Chiropractic management of mechanical neck and low-back pain: a retrospective, outcome-based analysis.

BACKGROUND: Evidence suggests that spinal manipulation is an effective treatment for mechanical neck and low-back pain (LBP). Treatment efficacy is important to establish for these symptoms because combined they account for a considerable amount of disability and substantial associated direct and indirect costs to society. OBJECTIVE: The purpose of this study was to examine the outcome of patients undergoing chiropractic treatment for mechanical neck or LBP. DESIGN AND SETTING: A retrospective, outcome-based analysis was done for patients seeking care at a private chiropractic practice over a 1-year period. A total of 512 files were reviewed, with 119 patients selected for inclusion. Patients were included if their chief symptom was uncomplicated mechanical neck or LBP. Diagnoses included cervical, lumbar, or sacroiliac joint sprain/strain (International Code of Diagnostics version 9 [ICD-9] code: 847.1, 847.3, 846.1, respectively), discogenic LBP (ICD-9: 722.1), and headaches (ICD-9: 784.0) because many patients with neck pain presented with concomitant headaches. Disability and pain were measured with the modified Oswestry scale (for the patients with LBP), Neck Disability Index, and an 11-box visual analogue pain scale before and after treatment. Treatment consisted of spinal manipulation, various soft-tissue techniques, home-care instructions, and ergonomic and return-to-activity advice, including rehabilitative exercises. Patients received an average of 12 treatments over a 4-week period. Statistical analysis was performed on pretreatment and posttreatment values for both disability and pain. Stratification was based on duration (acute/subacute, chronic, acute exacerbation of a chronic condition) and severity (mild, moderate, or severe) of symptoms. RESULTS: Statistically significant reductions in disability and pain scores were achieved in all groups. An average 52.5% and 52.9% reduction in pain and disability, respectively, was achieved in the low-back group. The chronic LBP group realized a less statistically significant reduction of pain and disability (19.7% and 19.8%, respectively) than the acute/subacute (66.8% and 62.5%) or the chronic/recurrent group (56. 5% and 63.4%). The differences were statistically significant. Patients with neck pain had an average 53.8% and 48.4% reduction in their pain and disability, respectively. Patients with concomitant neck pain and headaches had statistically significant higher pretreatment and posttreatment disability and pain scores than those with only neck pain. There was no statistically significant difference in outcomes between groups stratified according to pain intensity. CONCLUSIONS: Patients attending a private chiropractic clinic for treatment of mechanical neck pain or LBP had statistically significant reductions in their pain-related disability after treatment. These results indicate that chiropractic manipulation is beneficial for the treatment of mechanical neck pain and LBP. However, care must be taken when drawing conclusions from these outcomes. The study design does not account for the natural history of low back- or neck pain-related disability and therefore does not allow for claims of treatment efficacy. In addition, it has been suggested that patients presenting to medical doctors with these symptoms have significant overlying comorbidity when compared with patients presenting to a chiropractor.

Conservative lower back treatment reduces inhibition in knee-extensor muscles: a randomized controlled trial.

