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Spinal subdural empyema (SE) is a rare condition. We describe a young patient with a torathic SE after lumbar epidural anaesthesia. SE was distant from the region of manipulation. Spinal magnetic resonance was the most useful procedure for diagnosis and follow-up. Treatment with intravenous antibiotics and drainage was not enough, and she needed complete surgical excision of the lesion.
OBJECTIVE: This article specifically addresses the question of whether the manipulable cervical lesion is likely to cause extrinsic compression of the vertebral arteries sufficient to cause such symptoms of reduced regional cerebral blood flow as might be relieved by spinal manipulation. DATA SOURCES: Literature on normal and abnormal cerebral circulation, including vertebrobasilar insufficiency. DATA SYNTHESIS: Signs and symptoms produced by extrinsic compression of the vertebrobasilar system have been compared with those attributed elsewhere to the manipulable cervical lesion (cervical subluxation). RESULTS: Extrinsic compression of the vertebrobasilar system generally does not produce signs and symptoms consistent with those attributed to the manipulable cervical lesion. CONCLUSION: It has been hypothesized elsewhere that the manipulable cervical lesion may induce localized decreases in regional cerebral blood flow, and so signs and symptoms attributable to "cerebral hibernation." If a causal relationship does exist between the cervical subluxation and reduced regional cerebral blood flow, it is not likely to be caused by mechanical compression of the vertebral arteries.
This paper studies somatovisceral reflex responses in the cardiovascular organ, gastrointestinal tract, urinary bladder and adrenal medulla in anesthetized animals after eliminating emotional factors following somatic sensory stimulations. Various somatic sensory stimulations, including cutaneous, muscle and articular sensory stimulations, can produce differing autonomic reflex responses, depending on which visceral organs and somatic afferents are stimulated. Some responses have dominant sympathetic efferent involvement, whereas others have dominant parasympathetic efferent involvement. Some responses have propriospinal and segmental characteristics, while others have supraspinal and generalized characteristics in their reflex nature. These somatovisceral reflex responses may be functioning during spinal manipulative therapy in conscious humans.
OBJECTIVE: To discuss a case of sciatica associated with lower back pain that originates in a disc. We discuss the use of manipulative therapy as a conservative approach and compare it with other conservative methods and with surgery. CLINICAL FEATURES: The patient suffered from lower back and left leg pain that had increased in severity over a 6-day period. There was decreased sensation in the dorsum of the left foot and toes. Computed tomography demonstrated the presence of a small, contained disc herniation. INTERVENTION AND OUTCOME: The patient was initially treated with ice followed by flexion-distraction therapy. This was used over the course of her first three visits. Once she was in less pain, side posture manipulation was added to her care. Nine treatments were required before she was released from care. CONCLUSION: We need a nonsurgical, conservative approach to treat lower back pain with sciatica as an alternative to and before beginning the more aggressive, and potentially hazardous, surgical treatment. There is some support for the idea that lumbar disc herniation with neurological deficit and radicular pain does not contraindicate the judicious use of manipulation. Although significant questions remain for the evaluation and treatment of lumbar radiculopathy (sciatica) with disc herniations, there is ample evidence to suggest that a course of conservative care, including spinal manipulation, should be completed before surgical consult is considered.
Neck pain is a common complaint that typically represents a spectrum of disorders affecting the cervical spine. The clinical history and examination of patients with neck pain dictate the proper timing and selection of diagnostic studies such as plain radiography, MRI, and myelography with CT. Most neck pain is self-limiting and will resolve with appropriate conservative care. Nonsurgical treatment is the most appropriate first step in almost all cases of cervical radiculopathy. In contrast, the conservative care of cervical spondylotic myelopathy with measures such as physical therapy, spinal manipulation, medications, collars, and traction is limited.
