Patient education with or without manual therapy compared to a control group in patients with osteoarthritis of the hip. A proof-of-principle three-arm parallel group randomized clinical trial.

OBJECTIVE: To investigate the effectiveness of a patient education (PE) program with or without the added effect of manual therapy (MT) compared to a minimal control intervention (MCI). METHODS: In a single-center university hospital setting, a total of 118 patients with clinical and radiographic unilateral hip osteoarthritis (OA) from primary care were randomized into one of three groups: PE, PE plus MT or MCI. The PE was taught by a physiotherapist involving five sessions. The MT was delivered by a chiropractor involving 12 sessions and the MCI included a home stretching program. Primary outcome was self-reported pain severity on an 11-box numeric rating scale (NRS) immediately following a 6-week intervention period. Patients were followed for 1 year. RESULTS: Primary analysis included 111 patients (94%). In the combined group (PE + MT), a clinically relevant reduction in pain severity compared to the MCI of 1.90 points (95% confidence interval (CI) 0.9-2.9) was achieved. Effect size (Cohen's d) for the PE + MT minus the MCI was 0.92 (95% CI 0.41-1.42). Number needed to treat for PE + MT was 3 (95% CI 2-7). No difference was found between the PE and MCI groups, with mean difference 0.0 (95% CI -1.0 to 1.0). At 12 months, not including patients receiving hip surgery the statistically significant difference favoring PE + MT was maintained. CONCLUSIONS: For primary care patients with OA of the hip, a combined intervention of MT and PE was more effective than a MCI. PE alone was not superior to the MCI. TRIAL REGISTRATION: clinicaltrials.govNCT01039337.

Caries experience, dental health behaviour and social status--three comparative surveys among Danish military recruits in 1972, 1982 and 1993.

OBJECTIVE: To compare caries experience among young Danish men in 1972, 1982 and 1993; and on the same occasions to describe relationship between their utilisation of regular dental care and social status, as well as the relationship between their caries experience, utilisation of dental services and social status. DESIGN: During their routine health examinations in 1972, 1982 and 1993 all recruits enlisted in the Danish Air Force were subjected to an additional oral examination combined with a structured socio-dental questionnaire. Identical methods were applied in each of the three surveys. SETTING: Dental clinics at air bases in Denmark. SUBJECTS: 4,103 male military recruits, aged 18 to 25 years. OUTCOME MEASURES: Caries was registered in accordance with the WHO Basic Methods 1971. The questionnaire provided information on age, place of residence during childhood, social origin, and patterns of utilisation of dental services. RESULTS: The findings indicated a considerable decrease in average caries experience from 16.6 DMFT in 1972 to 11.8 in 1982 and 6.2 in 1993. The results further documented markedly increased availability of public school dental health services, the coverage rising from 33% in 1972 to 65% in 1982 and 100% in 1993, as well as moderately increased utilisation of regular dental care with private practitioners, rising from 71% in 1972 to 86% in 1982 and 84% in 1993. In 1993 as in 1982 and 1972, recruits who used the public school dental health services and also received regular dental care after their school leaving age showed the lowest average caries experience. CONCLUSIONS: The findings indicate a marked decrease in average caries experience and an increased utilisation of dental services among Danish young men from 1972 to 1993. However, in 1993 the least privileged social group continued to maintain the highest average caries experience and the lowest rate of utilisation of regular dental care.

Precision and accuracy of an electrogoniometer.

BACKGROUND: Spinal range of motion has been studied by use of a variety of different methods. One electrogoniometer has been used as a noninvasive, reliable, and accurate method. The accuracy and precision of this device has not been sufficiently documented. OBJECTIVE: To evaluate the precision and accuracy of an electrogoniometer in comparison with two manual protractors. STUDY DESIGN: This study investigated the precision and accuracy of an electrogoniometer (OSI CA 6000). METHODS: The precision and accuracy of the electrogoniometer were determined by a series of tests against two manual protractors. Six different movement directions were tested and 4 or 5 different angles for a given movement direction were evaluated. RESULTS: The precision of the electrogoniometer was found to be +/- 0.1 degree for 4 different angles (10 degrees, 20 degrees, 40 degrees, and 60 degrees) in 6 different movement directions (flexion, extension, left lateral flexion, right lateral flexion, left rotation, and right rotation). The accuracy was tested by comparing both manual protractors with the electrogoniometer. Substantial disagreement for 27 of 28 datasets was found. In only one dataset was there agreement between the two manual protractors and the electrogoniometer. The mean differences were in the interval 2.0% to 11.5% between the electrogoniometer and the protractors. CONCLUSION: The electrogoniometer evaluated has a very high precision when range of motion measurements are made. However, the accuracy of the device is less than acceptable.

