by Danny Stephens,DC,DO,MChiroSc; Henry Pollard,GradDipChiro,Grad Dip AppSc,MSportsSc; Don Bilton,DC, Peter Thomson,DC,DO,MChiroSc; Frank Gorman,MBBS,DO.
Objective: To discuss the recovery of optic nerve function after chiropractic spinal manipulation in a patient who suffered loss of vision as a result of facial fracture after a fall.
Clinical Features: In a fall down a stairwell, a 53-yr-old female migraineuse suffered a right zygomatic arch fracture which was treated surgically. Approximately three weeks after the accident, vision in her contralateral eye became reduced to light perception. Electrophysiological studies revealed diminished function of both optic nerves, the right significantly more than the left. Single photon emission tomography (SPECT ) showed pan-cerebral ischemic foci.
Intervention and Outcome: Chiropractic spinal manipulation was used to aid recovery of vision to normal over a course of 20 treatment sessions. At times, significant improvement in vision occurred immediately following spinal manipulation. Progressive recovery of vision was monitored by serial visual field tests and by electrophysiological studies. Unfortunately, the patient refused a further SPECT study when visual recovery was complete.
Conclusion: This case report adds to previous accounts of progressive and expeditious recovery of optic nerve function in association with spinal manipulation therapy.
Key Indexing Terms: Chiropractic Manipulation; Visual Loss; Optic Nerve; Ischemia.
Sitting biomechanics, Part I: Review of the literature.
by Donald D. Harrison,DC,PhD; Sanghak O. Harrison,DC; Arthur C. Croft,DC; Deed E. Harrison,DC; Stephan J. Troyanovich,DC.
Objective: To develop a new sitting spinal model and an optimal driver's seat using review of the literature of seated positions of the head, spine, pelvis and lower extremities.
Data Selection: Searches included MEDLINE of scientific journals, engineering standards and textbooks. Key terms included sitting ergonomics, sitting posture, spine model, seat design, sitting lordosis, sitting electromyography, seated vibration, and sitting and biomechanics.
Data Synthesis: Part I: Papers were selected if they (1) contained a first occurrence of a sitting topic; (2) were reviews of the literature; (3) corrected errors in previous studies; or (4) had improved study designs compared to previous papers. Part II: Separated information pertaining to sitting dynamics and drivers of automobiles from Part I.
Results: Sitting causes the pelvis to rotate backward, causes reduction in lumbar lordosis, trunk-thigh angle, knee angle, and causes an increase in muscle effort and disc pressure. Seated posture is affected by seat back angle, seat bottom angle and foam density, height above floor, and armrest.
Conclusion: The configuration of the spine, postural position, and weight transfer is different in the three types of sitting: anterior, middle, and posterior. Lumbar lordosis is affected by the trunk-thigh angle and the knee angle. Subjects in seats with backrest inclinations of 110-130À, with concomitant lumbar support, have the lowest disc pressures and lowest EMG recordings from spinal muscles. A seat bottom posterior inclination of 5À and armrests can further reduce lumbar disc pressures and EMG readings while seated. To reduce forward translated head postures, a seat back inclination of 110À is preferable over higher inclinations. Work objects, such as video monitors, are optimum at eye level. Forward tilting seat bottom inclines can increase lordosis, but subjects give high comfort ratings to adjustable chairs which allow changes in position.
Key Indexing Terms: Sitting; Biomechanics; Lordosis; Ergonomics; Spine; Model; Vibration; Posture; Chair Design.
The influence of a chiropractic manipulation on lumbar kinematics and EMG during simple and complex tasks: A case study.
by Gregory J. Lehman and Stuart M. McGill, PhD.
Objective: To investigate whether a more sophisticated and detailed analysis of both simple and complex tasks may yield more information regarding the short term influence of an adjustment on spine biomechanics.
Design: Single subject, pre-post design.
Methods: Three-dimensional spine kinematics and trunk muscle EMG were assessed during a variety of tasks in a professional golfer exhibiting nonspecific chronic low back pain. The patient received a right to left and left to right spinous pull adjustment.
Results: Following the adjustment, changes were seen in all three axes of motion during a golf swing with concomitant muscle responses. In addition, changes in the off axes of motion were seen during simple movement tasks.
Conclusions: A more detailed spine kinematic analysis, specifically analysis of motion in the non-principled axes, yielded more information regarding the short term influence of an adjustment on lumbar spine motion and muscle function.
Key Indexing Terms: Chiropractic Manipulation; Low Back Pain; Electromyography; Kinematics.