OBJECTIVES: To document the efficacy of combined epidural steroid injection (ESI) and manipulation to the lumbar spine in patients suffering from chronic low back pain (LBP). SUMMARY OF BACKGROUND DATA: The use of ESI in conjunction with lumbar manipulation has seldom been reported in the literature but has offered promising results when studied. STUDY DESIGN: Retrospective repeated-measures analysis of patients with chronic LBP who received ESIs combined with spinal manipulation. METHODS: A retrospective analysis using a repeated-measures format was performed on 17 cases of patients who had received ESI and manipulation to the lumbar spine. All patients were medically stable for chronic mechanical LBP and had experienced a suboptimal response to conventional care. The principle investigator was blinded from data outcomes when determining patient eligibility for the study. A subjective patient improvement scale was used to monitor degree of success. RESULTS: Ten of the 17 patients were eligible for the study. Patients were eliminated for lack of consistency of data collection, having received an additional procedure after conventional care, involvement of the cervical spine; one patient experienced an unrelated medical problem. After 1 yr of conventional care, the patients reported a 25.5% improvement. (Conventional care included ESI and manipulation done at separate times.) After on ESI with subsequent manipulation, these same patients reported a 50.5% improvement. Mean improvement was 25.00% (SD = 19.51, SEM 6.19, t = 4.04 and p = .0015). CONCLUSION: The use of ESI performed with manipulation seems to offer promise for a carefully selected group of patients. ESI combined with manipulation should be considered in patients who do not respond to conventional forms of care.
OBJECTIVE: To present an uncommon case of an isolated lamina fracture in the cervical spine found by taking stress films when a routine cervical series failed to demonstrate it. CLINICAL FEATURES: A 63-yr-old male was seen after suffering from mild neck pain and stiffness of 4 days' duration after a car accident. A review of emergency room X-rays demonstrated a small fragment of bone adjacent to the anterior superior end-plate of C6. Flexion/extension stress views were then done that demonstrated anterior slippage of C5 on C6 during flexion, and a cervical lamina fracture of C5 was diagnosed and confirmed with a subsequent MRI. INTERVENTION AND OUTCOME: This patient was treated with specific spinal mobilization for motion restrictions above and below the fracture site, avoiding stress on the C4-6 motor units. Soft tissue, gentle manual cervical traction and patient education on avoiding stress to the cervical spine were given. Resolution of neck pain and stiffness was achieved in three visits, and 6-wk follow-up radiographs demonstrated healing and increased stability at the fracture site. CONCLUSION: A significant percentage of the average chiropractor's practice will involve the management of cervical spine injuries from motor vehicle accidents. The inclusion of stress films in the regular cervical series can reduce the possibility of missing an occult fracture or instability. When neurological complications are absent, such cases can be managed conservatively with the judicious application of spinal manipulative and adjunctive procedures.
SUMMARY. The present study was undertaken to determine whether a sympathoexcitatory effect would result from a manipulative therapy technique applied to a peripheral joint. The technique selected was a Grade III posteroanterior accessory glide of the right glenohumeral joint with the arm positioned in glenohumeral abduction and internal rotation. Previously, spinal manipulative therapy techniques have been shown to produce such an effect. Nineteen normal subjects participated in the experiment. Treatment, placebo and control conditions were compared. Skin conductance and skin temperature of the distal finger tips were used as indicators of peripheral sympathetic activity. Results demonstrated that the treatment condition caused a significantly greater increase in skin conductance than the placebo or control conditions. The response was seen in both hands indicating a generalised sympathetic activation. The treatment condition also resulted in a significant reduction in skin temperature in the treated limb. The importance of this sympathoexcitatory effect in relation to potential neurophysiological mechanisms underlying manipulation induced analgesia is discussed. Copyright 1997 Harcourt Publishers Ltd.
