Jerrilyn A. Cambron

Pilot Study of the Effect of a Limited and Extended Course of Chiropractic Care on Balance, Chronic Pain, and Dizziness in Older Adults

OBJECTIVE The purpose of this study was to collect preliminary information on the effect of a limited and extended course of chiropractic care on balance, chronic pain, and associated dizziness in a sample of older adults with impaired balance. METHODS The authors conducted a randomized pilot study targeting a sample size of 30, comparing 2 schedules of chiropractic care to a no-treatment group. Group 1 (limited schedule) was treated for 8 weeks, group 2 (extended schedule) was treated for 8 weeks and then once per month for 10 months, and group 3 received no treatment. Assessments were made at baseline and 1, 2, 6, and 12 months later. The primary outcome was changed in the Berg Balance Scale (BBS) from baseline to 1 year. Changes in the Pain Disability Index and Dizziness Handicap Index were also measured. RESULTS Thirty-four patients were enrolled, 13 in group 1, 15 in group 2, and 6 in group 3. Only 5 had baseline BBS scores less than 45, indicating increased risk for falls. There were no treatment-related adverse events. Nine patients dropped out by 1 year. No significant differences within or between groups in median BBS from baseline to 12 months were observed. Median Pain Disability Index scores improved more from baseline to 1 year in group 2 compared with groups 1 and 3 (P = .06, Kruskal-Wallis test). For the 9 patients with dizziness, a clinically significant improvement in Dizziness Handicap Index scores of groups 1 and 2 was observed at 1 month and remained lower than baseline thereafter; this was not true of group 3. CONCLUSION Further investigation of the possible benefit of chiropractic maintenance care (extended schedule) for balance and pain-related disability is feasible and warranted, as well as both limited and extended schedules for patients with idiopathic dizziness.

Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Pilot Study

OBJECTIVES The purpose of this pilot study was to investigate the feasibility of a randomized clinical trial of shoe orthotics for chronic low back pain. METHODS The study recruited 50 patients with chronic low back pain through media advertising in a midwestern suburban area. Medical history and a low back examination were completed at a chiropractic clinic. Subjects were randomized to either a treatment group receiving custom-made shoe orthotics or a wait-list control group. After 6 weeks, the wait-list control group also received custom-made orthotics. This study measured change in perceived pain levels (Visual Analog Scale) and functional health status (Oswestry Disability Index) in patients with chronic low back pain at the end of 6 weeks of orthotic treatment compared with no treatment and at the end of 12 weeks of orthotic treatment. RESULTS This study showed changes in back pain and disability with the use of shoe orthotics for 6 weeks compared with a wait-list control group. It appears that improvement was maintained through the 12-week visit, but the subjects did not continue to improve during this time. CONCLUSIONS This pilot study showed that the measurement of shoe orthotics to reduce low back pain and discomfort after 6 weeks of use is feasible. A larger clinical trial is needed to verify these results.

Chiropractic Care for Older Adults: Effects on Balance, Dizziness, and Chronic Pain

OBJECTIVE This study is part of an avenue of research exploring the effect of chiropractic care on balance in older adults. The purpose of this study was to (1) assess the use of the 7-item version of the Berg Balance Scale, (2) explore possible effects of an 8-week course of chiropractic care on balance as measured by the 7-item Short-Form Berg Balance Scale (SF-BBS) in adults 65 years or older with impaired balance, and (3) collect preliminary information on the possible relationships of dizziness and/or chronic pain to poor balance. METHODS This was a single-group, pretest/posttest design intervention study. Patients 65 years and older who could stand on one leg for less than 5 seconds were eligible. They received pragmatic chiropractic care for 16 visits for an 8-week period. Outcomes were assessed at baseline, visit 8 and visit 16 in terms of balance SF-BBS, dizziness (Dizziness Handicap Inventory [DHI]), chronic pain (Pain Disability Index), and depression (Geriatric Depression Scale). RESULTS Sixteen patients were enrolled; 14 completed the study. There was one mild and transient adverse effect, muscle soreness, which self-resolved. One patient was depressed, and his Geriatric Depression Scale score improved significantly during the study. Of the 6 patients with significant dizziness at baseline, 3 had scores of 0 (no dizziness) on the DHI at visit 16. Patients with dizziness tended to have greater chronic pain and show greater reductions in that pain than nondizzy patients. No clinically important effects on balance as measured by the SF-BBS were apparent for the group as a whole, although 3 individual patients improved by 4 to 6 points. CONCLUSION The Short-Form Berg Balance Scale (SF-BBS) did not show a great deal of clinical responsiveness in this study population. The outcome measures used for chronic pain (Pain Disability Index) and dizziness (DHI) appear to be appropriate for assessing patients in future larger studies for longer periods.