BACKGROUND: Knee-joint pathologies, such as anterior knee pain (AKP), are associated with strength deficits and reduced activation of the knee extensors, which is referred to as muscle inhibition (MI). MI is thought to prevent full functional recovery, and treatment modalities that help to reduce or eliminate MI appear necessary for successful rehabilitation. Clinical observations suggest that AKP is typically associated with sacroiliac (SI) joint dysfunction. It is unknown whether SI-joint dysfunction contributes to knee-extensor deficits and whether correction of SI-joint dysfunction alleviates MI. OBJECTIVE: The objective of this study was to assess whether conservative low back treatment reduces lower limb MI. STUDY DESIGN: In a randomized, controlled, double-blind study the effects of conservative lower back treatment on knee-extensor strength and MI were evaluated in patients with AKP. METHODS: Twenty-eight patients with AKP were randomly assigned to either a treatment or a control group. After a lower back functional assessment, the treatment group received a conservative treatment in the form of a chiropractic spinal manipulation aimed at correcting SI-joint dysfunction. The control group underwent a lower back functional assessment but received no joint manipulation. Before and after the manipulation or the lower back functional assessment, knee-extensor moments, MI, and muscle activation during full effort, isometric knee extensions were measured. RESULTS: Patients showed substantial MI in both legs. Functional assessment revealed SI-joint dysfunction in all subjects (23 symptomatic and 5 asymptomatic). After the SI-joint manipulation, a significant decrease in MI of 7.5% was observed in the involved legs of the treatment group. MI did not change in the contralateral legs of the treatment group or the involved and contralateral legs of the control group. There were no statistically significant changes in knee-extensor moments and muscle activation in either group. CONCLUSIONS: The results of this study suggest that SI-joint manipulation reduces knee-extensor MI. Spinal manipulation may possibly be an effective treatment of MI in the lower limb musculature.

Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee pain.

BACKGROUND: Evidence exists that conservative rehabilitation protocols fail to achieve full recovery of muscle strength and function after joint injuries. The lack of success has been attributed to the high amount of muscle inhibition found in patients with pathologic conditions of the knee joint. Clinical evaluation shows that anterior knee pain is typically associated with sacroiliac joint dysfunction, which may contribute to the muscle inhibition observed in this patient group. OBJECTIVE: To assess whether sacroiliac joint manipulation alters muscle inhibition and strength of the knee extensor muscles in patients with anterior knee pain. DESIGN AND SETTING: The effects of sacroiliac joint manipulation were evaluated in patients with anterior knee pain. The manipulation consisted of a high-velocity low-amplitude thrust in the side-lying position aimed at correcting sacroiliac joint dysfunction. Before and after the manipulation, torque, muscle inhibition, and muscle activation for the knee extensor muscles were measured during isometric contractions using a Cybex dynamometer, muscle stimulation, and electromyography, respectively. PARTICIPANTS: Eighteen patients (mean age, 30.5 +/- 13.0 years) with either unilateral (n = 14) or bilateral (n = 4) anterior knee pain. RESULTS: Patients showed substantial muscle inhibition in the involved and the contralateral legs as estimated by the interpolated twitch technique. After the manipulation, a decrease in muscle inhibition and increases in knee extensor torques and muscle activation were observed, particularly in the involved leg. In patients with bilateral anterior knee pain, muscle inhibition was decreased in both legs after sacroiliac joint adjustment. CONCLUSIONS: Spinal manipulation might offer an interesting alternative treatment for patients with anterior knee pain and muscle inhibition. Because this clinical outcome study was of descriptive nature rather than a controlled design, biases might have occurred. Thus the results have to be verified in a randomized, controlled, double-blinded trial before firm conclusions can be drawn or recommendations can be made.

Patient-controlled analgesia following caesarean section under general anaesthesia: a comparison of fentanyl with morphine.

This prospective, randomised, double-blind study compared PCA fentanyl with PCA morphine for post-Caesarean section analgesia. Following a standardised general anaesthetic, 37 women were allocated to receive either fentanyl (n = 18) or morphine (n = 19). The PCA was commenced after the women had been made comfortable in the postanaesthetic recovery room with the appropriate opioid solution (mean dose required = fentanyl 375 micrograms or morphine 16 mg). Initial PCA settings were bolus 1 ml (fentanyl 25 micrograms or morphine 1 mg), lockout time ten minutes, and no background infusion. Both analgesic solutions provided effective analgesia for a mean of 37 hr with high levels of patient satisfaction, and there were no differences in VAS scores for pain and patient satisfaction, or for side effects (nausea, itch, and sleepiness) between fentanyl or morphine. However, more patients in the fentanyl group required supplementary boluses or alterations to the PCA settings (13/18 vs 4/19: P = 0.005), and one patient was removed from the study due to inadequate analgesia. We conclude that fentanyl is not recommended for routine PCA use following Caesarean section.

