John Triano,DC,PhD; Carolyn Rogers,MSBME; Sarah Combs,DC; David Potts,DC; Kenneth Sorrels,DC.
Objective: To quantify elements of spinal manipulation therapy performance and to test the strategy of combined rehearsal and quantitative feedback as a means of enhancing student skill development.
Design: Randomized, controlled study.
Setting: Chiropractic college.
Subjects: Thirty-nine chiropractic student volunteers entering the manipulation technique training course participating after obtaining informed consent.
Methods: Student performance of lumbar spinal manipulation therapy was quantified at the beginning, middle, and end of a trimester using a Leander 900 Z series manipulation table imbedded with an AMTI force plate. Loads passing through the L5/S1 functional spinal unit were estimated by inverse dynamics. Participating students rehearsed the mamillary push, diversified procedure, following the standard curriculum alone or a modified curriculum, adding the Dynadjust training aid as assigned on a randomized basis. Student-T and chi-square tests were used to explore and describe biomechanical parameter changes over time as the semester progressed.
Results: Significant changes in performance between the standard curriculum and modified curriculum (with the Dynadjust) were observed in several biomechanical parameters.
Conclusion: The reported project used a rehearsal program defined empirically, and was self-administered in practice by the student. Results demonstrated significant changes in performance of spinal manipulation by students using the Dynadjust instrument versus those who did not. Using quantitative training aids and biomechanical measurement systems, future training programs may be optimized and tested.
Key indexing terms: Chiropractic manipulation; training; skill; biomechanics; teaching aid.
Forces applied during manual therapy to patients with low back pain.
Adit Chiradejnant, MPhysio (Manips); Jane Latimer,PhD; Christopher Maher,PhD
Background: To date, there is little information available regarding the forces used during mobilization treatment of patients with low back pain.
Objective: This study measured such forces and investigated whether the force characteristics could be predicted based upon physical therapist and patient characteristics.
Subjects: Ten physical therapists applied a central PA mobilization treatment to 80 low-back-pain patients, providing data on treatment of 123 lumbar levels.
Methods: Physical therapists were required to treat their patients while each patient lay on an instrumented couch. This couch has been shown to be highly accurate in its measurement of force in three directions (error< two percent) and has demonstrated high test-retest reliability (ICC [2,1], 99 percent CI=0.99-1.00). The forces applied by the physical therapists were recorded over a 10-second period. Data on the characteristics of the physical therapists and patients were collected by questionnaires.
Results: The force used by physical therapists related to patient and physical therapist characteristics. Interestingly, current pain intensity and the nature of symptoms did not affect the forces used. The overall patterns of the force characteristics were generally consistent with previous studies performed in asymptomatic subjects. However, the magnitude of the force applied and the frequency of each grade used in the present study is relatively higher than in earlier studies.
Conclusion: These preliminary data provide some useful quantitative information about the forces used during mobilization treatment of patients with LBP. Also, the force characteristics described here may provide useful data for teaching and research in manual therapy.
Key indexing terms: Low back pain; mobilization; measurement; chiropractic manipulation; manual therapy.
Vertebral arteries and cervical rotation: Modelling and MRA studies.
Michael Haynes,BAppSc(Chiro); Lesley Cala,MD; Alison Melsom; Frank Mastaglia,MD; Nicholas Milne,PhD; John McGeachie, DSc.
Objective: To determine whether lumen narrowing in vertebral arteries during atlanto-axial rotation is due to stretch or localized compression.
Design and setting: Experiments using models were made in a private chiropractic clinic, while studies of cadaveric specimens were performed in an anatomy laboratory. Doppler ultrasound and MRA studies were carried out in the radiology department of a public hospital.
Patients: Eight patients had their vertebral arteries examined using a Doppler velocimeter and magnetic response angiography (MRA).
Main outcome measure: Stenosis of the vertebral arteries due to stretch, localized compression or kinking.
Results: All 16 vertebral arteries from the eight patients displayed no changes in their lumen dimensions with full cervical rotation, although curves in each of the arteries did change. The model and cadaveric vertebral arteries demonstrated localized compression, or kinking of the vessel wall with atlanto-axial rotation contralaterally, but revealed no evidence of major contributions of stretching to stenosis.
