Is there a role for premanipulative testing before cervical manipulation?

BACKGROUND: Spinal manipulative therapy is used millions of times every year to relieve symptoms from biomechanic dysfunction of the cervical spine. Concern about cerebrovascular accidents after cervical manipulative therapy is common but rarely reported. Premanipulative tests of the vertebral artery are presumed to identify patients at risk but controversy exists about their usefulness. OBJECTIVE: The aim of this study was to examine vertebral artery blood flow in patients with a positive premanipulative test for contraindication to spinal manipulative therapy and to investigate if chiropractors would reconsider treating such patients if dynamic vascular Doppler examination was normal. DESIGN AND SETTING: A prospective study at a university hospital vascular laboratory. METHODS: Chiropractors in private practice from 3 Danish counties referred patients with a positive premanipulative test for an examination of vertebral artery blood flow. Premanipulative testing was performed by an experienced chiropractor. Flow velocities were measured in both vertebral arteries by color duplex sonography. In addition, chiropractors were asked if they would treat their patient despite a positive premanipulative test if the vascular ultrasound examination was normal. RESULTS: A total of 20 consecutive patients with a positive premanipulative test were referred. Five were excluded because symptoms could not be reproduced during the vascular examination. In the remaining patients, no significant difference in peak flow velocity or time-averaged mean flow velocity with different head positions was found. Nineteen of 21 chiropractors would treat a patient with a positive premanipulative test if the vascular examination was normal. Eight of the patients with a positive manipulative test were treated without complications. Six are now symptom-free, and 2 have improved symptoms. The remaining 8 patients refused manipulation and continue to have the same symptoms. CONCLUSION: It appears that a positive premanipulative test is not an absolute contraindication to manipulation of the cervical spine. If the test is able to identify patients at risk for cerebrovascular accidents, we suggest patients with a reproducible positive test should be referred for a duplex examination of the vertebral artery flow. If duplex flow is normal, the patient should be eligible for cervical manipulation despite the positive premanipulative test.     

Groningen Manipulation Study. The effect of manipulation of the structures of the shoulder girdle as additional treatment for symptom relief and for prevention of chronicity or recurrence of shoulder symptoms. Design of a randomized controlled trial within a comprehensive prognostic cohort study

BACKGROUND: We present the design of the Groningen Manipulation Study. This randomized controlled trial is part of the Dutch Shoulder Disability Study, a comprehensive prognostic cohort study on shoulder disorders, with randomized controlled interventions in subcohorts. OBJECTIVE: To evaluate the effectiveness of manipulative treatment of the structures of the shoulder girdle, in addition to standard treatment by the general practitioner for relief of shoulder symptoms and prevention of persistent or recurrent shoulder symptoms. METHODS: A total of 250 patients with shoulder symptoms and a functional limitation of the shoulder girdle will be included from 30 general practices in Groningen, The Netherlands. All participating patients receive standard treatment by the general practitioner and will be randomly allocated to additional manipulative treatment. Evaluation measurements take place 6, 12, 26, and 52 weeks after randomization. CONCLUSION: The short-term primary outcome measure is the proportion of patients with relief of shoulder complaints and the long-term primary outcome is the proportion of patients without persistent or recurrent shoulder symptoms. Dependent and independent variables include a structured medical history, a physical examination of the shoulder and shoulder girdle, and a measure of the mobility of the cervico-thoracic spine with a 6-degree-of-freedom electromagnetic tracking device.     

Manipulative physiotherapists can reliably palpate nominated lumbar spinal levels.

Palpating a nominated spinal level is a prerequisite to more complex tasks such as palpating the level most likely to be the source of the patient's symptoms. The aim of this study was to investigate the reliability of physiotherapists with a post-graduate qualification in manipulation (manipulative physiotherapists) in palpating the lumbar spines of patients in a clinical setting. Three pairs of manipulative physiotherapists palpated the randomly-nominated lumbar spinal levels of 20 patients presenting to their practices for treatment of low-back pain. Each therapist marked the skin overlying the spinous process of the nominated spinal level with an ultraviolet pen and these marks were transcribed onto transparencies for analysis. The therapists obtained an overall weighted kappa of 0.92 indicating almost perfect agreement for locating the nominated spinal level. The results of this study indicate that manipulative physiotherapists can reliably palpate nominated lumbar spinal levels, suggesting further training in spinal therapy enhances the palpatory skills of physiotherapists in palpating nominated lumbar spinal levels.     

