M.Tech.

The primary objective of this study was to determine the acceleration characteristics of spinal manipulative therapy (SMT) and whether patient anthropometric parameters correlated with the SMT kinematic parameters. For this, a wireless tri-axial accelerometer was taped to the dorsum of a clinician’s hand to record the accelerations generated during clinical treatment of 95 symptomatic patients. Peak acceleration magnitudes differed significantly between spinal levels (p<0.0001; lumbar > cervical > thoracic = sacroiliac). The latencies of these peaks were also significantly different (p<0.0001; lumbar < cervical = thoracic < sacroiliac). Within a given spinal level, acceleration amplitudes varied over a wide range with temporal parameters remaining relatively constant. Overall, anthropometric parameters were poorly correlated with SMT parameters. In summary, distinct acceleration amplitudes were observed across spinal levels with relatively constant temporal factors. Thus, clinicians appear to vary the magnitude rather than the duration of the SMT thrust.

M.Tech.

M.Tech. / Palpation is a skill taught to manual practitioners on a daily basis. This skill is used by health care professionals, including chiropractors, to examine patients complaining of spinal pain. It is the chiropractor’s responsibility to have the ability and experience to locate and identify individual spinal levels, as well as any changes in tissues affected, to accurately diagnose and treat their patients (Downey, Taylor and Niere, 1999). The inability of the therapist to have this skill, can lead to incorrect diagnosis, and in turn, incorrect treatment being provided (Downey et al, 1999). Numerous research studies have been conducted to determine how significant clinical experience is in terms of reliable palpation being achieved. Researchers such as Koran (1975) and McConnell (1980), Simmonds and Kumar (1993), McKenzie and Taylor (1997), Burton and Edwards (1990) have all been unable to support the hypothesis that experience plays a significant role in improving inter-examiner or intra-examiner reliability in their research studies. This study aims to determine the inter-examiner reliability of locating the spinous process of the seventh cervical vertebra by palpation, and to explore the role that clinical experience plays upon efficacy. Thirty participants were recruited to become part of this study. The 6 examiners chosen consisted of two 5th year and two 6th year chiropractic students as well as two qualified chiropractors. A random allocation was used which ensured that every participant was examined by 3 examiners, each from the different clinical experiences. Examiners were provided with instructions before proceeding with the study. Each participant was palpated to locate the C7 spinous processes and once located, the level was marked with a UV pen. The UV marks were located by illuminating with a UV light and these were replaced with metal markers. Each participant was then positioned to have both the AP and lateral x-ray views done. vii Once all participants were x-rayed, horizontal lines were drawn through the C7 spinous processes and metal markers on both the AP and lateral x-ray films. Distances from the lines through the spinous processes to each metal marker, were measured. The provided statistical tests were used to analyse the data. According to the Pearson Chi-square test used, there was no statistically significant difference amongst all examiners on the ability to correctly palpate, locate and mark the C7 spinous processes. Results further showed that the 6th year students correctly identified more levels on the AP x-ray films, whilst both 6th year students and the qualified chiropractors correctly located more and equal levels on the lateral x-ray films. This study showed that there were difficulties amongst all examiners across all levels of clinical experience and this important role of experience is therefore not fully understood.

Introduction: Implicit within spinal manipulative therapy is the assumption that treatment loads are effectively transcribed to actuate consistent mechanisms for expected clinical results. There is conflicting evidence between the mechanistic understandings and the physiologic responses from experimental evidence. Greater clarity on how loads are transferred through tissues to the target sites would be useful in enhancing utilization and efficacy of spinal manipulative procedures. Purpose: Directly monitor displacement of tissue in strata at sequential depths between the load application site and target articulation in the thoracic spine. Tissue displacement served as a surrogate for evidence of load transmission. Methods: Ultrasound elastography techniques monitored displacement in sequential strata while electromyographic signals, force, kinematic motions were monitored synchronously. Volunteers were placed prone on a treatment table, while a typical spinal manipulative pre-load maneuver was applied in the thoracic spine. Results: When applying a therapeutic load to the skin the results demonstrate with increasing depth of tissue there is a sequentially decreasing rank order in the mean cumulative displacement with each layer being significantly greater than the deeper adjacent layer. Superficial loose connective tissue layer (0.34 mm ± 0.15) vs. intermediate muscle layer (0.28 mm ± 0.11), p=0.004. Intermediate muscle layer (0.28 mm ± 0.11) vs. deep muscle layer (0.16 mm ± 0.6), p<0.0001. Filtered myoelectric signals were linearly correlated with tissue strata cumulative displacements, but the relationship was not strong (-0.23 < r < 0.46). Conversely, Pearson correlation analysis revealed strong and relatively stable correlations (0.74 < r < 0.90) for the association between displacement at the load application site and tissue layers. Conclusion: The sequential tissue motion demonstrates that some degree of load transfer through layers occurs. Both direct and indirect stimulation of tissues across both depth and breadth is feasible, to an extent consistent with the stimulation of mechanoreceptors. / Thesis / Master of Science (MSc)

