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PubMed1995

Impact of varying panel membership on ratings of appropriateness in consensus panels: a comparison of a multi- and single disciplinary panel.

OBJECTIVE: The objective of the study was to examine the appropriateness ratings for the use of spinal manipulation for low back pain of a multidisciplinary panel of medical and chiropractic physicians, and those of a panel composed only of chiropractic physicians. DATA SOURCES: The study analyzed data from two consensus panels conducted at RAND in 1990 and 1991. STUDY DESIGN: The study design followed that of the traditional RAND consensus panels. Nine individuals comprised each panel, and each panelist was asked to rate, on a nine-point scale, the indications for spinal manipulation twice, the first time alone and the second time jointly with the panel. DATA COLLECTION: The ratings of the panelists from both groups, for both round one and round two, were collated and compared. PRINCIPAL FINDINGS: While both panels were more likely to rate the indications as inappropriate than appropriate, the single disciplinary panel was more likely to rate an indication as appropriate than the multidisciplinary panel. CONCLUSION: The composition of a panel clearly influences the ratings and those who use a given procedure in practice, in this case manipulation, are more likely to rate it as appropriate than those who do not use the procedure.

Chiropractic↗
PubMed2000

Complementary therapies and the general practitioner. A survey of Perth GPs.

OBJECTIVE: The purpose of this study was to identify the knowledge, attitudes and referral patterns of general practitioners (GPs) toward 10 specific complementary therapies. METHOD: The study was a descriptive cross-sectional postal survey, conducted between July 1998 and August 1998 inclusive. A random selection of 200 male and 200 female Western Australian GPs residing in Perth and listed in the Australian Medical Association database file of registered GPs. RESULTS: The response rate was 74.8% (n = 282). Over 90% of these GPs reported having been approached by more than 30 patients seeking their advice about complementary therapies in the past nine months. The majority of these patients were women, over the age of 35 years. Ten complementary therapies were listed in the questionnaire: acupuncture, hypnosis, meditation, spinal manipulation, yoga, homeopathy, herbal medicine, naturopathy, massage and aromatherapy. Just under half (132) of the respondents had undertaken studies in at least one of the listed complementary therapies, with over 60% reporting a wish for further training. Overall, 67.8% (191) of all respondents reported they were in favour of GP referrals to complementary therapists. However, 56.1% (158) were against complementary therapies being included in rebates for private health insurance. Overall, 75.0% (211) of GPs surveyed had already formally referred a patient to one or more of the listed therapies, the most frequent of these being acupuncture, massage, meditation, hypnosis and spinal manipulation as a part of their overall medical treatment. CONCLUSION: Perth GPs have a high level of interest in complementary therapies. Government regulation and registration of complementary therapies is seen by GPs as important in order to ensure professional standards of practice. Given the high level of interest, provision of undergraduate and postgraduate education in complementary therapies could be considered. In addition, the development of clinical guidelines would be of benefit.

Adult↗
PubMed2003

A pilot study for a randomized clinical trial assessing chiropractic care, medical care, and self-care education for acute and subacute neck pain patients.

OBJECTIVE: To conduct a pilot study in preparation for a full-scale randomized clinical trial assessing conservative treatments for acute and subacute neck pain. Study design Prospective, randomized pilot study. SETTING: Primary contact chiropractic and medical clinics. PATIENTS: Ages 21 to 65 with current episode of neck pain less than 12 weeks in duration. Outcome measures Patient self-report questionnaires and cervical spine motion were assessed at baseline and 3 and 12 weeks post-randomization. INTERVENTIONS: Chiropractic spinal manipulation, prescription medications, and self-care education. RESULTS: Recruitment took place over a 1-month period. Twenty-eight patients were randomized to treatment, and 1 patient (medical care group) refused their treatment assignment and was lost to further follow-up. Twenty-three patients were either "very satisfied" or "completely satisfied" with the care they received in the study. More than half the patients reported 75% or 100% improvement (n = 17). No between-group comparisons were planned or performed due to the small sample size. CONCLUSION: Recruitment of patients appears feasible for a full-scale randomized clinical trial evaluating chiropractic spinal manipulation, medical care, and self-care education for acute and subacute neck pain. Patient and provider compliance with study protocols was excellent, and the pilot study allowed us to further develop and optimize our data collection processes. Although pilot studies such as these require substantial time, money, and effort, they provide valuable information for future research efforts.

