Journal of Manipulative and Physiological Therapeutics

Comparison of methods of evaluating cervical range of motion.

Virginia Wolfenberger,PhD; Quynh Bui,DC; G. Brian Batenchuk,DC.

Objective: To determine if there are differences in results of evaluating cervical range of motion (ROM) using a bubble goniometer, a dual inclinometer, and radiographic analysis; and to learn if there is a relationship of particular physical parameters to cervical ROM.

Methods: Cervical ranges of motion of 115 volunteers were evaluated using each of the three clinical methods. Tape measurements of neck girth, chin-to-sternal-notch distance and ears-to-acromion distances were also recorded, as well as gender and age. Inter-rater and intra-rater reliabilities were determined. Pearson's product moment correlations and T-tests were performed on data.

Results: Cervical ROM as determined by radiographic analysis was greater than the results obtained using a dual inclinometer or a bubble goniometer. All tape measurements (except earlobes to acromion, which did not correlate with radiographic analysis) were correlated with all three means of cervical ROM evaluation. There were also differences found in cervical ROM by gender and age, with females and younger subjects having a greater ROM.

Conclusion: Compared to a dual inclinometer and a bubble goniometer, radiographic analysis provides a more accurate evaluation of cervical ROM.

Key Indexing Terms: range of motion; ROM; radiography; inclinometry; cervical spine.

Thomas Terenzi,DO,EdD,DC.

Objective: To discuss a case illustrating the role of transcranial Doppler sonography (TCD) in the screening and management of a patient with intermittent vertebral artery brainstem ischemia.

Clinical Features: A 28-year-old female suffered from neck and arm pain, headaches and dizziness. Her symptoms occurred intermittently over several years. Past care had provided little relief. De Kleyn's test, TCD and magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) 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 (SMT). 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 TCD procedures. Brain stem symptoms were correlated with a documented perfusion deficit during cervical positional testing. This case also demonstrated that spinal manipulative therapy may be safely utilized on patients with vertebrobasilar insufficiency when the biomechanics and related flow studies are elucidated.

Key Indexing Terms: transcranial Doppler; vertebral artery; vertebrobasilar system; chiropractic.

John Stump,DC,OMD,EdD; Daniel Redwood,DC.

Chiropractors play an increasingly active role in the treatment of athletes. They first participated at the Olympic Games in an official capacity in 1980, and chiropractic is now part of the sports medicine program of the U.S. Olympic Committee. In addition to widespread participation in amateur sports events, DCs also provide care for U.S. professional football, basketball, baseball, and hockey players. This study examines the opinions of head athletic trainers from each of the 32 National Football League (NFL) teams to determine the current utilization of sports chiropractors in the NFL, and to ascertain the role of sports chiropractic in the league. Results indicate that there is both official and unofficial utilization of chiropractic in the NFL. Most NFL trainers have referred players to chiropractors, and all trainers report that some players on their teams seek chiropractic services without official referral. Thirty-one percent of NFL teams have a DC on their medical staff, and an additional 12 percent of teams refer players to DCs they do not directly retain. Trainers see a role for the sports chiropractor as a spinal specialist, and some report resistance on the part of team medical physicians to an enhanced level of sports chiropractor participation.

Key Indexing Terms: chiropractic; sports medicine; sports management.

Tara Whelan,DC; J. Donald Dishman,DC; Jean Burke,PhD; Seymour Levine,PhD; Veronica Sciotti,PhD.

Background: The stress response in humans is a healthy response, and is necessary for life. The effects of chiropractic manipulation (CM), if any, on stress are ill-defined. Cortisol has been used as an accurate measure of the stress response system in humans. Salivary cortisol is a noninvasive technique by which to accurately quantify biologically active cortisol.

Objectives: To determine if basal salivary cortisol levels can be properly detected, and to determine if CM has any direct effect on basal salivary cortisol levels in human subjects.

Methods: Subjects were adult male students attending a chiropractic college. Salivary samples were collected for five weeks. During week one, samples were collected at home upon waking by the subjects. During weeks 2-5, home waking samples were collected, followed by an additional time course of samples collected in a laboratory setting, pre-CM and post-CM. Salivary cortisol was measured by enzyme-linked immunoassay.

