Journal of Chiropractic Medicine- Volume 9(2); June 2010

Journal of Chiropractic Medicine (2010) 9, 47–48

www.journalchiromed.com

Editorial

The Journal of Chiropractic Medicine and selected specialties in the chiropractic profession Abstract This article presents a brief description of the specialty chiropractic groups that are affiliated with the Journal of Chiropractic Medicine: American Academy of Chiropractic Physicians (AACP), The American Chiropractic Board of Sports Physicians (ACBSP), The College on Forensic Sciences (CFS), and The International Academy of Chiropractic Neurology (IACN). © 2010 National University of Health Sciences.

The Journal of Chiropractic Medicine (JCM) is a peer-reviewed journal dedicated to disseminating information to the chiropractic profession. The journal focuses on providing practical information for the practicing doctor of chiropractic and especially favors case reports and reviews of the literature. Since the journal began in 2002, it continues to grow and increase in quality and readership. The JCM contents are indexed in PubMed, the Table 1

Cumulative Index to Nursing and Allied Health Literature, the Manual Alternative and Natural Therapy Index System, and the Index to the Chiropractic Literature. The JCM serves a variety of specialty groups in the chiropractic profession—from primary care and sports medicine to forensic sciences and neurology. The American Academy of Chiropractic Physicians (AACP) was the first professional society affiliated

Professional societies that are affiliated with the JCM and offer the journal as a membership benefit

Professional Description Society

Web Site

AACP

www.aacp.net

ACBSP

CFS

IACN

The AACP is a professional organization representing chiropractic physicians. Its mission is to preserve, protect, improve, and promote the chiropractic medical profession and the services of chiropractic physicians for the benefit of the patients they serve. The ACBSP is a professional nonprofit organization that promotes the highest standards of excellence and clinical competence for chiropractors specializing in sports medicine and physical fitness. The CFS is a not-for-profit organization that provides graduate and postdoctoral needs-based educational activities in forensic sciences (application of medical facts to legal issues or proceedings) for forensic examiners. The IACN is a professional nonprofit organization that promotes those principles, policies, and practices that seek the attainment of the highest order of excellence in clinical neurologic skills by doctors of chiropractic to best serve humankind.

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2010.04.003

www.acbsp.com

www.forensic-sciences.org

www.iacn.org

48 with the JCM, beginning in 2002. The American Chiropractic Board of Sports Physicians (ACBSP) began offering its members the JCM in 2007, the College on Forensic Sciences (CFS) included the JCM as a membership benefit in September 2009, and the International Academy of Chiropractic Neurology (IACN) began offering the JCM as a membership benefit in December 2009. Each of these professional chiropractic societies offers valuable services and membership benefits (Table 1). It is important to include findings from the field of chiropractic practice in the scientific literature, especially those topics related to the chiropractic specialties. The readership of the JCM and the members of each of these professional societies are encouraged to submit their scholarly articles to the JCM through the Web site www.JournalChiroMed. com. The JCM will continue to maintain its editorial independence and scientific integrity, which will ensure that the contents of this peer-reviewed, PubMed-indexed journal will be of the highest quality for its readers. We look forward to your participation in contributing to the scientific literature.

Editorial

Funding sources and potential conflicts of interest No funding was received for this article. Disclosure statement: Claire Johnson, DC, MSEd, is the editor of the JCM; a full-time professor at the National University of Health Sciences; Peer Review Chair for the Association of Chiropractic Colleges; a Board member of NCMIC; and a member of the American Chiropractic Association, ACBSP, International Chiropractors Association, Association for the History of Chiropractic, Counsel of Science Editors, American Public Health Association, Committee on Publication Ethics, World Association of Medical Editors, American Medical Writers Association, and American Educational Research Association. Claire Johnson DC, MSEd Editor, JCM Professor, National University of Health Sciences Lombard, IL E-mail address: [email protected]

Journal of Chiropractic Medicine (2010) 9, 49–59

www.journalchiromed.com

Original articles

Assessment of patients with neck pain: a review of definitions, selection criteria, and measurement tools Victoria Misailidou PT, MS a,b,⁎, Paraskevi Malliou PhD c , Anastasia Beneka PhD d , Alexandros Karagiannidis PT, MS e , Georgios Godolias MD, PhD f a

Laboratory Instructor, Department of Physical Therapy, Technological Educational Institute of Thessaloniki, 57400, Thessaloniki, Greece b Postgraduate Student, Department of Physical Education and Sport Science, Democritus University of Thrace, 69100, Komotini, Greece c Associate Professor, Department of Physical Education and Sport Science, Democritus University of Thrace, 69100, Komotini, Greece d Assistant Professor, Department of Physical Education and Sport Science, Democritus University of Thrace, 69100, Komotini, Greece e Staff Physical Therapist, Department of Physical Therapy, AHEPA University Hospital, 54636, Thessaloniki, Greece f Professor, Department of Physical Education and Sport Science, Democritus University of Thrace, 69100, Komotini, Greece Received 28 October 2009; received in revised form 21 December 2009; accepted 7 March 2010 Key indexing terms: Neck pain; Assessment; Pain measurements; Patient outcome assessment; Treatment outcome

Abstract Objective: The purpose of this literature review was to synthesize the existing literature on various definitions, classifications, selection criteria, and outcome measures used in different studies in patients with neck pain. Methods: A literature search of MEDLINE and CINAHL through September 2008 was performed to gather articles on the reliability, validity, and utility of a wide variety of outcome measurements for neck pain. Results: Different types of definitions appear in the literature based on anatomical location, etiology, severity, and duration of symptoms. Classifications according to severity and duration of pain and the establishment of selection criteria seem to play a crucial role in study designs and in clinical settings to ensure homogeneous groups and effective interventions. A series of objective tests and subjective self-report measures are useful in assessing physical abilities, pain, functional ability, psychosocial well-being, general health status, and quality of life in patients with neck pain. Self-administered questionnaires are commonly used in clinical practice and research projects.

⁎ Corresponding author. Metsovou 9, 54636, Thessaloniki, Greece. Tel.: +30 2310213468; fax: +30 2310204995. E-mail address: [email protected] (V. Misailidou). 1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2010.03.002

50

V. Misailidou et al. Conclusions: Because of multidimensionality of chronic neck pain, more than just one index may be needed to gain a complete health profile of the patient with neck pain. The instruments chosen should be reliable, valid, and able to evaluate the effects of treatment. © 2010 National University of Health Sciences.

Introduction The introduction of evidence-based practice in the last years of the 20th century stimulated the development and research of an enormous number of instruments to assess many types of patient variables.1 Now, more rehabilitation professionals are familiarizing themselves with the use of outcome measures in clinical practice and for research purposes. 2,3 Outcomes assessment is primarily designed to establish baselines, to evaluate the effect of an intervention, to assist in goal setting, and to motivate patients to evaluate their treatment.4,5 When used in a clinical setting, it can enhance clinical decision making and improve quality of care.6 Many patients with neck pain visit health care clinics seeking treatment of their problem, and health professionals aim to use the best available evidence for making decisions about therapy. The best evidence comes from randomized clinical trials, systematic reviews, and evidence-based clinical practice guidelines.7 One objective of this study is to provide to health care professionals who work with patients with neck pain some useful information about the existing outcome measures and the criteria for selecting the most appropriate ones according to treatment goals. Researchers can use this information to form homogeneous groups of participants and select the right measures for various research studies. 8 The purpose of this study was to conduct a critical review on assessment and measurement tools and various definitions and classifications of the existing literature on neck pain. The main results of a search looking at the evidence regarding the reliability, validity, and utility of objective tests and self-reported impairment and disability assessment in people with neck pain are presented here.

Methods and results For this study, we considered neck pain to be a major or minor symptom of disease or disorder that occurs above the shoulder blades.9 In that aspect, it can be a component of headaches, temporomandibular joint disorder, sprain/strain, tumors, fractures, various infectious diseases, inflammatory arthropathies, and fibromyalgia. We excluded articles with neck pain definitions found in the literature associated with serious local

pathology or systemic disease. We searched MEDLINE and CINAHL and reviewed all relevant articles through September 2008, using neck pain, and measurements, functional ability, exercises, and assessment as search words and referring to neck pain as non-specific, soft tissue, or mechanical neck pain. Additional articles were identified from references of selected articles. Only articles written in English were included in this report. Eighty-six articles were selected for inclusion for this report.

Discussion Definitions of neck pain Different types of definitions appear in the literature based on anatomical location, etiology, severity, and duration of symptoms. Definitions based on anatomical location The International Association for the Study of Pain (IASP) in its classification of chronic pain defines cervical spinal pain as pain perceived anywhere in the posterior region of the cervical spine, from the superior nuchal line to the first thoracic spinous process. 10 This is clearly a topographic definition, and it states that neck pain is usually perceived posteriorly. This is consistent with patients' notions of neck pain. Pain to the front of the cervical spine is usually described as pain in the throat and not as neck pain. 11 Bogduk and McGuirk 11 also suggest that neck pain may be subdivided into upper cervical spinal pain and lower cervical spinal pain, above or below an imaginary transverse line through C4. From upper cervical segments, pain can usually be referred to the head, whereas from lower cervical segments, pain can be referred to the scapular region, anterior chest wall, shoulder, or upper limb. They also define suboccipital pain as the pain located between the superior nuchal line and C2, an area that appears to be the source of cervicogenic headache. In that aspect, the division of neck pain into suboccipital and upper and lower cervical pain may be important for clinicians and researchers in recognizing the area of the source of pain and trying to determine the possible causes.

Neck pain assessments and measurements The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders describes neck pain as pain located in the anatomical region of the neck with or without radiation to the head, trunk, and upper limbs. 12 It defines the posterior neck region from the superior nuchal line to the spine of the scapula and the side region down to the superior border of the clavicle and the suprasternal notch. The IASP definition limits the pain symptoms down to T1 vertebra and does not include the various regions that neck pain can be referred to, whereas the Neck Pain Task Force includes in its definition the areas of referral destination. Chronic neck pain is described as an often widespread sensation with hyperalgesia in the skin, ligaments, and muscles on palpation and in both passive and active movements in neck and shoulder area. 13 Etiology of symptoms In many studies, 12 the authors consider that all neck pain has a local pathologic cause that can be identified and treated. Others consider neck pain as a primarily nonorganic problem with psychosocial roots. 14 Some authors tend to categorize neck pain based on precipitating factors such as whiplash-associated neck pain, occupational neck pain, sports-related neck pain, and nonspecific neck pain. 15-18 Bogduk and McGuirk 11 argue that the causes of common neck pain are not known; the only recognizable causes are due to serious but rare conditions like tumors, fractures, etc. These varied approaches often imply different etiologic models for neck pain. When a pathoanatomical diagnosis of neck pain cannot be made, the IASP recommends the term cervical spinal pain of unknown origin to be applied.10 The Australian Acute Musculoskeletal Pain Guidelines Group19 also recommended for neck pain with no known cause the term idiopathic neck pain. Severity of symptoms The Neck Pain Task Force20 recommends a clinical classification in 4 grades according to severity of pain: grade I is neck pain with no signs or symptoms of major structural pathology and no or minor interference with activities of daily living, grade II is neck pain with no signs or symptoms of major structural pathology but major interference with activities of daily living, grade III is neck pain with no signs or symptoms of major structural pathology but with neurologic signs of nerve compression, and grade IV is neck pain with signs of major structural pathology. Major structural pathologies include, but are not limited to, fractures, spinal cord injuries, infections, neoplasm, or systemic diseases. To develop this taxonomy, the Neck Pain Task

51 Force was guided by the classification system developed by Von Korff et al 21 and by the Quebec Task Force on Whiplash-Associated Disorders. 15 This type of initial assessment seems to help the clinician determine the best evidence-based intervention. The above classification appears also very useful when used in research projects because it can ensure the homogeneity of groups in terms of severity of symptoms. In many studies 20 on neck pain, the researchers failed to show how effective their interventions are because they used patients with grade I pain that usually do not seek health care and the improvements they had were minimal. In addition, if a patient is classified as grade III, he or she should be referred for further medical management for nerve root compression. 11,20 Bogduk and McGuirk 11 state that the distinction between somatic referred pain and radicular pain is sometimes difficult to make, but the radicular pain is associated with neurologic signs and it is usually accompanied by paresthesia, numbness, weakness, and/or loss of reflexes. Patients with neurologic signs are a separate entity in terms of diagnosis and management and should be excluded11,20 from research projects or best evidence treatment interventions on neck pain unless the neurologic signs have subsided and the patient can now be classified as grade II. Duration of symptoms Another type of classification proposed by IASP 22 is based on the duration of neck pain. Acute neck pain usually lasts less than 7 days, subacute neck pain lasts more than 7 days but less than 3 months, and chronic neck pain has a duration of 3 months or more. The same time frames but with different terminology are proposed by the Neck Pain Task Force 12 ; they propose the term transitory neck pain instead of acute, short-duration for subacute, and long-duration for chronic neck pain. Investigators11 usually do not distinguish subacute neck pain from acute or chronic pain. In the literature, there are no studies showing a difference in response to the same treatment between patients with subacute neck pain and those with either acute or chronic neck pain. Therefore, it seems correct to identify and distinguish only acute and chronic neck pain.11 The evidence for acute neck pain is distinctly different from that for chronic neck pain; establishing which of the 2 the patient has predicates what interventions are appropriate. Selection criteria Study samples must be selected with care and health care providers should clearly define the population of

52 persons with neck pain. This is very important because the predictive outcome of a test is highly dependent and validated on the population in which it is intended to be used. 6,8 Neck pain is multifactorial in its etiology and in its impact on the individual. The origin and exact pathophysiologic mechanisms of chronic neck pain often remain obscure because trauma or severe degenerative conditions at working age are found only in a few cases.23 Excessive physical strain may cause microtrauma in connective tissues, and psychosocial stress may lead to increased muscular tension and pain.24 Inclusion criteria based on symptoms and clinical diagnosis Most studies 12,25,26 select their participating patients on the basis of their clinical diagnosis. This can be “neck pain” or “chronic neck pain” or “chronic nonspecific neck pain.” Inclusion criteria based on symptoms include duration of pain, pain intensity, and frequency of symptoms. For example, in a study by Dziedzic et al, 25 the selection of patients was based on “chronic or recurrent neck or shoulder pain of at least 3 months duration with or without arm pain.” Another study recruited patients with constant or frequently occurring neck pain for more than 3 or 6 months. 13 Other inclusion criteria The age of the participants may vary from 18 to 70 years. In some studies, the target population consists only of people of working age who are employed at various jobs.23 Epidemiologic studies have shown that women experience chronic neck pain more often than men; and therefore, patient populations commonly consist of women. 23,27 Pain perception in response to exercise appears to be influenced by sex differences; and therefore, some researchers 23 include only female participants in their studies. O'Leary et al 27 included in their study only patients that scored 5 or greater of 50 on the Neck Disability Index (NDI), which assesses perceived pain and physical disability. Furthermore, most authors23,25,27 mention that participants should be motivated for rehabilitation and able to comply with a treatment schedule to be included in studies. Exclusion criteria Exclusion criteria include serious injury, tumor, infection, or other nonmechanical cause of neck pain.23,25-27 Other studies exclude clinically significant herniated disk with positive radicular arm pain, spinal fractures, and recent cervical surgery. Furthermore,

V. Misailidou et al. shoulder diseases (tendonitis, bursitis, capsulitis), inflammatory rheumatic diseases, severe psychiatric illness, and pregnancy are typically excluded from research studies.23 Participants are usually excluded if they have neck pain from nonmusculoskeletal causes, signs of neurologic involvement, or any other medical disorder that would contraindicate physical exercise.23,25 The source of study participants must be well described and the inclusion and exclusion criteria clearly outlined and appropriate to ensure that the study population is representative of the population of interest. The diagnostic criteria must be clear, specific, and relevant. Some studies 13,28 evaluate the effectiveness of different treatments in patients with minor pain. These subjects often do not seek help from their health care providers; and if they do, their symptoms are easily treated with ergonomic advice and home exercise program. Rehabilitation research therefore needs to be targeted at the right patient population. If patients are entered into a study only on the basis of severe current neck pain, many may experience spontaneous relief from their symptoms over the course of the study, as has been observed in control groups in several randomized studies. 13 This places importance on the methodology of patient selection. The block randomization procedure that some researchers use ensures that patients with equal severity of neck symptoms are present in each group. 13,26 However, this method of sampling requires an efficient number of available participants simultaneously, which is not always possible. Clinical assessment and outcome measurement When taking a patient's history, the system of “red flags” allows clinicians to rule out serious pathology; this system is widely used and accepted in the literature. 11,28,29 The suggested red flags by the Neck Pain Task Force 28 include, but are not limited to, pathologic fractures, neoplasm, systemic inflammatory diseases, infections, cervical myelopathy, and previous neck surgery. After ruling out serious underlying structural disease and establishing the diagnosis of nonspecific mechanical neck pain, a series of objective tests and subjective self-report assessments will be conducted in assessing the patient's present status, monitoring the patient's course, and observing response to treatment, and in clinical research. 28 The most common reason patients with symptoms seek treatment is pain. Traditionally, health care professionals have based their evaluation and treatment approach on the biomedical model that views a patient's pain and associated disability merely as

Neck pain assessments and measurements symptoms of underlying tissue pathology. 30 Presently, the multidimensionality of neck pain, as with many chronic musculoskeletal disorders, is fully accepted; and the biopsychosocial model is implemented increasingly in diagnostics and in treatment of patients with neck pain. This model places a complaint of pain into a more holistic context and views the patient's experience of pain and disability as a system that comprises the pain itself, the person's attitudes and beliefs about the pain, elements of psychologic distress experienced, illness behaviors exhibited, and parameters of the social environment in which the person functions. 31,32 Loeser 33 has developed a conceptual model of pain that depicts the strong relationship between somatic dimension, psychologic dimension, and the social dimension in patients with musculoskeletal pain. Tissue damage results in pain perception (somatic dimension). When pain perception leads to suffering, a psychologic dimension is reached. Finally, a social dimension is added when suffering leads to pain behavior preventing the patient from assuming his/ her normal social role. 1 The implication of this is that either multidimensional indexes are required or more than just one index is needed to gain a complete health profile of the patient with neck pain. According to the International Classification of Functioning, Disability, and Health, 34 the relevant domains for examination and evaluation are impairments in body structures and function (pain), disabilities in daily activities and problems in participation (activities of daily living, sport, and work), and external and personal factors (negative cognitions about pain, passive coping strategy, general health perception). The instruments chosen must be reliable, valid and able to evaluate the effect of treatment. Self-assessment of pain, function/disability, general health status Self-administered questionnaires are commonly used in clinical practice and research projects. There is consistent evidence that these questionnaires provide useful information about (a) the impact of neck pain on the patient; (b) the patient's perceived functional ability, deficit, and psychosomatic status; (c) change of the condition over time; and (d) the effectiveness of treatment intervention for both clinicians and patients. 28 After the selection of the participants and their categorization into different intervention programs, researchers or clinicians should select the appropriate measurement tools to evaluate treatment outcomes.

