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A successfully treated case of sacroiliac syndrome coexisting with lumbosacral anomalies is presented. Spinal manipulative therapy is not contraindicated if properly modified to account for the anomalous anatomical orientation.
In conscious, chronically prepared sheep, blood flow through cutaneous arteriovenous anastomoses (AVAs) was varied by manipulating spinal cord temperature. Ultrastructural examination of nerve terminals or varicosities adjacent to the media of the AVA wall showed that they contained numerous small clear or dense-cored vesicles typical of noradrenergic vesicles in sympathetic nerves. During spinal cooling about 1% of femoral flow passed through AVAs, the AVAs showed more intense catecholamine fluorescence and the percentage of dense-cored vesicles and their density was significantly greater than during spinal warming; up to 50% of femoral flow passed through AVAs during spinal warming. Our results conform with pharmacological and electrophysiological evidence for alpha-adrenergic involvement in control of AVAs. This correlation between structure and function could provide a useful method for (a) obtaining relative indices of blood flow through AVAs in body regions where techniques to measure blood flow cannot be applied, and (b) studying sympathetic control of cutaneous AVAs in experimental conditions under which electrophysiological techniques cannot be applied.
OBJECTIVE: The purpose of this study was to compare the relative movements between adjacent vertebrae that were accompanied by a cavitation sound to those relative movements wherein no cavitation sound was recorded, during spinal manipulative treatments (SMTs) to T12 of an unembalmed human cadaver. SETTING: The experiment was conducted in the gross anatomy laboratory at the University of Calgary. SUBJECTS: One 77-yr-old male cadaver was used. INTERVENTIONS: High speed cinematography and embedded bone pin markers were used to record the movements of T10, T11, and T12, during the manipulations. A pressure pad was used to measure the posterior-to-anterior (p-to-a) forces exerted by the clinician onto the cadaver. Two uniaxial accelerometers were used to record the p-to-a accelerations of T11 and T12. The clinician delivered five p-to-a thrusts to the right transverse process of T12. P-to-a forces, p-to-a accelerations, and relative (between T10 and T11, and, T11 and T12) p-to-a translations, lateral translations, and axial rotations, were calculated for each thrust. MAIN RESULTS: A cavitation sound was recorded by the T12 accelerometer during the fourth manipulation. The p-to-a force parameters of the fourth trial were not different from those of the other trials. However, the relative lateral translations between the adjacent vertebrae were substantially greater during the fourth manipulation, compared to the other trials. CONCLUSIONS: The characteristics of the relative lateral translations between adjacent vertebrae suggest that the cavitation sound recorded during the fourth manipulation may have been associated with greater laterally applied forces than those during the other manipulations to T12, wherein no cavitation was recorded.
A new group has been formed to represent chiropractors and other health care professionals who limit their use of spinal manipulation to the treatment of back problems, and who oppose claims that chiropractic can treat problems such as asthma and enuresis. However, some Canadian chiropractors respond that most claims that chiropractic can cure disease originate in the US, and that Canadian chiropractors are conservative in their claims. Some Canadian pediatricians are concerned that chiropractors are attempting to treat more children.
OBJECTIVE: To discuss the evaluation and treatment used in the resolution of a case of double crush syndrome. CLINICAL FEATURES: A 63-yr-old male suffered from a 36-month history of right anterior leg numbness and recurrent lower back pain. Onset of initial complaint followed a slip and fall on ice. A clinical diagnosis of double crush syndrome was made after appropriate testing was performed. INTERVENTION AND OUTCOME: The patient was put on a 6-wk treatment plan at a two visit per week frequency. Treatment consisted of spinal manipulation and H-wave current electrotherapy. Follow-up at 6, 8, 12, 26 and 52 wk revealed complete resolution of the right anterior leg numbness and reduced occurrence of lower back pain. CONCLUSION: Chiropractic treatment consisting of manual manipulation and physiotherapy can be an effective treatment regimen in the successful treatment of double crush syndrome. For cases of double crush syndrome, chiropractic consideration should be given.
