OBJECTIVE: The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death. DESIGN: This study is a systematic review of case reports. METHODS: Literature searches in four electronic databases with no restrictions of time or language. MAIN OUTCOME MEASURE: Death. RESULTS: Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery. CONCLUSION: Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit.

Int J Clin Pract. 2010 Jul;64(8):1162-5. Ernst E. Complementary Medicine, Peninsula Medical School, University of Exeter, Exeter, UK. Edzard.Ernst@pms.ac.uk

ABSTRACT: BACKGROUND: Chiropractic (Greek: done by hand) is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. There is an emphasis on manual techniques, including joint adjustment and/or manipulation, with a particular focus on joint subluxation (World Health Organization 2005) or mechanical lesion and restoring function. The chiropractor's role in wellness care, prevention and treatment of injury or illness is based on education in anatomy and physiology, nutrition, exercise and healthy lifestyle counseling as well as referral to other health practitioners. Depending on education, geographic location, scope of practice, as well as consumer preference, chiropractors may assume the role of primary care for families who are pursuing a more natural and holistic approach to health care for their families. OBJECTIVE: To present a perspective on current management of the paediatric patient by members of the chiropractic profession and to make recommendations as to how the profession can safely and effectively manage the paediatric patient. DISCUSSION: The chiropractic profession holds the responsibility of ethical and safe practice and requires the cultivation and mastery of both an academic foundation and clinical expertise that distinguishes chiropractic from other disciplines.Research into the effectiveness of chiropractic care for paediatric patients has lagged behind that of adult care, but this is being addressed through educational programs where research is now being incorporated into academic tracks to attain advanced chiropractic degrees. CONCLUSION: Studies in the United States show that over the last several decades, chiropractors are the most common complementary and alternative medicine providers visited by children and adolescents. Chiropractors continue to seek integration with other healthcare providers to provide the most appropriate care for their paediatric patients.In the interest of what is best for the paediatric population in the future, collaborative efforts for research into the effectiveness and safety of chiropractic care as an alternative healthcare approach for children should be negotiated and are welcomed.

Chiropr Osteopat. 2010 Jun 2;18:16. Vallone SA, Miller J, Larsdotter A, Barham-Floreani J. Private Practice, Connecticut, USA. svallonedc@aol.com.

Full Title: The evidence base for chiropractic treatment of musculoskeletal conditions in children and adolescents: The emperor's new suit?

ABSTRACT: Five to ten percent of chiropractic patients are children and adolescents. Most of these consult because of spinal pain, or other musculoskeletal complaints. These musculoskeletal disorders in early life not only affect the quality of children's lives, but also seem to have an impact on adult musculoskeletal health. Thus, this is an important part of the chiropractors' scope of practice, and the objective of this review is to assess the evidence base for manual treatment of musculoskeletal disorders in children and adolescents.Randomized, quasi-randomized and non-randomized clinical studies were included if they investigated the effect of manual therapy on musculoskeletal disorders in children and/or adolescents. The MEDLINE and MANTIS databases were searched, and studies published in English, Danish, Swedish or Norwegian were included.Only three studies were identified that in some way attempted to look at the effectiveness of manual therapy for children or adolescents with spinal problems, and none of these was a randomized controlled clinical trial. As for the rest of the musculoskeletal system, only one study of temporomandibular disorder was identified.With this review, we have detected a paradox within the chiropractic profession: Although the major reason for pediatric patients to attend a chiropractor is spinal pain, no adequate studies have been performed in this area. It is time for the chiropractic profession to take responsibility and systematically investigate the efficiency of joint manipulation of problems relating to the developing musculoskeletal system.

Chiropr Osteopat. 2010 Jun 2;18:15. Hestbaek L, Stochkendahl MJ. Nordic Institute of Chiropractic and Clinical Biomechanics, Forskerparken 10, DK-5230 Odense M, Denmark. l.hestbaek@nikkb.dk.11

OBJECTIVES: To describe the extent to which chiropractors utilize standardized outcome and various clinical measures to systematically document patients' baseline health status and responses to treatment, with particular consideration being given towards quantifiable outcome instruments. STUDY DESIGN: Cross-sectional mailed survey. PARTICIPANTS: Registered chiropractors in the province of Saskatchewan. METHODS: A survey was mailed to all registrants of the Chiropractors' Association of Saskatchewan. Respondents graded their frequency of using various standardized pencil-and-paper instruments and functional chiropractic, orthopaedic and neurological tests in the contexts of both the initial intake assessment ('always,' 'commonly,' 'occasionally,' or 'never') and the course of subsequent treatment (after 'each visit,' after '9-12 visits,' 'annually,' when patient 'not responding,' on 'dismissal/discharge,' 'never' or for some 'other' reason). Data were tabulated for all item and response category combinations as frequencies and percentages using the total sample size as the denominator. RESULTS: Of 164 registered chiropractors, 62 (38%) returned a completed questionnaire. A pain diagram was the most commonly used subjective outcome measure and was administered routinely (either "always" or "commonly") by 75% of respondents, at either the initial consultation or during a subsequent visit. Numerical rating and visual analogue scales were less popular (routinely used by 59% and 42% respectively). The majority of respondents (80%) seldom ("occasionally" or "never") used spine pain-specific disability indices such as the Low Back Revised Oswestry, Neck Disability Index or the Roland-Morris Questionnaire. As well, they did not use standardized psychosocial instruments such as the Beck Depression Index, or general health assessment measures such as the SF-36 or SF-12 questionnaire. Neurological testing was the most commonly used objective outcome measure. Most respondents (84% to 95%) indicated that they continually monitored neurological status through dermatomal, manual muscle strength and deep tendon reflex testing. Ranges of motion were routinely measured by 95% of respondents, usually visually (96%) rather than goniometrically or by some other specialized device (7%). CONCLUSIONS: Our findings suggest that the majority of chiropractors do not use psychosocial questionnaires or condition-specific disability indices to document baseline or subsequent changes in health status. Chiropractors are more likely to rely on medical history taking and pain drawings during an initial intake assessment, as well as neurological and visually estimated range of motion testing during both initial intake and subsequent treatment visits.

BACKGROUND: Some chiropractors and their associations claim that chiropractic is effective for conditions that lack sound supporting evidence or scientific rationale. This study therefore sought to determine the frequency of World Wide Web claims of chiropractors and their associations to treat, asthma, headache/migraine, infant colic, colic, ear infection/earache/otitis media, neck pain, whiplash (not supported by sound evidence), and lower back pain (supported by some evidence). METHODS: A review of 200 chiropractor websites and 9 chiropractic associations' World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom, and the United States was conducted between 1 October 2008 and 26 November 2008. The outcome measure was claims (either direct or indirect) regarding the eight reviewed conditions, made in the context of chiropractic treatment. RESULTS: We found evidence that 190 (95%) chiropractor websites made unsubstantiated claims regarding at least one of the conditions. When colic and infant colic data were collapsed into one heading, there was evidence that 76 (38%) chiropractor websites made unsubstantiated claims about all the conditions not supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%) associations made claims about lower back pain, whereas 179 (90%) websites and all 9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated claims were made about asthma, ear infection/earache/otitis media, neck pain, CONCLUSIONS: The majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue.

