Dean L. Smith

Chiropractic treatment of pregnancy-related low back pain: a systematic review of the evidence.

OBJECTIVE This study systematically reviewed the published evidence regarding chiropractic care, including spinal manipulation, for pregnancy-related low back pain (LBP). METHODS A multimodal search strategy was conducted, including multiple database searches along with reference and journal hand searching. Studies were limited to those published in English and in a peer-reviewed journal or conference proceeding between January 1982 and July 2007. All study designs were considered except single case reports, personal narratives, and qualitative designs. Retrieved articles that met the inclusion criteria were rated for quality by using a validated and reliable checklist. RESULTS Six studies met the reviews inclusion criteria in the form of 1 quasi-experimental single-group pretest-posttest design, 4 case series, and 1 cross-sectional case series study; their quality scores ranged from 5 to 14 of 27. All of the included studies reported positive results for chiropractic care of LBP during pregnancy. Outcome measure use between the studies was inconsistent as were descriptions of patients, treatments, and treatment schedules. CONCLUSIONS Results from the 6 included studies showed that chiropractic care is associated with improved outcomes in pregnancy-related LBP. However, the low-to-moderate quality of evidence of the included studies preclude any definitive statement as to the efficacy of such care because all studies lacked both randomization and control groups. Given the relatively common use of chiropractic care during pregnancy, there is need for higher quality observational studies and controlled trials to determine efficacy.

Relationship Between Body Composition, Leg Strength, Anaerobic Power, and On-Ice Skating Performance in Division I Men's Hockey Athletes

Potteiger, JA, Smith, DL, Maier, ML, and Foster, TS. Relationship between body composition, leg strength, anaerobic power, and on-ice skating performance in division I mens hockey athletes. J Strength Cond Res 24(7): 1755-1762, 2010-The purpose of this study was to examine relationships between laboratory tests and on-ice skating performance in division I mens hockey athletes. Twenty-one men (age 20.7 ± 1.6 years) were assessed for body composition, isokinetic force production in the quadriceps and hamstring muscles, and anaerobic muscle power via the Wingate 30-second cycle ergometer test. Air displacement plethysmography was used to determine % body fat (%FAT), fat-free mass (FFM), and fat mass. Peak torque and total work during 10 maximal effort repetitions at 120°·s−1 were measured during concentric muscle actions using an isokinetic dynamometer. Muscle power was measured using a Monark cycle ergometer with resistance set at 7.5% of body mass. On-ice skating performance was measured during 6 timed 89-m sprints with subjects wearing full hockey equipment. First length skate (FLS) was 54 m, and total length skate (TLS) was 89 m with fastest and average skating times used in the analysis. Correlation coefficients were used to determine relationships between laboratory testing and on-ice performance. Subjects had a body mass of 88.8 ± 7.8 kg and %FAT of 11.9 ± 4.6. First length skate-Average and TLS-Average skating times were moderately correlated to %FAT ([r = 0.53; p = 0.013] and [r = 0.57; p = 0.007]) such that a greater %FAT was related to slower skating speeds. First length skate-Fastest was correlated to Wingate percent fatigue index (r = −0.48; p = 0.027) and FLS-Average was correlated to Wingate peak power per kilogram body mass (r = −0.43; p = 0.05). Laboratory testing of select variables can predict skating performance in ice hockey athletes. This information can be used to develop targeted and effective strength and conditioning programs that will improve on-ice skating speed.

A survey of chiropractors’ use of nutrition in private practice

ABSTRACT Objective To survey the private practice use of nutrition by chiropractors with emphasis on recommendations and education. Design A 3-page mail survey was sent to chiropractors practicing in the United States. Results The response rate was within the normal response range, 34% (74 of 217). Of those that responded, 77% were male; the mean number of years since graduation from chiropractic college was 13, with a range from 1-39 years. The average practice time spent on nutrition was 19%. Fifty-three percent of responders felt that their chiropractic college provided them with an adequate understanding in nutrition. Eightyone percent incorporated nutritional counseling, handed out nutritional literature or recommended nutritional supplements. Forty-two percent felt that chiropractors are able to address all nutritional concerns and 21% feel that the services of a nutritional specialist should only be used for second opinion interpretations. Discussion Nutrition is an important factor in the pursuit of optimal health. Most chiropractors in our sample incorporated nutritional services in their practice. The results of this study suggest that a significant amount of practice time is spent on services other than chiropractic adjustments. Approximately half of the chiropractors felt that their chiropractic college provided an adequate understanding in nutrition.

