Journal of Manipulative and Physiological Therapeutics

Editorial Board

2012-03-01

JMPT Highlights

2012-03-01

Chiropractic Episodes and the Co-Occurrence of Chiropractic and Health Services Use Among Older Medicare Beneficiaries

2012-03-05

Abstract: Objective: The purpose of this study was to define and characterize episodes of chiropractic care among older Medicare beneficiaries and to evaluate the extent to which chiropractic services were used in tandem with conventional medicine.Methods: Medicare Part B claims histories for 1991 to 2007 were linked to the nationally representative survey on Assets and Health Dynamics among the Oldest Old baseline interviews (1993-1994) to define episodes of chiropractic sensitive care using 4 approaches. Chiropractic and nonchiropractic patterns of service use were examined within these episodes of care. Of the 7447 Assets and Health Dynamics among the Oldest Old participants, 971 used chiropractic services and constituted the analytic sample.Results: There were substantial variations in the number and duration of episodes and the type and volume of services used across the 4 definitions. Depending on how the episode was constructed, the mean number of episodes per chiropractic user ranged from 3.74 to 23.12, the mean episode duration ranged from 4.7 to 28.8 days, the mean number of chiropractic visits per episode ranged from 0.88 to 2.8, and the percentage of episodes with co-occurrent use of chiropractic and nonchiropractic providers ranged from 4.9% to 10.9% over the 17-year period.Conclusion: Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

The Association Between Self-Reported Cardiovascular Disorders and Troublesome Neck Pain: A Population-Based Cohort Study

Paul S. Nolet, Pierre Côté, J. David Cassidy, Linda J. Carroll — 2012-02-27

Abstract: Objective: The purpose of this population-based cohort study was to investigate the association between self-reported cardiovascular disorders and troublesome neck pain.Methods: Using data from the Saskatchewan Health and Back Pain Survey (1995), we formed a cohort of 922 randomly sampled Saskatchewan adults with no or mild neck pain. We used the Comorbidity Questionnaire to measure the point prevalence of self-reported cardiovascular disorders and classified them into 3 levels of severity: (1) absent, (2) present but does not or mildly impacts on my health, and (3) present and moderately or severely impacts on my health. Six and 12 months later, we measured the presence of troublesome neck pain (grades II-IV) using the Chronic Pain Questionnaire. Multivariable Cox regression was used to estimate the association between cardiovascular disorders and the troublesome neck pain while controlling for confounders.Results: The follow-up rate was 73.8% (680/922) at 6 months and 62.7% (578/922) at 1 year. No association was found between self-reported cardiovascular disorders that had no or mild impact on health and the onset of troublesome neck pain. We found a crude association between self-reported cardiovascular disorders that moderately or severely impacted health and the onset of troublesome neck pain (crude hazard rate ratio, 4.3; 95% confidence interval, 1.8-10.0). The association was positively confounded by age, sex, and education (adjusted hazard rate ratio, 5.9; 95% confidence interval, 2.3-14.9).Conclusions: Our analysis suggests that self-reported cardiovascular disorders that moderately or severely impact one's health are a risk factor for developing troublesome neck pain.

Reconstruction of the Decision-Making Process in Assessing Musculoskeletal Chest Pain: An Exploratory Study Using Recursive Partitioning

2012-02-29

Abstract: Objective: The purposes of this study were to identify the most important determinants from the patient history and clinical examination in diagnosing musculoskeletal chest pain (MSCP) in patients with acute noncardiac chest pain when supported by a structured protocol and to construct a decision tree for identification of MSCP in acute noncardiac chest pain.Methods: Consecutive patients with noncardiac chest pain (n = 302) recruited from an emergency cardiology department were assessed. Using data from self-report questionnaires, interviews, and clinical assessment, patient characteristics were associated with the MSCP diagnosis, and the decision-making process of the clinician was reconstructed using recursive procedures in the tradition of constructing Classification and Regression Trees.Results: Thirty-eight percent of patients had MSCP. There was no single determinant that predicted the condition completely. However, many items with high associations could be identified, mainly with high negative predictive value. The decision-making process was reconstructed giving rise to a 5-step, linear decision tree without branches.Conclusions: Clinicians use a combination of indicators including systematic palpation of the spine and chest wall and items from the case history to diagnose MSCP. However, the high negative predictive values of the main determinants suggest that the MSCP diagnosis may be a diagnosis by exclusion.

