The general stability of synovial joints is established by action of surrounding muscles. Excessive joint stress results in strained muscles and tendons and sprained or ruptured ligaments and capsules. When stress is chronic, degenerative changes occur.
The lining of synovial joints is slightly phagocytic, is regenerative if damaged, and secretes synovial fluid that is a nutritive lubricant having bacteriostatic and anticoagulant characteristics. This anticoagulant effect may result in poor callus formation in intra-articular fractures where the fracture line is exposed to synovial fluid. Synovial versus mechanical causes of joint pain are shown in Table 1.
Table 1. Synovial vs Mechanical Causes of Joint Pain
Feature
Synovitic
Lesions
Mechanical
Lesions
Onset
Symptoms fairly consistent, during use and at rest.
Symptoms arise chiefly during use
Location
Any joint may be involved.
Primarily involves weight-bearing joints.
Course
Usually fluctuates. Episodic flares are common.
Persistently worsening progression. No acute exacerbations.
Stiffness
Prolonged in the morning.
Little morning stiffness.
Anti-inflammatory effect
Aided by cold and other anti-inflammatory therapies.
Anti-inflammatory therapy of only minimum value.
Major pathologic features
Negative radiographic signs or diffuse cartilage loss, marginal bony erosions, but no osteophytes.
Radiographic signs of cartilage loss and osteophyte developments
Although it may be easier to teach anatomy by dividing the body into arbitrary parts, a misinterpretation can be created. For instance, we find clinically that the lumbar spine, sacrum, ilia, pubic bones, and hips work as a functional unit. Any disorder of one part immediately affects the function of the other parts. We should also keep in mind that an axial kinematic chain of weight-supporting segments extends from the occipital base to the soles of the feet.
Because the number of professional papers concerning the cause and diagnosis of low-back pain is voluminous, emphasis herein is placed on points that the author believes are important but not often emphasized in popular literature.
BACKGROUND
A wide assortment of muscle, tendon, ligament, bone, nerve, and vascular injuries in this area is witnessed during posttrauma care. As with other areas of the body, the first step in the posttrauma examination process is knowing the mechanism of injury if possible. Evaluation can be rapid and accurate with this knowledge.
Low-back disability rapidly demotivates productivity and athletic participation. The mechanism of injury is usually intrinsic rather than extrinsic. The cause can often be through overbending, a heavy steady lift, or a sudden release –all which primarily involve the muscles. IVD disorders are more often, but not exclusively, attributed to extrinsic blows and intrinsic wrenches. An accurate and complete history is invariably necessary to offer the best management and counsel.
The kinetic aspects of spinal biomechanics are an important consideration in traumatology since the totality of function is essentially the sum of its individual components. However, although reminders are frequently given, the multitude of causes and effects of an articular subluxation complex (spinal or extraspinal) will not be detailed here that is primarily directed to chiropractic clinicians and advanced students who are well acquainted with standard hypotheses. For a detailed description, the reader is referred to: Basic Principles of Chiropractic: The Neuroscience Foundation of Clinical Practice
Arlington, Virginia, American Chiropractic Association, 1990.
Basic Implications
The biomechanical efficiency of any one of the 25 vertebral motor units, from atlas to sacrum, can be described as that condition (individually and collectively) in which each gravitationally dependent segment above is free to seek its normal resting position in relation to its supporting structure below, is free to move efficiently through its normal ranges of motion, and is free to return to its normal resting position after movement. The degree of fixed derangement (subluxation-fixation) of a bony segment within its articular bed and normal range of motion may be an effect in the range of microtrauma to macroscopic damage. Regardless, it is always attended by some degree of mobility dysfunction; neurologic insult; and overstress of the muscles, tendons, and ligaments involved and their respective mechanoreceptors.
Once produced, the lesion becomes a focus of sustained pathologic irritation in which a barrage of impulses streams into the spinal cord where internuncial neurons receive and relay them to motor pathways. The contraction that provoked the subluxation initially is thereby reinforced, thus perpetuating both the subluxation and the pathologic process engendered. Sensory reflex phenomena can also be involved, and they frequently are. The nerve impulse creates a multitude of cellular reactions and responses besides those of even the most intricate, subtle, and variable sensations and motor activities. Once this is appreciated, we must add the complexities of trophic effects, neuroendocrine interrelations, biochemical affinities, proprioceptive buildup, summation increments, facilitation patterns, the input of the ascending and descending reticular activating mechanisms, genetic neurologic diatheses, synaptic overlaps, demoralization and disintegration of synaptic thresholds, the neurologic spread and buildup, reflex instability, predisposition to sensorial aberrations, undue cerebrovisceral or viscerocerebral interactions, psychosomatic overtones, and those many phenomena that science is only beginning to understand or are beyond our present understanding. This underscores that the quality and sometimes quantity of nerve function relates directly or indirectly to practically every bodily function and contributes significantly to the beginning of physiologic dysfunction and the development of pathologic processes.
