By Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC
Director of Research and Education for the Foundation for Chiropractic Education and Research (FCER) until its demise (1992-2007), and the current Director of Research at International College of Applied Kinesiology (USA).

In the space of just 115 years from its inception, chiropractic has emerged as the third largest healthcare profession in the United States offering diagnostic as well as therapeutic services to patients. It has reached this lofty height driven by research which has made particularly dramatic strides over the past 30 years, supported by a budget which represents merely an infinitesimal fraction of that applied to medical and pharmaceutical research.

Like all health professions, chiropractic regularly tests the effectiveness, safety, and costs of its approaching health care. Studies continue to show that chiropractors offer the public a viable alternative to invasive healthcare (drugs, surgery) especially in the treatment of musculoskeletal problems such as back, neck, and headache pain. But chiropractic treatments are likewise effective in the treatment of non-musculoskeletal health issues, including infantile colic, enuresis, asthma, dysmenorrheal, otitis media, hypertension, and heart rate variability. And few medical professions outside of chiropractic can offer such healthcare solutions with equal safety and cost records.

So what is it that one means by chiropractic research? The research related to the practice of chiropractic, to be reviewed in this chapter, has been presented in multiple dimensions, including:

1.   Published clinical articles;
2.   Literature reviews;
3.   Surveys and public opinion research;
4.   Analyses of insurance claims [actuarial research];
5.   Guidelines

Thanks to Dynamic Chiropractic for access to these Key Findings from the study

• “There was a clear difference between the treatment groups: the subjects [receiving] spinal manipulation showed a faster and quantitatively more distinct reduction in the RMS” (compared to subjects receiving diclofenac therapy).

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• “Subjects [also] noticed a faster and quantitatively more distinct reduction in [their] subjective estimation of pain after manipulation. … A similar observation was made when comparing the somatic part of the SF-12 inventory … indicating that the subjects experienced better quality of life after the spinal manipulation compared to diclofenac.”
  

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• “The rescue medication was calculated both for the mean cumulative dose (numbers of 500 mg paracetamol tablets) and for the number of days on which rescue medication was taken. … In the diclofenac arm, the patients on average took almost 3 times as many tablets and the number of days [taking the tablets] was almost twice as high” compared to patients in the manipulation arm. While the authors note that these results were not significant due to large between-individual variations (meaning a few patients could have taken many tablets, throwing off the overall totals), it still suggests that value of spinal manipulation vs. drug therapy (because even if both patient groups had taken the same amount of rescue medication for the same number of days, it wouldn’t discount the fact that patients in the manipulation group showed significant improvement on outcome variables compared to patients in the diclofenac group).

BACKGROUND:   Spinal manipulative therapy (SMT) is frequently used by health professionals to manage spinal pain. With many treatments having comparable outcomes to SMT, determining the cost-effectiveness of these treatments has been identified as a high research priority.

OBJECTIVE:   To investigate the cost-effectiveness of SMT compared to other treatment options for people with spinal pain of any duration.

METHODS:   We searched eight clinical and economic databases and the reference lists of relevant systematic reviews. Full economic evaluations conducted alongside randomised controlled trials with at least one SMT arm were eligible for inclusion. Two authors independently screened search results, extracted data and assessed risk of bias using the CHEC-list.

RESULTS:   Six cost-effectiveness and cost-utility analysis were included. All included studies had a low risk of bias scoring ≥16/19 on the CHEC-List. SMT was found to be a cost-effective treatment to manage neck and back pain when used alone or in combination with other techniques compared to GP care, exercise and physiotherapy.

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Cost-Effectiveness of Chiropractic Page

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This is Chapter 4 from RC’s best-selling book:

“Basic Principles of Chiropractic Neuroscience”

The common causes of pain and paresthesia are:

(1) obvious direct trauma or injury;

(2) reflex origins in musculoskeletal lesions, which deep pressure often exaggerates, such as trigger areas;

(3) peripheral nerve injury (eg, causalgia), which results in an intense burning superficial pain;

(4) the presence of nerve inflammations and degeneration of the peripheral or CNS, which frequently cause other changes indicative of such lesions;

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Our thanks to ACAPress for access to these materials!

