Journal of Manipulative and Physiological Therapeutics

To compare magnetic resonance imaging (MRI) scans obtained from 1.5 Tesla (T) MRI units with scans obtained from 0.35T MRI units in the morphometric evaluation of the lumbar intervertebral foramina (IVF). Three dimensions of lumbar IVFs were measured on a cadaveric lumbar spine by using Vernier calipers. The spine was embedded in gelatin to simulate soft tissue and scanned twice in a 1.5T MRI unit (3-mm and 5-mm slice thicknesses) and once in a 0.35T MRI unit (5-mm slice thickness). Measurements from the scans were made independently by three observers. The results obtained from the two units were compared to the actual IVF size (as measured by calipers) and to one another. The greatest superior-to-inferior distance had the strongest statistically significant correlation to the actual cadaver measurements for both the 0.35T and 1.5T imaging units [r = 0.986 (0.35T); r = 0.985 (1.5T at 3 mm) and r = 0.981 (1.5T at 5 mm); p < .0001 in all cases]. Mean differences and standard errors were minimal between measurements made from MRI scans of both 1.5T and 0.35T units and measurements made directly from the cadaveric spine. Both imaging units produced images that accurately depicted the actual size of the IVF. The MRI units of 0.35T field strength produced images of high morphometric accuracy. In addition, the potential for side effects and the operating costs are less with 0.35T units. Therefore, 0.35T MRI units may be a prudent choice as a clinical and research imaging tool in the evaluation of the lumbar IVF.

The following critique of the Chiropractic Services Pilot Program (SDR #86-09) focuses on two major issues: the terms of reference established for the study and the research constraints that arose from either the terms of reference or their interpretation; the technical design and execution of the research. The review suggests that the constraints invalidated the study and ensured that no comparisons are possible between chiropractic and medical care for VA patients based on these results. The constraints resulted in the use of a nonexperimental design, distinct samples being chosen and nonequivalent care settings being compared. The critique also reveals that in each of the design steps (eligibility criteria, sampling, protocols, data collection, analysis, interpretations) there were serious methodological flaws. These ensured that the two populations being compared (chiropractic patients versus medical patients) were in fact noncomparable. In terms of the economic cost comparisons, the design guaranteed the comparison was unfair, pitting a private, fee-for-service chiropractic practice against a not-for-profit, managed-care, federally regulated and budgeted institution. Furthermore, the allocation of costs to the two groups was done inaccurately. The critique concludes that the results are not valid, they cannot be used for generalizing, they cannot be used for statistical analysis and they should not be used to establish policy. The research design and the methodological flaws meant that the objectives of the study could not be met.

The purpose of this study was to evaluate neck-related physical function in individuals 11 to 14 years after anterior cervical decompression and fusion (ACDF) surgery for degenerative cervical disk disease and to compare the long-term outcome of 2 surgical techniques, including the Cloward procedure and cervical intervertebral fusion cage. In this cross-sectional study, 51 individuals, 11 years or more after ACDF, underwent testing of cervical active range of motion, hand-grip strength, static and dynamic balance, neck muscle endurance, and completed pain ratings. The participants' values were compared with values of age- and sex-matched healthy individuals to evaluate impairments. Correlations between different test scores and pain were performed. Group differences were analyzed between the 2 surgical techniques. Sixty-five percent and 82% exhibited impairment in ventral and dorsal neck muscle endurance, respectively. Impairment rates of 18% to 39% for cervical active range of motion, 27% to 43% for hand-grip strength, 37% for standing balance, and 35% for dynamic balance were recorded. Twenty-nine percent of the participants had impairment (>30 mm visual analog scale) in pain. There were no significant differences in physical function between the 2 surgical treatment groups (Cloward procedure or cervical intervertebral fusion cage) (P = .10-.92). In those studied, a large percentage of patients who had anterior cervical decompression and fusion surgery have impairments in neck-related physical function when compared 11 to 14 years after surgery with age- and sex-matched healthy reference individuals. Neck-specific function, but not balance, was statistically correlated to pain. Neck muscle endurance was most affected, and balance impairments were also present in one-third of the individuals. There were no differences in long-term physical function between the 2 surgical techniques.

