The contemporary model of vertebral column joint dysfunction and impact of high-velocity, low-amplitude controlled vertebral thrusts on neuromuscular function

Retrospective review of case records of school-aged children receiving chiropractic care

BACKGROUND

Chiropractic care is utilized in school aged children for a variety of health complaints, including headaches, postural issues, nocturnal enuresis, neurodevelopmental disorders, and back pain. Chiropractic care, with its ability to impact sensorimotor integration, motor control and the prefrontal cortex, could therefore potentially benefit school aged children.

METHODS

In this retrospective case series, records of patients presenting for chiropractic care at an onsite school chiropractic clinic were reviewed. Patients underwent 12 weeks of chiropractic care and completed three questionnaires and two sets of neurophysiological scans. The data from these questionnaires and scans were combined, averaged, and statistically analyzed.

RESULTS

One hundred and eighty records of children aged 5-18 years from nine schools were included in the overall analyses. Statistically significant improvements were noted in the 'health and activities' sub-section and overall score of the Pediatric Quality of Life Inventory™ and in the hyperactivity domain of the Strengths and Difficulties questionnaire.

CONCLUSION

This retrospective review of case records from children attending an onsite school chiropractic clinic has demonstrated some changes in health-related quality of life following a period of 12 weeks of chiropractic care. Further research using a clinical trial design is needed to extrapolate the findings and to assess causation.

The mechanisms of manual therapy: A living review of systematic, narrative, and scoping reviews

INTRODUCTION

Treatment mechanisms are the underlying process or pathway through which a treatment influences the body. This includes molecular, cellular and physiological processes or pathways contributing to treatment effect. Manual therapy (MT) evokes complex mechanistic responses across body systems, interacting with the individual patient and context to promote a treatment response. Challenges arise as mechanistic studies are spread across multiple professions, settings and populations. The purpose of this review is to summarize treatment mechanisms that have been reported to occur with MT application.

METHODS

Four electronic databases were searched (Medline, CINAHL, Cochrane Library, and PEDro) for reviews investigating mechanistic responses which occur during/post application of MT. This review was registered a priori with PROSPERO (CRD42023444839). Methodological quality (AMSTAR-2) and risk of bias (ROBIS) were assessed for systematic and scoping reviews. Data were synthesized by mechanistic domain.

RESULTS

Sixty-two reviews were included. Systematic reviews (n = 35), narrative reviews (n = 24), and scoping reviews (n = 4) of asymptomatic (n = 37), symptomatic (n = 43), non-specified human subjects (n = 7) and animals (n = 7) were included. Reviews of moderate quality supported neurovascular, neurological, and neurotransmitter/neuropeptide changes. Reviews of low quality supported neuroimmunce, neuromuscular, and neuroendocrine changes. Reviews of critically low quality support biomechanical changes.

CONCLUSIONS

Findings support critically low to moderate quality evidence of complex multisystem mechanistic responses occurring with the application of MT. Results support peripheral, segmental spinal, and supraspinal mechanisms occurring with the application of MT, which can be measured directly or indirectly. The clinical value of these findings has not been well established. While MT has proven to be an effective intervention to treat conditions such as pain, the current body of literature leaves uncertainty as to 'why' MT interventions work, and future research should look to better define which mechanisms (or combinations of mechanisms) are mediators of clinical response.

Neuromuscular Response to High-Velocity, Low-Amplitude Spinal Manipulation-An Overview

The clinical use of spinal manipulation to treat musculoskeletal conditions has nearly tripled in the United States since 1980, and it is currently recommended by most global clinical guidelines as a conservative treatment for musculoskeletal pain, despite a lack of knowledge concerning its mechanisms of action. This overview highlights evidence of direct neuromuscular responses to high-velocity, low-amplitude spinal manipulation (HVLA-SM) as delivered by chiropractic, osteopathic, and physical therapy clinicians, with an intent to foster greater interprofessional dialogue and collaborative research to better address current gaps in mechanistic knowledge of the neuromuscular response to HVLA-SM. Three databases (PubMed, CINAHL Ultimate (EBSCO), EMBASE (Elsevier)) were searched from 2000 to December 2024 with specific search terms related to thrust HVLA-SM and the neuromuscular response. To focus strictly on neuromuscular responses related to HVLA-SM, this literature overview excluded articles using non-HVLA-SM manual therapy techniques (i.e., massage, non-thrust joint mobilization, and/or combined HVLA-SM with other forms of treatment such as exercise or non-thrust joint mobilization) and studies in which patient-centered outcomes (i.e., pain scores) were the primary outcomes of the HVLA-SM interventions. Pediatric studies, animal studies, and studies in languages other than English were also excluded. One-hundred and thirty six articles were identified and included in this overview. Neuromuscular findings related to HVLA-SM in the areas of electromyography (EMG), muscle thickness, muscle strength, reflexes, electroencephalogram (EEG), and evoked potential were often mixed; however, evidence is beginning to accumulate either in favor of or opposed to particular neuromuscular responses to HVLA-SM as larger and more scientifically rigorous studies are being performed. Recurrent limitations of many HVLA-SM-related studies are small sample sizes, leading to a lack of generalizability, and the non-standardization of HVLA-SM delivery, which has prevented researchers from arriving at definitive conclusions regarding neuromuscular responses to HVLA-SM. Discussions of future neuromuscular research needs related to HVLA-SM are included for clinicians and researchers inside and outside of the field of manual therapy, to advance this field.

