Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study

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.

Evidence on the use of alternative substances and therapies in hypertension

OBJECTIVE

Review of some of the best-known biological and non-biological complementary/alternative therapies/medicines (CAM) and their relationship with blood pressure (BP) and hypertension (HT).

SEARCH STRATEGY

Narrative review assessing a recent series of systematic reviews, meta-analyses, and clinical trials published in recent years, focusing on the effects of CAM on BP and HT.

SELECTION OF STUDIES

We searched EMBASE, MEDLINE, Cochrane Library and Google Scholar, obtaining a total of 4336 articles, finally limiting the search to 181 after applying filters.

SYNTHESIS OF RESULTS

Some studies on biological therapies show some usefulness in BP reduction with an adequate benefit-risk balance, although there is a scarcity of high-quality trials that support these results. Some mind-body therapies have shown hypothetical benefit; in contrast, others lack robust evidence.

CONCLUSIONS

Although some therapies present a reasonable risk-benefit ratio, they should in no case replace pharmacological treatment when indicated.

Atlas orthogonal chiropractic management of trigeminal neuralgia: A series of case reports

CONTEXT

Trigeminal neuralgia is a debilitating facial pain condition. Upper cervical chiropractic care has been mentioned as a possible solution OBJECTIVE: To determine the effects of Atlas Orthogonal upper cervical chiropractic technique adjustments on trigeminal neuralgia sufferers DESIGN: Case series SETTING: A private chiropractic practice PARTICIPANTS: Five persons with chronic, severe, daily trigeminal neuralgia pain, radiological findings of significant head tilt, pain upon upper cervical palpation, and supine leg length inequality INTERVENTIONS: Up to two consultations and/or Atlas Orthogonal adjustments a week for eight weeks OUTCOME MEASURES: Self-reported reduction in trigeminal neuralgia pain and changes in radiological findings, sensitivity to upper cervical palpation, and leg length inequality RESULTS: Four participants reported reduced trigeminal neuralgia pain, including two with complete cessation of pain. Three participants reduced medication dosages. One reported no change.

Autonomic nervous system and endocrine system response to upper and lower cervical spine mobilization in healthy male adults: a randomized crossover trial

BACKGROUND

Cervical spine mobilizations may differentially modulate both components of the stress response, consisting of the autonomic nervous system and hypothalamic pituitary adrenal-axis, depending on whether the target location is the upper or lower cervical spine. To date, no study has investigated this.

METHODS

A randomized, crossover trial investigated the effects of upper versus lower cervical mobilization on both components of the stress response simultaneously. The primary outcome was salivary cortisol (sCOR) concentration. The secondary outcome was heart rate variability measured with a smartphone application. Twenty healthy males, aged 21-35, were included. Participants were randomly assigned to block-AB (upper then lower cervical mobilization, n = 10) or block-BA (lower than upper cervical mobilization, n = 10), separated by a one-week washout period. All interventions were performed in the same room (University clinic) under controlled conditions. Statistical analyses were performed with a Friedman's Two-Way ANOVA and Wilcoxon Signed Rank Test.

RESULTS

Within groups, sCOR concentration reduced thirty-minutes following lower cervical mobilization (p = 0.049). Between groups, sCOR concentration was different at thirty-minutes following the intervention (p = 0.018).

CONCLUSION

There was a statistically significant reduction in sCOR concentration following lower cervical spine mobilization, and between-group difference, 30 min following the intervention. This indicates that mobilizations applied to separate target locations within the cervical spine can differentially modulate the stress response.

Conservative Treatment Using Chiropractic Care and Orofacial Myofunctional Therapy for Obstructive Sleep Apnea: A Case Report

Objective

The purpose of this case study was to describe the use of chiropractic care in the treatment of obstructive sleep apnea (OSA).

Clinical Features

A 42-year-old man with obesity presented for chiropractic care. He had OSA and was seeking a way to reduce snoring. The patient had a previous diagnosis of OSA and had been using a continuous positive airway pressure machine for over 5 years. The patient was a mouth breather, exhibiting poor oral and spinal posture.

Intervention and Outcome

The patient was treated for 90 days, which included chiropractic manipulation, orofacial myofunctional therapy exercises, nutritional modification, postural/ergonomic correction, and regular exercise. After a course of care, there was a drop in his apnea-hypopnea index from 55.4 events per hour to 3.4 events per hour. The patient lost 40 pounds, with an 8% reduction in body fat and an 8-point drop in his body mass index.

Conclusion

This patient's sleep apnea and other health outcomes improved under a course of a combination of chiropractic adjustments, orofacial myofunctional therapy, nutritional modification, postural/ergonomic correction, and exercise.

Immediate effects of the high-velocity low-amplitude thrust on the heart rate autonomic modulation of judo athletes

INTRODUCTION

There is controversy about the repercussions of high speed-low amplitude thrust (HVLAT) manipulation in the thoracic region on the autonomic nervous system.

OBJECTIVE

To evaluate the immediate effects of the HVLAT in the high thoracic region on the heart rate autonomic modulation of judo athletes.