Conclusion: The lumen of vertebral arteries is usually unaffected by atlanto-axial rotation. In cases where there is stenosis, this is mainly due to localized compression or kinking. These findings are relevant to pre-manipulative screening of vertebral arteries using Doppler ultrasound.
Key indexing terms: Vertebral artery; vertebrae; flow meters; ultrasonic diagnosis; magnetic resonance angiography; chiropractic.
The effect of talocrural joint manipulation on range of motion at the ankle.
Gary Fryer,BAppSc (Osteo); Jacob Mudge,BSc,MHSc (Osteo); Patrick McLaughlin,BAppSc,MApp Sc.
Objective: To determine whether a single high-velocity, low-amplitude thrust manipulation to the talocrural joint altered ankle range of motion.
Design: A randomized, controlled and blinded study.
Subjects: Asymptomatic male and female volunteers (N=41).
Methods: Subjects were randomly assigned into either an experimental group (N=20) or a control group (N=21). Both ankles of subjects in the experimental group were manipulated using a single high-velocity, low- amplitude thrust to the talocrural joint. Pre- and post-measurements of passive dorsiflexion range of motion were collected.
Results: No significant changes in dorsiflexion range of motion were detected between manipulated ankles and controls. A significantly greater pre-test dorsiflexion range of motion existed in those ankles where manipulation produced an audible cavitation.
Conclusion: Manipulation of the ankle does not increase dorsiflexion range of motion in asymptomatic subjects. Ankles that displayed a greater pre-test range of dorsiflexion were more likely to cavitate, raising the possibility that ligament laxity may be associated with the tendency for ankles to cavitate.
Key indexing terms: Ankle joint; chiropractic manipulation; dorsiflexion; range of motion.
Evaluation of axial and flexural stresses in the vertebral body cortex and trabecular bone in lordosis, and two sagittal cervical translation configurations with an elliptical shell model.
Deed Harrison,DC; E. William Jones,PhD; Tadeusz Janik,PhD; Donald Harrison,PhD,DC,MSE
Background: Osteoarthritis and spinal degeneration are factors in neck and back pain. Calculations of stress in clinically occurring configurations of the sagittal cervical spine are rare.
Objective: To calculate and compare combined axial and flexural stresses in lordosis, versus cervical configurations in anterior and vertical sagittal head translated positions.
Design: Digitized measurements from lateral cervical radiographs of three different shapes were used to calculate axial loads and bending moments on the vertebral bodies of C2-C7.
Methods: An elliptical shell model was used to model horizontal cross-sections of the vertebral bodies of C2 through T1. Axial and flexural stresses were calculated with short compression block equations. Elliptical shell modeling permitted separation of stresses into cortical and inner medullary regions. Digitized radiographic points were used to create polynomials representing the shape of the sagittal cervical curvatures from C1 to T1. To calculate bending moments at each vertebral segment, moment arms from a vertical line through C1 were determined from digitizing.
Results: Compared to the normal lordosis, stresses on the anterior vertebral body cortical margins of C5-T1 in the sagittal translated postures are compression, rather than tension. At the posterior vertebral bodies in the anteriorly translated position and vertically translated postures, the stresses change from compression to tension at C5 through T1. In absolute value (ABS) compared to values at the same segments in a normal lordosis, the magnitude of the combined anterior stresses in the sagittal postures is higher at C5-C7 (e.g., ABS[_straight/_normal] _1.25 to 4.25).
Conclusions: Vertebral body stresses are reversed in direction at C5-T1 in sagittal translated postures compared to a normal lordosis. Stress analysis, with implications for bone remodeling, indicates that both sagittal head translation postures, anterior head carriage and vertical head translation, are undesirable configurations in the cervical spine.
Key indexing terms: Cervical vertebrae; stress; lordosis; normal model; X-ray; posture; cortical bone.
