Chiropractic treatment of patients younger than 18 years of age: Frequency, patterns and chiropractors' beliefs

OBJECTIVES

To explore how and when chiropractors are involved in the care of patients younger than 18 years of age, and to examine chiropractors' beliefs about treating paediatric patients.

DESIGN

A cross-sectional survey of a random sample of 140 chiropractors practising in Alberta. Data were collected by means of a mailed questionnaire, which elicited practice information and chiropractors' beliefs, and included closed-and open-ended questions related to six vignettes of paediatric health problems.

RESULTS

Fifty-seven per cent of chiropractors responded to the questionnaire. All chiropractors indicated that they treat patients younger than 18 years of age. Nine per cent of respondents do not treat patients younger than age two years, and 4% do not treat patients from ages six to 11 years. On average, 13% of chiropractors' total patient load over the month preceding the completion of the questionnaires consisted of patients younger than the age of 18 years. With increasing age, patients are more likely to present with musculoskeletal problems (23% of patients younger than age two years, 84% of those aged 14 to 17 years). Chiropractors reported that they provided musculoskeletal treatment regardless of the cause of the problem. A high percentage of chiropractors refer to physicians and reported that they would like to provide concomitant care with physicians.

CONCLUSION

The present study has shown that chiropractors do treat children and that their opinions about this practice vary by specific condition. In addition, substantial percentages of chiropractors indicated that they would like to work with physicians in treating patients with nonmusculoskeletal conditions.

Chiropractic approach to running injuries

The chiropractic approach to the treatment of running injuries involves a thorough understanding of the anatomy, biomechanics, motor patterns, and kinetic chains of the lower limb, including the pelvis. By identifying the underlying dysfunction, the chiropractor can implement a multilevel treatment protocol that involves manipulative therapy, restoration of faulty biomechanics, strengthening of weakened muscle groups, and motor pattern re-education.

Electromyographic responses of back and limb muscles associated with spinal manipulative therapy

STUDY DESIGN

Ten young, asymptomatic male subjects underwent 11 clinically relevant spinal manipulative treatments along the length of the spine to test the magnitude and extent of reflex responses associated with the treatments.

OBJECTIVES

To determine the magnitude and extent of reflex responses elicited by spinal manipulative treatments.

SUMMARY OF BACKGROUND DATA

Spinal manipulative treatments have been associated with a reflexogenic relief of pain and a loss of hypertonicity in muscles within the treatment area. However, there is no study in which results show the probability of occurrence or the extent of reflex responses during spinal manipulative treatments.

METHODS

Asymptomatic subjects received spinal manipulative treatments on the cervical, thoracic, and lumbar levels and on the sacroiliac joint. Reflex activities were measured using 16 pairs of bipolar surface electrodes placed on the back and proximal limb musculature. The percentage of occurrence and the extent of reflex responses in the back and proximal limb musculature were determined.

RESULTS

Each treatment produced consistent reflex responses in a target-specific area. The reflex responses occurred within 50-200 msec after the onset of the treatment thrust and lasted for approximately 100-400 msec. The responses were probably of multireceptor origin and were elicited asynchronously.

CONCLUSIONS

This is the first study in which results show a consistent reflex response associated with spinal manipulative treatments. Because reflex pathways are evoked systematically during spinal manipulative treatment, there is a distinct possibility that these responses may cause some of the clinically observed beneficial effects, such as a reduction in pain and a decrease in hypertonicity of muscles.

Movements of vertebrae during manipulative thrusts to unembalmed human cadavers

OBJECTIVE

The purpose of this study was to measure the relative movements of vertebrae during manipulative thrusts to unembalmed post-rigor mortis human cadavers.

SETTING

The investigation was conducted in the gross anatomy laboratory at the University of Calgary.

SUBJECTS

Two 77-yr-old, unembalmed, post-rigor mortis, male cadavers were used.

INTERVENTIONS

The movements of vertebrae were investigated by using high-speed cinematography to record the movements of bone pins threaded into T10, T11 and T12 during spinal manipulative therapy to unembalmed post-rigor human cadavers. A single clinician delivered a series of posterior-to-anterior (p-to-a) thrusts to the right transverse process of either T10, T11 or T12, using a reinforced hypothenar contact. Relative p-to-a and lateral translations, as well as axial and sagittal rotations, in T10-T11 and T11-T12 were calculated. Corresponding p-to-a forces exerted by the clinician onto the cadaver were recorded using a pressure pad.

MAIN RESULTS

Significant relative movements were measured primarily between the targeted and immediately adjacent vertebrae during the thrusts. Vertebral pairs remained slightly 'hyper-extended' after the rapid thrusts to T11, when the p-to-a forces returned to preload levels.

