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1.  Dry needling: a literature review with implications for clinical practice guidelines1 
Physical Therapy Reviews  2014;19(4):252-265.
Wet needling uses hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants, botulinum toxins, or other agents. In contrast, dry needling requires the insertion of thin monofilament needles, as used in the practice of acupuncture, without the use of injectate into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue. Dry needles may also be inserted in the vicinity of peripheral nerves and/or neurovascular bundles in order to manage a variety of neuromusculoskeletal pain syndromes. Nevertheless, some position statements by several US State Boards of Physical Therapy have narrowly defined dry needling as an ‘intramuscular’ procedure involving the isolated treatment of ‘myofascial trigger points’ (MTrPs).
To operationalize an appropriate definition for dry needling based on the existing literature and to further investigate the optimal frequency, duration, and intensity of dry needling for both spinal and extremity neuromusculoskeletal conditions.
Major findings:
According to recent findings in the literature, the needle tip touches, taps, or pricks tiny nerve endings or neural tissue (i.e. ‘sensitive loci’ or ‘nociceptors’) when it is inserted into a MTrP. To date, there is a paucity of high-quality evidence to underpin the use of direct dry needling into MTrPs for the purpose of short and long-term pain and disability reduction in patients with musculoskeletal pain syndromes. Furthermore, there is a lack of robust evidence validating the clinical diagnostic criteria for trigger point identification or diagnosis. High-quality studies have also demonstrated that manual examination for the identification and localization of a trigger point is neither valid nor reliable between-examiners.
Several studies have demonstrated immediate or short-term improvements in pain and/or disability by targeting trigger points (TrPs) using in-and-out techniques such as ‘pistoning’ or ‘sparrow pecking’; however, to date, no high-quality, long-term trials supporting in-and-out needling techniques at exclusively muscular TrPs exist, and the practice should therefore be questioned. The insertion of dry needles into asymptomatic body areas proximal and/or distal to the primary source of pain is supported by the myofascial pain syndrome literature. Physical therapists should not ignore the findings of the Western or biomedical ‘acupuncture’ literature that have used the very same ‘dry needles’ to treat patients with a variety of neuromusculoskeletal conditions in numerous, large scale randomized controlled trials. Although the optimal frequency, duration, and intensity of dry needling has yet to be determined for many neuromusculoskeletal conditions, the vast majority of dry needling randomized controlled trials have manually stimulated the needles and left them in situ for between 10 and 30 minute durations. Position statements and clinical practice guidelines for dry needling should be based on the best available literature, not a single paradigm or school of thought; therefore, physical therapy associations and state boards of physical therapy should consider broadening the definition of dry needling to encompass the stimulation of neural, muscular, and connective tissues, not just ‘TrPs’.
PMCID: PMC4117383  PMID: 25143704
Dry needling; Literature review; Trigger point; Practice guidelines; Physical therapy
Study Design:
Case Report.
Background and Purpose:
Dry needling (DN) is an increasingly popular intervention used by clinicians as a treatment of regional neuromusculoskeletal pain. DN is an invasive procedure that involves insertion of a thin monofilament needle directly into a muscle trigger point (MTP) with the intent of stimulating a local twitch response. Current evidence is somewhat limited, but recent literature supports the use of this intervention in specific neuromusculoskeletal conditions. The purpose of this case report is to present the outcomes of DN as a primary treatment intervention in an adolescent subject with subacute posterior knee pain.
Case Description:
The subject was a 16‐year‐old female competitive ballet dancer referred to physical therapy with a two month history of right posterior knee pain. Palpation identified MTPs which reproduced the patient’s primary symptoms. In addition to an exercise program promoting lower extremity flexibility and hip stability, the subject was treated with DN to the right gastrocnemius, soleus, and popliteus muscles.
The subject reported being pain free on the Numerical Pain Scale and a +7 improvement in perceived change in recovery on the Global Rating of Change at final follow‐up. Physical examination demonstrated no observed impairments or functional limitations, including normal mobility, full strength, and unrestricted execution of dance maneuvers.
The patient was able to return to high level dance training and competition without physical limitations and resumed pre‐injury dynamic movement activities including dancing, running, jumping, and pivoting without pain. DN can be an effective and efficient intervention to assist patients in decreasing pain and returning to high intensity physical activity. Additional research is needed to determine if DN is effective for other body regions and has long‐term positive outcomes.
Level of Evidence:
Level 4
PMCID: PMC3924615  PMID: 24567862
Dry needling; knee pain; trigger point; dancing
3.  The appropriate use of radiography in clinical practice: a report of two cases of biomechanical versus malignant spine pain 
To describe the evaluation, treatment, management and referral of two patients with back pain with an eventual malignant etiology, who were first thought to have a non-organic biomechanical disorder.
