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PubMedDate not supplied

Spinal reflex excitability changes after cervical and lumbar spinal manipulation: a comparative study.

BACKGROUND CONTEXT: Spinal manipulation (SM) is a commonly employed nonoperative treatment modality in the management of patients with neck, low back or pelvic pain. One basic physiologic response to SM is a transient decrease in motoneuron activity as assessed using the Hoffmann reflex (H-reflex) technique. Previous research from our laboratory indicates that both SM with a high-velocity, low-amplitude thrust and mobilization without thrust produced a profound but transient attenuation of motoneuronal activity of the lumbosacral spine in asymptomatic subjects. To date, effects of cervical SM procedures on the excitability cervical motoneuron pools are unknown. PURPOSE: The objective of this research was to a gain a more complete understanding of the physiologic effects of SM procedures on motoneuron activity, by comparing the effects of regional SM on cervical and lumbar motoneuron pool excitability. STUDY DESIGN/SETTING: Maximal H-reflex amplitudes were recorded before and after SM in both the cervical and lumbar regions of asymptomatic subjects in two successive experimental sessions. PATIENT SAMPLE: Asymptomatic, young healthy volunteers were used in this study. OUTCOME MEASURES: Changes in flexor carpi radialis and gastrocnemius H-reflex amplitudes before and after SM procedures. METHODS: H-reflexes recorded form the tibial and median nerves were evaluated before and after lumbar and cervical SM, respectively. RESULTS: Both Lumbar and cervical SM produced a transient but significant attenuation of motoneuron excitability. The attenuation of the tibial nerve H-reflex amplitude was proportionately greater than that of the median nerve, which occurred after cervical SM. CONCLUSIONS: SM procedures lead to transient suppression of motoneuron excitability, as assessed by the H-reflex technique. Lumbar spine SM appears to lead to greater attenuation of motoneuron activity compared with that of the cervical region. Thus, these two distinct regions of the spine may possess different responsiveness levels to spinal manipulative therapy.

Adult↗

PubMed2001

Electromyographic reflex responses to mechanical force, manually assisted spinal manipulative therapy.

STUDY DESIGN: Surface electromyographic reflex responses associated with mechanical force, manually assisted (MFMA) spinal manipulative therapy were analyzed in this prospective clinical investigation of 20 consecutive patients with low back pain. OBJECTIVES: To characterize and determine the magnitude of electromyographic reflex responses in human paraspinal muscles during high loading rate mechanical force, manually assisted spinal manipulative therapy of the thoracolumbar spine and sacroiliac joints. SUMMARY OF BACKGROUND DATA: Spinal manipulative therapy has been investigated for its effectiveness in the treatment of patients with low back pain, but its physiologic mechanisms are not well understood. Noteworthy is the fact that spinal manipulative therapy has been demonstrated to produce consistent reflex responses in the back musculature; however, no study has examined the extent of reflex responses in patients with low back pain. METHODS: Twenty patients (10 male and 10 female, mean age 43.0 years) underwent standard physical examination on presentation to an outpatient chiropractic clinic. After repeated isometric trunk extension strength tests, short duration (<5 msec), localized posteroanterior manipulative thrusts were delivered to the sacroiliac joints, and L5, L4, L2, T12, and T8 spinous processes and transverse processes. Surface, linear-enveloped electromyographic (sEMG) recordings were obtained from electrodes located bilaterally over the L5 and L3 erector spinae musculature. Force-time and sEMG time histories were recorded simultaneously to quantify the association between spinal manipulative therapy mechanical and electromyographic response. A total of 1600 sEMG recordings were analyzed from 20 spinal manipulative therapy treatments, and comparisons were made between segmental level, segmental contact point (spinous vs. transverse processes), and magnitude of the reflex response (peak-peak [p-p] ratio and relative mean sEMG). Positive sEMG responses were defined as >2.5 p-p baseline sEMG output (>3.5% relative mean sEMG output). SEMG threshold was further assessed for correlation of patient self-reported pain and disability. RESULTS: Consistent, but relatively localized, reflex responses occurred in response to the localized, brief duration MFMA thrusts delivered to the thoracolumbar spine and SI joints. The time to peak tension (sEMG magnitude) ranged from 50 to 200 msec, and the reflex response times ranged from 2 to 4 msec, the latter consistent with intraspinal conduction times. Overall, the 20 treatments produced systematic and significantly different L5 and L3 sEMG responses, particularly for thrusts delivered to the lumbosacral spine. Thrusts applied over the transverse processes produced more positive sEMG responses (25.4%) in comparison with thrusts applied over the spinous processes (20.6%). Left side thrusts and right side thrusts over the transverse processes elicited positive contralateral L5 and L3 sEMG responses. When the data were examined across both treatment level and electrode site (L5 or L3, L or R), 95% of patients showed positive sEMG response to MFMA thrusts. Patients with frequent to constant low back pain symptoms tended to have a more marked sEMG response in comparison with patients with occasional to intermittent low back pain. CONCLUSIONS: This is the first study demonstrating neuromuscular reflex responses associated with MFMA spinal manipulative therapy in patients with low back pain. Noteworthy was the finding that such mechanical stimulation of both the paraspinal musculature (transverse processes) and spinous processes produced consistent, generally localized sEMG responses. Identification of neuromuscular characteristics, together with a comprehensive assessment of patient clinical status, may provide for clarification of the significance of spinal manipulative therapy in eliciting putative conservative therapeutic benefits in patients with pain of musculoskeletal origin.

