Abstract Objective The objective was to develop a clinical practice guideline on the management of neck pain–associated disorders (NADs) and whiplash-associated disorders (WADs). This guideline ...replaces 2 prior chiropractic guidelines on NADs and WADs. Methods Pertinent systematic reviews on 6 topic areas (education, multimodal care, exercise, work disability, manual therapy, passive modalities) were assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR) and data extracted from admissible randomized controlled trials. We incorporated risk of bias scores in the Grading of Recommendations Assessment, Development, and Evaluation. Evidence profiles were used to summarize judgments of the evidence quality, detail relative and absolute effects, and link recommendations to the supporting evidence. The guideline panel considered the balance of desirable and undesirable consequences. Consensus was achieved using a modified Delphi. The guideline was peer reviewed by a 10-member multidisciplinary (medical and chiropractic) external committee. Results For recent-onset (0-3 months) neck pain, we suggest offering multimodal care; manipulation or mobilization; range-of-motion home exercise, or multimodal manual therapy (for grades I-II NAD); supervised graded strengthening exercise (grade III NAD); and multimodal care (grade III WAD). For persistent (>3 months) neck pain, we suggest offering multimodal care or stress self-management; manipulation with soft tissue therapy; high-dose massage; supervised group exercise; supervised yoga; supervised strengthening exercises or home exercises (grades I-II NAD); multimodal care or practitioner’s advice (grades I-III NAD); and supervised exercise with advice or advice alone (grades I-II WAD). For workers with persistent neck and shoulder pain, evidence supports mixed supervised and unsupervised high-intensity strength training or advice alone (grades I-III NAD). Conclusions A multimodal approach including manual therapy, self-management advice, and exercise is an effective treatment strategy for both recent-onset and persistent neck pain.
Abstract Objective The purpose of this study was to develop evidence-based treatment recommendations for the treatment of nonspecific (mechanical) neck pain in adults. Methods Systematic literature ...searches of controlled clinical trials published through December 2011 relevant to chiropractic practice were conducted using the databases MEDLINE, EMBASE, EMCARE, Index to Chiropractic Literature, and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, weak, or conflicting) and to formulate treatment recommendations. Results Forty-one randomized controlled trials meeting the inclusion criteria and scoring a low risk of bias were used to develop 11 treatment recommendations. Strong recommendations were made for the treatment of chronic neck pain with manipulation, manual therapy, and exercise in combination with other modalities. Strong recommendations were also made for the treatment of chronic neck pain with stretching, strengthening, and endurance exercises alone. Moderate recommendations were made for the treatment of acute neck pain with manipulation and mobilization in combination with other modalities. Moderate recommendations were made for the treatment of chronic neck pain with mobilization as well as massage in combination with other therapies. A weak recommendation was made for the treatment of acute neck pain with exercise alone and the treatment of chronic neck pain with manipulation alone. Thoracic manipulation and trigger point therapy could not be recommended for the treatment of acute neck pain. Transcutaneous nerve stimulation, thoracic manipulation, laser, and traction could not be recommended for the treatment of chronic neck pain. Conclusions Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain. Increased benefit has been shown in several instances where a multimodal approach to neck pain has been used.
Abstract Objective The purpose of this manuscript is to provide evidence-informed practice recommendations for the chiropractic treatment of headache in adults. Methods Systematic literature searches ...of controlled clinical trials published through August 2009 relevant to chiropractic practice were conducted using the databases MEDLINE; EMBASE; Allied and Complementary Medicine; the Cumulative Index to Nursing and Allied Health Literature; Manual, Alternative, and Natural Therapy Index System; Alt HealthWatch; Index to Chiropractic Literature; and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, limited, or conflicting) and to formulate practice recommendations. Results Twenty-one articles met inclusion criteria and were used to develop recommendations. Evidence did not exceed a moderate level. For migraine, spinal manipulation and multimodal multidisciplinary interventions including massage are recommended for management of patients with episodic or chronic migraine. For tension-type headache, spinal manipulation cannot be recommended for the management of episodic tension-type headache. A recommendation cannot be made for or against the use of spinal manipulation for patients with chronic tension-type headache. Low-load craniocervical mobilization may be beneficial for longer term management of patients with episodic or chronic tension-type headaches. For cervicogenic headache, spinal manipulation is recommended. Joint mobilization or deep neck flexor exercises may improve symptoms. There is no consistently additive benefit of combining joint mobilization and deep neck flexor exercises for patients with cervicogenic headache. Adverse events were not addressed in most clinical trials; and if they were, there were none or they were minor. Conclusions Evidence suggests that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and findings. Evidence for the use of spinal manipulation as an isolated intervention for patients with tension-type headache remains equivocal.
