Science In Brief

Chiropractic Litterature Review

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The Study: MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis.

The Facts:

  1. Both symptomatic and non symptomatic people have visible degenerative changes on imaging.
  2. The authors looked at studies that reported on the degenerative changes in asymptomatic and symptomatic subjects.
  3. The subjects were age 50 or younger.
  4. The studies used MRIs as the imaging.
  5. The 14 studies reviewed looked at over 3000 subjects.
  6. "Multiple previous studies have demonstrated a higher prevalence of disc findings in symptomatic-verses-asymptomatic individuals.
  7. "Disc extrusions are rare in asymptomatic populations."
  8. Most studies find less than 2% of asymptomatic subjects have disc extrusions.
  9. In symptomatic populations the prevalence of disc extrusions is 5 to 10%.
  10. The authors indicate that disc bulges are often considered to be incidental findings and that a surprising finding of their study "was that disc bulge had a strong association with low back pain.
  11. This study found that 6% of asymptomatic subjects had disc bulges while 43% of the symptomatic subjects had disc bulges.
  12. The authors warn that "the association between these degenerative findings and pain should not be interpreted as causation." They can be thought of as "candidate biomarkers for low back pain in..." patients younger than 50.

  

Take Home:

The authors conclude that: "disc bulge, degeneration, extrusion, protrusion, Modic 1 changes, and spondylolysis" are more common in subjects with low back pain in the 50 years or younger group than in those without low back pain.

Reviewer's Comments:

I really have little to say about this other than it seems to me that over and over again we see studies that indicate that often the closer spines are to" normal factory issue" the better it is for the subject and that physical changes predispose the patient to symptoms. I'm for appropriately aligned, non degenerated, normally functioning spines. But isn't the quest for that what chiropractic is all about?

Reviewer: Roger Coleman DC

  

Editor: Mark R. Payne DC

  

Reference: Brinjiki W, Diehn FE, Jarvik JG, carr CM, Kallme DF, Murad MH, Luetmer PH. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis.AJNR, Am J Neuroradiol 2015 Sep 10. [Epub ahead of print]

  

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/26359154

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The Study: The effects of cervical joint manipulation, based on passive motion analysis, on cervical lordosis, forward head posture, and cervical ROM in university students with abnormal posture of the cervical spine.

The Facts:

  1. 40 students complaining of chronic neck pain and who had a range of motion of less than 70 degrees in extension and 35 degrees in flexion along with a forward head posture of more than 15mm and a cervical lordosis on x-ray that was less than 21 degrees were used in the study.
  2. They were divided into two groups.
  3. One group received general mobilization.
  4. The other group was placed supine and they were manually examined to find restrictions.
  5. For extension the subjects were checked for restriction in the left and right cervical facet joints while supine and the restricted areas were manipulated. This was done for C2-C6.
  6. For flexion and side bending the subjects were check for restrictions while supine and the restricted joints manipulated. This was done for C4-C5.
  7. e. The manipulation group showed improvement in forward head posture, cervical lordosis, cervical extension and extension/flexion range of motion.
  8. Mobilization improved cervical extension and forward head posture.
  9. Cervical extension and cervical extension/flexion range of motion was significantly higher in the manipulation group as compared to the mobilization group.

Take Home:

This type of cervical manipulation might improve forward head posture, cervical lordosis and cervical range of motion.

Reviewer's Comments:

This study was conducted by a PhD, PT from the Department of Physical Therapy at the Korea Nazarene University. When performing the manipulation the provider attempted to isolate the restricted joint and to manipulate that joint. It appears they were attempting to provide a specific manipulation to a specific area to improve the motion of that joint and the care also improved structural alignment.

Reviewer:Roger Coleman DC

 

Editor’s Comments: The average correction in the cervical lordosis (ARA) achieved by the manipulation group was 5.2 degrees which compares very favorably with most studies which have looked at chiropractic adjustment/manipulation. Patients received a 10 minute session of manipulation three times weekly for four weeks. Spinal change was measured using before and after radiographs. The mobilization only group averaged only 2.6 degrees of improvement in the lordosis.

Once again we have physical therapists analyzing posture with radiography and motion palpation procedures and then documenting improvements in spinal posture using post treatment radiographs. Meanwhile chiropractors just keep turning out one study after another on back pain while our very profession is stolen in broad daylight..

Editor: Mark R. Payne DC

 

Reference: Gong W. The effects of cervical joint manipulation, based on passive motion analysis, on cervical lordosis, forward head posture, and cervical ROM in university students with abnormal posture of the cervical spine. J Phys Ther Sci. 2015 May;27(5):1609-11

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/26157273

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The Study: Validity of palpation of the C1 transverse process: comparison with a radiographic reference standard

The Facts:

  1. The authors wished to determine if it was possible to accurately locate the transverse of atlas by the use of palpation.
  2. They placed markers at the transverse of atlas on 21 subjects.
  3. The placement of the markers was determined by the use of palpation.
  4. Radiographs were taken and the accuracy of the placement of the markers compared to the transverse process of the atlases as seen on the radiographs was noted.
  5. The authors felt that it was not easy to place the markers as you had to remove your finger in order to make the placement and this may have affected accuracy. Also the patient's head may have tilted between the placement and the radiograph and that may have affected accuracy.
  6. The center of the transverse process as determined by radiograph was within + or - 4mm of the center of the markers placed by palpation in 57.1% of the cases.

Take Home:

Although there may have been some problem with placement of the marker it appears that an accuracy of locating the transverse of atlas within 4mm. can be done over half the time.

Reviewer's Comments:

Remember the line. "It depends on what the meaning of is, is." Well it depends on what you think accurate is. I always love people who say well you are off by X (put in some small value) therefore your idea is no good. On the other hand some people say that it's only off a little bit (put in a much larger value) so it's OK. If you are measuring a football field then 4mm is really great. If you are measuring the distance between electrons, then not so much.

In practical terms, I look at it in this manner. How big is the area that you are using to contact the transverse of atlas when you adjust? I've got a feeling that you'll find it's a lot bigger than 4mm. I've spent a large part of my life thinking about measurements on x-rays and I really like studies such as this one, but I always try to remember that there is a practical aspect to all of these measurements. So I leave it up to you as to how close you really need to be.

Reviewer: Roger Coleman DC

Editor's Comments: I had a personal interest in this paper, as I did essentially the same project as my senior research paper at Life College. As I recall we had only about 15-16 participants, all student clinicians, who were asked to palpate and mark the C-1 transverse process on their patients during the initial examination. Unfortunately, our results were not nearly so positive, with the average doctor palpating at about C2-3 instead of over Atlas. This study used two examiners with much more experienced (one with eight years and the other with two years of experience) and that experience appears to have played a tremendous role in terms of accuracy. Encouraging!

Editor: Mark R. Payne DC

Reference: Cooperstein R, Young M, Lew.Validity of palpation of the C1 transverse process: comparison with a radiographic reference standard. J Can Chiropr Assoc. 2015 Jun;59(2):91-100.

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/26136601

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The Study: Validation of Placebo in a Manual Therapy Randomized Controlled Trial.
  
  
The Facts:
 
a. The authors indicate that there is no recognized placebo to be used in scientific trials that look at spinal manipulation.
  
b. The lack of an adequate placebo has been problematic in chiropractic research. A documented placebo is needed in order to perform certain studies and would greatly benefit the research of chiropractic spinal manipulation.
  
c. The authors used an active treatment and a placebo and asked the subjects to identify if they had received the active treatment.
  
d. The active treatment was a Gonstead adjustment.
  
c. The placebo was a sham adjustment which consisted of "a broad non-specific contact low-velocity, low-amplitude sham push maneuver".
  
d. When asked if they received the active treatment more than 80% thought they had received active treatment regardless of whether they were in the active or sham group.
  
 
Take Home:
It appears possible to perform placebo manipulation(s).
 
Reviewer's Comments:
Placebos are used all the time in drug trials. This is a placebo manual manipulation and that allows us to do studies that we would be unable to perform without the use of a placebo. Studies could be designed to eliminate the criticism that improvement in the subjects was the result of the natural progression of the condition or just the attention paid to the patient by the doctor. The use of a placebo manual manipulation could be of great use to some researchers.
  
