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Stephen M.
Perle, D.C., M.S. Bridgeport, CT, USA E-mail address: Return to Dr. Perle's home page |
Kawchuk GN, Perle SM. The relation between the
application angle of spinal manipulative therapy (SMT) and resultant vertebral
accelerations in an in situ porcine model. Man Ther: In Press.
Abstract
It has been hypothesized that the posterior tissues of the spine are frictionless
and therefore allow only the normal force component of spinal manipulative
therapy (SMT) to pass to underlying vertebrae. Given this assumption, vertebrae
could not be moved in practitioner-defined directions by altering the application
angle of SMT. The subjects in this study were three cadaveric pigs. Increasing
SMT forces were applied at 90° to the posterior tissues of the target
vertebra. A standard curve was constructed of increasing SMT force versus
vertebral acceleration. SMT forces were then applied at 60° and 120°
and the resulting accelerations substituted into the standard curve to obtain
the transmitted force. Results showed that vertebral accelerations were greatest
at a 90° SMT application angle but then
decreased in all axes at application angles of 90°. Decrease in transmitted
forces using application angles of 60° and 120° were within 5% of
predicted absolute values. In this model, SMT applied at a non-normal angle
does not increase vertebral acceleration in that same direction, but acts
to reduce transmitted force. This work provides justification for future studies
in less available human cadavers. It is not yet known if variations in SMT
application angle have relevance to clinical outcomes or patient safety.
Murphy DR, Schneider MJ, Seaman DR, Perle SM,
Nelson CF. How can chiropractic become a respected mainstream profession?
The example of podiatry. Chiropr Osteopat 2008 Aug 29;16(1):10.
This article on the journal's
web site (free full text)
Abstract:
Background
The chiropractic profession has succeeded to remain in existence for over
110 years despite the fact that many other professions which had their start
at around the same time as chiropractic have disappeared. Despite chiropractic's
longevity, the profession has not succeeded in establishing cultural authority
and respect within mainstream society, and its market share is dwindling.
In the meantime, the podiatric medical profession, during approximately the
same time period, has been far more successful in developing itself into a
respected profession that is well integrated into mainstream health care and
society.
Objective
To present a perspective on the current state of the chiropractic profession
and to make recommendations as to how the profession can look to the podiatric
medical profession as a model for how a non-allopathic healthcare profession
can establish mainstream integration and cultural authority.
Discussion
There are several key areas in which the podiatric medical profession has
succeeded and in which the chiropractic profession has not. The authors contend
that it is in these key areas that changes must be made in order for our profession
to overcome its shrinking market share and its present low status amongst
healthcare professions. These areas include public health, education, identity
and professionalism.
Conclusion
The chiropractic profession has great promise in terms of its potential contribution
to society and the potential for its members to realize the benefits that
come from being involved in a mainstream, respected and highly utilized professional
group. However, there are several changes that must be made within the profession
if it is going to fulfill this promise. Several lessons can be learned from
the podiatric medical profession in this effort.
This article on the journal's web site (free full text)
Abstract:
Subluxation syndrome is a legitimate, potentially testable, theoretical
construct for which there is little experimental evidence. Acceptable as hypothesis,
the assertion of its clinical meaningfulness brings criticism from the scientific
and health care communities and creates confusion within the chiropractic
profession. We believe that an evidence based orientation among chiropractors
requires that we distinguish between subluxation dogma and subluxation as
the potential focus of clinical research. Regretfully, chiropractic's attempt
to gain political unity through consensus statements regarding subluxation
has been a significant factor in our failure to gain cultural authority and
will continue to do so as long as so many of us accept dogma as fact.
Abstract:
The chiropractic educational system in North America is currently in a
state of flux. The attempted conversion of some chiropractic schools into
"universities" and the want of university affiliation for chiropractic
schools suggests that we are searching for a better alternative to the present
system. In the early 20th century, the Flexner Report helped transform modern
medical education into a discipline that relies on scientific and clinical
knowledge. Some have wondered if it is time for a Flexner-type report regarding
the education of doctors of chiropractic. This article outlines the current
challenges within the chiropractic educational system and proposes positive
changes for that system.
