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PubMed2006

Effects of visual feedback on manipulation performance and patient ratings.

OBJECTIVE: This study examined the explicit targeted outcome (a criterion standard) and visual feedback on the immediate change in and the short-term retention of performance by novice operators for a high-velocity, low-amplitude procedure under realistic conditions. METHODS: This study used a single-blind randomized experimental design. Forty healthy male (n = 26) and female (n = 14) chiropractic student volunteers with no formal training in spinal manipulative therapy participated. Biomechanical parameters of an L4 mammillary push spinal manipulation procedure performed by novice operators were quantified. Participants were randomly assigned to 2 groups and paired. One group received visual feedback from load-time histories of their performance compared with a criterion standard before a repeat performance. Participants then performed a 10-minute distractive exercise consisting of National Board of Chiropractic Examiners review questions. The second group received no feedback. An independent rating of performance was conducted for each participant by his/her partner. Results were analyzed separately for biomechanical parameters for partner ratings using the Student t test with levels of significance (P < .01) adjusted for repeated testing. RESULTS: Expressed in percent change for each individual, visual feedback was associated with change in the biomechanical performance of group 2, a minimum of 14% and a maximum of 32%. Statistical analysis rating of the performance favored the feedback group on 4 of the parameters (fast, P < .0008; force, P < .0056; precision, P < .0034; and composite, P < .0016). CONCLUSION: Quantitative feedback, based on a tangible conceptualization of the target performance, resulted in immediate and significant improvement in all measured parameters. Newly developed skills were retained at least over short intervals even after distractive tasks. Learning what to do with feedback on one's own performance may be more important than the classic teaching of how to do it.

Adult↗
PubMed2000

Theory of small vertebral motions: an analytical model compared to data.

OBJECT: Develop an analytical theory describing the dynamics of small impulses applied to vertebrae, such as in chiropractic adjustments or spinal manipulative therapy. DESIGN: Data were compared with damped harmonic oscillator models of vertebrae. BACKGROUND: Evidence accumulates that chiropractic adjustments are effective in addressing a variety of health problems. However, the biomechanics characterizing spinal manipulation is largely unknown. Recently, relative separations of the L2-L3 vertebrae subsequent to activator adjusting instrument thrusts were measured in vivo at 2048 Hz. RESULTS: Nine-parameter models for axial, shear and angular motions were fit to sets of 350 data points. They required frequencies of 5, 8 and 11 Hz, corresponding to well-known spinal resonances. The fits are excellent, with 0.75 < corrected R(2) < 0.96. Stiffnesses are calculated to be less than 10% of elastic zone values. Viscosities of the paravertebral medium are predicted to be between 6 and 30 poise, comparable to synovial fluids. CONCLUSIONS: This model ties together vertebral responses to small impulses with spinal resonances and other spinal/vertebral characteristics. Stiffness dominates damping resistance except in angular motions. Coupling appears unimportant in adjacent vertebral responses to small impulses. Further research is needed to clarify this issue. RELEVANCE: This study indicates how both force (determining amplitude) and thrust speed or duration (determining frequencies excited) may enter in terms of optimizing the efficacy of chiropractic adjustments. If stimulation of specific spinal frequencies, say as central nervous input, were most essential, then many chiropractic thrusts could be clinically similar. This may explain how over 90 chiropractic techniques can co-exist.

Elasticity↗
PubMed2004

Osteoporotic fracture of the dens revealed by cervical manipulation.

Osteoporotic vertebral fractures selectively affect the thoracolumbar junction, usually sparing the cervical spine. A 65-year-old woman with documented osteoporotic fractures and chronic alcohol abuse presented with neck pain and occipital neuralgia that started after she suddenly flexed then extended her neck. Following several sessions of cervical manipulation, her pain became more severe, and she was admitted. Imaging studies showed multiple fractures in the dens, C6 and C7. These apparently spontaneous fractures suggested a bone tumor, for which investigations were negative. Osteoporosis was the only identifiable cause. The spinal manipulations probably worsened the lesions which were performed by a chiropractor who is not a physician and did not obtain cervical spine radiographs before treating the patient. Osteoporosis contraindicates spinal manipulation at any level, including the cervical spine.