BACKGROUND: Spinal pain is common and costly to health services and society. Management guidelines have encouraged primary care referral for spinal manipulation, but the evidence base is weak. More economic evaluations alongside pragmatic trials have been recommended. OBJECTIVE: Our aim was to assess the cost-utility of a practice-based osteopathy clinic for subacute spinal pain. METHODS: A cost-utility analysis was performed alongside a pragmatic single-centre randomized controlled trial in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. Patients with back pain of 2-12 weeks duration were randomly allocated to treatment with osteopathy plus usual GP care or usual GP care alone. Costs were measured from a National Health Service (NHS) perspective. All primary and secondary health care interventions recorded in GP notes were collected for the study period. We calculated quality adjusted life year (QALY) gains based on EQ-5D responses from patients in the trial, and then cost per QALY ratios. Confidence intervals (CIs) were estimated using non-parametric bootstrapping. RESULTS: Osteopathy plus usual GP care was more effective but resulted in more health care costs than usual GP care alone. The point estimate of the incremental cost per QALY ratio was 3560 pounds (80% CI 542 pounds-77,100 pounds). Sensitivity analysis examining spine-related costs alone and total costs excluding outliers resulted in lower cost per QALY ratios. CONCLUSION: A primary care osteopathy clinic may be a cost-effective addition to usual GP care, but this conclusion was subject to considerable random error. Rigorous multi-centre studies are needed to assess the generalizability of this approach.
BACKGROUND: There is epidemiologic evidence that chiropractors are a high-risk group for low-back disorders. However, to date there are no known biomechanical studies to determine whether their workstations may be a contributing factor. OBJECTIVE: To investigate whether chiropractors' workstation table height or the tasks they perform make them susceptible to low-back strain. As well as investigating low-back strain, a screening was performed to determine whether chiropractors' upper extremities were at risk for undue strain as workstation table height was varied. STUDY DESIGN: Experimental pilot study. SETTING: A university ergonomic laboratory. METHODS: An adjustable manipulation table was set at 3 different heights: 465 mm, 665 mm and 845 mm. Each of the 7 volunteer chiropractors were fitted with a triaxial electrogoniometer and were videotaped and photographed for analysis while performing spinal manipulation to the cervical, thoracic, and lumbar spine of a volunteer patient at each workstation table height. Two biomechanical models, one static and one dynamic, were used to record the dependent variables. A screening of various upper extremity variables was also performed with the static model. RESULTS: For the subjects under study, a significant difference was found for the variables maximum sagittal flexion, disk compression force, and ligament strain as table height was varied. For the lumbar and thoracic manipulation tasks, the medium table height (655 mm) was found to create the least low-back strain. For the cervical manipulation task, the high table height (845 mm) was found to be the least straining on the low-back. The low height table (465 mm) was the most straining for all tasks. Upper extremities were not significantly affected by changes to table height. Significant differences were found for the task performed for axial rotational velocity, disk compression force, ligament strain, maximum sagittal flexion, dominant (right) elbow moment, and dominant (right) shoulder moment variables. There was no significant interaction between table height and task performed. CONCLUSION: Workstation table height was found to have a significant effect on low-back load of subjects under study. The results of this study demonstrate an overall unacceptably high amount of sagittal flexion, ligament strain, and disk compression force on the chiropractor subjects in the tasks performed.
From 1975 through 1983, a total of 517 patients with protruded lumbar discs were admitted for manipulative treatment. Of these, 76.8% had satisfactory results. There were 73 recurrences (14.1%) at intervals ranging from two months to 12 years. Forty-seven cases did not respond to manipulation. These results indicate that manipulation of the spine can be effective treatment for lumbar disc protrusions. In general, the manipulation consists of eight maneuvers in three positions. The selection of the appropriate maneuvers depends on the patient's symptoms and signs and on the judgment and expertise of the operator. Practice is necessary to become proficient in spinal manipulation techniques. Several mechanisms of regression lumbar disc protrusions are possible.
