Background: Pain continues to be the main symptom reported to clinicians by patients. Often times patients are incorrectly diagnosed and resulting treatments are ineffective, which may promote the development of chronic pain. It is likely that this situation arises because there is a lack of clarity in the literature regarding pain syndromes.
Objective: To discuss the differences between nociceptive, neuropathic and psychologic induction of pain, and provide important clinical correlates to aid in diagnosis and treatment.
Data Sources: The data was accumulated over a period of years by hand-reviewing contemporary articles and books, and subsequently retrieving relevant papers. Articles were also selected from MEDLINE searches, as well as manual library searches.
Data Synthesis: Nociceptive pain syndromes are responsible for the majority of pain complaints in clinical practice. Care must be taken to avoid the all-too-common mistake of assigning the diagnosis of neuropathic pain, which can lead to inappropriate treatments.
Conclusions: While the treatment of neuropathic pain remains enigmatic, sufficient evidence in the literature demonstrates that the treatment of nociceptive pain should be multimodal and involve spinal manipulation, muscle lengthening/stretching, trigger point therapy, rehabilitation exercises, electrical modalities, a variety of nutritional factors, and mental/emotional support.
Key Indexing Terms: pain; referred pain; nociception; joints.
Preliminary study of the effects of a placebo chiropractic treatment using sham adjustments. Cheryl Hawk,DC,PhD, Ayla Azad, DC, Chutima Phongphua,MD,DC, and Cynthia Long,PhD.
Objective: To identify aspects of the delivery of placebo chiropractic treatments using sham adjustments that may cause a treatment effect and affect the success of blinding.
Design: Two-period crossover design.
Setting: Chiropractic college research clinic.
Subjects: Subjects were 18 volunteers from staff, students and faculty of the chiropractic college reporting low back pain within the last six months.
Interventions: Flexion-distraction technique was used to perform chiropractic adjustments, and a hand-held instrument (Activator adjusting instrument) with the pressure gauge set on the "zero" setting was used to perform sham adjustments. The treatment period was for two weeks with a total of four visits.
Main Outcome Measures: The visual analog scale (VAS) for pain and global well-being scale (GWBS).
Results: Although VAS and GWBS scores improved with both treatments, there was a somewhat greater improvement, in most cases, with the active treatment. Eight of 14 patients interviewed believed that the placebo treatment had a treatment effect.
Conclusions: This study proved to be useful in planning the protocol for a placebo chiropractic treatment in the randomized clinical trial for which it was designed to provide preliminary information.
Key Indexing Terms: chiropractic; complementary health care; placebo.
The importance of normalization in the interpretation of surface electromyography: A proof of principle. Gregory Lehmana, and Stuart McGill,PhD.
Objective: To demonstrate the errors in surface electromyogram interpretation that can be made when the EMG signal is not normalized.
Design: A case study as a proof of principle.
Main Outcome Measures: The EMG amplitude between the upper and lower portions of the rectus abdominis in one subject during a trunk curl was compared when the EMG signal was normalized (expressed as a percentage of a maximum voluntary contraction) and when the signal was expressed in raw, unnormalized arbitrary units or raw millivolts directly read from the instrumentation.
Results: Interpretation of the unnormalized EMG signal suggests that a large difference in neural activation of the upper and lower sections of the rectus abdominis is occurring. In this condition, the average activity in the lower rectus is 60.9% of that in the upper portion. This interpretation is incorrect. When the EMG signal is normalized, the differences between the upper and lower segments are reduced. When normalized the lower segment activity is equal that of the upper segment.
Conclusions: Due to the inherent variability of EMG signals, clinical interpretation of surface EMG signals requires normalization of the signal for physiological interpretation, and when comparing between bilateral muscles, between the same muscle on different days and different subjects.
Key Indexing Terms: electromyography; rectus abdominis; normalization.
Chiropractic care and ochronotic arthropathy. Michael Mestan,DC, Gary Bustin,DC, and Lisa Wagner,DC.
Objective: To discuss the case of a patient suffering from ochronotic arthropathy who was treated symptomatically with chiropractic care. An emphasis is placed on this condition's radiographic features.
Clinical Features: A 59-year-old female with low back, right knee and left ankle pain sought chiropractic evaluation. Black pigmentation was found in the sclera of both eyes and homogentisic acid was present in the urine. Orthopedic evaluation revealed uncomplicated, nonspecific joint pain and radiographs demonstrated characteristic spinal changes.
Intervention and Outcome: The patient was treated with chiropractic manipulation, physiotherapy modalities, bracing and exercises. This type of therapy was successful in reducing symptomatology and helping decrease the severity and frequency of acute exacerbations.
Conclusion: Ochronotic arthropathy is a rare metabolic disorder that can be diagnosed from spinal radiographs. Chiropractic care is a reasonable tool for reducing its symptomatology.
Key Indexing Terms: alkaptonuria; ochronosis; joints; chiropractic; x-rays.
Biological activity of melaleuca alternifolia (tea tree)oil component, terpinen-4-ol, in human myelocytic cell line HL-60. Shalini Budhirajaa; Malford Cullum,PhD; Susie Sioutis,DC; Lucio Evangelistaa; Susan Habanovaa.
Background: Tea tree oil is an aboriginal Australian traditional medicine for bruises, insect bites and skin infections. It was rediscovered in the 1920s as a topical antiseptic that is more effective than phenol. Previous studies have demonstrated its antiseptic qualities but its effects on human white blood cells have never been investigated.
Objective: To test the hypothesis that tea tree oil exerts its antiseptic action through white blood cell activation.
