Spinal manipulation characteristics: a scoping literature review of force-time characteristics.

BACKGROUND: Spinal manipulation (SM) is a recommended and effective treatment for musculoskeletal disorders. Biomechanical (kinetic) parameters (e.g. preload/peak force, rate of force application and thrust duration) can be measured during SM, quantifying the intervention. Understanding these force-time characteristics is the first step towards identifying possible active ingredient/s responsible for the clinical effectiveness of SM. Few studies have quantified SM force-time characteristics and with considerable heterogeneity evident, interpretation of findings is difficult. The aim of this study was to synthesise the literature describing force-time characteristics of manual SM. METHODS: This scoping literature review is reported following the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) statement. Databases were searched from inception to October 2022: MEDLINE (Ovid), Embase, CINAHL, ICL, PEDro and Cochrane Library. The following search terms and their derivatives were adapted for each platform: spine, spinal, manipulation, mobilization or mobilisation, musculoskeletal, chiropractic, osteopathy, physiotherapy, naprapathy, force, motor skill, biomechanics, dosage, dose-response, education, performance, psychomotor, back, neck, spine, thoracic, lumbar, pelvic, cervical and sacral. Data were extracted and reported descriptively for the following domains: general study characteristics, number of and characteristics of individuals who delivered/received SM, region treated, equipment used and force-time characteristics of SM. RESULTS: Of 7,607 records identified, 66 (0.9%) fulfilled the eligibility criteria and were included in the analysis. Of these, SM was delivered to the cervical spine in 12 (18.2%), the thoracic spine in 40 (60.6%) and the lumbopelvic spine in 19 (28.8%) studies. In 6 (9.1%) studies, the spinal region was not specified. For SM applied to all spinal regions, force-time characteristics were: preload force (range: 0-671N); peak force (17-1213N); rate of force application (202-8700N/s); time to peak thrust force (12-938ms); and thrust duration (36-2876ms). CONCLUSIONS: Considerable variability in the reported kinetic force-time characteristics of SM exists. Some of this variability is likely due to differences in SM delivery (e.g. different clinicians) and the measurement equipment used to quantify force-time characteristics. However, improved reporting in certain key areas could facilitate more sophisticated syntheses of force-time characteristics data in the future. Such syntheses could provide the foundation upon which dose-response estimates regarding the clinical effectiveness of SM are made.

Self-reported attitudes, skills and use of evidence-based practice among Swiss chiropractors: a national survey.

STUDY OBJECTIVES: The high burden of disease associated with musculoskeletal disorders severely impacts patients' well-being. As primary care providers, Swiss chiropractors ought to contribute towards identifying and using effective treatment strategies. An established approach is the full integration of evidence-based practice (EBP). This study aimed to investigate the attitudes, skills and use of EBP among Swiss chiropractors, as well as investigating potential facilitators and barriers for its adoption. METHODS AND MATERIAL: All 329 members of the Swiss Association of Chiropractic (ChiroSuisse) were invited in March 2021 to participate in this cross-sectional survey. Data were acquired anonymously online, using the Evidence-Based practice Attitude and utilization SurvEy (EBASE). The survey encompassed 55 questions measuring attitudes (n = 8, response range 1-5; total score range of 8-40), skills (n = 13, response range 1-5; total score range of range of 13-65) and use of EBP (n = 6, response range 0-4; total score range of 0-24). RESULTS: 228 (69.3%) chiropractors returned complete EBASE questionnaires. This sample was representative of all ChiroSuisse members with respect to gender, age groups and proportion of chiropractic residents. Respondents generally held positive attitudes towards EBP, as indicated by the high mean (31.2) and median (31) attitude sub-score (range 11-40). Self-reported skills had a mean sub-score of 40.2 and median of 40 (range 13-65). Knowledge about EBP-based clinical practice had been primarily obtained in chiropractic under- or postgraduate education (33.8% and 26.3%, respectively). Use of EBP achieved a lower sub-score, with mean and median values of 7.4 and 6, respectively (range 0-24). The most commonly identified barriers preventing EBP uptake were lack of time (67.9%) and lack of clinical evidence in chiropractic/manual therapy-related health fields (45.1%). CONCLUSION: Swiss chiropractors held favourable attitudes and reported moderate to moderate-high skill levels in EBP. Nevertheless, similar to chiropractors in other countries, the self-reported use of EBP was relatively low, with lack of time and lack of clinical evidence being the most named barriers.

