JMPT June 2001: Volume 24 - Number 5

Medically supervised water-only fasting in the treatment of hypertension.

Alan Goldhamer,DC; Douglas Lisle,PhD; Banoo Parpia,PhD; Scott Anderson,MD; and T. Colin Campbell,PhD.

Background: Hypertension-related diseases are the leading causes of morbidity and mortality in industrially developed societies. Although antihypertensive drugs are extensively used, dietary and lifestyle modifications also are effective in the treatment of hypertension. One such lifestyle intervention is the use of medically supervised, water-only fasting as a safe and effective means of normalizing blood pressure and initiating health-promoting behavioral changes.

Methods: One hundred and seventy-four consecutive hypertensive patients, with blood pressure in excess of 140 mm Hg systolic and/or 90 mm Hg diastolic (140/90 mm Hg), were treated in an inpatient setting under medical supervision. The treatment program consisted of a short pre-fasting period (approximately 2-3 days on average) during which food consumption was limited to fruits and vegetables, followed by medically supervised water-only fasting (approximately 10-11 days on average), and a refeeding period (approximately 6-7 days on average) introducing a low-fat, low-sodium, vegan diet.

Results: Almost 90 percent of the subjects achieved blood pressure below 140/90 mm Hg by the end of the treatment program. The average reduction in blood pressure was 37/13 mm Hg, with the greatest decrease observed in subjects with the most severe hypertension. Stage three hypertensives (those with systolic blood pressure above 180 mg Hg and/or diastolic blood pressure above 110 mg Hg) experienced an average reduction of 60/17 mm Hg at the conclusion of treatment. All of the subjects on antihypertensive medication at entry (6.3 percent of the total sample) successfully discontinued the use of medication.

Conclusion: Medically supervised water-only fasting appears to be a safe and effective means of normalizing blood pressure and may assist in motivating a health-promoting diet and lifestyle changes.

Key Indexing Terms: hypertension; vegetarian diet; complementary and alternative medicine.

Pierre Côté,DC,MS; Judith Clarke,MA; Suzanne Deguire,MA; John Frank,MD,MS; Annalee Yassi,MD,MS.

Objectives: To explore the views of chiropractors about timely return-to-work in treating patients with musculoskeletal injuries; to identify the approaches used by chiropractors when managing injured workers with musculoskeletal (MSK) disorders; and, to learn about chiropractors' perspectives on the barriers and facilitators of successful return-to-work.

Design: Qualitative study of three focus groups of chiropractors.

Methods: Focus groups of eight to 11 chiropractors were conducted in three large Canadian cities. The selected participants were experienced in treating occupational musculoskeletal injuries. Standard questions were used to collect data from each focus group, and were coded and analyzed separately and then considered in relation to each other.

Results: The participants indicated that timely return-to-work depends on patients' characteristics; severity of injury; clinical progress; the availability of work accommodation; and clinical judgment. The chiropractors commented that their management of injured workers rests on their strength in diagnosis and treatment and on providing patient-centered care. Positive human relations within workplaces, and the ability to accommodate the work of an injured worker, were described as important in return-to-work programs. The participants felt that a bias against chiropractic is present within the medical profession and workers' compensation boards. They viewed this bias as an important barrier when assisting their patients to successfully return to work.

Conclusion: The broad approaches described by the participating chiropractors to return injured workers to work are consistent with those proposed in evidence-based practice guidelines. Better communication between chiropractors, medical doctors and workers' compensation boards would likely decrease interprofessional tensions and improve the recovery of workers with musculoskeletal injuries.

Key Indexing Terms: chiropractic; work; rehabilitation; focus groups; insurance.

Jasper Chen,DC; Charles Lantz,DC,PhD; and Alan Solinger,PhD.

Objective: To quantify errors associated with examiner-assisted neutral head placement in cervical range of motion measurements in normal subjects, and to investigate the influence of these errors on ROM measurements.

Design: Repeated measures design, with cervical range of motion and errors in placement measured in 20 asymptomatic volunteers with the OSI CA-6000.

Methods: Examiner placement of head position was achieved using inclinometers and triangulation. Subjects estimated pain experienced during measurements with numerical pain scales. Angular data around three axes were analyzed using descriptive statistics. Possible correlations between errors and other variables were investigated.

