Stress reduction via neuro-emotional technique to achieve the simultaneous resolution of chronic low back pain with multiple inflammatory and biobehavioural indicators: A randomized, double-blinded, placebo-controlled trial.

BACKGROUND: Beginning with the concepts of stress developed by Selye, an approach to stress and pain management, known as neuro-emotional technique (NET), has been developed. It is a treatment approach based on the principle that the stressor effects of dormant and/or current unresolved issues or trauma are what determine one's bodily responses. These responses are relatively personalized to the conditioned, experiential and emotional reality of the individual. OBJECTIVE: To determine the effect of NET on patients with chronic low back pain (CLBP) over time. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS: In a randomized, double-blinded, placebo-controlled study conducted in a single clinic, NET or control treatments were given twice weekly for 4 weeks in a population of 112 patients. MAIN OUTCOME MEASURES: Outcome measures, including Oswestry Disability Index, Quadruple Visual Analogue Scale, the psychoneuroimmunology markers of blood serum levels of C-reactive protein, tumour necrosis factor-α, interleukin-1 (IL-1), IL-6, and IL-10, and 10 dimensions of the Short Form Health Survey scale, were assessed at baseline and at 1, 3 and 6 months following the intervention period. RESULTS: Compared to placebo, NET produced clinical and statistical significance (P < 0.001) via declines of virtually all physiological, pain and disability markers, accompanied by gains in quality-of-life indicators at 0 (baseline), 1, 3 and 6 months. Reductions of the percentages of patients whose 5 biomarkers lay outside the normative range were achieved at 1, 3 and 6 months by NET but not control interventions. CONCLUSION: A randomized, controlled trial of CLBP patients indicated that 8 NET interventions, compared to placebo, produced clinically and statistically significant reductions in pain, disability and inflammatory biomarkers, and improvements in quality-of-life measures. TRIAL REGISTRATION: The trial was registered with the Australian and New Zealand Clinical Trials Registry (No. ACTRN12608000002381).

Chiropractic Identity: A Neurological, Professional, and Political Assessment.

OBJECTIVE: The purpose of this article is to propose a focused assessment of the identity of chiropractic and its profession, triangulating multiple viewpoints converging upon various aspects and definitions of neurology, manual medicine, and alternative or mainstream medicine. DISCUSSION: Over 120 years since its inception, chiropractic has struggled to achieve an identity for which its foundations could provide optimal health care. Despite recognition of the benefits of spinal manipulation in various government guidelines, advances in US military and Veterans Administration, and persistently high levels of patient satisfaction, the chiropractic profession remains underrepresented in most discussions of health care delivery. Distinguishing characteristics of doctors of chiropractic include the following: (1) they embrace a model of holistic, preventive medicine (wellness); (2) they embrace a concept of neurological imbalance in which form follows function, disease follows disturbed biochemistry, and phenomenology follows physiology; (3) they diagnose, and their institutions of training are accredited by a body recognized by the US Department of Education; (4) they manage patients on a first-contact basis, often as primary care providers in geographical areas that are underserved; (5) the spine is their primary-but not exclusive-area of interaction; (6) they deliver high-velocity, low-amplitude adjustments with a superior safety record compared with other professions; and (7) they use a network of institutions worldwide that have shown increasing commitments to research. CONCLUSION: This article provides an overview of chiropractic identity from 6 points of view: (1) concepts of manual medicine; (2) areas of interest beyond the spine; (3) concepts of the chiropractic subluxation; (4) concepts of neurology; (5) concepts of mainstream or alternative health care; and (6) concepts of primary care, first-contact provider, or specialist.

Attenuation Effect of Spinal Manipulation on Neuropathic and Postoperative Pain Through Activating Endogenous Anti-Inflammatory Cytokine Interleukin 10 in Rat Spinal Cord.

