Notalgia Paresthetica Responding Positively to Chiropractic Spinal Manipulation: A Case Report.

Notalgia paresthetica (NP) is a chronic cutaneous neuropathy characterized by localized pruritus and pain, numbness, and/or paresthesia, often linked to degenerative cervicothoracic changes. Treatment options for NP are limited. This case report details a 54-year-old woman with a six-year history of right-sided periscapular pruritus and cervicothoracic discomfort who presented to a chiropractor upon referral with a prior diagnosis of NP. Prior topical treatments yielded minimal relief. Radiographs revealed degenerative spinal changes at C5/6 and C6/7 which correlated with her periscapular symptom distribution. The patient responded positively to chiropractic spinal manipulative therapy (SMT), focusing on the cervicothoracic region, coupled with myofascial release. Symptoms significantly improved after a single SMT session and resolved after a second session, with no pruritus returning over one-month follow-up. While this case highlights the potential benefits of SMT for NP, further research is needed to explore the effectiveness of this treatment.

Association between chiropractic spinal manipulation and cauda equina syndrome in adults with low back pain: Retrospective cohort study of US academic health centers.

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.

Efficacy of manual therapy for sacroiliac joint pain syndrome: a systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: This study examined the efficacy of manual therapy for pain and disability measures in adults with sacroiliac joint pain syndrome (SIJPS). METHODS: We searched six databases, including gray literature, on 24 October 2023, for randomized controlled trials (RCTs) examining sacroiliac joint (SIJ) manual therapy outcomes via pain or disability in adults with SIJPS. We evaluated quality via the Physiotherapy Evidence Database scale and certainty via Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) in post-treatment pain and disability scores were pooled using random-effects models in meta-regressions. RESULTS: We included 16 RCTs (421 adults; mean age = 37.7 years), with 11 RCTs being meta-analyzed. Compared to non-manual physiotherapy (i.e. exercise ± passive modalities; 10 RCTs) or sham (1 RCT) interventions, SIJ manual therapy did not significantly reduce pain (SMD: -0.88; 95%-CI: -1.84; 0.08, p = 0.0686) yet had a statistically significant moderate effect in reducing disability (SMD: -0.67; 95% CI: -1.32; -0.03, p = 0.0418). The superiority of individual manual therapies was unclear due to low sample size, wide confidence intervals for effect estimates, and inability to meta-analyze five RCTs with a unique head-to-head design. RCTs were of 'good' (56%) or 'fair' (44%) quality, and heterogeneity was high. Certainty was very low for pain and low for disability outcomes. CONCLUSION: SIJ manual therapy appears efficacious for improving disability in adults with SIJPS, while its efficacy for pain is uncertain. It is unclear which specific manual therapy techniques may be more efficacious. These findings should be interpreted cautiously until further high-quality RCTs are available examining manual therapy against control groups such as exercise. REGISTRATION: PROSPERO (CRD42023394326).

Engagement in Integrative and Nonpharmacologic Pain Management Modalities Among Adults with Chronic Pain: Analysis of the 2019 National Health Interview Survey.

Objective: To examine variables associated with engagement in (1) integrative health and medicine (IHM) and (2) nonpharmacologic modalities rather than opioids among United States adults with chronic pain. Methods: Using the 2019 National Health Interview Survey, we examined sociodemographic, pain, and mental health predictors of (1) the sum of IHM modalities (ie, chiropractic care, yoga/Tai Chi, massage, or meditation/guided imagery) used to manage pain and (2) exclusive engagement in nonpharmacologic pain management modalities (ie, IHM, a chronic pain self-management program, support groups, or physical, rehabilitative, occupational, or talk therapy) or opioids in the past 3 months. Results: Metropolitan residency, higher family income, higher education levels, increased number of pain locations, and increased frequency of pain limiting life/work activities were associated with increased odds of IHM engagement. Older age, male sex, non-Hispanic Black/African American race/ethnicity, and daily opioid use were associated with decreased odds of IHM engagement. Older age, male sex, and increased depressive symptoms were associated with decreases in the count of IHM modalities used to manage pain. Metropolitan residency, higher family income, and higher education levels were associated with increased odds of exclusive nonpharmacologic modality engagement. Older age and increasing frequency of pain limiting life/work activities were associated with decreased odds of exclusive nonpharmacologic modality engagement. Conclusions: We identified several contrasts between factors prevalent among individuals with chronic pain and factors associated with engagement in nonpharmacologic and IHM modalities. These results support efforts to address barriers to accessing these modalities among subpopulations of adults with chronic pain (eg, older adults, individuals identifying as Black/African American, rural residents, and those with lower levels of education and income).

