Use Of Spinal Manipulation Research Articles

Reflections on 50 years of IFOMPT

2024 marks the 50th anniversary of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT). IFOMPT became the first subgroup of World Physiotherapy. IFOMPT aims and works for global promotion of excellence and unity in clinical and academic standards for manual/musculoskeletal physiotherapists. This dissertation reflects on some of IFOMPT's initiatives and achievements as an international organisation in its first 50 years as well as challenges for next 50 years. IFOMPT has achieved in several initiatives. These include the development of an international educational curriculum in manipulative/musculoskeletal physiotherapy which underpins education standards for membership. Educational standards for membership is a relatively unique requirement of a professional organisation.IFOMPT has achieved in developing several initiatives to disseminate knowledge for best standards of practice for its members and the wider community. The pinnacle is its four yearly international scientific conferences where the latest issues in both research and practice are presented and discussed. IFOMPT has also developed frameworks to guide clinical practice in key areas for safe practice – vascular pathologies of the neck, a clinical reasoning pathway to identify ‘red flags’, and the use of spinal manipulation in paediatrics. Other resources include on-line lectures, podcasts and research reviews.IFOMPT has challenges for the future. These include increasing the number of member countries and further establishing its profile and position of leadership in manual/musculoskeletal physiotherapy in the international context, particularly with decision makers in world health.

Spinal manipulation and mobilisation among infants, children, and adolescents: an international Delphi survey of expert physiotherapists

ABSTRACT Objective The aim of this study was to establish international consensus regarding the use of spinal manipulation and mobilisation among infants, children, and adolescents among expert international physiotherapists. Methods Twenty-six international expert physiotherapists in manual therapy and paediatrics voluntarily participated in a 3-Round Delphi survey to reach a consensus via direct electronic mail solicitation using Qualtrics®. Consensus was defined a-priori as ≥75% agreement on all items with the same ranking of agreement or disagreement. Round 1 identified impairments and conditions where spinal mobilisation and manipulation might be utilised. In Rounds 2 and 3, panelists agreed or disagreed using a 4-point Likert scale. Results Eleven physiotherapists from seven countries representing five continents completed all three Delphi rounds. Consensus regarding spinal mobilisation or manipulation included: Manipulation is not recommended: (1) for infants across all conditions, impairments, and spinal levels; and (2) for children and adolescents across most conditions and spinal levels. Manipulation may be recommended for adolescents to treat spinal region-specific joint hypomobility (thoracic, lumbar), and pain (thoracic). Mobilisation may be recommended for children and adolescents with hypomobility, joint pain, muscle/myofascial pain, or stiffness at all spinal levels. Conclusion Consensus revealed spinal manipulation should not be performed on infants regardless of condition, impairment, or spinal level. Additionally, the panel agreed that manipulation may be recommended only for adolescents to treat joint pain and joint hypomobility (limited to thoracic and/or lumbar levels). Spinal mobilisation may be recommended for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels among children and adolescents.

Spinal manipulation and electrical dry needling as an adjunct to conventional physical therapy in patients with lumbar spinal stenosis: a multi-center randomized clinical trial

