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Trager RJ, Baumann AN, Perez JA, Dusek JA, Perfecto RPT, Goertz CM. Association between chiropractic spinal manipulation and cauda equina syndrome in adults with low back pain: Retrospective cohort study of US academic health centers. PLoS One 2024; 19:e0299159. [PMID: 38466710 PMCID: PMC10927125 DOI: 10.1371/journal.pone.0299159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/06/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period. METHODS A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES. RESULTS 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up. CONCLUSIONS These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.
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Affiliation(s)
- Robert J. Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
- Department of Biostatistics and Bioinformatics Clinical Research Training Program, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Anthony N. Baumann
- Department of Rehabilitation, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, United States of America
| | - Jaime A. Perez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
| | - Jeffery A. Dusek
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Romeo-Paolo T. Perfecto
- Department of Biostatistics and Bioinformatics Clinical Research Training Program, Duke University School of Medicine, Durham, North Carolina, United States of America
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
| | - Christine M. Goertz
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Durham, North Carolina, and Washington, District of Columbia, United States of America
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Anderson BR, Whedon JM, Herman PM. Dosing of lumbar spinal manipulative therapy and its association with escalated spine care: A cohort study of insurance claims. PLoS One 2024; 19:e0283252. [PMID: 38181030 PMCID: PMC10769084 DOI: 10.1371/journal.pone.0283252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 02/20/2023] [Indexed: 01/07/2024] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the relationship between three distinct spinal manipulative therapy dose groups and escalated spine care by analyzing insurance claims from a cohort of patients with low back pain. METHODS We compared three distinct spinal manipulative therapy dose groups (low = 1 SMT visits, moderate = 2-12 SMT visits, high = 13+ SMT visits), to a control group (no spinal manipulative therapy) regarding the outcome of escalated spine care. Escalated spine care procedures include imaging studies, injection procedures, emergency department visits, surgery, and opioid medication use. Propensity score matching was performed to address treatment selection bias. Modified Poisson regression modeling was used to estimate the relative risk of spine care escalation among three spinal manipulative therapy doses, adjusting for age, sex, retrospective risk score and claim count. RESULTS 83,025 claims were categorized into 11,114 unique low back pain episodes; 8,137 claims had 0 spinal manipulative therapy visits, with the remaining episodes classified as low dose (n = 404), moderate dose (n = 1,763) or high dose (n = 810). After propensity score matching, 5,348 episodes remained; 2,454 had 0 spinal manipulative therapy visits with the remaining episodes classified as low dose (n = 404), moderate dose (n = 1,761), or high dose (n = 729). The estimated relative risk (vs no spinal manipulative therapy) for any escalated spine care was 0.45 (95% confidence interval 0.38, 0.55, p <0.001), 0.58 (95% confidence interval 0.53, 0.63, p <0.001), and 1.03 (95% confidence interval 0.95, 1.13, p = 0.461) for low, moderate, and high dose spinal manipulative therapy groups, respectively. CONCLUSIONS For claims associated with initial episodes of low back pain, low and moderate dose spinal manipulative therapy groups were associated with a 55% and 42% reduction, respectively, in the relative risk of any escalated spine care.
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Affiliation(s)
- Brian R. Anderson
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa, United States of America
| | - James M. Whedon
- Health Services Research, Southern California University of Health Sciences, Whittier, California, United States of America
| | - Patricia M. Herman
- RAND Center for Collaborative Research in Complementary and Integrative Health, RAND Corporation, Santa Monica, California, United States of America
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Whedon JM, Petersen CL, Schoellkopf WJ, Haldeman S, MacKenzie TA, Lurie JD. The association between cervical artery dissection and spinal manipulation among US adults. Eur Spine J 2023; 32:3497-3504. [PMID: 37422607 PMCID: PMC10591258 DOI: 10.1007/s00586-023-07844-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/23/2023] [Accepted: 06/23/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE Cervical artery dissection (CeAD), which includes both vertebral artery dissection (VAD) and carotid artery dissection (CAD), is the most serious safety concern associated with cervical spinal manipulation (CSM). We evaluated the association between CSM and CeAD among US adults. METHODS Through analysis of health claims data, we employed a case-control study with matched controls, a case-control design in which controls were diagnosed with ischemic stroke, and a case-crossover design in which recent exposures were compared to exposures in the same case that occurred 6-7 months earlier. We evaluated the association between CeAD and the 3-level exposure, CSM versus office visit for medical evaluation and management (E&M) versus neither, with E&M set as the referent group. RESULTS We identified 2337 VAD cases and 2916 CAD cases. Compared to population controls, VAD cases were 0.17 (95% CI 0.09 to 0.32) times as likely to have received CSM in the previous week as compared to E&M. In other words, E&M was about 5 times more likely than CSM in the previous week in cases, relative to controls. CSM was 2.53 (95% CI 1.71 to 3.68) times as likely as E&M in the previous week among individuals with VAD than among individuals experiencing a stroke without CeAD. In the case-crossover study, CSM was 0.38 (95% CI 0.15 to 0.91) times as likely as E&M in the week before a VAD, relative to 6 months earlier. In other words, E&M was approximately 3 times more likely than CSM in the previous week in cases, relative to controls. Results for the 14-day and 30-day timeframes were similar to those at one week. CONCLUSION Among privately insured US adults, the overall risk of CeAD is very low. Prior receipt of CSM was more likely than E&M among VAD patients as compared to stroke patients. However, for CAD patients as compared to stroke patients, as well as for both VAD and CAD patients in comparison with population controls and in case-crossover analysis, prior receipt of E&M was more likely than CSM.
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Affiliation(s)
- James M Whedon
- Health Services Research, Southern California University of Health Sciences, Whittier, CA, USA.
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA.
| | - Curtis L Petersen
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
| | | | - Scott Haldeman
- Health Services Research, Southern California University of Health Sciences, Whittier, CA, USA
- Department of Neurology, University of California at Irvine, Irvine, CA, USA
| | - Todd A MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
| | - Jon D Lurie
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
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Minnucci S, Innocenti T, Salvioli S, Giagio S, Yousif MS, Riganelli F, Carletti C, Feller D, Brindisino F, Faletra A, Chiarotto A, Mourad F. Benefits and Harms of Spinal Manipulative Therapy for Treating Recent and Persistent Nonspecific Neck Pain: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther 2023; 53:510-528. [PMID: 37561605 DOI: 10.2519/jospt.2023.11708] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
OBJECTIVE: We aimed to estimate the benefits and harms of cervical spinal manipulative therapy (SMT) for treating neck pain. DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials (RCTs). LITERATURE SEARCH: We searched the MEDLINE, Cochrane CENTRAL, Embase, CINAHL, PEDro, Chiropractic Literature Index bibliographic databases, and grey literature sources, up to June 6, 2022. STUDY SELECTION CRITERIA: RCTs evaluating SMT compared to guideline-recommended and nonrecommended interventions, sham SMT, and no intervention for adults with neck pain were eligible for our systematic review. Prespecified outcomes included pain, range of motion, disability, health-related quality of life. DATA SYNTHESIS: Random-effects meta-analysis for clinically homogenous RCTs at short-term and long-term outcomes. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 Tool. We used the Grading of Recommendations, Assessment, Development, and Evaluations approach to judge the certainty of evidence. RESULTS: We included 28 RCTs. There was very low to low certainty evidence that SMT was more effective than recommended interventions for improving pain at short term (standardized mean difference [SMD], 0.66; 95% confidence interval [CI]: 0.35, 0.97) and long term (SMD, 0.73; 95% CI: 0.31, 1.16), and for reducing disability at short-term (SMD, 0.95; 95% CI: 0.48, 1.42) and long term (SMD, 0.65; 95% CI: 0.23, 1.06). Transient side effects only were found (eg, muscle soreness). CONCLUSION: There was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain. J Orthop Sports Phys Ther 2023;53(9):510-528. Epub: 10 August 2023. doi:10.2519/jospt.2023.11708.
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Stickler K, Kearns G. Spinal manipulation and adverse event reporting in the pregnant patient limits estimation of relative risk: a narrative review. J Man Manip Ther 2023; 31:162-173. [PMID: 36047253 PMCID: PMC10288923 DOI: 10.1080/10669817.2022.2118653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
OBJECTIVE To describe variability in spinal manipulation technique details and adverse event (AE) documentation of spinal manipulation during pregnancy. METHODS Five databases were searched for peer-reviewed investigations of spinal manipulation during pregnancy. Criteria for inclusion was as follows: high velocity, low amplitude thrust manipulation performed, subjects pregnant during manipulation, and English language. Studies were excluded when participants were not currently pregnant, and when the manipulation performed was not high-velocity, low-amplitude thrust. Data extraction included study design, number of participants, gestational age, spinal region, number of manipulations, manipulation technique details, profession of manipulator, AE reporting (Yes vs. No), type, and number of AE. RESULTS Out of 18 studies included in the review, only three provide details of the spinal manipulation technique. The reported variables include patient position, practitioner position, and direction of thrust. Fourteen studies documented AE; however, only seven provide AE details. DISCUSSION Reporting of spinal manipulation techniques and AE during pregnancy were inconsistent. Replication of methods in future investigations is limited without more detailed documentation of manipulation techniques performed. Furthermore, determining the relative risk and safety of spinal manipulation during pregnancy is not possible without more detailed reporting of AE. Due to these inconsistencies, a checklist is proposed for standardized reporting of spinal manipulation techniques and AE. With more consistent reporting of these parameters, results of future investigations may allow for more definitive and generalizable safety recommendations on spinal manipulation during pregnancy.
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Affiliation(s)
- Kellie Stickler
- Cerner Corporation, Workforce Health Services, Overland Park, Kansas, USA
| | - Gary Kearns
- Texas Tech University Health Sciences Center, DPT Program, Lubbock, Texas, USA
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Gorrell LM, Brown BT, Engel R, Lystad RP. Reporting of adverse events associated with spinal manipulation in randomised clinical trials: an updated systematic review. BMJ Open 2023; 13:e067526. [PMID: 37142321 PMCID: PMC10163511 DOI: 10.1136/bmjopen-2022-067526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 04/12/2023] [Indexed: 05/06/2023] Open
Abstract
OBJECTIVES To describe if there has been a change in the reporting of adverse events associated with spinal manipulation in randomised clinical trials (RCTs) since 2016. DESIGN A systematic literature review. DATA SOURCES Databases were searched from March 2016 to May 2022: MEDLINE (Ovid), Embase, CINAHL, ICL, PEDro and Cochrane Library. The following search terms and their derivatives were adapted for each platform: spinal manipulation; chiropractic; osteopathy; physiotherapy; naprapathy; medical manipulation and clinical trial. METHODS Domains of interest (pertaining to adverse events) included: completeness and location of reporting; nomenclature and description; spinal location and practitioner delivering manipulation; methodological quality of the studies and details of the publishing journal. Frequencies and proportions of studies reporting on each of these domains were calculated. Univariable and multivariable logistic regression models were fitted to examine the effect of potential predictors on the likelihood of studies reporting on adverse events. RESULTS There were 5399 records identified by the electronic searches, of which 154 (2.9%) were included in the analysis. Of these, 94 (61.0%) reported on adverse events with only 23.4% providing an explicit description of what constituted an adverse event. Reporting of adverse events in the abstract has increased (n=29, 30.9%) while reporting in the results section has decreased (n=83, 88.3%) over the past 6 years. Spinal manipulation was delivered to 7518 participants in the included studies. No serious adverse events were reported in any of these studies. CONCLUSIONS While the current level of reporting of adverse events associated with spinal manipulation in RCTs has increased since our 2016 publication on the same topic, the level remains low and inconsistent with established standards. As such, it is imperative for authors, journal editors and administrators of clinical trial registries to ensure there is more balanced reporting of both benefits and harms in RCTs involving spinal manipulation.