Comparison of the 25-gauge Whitacre with the 24-gauge Sprotte spinal needle for elective caesarean section: cost implications.

Spinal anaesthesia provides rapid, safe anaesthesia for Caesarean section. The pencil-point spinal needles (Sprotte and Whitacre) are reported to have a low incidence of post-dural puncture headache (PDPH). As the 25G Whitacre is less expensive than the 24G Sprotte needle, this prospective, randomized, double-blind study was designed to compare the incidence of PDPH and ease of insertion of these needles in 304 ASA 1 and 2 women having elective Caesarean section under spinal anaesthesia. Each patient was assessed daily for five consecutive days following Caesarean section by an investigator blinded to the needle used. The results indicate that the two needles have a similar ease of insertion, number of failed insertions, and failed subarachnoid blockade. An inability to insert the spinal needles occurred in two patients in each group. Therefore, 150 patients in each group completed the study. The incidence of PDPH with the 24G Sprotte needle was 4.0% (6/150) compared with 0.66% (1/150) with the 25G Whitacre (NS). There was no correlation between the occurrence of PDPH and the difficulty of needle insertion, presence of transient hypotension or the effectiveness of anaesthesia delivered. This study indicates that both needles are comparable with respect to ease of insertion and incidence of PDPH. As the Whitacre needle is less expensive it is a reasonable alternative to the more expensive Sprotte needle.

Anaesthetic management of a complex morbidly obese parturient.

A case is presented of a morbidly obese parturient who had multiple medical problems. She had angina and was receiving nitrate therapy, had insulin-dependent diabetes mellitus, hypertension, asthma and benign intracranial hypertension (pseudotumour cerebri). Lumbar epidural analgesia was chosen for labour and delivery and resulted in an uneventful outcome.

Determination of ritodrine in biological fluids of the pregnant sheep by fused-silica capillary gas chromatography using electron-capture detection.

A sensitive and selective gas chromatographic assay method employing splitless injection, fused-silica capillary columns and electron-capture detection is reported for the quantitation of the tocolytic drug, ritodrine, in a variety of biological fluids obtained from the pregnant ewe and fetus. This method has improved sensitivity and selectivity over previously published assay procedures. A 25 m x 0.31 mm I.D., cross-linked 5% phenylmethylsilicone, fused-silica capillary column was employed for all analyses. Linearity of response was observed over the range 2.5-75 ng of ritodrine base per 0.05-0.5 ml of biological fluid, representing approximately 1-75 pg at the detector. The coefficient of variation was less than 10% over the range 2.5-75 ng of added ritodrine. The minimum quantifiable amount is approximately 2.5 ng from a 0.5-ml biological fluid sample. Applicability of this method to biological fluids, obtained from ovine subjects, is demonstrated by the analysis of samples obtained during the course of ritodrine placental transfer studies.

Fetal and maternal placental and nonplacental clearances of metoclopramide in chronically instrumented pregnant sheep.

The placental and nonplacental clearances of metoclopramide were studied in nine chronically instrumented, near-term pregnant sheep using a two-compartment open model. Metoclopramide was administered to the ewe and fetus on separate occasions as an initial iv bolus loading dose followed by a constant-rate infusion, with steady-state maternal and fetal plasma concentrations being obtained by 45 min. Following the maternal infusions, metoclopramide reached average steady-state concentrations of 50.0 +/- 20.2 ng/mL in the ewe and 27.1 +/- 8.6 ng/mL in the fetus, with a mean fetal-to-maternal concentration ratio of 0.57 +/- 0.14. The ability of the fetus to eliminate metoclopramide by nonplacental routes appears to be responsible for this ratio being less than unity, rather than differential protein binding and ion-trapping effects. Mean steady-state concentrations were 13.8 +/- 4.5 and 253.7 +/- 92.1 ng/mL in the ewe and fetus, respectively, after fetal drug administration. Metoclopramide was bound significantly less to fetal (39.5 +/- 8.9%) than to maternal (49.5 +/- 7.9%) plasma proteins, with values similar to that reported for humans (approximately 40%). Clearance of metoclopramide across the placenta from the fetus to the ewe (6.2 +/- 2.4 L/h/kg) was significantly greater than that in the reverse direction (4.3 +/- 1.3 L/h/kg) and accounted for approximately 80% of total fetal drug elimination. This may be explained by the higher percentage of fetal cardiac output to the placenta and the flow-limited transfer of this compound.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidural morphine for analgesia after caesarean section: a report of 4880 patients.