Texas Chiropractic College, Pasadena, Texas, United States of America.

Purpose   1) To systematically collect and synthesize available reports of CAD that have been associated with cSMT in the literature and
2) assess the quality of these reports.

Methods   A systematic review of the literature was conducted using several databases. All clinical study designs involving CADs associated with cSMT were eligible for inclusion. Included studies were screened by two independent reviewers for the presence/absence of 11 factors considered to be important in understanding the relation between CAD and cSMT.

Results   Overall, 43 articles reported 901 cases of CAD and 707 incidents of stroke reported to be associated with cSMT. The most common type of stroke reported was ischemic stroke (92%). Time-to-onset of symptoms was reported most frequently (95%). No single case included all 11 factors.

Conclusions   This study has demonstrated that the literature infrequently reports useful data toward understanding the association between cSMT, CADs and stroke. Improving the quality, completeness, and consistency of reporting adverse events may improve our understanding of this important relation.

Copyright: © 2013 Wynd et al.   This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding:   Greg Kawchuk receives salary support from the Canada Research Chairs program. Sunita Vohra receives salary support from Alberta Innovates-Health Solutions. Training support for Shari Wynd was provided by the Alberta Canadian Institutes of Health Research (CIHR) Training Program in Bone and Joint Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests:   The authors have declared that no competing interests exist.

In the area of harms reporting, one topic that has received significant attention is cervical spinal manipulation therapy (cSMT), an intervention most often administered by chiropractors [1, 2] to treat musculoskeletal complaints of the head and neck [3] including headaches [4]. If harms are associated with cSMT, they most commonly involve additional head and neck pain [2]. While these adverse events tend to be self-limiting [2], more serious adverse events have been reported such as neurovascular sequelae and stroke. More specifically, injuries such as cervical artery dissection (CAD), whether vertebral, internal carotid, or vertebrobasilar, have been reported to be associated with cSMT [5-7]. Although this subset of adverse events appears to occur infrequently [1, 8, 9], understanding the relation between CADs, stroke and cSMT is important given the medical [7], societal [1], economic [9], and legal [8] implications of any event leading to cerebrovascular compromise.

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Introduction:

The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain. [1-3] Their recommendations were based on a combination of consideration of the current evidence and their clinical judgment. In addition, another consensus document related to care rendered by doctors of chiropractic for the purpose of health promotion, disease prevention, and wellness, developed through a project funded by the NCMIC Foundation, was also referenced to clarify terminology used in the algorithms. [4] (See Table 1.)

Chiropractic Physician, Chiropractic, Acupuncture and Yoga Center, Buffalo Grove, IL.

OBJECTIVE:   The purpose of this case study is to describe the treatment using acupuncture and spinal manipulation for a patient with a chronic tension-type headache and episodic migraines.

CLINICAL FEATURES:   A 32-year-old woman presented with headaches of 5 months’ duration. She had a history of episodic migraine that began in her teens and had been controlled with medication. She had stopped taking the prescription medications because of gastrointestinal symptoms. A neurologist diagnosed her with mixed headaches, some migrainous and some tension type. Her headaches were chronic, were daily, and fit the International Classification of Headache Disorders criteria of a chronic tension-type headache superimposed with migraine.

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For those who may have forgotten, or for those who never knew, organized medicine spent decades and tens of millions of dollars trying to discredit and destroy chiropractic. Today, the vestiges of that same oppression is still found on fringe web sites that ignore the body of peer-reviewed research supporting chiropractic care.