Adolescent↗

PubMed2001

A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain.

STUDY DESIGN: A randomized, parallel-group, single-blinded clinical trial was performed. After a 1-week baseline period, patients were randomized to 11 weeks of therapy, with posttreatment follow-up assessment 3, 6, and 12 months later. OBJECTIVES: To compare the relative efficacy of rehabilitative neck exercise and spinal manipulation for the management of patients with chronic neck pain. SUMMARY OF BACKGROUND DATA: Mechanical neck pain is a common condition associated with substantial morbidity and cost. Relatively little is known about the efficacy of spinal manipulation and exercise for chronic neck pain. Also, the combination of both therapies has yet to be explored. METHODS: Altogether, 191 patients with chronic mechanical neck pain were randomized to receive 20 sessions of spinal manipulation combined with rehabilitative neck exercise (spinal manipulation with exercise), MedX rehabilitative neck exercise, or spinal manipulation alone. The main outcome measures were patient-rated neck pain, neck disability, functional health status (as measured by Short Form-36 [SF-36]), global improvement, satisfaction with care, and medication use. Range of motion, muscle strength, and muscle endurance were assessed by examiners blinded to patients' treatment assignment. RESULTS: Clinical and demographic characteristics were similar among groups at baseline. A total of 93% of the patients completed the intervention phase. The response rate for the 12-month follow-up period was 84%. Except for patient satisfaction, where spinal manipulative therapy and exercise were superior to spinal manipulation with (P = 0.03), the group differences in patient-rated outcomes after 11 weeks of treatment were not statistically significant (P = 0.13). However, the spinal manipulative therapy and exercise group showed greater gains in all measures of strength, endurance, and range of motion than the spinal manipulation group (P < 0.05). The spinal manipulation with exercise group also demonstrated more improvement in flexion endurance and in flexion and rotation strength than the MedX group (P < 0.03). The MedX exercise group had larger gains in extension strength and flexion-extension range of motion than the spinal manipulation group (P < 0.05). During the follow-up year, a greater improvement in patient-rated outcomes were observed for spinal manipulation with exercise and for MedX exercise than for spinal manipulation alone (P = 0.01). Both exercise groups showed very similar levels of improvement in patient-rated outcomes, although the spinal manipulation and exercise group reported greater satisfaction with care (P < 0.01). CONCLUSIONS: For chronic neck pain, the use of strengthening exercise, whether in combination with spinal manipulation or in the form of a high-technology MedX program, appears to be more beneficial to patients with chronic neck pain than the use of spinal manipulation alone. The effect of low-technology exercise or spinal manipulative therapy alone, as compared with no treatment or placebo, and the optimal dose and relative cost effectiveness of these therapies, need to be evaluated in future studies.

Adult↗

PubMed1986

Spinal manipulative therapy in sports medicine.