This retrospective study was undertaken to assess the efficacy and safety of epidural morphine in providing analgesia following Caesarean section under epidural anaesthesia. The morphine was administered as a single bolus, following delivery, in doses ranging from 2 to 5 mg. The charts of 4880 Caesarean sections, performed on 4500 patients, were reviewed. The duration of analgesia and the occurrence of any symptoms which might be side-effects of the epidural morphine were recorded. The duration of analgesia was 22.9 +/- 10.1 hr and was not correlated with the dose of epidural morphine. Eleven per cent of the patients required no supplemental analgesia during the first 48 hr. Twelve patients (0.25 per cent) had respiratory rates less than 10 breaths per minute, on at least one occasion. No serious sequelae resulted from these periods of bradypnoea. Pruritus occurred in 58 per cent of patients, nausea and vomiting in 39.9 per cent and dizziness in ten per cent. Herpes simplex labialis was recorded in 3.5 per cent of patients. Epidural morphine is thus confirmed as an effective analgesic technique post-Caesarean section with 3 mg being the optimal dose. Even in this young healthy patient population, clinically detectable respiratory depression occurs so clinical respiratory monitoring is indicated.

Epidural sufentanil for post-caesarean section analgesia: lack of benefit of epinephrine.

Epidural sufentanil was administered to 57 women after Caesarean section, under epidural anaesthesia, to provide postoperative analgesia. Each patient received a 30 micrograms dose at the first complaint of pain and this dose was repeated when pain recurred. Epinephrine (1:200,000) was added to the local anaesthetic, sufentanil, both, or neither. The time of onset of analgesia, efficacy, duration of analgesia and the incidence of side-effects were recorded. This dose of epidural sufentanil provided satisfactory postoperative analgesia and no serious side-effects were observed. The onset of analgesia was rapid (4-6 min), but the duration of action was brief (4-5 hr). The addition of 1:200,000 epinephrine had no statistically significant influence on any of the measured variables. Pruritus occurred commonly but never required treatment. Drowsiness was experienced frequently and was felt by some patients to inhibit their interaction with their neonates. Respiratory depression, as defined by a respiratory rate less than 10 bpm, was not observed. A number of patients noted a transient period of euphoria 5-8 min after administration of the epidural sufentanil. The authors feel that epidural sufentanil provides satisfactory analgesia after Caesarean section, but the brief duration of action and the high incidence of drowsiness limit its acceptability for routine use in obstetric patients.

Comparison of lidocaine CO2, two per cent lidocaine hydrochloride and pH adjusted lidocaine hydrochloride for caesarean section anesthesia.

Lidocaine can be prepared in a variety of ways which may affect the characteristics of neural blockade achieved. Experimental evidence is equivocal as to the clinical impact of the use of different lidocaine preparations. A randomized, double-blind study was performed to investigate the differences in epidural anaesthesia for Caesarean section using three different lidocaine solutions: lidocaine CO2, two per cent lidocaine and two per cent lidocaine with its pH adjusted by the addition of bicarbonate. No differences were found among the groups in time of onset of neural blockade, quality or duration of neural blockade, time to delivery of the infant or volume of anaesthetic solution injected into the epidural space. A significant difference was found between the pH's of the solutions used. It is concluded that all three solutions are equally efficacious in epidural anaesthesia for Caesarean section.

