Search

Samuel N Rodgers-Melnick,1,2 Robert J Trager,1 Thomas E Love,2– 4 Jeffery A Dusek5 1Connor Whole Health, University Hospitals of Cleveland, Cleveland, OH, USA; 2Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA; 3Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA; 4Population Health and Equity Research Institute, The MetroHealth System, Cleveland, OH, USA; 5Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, OH, USACorrespondence: Samuel N Rodgers-Melnick, University Hospitals Connor Whole Health, 11100 Euclid Avenue, Wearn 548A, Cleveland, OH, 44106, USA, Tel +1 216 844 7727, Fax +1 216 201 6220, Email Samuel.RodgersMelnick@UHhospitals.orgObjective: To examine variables associated with engagement in (1) integrative health and medicine (IHM) and (2) nonpharmacologic modalities rather than opioids among United States adults with chronic pain.Methods: Using the 2019 National Health Interview Survey, we examined sociodemographic, pain, and mental health predictors of (1) the sum of IHM modalities (ie, chiropractic care, yoga/Tai Chi, massage, or meditation/guided imagery) used to manage pain and (2) exclusive engagement in nonpharmacologic pain management modalities (ie, IHM, a chronic pain self-management program, support groups, or physical, rehabilitative, occupational, or talk therapy) or opioids in the past 3 months.Results: Metropolitan residency, higher family income, higher education levels, increased number of pain locations, and increased frequency of pain limiting life/work activities were associated with increased odds of IHM engagement. Older age, male sex, non-Hispanic Black/African American race/ethnicity, and daily opioid use were associated with decreased odds of IHM engagement. Older age, male sex, and increased depressive symptoms were associated with decreases in the count of IHM modalities used to manage pain. Metropolitan residency, higher family income, and higher education levels were associated with increased odds of exclusive nonpharmacologic modality engagement. Older age and increasing frequency of pain limiting life/work activities were associated with decreased odds of exclusive nonpharmacologic modality engagement.Conclusions: We identified several contrasts between factors prevalent among individuals with chronic pain and factors associated with engagement in nonpharmacologic and IHM modalities. These results support efforts to address barriers to accessing these modalities among subpopulations of adults with chronic pain (eg, older adults, individuals identifying as Black/African American, rural residents, and those with lower levels of education and income).Plain Language Summary: This study examined factors influencing the use of integrative health and non-drug treatments for chronic pain in the United States. Results revealed that metropolitan residence, higher income, and education were associated with increased use of these treatments, while older age, male sex, daily opioid use, and non-Hispanic Black/African American ethnicity were associated with decreased use. The findings emphasize the importance of addressing barriers to these forms of care, especially among older adults, Black/African American individuals, and those with higher depressive symptoms and lower education and income levels, who are more likely to have chronic pain.Keywords: integrative medicine, chronic pain, nonpharmacologic, opioids

Introduction: This study examined the efficacy of manual therapy for pain and disability measures in adults with sacroiliac joint pain syndrome (SIJPS)., Methods: We searched six databases, including gray literature, on 24 October 2023, for randomized controlled trials (RCTs) examining sacroiliac joint (SIJ) manual therapy outcomes via pain or disability in adults with SIJPS. We evaluated quality via the Physiotherapy Evidence Database scale and certainty via Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) in post-treatment pain and disability scores were pooled using random-effects models in meta-regressions., Results: We included 16 RCTs (421 adults; mean age = 37.7 years), with 11 RCTs being meta-analyzed. Compared to non-manual physiotherapy (i.e. exercise ± passive modalities; 10 RCTs) or sham (1 RCT) interventions, SIJ manual therapy did not significantly reduce pain (SMD: -0.88; 95%-CI: -1.84; 0.08, p  = 0.0686) yet had a statistically significant moderate effect in reducing disability (SMD: -0.67; 95% CI: -1.32; -0.03, p  = 0.0418). The superiority of individual manual therapies was unclear due to low sample size, wide confidence intervals for effect estimates, and inability to meta-analyze five RCTs with a unique head-to-head design. RCTs were of 'good' (56%) or 'fair' (44%) quality, and heterogeneity was high. Certainty was very low for pain and low for disability outcomes., Conclusion: SIJ manual therapy appears efficacious for improving disability in adults with SIJPS, while its efficacy for pain is uncertain. It is unclear which specific manual therapy techniques may be more efficacious. These findings should be interpreted cautiously until further high-quality RCTs are available examining manual therapy against control groups such as exercise., Registration: PROSPERO (CRD42023394326).

Competing Interests: The authors report no conflict of interest.

Introduction: Limited research suggests that spinal manipulative therapy (SMT) might positively influence balance, yet its association with falls remains underexplored. We hypothesized that older adults receiving chiropractic SMT for spinal pain would have a reduced fall risk during 13 months of follow-up compared to matched controls., Methods: We searched >116 million patient records from TriNetX (2013-2023; Cambridge, MA, US) to identify adults aged ≥65 years with spinal pain. After excluding those with major fall risk factors, we formed SMT and non-SMT cohorts, using propensity score matching to control for confounders (e.g., age, sex, comorbidities). Risk ratios (RR) with 95% CIs and p-values were calculated for primary (fall) and secondary (limb fracture) outcomes over 13 months. We explored the cumulative incidence of falls and fractures and negative control outcomes (colonoscopy, vital signs, diabetes, nicotine/tobacco screening)., Results: After matching, each cohort had 1,666 patients (mean age 72 years). The SMT cohort had a lower fall rate than the non-SMT cohort (3.8% vs. 5.4%), yielding an RR (95% CI) of 0.71 ((0.52, 0.97); p=0.0319). Cumulative incidences revealed a brief lag in SMT cohort fall incidence. There was no meaningful difference in limb fractures (RR of 1.16 (0.87, 1.54); p=0.3153). Negative control outcomes were similar between cohorts., Conclusions: This study suggests that older adults receiving SMT for spinal pain may have a reduced risk of falls. However, given the observational nature of the study and the lack of significant differences in limb fracture incidence, the clinical significance of these findings remains uncertain. Further research, including randomized controlled trials, is needed to explore injurious falls, care utilization, pain, and costs., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. The University Hospitals Institutional Review Board issued approval STUDY20230244. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: This study was not supported by any specific grant. Peter Wayne’s time and resources were supported by general funding from a K24 investigator award from the National Center for Complementary and Integrative Health (#AT009282). The work conducted by RT received support from the Elisabeth Severance Prentiss Foundation (Cleveland, OH) through general funding. This project is also supported by the Clinical and Translational Science Collaborative of Northern Ohio, which is funded by the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Science Award grant, UM1TR004528. The funders were not involved in developing the study protocol or any key decisions. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Trager et al.)

