A review of intraexaminer and interexaminer reliability of static spinal palpation: a literature synthesis.

OBJECTIVE: The purposes of this study were to locate articles that assessed the reliability of static palpation of the spine and sacroiliac joints, to appraise the quality of these studies, and synthesize their results. METHODS: A structured literature search was conducted of chiropractic and medical databases PubMed, Manual Alternative and Natural Therapy System, Index to Chiropractic Literature, and Cumulative Index to Nursing and Allied Health Literature from 1965 through October 2007. Reference sections were inspected for additional citations. Only peer-reviewed articles in English containing information about static palpation of the spine or sacroiliac joints were selected. The resulting studies were appraised for quality by both of the authors using a 6-point scale instrument developed to assess the quality of reproducibility studies. RESULTS: The search generated 343 citations, and another 7 were harvested from the reference lists. After removing articles not meeting the inclusion criteria, 29 were retained. A total of 14 studies focused on the reliability of locating painful or tender points, 10 on the location of landmarks, and 5 on position or alignment of bone structures. A higher proportion of studies that assessed painful or tender points reported acceptable levels of reliability. However, there were no significant differences between methods of palpation when considering the proportions of high-quality studies that reported good reliability. Thus, no form of static palpation could be considered to be superior. CONCLUSION: Reported indices of agreement were generally low. More of the pain palpation studies reported acceptable kappa levels, although no one method of palpation could be deemed clearly superior.

Survey of health attitudes and behaviors of a chiropractic college population.

OBJECTIVES: We gathered information about health behaviors on a chiropractic campus, including compliance with recent guidelines for exercise as well as diet, smoking, and binge drinking. We also assessed the perceived importance of the chiropractic physician in role modeling and teaching healthy behaviors to patients. METHODS: A survey instrument composed of 16 questions was designed and distributed to 279 students, faculty, and staff at a chiropractic college campus in northern California. Confidentiality was maintained throughout the process, and a response rate of 92% was obtained. Statistical analysis was performed on the data collected. RESULTS: The levels of obesity, inactivity, and smoking on this college campus are lower than the levels reported for the metropolitan area, the state, and the nation. The level of binge drinking among our students was high but similar to the reported rates for college students generally. We found interesting and significant relationships between the behaviors of physical activity and diet (red meat consumption), obesity, and self-reported perceived health in our surveyed chiropractic college population. Without exception, all surveyed members of our campus community view doctors of chiropractic as having a responsibility to role model healthy behaviors and to educate their patients with regard to healthy behaviors; however, we also found that less importance was placed on role modeling and patient education by those who were obese or who consumed red meat in excess. CONCLUSIONS: This chiropractic college campus places a high level of importance on both educating patients and role modeling healthy behaviors. In the behavioral domain, the rates of smoking, obesity, and inactivity are lower than what is seen in the general population. However, there remains room for considerable improvement to bring actual health behaviors closer in line with evidence-informed behavioral health practices.

Spinal motion palpation: a comparison of studies that assessed intersegmental end feel vs excursion.

OBJECTIVE: Spinal motion palpation (MP) is a procedure used to detect intersegmental hypomobility/hypermobility. Different means of assessing intersegmental mobility are described, assessing either excursion of the segments (quantity of movement) or end feel (quality of motion when stressed against the paraphysiological space). The objective of this review was to classify and compare studies based on method of MP used, considering that some studies may have used both methods. METHODS: Four databases were searched: MEDLINE-PubMed, Manual Alternative and Natural Therapy System, Index to Chiropractic Literature, and Cumulative Index to Nursing and Allied Health Literature databases for the years 1965 through January 2007. Retrieved citations were independently screened for inclusion by 2 of the authors consistent with the inclusion and exclusion criteria. Included studies were appraised for quality, and data were extracted and recorded in tables. RESULTS: The search strategy generated 415 citations, and 29 were harvested from reference lists. After removing articles that did not meet the inclusion criteria, 44 were considered relevant and appraised for quality. Fifteen studies focused on MP excursion, 24 focused on end feel, and 5 used both. Eight studies reported high levels of reproducibility (kappa = >or=0.4), although 4 were not of acceptable quality, and 2 were only marginally acceptable. When only high-quality studies were considered, 3 of 24 end-feel studies reported good reliability compared with 1 of 15 excursion studies. There was no statistical support for a difference between the 2 groupings. CONCLUSIONS: A difference in reported reliability was observed when the method of MP varied, although it was not statistically significant. There was no support in the literature for the advantage of one MP method over the other.

