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3.  Transient osteoporosis of the hip: A case report 
We report a case of transient osteoporosis of the hip (TOH) in a 59-year-old man including the clinical presentation, diagnostic studies, management and clinical progress. TOH is a rare self-limiting condition that typically affects middle-aged men or, less frequently, women in the third trimester of pregnancy. Affected individuals present clinically with acute hip pain, limping gait, and limited ranges of hip motion. TOH may begin spontaneously or after a minor trauma. Radiographs are typically unremarkable but MR imaging studies yield findings consistent with bone marrow edema. TOH is referred to as regional migratory osteoporosis if it travels to other joints or the contralateral hip. TOH often resembles osteonecrosis but the two conditions must be differentiated due to different prognoses and management approaches. The term TOH is often used interchangeably and synonymously with transient bone marrow edema.
PMCID: PMC3661178  PMID: 23754856
osteoporosis; hip; transient; ostéoporose; hanche; transitoire
4.  Insufficiency fracture of the tibial plateau after anterior cruciate ligament reconstructive surgery: a case report and review of the literature 
Peri-articular fractures after anterior cruciate ligament (ACL) reconstructive surgery are rare. To our knowledge, this case documents the first insufficiency fracture of the tibial plateau after ACL reconstruction, which presented three weeks after the procedure. A 25-year-old female recreational soccer player suffered an insufficiency fracture of the tibial plateau, extending 1.5 mm into the anterior wall of tibial tunnel and medial compartment under the anterior horn of medial meniscus, which presented as a diagnostic challenge. Clinically, the fracture mimicked a low-grade infection of the surgical site, while radiographically, the fracture resembled an avulsion fracture, later confirmed as a tibial tunnel fracture with computed tomography. With the ACL graft integrity not in jeopardy, four weeks of non-weightbearing and a delayed post-operative rehabilitation program was effective in allowing the fracture to heal. Good functional outcome was achieved after conservative management, with minimal loss of terminal knee extension and minimal pain at 22-month follow-up.
PMCID: PMC3661179  PMID: 23754857
tibial plateau; fracture; ACL reconstruction; complication; conservative management; plateau tibial; chirurgie reconstructive du LCA; complication; gestion conservatrice
5.  Therapeutic interventions employed by Greater Toronto Area chiropractors on pregnant patients: results of a cross-sectional online survey 
Introduction:
Due to different biomechanical, nutritional, and hormonal considerations, it is possible that chiropractors may employ different therapeutic interventions and recommendations for pregnant patients than non-pregnant ones. The objective of this study was to determine the therapeutic interventions that chiropractors who are members of the Ontario Chiropractic Association in the Greater Toronto Area most commonly provide to pregnant patients.
Methods:
An introductory e-mail was sent in October 2011 to 755 members of the Ontario Chiropractic Association within the Greater Toronto Area five days prior to a 15 question survey being distributed via e-mail. Reminder e-mails were sent 13 days and 27 days later. Using descriptive statistics, demographic information was reported along with reported use of different treatments and recommendations for pregnant patients
Results:
A response rate of 23% was obtained. The majority of the respondents (90%) reported using the Diversified technique on pregnant patients, followed by soft tissue therapy (62%) and Activator (42%). The most common adjunctive therapy recommended to pregnant patients was referral to massage therapy (90%). Most of the respondents (92%) indicated that they prescribe stretching exercises to pregnant patients and recommend a multivitamin (84%) or folic acid (81%) to pregnant patients.
Conclusion:
In agreement with previous research on chiropractic technique usage on non-pregnant patients, the majority of respondents indicated treating pregnant patients with the Diversified technique, with other chiropractic techniques being utilized at varying rates on pregnant patients. Most respondents indicated prescribing exercise, and making adjunctive and nutritional recommendations frequently for their pregnant patients.
PMCID: PMC3661180  PMID: 23754858
chiropractic; pregnancy; interventions; therapy; chiropratique; grossesse; interventions; thérapie
6.  Straight Back Syndrome: positive response to spinal manipulation and adjunctive therapy – A case report 
Straight Back Syndrome (SBS) has been recognized for over 50 years. Not to be confused with flat back syndrome in the lumbar spine, SBS patients present with an obvious loss of the thoracic kyphosis accompanied by apparent heart symptoms. The main purpose of this article is to describe a patient diagnosed with SBS, whose symptoms were successfully managed using spinal manipulative therapy as well as ancillary modalities. The use of diagnostic and laboratory tests are essential to differentially diagnose cardiac disease from SBS. Genesis and incidence of this condition is also discussed as well as roentgenometric analysis. A suggested diagnostic algorithm is presented as well.