Chiropractic Management of Postsurgical Lumbar Spine Pain: A Retrospective Study of 32 Cases

OBJECTIVE Although chiropractic manipulation is commonly used for low back pain, applying this procedure to the patient with postlumbar spine surgery has not been adequately studied. The purpose of this retrospective chart review is to report on the results of chiropractic management (including Cox flexion distraction technique) of patients with postsurgical lumbar spine pain to determine the change in reported pain based on surgical type. METHODS Ten years of patient files from one chiropractic practice were electronically screened for lumbar spine surgery occurring before presenting for chiropractic care. Of the 58 patients with a postsurgical diagnosis, 32 files contained all pertinent components for this study including treatment with Cox flexion distraction manipulation (in addition to adjunct procedures) for at least 2 weeks and pretreatment and posttreatment pain measures using the Numeric Pain Scale (NPS) that ranged from 0 (no pain) to 10 (worst pain imaginable). RESULTS A change was observed in the mean pretreatment and posttreatment NPS pain scores of 6.4 to 2.3, a reduction of 4.1 of 10. The mean number of treatments was 14, with a range of 6 to 31. When stratified by surgical type, the mean change in pain was most remarkable in patients who underwent a surgery that combined lumbar discectomy, fusion, and/or laminectomy, with an average NPS pain reduction of 5.7 of 10. No adverse events were reported for any of these postsurgical patients. CONCLUSIONS The results of this study showed improvement for patients with low back pain subsequent to lumbar spine surgery who were managed with chiropractic care.

Quantification of cavitation and gapping of lumbar zygapophyseal joints during spinal manipulative therapy

OBJECTIVES The purpose of this study was to use previously validated methods to quantify and relate 2 phenomena associated with chiropractic spinal manipulative therapy (SMT): (1) cavitation and (2) the simultaneous gapping (separation) of the lumbar zygapophyseal (Z) joint spaces. METHODS This was a randomized, controlled, mechanistic clinical trial with blinding. Forty healthy participants (18-30 years old) without a history of low-back pain participated. Seven accelerometers were affixed to the skin overlying the spinous processes of L1 to L5 and the S1 and S2 sacral tubercles. Two additional accelerometers were positioned 3 cm left and right lateral to the L4/L5 interspinous space. Participants were randomized into group 1, side-posture SMT (n = 30), or group 2, side-posture positioning (SPP, n = 10). Cavitations were determined by accelerometer recordings during SMT and SPP (left side = upside for both groups); gapping (gapping difference) was determined by the difference between pre- and postintervention magnetic resonance imaging scan joint space measurements. Results of mean gapping differences were compared. RESULTS Upside SMT and SPP joints gapped more than downside joints (0.69 vs -0.17 mm, P < .0001). Spinal manipulative therapy upside joints gapped more than SPP upside joints (0.75 vs 0.52 mm, P = .03). Spinal manipulative therapy upside joints gapped more in men than in women (1.01 vs 0.49 mm, P < .002). Overall, joints that cavitated gapped more than those that did not (0.56 vs 0.22 mm, P = .01). No relationship was found between the occurrence of cavitation and gapping with upside joints alone (P = .43). CONCLUSIONS Zygapophyseal joints receiving chiropractic SMT gapped more than those receiving SPP alone; Z joints of men gapped more than those of women, and cavitation indicated that a joint had gapped but not how much a joint had gapped.

