Wednesday, December 6, 2006 08:57 GMT

Chiropractic & Osteopathy - Latest articles

The latest articles from Chiropractic & Osteopathy (ISSN 1746-1340) published by BioMed Central

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Accuracy of spinal orthopaedic tests: a systematic review

Background:The purpose of this systematic review was to critically appraise the literature on the accuracy of
orthopaedic tests for the spine.Methods:Multiple orthopaedic texts were reviewed to produce a
comprehensive list of spine orthopaedic test names and synonyms. A search was conducted in MEDLINE,
MANTIS, CINAHL, AMED and the Cochrane Library for relevant articles from inception up to December
2005. The studies were evaluated using the tool for quality assessment for diagnostic accuracy studies
(QUADAS).Results:Twenty-one papers met the inclusion criteria. The QUADAS scores ranged from 4 to 12
of a possible 14. Twenty-nine percent of the studies achieved a score of 10 or more. The papers covered a
wide range of tests for spine conditions.Conclusion:There was a lack of quantity and quality of orthopaedic
tests for the spine found in the literature. There is a lack of high quality research regarding the accuracy of
spinal orthopaedic tests. Due to this lack of evidence it is suggested that over-reliance on single orthopaedic
tests is not appropriate.

http://www.chiroandosteo.com/content/14/1/26

The organisation of the stress response, and its relevance to chiropractors: a commentary

The stress response is a natural reaction by the body, against potentially harmful stimuli to enhance the
chance for survival. Persistent activation of the stress response can cause changes to homeostatic
mechanisms. The study of stress neurophysiology, in the evaluation of the manifestation of disease in the
body, suggests that these chronic changes have detrimental effects on sub cortical structures. Furthermore,
there is much scientific support for the notion that chronic activation of supraspinal systems will lead to
maladaptation of homeostatic mechanisms, causing the impairment of processes within the body, and
ultimately leading to visceral disorders. The chiropractic profession for many years has alluded to chronic
change of neurophysiological pathways as a potential explanation of visceral disorders, but the profession
has typically described these in terms of somatovisceral or viscerosomatic reflex activity. Change in
supraspinal neurophysiological efferent activity is increasingly being used to explain "stress" related disease.
The chiropractic profession should consider investigating such stress responses by conducting spinal
manipulative therapy trials that evaluate supraspinal effects of manipulation. Such research may help
elucidate key mechanisms associated with the change of visceral disorders noted by some chiropractors
following manipulative therapy.

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An educational campaign to increase chiropractic intern advising roles on patient smoking cessation

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Background:Tobacco use, particularly smoking, is the most preventable cause of death in the United States.
More than 400,000 premature deaths are associated with its use and the health care costs are in the billions.
All health care provider groups should be concerned with patients who continue to smoke and use tobacco.
The US Preventive Services Taskforce and Health People 2010 guidelines encourage providers to counsel
smokers on cessation. Current studies, though limited regarding chiropractic advising practices indicate a low
engagement rate when it comes to providing cessation information.ObjectiveTo test a campaign regarding
initial impact aimed at increasing chiropractic interns advising on cessation and delivery of information to
smokers on cessation.DiscussionChiropractic interns do engage patients on smoking status and can be
encouraged to provide more cessation messages and information to patients. The initial impact assessment
of this campaign increased the provision of information to patients by about 25%. The prevalence of smoking
among chiropractic patients, particularly at teaching clinics may be lower than the national
averages.Conclusion:Chiropractic interns can and should be encouraged to advise smokers about cessation.
A systematic method of intake information on smoking status is needed and a standardized education
protocol for chiropractic colleges is needed. Chiropractic colleges should assess the adequacy of their
advising roles and implement changes to increase cessation messages to their patients as soon as possible.

http://www.chiroandosteo.com/content/14/1/24

The Council on Chiropractic Education's New Wellness Standard: A call to action for the chiropractic
profession

