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PubMed2005

A descriptive study of the usage of spinal manipulative therapy techniques within a randomized clinical trial in acute low back pain.

The majority of randomized clinical trials (RCTs) of spinal manipulative therapy have not adequately defined the terms 'mobilization' and 'manipulation', nor distinguished between these terms in reporting the trial interventions. The purpose of this study was to describe the spinal manipulative therapy techniques utilized within a RCT of manipulative therapy (MT; n = 80), interferential therapy (IFT; n = 80), and a combination of both (CT; n = 80) for people with acute low back pain (LBP). Spinal manipulative therapy was defined as any 'mobilization' (low velocity manual force without a thrust) or 'manipulation' (high velocity thrust) techniques of the spine described by Maitland and Cyriax. The 16 physiotherapists, all members of the Society of Orthopaedic Medicine, utilized three spinal manipulative therapy patterns in the RCT: Maitland Mobilization (40.4%, n = 59), Maitland Mobilization/Cyriax Manipulation (40.4%, n = 59) and Cyriax Manipulation (19.1%, n = 28). There was a significant difference between the MT and CT groups in their usage of spinal manipulative therapy techniques (chi2 = 9.178; df = 2; P = 0.01); subjects randomized to the CT group received three times more Cyriax Manipulation (29.2%, n = 21/72) than those randomized to the MT group (9.5%, n = 7/74; df = 1; P = 0.003). The use of mobilization techniques within the trial was comparable with their usage by the general population of physiotherapists in Britain and Ireland for LBP management. However, the usage of manipulation techniques was considerably higher than reported in physiotherapy surveys and may reflect the postgraduate training of trial therapists.

Acute Disease↗
PubMedDate not supplied

Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment.

OBJECTIVE: To provide a qualitative systematic review of the risk of spinal manipulation in the treatment of lumbar disk herniations (LDH) and to estimate the risk of spinal manipulation causing a severe adverse reaction in a patient presenting with LDH. DATA SOURCES: Relevant case reports, review articles, surveys, and investigations regarding treatment of lumbar disk herniations with spinal manipulation and adverse effects and associated risks were found with a search of the literature. DATA SYNTHESIS: Prospective/retrospective studies and review papers were graded according to quality, and results and conclusions were tabulated. From the data published, an estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or cauda equina syndrome (CES) in patients presenting with LDH was calculated. This was compared with estimates of the safety of nonsteroidal anti-inflammatory drugs (NSAIDs) and surgery in the treatment of LDH. RESULTS: An estimate of the risk of spinal manipulation causing a clinically worsened disk herniation or CES in a patient presenting with LDH is calculated from published data to be less than 1 in 3.7 million. CONCLUSION: The apparent safety of spinal manipulation, especially when compared with other "medically accepted" treatments for LDH, should stimulate its use in the conservative treatment plan of LDH.

Cauda Equina↗
PubMed2005

Spinal manipulative therapy in the management of cervicogenic headache.

Patients suffering from cervicogenic headache (CeH) are commonly treated with spinal manipulative therapy. We have analyzed the quality and the outcomes of published, randomized, controlled trials assessing the effectiveness of spinal manipulation in CeH. Among 121 relevant articles, only two met all the inclusion criteria. Methodological quality scores were 8/10 and 7/10 points. Only one of the trials made use of a headache diary. Both the trials reported positive (+) results on headache intensity, headache duration, and medication intake, so that spinal manipulative therapy obtained strong evidence of effectiveness (level 1) with regard to these outcomes. Conversely, spinal manipulation obtained no more than limited evidence (level 3) in reducing headache frequency, as it was analyzed only in one study with positive (+) results. A greater number of well-designed, randomized, controlled trials are required to confirm or refute the effectiveness of spinal manipulation in the management of CeH.

Female↗
PubMed2002

Risks associated with spinal manipulation.

The aim of this systematic review was to summarize the evidence about the risks of spinal manipulation. Articles were located through searching three electronic databases (MEDLINE, EMBASE, Cochrane Library), contacting experts (n =9), scanning reference lists of relevant articles, and searching departmental files. Reports in any language containing data relating to risks associated with spinal manipulation were included, irrespective of the profession of the therapist. Where available, systematic reviews were used as the basis of this article. All papers were evaluated independently by the authors. Data from prospective studies suggest that minor, transient adverse events occur in approximately half of all patients receiving spinal manipulation. The most common serious adverse events are vertebrobasilar accidents, disk herniation, and cauda equina syndrome. Estimates of the incidence of serious complications range from 1 per 2 million manipulations to 1 per 400,000. Given the popularity of spinal manipulation, its safety requires rigorous investigation.