Limited prognostic value of pain duration in non-specific neck pain patients seeking chiropractic care.

BACKGROUND: Pain chronicity is considered an important prognostic factor for outcome. Here, it was investigated whether pain duration influences outcome when only chronic patients (pain >3 months) are considered. Secondary aims were to determine, in patients of any pain duration, how much variance in outcome is explained by pain duration and whether pain duration truly predicts outcomes, that is out-of-sample prediction in independent data. METHODS: Secondary analysis of a cohort study of neck pain patients. Patients were assessed before start of treatment and at 1-week, 1-, 3-, 6- and 12-month follow-up. Outcomes were patient global impression of change (PGIC) and percent change in patients' perceived pain intensity, rated on a numerical rating scale (NRS). Regression analyses (linear and logistic) and supervised machine learning were used to test the influence of pain duration on PGIC and percent NRS change at 1-week, 1-, 3-, 6- and 12-month follow-up within sample and out-of-sample. Separate analyses were performed for the full sample (n = 720) and for chronic patients (n = 238) only. RESULTS: No relationship between pain duration and outcome was found for chronic patients only. For the full sample, statistical relationships between pain duration and outcomes were observed at all tested follow-up time points. However, the amount of variance in outcome explained by pain duration was low and no out-of-sample prediction was possible. CONCLUSIONS: Pain duration did not emerge as an important predictor of outcome in this database of 720 neck pain patients receiving chiropractic treatment. SIGNIFICANCE STATEMENT: The relatively large dataset of neck pain patients challenges the widely accepted wisdom that pain duration is an important predictor of pain outcomes and that very chronic patients might only have a small likelihood of getting better. It is postulated that these results are important for the attitude of the first encounter between healthcare professionals and chronic patients.

A prospective observational study on trajectories and prognostic factors of mid back pain.

BACKGROUND: Although mid back pain (MBP) is a common condition that causes significant disability, it has received little attention in research and knowledge about trajectories and prognosis of MBP is limited. The purpose of this study was to identify trajectories of MBP and baseline risk factors for an unfavorable outcome in MBP patients undergoing chiropractic treatment. METHODS: This prospective-observational study analyzes outcome data of 90 adult MBP patients (mean age = 37.0 ± 14.6 years; 49 females) during one year (at baseline, after 1 week, 1 month, 3, 6 and 12 months) after start of chiropractic treatment. Patients completed an 11-point (0 to 10) numeric pain rating scale (NRS) at baseline and one week, one month, three, six and twelve months after treatment start and the Patient's Global Impression of Change (PGIC) questionnaire at all time points except baseline. To determine trajectories, clustering with the package kml (software R), a variant of k-means clustering adapted for longitudinal data, was performed using the NRS-data. The identified NRS-clusters and PGIC data after three months were tested for association with baseline variables using univariable logistic regression analyses, conditional inference trees and random forest plots. RESULTS: Two distinct NRS-clusters indicating a favourable (rapid improvement within one month from moderate pain to persistent minor pain or recovery after one year, 80% of patients) and an unfavourable trajectory (persistent moderate to severe pain, 20% of patients) were identified. Chronic (> 3 months) pain duration at baseline significantly predicted that a patient was less likely to follow a favourable trajectory [OR = 0.16, 95% CI = 0.05-0.50, p = 0.002] and to report subjective improvement after twelve months [OR = 0.19, 95% CI = 0.07-0.51, p = 0.001], which was confirmed by the conditional inference tree and the random forest analyses. CONCLUSIONS: This prospective exploratory study identified two distinct MBP trajectories, representing a favourable and an unfavourable outcome over the course of one year after chiropractic treatment. Pain chronicity was the factor that influenced outcome measures using NRS or PGIC.

Excitatory and inhibitory responses in the brain to experimental pain: A systematic review of MR spectroscopy studies.