The articulations of the scapula, clavicle, and the humerus function as a biomechanical unit. Only when certain multiple segments are completely fixed can these parts possibly function independently in mechanical roles. Forces generated from or on one of the three segments influence the other two segments. Thus, they will be described here as a functional unit. Please underscore this point in your mind as you read this paper.
BACKGROUND
Shoulder pain can arise from either local or systemic causes. Jaquet points out that about 95% of all shoulder disorders are due to four conditions:
adhesive capsulitis
simple tendinitis,
tendinous perforation and rupture, and
hyperalgesic calcareous tendinitis.
Note that three of these four conditions are tendinous in origin, but tendon inflammation is not as common in the shoulder as it is in the elbow and wrist. However, because all tendons are relatively avascular, all are subject to chronic trauma, microtears, slow repair, and aging degeneration.
As in so many musculoskeletal disorders, thorough investigation of the history of shoulder pain may reveal that trauma did not initiate the first attack or an injury was just a precipitating event that revealed an underlying degenerative disorder. Besides direct injury, shoulder pain may have an inflammatory, a neurologic, a psychologic, a vascular, a metabolic, a neoplastic, a degenerative, a congenital, an autoimmune, or a toxic origin.
Shoulder pain has a high incidence. Cailliet says that it ranks third to low-back and neck pain. Despite its prevalence, posttraumatic shoulder pain can be deceiving. Accurate diagnosis is not an easy task. For example, there may be unavoidable occupational stress in the clinical picture that is aggravating the condition and delaying healing. How should the patient react when a doctor says “avoid overhead work” and the patient makes his living as a painter or pipe fitter of ceiling sprinkler systems? Temporary rest can be provided but not permanent relief from such occupational stress. It may have taken the patient many years of effort to reach his present status. This is not easily put aside. Counsel the patient thoroughly — from his or her viewpoint.
Normal mobility is extensive. The glenohumeral joint alone expresses abduction, adduction, elevation, extension, external rotation, flexion, horizontal abduction, horizontal adduction, and internal rotation. Thus, a thorough knowledge of shoulder kinematics, neurology, angiology, myology, and kinesiology is required for proper treatment to be applied.
The mechanical relationship between the head and neck has been crudely compared to a brick attached to a flexible rod. As the structural mass of the head is so much greater than that of the neck, it is no wonder that injuries of the neck are so prevalent. Even the person with a short neck and well-developed neck muscles and ligaments is not free of potential injury.
BACKGROUND
The viscera of the neck serve as a channel for vital vessels and nerves, the trachea, esophagus, and spinal cord, and as a site for lymph and endocrine glands. When the head is in balance, a line drawn through the nasal spine and the superior border of the external auditory meatus will be perpendicular to the ground.
Anterior injuries are more common to the head and chest as they project further forward, but a blunt blow from the front on the head or chest may cause an indirect extension or flexion injury of the cervical spine and soft tissues of the neck. In any neck injury, the injury may not be the product of a single force. For example, while extension, flexion, and lateral flexion injuries are often described separately, rotational, compressive, tensile, and shearing forces are invariably part of the picture.
The anterior and lateral aspects of the neck contain a variety of vital structures that have no bony protection. Partial protection is provided by the cervical muscles, the mandible, and the shoulder girdle.
After neck injury, a careful neurologic evaluation must be conducted, and every examination should begin with a thorough case history. See Table 1. Note any signs of impaired consciousness, inequality of pupils, or nystagmus. Do outstretched arms drift unilaterally when the eyes are closed? Standard coordination tests such as finger-to-nose, heel-to-toe, heel-to-knee, and for Romberg s sign should be conducted, along with superficial and tendon reflex tests.
Table 1 Typical Questions Asked During the Investigation of Joint Pain
Assistant Professor, Department of Human Health and Nutritional Sciences, University of Guelph.
CCRF Professorship in Spine Mechanics and Human Neurophysiology
College of Biological Sciences, University of Guelph
Chronic pain is a worldwide epidemic. It is characterized as “pain that persists beyond normal tissue healing time” [1] and is physiologically distinct from acute nociceptive pain. The current research estimates the prevalence of chronic pain in the general population to be anywhere from 10–55%, [2] predominantly affecting the adult population. Studies indicate that the prevalence of chronic pain in the over-60 age group is double that for younger adults. [3] Furthermore, over 80% of elderly (over 65) adults suffer from some form of painful chronic joint disease [4] and greater than 85% of the general population will experience some form of chronic myofascial pain during their lifetime. [5]
Chronic pain has substantial impact on sufferers, often citing significant impairments in physical, social and psychological function. [6] Many patients suffer from progressive health and physical deterioration owing to sleep and appetite disturbances, anxiety, depression, decreased physical energy and activity as well as excessive use of medication. [6] Chronic pain often leads to social withdrawal, impaired personal relationships and job loss. [1] Recent estimates suggest that 50–85% of adults report some degree of pain that may interfere with daily activities and quality of life. [7]
Chronic pain sufferers are five times more likely to utilize health care services than non-pain sufferers. [8] Conservative figures estimate that the annual cost of managing chronic pain in the United States currently exceeds $40 billion annually. [9] Of greatest concern is the fact that the ratio of the over-65:under-65 segments of the population is projected to double by 2050, [10] promising to make chronic pain one of healthcare’s foremost challenges in the future.
