Journal of Chiropractic Medicine

Traction apophysitis is a common condition in physically active and skeletally immature adolescents. This case study describes the clinical presentation and plain film imaging of traction apophysitis of the acromion process of the scapula. A physically active 13-year-old adolescent boy presented to a chiropractic physician with an acute onset of moderate shoulder pain. Plain film radiographs of the shoulder were performed that revealed fragmentation, sclerosis, and irregularity of the left acromial apophysis. The patient was treated with conservative therapy for 10 weeks, with complete resolution of symptoms. Follow-up radiographs 9 weeks later revealed no radiographic change in the appearance of the apophysis; however, clinical symptoms were absent. The apophyseal growth cartilage is the most vulnerable site in the muscle-tendon unit in the skeletally immature patient and is more susceptible to very small avulsion fractures. Repetitive microtrauma following chronic overuse at a tendon insertion site in a skeletally immature patient may result in traction apophysitis. Acromial apophysitis should be included in the differential diagnosis when presented with a young active patient with shoulder pain. Early treatment with restriction of activities is important in the prevention of permanent injury to the acromial cartilaginous growth plate. This case demonstrates that a prompt diagnosis can be made with a careful history, physical examination, and conventional imaging.

To describe a case of an adolescent with separation anxiety disorder (SAD) presenting to a chiropractor for treatment. The patient was a 13-year-old boy who had consulted with a clinical psychologist and had been diagnosed with SAD using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. The patient was unable to attend school camps or sleep at friends' homes because of anxiety. INTERVENTION/OUTCOME: The patient underwent 8 sessions with a chiropractor certified in the Neuro Emotional Technique (NET). Two days after his last NET treatment, he attended his first school camp without incident. He also slept away from home at a friend's home for the first time without incident. Six months postintervention, he returned to his clinical psychologist, where she independently reevaluated him stating that he no longer met the criteria for SAD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. This single case report cannot provide a causal relationship between the clinical outcome and NET without further investigations. Neuro Emotional Technique is a unique therapy that does not take the place of psychotherapy; however, it may be used as an adjunct to it. It is possible that, with valid and reliable follow-up research, the biopsychosocial principles that NET addresses may be of value to children and adolescents with SAD.

Vitamin C has been shown to be an effective therapeutic for reducing total serum cholesterol, but epidemiologic studies have determined that low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol are actually better predictive measures of coronary heart disease risk. Therefore, the purpose of this study was to provide a comprehensive meta-analysis of randomized controlled trials to investigate the effect of vitamin C supplementation on LDL and HDL cholesterol as well as triglycerides in patients with hypercholesterolemia. Thirteen randomized controlled trials published between 1970 and June 2007 were identified using Medline and a manual search. From the 13 trials, 14 separate group populations with hypercholesterolemia and who were supplemented with at least 500 mg/d of vitamin C for between 3 and 24 weeks were entered into the meta-analysis. This meta-analysis used a random-effects model; and the overall effect sizes were calculated for changes in LDL and HDL cholesterol, as well as triglyceride concentrations. The pooled estimate of effect for vitamin C supplementation on LDL and HDL cholesterol was -7.9 mg/dL (95% confidence interval [CI], -12.3 to -3.5; P = .000) and 1.1 mg/dL (95% CI, -0.2 to 2.3; not significant), respectively. The pooled estimate of effect for vitamin C supplementation on triglycerides was -20.1 mg/dL (95% CI, -33.3 to -6.8; P < .003). Supplementation with at least 500 mg/d of vitamin C, for a minimum of 4 weeks, can result in a significant decrease in serum LDL cholesterol and triglyceride concentrations. However, there was a nonsignificant elevation of serum HDL cholesterol.

Objective: The purpose of this report is to present a case of herpes zoster in a 6-month-old infant, conservatively managed without oral antivirals, and its 13-year follow-up, demonstrating no sequelae or recurrences. Clinical features: A 6-month-old white female infant presented with a vesicular rash of the right lower extremity to a chiropractic office. The rash consisted of grouped vesicles on erythematous plaques, the characteristic herpetiform lesion, distributed in the S1 dermatome of the right lower extremity only. The infant's history was significant for exposure to chicken pox at age 1 week through siblings. Consequently, only one vesicle developed, representing subclinical chicken pox. The clinical diagnosis of herpes zoster was made. Intervention and outcome: The infant was treated conservatively at home. Treatment consisted of aluminum acetate (Burow) solution compresses 3 times each day, followed by a loose dressing. The lesions crusted in 1 week and completely resolved in 2 weeks. Follow-up, consisting of 13 years of observation, demonstrated no evidence of sequelae, such as postherpetic neuralgia, or recurrence. Conclusion: Herpes zoster is uncommon in infants; however, it may occur. The presentation of the rash is characteristic; but otherwise, the condition differs from that in adults in that it is mild and not associated with postherpetic neuralgia. In uncomplicated cases, conservative treatment measures support the quick resolution with no sequelae.