Reviewer: Roger Coleman DC
  
Editor: Mark R. Payne DC
  
Reference: Chaibi A, Saltyte Benth J, Bjorn Russell M. Validation of Placebo in a Manual Therapy Randomized Controlled Trial. Sci Rep. 2015 Jul 6;5:11774. doi: 10.1038/srep11774.
  
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The Study: Chiropractic management of pubic symphysis shear dysfunction in a patient with overactive bladder.
The Facts:
  1. A patient suffered from overactive bladder.
  2. She could only sleep for two hours at a time due to this condition.
  3. Examination revealed "pubic symphysis shear dysfunction".
  4. The patient received drop table manipulation to reduce the problem.
  5. After 8 treatments over one month the patient's sleep times were up to 7 hours.
  6. Dr. Cooperstein then offers a discussion of why the chiropractic care may have been helpful in this case.
Take Home: In this particular case it appears that chiropractic care was quite helpful in a case of over active bladder and allowed for a much longer period of sleep. As there are a lot of patients who suffer from this condition this area seems ripe for further research. There is also a fairly lengthy discussion of why the improvement may have occurred which is a very important part of this article and although it is too long for this review it is certainly of interest.
Reviewer's Comments: Well first of all let me just say that Bill Ruch, DC, long time professor of Anatomy at Life College West, has been bending my ear for a long time about what he feels is the under discussed area of pubic symphysis shear and dysfunction. Also in full disclosure, Bill gave me an acknowledgement in his article on the radiographic analysis of pubic symphysis misalignment that was used as one of the references in this article. This article goes along with my line of thinking that whenever we have structural misalignment then we have the potential for problems. Cooperstein has proceeded to discuss this issue in an individual case report and in view of his results it seems that more extensive studies would be in order. I hope that such studies will be forthcoming and that we have the opportunity to report on them is Science in Brief.
Reviewer: Roger Coleman DC
Editor's Comments: I thought this was a great article, wish we had covered it earlier. Very informative and useful in your day to day practice in a way that few case studies are. I don't normally urge our subscribers to read the full text (that's our job), but the details of the adjustments given and the pictures included by the author were very explanatory. I have included the link to the full text below. Great job Drs. Cooperstein, Lisi, and Burd.
Editor: Mark R. Payne DC
Reference: Cooperstein R, Lisi A, Burd A. Chiropractic management of pubic symphysis shear dysfunction in a patient with overactive bladder. J Chiropr Med. 2014 Jun;13(2):81-9
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The Study:   Results of lumbar spine surgery: a postal survey.          
      

The Facts:

  1. a. The authors stated that. "No studies had been published regarding the results of lumbar spine surgery in a population-based setting in Finland."
  2. In order to study the results they sent out questionnaires to patients who had undergone surgery for either spinal stenosis, lumbar disc herniations or instability in the lumbar spine.
  3. They looked at the results of these questionnaires from 537 patients.
  4. 67% of these patients had undergone disc surgery while 17% had decompression for stenosis and the final 16% had spinal stabilizing surgery.
  5. The authors noted that the numbers were low for patients who were pain free: 9% for those who underwent disc surgery, 6% in the decompression group and only 1% of those who had spinal stability surgery.
  6. The study showed 70% and 74% of the decompression and stabilizing surgery groups respectively still had constant or daily pain.
  7. Disc surgery patients fared better as 51% reported being pain free or having only occasional pain.
  8. It should be noted that the average age of the disc surgery patients was the youngest of the three groups with an average age of 42 while the patients who underwent decompression for stenosis was the oldest at an average age of 55.
  9. The authors called this outcome in regards to the disc surgeries as follows: "Our study confirmed a good outcome for lumbar disc operations...."
 Take Home:
Outcomes for lumbar disc surgery were better than those for decompression for stenosis or spinal stabilizing surgeries. In the disc surgery patients 51% were pain free or had only occasional pain which the authors of the study felt was a good result.
Reviewer's Comments:
Let me see if I can make a comparison that I like. "Compared to a billiard ball, I have a great amount of hair." Yes, the disc surgeries had better outcomes than the other surgeries studied, but these surgeries are complicated, expensive and have the potential for very real complications. Am I glad they exist for the times when they are needed? Absolutely! This study underscores the need for chiropractors to give the best care possible in order to reduce, as much as possible, the need for spinal surgery.
Reviewer: Roger Coleman DC
Editor's Comments: Success rates of 6% for spinal stenosis decompression and 1% for lumbar instability. Hmmmm. Those are two good figures to remember when counseling your patients.
Editor: Mark R. Payne DC
Reference: Jarvimaki V, Juurikka L, Vakkala M, Kautiainen H, Haanpaa M.Results of lumbar spine surgery: a postal survey. Scandinavian Journal of Pain 6 (2015) 9-13
Link to Abstract: No abstract in PubMed
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The Study:Patients with low back pain had distinct clinical course patterns that were typically neither complete recovery nor constant pain

The Facts:

  1. The study looked at 1,082 patients with nonspecific low back pain.
  2. The authors examined both the intensity and frequency of the low back pain each week for a year.
  3. The patients were treated by either a general practitioner or a chiropractor.
  4. 106 general practitioners and 36 chiropractors were involved.
  5. The care was covered 100% when given by a general practitioner but only 20% of the cost was covered for chiropractic care.
  6. The patients, on average, improved for the first 10 weeks and then the progress stopped.
  7. The test was not designed to investigate the effects of chiropractic care as compared to medical care. However, the authors noted that "early improvement or recovery were a larger part of the chiropractic sample that the GP sample, whereas patterns of sustained LBP were more frequent in GP."
  8. Most patients in the study were not pain free at the end of the year time period. However, only a small group suffered from severe constant pain at the end of the year time period.

Take Home:

Most patients in the study did not completely recover within a year. The greatest amount of improvement that occurred in the cases tended to take place in the first 10 weeks.

Reviewer's Comments:The study was not set up to identify the differences between chiropractic and medical care but as can be seen above the chiropractors seemed to come out pretty good in the study. The take away from this study appears to be that low back pain doesn't just go away on its own and that even with care most patients will still have some pain a year later. I was also left to wonder if the chiropractic patients had as much care as they really needed because only 20% of the cost of their care was covered.

Reviewer:Roger Coleman DC

Editor: Mark R. Payne DC

Reference: Kongstead A, Kent P, Hestbaek L, Vach W. Patients with low back pain had distinct clinical course patterns that were typically neither complete recovery nor constant pain. A latent class analysis of longitudinal data. Spine J. 2015;15:885-94

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25681230

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The Study: Sonography of occult rib and costal cartilage fractures: a case series.

The Facts:

  1. The authors were looking at using diagnostic ultrasound to detect costal cartilage fractures and occult rib fractures.
  2. The study only covered three cases.
  3. The first patient had suffered a trauma to the chest. Ultrasound revealed fractured ribs but radiographs were interpreted as negative.
  4. The second patient had been diagnosed with a lower left rib fracture two months prior.. That diagnosis had been made clinically and no diagnostic imaging was done at the time. The pain persisted and when the patient was examined again ultrasound now revealed a costal fracture, however, radiography was negative at the time of re-examination.
  5. The third case had suffered trauma to the chest. Radiography one week after the trauma was negative. However, pain persisted and three weeks after the radiography an ultrasonic examination was done and revealed cortical discontinuity and callus formation on the second rib. A second ultrasound three weeks later "showed bridging of the callus indicating fracture healing."
  6. In these cases ultrasound "...was more sensitive for detecting acute, isolated fractures of the rib and costal cartilage than conventional radiography."

Take Home:

There are times that ultrasound will show fractures that are not apparent on the radiograph.

Reviewer's Comments:

This is quite interesting. If the patient has suffered from some injury where a costal or rib fracture might be suspected it appears that diagnostic ultrasound may reveal injuries not apparent on a radiograph. Another tool to aid in making the correct decisions regarding care.

Reviewer: Roger Coleman DC

Editor: Mark R. Payne DC

Reference: Matox R, Reckelhoff KE, Welk AB, Kettner NW. Sonography of occult rib and costal cartilage fractures: a case series. J Chiropr Med 2014;13:139-43

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25685124 

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The Facts:

  1. This is a case report.
  2. The author indicates that his design is to make it an evidence based report.
  3. The patient had symptoms of lumbar stenosis but the examination and imaging (MRI) were not conclusive.
  4. The author searched PubMed to find information from "systematic reviews of diagnostic studies" which were related to lumbar stenosis.
  5. He found two relevant articles and then used those in combination with the MRIs to further the accuracy of the diagnosis.
  6. With the additional information from the literature search,the author was able to make the diagnosis of lumbar spinal stenosis (LSS).
  7. Using the results of the literature search "a more accurate diagnosis of LSS was reached."