METHODS

In the experimental study, thirty-eight healthy men divided into 2 groups (Judo athletes and non-athletes) having heart rate variability (HRV) collected beat-to-beat using a cardio-pacemater during all stages of the manipulation: i) rest, ii) time 1 (participant positioning), iii) time 2 (positioning of the participant together with the therapist), iv) HVLAT manipulation, v) post 5min, vi) post 10min and vii) post 15min HVLAT. Systolic blood pressure (SBP), diastolic blood pressure (DBP), breath frequency (BF), and HRV were also analyzed.

RESULTS

A higher sympathetic modulation was observed with an increase in the standard deviation of successive normal R-R intervals (SDNN) and SD2 indices representing the total variability, however, there was no significant statistical difference in the root mean square of the mean squared differences (RMSSD), percentual of interval differences of successive NN intervals greater than 50 ms (pNN50), and SD1 variables, which represent the parasympathetic nervous system.

CONCLUSION

HVLAT manipulation was able to decrease HRV during manipulation, reflecting sympathetic hyperactivity. However, the return of the HRV indices to the baseline conditions in the first minutes of recovery in Judo athletes and non-athletes reflected the safety of the application of the manipulation in these conditions studied.

Radiophobia Overreaction: College of Chiropractors of British Columbia Revoke Full X-Ray Rights Based on Flawed Study and Radiation Fear-Mongering

Fears over radiation have created irrational pressures to dissuade radiography use within chiropractic. Recently, the regulatory body for chiropractors practicing in British Columbia, Canada, the College of Chiropractors of British Columbia (CCBC), contracted Pierre Côté to review the clinical use of X-rays within the chiropractic profession. A "rapid review" was performed and published quickly and included only 9 papers, the most recent dating from 2005; they concluded, "Given the inherent risks of radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine." The CCBC then launched an immediate review of the use of X-rays by chiropractors in their jurisdiction. Member and public opinion were gathered but not presented to their members. On February 4, 2021, the College announced amendments to their Professional Conduct Handbook that revoked X-ray rights for routine/repeat assessment and management of patients with spine disorders. Here, we highlight current and historical evidence that substantiates that X-rays are not a public health threat. We also point out critical and insurmountable flaws in the single paper used to support irrational and unscientific policy that discriminates against chiropractors who practice certain forms of evidence-based X-ray-guided methods.

The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature

Background

A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial.

Objectives

We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders.

Global summit

The Global Summit took place on September 14–15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence.

Systematic review of the literature

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus.

Results

We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report.

Conclusion

Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00362-9.

Chiropractic care for hypertension: Review of the literature and study of biological and genetic bases

Background and aim:

Hypertension is a multifactorial condition that is among the leading causes of mortality worldwide. Regulation of blood pressure greatly depends upon the activity of the autonomic nervous system. Alterations in the autonomic nervous system can lead to hypertension. In addition to nervous system control and individual physiologic state, various genes can directly influence autonomic responses. The complexity of blood pressure control is reflected in the 20-30% of individuals resistant to traditional pharmacological treatment, this indicates the need for alternative interventions. This article provides an integrative review and discussion of the key neurophysiologic and genetic factors that contribute to blood pressure regulation, the autonomic nervous system (ANS) and manual therapy literature, and the manual therapy and blood pressure literature.

Methods:

To assess the effects of chiropractic on the management of hypertension we searched articles published from 1980 to 2019 in PubMed, the Index to Chiropractic Literature and CINAHL, using the keywords: chiropractic, spinal manipulation, hypertension, and blood pressure.

Results:

We found 38 original studies that analyzed the effect of chiropractic therapy on hypertension. Of these studies, 10 were case reports and the statistical significance of the effects of chiropractic on blood pressure was not evaluated on these articles, so we focused on the remaining 28 articles.

Conclusions:

The results of the review relative to chiropractic care were promising, but often contradictory, suggesting more research should be done. In consideration of the complexity of ANS blood pressure control, an evaluation of patient presenting physiologic and genetic characteristics is recommended and could provide valuable insight relative to the likelihood of patient blood pressure related responsiveness to care (www.actabiomedica.it)

A systematic review and meta-analysis on effect of spinal mobilization and manipulation on cardiovascular responses

Background: Spinal pain or misalignment is a very common disorder affecting a significant number of populations resulting in substantial disability and economic burden. Various manual therapeutic techniques such as spinal manipulations and mobilizations can be used to treat and manage pain and movement dysfunctions such as spinal mal-alignments and associated complications. These manual therapeutic techniques can affect the cardiovascular parameters.

Objective: The objective of this systematic review and meta-analysis is to assess the effect of spinal manipulation and mobilization on cardiovascular parameters.

Methods: We conducted a systematic review and meta-analysis to assess the effects of spinal mobilization and manipulation on cardiovascular responses. Mean changes in Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP) and Heart Rate (HR) were primary outcome measures. RevMan 5.3 software was used for the meta-analyses. Quality of the included studies was assessed by PEDro Rating scale. Risk of bias was assessed by Cochrane collaboration tool of risk of bias.