Reliability of the Second and Third Iterations of the Sensory-Motor Dysfunction Questionnaire in a Subclinical Neck Pain Population

BACKGROUND/OBJECTIVES

This study aimed to address limitations of the pilot reliability study on the Sensory-Motor Dysfunction Questionnaire (SMD-Q) in two parts. Part 1 evaluated the intra-rater reliability of SMD-Q version 2 (V2). Part 2 addressed V2's limitations before assessing the intra-rater reliability of version 3 (V3). V2 framed questions as "over the past week", whereas V3 also framed questions as "in a typical/usual week".

METHODS

The SMD-Q was administered via QualtricsTM at baseline and 4 to 7 days later to subclinical neck pain participants, 51 in part 1 (32 F; mean age ± SD: 21.17 ± 2.66 y) and 27 in part 2 (20 F; mean age ± SD: 21.89 ± 2.81 y). Reliability statistics (quadratic weighted kappa (Kw) and Cronbach's alpha (α)) were calculated for all items (V2) and total scores (V2 and V3).

RESULTS

There was excellent agreement for V2 total scores (Kw ≥ 0.75), and V3 total scores for "in a typical/usual week" (Kw ≥ 0.75), but fair to good agreement for V3 total scores of "over the past week" (0.40 < Kw < 0.75). V2 had acceptable (0.7 ≤ α < 0.8) to good internal consistency (0.8 ≤ α < 0.9), while V3 had good internal consistency for both administrations.

CONCLUSIONS

Versions 2 and 3 of the SMD-Q appear to reliably capture disordered sensorimotor integration in people with subclinical neck pain, with improved reliability in V3 when questions are framed as "in a typical/usual week". However, further research is needed to confirm this finding.

The ligamentous cervical instability etiology of human disease from the forward head-facedown lifestyle: emphasis on obstruction of fluid flow into and out of the brain

Ligamentous cervical instability, especially ligamentous upper cervical instability, can be the missing structural cause and/or co-morbidity for many chronic disabling brain and systemic body symptoms and diagnoses. Due to the forward head-facedown lifestyle from excessive computer and cell phone usage, the posterior ligament complex of the cervical spine undergoes a slow stretch termed "creep" which can, over time, lead to cervical instability and a breakdown of the cervical curve. As this degenerative process continues, the cervical curve straightens and ultimately becomes kyphotic, a process called cervical dysstructure; simultaneously, the atlas (C1) moves forward, both of which can lead to encroachment of the structures in the carotid sheath, especially the internal jugular veins and vagus nerves. This obstruction of fluid flow can account for many brain diseases, and compression and stretch of the vagus nerve for body diseases, including dysautonomia. This article describes the consequences of impaired fluid flow into and out of the brain, especially venous flow through the internal jugular veins, leading to intracranial hypertension (formerly called pseudotumor cerebri). Cervical structural, internal jugular vein, and optic nerve sheath measurements are presented from a retrospective chart review of 227 consecutive patients with no obvious cause for 1 of 8 specific brain or mental health symptoms-anxiety, brain fog, concentration difficulty, depression/hopelessness, headaches, obsessive thoughts, panic attacks, and rumination on traumatic events. A case example is given to demonstrate how cervical structural treatments can open up internal jugular veins and improve a patient's chronic symptoms.

Neuroplastic Responses to Chiropractic Care: Broad Impacts on Pain, Mood, Sleep, and Quality of Life

OBJECTIVES

This study aimed to elucidate the mechanisms of chiropractic care using resting electroencephalography (EEG), somatosensory evoked potentials (SEPs), clinical health assessments (Fitbit), and Patient-reported Outcomes Measurement Information System (PROMIS-29).

METHODS

Seventy-six people with chronic low back pain (mean age ± SD: 45 ± 11 years, 33 female) were randomised into control (n = 38) and chiropractic (n = 38) groups. EEG and SEPs were collected pre and post the first intervention and post 4 weeks of intervention. PROMIS-29 was measured pre and post 4 weeks. Fitbit data were recorded continuously.

RESULTS

Spectral analysis of resting EEG showed a significant increase in Theta, Alpha and Beta, and a significant decrease in Delta power in the chiropractic group post intervention. Source localisation revealed a significant increase in Alpha activity within the Default Mode Network (DMN) post intervention and post 4 weeks. A significant decrease in N30 SEP peak amplitude post intervention and post 4 weeks was found in the chiropractic group. Source localisation demonstrated significant changes in Alpha and Beta power within the DMN post-intervention and post 4 weeks. Significant improvements in light sleep stage were observed in the chiropractic group along with enhanced overall quality of life post 4 weeks, including significant reductions in anxiety, depression, fatigue, and pain.

CONCLUSIONS

These findings indicate that many health benefits of chiropractic care are due to altered brain activity.

The cervico-ocular reflex changes following treatment in individuals with subclinical neck pain: a randomized control trial

Individuals with subclinical neck pain (SCNP) exhibit altered cerebellar processing, likely due to disordered sensorimotor integration of inaccurate proprioceptive input. This association between proprioceptive feedback and SMI has been captured in cervico-ocular reflex (COR) differences where SCNP showed higher gain than healthy participants. Previous neurophysiological research demonstrated improved cerebellar processing in SCNP participants following a single treatment session, but it is unknown whether these neurophysiological changes transfer to cerebellar function. In a parallel group, randomized control trial conducted at Ontario Tech University, 27 right-hand dominant SCNP participants were allocated to the 8-week chiropractic care (n = 15; 7M & 8 F) or 8-week control (n = 12; 6M & 6 F) group. COR gain (ratio of eye movement to trunk movement) was assessed using an eye-tracking device at baseline and at post 8-weeks (treatment vs. no treatment). COR gain (10 trials): participants gazed at a circular target that disappeared after 3 s, while a motorized chair rotated their trunk at a frequency of 0.04 Hz, with an amplitude of 5º, for 2 minutes. A 2 × 2 repeated measures ANOVA was performed. COR gain was significantly reduced following 8-weeks of chiropractic care compared to the SCNP control (8-weeks of no treatment) group (p = 0.012, ηp2 = 0.237). The decrease in COR gain following treatment is likely due to normalized proprioceptive feedback from the neck, enabling improved processing and integration within the flocculonodular lobe of the cerebellum.

