Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine.

OBJECTIVE: The chiropractic care of a patient with vertebral subluxations, neck pain, and cervical radiculopathy after a cervical diskectomy is described. CLINICAL FEATURES: A 55-year-old man had neck pain and left upper extremity radiculopathy after unsuccessful cervical spine surgery. INTERVENTION AND OUTCOME: Contact-specific, high-velocity, low-amplitude adjustments (i.e., Gonstead technique) were applied to sites of vertebral subluxations. Rehabilitation exercises were also used as adjunct to care. The patient reported a decrease in neck pain and left arm pain after chiropractic intervention. The patient also demonstrated a marked increase in range of motion (ROM) of the left glenohumeral articulation. CONCLUSION: The chiropractic care of a patient with neck pain and left upper extremity radiculopathy after cervical diskectomy is presented. Marked resolution of the patient's symptoms was obtained concomitant with a reduction in subluxation findings at multiple levels despite the complicating history of an unsuccessful cervical spine surgery. This is the first report in the indexed literature of chiropractic care after an unsuccessful cervical spine surgery.

Chiropractic management of a patient with myasthenia gravis and vertebral subluxations.

OBJECTIVE: The chiropractic management of a patient with myasthenia gravis and vertebral subluxation is described. We discuss the pathophysiology, clinical features, and treatment of patients with these diseases. CLINICAL FEATURES: The 63-year-old male patient suffered from complaints associated with the disease myasthenia gravis along with signs of vertebral subluxation. The patient had an initial complaint of dysphagia. In addition, the patient experienced swelling of the tongue, nausea, digestive problems, weakness in the eye muscles, difficulty breathing, myopia, diplopia, and headaches. Balance and coordination problems resulted in walking difficulties. INTERVENTION AND OUTCOME: Contact specific, high-velocity, low-amplitude adjustments were applied to sites of patient subluxation. Myasthenia gravis is no longer debilitating to the patient; he is medication free and has resumed a "normal life." CONCLUSION: The clinical aspects of the disease, including the possible role of chiropractic intervention in the treatment of patients suffering from myasthenia gravis, are also discussed. This case study encourages further investigation into the holistic approach to patient management by chiropractors vis-a-vis specific adjustments of vertebral subluxation.

Chiropractic management of a patient with subluxations, low back pain and epileptic seizures.

OBJECTIVE: To describe the chiropractic management of a patient presenting with complaints of low back pain and epileptic seizures. The discussion also addresses epilepsy and the current concepts of this disorder; possible mechanisms for the neurological effects of the chiropractic adjustment at sites of subluxation and its therapeutic implications are proposed. CLINICAL FEATURES: A 21-year-old woman with low back pain reported that she had fainted during the night and hit her head. She had been diagnosed since childhood with grand mal (tonicclonic) seizures as well as petit mal seizures. She had a seizure approximately every 3 hr, with a duration between 10 sec and 30 min for each episode. Examination indicated signs of subluxation/dysfunction at the L5-S1, C6-C7 and C3-C4 spinal levels. There was no evidence of cranial nerve involvement or any upper motor neuron lesion. Radiographic analysis revealed retrolisthesis of L5, hypolordosis of the cervical spine and hyperextension of the C6-C7 motion segment. INTERVENTION AND OUTCOME: Chiropractic adjustments using a specific-contact, short-lever arm, high-velocity, low-amplitude maneuver (i.e., Gonstead) were applied to the subluxations at the cervical, thoracic and lumbopelvic region. The patient's reported low back pain and neck complaints improved and her seizure frequency decreased. At 1.5-yr follow-up, the patient reported her low back complaints had resolved and her seizures had decreased (period between seizures as great as 2 months). CONCLUSION: Results encourage further investigation of possible neurological sequalae, such as epileptic seizures, from spinal dysfunction identified as vertebral subluxation complexes by chiropractors and treated by specific spinal adjustments.

Management of a patient with calcium pyrophosphate deposition disease and meniscal tear of the knee: a case report.

