James W. Brantingham

Manipulative therapy for lower extremity conditions: expansion of literature review.

OBJECTIVE The purpose of this study was to conduct a systematic review on manipulative therapy for lower extremity conditions and expand on a previously published literature review. METHODS The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. The Cumulative Index to Nursing and Allied Health Literature; PubMed; Manual, Alternative, and Natural Therapy Index System; Science Direct; and Index to Chiropractic Literature were searched from December 2006 to February 2008. Search terms included chiropractic, osteopathic, orthopedic, or physical therapy and MeSH terms for each region. Inclusion criteria required a diagnosis and manipulative therapy (mobilization and manipulation grades I-V) with or without adjunctive care. Exclusion criteria were pain referred from spinal sites (without diagnosis), referral for surgery, and conditions contraindicated for manipulative therapy. Clinical trials were assessed using a modified Scottish Intercollegiate Guidelines Network ranking system. RESULTS Of the total 389 citations captured, 39 were determined to be relevant. There is a level of C or limited evidence for manipulative therapy combined with multimodal or exercise therapy for hip osteoarthritis. There is a level of B or fair evidence for manipulative therapy of the knee and/or full kinetic chain, and of the ankle and/or foot, combined with multimodal or exercise therapy for knee osteoarthritis, patellofemoral pain syndrome, and ankle inversion sprain. There is also a level of C or limited evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for plantar fasciitis, metatarsalgia, and hallux limitus/rigidus. There is also a level of I or insufficient evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for hallux abducto valgus. CONCLUSIONS There are a growing number of peer-reviewed studies of manipulative therapy for lower extremity disorders.

Manipulative Therapy for Lower Extremity Conditions: Update of a Literature Review

OBJECTIVE The purpose of this study is to update a systematic review on manipulative therapy (MT) for lower extremity conditions. METHODS A review of literature was conducted using MEDLINE, MANTIS, Science Direct, Index to Chiropractic Literature, and PEDro from March 2008 to May 2011. Inclusion criteria required peripheral diagnosis and MT with or without adjunctive care. Clinical trials were assessed for quality using a modified Scottish Intercollegiate Guidelines Network (SIGN) ranking system. RESULTS In addition to the citations used in a 2009 systematic review, an additional 399 new citations were accessed: 175 citations in Medline, 30 citations in MANTIS, 98 through Science Direct, 54 from Index to Chiropractic Literature, and 42 from the PEDro database. Forty-eight clinical trials were assessed for quality. CONCLUSIONS Regarding MT for common lower extremity disorders, there is a level of B (fair evidence) for short-term and C (limited evidence) for long-term treatment of hip osteoarthritis. There is a level of B for short-term and C for long-term treatment of knee osteoarthritis, patellofemoral pain syndrome, and ankle inversion sprain. There is a level of B for short-term treatment of plantar fasciitis but C for short-term treatment of metatarsalgia and hallux limitus/rigidus and for loss of foot and/or ankle proprioception and balance. Finally, there is a level of I (insufficient evidence) for treatment of hallux abducto valgus. Further research is needed on MT as a treatment of lower extremity conditions, specifically larger trials with improved methodology.

Manipulative Therapy for Shoulder Pain and Disorders: Expansion of a Systematic Review