Clinical features
The study was a retrospective review of the clinical course of two patients seen by a chiropractor in a multi-disciplinary outpatient facility, who presented with what was thought to be non-organic biomechanical spine pain. Clinical examination by both medical and chiropractic physicians did not indicate the need for radiography in the early course of management of either patient. Upon subsequent re-evaluation, it was decided that certain clinical factors required investigation with advanced imaging.
In one instance, the patient responded to conservative care of low back pain for nine weeks, after which she developed severe pain in the pelvis. In the second case, the patient presented with signs and symptoms consistent with uncomplicated musculoskeletal pain that failed to respond to a course of conservative care. He was referred for medical therapy which also failed to relieve his pain. In both patients, malignancy was eventually discovered with magnetic resonance imaging and both patients are now deceased, resulting in an inability to obtain informed consent for the publication of this manuscript.
In these two cases, the prudent use of diagnostic plain film radiography did not significantly alter the appropriate long-term management of patients with neuromusculoskeletal signs and symptoms. The judicious use of magnetic resonance imaging was an effective procedure when investigating recalcitrant neuromusculoskeletal pain in these two patients.
PMCID: PMC1488857  PMID: 16734899
4.  Personalized neuromusculoskeletal modeling to improve treatment of mobility impairments: a perspective from European research sites 
Mobility impairments due to injury or disease have a significant impact on quality of life. Consequently, development of effective treatments to restore or replace lost function is an important societal challenge. In current clinical practice, a treatment plan is often selected from a standard menu of options rather than customized to the unique characteristics of the patient. Furthermore, the treatment selection process is normally based on subjective clinical experience rather than objective prediction of post-treatment function. The net result is treatment methods that are less effective than desired at restoring lost function. This paper discusses the possible use of personalized neuromusculoskeletal computer models to improve customization, objectivity, and ultimately effectiveness of treatments for mobility impairments. The discussion is based on information gathered from academic and industrial research sites throughout Europe, and both clinical and technical aspects of personalized neuromusculoskeletal modeling are explored. On the clinical front, we discuss the purpose and process of personalized neuromusculoskeletal modeling, the application of personalized models to clinical problems, and gaps in clinical application. On the technical front, we discuss current capabilities of personalized neuromusculoskeletal models along with technical gaps that limit future clinical application. We conclude by summarizing recommendations for future research efforts that would allow personalized neuromusculoskeletal models to make the greatest impact possible on treatment design for mobility impairments.
PMCID: PMC3342221  PMID: 22463378
Musculoskeletal model; Neural control model; Orthopedic surgery; Neurorehabilitation; Biomechanics
5.  Subject-Specific Tendon-Aponeurosis Definition in Hill-Type Model Predicts Higher Muscle Forces in Dynamic Tasks 
PLoS ONE  2012;7(8):e44406.
Neuromusculoskeletal models are a common method to estimate muscle forces. Developing accurate neuromusculoskeletal models is a challenging task due to the complexity of the system and large inter-subject variability. The estimation of muscles force is based on the mechanical properties of tendon-aponeurosis complex. Most neuromusculoskeletal models use a generic definition of the tendon-aponeurosis complex based on in vitro test, perhaps limiting their validity. Ultrasonography allows subject-specific estimates of the tendon-aponeurosis complex’s mechanical properties. The aim of this study was to investigate the influence of subject-specific mechanical properties of the tendon-aponeurosis complex on a neuromusculoskeletal model of the ankle joint. Seven subjects performed isometric contractions from which the tendon-aponeurosis force-strain relationship was estimated. Hopping and running tasks were performed and muscle forces were estimated using subject-specific tendon-aponeurosis and generic tendon properties. Two ultrasound probes positioned over the muscle-tendon junction and the mid-belly were combined with motion capture to estimate the in vivo tendon and aponeurosis strain of the medial head of gastrocnemius muscle. The tendon-aponeurosis force-strain relationship was scaled for the other ankle muscles based on tendon and aponeurosis length of each muscle measured by ultrasonography. The EMG-driven model was calibrated twice - using the generic tendon definition and a subject-specific tendon-aponeurosis force-strain definition. The use of subject-specific tendon-aponeurosis definition leads to a higher muscle force estimate for the soleus muscle and the plantar-flexor group, and to a better model prediction of the ankle joint moment compared to the model estimate which used a generic definition. Furthermore, the subject-specific tendon-aponeurosis definition leads to a decoupling behaviour between the muscle fibre and muscle-tendon unit in agreement with previous experiments using ultrasonography. These results indicate the use of subject-specific tendon-aponeurosis definitions in a neuromusculoskeletal model produce better agreement with measured external loads and more physiological model behaviour.
PMCID: PMC3430662  PMID: 22952973
6.  Common errors and clinical guidelines for manual muscle testing: "the arm test" and other inaccurate procedures 
The manual muscle test (MMT) has been offered as a chiropractic assessment tool that may help diagnose neuromusculoskeletal dysfunction. We contend that due to the number of manipulative practitioners using this test as part of the assessment of patients, clinical guidelines for the MMT are required to heighten the accuracy in the use of this tool.