Cerebrovascular Disorders↗
PubMedDate not supplied

The treatment of presumptive optic nerve ischemia by spinal manipulation.

OBJECTIVE: To discuss a case of presumptive optic nerve ischemia successfully treated by spinal manipulative therapy. CLINICAL FEATURES: A 62-yr-old male patient suffered from a 1-wk history of monocular visual defect in association with headaches and neck strain. Ocular examination revealed no pathology in the optic nerve head or retina that could explain the abnormality of vision. Based on physical signs, a presumptive diagnosis of optic nerve ischemia was made. INTERVENTION AND OUTCOME: Vision improved dramatically in the week of spinal manipulation therapy, as measured by serial computerized static perimetry. CONCLUSION: This case study records improvement in optic nerve function when measured before and after spinal manipulation using computerized static perimetry. It contends that spinal manipulation can affect the function of the optic nerve in some patients, presumably by increasing vascular perfusion. I hypothesize that derangement of the cervical spine produces microvascular spasm in the cerebral vasculature, including that of the eye.

Chiropractic↗
PubMed2004

A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study.

BACKGROUND: Conflicting evidence exists about the effectiveness of spinal manipulation. OBJECTIVE: To validate a manipulation clinical prediction rule. DESIGN: Multicenter randomized, controlled trial. SETTING: Physical therapy clinics. PATIENTS: 131 consecutive patients with low back pain, 18 to 60 years of age, who were referred to physical therapy. INTERVENTION: Patients were randomly assigned to receive manipulation plus exercise or exercise alone by a physical therapist for 4 weeks. MEASUREMENTS: Patients were examined according to the clinical prediction rule criteria (symptom duration, symptom location, fear-avoidance beliefs, lumbar mobility, and hip rotation range of motion). Disability and pain at 1 and 4 weeks and 6 months were assessed. RESULTS: Outcome from spinal manipulation depends on a patient's status on the prediction rule. Treatment effects are greatest for the subgroup of patients who were positive on the rule (at least 4 of 5 criteria met); health care utilization among this subgroup was decreased at 6 months. Compared with patients who were negative on the rule and received exercise, the odds of a successful outcome among patients who were positive on the rule and received manipulation were 60.8 (95% CI, 5.2 to 704.7). The odds were 2.4 (CI, 0.83 to 6.9) among patients who were negative on the rule and received manipulation and 1.0 (CI, 0.28 to 3.6) among patients who were positive on the rule and received exercise. A patient who was positive on the rule and received manipulation has a 92% chance of a successful outcome, with an associated number needed to treat for benefit at 4 weeks of 1.9 (CI, 1.4 to 3.5). LIMITATIONS: The response rate for the 6-month follow-up resulted in inadequate power to detect statistically significant differences for some comparisons. CONCLUSIONS: The spinal manipulation clinical prediction rule can be used to improve decision making for patients with low back pain.

Adolescent↗
PubMed2001

Spinal manipulative thrust technique using combined movement theory.

Spinal Manipulative Thrust Technique (SMTT) is employed by all manual therapy professions using different rationales for the selection of technique. A method of rationally selecting particular SMTT's is described with a view to integrating SMTT into the practice of manual therapists familiar with Combined Movement Theory (CMT), a corollary of the Maitland Concept. The similarities of CMT and SMTT methodologies are described and two examples of how CMT can be utilized for SMTT selection in the cervical spine are detailed.

Contraindications↗
PubMed2002

The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials.

