Use of spinal manipulation in a rheumatoid patient presenting with acute thoracic pain: a case report.

BACKGROUND: There is limited research related to spinal manipulation of uncomplicated thoracic spine pain and even less when pain is associated with comorbid conditions such as rheumatoid arthritis. In the absence of trial evidence, clinical experience and appropriate selection of the type of intervention is important to informing the appropriate management of these cases. CASE PRESENTATION: We present a case of a patient with long standing rheumatoid arthritis who presented with acute thoracic pain. The patient was diagnosed with costovertebral joint dysfunction and a myofascial strain of the surrounding musculature. The patient was unresponsive to treatment involving a generalized manipulative technique; however, improved following the administration of a specific applied manipulation with modified forces. The patient was deemed recovered and discharged with ergonomic and home care recommendations. DISCUSSION: This case demonstrates a clinical situation where there is a paucity of research to guide management, thus clinicians must rely on experience and patient preferences in the selection of an appropriate and safe therapeutic intervention. The case highlights the need to contextualize the apparent contraindication of manipulation in patients with rheumatoid arthritis and calls for further research. Finally the paper advances evidence based decision making that balances the available research, clinical experience, as well as patient preferences.

HISTORIQUE: Il existe peu d'études sur la manipulation vertébrale de douleur de la colonne dorsale sans complication, et encore moins lorsque la douleur est associée à des conditions comorbides comme la polyarthrite rhumatoïde. En l'absence de résultats d'essais cliniques, l'expérience clinique et le choix approprié du type d'intervention sont importants pour trouver la gestion appropriée de ces cas. PRÉSENTATION DE CAS: Nous présentons le cas d'un patient souffrant de polyarthrite rhumatoïde de longue date avec une douleur thoracique aiguë. Le patient a reçu un diagnostic de dysfonctionnement de l'articulation costo-vertébrale et une tension myofasciale de la masse musculaire qui l'enveloppe. Le patient ne répondait pas au traitement comprenant une technique de manipulation généralisée; cependant, il a démontré une amélioration à la suite de l'administration d'une manipulation spécifique avec des forces modifiées. Le patient a été jugé rétabli et a obtenu son congé avec des recommandations de soins ergonomiques et à domicile. DISCUSSION: Ce cas illustre une situation clinique où il y a n'y a pas assez d'études permettant d'orienter la gestion; par conséquent, les cliniciens doivent s'appuyer sur l'expérience et les préférences du patient pour choisir une intervention de traitement appropriée et sécuritaire. Ce cas souligne le besoin de contextualiser la contre-indication apparente de la manipulation chez les patients avec de l'arthrite rhumatoïde et le besoin de recherche supplémentaire. Finalement, l'étude préconise un processus décisionnel fondé sur des preuves qui équilibrent les études consultables, l'expérience en clinique et les préférences du patient.

The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature.

OBJECTIVE: Controversy surrounds the safety of cervical spine manipulation. Ischemic stroke secondary to cervical spine manipulation is a hypothesized adverse event. In Canada, the seriousness of these events and their perceived association to cervical spine manipulation has led some members of the public to call for a ban of the procedure. The primary objective of this study was to determine the incidence of internal carotid artery (ICA) dissection after cervical spine manipulation in patients who experience neck pain and its associated disorders. The secondary objective was to determine whether cervical spine manipulation is associated with an increased risk of ICA dissection in patients with neck pain, upper back pain, or headaches. METHODS: We systematically searched MEDLINE, CINAHL, Alternative Health, AMED, Index to Chiropractic Literature, and EMBASE from 1970 to November 2012. Two independent reviewers used standardized criteria to screen the eligibility of articles. We considered cohort studies, case-control studies, and randomized clinical trials that addressed our objectives. We planned to critically appraise eligible articles using the Scottish Intercollegiate Guideline Network methodology. RESULTS: We did not find any epidemiologic studies that measured the incidence of cervical spine manipulation and ICA dissection. Similarly, we did not find any studies that determined whether cervical spine manipulation is associated with ICA dissection. CONCLUSIONS: The incidence of ICA dissection after cervical spine manipulation is unknown. The relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is also unknown. Although several case reports and case series raise the hypothesis of an association, we found no epidemiologic studies that validate this hypothesis.