To present essential operational definitions of the MMT for chiropractors and other clinicians that should improve the reliability of the MMT as a diagnostic test. Controversy about the usefulness and reliability of the MMT for chiropractic diagnosis is ongoing, and clinical guidelines about the MMT are needed to resolve confusion regarding the MMT as used in clinical practice as well as the evaluation of experimental evidence concerning its use.
We expect that the resistance to accept the MMT as a reliable and valid diagnostic tool will continue within some portions of the manipulative professions if clinical guidelines for the use of MMT methods are not established and accepted. Unreliable assessments of this method of diagnosis will continue when non-standard MMT research papers are considered representative of the methods used by properly trained clinicians.
Practitioners who employ the MMT should use these clinical guidelines for improving their use of the MMT in their assessments of muscle dysfunction in patients with musculoskeletal pain.
PMCID: PMC2628341  PMID: 19099575
7.  Case Report: Schizophrenia Discovered during the Patient Interview in a Man with Shoulder Pain Referred for Physical Therapy 
Physiotherapy Canada  2010;62(4):308-315.
Purpose: The purpose of this case report is to demonstrate the importance of a thorough patient interview. The case involves a man referred for physical therapy for a musculoskeletal dysfunction; during the patient interview, a psychiatric disorder was recognized that was later identified as schizophrenia. A secondary purpose is to educate physical therapists on the recognizable signs and symptoms of schizophrenia.
Client description: A 19-year-old male patient with chronic shoulder, elbow, and wrist pain was referred for physical therapy. During the interview, the patient reported that he was receiving signals from an electronic device implanted in his body.
Measures and outcome: The physical therapist's initial assessment identified a disorder requiring medical referral. Further management of the patient's musculoskeletal dysfunction was not appropriate at this time.
Intervention: The patient was referred for further medical investigation, as he was demonstrating signs suggestive of a psychiatric disorder. The patient was diagnosed with schizophrenia by a psychiatrist and was prescribed Risperdal.
Implications: This case study reinforces the importance of a thorough patient interview by physical therapists to rule out non-musculoskeletal disorders. Patients seeking neuromusculoskeletal assessment and treatment may have undiagnosed primary or secondary psychiatric disorders that require recognition by physical therapists and possible medical referral.
PMCID: PMC2958076  PMID: 21886370
patient interview; physical therapy assessment; psychiatric disorder; referral source; schizophrenia; Entrevue avec le patient; évaluation en physiothérapie; source de renvoi; patient redirigé; problème psychiatrique; schizophrénie
8.  Sustained Release Myofascial Release as Treatment for a Patient with Complications of Rheumatoid Arthritis and Collagenous Colitis: A Case Report 
Myofascial release (MFR) is a manual therapeutic technique used to release fascial restrictions, which may cause neuromusculoskeletal and systemic pathology.
This case report describes the use of sustained release MFR techniques in a patient with a primary diagnosis of rheumatoid arthritis (RA) and a secondary diagnosis of collagenous colitis. Changes in pain, cervical range of motion, fatigue, and gastrointestinal tract function, as well as the impact of RA on daily activities, were assessed.
A 54-year-old white woman presented with signs and symptoms attributed to RA and collagenous colitis. Pre and post measurements were taken with each treatment and during the interim between the initial and final treatment series. The patient recorded changes in pain, fatigue, gastrointestinal tract function, and quality of life. Cervical range of motion was assessed. Six sustained release MFR treatment sessions were provided over a 2-week period. Following an 8-week interim, two more treatments were performed.
The patient showed improvements in pain, fatigue, gastrointestinal tract function, cervical range of motion, and quality of life following the initial treatment series of six sessions. The patient maintained positive gains for 5 weeks following the final treatment, after which her symptoms returned to near baseline measurements. Following two more treatments, positive gains were achieved once again.
In a patient with RA and collagenous colitis, the application of sustained release MFR techniques in addition to standard medical treatment may provide short-term and long-term improvements in comorbid symptoms and overall quality of life.
PMCID: PMC3184472  PMID: 22016756
Myofascial release; rheumatoid arthritis; inflammatory bowel disease; manual therapy
Objective: To assess the response of a patient with chronic migraines to a short program of chiropractic care (diversified technique).
Method: The study was run over a 13 week period with chiropractic spinal manipulative therapy (CSMT) on a once weekly schedule for 5 weeks, followed by an 8 week re-evaluation.
Outcome Measures: To measure the effect of treatment, a previously reported diary system was used which noted the intensity of a range of symptoms that are recorded following each migraine episode.
Results: The results attained showed there was a marked improvement in the migraine symptoms following the chiropractic care. The patient reported an improvement in frequency, intensity, duration and use of medication. These findings appear to also confirm other evidence which documented similar changes following a large randomised controlled trial of chiropractic treatment of migraine.