This case report aims to raise awareness in chiropractic physicians of the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in adolescents who participate in sports activities and to alert the chiropractic physician of the necessity to consider potential diagnoses that are not within their typical clinical heuristic. A 16-year-old adolescent girl entered the clinic with a complaint of left knee pain that had an insidious onset during her involvement in sports activities. Later that same day, her knee became enlarged, red, and had pustular formations with a discharge. She was taken to an urgent care facility and subsequently diagnosed with MRSA. Her history included treatment of a left knee musculoskeletal condition 6 weeks prior to which she had responded favorably. She was treated medically with an aggressive course of antibiotic therapy and excision of the furuncle. The chiropractic physician played a role in patient education and notifying local school authorities of the case. Doctors of chiropractic must prepare themselves for the unexpected and remain open to diagnostic possibilities outside of the normal scope of practice. Knee pain or cellulitis of any type may require additional diagnostic and patient care protocols to make the correct diagnosis. With the incidence of community-acquired MRSA increasing at an alarming rate, it is certainly a diagnosis doctors of chiropractic should be aware of when treating patients, especially those involved in sports activities.

The objective of this study was to gather descriptive information concerning the clinical outcomes of patients with cervical and lumbar radiculopathy treated with a nonsurgical, chiropractic treatment protocol in combination with other interventions. This is a retrospective review of 162 patients with a working diagnosis of radiculopathy who met the inclusion criteria (312 consecutive patients were screened to obtain the 162 cases). Data reviewed were collected initially, during, and at the end of active treatment. The treatment protocol included chiropractic manipulation, neuromobilization, and exercise stabilization. Pain intensity was measured using the numerical pain rating scale. Of the 162 cases reviewed, 85.5% had resolution of their primary subjective radicular complaints. The treatment trial was 9 (mean) treatment sessions. The number of days between the first treatment date and the first symptom improvement was 4.2 days (mean). The change in numeric pain scale between initial and final score was 4.2 (median). There were 10 unresolved cases referred for epidural steroid injection, 10 unresolved cases referred for further medication management, and 3 cases referred for and underwent surgery. The conservative management strategy we reviewed in our sample produced favorable outcomes for most of the patients with radiculopathy. The strategy appears to be safe. Randomized clinical trials are needed to separate treatment effectiveness from the natural history of radiculopathy.

The purpose of this case series is to report the effects of manipulation under anesthesia (MUA) for patients with lumbopelvic (lumbar spine, sacroiliac and/or pelvic, hip) pain in an outpatient ambulatory/hospital-based setting. A retrospective chart review of cases treated at an outpatient ambulatory surgical center in New York and a general hospital in New York was performed. Patients with pre- and postintervention Oswestry Low Back Pain Disability Index (ODI) scores and lumbopelvic and hip complaints were included (N = 18). No intervention other than MUA was administered between the initial and follow-up ODI scoring. Scores on the ODI were assessed within 1 week prior to MUA and again within 2 weeks postprocedure. Patients underwent 2 to 4 chiropractic MUA procedures over the course of 7 to 8 days as per National Academy of Manipulation Under Anesthesia physicians' protocols. Preprocedure ODI scores ranged from 38 to 76, with an average score of 53.4. Postprocedure scores ranged from 0 to 66, with an average score of 32.8. For each patient, ODI scores were lower after MUA, with an average decrease of 20.6. Sixteen of 18 patients experienced a clinically meaningful improvement in ODI score. No adverse reactions were reported. For 16 of the 18 patients with chronic lumbopelvic pain reported in this study, MUA showed clinically meaningful reduction in low back pain disability.

To identify studies measuring garlic powder tablets effects on systolic and diastolic blood pressure and to investigate if studies published prior to January 1994 would perform better than those published later. Using MEDLINE (January 1966 through December 2004) studies involving human subjects that examined the effect of garlic (Allium sativum) on serum lipids and blood pressure were obtained. Studies that were conducted using garlic in the form of garlic powder tablets were included in the data extraction. Correlation coefficients were calculated for total serum cholesterol, systolic and diastolic blood pressure with respect to date of publication. Trials published prior to January 1994 were placed into an "earlier" group and compared to the "latter" group of studies published from January 1994 onward. Eighteen trials were identified whereupon the inverse associations between total serum cholesterol, systolic and diastolic blood pressures with respect to time of publication were correlated (-0.614, -0.627, and -0.587 respectively, p < 0.05). No significant associations were observed between systolic and diastolic blood pressure with respect to total serum cholesterol (0.388 and 0.431 respectively). The following differences between the earlier and later groups were observed for total serum cholesterol (31.4 +/- 19.0 vs. 3.5 +/- 5.8 mg/dl, p = .004); systolic blood pressure (11.0 +/- 9.2 vs. 2.0 +/- 4.4 mmHg, p = .133) and diastolic blood pressure (5.8 +/- 3.4 vs. 0.9 +/- 2.4 mmHg, p = .018). Publications published prior to January 1994 performed better than those published after January 1994, suggesting that allicin may be responsible for the antihypertensive effects of garlic powder tablets. However, a lack of correlation between changes in total serum cholesterol and blood pressure suggests that other organo-sulfur compounds may also play a role in the antihyper-tensive mechanisms of garlic.

