Chiropractic care and ochronotic arthropathy.

OBJECTIVE: To discuss the case of a patient with ochronotic arthropathy whose symptoms were treated with chiropractic care. An emphasis is placed on this condition's radiographic features. CLINICAL FEATURES: A 59-year-old woman with pain in her low back, right knee, and left ankle sought chiropractic evaluation. Black pigmentation was found in the sclera of both eyes, and homogentisic acid was present in the urine. Orthopedic evaluation revealed uncomplicated, nonspecific joint pain, and radiographs demonstrated characteristic spinal changes. INTERVENTION AND OUTCOME: The patient was treated with chiropractic manipulation, physiotherapy modalities, bracing, and exercises. This type of therapy was successful in reducing the symptoms and helped decrease the severity and frequency of acute exacerbations. CONCLUSION: Ochronotic arthropathY is a rare metabolic disorder that can be diagnosed from spinal radiographs. Chiropractic care is an appropriate tool for reducing its symptomatology.     

Missed lumbar transverse process fractures in a high school football player

OBJECTIVE: To discuss the case of a football player who had suffered a transverse process fracture of the lumbar spine that was overlooked on initial chiropractic and medical examination. CLINICAL FEATURES: A 17-year-old male football player had been speared in the back by another player. He reported severe initial pain that caused him to fall to the ground, and there was a moderate degree of pain at the time of his chiropractic examination 1 week after injury. INTERVENTION AND OUTCOME: Initial chiropractic treatment consisted of spinal manipulation to the lumbar spine. Follow-up care consisted of lumbar spine radiographs that showed evidence of a lumbar transverse process fracture at 2 levels. The boy was referred to his medical doctor, who was not convinced of the presence of a fracture and returned him to play. A computed tomography scan was subsequently performed; this confirmed fractures of the transverse processes of L2 and L3. The patient was precluded from contact sports for 4 weeks. Chiropractic care 3 weeks after injury included physiotherapy and drop table mobilization to the sacroiliac joints. The patient returned to play 4 weeks after the injury. CONCLUSION: Transverse process fractures commonly occur secondary to blunt trauma in contact sports such as football. With high-force direct trauma, radiographs should be performed to rule out fracture before returning the athlete to play or commencing spinal manipulation.     

The effect of chiropractic care for a 30-year-old male with advanced ankylosing spondylitis: a time series case report

BACKGROUND: Manipulative treatment for ankylosing spondylitis is a controversial subject, and no literature on using this therapy for advanced cases with fusion of the spine could be found. OBJECTIVE: To discuss the case presentation of a patient with advanced ankylosing spondylitis who was treated with chiropractic manipulation and mobilization.Clinical features The patient was a 30-year-old Asian male who was first diagnosed with ankylosing spondylitis at age 12. Despite medical intervention, a series of exacerbations had fused his sacroiliac joints and the facet joints in his lumbar and cervical spine. He presented with local moderate-to-severe pain in his low back and neck and lack of mobility.Intervention and outcome The patient was treated with grade 5 manipulation of his thoracic spine and grade 3 mobilization of his lumbar and cervical spine, along with physical therapy and stretches for a period of 12 weeks. He reported some improvement of his condition as measured by the SF-36 Health Survey and several measures of spinal flexibility. CONCLUSIONS: This case shows that even advanced cases of ankylosing spondylitis may show a favorable response to chiropractic manipulative therapy.     

Patient-reported improvements of pain,disability, and health-related quality of life following chiropractic care for back pain – A national observational study in Sweden

BackgroundChiropractic care is a common but not often investigated treatment option for back pain in Sweden. The aim of this study was to explore patient-reported outcomes (PRO) for patients with back pain seeking chiropractic care in Sweden.MethodsProspective observational study. Patients 18 years and older, with non-specific back pain of any duration, seeking care at 23 chiropractic clinics throughout Sweden were invited to answer PRO questionnaires at baseline with the main follow-up after four weeks targeting the following outcomes: Numerical Rating Scale for back pain intensity (NRS), Oswestry Disability Index for back pain disability (ODI), health-related quality of life (EQ-5D index) and a visual analogue scale for self-rated health (EQ VAS).Results246 back pain patients answered baseline questionnaires and 138 (56%) completed follow-up after four weeks. Statistically significant improvements over the four weeks were reported for all PRO by acute back pain patients (n = 81), mean change scores: NRS -2.98 (p < 0.001), ODI -13.58 (p < 0.001), EQ VAS 9.63 (p < 0.001), EQ-5D index 0.22 (p < 0.001); and for three out of four PRO for patients with chronic back pain (n = 57), mean change scores: NRS -0.90 (p = 0.002), ODI -2.88 (p = 0.010), EQ VAS 3.77 (p = 0.164), EQ-5D index 0.04 (p = 0.022).ConclusionsPatients with acute and chronic back pain reported statistically significant improvements in PRO four weeks after initiated chiropractic care. Albeit the observational study design limits causal inference, the relatively rapid improvements of PRO scores warrant further clinical investigations.     