Discussion: The case is presented as further support for CSMT in the treatment of migraine. The outcome of this case is also discussed in relation to recent research that concludes that CSMT is a very effective treatment for some people with non-neuromusculoskeletal conditions.
Conclusion: It now appears clear that chiropractic care may be used to assist patients with migraine. Research is currently being undertaken to investigate the potential mechanisms of chiropractic in the treatment of migraine. This research should also assess what (if any) prognostic signs can be identified to assist practitioners making a more informed decision on the treatment of choice for migraine.
PMCID: PMC2051094  PMID: 17987195
Classic Migraine; chiropractic; manipulation; spinal; case report
10.  Computer Use and Habitual Spinal Posture in Australian Adolescents 
Public Health Reports  2007;122(5):634-643.
Computer use is common in adolescents, and there is evidence that adolescent spinal posture alters during computer use. However, it is unknown if computer use and habitual postures are associated. The objective of this study was to evaluate associations between adolescent computer use and habitual postures.
Eight hundred eighty-four adolescents (408 females, 476 males, mean age, 14.0 years, standard deviation, 0.2) completed a questionnaire assessing weekly computer use. Habitual spinal posture was assessed by photographic analysis while standing and sitting.
Computer use was associated with adolescent habitual postures. In males, increased computer use was associated with increased head flexion and neck flexion. In females, increased computer use was associated with increased lumbar lordosis.
The amount of weekly computer use was associated with changes in habitual spinal postures, and these depended on gender. These associations may result from temporary computer postures leading to adaptive neuromusculoskeletal changes, though further multivariate and longitudinal studies are needed to confirm causality. As some habitual posture changes may place a greater strain on the musculoskeletal system, computer use by adolescents should be viewed as a possible health concern.
PMCID: PMC1936962  PMID: 17877311
11.  Chiropractic management of breast-feeding difficulties: a case report 
Journal of Chiropractic Medicine  2011;10(3):199-203.
The purpose of this study is to discuss a chiropractic case of management and resolution of breast-feeding difficulties.
Clinical Features
The case involves an 8-day-old baby unable to breast-feed since 4 days old. Initial examination revealed cervical, cranial, and sacral restrictions. She was diagnosed with craniocervical syndrome by a doctor of chiropractic.
Intervention and Outcome
Following history and examination, the infant received gentle chiropractic manipulation based on clinical findings. Immediate improvement and complete resolution of the nursing problems were observed after 3 treatments over 14 days.
The results of this case suggest that neuromusculoskeletal dysfunction may influence the ability of an infant to suckle successfully and that intervention via chiropractic adjustments may result in improving the infant's ability to suckle efficiently.
PMCID: PMC3259991  PMID: 22014911
Manipulation; Chiropractic; Infant; Lactation; Breast-feeding
Study Design:
Case Report.
Background and Purpose:
Myofascial trigger points (MTrPs) are widely accepted by clinicians and researchers as a primary source of regional neuromusculoskeletal pain. Trigger point dry needling (TrP‐DN) is an invasive procedure that involves stimulation of MTrPs using an monofilament needle. The purpose of this case report is to report the outcomes of TrP‐DN and intramuscular electrical stimulation (IES) as a primary treatment intervention in a subject with chronic low back pain.
Case Description:
The subject was a 30‐year‐old female, active duty military, who was referred to physical therapy for low back and right posterolateral hip pain. She noticed symptoms after suffering a lumbar flexion injury while picking up a barbell during weight training. Physical examination demonstrated findings that supported the diagnosis of lumbar segmental instability with a right hip stability dysfunction. Objective findings included a multi‐segmental flexion movement pattern dysfunction and MTrPs in the right gluteus maximus and gluteus medius muscles with deep palpation. The subject was treated with TrP‐DN and IES for a total of two visits. Bilateral L3 and L5 multifidus and right gluteus maximus and medius muscles were treated, along with implementing a home exercise program consisting of core stability exercises.
The subject reported no existing pain and disability on the Numerical Pain Rating Scale and Oswestry Disability Questionnaire and a large perceived change in recovery on the Global Rating of Change at final follow‐up. Physical examination was normal, demonstrating no observed impairments or functional limitations, including normal multi‐segmental flexion and no MTrPs with deep palpation.
The subject was able to return to full military active duty without any physical limitations and resumed pre‐injury activity levels, including the ability to resume all activities without pain. There is much promise regarding the use of TrP‐DN with IES intervention for the treatment of lumbar and/or hip stability dysfunction. Future research is recommended to determine if TrP‐DN intervention, with and without IES, is effective for other body regions and long‐term subject outcomes.
Level of Evidence:
Level 4.
