Michael T. Haneline

Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis.

OBJECTIVES The purpose of this project was to review the literature for the use of spinal manipulation for low back pain (LBP). METHODS A search strategy modified from the Cochrane Collaboration review for LBP was conducted through the following databases: PubMed, Mantis, and the Cochrane Database. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. 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. RESULTS A total of 887 source documents were obtained. Search results were sorted into related topic groups as follows: randomized controlled trials (RCTs) of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnostic-related articles, methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. The team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and coh ort studies. This yielded a total of 12 guidelines, 64 RCTs, 13 systematic reviews/meta-analyses, and 11 cohort studies. CONCLUSIONS As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

A review of intraexaminer and interexaminer reliability of static spinal palpation: a literature synthesis.

OBJECTIVE The purposes of this study were to locate articles that assessed the reliability of static palpation of the spine and sacroiliac joints, to appraise the quality of these studies, and synthesize their results. METHODS A structured literature search was conducted of chiropractic and medical databases PubMed, Manual Alternative and Natural Therapy System, Index to Chiropractic Literature, and Cumulative Index to Nursing and Allied Health Literature from 1965 through October 2007. Reference sections were inspected for additional citations. Only peer-reviewed articles in English containing information about static palpation of the spine or sacroiliac joints were selected. The resulting studies were appraised for quality by both of the authors using a 6-point scale instrument developed to assess the quality of reproducibility studies. RESULTS The search generated 343 citations, and another 7 were harvested from the reference lists. After removing articles not meeting the inclusion criteria, 29 were retained. A total of 14 studies focused on the reliability of locating painful or tender points, 10 on the location of landmarks, and 5 on position or alignment of bone structures. A higher proportion of studies that assessed painful or tender points reported acceptable levels of reliability. However, there were no significant differences between methods of palpation when considering the proportions of high-quality studies that reported good reliability. Thus, no form of static palpation could be considered to be superior. CONCLUSION Reported indices of agreement were generally low. More of the pain palpation studies reported acceptable kappa levels, although no one method of palpation could be deemed clearly superior.

Chiropractic and public health: current state and future vision.

This article provides an overview of primary chiropractic issues as they relate to public health. This collaborative summary documents the chiropractic professions current involvement in public health, reflects on past barriers that may have prevented full participation within the public health movement, and summarizes the relationship of current chiropractic and public health topics. Topics discussed include how the chiropractic profession participates in preventive health services, health promotion, immunization, geriatrics, health care in a military environment, and interdisciplinary care.

Spinal Motion Palpation: A Comparison of Studies That Assessed Intersegmental End Feel Vs Excursion

OBJECTIVE Spinal motion palpation (MP) is a procedure used to detect intersegmental hypomobility/hypermobility. Different means of assessing intersegmental mobility are described, assessing either excursion of the segments (quantity of movement) or end feel (quality of motion when stressed against the paraphysiological space). The objective of this review was to classify and compare studies based on method of MP used, considering that some studies may have used both methods. METHODS Four databases were searched: MEDLINE-PubMed, Manual Alternative and Natural Therapy System, Index to Chiropractic Literature, and Cumulative Index to Nursing and Allied Health Literature databases for the years 1965 through January 2007. Retrieved citations were independently screened for inclusion by 2 of the authors consistent with the inclusion and exclusion criteria. Included studies were appraised for quality, and data were extracted and recorded in tables. RESULTS The search strategy generated 415 citations, and 29 were harvested from reference lists. After removing articles that did not meet the inclusion criteria, 44 were considered relevant and appraised for quality. Fifteen studies focused on MP excursion, 24 focused on end feel, and 5 used both. Eight studies reported high levels of reproducibility (kappa = >or=0.4), although 4 were not of acceptable quality, and 2 were only marginally acceptable. When only high-quality studies were considered, 3 of 24 end-feel studies reported good reliability compared with 1 of 15 excursion studies. There was no statistical support for a difference between the 2 groupings. CONCLUSIONS A difference in reported reliability was observed when the method of MP varied, although it was not statistically significant. There was no support in the literature for the advantage of one MP method over the other.

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.

Spinous process palpation using the scapular tip as a landmark vs a radiographic criterion standard.