Association between spinal manipulative therapy and lumbar spine reoperation after discectomy: a retrospective cohort study.

BACKGROUND: Patients who undergo lumbar discectomy may experience ongoing lumbosacral radiculopathy (LSR) and seek spinal manipulative therapy (SMT) to manage these symptoms. We hypothesized that adults receiving SMT for LSR at least one year following lumbar discectomy would be less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT, over two years' follow-up. METHODS: We searched a United States network of health records (TriNetX, Inc.) for adults aged ≥ 18 years with LSR and lumbar discectomy ≥ 1 year previous, without lumbar fusion or instrumentation, from 2003 to 2023. We divided patients into two cohorts: (1) chiropractic SMT, and (2) usual care without chiropractic SMT. We used propensity matching to adjust for confounding variables associated with lumbar spine reoperation (e.g., age, body mass index, nicotine dependence), calculated risk ratios (RR), with 95% confidence intervals (CIs), and explored cumulative incidence of reoperation and the number of SMT follow-up visits. RESULTS: Following propensity matching there were 378 patients per cohort (mean age 61 years). Lumbar spine reoperation was less frequent in the SMT cohort compared to the usual care cohort (SMT: 7%; usual care: 13%), yielding an RR (95% CIs) of 0.55 (0.35-0.85; P = 0.0062). In the SMT cohort, 72% of patients had ≥ 1 follow-up SMT visit (median = 6). CONCLUSIONS: This study found that adults experiencing LSR at least one year after lumbar discectomy who received SMT were less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT. While these findings hold promise for clinical implications, they should be corroborated by a prospective study including measures of pain, disability, and safety to confirm their relevance. We cannot exclude the possibility that our results stem from a generalized effect of engaging with a non-surgical clinician, a factor that may extend to related contexts such as physical therapy or acupuncture. REGISTRATION: Open Science Framework ( https://osf.io/vgrwz ).

Association between chiropractic spinal manipulation and gabapentin prescription in adults with radicular low back pain: retrospective cohort study using US data.

OBJECTIVES: Radicular low back pain (rLBP) is often treated off-label with gabapentin or by chiropractors using chiropractic spinal manipulative therapy (CSMT). To date, no studies have examined the association between these interventions. We hypothesised that adults under 50 years of age receiving CSMT for newly diagnosed rLBP would have reduced odds of receiving a gabapentin prescription over 1 year-follow-up. DESIGN: Retrospective cohort study. SETTING: US network including linked medical records, medical claims and pharmacy claims of >122 million patients attending large healthcare organisations (TriNetX), queried 15 June 2023, yielding data from 2017 to 2023. PARTICIPANTS: Adults aged 18-49 were included at their first occurrence of rLBP diagnosis. Exclusions were severe pathology, other spinal conditions, on-label gabapentin indications and gabapentin contraindications. Propensity score matching controlled for variables associated with gabapentin use and receipt of prescription medication over the preceding year. INTERVENTIONS: Patients were divided into CSMT or usual medical care cohorts based on the care received on the index date of rLBP diagnosis. PRIMARY AND SECONDARY OUTCOME MEASURES: OR for gabapentin prescription. RESULTS: After propensity matching, there were 1635 patients per cohort (mean age 36.3±8.6 years, 60% women). Gabapentin prescription over 1-year follow-up was significantly lower in the CSMT cohort compared with the usual medical care cohort, with an OR (95% CI) of 0.53 (0.40 to 0.71; p<0.0001). Sensitivity analyses revealed early divergence in cumulative incidence of prescription; and no significant between-cohort difference in a negative control outcome (gastrointestinal medication) suggesting adequate control for pharmacological care preference. CONCLUSIONS: Our findings suggest that US adults receiving CSMT for newly diagnosed rLBP have significantly reduced odds of receiving a gabapentin prescription over 1-year follow-up compared with those receiving usual medical care. Results may not be generalisable and should be replicated in other healthcare settings and corroborated by a prospective study to reduce confounding.