OBJECTIVE: A comprehensive review of the literature concerning the etiology, diagnosis, and the natural history of primary nocturnal enuresis is presented. Contemporary treatment options are discussed in light of the documented annual remission rate of this disorder. DATA SOURCE: Articles reviewed were obtained by conducting a computer-aided search of papers indexed in Medline and the Index to Chiropractic Literature from 1989 to 1993. In addition, the Chiropractic Research Abstracts Collection and bibliographies from pertinent articles were manually searched. DATA SYNTHESIS: Primary nocturnal enuresis affects some 200,000 children and their families throughout Canada. Twenty percent of children wet the bed at age 5, 10% at age 10, and only about 1% at age 15. The documented natural history of the disorder reveals that for those affected, 10% to 20% exhibit spontaneous resolution per year. Contemporary treatment options center on three factors that play primary roles in the etiology of this condition: functional bladder capacity, patient conditioning and the circadian rhythm of nocturnal ADH secretion. CONCLUSIONS: The success of each therapeutic option must, in part, be attributed to the natural history of enuresis, as well as any educational or placebo aspects of treatment. Conditioning therapy utilizing the urine pad alarm may be the most reasonable initial mode of intervention. Spinal manipulative therapy has been shown to possess an efficacy comparable to the natural history.
In order to summarize the available clinical evidence for the efficacy of physiotherapy, 400 randomized clinical trials were identified from the literature. Studies were found by using bibliographic databases, citation tracking, and correspondence with researchers in the field. Focusing on disorders of the musculoskeletal system, a number of criterion based meta-analyses were performed on 180 trials in order to summarize the available evidence. For each randomized clinical trial in each meta-analysis a methodological score was calculated using a set of explicit criteria and weighting factors applied by two or three independent reviewers who were blinded as to the outcomes, the journal and the authors of the publication. In each meta-analysis the randomized clinical trials were ordered hierarchically depending on their score for methodological quality. Meta-analyses were performed for spinal manipulation, exercise therapy, traction, ultrasound, and laser therapy, and for disorders of the back, neck, shoulder and knee. In general, the methodological quality of the studies appeared to be low, and the efficacy of physiotherapy was shown to be convincing for only a few indications and treatments. On the other hand, because of the prevalence of serious methodological flaws, it cannot be concluded that physiotherapy has no effect.
Until after the workshop on the research status of Spinal Manipulative Therapy at the National Institute of Neurological and Communicating Disorders and Strokes (NINCDS) in Bethesda, Maryland, in 1975, research had been a very elusive yet critical part of chiropractic evolution. In the past, chiropractic education emphasized basic sciences for legitimacy. To increase their competitive edge, chiropractors all too frequently looked to medical research rather than conducting research of their own. A few exceptionally gifted individuals and agencies within the profession developed new paradigms, improved modalities, and clinical mastery. Very little descriptive information has been made available to assess either these individuals or their achievements. With more than half the profession having less than 10 yr of practice, it becomes necessary to kindle a reappraisal of what once was in the particular area of chiropractic research. The case of Fred Illi has been chosen to illustrate the inherent difficulties that faced anyone bold enough to try and coherent enough to be successful.
OBJECTIVE: To assess the use of the term "torque" in the chiropractic literature and to analyze its usage in chiropractic technique procedures. DATA SOURCES, STUDY SELECTION AND DATA EXTRACTION: Articles were retrieved through literature searches of several indexing services [(MEDLINE, Index to Chiropractic Literature, Chiropractic Research Archives Collection (CRAC) and Chiropractic Literature Analysis and Retrieval System (ChiroLARS)] and hand searches in the technique section of a chiropractic college library. From textbooks, key terms included: Torque, Torsion, Biomechanics, Physics, Chiropractic, Nomenclature and Manipulation. For MEDLINE: Torque, Chiropractic Methods, Manipulation-Spinal Methods, Biomechanics, Nomenclature and Chiropractic Terminology. Texts and papers that discussed the word "torque" were reviewed for their association with the thrust of a spinal adjustment. Inferences of "torque" and its application were included to represent the present-day usage of the term in chiropractic. CONCLUSIONS: We believe that the term torque is misused in chiropractic literature. This misuse has been perpetuated in chiropractic college courses, student clinic examinations and state and national board examinations. We strongly suggest that references to the term torque that are not biomechanically correct must be removed from all such sources.
