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PubMed2005

Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention.

BACKGROUND: Patients with low back pain are frequently encountered in primary care. Although a specific diagnosis cannot be made for most patients, it is likely that sub-groups exist within the larger entity of nonspecific low back pain. One sub-group that has been identified is patients who respond rapidly to spinal manipulation. The purpose of this study was to examine the association between two factors (duration and distribution of symptoms) and prognosis following a spinal manipulation intervention. METHODS: Data were taken from two previously published studies. Patients with low back pain underwent a standardized examination, including assessment of duration of the current symptoms in days, and the distal-most distribution of symptoms. Based on prior research, patients with symptoms of <16 days duration and no symptoms distal to the knee were considered to have a good prognosis following manipulation. All patients underwent up to two sessions of spinal manipulation treatment and a range of motion exercise. Oswestry disability scores were recorded before and after treatment. If >or= 50% improvement on the Oswestry was achieved, the intervention was considered a success. Sensitivity, specificity, and positive likelihood ratio were calculated for the association of the two criteria with the outcome of the treatment. RESULTS: 141 patients (49% female, mean age = 35.5 (+/- 11.1) years) participated. Mean pre- and post-treatment Oswestry scores were 41.9 (+/- 10.9) and 24.1 (+/- 14.2) respectively. Sixty-three subjects (45%) had successful treatment outcomes. The sensitivity of the two criteria was 0.56 (95% CI: 0.43, 0.67), specificity was 0.92 (95% CI: 0.84, 0.96), and the positive likelihood ratio was 7.2 (95% CI: 3.2, 16.1). CONCLUSION: The results of this study demonstrate that two factors; symptom duration of less than 16 days, and no symptoms extending distal to the knee, were associated with a good outcome with spinal manipulation.

Adult↗
PubMedDate not supplied

Short-term responsiveness of manual thoracic end-play assessment to spinal manipulation: a randomized controlled trial of construct validity.

OBJECTIVE: To evaluate the short-term responsiveness of rotatory thoracic end-play assessment to spinal manipulation and, thereby, motion palpation construct validity. DESIGN: Prospective, single-blind, randomized, controlled trial (randomized blocks design). SETTING: Laboratory, Center for Technique Research. PARTICIPANTS: Sixty first-year chiropractic college student volunteers; seventy-three possible candidates were screened. INTERVENTIONS: The treatment group received manual high-velocity, low-amplitude rotatory manipulation. The control group received no intervention to minimize nonspecific effects of sham treatment. MAIN OUTCOME MEASURES: End-play response, defined as the change from restricted to normal end play immediately after intervention. Responsiveness, defined as the percentage of the end-play response attributable to spinal manipulation: relative response attributable to the maneuver, RRAM = (treatment group response--control group response)/treatment group response. RESULTS: Ten percent of the tests were positive for restriction of end play in left or right rotation from T3-T4 to T12-L1; the average rate was 2.1 restrictions per subject (SD = 1.4). End-play response was 60% in the treatment group, in contrast to the 37% response in the control group (z = 1.86, p = .04). More than a third of the response in the treatment group was attributable to spinal manipulation (RRAM = 39%). For one examiner, RRAM = 51%. Mild symptomatology did not affect responsiveness. CONCLUSIONS: The data suggest a moderate short-term responsiveness of rotatory thoracic end-play restriction to spinal manipulation, hence it has utility as a posttreatment evaluative test. This study was the first to use an external standard (manipulation) to demonstrate that segmental end-play restriction changes, hence end-play restriction itself, are detectable in human subjects with manual palpation by chiropractors. Further research is required to determine the generalizability of the study findings.

Adult↗
PubMedDate not supplied

The effects of spinal manipulation on the intensity of emotional arousal in phobic subjects exposed to a threat stimulus: a randomized, controlled, double-blind clinical trial.