Methods: Crude oil and the purified "active" component were studied using a model system that responds to bioactive components by induction of differentiation in white blood cells. Methods used included white blood cell oxidative burst assay (NBT dye reduction); cell proliferation assay (tritiated thymidine incorporation); cell surface differentiation marker assay (flow cytometric quantitation of phycoerythrin-anti-CD 11b binding); cell viability assay (trypan blue exclusion); and cellular differentiation enzyme assay (white cell esterase staining).
Results: Collectively, five assays that measure differentiation in white blood cells indicated monocytic differentiation posttreatment with either crude oil or the purified "active" component. Both the crude oil and the purified "active" component, (+:-) terpinene-4-ol, caused a similar type and amount of differentiation. The culture of cells in medium containing serum caused more activation than in medium containing no serum.
Conclusion: The antiseptic activity of tea tree oil appears due, in part, to white blood cell activation.
Key Indexing Terms: antigens; cell differentiation; flow cytometry; nitroblue tetrazolium; plant oils; medicine, traditional; receptors; cell surface.
Vertebral artery flow and cervical manipulation: An experimental study. Peter Licht,MD; Henrik Christensen,DC,MD; Per Svendsen,DVM; Poul Flemming Hoilund-Carlsen,MD,DMSc.
Background: Spinal manipulation therapy is used in millions of patients each year to relieve symptoms from biomechanical dysfunction of the spine. Cerebrovascular accidents in the posterior cerebral circulation are a feared complication, but hardly any research exists on vertebral artery hemodynamics and cervical manipulation.
Objective: The purpose of this study was to develop an experimental model for investigations of volume blood flow changes in the vertebral arteries during premanipulative testing of these vessels and during spinal manipulation therapy of the cervical spine.
Design and Setting: An experimental study in a university biomedical laboratory.
Material and Methods: The vertebral arteries were exposed in eight adult pigs after extensive mediastinal dissection. Volume blood flow was measured on both sides simultaneously by advanced transit-time flowmetry.
Results: Following cervical manipulation, the vertebral artery volume blood flow increased significantly for 40 seconds before returning to baseline values within less than three minutes. We found no significant changes in volume blood flow during premanipulative testing of the vertebral arteries (DeKleyn's test).
Conclusion: We have presented an experimental model for investigations of vertebral artery hemodynamics during biomechanical interventions. We found a modest and transient effect of cervical manipulation on vertebral artery volume flow. The model may have further applications in future biomechanical research, e.g., to identify if any of several spinal manipulative techniques imposes less strain on the vertebral artery, thereby reducing possible future cerebrovascular accidents following such treatment.
Key Indexing Terms: chiropractic manipulation; vertebral artery; experimental; volume flow; transit time; doppler.
A psychological profile of fibromyalgia patients: A chiropractic case study. Jennifer Jamison,MB,BCh,PhD,EdD.
Background: Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain and tenderness. Reversible modulation of the pain threshold is believed to contribute to the pathogenesis of this condition and psychosocial stress is known to alter the pain threshold.
Objective: To describe and compare the psychological profile of fibromyalgia patients attending chiropractic clinics in Australia.
Setting: Chiropractic clinics located in five Australian states and the Australian capital territory with practices in inner city, suburban, coastal and country areas were included.
Subjects: Chiropractic patients with acute and chronic biomechanical conditions, patients with fibromyalgia, and patients undergoing maintenance care were included in the study.
Method: A case study to explore the psychological profile of fibromyalgia patients was undertaken. The DRAM and SOC questionnaires were used to ascertain and compare the distress, sense of coherence and manageability levels of patients with fibromyalgia with those having maintenance chiropractic care. Purposive sampling of practitioners and convenience sampling of patients fulfilling the study's inclusion criteria were undertaken. Patients were requested to complete two and chiropractors to complete one questionnaire and an interview.
Results: While over half of the patients in the fibromyalgia group were distressed, less than one in seven maintenance patients were found to be distressed using the DRAM questionnaire. With several individual exceptions, fibromyalgia patients also tended to have lower SOC and manageability scores than the maintenance group.
Conclusion: This study supports the view that fibromyalgia may represent a problem of coping with various environmental, and psychosocial stresses. However, owing to individual variation, a diagnosis of fibromyalgia does not accurately predict at the clinical level that a particular patient is distressed or has a low SOC score. Screening of fibromyalgia patients may be helpful in determining whether intensive counseling and stress management by the chiropractor or another health professional should be contemplated.
Key Indexing Terms: fibromyalgia; psychological profile; pain; chiropractic.
The empty sella. William Atherton,DC, and Norman Kettner,DC.
Objective: To discuss the diagnostic imaging findings of an empty sella in a chiropractic patient, with emphasis on magnetic resonance imaging of normal and abnormal pituitary appearances.
Clinical Features: A 44-year-old female started experiencing headache, dizziness, nausea, vomiting and diarrhea after an argument with her boyfriend. She had been treated for acute torticollis for three weeks when the new symptoms began. Consultation with an internist led to an MRI examination of the cerebellopontine angles to exclude an acoustic neuroma. The MRI demonstrated an enlarged empty sella. There was no history of pituitary tumor or other sellar pathology.
Intervention and Outcome: There was complete remission of the symptoms after one additional dizzy spell, three days after the initial complaint. No intervention was performed, but the stress levels in her life had been reduced.
Conclusion: An enlarged empty sella can be present without symptomatology, representing an incidental finding on radiography and MRI. However, an enlarged sella seen on lateral cervical spine radiographs should prompt further evaluation to rule out pituitary pathology. The normal pituitary has a varied appearance and signal intensity on MRI, depending on the patient's age and pregnancy status.
Key Indexing Terms: pituitary gland; sella turcica; magnetic resonance imaging.
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