The Wilk anti-trust case against the AMA and 20 other named medical groups revealed that the AMA Plan was to:

• Undermine Chiropractic schools

• Undercut insurance programs for Chiropractic patients

• Conceal evidence of the effectiveness of Chiropractic care

• Subvert government inquires into the effectiveness of Chiropractic, and

• Promote other activities that would control the monopoly that the AMA had on health care

• They even threatened their own ranks: any MD who taught in our schools, or performed research with chiropractors, or accepted a referral from, or made a referral to a chiropractor, would lose their hospital privileges, leaving them unable to treat patients.

while, all along, they knew that:

There also was some evidence before the Committee that chiropractic was effective – more effective than the medical profession in treating certain kinds of problems such as workmen’s back injuries. The Committee on Quackery was also aware that some medical physicians believed chiropractic to be effective and that chiropractors were better trained to deal with musculoskeletal problems than most medical physicians.
(Opinion pp. 7)

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BACKGROUND:   Health care costs associated with use of complementary and alternative medicine (CAM) by patients with spine problems have not been studied in a national sample.

OBJECTIVES:   To estimate the total and spine-specific medical expenditures among CAM and non-CAM users with spine problems.

RESEARCH DESIGN:   Analysis of the 2002-2008 Medical Expenditure Panel Survey.

SUBJECTS:   Adults (above 17 y) with self-reported neck and back problems who did or did not use CAM services.

MEASURES:   Survey-weighted generalized linear regression and propensity matching to examine expenditure differences between CAM users and non-CAM users while controlling for patient, socioeconomic, and health characteristics.

RESULTS:   A total of 12,036 respondents with spine problems were included, including 4306 (35.8%) CAM users (40.8% in weighted sample). CAM users had significantly better self-reported health, education, and comorbidity compared with non-CAM users. Adjusted annual medical costs among CAM users was $424 lower (95% confidence interval: $240, $609; P<0.001) for spine-related costs, and $796 lower (95% confidence interval: $121, $1470; P = 0.021) for total health care cost than among non-CAM users. Average expenditure for CAM users, based on propensity matching, was $526 lower for spine-specific costs (P<0.001) and $298 lower for total health costs (P = 0.403). Expenditure differences were primarily due to lower inpatient expenditures among CAM users.

CONCLUSIONS:   CAM users did not add to the overall medical spending in a nationally representative sample with neck and back problems. As the causal associations remain unclear in these cross-sectional data, future research exploring these cost differences might benefit from research designs that minimize confounding.

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Cost-Effectiveness of Chiropractic Page and our

Chronic Neck Pain and Chiropractic Page

Background   The symptom ‘dizziness’ is common in patients with chronic whiplash related disorders. However, little is known about dizziness in neck pain patients who have not suffered whiplash. Therefore, the purposes of this study are to compare baseline factors and clinical outcomes of neck pain patients with and without dizziness undergoing chiropractic treatment and to compare outcomes based on gender.

Methods   This prospective cohort study compares adult neck pain patients with dizziness (n = 177) to neck pain patients without dizziness (n = 228) who presented for chiropractic treatment, (no chiropractic or manual therapy in the previous 3 months). Patients completed the numerical pain rating scale (NRS) and Bournemouth questionnaire (BQN) at baseline. At 1, 3 and 6 months after start of treatment the NRS and BQN were completed along with the Patient Global Impression of Change (PGIC) scale. Demographic information was also collected. Improvement at each follow-up data collection point was categorized using the PGIC as ‘improved’ or ‘not improved’. Differences between the two groups for NRS and BQN subscale and total scores were calculated using the unpaired Student’s t-test. Gender differences between the patients with dizziness were also calculated using the unpaired t-test.

Results   Females accounted for 75% of patients with dizziness. The majority of patients with and without dizziness reported clinically relevant improvement at 1, 3 and 6 months with 80% of patients with dizziness and 78% of patients without dizziness being improved at 6 months. Patients with dizziness reported significantly higher baseline NRS and BQN scores, but at 6 months there were no significant differences between patients with and without dizziness for any of the outcome measures. Females with dizziness reported higher levels of depression compared to males at 1, 3 and 6 months (p = 0.007, 0.005, 0.022).