PMCID: PMC3661181  PMID: 23754859
syndrome; straight back; thoracic; kyphosis; mitral valve; syndrome; dos droit; dorsale; cyphose; valvule mitrale
7.  Myxopapillary ependymoma as a cause of back pain in a young male – A case report 
Objective:
Primary spinal cord tumours are rare causes of low back pain but can be a significant cause of morbidity if undiagnosed and untreated. The following is a case of a young male patient presenting with low back pain and radicular symptoms caused by myxopapillary ependymoma.
Clinical Features:
A nineteen year old male presented to an orthopaedic surgeon with a long history of back pain. He was initially diagnosed with soft tissue injuries and discharged. He began to experience erectile and bowel dysfunction two years later and was re-referred to the orthopaedic surgeon by his family physician but was lost to follow-up. The patient did not present to the surgeon until two years after his symptom profile changed. At that point, MRI examinations revealed a large myxopapillary ependymoma extending from T12 to L4 that was confirmed by a pathologist.
Intervention and Outcome:
The tumour was surgically resected with subsequent adjuvant radiotherapy. After one year, the patient required continued catheterization and had poor anal tone. His back and leg complaints were almost normal. Follow-up MRI examinations revealed no disease progression or new spinal lesions at 4 years after the initial diagnosis.
Conclusion:
The clinical presentation of primary spinal cord tumours is non-specific and can easily be missed. In cases of chronic back pain, signs and symptoms should be regularly monitored for changes indicative of progressive neurological compromise such as sensory, motor and bowel/bladder dysfunction. If there is deterioration of clinical signs and symptoms, a spinal tumour should be considered in the list of differential diagnoses. Delayed diagnosis and treatment of these rare causes of back pain could lead to poor outcomes; therefore, a referral to a surgeon should be done immediately with proper follow up to ensure continuity of care.
PMCID: PMC3661182  PMID: 23754860
Spinal cord tumour; ependymoma; back pain; case reports; Tumeurs de la moelle épinière; épendymome; dorsalgie; études de cas
8.  Interexaminer reliability of cervical motion palpation using continuous measures and rater confidence levels 
Introduction:
Motion palpators usually rate the movement of each spinal level palpated, and their reliability is assessed based upon discrete paired observations. We hypothesized that asking motion palpators to identify the most fixated cervical spinal level to allow calculating reliability at the group level might be a useful alternative approach.
Methods:
Three examiners palpated 29 asymptomatic supine participants for cervical joint hypomobility. The location of identified hypomobile sites was based on their distance from the T1 spinous process. Interexaminer concordance was estimated by calculating Intraclass Correlation Coefficient (ICC) and mean absolute differences (MAD) values, stratified by degree of examiner confidence.
Results:
For the entire participant pool, ICC [2,1] = 0.61, judged “good.” MAD=1.35 cm, corresponding to mean interexaminer differences of about 75% of one cervical vertebral level. Stratification by examiner confidence levels resulted in small subgroups with equivocal results.
Discussion and Conclusion:
A continuous measures study methodology for assessing cervical motion palpation reliability showed more examiner concordance than was usually the case in previous studies using discrete methodology.
PMCID: PMC3661183  PMID: 23754861
motion palpation; fixation; cervical spine; concordance; palpation; focalisation; colonne vertébrale; 1concordance
9.  Frequency of use of diagnostic and manual therapeutic procedures of the spine currently taught at the Canadian Memorial Chiropractic College: A preliminary survey of Ontario chiropractors. Part 2 – procedure usage rates 
Objective:
The purpose of this study was to determine which diagnostic and therapeutic procedures of the spine are most commonly utilized by chiropractors practicing in Ontario, based on a list of currently taught procedures at CMCC. In Part 1 of this study (published previously), the demographics and practice patterns of the respondents were presented. Part 2 of this study (presented here) reports on the utilization rates of spinal diagnostic and therapeutic procedures by the respondents.