To carry out a systematic review of the literature examining the effectiveness of spinal manipulation for the treatment of headache disorders, computerized literature searches were carried out in Medline, Embase, Amed and CISCOM. Studies were included only if they were randomized trials of (any type of) spinal manipulation for (any type of) headache in human patients in which spinal manipulation was compared either to no treatment, usual medical care, a 'sham' intervention, or to some other active treatment. Two investigators independently extracted data on study design, sample size and characteristics, type of intervention, type of control/comparison, direction and nature of the outcome(s). Methodological quality of the trials was also assessed using the Jadad scale. Eight trials were identified that met our inclusion criteria. Three examined tension-type headaches, three migraine, one 'cervicogenic' headache, and one 'spondylogenic' chronic headache. In two studies, patients receiving spinal manipulation showed comparable improvements in migraine and tension headaches compared to drug treatment. In the 4 studies employing some 'sham' interventions (e.g. laser light therapy), results were less conclusive with 2 studies showing a benefit for manipulation and 2 studies failing to find such an effect. Considerable methodological limitations were observed in most trials, the principal one being inadequate control for nonspecific (placebo) effects. Despite claims that spinal manipulation is an effective treatment for headache, the data available to date do not support such definitive conclusions. It is unclear to what extent the observed treatment effects can be explained by manipulation or by nonspecific factors (e.g. of personal attention, patient expectation). Whether manipulation produces any long-term changes in these conditions is also uncertain. Future studies should address these two crucial questions and overcome the methodological limitations of previous trials.

Headache Disorders↗
PubMedDate not supplied

Does 'normal' vision improve with spinal manipulation?

OBJECTIVE: To discuss a patient whose spinal abnormalities may have caused subliminal visual field loss. CLINICAL FEATURES: A 22-yr-old man suffered from a painful neck. His vision was in the normal range, as measured by computerized static perimetry. INTERVENTION AND OUTCOME: To define a guideline for a proposed investigation into visual field changes with spinal adjustment, his visual fields were tested before and after a normal office spinal manipulation. After this procedure, there was a measurable rise in the visual sensitivity of both eyes. CONCLUSION: The use of computerized static perimetry changes to measure the cerebral effects of spinal manipulation is recommended for future chiropractic research.

Adult↗
PubMed1997

Frequency and characteristics of side effects of spinal manipulative therapy.

STUDY DESIGN: A prospective clinic-based survey. OBJECTIVES: To study the type, frequency, and characteristics of unpleasant side effects after spinal manipulative therapy. SUMMARY OF BACKGROUND DATA: Spinal manipulative therapy is a commonly used treatment, but there is little knowledge of its side effects. METHODS: Information regarding unpleasant reactions after spinal manipulative therapy was collected after 4712 treatments on 1058 new patients by 102 Norwegian chiropractors (response rate, 70%) through structured interviews. RESULTS: At least one reaction was reported by 55% of the patients some time during the course of a maximum of six treatments. Of the reported reactions, the most common were local discomfort (53%), headache (12%), tiredness (11%), or radiating discomfort (10%). Reactions were mild or moderate in 85% of patients. Sixty-four percent of reactions appeared within 4 hours of treatment, and 74% had disappeared within 24 hours. Uncommon reactions were dizziness, nausea, hot skin, or "other" complaints, each accounting for 5% or less of reactions. It was unusual that symptoms commenced later than on the day of or the day after treatment, were of long duration (not gone at the latest on the day after onset), described as severe, or that they resulted in reduced activities of daily living. There were no reports of serious complications in this study. CONCLUSIONS: Profiles now are described of common and uncommon reactions to spinal manipulative therapy and their latency, duration, and severity.

Activities of Daily Living↗
PubMedDate not supplied

Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation.

OBJECTIVE: To compare needle acupuncture, medication (tenoxicam with ranitidine), and spinal manipulation for managing chronic (>13 weeks duration) spinal pain syndromes. DESIGN: Prospective, randomized, independently assessed preintervention and postintervention clinical pilot trial. SETTING: Specialized spinal pain syndrome out-patient unit at Townsville General Hospital, Queensland, Australia. SUBJECTS: Seventy-seven patients (without contraindication to manipulation or medication) were recruited. INTERVENTIONS: One of three separate, clearly defined intervention protocols: needle acupuncture, nonsteroidal anti-inflammatory medication, or chiropractic spinal manipulation. MAIN OUTCOME MEASURES: Main outcome measures were changes (4 weeks vs. initial visit) in the scores of the (1) Oswestry Back Pain Disability Index, (2) Neck Disability Index, and (3) three visual analogue scales of local pain intensity. RESULTS: Randomization was successful. After a median intervention period of 30 days, spinal manipulation was the only intervention that achieved statistically significant improvements (all expressed as percentages of the original scores) with (1) a reduction of 30.7% on the Oswestry scale, (2) an improvement of 25% on the neck disability index, and (3) reductions on the visual analogue scale of 50% for low back pain, 46% for upper back pain, and 33% for neck pain (all P<.001). Neither of the other interventions showed any significant improvement on any of the outcome measures. CONCLUSIONS: The consistency of the results provides, in spite of several discussed shortcomings of this pilot study, evidence that in patients with chronic spinal pain syndromes spinal manipulation, if not contraindicated, results in greater improvement than acupuncture and medicine.