This article recognizes editorial board members and peer reviewers who completed manuscript reviews for the Journal of Chiropractic Medicine in 2013.

This article recognizes editorial board members and peer reviewers who completed manuscript reviews for the Journal of Chiropractic Medicine in 2011 and 2012.

This article recognizes editorial board members and peer reviewers who completed manuscript reviews for the Journal of Chiropractic Medicine in 2010.

This article describes 4 pediatric cases of overuse injuries related to playing Nintendo Wii (Nintendo, Redmond, WA). A brief discussion is also presented regarding other 21st century problems found in the literature, such as problems associated with playing the Nintendo DS portable electronic device, text messaging, and Blackberry (Research in Motion, Waterloo, Ontario) thumb. Four pediatric patients, ranging from 3 to 9 years old, who had injuries causally related to what has been described in the literature as "Wii-itis" (spinal pain, spinal joint dysfunction [chiropractic subluxation], and related extremity pain), presented to a chiropractic clinic. Each of the 4 pediatric cases was evaluated and managed using chiropractic techniques. All patients successfully had their complaints resolve with 1 chiropractic visit. Children in the new era of portable electronic devices are presenting to chiropractic offices with a set of symptoms directly related to overuse or repetitive strain from prolonged play on these systems.

The purpose of this case report is to describe the case of a 24-year-old woman complaining of diffuse abdominal pain following insertion of an intrauterine contraceptive device (IUC). A 24-year-old woman, 8 weeks postpartum, sought chiropractic care for intermittent stabbing pain in her left upper quadrant that had been present for a week. She returned 1 week later with no resolution of her complaint. She then recalled that, at her 6-week gynecological examination, she had undergone insertion of an IUC and that the abdominal pain had begun a week later. She was advised to return to her gynecologist. Subsequent evaluation by the gynecologist revealed that the IUC had perforated her uterus and had migrated to the upper left quadrant of her abdomen, where it was found anterior to the L1-2 vertebral bodies, lying in contact with the anterior surface of the abdominal aorta. To our knowledge, this is the only report of this type of presentation in a chiropractic office. The initial intervention with this patient included chiropractic adjustment and myofascial release. At her subsequent visit, with no resolution of her complaint, she was referred back to her gynecologist for additional evaluation. Because the IUC had perforated her uterus, she underwent emergency laparoscopic surgery. The surgery was successful, and she recovered fully. Chiropractic physicians should consider uterine perforation by IUC in the differential diagnosis of a female patient of childbearing age seeking care for abdominal pain.

The purpose of this study was to retrospectively report the results of patients who completed an exercise-based chiropractic program and its potential to alter the natural progression of adult scoliosis at 24 months after the clinic portion of treatment was concluded. A retrospective chart review was conducted at 2 spine clinics in Michigan, USA. Each clinic uses the same chiropractic rehabilitation program to treat patients with adult scoliosis. Multidimensional patient outcomes included radiographic, respiratory, disability, and pain parameters. Outcomes were measured at baseline, at end of active treatment, and at long-term follow-up. A total of 28 patients fit the inclusion criteria for the study. The average beginning primary Cobb angle was 44° ± 6°. Patients received the same chiropractic rehabilitation program for approximately 6 months. At the end of active treatment, improvements were recorded in Cobb angle, pain scores, spirometry, and disability rating. All radiographic findings were maintained at 24-month follow-up. This report is among the first to demonstrate sustained radiographic, self-rated, and physiologic benefits after treatment ceased. After completion of a multimodal chiropractic rehabilitation treatment, a retrospective cohort of 28 adult scoliosis patients reported improvements in pain, Cobb angle, and disability immediately following the conclusion of treatment and 24 months later.