Background Context: Osteoporosis has been proposed as a risk factor for reoperation after anterior cervical discectomy and fusion (ACDF), yet this potential association has been understudied, with conflicting results to date., Purpose: This study examines the hypothesis that adults with osteoporosis would have an increased risk of reoperation after ACDF compared to matched adults without osteoporosis., Study Design/setting: Retrospective cohort study., Patient Sample: Two matched cohorts (mean age: 62 years; 75% female), each with 1,019 patients, who underwent primary ACDF. Cohorts were determined by the presence or absence of a diagnosis of osteoporosis., Outcome Measures: Incidence of reoperation occurring over 4 years postoperatively, with our primary outcome being the risk ratio (RR) of reoperation with 95% confidence intervals (CI). Secondary outcomes included risk and mean count of oral opioid prescriptions and risk of pseudoarthrosis., Methods: We utilized the TriNetX network to identify adults undergoing their first ACDF from 2004 to 2020, excluding those with serious pathology, and divided patients into 2 cohorts: osteoporosis and nonosteoporosis. Patients were propensity matched according to key risk factors for reoperation., Results: Patients with osteoporosis had no statistically significant or meaningful difference in risk of reoperation compared to nonosteoporotic patients over 4-years' follow-up [95% CI] (17.3% vs. 16.5%; RR: 1.05 [0.86, 1.27]; p=.6361). Similarly, there were no significant differences in the risk of pseudoarthrosis (26.5% vs. 29.1%; RR: 0.91 [0.79, 1.05]; p=.1820), oral opioid prescription (75.0% vs. 76.0%; RR: 0.99 [0.94, 1.04]; p=.6067), or mean oral opioid prescription count (11.5 vs. 11.8; p=.7040)., Conclusion: Compared to matched nonosteoporosis controls, osteoporosis was not associated with a statistically significant or clinically meaningful increase in risk of reoperation in adults over 4 years after ACDF. Furthermore, osteoporosis was not associated with a significant or meaningful risk of pseudoarthrosis or oral opioid prescription after ACDF, although more research is needed for corroboration. Additional research is needed to clarify whether those with osteoporosis have meaningful differences in pain and function compared to those without osteoporosis following ACDF., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Chiropractors diagnose and manage musculoskeletal disorders, commonly using spinal manipulative therapy (SMT). Over the past half-century, the chiropractic profession has seen increased utilization in the United States following Medicare authorization for payment of chiropractic SMT in 1972. We reviewed chiropractic research trends since that year and recent clinical practice guideline (CPG) recommendations regarding SMT. We searched Scopus for articles associated with chiropractic (spanning 1972-2024), analyzing publication trends and keywords, and searched PubMed, Scopus, and Web of Science for CPGs addressing SMT use (spanning 2013-2024). We identified 6286 articles on chiropractic. The rate of publication trended upward. Keywords initially related to historical evolution, scope of practice, medicolegal, and regulatory aspects evolved to include randomized controlled trials and systematic reviews. We identified 33 CPGs, providing a total of 59 SMT-related recommendations. The recommendations primarily targeted low back pain (n = 21) and neck pain (n = 14); of these, 90% favored SMT for low back pain while 100% favored SMT for neck pain. Recent CPG recommendations favored SMT for tension-type and cervicogenic headaches. There has been substantial growth in the number and quality of chiropractic research articles over the past 50 years, resulting in multiple CPG recommendations favoring SMT. These findings reinforce the utility of SMT for spine-related disorders.

Background: The Schroth method is the most commonly used patient scoliosis-specific exercise paradigm for treating pediatric scoliosis. The aim of this study is to systematically and critically examine the evidence for the Schroth method for pediatric scoliosis., Methods: PubMed, MEDLINE, CINAHL, and Web of Science were searched through April 5, 2024, for articles examining the Schroth method for pediatric scoliosis (<18 years old). Thirteen review questions were created spanning the study aim. Each included article was independently assessed for the level of evidence (I-IV). Research questions were given a grade of recommendation (A, B, C, and I [insufficient])., Results: A total of 29 articles (41.4% Level I, 31.0% Level II, 13.8% Level II, and 13.8% Level IV) met inclusion criteria out of 845 initially retrieved, describing 1,555 patients with scoliosis aged 4 to 18 years. There was grade A evidence that the Schroth method is most commonly used for adolescent idiopathic scoliosis (AIS), can improve the angle of trunk rotation, and is safe; grade B evidence for improvement in posture; and grade I evidence for improvement in Cobb angle, cosmetic deformity, quality of life, ideal treatment parameters, economic value, utility in delaying/preventing surgery, effectiveness in relation to patient characteristics (e.g., skeletal maturity or curve size), and comparative effectiveness to other conservative interventions., Conclusion: While there is good evidence that the Schroth method is commonly and safely used in AIS and can minimally improve the angle of trunk rotation and fair evidence of improvement in posture, there is insufficient evidence regarding multiple important clinical and economic outcomes, such as comparative effectiveness to other conservative interventions and improvement of Cobb angle. Although clinicians may consider the Schroth method as 1 option of several conservative strategies, clinical benefit may be limited, and further high-quality research is needed to evaluate its performance in areas of insufficient evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/B159)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Objective: Owing to perceived additional costs, patients may avoid integrative health and medicine (IHM) treatments, while insurers may not cover IHM. We hypothesized that adult beneficiaries of a health system's employee insurance plan with musculoskeletal (MSK) conditions receiving covered outpatient IHM would have reduced total allowed costs over the 1-year follow-up compared with matched controls, secondarily exploring medical and pharmaceutical cost subsets. Methods: We queried medical records and claims spanning 2018-2023 for beneficiaries aged 18-89 years with a new MSK episode. Patients were divided into cohorts: (1) IHM within 3 months after MSK diagnosis and (2) no IHM after initial primary care. After inflation adjustment and trimming, propensity score matching was used to balance cohorts on demographics, comorbidity, health care utilization, and prior 12-month spend. Least-squares mean total, medical, and pharmaceutical allowed costs (United States Dollar) over the 1-year follow-up were analyzed using a linear mixed model. Findings were compared with a generalized linear model without trimming. Results: There were 251 patients per matched cohort, with adequate covariate balance. There was no meaningful between-cohort difference (IHM minus No IHM) in least-squares mean total cost (+703 [95% CI: -314, 1720]). Secondary outcomes included medical cost (+878 [95% CI: 61, 1695]) and pharmaceutical cost (+6 [95% CI: -71, 83]). A generalized linear model revealed no meaningful difference in estimated mean total medical costs (-2561 [95% CI: -7346, +2224]). Conclusions: IHM use among adult health system beneficiaries with MSK conditions was not associated with meaningful differences in 1-year follow-up total health care costs compared with matched controls. Our study was underpowered for secondary outcomes, which should be interpreted with caution. Future research should include a larger sample of patients and examine longitudinal changes in patient-reported outcomes.