The aim of this study is to examine the prevalence of chiropractic and osteopathy use and the profile of chiropractor/osteopath users among middle-aged Australian women. This article reports on research conducted as part of the Australian Longitudinal Study on Women's Health. The focus of this article is the middle-aged women who responded to Survey 3 in 2001 when they were between the ages of 50 and 55 years. The demographic characteristics, health status, and health service use of chiropractic/osteopathy users and nonusers were compared using chi2 tests for categorical variables and t tests for continuous variables. We estimate that 16% of middle-aged women consult with a chiropractor or osteopath (after adjustment for the oversampling of rural women). Area of residence, education, and employment status were all statistically significantly associated with chiropractic and osteopath use. Specifically, women who live in nonurban areas were more likely to consult a chiropractor or osteopath, compared with women who live in urban areas. Women are significantly more likely to consult with a chiropractor/osteopath if they have had a major personal injury in the previous year, and women who use chiropractic/osteopathy are also high users of 'conventional' health services. Chiropractic/osteopathy use among women in Australia is substantial and cannot be ignored by those providing or managing primary health care services for women. It is essential that the interface and communication between chiropractors/osteopaths and other health care providers be highlighted and maximized to establish and maintain effective overall patient coordination and management.

The purpose of this study was to describe the circumstances, clinical features, role, and results of chiropractic management of infants who were referred to a chiropractic clinic for failure to adequately feed at the breast. Clinical case series of 114 infant cases of hospital-diagnosed or lactation consultant diagnosed feeding problems that were treated with chiropractic therapy in addition to routine care and followed to short-term result. The most common age of referral was 1 week (mean, 3 weeks; range, 2 days-12 weeks), and the most common physical findings were cervical posterior joint dysfunction (89%), temporomandibular joint imbalance (36%), and inadequate suck reflex (34%). Treatment was chiropractic therapy in addition to any support given elsewhere. All children showed some improvement with 78% (N = 89) being able to exclusively breast feed after 2 to 5 treatments within a 2-week time period. Cooperative multidisciplinary care to support breastfeeding was demonstrated in this population. Chiropractic treatment may be a useful adjunct to routine care given by other professionals in cases of diagnosed breastfeeding problems with a biomechanical component.

This editorial reviews the scientific sessions and announces the 4 award-winning scientific articles from the World Federation of Chiropractic 11th Biennial Congress held in Rio de Janeiro from April 6, to 9, 2011, that are published in this issue of the Journal of Manipulative and Physiological Therapeutics.

This case series presents information on diagnosis and treatment of 13 cases of benign infant headache presenting to a chiropractic teaching clinic. A retrospective search was performed for files of infants presenting with probable headache revealing 13 cases of headache from 350 files. Thirteen cases (6 females, 7 males) from 2 days old to 8.5 months old were identified by behavioral presentation, parental, or medical diagnosis. In the cohort, historical findings included: birth trauma, assisted birth, familial headache history and feeding difficulty. Examination and behavioral findings were grabbing or holding of the face, ineffective latching, grimacing and positional discomfort, rapping head against the floor, photophobia and anorexia. Posterior joint restrictions of the cervical spine were found in these cases. No cases of malignant headache were found. All infants received a trial of chiropractic care including manual therapy. This case series offers information about potential signs of benign infant headache. The patients in this study responded favorably to chiropractic management.