This study retrospectively examined the effects of a 21-day nutritional intervention program, which included fruit and vegetable consumption, energy restriction, and nutritional supplements, on serum lipid measures in 28 chiropractic patients. Medical records were reviewed for 28 chiropractic patients who had completed a commercially available 21-day nutritional intervention program between April 2005 and August 2007 and for whom complete serum lipid and weight measures immediately pre- and postintervention were available. The primary outcome was change in serum lipids, and change in body weight was a secondary outcome variable. Significant reductions in total, low-density lipoprotein, very low-density lipoprotein, and high-density lipoprotein cholesterol, and triglycerides were observed. Serum triglycerides decreased from 116.3 +/- 54.6 (mean +/- SD) to 88.6 +/- 40.5 mg/dL (P < .01). Total cholesterol decreased from 223.3 +/- 40.7 to 176.2 +/- 30.0 mg/dL (P < .0001). Low-density lipoprotein cholesterol decreased from 145.7 +/- 36.8 to 110.9 +/- 25.3 mg/dL (P < .0001). High-density lipoprotein cholesterol decreased from 54.3 +/- 14.6 to 47.6 +/- 10.5 mg/dL (P < .001). Weight for patients decreased from 191.2 +/- 38.8 to 182.2 +/- 36.3 lb (P < .0001). This retrospective case series supports the hypothesis that a nutritional purification intervention program emphasizing fruit and vegetable consumption, energy restriction, and nutritional supplements reduces serum lipids and weight.

The purpose of this case study is to describe the treatment using acupuncture and spinal manipulation for a patient with a chronic tension-type headache and episodic migraines. A 32-year-old woman presented with headaches of 5 months' duration. She had a history of episodic migraine that began in her teens and had been controlled with medication. She had stopped taking the prescription medications because of gastrointestinal symptoms. A neurologist diagnosed her with mixed headaches, some migrainous and some tension type. Her headaches were chronic, were daily, and fit the International Classification of Headache Disorders criteria of a chronic tension-type headache superimposed with migraine. After 5 treatments over a 2-week period (the first using acupuncture only, the next 3 using acupuncture and chiropractic spinal manipulative therapy), her headaches resolved. The patient had no recurrences of headaches in her 1-year follow-up. The combination of acupuncture with chiropractic spinal manipulative therapy was a reasonable alternative in treating this patient's chronic tension-type headaches superimposed with migraine.

The purpose of this case report is to describe the clinical presentation and chiropractic management of Tietze syndrome. A 34-year-old woman presented with unexplained left-sided chest pain. Electrocardiogram and radiographs were taken at a medical emergency department to rule out cardiovascular and pulmonary causes, and pain medication did not relieve her pain. Physical examination showed tenderness on palpation and swelling of the second and third chondrosternal joints, as well as thoracic joint dysfunction. Heart and lung pathology was ruled out, and chondrosternal joint swelling was present, Tietze syndrome was diagnosed. A treatment plan aimed at restoring normal thoracic and rib joint movement and decreasing inflammation of the chondrosternal joints resulted in lower pain levels. Treatment consisted of diversified high-velocity, low-amplitude chiropractic manipulation; activator technique; and cryotherapy. Chiropractic management of Tietze syndrome was successful in reducing pain levels in this patient's case.

This article describes the chiropractic clinical management and therapeutic benefits accruing to a patient with temporomandibular joint (TMJ) disorder and spinal muscular atrophy type III. A 35-year-old white man presented at the university chiropractic outpatient clinic with a complaint of masseter muscle pain and mouth-opening restriction. Temporomandibular joint range of motion evaluation revealed restricted opening (11 mm interincisival), and pain was rated by the patient at an intensity of 5 on a pain scale of 0 to 10. Chiropractic care was provided and included TMJ mobilization, myofascial therapy, trigger point therapy, and light spinal mobilizations of the upper cervical vertebrae. Final evaluation of TMJ range of motion showed active opening of 12 mm with absence of pain and muscle tenderness of the jaw. This case suggests that a patient with musculoskeletal disorders related to underlying neurodegenerative pathologies may benefit from chiropractic management adapted to their condition. In the present case, chiropractic treatment of the TMJ represented a viable, low-cost approach with limited adverse effects compared with surgery.

To present a chiropractic treatment plan for a patient with lumbar disc herniation including radicular symptoms below the knee. A 38-year-old male experienced lumbar disc herniation with radicular symptoms to the lower extremities, below the knee. Etiology of this episode included a traumatic injury which was complicated by chronic degenerative joint and disc changes. The treatment regime included chiropractic spinal manipulation, modalities and exercise rehabilitation. Specific rehabilitation exercises were used during various stages of healing in an attempt to stabilize a potential surgical case. Goals of care were to alleviate pain, increase function, and decrease peripheralization related to disc herniation in this case. The patient reached a level of functional biomechanical stability over 15 weeks. This case demonstrates that with proper management, rehabilitation of a patient with disc herniation can be reached in a short duration of time.

