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Management of Chronic Spine-Related Conditions: Consensus Recommendations
Ronald Farabaugh, DC, Mark Dehen, DC, Cheryl Hawk, DC, PhD
Objective: Chronic spine-related conditions are very problematic in terms of treatment and indemnity costs, diagnostic complexity, and appropriate case management. Currently no chiropractic-directed guideline exists related to chiropractic management of the chronic spine pain patient. The purpose of this project was to develop a broad-based multidisciplinary consensus of medical and chiropractic clinical experts representing mainstream medical and chiropractic practice to produce a document designed to provide standardized parameters of care and documentation.
Methods: Background materials were provided to the panelists prior to the consensus process and served as the basis for the 29 seed statements. Delphi rounds were conducted electronically, and the Nominal Group Panel was conducted via conference call. The RAND/UCLA methodology was used to reach consensus, which was considered present if both the median rating was 7 or higher and at least 80% of panelists rated the statement 7 or higher. Consensus was reached through a combination of Delphi rounds and Nominal Group Panel. Of 29 panelists, five were non-doctors of chiropractic.
Results: Specific recommendations regarding treatment, frequency and duration, as well as outcome assessment and contraindications for manipulation, were agreed upon by the panel.
Conclusions: A multidisciplinary panel of experienced practitioners was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for complex patients with chronic spine-related conditions, based on both the scientific evidence and their clinical experience.
Editor's note: The above study was the subject of a front-page story in the Nov. 4 issue of DC. Read "How to Manage Chronic Pain: CCGPP Releases Guideline to Help Direct Case Management," which contains a link to the full text of the consensus recommendations.
Zygapophyseal Joint Adhesions After Induced Hypomobility
Gregory Cramer, DC, PhD, Charles Henderson, DC, PhD, Joshua Little, DC, et al.
Objective: Adhesions (ADH) have been previously identified in many hypomobile joints, but not in the zygapophyseal (Z) joints of the spine. The objective of this study was to determine if connective tissue ADH developed in lumbar Z joints after induced intervertebral hypomobility (segmental fixation).
Methods: Using an established rat model, three contiguous segments (L4, L5, L6) were fixed with specially engineered, surgically implanted, vertebral fixation devices. Z joints of experimental rats (17 rats, 64 Z joints) with four, eight, 12, or 16 weeks of induced hypomobility were compared with Z joints of age-matched control rats (23 rats, 86 Z joints). Tissue was prepared for brightfield microscopy, examined, and photomicrographed. A standardized grading system identified small, medium, and large ADH and the average numbers of each per joint were calculated.
Results: Connective tissue ADH were characterized and their location within Z joints described. Small and medium ADH were found in rats from all study groups. However, large ADH were found only in rats with eight, 12, or 16 weeks of experimentally induced intervertebral hypomobility. Significant differences among study groups were found for small (P < .003), medium (P < .000), and large (P < .000) ADH. The average number of medium and large ADH per joint increased with the length of experimentally induced hypomobility in rats with eight and 16 weeks of induced hypomobility.
Conclusions: We conclude that hypomobility results in time-dependent ADH development within the Z joints. Such ADH development may have relevance to spinal manipulation, which could theoretically break up Z joint intra-articular ADHs.
Quantifying the High-Velocity, Low-Amplitude Manipulative Thrust
Aron Downie, MChiro, et al.
Objectives: The purpose of this study was to systematically review studies that quantify the high-velocity, low-amplitude (HVLA) spinal thrust, to qualitatively compare the apparatus used and the force-time profiles generated, and to critically appraise studies involving the quantification of thrust as an augmented feedback tool in psychomotor learning.
Methods: A search of the literature was conducted to identify the sources that reported quantification of the HVLA spinal thrust. MEDLINE-OVID (1966-present), MANTIS-OVID (1950-present), and CINAHL-EBSCO host (1981-present) were searched. Eligibility criteria included that thrust subjects were human, animal, or manikin and that the thrust type was a hand-delivered HVLA spinal thrust. Data recorded were single force, force-time, or displacement-time histories. Publications were in English language and after 1980. The relatively small number of studies, combined with the diversity of method and data interpretation, did not enable meta-analysis.