Introduction Many chiropractic articles and textbooks discuss gait, but there actually has been little research into the effects of chiropractic adjustment on gait. This pilot study used a quantitative method of gait evaluation before and after a series of chiropractic visits. Hypotheses: (1) adults with chronic low back pain (CLBP) would show increased variability in vertical ground reaction forces (VGRF) while walking, as compared to healthy control subjects, and (2) that, following chiropractic care, will show decreased variability. Methods VGRF data were collected for 6 controls and compared to 9 CLBP participants, who were also evaluated before and after the first visit of care and over 7 visits. Data were analyzed by Mean Standard Deviation (MSD), Mean Coefficient of Variation (MCV), and the Coefficient of Variation of loading rate. Chiropractic care consisted of “high velocity low amplitude” thrust type procedures, flexion-distraction, pelvic wedges, light mobilization, and stretching. Results CLBP participants had somewhat greater variability and became slightly less variable post-care; differences were not significant. Limitations: Some participants had no impairment of walking at baseline; MSD is an uncommon measure, and more research is needed; these results (small group seen by a single doctor) may not be generalizable. Conclusions Participants with CLBP had slightly more variability and had slight decreases in variability following chiropractic care. Differences were not statistically significant. With this small pilot study as a guide, more research should be done with larger groups and improved participant selection.

This paper describes and tests a largely ignored but important preliminary step for comparative effectiveness research: retrospective evidence syntheses to first establish a knowledge base of condition-based medical conditions. By aggregating and organizing what is already known about a treatment or system, gaps in knowledge can be identified and future research designed to meet those gaps.An information synthesis process may also discover that few knowledge gaps in the knowledge base yet exist, the gaps are negligible, and / or treatment effectiveness and study quality is stable across many years, but is simply not clinically important. A consistent finding of low effectiveness is evidence against more research, including exclusion of a treatment from future comparative effectiveness studies. Though proponents of weak treatments or systems may choose to proceed with further research, use of public funds or resources that eventually increase costs to the public are unwarranted.By first establishing a treatment or system knowledge base, at least three comparative effectiveness research decisions are conceivable: (1) treatment or system should be included in future comparative effectiveness trials to establish relative effectiveness for a given condition, (2) has promise but requires more research in a prospective CER trial, or (3) the treatment is less effective than others for a given condition, making future research unnecessary. Thus, a "retroactive comparative effectiveness research method," rCER, is proposed here to identify which treatments are worth including in future prospective trials and which are known to have small to modest effect sizes and are not worth the time and expense of a closer look.The rCER method herein showed that for non-surgical low back pain any treatments did not improve greatly upon the normal and natural pain trajectory for acute low back pain. Therefore, any advantage in pain reduction by any treatment of acute low back pain over back pain's normal course of resolution without care, is quite small, and as such, the incremental cost for the marginal improvement over no treatment becomes quite large. While the quality of non-surgical low back pain studies over the past 34 years has steadily increased, the effect size has not, leading to the conclusion that future research on non-surgical low back pain treatment is unwarranted.

Purpose: Patients’ perspectives of informed consent for chiropractic care have not been investigated. This study explored how patients of chiropractors perceived the exchange of risk information during informed consent. Methods: Interviews were conducted with 26 participants, recruited from chiropractic clinics. Interview transcripts were analyzed using a constant comparative method of analysis. Findings: Participants experienced informed consent as an on-going process where risk perceptions were shaped throughout four distinct stages. In the first stage information acquired prior to arriving at the clinic for treatment shaped perceptions of risk. In the second stage participants assessed the perceived competence of the practitioners. Participants then signed the consent form and discussed the risks with t heir practitioner. Finally, they communicated with their practitioners during treatment to ensure their pain threshold was not crossed. Conclusion: These findings suggest that patients perceive informed consent as a social process involving on-going communication with their practitioners.