Acute Disease↗
PubMed2005

Complementary and alternative therapies for low back pain.

The support for the principles of evidence-based medicine has increased within the field of complementary and alternative medicine (CAM). The objective of this chapter is to determine the effectiveness of CAM therapies compared to placebo, no intervention, or other interventions for acute/subacute and chronic non-specific low back pain (LBP). Results from Cochrane reviews on acupuncture, botanical medicine, massage, neuroreflexotherapy, and spinal manipulation have been used. The results showed that acupuncture is more effective than no treatment or sham treatment for chronic LBP but that there are no differences in effectiveness compared with other conventional therapies. Specific botanical medicines can be effective for acute episodes of chronic non-specific LBP in terms of short-term improvement in pain and functional status; long-term efficacy was not assessed. Massage seems more beneficial than sham treatment for chronic non-specific LBP but effectiveness compared with other conventional therapies is inconclusive. Neuroreflexotherapy appears to be more effective than sham treatment or standard care for chronic non-specific LBP. Spinal manipulation was more effective than sham manipulation or ineffective therapies, and equally effective as other conventional therapies. In summary, the results on CAM therapies for (acute episodes of) chronic LBP are promising but more evidence on the relative cost-effectiveness compared to conventional treatments is needed.

Clinical Trials as Topic↗
PubMed2003

Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia.

BACKGROUND AND PURPOSE: Mulligan has proposed the use of mobilization with movement for lateral epicondylalgia. In this study, mobilization with movement for the elbow was examined to determine whether this intervention was capable of inducing physiological effects similar to those reported for some forms of spinal manipulation. PARTICIPANTS: Seven women and 17 men (mean age=48.5 years, SD=7.2) with chronic lateral epicondylalgia participated in the study. METHODS: A placebo, control, repeated-measures study was conducted to evaluate whether mobilization with movement at the elbow produced concurrent hypoalgesia and sympathoexcitation. RESULTS: The treatment demonstrated an initial hypoalgesic effect and concurrent sympathoexcitation. Improvements in pain resulted in increased pain-free grip force and pressure pain thresholds. Sympathoexcitation was indicated by changes in heart rate, blood pressure, and cutaneous sudomotor and vasomotor function. DISCUSSION AND CONCLUSION: This study showed that a mobilization with movement treatment technique exerted a physiological effect similar to that reported for some spinal manipulations.

Analysis of Variance↗
PubMed2006

History and overview of theories and methods of chiropractic: a counterpoint.

Spinal manipulation has been used for its therapeutic effects for at least 2500 years. Chiropractic as we know it today began a century ago in a simplistic manner but has developed into to a well-established profession with 33 colleges throughout the world. During the initial, bumpy years, many people thought it had little more value than a placebo. Nevertheless, there have always been satisfied recipients of chiropractic care during the years, and the profession slowly gained prominence--mostly by word of mouth. More recently, personal opinions based on isolated incidents have given way to the results of numerous clinical and basic science studies, primarily regarding low back pain. As of 2002, 43 randomized trials of spinal manipulation for low back pain had been published with 30 showing more improvement than with the comparison treatment, and none showing it to be less effective. Other studies have shown that chiropractic care compared with medical care is safer, costs no more and often costs much less, and has consistently greater patient satisfaction for treatment of similar conditions. Consequently, there is now better public and professional opinion of chiropractic with coverage by insurance companies and government agencies. That trend is likely to continue.

Chiropractic↗
PubMed1999

Use of complementary healthcare practices among chiropractors in the United States: a survey.