Known-Group Validity and Sensitivity to Change in the Sensory-Motor Dysfunction Questionnaire in Individuals with Neck Pain: A Pilot Study

BACKGROUND/OBJECTIVES

Sensorimotor dysfunction is often reported in individuals experiencing neck pain, irrespective of severity and chronicity. The treatment of neck dysfunction has been found to positively impact sensorimotor integration (SMI), thereby improving sensorimotor function. However, no patient-reported outcome measure has been validated for discrimination between healthy individuals and neck pain patients with disordered SMI, nor has there been documentation of positive change in SMI following neck pain treatment.The purpose of this study was to administer the Sensory-Motor Dysfunction Questionnaire (SMD-Q), for the purposes of: (1) known-group validity between individuals without and with chronic neck pain (CNP) or subclinical neck pain (SCNP); (2) assess the questionnaire's capacity to quantify changes in altered SMI following a tailored treatment plan.

METHODS

Part 1-Known Group Validity: The SMD-Q was administered to 30 neck pain (13 with CNP, and 17 with SCNP), and 30 healthy participants. Part 2-Sensitivity to Change: The SMD-Q was re-administered to neck pain participants following their tailored treatment plans (SCNP-8-weeks and CNP-12 weeks).

RESULTS

The SMD-Q can discriminate between healthy and neck pain participants (p ≤ 0.001), and may be sensitive to showing treatment effects (ηp2 = 0.162; large effect size (ES)), but the sample size was too small to determine if it can discriminate treatment effects between groups (ηp2 = 0.070; medium ES).

CONCLUSIONS

Differing degrees of disordered SMI can be discriminated by the SMD-Q, but further research is needed to determine its sensitivity to treatment.

Impact of subclinical neck pain on eye and hand movements in goal-directed upper limb aiming movements

Individuals with untreated, mild-to-moderate recurrent neck pain or stiffness (subclinical neck pain (SCNP)) have been shown to have impairments in upper limb proprioception, and altered cerebellar processing. It is probable that aiming trajectories will be impacted since individuals with SCNP cannot rely on accurate proprioceptive feedback or feedforward processing (body schema) for movement planning and execution, due to altered afferent input from the neck. SCNP participants may thus rely more on visual feedback, to accommodate for impaired cerebellar processing. This quasi-experimental study sought to determine whether upper limb kinematics and oculomotor processes were impacted in those with SCNP. 25 SCNP and 25 control participants who were right-hand dominant performed bidirectional aiming movements using two different weighted styli (light or heavy) while wearing an eye-tracking device. Those with SCNP had a greater time to and time after peak velocity, which corresponded with a longer upper limb movement and reaction time, seen as greater constant error, less undershoot in the upwards direction and greater undershoot in the downwards direction compared to controls. SCNP participants also showed a trend towards a quicker ocular reaction and movement time compared to controls, while the movement distance was fairly similar between groups. This study indicates that SCNP alters aiming performances, with greater reliance on visual feedback, likely due to altered proprioceptive input leading to altered cerebellar processing.

Development of the Sensory-Motor Dysfunction Questionnaire and Pilot Reliability Testing

Both chronic and recurrent spinal pain alter sensorimotor integration (SMI), which is demonstrated using complex neurophysiological techniques. Currently, there is no patient-reported outcome measure that documents and/or assesses SMI in populations with spinal problems. The purpose of this study was to develop the Sensory-Motor Dysfunction Questionnaire (SMD-Q) and assess its test-retest reliability and internal consistency in individuals with recurrent spinal pain. The SMD-Q was developed based on the existing literature on motor control disturbances associated with disordered SMI. The initial SMD-Q drafts underwent review by two separate panels of subject matter experts and a focus group with subclinical spine pain. Their suggestions were incorporated into the questionnaire prior to reliability testing. The questionnaire was administered twice at a seven-day interval using QualtricsTM. A total of 20 participants (14 females and 6 males; 20.95 ± 2.46 years of age) completed the study. Quadratic weighted kappa (Kw) was used to assess test-retest reliability and Cronbach's alpha (α) was used to assess internal consistency. Four items had a Kw < 0.40, seven had a 0.40 < Kw < 0.75, and one had a Kw > 0.75 (excellent agreement), with excellent internal consistency (α > 0.90). The pilot SMD-Q appears to reliably measure altered SMI, suggesting that revisions and testing with a larger sample are worth pursuing.

