Archive for category Cervical Spine

To the Editor:

We write concerning the recently published article by Klougart  et al, (Klougart N; Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic  practice. Part II: Treatment to the upper neck and the rate of  cerebrovascular incidents. J Manipulative Physiol Ther 1996; 19:563-9).  The authors should be commended for their exhaustive efforts in  evaluating the occurrence of cerebrovascular incidents in chiropractic  practice, a topic of great interest and importance to the profession (1,  2). Based on earlier conclusions by these authors (1); their  present study (2) and the findings of other authors (3-5), cervical  spine .rotational maneuvers have been found to be clearly more  associated with cerebrovascular accidents (CVAs) and cerebrovascular  incidents (CVIs), after spinal manipulation than other techniques.  Perhaps because of this fact, and the knowledge of the effects of  rotation upon vertebral artery blood flow (6), the authors attempted to  classify technique procedures as “rotation’. or “nonrotation” in their  retrospective analysis to estimate the occurrence of CVI s after  chiropractic treatment to the cervical spine.

Although the authors had good intentions in their survey to  attempt to identify what techniques might be associated with CVIs,  inherent problems exist in administering such a. survey to  chiropractors. The shortcomings may include (a) the failure to report  the use of several different techniques in a given treatment session (7,  8); (b) the reporting of a practitioner that they are using a  particular system (i.e., Gonstead), when in actuality they are not using  the appropriate protocols, screening procedures, case management,  set-ups, lines of drive, segmental contact points and vectors or  magnitude of force as taught and recommended by such a system and (c) a  wide variation of competency among practitioners (9). These issues  complicate the meaningfulness of any evaluation of a particular  chiropractic technique.

Although the authors acknowledged that “the unwanted side  effects” of the Gonstead technique may have been due to a modification  of the technique by the chiropractor, and that it may “include a  stronger element of rotation/extension than is generally thought,”  several questions still arise. Pertaining to the six cases reportedly  classified as “Gonstead,” were any of the treating practitioners trained  in the Gonstead technique, and how many hours of study were dedicated  to such training? Were any of the chiropractors certified in the  Gonstead technique? Did the practitioners use the protocols and  screening procedures suggested by the Gonstead system (10)? Did the  reported “Gonstead” practitioners use elements of rotation in the  set-up, or thrust procedure and to what degree (e.g.,-in case 10 it was  reported that no rotation was used, but in the other 5 cases it was not  mentioned whether rotation was used or not).

Moreover, assuming that “rotation” refers to rotation of the  cervical spine, or + or – 0 Y designation suggested by White and Panjabi  (11), for any valid conclusions to be made in a study of technique  comparison, differentiation must be made between techniques that provide  a thrust at the end range of the motion and those that only exhibit  limited + or – 0 Y rotation in the set-up and thrust. Classification of a  particular technique into one of three categories (rotational, low  rotational or nonrotational) instead of two (rotational or  nonrotational) would be more appropriate for significance. The authors  classified Gonstead as “mainly nonrotation,” yet elements of + or – 0 Y  are routinely included in both the set-up and thrust procedures for the  cervical spine in the Gonstead technique (10). Gonstead, therefore,  should have been classified under rotational or “low rotational,” which  would have significantly affected the extrapolated estimates for  rotation and nonrotation treatments regarding risk estimates for CVIs  among technique procedures.

To expound further, another case in question, specifically case  6, was considered a case of “definite nonrotation,” which involved a  patient who developed CVI-related symptoms after receiving “Traction”  and “Activator” combined in the treatment. The authors used this data to  formulate their conclusion, “although there seems to be a link between  upper cervical rotation manipulative techniques and cerebrovascular  incidents, treatment to the lower neck and the use of other techniques  are implicated. as well.”