Chiropractic care of a pediatric patient with myasthenia gravis

OBJECTIVE: To describe the chiropractic care of a pediatric patient with complaints associated with myasthenia gravis.Clinical features A 2-year-old girl was provided chiropractic care at the request and consent of her parents for complaints of ptosis and generalized muscle weakness (ie, lethargy), particularly in the lower extremities. Prior to entry into chiropractic management, magnetic resonance imaging of the brain and acetylcholine receptor antibody tests were performed with negative results. However, the Tensilon test was positive and the diagnosis of myasthenia gravis was made by a pediatrician and seconded by a medical neurologist.Intervention and outcome The patient was cared for with contact-specific, high-velocity, low-amplitude adjustments to sites of vertebral subluxation complexes in the upper cervical and sacral spine. The patient's response to care was positive and after 5 months of regular chiropractic treatment her symptoms abated completely. CONCLUSION: There are indications that patients suffering from disorders "beyond low back pain" as presented in this case report may derive benefits from chiropractic intervention/management.     

Dysfunctional uterine bleeding with concomitant low back and lower extremity pain.

In this case presentation, a temporal relationship between conservative chiropractic care and dysfunctional uterine bleeding (DUB) in a patient with mild low back and primary leg pain is described. Criteria are discussed to establish protocol that will be useful in the formulation of a diagnosis for DUB secondary to lower sacral nerve root compression and lumbar mechanical dysfunction. There have been investigations recently published that suggest a positive relationship between chiropractic lumbar, closed reduction distractive decompression (CRDD) and patients with pelvic pain and organic dysfunction. This case study presents the treatment response of one patient with one form of somatovisceral dysfunction, namely, dysfunctional uterine bleeding, in the absence of pelvic pain. Conservative chiropractic care may be an effective, noninvasive method for treating some individuals with dysfunctional uterine bleeding, caused secondarily from biomechanical and/or neurological insult. Further research in this area is encouraged.     

Pain, disability, and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians

BACKGROUND: Few studies exist on the prognostic value of demographic, clinical, or psychosocial factors on long-term outcomes for patients with chronic low back pain. OBJECTIVE: This study reports on long-term pain and disability outcomes for patients with chronic low back pain, evaluates predictors of long-term outcomes, and assesses the influence of doctor type on clinical outcome. METHODS: Sixty chiropractic (DC) and 111 general practice (MD) physicians participated in data collection for a prospective, longitudinal, practice-based, observational study of ambulatory low back pain of mechanical origin. The primary outcomes, measured at 6 months and 12 months, were pain (by using the Visual Analog Scale), and functional disability (by using the Revised Oswestry Disability Questionnaire). Satisfaction was a secondary outcome. RESULTS: Overall, long-term pain and disability outcomes were generally equivalent for patients seeking care from medical or chiropractic physicians. Medical and chiropractic care were comparable for patients without leg pain and for patients with leg pain above the knee. However, an advantage was noted for chronic chiropractic patients with radiating pain below the knee after adjusting for baseline differences in patient and complaint characteristics between MD and DC cohorts (adjusted differences = 8.0 to 15.2; P <.002). A greater proportion of chiropractic patients were satisfied with all aspects of their care (P =.0000). The strongest predictors of primary outcomes included an interaction of radiating pain below the knee with provider type and baseline values of the outcomes. Income, smoking, comorbidity, and chronic depression were also identified as predictors of outcomes in this study. CONCLUSION: Chiropractic care compared favorably to medical care with respect to long-term pain and disability outcomes. Further study is required to explore the advantage seen for chiropractic care in patients with leg pain below the knee and in the area of patient satisfaction. Identification of patient and treatment characteristics associated with better or worse outcomes may foster changes in physicians' practice activities that better serve these patients' needs.     