Vertebral Subluxation and Systems Biology: An Integrative Review Exploring the Salutogenic Influence of Chiropractic Care on the Neuroendocrine-Immune System

In this paper we synthesize an expansive body of literature examining the multifaceted influence of chiropractic care on processes within and modulators of the neuroendocrine-immune (NEI) system, for the purpose of generating an inductive hypothesis regarding the potential impacts of chiropractic care on integrated physiology. Taking a broad, interdisciplinary, and integrative view of two decades of research-documented outcomes of chiropractic care, inclusive of reports ranging from systematic and meta-analysis and randomized and observational trials to case and cohort studies, this review encapsulates a rigorous analysis of research and suggests the appropriateness of a more integrative perspective on the impact of chiropractic care on systemic physiology. A novel perspective on the salutogenic, health-promoting effects of chiropractic adjustment is presented, focused on the improvement of physical indicators of well-being and adaptability such as blood pressure, heart rate variability, and sleep, potential benefits that may be facilitated through multiple neurologically mediated pathways. Our findings support the biological plausibility of complex benefits from chiropractic intervention that is not limited to simple neuromusculoskeletal outcomes and open new avenues for future research, specifically the exploration and mapping of the precise neural pathways and networks influenced by chiropractic adjustment.

Changes in biochemical markers following a spinal manipulation - a systematic review update

OBJECTIVE

The aim of this systematic review was to update the current level of evidence for spinal manipulation in influencing various biochemical markers in healthy and/or symptomatic population.

METHODS

This is a systematic review update. Various databases were searched (inception till May 2023) and fifteen trials (737 participants) that met the inclusion criteria were included in the review. Two authors independently screened, extracted and assessed the risk of bias in included studies. Outcome measure data were synthesized using standard mean differences and meta-analysis for the primary outcome (biochemical markers). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of the body of evidence for each outcome of interest.

RESULTS

There was low-quality evidence that spinal manipulation influenced various biochemical markers (not pooled). There was low-quality evidence of significant difference that spinal manipulation is better (SMD -0.42, 95% CI - 0.74 to -0.1) than control in eliciting changes in cortisol levels immediately after intervention. Low-quality evidence further indicated (not pooled) that spinal manipulation can influence inflammatory markers such as interleukins levels post-intervention. There was also very low-quality evidence that spinal manipulation does not influence substance-P, neurotensin, oxytocin, orexin-A, testosterone and epinephrine/nor-epinephrine.

CONCLUSION

Spinal manipulation may influence inflammatory and cortisol post-intervention. However, the wider prediction intervals in most outcome measures point to the need for future research to clarify and establish the clinical relevance of these changes.

A randomized controlled trial comparing different sites of high-velocity low amplitude thrust on sensorimotor integration parameters

Increasing evidence suggests that a high-velocity, low-amplitude (HVLA) thrust directed at a dysfunctional vertebral segment in people with subclinical spinal pain alters various neurophysiological measures, including somatosensory evoked potentials (SEPs). We hypothesized that an HVLA thrust applied to a clinician chosen vertebral segment based on clinical indicators of vertebral dysfunction, in short, segment considered as "relevant" would significantly reduce the N30 amplitude compared to an HVLA thrust applied to a predetermined vertebral segment not based on clinical indicators of vertebral dysfunction or segment considered as "non-relevant". In this double-blinded, active-controlled, parallel-design study, 96 adults with recurrent mild neck pain, ache, or stiffness were randomly allocated to receiving a single thrust directed at either a segment considered as "relevant" or a segment considered as "non-relevant" in their upper cervical spine. SEPs of median nerve stimulation were recorded before and immediately after a single HVLA application delivered using an adjusting instrument (Activator). A linear mixed model was used to assess changes in the N30 amplitude. A significant interaction between the site of thrust delivery and session was found (F1,840 = 9.89, p < 0.002). Pairwise comparisons showed a significant immediate decrease in the N30 complex amplitude after the application of HVLA thrust to a segment considered "relevant" (- 16.76 ± 28.32%, p = 0.005). In contrast, no significant change was observed in the group that received HVLA thrust over a segment considered "non-relevant" (p = 0.757). Cervical HVLA thrust applied to the segment considered as "relevant" altered sensorimotor parameters, while cervical HVLA thrust over the segment considered as "non-relevant" did not. This finding supports the hypothesis that spinal site targeting of HVLA interventions is important when measuring neurophysiological responses. Further studies are needed to explore the potential clinical relevance of these findings.

Effect of Chiropractic Intervention on Oculomotor and Attentional Visual Outcomes in Young Adults With Long-Term Mild Traumatic Brain Injury: A Randomized Controlled Trial

OBJECTIVE

This study aimed to establish if chiropractic care can improve oculomotor and cognitive symptoms in individuals with persistent postconcussion syndrome (PPCS).

METHODS

A single-blind, randomized controlled intervention study recorded baseline computerized eye-tracker assessment (CEA) outcomes in 40 young adults with PPCS following mild traumatic brain injury. Participants were randomly allocated to either a chiropractic or age-matched active control intervention, and the change in CEA outcomes following intervention was compared between the chiropractic and control groups. A battery of CEAs including egocentric localization, fixation stability, pursuit, saccades, Stroop, and the vestibulo-ocular reflex, were used to assess oculomotor function, visual attention/processing, and selective attention.

RESULTS

Relative to the control group, participants receiving the chiropractic intervention scored better in the Stroop test (P < .001), had improved gaze stability during both vestibulo-ocular reflex (P < .001) and fixation stability (P = .009), and a lower vertical error in egocentric localization (P < .001). However, performance was poorer in pursuits, where they had an increased tracking error (P < .001).

CONCLUSION

Chiropractic care in participants with PPCS significantly improved static and dynamic gaze stability, and performance in the Stroop test, compared with a control intervention. These results suggest that chiropractic care can offer a novel avenue for alleviating certain visual and cognitive symptoms in patients with PPCS. It also adds to the growing evidence that suggests that some longstanding PPCS visual symptoms may have a spinal or proprioceptive basis.