CONTEXT: Although chiropractic is the most commonly used complementary healthcare practice, chiropractors have not been surveyed in depth about their attitudes toward and practice of complementary and alternative therapies apart from spinal manipulation. OBJECTIVES: To examine attitudes among US chiropractors on the role of their profession in complementary healthcare and to gather data on the types of complementary healthcare practices chiropractors use. DESIGN: Descriptive, cross-sectional study using a mail-in survey. SETTING: United States. PARTICIPANTS: Random sample of US chiropractors stratified by zip code region. RESULTS: A total of 563 surveys were completed, for a response rate of 30%. Respondents were almost equally divided on their responses to the question "Do you feel that chiropractic should at the present time be termed 'complementary'?" Although many respondents (68%) believed that chiropractic was viewed as a therapeutic modality, more (82%) believed that it should be viewed as a complete system. The therapies most commonly used by respondents in their practice were acupressure (72%), massage (72%), mineral supplements (63%), and herbs (56%). CONCLUSION: The disparity between the established view of chiropractic as synonymous with spinal manipulation and the profession's view of chiropractic as a complete system indicates a need for better interprofessional communication.

Chiropractic↗
PubMed1993

The Hmax/Mmax ratio as an outcome measure for acute low back pain.

OBJECTIVE: To evaluate the use of the Hmax/Mmax (H/M) ratio as an outcome measure for acute low back pain and to determine the change of this ratio in acute low back pain patients treated with spinal manipulation. DESIGN: Randomized clinical trial. SETTING: Chiropractic college teaching clinic. PATIENTS: Thirty-six patients with acute low back pain (pain of less than 2 wk duration) were referred by clinicians of the teaching clinic. Eligibility criteria for inclusion into the study consisted of the following: a score of eight or more on the Oswestry questionnaire, 33 mm or greater on a 100-mm visual analog scale, no involvement in litigation related to the low back pain complaint, patient not pregnant and no physical or electrodiagnostic signs of nerve root entrapment. INTERVENTIONS: The patients were randomly assigned to either a treatment or control group. The treatment group (n = 17) received treatment deemed appropriate by the clinician as long as it included a side-lying manipulation to the appropriate level. The control group (n = 19) received detuned ultrasound, application of a cold pack and 15-30 sec of very gentle soft tissue massage. Patients were treated three to five times over a period of 10 days and were subsequently reevaluated. MEASUREMENTS: The Hmax/Mmax ratio was calculated from the results of electrodiagnostic testing of the posterior tibial nerve. Extension/flexion ratio of the trunk musculature, Oswestry score and Visual Analog Scale score were also measured. MAIN RESULTS: The mean difference between H/M ratios pre- and postintervention for the group treated by chiropractic methods was -0.101 on the left and -0.117 on the right. The mean difference for the control group was 0.038 on the left and 0.036 on the right. Although not statistically significant, trends suggest that at the time of final assessment, the group receiving chiropractic care had improved more than the control group. CONCLUSIONS: The H/M ratio was found to be within normal limits in subjects with acute low back pain. The H/M ratio showed greater change in the group which received spinal manipulation, but the change was subtle. The results indicate that the H/M ratio may be of limited value in clinical practice.

Adult↗
PubMed2005

Use of lumbosacral region manipulation and therapeutic exercises for a patient with a lumbosacral transitional vertebra and low back pain.

STUDY DESIGN: Case report. BACKGROUND: A lumbosacral transitional vertebra (LTV) is a congenital anomaly that occurs in 3% to 21% of people with and without low back pain (LBP). There is lack of agreement in the literature as to whether or not the presence of a LTV may cause LBP. The objective of this case report is to present the use of lumbosacral region manipulation and therapeutic exercises on a patient with a known LTV and LBP. CASE DESCRIPTION: In this case report, an active-duty US Army soldier was referred to physical therapy with right-sided LBP and a lumbar radiograph showing a hemisacralized transitional L5 vertebra on the same side as his pain. The patient was treated with lumbosacral region manipulation and flexion exercises aimed at regaining total spinal motion and reducing pain. The patient responded favorably to spinal manipulation and exercise and was discharged from physical therapy after 4 visits. A modified Oswestry Low Back Pain Disability Questionnaire and inclinometer were used to measure outcome after physical therapy intervention. OUTCOMES: After a 2-week period of treatment in physical therapy, the patient improved from an initial Oswestry score of 32% to a score of 4%. Forward bending and left side bending improved from 74 degrees to 140 degrees and from 21 degrees to 45 degrees, respectively. DISCUSSION: Lumbosacral region manipulation along with therapeutic exercises appears to have been an effective treatment approach for this patient with LBP associated with a type IIA LTV.