Take Home:

A literature search done by a clinician can result in a better understanding of the case and serve as a tool in appropriate care.

Reviewer's Comments:

We usually don't discuss a lot of case studies in Science in Brief because of the difficulty in extrapolating valid information. But this case report is different, in that it illustrates a broader point. It is a practical reason for reading the literature. The literature is there to be used. It is great to learn things in college. It is wonderful to have clinical experience. It is fantastic to get an overview of articles from Science in Brief. But when you need further information on a troublesome case you can search PubMed and then use the information to guide your care of the patient. It's an obvious thing, but one that is probably used far too seldom by most doctors. Thanks for writing this article Dr. Emary.

  

Reviewer: Roger Coleman DC

  

Editor: Mark R. Payne DC

  

Reference: Emary PC. Diagnosis of a 64-year-old patient presenting with suspected lumbar spinal stenosis: an evidence-based case report. J Can Chiropr Assoc. 2015;59:46-52.

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25729085 

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The Study: The location of the inferior angle of the scapula in relation to the spine in the upright position: a systematic review of the literature and meta-analysis.

The Facts:

  1. Anatomical landmarks are sometimes used by clinicians in order to identify spinal levels.
  2. Some sources indicate that the inferior scapular angle is at the same level as the spinous (SP) of T7 when the patient is in the upright position.
  3. However, other sources place the inferior scapular angle at the level of the T7-T8 interspace and still others place it at the level of T8.
  4. The authors performed an extensive reviewed of the literature to better determine which spinal level most closely correlated with the level of the inferior scapular angle (IAS).
  5. "... the upright IAS on average aligns closely with the T8 SP, range T4-T11."
  6. "...using the IAS may be less preferred than using the location of vertebral prominens to identify thoracic spine locations."
  7. The authors felt that this should be of interest to the medical profession as well as the providers of manual therapy.

Take Home:

Let me repeat, "... the upright IAS on average aligns closely with the T8 SP, range T4-T11."

Reviewer's Comments:

I think this one speaks for itself. How an individual provider practices is likely to determine how important this information is to them.

Reviewer: Roger Coleman DC

Editor's Comments: The very wide range (T4 to T11) shows just how difficult it can be to accurately identify spinal levels using the IAS alone. One of the studies cited "reported accuracy rates of 18%, 62%, and 41% respectively in using the IAS for identifying T-7" This can be an important issue for chiropractors because errors in accurately numbering spinal levels in the patient's charts, could easily lead to non intended consequences during treatment...especially if/when communicating with other practitioners. The authors mentioned using both the vertebral prominens (C7 SP) and/or the iliac crests as possibly better options for locating specific spinal levels.

Editor: Mark R. Payne DC

Reference: Cooperstein R, Hanelline M, Young M. The location of the inferior angle of the scapula in relation to the spine in the upright position: a systematic review of the literature and meta-analysis. Chiropr Man Therap 2015;23:7.

Link to Abstract:http://www.ncbi.nlm.nih.gov/pubmed/25729566 

 

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The Study:Clinical examination findings as prognostic factors in low back pain: a systematic review of the literature

The Facts:

 

  1. A clinical examination is commonly done on patients.
  2. However, making "a pathoanatomic diagnosis" is usually not possible in the average low back pain patient.
  3. The authors felt that perhaps the clinical examination might be more helpful in determining the prognosis for the case.
  4. They tried to find an association between clinical tests used in cases of "acute, recurrent or chronic low back pain and short- and long-term outcome".
  5. It was a review of the literature and was directed at adult patients.
  6. "There is evidence from confirmatory studies for an association between centralization and non-organic signs and outcome."
  7. "...consistent evidence of non-organic signs being predictive of long-term poor outcome of return to work."
  8. But as regards the prognostic value of the other tests, there was either no evidence at all, or a lack of good quality evidence in terms of their predictive value.
  9. Included among the other tests looked at were palpation, range of motion, and straight leg raise.

Take Home:

Bottom line is that it's often pretty difficult to make a prognosis based on most clinical tests, but there is some evidence for the predictive value of non-organic signs and centralization . The authors took pains to note that clinical tests are designed and used for other purposes, and a poor association with prognosis does not discredit the test as being diagnostic or otherwise informative for clinical management. Clinical tests may still have potential as treatment effect modifiers or as part of comprehensive predictive models.”

Reviewer's Comments: Now for my take. Even though the authors of the article found evidence of non-organic signs and centralization being predictive of outcomes, this evidence is not as clear cut as I would like. I suggest keeping in mind that making a prognosis is difficult at best. No single test can predict outcomes accurately. Ultimately we must still use our own best clinical judgment based on our own experience with similar cases.

Reviewer:Roger Coleman DC

Editor’s Comments: In case you don’t remember much about “non organic signs

(I didn’t) here’s the quick review.Five types of nonorganic findings were classified by Waddell et al in 1980: 1) Tenderness, 2) pain, or reduction of pain free range of motion, upon distraction, 3) regional weakness or sensory disturbance, 4) “over reaction” such as pulling away, grimacing, etc., 5) expressed pain upon “simulated” spinal motions which don’t actually stress the spine. Presence of three or more types of non organic signs, although not necessarily associated with malingering, may still indicate the presence of psychosocial factors which will need to be dealt with in managing the patient. Psychosocial factors may be one possible explanation for the association between non-organic signs and poor therapeutic outcomes.

Editor: Mark R. Payne DC

 Reference: Hartvigsen L, Kongsted A, Hestbaek L. Clinical examination findings as prognostic factors in low back pain: a systematic review of the literature. Chiropr Man Therap. 2015;23:13

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25802737

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The Study: The single-leg-stance test in Parkinson's disease. (1)

The Facts:

  1. Determining how long a person can stand on one leg has been used in the evaluation of elderly patients.
  2. In Parkinson patients, being capable of standing on one leg for around 10 seconds or less appears to be an indicator that the patient is at risk for falls.
  3. They looked at 27 patients who had Parkinson's disease.
  4. The mean age was 67.1 years.
  5. The patients kept their eyes open and were timed standing on one leg. Each leg was tested three times unless the patient was able to stand perfectly on each leg for 60 seconds on the first two trials. In those cases the test was terminated after standing on each leg twice.
  6. It was concluded that those who had standing times of approximately 10 seconds or less "had reached a clinically important stage of disease progression with significant worsening of postural stability..."

Take Home:
Those who can stand on one leg for 10 seconds or less have a "significant worsening of postural stability..." and are at a greater risk of falls.

Reviewer's Comments:
It appears that if you can stand on one leg with eyes open for 60 seconds and do it perfectly on each leg for two times in a row that's pretty good. But as the times decrease and we approach the 10 second mark, that's a significant reason for concern. It would appear this test might provide a quick and simple assessment tool to determine disease progress in Parkinson's patients.

Reviewer: Roger Coleman DC

Editor: Mark R. Payne DC
Editor's Comments: Just as a side note, leg tremors during both bilateral and single leg standing have also been associated with early Parkinson's. Presence of rapid or low frequency leg tremors during the test described above should also alert the practitioner as a possible harbinger of neurological dysfunction. (2)

References:

1. Chomiak T, Pereira FV, Hu B. The single-leg-stance test in Parkinson's disease. J Clin Med Res. 2015;3:182-5.

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25584104

2. Suk Yun Kang,a,b Sook-Keun Song,a Jin-Soo Kim,a and Young Ho SohnaUnilateral Standing Leg Tremor as the Initial Manifestation of Parkinson DiseaseJ Mov Disord. 2009 May; 2(1): 29-32.