To discuss the immediate increment of improvement in vision that occurs when the spine is manipulated. Two juvenile patients (13-yr-old female cousins) were found to have constricted visual fields and diminished visual acuities. Spinal manipulation was associated with recovery of normal vision over seven treatment sessions. It was noted that significant improvement in vision occurred immediately after the spinal manipulation treatments. Full recovery of vision was attained by series of these steps. In addition, both patients reported significant constitutional benefits after the treatment in addition to the improved vision. The change in visual function immediately related to spinal manipulation has been described as the "step phenomenon." The step phenomenon raises questions about the nature of the condition that may be treated by spinal manipulation and the method of action of the treatment. A vascular hypothesis is mentioned that could explain these events. The consistent occurrence of the step phenomenon indicates that spinal manipulation may have an effect on brain function.

To identify if there were differences in the cervical biomechanics in preadolescents who had recurrent neck pain and/or headaches and those who did not. A controlled comparison study with a convenience sample of 131 students (10-13 years old) was performed. A questionnaire placed students in the no pain group or in the neck pain/headache group. A physical examination was performed by a doctor of chiropractic to establish head posture, active cervical rotation, passive cervical joint functioning, and muscle impairment. The unpaired t test and the chi(2) test were used to test for differences between the 2 groups, and data were analyzed using SPSS 15 (SPSS Inc, Chicago, Ill). Forty percent of the children (n = 52) reported neck pain and/or recurrent headache. Neck pain and/or headache were not associated with forward head posture, impaired functioning in cervical paraspinal muscles, and joint dysfunction in the upper and middle cervical spine in these subjects. However, joint dysfunction in the lower cervical spine was significantly associated with neck pain and/or headache in these preadolescents. Most of the students had nonsymptomatic biomechanical dysfunction of the upper cervical spine. There was a wide variation between parental report and the child's self-report of trauma history and neck pain and/or headache prevalence. In this study, the physical examination findings between preadolescents with neck pain and/or headaches and those who were symptom free differed significantly in one of the parameters measured. Cervical joint dysfunction was a significant finding among those preadolescents complaining of neck pain and/or headache as compared to those who did not.

The purpose of this study was to evaluate survey data from a national cross-sectional sample of 1427 urban and nonurban Australian women focusing on the relationship between the use of specific complementary and alternative medicine (CAM) practitioner types and the levels of CAM use across urban and nonurban areas. A cross-sectional survey of 1427 middle-aged participants from the Australian Longitudinal Study on Women's Health conducted in 2009 was performed. The survey was designed to investigate multiple factors affecting the health and well-being of a cohort of women, with a particular emphasis on urban and nonurban residence. Women in 3 age groups ("young" 18-23 years, "mid-age" 45-50 years, and "older" 70-75 years) were randomly selected from the national Medicare database. The survey covered place of residence, measures of health status, rating of health care providers/services, and consultation with CAM practitioners. The most commonly consulted CAM practitioners for this sample were massage therapists (n = 912; 63.9%), doctors of chiropractic/chiropractors (n = 614; 43.0%), and naturopaths/herbal therapists (n = 327; 22.9%). Statistically significant differences between the areas of residence were found for women who used chiropractors (P = .0165), yoga practitioners (P = .0087), and osteopaths (P < .0001). Women residing in nonurban areas were more likely to consult with a chiropractor compared with women residing in major cities. Women in major cities were more likely to consult with a yoga practitioner or osteopath than women from nonurban areas. Women from nonurban areas who consulted a chiropractor were significantly less satisfied with their access to a medical specialist (P < .0001), access to a female general practitioner (P = .043), the number of general practitioners they have to choose from (P = .001), how long they have to wait for an appointment (0.0146), and the amount of information sharing by their general practitioner (P = .003), compared with urban women. For the population sample studied, the higher overall consultation rates with CAM therapists by Australian nonurban women were caused by consultations for chiropractic care.