Adult↗
PubMed1989

An overview of neuroimmunomodulation and a possible correlation with musculoskeletal system function.

There is an increasing body of evidence that the nervous system is capable of modulating the immune response. Receptors for neuromodulators and neurohormones have been found on human T lymphocytes. Activation of these receptors can be stimulatory or inhibitory depending on the neuroactive substance. The immune system may be able to communicate with the nervous system using neuromodulators and neurohormones secreted by lymphocytes. Sympathetic innervation of lymphoid tissues is not restricted to blood vessels and smooth muscle, but directly supplies lymphocytes and blood precursor cells. It is theorized that spinal fixations may adversely affect the immune response through somatosympathetic reflexes. Spinal manipulation can correct the spinal fixations and may eliminate the adverse affects of somatosympathetic reflexes.

Humans↗
PubMed1988

Unilateral intermittent claudication of the left lower extremity.

Numerous approaches including surgery for the release of cauda equina compression symptoms due to vertebral canal stenosis are well known. The successful use of spinal manipulative therapy for reduction of neurogenic claudication symptoms is discussed in this case presentation. An elderly male presents with vague leg pain and paresthesias of the left lower extremity precipitated by walking. A brief discussion of the etiology, symptomatology and diagnosis of claudication is made. Methods of differential diagnosis of vascular vs. neurogenic claudication are discussed.

Aged↗
PubMed1988

Static and dynamic components of the chiropractic subluxation complex: a literature review.

Intervertebral dysfunction refers to a biomechanical fault which is abnormal in both its dynamic and static components. A subluxation may be considered as being fixated and also slightly malpositioned in one or more axes of rotation. Subluxation may be considered as one component of a complex or syndrome of intervertebral dyskinesia, dysarthrosis or dysfunction. The biochemical and histological components explain some of the pain mechanisms, tissue changes and residual effects of acute and chronic intervertebral fixation and the need for repeated spinal manipulations and prolonged care. Interexaminer reliability studies indicate that a standard method of motion palpation is quite feasible and accurate. X-ray evidence of dyskinesia shows promise as a means of documenting subluxation fixations.

Animals↗
PubMed2002

The frictional properties at the thoracic skin-fascia interface: implications in spine manipulation.

OBJECTIVE: To assess the friction at the thoracic skin-fascia interface to determine the potential reaction force vectors during thoracic manual therapy. DESIGN: A basic in vivo study of human subjects, documenting the frictional properties at the interface between the thoracic skin and underlying fascia. BACKGROUND: Chiropractors, and other spine manipulative therapists, during thoracic manipulation have been attempting to apply force vectors to spine tissues in specific directions in addition to those applied normal to the skin. For obliquely applied forces to be directly transmitted to the underlying vertebrae, either friction is required at the skin-fascia interface or the applied force must "hook" on a bony process. METHODS: Subjects were placed in the prone position with the thoracic skin exposed. The posterior thoracic region was loaded with normal forces, incrementally from 125.3 to 392.9 N. The interface between the load and the skin was either a plexiglass plate or modelled hands. A force was then applied to either apparatus in the cephalad direction. The applied forces and corresponding displacements were measured using a load cell and an optoelectronic camera system, respectively. Chiropractors then performed actual thoracic manipulation to determine if they could maintain their location of contacts (spinous process/transverse process) on the underlying vertebra. RESULTS: Each of the subjects exhibited negligible friction between the thoracic skin and underlying fascia for both the plexiglass and modelled hand contacts. Furthermore, in each case, the apparatus travelled a distance greater than that between two transverse or spinous processes without showing an abrupt change in the slope of the force-displacement curves. The hands of chiropractors performing thoracic manipulation travelled a similar distance during the dynamic thrust. CONCLUSIONS: The skin-fascia interface over the thoracic spine exhibits negligible friction. Therefore, the reaction force from a thoracic vertebra will be normal to the overlying skin. Furthermore, the data show that the ability to "hook" either a thoracic transverse or spinous process in the superior-inferior direction during a manipulative thrust may be greatly over-rated. RELEVANCE: During thoracic spinal manipulation, one cannot direct a force vector to a thoracic vertebra at a given angle by simply directing their thrust in that direction.