OBJECTIVES: The purpose of this study was to investigate roles of the anti-inflammatory cytokine interleukin (IL) 10 and the proinflammatory cytokines IL-1ß and tumor necrosis factor α (TNF-α) in spinal manipulation-induced analgesic effects of neuropathic and postoperative pain. METHODS: Neuropathic and postoperative pain were mimicked by chronic compression of dorsal root ganglion (DRG) (CCD) and decompression (de-CCD) in adult, male, Sprague-Dawley rats. Behavioral pain after CCD and de-CCD was determined by the increased thermal and mechanical hypersensitivity of the affected hindpaw. Hematoxylin and eosin staining, whole-cell patch clamp electrophysiological recordings, immunohistochemistry, and enzyme-linked immunosorbent assay were used to examine the neural inflammation, neural excitability, and expression of c-Fos and PKC as well as levels of IL-1ß, TNF-α, and IL-10 in blood plasma, DRG, or the spinal cord. We used the activator adjusting instrument, a chiropractic spinal manipulative therapy tool, to deliver force to the spinous processes of L5 and L6. RESULTS: After CCD and de-CCD treatments, the animals exhibited behavioral and neurochemical signs of neuropathic pain manifested as mechanical allodynia and thermal hyperalgesia, DRG inflammation, DRG neuron hyperexcitability, induction of c-Fos, and the increased expression of PKCγ in the spinal cord as well as increased level of IL-1ß and TNF-α in DRG and the spinal cord. Repetitive Activator-assisted spinal manipulative therapy significantly reduced simulated neuropathic and postoperative pain, inhibited or reversed the neurochemical alterations, and increased the anti-inflammatory IL-10 in the spinal cord. CONCLUSION: These findings show that spinal manipulation may activate the endogenous anti-inflammatory cytokine IL-10 in the spinal cord and thus has the potential to alleviate neuropathic and postoperative pain.

Influence of foot orthotics upon duration of effects of spinal manipulation in chronic back pain patients: a randomized clinical trial.

OBJECTIVE: The purpose of this study was to investigate the effects of 4 weeks of custom foot orthotics on pain, disability, recurrence of spinal fixation, and muscle dysfunction in adult low back pain patients receiving limited chiropractic care. METHODS: Adult volunteers with low back pain of greater than or equal to 1 month's duration were randomized to receive custom orthotics (group A) or a flat insole sham (group B) with limited chiropractic care in 5 visits over 4 weeks. Primary outcome measures are as follows: Quadruple Numerical Pain Rating Scale (for back), the Roland-Morris Disability Questionnaire, the number of muscles grade 4 or lower on manual muscle testing, and the number of spinal fixations detected by motion palpation and vertebral challenge at intake (B1), 2 weeks later before treatment began and orthotic use was initiated (B2) and before each subsequent treatment at approximately days 3, 10, 17, and 24 after B2. Secondary outcome measures are correlations of all primary outcomes. RESULTS: Both groups improved on all Numerical Pain Rating Scale, Roland-Morris Disability Questionnaire, and the number of muscles from intake (B1) to final visit. Only group B yielded significant improvements in the number of spinal fixations. No outcome measures showed statistical difference between groups at any time point; however, those who wore custom orthotics longer each day showed trends toward greater improvements in some outcome measures. CONCLUSIONS: Both groups improved with chiropractic care including spinal manipulation; however, there were no statistical differences shown between sham and custom orthotic groups. Future studies should formally measure the time that orthotics or shams are worn in a weight-bearing capacity each day.

Applied kinesiology: distinctions in its definition and interpretation.