Results: Drift, defined as displacement from original head positioning at first data acquisition and before initiation of motion, was negligible (±0.8Á). Standard errors in neutral head placement ranged from 1.0Á in axial rotation to 3.2Á in flexion/extension. Within-trial variability of neutral position did not correlate with between-trial differences in ranges of motion.

Conclusion: Head position errors were not the primary sources of variability for between-trial measurements of cervical range of motion. The largest errors were in flexion/extension, and least, in axial rotation. Neutral position errors up to about 5Á for lateral bending, 3Á for rotation, and 9Á for flexion and extension, fall within 95-percent confidence intervals, and are the recommended lower limits for significant changes in clinical settings.

Key Indexing Terms: repeatability; standardization; cervical vertebrae; range of motion; errors.

Jeffrey Cooley,DC; Clark Danielsonb; Gary Schultz,DC; and Timothy Hall,DC.

Background: Magnetic resonance imaging is often used to assess for disc displacement following manipulation, but limited information about the true incidence of iatrogenic herniations exists. To design a study that evaluates for a causal relationship, preliminary data must be obtained relating to the size of different types of disc displacement. The reliability of chiropractic radiologists in assessing discs, and a comparison of different measuring devices, should also be evaluated.

Objective: To identify average measurements for normal and displaced discs, and to assess the reliability of measurements by chiropractic radiologists.

Study Design: Intraobserver and interobserver reliability study assessing disc displacement on magnetic resonance scans.

Methods: Three evaluators assessed the discs on 122 magnetic resonance scans from two imaging centers. Six categories were graded, and digitizer and ruler measurements were compared. Forty-four scans were reassessed for intraobserver agreement. Intraobserver and interobserver variations were measured with intraclass correlation coefficient and kappa statistical analysis. Measurement device correlation was assessed utilizing Pearson's r.

Results: Clear size differences between different types of disc displacement were noted. Interexaminer measurement reliability (ICC) was 0.78-0.84. Agreement concerning the presence of disc displacement was 85% (K = 0.68), and the classification of disc displacements was 76% (K = 0.60). Intraexaminer measurement reliability was 0.40 - 0.49. Intraexaminer agreement concerning the presence of disc displacement was 76% (K = 0.52) and the classification of disc displacements was 62%-69% (K = 0.38-0.46). Normal versus bulged disc distinctions demonstrated the most disagreement. The ruler and digitizer correlation coefficient was 0.968.

Conclusions: Different disc types demonstrated distinct size averages. Interexaminer agreement was good concerning disc assessment and measurements. Intraexaminer agreement was lower than expected. A millimetric ruler is an acceptable alternative to digital measurement devices.

Key Indexing Terms: magnetic resonance imaging; intervertebral disc; measurement reliability.

Jennifer R. Jamison, MBBCh, PhD, EdD.

Background: It has been suggested that clinicians should be looking at new ways to enhance their patientsÍ self-care. Patient education is one strategy that primary providers may use.

Objective: This study investigates the format in which patients would like to pursue their health education within the chiropractic clinic.

Methods: An exploratory study of chiropractic patients was undertaken to investigate patientsÍ preferred health education formats, their commitment to pursuing health objectives, and their literacy level. Purposive sampling of nine Australian chiropractic clinics was undertaken. Convenience sampling of patients attending these clinics resulted in 102 patients participating. Participants completed a questionnaire. A research assistant was available to clarify any questions. Data were collected and collated. A Likert scale was used to capture responses to questions ascertaining patient opinions.

Results: Patients considered health the most important of the life objectives listed, but preferred spending time with family to undertaking health and fitness promoting activity. More chiropractic patients opted for health information brochures than health promotion classes, personally supervised self-care programs or practitioner-supervised self-care contracts. Patient literacy levels varied within and between clinics.

Conclusions: Brochures may provide a definitive health information tool for chiropractors who limit their clinical role to primary contact and a helpful adjunct to patient education for chiropractors committed to a primary care role. Care should however be taken to select brochures consistent with the patientsÍ literacy levels. Tips for selecting and preparing suitable brochures are provided. The discrepancy between how greatly patients value health and how they prefer spending their time may have implications for successful behavior change. Brochures alone may not constitute adequate practitioner involvement.

Key Indexing Terms: chiropractic; health information; brochures; readability.

Jason Busse,DC,MS, and William Hsu,DC.