OBJECTIVE: To determine the effect of spinal manipulation upon the intensity of emotional arousal in phobic subjects exposed to a threat stimulus. DESIGN: Randomized, controlled, double-blind clinical trial. SETTING: Community college campus. SUBJECTS: Eighteen phobic community college student volunteers randomized into treatment and control groups. INTERVENTION: Visual analog scale (VAS) and pulse rates were obtained in response to the subjects' viewing their phobogenic stimulus. Spinal manipulation was performed while the subjects experienced emotional responses. Manual muscle testing was utilized to ascertain the associated spinal segments and involved emotion. RESULTS: Data were analyzed using analysis of variance for a repeated measures experimental design and Least Significant Differences (LSDs) for mean comparisons. Baseline, preintervention and postintervention pulse rates were not statistically different for the control and treatment groups (p = .0807). VAS postintervention mean for the spinal manipulation group was significantly lower than the control means (p = .05) and from its corresponding preintervention mean (p = .001). CONCLUSION: Spinal manipulation significantly decreased the intensity of emotional arousal reported by phobic subjects. The mechanism for this effect is not known.

Analysis of Variance↗
PubMedDate not supplied

Serious complications of lumbar spinal manipulation.

We describe seven cases of serious complications after lumbar spinal manipulation, including massive cauda equina compression and vertebral pedicle fracture, to emphasize that lumbar spinal manipulations are not without potentially serious risk.

Adult↗
PubMed1999

The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled clinical trial with a blinded observer.

OBJECTIVE: To determine whether there is a short-term effect of spinal manipulation in the treatment of infantile colic. DESIGN: A randomized controlled trial. SETTING: A private chiropractic practice and the National Health Service's health visitor nurses in the suburb Ballerup (Copenhagen, Denmark). SUBJECTS: Infants seen by the health visitor nurses, who fulfilled the diagnostic criteria for infantile colic. INTERVENTION: One group received spinal manipulation for 2 weeks, the other was treated with the drug dimethicone for 2 weeks. OUTCOME MEASURE: Changes in daily hours of crying as registered in a colic diary. RESULTS: By trial days 4 to 7, hours of crying were reduced by 1 hour in the dimethicone group compared with 2.4 hours in the manipulation group (P = .04). On days 8 through 11, crying was reduced by 1 hour for the dimethicone group, whereas crying in the manipulation group was reduced by 2.7 hours (P = .004). From trial day 5 onward the manipulation group did significantly better that the dimethicone group. CONCLUSION: Spinal manipulation is effective in relieving infantile colic.

Birth Weight↗
PubMed1996

Predictors of side effects to spinal manipulative therapy.

OBJECTIVE: To study whether side effects of spinal manipulative therapy can be predicted and, if so, whether they are patient- or treatment-related. Also, to determine if there are different predictors for common reactions (i.e., local discomfort, headache, tiredness or radiating discomfort) and for uncommon reactions (i.e., dizziness, nausea, hot skin or "other" complaints). STUDY DESIGN: Data were collected in patient interviews using standard questionnaires in a prospective clinic-based survey. Several outcome variables (reactions during the course of treatment, reactions after each treatment, specific types of treatment reactions, severe or long-lasting reactions) were then cross-tabulated against sex, age, treatment session number, type of area treated, number of areas treated and type of treatment. SETTING: Chiropractic clinics in Norway. PARTICIPANTS: One hundred and two chiropractors (response rate: 70%) and 12 consecutive patients per chiropractor (resulting in 1058 chiropractic patients) attending for up to six treatments (totaling 4712 treatments). RESULTS: Some patient- and treatment-related predictors were identified. Women were more likely to report reactions to treatment than men. There were also differences between gender in the types of reactions reported. More reactions occurred during the first treatment sessions, when more than one spinal region was treated, or when the thoracic spine only was treated. However, there were no specific predictors for uncommon side effects. CONCLUSION: Some predictors to the side effects of spinal manipulative therapy were identified but more information is needed regarding their clinical significance.

Adolescent↗
PubMed1991

Spinal manipulation and mobilisation for back and neck pain: a blinded review.