Effect Sizes for Changes in Health and Well-Being Following Treatment With the One-To-Zero Technique in Individuals With Occipito-Atlantal Joint Dysfunction: A Repeated Measures Study

Objectives

The purpose of this study was to determine effect sizes (ES) for changes in self-reported measures of musculoskeletal pain and dysfunction resulting from the one-to-zero method using a repeated measures study design.

Methods

Twenty participants presenting with articular dysfunction of the occipito-atlantal (C0-C1) complex were treated using the one-to-zero method, a high-velocity low-amplitude thrust administered between the C0-C1 complex before treating other restrictive segments in a cephalocaudal direction. The participants completed online questionnaires using Google Forms that assessed aspects of the biopsychosocial model of pain at baseline and within a week after treatment. The questionnaires included the following: (1) Demographic and Health Behavior Survey; (2) Neck Bournemouth Questionnaire (NBQ) or Neck Disability Index (NDI); (3) Beck Anxiety Index (BAI); (4) Insomnia Severity Index (ISI); and (5) 36-Item Short Form Health Survey (SF-36). Paired t test or Wilcoxon signed ranks test was performed, dependent on normality. Cohen's d values were calculated for each questionnaire score (0.20 indicative of small; ≥0.50 medium; and ≥0.80 large ES).

Results

The NDI, NBQ, BAI, and ISI had a large ES (all d ≥ 0.80). In the SF-36, 4 subscales had a small to near-medium ES, 1 subscale had a medium to near-large ES, and the remaining 2 had a large ES (d ≥ 0.80). The physical and mental component summary had a large (d = 0.88) and small ES (d = 0.35), respectively.

Conclusion

The effect sizes suggest the one-to-zero treatment induces change in various aspects of the biopsychosocial model.

Regional Sensorimotor Effects of Chiropractic Spinal Manipulation: Preliminary Results From an Experimental Study

OBJECTIVE

The purpose of this study was to assess the effects of different spinal manipulation (SM) techniques and target segments on a specific dermatome and myotome, when compared with a remote spinal cord segment that served as a control location.

METHODS

Twenty-nine healthy volunteers were randomized to receive instrumental (Activator IV, Activator Methods International Ltd) or manual SM at the C6, C1, and T4 vertebral segments in 3 independent sessions. Pressure pain thresholds (PPTs) and muscle strength were examined at the C6 (test) and L4 (control) dermatomes and myotomes, at baseline and after intervention. Linear mixed-effects models were used to analyze changes over time and interindividual variability.

RESULTS

Pressure pain thresholds significantly increased at both proximal and distal C6 dermatome locations (P < .05), irrespective of the technique and segment of application (P > .2). No significant changes were observed at the L4 dermatome. Muscle strength remained unchanged throughout the study. Multilevel modeling revealed significant associations between increased PPTs along the C6 dermatome (P < .001), whereas the combination of technique and target segment predicted PPT increases at the proximal C6 dermatome.

CONCLUSION

These findings support regional, rather than segmental mechanisms underlying the sensory effects of SM. Specifically, significant increases in PPTs along the C6 dermatome suggest localized effects on pain sensitivity, which may depend on the target spinal region. Further investigation is needed to better understand these regional changes of SM and their potential clinical implications.

Remission of cervicogenic dysphagia associated with biomechanical dysfunction following chiropractic therapy

Cervicogenic dysphagia is a complex condition that can arise from biomechanical dysfunction in the cervical spine. Conventional treatment outcomes are not always guaranteed. Chiropractic treatment is considered an alternative treatment for dysphagia, yet there is a lack of evidence supporting its effectiveness. We present the case of a 48-year-old male who had difficulty swallowing for eight months. He had a feeling of food stuck in his throat when eating hard food but without any pain when swallowing, and eventually, he could not swallow any dry food. He was diagnosed with dysphagia associated with an anxiety disorder and was treated with medication, but there was no improvement in his condition. A full-spine radiograph revealed biomechanical dysfunction, including reduced cervical lordosis and levoscoliosis of the upper thoracic spine. After nine months of conventional physiotherapy, the patient completely recovered from his symptoms, with significantly improved biomechanical parameters. This study highlights the potential mechanism of cervicogenic dysphagia and the effect of chiropractic treatment in managing it. Applying chiropractic treatment, including spinal manipulative therapy, instrument-assisted soft tissue manipulation, and mechanical traction, might bring a positive outcome for dysphagia patients with careful consideration.

A Cross-Sectional Study on Mediating Effect of Chronic Pain on the Relationship between Cervical Proprioception and Functional Balance in Elderly Individuals with Chronic Neck Pain: Mediation Analysis Study

(1) Background: Cervical proprioception maintains head orientation in space and contributes to maintaining bodily balance. Evaluating cervical proprioception in elderly individuals with chronic neck pain (CNP) and understanding how pain intensity mediates the relationship between proprioception and functional balance helps formulate treatment strategies for this population. The objectives of this study are to (a) compare the cervical proprioception and functional balance between CNP and asymptomatic, (b) investigate the relationship between cervical proprioception and functional balance ability in CNP individuals and (c) mediation effect of chronic pain on the relationship between cervical proprioception and functional balance tests (2) Methods: This cross-sectional comparative study recruited 60 elderly individuals with a diagnosis of CNP (mean age: 66.40 years) and 60 asymptomatic (mean age: 66.42 years). The cervical proprioception is measured using the target head repositing technique. The subjects were asked to close their eyes and reposition their head actively to the target position from the neutral position, and the reposition accuracy is estimated as joint position errors (JPE) in degrees. The cervical proprioception was measured in the directions of flexion, extension, and left and right rotation. The functional balance was assessed using the berg balance test (BBS) score and timed-up-and-go (TUG) test in seconds. (3) Results: The elderly individuals with CNP had increased cervical JPE compared to the asymptomatic group (p < 0.001) in all the directions tested, indicating that cervical proprioception is impaired in CNP patients. Moreover, the CNP individual functional balance is significantly impaired (p < 0.001) compared to asymptomatic. The BBS test scores were lower, and the TUG scores were higher in the CNP group. In CNP individuals, the cervical JPE showed a significant correlation with the BBS test scores (r = -0.672 to -0.732, p < 0.001) and TUG scores (r = 0.328 to -0.414, p < 0.001). (4) Conclusions: Cervical proprioception and functional balance are impaired in elderly individuals with CNP. Physical therapists and rehabilitation professionals may consider these factors during the evaluation and development of treatment strategies in elderly adults with CNP.

