Stephen M. Perle

Masters athletes : Factors affecting performance

AbstractIn recent years there has been an increase in interest in issues related to the enhancement of the performance of the masters athlete. Many of the changes in health status that have been thought to be the normal result of aging have been found to be actually the result of a long-standing sedentary lifestyle. Thus, masters athletes may be able to increase their athletic performance to higher levels than what was once thought. Decreases in muscle strength thought to be the result of aging do not appear to be so. The masters athlete may be able to maintain and increase strength in situations where strength training has not been previously engaged in. However, the literature lacks longitudinal studies demonstrating improvements in strength with age in masters athletes who have maintained habitual strength training. Studies in the past have shown that aging results in changes in fibre type, with a shift towards a higher percentage of type I fibres. This again may be an adaptation to lack of use. Decreases in heart function and aerobic capacity appear to be immutable, but in the masters athlete the rate of this decrease can be slowed. The masters athlete has certain elevated nutritional needs over younger athletes. Degenerative joint disease, although effecting most persons as they age, is not a certain result of aging and disability as the condition is reduced in the active person. Some orthopaedic conditions are related to decreases in flexibility of soft tissues that appear to accompany the aging process. Performance improvement in the masters athlete requires the same commitment to hard training that it requires from younger athletes, with some modifications for changes that are associated with aging.

Chiropractic as spine care: a model for the profession

BackgroundMore than 100 years after its inception the chiropractic profession has failed to define itself in a way that is understandable, credible and scientifically coherent. This failure has prevented the profession from establishing its cultural authority over any specific domain of health care.ObjectiveTo present a model for the chiropractic profession to establish cultural authority and increase market share of the public seeking chiropractic care.DiscussionThe continued failure by the chiropractic profession to remedy this state of affairs will pose a distinct threat to the future viability of the profession. Three specific characteristics of the profession are identified as impediments to the creation of a credible definition of chiropractic: Departures from accepted standards of professional ethics; reliance upon obsolete principles of chiropractic philosophy; and the promotion of chiropractors as primary care providers. A chiropractic professional identity should be based on spinal care as the defining clinical purpose of chiropractic, chiropractic as an integrated part of the healthcare mainstream, the rigorous implementation of accepted standards of professional ethics, chiropractors as portal-of-entry providers, the acceptance and promotion of evidence-based health care, and a conservative clinical approach.ConclusionThis paper presents the spine care model as a means of developing chiropractic cultural authority and relevancy. The model is based on principles that would help integrate chiropractic care into the mainstream delivery system while still retaining self-identity for the profession.

How can chiropractic become a respected mainstream profession? The example of podiatry

BackgroundThe chiropractic profession has succeeded to remain in existence for over 110 years despite the fact that many other professions which had their start at around the same time as chiropractic have disappeared. Despite chiropractics longevity, the profession has not succeeded in establishing cultural authority and respect within mainstream society, and its market share is dwindling. In the meantime, the podiatric medical profession, during approximately the same time period, has been far more successful in developing itself into a respected profession that is well integrated into mainstream health care and society.ObjectiveTo present a perspective on the current state of the chiropractic profession and to make recommendations as to how the profession can look to the podiatric medical profession as a model for how a non-allopathic healthcare profession can establish mainstream integration and cultural authority.DiscussionThere are several key areas in which the podiatric medical profession has succeeded and in which the chiropractic profession has not. The authors contend that it is in these key areas that changes must be made in order for our profession to overcome its shrinking market share and its present low status amongst healthcare professions. These areas include public health, education, identity and professionalism.ConclusionThe chiropractic profession has great promise in terms of its potential contribution to society and the potential for its members to realize the benefits that come from being involved in a mainstream, respected and highly utilized professional group. However, there are several changes that must be made within the profession if it is going to fulfill this promise. Several lessons can be learned from the podiatric medical profession in this effort.

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.

Subluxation: dogma or science?

