Jaroslaw Grod,DC,FCCS(C), David Sikorski, DC, and Joseph Keating, Jr.,PhD
Objective: To determine the presence/absence of claims for the clinical art that are not currently justified by available scientific evidence, or which are intrinsically "untestable."
Design: A survey of patient education/promotional material produced by national, state and provincial societies and research agencies in Canada and the United States.
Method: Patient brochures were solicited from the three largest provincial, three largest state, and the three largest national professional associations in the United States and Canada. Similar requests were made of two research agencies supported by the national associations. Brochures were reviewed for the presence or absence of unsubstantiated claims.
Results: Of the 11 organizations sampled, nine distribute patient brochures. Of these nine organizations, all distribute patient brochures which make claims for chiropractic services not shown to have been scientifically validated.
Conclusion: The largest professional associations in the United States and Canada distribute patient brochures that make claims for the clinical art not currently justified by available scientific evidence or intrinsically untestable. These assertions are probably self-defeating, since they reinforce an image of the chiropractic profession as functioning outside the boundaries of scientific behavior.
Key indexing terms: chiropractic; marketing; patient education.
The effects of combined X-axis translations and Y-axis rotations on projected lamina junction offset.
Roger Coleman,DC, Deed Harrison,DC, and Bert Bernard
Objectives: To quantify the projection errors caused by the combining of selected x-axis translations with selected y-axis rotations as seen on plain film AP radiographs.
Study design: A computer was used to model the projection of the lamina junction and points on the lateral body margins of a 2-D vertebral model onto an AP radiograph. This simulation was done in the neutral position and in a number of combinations of x-axis translations and y-axis rotations.
Results: Depending upon the combination, the combining of x-axis translation and y-axis rotation can either increase or decrease the projected horizontal lamina offset as compared to what would be found with rotation alone. The projection of some combinations may lead the viewer to believe that rotation of the vertebral model is in the opposite direction of its true rotation.
Conclusion: The projections of combined movements of x-axis translations and y-axis rotations can lead to confusion when the clinician attempts to discern quantity and direction of y-axis vertebral rotation from the AP radiograph.
Key indexing terms: projection; anatomic model; radiography; spine; vertebrae.
Measuring the sacral inclination angle in clinical practice: Is there an alternative to x-rays?
Sita Bierma-Zeinstra,PhD,PT; Jack van Gool,MD,PT; Roos Bernsena,MD; and Khing Njoo,PhD,MD
Background: In patients with low-back pain (LBP) the position of the pelvis is often a focus of physical or manual therapy. The gold standard to determine sacral inclination is by x-ray, but methods to measure sacral inclination externally with an inclinometer have also been introduced.
Objective: To determine the validity of the inclinometer in measuring the sacral inclination in patients with LBP.
Subjects: Adult LBP patients referred by the general practitioner to the hospital for x-ray of the lumbosacral spine were included.
Methods: Measurement of sacral inclination acquired with the inclinometer, simultaneous with the x-ray exposure, was compared with the 'gold standard' measurement of sacral inclination on the x-ray. Regression analysis was used to define the measurement error.
Results: Of 50 consecutive LBP patients, x-rays of 41 patients were useful for the required measurements on the x-ray. The mean difference between the x-ray and inclinometer method was 23.12 degrees. The measurement error was 8.26 degrees. Regression analyses showed poor correlation between both methods (r=0.28).
Conclusions: The method we used to measure sacral inclination with an inclinometer was shown to be invalid.
Key indexing terms: validity; pelvis; lumbar lordosis; prognosis; low back pain.
Responsiveness of visual analogue and McGill pain scale measures.
Sally Scrimshaw,BAppS (Phty), Christopher Maher,PhD
Objective: To compare the responsiveness of the McGill pain questionnaire and the visual analogue scale.
Design: Repeated measures two-group design, with subjects divided into 'improved' and 'non-improved' groups. The external criterion to identify improved and non-improved patients was a seven-point global perceived effect (GPE) scale.
Subjects: Seventy-five low-back-pain patients who had participated in a randomized controlled trial of post-surgical rehabilitation.
Interventions: All patients completed both a VAS and McGill pain scale to describe their pain over the last two to four hours and a separate VAS to describe their current pain.
Main outcome measures: Responsiveness was evaluated using receiver-operating characteristic curves, with the analysis repeated for a range of cut off points on the GPE scale. Secondary analyses of responsiveness were provided by the T-value for independent change scores and Spearman's rho.
Results: The study confirmed the results of earlier studies in finding that the VAS was less responsive to clinical change when used to rate current pain, in comparison to pain over the last 24 hours. The study found that the VAS was more responsive than the McGill pain questionnaire when both instruments were used to rate pain over the last 24 hours.
Conclusion: The results of this study suggest that the VAS may be a better tool than the McGill pain questionnaire for measuring pain in clinical trials and/or clinical practice.
Key indexing terms: pain measurement; sensitivity to change; responsiveness; psychometric properties.
Cervical manipulation to a patient with a history of traumatically induced dissection of the internal carotid artery: a case report and review of the literature on recurrent dissections.