Agreement and Correlation Between the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs and Douleur Neuropathique 4 Questions Neuropathic Pain Screening Tools in Subjects With Low Back–Related Leg Pain

Jeremy Walsh, Martin I. Rabey, Toby M. Hall — 2012-03-09

Abstract: Objective: The self-report Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) and Douleur Neuropathique 4 Questions (DN4) neuropathic pain screening tools have been shown to be reliable, valid, and able to differentiate neuropathic pain from inflammatory or mixed pain syndromes. However, no studies have compared these tools to determine whether their outcomes are similar. This study evaluated agreement and correlation between the S-LANSS and DN4 in the identification of neuropathic pain in subjects with low back–related leg pain.Methods: This observational study compared S-LANSS and DN4 scores in 45 patients with low back–related leg pain. The S-LANSS and DN4 cutoff scores of 12 and 4, respectively, were used to classify subjects as positive or negative for the presence of neuropathic pain for each screening tool. The κ statistic was used to determine whether there was agreement in classification of neuropathic pain between the 2 screening tools. Pearson correlation coefficient was used to determine correlation between scores of the 2 screening tools.Results: Neuropathic pain was identified in 15 subjects (33%) using the S-LANSS and in 19 subjects (42%) using the DN4. Agreement on neuropathic pain classification was fair, with a κ value of 0.34. There was moderate to good correlation (r = 0.62; P < .001) between scores obtained from the 2 tools.Conclusions: The finding of fair agreement suggests that despite the moderate to good correlation between scores, the cutoff points for the classification of neuropathic pain of the 2 tools may not be congruent.

Functional Radiographic Analysis of Thoracic Spine Extension Motion in Asymptomatic Men

2012-03-05

Abstract: Objective: The purposes of this study were to examine the range of thoracic spine extension motion in a group of young, asymptomatic subjects and compare the radiologically derived measurements with those obtained using photographic analysis, and to examine the relationship between the magnitude of the neutral thoracic kyphosis and the range of thoracic spine extension motion.Methods: In 14 asymptomatic male subjects (mean age ± SD, 30.2 ± 7 years), the thoracic kyphosis in standing and full thoracic spine extension was measured from lateral thoracic spine radiographs and digital photographs. The difference between the 2 measurements was used to define the range of thoracic extension motion.Results: The range of thoracic extension motion measured radiologically was between 0 and 26° (mean ± SD, 12.0° ± 8.9°), whereas the photographic range was between 8° and 23° (mean ± SD, 12.4° ± 4.1°). There was a significant correlation between the photographic and radiographic measurements of extension range (r = 0.69, P < .01). Extension range of motion measured radiologically was significantly correlated with the magnitude of the thoracic kyphosis (r = 0.71, P < .01).Conclusion: Functional radiographs of the thoracic spine can be used to measure the extension range of motion and define the extreme of range. The range of thoracic extension motion may be influenced by the magnitude of the neutral kyphosis. This technique may be used in future studies to evaluate the impact of spinal disorders on thoracic spine mobility.

Short-Term Effects of Manipulation to the Upper Thoracic Spine of Asymptomatic Subjects on Plasma Concentrations of Epinephrine and Norepinephrine—A Randomized and Controlled Observational Study

Aaron A. Puhl, H. Stephen Injeyan — 2012-02-20

Abstract: Objective: The purpose of this study was to investigate the short-term effects of spinal manipulation applied to a hypomobile segment of the upper thoracic spine (T1-T6), on plasma concentrations of norepinephrine (NE) and epinephrine (E) in asymptomatic subjects, under strictly controlled conditions.Methods: Fifty-six asymptomatic subjects were randomly assigned to receive either a chiropractic manipulative intervention or a sham intervention in the upper thoracic spine. A 20-gauge catheter fitted with a saline lock was used to sample blood before, immediately after, and 15 minutes after intervention. Plasma NE and E concentrations were determined using an enzyme-linked immunosorbent assay. Changes in plasma catecholamine concentrations were analyzed within and between groups using 1- and 2-sample t tests, respectively.Results: The plasma samples of 36 subjects (18 treatment, 18 control) were used in the analysis. Mean plasma concentrations of NE and E did not significantly differ between the 2 groups at any time point and did not change significantly after either the manipulative or sham intervention.Conclusions: The results of this study indicate that a manipulative thrust directed to a hypomobile segment in the upper thoracic spine of asymptomatic subjects does not have a measurable effect on the plasma concentrations of NE or E. These results provide a baseline measure of the sympathetic response to spinal manipulation.

Shared Decision Making Through Informed Consent in Chiropractic Management of Low Back Pain

Simon Dagenais, O'Dane Brady, Scott Haldeman — 2012-03-12

Abstract: 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.