To discuss the treatment of a patient with type 1 diabetes presenting with chronic neck and shoulder pain by using chiropractic manipulation and an active rehabilitation program with emphasis on correcting postural imbalances. A 46-year-old insulin dependant (type1) diabetic female presented with neck and right shoulder pain of 6 to 8 months duration. Her history included similar left-sided complaints 2 years prior at which time she underwent 3 months of rehabilitation at a local medical center, which improved her condition. Over time her pain resolved but the residuals of restricted left shoulder range of motion remained. The patient had postural changes consisting of forward head posture, rounded shoulders and internally rotated arms. Treatment included spinal manipulation, ultrasound and active rehabilitation consisting of at home exercises initially and followed with in office low-tech rehabilitation. Rehabilitation was primarily aimed at improving postural abnormalities, muscle imbalances and abnormal movement patterns. The patient improved with this course of treatment. Chiropractic care including active rehabilitation may be helpful in treating diabetic patients suffering from chronic neck and shoulder problems.

Objective: The purpose of this case study is to describe the effect of chiropractic care on a patient with chronic Bell's palsy. Clinical features: A 47-year-old woman with medically diagnosed Bell's palsy presented for chiropractic care. She had experienced right sinus pressure and congestion, lack of facial tone on the right, and intermittent tingling of the right side of her face. Interventions and outcomes: The patient received high-velocity, low-amplitude chiropractic manipulation (adjustments) to the cervical and thoracic spine, interferential muscle stimulation, and hydroculation on the trapezius muscles bilaterally. Reduction in symptoms occurred following the initial visit and continued over the next 9 weeks of care. After the course of a year of chiropractic care, the patient reached 90% improvement. Conclusions: For this patient, chiropractic care reduced Bell's palsy symptoms.

This case report describes the effect of exercise-based chiropractic treatment on chronic and intractable low back pain complicated by lumbar disk extrusion. 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. 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. 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.

Observational studies in humans have shown an inverse relationship between plasma vitamin C concentration and total serum cholesterol. However, experimental studies have shown inconsistent results regarding the ability of vitamin C to reduce total serum cholesterol. Published reports of trials studying the effects of vitamin C on serum lipids were identified by a search of Medline from 1966 to 2004. Data from 51 experimental studies comprising of 1666 pooled subjects were selected for analysis. A very strong negative association was observed between baseline total serum cholesterol and the percent change in cholesterol (r = -0.585, p<0.001). When subjects were divided into 4 groups based on their baseline total serum cholesterol levels, the following weighted mean percent changes in cholesterol from baseline were observed: normal cholesterol (<199mg/dl): 0.91+/-6.8% (n=508); borderline high cholesterol (200-239mg/dl): 3.90+/-5.78% (n=605); high cholesterol (240-279mg/dl): 11.40+/-7.96% (n=300); severe cholesterol (>280mg/dl): 14.30+/-8.36% (n=253). A significant inverse relationship was found between the baseline plasma vitamin C concentrations and mean percent change in total cholesterol from baseline (r = -0.500, p<0.005). It was also observed that the high and severe baseline cholesterol groups possessed lower baseline plasma vitamin C concentrations than those in the normal cholesterol groups (0.79 and 0.55 versus 1.24 mg/dl respectively). This finding strengthens the hypothesis that the cholesterol lowering and cardio-protective benefit of vitamin C supplementation may be in its ability to elevate plasma vitamin C concentrations in those patients who initially possess lower than normal vitamin C plasma concentrations.

Manipulation under anesthesia (MUA) is an outpatient procedure that is performed to restore normal joint kinematics and musculoskeletal function. This article presents a case of a patient with idiopathic lumbar degenerative scoliosis who developed intractable pain as an adult and reports on the outcomes following a trial of MUA. A 59-year-old female patient presented to a chiropractic office with primary subjective symptoms of lower back and bilateral hip pain. Numerical pain rating scores were reported at 8 of 10 for the lower back and 9 of 10 for the sacroiliac joint/gluteal region. A disability score using a functional rating index demonstrated a score of 26 of 40 (or 64% disability). Over the preceding 5 years, the patient had tried a number of conservative therapies to relieve her pain without success. The patient was evaluated for MUA. The patient was scheduled for a serial MUA over 3 days. Numerical pain rating scores 8 weeks after the MUA were 1 of 10 for the lower back and 3 of 10 for the sacroiliac joint. Her disability rating decreased to 11 of 40 (28%). Radiological improvements were also observed. These outcomes were maintained at 6-month follow-up. Pain, functional, and radiographic outcomes demonstrated improvements immediately following treatment for this patient.

