Temporal Trends and Geographic Variations in the Supply of Clinicians Who Provide Spinal Manipulation to Medicare Beneficiaries: A Serial Cross-Sectional Study.

OBJECTIVE: Spinal manipulation (SM) is recommended for first-line treatment of patients with low back pain. Inadequate access to SM may result in inequitable spine care for older US adults, but the supply of clinicians who provide SM under Medicare is uncertain. The purpose of this study was to measure temporal trends and geographic variations in the supply of clinicians who provide SM to Medicare beneficiaries. METHODS: Medicare is a US government-administered health insurance program that provides coverage primarily for older adults and people with disabilities. We used a serial cross-sectional design to examine Medicare administrative data from 2007 to 2015 for SM services identified by procedure code. We identified unique providers by National Provider Identifier and distinguished between chiropractors and other specialties by Physician Specialty Code. We calculated supply as the number of providers per 100 000 beneficiaries, stratified by geographic location and year. RESULTS: Of all clinicians who provide SM to Medicare beneficiaries, 97% to 98% are doctors of chiropractic. The geographic supply of doctors of chiropractic providing SM services in 2015 ranged from 20/100 000 in the District of Columbia to 260/100 000 in North Dakota. The supply of other specialists performing the same services ranged from fewer than 1/100 000 in 11 states to 8/100 000 in Colorado. Nationally, the number of Medicare-active chiropractors declined from 47 102 in 2007 to 45 543 in 2015. The count of other clinicians providing SM rose from 700 in 2007 to 1441 in 2015. CONCLUSION: Chiropractors constitute the vast majority of clinicians who bill for SM services to Medicare beneficiaries. The supply of Medicare-active SM providers varies widely by state. The overall supply of SM providers under Medicare is declining, while the supply of nonchiropractors who provide SM is growing.

Moderators of the Effect of Spinal Manipulative Therapy on Pain Relief and Function in Patients with Chronic Low Back Pain: An Individual Participant Data Meta-analysis.

STUDY DESIGN: Individual participant data (IPD) meta-analysis. OBJECTIVE: The aim of this study was to identify which participant characteristics moderate the effect of spinal manipulative therapy (SMT) on pain and functioning in chronic LBP. SUMMARY OF BACKGROUND: The effects of SMT are comparable to other interventions recommended in guidelines for chronic low back pain (LBP); however, it is unclear which patients are more likely to benefit from SMT compared to other therapies. METHODS: IPD were requested from randomized controlled trials (RCTs) examining the effect of SMT in adults with chronic LBP for pain and function compared to various other therapies (stratified by comparison). Potential patient moderators (n = 23) were a priori based on their clinical relevance. We investigated each moderator using a one-stage approach with IPD and investigated this interaction with the intervention for each time point (1, 3, 6, and 12 months). RESULTS: We received IPD from 21 of 46 RCTs (n = 4223). The majority (12 RCTs, n = 2249) compared SMT to recommended interventions. The duration of LBP, baseline pain (confirmatory), smoking, and previous exposure to SMT (exploratory) had a small moderating effect across outcomes and follow-up points; these estimates did not represent minimally relevant differences in effects; for example, patients with <1 year of LBP demonstrated more positive point estimates for SMT versus recommended therapy for the outcome pain (mean differences ranged from 4.97 (95% confidence interval, CI: -3.20 to 13.13) at 3 months, 10.76 (95% CI: 1.06 to 20.47) at 6 months to 5.26 (95% CI: -2.92 to 13.44) at 12 months in patients with over a year LBP. No other moderators demonstrated a consistent pattern across time and outcomes. Few moderator analyses were conducted for the other comparisons because of too few data. CONCLUSION: We did not identify any moderators that enable clinicians to identify which patients are likely to benefit more from SMT compared to other treatments.Level of Evidence: 2.

The clinical efficacy of Shi-style lumbar manipulations for symptomatic degenerative lumbar spondylolisthesis: protocol for a randomized, blinded, controlled trial.