Results: Chiropractic manipulative therapy did not significantly change basal salivary cortisol levels. The time course of acute changes to cortisol levels was independent of testing week and group. A decrease in salivary cortisol was detected over time on each trial testing day. Overall, cortisol levels significantly decreased from the home samples until the pretreatment laboratory measurement (p < .05). Cortisol levels subsequently decreased from the pretreatment time point to the 15-minute posttreatment time point (p < .05). Posttreatment, there were progressive decreases in cortisol levels from the 15 and 30-minute time points to the 60-minute time point (p < .05).

Conclusion: The results of this pilot study suggest that there is no effect of chiropractic manipulation on salivary cortisol levels in asymptomatic subjects. As such, the authors conclude that neither the anticipation of CM nor the spinal manipulative procedure itself induces a state of stress or anxiety.

Key Indexing Terms: chiropractic; salivary cortisol; stress.

Jennifer Bolton,PhD,MA; B.Kim Humphreys,DC,PhD.

Objective: To modify an existing outcome measure (Bournemouth questionnaire - BQ) for use in nonspecific neck pain patients, and test its psychometric properties.

Design: Prospective longitudinal study in which the questionnaire was administered on three occasions (pre-treatment, retest and posttreatment).

Setting: Anglo-European College of Chiropractic outpatient clinic, and eight field chiropractic practices.

Method: Seven core items relating to the biopsychosocial (BPS) model of pain were included in the original questionnaire (back BQ). The wording of one of these items (disability in activities of daily living) was modified to include activities likely to be affected by neck pain. Testing of the neck BQ was carried out in 102 nonspecific neck pain patients.

Results: The instrument demonstrated high internal consistency on three administrations (Cronbach's alpha = 0.87, 0.91, 0.92). All seven items were retained on the basis that they each significantly contributed to the total score (item-corrected total score correlations > 0.43) and to the instrument's responsiveness to clinical change (item change-corrected total change score correlations > 0.42). The instrument was reliable in test-retest administrations in stable subjects (ICC = 0.65). The instrument demonstrated acceptable construct validity and longitudinal construct validity with established external measures. The treatment effect size of the instrument was found to be high (1.67).

Conclusion: The neck BQ covers the salient dimensions of the biopsychosocial model of pain, is quick and easy to complete, and has been shown to be reliable, valid and responsive to clinically significant change in non-specific neck pain patients. Its use as an outcome measure in clinical trials and outcomes research is recommended.

Key Indexing Terms: neck pain; outcome measure; reliability; validity; responsiveness.

MelanieOsterhouse,DC; Norman Kettner,DC; Patrick Birrer,DC,MD; Kenneth Mankamyer,BS.

Objective: To discuss the clinical features of ganglioneuroma and to propose it as a differential diagnosis for a young patient suffering from chronic back pain.

Clinical Features: A 25-year-old patient suffered from chronic midthoracic pain and a history of scoliosis. The physical exam was unremarkable; thus, radiographs were obtained. A posteroanterior (PA) and lateral chest radiograph demonstrated a well-defined opacity extending from the region of the left hilum to below the diaphragm. A differential diagnosis of a posterior mediastinal mass was advanced. Computed tomography revealed a homogenous, non-enhancing left posterior mediastinal mass with adjacent posterior rib deformity. A CT-guided biopsy subsequently defined the mass as a ganglioneuroma.

Intervention and Outcome: The mass was surgically resected. Although the patient experienced some postsurgical discomfort, she has fared well.

Conclusion: Twenty percent of mediastinal tumors are neurogenic, and 10 percent of neurogenic tumors are ganglioneuromas. Despite the rarity of this tumor, ganglioneuroma should be considered in the differential diagnosis of young patients suffering from back pain. The diagnosis is important to ascertain because surgical resection is curative and can relieve the symptomatology.

Key Indexing Terms: neoplasm; ganglioneuroma; sympathetic nervous system; mediastinum.

Jan Hartvigsen,DC; Line Sorensen,DC; Kristian Graesborg, MA; Niels Grunnet-Nilsson,DC,MD,PhD.

Background: The vast majority of information on chiropractic and chiropractic patients originates from English-speaking countries. Lately, however, reports describing chiropractic patients and practice in European countries have emerged.

Objective: To describe basic characteristics of Danish chiropractic patients.

Design: Survey questionnaire. All chiropractic clinics in Denmark were asked to collect information on new patients during one randomly assigned week in 1999.