Methods:
The study consisted of a paper-based survey that was sent to 500 randomly selected Ontario chiropractors who responded confidentially. Survey questions inquired into demographic and practice style characteristics as well as the frequency with which spinal diagnostic and therapeutic procedures were performed.
Results:
There were 108 respondents to the survey, giving a response rate of 22.4%. Frequency of use of diagnostic procedures fell into three broad categories: (i) those tests that are almost always performed, (ii) those tests that are almost always performed by two-thirds to one-half of patients, and (iii) those tests that are virtually never used. By comparison, respondents utilized the same therapeutic procedures for patients care less consistently.
Conclusions:
Despite a low response rate, respondents reported mostly relying on static and motion palpation, joint play, neurological tests, and ranges of motion when assessing their patients. Due to a low response rate, the results of this study may not be generalizable to all Ontario chiropractors.
PMCID: PMC3661184  PMID: 23754862
Chiropractors; manual therapy; physical examination; survey; chiropraticiens; thérapeutique manuelle; examen physique; sondage
10.  Comminuted scapular body fractures: A report of three cases managed conservatively in chiropractic settings 
Fractures of the scapula are relatively uncommon. Fractures specific to the scapular body comprise 35–65% of these fractures. Currently, 99% of all isolated scapular body fractures are being treated nonoperatively with an immobilizing sling or brace and some form of manual therapy with an 86% success rate. We present the conservative management of three patients with comminuted fractures involving the scapular body that were managed in chiropractic settings. Residual disabilities in these three patients as measured by a standardized outcome tool were 2%, 5% and 23% after 3 years, 2 years, and 6 years respectively.
PMCID: PMC3661185  PMID: 23754863
scapula; fractures; comminuted; chiropractic; case management; scapula; fractures; comminutives; chiropratique; gestion de cas
12.  The life and contribution of Dr. Ronald Gitelman: a pioneer of modern chiropractic science 
Objective:
The life and contribution to chiropractic science of Dr. Ronald Gitelman is reviewed.
Methods:
Sources for this article included review of the notes prepared by Dr. Joseph Keating in his “biography” of the Canadian Memorial Chiropractic College (CMCC); review of the important articles published by Dr. Gitelman; review of the important projects undertaken by him along with various colleagues; notes from reminiscences obtained from many of these colleagues and discussions with his family.
Discussion:
Dr. Gitelman’s academic career spanned from 1963 to the late 1980’s. During that time, he made foundational contributions to the development of chiropractic science including: developing the Archives (1974), the first collection of scientific articles supporting chiropractic science (which was subsequently published as the Chiropractic Archives Research Collection (CRAC)); delivering one of the few chiropractic papers at the seminal NINCDS conference (1975) and, developing the collaboration between CMCC and Dr. Kirkaldy-Willis at the University of Saskatoon (1976). He practiced in Toronto from 1961 to 2007.
Summary:
Dr. Gitelman was a pioneer in the development of chiropractic science. He died on October 7, 2012.
PMCID: PMC3580999  PMID: 23482630
Gitelman; NINCDS; pioneer; Gitelman; NINCDS; pionnier
13.  Assessing the attitudes, knowledge and perspectives of medical students to chiropractic 
Objective:
To assess second-year medical students’ views on chiropractic.
Methods:
A three-step triangulation approach was designed, comprising a 53-item survey, nine key informant interviews and one focus group of 8 subjects. ANOVA was used to assess attitude-response survey totals over grouping variables. Constant comparison method and NVivo was used for thematic analysis.
Results:
112 medical students completed the survey (50% response rate). Subjects reporting no previous chiropractic experience/exposure or interest in learning about chiropractic were significantly more attitude-negative towards chiropractic. Thematically, medical students viewed chiropractic as an increasingly evidence-based complementary therapy for low back/chronic pain, but based views on indirect sources. Within formal curriculum, they wanted to learn about clinical conditions and benefits/risks related to treatment, as greater understanding was needed for future patient referrals.
Conclusion:
The results highlight the importance of exposure to chiropractic within the formal medical curriculum to help foster future collaboration between these two professions.