Results: Results of meta-analysis showed that there was statistically significant decrease in SBP ([Formula: see text], 95% [Formula: see text], 0.08; [Formula: see text]) with moderate heterogeneity ([Formula: see text], [Formula: see text]) in experimental group as compared to control group. There was statistically non-significant decrease in DBP ([Formula: see text], 95% [Formula: see text], 0.69; [Formula: see text]) with high heterogeneity ([Formula: see text], [Formula: see text]), Change HR was statistically non-significant ([Formula: see text], 95% [Formula: see text], 3.11; [Formula: see text]) with moderate heterogeneity ([Formula: see text], [Formula: see text]). Exclusion of short duration studies in sensitivity analysis revealed a statistically significant change in DBP ([Formula: see text], 95% [Formula: see text], [Formula: see text]; [Formula: see text]). However, the result was statistically non-significant for HR after sensitivity analysis.

Conclusion: Spinal manipulations and mobilizations may result in significant decrease of systolic as well as diastolic Blood Pressure.

Nondrug therapies for hypertensive patients complicated with cervical spondylosis: A systematic review and meta-analysis

PURPOSE

The aim of this study was to systematically evaluate the efficacy and safety of nondrug therapies for hypertensive patients complicated with cervical spondylosis.

METHODS

Randomized controlled trials (RCTs) concerned with nondrug therapies for hypertensive patients complicated with cervical spondylosis were identified by searching 5 English and Chinese databases. Study selection, data extraction, and risk of bias assessment were conducted independently by 2 authors. RevMan 5.3 software was used for meta-analysis with effect estimate presented as relative risk (RR) and mean difference (MD) with a 95% confidence interval (CI).

RESULTS

A total of 13 studies involving 929 patients were included. The majority of the included trials were assessed to be of high clinical heterogeneity and high risk of bias. The results of meta-analysis showed that there was a significant improvement in the effectiveness rate of cervical vertebra symptoms (RR = 1.67, 95% CI [1.33, 2.10], P < .0001), effectiveness rate of blood pressure lowering (RR = 1.35, 95% CI [1.06, 1.71], P = .02), systolic blood pressure reduction (MD = -11.05, 95% CI [-14.12, -7.98] mmHg, P < .0001), and diastolic blood pressure reduction (MD = -6.96, 95% CI [-8.89, -5.04] mmHg, P < .00001). Nondrug therapies had no significant difference compared with drugs in the effectiveness rate of overall improvement (RR = 1.3, 95% CI [0.93, 1.82], P = .12). There were no serious adverse effects related to nondrug therapies in the included trials.

CONCLUSION

The results show sound advantages of nondrug therapies over conventional medicine or sham procedure in efficacy. However, the evidence remains weak because of the high clinical heterogeneity and high risk of the included trials. Therefore, further thorough investigation, large-scale, proper-designed, randomized trials of nondrug therapies for hypertension complicated with cervical spondylosis are warranted.

PROSPERO REGISTRATION NUMBER

CRD2019123175.

Effects of the Right Carotid Sinus Compression Technique on Blood Pressure and Heart Rate in Medicated Patients with Hypertension

OBJECTIVES

To identify the immediate and middle-term effects of the right carotid sinus compression technique on blood pressure and heart rate in hypertensive patients.

DESIGN

Randomized blinded experimental study.

SETTINGS

Primary health centers of Cáceres (Spain).

SUBJECTS

Sixty-four medicated patients with hypertension were randomly assigned to an intervention group (n = 33) or to a control group (n = 31).

INTERVENTION

In the intervention group a compression of the right carotid sinus was applied for 20 sec. In the control group, a placebo technique of placing hands on the radial styloid processes was performed.

OUTCOME MEASURES

Blood pressure and heart rate were measured in both groups before the intervention (preintervention), immediately after the intervention, 5 min after the intervention, and 60 min after the intervention.

RESULTS

The intervention group significantly decreased systolic and diastolic blood pressure and heart rate immediately after the intervention, with a large clinical effect; systolic blood pressure remained reduced 5 min after the intervention, and heart rate remained reduced 60 min after the intervention. No significant changes were observed in the control group.

CONCLUSIONS

Right carotid sinus compression could be clinically useful for regulating acute hypertension.

The Kaleidoscope Model of Integrative Healthcare as a collaborative paradigm for cardiology and chiropractic: a call to action

This review article proposes a model of integrative care for cardiovascular patients in institutional settings. We review relevant historic and contemporary examples of medical-chiropractic cooperation and a brief review of the literature illustrating the clinical benefits of chiropractic care for patients with cardiovascular disease. The groundwork proposes a distinct research and clinical practice model incorporating the doctor of chiropractic (D.C.) as a synergistic partner with the medical cardiologist coined the Kaleidoscope Model of Integrative Care (KM). While a traditional kaleidoscope does not alter the nature of light itself, the observer does see the 'raw data' of colors and shapes, wavelengths, etc. contained within the "potential" of the light itself; left unrecognized, even subtle re-orientations of the instrument changes the perspective. Similarly, the KM is intended as a conduit for slight reorientations to traditional medical-chiropractic-patient hierarchies, thus creating new treatment options and generating robust changes in inter-professional perception of the patient's condition(s) and treatment options. It is hoped that this model will not only serve future patients within hospitals, but that institutions will serve as incubators for better collaboration and research among the majority of free-standing medical and chiropractic practices ultimately benefitting the patient with cardiovascular disease.