Patients With a History of Spine Surgery Receiving Chiropractic Spinal Manipulation in US Academic Health Centers: A Cross-Sectional Cohort Study.

INTRODUCTION: The number and characteristics of patients with previous spine surgery receiving chiropractic spinal manipulation (CSM) are largely unknown. This study aimed to explore the proportion of patients receiving CSM with a history of spine surgery, the characteristics of these patients, and the treatments received compared to a broader population of patients receiving CSM. METHODS: We queried a 110-million-patient United States (US) network of aggregated records and claims data from patients attending integrated academic health centers (TriNetX, Inc.) on March 6, 2023, yielding data spanning 2013-2023. We identified two patient groups: (1) those receiving CSM and (2) a subset receiving CSM with prior spine surgery. We compared baseline characteristics and treatments received over a one-year follow-up after CSM. RESULTS: Of the 81,291 patients receiving CSM, 8,808 (10.8%) had at least one prior spine surgery. Patients with prior spine surgery receiving CSM were older, more often female, more often non-Hispanic/Latino and White, less often Black, had a greater body mass index, and had a higher prevalence of low back and neck pain compared to the broader CSM cohort (p<0.0001 for each). Those with prior spine surgery were also more likely to receive multiple medications, physiotherapy procedures, and spinal injections (p<0.0001 for each). CONCLUSION: Patients receiving CSM with a history of spine surgery comprise a substantial proportion of CSM patients in large US academic health centers. This subset of patients differs characteristically from the broader CSM population and more often receives medications, physiotherapy, and spinal injections. Further research is needed to examine the safety and efficacy of CSM in this population, given the high proportion of patients and limited research on this topic.

Spinal Metastasis Causing Dropped Head Syndrome in the Chiropractic Office: A Case Report.

Dropped head syndrome is a rare disorder involving an inability to hold the head upright. It may be caused by a variety of neuromuscular disorders and occasionally by pathological vertebral fractures. A 79-year-old man presented to a chiropractor with a two-year history of gradual-onset chin-on-chest posture and increased thoracic kyphosis, which had failed to respond to physical therapy. The chiropractor ordered whole spine computed tomography which revealed extensive mixed lytic and sclerotic changes and multiple thoracic compression fractures suggestive of metastasis. The chiropractor promptly referred the patient to an oncologist, who performed a biopsy confirming prostate adenocarcinoma. The patient's health deteriorated, and he expired three weeks later. This case highlights that chiropractors should be aware that patients may present to their office with symptoms related to undiagnosed cancer, such as spinal deformity and dropped head syndrome. Chiropractors should order advanced imaging when patients have red flag signs or symptoms (e.g., older age, progressive symptoms despite care) and refer to an oncologist when clinical features or testing are suggestive of metastasis.

Clinician approaches to spinal manipulation for persistent spinal pain after lumbar surgery: systematic review and meta-analysis of individual patient data.

BACKGROUND: This review aimed to identify variables influencing clinicians' application of spinal manipulative therapy (SMT) for persistent spine pain after lumbar surgery (PSPS-2). We hypothesized markers of reduced clinical/surgical complexity would be associated with greater odds of applying SMT to the lumbar region, use of manual-thrust lumbar SMT, and SMT within 1-year post-surgery as primary outcomes; and chiropractors would have increased odds of using lumbar manual-thrust-SMT compared to other practitioners. METHODS: Per our published protocol, observational studies describing adults receiving SMT for PSPS-2 were included. PubMed, Web of Science, Scopus, OVID, PEDro, and Index to Chiropractic Literature were searched from inception to January 6, 2022. Individual patient data (IPD) were requested from contact authors when needed for selection criteria. Data extraction and a customized risk-of-bias rubric were completed in duplicate. Odds ratios (ORs) for primary outcomes were calculated using binary logistic regressions, with covariates including age, sex, symptom distribution, provider, motion segments, spinal implant, and surgery-to-SMT interval. RESULTS: 71 articles were included describing 103 patients (mean age 52 ± 15, 55% male). The most common surgeries were laminectomy (40%), fusion (34%), and discectomy (29%). Lumbar SMT was used in 85% of patients; and of these patients was non-manual-thrust in 59%, manual-thrust in 33%, and unclear in 8%. Clinicians were most often chiropractors (68%). SMT was used > 1-year post-surgery in 66% of cases. While no primary outcomes reached significance, non-reduced motion segments approached significance for predicting use of lumbar-manual-thrust SMT (OR 9.07 [0.97-84.64], P = 0.053). Chiropractors were significantly more likely to use lumbar-manual-thrust SMT (OR 32.26 [3.17-327.98], P = 0.003). A sensitivity analysis omitting high risk-of-bias cases (missing ≥ 25% IPD) revealed similar results. CONCLUSIONS: Clinicians using SMT for PSPS-2 most often apply non-manual-thrust SMT to the lumbar spine, while chiropractors are more likely to use lumbar-manual-thrust SMT relative to other providers. As non-manual-thrust SMT may be gentler, the proclivity towards this technique suggests providers are cautious when applying SMT after lumbar surgery. Unmeasured variables such as patient or clinician preferences, or limited sample size may have influenced our findings. Large observational studies and/or international surveys are needed for an improved understanding of SMT use for PSPS-2. Systematic review registration PROSPERO (CRD42021250039).

