Meridel Gatterman,DC; Robert Cooperstein,DC; Charles Lantz,DC,PhD; Stephen Perle,DC; and Michael Schneider,DC.
Objective: To rate specific chiropractic technique procedures used in the treatment of common low back conditions.
Design and Methods: A panel of chiropractors rated specific chiropractic technique procedures for their effectiveness in the treatment of common low back conditions, based on the quality of supporting evidence following systematic literature reviews, and expert clinical opinion. Statements related to the rating process and clinical practices were then developed through a facilitated nominal consensus process.
Results: For most low back conditions presented in this study, the three procedures rated most effective were HVLA with no drop table (side posture), distraction technique, and HVLA prone with drop table assist. The three rated least effective were upper cervical technique, nonthrust reflex/low force, and lower extremity adjusting. The four conditions rated most amenable to chiropractic treatment were noncomplicated low back pain, sacroiliac joint dysfunction, posterior joint/subluxation, and low back pain with buttock or leg pain.
Conclusions: The ratings for the effectiveness of chiropractic technique procedures for the treatment of common low back conditions are not equal. Those procedures rated highest are supported by the highest quality of literature. Much more evidence is necessary for chiropractors to understand which procedures maximally benefit patients for which conditions.
Key indexing terms: chiropractic; low back pain; practice guidelines; consensus methodology.
Reliability of lateral bending and axial rotation with validity of a new method to determine axial rotation on AP cervical radiographs.
Tadeusz Janik,PhD; Deed Harrison,DC; Donald Harrison,PhD,DC,MSE; Burt Holland,PhD; Roger Coleman,DC; and Mark Payne,DC.
Objective: To investigate the reliability of a new radiographic measurement of axial rotation and lateral bending on anterior-posterior cervical views using a computer and sonic digitizer.
Design: A blind, repeated-measure design was used. Anteroposterior cervicothoracic radiographs were presented to each of three examiners in random order. Each film was digitized; one week later, the films were randomized for a second run.
Setting: Private, primary-care chiropractic clinic.
Main Outcome Measures: Correlation coefficients (ICC) for intra- and inter-examiner reliability for measures on radiographs for determining axial rotations (Ry) and lateral bending (Rz) of C3-T3.
Results: When the new axial rotation method was applied to small rotations of a C3 plastic model, the average error was less than one degree. For the calculations of axial rotation (Ry), the ICC values were in the "good" to "excellent" range. For axial rotation, the intraclass correlation coefficients were ICCs 0.78, and interclass correlation coefficients were ICCs 0.67. For lateral flexions (Rz) of C3-T3, all intraclass and interclass correlation coefficients were in the "excellent" range (ICCs > 0.87).
Conclusions: Methods of calculating axial rotations in the spine for large angles (5-30°) have been reported, but not for smaller angles. A new method for determining axial rotations of the cervical segments on AP views, based on the chord across the arc displaced by the spinous-lamina junction, had reliability (ICC values) in the good to excellent range. Compared to measured rotations of a C3 model (-5° to +5°), the new method had an average error of less than ne degree, and averaged approximately 11.5 percent. The reliability for the axial rotation measurements were in the "good" to "excellent" range, and the lateral bending measurements are all in the excellent range.
Key Indexing Terms: cervical spine; x-ray; reliability; axial rotation; instability.
Expectations of chiropractic patients: the construction of a questionnaire.
Background: As chiropractic increasingly has become incorporated in the National Health Services and insurance company policies, it is also important to evaluate treatment outcomes and patient satisfaction. There are conflicting views as to whether expectation plays a role in patient satisfaction.
Objective: To design a questionnaire that can be used to identify patients' expectations of chiropractic management.
Methods: A series of five questionnaires were tested for validity in relation to patients' expectations of chiropractic management in patients who report having had low-back pain of more than two weeks duration, and a history of 30 days with low-back pain within the last year.
Results: A final questionnaire was produced, and the information collected indicates that patients' main expectations of the chiropractic management are that: the chiropractor makes an accurate diagnosis, explains the complaint or affliction to the patient and that the treatment results in a positive outcome.
Conclusion: Preliminary results indicate that patients expect to consult a knowledgeable professional who is good at communicating and who provides effective treatment. We are confident that the final questionnaire can be successfully used in future studies to explore the relationship between patient expectations and satisfaction.
Key indexing terms: chiropractic; expectations; patient satisfaction.