Aged↗
PubMed2003

Global 3D head-trunk kinematics during cervical spine manipulation at different levels.

OBJECTIVE: Determination of the three-dimensional kinematics of the head relative to the upper trunk obtained during a manipulation applied on two different cervical levels and on both sides. DESIGN: Descriptive study performed on 14 asymptomatic volunteers. The range of motion was measured by a 3D electrogoniometer during manipulation executed by the same practitioner. BACKGROUND: Spinal manipulative therapy is a common treatment approach in patients suffering from some spinal disorders. Complications exist; they are thought to be related to the force applied by the practitioner and the range of spinal motion obtained during the manipulation. Yet, little is known about cervical spine motion during manipulation. METHODS: Three dimensional electrogoniometry using a 6 degree-of-freedom spatial linkage fixed between the head and the upper trunk was used to record the pattern of motion and the amplitudes obtained during a manipulation on two cervical levels (C3 and C5) and on left and right sides. On single practitioner applied the same technique to all subjects in a seated position. RESULTS: The side and the spinal level manipulated did not influence 3D ranges of motion. The mean ranges of motion obtained were 30 degrees axial rotation, 46 degrees lateral bending and 2 degrees flexion. A significant difference of the flexion-extension range existed between manipulations with and without audible release. Axial rotation and lateral bending ranges were correlated. Except for lateral bending which was close to active range, the motion ranges obtained during manipulation were well below active range of motion reported in literature. CONCLUSIONS: The results of this study suggest that for the kind of manipulation applied, maximal amplitude between head and trunk does not exceed physiological active range of motion. The amplitude for rotation, which is generally assumed to involve greatest risks for negative side effects, is significantly lower than during active motion. As the study was performed with one practitioner, this result may only be generalized with care. RELEVANCE: In spinal manipulative therapy, extreme range of motion as the result of the forces applied is generally believed to represent a major risk for negative side effects, especially with regard to the cervical spine. With a multiple component technique, amplitudes between head and upper trunk were shown not to differ significantly with regard to the side nor to the spinal level. Recorded ranges of motion did not exceed those reported for active motion in literature.

Adult↗
PubMed1994

Chiropractic: a medical perspective.

Chiropractic health care is founded on the premise that many diseases are the result of spinal nerve impingements or interference. These nerve impingements are postulated to be the result of misaligned vertebra or "subluxations." Research indicates that spinal manipulation may be beneficial in low back pain, but the claim that spinal manipulation is of value for optimizing general health and treating non-musculoskeletal conditions is unfounded.

Antitrust Laws↗
PubMed2002

Decrease in elbow flexor inhibition after cervical spine manipulation in patients with chronic neck pain.

OBJECTIVE: This study measured functional capacity and subjective pain in patients with chronic neck pain before and after manipulation of the cervical spine. DESIGN: Outcomes study on 16 patients with chronic neck pain. BACKGROUND: Muscle inhibition, i.e., the inability to fully activate a muscle, has been observed following joint pathologies and in low back pain conditions. Although chronic neck pain has been associated with changes in muscle recruitment and coordination in the shoulder and arms, the possibility of muscle inhibition has not been explored. METHODS: Biceps activation during a maximal voluntary elbow flexor contraction was assessed using the interpolated twitch technique and electromyography. Cervical range of motion and pressure pain thresholds were measured using a goniometer and an algometer. Manipulation of the cervical spine was applied at the level of C5/6/7, and functional assessments were repeated. RESULTS: Patients showed significant inhibition in their biceps muscles. Cervical range of motion was restricted laterally, and increased pressure pain sensitivity was evident. After cervical spine manipulation, a significant reduction in biceps inhibition and an increase in biceps force occurred. Cervical range of motion and pressure pain thresholds increased significantly. CONCLUSIONS: Significant dysfunction in biceps activation was evident in patients with chronic neck pain, indicating that this muscle group cannot be used to the full extent. Spinal manipulation decreased muscle inhibition and increased elbow flexor strength at least in the short term. RELEVANCE: Muscle inhibition in the biceps has not been previously documented in patients with chronic neck pain. Further research is needed to establish whether muscle inhibition is related to clinical symptoms and functional outcome. Spinal manipulation improved muscle function, cervical range of motion and pain sensitivity, and might therefore be beneficial for treating patients with chronic neck pain.

