Objective: To review literature pertaining to neurologic disorders stemming from abnormal postures of the spine.
Data Collection: A hand search of available reference texts and a computer search of literature from Index Medicus sources was performed with special emphasis placed on spinal cord stresses and strains caused by various postural rotations and translations of the skull, thorax and pelvis.
Results: Spinal postures will often deform the neural elements within the spinal canal. Spinal postures can be broken down into four types of loading: axial, pure bending, torsion, and transverse, which cause normal and shear stresses and strains in the neural tissues and blood vessels. Prolonged stresses and strains in the neural elements cause a multitude of disease processes.
Conclusion: Four types of postural loads create a variety of stresses and strains in the neural tissue, depending on the exact magnitude and direction of the forces. Transverse loading is the most complex load. The stresses and strains in the neural elements and vascular supply are directly related to the function of the sensory, motor and autonomic nervous systems. The literature indicates that prolonged loading of the neural tissue may lead to a wide variety of degenerative disorders or symptoms. The most offensive postural loading of the CNS and related structures occurs in any procedure or position requiring spinal flexion. Thus, flexion traction, rehabilitation positions, exercises, spinal manipulation and surgical fusions in any position other than lordosis for the cervical and lumbar spines should be questioned.
Key Indexing Terms: Spinal Canal; Myelopathy; Multiple Sclerosis; Posture; Biomechanics; Nerve.
Extraspinal enthesopathy secondary to accutane therapy. James Brandt,DC, and Timothy Mick,DC.
Objective: To discuss a case of diffuse peripheral enthesopathy in a patient previously treated with long-term Accutane for severe acne.
Clinical Features: A 47-year-old male with one month history of moderate neck and right upper extremity pain, with hypesthesia of the right second and third fingers. Palpable bony prominences around multiple superficial joints were noted on physical examination, raising initial question of osteochondromatosis. Multiple active acne pustules were noted. A limited skeletal survey demonstrated diffuse peripheral enthesophyte formation and hyperostoses, resembling those of diffuse idiopathic skeletal hyperostosis (DISH), but without accompanying spinal changes. A history of long-term Accutane therapy was then elicited.
Intervention and Outcome: The enthesopathy was felt to represent an asymptomatic, long-standing, iatrogenically induced abnormality. No specific therapy or follow up was indicated. The patient had discontinued use of Accutane years ago. Cervical symptoms improved with four sessions of cervical traction and nonsteroidal antiinflammatory medications, but upper extremity symptoms were refractory.
Conclusion: Accutane-induced enthesopathy should be considered in individuals with correlating radiologic and clinical features and history of retinoic acid therapy for acne. This should be a diagnosis by exclusion, after eliminating other potential causes of peripheral enthesopathy, particularly DISH, seronegative spondylarthropathies and fluorosis.
Key Indexing Terms: Rheumatic Diseases; Isotretinoin.
Vertebral artery volume flow in man. Peter Licht,MD, Henrik Christensen,DC,MD, and Poul Flemming Hoilund-Carlsen,MD,DMSc.
Background: A number of studies have investigated vertebral artery flow velocity. Since perfusion relates to the volume of blood flowing through the vessel, this parameter is of great importance when investigating vertebral artery hemodynamics. We could not find any such Doppler studies in the literature, possibly due to known errors with previous techniques. A new advanced color-coded duplex has since been validated and may be used with confidence for volume flow investigations.
Objective: To use advanced color-coded duplex sonography to investigate volume flow through the vertebral arteries during cervical rotation, and before and after spinal manipulation therapy.
Design and Setting: A randomized controlled study at a university hospital vascular laboratory.
Participants: Twenty university students.
Results: Volume blood flow through the vertebral arteries does not change with cervical rotation or after spinal manipulation therapy.
Conclusion: This appears to be the first in vivo Doppler study on human vertebral artery volume blood flow. Our results indicate that in asymptomatic subjects there is no change in vertebral artery perfusion during rotation despite significant changes in flow velocity. This finding, and the observed changes in flow velocity reported by others, may be explained by a positional change in the vertebral artery diameter. In addition, we have investigated volume blood flow in the vertebral arteries before or after spinal manipulation therapy, but found no significant changes.
Key Indexing Terms: Volume Flow; Vertebral Artery; Rotation; Spinal Manipulation Therapy.
Chiropractic treatment of coccygodynia: Instrumental adjusting procedure utilizing activator methods chiropractic technique. Bradley Polkinghorn,DC, and Christopher Colloca,DC.
Objective: To document a case of coccygodynia that responded favorably to conservative chiropractic adjusting procedures using Activator methods chiropractic technique (AMCT), and the Activator II adjusting instrument (AAI II).
Clinical Features: A 29-year-old woman suffered from unremitting coccygeal pain of three weeks duration. The problem began after she had moved heavy boxes while at work. The pain was characterized by a continual dull ache in the coccygeal region, accompanied by intermittent sharp pain, particularly upon sitting or rising from a seated position. She had been taking self-prescribed over-the-counter analgesics (aspirin and Motrin) for three weeks without obtaining relief.