Chiropractic Care in a Patient With Hereditary Spastic Paraplegia and Chronic Pain

Hereditary spastic paraplegia (HSP) is a rare neurodegenerative disorder, which is challenging to diagnose and is known to be associated with more than 73 genes. Neurodegenerative disorders are characterized by progressive spasticity and weakness of the lower limbs. Here, we report the case of a 13-year-old girl with a history of HSP who presented to a chiropractic clinic with chronic low back pain and rehabilitation for lower extremity weakness. She had been receiving non-steroidal anti-inflammatory drugs and baclofen for spasticity. Full-spine radiography revealed borderline acetabular dysplasia in the right hip. After nine months of chiropractic therapy, the patient reported reduced lower extremity spasticity and pain as well as improved strength and functionality. As non-invasive therapies have minimal side effects, chiropractic therapy can be used alongside or in combination with other treatments as an additional option for the long-term management of HSP.

Improvement of Chronic Neck Pain After Posterior Atlantoaxial Surgical Fusion via Multimodal Chiropractic Care: A Case Report

There is a lack of research regarding the effectiveness and safety of manual therapies, including spinal manipulative therapy (SMT), for patients with previous cervical spine surgery. A 66-year-old, otherwise healthy, woman who underwent C1/2 posterior surgical fusion for rotatory instability during adolescence presented to a chiropractor with a six-month history of progressive worsening of chronic neck pain and headaches despite acetaminophen, tramadol, and physical therapy. Upon examination, the chiropractor noted postural changes, limited cervical range of motion, and muscle hypertonicity. Computed tomography revealed a successful C1/2 fusion, and degenerative findings at C0/1, C2/3, C3/4, and C5/6, without cord compression. As the patient had no neurologic deficits or myelopathy and tolerated spinal mobilization well, the chiropractor applied cervical SMT, along with soft tissue manipulation, ultrasound therapy, mechanical traction, and thoracic SMT. The patient's pain was reduced to a mild level and the range of motion improved over three weeks of treatment. Benefits were maintained over a three-month follow-up as treatments were spaced apart. Despite the apparent success in the current case, evidence for manual therapies and SMT in patients with cervical spine surgery remains limited, and these therapies should be used with caution on an individual patient basis. Further research is needed to examine the safety of manual therapies and SMT in patients following cervical spine surgery and determine predictors of treatment response.

Case report: Morphological changes evident after manual therapy in two cases of late-diagnosed developmental dysplasia of the hip

BACKGROUND

Late diagnosed Developmental Dysplasia of the Hip (DDH) is the detection of DDH after 3 months of age and is associated with significantly poorer outcomes than when diagnosed and managed early. Late diagnosed DDH has lower rates of success with bracing, higher rates of surgery and higher rates of complications, including avascular necrosis of the femoral head and early osteoarthritis of the hip. We describe two cases of late-diagnosed DDH which demonstrated changes in femoroacetabular joint morphology on radiographic interpretation after a 6-month trial period of manual therapy.

CASE PRESENTATION

Two cases (13 and 30 months of age) with late-diagnosed DDH presented to a private chiropractic clinic for conservative, non-bracing management. One case had unilateral DDH and the other bilateral DDH. A trial of manual therapy was utilized over a 6-month period. Both cases demonstrated changes to femoroacetabular morphology as well as improvements in gross motor activity and lower extremity muscle tone.

CONCLUSION

Manual therapy, as an adjunct or alternative to static bracing, may be of benefit in individuals with late-diagnosed DDH not responding to bracing, and prior to more invasive interventions. Additional cases of manual therapy-based management of this condition are required to inform the design of future trials to investigate this hypothesis.

The Effects of Four Weeks of Chiropractic Spinal Adjustments on Blood Biomarkers in Adults with Chronic Stroke: Secondary Outcomes of a Randomized Controlled Trial

Certain blood biomarkers are associated with neural protection and neural plasticity in healthy people and individuals with prior brain injury. To date, no studies have evaluated the effects chiropractic care on serum brain-derived neurotrophic factor (BDNF), insulin-like growth factor-II (IGF-II) and glial cell-derived neurotrophic factor (GDNF) in people with stroke. This manuscript reports pre-specified, exploratory, secondary outcomes from a previously completed parallel group randomized controlled trial. We evaluated differences between four weeks of chiropractic spinal adjustments combined with the usual physical therapy (chiro + PT) and sham chiropractic with physical therapy (sham + PT) on resting serum BDNF, IGF-II and GDNF in 63 adults with chronic stroke. Blood samples were assessed at baseline, four weeks (post-intervention), and eight weeks (follow-up). Data were analyzed using a linear multivariate mixed effects model. Within both groups there was a significant decrease in the mean log-concentration of BDNF and IGF-II at each follow-up, and significant increase log-concentration of GDNF at eight-weeks' follow-up. However, no significant between-group differences in any of the blood biomarkers at each time-point were found. Further research is required to explore which factors influence changes in serum BDNF, IGF-II and GDNF following chiropractic spinal adjustments and physical therapy.