Objective: To demonstrate the importance of clinical examination and continued vigilance for neurological deterioration in patients suffering from sciatica. Cauda equina syndrome is a rare sequela of sciatica considered a medical emergency requiring surgical decompression.

Clinical Features: A 32-year-old woman suffered from sciatica that rapidly progressed to cauda equina syndrome. Magnetic resonance imaging revealed the presence of a large, non-sequestered disk fragment in the lower lumbar spine.

Intervention and Outcome: The disk fragment was surgically excised. The patient experienced immediate pain relief following surgery, but retained neurological deficits. Following six months of rehabilitation, neurological integrity was restored aside from patchy sensory loss of the left foot and buttocks. At six-month follow-up, the patientÍs sciatica had not returned.

Conclusion: Most cases of sciatica, regardless of cause, will self-resolve; as a result, there may be a tendency to maintain a low index of suspicion for serious, progressive disorders such as cauda equina syndrome. Patients need to be educated as to signs of this emergency condition, and informed as to the possible consequences of delaying treatment. By maintaining a high index of suspicion for those patients who fail to respond as expected to a course of conservative therapy, or who demonstrate signs of cauda equina syndrome, chiropractors can assume a pivotal role by investigating and referring appropriately, and by aiding in active rehabilitation postoperatively.

Key Indexing Terms: cauda equina syndrome; intervertebral disk herniation; sciatica; low back pain; chiropractic.

Michael Mestan,DC,DACBR, John Bassano,DC, DACBR.

Objective: To discuss the clinical manifestation, radiographic features, and treatment of seven cases of post-traumatic osteolysis of the distal clavicle; Also, to furnish evidence indicating that the current terminology for this disorder is ambiguous, and to propose a new classification system.

Clinical Features: Three cases resulted from acute trauma and four cases were subsequent to sports-related repetitive microtrauma. All the cases involved young males who suffered similar clinical presentations that included shoulder pain with decreased shoulder range-of-motion. Radiographic findings ranged from small erosive changes to aggressive osteolysis of the distal of the clavicle.

Intervention and Outcome: All the patients were treated with conservative care consisting of sling immobilization, ice, various physiotherapeutic modalities, and mobilization exercises.

The patients that followed through with care showed clinical improvement within three months. Follow-up radiographic examinations, when performed, demonstrated reconstitution of the distal clavicle of various degrees, although lagging behind clinical evidence of improvement.

Conclusion: Traumatic osteolysis of the distal clavicle may result from acute trauma or repetitive microtrauma. Radiographic changes are varied including irregularity of the distal clavicle, cystic erosions, and blatant osteolysis. Positive outcomes may be achieved with conservative care; however, patient compliance plays a fundamental role in the overall prognosis.

L. James Smart Jr.,PhD, and Dean Smith,DC.

Objective: To provide a rationale for the examination of posture from a dynamic (behavioral) perspective, and to relate the vertebral subluxation to postural instability and motion sickness via inefficiency.

Data Collection: A manual search of available reference texts and a computer search of literature from Index Medicus, PsycINFO, and ISI Science Citation Index Expanded were collected with an emphasis on postural dynamics, vertebral subluxation and motion sickness.

Results: Evidence linking behavioral and health research has emerged from the study of posture and postural dynamics. Studies examining the relation between postural control and motion sickness have shown that motion sickness is preceded and predicted by postural instability. Motion sickness is characterized by maladaptive response to unusual motion events. Symptomology is nonspecific and variable. While the postural instability theory of motion sickness predicted that instability should precede sickness, it did not make any claims regarding the symptomology associated with it. Chiropractic literature has emphasized the effects of vertebral subluxation on neurological dysfunction. Vertebral subluxation is a condition postulated to interfere with neurological processes and may influence organ system function and general health. As in the case of motion sickness, symptomology is nonspecific and variable (and in some instances the person may be asymptomatic). So what do these disorders have in common? In each instance the disruptions lead to inefficiency in the system.

Conclusion: Given this potential commonality, we propose that some of the methods employed by behavioral researchers to study postural dynamics may also be of great utility to healthcare practitioners and psychologists alike. Further, we propose that this link will provide a framework, which will allow scientists to address seemingly intractable problems such as motion sickness or subluxation.

Key Indexing Terms: posture; motion sickness; biomechanics; dysponesis.