BACKGROUND: Chiropractors commonly use a combination of interventions to treat people with low-back pain (LBP). OBJECTIVES: To determine the effects of combined chiropractic interventions (that is, a combination of therapies, other than spinal manipulation alone) on pain, disability, back-related function, overall improvement, and patient satisfaction in adults with LBP, aged 18 and older. SEARCH STRATEGY: We searched: The Cochrane Back Review Group Trials Register (May 2009), CENTRAL (The Cochrane Library 2009, Issue 2), and MEDLINE (from January 1966), EMBASE (from January 1980), CINAHL (from January 1982), MANTIS (from Inception) and the Index to Chiropractic Literature (from Inception) to May 2009. We also screened references of identified articles and contacted chiropractic researchers. SELECTION CRITERIA: All randomised trials comparing the use of combined chiropractic interventions (rather than spinal manipulation alone) with no treatment or other therapies. DATA COLLECTION AND ANALYSIS: At least two review authors selected studies, assessed the risk of bias, and extracted the data using standardised forms. Both descriptive synthesis and meta-analyses were performed. MAIN RESULTS: We included 12 studies involving 2887 participants with LBP. Three studies had low risk of bias. Included studies evaluated a range of chiropractic procedures in a variety of sub-populations of people with LBP.No trials were located of combined chiropractic interventions compared to no treatment. For acute and subacute LBP, chiropractic interventions improved short- and medium-term pain (SMD -0.25 (95% CI -0.46 to -0.04) and MD -0.89 (95%CI -1.60 to -0.18)) compared to other treatments, but there was no significant difference in long-term pain (MD -0.46 (95% CI -1.18 to 0.26)). Short-term improvement in disability was greater in the chiropractic group compared to other therapies (SMD -0.36 (95% CI -0.70 to -0.02)). However, the effect was small and all studies contributing to these results had high risk of bias. There was no difference in medium- and long-term disability. No difference was demonstrated for combined chiropractic interventions for chronic LBP and for studies that had a mixed population of LBP. AUTHORS' CONCLUSIONS: Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. Future research is very likely to change the estimate of effect and our confidence in the results.

Cochrane Database Syst Rev. 2010 Apr 14;4:CD005427. Walker BF, French SD, Grant W, Green S. School of Chiropractic and Sports Science, Murdoch University, Faculty of Health Sciences, Murdoch, Australia, 6150.

ABSTRACT: BACKGROUND: When conservative therapies for low back pain (LBP) are not effective, elective surgery may be proposed to these patients. Over the last 20 years, a new technology, disc replacement, has become increasingly popular because it is believed to maintain or restore the integrity of spinal movement and minimize the side-effects compared to fusion. Although disc replacement may relieve a patient from pain and related disability, soreness and stiffness of the lumbopelvic region seem to be common aftermaths of the surgery. This prospective case series was undertaken to identify and describe potential adverse events of lumbar spinal manipulation, a common therapy for low back pain, in a group of patients with symptoms after disc prostheses. CASES PRESENTATION: Eight patients who underwent lumbar spine total disc replacement were referred by an orthopaedic surgeon for chiropractic treatments. These patients had 1 or 2 total lumbar disc replacements and were considered stable according to the surgical protocol but presented persistent, post-surgical, non-specific LBP or pelvic pain. They were treated with lumbar spine side posture manipulations only and received 8 to 10 chiropractic treatments based on the clinical evolution and the chiropractor's judgment. Outcome measures included benign, self-limiting, and serious adverse events after low back spinal manipulative therapy. The Oswestry Disability Index, a pain scale and the fear avoidance belief questionnaire were administered to respectively assess disability, pain and fear avoidance belief about work and physical activity. This prospective case series comprised 8 patients who all had at least 1 total disc replacement at the L4/L5 or L5/S1 level and described persistent post-surgical LBP interfering with their daily activities. Commonly-reported side-effects of a benign nature included increased pain and/or stiffness of short duration in nearly half of the chiropractic treatment period. No major or irreversible complication was noted. CONCLUSIONS: During the short treatment period, no major complication was encountered by the patients. Moreover, the benign side-effects reported after lumbar spine manipulation were similar in nature and duration to those frequently experienced by the general population.

Chiropr Osteopat. 2010 Apr 21;18:7. O'Shaughnessy J, Drolet M, Roy JF, Descarreaux M. Département de chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada. martin.descarreaux@uqtr.ca.

Full Title: Management of Operation Iraqi Freedom and Operation Enduring Freedom veterans in a Veterans Health Administration chiropractic clinic: a case series

Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans commonly seek care for musculoskeletal complaints in Veterans Health Administration (VHA) facilities. Chiropractic services for musculoskeletal conditions have recently been introduced to VHA. No reports have been published on chiropractic care for OIF/OEF veterans. This study was designed to describe elements of the processes and outcomes of care for OIF/OEF veterans in a VHA chiropractic clinic. A retrospective review of consecutive cases consulted to one VHA chiropractic clinic was conducted. Thirty-one cases were identified. Consultations originated in primary care and specialty clinics that commonly manage musculoskeletal conditions. Military traumatic injury and posttraumatic stress disorder were common. Adverse effects of treatment were mild and transitory. In 19 cases (61%), a pain decrease above the threshold for minimally important change was reported. This article is the first description of health services delivered to OIF/OEF veterans in a VHA chiropractic clinic. Chiropractic management was safe in these cases, and results support the hypothesis that such management may be effective in certain OIF/OIF veterans. A better understanding of the characteristics of these particular patients and the processes of care received in VHA chiropractic clinics is needed to improve the clinical care of these veterans.

J Rehabil Res Dev. 2010;47(1):1-6. Lisi AJ. Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT 06516, USA. Anthony.lisi@va.gov

Full Title: The chiropractic care of children with attention-deficit/hyperactivity disorder: a retrospective case series

BACKGROUND: Characterized with hyperactivity, inattention and impulsivity, attention-deficit/hyperactivity disorder (ADHD) has a prevalence in children, ranging from 2.6% to 11.4%. The medical approach is multimodal, with combination therapies of behavioral modification and pharmacotherapy. With growing concerns regarding the safety of both short-term and long-term use of psychotropic medications, the need for investigating alternative approaches to the care of children is warranted. OBJECTIVE: The aim of this review was to describe the chiropractic care of children with medically diagnosed ADHD. DESIGN: Retrospective case series were reviewed. SETTING: The review was conducted in a private practice of chiropractic with a solo practitioner. PATIENTS/PARTICIPANTS: Pediatric patients (aged < or =18 years) attending chiropractic care for a minimum period of five months following a medical diagnosis of ADHD were included in this review. INTERVENTION: The intervention was chiropractic spinal manipulative therapy augmented by nutritional supplements. RESULTS: Our review found four patient files satisfying the inclusion criteria. All patients were males, ranging in age from nine to 13 years (mean age, 10 years), with three patients having a history of medication use and two patients having prescribed medication at the start of chiropractic care. Using a 15-item parent/teacher ADHD questionnaire, the patients' responses to chiropractic care were monitored. Using the Friedman test to compare observations repeated on the same subjects, our findings found improvement in ADHD symptoms (ie, hyperactivity, impulsivity, and inattentiveness, as well as behavioral, social, or emotional difficulties) and provide supporting evidence on the effectiveness of chiropractic in the treatment of children with ADHD. CONCLUSION: A retrospective case series of ADHD patients under chiropractic care is described. This provides supporting evidence on the benefits of chiropractic spinal manipulative therapy. We encourage further research in this area. Copyright (c) 2010 Elsevier Inc. All rights reserved. BACKGROUND: Characterized with hyperactivity, inattention and impulsivity, attention-deficit/hyperactivity disorder (ADHD) has a prevalence in children, ranging from 2.6% to 11.4%. The medical approach is multimodal, with combination therapies of behavioral modification and pharmacotherapy. With growing concerns regarding the safety of both short-term and long-term use of psychotropic medications, the need for investigating alternative approaches to the care of children is warranted. OBJECTIVE: The aim of this review was to describe the chiropractic care of children with medically diagnosed ADHD. DESIGN: Retrospective case series were reviewed. SETTING: The review was conducted in a private practice of chiropractic with a solo practitioner. PATIENTS/PARTICIPANTS: Pediatric patients (aged < or =18 years) attending chiropractic care for a minimum period of five months following a medical diagnosis of ADHD were included in this review. INTERVENTION: The intervention was chiropractic spinal manipulative therapy augmented by nutritional supplements. RESULTS: Our review found four patient files satisfying the inclusion criteria. All patients were males, ranging in age from nine to 13 years (mean age, 10 years), with three patients having a history of medication use and two patients having prescribed medication at the start of chiropractic care. Using a 15-item parent/teacher ADHD questionnaire, the patients' responses to chiropractic care were monitored. Using the Friedman test to compare observations repeated on the same subjects, our findings found improvement in ADHD symptoms (ie, hyperactivity, impulsivity, and inattentiveness, as well as behavioral, social, or emotional difficulties) and provide supporting evidence on the effectiveness of chiropractic in the treatment of children with ADHD. CONCLUSION: A retrospective case series of ADHD patients under chiropractic care is described. This provides supporting evidence on the benefits of chiropractic spinal manipulative therapy. We encourage further research in this area. Copyright (c) 2010 Elsevier Inc. All rights reserved.

