Perle, D.C., M.S.
Bridgeport, CT, USA
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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.
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)
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.
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.
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.
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.
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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.
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.
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
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
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.
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web site (free full text)
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.
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.
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.
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)
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:
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.
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
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.
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.
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.