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PubMedDate not supplied

Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee pain.

BACKGROUND: Evidence exists that conservative rehabilitation protocols fail to achieve full recovery of muscle strength and function after joint injuries. The lack of success has been attributed to the high amount of muscle inhibition found in patients with pathologic conditions of the knee joint. Clinical evaluation shows that anterior knee pain is typically associated with sacroiliac joint dysfunction, which may contribute to the muscle inhibition observed in this patient group. OBJECTIVE: To assess whether sacroiliac joint manipulation alters muscle inhibition and strength of the knee extensor muscles in patients with anterior knee pain. DESIGN AND SETTING: The effects of sacroiliac joint manipulation were evaluated in patients with anterior knee pain. The manipulation consisted of a high-velocity low-amplitude thrust in the side-lying position aimed at correcting sacroiliac joint dysfunction. Before and after the manipulation, torque, muscle inhibition, and muscle activation for the knee extensor muscles were measured during isometric contractions using a Cybex dynamometer, muscle stimulation, and electromyography, respectively. PARTICIPANTS: Eighteen patients (mean age, 30.5 +/- 13.0 years) with either unilateral (n = 14) or bilateral (n = 4) anterior knee pain. RESULTS: Patients showed substantial muscle inhibition in the involved and the contralateral legs as estimated by the interpolated twitch technique. After the manipulation, a decrease in muscle inhibition and increases in knee extensor torques and muscle activation were observed, particularly in the involved leg. In patients with bilateral anterior knee pain, muscle inhibition was decreased in both legs after sacroiliac joint adjustment. CONCLUSIONS: Spinal manipulation might offer an interesting alternative treatment for patients with anterior knee pain and muscle inhibition. Because this clinical outcome study was of descriptive nature rather than a controlled design, biases might have occurred. Thus the results have to be verified in a randomized, controlled, double-blinded trial before firm conclusions can be drawn or recommendations can be made.

Adult↗
PubMed2000

Short-term effects of cervical manipulation on edge light pupil cycle time: a pilot study.

BACKGROUND: Edge light pupil cycle time (ELPCT) is one of the eye's light reflexes. Studies have shown ELPCT to be a measurable constant, unaffected by visual acuity, refractive error, eye color, pupil size, or sex. Control of this reflex occurs through the autonomic nervous system. Various authors suggest that spinal manipulative techniques can produce distant effects mediated in part by alterations in autonomic tone after intervention. OBJECTIVE: To investigate the effects of a C1-2 high-velocity, low-amplitude manipulation on ELPCT. DESIGN: A single-group, randomized pilot study without a control group. METHODS: Thirteen men (mean age 24.2 years) without a history of eye disease or central or autonomic nervous system pathologic conditions had their ELPCT measured before and after manipulation. The manipulation comprised a high-velocity, low-amplitude rotatory thrust, localized to the C1-2 joint on the left (n = 6) or right (n = 7) eye, determined randomly. RESULTS: ELPCT measures demonstrated a significant difference for both eyes before and after manipulation (P = .002; the right eye, P = .027; the left eye, P = .046). CONCLUSION: This suggests that ELPCT, which is mediated through the autonomic nervous system, can be directly influenced by high-velocity manipulation to the upper cervical spine.

Adolescent↗
PubMedDate not supplied

[Extensive spinal epidural hematoma--an uncommon entity following cervical chiropractic manipulation].

INTRODUCTION: Spinal epidural hematoma is a rare complication after chiropractic manipulation. In the literature, only three cases have been reported, which all necessitated surgical treatment. CASE: A 27-year-old woman was treated with cervical chiropractic manipulation (C5/6) and facet joint infiltration. 10 minutes later the patient presented signs of intracranial pressure with nausea, vertigo, headache and vomiting. The magnetic resonance imaging of the spine demonstrated an epidural hematoma extending from the cervical to the sacral spine. As the patient had no sensible or motor deficits and recovered quickly, surgical treatment was not necessary. A few days later the patient had a complete persisting remission of symptoms. CONCLUSION: If neurological deficits occur after chiropractic manipulation, a spinal epidural hematoma should be considered to provide adequate therapy without delay. The current case report shows an unusual expansion of the hematoma which has not described so far after chiropractic manipulation. But, in contrast to the three cases reported before, a surgical intervention was not necessary.