Explore (NY). 2010 May-Jun;6(3):173-82. Alcantara J, Davis J. International Chiropractic Pediatric Association, 327 N. Middletown Road, Media, PA 19063, USA. dr_jalcantara@yahoo.com

Full Title: The Nordic maintenance care program: case management of chiropractic patients with low back pain - defining the patients suitable for various management strategies.

ABSTRACT: BACKGROUND: Maintenance care is a well known concept among chiropractors, although there is little knowledge about its exact definition, its indications and usefulness. As an initial step in a research program on this phenomenon, it was necessary to identify chiropractors' rationale for their use of maintenance care. Previous studies have identified chiropractors' choices of case management strategies in response to different case scenarios. However, the rationale for these management strategies is not known. In other words, when presented with both the case, and different management strategies, there was consensus on how to match these, but if only the management strategies were provided, would chiropractors be able to define the cases to fit these strategies? The objective with this study was to investigate if there is a common pattern in Finnish chiropractors' case management of patients with low back pain (LBP), with special emphasis on long-term treatment. METHODS: Information was obtained in a structured workshop. Fifteen chiropractors, members of the Finnish Chiropractors' Union, and present at the general assembly, participated throughout the entire workshop session. These were divided into five teams each consisting of 3 people. A basic case of a patient with low back pain was presented together with six different management strategies undertaken after one month of treatment. Each team was then asked to describe one (or several) suitable case(s) for each of the six strategies, based on the aspects of 1) symptoms/findings, 2) the low back pain history in the past year, and 3) other observations. After each session the people in the groups were changed. Responses were collected as key words on flip-over boards. These responses were grouped and counted. RESULTS: There appeared to be consensus among the participants in relation to the rationale for at least four of the management strategies and partial consensus on the rationale for the remaining two. In relation to maintenance care, the patient's past history was important but also the doctor-patient relationship. CONCLUSION: These results confirm that there is a pattern among Nordic chiropractors in how they manage patients with LBP. More information is needed to define the "cut-point" for the indication of prolonged care.

Chiropr Osteopat. 2009 Jul 12;17:7. Malmqvist S, Leboeuf-Yde C. Department of Health Studies, Faculty of Social Sciences, University of Stavanger, Stavanger, Norway. stefan.malmqvist@uis.no.

Full Title: A retrospective analysis of self-reported symptoms from 761 consecutive new patients presenting to a Neuro Emotional Technique chiropractic clinic.

PURPOSE: To describe the profile of patients presenting to a private chiropractic clinic specialising in Neuro Emotional Technique (NET) and to identify trends in the presentation of symptoms from these patients. METHODS: 761 consecutive new patients presented to a large, multi-doctor chiropractic clinic in which practitioners all adopt a similar philosophical paradigm and practice NET From January 2005 to December 2005, self-referred patients completed a new patient questionnaire, in which they self-reported one primary complaint for why they were visiting the practitioner. Predetermined patient information was entered manually into a database and basic descriptive statistics extracted. RESULTS: 67.3% of participants were female and 32.6% of the participants were between the ages of 31 and 40. 54.8% of patients presented with a primary musculoskeletal complaint and 36.0% a non-musculoskeletal complaint. Of the musculoskeletal complaints, 40.8% of patients presented with back pain, 20.9% with neck pain and 11.5% with shoulder pain. The most common form of non-musculoskeletal complaint was immune and recurrent infections (13.9%), stress and anxiety (12.8%) and depression (10.9%). 41.4% of participants reported a first time complaint, however, of the patients who had had the presenting complaint before 60.7% reported as having the complaint for greater than 1 year. Musculoskeletal and non-musculoskeletal participants had similar pain profiles. CONCLUSION: This retrospective analysis is the first comprehensive description of the scope of NET patients and their presenting complaints. The patient profile of this NET clinic has a higher degree of non-musculoskeletal patients than that usually reported in non-NET chiropractic offices, and other forms of chiropractic previously described in the literature. Further cross sectional research is required to determine if this particular clinic is indicative of all NET practices and whether the presenting symptoms, especially the non-musculoskeletal, are resolved with NET.

Complement Ther Clin Pract. 2009 Aug;15(3):166-71. Epub 2009 Mar 4. Bablis P, Pollard H, Bonello R. Macquarie Injury Management Group, Department of Health and Chiropractic, Macquarie University, Sydney, NSW 2109, Australia.

Full Title: Chiropractic management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report.

OBJECTIVE: This case report describes the evaluation and conservative management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran within a Veterans Affairs Medical Center chiropractic clinic. CLINICAL FEATURES: The 43-year-old patient had a 20-year history of mechanical back pain secondary to an injury sustained during active military duty. He had intermittent radiation of numbness and tingling involving the right lower extremity distal to the knee. Radiographs of the lumbosacral region demonstrated a grade I spondylolisthesis of L3 in relation to L4 and a grade II spondylolisthesis of L4 in relation to L5 secondary to bilateral pars interarticularis defects. There was marked narrowing of the L4-5 disk space with associated subchondral sclerosis. INTERVENTION AND OUTCOME: A course of conservative management consisting of 10 treatments including lumbar flexion/distraction and activity modification was provided over an 8-week period. Despite the long-standing nature of the complaint and underlying multiple-level lumbar spondylolysis with spondylolisthesis, there was a 25% reduction in low back pain severity on the numeric rating scale and a 22% reduction in perceived disability related to low back pain on the Revised Oswestry Disability Questionnaire. CONCLUSIONS: Conservative management is considered to be the standard of care for spondylolysis and should be explored in its various forms for symptomatic low back pain patients who present without neurologic deficits and with spondylolisthesis below grade III. The response to treatment for the veteran patient in this case suggests that lumbar flexion/distraction may serve as a safe and effective component of conservative management of mechanical low back pain for some patients with spondylolysis and spondylolisthesis.

J Chiropr Med. 2009 Sep;8(3):125-30. Dunn AS, Baylis S, Ryan D. Staff Chiropractor, VA of Western New York, Buffalo, NY 14215; Adjunct Assistant Professor, New York Chiropractic College, Buffalo, NY 14215.

Full Title: An exploratory mixed-method study to determine factors that may affect satisfaction levels of athletes receiving chiropractic care in a nonclinic setting

OBJECTIVES: The objectives of this study were to determine factors that may affect satisfaction levels of participants in a nonclinic (sport) setting through participant observation and participation. Factors associated with general satisfaction (observed) were determined along with a participant demographic profile, participant knowledge about chiropractic, and satisfaction with treatment received from a chiropractic student. Thereafter, the relationships between the demographic factors, participant knowledge, and participant general satisfaction were determined. Lastly, factors affecting satisfaction levels were compared between the participants and the observers. METHODS: An exploratory mixed-method observational study that compared results reported by 30 participants and 2 observers, regarding the treatment process, by completion of a self-administered questionnaire. Statistical significance was set at P less than or equal to .05. RESULTS: Of the 30 participants, 83.3% were South African, 90% were white, and 63.3% were male, with a mean age of 35.6 years, who reported they were very satisfied with chiropractic care (P = .229). The only factor to produce a significant difference between participants and observers was communication (P = .082 with Spearman = .332). CONCLUSION: In this study, communication had the greatest impact; therefore, it is suggested that positive verbal and nonverbal communication be emphasized in the training of future chiropractic professionals.