Running Posture and Step Length Changes Immediately After Chiropractic Treatment in a Patient With Xeroderma Pigmentosum

OBJECTIVE This case study reports on selected measures of locomotion (running) in a 5-year-old patient with xeroderma pigmentosum after chiropractic care. CLINICAL FEATURE A 5-year-old female patient (16.4 kg, 99.1 cm) with xeroderma pigmentosum (type A) volunteered to participate in the experiment with the consent of her parents. The patient had well-documented signs of delayed fine motor (eg, difficulty with writing, coloring, cutting) and gross motor control (eg, balance and coordination dysfunction and falling while running), and delayed speech. INTERVENTION AND OUTCOMES Trunk forward lean angles, step lengths, and hip horizontal translations were assessed by video as the participant ran as fast as possible down a laboratory runway. After chiropractic manipulation (adjustments), the patient reduced the trunk forward lean angle to become more vertical (P = .000). In addition, the patient experienced an increase in step length (P = .031). No significant change in lateral translation was observed after the intervention. CONCLUSION For this patient with xeroderma pigmentosum, chiropractic manipulation (adjustments) resulted in immediate changes in running performance. Further investigation is needed to examine the effect of chiropractic on locomotion in both symptomatic and asymptomatic patients.

Correctly identify practitioners and put adverse events of spinal manipulation into perspective.

Dear Editor We read with interest the paper by Struewer et al. in Orthopedic Reviews.1 While appreciating their recognition of potential benefits of spinal manipulation, we would like to address two issues raised by the paper. The first is accuracy in use of the term chiropractic manipulation. The terms manipulation and chiropractic appear to be used synonymously; if so we would recommend this practice be changed in the future. Even though an osteopathic physician performed the manipulation in the reported case, much of the Introduction and Discussion focused on chiropractic spinal manipulation. The authors make the same mistake in the body of the case presentation where they accurately describe the manipulative procedure as being performed by a doctor of osteopathy; however, immediately following this description they state: Two days after the chiropractic procedure [emphasis added] he [the patient] was referred to our institution… Manipulation performed by doctors of osteopathy and chiropractic can differ,2-5 as can manipulation and mobilization procedures performed by physical therapists.6 Inappropriate use of the term chiropractic manipulation when describing adverse events was explored by Terrett who concluded that medical authors had misrepresented or inaccurately reported the literature by frequently attributing adverse events of manipulation as being performed by doctors of chiropractic when they had been performed by other health care practitioners or by lay manipulators.7 The next issue is Struewer et al.’s assumption that adverse events following spinal manipulation are underreported and based on poor overall data. Yet the authors do not indicate that several excellent recent studies have assessed adverse events related to spinal manipulation.8-10 A recent systematic literature review concluded the risk of a major adverse event following spinal manipulation to be 0.003% (upper 95% confidence interval, i.e., conservative estimate).8 This is a low risk, much lower than the risks attributed to medications and surgical procedures used to treat back and neck pain. For example, Struewer et al. list cauda equina syndrome as a potential life-threatening complication of manipulation. Shekelle et al. reviewed the literature on this topic and found the risk of cauda equina syndrome following spinal manipulation to be 1 case in 100,000,000.11 To put this in perspective, a patient is approximately 20,000 times more likely to die of a lightning strike than experiencing cauda equina syndrome following a spinal manipulation, and cauda equina syndrome is 7400-37,000 times more likely to result from surgery than from spinal manipulation.10 Struewer et al. suggest that medical physicians should remain vigilant for potential serious adverse effects that may arise after chiropractic [sic] treatment, that serious adverse events are only published on occasion…, and that medical physicians should deliberately educate their patients of dangers and possible harmful outcomes. However, such intentional increased vigilance may lead to an over reporting of adverse events attributed to spinal manipulation.12 Again, we appreciate Struewer et al.’s interest in spinal manipulation and agree that reporting adverse events is important. However, we would suggest that the authors refrain from attributing adverse events following manipulation to chiropractic manipulation when the procedures are performed by other health care providers. We also would encourage physicians to have a balanced approach when discussing manipulation with their patients, understanding that the risk of serious adverse events following manipulation is very low.

Spinal Manipulation is Not an Emerging Risk Factor for Stroke Nor is it Major Head/Neck Trauma. Don't Just Read the Abstract!