BACKGROUND: Symptomatic degenerative lumbar spondylolisthesis (DLS) presents spinal problems in daily life. Shi-style lumbar manipulation (SLM), as an alternative treatment for DLS, is popular in China. SLM is based on the channels and collaterals theory of the traditional Chinese medicine, in which the symptoms are believed to result from channel blockage and joint displacement. However, there is no solid evidence to show the effect of the SLM on the management of symptomatic DLS. METHODS/DESIGN: We conduct a prospective randomized, blinded, controlled trial to compare the effectiveness of SLM with mechanical lumbar traction and explore whether it could be a potential therapy for symptomatic DLS. A total of 60 patients with symptomatic DLS will be enrolled and treated with the SLM or mechanical lumbar traction for 2 weeks. VAS score and SF-36 questionnaire were assessed at baseline and at 2, 4, 12, and 24 weeks. Any signs of acute adverse reactions, such as lower limb paralysis or syndrome of cauda equina, will be recorded at each visit during treatment. DISCUSSION: Although the SLM has been used in China for many years to treat symptomatic DLS, there is a lack of consensus about its effectiveness. This trial will provide convincing evidence about the effect of SLM on symptomatic DLS. TRIAL REGISTRATION: Registered on 6 January 2019; the trial number is ChiCTR1900020519 .

Effects of spinal manipulative therapy biomechanical parameters on clinical and biomechanical outcomes of participants with chronic thoracic pain: a randomized controlled experimental trial.

BACKGROUND: Spinal manipulative therapy (SMT) includes biomechanical parameters that vary between clinicians, but for which the influence on the therapy clinical effects is unknown. This parallel-randomized controlled trial aimed to investigate the effect of SMT biomechanical parameters on the outcomes of participants with chronic thoracic pain (CTP) following three treatment sessions (follow-up at one week). METHODS: Adults reporting CTP (pain within the evaluated region [T6 to T8] for ≥3 months) were asked to participate in a four-session trial. At the first session, participants were randomly assigned to one of three experimental groups (different SMT doses) or the control group (no SMT). During the first three sessions, one SMT was executed at T7 for the experimental groups, while a 5-min rest was provided to the control group. SMT were delivered through an apparatus using a servo-controlled linear actuator motor and doses consisted of peak forces, impulse durations, and rates of force application set at 135 N, 125 ms and 920 N/s (group 1), at 250 N, 125 ms and 1840 N/s (group 2), and at 250 N, 250 ms, 920 N/s (group 3). Disability and pain intensity were evaluated at each session (primary outcomes). Spinal stiffness was assessed before-and-after each SMT/rest and at follow-up. Tenderness and muscle activity were evaluated during each spinal stiffness trial. Improvement was evaluated at follow-up. Differences in outcomes between groups and sessions were evaluated as well as factors associated with clinical improvement. RESULTS: Eighty-one participants were recruited and 17, 20, 20 participants of the three experimental groups and 18 of the control group completed the protocol. In exception of higher pain intensity at baseline in the control group, no between-group differences were found for any of the outcomes. A decrease in pain intensity, disability, spinal stiffness, and tenderness during spinal stiffness were observed (p-values< 0.05). At follow-up, 24% of participants were classified as 'improved'. Predictors of improvement were a greater decrease in pain intensity and in tenderness (p-values< 0.05). CONCLUSIONS: In an experimental setting, the delivery of a SMT does not lead to significantly different outcomes in participants with CTP than a control condition (spinal stiffness assessment). Studies are still required to explore the mechanisms underlying SMT effects. TRIAL REGISTRATION: ClinicalTrials.gov NCT03063177 , registered 24 February 2017).

Effectiveness of Kinesio Taping in Patients With Chronic Nonspecific Low Back Pain: A Systematic Review With Meta-analysis.