The ability to reproduce the neutral zero position of the head.

OBJECTIVE: To determine how precisely asymptomatic subjects can reproduce a neutral zero position of the head. STUDY DESIGN: Repeated measures of the active cervical neutral zero position. SETTING: Institute of Medical Biology (Center of Biomechanics) at Odense University. PARTICIPANTS: Thirty-eight asymptomatic students from the University of Odense, male/female ratio 20:18 and mean age 24.3 years (range, 20 to 30 years). INTERVENTION: Measurements of the location of the neutral zero head position by use of the electrogoniometer CA-6000 Spine Motion Analyzer. Each subject's neutral zero position with eyes closed was measured 3 times. The device gives the localization of the neutral zero as coordinates in 3 dimensions (x, v, z) corresponding to the 3 motion planes. RESULTS: The mean difference from neutral zero in 3 motion planes was found to be 2.7 degrees in the sagittal plane, 1.0 degree in the horizontal plane, and 0.65 degree in the frontal plane. CONCLUSION: We found that young adult asymptomatic subjects are very good at reproducing the neutral zero position of the head. This suggests the existence of some advanced neurologic control mechanisms.

The reliability of measuring active and passive cervical range of motion: an observer-blinded and randomized repeated-measures design.

PURPOSE: To study the intra- and interexaminer reliability of measuring active and passive cervical range of motion (ROM). STUDY DESIGN: Observer-blinded, randomized repeated measures of active or passive cervical ROM by two different examiners. SETTING: Institute of Medical Biology (Center of Biomechanic) at Odense University. PARTICIPANTS: Forty asymptomatic students, 20 of each gender, aged 20 to 30 yr, from the University of Odense. INTERVENTION: Measurements of either active or passive cervical ROM using the electrogoniometer CA-6000 Spine Motion Analyzer by two blinded examiners. Each subject was measured four times, twice by each examiner in random order, using a mean-of-three-measurements protocol. MAIN OUTCOME MEASURES: The reliability within and between examiners in active and passive ROM was assessed by the Intraclass Correlation Coefficient [ICC (2,k)]. Coefficient of variation (CV) was used to assess the reproducibility within and between examiners in active and passive ROM. RESULTS: Intraexaminer ICCs for active ROM ranged from .81 to .97 and for passive ROM from .85 to .98. The interexaminer ICCs for active ROM ranged from .76 to .98 and for passive ROM from .65 to .95. Intraexaminer CVs for active ROM ranged from 2.42 to 10.93 and for passive ROM, from 1.82 to 5.77. The interexaminer CVs for active ROM ranged from 2.30 to 14.43 and for passive ROM, from 2.58 to 10.93. CONCLUSION: Active and passive ROM could be measured reliably in six movement directions by the same examiner. Measurements were reliable when measured by different examiners for active cervical ROM in six movement directions and passive total ROM in three motion planes.

Natural variation of cervical range of motion: a one-way repeated-measures design.

OBJECTIVE: To describe the natural variation of the active and passive cervical range of motion (ROM) in asymptomatic subjects over a 3-wk period. STUDY DESIGN: One-way repeated measures of active and passive cervical ROM. SETTING: Institute of Medical Biology (Center of Biomechanics) at Odense University, Denmark. PARTICIPANTS: Forty asymptomatic students from the University of Odense. Male/female ratio, 20:20; mean age, 23.9 yr (range, 20-30 yr). INTERVENTION: Measurements of the active and passive cervical ROM were taken using the electrogoniometer CA-6000 Spine Motion Analyzer. Each subject was measured six times during a 3-wk period. The measurements were performed at the same time of the day. The device gives the maximum end ROM for the motion plane examined. RESULTS: The natural variation in active and passive ROM was found to be in the order of chi +/- 20 degrees for flexion/extension, chi +/- 12 degrees for lateral flexion and chi +/- 14 degrees for rotation. CONCLUSION: In asymptomatic subjects, the individual natural variation is quite large for active and passive cervical flexion/extension, lateral flexion and rotation. When measuring individual patients, one should allow for a natural variation of 12-20 degrees.