A lombalgia e a cervicalgia estao entre as principais dores cr6nicas de origem musculoesqueletica. Alern do aspecto fisico, a dor possui aspectos cognitivos, emocionais e comportamentais e, quando cr6nica, pode tornar-se incapacitante. A percepcao e perpetuacao da dor resultam de inumeros mecanismos de transmissao e codificagao neural. Neste processo, participam diferentes moleculas e mensageiros quimicos. Destacamos as especies reativas de oxigenio e nitrogenio, envolvidas no processo de sensibilizacao central. A regulagao da formagao destas especies reativas depende de sistemas antioxidantes enzimaticos e nao enzimaticos. A manipulacao articular vertebral (MAV) parece ter influencia sobre mecanismos de controle envolvidos na sensibilidade dolorosa. Estudo anterior do nosso laboratorio demonstrou que a MAV pode influenciar a atividade de enzimas envolvidas no equilibrio entre pro- e antioxidantes num tratamento a curto prazo, por duas semanas. 0 presente estudo avaliou o efeito analgesic° do tratamento de MAV de alta velocidade e baixa amplitude em individuos corn cervicalgia e/ou lombalgia cr6nica apOs cinco semanas, sendo duas sessoes por semana, e a influencia deste tratamento sobre marcadores perifericos de estresse oxidativo e nitrosativo. Para avaliacao da dor e incapacitagao utilizou-se escala visual analogica, escala graduada de dor cronica, o formulario SF-36, o indice de disfuncao relacionado ao pescogo e o questionario de Roland-Morris. Alem disso, determinaram-se os limiares mecanicos de dor pars as regiOes cervical, lombar e dorsal. Os efeitos sobre marcadores perifericos de estresse oxidativo e nitrosativo foram avaliados pela medida do estudo oxidante total, do potencial reativo antioxidante total e dos metabolitos do oxido nitrico, em plasma. As defesas antioxidantes foram determinadas em eritr6citos pela atividade das enzimas superoxido dismutase (SOD), catalase e glutationa peroxidase (GPx). Determinouse, tambem, a concentragao do Fator de Necrose Tumoral alfa (TNF-a) em plasma. Devido a dificuldade em se realizar urn grupo placebo corn MAV, avaliou-se os mesmos parametros em pacientes tratados corn urn protocolo de exercicios fisicos de resistencia e estabilizacao da coluna, uma vez que os mesmos tambem demonstram efeitos positivos na reducao da dor lombar e/ou cervical. A reducao na percepcao dolorosa e na incapacitacao dos pacientes foram demonstradas logo apps cinco semanas de tratamento corn MAV, bem como passados trinta dias do final do tratamento. Alem disso, a MAV de alta velocidade e baixa amplitude foi capaz de aumentar significativamente a atividade das enzimas antioxidantes SOD e GPx. Os demais parametros de estresse oxidativo e nitrosativo estudados nao apresentaram alteracOes estatisticamente significativas. Por outro lado, o programa de exercicios utilizado neste estudo so foi capaz de reduzir a dor e incapacitagao imediatamente apOs o tratamento, sem alteracaes significativas em marcadores proou antioxidantes. Assim, os resultados mostram a eficacia da MAV e do exercicio terapeutico na reducao da dor e incapacitacao de pacientes corn cervicalgia e/ou lombalgia. Porem, apenas o efeito da MAV se estende por major period() de tempo. Ainda, nossos dados sugerem a existencia de relacao entre parametros oxidativos perifericos e analgesia apenas no tratamento corn MAV. Contudo, estudos complementares sao necessarios para melhor compreensao dessa relacao nos dois tipos de tratamentos. / Low back pain and neck pain are among the leading chronic pains of musculoskeletal origin. Besides the physical aspect, pain has cognitive, emotional and behavioral aspects, and chronic pain may become incapacitating. The perception and perpetuation of pain may result from numerous mechanisms of neural transmission. Different molecules and chemical messengers take part in this process, such as reactive oxygen and nitrogen species that are involved in the central sensitization process. Enzymatic and non-enzymatic antioxidant systems regulate the formation of these reactive species. Spinal manipulation treatment (SMT) seems to influence the control mechanisms involved in pain sensitivity. A previous study by our group demonstrated that short-term SMT can change the activity of enzymes involved in the balance between pro- and antioxidants. For this reason, the present study evaluated the analgesic effect of SMT of high velocity and low amplitude (HVLA) for a longer period in subjects with neck pain and/or chronic low back pain and also the influence of this treatment on peripheral markers of oxidative and nitrosative stress. The treatment was carried out for five weeks with two weekly sessions. Pain and disability were assessed using the visual analog scale (VAS), the Chronic Pain Grade, the SF-36 form, the Neck Pain Index, and the Roland Morris questionnaire. Pressure pain thresholds for cervical, lumbar and dorsal regions were determined as well. The effects on peripheral markers of oxidative and nitrosative stress were determined by measuring the total oxidant status (TOS), total reactive antioxidant potential (TRAP), and nitric oxide metabolites in plasma. The antioxidant defenses in erythrocytes were determined by the activity of superoxide dismutase (SOD), catalase and glutathione peroxidase (GPx). The concentration of tumor necrosis factor alpha (TNF-a) in plasma was also investigated. Due to the difficulty in performing a placebo group with SMT, we evaluated the same parameters in patients treated with a protocol of therapeutic exercises (resistance and stabilization of the spine), since these also show positive effects in the reduction of lumbar or neck pain. Our results indicate that SMT had analgesic effects and reduced disability, even past 30 days after end of treatment, and it significantly increased activity of antioxidant enzymes SOD and GPx. The other parameters of oxidative stress and nitrosative studied did not show statistically significant changes. On the other hand, the exercise protocol used in this study was able to reduce pain and disability only after the end of treatment, without significant changes in pro- or antioxidants markers. Thus, our results show the effectiveness of both SMT and therapeutic exercise in reducing pain and disability in patients with neck and/or back pain. However, only the effect of SMT extends for a longer period of time. In addition, our data suggest the existence of a relationship between oxidative parameters and peripheral analgesia only in SMT. Further studies are required to better understand this relationship in both treatments.