Missed cervical spine fracture: Chiropractic implications.
by Rona Brynin,DC and Curtis Yomtob,DC.
Objective: To discuss the case of a patient suffering from an anterior compression fracture of the cervical spine which had been previously overlooked upon initial examination.
Clinical features: A 36-yr-old male was seen at a chiropractic clinic one month after diving into the ocean and hitting his head on the ocean surface. He chipped a tooth, but denied loss of consciousness. Initial medical examination in the emergency room did not include x-rays, but an anti-inflammatory medication was prescribed. X-rays taken at the chiropractic clinic one month later revealed an anterior compression fracture of the C-7 vertebra, with migration of the fragment noted on flexion and extension views.
Intervention and Outcome: The patient was referred back to his medical doctor for further evaluation and management. He was instructed to wear a Philadelphia collar for four weeks. During this time period, he reported "shooting" pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at two and one-half months post-injury. Follow-up x-rays at six months post-injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment.
Conclusion: Following head trauma, it is essential to x-ray the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation following head/neck trauma.
Key Indexing Terms: Cervical Spine; Trauma; Chiropractic; Fracture.
Interexaminer reliability of Activator Methods relative leg length evaluation in the prone, extended position.
by Hang T. Nguyen,DC; Diane N. Resnick,DC; Sylvia G. Caldwell,DC; Ernest W. Elston, Jr,DC; Bart B. Bishop,DC; Joseph B. Steinhouser,DC; Terry J. Gimmillaro,DC; Joseph C. Keating, Jr, PhD.
Objective: To investigate the inter-examiner reliability of the prone extended relative leg length check as described by Activator Methods, Inc (AMI).
Subjects: Thirty-four subjects were selected from a pool of 52 consecutive patients visiting a private chiropractic office.
Methods: Exclusion criteria included congenital or acquired conditions known to affect lower extremity length and inability to lie prone for 10 minutes. Two experienced, Activator advanced proficiency rated examiners assessed each patient in random order for leg length inequality (LLI). Findings were recorded as left short leg, equal leg length, or right short leg.
Results: The data for 34 subjects were organized in a 3x3 contingency table. Total agreement was 85%. A simple, unweighted Kappa yielded K=.66. A disproprortionately greater number of right short leg findings than left short leg findings were observed by both examiners. In only two instances were equal leg lengths observed; and both were detected by the same examiner. Because examiners found only two out of 34 subjects with equal leg lengths, several secondary analyses involving data reductions were conducted. The resulting Kappa values were similar to the 3x3 analysis.
Conclusion: There was good reproducibility between two examiners using the Activator method to detect leg length inequality in the prone extended position. This study does not address the validity or clinical significance of the measurement method. Future studies should include larger numbers and a wider variety of subjects as well as a diversity of examiners.
Key Indexing Terms: Reproducibility; Leg Length Inequality; Chiropractic.
Cervical flexion: A study of dynamic sEMG and ROM
by Jeffrey R. Cram,PhD and William J. Kneebone, DC.
Background: In the comprehensive assessment of painful conditions, dynamic sEMG and ROM recordings can provide information regarding muscle spasm, antalgic postures, fear of pain (protective guarding), muscle injury and disordered movement secondary to pain. This study examines ROM and sEMG patterns observed during cervical flexion.
Objective: To demonstrate two distinctive sEMG recruitment and dynamic ROM patterns observed during cervical flexion and return to midline.
Design: Single-subject design, with independent measurement of dynamic ROM and sEMG.
Setting: Applied clinical setting.
Participants: Two subjects with normal ROM and cervical muscles were studied.
Main Outcome Measure: One subject was studied electromyographically (sEMG), looking at the cervical paraspinals (CPS) and sternocleidomastoid (SCM) muscles, while the other subject was studied using an active range of motion (ROM) device. Three cervical movements were studied: lower cervical flexion; atlantoaxial (upper) cervical flexion; and combination upper/lower cervical flexion.
Results: The active ROM device indicates larger movements (higher degrees of flexion) for the lower cervical flexion compared to upper flexion. The combined movement indicates a differential movement from two spinal segments. The sEMG recordings indicated differential recruitment patterns. The SCM recruits briskly during the flexion phase of the upper cervical flexion movement, while the CPS recruits briskly during return to midline when the lower cervical flexion is utilized. The combined upper, then lower, cervical flexion movement recruits both sets of muscles.