PMCID: PMC3581000  PMID: 23482682
attitudes; medical; students; survey; interprofessional; attitudes; médical; étudiants; sondage; interprofessionnel
14.  Frequency of use of diagnostic and manual therapeutic procedures of the spine taught at the Canadian Memorial Chiropractic College: A preliminary survey of Ontario chiropractors. Part 1 – practice characteristics and demographic profiles 
Background:
Students learn a plethora of physical examination and manual therapy procedures over the course of their chiropractic education. However, it is uncertain to what extent they continue to use these procedures in practice after graduation.
Objective:
The purpose of this study was to determine which diagnostic and therapeutic procedures of the spine are most commonly utilized by chiropractors practicing in Ontario. In Part 1 of this study (presented here), the demographics and practice patterns of the respondents are presented. Part 2 of this study will present the results of the utilization rates of diagnostic and therapeutic procedures used by respondents.
Methods:
The study consisted of a paper-based survey that was sent to 500 pseudo-randomly selected Ontario chiropractors who responded confidentially. Survey questions inquired into demographic and practice style characteristics.
Results:
There were 108 respondents to the survey, giving a response rate of 22.4%. Many chiropractors self-identified themselves with more than one practice style characteristic such as 72.4% of the self-described pain-based chiropractors who also described themselves as evidence-based, compared with 51.9% of subluxation-based chiropractors who also described themselves as evidence-based. Diversified technique was the most commonly employed technique used by 90.7% of respondents, followed by trigger point therapy indicated by 57.4% of respondents.
Conclusions:
Despite a low response rate, respondents reported practice characteristics in this study that were similar to practice characteristics previously published, particularly in terms of professional demographics and techniques employed. While Diversified was the most commonly used technique, respondents reported higher levels of use of proprietary soft tissue techniques systems and upper cervical techniques than have been previously reported.
PMCID: PMC3581001  PMID: 23482716
chiropractors; manual therapy; physical examination; survey; chiropraticiens; thérapeutique manuelle; examen physique; sondage
15.  Sternal insufficiency fracture related to steroid-induced osteoporosis: A case report 
Osteoporosis often results in fractures, deformity and disability. A rare but potentially challenging complication of osteoporosis is a sternal insufficiency fracture. This case report details a steroid-induced osteoporotic male who suffered a sternal insufficiency fracture after minimal trauma. Prompt diagnosis and appropriate management resulted in favourable outcome for the fracture, though a sequalae involving a myocardial infarction ensued with his osteoporosis and complex health history. The purpose of this case report is to heighten awareness around distinct characteristics of sternal fractures in osteoporotic patients. Discussion focuses on the incidence, mechanism, associated factors and diagnostic challenge of sternal insufficiency fractures. This case report highlights the role primary contact practitioners can play in recognition and management of sternal insufficiency fractures related to osteoporosis.
PMCID: PMC3581002  PMID: 23482849
sternal fracture; osteoporosis; insufficiency fracture; fracture du sternum; ostéoporose; fracture par insuffisance osseuse
16.  A diachronic study of the language of chiropractic 
This study investigates how the language of chiropractic has changed over time. A collection of material, published up until approximately 1950 and consisting of textbooks, monographs and lecture notes from Canadian Memorial Chiropractic College, was analyzed to identify commonly occurring words and phrases. The results were compared to a corpus of recent articles from the Journal of the Canadian Chiropractic Association. This permitted the identification of words which were over-represented in the historical literature and therefore likely have become somewhat archaic or represent themes which are of less import in the modern chiropractic literature. Words which were over-represented in the historical literature often referred to anatomical, pathological and biomechanical concepts. Conversely, words which were comparatively over-represented in the modern chiropractic literature often referred to concepts of professionalism, the clinical interaction and evidence-based care. A detailed analysis is presented of trends in the use of the conceptually important terms subluxation and adjustment.
PMCID: PMC3581003  PMID: 23482885
chiropractic; corpus linguistics; diachronic; lexicon; subluxation; adjustment; chiropratique; linguistique de corpus; diachronique; lexique; subluxation; ajustement
17.  Canadian Chiropractors are not alone: external advocacy in Ontario, 1902–2012 
This article focuses primarily on Ontario, identifying a number of the profession’s allies and their advocacy effectiveness, under two main headings: The Ontario Chiropractic Association; and the Canadian Memorial Chiropractic College during the period of 1902 to 2012. While part of our success in gaining recognition has been attributed to intense lobbying by the profession, here the public support of several labour unions is reviewed. The part played by various politicians, educators, entrepreneurs, legal counsel, academic administrators and historians is also discussed.
