Superficial heat or cold for low back pain.

BACKGROUND: Heat and cold are commonly utilised in the treatment of low-back pain by both health care professionals and people with low-back pain. OBJECTIVES: To assess the effects of superficial heat and cold therapy for low-back pain in adults. SEARCH STRATEGY: We searched the Cochrane Back Review Group Specialised register, the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to October 2005), EMBASE (1980 to October 2005) and other relevant databases. SELECTION CRITERIA: We included randomised controlled trials and non-randomised controlled trials that examined superficial heat or cold therapies in people with low-back pain. DATA COLLECTION AND ANALYSIS: Two authors independently assessed methodological quality and extracted data, using the criteria recommended by the Cochrane Back Review Group. MAIN RESULTS: Nine trials involving 1117 participants were included. In two trials of 258 participants with a mix of acute and sub-acute low-back pain, heat wrap therapy significantly reduced pain after five days (weighted mean difference (WMD) 1.06, 95% confidence interval (CI) 0.68 to 1.45, scale range 0 to 5) compared to oral placebo. One trial of 90 participants with acute low-back pain found that a heated blanket significantly decreased acute low-back pain immediately after application (WMD -32.20, 95%CI -38.69 to -25.71, scale range 0 to 100). One trial of 100 participants with a mix of acute and sub-acute low-back pain examined the additional effects of adding exercise to heat wrap, and found that it reduced pain after seven days. There is insufficient evidence to evaluate the effects of cold for low-back pain, and conflicting evidence for any differences between heat and cold for low-back pain. AUTHORS' CONCLUSIONS: The evidence base to support the common practice of superficial heat and cold for low back pain is limited and there is a need for future higher-quality randomised controlled trials. There is moderate evidence in a small number of trials that heat wrap therapy provides a small short-term reduction in pain and disability in a population with a mix of acute and sub-acute low-back pain, and that the addition of exercise further reduces pain and improves function. The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain. There is conflicting evidence to determine the differences between heat and cold for low-back pain.

Multiple channel recording of the articular crack associated with manipulation of the metacarpophalangeal joint. An observational study.

BACKGROUND: The audible release or cracking sound associated with spinal manipulation is familiar to practitioners of spinal manipulative therapy. Furthermore, some authors believe the articular crack to be at least in part responsible for the therapeutic benefits derived from spinal manipulative therapy. Although some research has been directed towards the investigation of some aspects of this phenomenon, little research has be conducted in order to establish from which side and vertebral level the audible release occurs during the manipulative process. OBJECTIVE: To assess the reliability and accuracy of multiple surface mounted microphones to detect the audible release of the target joint during manipulation of the third metacarpophalangeal joint. DESIGN: Observational study. SETTING: Private practice of chiropractic, Ringwood, Victoria, Australia. PARTICIPANTS: Twenty volunteers recruited from staff and patients of the private practice of chiropractic. METHOD: Eight omnidirectional microphones were affixed to the palmar surface of the hand. Microphone No.1 was positioned directly over the third metacarpophalangeal joint while the remaining microphones were arranged in a uniform pattern over the palmar surface of the hand. Manipulation in the form of long axis traction was then applied to the third metacarpophalangeal joint. Where an audible release was associated with the manipulation the resultant signals were captured via computer and stored for later analysis. MAIN OUTCOME MEASURE: A difference of greater than one volt in peak amplitude between the microphone positioned over the target joint and the other microphones. The student's t-test was then applied to the data in order to determine if the mean output of the target joint microphone was statistically different to the mean output of the other microphones. RESULTS: A total of eighteen manipulations resulted in nineteen audible release signals. The mean voltage of channel 1 was consistently greater than all the other channels in this group of subjects. This difference was statistically significant for all the channels. CONCLUSION: This research suggests that multiple surface mounted microphones are capable of consistently detecting the audible release from the target joint, with manipulation directed to the third MCP joint. It is hoped that this method will be able to be applied to the audible release associated with spinal manipulative therapy and a better understanding of the manipulative process will ensue.

The therapeutic benefit of the audible release associated with spinal manipulative therapy. A critical review of the literature.