Modification of the motor system in assessing and treating as well as understanding one of the causes of musculoskeletal dysfunctions is a topic of growing importance in healthcare. Applied kinesiology (AK) addresses this interest in that it is a system which attempts to evaluate numerous aspects of health (structural, chemical, and mental) by the manual testing of muscles combined with other standard methods of diagnosis. It leads to a variety of conservative, non-invasive treatments which involve joint manipulations or mobilizations, myofascial therapies, cranial techniques, meridian and acupuncture skills, clinical nutrition and dietary management, counseling skills, evaluating environmental irritants, and various reflex techniques. The effectiveness of these ancillary treatments is believed to be consistent with the expanded construct validity of the manual muscle test (MMT), as described, although this assertion has primarily been tested in outcome studies. AK and its adjunctive procedures (challenge and therapy localization) are highlighted in this review providing details of its implementation as prescribed by an International College of Applied Kinesiology's Board of Examiners, cited for its scholarly and scientific activities. Because these procedures are believed to identify specific articular, soft tissue, biochemical, or emotional issues underlying muscle function, the applicability of this diagnostic method for all clinicians treating muscle imbalance disorders is described. As of yet, MMT efficacy in therapy localization and challenge techniques has not been established in published, peer-reviewed research. A variety of challenges likewise remain for professional AK to establish itself as an emerging science, with numerous gaps in the literature and testable hypotheses enumerated. Of particular concern are a multiplicity of derivatives of AK that have been described in the literature, which should be greeted with caution in light of the fact that they lack one or more of the essential attributes of AK as described in this report. The validity of these studies which have been critical of applied kinesiology appears in many instances to be no greater than several of the randomized controlled trials, cohort studies, case control studies, and case studies found in this communication to support various aspects of applied kinesiology.

Conservative chiropractic management of urinary incontinence using applied kinesiology: a retrospective case-series report.

OBJECTIVE: The purpose of this case series is to describe the chiropractic management of 21 patients with daily stress and occasional total urinary incontinence (UI). CLINICAL FEATURES: Twenty-one case files of patients 13 to 90 years of age with UI from a chiropractic clinic were reviewed. The patients had a 4-month to 49-year history of UI and associated muscle dysfunction and low back and/or pelvic pain. Eighteen wore an incontinence pad throughout the day and night at the time of their appointments because of unpredictable UI. INTERVENTION AND OUTCOME: Patients were evaluated for muscle impairments in the lumbar spine, pelvis, and pelvic floor and low back and/or hip pain. Positive manual muscle test results of the pelvis, lumbar spine muscles, and pelvic floor muscles were the most common findings. Lumbosacral dysfunction was found in 13 of the cases with pain provocation tests (applied kinesiology sensorimotor challenge); in 8 cases, this sensorimotor challenge was absent. Chiropractic manipulative therapy and soft tissue treatment addressed the soft tissue and articular dysfunctions. Chiropractic manipulative therapy involved high-velocity, low-amplitude manipulation; Cox flexion distraction manipulation; and/or use of a percussion instrument for the treatment of myofascial trigger points. Urinary incontinence symptoms resolved in 10 patients, considerably improved in 7 cases, and slightly improved in 4 cases. Periodic follow-up examinations for the past 6 years, and no less than 2 years, indicate that for each participant in this case-series report, the improvements of UI remained stable. CONCLUSION: The patients reported in this retrospective case series showed improvement in UI symptoms that persisted over time.

Evidence-based medicine: revisiting the pyramid of priorities.

Evidence-based medicine (EBM) is beset with numerous problems. In addition to the fact that varied audiences have each customarily sought differing types of evidence, EBM traditionally incorporated a hierarchy of clinical research designs, placing systematic reviews and meta-analyses at the pinnacle. Yet the canonical pyramid of EBM excludes numerous sources of research information, such as basic research, epidemiology, and health services research. Models of EBM commonly used by third party payers have ignored clinical judgment and patient values and expectations, which together form a tripartite and more realistic guideline to effective clinical care. Added to this is the problem in which enhanced placebo treatments in experimentation may obscure verum effects seen commonly in practice. Compounding the issue is that poor systematic reviews which comprise a significant portion of EBM are prone to subjective bias in their inclusion criteria and methodological scoring, shown to skew outcomes. Finally, the blinding concept of randomized controlled trials is particularly problematic in applications of physical medicine. Examples from the research literature in physical medicine highlight conclusions which are open to debate. More progressive components of EBM are recommended, together with greater recognition of the varying audiences employing EBM.

