JMPT Abstracts for November 2005 • Volume 28 - Number 9

Characteristics of chiropractic practitioners, patients, and encounters in Massachusetts and Arizona.
Robert D. Mootz, DC; Daniel C. Cherkin, PhD; Carson E. Odegard, DC, MPH; David M. Eisenberg, MD; James P. Barassi, DC; Richard A. Deyo, MD, MPH

Objective: To describe chiropractic care using data collected at the time of each patient visit.

Methods: Random samples of chiropractors licensed in Arizona and Massachusetts were recruited to participate in interviews about their training, demographics, and practice characteristics. Interviewees were then recruited to record information about patient condition, evaluation, care, and visit disposition on 20 consecutive patient visits.

Results: Data for 2,550 chiropractic patient visits were recorded. Care for low back, head and neck pain accounted for almost three quarters of visits. Extremity conditions and wellness care accounted for approximately half of the remaining visits. Spinal and soft-tissue examinations were the most frequently reported diagnostic procedures (80% and 56% of visits, respectively), and high-velocity spinal manipulation techniques were the most frequently reported therapeutic procedures (almost 85% of visits). Rehabilitation exercises, thermal modalities, electric stimulation, and counseling/education/self-care were each performed during approximately 25% of visits. Approximately 85% of patients seen were self-referred, whereas only approximately 5% came from medical physicians. Approximately 35% of visits had an expected source of payment directly from the patient. Approximately 80% of visits ended with a plan for the patient to return at a specified time.

Conclusion: These findings are consistent with the findings of previous studies and confirm that chiropractors use conventional patient assessment approaches with specific attention to spinal and musculoskeletal procedures, infrequently incorporating interventions commonly associated with other complimentary and alternative care providers. These findings illustrate that diagnostic assessment and follow-up are integral to chiropractic clinical encounters and offer a baseline for best practices development. The data also offer insight into chiropractic use and may be of interest to chiropractic leaders and education planners for professional development purposes.

Manual therapy for patients with stable angina pectoris: a nonrandomized open prospective trial.
Henrik W. Christensen, DC, MD, PhD; Werner Vach, PhD; Anthony Gichangi, MSc; Claus Manniche, MD, DMSc; Torben Haghfelt, MD, DMSc; Poul F. Høilund-Carlsen, MD, DMSc

Objective: To examine if participants with chest pain originating from the spine would benefit from manual therapy.

Methods: A nonrandomized, open, prospective trial was performed at a tertiary hospital. Patients who were referred for coronary angiography because of known or suspected stable angina pectoris were invited to participate in this study. A total of 275 took part; 50 were diagnosed as cervicothoracic angina (CTA)-positive (chest pain from the cervicothoracic spine) and 225 as CTA-negative. The intervention performed was manual therapy according to chiropractic standards. Patient self reported questionnaires at baseline and 4-week follow-up, including pain measured with an 11-point box scale, Short Form 36 (quality of life), and perceived improvement.

Results: Approximately 75% of CTA-positive patients reported improvement of pain and of general health after treatment, compared with 22% to 25% of CTA-negative patients (P < .0001). Pain intensity decreased in both groups with consistently larger decreases for all measures of pain among CTA-positive patients. Short Form 36 scores increased in the CTA-positive group in 5 of 8 scales and remained unchanged in the CTA-negative group.

Conclusion: This study suggested that patients with known or suspected angina pectoris and a diagnosis of CTA may benefit from chiropractic manual therapy. Methodologically sound randomized clinical trials are needed to corroborate our results.

Objective: To develop a sham manipulation procedure for the cervical spine for use in randomized clinical trials of cervical disorders.