OBJECTIVE: To describe the chiropractic management of a patient suffering from a right lateral meniscus tear concurrent with calcium pyrophosphate dihydrate (CPPD) deposition disease. CLINICAL FEATURES: A 51-yr-old bus driver suffered from right knee pain (7 on a 1-10 pain scale). The onset of the pain was gradual and increased during braking and accelerating. Palpatory tenderness was noted at the right lateral knee joint line and the inferior lateral margin of the patella. Active resistive range of motion (ROM) in the knee during extension was painful throughout the full ROM, whereas passive ROM was restricted in flexion at 110 degrees. A positive McMurray's test reproduced pain at the knee. Radiographic analysis revealed CPPD deposition disease, and magnetic resonance imaging revealed a probable "parrot's beak" tear in the posterior horn of the right lateral meniscus. INTERVENTION AND OUTCOME: The patient was treated conservatively. He was instructed not to put weight on the knee and not to return to work for 5 days. Initial treatments involved the use of ice and interferential electrical stimulation along with glucosamine sulfate supplements. Bicycling, weight lifting for general fitness and general knee strengthening exercises were prescribed. Approximately 5 months after initial treatment, the patient was lost to follow-up; 12 months later, he returned for treatment because of a recurrence. Physical examination at that time revealed knee pain rated at 3/10 but there was no pain upon palpation, McMurray's test was negative and right knee ROM was full without pain. CONCLUSION: A patient suffering from CPPD can be managed by conservative means. The pathophysiology, clinical features and management considerations in the treatment of the patient's condition(s) are also discussed.

Management of a patient with a lamina fracture of the sixth cervical vertebra and concomitant subluxation.

OBJECTIVE: To discuss the chiropractic management of a patient who sustained a unilateral lamina fracture of the sixth cervical vertebra. CLINICAL FEATURES: The patient had suffered cervical trauma from a motor vehicle accident. Clinical evaluation revealed acute global neck pain with associated left arm radiculitis and approximately 75% loss of useful left-arm motor function. The patient also complained of headache and low back pain. Computerized tomography and radiographic findings indicated a left lamina fracture of the sixth cervical vertebra. INTERVENTION AND OUTCOME: A rigid cervical collar was prescribed for the patient and specific-contact, short lever-arm, high-velocity, low-amplitude adjustments were applied at the levels of C2, C7 and L5, on different treatment visits, 11 days after trauma. The patient continued to wear the orthosis after each adjustment. The patient recovered from his injury and had no late biomechanical or neurological instability as a result of this management approach. CONCLUSION: The chiropractic management of a patient who sustained a unilateral lamina fracture of C6 with concomitant subluxations at C2 and C7 is discussed. This case study is the second reported in the scientific literature in which conservative chiropractic methods were applied to a patient with a lamina fracture.

Management of the patient with a Chance fracture of the lumbar spine and concomitant subluxation.

OBJECTIVE: To document the chiropractic management of a patient who sustained a Chance fracture of the third lumbar vertebra. This case study represents the first report in the scientific literature of such an injury managed through chiropractic methods. CLINICAL FEATURES: An 18-yr-old man complained of low back pain and paresthesia in the lower extremities 10 days after suffering an automobile accident. Examination revealed a large circular edematous area from L1 to L4, tenderness to palpation at the L3 spinous process, reduction in global range of motion at the thoracolumbar region, and positive Lasègue and Kemp tests (bilaterally). Radiographic and computed tomographic scans revealed a Chance fracture of the L3 vertebra. INTERVENTION AND OUTCOME: The patient received specific-contact, short-lever arm spinal adjustments delivered primarily at L3 and L5, as well as bracing. Four months after initial treatment, the patient's complaint of paresthesia had resolved and he suffered only occasional minor low back pain. The comparative radiographs demonstrate a reduction in the separation of the fracture fragments. CONCLUSION: A case report is presented of a patient who suffered a Chance fracture of L3. The patient was eventually managed by chiropractic methods including a specific contact high-velocity thrust procedure administered at the level of the fractured vertebra. The case represents the first known reporting of this type of chiropractic procedure applied to a patient with a Chance fracture.

Missed sacral fracture before chiropractic adjustment.