Symptomatic outcomes and perceived satisfaction levels of chiropractic patients with a primary diagnosis involving acute neck pain.

OBJECTIVE: The aim of this study was to determine the extent to which a group of patients with acute neck pain managed with chiropractic manipulative therapy benefited from chiropractic care and the degree to which they were subsequently satisfied. METHODS: A two-part retrospective survey, each composed of 14 questions. One part was completed by practicing doctors of chiropractic concerning various aspects of their treatment for patients with former acute neck pain. In the second part, these same patients responded to a telephone survey to measure pre- and posttreatment pain levels and their level of satisfaction with the treatment they received. Chiropractic manipulative therapy was the primary independent variable, although other therapies were used, such as physical therapy, nutritional advice, and exercise. RESULTS: A total of 115 patients were contacted, of whom 94 became study participants, resulting in 60 women (64%) and 34 men. The mean age was 39.6 years (SD, 15.7). The mean number of visits was 24.5 (SD, 21.2). Pain levels improved significantly from a mean of 7.6 (median, 8.0) before treatment to 1.9 (median, 2.0) after treatment (P < .0001). The overall patient satisfaction rate was 94%. CONCLUSION: Patients with acute neck pain involved in this study seemed to be satisfied with chiropractic treatment and reported reductions in associated pain levels and activity restrictions. However, because of the study's design and limitations, care must be taken before drawing firm conclusions from the data presented.

Chiropractic manipulation and acute neck pain: a review of the evidence.

OBJECTIVE: The aim of this study was to review the chiropractic and medical literature in an effort to determine the extent of current evidence supporting the use of chiropractic manipulation for the treatment of acute neck pain. METHODS: A literature search of the MEDLINE/PubMed and MANTIS (Manual Alternative and Natural Therapy Index System) databases, extending from 1966 to September 2003, was conducted. Search terms included "cervical," "neck," "chiropractic," "neck pain," "patient satisfaction," and "manipulation." The inclusion criteria for article selection were studies dealing with the treatment of neck pain by means of chiropractic manipulation, regardless of the number of subjects involved or whether randomization was implemented. RESULTS: Two hundred sixty-seven citations were identified. Most were eliminated because they either did not specifically deal with the treatment of acute neck pain with manipulation or were not written in English. Less than 10 articles marginally dealt with the treatment of acute neck pain with cervical manipulation. Moreover, there has only been one randomized clinical trial published in the English language that specifically dealt with the treatment of acute neck pain by manipulation. Other studies involved patients with neck pain of a subacute or chronic nature or treated test subjects with mobilization techniques rather than manipulation. CONCLUSION: There has been scant investigative research into the treatment of acute neck pain with chiropractic manipulation. Consequently, more data are needed and appropriate studies should be initiated.

Patient recall of the mechanics of cervical spine manipulation.

OBJECTIVE: To determine how accurately patients with neck pain and/or headache can recall the mechanics of their cervical spine manipulative therapy immediately after its administration. METHODS: A survey analysis of immediate patient recall after cervical spine manipulative therapy was performed in a private clinic. The group consisted of 94 sequentially presenting neck pain and/or headache patients with 54 (57%) females and 40 (43%) males. The mean age of the patients was 41.9 years (SD = 13.8; range, 17-96 years). Patients received diversified cervical spine manipulative therapy using a standardized set-up of lateral flexion coupled with flexion. Immediately after the cervical spine manipulative therapy, each patient completed a one-page questionnaire regarding the mechanics of the procedure. Patient responses were analyzed to determine the accuracy of their recall of head positioning. RESULTS: Among the patients, 78.7% reported that they experienced a component of rotation and/or extension, although the technique used involved a premanipulative set-up of lateral bending coupled with flexion. CONCLUSION: Patients with primary complaints of neck pain and/or headache, when asked to recall the mechanics of their recently applied cervical spine manipulative therapy, displayed a low rate of accuracy. Rotation and/or extension of the cervical spine were the most frequently given incorrect responses.