The Webster technique: A chiropractic technique with obstetric implications
Objective: To survey members of the International Chiropractic Pediatric Association (ICPA) on the use of Webster technique for managing the musculoskeletal causes of intrauterine constraint, which may lead to Cesarean section births.
Methods: The study entailed sending surveys to 1,047 members of the ICPA throughout the United States and Canada.
Results: 187 surveys were returned from 1,047 ICPA members throughout the United States and Canada, constituting a return rate of 17.86 percent. Seventy-five responses did not meet the study inclusion criteria and were excluded. One hundred and twelve surveys were returned from which to derive data (11 percent). Of the 112 responses, 102 (92 percent) resulted in resolution of the breech presentation, while 10 (nine percent) remained unresolved.
Conclusion: In this study, the doctors surveyed reported a high rate of success in relieving the musculoskeletal causes of intrauterine constraint using the Webster technique (82 percent). Although the sample size is small, the results suggest that it may be of particular promise to perform the technique in the eighth month of pregnancy, when breech presentation is unlikely to spontaneously convert to cephalic presentation, and before ECV is shown to be effective. When successful, it avoids the costs and/or risks of either ECV, cesarean section or vaginal trial of breech. In view of these findings, the technique deserves serious consideration in the health care management of expectant mothers exhibiting adverse fetal presentation.
Key indexing terms: Breech; chiropractic; intrauterine constraint; labor; pregnancy.
Guidelines for the diagnosis of osteoporosis by densitometric methods: A literature review.
Background: Osteoporosis is a major health hazard for postmenopausal women and elderly people. Local, national and international organizations developed clinical practice guidelines for the diagnosis and management of osteoporosis and the prevention of osteoporotic fractures. Low bone mineral density (BMD) is the most important risk factor for fragility fractures. Bone densitometry is the best method to measure BMD in an individual. Many risk factors contribute to the development of osteoporosis and increase the fracture risk independently from BMD. Guidelines must be comprehensive, factual, simple to implement, and should provide the clinician, patients, governments and payers with the best evidence available.
Objectives: To review national and international guidelines to establish a congruent set of parameters that may aid the clinician in the decision-making process for the diagnosis of osteoporosis.
Data sources: An online search of several databases provided 18 guidelines for this review. Comparison between the guidelines was made on ten different aspects: format; focus; significance of hip and vertebral body fractures; primary diagnostic considerations; BMD measurement technology; interpretation; reporting and follow-up; equipment reliability and quality control; risk factors considered; and methodological quality of the guidelines. Tables were created for easier comparison on the aspects covered and supported by each guideline.
Results: None of the guidelines reviewed fulfills all the requirements of good clinical practice guidelines.
Conclusions: Further works should finally provide all those interested with a more complete and thorough set of guidelines based on the best evidence available.
Key indexing terms: Osteoporosis; risk factors; fractures; bone densitometry; guidelines.
Neuropathic osteoarthropathy in the diabetic foot.
Melanie Osterhouse,DC, Norman Kettner,DC,DACBR
Objective: To discuss a case involving a 55-year-old female diabetic with neuropathic osteoarthropathy initiated by a fall.
Clinical features: The patient fell into a hole, injuring her left foot. Due to the anesthesia associated with her diabetic peripheral neuropathy, she did not notice the ensuing plantar puncture wound. The patient assumed that her swelling was a result of a sprain. Mild dislocation and osseous fragmentation was noted within the midfoot on radiographs. The neuropathic osteoarthropathy progressed until she was later casted. Plain film taken at the time of cast removal demonstrated resorption and consolidation of fragmentation, but the dislocation was unaltered.
Intervention and outcome: The patient was scheduled for surgery and wound debridement. However, prior to surgery, complications of a burn sustained on the contralateral foot required fifth-ray amputation. Surgery of the left foot has been postponed until adequate post-surgical healing has occurred at the right foot amputation site.
Conclusion: This paper provides tools for the timely diagnosis and treatment of neuropathic osteoarthropathy. An increased understanding of this entity will help lead to a reduction in the incidence of delayed treatment due to misdiagnosis.
Key indexing terms: Neuropathic osteoarthropathy; diabetes; radiography.