A narrative review of manual muscle testing and implications for muscle testing research.

OBJECTIVE: Manual muscle testing (MMT) is used for a variety of purposes in health care by medical, osteopathic, chiropractic, physical therapy, rehabilitation, and athletic training professionals. The purpose of this study is to provide a narrative review of variations in techniques, durations, and forces used in MMT putting applied kinesiology (AK) muscle testing in context and highlighting aspects of muscle testing important to report in MMT research. METHOD: PubMed, the Collected Papers of the International College of Applied Kinesiology-USA, and related texts were searched on the subjects of MMT, maximum voluntary isometric contraction testing, and make/break testing. Force parameters (magnitude, duration, timing of application), testing variations of MMT, and normative data were collected and evaluated. RESULTS: "Break" tests aim to evaluate the muscle's ability to resist a gradually increasing pressure and may test different aspects of neuromuscular control than tests against fixed resistances. Applied kinesiologists use submaximal manual break tests and a binary grading scale to test short-term changes in muscle function in response to challenges. Many of the studies reviewed were not consistent in reporting parameters for testing. CONCLUSIONS: To increase the chances for replication, studies using MMT should specify parameters of the tests used, such as exact procedures and instrumentation, duration of test, peak force, and timing of application of force.

Conservative management of post-surgical urinary incontinence in an adolescent using applied kinesiology: a case report.

INTRODUCTION: This case report describes the successful treatment of an adolescent female suffering daily stress and occasional total urinary incontinence with applied kinesiology methods and chiropractic manipulative therapy. PATIENT PRESENTATION: A 13-year-old female developed unpredictable urinary incontinence and right hip pain immediately following emergency open appendectomy surgery. The patient was forced to wear an incontinence pad throughout the day and night for 10 months because of unpredictable urinary incontinence. ASSESSMENT AND INTERVENTION: Chiropractic and applied kinesiology (AK) methods - a multi-modal diagnostic technique that utilizes manual muscle tests (MMT) for the detection of musculoskeletal impairments and specific AK techniques for correction of identified issues - were utilized to diagnose and treat this patient for muscle impairments in the lumbar spine and pelvis. RESULTS: Patient experienced a rapid resolution of her urinary incontinence and hip pain. A six-year follow-up confirmed complete resolution of symptoms. DISCUSSION: In this case, utilization of MMT allowed for the identification of several inhibited muscles. Utilizing the appropriate corrective techniques improved the strength of these muscles and resulted in their being graded as facilitated. Symptoms of urinary incontinence and hip pain resolved with this diagnostic and treatment approach. CONCLUSION: AK methods were useful for the discovery of a number of apparent causative factors underlying this patient's urinary incontinence and hip pain. Treatment for these pelvic-floor muscle and joint abnormalities resulted in rapid, long-lasting resolution of her urinary incontinence and hip pain.

Association of manual muscle tests and mechanical neck pain: results from a prospective pilot study.

OBJECTIVE: To determine whether there was a statistical difference for manual muscle test (MMT) findings for cervical muscles in subjects with and without mechanical neck pain (MNP), and to use confidence intervals to evaluate the sensitivity and specificity of the MMT in this group of subjects. CLINICAL FEATURES: Manual muscle strength tests were conducted on two groups of patients who reported to two outpatient chiropractic clinics. In group 1, 148 patients were evaluated for MMT data (50 males and 98 females, average age 37), 127 with "whiplash"-type injuries (average duration 16 weeks) and 21 with non-traumatic chronic neck pain (average duration 36 weeks). In group 2, 100 patients were evaluated for comparative MMT data (39 males and 61 females, average age 38) with no current MNP or remarkable history of MNP. METHODS: Standardized MMT assessments of the strength of the sternocleidomastoid, anterior scalene, upper trapezius, and cervical extensor muscles bilaterally were performed on all subjects in groups 1 and 2. RESULTS: In group 1, 139 of 148 patients reporting neck pain also showed positive results in at least one of four MMT tests (sternocleidomastoid, anterior scalene, upper trapezius, and cervical extensors). In group 2, 30 of the 100 patients without MNP showed positive results in one or more of the four MMT tests. Confidence intervals were calculated and showed that, in terms of MMT findings, there was a significant difference between the two groups of patients. CONCLUSIONS: A symptomatic group of patients with MNP demonstrated significantly increased MMT findings in the form of reduced strength levels compared to a control group. This evidence suggests that the MMT is potentially a sensitive and specific test for evaluating cervical spine muscular impairments in patients with MNP.

