By Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC
Former Director of Research and Education for the Foundation for Chiropractic Education and Research (FCER) until its demise (1992-2007), and is now 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

This is Chapter 13 from RC’s best-selling book:

“Clinical Biomechanics:
Musculoskeletal Actions and Reactions”

Second Edition ~ Wiliams & Wilkins

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).

This is Chapter 27 from RC’s best-selling book:

“Chiropractic Management of Sports and Recreational Injuries”

Second Edition ~ Wiliams & Wilkins

This is Chapter 22 from RC’s best-selling book:

“Chiropractic Management of Sports and Recreational Injuries”

Second Edition ~ Wiliams & Wilkins

The versatile shoulder girdle consists of the sternoclavicular, acromioclavicular, and glenohumeral joints, and the scapulothoracic articulation. These allow, as a whole, universal mobility by way of a shallow glenoid fossa, the joint capsule, and the suspension muscles and ligaments. The shoulder, a ball-and-socket joint, is freely movable and lacks a close connection between its articular surfaces.

The regional anatomy offers little to resist violent shoulder depression, and the shoulder tip itself has little protection from trauma. The length of the arm presents a long lever with a large head within a relatively small joint. This allows a great range of motion with little stability. The stability of the shoulder is derived entirely from its surrounding soft tissues.

History and Initial Care

A careful history recording the mechanism of trauma and the position of the limb during injury, careful inspection and palpation of the entire region, muscle and range-of-motion tests, and other standard neurologic-orthopedic tests will often arrive at an accurate diagnosis without the necessity of x-ray exposure. Forceful manipulations should always be reserved for late in the examination to evaluate contraindications.

Contusions, strains, sprains, bursitis, and neurologic deficits must be alertly recognized and treated. Fractures and dislocations, obviously, take precedence over soft-tissue injuries with the exception of severe bleeding. Always check for bony crepitus, fracture line tenderness and swelling, angulation and deformity. Because the shoulder readily “freezes” after injury, treatment must strive to maintain motion as soon as possible without encouraging recurring problems. The key to avoiding prolonged disability is early recognition and early mobilization.

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Shoulder Girdle Page

Purpose of this Study

The purpose of this study is to assess changes in Health-Related Quality of Life over a 12 month period for chiropractic patients who do, or do not participate in wellness care. It is being conducted in the offices of U.S. chiropractors who are members of the Integrated Chiropractic Outcomes Network (ICON).

For this study, we define chiropractic wellness care as a course of long-term care provided to a patient who is either asymptomatic or whose original presenting complaint has been resolved or stabilized, and is provided for the purpose of preventing disease, optimizing function, and supporting the patient’s wellness-related activities and/or minimizing recurrences of previous complaints.

Cheryl Hawk, DC, PhD, Michael Schneider, DC, PhD, Marion Willard Evans Jr., DC, PhD, MCHES, Daniel Redwood, DC
Consensus Process to Develop a Best-Practice Document on the Role of Chiropractic Care in Health Promotion, Disease Prevention, and Wellness
J Manipulative Physiol Ther. 2012 (Sep); 35 (7): 556-567

Study Design

Baseline data are collected in practitioners’ offices; follow-up is conducted by the central office at Logan, by phone and email. Each doctor enrolls 5 consecutive new patients. New patients of any age are eligible! Data are collected at 4 points: first visit and 1, 6 and 12 months later. Outcomes are assessed primarily via questions from the CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Patients are entered in a drawing for a $100 gift card when they complete the follow-up.

You may also want to review our:

Maintenance Care, Wellness and Chiropractic Page

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”

Chapter 4: The Horizontal Neurologic Levels
and Related Clinical Concerns

This chapter describes the basic functional anatomy and clinical considerations of the horizontal aspects of the supratentorial, posterior fossa, spinal, and peripheral levels of the nervous system.

The reader should keep in mind that the various aspects of the nervous system as described in this manual (eg, longitudinal and horizontal systems) are only reference guides that are visualizations of a patient’s nervous system in the upright position. They can be likened to the lines of longitude and latitude on a globe of the earth.