Conclusions   Neck pain patients with dizziness reported significantly higher pain and disability scores at baseline compared to patients without dizziness. A high proportion of patients in both groups reported clinically relevant improvement on the PGIC scale. At 6 months after start of chiropractic treatment there were no differences in any outcome measures between the two groups.

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Vertigo and Chiropractic Page and our:

Whiplash and Chiropractic Page

Introduction

The complaint of neck pain is second only to low back pain in terms of common musculoskeletal problems in society today with a lifetime prevalence of 26-71% and a yearly prevalence of 30-50%. [1, 2] Most concerning is that many patients, particularly those in the working population or who have suffered whiplash trauma, will become chronic and continue to report pain and disability for greater than 6-months. [3-6] In terms of symptoms, dizziness and unsteadiness are the most frequent complaints following pain for chronic whiplash sufferers with up to 70% of patients reporting these problems. [7, 8] Apart from whiplash trauma, little is known about dizziness in the chronic neck pain population and much remains unknown about the etiology of chronic neck pain in general. [9]

Gender differences in reporting pain intensity is currently a topic of debate. Recent research suggests that females report more pain because they feel pain more intensely than males over a variety of musculoskeletal complaints. [10, 11] Furthermore, LeResche suggests that these differences may not be taken into account by health care providers, leading to less than optimal pain management for females. [12] However gender differences in neck pain patients with or without dizziness have not been described with respect to clinical outcomes over time.

Therefore, the purposes of this study on neck pain patients receiving chiropractic care are twofold:

1. to compare baseline variables and the clinical outcomes of neck pain patients with and without dizziness in terms of clinically relevant ‘improvement’, pain, disability, and psychosocial variables over a 6-month period;
2. to evaluate gender differences for neck pain patients with dizziness in terms of clinically relevant ‘improvement’, pain, disability, and psychosocial variables in a longitudinal study.

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This is Chapter 2 from RC’s best-selling book:

“Clinical Biomechanics:
Musculoskeletal Actions and Reactions”

Second Edition ~ Wiliams & Wilkins

Chapter 2:   Mechanical Concepts and Terms

Biomechanics is constantly concerned with a quantity of matter (whatever occupies space, a mass) to which a force has been applied. Such a mass is often the body as a whole, a part of the body such as a limb or segment, or an object such as a load to be lifted or an exercise weight. By the same token, the word “body” refers to any mass; ie, the human body, a body part, or any object.

This review, by scientists at the Department of Orthopaedics at the Geisel School of Medicine, clearly suggests that the first doctor you choose to see will have a profound effect on whether you end up having spinal surgery.

Just look at these stats:

42.7% of workers who first saw a surgeon ended in surgery, as opposed to only

1.5% of those who (first) saw a chiropractor.

Ashbridge’s Health Centre, 1522 Queen St. East, Toronto, ON M4L 1E3. dremilyhowell@hotmail.com

OBJECTIVE:   This case study reported the conservative management of a patient presenting with left sided low back and leg pain diagnosed as a left sided L5-S1 disc prolapse/herniation.

CLINICAL FEATURES:   A 31-year-old male recreational worker presented with left sided low back and leg pain for the previous 3-4 months that was exacerbated by prolonged sitting.

INTERVENTION AND OUTCOME:   The plan of management included interferential current, soft tissue trigger point and myofascial therapy, lateral recumbent manual low velocity, low amplitude traction mobilizations and pelvic blocking as necessary. Home care included heat, icing, neural mobilizations, repeated extension exercises, stretching, core muscle strengthening, as well as the avoidance of prolonged sitting and using a low back support in his work chair. The patient responded well after the first visit and his leg and back pain were almost completely resolved by the third visit.

