Review of methods used by chiropractors to determine the site for applying manipulation

Background: With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established. The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation. Methods: Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation. Results: A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement. Conclusions: A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care– methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine–such as skin conductance or thermography–tend not to be supported by the available evidence.https://doi.org/10.1186/2045-709X-21-3

Pain centralization and lumbar disc MRI findings in chronic low back pain patients

Background: Centralization of pain is a specific finding in assessing low back pain (LBP). A dynamic, internal "disc model" has been hypothesized as an underlying mechanism for pain centralization, which has shown a high positive correlation with pain during provocation discography. Structural abnormalities on MRI are also common among asymptomatic individuals, but association of centralization among symptomatic individuals to imaged disc pathology has not been evaluated. Aims: To estimate the association (criterion-related validity) of the centralization phenomenon with magnetic resonance imaging (MRI) findings of lumbar disc pathology, as the criterion standard among chronic low back pain patients. Methods: Randomly drawn volunteers (N=39) with non-specific LBP from a larger randomized controlled trial were clinically assessed for the presence of centralization by two physiotherapists using the McKenzie Method. MRI slices of patients' lumbar spines from L1 to S1 levels were acquired with a 1.5 Tesla superconducting magnet. Findings were recorded by an experienced radiologist. Validity was estimated with sensitivity, specificity, positive (PPV) and negative predictive values (NPV) and likelihood ratios. Results: In the total sample, the prevalence of the MRI features most closely associated to pain was 82%, and among centralizers 94%. Sensitivity of centralization was 0.91, specificity 0.5, PPV 0.94; NPV 0.40, positive likelihood ratio 1.8 and negative likelihood ratio -0.18. Conclusion: In this study, MRI showed that pain centralization is associated with abnormalities of lumbar discs. As the centralization phenomenon is closely associated with good treatment outcomes, we recommend centralization guided conservative treatment for disc pathologies before surgical referral