OBJECTIVE The purpose of this study was to conduct a systematic review on manual and manipulative therapy (MMT) for common shoulder pain and disorders. METHODS A search of the literature was conducted using the Cumulative Index of Nursing Allied Health Literature; PubMed; Manual, Alternative, and Natural Therapy Index System; Physiotherapy Evidence Database; and Index to Chiropractic Literature dating from January 1983 to July 7, 2010. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, musculoskeletal, physical therapies, shoulder, etc. Inclusion criteria required a shoulder peripheral diagnosis and MMT with/without multimodal therapy. Exclusion criteria included pain referred from spinal sites without a peripheral shoulder diagnosis. Articles were assessed primarily using the Physiotherapy Evidence Database scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring were complete, with subsequent participant review and agreement, evidence grades of A, B, C, and I were applied. RESULTS A total of 211 citations were retrieved, and 35 articles were deemed useful. There is fair evidence (B) for the treatment of a variety of common rotator cuff disorders, shoulder disorders, adhesive capsulitis, and soft tissue disorders using MMT to the shoulder, shoulder girdle, and/or the full kinetic chain (FKC) combined with or without exercise and/or multimodal therapy. There is limited (C) and insufficient (I) evidence for MMT treatment of minor neurogenic shoulder pain and shoulder osteoarthritis, respectively. CONCLUSIONS This study found a level of B or fair evidence for MMT of the shoulder, shoulder girdle, and/or the FKC combined with multimodal or exercise therapy for rotator cuff injuries/disorders, disease, or dysfunction. There is a fair or B level of evidence for MMT of the shoulder/shoulder girdle and FKC combined with a multimodal treatment approach for shoulder complaints, dysfunction, disorders, and/or pain.

Sagittal plane blockage of the foot, ankle and hallux and foot alignment-prevalence and association with low back pain

INTRODUCTION Some practitioners believe mechanical low back pain may be caused or aggravated by a stiff ankle, stiff great toe or flat feet. This study investigates subjects with and without mechanical low back pain and measures ankle and great toe range of motion and flattening of the medial longitudinal arch in both groups. METHODS The study was a blinded, 2-arm, non- randomized clinical study involving 100 subjects with chronic or recurrent mechanical low back pain (intervention group) and 104 subjects without chronic mechanical low back pain (control group) between the ages of 18 and 45. A blind assessor performed weight-bearing goniometry of the ankle and big toe and the navicular drop test on all subjects in both groups. RESULTS An independent t-test (inter-group) revealed a statistically significant decrease (p </= 0.05) in ankle dorsiflexion range of motion in individuals with chronic mechanical low back pain. The independent t-test suggested individuals with chronic mechanical low back pain have a significantly smaller navicular drop and higher arches (p < 0.05). CONCLUSION This study supports previous reports suggesting decreased ankle dorsiflexion may be a factor in chronic mechanical low-back pain. Further research and replication of this study is necessary before firm conclusions or recommendations can be made.

Full Kinetic Chain Manual and Manipulative Therapy Plus Exercise Compared With Targeted Manual and Manipulative Therapy Plus Exercise for Symptomatic Osteoarthritis of the Hip: A Randomized Controlled Trial

OBJECTIVE To determine the short-term effectiveness of full kinematic chain manual and manipulative therapy (MMT) plus exercise compared with targeted hip MMT plus exercise for symptomatic mild to moderate hip osteoarthritis (OA). DESIGN Parallel-group randomized trial with 3-month follow-up. SETTING Two chiropractic outpatient teaching clinics. PARTICIPANTS Convenience sample of eligible participants (N=111) with symptomatic hip OA were consented and randomly allocated to receive either the experimental or comparison treatment, respectively. INTERVENTIONS Participants in the experimental group received full kinematic chain MMT plus exercise while those in the comparison group received targeted hip MMT plus exercise. Participants in both groups received 9 treatments over a 5-week period. MAIN OUTCOME MEASURES Western Ontario and McMasters Osteoarthritis Index (WOMAC), Harris hip score (HHS), and Overall Therapy Effectiveness, alongside estimation of clinically meaningful outcomes. RESULTS Total dropout was 9% (n=10) with 7% of total data missing, replaced using a multiple imputation method. No statistically significant differences were found between the 2 groups for any of the outcome measures (analysis of covariance, P=.45 and P=.79 for the WOMAC and HHS, respectively). CONCLUSIONS There were no statistically significant differences in the primary or secondary outcome scores when comparing full kinematic chain MMT plus exercise with targeted hip MMT plus exercise for mild to moderate symptomatic hip OA. Consequently, the nonsignificant findings suggest that there would also be no clinically meaningful difference between the 2 groups. The results of this study provides guidance to musculoskeletal practitioners who regularly use MMT that the full kinematic chain approach does not appear to have any benefit over targeted treatment.