Adult↗
PubMed2005

Manipulative therapy and/or NSAIDs for acute low back pain: design of a randomized controlled trial [ACTRN012605000036617].

BACKGROUND: Acute low back pain is a common condition resulting in pain and disability. Current national and international guidelines advocate general practitioner care including advice and paracetamol (4 g daily in otherwise well adults) as the first line of care for people with acute low back pain. Non-steroidal anti-inflammatory drugs (NSAIDs) and spinal manipulative therapy (SMT) are advocated in many guidelines as second line management options for patients with acute low back pain who are not recovering. No studies have explored the role of NSAIDs and/or SMT in addition to first line management for acute low back pain. The primary aim of this study is to investigate if NSAIDs and/or SMT in addition to general practitioner advice and paracetamol results in shorter recovery times for patients with acute low back pain. The secondary aims of the study are to evaluate whether the addition of SMT and/or NSAIDs influences pain, disability and global perceived effect at 1, 2, 4 and 12 weeks after onset of therapy for patients with significant acute low back pain. METHODS/DESIGN: This paper presents the rationale and design of a randomised controlled trial examining the addition of NSAIDs and/or SMT in 240 people who present to their general practitioner with significant acute low back pain.

Acute Disease↗
PubMed2004

Is it time to stop functional pre-manipulation testing of the cervical spine?

The combined extended and rotated cervical spine position has been postulated to affect vertebral artery blood flow by primarily causing a narrowing of the vessel lumen, usually within the artery contralateral to the side of head rotation. The production of brainstem symptoms during the manoeuvre has generally been considered to be a positive test result. As a consequence, functional pre-manipulation testing of the cervical spine has been part of clinical screening undertaken by chiropractors and other manual practitioners to rule out the risk of possible injury to the vertebral artery. To date, these testing procedures are taught to students and carried out in daily clinical practice, despite the considerable controversy that exists about their validity. This paper considers and discusses the usefulness of functional pre-manipulation testing for clinical scenarios, involving dissection, spasm or stenosis of the vertebral artery, and makes the following recommendations: (1) Practitioners must assess the patient thoroughly, through careful history taking and physical examination, for the possibility of vertebral artery dissection. It is important to note that vertebral artery dissection (VAD) may present as pain only, and may not be associated with symptoms and signs of brainstem ischaemia. (2) If there is a strong likelihood of VAD, provocative pre-manipulation tests should not be performed, and the patient must be referred appropriately. (3) In the patient presenting with symptoms of brainstem ischaemia due to non-dissection stenotic vertebral artery pathologies, provocative testing is very unlikely to provide any useful additional diagnostic information. (4) In the patient with unapparent vertebral artery pathology, where spinal manipulative therapy (SMT) is considered as the treatment of choice, provocative testing is very unlikely to provide any useful information in assessing the probability of manipulation induced vertebral artery injury.

Bias↗
PubMedDate not supplied

Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome.

OBJECTIVE: To demonstrate the benefits of cervical spine manipulation with the patient under anesthesia as an approach to treating a patient with chronic cervical disk herniation, associated cervical radiculopathy, and cervicogenic headache syndrome. CLINICAL FEATURES: The patient had neck pain with radiating paresthesia into the right upper extremity and incapacitating headaches and had no response to 6 months of conservative therapy. Treatment included spinal manipulative therapy, physical therapy, anti-inflammatory medication, and acupuncture. Magnetic resonance imaging, electromyography, and somatosensory evoked potential examination all revealed positive diagnostic findings. INTERVENTION AND OUTCOME: Treatment included 3 successive days of cervical spine manipulation with the patient under anesthesia. The patient had immediate relief after the first procedure. Her neck and arm pain were reported to be 50% better after the first trial, and her headaches were better by 80% after the third trial. Four months after the last procedure the patient reported a 95% improvement in her overall condition. CONCLUSION: Cervical spine manipulation with the patient under anesthesia has a place in the chiropractic arena. It is a useful tool for treating chronic discopathic disease complicated by cervical radiculopathy and cervicogenic headache syndrome. The beneficial results of this procedure are contingent on careful patient selection and proper training of qualified chiropractic physicians.