Because both traction and Activator were used in the treatment  of the patient in case 6, and the methodology of neither treatment was  neither explained nor discussed, it is impossible to draw a conclusion  specific to the use of Activator or a “nonrotation” technique in this  case, which deserves mention. The authors failed to provide discussion  of this issue, as they did pertaining to “Gonstead technique” in the  preceding paragraph regarding the modification of the technique by the  individual chiropractor. We want to make it clear that practitioners  trained in use of the Activator Adjusting Instrument (AAI) and Activator  Methods Chiropractic Technique (AMCT) are not taught to incorporate  traction into treatment regimens and, furthermore, that cervical spinal  adjustments/manipulations are performed in the prone neutral position  (12-14). Because there are several types of traction in use in  chiropractic practice, some of which contain postures away from neutral  including flexion and extension (15), the authors understandably  referenced how the vertebral artery can be affected through traction  (16). They further noted that “toggle” and “Activator” techniques seem  not to be under suspicion in CVIs after spinal manipulation.


J Manipulative Physiol Ther. 1997 Oct;20(8):567-8. [PMID:9345689]

Author information: Colloca CJ, Fuhr AW. Activator Methods International Ltd., Phoenix, AZ.

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Abstract

Musculoskeletal disorders affect 5-7% of the  population in Canada. Neck pain is one of the more common  musculoskeletal complaints. Spinal manipulative therapy attempts to  reduce pain and increase range of motion. Treatments from any profession  require valid evidence of efficacy. This study examines two popular  treatments used by Canadian chiropractors, a mechanically assisted  device commonly known as the Activator Adjusting Instrument ™, and  spinal manipulative therapy. Fourteen subjects were randomly into two  groups. Each subject was assigned by a blind examiner and then given one  of the two treatment interventions provided by an experienced  chiropractor. The outcome measures used were lateral flexion and a  subjective pain rating scale. The results revealed that there were no  statistically significant differences before and after the  interventions. Further study is required using larger sample sizes  before conclusions can be made regarding the efficacy of the selected  interventions. However, the importance of the need for future  comparative studies is discussed.


Chiropr Tech 1996; 8(4):155-62.

Author information: Yurkiw D, Mior S. Canadian Memorial Chiropractic College, Toronto, Ontario, Canada.

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Abstract

STUDY DESIGN:

Cervical spine manipulation and mobilization were reviewed in an analysis of the literature from 1966 to the present.

OBJECTIVES:

To assess the evidence for the efficacy and complications of cervical spine manipulation and mobilization for the treatment of neck pain and headache.

SUMMARY OF BACKGROUND DATA:

Although recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is known about its efficacy for neck pain and headache.

METHODS:

A structured search of four computerized bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality. The confidence profile method of meta-analysis was used to estimate the effect of spinal manipulation on patients’ pain status.

RESULTS:

Two of three randomized controlled trials showed a short-term benefit for cervical mobilization for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations.

CONCLUSIONS:

Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death.


 

Spine (Phila Pa 1976). 1996 Aug 1;21(15):1746-59. [PMID: 8855459]

Author information: Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. RAND, Santa Monica, CA, USA.

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Abstract

OBJECTIVE:

To create a statistical model using three-dimensional (3D) head kinematics and range of motion (ROM) to distinguish between people with whiplash syndrome and asymptomatic controls.

STUDY DESIGN:

Cross-sectional study to estimate validity of diagnostic measures.

METHODS:

Fifty-one asymptomatic controls (most of whom were women), 18-35 yr old and 30 matched whiplash trauma patients seeking care from suburban outpatient clinics were sought. 3D kinematic parameters of head motion were obtained during tracking tasks (e.g., flexion, extension, etc.) and cervical ROM was measured via a head mounted inclinometer. Their level of pain and disability was assessed via a self-administered neck disability index questionnaire and visual analog pain scale (VAS).

RESULTS:

A scoring system of biomechanical abnormalities derived from the vertical piercing point, its second derivative and symmetry during oblique tasks. The scores ranged from a minimum of 0 to a maximum of 3. A cutoff of > or = 0.5 correctly identified the greatest number of subjects and minimized false positives (sensitivity 77%, specificity 82%, likelihood ratio 4.5). ROM performed similarly well at a cutoff of 1 SD below the normative mean (sensitivity 77%, specificity 84%, likelihood ratio 3.9).