A FEASIBILITY STUDY COMPARING TWO CHIROPRACTIC PROTOCOLS IN THE TREATMENT OF PATELLOFEMORAL PAIN SYNDROME

OBJECTIVE The purpose of this pilot study was to determine the feasibility of (1) using the existing clinic, clinicians, interns, faculty, and staff from our college in conducting all components of a planned randomized controlled clinical trial; (2) successfully recruiting patients with patellofemoral pain syndrome (PFPS); and (3) consistently, effectively, and safely implementing the study protocols and therapy. METHODS Diagnostic, treatment, and blind assessment procedures were carried out while recruitment and administrative techniques for managing long-term storage of data and files were developed. Thirty-one patients were randomized into a local manipulative group (group A) or to a full kinetic chain manipulative therapy group (group B), each combined with exercise and soft tissue treatment. The Anterior Knee Pain Scale, visual analog scale, and Patient Satisfaction Scale were used. RESULTS All phases of the feasibility study including use of the clinic, staff, recruitment techniques, treatment protocols, data collection, input, and analysis were effectively and safely carried out. CONCLUSIONS A feasibility study investigating the ability to conduct a randomized controlled trial of a manipulative therapy protocol for PFPS using available chiropractic college infrastructure was accomplished. A fully powered PFPS trial is feasible and merited.

Manual and manipulative therapy compared to night splint for symptomatic hallux abducto valgus: an exploratory randomised clinical trial.

CONTEXT Hallux abducto valgus (HAV) is a frequent cause of great toe pain and disability, yet common treatments are only supported by mixed or equivocal research findings. Surgery often only provides modest improvement and post-surgery complications may significantly hamper outcomes, implying the need for trials testing conservative treatment, such as manual and manipulative therapy, particularly in cases where surgery may be contraindicated or premature. The purpose of this exploratory trial was to test an innovative protocol of manual and manipulative therapy (MMT) and compare it to standard care of a night splint(s) for symptomatic mild to moderate HAV, with a view gather insight into the effectiveness of MMT and inform the design of a definitive trial. DESIGN Parallel-group randomised trial set in an out-patient teaching clinic. PARTICIPANTS A convenience sample of 75 patients was assessed for eligibility, with 30 participants (15 per group) being consented and randomly allocated to either the control group (standard care with a night splint) or the experimental group (MMT). INTERVENTION Participants in the control group used a night splint(s) and those in the experimental group (MMT) received a structured protocol of MMT, with the participants in the experimental group receiving 4 treatments over a 2-week period. OUTCOME MEASURES Visual analogue scale (HAV-related pain), foot function index (HAV-related disability) and hallux dorsiflexion (goniometry). RESULTS There were no participant dropouts and no data was missing. There were no statistical (p<0.05) or clinically meaningful differences (MCID<20%) between the two groups based on outcome measure scores. However, the outcome measure scores in the control group (night splint) regressed between the 1-week follow-up and 1-month follow-up, while the scores in the experimental group (MMT) were sustained up to the 1-month follow-up. The within-group data analysis produced statistically and clinically significant changes from baseline to the 1-week flow-up across all outcome measures. Post hoc power analysis and sample size calculations suggest that the average between group power of this trial was approximately 60% (ES = 0.33) and that a definitive trial would require a minimum of 102 participants per group (N = 204) to achieve satisfactory power of ≥80%. CONCLUSIONS The trend in results of this trial suggest that an innovative structured protocol of manual and manipulative therapy (experimental group) is equivalent to standard care of a night splint(s) (control group) for symptomatic mild to moderate HAV in the short term. The protocol of MMT maintains its treatment effect from 1-week to 1-month follow-up without further treatment, while patients receiving standard care seem to regress when not using the night splint. Insights from this study support further testing of MMT for symptomatic mild to moderate HAV, particularly where surgery is premature or where surgical outcomes may be equivocal, and serve to inform the design of a future definitive trial.