Background:The chiropractic profession has long considered itself to be a preventive science. Recently the
Council on Chiropractic Education (CCE) has defined a set of standards that must be implemented at all US
chiropractic colleges as of January of 2007. These are specific to wellness measures and health promoting
efforts that should be performed by chiropractors. This will mandate traditional health promotion and
prevention methods be taught to students at accredited colleges and to practicing chiropractors.ObjectiveTo
present the idea of performing traditional health promotion and wellness-concepts in chiropractic practice as
a call to action for clinicians and generate discussion on the topic.DiscussionThis manuscript discusses
relevant topics of health promotion and prevention for chiropractors and other practicing clinicians that should
be made priorities with patients in order to enhance both patient health and community and population
health.Conclusion:All practicing chiropractors, as well as other clinicians should take these new standards
from the CCE as a call to action to begin helping patients address the removable causes of morbidity,
disability and premature mortality where they exist, in addition to treating their painful spinal conditions.

http://www.chiroandosteo.com/content/14/1/23

Case report of right hamate hook fracture in a patient with previous fracture history of left hamate
hook: is it hamate bipartite?

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Background:Hamate hook fracture is a common fracture in golfers and others who play sports that involve
rackets or sticks such as tennis or hockey. This patient had a previous hamate fracture in the opposing wrist
along with potential features of hamate bipartite.Case presentationA 19 year old male presented with a
complaint of right wrist pain on the ulnar side of the wrist with no apparent mechanism of injury. The pain
came on gradually one week before being seen in the office and he reported no prior care for the complaint.
His history includes traumatic left hamate hook fracture with surgical excision.Conclusion:The patient was
found to have marked tenderness over the hamate and with a prior fracture to the other wrist, computed
tomography of the wrist was ordered revealing a fracture to the hamate hook in the right wrist. He was
referred for surgical evaluation and the hook of the hamate was excised. Post-surgically, the patient was able
to return to normal activity within eight weeks. This case is indicative of fracture rather than hamate bipartite.
This fracture should be considered in a case of ulnar sided wrist pain where marked tenderness is noted over
the hamate, especially after participation in club or racket sports.

http://www.chiroandosteo.com/content/14/1/22

Segment-specific association between cervical pillar hyperplasia (CPH) and degenerative joint
disease (DJD)

Background:Cervical pillar hyperplasia (CPH) is a recently described phenomenon of unknown etiology and
clinical significance. Global assessment of pillar hyperplasia of the cervical spine as a unit has not shown a
relationship with degenerative joint disease, but a more sensible explanation of the architectural influence of
CPH on cervical spine biomechanics may be segment-specific.ObjectiveThe objective of this study was to
determine the level of association between degenerative joint disease (DJD) and cervical pillar hyperplasia
(CPH) in an age- and gender-matched sample on a [cervical spine] by-level basis.Research
MethodsTwo-hundred and forty radiographs were collected from subjects ranging in age between 40 and 69
years. The two primary outcome measures used in the study were the segmental presence/absence of
cervical pillar hyperplasia from C3 to C6, and segment-specific presence/absence of degenerative joint
disease from C1 to C7. Contingency Coefficients, at the 5% level of significance, at each level, were used to
determine the strength of the association between CPH and DJD. Odds Ratios (OR) with their 95%
Confidence Intervals (95% CI) were also calculated at each level to assess the strength of the
association.Results:Our study suggests that an approximately two-to-one odds, or a weak-to-moderate
correlation, exists at C4 and C5 CPH and adjacent level degenerative disc disease (DDD); with the strongest
(overall) associations demonstrated between C4 CPH and C4?5 DDD and between C5 CPH and C5?6 DDD.
Age-stratified results demonstrated a similar pattern of association, even reaching the initially hypothesized
OR ? 5.0 (95% CI > 1.0) or "moderately-strong correlation of C ? .4 (p ? .05)" in some age categories,
including the 40?44, 50?59, and 60?64 years of age subgroups; these ORs were as follows: OR = 5.5 (95%
CI 1.39?21.59); OR = 6.7 (95% CI 1.65?27.34); and OR = 5.3 (95% CI 1.35?21.14),
respectively.Conclusion:Our results suggest that CPH has around two-to-one odds, that is, only a
weak-to-moderate association with the presence of DJD (DDD component) at specific cervical spine levels;
therefore, CPH may be but one of several factors that contributes (to a clinically important degree) to the
development of DJD at specific levels in the cervical spine.

http://www.chiroandosteo.com/content/14/1/21

Improvement of lower extremity electrodiagnostic findings following a trial of spinal manipulation and
motion-based therapy