OBJECTIVE: To review the available literature pertaining to the therapeutic benefits of the audible release associated with spinal manipulative therapy. A critical appraisal of the scientific literature, empirical evidence and theories relating to this aspect of manipulation is presented. DATA SOURCE: A broad based search of the English language literature was conducted utilising the databases Medline (1966-1998), Mantis (Health Index) (1880-1998) and Cumulative Index to Nursing and Allied Health (CINAHL) (1982-1998), using the key words crack/ing, cavitation, audible release, gapping, sound/s, noise/s, vibration, biomechanics, coupled with joint, articular, manipulation, spinal manipulation and spinal manipulative therapy. A manual search was also conducted of non-indexed journals and text books relating to manual therapy of the library of RMIT University, Bundoora, Victoria as well as a broad based Internet search. RESULTS: There is a paucity of scientific research relating to this specific aspect of spinal manipulative therapy. Although there is ample empirical evidence to support some therapeutic benefit from the audible release, only one scientific study specifically relating to this topic was uncovered. CONCLUSION: Currently there is little scientific evidence to support any therapeutic benefit derived from the audible release and in fact, it appears the available evidence tends to refute many of the alleged beneficial effects. Given that many practitioners and patients alike place an importance on this aspect of manipulation further research is required in order to fully investigate this phenomenon.

A CASE OF LEPTOMENINGEAL DISEASE PRESENTING AS A LUMBAR NERVE ROOT RADICULOPATHY: A Case Report.

Objective: To discuss a case of leptomenigeal disease mimicking a lower lumbar disc lesion and accompanying neurological deficit.Clinical Features: A 62 year old male presented with a 3-4 day history of left low back and left posterior thigh pain. The patient had a previous history of non-specific low back pain for approximately 10-25 years, which was relieved in the past by manual therapy. He was also currently being treated by a medical oncologist with chemotherapy for low grade non-Hodgkin's lymphoma, which was considered stable.Intervention and Outcome: After a favourable initial response to therapy, the patient developed a noticeable left-sided limp. Computed tomography scanning of the lumbar spine and pelvis was then performed, which revealed a mild posterior annular bulging of the intervertebral disc at the L4/5 level. The patient was then treated with axial lumbar spine traction but on review two days later had also developed a left sided facial droop, consistent with a Bell's palsy. A subsequent magnetic resonance imaging scan of the brain and lumbar spine revealed sites of abnormal enhancement of multiple cranial nerves, the cauda equina and the vertebral bodies L1 and L5. The findings were consistent with widespread leptomeningeal disease or leptomenigeal carcinomatosis and unfortunately the patient died as a direct consequence of the disease approximately three weeks after diagnosis.Conclusion: Although relatively rare, leptomenigeal disease must considered as a differential diagnosis in a patient with a history of carcinoma who presents with low back pain and/or any neurological signs and symptoms.

Recording techniques and analysis of the articular crack. A critical review of the literature.

OBJECTIVE: To review the available literature pertaining to the recording and analysis of the joint crack/cavitation sound produced as a result of spinal manipulative therapy. A critical appraisal of the recording and analysis techniques is presented. DATA SOURCE: A broad based search of the English language literature was conducted utilising the databases Medline (1966-1996) and Chirolars (1800-1996), using the key words cavitation, noise, sound, audible release, crack/s/ing, vibration, sound recording, acoustic recording and accelerometers, coupled with the terms facet joint, spinal joint and apophyseal joint and chiropractic, osteopathic and spinal manipulation. A manual search was also conducted of non-indexed journals and text books relating to manual therapy of the library at RMIT University, Bundoora, Victoria. RESULTS: There appears to be a paucity of this research relating to spinal manipulative therapy. Research to date has focused on recording the joint crack sounds via microphones or piezoelectric accelerometers both of which appear to have limited applications. CONCLUSION: Some worthwhile information may be gained by conducting further research into the joint crack phenomenon, particularly with respect to spectral analysis. However, before this research is undertaken a more reliable and accurate means of capturing and processing the joint crack signal needs to be established.

The manipulative crack. Frequency analysis.