Comparison of patient-controlled epidural analgesia and conventional intermittent "top-up" injections during labor.

In a prospective, randomized manner, bolus injection patient-controlled epidural analgesia (PCEA; n = 30) and conventional intermittent "top-up" injections (CIT; n = 28) of bupivacaine in nulliparous parturients during first stage of labor were compared. Group A (PCEA) patients self-administered, using a patient-controlled analgesia device, 4-mL increments of 0.125% bupivacaine with 1: 400,000 epinephrine, to a maximum 12 mL/h as required. Group B (CIT) patients received 12 mL of the same solution, on request, from the anesthesiologist. Hourly assessments of pain relief (visual analogue scale), satisfaction, sensory and motor block, blood pressure, and cervical dilatation were made. In addition, retrospective pain assessments were made in patients requesting analgesia in the preceding hour, indicating their maximum pain during that time. The groups were demographically comparable and equally low hourly bupivacaine requirements were seen (group A, 6.36 +/- 0.43 mg; group B, 6.23 +/- 0.39 mg) producing similar mean sensory levels. Pain relief obtained in both groups was similar but was associated with greater satisfaction in patients using PCEA (P less than 0.05). This study shows that PCEA is a viable alternative for providing pain relief in the first stage of labor.

Predictability of spread of epidural anesthesia for cesarean section using incremental doses of lidocaine hydrocarbonate with epinephrine.

The relationship between patient height and total volume of lidocaine hydrocarbonate (1.73%) with epinephrine, required to produce epidural anesthesia for Cesarean section, was studied. Volume of local anesthetic, time to maximum block, highest segmental block, and number of spinal segments blocked were recorded. The segmental dose requirement (SDR) was calculated. All the results from 9 "short" (less than 5'2") and 18 "tall" (greater than 5'2") patients were compared. There were no intergroup differences between any of the measured variables, and a scatterplot showed no linear relationship between patient height and the volume of the local anesthetic used. The mean values obtained for volume of local anesthetic used in both subgroups were compared with suggested arbitrary volumes of 25 ml for "tall" patients and 18 ml for "short" patients, used as a single-dose through an epidural needle. Using a one-sample hypothesis test, a significant difference was seen in tall patients (16.0 +/- 2.9 v 25; p less than .001), but not in the short subgroup (15.9 +/- 3.2 v 18; p less than .082). Patient height is a poor predictor of the volume of lidocaine hydrocarbonate required for epidural anesthesia in pregnant women. Selecting an arbitrary volume of local anaesthetic for use as a single epidural dose may result in either an excessively high or inadequate segmental block. Well-controlled titration of local anesthetic through an epidural catheter is recommended for elective Cesarean section.

Influence of bupivacaine as an adjuvant to epidural morphine for analgesia after cesarean section.

The effect of the addition of bupivacaine to epidural morphine (EM) on postoperative analgesia was evaluated in 150 patients after cesarean section performed under epidural anesthesia with carbonated lidocaine. Fifty patients received 3 mg EM without bupivacaine, 50 received 3 mg EM with 0.125% bupivacaine, 25 received 5 mg EM without bupivacaine, and 25 patients received 5 mg EM with 0.125% bupivacaine. Patients were assessed for quality and duration of postoperative analgesia, as well as the incidence and severity of side effects. The addition of bupivacaine did not affect the quality or duration of analgesia afforded by EM and did not influence the incidence or severity of side effects. Furthermore, there was no statistically significant difference in the analgesia obtained by patients receiving 3- and 5-mg doses of EM with or without bupivacaine.

Utilization of red blood cell transfusion in an obstetric setting.