Improvement of Chronic Neck Pain After Posterior Atlantoaxial Surgical Fusion via Multimodal Chiropractic Care: A Case Report.

There is a lack of research regarding the effectiveness and safety of manual therapies, including spinal manipulative therapy (SMT), for patients with previous cervical spine surgery. A 66-year-old, otherwise healthy, woman who underwent C1/2 posterior surgical fusion for rotatory instability during adolescence presented to a chiropractor with a six-month history of progressive worsening of chronic neck pain and headaches despite acetaminophen, tramadol, and physical therapy. Upon examination, the chiropractor noted postural changes, limited cervical range of motion, and muscle hypertonicity. Computed tomography revealed a successful C1/2 fusion, and degenerative findings at C0/1, C2/3, C3/4, and C5/6, without cord compression. As the patient had no neurologic deficits or myelopathy and tolerated spinal mobilization well, the chiropractor applied cervical SMT, along with soft tissue manipulation, ultrasound therapy, mechanical traction, and thoracic SMT. The patient's pain was reduced to a mild level and the range of motion improved over three weeks of treatment. Benefits were maintained over a three-month follow-up as treatments were spaced apart. Despite the apparent success in the current case, evidence for manual therapies and SMT in patients with cervical spine surgery remains limited, and these therapies should be used with caution on an individual patient basis. Further research is needed to examine the safety of manual therapies and SMT in patients following cervical spine surgery and determine predictors of treatment response.

Spondylodiscitis Presenting to a Chiropractor: A Case Report and Literature Review.

An 80-year-old man under combination therapy for pulmonary tuberculosis presented to a chiropractor with a one-month history of worsening chronic low back pain, yet denied having any respiratory symptoms, weight loss, or night sweats. Two weeks prior, he saw an orthopedist who ordered lumbar radiographs and magnetic resonance imaging (MRI), showing degenerative changes and subtle findings of spondylodiscitis, but was treated conservatively with a nonsteroidal anti-inflammatory drug. The patient was afebrile, yet considering his older age and worsening symptoms, the chiropractor ordered a repeat MRI with contrast, which revealed more advanced findings of spondylodiscitis, psoas abscesses, and epidural phlegmon, and referred the patient to the emergency department. A biopsy and culture confirmed Staphylococcus aureus infection and were negative for Mycobacterium tuberculosis. The patient was admitted and treated with intravenous antibiotics. We conducted a literature review revealing nine previously published cases of patients with spinal infection presenting to a chiropractor, who were typically afebrile men with severe low back pain. Chiropractors rarely encounter patients with undiagnosed spinal infections and should manage those suspected of infection with urgency via advanced imaging and/or referral.

Lung Cancer With Vertebral Metastases Presenting as Low Back Pain in the Chiropractic Office: A Case Report.