Background: There has been rapid growth of chiropractors pursuing career opportunities in both public and private hospitals and other integrated care settings. Chiropractors that prosper in integrated care settings deliver patient-centered care, focus on the institutional mission, understand and adhere to organizational rules, and are proficient in navigating complex systems. The Council on Chiropractic Education Accreditation Standards do not outline specific meta-competencies for integrated care clinical training., Objective: The purpose of this study was to develop preliminary integrated health care competencies for DC programs to guide the advancement of clinical chiropractic education., Methods: A systematic literature search was performed. Articles were screened for eligibility and extracted in duplicate. Domains and seed statements were generated from this literature, piloted at a conference workshop, and evaluated via a modified Delphi consensus process. Of 42 invited, 36 chiropractors participated as panelists. Public comment period yielded 20 comments, none resulting in substantive changes to the competencies., Results: Of 1718 citations, 23 articles met eligibility criteria. After 2 modified Delphi rounds, consensus was reached on all competency statements. A total of 78 competency statements were agreed upon, which encompassed 4 domains and 11 subdomains. The 4 domains were: 1) Collaboration, (2) Clinical Excellence, (3) Communication, and (4) Systems Administration., Conclusion: We identified 78 preliminary competencies appropriate for preparing DC students and early career chiropractors for clinical practice in integrated healthcare settings. Educational programs may consider these competencies for curricular design and reform to strengthen DC program graduates for integrated practice, advanced training, and employment., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Objectives: In this study, we explored the effects of chiropractic spinal adjustments on resting-state electroencephalography (EEG) recordings and early somatosensory evoked potentials (SEPs) in Alzheimer's and Parkinson's disease., Methods: In this randomized cross-over study, 14 adults with Alzheimer's disease (average age 67 ± 6 years, 2 females:12 males) and 14 adults with Parkinson's disease (average age 62 ± 11 years, 1 female:13 males) participated. The participants underwent chiropractic spinal adjustments and a control (sham) intervention in a randomized order, with a minimum of one week between each intervention. EEG was recorded before and after each intervention, both during rest and stimulation of the right median nerve. The power-spectra was calculated for resting-state EEG, and the amplitude of the N30 peak was assessed for the SEPs. The source localization was performed on the power-spectra of resting-state EEG and the N30 SEP peak., Results: Chiropractic spinal adjustment significantly reduced the N30 peak in individuals with Alzheimer's by 15% ( p = 0.027). While other outcomes did not reach significance, resting-state EEG showed an increase in absolute power in all frequency bands after chiropractic spinal adjustments in individuals with Alzheimer's and Parkinson's disease. The findings revealed a notable enhancement in connectivity within the Default Mode Network (DMN) at the alpha, beta, and theta frequency bands among individuals undergoing chiropractic adjustments., Conclusions: We found that it is feasible to record EEG/SEP in individuals with Alzheimer's and Parkinson's disease. Additionally, a single session of chiropractic spinal adjustment reduced the somatosensory evoked N30 potential and enhancement in connectivity within the DMN at the alpha, beta, and theta frequency bands in individuals with Alzheimer's disease. Future studies may require a larger sample size to estimate the effects of chiropractic spinal adjustment on brain activity. Given the preliminary nature of our findings, caution is warranted when considering the clinical implications., Clinical Trial Registration: The study was registered by the Australian New Zealand Clinical Trials Registry (registration number ACTRN12618001217291 and 12618001218280)., Competing Interests: The authors declare no conflict of interest. Imran Khan Niazi is serving as one of the Editorial Board members/Guest editors of this journal. We declare that Imran Khan Niazi had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Yoshihiro Noda., (© 2024 The Author(s). Published by IMR Press.)

Background: Attention deficit hyperactivity disorder (ADHD) is a neurobiological disorder characterized by inattention, hyperactivity, and impulsivity. We hypothesized that chiropractic adjustments could improve these symptoms by enhancing prefrontal cortex function. This pilot study aimed to explore the feasibility and efficacy of 4 weeks of chiropractic adjustment on inattention, hyperactivity, and impulsivity in children with ADHD., Methods: 67 children with ADHD were randomly allocated to receive either chiropractic adjustments plus usual care (Chiro+UC) or sham chiropractic plus usual care (Sham+UC). The Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS), Swanson, Nolan and Pelham Teacher and Parents Rating Scale (SNAP-IV), and ADHD Rating Scale-IV were used to assess outcomes at baseline, 4 weeks, and 8 weeks. Feasibility measures such as recruitment, retention, blinding, safety, and adherence were recorded. Linear mixed regression models were used for data analysis., Results: 56 participants (mean age ± SD: 10.70 ± 3.93 years) were included in the analysis. Both the Chiro+UC and Sham+UC groups showed significant improvements in total and subscale ADHD scores at 4 weeks and 8 weeks. However, there were no significant differences between the two groups., Conclusion: This pilot study demonstrated that it was feasible to examine the effects of chiropractic adjustment when added to usual care on ADHD outcomes in children. While both groups showed improvements, the lack of significant between-group differences requires caution in interpretation due to the small sample size. Further research with larger samples and longer follow-up periods is needed to conclusively evaluate the effects of chiropractic adjustments on ADHD in children., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Amjad, Niazi, Kumari, Duehr, Shehzad, Rashid, Duehr, Trager, Holt and Haavik.)

Objectives: Patients receiving chiropractic spinal manipulation (CSM) for low back pain (LBP) are less likely to receive any opioid prescription for subsequent pain management. However, the likelihood of specifically being prescribed tramadol, a less potent opioid, has not been explored. We hypothesised that adults receiving CSM for newly diagnosed radicular LBP would be less likely to receive a tramadol prescription over 1-year follow-up, compared with those receiving usual medical care., Design: Retrospective cohort study., Setting: US medical records-based dataset including >115 million patients attending academic health centres (TriNetX, Inc), queried 9 November 2023., Participants: Opioid-naive adults aged 18-50 with a new diagnosis of radicular LBP were included. Patients with serious pathology and tramadol use contraindications were excluded. Variables associated with tramadol prescription were controlled via propensity matching., Interventions: Patients were divided into two cohorts dependent on treatment received on the index date of radicular LBP diagnosis (CSM or usual medical care)., Primary and Secondary Outcome Measures: Risk ratio (RR) for tramadol prescription (primary); markers of usual medical care utilisation (secondary)., Results: After propensity matching, there were 1171 patients per cohort (mean age 35 years). Tramadol prescription was significantly lower in the CSM cohort compared with the usual medical care cohort, with an RR (95% CI) of 0.32 (0.18 to 0.57; p<0.0001). A cumulative incidence graph demonstrated that the reduced incidence of tramadol prescription in the CSM cohort relative to the usual medical care cohort was maintained throughout 1-year follow-up. Utilisation of NSAIDs, physical therapy evaluation and lumbar imaging was similar between cohorts., Conclusions: This study found that US adults initially receiving CSM for radicular LBP had a reduced likelihood of receiving a tramadol prescription over 1-year follow-up. These findings should be corroborated by a prospective study to minimise residual confounding., Competing Interests: Competing interests: Dr Trager reports he has received book royalties as the author of two texts on the topic of sciatica. The other authors report no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period., Methods: A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES., Results: 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up., Conclusions: These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation., Competing Interests: Robert J. Trager acknowledges that he has received royalties as the author of two texts on the topic of sciatica. The authors have declared no competing interests., (Copyright: © 2024 Trager et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Increasing evidence suggests that a high-velocity, low-amplitude (HVLA) thrust directed at a dysfunctional vertebral segment in people with subclinical spinal pain alters various neurophysiological measures, including somatosensory evoked potentials (SEPs). We hypothesized that an HVLA thrust applied to a clinician chosen vertebral segment based on clinical indicators of vertebral dysfunction, in short, segment considered as "relevant" would significantly reduce the N30 amplitude compared to an HVLA thrust applied to a predetermined vertebral segment not based on clinical indicators of vertebral dysfunction or segment considered as "non-relevant". In this double-blinded, active-controlled, parallel-design study, 96 adults with recurrent mild neck pain, ache, or stiffness were randomly allocated to receiving a single thrust directed at either a segment considered as "relevant" or a segment considered as "non-relevant" in their upper cervical spine. SEPs of median nerve stimulation were recorded before and immediately after a single HVLA application delivered using an adjusting instrument (Activator). A linear mixed model was used to assess changes in the N30 amplitude. A significant interaction between the site of thrust delivery and session was found (F 1,840  = 9.89, p < 0.002). Pairwise comparisons showed a significant immediate decrease in the N30 complex amplitude after the application of HVLA thrust to a segment considered "relevant" (- 16.76 ± 28.32%, p = 0.005). In contrast, no significant change was observed in the group that received HVLA thrust over a segment considered "non-relevant" (p = 0.757). Cervical HVLA thrust applied to the segment considered as "relevant" altered sensorimotor parameters, while cervical HVLA thrust over the segment considered as "non-relevant" did not. This finding supports the hypothesis that spinal site targeting of HVLA interventions is important when measuring neurophysiological responses. Further studies are needed to explore the potential clinical relevance of these findings., (© 2024. The Author(s).)