Essential literature for the chiropractic profession: Results and implementation challenges from a survey of international chiropractic faculty

OBJECTIVE

Scientific literature applicable to chiropractic practice proliferates in quantity, quality, and source. Chiropractic is a worldwide profession and varies in scope between states or provinces and from country to country. It is logical to consider that the focus and emphasis of chiropractic education varies between programs as well. This original research study endeavored to determine "essential literature" recommended by chiropractic faculty. The purpose of this article is (1) to share our results and (2) to promote discussion and explore means for future collaboration of chiropractic faculty through a worldwide platform.

METHODS

A 2-phase recruitment occurred initially at the institutional level and subsequently at the faculty level. A Web-based survey used qualitative data collection methods to gather bibliographic citations. Descriptive statistics were calculated for demographics, and citation responses were ranked per number of recommendations, grouped into categories, and tabulated per journal source and publication date.

RESULTS

Forty-one chiropractic programs were contacted, resulting in 30 participating chiropractic programs (16 US and 14 international). Forty-five faculty members completed the entire survey, submitting 126 peer-reviewed publications and 25 additional citations. Readings emphasized clinical management of spine pain, the science of spinal manipulation, effectiveness of manual therapies, teaching of chiropractic techniques, outcomes assessments, and professional issues.

CONCLUSION

A systematic approach to surveying educators in international chiropractic institutions was accomplished. The results of the survey provide a list of essential literature for the chiropractic profession. We recommend establishing a chiropractic faculty registry for improved communication and collaboration.

Atlantoaxial Misalignment Causes High Blood Pressure in Rats: A Novel Hypertension Model

Atlantoaxial disorders are often correlated with hypertension in practice. In order to study the relationship between atlantoaxial disorder and hypertension, we attempted to construct an animal model. In this work, we presented an animal model where their atlantoaxial joints were misaligned. We investigated the changes of blood pressure before and after treatments of the modeled rats. We had the following results. (1) SBP and DBP of each surgery group were significantly higher than those of control and sham groups. (2) After the second operation (the fixture was removed), SBP and DBP of both surgery groups decreased and got closer to the control and sham groups after 7 days. (3) Heart rates got significantly higher in both surgery groups, compared to control and sham groups. (4) The blood Ach levels of the surgery groups were significantly lower than those of control and sham groups. With these results, we concluded that we successfully constructed cervical atlantoaxial disorder models in rats that showed hypertension symptom. However, the underlying mechanism connecting atlantoaxial disorder and hypertension still requires further study.

Glucose Metabolic Changes in the Brain and Muscles of Patients with Nonspecific Neck Pain Treated by Spinal Manipulation Therapy: A [18F]FDG PET Study

Objective. The aim of this study was to investigate changes in brain and muscle glucose metabolism that are not yet known, using positron emission tomography with [¹⁸F]fluorodeoxyglucose ([¹⁸F]FDG PET). Methods. Twenty-one male volunteers were recruited for the present study. [¹⁸F]FDG PET scanning was performed twice on each subject: once after the spinal manipulation therapy (SMT) intervention (treatment condition) and once after resting (control condition). We performed the SMT intervention using an adjustment device. Glucose metabolism of the brain and skeletal muscles was measured and compared between the two conditions. In addition, we measured salivary amylase level as an index of autonomic nervous system (ANS) activity, as well as muscle tension and subjective pain intensity in each subject. Results. Changes in brain activity after SMT included activation of the dorsal anterior cingulate cortex, cerebellar vermis, and somatosensory association cortex and deactivation of the prefrontal cortex and temporal sites. Glucose uptake in skeletal muscles showed a trend toward decreased metabolism after SMT, although the difference was not significant. Other measurements indicated relaxation of cervical muscle tension, decrease in salivary amylase level (suppression of sympathetic nerve activity), and pain relief after SMT. Conclusion. Brain processing after SMT may lead to physiological relaxation via a decrease in sympathetic nerve activity.

Analysis and Adjustment of Vertebral Subluxation as a Separate and Distinct Identity for the Chiropractic Profession: A Commentary

OBJECTIVE

The purpose of this paper is to discuss various statements related to chiropractic identity from¹ D. D. Palmer²; selected chiropractic organizations, associations, and colleges; and³ attitudes and perceptions of chiropractic from chiropractic students, practitioners, and patients.

DISCUSSION

For comparison purposes, identity statements and perceptions from the various chiropractic associations and colleges, as well as from students and patients, were explored. Identity statements for chiropractic were searched in various sources such as Palmer's 1910 textbook, recent literature on viewpoints from chiropractic students and practitioners, and websites for chiropractic colleges and organizations. Palmer taught that the chiropractor's focus was on vertebral subluxation. Today, a number of chiropractic colleges and organizations continue to include the vertebral subluxation model in their instruction, with a majority of students and practitioners subscribing to the model. Conversely, a number of other colleges and organizations portray chiropractic as being essentially about the treatment of back and neck pain, which is what patients associate with chiropractic. However, settling on any particular identity for the chiropractic profession will likely be met with resistance by some, given the plethora of opinions among chiropractic professionals as to what the identity of the chiropractic profession should be. Common ground between the different factions within the chiropractic profession might be found in a unifying expression such as "functional neurology."