OBJECTIVES: This research was designed to analyse the frequency spectra of joint crack sounds produced during spinal manipulative therapy applied to the upper cervical spine of 50 volunteers and to determine if the spectra differed between the sexes and or for those with a history of previous neck trauma compared with those without a history of trauma. DESIGN: Randomised experimental study. SETTING: Macquarie University, Centre for Chiropractic, Summer Hill, New South Wales. SUBJECTS: Fifty asymptomatic subjects were recruited from the students and staff of the above college. INTERVENTION: Single, unilateral "diversified", high velocity, low amplitude, rotatory thrust technique applied to the region of the C3/4 zygapophyseal joints. MAIN OUTCOME MEASURES: Joint crack sound wave analysis of Digital Audio Tape (DAT) recordings, taken from two skin mounted microphones positioned on either side of the cervical spine and later analysed by the use of a computer equipped with professional quality frequency spectrum analysis software. RESULTS: All fifty manipulations resulted in at least one audible joint crack sound and in total the fifty subjects combined produced 123 individual joint cracks. Only 9 subjects (18%) produced a single joint crack, the majority of the subjects (82%) produced either two (22 subjects) or three (10 subjects) distinct joint crack signals, while seven subjects produced four and two subjects five separate joint crack signals. Frequency analysis was performed on a total of 122 individual wave forms. Peak frequencies for all analysed crack signals ranged from 1,830 Hz to 86 Hz with an mean of 333 Hz (95% C.I., 285-380 Hz), a mode of 215 Hz and a median of 215 Hz. Statistical analysis for recorded signals revealed 95% Confidence Interval for the mean of 285-380 Hz. No statistically significant differences were found for peak frequencies between the sexes or for a previous history of trauma and no trauma and for pre-manipulative and manipulative joint cracks.

Sometimes they may be zebras: herpes zoster of the L2 spinal nerve. A case report.

This case report describes a relatively uncommon presentation of herpes zoster affecting the cutaneous distribution of the L2 spinal nerve. The coexistence of a previous history of leg pain, cortical thickening of the femoral shaft on plain film x-ray examination, and the absence, at the time of examination, of the tell tale rash of herpes zoster provided the clinician with a diagnostic challenge. Furthermore, this case stresses the importance of a thorough neurological and orthopaedic examination as well as careful visual inspection of the painful region.

Analysis of zygapophyseal joint cracking during chiropractic manipulation.

OBJECTIVES: To determine if there is a relationship between the side of head rotation and the side of joint crack during "diversified" rotatory manipulation of the cervical spine. DESIGN: Randomized experimental study. SETTING: Macquarie University, Centre for Chiropractic, Summer Hill, New South Wales. SUBJECTS: Fifty asymptomatic subjects were recruited from the students and staff of the above college. INTERVENTION: Single, unilateral "diversified," high velocity, low amplitude, rotatory thrust technique. MAIN OUTCOME MEASURES: Joint crack sound wave analysis of digital audio tape (DAT) recordings, taken from two skin mounted microphones positioned on either side of the cervical spine. RESULTS: All 50 subjects exhibited at least one audible joint crack sound during manipulation. Forty-seven subjects (94%) exhibited cracking on the ipsilateral side to head rotation (95% confidence interval, 83.5% to 98.7%). One subject exhibited joint cracking on the contralateral side only, while two subjects exhibited bilateral joint crack sounds. There was a statistically significant lower rate of exclusively ipsilateral joint cracking in subjects with a history of neck trauma (80% vs. 100%, p = .023). CONCLUSIONS: This research suggests that during the "diversified" rotatory manipulation of the cervical spine utilized in this study, there is a higher occurrence of the joint crack on the ipsilateral side to head rotation.

The cardiovascular manifestations of certain rheumatological disorders.

Chiropractors and other practitioners of spinal manipulative therapy (SMT) are often called upon to treat the musculo-skeletal symptoms of patients suffering from a wide variety of rheumatological disorders. The SMT practitioner may be the primary contact, or alternatively these patients may seek help from the SMT practitioner after diagnosis from a medical practitioner. Either way it is essential that whoever treats these patients for their musculo-skeletal symptoms is fully cognisant of the cardiovascular manifestations which may accompany rheumatological disorders. This paper discusses ten rheumatological disorders and their possible cardiovascular manifestations.

Differential diagnosis of buttock pain: using a flow chart.

Buttock pain is often seen in chiropractic general practice, either as the only presenting symptom or as part of a symptom complex. The following flow chart has been prepared in an attempt to assist the clinician in arriving at an accurate diagnosis and aetiology.