OBJECTIVE: To assess the efficacy of spinal manipulation for patients with back or neck pain. DESIGN: Computer aided search for published papers and blinded assessment of the methods of the studies. SUBJECTS: 35 randomised clinical trials comparing spinal manipulation with other treatments. MAIN OUTCOME MEASURES: Score for quality of methods (based on four main categories: study population, interventions, measurement of effect, and data presentation and analysis) and main conclusion of author(s) with regard to spinal manipulation. RESULTS: No trial scored 60 or more points (maximum score 100) suggesting that most were of poor quality. Eighteen studies (51%) showed favourable results for manipulation. In addition, five studies (14%) reported positive results in one or more subgroups. Of the four studies with 50-60 points, one reported that manipulation was better, two reported that manipulation was better in only a subgroup, and one reported that manipulation was no better or worse than reference treatment. Eight trials attempted to compare manipulation with some placebo, with inconsistent results. CONCLUSIONS: Although some results are promising, the efficacy of manipulation has not been convincingly shown. Further trials are needed, but much more attention should be paid to the methods of study.

Acute Disease↗
PubMed2000

The use of spinal manipulation in the treatment of low back pain: a review of goals, patient selection, techniques, and risks.

Spinal manipulation is routinely obtained for low back pain by much of the general public, but there remains a lack of understanding of its rationale and effectiveness in the medical community. Because of the increasing use of manipulation, it is advantageous for back specialists to gain a better understanding of these techniques in order to counsel patients on the associated risks and benefits of manipulation. The purpose of this review is to present the specific goals of spinal manipulation, with emphasis on proper patient selection, specific techniques, and associated risks.

Contraindications↗
PubMed2003

Spinal manipulation for low-back pain: a treatment package agreed to by the UK chiropractic, osteopathy and physiotherapy professional associations.

Trials of manipulative treatment have been compromised by, amongst other things, different definitions of the therapeutic procedures involved. This paper describes a spinal manipulation package agreed by the UK professional bodies that represent chiropractors, osteopaths and physiotherapists. It was devised for use in the UK Back pain Exercise And Manipulation (UK BEAM) trial--a national study of physical treatments in primary care funded by the Medical Research Council and the National Health Service Research and Development Programme. Although systematic reviews have reported some beneficial effects of spinal manipulation for low-back pain, due to the limited methodological quality of primary studies and difficulties in defining manipulation, important questions have remained unanswered. The UK BEAM trial was designed to answer some of those questions. Early in the design of the trial, it was acknowledged that the spinal manipulation treatment regimes provided by practitioners from the three professions shared more similarities than differences. Because the trial design specifically precluded comparison of the effect between the professions, it was necessary to devise a homogenous package representative of, and acceptable to, all three. The resulting package is 'pragmatic', in that it represents what happens to most people undergoing manipulation, and 'explanatory' in that it excludes discipline-specific variations and other ancillary treatments.

Chiropractic↗
PubMedDate not supplied

Chiropractic high-velocity low-amplitude spinal manipulation in the treatment of a case of postsurgical chronic cauda equina syndrome.

OBJECTIVE: To present an evidence-based case report on the use of chiropractic high-velocity low-amplitude spinal manipulation in the treatment a postsurgical, chronic cauda equina syndrome patient. CLINICAL FEATURES: A 35-year-old woman presented with complaints of midback pain, low-back pain, buttock pain, saddle anesthesia, and bladder and bowel incontinence, all of 6 months duration. The patient was 6 months post emergency surgery for acute cauda equina syndrome due to lumbar disc herniation. She had been released from neurosurgical care with the current symptoms considered to be residual and nonprogressive. INTERVENTION AND OUTCOME: The patient was treated with high-velocity low-amplitude spinal manipulation and ancillary myofascial release. After 4 treatments, the patient reported full resolution of midback, low back, and buttock pain. The patient was seen another 4 times with no improvement in her neurologic symptoms. No adverse effects were noted. CONCLUSION: This appears to be the first published case of chiropractic high-velocity low-amplitude spinal manipulation being used for a patient with chronic cauda equina syndrome. It seems that this type of spinal manipulation was safe and effective for reducing back pain and had no effect on neurologic deficits in this case.

