective primary outcome measures. Secondary descriptive measures included impulse, rise time, downward incisural point (DIP), fall time, total force, force components and direction cosines. RESULTS: Both novice and experienced manipulators were familiar with the transverse-thenar procedure, but only three of the experienced manipulators professed common use of it. Mean values for primary outcomes were all higher for the experienced participants; however, no statistically significant differences were found. DISCUSSION: Differences are presumed to exist between novice and experienced manipulators, as evidenced by measurement of arbitrarily selected thoracic and lumbar SMT. However, no systematic differences were found when the manipulators have a similar lack of practice experience specific to the test procedure. These results suggest the importance of regular use in developing skill of performance.
OBJECTIVE: The purpose of this study was to confirm a practitioner's perception of cavitation during spinal manipulative therapy in a clinically relevant situation using accelerometer recordings. DESIGN: Experimental study. SETTING: Human Performance Laboratory and Sports Medicine Center, University of Calgary. PARTICIPANTS: Twenty-eight patients from a single practitioner's patient pool who had pain in the area of the thoracic spine. INTERVENTION: Spinal manipulative treatment (SMT) on the transverse process of T4 using a reinforced unilateral contact and delivering a thrust in the posterior to anterior direction. MAIN OUTCOME MEASURES: Instantaneous acceleration signals obtained from the spinous process of T3 during SMT and the practitioner's perception if cavitation had occurred or not at the end of each treatment. CONCLUSIONS: It appears that cavitation may be measured during SMT using accelerometry and that a practitioner's perception of the occurrence of cavitation during SMT is very accurate.
Non-drug therapies for women with primary dysmenorrhea are primarily based on anecdotal evidence and small-scale clinical studies. This randomized, observer-blinded, clinical trial evaluated the efficacy of spinal manipulative therapy (SMT) in the treatment of women with primary dysmenorrhea. Women were recruited from the Chicago metropolitan area and evaluated for inclusion through four screening levels. One hundred thirty eight women, ages 18-45, with primary dysmenorrhea diagnosed by participating gynecologists, were randomly assigned to either SMT or a low-force mimic (LFM) maneuver. No treatment occurred at menstrual cycle 1. Treatment for both groups took place on day 1 of cycles 2, 3 and 4, and prophylactic treatment of three visits took place during the 7 days before cycles 3 and 4. Main outcome measures were the Visual Analog Scale (VAS) and plasma concentration of the prostaglandin F2alpha metabolite, 15-keto-13,14-dihydro-prostaglandin F2alpha (KDPGF2alpha), measured 15 min before treatment and 60 min after treatment on day 1 of four consecutive menstrual cycles. The Moos' Menstrual Distress Questionnaire (MDQ) was also administered after treatment on day 1 of each cycle. At cycle 2, the post-treatment VAS scores decreased for both groups, with no statistically significant difference in pre- to post-treatment scores between the two groups (P = 0.44). The changes in pre- to post-treatment KDPGF2alpha levels were not statistically different between the SMT and LFM groups (P = 0.15). No treatment effects were detected over the three cycles for VAS, KDPGF2alpha or MDQ (P = 0.65, P = 0.61 and P = 0.78, respectively). However, there were statistically significant linear time effects for VAS (P = 0.008), MDQ (P < 0.001), and borderline significance for KDPGF2alpha (P = 0.054); these decreases were not considered clinically meaningful. The LFM maneuver used in this study was designed to act as a 'placebo-like' control treatment in comparison with SMT. Although it is possible that the trial did not continue long enough for any placebo effect of the LFM to wash out, it seems more likely that this maneuver was indistinguishable from SMT. Therefore, the postulated superior benefit of high-velocity, short-lever, low-amplitude, high-force spinal manipulation to a low-force maneuver is not supported by the results of this study. 1999 International Association for the Study of Pain.