Interprofessional collaboration and turf wars how prevalent are hidden attitudes?

PURPOSE: Interprofessional collaboration in health care is believed to enhance patient outcomes. However, where professions have overlapping scopes of practice (eg, chiropractors and physical therapists), "turf wars" can hinder effective collaboration. Deep-rooted beliefs, identified as implicit attitudes, provide a potential explanation. Even with positive explicit attitudes toward a social group, negative stereotypes may be influential. Previous studies on interprofessional attitudes have mostly used qualitative research methodologies. This study used quantitative methods to evaluate explicit and implicit attitudes of physical therapy students toward chiropractic. METHODS: A paper-and-pencil instrument was developed and administered to 49 individuals (students and faculty) associated with a Canadian University master's entry-level physical therapy program after approval by the Research Ethics Board. The instrument evaluated explicit and implicit attitudes toward the chiropractic profession. Implicit attitudes were determined by comparing response times of chiropractic paired with positive versus negative descriptors. RESULTS: Mean time to complete a word association task was significantly longer (t = 4.75, p =.00) when chiropractic was associated with positive rather than negative words. Explicit and implicit attitudes were not correlated (r = 0.13, p =.38). CONCLUSIONS: While little explicit bias existed, individuals associated with a master's entry-level physical therapy program appeared to have a significant negative implicit bias toward chiropractic.

The pharmacognosy of Humulus lupulus L. (hops) with an emphasis on estrogenic properties.

As the population ages, there is an ever-increasing need for therapeutic agents that can be used safely and efficaciously to manage symptoms related to postmenopausal estrogen deficiency. Endogenous estrogens, e.g., 17beta-estradiol, of exogenous mammalian origin, e.g., horses, have long been used to manage such symptoms. There are more than 20 different classes of phytochemicals that have demonstrated affinity for human estrogen receptors in vitro. Some studies on exogenous estrogenic substances of botanical origin (phytoestrogens), such as standardized formulations of plant extracts with in vitro and in vivo estrogenic activity from soy (Glycine max Merill.) and red clover (Trifolium pratense L.), suggest clinical efficacy. Few clinical data for phytoestrogens other than isoflavonoids are available. In an exhaustive review of the literature through 2003, only two clinical trials were identified that were designed to evaluate the effect of hops (Humulus lupulus L.) on symptoms related to menopause. Folkloric, chemical, and biological literature relating primarily to the use of hops for their estrogenic activity, and two human clinical trials, are reviewed.

Ticlopidine hydrochloride: its current use in cerebrovascular disease.

It is estimated that half a million Americans will suffer strokes this year (National Stroke Association, 1989). The physical, emotional, and financial impacts of such an event are enormous. While stroke treatment methods have improved and rehabilitation programs have expanded, a substantial number of stroke patients are left with major disabilities. The only way to intervene is to focus on stroke prevention through the identification and modification of risk factors. One such intervention involves antiplatelet therapy, which has been found to reduce the risk of initial thrombotic stroke and the potential for recurrent stroke. Nurses caring for stroke patients need to know about this type of therapy, because continuity of pharmacological treatment, patient compliance, and education are essential for adequate stroke prevention.

Professional nursing with a new focus: staff nurse to research coordinator.

My positive feelings toward the data which will be accumulated abounds with excitement. I have read that one of the major rules of a clinical drug trial is that things never turn out as designated or expected. The volunteer participants really are the silent heroes. Nurses, as professionals, have many avenues for career planning. Nurses can identify what they want to do, reset their goals, and establish a plan to achieve these goals. In retrospect, my years as a staff nurse did educate and prepare me for a change in my professional status. For awhile, I took my staff nurse position for granted. Through all the trials and tribulations, through the happy and sad times, I was being prepared for a role change. I believe in fate as this fell into place for me after I decided to be patient and wait for the proper situation. I encourage any nurse who has similar goals to learn how to seek the appropriate job, go to seminars or take classes, remain a productive member of your unit and learn how to interview. It is definitely worth all the anxiety caused by the waiting.