Background: Patients who undergo lumbar discectomy may experience ongoing lumbosacral radiculopathy (LSR) and seek spinal manipulative therapy (SMT) to manage these symptoms. We hypothesized that adults receiving SMT for LSR at least one year following lumbar discectomy would be less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT, over two years' follow-up., Methods: We searched a United States network of health records (TriNetX, Inc.) for adults aged ≥ 18 years with LSR and lumbar discectomy ≥ 1 year previous, without lumbar fusion or instrumentation, from 2003 to 2023. We divided patients into two cohorts: (1) chiropractic SMT, and (2) usual care without chiropractic SMT. We used propensity matching to adjust for confounding variables associated with lumbar spine reoperation (e.g., age, body mass index, nicotine dependence), calculated risk ratios (RR), with 95% confidence intervals (CIs), and explored cumulative incidence of reoperation and the number of SMT follow-up visits., Results: Following propensity matching there were 378 patients per cohort (mean age 61 years). Lumbar spine reoperation was less frequent in the SMT cohort compared to the usual care cohort (SMT: 7%; usual care: 13%), yielding an RR (95% CIs) of 0.55 (0.35-0.85; P = 0.0062). In the SMT cohort, 72% of patients had ≥ 1 follow-up SMT visit (median = 6)., Conclusions: This study found that adults experiencing LSR at least one year after lumbar discectomy who received SMT were less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT. While these findings hold promise for clinical implications, they should be corroborated by a prospective study including measures of pain, disability, and safety to confirm their relevance. We cannot exclude the possibility that our results stem from a generalized effect of engaging with a non-surgical clinician, a factor that may extend to related contexts such as physical therapy or acupuncture., Registration: Open Science Framework ( https://osf.io/vgrwz )., (© 2024. The Author(s).)

Early symptoms of vertebral artery dissection (VAD) may be nonspecific, including neck pain and headache. Neck pain and headache are also common reasons for patients to seek chiropractic care. We hypothesized that neck pain and/or headache would be the most prevalent symptoms among patients with undiagnosed VAD presenting to chiropractors compared to dizziness or other symptoms. We searched PubMed, Ovid, the Index to Chiropractic Literature, Google Scholar, and gray literature through September 2023 for observational studies describing patients aged ≥10 with previously undiagnosed VAD presenting to a chiropractor. Article selection, data extraction, and quality assessment were performed in duplicate. We synthesized the point prevalence of symptoms and other clinical features. We included 10 case reports describing 10 patients (mean age = 37, SD = 7, 60% female). All patients had either neck pain or headache (100%; 95% confidence interval (CI) = 100%-100%). The most prevalent individual symptoms were neck pain (90%; 95% CI = 71%-100%), headache (80%; 95% CI = 55%-100%), visual disturbance (50%; 95% CI = 19%-81%), and dizziness (40%; 95% CI = 10%-70%). The certainty of results was very low due to publication bias. While our findings suggest that neck pain and/or headache are the most prevalent symptoms among patients with undiagnosed VAD visiting a chiropractor, the small sample size and reliance on case reports preclude any definitive conclusions. Further research with larger sample sizes, control groups, and better control of confounders is required to corroborate these results. Chiropractors should be aware of VAD features and refer suspected patients for emergency care., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Trager et al.)

Objectives: We hypothesized that pregnant women would have an increased risk of spontaneous cervical artery dissection (sCeAD) affecting the carotid or vertebral arteries over one-year follow-up after the first trimester ultrasound compared to matched non-pregnant controls., Materials and Methods: We queried a United States research network (TriNetX, Inc.) of de-identified medical records of >111 million patients, with data spanning 2008-2023. We included women aged ≥18 and excluded those with trauma and conditions potentially causative of sCeAD. Women were divided into cohorts based on a 1 first trimester ultrasound and subsequent labor, delivery, or full-term pregnancy, or 2 gynecological examination and no pregnancy. We used propensity matching to control for variables associated with sCeAD and calculated the risk ratio (RR) of sCeAD occurring over one-year follow-up from the index date of ultrasound or gynecological exam., Results: After matching, the incidence rate of sCeAD in the pregnancy cohort was 8.0 (95% CI: 8.0-8.1) per 100,000 person-years, compared to 3.9 (95% CI: 3.9-3.9) per 100,000 person-years in the non-pregnancy cohort, yielding an RR (95% CI) of 2.06 (1.17-3.61; P= .0104). A cumulative incidence graph suggested that most cases of sCeAD in the pregnancy cohort occurred during pregnancy rather than the postpartum period., Conclusions: Our findings demonstrate that women have a twofold increased risk of sCeAD during pregnancy and the postpartum period compared to non-pregnant women. Further research is needed to determine whether maternal comorbidities such as preeclampsia account for these findings, and clarify when sCeAD occurs in relation to pregnancy or the postpartum period., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background Case reports have raised the possibility of an association between coronavirus disease 2019 (COVID-19) and spontaneous cervical artery dissection (sCeAD), yet no large studies have examined this association. We hypothesized that adults with confirmed COVID-19 would have an increased risk of sCeAD over the subsequent six months compared to test-negative controls after adjusting for confounding variables. Methods We obtained data from a United States medical records network (TriNetX, Inc., Cambridge, MA) of >106 million patients, providing adequate power needed for this rare outcome. We identified two cohorts of adults meeting the criteria of (1) test-confirmed COVID-19 or (2) non-COVID-19 test-negative controls, from April 1, 2020, to December 31, 2022. Patients with previous COVID-19 or conditions predisposing to sCeAD were excluded. Propensity matching was used to control for variables associated with sCeAD and markers of healthcare utilization. Results The number of patients reduced from before matching (COVID-19: 491,592; non-COVID-19: 1,472,895) to after matching, resulting in 491,115 patients per cohort. After matching, there were 22 cases of sCeAD in the COVID-19 cohort (0.0045%) and 20 cases in the non-COVID-19 cohort (0.0041%), yielding a risk ratio of 1.10 (95% CI: 0.60-2.02; P   = 0.7576). Both cohorts had a median of five healthcare visits during follow-up. Conclusions Our results suggest that COVID-19 is not a risk factor for sCeAD. This null finding alleviates the concern raised by initial case reports and may better direct future research efforts on this topic., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Trager et al.)