Such systems do not exist physically, but they do serve as excellent mental grid-like tools (viewpoints) during localization and areas in which and from which relationships can be described. For example, although the longitudinal systems take a general vertical course within the spinal column there are numerous alterations and they actually become horizontal when decussating. While the horizontal levels are spatially placed in and extend from the CNS in a general segmental manner, they soon take a widely diffuse course as they project toward their destinations. Thus, references to longitudinal and horizontal levels are just general viewpoints.

It is helpful for study purposes to isolate the body into certain systems, as described above, organize systems into organs, organs into tissues, tissues into cells, and cells into their components. However, we should keep in mind that, physically and functionally, there is only one integrated body and it is more than the sum of its parts. And even the body cannot be thought of as truly separate from its external environment. Although we may do this for study purposes, it is a limited viewpoint.

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Our thanks to ACAPress for access to these materials!

This is Chapter 1 from RC’s best-selling book:

“Chiropractic Management of Sports and Recreational Injuries”

Second Edition ~ Wiliams & Wilkins

This is Chapter 4 from RC’s best-selling book:
“The Chiropractic Assistant”

Chapter 4: The Language of the Health-Care Professions

When more than one person is involved in any task, good communication is basic for success. Thus, a sound foundation in chiropractic terminology is an important functional skill to be possessed by any chiropractic assistant. It is a requisite to becoming an important asset to the office.

If a CA’s duties include taking dictation of case histories, examination findings, or narrative reports, she must know how to record scientific terms in shorthand and know how to spell them accurately. A good medical dictionary will be an important reference. Even if dictation is not required, she still must know what the doctor means when certain terms are used. He will expect his assistants to have a fundamental grasp of commonly used medical terms, abbreviations, and acronyms.

Do not enter this study lightly. On the other hand, do not let yourself be appalled by the formidable and specialized vocabulary used in health care. The learning of professional terms will not come overnight. It will extend the entire length of your career as new and unfamiliar words are confronted.

It would not be unusual if you found many words used in the first three chapters of this program strange or at least unknown. When you undertake the transposition from lay person to chiropractic assistant, you are faced with an entirely new language that must be mastered so the transition be successful. The most efficient method to accomplish this is by securing an understanding of basic word roots, prefixes, and suffixes used in the formation of technical words and gaining an understanding of the meaning of commonly used abbreviations and acronyms. Study and repetitive use is the way to mastery.

A fundamental knowledge of anatomy (structure) and physiology (function) will be of great assistance in learning terminology. A basic understanding of human anatomy and physiology is offered in the following chapter. This chapter will prepare you for the terminology of those and other clinical subjects. While professional terms may at first seem strange, you will see their purpose in this and following chapters.

PHONETICS: THE QUICK WAY TO GRASP MEANINGS

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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.)

Intervention & Implementation Research, Institute of Environmental Medicine, Karolinska Institutet, Nobels väg 13, Stockholm 171 77, Sweden

Background   Low back pain (LBP) is a prevalent condition and has been found to be recurrent and persistent in a majority of cases. Chiropractors have a preventive strategy, maintenance care (MC), aimed towards minimizing recurrence and progression of such conditions. The indications for recommending MC have been identified in the Nordic countries from hypothetical cases. This study aims to investigate whether these indications are indeed used in the clinical encounter.

Methods   Data were collected in a multi-center observational study in which patients consulted a chiropractor for their non-specific LBP. Patient baseline information was a) previous duration of the LBP, b) the presence of previous episodes of LBP and c) early improvement with treatment. The chiropractors were asked if they deemed each individual patient an MC candidate. Logistic regression analyses (uni– and multi-level) were used to investigate the association of the patient variables with the chiropractor’s decision.

Conclusions   The study largely confirms the clinical use of the previously identified indications for recommending MC for recurrent and persistent LBP. Previous episodes of LBP was the strongest indicator.