The effect of spinal manipulation in the treatment of cervicogenic headache.

PURPOSE: To study whether the isolated intervention of high-speed, low-amplitude spinal manipulation in the cervical spine has any effect on cervicogenic headache. DESIGN: Prospective randomized controlled trial with a blinded observer. SETTING: Ambulatory outpatient facility in an independent research institution. PARTICIPANTS: Fifty-three subjects suffering from frequent headaches who fulfilled the International Headache Society criteria for cervicogenic headache (excluding radiological criteria). These subjects were recruited from 450 headache sufferers who responded to newspaper advertisements. INTERVENTION: After randomization, 28 of the group received high-velocity, low-amplitude cervical manipulation twice a week for 3 wk. The remaining 25 received low-level laser in the upper cervical region and deep friction massage (including trigger points) in the lower cervical/upper thoracic region, also twice a week for 3 wk. MAIN OUTCOME MEASURES: The change from week 1 to week 5 in analgesic use per day, in headache intensity per episode and in number of headache hours per day, as registered in a headache diary. RESULTS: The use of analgesics decreased by 36% in the manipulation group, but was unchanged in the soft-tissue group; this difference was statistically significant (p = .04, chi 2 for trend). The number of headache hours per day decreased by 69% in the manipulation group, compared with 37% in the soft-tissue group; this was significant at p = .03 (Mann-Whitney). Finally, headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group; this was significant at p = .04 (Mann-Whitney). CONCLUSION: Spinal manipulation has a significant positive effect in cases of cervicogenic headache.

The interexaminer reliability of measuring passive cervical range of motion, revisited.

PURPOSE: To study the interexaminer reliability of measuring passive cervical range of motion (ROM). DESIGN: Repeated blind measures of passive cervical ROM by two different examiners. SETTING: Ambulatory outpatient facility in an independent National Health Service of Denmark funded chiropractic research institution. PARTICIPANTS: Thirty-five asymptomatic volunteers (17 men and 18 women) aged 20-28 yr. INTERVENTION: Measurement of passive cervical ROM with the use of a strap-on head goniometer by two blind examiners. Each subject was measured twice with 15-min intervals, using a mean-of-five-measurements protocol. MAIN OUTCOME MEASURE: The reliability of measuring passive cervical ROM in six separate directions of movement from "neutral zero" and from one extreme to the other in three planes. RESULTS: The inter- and intra-examiner reliability was evaluated using a paired t test and Pearson's Correlation Coefficient (supplemented by a scatterplot). Intraclass Correlation Coefficients were also calculated. Interexaminer reliability was found to be acceptable (Pearson's r = .61 - .88) for measuring in three planes. Interexaminer reliability was less than acceptable (Pearson's r = .39 - .70) for measuring passive ROM in 6 directions from neutral zero. CONCLUSION: Passive cervical ROM could be measured reliably by different examiners for measurements in three planes. Measurements from neutral zero in six directions were unreliable when measured by different examiners.

Normal ranges of passive cervical motion for women and men 20-60 years old.

OBJECTIVE: To define normal ranges of passive cervical motion for 20-60-yr-olds. DESIGN: A survey of 90 asymptomatic white-collar workers. SETTING: A local government administrative headquarters. PARTICIPANTS: Ninety healthy volunteers, recruited through in-house advertisements among the employees at the Funen County Hall (Denmark). INTERVENTION: Measurement of range of motion using a strap-on head goniometer. MAIN OUTCOME MEASURE: Passive range of cervical motion from one extreme to the other in three planes: frontal, sagittal and horizontal. RESULTS: Statistically significant differences were found between the two genders; normal ranges for both women and men are therefore given. We also found that increasing age meant decreasing passive range of motion and that this decrease in motion was well described by a simple linear regression. As a result, normal passive range of motion was described as an interval of +/- 2 SD around the regression means for passive cervical motion in three planes (sagittal, frontal and horizontal) for men and for women in the age range of 20-60 yr. CONCLUSIONS: Normal ranges of passive cervical motion have been generated. The importance of following the appropriated measurement protocols when using such normal ranges is stressed.

Lasting changes in passive range motion after spinal manipulation: a randomized, blind, controlled trial.