OBJECTIVE This study aimed at determining the standing spinal landmark that corresponds to the inferior tip of the scapula and determining the accuracy of experienced palpators in locating a spinous process (SP) 3 levels above and below a given SP. METHODS The study participants were 34 asymptomatic or minimally symptomatic chiropractic students. An experienced palpator located the inferior scapular tip on each and then positioned a 2-mm lead marker about 5 cm lateral to the nearest SP. Two more markers were placed at levels intended to be 3 levels above and below the first marker placed. The locations of the scapular tip and the spinal targets were determined by comparison with a radiological criterion standard. RESULTS The standing inferior scapular tip corresponded to the T8 SP on average (SD = 0.9). Having placed the first lead marker, examiners on average overshot the upper marker by 0.26 (SD = 0.51) vertebral levels and undershot the lower marker by 0.21 (SD = 0.48) vertebral levels. The modes for the placement of the 3 markers were at T5, T8, and T11. CONCLUSION Approximately 68% of patients would be palpated to have their inferior scapular tips at T7, T8, or T9. An experienced palpator can quite accurately locate vertebral levels 3 above or below a given landmark. Chiropractors and other health professionals using the typical rule of thumb linking the inferior scapular tip to the standing T7 SP have likely been applying clinical interventions at spinal locations different from those intended.

Survey of Health Attitudes and Behaviors of a Chiropractic College Population

OBJECTIVES We gathered information about health behaviors on a chiropractic campus, including compliance with recent guidelines for exercise as well as diet, smoking, and binge drinking. We also assessed the perceived importance of the chiropractic physician in role modeling and teaching healthy behaviors to patients. METHODS A survey instrument composed of 16 questions was designed and distributed to 279 students, faculty, and staff at a chiropractic college campus in northern California. Confidentiality was maintained throughout the process, and a response rate of 92% was obtained. Statistical analysis was performed on the data collected. RESULTS The levels of obesity, inactivity, and smoking on this college campus are lower than the levels reported for the metropolitan area, the state, and the nation. The level of binge drinking among our students was high but similar to the reported rates for college students generally. We found interesting and significant relationships between the behaviors of physical activity and diet (red meat consumption), obesity, and self-reported perceived health in our surveyed chiropractic college population. Without exception, all surveyed members of our campus community view doctors of chiropractic as having a responsibility to role model healthy behaviors and to educate their patients with regard to healthy behaviors; however, we also found that less importance was placed on role modeling and patient education by those who were obese or who consumed red meat in excess. CONCLUSIONS This chiropractic college campus places a high level of importance on both educating patients and role modeling healthy behaviors. In the behavioral domain, the rates of smoking, obesity, and inactivity are lower than what is seen in the general population. However, there remains room for considerable improvement to bring actual health behaviors closer in line with evidence-informed behavioral health practices.

The notion of a “whiplash culture”: a review of the evidence

OBJECTIVE Most whiplash patients eventually recover, although some are left with ongoing pain and impairment. Why some develop long-term symptoms after whiplash, whereas others do not, is largely unknown. One explanation blames the cultural expectations of the population wherein the injury occurred, engendering the moniker whiplash culture. The purpose of this review was to locate and discuss studies that were used as a basis for developing the whiplash culture concept and to evaluate its plausibility. METHODS The PubMed database was searched using combinations of the terms whiplash culture, whiplash OR WAD, and chronic OR late OR long term. Search dates spanned from 1950 to June 2008. Filters were set to only retrieve English-language citations. Articles that dealt with the whiplash culture were selected and examined to determine which studies had been used to create the concept. RESULTS Nineteen articles discussed the cultural aspects of whiplash and were explored to determine which were used as a basis for the whiplash culture. Eight studies were found that met this final criterion. CONCLUSION There are many unanswered questions about the basis of chronic whiplash, and the notion of a whiplash culture is controversial. Chronic whiplash symptoms are surely not caused entirely by cultural issues, yet they are probably not entirely physical. Presumably, a tissue injury component exists in most chronic whiplash-associated disorder victims that becomes aggravated in those who are susceptible to biopsychosocial factors. As with many other controversial health care topics, the answer to the debate probably lies somewhere in the middle.

Comments about "Atherosclerosis in the vertebral artery: an intrinsic risk factor in the use of spinal manipulation? (2006) Surg Radiol Anat 28:129-134, by Cagnie B, Barbaix E, Vinck E, D'Herde K, Cambier D".