STUDY DESIGN: Systematic review. OBJECTIVE: To investigate the effects of Kinesio Taping (KT) in patients with nonspecific low back pain. SUMMARY OF BACKGROUND DATA: KT is widely used in patients with low back pain. METHODS: We conducted searches on PubMed, EMBASE, PEDro, SciELO, and LILACS up to February 26, 2018. We included only randomized controlled trials (RCTs) in adults with chronic nonspecific low back pain that compared KT to no intervention or placebo as well as RCTs that compared KT combined with exercise against exercise alone. The methodological quality and statistical reporting of the eligible trials were measured by the 11-item PEDro scale. The quality of the evidence was assessed using the GRADE classification. We considered pain intensity and disability as the primary outcomes. Whenever possible, the data were pooled through meta-analysis. RESULTS: We identified 11 RCTs for this systematic review (pooled n = 743). Two clinical trials (pooled n = 100) compared KT to no intervention at the short-term follow-up. Four studies compared KT to placebo (pooled n = 287) at short-term follow-up and two trials (pooled n = 100) compared KT to placebo at intermediate-term follow-up. Five trials (pooled n = 296) compared KT combined with exercises or electrotherapy to exercises or spinal manipulation alone. No statistically significant difference was found for most comparisons. CONCLUSION: Very low to moderate quality evidence shows that KT was no better than any other intervention for most the outcomes assessed in patients with chronic nonspecific low back pain. We found no evidence to support the use of KT in clinical practice for patients with chronic nonspecific low back pain. LEVEL OF EVIDENCE: 1.

Physicians using spinal manipulative treatment in The Netherlands: a description of their characteristics and their patients.

BACKGROUND: Various health care professionals apply Spinal Manipulative Treatment (SMT) in daily practice. While the characteristics of chiropractors and manual therapists and the characteristics of their patient populations are well described, there is little research about physicians who use SMT techniques. A distinct group of physicians in The Netherlands has been trained in musculoskeletal (MSK) medicine, which includes the use of SMT. Our objective was to describe the characteristics of these physicians and their patient population. METHODS: All registered MSK physicians were approached with questionnaires and telephone interviews to collect data about their characteristics. Data about patient characteristics were extracted from a web-based register. In this register physicians recorded basic patient data (age, gender, the type and duration of the main complaint, concomitant complaints and the type of referral) at the first consultation. Patients were invited to fill in web-based questionnaires to provide baseline data about previous treatments and the severity of their main complaint. Functional impairment was measured with Patient Reported Outcome Measures (PROMs). RESULTS: Questionnaires were sent to 138 physicians of whom 90 responded (65%). Most physicians were trained in MSK medicine after a career in other medical specialities. They reported to combine their SMT treatment with a variety of diagnostic and treatment options part of which were only permissible for physicians, such as prescription medication and injections. The majority of patients presented with complaints of long duration (62.1% > 1 year), most frequently low back pain (48.1%) or neck pain (16.9%), with mean scores of 6.0 and 6.2, respectively, on a 0 to10 numerical rating scale (NRS) for pain intensity. Mean scores on all PROMs showed moderate impairment. Patients most frequently reported previous treatment by physical therapists (68.1%), manual therapists (37.7%) or chiropractors (17.0%). CONCLUSION: Our study showed that MSK physicians in The Netherlands used an array of SMT techniques. They embedded their SMT techniques in a broad array of other diagnostic and treatment options, part of which were limited to medical doctors. Most patients consulted MSK physicians with spinal pain of long duration with moderate functional impairment.

Fiabilidad y validez de la medida de la movilidad cervical en pacientes con espondiloartritis axial utilizando un sensor inercial / Reliability and validity of cervical mobility analysis measurement using an inertial sensor in patients with axial spondyloarthritis

Introducción. La espondiloartritis axial (EA) produce una reducción de la movilidad debido a la inflamación y el daño estructural a nivel vertebral. El análisis de la movilidad cervical es un componente fundamental en la evaluación de pacientes con EA. Diversos índices y herramientas se han propuesto para analizar la movilidad cervical en estos pacientes, si bien, algunos de ellos carecen de precisión y sensibilidad y otros necesitan amplios recursos para ser usados. Los sensores de movimiento inerciales (IMU) podrían ser útiles para este cometido, pero se necesitan procesos de validación. Material y método. Se evaluó el movimiento cervical en tres planos (flexión frontal, lateral y rotación cervical) utilizando un IMU y un sistema de captura de movimiento de forma sincronizada. Se hizo una prueba test/retest del sensor. Se tomaron otras medidas habitualmente usadas para monitorizar a los pacientes con EA. Resultados. El análisis de fiabilidad según el índice de correlación intraclase fue muy bueno (0,99) para el test/retest del sensor IMU y para la comparación con el sistema de captura de movimiento. Las diferencias en grados fueron pequeñas (2-9°). Discusión. La tecnología IMU proporciona una forma flexible y económica de medir la movilidad en este tipo de patologías. Según nuestros resultados, la comparativa con respecto a la captura de movimiento como «gold standard», ha sido satisfactoria. Es por esto que esta tecnología puede ser útil para analizar la movilidad cervical en la EA (AU)