abstract: Introduction. Intervertebral disc degeneration (DD) is one of the most common diagnoses in patients with neck pain and contributes to worldwide disability. Despite the advances in diagnostic imaging today, little is known about functional status of cervical DD. The purpose of this research was to 1) develop and validate an ovine model of cervical spine DD, 2) to quantify and compare the effect of disc lesions on dynamic spinal stiffness, and 3) study the effect of disc lesions on spinal accelerations and displacements during two types of spinal manipulative therapy (SMT). Methods. Fifteen sheep received surgically induced disc injury to the mid-cervical spine via scalpel wound a minimum of five months earlier and 15 sheep served as controls. All animals were biomechanically assessed at the level of the lesion using swept-sine mechanical loads from 0-20 Hz under load control to quantify dynamic dorsoventral (DV) spine stiffness (load/deformation, N/mm). The effect of disc lesion on stiffness was assessed using a one-factor repeated measures ANOVA comparing 32 mechanical excitation frequencies. Tri-axial accelerometers rigidly attached to adjacent vertebrae across the target level further evaluated the effect of disc lesion on spinal motion response during two types of SMTs. A 2x6x2 repeated measures ANOVA examined the effect of disc lesion and SMT force-time profile on spine motion response. Postmortem histological analysis graded specimens at the target site and comparison was made with descriptive statistics. Results. Annular disc tears were only observed in the disc lesion group and the mild degeneration identified was localized to the injured annular tissue that did not progress to affect other areas of the disc. No difference in overall DD grading was found among the groups. DV stiffness was significantly increased in the disc lesion group by approximately 34% at 31 of 32 frequencies examined (p<.05). SMTs resulted in decreased displacements in the disc lesion group (p<.05), and SMT type significantly influenced spinal accelerations for both the DV and axial planes. Conclusion. Disc lesions in the ovine cervical spine produce localized annular degenerative changes that increase the cervical spine dynamic stiffness and reduce its spinal motion response during manual examination and treatment that is further augmented by the force-time profile administered by the clinician. / Dissertation/Thesis / Doctoral Dissertation Kinesiology 2015