53 Self-assessment pain scales and questionnaires An initial recording of the individual's pain and its characteristics is necessary to draw safe conclusions related to changes. The IASP 22 has described pain as “an unpleasant sensory and emotional experience.” Because pain is a subjective experience, clinicians and researchers rely on what the person reports about his/ her own pain. This approach to assessing pain has its limitations because the accuracy of reports cannot be evaluated against criteria like the mental status or the communication ability of the person. Although the concept of pain as a personal experience is widely accepted, great variation exists in how neck pain is described and considered in the published literature. Pain scales According to the Interactive Guide to Physical Therapist Practice, careful evaluation of the patients' perception of the intensity, quality, and distribution of their pain is important in the assessment of treatment outcomes. There are several methods of pain evaluation used in the clinical setting including verbal, visual, numeric, and semantic differential scales. 35 Simple descriptive scale The simple descriptive scale (SDS), also called the verbal pain report, uses a 4- or 5-point scale based on the patient's selection of a word that best describes current pain intensity. The value of this scale appears to be limited by its lack of sensitivity in detecting small changes in pain intensity. 36 Visual analog scale The visual analog scale (VAS) is a 10-cm line, oriented vertically or horizontally, with one end representing “no pain” and the other end representing “pain as bad as it can be.” The patient is asked to mark a place on the line corresponding to the current pain intensity. The VAS is the most frequently used pain measure because it is simple to use and has good psychometric properties. 29,37-42 Numeric rating scale The numeric rating scale (NRS) is a verbal or written determination of a pain level on a scale from 0 to 10, in which 0 represents no pain and 10 represents excruciating pain. Sternbach has expanded the NRS to a rating from 0 to 100, and the patient is asked to describe current or average pain intensity as a percentage of 100. According to a study by Downie et al, 43 the NRS provides better discrimination of small changes in pain

54

V. Misailidou et al.

intensity than the SDS does. When comparing the VAS with the NRS, some investigators state that the NRS is not as sensitive to patients' ability to express distress; and therefore, they recommend using the VAS because it is better suited to parametric analysis and because it provides a continuous score. 36 Semantic differential scales These are composed of word lists and categories developed by physicians, students, and patients and measure the quality of pain in 3 dimensions: affective, evaluative, and sensory. Words are categorized by whether they describe fear, anxiety, and tension in the pain experience (affective); the overall cognitive experience of pain based on learned behaviors (evaluative); and temporal, spatial, pressure, or thermal characteristics of pain (sensory). Words within each category are ranked in terms of intensity. One of the most popular pain scales that uses word lists and has been adopted for many clinical trials is the McGill Pain Questionnaire (MPQ) and especially the short form (SF-MPQ). 44 Whereas the VAS measures only pain intensity, the SF-MPQ, which includes the VAS, measures also the quality of pain. In general, semantic differential scales are difficult and time consuming to complete and require a higher literacy level and a normal cognitive state. Although they are less convenient to use, they are valuable when a more detailed analysis of a patient's perception of pain is needed, as in a clinical research setting or a pain clinic. Reliability and validity of pain scales The issue of reliability has been addressed in many reports particularly for the VAS and the MPQ. Most of the reports suggest that reliability varies based on

Table 1

the patient groups examined. Generally, the VAS measurements have been found to be both valid and reliable. In many studies, the VAS has been considered to be the most easy to use and is believed to provide the most reliable measurements of pain intensity and is therefore used as the criterion standard against new rating methods. 28 Melzack and Torgeson 44 argue that the MPQ provides reliable, valid, and consistent measurements. The short form also has proven to provide reliable and valid measurements when the intensity of pain is the primary subject of the examination. A major advantage of the MPQ is the fact that it has been validated in many multilingual versions 45 (Table 1). Pain questionnaires Questionnaires that incorporate assessments of pain include the Extended Aberdeen Spine Pain Scale (ASPS), 46 the Bournemouth Questionnaire (BQ), 47 the Cervical Spine Outcomes Questionnaire (CSOQ), 48 the Current Perceived Health 42 Profile (CPH42), 49 the NDI, 42,50-52 the Northwick Park Neck Pain Questionnaire (NPQ), 52 the Problem Elicitation Technique (PET), 52 and the Whiplash Disability Questionnaire (WDQ) 53 (Table 2). The Aberdeen Back Pain Scale was extended to fit to patients with neck and upper back pain, and it measures pain behavior during various activities and rest. Authors suggest that the scale is reliable, valid, and responsive.46 The modified BQ covers the salient dimensions of the biopsychosocial model of pain; and it is reliable, valid, and responsive to clinically significant change in patients with nonspecific neck pain.47,54

Self-report measures of pain characteristics that may be used in neck pain

Measure

Style

Psychometric status

Utility

SDS (verbal pain report)

4- to 5-point scale describes current pain intensity 10-cm line oriented vertically or horizontally Verbal or written scale from 0 to 10 or 0 to 100. Describes pain intensity as a percentage of 100 20 Sets of adjectives to select one in each relevant category. Short form has 15-item adjective checklist and includes VAS and SDS for pain intensity

Lack of sensitivity in detecting small changes Good reliability and validity; criterion standard. Continuous score More sensitive than SDS but less sensitive than VAS in detecting small changes

Measures pain intensity. Simple

VAS NRS

MPQ. Also has short form (SF-MPQ)45

Well-established reliability and validity. Validated in many languages.

Measures pain intensity. Easy to use Measures pain intensity

Measures quality of pain; 3 dimensions: affective, evaluative, and sensory. Includes also pain intensity measures

Neck pain assessments and measurements Table 2

55

Self-assessment questionnaires used for patients with neck pain

Questionnaire ASPS (extended)

46

BQ (modified)47

Constructs measured

Psychometric status

Pain behavior during activities and rest

Extended to fit to neck pain. Reliable, valid, and responsive Reliable, valid, and responsive in nonspecific neck pain Similar to NDI

Neck Pain and Disability Scale57,58

Covers all dimensions of the biopsychosocial model of pain Function/disability; 15 questions of normal daily activities Function/disability; 5 categories from “free of neck trouble” to totally disabled by neck trouble Function/disability

NDI50,59,60

Pain; function/disability; 10 sections

NPQ52 CSOQ48

Pain; function/disability; 10 parameters Pain; function/disability; psychosocial status; health care utilization Function/disability

CNFDS55 Global Assessment of Neck Pain56

PSFS (neck)51 PET52 WDQ53,58 Short Core Neck Pain Questionnaire61 NHANES-ADL (neck)62 CPH4263 Fear-Avoidance Beliefs Questionnaire (neck)64,65 SF-36 Item Health Survey66

Pain; function/disability; psychosocial status Pain; function/disability; psychosocial status Function/disability

Correlates well with CNFDS

Scores strongly correlated with NDI; r = 0.86. Good content validity Criterion standard revalidated in different study populations Similar to NDI High reliability, good validity, and responsiveness to change Very sensitive to functional changes in individual patients Cannot be used in research; no standardization of content (like PSFS) Whiplash specific; ICC = 0.96

Good reliability and validity in mechanical neck pain Function/disability; physical, social, Good reliability and validity in cervical emotional; 16 items of ADLs pain Pain; function/disability; psychosocial ICC = 0.91, a = 0.90. Sensitive to changes status in severity over time Psychosocial status: how physical activity Modified for neck patients. ICC = 0.81, and work affect pain, 16 statements a = 0.90. Good construct validity, medium responsiveness Health-related quality of life physical Measures general health status; widely used and mental components

Self-assessment of functional performance Questionnaires that evaluate functional performance in patients with neck pain include the CSOQ, 48 Copenhagen Neck Functional Disability Scale (CNFDS), 55,56 CPH42, 67 Global Assessment of Neck Pain, 5 6 NDI, 5 0 , 5 1 Neck Pain and Disability Scale,29,41,42,57 NPQ, 42,52,67 Patient-Specific Functional Scale (PSFS) (neck), 51 PET,52 WDQ, 53 Short Core Neck Pain Questionnaire, 61 and the National Health and Nutrition Examination Surveys NHANES-ADL Scale (neck) 62 (Table 2). Pietrobon et al 68 argues that NDI, CNFDS, and NPQ are similar in terms of structure and psychometric properties; but only NDI has been revalidated in heterogeneous study populations and in many languages. The NDI, a neck-specific questionnaire, has been cited in the literature as the criterion standard for many other questionnaires. 69 The PET and PSFS

evaluate problems specific to the individual patient and have the disadvantage that they cannot be used in research because without standardization of content, the scale is different for each patient and comparisons between them are impossible. 70 Self-assessment of psychosocial and general health status The CSOQ, 48 PET,52 WDQ, 53 NHANES-ADL, 62 CPH42, 67 FABQ, 64 and the SF-36 Health Survey66 also assess the psychosocial status of patients with neck pain (Table 2). The CSOQ is a disease-specific questionnaire that assesses pain severity, functional disability, psychologic distress, physical symptoms, health care utilization, and satisfaction. 48 The PET identifies problems that are important to the individual patient including emotional and social items such as anger, frustration, and depression. 52 The NHANES-

56 ADL Scale measures physical, social, and emotional disability in patients with a cervical impairment. 62 The SF-36 Health Survey is a generic questionnaire that measures the general health status and includes physical and mental components. It is a quality of life measure used in many research studies. Reliability and validity of pain and functional performance questionnaires Most self-assessment questionnaires are more sensitive in detecting health improvement than deterioration. The NDI discriminates between those who improved or deteriorated and, as expected, does not detect change in score in those who remained stable. 42 The NDI, a neckspecific questionnaire, has been cited in the literature as the criterion standard for many other questionnaires and is the most valid of the tools reported. 41,50,52,69 The ASPS, CSOQ, CPH42, and NDI were all responsive to change with some variation. 46,48 The CNFDS was tested on patients with chronic neck pain and showed moderate to good validity. 55 The CSOQ and the CNFDS both showed good reliability. 48,55 Assessing physical abilities Range of motion of the cervical spine Studies reporting range of motion (ROM) include intersegmental ROM of the cervical spine and passive and active ROM of the neck measured in patients with neck pain and in controls. Intersegmental cervical spine motion, tested by physical therapists, had slight to moderate interrater reliability (κ = 0.05-0.61). 71-73 Interrater examination reliability for passive cervical ROM has also been shown as slight to moderate. 29,71 Active ROM of the cervical spine can be visually estimated by clinicians or measured with external devices. 40 ,74-80 Only one of the studies for active ROM of the neck used a criterion standard (radiography in asymptomatic subjects) as a comparison. 79 Active ROM of the neck estimated visually was as reliable as using an external device for intrarater and interrater reliability. 28 The variations in ratings were about 10° for intrarater and 20° for interrater measurements irrespective of method used. 80 Measurements of protraction and retraction of the head showed less reliability compared with flexion, extension, side bending, or rotation of the head. 76,77 Patients with neck pain had slightly decreased active ROM when compared with individuals with no neck pain, but there was a large degree of overlap between groups. 75,76 Chronic whiplash-associated disorders (WAD) patients had significantly lower volitional

V. Misailidou et al. ROM in the cervical spine compared with controls. 79 It appears that functional active ROM of the neck is used widely as a diagnostic tool in many studies regarding patients with neck pain. It is also used in research as an assessment tool to test the usefulness of various treatment interventions. Interrater and intrarater reliability in active ROM measurements is moderate with or without external devices especially for neck flexion, extension, side bending, and rotation. Muscle strength and endurance Muscle testing of the neck and upper extremity for diagnostic purposes had consistent slight to moderate interexaminer reliability (κ ≤ 60) in patients with neck pain.40,81 There is some evidence that patients with chronic neck pain have slightly lower neck strength compared with control subjects. 75 In subjects with neck pain, self-reported pain and disability ratings showed no correlation with strength measurements. 29,75,82 One study evaluated neck muscle endurance in patients with WAD compared with age-matched healthy controls. 83 Cervical flexor endurance tested in a supine position could distinguish well between WAD patients and the controls. Muscle endurance measurement by electromyography for repeated forward flexion of the arm tested in people with neck pain and myalgia compared with symptom-free subjects was significantly lower. 82 Palpation of trigger and tender points Assessments of trigger points around the neck by clinicians have fair to moderate interrater reliability (κ = 0.24-0.56) in patients with acute or chronic neck pain. 81 In a study with patients with chronic neck pain, using an algometer increased interrater reliability for trigger point examination from moderate to excellent. 77 When palpation around the neck in patients and nonpatients was tested against a criterion standard (pain elicitation on physical examination), the sensitivity and specificity for trigger points were about 80% for both.84,85 Objective functional tests: lifting, stepping, and walking tests There is some evidence from a construct validity study that patients with chronic neck pain and high neck pain intensity during functional testing have low performance. 86 Limitations There are limitations to this study. The computerized search included only MEDLINE and CINAHL, and all

Neck pain assessments and measurements searches were limited to English-language studies. It is possible that other relevant outcome measures were not identified based upon the search terms and strategies that we used. This article is a qualitative review that summarizes and critically synthesizes the relevant findings in a narrative fashion with its inherent limitations. Because our focus was not on a single research question, we did not follow the strict criteria to evaluate the methodological quality that most systematic reviews use. Each study that was identified through the literature search was evaluated for inclusion based on the relevance of its context to the purpose of our study and not on level of evidence.

Conclusion Different types of neck pain definitions appear in the literature based on anatomical location, etiology, severity, and duration of symptoms. Classification according to severity and duration of symptoms and the establishment of clearly outlined inclusion and exclusion criteria help researchers to form homogeneous groups representative of the population under study and also help clinicians to apply the best evidence-based treatment. The multidimensionality of chronic neck pain is fully accepted, and the biopsychosocial model is implemented increasingly in diagnostics and the treatment of patients with neck pain. Outcome measures assessing patients with neck pain are used widely in research and in clinical settings to establish baselines, to evaluate the effect of an intervention, to assist in goal setting, and to motivate patients to evaluate their treatment. Because of the multifactorial nature of chronic neck pain, either multidimensional indexes or more than one index may be needed to gain a complete health profile of the patient with neck pain. The instruments used including clinical tests and selfadministered questionnaires should be reliable, valid, and able to evaluate the effect of treatment.

Funding sources and potential conflicts of interests The authors reported no funding sources or conflicts of interest.

References 1. Swinkels RA, Oostendorp RA. Outcomes assessment and measurement in spinal musculoskeletal disorders (chapter 41). In: Boyling J, Jull G, editors. Grieve's modern manual therapy: the vertebral column. 3rd ed. London: Churchill Livingstone; 2005. p. 591-601.

57 2. Kay TM, Myers AM, Huijbregts MPJ. How far have we come since 1992? A comparative study of physiotherapists' use of outcome measures. Physiother Can 2001;53:268-75. 3. Huijbregts MPJ, Myers AM, Kay TM, Gavin TS. Systematic outcome measurement in clinical practice: challenges experienced by physiotherapists. Physiother Can 2002;54: 25-31. 4. Liebenson C, Yeomans S. Outcome assessment in musculoskeletal medicine. Man Ther 1997;2(2):67-74. 5. Petty NJ, Moore AP. Principles of neuromusculoskeletal treatment and management: a guide for therapists. London: Churchill Livingstone; 2004. 6. Finch E, Brooks D, Stratford P, Mayo N. Physical rehabilitation outcome measures: a guide to enhanced clinical decision making. 2nd ed. Toronto (ON: Canadian Physiotherapy Association; 2002. 7. Maher CG, Herbert RD, Moseley AM, Sherrington C, Elkins M. Critical appraisal of randomized trials, systematic reviews of randomized trials and clinical practice guidelines (Chapter 42). In: Boyling J, Jull G, editors. Grieve's modern manual therapy: the vertebral column. 3rd ed. London: Churchill Livingstone; 2005. p. 603-14. 8. Malliou P, Gioftsidou A, Beneka A, Godolias G. Measurements and evaluations in low back pain patients. Scand J Med Sci Sports 2006;16:219-30. 9. Bliss SJ, Flanders SA, Saint S. Clinical problem-solving. A pain in the neck. N Engl J Med 2004;350:1037-42. 10. Merskey H, Bogduk N, editors. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle: IASP Press; 1994. p. 11. 11. Bogduk N, McGuirk B. Management of acute and chronic neck pain: an evidence based approach. Pain research and clinical management. 1st ed. Philadelphia: Elsevier; 2006. p. 3-20. 12. Guzman J, Hurwitz EL, Carroll LJ, Haldeman S, Cote P, Carragee EJ, et al. A new conceptual model of neck pain. Linking onset, course, and care: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33(4S):S14-S23. 13. Ylinen J. Physical exercises and functional rehabilitation for the management of chronic neck pain. Eura Medicophys 2007;43: 119-32. 14. Ariens G, van Mechelen W, Bongers P, Bouter LM, van der Wal G. Psychosocial risk factors for neck pain: a systematic review. Am J Ind Med 2001;39:180-93. 15. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientific monograph of the Quebec Task Force on whiplash-associated disorders: redefining “whiplash” and its management. Spine 1995;20:1S-73S. 16. Borghouts JA, Koes BW, Bouter LM. The clinical course and prognostic factors of non-specific neck pain: a systematic review. Pain 1998;77:1-13. 17. Dorshimer GW, Kelly M. Cervical pain in the athlete: common conditions and treatment. Prim Care 2005;32:231-43. 18. Bongers PM, Ijmker S, Van Den Heuvel S. Epidemiology of work related neck and upper limb problems: psychosocial and personal risk factors (part I) and effective interventions from a bio behavioral perspective (part II). J Occup Rehabil 2006: 279-302. 19. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain: a

58

20.

21. 22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33. 34. 35.

36.

V. Misailidou et al. guide for clinicians. Brisbane: Australian Academic Press; 2004. Available from http://www.nhmrc.gov.au. Guzman J, Haldeman S, Carroll L, et al. Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. Spine 2008;33 (4S):S199-S233. Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992;50:133-49. International Association for the Study of Pain (IASP). IASP Task Force for Taxonomy. Pain Terminology. Seattle: IASP; 2004. Ylinen J, Takala EP, Nykanen M, Hakkinen A, Malkia E, Pohjolainen T, et al. Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial. JAMA 2003;289(19):2509-16. Sjogaard G, Lundberg U, Kadefors R. The role of muscle activity and mental load in the development of pain and degenerative processes at the muscle cell level during computer work. Eur J Appl Physiol 2000;83:99-105. Dziedzic K, Hill J, Lewis M, Sim J, Daniels J, Hay EM. Effectiveness of manual therapy or pulsed shortwave diathermy in addition to advice and exercise for neck disorders: a pragmatic randomized controlled trial in physical therapy clinics. Arthritis Rheum 2005;53(2):214-22. Hoving JL, Koes BW, DeVet H, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. Ann Intern Med 2002;136:713-22. O'Leary S, Falla D, Hodges P, et al. Specific therapeutic exercise of the neck induces immediate local hypoalgesia. J Pain 2007;8(11):832-9. Nordin M, Carragee E, Hogg-Johnson S, et al. Assessment of neck pain and its associated disorders. Results of the bone and joint decade 2000-2010 Task Force on neck pain and its associated disorders. Spine 2008;33(suppl):S101-22. Ylinen J, Salo P, Nykanen M, Kautiainen H, Hakkinen A. Decreased isometric neck muscle strength in women with chronic neck pain and the repeatability of neck strength measurements. Arch Phys Med Rehabil 2004;85:1303-8. Jones MA, Edwards I, Gifford L. Conceptual models for implementing biopsychosocial theory in clinical practice. Man Ther 2002;7(1):2-9. Watson P, Kendall N. Assessing psychosocial yellow flags. In: Gifford L, editor. Topical issues in pain 2: biopsychosocial assessment and management. Relationships and pain. Cornwall (UK): CNS press; 2000. p. 111-29. Henderson M, Bass C. Chronic pain: the role of psychosocial factors in common musculoskeletal disorders. Psychiatry 2006;5(2):52-6. Loeser JD. Disability, pain and suffering. Clin Neurosurg 1989;35:398-408. World Health Organization. International classification of function, disability and health: ICF. Geneva: WHO; 2001. Echternach JL. Management of the individual with pain, parts 1 and 2. PT Magazine (article on the Internet). Nov-Dec 1996. Available from http://iweb.apta.org/Purchase/ProductDetail. aspx?Product_code=LMS-16. Good M, Stiller C, Zauszniewski JA, Anderson GC, StantonHicks M, Grass JA. Sensation and distress of pain scales: reliability, validity, and sensitivity. J Nurs Meas 2001;9(3): 219-38.

37. Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 1983;17:45-56. 38. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med 2001;8:1153-7. 39. Gonzalez T, Balsa A, Sainz DM, Zamorano E, Gonzales I, Martin-Mola E. Spanish version of the Northwick Park Neck Pain Questionnaire: reliability and validity. Clin Exp Rheumatol 2001;19:41-6. 40. Wainner RS, Fritz JM, Boninger M, Irrgang JJ, Delitto T, Allison SC. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine 2003;28:52-62. 41. Bicer A, Yazici A, Camdeviren H, Erdogan C. Assessment of pain and disability in patients with chronic neck pain: reliability and construct validity of the Turkish version of the neck pain and disability scale. Disabil Rehabil 2004;26:959-62. 42. Wlodyka-Demaille S, Poiraudeau S, Catanzariti JF, Rannou F, Fermanian J, Revel M. The ability to change of three questionnaires for neck pain. Spine 2004;71:317-26. 43. Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with pain rating scales. Ann Rheum Dis 1978;37:378-81. 44. Melzack R, Torgerson W. On the language of pain. Anesthesiology 1971;34:50-9 Reprinted in “The McGill Pain Questionnaire” from description to measurement. Anesthesiology 2005; 103:199-202. 45. Georgoudis G, Watson P, Oldham J. The development and validation of a Greek version of the short-form McGill Pain Questionnaire. Eur J Pain 2000;4:275-81. 46. Williams NH, Wilkinson C, Russell IT. Extending the Aberdeen back pain scale to include the whole spine: a set of outcome measures for the neck, upper and lower back. Pain 2001;94:261-74. 47. Bolton JE, Humphreys BK. The Bournemouth Questionnaire: a short-form comprehensive outcome measure. II. Psychometric properties in neck pain patients. J Manipulative Physiol Ther 2002;25(3):141-8. 48. Bendebba M, Heller J, Ducker TB, Eisinger JM. Cervical spine outcomes questionnaire: its development and psychometric properties. Spine 2002;27:2116-23. 49. Chiu TTW, Lam T, Hedley AJ. A randomized controlled trial on the efficacy of exercise for patients with chronic neck pain. Spine 2005;30:E1-E7. 50. Hains F, Waalen J, Mior S. Psychometric properties of the neck disability index. J Manipulative Physiol Ther 1998;21: 75-80. 51. Riddle DL, Stratford PW. Use of generic versus region-specific functional status measures on patients with cervical spine disorders. Phys Ther 1998;78:951-63. 52. Hoving J, O'Leary E, Niere K. Validity of the neck disability index, Northwick Park neck pain questionnaire and problem elicitation technique for measuring Disability associated with whiplash-associated disorders. Pain 2003;102:273-81. 53. Pinfold M, Niere KR, O'Leary EF. Validity and internal consistency of a whiplash-specific disability measure. Spine 2004;29:263-8. 54. Hurst H, Bolton J. Assessing the clinical significance of change scores recorded on subjective outcome measures. J Manipulative Physiol Ther 2004;27:26-35.