An analysis of the etiology of cervical artery dissections: 1994 to 2003.

OBJECTIVE: To provide a literature review of the etiologic breakdown of cervical artery dissections. METHODS: A literature search of the MEDLINE database was conducted for English-language articles published from 1994 to 2003 using the search terms cervical artery dissection (CAD), vertebral artery dissection, and internal carotid artery dissection. Articles were selected for inclusion only if they incorporated a minimum of 5 case reports of CAD and contained sufficient information to ascertain a plausible etiology. RESULTS: One thousand fourteen citations were identified; 20 met the selection criteria. There were 606 CAD cases reported in these studies; 321 (54%) were internal carotid artery dissection and 253 (46%) were vertebral artery dissection, not including cases with both. Three hundred seventy-one (61%) were classified as spontaneous, 178 (30%) were associated with trauma/trivial trauma, and 53 (9%) were associated with cervical spinal manipulation. If one apparently biased study is dropped from the data pool, the percentage of CADs related to cervical spinal manipulation drops to approximately 6%. CONCLUSIONS: The case series that were reviewed in this article indicated that most CADs reported in the previous decade were spontaneous but that some were associated with trauma/trivial trauma, and a minority with cervical spine manipulation. This etiologic breakdown of CAD does not differ significantly from what has been portrayed by most other authors.

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

OBJECTIVE: The aims of this study were to examine autonomic nervous system responses by using heart rate variability analysis (HRV), hemodynamic parameters and numeric pain scale (NPS) when either upper (C1 and C2) or lower (C6 and C7) cervical segments were manipulated in volunteers, and whether such response would be altered in acute mechanical neck pain patients after spinal manipulative therapy (SMT). METHODS: A randomized controlled, cross-over, preliminary study was conducted on 10 asymptomatic normotensive volunteers and 10 normotensive patients complaining of acute neck pain. HRV, blood pressure (BP) and heart rate (HR), and NPS were recorded after upper cervical and lower cervical segments SMT in volunteer and patient groups. RESULTS: The standard deviation of average normal to normal R-R intervals (SDNN) increased (83.54 ± 22 vs. 105.41 ± 20; P = .02) after upper cervical SMT. The normalized unit of high frequency (nuHF), which shows parasympathetic activity, was predominant (40.18 ± 9 vs. 46.08 ± 14) after upper cervical SMT (P = .03) with a significant decrease (109 ± 10 vs. 98 ± 5) in systolic BP (P = .002). Low frequency to high frequency (LF/HF) ratio, which shows predominance of sympathetic activity increased (1.05 ± 0.7 vs. 1.51 ± 0.5; P = .02) after lower cervical SMT in the healthy volunteers group. However, there was an increase in SDNN (70.48 ± 18 vs. 90.23 ± 20; P = .02 and 75.19 ± 16 vs 97.52 ± 22; P = .01), a decrease in LF/HF ratio (1.33 ± 0.3 vs. 0.81 ± 0.2; P = .001 and 1.22 ± 0.4 vs. 0.86 ± 0.3; P = .02), which was associated with decreased systolic BP (105 ± 10 vs. 95 ± 9; P = .01 and 102 ± 9 vs. 91 ± 10; P = .02) and NPS scores (3 ± 1 vs. 0; P = .01 and 3 ± 1 vs. 1 ± 1; P = .03) following both upper and lower cervical SMT in the patient's group. The baseline HR was 67 ± 9 vs 64 ± 5 (upper cervical) and 65 ± 7 vs 69 ± 11 (lower cervical) in both the healthy volunteer' and patient' groups. CONCLUSION: Upper cervical SMT enhances dominance of parasympathetic and lower cervical SMT enhances dominance of sympathetic activity in this young volunteer group. However, dominance of parasympathetic activity was found in patients with neck pain that received both upper and lower cervical SMT.