CONCLUSION

When a profession's identity is not clear with respect to its area of interest and mission, then the public may be less inclined to seek its services. Identifying the chiropractic profession with a focus on vertebral subluxation would give the profession uniqueness not duplicated by other health care professions and, therefore, might legitimatize the existence of chiropractic as a health care profession. An identity having a focus on vertebral subluxation would also be consistent with the original intent of the founding of the chiropractic profession.

Effect of Atlas Vertebrae Realignment in Subjects with Migraine: An Observational Pilot Study

Introduction. In a migraine case study, headache symptoms significantly decreased with an accompanying increase in intracranial compliance index following atlas vertebrae realignment. This observational pilot study followed eleven neurologist diagnosed migraine subjects to determine if the case findings were repeatable at baseline, week four, and week eight, following a National Upper Cervical Chiropractic Association intervention. Secondary outcomes consisted of migraine-specific quality of life measures. Methods. After examination by a neurologist, volunteers signed consent forms and completed baseline migraine-specific outcomes. Presence of atlas misalignment allowed study inclusion, permitting baseline MRI data collection. Chiropractic care continued for eight weeks. Postintervention reimaging occurred at week four and week eight concomitant with migraine-specific outcomes measurement. Results. Five of eleven subjects exhibited an increase in the primary outcome, intracranial compliance; however, mean overall change showed no statistical significance. End of study mean changes in migraine-specific outcome assessments, the secondary outcome, revealed clinically significant improvement in symptoms with a decrease in headache days. Discussion. The lack of robust increase in compliance may be understood by the logarithmic and dynamic nature of intracranial hemodynamic and hydrodynamic flow, allowing individual components comprising compliance to change while overall it did not. Study results suggest that the atlas realignment intervention may be associated with a reduction in migraine frequency and marked improvement in quality of life yielding significant reduction in headache-related disability as observed in this cohort. Future study with controls is necessary, however, to confirm these findings. Clinicaltrials.gov registration number is NCT01980927.

Immediate effects of upper thoracic spine manipulation on hypertensive individuals

PURPOSE

The aims of this study were to determine if there were any statistically significant immediate effects of upper thoracic spinal manipulative therapy (SMT) on cardiovascular physiology in hypertensive individuals.

INTRODUCTION

Preliminary research suggests that SMT to various regions of the spine may be capable of lowering systolic and diastolic blood pressure in hypertensive individuals. Further studies are warranted to corroborate or refute these findings as well as measure how other attributes of cardiovascular physiology are impacted by SMT.

METHODS

Fifty hypertensive participants (age = 45.5±13.9 years, height = 1.69±0.10 m, body mass = 93.9±21.5 kg: mean±standard deviation (SD)) were equally randomized into a single-blind, controlled trial involving two study groups: supine diversified anterior upper thoracic SMT of T1-4, or a 'no T-spine contact' control. Outcome measures were electrocardiogram, bilateral pulse oximetry, and bilateral blood pressure measurement performed at baseline, post 1-minute intervention, and post 10-minute intervention. An independent samples t-test was used to compare between-group differences at baseline. A repeated measures ANOVA was used to compare within-group changes over time.

RESULTS

Within-group changes in PR interval and QRS duration demonstrated that the atria were transiently less active post-SMT and the ventricles were more active post-SMT, however the changes were clinically minimal.

CONCLUSION

The results of this study, and the limited existing normotensive, thoracic-specific SMT research in this field, suggest that cardiovascular physiology, short-term, is not affected by upper thoracic spine SMT in hypertensive individuals to a clinically relevant level.

Effects of Upper and Lower Cervical Spinal Manipulative Therapy on Blood Pressure and Heart Rate Variability in Volunteers and Patients With Neck Pain: A Randomized Controlled, Cross-Over, Preliminary Study

OBJECTIVE

The aims of this study were to examine autonomic nervous system responses by using heart rate variability analysis (HRV), hemodynamic parameters and numeric pain scale (NPS) when either upper (C1 and C2) or lower (C6 and C7) cervical segments were manipulated in volunteers, and whether such response would be altered in acute mechanical neck pain patients after spinal manipulative therapy (SMT).

METHODS

A randomized controlled, cross-over, preliminary study was conducted on 10 asymptomatic normotensive volunteers and 10 normotensive patients complaining of acute neck pain. HRV, blood pressure (BP) and heart rate (HR), and NPS were recorded after upper cervical and lower cervical segments SMT in volunteer and patient groups.

RESULTS

The standard deviation of average normal to normal R-R intervals (SDNN) increased (83.54 ± 22 vs. 105.41 ± 20; P = .02) after upper cervical SMT. The normalized unit of high frequency (nuHF), which shows parasympathetic activity, was predominant (40.18 ± 9 vs. 46.08 ± 14) after upper cervical SMT (P = .03) with a significant decrease (109 ± 10 vs. 98 ± 5) in systolic BP (P = .002). Low frequency to high frequency (LF/HF) ratio, which shows predominance of sympathetic activity increased (1.05 ± 0.7 vs. 1.51 ± 0.5; P = .02) after lower cervical SMT in the healthy volunteers group. However, there was an increase in SDNN (70.48 ± 18 vs. 90.23 ± 20; P = .02 and 75.19 ± 16 vs 97.52 ± 22; P = .01), a decrease in LF/HF ratio (1.33 ± 0.3 vs. 0.81 ± 0.2; P = .001 and 1.22 ± 0.4 vs. 0.86 ± 0.3; P = .02), which was associated with decreased systolic BP (105 ± 10 vs. 95 ± 9; P = .01 and 102 ± 9 vs. 91 ± 10; P = .02) and NPS scores (3 ± 1 vs. 0; P = .01 and 3 ± 1 vs. 1 ± 1; P = .03) following both upper and lower cervical SMT in the patient's group. The baseline HR was 67 ± 9 vs 64 ± 5 (upper cervical) and 65 ± 7 vs 69 ± 11 (lower cervical) in both the healthy volunteer' and patient' groups.