Neck pain assessments and measurements 55. Jordan A, Manniche C, Mosdal C, Hindsberger C. The Copenhagen neck functional disability scale: a study of reliability and validity. J Manipulative Physiol Ther 1998;21: 520-7. 56. Fejer R, Jordan A, Hartvigsen J. Categorizing the severity of neck pain: establishment of cut-points for use in clinical and epidemiological research. Pain 2005;119:176-82. 57. Wheeler AH, Goolkasian P, Baird AC, Darden BV. Development of the neck pain and disability scale—item analysis, face, and criterion-related validity. Spine 1999;24:1290-4. 58. Willis C, Niere KR, Hoving JL, Green S, O'Leary EF, Buchbinder R. Reproducibility and responsiveness of the Whiplash Disability Questionnaire. Pain 2004;110:681-8. 59. Cleland JA, Childs JD, Whitman JM. Psychometric properties of the Neck Disability Index and Numeric Pain Rating Scale in patients with mechanical neck pain. Arch Phys Med Rehabil 2008;89(1):69-74. 60. Trouli MN, Vernon HT, Kakavelakis KN, et al. Translation of the Neck Disability Index and validation of the Greek version in a sample of neck pain patients. BMC Musculoskelet Disord 2008;9:106. 61. White P, Lewith G, Prescott P. The core outcomes for neck pain: validation of a new outcome measure. Spine 2004;29: 1923-30. 62. Cook CE, Richardson JK, Pietrobon R, Braga L, Silva HM, Turner D. Validation of the NHANES ADL scale in a sample of patients with report of cervical pain: factor analysis, item response theory analysis, and line item validity. Disabil Rehabil 2006;28:929-35. 63. Chiu TTW, Lo SK. Evaluation of cervical range of motion and isometric neck muscle strength: reliability and validity. Clin Rehabil 2002;16:851-8. 64. Lee CE, Browell LM, Jones DL. Measuring health in patients with cervical and lumbosacral spinal disorders: is the 12-item short form health survey a valid alternative for the 36-item short form health survey? Arch Phys Med Rehabil 2006;89(5): 829-33. 65. Lee KC, Chiu TT, Lam TH. Psychometric properties of the Fear-Avoidance Beliefs Questionnaire in patients with neck pain. Clin Rehabil 2006;20(10):909-20. 66. Hickey A, Barker M, Mc Gee H, O'Boyle C. Measuring health-related quality of life in older patient populations: a review of current approaches. Pharmacoeconomics 2005;23 (10):971-93. 67. Chiu TTW, Lam T, Hedley AJ. Psychometric properties of a generic health measure in patients with neck pain. Clin Rehabil 2003:505-13. 68. Pietrobon R, Coeytaux RR, Carey TS, Richardson WJ, De Vellis RF. Standard scales for measurement of functional outcome for cervical pain or dysfunction: a systematic review. Spine 2002;27(5):515-22. 69. Vernon H. The Neck Disability Index: state-of-the art, 19912008. J Manipulative Physiol Ther 2008;31(7):491-502. 70. Jolles BM, Buchbinder R, Beaton DE. A study compared nine patient-specific indices for musculoskeletal disorders. J Clin Epidemiol 2005;58:791-801.

59 71. Smedmark V, Wallin M, Arvidsson I. Inter-examiner reliability in assessing passive intervertebral motion of the cervical spine. Man Ther 2000;5:97-101. 72. Pool JJ, Hoving JL, de Vet HC, VanMameren H, Bouter LM. The interexaminer reproducibility of physical examination of the cervical spine. J Manipulative Physiol Ther 2004;27: 84-90. 73. Van Trijffel E, Anderegg Q, Bossuyt PM, Lucas C. Interexaminer reliability of passive assessment of intervertebral motion in the cervical and lumbar spine: a systematic review. Man Ther 2005;10:256-69. 74. Osterbauer PJ, Long K, Ribaudo TA, et al. Three-dimensional head kinematics and cervical range of motion in the diagnosis of patients with neck trauma. J Manipulative Physiol Ther 1996;19:231-7. 75. Jordan A, Mehlsen J, Ostergaard K. A comparison of physical characteristics between patients seeking treatment for neck pain and matched healthy individuals. J Manipulative Physiol Ther 1997;20:468-75. 76. Hanten WP, Olson SL, Russell JL, Lucia RM, Campell AH. Total head excursion and resting head posture: normal and patient comparisons. Arch Phys Med Rehab 2000;81:62-6. 77. Olson SL, O'Connor DP, Birmingham G, Broman P, Herrera L. Tender point sensitivity, range of motion and perceived disability in subjects with neck pain. J Orthop Sports Phys Ther 2000;30:13-20. 78. Petersen CM, Johnson RD, Schuit D. Reliability of cervical range of motion using the OSI CA 6000 spine motion analyser on asymptomatic and symptomatic subjects. Man Ther 2000;5: 82-8. 79. Puglisi F, Ridi R, Cecchi F, Bonelli A, Ferrari R. Segmental vertebral motion in the assessment of neck range of motion in whiplash patients. Int J Legal Med 2004;118:235-9. 80. Hoving J, Pool J, Van Mameren H, et al. Reproducibility of cervical range of motion in patients with neck pain. BMC Musculoskelet Disord 2005;6:59. 81. Viikari-Juntura E. Interexaminer reliability of observations in physical examinations of the neck. Phys Ther 1987;67: 1526-32. 82. Larsson B, Bjork J, Elert J, Gerdle B. Mechanical performance and electromyography during repeated maximal isokinetic shoulder forward flexions in female cleaners with and without myalgia of the trapezious muscle and in healthy controls. Eur J Appl Physiol 2000;83:257-67. 83. Kumbhare DA, Balsor B, Parkinson WL, Harding Bsckin P, Bedard M, Papaioannou A. Measurement of cervical flexor endurance following whiplash. Disabil Rehabil 2005;27:801-7. 84. Andersen JH, Gaardboe O. Musculoskeletal disorders of the neck and upper limb among sewing machine operators: a clinical investigation. Am J Ind Med 1993;24:689-700. 85. Sandmark H, Niseli R. Validity of five common manual neck pain provocative tests. Scand J Rehabil Med 1995;27:131-6. 86. Ljungquist T, Jensen IB, Nygren A, Harms-Ringdahl K. Physical performance tests for people with long-term spinal pain: aspects of construct validity. J Rehabil Med 2003;35: 69-75.

Journal of Chiropractic Medicine (2010) 9, 60–68

www.journalchiromed.com

Inter- and intraexaminer reliability of the Blair protractoview method: examination of a chiropractic radiographic technique Todd A. Hubbard DC a,b, c,⁎, Brett M. Vowles DC d , Tom Forest DC b,c,e a

Assistant Professor, Palmer College of Chiropractic, Davenport, IA Board Member, Past President, Blair Upper Cervical Chiropractic Society, Lubbock, TX c Certified Advanced Instructor, Blair Upper Cervical Technique d Private Practice, Alpine, CA e Private Practice, Forest Chiropractic Clinic, Pleasanton, CA b

Received 16 October 2009; received in revised form 22 January 2010; accepted 3 February 2010 Key indexing terms: Manipulation; Chiropractic; Reproducibility of results; Cervical; Atlas; Radiography; Diagnostic radiograph

Abstract Objective: The purpose of this study was to evaluate the inter- and intraexaminer reliability of the Blair protractoview radiographic method. Methods: This retrospective study evaluated 25 participants attending a Blair technique seminar. Participants included chiropractic students and doctors of chiropractic with more than 11 years of experience. Participants evaluated 100 Blair protractoview radiographs (oblique nasium). A κ analysis was used to determine the inter- and intraexaminer reliability because of the nominal categorical value of the variables. For the interexaminer reliability, a κ score was given for each examiner combination. The scores were then averaged to give the total interexaminer reliability. Results: The overall interexaminer reliability showed substantial reliability at 0.62. Withingroup κ values were as follows: no certification = 0.61, proficiency = 0.66, primary level = 0.61, and advanced level = 0.74. The overall intraexaminer reliability showed outstanding reliability at 0.81. Within-group κ values were as follows: no certification = 0.76, proficiency = 0.84, primary level = 0.82, and advanced level = 0.92. All κ values had a P value b .001. Conclusion: The participants in this study showed good inter- and intraexaminer reliability using the Blair protractoview radiographic method. © 2010 National University of Health Sciences.

Introduction ⁎ Corresponding author. Academic Health Center, Palmer College of Chiropractic, 1000 Brady St., Davenport, IA 52803. Tel.: +1 563 884 5184; fax: +1 563 884 5470. E-mail address: [email protected] (T. A. Hubbard).

Some doctors of chiropractic (DCs) practice using the theory that spinal misalignments or dysfunctions may occur and that these misalignments may affect the

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2010.02.004

Reliability of the Blair custom radiograph function of the nervous system. 1,2 Static and functional radiographic analysis is sometimes used by chiropractors to detect spinal misalignment. 2,3 However, questions about the reliability and validity of radiographic analysis as an indicator for spinal misalignment have been raised; and studies have been completed in an effort to establish the inter- and intraexaminer reliability of various cervical radiographic analysis systems. 4,5 The Blair Upper Cervical Chiropractic Technique is one system that uses radiographic analysis to try to determine spinal misalignment. It is based on the premise that naturally occurring asymmetry in the cervical spine would lead to error in size comparison of the left and right spinal structures, like point analysis and other line-drawing analysis used to determine a segmental misalignment. 6-8 Blair theorized that if a misalignment of a joint occurs at the articulation, diagnostic imaging of the joint should allow visualization of the misalignment. This

Fig 1. A base posterior radiograph. Leaded ear plugs are placed in the patient's external auditory meatus allowing for the creation of an earplug line. A sagittal line is then drawn perpendicular to the earplug line, allowing a reference to the occipital condyle angle. The left and right OA articulation is outlined, and the convergence angle of each articulation is drawn down the long axis of the joint. A, The right convergence angle. B, The left convergence angle.

61 follows the premise that a joint should be properly juxtaposed when no misalignment is present. 9 Blair proposed that imaging the spinal joint would remove the error of asymmetry in the body. The Blair radiographic analysis is based on the presumption that the lateral edge of the occipitoatlantal (OA) articulation, 90° to the occipital convergence angle, would be seen as mirror images of one another on the 2-dimensional radiograph image. 10 To see this part of the OA articulation clearly, Blair tailored the oblique nasium radiographic view so that the diagnostic image's central ray would be in line with the occipital condyle convergence angle of the patient. This is called the Blair protractoview (PV). The occipital condyle convergence angles used for the PV are measured on the base posterior radiograph. Blair theorized that when bisected in half along the longest longitudinal axis, the convergence angle of the right and left individual OA articulation could be determined (Fig 1). From this angle, Blair believed that if a patient was rotated to match the convergence angle during an oblique nasium radiograph, then a PV could be taken that would show the lateral edge of the lateral mass/occipital condyle articulation and

Fig 2. The left PV showing an overlap at the OA articulation. This is labeled as an atlas misalignment that has occurred ASL. The white arrow represents the most lateral edge of the occipital condyle, and the black arrow represents the most lateral edge of the lateral mass of atlas.

62

T. A. Hubbard et al.

therefore demonstrate the position of the articulating structures. Blair theorized that when a misalignment of the OA joint occurs, the atlas lateral mass travels (eg, anterior or posterior) along the longitudinal articular axis of the corresponding occipital condyle. It is theorized that the partner lateral mass travels obliquely across the longitudinal articular axis of the corresponding occipital condyle. This would result in a longitudinal misalignment in a plane parallel to the longitudinal axis of the opposite articulation. Another premise of the Blair technique is that if atlas is misaligned anterior to the occipital condyle, the lateral edge of the lateral mass will appear as an overlap or lateral to the condyle on the PV (Fig 2). If the atlas has misaligned posterior to the occipital condyle, then the lateral edge of the lateral mass will appear as an underlap or medial to the condyle on the PV (Fig 3). If the lateral mass and condyle are juxtaposed, then no misalignment will be seen (Fig 4). Up to this point in time, there have been no known published inter- and intraexaminer reliability studies of

Fig 4. The left PV showing juxtaposed OA articulation. This is labeled as an even atlas alignment. The white arrow represents the most lateral edge of the occipital condyle, and the black arrow represents the most lateral edge of the lateral mass of atlas.

this method. The purpose of this study is to investigate the inter- and intraexaminer reliability of PV analysis by chiropractic practitioners.

Methods

Fig 3. The left PV showing an underlap at the OA articulation. This is labeled as an atlas misalignment that has occurred PIR. The white arrow represents the most lateral edge of the occipital condyle, and the black arrow represents the most lateral edge of the lateral mass of atlas.

This is a retrospective study designed to measure the intra- and interexaminer reliability of practitioners in the determination of the direction of atlas misalignment at the OA articulation seen on Blair PV radiographs. A convenience sample of 50 sets (right and left) of Blair PV radiographs, totaling 100 films, was selected by an independent certified Blair instructor from his clinic. The radiographs were duplicated, and all patients' identifying data were removed from the films. The radiographs were then labeled 1 to 50 and sublabeled A (left PV) or B (right PV), that is, 1A and 1B. This study was reviewed and approved by the Institutional Review Board chair of Palmer College of Chiropractic, Davenport, IA.

Reliability of the Blair custom radiograph

63

Exclusion criteria

Radiograph examiners

Protractoviews were excluded from the study if they did not show a clear image of the OA articulation. Radiographs in which the zygomatic process or occipital shelf obscured the OA articulation were excluded. According to Blair guidelines, a PV must show an occipital condyle with a clear corner at the lateral edge of the inferior articulating surface. A PV that is not taken 90° to the convergence angle will show a rounded surface, not a “corner,” at the lateral edge of the articulation surface and would have been retaken in clinical practice. All PVs for this study were viewed by an independent advanced Blair instructor and were found to be acceptable Blair PVs. The film could not be a “stereo view” that is taken to see the radiograph in 3 dimensions. Because of the lack of training by the student examiners in viewing stereo radiographs, these films were excluded from the study.

This study used volunteers in attendance at the 2009 Blair Chiropractic Society, Inc, annual convention. We did not handpick the examiners. Our goal for the study was to have at least 3 examiners from several chiropractic proficiency levels, from student through advanced-level certified chiropractor. The participants were volunteers from a group of attendees of the 2009 Annual Blair Conference in Atlanta, GA. The participants ranged from chiropractic students to DCs with more than 11 years of experience. This study used participants with 4 different levels of experience with the Blair technique. These were students who are currently in chiropractic school; chiropractors who have attended Blair technique seminars, but have not had any postgraduate testing; proficiency certified chiropractors who have taken a Blair technique examination; certified Blair primary instructors who have taken a Blair technique examination; and certified Blair advanced instructors. Participants were assigned an examiner number in random order. They were placed in front of a view box and given a data sheet and instructions for analyzing the PV radiographs (as listed above). The radiographs were divided into stacks of 50 (25 pairs) radiographs and placed in front of 2 separate view boxes. When a participant was finished with the first 50 radiographs, they were moved to the view box with the other 50. The participants were instructed to put each pair of radiographs (right and left PV of each patient) on the view box and list the finding on the data sheet. The participants were blinded to all patient information and to the answers of the other examiners. Each participant was asked to view all 100 radiographs (50 sets of left and right PV) twice, at 2 different times during the conference, and was asked to not discuss the film findings between analyses.

Blair PV interpretation The Blair technique protocol instructs the DC to view the most lateral edge of the OA articulation on the Blair PV. If the most lateral edges of the occipital condyle and first cervical lateral mass are juxtaposed, there is no misalignment. If the lateral mass is further lateral than the condyle, an anterior-superior misalignment of atlas is present, toward the side of atlas laterality (left laterality on the left PV, right laterality on the right PV). If the lateral mass is medial to the condyle, a posterior-inferior atlas misalignment is present, toward the medial direction (right on the left PV, left on the right PV). The examiners were instructed to list the misalignment finding for each PV radiograph. The possible findings on the left PV (A films) were atlas “anteriorsuperior-left” (ASL), atlas “posterior-inferior-right” (PIR), or “even.” The possible findings on the right PV (B films) were atlas “anterior-superior-right” (ASR), atlas “posterior-inferior-left” (PIL), or “even.” In this study, examiners were instructed to consider findings less than 1 mm to be “even.” When analyzing the PV, no line drawing is required; the misalignment is visualized without any markings or line-drawing analysis. No pencil marks or lines were placed on the films by the principle investigator or any of the radiograph examiners. The radiographs were checked between examiners to ensure that no pencil markings were on the films.

Statistical analysis Data were analyzed using SPSS package, version 13.0 (SPSS, Inc, Chicago, IL). Each PV radiograph was analyzed independently of the other. For the left PV, the participant would determine the left OA articulation to be an ASL, PIR, or even. For the right PV, the participant would determine the right OA articulation to be an ASR, PIL, or even. An unweighted κ analysis was used to determine the inter- and intraexaminer reliability because of the nominal categorical value of the variables. The κ score was obtained by using the crosstabs option in SPSS. For the interexaminer

64 reliability, a κ score was determined for each participant by comparing his/her answers to each of the other participant's answers for each radiograph (both first and second readings). All the scores comparing an individual participant to every other participant were then averaged together to give the overall κ score for that individual examiner. All of the overall individual participant κ scores were then averaged together to give the total interexaminer reliability. For the intraexaminer reliability, the 2 readings of the radiographs for each examiner were determined using the unweighted κ statistic. The scores for each participant were then averaged to find the overall intraexaminer κ statistic. The Blair Upper Cervical Chiropractic Society, Inc, has 4 levels of certification (none, proficient, primary-level instructor, and advanced-level instructor). Therefore, participants were grouped into certification levels. We also grouped participants into students or DCs. The κ value was considered as statistically significant if the P value was b .05. Determination of the level of reliability was categorized following Landis and Koch, 11 where κ values of 0.40 to 0.59 are considered moderate; 0.60 to 0.79, substantial; and 0.80 and greater, outstanding. 12 κ analysis was performed to determine the overall interand intraexaminer reliability of all of the participants, as well as within the 4 levels of certification within the Blair Chiropractic Society.

Results A total of 25 participants analyzed 100 films, of whom 22 participants analyzed the films twice over the course of the conference, giving 47 readings of the radiographs. Examiners included 7 chiropractic students and 18 chiropractors. For the DCs, 7 had no level of Blair certification, 3 had proficiency certification, 4 had primary-level certification, and 4 had advancedlevel Blair certification. Interexaminer reliability The overall interexaminer reliability for all participants showed reliability at 0.62 (Table 1). The student participants showed a κ of 0.60. The DCs had an interexaminer reliability of 0.61. Within-group κ values were as follows: no certification = 0.61, proficiency = 0.66, primary level = 0.61, and advanced level = 0.74. All κ values had a P value b .001.

T. A. Hubbard et al. Intraexaminer reliability The overall intraexaminer reliability for all participants showed reliability at 0.81 (Table 1). The student participants showed a κ of 0.71. The DCs had an intraexaminer reliability of 0.84 (no certification = 0.76, proficiency = 0.84, primary level = 0.82, and advanced level = 0.92). All κ values had a P value b .001.

Discussion Spinal radiographs are a fundamental element of patient spinal assessment in some chiropractic techniques. 3 The Blair Upper Cervical Chiropractic Technique uses radiographs for the determination of cervical spine segmental alignment and to determine a specific vector for spinal manipulation to the upper cervical spine. Until now, there has been no literature published in peer-reviewed journals evaluating the reliability of measuring these radiographs; and there has been only one abstract in a conference proceeding that compared the Blair technique to another upper cervical technique. 12 This study evaluated the inter- and intraexaminer reliability for analyzing the Blair PV. The κ value for interexaminer reliability of the average participant was substantial at 0.61 (intraexaminer = 0.81), and the value for highest certified Blair chiropractors also was substantial at 0.74 (intraexaminer = 0.92). This suggests that the Blair PV may be a reliable tool for analyzing the OA articulation for misalignment/juxtaposition as defined by the Blair protocol. The Blair radiographic analysis for the complete misalignment of a patient's first cervical vertebra is obtained when the misalignment listings from the left and right PVs are combined. This study did not combine the listings found on the left and right PVs, but looked at each view independently. Therefore, we can only determine the reliability of the PV analysis and not the analysis of the complete Blair first cervical misalignment listing. The PV is the last step of the Blair radiograph protocol for determining a misalignment of the atlas. To test the reliability of the Blair technique protocols for assessing atlas misalignment, the base posterior radiograph will need to be studied for reliability in determining the occipital convergence angles. The reliability of the combined left and right PVs listings for the patient will also need to be tested. Chiropractors may also use palpation to determine OA misalignment. Studies have discussed palpation

Examiner

Inter- and intraexaminer reliability results of 18 chiropractors and 7 chiropractic students Student/ DC

Years in Practice

Certification Level

No. of Radiographs Analyzed

Overall κ Intra Inter

01 02 03 04 05 06 07 08 09 10 11 12 13 14

Student Student Student Student Student Student Student DC DC DC DC DC DC DC

0 0 0 0 0 0 0 11+ 6-10 11+ 1-5 11+ 1-5 6-10

NA NA NA NA NA NA NA None None None None None None None

200 200 200 200 200 200 200 200 200 200 200 100 200 100

0.63 0.69 0.73 0.55 0.79 0.85 0.71 0.65 0.81 0.90 0.68

15 16 17

DC DC DC

11+ 6-10 1-5

Proficient Proficient Proficient

200 200 200

18 19 20 21

DC DC DC DC

11+ 11+ 6-10 11+

Primary Primary Primary Primary

22 23 24 25

DC DC DC DC

6-10 11+ 11+ 11+

Advanced Advanced Advanced Advanced

Within-Student/ DC Group Interexaminer κ

WithinCertification Group Interexaminer κ

0.57 0.55 0.58 0.53 0.59 0.60 0.60 0.49 0.58 0.66 0.55 0.60 0.64 0.66

0.58 0.58 0.61 0.58 0.62 0.61 0.61 0.48 0.59 0.64 0.54 0.58 0.63 0.65

NA NA NA NA NA NA NA 0.59 0.63 0.67 0.58 0.58 0.62 0.62

0.77 0.87 0.89

0.58 0.63 0.63

0.57 0.62 0.64

0.66 0.68 0.65

100 200 200 200

0.82 0.82 0.81

0.68 0.54 0.65 0.54

0.69 0.52 0.64 0.55

0.65 0.55 0.63 0.59

200 200 200 200

0.88 0.88 0.97 0.96

0.66 0.67 0.69 0.67

0.68 0.66 0.68 0.67

0.76 0.67 0.76 0.75

0.77

Average WithinCertification Group κ Intra

Inter

NA NA NA NA NA NA NA

NA NA NA NA NA NA NA

0.76

0.61

0.84

0.66

0.82

0.62

0.92

0.74

Reliability of the Blair custom radiograph

Table 1

All κ values have a P value b .001.