CONCLUSIONS

These findings may be useful for the understanding of the deformation behavior of the vertebral column during therapeutic manipulation. A fully three-dimensional analysis of all six degrees of freedom, using a larger number of unembalmed cadavers, would be useful in clarifying the relationship between the externally applied forces and the observed relative movement patterns of the vertebrae.

Reflex responses associated with manipulative treatments on the thoracic spine: a pilot study

OBJECTIVE

To test systematically if spinal manipulative treatments (SMT) and the audible release associated with SMT cause activation of spinal muscles.

DESIGN

Experimental pilot study.

SETTING

Human Performance Laboratory, The University of Calgary.

PARTICIPANTS

One male and one female asymptomatic volunteer.

INTERVENTION

Slow and fast SMTs to the left transverse process of thoracic vertebrae using a reinforced hypothenar contact. The treatment forces were directed in a posterior-to-anterior direction with the subjects in a prone position.

MAIN OUTCOME MEASURES

Forces applied by the chiropractor during SMT. Measurements of the audible release using skin-mounted accelerometers. Electromyographical activity of selected spinal muscles.

RESULTS

Electromyographical (EMG) activity was observed consistently 50-100 msec after the onset of each of the fast SMTs, whether the treatment resulted in an audible release or not; for slow SMTs, there was never any visible electromyographical activity of the target muscles, whether the treatment resulted in an audible release or not.

CONCLUSION

The results of this study suggest that fast treatment thrusts elicit muscle activation, whereas slow force application does not. The timing of the onset of the EMG response suggests that activation may be produced by a reflex response originating in the muscle spindles. It also appears that the audible release does not (by itself) evoke muscle activation or a joint proprioceptive reflex response as has been speculated in the literature.

Forces and relative vertebral movements during SMT to unembalmed post-rigor human cadavers: peculiarities associated with joint cavitation

OBJECTIVE

The purpose of this study was to compare the relative movements between adjacent vertebrae that were accompanied by a cavitation sound to those relative movements wherein no cavitation sound was recorded, during spinal manipulative treatments (SMTs) to T12 of an unembalmed human cadaver.

SETTING

The experiment was conducted in the gross anatomy laboratory at the University of Calgary.

SUBJECTS

One 77-yr-old male cadaver was used.

INTERVENTIONS

High speed cinematography and embedded bone pin markers were used to record the movements of T10, T11, and T12, during the manipulations. A pressure pad was used to measure the posterior-to-anterior (p-to-a) forces exerted by the clinician onto the cadaver. Two uniaxial accelerometers were used to record the p-to-a accelerations of T11 and T12. The clinician delivered five p-to-a thrusts to the right transverse process of T12. P-to-a forces, p-to-a accelerations, and relative (between T10 and T11, and, T11 and T12) p-to-a translations, lateral translations, and axial rotations, were calculated for each thrust.

MAIN RESULTS

A cavitation sound was recorded by the T12 accelerometer during the fourth manipulation. The p-to-a force parameters of the fourth trial were not different from those of the other trials. However, the relative lateral translations between the adjacent vertebrae were substantially greater during the fourth manipulation, compared to the other trials.

CONCLUSIONS

The characteristics of the relative lateral translations between adjacent vertebrae suggest that the cavitation sound recorded during the fourth manipulation may have been associated with greater laterally applied forces than those during the other manipulations to T12, wherein no cavitation was recorded.

Cavitation sounds during spinal manipulative treatments

OBJECTIVE

The purpose of this study was to confirm a practitioner's perception of cavitation during spinal manipulative therapy in a clinically relevant situation using accelerometer recordings.

DESIGN

Experimental study.

SETTING

Human Performance Laboratory and Sports Medicine Center, University of Calgary.

PARTICIPANTS

Twenty-eight patients from a single practitioner's patient pool who had pain in the area of the thoracic spine.

INTERVENTION

Spinal manipulative treatment (SMT) on the transverse process of T4 using a reinforced unilateral contact and delivering a thrust in the posterior to anterior direction.

MAIN OUTCOME MEASURES

Instantaneous acceleration signals obtained from the spinous process of T3 during SMT and the practitioner's perception if cavitation had occurred or not at the end of each treatment.

CONCLUSIONS

It appears that cavitation may be measured during SMT using accelerometry and that a practitioner's perception of the occurrence of cavitation during SMT is very accurate.