PMCID: PMC3625794  PMID: 23593553
Dry needling; intramuscular electrical stimulation; low back pain; myofasical trigger points
13.  Prevention of Neuromusculoskeletal Frailty in Slow-Aging Ames Dwarf Mice: Longitudinal Investigation of Interaction of Longevity Genes and Caloric Restriction 
PLoS ONE  2013;8(10):e72255.
Ames dwarf (Prop1df/df) mice are remarkably long-lived and exhibit many characteristics of delayed aging and extended healthspan. Caloric restriction (CR) has similar effects on healthspan and lifespan, and causes an extension of longevity in Ames dwarf mice. Our study objective was to determine whether Ames dwarfism or CR influence neuromusculoskeletal function in middle-aged (82 ± 12 weeks old) or old (128 ± 14 w.o.) mice. At the examined ages, strength was improved by dwarfism, CR, and dwarfism plus CR in male mice; balance/ motor coordination was improved by CR in old animals and in middle-aged females; and agility/ motor coordination was improved by a combination of dwarfism and CR in both genders of middle-aged mice and in old females. Therefore, extension of longevity by congenital hypopituitarism is associated with improved maintenance of the examined measures of strength, agility, and motor coordination, key elements of frailty during human aging, into advanced age. This study serves as a particularly important example of knowledge related to addressing aging-associated diseases and disorders that results from studies in long-lived mammals.
PMCID: PMC3796515  PMID: 24155868
14.  Chest pain without established ischaemic heart disease in primary care patients: associated comorbidities and mortality 
Ischaemic heart disease (IHD) can be excluded in the majority of patients with unspecific chest pain. The remainder have what is generally referred to as non-cardiac chest pain, which has been associated with gastrointestinal, neuromusculoskeletal, pulmonary, and psychiatric causes.
To assess morbidity and mortality following a new diagnosis of non-specific chest pain in patients without established IHD.
Design of study
Population-based cohort study with nested case-control analysis.
UK primary care practices contributing to the General Practice Research Database.
Patients aged 20–79 years with chest pain who had had no chest pain consultation before 2000 and no IHD diagnosis before 2000 or within 2 weeks after the index date were selected from the General Practice Research Database. The selected 3028 patients and matched controls were followed-up for 1 year.
The incidence of chest pain in patients without established IHD was 12.7 per 1000 person-years. In the year following the index date, patients who had chest pain but did not have established IHD were more likely than controls to receive a first IHD diagnosis (hazard ratio [HR] = 18.2, 95% confidence interval [CI] = 11.6 to 28.6) or to die (HR = 2.3, 95% CI = 1.3 to 4.1). Patients with chest pain commonly had a history of gastro-oesophageal reflux disease (GORD; odds ratio [OR] = 2.0, 95% CI = 1.5 to 2.7) or went on to be diagnosed with GORD (risk ratio 4.5, 95% CI = 3.1 to 6.4).
Patients with chest pain but without established IHD were found to have an increased risk of being diagnosed with IHD. Chest pain in patients without established IHD was also commonly associated with GORD.
PMCID: PMC2648936  PMID: 19275827
chest pain; gastro-oesophageal reflux disease; mortality; myocardial ischaemia; primary healthcare
15.  A comparison of functioning, activity, and participation in school-aged children with cerebral palsy using the manual ability classification system 
[Purpose] The purpose of this study was to evaluate the functioning, extent of activity, and participation of school-aged children with cerebral palsy (CP) using the Manual Ability Classification System (MACS). [Subjects and Methods] The Subjects were 57 school-aged children (7–12 years old) with CP. The MACS, Gross Motor Function Measure (GMFM), International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) Checklist, and a questionnaire were used to measure children’s functioning, activity, and participation. [Results] GMFM scores differed significantly across the MACS levels. The following differed significantly according to MACS level when assessed with the ICF-CY function section: mental functions; sensory function and pain; voice and speech functions; functions of the digestive, metabolic, and endocrine systems; genitourinary and reproductive function; and neuromusculoskeletal and movement related function. The data from the activities and participation section of the ICF-CY also showed statistically significant differences across MACS levels. [Conclusion] These results suggest that the functioning, activity, and participation of school-aged children with CP depend on their MACS level and that the functioning of children with CP affects their activities and participation.
PMCID: PMC4305573  PMID: 25642083
Cerebral palsy; Manual Ability Classification System; ICF-CY
Objective: To investigate a patient with atopic eczema and assess how they responded to chiropractic care.
Method: The study was run over a 7 week period with chiropractic treatments (diversified technique) on a once weekly schedule.
Outcome Measures: To measure the effect of treatment, a rating system was developed and the intensity of a range of symptoms was recorded (through a questionnaire) on a twice weekly basis.
Results: The results attained showed there was a marked improvement in the eczema symptoms following the chiropractic care. The patient reported an improvement in eczematous symptoms of excoriation, pruritus, oedema and general psychological ease. These findings were also confirmed by photographic evidence which documented the change in the lesions.