Abstract:
BACKGROUND: More than 100 years after its inception the chiropractic profession
has failed to define itself in a way that is understandable, credible and scientifically
coherent. This failure has prevented the profession from establishing its cultural
authority over any specific domain of health care. OBJECTIVE: To present a model
for the chiropractic profession to establish cultural authority and increase
market share of the public seeking chiropractic care. DISCUSSION: The continued
failure by the chiropractic profession to remedy this state of affairs will
pose a distinct threat to the future viability of the profession. Three specific
characteristics of the profession are identified as impediments to the creation
of a credible definition of chiropractic: Departures from accepted standards
of professional ethics; reliance upon obsolete principles of chiropractic philosophy;
and the promotion of chiropractic as a primary care provider. A chiropractic
professional identity should be based on spinal care as the defining clinical
purpose of chiropractic, chiropractic as an integrated part of the healthcare
mainstream, the rigorous implementation of accepted standards of professional
ethics, chiropractic as a portal-of-entry provider, the acceptance and promotion
of evidence-based health care, and a conservative clinical approach. CONCLUSION:
This paper presents the spine care model as a means of developing chiropractic
cultural authority and relevancy. The model is based on principles which would
help integrate chiropractic care into the mainstream delivery system while still
retaining self-identity for the profession.
Perle SM, Kawchuk GN. Pressures Generated During Spinal Manipulation and Their Association With Hand Anatomy. J Manipulative Physiol Ther 2005; 28(40):265.e1- 265.e7
This article on journal's web site & on PubMed's web site
Abstract:
Background Context The role of the variation in the application manipulation
itself is largely unknown. A greater understanding of its input parameters
is necessary to better understand spinal manipulation outcomes.
Purpose The objective of this study is to determine if pressures generated
during manipulation are altered by hand configuration.
Design/Setting Paired comparison of 2 different variable groups.
Methods Sixteen chiropractors provided 2 manipulations to a rigid surface
using 2 hand configurations used commonly in clinical practice: arched and
flat. Interposed between the hand and the rigid surface was a pressure sensor
array and radiographic cassette. For each manipulation, pressures were recorded
and a radiographic image was captured. Two radiologists then located the osseous
features of the hand with respect to the sensor array.
Results In 15 of 16 cases, arched configurations produced peak pressures
that corresponded to the radiographic location of the pisiform bone. In flat
configurations, peak pressure migrated about the location of the hamate bone.
Radiologists' agreement for bone position was high (? = 0.96). Measures of
peak pressure, total pressure, and pressure distribution were statistically
different between hand configurations.
Conclusions The results of this study suggest that hand configuration
influences the magnitude, location, and distribution of pressure generated
by the hand during manipulation. This knowledge may have importance in understanding
the relation among application parameters of manipulation, therapeutic benefit,
and patient safety.
Jahn WT,Cupon LN, Perle SM. Guidelines of Conduct in Forensic Practice. J Chiropr Med. 2004;3(2):63-5
Abstract:
As the profession of chiropractic grows in stature within our society, the
morality of each chiropractor's conduct will be increasingly examined and
scrutinized by the public, the media, the government and the profession itself.
Immoral conduct occurs not by just a few unscrupulous individuals, but by
a host of apparently good, successful professionals who lead what appear to
be exemplary private lives. Recent increasing examples of professional and
corporate moral decay as reported by chiropractic state boards, in print media,
etc., should spur chiropractic colleges to make determined efforts to reemphasize
ethics as part of the core curriculum. Ethical judgments depend upon both
the decision making process itself and the experience, intelligence and integrity
of the decision maker. The College on Forensic Sciences (CFS), a subsidiary
of the American Chiropractic Association's (ACA's) Council on Chiropractic
Orthopedics (CCO), developed a guideline of conduct to assist forensic examiners
in making decisions in their every day subspecialty practice. Guidelines provide
guideposts that can be helpful in assisting forensic examiners in evaluating
the circumstances they are encountering and providing possible approaches
that may be taken in addressing the ethical issues involved.
This article on the journal's
web site (free full text)
Abstract
Introduction: Graston Instrument-assisted Soft Tissue Mobilization
(GISTM) is a soft tissue diagnostic and therapeutic method that was developed
approximately ten years ago. Originally introduced to the physical therapy
profession, GISTM, a key protocol of the Graston Technique has only recently
been introduced to the chiropractic profession. Graston instruments were developed
as an alternative to transverse friction massage wherein specially designed
stainless steel instruments are used to aid in the diagnosis and treatment
of soft tissue dysfunction or pathology. In vitro research with a rat tendon
injury model has shown that GISTM significantly activates fibroblasts to both
replicate and synthesize. A few case studies have been published about the
effects of GISTM treatment. The purpose of this study is to evaluate the effects
of GISTM on a variety of soft tissue conditions in humans in a large case
series.