Adult↗
PubMedDate not supplied

Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias.

BACKGROUND CONTEXT: The growing recognition of cervical manipulation as a treatment of neck pain and cervicogenic headaches has lead to increased interest in potential complications that may result from this treatment approach. Recent surveys have reported that many neurologists will encounter cases of vertebral artery dissection that occur at various times after cervical manipulation, whereas most practitioners of spinal manipulation are of the opinion that these events are extremely rare. We asked the question whether these differences in perception could be explained in part by referral or selection bias. PURPOSE: To assess the effect of referral bias on the differences in perceived incidence of vertebral artery dissection after cervical manipulation between neurologists and chiropractors in Canada. STUDY DESIGN: This study was a retrospective review of cases where neurological symptoms consistent with cerebrovascular ischemia were reported by chiropractors in Canada. METHODS: An analysis of data from a chiropractic malpractice insurance carrier (Canadian Chiropractic Protective Association [CCPA]) and results of a survey of chiropractors was performed to determine the likelihood that a vertebral artery dissection after cervical manipulation would be reported to practicing chiropractors. This was compared with the likelihood that a neurologist would be made aware of such a complication. RESULTS: For the 10-year period 1988 to 1997, there were 23 cases of vertebral artery dissection after cervical manipulation reported to the CCPA that represents 85% of practicing chiropractors in Canada. Based on the survey, an estimated 134,466,765 cervical manipulations were performed during this 10-year period. This gave a calculated rate of vertebral artery dissection after manipulation of 1:5,846,381 cervical manipulations. Based on the number of practicing chiropractors and neurologists during the period of this study, 1 of every 48 chiropractors and one of every two neurologists would have been made aware of a vascular complication from cervical manipulation that was reported to the CCPA during their practice lifetime. CONCLUSIONS: The perceived risk after cervical manipulation by chiropractors and neurologists is related to the probability that a practitioner will be made aware of such an incident. The difference in the number of chiropractors (approximately 3,840 in 1997) and neurologists (approximately 4,000 in 1997) in active practice and the fact that each patient who has a stroke after manipulation will likely be seen by only one chiropractor but by three or more neurologists partly explains the difference in experience and the perception of risk of these two professions. This selection or referral bias is important in shaping the clinical opinions of the various disciplines and distorts discussion on the true incidence of these complications of cervical manipulation. The nature of this study, however, describes the likelihood that a clinician will be made aware of such an event and cannot be interpreted as describing the actual risk of stroke after manipulation.

Bias↗
PubMed2003

UK Back pain Exercise And Manipulation (UK BEAM) trial--national randomised trial of physical treatments for back pain in primary care: objectives, design and interventions [ISRCTN32683578].

