Clinical Chiropractic

Published by Elsevier
Print ISSN: 1479-2354
Publications
Metaphyseal dysplasia is a benign condition, usually discovered incidentally on plain film radiography. However, there are a number of other skeletal dysplasias with overlapping clinical and radiological findings that have important clinical implications for manipulative therapists. This article presents a case of metaphyseal dysplasia (Pyle’s disease) in a 14-year-old boy with coincidental low back pain. The radiological and clinical features are discussed along with some of the more commonly encountered differential diagnoses, including Hurler’s syndrome, spondylo-epiphyseal dysplasia, Marfan’s syndrome and homocystinuria, all of which may potentially be associated with joint instability or reduced bone density (as well as other complicating factors) that may require modification to management protocols.
 
The purpose of this study was to develop a thoracic adjusting simulator for chiropractic students to evaluate and improve their adjusting skills, and to test reliability and validity of the device. Attempting to make an adjustment more objective by using a simulator may help to improve students’ adjusting skills in respect to speed, force and displacement of the thoracic spine. Evaluating a learned skill in an objective manner may allow better comparison with other students and tutors and possibly improve learning outcomes.
 
There is now an increasing demand for chiropractic practice to encompass all the aspects of orthodox medicine, including the appreciation of pharmaceutical products. With the future possibility of chiropractors being given limited prescribing rights, practitioner appreciation of possible drug toxicity problems becomes even more imperative.This is a complex arena with no ‘cookbook’ approach easily available to hand. For this reason a good grounding in pharmacological principles should now be a vital part of every chiropractor's repertoire.This introduction is the first of a series of articles placing the utilisation of pharmacological principles within a clinical setting.
 
ObjectiveThe published guidelines for radiographic examination of lower extremity injuries are known as the ‘Ottawa rules’. These rules, initially published in 1992, were established to decrease the amount of unnecessary radiographs. False negatives when following the Ottawa rules are low and have reduced the number of unnecessary x-rays. In clinical settings, the rules and their associated algorithms are important as an aid for determining course of care. This paper documents two cases where adaptation of the Ottawa rules suggested the need for upper extremity radiography. Subsequent x-rays revealed the presence of a fracture in both cases.Clinical featuresThe first case was an 8-year-old girl who was struck on the arm while playing. She experienced pain but refused to let anyone examine her arm. The second case was a 24-year-old male who fell 5 days earlier and landed on his right hand. The application of the adapted Ottawa rules suggested the potential for fracture, which was subsequently confirmed by radiographs.Intervention and outcomeRadiographs confirmed the fracture and both patients were referred for orthopedic consultation and treatment.ConclusionThese two cases, where the clinical decision making for a wrist injury was guided by an adaptation of the Ottawa ankle rules, highlight the lack of guidelines for upper extremity x-rays following injury and suggest that the Ottawa rules could form the basis for such guidelines. Further studies are required to demonstrate their reliability and validity for everyday clinical use.
 
Errors (degrees) made by asymptomatic control subjects in aligning rod to vertical. (a) No frame displayed. (b) Frame displayed tilted 08 (horizontal). (c) Frame displayed tilted by +158 (filled bars) or À158 (open bars). (d) Plot of absolute errors with frame tilted +158 and À158.
Absolute alignment errors in each subject group classified as 2.58 (shaded bars) or >2.58 (open bars), expressed as a percentage of the number in each group. 
Objective:To investigate the use of the Computer Rod and Frame (CRAF) Test in a clinical environment as a means of measuring errors in the perception of vertical in subjects with neck pain.Design:Comparison of vertical alignment errors generated using the CRAF in two groups of subjects with neck pain, compared to an asymptomatic control group.Setting:Two urban chiropractic clinics in the UK.Patients:New patients with neck pain as the primary complaint classified according to traumatic (n = 26) or insidious (n = 45) onset of their neck pain. Seventeen asymptomatic subjects formed a control group.Intervention:Subjects were tested before treatment. They viewed a display of a tilted rod on a plain dark background through head mounted video glasses. The task was to use the mouse to align the rod to vertical in the presence or absence of a surrounding frame.Main outcome measures:Errors in rod alignment measured to an accuracy of 0.5°.Results:In the asymptomatic group, tilting the frame 15° from the horizontal caused significant errors in alignment of the rod. The mean and range of absolute alignment errors were greater in the neck pain patient groups than controls, although this did not reach statistical significance. Classification of the absolute errors by size, ≤2.5° or >2.5°, suggested a possible association between neck pain and alignment error in a subgroup of subjects.Conclusion:This pilot study has demonstrated that the CRAF Test provides a practical method for assessing disturbances of the perception of vertical within a clinical practice setting. The results indicate that there may be a subpopulation of patients in which neck pain is associated with reduced performance on this test.
 