Lung cancer commonly metastasizes to the skeletal system, and when affecting the spine, it may initially be mistaken for a typical musculoskeletal source of back pain. We report a previously healthy 52-year-old male non-smoker with an eight-week history of low back pain that radiated into his left thigh and recent weight loss, yet no respiratory symptoms. Initially, the patient visited his primary care physician, who suspected a musculoskeletal condition and prescribed a nonsteroidal anti-inflammatory drug and muscle relaxant, then referred the patient to the chiropractor. Based on the patient's pain pattern, limited mobility, and other features, the chiropractor suspected a lumbar disc herniation. However, the patient's condition worsened during a one-week trial of care, so the chiropractor ordered magnetic resonance imaging (MRI) and, as the findings suggested vertebral metastasis, promptly referred the patient to an oncologist, who confirmed a diagnosis of lung adenocarcinoma via positron emission tomography (PET)/computed tomography and biopsy. Chiropractors should be aware of warning signs of malignancy, such as unexplained weight loss or progressive worsening despite treatment. If providers suspect spinal metastasis, they should order advanced imaging such as an MRI and refer patients to an oncologist for timely care.

Sacral Giant Cell Tumor Presenting as Low Back Pain in the Chiropractic Office: A Case Report.

Sacral giant cell tumors are a rare cause of low back pain and may be challenging to identify via routine clinical examination and radiography. A 47-year-old woman presented to a chiropractor with a one-month history of worsening low back pain with radiation to the posterior thighs, worsened with ambulation, and used a cane to walk. She previously saw an orthopedic surgeon and was diagnosed with lumbar spondylosis, having tried anti-inflammatory medications, exercises, and acupuncture without success. The chiropractor ordered lumbar magnetic resonance imaging which revealed an aggressive sacral lesion and referred the patient to an oncologist. The oncologist performed positron emission tomography/computed tomography and biopsy, confirming a sacral giant cell tumor. A surgical team recommended tumor resection, lumbosacral fusion, radiotherapy, and zoledronic acid infusion. Sacral giant cell tumors are rare and may be challenging to identify via routine radiography. These tumors are an important differential to consider for patients with unexplained lumbosacral symptoms unresponsive to care.

A retrospective analysis of the incidence of severe adverse events among recipients of chiropractic spinal manipulative therapy.

This study examined the incidence and severity of adverse events (AEs) of patients receiving chiropractic spinal manipulative therapy (SMT), with the hypothesis that < 1 per 100,000 SMT sessions results in a grade ≥ 3 (severe) AE. A secondary objective was to examine independent predictors of grade ≥ 3 AEs. We identified patients with SMT-related AEs from January 2017 through August 2022 across 30 chiropractic clinics in Hong Kong. AE data were extracted from a complaint log, including solicited patient surveys, complaints, and clinician reports, and corroborated by medical records. AEs were independently graded 1-5 based on severity (1-mild, 2-moderate, 3-severe, 4-life-threatening, 5-death). Among 960,140 SMT sessions for 54,846 patients, 39 AEs were identified, two were grade 3, both of which were rib fractures occurring in women age > 60 with osteoporosis, while none were grade ≥ 4, yielding an incidence of grade ≥ 3 AEs of 0.21 per 100,000 SMT sessions (95% CI 0.00, 0.56 per 100,000). There were no AEs related to stroke or cauda equina syndrome. The sample size was insufficient to identify predictors of grade ≥ 3 AEs using multiple logistic regression. In this study, severe SMT-related AEs were reassuringly very rare.

Concurrent Spinal and Intracranial Subdural Hematomas as a Cause of Near-Fatal Low Back Pain in the Chiropractic Office: A Case Report.

In older individuals, minor trauma may cause potentially fatal intracranial subdural hematoma (SDH). Rarely, these patients present with only low back and radicular pain as gravity redistributes the SDH to the lumbar spine. A 69-year-old male presented to a chiropractor with a 10-day history of acute on chronic low back pain, which radiated into his lower extremities bilaterally, involving weakness and difficulty walking, and a ground-level fall onto his elbows 16 days prior. He had visited his primary care provider, orthopedist, and traditional Chinese medicine practitioner, received oral analgesics and three ketorolac injections, and had lumbar radiographs, followed by acupuncture, cupping, and spinal manipulation without lasting relief. Considering the patient's concerning presentation, the chiropractor ordered lumbar magnetic resonance imaging (MRI) on the first visit, revealing findings suggestive of late subacute lumbar SDH, and recommended urgent brain MRI and neurosurgical referral. The patient went to an orthopedic surgeon at a nearby hospital, becoming disoriented upon presentation, prompting admission. Brain MRI confirmed bilateral chronic intracranial SDH, prompting emergency hematoma evacuation via burr hole craniostomy. The patient's gait rapidly improved, and the pain subsided over the following two weeks. This case highlights an older male identified as having spinal SDH by a chiropractor, leading to referral and surgery for concurrent life-threatening intracranial SDH. Clinicians should be aware that spinal SDH may stem from asymptomatic intracranial SDH and should be suspicious of SDH in older individuals after a fall, signs of which warrant emergency referral for MRI and surgical evaluation.