BACKGROUND: Low back pain has major health and social implications. Although there have been many randomised controlled trials of manipulation and exercise for the management of low back pain, the role of these two treatments in its routine management remains unclear. A previous trial comparing private chiropractic treatment with National Health Service (NHS) outpatient treatment, which found a benefit from chiropractic treatment, has been criticised because it did not take treatment location into account. There are data to suggest that general exercise programmes may have beneficial effects on low back pain. The UK Medical Research Council (MRC) has funded this major trial of physical treatments for back pain, based in primary care. It aims to establish if, when added to best care in general practice, a defined package of spinal manipulation and a defined programme of exercise classes (Back to Fitness) improve participant-assessed outcomes. Additionally the trial compares outcomes between participants receiving the spinal manipulation in NHS premises and in private premises. DESIGN: Randomised controlled trial using a 3 x 2 factorial design. METHODS: We sought to randomise 1350 participants with simple low back pain of at least one month's duration. These came from 14 locations across the UK, each with a cluster of 10-15 general practices that were members of the MRC General Practice Research Framework (GPRF). All practices were trained in the active management of low back pain. Participants were randomised to this form of general practice care only, or this general practice care plus manipulation, or this general practice care plus exercise, or this general practice care plus manipulation followed by exercise. Those randomised to manipulation were further randomised to receive treatment in either NHS or private premises. Follow up was by postal questionnaire one, three and 12 months after randomisation. The primary analysis will consider the main treatment effects before interactions between the two treatment packages. Economic analysis will estimate the cost per unit of health utility gained by adding either or both of the treatment packages to general practice care.

Adult↗
PubMed1992

Enhanced neutrophil respiratory burst as a biological marker for manipulation forces: duration of the effect and association with substance P and tumor necrosis factor.

A critical need in assessing the clinical utility of manipulative therapy for back pain is the identification of biological changes associated with the forces applied by spinal manipulation. Such changes could then serve as markers for both sham treatment and manipulation. We determined the priming of polymorphonuclear neutrophils for an enhanced respiratory burst and its duration, the priming of mononuclear cells for enhanced endotoxin-stimulated tumor necrosis factor production and plasma levels of substance P following a single thoracic spine manipulation. There was a significant difference in the respiratory burst of polymorphonuclear neutrophils in response to a particulate challenge, depending on the time of blood sample collection. The response of polymorphonuclear neutrophils isolated from blood collected 15 min after manipulation was significantly higher than the response of cells isolated from blood collected 15 min before and 30 and 45 min after manipulation. Mononuclear cells were also primed for enhanced endotoxin-stimulated tumor necrosis factor production by spinal manipulation. Both of these priming effects were accompanied by a slight, but significant elevation in plasma substance P. The mean manipulation force associated with these biological effects was 878 +/- 99 N. These biological effects may provide a means of monitoring the delivery of both sham and manipulative treatment and, therefore, provide a crucial tool for understanding the efficacy of manipulative therapy.

Adult↗
PubMed1999

Massage therapy for low back pain: a systematic review.

Massage therapy is frequently employed for low back pain (LBP). The aim of this systematic review was to find the evidence for or against its efficacy in this indication. Four randomized clinical trials were located in which massage was tested as a monotherapy for LBP. All were burdened with major methodological flaws. One of these studies suggests that massage is superior to no treatment. Two trials imply that it is equally effective as spinal manipulation or transcutaneous electrical stimulation (TES). One study suggests that it is less effective than spinal manipulation. It is concluded that too few trials of massage therapy exist for a reliable evaluation of its efficacy. Massage seems to have some potential as a therapy for LBP. More investigations of this subject are urgently needed.

Humans↗
PubMed1987

Use of force platform variables to quantify the effects of chiropractic manipulation on gait symmetry.

The purpose of this investigation was to determine whether force platform measurements can be used to objectively assess short-term effects of spinal manipulation on patients with diagnosed, chronic unilateral "sacroiliac dyskinesia," here defined as decreased interarticular mobility of the sacroiliac joint. Nine patients walked across a force platform, were than manipulated by a chiropractor and then repeated the gait trials. Temporal and kinetic gait variables from the force platform measurements were analyzed for changes in the symmetry of the subjects' gait before and after treatment sessions. There was a distinct tendency towards improved gait symmetry after treatment in those cases where the gait was asymmetric prior to the treatment. This result indicated that force platform measurements may be used successfully to assess the effects of spinal manipulations on the gait of patients with sacroiliac dyskinesia.