OBJECTIVE: To discuss the surgical technique, indication and the clinical effects of the Microscope Endoscopic Tubular Retractor System (METRx) for microendoscopic lumbar diskectomy with the preservation of the ligamentum flavum. METHODS: Two hundred and eleven patients underwent single-segment METRx, with ligamentum flavum preservation in 65 patients (Group A), and without preservation in 146 patients (Group B). The two groups were compared clinically. All the patients suffered from low back pain and radicular syndrome to some extent, and the diagnosis was affirmed by CT and/or MRI. After exposed the interlaminar space regularly, the superior, inferior and lateral edge of the ligamentum flavum was released, the 3-sided dissociative ligament pacth was retracted medially during the spinal manipulation and restored anatomically after disc removal and the decompression of the nerve root. RESULTS: According to the results of two groups, ligamentum flavum preservation technique was feasible under endoscope and helpful in reducing the scar formation in the spinal canal. CONCLUSIONS: The ligamentum flavum preservation technique enable the surgeons to preserve the natural barrier. It is feasible to perform METRx, and it is helpful in reducing the epidural fibrosis.
STUDY DESIGN: A case series of patients with low back pain (LBP) who satisfy a clinical prediction rule (CPR). BACKGROUND: A CPR that identifies patients with LBP who are likely to respond with rapid and prolonged reductions in pain and disability following spinal manipulation was developed and recently validated. The CPR developed to predict favorable response to manipulation investigated the effects of only 1 manipulation technique. The accuracy of the CPR for predicting outcomes using other manipulation techniques is not known. The purpose of the case series was to describe the outcomes of patients presenting to physical therapy with LBP who met the CPR and were treated with an alternative lumbar manipulation technique. CASE DESCRIPTION: Consecutive patients referred to physical therapy who satisfied the eligibility criteria, including the presence of at least 4 of the 5 criteria on the CPR, were invited to participate in the case series. Patients were treated for 2 visits with a side-lying lumbar manipulation technique, followed by a basic range of motion exercise. Patients who exhibited a 50% reduction or greater in disability, as measured by the Oswestry Disability Index (ODI), were considered to have experienced a successful outcome. OUTCOMES: A total of 12 patients participated in the case series. The mean age of the group was 39 years (SD, 8.9 years) and the median duration of symptoms was 19 days (range, 8-148 days). Of the 12 patients who participated in this case series, the mean reduction in disability as measured with the ODI was 57% (SD, 9%). Only 1 patient did not surpass the 50% reduction in ODI scores. DISCUSSION: Eleven of the 12 patients (92%) in this case series who satisfied the CPR and were treated with an alternative lumbar manipulation technique demonstrated a successful outcome in 2 visits. It is plausible that patients with LBP who satisfy the CPR may obtain a successful outcome with either manipulation technique directed at the lumbopelvic region.
OBJECTIVE: The diminution of the signs and symptoms of cervical dystonia following an extended course of specific chiropractic manipulation is described. CLINICAL FEATURES: A 38-year-old man had gross anterior-lateral torticollis, focal dystonia of the head and neck, and radicularlike pains which failed to respond to physical therapy, medication, and injection. INTERVENTIONS AND OUTCOMES: Two specific spinal manipulative technique systems unique to the chiropractic profession (Applied Biostructural Therapy [ABT] and Atlas Coccygeal Technique [ACT]) were applied to the patient. The patient's grading on a modified cervical dystonia scale dropped from a grade 16 to a grade 5 after an extended course of these specific chiropractic manipulative techniques. CONCLUSIONS: The application of Advanced Biostructural Therapy and Atlas Coccygeal chiropractic techniques for management of cervical dystonia is presented. Substantial reduction in the cervical dystonia rating scale was observed with this approach, even after standard medical interventions had failed.