CONCLUSION

Upper cervical SMT enhances dominance of parasympathetic and lower cervical SMT enhances dominance of sympathetic activity in this young volunteer group. However, dominance of parasympathetic activity was found in patients with neck pain that received both upper and lower cervical SMT.

Blood pressure changes in African American patients receiving chiropractic care in a teaching clinic: a preliminary study

OBJECTIVE

The purpose of this preliminary study was to determine if a course of chiropractic care would change blood pressure measurements in African American patients and to determine if a study was feasible in a chiropractic teaching clinic.

METHODS

Twenty-four African American patients received chiropractic care in a chiropractic teaching clinic over a study period that spanned 23 visits for each patient. Inclusion criteria consisted of patients having a diagnosis of prehypertension (120-139/80-89) or hypertension stage 1 (140-159/90-99). The mean values of 3 baseline blood pressure readings were compared with the mean values of blood pressure readings taken on visits 21, 22, and 23.

RESULTS

For the entire sample, reductions for both systolic and diastolic blood pressures were not statistically significant (P > .07). When 4 patients having body mass index values that were considered as outliers were excluded, a statistically significant decrease in diastolic blood pressure was observed (P = .004). By group, a statistically significant reduction occurred in the hypertension stage 1 group for systolic and diastolic blood pressures.

CONCLUSION

This study showed that research of this nature may be feasible in chiropractic teaching clinics. The preliminary findings of this study showed that, for a subgroup of African American patients receiving chiropractic care, blood pressure decreased for (a) hypertension stage 1 patients and (b) the sample when those with excessive body mass index were excluded.

Immediate effects of anterior upper thoracic spine manipulation on cardiovascular response

OBJECTIVE

The aims of this study were (1) to determine if there were statistically significant immediate effects of anterior upper thoracic chiropractic manipulative therapy on cardiovascular response in normotensive individuals and (2) to quantify responses if any were found.

METHODS

Thirty-six chiropractic college students (age, 26.8 ± 4.6 years; height, 1.71 ± 0.12 m; body mass, 75.6 ± 20.0 kg; mean ± SD) were equally randomized into a single-blind, controlled trial involving 3 study groups: anterior thoracic manipulation of T1-4, Activator-based placebo manipulation, or a "no T-spine contact" control. Outcome measures were electrocardiogram, bilateral pulse oximetry, and bilateral blood pressure measurement performed at baseline, post 1-minute intervention, post 10-minute intervention, and post 24-hour (±1 hour) intervention. Between-group dependent variables were analyzed through 1-wsay analysis of variance at each of the 4 time points. Within-group dependent variables were analyzed through 2 paired-samples t tests comparing baseline to post 10 minutes and again between baseline to post 24 hours (±1 hr).

RESULTS

No statistically significant difference was shown amongst any between-group or within-group cardiovascular dependent variables in this study.

CONCLUSIONS

The results of this study suggest cardiovascular physiologic responses are not affected in the short term by anterior upper thoracic spine chiropractic manipulative therapy in young normotensive individuals.

Knowledge of accurate blood pressure measurement procedures in chiropractic students

Objective : Blood pressure measurement is a basic clinical procedure. However, studies have shown that many errors are made when health care providers acquire blood pressure readings. Our study assessed knowledge of blood pressure measurement procedures in chiropractic students. Methods : This was an observational, descriptive study. A questionnaire based on one created by the American Heart Association was given to 1st, 2nd, 3rd, and final year students (n = 186). A one way ANOVA was used to analyze the data. Results : Of the students 80% were confident that their knowledge of this clinical skill was adequate or better. However, the overall score on the knowledge test of blood pressure-taking skills was 52% (range, 24%-88%). The only significant difference in the mean scores was between the 1st and 2nd year students compared to the 3rd and 4th year students (p < .005). Of the 16 questions given, the following mean scores were: 1st year 10.45, 2nd year 9.75, 3rd year 7.93, and 4th year 8.33. Of the 16 areas tested, 10 were of major concern (test item score <70%), showing the need for frequent retraining of chiropractic students. Conclusion : Consistent with studies in other health care disciplines, our research found the knowledge of blood pressure skills to be deficient in our sample. There is a need for subsequent training in our teaching program.