Sidney Rubinstein,DC, and Scott Haldeman,DC,MD,PhD
Objective: To describe the use of rotational cervical manipulation in treating a patient who had previously suffered from a traumatically induced dissection of the internal carotid artery (ICA), and to review the literature on recurrent cervical artery dissections (CAD).
Clinical features: A 21-year-old woman with hemiparesis as the result of an ICA dissection, which occurred as the result of a motor vehicle accident, suffered from neck pain and headaches. Moderate range of motion restrictions in the neck were present along with articular restrictions to movement palpation.
Intervention and outcome: Following a year of soft tissue treatment and detailed informed consent, diversified manipulation to the neck was attempted. The patient described greater and more immediate relief and longer pain-free periods than could be achieved by soft tissue treatment alone.
Conclusion: Patients with previous cervical artery dissections may present with unrelated neck pain and headaches requesting treatment. In selected cases with complete informed consent, manipulation of the neck may relieve these symptoms. A review of published case reports on recurrent dissections suggests that trauma is not a significant factor in the second dissection. Care must be taken in extrapolating the results from this case to any other patient with a prior history of cervical artery dissection.
Key indexing terms: chiropractic manipulation; carotid artery; complications; dissection.
Stiffness and neuromuscular reflex response of the human spine to posteroanterior manipulative thrusts in patients with low back pain.
Christopher Colloca,DC, and Tony Keller,PhD
Background: Studies investigating posteroanterior (PA) forces in spinal stiffness assessment have shown relationships to spinal level, body type, and lumbar extensor muscle activity. Such measures may be important determinants to discriminate between patients with low back pain and asymptomatic subjects. However, little objective evidence is available discerning variations in PA stiffness and its clinical significance. Moreover, while several studies have assessed only load input in relation to stiffness, a more complete assessment based upon dynamic stiffness measurements (force/velocity) and concomitant neuromuscular response may offer more information concerning mechanical properties of the low back.
Objective: To determine the stiffness and neuromuscular characteristics of the symptomatic low back.
Study design: This study is a prospective clinical study investigating the in vivo mechanical and muscular behavior of human lumbar spinal segments to high loading rate PA manipulative thrusts in subjects with low back pain (LBP).
Methods: Twelve male and 10 female subjects (range of 15-73 years; mean age 42.8) underwent physical examination and completed outcome assessment instruments including visual analog scale, Oswestry Low-Back Disability Index, and SF-36 Health Status questionnaires. Clinical categorization was made on the basis of symptom frequency and LBP history. A hand-held spinal manipulation device, the Activator(r) adjusting instrument, equipped with a preload control frame and impedance head, was used to deliver high-rate (< 0.1 msec) PA manipulative thrusts (190 N) to several common spinal landmarks including the ilium (PSIS), sacral base, and L5; L4; L2; T12; and T8 spinous and transverse processes. Surface linear-enveloped electromyographic (sEMG) recordings were obtained from electrodes (eight leads) located over the L3 and L5 paraspinal musculature to monitor the bilateral neuromuscular activity of the erector spinae group during the PA thrusts. Maximal effort isometric trunk extensions were performed by the subjects, prior to and immediately following the testing protocol to normalize sEMG data. The accelerance (peak acceleration/peak force, kg-1), or stiffness index, and composite sEMG neuromuscular reflex response was calculated for each of the thrusts.
Results: PA stiffness obtained at the sacroiliac joints, transverse processes, or spinous processes were not different for subjects groupedaccording to LBP chronicity. However, in subjects with frequent or constant LBP symptoms, there was a significantly increased spinous process (SP) stiffness index (7.0 kg-1) (P<0.05) in comparison to SP stiffness index (6.5 kg-1) of subjects with none or only occasional LBP symptoms. Patients with frequent or constant LBP symptoms also reported significantly greater VAS (P=0.001), Oswestry (P=0.001) and perceived health status (P=0.03) scores. The average SP stiffness index was 6.6 percent greater (P<0.05) and 19.1 percent greater (P<<0.001) than the average sacroiliac (SI) stiffness index and average transverse process (TP) stiffness index, respectfully.
Conclusions: This study is the first to assess erector spinae neuromuscular reflex responses simultaneously during spinal stiffness examination. This study demonstrated increased spinal stiffness index and positive neuromuscular reflex responses in subjects with frequent-constant LBP as compared to subjects reporting none-intermittent LBP.
Key indexing terms: biomechanics; electromyography; low back pain; manipulation-chiropractic; reflex responses; trunk muscle; spine-thoracic/lumbar, stiffness.
Schwannoma: challenging diagnosis.
James Cox,DC, and Michael Alter,DC
Objective: To discuss the presentation of a schwannoma in a 30-year-old male and to discuss the clinical features of this tumor.
Clinical features: The patient suffered from lower right back and abdominal pain, which was made worse by any jarring motion. MRI demonstrated an intradural extramedullary mass of the thoracic spine behind the T10 vertebral body, which was found to be a cchwannoma.
Intervention and outcome: A T10 full laminectomy and partial laminectomies of T9 and Y11 allowed removal of the tumor.
Conclusion: When undiagnosed abdominal pain is present, a spinal tumor should be considered one possible diagnosis.
Key indexing terms: schwannoma; MRI; chiropractic.
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