The initial effectiveness as well as the temporal stability of the effect of cervical spinal manipulation with respect to the amelioration of goniometrically verified cervical lateral-flexion passive end-range asymmetry was examined. Responses of two groups of pain-free subjects were compared: a) those exhibiting end-range asymmetries of greater than 10 degrees who, in addition, had suffered previous neck trauma, and; b) those who happened to exhibit end-range asymmetries of greater than 10 degrees but who had no history of prior neck trauma. All subjects received a single lower cervical adjustment delivered to the side of most-restricted end-range, and goniometric reassessments were performed 30 min, 4 hr, and 48 hr following the adjustment. A dramatic amelioration of asymmetry was observed in both groups at 30 min and 4 hr postmanipulation. Furthermore, the magnitudes of these short-term effects were similar for the two groups. However, by 24 hours, a difference in the temporal responses of the groups had become readily apparent. By 48 hours, the difference was even more striking; whereas 14 of 16 of the subjects with no previous neck trauma continued to exhibit asymmetries of less than 10 degrees (mean +/- SEM = 3.8 +/- 1.0 degrees), 12 of the 16 subjects with previous neck trauma had regained asymmetries of greater than 10 degrees (mean +/- SEM = 11.4 +/- 1.7 degrees). These results indicate that among asymptomatic (pain-free) individuals, the mere presence of passive end-range asymmetry as well as the magnitude of the short-term ameliorative effect of cervical manipulation do not distinguish these two categories of subjects.(ABSTRACT TRUNCATED AT 250 WORDS)
The use of manual therapy to treat somatic pain syndromes and associated disabilities is widespread. Yet, the efficacy of manual therapy has not been previously established because equivocal findings in the literature prevent definitive conclusions. The purposes of this article are (1) to establish objective criteria for judging the validity of manual therapy research, (2) to identify and discuss the results of those trials that were determined to be valid demonstrations of treatment efficacy or valid demonstrations of nonuseful therapy, and (3) to determine whether patients who benefit from manual therapy have common characteristics. The abstracts or full reports of 146 titles with appropriate key words were reviewed. Of these, 105 studies were not primary studies of manual therapy and were thus eliminated from review. In the 41 remaining studies, 18 did not utilize statistical comparisons or report blinded assessment of outcome measures. Nine controlled studies yielded negative results, but the statistical power or minimum sample size required to detect potential differences between manual therapy and control groups was not described. The 14 studies that met the efficacy criteria were categorized by the following factors: (1) the anatomical region of intervention, (2) pragmatic versus explanatory goals, and (3) primary intervention (manipulation, mobilization, combination). There was a paucity of valid explanatory research in all areas and a particular absence of controlled trials involving manual therapy applied to the peripheral joints. Manual therapy for low back pain, however, was studied extensively. The analysis of valid trials provided clear evidence that manual therapy, particularly manipulation, can be an effective modality when used to treat patients who have low back pain. A preliminary "profile" of the patient with low back pain who would likely benefit from manual therapy included acute symptom onset with less than a 1-month duration of symptoms, central or paravertebral pain distribution, no previous exposure to spinal manipulation, and no pending litigation or workers' compensation. Suggestions for future manual therapy research are discussed.
OBJECTIVE: To analyze the clinical significance of herniated lumbar intervertebral nucleus pulposus (HNP) inside the spinal canal. STUDY DESIGN: This was a comparison study between patients with multiple lumbar disk herniation and those with single lumbar disk herniation receiving conservative treatment. METHODS: Four indices, including computed tomography, plain and dynamic radiology and quantified physical examinations, were compared among 22 consecutive patients with multiple disk protrusions and 37 with single disk protrusion before and after a period of conservative treatment, mainly using spinal manipulation. RESULTS: There were no obvious changes of HNP size, position and volume, even after clinical improvement. However, structural and functional recovery in the group with multiple segments was less satisfactory than that of the group with single segment involvement. CONCLUSIONS: The protruded disk tissue plays an important role in the biomechanical disturbances of the spinal column besides that of an irritating agent to nerve root(s).
The Lateral Recess Syndrome (LRS) represents stenosis of the lateral subarticular gutter that will often lead to nerve root compression. The most common etiology is hypertrophy of the superior articular facets, associated with lumbar instability and arthrosis of the posterior joint complex. The diagnosis may be made clinically with a routine lumbosacral x-ray series, but is not definitive without the use of CT scanning. Recent studies indicate that spinal manipulation can provide relief and should be considered before surgical referral is made for decompression.