BACKGROUND CONTEXTNonoperative management of lumbar spinal stenosis (LSS) includes activity modification, medication, injections, and physical therapy. Conventional physical therapy includes a multimodal approach of exercise, manual therapy, and electro-thermal modalities. There is a paucity of evidence supporting the use of spinal manipulation and dry needling as an adjunct to conventional physical therapy in patients with LSS. PURPOSEThis study aimed to determine the effects of adding thrust spinal manipulation and electrical dry needling to conventional physical therapy in patients with LSS. STUDY DESIGN/SETTINGRandomized, single-blinded, multi-center, parallel-group clinical trial. PATIENT SAMPLEOne hundred twenty-eight (n=128) patients with LSS from 12 outpatient clinics in 8 states were recruited over a 34-month period. OUTCOME MEASURESThe primary outcomes included the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Secondary outcomes included the Roland Morris Disability Index (RMDI), Global Rating of Change (GROC), and medication intake. Follow-up assessments were taken at 2 weeks, 6 weeks, and 3 months. METHODSPatients were randomized to receive either spinal manipulation, electrical dry needling, and conventional physical therapy (MEDNCPT group, n=65) or conventional physical therapy alone (CPT group, n=63). RESULTSAt 3 months, the MEDNCPT group experienced greater reductions in overall low back, buttock, and leg pain (NPRS: F=5.658; p=.002) and related-disability (ODI: F=9.921; p<.001; RMDI: F=7.263; p<.001) compared to the CPT group. Effect sizes were small at 2 and 6 weeks, and medium at 3 months for the NPRS, ODI, and RMDI. At 3 months, significantly (p=.003) more patients in the MEDNCPT group reported a successful outcome (GROC≥+5) than the CPT group. CONCLUSIONPatients with LSS who received electrical dry needling and spinal manipulation in addition to impairment-based exercise, manual therapy and electro-thermal modalities experienced greater improvements in low back, buttock and leg pain and related-disability than those receiving exercise, manual therapy, and electro-thermal modalities alone at 3 months, but not at the 2 or 6 week follow-up.

Immediate Effects of a Single Spinal Manipulation on Lower-Limb Strength in Healthy Individuals: A Critically Appraised Topic.

Clinical Scenario: Many people with lower quarter musculoskeletal dysfunction present with muscle weakness. Strength training hypertrophies muscle and increases strength, but often requires periods over 6 weeks, which can exceed the episode of care. Weakness can persist despite muscle hypertrophy, particularly in the early stages of joint pathology or in the presence of limb or spinal joint hypomobility, which may inhibit muscle activation. Emerging evidence suggests spinal manipulation can increase short-term strength. Screening for specific muscle weakness that could benefit from manipulation to particular spinal segments could facilitate efficient clinical intervention. Although the neuromuscular mechanisms through which manipulation can increase strength remains a topic of investigation, immediate gains can benefit patients by jump-starting an exercise program to train new muscle function gained and enhancing the motivation to continue strengthening. Evidence from randomized controlled trials would provide support for using manipulation to increase muscle strength, while studying healthy people would eliminate confounding factors, such as pain and pathology. Clinical Question: Does randomized controlled trial-level evidence support the concept that a single lumbar spine manipulation session can increase lower-limb strength in healthy individuals? Summary of Key Findings: Level 1b evidence of moderate quality from 3 randomized controlled trials showed immediate small to large effect size muscle strength increases immediately after lumbar spine manipulation. Clinical Bottom Line: Lumbar spine manipulation can result in immediate lower-limb isometric strength increases. While healthy people with normal muscle strength may improve minimally, joint manipulation for people with knee and hip weakness who are otherwise healthy can result in large effect size strength gains. Strength of Recommendation: Moderate quality level 1b evidence from randomized controlled trials with small samples support the use of spinal manipulation to immediately increase lower-limb strength. Additional studies investigating impact on strength and function immediately in people with musculoskeletal pathology are warranted.

Complementary therapies in addition to medication for patients with nonchronic, nonradicular low back pain: a systematic review

BackgroundA total of 2.7 million patients present to US emergency departments annually for management of low back pain (LBP). Despite optimal medical therapy, more than 50% remain functionally impaired 3 months later. We performed a systematic review to address the following question: Among patients with nonchronic LBP, does spinal manipulation, massage, exercise, or yoga, when combined with standard medical therapy, improve pain and functional outcomes more than standard medical therapy alone? MethodsWe used published searches to identify relevant studies, supplemented with our own updated search. Studies were culled from the Cochrane Register of Controlled Trials, Medline, EMBASE, CINAHL, and the Index to Chiropractic Literature. Our goal was to identify randomized studies that included patients with nonradicular LBP of <12 weeks’ duration that compared the complementary therapy to usual care, sham therapy, or interventions known not to be efficacious, while providing all patients with standard analgesics. The outcomes of interest were improvement in pain scores or measures of functionality. ResultsWe identified 2 randomized controlled trials in which chiropractic manipulation + medical therapy failed to show benefit vs medical therapy alone. We identified 4 randomized controlled trials in which exercise therapy + medical therapy failed to show benefit vs medical therapy alone. We did not identify any eligible studies of yoga or massage therapy. ConclusionsIn conclusion, for patients with nonchronic, nonradicular LBP, available evidence does not support the use of spinal manipulation or exercise therapy in addition to standard medical therapy. There is insufficient evidence to determine if yoga or massage is beneficial.