Coping and Management Techniques Used by Chronic Low Back Pain Patients Receiving Treatment From Chiropractors

ObjectivesThe purpose of this study was to describe coping strategies (eg, mechanisms, including self-treatment) that a person uses to reduce pain and its impact on functioning as reported by patients with chronic low back pain who were seen by doctors of chiropractic and how these coping strategies vary by patient characteristics.MethodsData were collected from a national sample of US chiropractic patients recruited from chiropractic practices in 6 states from major geographical regions of the United States using a multistage stratified sampling strategy. Reports of coping behaviors used to manage pain during the past 6 months were used to create counts across 6 domains: cognitive, self-care, environmental, medical care, social activities, and work. Exploratory analyses examined counts in domains and frequencies of individual items by levels of patient characteristics.ResultsA total of 1677 respondents with chronic low back pain reported using an average of 9 coping behaviors in the prior 6 months. Use of more types of behaviors were reported among those with more severe back pain, who rated their health as fair or poor and who had daily occurrences of pain. Exercise was more frequent among the healthy and those with less pain. Female respondents tended to report using more coping behaviors than men, and Hispanics more than non-Hispanics.ConclusionPersons with chronic back pain were proactive in their coping strategies and frequently used self-care coping strategies like those provided by chiropractors in patient education. In alignment with patients’ beliefs that their condition was chronic and lifelong, many patients attempted a wide range of coping strategies to relieve their pain.     

Chiropractic management of postsurgical lumbar spine pain: a retrospective study of 32 cases

Objective

Although chiropractic manipulation is commonly used for low back pain, applying this procedure to the patient with postlumbar spine surgery has not been adequately studied. The purpose of this retrospective chart review is to report on the results of chiropractic management (including Cox flexion distraction technique) of patients with postsurgical lumbar spine pain to determine the change in reported pain based on surgical type.

Methods

Ten years of patient files from one chiropractic practice were electronically screened for lumbar spine surgery occurring before presenting for chiropractic care. Of the 58 patients with a postsurgical diagnosis, 32 files contained all pertinent components for this study including treatment with Cox flexion distraction manipulation (in addition to adjunct procedures) for at least 2 weeks and pretreatment and posttreatment pain measures using the Numeric Pain Scale (NPS) that ranged from 0 (no pain) to 10 (worst pain imaginable).

Results

A change was observed in the mean pretreatment and posttreatment NPS pain scores of 6.4 to 2.3, a reduction of 4.1 of 10. The mean number of treatments was 14, with a range of 6 to 31. When stratified by surgical type, the mean change in pain was most remarkable in patients who underwent a surgery that combined lumbar discectomy, fusion, and/or laminectomy, with an average NPS pain reduction of 5.7 of 10. No adverse events were reported for any of these postsurgical patients.

Conclusions

The results of this study showed improvement for patients with low back pain subsequent to lumbar spine surgery who were managed with chiropractic care.     

A missed Jefferson fracture in chiropractic practice

OBJECTIVE: To review the case of a missed cervical spine fracture in a patient with neck pain. CLINICAL FEATURES: A 21-year-old thatcher with neck pain presented to a chiropractic clinic after a fall from a roof 4 m high. The hospital radiographs were read as normal. The chiropractor suspected a Jefferson fracture of the atlas after evaluation of the same radiographs. INTERVENTION AND OUTCOME: The chiropractor retook the anteroposterior open-mouth radiograph to confirm the suspected fracture. The patient was referred for further imaging and underwent neurosurgical treatment, after which he recovered well. CONCLUSION: Normal radiologic reports from a hospital cannot be relied on for contraindications to manipulative treatment in all instances, as shown in this case of a missed fracture. Chiropractors should therefore always evaluate radiographs that are brought to them.     

Optimizing pain relief during pregnancy using manual therapy

Question Many of my pregnant patients have muscle and joint aches, and are reluctant to use analgesics. What is known about chiropractic care during pregnancy?Answer As pregnant women move into their second and third trimesters, their centres of mass shift anteriorly, causing an increase in lumbar lordosis, which causes low back and pelvic girdle pain. Increasing recent evidence attests to the effectiveness and safety of treating this pain using manual therapy. Massage therapy and chiropractic care, including spinal manipulation, are highly safe and effective evidence-based options for pregnant women suffering from mechanical low back and pelvic pain.     