Forces required to cause cavitation during spinal manipulation of the thoracic spine

The purpose of this study was to measure the forces exerted during spinal manipulative therapy of the thoracic spine simultaneously with corresponding cavitation signals. Forces were measured using a thin, flexible pressure mat which was placed on patients over the contact area between doctor and patient. Cavitation signals were measured using a skin mounted accelerometer on the spinous process of a vertebral body adjacent to the manipulated vertebral body. Mean forces of spinal manipulative therapy at the instant of cavitation were 364 N with a standard deviation of 106 N. These values are considerably larger than corresponding values reported for cavitation at metacarpophalangeal joints. The precise factors causing cavitation of the spinal joints could not be determined. Study designs which may allow identification of these factors are suggested.

Forces exerted during spinal manipulative therapy

Spinal manipulative therapy has been widely recognized in the medical fields as a conservative treatment modality for spinal dysfunction and pain. Spinal manipulative therapy consists of an application of a thrusting force on a specific part of the spine in a well-defined direction. The magnitude of this force has been associated with positive treatment effects, such as realigning vertebral bodies, mobilizing spinal joints, relaxing back musculature through reflex pathways, and producing a respiratory burst. However, direct force measurements during spinal manipulative therapy in a clinically relevant situation have not been performed to date. The purpose of this study was to measure the forces exerted onto patients during spinal manipulative therapy on various locations of the spinal column. Force measurements were obtained using a thin, flexible pressure mat. The results indicate that peak and preload forces are considerably smaller for spinal manipulative therapy performed on the cervical spine compared to corresponding values obtained on the thoracic spine and sacroiliac joint. Furthermore, for treatments on the thoracic spine and sacroiliac joint, a significant relation was found to exist between preload and peak forces.

Changes in walking mechanics associated with wearing an intertrochanteric support belt

This study assesses changes in the mechanics of walking for sacroiliac joint patients when: a) wearing an intertrochanteric support belt, b) wearing an intertrochanteric support belt in a placebo position and c) not wearing a support belt at all. The mechanics of walking were assessed by measuring the ground reaction forces during the support phase of gait using a force-platform. The results obtained did not show clear differences between the walking patterns of three experimental situations; however, some tendencies were observed which led to the speculation that the intertrochanteric support belt may restrict motion in the sacroiliac joint.

Effects of different treatment modalities on gait symmetry and clinical measures for sacroiliac joint patients

The purpose of this study was to assess the effects of two different treatment modalities on the rehabilitation process of chronic sacroiliac joint patients. The treatment modalities included spinal manipulative therapy given by a chiropractor and a program of back school therapy given by a physiotherapist. The rehabilitation process was assessed using clinical and biomechanical measures. It was found that back school therapy was a better treatment modality than the spinal manipulative therapy, according to the clinical measures of rehabilitation. Precisely the opposite result was found for the biomechanical measures.

Experimental measurement of the force exerted during spinal manipulation using the Thompson technique

The purpose for conducting this study was to quantify the forces exerted by a chiropractor on a patient during spinal manipulative therapy. Six patients received three treatments each from two chiropractors for a sacroiliac joint fixation. The Thompson technique was used to treat the patients. The force characteristics of the spinal manipulation were analyzed with respect to the following five points: preloading force, peak force, duration of manipulation, impulse of manipulation and point of application of the peak force. The results obtained indicated that all treatments have certain common characteristics; for example, a preload force is always followed by a large thrusting force. The values for the preload force, peak force, duration and impulse were found to have large standard deviations for a given adjuster and between patients. The location of the point of application of the peak force relative to a low back reference system appeared to be very consistent. However, it was not on the posterior superior iliac spines (PSIS) as expected, but always slightly medial to this point. This is the first study to report force results which were measured directly during spinal manipulative therapy in a clinical situation. In further studies, the results of this investigation will be compared to results obtained from a large population of patients and chiropractic adjusters. Differences in the force characteristics between chiropractors will be compared to clinical and objective measures of the rehabilitation process of the patients in order to find an "optimal" way of performing spinal manipulative therapies.

Reliability of motion palpation procedures to detect sacroiliac joint fixations

The purpose of this study was to assess the inter- and intraexaminer reliability of the Gillet-motion palpation procedure using 10 qualified chiropractors and 11 patients with a sacroiliac joint problem. Intraexaminer reliability was found to be statistically significant for all agreement scores investigated. Interexaminer reliability was found to be statistically significant for some of the agreement scores investigated but not for others. Severity of the low back problems did not seem to influence intra- or interexaminer agreement scores; however, chiropractor expertise did. High expertise was associated with lower intraexaminer agreement scores than low expertise. This finding is in contradiction with traditional beliefs and reported findings. The gait of the patient group was found to be significantly different from that of normal subjects as noted in an earlier report.