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The Study:   Short-term effect of spinal manipulation on pain perception, spinal mobility, and full height recovery in male subjects with degenerative disk disease: a randomized controlled trial

The Facts:

  1. The treatment was high velocity low amplitude manipulation of the L5-S1 area.
  2. The subjects were men with degenerative joint disease.
  3. The authors sought to determine the short term effect of treatment on these subjects on the following factors: "spinal mobility, pain perception, neural mechancosensitivity and full height recovery". (They indicated that they used "passive straight-leg raise ROM" as a measure of observing neural mechanosensitivity with the end point of the test being the start of the patient's pain or discomfort. The full height recovery was done with a Stadiometer in which the person's height is measured 90 seconds after they stand up.)
  4. Subjects were divided into both a treatment and a control group.
  5. The type of manipulation was a L5-S1 pull move (side posture).
  6. The treatment group received just one manipulation.
  7. The treatment group showed a significant improvement in all the variables studied following the single manipulation.
  8. One of the outcomes was to measure pre and post manipulation height and the manipulation group showed an increase in height following the manipulation of 3.98mm plus or minus 1.46mm.
  9. Following manipulation there was "an immediate reduction in self-perceived LBP."

Take Home:

The treatment subjects improved in the variables studied following a single side posture manipulation.

Reviewer's Comments:

I think we've come to expect studies to show improvement in pain and spinal motion. This one also showed an increase in height and I found that quite interesting.

Reviewer:Roger Coleman DC

Editor: Mark R. Payne DC

Reference: Viera-Pellenz F, Oliva-Pascual-Vaca A, Rodriguez-Blanco C, Heredia-Rizo AM, Ricard F, Almazan-Campos G. Short-term effect of spinal manipulation on pain perception, spinal mobility, and full height recovery in male subjects with degenerative disk disease: a randomized controlled trial. Arch Phys Med Rehabil. 2014;95:1613-9

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/24862763

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The Study:The correlation of radiographic findings and patient symptomatology in cervical degenerative joint disease: a cross-sectional study

The Facts:

  1. The authors note that there is little study on correlation of patient's symptoms to findings of degenerative joint disease on x-rays.
  2. They looked at the cervical x-rays of 322 patients who suffered from neck pain and related symptoms
  3. They did not find a correlation between degenerative joint disease and "pain level, headaches, shoulder referral, hand radiculopathy or numbness."
  4. There was only a small degree of correlation between cervical degenerative joint disease and "shoulder and neck stiffness".
  5. Age was the only thing that was significantly associated with degenerative joint disease.
  6. This study agrees with prior studies which also indicated that there was not a correlation of the degree of degenerative joint disease to the degree of pain.

Take Home:
There is a poor correlation between the severity of the degenerative joint disease and the severity of symptoms in this study.

Reviewer's Comments:
I am not at all surprised, but you may be surprised at my comments. First, if there was a strong association between the degree of degenerative joint disease and the severity of neck pain/symptoms then manipulation wouldn't provide much in the way of relief. The logic here is pretty simple because an average trial of manipulation will not significantly reduce the degree of DJD, and yet, manipulation often provides significant relief to patients with neck pain or neck associated symptoms. Next, as there is not much of an association between neck stiffness and degenerative joint disease it shows me that you can't use range of motion to determine the health of the disc very accurately. Perhaps most importantly it reinforces my thought that it's pretty hard to tell much about the condition of the spine without imaging. To see and understand what's going on inside our patients, we need imaging.

Reviewer: Roger Coleman DC

Editor: Mark R. Payne DC

Reference: Rudy IS, Poulos A, Owen L, batters A, Kieliszek K, Willow J, Jenkins H. The correlation of radiographic findings and patient symptomatology in cervical degenerative joint disease: a cross-sectional study.Chiropr Man therap. 2015 Feb 9;23:9. doi: 10.1186/s12998-015-0052-0. eCollection 2015.

Link to Abstract:
http://www.ncbi.nlm.nih.gov/pubmed/25671078

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The Study: The effect of adding forward head posture corrective exercises in the management of lumbosacral radiculopathy: a randomized controlled study.

The Facts:

  1. The authors performed a study lasting 2 years on patients who suffered from "chronic discogenic lumbosacral radiculopathy".
  2. The treatment was multimodal and a part of the treatment in one group was to give them exercises designed to correct forward head translation.
  3. They had two groups, one of which got the "functional restoration program".
  4. The other group also received the functional program and in addition "the experimental group received the forward head posture corrective exercise".
  5. The primary outcome measurement was the Oswestry Disability Index.
  6. There were a lot of secondary outcome measurements which dealt with mechanical factors such as translation, lordosis and kyphosis. In addition to the mechanical measurements they also included "leg and back pain scores, and H-reflex latency and amplitude."
  7. Patients were evaluated prior to treatment, 10 weeks post treatment plus a follow up evaluation at 2 years.
  8. At 10 weeks there was really no difference between the two groups in terms of disability. But at 2 years they found significant differences between the two groups. The group that received the forward head posture corrective exercises added to their program was significantly improved in all the variables studied.
  9. The authors concluded that adding the corrective head posture exercises to the treatment conferred a positive effect on disability, spinal posture, back pain, leg pain and the function of the S1 nerve in these patients.
  10. In the introduction they referenced Brumagne writing in the European Spine Journal and Wong writing in the journal BMC Musculoskeletal Disorders and stated, "Abnormal posture is one of the most important etiological factors associated with low back pain." (emphasis ours.)
  11. They also note there is a lack of study on the affect of the cervical spine on "spinal posture closely linked to low back pain."
  12. In the discussion section the authors also suggest the possibility tha "the cervical spine has an important role in global spinal posture".
  13. Abnormal posture may lead to joint dysfunction and abnormal afferent information.

Take Home:

Functional restoration was just as good as functional restoration coupled with forward head posture corrective exercises as far as disability in the short term but at 2 years the patients who received the corrective exercises (note: the alignment of this group was significantly improved) were significantly better in all the variables used to study these patients.

Reviewer's Comments:

I'm sorry you can't see the pre, 10 week post, and and 2 year follow up lateral cervical x-rays of the group receiving the corrective exercise in addition to the functional restoration program. The pre x-rays show spines with very little cervical lordosis and pronounced forward head posture. The post treatment film shows a very nice lordosiswith the head balanced over the thorax and the 2 year follow up shows that the great majority of what was accomplished by the treatment has been maintained.

I have always found it unreasonable not to acknowledge that the structural alignment of the spine can have a significant effect on the health and well being of patients. Skyscrapers do not rise toward the heavens at 45 degree angles. No architect would say that the alignment of the supporting structures in their new 40 story building don't matter. But I've heard chiropractors say the equivalent when it comes to patients. Spinal alignment is important.

But here is the other side of the argument. Am I saying the only thing important to health is spinal alignment or that we get to treat patients endlessly in an effort to achieve our own model of perfection. Absolutely not! We need to recognize that structural alignment is important to all things on this earth. In addition we should consider its importance as we undertake the reasonable and appropriate care of our patients. I'd like to thank the physical therapist who wrote this article for doing the type of research which is so important to the health of patients.

Reviewer: Roger Coleman DC

Editor's Comments: Once again, we see competing professions doing good research into the most basic tenets of chiropractic. The physical therapy profession realizes full well the importance of healthy spinal alignment and they will be more than willing to steal our professional birthright if we are stupid enough to abandon this concept. Chiropractic academia at large, no doubt still influenced by the same old intra professional politics of the past hundred years, is letting our profession and the people we serve down terribly in this area.

Editor: Mark R. Payne DC

Reference: Moustafa IM, Diab AA. The effect of adding forward head posture corrective exercises in the management of lumbosacral radiculopathy: a randomized controlled study. J Manipulative Physiol Ther 2015;38:167-78

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25704221

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The Study: The influence of pelvic adjustment on vertical jump height in female university students with functional leg length inequality

The Facts:

  1. The authors took 30 female university students who all had functional leg length inequality.
  2. They divided them into two groups.
  3. One group was the control who performed stretching exercises.
  4. The other group was the adjustment group and those subjects were adjusted.
  5. The adjustment used was to place the subject prone and adjust for both PI and AS misalignments "in accordance with Gonstead's theory".
  6. The adjustments were performed by "one skilled physical therapist".
  7. The vertical jump height improved only in the adjustment group. But, the functional leg length inequality improved in both the adjustment and stretching group.

Take Home:
Stretching did affect functional leg length inequality but adjustment improved the functional leg length inequality as well as the jump height.

Reviewer's Comments:
Am I really surprised? No! I think both stretching and adjustments can have an effect on patients. I also think that adjustments are pretty effective in lots of cases. It appears that the adjustments in this article had a greater impact on the function (in this case vertical jump height) than did stretching and that doesn't surprise me either. But what disappoints me is that I see more and more of these types of studies done by physical therapists in a time when it appears that many chiropractors are moving away from tying structural alignment with function. Many chiropractors feel we don't need to be very concerned about alignment. Well don't worry about it. Surgeons are using alignment as an outcome measure and physical therapists are very interested in the link between alignment and function. There will always be providers who recognize the importance of structural alignment. I'm just wondering who will be doing it and what it will be called. So send me your thoughts. I'll probably get too many to answer but I am interested in what you think.