Pain is the most prevalent health condition among U.S. workers and the most expensive in terms of lost productivity. Recent studies suggest more than six in 10 adults over the age of 30 experience chronic pain. Furthermore, health care expenditures for back and neck pain have risen to more than $80 billion a year in the U.S. – a dramatic increase over the past eight years, without evidence of improved health. In addition to the costs of lost productivity, an estimated $64 billion per year is lost due to workers continuing to work, even though pain reduces their job performance. This phenomenon is called “presenteeism.”
Unfortunately, workers’ comp can be a quagmire of contradictory and insufficient rules and regulations as to what treatments are and aren’t covered. The American College of Occupational and Environmental Medicine (ACOEM) has been in the process of revising its Occupational Medicine Practice Guidelines, which have not always taken a positive view of chiropractic manipulation. In fact, the second edition of the guidelines, released in 2005, was heavily criticized by some in the chiropractic community. [1]
ACOEM’s latest chronic pain guidelines (a chapter of the overall guidelines) may represent a step in the right direction in terms of recognizing the value of chiropractic care. The guidelines actually recommend manipulation for chronic, persistent low back or neck pain and cervicogenic headache. [2] This is significant because in the past, the guidelines failed to recommend manipulation, even when other treatment strategies (medication, etc.) were rated as less effective.
Joel Alcantara, Joey D. Alcantara, Junjoe Alcantara
International Chiropractic Pediatric Association, Media, 327 N Middletown Rd, Media, PA 19063, USA
Introduction Estimates place some 300 million people worldwide suffer from asthma with 180,000 deaths attributed to the disease. The financial burden from Asthma in Western countries ranges from $300 to $1,300 per patient per year. In the United States, asthma medication costs between $1 billion and $6.2 billion per annum. With an increasing prevalence of 50% every decade, there is no question that the burden of asthma is tremendous. The prevalence of complementary and alternative medicine (CAM) use amongst adult asthmatics ranges from 4% to 79% whilst, in children, it ranges from 33% to 89%. Of the various practitioner-based CAM therapies, chiropractic stands as the most popular for both children and adults. As with other chiropractors, the authors aspire to the principles of evidence-based practice in the care of asthma sufferers. Recent systematic reviews of the literature places into question the effectiveness of chiropractic. To assuage the discord between our clinical experience and those of our patients with the dissonant literature, we performed a systematic review of the literature on the chiropractic care of patients with asthma.
Methods Our systematic review utilized the following databases for the years indicated: MANTIS [1965–2010]; Pubmed [1966–2010]; ICL [1984–2010]; EMBASE [1974–2010], AMED [1967–2010], CINAHL [1964–2010], Index to Chiropractic Literature [1984–2010], Alt-Health Watch [1965–2010] and PsychINFO [1965–2010]. Inclusion criteria for manuscript review were manuscripts of primary investigation/report published in peer-reviewed journals in the English language involving the care of asthmatic patients.
Results The studies found span of research designs from non-experimental to true experimental studies consisting of 3 randomized controlled clinical trials (RCTs), 10 case reports, 3 case series, 7 cohort studies, 3 survey studies, 5 commentaries8 and 6 systematic reviews. The lower level design studies provide some measure of evidence on the effectiveness of chiropractic care for patients with asthma while a critical appraisal of 3 RCTs revealed questionable validity of the sham SMTs involved and hence the conclusions and interpretations derived from them. The RCTs on chiropractic and asthma are arguably comparison trials rather than controlled clinical trials per se.
Conclusion Chiropractic may offer an alternative care approach for asthmatic patients. Future investigations of this conservative care approach for patients with asthma should pave the way for higher-level design studies such as randomized controlled clinical trials.