Methods: A single-group, single-intervention study design was used. Adult neck pain subjects underwent a screening examination that included palpation for a site of cervical spine joint dysfunction. Eligible subjects underwent measurements of regional cervical ranges of motion as well as pressure algometry (tenderness) at the site of cervical joint dysfunction. Subjects were instructed that they would receive one of several types of manipulative procedures. A newly developed sham manipulation was delivered once. Subjects were then re-measured for ranges of motion and tenderness. They were asked if they had experienced any pain during the procedure, if they had experienced a "cavitation" sound, and if they thought that the procedure they received was a "real" manipulation. Finally, they were debriefed as to the deception involved in this study. A prior level of 65% was set for endorsement that the procedure was a real manipulation. Changes in pre/post measures of ranges of motion and tenderness were analyzed descriptively for clinically important differences.

Results: Twenty eligible subjects were included (12 males, 8 females) with an average age of 30.4 (2.8) years. Twelve of the subjects were not students, with 3 of these having no prior experience with chiropractic treatment; 8 were students. Of the total sample (N = 19), 8 (42.1%) indicated that the procedure was a "real adjustment"; of the 12 nonstudents, 8 (58.3%) indicated similarly. None of the procedures in the final sample resulted in a cavitation, and none of the subjects registered the procedure as painful. None of the measures for ranges of motion or tenderness showed clinically important changes.

Conclusions: The sham cervical manipulation studied here appears to approximate the necessary features of a placebo maneuver in that it is perceived by a majority of nonstudent neck pain subjects to be a real manipulation, although it does not produce any important change in cervical status. The small sample size of nonstudent participants precludes a strong recommendation for this procedure at this time.

Short-term effects of spinal manipulation on H-reflex amplitude in healthy and symptomatic subjects.
Esther Suter, PhD; Gordon McMorland, DC; Walter Herzog, PhD

Objectives: The purpose of this study is to assess Hoffman (H) reflex after spinal manipulation (1) as a function of experimental position in healthy subjects and (2) in patients with low back pain.

Methods: An intervention study was performed to evaluate the effects of sacroiliac (SI) joint manipulation on motoneuron excitability, as measured by the H-reflex. Manual treatment of the SI joint was performed. Hoffman reflex amplitudes before and after SI joint manipulations were measured with subjects lying on the right side (n = 12 healthy subject) or with subjects lying supine (n = 5 healthy subjects), which required turning of subjects onto their sides for SI joint manipulation. Hoffman reflex amplitudes were also measured in 15 patients with low back pain.

Results: No significant changes in H-reflex amplitude in healthy subjects receiving manipulation to the SI joint were observed, provided that H-reflex testing and treatments were performed in the same position; that is, the subject was not moved during the experimental procedure. However, changes in motoneuron excitability after SI joint manipulation were observed in patients with low back pain.

Conclusions: It appears that H-reflex responses after spinal manipulation are sensitive to movement/repositioning, and that the H-reflex depressions after manipulation documented in previous studies were movement artifacts rather than treatment effects. The relationship between etiology of low back pain and changes in H-reflex amplitude after spinal manipulation is not clear and needs further investigation.

High loading rate during spinal manipulation produces unique facet joint capsule strain patterns compared with axial rotations.
Allyson Ianuzzi, MS Partap S. Khalsa, DC, PhD

Purpose: Lumbar spinal manipulation (SM) is a popular, effective treatment for low back pain, but the physiological mechanisms remain elusive. During SM, mechanoreceptors innervating the facet joint capsule (FJC) may receive a novel stimulus, contributing to the neurophysiological benefits of SM. The biomechanics of SM and physiological axial rotations were compared to determine whether speed or loading site affected FJC strain magnitudes or patterns.

Methods: Human lumbar spine specimens were tested during physiological rotations and simulated SM while measuring applied torque, vertebral motion, and FJC strain. During physiological rotations, specimens were actuated at T12 to 20° left and right axial rotation at 2° to 125° per second. During SM simulations, a 7 mm impulse displacement was applied to L3, L4, or L5 at 5 to 50 mm per second.

Results: Physiological rotations. Increasing displacement rate resulted in significantly larger torque magnitudes (P < .001), whereas vertebral kinematics and FJC strain magnitudes were unchanged (P > .05). Physiological rotations vs. SM. Applied torque and vertebral rotation magnitudes were similar across speed and vertebral level. Total vertebral translations were slightly larger during physiological rotations vs. SM at a given loading rate (P < .05). Patterns of vertebral motions and FJC strain during SM and physiological rotations varied significantly with loading rate (P < .05) but not with actuation site (P > .15).