J Chiropr Med. 2009 Jun;8(2):62-71. Talmage G, Korporaal C, Brantingham JW. Lecturer, Department Chiropractic and Somatology, DUT, PO Box 1334, Durban 4001, South Africa (RSA).

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.

J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):659-74. Lawrence DJ, Meeker W, Branson R, Bronfort G, Cates JR, Haas M, Haneline M, Micozzi M, Updyke W, Mootz R, Triano JJ, Hawk C. Center for Teaching and Learning, Palmer College of Chiropractic, Davenport, Iowa, USA. dana.lawrence@palmer.edu

Full Title: A randomized, placebo-controlled clinical trial of chiropractic and medical prophylactic treatment of adults with tension-type headache: results from a stopped trial

OBJECTIVES: Tension-type headache (TTH) is the most common headache experienced by adults in Western society. Only 2 clinical trials of spinal manipulation for adult tension-type headache have been reported, neither of which was fully controlled. In 1 trial, spinal manipulation was compared to amitriptyline. There is an urgent need for well-controlled studies of chiropractic spinal manipulation for TTH. This trial was stopped prematurely due to poor recruitment. The purposes of this report are (1) to describe the trial protocol, as it contained several novel features, (2) to report the limited data set obtained from our sample of completed subjects, and (3) to discuss the problems that were encountered in conducting this study. METHODS: A randomized clinical trial was conducted with a factorial design in which adult TTH sufferers with more than 10 headaches per month were randomly assigned to four groups: real cervical manipulation + real amitriptyline, real cervical manipulation + placebo amitriptyline, sham cervical manipulation + real amitriptyline, and sham cervical manipulation + placebo amitriptyline. A baseline period of four weeks was followed by a treatment period of 14 weeks. The primary outcome was headache frequency obtained from a headache diary in the last 28 days of the treatment period. RESULTS: Nineteen subjects completed the trial. In the unadjusted analysis, a statistically significant main effect of chiropractic treatment was obtained (-2.2 [-10.2 to 5.8], P = .03) which was just below the 3-day reduction set for clinical importance. As well, a clinically significant effect of the combined therapies was obtained (-9 [20.8 to 2.9], P = .13), but this did not achieve statistical significance. In the adjusted analysis, neither the main effects of chiropractic nor amitriptyline were statistically significant or clinically important; however, the effect of the combined treatments was -8.4 (-15.8 to -1.1) which was statistically significant (P = .03) and reached our criterion for clinical importance. CONCLUSION: Although the sample size was smaller than initially required, a statistically significant and clinically important effect was obtained for the combined treatment group. There are considerable difficulties with recruitment of subjects in such a trial. This trial should be replicated with a larger sample.

J Manipulative Physiol Ther. 2009 Jun;32(5):344-51. Vernon H, Jansz G, Goldsmith CH, McDermaid C. Division of Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada. hvernon@cmcc.ca

Full Title: The Nordic back pain subpopulation program: predicting outcome among chiropractic patients in Finland

ABSTRACT: BACKGROUND: In a previous Swedish study it was shown that it is possible to predict which chiropractic patients with persistent LBP will not report definite improvement early in the course of treatment, namely those with LBP for altogether at least 30 days in the past year, who had leg pain, and who did not report definite general improvement by the second treatment. The objectives of this study were to investigate if the predictive value of this set of variables could be reproduced among chiropractic patients in Finland, and if the model could be improved by adding some new potential predictor variables. METHODS: The study was a multi-centre prospective outcome study with internal control groups, carried out in private chiropractic practices in Finland. Chiropractors collected data at the 1st, 2nd and 4th visits using standardized questionnaires on new patients with LBP and/or radiating leg pain. Status at base-line was identified in relation to pain and disability, at the 2nd visit in relation to disability, and "definitely better" at the 4th visit in relation to a global assessment. The Swedish questionnaire was used including three new questions on general health, pain in other parts of the spine, and body mass index. RESULTS: The Swedish model was reproduced in this study sample. An alternative model including leg pain (yes/no), improvement at 2nd visit (yes/no) and BMI (underweight/normal/overweight or obese) was also identified with similar predictive values. Common throughout the testing of various models was that improvement at the 2nd visit had an odds ratio of approximately 5. Additional analyses revealed a dose-response in that 84% of those patients who fulfilled none of these (bad) criteria were classified as "definitely better" at the 4th visit, vs. 75%, 60% and 34% of those who fulfilled 1, 2 or all 3 of the criteria, respectively. CONCLUSION: When treating patients with LBP, at the first visits, the treatment strategy should be different for overweight/obese patients with leg pain as it should be for all patients who fail to improve by the 2nd visit. The number of predictors is also important.

Chiropr Osteopat. 2008 Nov 7;16:13. Malmqvist S, Leboeuf-Yde C, Ahola T, Andersson O, Ekström K, Pekkarinen H, Turpeinen M, Wedderkopp N. The Faculty of Social Sciences, University of Stavanger, and the Norwegian Centre for Movement Disorders, Stavanger University Hospital, Stavanger, Norway. nils.s.malmqvist@uis.no.

OBJECTIVE: This article describes and discusses the case of a patient with benign paroxysmal positional vertigo (BPPV) characterized by severe vertigo with dizziness, nausea, and nystagmus, treated without the use of spinal manipulation by a doctor of chiropractic. CLINICAL FEATURES: A 46-year-old woman presented for care with complaints of acute vertigo and dizziness. INTERVENTION AND OUTCOME: The patient was examined and diagnosed with left posterior canalolithiasis by means of the Dix-Hallpike maneuver. She was treated successfully with the Epley maneuver once and subsequently discharged without further treatment. CONCLUSION: This case demonstrates the importance of correctly identifying patients with BPPV. This case also demonstrates the successful treatment of BPPV.

J Manipulative Physiol Ther. 2009 Jun;32(5):387-90. Nørregaard AR, Lauridsen HH, Hartvigsen J. Clinical Locomotion Science, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark. anorregaard@health.sdu.dk

OBJECTIVE: To summarize scholarly literature that describes practice, utilization, and/or policy of chiropractic services within international active duty and/or veteran health care environments. DATA SOURCES: PubMed, the Cumulative Index to Nursing and Allied Health Literature, and the Index to Chiropractic Literature were searched from their starting dates through June 2009. REVIEW METHODS: All authors independently reviewed each of the articles to verify that each met the inclusion criteria. Citations of included papers and other pertinent findings were logged in a summary table. RESULTS: Thirteen articles were included in this study. Integration of chiropractic care into military or veteran health care systems has been described in 3 systems: the United States Department of Defense, the United States Department of Veterans Affairs, and the Canadian Forces. CONCLUSION: Chiropractic services seem to be included successfully within military and veteran health care facilities. However, there is a great need for additional written evaluation of the processes, policies, practices, and effectiveness of chiropractic services in these environments.

J Can Chiropr Assoc. 2009 Aug;53(3):194-204. Green BN, Johnson CD, Lisi AJ, Tucker J. Chiropractic Division, Department of Physical and Occupational Therapy, Naval Medical Center San Diego, MCAS Miramar Branch Medical Clinic, PO Box 452002, San Diego, CA 92145-2002. Email: bart.green@med.navy.mil.