This article provides a brief overview of magnetic resonance imaging (MRI) of the knee for the clinician. A basic review of MRI knee protocols is followed by a discussion of the most common imaging sequences. The appearance of normal knee anatomy is reviewed with emphasis on structures prone to injury. This is correlated to annotated images. Imaging of knee pathology and trauma is discussed in part II of the article.
 
One of the most prevalent causes of neck pain is related to automobile accidents in the form of “Whiplash”, or acceleration/deceleration injuries. The debate on causes of chronicity of symptoms, pain mediation, the most effective treatment regime and the socio-economic impact of the problem has produced a marked increase in the number of research studies and funding available for such in recent years. Whilst the majority of chiropractors include basic ergonomic advice in their treatment of cervical dysfunction, Spinal Manipulative Therapy (SMT) alone is still the treatment of choice. This is despite the lack of conclusive statistical evidence to support this approach. Recent interest and preliminary research in the effectiveness of a combined approach, incorporating rehabilitation of the cervical spine via sensorimotor and cervical stabilisation techniques, has created much interest. The following case demonstrates how the initial SMT approach failed to gain a satisfactory improvement in the clinical symptoms. Emphasis is placed on the ability to perform rehab at home without the need for specific rehabilitation equipment, which is still not widely available in many chiropractic clinics. The Biopsychosocial model and the effect that an active patient approach has on this often-chronic problem is discussed.
 
Polymyalgia rheumatica (PMR) is a systemic disease that most frequently affects females over the age of 50 years. It is less common in males and rare in younger populations. Characteristically, the onset of the disease is sudden and distinguished by a combination of clinical symptoms. These may include generalised, severe pain with stiffness affecting the muscles around the shoulder and pelvic girdles, particularly in the morning. Additionally, patients frequently report systemic symptoms including weight loss, fever, malaise and fatigue. A diagnosis of PMR is usually made clinically, but can be confirmed by the presence of an elevated erythrocyte sedimentation rate (ESR) of above 50 mm/h.This case discusses a 70-year-old male, a pre-existing patient at a chiropractic clinic, who presented with a 24-h history of localised pain and stiffness in his neck and low back that had commenced the previous day after a long flight. His history and examination findings pointed to a straightforward biomechanical diagnosis, for which he was treated over the course of 6 weeks. During that period, his symptoms fluctuated and he subsequently began to report bilateral groin pain and subjective weakness in both thighs. Referral for blood tests confirmed the presence of PMR, despite the atypical symptomatology, and he was immediately placed on steroid therapy.This report highlights the discrepancy between this patient's case and the classic presentation of a patient with PMR. It also highlights the under-reporting of this disease in the chiropractic literature, despite it being a common disorder, suggesting the diagnosis may be missed within chiropractic practices, and puts forward some recommendations as to how chiropractors might be able to minimise the risk of missing this or similar conditions in patients presenting to their clinics.
 
Background: The flexion relaxation phenomenon (FRP) is an interesting model to study the modulation of lumbar stability. Previous investigations have explored the effect of load, angular velocity and posture on this particular response. However, the influence of muscular fatigue on FRP parameters has not been thoroughly examined. The objective of the study is to identify the effect of erector spinae (ES) muscle fatigue and spine loading on myoelectric silence onset and cessation in healthy individuals during a flexion-extension task.
 