Topical application of compound Ibuprofen suppresses pain by inhibiting sensory neuron hyperexcitability and neuroinflammation in a rat model of intervertebral foramen inflammation.

UNLABELLED: There is lack of evidence that topical application of an anti-inflammatory reagent could reduce pain due to intervertebral foramen (IVF) inflammation (IVFI). We investigated analgesic effects and underlying mechanisms of topical application of a compound ibuprofen cream (CIC) onto the surface of back skin covering the inflamed L(5) IVF in a rat model. Repetitive CIC treatment (~.54 g each treatment daily for 5 consecutive days) significantly reduces severity and duration of IVFI-induced thermal hyperalgesia and mechanical allodynia by 80 to 100% and 50 to 66%, respectively. Electrophysiological studies and Western blot analysis demonstrated that CIC treatment significantly inhibited hyperexcitability of the inflamed dorsal root ganglion (DRG) neurons and upregulation of Nav1.7 and Nav1.8 protein, respectively. Pathological manifestations of the inflamed DRG were also markedly improved following CIC treatment. Further, in the inflamed DRGs, phosphorylation and expression of transcription factor NF-κB and pro-inflammatory enzyme cyclooxygenase-2 (COX-2) were significantly increased, while a cytokine IL-1ß level was increased. IVFI-induced upregulation of these molecules was significantly inhibited by CIC treatment. This study provides evidence that an anti-inflammatory reagent can be used topically to suppress pain due to IVFI and/or DRG inflammation through inhibition of sensory neuron hyperexcitability and the immune and inflammatory responses. PERSPECTIVE: This study suggests a convenient and safe clinical intervention for treating pain due to intervertebral foramen inflammation and similar syndromes.

The etiology of cervical artery dissection.

The etiology of cervical artery dissection (CAD) is unclear, although a number of risk factors have been reported to be associated with the condition. On rare occasions, patients experience CAD after cervical spine manipulation, making knowledge about the cervical arteries, the predisposing factors, and the pathogenesis of the condition of interest to chiropractors. This commentary reports on the relevant anatomy of the cervical arteries, developmental features of CAD, epidemiology of the condition, and mechanisms of dissection. The analysis of CAD risk factors is confusing, however, because many people are exposed to mechanical events and known pathophysiological associations without ever experiencing dissection. No cause-and-effect relationship has been established between cervical spine manipulation and CAD, but it seems that cervical manipulation may be capable of triggering dissection in a susceptible patient or contributing to the evolution of an already existing CAD. Despite the many risk factors that have been proposed as possible causes of CAD, it is still unknown which of them actually predispose patients to CAD after cervical spine manipulation.

Alternatives in cancer pain treatment: the application of chiropractic care.

OBJECTIVES: To review written resources disclosing reliable facts and knowledge in chiropractic services in cancer pain management. DATA SOURCES: Conventional and biomedical and complementary and alternative medicine journals, electronic media, full text databases, electronic resources, books in print, and newsletters. CONCLUSION: The judicial use of chiropractic services in cancer patients appears to offer many economical and effective strategies for reducing the pain and suffering of cancer patients, as well as providing the potential to improve patient health overall. IMPLICATIONS FOR NURSING PRACTICE: Clinicians should assess and support the use of chiropractic services in cancer patients. Chiropractic is one of the leading alternatives to standard medical treatment in cancer pain management.