Abstract Objective The purpose of the study was to evaluate if systematic augmented feedback during short sessions of spinal manipulation (SM) training creates a dependency compared with short ...training session characterized by progressive withdrawal of augmented feedback. Methods Forty fourth- and fifth-year chiropractic students enrolled in a 5-year chiropractic program were randomized into 2 groups. The 2 groups performed the same number of SM with a 300-N peak force target on an instrumented device. Baseline assessment consisted of 10 trials without feedback. Three training blocks of 10 SMs were then performed with visual and verbal feedback. For the control group, feedback was always provided. For the experimental group, augmented feedback was provided for each trial of the first training block, 50% of the second block, and 20% of the last training block. A postintervention assessment of 10 trials without feedback was performed, and a retention assessment was conducted 20 minutes later. Results No group main effect was found on biomechanical parameters and error variables. A main effect of learning for the absolute error was observed, suggesting that short sessions of feedback training improve participants’ accuracy. Conclusion The results of the study suggest that feedback scheduling does not influence SM motor performance and learning in clinically experienced students.
Abstract Background context Alterations of the neuromuscular control of the lumbar spine have been reported in patients with chronic low back pain (LBP). During trunk flexion and extension tasks, the ...reduced myoelectric activity of the low back extensor musculature observed during full trunk flexion is typically absent in patients with chronic LBP. Purpose To determine whether pain expectations could modulate neuromuscular responses to experimental LBP to a higher extent in patients with chronic LBP compared with controls. Study design A cross-sectional, case-control study. Patient sample Twenty-two patients with nonspecific chronic LBP and 22 age- and sex-matched control participants. Methods Trunk flexion-extension tasks were performed under three experimental conditions: innocuous heat, noxious stimulation with low pain expectation, and noxious stimulation with high pain expectation. Noxious stimulations were delivered using a contact heat thermode applied on the skin of the lumbar region (L4–L5), whereas low or high pain expectations were induced by verbal and visual instructions. Outcome measures Surface electromyography of erector spinae at L2–L3 and L4–L5, as well as lumbopelvic kinematic variables were collected during the tasks. Pain was evaluated using a numerical rating scale. Pain catastrophizing, disability, anxiety, and fear-avoidance beliefs were measured using validated questionnaires. Results Two-way mixed analysis of variance revealed that pain was significantly different among the three experimental conditions (F2,84=317.5; p<.001). Increased myoelectric activity of the low back extensor musculature during full trunk flexion was observed in the high compared with low pain expectations condition at the L2–L3 level (F2,84=9.5; p<.001) and at the L4–L5 level (F2,84=3.7; p=.030). At the L4–L5 level, this effect was significantly more pronounced for the control participants compared with patients with chronic LBP (F2,84=3.4; p=.045). Pearson correlation analysis revealed that increased lumbar muscle activity in full flexion induced by expectations was associated with higher pain catastrophizing in patients with chronic LBP (r=0.54; p=.012). Conclusions Repeated exposure to pain appears to generate rigid and less variable patterns of muscle activation in patients with chronic LBP, which attenuate their response to pain expectations. Patients with high levels of pain catastrophizing show higher myoelectric activity of lumbar muscles in full flexion and exhibit greater neuromechanical changes when expecting strong pain.
Abstract Objective The aims of this study were to determine whether the application of vibration on a postural lower limb muscle altered the sensorimotor control of its joint as measured by isometric ...force production parameters and to compare present findings with previous work conducted on trunk muscle. Methods Twenty healthy adults were asked to reproduce submaximal isometric plantar flexion under 3 different conditions: no vibration and vibration frequencies of 30 and 80 Hz on the soleus muscle. Time to peak torque, variable error, as well as constant error and absolute error in peak torque were calculated and compared across conditions. Results Under vibration, participants were significantly less accurate in the force reproduction task, as they mainly undershot the target torque. Applying an 80-Hz vibration resulted in a significantly higher negative constant error than lower-frequency vibration (30 Hz) or no-vibration condition. Decreases in isometric force production accuracy under vibration influence were also observed in a previous study conducted on trunk muscle. However, no difference in constant error was found between 30- and 80-Hz vibration conditions. Conclusion The results suggest that acute soleus muscle vibration interferes with plantar flexion torque generation by distorting proprioceptive information, leading to decreases in accuracy of a force reproduction task. Similar results in an isometric trunk extension force reproduction task were found with vibration applied on erector spinae muscle. However, high-frequency vibration applied on soleus muscle elicited higher force reproduction errors than low-frequency stimulation.