The purpose of this case report is to describe the care and outcomes of a patient with cervical dystonia who was treated using chiropractic and other alternative medicine interventions. A 59-year-old woman had an 11-year history of cervical dystonia. She had an uncontrollable 60° leftward head rotation upon shutting her eyes and had spasmodic contractions that caused fatigue. The management consisted of blue-lensed glasses, vibration stimulation, spinal manipulation, and eye-movement exercises. Within the first week of treatment, she had a reduction in symptoms, which was documented using a functional numeric scale, and improved posture, which was assessed using measurements from her midsternal line to the center of her chin. This patient with cervical dystonia responded to the use of conservative, nonpharmacological treatment procedures that consisted of chiropractic care using a functional neurologic approach aimed at improving her spasmodic contractions and function.

A metatarsal pad is generally considered a useful addition to the orthotic prescription, but anecdotal reports suggest that this element is not prescribed because of patients' reports of excessive discomfort. The purpose of this study was to determine the occurrence of intolerance to metatarsal pads in a group of patients prescribed customized foot orthotics in a primary care setting. Sixty consecutive patients presenting in a primary care clinic in Edmonton, Canada, with chronic (>3 months), nonspecific, low back pain and/or soft-tissue lower limb disorders were prescribed customized foot orthotics, which in each case included a large metatarsal pad as a routine measure. Patients were educated at the outset that the metatarsal pad may produce initial discomfort, but that this should subside within 1 week and that the pad should be retained if tolerable. All patients were assessed 6 weeks later for their tolerance of the metatarsal pad. All subjects completed the 6-week follow-up. The mean age of the sample was 52.6 ± 10.9 years, with 51% male and 49% female. Ten of the 60 subjects reported pain and/or discomfort that they related to the presence of the metatarsal pad beyond 1 week after initial use and requested adjustment or removal of the metatarsal pad. With reassessment and education, addressing problems of inadequate shoe size or a need for reassurance to persist with orthotic use, only 1 required adjustment to the metatarsal pad to continue orthotic use. A group of primary care patients prescribed customized foot orthotics seemed to tolerate a large metatarsal pad. This suggests that metatarsal pads should not be avoided or immediately removed in customized orthotics because of initial discomfort, as this discomfort may be transient or responds to reassurance and education.

Objective: The purpose of this case report is to describe chiropractic management of a patient with a C6/C7 left posteromedial disk herniation with foraminal narrowing and concomitant neurological compromise in the form of left upper extremity radiating pain and hypoesthesia/anesthesia using Cox flexion-distraction technique. Clinical features: A 64-year-old man presented to a chiropractic clinic with complaints of neck/left shoulder pain and hypoesthesia/anesthesia into the palmar side of his left hand. Magnetic resonance images of the cervical spine revealed a left posteromedial C6/C7 disk herniation along with foraminal narrowing. In addition, there were other levels of degeneration, most noted at the C3/C4 spinal level, which also had significant left-sided foraminal narrowing. Intervention and outcome: Treatment included Cox flexion-distraction protocols aimed to reduce nerve root compression along with supportive physiological therapeutic interventions to aid with pain reduction and functional improvement. The patient was treated a total of 10 times over a course of 4 weeks. The patient reported being pain-free and fully functional 8 months following the conclusion of care. Conclusion: This case study demonstrated the use of Cox flexion-distraction for treatment of a patient with a cervical disk herniation, foraminal narrowing, and associated radiating pain and radiculopathy in the left upper extremity.

Prostate cancer remains the second leading cause of cancer-related deaths, and African American men are affected with this disease disproportionately in terms of incidence and mortality. The purpose of this article is to present a case report that illustrates the importance of a careful evaluation, including a comprehensive historical review and appropriate physical and laboratory assessment, of a patient with back pain and seemingly unrelated symptoms. A 65-year-old African American man presented to a chiropractic clinic after experiencing lower back pain for 1 month. The digital rectal examination was unremarkable, but the serum prostate-specific antigen was markedly elevated. A suspicion of metastatic prostate cancer resulted in subsequent referral, further diagnostic evaluation, and palliation. The patient was referred for medical evaluation and palliation of his condition. Spinal decompression surgery of the thoracic spine was initiated, resulting in weakness and paresthesia in the lower limbs bilaterally. The patient died because of the complications associated with the medical interventions and the disease about 12 months after the referral. Chiropractic physicians should maintain a high degree of suspicion for catastrophic causes of back-related complaints, such as metastatic prostate cancer. The Prostate Cancer Prevention Trial Risk Calculator, a research validated instrument, should be used in the assessment of prostate cancer risk. Performance of the digital rectal examination and of the prostate-specific antigen determination remains integral in the clinical assessment of the health status in aging men, with or without back pain.