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Affiliation(s)
- Lindsay M Gorrell
- Integrative Spinal Research Group, Department of Chiropractic Medicine, University Hospital Balgrist and University of Zurich, Zurich, Switzerland
| | - Benjamin T Brown
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Roger Engel
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Reidar P Lystad
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
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Gevers-Montoro C, Ortega-De Mues A, Piché M. Mechanisms of chiropractic spinal manipulative therapy for patients with chronic primary low back pain: protocol for a mechanistic randomised placebo-controlled trial. BMJ Open 2023; 13:e065999. [PMID: 36764718 PMCID: PMC9923302 DOI: 10.1136/bmjopen-2022-065999] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION Chronic low back pain (CLBP) is a highly prevalent and disabling condition. Identifying subgroups of patients afflicted with CLBP is a current research priority, for which a classification system based on pain mechanisms was proposed. Spinal manipulative therapy (SMT) is recommended for the management of CLBP. Yet, little data are available regarding its mechanisms of action, making it difficult to match this intervention to the patients who may benefit the most. It was suggested that SMT may influence mechanisms associated with central sensitisation. Therefore, classifying patients with CLBP according to central sensitisation mechanisms may help predict their response to SMT. METHODS AND ANALYSIS This protocol describes a randomised placebo-controlled trial aiming to examine which variables linked to central sensitisation may help predict the clinical response to SMT in a cohort of patients with CLBP. One hundred patients with chronic primary low back pain will be randomised to receive 12 sessions of SMT or placebo SMT over a 4-week period. Pain intensity and disability will be assessed as primary outcomes after completing the 4-week treatment (primary endpoint), and at 4-week and 12-week follow-ups. Baseline values of two pain questionnaires, lumbar pressure pain thresholds, concentrations of an inflammatory cytokine and expectations of pain relief will be entered as predictors of the response to SMT in a multiple regression model. Changes in these variables after treatment will be used in a second multiple regression model. The reference values of these predictors will be measured from 50 age and sex-matched healthy controls to allow interpretation of values in patients. Mixed analyses of variance will also be conducted to compare the primary outcomes and the predictors between groups (SMT vs placebo) over time (baseline vs post-treatment). ETHICS AND DISSEMINATION Ethical approval was granted by the Fundación Jiménez Díaz Clinical Research Ethics Committee. TRIAL REGISTRATION NUMBER NCT05162924.
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Affiliation(s)
- Carlos Gevers-Montoro
- Chiropractic, Real Centro Universitario Escorial Maria Cristina, San Lorenzo de El Escorial, Spain
- Department of Anatomy, Université du Québec à Trois-Rivières, Trois-Rivieres, Quebec, Canada
| | - Arantxa Ortega-De Mues
- Chiropractic, Real Centro Universitario Escorial Maria Cristina, San Lorenzo de El Escorial, Spain
| | - Mathieu Piché
- Department of Anatomy, Université du Québec à Trois-Rivières, Trois-Rivieres, Quebec, Canada
- CogNAC (Cognition, Neurosciences, Affect et Comportement) Research Group, Université du Québec à Trois-Rivières, Trois-Rivieres, Quebec, Canada
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Whedon JM, Petersen CL, Li Z, Schoelkopf WJ, Haldeman S, MacKenzie TA, Lurie JD. Association between cervical artery dissection and spinal manipulative therapy -a medicare claims analysis. BMC Geriatr 2022; 22:917. [PMID: 36447166 PMCID: PMC9710172 DOI: 10.1186/s12877-022-03495-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/29/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Cervical artery dissection and subsequent ischemic stroke is the most serious safety concern associated with cervical spinal manipulation. METHODS We evaluated the association between cervical spinal manipulation and cervical artery dissection among older Medicare beneficiaries in the United States. We employed case-control and case-crossover designs in the analysis of claims data for individuals aged 65+, continuously enrolled in Medicare Part A (covering hospitalizations) and Part B (covering outpatient encounters) for at least two consecutive years during 2007-2015. The primary exposure was cervical spinal manipulation; the secondary exposure was a clinical encounter for evaluation and management for neck pain or headache. We created a 3-level categorical variable, (1) any cervical spinal manipulation, 2) evaluation and management but no cervical spinal manipulation and (3) neither cervical spinal manipulation nor evaluation and management. The primary outcomes were occurrence of cervical artery dissection, either (1) vertebral artery dissection or (2) carotid artery dissection. The cases had a new primary diagnosis on at least one inpatient hospital claim or primary/secondary diagnosis for outpatient claims on at least two separate days. Cases were compared to 3 different control groups: (1) matched population controls having at least one claim in the same year as the case; (2) ischemic stroke controls without cervical artery dissection; and (3) case-crossover analysis comparing cases to themselves in the time period 6-7 months prior to their cervical artery dissection. We made each comparison across three different time frames: up to (1) 7 days; (2) 14 days; and (3) 30 days prior to index event. RESULTS The odds of cervical spinal manipulation versus evaluation and management did not significantly differ between vertebral artery dissection cases and any of the control groups at any of the timepoints (ORs 0.84 to 1.88; p > 0.05). Results for carotid artery dissection cases were similar. CONCLUSION Among Medicare beneficiaries aged 65 and older who received cervical spinal manipulation, the risk of cervical artery dissection is no greater than that among control groups.
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Affiliation(s)
- James M Whedon
- Health Services Research, Southern California University of Health Sciences, 16200 Amber Valley Drive, 90604, Whittier, CA, USA.
| | - Curtis L Petersen
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
| | - Zhongze Li
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
| | | | - Scott Haldeman
- Department of Neurology, University of California at Irvine, Irvine, CA, USA
| | - Todd A MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
| | - Jon D Lurie
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
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Funabashi M, Gorrell LM, Pohlman KA, Bergna A, Heneghan NR. Definition and classification for adverse events following spinal and peripheral joint manipulation and mobilization: A scoping review. PLoS One 2022; 17:e0270671. [PMID: 35839253 PMCID: PMC9286262 DOI: 10.1371/journal.pone.0270671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 06/14/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction
Spinal and peripheral joint manipulation and mobilization are interventions used by many healthcare providers to manage musculoskeletal conditions. Although there are many reports of adverse events (or undesirable outcomes) following such interventions, there is no common definition for an adverse event or clarity on any severity classification. This impedes advances of patient safety initiatives and practice. This scoping review mapped the evidence of adverse event definitions and classification systems following spinal and peripheral joint manipulation and mobilization for musculoskeletal conditions in adults.
Methods
An electronic search of the following databases was performed from inception to February 2021: MEDLINE, EMBASE, CINAHL, Scopus, AMED, ICL, PEDro, Cochrane Library, Open Grey and Open Theses and Dissertations. Studies including adults (18 to 65 years old) with a musculoskeletal condition receiving spinal or peripheral joint manipulation or mobilization and providing an adverse event definition and/or classification were included. All study designs of peer-reviewed publications were considered. Data from included studies were charted using a standardized data extraction form and synthesised using narrative analysis.
Results
From 8248 identified studies, 98 were included in the final synthesis. A direct definition for an adverse event and/or classification system was provided in 69 studies, while 29 provided an indirect definition and/or classification system. The most common descriptors to define an adverse event were causality, symptom severity, onset and duration. Twenty-three studies that provided a classification system described only the end anchors (e.g., mild/minor and/or serious) of the classification while 26 described multiple categories (e.g., moderate, severe).
Conclusion
A vast array of terms, definition and classification systems were identified. There is no one common definition or classification for adverse events following spinal and peripheral joint manipulation and mobilization. Findings support the urgent need for consensus on the terms, definition and classification system for adverse events related to these interventions.
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Affiliation(s)
- Martha Funabashi
- Division of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, ON, Canada
- Department of Chiropractic, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- * E-mail:
| | - Lindsay M. Gorrell
- Department of Chiropractic Medicine, Integrative Spinal Research Group, University of Zürich and University Hospital Balgrist, Zürich, Switzerland
| | | | - Andrea Bergna
- Research Department, SOMA Istituto Osteopatia Milano, Milan, Italy
- AISO-Associazione Italiana Scuole di Osteopatia, Pescara, Italy
| | - Nicola R. Heneghan
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
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Freitas JP, Corrêa LA, Bittencourt JV, Armstrong KM, Nogueira LAC. Immediate effects of spinal manipulation on painful sensitivity and postural stability in patients with chronic nonspecific low back pain: study protocol for a controlled randomised clinical trial. Trials 2022; 23:188. [PMID: 35241124 PMCID: PMC8895827 DOI: 10.1186/s13063-022-06111-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low back pain is one of the main public health concerns. Chronic low back pain (cLBP) reduces functional capacity and affects postural stability. Although health professionals widely use spinal manipulation, its immediate effect on painful sensitivity and postural stability is lacking. This study aims to verify the immediate effects of lumbar spinal manipulation on the pressure pain threshold and postural stability in individuals with cLBP. METHODS A two-arm, placebo-controlled clinical trial with parallel groups and examiner-blinded will be conducted with 80 participants with cLBP from an outpatient physical therapy department, randomly allocated at a 1:1 distribution. The experimental group will receive a lumbar spinal manipulation technique, and the placebo group will receive a simulated lumbar spinal manipulation. Both groups will receive one session of treatment and will be evaluated before and immediately after the intervention. The primary outcomes will be the pressure pain threshold and postural stability. Pain intensity and patient's expectation will be assessed as a secondary outcome. The pressure pain threshold will be assessed using a pressure algometer in 6 different anatomical regions. The evaluation of postural stability will be performed in a baropodometry exam by displacing the centre of pressure. The pain intensity will be measured using the Numeric Pain Rating Scale. A Likert scale will be used for the patient's expectation about the treatment. A two-way analysis of variance will compare the effect of the interventions between groups. DISCUSSION This study will provide insights regarding the immediate effects of spinal manipulation in patients with cLBP against a simulated spinal manipulation using objective outcomes and considering patients' expectations regarding the treatment. TRIAL REGISTRATION Brazilian Registry of Clinical Trials RBR-3ksq2c . Registered on 13 July 2020.