BACKGROUND: With continued popularity of complementary and alternative medicine (CAM) therapies for children, their safety and effectiveness are of high concern for both CAM and conventional therapy providers. Chiropractic is the most popular form of practitioner-based CAM therapies for children. OBJECTIVE: The objective of this study was to describe the practice of pediatric chiropractic, including its safety and effectiveness. DESIGN: This study used a cross-sectional survey. SETTING: A practice-based research network was used for this study. PATIENTS/PARTICIPANTS: Participants were chiropractors and parents of pediatric patients (aged Explore (NY). 2009 September - October;5(5):290-295. Alcantara J, Ohm J, Kunz D. International Chiropractic Pediatric Association, Media, PA; Private practice, Alcantara Chiropractic Wellness Care, San Jose, CA.

Full Title: Neck pain and disability outcomes following chiropractic upper cervical care: a retrospective case series.

OBJECTIVE: To investigate the use of an upper cervical low-force (UCLF) chiropractic procedure, based on a vertebral alignment model, in the management of neck pain and disability by assessing the impact on valid patient outcome measures. DESIGN: A retrospective case series. METHODS: Consecutive patient files at a private chiropractic practice over a 1-year period were reviewed for inclusion. Data for the first visit, pre- and post-adjustment atlas alignment radiographic measurements, baseline and 2-weeks NDI (100 point) and verbal NRS (11 point) were recorded. The data were analyzed in their entirety and by groups comparing <30% vs. >30% post adjustment atlas alignment changes. RESULTS: Statistically significant clinically meaningful improvements in neck pain NRS (P < 0.01) and disability NDI (P < 0.01) after an average of 13.6 days of specific chiropractic care including 5.7 office visits and 2.7 upper cervical adjustments were demonstrated. There were no serious adverse events. Cases with the post-adjustment skull/atlas alignment measurement (atlas laterality) that were changed more than 30% on the first visit toward the orthogonal alignment predicted a statistically and clinically significant better outcome for NDI in 2 weeks. CONCLUSIONS: UCLF chiropractic instrument adjustments utilizing a vertebral alignment model are promising for the management of patients with neck pain based on assessment using valid outcome measures.

J Can Chiropr Assoc. 2009 Aug;53(3):173-85. Rochester RP. Chiropractic Spine Center of North Georgia, Inc., 475 S. Washington Street, Suite C, Clarkesville, GA 30523. Society of Chiropractic Orthospinology, Inc. (Non-profit organization) Board of Directors, Co-Author of the text: Orthospinology Procedures, An Evidence-Based Approach to Spinal Care. Philadelphia: Lippincott Williams & Wilkins, 2007.

Many patients use chiropractic as a treatment of fibromyalgia, and many chiropractors seem to be convinced that it is effective for that condition. The aim of the study was to conduct a systematic review of randomised clinical trials testing the effectiveness of chiropractic care for fibromyalgia. Six electronic literature searches were conducted. No language restrictions were applied. Data extraction and validation were carried out by two independent reviewers. Three studies met the inclusion criteria. Their methodological quality was poor. They generated no evidence to suggest that chiropractic care is effective for fibromyalgia. Currently, there is insufficient evidence to conclude that chiropractic is an effective treatment for fibromyalgia.

Clin Rheumatol. 2009 Oct;28(10):1175-8. Epub 2009 Jun 21. Ernst E. Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter, EX2 4NT, UK. Edzard.Ernst@pms.ac.uk

Full Title: Slipped capital femoral epiphysis (SCFE) detected in a chiropractic office: a case report

OBJECTIVE: To report on a case of slipped capital femoral epiphysis (SCFE), which is a somewhat rare condition but one that can present in a chiropractic clinic, particularly one with a musculoskeletal scope of practice. CASE: This is a single case report of a 16-year-old adolescent male patient who presented with an 18-month history of hip pain. Radiographs originally ordered by the patient's family physician were read by the medical radiologist as "unremarkable." The family physician diagnosed the patient with tendonitis. TREATMENT: After reviewing the radiographs and examining the patient, the chiropractor suspected a SCFE that was confirmed with a repeat radiographic examination. The patient was referred back to his family physician with a diagnosis of SCFE and recommendation for orthopedic surgical consultation. The patient was subsequently treated successfully with surgical reduction by in situ pinning. CONCLUSION: The prognosis for the SCFE patient when diagnosed early and managed appropriately is good. The consequences of a delay in the diagnosis of SCFE are an increased risk of further slippage and deformity, increased complications such as avascular necrosis and chondrolysis and increased likelihood of degenerative osteoarthritis of the involved hip later in life. The diagnosis and appropriate management of SCFE is where the chiropractor has an important role to play in the management of this condition.

J Can Chiropr Assoc. 2009 Aug;53(3):158-64. Emary P. Private practice: Parkway Back Clinic, 201C Preston Parkway, Cambridge, Ontario, N3H 5E8. E-mail: drpeter@parkwaybackclinic.ca.

Full Title: 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.

J Manipulative Physiol Ther. 2009 Jul-Aug;32(6):438-47. Hawk C, Cambron JA, Pfefer MT. Cleveland Chiropractic College, Kansas City, Mo, USA. cheryl.hawk@cleveland.edu

Full Title: Characterization of health status and modifiable risk behavior among United States adults using chiropractic care as compared with general medical care

OBJECTIVE: The causes of death in the United States have moved from infectious to chronic diseases with modifiable behavioral risk factors. Simultaneously, there has been a paradigm shift in health care provisions with increased emphases on prevention and health promotion. Use of professional complementary and alternative medicine, such as chiropractic care, has increased. The purpose of this study was to characterize typical conditions, modifiable risk behaviors, and perceived changes in overall general health of patients seeing chiropractors as compared with general medical doctors in the United States. METHODS: Secondary analyses of the National Health Interview Survey 2005 adult sample (n = 31,248) were performed. Multiple logistic regression models were applied to assess associations of health conditions/risk behaviors of patients with the doctors (chiropractors vs medical doctors) they saw within the past 12 months. RESULTS: Respondents who saw/talked to chiropractors were 9.3%. Among these, 21.4% did not see a medical doctor. Comparing chiropractor-only with medical doctor-only patients, we found no significant difference in smoking/alcohol consumption status, but chiropractor-only patients were more likely to be physically active (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.2-1.8) and less likely to be obese (OR, 0.7; 95% CI, 0.6-0.9). Respondents reporting acute neck (OR, 2.7; 95% CI, 2.2-3.2) and low back pain (OR, 2.4; 95% CI, 2.0-2.8) were more likely to have seen a chiropractor. CONCLUSIONS: Based on these analyses, Americans seem to be using chiropractic care for acute neck and low back pain more so than for other health conditions. However, there is no marked difference in their overall health promotion habits and changes in overall general health based on health care provider types.

J Manipulative Physiol Ther. 2009 Jul-Aug;32(6):414-22. Ndetan HT, Bae S, Evans MW Jr, Rupert RL, Singh KP. Parker College Research Institute, Dallas, Tex 75229, USA. hndetan@parkercc.edu

OBJECTIVE: The objective of this article was to review the literature on the use of chiropractic for the treatment of lumbar spinal stenosis. METHODS: A literature search was conducted on 4 electronic databases (Medline, Index to Chiropractic Literature, Cumulative Index to Nursing and Allied Health Literature, and Allied and Complementary Medicine Database) for clinical research pertaining to chiropractic treatment of lumbar spinal stenosis. Retrieved articles were hand searched for relevant references. Inclusion criteria consisted of any clinical study design (including case reports) using chiropractic care on patients with lumbar spinal stenosis published in English in the past 25 years. RESULTS: Six articles on a total of 70 patients met the inclusion criteria for the review. These articles included 4 case studies, a case series, and an observational cohort study. Treatments included spinal manipulation and, most often, flexion-distraction manipulation. Numerous other interventions including exercise, activity of daily living modifications, and various passive care modalities were selectively used in the included studies. CONCLUSIONS: There is a paucity of evidence available with respect to chiropractic treatment of spinal stenosis. The limited evidence that is available points toward chiropractic care being potentially beneficial in the treatment of patients with lumbar spinal stenosis, but further clinical investigations are necessary.

