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PubMed2002

Professional responsibility in relation to cervical spine manipulation.

Manipulation of the cervical spine is one of the few potentially life-threatening procedures performed by physiotherapists. Is it worth the risk? A comparison of risks versus benefits indicates that at present, the risks of cervical manipulation outweigh the benefits: manipulation has yet to be shown to be more effective for neck pain and headache than other interventions such as mobilisation, whereas the risks, although infrequent, are serious. This analysis is of particular concern because the conditions for which manipulation is indicated are benign and usually self-limiting. Because physiotherapists have legal and ethical obligations to the community to avoid foreseeable harm and provide optimum care, it may be prudent to determine who in our profession should perform cervical manipulation. That is, the profession could restrict the practice of cervical spine manipulation. Although all registered physiotherapists in Australia are entitled to perform cervical manipulation, few choose to use this intervention. Therefore, it might be feasible to encourage those practitioners who wish to use cervical manipulation to undertake formal education programs. Such a requirement could be embodied in a code of practice that discourages those without formal training from performing cervical manipulation. By taking such measures, we could ensure that our profession exercises wisdom in its monitoring and use of cervical manipulation.

Australia↗
PubMed2002

Use of high and low velocity cervical manipulative therapy procedures by Australian manipulative physiotherapists.

The use of cervical manipulation presents concerns because of a risk of devastating side effects of trauma to the vertebral artery. Little is known about the frequency of use of cervical manipulation versus passive mobilisation by physiotherapists. A recent national, multi-centre randomised clinical trial of the physiotherapy management of cervicogenic headache provided an opportunity to gain an insight into practices of a sample of manipulative physiotherapists across Australia. The treatment records for the 100 subjects who received only manipulative therapy, or manipulative therapy with exercise as per the trial protocol, were audited. The results revealed that cervical manipulation was used in 20.2% of the 1090 treatments provided to these subjects but cervical joint mobilisation only was used in the vast majority of treatments (77.6%). Nevertheless, 42% of subjects were treated with cervical manipulation at some time. In most instances, manipulation was accompanied by passive mobilisation in the same treatment session. Patients were manipulated on one to six occasions and this occurred predominantly in the latter half of the 12-treatment program. Cervical manipulation was used less frequently in the group who also received exercise. The data suggest that the physiotherapists participating in this study used cervical manipulation selectively and relatively conservatively considering the high use of cervical mobilisation techniques. This may reflect their due regard to safety in the treatment of the cervical region.

Adult↗
PubMed2001

Causes of complications from cervical spine manipulation.

Cervical manipulation occasionally causes serious vertebrobasilar complications. The usual cause is vertebral artery dissection, however in some cases there has been no obvious arterial injury. The present paper reviews the mechanisms by which complications occur, particularly when the applied force is trivial or there is no injury to the vertebral arteries, and the factors that increase risk of complications. In addition, implications are drawn for use of the recently revised Australian Physiotherapy Association (APA) guidelines. In the absence of vertebral artery rupture, complications are proposed to arise from vasospasm, haemostasis, endothelial injury or turbulent flow. These mechanisms have a sound scientific basis but have yet to be demonstrated as specifically causing vertebrobasilar complications. The most important risk factors for vertebrobasilar complications appear to be prior trauma to the vertebral arteries and symptoms of vertebrobasilar ischaemia from previous manipulation. There is weak evidence that hypoplasia of the vertebral arteries also increases the risk of complications. Neither general vascular factors nor pre-existing degenerative conditions of the cervical spine increase risk of vertebrobasilar complications. The procedures described in the APA guidelines test adequacy of total cerebral perfusion during cervical movements rather than patency of the vertebral arteries or their susceptibility to injury. The guidelines may therefore indicate potential for surviving a complication from manipulation. They may also identify patients at risk of complications from minor trauma. It is recommended that the procedures described in the APA guidelines be applied prior to every manipulation, and that manipulation be avoided in the presence of any signs of vertebrobasilar insufficiency.

Humans↗
PubMed2000

Reflex effects of vertebral subluxations: the peripheral nervous system. An update.