PURPOSE: To study whether a 3-wk series of spinal manipulation has any lasting effect on passive cervical range of motion. DESIGN: Randomized, controlled trial with a blind observer. SETTING: Ambulatory outpatient facility in an independent National Health Service funded chiropractic research institution. PARTICIPANTS: Thirty-nine headache sufferers who, on entering the study, displayed objectively decreased passive cervical range of motion. These subjects were recruited from 400 headache sufferers who responded to newspaper advertisements. INTERVENTION: Half of the group received high-velocity, low-amplitude cervical manipulation twice a week for 3 wk. The other half received low-level laser in the upper cervical region and deep friction massage in the lower cervical/upper thoracic region, also twice a week for 3 wk. MAIN OUTCOME MEASURE: Goniometrically assessed passive range of motion of the cervical spine. RESULTS: Although passive cervical range of motion increased in both groups during the trial period, there were no statistically significant differences between the two groups 1 wk after the last treatment. CONCLUSION: It seems that any changes in passive range of motion after spinal manipulation are of a temporary nature.

Is there a role for premanipulative testing before cervical manipulation?

BACKGROUND: Spinal manipulative therapy is used millions of times every year to relieve symptoms from biomechanic dysfunction of the cervical spine. Concern about cerebrovascular accidents after cervical manipulative therapy is common but rarely reported. Premanipulative tests of the vertebral artery are presumed to identify patients at risk but controversy exists about their usefulness. OBJECTIVE: The aim of this study was to examine vertebral artery blood flow in patients with a positive premanipulative test for contraindication to spinal manipulative therapy and to investigate if chiropractors would reconsider treating such patients if dynamic vascular Doppler examination was normal. DESIGN AND SETTING: A prospective study at a university hospital vascular laboratory. METHODS: Chiropractors in private practice from 3 Danish counties referred patients with a positive premanipulative test for an examination of vertebral artery blood flow. Premanipulative testing was performed by an experienced chiropractor. Flow velocities were measured in both vertebral arteries by color duplex sonography. In addition, chiropractors were asked if they would treat their patient despite a positive premanipulative test if the vascular ultrasound examination was normal. RESULTS: A total of 20 consecutive patients with a positive premanipulative test were referred. Five were excluded because symptoms could not be reproduced during the vascular examination. In the remaining patients, no significant difference in peak flow velocity or time-averaged mean flow velocity with different head positions was found. Nineteen of 21 chiropractors would treat a patient with a positive premanipulative test if the vascular examination was normal. Eight of the patients with a positive manipulative test were treated without complications. Six are now symptom-free, and 2 have improved symptoms. The remaining 8 patients refused manipulation and continue to have the same symptoms. CONCLUSION: It appears that a positive premanipulative test is not an absolute contraindication to manipulation of the cervical spine. If the test is able to identify patients at risk for cerebrovascular accidents, we suggest patients with a reproducible positive test should be referred for a duplex examination of the vertebral artery flow. If duplex flow is normal, the patient should be eligible for cervical manipulation despite the positive premanipulative test.

Vertebral artery flow and cervical manipulation: an experimental study.

BACKGROUND: Spinal manipulation therapy is used by millions of patients each year to relieve symptoms caused by biomechanical dysfunction of the spine. Cerebrovascular accidents in the posterior cerebral circulation are a feared complication, but little research has been done on vertebral artery hemodynamics during cervical manipulation. OBJECTIVE: The purpose of this study was to develop an experimental model for investigations of volume blood flow changes in the vertebral arteries during premanipulative testing of these vessels and during spinal manipulation therapy of the cervical spine. DESIGN AND SETTING: An experimental study in a university biomedical laboratory. MATERIAL AND METHODS: The vertebral arteries were exposed in 8 adult pigs after extensive mediastinal dissection. Volume blood flow was measured on both sides simultaneously by advanced transit-time flowmetry. RESULTS: After cervical manipulation, the vertebral artery volume blood flow increased significantly for 40 seconds before returning to baseline values in less than 3 minutes. We found no significant changes in volume flow during premanipulative testing of the vertebral arteries (DeKleyn's test). CONCLUSION: We present an experimental model for investigations of vertebral artery hemodynamics during biomechanical interventions. We found a modest and transient effect of cervical manipulation on vertebral artery volume flow. The model may have further applications in future biomechanical research, for example, to determine whether any of several spinal manipulative techniques imposes less strain on the vertebral artery, thereby reducing possible future cerebrovascular accidents after such treatment.

Vertebral artery volume flow in human beings.

