Chiropractic rehabilitation of the cervical spine
Donald R. Murphy, DC
Background: Rehabilitation has been a part of chiropractic almost since its beginning. Yet today, relatively few chiropractors provide rehabilitation in any systematic way in their practices. The modern era of health care calls for all spine specialists to emphasize exercise in their management strategies, and the chiropractic profession has the opportunity to establish itself as a leader in the area of rehabilitation in patients with spinal disorders.
Objective: To present the principles and techniques of cervical rehabilitation as it is utilized by the author and explain the rationale for these procedures based on current knowledge of the neurophysiology of the cervical spine.
Conclusion: Rehabilitation of the cervical spine can be performed by virtually any chiropractor, as effective rehabilitative methods can be applied with the minimum of space and equipment. The methods presented here are designed to assess several essential functions of the cervical spine and apply procedures that are designed to maximize these functions, while monitoring the clinical response to the management strategy. It is hoped that future research in this area will shine more light on cervical function and assist in the development of improved management of patients with cervical spine syndromes.
Key Indexing Terms: Cervical Spine; Rehabilitation; Chiropractic
W. Mark Erwin, BA, DC
Background: The diagnosis of pain in the upper back, shoulder, chest and arm is often made with considerable confusion, and may be accompanied by needless expense and suffering by the patient. Despite the paucity of evidence concerning the tissues and mechanisms responsible for interscapular and atypical chest pain or "pseudo-angina" practitioners of manual therapy maintain that manipulation of the costovertebral elements and associated soft tissues may be helpful in the treatment of these painful conditions.
Objective: We have examined the costovertebral complex in humans with respect to the presence of immune-like-reactivity to neurofilament protein and the neuropeptides substance P and calcitonin gene related peptide (CGRP), markers which reveal the presence of axons in peripheral tissues.
Design: Human costovertebral complexes obtained at autopsy were processed using standard histology as well as immunocytochemical methods to detect the presence of neurofilaments, substance P CGRP.
Main Outcome Measures: Outcomes were descriptive and did not require statistical methods.
Results: All costovertebral joints contained innervation within the anterior capsule and synovial tissues. In four separate cases, the costovertebral joints contained large intra-articular synovial inclusions or "meniscoids" found to contain small bundles of axons with immune-like-reactivity to substance P. Axon bundles were identified in serial section with monoclonal antibodies to neurofilaments as well as with urea-silver nitrate staining.
Conclusions: The costovertebral joint has been considered to be a candidate in producing back pain and/or psuedo-angina that may be ameliorated by spinal manipulation. This study has demonstrated that the costovertebral joint has the requisite innervation for pain production in a similar manner to other joints of the spinal column. (J Manipulative Physiol Ther 1999;23:000-000)
Key Indexing Terms: Costovertebral Joint; Innervation; Neuropeptides; Pain Syndromes
Background: Advances in mind-body medicine have resulted in the realization that beliefs can modulate pathophysiological processes. As symbolic interaction affects health status, perceptions and the congruence between the perceptions of chiropractors and their patients becomes a relevant clinical consideration.
Objective: A case study to explore the congruence of health relevant perceptions of chiropractors and their patients was undertaken.
Method: This Australian case study was undertaken to explore the concurrence of patient-practitioner perceptions with respect to the patient's stress levels, the importance of injury as a causative factor in the presenting complaint and the responsibility the patient should take "in getting themselves well." Purposive sampling of practitioners and convenience sampling of patients was undertaken. Data were collected by means of a patient questionnaire and a practitioner questionnaire and interview. Data was analyzed to determine the congruence of patient-practitioner perceptions within each of the 173 consultations.
Results: Nine practitioners and 173 patients participated. Within each patient-practitioner dyad, congruence of perceptions was less than 50% in each of the three dimensions examined. Most patients believed they should take a high level of responsibility for "getting well."
Discussion: Although the results of a case study cannot be extrapolated to the chiropractic-patient population, this study does suggest that it may be prudent for chiropractors to ascertain the extent to which their patients share their perceptions of the presenting clinical problem. De Bono's thinking hats are proposed as a helpful perception management tool.
Conclusion: This exploratory study suggests practitioners should not assume that their patients share their perceptions. Given that each patient-practitioner encounter is unique, it may be prudent for chiropractors to actively ascertain the patient's opinions. Patient's perception of their responsibility for "getting well" should be harnessed in developing management plans with high compliance. (J Manipulative Physiol Ther 2000;23:000-000)
Key Indexing Terms: Chiropractic; Perceptions; Patient Participation
Gregory D. Cramer, DC, PhD; Nathaniel R. Tuck Jr., DC; Todd J. Knudsen, DC,DACBR: Scott D. Fonda, DC; Jason S. Schliesser, DC; Jaeson T. Fournier, DC; Pritish Patel, DC
Objective: To test the a priori hypothesis that one of the positive mechanisms of action of chiropractic side-posture manipulation (adjusting) of the lumbar spine is to separate ("gap") the zygapophysial (Z) joints.
Design: Before and after study with randomization.
Setting: Chiropractic college clinic and magnetic resonance imaging (MRI) facility.
Participants: Sixteen (8 male and 8 female) healthy student volunteers ages 22 to 29 years with no history of significant low back pain. Nineteen volunteers were screened, with three being disqualified from the study. Subjects were randomized into four groups, each with two males and two females.