65

66 of the C1 vertebra. Hart 13 reported that first cervical palpation findings matched line-drawing radiograph findings in only 16.1% of his 31 cases. Jende and Peterson 14 found that the difference in the palpated lateral prominence of the C1TP did not match first cervical laterality measurements found on radiographs. Ross et al 15 and Meseke et al 16 have questioned the interpretation of palpation findings because of asymmetry of the first cervical vertebrae. They agreed with Blair on the implication of how asymmetry of the spine may affect palpation evaluation for the spinal misalignment. Meseke et al state that “variation in the structure of the atlantoaxial joint may also lead to abnormal biomechanics related to lateral bending. These biomechanical abnormalities based on anatomical variation may be mistaken for a subluxation.” 16 When palpating the atlas to determine a misalignment, the left and right transverse processes are used as references to each other. Meseke et al 16 found the mean ± SD of the atlas transverse process to be 23.06 ± 2.62 mm on the left and 23.17 ± 2.41 mm on the right. When doubling the SD, an examiner would have to account for 5-mm difference in palpation findings to account for asymmetry before determining a misalignment. Line-drawing analysis of chiropractic radiographs are based on symmetry, which includes size comparison and like point procedures. Meseke found the mean ± SD of the width of the superior articulating surface to be 9.15 ± 1.28 mm on the left and 9.00 ± 1.29 mm on the right.16 The width of the inferior articulating surface of the lateral mass was 13.97 ± 1.48 mm on the left and 13.91 ± 1.57 mm on the right. The height of the lateral mass was found to be 19.60 ± 2.24 mm on the left and 19.56 ± 2.09 mm on the right. Dong et al 17 found the width of the lateral mass to be 15.52 ± 1.35 mm on the left and 15.43 ± 1.06 mm on the right. Dong et al also found the lateral mass height to be 14.18 ± 1.88 mm on the left and 14.00 ± 2.03 mm on the right. Because of the standard deviation of these measurements, the left and right lateral masses were not formed as mirror images to each other. In fact, any size comparison analysis would have to be twice the SD to be considered a significant finding or interpreted as a misalignment. In the line-drawing analysis using “like points” of the spine, lines creating a wedge, which were interpreted as the presence of a misalignment, may be in fact just a difference in the height between the left and right lateral masses, occipital condyles, or both. Briggs et al 18 studied the surface area of the occipital condyle and the corresponding lateral mass

T. A. Hubbard et al. superior articulating surface. In that study, they showed that the inferior articulation surface of the occipital condyle and the superior articulation surface of the lateral mass are not mirror images of one another, which is not in dispute. This may be why Blair evaluated the lateral edge of this articulation 90° to the long axis of the occipital condyle. 10 Briggs et al 18 state that because of the asymmetry of the articulating surfaces, the analysis of an overlap/underlap seen on the PV may be due to normal anatomical variants. When testing this theory, they looked at the image mimicking a base posterior (a coronal view).It is suggested that the relationships of the condylar and lateral mass distal margins should be assessed from a diagonally vertical perspective “on a plane 90° to the long axis of the articulation.”10 Briggs et al 18 also acknowledge that “the procedures used” in their study “do not directly transfer to real-life radiographic measurements.” More research needs to be done on the correlation between a misalignment seen on the PV and the status of patient health and symptoms. When a large disagreement occurred for naming the misalignment on the PVs, the participants disagreed on the articulation being either an anterior vs even or posterior vs even. There were no radiographs that showed more than 12.8% (n = 6) disagreement between an anterior vs posterior misalignment, for example, an ASR vs a PIL. There were only 2 films that received this level of disagreement. The first film had 83% (n = 39) of the misalignment read as PIL. The second film had 80.9% agreement that the articulation was even. This would indicate that on the radiographs where there was a disagreement, it was whether there was a misalignment or not, and not disputing the direction of the misalignment, for example, an ASR vs a PIL Limitations Our instructions to the examiners included that misalignments less than 1 mm should be considered “even” and not be marked as an anterior or posterior misalignment. This was an attempt to express Blair clinical protocol only in adjusting the larger misalignment first. The chiropractor would then use subluxation indicators (Tyron C3000 [Titronics, Tipton, IA]; for cervical thermography, leg length inequality analysis, and spinal palpation) to determine if the patient was in need of further spinal manipulation. We did not provide the examiners with a ruler to measure the misalignment observed. We also did not allow the examiners to draw on or mark the radiographs in any way. Therefore, they

Reliability of the Blair custom radiograph had to visualize what 1 mm would be. A future study without the definition of “less than 1 mm” may show a different result. The radiographs used in the current study were chosen as a convenience sample from a certified advanced Blair instructors' office. The Blair chiropractor, who used the exclusion criteria for this study when reviewing the radiographs, was to not include any films that did not show a clear image of the OA articulation. In the process of choosing radiographs for the study, it is possible that radiographs in which the misalignment of the OA articulation was difficult to analyze may have been excluded inadvertently. If this was the case, the reliability results in this study may be inflated, as the practitioner would not be able to handpick radiographs in his/her office. Future studies should not be predetermined “acceptable,” but allow the examiners themselves to indicate if the radiograph is readable. If most or all of the examiners indicate that the radiograph is not readable, the radiograph could then be excluded from the study. Doing so would help to eliminate this bias from the exclusion process. Between readings of the radiographs, the examiners were attending the 2009 Blair convention. Although we instructed the examiners to not discuss their findings, we cannot ensure that this was the case. Discussion of the radiographs may affect the reliability results. The 100 radiographs were separated into 2 piles of 50 radiographs each for the examiners. The order of the radiographs, however, was not shuffled between readings. There is a possibility that the examiners may have recalled their first answers to the radiographs, which could have inflated the reliability results. We tried to avoid this by including a large sample size. In the future, shuffling the order of the radiographs between examiners may help to avoid recall. Furthermore, having 2 or 3 sets of radiographs with random numbering may limit the affect of examiner recall. It could be argued that we should have used more participants. Standard reliability studies typically use 3 to 5 examiners. Choosing to use more examiners does not necessarily increase the power of the hypotheses being tested, as long as there is a sufficient amount of subjects being tested. 19 It is also important to note that good inter- and intraexaminer reliability of a radiographic method does not necessarily imply clinical relevance. As well, this study was performed on a unique set of practitioners; and therefore, the findings for this study may not necessarily be generalized to other DCs or those who are trained in Blair methods. More inter- and intraexaminer studies need to be performed

67 before these findings can be generalized beyond the study group.

Conclusion Based upon the findings of this study, the participants showed good inter- and intraexaminer reliability for analyzing the Blair PV.

Acknowledgment The authors acknowledge Dana Lawrence for his help in editing and guidance in the writing of this study.

Funding sources and potential conflicts of interest Drs Hubbard and Forest are members of the Blair Upper Cervical Chiropractic Society. Drs Hubbard and Forest are Board Members and Past Presidents of this society, are Certified Advanced Instructors of Blair Upper Cervical technique, and receive income from teaching this technique. This study was done as a project for a Masters of Clinical Research program at Palmer that the first author is enrolled in at this time. No outside funding was accepted for this project.

References 1. Rochester RP. Inter- and intra-examiner reliability of the upper cervical x-ray marking system: a third and expanded look. Chiropr Res J 1994;3(1):23-31. 2. Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136(3):216-27. 3. Bussieres AE, Peterson C, Taylor JA. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults— an evidence-based approach: introduction. J Manipulative Physiol Ther 2007;30(9):617-83. 4. Kavanagh JJ, Morrison S, Barrett RS. Lumbar and cervical erector spinae fatigue elicit compensatory postural responses to assist in maintaining head stability during walking. J Appl Physiol 2006;101(4):1118-26. 5. Ernst E. Chiropractors' use of x-rays. Br J Radiol 1998;71 (843):249-51. 6. Blair WG. A synopsis of the Blair upper cervical spinographic research; scientific review of chiropractic. Int Rev Chiropr 1964;1(1):1-19.

68 7. Blair WG. For evaluation; for progress, part II. Int Rev Chiropr 1968;22(9):10-4. 8. Blair WG. For evaluation; for progress, part 1. Int Rev Chiropr 1968;22(8):8-11. 9. Stephenson RW. The freshman text. Chiropractic text book. 8th ed. USA: The Palmer School of Chiropractic; 1948. p. 2. 10. Addington EA, Hubbard TA. Surface area congruence of atlas superior articulating facets and occipital condyles. J Chiropr Med 2009;8(2):92-3. 11. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159-74. 12. Brown SH, Hinson R, Owens E. Comparison of radiographic analysis and clinical outcome for two upper cervical specific techniques. J Chiropr Educ 2000;14(1):28. 13. Hart J. Palpation and x-ray of the upper cervical spine: a reliability study. J Vertebral Subluxation Res 2006;10:14.

T. A. Hubbard et al. 14. Jende A, Peterson CK. Validity of static palpation as an indicator of atlas transverse process asymmetry. Eur J Chiropr 1997;45:35-42. 15. Ross JK, Bereznick DE, McGill SM. Atlas-axis facet asymmetry. Implications in manual palpation. Spine 1999;24(12):1203-9. 16. Meseke C, Duray S, Brillon S. Principal components analysis of the atlas vertebra. J Manipulative Physiol Ther 2008;31:212-6. 17. Dong Y, Hong MX, Jianyi L, Lin MY. Quantitative anatomy of the lateral mass of the atlas. Spine (Phila Pa 1976) 2003;28(9): 860-3. 18. Briggs L, Hart J, Navis M, Clayton S, Boone R. Surface area congruence of atlas superior articulating facets and occipital condyles. J Chiropr Med 2008;7(1):9-16. 19. Sim J, Wright CC. The kappa statistic in reliability studies: use, interpretation, and sample size requirements. Phys Ther 2005; 85(3):257-68.

Journal of Chiropractic Medicine (2010) 9, 69–72

www.journalchiromed.com

An atypical case of nephrolithiasis with transient remission of symptoms following spinal manipulation Christopher C. Wolcott DC⁎ Director, Southport Grace Wellness Center, Chicago, IL Adjunct Faculty, Research Department, National University of Health Sciences, Lombard, IL Received 2 October 2009; received in revised form 7 January 2010; accepted 3 February 2010 Key indexing terms: Spinal manipulation; Renal calculi; Nephrolithiasis; Chiropractic

Abstract Objective: Nephrolithiasis is a common condition with symptoms similar to common mechanical lesions of the lumbar spine and pelvis. The purpose of this report is to outline a case of nephrolithiasis that closely mimicked sacroiliac joint syndrome in subjective report, objective findings, and reduction of symptoms with spinal manipulation. Clinical Features: A 41-year-old obese male patient with mild pain over the left posterior sacroiliac joint, penile paresthesia, and the penile sensation of urinary urgency presented for chiropractic care. Subjective history and objective evaluation suggested sacroiliac joint syndrome. Intervention and Outcome: A trial of conservative management including spinal manipulation was initiated. Following each treatment, the patient reported temporary relief of all symptoms (4 hours to 2 days). After unsuccessful permanent resolution of symptoms, a urinalysis was performed; and a follow-up computerized tomography scan revealed a large renal calculus obstructing the left ureter. Laser lithotripsy produced obliteration of the stone and complete resolution of symptoms. Conclusions: This report outlines the potential overlap of symptoms of visceral and somatic lesions in both presentation and response to care. In this case, a favorable response to spinal manipulation masked the most likely underlying symptom generator. This encounter demonstrates the potential need for further clinical examination in the instance of the unresponsive mechanical lesion. This report also supports the need for future research into spinal manipulation as a possible adjunct for visceral pain management. © 2010 National University of Health Sciences.

Introduction

⁎ Southport Grace Wellness Center, 1209 W Grace St, Chicago, IL 60613. Tel.: +1 773 525 2225; fax: +1 773 525 2990. E-mail address: [email protected].

Nephrolithiasis, commonly referred to as kidney stones or renal calculi, is a common ailment in the adult population, with a lifetime prevalence of 2% to 5% and an approximately 12% lifetime risk for white males. 1,2 Nephrolithiases are 2 to 3 times more common in males

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2010.02.005

70 and have a 50% recurrence rate. 2,3 A common acute symptom of nephrolithiasis is flank or lower back pain, prompting some patients to seek chiropractic care. In a typical case of nephrolithiasis, the patient presents with telltale signs that when noted on subjective history and objective evaluation will induce an appropriate referral. Sacroiliac joint (SIJ) syndrome is a common condition that typically presents with pain over the affected joint, often with referral into the posteriolateral thigh, groin, or scrotum/labia. 4 The following report outlines a case of nephrolithiasis that closely resembled SIJ syndrome and temporarily responded to spinal manipulation and physiotherapy. A review of the chiropractic and allopathic literature revealed atypical nephrolithiasis symptoms including inguinal and periumbilical pain. 5 Although penile pain is a reported symptom of nephrolithiasis, penile paresthesia has not been reported in the literature. 1 Several authors discuss viscerosomatic pain in relation to spinal manipulation. 6-8 To our knowledge, this is the first reported case of nephrolithiasis that closely mimicked a common mechanical lesion in both clinical presentation and response to therapy.

Case report A 41-year-old white man who was a previous patient presented with a new problem. He noted a 2-week history of mild left posterior “hip pain” and described a constant “electric” or “buzzing” sensation in his penis that he noted was most akin to the penile sensation of urinary urgency. Movement was palliative for the hip pain. Urination reduced the penile paresthesia. Prolonged sitting was provocative for both problems. The patient denied recent fever, chills, nausea, vomiting, or painful urination. He also denied the presence of blood, foul smell, or color change of urine. His pain level measured 3 cm out of 10 cm on the visual analogue scale and was described as “dull” and “achy.” Relevant history included previous kidney stones and obesity. The patient noted that on annual physical examination 3 weeks prior, he had a “normal” urinalysis; and a review of his medical records confirmed his report. The patient's vital signs were normal. The patient's weight was 351 lb and his height was 71 in. Neither deep abdominal palpation nor Murphy's punch test elicited pain. Active lumbar range of motion was full with end range pain in the left sacroiliac region with extension. Yeoman test proved mildly provocative on the left for SIJ pain. The Valsalva maneuver produced

C. C. Wolcott an increase in penile paresthesia and no change in back pain. Restriction was noted bilaterally in SIJ intersegmental motion. All other physical examination findings were unremarkable. Differential diagnosis included SIJ dysfunction, prostatitis, nephrolithiasis, and a lumbar disk lesion. Further questioning revealed “normal” prostate examination and prostate specific antigen level 3 weeks prior. Based on the recent negative laboratory test results, objective findings, and subjective history that movement was palliative and sitting was provocative, a trial of conservative care was initiated to address probable SIJ dysfunction. Treatments included drop table manipulation for SIJ restriction and flexion distraction manipulation of the lower lumbar spine for potential lumbar disk lesion. In addition, hot moist packs and interferential therapy over the lumbosacral region were used for relaxation and pain management. Finally, home lumbar strengthening and stability exercises were recommended daily. The treatment frequency was twice weekly for 3 weeks. After each treatment, the patient reported immediate resolution of both SIJ pain and penile paresthesias. Relief lasted from 4 hours to 2 days before the symptoms returned. At the end of the 3-week trial, the patient's condition remained unchanged with only intermittent relief of symptoms following care and occasional periods where the patient felt that the SIJ pain was “worse.” A literature search was conducted to further explore this case. Several case studies were recovered reporting nephrolithiasis with associated penile, periumbilical, and inguinal pain. Based on the retrieved articles and the lack of permanent symptomatic resolution, a visceral etiology was revisited. A dipstick urinalysis was performed, and the test results indicated the presence of blood and elevated specific gravity. Follow-up urinalysis confirmed these findings, and an abdominal/pelvis computerized tomography scan was ordered. The computerized tomography scan revealed a 7-mm × 4-mm calculus lodged in the left distal ureter. Laser lithotripsy was performed to obliterate the stone. After a brief recovery from the procedure, the patient reported no further SIJ pain or penile paresthesia.

Discussion The patient provided written consent to publish this case. Although perceived somatic pain of visceral origin is common, it is difficult to treat. 9 This case was unique in both clinical presentation and response to

Atypical nephrolithiasis therapy. Presenting symptoms of penile paresthesia and posterior hip pain appear to be a unique presentation of nephrolithiasis. Although authors have documented inguinal and penile pain associated with renal disease, no literature describing penile paresthesia associated with nephrolithiasis was located. 1,5 After the initial evaluation, the clinical picture was not particularly clear with both somatic and visceral disease on the list of potential causes. Orthopedic assessment was complicated by the size of the patient; reproducing symptoms of a mechanical nature while excluding pain of visceral origin was difficult. The trial of conservative care was initiated based on a “most likely” scenario supported by recent (3 weeks prior) normal urinalysis and prostate examination result. Symptomatic resolution after each treatment bolstered the diagnosis of SIJ dysfunction. However, permanent symptom resolution following lithotripsy obliteration of the stone suggested that the most likely symptom generator was the presence of the nephrolithiasis. There are several possible explanations for the reported relief of symptoms following manipulation. Spinal manipulation has been shown to inhibit the production of proinflammatory cytokines by increasing the production of interleukin-2, potentially reducing both somatic and visceral pain.8 Spinal manipulation also appears to provide neurologic stimulation of mechanoreceptors (Golgi tendon organs and muscle spindles) supplied by Ia sensory fibers that can participate in “pain gating” and somatosomatic and somatovisceral reflexes. 7 Another possible explanation for the patient's symptomatic relief is concurrent SIJ syndrome and nephrolithiasis with concurrent resolution. Finally, the placebo effect could explain the perceived relief of symptoms. 10 Although the symptom generator in this case proved to be visceral in nature, the patient had transient elimination of all pain and paresthesias following spinal manipulation. This case supports the need for future research into spinal manipulation as a possible adjunctive therapy for visceral pain management. This case is important from a diagnostic perspective because it provides evidence that perceived somatic pain of visceral origin may be potentially influenced by manual therapies, which may complicate the diagnostic process. Limitations This report has several limitations. This case was a single patient with both a unique presentation and unique response to therapy. These qualities make any definitive conclusions or comparisons to other cases

71 difficult. In addition, the symptomatic resolution was strictly subjective, with no objective observations noted. Objective reevaluation following treatment may have provided additional insight.

Conclusion The presenting symptoms in this case mimicked a common mechanical lesion that is often treated conservatively. Penile paresthesia appears to be an uncommon but possible symptom associated with renal calculi. Although the cause of the symptoms was discovered to be visceral in origin, spinal manipulation appeared to provide short-term symptomatic relief. This case demonstrates that symptom reduction with spinal manipulation does not necessarily indicate that the pain is of somatic origin. Exploration of potential pain of visceral origin may be necessary in cases of apparent somatic pain even if the symptoms are temporarily relieved with manual therapy.

Acknowledgment The authors gives special thanks to Dr Gregory Cramer and Dr Thomas Grieve for reviewing this manuscript and for their valuable input.

Funding sources and potential conflicts of interest No conflicts of interest were reported for this study. The author received salary support from the National Institutes of Health/National Center for Complementary & Alternative Medicine Award, Number R25 AT002872, project title: Curriculum Development in Evidence Based Practice.

References 1. Pietrow P, Karellas M. Medical management of common urinary calculi. Am Fam Physician 2006;74(1):86-94. 2. Portis A, Sundaram C. Diagnosis and initial management of kidney stones. Am Fam Physician 2001;63(7):1329-38. 3. Miller N, Lingeman J. Management of kidney stones. BMJ 2007;334(7591):468-72. 4. Cohen S. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg 2005;101(5): 1440-53.

72 5. Wells K. Nephrolithiasis with unusual initial symptoms. J Manipulative Physiol Ther 2000;23(3):196-201. 6. Nansel D, Szlazak M. Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manipulative Physiol Ther 1995;18(6): 379-97. 7. Pickar J. Neurophysiological effects of spinal manipulation. Spine J 2002;2(5):357-71.

C. C. Wolcott 8. Teodorczyk-Injeyan J, Injeyan H, McGregor M, Harris G, Ruegg R. Enhancement of in vitro interleukin-2 production in normal subjects following a single spinal manipulative treatment. Chiropr Osteopat 2008;16:5. 9. Robinson DR, Gebhart GF. Inside information—the unique features of visceral sensation. Mol Interv 2008;8(5): 242-53. 10. Turner J, Deyo R, Loeser J, Von Korff M, Fordyce W. The importance of placebo effects in pain treatment and research. JAMA 1994;271(20):1609-14.