BACKGROUND: The role of the brain in processing pain has been extensively investigated using various functional imaging techniques coupled with well controlled noxious stimuli. Studies applying experimental pain have also used proton magnetic resonance spectroscopy (1H-MRS). The advantage of MRS compared to other techniques is the capacity to non-invasively examine metabolites involved in neurotransmission of pain, including glutamate, γ-aminobutyric acid (GABA), glutamate â€‹+ â€‹glutamine (Glx), and glutamine. OBJECTIVE: To systematically review MRS studies used in the context of studying experimental pain in healthy human participants. DATA SOURCES: PubMed, Ovid Medline, and Embase databases were searched using pre-specified search terms. ELIGIBILITY CRITERIA: Studies investigating glutamate, GABA, Glx and/or glutamine in relation to experimental pain (e.g., heat) in healthy participants via MRS. APPRAISAL CRITERIA: Each study was evaluated with a modified quality criterion (used in previous imaging systematic reviews) as well as a risk of bias assessment. RESULTS: From 5275 studies, 14 met the selection criteria. Studies fell into two general categories, those examining changes in metabolites triggered by noxious stimulation or examining the relationship between sensitivity to pain and resting metabolite levels. In five (out of ten) studies, glutamate, Glx and/or glutamine increased significantly in response to experimental pain (compared to baseline) in three different brain areas. To date, there is no evidence to suggest Glx, glutamate or glutamine levels decrease, suggesting an overall effect in favour of increased excitation to pain. In addition to no changes, both increases and decreases were reported for levels of GABA+ (=GABA â€‹+ â€‹macromolecules). A positive correlation between pain sensitivity and resting glutamate and Glx levels were reported across three studies (out of three). Further research is needed to examine the relationship of GABA+ and pain sensitivity. LIMITATIONS: A major limitation of our review was a limited number of studies that used MRS to examine experimental pain. In light of this and major differences in study design, we did not attempt to aggregate results in a meta-analysis. As for the studies we reviewed, there was a limited number of brain areas were examined by studies included in our review. Moreover, the majority of studies included lacked an adequate control condition (i.e., non-noxious stimulation) or blinding, which represent a major source of potential bias. CONCLUSION: MRS represents a promising tool to examine the brain in pain, functionally, and at rest with support for increased glutamate, glutamine and Glx levels in relation to pain. IMPLICATIONS: Resting and functional MRS should be viewed as complementary to existing neuroimaging techniques, and serve to investigate the brain in pain. Systematic review registration number- CRD42018112917.

Unravelling functional neurology: does spinal manipulation have an effect on the brain? - a systematic literature review.

Background: A recent hypothesis purports that spinal manipulation may cause changes at a brain level. Functional Neurology, a mainly chiropractic approach, promotes the use of spinal manipulation to improve 'brain function' as if it were a proven construct. No systematic review has been performed to investigate how well founded this hypothesis is. Objective: To investigate whether spinal manipulation has an effect on 'brain function' that is associated with any clinical benefits. Method: In this systematic review, the literature was searched in PubMed, Embase, and PEDro (final search February 2018). We included randomized or non-randomized controlled studies, in which spinal manipulation was performed to any region of the spine, applied on either symptomatic or asymptomatic humans, and compared to a sham or to another type of control. The outcome measures had to be stated as direct or proxy markers of 'brain function'. Articles were reviewed blindly by at least two reviewers, using a quality checklist designed for the specific needs of the review. Studies were classified as of 'acceptable', 'medium', or 'low' methodological quality. Results were reported in relation to (i) control intervention (sham, 'inactive control', or 'another physical stimulus') and (ii) study subjects (healthy, symptomatic, or with spinal pain" subjects/spinal pain"), taking into account the quality. Only results obtained from between-group or between-intervention comparisons were considered in the final analysis. Results: Eighteen of 1514 articles were included. Studies were generally of 'low' or 'medium' methodological quality, most comparing spinal manipulation to a control other than a sham. Thirteen out of the 18 studies could be included in the final analysis. Transitory effects of different types of 'brain function' were reported in the three studies comparing spinal manipulation to sham (but of uncertain credibility), in "subclinical neck/spinal pain" subjects or in symptomatic subjects. None of these three studies, of 'medium' or 'acceptable' quality, investigated whether the neurophysiological effects reported were associated with clinical benefits. The remaining 10 studies, generally of 'low' or 'medium' quality, compared spinal manipulation to 'inactive control' or 'another physical stimulus' and similarly reported significant between-group differences but inconsistently. Conclusion: The available evidence suggests that changes occur in 'brain function' in response to spinal manipulation but are inconsistent across and - sometimes - within studies. The clinical relevance of these changes is unknown. It is therefore premature to promote the use of spinal manipulation as a treatment to improve 'brain function'.