Spinal manipulation or manual therapy is becoming an increasingly popular method of treating athletes with spinal problems. The primary theoretic basis for the claimed beneficial results of manipulation is the restoration of motion with subsequent effect on ligamentous adhesions, muscle spasm, disk nutrition, and central nervous system endorphin systems. The concept of joint barriers has been developed to differentiate among exercise therapy, mobilization, and manipulation. Research trials suggest that spinal manipulation is beneficial in relieving or reducing the duration of acute low back pain and acute neck pain but has much less effect on chronic low back pain and neck pain. There is evidence that manipulation increases certain parameters of motion of the spine but this evidence is not yet conclusive. There are a wide variety of manipulative procedures that are utilized to manipulate the spine to increase range of motion, and the selection of the procedures is based on manual diagnostic skills. Manipulation, however, is not a benign procedure and has been implicated in the aggravation of disk herniation or bony fractures as well as the precipitation of vertebrobasilar artery occlusion.

Back Pain↗

PubMedDate not supplied

Spinal manipulation in China.

BACKGROUND: Although there is a long history of the use spinal manipulation in China, little has been formally written on this topic. OBJECTIVE: To discuss the history and status of Chinese spinal manipulation. DISCUSSION: This article describes the history of Chinese spinal manipulation as revealed through past formal textbook publications on this topic, along with journal articles describing both the basic science foundation and clinical applications of such manipulation. In addition, the current status of Chinese spinal manipulation is described. CONCLUSION: There is a long history of the use of spinal manipulation throughout China, though some basic problems of application remain. Current research may help to resolve these problems.

China↗

PubMedDate not supplied

Evaluation of the effect of postural perturbation on motoneuronal activity following various methods of lumbar spinal manipulation.

BACKGROUND AND CONTEXT: One basic physiologic response to spinal manipulation (SM) is a transient decrease in motoneuronal activity, as assessed by the Hoffmann reflex (H-reflex) technique. However, questions of appropriate control procedures when using the H-reflex technique to study the basic physiologic mechanisms of SM still exist. The identification of appropriate control procedures may allow us to better differentiate among the specific and nonspecific aspects of SM. PURPOSE: The purpose of the research was to determine the contributions of postural perturbations on the attenuation of motoneuronal activity following spinal manipulative thrusts and spinal joint preload procedures applied to the lumbar spine. STUDY DESIGN/SETTING: H/M(max) ratios, recorded from the gastrocnemius muscle, were measured before and after lumbar spinal procedures. The experimental designs for the laboratory data collection protocols were repeated measures and between-subjects. PATIENT SAMPLE: The subjects were asymptomatic, young, healthy volunteers. OUTCOME MEASURE: H/M(max) ratios recorded from the gastrocnemius muscle. METHODS: In Experiment 1, the administration of prone lumbar procedures involved either manual assist to more fully shear the lumbar zygapophyseal joints or no manual assist. One set of subjects (n=17) received assisted joint preload force and manipulation, whereas a second set of subjects (n=17) received unassisted joint preload force and manipulation. In a second laboratory experiment, one set of subjects (n=10) received a L5-S1 side-posture SM, whereas a second set of subjects (n=10) were just positioned into side-posture. RESULTS: There was a H/M(max) ratio attenuation of 18.2% after assisted spinal manipulation, whereas H/M(max) ratio attenuation was only 9.5% after unassisted spinal manipulation. Decreases of H/M(max) ratios by 8.5% and 7.5% were observed after assisted and unassisted joint preload forces, respectively. The amount of H/M(max) ratio attenuation was significantly greater immediately after the L5-S1 SM procedure (28.4%) as compared with a side-posture positioning maneuver (15.3%). CONCLUSION: SM may provide procedure-specific sensory input that appears to vary, based upon the various types of vertebral loading applied to the lumbar spine.

Adult↗

PubMed2004

How common are side effects of spinal manipulation and can these side effects be predicted?

Little scientific support is available concerning usual and unusual reactions after spinal manipulation although such reactions are very common in clinical practice. Fifty-nine manipulative therapists were requested to enroll 15 consecutive patients attending for their first visit to receive spinal manipulation. These patients were asked to complete a questionnaire after this first visit that asked for possible risk factors for spinal manipulation and asked about any side effects after the manipulation. The participating practitioners were asked to note medical diagnosis, manipulated spinal region, number of treated areas and type of additional treatment. Four hundred and sixty five valuable responses were analysed. Two hundred and eighty three patients (60.9%) reported at least one post-manipulative reaction. The most common were headache (19.8%), stiffness (19.5%), local discomfort (15.2%), radiating discomfort (12.1%) and fatigue (12.1%). Most of these reactions began within 4 h and generally disappeared within the next 24 h. Women were more likely to report adverse effects than men (P < 0.001). Multivariate analysis showed that upper cervical manipulation (OR: 3.20; 95%CI: 1.89-7.77), use of medication (OR: 2.20; 95%CI: 1.31-3.69), gender (OR: 1.66; 95%CI: 1.01-2.75) and age (OR: 1.02; 95%CI: 1.00-1.05) were independent predictors of headache after spinal manipulation. The results of this study indicate that reactions to spinal manipulation may be relatively common but are benign in nature and of short duration. Although it is difficult to label side effects as a risk, it is important to differentiate those patients who are susceptible to side effects in order to inform them correctly.