Journal of Chiropractic Medicine (2010) 9, 73–76

www.journalchiromed.com

Inferior lumbar triangle hernia as a rarely reported cause of low back pain: a report of 4 cases Gregory R. Lillie DC, MS a,b,c,⁎, Eric Deppert MD, FACP d, e,f a

Contracted Chiropractic Physician, Naval Hospital Pensacola, Naval Branch Health Clinic NATTC, Pensacola, FL 32508 b Adjunct Clinical Faculty, Palmer College of Chiropractic, Davenport, IA 52803 c Adjunct Clinical Faculty, National University of Health Sciences, Lombard, IL 60148 d Primary Care Physician, Philadelphia, PA 19146 e President and CEO of Global Health Educators, Philadelphia, PA 19129 f Associate Professor, Drexel University College of Medicine, Philadelphia, PA 19146 Received 29 July 2009; received in revised form 21 January 2010; accepted 3 February 2010 Key indexing terms: Hernia; Abdominal wall; Low back pain

Abstract Objective: Lumbar triangle hernias are rarely reported causes of low back pain. We describe the symptoms, signs, and anatomical location of 2 possible defects in the posterior abdominal wall where lumbar hernias may appear. The clinical diagnosis was challenging, and advanced imaging failed to initially uncover the conditions. Clinical Features: We report 4 patients with spontaneous inferior lumbar triangle hernias (Petit triangle hernias) initially presenting to a primary care clinic with the primary complaint of low back pain. Intervention and Outcomes: Thorough histories and examinations led to successful outcomes. All 4 patients were operated on to correct the defect. No recurrence has occurred. Conclusions: Anatomical knowledge and clinical acumen led to correct diagnosis of these rare lumbar hernias. This information should help both medical and chiropractic clinicians detect these conditions, and aid in appropriate management. © 2010 National University of Health Sciences.

Introduction ⁎ Corresponding author. Naval Branch Health Clinic NATTC, 760 East Ave, Bldg 3911, Pensacola, FL 32508. Tel.: +1 850 492 5832. E-mail address: [email protected] (G. R. Lillie).

Not to be confused with herniated lumbar disks, lumbar hernias form through defects in the posterior lumbar wall. Such hernias manifest in either of 2 areas of potential weakness found within an area

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2010.02.001

74 bordered superiorly by the 12th rib, medially by the erector spinae, and laterally by the external oblique muscle. The iliac crest borders the area inferiorly. Within the confines of this space are 2 triangles, one superior and deep, the other inferior and superficial, 1 often referred to as the triangles of Grynfeltt and Petit, respectively. Before 1980, less than 300 cases of lumbar hernias were reported in the literature. Our recent search discovered 10 articles published since 1989, reviewing 82 patients with this condition. 2,3 It is important that practitioners become more aware of this condition and consider it as a differential diagnosis in appropriate cases. Timely referral is important, before complications occur. The purpose of this article is to report on this rarely observed cause of low back pain. We report 4 cases of spontaneous inferior lumbar triangle hernias, each of which had low back pain as their presenting symptom.

Case reports Signed consents were obtained from the patients, allowing for publication of the following deidentified clinical details. A 60-year-old man presented with 4 to 6 weeks of left lower back soreness. Trauma was not associated with the onset of symptoms. Physical examination was remarkable for point tenderness and a palpable bulge superior to the left iliac crest. The bulge increased with forceful coughing. Radiographs and magnetic resonance imaging (MRI) of the lumbar spine confirmed degenerative disk disease, but were negative for other pathology. Ultrasound was negative for retroperitoneal pathology. Surgical exploration revealed a hernia in the region of Petit triangle on the left, which was subsequently repaired, resulting in resolution of the symptoms. A 42-year-old woman presented with 2 months of low back pain on her right side when coughing and straining. No history of trauma was recalled. Physical examination revealed significantly decreased active range of motion with flexion and extension. There were tenderness and a palpable defect superior to the right iliac crest. Magnetic resonance imaging confirmed degenerative disk disease, but was negative for other pathology. Surgical exploration revealed a hernia in the region of Petit triangle on the right, which was subsequently surgically repaired, resulting in resolution of symptoms.

G. R. Lillie and E. Deppert A 32-year-old woman presented with a 2-week history of soreness in the right side of her low back that started after putting away boxes of Christmas decorations. No prior history of trauma was recalled. Physical examination was normal except for a tender bulge superior to the right iliac crest. Forceful coughing caused the bulge to increase in size. Lumbar radiographs and an MRI were read as normal. Surgery revealed a hernia in the region of the right Petit triangle, which was subsequently repaired, resulting in resolution of symptoms. A 52-year-old woman presented with chronic low back pain, described as bothering her for several years but increased in the previous 3 months. No recent trauma was recalled. She had been previously diagnosed with degenerative disk disease. New imaging studies, both plain film and MRI, confirmed degenerative disk disease and several bulging lumbar disks. Recent treatments included a failed course of spinal manipulation and a series of 3 epidural steroid injections, which also failed to provide relief. She was evaluated by a neurosurgeon who recommended that a laminectomy be performed. The patient presented to her primary care physician for preoperative clearance, at which time a palpable bulge and point tenderness were found in the area of complaint. She was referred to a general surgeon who subsequently found a hernia in the region of the left Petit triangle, which was surgically repaired. Spinal surgery was avoided, and the patient remained pain free through a 4-year follow-up period.

Discussion Description, and subsequent classification, of lumbar hernias has changed over the years. Early categories were based on the contents of the hernia. Most recently, Loukas et al 4,5 classified the 2 triangles into 4 types, depending on the surface area. Dividing each triangle into 4 types is rather complex and may be most useful for radiologists and surgeons. For the practitioner of manual medicine, knowledge of general anatomical locations, causes, and relevant clinical findings of lumbar hernias will provide for easier understanding and aid in improved clinical outcomes. Lumbar hernias may be congenital or acquired. Congenital cases are most rare and are often seen with other anomalies, such as undescended testes, bilateral renal agenesis, and lumbocostovertebral syndrome. 6

Lumbar hernia cases

75

Fig 1.

Diagram of the superior and inferior lumbar triangles.

Acquired lumbar hernias represent 80% of cases and are classified as either primary or secondary. Primary cases are nontraumatic and account for over half of acquired hernias. 4 Twenty-five percent of lumbar hernias are considered secondary. These are related to trauma, such as motor vehicle crashes, falls, and blunt trauma, or surgeries such as renal surgery, flank incisions, and iliac bone graft harvesting. 7,8 Contents of the hernias may be retroperitoneal fat, colon, small bowel, or kidney. The superior, or Grynfeltt, triangle (Fig 1) has an inconsistent morphology and, according to Watson, 9 may actually have a quadrilateral, deltoid, trapezoid, or polyhedral shape. The most consistent description in the literature is an inverted triangle, apex caudal, below the 12th rib. The medial border is the erector spinae muscle, and the internal oblique muscle forms the lateral border. Primary lesions in the superior triangle are seen more frequently than those in the lower triangle. This may be due to larger size and inherent weakness when compared with the lower triangle. 10 The inferior, or Petit, triangle is smaller than the superior and is positioned apex cephalic (Fig 1). The iliac crest forms the base, with the external oblique muscle forming the lateral border and the latissimus dorsi the medial. Secondary traumatic hernias are most often found in the inferior triangle. 11

Clinical findings are not always clear, but good palpation skills and a complete history will aid the clinician in making the correct diagnosis. Back and abdominal pain is common to many patients with lumbar hernias.12 It will typically be a vague soreness, with varying levels of intensity, but may be described by the patient as a specific site of tenderness. Palpation will help confirm one common clinical finding, a bulge, also often discovered by the patient, over either triangle. 10,13 The bulge may become more noticeable when coughing or straining, sometimes receding when lying prone. As with the cases described above, palpation helps distinguish defects in the triangles. Challenges to accurate diagnosis include individuals who have recently lost a considerable amount of weight or the obese patient, especially if the hernia is small. Common conditions that may cause the clinician to overlook a lumbar hernia may be lumbago, lumbar radicular syndrome, or lumbar somatic dysfunction. This problem will not have radicular signs or symptoms; and the area of complaint will be lateral to the spine, sometimes a specific point of pain. A lumbar hernia may be confused with a lipoma; tumor; chronic abscess; fibroma; or, if trauma has been involved, a flank hematoma, making advanced imaging a necessity. 14 Complications of lumbar hernias include incarceration, bowel obstruction, strangulation, and volvulus. 15,16 Surgery is the only treatment. 1 It is beyond the scope of

76 this article to go into surgical procedures used to repair these defects. Computerized tomography (CT) is a useful tool in differentiating lumbar hernias from other conditions. The literature is weighted toward the use of CT in the diagnosis of abdominal wall hernias. Although some authors reference the use of MRI, our literature search failed to identify any specific studies on the use of MR in diagnosing abdominal, in particular lumbar, hernias. One case report was found that supported the consideration of ultrasound in the diagnosis of lumbar hernias, due primarily to the portability of the modality, making it more accessible in some localities. 17 The ability to detect defects between muscular and fascial layers, visualize herniated viscera, and differentiate a hernia from renal and other soft-tissue tumors is one of the advantages described by several authors of CT over other imaging modalities. 11,15,16,18-20 Aguirre et al 20 express, among other justifications, the multiplanar capabilities of multi–detector row CT as being particularly useful because of the exceptional anatomical depiction.

Conclusions Lumbar triangle hernias are rarely reported, possibly because of a lack of clinical awareness. They may occur through defects in the inferior or superior triangles of the posterior abdominal wall. Accurate diagnosis may be a challenge. Improved understanding of the anatomy and associated clinical findings will help the practitioner of manual medicine place a timely referral if indicated. Advanced imaging, specifically MRI, failed to reveal lumbar hernias in the cases described in this report. The literature leans toward the use of CT to detect the defects associated with these conditions. The information from this case series suggests that it is important for the clinician to rely on a thorough history and physical examination, then order the appropriate diagnostic studies.

Funding sources and potential conflicts of interest No funding sources or conflicts of interest were reported for this study.

G. R. Lillie and E. Deppert

References 1. Armstrong O, Hamel A, Grignon B, NDoye JM, Hamel O, Robert R, et al. Lumbar hernia: anatomical basis and clinical aspects. Surg Radiol Anat 2008;30:533-7. 2. Cavallaro G, Sadighi A, Miceli M, Burza A, Carbone G, Cavallaro A. Primary lumbar hernia repair: the open approach. Eur Surg Res 2007;39:88-92. 3. Hsu SD, Shen KL, Liu HD, Chen TW, Yu JC. Lumbar hernia: clinical analysis of cases and review of the literature. Chir Gastroenterol 2008;24:221-4. 4. Loukas M, Tubbs R, El-Sedfy A, Jester A, Polepalli S, Kinsela C, et al. The clinical anatomy of the triangle of petit. Hernia 2007;11:441-4. 5. Loukas M, El-Zammar D, Shoja MM, Tubbs RS, Zhan L, Protyniak B, et al. The clinical anatomy of the triangle of Grynfeltt. Hernia 2008;12:227-31. 6. Parihar S, Bali G, Sharma S, Koul N. Congenital lumbar hernia. JK Science 2008;10(3):144-5. 7. Loukas M, Tubbs RS, Shoja M. Lumbar hernia, anatomical basis and clinical aspects. Letter to the editor; Surg Radiol Anat 2008;30:609-10. 8. Naidoo M, Singh B, Ramsaroop L, Satyapal KS. Inferior lumbar triangle hernia: a case report. East Afr Med J 2003;80(5): 277-80. 9. Watson L. Lumbar hernia. Hernia, 3rd ed. St Louis: CV Mosby; 1948. p. 446. 10. Zhou X, Nve JO, Chen G. Lumbar hernia: clinical analysis of 11 cases. Hernia 2004;8:260-3. 11. Hickey NA, Ryan MF, Hamilton PA, Bloom C, Murphy HP, Brenneman F. Computed tomography of traumatic abdominal wall hernia and associated deceleration injuries. Can Assoc Radiol J 2002;53(3):153-9. 12. Carbonell AM, Kercher KW, Sigmon L, Matthews BD, Sing RF, Kneisl JS, et al. A novel technique of lumbar hernia repair using bone anchor fixation. Hernia 2005;9:22-6. 13. Grauls A, Lallemand B, Krick M. The retroperitoneoscopic repair of a lumbar hernia of petit: case report and review of literature. Acta Chir Belg 2004;104:330-4. 14. Sarela AI, Mavanur AA, Bhaskar AA, Soonawala ZF, Devnani GG, Shah HK, et al. Post traumatic lumbar hernia. J Postgrad Med 1996;42:78-80. 15. Aguirre DA, Casola G, Sirlin C. Abdominal wall hernias: MDCT findings. AJR 2004;183:681-90. 16. Baker ME, Weinerth JL, Andriani RT, Cohan RH, Dunnick NR. Lumbar hernia: diagnosis by CT. AJR Am J Roentgenol 1987;148:565-7. 17. Siffring PA, Forrest TS, Frick MP. Hernias of the inferior lumbar space: diagnosis with US. Radiology 1989;170:190. 18. Killeen KL, Girard S, DeMeo JH, Shanmuganathan K, Mirvis SE. Using CT to diagnose traumatic lumbar hernia. AJR Am J Roentgenol 2000;174:1413-5. 19. Ng SS, Ng NC, Liu SY, Lee JF. Radiology for the surgeon: soft-tissue case 58. Can J Surg 2006;49(2):129-30. 20. Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics 2005;25: 1501-20.

Journal of Chiropractic Medicine (2010) 9, 77–83

www.journalchiromed.com

Management of a 59-year-old female patient with adult degenerative scoliosis using manipulation under anesthesia Mark W. Morningstar DC a,⁎, Megan N. Strauchman DO, MBA b a b

Private Chiropractic Practice, Grand Blanc, MI 48439 Private Medical Practice, Grand Blanc, MI 48439

Received 19 March 2009; received in revised form 15 January 2010; accepted 3 February 2010 Key indexing terms: Anesthesia; Manipulation; Spinal; Scoliosis; Chiropractic

Abstract Objective: 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. Clinical Features: 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. Intervention and Outcome: 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. Conclusion: Pain, functional, and radiographic outcomes demonstrated improvements immediately following treatment for this patient. © 2010 National University of Health Sciences.

Introduction ⁎ Corresponding author. Private Chiropractic Practice, 10683 S Saginaw St Suite B, Grand Blanc, MI 48439. E-mail addresses: [email protected] (M. W. Morningstar), [email protected] (M. N. Strauchman).

Manipulation under anesthesia (MUA) is an outpatient procedure that is performed to restore normal joint kinematics and musculoskeletal function. Manipulation under anesthesia for spinal conditions has been

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2010.02.002

78 performed at least as early as 1930. 1 In 1952, Siehl and Bradford 2 reported their results of 87 patients treated for lumbar disk herniation. Since that time, several case reports have been published on hundreds of patients on the clinical effectiveness of MUA 3-10 for chronic musculoskeletal pain and dysfunction. For example, in 1955, Mensor 3 reported results in 205 cases of lumbar intervertebral disk syndrome, wherein 51% of patients obtained a “good” or “excellent” result. In the largest study to date, Siehl 4 published his results of 666 cases of nonspecific back pain. About 90% of these patients received a “good” or “fair” result. Another 1986 study by Krumhansl and Nowacek6 showed that 75% of 171 patients rated their improvements as “much improved” or “cured.” More recently, a study by West et al 9 evaluated 177 patients 6 months and 2 years following spinal MUA. They found that pain medication use among patients after MUA was reduced by 58%; cervical and lumbar spine range-of-motion increased 47% and 83%, respectively; and visual analog scale scores decreased 62% in the cervical spine and 60% in the lumbar spine. These results were maintained at the 2-year follow-up. The clinical indications for MUA are quite comprehensive. These indications have been predominantly based on anecdotal evidence. However, there tends to be universal agreement on these indications. A list of the indications and contraindications can be found in Fig 1. This figure has been adapted from the curricula of 4 different postgraduate MUA courses. 11-14 Scoliosis is a condition that can cause chronic back pain in adulthood. 15 Nonsurgical treatment of scoliosis is typically designed to treat the pain and symptoms associated with scoliosis, rather than correcting the spinal curvature. Among these treatments includes pilates, chiropractic manipulation, and massage therapy, all of whose individual efficacy remains largely unknown. 16,17 The first line of conventional treatment of idiopathic scoliosis is usually observation, when the Cobb angle is less than 25° to 30°. 18 Many of these spinal curvatures never progress beyond this observational threshold. Therefore, a certain portion of patients with idiopathic scoliosis, even when diagnosed as a juvenile or adolescent, never end up having treatment of any kind beyond observation. However, scoliotic curvatures that remain into adulthood have a linear rate at which they progress. 19 Several case reports have been published about the clinical utility of MUA for chronic musculoskeletal pain and dysfunction. However, MUA has not yet been reported for use on a patient with adult degenerative scoliosis causing intractable pain that had been only

M. W. Morningstar and M. N. Strauchman Indications • Disk herniation/prolapse/protrusion/bulge • Joint or spinal ankylosis • Failed low back surgery • Nonsurgical conditions that have reached maximum medical improvement • Nonresponsive muscle contraction • Whiplash-associated disorders • Compression syndromes with nonosteophytic entrapment • Pain interfering with daily activities or sleep Contraindications • Malignancy • Bone metastasis • Bony tuberculosis • Acute fracture • Acute autoimmune arthritides • Acute gout • Venereal spinal or joint infiltration • Advanced osteoporosis • Osteomyelitis • Septicemia • Spondylolysis • Active spondylolisthesis

Fig 1. Indications and contraindications for MUA.

partially responsive to many other conservative therapies. This article presents a case of a patient with idiopathic lumbar degenerative scoliosis who developed intractable pain as an adult, wherein treatment as an adolescent was not sought. We report on the patient's history of her scoliosis, past treatment in adulthood, and her outcomes following a trial of MUA. The patient gave both verbal consent and HIPAAapproved written consent to have her results published.

Case report Clinical features A 59-year-old female patient presented to our office with a primary complaint of lower back and bilateral hip pain. The lower back pain was described as an intense ache that was unchanged by varying postures or movements. Her pain was reduced in the morning when arising from bed and gradually increased throughout the day. The pain was located bilaterally at approximately the L2-L5 paraspinal levels, with the left side being noticeably worse than the right. She also reported bilateral hip pain with radiation into the right sacroiliac joint and gluteal region. Although both hips were painful during movement, only the right hip was accompanied by radiating pain into the posterior thigh

Adult degenerative scoliosis and knee. Numerical pain rating scores (patient was asked what her pain was at that moment) were reported at 8 of 10 for the lower back and 9 of 10 for the sacroiliac joint/gluteal region. Lumbar spine flexion and extension were reduced by 66% and 75%, respectively; right lumbar lateral flexion was reduced by 80%; and left and right hip mobility was reduced in all planes. Palpatory tenderness was present over the right sacroiliac joint and piriformis muscle, as well as over the lumbar multifidis and quadratus lumborum bilaterally. The disability score using a functional rating index was 26 of 40 (or 64% disability). Radiographically, the patient's spinal curvature was located in the thoracolumbar spine, with a T11 upperend vertebra and L4 lower-end vertebra, with a 49° Cobb angle. Nash-Moe rotation of the apical L1 vertebra was 3+, with an apical deviation of 39 mm. With one exception, her chief complaints could not be aggravated by orthopedic testing of the lumbar spine and hip. However, a standing stork test demonstrated a sharp increase in pain in the right sacroiliac joint when standing on the right leg with the lower spine and pelvis slightly hyperextended. Based on the history and examination, the patient was diagnosed with right sacroiliitis and myofascitis of the right gluteal and erector spinae muscles. The patient's medical history included hysterectomy, with follow-up abdominal surgery to remove fibroadhesions. The patient had also been diagnosed with bilateral carpal tunnel syndrome via electrodiagnostic testing. No evidence of lumbar radiculopathy was found. Over the preceding 5 years, the patient had tried a number of conservative therapies to relieve her chief complaints. These included chiropractic manipulation weekly for 8 months, 12 consecutive weeks of physical therapy, 3 corticosteroid injections into the sacroiliac joints 6 to 8 weeks apart, an epidural steroid injection in the lumbar spine, massage therapy, nonsteroidal anti-inflammatory drugs, muscle relaxants, and opioid medications. Given the treatment history of the patient, including surgical history of fibroadhesions, the examining physician (MNS) recommended the MUA procedure. The patient was scheduled for preanesthesia testing. To determine if the patient was a suitable candidate for the anesthesia used during the MUA procedure, the patient was referred for the following standard preanesthesia testing: a Chem 18 panel, including prothrombin, partial thromboplastin time, and the international normalized ratio; a chest radiograph (because the patient was older than 50 years); and an electrocardiogram due to age and positive cardiovascular history

79 (hyperlipidemia, hypertension). Previous electrodiagnostic studies of the upper and lower extremities taken within the prior year were used to determine the patient's prognosis with MUA. Subjective and objective clinical determinants for MUA candidacy have been outlined as follows 20 : 1. Neuromusculoskeletal complaints that have only partially responded to manipulation, yet manipulation is still the therapy of choice. 2. Neuromusculoskeletal complaints that normally respond to manipulation, but the complaint is too painful to allow manipulative intervention. 3. Patients with chronic conditions that have previously been treated to maximum medical improvement, but the patient continues to experience regular exacerbations. 4. Patients who have been treated for 2 to 8 weeks but continue to maintain a pain threshold that disallows manipulative intervention. 5. Patients who cannot control voluntary muscle contraction during manipulation or are causing manipulative therapy to be prolonged. Manipulation under anesthesia would reduce the patient's treatment period. 6. Patients who are candidates for manipulation but the extent of the presenting injury has limited the effectiveness of in-office manipulation where more joint movement is necessary to produce expected clinical results. 7. Patients who are considered disk surgery patients but fall within the parameters of MUA, which may be an alternative or interim step and may be useful as either a therapeutic or diagnostic tool in determining the prognosis of the patient's care. 8. Patients who are candidates for manipulation, but because of restrictive adhesions causing articular fixation, are responding only minimally to clinical conservative care. Based upon one of the authors' (MNS) initial history of the patient, she felt that the patient was an MUA candidate based upon reasons 1, 5, and 8 above. Intervention and outcome Once MUA candidacy was approved, the patient was scheduled for a serial MUA over 3 days. The procedures were performed at an ambulatory surgical center in West Bloomfield, MI. Before the MUA, the patient was given robinol intravenously to decrease oral secretions and torodol to minimize postprocedural

80 discomfort. Once the anesthesiologist was ready, the patient was taken to the surgical suite where she was assisted into a deep conscious sedation using propofol. The patient was not responsive during the MUA. The MUA techniques used consisted of a combination of passive stretching and low-velocity/moderate-amplitude manipulative techniques for treating dysfunctional articulations. These techniques are modified to accommodate varying body types, conditions, as well as anatomical variations. These modifications are essential to prevent joint damage, ligamentous instability, and/or neurologic compromise. Passive stretching was combined with distraction to increase range of motion while decreasing fibroadhesions. Passive stretching was performed to each joint's elastic end range of motion and held there for approximately 15 to 20 seconds. Muscular trigger points were treated with percussive techniques or myofascial release techniques at the time of passive stretching to overcome any muscular resistance. Subsequent to the stretches, low-velocity/moderateamplitude articular manipulation was delivered to the dysfunctional spinopelvic segments. In this case, MUA techniques were performed on the thoracic spine, lumbar spine, pelvis, and hip joints bilaterally. These techniques are thoroughly illustrated by Gordon. 20 All of the procedures were performed by both of the authors in tandem. Because the patient was nonresponsive, one physician performed the techniques, whereas the other stabilized the patient. Following the conclu-

Fig 2. Photograph of vibration inversion therapy. The patient was inverted approximately 20° and vibrated at approximately 25 Hz. This procedure was performed at every office visit for the entire 8-week trial.