Introduction. Axial spondyloarthritis (AS) reduces mobility due to inflammation and structural damage in the vertebra. Analysis of cervical mobility is a key component of the assessment of patients with AS. Several indices and tools have been proposed to analyse cervical mobility in these patients, but some of them lack accuracy and sensitivity and others require extensive resources for their use. Inertial motion sensors (IMU) might be useful for this purpose, but require validation. Material and method. Cervical movement was assessed synchronously in three planes (frontal flexion, lateral flexion and cervical rotation) by using an inertial sensor (IMU) and a motion capture system. A test/retest with the sensor was also performed. Other measurements commonly used to monitor AS patients were taken. Results. The reliability analysis using the intraclass correlation index was very good (0.99) for the test/retest with the IMU sensor and for the comparison with the motion capture system. Differences in degrees were small (2-9°). Discussion. IMU technology provides a flexible and economic way to measure mobility in this type of disease. In this study, the results of IMU versus motion capture as the gold standard were satisfactory. This technology can be useful for analysing cervical mobility in AS (AU)

Prediction of pain outcomes in a randomized controlled trial of dose-response of spinal manipulation for the care of chronic low back pain.

BACKGROUND: No previous studies have created and validated prediction models for outcomes in patients receiving spinal manipulation for care of chronic low back pain (cLBP). We therefore conducted a secondary analysis alongside a dose-response, randomized controlled trial of spinal manipulation. METHODS: We investigated dose, pain and disability, sociodemographics, general health, psychosocial measures, and objective exam findings as potential predictors of pain outcomes utilizing 400 participants from a randomized controlled trial. Participants received 18 sessions of treatment over 6-weeks and were followed for a year. Spinal manipulation was performed by a chiropractor at 0, 6, 12, or 18 visits (dose), with a light-massage control at all remaining visits. Pain intensity was evaluated with the modified von Korff pain scale (0-100). Predictor variables evaluated came from several domains: condition-specific pain and disability, sociodemographics, general health status, psychosocial, and objective physical measures. Three-quarters of cases (training-set) were used to develop 4 longitudinal models with forward selection to predict individual "responders" (≥50% improvement from baseline) and future pain intensity using either pretreatment characteristics or post-treatment variables collected shortly after completion of care. The internal validity of the predictor models were then evaluated on the remaining 25% of cases (test-set) using area under the receiver operating curve (AUC), R(2), and root mean squared error (RMSE). RESULTS: The pretreatment responder model performed no better than chance in identifying participants who became responders (AUC = 0.479). Similarly, the pretreatment pain intensity model predicted future pain intensity poorly with low proportion of variance explained (R(2) = .065). The post-treatment predictor models performed better with AUC = 0.665 for the responder model and R(2) = 0.261 for the future pain model. Post-treatment pain alone actually predicted future pain better than the full post-treatment predictor model (R(2) = 0.350). The prediction errors (RMSE) were large (19.4 and 17.5 for the pre- and post-treatment predictor models, respectively). CONCLUSIONS: Internal validation of prediction models showed that participant characteristics preceding the start of care were poor predictors of at least 50% improvement and the individual's future pain intensity. Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best.