Discussion: The case is presented to assist practitioners making a more informed decision on the treatment of choice for eczema. The outcome of this case is also discussed in relation to recent research that concludes that chiropractic spinal manipulative therapy has a role in the treatment for some people with non-neuromusculoskeletal conditions.
Conclusion: It appears that chiropractic care may have assisted this patient with eczema. However, more research is required to investigate the role that chiropractic has in the treatment of patients with eczema, and the potential mechanisms that could explain the improvement.
PMCID: PMC2051093  PMID: 17987197
Eczema; dermatitis; atopic; chiropractic; case report
17.  Is chiropractic care primary health care? 
The following paper sets out to examine three issues: primary health care, chiropractic care, and the challenges to both in the next decade. The current crisis of primary health within the health care system provides chiropractic with an opportunity to choose between functioning as primary care or primary contact care. Chiropractic has seldom met its potential, or its own rhetoric, with regard to holistic health care which would make the case for being primary health care much stronger. There have been numerous social and political factors that have influenced this but part of the problem is that chiropractic has failed to clearly articulate itself as primary health care, and in some instances, has denied that it was. New opportunities and challenges will force chiropractors to resolve the issue of whether chiropractic is a general model of health care, or a form of health specialty (the neuromusculoskeletal practitioner verses the primary health practitioner).
PMCID: PMC2484820
chiropractic; manipulation; health care
18.  Faculty Perception of Clinical Value of Five Commonly Used Orthopedic Tests 
The purpose of this study is to examine the perceptions of the value of five orthopedic tests (straight leg raise, Braggard’s test, Kemp’s test, Valsalva maneuver, and Patrick’s fabere test) in the diagnosis of specific neuromusculoskeletal conditions among the chiropractic faculty at a large chiropractic college.
This is an observational study that employed a survey of 41 academic and clinic faculty members with a Doctor of Chiropractic degree.
Of the 12 posed questions, only five demonstrated statistically significant consistency (positive straight leg raise for the presence of disc pathology, positive Valsalva maneuver for the presence of disc pathology, negative Valsalva maneuver to rule out disc pathology, negative Braggard’s test to rule out the presence of disc pathology, and positive Patrick’s fabere test for the presence of hip joint pathology). Subgroup analysis demonstrated that the school of graduation may be the only predictor of consistency.
There were strong indications that faculty members were not consistent in their perception of the value for common orthopedic tests for diagnosing specific conditions. In an evidence-based model of education, there should be a consensus among academic and clinical faculty in order for the students to learn, integrate, and apply in practice what they have learned in the classroom. Active intervention in the academic process is required to accomplish necessary change.
PMCID: PMC3204952  PMID: 22069341
Chiropractic; Diagnosis; Evidence-Based Practice; Physical Examination
19.  Spinal circuits can accommodate interaction torques during multijoint limb movements 
The dynamic interaction of limb segments during movements that involve multiple joints creates torques in one joint due to motion about another. Evidence shows that such interaction torques are taken into account during the planning or control of movement in humans. Two alternative hypotheses could explain the compensation of these dynamic torques. One involves the use of internal models to centrally compute predicted interaction torques and their explicit compensation through anticipatory adjustment of descending motor commands. The alternative, based on the equilibrium-point hypothesis, claims that descending signals can be simple and related to the desired movement kinematics only, while spinal feedback mechanisms are responsible for the appropriate creation and coordination of dynamic muscle forces. Partial supporting evidence exists in each case. However, until now no model has explicitly shown, in the case of the second hypothesis, whether peripheral feedback is really sufficient on its own for coordinating the motion of several joints while at the same time accommodating intersegmental interaction torques. Here we propose a minimal computational model to examine this question. Using a biomechanics simulation of a two-joint arm controlled by spinal neural circuitry, we show for the first time that it is indeed possible for the neuromusculoskeletal system to transform simple descending control signals into muscle activation patterns that accommodate interaction forces depending on their direction and magnitude. This is achieved without the aid of any central predictive signal. Even though the model makes various simplifications and abstractions compared to the complexities involved in the control of human arm movements, the finding lends plausibility to the hypothesis that some multijoint movements can in principle be controlled even in the absence of internal models of intersegmental dynamics or learned compensatory motor signals.
PMCID: PMC4227517  PMID: 25426061
motor control; interaction torques; intersegmental dynamics; spinal circuits; internal model; intralimb coordination; equilibrium-point hypothesis
20.  Neuromusculoskeletal disorders in the neck and upper extremities among drivers of all-terrain vehicles – a case series 
The purpose of this study was to investigate whether professional drivers of all-terrain vehicles (ATVs) with neck pain have a different array of neuromusculoskeletal disorders in the neck and upper extremities than a referent group with neck pain from the general population. It is hypothesized that exposure to shock-type vibration and unfavorable working postures in ATVs have the capacity to cause peripheral nervous lesions.