Results: Twenty-seven studies met eligibility criteria: 17 studies measured thrust as a primary outcome (13 human, two cadaver, and two porcine). Ten studies demonstrated changes in psychomotor learning related to quantified thrust data on human, manikin, or other device.
Conclusions: Quantifiable parameters of the HVLA spinal thrust exist and have been described. There remain a number of variables in recording that prevent a standardized kinematic description of HVLA spinal manipulative therapy. Despite differences in data between studies, a relationship between preload, peak force, and thrust duration was evident. Psychomotor learning outcomes were enhanced by the application of thrust data as an augmented feedback tool.
Global Posture Re-Education and Static Stretching for Myogenic TMD
Samia Maluf, PhD, Bruno Moreno, MS, Osvaldo Crivello, PhD, et al.
Objective: The purpose of this study was to compare two different interventions, global postural reeducation (GPR) and static stretching exercises (SS), in the treatment of women with temporomandibular disorders (TMDs).
Methods: A total of 28 subjects with TMDs were randomized into two treatment groups: GPR, where therapy involved muscle global chain stretching, or SS, with conventional static stretching; but only 24 completed the study. Eight treatment sessions lasting 40 minutes each (weekly) were performed. Assessments were conducted at baseline, immediately after treatment end, and two months later. Measurements included pain intensity at the temporomandibular joint, headache, cervicalgia, teeth clenching, ear symptoms, restricted sleep, and difficulties for mastication, using a visual analogue scale. In addition, electromyographic activity and pain thresholds were measured at the masseter, anterior temporalis, sternocleidomastoid, and upper trapezius muscles. Two-way analysis of variance with Tukey post hoc test was used for between-group comparisons. Significance level was .05.
Results: Comparing the pain assessments using the visual analogue scale, no significant differences were seen with the exception of severity of headaches at treatment end (GPR, 3.92 ± 2.98 cm; SS, 1.64 ± 1.66 cm; P < .024). In addition, no significant differences were seen for pain thresholds and for electromyographic activity (P > .05).
Conclusions: For the subjects in this study, both GPR and SS were similarly effective for the treatment of TMDs with muscular component. They equally reduced pain intensity, increased pain thresholds, and decreased electromyographic activity.
Somatosensory Impairments in Subjects With Mechanical Idiopathic Neck Pain
Khodabakhsh Javanshir, PT, MSc, et al.
Objective: The purpose of this study was to investigate the differences in pressure and thermal pain hypersensitivity between patients with acute and chronic neck pain and healthy subjects.
Methods: Five patients with acute neck pain, seven patients with chronic neck pain, and six matched controls participated. Pressure pain thresholds (PPTs) were assessed over the supraorbital, infraorbital, mental, median, ulnar, and radial nerves; the C5-C6 zygapophyseal joint; the second metacarpal; and the tibialis anterior muscle by an assessor blinded to the subjects' condition. Head pain threshold and cold pain threshold (CPT) were measured over the cervical region and over the tibialis anterior muscle.
Results: The analysis of variance found significant differences between groups, but not between sides, for PPT over the supraorbital, mental, median, ulnar and radial nerves; the C5-C6 joint; the second metacarpal; and the tibialis anterior muscle: patients with chronic neck pain showed bilateral lower PPTs as compared with controls (P < .01). Patients with acute neck pain also showed lower PPT (P < .01) over the median and ulnar nerves. No significant differences between groups or sides for head pain threshold over the cervical area or the tibialis anterior muscle were found. Significant differences between groups, but not between sides, for CPT over the neck and the tibialis anterior muscles were found: CPT was also reduced in patients with chronic, but not acute, neck pain (P < .01).
Conclusions: We found widespread decreased PPT in patients with chronic, but not acute, mechanical neck pain as compared with controls. Patients with chronic neck pain also showed cold pain hypersensitivity as compared with patients with acute neck pain and controls. These results support the existence of different sensitization mechanisms between patients with acute and chronic mechanical insidious neck pain.
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.journals.elsevierhealth.com/periodicals/ymmt for access to the complete September 2010 issue of JMPT.