Suzanne J. Snodgrass, PhD, Darren A. Rivett, PhD, Val J. Robertson, PhD, Elizabeth Stojanovski, PhD
Objective: There is little information on manual forces applied during cervical mobilization, a common treatment technique. Potential variability of applied forces between therapists and treatment occasions, and factors associated with different force applications, are unknown. The purpose of this study is to establish the baseline mechanical properties of cervical spine mobilization and to determine if the applied forces are affected by the characteristics of therapists and mobilized subjects.
Methods: Physiotherapists (n = 116) applied four grades of posteroanterior mobilization to the premarked C2 and C7 spinous (central technique) and articular processes (unilateral technique, one right and one left) of one of 35 asymptomatic subjects. Techniques were performed in randomized order, and the first one was repeated after 20 minutes. Load cells attached to the treatment table recorded forces in three directions. Before mobilization, subjects' spinal stiffness at the C2 and C7 spinous processes was measured using a custom device. Analyses of variance with Bonferroni post hoc tests determined technique and grade differences, intraclass correlation coefficients the reliability between therapists, and linear regression the factors associated with forces.
Results: Therapists apply distinct manual forces for different techniques and grades (P < .001). Variability between therapists is high, but intratherapist reliability is good (intraclass correlation coefficient [2,1] for different force parameters, 0.84-0.93). Mean peak forces increase from grades I to IV, ranging from 22 to 92 N for resultant forces. Greater vertical and caudad-cephalad forces are applied to C7 than C2 (P < .01), with higher mediolateral forces during unilateral techniques (P < .001). Male sex of the therapist or the mobilized subject is associated with higher forces, and C2 stiffness, thumb pain and postgraduate training with lower (P < .05).
Conclusion: These results quantify cervical mobilization forces, which will inform future research aimed at improving its application and clinical effectiveness.
Running Posture and Step Length Changes Immediately After Chiropractic Treatment
Dean L. Smith, DC, PhD, Mark Walsh, PhD, Jane P. Smith, DC
Objective: This case study reports on selected measures of locomotion (running) in a 5-year-old patient with xeroderma pigmentosum after chiropractic care.
Clinical Feature: A 5-year-old female patient (16.4 kg, 99.1 cm) with xeroderma pigmentosum (type A) volunteered to participate in the experiment with the consent of her parents. The patient had well-documented signs of delayed fine motor (e.g., difficulty with writing, coloring, cutting) and gross motor control (e.g., balance and coordination dysfunction and falling while running), and delayed speech.
Intervention and Outcomes: Trunk forward lean angles, step lengths, and hip horizontal translations were assessed by video as the participant ran as fast as possible down a laboratory runway. After chiropractic manipulation (adjustments), the patient reduced the trunk forward lean angle to become more vertical (P = .000). In addition, the patient experienced an increase in step length (P = .031). No significant change in lateral translation was observed after the intervention.
Conclusion: For this patient with xeroderma pigmentosum, chiropractic manipulation (adjustments) resulted in immediate changes in running performance. Further investigation is needed to examine the effect of chiropractic on locomotion in both symptomatic and asymptomatic patients.
Manipulative Therapy for Lower Extremity Conditions: Expansion of Literature Review
James W. Brantingham, DC, PhD, Gary Globe, DC, MBA, PhD, Henry Pollard, DC, PhD, et al.
Objective: The purpose of this study was to conduct a systematic review on manipulative therapy for lower extremity conditions and expand on a previously published literature review.
Methods: The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. The Cumulative Index to Nursing and Allied Health Literature; PubMed; Manual, Alternative, and Natural Therapy Index System; Science Direct; and Index to Chiropractic Literature were searched from December 2006 to February 2008. Search terms included chiropractic, osteopathic, orthopedic, or physical therapy and MeSH terms for each region. Inclusion criteria required a diagnosis and manipulative therapy (mobilization and manipulation grades I-V) with or without adjunctive care. Exclusion criteria were pain referred from spinal sites (without diagnosis), referral for surgery, and conditions contraindicated for manipulative therapy. Clinical trials were assessed using a modified Scottish Intercollegiate Guidelines Network ranking system.
Results: Of the total 389 citations captured, 39 were determined to be relevant. There is a level of C or limited evidence for manipulative therapy combined with multimodal or exercise therapy for hip osteoarthritis. There is a level of B or fair evidence for manipulative therapy of the knee and/or full kinetic chain, and of the ankle and/or foot, combined with multimodal or exercise therapy for knee osteoarthritis, patellofemoral pain syndrome, and ankle inversion sprain. There is also a level of C or limited evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for plantar fasciitis, metatarsalgia, and hallux limitus/rigidus. There is also a level of I or insufficient evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for hallux abducto valgus.
Conclusion: There are a growing number of peer-reviewed studies of manipulative therapy for lower extremity disorders.
Chiropractic Management of Myofascial Trigger Points and Myofascial Pain Syndrome: A Systematic Review of the Literature
Howard Vernon, DC, PhD, Michael Schneider, DC
Objective: Myofascial pain syndrome (MPS) and myofascial trigger points (MTrPs) are important aspects of musculoskeletal medicine, including chiropractic. The purpose of this study was to review the most commonly used treatment procedures in chiropractic for MPS and MTrPs.