Lumbar Schwannoma as a Rare Cause of Radiculopathy in the Chiropractic Office: A Case Report.

Cauda equina tumors are rare, slow-growing, and typically benign. These tumors present with low back pain resembling disc displacement with radiculopathy and thus may go undiagnosed for months. A 52-year-old, otherwise healthy man presented to a chiropractor with a one-year history of worsening low back pain radiating to the right lower extremity, rated an 8/10 in severity and aggravated by recumbency. Previously, his primary care physician had ordered radiographs revealing mild lumbar degenerative changes, prescribed a non-steroidal anti-inflammatory medication, and referred him to an orthopedist and physical therapist. There had been no change in symptoms. Upon examination by the chiropractor, the patient had neurologic deficits, and due to progressive worsening, the chiropractor recommended magnetic resonance imaging (MRI), which the patient deferred due to cost. The chiropractor initiated a trial of care, with initial success; however, the patient's symptoms recurred, and he consented to an MRI. MRI revealed an intradural extramedullary lumbar tumor, and the chiropractor referred the patient to an oncologist, who referred the patient to a neurosurgeon. The neurosurgeon surgically removed the mass, with a biopsy confirming a schwannoma. The patient had significantly improved six weeks after surgery. This case highlights a patient with chronic low back pain for whom a chiropractor identified a cauda equina tumor and referred him for further evaluation and surgery. Clinicians should consider night pain and persistent symptoms, despite conservative care, as red flags warranting further investigation in those with low back pain. Providers should refer for neurosurgical evaluation when clinical and radiological findings suggest a cauda equina tumor.

The Effects of Four Weeks of Chiropractic Spinal Adjustments on Blood Biomarkers in Adults with Chronic Stroke: Secondary Outcomes of a Randomized Controlled Trial.

Certain blood biomarkers are associated with neural protection and neural plasticity in healthy people and individuals with prior brain injury. To date, no studies have evaluated the effects chiropractic care on serum brain-derived neurotrophic factor (BDNF), insulin-like growth factor-II (IGF-II) and glial cell-derived neurotrophic factor (GDNF) in people with stroke. This manuscript reports pre-specified, exploratory, secondary outcomes from a previously completed parallel group randomized controlled trial. We evaluated differences between four weeks of chiropractic spinal adjustments combined with the usual physical therapy (chiro + PT) and sham chiropractic with physical therapy (sham + PT) on resting serum BDNF, IGF-II and GDNF in 63 adults with chronic stroke. Blood samples were assessed at baseline, four weeks (post-intervention), and eight weeks (follow-up). Data were analyzed using a linear multivariate mixed effects model. Within both groups there was a significant decrease in the mean log-concentration of BDNF and IGF-II at each follow-up, and significant increase log-concentration of GDNF at eight-weeks' follow-up. However, no significant between-group differences in any of the blood biomarkers at each time-point were found. Further research is required to explore which factors influence changes in serum BDNF, IGF-II and GDNF following chiropractic spinal adjustments and physical therapy.

Thoracic Schwannoma as an Unusual Cause of Sciatic Pain in the Chiropractic Office: A Case Report.