Association of internal carotid artery dissection and chiropractic manipulation.

BACKGROUND: To determine the relationship between chiropractic manipulative therapy and internal carotid artery dissection, a MEDLINE literature search was performed for the years 1966 through 2000 using the terms internal carotid dissection. Literature that included information concerning causation of ICAD, as well as all case studies and series, was selected for review. REVIEW SUMMARY: In reviewing the cases of internal carotid dissection potentially related to CMT, there were many confounding factors, such as connective tissue aberrations, underlying arteriopathy, or coexistent infection, that obscured any obvious cause-and-effect relationship. To date there are only 13 reported cases of ICAD temporally related to CMT. Most ICADs seem to occur spontaneously and progress from local symptoms of headache and neck pain to cortical ischemic signs. Approximately one third of the reported cases were manipulated by practitioners other than chiropractic physicians, and because of the differential risk related to major differences in training and practice between practitioners who manipulate the spine, it would be inappropriate to compare adverse outcomes between practitioner groups. CONCLUSIONS: The medical literature does not support a clear causal relationship between CMT and ICAD. Reported cases are exceedingly scarce, and none support clear cause and effect.

The neck injury criterion: future considerations.

The cost of whiplash injuries--both in dollars spent for medical care and disability, and in terms of human suffering--are quite high in westernized nations. This is of particular interest both from a public health perspective and a general societal one because the disorder is theoretically preventable: in the very least it can be minimized. This can be achieved with crash prevention strategies and improvements in vehicle safety design--especially with more effective seat back and head restraint systems. Toward the goal of developing a gold standard for safety research in this area, a neck injury criterion (NIC) was proposed by Boström et al. in 1996 (Boström O., Svennson, M.Y., Aldman, B. et al., 1996. In: Proceedings of the International Conference on the Biomechanics of Impact, Dublin, Ireland). This criterion considers the relative horizontal acceleration and velocity between the bottom (T1) and top (C1) of the cervical spine and has face validity based on current literature. However, the NIC has still not been subjected to rigorous scientific investigation or validation in terms of its representativeness of human occupant injury. Such investigation should specifically consider, first, whether the NIC provides an adequate proxy for all potential neck injuries due to whiplash and, secondly, whether the proposed threshold value of 15 m2/s2 is an appropriate level for the stated goal. Based on a review of recent literature, recent human volunteer crash tests by Wheeler et al. and the those of the Spine Research Institute of San Diego, and based on mathematical MADYMO analysis of the first real world crash pulse data, it appears that the threshold for acute injury in the general population is likely to require a lowering of the originally proposed NIC value, and additional parameters, such as considering a forward rebound phase or neck extension criteria may be necessary. The conclusions of this paper should be considered preliminary because the numbers of crash test subjects and real world injury victims does not allow for rigorous statistical analysis. Certainly, ongoing work will be necessary to investigate this further and larger scale analysis of more onboard crash data will prove invaluable.

Low speed frontal crashes and low speed rear crashes: is there a differential risk for injury?

We compared male and female subjects in crash tests in which each subject experienced both frontal and rear impacts. Crash speed and other crash parameters were held constant. We believe this was the first experiment using an independent variable of crash vector and dependent variables of head linear acceleration and volunteer qualitative tolerance. Analysis of data revealed that the rear impact vector crash resulted in 2.8 times greater head linear acceleration than frontal crashes. Rear impact crashes resulted in biphasic, complex kinematics compared to the monophasic, less complex frontal crashes. Rear impact crashes were rated markedly less tolerable. Sex-specific differences are also discussed.

The notion of a "whiplash culture": a review of the evidence.