Influencia de la manipulación osteopática cervical sobre el flujo arterial / No disponible

Introducción: La medicina osteopática es uno de los medios de tratamiento más empleados en las dolencias de la columna cervical. Debemos conocer con precisión la relación entre manipulación cervical y valores hemodinámicos arteriales carotideos y vertebrales. Objetivos: Revisar el cuerpo de conocimientos que la literatura científica recoge sobre la relación entre la manipulación cervical osteopática y los posibles cambios en el flujo arterial carotideo. Material y Métodos: Realizamos una revisión bibliográfica en las bases de datos Pubmed, Web of Science y la plataforma EBSCOhost con los términos «spinal», «vertebral», «cervical manipulation», «carotid», «vertebral», «blood flow», «carotid», «vertebral», «blood velocity». Resultados: Obtenemos inicialmente una muestra de 232 estudios (n=232). Tras excluir los estudios que no cumplen los criterios establecidos, obtenemos una muestra de 12 estudios de lectura completa, de los que 5 (n=5) se incluyen en la revisión. Conclusiones: Hay escasa evidencia científica de los efectos postmanipualtivos sobre la circulación arterial cervical (AU)

No disponible

Abordajes terapéuticos no farmacológicos para el tratamiento de la cefalea tensional. Revisión bibliográfica / Non-pharmacological therapeutic approaches for the treatment of tension-type headache. Bibliographic review

Introducción: La cefalea tensional (CT) es la más prevalente dentro de las cefaleas primarias. Representa un impacto económico alto y una repercusión importante en la vida de los pacientes que las sufren y en el sistema público de salud. Objetivos: Conocer el número y fechas de publicación de los estudios realizados en el tratamiento de la CT. Material y Métodos: Se procedió a una búsqueda bibliográfica en PubMed recurriendo al uso de las palabras clave contenidas en dichas publicaciones referidas específicamente a CT y se realizó una búsqueda incluyendo los términos tension-type headache y manual therapy, manipulation therapy, physical therapy, vertebral manipulation, cervical manipulation, osteopathy, osteopathic treatment, osteopathic medicine, osteopathic manipulative treatment, osteopathic manipulative. Se encontraron y analizaron un total de 5 estudios que cumplieron los criterios de selección. Resultados: Los resultados encontrados tras la revisión mostraron que respecto a la cefalea tensional (Tension-type headache) existen 2.506 estudios desde 1947 hasta la actualidad. Los resultados mostraron hasta 15 estudios que comenzaron en 1977 hasta el 2009 cuando se asoció a osteopatía (osteopathy) como concepto general resultaron; con tratamiento osteopático (osteopathic treatment) 14 estudios desde 1993 hasta 2011; con medicina osteopática (osteopathic medicine) resultaron 8 estudios desde 1993 hasta 2009; con tratamiento osteopático manipulativo (osteopathic manipulative treatment) 11 estudios desde 1993 hasta 2009; y con osteopatía manipulativa (osteopathic manipulative) 8 estudios desde 1993 hasta 2011. Conclusiones: Existe escasez de estudios que relacionen la terapia osteopática y la CT. Respecto a la aplicación del tratamiento osteopático, junto y por separado, resulta eficaz, pero es necesario que los estudios tengan mayor calidad metodológica (AU)

Introduction: Tension-type headache (TTH) is the most predominant primary headache. It has a high economic impact and a significant consequence for patients whom suffer from it and for the public health system. Objectives: To know how many studies for treating the TTH were performed and when they were published. Material and methods: A bibliographical search was carried out in PubMed, using keywords included in these publications that strictly refer to TTH. This search included terms such as tension-type headache and manual therapy, manipulation therapy, physical therapy, vertebral manipulation, cervical manipulation, osteopathy, osteopathic treatment, osteopathic medicine, osteopathic manipulative treatment, osteopathic manipulative. Five studies were found and analysed that fulfilled the selection criteria. Results: Results that were found after the review showed that regarding the tension-type headache, there are 2,506 studies since 1947 until now. Results showed until 15 studies that started in 1977 until 2009, when osteopathy was associated as general concept; there were 14 studies of osteopathic treatment since 1993 until 2011; 8 studies of osteopathic medicine since 1993 until 2009; 11 studies of osteopathic manipulative treatment since 1993 until 2009 and 8 studies of osteopathic manipulative since 1993 until 2011. Conclusions: There is a lack of studies that link the osteopathic therapy with the TTH. As for the application of an osteopathic treatment, either singly or in conjunction, it is effective, but it is necessary to have more methodological quality in these studies (AU)