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Affiliation(s)
- João Paulo Freitas
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
- Physiotherapy Department, Midwestern Parana State University (UNICENTRO), Paraná, Brazil
- Physiotherapy Department, Guairacá University Centre (UNIGUAIRACA), Paraná, Brazil
| | - Leticia Amaral Corrêa
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
| | - Juliana Valentim Bittencourt
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
| | | | - Leandro Alberto Calazans Nogueira
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
- Physiotherapy Department, Federal Institute of Rio de Janeiro (IFRJ), Rio de Janeiro, Brazil
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Trager RJ, Daniels CJ, Meyer KW, Stout AC, Dusek JA. Clinical decision-making for spinal manipulation for persistent spinal pain following lumbar surgery: a protocol for a systematic review and meta-analysis of individual participant data. BMJ Open 2021; 11:e054070. [PMID: 34949627 PMCID: PMC8712988 DOI: 10.1136/bmjopen-2021-054070] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION There are limited available research and guidance regarding the use of spinal manipulative therapy (SMT) in patients with low back-related symptoms following lumbar spine surgery, a condition called persistent spinal pain syndrome type 2 (PSPS-2). This publication outlines a review protocol to identify and synthesise individual participant data (IPD) to examine associations between patient, clinical and surgical variables and SMT application in adults with PSPS-2. METHODS AND ANALYSIS PubMed, OVID, Web of Science, Scopus, PEDro, Index to Chiropractic Literature and KoreaMed will be searched from inception to 1 January 2022 without language restrictions. Case reports, series, observational studies and cases from grey literature of adults receiving SMT for PSPS-2 will be included. Two investigators will independently screen citations, abstracts and full-text articles. A risk-of-bias assessment will be performed in duplicate to rate cases according to exposure and outcome ascertainment and data completeness. Data extraction will be performed in duplicate and missing IPD will be requested from corresponding authors. Multiple binary logistic regression will be used to identify independent predictors of the use of lumbar-SMT, lumbar-manual-thrust SMT and SMT within 1-year postsurgery. Patient, clinical and surgical variables will be summarised using descriptive statistics, while SMT-related outcomes (lumbar-SMT, lumbar-manual-thrust SMT and 1-year surgery-to-SMT interval) will be described using adjusted ORs with 95% CIs. ETHICS AND DISSEMINATION This study was deemed not human subjects research by the University Hospitals' institutional review board. The results of this review will be disseminated at conferences and/or published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021250039.
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Affiliation(s)
- Robert James Trager
- Connor Whole Health, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | | | - Kevin W Meyer
- Rehabilitation Care Services, VA Puget Sound Health Care System American Lake Campus, Tacoma, Washington, USA
| | - Amber C Stout
- Lakeside Hospital Library, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - Jeffery A Dusek
- Connor Whole Health, University Hospitals of Cleveland, Cleveland, Ohio, USA
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Hadizadeh M, Kawchuk GN, Prasad N, Fritz JM. Predicting who responds to spinal manipulative therapy using a short-time frame methodology: Results from a 238-participant study. PLoS One 2020; 15:e0242831. [PMID: 33232379 PMCID: PMC7685475 DOI: 10.1371/journal.pone.0242831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/09/2020] [Indexed: 11/25/2022] Open
Abstract
Background Spinal manipulative therapy (SMT) is among the nonpharmacologic interventions that has been recommended in clinical guidelines for patients with low back pain, however, some patients appear to benefit substantially more from SMT than others. Several investigations have examined potential factors to modify patients’ responses prior to SMT application. The objective of this study was to determine if the baseline prediction of SMT responders can be improved through the use of a restricted, non-pragmatic methodology, established variables of responder status, and newly developed physical measures observed to change with SMT. Materials and methods We conducted a secondary analysis of a prior study that provided two applications of standardized SMT over a period of 1 week. After initial exploratory analysis, principal component analysis and optimal scaling analysis were used to reduce multicollinearity among predictors. A multiple logistic regression model was built using a forward Wald procedure to explore those baseline variables that could predict response status at 1-week reassessment. Results Two hundred and thirty-eight participants completed the 1-week reassessment (age 40.0± 11.8 years; 59.7% female). Response to treatment was predicted by a model containing the following 8 variables: height, gender, neck or upper back pain, pain frequency in the past 6 months, the STarT Back Tool, patients’ expectations about medication and strengthening exercises, and extension status. Our model had a sensitivity of 72.2% (95% CI, 58.1–83.1), specificity of 84.2% (95% CI, 78.0–89.0), a positive likelihood ratio of 4.6 (CI, 3.2–6.7), a negative likelihood ratio of 0.3 (CI, 0.2–0.5), and area under ROC curve, 0.79. Conclusion It is possible to predict response to treatment before application of SMT in low back pain patients. Our model may benefit both patients and clinicians by reducing the time needed to re-evaluate an initial trial of care.
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Affiliation(s)
- Maliheh Hadizadeh
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Gregory Neil Kawchuk
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
| | - Narasimha Prasad
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Canada
| | - Julie M. Fritz
- College of Health, University of Utah, Salt Lake City, Utah, United States of America
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Funabashi M, Pohlman KA, Goldsworthy R, Lee A, Tibbles A, Mior S, Kawchuk G. Beliefs, perceptions and practices of chiropractors and patients about mitigation strategies for benign adverse events after spinal manipulation therapy. Chiropr Man Therap 2020; 28:46. [PMID: 32895053 PMCID: PMC7487931 DOI: 10.1186/s12998-020-00336-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/05/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Approximately 50% of patients who receive spinal manipulative therapy (SMT) experience some kind of adverse event (AE), typically benign and transient in nature. Regardless of their severity, mitigating benign AEs is important to improve patient experience and quality of care. The aim of this study was to identify beliefs, perceptions and practices of chiropractors and patients regarding benign AEs post-SMT and potential strategies to mitigate them. METHODS Clinicians and patients from two chiropractic teaching clinics were invited to respond to an 11-question survey exploring their beliefs, perceptions and practices regarding benign AEs post-SMT and strategies to mitigate them. Responses were analyzed using descriptive statistics. RESULTS A total of 39 clinicians (67% response rate) and 203 patients (82.9% response rate) completed the survey. Most clinicians (97%) believed benign AEs occur, and 82% reported their own patients have experienced one. For patients, 55% reported experiencing benign AEs post-SMT, with the most common symptoms being pain/soreness, headache and stiffness. While most clinicians (61.5%) reported trying a mitigation strategy with their patients, only 21.2% of patients perceived their clinicians had tried any mitigation strategy. Clinicians perceived that patient education is most likely to mitigate benign AEs, followed by soft tissue therapy and/or icing after SMT. Patients perceived stretching was most likely to mitigate benign AEs, followed by education and/or massage. CONCLUSIONS This is the first study comparing beliefs, perceptions and practices from clinicians and patients regarding benign AEs post-SMT and strategies to mitigate them. This study provides an important step towards identifying the best strategies to improve patient safety and improve quality of care.
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Affiliation(s)
- Martha Funabashi
- Department of Chiropractic, Université du Québec à Trois-Rivières, 3351 boul. Des Forges, Trois-Rivières, QC, G8Z 4M3, Canada.
- Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, ON, M2H 3J1, Canada.
| | | | - Rachel Goldsworthy
- Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, ON, M2H 3J1, Canada
| | - Alex Lee
- Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, ON, M2H 3J1, Canada
| | - Anthony Tibbles
- Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, ON, M2H 3J1, Canada
| | - Silvano Mior
- Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, ON, M2H 3J1, Canada
| | - Greg Kawchuk
- University of Alberta, 8205 114 St, Edmonton, AB, T6G 2G4, Canada
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Corso M, Cancelliere C, Mior S, Taylor-Vaisey A, Côté P. The safety of spinal manipulative therapy in children under 10 years: a rapid review. Chiropr Man Therap 2020; 28:12. [PMID: 32093727 PMCID: PMC7041232 DOI: 10.1186/s12998-020-0299-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 01/20/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The safety of spinal manipulative therapy (SMT) in children is controversial. We were mandated by the College of Chiropractors of British Columbia to review the evidence on this issue. OBJECTIVES We conducted a rapid review of the safety of SMT in children (< 10 years). We aimed to: 1) describe adverse events; 2) report the incidence of adverse events; and 3) determine whether SMT increases the risk of adverse events compared to other interventions. EVIDENCE REVIEW We searched MEDLINE, CINAHL, and Index to Chiropractic Literature from January 1, 1990 to August 1, 2019. We used rapid review methodology recommended by the World Health Organization. Eligible studies (case reports/series, cohort studies and randomized controlled trials) were critically appraised. Studies of high and acceptable methodological quality were included. The lead author extracted data. Data extraction was independently validated by a second reviewer. We conducted a qualitative synthesis of the evidence. FINDINGS Most adverse events are mild (e.g., increased crying, soreness). One case report describes a severe adverse event (rib fracture in a 21-day-old) and another an indirect harm in a 4-month-old. The incidence of mild adverse events ranges from 0.3% (95% CI: 0.06, 1.82) to 22.22% (95% CI: 6.32, 54.74). Whether SMT increases the risk of adverse events in children is unknown. CONCLUSION The risk of moderate and severe adverse events is unknown in children treated with SMT. It is unclear whether SMT increases the risk of adverse events in children < 10 years.
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Affiliation(s)
- Melissa Corso
- Faculty of Health Sciences, Centre for Disability Prevention and Rehabilitation, Ontario Tech University and CMCC, 2000 Simcoe St N, Oshawa, ON, L1G 0C5, Canada
| | - Carol Cancelliere
- Faculty of Health Sciences, Centre for Disability Prevention and Rehabilitation, Ontario Tech University and CMCC, 2000 Simcoe St N, Oshawa, ON, L1G 0C5, Canada
| | - Silvano Mior
- Faculty of Health Sciences, Centre for Disability Prevention and Rehabilitation, Ontario Tech University and CMCC, 2000 Simcoe St N, Oshawa, ON, L1G 0C5, Canada
- Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, ON, M2H 3J1, Canada
| | - Anne Taylor-Vaisey
- Faculty of Health Sciences, Centre for Disability Prevention and Rehabilitation, Ontario Tech University and CMCC, 2000 Simcoe St N, Oshawa, ON, L1G 0C5, Canada
- Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, ON, M2H 3J1, Canada
| | - Pierre Côté
- Faculty of Health Sciences, Centre for Disability Prevention and Rehabilitation, Ontario Tech University and CMCC, 2000 Simcoe St N, Oshawa, ON, L1G 0C5, Canada.
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Sun K, Liang L, Yin H, Yu J, Feng M, Zhan J, Jin Z, Yin X, Wei X, Zhu L. Manipulation for treatment of degenerative lumbar spondylolisthesis: A protocol of systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e18135. [PMID: 31804324 PMCID: PMC6919453 DOI: 10.1097/md.0000000000018135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Degenerative lumbar spondylolisthesis (DLS) is one of the common orthopedic diseases which causes low back pain in patients, which seriously affects people's daily life and work. As a method of conservative treatment of this disease, manipulation is widely used in clinical practice. We will summarize the current published evidence of manipulation in the treatment of DLS, and evaluate the effectiveness and safety of manipulation through systematic review and meta-analysis, so as to provide more reliable evidence for future clinical practice. METHODS We will conduct a comprehensive search of the following 9 databases until January 2019: PubMed, Embase, Cochrane Library, ClinicalTrials.gov, Web of Science, Chinese National Knowledge Infrastructure, Chinese Science and Technique Journals Database, Wan Fang Database, and Chinese Biomedical Database. The 2 researchers will independently search, screen, extract data, and evaluate the quality of the literatures. The primary outcomes include clinical effectiveness, Japanese Orthopaedic Association scores, and the secondary outcomes include visual analog scale scores, symptom scores, and adverse events. Bias risk tools provided by Cochrane Collaboration will be used for literature quality assessment, and RevMan 5.3 software will be used for meta-analysis. RESULTS The results of this study will systematically evaluate the effectiveness and safety of manipulation intervention for people with DLS, especially in improving lumbar function scores and pain scores. CONCLUSION The systematic review of this study will summarize the current published evidence of manipulation for the treatment of DLS, which can further guide the promotion and application of it. ETHICS AND DISSEMINATION This study does not require ethical approval and the results will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42019139933.