Adult↗

PubMed2006

Learning spinal manipulation: the importance of augmented feedback relating to various kinetic parameters.

BACKGROUND CONTEXT: Spinal manipulation is a widely accepted therapeutic approach in the treatment of back pain. In standard training programs, feedback on student performances is provided by an instructor based on teaching and clinical experience. Systematic study of the type of augmented feedback provided and skill learning is lacking in the literature. PURPOSE: The goal of this investigation is to compare the performance of two groups of chiropractic students, one receiving traditional training from experienced instructors, and the other, augmented feedback on specific biomechanical aspects of spinal manipulation therapy using an instrumented manikin. STUDY DESIGN: Randomized controlled study. PATIENT SAMPLE: Thirty-one fourth-year students from the Department of Chiropractic of Université du Québec à Trois-Rivières participated in this study. OUTCOME MEASURES: Kinetic parameters (force-time curves) of spinal manipulation were evaluated. METHODS: Spinal manipulation parameters were measured before and after a 5-week training period in which one group received standard chiropractic training while a second group received augmented feedback about specific biomechanical parameters of spinal manipulation. For both groups, practice scheduling and time duration were similar and consisted of a weekly practice session of 90 minutes for five consecutive weeks. Both groups had to practice thoracic spine manipulation throughout the training period. RESULTS: Both groups showed a decrease in peak force applied, with a diminution in the number of trials where a downward incisural point was present in preload force. Participants in the feedback training group significantly reduced their peak force variability and significantly increased their preload force. No significant difference was observed for time to peak force. CONCLUSIONS: The results of this study highlight the merits of practicing with an instrumented manikin or other instrumented training aids. Such a device can provide specific feedback on specific parameters of the task during learning; it can also serve as a tool to assess the progress of students and eliminate the risks relating to repetitive spinal manipulative therapy practice on student colleagues.

Adult↗

PubMed2001

Spinal manipulation: a systematic review of sham-controlled, double-blind, randomized clinical trials.

For many years, spinal manipulation has been a popular form of treatment. Yet the debate about its clinical efficacy continues. The research question remains: Does spinal manipulation convey more than a placebo effect? To summarize the evidence from sham-controlled clinical trials of spinal manipulation as a treatment of various conditions, and to assess the methodological quality of these studies, a comprehensive search strategy was designed to locate all sham-controlled, double-blind, randomized trials of spinal manipulation as a treatment of any medical condition. Data were extracted from these trials and validated by two independent reviewers in a standardized fashion. All trials were critically analyzed and their methodological quality evaluated. Eight studies fulfilled the pre-defined inclusion/exclusion criteria. Three trials (two on back pain and one on enuresis) were judged to be burdened with serious methodological flaws. The results of the three most rigorous studies (two on asthma and one on primary dysmenorrhea) do not suggest that spinal manipulation leads to therapeutic responses which differ from an inactive sham-treatment. This analysis demonstrates that sham-controlled trials of spinal manipulation are sparse but feasible. The most rigorous of these studies suggest that spinal manipulation is not associated with clinically-relevant specific therapeutic effects.

Double-Blind Method↗

PubMed2001

Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation.

AIMS: To investigate the efficacy of chiropractic spinal manipulation in the management of infantile colic. METHODS: One hundred infants with typical colicky pain were recruited to a randomised, blinded, placebo controlled clinical trial. RESULTS: Nine infants were excluded because inclusion criteria were not met, and five dropped out, leaving 86 who completed the study. There was no significant effect of chiropractic spinal manipulation. Thirty two of 46 infants in the treatment group (69.9%), and 24 of 40 in the control group (60.0%), showed some degree of improvement. CONCLUSION: Chiropractic spinal manipulation is no more effective than placebo in the treatment of infantile colic. This study emphasises the need for placebo controlled and blinded studies when investigating alternative methods to treat unpredictable conditions such as infantile colic.