BACKGROUND: A number of studies have investigated vertebral artery flow velocity. Because perfusion relates to the volume of blood flowing through the vessel, this parameter is of great importance when vertebral artery hemodynamics are investigated. We could not find any such Doppler studies in the literature, possibly because of known errors with previous techniques. New advanced color-coded duplex sonography has since been validated and may be used with confidence for volume flow investigations. OBJECTIVE: To use advanced color-coded duplex sonography to investigate volume flow through the vertebral arteries during cervical rotation, as well as before and after spinal manipulation therapy. DESIGN AND SETTING: A randomized controlled study at a university hospital vascular laboratory. PARTICIPANTS: Twenty university students. RESULTS: Volume blood flow through the vertebral arteries does not change with cervical rotation or after spinal manipulation therapy. CONCLUSION: This appears to be the first in vivo Doppler study on human vertebral artery volume blood flow. Our results indicate that in symptom-free subjects there is no change in vertebral artery perfusion during rotation in spite of significant changes in flow velocity. This finding, as well as the observed changes in flow velocity reported by others, may be explained by a positional change in the vertebral artery diameter. In addition, we have investigated volume blood flow in the vertebral arteries before or after spinal manipulation therapy but found no significant changes.

Volume flow estimation by colour duplex.

OBJECTIVE: To assess the accuracy of volume blood flow using a digitised colour duplex scanner. DESIGN: Observer-blinded experimental study. MATERIALS AND METHODS: Method comparison was performed with linear regression analysis of 89 paired observations in 11 anaesthetised pigs. A Siemens Sonoline Elegra ultrasound system was used for transcutaneous volume flow estimation using invasive transit time flowmetry by Cardiomed as a reference. RESULTS: For the individual measurement we found a standard error of the estimate (SEE) of 22 ml/min. For the regression line, however, the SEE was only 0.2 ml/min. CONCLUSIONS: Digitised colour-duplex sonography has a volume flow measurement error that is too high for single measurements in the individual patient for the method to be useful in clinical decision making, but sufficient for examinations of groups and comparison of groups.

Triplex ultrasound of vertebral artery flow during cervical rotation.

BACKGROUND: Reviewing the literature on vertebral artery flow during cervical rotation shows various results. Furthermore, most studies have investigated exclusively the effects of contralateral rotation employing less-than-optimal Doppler ultrasound technique. OBJECTIVE: The aim of this study was to use the latest advancement in Doppler ultrasound technology to investigate flow velocity in the vertebral artery during both ipsilateral and contralateral cervical rotation in normal subjects. DESIGN AND SETTING: A prospective, controlled study in a university hospital vascular laboratory. PARTICIPANTS: Twenty healthy university students. RESULTS: Peak flow velocity decreased significantly during contralateral rotation and increased significantly during ipsilateral rotation. The differences, however, were modest. We found no correlation between peak flow velocity and systolic blood pressure. CONCLUSION: With modern Doppler ultrasound technique, preventing some sources of error in measuring, our finding during contralateral rotation were in accordance with most previous studies showing a decrease in peak flow velocity. For the first time, however, we report an increased flow velocity in the vertebral artery during ipsilateral rotation.

Vertebral artery flow and spinal manipulation: a randomized, controlled and observer-blinded study.

BACKGROUND: Several studies have been published on the effect of cervical rotation alone upon blood flow in the vertebral arteries. However, we have not found articles addressing the question of how spinal manipulative therapy per se affects the vertebral artery flow. OBJECTIVE: The aim of the present study was to investigate whether any changes occur in peak flow velocity in the vertebral artery after spinal manipulative therapy as measured using the latest Doppler ultrasound technology. DESIGN AND SETTING: A randomized, controlled and observer-blinded study at a university hospital vascular laboratory. PARTICIPANTS: Twenty university students with a "biomechanical dysfunction" in the cervical spine. RESULTS: We observed no change in peak flow velocity immediately after spinal manipulative therapy and found no correlation between peak flow velocity and systolic blood pressure. CONCLUSION: To the best of our knowledge, this is the first study comparing flow velocity in the vertebral artery before and after spinal manipulative therapy. We found no significant changes in otherwise healthy subjects with a biomechanical dysfunction of the cervical spine. Major changes in peak flow velocity might in theory explain the pathophysiology of cerebrovascular accidents after spinal manipulative therapy. However, in uncomplicated spinal manipulative therapy, this potential risk factor was not prevalent.