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Affiliation(s)
- Kai Sun
- Department of Spine, Wangjing Hospital of China Academy of Chinese Medical Sciences
| | - Long Liang
- Department of Spine, Wangjing Hospital of China Academy of Chinese Medical Sciences
| | - He Yin
- Department of Spine, Wangjing Hospital of China Academy of Chinese Medical Sciences
| | - Jie Yu
- Department of Spine, Wangjing Hospital of China Academy of Chinese Medical Sciences
| | - Minshan Feng
- Department of Spine, Wangjing Hospital of China Academy of Chinese Medical Sciences
- Beijing Key Laboratory of Orthopedics of Traditional Chinese Medicine
| | | | - Zhefeng Jin
- Department of Spine, Wangjing Hospital of China Academy of Chinese Medical Sciences
| | - Xunlu Yin
- Department of Spine, Wangjing Hospital of China Academy of Chinese Medical Sciences
| | - Xu Wei
- Office of Academic Research, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Liguo Zhu
- Department of Spine, Wangjing Hospital of China Academy of Chinese Medical Sciences
- Beijing Key Laboratory of Orthopedics of Traditional Chinese Medicine
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Akdal G, Özçelik P, Kirkim G, Kaya Ö, Men S, Halmágyi GM. Vertebral artery dissection from neck self-manipulation presenting with acute severe bilateral hearing loss. J Neurol 2019; 267:285-287. [PMID: 31741035 DOI: 10.1007/s00415-019-09636-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 11/11/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Gülden Akdal
- Neurology Department, Dokuz Eylül University Hospital, Izmir, Turkey
- Department of Neuroscience, Dokuz Eylül University, Izmir, Turkey
| | - Pınar Özçelik
- Neurology Department, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Günay Kirkim
- Department of Otorhinolaryngology, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Özgecan Kaya
- Neurology Department, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Süleyman Men
- Neuroradiology Department, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Gábor Michael Halmágyi
- Neurology Department, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia.
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Colombi A, Testa M. The Effects Induced by Spinal Manipulative Therapy on the Immune and Endocrine Systems. ACTA ACUST UNITED AC 2019; 55:medicina55080448. [PMID: 31394861 PMCID: PMC6722922 DOI: 10.3390/medicina55080448] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/27/2019] [Accepted: 08/02/2019] [Indexed: 12/18/2022]
Abstract
Background and Objectives: Spinal manipulations are interventions widely used by different healthcare professionals for the management of musculoskeletal (MSK) disorders. While previous theoretical principles focused predominantly on biomechanical accounts, recent models propose that the observed pain modulatory effects of this form of manual therapy may be the result of more complex mechanisms. It has been suggested that other phenomena like neurophysiological responses and the activation of the immune-endocrine system may explain variability in pain inhibition after the administration of spinal manipulative therapy (SMT). The aim of this paper is to provide an overview of the available evidence supporting the biological plausibility of high-velocity, low-amplitude thrust (HVLAT) on the immune-endocrine system. Materials and Methods: Narrative critical review. An electronic search on MEDLINE, ProQUEST, and Google Scholar followed by a hand and "snowballing" search were conducted to find relevant articles. Studies were included if they evaluated the effects of HVLAT on participants' biomarkers Results: The electronic search retrieved 13 relevant articles and two themes of discussion were developed. Nine studies investigated the effects of SMT on cortisol levels and five of them were conducted on symptomatic populations. Four studies examined the effects of SMT on the immune system and all of them were conducted on healthy individuals. Conclusions: Although spinal manipulations seem to trigger the activation of the neuroimmunoendocrine system, the evidence supporting a biological account for the application of HVLAT in clinical practice is mixed and conflicting. Further research on subjects with spinal MSK conditions with larger sample sizes are needed to obtain more insights about the biological effects of spinal manipulative therapy.
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Affiliation(s)
- Andrea Colombi
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Via Magliotto, 2 17100 Savona, Italy
| | - Marco Testa
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Via Magliotto, 2 17100 Savona, Italy.
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Moser N, Mior S, Noseworthy M, Côté P, Wells G, Behr M, Triano J. Effect of cervical manipulation on vertebral artery and cerebral haemodynamics in patients with chronic neck pain: a crossover randomised controlled trial. BMJ Open 2019; 9:e025219. [PMID: 31142519 PMCID: PMC6549698 DOI: 10.1136/bmjopen-2018-025219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE It is hypothesised that cervical manipulation may increase the risk of cerebrovascular accidents. We aimed to determine whether cervical spine manipulation is associated with changes in vertebral artery and cerebrovascular haemodynamics measured with MRI compared with neutral neck position and maximum neck rotation in patients with chronic neck pain. SETTING The Imaging Research Centre at St. Joseph's Hospital in Hamilton, Ontario, Canada. PARTICIPANTS Twenty patients were included. The mean age was 32 years (SD ±12.5), mean neck pain duration was 5.3 years (SD ±5.7) and mean neck disability index score was 13/50 (SD ±6.4). INTERVENTIONS Following baseline measurement of cerebrovascular haemodynamics, we randomised participants to: (1) maximal neck rotation followed by cervical manipulation or (2) cervical manipulation followed by maximal neck rotation. The primary outcome, vertebral arteries and cerebral haemodynamics, was measured after each intervention and was obtained by measuring three-dimensional T1-weighted high-resolution anatomical images, arterial spin labelling and phase-contrast flow encoded MRI. Our secondary outcome was functional connectivity within the default mode network measured with resting state functional MRI. RESULTS Compared with neutral neck position, we found a significant change in contralateral blood flow following maximal neck rotation. There was also a significant change in contralateral vertebral artery blood velocity following maximal neck rotation and cervical manipulation. We found no significant changes within the cerebral haemodynamics following cervical manipulation or maximal neck rotation. However, we observed significant increases in functional connectivity in the posterior cerebrum and cerebellum (resting state MRI) after manipulation and maximum rotation. CONCLUSION Our results are in accordance with previous work, which has shown a decrease in blood flow and velocity in the contralateral vertebral artery with head rotation. This may explain why we also observed a decrease in blood velocity with manipulation because it involves neck rotation. Our work is the first to show that cervical manipulation does not result in brain perfusion changes compared with a neutral neck position or maximal neck rotation. The changes observed were found to not be clinically meaningful and suggests that cervical manipulation may not increase the risk of cerebrovascular events through a haemodynamic mechanism. TRIAL REGISTRATION NUMBER NCT02667821.
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Affiliation(s)
- Nicholas Moser
- Graduate Studies, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Silvano Mior
- Graduate Studies, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada
| | - Michael Noseworthy
- Radiology, McMaster University Faculty of Engineering, Hamilton, Ontario, Canada
| | - Pierre Côté
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada
| | - Greg Wells
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Michael Behr
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - John Triano
- Graduate Studies, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
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Low SYY, Ker JR, Ng LP, Seow WT, Low DCY. Thoracic epidural haematoma after spinal manipulation treatment. Childs Nerv Syst 2019; 35:735-737. [PMID: 30903282 DOI: 10.1007/s00381-019-04122-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 03/08/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore, Singapore.
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore.
- SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore.
| | - Justin R Ker
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore, Singapore
| | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore, Singapore
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore
- SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore
| | - David C Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore, Singapore
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore
- SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, 308433, Singapore, Singapore
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Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ 2019; 364:l689. [PMID: 30867144 PMCID: PMC6396088 DOI: 10.1136/bmj.l689] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, and trial registries up to 4 May 2018, including reference lists of eligible trials and related reviews. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded, as was grey literature. No restrictions were applied to language or setting. REVIEW METHODS Two reviewers independently selected studies, extracted data, and assessed risk of bias and quality of the evidence. The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months. Quality of evidence was assessed using GRADE. A random effects model was used and statistical heterogeneity explored. RESULTS 47 randomised controlled trials including a total of 9211 participants were identified, who were on average middle aged (35-60 years). Most trials compared SMT with recommended therapies. Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief (mean difference -3.17, 95% confidence interval -7.85 to 1.51) and a small, clinically better improvement in function (SMD -0.25, 95% confidence interval -0.41 to -0.09). High quality evidence suggested that compared with non-recommended therapies SMT results in small, not clinically better effects for short term pain relief (mean difference -7.48, -11.50 to -3.47) and small to moderate clinically better improvement in function (SMD -0.41, -0.67 to -0.15). In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy. Evidence for sham SMT was low to very low quality; therefore these effects should be considered uncertain. Statistical heterogeneity could not be explained. About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT. CONCLUSION SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.
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Affiliation(s)
- Sidney M Rubinstein
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
| | - Annemarie de Zoete
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
| | | | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Michiel R de Boer
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
- Department of Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
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Tal A, Taeymans J, Karstens S, Clijsen R, Clarys P, Rogan S. [Acute Effects on TH4 Thoracic Spine Mobilisation Techniques on the Sympathetic Nervous System - a Cross-Over Feasibility Study]. Praxis (Bern 1994) 2018; 107:1139-1146. [PMID: 30326808 DOI: 10.1024/1661-8157/a003089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Acute Effects on TH4 Thoracic Spine Mobilisation Techniques on the Sympathetic Nervous System - a Cross-Over Feasibility Study Abstract. Up to date, empiric evidence about effects of thoracic spine mobilisation (TH4) on the sympathetic nervous system is lacking. The primary goal of this feasibility study was to determine adherence rate, side effects and the protocol as well as the implementation of the study design. The secondary goal was to analyse and interpret acute effects on the sympathetic nervous system after thoracic mobilisation in anterior thrust and posterior thrust on six healthy participants on two following days. The feasibility of this study was adequate. The spine mobilisations did not produce any adverse effects. The anterior thrust spine mobilisations showed a tendency in reducing the heart rate activity.
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Affiliation(s)
- Amir Tal
- 1 Disziplin Physiotherapie, Departement Gesundheit, Berner Fachhochschule, Bern
| | - Jan Taeymans
- 1 Disziplin Physiotherapie, Departement Gesundheit, Berner Fachhochschule, Bern
- 2 Labor für menschliche Biometrie und Biomechanik, Vrije Universiteit Brussel, Brüssel, Belgien
| | - Sven Karstens
- 3 Fachbereich Informatik, Therapiewissenschaften, Hochschule Trier, Deutschland
| | - Ron Clijsen
- 2 Labor für menschliche Biometrie und Biomechanik, Vrije Universiteit Brussel, Brüssel, Belgien
- 4 Rehabilitation Research Laboratory, Department of Business Economics, Health and Social Care, Fachhochschule Südschweiz SUPSI, Landquart
| | - Peter Clarys
- 2 Labor für menschliche Biometrie und Biomechanik, Vrije Universiteit Brussel, Brüssel, Belgien
| | - Slavko Rogan
- 1 Disziplin Physiotherapie, Departement Gesundheit, Berner Fachhochschule, Bern
- 5 Akademie für Physiotherapie und integrative Trainingslehre, Grenzach-Whylen, Deutschland
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Abstract
Background Communicating to patients the risks of manual treatment to the spine is an important, but challenging element of informed consent. This scoping review aimed to characterise and summarise the available literature on risks and to describe implications for clinical practice and research. Method A methodological framework for scoping reviews was followed. Systematic searches were conducted during June 2017. The quantity, nature and sources of literature were described. Findings of included studies were narratively summarised, highlighting key clinical points. Results Two hundred and fifty articles were included. Cases of serious adverse events were reported. Observational studies, randomised studies and systematic reviews were also identified, reporting both benign and serious adverse events.Benign adverse events were reported to occur commonly in adults and children. Predictive factors for risk are unclear, but for neck pain patients might include higher levels of neck disability or cervical manipulation. In neck pain patients benign adverse events may result in poorer short term, but not long term outcomes.Serious adverse event incidence estimates ranged from 1 per 2 million manipulations to 13 per 10,000 patients. Cases are reported in adults and children, including spinal or neurological problems as well as cervical arterial strokes. Case-control studies indicate some association, in the under 45 years age group, between manual interventions and cervical arterial stroke, however it is unclear whether this is causal. Elderly patients have no greater risk of traumatic injury compared with visiting a medical practitioner for neuro-musculoskeletal problems, however some underlying conditions may increase risk. Conclusion Existing literature indicates that benign adverse events following manual treatments to the spine are common, while serious adverse events are rare. The incidence and causal relationships with serious adverse events are challenging to establish, with gaps in the literature and inherent methodological limitations of studies. Clinicians should ensure that patients are informed of risks during the consent process. Since serious adverse events could result from pre-existing pathologies, assessment for signs or symptoms of these is important. Clinicians may also contribute to furthering understanding by utilising patient safety incident reporting and learning systems where adverse events have occurred.