SUMMARY:   Conservative chiropractic care appears to reduce pain and improve mobility in this case of a L5-S1 disc herniation. Active rehabilitative treatment strategies are recommended before surgical referral.

Recent Studies Have Also Shown That:

Back Surgery Fails 74% of the Time

School of Health Sciences, Faculty of Medicine, Kyoto University, Kyoto, Japan

Background:   As standards for randomised, controlled, clinical trials in medicine evolve, there is debate about whether the RCT model of investigation is appropriate for chiropractic and other forms of so-called “complementary and alternative medicine.” There may be some question as to whether the use of placebo interventions can be justified ethically and scientifically given that experimental treatments must eventually compete in a marketplace where there is often already a clinical alternative which is more effective than placebo. Beyond these concerns, design of an appropriate placebo for chiropractic trials is particularly problematic since the therapeutic component of overall chiropractic treatment may be difficult to isolate.

Objective:   To compare placebo interventions in current use in chiropractic clinical research with simple somatic stimuli that produce significant physiological effects in a selected group of patients (those suffering from dystonia).

Methods:   A literature search was made using MEDLINE, with the key words dystonia, sensory trick and geste antagoniste. Articles were reviewed for descriptions of these stimuli. The stimuli were compared, in terms of site and modality, with placebo interventions used in recent chiropractic clinical trials.

Results:   Stimuli used as placebo procedures in recent chiropractic clinical trials are quite similar, in terms of site and modality, to the “sensory tricks” that either cause substantial temporary relief, or, alternatively, provocation of symptoms in dystonic patients.

Conclusions:   Caution should be used in assuming that control (placebo) procedures used in chiropractic clinical trials—procedures that involve physical contact or positioning of patients—lack specific effects on neuromusculoskeletal symptomatology.

INDEX TERMS: (MeSH)   PLACEBO, SENSORY TRICK, GESTE ANTAGONISTE, CHIROPRACTIC

Macquarie University, Bld E5A Rm 355, Waterloo Rd, North Ryde, Sydney, NSW 2109, Australia: peter.tuchin@mq.edu.au

Objective   To assess the significance of adverse events after spinal manipulation therapy (SMT) by replicating and critically reviewing a paper commonly cited when reviewing adverse events of SMT as reported by Ernst. (J R Soc Med. 2007 (Jul); 100 (7): 330-338).

Method   Replication of a 2007 Ernest paper to compare the details recorded in this paper to the original source material. Specific items that were assessed included the time lapse between treatment and the adverse event, and the recording of other significant risk factors such as diabetes, hyperhomocysteinemia, use of oral contraceptive pill, any history of hypertension, atherosclerosis and migraine.

OBJECTIVE:   The purpose of this case series is to describe the chiropractic management of 21 patients with daily stress and occasional total urinary incontinence (UI).

Background   Neck pain is a common complaint in patients presenting for chiropractic treatment. The few studies on predictors for improvement in patients while undergoing treatment identify duration of symptoms, neck stiffness and number of previous episodes as the strong predictor variables. The purpose of this study is to continue the research for predictors of a positive outcome in neck pain patients undergoing chiropractic treatment.

Methods   Acute (< 4 weeks) (n = 274) and chronic (> 3 months) (n = 255) neck pain patients with no chiropractic or manual therapy in the prior 3 months were included. Patients completed the numerical pain rating scale (NRS) and Bournemouth questionnaire (BQ) at baseline prior to treatment. At 1 week, 1 month and 3 months after start of treatment the NRS and BQ were completed along with the Patient Global Impression of Change (PGIC) scale. Demographic information was provided by the clinician. Improvement at each of the follow up points was categorized using the PGIC. Multivariate regression analyses were done to determine significant independent predictors of improvement.