Adult↗
PubMed2005

Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement their conventional treatment of musculoskeletal disorders. Previous reviews and meta-analyses of spinal manipulation for low back pain have not specifically addressed OMT and generally have focused on spinal manipulation as an alternative to conventional treatment. The purpose of this study was to assess the efficacy of OMT as a complementary treatment for low back pain. METHODS: Computerized bibliographic searches of MEDLINE, EMBASE, MANTIS, OSTMED, and the Cochrane Central Register of Controlled Trials were supplemented with additional database and manual searches of the literature. Six trials, involving eight OMT vs control treatment comparisons, were included because they were randomized controlled trials of OMT that involved blinded assessment of low back pain in ambulatory settings. Data on trial methodology, OMT and control treatments, and low back pain outcomes were abstracted by two independent reviewers. Effect sizes were computed using Cohen's d statistic and meta-analysis results were weighted by the inverse variance of individual comparisons. In addition to the overall meta-analysis, stratified meta-analyses were performed according to control treatment, country where the trial was conducted, and duration of follow-up. Sensitivity analyses were performed for both the overall and stratified meta-analyses. RESULTS: Overall, OMT significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 - -0.13; P = .001). Stratified analyses demonstrated significant pain reductions in trials of OMT vs active treatment or placebo control and OMT vs no treatment control. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States. Significant pain reductions were also observed during short-, intermediate-, and long-term follow-up. CONCLUSION: OMT significantly reduces low back pain. The level of pain reduction is greater than expected from placebo effects alone and persists for at least three months. Additional research is warranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits are long lasting, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain.

Humans↗
PubMed2005

An analysis of the etiology of cervical artery dissections: 1994 to 2003.

OBJECTIVE: To provide a literature review of the etiologic breakdown of cervical artery dissections. METHODS: A literature search of the MEDLINE database was conducted for English-language articles published from 1994 to 2003 using the search terms cervical artery dissection (CAD), vertebral artery dissection, and internal carotid artery dissection. Articles were selected for inclusion only if they incorporated a minimum of 5 case reports of CAD and contained sufficient information to ascertain a plausible etiology. RESULTS: One thousand fourteen citations were identified; 20 met the selection criteria. There were 606 CAD cases reported in these studies; 321 (54%) were internal carotid artery dissection and 253 (46%) were vertebral artery dissection, not including cases with both. Three hundred seventy-one (61%) were classified as spontaneous, 178 (30%) were associated with trauma/trivial trauma, and 53 (9%) were associated with cervical spinal manipulation. If one apparently biased study is dropped from the data pool, the percentage of CADs related to cervical spinal manipulation drops to approximately 6%. CONCLUSIONS: The case series that were reviewed in this article indicated that most CADs reported in the previous decade were spontaneous but that some were associated with trauma/trivial trauma, and a minority with cervical spine manipulation. This etiologic breakdown of CAD does not differ significantly from what has been portrayed by most other authors.

Aortic Dissection↗
PubMed1992

The efficacy of chiropractic manipulation for back pain: blinded review of relevant randomized clinical trials.