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Background:Lumbar disc herniation is a problem frequently encountered in manual medicine. While manual
therapy has shown reasonable success in symptomatic management of these cases, little information is
known how manual therapy may affect the structure and function of the lumbar disc itself. In cases where
lumbar disc herniation is accompanied by radicular symptoms, electrodiagnostic testing has been used to
provide objective clinical information on nerve function. This report examines the treatment rendered for a
patient with lower extremity neurological deficit, as diagnosed on electrodiagnostic testing. Patient was
treated using spinal manipulation and exercises performed on a Pettibon Wobble Chair?, using
electrodiagnostic testing as the primary outcome assessment.Case PresentationAn elderly male patient
presented to a private spine clinic with right-sided foot drop. He had been prescribed an ankle-foot orthosis
for this condition. All sensory, motor, and reflex findings in the right leg and foot were absent. This was
validated on prior electromyography and nerve conduction velocity testing, performed by a board certified
neurologist. Patient was treated using spinal manipulation twice-weekly and wobble chair exercises three
times daily for 90 days total. Following this treatment, the patient was referred for follow-up electrodiagnostic
studies. Significant improvements were made in these studies as well as self-rated daily
function.Conclusion:Motion-based therapies, as part of a comprehensive rehabilitation program, may
contribute to the restoration of daily function and the reversal of neurological insult as detected by
electrodiagnostic testing. Electrodiagnostic testing may be a useful clinical tool to evaluate the progress of
chiropractic patients with lumbar disc herniation and radicular pain syndromes.

http://www.chiroandosteo.com/content/14/1/20

Amount of health care and self-care following a randomized clinical trial comparing
flexion-distraction with exercise program for chronic low back pain

Background:Previous clinical trials have assessed the percentage of participants who utilized further health
care after a period of conservative care for low back pain, however no chiropractic clinical trial has
determined the total amount of care during this time and any differences based on assigned treatment group.
The objective of this clinical trial follow-up was to assess if there was a difference in the total number of office
visits for low back pain over one year after a four week clinical trial of either a form of physical therapy
(Exercise Program) or a form of chiropractic care (Flexion Distraction) for chronic low back pain.Methods:In
this randomized clinical trial follow up study, 195 participants were followed for one year after a four-week
period of either a form of chiropractic care (FD) or a form of physical therapy (EP). Weekly structured
telephone interview questions regarded visitation of various health care practitioners and the practice of
self-care for low back pain.Results:Participants in the physical therapy group demonstrated on average
significantly more visits to any health care provider and to a general practitioner during the year after trial care
(p http://www.chiroandosteo.com/content/14/1/19

Effectiveness of an evidence-based chiropractic continuing education workshop on participant

knowledge of evidence-based health care

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Background:Chiropractors must continue to learn, develop themselves professionally throughout their
careers, and become self-directed and lifelong learners. Using an evidence-based approach increases the
probability of optimal patient outcomes. But most chiropractors lack knowledge and interest in
evidence-based approaches. The purpose of this study was to develop and measure the effectiveness of
evidence-based training for chiropractic practitioners in a continuing education setting.Methods:We
developed and evaluated a continuing education workshop on evidence-based principles and methods for
chiropractic practitioners. Forty-seven chiropractors participated in the training and testing. The course
consisted of 12.5 hours of training in which practitioners learned to develop focused questions, search
electronic data bases, critically review articles and apply information from the literature to specific clinical
questions. Following the workshop, we assessed the program performance through the use of knowledge
testing and anonymous presentation quality surveys.Results:Eighty-five percent of the participants completed
all of the test, survey and data collection items. Pretest knowledge scores (15-item test) were low (47%). Post
intervention scores (15-item test) improved with an effect size of 2.0. A 59-item knowledge posttest yielded
very good results (mean score 88%). The quality of presentation was rated very good, and most participants
(90%) would "definitely recommend" or "recommend" the workshop to a colleague.Conclusion:The results of
the study suggest that the continuing education course was effective in enhancing knowledge in the
evidence-based approach and that the presentation was well accepted.

http://www.chiroandosteo.com/content/14/1/18

Physical injury assessment of male versus female chiropractic students when learning and
performing various adjustive techniques: a preliminary investigative study