Efectos de las técnicas manipulativas de tratamiento comúnmente utilizadas en osteopatía para la cervicalgia / Effects of the manipulative treatment techniques commonly used in osteopathy for cervicalgias

Introducción: Diversas técnicas se han estudiado a lo largo de la historia para proponer tratamientos que optimicen la regeneración del tejido, la resolución de dolor o la limitación, en varias estructuras que podrían ser responsables de la cervicalgia mecánica, considerada de etiología idiopática. Dirigido a las articulaciones inter-apofisarias, con sus efectos neurofisiológicos asociados, encontramos técnicas de manipulación de alta velocidad y corta amplitud (HVLA) y técnicas de movilización descritas por quiroprácticos, osteópatas y terapeutas manuales, con la intención de generar un efecto general en todos los tejidos a través del sistema vascular y del sistema nervioso. En la bibliografía tienen respaldo científico sus efectos tanto en la recuperación de la movilidad, como en la disminución del dolor y la discapacidad. Objetivos: En este estudio la intención será comparar los distintos abordajes manipulativos para determinar cual podría ser más conveniente en el tratamiento de la cervicalgia mecánica. Material y Métodos: Se realizado un comentario crítico tras la revisión bibliográfica de estudios aleatorizados y controlados, analizando los posibles riesgos y beneficios asociados a la manipulación y la movilización en la zona cervical y dorsal. Resultados: Las técnicas de alta velocidad cuentan con mas evidencia científica que apoya su efectividad, tanto aplicadas a la región dorsal como a la cervical, aunque se asocian con riesgos neurovasculares poco frecuentes. Las movilizaciones también resultan efectivas para ese fin. Conclusiones: Tanto las manipulaciones (cervicales y dorsales) como las movilizaciones consiguen analgesia, y mejoran la movilidad de la columna cervical y la satisfacción del paciente, así como su discapacidad a corto, medio y largo plazo, comparado con el uso de medicamentos. Tiene un efecto mayor la manipulación, al menos a corto plazo, en la cervicalgia (AU)

Introduction: Different techniques were studied throughout the history, in order to propose treatments for optimizing tissue regeneration, pain resolution or limitation, in several structures that could responsible for mechanical cervicalgia, which has an idiopathic etiology. Aimed for the interapophyseal joints, with their corresponding neurophysiologic effects, we found high-velocity low-amplitude manipulation techniques (HVLA) and mobilisation techniques described by chiropractors, osteopaths and manual therapists, with the purpose of producing a general effect in all the tissues, through the vascular and nervous system. References reveal the scientific support of their effects for both recovering mobility and decreasing pain and disability. Objectives: In this study, the objective is to compare different manipulative approaches, to be able to choose the most convenient one for treating mechanical cervicalgia. Material and methods: A critical commentary was performed after the bibliographic review of the randomized and controlled trials, analysing the possible risks and benefits associated to manipulation and mobilisation in the cervical and thoracic area. Results: High-velocity techniques have more scientific evidences that support their effectiveness, no matter if they are applied in the cervical or thoracic area, although they are associated with rare neurovascular risks. Mobilisations are also effective for this purpose. Conclusions: Both manipulations (cervical and thoracic) obtain analgesia, like mobilisations, and improve cervical spinal ́s mobility and patient's satisfaction, as well as his/her disability in short, medial and long-term, compared to the use of drugs. Manipulation has a greater effect, at least in short-term, for cervicalgia (AU)

Efectos Inmediatos de la Técnica de Manipulación de Ashmore C5/C6 en la Actividad Muscular, en pacientes con Cervicalgia Mecánica / Immediate Effects of the Ashmore Manipulation Technique C5/C6, in Muscle Activity in patients with Mechanical Neck Pain