Introduction: Une hypothèse récente propose que la manipulation vertébrale causerait des changements neurophysiologiques au niveau du cerveau. En Neurologie Fonctionnelle, approche principalement présente en chiropraxie, l'utilisation de la manipulation vertébrale est déjà promue comme capable d'améliorer le fonctionnement du cerveau. A ce jour, aucune revue systématique de la littérature n'a été conduite afin de connaître l'étendue et la qualité de l'évidence scientifique susceptible de justifier cet usage de la manipulation vertébrale. Objectif: Déterminer, à travers une revue systématique et critique de la littérature, si la manipulation vertébrale a un effet (spécifique) sur le cerveau et, si oui, si celui-ci est associé à un effet clinique. Méthode: Le moteur de recherche PubMed et deux bases de données, Embase et PEDro, ont fait l'objet d'une recherche bibliographique (actualisée en février 2018). Les critères d'inclusion étaient: essais contrôlés, randomisés ou non, dans lesquels la manipulation vertébrale avait été comparée à un placébo ou à un autre type de contrôle, chez des sujets symptomatiques ou asymptomatiques. La manipulation vertébrale pouvait avoir été effectuée au niveau de n'importe quelle région de la colonne vertébrale et les critères de jugement utilisés devaient être indiqués comme capables de mesurer, directement ou indirectement, une forme 'd'activité cérébrale'. La qualité méthodologique des études a été évaluée de manière indépendante par au moins deux chercheurs à l'aide d'une grille de qualité créée pour les besoins de cette revue. Les études ont été classifiées comme étant de qualité méthodologique 'acceptable', 'moyenne', ou 'faible'. Les résultats ont été rapportés de façon narrative, en fonction du type de contrôle utilisé (placébo, 'inactif', ou 'autre stimulus physique') et du type de sujets d'étude (sans problème de santé, symptomatiques, ou présentant des « douleurs rachidiennes subcliniques ¼), en tenant compte de la qualité méthodologique. Seuls les résultats issus de comparaisons inter-groupes ont été pris en compte dans notre analyse finale. Résultats: Dix-huit articles parmi les 1514 titres obtenus ont été inclus. Les études étaient pour la plupart de qualité méthodologique 'faible' ou 'moyenne' et avaient principalement comparé la manipulation vertébrale à une intervention autre que placébo. Les résultats rapportés dans 13 des 18 articles inclus ont finalement été pris en compte. Un effet transitoire sur différentes formes 'd'activité cérébrale' a été rapporté à l'issue de trois études dans lesquelles la manipulation vertébrale avait été comparée à un placébo (de crédibilité cependant incertaine), chez des sujets présentant des « douleurs rachidiennes subcliniques ¼ (n = 2) ou souffrant de cervicalgies non spécifiques aiguës / subaiguës (n = 1). Une potentielle association avec un effet clinique n'a pas été étudiée dans ces trois études, de qualité méthodologique 'moyenne' (n = 2) ou 'acceptable' (n = 1). Dans les 10 études restantes, la plupart de qualité méthodologique 'faible' ou 'moyenne', la manipulation vertébrale avait été comparée à un contrôle 'inactif' ou à un 'autre stimulus physique'. Des différences inter-groupes y ont également été rapportées, parfois de façon inconsistante. Conclusion: La littérature scientifique suggère que des changements neurophysiologiques surviennent au niveau du cerveau en réponse à la manipulation vertébrale mais, de façon inconsistante. La pertinence clinique de ces changements n'est pas connue. Ainsi, il est prématuré d'attribuer à la manipulation vertébrale des bénéfices cliniques via un effet sur le cerveau.

An observational study on trajectories and outcomes of chronic low back pain patients referred from a spine surgery division for chiropractic treatment.