Accidents, Traffic↗
PubMedDate not supplied

Reflex responses associated with activator treatment.

BACKGROUND: Previous studies have demonstrated the existence era reflex response, measurable by surface electromyography (sEMG), after manually delivered spinal manipulative therapy (SMT). This reflex response has been characterized as consistent, reproducible within individual subjects, and nonlocal because it extends beyond the site of manipulation. However, the nature and magnitude of possible reflex responses in the paraspinal and proximal limb muscles elicited by nonmanual SMT, such as with an adjusting instrument, remain unknown. OBJECTIVE: To characterize the reflex responses associated with SMT by using sEMG to record the responses of 16 muscles before, during, and after treatment. STUDY DESIGN: The eleetromyographic responses of 16 para-spinal and proximal limb muscles in 9 healthy, asymptomatic male volunteers were measured simultaneously by sEMG before, during, and after chiropractic SMT. METHODS: SMT thrusts were delivered to 9 asymptomatic volunteers at 6 bilateral sites (C3/4, T2/3, T6/8, T11/12, L2-4, and s1). Reflex responses were measured from 16 muscles with bipolar sEMG electrodes and collected at 2000 Hz per channel with data acquisition software. RESULTS: Approximately 68% of the SMT thrusts resulted in a detectable reflex response. The cervical spine resulted in a detectable response of 50%, thoracic spine 59%, lumbar spine 83%, and sacroiliac joints 94%. Treatments delivered to the thoracic spine elicited the largest peak-to-peak amplitude sEMG responses, whereas the lumbar spine demonstrated the most heterogeneous responses. When a reflex response was observed, it always occurred close to the treatment site ipsilaterally and was detected in muscles that had either their origin or insertion at the vertebral level that was adjusted. CONCLUSIONS: Based on the local nature, magnitude, and characteristic shape of all reflex responses observed, we hypothesized that they were likely generated by a single proprioceptor. Furthermore, the temporal properties of this reflex response suggest that they originated from the muscle spindles. In contrast to previous observations on reflex responses after manual SMT, these treatments elicited reflex responses that varied between subjects but were consistent within an individual and were local in nature. We conclude that SMT delivered in this manner results in a reflex response that is both quantitatively and qualitatively different from a manual SMT.

Adult↗
PubMed2000

A combined approach for the treatment of cervical vertigo.

BACKGROUND: Cervical vertigo is a diagnosis commonly made at both otorhinolaryngologist and chiropractic offices. Hypothesized non-vascular mechanisms are reviewed. Therapeutic approaches have been suggested in the literature, ranging from cervical immobilization to vertebral manipulation. OBJECTIVE: To characterize the patient population with cervical vertigo and observe therapeutic results of a treatment protocol by using distinct conservative modalities. METHODS: Fifteen subjects with cervical vertigo were selected from patients presenting with dizziness at an otorhinolaryngology medical office. Diagnosis was based on specific criteria and results of an otoneurologic examination. All patients were submitted to a treatment protocol, including spinal manipulation, manual therapy on affected muscle groups, analgesic electrotherapy, labyrinth sedation, surface electromyography biofeedback, and an exercise program. Evolution of dizziness complaints and related musculoskeletal dysfunction was observed. RESULTS: Musculoskeletal complaints were present in 93% of the patients, mainly cervical pain, shoulder-girdle pain, and tension-type headache. Median duration of musculoskeletal symptoms was 7.5 years, whereas the median duration of dizziness before the beginning of treatment was 52 days. Treatment duration averaged 5 sessions and 41 days. At the end of treatment, 60% of patients reported remission, 20% reported consistent improvement of vertigo. Remission of musculoskeletal symptoms was observed in 26.7% of patients, and improvement was observed in 60% of patients. CONCLUSION: Chronic, nontraumatic, cervical and shoulder-girdle dysfunction was an important causal and perpetuating factor of cervical vertigo in the population studied, and a consistent improvement was observed with the use of a conservative treatment protocol involving multiple modalities for patients with cervical vertigo. Further controlled studies are needed to access its validity.