腰三针配合手法复位治疗腰椎间盘突出症的疗效及肌电图分析

目的：探讨腰三针配合手法复位治疗腰椎间盘突出症的作用机理。方法：腰椎间盘突出症患者60例均采用腰三针配合手法复位治疗，治疗前后进行肌电图检测并分析。结果；经过20次治疗后。60例患者临床治愈35例（58．3％），总有效率为95．0％。肌电图显示腓总神经及胫神经传导速度与治疗前比较显著增高，接近正常值，并能使延长的神经远端潜伏期显著缩短。结论：腰三针配合手法复位治疗腰椎间盘突出症可显著改善患者的临床症状。提高神经传导速度，促进患肢功能的恢复。     

Transcranial sonography and vertebrobasilar insufficiency

OBJECTIVE: The objective was to discuss a case illustrating the role of transcranial Doppler sonography in the screening and treatment of a patient with intermittent vertebral artery brainstem ischemia. CLINICAL FEATURES: A 28-year-old woman had neck pain, arm pain, headaches, and dizziness. Her symptoms occurred intermittently over several years. Past care had provided little relief. De Kleyn's test, transcranial Doppler sonography, and magnetic resonance imaging/magnetic resonance angiography helped establish a diagnosis of vertebrobasilar syndrome. INTERVENTION AND OUTCOME: The patient was referred for neurosurgical evaluation. She subsequently chose to be treated with spinal manipulative therapy. Her neck pain, headaches, and radicular symptoms resolved. The dizzy spells abated to a tolerable level. The neurosurgeon subsequently re-evaluated the patient and recommended that surgery not be performed. CONCLUSIONS: This illustrates a case of extra-arterial mechanical compression of the vertebral arteries documented by transcranial Doppler sonography procedures. Brainstem symptoms were correlated with a documented perfusion deficit during cervical positional testing. This case also demonstrated that spinal manipulative therapy may be safely used on patients with vertebrobasilar insufficiency when the biomechanics and related flow studies are elucidated.     

The types and frequencies of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulative therapy

OBJECTIVE: To investigate the frequency and types of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulative therapy. DESIGN: Retrospective information obtained by chiropractors through standardized interview of patients on return visit within 2 weeks of previous treatment. SETTING: The private practice of 87 Swedish chiropractors (response rate 81%). SUBJECTS: Twenty consecutive (presumably naive) patients per chiropractor (1504 valid questionnaires returned, 86% of optimal number of replies). INTERVENTION: Spinal manipulation with or without additional therapy provided by chiropractors. MAIN OUTCOME MEASURES: Self-reported improved nonmusculoskeletal symptoms (reactions). RESULTS: At least I reaction was reported after the previous treatment in 21% to 25% of cases. Of these responses, 26% were related to the airway passages (usually reported as "easier to breathe"), 25% were related to the digestive system (mostly reported as "improved function"), 14% were classified under eyes/vision (usually reported as "improved vision"), and 14% under heart/ circulation (about half of these reported as "improved circulation"). The number of spinal areas treated was positively associated with the number of reactions. CONCLUSION: A minority of chiropractic patients report having positive nonmusculoskeletal reactions after spinal manipulative therapy but such reports cluster predominantly around specific symptoms. It would be interesting to find out if these can be verified objectively and, if so, to investigate if they are caused by the treatment or if they are signs of natural variations in human physiology.     

Use of a modified ESAS in cancer patients: a pilot study of patient and staff experiences

AIM: To evaluate the feasibility of a modified Edmonton Symptom Assessment Scale (ESAS) for monitoring symptoms in oncological palliative care. METHODS: A modified ESAS was delivered daily to 28 patients with advanced cancer. A questionnaire to discover staff members' opinions on the ESAS was delivered at the end of the study. Structured interviews were used to examine patients' opinions on the ESAS. RESULTS: The mean total ESAS score was 28.9 on inclusion day and 25.8 on Day 3 (p=0.531). Eleven of 21 of the staff considered the ESAS to be a 'good' or 'very good' way to obtain information about patients' symptoms. Seventeen of 24 patients who participated in the interview felt that ESAS was easy to fill in, and that there were no missing questions. CONCLUSION: The patients felt that the modified ESAS contained relevant symptoms, and that the questionnaires were easy to fill in. The staff considered the modified ESAS to be a useful instrument for obtaining information about patients' symptom distress. The modified ESAS is a good instrument for use as part of the daily clinical routine, as well as for monitoring symptoms in palliative oncological care.     

Long-term follow-up of patients with low back pain attending for manipulative care: outcomes and predictors

Psychosocial factors are known to act as obstacles to recovery from low back pain, but predictors of longer-term outcomes are not established. An average 4-year follow-up of a cohort of 252 low back pain patients attending for manipulative care was conducted to describe the longer-term course of low back pain, and to identify predictors of outcomes. Clinical and psychosocial data were obtained at baseline. Mailed questionnaires collected self-reported outcomes (pain, disability, recurrence and care seeking). Among the 60% who responded, the statistically significant reduction in mean Roland Disability Questionnaire score seen at 1 year did not improve further during follow-up. At the 4-year point, 49% of respondents reported residual disability, and 59% reported at least 'mild' pain. Symptom recurrence beyond the 1-year point was reported by 78% of respondents, with half of them seeking further care. Recurrence and care seeking were related to fear avoidance beliefs and duration of presenting symptoms. The disability score at 4-years was statistically significantly related to baseline depressive symptoms and higher pain intensity. Low back pain presenting for manipulative care is characterized by high levels of recurrence and care seeking over at least 4-years for many patients. Because psychosocial factors at presentation exert a long-term influence, they need to be considered by manual therapists.     