Abstract Objective It is believed that systematic modulation of spinal manipulative therapy (SMT) parameters should yield varying levels of physiological responses and eventually a range of clinical ...responses. However, investigation of SMT dose–physiological response relationship is recent and has mostly been conducted using animal or cadaveric models. The main objective of the present study is to investigate SMT dose–physiological response relation in humans by determining how different levels of force can modify electromyographic (EMG) responses to spinal manipulation. Methods Twenty-six participants were subjected to 2 trials of 4 different SMT force-time profiles using a servo-controlled linear actuator motor. Normalized EMG activity of paraspinal muscles (left and right muscles at level T6 and T8) was recorded during and after SMT, and EMG values were compared across the varying levels of force. Results Increasing the level of force yielded an increase in paraspinal muscle EMG activity during the thrust phase of SMT but also in the two 250-millisecond time windows after the spinal manipulation impulse. These muscle activations quickly attenuated (500 milliseconds after spinal manipulation impulse). Conclusion The study confirmed the presence of a local paraspinal EMG response after SMT and highlighted the linear relationship between the SMT peak force and paraspinal muscle activation.
Abstract Objective Teaching spinal manipulation (SM) is a fundamental aspect of chiropractic training. Recent works have identified various biomechanical variables as indicators of SM performance and ...learning. However, only data from cross-sectional studies are available, limiting conclusions regarding the persistence of SM performance over the years. Therefore, the main objective of this investigation was to quantify the evolution of biomechanical parameters of SM over a 5-year learning period. Methods Thirty-three students enrolled in a chiropractic program participated in the present study. They were tested each year at the beginning of each fall semester by performing 10 SMs on an instrumented manikin while standing on a force plate. The procedure allowed us to measure various force-time parameters. Results Overall, significant time effects were noted for most dependent variables. The results indicated rapid improvement in the peak force applied and the rate of force production during the first 2 years. Time to peak force decreased drastically during the first year, whereas preload forces reached satisfactory levels during the third year. When various force-time requirements of bimanual task components were met, learners significantly reduced trial-to-trial variability of SM peak and preload forces, indicating automaticity of performance. Although global coordination improved in all learning processes, it was only in the later phase that learners reached values approaching those of experts. Conclusion Overall, these results highlighted the importance of considering learning principles in the development of didactic strategies related to SM motor skills.
Abstract Objective The main objective of this report is to present an innovative research tool that will provide the opportunity to study fundamental aspects of the spinal manipulation ...dose-physiological response relation in humans. Methods A servo-controlled linear actuator motor was developed to simulate spinal manipulative therapy. Coefficient of multiple correlations was calculated to assess the degree of similarity between each measured force curves, whereas precision was obtained by comparing resulting peak force and time-to-peak force to the target curves. Results The coefficient of multiple correlations calculations showed that repeatability was very high with all correlation values over 0.98. Precision was also very high with average differences in peak force and time-to-peak force of less than 3 N and less than 5 milliseconds. Conclusion The tool was designed to optimize precision, repeatability, and safety in the delivery of force to the spine in humans. It offers a unique opportunity to study dose-response relationship for several spinal manipulation parameters such as peak force, time-to-peak force, and preload.
Abstract Objective The aim of this clinical trial was to evaluate the effect of 15 myofascial therapy treatments using ischemic compression on shoulder trigger points in patients with chronic ...shoulder pain. Methods Forty-one patients received 15 experimental treatments, which consisted of ischemic compressions on trigger points located in the supraspinatus muscle, the infraspinatus muscle, the deltoid muscle, and the biceps tendon. Eighteen patients received the control treatment involving 15 ischemic compression treatments of trigger points located in cervical and upper thoracic areas. Of the 18 patients forming the control group, 16 went on to receive 15 experimental treatments after having received their initial control treatments. Outcome measures included a validated 13-question questionnaire measuring shoulder pain and functional impairment. A second questionnaire was used to assess patients' perceived amelioration, using a scale from 0% to 100%. Outcome measure evaluation was completed for both groups at baseline after 15 treatments, 30 days after the last treatment, and finally for the experimental group only, 6 months later. Results A significant group × time interval interaction was observed after the first 15 treatments, indicating that the experimental group had a significant reduction in their Shoulder Pain and Disability Index (SPADI) score compared with the control group (62% vs 18% amelioration). Moreover, the patients perceived percentages of amelioration were higher in the experimental group after 15 treatments (75% vs 29%). Finally, the control group subjects significantly reduced their SPADI scores after crossover (55%). Conclusion The results of this study suggest that myofascial therapy using ischemic compression on shoulder trigger points may reduce the symptoms of patients experiencing chronic shoulder pain.
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