Intervention and Outcome: Chiropractic treatment consisted of mechanical force, manually assisted, short-lever (MFMA) chiropractic adjusting procedures to the coccygeal area, primarily the sacrococcygeal ligament. The AAI II was used to deliver the adjustment, following diagnostic and treatment protocol specified for AMCT. The patient experienced a complete resolution of her pain following the first treatment.
Conclusion: Chiropractic coccygeal manipulation may be effectively delivered via instrumental adjustment in certain cases of coccygodynia. The use of the Activator II adjusting instrument in administering the coccygeal adjustment has the benefit of being a gentle, non-invasive procedure, as well as being comfortably tolerated by the patient. This method of coccygeal adjustment may bear consideration in certain cases of coccygodynia.
Key Indexing Terms: Chiropractic; Coccyx.
Effect of pre-manipulative tests on vertebral artery and internal carotid artery blood flow: a pilot study. Darren Rivett, MAppSc (ManipPhty), Katrina Sharples,PhD, and Peter Milburn,PhD.
Background: Neck manipulation occasionally causes stroke following trauma to the vertebral or internal carotid artery. Pre-manipulative tests involving cervical spine rotation and/or extension have been recommended to detect patients at risk of neurovascular ischemia. However, the effect of these procedures on extra-cranial blood flow is not well established, and their validity is thus controversial.
Objective: To determine the effect of pre-manipulative tests involving cervical spine rotation and/or extension on vertebral artery and internal carotid artery blood flow parameters.
Design: Two-group experimental study.
Subjects: Twenty subjects consisting of 16 physiotherapy patients and four volunteers.
Methods: Subjects were tested using a recommended pre-manipulative protocol by both an independent physiotherapist and an investigator. One group consisted of 10 subjects testing positive, with 10 subjects testing negative comprising the second group. Hemodynamic measurements for both vertebral and both internal carotid arteries were taken using duplex Doppler ultrasound with color flow imaging in the following positions: neutral, end-range extension, 45 degrees contralateral rotation, end-range contralateral rotation and combined end-range contralateral rotation/extension.
Results: The reliability of pre-manipulative testing was supported. Significant changes in flow velocity of the vertebral artery were shown in end-range positions involving rotation and extension. The internal carotid artery demonstrated flow change at end-range extension. There were no significant differences found between the two groups.
Conclusions: Screening procedures utilizing rotation and extension may be useful tests of the adequacy of collateral circulation. A larger study is needed to determine whether subjects testing positive significantly differ from those testing negative.
Key Indexing Terms: Manipulation Therapy; Head Movements; Vertebral Artery; Internal Carotid Artery; Doppler Ultrasonography; Blood Flow Velocity.
Chronic spinal pain syndromes: A clinical pilot trial comparing acupuncture, a nonsteroidal antiinflammatory drug and spinal manipulation. Lynton Giles,DC(C),PhD, and Reinhold Muller,PhD.
Objective: To compare needle acupuncture, medication (Tenoxicam with Ranitidine) and spinal manipulation for managing chronic (>13 weeks duration) spinal pain syndromes.
Design: Prospective, randomized, independently assessed pre/post-intervention clinical pilot trial.
Setting: Specialized spinal pain syndrome outpatient unit at Townsville General Hospital, Queensland Australia.
Subjects: 77 patients (without contraindication to manipulation or medication) were recruited.
Interventions: One of three separate, clearly defined intervention protocols: needle acupuncture, nonsteroidal antiinflammatory medication or chiropractic spinal manipulation.
Main Outcome Measures: Main outcome measures were changes (four weeks vs. initial visit) in the scores of (i) Oswestry Back Pain Disability Index; (ii) Neck Disability Index; and (iii) three Visual Analogue Scales of local pain intensity.
Results: Randomization was successful. After a median intervention period of 30 days, consistently, over all outcome measures, spinal manipulation was the only intervention which achieved statistically significant improvements (all expressed as percentages of the original scores) with: (i) a reduction of 30.7% on the Oswestry scale; (ii) an improvement of 25% on the Neck Disability Index; and (iii) reductions on the Visual Analogue Scale of 50% for low back pain, 46% for upper back pain and 33% for neck pain (all p<0.001). Neither of the other interventions showed any significant improvement on any of the outcome measures.
Conclusions: The consistency of the results provides, despite several discussed shortcomings of this pilot study, evidence that, in patients with chronic spinal pain syndromes, spinal manipulation, if not contraindicated, results in greater improvement than acupuncture and medicine.
Key Indexing Terms: Spine; Acupuncture; Chiropractic Manipulation; Medicine; Clinical Trial; Chiropractic.
Preliminary study of the reliability of assessment procedures for indications for chiropractic adjustments of the lumbar spine. Cheryl Hawk,DC PhD; Chutima Phongphua,MD,DC; James Bleecker,DC; Larry Swank,DC; Dennis Lopez,DC; and Todd Rubley,DC.
Objective: To assess the intraexaminer and interexaminer reliability of clinicians trained in flexion-distraction technique to determine the need for chiropractic adjustment of each segment of the lumbar spine.
Design: This was an intra/interexaminer reliability study of commonly used chiropractic assessment procedures, including static and motion palpation and visual observation.