Work Motivating Factors in Rehabilitation: A Brief Review

Abstract

Background: Back pain is a common condition for which chiropractic treatment is often recommended.

Aim: To evaluate critically the evidence for or against the effectiveness of chiropractic spinal manipulation for back pain.

Data sources: Five independent literature searches were carried out and bibliographies were searched.

Study selection: Only randomised clinical trials of chiropractic spinal manipulation with patients suffering from back pain were included.

Data extraction: The authors extracted data on trial design, methodological quality, sample size, patient characteristics, nature of intervention, outcome measures, follow-up and results.

Main results: Twelve studies could be included. They related to all forms of back pain. Many trials had significant methodological shortcomings. Some degree of superiority of chiropractic spinal manipulation over control interventions was noted in 5 studies. More recent trials and those with adequate follow-up periods tended to be negative.

Conclusions: The effectiveness of chiropractic spinal manipulation is not supported by compelling evidence from the majority of randomised clinical trials.     

Missed cervical spine fracture: chiropractic implications

OBJECTIVE: To discuss the case of a patient with an anterior compression fracture of the cervical spine, which had been overlooked on initial examination. CLINICAL FEATURES: A 36-year-old man was seen at a chiropractic clinic 1 month after diving into the ocean and hitting his head on the ocean floor. He chipped a tooth but denied loss of consciousness. Initial medical examination in the emergency department did not include radiography, but an anti-inflammatory medication was prescribed. Radiographs taken at the chiropractic clinic 1 month later revealed an anterior compression fracture of the C7 vertebra, with migration of the fragment noted on flexion and extension views. INTERVENTION AND OUTCOME: The patient was referred back to his medical doctor for further evaluation and management.He was instructed to wear a Philadelphia collar for 4 weeks. During this time period, he reported "shooting" pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at 2.5 months after injury. Follow-up radiographs at 6 months after injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment. CONCLUSION: After head trauma, it is essential to obtain a radiograph of the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation after head and neck trauma.     

Vertebral osteomyelitis as another cause of low back pain: case report

A case is reported of a 47 year old man with an insidious onset of low back pain while hospitalized for septicemia. The etiology was not investigated and pharmacologic therapy was instituted. Several weeks after discharge, the patient presented to our chiropractic college clinic for the diagnosis and therapy for his low back pain. Radiologic examination of the lumbar spine revealed classic signs of a vertebral osteomyelitis. Manipulative therapy was contraindicated and the patient was referred for biopsy and appropriate antibiotic therapy. A review of the clinical presentation and appropriate diagnostic protocol are presented.     

Prehospital clinical findings associated with spinal injury

Objective. The objective of this study was to identify clinical findings that are associated with spinal fracture and/or spinal cord injuries in prehospital trauma patients.

Methods. A retrospective chart review was performed at three tertiary referral centers in Southeastern Michigan. All charts of patients with spinal fractures or spinal cord injuries during 1992 and 1993 were reviewed. Patients with available pre-hospital records were included in the study analysis. Prehospital data points included documentation of head injury; altered mental status; neurologic deficit; evidence of intoxication; cervical, thoracic, and lumbar pain or tenderness; nonspecified back pain or tenderness; and a narrative for all other documented injuries. Hospital data collected included type and level of spinal injury and age and sex of the patient.

Results. Of 867 injury patients identified, 536 were excluded, leaving 346 analyzable fractures in 331 patients. The 346 spinal fractures/spinal cord injuries were distributed as: 100 (29%) cervical, 83 (24%) thoracic, 128 (37%) lumbar, and 35 (10%) sacral. Prehospital documentation of altered mental status, neurologic deficit, evidence of intoxication, spinal pain, or suspected extremity fracture was found for every patient with a cervical injury, 82/83 patients with thoracic injuries (99%), and 124/128 patients with lumbar injuries (97%). All five patients who were not documented as having one of the predictors had stable injuries.

Conclusion. Prehospital clinical findings of altered mental status, neurologic deficit, evidence of intoxication, spinal pain, and suspected extremity fracture were documented for all patients with significant spinal injuries in this series. These findings may be useful to identify patients who require prehospital spinal immobilization.     