From the FULL TEXT Article:
Introduction
The burden of asthma is tremendous. Prevalence estimates of asthma range from 7% in France and Germany to 11% in the United States and as high as 15–18% in the United Kingdom. [1] In Britain, asthma is the commonest chronic childhood disease. [1] [2] In the United States, approximately 6.7 million children (or 9.1% of the pediatric population) have asthma. Some 10.6 million office visits to medical physicians are attributed to the symptoms of asthma. Deaths as a result of asthma have been estimated at approximately 1.2 deaths per 100,000 population. [3] Asthma medications alone have been placed at costing $1 billion per year in the United States. In 1985, the burden of asthma was placed at almost $4.5 billion and extrapolated to $6.2 billion in 1990 in the United States. Given the ever increasing prevalence of asthma since the 1990s, the cost to society undoubtedly enormous. [4]
An examination of the prevalence of complementary and alternative medicine (CAM) use for asthma sufferers found that adult CAM use ranged from 4% to 79% whilst, for children, CAM use ranged from 33% to 89%. [5] Of the various practitioner-based CAM therapies, chiropractic stands as the most popular for both children and adults. [6] Given the popularity of chiropractic, it stands to reason that individuals with asthma would consider a trial of chiropractic care; indeed, the chiropractic clinical experience is such that asthmatics benefit from chiropractic care (i.e., improved symptoms of dyspnea and decrease medication use) (unpublished observations). Recent systematic reviews of the literature on chiropractic, however, spinal manipulative therapy (SMT) and asthma [7, 8] place into question the effectiveness of chiropractic for this patient population. As stated above, this is dissonant with the chiropractic clinical experience and the reported benefits experienced by chiropractic patients. In keeping with evidence-based practice and to reconcile the “conscientious, explicit, and judicious use of current best evidence” with that of empirical clinical experience, a systematic review of the literature on the chiropractic care of patients with asthma was performed.
Maxim A. Bakhtadze, MD, PhD, Howard Vernon, DC, PhD, Anatoliy V. Karalkin, MD, PhD, Sergey P. Pasha, MD, PhD, Igor O. Tomashevskiy, MD, PhD, David Soave, MSc
OBJECTIVE: The purpose of this study was to determine the correlation between cerebral perfusion levels, Neck Disability Index (NDI) scores, and spinal joint fixations in patients with neck pain.
METHODS: Forty-five adult patients (29 were female) with chronic neck/upper thoracic pain during exacerbation were studied. The subjects were grouped according to NDI scores: mild, moderate, and severe. The number of painful/blocked segments in the cervical and upper thoracic spine and costovertebral joints, pain intensity using the visual analog scale, and regional cerebral blood flow of the brain using single-photon emission computed tomography (SPECT) were obtained. The SPECT was analyzed semi-quantitatively. Analysis of variance tests were conducted on total SPECT scores in each of the NDI groups (P < .05). Univariate correlations were obtained between blockage, pain, and SPECT scores, as well as age and duration. A multivariate analysis was then conducted.
RESULTS: Group 1 (mild) consisted of 14 patients. Cerebral perfusion measured by SPECT was normal in all 8 brain regions.
Group 2 (moderate) consisted of 16 patients. In this group, a decrease in cerebral perfusion was observed (range, 20%-35%), predominantly in the parietal and frontal zones.
Takeshi Ogura,DC, PhD, is a research fellow in the Division of Cyclotron Nuclear Medicine, Cyclotron and Radioisotope Center, Tohoku University, Sendai, Japan, and a director at the Japan Chiropractic Doctor College, Sendai.
Background: Chiropractic spinal manipulation (CSM) is an alternative treatment for back pain. The autonomic nervous system is often involved in spinal dysfunction. Although studies on the effects of CSM have been performed, no chiropractic study has examined regional cerebral metabolism using positron emission tomography (PET).
Objective: The aim of the present study was to investigate the effects of CSM on brain responses in terms of cerebral glucose metabolic changes measured by [18F]fluorodeoxyglucose positron emission tomography (FDG-PET).
Methods: Twelve male volunteers were recruited. Brain PET scanning was performed twice on each participant, at resting and after CSM. Questionnaires were used for subjective evaluations. A visual analogue scale (VAS) was rated by participants before and after chiropractic treatment, and muscle tone and salivary amylase were measured.
Paul E Dougherty, Cheryl Hawk, Debra K Weiner, Brian Gleberzon, Kari Andrew, Lisa Killinger
There are a rising number of older adults; in the US alone nearly 20% of the population will be 65 or older by 2030. Chiropractic is one of the most frequently utilized types of complementary and alternative care by older adults, used by an estimated 5% of older adults in the U.S. annually. Chiropractic care involves many different types of interventions, including preventive strategies. This commentary by experts in the field of geriatrics, discusses the evidence for the use of spinal manipulative therapy, acupuncture, nutritional counseling and fall prevention strategies as delivered by doctors of chiropractic. Given the utilization of chiropractic services by the older adult, it is imperative that providers be familiar with the evidence for and the prudent use of different management strategies for older adults.