Dear Editor, We read with interest the article by Micheli et al. [1] describing the emerging risk factors for cervical artery dissection. In their abstract, the authors’ state, “Other known risks factors for CAD are major head/neck trauma like chiropractic maneuver, coughing or hyperextension injury associated to car.” We would like to address two points in this letter: 1) the current best-evidence indicates no causal relationship between spinal manipulation (‘chiropractic maneuver’ in the paper) and vertebrobasilar artery (VBA) stroke, and 2) spinal manipulation or ‘chiropractic maneuvers’ are not major head/neck trauma as suggested in abstract of this article. First, evidence is mounting that the association between spinal manipulation and stroke is coincidental rather than causal and reflects the natural history of the disorder [2]. The largest population-based study to date was conducted by Cassidy et al. [3] and included all vertebrobasilar artery (VBA) strokes in Ontario, Canada over a period of 9 years. The authors found no evidence of excess risk (i.e. no risk) of VBA stroke associated with chiropractic care [3]. Interestingly there was an association between stroke and visits to both chiropractic and medical physicians but the association was the same for each type of provider [3]. The prevailing hypothesis is that patients with vertebral artery dissections often have initial symptoms that cause them to seek care from a chiropractic or medical physician and the stroke is independent of their visit [2-4]. This population-based study (Cassidy et al., 2008) provides higher quality evidence than previous case reports, case series, and physician surveys frequently referenced when discussing spinal manipulation in this context [2]. If anything, the latest scientific evidence questions whether spinal manipulation is a risk factor at all for cervical artery dissection. In contrast to the title of the Micheli et al. (2010) paper, chiropractic spinal manipulations may very well be a demerging risk factor for stroke since there may not be any risk. Secondly, spinal manipulation or ‘chiropractic maneuver’ (assumed to be cervical spine manipulation) is not major head/neck trauma as inferred in the abstract. The body of the Micheli et al. paper [1] even mentions that spinal manipulations are not considered major trauma, so the abstract is clearly inconsistent with the findings and should be corrected. The evidence, albeit limited to date, suggests that spinal manipulative treatments produce stretches of the vertebral artery that are much smaller than those that are produced during normal everyday movements, and thus they appear harmless [5]. Major trauma is usually associated with high-energy mechanisms of injury and results in serious visceral injury or spinal motion unit injury such as fracture or dislocation [6]. High-energy mechanisms of cervical spine injury have been described as those involving a high-speed motor vehicle crash (greater than 50 km/h), pedestrian being struck by car or a fall from greater than 3 m [7]. Clearly, spinal manipulations delivered by licensed chiropractors do not fulfill the criteria for major trauma and should not be considered major trauma. In addition, contrary to what was stated in the Micheli et al. [1] paper, it is also equally unlikely that most episodes of coughing fulfill the criteria for major trauma.

Letter to the editorRegarding the locked-in syndrome

Sir: I read with interest the article by León-Carrión et al. [1] in Brain Injury, titled ‘The locked-in syndrome: a syndrome looking for a therapy’. This article cited a particular study [2] which inappropriately used the term ‘chiropractic manipulation’ to describe cervical spine manipulation done by other practitioners. The study by Hufnagel et al. [2] was one of three studies cited by León-Carrión et al. [1] in their section titled ‘Cervical spine manipulation and LIS’ to make their point that ‘Patients with cervical vertebral column syndromes should receive chiropractic treatment only after careful diagnosis’. A careful review of the methods section of the Hufnagel et al. [2] article reveals that, of the 10 patients involved in receiving the ‘chiropractic maneouvre type’ of manipulations, seven patients were manipulated by orthopedists, a physiotherapist in one instance and health practitioners who were not physicians in two cases. Not a single mention of a chiropractor in the original source! It has previously been reported in the literature that the terms chiropractic and chiropractor have often been inappropriately applied to non-chiropractors when the care they provided resulted in adverse events [3, 4]. More specifically, Terrett [5] has stated,

Can a Back Belt Effect Working Posture: Laboratory Evaluation of a New Design

This study investigated the impact of a new back belt design on postural transitions during reaching. That is, an object close to the operator can be reached by just extending the arm; however, at some point, the operator must change postures by flexing the trunk. Previous work in our laboratory has determined that these transition points occur closer than the maximum distance set by the subjects anthropometry. Such transition points may reflect a user-generated margin of safety; protecting against extremes of ranges of motion. The current study compared back belt with no back belt reaching in a simulated pick and place task at various distances. Results indicate that when subjects wore the belt while reaching, they tended to have transition points closer to their bodies, than while not reaching. Hence, the belt seems to act to preserve a greater margin of safety-keeping the user from extreme ranges of motion.