BACKGROUND: The traditional chiropractic vertebral subluxation hypothesis proposes that vertebral misalignment cause illness, disease, or both. This hypothesis remains controversial. OBJECTIVE: To briefly review and update experimental evidence concerning reflex effects of vertebral subluxations, particularly concerning peripheral nervous system responses to vertebral subluxations. DATA SOURCE: Information was obtained from chiropractic or scientific peer-reviewed literature concerning human or animal studies of neural responses to vertebral subluxation, vertebral displacement or movement, or both. CONCLUSION: Animal models suggest that vertebral displacements and putative vertebral subluxations may modulate activity in group I to IV afferent nerves. However, it is not clear whether these afferent nerves are modulated during normal day-to-day activities of living and, if so, what segmental or whole-body reflex effects they may have.

Animals↗
PubMed2000

Neurological effects of the adjustment.

This paper discusses the several theories pertaining to the chiropractic adjustment, including the nerve compression theory, reflex theories, and pain relief theories. There is now sufficient scientific research to consider these theories reasonable working models to explain the effects of the adjustment but insufficient to consider them valid.

Humans↗
PubMed2000

An alteration in arterial compliance associated with elevated aerobic fitness.

OBJECTIVE: To identify a nonpharmacologic method of enhancing arterial compliance, a correlate of atherogenesis; to determine the relationship between aerobic fitness levels and arterial compliance; and to identify a characteristic Doppler analog waveform associated with elevated levels of aerobic fitness. DESIGN: A cross-sectional design was used to compare the Doppler studies of sedentary subjects and aerobically trained subjects. The trained subjects were divided into a moderately trained group and a highly trained group. SETTING AND PARTICIPANTS: One hundred subjects consisting of 50 sedentary control subjects and 50 aerobically trained subjects in a university-based setting. The mean age of the total group of subjects was 36.0+/-8.6 years. Each group had an equal number of male and female subjects. Control subjects were sedentary, with normal vascular risk factor profiles and a mean aerobic capacity (maximum oxygen consumption) of 25.8+/-3.0 mL x kg(-1) x min(-1). Trained subjects were divided into a moderately trained group and a highly trained group. The mean aerobic capacity for the moderately trained group was 46.0+/-4.4 mL x kg(-1) x min(-1), and that for the highly trained group was 63.3+/-6.7 mL x kg(-1) x min(-1). A standard Doppler examination, including ankle pressure index was performed on each subject. MAIN OUTCOME MEASURE: Arterial compliance measurements were recorded by using A-mode Doppler ultrasonography and analyzed by diastolic flow analysis. RESULTS: Control subjects had a mean arterial compliance level of 21.1%+/-2.5%. The moderately trained subjects had a mean compliance level of 34.8%+/-4.9%, and the highly trained subjects had a mean compliance level of 46.0%+/-6.7%. An analysis of variance was used for this comparison and was significant at a P value of less than .01. CONCLUSION: These results demonstrate that elevated aerobic fitness levels are associated with an augmentation in arterial compliance. A linear relationship existed in our data between aerobic fitness levels and arterial compliance. This study suggests that enhanced arterial compliance is another beneficial cardioprotective effect associated with aerobic training.

Adult↗
PubMed2000

Pelvic stress fracture: assessment and risk factors.

OBJECTIVE: To discuss the case of a patient with a pelvic stress fracture and the differential considerations among patients presenting with hip and/or groin pain. FEATURES: A 42-year-old woman had hip pain after running. Initial radiograph of the pelvis was negative. Subsequent films showed a right inferior pubic ramus stress fracture. Stress fractures of the pelvis are relatively uncommon, accounting for only 1% to 2% of all stress fractures. INTERVENTION AND OUTCOME: Treatment included high-velocity, low-amplitude chiropractic manipulation, ultrasound, and stretching of the psoas and piriformis muscles. After 8 weeks, care was discontinued because the patient's hip pain had resolved. The pelvic fracture was left to heal with time. After 1 year, the patient still had delayed union of the fracture. CONCLUSION: When predisposing factors are present, such as osteoporosis and rheumatoid arthritis, pelvic stress fracture should be suspected in patients with groin or hip-area pain. However, because pelvic stress fractures are relatively rare, radiographic studies are often postponed, making diagnosis difficult.

Adult↗
PubMedDate not supplied

Assessment of published reliability studies for cervical spine range-of-motion measurement tools.