Reviewer: Roger Coleman DC

Editor's Comments: Honestly, I couldn't make this stuff up if I tried. Here we have a study in which physical therapists are not only researching a traditional chiropractic treatment method (Gonstead) but unabashedly appropriating the term "adjustment" as well. Meanwhile we adopt terms like "manipulation" to better emphasize our focus on function instead and distance ourselves from the structural based roots of chiropractic. On the one hand we continue to have a sizeable portion of the profession clinging to late 19th century models of subluxation to explain what we do. On the other, we see a huge chunk of the profession which would rather abandon our birthright totally than do the heavy intellectual lifting required to understand chiropractic in modern terms. And finally we have PTs who are more than happy to embrace what we threw out with the bathwater. They pick up our discarded concepts, clean them up, and eventually will adopt them as their very own. We fiddle. Rome burns.

Editor: Mark R. Payne DC

Reference: Gong W J Phys Ther Sci. 2015;27:251-3.The influence of pelvic adjustment on vertical jump height in female university students with functional leg length inequality. J Phys Ther Sci. 2015;27:251-3.

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25642085

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The Study: Regional lumbar motion and patient-rated outcomes: a secondary analysis of data from a randomized clinical trial.

The Facts:

  1. Let's start at the end and work backwards on this one.
  2. "Overall, changes in regional lumbar motion were poorly associated with patient-rated outcomes..."
  3. This paper looked at data from a randomized clinical trial.
  4. The study looked at chronic low back pain patients who were treated over a 12 week time period.
  5. The types of care they received were spinal manipulation (77 subjects), supervised exercise (62 subjects) and advice on home exercise (60 subjects).
  6. Range of motion was done at baseline and at 12 weeks.
  7. They used a sophisticated device (CA 6000 Spine Motion Analyzer) to measure the motion.
  8. The authors felt that "in general" the changes in "regional lumbar motion patterns" didn't really match the patient reported pains or function.
  9. "...the actual usefulness of regional lumbar measurements remains controversial..."

Take Home:

Lumbar motion changes don't necessarily correlate with pain and function.

Reviewer's Comments:

This is a large and complex article that I recommend for your reading. I wished to concentrate on the idea that just because motion improves it doesn't mean that pain will. Now I think that motion is important. But there is a problem in that our profession has become obsessed with trying to correlate every treatment to its immediate effect on spinal pain. Sorry, but that's not a good way to run a profession and this article helps to point that out.

Reviewer: Roger Coleman DC

Editor: Mark R. Payne DC

Reference: Mieritz RM, Bronfort G, Hartvigsen J. Regional lumbar motion and patient-rated outcomes: a secondary analysis of data from a randomized clinical trial. J Manipulative Physiol Ther 2014;37:628-40.

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25455833

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The Study: The perils of complementary alternative medicine.

  

The Facts:

  1. The authors state there are over "11,000 articles lauding alternative Medicine" in PubMed.
  2. However, there are few articles which describe complications from alternative medicine.
  3. They indicate that two patients have been seen in their hospital with complications from alternative medical treatment.
  4. They go on to state that one patient suffered from necrotizing fascitis following acupuncture while the second developed an epidural hematoma following chiropractic care.
  5. They then say that these complications should be a "clarion call" to health ministries around the world and specifically the Israeli Health Ministry "to include complementary medicine under its inspection and legislative authority."
  6. They say that health ministries should include an education on hygiene and safety issues in order to improve care by alternative providers.
  7. They further state they are not trying to scold alternative medical providers and acknowledge that traditional medicine has "problematic consequences" as well but that the medical providers "practice under, severe surveillance in an environment conducive to damage control."

Take Home:

The gist of the paper is that because two cases of complications following care with alternative medicine were seen in a hospital, which I would assume has seen many complications due to medical care, alternative medicine should be regulated by health ministires.

Reviewer: Roger Coleman DC

Editor's Comments: This paper contains more than a small dose of hubris. For a group of medical researchers to get worked up over the "perils" alternative healthcare. two hospitalizations resulting from alternative care procedures seems pretty farfetched. After all, their own profession killed an estimated 142,000 people worldwide in 2013 alone through iatrogenic illness and medical errors. And while there's some truth in their contention that nations who neither license nor oversee alternative health care professions can do little to improve public safety, it's also equally true that in almost all cases it is the medical profession which fights tooth and nail to prevent licensing and legitimization for alternative health care providers of all types.

Editor: Mark R. Payne DC

Reference: Bayme MJ, Geftler A, Netz U, Kirshtein B, Glazer Y, Atias S, Perry Z. The perils of complementary alternative medicine. Rambam Maimonides Med J. 2014 Jul 25;5(3):e0019. doi: 10.5041/RMMJ.10153. eCollection 2014

Link to Abstract:

http://www.ncbi.nlm.nih.gov/pubmed/25120919

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The Study: Patient characteristics upon initial presentation to chiropractic teaching clinics: A descriptive study conducted at one university

The Facts:

  1. This review is going to be a little different as I wish to use this study to discuss the type of patients most chiropractors are treating.
  2. The authors looked at the chief complaints and ICDA 9 codes of new patients presenting at Logan University's fee-for-service clinics compared to the patient population of U.S. chiropractors. (For this review we will look only at the chief complaints as there is a point I wish to make regarding the presenting complaint.)
  3. "...nearly all chief complaints were musculoskeletal..."
  4. The most frequent chief complaint at the Logan clinics was low back pain (31.3%) as compared to 23.6% across the U.S. This was followed by lower extremity pain (21%) at Logan compared to 8.8% across the U.S. Neck pain made up 16.5% of the Logan patients compared to the 18.7% nationwide. Mid back was 9.8% in the population compared to 11.5% of the US group. Upper extremity was 8.5% at Logan and 8.3% in the US. And finally, Headache/facial pain was 7.1% at Logan and in the 12.0% of the US patients.
  5. Wellness at Logan was 1.8% and 8.0% in the US.
  6. Nonmusculoskeletal was 1.3% compared to 2.5% in the US.

Take Home:

The great majority of chief complaints were musculoskeletal in nature.

Reviewer's Comments:

First I want to thank the authors for writing this article. It is important to periodically look at ourselves in this manner. As you can see, the vast majority of cases are coming to chiropractors for musculoskeletal problems. Now I want to say that I've talked to other OLD chiropractors like myself and while we also treated mostly musculoskeletal problems, years ago we seem to remember that we treated more non-musculoskeletal problems than is done today.

I started practice in 1974 and my impression is that chiropractic has moved away from a more broad-based health care system to what is now a profession related almost exclusively focused on musculoskeletal problems. I would like your input on this. Please e-mail me directly at This email address is being protected from spambots. You need JavaScript enabled to view it. and let me know your thoughts as to whether or not our profession has become much more focused on musculoskeletal problems only over the years. And if so, is that a good or a bad thing?

If you do e-mail me please let me know if you are a student or how many years you have been in practice. I would like to get a feel for how our readers feel about this subject.

           

Reviewer: Roger Coleman DC

Reference: Kaeser MA, Hawk C, Anderson M. Patient characteristics upon initial presentation to chiropractic teaching clinics: A descriptive study conducted at one university. J Chiropr Educ. 2014;28:146-51.

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25162982

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The Study: The diagnostic accuracy of the Kemp's test: a systematic review

The Facts:

  1. The authors looked at the literature pertaining to the ability of Kemp's test to diagnose facet joint pain.
  2. Facet joint pain arises "from any structure related to the facet joints."
  3. Kemp's test is used to diagnose pain in the facet joints.
  4. The current "gold standard" for diagnosing facet pain is anesthetic injections to either the facet joints or their nerve supply.
  5. The authors searched the literature to determine how accurate the Kemp's test was in diagnosing facet joint pain.
  6. They concluded that:
    1. The literature supporting the test is limited.
    2. The literature which is available "generally indicates the test has poor diagnostic accuracy."
    3.  A negative test may be of some "value in eliminating the facet joint as a source of pain."
  7. They also noted that their search only found five studies that met their inclusion criteria and that "these studies varied in several important aspects of the methods used..." Also only two of these five studies were uncovered by the author's database search.