Effectiveness of the Rehabilitation Training Combined with Maitland Mobilization for the Treatment of Chronic Ankle Instability: A Randomized Controlled Trial

The study aims to determine whether routine rehabilitation training combined with the Maitland mobilization is more effective than routine rehabilitation training alone in patients with chronic ankle instability, intending to provide a novel rehabilitation strategy for chronic ankle instability. A total of 48 subjects were divided into three groups: EG (Maitland mobilization and routine rehabilitation), CG (routine rehabilitation), and SG (sham mobilization and routine rehabilitation). The intervention was performed three times each week for 4 weeks, for a total of 12 sessions. Before and after the intervention, the muscle strength, star excursion balance test (SEBT), weight-bearing dorsiflexion range of motion (WB-DFROM), ankle range of movement, Cumberland ankle instability tool (CAIT), self-comfort visual analog scale (SCS-VAS), and self-induced stability scale (SISS-VAS) were assessed. The results showed that the improvement of SEBT, WB-DFROM, and active ankle range of movement without the pain in EG was more obvious than CG and SG, but the improvement of the self-report of ankle severity and muscle strength was not. Compared with routine rehabilitation training alone, routine rehabilitation training combined with Maitland mobilization for patients with chronic ankle instability may provide more benefit in terms of balance and ankle range of movement than routine rehabilitation alone, but the improvement in muscle strength was not evident enough.

Chiropractic Management of Neck Pain Complicated by Symptomatic Vertebral Artery Stenosis and Dizziness

BACKGROUND Vertebrobasilar insufficiency (VBI) is most often caused by vertebrobasilar atherosclerosis, often presenting with dizziness and occasionally neck pain. Little research or guidelines regarding management of neck pain in affected patients exists. CASE REPORT A 62-year-old male hypertensive smoker presented to a chiropractor with a 13-year history of insidious-onset neck pain, dizziness, and occipital headache with a Dizziness Handicap Inventory (DHI) of 52%. The patient had known VBI, caused by bilateral vertebral artery plaques, and cervical spondylosis, and was treated with multiple cardiovascular medications. The chiropractor referred patient to a neurosurgeon, who cleared him to receive manual therapies provided manual-thrust cervical spinal manipulative therapy (SMT) was not performed. The chiropractor administered thoracic SMT and cervicothoracic soft tissue manipulation. The neck pain and dizziness mostly resolved by 1 month. At 1-year follow-up, DHI was 0%; at 2 years it was 8%. A literature search revealed 4 cases in which a chiropractor used manual therapies for a patient with VBI. Including the present case, all patients had neck pain, 60% had dizziness, and all were treated with SMT either avoiding manual cervical manipulation altogether or modifying it to avoid or limit cervical rotation, yielding positive outcomes. CONCLUSIONS The present and previous cases provide limited evidence that some carefully considered chiropractic manual therapies can afford patients with VBI relief from concurrent neck pain and possibly dizziness. Given the paucity of research, cervical SMT cannot be recommended in such patients. These findings do not apply to vertebral artery dissection, for which SMT is an absolute contraindication.

Conservative Management of Low Back Pain Related to an Unresectable Aggressive Sacral Hemangioma: A Case Report

BACKGROUND Aggressive sacral hemangiomas are extremely rare benign tumors that can extend into the spinal canal, causing neurologic symptoms. Research on these tumors is limited given their rarity, and they have no agreed-upon treatment strategy. We report the first case of an aggressive sacral hemangioma responding well to conservative care, including manual therapies. CASE REPORT A 56-year-old Asian woman presented upon referral to a chiropractic office in Hong Kong with a 6-month exacerbation of chronic low back and lower extremity pain and weakness, requiring the use of a cane to walk. She had a known history of an aggressive sacral hemangioma with neural compromise and had been deemed ineligible for surgery and tumor ablation due to the large hemangioma size and risk of complications. Examination and imaging findings were consistent with compensatory myofascial pain, postural changes, sacral plexopathy, and lower cauda equina involvement. After coordinating with the neurosurgical team, the chiropractor carefully treated the patient with manual therapies, including thoracic spinal manipulation and instrument-assisted soft tissue manipulation, and mobility and strengthening exercises. She responded well, with symptom reduction lasting through 1-year follow-up, and no longer required the use of a cane. CONCLUSIONS This case illustrates the success of conservative chiropractic care for a patient with an aggressive sacral hemangioma not amenable to other treatments. As further research is needed on this topic, providers considering using manual therapies on patients with an aggressive sacral hemangioma should do so with caution and in collaboration with the patient's medical or surgical team.

Chiropractic Management of Symptomatic Pedicle Hemangioma: a Case Report

Spinal hemangiomas are the most commonly encountered primary vertebral tumors, which are benign and asymptomatic. They usually occur in the vertebral body and rarely extend into or originate from the posterior column. Thus, hemangiomas of the pedicle are extremely rare. Only one case of pedicle hemangioma has been documented in the literature. Disc herniations and annular tears are not always symptomatic, and they have always been observed in asymptomatic patients. Therefore, even with a thorough medical history and physical examination, patients with comorbid hemangioma and annular tears present a formidable challenge to the most experienced clinicians. This report describes a rare case of pedicle hemangioma and disc herniation without spinal cord compression in a 47-year-old woman complaining of lower back pain and inability to walk.