There are many similar studies in our new

Maintenance Care, Wellness and Chiropractic Page

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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Doctors of chiropractic have long emphasized the importance of posture and other lifestyle factors in the body’s ability to function optimally. In a broad sense, good posture can be considered an ongoing battle against bad habits. “The body endures hundreds of insults each day,” says Scott W. Donkin, DC, DACBOH, “but we have the choice of controlling how they affect us. Once destructive habits are identified, people can change, prevent, and relieve both present and future physical problems. The quality of our later years can be enhanced and many physical problems prevented if we understand and deal early on with the underlying issues.” Dr. Donkin is the author of Sitting on the Job. [1]

Lifetime Regimen

What most people don’t know is that the following should be a lifetime regimen-for everyone-and not just when the back hurts. ACA Council on Chiropractic Orthopedics vice president Gary L. Carver, DC, DABCO, says that when they first get up in the morning, “People should use their hands and arms for support to get into a seated position. Next, they should swing their legs to the floor and stand up-using the hinge of the hips, rather than the back.”

But once the body is upright, is it up right? In other words, are the muscles, joints, and skeleton in a balanced posture? Too often, the answer is “no.” “As long as our body is performing, we take it for granted. We don’t concentrate on what we need to do to maintain good posture habits,” says Leo Bronston, DC, DABCO, DACAN, CCSP, and secretary of the ACA Council on Chiropractic Orthopedics. “Generally, we tend to hunch forward when we should be rolling our shoulders back and opening up the chest wall. That is something we need to practice-activating the proper postural muscles. We see many patients who simply don’t know how to achieve a more balanced trunk and neutral spine. Just as we learned to eat with a fork and that became automatic, we can train our muscles for good posture and balance, whether we’re standing, rising from a seated position, or getting out of bed.”

There are many more articles like this in our:

Backpacks and Children Page

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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.

There are many more articles like this @ our:

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

All motor activities such as walking, running, jumping, squatting, pushing,
pulling, lifting, and throwing are examples of dynamic musculoskeletal mechanics. To better appreciate the sometimes simple and often complex factors involved, this chapter reviews the basic concepts and terms involved in maintaining static equilibrium. Static equilibrium is the starting point for all dynamic activities.

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.

Chapter 6:   General Spinal Biomechanics

This chapter discusses the vertebral column as a whole and serves as a foundation for the following three chapters that consider the regional aspects of the spine and pelvis. Emphasis here is on gross structure, function, spinal kinematics, and other general biomechanical implications.

The vertebral column is a mechanical marvel in that it must afford both rigidity and flexibility.

The Spine as a Whole

The segmental design of the vetebral column allows adequate motion among the head, trunk, and pelvis; affords protection of the spinal cord; transfers weight forces and bending moments of the upper body to the pelvis; offers a shockabsorbing apparatus; and serves as a pivot for the head. Without stabilization from the spine, the head and upper limbs could not move evenly, smoothly, or support the loads imposed upon them (Fig. 6.1).

Essentially because of its various adult curvatures, the bony spine is anatomically divided into the seven cervical vertebrae, the twelve thoracic vertebrae, the five lumbar vertebrae, and the ossified five sacral and four coccygeal segments. From C1 to S1, the articulating parts of these vertebrae are the vertebral bodies, which are separated by intervertebral discs (IVD’s), and the posterior facet joints. The IVD’s tend to be static weight-bearing joints, while the facets function as dynamic sliding and gliding joints.

      WEIGHT DISTRIBUTION

The flexible vertebral column is balanced upon its base, the sacrum. In the erect position, weight is transferred across the sacroiliac joints to the ilia, then to the hips, and then to the lower extremities. In the sitting position, weight is transferred from the sacroiliac joints to the ilia, and then to the ischial tuberosities.

      SPINAL LENGTH

About 75% of spinal length is contributed by the vertebral bodies, while 25% of its length is composed of disc material. The contribution by the discs, however, is not spread evenly throughout the spine. About 20% of cervical and thoracic length is from disc height, while approximately 30% of lumbar length is from disc height. In all regions, the contribution by the discs diminishes with age.

Development of the Spine

In brief, development occurs in three stages: mesenchymal, chondrification, and ossification.