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Affiliation(s)
- Gabrielle Swait
- The Royal College of Chiropractors, Chiltern Chambers, St. Peters Avenue, Reading, RG4 7DH UK
| | - Rob Finch
- The Royal College of Chiropractors, Chiltern Chambers, St. Peters Avenue, Reading, RG4 7DH UK
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Kennell KA, Daghfal MM, Patel SG, DeSanto JR, Waterman GS, Bertino RE. Cervical artery dissection related to chiropractic manipulation: One institution's experience. J Fam Pract 2017; 66:556-562. [PMID: 28863201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE The purpose of this study was to determine the frequency of patients seen at a single institution who were diagnosed with a cervical vessel dissection related to chiropractic neck manipulation. METHODS We identified cases through a retrospective chart review of patients seen between April 2008 and March 2012 who had a diagnosis of cervical artery dissection following a recent chiropractic manipulation. Relevant imaging studies were reviewed by a board-certified neuroradiologist to confirm the findings of a cervical artery dissection and stroke. We conducted telephone interviews to ascertain the presence of residual symptoms in the affected patients. RESULTS Of the 141 patients with cervical artery dissection, 12 had documented chiropractic neck manipulation prior to the onset of the symptoms that led to medical presentation. The 12 patients had a total of 16 cervical artery dissections. All 12 patients developed symptoms of acute stroke. All strokes were confirmed with magnetic resonance imaging or computerized tomography. We obtained follow-up information on 9 patients, 8 of whom had residual symptoms and one of whom died as a result of his injury. CONCLUSION In this case series, 12 patients with newly diagnosed cervical artery dissection(s) had recent chiropractic neck manipulation. Patients who are considering chiropractic cervical manipulation should be informed of the potential risk and be advised to seek immediate medical attention should they develop symptoms.
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Cui XJ, Yao M, Ye XL, Wang P, Zhong WH, Zhang RC, Li HY, Hu ZJ, Tang ZY, Wang WM, Qiao WP, Sun YL, Li J, Gao Y, Shi Q, Wang Y. Shi-style cervical manipulations for cervical radiculopathy: A multicenter randomized-controlled clinical trial. Medicine (Baltimore) 2017; 96:e7276. [PMID: 28767566 PMCID: PMC5626120 DOI: 10.1097/md.0000000000007276] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There is a lack of high-quality evidence supporting the use of manipulation therapy for patients with cervical radiculopathy (CR). This study aimed to evaluate the effectiveness of Shi-style cervical manipulations (SCMs) versus mechanical cervical traction (MCT) for CR. METHODS This was a randomized, open-label, controlled trial carried out at 5 hospitals in patients with CR for at least 2 weeks and neck pain. The patients received 6 treatments of SCM (n = 179) or MCT (n = 180) over 2 weeks. The primary outcome was participant-rated disability (neck disability index), measured 2 weeks after randomization. The secondary outcomes were participant-rated pain (visual analog scale) and health-related quality of life (36-Item Short Form Health Survey [SF-36]). Assessments were performed before, during, and after (2, 4, 12, and 24 weeks) intervention. RESULTS After 2 weeks of treatment, the SCM group showed a greater improvement in participant-rated disability compared with the control group (P = .018). The SCM group reported less disability compared with the control group (P < .001) during the 26-week follow-up. The difference was particularly important at 6 months (mean -28.91 ± 16.43, P < .001). Significant improvements in SF-36 were noted in both groups after 2 weeks of treatment, but there were no differences between the 2 groups. CONCLUSION SCM could be a better option than MCT for the treatment of CR-related pain and disability.
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Affiliation(s)
- Xue-jun Cui
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Min Yao
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Xiu-lan Ye
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Ping Wang
- First Teaching Hospital, Tianjin University of Traditional Chinese Medicine, Tianjin
| | - Wei-hong Zhong
- Rehabilitation Hospital, Fujian University of Traditional Chinese Medicine, Fuzhou
| | - Rui-chun Zhang
- Xinjiang Uygur Autonomous Region Hospital of traditional Chinese Medicine, Urumqi
| | - Hui-ying Li
- First Affiliated Hospital, Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | - Zhi-jun Hu
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Zhan-ying Tang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Wei-min Wang
- First Teaching Hospital, Tianjin University of Traditional Chinese Medicine, Tianjin
| | - Wei-ping Qiao
- First Affiliated Hospital, Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | - Yue-li Sun
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Jun Li
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Yang Gao
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Qi Shi
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Yongjun Wang
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai
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Muheim L. [Not Available]. Praxis (Bern 1994) 2017; 106:895-896. [PMID: 28795625 DOI: 10.1024/1661-8157/a002763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Leander Muheim
- 1 Institut für Hausarztmedizin, Horten-Zentrum für praxisorientierte Forschung und Wissenstransfer, Universitätsspital Zürich
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Rhon D, Greenlee T, Fritz J. Utilization of Manipulative Treatment for Spine and Shoulder Conditions Between Different Medical Providers in a Large Military Hospital. Arch Phys Med Rehabil 2017; 99:72-81. [PMID: 28712922 DOI: 10.1016/j.apmr.2017.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 06/05/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the use of manipulative treatment for shoulder and spine conditions among various provider types. DESIGN Retrospective observational cohort. SETTING Single military hospital. PARTICIPANTS Consecutive sample of patients (N=7566) seeking care for an initial spine or shoulder condition from January 1 to December 31, 2009. INTERVENTIONS Manipulative treatment (eg, manual therapy, spinal and joint manipulation). MAIN OUTCOME MEASURE Manipulation treatment was identified with procedure billing codes in the medical records. Spine and shoulder conditions were identified by using the International Classification of Diseases, 9th Revision codes. All data were abstracted from the Department of Defense Military Health System Management and Analysis Tool. RESULTS Of 7566 total patients seeking care, 2014 (26.6%) received manipulative treatment at least once, and 1883 of those received this treatment in a military facility (24.7%). Manipulative treatment was used most often for thoracic conditions and least often for shoulder conditions (50.8% and 24.2% of all patients). There was a total of 6706 unique medical visits with a manipulative treatment procedure (average of 3.3 manipulative treatment procedure visits per patient). CONCLUSIONS Manipulative treatment utilization rates for shoulder and spine conditions ranged from 26.6% to 50.2%. Chiropractors used manipulation the most and physical therapists the least.
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Affiliation(s)
- Daniel Rhon
- Department of Physical Medicine & Rehabilitation, Madigan Army Medical Center, Joint Base Lewis McChord, Tacoma, WA.
| | - Tina Greenlee
- Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, TX
| | - Julie Fritz
- College of Health, University of Utah, Salt Lake City, UT
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Engel RM, Wearing J, Gonski P, Vemulpad S. The effect of combining manual therapy with exercise for mild chronic obstructive pulmonary disease: study protocol for a randomised controlled trial. Trials 2017; 18:282. [PMID: 28623944 PMCID: PMC5474053 DOI: 10.1186/s13063-017-2027-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 05/30/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a major cause of disability and hospital admission. Current management strategies have not been successful in altering the loss of lung function typically seen as the disease progresses. A recent systematic review into the use of spinal manipulative therapy (SMT) in the management of COPD concluded that there was low level evidence to support the view that a combination of SMT and exercise had the potential to improve lung function more than exercise alone in people with moderate to severe COPD. The aim of this study is to investigate whether the combination of exercise and manual therapy (MT) that includes SMT produces sustainable improvements in lung function and exercise capacity in people with mild COPD. METHODS/DESIGN The study is a randomised controlled trial of 202 people with stable mild COPD. The cohort will be divided into two equal groups matched at baseline. The first group will receive a standardised exercise program. The second group will receive MT that includes SMT plus the same standardised exercise program. Exercise will be administered a total of 36 times over an 18-week period, while MT will be administered in conjunction with exercise a total of 15 times over a 6-week period. The primary outcome measure is lung function (forced expiratory volume in the 1st second: FEV1 and forced vital capacity: FVC). The secondary outcome measures are the 6-minute walking test (6MWT), quality of life questionnaire (St George's Respiratory Questionnaire: SGRQ), anxiety and depression levels (Hospital Anxiety and Depression Scale: HADS), frequency of exacerbations, chest wall expansion measurements (tape measurements) and systemic inflammatory biomarker levels. Outcome measurements will be taken by blinded assessors on seven occasions over a 48-week period. Adverse event data will also be gathered at the beginning of each intervention session. DISCUSSION This randomised controlled trial is designed to investigate whether the combination of MT and exercise delivers any additional benefits to people with mild COPD compared to exercise alone. The study is designed in response to recommendations from a recent systematic review calling for more research into the effect of MT in the management of COPD. TRIAL REGISTRATION ANZCTRN, 12614000766617 . Registered on 18 July 2014.
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Affiliation(s)
- Roger M. Engel
- Department of Chiropractic, Macquarie University, North Ryde, Sydney, NSW 2109 Australia
| | - Jaxson Wearing
- Department of Chiropractic, Macquarie University, North Ryde, Sydney, NSW 2109 Australia
| | - Peter Gonski
- Southcare, Sutherland Hospital, Sydney, Australia
| | - Subramanyam Vemulpad
- Department of Chiropractic, Macquarie University, North Ryde, Sydney, NSW 2109 Australia
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Chaibi A, Benth JŠ, Tuchin PJ, Russell MB. Adverse events in a chiropractic spinal manipulative therapy single-blinded, placebo, randomized controlled trial for migraineurs. Musculoskelet Sci Pract 2017; 29:66-71. [PMID: 28324697 DOI: 10.1016/j.msksp.2017.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/27/2017] [Accepted: 03/11/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Unlike pharmacological randomized controlled trials (RCTs), manual-therapy RCTs do not always report adverse events (AEs). The few manual-therapy RCTs that provide information on AEs are frequently without details, such as the type and-, severity of the AE and reason for withdrawal. OBJECTIVE To prospectively report all AEs in a chiropractic spinal manipulative therapy (CSMT) RCT. DESIGN A prospective 3-armed, single-blinded, placebo, RCT. METHODS Seventy migraineurs were randomized to the CSMT or a placebo, with 12 intervention sessions over three months. The recommendations by CONSORT and the International Headache Society's Task Force on AEs in migraine RCTs were followed. A standardized reporting scheme designed for pharmacological RCTs was used, and the AEs were described as frequencies and percentages within each group. The 95% confidence intervals (CIs) for the percentages (absolute risk) of AEs in each group were calculated when possible. Attributable risk (%) and relative risk were calculated with the corresponding 95% CIs. RESULTS AEs were assessed in 703 sessions, with 355 in the CSMT group and 348 in the placebo group. Local tenderness was the most common AE, reported by 11.3% and 6.9% of the CSMT group and the placebo group, respectively, and tiredness on the intervention day was reported by 8.5% and 1.4% of CSMT group and the placebo group, respectively. The highest attributable risk was for tiredness on the treatment day, 7.0% (CI 3.9-10.2%) which presented a relative risk of 5.9 (CI 2.3-15.0). CONCLUSIONS AEs were mild and transient, and severe or serious AEs were not observed.