Methods: A prospective multi-center case series with outcomes analyzed
comparing intake with discharge visual analog scale (10 cm long VAS) ratings
in four domains: function, pain, numbness and achievement of treatment goals.
Function was assessed in three categories by the health care provider (HCP):
activities of daily living, work and recreation. A mean percent composite
function level was analyzed. Long term treatment goals were established by
the patient and HCP at intake and rated by HCP at discharge on a VAS for percent
achievement of these goals. Wilcoxon Signed Ranks test, one-way ANOVA, general
linear models for repeated measure and Dunnett=s T3 post hoc tests were used
to analyzed the data set.
Results: Fifty-one clinical sites participated with 1004 patients included
in the data set. Conditions treated include: carpal tunnel syndrome, cervical
pain, de Quervain's syndrome, epicondylitis, fibromyalgia, IT band syndrome,
joint sprain, lower back pain, muscle strain, painful scar, plantar fasciitis,
post fracture pain, and tendinitis. Patients were treated a mean of 8 treatments/patient,
with significant differences (p=0.001) between clinics unrelated to the diagnosis.
The highest average treatments per patient was 9 and the lowest was 4. The
mean number of treatments per patient was significantly related to the specific
condition, with a high of 10 for low back pain and a low of 5 for iliotibial
band syndrome. There were no significant differences in outcomes between clinics.
For all conditions treated there was a significant decrease in pain (p<0.001)
and numbness (p<0.002), and increase in function (p<0.001). These improvements
in condition were generally not related to the patient=s diagnosis. Eighty
seven percent of patients achieved at least 50% of their treatment goals,
73% achieved at least 75% of their goals, and 42% achieved at least 90% of
their goals. The proportion of patients on full work duty increased from 69%
at beginning of treatment to 83% at end of treatment. In addition, the proportion
of patients on restricted duty or unable to work due to injury fell from 14%
to 10% and 17% to 7%, respectively, at beginning and end of treatment. These
results were statistically significant (p < 0.0001).
Discussion: Despite the fact that soft tissue conditions are commonly
treated by chiropractors and taught in chiropractic colleges there is a paucity
of papers on the topic in the chiropractic literature.
Conclusions: These results suggest that GISTM appears to be effective
in reducing pain, numbness and work related disability and increasing patient=s
functional ability and thus, is an effective treatment for the variety of
soft tissue conditions studied. Obviously, a case series such as this cannot
distinguish between the effect of the treatment independent of placebo effect
or natural history. Randomized controlled clinical trials are currently in
the planning stages.
Abstract
It has been suggested that joint dysfunction may change the instantaneous axis
of rotation of the dysfunctional joint and that manipulation corrects the axis
of rotation. Woltring et al, (1994) found that manipulation does change the
instantaneous helical axes of the cervical spine in those who have suffered
from whiplash injury. However, we were unable to find studies documenting changes
in axes of motion after manipulation of an extremity joint. Nield et al (1993)
studied the effect of manipulation of the ankle but found only that dorsiflexion
range of motion was unchanged. Innes (1999) and Michaud (1999) indicate that
a loss of A-P glide of the tibia on the talus, which occurs when the tibia cannot
internally rotate on the talus, is responsible for a loss of adequate dorsiflexion
during stance late phase of gait. This joint dysfunction is implicated as the
etiology of some cases of hyperpronation and plantar fasciitis. The purpose
of this pilot study was to determine if manipulation of the tibiotalar joint
in subjects who had a doctor assessed restriction of A-P glide of the tibiotalar
joint had an effect upon the axes of rotation joints of the lower extremity.
Procedures were IRB approved. Advanced 3D motion analysis was performed pre/post
manipulation on 5 volunteer subjects, 5 other control subjects were tested without
manipulation. Trials included quiet standing, low-amplitude dipping activities,
deep squats and walking. Results were examined using a single-subject ANOVA
design. Independent variables included stance width (10,15,20,25 cm), side (R/L
asymmetry), and pre/post manipulation. Dependent variables were A/P and M/L
orientation of the axes of rotation determined for the hips, knees and ankles
using rigid body modeling. Considerable inter-subject variability was noted,
however manipulation produced significant differences (p<.05) in 3 subjects
at the ankle, 3 subjects at the knee and 4 subjects at the hip, 2 subjects demonstrated
changes at all three joints. No between trials differences were noted in the
control group.