Acupuncture Therapy↗
PubMedDate not supplied

Effects of a mechanical pain stimulus on erector spinae activity before and after a spinal manipulation in patients with back pain: a preliminary investigation.

BACKGROUND: Several recent studies in animal models of spinal pain have shown changes in sensory processing and in reflex muscular responses. One group of researchers reported consistent electromyographic responses in the paraspinal muscles of healthy men after spinal manipulation, and they speculated that such responses may underlie some of the observed clinical effects of spinal manipulation (namely, reduction in pain and muscular hypertonicity). OBJECTIVES: To determine whether a painful mechanical stimulus applied above a spinous process influences paraspinal electromyographic amplitude and whether this response is modulated by a spinal manipulation. STUDY DESIGN: Analytic cohort with a convenience sample in a research clinic. METHODS: Seventeen subjects with back pain (9 men and 8 women) were recruited. Electromyographic signals were recorded from the paraspinal musculature during the following procedures before and after manipulation: quiet stance and prone during the application of a mechanical pain stimulus. A 2-way repeated-measures analysis of variance was used to compare the effect of the force application on electromyographic amplitude. A second 2-way repeated-measures analysis of variance investigated whether the muscular response to a painful stimulus at either segment was influenced by the manipulative procedure. RESULTS: A statistically significant increase in bilateral electromyographic activity was observed at the painful motion segment; however, no such statistical increase occurred at the segment that was not painful. It appears that manipulation results in a decrease in bilateral local electromyographic activity in the painful motion segment during the application of the mechanical stimulus; however, a statistically significant decrease was not found in the control segment. It was also found that while the subjects were quietly standing, the left erector spinae at a painful segment was the only muscle group to show significant differences before and after manipulation. CONCLUSION: This study suggests that motion segments identified as a problem in subjects with chronic low back pain have an exaggerated local muscular response to a painful stimulus compared with that observed in problem segments. In addition, spinal manipulation appears to attenuate the electromyographic response to a painful stimulus.

Adult↗
PubMedDate not supplied

A meta-analysis of clinical trials of spinal manipulation.

OBJECTIVE: To assess the efficacy of spinal manipulative therapy (SMT) in the treatment of back pain using meta-analytical techniques. DATA SOURCES: The literature was systematically searched for all studies of SMT through June 1989. The Index Medicus from 1980 was expanded by citation tracking. The Chiropractic Research Archives Collection was utilized as a regularly updated bibliographic source for the location of research publications. A hand search of professional chiropractic journals was also undertaken. STUDY SELECTION: Studies in English with concurrent controls treated by methods other than SMT, including sham, produced 23 randomized controlled clinical trials of the effectiveness of spinal manipulation. Because a single trial might include more than one comparison of treatments, these trials produced a total of 34 mutually exclusive, discrete samples. DATA EXTRACTION: Data were extracted via a standardized coding document by one author and verified by two of the others. Data were independently extracted from a subset of the studies by a blinded research assistant to ensure that coding methods produced acceptable consistency. DATA SYNTHESIS: Effect sizes (Cohen's D index) were calculated for nine outcome variables at eight time points following the initiation of treatment. Thirty-eight of 44 effect sizes indicated that SMT was better than the comparison treatment. It was also found that meta-analysis was an imperfect instrument for the kind of trials that were pooled in this study because the research protocols were highly diverse. Furthermore, because the nature of SMT does not permit an easy use of placebos, true no-treatment control groups were rare. Most studies compared SMT to an alternative treatment. This probably obscured the effectiveness of SMT since the comparison treatments were presumably also effective. CONCLUSIONS: SMT proved to be consistently more effective in the treatment of low back pain than were any of the array of comparison treatments. The analysis provided some suggestion that manipulation, as such, is more effective than mobilization, as such. For the future, it is suggested that researchers strive for more consistent measures in terms of explicit descriptions of the nature of SMT, the times of post-treatment assessments and the nature of outcome measures. Only then can meta-analysis fulfill its potential in this clinical area.

Back Pain↗
PubMedDate not supplied

Vertebral artery flow and spinal manipulation: a randomized, controlled and observer-blinded study.