Conclusions: The results of the study indicates two distinct movement patterns associated with upper versus lower cervical flexion, as well as sEMG recruitment patterns. The study tends to suggest two distinct movements involve two distinct cervical segments and are associated with recruit of different muscle groups. It is recommended that applied clinical research be used on the cervical spine, which utilizes sEMG recordings that assess both the upper and lower flexion movements as the standard for the study of cervical flexion.
Key Indexing Terms: Surface Electromyography; Range Of Motion; Cervical Vertebrae.
A randomized placebo controlled clinical trial on the efficacy of chiropractic therapy on premenstrual syndrome.
by Maxwell J. Walsh, BAppSc(Chiro),BSc, GradDipMuscMgt,DipEd and Barbara I. Polus, PhD,BAppSc(Chiro).
Objective: To evaluate the efficacy of chiropractic therapy on the treatment of symptoms associated with premenstrual syndrome (PMS).
Design: A prospective randomized placebo controlled crossover clinical trial.
Setting: Multi-center private clinics.
Subjects: Twenty-five subjects with diagnosed premenstrual syndrome (using a Moos PMS questionnaire plus daily symptom monitoring).
Intervention: After randomization, 16 subjects received high-velocity, low-amplitude spinal manipulation plus soft tissue therapy 2-3 times in the week prior to menses for at least three cycles. The remaining nine subjects received a placebo using an Activator adjusting instrument turned down. After a one-cycle washout, the two groups changed over.
Outcome Measure: Daily rating of symptom level, comparing total scores for premenstrual week for baseline, treatment and placebo phases.
Data Analysis: The data were analysed using paired t-tests and Wilcoxon Signed Rank tests, with the statistical significance being set at p<0.05.
Results: There was a significant decrease in scores following treatment compared to baseline scores (p=0.00001), and a statistically significant decrease in scores for the treatment phase compared to the placebo (p= 0.006). For Group 1 (n=16), there was a significant decrease in scores following treatment compared to baseline scores (p=0.0001), and a statistically significant decrease in scores for the treatment phase compared to the placebo (p= 0.041). For Group 2 (n=9), there was a significant decrease in scores during treatment compared to the base line (p=0.01); however,there was no difference at the p=0.05 level between treatment and placebo scores.
Conclusions: Within the limitations of the study, the results support the hypothesis that the symptoms associated with PMS can generally be reduced by chiropractic treatment consisting of adjustments and soft tissue therapy. However, the role of a placebo effect needs further elucidation, given that the group receiving the placebo first, while improving over the baseline, showed no further improvement when they had actual treatment.
Key Indexing Terms: Premenstrual Syndrome; Chiropractic Manipulation.
The types and frequencies of improved non-musculoskeletal symptoms reported after chiropractic spinal manipulative therapy.
by Charlotte Leboeuf-Yde, DC,MPH,PhD; Iben AxÐn,DC; Gregers Ahlefeldt, DC; Per Lidefelt,DC, Annika Rosenbaum, BAppSc(Chiro); Thomas Thurnherr, DC.
Objectives: To investigate the frequency and types of improved non-musculoskeletal symptoms reported after chiropractic spinal manipulative therapy.
Design: Retrospective information obtained by chiropractors through standardized interview of patients on return visit within two weeks of previous treatment.
Setting: Eighty-seven Swedish chiropractors in private practice (response rate, 81%).
Subjects: Twenty consecutive (presumably naive) patients per chiropractor (1504 valid questionnaires returned, 86% of optimal number of replies).
Intervention: Spinal manipulation with or without additional therapy provided by chiropractors.
Main Outcome Measures: Self-reported improved non-musculoskeletal symptoms ("reactions").
Results: At least one reaction was reported after the previous treatment in 21-25% of cases. Twenty-six percent of these were related to the airway passages (usually reported as "easier to breathe"); 25% were related to the digestive system (mostly reported as "improved function"); 14% were classified under eyes/vision (usually reported as "improved vision"); and 14% under heart/circulation (about half of these reported as "improved circulation"). The number of spinal areas treated was positively associated with the number of reactions.
Conclusion: A minority of chiropractic patients report having experienced non-musculoskeletal positive reactions after spinal manipulative therapy but such reports cluster predominantly around specific symptoms. It would be interesting to find out whether these can be verified objectively, and if so, to investigate if they are caused by the treatment or if they are signs of natural variations in the human physiology.
Key Indexing Terms: Chiropractic Manipulation; Muskuloskeletal System; Side Effects; Digestion; Circulation; Respiration; Vision.
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