J Chiropr Med. 2009 Jun;8(2):77-85. Stuber K, Sajko S, Kristmanson K. Private practice of chiropractic, Calgary, Alberta, Canada.

Full Title: A cross-sectional analysis of clinical outcomes following chiropractic care in veterans with and without post-traumatic stress disorder

This study was a cross-sectional analysis of clinical outcomes for 130 veteran patients with neck or low back complaints completing a course of care within the chiropractic clinic at the VA of Western New York in 2006. Multivariate analysis of variance (MANOVA) was utilized, comparing baseline and discharge scores for both the neck and low back regions and for those patients with and without post-traumatic stress disorder (PTSD). Patients with PTSD (n = 21) experienced significantly lower levels of score improvement than those without PTSD (n = 119) on self-reported outcome measures of neck and low back disability. These findings, coupled with the theorized relationships between PTSD and chronic pain, suggest that the success of conservative forms of management for veteran patients with musculoskeletal disorders may be limited by the presence of PTSD. Further research is warranted to examine the potential contributions of PTSD on chiropractic clinical outcomes with this unique patient population.

Mil Med. 2009 Jun;174(6):578-83. Dunn AS, Passmore SR, Burke J, Chicoine D. Chiropractic Service, VA of Western New York Healthcare System, 3495 Bailey Avenue, Buffalo, NY 14215, USA.

OBJECTIVE: The purpose of this study was to identify short-term and long-term determinants of costs and pain improvement for care of low back pain (LBP) provided by medical doctors (MDs) and chiropractors (DCs). METHODS: Determinants of office-based costs and pain improvement were modeled for 2872 patients with primary complaint of acute or chronic LBP of mechanical origin enrolled from practices of 111 MDs and 60 DCs using multiple regression analysis. The independent variables were baseline pain intensity (10 cm visual analog scale), chronicity (current episode > or <7 weeks), referred pain above/below the knee, history of LBP, physical health, depression screen, comorbidity, and stress index; age, sex, married, and smoker; pay variables including out-of-pocket, health insurance, auto insurance, Workers' Compensation, and Oregon Health Plan/Medicaid; and a choice of provider indicator based on relative confidence in DC and MD care. RESULTS: Determinants of increased office-based costs for MD care were Workers' Compensation, pain below the knee, and chronic LBP with comorbidity. Predictors of increased cost for DC care were Workers' Compensation, auto and health insurance, LBP chronicity, and baseline pain. Predictors of decreased DC cost were Medicaid and better physical health. Pain improvement was predicted consistently across groups by baseline pain, pain radiating below the knee, physical health, LBP chronicity, and chronicity by baseline pain interaction. There was also a large chronicity by comorbidity interaction at 12 months for both provider types. CONCLUSIONS: Cost predictors were driven by insurance type and pain improvement was driven by LBP complaint characteristics.

J Manipulative Physiol Ther. 2009 May;32(4):252-61. Sharma R, Haas M, Stano M, Spegman A, Gehring R. Department of Economics, Portland State University, Portland, OR 97207, USA. sharmar@pdx.edu

Full Title: Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study

STUDY DESIGN: Population-based, case-control and case-crossover study. OBJECTIVE: To investigate associations between chiropractic visits and vertebrobasilar artery (VBA) stroke and to contrast this with primary care physician (PCP) visits and VBA stroke. SUMMARY OF BACKGROUND DATA: Chiropractic care is popular for neck pain and headache, but may increase the risk for VBA dissection and stroke. Neck pain and headache are common symptoms of VBA dissection, which commonly precedes VBA stroke. METHODS: Cases included eligible incident VBA strokes admitted to Ontario hospitals from April 1, 1993 to March 31, 2002. Four controls were age and gender matched to each case. Case and control exposures to chiropractors and PCPs were determined from health billing records in the year before the stroke date. In the case-crossover analysis, cases acted as their own controls. RESULTS: There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke. CONCLUSION: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

J Manipulative Physiol Ther. 2009 Feb;32(2 Suppl):S201-8. Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Centre of Research Expertise for Improved Disability Outcomes, University Health Network Rehabilitation Solutions, Toronto Western Hospital, Toronto, ON, Canada. dcassidy@uhnresearch.ca

Full Title: Running posture and step length changes immediately after chiropractic treatment in a patient with xeroderma pigmentosum

OBJECTIVE: This case study reports on selected measures of locomotion (running) in a 5-year-old patient with xeroderma pigmentosum after chiropractic care. CLINICAL FEATURE: A 5-year-old female patient (16.4 kg, 99.1 cm) with xeroderma pigmentosum (type A) volunteered to participate in the experiment with the consent of her parents. The patient had well-documented signs of delayed fine motor (eg, difficulty with writing, coloring, cutting) and gross motor control (eg, balance and coordination dysfunction and falling while running), and delayed speech. INTERVENTION AND OUTCOMES: Trunk forward lean angles, step lengths, and hip horizontal translations were assessed by video as the participant ran as fast as possible down a laboratory runway. After chiropractic manipulation (adjustments), the patient reduced the trunk forward lean angle to become more vertical (P = .000). In addition, the patient experienced an increase in step length (P = .031). No significant change in lateral translation was observed after the intervention. CONCLUSION: For this patient with xeroderma pigmentosum, chiropractic manipulation (adjustments) resulted in immediate changes in running performance. Further investigation is needed to examine the effect of chiropractic on locomotion in both symptomatic and asymptomatic patients.

J Manipulative Physiol Ther. 2009 Jan;32(1):93-8. Smith DL, Walsh M, Smith JP. Essence of Wellness Chiropractic Center, Eaton, Ohio 45320, USA. drdean@essenceofwellness.com

OBJECTIVE: This case report describes the effect of exercise-based chiropractic treatment on chronic and intractable low back pain complicated by lumbar disk extrusion. CLINICAL FEATURES: A 47-year-old male firefighter experienced chronic, unresponsive low back pain. Pre- and posttreatment outcome analysis was performed on numeric (0-10) pain scale, functional rating index, and the low back pain Oswestry data. Secondary outcome assessments included a 1-rep maximum leg press, balancing times, push-ups and sit-ups the patient performed in 60 seconds, and radiographic analysis. INTERVENTION AND OUTCOME: The patient was treated with Pettibon manipulative and rehabilitative techniques. At 4 weeks, spinal decompression therapy was incorporated. After 12 weeks of treatment, the patient's self-reported numeric pain scale had reduced from 6 to 1. There was also overall improvement in muscular strength, balance times, self-rated functional status, low back Oswestry scores, and lumbar lordosis using pre- and posttreatment radiographic information. CONCLUSION: Comprehensive, exercise-based chiropractic management may contribute to an improvement of physical fitness and to restoration of function, and may be a protective factor for low back injury. This case suggests promising interventions with otherwise intractable low back pain using a multimodal chiropractic approach that includes isometric strengthening, neuromuscular reeducation, and lumbar spinal decompression therapy.

J Chiropr Med. 2008 Dec;7(4):146-54. Schwab MJ. Private practice, Schwab Chiropractic Clinic, Eau Claire, WI 54701.