The use of spinal manipulation in the treatment of low back pain: a review of goals, patient selection, techniques, and risks

Spinal manipulation is routinely obtained for low back pain by much of the general public, but there remains a lack of understanding of its rationale and effectiveness in the medical community. Because of the increasing use of manipulation, it is advantageous for back specialists to gain a better understanding of these techniques in order to counsel patients on the associated risks and benefits of manipulation. The purpose of this review is to present the specific goals of spinal manipulation, with emphasis on proper patient selection, specific techniques, and associated risks.

Pharmacological management of chronic lower back pain: a review of cost effectiveness.

Lower back pain is one of the most prevalent musculoskeletal conditions in the developed world and accounts for significant health services use. The American College of Physicians and the American Pain Society have published a joint clinical guideline that recommends providing patients with information on prognosis and self-management, the use of medications with proven benefits and, for those who do not improve, consideration be given to the use of spinal manipulation (for acute lower back pain only), interdisciplinary rehabilitation, exercise, acupuncture, massage, yoga, cognitive behavioural therapy or relaxation. The purpose of this review was to evaluate published economic evaluations of pharmacological management for chronic lower back pain. A total of seven studies were eligible for inclusion in there view. The quality of the economic evaluations undertaken in the included studies was not high. This was primarily because of the nature of the underlying clinical evidence, most of which did not come from rigorous randomised controlled trials (RCTs), and the manner in which it was incorporated into the economic evaluations. All studies provided reasonable information about what aspects of healthcare and other resource use were identified, measured and valued. However, the reporting of total costs was not uniform across studies. Measures of pain and disability were the most commonly collected outcomes measures. Two studies collected information on quality of life directly from participants while two studies modelled this information based on the literature. Future economic evaluations of interventions for chronic lower back pain, including pharmacological interventions, should be based on the results of well-conducted RCTs where the measurement of costs and outcomes such as quality of life and quality-adjusted life-years is included in the trial protocol, and which have a follow-up period sufficient to capture meaningful changes in both costs and outcomes. In the absence of RCT data, economic models should be used to estimate future costs and outcomes using robust methods.

Beliefs and Practice Patterns in Spinal Manipulation and Spinal Motion Palpation Reported by Canadian Manipulative Physiotherapists

This practice survey describes how Fellows of the Canadian Academy of Manipulative Physiotherapy (FCAMPT) use spinal manipulation and mobilization and how they perceive their competence in performing spinal assessment; it also quantifies relationships between clinical experience and use of spinal manipulation. A cross-sectional survey was designed based on input from experts and the literature was administered to a random sample of the FCAMPT mailing list. Descriptive (including frequencies) and inferential statistical analyses (including linear regression) were performed. The response rate was 82% (278/338 eligible FCAMPTs). Most (99%) used spinal manipulation. Two-thirds (62%) used clinical presentation as a factor when deciding to mobilize or manipulate. The least frequently manipulated spinal region was the cervical spine (2% of patients); 60% felt that cervical manipulation generated more adverse events. Increased experience was associated with increased use of upper cervical manipulation among male respondents (14% more often for every 10 years after certification; β, 95%CI=1.37, 0.89-1.85, p<0.001) but not among female respondents. Confidence in palpation accuracy decreased in lower regions of the spine. The use of spinal manipulation/mobilization is prevalent among FCAMPTs, but is less commonly used in the neck because of a perceived association with adverse events.

Efectividad de la manipulación cervical en pacientes con cefalea de tipo tensional: revisión sistemática

ObjectiveThis systematic review has aimed to determine the effectiveness of cervical manipulations for the treatment of tension-type headache. Search strategyA systematic review of five computerized bibliographic databases was performed: PEDro, Central (Cochrane), MEDLINE, CINAHL and EMBASE. Randomized controlled trials, systematic reviews and meta-analysis of adult patients with tension-type headache were included. Articles published from January 1, 1990 to January 1, 2012 in Spanish and English were selected. A total of 4422 articles were reviewed, 11 studies finally being selected. Study screeningStudies were independently selected, unblinded, by two reviewers. The PEDro scale was used to classify the studies. ConclusionsThere is limited evidence regarding the use of spinal manipulation alone or combined with therapies other than physiotherapy for the treatment of tension-type headache. The current evidence is encouraging, but not conclusive. More research is needed.