Introduction: Vertebrobasilar vascular pathology and upper cervical ligament instability may contraindicate the use of cervical manual therapy. We examined physical therapists' documentation of screening for these conditions and hypothesized screening would be more common with specific risk factors and when using manual therapy., Methods: This chart review included adults with neck pain presenting for outpatient physical therapy from 2015-2021. Exclusions were age<18 and history of cervical spine surgery. Demographics, vertebrobasilar and upper cervical ligament instability screening questions and examination tests, risk factors (i.e. hypertension, whiplash), and use of manual therapy were extracted., Results: 260 patients were included (mean age ± standard deviation 59.6 ± 16.2 years, 70.8% female). Physical therapists infrequently administered vertebrobasilar and upper cervical ligament instability tests (each<14%). Screening questions were generally more common (e.g. headache, visual disturbances; each>13%). There was no significant difference in any frequency of screening method given the presence of hypertension, whiplash, or use of manual therapy ( p  > .05 for each)., Conclusion: In the present study, physical therapists infrequently documented performance of vertebrobasilar or upper cervical ligament instability screening for adults with neck pain, even in the presence of risk factors or preceding manual therapy. Further research should corroborate these findings and explore reasons for use/avoidance of screening.

Objectives: Radicular low back pain (rLBP) is often treated off-label with gabapentin or by chiropractors using chiropractic spinal manipulative therapy (CSMT). To date, no studies have examined the association between these interventions. We hypothesised that adults under 50 years of age receiving CSMT for newly diagnosed rLBP would have reduced odds of receiving a gabapentin prescription over 1 year-follow-up., Design: Retrospective cohort study., Setting: US network including linked medical records, medical claims and pharmacy claims of >122 million patients attending large healthcare organisations (TriNetX), queried 15 June 2023, yielding data from 2017 to 2023., Participants: Adults aged 18-49 were included at their first occurrence of rLBP diagnosis. Exclusions were severe pathology, other spinal conditions, on-label gabapentin indications and gabapentin contraindications. Propensity score matching controlled for variables associated with gabapentin use and receipt of prescription medication over the preceding year., Interventions: Patients were divided into CSMT or usual medical care cohorts based on the care received on the index date of rLBP diagnosis., Primary and Secondary Outcome Measures: OR for gabapentin prescription., Results: After propensity matching, there were 1635 patients per cohort (mean age 36.3±8.6 years, 60% women). Gabapentin prescription over 1-year follow-up was significantly lower in the CSMT cohort compared with the usual medical care cohort, with an OR (95% CI) of 0.53 (0.40 to 0.71; p<0.0001). Sensitivity analyses revealed early divergence in cumulative incidence of prescription; and no significant between-cohort difference in a negative control outcome (gastrointestinal medication) suggesting adequate control for pharmacological care preference., Conclusions: Our findings suggest that US adults receiving CSMT for newly diagnosed rLBP have significantly reduced odds of receiving a gabapentin prescription over 1-year follow-up compared with those receiving usual medical care. Results may not be generalisable and should be replicated in other healthcare settings and corroborated by a prospective study to reduce confounding., Competing Interests: Competing interests: RJT reports he has received royalties as the author of two texts on the topic of sciatica., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The number and characteristics of patients with previous spine surgery receiving chiropractic spinal manipulation (CSM) are largely unknown. This study aimed to explore the proportion of patients receiving CSM with a history of spine surgery, the characteristics of these patients, and the treatments received compared to a broader population of patients receiving CSM., Methods: We queried a 110-million-patient United States (US) network of aggregated records and claims data from patients attending integrated academic health centers (TriNetX, Inc.) on March 6, 2023, yielding data spanning 2013-2023. We identified two patient groups: (1) those receiving CSM and (2) a subset receiving CSM with prior spine surgery. We compared baseline characteristics and treatments received over a one-year follow-up after CSM., Results: Of the 81,291 patients receiving CSM, 8,808 (10.8%) had at least one prior spine surgery. Patients with prior spine surgery receiving CSM were older, more often female, more often non-Hispanic/Latino and White, less often Black, had a greater body mass index, and had a higher prevalence of low back and neck pain compared to the broader CSM cohort ( p <0.0001 for each). Those with prior spine surgery were also more likely to receive multiple medications, physiotherapy procedures, and spinal injections ( p <0.0001 for each)., Conclusion: Patients receiving CSM with a history of spine surgery comprise a substantial proportion of CSM patients in large US academic health centers. This subset of patients differs characteristically from the broader CSM population and more often receives medications, physiotherapy, and spinal injections. Further research is needed to examine the safety and efficacy of CSM in this population, given the high proportion of patients and limited research on this topic., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2023, Trager et al.)

Background: This review aimed to identify variables influencing clinicians' application of spinal manipulative therapy (SMT) for persistent spine pain after lumbar surgery (PSPS-2). We hypothesized markers of reduced clinical/surgical complexity would be associated with greater odds of applying SMT to the lumbar region, use of manual-thrust lumbar SMT, and SMT within 1-year post-surgery as primary outcomes; and chiropractors would have increased odds of using lumbar manual-thrust-SMT compared to other practitioners., Methods: Per our published protocol, observational studies describing adults receiving SMT for PSPS-2 were included. PubMed, Web of Science, Scopus, OVID, PEDro, and Index to Chiropractic Literature were searched from inception to January 6, 2022. Individual patient data (IPD) were requested from contact authors when needed for selection criteria. Data extraction and a customized risk-of-bias rubric were completed in duplicate. Odds ratios (ORs) for primary outcomes were calculated using binary logistic regressions, with covariates including age, sex, symptom distribution, provider, motion segments, spinal implant, and surgery-to-SMT interval., Results: 71 articles were included describing 103 patients (mean age 52 ± 15, 55% male). The most common surgeries were laminectomy (40%), fusion (34%), and discectomy (29%). Lumbar SMT was used in 85% of patients; and of these patients was non-manual-thrust in 59%, manual-thrust in 33%, and unclear in 8%. Clinicians were most often chiropractors (68%). SMT was used > 1-year post-surgery in 66% of cases. While no primary outcomes reached significance, non-reduced motion segments approached significance for predicting use of lumbar-manual-thrust SMT (OR 9.07 [0.97-84.64], P = 0.053). Chiropractors were significantly more likely to use lumbar-manual-thrust SMT (OR 32.26 [3.17-327.98], P = 0.003). A sensitivity analysis omitting high risk-of-bias cases (missing ≥ 25% IPD) revealed similar results., Conclusions: Clinicians using SMT for PSPS-2 most often apply non-manual-thrust SMT to the lumbar spine, while chiropractors are more likely to use lumbar-manual-thrust SMT relative to other providers. As non-manual-thrust SMT may be gentler, the proclivity towards this technique suggests providers are cautious when applying SMT after lumbar surgery. Unmeasured variables such as patient or clinician preferences, or limited sample size may have influenced our findings. Large observational studies and/or international surveys are needed for an improved understanding of SMT use for PSPS-2. Systematic review registration PROSPERO (CRD42021250039)., (© 2023. The Author(s).)

