The JMPT is the premier scientific journal of the chiropractic profession, dedicated to the advancement of chiropractic health care.
Chest Compression During Chiropractic Manipulation of the Thoracic Spine
Brian Stemper, PhD, et al.
Purpose: Chiropractic manipulation of the thoracic spine may induce chest deformations in the anterior-posterior direction; yet few studies have examined the biomechanical response of the chest associated with these manipulations. Consequently, an experimental analysis was undertaken to quantify chest compressions resulting from chiropractic thoracic spine manipulations and to estimate amount of risk for injury.
Methods: A two-part study approach was used with a Hybrid III anthropomorphic test dummy. In part 1, the dummy was positioned prone on a chiropractic table and subjected to thoracic spine manipulation by two experienced doctors of chiropractic. Chest compressions were quantified in the anterior-posterior direction. Manipulation forces were self-selected, with "typical" and "maximum" efforts examined. In part 2, the dummy was positioned beneath a force-instrumented mechanical piston device. Using the piston, chest compressions were induced with magnitudes identical to those recorded during chiropractic manipulation as well as magnitudes sufficient to induce injury. In all trials, force measurements were recorded.
Results: Thoracic manipulations incorporating the typical and maximum efforts by the chiropractors resulted in maximum chest compressions attaining 1.8% and 4.5% of total chest depth, respectively. According to previously developed correlations between chest compression and injury severity defined using the Abbreviated Injury Scale (AIS), maximum chest compression measured during this study was only 22.7% of the compression required for greater than 10% risk of an AIS 1 injury. Abbreviated Injury Scale 1 level injuries are graded as minor severity and correspond to sternum contusion or fracture of a single rib.
Conclusions: Results from this preliminary study showed that maximum chest compression during thoracic spine manipulation corresponded to minimal risk of AIS 1 level injuries.
Evidence-Based Guidelines for Chiropractic Treatment of Adult Headache
Roland Bryans, DC, et al.
Objective: The purpose of this manuscript is to provide evidence-informed practice recommendations for the chiropractic treatment of headache in adults.
Methods: Systematic literature searches of controlled clinical trials published through August 2009 relevant to chiropractic practice were conducted using the databases MEDLINE; EMBASE; Allied and Complementary Medicine; the Cumulative Index to Nursing and Allied Health Literature; Manual, Alternative, and Natural Therapy Index System; Alt HealthWatch; Index to Chiropractic Literature; and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, limited, or conflicting) and to formulate practice recommendations.
Results: Twenty-one articles met inclusion criteria and were used to develop recommendations. Evidence did not exceed a moderate level. For migraine, spinal manipulation and multimodal multidisciplinary interventions including massage are recommended for management of patients with episodic or chronic migraine. For tension-type headache, spinal manipulation cannot be recommended for the management of episodic tension-type headache. A recommendation cannot be made for or against the use of spinal manipulation for patients with chronic tension-type headache. Low-load craniocervical mobilization may be beneficial for longer term management of patients with episodic or chronic tension-type headaches. For cervicogenic headache, spinal manipulation is recommended. Joint mobilization or deep neck flexor exercises may improve symptoms. There is no consistently additive benefit of combining joint mobilization and deep neck flexor exercises for patients with cervicogenic headache. Adverse events were not addressed in most clinical trials; and if they were, there were none or they were minor.
Conclusions: Evidence suggests that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and findings. Evidence for the use of spinal manipulation as an isolated intervention for patients with tension-type headache remains equivocal.
Headache: Placebo Effects in the Control Groups in Randomized Clinical Trials
Femke de Groot, BSc, et al.
Objective: The purpose of this study is to describe the effects in the placebo and "no treatment" arms in trials with headache patients.
Method: This is a secondary analysis of randomized controlled trials from eight systematic reviews and selected trials with a "no treatment" or placebo control group. The different types of "no treatment" and placebo interventions were assessed and classified into six subgroups. The analyses were carried out according to type of outcome variable.