Adult↗
PubMed2005

Spinal manipulation alters electromyographic activity of paraspinal muscles: a descriptive study.

OBJECTIVE: To examine the effect of spinal manipulation on electromyographic (EMG) activity in areas of localized tight muscle bundles of the low back. METHODS: Surface EMG activity was collected from 16 participants in 2 chiropractic offices during the 5 to 10 minutes of the treatment protocol. Electrodes were placed over the 2 sites of greatest paraspinal muscle tension as determined by manual palpation. Spinal manipulation was administered to 8 participants using Activator protocol; the other 8 were treated using Diversified protocol. RESULTS: Electromyographic activity decreased by at least 25% after treatment in 24 of the 31 sites that were monitored. There was less than 25% change at 3 sites and more than 25% increase at 4 sites. Multiple distinct increases and decreases were observed in many data plots. CONCLUSION: The results of this study indicate that manipulation induces a virtually immediate change, usually a reduction, in resting EMG levels in at least some patients with low back pain and tight paraspinal muscle bundles. In some cases, EMG activity increased during the treatment protocol and then usually, but not always, decreased to a level lower than the pretreatment level.

Back↗
PubMed2006

Spinal manipulation for primary and secondary dysmenorrhoea.

BACKGROUND: Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological condition. One possible treatment is spinal manipulation therapy. One hypothesis is that mechanical dysfunction in certain vertebrae causes decreases spinal mobility. This could affect the sympathetic nerve supply to the blood vessels supplying the pelvic viscera, leading to dysmenorrhoea as a result of vasoconstriction. Manipulation of these vertebrae increases spinal mobility and may improve pelvic blood supply. Another hypothesis is that dysmenorrhoea is referred pain arising from musculoskeletal structures that share the same pelvic nerve pathways. The character of pain from musculoskeletal dysfunction can be very similar to gynaecological pain as it can present as cyclic pain altered by hormonal influences associated with menstruation. OBJECTIVES: To determine the safety and efficacy of spinal manipulative interventions for the treatment of primary or secondary dysmenorrhoea when compared to each other, placebo, no treatment, or other medical treatment. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched April 2006), CENTRAL (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to March 2006), EMBASE (1980 to April 2006), CINAHL (1982 to March 2006), AMED (1985 to April 2006), Biological Abstracts (1969 to March 2006), PsycINFO (1806 to April 2006), and SPORTDiscus (1830 to April 2006). Attempts were also made to identify trials from the metaRegister of Controlled Trials and the citation lists of review articles and included trials. In most cases the first or corresponding author of each included trial was contacted for additional information. SELECTION CRITERIA: Any randomised controlled trials (RCTs) including spinal manipulative interventions (for example chiropractic, osteopathy, or manipulative physiotherapy) versus each other, placebo, no treatment, or other medical treatment were considered. Exclusion criteria were: mild or infrequent dysmenorrhoea or dysmenorrhoea from an intrauterine device (IUD). DATA COLLECTION AND ANALYSIS: Four trials of high velocity, low amplitude manipulation (HVLA), and one of the Toftness manipulation technique were included. Quality assessment and data extraction were performed independently by two review authors. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Data unsuitable for meta-analysis were reported as descriptive data and were also included for discussion. The outcome measures were pain relief or pain intensity (dichotomous, visual analogue scales, descriptive) and adverse effects. MAIN RESULTS: Results from the four trials of high velocity, low amplitude manipulation suggest that the technique was no more effective than sham manipulation for the treatment of dysmenorrhoea, although it was possibly more effective than no treatment. Three of the smaller trials indicated a difference in favour of HVLA, however the one trial with an adequate sample size found no difference between HVLA and sham treatment. There was no difference in adverse effects experienced by participants in the HVLA or sham treatment. The Toftness technique was shown to be more effective than sham treatment by one small trial, but no strong conclusions could be made due to the small size of the trial and other methodological considerations. AUTHORS' CONCLUSIONS: Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea. There is no greater risk of adverse effects with spinal manipulation than there is with sham manipulation.