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Affiliation(s)
- Aleksander Chaibi
- Head and Neck Research Group, Research Centre, Akershus University Hospital, 1478, Lørenskog, Oslo, Norway; Institute of Clinical Medicine, Campus Akershus University Hospital, University of Oslo, 1474, Nordbyhagen, Oslo, Norway.
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Akershus University Hospital, University of Oslo, 1474, Nordbyhagen, Oslo, Norway; HØKH, Research Centre, Akershus University Hospital, 1478, Lørenskog, Oslo, Norway.
| | - Peter J Tuchin
- Department of Chiropractic, Macquarie University, NSW, 2109, Australia.
| | - Michael Bjørn Russell
- Head and Neck Research Group, Research Centre, Akershus University Hospital, 1478, Lørenskog, Oslo, Norway; Institute of Clinical Medicine, Campus Akershus University Hospital, University of Oslo, 1474, Nordbyhagen, Oslo, Norway.
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29
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Paige NM, Miake-Lye IM, Booth MS, Beroes JM, Mardian AS, Dougherty P, Branson R, Tang B, Morton SC, Shekelle PG. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA 2017; 317:1451-1460. [PMID: 28399251 PMCID: PMC5470352 DOI: 10.1001/jama.2017.3086] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT. OBJECTIVE To systematically review studies of the effectiveness and harms of SMT for acute (≤6 weeks) low back pain. DATA SOURCES Search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature from January 1, 2011, through February 6, 2017, as well as identified systematic reviews and RCTs, for RCTs of adults with low back pain treated in ambulatory settings with SMT compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. Observational studies were included to assess harms. DATA EXTRACTION AND SYNTHESIS Data extraction was done in duplicate. Study quality was assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool. This tool has 11 items in the following domains: randomization, concealment, baseline differences, blinding (patient), blinding (care provider [care provider is a specific quality metric used by the CBN Risk of Bias tool]), blinding (outcome), co-interventions, compliance, dropouts, timing, and intention to treat. Prior research has shown the CBN Risk of Bias tool identifies studies at an increased risk of bias using a threshold of 5 or 6 as a summary score. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. MAIN OUTCOMES AND MEASURES Pain (measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale), function (measured by the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index [range, 0-100]), or any harms measured within 6 weeks. FINDINGS Of 26 eligible RCTs identified, 15 RCTs (1711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, -9.95 [95% CI, -15.6 to -4.3]). Twelve RCTs (1381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, -0.39 [95% CI, -0.71 to -0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT. CONCLUSIONS AND RELEVANCE Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.
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Affiliation(s)
- Neil M. Paige
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, California
| | - Isomi M. Miake-Lye
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, California
- University of California, Los Angeles Fielding School of Public Health, Los Angeles
| | - Marika Suttorp Booth
- RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica
| | - Jessica M. Beroes
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, California
| | - Aram S. Mardian
- Phoenix Veterans Affairs Healthcare System, Phoenix, Arizona
| | - Paul Dougherty
- Canandaigua Veterans Affairs Medical Center, Rochester, New York
| | - Richard Branson
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Baron Tang
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont
| | | | - Paul G. Shekelle
- West Los Angeles Veterans Affairs Medical Center, Los Angeles, California
- RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica
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Cassidy JD, Boyle E, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S. Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study. J Stroke Cerebrovasc Dis 2016; 26:842-850. [PMID: 27884458 DOI: 10.1016/j.jstrokecerebrovasdis.2016.10.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 09/07/2016] [Accepted: 10/23/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Chiropractic manipulation is a popular treatment for neck pain and headache, but may increase the risk of cervical artery dissection and stroke. Patients with carotid artery dissection can present with neck pain and/or headache before experiencing a stroke. These are common symptoms seen by both chiropractors and primary care physicians (PCPs). We aimed to assess the risk of carotid artery stroke after chiropractic care by comparing association between chiropractic and PCP visits and subsequent stroke. METHODS A population-based, case-crossover study was undertaken in Ontario, Canada. All incident cases of carotid artery stroke admitted to hospitals over a 9-year period were identified. Cases served as their own controls. Exposures to chiropractic and PCP services were determined from health billing records. RESULTS We compared 15,523 cases to 62,092 control periods using exposure windows of 1, 3, 7, and 14 days prior to the stroke. Positive associations were found for both chiropractic and PCP visits and subsequent stroke in patients less than 45 years of age. These associations tended to increase when analyses were limited to visits for neck pain and headache-related diagnoses. There was no significant difference between chiropractic and PCP risk estimates. We found no association between chiropractic visits and stroke in those 45 years of age or older. CONCLUSIONS We found no excess risk of carotid artery stroke after chiropractic care. Associations between chiropractic and PCP visits and stroke were similar and likely due to patients with early dissection-related symptoms seeking care prior to developing their strokes.
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Affiliation(s)
- J David Cassidy
- Department of Sports Science and Clinical Biomechanics, Faculty of Health, University of Southern Denmark, Odense, Denmark; Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Eleanor Boyle
- Department of Sports Science and Clinical Biomechanics, Faculty of Health, University of Southern Denmark, Odense, Denmark; Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Pierre Côté
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Faculty of Health Sciences, University of Ontario Institute of Technology and UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Oshawa, Ontario, Canada
| | - Sheilah Hogg-Johnson
- Institute for Work and Health, Toronto, Ontario, Canada; Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Susan J Bondy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Scott Haldeman
- Department of Neurology, University of California, Irvine, California
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Abstract
Please e-mail letters for publication to Dr Kamran Abbasi [ kamran.abbasi@rsm.ac.uk ]. Letters should be no longer than 300 words and preference will be given to letters responding to articles published in the JRSM. Our aim is to publish letters quickly. Not all correspondence will be acknowledged.
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Abstract
Please e-mail letters for publication to Dr Kamran Abbasi [ kamran.abbasi@rsm.ac.uk ]. Letters should be no longer than 300 words and preference will be given to letters responding to articles published in the JRSM. Our aim is to publish letters quickly. Not all correspondence will be acknowledged.
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Rozmovits L, Mior S, Boon H. Exploring approaches to patient safety: the case of spinal manipulation therapy. BMC Complement Altern Med 2016; 16:164. [PMID: 27251398 PMCID: PMC4890537 DOI: 10.1186/s12906-016-1149-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/27/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND The purpose of this study was to gain insight into the current safety culture around the use of spinal manipulation therapy (SMT) by regulated health professionals in Canada and to explore perceptions of readiness for implementing formal mechanisms for tracking associated adverse events. METHODS Fifty-six semi-structured telephone interviews were conducted with professional leaders and frontline practitioners in chiropractic, physiotherapy, naturopathy and medicine, all professions regulated to perform SMT in the provinces of Alberta and Ontario Canada. Interviews were digitally audio-recorded for verbatim transcription. Transcripts were entered into HyperResearch software for qualitative data analysis and were coded for both anticipated and emergent themes using the constant comparative method. A thematic, descriptive analysis was produced. RESULTS The safety culture around SMT is characterized by substantial disagreement about its actual rather than putative risks. Competing intra- and inter-professional narratives further cloud the safety picture. Participants felt that safety talk is sometimes conflated with competition for business in the context of fee-for-service healthcare delivery by several professions with overlapping scopes of practice. Both professional leaders and frontline practitioners perceived multiple barriers to the implementation of an incident reporting system for SMT. CONCLUSIONS The established 'measure and manage' approach to patient safety is difficult to apply to care which is geographically dispersed and delivered by practitioners in multiple professions with overlapping scopes of practice, primarily in a fee-for-service model. Collaboration across professions on models that allow practitioners to share information anonymously and help practitioners learn from the reported incidents is needed.
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Affiliation(s)
| | - Silvano Mior
- Canadian Memorial Chiropractic College, Toronto, ON, Canada
| | - Heather Boon
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada.
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Yang HS, Oh YM, Eun JP. Cervical Intradural Disc Herniation Causing Progressive Quadriparesis After Spinal Manipulation Therapy: A Case Report and Literature Review. Medicine (Baltimore) 2016; 95:e2797. [PMID: 26871842 PMCID: PMC4753938 DOI: 10.1097/md.0000000000002797] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/15/2016] [Accepted: 01/20/2016] [Indexed: 02/07/2023] Open
Abstract
Cervical intradural disc herniation (IDH) is an extremely rare condition, comprising only 0.27% of all disc herniations. Three percent of IDHs occur in the cervical, 5% in the thoracic, and over 92% in the lumbar spinal canal. There have been a total of 31 cervical IDHs reported in the literature. The pathogenesis and imaging characteristics of IDH are not fully understood. A preoperative diagnosis is key to facilitating prompt intradural exploration in patients with ambivalent findings, as well as in preventing reoperation. The purpose of reporting our case is to remind clinicians to consider the possibility of cervical IDH during spinal manipulation therapy in patient with chronic neck pain.The patient signed informed consent for publication of this case report and any accompanying image. The ethical approval of this study was waived by the ethics committee of Chonbuk National University Hospital, because this study was case report and the number of patients was <3.A 32-year-old man was transferred our emergency department with progressive quadriparesis. He had no history of trauma, but had received physical therapy with spinal manipulation for chronic neck pain over the course of a month. The day prior, he had noticed neck pain and tingling in the bilateral upper and lower extremities during the manipulation procedure. The following day, he presented with bilateral weakness of all 4 extremities, which rendered him unable to walk. Neurological examination demonstrated a positive Hoffmann sign and ankle clonus bilaterally, hypoesthesia below the C5 dermatome, 3/5 strength in the bilateral upper extremities, and 2/5 strength in the lower extremities. This motor weakness was progressive, and he further complained of voiding difficulty.Urgent magnetic resonance imaging (MRI) of the cervical spine revealed large, central disc herniations at C4-C5 and C5-C6 that caused severe spinal cord compression and surrounding edema. We performed C4-C5-C6 anterior cervical discectomy and fusion.The patient's limb weakness improved rapidly within 1 day postoperatively, and he was discharged 4 weeks later. At his 12-month follow-up, the patient had recovered nearly full muscle power.We presented an extremely rare case of cervical IDH causing progressive quadriparesis after excessive spinal manipulation therapy. The presence of a "halo" and "Y-sign" were useful MRI markers for cervical IDH in this case.