Colic↗

PubMed1995

The appropriateness of chiropractic spinal manipulation for low back pain: a pilot study.

OBJECTIVE: Spinal manipulation is an efficacious therapy for some patients with low back pain (LBP). In this pilot study, we tested the feasibility of assessing the appropriateness of chiropractic spinal manipulation for patients with LBP. METHODS: Criteria for the appropriate and inappropriate use of spinal manipulation for low back pain were developed using the RAND/UCLA appropriateness method. Two separate expert panels, one multidisciplinary and one all chiropractic, each rated a comprehensive array of clinical scenarios for appropriateness. A random sample of practicing chiropractors was selected, and data were collected from ten randomly selected office records from each participating clinician. Assessment of the appropriateness for the use of spinal manipulation was made by comparing the care delivered with the appropriateness criteria determined by each expert panel. RESULTS: Eight of thirteen (62%) eligible chiropractors agreed to participate. For the remainder, by the multidisciplinary panel's criteria, 38% of care was appropriate and 26% of care was inappropriate. By the all-chiropractic panel's criteria, the same cases were judged 74% appropriate and 7% inappropriate. The two panel's appropriateness ratings were in agreement on 48% of all cases. CONCLUSIONS: In this geographic area, the rate of appropriate care is between 38% and 74% and the rate of inappropriate care is between 7% and 19%, depending on the criteria used to assess appropriateness. Data from other geographic areas of the U.S. will be needed before inferences to a larger population may be drawn, and we have demonstrated that such a study is feasible.

Adolescent↗

PubMed2004

Spinal manipulative therapy for low back pain.

BACKGROUND: Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain. OBJECTIVES: To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened. SELECTION CRITERIA: Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure. DATA COLLECTION AND ANALYSIS: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). MAIN RESULTS: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. REVIEWER'S CONCLUSIONS: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.

Humans↗

PubMed2002

Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain.

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To compare the effects of spinal manipulation combined with low-tech rehabilitative exercise, MedX rehabilitative exercise, or spinal manipulation alone in patient self-reported outcomes over a two-year follow-up period. SUMMARY OF BACKGROUND DATA: There have been few randomized clinical trials of spinal manipulation and rehabilitative exercise for patients with neck pain, and most have only reported short-term outcomes. METHODS: One hundred ninety-one patients with chronic neck pain were randomized to 11 weeks of one of the three treatments. Patient self-report questionnaires measuring pain, disability, general health status, improvement, satisfaction, and OTC medication use were collected after 5 and 11 weeks of treatment and 3, 6, 12, and 24 months after treatment. Data were analyzed taking into account all time points using repeated measures analyses. RESULTS: Ninety-three percent (178) of randomized patients completed the 11-week intervention phase, and 76% (145) provided data at all evaluation time points over the two-year follow-up period. A difference in patient-rated pain with no group-time interaction was observed in favor of the two exercise groups [F(2141) = 3.2; P= 0.04]. There was also a group difference in satisfaction with care [F(2143) = 7.7; P= 0.001], with spinal manipulation combined with low-tech rehabilitative exercise superior to MedX rehabilitative exercise (P = 0.02) and spinal manipulation alone (P < 0.001). No significant group differences were found for neck disability, general health status, improvement, and OTC medication use, although the trend over time was in favor of the two exercise groups. CONCLUSION: The results of this study demonstrate an advantage of spinal manipulation combined with low-tech rehabilitative exercise and MedX rehabilitative exercise versus spinal manipulation alone over two years and are similar in magnitude to those observed after one-year follow-up. These results suggest that treatments including supervised rehabilitative exercise should be considered for chronic neck pain sufferers. Further studies are needed to examine the cost effectiveness of these therapies and how spinal manipulation compares to no treatment or minimal intervention.

Adult↗

PubMed1998

Congruence between decisions to initiate chiropractic spinal manipulation for low back pain and appropriateness criteria in North America.