M. W. Morningstar and M. N. Strauchman

Fig 3. Image of external weighting system designed to facilitate correction of the thoracolumbar curvature while at home. She was instructed to wear these weights at home daily for 15 minutes beginning in week 3 of her care. These weights were specifically configured for her based upon her existing spinal structure, and she was radiographed while wearing the weights to ensure correct placement.

sion of the MUA, the patient was taken by hospital bed to recovery and was discharged without any intra- or postoperative complications. The patient was instructed to relax for the rest of the day and report back for days 2 and 3 of the serial MUA. Before days 2 and 3 of the MUA, the patient was assessed to document any subjective and objective improvements following the first MUA procedure. Subsequent MUAs are not administered if functional or subjective improvements are not observed, or if the patient improves 80% or more after the first MUA. However, a second and third MUA is scheduled if the patient makes an approximately 50% to 70% improvement following the prior MUA. 20 Each of the procedures discussed above was repeated on both days 2 and 3. When the patient was discharged on the third day, the author (MNS) prescribed 600 mg ibuprofen every 6 hours to mitigate the inflammatory response, thus inhibiting the reformation of fibroadhesions around the affected joint structures.

Adult degenerative scoliosis Following the MUA on the third day, the patient reported later in the afternoon for her first session of post-MUA rehabilitation therapy. This therapy was prescribed for 3 visits weekly for 8 weeks. During this visit, the patient again completed a functional rating index, which resulted in a score of 20 of 40 (or 50% disability). She stated that her pain level overall was 6 of 10 for both the lower back and hips. Initially, her first week of post-MUA therapy consisted mainly of passive procedures, such as cryotherapy, massage therapy, light assisted stretching, and intersegmental traction. She also received vibration inversion therapy to counteract the gravitational stress on her spinal curvature for approximately 10 minutes (Fig 2). As the patient progressed with care, she was also given an external weighting system developed by Pettibon (Chehalis, WA; patent #6,788,968; Fig 3). After 8 weeks of post-MUA therapy, the patient was again asked to complete a functional rating index and provide a numerical pain rating; and her ranges of motion in her lumbar spine and hips were observed. Her functional rating index score was 11 of 40, or 28% disability rating, whereas her pain scores were rated as 1 of 10 for the low back and 3 of 10 for the hips. Her lumbar flexion and extension both increased approximately 60%, whereas her hips significantly improved in all planes of motion. The patient verbalized that she was very pleased with her results. The patient's thoracolumbar spinal curvature improved on postinter-

Fig 4. Pre- and postintervention films showing Nash-Moe rotation of the apical L1 vertebra reduced to 2+.

81 vention radiograph to a 38° Cobb angle and an apical deviation of 31 mm (Fig 4). Upon release from therapy, the patient was instructed on specific home care stretches and exercises that had been previously performed in the clinic setting. She was told to perform these exercises twice a day, 3 days a week. All of the above values were maintained 6 months following her release from post-MUA therapy, including continued improvement in her functional rating index score (10/40 or 25% disability); lumbar flexion increased an additional 8%; and bilateral hip pain was rated at 2 of 10.

Discussion Previously reported data suggest that more than two thirds of adult scoliosis cases progress after skeletal maturity. 21 Whereas surgical management has been well documented, 22 conservative options for adult scoliosis are relatively scant.23-27 Therefore, any and all possible conservative treatment options should be investigated so that adult scoliosis patients have more care choices. The incidence of scoliosis is reportedly 2% to 3% of the population.28 We mention this because in a review by Kohlbeck and Haldeman, 29 they cite a total of 1525 peer-reviewed MUA cases. These patients were treated predominantly for chronic spine conditions not unlike our patient here. Applying this scoliosis incidence to these 1525 cases means that potentially 30 to 45 of these patients had scoliosis at the time of their MUA. However, we could not find any mention of scoliosis in our review of these articles. It may be prudent in the future to look at how different types of comorbid spinal pain syndromes may impact, or be impacted by, scoliosis. In our experience, because of the chronicity of our patient's complaints and the long history of scoliosis, we believed that an extremely protracted treatment plan would be required to significantly affect her scoliotic curvature, based upon research using the rehabilitative modalities outlined here. 23,24 Therefore, our decision to use MUA for this patient was at least partially based on ultimately wanting a shorter treatment duration. Using MUA in this particular case was based on the lack of flexibility and resultant pain found in the spine and hips. These symptoms had been largely unresponsive to other conservative approaches, including conventional chiropractic manipulation. Other researchers have reported that the addition of anesthesia

82 can significantly increase the flexibility of scoliotic curvatures, which can be a better predictor of surgical outcomes. 30 Our findings with this patient, as well as those findings of Ibrahim et al, 30 suggest that flexibility can be improved once normal reflexive muscle response is muted by the introduction of anesthesia. Historically, MUA has maintained a low rate of complications. Kohlbeck and Haldeman 29 identified a complication rate of 0.7% in their 2002 review. This rate compares favorably against injection therapy, for example, which has a range of 1.64% to 10% depending upon the anatomical region involved.31,32 This is an important statistic for patients in determining which therapies they would decide to pursue. By virtue of being a case report, we can only draw limited conclusions as a result of the study design. Following a course of 3 serial manipulations under anesthesia and 8 weeks of post-MUA therapy, the patient reported improved outcomes in activities of daily living and pain. Comparative radiographs demonstrated an improved spinal coronal balance and reduced Cobb angle measurement. Despite these demonstrated improvements, it is impossible to say for certain which specific modality(ies), if any, accounted for the observed improvements. Because conventional treatments for scoliosis are typically prescribed for adolescents and not adults, adult patients may often seek unconventional or alternative medicine treatment methods. The patient presented in this case study had pain that we believed ultimately arose from the presence of her lumbar degenerative scoliosis. This may be why her symptoms were largely unresponsive to other nonsurgical therapies. Our own theory is that the presence of chronic muscular contraction and ligamentous shortening in the concavities of scoliotic curvatures may be too much resistance for nonsurgical therapies to overcome. Therefore, we believe that the addition of MUA to this patient's total treatment plan allowed us to mobilize regions of her spine and pelvis, which was not successful by other means. Because the intensity and frequency of her symptoms would have likely interfered with the rehabilitation system used in this case, MUA was a critical piece of the treatment puzzle for this patient to achieve her good clinical outcome. We believe that adult patients with chronic degenerative scoliosis may benefit from serial MUA if their symptoms preclude performance of a comprehensive and moderately aggressive spinal rehabilitation program. This would include instances where reducing the scoliotic Cobb angle was not necessarily a goal of treatment.

M. W. Morningstar and M. N. Strauchman

Conclusion An adult patient with degenerative lumbar levoscoliosis was treated conservatively using MUA followed by 8 weeks of multimodal rehabilitation therapy. Pain, functional, and radiographic outcomes all demonstrated improvements immediately following treatment. These improvements were maintained 6 months following the conclusion of therapy. This case adds to the body of literature illustrating the use of MUA in cases where previous therapies were tried unsatisfactorily. Adults with scoliosis, who have few conservative treatment options to choose from, may be helped symptomatically and/or functionally by procedures like MUA that is designed to increase articular range of motion in a short period. Manipulation under anesthesia was performed on this adult patient with moderate degenerative scoliosis without any intra- or postoperative complications.

Funding sources and potential conflicts of interest No funding sources or conflicts of interest were reported for this study.

References 1. Riches EW. End-results of manipulation of the back. Lancet 1930;1:957-60. 2. Siehl D, Bradford WG. Manipulation of the low back under general anesthesia. J Am Osteopath Assoc 1952;52:239-42. 3. Mensor MC. Non-operative treatment, including manipulation, for lumbar intervertebral disc syndrome. J Bone J Surg 1955; 37A:925-36. 4. Siehl D. Manipulation of the spine under general anesthesia. J Am Osteopath Assoc 1963;62:881-7. 5. Morey LW. Osteopathic manipulation under general anesthesia. J Am Osteopath Assoc 1973;73:116-27. 6. Krumhansl BR, Nowacek CJ. Manipulation under anesthesia. In: Grieve GP, editor. Modern manual therapy of the vertebral column. Edinburgh: Churchill Livingstone; 1986. p. 777-86. 7. Greenman PE. Manipulation with the patient under anesthesia. J Am Osteopath Assoc 1992;92:1159-69. 8. Cremata E, Collins S, Clauson W, Solinger AB, Roberts ES. Manipulation under anesthesia: a report of 4 cases. J Manipulative Physiol Ther 2005;28:526-33. 9. West DT, Mathews RS, Miller MR, Kent GM. Effective management of spinal pain in one hundred seventy seven patients evaluated for manipulation under anesthesia. J Manipulative Physiol Ther 1999;22:299-308.

Adult degenerative scoliosis 10. Palmieri NF, Smoyak S. Chronic low back pain: a study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther 2002;25:E8-17. 11. Gordon R. Manipulation under anesthesia course notes. Lombard (Ill): Lincoln School of Postgraduate Education; 2001. 12. Francis R. Manipulation under anesthesia course notes. Pasadena (Tex): Texas Chiropractic College; 2000. 13. Cerf J, Salamone J. Manipulation under anesthesia course notes. Seneca Falls (NY): New York Chiropractic College; 2008. 14. Kelly W. Manipulation under anesthesia course notes. Bridgeport (Conn): College of Chiropractic, University of Bridgeport; 2006. 15. Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study. JAMA 2003;289:559-67. 16. Blum CL. Chiropractic and pilates therapy for the treatment of adult scoliosis. J Manipulative Physiol Ther 2002;25:E3. 17. Romano M, Negrini S. Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review. Scoliosis 2008;3:2. 18. Greiner KA. Adolescent idiopathic scoliosis: radiologic decision-making. Am Fam Physician 2002;65:1817-22. 19. Marty-Poumarat C, Scattin L, Marpeau M, Garreau de Loubresse C, Aegerter P. Natural history of progressive adult scoliosis. Spine 2007;32:1227-34. 20. Gordon RC, editor. Manipulation under anesthesia: concepts in theory and application. Boca Raton (Fla): CRC Press Taylor & Francis Group; 2005. 21. Weinstein SL. Natural history. Spine 1999;24:2592-600.

83 22. Aebi M. The adult scoliosis. Eur Spine J 2005;14:925-48. 23. Morningstar MW, Woggon D, Lawrence G. Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BMC Musculoskelet Disord 2004;5:32. 24. Morningstar MW, Joy T. Scoliosis treatment using spinal manipulation and the Pettibon weighting system: a summary of three atypical presentations. Chiropr Osteopath 2006;14:1. 25. Weiss HR. Influence of an in-patient exercise program on scoliotic curve. Ital J Orthop Traumatol 1992;18:395-406. 26. Tarola GA. Manipulation for the control of back pain and curve progression in patients with skeletally mature idiopathic scoliosis: two cases. J Manipulative Physiol Ther 1994;17: 253-7. 27. Negrini A, Parzini S, Negrini MG, Romano M, Atanasio S, Zaina F, et al. Adult scoliosis can be reduced through specific SEAS exercises: a case report. Scoliosis 2008;3:20. 28. Hawes MC. Scoliosis and the human spine. Tucson (Ariz): West Press; 2002. 29. Kohlbeck FJ, Haldeman S. Medication-assisted manipulation. Spine J 2002;2:288-302. 30. Ibrahim T, Gabbar OA, El-Abed K, Hutchinson MJ, Nelson IW. The value of radiographs obtained during forced traction under general anesthesia in predicting flexibility in idiopathic scoliosis with Cobb angles exceeding 60 degrees. J Bone J Surg Br 2008;90:1473-6. 31. Malhotra G, Abbasi A, Rhee M. Complications of transforaminal cervical epidural steroid injections. Spine 2009;34:731-9. 32. Bhargava A, DePalma MJ, Ludwig S, Gelb D, Slipman CW. Injection therapy for lumbar radiculopathy. Curr Opin Orthop 2005;16:152-7.

Journal of Chiropractic Medicine (2010) 9, 84–89

www.journalchiromed.com

Triad of spinal pain, spinal joint dysfunction, and extremity pain in 4 pediatric cases of bWii-itisQ: a 21st century pediatric condition Drew Rubin DC, CCSP, DACCP⁎ Adjunct Faculty, Departments of Clinical and Chiropractic Sciences, Life University, Marietta, GA 30067 Received 1 September 2009; received in revised form 20 December 2009; accepted 3 February 2010 Key indexing terms: Chiropractic; Children; Electronic equipment and supplies

Abstract Objective: 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. Clinical Features: 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. Intervention and Outcomes: Each of the 4 pediatric cases was evaluated and managed using chiropractic techniques. All patients successfully had their complaints resolve with 1 chiropractic visit. Conclusion: 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. © 2010 National University of Health Sciences.

Introduction There has been a rise in repetitive strain disorders that are a result of using portable electronic devices. With the significant rise in the utilization of cell

⁎ 255 Village Parkway, Suite 620, Marietta, GA 30067. Tel.: +1 770 937 6300; fax: +1 770 937 9296. E-mail address: [email protected].

phones, iPods (Apple Corporation, Cupertino, CA), computers, and video games, people of all ages are spending more and more time in sedentary positions, creating forward head posture, and experiencing an alarming rate of neck and shoulder pain, especially in pediatric populations. 1-4 Many adult patients who are in the business world use the Blackberry (Research in Motion, Waterloo, Ontario) and iPhone (Apple Corporation), which are mini-computer phones with Web accessibility. Overuse

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2010.02.003

21st century pediatric injury of this type of device has caused an increase in what has been dubbed by US News and World Report as the “Blackberry thumb.” Children also have trouble putting down their portable electronic gaming systems, such as the Nintendo DS (Redmond, WA) or Sony PSP (Sony Corporation of America, New York, NY). This has caused an increase in pediatric neck pain and in shoulder and hand pain, as well as raising the likelihood of forward posture. 1-4 In 2007, the Nintendo Wii, the latest in video game technology, was introduced. It combines the incredible graphics now available because of the vast improvement in microchip engineering with motionsensitive controllers that respond to one's every hand movement. This technological wonder has created a different and interactive way to play certain video games, especially games that involve sports. Rather than sit motionless with a controller in one's hands, the Wii enables the players' movements to be translated to the character they are controlling. For example, if the children are “bowling,” they actually move their arms and body as if they were holding and releasing the bowling ball itself. The advances in technology are brilliant, but the creators of the Wii most likely did not take into account 2 concerns. First, if children or adults play a sportsrelated video game on the Wii for hours at a time, it is possible that they may develop overuse or repetitive strain injuries. Second, injury may occur while using one's arms or body in a fast motion (ie, swinging a baseball bat, hitting a tennis ball), when there is no resistance offered either by the weight of the object they are holding or by the incoming object they are striking. If children are playing Nintendo Wii tennis and are “swinging a tennis racket,” when in fact they are not swinging anything but a Wii remote control that weighs a few ounces, this can potentially create a sprain/strain injury to the players' neck and upper extremities. This may be complicated when the normal counterforce of a tennis ball contacting a racket is nonexistent as well. The risk of injury may be heightened when the player is performing these repetitive motions over the course of several hours. The 4 cases presented in this article are reportedly due to overuse injuries caused by this uniquely 21st century device. The purpose of this article is to describe the objective and subjective complaints that a child or adult may present with associated with playing Wii games and what patterns may be seen so as to address this increasingly common problem with conservative chiropractic treatment.

85

Method Four pediatric patients presented to the author's chiropractic office with overuse injuries related to the use of the Nintendo Wii. Each patient had been a regular client in our office. Because they presented with new symptoms, each was given a brief reexamination to determine their status. They then were adjusted using the Activator Adjusting Instrument and in accordance with Activator protocols. Appropriate patient consent was obtained to publish this information. Case 1 The first patient was an 8-year-old athletic boy who had just received the Wii as a present the day before. He played on the Wii for 8 hours that day (with only a brief lunch break), after which he reported to his mother that he was tired and had a sore arm. The following day, the mother brought her son in with significant complaints of pain and stiffness in his right shoulder and neck. This was the first case of “Wii-itis” seen in the author's office. The discomfort had interfered with his ability to concentrate in school and hampered his playtime during gym class and recess. A cervical/thoracic spine examination revealed joint restrictions and slight discomfort. There was mild point tenderness about the cervical spine and during palpation of the cervical paravertebral musculature. There were mild paravertebral muscle spasms in the cervical region as well as trigger points in the surrounding tissues, especially on the right side. The left and right shoulder musculature was in mild spasm, and he complained that his neck was stiff while in motion. His right scapula was found to be hypomobile. He had slightly limited motion in right shoulder flexion and internal rotation. Segmental joint dysfunctions (ie, chiropractic subluxations) were found at the C2, C6, T2, and T4 segments. The right scapula was laterally misaligned, and the right humerus appeared posterior. Motion and static palpation of the cervical and thoracic vertebra indicated spinal joint dysfunctions at several levels. Postural deviations were noted, including right head tilt and a half-inch–high right shoulder. The child was diagnosed with cervicalgia (723.1) assumed to be from overuse of the Nintendo Wii, somatic dysfunction (cervical, 739.1; thoracic, 739.2), and shoulder pain (719.41). For purposes of this article, the triad of cervicalgia, spinal dysfunction/chiropractic subluxation, and upper extremity pain is identified as “Wii-itis.” Treatment consisted of conservative

86 chiropractic spinal manipulation using the Activator adjusting technique. Spinal manipulations were delivered to C2 and C6 at the lamina pedicle junction in an anterior, superior, and medial line of drive (LOD); T2 and T4 at the transverse process with an anterior and superior LOD; and the opposite rib in a lateral and inferior LOD. His right scapula was adjusted with the lateral scapula protocol, and the right posterior humerus was adjusted with an anterior LOD. Immediately after the treatment, he felt improvement, most notably in his neck. Prognosis for full recovery was good. The patient was told to not play any video games of any kind for 48 hours. He was advised to put ice on his neck and shoulders while watching television. By the next visit the following week, he reported full recovery in both his neck and upper extremity complaints. Cases 2 to 4 Cases 2 to 4 were 3 children from the same family. The parents had purchased a Wii device the prior weekend; and the parents reported that the children played “more than 10 hours in the last 2 days,” calling it a “Wii-a-thon.” The 3 children, ranging in age from 3 to 9 years old, all had similar complaints of pain and stiffness in the right side of the neck and right shoulder. The discomfort had interfered with their activities of normal daily living for all 3 children, including irritability in school and at home. An examination was performed on each child. The first child (case 2), a 9-year-old girl, had cervical and thoracic spinal joint restrictions; and she was mildly uncomfortable during palpation. There existed mild point tenderness about the cervical spine and during palpation of the cervical paravertebral musculature. There were mild paravertebral muscle spasms in the cervical region as well as trigger points in the surrounding tissues, especially on the right side. She had slightly limited motion in right shoulder flexion and internal rotation. The right scapula was laterally misaligned. Motion and static palpation of the cervical and thoracic vertebra indicated spinal joint dysfunctions at the C2, C5, and T4 segments. Postural deviations were noted, including a half-inch– high left shoulder. Examination of the second child (case 3), a 7-yearold boy, revealed a mild restriction in the child's upper cervical spine and in his midthoracic spine. There was mild point tenderness about the lower cervical spine and during palpation of the lower cervical paravertebral musculature. Motion and static palpation of the spine indicated spinal joint dysfunctions at C1, C6, and T3.