Chiropractic Management of a Patient With Benign Paroxysmal Positional Vertigo: A Case Report

Objective This article describes and discusses the case of a patient with benign paroxysmal positional vertigo (BPPV) characterized by severe vertigo with dizziness, nausea, and nystagmus, treated without the use of spinal manipulation by a doctor of chiropractic. Clinical Features A 46-year-old woman presented for care with complaints of acute vertigo and dizziness. Intervention and Outcome The patient was examined and diagnosed with left posterior canalolithiasis by means of the Dix-Hallpike maneuver. She was treated successfully with the Epley maneuver once and subsequently discharged without further treatment. Conclusion This case demonstrates the importance of correctly identifying patients with BPPV. This case also demonstrates the successful treatment of BPPV.

Improved Activation of Lumbar Multifidus Following Spinal Manipulation: A Case Report Applying Rehabilitative Ultrasound Imaging

Case report. The use of spinal manipulation as a treatment to facilitate neuromuscular control of the paraspinal musculature is not well described in the literature. The use of rehabilitative ultrasound imaging (RUSI) may offer a convenient way to investigate and document possible changes occurring in the lumbar multifidus associated with manipulation intervention. The patient was a 33-year-old male with a 21-year history of low back pain and left posterior thigh pain who presented with lumbar hypomobility and met a previously published clinical prediction rule for spinal manipulation. During examination, the patient was asked to perform a prone upper extremity lifting task to assess activation in the lumbar multifidus during an automatic task. Through palpation the examiner noted a decreased contraction of the left multifidus between L4-S1 compared to the right. To explore this further, a decision was made to assess the multifidus with RUSI, which confirmed the activation deficit noted during palpation. A lumbar regional manipulation was performed with the intention of reducing spinal hypomobility and of assessing changes in multifidus activation. Imaging of the multifidus muscles at the L4-5 and L5-S1 levels were obtained premanipulation, immediately postmanipulation, and 1 day after manipulation. An increased ability to thicken the multifidus during a prone upper extremity lifting task was noted immediately and 1 day after manipulation. Average percent change in thickness at the L4-5 and L5-S1 levels with the prone arm lift was 3.6% premanipulation, 17.2% immediately postmanipulation, and 20.6% approximately 24 hours postmanipulation. Improvements in the thickening of the multifidus muscle during the upper extremity lifting task were greater than 3 standard errors of the measurement. Other changes included immediate palpable improvement in the contraction of the multifidus during the upper extremity lifting task, along with the patient report of increased ease of lifting. In this case report we quantified the short-term influence of spinal manipulation on multifidus muscular activation using RUSI. No cause-and-effect claims can be made; however, the results provide preliminary evidence to suggest that spinal manipulation may influence multifidus muscle function. RUSI offers a convenient way to investigate and document these changes.

An eclectic but combustible mix of shareholders, sex, societies, and spinal manipulation