MESENCHYMAL AND CHONDRIFICATION ORIGINS

Just prior to the 4th week of embryonic development, a vertebral segment begins to develop as paired condensations of mesenchyme (somites) around the longitudinal notochord and dorsal neural tube. One or usually two chondrification centers appear (6 weeks) in the centrum and begin to form a cartilaginous model surrounded by anterior and posterior longitudinal ligaments which are complete by 7-8 weeks. Chondrification centers also form in the neural arches and costal processes. A thick ring of nonchrondrous cells establishes the model IVD around the longitudinal string of beaded notochordal segments (Fig. 6.2).

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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.

By Vern Saboe, DC, DACAN, DABFP, FACO
Lobbyist, Oregon Chiropractic Association

The new State of Oregon Evidence-Based Clinical Guidelines for the Evaluation and Management of Low Back Pain recommends spinal manipulation as the only nonpharmacological treatment for acute lower back pain. The guidelines, which have been adopted by the Oregon Health Authority, are a collaborative effort between the Center for Evidence-Based Practice, Oregon Corporation for Health Care Quality, Oregon Health and Sciences University’s Center for Evidence-based Policy, and the new Oregon Health Evidence Review Commission.

The Oregon Chiropractic Association (OCA) repeatedly gave written and oral testimony that the original draft guidelines placed too much emphasis on drugs and surgery. A close review of the original algorithm, “Management of Low Back Pain (LBP) (Image 2), relative to “#23 Signs or symptoms of radiculopathy or spinal stenosis,” reveals this. For example, if subsequent special imaging (MRI) revealed concordant nerve root impingement or spinal stenosis (#25), the original draft algorithm led the clinician into a surgical or other invasive procedure “dead end,” meaning there was no contingency for conservative chiropractic treatment (#26).

Associate Professor, Anglo-European College of Chiropractic, Bournemouth, UK. jmiller@aecc.ac.uk.

OBJECTIVE:   The purpose of this study was to determine the efficacy of chiropractic manual therapy for infants with unexplained crying behavior and if there was any effect of parental reporting bias.

METHODS:   Infants with unexplained persistent crying (infant colic) were recruited between October 2007 and November 2009 at a chiropractic teaching clinic in the United Kingdom. Infants younger than 8 weeks were randomized to 1 of 3 groups: (i) infant treated, parent aware; (ii) infant treated, parent unaware; and (iii) infant not treated, parent unaware. The primary outcome was a daily crying diary completed by parents over a period of 10 days. Treatments were pragmatic, individualized to examination findings, and consisted of chiropractic manual therapy of the spine. Analysis of covariance was used to investigate differences between groups.

RESULTS:   One hundred four patients were randomized. In parents blinded to treatment allocation, using 2 or less hours of crying per day to determine a clinically significant improvement in crying time, the increased odds of improvement in treated infants compared with those not receiving treatment were statistically significant at day 8 (adjusted odds ratio [OR], 8.1; 95% confidence interval [CI], 1.4-45.0) and at day 10 (adjusted OR, 11.8; 95% CI, 2.1-68.3). The number needed to treat was 3. In contrast, the odds of improvement in treated infants were not significantly different in blinded compared with nonblinded parents (adjusted ORs, 0.7 [95% CI, 0.2-2.0] and 0.5 [95% CI, 0.1-1.6] at days 8 and 10, respectively).

CONCLUSIONS:   In this study, chiropractic manual therapy improved crying behavior in infants with colic. The findings showed that knowledge of treatment by the parent did not appear to contribute to the observed treatment effects in this study. Thus, it is unlikely that observed treatment effect is due to bias on the part of the reporting parent.

Introduction

University of Calgary, 2500 University Drive N.W., Calgary, Alberta, Canada T2N 1N4. Tel: 403-220-8525; Fax: 403-284-3553; email: walter@kin.ucalgary.ca

In recent weeks, we have learnt that chiropractors may have to carefully review the application of high-speed, low-amplitude spinal manipulative treatments to the neck. The concern is the possible risk associated with neck manipulation. Specifically, vertebral artery dissection, or ther mechanical injury, are an acknowledged, albeit a very low, risk.