This study examined the incidence and severity of adverse events (AEs) of patients receiving chiropractic spinal manipulative therapy (SMT), with the hypothesis that < 1 per 100,000 SMT sessions results in a grade ≥ 3 (severe) AE. A secondary objective was to examine independent predictors of grade ≥ 3 AEs. We identified patients with SMT-related AEs from January 2017 through August 2022 across 30 chiropractic clinics in Hong Kong. AE data were extracted from a complaint log, including solicited patient surveys, complaints, and clinician reports, and corroborated by medical records. AEs were independently graded 1-5 based on severity (1-mild, 2-moderate, 3-severe, 4-life-threatening, 5-death). Among 960,140 SMT sessions for 54,846 patients, 39 AEs were identified, two were grade 3, both of which were rib fractures occurring in women age > 60 with osteoporosis, while none were grade ≥ 4, yielding an incidence of grade ≥ 3 AEs of 0.21 per 100,000 SMT sessions (95% CI 0.00, 0.56 per 100,000). There were no AEs related to stroke or cauda equina syndrome. The sample size was insufficient to identify predictors of grade ≥ 3 AEs using multiple logistic regression. In this study, severe SMT-related AEs were reassuringly very rare., (© 2023. The Author(s).)

Certain blood biomarkers are associated with neural protection and neural plasticity in healthy people and individuals with prior brain injury. To date, no studies have evaluated the effects chiropractic care on serum brain-derived neurotrophic factor (BDNF), insulin-like growth factor-II (IGF-II) and glial cell-derived neurotrophic factor (GDNF) in people with stroke. This manuscript reports pre-specified, exploratory, secondary outcomes from a previously completed parallel group randomized controlled trial. We evaluated differences between four weeks of chiropractic spinal adjustments combined with the usual physical therapy (chiro + PT) and sham chiropractic with physical therapy (sham + PT) on resting serum BDNF, IGF-II and GDNF in 63 adults with chronic stroke. Blood samples were assessed at baseline, four weeks (post-intervention), and eight weeks (follow-up). Data were analyzed using a linear multivariate mixed effects model. Within both groups there was a significant decrease in the mean log-concentration of BDNF and IGF-II at each follow-up, and significant increase log-concentration of GDNF at eight-weeks' follow-up. However, no significant between-group differences in any of the blood biomarkers at each time-point were found. Further research is required to explore which factors influence changes in serum BDNF, IGF-II and GDNF following chiropractic spinal adjustments and physical therapy.

Objectives: Chiropractic spinal manipulative therapy (CSMT) and lumbar discectomy are both used for lumbar disc herniation (LDH) and lumbosacral radiculopathy (LSR); however, limited research has examined the relationship between these therapies. We hypothesised that adults receiving CSMT for newly diagnosed LDH or LSR would have reduced odds of lumbar discectomy over 1-year and 2-year follow-up compared with those receiving other care., Design: Retrospective cohort study., Setting: 101 million patient US health records network (TriNetX), queried on 24 October 2022, yielding data from 2012 query., Participants: Adults age 18-49 with newly diagnosed LDH/LSR (first date of diagnosis) were included. Exclusions were prior lumbar surgery, absolute indications for surgery, trauma, spondylolisthesis and scoliosis. Propensity score matching controlled for variables associated with the likelihood of discectomy (eg, demographics, medications)., Interventions: Patients were divided into cohorts according to receipt of CSMT., Primary and Secondary Outcome Measures: ORs for lumbar discectomy; calculated by dividing odds in the CSMT cohort by odds in the cohort receiving other care., Results: After matching, there were 5785 patients per cohort (mean age 36.9±8.2). The ORs (95% CI) for discectomy were significantly reduced in the CSMT cohort compared with the cohort receiving other care over 1-year (0.69 (0.52 to 0.90), p=0.006) and 2-year follow-up (0.77 (0.60 to 0.99), p=0.040). E-value sensitivity analysis estimated the strength in terms of risk ratio an unmeasured confounding variable would need to account for study results, yielding point estimates for each follow-up (1 year: 2.26; 2 years: 1.92), which no variables in the literature reached., Conclusions: Our findings suggest receiving CSMT compared with other care for newly diagnosed LDH/LSR is associated with significantly reduced odds of discectomy over 2-year follow-up. Given socioeconomic variables were unavailable and an observational design precludes inferring causality, the efficacy of CSMT for LDH/LSR should be examined via randomised controlled trial to eliminate residual confounding., Competing Interests: Competing interests: RJT reports he has received book royalties as the author of two texts on the topic of sciatica., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background Chiropractors often use manual thrust cervical spinal manipulative therapy (thrust-cSMT) to treat musculoskeletal neck conditions. We hypothesized <50% of surveyed Asia-Pacific chiropractors would report using thrust-cSMT given potential contraindications, and secondarily explored predictors of thrust-cSMT use. Materials and methods We designed, validated, achieved sufficient reliability, and disseminated a survey to explore thrust-cSMT use. The survey queried chiropractors' characteristics (e.g., years in practice, education level, time with patients, importance of subluxation), and use of thrust-cSMT for uncomplicated neck pain and vignettes describing vertebral artery disorders, Arnold-Chiari malformation, and anterior cervical discectomy and fusion (ACDF). We performed logistic regression for each vignette with thrust-cSMT as the dependent variable and chiropractor characteristics as covariates. Results There were 241 respondents, having 12.8±10.9 years in practice, representing >15 countries. Less than 50% of chiropractors reported the use of thrust-cSMT for each vignette, including vertebral artery insufficiency (14%) and stenosis (17%), Arnold-Chiari type I (18%) and type II (5%), C5/6 ACDF (39%) and C3-6 ACDF (27%). Regressions identified significant predictors of increased or decreased use of thrust-cSMT including time spent with new patients, focus on subluxation, degree, group practice environment, use of thrust-cSMT on a healthy patient, and hours reading scientific literature (P<.05 for each). Conclusions This study was the first to chiropractors' use of thrust-cSMT for complicated neck pain and found that most Asia-Pacific chiropractors reported avoiding this treatment in the presence of a potential treatment contraindication. The use of thrust-cSMT in complicated neck pain may be related to practice characteristics. However, further research is needed to identify specific reasons why chiropractors use or avoid thrust-cSMT., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Chu et al.)