Subluxation syndrome is a legitimate, potentially testable, theoretical construct for which there is little experimental evidence. Acceptable as hypothesis, the widespread assertion of the clinical meaningfulness of this notion brings ridicule from the scientific and health care communities and confusion within the chiropractic profession. We believe that an evidence-orientation among chiropractors requires that we distinguish between subluxation dogma vs. subluxation as the potential focus of clinical research. We lament efforts to generate unity within the profession through consensus statements concerning subluxation dogma, and believe that cultural authority will continue to elude us so long as we assert dogma as though it were validated clinical theory.

Rating specific chiropractic technique procedures for common low back conditions

OBJECTIVE To rate specific chiropractic technique procedures used in the treatment of common low back conditions. DESIGN AND METHODS A panel of chiropractors rated specific chiropractic technique procedures for their effectiveness in the treatment of common low back conditions, based on the quality of supporting evidence after systematic literature reviews and expert clinical opinion. Statements related to the rating process and clinical practice were then developed through a facilitated nominal consensus process. RESULTS For most low back conditions presented in this study, the three procedures rated most effective were high-velocity, low- amplitude (HVLA) with no drop table (side posture), distraction technique, and HVLA prone with drop table assist. The three rated least effective were upper cervical technique, non-thrust reflex/low force, and lower extremity adjusting. The four conditions rated most amenable to chiropractic treatment were noncomplicated low back pain, sacroiliac joint dysfunction, posterior joint/subluxation, and low back pain with buttock or leg pain. CONCLUSIONS The ratings for the effectiveness of chiropractic technique procedures for the treatment of common low back conditions are not equal. Those procedures rated highest are supported by the highest quality of literature. Much more evidence is necessary for chiropractors to understand which procedures maximally benefit patients for which conditions.

The establishment of a primary spine care practitioner and its benefits to health care reform in the United States

It is widely recognized that the dramatic increase in health care costs in the United States has not led to a corresponding improvement in the health care experience of patients or the clinical outcomes of medical care. In no area of medicine is this more true than in the area of spine related disorders (SRDs). Costs of medical care for SRDs have skyrocketed in recent years. Despite this, there is no evidence of improvement in the quality of this care. In fact, disability related to SRDs is on the rise. We argue that one of the key solutions to this is for the health care system to have a group of practitioners who are trained to function as primary care practitioners for the spine. We explain the reasons we think a primary spine care practitioner would be beneficial to patients, the health care system and society, some of the obstacles that will need to be overcome in establishing a primary spine care specialty and the ways in which these obstacles can be overcome.

The relation between the application angle of spinal manipulative therapy (SMT) and resultant vertebral accelerations in an in situ porcine model

It has been hypothesized that the posterior tissues of the spine are frictionless and therefore allow only the normal force component of spinal manipulative therapy (SMT) to pass to underlying vertebrae. Given this assumption, vertebrae could not be moved in practitioner-defined directions by altering the application angle of SMT. To investigate this possibility, porcine lumbar spines were excised and then SMT applied at 90 degrees to the posterior tissues of the target vertebra. A standard curve was constructed of increasing SMT force versus vertebral acceleration. SMT forces were then applied at 60 degrees and 120 degrees and the resulting accelerations substituted into the standard curve to obtain the transmitted force. Results showed that vertebral accelerations were greatest at a 90 degrees SMT application angle and decreased in all axes at application angles not equa l90 degrees . The average decrease in transmitted force using application angles of 60 degrees and 120 degrees was within 5% of the predicted absolute value. In this model, SMT applied at a non-normal angle does not increase vertebral acceleration in that same direction, but acts to reduce transmitted force. This work provides justification for future studies in less available human cadavers. It is not yet known if variations in SMT application angle have relevance to clinical outcomes or patient safety.

Letter to the editor concerning ''Independent evaluation of a clinical prediction rule for spinal manipulative therapy: a randomised controlled trial'' (M. Hancock et al.)