Setting: A chiropractic college, by four licensed chiropractors trained in flexion-distraction technique; two with over 20 years experience and two with three or fewer years of experience.
Subjects: Subjects were 18 volunteers; 16 were asymptomatic and two were symptomatic for low back pain at the time the study was conducted.
Main Outcome Measure: The Kappa statistic was computed for all comparisons and interpreted in categories ranging from "poor" (<0.00) to "almost perfect" (>0.80).
Results: Intra-examiner reliability was greater than interexaminer reliability. For intra-examiner reliability, there was considerable variation by segment and among the four examiners, but intra-examiner reliability appeared generally higher than interexaminer reliability. Overall, more subluxations were identified on the second examination than on the first. For interexaminer reliability, Kappa scores were generally in the "poor" to "slight" categories.
Discussion: The results of this study, similar to those of other studies, indicate that even chiropractors trained in the same technique appear to show little consensus on the indications for the necessity to adjust specific segments of the spine. A more standardized assessment approach might be helpful in improving the reliability of diagnostic assessments.
Key Indexing Terms: Chiropractic: Reliability; Palpation.
Prevalence of hyperplastic articular pillars in the cervical spine and relationship with cervical lordosis. Cynthia Peterson, DC; R.J. Kirk, M. Isdahl; and B. K. Humphrey,DC,PhD.
Background: Cervical lordosis is often used as an indicator for a number of clinical conditions ranging from traumatic to degenerative. Previous research has indicated that a number of factors may change the lordosis. However, the link between hyperplastic articular pillars and cervical lordosis measurements has never been studied.
Objective: To investigate the reliability of determining articular pillar hyperplasia, to determine its prevalence and to compare lordosis measurements between persons with and without hyperplasia of the cervical articular pillars.
Methods: Twelve normal neutral lateral cervical radiographs were chosen for the reliability study. Two chiropractors independently evaluated the articular pillars of C3 through C6 by drawing lines along the planes of the superior and inferior articular surfaces of each pillar. Each pillar was categorized as "normal" or "hyperplastic" depending on the convergence or divergence of these lines. One examiner repeated this procedure after a one month interval. Percent agreement and Kappa statistics were calculated for inter and intra-examiner agreement.
Forty-eight normal neutral lateral cervical radiographs with a horizontal Chamberlain's line were evaluated for the presence or absence of pillar hyperplasia. Two measurement techniques were used to assess the cervical lordosis: The method of Jochumsen and the "angle of the cervical lordosis." The unpaired t-test was used to compare the angle of cervical lordosis measurements between the two groups. The Mann-Whitney U test was used to analyze data obtained with the method of Jochumsen. The prevalence of pillar hyperplasia was calculated on 100 normal lateral cervical radiographs.
Results: Inter- and intra-examiner reliability of determining pillar hyperplasia was fair to substantial (K =.4 to .61; 75-92%). Forty-six percent of the patients demonstrated pillar hyperplasia of at least one cervical level. Patients with pillar hyperplasia had a mean cervical curve of 31.52 while the curve in patients without pillar hyperplasia was 44.76 (p = .0001). The method of Jochumsen also detected a significant difference in the curve measurements between the two patient groups (p =.0127).
Conclusion: Articular pillar hyperplasia is common and significantly reduces cervical lordosis measurements. Accepted normal values for lordosis evaluation need to be reassessed and articular pillar configuration considered when treatment plans include attempts to restore a "normal" cervical lordosis. Previous studies attempting to link lordosis measurements with pathology or symptomatology may need to be re-evaluated.
Key Indexing Terms: Cervical Spine; Lordosis; Articular Pillars; X-ray; Measurement; Reliability.
Stress: The chiropractic patient's self-perceptions. Jennifer Jamison,MB,BCh,PhD,EdD.
Background: Psychosocial stress pervades modern life and is known to impact health. Pain, especially chronic back pain, is influenced by stress. Various strategies have been shown to successfully reduce stress and its consequences.
Objectives: This study explores stress as a potential health-disease trigger amongst chiropractic patients.
Method: A descriptive study was undertaken to ascertain the stress perceptions of chiropractic patients. Purposive sampling of chiropractic practices and convenience sampling of patients were undertaken. Patients were allocated to one of four groups according to their presentation: acute, chronic biomechanical, fibromyalgia or maintenance care. Participating patients were requested to complete a questionnaire.
Results: Of the 138 patients attending one of 10 participating chiropractic clinics, more than 30 percent regarded themselves as moderately to severely stressed, and over 50 percent felt that stress had a moderate or greater affect on their current problem. Some 71 percent of patients felt it would be helpful if their chiropractic care included strategies to help them cope with stress, and 44 percent were interested in taking a self-development program to enhance their stress management skills.
Conclusion: Patient perceptions are known to be important in health care. A number of chiropractic patients perceive they are moderately or severely stressed. Interventions that reduce stress, or even the patient's perception of being stressed, may be construed as valid nonspecific clinical interventions. It may be timely for chiropractors to actively contemplate routinely including stress management in their clinical care protocols.
Key Indexing Terms: Chiropractic; Stress; Patient.
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