BACKGROUND: Recent U.S. practice guidelines recommend spinal manipulation for some patients with low back pain. If followed, these guidelines are likely to increase the number of persons referred for chiropractic care. Concerns have been raised about the appropriate use of chiropractic care, but systematic data are lacking. OBJECTIVE: To determine the appropriateness of chiropractors' decisions to use spinal manipulation for patients with low back pain. DESIGN: Retrospective review of chiropractic office records against preset criteria for appropriateness that were developed from a systematic review of the literature and a nine-member panel of chiropractic and medical specialists. Appropriateness criteria reflect the expected balance between risk and benefit. SETTING: 131 of 185 (71%) chiropractic offices randomly sampled from sites in the United States and Canada. PATIENTS: 10 randomly selected records of patients presenting with low back pain from each office (1310 patients total). MEASUREMENTS: Sociodemographic data on patients and chiropractors; use of health care services by patients; assessment of the decision to initiate spinal manipulation as appropriate, uncertain, or inappropriate. RESULTS: Of the 1310 patients who sought chiropractic care for low back pain, 1088 (83%) had spinal manipulation. For 859 of these patients (79%), records contained data sufficient to determine whether care was congruent with appropriateness criteria. Care was classified as appropriate in 46% of cases, uncertain in 25% of cases, and inappropriate in 29% of cases. Patients who did not undergo spinal manipulation were less likely to have a presentation judged appropriate and were more likely to have a presentation judged inappropriate than were patients who did undergo spinal manipulation (P = 0.01). CONCLUSIONS: The proportion of chiropractic spinal manipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care. However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased.

Adult↗

PubMedDate not supplied

Efficacy of spinal manipulative therapy for low back pain of less than three months' duration.

OBJECTIVES: To review the efficacy of spinal manipulation for low back pain of less than 3 months duration. Data sources Randomized clinical trials on spinal manipulative therapy for low back pain were identified by searching EMBASE, CINAHL, MEDLINE, and the Physiotherapy Evidence Database (PEDro). Study selection Outcome measures of interest were pain, return to work, adverse events, disability, quality of life, and patient satisfaction with therapy. Data extraction Methodological assessment of the trials was performed using the PEDro scale. Trials were grouped according to the type of intervention, outcome measures, and follow-up time. Where there were multiple studies with sufficient homogeneity of interventions, subjects, and outcomes, the results were analyzed in a meta-analysis using a random effects model. Data synthesis Thirty-four papers (27 trials) met the inclusion criteria. Three small studies showed spinal manipulative therapy produces better outcomes than placebo therapy or no treatment for nonspecific low back pain of less than 3 months duration. The effects are, however, small. The findings of individual studies suggest that spinal manipulative therapy also seems to be more effective than massage and short wave therapy. It is not clear if spinal manipulative therapy is more effective than exercise, usual physiotherapy, or medical care in the first 4 weeks of treatment. CONCLUSIONS: Spinal manipulative therapy produces slightly better outcomes than placebo therapy, no treatment, massage, and short wave therapy for nonspecific low back pain of less than 3 months duration. Spinal manipulative therapy, exercise, usual physiotherapy, and medical care appear to produce similar outcomes in the first 4 weeks of treatment.

Chiropractic↗

PubMedDate not supplied

Neuromechanical characterization of in vivo lumbar spinal manipulation. Part II. Neurophysiological response.

OBJECTIVE: To simultaneously quantify vertebral motions and neuromuscular and spinal nerve root responses to mechanical force, manually assisted, short-lever spinal manipulative thrusts. METHODS: Four patients underwent lumbar laminarthrectomy to decompress the central spinal canal and neuroforamina, as clinically indicated. Prior to decompression, finely threaded, 1.8-mm diameter intraosseous pins were rigidly fixed to the lumbar spinous process (L1 or L3) using fluoroscopic guidance, and a high-frequency, low-noise, 10-g, triaxial accelerometer was mounted to the pin. Following decompression, 4 needle electromyographic (nEMG) electrodes were inserted into the multifidus musculature adjacent to the pin mount bilaterally, and 2 bipolar platinum electrodes were cradled around the left and right S1 spinal nerve roots. With the spine exposed, spinal manipulative thrusts were delivered internally to the lumbosacral spinous processes and facet joints and externally by contacting the skin overlying the respective spinal landmarks using 2 force settings ( approximately 30 N, < 5 milliseconds (ms); approximately 150 N, < 5 ms) and 2 force vectors (posteroanterior and superior; posteroanterior and inferior). RESULTS: Spinal manipulative thrusts resulted in positive electromyographic (EMG) and compound action potential (CAP) responses that were typically characterized by a single voltage potential change lasting several milliseconds in duration. However, multiple EMG and CAP discharges were observed in numerous cases. The temporal relationship between the initiation of the mechanical thrust and the neurophysiologic response to internal and external spinal manipulative therapy (SMT) thrusts ranged from 2.4 to 18.1 ms and 2.4 to 28.6 ms for EMG and CAP responses, respectively. Neurophysiologic responses varied substantially between patients. CONCLUSIONS: Vertebral motions and resulting spinal nerve root and neuromuscular reflex responses appear to be temporally related to the applied force during SMT. These findings suggest that intersegmental motions produced by spinal manipulation may play a prominent role in eliciting physiologic responses.