D. Rubin The shoulder misalignment pattern indicated that his right humerus was posterior and had a right shoulder trigger point. Postural deviations were noted, including right head tilt and half-inch–high right shoulder. The third child (case 4), a 3-year-old boy, had very mild point tenderness about the lower cervical spine and during palpation of the lower cervical paravertebral musculature. Motion and static palpation of the spine vertebra indicated spinal joint dysfunctions at 2 levels (C2 and T4). Postural deviations were evident, including slight anterior head tilt and slightly high right shoulder. The 3 children were diagnosed with the triad of cervicalgia (723.1), assumed to be due to overuse of the Wii; somatic dysfunction (cervical, 739.1; thoracic, 739.2); and shoulder pain (719.41). Treatment consisted of conservative chiropractic spinal manipulation using the Activator adjusting technique. For case 2, manipulations were delivered to C2 and C5 at the lamina pedicle junction in an anterior, superior, and medial LOD; T4 at the transverse process with an anterior and superior LOD; and the opposite rib in a lateral and inferior LOD. Her right scapula was adjusted with the lateral scapula protocol. Regarding case 3, manipulations were delivered to C1 with a medial LOD; C6 at the lamina pedicle junction in an anterior, superior, and medial LOD; T3 at the transverse process with an anterior and superior LOD; and the opposite rib in a lateral and inferior LOD. His right posterior humerus was adjusted with an anterior LOD; and a trigger point located in the right trapezius muscle, with an anterior inferior LOD. Case 4 manipulations were given at C2 lamina pedicle junction with an anterior, superior, and medial LOD; T4 transverse process with an anterior and superior LOD; and the opposite rib in a lateral and inferior LOD. Immediately after their treatment, each patient reported improvement, most notably in their neck and thoracic regions. The patients were told to refrain from playing any video games of any kind for 48 hours. The 7- and 9-year-old children were advised to put ice on their necks and shoulders while watching television. The 3-year-old boy was given a recommendation to take a bath. By the following visit the next week, they had full resolution of all complaints.

Discussion These 4 patient complaints temporally associated with playing a Wii device were similar in their histories

21st century pediatric injury (pediatric patients playing for hours on this particular video gaming system), presentation of subjective complaints (neck and shoulder pain), and objective findings (cervical and thoracic subluxations with scapula and/or humeral involvement). Of interest is that in the cases in which the scapula was misaligned, it was in a lateral malposition and that in the cases in which the humerus was misaligned, it was in a posterior mal-position. This article defines “Wii-itis” as having 3 components: spinal pain, spinal joint dysfunction (ie, chiropractic subluxation), and related extremity pain after playing on this particular gaming system. In the 4 presented cases, the triad is cervicalgia, cervical and thoracic joint dysfunctions, and shoulder pain. Future research is needed to assess why these gaming devices seem to create rapid overuse or repetitive strain disorders. As stated in Conservative Management of Sports Injuries, “In 80% of cases of overuse injuries, the young athlete has only recently taken up the sport.”5 A further question is to identify if extended playing of sports games on the Wii can cause these types of overuse injuries. Therefore, the possible mechanism of injury must be addressed. A number of the sports-based games played on the Wii involve the use of a single arm with a throwing/ swinging motion (pitching a baseball, throwing a bowling ball, hitting with a tennis racket). According to the Activator Method textbook, repetitive motions such as these can “… generate very high stresses in the rotator cuff.”6 These stresses can quickly accumulate, causing problems due to repetitive microtrauma. Hammer 7 defines repetitive microtrauma as “… cumulative forces over a period of time, as in throwing or racquet sports.” These forces will create tension in the shoulder stabilizers, increasing the likelihood of humeral head translation, thereby leading to instability. 7 This instability could also affect surrounding muscles and joints, such as the cervical spine, shoulder muscles, and scapula. Instability can lead to scapular dysfunction. Because the scapulothoracic region is the interface between the upper extremity and the torso, scapula involvement can affect the entire kinetic chain of the arm. 6 The kinetic chain of the arm begins with the cervical spine. Hence, playing for hours on this gaming system can potentially create an instability, causing an overuse syndrome due to the accumulation of repetitive microtraumas of the upper extremity kinetic chain. This may also explain the rapid recovery seen with these children because the Activator Method aims at addressing the entire kinetic chain from the cervical spine to the scapula adjustment. The 4-part scapula manipulation consists of working on

87 the scapula, humerus, ulna or radius, and the carpal bones. 6 Activator trigger point therapy was additionally used on case 3, which has been shown in a recent trial to have an immediate beneficial effect. 8 Sports-based games played on the Wii are not the only source of injury on a video gaming system. The recent introduction of games such as Rock Band and Guitar Hero, in which players “strum” a guitar or beat the equivalent of electronic drums in time with the music, has also created similar syndromes. Symptoms have been reported through blogs and news articles of wrist pain related to Guitar Hero. For example, there was a notable article on NBC sports regarding the Detroit Tigers' star pitcher missing games in the playoffs because of straining his wrist playing Guitar Hero (http://nbcsports.msnbc.com/id/16212095/). Presently, no reports of long-term or permanent shoulder or spinal injury due to playing on this system have been seen in the literature. In 2007 and 2008, 4 articles did appear in medical journals regarding “Acute Wii-itis” in shoulder injuries 9,10 and “Wii Knee.”11,12 A recent presentation at the American College of Rheumatology Annual Scientific Meeting measured wrist pain in children playing with video games. It was found that playing the Wii was associated with increased reporting of wrist pain. 13 No reports have appeared in peer-reviewed chiropractic journals regarding Wii injuries. However, in the August/September issue of Today's Chiropractic Lifestyle, a brief editorial outlined several Wii-related problems. 14 There have been some reports of blunt trauma from the use of the Wii found on the Internet. Hundreds of incidents on a popular blog entitled “Wii have a problem” (http://www.wiihaveaproblem.com) show children and adults with facial or arm trauma, including black eyes, due to being struck by another player holding a Wii remote. Serious injuries have occurred when children struck a window with a Wii remote, breaking the window and lacerating their hands in the process. Electronic devices are becoming a necessity to keep up with the fast pace of Western culture. Text messaging does have the potential to create repetitive strain injuries to the fingers or thumbs, and is being seen not only with older more established patients who carry the Blackberry or iPhone, but with younger preteens and teens with standard phones. 1-4,15 According to a survey by the Chartered Society of Physiotherapists in the United Kingdom, 1 in 6 teenagers reports discomfort in his or her hands when texting.15 Handheld games such as Nintendo DS are prevalent, and their regular use can cause an increase in neck and hand injuries as well as forward head positioning. 1-4

88 This may lead to cervical hypolordosis and thoracic kyphosis; so it is possible that when this current generation of children is in their 20s, their postures may show the results of years of anterior head tilt, which can lead to a large segment of that generation having poor posture. 1-4 Technology encompasses more than just electronic gaming devices. For instance, remote surgery is becoming a subspecialty in which a patient can be in one hospital and their surgeon in any other hospital in the world, provided both centers have the appropriate technology. 16 This certainly has its benefits; but as with all technological improvements, there are potential downsides. For example, there may be repercussions of not actually performing the task that your fine hand movements are initiating, both for the doctor performing the surgery and the patient being operated on. This may lead to the development of new forms of carpal tunnel, epicondylitis, or rotator cuff tendinitis from poor biomechanics leading to repetitive strain injuries in these doctors performing remote surgery. There exists in the literature a surprisingly small amount of information on 21st century injuries due to overuse or misuse of technology. Interestingly enough, there are many more orthopedic-related articles to 21st century footwear such as injuries from Heelys Street Gliders (Carrollton, TX). 17 Because doctors of chiropractic have been shown in a recent survey by the National Center for Complementary and Alternative Medicine to be taking care of 2.8% of children compared with 8.6% of adults, the chances of chiropractors seeing more pediatric patients is probable. 18 Doctors of chiropractic should become well versed not only in pediatric treatment (which includes the necessity for pediatric extremity adjusting), but also in their differential diagnosis and case presentation. More research needs to be done in this area to elucidate the causal relationship of these 21st century devices and the problems they are potentially creating. Limitations A limitation of this study is the small amount of subjects and the fact that this is a retrospective work rather than a clinical trial. A further limitation exists in that the injuries were all self-reported as being due to excessive playing on an electronic gaming device. These injuries all appeared to be due to such play activity, but a causal relationship could not be fully identified. A visual analog scale outcome tool to measuring pain was not used because it has been shown

D. Rubin in pediatric populations that these devices do not offer a high degree of validity. 19 Hence, in a further study, a different outcome measurement tool such as the Faces Pain Scale may be used.20

Conclusion Nintendo Wii–related injuries are currently a novel mechanism of trauma and hence are something that pediatric patients are very willing and eager to share with their clinician. But this will not always be the case, as are injuries currently seen in pediatrics due to highvolume text messaging, overuse of cell phones causing neck strain, or even back-pack–related injuries. These problems are very often an embarrassment for the child/ teenager and hence may not be the first words that come out of their mouth during the initial consultation. Doctors of chiropractic must use best clinical judgment as they negotiate the current trendy issues of today with their concomitant potential for injury.

Funding sources or potential conflicts of interest No funding sources or conflicts of interest were reported for this study.

References 1. Auvinen J, Tammelin T, Taimela S, Zitting P, Karppinen J. Neck and shoulder pains in relation to physical activity and sedentary activities in adolescence. Spine 2007;32(9):1038-44. 2. Gillespie RM. The physical impact of computers and electronic game use on children and adolescents, a review of current literature. Work 2002;3(18):249-59. 3. Straker L, Sullivan PO, Kendall G, et al. IT kids. Exposure to computers and adolescents neck posture and pain. Proceedings from: International Ergonomics Association 16th Annual Meeting; 2006. Maastricht, Netherlands. Available from: www.iea.cc/ergonomics4children/pdfs/art0211.pdf. 4. Ramos EM, James CA, Bear-Lehman J. Children's computer usage: are they at risk for developing repetitive strain injury? Work 2005;2(25):143-54. 5. Hyde TE, Gengenbach MS. Conservative management of sports injuries. 2nd ed. Boston: Jones and Bartlett; 2007. 6. Fuhr AW. The Activator method. 2nd ed. Philadelphia: Mosby; 2008. 7. Hammer WI. Functional soft tissue examination and treatment by manual methods. 3rd ed. Boston: Jones and Bartlett; 2007. 8. Gemmell H, Allen A. Relative immediate effect of ischaemic compression and activator trigger point therapy on active upper

21st century pediatric injury

9. 10.

11.

12. 13.

14. 15.

trapezius trigger points: a randomized trial. ClinChiropr 2008; 11(4):175-81. Bonis J. Acute Wiiitis. Correspondence. N Engl J Med 2007; 356:2341. Nett MP, Collins MS, Sperling JW. Magnetic resonance imaging of acute “wiiitis” of the upper extremity. Skeletal Radiol 2008;5(37):481-3. Hirpara KM, Abouazza OA. The “Wii Knee”: a case of patellar dislocation secondary to computer video games. Injury Extra 2008;3(39):86-7. Robinson RJ, Barron DA, Grainger AJ, Venkatesh R. Wii knee. Emerg Radiol 2008;4(15):255-7. Ince DC, Yazici Y. Wrist pain in 7-12 year olds playing with game consoles/handhelds. Proceedings of the ACR/ARHP Annual Scientific Meeting 2009; Oct 16-21. Philadelphia: American College of Rheumatology; 2009. Available from: http://acr.confex.com/acr/2009/webprogram/Paper15700.html. Dickinson M. Ow-Wii! Today's Chiropractic Lifestyle. August/September 2008: 37. Chartered Society of Physiotherapy Press Office [Homepage on the Internet]. Teenage text lives causing pain. July 29 2008.

89

16.

17.

18.

19.

20.

Available from: http://www.csp.org.uk/director/press/pressreleases. cfm?item_id=6EC2630D021AAA5FABD851B77BA460BE. Marescaux J, Leroy J, Rubino F, Smith M, Vix M, Simone M, et al. Transcontinental robot-assisted remote telesurgery: feasibility and potential applications. Ann Surg 2002;235(4): 487-92. Vioreanu M, Sheehan E, Glynn A, Casidy N, Stephens M, McCormack D. Heelys and Street Gliders injuries: a new type of pediatric injury. Pediatrics 2007;6(119):1294-8. Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complementary and alternative medicine use among adults and children: United States, 2007. Atlanta: Centers for Disease Control; 2008. Shields BJ, Cohen DM, Harbeck-Weber C, Powers JD, Smith GA. Pediatric pain measurement using a visual analog scale: a comparison of two teaching methods. Clin Pediatr (Phila) 2003; 42(3):227-34. Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale–Revised: toward a common metric in pediatric pain measurement. Pain 2001;93 (2):173-83.

Journal of Chiropractic Medicine (2010) 9, 90–94

www.journalchiromed.com

Upper cervical chiropractic care for a 25-year-old woman with myoclonic seizures Todd A. Hubbard DC a,⁎, Casey A. Crisp DC a , Brett Vowles DC b a b

Assistant Professor, Academic Health Center, Palmer College of Chiropractic, Davenport, IA 52803 Private Practice, Alpine, CA 91901

Received 27 October 2009; received in revised form 9 December 2009; accepted 11 March 2010 Key indexing terms: Manipulation, Chiropractic; Myoclonic epilepsy, Juvenile; Cervical, Atlas; Menstrual cycle

Abstract Objective: The purpose of this case report is to describe the chiropractic management using upper cervical techniques of a 25-year-old woman diagnosed with juvenile myoclonic epilepsy (JME). Clinical Features: A 25-year-old woman had a history of JME, which was diagnosed at the age of 14 years. Her seizure episodes began shortly after trauma to her cervical spine and the onset of menarche. Intervention and Outcome: After case history and physical examination, the patient received high-velocity, low-amplitude chiropractic spinal manipulation to her upper cervical spine using the Blair upper cervical chiropractic technique protocol. There was improvement in her seizure episodes and menstrual cycles following 12 weeks of chiropractic care. Conclusion: This case study demonstrated improvement in a young woman with a seizure disorder after she received upper cervical chiropractic manipulation. This case suggests the need for more rigorous research to examine how upper cervical chiropractic techniques may provide therapeutic benefit to patients with seizure disorders. © 2010 National University of Health Sciences.

Introduction Current estimates are that 2 million Americans have epilepsy; 125 000 new cases develop each year, with 50% of these cases occurring in children

⁎ Corresponding author. Academic Health Center, Palmer College of Chiropractic, 1000 Brady St., Davenport, IA 52803. Tel.: +1 563 884 5184; fax: +1 563 884 5470. E-mail address: [email protected] (T. A. Hubbard).

and adolescents. The prevalence of epilepsy in those younger than 18 years is estimated to be 4.7 per 1000. 1,2 Juvenile myoclonic epilepsy (JME) accounts for about 10% of all epileptic patients. It is the most common idiopathic generalized epileptic syndrome, having a prevalence of 10 to 20 per 100 000.2,3 Very few case reports have been published on chiropractic management of JME. The purpose of this article is to describe the chiropractic management of a patient with an 11-year history of JME.

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2010.03.001

Juvenile myoclonic seizure disorder

91

Case report A 25-year-old female patient had been diagnosed with JME by the Michigan Institute for Neurological Disorders in 1998, 11 years before presentation for care, and had experienced seizures throughout this time. Her seizures began when she was 14 years of age, when her menstrual cycle began. This time also coincided with a trauma in which she fell out of bed and hit her head on a desk 2 to 3 months before the seizures began. At the time of her first chiropractic visit, she was taking 200 mg of lamotrigine per day to control the seizure activity. Over the previous 11 years, she experienced 1 to 2 seizures per month. She reported that her menstrual cycles lasted approximately 10 days, with 10 to 15 days between cycles. She began using an intrauterine device to control heavy flow and maintain hormone levels once she began her menstrual cycles. She reported having a decrease in the frequency of seizures in the past with what she called a “more specific” chiropractic approach. However, she did not experience similar results from other types of chiropractic treatment. Physical examination showed normal cervical spine range of motion with local neck pain upon the Soto-Hall maneuver. Cranial nerve, deep tendon reflexes, and

Fig 1. Base posterior radiograph. The right and left occipital condyles-lateral mass articulations are outlined to show the center of each joint. A, The right “condyle convergence angle.” B, The left “condyle convergence angle.”

Fig 2. The left Blair protractoview. The most lateral end of the superior articulating surface of the lateral mass is lateral to the most lateral tip of the inferior articulating surface of the occipital condyle. This is determined to be an ASL misalignment of the left occipitoatlantal articulation.

muscles strength tests were unremarkable. The Commission on the Outcome Measurement in Epilepsy states that there is no single standard outcome measure used to rate seizure activity and that the outcome used should focus on the health-related quality of life.4 Therefore, we used the Bournemouth Neck Questionnaire (BNQ) and the Headache Disability Index (HDI)5,6 and instructed her to replace the word pain with seizures when answering the questions. The BNQ scored 90%, and the HDI scored 76 overall (E = 44, F = 32). The Blair upper cervical chiropractic technique protocols were used to guide treatment for this patient. This technique uses a base posterior radiograph (Fig 1) to find the occipital condyle convergence angle for the left and right condyle. From the occipital convergence angle, an oblique nasium radiograph, called the Blair protractoview (PV), is exposed down the center of the left (Fig 2) and right (Fig 3) condyles. This measurement attempts to determine occipitoatlantal alignment. The patient's PV indicated a misalignment of the C1 vertebra to be anterior-superior-left (ASL), compared with the occiput. The PVs also showed the inferior articulating surface of her right condyle to be relatively steep (44°). With an inferior condyle articulation greater than 40°, Blair protocol is to manipulate (ie, adjust) the ASL misalignment from the right. With this particular

92

Fig 3. The right Blair protractoview. The most lateral occipital condyle and lateral mass articulation surfaces are under each other. There is no misalignment of the right occipitoatlantal articulation.

misalignment, the right posterior arch is used as a lever to manipulate the joint, pulling it toward the correct position. The spinal manipulation therapy (SMT) was given using a side-posture, toggle table, incorporating a modified high-velocity and low-amplitude Palmer Hole In One (HIO) toggle manipulation. The patient was seen 11 times over a period of 12 weeks. She received 3 Blair spinal manipulations to her C1 during this time. She reported having 1 seizure a few days after the first manipulation. Since that time, she had reported no seizure episodes. She reported 6 episodes of minor twitching that did not progress into seizure. She also reported that her last 2 menstrual cycles lasted less than 7 days and were 28 days apart. Her follow-up BNQ and HDI questionnaire scores were 0 and 4 (E = 4, F = 0), respectively. Written consent from the patient was obtained allowing us to publish her personal health information without divulging personal identifiers.

Discussion The onset of JME may occur from 6 to 22 years of age. Symptoms include myoclonic jerks, often associated with generalized tonic-clonic seizures and absence

T. A. Hubbard et al. seizures. 2 There are typically no abnormalities seen on clinical examination or any intellectual deficits associated with JME. It is nonprogressive. 2 The etiology of JME is thought to stem from genetics. 2,3,7 Patients report that certain factors such as sleep deprivation, menses, alcohol, and overall stress can increase their incidence of seizure. 2,3,8 The most characteristic electroencephalographic pattern is generalized multiple high-frequency spikes followed by slower waves. 2,8 Neuroimaging studies generally show no abnormalities. Atypical presentations are often misdiagnosed. 2 The diagnosis of JME can be difficult because it can clinically mimic other disorders. Such disorders include forms of generalized epilepsy, lipid storage disorders, nonepileptic seizures, postanoxic myoclonus, and other seizure disorders. Thus, it is critical to perform a thorough patient history, focusing on precipitating seizure factors; it is also important to conduct an electroencephalogram. 2,3,7 Medical approaches to management of JME involve antiepileptic drugs (AEDs), the most common of which is valproic acid. Other AEDs include lamotrigine, topiramate, zonisamide, levetiracetam, and benzodiazepines. 2,3,8 Juvenile myoclonic epilepsy is a lifelong disorder. Treatment is often continued indefinitely to prevent recurrences, which are frequent. Seizure recurrence, which can return months to years after discontinuation of AEDs, may lead to status epilepticus. 2 Alternative and complementary options to the medical treatment of JME are few. However, there is some evidence that spinal manipulation may be helpful in the treatment of JME. A case report by Goodman and Mosby 9 discussed a 5-year-old girl who experienced seizures after head trauma. There was substantial occipital-atlantal-axial misalignment. After 1 month of care involving spinal manipulation to the upper cervical area, she experienced cessation of her seizures. Another case reported a patient with a history of low back pain and clonic-tonic seizures approximately every 3 hours. 10 The patient received spinal manipulative care. At 1.5-year follow-up, she had intermittent short-duration seizures spaced up to 2 months apart. 10 A literature review by Pistolese 1 states that a potential exists for a chiropractic management approach to epileptic seizures. Christensen et al 11 conducted a population-based cohort study of more than 1.5 million people and found that the relative risk of epilepsy raised about 2-fold after mild head injury, which our patient had, and 7-fold after a severe head injury. Incidence was slightly greater in women than in men. Our patient fell out of bed, hitting her head on a nightstand, which may have

Juvenile myoclonic seizure disorder caused trauma to her head and cervical spine. Trauma to the cervical spine has been assumed to be a cause of spinal segmental dysfunction. 12 There are several theories that may explain how SMT may have been of benefit to this patient. The first involves displacement of the C1 vertebrae, placing pressure or torsion on the carotid sheath containing the common carotid artery; internal carotid artery; internal jugular vein; and glossopharyngeal, vagus, and spinal accessory nerves.13,14 A second theory arises from torsion or pressure upon the superior cervical ganglion located at the vertebral body of the axis and posterior to the carotid sheath.15 Vagal nerve stimulation, which is reported as an acceptable treatment of epilepsy, has been shown to reduce seizure frequency, even in pharmacoresistant generalized epilepsies. 16 This may be a reason why we saw an improvement in the patient's seizure frequency following SMT to the C1 vertebrae. There is also the Grostic dentate ligamentcord distortion hypothesis, which describes the possibility of mechanical irritation and ischemia of the cord caused by abnormal tension on the dura when the upper cervical segmental dysfunction is present. 17 Pickar 18 states that there is evidence demonstrating that SMT evokes paraspinal muscle reflexes and alters motoneuron excitability. He states that “sensory input from paraspinal tissues can evoke visceral reflexes affecting the sympathetic nervous system and may alter end-organ function.” 18 Noxious paraspinal sensory input, which may be caused by the spinal segmental dysfunction, appears to have an excitatory effect on sympathetic outflow. Correcting the segmental dysfunction through SMT may normalize the sensory input, thus having an inhibitory effect on somatovisceral reflexes. 18 A study conducted by Matsumoto et al 19 found that women who suffered from more symptomatic premenstrual phases had a higher level of sympathetic nerve activity. Levine 20 states that cervical spondylotic myelopathy may be caused by tensile stress transmitted to the spinal cord by the dentate ligaments that may cause stress at the lateral columns of the spinal cord. This stress may be the cause of noxious sympathetic input causing abnormal viscerosomatic effects. Noxious sympathetic input causing a higher level of sympathetic nerve activity may have been causing our patient's abnormal menstrual cycle, which is a known trigger for seizure activity. 2,8 Our patient also reported that her menstrual cycle normalized after treatment. She stated in her history that her menses started around the same time as her epileptic seizures. Alfradique and Vasconcelos 2 and