Association of hypertension mortality rates with geographic concentrations of chiropractors and medical doctors in the u.s., 2008

As concentration (dose) of health care providers increases, health outcomes (responses) are expected to be favorable (e.g., decrease in mortality rates). Accordingly, this data-driven, ecological study compares hypertension mortality rates in the U.S. by state to concentrations of doctors of chiropractic (DC) and medical doctors (MD). DC and MD concentrations (per 10,000 population) were separately compared to 2008 hypertension death rates using Spearman correlation analysis and linear regression (where appropriate). DC concentrations revealed a stronger beneficial association with hypertension death rates (r = -0.430, p = 0.0020) compared to MD concentrations (r = -0.029 with an observed outlier, and r = -0.085 without the outlier; both coefficients not statistically significant). Linear regression revealed that an average national decrease of approximately one hypertension death per 100,000 population (95% CI = -1.4 to -0.4) would be expected with an increase of one DC per 10,000 population within the range in this study (1.0 to 5.2 DCs per 10,000 population). Since this is an observational study, causal inference is not claimed. The study is intended as a first step to research having other designs such as case-control.

Spinal manipulation for the treatment of hypertension: a systematic qualitative literature review

OBJECTIVE

Spinal manipulative therapy (SMT) has been reported to successfully treat hypertension (HTN). The purpose of this study was to perform a qualitative literature review on the efficacy of SMT for treating HTN.

METHODS

The literature was systematically searched in PubMed, Medline, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, and Index of Chiropractic Literature. Included articles were rated for bias using the Cochrane Collaboration's tool for assessing risk of bias. Studies reporting differing methodologies, types of SMT, frequency of treatment, and time of follow-up were considered too dissimilar for meta-analysis.

RESULTS

Of 208 articles identified, 10 were selected as relevant and were assessed. Risk of bias scores revealed 2 studies with low risk, 3 studies with unclear risk, and 5 studies with high risk. The maximum improvement observed in any SMT group, in low risk of bias studies was -9.7 (95% confidence interval [CI], -21.1 to 1.8) systolic improvement and -9.0 (95% CI, -16.8 to -1.2) diastolic; and in unclear risk of bias studies, it was -17.2 (95% CI, -20.7 to -13.7) systolic and -13.0 (95% CI, -15.4 to -10.6) diastolic. Statistically significant decreases in blood pressure were not observed in clinical trials with low bias when SMT was compared with effleurage massage and a 5-minute wait. The studies with more risk of bias showed a greater treatment effect.

CONCLUSION

There is currently a lack of low bias evidence to support the use of SMT as a therapy for the treatment of HTN. Future investigations may clarify if SMT is effective for treating HTN, either by itself or as an adjunctive therapy, and by which physiologic mechanism this occurs.

Interexaminer reliability of supine leg checks for discriminating leg-length inequality

OBJECTIVE

The purpose of this study was to quantify interexaminer reliability of a standardized supine leg check procedure used to screen for leg-length inequality.

METHODS

Two doctors of chiropractic used a standardized supine leg check procedure to examine 50 volunteers for leg-length inequality. The order of examination was randomized. The side and magnitude of leg-length inequality were determined to the nearest 1/8 in. Subjects and examiners were blinded. Interexaminer reliability was assessed with a Bland-Altman plot, tolerance table of absolute differences, a quadratic weighted κ statistic for quantitative scores, and a Gwet's first-order agreement coefficient for dichotomous ratings.

RESULTS

The quadratic weighted κ statistic to quantify the reliability of the rating scale was 0.44 (95% confidence interval, 0.21-0.67), indicating moderate reliability. The 2 examiners agreed exactly 32% of the time, within 1/8 in 58% of the time, within 3/16 in 72% of the time, and within 3/8 in 92% of the time. The Bland-Altman plot revealed possible heterogeneity in reliability that requires additional study. The examiners agreed on the presence of a leg-length inequality of at least 1/8 in in 40 (80%) of 50 subjects (first-order agreement coefficient, 0.76), suggesting good agreement for this diagnostic category.

CONCLUSION

The examiners showed moderate reliability in assessing leg-length inequality at 1/8-in increments and good reliability in determining the presence of a leg-length inequality.

Chiropractic care of a patient with thoracic outlet syndrome and arrhythmia

OBJECTIVE

The purpose of this article is to describe a case report and discuss a possible anatomical explanation of the occurrence of arrhythmias in patients with thoracic outlet syndrome (TOS).

CLINICAL FEATURES

A 60-year-old man experienced arrhythmia when he turned his head to the left and had these symptoms for 7 years. The patient attributed his symptoms to TOS. The arrhythmia was triggered while performing an Adson test during the clinical evaluation.

INTERVENTION AND OUTCOME

The Grostic procedure as a measure of analysis of the biomechanical relationship of C1 to C0 and the lower cervical spine was performed. According to this analysis, the patient had a right laterality malposition of the atlas. High-velocity, low-amplitude manipulations (adjustments) were applied. The patient's symptoms improved after one visit and demonstrated resolution upon evaluation at the third visit. In the year following the initial presentation, he has had minor recurrent short-lived episodes of arrhythmia that abated with the atlas manipulation/adjustment.

CONCLUSION

There is a paucity of published reports describing the management of patients with arrhythmias through manipulative methods. This appears to be the first case that describes the successful amelioration of an arrhythmia associated with TOS using chiropractic adjustment of the atlas vertebra as the sole intervention.

Symptomatic reactions, clinical outcomes and patient satisfaction associated with upper cervical chiropractic care: a prospective, multicenter, cohort study

BACKGROUND

Observational studies have previously shown that adverse events following manipulation to the neck and/or back are relatively common, although these reactions tend to be mild in intensity and self-limiting. However, no prospective study has examined the incidence of adverse reactions following spinal adjustments using upper cervical techniques, and the impact of this care on clinical outcomes.