Introducción: La manipulación vertebral se relaciona con el aumento de la fuerza muscular, aunque no existen suficientes evidencias relativas a su aplicación en el raquis cervical. Objetivo: Determinar los efectos inmediatos de la técnica de manipulación de C5/C6 (Ashmore) en la actividad electromiográfica en reposo y en las contracciones del músculo deltoides medio bilateralmente. Material y Métodos: Estudio experimental, aleatorizado, cegado y controlado. Treinta (n=30) pacientes con Cervicalgia Mecánica (CM) se distribuyeron aleatoriamente en dos grupos, experimental (GE; n=15) y control (GC; n=15). Los pacientes fueron evaluados mediante el cuestionario Neck Disability Index (NDI), el test de la arteria vertebral y electromiografía (EMG) antes de la intervención. Después de las intervenciones en los grupos de estudio, realizamos otra vez la prueba EMG. Resultados: Los análisis comparativos intergrupos post-intervención presentaron diferencias estadísticamente significativas para las variables Root Mean Square (RMS) en isometría de 30 segundos bilateral, para el músculo deltoides medio. Conclusiones: La manipulación vertebral C5-C6 disminuye la actividad electromiográfica en la contracción isométrica, pero no produce cambios electromiográficos en reposo ni en contracción isotónica (AU)

Introduction: The effects of spinal manipulation are not yet entirely clear. Previous studies have found both increased and decreased electromyographic (EMG) activity of muscles related to the level being manipulated, although few of them have considered the cervical region or symptomatic individuals. Objetives: To determine the immediate effects of the C5/C6 (Ashmore) manipulation technique on bilateral EMG activity of the middle deltoid muscle at rest and in contractions. Patients, Materials and Methods: A randomized, controlled, single blind, experimental study was conducted. A total of 30 individuals presenting with mechanical neck pain were assigned randomly to two groups: 15 formed the experimental group (EG), and 15 the control group (CG). All participants completed a data questionnaire and the NDI (Neck Disability Index), and underwent a vertebral artery and EMG evaluation before their participation. After C5/C6 manipulation in the intervention group and no manipulation in the control group, the EMG evaluation was repeated. Results: All the variables were normally distributed, indicative of the total sample's initial homogeneity. Comparative post-intervention inter-group analyses showed statistically significant differences in the root mean square (RMS) values of the 30-s isometric bilateral EMG measurements of the middle deltoid muscle's activity. Conclusions: C5-C6 spinal manipulation reduced EMG activity in the longer isometric contractions, but no changes were observed neither in the resting EMG values nor in the isotonic contractions performed(AU)

Shared decision making through informed consent in chiropractic management of low back pain.

OBJECTIVE: The purpose of this study was to propose questions that may be helpful to educate patients considering treatment approaches to manage low back pain (LBP) and to determine if the information currently presented in informed consent (IC) documents at chiropractic colleges is sufficient to help a patient considering chiropractic management of LBP make a fully informed decision. METHODS: Questions to inform decision making for a patient contemplating any intervention for LBP were developed by the authors based on their clinical and research experience. Answers to the questions were suggested based on findings from recent clinical practice guidelines and systematic reviews. Institutions that are members of the Association of Chiropractic Colleges (ACC) were surveyed and asked to provide a copy of the IC documents currently used in their outpatient educational clinics. The IC documents were analyzed to determine if they stated (or implied) information that may be helpful in addressing each of the proposed questions. RESULTS: The list of 20 questions included 4 questions on each of the following 5 topics: condition, proposed treatment, potential benefits, potential harms, and possible alternatives. A total of 21 ACC institutions were contacted, of which 20 responded. The number of questions that could potentially be answered with information provided in the IC documents ranged from 2 to 13, with a mean of 6.5, including a mean of 3.6 stated answers and 2.9 implied answers. CONCLUSIONS: Some information to help patients consider chiropractic management of LBP is currently included in the IC documents used in clinics of ACC institutions. However, many of the questions that could help achieve shared decision making are not included. Modifying IC documents may help patients understand the nature, benefits, harms, costs, and alternatives to LBP care.

Spinal manipulation: an update of a systematic review of systematic reviews.