The purpose of this case report is to describe the response to chiropractic care of a geriatric patient with left hip pain, a history of repetitive falls, poor balance, myofascial dysfunction, and hip osteoarthritis. A 70-year-old, white, female patient presented for chiropractic care with a chief complaint of left hip pain of 1 year's duration and a history of 2 falls within the past 5 years. The patient's initial Lower Extremity Functional Index score was 42%. Important initial examination findings include a body mass index of 45.0, a One Leg Standing Test of 4 seconds, a Timed Up and Go test of 17 seconds, decreased active range of motion findings, and degenerative radiological findings of the left hip joint. Chiropractic treatment primarily consisted of hip and spinal manipulation, mobilization, and passive stretching. The patient was seen 16 times over a 12-week period. After 12 weeks of care, the patient had a significant decrease on the Lower Extremity Functional Index and had demonstrated improvements in left hip internal rotation and in Timed Up and Go and One Leg Standing Test times. The Patient Global Impression of Change scale indicated that the patient was "very much better." This case illustrates a patient who had increased range of motion, improved balance and gait speed, and decreased disability after a 12-week course of chiropractic care.

The purpose of this article is to present a case of abdominal aortic aneurysm to illustrate its clinical detection through history and physical examination and the importance of this condition to the chiropractic clinical setting. A 74-year-old retired man consulted a doctor of chiropractic for chronic low back pain. The history and physical examination confirmed chronic sacroiliac and a lumbar facet dysfunction. After 5 weeks, the patient stated he had stomach cramps. After this, a more thorough abdominal examination was done. The doctor of chiropractic detected an enlarged pulsatile mass upon abdominal palpation. The patient was sent to the cardiologist and had successful surgery within weeks. An abdominal aortic aneurysm has specific symptoms and associated risk factors. If known risk factors are present, a clinical examination needs to be carried out, even though sensitivity of the clinical examination may be low. It should be a differential diagnosis in every male patient older than 50 years with low back pain. In case of suspicion, the patient should be referred for advanced imaging.

The purpose of this study was to compare the 84-in focal film distance anteroposterior (A-P) full spine view to selected sectional views taken at a 40-in focal film distance for angles of divergence and changes produced by lateral translation and variation in source object distance. Computer models were used to determine angles of divergence and study the effects of lateral translation and changes in source object distance. Lateral translation produced less projected axial (y-axis) vertebral rotation on the 84-in A-P full spine view than the film at 40 in. Angles of divergence are equal on the 14 × 17-in film at 40 in compared with the 84-in A-P full spine, and 70% of the 84-in full spine view is within the angles of divergence of the 40-in 10 × 12. The 84-in A-P full spine produced lowering and lengthening of the projected ilium when source object distance was reduced. In this study, the 84-in A-P full spine produced less projected vertebral rotation on lateral translation. Its angles of divergence were greater than the 40-in 10 × 12 and equal to the 40-in 14 × 17-in film. Except for a 5.4-in section at both the upper and lower margins, the 84-in full spine view was within the angles of divergence of a 40-in 10 × 12. The full spine film produced projected ilium lengthening and lowering.

The purpose of this case is to describe a patient who had a stroke preceding a chiropractic appointment and was unaware that the cerebrovascular event had occurred. An 85-year-old established patient presented for chiropractic treatment of pain in the left side of the neck, hip, and low back associated with known advanced degenerative spinal disease and lumbar stenosis. On the day of presentation, the patient reported morning nausea, double vision, and right-sided vision loss; she related that she had collided into a car while driving to the appointment. Review of her medical history divulged residual neurological deficits related to a previous subdural hematoma, resulting in craniotomy. Examination revealed a right inferior quadrantanopia in the right eye and right nasal hemianopia in the left eye. Nystagmus was present in the left eye with saccadic intrusion on pursuit right to left. The patient was transported immediately to an emergency room,where diagnosis of an Acute infarct in the left cerebrum at the junction of the left occipital, parietal and temporal lobes in the watershed area was confirmed. Patients with signs and symptoms of stroke in progress may occasionally present for chiropractic care. It is imperative to complete a thorough history and examination prior to care.

To describe the importance of health promotion techniques and use of active disease prevention techniques as part of chiropractic practice through a selective review of literature using a mnemonic device. There is evidence that doctors of chiropractic use some health promotion techniques in practice such as instruction on exercise, dietary advice, smoking cessation recommendations and the encouraging of preventive chiropractic visits. Healthy People goals for the nation suggest that providers encourage preventive services, work toward better access to care and stress disease prevention. However, information on how this can be routinely done in chiropractic practice is fragmented. This article suggests ways to implement health promotion into the everyday management of the chiropractic patient. Health promotion and disease prevention can be easily performed in chiropractic practice. The nature of the chiropractic supportive or maintenance visit gives doctors a unique platform on which they can launch full-scale health promotion efforts on their patients.