CONCLUSIONS:

There is potential for biomechanical analysis to objectively detect abnormalities. The statistical model yielded moderate to high sensitivity and specificity using 3D helical-axis parameters of the head and standard ROM. The model development will continue via this process in future studies. These data could be a first step toward the creation of useful, noninvasive protocols for the diagnosis and management of soft tissue trauma of the neck.


J Manipulative Physiol Ther. 1996 May;19(4):231-7. [PMID:8734397]

Author information: Osterbauer PJ, Long K, Ribaudo TA, Petermann EA, Fuhr AW, Bigos SJ, Yamaguchi GT. Gait Laboratory, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, USA.

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Abstract

To date, the diagnosis of whiplash injuries  has been very difficult and largely based on subjective, clinical  assessment. The work by Winters and Peles Multiple Muscle  Systems–Biomechanics and Movement Organization. Springer, New York  (1990) suggests that the use of finite helical axes (FHAs) in the neck  may provide an objective assessment tool for neck mobility. Thus, the  position of FHA describing head-trunk motion may allow discrimination  between normal and pathological cases such as decreased mobility in  particular cervical joints. For noisy, unsmoothed data, the FHAs must be  taken over rather than large angular intervals if the FHAs are to be  reconstructed with sufficient accuracy; in the Winters and Peles study,  these intervals were approximately 10 degrees.

In order to study the  movements’ microstructure, the present investigation uses instantaneous  helical axes (IHAs) estimated from low-pass smoothed video data. Here,  the small-step noise sensitivity of the FHA no longer applies, and  proper low-pass filtering allows estimation of the IHA even small  rotation velocity omega of the moving neck. For marker clusters mounted  on the head and trunk, technical system validation showed that the IHAs  direction dispersions were on the order of one degree, while their  position dispersions were on the order of 1 mm, for low-pass cut-off  frequencies of a few Hz (the dispersions were calculated from  omega-weighted errors, in order to account for the adverse effects of  vanishing omega).

Various simple, planar models relating the  instantaneous, 2-D centre of rotation with the geometry and kinematics  of a multi-joint neck model are derived, in order to gauge the utility  of the FHA and IHA approaches.

Some preliminary results on asymptomatic  and pathological subjects are provided, in terms of the ‘ruled surface’  formed by sampled IHAs and of their piercing points through the  mid-sagittal plane during a prescribed flexion-extension movement of the  neck.


J Biomechanics. 1994; 27(12):1415-32.

Author information: Woltring HJ, Long K, Osterbauer PJ, Fuhr AW.  Whiplash Analysis, Inc. Phoenix, AZ.

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Abstract

OBJECTIVE:

To determine the biomechanical characteristics of five clinically common methods of cervical spine manipulation.

DESIGN:

Descriptive study.

SETTING:

Human Performance Lab, University of Calgary.

PARTICIPANTS:

Five volunteer practitioners treating symptomatic patients from their own clinical populations.

INTERVENTION:

Five commonly used methods of cervical spine manipulation: lateral break (LAT), Gonstead (GON), Activator (ACT), toggle (TOG), rotation (ROT).

MAIN OUTCOME MEASURE:

Mean thrust duration (msec), normalized mean peak force (N), slope (N/msec), force profile (graphic representation of the above values.

RESULTS:

Outcome measures for each manipulative technique were as follows: LAT = normalized mean peak force of 102.2 N at 86.7 msec, GON = 109.8 N at 91.9 msec, ACT = 40.9 N at 31.8 msec, TOG = 117.6 N at 47.5 msec, ROT = 40.5 N at 79.1 msec.

CONCLUSION:

The observed differences and similarities in force profiles between the five techniques studied here may partly be the manifestation of how a particular technique delivers force to the cervical spine. The clinical significance of force profile characterization is not yet known.


J Manipulative Physiol Ther. 1993 Nov-Dec;16(9):573-7. [PMID:8133191]

Author information: Kawchuk GN, Herzog W. University of Calgary, Faculty of Physical Education, Alberta, Canada.