METHODS

Consecutive new patients from the offices of 83 chiropractors were recruited for this practice-based study. Clinical outcome measures included 1) Neck pain disability index (100-point scale), 2) Oswestry back pain index (100-point scale), 3) 11-point numerical rating scale (NRS) for neck, headache, midback, and low back pain, 4) treatment satisfaction, and 5) Symptomatic Reactions (SR). Data were collected at baseline, and after approximately 2 weeks of care. A patient reaching sub-clinical status for pain and disability was defined as a follow-up score <3 NRS and <10%, respectively. A SR is defined as a new complaint not present at baseline or a worsening of the presenting complaint by >30% based on an 11-point numeric rating scale occurring <24 hours after any upper cervical procedure.

RESULTS

A total of 1,090 patients completed the study having 4,920 (4.5 per patient) office visits requiring 2,653 (2.4 per patient) upper cervical adjustments over 17 days. Three hundred thirty- eight (31.0%) patients had SRs meeting the accepted definition. Intense SR (NRS ≥8) occurred in 56 patients (5.1%). Outcome assessments were significantly improved for neck pain and disability, headache, mid-back pain, as well as lower back pain and disability (p <0.001) following care with a high level (mean = 9.1/10) of patient satisfaction. The 83 chiropractors administered >5 million career upper cervical adjustments without a reported incidence of serious adverse event.

CONCLUSIONS

Upper cervical chiropractic care may have a fairly common occurrence of mild intensity SRs short in duration (<24 hours), and rarely severe in intensity; however, outcome assessments were significantly improved with less than 3 weeks of care with a high level of patient satisfaction. Although our findings need to be confirmed in subsequent randomized studies for definitive risk-benefit assessment, the preliminary data shows that the benefits of upper cervical chiropractic care may outweigh the potential risks.

Systematic review of clinical trials of cervical manipulation: control group procedures and pain outcomes

Objective

To characterize the types of control procedures used in controlled clinical trials of cervical spine manipulation and to evaluate the outcomes obtained by subjects in control groups so as to improve the quality of future clinical trials

Methods

A search of relevant clinical trials was performed in PubMed 1966-May 2010 with the following key words: "Chiropractic"[Mesh] OR "Manipulation, Spinal"[Mesh]) AND "Clinical Trial "[Publication Type]. Reference lists from these trials were searched for any additional trials. The reference lists of two prior studies, one review and one original study were also searched. Accepted reports were then rated for quality by 2 reviewers using the PEDro scale. Studies achieving a score of >50% were included for data extraction and analysis. Intra-group change scores on pain outcomes were obtained. For determining clinically important outcomes, a threshold of 20% improvement was used where continuous data were available; otherwise, an effect size of 0.30 was employed

Results

The PubMed search yielded 753 citations of which 13 were selected. Eight (8) other studies were identified by reviewing two systematic reviews and through reference searches. All studies scored >50% on the PEDro scale. There were 9 multi-session studies and 12 single-session studies. The most commonly used control procedure was "manual contact/no thrust". Four (4) studies used a placebo-control (patient blinded). For two of these studies with VAS data, the average change reported was 4.5 mm. For the other control procedures, variable results were obtained. No clinically important changes were reported in 57% of the paired comparisons, while, in 43% of these, changes which would be considered clinically important were obtained in the control groups. Only 15% of trials reported on post-intervention group registration.

Conclusions

Most control procedures in cervical manipulation trials result in small clinical changes, although larger changes are observed in 47% of paired comparisons. The vast majority of studies do not result in subject blinding; the effect of unmasking of control subjects in these studies makes the interpretation of the existing clinical trials challenging. The greatest majority of trials do not report on post-intervention blinding. A small number of candidate procedures for effective control interventions exist. Much more research is required to improve this important aspect of clinical trial methodology in cervical manipulation studies.

Effectiveness of manual therapies: the UK evidence report

BACKGROUND

The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.

METHODS

The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs.

RESULTS

By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments.

CONCLUSIONS

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.

Prevention and Health Promotion by Chiropractors

Chiropractic care includes a variety of minimally invasive approaches, with both treatment and prevention as essential elements of clinical practice. Although chiropractic adjustment (manipulation) is the signature therapy and best-known identifier of the profession, the practice of chiropractic involves more than manual therapeutics. In general, chiropractors seek to bring a holistic worldview to the doctor—patient encounter, seeking not only to relieve pain and restore neuromusculoskeletal function but also to support the inherent self-healing and self-regulating powers of the body. Aside from applying their diagnostic training to the evaluation of a variety of physical disorders and delivering manual adjustments and related therapeutic interventions, many chiropractors encourage patients to take an active role in restoring and maintaining health, with particular emphasis on doctor-guided self-care through exercise and nutrition. In this review, the authors summarize the peer-reviewed literature on chiropractic and prevention, describe health promotion and wellness approaches currently taught at chiropractic colleges and used in chiropractic clinical settings, discuss duration of care, emphasize the importance of interprofessional cooperation and collaboration, and address the hypothesis that chiropractic adjustments yield preventive effects.