A Pilot Randomized Controlled Trial of Flexion-Distraction Dosage for Chiropractic Treatment of Lumbar Spinal Stenosis

OBJECTIVE The purpose of this pilot clinical trial was to assess the feasibility of recruiting older adults with lumbar spinal stenosis (LSS) into a clinical trial that used different dosages of flexion-distraction manipulation. METHODS This randomized controlled trial used a 4-group design. Three groups consisted of chiropractic flexion-distraction manipulation applied at different dosages (8, 12, or 18 treatments). The fourth group was given 8 treatments of placebo care. Feasibility measures included recruitment goals, adherence to various treatment schedules, credibility of the placebo treatment, and rates of adverse events. The primary outcome measure was the Swiss Spinal Stenosis Questionnaire, a validated self-report of LSS symptom severity and physical function. RESULTS The recruitment and adherence goals of the study were met with a total of 60 subjects randomized (n = 15 per group) and most subjects attending at least 75% of their scheduled visits. No adverse events were reported by any of the subjects in the trial. Our placebo treatment did not appear to be credible; most subjects correctly guessed that they were receiving a placebo treatment. Between-group effect size estimates were small, indicating larger samples are needed for future studies. CONCLUSION This pilot study showed that it is feasible to recruit patients with LSS and that most subjects will adhere to a 6-week treatment schedule. The information gained from this trial will be useful to inform the design of larger trials.

Large C4/5 Spondylotic Disc Bulge Resulting in Spinal Stenosis and Myelomalacia in a Klippel-Feil Patient

OBJECTIVES The purpose of this report is to document a case of cervical spinal stenosis and myelomalacia in a patient with Klippel-Feil (KF) syndrome with a large C4/5 disc bulge presenting with cervical radiculopathy. SUBJECT A 39-year-old man was referred to a private chiropractic practice for a consultation. He complained of limited motion in his neck with pain and numbness radiating down both arms and left leg. Diagnostic imaging revealed KF syndrome and a large spondylotic disc bulge at C4/5 compressing the cord and causing myelomalacia. A plethora of symptoms and objective findings associated with KF syndrome were also present. RESULTS After reviewing the previous diagnostic imaging, examining this patient, and discovering that upper motor neuron pathological reflexes were present, the patient was recommended to proceed with the surgical intervention as recommended by his neurosurgeon. No chiropractic care was rendered. CONCLUSIONS This patient presented with primary complaints consistent with cervical radiculopathy. However, due to the severity of the neurologic findings and presence of myelomalacia, the patient was not treated. The patient had not previously been diagnosed with KF syndrome, although he presented clinically with many of the congenital issues commonly associated with the condition. This case demonstrates the vital importance of differential diagnostic skills as well as the need to continue fostering improved communication and integration of care among various clinical disciplines for patients presenting with challenging symptoms.

Recruitment Methods and Costs for a Randomized, Placebo-Controlled Trial of Chiropractic Care for Lumbar Spinal Stenosis: A Single-Site Pilot Study

OBJECTIVE The purpose of this article is to describe the methods for recruitment in a clinical trial on chiropractic care for lumbar spinal stenosis. METHODS This randomized, placebo-controlled pilot study investigated the efficacy of different amounts of total treatment dosage over 6 weeks in 60 volunteer subjects with lumbar spinal stenosis. Subjects were recruited for this study through several media venues, focusing on successful and cost-effective strategies. Included in our efforts were radio advertising, newspaper advertising, direct mail, and various other low-cost initiatives. RESULTS Of the 1211 telephone screens, 60 responders (5.0%) were randomized into the study. The most successful recruitment method was radio advertising, generating more than 64% of the calls (776 subjects). Newspaper and magazine advertising generated approximately 9% of all calls (108 subjects), and direct mail generated less than 7% (79 subjects). The total direct cost for recruitment was

Foot orthotics for low back pain: The state of our understanding and recommendations for future research

40 740 or

Distribution of Cavitations as Identified with Accelerometry During Lumbar Spinal Manipulation

679 per randomized patient. The costs per randomization were highest for direct mail (