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Affiliation(s)
- Hwan-Seo Yang
- From the Department of Neurosurgery, Biomedical Research Institute, Chonbuk National University Medical School and Hospital, Jeonju, Korea
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Abstract
BACKGROUND Stroke is a decidedly devastating event for any patient, but particularly for a military aviator in a single-seat aircraft. Incidence of acute ischemic infarct in men ages 25 to 29 ranges from 3.4 to 5.6/100,000. The neurological sequelae of stroke can have a lasting and profound impact on an aviator's career. Literature review revealed a relatively small number of cases where stroke was attributable to cervical manipulation. CASE REPORT A 29-yr-old male jet pilot with a 2-wk history of cervicalgia following a mountain bike ride performed self-manipulation of his neck at home following a visit to a chiropractor. He sustained an immediate onset of euphoria, nausea, dysarthria, vertigo, diploplia, and occipital headache, and was transported via ambulance to the nearest emergency department. The patient's MRI/MRA imaging revealed a dissection of his right vertebral artery, as well as bilateral cerebellar infarcts. During the course of the following months, the patient's residual symptoms included neck pain, headaches, disequilibrium, and quadrantanopia. DISCUSSION The ability to recognize the symptoms of stroke and seek treatment in a timely manner are paramount and can drastically reduce the potential for permanent deficit. The evaluation of residual sequelae in military aviators who fly single-seat aircraft is of particular interest to aerospace medicine physicians when it comes time to return a pilot to flight duties. Additionally, the link between cervical manipulation and vertebral artery dissection leading to stroke remains equivocal, and further research is warranted.
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Stevenson JS, Soule S, Parkin P, O'Neill-Kerr D. Bilateral vertebral artery dissection in a patient with Turner Syndrome following manipulation of the cervical spine. N Z Med J 2015; 128:75-77. [PMID: 27377026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Jonathan S Stevenson
- Department of Medicine, Wellington Hospital, Private Bag 7902, Wellington, New Zealand.
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Fritz JM, Magel JS, McFadden M, Asche C, Thackeray A, Meier W, Brennan G. Early Physical Therapy vs Usual Care in Patients With Recent-Onset Low Back Pain: A Randomized Clinical Trial. JAMA 2015; 314:1459-67. [PMID: 26461996 DOI: 10.1001/jama.2015.11648] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Low back pain (LBP) is common in primary care. Guidelines recommend delaying referrals for physical therapy. OBJECTIVE To evaluate whether early physical therapy (manipulation and exercise) is more effective than usual care in improving disability for patients with LBP fitting a decision rule. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial with 220 participants recruited between March 2011 and November 2013. Participants with no LBP treatment in the past 6 months, aged 18 through 60 years (mean age, 37.4 years [SD, 10.3]), an Oswestry Disability Index (ODI) score of 20 or higher, symptom duration less than 16 days, and no symptoms distal to the knee in the past 72 hours were enrolled following a primary care visit. INTERVENTIONS All participants received education. Early physical therapy (n = 108) consisted of 4 physical therapy sessions. Usual care (n = 112) involved no additional interventions during the first 4 weeks. MAIN OUTCOMES AND MEASURES Primary outcome was change in the ODI score (range: 0-100; higher scores indicate greater disability; minimum clinically important difference, 6 points) at 3 months. Secondary outcomes included changes in the ODI score at 4-week and 1-year follow-up, and change in pain intensity, Pain Catastrophizing Scale (PCS) score, fear-avoidance beliefs, quality of life, patient-reported success, and health care utilization at 4-week, 3-month, and 1-year follow-up. RESULTS One-year follow-up was completed by 207 participants (94.1%). Using analysis of covariance, early physical therapy showed improvement relative to usual care in disability after 3 months (mean ODI score: early physical therapy group, 41.3 [95% CI, 38.7 to 44.0] at baseline to 6.6 [95% CI, 4.7 to 8.5] at 3 months; usual care group, 40.9 [95% CI, 38.6 to 43.1] at baseline to 9.8 [95% CI, 7.9 to 11.7] at 3 months; between-group difference, -3.2 [95% CI, -5.9 to -0.47], P = .02). A significant difference was found between groups for the ODI score after 4 weeks (between-group difference, -3.5 [95% CI, -6.8 to -0.08], P = .045]), but not at 1-year follow-up (between-group difference, -2.0 [95% CI, -5.0 to 1.0], P = .19). There was no improvement in pain intensity at 4-week, 3-month, or 1-year follow-up (between-group difference, -0.42 [95% CI, -0.90 to 0.02] at 4-week follow-up; -0.38 [95% CI, -0.84 to 0.09] at 3-month follow-up; and -0.17 [95% CI, -0.62 to 0.27] at 1-year follow-up). The PCS scores improved at 4 weeks and 3 months but not at 1-year follow-up (between-group difference, -2.7 [95% CI, -4.6 to -0.85] at 4-week follow-up; -2.2 [95% CI, -3.9 to -0.49] at 3-month follow-up; and -0.92 [95% CI, -2.7 to 0.61] at 1-year follow-up). There were no differences in health care utilization at any point. CONCLUSIONS AND RELEVANCE Among adults with recent-onset LBP, early physical therapy resulted in statistically significant improvement in disability, but the improvement was modest and did not achieve the minimum clinically important difference compared with usual care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01726803.
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Affiliation(s)
- Julie M Fritz
- Department of Physical Therapy, University of Utah, Salt Lake City
| | - John S Magel
- Department of Physical Therapy, University of Utah, Salt Lake City2Department of Physical Therapy, Intermountain Healthcare, Salt Lake City, Utah
| | - Molly McFadden
- Department of Physical Therapy, University of Utah, Salt Lake City
| | - Carl Asche
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Anne Thackeray
- Department of Physical Therapy, University of Utah, Salt Lake City2Department of Physical Therapy, Intermountain Healthcare, Salt Lake City, Utah
| | - Whitney Meier
- Department of Physical Therapy, University of Utah, Salt Lake City
| | - Gerard Brennan
- Department of Physical Therapy, Intermountain Healthcare, Salt Lake City, Utah
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Affiliation(s)
- Fabio De-Giorgio
- Institute of Public Health, Section of Legal Medicine, Catholic University, Rome
| | | | - Massimo Miscusi
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome
| | | | | | - Vincenzo L Pascali
- Institute of Public Health, Section of Legal Medicine, Catholic University, Rome
| | - Giuseppe Vetrugno
- Institute of Public Health, Section of Legal Medicine, Catholic University, Rome
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Langenfeld A, Humphreys BK, de Bie RA, Swanenburg J. Effect of manual versus mechanically assisted manipulations of the thoracic spine in neck pain patients: study protocol of a randomized controlled trial. Trials 2015; 16:233. [PMID: 26013142 PMCID: PMC4464708 DOI: 10.1186/s13063-015-0763-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 05/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Neck pain is a common musculoskeletal condition with a point prevalence of around 15% in males and 23% in females that often presents in physiotherapy practice. Physical therapy and/or manipulation therapy is generally the first management option for patients with mechanical neck pain. Physical therapists treat mechanical neck pain with a number of interventions including joint mobilization and/or manipulation, therapeutic exercises or education. However, manipulation of the cervical spine carries some risks. Treating the thoracic spine for neck pain is an alternative approach. Emerging evidence suggests that it may be effective for treating neck pain without the risks associated with cervical spine manipulation. A new electromechanical device has recently been developed and tested for delivering multiple high velocity, low amplitude thrust manipulations to the spine. This device incorporates both auditory and visual systems that provide real time feedback on the applied treatment. The objective of this study is to compare the short- and long-term effects of manual versus mechanically assisted manipulations of the thoracic spine for neck pain patients. METHODS/DESIGN A 6-month, randomized controlled trial consisting of 54 patients with acute or chronic neck pain patients will be conducted. Patients with no signs of major pathology and with little or no interference with daily activities will be recruited. Three treatment sessions with 4-day intervals will be carried out. The patients will be randomly assigned to receive either manually performed manipulations or electromechanical manipulations at the thoracic spine. The primary outcome is pain intensity as measured by the Visual Analogue Pain Rating Scale. The secondary outcome measures are neck physical disability using the Neck Disability Index, quality of life measured by the European Quality of Life 5 Dimensions 5 Levels and patients' improvement using the Patient's Global Impression of Change Scale. DISCUSSION It is expected that both interventions will improve neck pain. This would be a significant finding, as thoracic spine manipulation for neck pain does not carry the same risk of injury as cervical spine manipulation. In addition, the results may provide useful information about therapeutic options for health care providers and patients for the problem of neck pain. TRIAL REGISTRATION Current Controlled Trials ISRCTN88585962, registered January 2013.
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Affiliation(s)
- Anke Langenfeld
- Department of Chiropractic Medicine, University of Zurich and Balgrist University Hospital, Forchstrasse 340, CH-8008, Zurich, Switzerland.
- Department of Physiotherapy, Balgrist University Hospital, Zurich, Switzerland.
- Department of Epidemiology and CAPHRI School for Public Health and Primary Care, Maastricht University, Universiteitssingel 60, NL-6229, Maastricht, ER, The Netherlands.
| | - B Kim Humphreys
- Department of Chiropractic Medicine, University of Zurich and Balgrist University Hospital, Forchstrasse 340, CH-8008, Zurich, Switzerland.
| | - Rob A de Bie
- Department of Epidemiology and CAPHRI School for Public Health and Primary Care, Maastricht University, Universiteitssingel 60, NL-6229, Maastricht, ER, The Netherlands.
| | - Jaap Swanenburg
- Department of Chiropractic Medicine, University of Zurich and Balgrist University Hospital, Forchstrasse 340, CH-8008, Zurich, Switzerland.
- Department of Physiotherapy, Balgrist University Hospital, Zurich, Switzerland.
- Physiotherapy Occupational Therapy Research, Directorate of Research and Education, University Hospital Zurich, Zurich, Switzerland.
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Abstract
The aim of this article was to delineate the characteristics of lumbar disc herniation (LDH) in patients with exacerbation of symptoms caused by spinal manipulative therapy (SMT). The main emphasis should be on the prevention of this condition by identifying relevant risk factors. Detailed clinico-radiological profiles of a total number of 10 LDH patients with exacerbation of presentation after SMT were reviewed. All the patients underwent neurological and magnetic resonance imaging examinations. Laminectomy and discectomy were performed, and follow-up was carried out in all patients. The duration of symptoms in the patients before SMT was 4-15 years. After the therapy, an acute exacerbation of back and radicular pain was observed within 24 h. Magnetic resonance imaging showed that L4-L5 was the most frequently affected level observed (7 patients), and each patient had a large disc fragment in the spinal canal. The disc fragments were classified into 3 types according to their localizations. The time internal between the exacerbation of presentation and surgery was 23.1 days. No perioperative complications were noted. All the patients were relieved of radicular pain a few days after surgery. During postoperative follow-up, all patients regained the ability to walk; one patient received catheterization for 1 month and another for 6 months. Eight patients reported a complete resolution of presentation and the rest 2 patients were significantly improved. SMT should be prohibited in some LDH patients to prevent neurological damages, in whom there are 5 possible risk factors. Surgical results for these patients are encouraging.