OBJECTIVE: Most whiplash patients eventually recover, although some are left with ongoing pain and impairment. Why some develop long-term symptoms after whiplash, whereas others do not, is largely unknown. One explanation blames the cultural expectations of the population wherein the injury occurred, engendering the moniker whiplash culture. The purpose of this review was to locate and discuss studies that were used as a basis for developing the whiplash culture concept and to evaluate its plausibility. METHODS: The PubMed database was searched using combinations of the terms whiplash culture, whiplash OR WAD, and chronic OR late OR long term. Search dates spanned from 1950 to June 2008. Filters were set to only retrieve English-language citations. Articles that dealt with the whiplash culture were selected and examined to determine which studies had been used to create the concept. RESULTS: Nineteen articles discussed the cultural aspects of whiplash and were explored to determine which were used as a basis for the whiplash culture. Eight studies were found that met this final criterion. CONCLUSION: There are many unanswered questions about the basis of chronic whiplash, and the notion of a whiplash culture is controversial. Chronic whiplash symptoms are surely not caused entirely by cultural issues, yet they are probably not entirely physical. Presumably, a tissue injury component exists in most chronic whiplash-associated disorder victims that becomes aggravated in those who are susceptible to biopsychosocial factors. As with many other controversial health care topics, the answer to the debate probably lies somewhere in the middle.

Chiropractic care for patients with acute neck pain: results of a pragmatic practice-based feasibility study.

OBJECTIVE: The purpose of this study was to determine the feasibility of a chiropractic practice-based research network to investigate the treatment of acute neck pain (ANP) and to report resulting findings. METHODS: Participating chiropractors recruited sequentially presenting ANP patients on their initial visit to the office. Patients were treated by the chiropractors using their usual methods. Data were prospectively collected by having patients complete the Neck Disability Index, Characteristic Pain Intensity score, and a patient satisfaction questionnaire. Questionnaires were completed during routine office visits at baseline and then at weeks 1, 2, 4, 8, and 26, either in the office or by mail. RESULTS: Ten chiropractors supplied data on 99 patients. The number of cases contributed by each of the participating chiropractors ranged from 1 to 54, with a mean (SD) of 9.2 (10.5). Mean (SD) Neck Disability Index scores were 36 (17.9) at baseline and 9.8 (12.2) at the final evaluation; the Characteristic Pain Intensity scores were initially 55.3 (20.4) and were 24.5 (21.5) at the final evaluation. Transient minimal adverse effects were reported by chiropractors for only 7 (7.8%) patients. No serious adverse reactions were reported. CONCLUSION: The practice-based research methodology used in this study appears to be a feasible way to investigate chiropractic care for ANP, and its methodologies could be used to plan future research.

The location of the inferior angle of the scapula in relation to the spinal level of prone patients.

BACKGROUND: In two previous studies we established the mean location of the upright inferior angle of the scapula (IAS) to be near the spinous process of T8. The current study investigates the common belief that the prone IAS lines up with the T6 SP. METHODS: The location of the IAS in relation to the spine of 20 mostly asymptomatic subjects was assessed on a Hi-Lo table in 7 different postures, 2 upright and 5 prone. RESULTS: THE SCAPULA MOVED CEPHALAD IN TWO OF THE TEST POSITIONS: prone, arms at side and prone, chicken-wing. It moved caudad in the other 4 test positions, including prone, using armrest (18.4 mm). CONCLUSIONS: With the prone patient's arms on the arm pieces, the most likely patient posture, the average caudad IAS movement is about one vertebral level, notwithstanding the common belief that the IAS is one level cephalad to the upright level.

Determining spinal level using the inferior angle of the scapula as a reference landmark: a retrospective analysis of 50 radiographs.

OBJECTIVE: The purpose of this study was to determine which spinal segment most closely corresponds to the level of the inferior angle of the scapula (IAS) using measurements taken on A-P full-spine radiographs. METHODS: Fifty sequentially selected radiographs were analyzed independently by two examiners. A straight edge was used to ascertain which spinal levels corresponded with the right and left IASs. For analysis, each spinal level was subdivided into three regions: upper vertebral body, lower vertebral body, and intervertebral space. RESULTS: he mean spinal level corresponding to the left IAS was midway between the T8-9 interspace and the upper T9 body (range, lower T7 to upper T10). The mean spinal level corresponding to the right IAS was slightly lower, but still within the upper T9 body (range, lower T7 to lower T10). These levels correspond to the T8 spinous process. CONCLUSIONS: There is a considerable amount of variability in where the IASs are located, but most commonly, they correspond to the level of the upper body of T9.