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Abstract

The purpose of this article is to report normal variation in the screw (helical) axis of rotation of the head during various types of natural tracking movements. Nine normal subjects and eighteen subjects with neck injury faced a grid of targets separated by 10-degree intervals, and were instructed to use a head pointer (laser) to track whatever target was lit. Various horizontal, vertical, and oblique target sequences were employed. The normal subjects exhibited several consistent trends in finite screw axis parameter variation: vertical movements have a laterally-directed axis whose midsagittal plane crossing position is a function of the head orientation (typical range C3-T1); oblique movements have a diagonally-directed axis and an even greater orientation-specific range (C1-T1); and horizontal movements have a vertical axis that is modified near horizontal orientation extremes and is asymmetrically influenced by upward and downward bias orientations. Subjects with neck injury were seen to exhibit a variety of abnormal screw axis patterns.


Spine (Phila Pa 1976). 1993 Jul;18(9):1178-85. [PMID:8362323]

Author information: Winters JM, Peles JD, Osterbauer PJ, Derickson K, Deboer KF, Fuhr AW. Arizona State University, Tempe, AZ.

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Abstract

OBJECTIVE:

Finite helical axis parameters (FHAP) of the cervical spine and clinical measures were obtained to evaluate neck function and the clinical effects of spinal manipulative therapy in patients with “whiplash” (WL) type neck injury.

DESIGN:

Descriptive case series, 1 yr follow-up.

SETTING:

Three private chiropractic practices.

SUBJECTS:

Ten consecutive new patients with a history of neck injury, nine asymptomatic, volunteer controls.

INTERVENTIONS:

A 6-wk regimen of short lever manually assisted adjustments with an Activator Instrument, while acute, four patients received interferential electrotherapy.

MAIN OUTCOME MEASURES:

Cervical FHAP during normal movements, neck pain (visual analogue scale), active cervical range of motion and follow-up questionnaire.

RESULTS:

Based on six patients, the FHAPs appeared to mirror the clinical condition, being markedly deviant from the patterns observed in the control group for at least one or more of the tracking tasks for all but one of the patients. Mean pain scores decreased from 44.1 to 10.5 (t = 4.93; p < .0001) and mean total range of motion increased from 234 to 297 degrees (t = 5.68; p < .0001). At 1 yr, seven respondents noted stability of their symptoms at or near the level reported immediately after the 6-wk treatment period.

CONCLUSIONS:

Based on these preliminary data: a) FHAPs may aid in diagnosing and monitoring treatment of neck dysfunction, b) spinal manipulative therapy may be beneficial to some patients with neck injury and future study is warranted as a means to promote recovery of patients with neck injuries.


J Manipulative Physiol Ther. 1992 Oct;15(8):501-11. [PMID:1402410]

Author information: Osterbauer PJ, Derickson KL, Peles JD, DeBoer KF, Fuhr AW, Winters JM. Whiplash Analysis, Inc., Phoenix, AZ 85018.

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Abstract

This paper illustrates the role cervical spine dysfunction  plays as an important aetiological factor in the clinical presentation  of various pain syndromes and the application of spinal manipulative  therapy as a therapeutic procedure. Specific manipulative skills and  application of these skills to help reduce the possibility of  post-manipulative cerebrovascular complications are presented.


Eur J Chiropr.  1991: 39: 45-52.

Author information: Byfield D.  Anglo-European College of  Chiropractic, Bournemouth, Dorset, UK.

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Abstract

The influence of nociceptive peripheral input on the response characteristics of spinal interneurons may result in long-term alterations of interneuronal excitability and modify their responses to subsequent stimuli. Such neuromodulation has been found to result in physiological changes including hyperalgesia, lowering of pain thresholds, expansion of receptive fields and changes in response behaviors of muscles. These types of alterations may contribute to clinically significant findings including muscle spasm, hypomobility, edema, chronic pain, recurrences in areas of previous injury and resistance to treatment. This article reviews studies concerning plasticity of response behaviors of interneurons including habituation, spinal learning, spinal fixation, neuromodulation and the effects of substance P. Potential clinical and chiropractic application are discussed and a brief review of clinically relevant studies of chiropractic adjustments are cited.


J Manipulative Physiol Ther. 1990 Jul-Aug;13(6):326-36. [PMID:1697616]

Author information: Slosberg M. Department of Research, Life Chiropractic College-West, San Lorenzo 94580.

 

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