OBJECTIVE: To prospectively investigate the effect of chiropractic management on clinical and anatomical outcome of disc pathomorphology in previously magnetic resonance imaging (MRI)-documented disc herniation of the cervical and lumbar spine. SETTING: Private practice. SUBJECTS: Twenty-seven patients with MRI-documented and symptomatic disc herniations of the cervical or lumbar spine. A prospective clinical case series. DESIGN: All patients were evaluated before commencement of chiropractic care by MRI scans for presence of disc herniations. Precare evaluations also included clinical examination and visual analog scores. Patients were then treated with a course of care that included traction, flexion distraction, spinal manipulative therapy, physiotherapy and rehabilitative exercises. All patients were re-evaluated by postcare follow-up MRI scans, clinical examination and visual analog scores. Percentage of disc shrinkage on repeat MRI, resolution of clinical examination findings, reduced visual analog pain scores and whether the patient returned to work were all recorded. RESULTS: Clinically, 80% of the patients studied had a good clinical outcome with postcare visual analog scores under 2 and resolution of abnormal clinical examination findings. Anatomically, after repeat MRI scans, 63% of the patients studied revealed a reduced size or completely resorbed disc herniation. There was a statistically significant association (p < .005) between the clinical and MRI follow-up results. Seventy-eight percent of the patients were able to return to work in their predisability occupations. CONCLUSION: This prospective case series suggests that chiropractic care may be a safe and helpful modality for the treatment of cervical and lumbar disc herniations. A random, controlled, clinical trial is called for to further substantiate the role of chiropractic care for the nonoperative clinical management of intervertebral disc herniation.
OBJECTIVE: To discuss the difficulties encountered in the diagnosis of concentric narrowing of the visual fields. CLINICAL FEATURES: A 13-yr-old child was referred to a chiropractic clinic after an ocular examination concerning a 6-month period of minor headaches, which culminated in a more severe attack, during which she had to lie down. Her examination was essentially normal, with the exception of the presence of constricted visual fields when measured to a small stimulus. INTERVENTION AND OUTCOME: Standard outpatient spinal adjustments were followed by recovery of vision. DISCUSSION: The recovery of constricted fields of vision with spinal manipulation has now been discussed with greater frequency in the chiropractic literature. The diagnosis of constriction of the visual fields is often the factor that may decide the further management of the patient. In this instance, constriction of the visual fields could easily have been missed, even though clinical examination of the visual fields had been done. CONCLUSION: Elements in the history and physical examination will suggest when a sensitive assessment of the visual fields may be of benefit to the patient.
OBJECTIVE: To demonstrate the effectiveness of chiropractic management for fibromyalgia patients using reported pain levels, cervical and lumbar ranges of motion, strength, flexibility, tender points, myalgic score and perceived functional ability as outcome measures. DESIGN: A. Preliminary randomized control crossover trial. B. Before and after design. PATIENTS: Twenty-one rheumatology patients (25-70 yr). CHIROPRACTIC INTERVENTIONS: Treatment consisted of 4 wk of spinal manipulation, soft tissue therapy and passive stretching at the chiropractors' discretion. CONTROL INTERVENTION: Chiropractic management withheld for 4 wk with continuation of prescribed medication. MAIN OUTCOME MEASURES: Changes in scores on the Oswestry Pain Disability Index, Neck Disability Index, Visual Analogue Scale, straight leg raise and lumbar and cervical ranges of motion were observed. RESULTS: Chiropractic management improved patients' cervical and lumbar ranges of motion, straight leg raise and reported pain levels. These changes were judged to be clinically important within the confines of our sample only. CONCLUSIONS: Further study with a sample size of 81 (for 80% power at alpha < or = .05) is recommended to determine if these findings are generalizable to the target population of fibromyalgia suffers.