Taking a "leap of faith": acceptance and value of a cancer program-sponsored spiritual event

Investigations of spiritual interventions for cancer patients are disproportionately few compared to the reported importance of religion to Americans. We report on the implementation and evaluation of a spiritual, community-based intervention developed with interdenominational community clergy. Approximately 1200 people attended a total of 3 gatherings: 2 at Roman Catholic and another at a Protestant Church. Respondents to questionnaires evaluating attendee characteristics and satisfaction (n = 209) were predominantly women (85%); 50% were patients and 45% were aged 60 years and older. Men were more likely to be currently under treatment for cancer, while women were more likely to be past patients or friends. Fewer than 2% felt anger or anxiety; attendees felt the service was very (90%) or somewhat (9.5%) helpful and expressed appreciation for cancer program clinician attendance and for hospital sponsorship of the event. Components in order of preference were prayer, music, Scripture, and litany. Logistic regression models reveal that music was most appreciated by previously treated patients, and prayer by currently treated patients. Secular healthcare systems can offer a religious service that comforts and links attendees to a broader community, including clergy and cancer program clinicians. Surveys can identify service components that appeal to differing groups and can facilitate service development.     

Migraine and the Neck

SYNOPSIS
Fifty patients with migraine were asked about the occurrence of neck symptoms during different phases of their attacks, and if they felt the neck could act as a precipitant. Of the 32 reporting neck pain or stiffness, 10 noted symptoms during the premonitory phase, 30 during the headache phase, and 10 postdromally. In 7 cases the pain radiated into the shoulder and in 1 case into the lumbar region. These findings indicate extracerebral involvement of the migraine process and an overlap between the trigeminal and cervical distribution.     

膝关节功能障碍被动治疗引起疼痛的防治

目的研究膝关节功能障碍被动治疗所引起疼痛的防治。方法将32例骨折后膝关节功能障碍患者分为单纯手法治疗组和综合治疗组,治疗前后分别测关节活动度和恢复程度,同时评定患者的疼痛值。结果单纯手法治疗组治疗前关节活动范围(ROM)主动(64±30)°,被动(73±27)°,综合治疗组治疗前ROM主动(57±30)°,被动(67±30)°,两组间无显著差异(P>0.05)。治疗后综合治疗组ROM改善程度明显优于单纯治疗组,数字评价量表(NRS)评分也明显低于单纯手法治疗组。结论综合治疗能有效防治手法治疗骨折后膝关节功能障碍所引起的疼痛,并明显促进膝关节功能恢复。     

Percutaneous cryotherapy for post-thoracotomy neuralgia

Fourteen patients had percutaneous cryotherapy for persistent post-thoracotomy neuralgia. Although a significant proportion had their condition improved, relief was temporary. However, a third felt that symptoms were exacerbated by the therapy.     

Experimental measurement of the force exerted during spinal manipulation using the Thompson technique

The purpose for conducting this study was to quantify the forces exerted by a chiropractor on a patient during spinal manipulative therapy. Six patients received three treatments each from two chiropractors for a sacroiliac joint fixation. The Thompson technique was used to treat the patients. The force characteristics of the spinal manipulation were analyzed with respect to the following five points: preloading force, peak force, duration of manipulation, impulse of manipulation and point of application of the peak force. The results obtained indicated that all treatments have certain common characteristics; for example, a preload force is always followed by a large thrusting force. The values for the preload force, peak force, duration and impulse were found to have large standard deviations for a given adjuster and between patients. The location of the point of application of the peak force relative to a low back reference system appeared to be very consistent. However, it was not on the posterior superior iliac spines (PSIS) as expected, but always slightly medial to this point. This is the first study to report force results which were measured directly during spinal manipulative therapy in a clinical situation. In further studies, the results of this investigation will be compared to results obtained from a large population of patients and chiropractic adjusters. Differences in the force characteristics between chiropractors will be compared to clinical and objective measures of the rehabilitation process of the patients in order to find an "optimal" way of performing spinal manipulative therapies.     

A comparison of the effectiveness of spinal manipulative therapy for low back pain patients with and without spondylolisthesis

The effectiveness of spinal manipulative therapy for low back pain is compared between two groups of patients: a small group (25) of patients with lumbar spondylolisthesis and a larger group (260) of patients without spondylolisthesis. This data, which was collected from a previously published study on the effectiveness of manipulation for chronic low back pain, shows that the results of manipulative treatment are not significantly different in those patients with or without lumbar spondylolisthesis.     