Introduction:
By 2030, nearly one in five U.S. residents is expected to be age 65 or older [
1]. An estimated 14% of patients treated by doctors of chiropractic (DCs) are 65 and older [2]. The most common reason for an older adult to see a DC is musculoskeletal pain, most often lower back pain [3]. Although the most common reason for older adults seeking chiropractic care is for musculoskeletal symptoms, DCs may also provide a diverse range of services to these patients [4] .Given this fact, for the purpose of this manuscript chiropractic care will be defined as; “the provision by a doctor of chiropractic of services related to patient assessment, maintenance of health, prevention of illness, and treatment of illness or injury.” The focus of this manuscript is to describe the evidence for achievement of some of these goals in the older adult population. The purpose of this manuscript is to present an overview of information to the practicing chiropractor on utilization of specific management tools. This is not meant to be a systematic review of the literature or an evidence based guideline. The authors each have personal experience in evaluating and treating older adults as well as established expertise in research and publication in these areas. The authors recognize that there is a need for further research in the area of management of the older adult by DC’s and discuss in the conclusion future research considerations.
Since chiropractic’s breakthrough decade in the 1970s — when the U.S. federal government included chiropractic services in Medicare and federal workers’ compensation coverage, approved the Council on Chiropractic Education (CCE) as the accrediting body for chiropractic colleges, and sponsored a National Institutes of Health (NIH) conference on the research status of spinal manipulation — the profession has grown and matured into an essential part of the nation’s healthcare system.
Chiropractic was born in the United States in the late 19th century and the U.S. is home to approximately 65,000 of the world’s 90,000 chiropractors. [
1] The chiropractic profession is the third largest independent health profession in the Western world, after medicine and dentistry. Doctors of chiropractic are licensed throughout the English-speaking world and in many other nations as primary contact providers, licensed for both diagnosis and treatment without medical referral. In 2005, the World Health Organization (WHO) published WHO Guidelines on Basic Training and Safety in Chiropractic, which documented the status of chiropractic education and practice worldwide and sought to ensure high standards in nations where chiropractic is in the early stages of development. [2]
Rigorous educational standards are supervised by government-recognized accrediting agencies in many nations, including CCE in the United States. After fulfilling college science prerequisites similar to those required to enter medical schools, chiropractic students must complete a chiropractic college program of four academic years, which includes a wide range of courses in anatomy, physiology, pathology, and diagnosis, as well as spinal adjusting, physiotherapy, rehabilitation, public health and nutrition.
A Systematic Review and Meta-analysis of Efficacy, Cost-effectiveness, and Safety of Selected Complementary and Alternative Medicine for Neck and Low-back Pain
Andrea D. Furlan, Fatemeh Yazdi, Alexander Tsertsvadze, * Anita Gross, Maurits Van Tulder, Lina Santaguida, Joel Gagnier, Carlo Ammendolia, Trish Dryden, Steve Doucette, Becky Skidmore, Raymond Daniel, Thomas Ostermann, and Sophia Tsouros
Clinical Epidemiology Methods Centre, Ottawa Hospital Research Institute, University of Ottawa Evidence-Based Practice Center, Box 208, Ottawa, ON, Canada K1H 8L6
Background: Back pain is a common problem and a major cause of disability and health care utilization.
Purpose: To evaluate the efficacy, harms, and costs of the most common CAM treatments (acupuncture, massage, spinal manipulation, and mobilization) for neck/low-back pain.
Data Sources: Records without language restriction from various databases up to February 2010.
Data Extraction: The efficacy outcomes of interest were pain intensity and disability.
Data Synthesis: Reports of 147 randomized trials and 5 non-randomized studies were included. CAM treatments were more effective in reducing pain and disability compared to no treatment, physical therapy (exercise and/or electrotherapy) or usual care immediately or at short-term follow-up. Trials that applied sham-acupuncture tended towards statistically non-significant results. In several studies, acupuncture caused bleeding on the site of application, and manipulation and massage caused pain episodes of mild and transient nature.
Conclusions: CAM treatments were significantly more efficacious than no treatment, placebo, physical therapy, or usual care in reducing pain immediately or at short-term after treatment. CAM therapies did not significantly reduce disability compared to sham. None of the CAM treatments was shown systematically as superior to one another. More efforts are needed to improve the conduct and reporting of studies of CAM treatments.
Introduction:
Back pain is a general term that includes neck, thoracic, and lower-back spinal pain. In the majority of cases, the aetiology of back pain is unknown and therefore is considered as “nonspecific back pain”. Back pain is considered “specific” if its aetiology is known (e.g., radiculopathy, discogenic disease). Although back pain is usually self-limited and resolves within a few weeks, approximately 10% of the subjects develop chronic pain, which imposes large burden to the health-care system, absence from work, and lost productivity [1]. In a recent study, the direct costs of back pain related to physician services, medical devices, medications, hospital services, and diagnostic tests were estimated to be US$ 91 billion or US$ 46 per capita [2]. Indirect costs related to employment and household activities were estimated to be between US$ 7 billion and US$ 20 billion, or between US$25 and US$ 71 per capita, respectively [3–5]. One study published in 2007 showed that the 3-month prevalence of back and/or neck pain in USA was 31% (low-back pain: 34 million, neck pain: nine million, both back and neck pain: 19 million) [6].