Efficacy of spinal manipulation for chronic headache: a systematic review.
Gert Bronfort,DC,PhD; Willem Assendelft,MD,PhD; Roni Evans,DC; Mitchell Haas,DC; and Lex Bouter,PhD.
Background: Chronic headache is a prevalent condition with substantial socioeconomic impact. Complementary or alternative therapies are increasingly being used by patients to treat headache pain, and spinal manipulative therapy (SMT) is among the most common of these.
Objective: To assess the efficacy/effectiveness of SMT for chronic headache through a systematic review of randomized clinical trials.
Study Selection: Randomized clinical trials on chronic headache including tension, migraine and cervicogenic types, comparing SMT to other interventions or placebo. The trials had to have at least one patient-rated outcome measure such as pain severity, frequency, duration, improvement, use of analgesics, disability, or quality of life. Studies were identified by a comprehensive search of MEDLINE (1966-1998) and EMBASE (1974-1998). Additionally, all available data from CINAHL and the chiropractic reference systems CRAC and MANTIS were utilized, as well as citation tracking, and hand-searching of nonindexed chiropractic, osteopathic and manual medicine journals.
Data Extraction: Information about outcome measures, interventions and effect sizes was used to evaluate treatment efficacy. Levels of evidence were determined by a classification system incorporating study validity and statistical significance of study results. Two authors independently extracted data and performed methodological scoring of selected trials.
Data Synthesis: Nine trials involving 683 patients with chronic headache were included. The methodological quality (validity) scores ranged from 21 to 87 (100-point scale). The trials were too heterogeneous in terms of patient clinical characteristic, control groups and outcome measures to warrant statistical pooling. Based on predefined criteria, there is moderate evidence that SMT has short-term efficacy similar to amitriptyline in the prophylactic treatment of chronic tension-type headache and migraine. SMT does not appear to improve outcomes when added to soft-tissue massage for episodic tension-type headache. There is moderate evidence that SMT was more efficacious than massage for cervicogenic headache. Sensitivity analyses showed that the results and the overall study conclusions remained the same even when substantial changes in the prespecified assumptions/rules regarding the evidence determination were applied.
Conclusions: Spinal manipulation appears to have a better effect than massage for cervicogenic headache. It also appears that spinal manipulation has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache. This conclusion rests upon a few trials with adequate methodological quality, and needs to be further tested in rigorously designed, executed, and analyzed trials, with sufficient length of follow-up periods before any firm conclusions can be drawn.
Key indexing terms: headache; orthopedic manipulation; chiropractic manipulation; osteopathy; systematic review.
Pain, disability and satisfaction outcomes and predictors of outcomes: A practice-based study of chronic low back pain patients attending primary care and chiropractic physicians.
Joanne Nyiendo,PhD; Mitchell Haas,DC; Bruce Goldberg,MD; and Gary Sexton,PhD.
Background: Few studies exist on the prognostic value of demographic, clinical or psychosocial factors on long-term outcomes for chronic low back pain patients.
Objective: This study reports on long-term pain and disability outcomes for chronic low back pain patients, evaluates predictors of long-term outcomes, and assesses the influence of doctor type on clinical outcome.
Methods: Sixty chiropractic (DC) and 111 general practice (MD) physicians participated in data collection for a prospective, longitudinal, practice-based observational study of ambulatory low back pain of mechanical origin. The primary outcomes, measured at six months and 12 months, were pain, using a VAS, and functional disability, using the Revised Oswestry Disability Questionnaire. Satisfaction was a secondary outcome.
Results: Overall, long-term pain and disability outcomes were generally equivalent for patients seeking care from medical or chiropractic physicians. Medical and chiropractic care were comparable for patients without leg pain and for patients with leg pain above the knee. However, an advantage was noted for chronic chiropractic patients with radiating pain below the knee after adjusting for baseline differences in patient and complaint characteristics between MD and DC cohorts (adjusted differences = 8.0 to 15.2; P<.002; N=71,80). A greater proportion of chiropractic patients was satisfied with all aspects of their care (P=.0000). The strongest predictors of primary outcomes included an interaction of radiating pain below the knee with provider type and baseline values of the outcomes. Income, smoking, comorbidity, and chronic depression were also identified as predictors of outcomes in this study.
Conclusions: Chiropractic care compared favorably to medical care with respect to long-term pain and disability outcomes.