To the Editor: We congratulate Hancock and colleagues for undertaking a randomized trial which in part, examined the effectiveness of an eclectic approach to manual therapy for non-specific low back pain (LBP) [8]. These results were reported elsewhere and demonstrate that individuals with non-specific LBP, who receive paracetamol and advice from a general medical practitioner, do not experience a shortened time to recovery with the addition of diclofenac or an assortment of manual therapy techniques. The authors carried out a secondary analysis of this data [9] to evaluate the performance of a clinical prediction rule [3], which identifies individuals who have a high probability of achieving clinical success with a combination of a spinal manipulation technique and therapeutic exercise. It appears in part, that the authors sought to determine whether the prediction rule would also identify patients with LBP who experience clinical success with treatment consisting of a diverse collection of predominantly mobilization techniques, in the absence of therapeutic exercise, and when applied in a non-standardized manner. Curiously, while the authors felt the need to highly standardize the medical treatment (e.g., drug, dosage, frequency) in this trial, there was no like effort to standardize the manual therapy approaches. The inevitable result was that the clinicians utilized a diverse mix of manual therapy techniques, which may be an explanation for the lack of clinically important change in those receiving this therapy. Indeed, a recent metaanalysis [10] investigating manual therapy as a treatment for non-specific LBP, observed smaller treatment effects in trials where clinicians were not restricted as to the type of treatment technique. Given these differences in treatment type and application, it is clear that the treatment employed in this trial differs greatly from those used to develop [3] and validate [1] the clinical prediction rule, on which this analysis was purportedly evaluating. The terminology used to describe manual therapies has been identified as problematic [4]. Only 5% of all manual treatments in this study involved spinal manipulation, and yet Hancock and colleagues chose to use the term “spinal manipulative therapy” to describe the treatment evaluated in these papers. This is confusing to the biomedical community who may not understand the subtle differences in terminology used by clinicians and researchers who employ these treatments. While we feel confident that this was not an attempt at obfuscation by the authors, this appears to be the result nonetheless. Secondary sources such as Medscape®, have cited the author’s work as evidence arguing against the effectiveness of spinal manipulation [11]. We respectfully suggest that in future work, researchers differentiate between manipulation (i.e., thrust or high-velocity passive joint movements) and mobilization (i.e., non-thrust or low velocity passive joint movements) to avoid on-going confusion over this issue. The analysis conducted by Hancock et al. does contribute to a greater understanding of the performance of the clinical prediction rule, when a very different treatment package is utilized. In other words; a prediction rule which identifies individuals likely to experience clinical success with manipulation and therapeutic exercise, does not identify individuals who experience clinical success when receiving a variety of mobilization techniques directed at the thorax, lumbar spine, pelvis and hips. Unfortunately, Hancock and colleagues chose to frame their results by questioning the external validity of the clinical prediction rule. We find this curious, as the prediction rule is part of a treatment-based approach to sub-grouping individuals with LBP [7]. It appears that the treatment received by individuals in this trial is very different than the manipulation and exercise techniques which have been the basis of previous investigations of the prediction rule [1–3, 5, 6]. Given these differences, we fail to understand how the results of this secondary analysis can be used to shed light on the clinical utility of the prediction rule, when used in a manner for which it was intended; that being the application of therapeutic exercise and a manipulation technique to individuals with specific prognostic indicators. We would make the argument that the findings of Hancock and colleagues do not test the validity of the prediction rule, but make the case for the implementation of the rule in the same manner as it was developed, validated and examined in other clinical settings.

Chiropractic care for children: too much, too little or not enough?

This editorial provides an overview of this Thematic Series of the journal titled Chiropractic Care for Children. In commissioning this series of articles we aimed to bring the busy clinician up to date with the current best evidence in key aspects of evaluation and management of chiropractic care for children. Individual articles address a chiropractic approach to the management of children, chiropractic care of musculoskeletal conditions in children and adolescents, chiropractic care of non-musculoskeletal conditions in children and adolescents, chiropractic care for attention-deficit/hyperactivity disorder and possible adverse effects from chiropractic management of children. The final article by Charlotte Leboeuf-Yde and Lise Hestbæk is an overview of the current state of the evidence and future research opportunities for chiropractic care for children. We conclude this editorial discussing the strengths and weaknesses of contemporary research relevant to chiropractic care of children and the implications for chiropractic practice.