PMCID: PMC3581004  PMID: 23482916
chiropractic; advocacy; Ontario; historical; chiropratique; promotion; Ontario; historique
18.  Urolithiasis presenting as right flank pain: a case report 
Background:
Urolithiasis refers to renal or ureteral calculi referred to in lay terminology as a kidney stone. Utolithiasis is a potential emergency often resulting in acute abdominal, low back, flank or groin pain. Chiropractors may encounter patients when they are in acute pain or after they have recovered from the acute phase and should be knowledgeable about the signs, symptoms, potential complications and appropriate recommendations for management.
Case presentation:
A 52 year old male with acute right flank pain presented to the emergency department. A ureteric calculus with associated hydronephrosis was identified and he was prescribed pain medications and discharged to pass the stone naturally. One day later, he returned to the emergency department with severe pain and was referred to urology. He was managed with a temporary ureteric stent and antibiotics.
Conclusion:
This case describes a patient with acute right flank and lower quadrant pain which was diagnosed as an obstructing ureteric calculus. Acute management and preventive strategies in patients with visceral pathology such as renal calculi must be considered in patients with severe back and flank pain as it can progress to hydronephrosis and kidney failure.
PMCID: PMC3581005  PMID: 23483000
urolithiasis; back pain; groin pain; lithiase urinaire; douleur dorsale; douleur à l’aine
19.  Anterior cruciate ligament laxity related to the menstrual cycle: an updated systematic review of the literature 
Objectives:
The purpose of this study was to conduct a systematic review regarding the purported differences in anterior cruciate ligament (ACL) laxity throughout the course of the menstrual cycle.
Methods:
A systematic review was performed by searching electronic databases, along with hand-searching of journals and reference tracking for any study that assessed ACL integrity throughout the menstrual cycle from 1998 until 2011. Studies that met the pre-defined inclusion criteria were evaluated using the Modified Sackett Score (MSS) instrument that assessed their methodological quality.
Results:
Thirteen articles out of a possible 28 met the inclusion criteria.
Conclusions:
This systematic review found 13 clinical trials investigating the effect of the menstrual cycle on ACL laxity. There is evidence to support the hypothesis that the ACL changes throughout the menstrual cycle, with it becoming more lax during the pre-ovulatory (luteal) phase. Overall, these reviews found statistically significant differences for variation in ACL laxity and injury throughout the menstrual cycle, especially during the pre-ovulatory phase. Female athletes may need to take precautions in order to reduce the likelihood of ACL injury. However, the quality of the assessments was low and the evidence is still very limited. More and better quality research is needed in this area.
PMCID: PMC3581006  PMID: 23483028
ligament; laxity; menstrual; ligament; laxisme; menstruel
20.  Spontaneous resolution of symptoms associated with a facet synovial cyst in an adult female – a case report 
Background:
Facet cysts are implicated in neural compression in the lumbar spine. Surgery is the definitive treatment for symptomatic facet cysts since the failure rate for conservative treatment is quite high; however, the role of physical/manual medicine practitioners in the management of symptomatic facet cysts has not been well explored. This case report will add to the body of evidence of spontaneous resolution of symptoms associated with facet cysts in the chiropractic literature.
Case:
A 58 year old female presented with acute low back and right leg pain which she attributed to a series of exercise classes that involved frequent foot stomping. Physical examination did not elicit any objective evidence of radiculopathy but MRI and CT scans revealed a facet cyst impinging on the right L5 nerve root. Injections and surgery were recommended; however, the patient’s radicular symptoms completely resolved after three months without surgical intervention.
Summary:
There is currently a paucity of data in the literature regarding the chiropractor’s role in the management of symptomatic facet cysts. The case presented here has added to this literature and possible areas for future research have been explored.
PMCID: PMC3581007  PMID: 23483069
facet; cyst; lumbar spine; facette; kyste; rachis lombaire

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