Background:Reports of musculoskeletal injuries that some chiropractic students experienced while in the role
of adjustor became increasingly evident and developed into the basis of this study. The main objective of this
study was to survey a select student population and identify, by gender, the specific types of musculoskeletal
injuries they experienced when learning adjustive techniques in the classroom, and performing them in the
clinical setting.Methods:A survey was developed to record musculoskeletal injuries that students reported to
have sustained while practicing chiropractic adjustment set-ups and while delivering adjustments. The survey
was modeled from similar instruments used in the university's clinic as well as those used in professional
practice. Stratified sampling was used to obtain participants for the study. Data reported the anatomical areas
of injury, adjustive technique utilized, the type of injury received, and the recovery time from sustained
injuries. The survey also inquired as to the type and area of any past physical injuries as well as the
mechanism(s) of injury.Results:Data obtained from the study identified injuries of the shoulder, wrist, elbow,
neck, low back, and mid-back. The low back was the most common injury site reported by females, and the
neck was the most common site reported by males. The reported wrist injuries in both genders were 1% male
complaints and 17% female complaints. A total of 13% of female respondents reported shoulder injuries,
whereas less than 1% of male respondents indicated similar complaints.Conclusion:The data collected from
the project indicated that obtaining further information on the subject would be worthwhile, and could provide
an integral step toward developing methods of behavior modification in an attempt to reduce and/or prevent
the incidence of musculoskeletal injuries.

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Inappropriate use of the title 'chiropractor' and term 'chiropractic manipulation' in the peer-reviewed
biomedical literature

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Background:The misuse of the title 'chiropractor' and term 'chiropractic manipulation', in relation to injury
associated with cervical spine manipulation, have previously been reported in the peer-reviewed
literature.The objectives of this study were to -1) Prospectively monitor the peer-reviewed literature for papers
reporting an association between chiropractic, or chiropractic manipulation, and injury;2) Contact lead authors
of papers that report such an association in order to determine the basis upon which the title 'chiropractor'
and/or term 'chiropractic manipulation' was used;3) Document the outcome of submission of letters to the
editors of journals wherein the title 'chiropractor', and/or term 'chiropractic manipulation', had been misused
and resulted in the over-reporting of chiropractic induced injury.Methods:One electronic database (PubMed)
was monitored prospectively, via monthly PubMed searches, during a 12 month period (June 2003 to May
2004). Once relevant papers were located, they were reviewed. If the qualifications and/or profession of the
care provider/s were not apparent, an attempt was made to confirm them via direct e-mail communication
with the principal researcher of each respective paper. A letter was then sent to the editor of each involved
journal.Results:A total of twenty four different cases, spread across six separate publications, were located
via the monthly PubMed searches. All twenty four cases took place in one of two European countries.The six
publications consisted of four case reports, each containing one patient, one case series, involving twenty
relevant cases, and a secondary report that pertained to one of the four case reports. In each of the six
publications the authors suggest the care provider was a chiropractor and that each patient received
chiropractic manipulation of the cervical spine prior to developing symptoms suggestive of traumatic injury.In
two of the four case reports contact with the principal researcher revealed that the care provider was not a
chiropractor, as defined by the World Federation of Chiropractic. The authors of the other two case reports
did not respond to my communications. In the case series, which involved twenty relevant cases, the principal
researcher conceded that the term chiropractor had been inappropriately used and that his case series did
not relate to chiropractors who had undergone appropriate formal training. The author of the secondary
report, a British Medical Journal editor, conceded that he had misused the title chiropractor. Letters to editors
were accepted and published by all four journals to which they were sent. To date one of the four journals
has published a correction.Conclusion:The results of this year-long prospective review suggests that the
words 'chiropractor' and 'chiropractic manipulation' are often used inappropriately by European biomedical
researchers when reporting apparent associations between cervical spine manipulation and symptoms
suggestive of traumatic injury. Furthermore, in those cases reported here, the spurious use of terminology
seems to have passed through the peer-review process without correction. Additionally, these findings
provide further preliminary evidence, beyond that already provided by Terrett, that the inappropriate use of
the title 'chiropractor' and term 'chiropractic manipulation' may be a significant source of over-reporting of the
link between the care provided by chiropractors and injury. Finally, editors of peer-reviewed journals were
amenable to publishing 'letters to editors', and to a lesser extent 'corrections', when authors had
inappropriately used the title 'chiropractor' and/or term 'chiropractic manipulation'.

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