OBJECTIVE: The purpose of this study was to evaluate the mechanical allodynia in animals after immobilization and chiropractic manipulation using the Activator instrument through the Von Frey test in an animal model that had its hind limb immobilized as a form to induce mechanical allodynia.
METHOD: Eighteen adult male Wistar rats were used and divided into 3 groups:
1. control group (C) (n = 6) that was not immobilized;
2. immobilized group (I) (n = 6) that had its right hind limb immobilized;
3. immobilized and adjusted group (IAA) (n = 6) that had its right hind limb immobilized and received chiropractic manipulation after.
The mechanical allodynia was induced through the right hind limb immobilization. At the end of the immobilization period, the first Von Frey test was performed, and after that, 6 chiropractic manipulations on the tibial tubercle were made using the Activator instrument. After the manipulation period, Von Frey test was performed again.
RESULTS: It was observed that after the immobilization period, groups I and IAA had an exacerbation of mechanical allodynia when compared with group C (P < .001) and that after the manipulation, group IAA had a reversion of these values (P < .001), whereas group I kept a low pain threshold when compared with group C (P < .001).
CONCLUSION: This study demonstrates that immobilization during 4 weeks was sufficient to promote mechanical allodynia. Considering the chiropractic manipulation using the Activator instrument, it was observed that group IAA had decreased levels of mechanical allodynia, obtaining similar values to group C.
Discussion
The present study investigated the effects of instrumented assisted spinal manipulation therapy on mechanical allodynia produced by the immobilization of the right hind limb in a small animal model through the Von Frey test. Our group observed that the immobilization of the right hind limb, for a period of 4 weeks, might produce an exacerbation of the local mechanical allodynia and that the manipulation applied to the tibial tubercle, using the Activator instrument, might reduce the severity of local allodynia induced by the immobilization.
BACKGROUND: Substantial recent research examines the efficacy of many types of complementary and alternative (CAM) therapies. However, outcomes associated with the “real-world” use of CAM has been largely overlooked, despite calls for CAM therapies to be studied in the manner in which they are practiced. Americans seek CAM treatments far more often for chronic musculoskeletal pain (CMP) than for any other condition. Among CAM treatments for CMP, acupuncture and chiropractic (A/C) care are among those with the highest acceptance by physician groups and the best evidence to support their use. Further, recent alarming increases in delivery of opioid treatment and surgical interventions for chronic pain–despite their high costs, potential adverse effects, and modest efficacy–suggests the need to evaluate real world outcomes associated with promising non-pharmacological/non-surgical CAM treatments for CMP, which are often well accepted by patients and increasingly used in the community.
If the public is to be better educated about the benefits of chiropractic care, doctors of chiropractic must be the ones to do the educating. Research is the strongest tool we have to promote our healing art to those unfamiliar with its value and to defend it from unwarranted attacks. We owe it to our patients, our profession, ourselves and future generations to know the facts so that we can share them far and wide.
This does not mean that every practicing DC needs to become a full-time scholar, familiar with the details and nuances of the approximately 100 randomized clinical trials on spinal manipulation. It does mean that to be effective chiropractic ambassadors, we all need a good grasp of the overall picture, along with working knowledge of a small number of studies, reviews and guidelines that will allow us to most effectively deliver our message. And we need to stay up-to-date as new studies emerge.
For much of our history, prior to the dawn of the modern era of chiropractic research in the 1970s and 1980s, DCs had no choice but to rely completely on powerful, true stories about the patients we had helped in our offices. These individual stories still matter and can legitimately be shared with others as part of our outreach.But in this evidence-based era, we must use these anecdotes as the spice only, rather than the main course. Otherwise, we risk losing many opportunities to strengthen our case through strategic use of the increasingly broad and deep body of evidence researchers have made available to us. We best honor their work by sharing it widely, forcefully and accurately.
John’s recent posting about the Sid Crosby Press Conference with Dr. Ted Carrick has excited many of our readers, as well as going completely viral on the web, because it really struck a nerve. (excuse the pun)
I’m more of a football fan, so I thought you might also like to hear how Jerry Rice (the all-time NFL leader in touchdowns) maintained his long and productive football career by receiving regular chiropractic care.
Jerry Rice Shares His Personal Success With Chiropractic
Joe Montana is a 4-time winner of the Super Bowl, and he credits his career resiliency to chiropractic.
This new “best evidence” literature review explored reported adverse events and the overall safety of chiropractic pediatric care, as well as other forms of care for the same complaints routinely treated in a chiropractic office.