Conclusions: The similar patterns observed in vertebral motion and FJC strain across actuation sites during SM and physiological rotations suggest that site specificity of SM may have minimal clinical relevance. High loading rates during lumbar SM resulted in unique patterns in FJC strain, which may result in unique patterns of FJC mechanoreceptor response.

Objective: The objective of this study was to determine whether applied force and time interval of force exposure varied within and between physiotherapists (PTs) when they used sacroiliac (SI) distraction testing to provoke pain among subjects with sacroiliitis.

Methods: Two force plates recording 3 orthogonal forces and time intervals were used during repetitive testing. Eleven subjects with sacroiliitis were examined with the use of distraction testing by each of 3 PTs. Subjects lay on an examination board equipped with one force plate for each SI joint. They indicated provoked pain by pressing a button that gave a mark in the data collection.

Results: Applied force and time interval of force exposure varied within and between PTs. Significant differences between PTs were found in the impulse (force time) for the vertical and lateral force components (P ≤ .05). A significant decrease was found in the amplitude of force during the time interval of force exposure (P ≤ .05) for 2 of the 3 PTs. The median level of pain was lowest when examined by the PT who applied the least magnitude of force.

Conclusions: Recording force and time events indicates that variation in examination technique within and between PTs may influence the outcome of the distraction test. Such recording, simultaneously monitored by the investigator, would therefore seem to offer standardized testing and improve clinical evaluation of SI pain over time.

Objective: To determine how accurately patients with neck pain and/or headache can recall the mechanics of their cervical spine manipulative therapy immediately after its administration.

Methods: A survey analysis of immediate patient recall after cervical spine manipulative therapy was performed in a private clinic. The group consisted of 94 sequentially presenting neck pain and/or headache patients with 54 (57%) females and 40 (43%) males. The mean age of the patients was 41.9 years (SD = 13.8; range, 17-96 years). Patients received diversified cervical spine manipulative therapy using a standardized set-up of lateral flexion coupled with flexion. Immediately after the cervical spine manipulative therapy, each patient completed a one-page questionnaire regarding the mechanics of the procedure.

Results: Among the patients, 78.7% reported that they experienced a component of rotation and/or extension, although the technique used involved a pre-manipulative setup of lateral bending coupled with flexion.

Conclusion: Patients with primary complaints of neck pain and/or headache, when asked to recall the mechanics of their recently applied cervical spine manipulative therapy, displayed a low rate of accuracy. Rotation and/or extension of the cervical spine were the most frequently given incorrect responses.

Improving preventive health services training in chiropractic colleges: a pilot impact evaluation of the introduction of a model public health curriculum.
Gary A. Globe, DC, MBA, PhD; Stanley P. Azen, PhD; Thomas Valente, PhD

Objective: To investigate the impact of the dissemination of the model public curriculum at one U.S. chiropractic college on chiropractic interns during their outpatient clinical internship.

Methods: A retrospective pilot study was performed to evaluate the frequency of 9 patient clinical preventive health recommendations made by interns during their clinical training. The frequency of recommendations by interns completing their public health coursework after dissemination of the model curriculum was compared with those completing their coursework during the period immediately proceeding dissemination. A standardized data abstraction tool was developed to collect data from clinic charts that established a patient's need for any one of 9 preventive health services.

Results: Of the 408 charts examined (204 from each group), there were only 4 documented instances (1%) of recommendations for any of the 9 preventive health service categories. Two recommendations occurred in the pre-curriculum change period.

Conclusion: The results of this pilot study indicate that there has been no observable impact on intern behaviors toward educating patients in preventive health services since the dissemination of the model public health curriculum at one of the chiropractic colleges in the United States. The impact of this reform in public health education may have been limited by its minimal focus on clinical preventive services and by a focus on didactic rather than a clinically relevant learning exposure.