The transfusion experience for a 1-year period (September 1985 to August 1986) at a tertiary referral obstetric hospital was reviewed retrospectively. During the review period 7731 mothers were delivered and 6003 patients (83%) underwent type-and-screen procedures. A total of 1057 units of red blood cells were crossmatched, and 362 of these 1057 units were transfused to 100 parturient women so that the overall crossmatch/transfusion ratio was 2.9:1. Five percent of transfused patients received 1 unit; 52% of patients received 2 units, 19% received 3 units and 24% received greater than or equal to 4 units of packed red blood cells. Major indications for transfusion were uterine atony, 27%; retained placenta, 17%; trauma, 17%, placenta previa, 7%; and abruptio placentae, 5%. In 12% of patients transfusions were done because of anemia. This study shows the value of audit and confirms that the type-and-screen procedure is an effective way of reducing the crossmatch/transfusion ratio without compromising patient care, even in high-risk patients.

Linearity of metoclopramide kinetics at doses of 5-20 mg.

The disposition of metoclopramide was studied on a four-way crossover basis in six healthy non-smoking volunteers. The linearity of kinetic parameters and absolute bioavailability of metoclopramide were examined. In contrast to previous reports, metoclopramide obeyed linear kinetics over oral doses ranging from 5 to 20 mg. The absolute bioavailability of metoclopramide was 0.76 +/- 0.38 (mean +/- s.d.) from the oral dosage forms examined in this study.

Effect of haemodialysis on metoclopramide kinetics in patients with severe renal failure.

The kinetics of metoclopramide and the effects of haemodialysis on metoclopramide kinetics were examined in eight uraemic subjects 1 h and 24 h prior to the onset of dialysis. In spite of the relatively minor contribution of renal clearance to total body clearance in normals, metoclopramide kinetics were substantially altered in uraemia. The total body clearance was decreased by 2-4 fold, terminal elimination half-life proportionately increased, while the volume of distribution appeared to be unaffected compared with that previously demonstrated in normal healthy subjects. Haemodialysis does not appear to be effective in removing metoclopramide from the body and metoclopramide clearance subsequent to dialysis is unaltered. The kinetic parameters in the uraemic subjects are not significantly different between drug administrations 1 or 24 h prior to the time of onset of haemodialysis. Following kidney transplantation, in one subject, there appeared to be a rapid return to apparently normal kinetics from the uraemic state.

The effect of pH adjustment of bupivacaine on onset and duration of epidural anaesthesia for caesarean section.

Previous studies have reported that elevation of the pH of local anaesthetics results in more rapid onset of action, with enhanced quality and duration of block. This study investigated the effect of pH adjustment of 0.5 per cent bupivacaine immediately prior to epidural anaesthesia for Caesarean section. Addition of 0.1 ml of 8.4 per cent sodium bicarbonate to 20 ml of 0.5 per cent bupivacaine consistently raised the pH of the local anaesthetic from 5.49 to 7.04 (mean values). One hundred patients, presenting for elective Caesarean section under epidural anaesthesia participated in the study. Forty patients received epidural anaesthesia, using pH-adjusted 0.5 per cent bupivacaine, in a dosage adequate to produce block to the T4 level. A control group of 40 patients received the standard commercial preparation of 0.5 per cent bupivacaine. A further ten patients in each group received epidural anaesthesia using 0.5 per cent bupivacaine with the addition of 1:400,000 epinephrine, to study the effect of epinephrine on pH adjustment of the local anaesthetic. Elevation of the pH of the local anaesthetic significantly increased the speed of onset of action from 6.4 minutes to 3.2 minutes and the time to peak effect from 24.8 minutes to 18.1 minutes, while the duration of anaesthesia was increased from 124.8 minutes to 147.3 minutes. The time to S2 segment blockade was also shortened from 13.5 to 8.6 minutes. Addition of 1:400,000 epinephrine to the local anaesthetic did not influence the effect of pH adjustment. Maternal and umbilical cord plasma levels of bupivacaine were not affected by pH adjustment of the local anaesthetic, while MV/UV and UA/UV ratios were unaltered.