OBJECTIVES: The aim of this update is to critically evaluate the evidence for or against the effectiveness of spinal manipulation in patients with any type of clinical condition. DESIGN: Four electronic databases were searched to identify all relevant systematic reviews of the effectiveness of spinal manipulation in any condition published between 2005 and January 2011. Reviews were defined as systematic, if they included an explicit and repeatable inclusion and exclusion criteria for studies. RESULTS: Forty-five systematic reviews were included relating to the following conditions: low back pain (n=7), headache (n=6), neck pain (n=4), asthma (n=4), musculoskeletal conditions (n=3), any non-musculoskeletal conditions (n=2), fibromyalgia (n=2), infant colic (n=2), any medical problem (n=1), any paediatric conditions (n=1), carpal tunnel syndrome (n=1), cervicogenic dizziness (n=1), dysmenorrhoea (n=1), gastrointestinal problems (n=1), hypertension (n=1), idiopathic scoliosis (n=1), lateral epicondylitis (n=1), lower extremity conditions (n=1), pregnancy and related conditions (n=1), psychological outcome (n=1), shoulder pain (n=1), upper extremity conditions (n=1) and whiplash injury (n=1). Positive or, for multiple SR, unanimously positive conclusions were drawn for psychological outcomes (n=1) and whiplash (n=1). CONCLUSION: Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition.

Systematic reviews of spinal manipulations for headaches: an attempt to clear up the confusion.

BACKGROUND: Spinal manipulation (SM) is a therapy which is frequently used for headaches. During the last decade, several systematic reviews (SRs) of this topic have been published. Confusingly, their conclusions are far from uniform. The aim of this article is to identify the reasons for this confusion and to create more clarity about the therapeutic value of SM. METHODS: SRs were identified through searches of Medline, Embase, Cochrane Library, Amed, Cinahl, and PsychInfo. They were considered if they were recent, systematic, and evaluated the effectiveness of SM for headache disorders. RESULTS: Six SRs were included. Their methodological quality was assessed using the Oxman criteria for SRs. Five SRs were of high quality and one was associated with a high risk of bias. The findings of the SRs differed considerably. This variance seemed to be caused by several factors: differences in conditions included, treatments assessed, or primary studies analyzed. CONCLUSION: We conclude that high-quality SRs with a clear focus are required before the value of SM for headaches can be defined.

Lack of efficacy of manual therapy in children and adolescents with suspected cervicogenic headache: results of a prospective, randomized, placebo-controlled, and blinded trial.

OBJECTIVE: Clinical trials concerning cervical spine manipulation and mobilization in children and adolescents with cervicogenic headache are lacking. METHODS: We performed a multicenter, prospective, randomized, placebo-controlled, and blinded trial in 52 children and adolescents (21 boys, 31 girls) aged 7-15. After prospective baseline documentation for 2 months patients were either assigned to placebo or true manipulation with another 2-month follow-up. Main outcome measures were defined as: percentage of days with headache, total duration of headache, days with school absence due to headache, consume of analgesics, intensity of headache. RESULTS: We did not find a significant difference comparing the groups with placebo and true manipulation with respect to the defined main outcome measures. CONCLUSIONS: We were not able to show an efficacy of cervical spine manipulation in 52 children and adolescents.

[The history and principle of spinal manipulation in the treatment of lumbar intervertebral disc herniation].

It is generally agreed that spinal manipulation has been applied into the treatment of lumbar intervertebral disc herniation (LDH) for thousands of years according to historical reviews of the paper. The balance restore of spinal column had been always the main aim of spinal manipulation during the time. The situation has been changed after LDH was discovered pathomechanically about 70 years ago and the protruded nucleus pulposus has attracted the attention of whole world ever since and surgery become the major choice for LDH patients. Nevertheless, some latest reports of clinical observation in past decades explored more and more solid evidences to prove that most of the patients need no surgery at all and would be cured by conservative therapy without any changes of protruded nucleus pulposus at involved segment. The modern management of LDH suggests that we should not only pay attention to the protruded disk but also to the biomechanical balance of spinal column again as we had for thousands of years,which is concluded from the reviews of previous reports and history of LDH recognition in the paper. The only thing we should care more about is how to make full use of our modern knowledge to adjust our view of observation and management in clinical practice of spinal manipulation and to make a further understanding of the pathomechanics of LDH.