93 Sokic et al 8 have reported menses as a trigger for epileptic seizures. However, we cannot be sure if there was a direct link between the cessation of our patient's seizure episodes, SMT, and the return of a normal menstrual cycle. More research is needed to investigate this question. The most common medical treatments have inconsistent success, which was the case here. 3 Drug treatment of JME is mainly based on clinical experience and prospective and retrospective studies, with little evidence from randomized clinical trials. 21 There are few head-to-head comparisons between old and new AEDs. Valproate is the drug of first choice in men with JME. 21 In women, lamotrigine (which our patient was taking) would be considered first because of the teratogenicity and adverse effects of valproate. Levetiracetam is also effective. Recent data suggest that it may soon be used as a first-line treatment. Some AEDs can aggravate JME. 2,21 In addition to AEDs, nonpharmacologic treatments are important in JME. Juvenile myoclonic epilepsy usually requires lifelong treatment because seizures nearly always return after withdrawal of therapy. 22 Valproate and lamotrigine have shown to produce a complete remission of seizures in a majority of patients. It may be possible that our patient is experiencing a remission phase due to the medication she has been taking. 2,3,8 However, our patient informed us that she has reduced her lamotrigine dosage to 50 mg/ d without a return of the seizures. Limitations Because this is a case report, it is not possible to generalize this treatment approach to all myoclonic seizure patients. Because of the cyclic nature of JME, we do not know if the improvements seen in this patient are from the SMT or if we are entering a cyclic phase sometimes seen with seizure disorders. 22 A JME patient will need lifelong follow-up care for the possibility of reoccurrence of seizure episodes. This follow-up care would enable the patient to be treated if she had entered an absence phase of her seizures or reoccurring episodes begin; current literature states that this is likely. 2,22 In our attempt to use outcome measures for this study, we chose to use the BNQ and HDI and replace pain with seizure. Anytime an outcome instrument is revised or used in an alternate setting, its validity and reliability need to be studied. Therefore, although our pre- and postintervention scores for these outcome measures decreased substantially, we cannot view their validity and reliability as we would have if they had not

94 been altered. Furthermore, the Commission on Outcome Measurement in Epilepsy states there is no one outcome measure that is recommended. 4 Some of the current epilepsy-specific health-related quality of life instruments are the Liverpool Health-Related Quality of Life Battery, the Quality of Life in Epilepsy instruments, and the Impact of Childhood Illness Scale. Outcome measures related to global evaluation that are useful include the RAND 36-item Health Survey, the Nottingham Health Profile, the Sickness Impact Profile, and the Dartmouth COOP Function Charts. Future assessments of the epileptic patient should include one of these outcome measures.

Conclusion This case is interesting and novel because the patient experienced a cessation of her JME seizures following upper cervical chiropractic treatment. The potential relationship between first cervical vertebrae misalignment and JME seizures is not yet known, and there are no studies that have been performed investigating this relationship. Based upon our clinical observations, there might be a correlation between the specific SMT and this patient's relief of symptoms. Future clinical trials need to be conducted to investigate the role of chiropractic care in the treatment of JME.

Acknowledgment The authors acknowledge Dr Dana Lawrence for his help in editing and guidance in the writing of this case report.

Funding sources and potential conflicts of interest Dr. Hubbard is a member of the Blair Upper Cervical Chiropractic Society. Dr Hubbard is a Board member and Past President. Dr. Hubbard is a Certified Advanced Instructor of Blair Upper Cervical technique and receives income from teaching this technique. No outside funding was accepted for this project.

References 1. Pistolese RA. Epilepsy and seizure disorders: a review of literature relative to chiropractic care of children. J Manipulative Physiol Ther 2001;24(3):199.

T. A. Hubbard et al. 2. Alfradique I, Vasconcelos MM. Juvenile myoclonic epilepsy. Arq Neuropsiquiatr 2007;65(4B):1266-71. 3. Abou-Khalil BW. Juvenile myoclonic epilepsy: more trials are needed to guide therapy. Epilepsy Curr 2009;9(1):10-1. 4. Baker GA, Camfield C, Camfield P, et al. Commission on Outcome Measurement in Epilepsy 1994-1997: final report. Epilepsia 1998;39:213-31. 5. Bolton JE, Humphreys BK. The Bournemouth Questionnaire: a short-form comprehensive outcome measure. II. Psychometric properties in neck pain patients. J Manipulative Physiol Ther 2002;25(3):141-8. 6. Jacobson GP, Ramadan NM, et al. The Henry Ford Hospital headache disability inventory (HDI). Neurology 1994;44:837-42. 7. Welty TE. Juvenile myoclonic epilepsy: epidemiology, pathophysiology, and management. Paediatr Drugs 2006;8(5):303-10. 8. Sokic D, Ristic AJ, Vojvodic N, Jankovic S, Sindjelic AR. Frequency, causes and phenomenology of late seizure recurrence in patients with juvenile myoclonic epilepsy after a long period of remission. Seizure 2007;16(6):533-7. 9. Goodman RJ, Mosby J. Cessation of a seizure disorder: correction of the atlas subluxation complex. Chiropractic 1990;6(2):43-6. 10. Alcantara J, Heschong R, Plaugher G, Alcantara J. Chiropractic management of a patient with subluxations, low back pain and epileptic seizures. J Manipulative Physiol Ther 1998;21 (6):410-8. 11. Christensen J, Pedersen MG, Pedersen CB, Sidenius P, Olsen J, Vestergaard M. Long-term risk of epilepsy after traumatic brain injury in children and young adults: a population-based cohort study. Lancet 2009;373(9669):1105-10. 12. Palmer DD. Tone and function. In: The chiropractor's adjuster: the science, art and philosophy of chiropractic. Portland, OR: Portland Publishing Group Co; 1910. p. 363-8. 13. Standring S, editor. Head and neck. In: Gray's anatomy; the anatomical basis of clinical practice. 39th ed. Edinburgh: Churchill Livingstone; 2005. p. 542-54. 14. Ozveren MF, Ture U, Ozek MM, Pamir MN. Anatomic landmarks of the glossopharyngeal nerve: a microsurgical anatomic study. Neurosurgery 2003;52(6):1400-10 [discussion 1410]. 15. Knutson GA. Significant changes in systolic blood pressure post vectored upper cervical adjustment vs resting control groups: a possible effect of the cervicosympathetic and/or pressor reflex. J Manipulative Physiol Ther 2001;24(2):101-9. 16. Kostov H, Larsson PG, Røste GK. Vagus nerve stimulation for generalized epilepsy. Show me the evidence; accession number: 13774998. Acta Neurol Scand Suppl 2007;187:55-8. 17. Grostic JD. Dentate ligament-cord distortion hypothesis. Chiropr Res J 1988;1(1):47-55. 18. Pickar JG. Neurophysiological effects of spinal manipulation. Spine J 2002;2(5):357-71. 19. Matsumoto T, Ushiroyama T, Morimura M, Hayashi T, Moritani T. Sympatho-vagal activities during the menstrual cycle of eumenorrheic women with premenstrual symptomatology. Int Congr Ser 2006;1287:323-8. 20. Levine DN. Pathogenesis of cervical spondylotic myelopathy. J Neurol Neurosurg Psychiatry 1997;62(4):334-40. 21. Wheless JW, Clarke DF, Arzimanoglou A, Carpenter D. Treatment of pediatric epilepsy: European expert opinion, 2007. Epileptic Disord 2007;9(4):353-412. 22. Auvin S. Treatment of juvenile myoclonic epilepsy. CNS Neurosci Ther 2008;14(3):227-33.

Journal of Chiropractic Medicine (2010) 9, 95–97

www.journalchiromed.com

Letters to the Editor The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature To the Editor: The Cooperstein and Lew 1 article, “The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature,” referenced our work.2 We feel that their statements should distinguish between anatomical leg length inequality (LLI) and functional LLI. In the discussion section, they indicated that there was “… poor agreement found by Rhodes et al. between visual methods of leg checking and upright radiographs.” We reported the relationship between prone LLI measurements and standing radiograph as “The … correlation coefficient (r) between the two variables was … 0.719.”2 Most statisticians characterize this as a moderate positive correlation and not “poor agreement.” Anatomical LLI exists. The LLI incidence is not known perhaps because of confused definitions. Mannello3 stated, “It appears that the least controversial issue associated with LLI is its anatomical existence.” As we previously stated, 2 “Structural, anatomical or actual LLI are synonymous terms and are diagnosed when either the femur or tibia is longer in one leg than in the other, as shown on X-ray.” Mannello3 defined it similarly. Anatomical LLI denotes different bones lengths of right and left lower extremities. The criterion standard for anatomical LLI is the scanogram, radiograph of both femurs and tibias; so comparisons can be made. Of the scanogram, Mannello 3 said, “This procedure is considered a valid indicator of lower extremity length.” The Cooperstein and Lew review on anatomical LLI did not include any studies involving actual bony differences in leg length. However, Mannello 3 pointed out, “Others define anatomical short leg as that which is shorter in length from the floor to the weight bearing surface of the femoral head.” This seems to be the definition adopted by Cooperstein and

Lew, but no definition of anatomical LLI was included in their review. Of the 9 studies in their review, 7 involved simulated LLI, with no anatomical bone length differences seen on radiograph. Of the other 2 included, one used tape measures of legs, which have been shown to be unreliable; as Cooperstein and Lew 1 pointed out in their article, “Tape measure methods for measuring LLI have been found to be of equivocal accuracy and may be less accurate than radiological criterion standard method for assessing anatomical LLI.…” The other study included used radiographs of the femur heads, without full views of both lower extremities (Friberg 4 method). A developer of that radiograph technique stated, “The method described here is not meant to substitute the methods for measuring accurately the length of the different parts of the lower extremity.” 4 One cannot distinguish anatomical (structural) LLI from functional LLI with the Friberg method of comparison. Methods that incorporate both anatomical and functional LLI without distinction (eg, Friberg method) necessarily overestimate the incidence of anatomical LLI 5 compared with a stricter definition. D. Wayne Rhodes DC, PhD Private Practice of Chiropractic Tuscaloosa, AL 35401 E-mail address: [email protected] Phillip A. Bishop EdD Professor Department of Kinesiology University of Alabama

References 1. Cooperstein R, Lew M. The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature. J Chiropr Med 2009;8(3):107-18. 2. Rhodes DW, Mansfield ER, Bishop PA, Smith JF. The validity of the prone leg check as an estimate of standing leg length inequality measured by X-ray. J Manipulative Physiol Ther 1995;18(6):343-6.

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2010.02.006

96 3. Mannello DM. Leg length inequality. J Manipulative Physiol Ther 1992;15(9):576-90. 4. Friberg O, Koivisto E, Wegelius C. A radiographic method for measurement of leg length inequality. Diagn Imag Clin Med 1985;54:78-81. 5. Knutson GA. Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance. Chiropr Osteopat 2005;13 (1):11.

The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature In Reply: We appreciate the opportunity to explore issues related to the appropriate use of statistical analysis to

Letters to the Editor determine level of agreement between measuring methods. Our correspondent feels we misrepresented the findings by Rhodes et al1 by stating there was “poor agreement found … between visual methods of leg checking and upright radiographs.”2 The authors found that the correlation coefficient (r) was 0.719 and conclude, “most statisticians characterize this as a ‘moderate positive’ correlation.” We did not consider this finding as relevant as the investigators' own qualitative interpretation: “Results indicated … the relationship was not as strong as anticipated. Measurement differences between methods in this investigation, which were greater than 3 mm 48% of the time, indicated that prone measurement by itself is not accurate as a predictor of X-ray leg length differences.” The results section of the Rhodes et al article documents considerable divergence of the prone leg check and radiographic findings. The highly dispersed scatter plot in their Fig 2 speaks for itself; the

Fig 1. Upper left, scatterplot and trendline for raw data; upper right, limits of agreement; lower left, Bland-Altman plot; lower right, histogram of differences. (Color version of figure is available online.)

96 3. Mannello DM. Leg length inequality. J Manipulative Physiol Ther 1992;15(9):576-90. 4. Friberg O, Koivisto E, Wegelius C. A radiographic method for measurement of leg length inequality. Diagn Imag Clin Med 1985;54:78-81. 5. Knutson GA. Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance. Chiropr Osteopat 2005;13 (1):11.

The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature In Reply: We appreciate the opportunity to explore issues related to the appropriate use of statistical analysis to

Letters to the Editor determine level of agreement between measuring methods. Our correspondent feels we misrepresented the findings by Rhodes et al1 by stating there was “poor agreement found … between visual methods of leg checking and upright radiographs.”2 The authors found that the correlation coefficient (r) was 0.719 and conclude, “most statisticians characterize this as a ‘moderate positive’ correlation.” We did not consider this finding as relevant as the investigators' own qualitative interpretation: “Results indicated … the relationship was not as strong as anticipated. Measurement differences between methods in this investigation, which were greater than 3 mm 48% of the time, indicated that prone measurement by itself is not accurate as a predictor of X-ray leg length differences.” The results section of the Rhodes et al article documents considerable divergence of the prone leg check and radiographic findings. The highly dispersed scatter plot in their Fig 2 speaks for itself; the

Fig 1. Upper left, scatterplot and trendline for raw data; upper right, limits of agreement; lower left, Bland-Altman plot; lower right, histogram of differences. (Color version of figure is available online.)

Letters to the Editor interpretation of the slope of the regression line is mathematically incorrect and thus misleading. How can we reconcile a high value for the Pearson product moment correlation coefficient (r), whereas inspection of the data tells a different story? Bland and Altman 3 discuss the common error of using the Pearson statistic to determine agreement between 2 measuring methods: “r measures the strength of a relation between two variables, not the agreement between them … it would be amazing if two methods designed to measure the same quantity were not related.” As an alternative, Bland and Altman advocate a “difference vs means plot,” which plots the difference between measures as a function of their average. It includes confidence intervals between which 95% of the differences would lie (“limits of agreement”). Because Rhodes et al provided their raw data, we were able to calculate the following: lower limit = −11.6 mm, upper limit = 10.4 mm (Fig 1). The statistical calculations and outputs were performed using Analyse-it version 2.21 (Analyse-it Software, Ltd; Leeds, United Kingdom). More simply, the standard deviation of the absolute value of the differences between the 2 measuring methods is 5.6 mm; so 95% of the differences would be about ±11 mm. Although the Pearson value of 0.719 shows high correlation between prone leg checks and radiograph measures, at best, they will be within about a centimeter of each other. Although our correspondent states that we should have distinguished between anatomical and functional leg length inequality (LLI), we cannot determine why, nor why “Methods which incorporate both anatomical and functional LLI without distinction … overestimate the incidence of anatomical LLI.” We do not believe

97 that weight-bearing LLI includes a functional component. In our view, functional LLI can only manifest in the non–weight-bearing position, when asymmetry in suprapelvic muscle tone may pull on the iliac crest and thus the lower extremity on that side, creating an apparent short leg. 4-7 Robert Cooperstein MA, DC Palmer College of Chiropractic West E-mail address: [email protected]

References 1. Rhodes DW, Mansfield ER, Bishop PA, Smith JF. The validity of the prone leg check as an estimate of standing leg length inequality measured by X-ray. J Manipulative Physiol Ther 1995;18(6):343-6. 2. Cooperstein R, Lew M. The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature. J Chiropr Med 2009;8(3):107-18. 3. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1(8476):307-10. 4. Cooperstein R, Laguex M. Concurrent validity of tape measure methods for determining leg length inequality compared to a radiographic reference standard. J Chiropr Educ [in press]. 5. Schneider M. The “muscular” short leg. Am J Clin Chiropr 1993;3(3):8. 6. Cooperstein R. Functional leg length inequality: geometric analysis and an alternative muscular model. 8th Annual Conference on Research and Education. Monterey, California: Consortium for Chiropractic Research California Chiropractic Association; 1993. p. 202-3. 7. Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual. The lower extremities. Baltimore: Williams and Wilkins; 1992.

Journal of Chiropractic Medicine (2010) 9, 98

www.journalchiromed.com

News item

The American Chiropractic Board of Sports Physicians wishes to congratulate the following doctors for receiving their DACBSP and CCSP certifications in 2009 DACBSP David R. Holmes, DC Todd M. Narson, DC

Paul L. Peters, DC Brian R. Saul, DC

Allen M. Manison, DC Scott D. Vanina, DC CCSP

Jennifer Ann Amato, DC Jason W. Amstutz, DC Holly B. Anderson, DC Rebecca J. Ault, DC Robert J. Ault, DC David Vincent Avolio, DC Jonathan K. Bafford, DC Lori A. Baggett, DC Craig C. Banks, DC Alicia L. Barnes, DC Steven Barrett, DC Robert H. Beam, Jr, DC Daniel J. Becker, DC Douglas E. Bedichek, DC Brock A. Bennett, DC Julie L. Blavier, DC Joshua J. Bletzinger, DC Robert M. Blum, DC Gerard J. Bogin, DC Gregory S. Cartmell, DC Mark H. Chen, DC Ronald Clary, Jr, DC John E. Clayton, IV, DC Gregory E. Cobb, DC A. Chandler Collins, DC Robert Charles Cooper, DC Thomas Crabbe, DC Sandra Aurelia Cramer, DC Renee Ann Daly, DC Michael C. D'Arienzo, DC David A. Dewar, DC Daniel T. DiCesaro, DC L. Darin Dunnagan, DC Joy M. Dunwoodie, DC John W. Emde, DC

Brad Patrick Farra, DC Ruth Ann Fernandez, DC Marian H. Fish, DC Robert H. George, DC Adam Gillman, DC Terence Golden, DC Christopher Good, DC Peter G. Gorman, DC Kirsten S. Grove, DC Lance E. Groves, DC A. Carlo Guadagno, DC Christopher M. Hall, DC Justin M. Hamblet, DC Matthew T. Hartsburg, DC Drew Hohensee, DC Jeffrey A. Holtz, DC Arthur Hong, DC George Rolland House, III, DC Coby Johns, DC Julia Crystal Johnson, DC Tanya K. Kekki, DC Ross Christopher Keys, DC Zareena Khan, DC Dio Kim, DC Jeffery P. Konwinski, DC Scott Charles Kopazna, DC Theresa Ann Krawczyk, DC Martin V. Kunz, DC Danny J. Kurth, DC Christopher M. Land, DC Jamie Marie Lenz, DC Zachary Z. Leslie, DC William R. Mackenzie, DC William P. Macnamara, III, DC

C. Dax Maggiore, DC Edward John Mallen, DC Martin E. Manzo, DC Kevin M. Marcinkowski, DC Denise Anne Martino, DC Roni Yoshiko Matsumoto, DC Lauren E. McCabe, DC Casey A. McKeown, DC Michael A. Miller, DC Sheridan A. Mish, DC Betsy Mitchell, DC Danielle A. Monken, DC Keith W. Morehouse, DC Adam Palmer Morrell, DC Jonathan Mulholland, DC Dustin C. Nabhan, DC Melissa A. Nagare, DC Tory D. Naugle, DC Brandon T. Nevel, DC Justina Dong-Yain Ngo, DC Tim Nguyentu, DC Christopher J. Ourganian, DC Kevin Paape, DC Ti Pence, DC Johnmichael Pizzimenti, DC Christopher S. Plate, DC Shailly Prasad, DC Heather M. Prenger, DC Michael D. Raeburn, DC Robert M. Reass, II, DC Lucas P. Reinhart, DC Donald James Richardson, DC Anthony M. Rivano, DC Douglas W. Sanford, DC

1556-3707/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jcm.2010.04.001

Raymond Santa, DC Rena G. Sawyers, DC Vince Scheffler, DC Jason A. Schlenkler, DC Jaime Schultz, DC Aaron Russell Schuman, DC Cori Anne Seyhoon, DC Kyle L. Skinner, DC Graeme Smith, DC John A. Sparks, DC Keith L. Sparks, DC Brandon K. Stephans, DC Charlene R. Stoddard, DC Matthew M. Stone, DC Aaron J. Stump, DC Brent Symes, DC Kevin C. Teagle, DC Lawrence I. Teixeira, DC Steven M. Thacker, DC Robert D. Thompson, DC Man Minh Tran, DC David Eugene Trimboli, DC John S. Urban, III, DC AnnaMarie F. Valeriote, DC Joseph M. Valeriote, DC Andrew A. Waitkevich, DC David Walters, DC Chad E. Weinzetl, DC Dianna Welty, DC David S. Williams, DC Stephen A. Wooten, DC Anthony Wyrwas, DC Kyle R. Younger, DC Edward J. Zebro, DC