Setting: A private chiropractic practice and a nonprofit research institution.

Outcome Measures: Age and gender, location and duration of a chief complaint, pain intensity and limitation of activities of daily living due to a chief complaint and mode of referral.

Results: Eighty-eight percent of all chiropractic clinics in Denmark participated in the study, and 1,897 out of 2,020 patients (94 percent) from the participating clinics filled out a self-administered questionnaire. The mean age of participants was 42 years, and slightly more women than men returned the questionnaire. By far, the most frequent area of complaint was pain related to the lower back (50 percent) followed by pain related to the neck (15 percent). The majority of patients were in the subacute or chronic category (complaint duration 1-6 months). Patients with sciatica had significantly higher pain scores and limitation in activities of daily living (ADL) than any other group, whereas patients with neck pain tended to score lower. Patients in the subacute category had the highest pain scores and limitation in ADL. For complaints lasting more than six months, limitation in ADL remained constant at a low level. Twenty-three percent of all patients were referred to the chiropractor, most frequently from a general medical practitioner. Over half of all patients had previously been treated for the same or similar problems, most frequently by a chiropractor. Fifty-one percent had also received chiropractic care for other types of problems.

Conclusions: Most Danish chiropractic patients complain of pain related to the low back or neck of between one and six months' duration. This study confirms that chiropractic is fairly well integrated in the Danish primary health care system. There are differences between the chiropractic patient population in Denmark, compared to Sweden and Holland.

Key Indexing Terms: chiropractic; Denmark; pain; low back; neck; survey.

David Seaman,DC,MS,DABCN.

Background: It is the rare physician who includes diet therapy and nutritional supplements in patient care. Perhaps this is because chiropractic and medical schools devote very few classroom hours to nutrition. It is also possible that physicians espouse the misconception that a detailed biochemical understanding of each disease is required before nutritional interventions can be utilized.

Objective: The purpose of this paper is to (1) demonstrate that chronic pain and other degenerative conditions encountered in clinical practice have similar biochemical etiologies, i.e., a diet-induced, pro-inflammatory state; and (2) outline a basic nutritional program that could be utilized by all practitioners.

Data Sources: The data was accumulated over a period of years by reviewing contemporary articles and books and subsequently retrieving relevant papers. Articles were also selected from MEDLINE searches and manual library searches.

Results: The typical American diet is deficient in fruits and vegetables, and contains excessive amounts of meat, refined grain products, and dessert foods. Such a diet can have numerous untoward biochemical effects,which create a pro-inflammatory state and predispose the body to develop degenerative diseases. It appears that an inadequate intake of fruits and vegetables can result in a suboptimal intake of antioxidants and phytochemicals, and an imbalance intake of essential fatty acids. Through different mechanisms, each nutritional alteration can promote inflammation and disease.

Conclusion: We can no longer view different diseases as distinct biochemical entities. Nearly all degenerative diseases have the same underlying biochemical etiology, that is, a diet-induced pro-inflammatory state. While specific diseases may require specific treatments (i.e., adjustments for hypomobile joints, beta-blockers for hypertension, and chemotherapy for cancer), the treatment program must also include nutritional protocols to reduce the pro-inflammatory state.

Key Indexing Terms: degenerative disease; inflammation; pain; antioxidants; diet; prostaglandins.

Constantine Constantoyannis, MD; Demetres Konstantinou, MD; Harry Kourtopoulos, MD. PhD; Nicolas Papadakis, MD.

Objective: To describe the use of intermittent cervical traction in managing four patients suffering from cervical radiculopathy and large-volume herniated discs.

Clinical Features: Four patients suffered from neck pain radiating to their arms. The clinical examination was typical in all cases for radiculopathy of cervical origin. MRI of the cervical spine revealed large-volume herniated discs in all patients.

Intervention and Outcome: The treatment used intermittent on-the-door cervical traction under the supervision of our physiotherapists. Complete symptom resolution for each patient occurred within three weeks. One patient experienced an episode of recurrence 16 months after the first treatment that was successfully managed again with cervical traction and physiotherapy.

Conclusion: Cervical spine traction could be considered a therapy of choice for radiculopathy due to herniated discs, even in cases of large-volume herniated discs or recurrent episodes.

Key Indexing Terms: disc herniation; cervical vertebrae; radiculopathy; traction; neck pain; treatment.