Take Home:

The authors concluded Kemp's test is not diagnostically accurate but may have some value in eliminating the facet joint as a source of pain. Their inclusion criteria allowed for only a very small number of studies to be included for consideration and these studies varied in important aspects of the methods used.

Reviewer's Comments:

Disappointing, as this is a common test for facet joint pain, but the article is based on a very small number of previous studies. I suggest you read the article and come to your own conclusions regarding your use of this test. It would be nice to see a number of new studies in the future.

Reviewer: Roger Coleman DC

Editor's Comments: A number of the orthopedic tests most of us learned in college have serious problems in terms of accuracy and reliability. I agree with Dr. Coleman that this is a basic area in which the profession at large could use more information. More studies could help eliminate self deluding practices.

Editor: Mark R. Payne DC

Reference: Stuber K, Lerede C, Kristmanson K, Sajko S, Bruno P. The diagnostic accuracy of the Kemp's test: a systematic review. J Can Chiropr Assoc.2014;58:258-67.

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25202153

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The Study: Varied clinical presentation of os odontoideum: a case report.

The Facts:

  1. The purpose of the article was, To present a case of os odontoideum and to provide insight into the various clinical presentatoins."
  2. The patient was 54 years of age and suffered from chronic neck pain. They had been involved in a motor vehicle accident in the 1970s and another one in the 1980s. They did not seek medical care after either accident.
  3. Physical examination and A-P and later cervical radiographs were obtained.
  4. The patient was diagnosed as having grade II mechanical neck pain and received manipulation/mobilization.
  5. The clinician requested MRI and flexion and extension radiographs which had been taken previously by another provider in 2009.
  6. When the reports of the MRI and flexion and extension views came in they "described the presence of an os odontoideum."
  7. The patient was advised that they would not receive any more spinal manipulations due to the condition and was referred to a medical provider.
  8. Imaging is necessary to diagnose an os odontoideum.
  9. Some patients who have os odontoideum will be asymptomatic.
  10. In one study 64% of the cases with os odontoideum had neck pain. However, there is a high percentage of neck pain in the general population and the lack of prospective studies in this area make it difficult to make a link between neck pain and os odontiodeum.
  11. "...the association between os odontiodeum and headache is unclear."
  12. Although there is debate, the evidence indicates that the majority of cases have a traumatic etiology.
  13. The condition is associated with Down syndrome, Klippel-Feil syndrome, Morquio's disease, multiple epiphyseal dysplasia, pseudoachondroplasis, achondroplasia, Larson syndrome, and chondrodystrophia calcificans."
  14. Patients may be asymptomatic but may also present with such neurological symptoms as subtle transient myelopathy, tetraplegia, paresis, bulbar sign or central cord syndrome.
  15. Manual therapists should be trained to recognize this condition, educate patients and refer for medical/surgical consultation.
  16. The prevalence of this condition is not clear but the authors of this article refer to it as a rare condition.

Take Home:

Imaging is the needed to diagnose this condition and it may present in many ways.

Reviewer's Comments:

I like the usefulness of imaging in the chiropractic practice. It would be really easy to take a shot at those who are reluctant to obtain imaging on patients by saying, look at this potentially serious problem you are missing. But that's not fair. I certainly don't like it when providers who feel radiography has very limited usefulness in a chiropractic practice criticize those who feel differently. We all have to look at each case individually and decide what is best for our patients. I'm going to close with one of my favorite quotes from the Handbook of Clinical Chiropractic by Lawrence H. Wyatt concerning diagnostic imaging, "Will the treatment or the prognosis for the patient change if this study is performed? If the answer is yes, then the study should be performed, barring any contraindications. If the answer is no, then serious thought should be given to other diagnostic studies that might be more helpful."

Reviewer: Roger Coleman DC

Editor: Mark R. Payne DC

Reference: Chrobak K, Larson R, Stern PJ. Varied clinical presentation of os odontoideum: a case report. J Can Chiropr Assoc.   See comment in PubMed Commons below2014; 58:268-72

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25202154 

Special Thanks!

This is Dr. Coleman's 200th review article for Science In Brief.

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The Study: Assessing the change in attitudes, knowledge, and perspectives of medical students towards chiropractic after an educational intervention

The Facts:

  1. The authors looked at the changes that occurred in the attitudes and understanding regarding chiropractic by a group of medical students following a 1-hour presentation.
  2.  The authors gave a 52 item survey to second year medical students and then presented the same survey to the students when they were in their third year.
  3.  However, in the third year they presented a 1-hour class on chiropractic prior to the students completing the form.
  4.  The class presented such topics as chiropractic education, treatment methods, scope of chiropractic and current evidence regarding safety and effectiveness.
  5.  The students scored higher, having more correct answers on the survey, following the presentation than they did the previous year.
  6.  The attitudes of the students toward chiropractic also improved.
  7.  The authors selected 6 students and held a focus group. The focus group indicated the medical students would like to see chiropractic in a clinical setting and that they had concerns over the safety of chiropractic care. They also indicated that education concerning chiropractic needed to be presented to medical students sooner than the third year of medical school.
  8.  Educating medical students regarding chiropractic might improve working relations between medical and chiropractic providers.

Take Home:

Educating medial students early in their medical training on the facts related to chiropractic and exposing them to chiropractic in a clinical setting may improve relations between the two professions.

 Reviewer's Comments:

I think it would improve relations. I am most happy to have everyone look at the science related to the practice of chiropractic especially in the area of safety. I always say it is harder to hate people you know. I think all providers should work together for the health of the patient and sometimes only our differences get highlighted instead of the cooperation. To the chiropractors that inappropriately attack medical providers, just stop it's not helping. To the medical providers that inappropriately attack chiropractors, especially regarding safety, just stop it's not helping. But just to take a little jab at my medical colleagues. I was wondering if you might like to show us the studies on the safety of spinal surgery. What's good for the goose should be good for the gander.

 Reviewer: Roger Coleman DC

 Reference: Wong JJ, Di Loreto L, Kara A, Yu K, Mattia A, Soave D, Weyman K, Kopansky-Giles D. Assessing the change in attitudes, knowledge, and perspectives of medical students towards chiropractic after an educational intervention. J Chiropr Educ. 2014;28:112-22.

 Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25237768

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The Study: The effect of pressure pain sensitivity and patient factors on self-reported pain-disability in patients with chronic neck pain

The Facts:

  1. The authors studied the relationship of pain pressure sensitivity and patient factors to the disability of patients who were suffering from chronic neck pain. 
  2. They studied 44 subjects who suffered from a moderate level of chronic neck pain. 
  3. The patients completed a self assessment of their pains and disability and of their level of comorbidities. The comordidities were on a Katz comorbidity scale (See Editor's comments) which looks at 12 co-morbid conditions and then gives them a value based upon whether the patient currently has the condition, were receiving treatment for the condition and if the condition caused them to limit their activities. 
  4. Pain pressure sensitivity was measured using a JTECH pressure algometer. 
  5. Higher pain pressure threshold and sensitivity was correlated with less self reported pain disability. 
  6. Age did not correlate to either pain or disability. 
  7. The role of gender was less clear. Females tended to be more sensitive to pressure pain than males however, that sensitivity did not appear to be correlated with differences in self related disability. 
  8. The greatest predictor of pain disability was found to be cormorbidity factors. 
  9. Pain pressure sensitivity "may play a role in outcome measures of pain and disability but between-subject comparisons should consider gender and comorbidity issues." 

Take Home:

Pain pressure sensitivity can be useful for outcome assessment but "must be considered with caution until larger samples are used to confirm any interactions between comorbidity and" pain pressure sensitivity.

Reviewer: Roger Coleman DC

Editor's Comments:

If you aren't particularly familiar with the concept of comorbidity or the instruments used in this study to measure it (I certainly wasn't), here's a brief introduction to the subject.*

The term comorbidity refers to the presence of additional factors or disorders which are observed to be "co-occuring" with the primary disease/disorder...in this study, chronic neck pain.

The Katz comorbidity scale used in this study (also called the "Self Administered Comorbidity Questionnaire" ) looks at a number of basic factors such as age, sex, race, level of education, insurance status, type of services provided (medical vs. surgical), mean length of stay in hospital, mean total hospital charges, and the Mean Charlson Index Score.