OBJECTIVE: Reports of complications after chiropractic adjustments were administered to the lumbar spine and/or pelvis are rare. This case report provides the events associated with a sacral fracture that was not identified before a side-posture sacroiliac adjustment. CLINICAL FEATURES: The patient suffered from blunt, low back trauma as a result of a fall. Clinical evaluation indicated fixation dysfunction at the left sacroiliac articulation, with minimal edema/tenderness at the inferior portion of the left sacroiliac joint. Initial radiological evaluation failed to disclose the zone 2 sacral fracture because of an underexposed radiograph; thus, the patient was given a diagnosis of a sacroiliac sprain subluxation. INTERVENTION AND OUTCOME: A specific contact sacroiliac adjustment that uses the innominate as the short lever arm was administered to the patient in the side-posture position. Two adjustments were administered over 2 days. The patient developed sciatic pain after the second adjustment and subsequently referred herself to a medical orthopedist. Additional plain films were obtained, and a diagnosis of a zone 2 sacral fracture was made. The patient was prescribed bed rest; at 6 wk, her symptoms resolved and she returned to normal activity levels. CONCLUSION: Fractures of the spine and pelvis need to be considered in a patient who suffers blunt trauma. An adequate radiographic examination is necessary to make the appropriate diagnosis. Failure to diagnose the fracture may lead to complications, because the adjustment is not administered with regard to the biomechanics of the trauma or the actual clinical entity under scrutiny. This case study represents the first report of a complication after a sacroiliac adjustment in a patient who had a zone 2 sacral fracture that was missed in the diagnosis.

The reliability of patient positioning for evaluating static radiologic parameters of the human pelvis.

OBJECTIVE: To determine the reproducibility of patient positioning on radiographically evaluated static configurations of the human pelvis. DESIGN: Repeat anteroposterior radiography of the human pelvis was performed in vivo. Comparative examinations were performed after 1 hr in one subject pool. A second sample underwent repeat examination after a mean of 18 days. SETTING: Outpatient private practice chiropractic clinic. SUBJECTS: Thirty-seven relatively asymptomatic subjects participated in the experiment. MAIN OUTCOME MEASURES: Millimetric evaluations were made for leg length inequality, right/left sacral discrepancies and right/left innominate differences. The null hypothesis was that the difference of the measurements from the two radiographs would be equal to zero. A paired t-test was used to analyze if there were any significant differences. The mean measured difference in millimeters and correlation coefficients were also determined for each variable. RESULTS: Individual variations for several roentgenometric parameters, including leg length inequality and pelvic torsion, did not reach statistical significance (p > .05) although minor millimetric discrepancies were recorded. Correlation coefficients, in most cases, were relatively high. CONCLUSION: A subject can be reliably positioned for repeat anteroposterior pelvic radiography for both 1 hr and 18-day intervals. The methodology described has applicability to full spine radiography when roentgenometric parameters of the pelvis are scrutinized.

Chiropractic management of a hypertensive patient.

OBJECTIVE: Although many chiropractors may treat patients who have concomitant hypertensive disease, there is a paucity of literature on the nuances of case management for these patients. We report a patient who underwent a course of chiropractic care with a previous diagnosis of chronic essential hypertension. CLINICAL FEATURES: A 38-yr-old male presented for chiropractic care with complaints of hypertension, drug-related side effects and lower back pain. He was also receiving concurrent medical care for his hypertension. INTERVENTION AND OUTCOME: The patient received specific contact, short lever arm spinal adjustments as the primary mode of chiropractic care. During the course of chiropractic treatment, the patient's need for hypertensive medication was reduced. The patient's medical physician gradually withdrew the medication over 2 months. CONCLUSION: Specific contact short lever arm spinal adjustments may cause a hypotensive effect in a medicated hypertensive patient that may lead to complications (e.g., hypotension). Since a medicated hypertensive patient's blood pressure may fall below normal while he or she is undergoing chiropractic care, it is advised that the blood pressure be closely monitored and medications adjusted, if necessary, by the patient's medical physician.

The interexaminer reliability of a galvanic skin response instrument.

OBJECTIVE: To determine the interexaminer reliability of a protocol of use of a galvanic skin resistance device for detection of low resistance areas along the spinal column, in relatively pain-free subjects. DESIGN: A blinded investigation of concordance of skin resistance examination findings over the spinal column using two clinicians experienced in the use of the instrument. SETTING: A private practice chiropractic outpatient clinic. PATIENTS: Sixty-four male and female chiropractic college students (mean age: 35 yr). The Visual Analog Pain Scale indicated a mean response of 7.6 mm on a 100-mm range. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Concordance of examiners evaluated with the kappa statistic. RESULTS: The results indicated modest levels of concordance for the first study sample (n = 46). The average kappa was 0.37. The second group assessed (n = 18) also demonstrated only modest levels of interexaminer concordance. The average kappa value for this sample was 0.36. CONCLUSION: The use of the Electrical Conductor Scanner instrument for evaluating putative spinal pathology through manifestations in skin resistance in relatively asymptomatic subjects is not supported by the results of this experiment. The unevenness of data generated from this experiment in certain spinal regions necessitates further investigation prior to making any strong conclusions regarding the usefulness of this instrument in the clinical setting.