Dysmenorrhea↗
PubMed2004

Spinal manipulation for primary and secondary dysmenorrhoea.

BACKGROUND: Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological condition. One possible treatment is spinal manipulation therapy. One hypothesis is that mechanical dysfunction in certain vertebrae causes decreased spinal mobility. This could affect the sympathetic nerve supply to the blood vessels supplying the pelvic viscera, leading to dysmenorrhoea as a result of vasoconstriction. Manipulation of these vertebrae increases spinal mobility and may improve pelvic blood supply. Another hypothesis is that dysmenorrhoea is referred pain arising from musculoskeletal structures that share the same pelvic nerve pathways. The character of pain from musculoskeletal dysfunction can be very similar to gynaecological pain and can present as cyclic pain as it can also be altered by hormonal influences associated with menstruation. OBJECTIVES: To determine the safety and efficacy of spinal manipulative interventions for the treatment of primary or secondary dysmenorrhoea when compared to each other, placebo, no treatment, or other medical treatment. SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 18 March 2004), CENTRAL (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to March 2004), EMBASE (1980 to March 2004), CINAHL (1982 to March 2004), AMED (1985 to March 2004), Biological Abstracts (1969 to Dec 2003), PsycINFO (1872 to March 2004) and SPORTDiscus (1830 to March 2004). The Cochrane Complementary Medicine Field's Register of controlled trials (CISCOM) was also searched. Attempts were also made to identify trials from the metaRegister of Controlled Trials and the citation lists of review articles and included trials. In most cases, the first or corresponding author of each included trial was contacted for additional information. SELECTION CRITERIA: Any randomised controlled trials (RCTs) including spinal manipulative interventions (e.g. chiropractic, osteopathy or manipulative physiotherapy) vs each other, placebo, no treatment, or other medical treatment were considered. Exclusion criteria were: mild or infrequent dysmenorrhoea or dysmenorrhoea from an IUD. DATA COLLECTION AND ANALYSIS: Four trials of high velocity, low amplitude manipulation (HVLA), and one of the Toftness manipulation technique were included. Quality assessment and data extraction were performed independently by two reviewers. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Data unsuitable for meta-analysis were reported as descriptive data and were also included for discussion. The outcome measures were pain relief or pain intensity (dichotomous, visual analogue scales, descriptive) and adverse effects. MAIN RESULTS: Results from the four trials of high velocity, low amplitude manipulation suggest that the technique was no more effective than sham manipulation for the treatment of dysmenorrhoea, although it was possibly more effective than no treatment. Three of the smaller trials indicated a difference in favour of HVLA, however the one trial with an adequate sample size found no difference between HVLA and sham treatment. There was no difference in adverse effects experienced by participants in the HVLA or sham treatment. The Toftness technique was shown to be more effective than sham treatment by one small trial, but no strong conclusions could be made due to the small size of the trial and other methodological considerations. REVIEWERS' CONCLUSIONS: Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea. There is no greater risk of adverse effects with spinal manipulation than there is with sham manipulation.

Dysmenorrhea↗
PubMed2006

Paraspinal muscle spindle responses to the duration of a spinal manipulation under force control.

OBJECTIVE: More than 90% of chiropractic patients receive high-velocity, low-amplitude spinal manipulation (HVLA-SM) as part of their chiropractic care. The purpose of the current study was determine how the duration of a lumbar HVLA-SM given under force control affects the discharge of paraspinal muscle spindle afferents. METHODS: Experiments were performed on deeply anesthetized adult cats treated in accordance with the Guiding Principles in the Care and Use of Animals approved by the American Physiological Society. Muscle spindle afferents were identified in the dorsal roots. Neural activity was recorded from individual spindles located in the low back predominately from multifidus and longissimus muscles. Spinal manipulative loads were applied to the L6 vertebra. Force-time profiles were half-sine waves with impulse durations of 25, 50, 100, 200, 400, and 800 milliseconds, delivered at constant magnitudes of 33%, 66%, or 100% body weight. The relationships between spinal manipulation duration and muscle spindle responses were determined using a randomized block design. RESULTS: Mean instantaneous discharge frequency increased with decreasing impulse duration. There appeared to be a threshold effect for impulse duration below which the increase in muscle spindle discharge changed greatly with decreasing impulse duration and above which the discharge did not substantially change with decreasing impulse duration. This threshold was in the vicinity of the duration of an HVLA-SM applied clinically (<or=200 milliseconds). After the manipulation, muscle spindle afferents often became silent, but manipulation duration had little effect on this duration and also had little effect on the time it took for the afferents to recover their initial resting discharge. CONCLUSIONS: The findings suggest that one biomechanical characteristic of an HVLA-SM is its capacity to load paraspinal muscle spindles at a rate where their velocity sensitivity predominates over their length sensitivity.