To review commonly encountered calcifications found within the abdomen as seen on the lumbar spine radiograph and to determine which advanced imaging modality is best to thoroughly assess the patient. Searches of electronic databases and textbooks were conducted to construct this narrative overview. By categorizing the type of calcification and localizing it anatomically, most often a definitive diagnosis can be reached. Two commonly encountered conditions, abdominal aortic aneurysms and urinary calculi, are used to compare the main advanced imaging modalities (diagnostic ultrasound and computed tomography) used to further assess abdominal calcifications. In most circumstances, either diagnostic ultrasound or computed tomography will establish a definitive diagnosis and offer thorough imaging assessment for abdominal calcifications.

This study presents a case of a posttraumatic subacute osteomyelitis in a child with leg pain. A 10-year-old female gymnast with leg pain presented to a chiropractic clinic after having been treated over the previous year for a leg fracture. The patient had leg pain associated with prolonged use of her right leg, restlessness at night, and tenderness over the right tibia. The history did not suggest a mechanical cause of the patient's pain. All available radiographs were reviewed by the chiropractor; a diffuse lytic lesion with bone thickening and sclerosis was clearly visible in the area of the patient's chief complaint, representing a Brodie abscess. The doctor of chiropractic sent the patient back to the hospital. She was treated first with oral antibiotics, which were not successful. She underwent surgery and recovered well. Subacute osteomyelitis may have a diagnostic delay; thus, it is possible for a chiropractor to see this condition in the office. A good case history, examination, and radiographs are important for the diagnosis and to make a proper referral.

To examine changes in electromyography (EMG) and a valid self-administered outcome measure after applying active release technique to carpal tunnel syndrome (CTS) patients. Five subjects (mean age 48.2 SD +/- 16.7) with CTS were included in the trial. Subjects completed the Boston Questionnaire (BQ) and an EMG examination before the first treatment. Participants were treated with Active Release technique using a protocol intended to affect the median nerve 3 times a week for 2 weeks. The BQ was re-administered following the final treatment. The mean scores for the initial and final BQ were compared using a paired samples t-test. An analysis of variance compared the mean contraction amplitudes for EMG parameters before and after the first treatment. There was significant improvement (p < 0.05) in the mean symptom severity and functional status scores of the BQ following the intervention. There were no significant differences found in the EMG analyses. The preliminary data from this clinical pilot trial suggest that active release technique may be an effective conservative management strategy for CTS patients. These results support the need for further clinical trials with larger samples.

The purpose of this study was to evaluate if manual muscle testing (MMT) could identify fetal sex in women who did not know the sex of their babies. The null hypothesis was that MMT is no more accurate than chance. A prospective case series of 27 sequential pregnant patients who did not know the sex of their fetus were included in this study. The examiner was also blind to the sex of the fetus. Manual muscle testing was evaluated after the mother stated "I am having a boy." Likelihood ratios, specificity, sensitivity, positive predictive value, and negative predictive value were calculated. Fourteen girl babies and 13 boy babies were born. Manual muscle testing accurately predicted the sex 13 times. The positive likelihood ratio was 0.92 (95% confidence interval, 0.42-2.03), sensitivity was 0.40, specificity was 0.54, positive predictive value was 0.46, and negative predictive value was 0.44. Manual muscle testing was no better than chance at predicting fetal sex in this case series.

Objective: The purpose of this study is to present a 10-year prospective case of a right incomplete type III acromioclavicular (AC) separation in a 26-year-old patient. Clinical features: A 26-year-old male patient fell directly on his right shoulder with the arm in an outstretched and overhead position. Pain and swelling were immediate and were associated with a "step deformity." The patient had limited right shoulder range of motion (ROM), strength, and function. Radiographic findings confirmed a type III AC separation on the right. At 1-year follow-up, the patient did not report any deficits in ROM or function, but did note a prominent distal clavicle on the right. At 3-, 5-, 7-, and 10-year follow-up, the patient did not report changes from 1 year. The radiographic findings at the 10-year follow-up indicated mild degenerative joint disease in both AC joints and mild elevation of the distal clavicle on the right. Intervention and outcome: The patient received chiropractic care to control for pain, swelling, and loss of ROM. The patient received acupuncture, joint mobilizations, palliative adhesive taping of the AC joint, Active Release Technique, and progressive resisted exercises. Radiographic study was done at the time of the injury and at 10 years to observe for any osseous changes in the AC joint. Conclusion: The patient yielded excellent results from conservative chiropractic management that was reflected in a prompt return to work 19 days after the injury. Follow-up at 1, 3, 5, 7, and 10 years exhibited absence of residual deficits in ROM and function. The "step deformity" was still present after the injury on the right.