Shock-absorbing and biomechanic shoe orthoses are frequently used in the prevention and treatment of back and lower extremity problems. One review concludes that the former is clinically effective in relation to prevention, whereas the latter has been tested in only 1 randomized clinical trial, concluding that stress fractures could be prevented. To investigate if biomechanic shoe orthoses can prevent problems in the back and lower extremities and if reducing the number of days off-duty because of back or lower extremity problems is possible. Prospective, randomized, controlled intervention trial. One female and 145 male military conscripts (aged 18 to 24 years), representing 25% of all new conscripts in a Danish regiment. Health data were collected by questionnaires at initiation of the study and 3 months later. Custom-made biomechanic shoe orthoses to be worn in military boots were provided to all in the study group during the 3-month intervention period. No intervention was provided for the control group. Differences between the 2 groups were tested with the chi-square test, and statistical significance was accepted at P <.05. Risk ratio (RR), risk difference (ARR), numbers needed to prevent (NNP), and cost per successfully prevented case were calculated. Outcome variables included self-reported back and/or lower extremity problems; specific problems in the back or knees or shin splints, Achilles tendonitis, sprained ankle, or other problems in the lower extremity; number of subjects with at least 1 day off-duty because of back or lower extremity problems and total number of days off-duty within the first 3 months of military service because of back or lower extremity problems. Results were significantly better in an actual-use analysis in the intervention group for total number of subjects with back or lower extremity problems (RR 0.7, ARR 19%, NNP 5, cost 98 US dollars); number of subjects with shin splints (RR 0.2, ARR 19%, NNP 5, cost 101 US dollars); number of off-duty days because of back or lower extremity problems (RR 0.6, ARR < 1%, NNP 200, cost 3750 US dollars). In an intention-to-treat analysis, a significant difference was found for only number of subjects with shin splints (RR 0.3, ARR 18%, NNP 6 cost 105 US dollars), whereas a worst-case analysis revealed no significant differences between the study groups. This study shows that it may be possible to prevent certain musculoskeletal problems in the back or lower extremities among military conscripts by using custom-made biomechanic shoe orthoses. However, because care-seeking for lower extremity problems is rare, using this method of prevention in military conscripts would be too costly. We also noted that the choice of statistical approach determined the outcome.

This study presents a case series of 157 children with developmental delay syndromes, including the conditions such as dyspraxia, dyslexia, attention-deficit hyperactivity disorder, and learning disabilities who received chiropractic care. A consecutive sample of 157 children aged 6 to 13 years (86 boys and 71 girls) with difficulties in reading, learning, social interaction, and school performance who met these inclusion criteria were included. Each patient received a multimodal chiropractic treatment protocol, applied kinesiology chiropractic technique. The outcome measures were a series of 8 standardized psychometric tests given to the children by a certified speech therapist pre- and posttreatment, which evaluate 20 separate areas of cognitive function, including patient- or parent-reported improvements in school performance, social interaction, and sporting activities. Individual and group data showed that at the end of treatment, the 157 children showed improvements in the 8 psychometric tests and 20 areas of cognitive function compared with their values before treatment. Their ability to concentrate, maintain focus and attention, and control impulsivity and their performance at home and school improved. This report suggests that a multimodal chiropractic method that assesses and treats motor dysfunction reduced symptoms and enhanced the cognitive performance in this group of children.

This case report discusses the diagnosis and conservative management of a patient with femoral trochlear dysplasia (FTD) and subacute patellar dislocation. Femoral trochlear dysplasia is characterized by an abnormally shallow trochlear groove. Disengagement of the patella from the shallow femoral trochlea is common in FTD and is a predisposing risk factor to recurrent patellar dislocation and subsequent premature osteoarthrosis. Accurate diagnosis is necessary to prevent recurrent patellar dislocations and damage of the patellofemoral joint cartilage and supporting structures. A 16-year-old male adolescent presented with pain, ecchymosis, and swelling about the right anterior knee approximately one month after a self-described dislocating event. Clinical and imaging findings, including magnetic resonance imaging and ultrasonography, demonstrated evidence of patellar dislocation with previously undiagnosed FTD. After drainage of the knee effusion at a local hospital, the patient underwent a chiropractic treatment protocol consisting of stabilization with patellar tracking orthosis, customized orthotic support, and various muscular stabilization and strengthening exercises. After 6 weeks of treatment, the swelling and ecchymosis resolved. The knee ranges of motion were full without pain. Although the hypermobility of the patella demonstrated no interval change, the patient reported improved strength and stability of the right knee. This case highlights a young athlete with subacute patellar dislocation and FTD who responded successfully to conservative management. Conservative stabilization and strengthening protocols improved patient outcome without surgical repair of the underlying FTD. Conservative management of FTD has not been reported and it makes the current case unique. However, the long-term outcome of conservative management is unknown at this point and further studies are necessary to evaluate treatment protocols.