Background There are potential clinical consequences and medicolegal implications related to inadequacies in medication documentation in osteopathic practice but limited information about accuracy of medication recording by osteopaths or osteopathic students. Objective To audit how well British School of Osteopathy (BSO) students record patient medication on case history forms, implement an educational intervention to maximise accuracy, and reassess recording, to improve patient care. Method A clinical audit cycle was conducted. Benchmark criteria were defined by distributing a questionnaire to 61 BSO clinic tutors, and an a priori optimum standard of recording accuracy was set at 75%. A retrospective audit was conducted on 100 anonymised case histories to establish baseline accuracy levels, followed by an educational intervention which included a lecture, Drugs Handbook, and Quick Reference Sheet. A second audit 7 weeks later evaluated changes in recording accuracy. Results In the pre-intervention audit only 19% of case histories recorded total accuracy scores of more than 75% (the a priori optimum standard). After intervention total percentage accuracy scores in the ‘more than 75% accurate’ group increased to 31% (p=0.05). The least accurately recorded aspects of medication were strength and frequency of dosage. Conclusion The educational intervention appeared to contribute to improved accuracy of medication recording by BSO students, although some areas require further improvement. Complex barriers to obtaining full and accurate patient medication lists exist within orthodox and osteopathic healthcare practice, so ongoing audits and interventions within the BSO are recommended, as well as further research in osteopathic practice.
 
Objective:To present the case of a patient affending for chiropractic care with acute low back pain. Incidentally, a previously unknown long-standing axis odontoid fracture was diagnosed, which resulted in a referral for neurosurgical management.Clinical features:A 63-year-old man presented for chiropractic care with a chief complaint of severe acute low back pain. His examination revealed evidence of lumbar and upper cervical subluxations. Subsequent X-rays revealed a double rotatory lumbar scoliosis and an axis odontoid fracture at its base. A cervical flexion X-ray revealed instability and a later computed tomography confirmed the fracture.Intervention and outcome:Due to poor patient compliance, a neurosurgical consultation and subsequent upper cervical arthrodesis did not take place until over 4 months after the initial diagnosis. A Brooks C1-C2 posterior fusion using Songer cables and an iliac crest bone graft resulted in a successful outcome. Prior to surgery, the patient's low back pain was managed by the chiropractor with a successful outcome.Conclusion:This case presents a rare, yet precarious situation with the chiropractic management of a patient with a potentially catastrophic condition. This clinical example also stresses the importance of careful clinical assessment and imaging procedures for patients before providing spinal adjustments in order to avoid a potential iatrogenic incident. This case report also demonstrates the successful outcome of specific chiropractic care in the amelioration of acute low back pain.
 
Acute traumatic injuries to the cervical spine are common consequences of motor vehicle accidents. Typically, routine radiographs are the first imaging approach to these injuries; however with the use of computed tomography and magnetic resonance scans, it can be appreciated how radiographs can miss important fractures. The aim of this article is to report a case study of a missed diagnosis of a fracture-subluxation of the lower cervical spine and present a literature review.
 
Poor adherence to treatment can have negative effects on outcomes and healthcare cost. However, little is known about the barriers to treatment adherence within physiotherapy. The aim of this systematic review was to identify barriers to treatment adherence in patients typically managed in musculoskeletal physiotherapy outpatient settings and suggest strategies for reducing their impact. The review included twenty high quality studies investigating barriers to treatment adherence in musculoskeletal populations. There was strong evidence that poor treatment adherence was associated with low levels of physical activity at baseline or in previous weeks, low in-treatment adherence with exercise, low self-efficacy, depression, anxiety, helplessness, poor social support/activity, greater perceived number of barriers to exercise and increased pain levels during exercise. Strategies to overcome these barriers and improve adherence are considered. We found limited evidence for many factors and further high quality research is required to investigate the predictive validity of these potential barriers. Much of the available research has focussed on patient factors and additional research is required to investigate the barriers introduced by health professionals or health organisations, since these factors are also likely to influence patient adherence with treatment.
 
Top-cited authors
Peter Miller
  • AECC University College
Dave Newell
  • AECC University College
Jeff Bagust
  • Bournemouth University
Robin Pauc
  • Semi retired
Paul Bruno
  • University of Regina