OBJECTIVE: To assess the reliability of tools to measure cervical spine range of motion in clinical settings and discuss the necessary components for reliability studies. DATA SOURCES: Database searches included Bandolier, Bath Information and Data Services including Index of Scientific and Technical Proceedings, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, English National Health Care Database, MEDLINE, Occupational Therapy Index, Physiotherapy Index, and Rehabilitation index for English language articles from 1966. In addition, citations were searched. STUDY SELECTION: Studies were selected that assessed the tool for intraobserver or interobserver reliability, evaluated it on movements of flexion/extension, lateral flexion, or rotation, and measured range of motion of the whole cervical spine. DATA EXTRACTION: All papers were read by one nonclinical researcher with a data extraction sheet. A consultant rheumatologist and a physiotherapist were each asked to read a sample of the papers to give a clinical viewpoint. DATA SYNTHESIS: Evidence for the reliability of measurement tools was assessed qualitatively based on the quality of the study designs, appropriateness of analysis, and strength of the reliability based on reported intraclass correlation coefficients (the most appropriate analysis technique for reliability studies of this nature). Measurement tools were found to have not been fully tested for reliability, particularly in terms of adequate sample size and appropriate analysis techniques. There were also wide variations in the research design, including the protocol for movement, the characteristics of observers and study population, whether warm-ups were allowed, whether the movement was active or passive, and time intervals between repeated measurements. CONCLUSION: Although a range-of-motion device has shown promise in reliability and has many advocates, its practicality for clinical use is questionable. Further work must be performed on all measurement tools. Researchers need to produce more rigorous studies and consider the issues discussed here.

Cervical Vertebrae↗
PubMedDate not supplied

Nephrolithiasis with unusual initial symptoms.

OBJECTIVE: To describe a less common initial symptom of nephrolithiasis, its diagnostic pitfalls, risk factors, and mimicry of other conditions. Intervention and long-term management of nephrolithiasis is also discussed. CLINICAL FEATURES: A Caucasian man aged 25 years had sudden bilateral inguinal and occasional periumbilical pain. The initial symptom suggested an abdominal pathologic condition; however, costovertebral angle pain followed 1 hour later with no radiation between the 2 anatomic sites. The initial urine dipstick result was negative for hematuria, but a kidney, ureter, and bladder radiograph revealed a smooth 2-mm x 3-mm stone lodged at the left: vesico-ureteral junction. INTERVENTION AND OUTCOME: The patient was referred to a regional university medical center to receive extracorporeal shockwave lithotripsy several days after his initial visit. He was given pain medicine for the waiting period and received daily lumbar spine adjustments with a mild reduction in pain. He eventually received ureteroscopic laser lithotripsy because the shock-wave unit had malfunctioned before his appointment. The fragment analysis showed a calcium oxalate composition, and the patient was advised to lower his intake of oxalates. The patient had become a vegetarian approximately 3 months before this first stone episode. CONCLUSION: Nephrolithiasis is a condition commonly seen in chiropractic practice. Although it is usually easy to recognize, the diagnosis can be elusive if the typical historic factors and diagnostic results are absent or altered. The short-term management of nephrolithiasis is pain management, stone elimination, and the collection of a specimen to identify the composition and underlying metabolic abnormality. Long-term management is to prevent the recurrence of stones. Conservative comanagement by the chiropractic physician can be implemented through nutritional means.

Abdominal Pain↗
PubMedDate not supplied

Vectored upper cervical manipulation for chronic sleep bruxism, headache, and cervical spine pain in a child.

OBJECTIVE: To discuss the management of chronic sleep bruxism in a 6-year old girl. Clinical features The patient had morning headaches and cervical spine pain. Due to abnormal tooth wear, bruxism had been previously diagnosed and was verified by observation during sleep. She also had abnormal postural and palpatory findings, indicating upper cervical joint dysfunction. Intervention and outcome Bilateral rotary cervical stretching/mobilization and a vectored high-velocity, low-amplitude adjustment were performed in the upper cervical spine, using the atlas transverse process as the contact point. There was complete relief of the chronic subjective symptoms concomitant with remission of the objective signs of joint dysfunction. CONCLUSIONS: Cervical, particularly upper cervical, spine muscle-joint dysfunction should be considered as a potential etiology in chronic childhood sleep bruxism.

Bruxism↗