This study was based on a case series analyzed according to a case-case comparison design. The study population consisted of 60 male subjects, including professional drivers of forest machines (n = 15), snowmobiles (n = 15), snowgroomers (n = 15) and referents from the general population (n = 15) all of whom had reported neck pain in a questionnaire and underwent an extensive physical examination of the neck and upper extremities. Based on symptom history, symptoms and signs, and in some cases chemical, electroneurographical and radiological findings, subjects were classified as having a nociceptive or neuropathic disorder or a mix of these types.
The occurrence of asymmetrical and focal neuropathies (peripheral nervous lesion), pure or in a mix with a nociceptive disorder was common among cases in the ATV driver groups (47%–79%). This contrasted with the referents that were less often classified as having asymmetrical and focal neuropathy (27%), but instead had more nociceptive disorders. The difference was most pronounced among drivers of snowgroomers, while drivers of forest machines were more frequently classified as having a nociceptive disorder originating in the muscles.
This study found a high prevalence of assymetrical and focal neuropathies among drivers with pain in the neck, operating various ATVs. It seems as if exposure to shock-type whole-body vibration (WBV) and appurtenant unfavorable postures in ATVs may be associated to peripheral nervous lesions.
PMCID: PMC324409  PMID: 14718063
21.  Improvement in hearing after chiropractic care: a case series 
The first chiropractic adjustment given in 1895 was reported to have cured deafness. This study examined the effects of a single, initial chiropractic visit on the central nervous system by documenting clinical changes of audiometry in patients after chiropractic care.
Case presentation
Fifteen patients are presented (9 male, 6 female) with a mean age of 54.3 (range 34–71). A Welch Allyn AudioScope 3 was used to screen frequencies of 1000, 2000, 4000 and 500 Hz respectively at three standard decibel levels 20 decibels (dB), 25 dB and 40 dB, respectively, before and immediately after the first chiropractic intervention. Several criteria were used to determine hearing impairment. Ventry & Weinstein criteria of missing one or more tones in either ear at 40 dB and Speech-frequency criteria of missing one or more tones in either ear at 25 dB.
All patients were classified as hearing impaired though greater on the right. At 40 dB using the Ventry & Weinstein criteria, 6 had hearing restored, 7 improved and 2 had no change. At 25 dB using the Speech-frequency criteria, none were restored, 11 improved, 4 had no change and 3 missed a tone.
A percentage of patients presenting to the chiropractor have a mild to moderate hearing loss, most notably in the right ear. The clinical progress documented in this report suggests that manipulation delivered to the neuromusculoskeletal system may create central plastic changes in the auditory system.
PMCID: PMC1395318  PMID: 16423302
22.  Chiropractic practice in Hong Kong: the need for amendments of health laws and provisions 
Chiropractic practitioners with accredited qualifications should have the right to diagnose, the right to operate diagnostic imaging machines, and the right to the title doctor and Yee San. This paper reviews chiropractic practice in Hong Kong as well as laws and provisions of the health professions namely Chiropractors Registration Ordinance, Medical Registration Ordinance, Dentists Registration Ordinance, Radiation Ordinance, and the provisions of codes of practice of Medical Laboratory Technologists and Radiographers. The need for amendments of relevant sections of health laws and provisions, which concern chiropractic rights, chiropractic practice, and clinical research of mechanical neuromusculoskeletal disorders is discussed. Patient privileges relevant to chiropractic practice are proposed. The Chinese title Yee San or Yee and the English title Doctor are generic terms. Hence, legally “Yee San” and “Doctor” should not be coined by medical practitioners and vice versa. Diagnostic imaging and laboratory procedures are essential for differential diagnosis of neuromusculoskeletal disorders, which may indicate or contraindicate the application of manipulation, and hence are essential for chiropractic practice and clinical research. Proposed amendments of the listed sections of the ordinances and provisions are also outlined.
PMCID: PMC2485020
chiropractic; chiropractic legislation and jurisprudence; chiropractic history; doctor; rights; diagnosis; diagnostic imaging; laboratory diagnosis; Hong Kong; doctor title; health laws
23.  Neuromusculoskeletal disorders following SARS: a case series 
To detail the presentation of three health care workers diagnosed with sudden acute respiratory syndrome (SARS) who later presented to a CMCC teaching clinic with neuromusculoskeletal sequelae and underwent conservative treatments. This case series aims to inform practitioners of the potential pathogenesis of these neuromuscular complaints and describes their treatment in a chiropractic practice.
Clinical Features:
Three patients presented with a variety of neurological, muscular and joint findings. Conservative treatment was aimed at decreasing hypertonic muscles, increasing joint mobility, and improving ability to perform activities of daily living.
Intervention and Outcome:
The conservative treatment approach utilized in these cases involved spinal manipulative therapy, soft tissue therapy, modalities, and rehabilitation. Outcome measures included subjective pain ratings, disability indices, and return to work.