Analgesics↗
PubMed2005

Differential recruitment in a cluster randomized trial in primary care: the experience of the UK back pain, exercise, active management and manipulation (UK BEAM) feasibility study.

BACKGROUND: Cluster randomized trials, which randomize groups of patients rather than individuals, are commonly used to evaluate healthcare interventions such as training programmes targeted at health professionals. This article reports the dangers of randomizing entire primary care practices when participants cannot be identified before randomization, as shown by a UK national trial. METHOD: The UK BEAM trial, a national cluster randomized 3 x 2 x 2 factorial trial, was designed to evaluate three treatments for back pain in primary care: "active management"; randomized by practice; and spinal manipulation and exercise classes, both randomized by individual. RESULTS: Two hundred and thirty-one participants were recruited in the feasibility study, 165 (141% of expected recruitment) from active (management) practices but only 66 (54% of expected recruitment) from traditional (management) practices. The participants in active practices were significantly different from those in traditional practices, notably in suffering from milder back pain. CONCLUSIONS: The feasibility study highlighted the dangers of randomizing clusters when individuals cannot be identified beforehand. Different numbers and types of participants were recruited in the two types of cluster. This differential recruitment led us to change the main trial design by abandoning practice level randomization. Instead all practices were trained in active management to maximize recruitment. Ideally cluster randomized trials should identify patients beforehand, to minimize the chance of selection bias. If this is not possible, patient recruitment should be independent in both intervention and control clusters. Pilot studies are especially important for cluster randomized trials, to identify unforeseen problems.

Adult↗
PubMed2006

An etiologic model to help explain the pathogenesis of cervical artery dissection: implications for cervical manipulation.

We present a theoretical etiologic model of cervical artery dissection for the purpose of coalescing our present understanding of its pathogenesis. Although the notion of an underlying arteriopathy and a trigger are universally accepted concepts, we propose in our model that dissection is a product of an underlying (genetic) predisposition, triggered specifically by risk factors associated with environmental exposure, with or without trivial trauma. Given the widespread daily occurrence of neck movements and sporting activities, it seems unlikely that trivial trauma, in the absence of other triggers and an underlying arteriopathy, is sufficient to cause dissection. This concept has significant implications for practitioners of spinal manipulation. This may represent a paradigm shift because the model suggests that stroke following manipulation is unlikely in otherwise healthy individuals. Although this model is consistent with current published case-control studies on cervical artery dissection, further research is necessary to accept or refute it as a tenable hypothesis.

Aortic Dissection↗
PubMed2002

A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial.

OBJECTIVE: To evaluate a new 3-point bending type of cervical traction. DESIGN: Nonrandomized controlled trial of prospective, consecutive patients compared with control subjects. Follow-up patient data were obtained at 3 and 15(1/2) months, and 8 1/10 months for controls. SETTING: Data were collected at a spine clinic in Nevada. PATIENTS: Volunteer subjects consisted of 30 patients and 24 controls. Subjects had cervicogenic pain (neck pain, headaches, arm pain, and/or numbness). Subjects were included if their Ruth Jackson radiographic stress lines measured less than 25 degrees but were excluded if they had suspected disk herniation or canal stenosis. All subjects completed the first follow-up examinations, and 25 of 30 patients completed the long-term follow-up examination. INTERVENTIONS: Spinal manipulation for pain and a new form of 3-point bending cervical traction to improve lordosis. Cervical manipulation was provided for the first 3 to 4 weeks of treatment. Traction treatment consisted of 3 to 5 sessions per week for 9 +/- 1 weeks. MAIN OUTCOMES MEASURES: Besides pain visual analog scale (VAS) ratings, pre- and posttreatment lateral cervical radiographs were analyzed. RESULTS: Control subjects reported no change in the pain VAS ratings and had no statistically significant change in segmental or global radiographic alignment. For the traction group, VAS ratings were 4.3 pretreatment and 1.6 posttreatment. Traction group radiographic measurements showed statistically significant improvements (P <.008 in all instances of statistical significance), including anterior head weight bearing (improved 6.2mm), Cobb angle at C2-7 (improved 12.1 degrees ), and angle between posterior tangents at C2-7 (improved 14.2 degrees ). For the treatment group, at 15(1/2)-month follow-up, only minimal loss of C2-7 lordosis (3.5 degrees ) was observed. CONCLUSIONS: Sagittal cervical traction with transverse load at midneck (2-way cervical traction) combined with cervical manipulation can improve cervical lordosis in 8 to 10 weeks as indicated by increases in segmental and global cervical alignment. Magnitude of lordosis at C2-7 remained stable at long-term follow-up.