Abstract
It has been suggested that manipulation may have an ergogenic effect, specifically
improving joint range of motion and muscle strength. However, this has not been
documented with valid clinical research.
Forty subjects between the ages of 18 and 40 volunteered to participate in a
study to test the effects of a single manipulation of the tibiotalar joint on
joint range of motion and smoothness of movement during walking and on an isokinetic
measure of muscle function for plantar- and dorsiflexion of the ankle at 30
deg/s. Ten subjects were randomly assigned to a test-retest reliability study.
The remaining 30 were randomly assigned to either a sham manipulation control
group or an experimental group receiving manipulation of the tibiotalar joint.
All 40 subjects were measured isokinetically for three repetitions of maximum
plantar- and dorsiflexion of the ankle. The subjects then had reflective markers
placed on boney landmarks of the lower extremity and walked upon a treadmill
at a self-selected pace for five minutes. Computerized motion data were acquired
in the last 5 seconds of the 5-minute walk. Subjects either rested, were sham-manipulated
or received a manipulation depending on assignment. All tests were repeated.
The test-retest data showed that isokinetic testing of plantar- and dorsiflexion
of the ankle and range of motion testing are very reliable but that the measurement
of jerk at the ankle is not reliable. No statistically significant differences
were observed between the sham-manipulation group and the experimental manipulation
group. A single manipulation of the tibiotalar joint in healthy normal individuals
has no effect on isokinetic measures of muscle function for plantar- and dorsiflexion
of the ankle. Isokinetic testing of muscle function for plantar- and dorsiflexion
of the ankle using a MERAK is reliable. Computerized motion analysis of the
ankle to determine ROM is reliable, but to determine jerk while walking, it
is not reliable.
Abstract
Background: Many original clinical trials and several review
papers have come to the conclusion that manipulation is safe and effective
for the treatment of low back pain. However, it is necessary to determine
which specific types of manipulation and nonmanipulative types of chiropractic
adjustive care are most effective for particular types of low back pain
across both tissue-specific and functional classifications.
Objective: To characterize the quantity and quality of literature
gathered for an Expert Panel that was convened to rate various specific
chiropractic adjustive procedures for the treatment of common types of
low back pain, drawing on the clinical expertise of the panel members and
the relevant literature.
Study Design: Systematic review of treatment-specific, condition-specific
trials, studies, and case reports of chiropractic care for low back pain.
Methods: Computerized searching and hand searching were used
to identify references in the medical and chiropractic literature pertaining
to the chiropractic treatment of low back pain in which both the condition
and specific treatment procedures were adequately described. This literature
was then categorized according to a variety of characteristics and used
by a panel to evaluate the specific procedures.
Results: The 3 most studied adjustive procedures are side-posture
high-velocity, low-amplitude; distraction (mostly flexion distraction);
and mobilization, respectively. The clinical condition most commonly addressed
by the included studies is low back pain. The procedure with the widest
base of evidence support is side posture manipulation for low back pain.
(J Manipulative Physiol Ther 2001;24:407-24)
Abstract
Objective: To rate specific chiropractic technique procedures used in
the treatment of common low back conditions.
Design and Methods: A panel of chiropractors rated specific chiropractic
technique procedures for their effectiveness in the treatment of common low
back conditions, based on the quality of supporting evidence following systematic
literature reviews, and expert clinical opinion. Statements related to the rating
process and clinical practice were then developed through a facilitated nominal
consensus process.
Results: For most low back conditions presented in this study, the three
procedures rated most effective were:
Abstract
In recent years there has been an increase in interest in issues related
to the enhancement of the performance of the masters athlete. Many of the
changes in health status that have been thought to be the normal result
of aging have been found to be actually the result of a long-standing sedentary
lifestyle. Thus, masters athletes may be able to increase their athletic
performance to higher levels than what was once thought. Decreases in muscle
strength thought to be the result of aging do not appear to be so. The
masters athlete may be able to maintain and increase strength in situations
where strength training has not been previously engaged in. However, the
literature lacks longitudinal studies demonstrating improvements in strength
with age in masters athletes who have maintained habitual strength training.