Paralympic Powerlifting as a Sustainable Way to Improve Strength in Athletes with Spinal Cord Injury and Other Disabilities

Background: in Paralympic Powerlifting (PP), athletes with a spinal cord injury (SCI) and other disabilities (OD) compete together. However, athletes with SCI are at a disadvantage in terms of force production and transfer. Objective: to analyze the strength and the dynamic and static indicators, at different intensities, tied and untied in athletes with SCI and OD. Methods: the sample presented 10 OD (28.30 ± 4.92 years) and 10 SCI (30.00 ± 4.27 years), classified competitors, and eligible to compete in the sport (all males). Maximum isometric force (MIF); time to MIF (Time); rate of force development (RFD); impulse, variability, and fatigue index (FI); and the dynamic tests of Mean Propulsive Velocity (MPV), Velocity Maximum (Vmax), and Power with loads of 40, 60, and 80% of 1 Repetition Maximum (1 RM), respectively. Results: there were no differences between OD and SCI in dynamic and isometric strength indicators. In MPV, there was an 80% difference between tethered and untethered SCI (p = 0.041). In VMax, there were differences in SCI between tethered and untethered, 40% (p = 0.004) and 80% (p = 0.023), respectively. There were no differences in the other intensities. Conclusion: PP training seems to be a sustainable way to promote strength gains in SCI, since there were no differences between athletes with SCI and OD, as practitioners of Paralympic Powerlifting.

Chiropractic Spinal Adjustment Increases the Cortical Drive to the Lower Limb Muscle in Chronic Stroke Patients

This study aimed to investigate the effects of a single session of chiropractic spinal adjustment on the cortical drive to the lower limb in chronic stroke patients. In a single-blinded, randomized controlled parallel design study, 29 individuals with chronic stroke and motor weakness in a lower limb were randomly divided to receive either chiropractic spinal adjustment or a passive movement control intervention. Before and immediately after the intervention, transcranial magnetic stimulation (TMS)-induced motor evoked potentials (MEPs) were recorded from the tibialis anterior (TA) muscle of the lower limb with the greatest degree of motor weakness. Differences in the averaged peak-peak MEP amplitude following interventions were calculated using a linear regression model. Chiropractic spinal adjustment elicited significantly larger MEP amplitude (pre = 0.24 ± 0.17 mV, post = 0.39 ± 0.23 mV, absolute difference = +0.15 mV, relative difference = +92%, p &lt; 0.001) compared to the control intervention (pre = 0.15 ± 0.09 mV, post = 0.16 ± 0.09 mV). The results indicate that chiropractic spinal adjustment increases the corticomotor excitability of ankle dorsiflexor muscles in people with chronic stroke. Further research is required to investigate whether chiropractic spinal adjustment increases dorsiflexor muscle strength and walking function in people with stroke.

Detection of Tibiofemoral Joint Injury in High-Impact Motion Based on Neural Network Reconstruction Algorithm

In order to reduce the damage degree of joint bones, ligaments, and soft tissues caused by the high impact on the tibiofemoral joint during landing, a method for detecting the damage of tibiofemoral joint under high-impact action based on neural network reconstruction algorithm is proposed. Two dimensional X-ray images of knee joints from straightening to bending in 10 healthy volunteers were selected. CT scans were performed on the knee joint on the same side, and the 3D model from the acquired images was reconstructed. The kinematics data of the femur relative to the tibia with full degree of freedom were measured by registering the 3D model with 2D images. The results showed that in the extended position, the femur was rotated inward (5.5° ± 6.3°) relative to the tibia. The range of femoral external rotation is (18.7° ± 5.9°) from flexion to 90° in straight position. However, from 90° to 120°, a small amount of internal rotation occurred (1.4° ± 1.9°), so during the whole flexion process, the femur rotated (17.3° ± 6.9°), among which, from the straight position to 15°, the femur rotated (10.0° ± 5.6°). Damage in different areas is determined by the size of the interlayer displacement sample size method of sample space reduction. It is proved that the detection method of tibiofemoral joint injury in high-impact motion based on neural network reconstruction algorithm has high accuracy and consistency.

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain

Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.

Does My Neck Make Me Clumsy? A Systematic Review of Clinical and Neurophysiological Studies in Humans

Introduction: Clumsiness has been described as a symptom associated with neck pain and injury. However, the actuality of this symptom in clinical practice is unclear. The aim of this investigation was to collect definitions and frequency of reports of clumsiness in clinical studies of neck pain/injury, identify objective measures of clumsiness and investigate the association between the neck and objective measures of clumsiness.

Methods: Six electronic databases were systematically searched, records identified and assessed including a risk of bias. Heterogeneity in designs of studies prevented pooling of data, so qualitative analysis was undertaken.

Results: Eighteen studies were retrieved and assessed; the overall quality of evidence was moderate to high. Eight were prospective cross-sectional studies comparing upper limb sensorimotor task performance and ten were case series involving a healthy cohort only. Clumsiness was defined as a deficit in coordination or impairment of upper limb kinesthesia. All but one of 18 studies found a deterioration in performing upper limb kinesthetic tasks including a healthy cohort where participants were exposed to a natural neck intervention that required the neck to function toward extreme limits.

Conclusion: Alterations in neck sensory input occurring as a result of requiring the neck to operate near the end of its functional range in healthy people and in patients with neck pain/injury are associated with reductions in acuity of upper limb kinesthetic sense and deterioration in sensorimotor performance. Understanding the association between the neck and decreased accuracy of upper limb kinesthetic tasks provide pathways for treatment and rehabilitation strategies in managing clumsiness.