A review of the use of likelihood ratios in the chiropractic literature.

OBJECTIVE: The objective of this review is to determine how frequently likelihood ratios (LRs) have been used or described in the chiropractic literature and to depict their appropriate use in the clinical setting. METHODS: A literature search was conducted of the MEDLINE, Manual Alternative and Natural Therapy Index System, and Index to Chiropractic Literature databases, with search years encompassing 1966 through June 2006. Citations in the English language that addressed the following search terms were retrieved: likelihood ratio in combination with manipulation and chiropractic. RESULTS: The searches netted a total of 64 citations: 10 in MEDLINE, 34 in the Manual Alternative and Natural Therapy Index System, and 20 in the Index to Chiropractic Literature. After eliminating articles from journals that were not focused specifically on chiropractic, duplicates, and those that did not involve LRs, 3 articles remained and were reviewed. None of the reviewed articles provided a description of LRs, and only 2 used them in a clinical context. CONCLUSIONS: The use of LRs can be very helpful in patient management; however, LRs are rarely reported in the chiropractic literature. Accordingly, chiropractic practitioners are most likely uninformed on the subject and may not have the capacity to use them in formulating diagnoses. It is suggested that researchers increase the reporting of LRs and that chiropractic clinicians begin to make use of them in day-to-day practice.

Spinous process palpation using the scapular tip as a landmark vs a radiographic criterion standard.

OBJECTIVE: This study aimed at determining the standing spinal landmark that corresponds to the inferior tip of the scapula and determining the accuracy of experienced palpators in locating a spinous process (SP) 3 levels above and below a given SP. METHODS: The study participants were 34 asymptomatic or minimally symptomatic chiropractic students. An experienced palpator located the inferior scapular tip on each and then positioned a 2-mm lead marker about 5 cm lateral to the nearest SP. Two more markers were placed at levels intended to be 3 levels above and below the first marker placed. The locations of the scapular tip and the spinal targets were determined by comparison with a radiological criterion standard. RESULTS: The standing inferior scapular tip corresponded to the T8 SP on average (SD = 0.9). Having placed the first lead marker, examiners on average overshot the upper marker by 0.26 (SD = 0.51) vertebral levels and undershot the lower marker by 0.21 (SD = 0.48) vertebral levels. The modes for the placement of the 3 markers were at T5, T8, and T11. CONCLUSION: Approximately 68% of patients would be palpated to have their inferior scapular tips at T7, T8, or T9. An experienced palpator can quite accurately locate vertebral levels 3 above or below a given landmark. Chiropractors and other health professionals using the typical rule of thumb linking the inferior scapular tip to the standing T7 SP have likely been applying clinical interventions at spinal locations different from those intended.

The etiology of cervical artery dissection.

The etiology of cervical artery dissection (CAD) is unclear, although a number of risk factors have been reported to be associated with the condition. On rare occasions, patients experience CAD after cervical spine manipulation, making knowledge about the cervical arteries, the predisposing factors, and the pathogenesis of the condition of interest to chiropractors. This commentary reports on the relevant anatomy of the cervical arteries, developmental features of CAD, epidemiology of the condition, and mechanisms of dissection. The analysis of CAD risk factors is confusing, however, because many people are exposed to mechanical events and known pathophysiological associations without ever experiencing dissection. No cause-and-effect relationship has been established between cervical spine manipulation and CAD, but it seems that cervical manipulation may be capable of triggering dissection in a susceptible patient or contributing to the evolution of an already existing CAD. Despite the many risk factors that have been proposed as possible causes of CAD, it is still unknown which of them actually predispose patients to CAD after cervical spine manipulation.