BACKGROUND: Most information on chiropractors and chiropractic emanates from North America. With an increasing number of chiropractors in Europe, it is important to produce relevant documentation concerning the European practice of chiropractic. OBJECTIVES: To describe the typical Swedish chiropractic patient and the treatment he/she receives. DESIGN: Chiropractors interviewed 10 consecutive patients using a standardized questionnaire. OUTCOME VARIABLES: Age, sex, previous treatment by chiropractor, area and duration of complaint, area and type of treatment and number of return visits (truncated data). RESULTS: Of the 86 chiropractors who could take part in the study, 78% participated. They each collected information on 10 consecutive patients (n = 628, response rate 73% of target sample), altogether 1858 return visits. Most patients were aged between 25 and 64 yr, with no difference in numbers between genders. Typically, they sought care for low back pain of up to 1 month's duration, were treated with spinal manipulation and received 2-3 treatments. Swedish chiropractic patients thus seem to seek care relatively early and undergo a short-lasting treatment program. However, a larger number of treatments was given to patients with problems of longer duration; patients who had not previously consulted a chiropractor presented with more long-lasting problems. CONCLUSIONS: The findings are in line with present-day concepts that emphasize the concurrent needs to avoid both the development of chronicity and long-lasting, invasive clinical intervention. Chiropractic care seems not to be a first choice therapy for those who have not previously received chiropractic care.
BACKGROUND: Wall perimetry is a method of examination that led to the initial appreciation of the "tunnel vision information." The visual field loss that wall perimetry indicates generally defines the overall characteristics of the dysfunction associated with 'tunnel vision.' Wall perimetry is an inexpensive, yet sensitive, preliminary screening test for perception abnormality in the outermost periphery of vision. OBJECTIVE: To describe wall perimetry. The term "wall perimetry" denotes a simple preliminary method of examining the visual fields of chiropractic patients. DISCUSSION: The test is described with reference to photographs. The patient stands 1 m from the corner of a room and is instructed to look directly at the junction of the walls, with the head remaining still and gaze fixed. Standing behind the patient, the examiner projects a target of light onto the wall and moves it until it is seen by the subject. CONCLUSION: Chiropractors are encouraged to test appropriate patients by wall perimetry before spinal manipulation therapy. On the basis of existing experience, detection of patients with visual field loss is to be expected. From that point, formal examination of the visual fields using kinetic or static perimetry apparatus is recommended to further verify the "tunnel vision" discovery.
OBJECTIVE: To determine the relationship between an audible pop and symptomatic improvement with spinal manipulation in patients with low back pain (LBP). DESIGN: A prospective cohort study. SETTING: Two outpatient physical therapy clinics located in military medical centers. PARTICIPANTS: A cohort of 71 patients with nonradicular LBP referred to physical therapy. INTERVENTIONS: Participants underwent a standardized examination and standardized spinal manipulation treatment program. All patients were treated with a sacroiliac (SI) region manipulative technique and the presence or absence of an audible pop was noted. MAIN OUTCOME MEASURES: Subjects were reassessed 48 hours after the manipulation for changes in range of motion (ROM), numeric pain rating scale (PRS) scores, and modified Oswestry Disability Questionnaire (ODQ) scores. RESULTS: An audible pop occurred in 50 of the 71 subjects during the manipulative procedure. Both groups-those who had an audible pop and those who did not-improved over time in flexion ROM, PRS scores, and modified ODQ scores; however, there were no differences between groups (P>.05). Nineteen of the 71 (27%) patients improved dramatically (mean drop in modified ODQ, 67.6%). In 14 of the 19 dramatic responders, an audible pop occurred. However, the odds ratio (1.2; 95% confidence interval, 0.38-4.04) suggested that the occurrence of a manipulative pop would not improve the odds of achieving a dramatic reduction in symptoms after the manipulation. CONCLUSION: There is no relationship between an audible pop during SI region manipulation and improvement in ROM, pain, or disability in individuals with nonradicular LBP. Additionally, the occurrence of a pop did not improve the odds of a dramatic improvement with manipulation treatment.