Interventions: Lumbar side-posture spinal adjusting (manipulation) and side-posture positioning.
Main Outcome Measures: 1) Comparison of anterior to posterior measurements of the Z joints from MRI scans taken before and after side-posture spinal adjusting and before and after side-posture positioning, and 2) a rigorous subjective evaluation protocol of the Z joints by three radiologists blinded to the randomized groups.
Main Results: Observers making measurements were blinded to group and first and second scans. Radiologists were blinded to group. Differences were found between the groups. Those receiving side-posture spinal adjusting and remaining in side posture showed the greatest increase in gapping (0.7 mm vs. 0.0 mm for controls).
Conclusions: Lumbar side-posture spinal adjusting produced increased separation (gapping) of the zygapophysial joints. Side-posture positioning also produced gapping, but less than that seen with lumbar side-posture adjusting. A larger clinical trial should be performed to further define the results of this study.
Key Indexing Terms: Chiropractic; Mechanism of Action; Zygapophysial Joints
Roger Coleman, DC, Deed Harrison, DC, Tim Fischer and Sanghak O. Harrison,DC
Background: The use of lines erected upon the vertebral endplates of the AP radiograph, in order to assess z-axis vertebral rotation, is a common clinical practice.
Objective: To quantify the projection/distortion error of lateral flexion (z-axis rotation) measurement on AP radiographs which results from actual axial (y-axis) rotation and changes in focal spot elevation.
Study Design: A three-dimensional (3-D) model of a fourth and fifth lumbar vertebra was constructed in a computer. The angle between the projected inferior vertebral endplate of the fourth lumbar and the projected superior vertebral endplate of the fifth lumbar was measured. This was done for combinations of zero, seven, 14 and 21 degrees of axial (-y-axis) rotation with zero, 15 and 30 centimeters of elevation of a modeled focal spot.
Results: An angle was produced between the projected inferior fourth lumbar vertebral endplate and the projected superior fifth lumbar vertebral endplate as a result of y-axis rotation of the 3-D model. Increasing magnitudes of y-axis rotation and increasing focal spot elevation produced a lack of confidence in this measurement.
conclusion: In a clinical setting, limited ranges of y-axis rotation have little significant effect on the accuracy of this measurement. Increases in y-axis rotation and focal spot elevation can affect measurement accuracy.
Key Indexing Terms: Anatomic Models; Radiography; Vertebral endplates; Spine
Benjamin R. Wingfield,BAppSc(Chiro) and R. Frank Gorman,MBBS,DO,FRACO
Objective: To discuss the case of a patient suffering from severely reduced visual fields arising from terminal glaucomatous retinal damage and the treatment of this condition by spinal manipulation.
Clinical Features: A 25-year-old uniocular female patient who had suffered congenital glaucoma sought chiropractic treatment for spinal pain, headache and classic migraine. Advanced optic disc cupping was present, and loss of vision was near complete. A three-degree island of central vision and a small area of peripheral light sensitivity had remained relatively stable for three years following a trabeculectomy procedure that had resulted in intraocular hypotony.
Intervention and Outcome: Because it was considered possible that chiropractic SMT may have a positive outcome in visual performance, prior to commencing chiropractic SMT, ophthalmologic examination was performed, and visual performance was monitored through a course of treatment. Immediately following the first treatment, significant visual field improvement was recorded in the remaining eye. Maximal improvement of vision was achieved after one week (four treatment sessions). Total monocular visual field had increased from about 2% to approximately 20% of normal. Corrected central acuity had improved from 6/12 to 6/9. Independent re-examination by her regular ophthalmic surgeon confirmed the results.
Conclusion: Recovery of vision in this patient was an unexpected and remarkable outcome, raising the question whether chiropractic SMT may be of value in the management of glaucomatous visual field loss. More intensive research is required.
Key Indexing Terms: Glaucoma; Visual Field Deficit; Migraine; Barre-Leiou Syndrome; Chiropractic Manipulation
Charles G. Davis, DC
Objectives: To review current knowledge and recent concepts of the causes of injuries following minor impact automobile collisions, and to acquaint those who treat these injuries of possible injury thresholds and mechanisms that may contribute to symptoms.
Data Sources: A review of literature involving mechanisms of injury, tissue tensile threshold, and neurological considerations was undertaken. A hand search of relevant engineering, medical/chiropractic and computer Index Medicus sources in disciplines that cover the variety of symptoms was gathered.
Results: Soft tissue injuries are hard to diagnose or quantify. There is no one specific injury mechanism or threshold of injury. With physical variations of tissue tensile strength, anatomic differences and neurophysiological considerations such threshold designation is not possible.
Conclusions: To make a competent assessment of injury, it is important to evaluate each patient individually. The same collision may cause injury to some individuals and leave others unaffected. With the variability of human postures, variability of human postures, variability of tensile strength of the ligaments between individuals, body positions in the vehicle, the differences of collagen fibers in the same specimen segment, the amount of muscle activation and inhibition of muscles, the size of the spinal canals and the excitability of the nervous system, one specific threshold is not possible. There is a vide variability on how individuals react to a stimulus and it is clearly evident peripheral stimulation has effects on the central nervous system. It is also clear the somatosensory system of the neck in addition to signaling nociception, may influence the control of neck, eyes, limbs, respiratory muscles and some preganglionic sympathetic nerves.
Key Indexing Terms: whiplash injury; cervical vertebrae; spine; central nervous system.
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