To present an unusual case of chronic myelogenous leukemia (CML) in an adolescent with a complaint of leg pain. Clinical presentation is highlighted and a brief review of the childhood leukemias and common clinical features are outlined. A 16-yr-old black male was seen after suffering from leg and knee pains for 7 months. Exquisite tibial pain, normal radiographs and an abnormal CBC led to the diagnosis of leukemia. Subsequent referral for bone marrow examination confirmed the final diagnosis of chronic myelogenous leukemia. The patient was referred to a pediatric hematologist-oncologist for medical management of his condition. He is currently receiving chemotherapy and the search for a suitable donor for bone marrow transplant is in progress. This case demonstrates the importance of considering one of the more common pediatric malignancies, such as leukemia, in the differential diagnosis of children with musculoskeletal complaints. Chronic myelogenous leukemia accounts for only 3-5% of cases of childhood onset. Its rare incidence in childhood constitutes the basis for this case report.

To describe the importance of correlating symptoms with objective clinical findings and appropriate diagnostic imaging in a patient with traumatic wrist pain. A 17-year-old golfer had persistent left wrist pain of 4 months' duration that began while playing golf. Approximately 1 week after injury, he was diagnosed with a scaphoid fracture and was splinted. He reported that his pain did not decrease with splinting or with subsequent physical therapy, and on dismissal from orthopedic care he could not use the wrist well enough to return to golf. The patient was found to have marked point tenderness at the hamate. Although plain-film radiography was negative, secondary computed tomography of the wrist showed a fracture to the hook of the hamate. A referral was made to an orthopedic surgeon and surgical excision of the hook of the hamate was recommended because of the failure of union at the fracture site. This case shows the significance of follow-up diagnostic imaging in a patient who does not respond as expected. In addition, it stresses the importance of the doctor of chiropractic in the diagnostic process, although the patient may have been treated and released by another physician.

This editorial presents a brief description of the Association of Chiropractic Colleges Educational Conference and Research Agenda Conference, the components of the conference, and long range goals of the peer-review committee.

This case study presents the delayed diagnosis, surgical management, and postsurgical follow-up of an intra-articular osteoid osteoma of the left femoral neck in an 18-year-old male patient with special emphasis on discussing the confusing clinical and imaging characteristics of the lesion often associated with delayed diagnosis and increased morbidity. The patient initially complained of left knee and hip pain at which time conventional radiographs were reported as normal. In magnetic resonance imaging studies, the diagnosis of intra-articular osteoid osteoma of the femoral neck was suggested; however, working diagnoses also included old posttraumatic injury, hip infection, juvenile chronic arthritis, and posttraumatic arthritis. The correct diagnosis was made 31 months after presentation based on computed tomography depiction of the lesion. Pain associated with the tumor was alleviated after surgical removal with minimal loss of motion and muscle atrophy 19 months after tumor excision. Clinicians and radiologists should be aware of the potentially confusing clinical and imaging findings associated with intra-articular osteoid osteoma of the hip. Early correlation between juvenile joint pain and imaging abnormalities as well as the use of thin slice computed tomography imaging could reduce the time to diagnose the lesion and prevent unnecessary morbidity.