Studies in the past have shown that aging results in changes in fibre type,
with a shift towards a higher percentage of type I fibres. This again may
be an adaptation to lack of use. Decreases in heart function and aerobic
capacity appear to be immutable, but in the masters athlete the rate of
this decrease can be slowed. The masters athlete has certain elevated nutritional
needs over younger athletes. Degenerative joint disease, although effecting
most persons as they age, is not a certain result of aging and disability
as the condition is reduced in the active person. Some orthopaedic conditions
are related to decreases in flexibility of soft tissues that appear to
accompany the aging process. Performance improvement in the masters athlete
requires the same commitment to hard training that it requires from younger
athletes, with some modifications for changes that are associated with
aging.
Abstract
Purpose: Peripheral neuropathy is one of the most common conditions
treated by chiropractors in the US. The purpose of this paper is
to review the anatomy of peripheral nerves and the pathophysiology, outcome
measures and chiropractic manual treatment methods used with peripheral
neuropathy syndromes.
Methods: A qualitative review of literature in referred literature
and textbooks.
Summary: An understanding of the pathophysiology of peripheral
neuropathy and the symptomatic picture associated with peripheral neuropathy
is important in order to choose an appropriate treatment and outcome measure.
Symptoms range from no symptoms, to loss of light touch/vibration sense
to chronic pain. Proper management requires the use of appropriate outcome
measures so that treatment effectiveness can be determined. Low-tech, non-invasive
outcome measures are the recommend evaluation tools in the management of
peripheral neuropathy. At present clinical trials documenting the effectiveness
of chiropractic management of peripheral neuropathy are lacking. This article
reviews chiropractic treatment ranging from variety of soft tissue treatment
methods as well as spinal and extremity manipulation peripheral neuropathy
Abstract
Objective: To determine the effectiveness of having chiropractic and
naturopathic evaluate a simulated diagnostic/therapeutic technique system in
teaching the evaluation of technique systems. To determine factors that
effect this pedagological technique.
Design: A prospective evaluation of students attitudes about technique
evaluation.
Setting: A university based colleges of chiropractic and naturopathic
medicine.
Participants: First semester chiropractic and naturopathic medicine students(N=31).
Interventions: Student evaluation of a simulated diagnostic/therapeutic
technique system, the Mock Technique System (MTS).
Main Outcome Measures: Surveys and interviews of student attitudes.
Results: The majority of students found that the evaluation of the MTS
was a valuable exercise and that it improved their confidence in their ability
to perform a similar evaluation on a real chiropractic diagnostic/therapeutic
technique system.
Conclusions: The evaluation of the MTS is a valuable classroom simulation
exercise for chiropractic and naturopathic students. This exercise allowed
the majority of students to strengthen their analytical skills concerning the
evaluation of diagnostic/therapeutic technique systems.
Abstract
Soft tissue injuries are a staple of a sports medicine practice.
Many of the common beliefs and treatment methods are not appropriate to
the pathology present or consistent with the physiology of repair.
An understanding of the biomechanics and physiology of injury and repair
can help in the development of appropriate treatment methods for these
injuries. These treatments are directed at supporting and stimulating
the body's own self-repair mechanisms.
Abstract
As individuals age in industrialized societies there is a concomitant
loss of muscle strength. This loss of strength is often thought a
direct result of the aging process. There is a direct association
between the loss of strength and loss of cross-sectional area of muscle.
Thus, decreased strength appears to be the result of atrophy and not some
inherent change in the function of the muscles themselves. There
are morphological changes to skeletal muscle that are also associated with
aging. Specifically, there is a shift in muscle fiber types from
type II fibers to type I fibers. Thus, endurance increases while
power decreases. Morphologically there appears to be a shift from
random distribution of both fiber types toward a tendency for type II fibers
to localize to the boundaries of muscle fascicles, while type I fibers
localize more centrally in the fascicle. These changes in muscle
fibers may be the result of age-related decrease in number of motor neurons.
Studies have investigated the effectiveness of self-directed and investigator-directed
exercise programs in preventing and reversing the age-related loss of muscle
strength. These studies have shown that the ability of the elderly
to increase muscle strength is comparable to young individuals. Few
studies have looked a preventing morphological changes but these studies
have found that exercise prevents the changes thought to be the result
of aging. It is concluded that most of the changes seen muscles of
the elderly are the result of lifestyle and not direct effects of
the aging process.