The results were quite interesting:
The chiropractic literature reports incidence between 0.53% and 1% for mild adverse events (AE) associated with chiropractic pediatric manipulative therapy (PMT). Put in terms of individual patients, this means that somewhere between one in 100-200 patients presenting for chiropractic care may experience a mild adverse event; in terms of total patient visits, this means that one mild AE may occur every 1310 to 1812 visits.
Reidar P Lystad, Gregory Bell, Martin Bonnevie-Svendsen and Catherine V Carter
Department of Chiropractic, Macquarie University, Sydney, Australia. reidar.lystad@mq.edu.au
BACKGROUND: Manual therapy is an intervention commonly advocated in the management of dizziness of a suspected cervical origin. Vestibular rehabilitation exercises have been shown to be effective in the treatment of unilateral peripheral vestibular disorders, and have also been suggested in the literature as an adjunct in the treatment of cervicogenic dizziness. The purpose of this systematic review is to evaluate the evidence for manual therapy, in conjunction with or without vestibular rehabilitation, in the management of cervicogenic dizziness.
METHODS: A comprehensive search was conducted in the databases Scopus, Mantis, CINHAL and the Cochrane Library for terms related to manual therapy, vestibular rehabilitation and cervicogenic dizziness. Included studies were assessed using the Maastricht-Amsterdam criteria.
RESULTS: A total of fifteen articles reporting findings from thirteen unique investigations, including five randomised controlled trials and eight prospective, non-controlled cohort studies were included in this review. The methodological quality of the included studies was generally poor to moderate. All but one study reported improvement in dizziness following either unimodal or multimodal manual therapy interventions. Some studies reported improvements in postural stability, joint positioning, range of motion, muscle tenderness, neck pain and vertebrobasilar artery blood flow velocity.
Manipulation is a form of treatment that dates to antiquity and has been practiced in some form in most cultures since that time (Lomax, 1997; Anderson, 1992). One of the first theories related to manipulation might be the statement attributed to Hippocrates: “Look to the spine as the cause of disease.” The theories of the early pioneers of chiropractic were firmly grounded in notions that had been widely held in the 1800s, particularly the idea of “spinal irritability” and its correlation with disease (Lomax, 1997; Terrett, 1987). Theories on the nature of the primary spinal disorder amenable to manipulation and on the mechanisms of action of spinal manipulation abound within chiropractic, osteopathy, physiotherapy, and manual medicine. The original chiropractic theory suggested that misaligned spinal vertebrae interfered with nerve function, ultimately resulting in altered physiology that could contribute to pain and disease. In recent decades, chiropractic theories about how mechanical spinal joint dysfunction might influence neurophysiology have undergone significant modification and reflect more contemporary views of physiology (Gatterman, 1995).
Spinal manipulative procedures produce a short-lasting (100-300 milliseconds), high velocity impulse into the body (Herzog, 1996; Triano, 1992). Herzog (1996, p.271) has summarized the work done on manipulative forces in his laboratory (Conway, 1993; Gal, 1995; Kawchuk, 1992; Kawchuk, 1993; Herzog, 1991; Herzog, 1993a; Herzog, 1993b; Herzog, 1995; Hessel, 1990; Suter, 1994) as follows:
“The peak and preload forces achieved in CSMT (chiropractic spinal manipulative therapy) were lowest for (manipulations) in the cervical spine” while being similar in the thoracic and lumbo-pelvic regions.
“The peak forces achieved using a (mechanical assistive adjusting device) were considerably smaller than any of the peak forces resulting from CSMT.”
Objectives: The purpose of this study was to retrospectively report the results of patients who completed an exercise-based chiropractic program and its potential to alter the natural progression of adult scoliosis at 24 months after the clinic portion of treatment was concluded.
Methods: A retrospective chart review was conducted at 2 spine clinics in Michigan, USA. Each clinic uses the same chiropractic rehabilitation program to treat patients with adult scoliosis. Multidimensional patient outcomes included radiographic, respiratory, disability, and pain parameters. Outcomes were measured at baseline, at end of active treatment, and at long-term follow-up.
Donald R Murphy, DC, DACAN, and Eric L Hurwitz, DC, PhD
Background: Neck pain (NP) is a common cause of disability. Accurate and efficacious methods of diagnosis and treatment have been elusive. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based guide in applying the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with NP.
Methods: Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of NP patients examined by one of three examiners trained in the application of the DBCDG.
Results: Data were gathered on 95 patients. Signs of visceral disease or potentially serious illness were found in 1%. Centralization signs were found in 27%, segmental pain provocation signs were found in 69% and radicular signs were found in 19%. Clinically relevant myofascial signs were found in 22%. Dynamic instability was found in 40%, oculomotor dysfunction in 11.6%, fear beliefs in 31.6%, central pain hypersensitivity in 4%, passive coping in 5% and depression in 2%.