JRSM readers often tell me that they find the journal to be an eclectic mix, leaving me unsure whether I have just received a compliment or a complaint. But if ‘eclectic mix’ means ‘something for everybody’, I'm all for it. On that basis, this issue of the JRSM will not disappoint. Journals struggle to convince their readers to change behaviour. Many journals are written in an inscrutable scientific script that defies understanding. Those that are readable—something the JRSM aspires to be, but which you may believe we fail to achieve—struggle to publish enough of direct relevance to clinical practice. Even when they do, there may be powerful external forces, such as companies and governments, unwilling to allow them to change behaviour based on the evidence. Increasingly, journals try to modify the practices of companies and governments. While changes in clinical practice can be difficult to measure, a drop in share price or a U-turn in government policy are rare but highly visible events. When the JRSM and others began a campaign against Reed Elsevier's support of arms exhibitions—were they about saving lives or ending them?—there seemed little hope of immediate relief for the unhappiness of the editorial team and readers of the Lancet, Reed Elsevier's premier healthcare journal. Richard Smith took the campaign to Reed Elsevier's annual shareholders' meeting, where he and his fellow minority-shareholders-in-arms bombarded the Board with questions (JRSM 2007;100:350). A thin crowd, writes Smith, didn't care much for him and his fellow lobbyists, although he believes they made an impact with the Board. This was one example of the visible campaign against Reed Elsevier. Meanwhile, a less publicised campaign by the Lancet's editorial team exerted internal pressure upon senior management. Hence, last month's decision by Reed Elsevier to exit the arms exhibition business was a triumph for the Lancet's editorial team, a smaller but significant triumph for the journals and scientists who campaigned on behalf of the Lancet, and a victory for minority shareholders. As Smith and his dissidents showed, it doesn't pay to hold your tongue. I once made that mistake in my brief stint in psychiatry, when I failed to ask a patient her sexual history. As a very junior doctor, I felt embarrassed at probing a depressed woman's intimate details—but my consultant damned me for being ‘mealy mouthed’. After that I made it a habit to ask tricky questions, even when there was probably no need to—a good training for journalism. With Kevan Wylie's editorial kicking off a series of articles on sexual health (JRSM 2007;100:300-301), I now realise that being mealy mouthed is a problem for many doctors. Qualitative research has shown that doctors fear opening up ‘a can of worms’ or sexualizing the consultation, for example. Wylie, a free-talking consultant in sexual medicine, has no truck with such inhibitions, stating that ‘Knowledge is necessary to secure the confidence of the physician to broach and manage the topics within the specialty.’ This new series is an attempt to bridge this knowledge and confidence gap, and begins with an article on sexual assault (JRSM 2007;100:321-324). The JRSM's eclectic mix becomes combustible else-where, as Alan Maynard launches a few grenades at the Royal Colleges (JRSM 2007;100:306-308). Are they fit for purpose? They need to be, he argues, ‘but they have grown without regard to purpose and value for money.’ Another well known agitator, Edzard Ernst, revisits the safety of spinal manipulation with a further systematic review which concludes that, because of the uncertain incidence of adverse events, ‘In the interests of patient safety we should reconsider our policy towards the routine use of spinal manipulation’ (JRSM 2007;100:330-338) I can hear the complaints whizzing into my email inbox already—an adverse effect of the eclectic mix.

Adverse effects of spinal manipulation: a systematic review

To identify adverse effects of spinal manipulation. Systematic review of papers published since 2001. Six electronic databases. Reports of adverse effects published between January 2001 and June 2006. There were no restrictions according to language of publication or research design of the reports. The searches identified 32 case reports, four case series, two prospective series, three case-control studies and three surveys. In case reports or case series, more than 200 patients were suspected to have been seriously harmed. The most common serious adverse effects were due to vertebral artery dissections. The two prospective reports suggested that relatively mild adverse effects occur in 30% to 61% of all patients. The case-control studies suggested a causal relationship between spinal manipulation and the adverse effect. The survey data indicated that even serious adverse effects are rarely reported in the medical literature. Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.

Improved contraction of the transversus abdominis immediately following spinal manipulation: A case study using real-time ultrasound imaging

The authors encountered a clinical dilemma when attempting to apply a clinical prediction rule for manipulation (Flynn et al., 2002; Childs et al., 2004) to a patient with a history and physical examination consistent with clinical lumbar instability (Hicks et al., 2005). Although the patient met four of five criteria predicting short-term success with manipulation, the presence of symptoms suggestive of underlying clinical instability remains a relative contraindication to thrust manipulation (Greenman, 1996; Maitland, 2001). Could the application of both manipulation and stabilization be logically justified in this patient? Despite the widespread use of spinal manipulation, the biological mechanisms by which it produces a beneficial effect in certain patients are not fully understood (Pickar, 2002). There is evidence which supports a reflexogenic effect from manipulation in the paraspinal muscles as one possible mechanism (Herzog et al., 1995, 1999; Lehman et al., 2001; Pickar, 2002). Specifically, several researchers have identified altered motor neuron pool excitability following spinal manipulation (Murphy et al., 1995; Floman et al., 1997; Herzog et al., 1999; Dishman and Bulbulian, 2000). The effect on neural pathways associated with manipulation has been suggested as one possible mechanism that may improve muscle performance (Pickar, 2002) and patient symptoms.