Background: A close collaboration between surgeons and non-surgical spine experts is crucial for optimal care of low back pain (LBP) patients. The affiliation of a chiropractic teaching clinic to a university hospital with a large spine division in Zurich, Switzerland, enables such collaboration. The aim of this study was to describe the trajectories and outcomes of patients with chronic LBP referred from the spine surgery division to the chiropractic teaching clinic. Methods: The patients filled in an 11-point numeric rating scale (NRS) for pain intensity and the Bournemouth Questionnaire (BQ) (bio-psycho-social measure) at baseline and after 1 week, 1, 3, 6 and 12 months. Additionally, the Patient's Global Impression of Change (PGIC) scale was recorded at all time points apart from baseline. The courses of NRS and BQ were analyzed using linear mixed model analysis and repeated measures ANOVA. The proportion of patients reporting clinically relevant overall improvement (PGIC) was calculated and the underlying factors were determined using logistic regression analyses. Results: Between June 2014 and October 2016, 67 participants (31 male, mean age = 46.8 ± 17.6 years) were recruited, of whom 46 had suffered from LBP for > 1 year, the rest for > 3 months, but < 1 year. At baseline, mean NRS was 5.43 (SD 2.37) and mean BQ was 39.80 (SD 15.16) points. NRS significantly decreased [F(5, 106.77) = 3.15, p = 0.011] to 4.05 (SD 2.88) after 12 months. A significant reduction was not observed before 6 months after treatment start (p = 0.04). BQ significantly diminished [F(5, 106.47) = 6.55, p < 0.001] to 29.00 (SD 17.96) after 12 months and showed a significant reduction within the first month (p < 0.01). The proportion of patients reporting overall improvement significantly increased from 23% after 1 week to 47% after 1 month (p = 0.004), when it stabilized [56% after 3 and 6 months, 44% after 12 months]. Reduction in bio-psycho-social impairment (BQ) was of higher importance for overall improvement than pain reduction. Conclusions: Chiropractic treatment is a valuable conservative treatment modality associated with clinically relevant improvement in approximately half of patients with chronic LBP. These findings provide an example of the importance of interdisciplinary collaboration in the treatment of chronic back pain patients.

Effects of topical combinations of clonidine and pentoxifylline on capsaicin-induced allodynia and postcapsaicin tourniquet-induced pain in healthy volunteers: a double-blind, randomized, controlled study.

This double-blind randomized controlled study was designed to evaluate the analgesic effects of topical treatments with clonidine (CLON) and pentoxifylline (PTX) tested alone or as low- and high-dose combinations in a human experimental model of pain. Of 69 healthy subjects aged 18 to 60 years, 23 each were randomly allocated to low-dose (0.04% + 2%) and high-dose (0.1% + 5%) CLON + PTX groups. Both of these groups also received their corresponding placebos in one of 2 treatment periods separated by at least 48 hours. Twenty-three additional subjects received either CLON (0.1%) or PTX (5%) as single drug treatments, in each of 2 treatment periods. Assessment of analgesic efficacy was based on allodynic effects of previous intraepidermal capsaicin injection, as well as postcapsaicin tourniquet-induced pain 50 minutes following capsaicin injection. Visual Analogue Scale (VAS) ratings of pain intensity and the area of dynamic mechanical allodynia were the primary outcome measures, whereas area of punctate mechanical allodynia (PMA) served as a secondary outcome measure. Topical treatments with high- or low-dose combinations significantly reduced VAS ratings compared with corresponding placebo treatments throughout the period of postcapsaicin tourniquet-induced pain. Importantly, the high-dose combination produced lower VAS ratings than CLON alone, which were lower than PTX alone. Results also revealed significant inhibition of postcapsaicin dynamic mechanical allodynia and PMA for the high-dose combination compared with placebo, and of PMA for CLON compared with the low-dose combination. Hence, the present data are supportive of further clinical investigation of the high-dose topical combination of CLON + PTX in complex regional pain syndrome and neuropathic pain patients, for which our preclinical data predict efficacy.

Numb rats walk - a behavioural and fMRI comparison of mild and moderate spinal cord injury.

Assessment of sensory function serves as a sensitive measure for predicting the functional outcome following spinal cord injury in patients. However, little is known about loss and recovery of sensory function in rodent spinal cord injury models as most tests of sensory functions rely on behaviour and thus motor function. We used functional magnetic resonance imaging (fMRI) to investigate cortical and thalamic BOLD-signal changes in response to limb stimulation following mild or moderate thoracic spinal cord weight drop injury in Sprague-Dawley rats. While there was recovery of close to normal hindlimb motor function as determined by open field locomotor testing following both degrees of injury, recovery of hindlimb sensory function as determined by fMRI and hot plate testing was only seen following mild injury and not following moderate injury. Thus, moderate injury can lead to near normal hindlimb motor function in animals with major sensory deficits. Recovered fMRI signals following mild injury had a partly altered cortical distribution engaging also ipsilateral somatosensory cortex and the cingulate gyrus. Importantly, thoracic spinal cord injury also affected sensory representation of the upper nonaffected limbs. Thus, cortical and thalamic activation in response to forelimb stimulation was significantly increased 16 weeks after spinal cord injury compared to control animals. We conclude that both forelimb and hindlimb cortical sensory representation is altered following thoracic spinal cord injury. Furthermore tests of sensory function that are independent of motor behaviour are needed in rodent spinal cord injury research.