Cagnie et al. [1] fail to support their case when they suggest that because atherosclerotic changes were frequently present in the third segment of the vertebral arteries of a very old population, rotational manipulative techniques on atherosclerotic vessels impose a risk factor for vertebrobasilar insuYciency (VBI). Moreover, it has never been established that atherosclerotic changes are associated with an increased incidence of manipulation-related VBI. In fact, the paper [4] used by the authors to support their arguments does just the opposite. Although the authors argue that “...atherosclerosis may also play a role in the pathogenesis of dissecting aneurysms...” and “The combination of atherosclerosis and direct trauma, such as manipulation of the neck, may, therefore, increase the risk of a dissection,” the paper cited does not refer to atherosclerosis as a risk factor for either dissection or dissecting aneurysms. Conversely, it reports that “...atherosclerosis appears to be distinctly uncommon (italics ours) in patients with a dissection of the carotid or vertebral artery.” The authors state that “spinal manipulation could theoretically dislodge an embolus from an atherosclerotic plaque and subsequently cause an ischemic stroke.” However, this relationship is highly speculative and has not been reported in the literature. The association that has been reported between cervical manipulation and stroke has to do with dissection of the vertebral artery (VA), not atherosclerosis. In contrast to this study’s population, the association occurs in persons who are relatively young, peaking between 40 and 45 years of age [2], and occurs at a frequency of approximately one per one million cervical manipulations [3]. From a mechanistic viewpoint, the most direct means of assessing the eVects of spinal manipulative therapy upon the integrity of the VAs would be to directly measure how the forces anticipated during manipulations might be transmitted through the various skeletal and soft-tissue layers of the cervical milieu to the region of the VA. In an investigation of excised VAs, Herzog has actually shown that the forces measured during spinal manipulative therapy were 1/9 those needed to achieve arterial failure and actually less than those experienced during provocative testing procedures which the authors suggest might give “a false sense of safety” rather than actually causing a VA accident [5]. It is puzzling that the authors state in their conclusion that “vigorous manual procedures should be avoided until...gentle manual therapy has proven eVective.” If such an approach did in fact prove eVective, it is diYcult to understand why a therapist would progress up the ladder to an intervention that was more vigorous. The purpose of the Cagnie et al. study was “...to identify the sites and frequency of atherosclerotic plaques and to determine its relation to the tortuous course of the vertebral artery...” yet the conclusion deviates from this objective and introduces a speculative and non-related issue. The fact that VA dissections have been identiWed in the literature from either spontaneous circumstances [4] or from such non manipulative lifestyle events as turning the head while driving a M. T. Haneline (&) Palmer College of Chiropractic West, 90 E. Tasman Drive, San Jose, CA 95134, USA e-mail: michael.haneline@palmer.edu

Mathematical modeling of the socalled Allis test: a field study in orthopedic confusion

BackgroundChiropractors use a variety of supine and prone leg checking procedures. Some, including the Allis test, purport to distinguish anatomic from functional leg length inequality. Although the reliability and to a lesser extent the validity of some leg checking procedures has been assessed, little is known on the Allis test. The present study mathematically models the test under a variety of hypothetical clinical conditions. In our search for historical and clinical information on the Allis test, nomenclatural and procedural issues became apparent.MethodsThe test is performed with the subject carefully positioned in the supine position, with the head, pelvis, and feet centered on the table. After an assessment for anatomic leg length inequality, the knees are flexed to approximately 90°. The examiner then sights the short leg side knee sequentially from both the foot and side of the table, noting its relative locations: both its height from the table and Y axis position. The traditional interpretation of the Allis test is that a low knee identifies a short tibia and a cephalad knee a short femur. Assuming arbitrary lengths and a tibio/femoral ratio of 1/1.26, and a hip to foot distance that placed the knee near 90°, we trigonometrically calculated changes in the location of the right knee that would result from hypothetical reductions in tibial and femoral length. We also modeled changes in the tibio/femoral ratio that did not change overall leg length, and also a change in hip location.ResultsThe knee altitude diminishes with either femoral or tibial length reduction. The knee shifts cephalad when the femoral length is reduced, and caudally when the tibial length is reduced. Changes in the femur/tibia ratio also influence knee position, as does cephalad shifting of the hip.ConclusionThe original Allis (aka Galeazzi) test was developed to identify gross hip deformity in pediatric patients. The extension of this test to adults suspected of having anatomical leg length inequality is problematic, and needs refinement at the least. Our modeling questions whether this test can accurately identify aLLI, let alone distinguish a short tibia from a short femur.