Outcome measures for physiotherapy in a primary health care setting should be evaluated before physiotherapy becomes widely available in general practice. The aim of this study was to assess changes in outcome measures in patients with spinal problems treated with bed rest, advice and analgesia ('traditional' treatment) and with manual/manipulative physiotherapy ('active' treatment). A retrospective analysis was carried out of computerized records of patients treated in primary care with manual and manipulative physiotherapy for spinal problems and a group with a similar age/sex/diagnosis profile who were given traditional treatment. Outcome measures in the 12 months following the initial diagnosis were: referrals, recurrences, casualty attendances, X-rays and number of prescribed analgesic and non-steroidal anti-inflammatory agents (NSAIDs). In the active group, there were 231 lumbar and 154 cervical patients, and 82 and 75, respectively, in the traditional group. There was a significant decrease in the recurrence rate [odds ratio (OR) = 0.56, 95% confidence interval (CI) 0.37-0.84] and in the numbers attending casualty (OR = 0.19, 95% CI 0.04-0.76) for 'active' compared with 'traditional' patients. For patients with cervical problems, there was a significant decrease in the active group of NSAIDs prescribed (P < 0.05). Certain outcomes of spinal problems are improved by the provision of manipulative physiotherapy in general practice.
AIMS: Chiropractic manipulation is mostly used for spinal problems but, in an increasing number of cases, also for non-spinal conditions. This systematic review is aimed at critically evaluating the evidence for or against the effectiveness of this approach. METHODS: Five electronic databases were searched for all randomised clinical trials of chiropractic manipulation as a treatment of non-spinal pain. They were evaluated according to standardised criteria. RESULTS: Eight such studies were identified. They related to the following conditions: fibromyalgia, carpal tunnel syndrome, infantile colic, otitis media, dysmenorrhoea and chronic pelvic pain. Their methodological quality ranged from mostly poor to excellent. Their findings do not demonstrate that chiropractic manipulation is an effective therapy for any of these conditions. CONCLUSIONS: Only very few randomised clinical trials of chiropractic manipulation as a treatment of non-spinal conditions exist. The claim that this approach is effective for such conditions is not based on data from rigorous clinical trials.
OBJECTIVES: When the clinical efficacy of spinal manipulative treatment for spinal pain has been assessed, high-velocity low-amplitude thrust (HVLAT) manipulation and mobilization have been regarded as clinical interventions giving identical and equivalent biologic effects. The objective of this review is to critically discuss previous theories and research of spinal HVLAT manipulation, highlighting reported neurophysiologic effects that seem to be uniquely associated with cavitation of synovial fluid. DATA SOURCE: The biomedical literature was searched for research and reviews on spinal manipulation. MEDLINE and EMBASE databases were used to help find relevant articles. STUDY SELECTION: All articles relevant to the objectives were selected. DATA EXTRACTION: All available data were used. DATA SYNTHESIS: The main hypotheses for lesions that respond to HVLAT manipulation were critically discussed: (1) release of entrapped synovial folds or plica, (2) relaxation of hypertonic muscle by sudden stretching, (3) disruption of articular or periarticular adhesions, and (4) unbuckling of motion segments that have undergone disproportionate displacements. RESULTS: There appear to be 2 separate modes of action from zygapophyseal HVLAT manipulation. Intra-articular "mechanical" effects of zygapophyseal HVLAT manipulation seem to be absolutely separate from and irrelevant to the occurrence of reported "neurophysiologic" effects. Cavitation should not be an absolute requirement for the mechanical effects to occur but may be a reliable indicator for successful joint gapping. CONCLUSIONS: It is hoped that identification of these unique neurophysiologic effects will provide enough theoretical reason for HVLAT manipulation and mobilization to be assessed independently as individual clinical interventions.