Being a close relative of a dying person. Development of the concepts "involvement in the light and in the dark"

The current study is based on an earlier article in which relatives' involvement in care was described as "involvement in the light" or "involvement in the dark." Involvement in the light was characterized as the relative being well informed and experiencing a meaningful involvement. The relatives involved in the dark felt uninformed, that they were "grouping around in the dark" when they tried to support the patient. The present study analyzed further the meaning of "involvement in the light" and "involvement in the dark," and investigated whether two different care cultures, the relationship with the staff, and a rapid course of illness influence the involvement of relatives. Relatives of 52 patients who died, 30 at a surgical department and 22 in a hospice ward, were interviewed after the patients' deaths. All the relatives of the patients in the hospice ward and 13 of those in the surgical department were judged to be involved in the light. Of the relatives judged to be involved in the dark, 12 either had a sick relative with a rapid course of illness or felt that the sick relative had died unexpectedly. A pattern was clearly observed: The relatives involved in the light described being met with respect, openness, sincerity, confirmation, and connection, whereas the opposite was experienced by those involved in the dark.     

The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain

OBJECTIVE: To determine the relationship between an audible pop and symptomatic improvement with spinal manipulation in patients with low back pain (LBP). DESIGN: A prospective cohort study. SETTING: Two outpatient physical therapy clinics located in military medical centers. PARTICIPANTS: A cohort of 71 patients with nonradicular LBP referred to physical therapy. INTERVENTIONS: Participants underwent a standardized examination and standardized spinal manipulation treatment program. All patients were treated with a sacroiliac (SI) region manipulative technique and the presence or absence of an audible pop was noted.Main Outcome Measures: Subjects were reassessed 48 hours after the manipulation for changes in range of motion (ROM), numeric pain rating scale (PRS) scores, and modified Oswestry Disability Questionnaire (ODQ) scores. RESULTS: An audible pop occurred in 50 of the 71 subjects during the manipulative procedure. Both groups-those who had an audible pop and those who did not-improved over time in flexion ROM, PRS scores, and modified ODQ scores; however, there were no differences between groups (P>.05). Nineteen of the 71 (27%) patients improved dramatically (mean drop in modified ODQ, 67.6%). In 14 of the 19 dramatic responders, an audible pop occurred. However, the odds ratio (1.2; 95% confidence interval, 0.38-4.04) suggested that the occurrence of a manipulative pop would not improve the odds of achieving a dramatic reduction in symptoms after the manipulation. CONCLUSION: There is no relationship between an audible pop during SI region manipulation and improvement in ROM, pain, or disability in individuals with nonradicular LBP. Additionally, the occurrence of a pop did not improve the odds of a dramatic improvement with manipulation treatment.     

Problem Events and Psychosomatic Disorders In Family Practice

Two groups of patients studied in 1970 were reviewed over a two year period until 1972. The first group consisted of 77 patients suffering from psychosomatic illnesses, while the second was a control group. Their histories were studied in depth and the predominant family problem was selected. This was correlated to the patient's presenting symptoms. The ten predominant problems in the psychosomatic group were surveyed against the control group of patients. It was felt that problems cause emotional disturbances which in turn cause dysfunctional, somatic symptoms and mental aberrations.     

Frustrated and invisible--younger stroke patients' experiences of the rehabilitation process

PURPOSE: This study aimed to get knowledge of the younger stroke patient's viewpoint and to describe how young stroke patients experience the rehabilitation process. The purpose was also to develop hypotheses about the relationship between young stroke patients and the rehabilitation process. METHOD: Thematised in-depth interviews were performed with two women and three men who suffered from stroke (37 - 54 years). The analysis used was the Grounded Theory method of constant comparison. RESULTS: The analyses resulted in the core category 'Frustration' which was derived from the categories labelled 'The paralysed everyday' and 'Outside and invisible'. 'The paralysed everyday' category involved different aspects of everyday life after a stroke. Because of their fatigue they were unable to work and their family and social life were negatively affected. They found it difficult to engage in daily life activities and felt indifferent. The three women expressed frustration over the demands they experienced as being mothers and housekeepers, whereas the two men emphasised economic responsibility of the family as problematic. The category 'Outside and invisible' describes the lack of participation the informants experienced regarding the rehabilitation process. The informants felt they lacked information and age-adapted interventions. Their needs were not provided for and they felt distant from the other patients. Their remaining symptoms were probably on a cognitive basis and therefore invisible. This was a source of frustration. CONCLUSION: The hypotheses generated indicated that young stroke patients are frustrated and invisible due to the fact that the rehabilitation setting does not acknowledge the different needs of young stroke patients compared with older patients.