BACKGROUND Pineal gland tumors are rare central nervous system tumors, and while neck pain and headaches may be common among those who have had these tumors removed, there is little research regarding management of these symptoms. CASE REPORT A 45-year-old man with a history of pineal germinoma treated with pinealectomy, chemotherapy, radiation therapy, and ventriculoperitoneal shunt placement at age 21 presented with chronic neck pain and headaches, which initially improved following his surgery and concurrent therapies, yet progressively worsened over the following years. He required thyroid and testosterone medication because of radiation-induced hypopituitarism, yet was employed, and until recently, active with playing tennis. He had previously seen his primary care provider, orthopedist, and neurologist, and had been cleared of severe pathology via brain magnetic resonance imaging and was referred to the chiropractor. On examination, the patient had severely limited passive cervical spine range of motion, yet hat no neurologic deficits, and radiographs showed mild cervical spondylosis and cervicothoracic scoliosis. His history and presentation were suggestive of radiation-induced fibrosis. The patient's neck pain, headaches, and quality of life improved with multimodal treatments including spinal and soft-tissue manipulation, stretches, and yoga. CONCLUSIONS This case illustrates long-term sequelae of a pineal gland tumor and its treatment, including neck pain and headache, and improvement with multimodal chiropractic therapies. Despite the success in this case, these results are not broadly generalizable. Further research is needed to understand the natural history of symptoms and effectiveness of multimodal therapies among patients who have had pineal tumor surgery.

BACKGROUND Sciatica, which is pain radiating along the sciatic nerve distribution, is most often caused by degenerative conditions of the lower back and rarely results from lesions of the spinal cord. This case report illustrates a patient with suspected lumbar radiculopathy, ultimately diagnosed with a thoracic schwannoma after visiting a chiropractor. CASE REPORT A 61-year-old woman presented to a chiropractor with progressively worsening lower back pain radiating to the right lower extremity and unsteady gait. Her symptoms began 10 years previously and she had been diagnosed by an orthopedist with lumbar disc herniation causing radiculopathy via magnetic resonance imaging (MRI) and was treated with physical therapy and diclofenac. Upon examination by the chiropractor, the patient had bilateral lower-extremity neurologic deficits, hyperreflexia, and upgoing Babinski responses. The chiropractor ordered thoracic MRI, but the patient preferred to initiate a trial of care, which was unsuccessful. After a delay imposed by cardiac bypass surgery, the patient returned to the chiropractor with worsened symptoms and underwent thoracic MRI, revealing an intraspinal mass at T9. The patient underwent laminectomy and tumor removal, with histopathology confirming a diagnosis of schwannoma. The patient gradually improved after surgery with the help of rehabilitative exercises. CONCLUSIONS Clinicians should suspect a spinal cord lesion as a cause of sciatic pain when patients fail to improve with treatment, have a broad sensorimotor distribution unexplained by lumbar imaging findings, hyperreflexia/pathological reflexes, or other atypical findings (eg, negative neural tension tests). In such cases, MRI of the cervical and thoracic spine may be indicated.

BACKGROUND Patients with Arnold-Chiari Malformation I (CM-I) treated with foramen magnum decompression (FMD) can have ongoing neck pain, headaches, and other symptoms complicated by persistent syringomyelia, yet there is little research regarding treatment of these symptoms. CASE REPORT A 62-year-old woman with a history of residual syringomyelia following FMD and ventriculoperitoneal shunt for CM-I presented to a chiropractor with progressively worsening neck pain, occipital headache, upper extremity numbness and weakness, and gait abnormality, with a World Health Organization Quality of Life score (WHO-QOL) of 52%. Symptoms were improved by FMD 16 years prior, then progressively worsened, and had resisted other forms of treatment, including exercises, acupuncture, and medications. Examination by the chiropractor revealed upper extremity neurologic deficits, including grip strength. The chiropractor ordered whole spine magnetic resonance imaging, which demonstrated a persistent cervico-thoracic syrinx and findings of cervical spondylosis, and treated the patient using a multimodal approach, with gentle cervical spine mobilization, soft tissue manipulation, and core and finger muscle rehabilitative exercises. The patient responded positively, and at the 6-month follow-up her WHO-QOL score was 80%, her grip strength and forward head position had improved, and she was now able to eat using chopsticks. CONCLUSIONS This case highlights a patient with neck pain, headaches, and persistent syringomyelia after FMD for CM-I who improved following multimodal chiropractic and rehabilitative therapies. Given the limited, low-level evidence for these interventions in patients with persistent symptoms and syringomyelia after FMD, these therapies cannot be broadly recommended, yet could be considered on a case-by-case basis.

BACKGROUND Patients commonly visit chiropractic clinics for treatment for low back pain, which is often due to injury or degenerative spinal conditions. Rarely, serious underlying pathology may be identified. This report describes a 68-year-old woman with a remote history of breast cancer presenting with low back pain to a chiropractic clinic in Hong Kong with imaging findings consistent with vertebral hemangioma and vertebral metastatic lesions. CASE REPORT A 68-year-old woman with a history of breast cancer status after chemotherapy and mastectomy 20 years prior presented to a chiropractor with an acute exacerbation of chronic low back pain with lower extremity paresthesia. She previously visited her general practitioner and underwent radiography, which supported diagnoses of degenerative lumbar spondylosis and hemangioma of the fifth lumbar vertebra. Given the patient's worsening status and previous cancer, the chiropractor ordered lumbar magnetic resonance imaging at the initial visit, consistent with multilevel spinal metastasis. The chiropractor referred the patient to an oncologist who performed positron emission tomography/computed tomography, which suggested breast cancer recurrence and metastasis. The greatest hypermetabolic activity was evident within the level of the suspected vertebral hemangioma, suggesting this finding which initially appeared innocuous on plain radiography contained underlying metastasis. CONCLUSIONS This case illustrates that when patients fail to respond to treatment for low back pain, clinical referral should be undertaken for investigations to identify possible serious underlying pathology.

BACKGROUND Vertebrobasilar insufficiency (VBI) is most often caused by vertebrobasilar atherosclerosis, often presenting with dizziness and occasionally neck pain. Little research or guidelines regarding management of neck pain in affected patients exists. CASE REPORT A 62-year-old male hypertensive smoker presented to a chiropractor with a 13-year history of insidious-onset neck pain, dizziness, and occipital headache with a Dizziness Handicap Inventory (DHI) of 52%. The patient had known VBI, caused by bilateral vertebral artery plaques, and cervical spondylosis, and was treated with multiple cardiovascular medications. The chiropractor referred patient to a neurosurgeon, who cleared him to receive manual therapies provided manual-thrust cervical spinal manipulative therapy (SMT) was not performed. The chiropractor administered thoracic SMT and cervicothoracic soft tissue manipulation. The neck pain and dizziness mostly resolved by 1 month. At 1-year follow-up, DHI was 0%; at 2 years it was 8%. A literature search revealed 4 cases in which a chiropractor used manual therapies for a patient with VBI. Including the present case, all patients had neck pain, 60% had dizziness, and all were treated with SMT either avoiding manual cervical manipulation altogether or modifying it to avoid or limit cervical rotation, yielding positive outcomes. CONCLUSIONS The present and previous cases provide limited evidence that some carefully considered chiropractic manual therapies can afford patients with VBI relief from concurrent neck pain and possibly dizziness. Given the paucity of research, cervical SMT cannot be recommended in such patients. These findings do not apply to vertebral artery dissection, for which SMT is an absolute contraindication.