Three patients previously diagnosed with SARS presented with neuromusculoskeletal complaints and subjectively experienced intermittent relief of pain and improvement in disability status after conservative treatments.
PMCID: PMC3044805  PMID: 21403780
SARS; neuromusculoskeletal; manipulative therapy; SRAS; neuromusculosquelettique; thérapie manuelle
24.  Relating reflex gain modulation in posture control to underlying neural network properties using a neuromusculoskeletal model 
During posture control, reflexive feedback allows humans to efficiently compensate for unpredictable mechanical disturbances. Although reflexes are involuntary, humans can adapt their reflexive settings to the characteristics of the disturbances. Reflex modulation is commonly studied by determining reflex gains: a set of parameters that quantify the contributions of Ia, Ib and II afferents to mechanical joint behavior. Many mechanisms, like presynaptic inhibition and fusimotor drive, can account for reflex gain modulations. The goal of this study was to investigate the effects of underlying neural and sensory mechanisms on mechanical joint behavior. A neuromusculoskeletal model was built, in which a pair of muscles actuated a limb, while being controlled by a model of 2,298 spiking neurons in six pairs of spinal populations. Identical to experiments, the endpoint of the limb was disturbed with force perturbations. System identification was used to quantify the control behavior with reflex gains. A sensitivity analysis was then performed on the neuromusculoskeletal model, determining the influence of the neural, sensory and synaptic parameters on the joint dynamics. The results showed that the lumped reflex gains positively correlate to their most direct neural substrates: the velocity gain with Ia afferent velocity feedback, the positional gain with muscle stretch over II afferents and the force feedback gain with Ib afferent feedback. However, position feedback and force feedback gains show strong interactions with other neural and sensory properties. These results give important insights in the effects of neural properties on joint dynamics and in the identifiability of reflex gains in experiments.
PMCID: PMC3108017  PMID: 20865310
Reflexes; Afferent feedback; Reflex gains; Sensitivity analysis; System identification
25.  Spinal Mechanisms May Provide a Combination of Intermittent and Continuous Control of Human Posture: Predictions from a Biologically Based Neuromusculoskeletal Model 
PLoS Computational Biology  2014;10(11):e1003944.
Several models have been employed to study human postural control during upright quiet stance. Most have adopted an inverted pendulum approximation to the standing human and theoretical models to account for the neural feedback necessary to keep balance. The present study adds to the previous efforts in focusing more closely on modelling the physiological mechanisms of important elements associated with the control of human posture. This paper studies neuromuscular mechanisms behind upright stance control by means of a biologically based large-scale neuromusculoskeletal (NMS) model. It encompasses: i) conductance-based spinal neuron models (motor neurons and interneurons); ii) muscle proprioceptor models (spindle and Golgi tendon organ) providing sensory afferent feedback; iii) Hill-type muscle models of the leg plantar and dorsiflexors; and iv) an inverted pendulum model for the body biomechanics during upright stance. The motor neuron pools are driven by stochastic spike trains. Simulation results showed that the neuromechanical outputs generated by the NMS model resemble experimental data from subjects standing on a stable surface. Interesting findings were that: i) an intermittent pattern of muscle activation emerged from this posture control model for two of the leg muscles (Medial and Lateral Gastrocnemius); and ii) the Soleus muscle was mostly activated in a continuous manner. These results suggest that the spinal cord anatomy and neurophysiology (e.g., motor unit types, synaptic connectivities, ordered recruitment), along with the modulation of afferent activity, may account for the mixture of intermittent and continuous control that has been a subject of debate in recent studies on postural control. Another finding was the occurrence of the so-called “paradoxical” behaviour of muscle fibre lengths as a function of postural sway. The simulations confirmed previous conjectures that reciprocal inhibition is possibly contributing to this effect, but on the other hand showed that this effect may arise without any anticipatory neural control mechanism.
Author Summary
The control of upright stance is a challenging task since the objective is to maintain the equilibrium of an intrinsically unstable biomechanical system. Somatosensory information is used by the central nervous system to modulate muscle contraction, which prevents the body from falling. While the visual and vestibular systems also provide important additional sensory information, a human being with only somatosensory inputs is able to maintain an upright stance. In this study, we used a biologically-based large-scale neuromusculoskeletal model driven only by somatosensory feedback to investigate human postural control from a neurophysiological point of view. No neural structures above the spinal cord were included in the model. The results showed that the model based on a spinal control of posture can reproduce several neuromechanical outcomes previously reported in the literature, including an intermittent muscle activation. Since this intermittent muscular recruitment is an emergent property of this spinal-like controller, we argue that the so-called intermittent control of upright stance might be produced by an interplay between spinal cord properties and modulated sensory inflow.
PMCID: PMC4230754  PMID: 25393548

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