Atherosclerosis in the vertebral artery: an intrinsic risk factor in the use of spinal manipulation?

The presence of atherosclerotic plaques and their influence on the vertebral artery is of clinical importance within the scope of spinal manipulation. Manipulation may stimulate the development of atherosclerotic plaques, could detach an embolus with ensuing infarction, injure the endothelium or may directly cause a dissection in the presence of atherosclerotic plaques. In order to identify the sites and frequency of atherosclerotic plaques and to determine its relation to the tortuous course of the vertebral artery, a cadaveric study was performed. The vertebral arteries of 57 human cadavers were studied. The vertebral artery was virtually divided into four segments: the pre-vertebral (V1), the vertebral (V2), the atlanto-axial (V3), and the intracranial segment (V4). Abnormalities in the origin and course of the vertebral artery were noted, along with any associated osseous, or cartilaginous anomalies in the neck. After dissection, the artery was opened and macroscopically screened for the presence of atherosclerotic plaques. In 22.8% of the cases, no atherosclerotic plaques were present. In 35.1% of the cases, the atherosclerotic plaques were unilateral, of which 60.0% was on the left side, 40.0% on the right side, and in 42.1%, the occurrence was bilateral. Atherosclerotic plaques were significantly more present in the V3 segment than in the V1 (0.007) and V2 segment (0.049). In the V1 (P=0.008) and V2 segment (P=0.002), there was a correlation between a tortuous course of the vessel and the occurrence of atherosclerotic plaques. In individuals with marked atherosclerotic disease, stretching and compression effects of rotational manipulative techniques on atherosclerotic vessels impose a further risk factor for vertebrobasilar insufficiency. As direct evidence of atherosclerotic plaques are rarely available, therapists should avoid manipulative techniques at all levels of the cervical spine in the presence of any indirect sign of atherosclerotic disease or in the presence of calcified arterial walls or tortuosities of the vessels visible on routinely available X-ray images of the cervical or thoracic spine. It is strongly recommended, that if any doubt exists about the nature of a clinical presentation, vigorous manual procedures should be avoided until either the diagnosis is definitive or gentle manual therapy has proven effective.

Chiropractic

Chiropractic is one of the most controversial and poorly defined healthcare professions with recognition and licensure in the United States. Chiropractic was started by D. D. Palmer, a magnetic healer who formulated the vertebral subluxation theory. The profession was developed by his son, B. J. Palmer. Although the definition of chiropractic as a method of correcting vertebral subluxations to restore and maintain health is questionable, spinal manipulation is of value in the treatment of some types of back pain. The chiropractic profession is still based on the vertebral subluxation theory, and has the confusing image of a back specialty capable of treating a broad scope of health problems. Despite opposition to use of spinal manipulation as a method of treating a broad scope of health problems (as opposed to the generally accepted use of manipulation in the treatment of back pain), chiropractors seek support as primary care providers in alternative medicine. It is essential to understand the theories, philosophies, and methods of chiropractic for an objective evaluation.

Les manipulations vertébrales : enquête concernant la pratique des médecins formés dans le cadre du diplôme inter-universitaire de Strasbourg

Introduction. – The use of spinal manipulation (SM) is widespread, particularly in English-speaking countries, where many studies are published showing its popularity. However, no study exists of the demography and activity of the French medical profession. Our objective was to investigate the use of SM by French doctors in their daily practice. Materials and methods. – We questionned 234 doctors, general practitioners and specialists who obtained the Inter-Academy of Manual Medicine and Osteopathy Diploma from Strasbourg University between 1985 and 2002. Results. – We obtained a response from140 physicians: 110 (79%) practiced SM in their daily practice. They considered the technique efficient and used it as a first intention. Approximately one quarter of cases resulted in adverse effects on the back. Most of the doctors (77%) continued their education during their career. Conclusion. – This first assessment of the practice of physicians trained in a university in manual medicine allows for confirming the respect of good medical practice with regular actualization of knowledge and reasonable outpatient care.