Results   Baseline mean neck pain and total disability scores were significantly (p < 0.001and p < 0.008 respectively) higher in acute patients. Both groups reported significant improvement at all data collection time points, but was significantly larger for acute patients. The PGIC score at 1 week (OR = 3.35, 95% CI = 1.13-9.92) and the baseline to 1 month BQ total change score (OR = 1.07, 95% CI = 1.03-1.11) were identified as independent predictors of improvement at 3 months for acute patients. Chronic patients who reported improvement on the PGIC at 1 month were more likely to be improved at 3 months (OR = 6.04, 95% CI = 2.76-13.69). The presence of cervical radiculopathy or dizziness was not predictive of a negative outcome in these patients.

CONCLUSIONS:   The most consistent predictor of clinically relevant improvement at both 1 and 3 months after the start of chiropractic treatment for both acute and chronic patients is if they report improvement early in the course of treatment. The co-existence of either radiculopathy or dizziness however do not imply poorer prognosis in these patients.

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Chronic Neck Pain and Chiropractic Page

Marita Bringsli, Aurora Berntzen, Dorthe B Olsen, Charlotte Leboeuf-Yde and Lise Hestbaek

Background:   Because maintenance care (MC) is frequently used by chiropractors in the management of patients with back pain, it is necessary to define the rationale, frequency and indications for MC consultations, and the contents of such consultations. The objectives of the two studies described in this article are: i) to determine the typical spacing between visits for MC patients and to compare MC and non-MC patients, ii) to describe the content of the MC consultation and to compare MC and non-MC patients and iii) to investigate the purposes of the MC program.

Method:   In two studies, chiropractors who accepted the MC paradigm were invited to assist with the data collection. In study 1, patients seen by seven different chiropractors were observed by two chiropractic students. They noted the contents of the observed consultations. In study 2, ten chiropractors invited their MC patients to participate in an anonymous survey. Participants filled in a one page questionnaire containing questions on their view of the purposes and contents of their MC consultations. In addition, information was obtained on the duration between appointments in both studies.

Results:   There were 178 valid records in study 1, and in study 2 the number of questionnaires received was 373. The time interval between MC visits was close to nine weeks and for non-MC consultations it was two weeks. The content of the consultations in study 1 was similar for MC and non-MC patients with treatment being the most time-consuming element followed by history taking/examination. MC consultations were slightly shorter than non-MC consultations. In study 2, the most common activities reported to have taken place were history taking and manipulative therapy. The most commonly reported purposes were to prevent recurring problems, to maintain best possible function and /or to stay as pain free as possible.

Conclusions:   The results from these two studies indicate that MC consultations commonly take place with around two months intervals, and that history taking, examination and treatment are as important components in MC as in non-MC consultations. Further, the results demonstrate that most patients consider the goal to be secondary or tertiary prevention.

BACKGROUND:   The mechanisms subserving deep spinal pain have not been studied as well as those related to the skin and to deep pain in peripheral limb structures. The clinical phenomenology of deep spinal pain presents unique features which call for investigations which can explain these at a mechanistic level.

METHODS:   Targeted searches of the literature were conducted and the relevant materials reviewed for applicability to the thesis that deep spinal pain is distinctive from deep pain in the peripheral limb structures. Topics related to the neuroanatomy and neurophysiology of deep spinal pain were organized in a hierarchical format for content review.

RESULTS:   Since the 1980′s the innervation characteristics of the spinal joints and deep muscles have been elucidated. Afferent connections subserving pain have been identified in a distinctive somatotopic organization within the spinal cord whereby afferents from deep spinal tissues terminate primarily in the lateral dorsal horn while those from deep peripheral tissues terminate primarily in the medial dorsal horn. Mechanisms underlying the clinical phenomena of referred pain from the spine, poor localization of spinal pain and chronicity of spine pain have emerged from the literature and are reviewed here, especially emphasizing the somatotopic organization and hyperconvergence of dorsal horn “low back (spinal) neurons”. Taken together, these findings provide preliminary support for the hypothesis that deep spine pain is different from deep pain arising from peripheral limb structures.