"The Charlson Comorbidity Index predicts the ten year mortality for a patient who may have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each of the 22 conditions is assigned a score depending upon the risk of dying associated with the condition. Finally, scores are summed to provide a total score used to predict risk of mortality.

*Source: Wikipedia

Editor: Mark R. Payne DC

Reference: Uddin Z, MacDermid JC, Woodhouse LJ, Triano JJ, Galea V, Gross Ar.  The effect of pressure pain sensitivity and patient factors on self-reported pain-disability in patients with chronic neck pain. Open Orthop J. 2014 Sep 30;8:302-9.            

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25320651

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The Study: Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation

The Facts:

  1. The authors indicate there is little research to guide our treatment of back related leg pain.
  2. The authors wished to compare spinal manipulation combined with home exercise and advice, to care which consisted of only home exercise and advise. (In other words one group got home exercise and advice and the other group had spinal manipulation added to that care.)
  3. The subjects in the study were 21 or older.
  4. The time period in which patients could be treated was 12 weeks.
  5. Subjects had suffered from back-related leg pains for a minimum of 4 weeks.
  6. Subjects attended 4 home exercise and advice training sessions.
  7. The group who received spinal manipulation could have up to 20 manipulations in the 12 week period.
  8. The patients rated their leg pain at 12 and 52 weeks as the primary outcome.
  9. For secondary outcomes the patients also rated their "low-back pain, disability, global improvement, satisfaction, medication use and general health status" at the 12 and 52 week intervals.
  10. Subjects that received the spinal manipulation along with the exercise and advice they showed greater improvement at the 12 week time period.
  11. However, they only sustained better improvement at the 52 week time period in the areas of global improvement, satisfaction and using less medication.

Take Home:

The addition of spinal manipulation resulted in better short term outcomes ( at 12 weeks. However, differences in improvement for the manipulation group were less pronounced at the 52 week time period.

Reviewer's Comments:

The patients received care through the use of spinal manipulation for up to 20 manipulations over a 12 week period. The home exercise and advice that both groups received could be continued by the patient at home for the whole 52 week period. At 12 weeks the group that also received the manipulation did better but the difference in the improvement for the manipulation and non manipulation groups had decreased by the end of the 52 week study period. This makes sense to me in that time tends to decrease the effect of pretty much any therapy. That's pretty much how life works. The further we get from the time we stopped dieting, the less the diet's effect. The further we get away from the time we last exercised, the less the exercise's effect.

Conversely, I think this study lends support to the thought of having patients seek chiropractic care again when they have a return of symptoms or better yet when their attending doctor of chiropractic feels that they need their next appointment. Our medical colleagues might well advise someone who had discontinued their medication, to resume taking should their symptoms return some months after their last dose. So it might be appropriate for patients for whom spinal manipulation was helpful to return for more of the same if in some months their pain returned. To me this study reinforces the concept that patients need to work with their doctor of chiropractic to receive care that is individualized for that patient.  

Reviewer: Roger Coleman DC

Reference: Bronfort, G, Hondras MA, Schmulz CA, Evans RL, Long CR, Grimm R. Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation. Ann Intern Med. 2014;161:381-91.

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25222385 

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The Study: An audiometric study of the effects of paraspinal stimulation on hearing acuity in human subjects - understanding the Harvey Lillard phenomenon

The Facts:

  1. Some of you will soon begin to wonder why I reported on this article but bear with me for a moment.
  2. DD Palmer adjusted a vertebra in the thoracic spine of Harvey Lillard and his hearing was restored.
  3. Others have reported patients having lost their hearing due to spinal injury or having it restored by spinal manipulation.
  4. The authors cite an alternative theory that Lillard's hearing loss was not due to nerve impingement as Palmer inaccurately surmised at the time but instead was caused by the following mechanism: "altered sensory input from Harvey Lillard's back injury may have altered the central processing of information from his ears."
  5. The authors wished to test this alternative mechanism and therefore set up the present study.
  6. They applied TENS to the upper thoracic spines of healthy subjects.
  7. They measured the hearing acuity during the administration of both TENS and a sham TENS.
  8. There was no difference in the auditory acuity between the real and sham TENS applications.
  9. They concluded that innocuous afferent input into the upper thoracic paraspinal muscles did not affect thresholds of audibility.

Take Home:

TENS stimulation of the upper thoracic area did not affect hearing.

Reviewer's Comments:

So why did I cover this article. First I thought it was a good idea to test alternative theories as to how treatment/injuries to the spine might have an effect on hearing acuity. This study showed found that TENS stimulation of healthy subjects didn't affect their hearing and used that to reject this new theory. Nothing wrong with the authors or their study. But I've been around awhile and I am sure that if we give it a few years that those people who only read abstracts and often not even that, will be telling me of a study which proves chiropractic adjustments can't possibly have any effect on hearing and that is not what this study says.

One of the reasons I write this column is that along with a lot of good information that is being discussed, there is always the possibility of bad information being disseminated. Whether an article supports or refutes your thoughts on a subject, it should be given the weight that it is due and evaluated fairly. So pass Science in Brief on to your friends, the more they read (not only this column but also the whole papers which interest them) the better the chiropractic profession will become. And it is a great profession.

Reviewer: Roger Coleman DC

Editor's Comments:

Truth, like gold, is to be obtained not by its growth, but by washing away from it all that is not gold. (Leo Tolstoy)

I have not failed. I've just found 10,000 ways that won't work. (Thomas Alva Edison)

Editor: Mark R. Payne DC

Reference: Demers M, Gajic Z, Gerretsen E, Budgell B. An audiometric study of the effects of paraspinal stimulation on hearing acuity in human subjects - understanding the Harvey Lillard phenomenon. Chiropr Man Therap 2014;22:39.

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25419454

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The Study: Prevalence of radiographic findings in individuals with chronic low back pain screened for a randomized controlled trial: secondary analysis and clinical implications.

The Facts:

  1. The authors looked at the following: disc degeneration, spondylolisthesis, transitional segmentation, and sacral slope.
  2. The subjects all had chronic low back pain and were aged from 21 to 65.
  3. The study included 247 subjects and they used x-rays of those subjects to obtain the information.
  4. The subjects had suffered from low back pain for 12 or more weeks.
  5. Transitional segments were seen in 14% of the cases.
  6. Disc degeneration was seen in 29% of the subjects at L1-2, 41% of the subjects at L2-3, 49% of the subjects at L3-4, 42% of the subjects at L4-5 and 37% of the subjects at L5-S1.
  7. 18% of the subjects had degenerative spondylolisthesis while only 5% had isthmic spondylolisthesis.
  8. The sacral slope was similar to the amounts reported in other populations.
  9. Although the subjects had to have suffered from low back pain for at least 12 weeks to be included in the study, 91% of the subjects had suffered from the low back pain for over a year.

Take Home:

Abnormal findings are quite common on radiographs in subjects having chronic low back pain.

Reviewer's Comments:

There is a debate in our profession as to when and why imaging is needed in a patient's case. I think that this question is the one most likely to tear apart the fabric of chiropractic (see my article in the journal Chiropractic History Volume 33, No. 1 entitled History or Science: The Controversy over Chiropractic Spinography.) But whatever side of this issue that you support, you should be aware that there were a lot of patients in this study with chronic low back pain that had changes in their spine that could only be seen with imaging. Now you may have other reasons than just pathologies for obtaining radiographs, such as structural alignment, and you have to decide what findings will prompt you to obtain an x-ray. But no matter how you decide to obtain imaging in a patient's case you should be aware of studies such as this. Like Fox news "we report, you decide".

Reviewer: Roger Coleman DC

Editor's Comments: The authors only looked for four types of findings; disc degeneration, spondylolisthesis, transitional segments, and sacral slope. Despite the very limited nature of their inquiry, 59% of these subjects exhibited at least one positive finding...what seems to me to be a very high number. Of course in a real world scenario, many other types of information could have also been gleaned from the films; various other pathologies, fractures, developmental anomalies, and last but certainly not least, valuable insight as to the patient's biomechanical status. Doctors who are sitting the fence as chiropractic goes through its internal debate regarding the need (or lack thereof) for spinal radiographs might want to keep the results of this study in mind before allowing their scope of practice to be infringed upon any further.