Skin temperature assessment for neuromusculoskeletal abnormalities of the spinal column.

OBJECTIVE: A qualitative review of the scientific literature on thermographic instrumentation for detecting neuromusculoskeletal abnormalities of the spinal column was made. Electronic infrared instrumentation (telethermography), liquid crystal thermography and various hand-held devices were scrutinized in terms of reliability and comparison with other diagnostic tests (e.g., computed tomography, myelography, electromyography, magnetic resonance imaging). DATA SOURCES: A Medline literature search was performed from 1966 through 1990. English language material was retrieved using the following key words: thermography and spine, spinal injuries, cervical vertebrae, thoracic vertebrae, lumbar vertebrae, sacroiliac joint, lumbosacral region, back or neck. The Index to Chiropractic Literature was also reviewed. The categories of skin temperature and thermography were scrutinized. Chapters of texts and nonpublished works were not incorporated. STUDY SELECTION: Studies involving the comparison of thermographic findings with those of other tests were the primary focus of the review. Case reports, as well as the use of thermography as an outcome measure, were also studied. Interexaminer reliability studies are reported. DATA EXTRACTION: The study populations are characterized as well as binding procedures, if any. The authors' statistical work, if applicable, is presented and criticized. DATA SYNTHESIS: Relatively few reliability studies exist for thermography. Emphasis has been on validity studies that compare the results of the thermogram with other reference tests. There has been a general lack of high-quality research design (e.g., blinding) throughout the thermographic literature base. The sensitivity of the various thermographic instrumentation has shown encouraging results, although this must be tempered with the generally poor design of many studies. Specificity, in contrast, has shown mixed results. The review indicated telethermography to be a sensitive diagnostic procedure for detecting abnormalities, such as disc protrusion, of the lumbar and cervical spine. Liquid crystal thermography effectiveness is difficult to determine due to the paucity of blinded investigations, although normative data for the cervical spine and upper extremities is present. Literature on the various hand-held instruments has revealed moderate levels of examiner reliability for infrared devices, with less information available for thermocouple instruments. Normative data for hand-held instruments is absent. CONCLUSION: Continued investigation is needed in the area of thermographic research in light of the paucity of blinded and/or controlled investigations. More sensitive neurophysiological and anatomical measures must be used when comparing the results from thermography. The lack of an available gold standard for comparing thermographic findings has been problematic. Future research should focus on thermography as a noninvasive outcome measure and interpreter reliability.

The inter- and intraexaminer reliability of the Gonstead pelvic marking system.

An investigation was undertaken to determine the inter- and intraexaminer reliability of the Gonstead pelvic radiographic marking system. This methodology analyzes the relative dimensions and spatial positions of the two innominate bones and sacrum and measures leg length inequality through an evaluation of femur head height. Two examiners marked 71 full spine radiographs twice to provide data from 284 analyses. Reliability was ascertained with the Pearson r, Spearman, intraclass correlation coefficient (ANOVA) and Kappa statistics. All results were statistically significant (less than 0.001) and indicated high levels of concordance. In every case, intraexaminer agreement was superior to interexaminer concordance.

The inter- and intraexaminer reliability of a paraspinal skin temperature differential instrument.

An experiment was undertaken to determine the intra- and interexaminer reliability of a paraspinal skin temperature differential instrument. Nineteen pain-free female chiropractic college students participated as subjects for the investigation. Three separate areas of the spine (C4-T2, T4-T8 and L2-L5) were examined for concordance between two examiners. Additionally, intraexaminer reliability was tested by having each examiner repeat the scanning procedure. Concordance for whether a temperature differential existed in a particular area was evaluated with the Kappa statistic. Kappas ranged from 0.034 to 0.6591 and were all statistically significant (p less than 0.05). This represented slight to moderate reliability in the area C4-T2 and substantial agreement in the region T4-T8. The lumbar region could not be evaluated with the Kappa statistic due to limited variation. Following agreement for a positive finding in a given area, the numerical ratings were evaluated for agreement with the intraclass correlation coefficient (ICC). The first observation between examiners indicated fair agreement (ICC = 0.2756, p = 0.0478). The second observation between examiners had substantial agreement (ICC = 0.6402, p = 0.042). Intraexaminer agreement was moderate for one examiner (ICC = 0.5078, p = 0.0016). The other examiner showed an excellent level of agreement (ICC = 0.8588, p less than 0.001) between observations.