STUDY DESIGN: Systematic review of reported adverse events. OBJECTIVE: To evaluate the tolerability and safety of chiropractic procedures. SUMMARY OF BACKGROUND DATA: Despite the increasing popularity of chiropractic, there are few properly designed prospective controlled trials, and there is a disproportionate lack of evaluation of its safety profile. The literature reports multiple neurologic complications of spinal manipulation, some of which are clinically relevant and even life threatening. METHODS: We performed an electronic search in 2 databases: Pubmed and the Cochrane Library for the years 1966 to 2007. All articles that reported adverse reactions associated with chiropractic were included irrespective of type of design. The outcome measures were the type of adverse events associated or attributed to chiropractic interventions and their frequency. RESULTS: A total of 376 potential relevant articles were identified, 330 of which were discarded after abstract or complete article analysis. The search identified 46 articles that included data concerning adverse events: 1 randomized controlled trial, 2 case-control studies, 7 prospective studies, 12 surveys, 3 retrospective studies, and 115 case reports. Most of the adverse events reported were benign and transitory, however, there are reports of complications that were life threatening, such as arterial dissection, myelopathy, vertebral disc extrusion, and epidural hematoma. The frequency of adverse events varied between 33% and 60.9%, and the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations. CONCLUSION: There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue.

Spine. 2009 May 15;34(11):E405-13. Gouveia LO, Castanho P, Ferreira JJ. Department of Neurology, Hospital de Santa Maria, Lisbon, Portugal. lilianafog@gmail.com

We hypothesize that stasis of the cerebrospinal fluid (CSF) occurs commonly and is detrimental to health. Physiologic factors affecting the normal circulation of CSF include cardiovascular, respiratory, and vasomotor influences. The CSF maintains the electrolytic environment of the central nervous system (CNS), influences systemic acid-base balance, serves as a medium for the supply of nutrients to neuronal and glial cells, functions as a lymphatic system for the CNS by removing the waste products of cellular metabolism, and transports hormones, neurotransmitters, releasing factors, and other neuropeptides throughout the CNS. Physiologic impedance or cessation of CSF flow may occur commonly in the absence of degenerative changes or pathology and may compromise the normal physiologic functions of the CSF. CSF appears to be particularly prone to stasis within the spinal canal. CSF stasis may be associated with adverse mechanical cord tension, vertebral subluxation syndrome, reduced cranial rhythmic impulse, and restricted respiratory function. Increased sympathetic tone, facilitated spinal segments, dural tension, and decreased CSF flow have been described as closely related aspects of an overall pattern of structural and energetic dysfunction in the axial skeleton and CNS. Therapies directed at affecting CSF flow include osteopathic care (especially cranial manipulation), craniosacral therapy, chiropractic adjustment of the spine and cranium, Network Care (formerly Network Chiropractic), massage therapy (including lymphatic drainage techniques), yoga, therapeutic breath-work, and cerebrospinal fluid technique. Further investigation into the nature and causation of CSF stasis, its potential effects upon human health, and effective therapies for its correction is warranted.

Altern Ther Health Med. 2009 May-Jun;15(3):54-60. Whedon JM, Glassey D. The Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, New Hampshire, USA.

There is a need to further our understanding of the neurophysiological effects of chiropractic spinal manipulation on brain activity as it pertains to both musculoskeletal and non-musculoskeletal complaints. This paper aims to provide a basic overview of the most commonly utilised techniques in the neurosciences for functional imaging the brain (positron emission tomography, single-photon emission computerised tomography, functional magnetic resonance imaging, electroencephalography, and magnetoencephalography), and discuss their applicability in future chiropractic research. Functional neuroimaging modalities are used in a wide range of different research and clinical settings, and are powerful tools in the investigation of neuronal activity in the human brain. There are many potential applications for functional neuroimaging in future chiropractic research, but there are some feasibility issues, mainly pertaining to access and funding. We strongly encourage the use of functional neuroimaging in future investigations of the effects of chiropractic spinal manipulation on brain function.

JCCA J Can Chiropr Assoc. 2009 Mar;53(1):59-72. Lystad RP, Pollard H. Postgraduate Student, Department of Health and Chiropractic, Macquarie University.

OBJECTIVE: The objective of this review is to evaluate the evidence on the effects of Spinal Manipulative Therapy (SMT) on back pain and other related symptoms during pregnancy. DATA SOURCES: A literature search was conducted using Pubmed, Manual, Alternative and Natural Therapy Index System, Cumulated Index to Nursing and Allied Health, Index to Chiropractic Literature, the Cochrane Library, and Google Scholar. In addition hand searches and reference tracking were also performed, and the citation list was assessed for comprehensiveness by content experts. METHODS OF STUDY SELECTION: This review was limited to peer-reviewed manuscripts published in English from 1966 until September 2008. The initial search strategy yielded 140 citations of which 12 studies were reviewed for quality. TABULATION, INTEGRATION, AND RESULTS: The methodological quality of the included studies was assessed independently using quality checklists of the Scottish Intercollegiate Guidelines Network and Council on Chiropractic Guidelines and Practice Parameters. The review indicates that the use of SMT during pregnancy to reduce back pain and other related symptoms is supported by limited evidence. CONCLUSION: Overall, this body of evidence is best described as emergent. However, since effective treatments for pregnancy-related back pain are limited, clinicians may want to consider SMT as a treatment option, if no contraindications are present. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader should be able to describe the concepts of spinal manipulative therapy and types of symptoms for which it might be considered in pregnancy, explain the quality of available research on the use of spinal manipulative therapy, and plan to discuss this therapy with interested pregnant patients.

Obstet Gynecol Surv. 2009 Jun;64(6):416-27. Khorsan R, Hawk C, Lisi AJ, Kizhakkeveettil A. Military Medical Research and Integrative Medicine, Samueli Institute, Corona del Mar, California 92625, USA. rkhorsan@siib.org

Full title: Intentions of Chiropractic Interns Regarding use of Health Promotion in Practice: Applying Theory of Reasoned Action to Identify Attitudes, Beliefs, and Influencing Factors.

PURPOSE: The theory of reasoned action is a health behavioral theory that has been used to predict personal health behaviors and intentions as well as those of providers delivering health care. The purpose of this study was to determine interns' future practices regarding the use of health promotion using this model to develop survey questions and to determine attitudes and perceived influences on their prospective behaviors in general, toward the use of health promotion once in practice. METHODS: Across the course of one year, all graduating interns at a chiropractic college were queried with a 20 question survey designed using the theory of reasoned action. Frequencies and inferential statistics were performed including prediction modeling using logistic regression. RESULTS: A majority (>85%) of interns indicated they would use health promotion in practice. Differences were noted based on perceived skill levels, perception of educational emphasis, various normative beliefs, and gender. CONCLUSION: Most interns will use some form of health promotion in practice. Normative influences including those seen as key influencers are as powerful a predictor as perceived education or skill levels on future practice of health promotion.

J Chiropr Educ. 2009 Spring;23(1):17-27. Evans MW, Ndetan H, Williams RD. Cleveland Chiropractic College.

A computer aided method for closed tibial shaft fracture reduction based on measurements of 12 projection parameters (6 angulations and 6 translations) from an anteroposterior radiograph, a lateral radiograph, and a transverse projection photograph is examined. The development, validation and reliability of the computer aided method are presented. A custom-made unilateral external fixation device consisting of 7 calibrated one-degree-of-freedom joints was employed to execute the reduction. Five tibial fracture phantoms with initial deformities that covered a wide range of misalignments were tested. The mean (standard deviation) resultant rotational and translational errors after the reduction were 3.32 degrees (0.96 degrees ) and 1.65 (0.86) mm, respectively, which indicates good reduction accuracy. Three indFrelendent raters made the measurements of the projection parameters to test inter-rater reliability. The intra-class correlation coefficients were found to range between 0.935 and 1, indicating good reliability. Since ideal patient positioning for AP, lateral and transverse image acquisition is not easily attainable, the effect of patient positioning errors on the measurement of projection parameters was explored using a tibial phantom. The preliminary results revealed that 10 degrees deviations in positioning do not greatly affect the measurement of AP and lateral angulation parameters (<1.7 degrees ). However, a 10 degrees positioning error about the long bone axis may result in a change of as much as 10.7 degrees in the measurements of transverse projection angulation parameters. In addition, a 10 degrees positioning error about an arbitrary anatomical axis may result in translational projection parameter changes of up to 6.8 mm. For these reasons, a previously validated method that allows for accurate positioning of the tibia about its long axis and a two-step reduction strategy to achieve the best possible deformity reduction are proposed. Procedures to facilitate reliable measurement of tibial torsion are also discussed. It appears that the projection-based reduction method exposes the patient to less radiation and allows for simple, quick and accurate reductions, making it an attractive choice for acute clinical applications.