Editor: Mark R. Payne DC

Reference: Vining RD, Potocki E, McLean I, Seidman M, Morgenthal AP, Boysen J, Goetz C. Prevalence of radiographic findings in individuals with chronic low back pain screened for a randomized controlled trial: secondary analysis and clinical implications. J Manipulative Physiol Ther. 2014;37:678-87

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25455834

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The Study: Exploratory Evaluation of the Effect of Axial Rotation, Focal Film Distance and Measurement Methods on the Magnitude of Projected Lumbar Retrolisthesis on Plain Film Radiographs

Today we're going to try something a little different because this is one of my own articles. In fact, as I write this, I have just received my copy of the Journal of Chiropractic Medicine a few hours ago. Many of you are familiar with a number of my other articles that have explored the projection of the vertebrae on radiographs. As you are well aware, the image on the radiograph is a projection, not a picture and is subject to a number of errors. Projection errors, patient positioning errors and measurement errors can all come together to be confounders to the clinician seeking to accurately measure the spine. However, the question is not if there can be errors but how large are those errors and how are they created. This exploratory study seeks to "evaluate the amount of error in retrolisthesis measurement due to measurement methods or projection factors inherent in spinal radiography". We also tried to find out how accurate the measurements were when compared to the real size of the retrolisthesis and when compared to the projected size of the retrolisthesis that was expected to be found on the film. The study looked at both 40 and 84 inch focal film distances and at the changes that occurred due to y-axis rotation of the vertebrae at 0, 5, 10, 15 and 20 degrees of rotation.

So now for the good stuff. While this is far too big an article to give all the answers here, our findings suggest that if you exceed 10 degrees of y-axis rotation when placing the patient in front of the film surface, your retrolisthesis measurements became less accurate. We also looked at three different measurement methods: Gohl, Iguchi and Lopes methods. In general, the Gohl method, which is the method most commonly used in chiropractic, did not appear to be as accurate as good as the other two. In addition there are pictures of radiographs with y-axis rotations of 0 to 20 degrees in 5 degree increments that show visible changes in the look of the vertebrae on the radiographs as they undergo rotation. This will give you a better idea of how rotated vertebrae appear on the film and may tip you off sometimes when you have poor patient placement or some other factor that has produced axial rotation on the film. We also produced tables showing the amount of error relative to the actual amount of retrolisthesis and the amount of projected retrolisthesis that was expected to be found on the film.

So do we have to quit measuring spinal displacement on radiographs? Of course not. But we do have to consider sources of introduced error and understand the amounts of error that can occur. This article is just another step in understanding what causes errors when radiographs are being measured and the magnitude of those errors. By knowing these things we can make better clinical judgments.
So here's the take home. X-rays are a tool and just like any other tool they have advantages and disadvantages. One major disadvantage is that axial rotation can significantly affect your ability to accurately measure retrolisthesis on the lateral radiograph. You should be aware of that and pay attention to patient placement to help reduce projection errors on your radiographs.

I personally deplore blanket attitudes that we either do or don't need x-rays to treat patients. It depends on the case, including what your goal is for a particular patient. Although I don't always agree with them, I like the idea of practice aids (notice that I didn't say guidelines) that help improve our clinical decision making. The more you understand about radiography the better you can decide how it works best in your practice. I hope our readers here at ScienceInBrief.com will take the time to read this article in its entirety and that you find it helpful in your understanding of factors which may affect your evaluation of retrolisthesis cases.

Reference: Coleman RR, Cremata EJ Jr, Lopes MA, Suttles RA, Rairbanks VR. Exploratory Evaluation of the Effect of Axial Rotation, Focal Film Distance and Measurement Methods on the Magnitude of Projected Lumbar Retrolisthesis on Plain Film Radiographs. J Chiropr Med. 2014 Dec;13(4):247-259.

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25435838

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The Study: The effect of manual therapy techniques on headache disability in patients with tension-type headache.

The Facts:

  1. Tension headaches are the most common primary type of headache.
  2. Unfortunately "there is no clear evidence" which tells us which type treatment is most effective for this condition.
  3. The authors looked at three treatment types: "suboccipital soft tissue inhibition" (deep pressure applied to this area), manipulation of the CO-C1 area and a combination of the two techniques. They also had a control group which received no treatment.
  4. 76 patients (of whom 62 were female) completed the study.
  5. The patients received care for four sessions a week apart.
  6. The care was provided by two therapists.
  7. Suboccipital soft tissue inhibition alone was not shown to be superior to the control group.
  8. Manipulation alone reduced the disability of "the headache severity, frequency, functional and emotional aspects related to the condition."
  9. But combining manipulation with the suboccipital soft tissue inhibition reduced all those disabilities and in addition helped "other symptoms including photophobia, phonophobia and pericranial tenderness."

Take Home:

Manipulation by itself was helpful in this condition but when combined with suboccipital soft tissue inhibition, the results were further improved.

Reviewer's Comments:
The astute reader will note a similarity to an article in the Journal of Chiropractic Medicine upon which we reported previously. It was pretty much the same study which yielded the same type of result. The lead author is the same although the way the name is indexed is different in the two papers. No matter, what we can say is that manipulation by itself is helpful and manipulation combined with this type of soft tissue work in the suboccipital area is better. I'm happy to report on this article again and if the same author takes another bite of the apple I may report on it again, well maybe not.

Reviewer: Roger Coleman DC

Reference: Espi-Lopez G, Rodrigueq-Blanco C, Oliva-Pascual-Vaca A, Benitez-Martinez J, Lluch E, Falla D. The effect of manual therapy techniques on headache disability in patients with tension-type headache. Eur J Phys Rehabil Med. 2014 Apr 30. [Epub ahead of print]

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/24785463

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The Study: The shift of segmental contribution ratio in patients with herniated disc during cervical lateral bending

The Facts:

  1. There has been an underestimation of "the importance of objective spinal motion imaging assessment in the frontal plane".
  2. In lateral bending each segment contributes to the total magnitude of lateral flexion.
  3. Some segmental levels may contribute more or less to the total than is appropriate for that level.
  4. The authors looked at 92 subjects, half of which were healthy and half had suffered from a herniated disc at either C4/5 or C5/6.
  5. The subjects performed lateral bending while being viewed on videofluroscopy.
  6. They started in the neutral position and then smoothly laterally flexed their cervical spines all the way to the right and without stopping then flexed all the way to the left and returned to the neutral starting position. The total process lasted approximately 5 seconds.
  7. Compared to the normal patients those with herniated discs showed "a significant increase in segmental contribution ratio of C3/4...".
  8. In other words, the C3/4 motor unit of the disc herniated patients contributed a greater percentage to the total movement than occurred in the healthy subjects.
  9. Likewise, there was also a decrease in the contribution of the C5/6 level in the disc herniation patients. (Remember those with herniations had them at either C4/5 or C5/6.)
  10. In disc patients "segmental contribution shifted toward the middle cervical spine".
  11. To put this more into perspective, for healthy patients the "intervertebral angulation during cervical lateral bending" was 8.37 plus or minus 2.11 degrees for C3/4 and 7.19 plus or minus 2.29 degrees in the C5/6 area. In the disc patients it was 7.83 plus or minus 1.79 degrees for C3/4 and 5.13 plus or minus 2.05 degrees for C5/6. So, even though the disc injured patients showed a slight decrease in bending motion at the C3/4 level, the C5/6 areas exhibited an even greater decrease resulting in a greater percentage of the total lateral bending movement being contributed by the C3/4 segment.

Take Home:
Disc herniation resulted in reduced motion in both the lower and mid cervical spine however, the percentage of the total lateral bending motion contributed by the mid cervical area was increased in comparison to healthy patients.

Reviewer's Comments:
It makes sense to me that if one area is injured it will contribute less to the total moment and an uninjured area will therefore show a greater contribution to the total movement. I did like the idea of using imaging to measure intersegmentally rather than just an overall range of motion. However, I think that pretty much the same study could have been made with just neutral and a left and right lateral flexion views. What really stands out to me is that if you mess up the structure then you mess up the function. That altered structure causes altered function is intuitive, but how much structural alteration does it take to create a certain amount of altered function, that is the question. Studies like this are a step in that direction.

Reviewer: Roger Coleman DC

Editor: Mark R. Payne DC

Reference: Lan HC, Chen HY, Kuo LC, You JY, Li WC, Wu SK. The shift of segmental contribution ratio in patients with herniated disc during cervical lateral bending. BMC Musculoskelet Disord 2014;15:273

Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25112463

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