Aged↗

PubMedDate not supplied

Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial.

OBJECTIVE: To compare the effectiveness of spinal manipulation and pharmaceutical treatment (amitriptyline) for chronic tension-type headache. DESIGN: Randomized controlled trial using two parallel groups. The study consisted of a 2-wk baseline period, a 6-wk treatment period and a 4-wk posttreatment, follow-up period. SETTING: Chiropractic college outpatient clinic. PATIENTS: One hundred and fifty patients between the ages of 18 and 70 with a diagnosis of tension-type headaches of at least 3 months' duration at a frequency of at least once per wk. INTERVENTIONS: 6 wk of spinal manipulative therapy provided by chiropractors or 6 wk of amitriptyline treatment managed by a medical physician. MAIN OUTCOME MEASURES: Change in patient-reported daily headache intensity, weekly headache frequency, over-the-counter medication usage and functional health status (SF-36). RESULTS: A total of 448 people responded to the recruitment advertisements; 298 were excluded during the screening process. Of the 150 patients who were enrolled in the study, 24 (16%) dropped out: 5 (6.6%) from the spinal manipulative therapy and 19 (27.1%) from the amitriptyline therapy group. During the treatment period, both groups improved at very similar rates in all primary outcomes. In relation to baseline values at 4 wk after cessation of treatment, the spinal manipulation group showed a reduction of 32% in headache intensity, 42% in headache frequency, 30% in over-the-counter medication usage and an improvement of 16% in functional health status. By comparison, the amitriptyline therapy group showed no improvement or a slight worsening from baseline values in the same four major outcome measures. Controlling for baseline differences, all group differences at 4 wk after cessation of therapy were considered to be clinically important and were statistically significant. Of the patients who finished the study, 46 (82.1%) in the amitriptyline therapy group reported side effects that included drowsiness, dry mouth and weight gain. Three patients (4.3%) in the spinal manipulation group reported neck soreness and stiffness. CONCLUSIONS: The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline therapy was slightly more effective in reducing pain at the end of the treatment period but was associated with more side effects. Four weeks after the cessation of treatment, however, the patients who received spinal manipulative therapy experienced a sustained therapeutic benefit in all major outcomes in contrast to the patients that received amitriptyline therapy, who reverted to baseline values. The sustained therapeutic benefit associated with spinal manipulation seemed to result in a decreased need for over-the-counter medication. There is a need to assess the effectiveness of spinal manipulative therapy beyond four weeks and to compare spinal manipulative therapy to an appropriate placebo such as sham manipulation in future clinical trials.

Adult↗

PubMed1991

Enhanced phagocytic cell respiratory burst induced by spinal manipulation: potential role of substance P.

The effect of spinal manipulation on the respiratory burst of polymorphonuclear neutrophils (PMN) and monocytes from treated adults was measured by zymosan-stimulated chemiluminescence (CL). Peripheral blood was collected 15 min before and 15 min after treatment (sham manipulation, thoracic spine manipulation, or soft tissue manipulation), the cells were isolated, challenged with a standardized, opsonized luminol-containing suspension of zymosan, and monitored for CL. Plasma from two subsets of subjects was radioimmunoassayed for Substance P (SP). PMN were also preincubated with SP in vitro over the dose range 5 x 10(-12) M to 5 x 10(-8) M and the CL response monitored. The CL responses of both PMN and monocytes from subjects who received spinal manipulation were significantly higher after than before treatment, and significantly higher than the response in sham or soft-tissue treated subjects. Measurement of the force applied by sham and spinal manipulation suggested a force threshold for the enhancement of the CL response. Plasma levels of SP before and after treatment in sham treated subjects did not differ significantly; however, elevated plasma SP was observed in subjects after spinal manipulation. Preincubation of PMN with 1 x 10(-11) M, 5 x 10(-11) M or 1 x 10(-10) M SP in vitro primed PMN for an enhanced respiratory burst when the cells were subsequently challenged.

Adult↗