Comput Aided Surg. 2009 Jun 10:1-13. Koo TK Assistant Professor, Papuga MO. Foot Levelers Biomechanics Research Laboratory, Department of Research, New York Chiropractic College, Seneca Falls, New York.

For many years hypothyroid dysfunction has been treated with standard medical approaches yet some seek newer experimental conservative approaches. This paper describes the management of a new conservative approach to management in two individuals who sought treatment from a practitioner specialising in a new integrative mind-body based treatment. The purpose of this study is to present two case studies of the management of hypothyroid dysfunction using the mind-body neuro-emotional technique (NET). METHOD: The study was set in a private practice setting in Sydney, Australia. Two cases had been diagnosed with primary hypothyroidism by independent medical and laboratory based assessment, of which conservative management had not resolved the symptoms. Both cases underwent a schedule of NET as a modality to treat their hypothyroidism. RESULTS: Objective measures such as thyroid stimulating hormone and T(4) levels were reported, along with more subjective measures such as feelings of tiredness and general well being. In both cases, there were improvements in TSH and T(4) levels, both returning to normal levels. CONCLUSIONS: Thyroid dysfunction has been effectively treated by conventional medicine for many years. Changes in thyroid dysfunction after a course of NET have been described. As the standard medical model is associated with some adverse effects such as long-term medication use and potential side effects, all natural, non-invasive approaches to management should be reviewed. Further research into this mind-body therapy is recommended to evaluate its potential effectiveness for this common condition.

Complement Ther Clin Pract. 2009 May;15(2):67-71. Bablis P, Pollard H. Private practice; Macquarie Injury Management Group, Department of Health and Chiropractic, Macquarie University, Sydney 2109, Australia.

Chiropractors are an integral part of the management of musculoskeletal injuries. A considerable communication gap between the chiropractic and medical professions exists. Subsequently referring allopathic practitioners lack confidence in picking a chiropractic practitioner with appropriate management strategies to adequately resolve sporting injuries. Subsequently, the question is often raised: "how do you find a good chiropractor?". DISCUSSION: Best practice guidelines are increasingly suggesting that musculoskeletal injuries should be managed with multimodal active and passive care strategies. Broadly speaking chiropractors may be subdivided into "modern multimodal" or "classical" (unimodal) in nature. The modern multimodal practitioner is better suited to managing sporting injuries by incorporating passive and active care management strategies to address three important phases of care in the continuum of injury from the acute inflammation/pain phase to the chronic/rehabilitation phase to the injury prevention phase. In contrast, the unimodal, manipulation only and typically spine only approach of the classical practitioner seems less suited to the challenges of the injured athlete. Identifying what part of the philosophical management spectrum a chiropractor falls is important as it is clearly not easily evident in most published material such as Yellow Pages advertisements. SUMMARY: Identifying a chiropractic practitioner who uses multimodal treatment of adequate duration, who incorporates active and passive components of therapy including exercise prescription whilst using medical terminology and diagnosis without mandatory x-rays or predetermined treatment schedules or prepaid contracts of care will likely result in selection of a chiropractor with the approach and philosophy suited to appropriately managing athletic conditions. Sporting organizations and associations should consider using similar criteria as a minimum standard to allow participation in health care team selections.

Chiropr Osteopat. 2009 Mar 10;17:3. Hoskins W, Pollard H, Garbutt P. Macquarie Injury Management Group, Department of Health & Chiropractic, Macquarie University, Sydney, NSW 2109, Australia. waynehoskins@iinet.com.au.

The objective of this study was to evaluate resistance training (RES) and RES combined with chiropractic treatment (RES-C) on fibromyalgia (FM) impact and functionality in women with FM. DESIGN: The design of the study was a randomized control trial. SETTING: Testing and training were completed at the university and chiropractic treatment was completed at chiropractic clinics. PARTICIPANTS: Participants (48 +/- 9 years; mean +/- standard deviation) were randomly assigned to RES (n = 10) or RES-C (n = 11). INTERVENTION: Both groups completed 16 weeks of RES consisting of 10 exercises performed two times per week. RES-C received RES plus chiropractic treatment two times per week. OUTCOME MEASURES: Strength was assessed using one repetition maximum for the chest press and leg extension. FM impact was measured using the FM impact questionnaire, myalgic score, and the number of active tender points. Functionality was assessed using the 10-item Continuous Scale Physical Functional Performance test. Analyses of variance with repeated measures compared groups before and after the intervention. RESULTS: Six (6) participants discontinued the study: 5 from RES and 1 from RES-C. Adherence to training was significantly higher in RES-C (92.0 +/- 7.5%) than in RES (82.8 +/- 7.5%). Both groups increased (p < or = 0.05) upper and lower body strength. There were similar improvements in FM impact in both groups. There were no group interactions for the functionality measures. Both groups improved in the strength domains; however, only RES-C significantly improved in the pre- to postfunctional domains of flexibility, balance and coordination, and endurance. CONCLUSIONS: In women with FM, resistance training improves strength, FM impact, and strength domains of functionality. The addition of chiropractic treatment improved adherence and dropout rates to the resistance training and facilitated greater improvements in the domains of functionality.

J Altern Complement Med. 2009 Mar;15(3):321-8. Panton LB, Figueroa A, Kingsley JD, Hornbuckle L, Wilson J, St John N, Abood D, Mathis R, VanTassel J, McMillan V. Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee, FL 32306, USA. lpanton@fsu.edu

The objective of this study was to describe the profile of a cohort of patients who presented to a Neuro-Emotional Technique (NET) clinic. This study investigated the change in the Distress and Risk Assessment Method (DRAM) outcome measure score after a 3-month course of NET was administered to participants. Design and setting: This was an uncontrolled cohort study in private practice. Subjects: One hundred and eighty-eight (188) consecutive new patients presented to a NET clinic. Intervention: The intervention was a 3-month course of NET, which incorporates elements of muscle testing, general semantics, Traditional Chinese Medicine, acupuncture, and chiropractic principles to manage patients' conditions. Outcome measures: Scoring on the DRAM questionnaire was the outcome measure. Results: Of the participants, 55.9% had musculoskeletal complaints, 34.6% had nonmusculoskeletal complaints, and 9.6% reported no presenting complaint. Strongly significant differences in the mean DRAM scores and the mean individual component scores were found between pre- and post-treatment. There was strong evidence to suggest that the Modified Somatic Perceptions Questionnaire and the Modified Zung Depression Index scores were correlated (p < 0.001), and that the allocation of subjects in any pretest category to categories on the basis of post-test scores changed from category to category. Conclusions: NET is different from traditionally described chiropractic practice, and appears, based on this one clinic, to have far more nonmusculoskeletal presentations. This profile, if consistent with other practices, has strong implications for scope of practice for this form of chiropractic practitioners. Many participant presentations were "at risk" of, or were clinically depressed, according to the DRAM. The DRAM status of the patient cohort significantly and clinically improved with the NET treatment. As this study was nonrandomized and uncontrolled, the results should be viewed with caution. We recommend that larger-scale randomized controlled trials be commenced to investigate the preliminary findings of this report.

J Altern Complement Med. 2009 Feb;15(2):121-7. Bablis P, Pollard H. Macquarie Injury Management Group, Macquarie University, Sydney, New South Wales, Australia.