The Effects of Manual Therapy on Balance and Falls: A Systematic Review

Kelly R. Holt, Heidi Haavik, C. Raina Elley — 2012-02-20

Abstract: Objective: The purpose of this study was to review the scientific literature on the effects of manual therapy interventions on falls and balance.Methods: This systematic review included randomized and quasi-randomized controlled trials that investigated the effects of manual therapy interventions on falls or balance. Outcomes of interest were rate of falls, number of fallers reported, and measures of postural stability. Data sources included searches through June 2011 of Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL, PsycINFO, Allied and Complimentary Medicine, Current Controlled Trials, Manual Alternative and Natural Therapy Index System, Index to the Chiropractic Literature, National Institutes of Health (USA), and Google Scholar.Results: Eleven trials were identified that met the inclusion criteria. Most trials had poor to fair methodological quality. All included trials reported outcomes of functional balance tests or tests that used a computerized balance platform. Nine of the 11 trials reported some statistically significant improvements relating to balance after an intervention that included a manual therapy component. The ability to draw conclusions from a number of the studies was limited by poor methodological quality or very low participant numbers. A meta-analysis was not performed due to heterogeneity of interventions and outcomes. Only 2 small trials included falls as an outcome measure, but as a feasibility study and a pilot study, no meaningful conclusions could be drawn about the effects of the intervention on falls.Conclusion: A limited amount of research has been published that supports a role for manual therapy in improving postural stability and balance. More well-designed controlled trials with sufficient participant numbers are required to draw meaningful clinical conclusions about the role that manual therapies may play in preventing falls or improving postural stability and balance.

Spinal Manipulation for the Treatment of Hypertension: A Systematic Qualitative Literature Review

Kevin Mangum, Lester Partna, Darcy Vavrek — 2012-02-20

Abstract: Objective: Spinal manipulative therapy (SMT) has been reported to successfully treat hypertension (HTN). The purpose of this study was to perform a qualitative literature review on the efficacy of SMT for treating HTN.Methods: The literature was systematically searched in PubMed, Medline, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, and Index of Chiropractic Literature. Included articles were rated for bias using the Cochrane Collaboration's tool for assessing risk of bias. Studies reporting differing methodologies, types of SMT, frequency of treatment, and time of follow-up were considered too dissimilar for meta-analysis.Results: Of 208 articles identified, 10 were selected as relevant and were assessed. Risk of bias scores revealed 2 studies with low risk, 3 studies with unclear risk, and 5 studies with high risk. The maximum improvement observed in any SMT group, in low risk of bias studies was −9.7 (95% confidence interval [CI], −21.1 to 1.8) systolic improvement and −9.0 (95% CI, −16.8 to −1.2) diastolic; and in unclear risk of bias studies, it was −17.2 (95% CI, −20.7 to −13.7) systolic and −13.0 (95% CI, −15.4 to −10.6) diastolic. Statistically significant decreases in blood pressure were not observed in clinical trials with low bias when SMT was compared with effleurage massage and a 5-minute wait. The studies with more risk of bias showed a greater treatment effect.Conclusion: There is currently a lack of low bias evidence to support the use of SMT as a therapy for the treatment of HTN. Future investigations may clarify if SMT is effective for treating HTN, either by itself or as an adjunctive therapy, and by which physiologic mechanism this occurs.

2012-03-01

Information for Readers

2012-03-01

Journal of Manipulative and Physiological Therapeutics

Editorial Board

JMPT Highlights

Chiropractic Episodes and the Co-Occurrence of Chiropractic and Health Services Use Among Older Medicare Beneficiaries

The Association Between Self-Reported Cardiovascular Disorders and Troublesome Neck Pain: A Population-Based Cohort Study

Reconstruction of the Decision-Making Process in Assessing Musculoskeletal Chest Pain: An Exploratory Study Using Recursive Partitioning

Agreement and Correlation Between the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs and Douleur Neuropathique 4 Questions Neuropathic Pain Screening Tools in Subjects With Low Back–Related Leg Pain

Functional Radiographic Analysis of Thoracic Spine Extension Motion in Asymptomatic Men

Short-Term Effects of Manipulation to the Upper Thoracic Spine of Asymptomatic Subjects on Plasma Concentrations of Epinephrine and Norepinephrine—A Randomized and Controlled Observational Study

Shared Decision Making Through Informed Consent in Chiropractic Management of Low Back Pain

The Effects of Manual Therapy on Balance and Falls: A Systematic Review

Spinal Manipulation for the Treatment of Hypertension: A Systematic Qualitative Literature Review

Table of Contents

Information for Readers