Successful management of hamstring injuries in Australian Rules footballers: two case reports

Hamstring injuries are the most prevalent injury in Australian Rules football. There is a lack of evidence based literature on the treatment, prevention and management of hamstring injuries, although it is agreed that the etiology is complicated and multi-factorial. We present two cases of hamstring injury that had full resolution after spinal manipulation and correction of lumbar-pelvic biomechanics. There was no recurrence through preventative treatment over a twelve and sixteen week period. The use of spinal manipulation for treatment or prevention of hamstring injury has not been documented in sports medicine literature and should be further investigated in prospective randomized controlled trials.

The passive straight leg raising test in the diagnosis and treatment of lumbar disc herniation: a survey of United kingdom osteopathic opinion and clinical practice.

Postal questionnaire survey. To carry out a confidential postal survey of United Kingdom osteopaths in order to record and assess their use of the passive straight leg raising test in the diagnosis of, and choice of, manipulation for lumbar disc herniation. The study also sought to determine whether an association existed between osteopaths' manipulation of suspected lumbar disc herniation and their use of the straight leg raising test, the length of their working hours, and their use of manipulation for the treatment of other lumbar conditions. The literature is not agreed on important aspects of the straight leg raising test, or on the use of spinal manipulation for suspected lumbar disc herniation. This is thought to be the first study to investigate opinion and practice in a large group of spinal manipulators, in this case United Kingdom osteopaths. A questionnaire was sent to all 1030 United Kingdom osteopaths registered with the General Osteopathic Council in January 2000. It comprised four sections: personal characteristics, professional characteristics, background to low back pain cases, details of straight leg raising test understanding and use within the diagnosis and treatment of lumbar disc herniation. A response rate of 44% was achieved. United Kingdom osteopaths' opinions of low back pain and lumbar disc herniation clinical presentations, details of straight leg raising test mode of action, procedure, and interpretation were in keeping with the literature. Fifty-four percent of respondents sometimes employed manipulation in the treatment of lumbar disc herniation, but most of the others described the practice as "dangerous." The literature is similarly divided on the practice. Chi-square and Cramer V analysis implied that respondents were not influenced in choosing manipulation for lumbar disc herniation by their use of the straight leg raising test (chi2 = 4.002, df = 3, Cramer V = 0.0959, P = 0.261, alpha 0.05, n = 435). A moderate association implied that the frequency of use of such manipulation for all lumbar conditions influenced the choice of that treatment for lumbar disc herniation (chi2 = 81.808, df = 4, Cramer V = 0.4302, P < 0.001, alpha = 0.05, n = 442). There was also a weak association suggesting that hours worked per week influenced the choice of manipulation for lumbar disc herniation (chi2 = 9.840, df = 3, Cramer V = 0.1499, P = 0.020, alpha = 0.05, n = 438). Respondents to this survey frequently treated low back pain and often employed the straight leg raising test in its diagnosis. Their recognition of the clinical presentation of lumbar disc herniation and their use and understanding of the straight leg raising test were in keeping with the literature. Respondents were divided nearly equally between those who would expect patient benefit from the use of manipulation for lumbar disc herniation and those who criticized the practice. There is a need for further research into the clinical reasoning employed for the manipulative treatment of lumbar disc herniation.

Some effects of chiropractic manipulation on reflux oesophagitis: a case report

Chiropractors claim to be able to affect somatic as well as visceral disorders by the use of spinal manipulation. Despite much research investigating the relationship between somatic and visceral structures the exact mechanism has not been established. This case describes how a 47-year old male suffering from indigestion, neck and mid-thoracic pain found relief of these symptoms following chiropractic spinal manipulation. He experienced symptoms severe enough to mimic ischaemic heart disease, but was diagnosed as having reflux oesophagitis. Possible relationships between somatic and visceral structures are discussed. It is suggested that patients suffering from true visceral disease may benefit from chiropractic care.