Chiropractic Care of Adults With Postpartum-Related Low Back,Pelvic Girdle,or Combination Pain: A Systematic Review

ObjectiveThe purpose of this study was to conduct a systematic review (SR) of the literature to assess the effectiveness of specific chiropractic care options commonly used for postpartum low back pain (LBP), pelvic girdle pain (PGP), or combination (LBP and PGP) pain.MethodsA search strategy was developed. Interventions were those manual or other nonpharmacologic therapies commonly used by chiropractors (not requiring additional certifications). The outcomes were self-reported changes in pain or disability self-reported outcomes. We used the Scottish Intercollegiate Guideline Network checklists. Strength of the evidence (excluding cohort studies) was determined using an adapted version of the US Preventive Services Task Force criteria as described in the UK report.ResultsOf the 1611 published articles, 16 were included. These were 5 SRs, 10 randomized controlled trials (RCTs), and 1 cohort study. Postpartum LBP (1 RCT): moderate, favorable strength for spinal manipulation therapy/mobilization. Postpartum PGP (4 RCTs): moderate, unclear strength for exercise; and inconclusive, unclear strength for patient education. Postpartum LBP or PGP (3 SRs and 4 RCTs): inconclusive, unclear strength for exercise, self-management, and physiotherapy; while osteopathic manipulative therapy was inconclusive, favorable.ConclusionNo treatment option was identified as having sufficient evidence to make a clear recommendation. This SR identified a scarcity of literature regarding chiropractic care and back pain for postpartum women, as well as inconsistency among the terms LBP, PGP, and combination pain.     

Chiropractic Care for Adults With Pregnancy-Related Low Back,Pelvic Girdle Pain,or Combination Pain: A Systematic Review

ObjectiveThe purpose of this study was to conduct a systematic review (SR) of the literature to assess the effectiveness of chiropractic care options commonly used for pregnancy-related low back pain (LBP), pelvic girdle pain (PGP), or combination pain for both experienced practitioners and students of chiropractic.MethodsWe included procedures that were commonly used by chiropractors and not requiring additional certifications. Outcomes were self-reported changes in pain or disability. We used the Scottish Intercollegiate Guideline Network checklists to assess outcomes. For strength of evidence, we used the adapted version of the US Preventive Services Task Force criteria as described in the UK report.ResultsFifty articles were included from 18 SRs, 30 randomized controlled trials (RCTs), and 2 cohort studies. Pregnancy LBP (7 SRs and 12 RCTs): moderate, favorable evidence for electrotherapy and osteopathic manipulative therapy; inconclusive, favorable strength for chiropractic care, exercise, and support devices; and inconclusive, unclear strength for spinal manipulative therapy. Pregnancy PGP (4 SRs and 4 RCTs): inconclusive, favorable strength for exercise; and inconclusive, unclear evidence for patient education, information, and support devices. Pregnancy LBP or PGP (13 SRs and 12 RCTs): moderate, unclear evidence for complementary and alternative medicine; moderate, unclear evidence for exercise; inconclusive, favorable evidence for multimodal care, patient education, and physiotherapy; and inconclusive, unclear strength for spinal manipulative therapy, osteopathic manipulative therapy, and support devices.ConclusionAlthough there is a lack of conclusive evidence, many of the interventions have moderate or unclear but favorable evidence.     

Min-invasive surgical treatment for multiple axis fractures: A case report

BACKGROUND Fractures of the axis are commonly seen in spinal injuries. Upper cervical fractures are usually managed conservatively. However, the complications due to long-term external immobilization cannot be ignored. The traditional open surgery has the disadvantages of too much blood loss and soft tissue injury. The aim of our paper is to introduce a minimally invasive surgical treatment for multiple axis fractures.CASE SUMMARY We report a 40-year-old Chinese male who had severe neck pain and difficult neck movement after falling from 3 meters. X-ray and computed tomography(CT) scan revealed an axis injury consisting of an odontoid Type Ⅲ fracture associated with a Hangman fracture categorized as a Levine-Edwards Type Ⅰ fracture. The patient underwent anterior odontoid screw fixation and posterior percutaneous screw fixation using intraoperative O-arm navigation. Neck pain was markedly improved after surgery. X-rays and CT scan reconstructions of 3-mo follow-up showed good stability and fusion. The range of cervical motion was well preserved.CONCLUSION Anterior odontoid screw fixation and posterior direct C2 percutaneous pedicle screw fixation with the aid of O-arm navigation and neurophysiological monitoring can be an interesting alternative option for complicated multiple axis fractures.