Adult↗
PubMed2001

Chiropractic manipulation and stroke: a population-based case-control study.

BACKGROUND AND PURPOSE: Several reports have linked chiropractic manipulation of the neck to dissection or occlusion of the vertebral artery. However, previous studies linking such strokes to neck manipulation consist primarily of uncontrolled case series. We designed a population-based nested case-control study to test the association. METHODS: Hospitalization records were used to identify vertebrobasilar accidents (VBAs) in Ontario, Canada, during 1993-1998. Each of 582 cases was age and sex matched to 4 controls from the Ontario population with no history of stroke at the event date. Public health insurance billing records were used to document use of chiropractic services before the event date. RESULTS: Results for those aged <45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had >/=3 visits with a cervical diagnosis in the month before the case's VBA date (95% CI from bootstrapping, 1.34 to 18.57). No significant associations were found for those aged >/=45 years. CONCLUSIONS: While our analysis is consistent with a positive association in young adults, potential sources of bias are also discussed. The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment. Because of the popularity of spinal manipulation, high-quality research on both its risks and benefits is recommended.

Adult↗
PubMed1998

Brown-Séquard syndrome of the cervical spinal cord after chiropractic manipulation.

We report a case of increased signal in the left hemicord at the C4 level on T2-weighted MR images after chiropractic manipulation, consistent with contusion. The patient displayed clinical features of Brown-Séquard syndrome, which stabilized with immobilization and steroids. Follow-up imaging showed decreased cord swelling with persistent increased signal. After physical therapy, the patient regained strength on the left side, with residual decreased sensation to pain involving the right arm.

Braces↗
PubMed1995

Reflex responses associated with manipulative treatments on the thoracic spine: a pilot study.

OBJECTIVE: To test systematically if spinal manipulative treatments (SMT) and the audible release associated with SMT cause activation of spinal muscles. DESIGN: Experimental pilot study. SETTING: Human Performance Laboratory, The University of Calgary. PARTICIPANTS: One male and one female asymptomatic volunteer. INTERVENTION: Slow and fast SMTs to the left transverse process of thoracic vertebrae using a reinforced hypothenar contact. The treatment forces were directed in a posterior-to-anterior direction with the subjects in a prone position. MAIN OUTCOME MEASURES: Forces applied by the chiropractor during SMT. Measurements of the audible release using skin-mounted accelerometers. Electromyographical activity of selected spinal muscles. RESULTS: Electromyographical (EMG) activity was observed consistently 50-100 msec after the onset of each of the fast SMTs, whether the treatment resulted in an audible release or not; for slow SMTs, there was never any visible electromyographical activity of the target muscles, whether the treatment resulted in an audible release or not. CONCLUSION: The results of this study suggest that fast treatment thrusts elicit muscle activation, whereas slow force application does not. The timing of the onset of the EMG response suggests that activation may be produced by a reflex response originating in the muscle spindles. It also appears that the audible release does not (by itself) evoke muscle activation or a joint proprioceptive reflex response as has been speculated in the literature.

Adult↗
PubMedDate not supplied

Manipulation under epidural anesthesia with corticosteroid injection: two case reports.

