Scott Haldeman

Colonic Dysfunction in Multiple Sclerosis

Multiple sclerosis is a central nervous system disease frequently accompanied by urinary symptoms and severe constipation. In order to investigate the pathophysiology of these symptoms, we studied colonic motor and myoelectrical activity, as well as colonic volume-pressure relationships (colonometrograms) and have correlated these data with cystometry and electrophysiologic studies of the central and peripheral somatosensory nervous system. The study group consisted of 7 patients with advanced multiple sclerosis marked by symptoms and signs of somatic and visceral nervous system dysfunction including severe constipation. Ten normal volunteers served as control subjects. The multiple sclerosis group demonstrated electrophysiologic evidence of lesions in the somatosensory neuroaxis central to the lumbosacral spinal cord. Abnormal cystometrograms suggested visceral central nervous system dysfunction. Colonometrograms in the multiple sclerosis group demonstrated a more rapid pressure rise than in the control group (p less than 0.01). The multiple sclerosis group failed to demonstrate the postprandial increase in colonic motor and myoelectrical activity observed in the control group (p less than 0.01). Abnormal colonometrograms and absent postprandial colonic motor and myoelectric responses may be features of visceral neuropathy in patients with advanced multiple sclerosis and severe constipation.

Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias

BACKGROUND CONTEXT The growing recognition of cervical manipulation as a treatment of neck pain and cervicogenic headaches has lead to increased interest in potential complications that may result from this treatment approach. Recent surveys have reported that many neurologists will encounter cases of vertebral artery dissection that occur at various times after cervical manipulation, whereas most practitioners of spinal manipulation are of the opinion that these events are extremely rare. We asked the question whether these differences in perception could be explained in part by referral or selection bias. PURPOSE To assess the effect of referral bias on the differences in perceived incidence of vertebral artery dissection after cervical manipulation between neurologists and chiropractors in Canada. STUDY DESIGN This study was a retrospective review of cases where neurological symptoms consistent with cerebrovascular ischemia were reported by chiropractors in Canada. METHODS An analysis of data from a chiropractic malpractice insurance carrier (Canadian Chiropractic Protective Association [CCPA]) and results of a survey of chiropractors was performed to determine the likelihood that a vertebral artery dissection after cervical manipulation would be reported to practicing chiropractors. This was compared with the likelihood that a neurologist would be made aware of such a complication. RESULTS For the 10-year period 1988 to 1997, there were 23 cases of vertebral artery dissection after cervical manipulation reported to the CCPA that represents 85% of practicing chiropractors in Canada. Based on the survey, an estimated 134,466,765 cervical manipulations were performed during this 10-year period. This gave a calculated rate of vertebral artery dissection after manipulation of 1:5,846,381 cervical manipulations. Based on the number of practicing chiropractors and neurologists during the period of this study, 1 of every 48 chiropractors and one of every two neurologists would have been made aware of a vascular complication from cervical manipulation that was reported to the CCPA during their practice lifetime. CONCLUSIONS The perceived risk after cervical manipulation by chiropractors and neurologists is related to the probability that a practitioner will be made aware of such an incident. The difference in the number of chiropractors (approximately 3,840 in 1997) and neurologists (approximately 4,000 in 1997) in active practice and the fact that each patient who has a stroke after manipulation will likely be seen by only one chiropractor but by three or more neurologists partly explains the difference in experience and the perception of risk of these two professions. This selection or referral bias is important in shaping the clinical opinions of the various disciplines and distorts discussion on the true incidence of these complications of cervical manipulation. The nature of this study, however, describes the likelihood that a clinician will be made aware of such an event and cannot be interpreted as describing the actual risk of stroke after manipulation.

The neurovisceral and electrodiagnostic evaluation of patients with thoracic spinal cord injury

We studied nine patients with complete thoracic spinal cord injury in order to investigate distal electrophysiologic and end organ function. Studies included motor and sensory nerve conduction velocities, spinal and cortical somatosensory evoked responses, bulbocavernosus reflex responses, cystometry and colonic compliance, motor and myoelectrical activity. These studies confirmed an intact peripheral nervous system, as well as normal nerve root, cauda equina, conus medullaris and distal spinal cord function. Cystometry demonstrated decreased bladder capacity and inability to suppress detrusor contractions. Colonic compliance was greatly reduced, compared to control subjects. While basal colonic motor and myoelectrical activity was normal, these spinal cord injury patients failed to demonstrate the postprandial increase in colonic motor and myoelectric activity seen in normal subjects. These tests allow the clinician to define and document the extent of neuronal injury distal to a transverse myelopathy and to evaluate visceral end organ function.

How can we assess the burden of muscle, bone and joint conditions in rural Botswana: context and methods for the MuBoJo focused ethnography

BackgroundMusculoskeletal diseases are the most common causes of long-term pain and disability worldwide and a growing international public health concern. However, the everyday burden and impact of musculoskeletal conditions are not well understood, especially among people living in low- and middle-income countries in Africa. Since 2011, World Spine Care, a nongovernmental organisation, has collaborated with the Botswana Ministry of Health to open spine care centres and to conduct research. The broad aim of the Muscle, Bone and Joint (MuBoJo) research project is to examine the sociocultural, organisational and clinical characteristics for the burden of living with and caring for people living with musculoskeletal conditions in rural Botswana. In this paper, we describe the community context, theoretical framework, and research methods to address the project aim with a qualitative study.Methods/DesignThis focused ethnography is based on eight months (November 2011, April 2013, October 2013-March 2014) of fieldwork in Botswana. The project was theoretically informed by the concepts of explanatory models of illness, social suffering, and biographical disruption. Data collection included fieldnotes, non-participant and participant observations, and informal and in-depth interviews with villagers and healthcare providers. Villager interviews were typically conducted in Setswana with an interpreter. Audio recordings were transcribed verbatim in the language spoken with Setswana contextually translated into English. Computer software supported qualitative data management. Analysis is ongoing using constant comparison and a template organising style to facilitate pattern-finding and reveal insights for the burden and care of musculoskeletal conditions.DiscussionFindings from the MuBoJo Project will document the context of musculoskeletal burden, illness beliefs, self-care behaviours, and healthcare options in a Botswana rural village. These data will inform ongoing efforts to establish spine care clinics for underserved populations in low-middle income countries and sustain these healthcare services through local providers and volunteer health professionals. This study also will generate new knowledge about the burden and impact of muscle, bone and joint disorders for cross-cultural comparisons and patient-centred interventions.ConclusionsOur systematic and transparent methodology to conduct musculoskeletal research in more than one language and in a cross-cultural setting may be useful for investigators and NGO healthcare personnel.