Background: While most cases of sciatica result from degenerative conditions of the low back, some cases result from conditions of the hip and pelvic region. Sciatica developing in relation to pregnancy or labor also presents unique considerations., Case Presentation: A 37-year-old African American woman with a history of hypertension and polycystic ovary syndrome presented to a chiropractor at a hospital-based outpatient clinic with a seven-week history of low back pain with radiation into the right lower extremity which began during labor. The chiropractor performed a brief trial of care, yet when the patient's symptoms worsened, ordered lumbar spine radiographs, followed by lumbar magnetic resonance imaging (MRI), which were both normal. The chiropractor then ordered hip radiographs, which were suggestive of ischial osteochondroma, and referred the patient to an orthopedic oncologist. MRI findings were compatible with an osteochondroma with associated adventitial bursitis and mass effect on the sciatic nerve. The patient initially chose conservative management with bursa aspiration and therapeutic injection. Despite initial relief, there was eventual return of symptoms. The patient elected to undergo surgical removal, with a positive outcome., Conclusion: The key distinguishing features that led to a diagnosis of osteochondroma in this case included attention to the patient-reported symptoms and history, worsening of symptoms despite conservative care, and lack of explanatory findings on lumbar imaging. This case highlights the benefit of evaluating the hip and pelvis when the clinical features of sciatica cannot be ascribed to a lumbar etiology. This case also illustrates the role of a chiropractor working in an integrative health system to facilitate timely imaging and referrals to resolve a challenging diagnosis., (© 2022. The Author(s).)

BACKGROUND Streptococcus oralis (S. oralis) is a gram-positive bacterium and component of the oral microbiota that can rarely cause opportunistic infection in the immunosuppressed. This report presents a 60-year-old man from Hong Kong with gingivitis and poorly controlled diabetes who visited his chiropractor with low back pain 2 weeks following mild COVID-19 and was diagnosed with paraspinal, psoas, and epidural abscess due to S. oralis. CASE REPORT The patient tested positive for COVID-19 when asymptomatic, then had a mild 10-day course of the illness, followed by low back pain 1 week later, prompting him to visit his primary care provider, who diagnosed sciatica and treated him with opioid analgesics. He presented to a chiropractor the following week, noting severe low back pain with radiation into the gluteal regions and posterior thighs, difficulty with ambulation, and mild neck pain. Considering the patient's diabetes, widespread symptoms, and weakness, the chiropractor ordered whole-spine magnetic resonance imaging, which suggested possible multifocal spinal abscess and referred him urgently to a spine surgeon. The surgeon conducted testing consistent with bacterial infection, and referred to an infectious disease specialist, who confirmed S. oralis spinal infection via lumbar paraspinal needle biopsy and culture. The patient was first treated with oral antibiotics, then intravenous antibiotics in a hospital. Over 4 weeks, his spinal pain improved, and laboratory markers of infection normalized. CONCLUSIONS This case illustrates an opportunistic pyogenic spinal infection including paraspinal, psoas, and epidural abscesses caused by S. oralis in an immunocompromised patient following COVID-19 illness.

BACKGROUND There is a limited understanding of the frequency at which chiropractors encounter patients with serious pathology such as malignancy, fracture, and infection. This retrospective study aimed to estimate the prevalence and types of serious pathology among adults with new low back pain presenting to chiropractors in an integrated healthcare organization in Hong Kong, with the hypothesis that such pathology would be found in less than 5% of patients. MATERIAL AND METHODS We identified adults presenting to a chiropractor with new low back pain across 30 clinics with 38 chiropractors, and a subset with previously undiagnosed serious pathology from January 2020 through July 2022. Data were extracted from the electronic medical records, including messaging alerts for serious pathology, notes, radiology reports, and specialist follow-up. Descriptive statistics were utilized to analyze results. RESULTS Among the 7221 identified patients with new-onset low back pain (mean age 61.6±14.3), 35 presented with serious pathology. After excluding 54 cases not meeting inclusion criteria, the prevalence of serious pathology (95% CI) was 35/7221 (0.48%; 0.35-0.67%). Individual condition prevalence included metastasis (0.25%; 0.16-0.39%), fracture (0.12%; 0.07-0.24%), infection (0.04%; 0.01-0.12%), vascular pathology (0.03%; 0.01-0.10%), primary tumor (0.03%; 0.01-0.10%), and gastrointestinal emergency (0.01%; 0.00-0.08%). CONCLUSIONS This study found that serious pathology was uncommon among adults with new low back pain presenting for chiropractic care in Hong Kong, findings which are most consistent with previous research describing the prevalence of serious pathology among low back pain patients in primary care settings.

BACKGROUND Bell's palsy, also called facial nerve palsy, occasionally co-occurs with trigeminal neuropathy, which presents as additional facial sensory symptoms and/or neck pain. Bell's palsy has a proposed viral etiology, in particular when occurring after dental manipulation. CASE REPORT A 52-year-old Asian woman presented to a chiropractor with a 3-year history of constant neck pain and left-sided maxillary, eyebrow, and temporomandibular facial pain, paresis, and paresthesia, which began after using a toothpick, causing possible gum trauma. She had previously been treated with antiviral medication and prednisone, Chinese herbal medicine, and acupuncture, but her recovery plateaued at 60% after 1 year. The chiropractor ordered cervical spine magnetic resonance imaging, which demonstrated cervical spondylosis, with no evidence of myelopathy or major pathology. Treatment involved cervical and thoracic spinal manipulation, cervical traction, soft-tissue therapy, and neck exercises. The patient responded positively. At 1-month follow-up, face and neck pain and facial paresis were resolved aside from residual eyelid synkinesis. A literature review identified 12 additional cases in which chiropractic spinal manipulation with multimodal therapies was reported to improve Bell's palsy. Including the current case, 85% of these patients also had pain in the face or neck. CONCLUSIONS This case illustrates improvement of Bell's palsy and concurrent trigeminal neuropathy with multimodal chiropractic care including spinal manipulation. Limited evidence from other similar cases suggests a role of the trigeminal pathway in these positive treatment responses of Bell's palsy with concurrent face/neck pain. These findings should be explored with research designs accounting for the natural history of Bell's palsy.

BACKGROUND Breast cancer is the most common cancer in women and the most common cause of spinal metastasis, and it may recur months to years after treatment. CASE REPORT A 41-year-old woman, recovered from breast cancer, presented to a chiropractor with acute-on-chronic 3-week history of low back pain radiating to the right leg. She had seen 2 providers previously; lumbar spondylosis had been diagnosed via radiography. Given her recent symptom progression and cancer history, the chiropractor ordered lumbar magnetic resonance imaging, revealing L5 vertebral marrow replacement, suggestive of metastasis. The chiropractor referred her to an oncologist. While awaiting biopsy and oncologic treatments, the oncologist cleared the patient to receive gentle spinal traction and soft tissue manipulation, which alleviated her back pain. The patient continued radiation and chemotherapy, with low back pain remaining improved over 18 months. A literature review identified 7 previous cases of women presenting to a chiropractor with breast cancer metastasis. Including the current case, most had spinal pain and vertebral metastasis (75%) and history of breast cancer (88%) diagnosed a mean 5±3 years prior. CONCLUSIONS This case illustrates a woman with low back pain due to recurrent metastatic breast cancer, identified by a chiropractor, and the utility of a multidisciplinary approach to pain relief during oncologic care. Our literature review suggests that although uncommon, such patients can present to chiropractors with spinal pain from vertebral metastasis and have a known history of breast cancer. Conservative therapies should be used cautiously and under oncologic supervision in such cases.