OBJECTIVE: To discuss the combined use of selective epidural steroid injection (ESI) and spinal manipulative therapy (SMT) in treating recalcitrant lumbar radiculopathy. CLINICAL FEATURES: In a first case, a patient suffered from numbness and pain in an S1 dermatome distribution 6 months after undergoing lumbar discectomy. Clinical correlation with advanced imaging led to the diagnosis of L5 intervertebral disc (IVD) syndrome with peridural scar formation. In a second case, a patient suffered from low-back and right-leg pain of 9 months' duration. Various forms of conservative treatment were not effective. A diagnosis of L4 IVD syndrome with radiculopathy was made. INTERVENTION AND OUTCOME: The first patient received conventional treatments, including physical therapy, SMT, fluoroscopically guided ESI and oral medications, with consistent but short-lived response. A team consisting of an anesthesiologist (dedicated spinal injectionist) and chiropractor performed manipulation under epidural anesthesia (MUEA) with corticosteroid injection. Follow-up at 60 days showed marked improvement in visual analogue scale, pain drawing and Oswestry pain and disability index. The second patient received all of the same conventional care except ESI before the combined procedure. The patient underwent MUEA, followed up with eight sessions of stretching and manipulation over the ensuing 3 wk. At 45 days after the combined procedure, the patient had a negative SLR (previously positive at 70 degrees), no leg pain and a marked reduction in back pain. CONCLUSION: This article discusses an integrated procedure that combines two standard treatments that may act synergistically. Our positive results are consistent with other reports, both published and anecdotal. The technique of MUEA warrants further investigation by the health care industry.

Adrenal Cortex Hormones↗
PubMed2005

Manual therapy for asthma.

BACKGROUND: A variety of manual therapies with similar postulated biologic mechanisms of action are commonly used to treat patients with asthma. Manual therapy practitioners are also varied, including physiotherapists, respiratory therapists, chiropractic and osteopathic physicians. A systematic review across disciplines is warranted. OBJECTIVES: To evaluate the evidence for the effects of manual therapies for treatment of patients with bronchial asthma. SEARCH STRATEGY: We searched for trials in computerized general (EMBASE, CINAHL and MEDLINE) and specialized databases (Cochrane Complementary Medicine Field, Cochrane Rehabilitation Field, Index to Chiropractic Literature (ICL), and Manual, Alternative and Natural Therapy (MANTIS)). In addition, we assessed bibliographies from included studies, and contacted authors of known studies for additional information about published and unpublished trials. Date of most recent search: August 2004. SELECTION CRITERIA: Trials were included if they: (1) were randomised; (2) included asthmatic children or adults; (3) examined one or more types of manual therapy; and (4) included clinical outcomes with observation periods of at least two weeks. DATA COLLECTION AND ANALYSIS: All three reviewers independently extracted data and assessed trial quality using a standard form. MAIN RESULTS: From 473 unique citations, 68 full text articles were retrieved and evaluated, which resulted in nine citations to three RCTs (156 patients) suitable for inclusion. Trials could not be pooled statistically because studies that addressed similar interventions used disparate patient groups or outcomes. The methodological quality of one of two trials examining chiropractic manipulation was good and neither trial found significant differences between chiropractic spinal manipulation and a sham manoeuvre on any of the outcomes measured. One small trial compared massage therapy with a relaxation control group and found significant differences in many of the lung function measures obtained. However, this trial had poor reporting characteristics and the data have yet to be confirmed. AUTHORS' CONCLUSIONS: There is insufficient evidence to support the use of manual therapies for patients with asthma. There is a need to conduct adequately-sized RCTs that examine the effects of manual therapies on clinically relevant outcomes. Future trials should maintain observer blinding for outcome assessments, and report on the costs of care and adverse events. Currently, there is insufficient evidence to support or refute the use of manual therapy for patients with asthma.

Adult↗
PubMed1992

Cauda equina syndrome in patients undergoing manipulation of the lumbar spine.

Cauda equina syndrome has been implicated as a potential complication of spinal manipulation. A review of the literature from 1911 to 1989 revealed ten reported cases of cauda equina syndrome in patients undergoing manipulation without anesthesia. This article presents three new cases where a temporal association was found between the onset of cauda equina symptoms and lumbar manipulation. The type of manipulation administered and the relationship between the treatment and symptoms is reviewed. In each of these cases both the chiropractic practitioner and the emergency room physician failed to comprehend the nature of the problem and take appropriate action. As a consequence, the patients went untreated for several days. This may have led to residual symptomatology. It is concluded that patients who present with bowel or bladder disturbances, leg weakness, or rectal and genital sensory changes after manipulation, be recognized as experiencing a cauda equina syndrome.

Adult↗