Animals↗
PubMed2003

Vertebrobasilar ischemia and spinal manipulation.

OBJECTIVE: To examine cerebral arterial blood flow in 2 patients exhibiting signs of vertebrobasilar arterial ischemia (VBI) before and after spinal manipulative therapy. CLINICAL FEATURES: Two patients had a repetitive/resting tremor, one from a spastic torticollis with the onset immediately after self-manipulation by the patient 6 months earlier, and the second one with a generalized resting tremor, hip clonus, dizziness, and presyncope. The diagnosis of vertebrobasilar ischemia was established by continuous wave Doppler ultrasound and physical examination. INTERVENTION AND OUTCOME: Nonrotary cervical manipulation and diversified technique to the thoracic spine were performed. In the first patient, the spastic tremor improved by 80%. The repeat Doppler performed 13 months later showed an improvement in the arterial flow in the right external carotid artery peak flow from 0.7 kHz to 1.75 kHz. In the second patient, the resting tremor diminished in 4 days, with the right common carotid artery peak systolic flow improving from 1.0 kHz to 1.9 kHz and the left vertebral artery flow improving from 0.175 kHz to 0.5 kHz. The symptoms of VBI and objective Doppler findings improved following spinal manipulation. Both cases had impaired vertebral arterial flow. CONCLUSION: Spinal manipulation may have a normalizing effect on the sympathetic nervous system, allowing for a change in vasospastic cerebral vascular arteries.

Adult↗
PubMed2000

A randomized controlled trial of chiropractic spinal manipulative therapy for migraine.

OBJECTIVE: To assess the efficacy of chiropractic spinal manipulative therapy (SMT) in the treatment of migraine. DESIGN: A randomized controlled trial of 6 months' duration. The trial consisted of 3 stages: 2 months of data collection (before treatment), 2 months of treatment, and a further 2 months of data collection (after treatment). Comparison of outcomes to the initial baseline factors was made at the end of the 6 months for both an SMT group and a control group. SETTING: Chiropractic Research Center of Macquarie University. PARTICIPANTS: One hundred twenty-seven volunteers between the ages of 10 and 70 years were recruited through media advertising. The diagnosis of migraine was made on the basis of the International Headache Society standard, with a minimum of at least one migraine per month. INTERVENTIONS: Two months of chiropractic SMT (diversified technique) at vertebral fixations determined by the practitioner (maximum of 16 treatments). MAIN OUTCOME MEASURES: Participants completed standard headache diaries during the entire trial noting the frequency, intensity (visual analogue score), duration, disability, associated symptoms, and use of medication for each migraine episode. RESULTS: The average response of the treatment group (n = 83) showed statistically significant improvement in migraine frequency (P < .005), duration (P < .01), disability (P < .05), and medication use (P< .001) when compared with the control group (n = 40). Four persons failed to complete the trial because of a variety of causes, including change in residence, a motor vehicle accident, and increased migraine frequency. Expressed in other terms, 22% of participants reported more than a 90% reduction of migraines as a consequence of the 2 months of SMT. Approximately 50% more participants reported significant improvement in the morbidity of each episode. CONCLUSION: The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic SMT. A high percentage (>80%) of participants reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced.

Adolescent↗