BACKGROUND Sciatica, which is pain radiating along the sciatic nerve distribution, is most often caused by degenerative conditions of the lower back and rarely results from lesions of the spinal cord. This case report illustrates a patient with suspected lumbar radiculopathy, ultimately diagnosed with a thoracic schwannoma after visiting a chiropractor. CASE REPORT A 61-year-old woman presented to a chiropractor with progressively worsening lower back pain radiating to the right lower extremity and unsteady gait. Her symptoms began 10 years previously and she had been diagnosed by an orthopedist with lumbar disc herniation causing radiculopathy via magnetic resonance imaging (MRI) and was treated with physical therapy and diclofenac. Upon examination by the chiropractor, the patient had bilateral lower-extremity neurologic deficits, hyperreflexia, and upgoing Babinski responses. The chiropractor ordered thoracic MRI, but the patient preferred to initiate a trial of care, which was unsuccessful. After a delay imposed by cardiac bypass surgery, the patient returned to the chiropractor with worsened symptoms and underwent thoracic MRI, revealing an intraspinal mass at T9. The patient underwent laminectomy and tumor removal, with histopathology confirming a diagnosis of schwannoma. The patient gradually improved after surgery with the help of rehabilitative exercises. CONCLUSIONS Clinicians should suspect a spinal cord lesion as a cause of sciatic pain when patients fail to improve with treatment, have a broad sensorimotor distribution unexplained by lumbar imaging findings, hyperreflexia/pathological reflexes, or other atypical findings (eg, negative neural tension tests). In such cases, MRI of the cervical and thoracic spine may be indicated.

Neck Pain and Headache After Pinealectomy: Improvement with Multimodal Chiropractic Therapies.

BACKGROUND Pineal gland tumors are rare central nervous system tumors, and while neck pain and headaches may be common among those who have had these tumors removed, there is little research regarding management of these symptoms. CASE REPORT A 45-year-old man with a history of pineal germinoma treated with pinealectomy, chemotherapy, radiation therapy, and ventriculoperitoneal shunt placement at age 21 presented with chronic neck pain and headaches, which initially improved following his surgery and concurrent therapies, yet progressively worsened over the following years. He required thyroid and testosterone medication because of radiation-induced hypopituitarism, yet was employed, and until recently, active with playing tennis. He had previously seen his primary care provider, orthopedist, and neurologist, and had been cleared of severe pathology via brain magnetic resonance imaging and was referred to the chiropractor. On examination, the patient had severely limited passive cervical spine range of motion, yet hat no neurologic deficits, and radiographs showed mild cervical spondylosis and cervicothoracic scoliosis. His history and presentation were suggestive of radiation-induced fibrosis. The patient's neck pain, headaches, and quality of life improved with multimodal treatments including spinal and soft-tissue manipulation, stretches, and yoga. CONCLUSIONS This case illustrates long-term sequelae of a pineal gland tumor and its treatment, including neck pain and headache, and improvement with multimodal chiropractic therapies. Despite the success in this case, these results are not broadly generalizable. Further research is needed to understand the natural history of symptoms and effectiveness of multimodal therapies among patients who have had pineal tumor surgery.

Identification of Degenerative Cervical Myelopathy in the Chiropractic Office: Case Report and a Review of the Literature.

Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction, yet it may be challenging to identify as it presents with variable symptoms. A 62-year-old woman presented to a chiropractor with a three-month exacerbation of neck pain, hand/finger numbness, and torso dysesthesia. She had previously seen primary care, physical therapy, rheumatology, and pain management. Previous cervical magnetic resonance imaging showed moderate cervical canal stenosis; however, previous providers had diagnosed her with radiculopathy and possible carpal tunnel syndrome yet had not requested neurosurgical consultation. On examination, the chiropractor identified sensorimotor deficits, hyperreflexia, and bilateral Hoffman reflexes, and referred the patient to a neurosurgeon for suspected DCM. The neurosurgeon performed an anterior cervical discectomy and fusion from C4-7. The patient's symptoms and disability level improved within two months of follow-up. We identified 11 previous cases in which a chiropractor suspected DCM which was then confirmed by a surgeon. Including the current case (i.e., 12 total), patients were older and mostly male; 50% had neck pain, 92% had hyperreflexia. Chiropractors referred each patient to a surgeon; 83% underwent cervical spine surgery. This case highlights the identification of DCM by a chiropractor and referral for neurosurgical evaluation with a positive outcome. Patients with previously undiagnosed DCM may present to chiropractors with varied symptoms and examination findings. DCM may contraindicate spinal manipulation and instead warrant surgery. Accordingly, chiropractors play a key role in the detection and referral of patients with misdiagnosed or overlooked DCM.