Adult↗
PubMed1998

A survey of UK manual therapists' practice of and attitudes towards manipulation and its complications.

BACKGROUND AND PURPOSE: Little is known about the practice of manipulation by UK physiotherapists. This study was conducted to discover current practice of, and attitudes towards, manipulation among UK manipulative therapists. METHODS: A postal questionnaire was sent to 300 UK manipulative therapists who were members of two professional associations representing differing approaches to manual therapy: the Society of Orthopaedic Medicine (SOM) and the Manipulation Association of Chartered Physiotherapists (MACP). RESULTS: A 50% response rate was achieved and 129 respondents identified themselves as 'users' of manipulation. Anxiety about possible complications was a prominent reason adduced by 'non-users' and 'partial users' for their avoidance of manipulative procedures. The thoracic spine was the region most often manipulated, followed by the lumbar spine. Nineteen per cent of users had encountered complications from manipulation, which were most common in the cervical region and were predominantly non-serious. The majority of SOM members and a minority of MACP members used generalized cervical rotary manipulations--thought by some to be potentially dangerous. Attitudes to manipulation were generally positive, although overall respondents were uncertain as to whether its benefits outweighed its risks. Members of the SOM emerged as more frequent users of manipulation and as less conservative in their attitudes to certain aspects of manipulation. CONCLUSIONS: Allowing for possible under-reporting or other response biases, spinal manipulation emerged as a relatively safe and widely practised technique among this sample.

Attitude of Health Personnel↗
PubMed1990

Vertebral artery injuries following chiropractic cervical spine manipulation--case reports.

Four patients undergoing cervical spinal manipulations for nonneurologic diseases and with no previous neurologic signs or symptoms all developed significant neurologic deficits, one fatal, following manipulations of the cervical spine. Both the literature and the authors' series show that a number of patients have a prodrome prior to the onset of neurologic changes. There is no established therapy for the syndrome. Perhaps prevention is the best means of reducing neurologic injury.

Adult↗
PubMed1982

Myelopathy following cervical spine manipulation.

Manipulation of the spine, a controversial mechanotherapeutic procedure, has been taught and practiced widely. Occlusion of vertebral, basillar, and cerebellar arteries with head and neck manipulation is well documented in the literature. However, there is a paucity of references about myelopathy associated with cervical spine manipulation. Three cases of cervical myelopathy following spinal manipulation are presented. All patients noted increase in cervical pain following manipulation, developed significant sensary/motor deficits within 24 hours and became tetraparetic. Two patients were found to have fracture of C5 and C6 vertebral bodies. On myelography, partial block was noted in all and widening of the spinal cord was noted in two. One patient underwent excision of C5 vertebral body and anterior interbody fusion C4/6. Two patients underwent cervical laminectomy. Hematomyelia was present in one, and in the other patient the spinal cord was reported to be hyperemic and oedematous. Only one patient showed neurological return and became ambulatory, while the other two remained tetraparetic.

Adult↗
PubMed2000

Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study.

In a single-subject experiment undertaken on 14 consecutive patients, the effects of acupuncture, cervical manipulation, no therapy, and NSAID-percutan application on kinesthetic sensibility, dizziness/vertigo and pain were studied in patients with dizziness/vertigo of suspected cervical origin. The ability to perceive position of the head with respect to the trunk was studied. The effects of different forms of therapy-and none-on dizziness and neck pain were compared, using a 100 mm visual analogue scale (VAS). Active head relocation by subjects with dizziness was significantly less precise than in the control group. Manipulation was the only treatment to diminish the duration of dizziness/vertigo complaints during the past 7 days and increased the cervical range of motion. Both acupuncture and manipulation reduced dizziness/vertigo on the VAS scale and had positive effects on active head repositioning. Ketoprofen percutan application and acupuncture both alleviated pain. The results of this study would suggest that spinal manipulation may impact most efficiently on the complex process of proprioception and dizziness of cervical origin.

Acupuncture Therapy↗