BACKGROUND: Several studies have been published on the effect of cervical rotation alone upon blood flow in the vertebral arteries. However, we have not found articles addressing the question of how spinal manipulative therapy per se affects the vertebral artery flow. OBJECTIVE: The aim of the present study was to investigate whether any changes occur in peak flow velocity in the vertebral artery after spinal manipulative therapy as measured using the latest Doppler ultrasound technology. DESIGN AND SETTING: A randomized, controlled and observer-blinded study at a university hospital vascular laboratory. PARTICIPANTS: Twenty university students with a "biomechanical dysfunction" in the cervical spine. RESULTS: We observed no change in peak flow velocity immediately after spinal manipulative therapy and found no correlation between peak flow velocity and systolic blood pressure. CONCLUSION: To the best of our knowledge, this is the first study comparing flow velocity in the vertebral artery before and after spinal manipulative therapy. We found no significant changes in otherwise healthy subjects with a biomechanical dysfunction of the cervical spine. Major changes in peak flow velocity might in theory explain the pathophysiology of cerebrovascular accidents after spinal manipulative therapy. However, in uncomplicated spinal manipulative therapy, this potential risk factor was not prevalent.

Adult↗
PubMed2004

Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: a preliminary study.

OBJECTIVE: To document the potential role of maintenance chiropractic spinal manipulation to reduce overall pain and disability levels associated with chronic low-back conditions after an initial phase of intensive chiropractic treatments. METHODS: Thirty patients with chronic nonspecific low-back pain were separated into 2 groups. The first group received 12 treatments in an intensive 1-month period but received no treatment in a subsequent 9-month period. For this group, a 4-week period preceding the initial phase of treatment was used as a control period to examine the sole effect of time on pain and disability levels. The second group received 12 treatments in an intensive 1-month period and also received maintenance spinal manipulation every 3 weeks for a 9-month follow-up period. Pain and disability levels were evaluated with a visual analog scale and a modified Oswestry questionnaire, respectively. RESULTS: The 1-month control period did not modify the pain and disability levels. For both groups, the pain and disability levels decreased after the intensive phase of treatments. Both groups maintained their pain scores at levels similar to the postintensive treatments throughout the follow-up period. For the disability scores, however, only the group that was given spinal manipulations during the follow-up period maintained their postintensive treatment scores. The disability scores of the other group went back to their pretreatment levels. CONCLUSIONS: Intensive spinal manipulation is effective for the treatment of chronic low back pain. This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective postintensive treatment disability levels. Future studies, however, are needed to confirm the finding in a larger group of patients with chronic low-back pain.

Adult↗
PubMed1996

Monocular scotomata and spinal manipulation: the step phenomenon.

OBJECTIVE: To discuss a case history wherein microvascular spasm of the optic nerve was treated by spinal manipulation. CLINICAL FEATURES: A 62-yr-old man developed a scotoma in the vision of the right eye during chiropractic treatment. INTERVENTION AND OUTCOME: Spinal manipulation treatment was continued with total resolution of the scotoma. The rate of recovery of the scotoma was mapped using computerized static perimetry. These measurements showed that significant recovery occurred at each spinal manipulation treatment, producing a stepped graph. CONCLUSION: The use of computerized static perimetry to measure the cerebral effects of spinal manipulation has increased knowledge of how chiropractic works. The further recovery of vision with each spinal adjustment suggests that more treatment may be better than less treatment in the chiropractic management of such cases.

Chiropractic↗
PubMed2002

MRI confirmed cervical cord injury caused by spinal manipulation in a Chinese patient.

OBJECTIVE: To report a rare case of cervical cord injury caused by spinal manipulation in a Chinese patient. METHOD: A 46-year-old man suffered from acute tetraplegia immediately after spinal manipulation by a bonesetter. There was nothing abnormal in the plain X-ray but Magnetic Resonance Imaging (MRI) of his cervical spine demonstrated cervical cord oedema at the level of C1/2. RESULT: The patient was treated with high doses of methylprednisolone. Coupled with intensive rehabilitation, the patient made a nearly complete recovery 6 months after injury. Repeated MRI demonstrated syrinx formation at the previous location of cervical cord oedema. CONCLUSION: Spinal manipulation may cause cervical cord injury. MRI is useful in the documentation of this injury and exclusion of other pathology.

Cervical Vertebrae↗