CONCLUSIONS:   This thesis addressed the question “what is different about spine pain?” Neuroanatomic and neurophysiologic findings from studies in the last twenty years provide preliminary support for the thesis that deep spine pain is different from deep pain arising from peripheral limb structures.

OBJECT:   The purpose of this article is to discuss a theoretical basis for wellness chiropractic manipulative care and to develop a hypothesis for further investigation.

METHODS:   A SEARCH OF PUBMED AND OF THE MANUAL, ALTERNATIVE, AND NATURAL THERAPY INDEX SYSTEM WAS PERFORMED WITH A COMBINATION OF KEY WORDS: chiropractic, maintenance and wellness care, maintenance manipulative care, preventive spinal manipulation, hypomobility, immobility, adhesions, joint degeneration, and neuronal degeneration. Articles were collected, and trends were identified.

RESULTS:   The search revealed surveys of doctors and patients, an initial clinical pilot study, randomized control trials, and laboratory studies that provided correlative information to provide a framework for development of a hypothesis for the basis of maintenance spinal manipulative therapy. Maintenance care optimizes the levels of function and provides a process of achieving the best possible health. It is proposed that this may be accomplished by including chiropractic manipulative therapy in addition to exercise therapy, diet and nutritional counseling, and lifestyle coaching.

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By R. C. Schafer, DC, PhD, FICC

The proximal ulna forms the most important articulation in the elbow area, while the distal radius forms the most important articulation in the wrist.

Elbow area injuries are commonly the result of direct blows or falls. Avulsion-type injuries of the elbow are often seen as a result of acute or chronic strain at a site of tendon or ligament attachment. As in all traumatic injuries, the sooner the patient is examined after injury, the more accurate the diagnosis. Swelling, spasm, tenderness, and motion limitations rapidly cloud the picture. A list of common elbow injury syndromes is shown in Table 1.

Study Design   Serial, cross-sectional, nationally representative surveys of non-institutionalized adults.

Objective   To examine expenditures on common ambulatory health services for the management of back and neck conditions.

Summary of Background Data   Although it is well recognized that national costs associated with back and neck conditions have grown considerably in recent years, little is known about the costs of care for specific ambulatory health services that are used to manage this population.

Methods   We used the Medical Expenditure Panel Survey (MEPS) to examine adult (age ≥ 18 years) respondents from 1999 to 2008 who sought ambulatory health services for the management of back and neck conditions. We used complex survey design methods to make national estimates of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions.

Results   Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008).

Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from $487 to $950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians.

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Philip S. Bolton, Brian Budgell

School of Biomedical Sciences & Pharmacy, Faculty of Health, University of Newcastle, Callaghan NSW 2308, Australia; Centre for Brain and Mental Health Research at the Hunter Medical Research Institute, Newcastle, Australia

While spinal manipulation is widely seen as a reasonable treatment option for biomechanical disorders of the spine, such as neck pain and low back pain, the use of spinal manipulation to treat non-musculoskeletal complaints remains controversial. This controversy is due in part to the perception that there is no robust neurobiological rationale to justify using a biomechanical treatment of the spine to address a disorder of visceral function. This paper therefore looks at the physiological evidence that spinal manipulation can impact visceral function. A structured search was conducted, using PubMed and the Index to Chiropractic Literature, to construct of corpus of primary data studies in healthy human subjects of the effects of spinal manipulation on visceral function. The corpus of literature is not large, and the greatest number of papers concerns cardiovascular function.

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Upper-thoracic spasms and trigger points are common within the milder complaints heard in a chiropractic office. Typical posttraumatic injuries of the posterior thorax involve the large posterior musculature, thoracic spine, spinocostal joints, and tissues supporting and mobilizing the scapula (especially the rhomboids). Upper right abdominal quadrant ailments (eg, gallbladder, liver) commonly refer pain and sometimes tenderness to the right scapular area.