Hand Hygiene and Treatment Table Sanitizing in Chiropractic Teaching Institutions: Results of an Education Intervention to Increase Compliance

OBJECTIVE The purpose of this study was to test an educational intervention designed to increase hand and treatment table sanitizing on 3 chiropractic college campuses using a theory-based intervention. The second purpose is to see if an increase in observed hand hygiene would be noted as a result of the intervention. METHODS Students at 3 campuses were surveyed, and their attitudes and practices of hand and table sanitizing were observed. The education intervention was developed using ecological theory of health promotion and involved educating staff and students along with a focus on modeling proper behaviors. The surveys were analyzed and generated frequencies. chi(2) analysis and logistic regression models were used to explore effects. RESULTS The education campaign was associated with increases in desired behaviors regarding both hand hygiene and table sanitizing. Good hand hygiene practices increased 35% (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.03-1.77), and observed practices increased more than 2-fold (OR, 2.6; 95% CI, 1.90-3.52). A 30% increase in table sanitizing was noted as well (OR, 1.30; 95% CI, 1.04-1.64). CONCLUSIONS Educational interventions after a theory-based model can have an initial impact on increasing hand hygiene and table sanitizing. Further studies should look at a policy component as an effect modifier and whether long-term effects will be seen from such an intervention.

Manipulative therapy and rehabilitation for recurrent ankle sprain with functional instability: A short-term, assessor-blind, parallel-group randomized trial

OBJECTIVE The purpose of this study was to compare manipulative therapy (MT) plus rehabilitation to rehabilitation alone for recurrent ankle sprain with functional instability (RASFI) to determine short-term outcomes. METHODS This was an assessor-blind, parallel-group randomized comparative trial. Thirty-three eligible participants with RASFI were randomly allocated to receive rehabilitation alone or chiropractic MT plus rehabilitation. All participants undertook a daily rehabilitation program over the course of the 4-week treatment period. The participants receiving MT had 6 treatments over the same treatment period. The primary outcome measures were the Foot and Ankle Disability Index and the visual analogue pain scale, with the secondary outcome measure being joint motion palpation. Data were collected at baseline and during week 5. Missing scores were replaced using a multiple imputation method. Statistical analysis of the data composed of repeated-measures analysis of variance. RESULTS Between-group analysis demonstrated a difference in scores at the final consultation for the visual analogue scale and frequency of joint motion restrictions (P ≤ .006) but not for the Foot and Ankle Disability Index (P = .26). CONCLUSIONS This study showed that the patients with RASFI who received chiropractic MT plus rehabilitation showed significant short-term reduction in pain and the number of joint restrictions in the short-term but not disability when compared with rehabilitation alone.

A Single-Group Pretest Posttest Design Using Full Kinetic Chain Manipulative Therapy With Rehabilitation in the Treatment of 18 Patients With Hip Osteoarthritis

OBJECTIVE Hip osteoarthritis (HOA) affects 30 million Americans or more, and is a leading cause of disability, suffering, and pain. Standard treatments are minimally effective and carry significant risk and expense. This study assessed treatment effects of a chiropractic protocol for HOA. METHODS Eighteen individuals, who did not qualify due to low baseline Western Ontario and McMaster Osteoarthritis Index scores (WOMAC) for other ongoing HOA randomized control trials, were selected. A prospectively planned protocol, consisting of axial manipulation to the affected hip with modified Thomas and active assisted stretch, was combined with full kinetic chain treatment or manipulative therapy to the spine, knee, ankle, or foot and assessed with use of valid and reliable outcome measures. RESULTS The primary outcome measure, the Overall Therapy Effectiveness Tool, was assessed with chi(2) and demonstrated that 83.33% of participants were improved after the ninth visit, P = .005, and 78% improved at the 3-month follow-up, P = .018. Using the paired t test, WOMAC was improved 64% at the ninth visit, P = .000, and 47% at follow-up, P = .016. CONCLUSION In HOA patients with lower WOMAC scores, a highly organized HOA treatment appears to have resulted in statistically and clinically meaningful intragroup changes in the Overall Effectiveness Therapy Tool, WOMAC, Harris Hip Scale, and range of motion, all with P <or= .05. Although the directionality and strength of the findings are encouraging, fully powered clinical trials are necessary to report generalizable findings.