Conclusion: The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, oculomotor dysfunction, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as interexaminer reliability, validity and efficacy of treatment based on the DBCDG.
Excerpted from: Triano J: Manipulative Therapy in the Management of Pain. Clinical Pain Management: A Practical Approach 3rd Edition, Lippincott, Williams & Wilkins Pub, November 2001.
Chiropractic care, particularly spinal manipulation or adjustment, is an increasingly frequent topic in medicine and health care policy circles. As evidence has accumulated to support use of these services, there is frequent reference to a presumption of placebo effect being the mechanism of favorable responses reported in the literature. These charges are easily refuted by specific data. In my experience, a professional head-on response silences these critiques and allows the discussion to refocus on a much more useful topic: appropriate use the paragraphs that follow were crafted as a part of a book chapter on the role of chiropractic manipulation in management of pain the basis often used to set the stage for a claim of a placebo effect. An effective rejoinder follows.
Discourse on manipulation usually raises the question of placebo effect. A frequent observation is that chiropractic patients are more satisfied by their treatment experience than when they are attended by other proaviders. [1, 2]
A number of elements contribute to this popular contentment, including physician-patient interaction. Manipulation treatment often requires several encounters involving physical contact and direct physician attention over a focused time interval. Can these factors be responsible for the perceived clinical benefits?
By James Brantingham, DC, CCF , Randy Snyder, DC, CCFC,
and David Biedebach, DC, CCFC
Has the hypomobile manipulable joint lesion been demonstrated to exist? Historically the manipulable joint lesion has, from the beginning of the chiropractic profession, been described as a painful stiff joint. [1, 2] Joint stiffness, commonly called hypomobility (also known in the chiropractic profession as “fixation”) has become by consensus one of the most important aspects of the manipulable joint lesion in the professions of chiropractic, osteopathy, and manual medicine. [3, 4] Nearly 100 years of clinical agreement between three separate professions supports the existence of such a lesion although research now supports its existence.
Loss of full, or global, range of motion in the lumbar or cervical spines is an indirect proof that the segmental hypomobile manipulable vertebral joint lesion exists, because it is a fact that loss of full global range of motion occurs and such stiffness is considered an objective factor in chronic back pain. [5] therefore, even if this decreased range of motion is a mixture of hypermobile and hypomobile joints (i.e., a mixture of loose and stiff joints) there must be intervertebral hypomobility for global hypomobility to exist. Randomized controlled trials of manipulation documenting decreased global range of motion, and post-treatment global range of motion are growing. [6-12]
A meta-analysis of clinical trials of spinal manipulation performed by Anderson et al., clearly and strongly demonstrated that spinal manipulation is effective in restoring or increasing global, and therefore segmental lumbar mobility. Mead et al., documented post-manipulation treatment restored or increased lumbar mobility: data proving that the hypomobile manipulable joint lesion must have existed prior to treatment, and that manipulation restored to these hypomobile joints fuller mobility (Fig 1.). [6] Other studies have documented similar results. Nansel and his associates have demonstrated in three, multiply blinded, controlled studies, in which goniometer measurements confirmed cervical range of motion or global end range asymmetries or hypomobility, that after chiropractic high velocity low amplitude manipulation, statistically significant increased mobility was restored to the global and therefore segmental hypomobility areas: proof that global and therefore segmental hypomobility was returned to more normal mobility by manipulation. [14-16]
For many years, chiropractors have observed in their own practices that their patients sometimes demonstrate improvements of complaints related to immune problems: the disappearance or lessening of allergy symptoms, quicker recovery from or less frequent and severe colds and other respiratory infections, and so on.
In the scientific literature, there have been occasional case reports that corroborate such findings, but no sound evidence to really document their veracity. These clinical observations remain suspended in that grey area unsubstantiated by scientific data to confirm their validity. Significant limitations of changes attributed to spinal manipulation in individual patients include
1) there is never a control group;
2) there is no blinding;
3) the improvement may simply be due to time;
4) they may be a nonspecific effect of care and attention;
5) it may be a regression to the mean; or
6) the result may be due to something other than spinal manipulation.
In some large studies, it has been found that chiropractic care for nonmusculoskeletal conditions is only weakly to moderately successful, but rarely harmful. [1-2] The most recent and thorough systematic literature review found that the evidence for effectiveness of spinal manipulation was inconclusive for nonmusculoskeletal conditions. [3]
Despite the lack of evidence of clinical effectiveness for nonmusculoskeletal conditions, a series of recent studies from several international research groups is systematically building the case that spinal manipulation appears to reduce the production of pro-inflammatory cytokines and increase the blood levels of immunoregulatory cytokines. Cytokines are small cell-signaling protein molecules that are secreted by numerous cells of the immune system and are a category of signaling molecules used extensively in intercellular communication.
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