OBJECTIVE: To assess the efficacy of chiropractic for patients with back pain. DATA SOURCES: Randomized clinical trials (RCTs) on spinal manipulation were identified with a Medline search (1966-1990), by citration tracking, and by manual examination of the relevant chiropractic reference systems [Chiropractic Research Archives Collection and Index to Chiropractic Literature]. [Indexing terms, Medline; backache, musculoskeletal diseases, manipulation, osteopathy or chiropractic in combination with evaluation studies, outcome and process assessment, prospective studies, comparative studies, clinical trials or double blind method. Indexing terms, Chiropractic Research Archives Collection: backache therapy-chiropractic clinical trials, cost benefit analysis, evaluation studies--chiropractic, manipulation--spinal, prospective studies, sciatica-therapy. Indexing terms, Index to Chiropractic Literature, backache therapy, clinical trials, cost benefit analysis, intervertebral disc displacement-therapy.] STUDY SELECTION: All RCTs involving chiropractors as therapists. To find additional evidence from nonchiropractic RCTs, chiropractic standards similar to the type of treatment used in nonchiropractic trials were determined by a panel of blinded chiropractors. DATA EXTRACTION: Review by two blinded reviewers independently, using a list of methodological criteria, each of which was attached to a weight. The maximum was set at 100 points. DATA SYNTHESIS: We identified five chiropractic RCTs. No similarity to chiropractic standards could be detected in any of the nonchiropractic RCTs. No chiropractic RCT had a methodological score of more than 50 points. The authors of four of the trials report favorable results for chiropractic, while one refrains from drawing conclusions. The results of the chiropractic RCTs differed on the timing of maximal effect as well as on the subgroups showing the best treatment results. CONCLUSIONS: Although the small number of chiropractic RCTs and the poor general methodological quality precludes the drawing of strong conclusions, chiropractic seems to be an effective treatment of back pain. However, more studies with a better research methodology are clearly still needed.

Back Pain↗
PubMed2000

Economic analysis of complementary medicine: a systematic review.

OBJECTIVE: To review systematically all reports of economic analysis of complementary and alternative medicine. METHOD: Searches were performed in Medline, Embase and AMED for reports of cost description, cost comparison, cost effectiveness, or cost benefit studies. Prospective studies that investigated comparative groups were considered to be of higher quality. RESULTS: A total of 34 reports was included. Retrospective studies in which a range of therapies are provided in primary care suggest that these may reduce referral and treatment costs, but prospective studies suggest that complementary medicine is an additional expense and does not substitute for orthodox care. For individual therapies, one thorough but retrospective study suggests that carefully targeted acupuncture may reduce referral costs for musculoskeletal problems. One large pragmatic study of spinal manipulative therapy suggests that this treatment may reduce the societal costs of back pain, but four controlled trials found that manipulative therapy does not reduce the costs incurred by the back pain patients themselves or by their health insurance provider. CONCLUSION: Spinal manipulative therapy for back pain may offer cost savings to society, but it does not save money for the purchaser. There is a paucity of rigorous studies that could provide conclusive evidence of differences in costs and outcomes between other complementary therapies and orthodox medicine. The evidence from methodologically flawed studies is contradicted by more rigorous studies, and there is a need for high quality investigations of the costs and benefits of complementary medicine.

Complementary Therapies↗
PubMed1989

The recognition of mechanically induced pelvic pain and organic dysfunction in the low back pain patient.

Mechanical disorders of the lumbar spine have been identified as a cause of pelvic pain and organic dysfunction (PPOD). Categorically, the clinical features indicative of mechanically induced PPOD fall into three areas: the history of the development or onset of pelvic symptomatology attributable to lower sacral nerve root compression (LSNRC), identification of related symptomatology on presentation, and the recognition of clinical findings indicative of mechanically induced PPOD on examination. Characteristic features of each category are presented. The clinical signs that most reliably indicate the presence of PPOD secondary to a mechanical lesion of the low back are of a sensory nature, and the disappearance or lack of improvement of these signs closely parallels the patient's overall response to manipulative treatment. Without a thorough understanding of the salient features of mechanically induced PPOD, the practitioner is likely to overlook this as a diagnostic possibility. As a result, efforts to document chiropractic spinal manipulative therapy in relieving disorders of pelvic organic function may be hampered. The empirical efficacy of chiropractic spinal manipulative therapy for treating disorders of pelvic organic function would be enhanced if more chiropractors were apprised of the salient features indicating the presence of mechanically induced PPOD.

Back Pain↗