Conclusion: Further study is required to explore the advantage seen for chiropractic in patients with leg pain below the knee and in patient satisfaction. Identification of patient and treatment characteristics associated with better or worse outcomes may foster changes in physicians' practice activities that better serve these patients' needs.
Key indexing terms: low back pain; predictors; outcomes; medical physicians; chiropractic.
Acute lymphangitis mimicking mechanical neck pain.
L.A. Boudreau,BSc,DC, and A. Pinto,MD,CCFP.
Objective: To discuss acute lymphangitis as a potentially serious infectious process that can mimic mechanical musculoskeletal pain.
Clinical Features: A 27-year-old male plant worker suffered from right-sided neck pain. Numerous lesions on the patient's scalp were observed, but were not considered related to the chief complaint.
Intervention and Outcome: Conservative therapy was initiated to address what was thought to be mechanical neck pain. Shortly after the initial visit, it became evident that the source of the neck pain was infection, as the patient developed lymphangitis. Treatment consisting of antibiotic therapy was initiated and complete resolution of the complaint occurred within one week.
Conclusion: Primary contact practitioners need to consider all aspects of the patient history and physical findings when formulating a diagnosis. This is especially important in the case of patients presenting with lymphangitis as mismanagement could have serious consequences. The importance of a good patient history and team approach to care is demonstrated by this case.
Key indexing terms: lymphangitis; infection; neck pain; chiropractic.
Adult (Acute) Respiratory Distress Syndrome: clinical recognition and preventive management in chiropractic acute care practice.
Objective: To present clinical information relevant to acute respiratory distress syndrome (ARDS) and its potential appearance in chiropractic acute care practice.
Data Sources: The National Library of Medicine MEDLINE database and the bibliographies of selected articles and textbooks commonly found in chiropractic college libraries and bookstores.
Study Selection: Clinical studies were selected from the English literature if they pertained to either incidence, clinical relevancy, or its association with commonly seen diagnoses in chiropractic neuromusculoskeletal or orthopedic practice.
Data Extraction: All relevant studies identified by the search were evaluated based on information pertinent to chiropractic acute care management of patients.
Results: Acute (adult) respiratory distress syndrome (ARDS) is a pulmonary distress syndrome with high mortality. Chiropractic physician recognition for possible development of ARDS includes chest pain, head injury, and thoracic spine pain with or without trauma. Clinical evaluation, radiographic and laboratory findings are presented to assist practitioners in identifying this disease process of multiple etiology. A study of basic pathophysiological processes that occur in the formation of ARDS is presented to help practitioners gain clinical appreciation. Preventive strategies in lessening potential respiratory distress in the chiropractic practice are presented. These include postural position and the clinical maxim of "slow, deep breathing despite pain" to lessen incident rates of potential subjects at risk.
Conclusion: ARDS probably presents itself in low prevalence in chiropractic practice. Despite possible low-rate clinician awareness in clinical basics, including pathophysiology, medical significance, and preventive strategies to minimize occurrence is important. This basic understanding is to further advance knowledge of this disease complex.
Key indexing terms: chiropractic; adult respiratory distress syndrome; chest trauma; pneumonia; prevention.
Chiropractic care of a patient with vertebral subluxations and failed surgery of the cervical spine.
Joel Alcantara,DC; Gregory Plaugher,DC; Richard Thornton,DC; and Chris Salem,DC
Objective: The chiropractic care of a patient with vertebral subluxations, neck pain and cervical radiculopathy (postsurgical cervical discectomy) is described.
Clinical Features: A 55-year-old male patient suffered from neck pain and left upper extremity radiculopathy following failed cervical spine surgery.
Intervention and Outcome: Contact specific, high-velocity, low-amplitude adjustments (i.e., Gonstead technique) were applied to sites of vertebral subluxations. Rehabilitation exercises were also used as an adjunct to care. The patient reported a decrease in neck pain and left arm pain after chiropractic intervention. The patient also demonstrated a marked increase in ROM of the left glenohumeral articulation.
Conclusion: The chiropractic care of a patient with neck pain and left upper extremity radiculopathy (postsurgical cervical discectomy) is presented. Marked resolution of the patient's symptoms was obtained concomitant with a reduction in subluxation findings at multiple levels despite the complicating history of a failed cervical spine surgery. This is the first report in the indexed literature of chiropractic care following a failed cervical spine surgery.
Key indexing terms: cervical spine; surgery; chiropractic.