Results: In total, 119 studies were included (7,119 participants). The mean recovery rate in all control groups was 35.7%. Significantly more participants recovered in control groups of pharmacological studies than in nonpharmacological studies: 38.5% vs 15.0%, respectively. Adults were more likely to recover in nonpharmacological studies and children in pharmacological studies.
Conclusions: The mean recovery rate in the control groups was 36%. The recovery rate varied substantially between type of intervention and patients.
Palpatory Accuracy of Lumbar Spinous Processes Using Multiple Bony Landmarks
Karen Snider, DO, MS, et al.
Objective: Accurate localization of vertebral segments is crucial for many treatment procedures. The objective of this study was to determine accuracy of identification of lumbar spinous process levels by palpation.
Methods: Three examiners independently identified the spinous processes of L1-L4 on 60 prone volunteers using multiple bony landmarks including the sacral base, L5, Tuffier's line, T12, and the 12th ribs. The spinous processes were marked with radiopaque skin markers. Location of marker placement and presence of anatomical anomalies were determined by posteroanterior lumbar radiographs. Accuracy of marker placement and interobserver reliability were assessed using weighted k values. Generalized linear mixed models and Cochran-Mantel-Haenszel tests assessed the relationship of accuracy to training level, presence of anatomical anomalies, and participant characteristics.
Results: Examiners identified a spinous process in 91% of vertebral assessments. Correct identification of vertebral level occurred 69% of the time (k = 0.81; 95% confidence interval, 0.79-0.83). Faculty examiners were significantly more accurate in identifying the correct vertebral level than the resident examiner (67%-78% vs 51%, P ≤ .03). The presence of 12th rib anomalies decreased accuracy for all examiners (P ≤ .05), reducing accuracy from 74% to 55%. Accuracy was higher in male participants than in female participants (P = .01). Obesity significantly decreased accuracy (P = .0003) at L3 (50% vs 73%) and L4 (44% vs 72%).
Conclusions: Identification of lumbar spinous processes using multiple landmarks was more accurate than previously reported values. However, accuracy was dependent on examiner experience, presence of anatomical anomalies, and participant characteristics.
Manipulation for Shoulder Pain and Disorders: Expansion of a Systematic Review
James Brantingham, DC, PhD, et al.
Objective: The purpose of this study was to conduct a systematic review on manual and manipulative therapy (MMT) for common shoulder pain and disorders.
Methods: A search of the literature was conducted using the Cumulative Index of Nursing Allied Health Literature; PubMed; Manual, Alternative, and Natural Therapy Index System; Physiotherapy Evidence Database; and Index to Chiropractic Literature dating from January 1983 to July 7, 2010. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, musculoskeletal, physical therapies, shoulder, etc. Inclusion criteria required a shoulder peripheral diagnosis and MMT with/without multimodal therapy. Exclusion criteria included pain referred from spinal sites without a peripheral shoulder diagnosis. Articles were assessed primarily using the Physiotherapy Evidence Database scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring were complete, with subsequent participant review and agreement, evidence grades of A, B, C, and I were applied.
Results: A total of 211 citations were retrieved, and 35 articles were deemed useful. There is fair evidence (B) for the treatment of a variety of common rotator-cuff disorders, shoulder disorders, adhesive capsulitis, and soft-tissue disorders using MMT to the shoulder, shoulder girdle, and/or the full kinetic chain (FKC) combined with or without exercise and/or multimodal therapy. There is limited (C) and insufficient (I) evidence for MMT treatment of minor neurogenic shoulder pain and shoulder osteoarthritis, respectively.
Conclusions:This study found a level of B or fair evidence for MMT of the shoulder, shoulder girdle, and/or the FKC combined with multimodal or exercise therapy for rotator cuff injuries/disorders, disease, or dysfunction. There is a fair or B level of evidence for MMT of the shoulder / shoulder girdle and FKC combined with a multimodal treatment approach for shoulder complaints, dysfunction, disorders, and/or pain.
JMPT abstracts appear in DC with permission from the journal. Due to space restrictions, we cannot always print all abstracts from a given issue. Visit www.journals.elsevierhealth.com/periodicals/ymmt for access to the complete June 2011 issue of JMPT.