Methods: The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. PubMed, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, and databases for systematic reviews and clinical guidelines were searched. Separate searches were conducted for (1) manual palpation and algometry, (2) chiropractic and other manual therapies, and (3) other conservative and complementary/alternative therapies. Studies were screened for relevance and rated using the Oxford Scale and Scottish Intercollegiate Guidelines Network rating system.
Results: A total of 112 articles were identified. Review of these articles resulted in the following recommendations regarding treatment: Moderately strong evidence supports manipulation and ischemic pressure for immediate pain relief at MTrPs, but only limited evidence exists for long-term pain relief at MTrPs. Evidence supports laser therapy (strong), transcutaneous electrical nerve stimulation, acupuncture, and magnet therapy (all moderate) for MTrPs and MPS, although the duration of relief varies among therapies. Limited evidence supports electrical muscle stimulation, high-voltage galvanic stimulation, interferential current, and frequency modulated neural stimulation in the treatment of MTrPs and MPS. Evidence is weak for ultrasound therapy.
Conclusion: Manual-type therapies and some physiologic therapeutic modalities have acceptable evidentiary support in the treatment of MPS and TrPs.
Chiropractic Management of Fibromyalgia Syndrome: A Systematic Review of the Literature
Michael Schneider, DC, PhD, Howard Vernon, DC, PhD, Gordon Ko, MD, Gordon Lawson, MSc, DC, Jerome Perera
Objective: Fibromyalgia syndrome (FMS) is one of the most commonly diagnosed nonarticular soft-tissue conditions in all fields of musculoskeletal medicine, including chiropractic. The purpose of this study was to perform a comprehensive review of the literature for the most commonly used treatment procedures in chiropractic for FMS and to provide evidence ratings for these procedures. The emphasis of this literature review was on conservative and nonpharmaceutical therapies.
Methods: The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. Online comprehensive literature searches were performed of the following databases: Cochrane Database of Systematic Reviews; National Guidelines Clearinghouse; Cochrane Central Register of Controlled Trials; Manual, Alternative, and Natural Therapy Index System; Index to Chiropractic Literature, Cumulative Index to Nursing and Allied Health Literature; Allied and Complementary Medicine; and PubMed up to June 2006.
Results: Our search yielded the following results: eight systematic reviews, three meta-analyses, five published guidelines, and one consensus document. Our direct search of the databases for additional randomized trials did not find any chiropractic randomized clinical trials that were not already included in one or more of the systematic reviews/guidelines. The review of the Manual, Alternative, and Natural Therapy Index System and Index to Chiropractic Literature databases yielded an additional 38 articles regarding various nonpharmacologic therapies such as chiropractic, acupuncture, nutritional/herbal supplements, massage, etc. Review of these articles resulted in the following recommendations regarding nonpharmaceutical treatments of FMS: Strong evidence supports aerobic exercise and cognitive behavioral therapy. Moderate evidence supports massage, muscle strength training, acupuncture, and spa therapy (balneotherapy). Limited evidence supports spinal manipulation, movement/body awareness, vitamins, herbs, and dietary modification.
Conclusion: Several nonpharmacologic treatments and manual-type therapies have acceptable evidentiary support in the treatment of FMS.
Chiropractic Management of Tendinopathy: A Literature Synthesis
Mark T. Pfefer, RN, MS, DC, Stephan R. Cooper, DC, Nathan L. Uhl, DC
Objective: Chronic tendon pathology is a soft-tissue condition commonly seen in chiropractic practice. Tendonitis, tendinosis, and tendinopathy are terms used to describe this clinical entity. The purpose of this article is to review interventions commonly used by doctors of chiropractic when treating tendinopathy.
Methods: The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. A literature search was performed using the PubMed; Cumulative Index to Nursing and Allied Health Literature; Index to Chiropractic Literature; Manual, Alternative, and Natural Therapy Index System; National Guidelines Clearinghouse; Database of Abstracts of Reviews of Effects; and Turning Research Into Practice databases. The inclusion criteria were manual therapies, spinal manipulation, mobilization, tendonitis, tendinopathy, tendinosis, cryotherapy, bracing, orthotics, massage, friction massage, transverse friction massage, electrical stimulation, acupuncture, exercise, eccentric exercise, laser, and therapeutic ultrasound.
Results: There is evidence that ultrasound therapy provides clinically important improvement in the treatment of calcific tendonitis. There is limited evidence of the benefit of manipulation and mobilization in the treatment of tendinopathy. Limited evidence exists to support the use of supervised exercise, eccentric exercise, friction massage, acupuncture, laser therapy, use of bracing, orthotics, and cryotherapy in the treatment of tendinopathy.
Conclusion: Chiropractors often provide a number of conservative interventions commonly used to treat tendinopathy.
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.mosby.com/jmpt for access to the complete January issue of JMPT.
Dynamic Chiropractic editorial staff members research, investigate and write articles for the publication on an ongoing basis. To contact the Editorial Department or submit an article of your own for consideration, email
.