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Affiliation(s)
- Sheng-Li Huang
- From the Department of Orthopaedics (S-LH, H-WY), Central Laboratory for Scientific Research (G-LY), Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an; Department of Neurosurgery (Y-XL), First Hospital of Yulin City, Yulin; and Department of Orthopaedics (JZ), Weinan Central Hospital, Weinan, China
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Cattrysse E, Gianola S, Provyn S, Van Roy P. Intended and non-intended kinematic effects of atlanto-axial rotational high-velocity, low-amplitude techniques. Clin Biomech (Bristol, Avon) 2015; 30:149-52. [PMID: 25556040 DOI: 10.1016/j.clinbiomech.2014.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 12/12/2014] [Accepted: 12/15/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The study of neck kinematics during high-velocity, low-amplitude manipulations of the atlanto-axial segment is essential to understanding cervical motion mechanisms and their impact and possible risk for soft-tissue injuries during treatment of spine disorders. METHODS Twenty fresh-frozen specimens were tested during manual application of an axial rotation technique. FINDINGS The kinematics indicate the thrust induced motion components of approximately 1° at the treated segment around all three axes of the local embedded reference frame. Moreover, an equal amount of axial rotation motion took place at the adjacent atlanto-occipital joint. INTERPRETATION Overall atlanto-axial motion remained below the level of slow regional mobilization of the cervical spine. These findings can be correlated to literature data concerning the limited increase in vertebral artery strain during high-velocity, low-amplitude manipulation.
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Affiliation(s)
- Erik Cattrysse
- Vrije Universiteit Brussel, Department of Experimental Anatomy, Laarbeeklaan 103, 1090 Brussels, Belgium.
| | - Silvia Gianola
- Vrije Universiteit Brussel, Department of Experimental Anatomy, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Steven Provyn
- Vrije Universiteit Brussel, Department of Experimental Anatomy, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Peter Van Roy
- Vrije Universiteit Brussel, Department of Experimental Anatomy, Laarbeeklaan 103, 1090 Brussels, Belgium
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Bolino G, Mangiulli T. Case in accordance with the journal editorial guidelines. Med Sci Law 2014; 54:238-239. [PMID: 25323292 DOI: 10.1177/0025802414550954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Giorgio Bolino
- Department of Anatomic, Histologic, Medical-Legal Sciences and of Locomotor System, Rome University Sapienza, Rome, Italy
| | - Tatiana Mangiulli
- Department of Anatomic, Histologic, Medical-Legal Sciences and of Locomotor System, Rome University Sapienza, Rome, Italy
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Cicconi M, Mangiulli T, Bolino G. Onset of complications following cervical manipulation due to malpractice in osteopathic treatment: a case report. Med Sci Law 2014; 54:230-233. [PMID: 24402084 DOI: 10.1177/0025802413513451] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The aim of this study is to correlate cervical disc herniation with manipulation performed by a non-physician osteopath on a patient complaining of neck pain. The authors report a case in which a woman - treated with osteopathic spinal manipulation - developed cervical-brachial neuralgia following the cervical disc herniation. The patient then underwent surgery and was followed by physiotherapists. A clinical condition characterized by limitation of neck mobility, with pain and sensory deficit in the right arm and II-III fingers, still persists. The patient consulted the authors to establish whether cervical disc herniation could be attributed to manipulation. Adverse events or side effects of spinal manipulative therapy are relatively common and usually benign. Most of these side effects are mild or moderate, but sometimes they can be severe. Cervical manipulation can provoke complications less often than thoracic or lumbar manipulation. Furthermore, many diseases can be absolutely and relatively contraindicated to osteopathic treatment. Therefore, the knowledge of a patient's clinical conditions is essential before starting a manipulative treatment; otherwise the osteopath could be accused of malpractice. It is the authors' opinion that a cause-effect relationship exists between the manipulative treatment and the development of disc herniation.
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Affiliation(s)
- Michela Cicconi
- Department of Anatomic, Histologic, Medical-Legal Sciences and of Locomotor System, Rome University Sapienza, Rome, Italy
| | - Tatiana Mangiulli
- Department of Anatomic, Histologic, Medical-Legal Sciences and of Locomotor System, Rome University Sapienza, Rome, Italy
| | - Giorgio Bolino
- Department of Anatomic, Histologic, Medical-Legal Sciences and of Locomotor System, Rome University Sapienza, Rome, Italy
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Vaughan B, Thomson O. Valuable information about current clinical practice. Med Sci Law 2014; 54:236-237. [PMID: 25261008 DOI: 10.1177/0025802414549893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Brett Vaughan
- Osteopathy, College of Health and Biomedicine, Victoria University, Melbourne, Australia
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Biller J, Sacco RL, Albuquerque FC, Demaerschalk BM, Fayad P, Long PH, Noorollah LD, Panagos PD, Schievink WI, Schwartz NE, Shuaib A, Thaler DE, Tirschwell DL. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association. Stroke 2014; 45:3155-74. [PMID: 25104849 DOI: 10.1161/str.0000000000000016] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional. METHODS Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. RESULTS Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery-artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard. CONCLUSIONS CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.
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Tazelaar GHP, Tijssen CC. [Intracranial hypotension syndrome following manipulation of the cervical spine]. Ned Tijdschr Geneeskd 2014; 158:A7050. [PMID: 24518846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Chiropractic interventions such as manipulation of the cervical spine can incidentally lead to severe neurological complications. CASE DESCRIPTION A 63-year-old female patient presented at the Neurology outpatient clinic with a five-week history of severe postural headache, tinnitus and nausea. The onset of these symptoms was concurrent with chiropractic manipulation of the cervical spine because of cervical pain. Cranial MRI showed findings characteristic for intracranial hypotension syndrome. Cervical MRI revealed a large posterior dural tear at the level of Ci-ii. Following unsuccessful conservative therapy, the patient underwent a lumbar epidural blood patch after which she recovered rapidly. CONCLUSION Manipulation of the cervical spine can cause a dural tear and subsequently an intracranial hypotension syndrome. Postural headaches directly after spinal manipulation should therefore be a reason to suspect this complication. If conservative management fails, an epidural blood patch may be performed.
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Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R. International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention. ACTA ACUST UNITED AC 2013; 19:222-8. [PMID: 24378471 DOI: 10.1016/j.math.2013.11.005] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 11/11/2013] [Accepted: 11/16/2013] [Indexed: 12/16/2022]
Abstract
A consensus clinical reasoning framework for best practice for the examination of the cervical spine region has been developed through an iterative consultative process with experts and manual physical therapy organisations. The framework was approved by the 22 member countries of the International Federation of Orthopaedic Manipulative Physical Therapists (October 2012). The purpose of the framework is to provide guidance to clinicians for the assessment of the cervical region for potential of Cervical Arterial Dysfunction in advance of planned management (inclusive of manual therapy and exercise interventions). The best, most recent scientific evidence is combined with international expert opinion, and is presented with the intention to be informative, but not prescriptive; and therefore as an aid to the clinician's clinical reasoning. Important underlying principles of the framework are that 1] although presentations and adverse events of Cervical Arterial Dysfunction are rare, it is a potentially serious condition and needs to be considered in musculoskeletal assessment; 2] manual therapists cannot rely on the results of one clinical test to draw conclusions as to the presence or risk of Cervical Arterial Dysfunction; and 3] a clinically reasoned understanding of the patient's presentation, including a risk:benefit analysis, following an informed, planned and individualised assessment, is essential for recognition of this condition and for safe manual therapy practice in the cervical region. Clinicians should also be cognisant of jurisdictionally specific requirements and obligations, particularly related to patient informed consent, when intending to use manual therapy in the cervical region.
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Affiliation(s)
- A Rushton
- School of Sport, Exercise and Rehabilitation Science, College of Life and Environmental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.
| | - D Rivett
- School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
| | - L Carlesso
- University Health Network, Toronto Western Research Institute, Toronto, Ontario M5T 2S8, Canada
| | - T Flynn
- Rocky Mountain University of Health Professions, 561 East 1860 South, Provo, UT 84606, USA
| | - W Hing
- Bond University, Faculty of Health Sciences and Medicine, Bond University Institute of Health and Sport, Gold Coast, Robina, Queensland 4226, Australia
| | - R Kerry
- Division of Physiotherapy Education, School of Health Sciences, University of Nottingham, Nottingham NG5 1PB, United Kingdom
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Harrasser N, Stahlhofer H. [Manual medicine applied at the cervical spine: do we have to be afraid of vertebral artery dissection?]. MMW Fortschr Med 2013; 155:54-55. [PMID: 24288925 DOI: 10.1007/s15006-013-2282-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Norbert Harrasser
- Norbert Harrasser Klinik für Orthopädie und Sportorthopädie Klinikum rechts der Isar der Technischen Universität München
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Wynd S, Westaway M, Vohra S, Kawchuk G. The quality of reports on cervical arterial dissection following cervical spinal manipulation. PLoS One 2013; 8:e59170. [PMID: 23527121 PMCID: PMC3604043 DOI: 10.1371/journal.pone.0059170] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 02/13/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cervical artery dissection (CAD) and stroke are serious harms that are sometimes associated with cervical spinal manipulation therapy (cSMT). Because of the relative rarity of these adverse events, studying them prospectively is challenging. As a result, systematic review of reports describing these events offers an important opportunity to better understand the relation between adverse events and cSMT. Of note, the quality of the case report literature in this area has not yet been assessed. PURPOSE 1) To systematically collect and synthesize available reports of CAD that have been associated with cSMT in the literature and 2) assess the quality of these reports. METHODS A systematic review of the literature was conducted using several databases. All clinical study designs involving CADs associated with cSMT were eligible for inclusion. Included studies were screened by two independent reviewers for the presence/absence of 11 factors considered to be important in understanding the relation between CAD and cSMT. RESULTS Overall, 43 articles reported 901 cases of CAD and 707 incidents of stroke reported to be associated with cSMT. The most common type of stroke reported was ischemic stroke (92%). Time-to-onset of symptoms was reported most frequently (95%). No single case included all 11 factors. CONCLUSIONS This study has demonstrated that the literature infrequently reports useful data toward understanding the association between cSMT, CADs and stroke. Improving the quality, completeness, and consistency of reporting adverse events may improve our understanding of this important relation.
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Affiliation(s)
- Shari Wynd
- Texas Chiropractic College, Pasadena, Texas, United States of America.
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Abstract
BACKGROUND Strokes, typically involving vertebral artery dissection, can follow cervical spinal manipulative therapy, and these types of stroke occur rarely. There is disagreement about whether a strong association between neck manipulation and stroke exists. An earlier systematic review found two relevant studies of association that used controls, which also discussed the limitations of the two papers. Our systematic review updates the earlier review, and aims to determine whether conclusive evidence of a strong association exists. METHODS PRISMA guidelines for systematic reviews were followed, and the literature was searched using a strategy that included the terms 'neck manipulation' and 'stroke' from the PubMed, Embase, CINAHL Plus and AMED databases. Citations were included if they met criteria such as being case-control studies, and dealt with neck manipulation and/or neck movement/positioning. Papers were scored for their quality, using similar criteria to the earlier review. For individual criteria, each study was assigned a full positive score if the criterion was satisfied completely. RESULTS Four case-control studies and one case-control study, which included a case- crossover design, met the selection criteria, but all of them had at least three items in the quality assessment that failed to be completely positive. Two studies were assessed to be the most robustly designed, one indicating a strong association between stroke and various intensities of neck movement, including manipulation, and the other suggesting a much reduced relative association when using primary care practitioners' visits as controls. However, potential biases and confounders render the results inconclusive. CONCLUSION Conclusive evidence is lacking for a strong association between neck manipulation and stroke, but is also absent for no association. Future studies of association will need to minimise potential biases and confounders, and ideally have sufficient numbers of cases to allow subgroup analysis for different types of neck manipulation and neck movement.
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Affiliation(s)
- M J Haynes
- The University of Western Australia, Crawley, WA, Australia.
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