The vast amount of research on vertebrobasilar injury in the past has been focused on blood flow through the vertebral artery during diagnostic, and before and after manipulative treatment. There was (is) concern that vertebral artery occlusion may occur during neck manipulation, and that a lack of blood supply to the brain may lead to a series of complications. This line of argument has always struck us as weak, because a high-speed, low-amplitude thrust to the cervical spine lasts typically less than 150 ms, and the brain has sufficient oxygen to survive such a small amount of (possible) loss of blood flow from one of its many supply arteries.

Another way of attempting to gain insight into the possible risk of neck manipulation and vertebrobasilar accidents is a statistical (epidemiological) approach. The basic question that people would like to answer is: are people who receive neck manipulative treatments at a greater risk of vertebrobasilar accidents than people who do not receive such treatments? On the surface, this approach seems feasible, and so it would be, if the occurrence of such accidents was high (let’s say one time in a hundred or a thousand). However, it appears that we deal with incidence rates (if there is an actual incidence) of one in several millions (i.e. very low). Therefore, any statistical pproach has a miniscule power, and a couple of “fluke accidents” (i.e., accidents that occur, let’s say in a chiropractic clinic, but in reality have nothing to do with the chiropractic treatment) may produce a “statistical error” that may persist for years in a community as small as Canada.   Also, using an epidemiological approach, the question of “cause and effect” cannot be resolved.

When starting to tackle the problem of the mechanics of neck manipulative treatments three years ago with my student B. Symons (DC), we were surprised that, to the best of our knowledge, there were no data on what actually happens mechanically to the vertebral artery during cervical spinal manipulation. I was further surprised, when asked to review a case on a vertebrobasilar accident, that one of the arguments went as follows: Pathology revealed no dissection of the vertebral artery, therefore, the vertebrobasilar accident cannot be associated with chiropractic treatment.

Discussing this particular statement within the chiropractic community, it became apparent that mechanical injury to the vertebral artery was an accepted, but very, very very rare occurrence; but nevertheless, accepted. And all this without a shred of scientific evidence about the mechanics of the vertebral artery during cervical manipulation.

So, when does the vertebral artery, or for that matter, any tissue, become injured?

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Back and neck pain are common ailments in school age children with prevalence rates ranging from 5% to 74%. [38, 39] The prevalence of low back pain increases from preadolescence to early adulthood, [38, 40] but after that, the prevalence rates change surprisingly little. [41] A similar pattern is seen for neck pain, [41] but less is known about the course of other musculoskeletal disorders throughout life. However, extremity complaints are found frequently in children. [42]

It has been demonstrated that children and adolescents with musculoskeletal complaints have a higher risk of having these problems as adults. [43-45] Pain and aberrant musculoskeletal function are known to have other consequences with regard to health. Long-lasting pain conditions, including back pain, have been associated with a generally decreased pain threshold, [46-48] which seems to develop alongside pain, because patients did not have a higher pain threshold than asymptomatic subjects before the onset of back pain. [49] If this process is initiated in childhood, it is likely to increase the impact of minor trauma or overuse in everyday life and thus may induce a lifelong cascade of negative health events, resulting in poorer general health and lower quality of life.

Another possible consequence of musculoskeletal disorders in childhood is pain becoming a barrier to physical activity. Children who are injured while performing sport activities [42, 50] may avoid or stop the activity that caused the original injury. It is also plausible that continued pain or discomfort may reduce motivation to participate and enjoy physical activities. Reduction in activity can have serious health implications over time. It is established that physical activity is one of the most important factors relating to several lifestyle disorders such as diabetes and cardiovascular disease, [51, 52] and it has been shown that increased physical activity in youth can reduce the risk of these disorders in adulthood. [53, 54] Moreover, health habits throughout the lifespan are established in youth, [55, 56] and therefore, promoting and maintaining a healthy level of physical activity in children and adolescence are essential to improve public health. Thus, an important element to reach lifelong health is to optimize musculoskeletal health.

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