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1.  Risk Management for Chiropractors and Osteopaths. Informed consent 
Obtaining the informed consent of a patient before undertaking chiropractic or osteopathic treatment is a common law requirement in Australia. This paper outlines the essential elements of informed consent and provides some practice tips on streamlining the process.
PMCID: PMC2051308  PMID: 17987206
Chiropractic; osteopathy; informed consent; risk management
This article is the second in a series of articles dealing with risk management in the practise of chiropractic and osteopathy, prepared by the COCA Risk Management Subcommittee.
Background: Radiographic examination carries risks that must be weighed against the possible benefits when determining patient care.
Objective: The objective of this article is to propose guidelines for the use of imaging in chiropractic and osteopathic practice.
Discussion: Plain film radiography, CT scan, magnetic resonance imaging (MRI) and other forms of imaging are available for use in chiropractic and osteopathic practice in Australia. The astute practitioner utilises these imaging procedures for clinical decision making in order to make an accurate diagnosis that will determine a patient’s management. This article attempts to guide the practitioner in the proper use of these imaging procedures for different regions of the body.
PMCID: PMC2051318  PMID: 17987210
Chiropractic; risk management; osteopathy
Although rare, vertebrobasilar stroke is the best known of the possible side effects of cervical manipulation. Due to the serious sequelae that may result from cervical manipulation, chiropractors and osteopaths must take the appropriate steps to ensure the risk is minimised. This article outlines how the astute practitioner can minimise this risk. Practitioners must decide on the options for treatment of a patient with neck problems. Practitioners must also advise the patient of these options as part of an appropriate informed consent.
PMCID: PMC2051301  PMID: 17987199
Chiropractic; stroke; manipulation
Background: The audible release or cracking sound associated with spinal manipulation is familiar to practitioners of spinal manipulative therapy. Furthermore, some authors believe the articular crack to be at least in part responsible for the therapeutic benefits derived from spinal manipulative therapy. Although some research has been directed towards the investigation of some aspects of this phenomenon, little research has be conducted in order to establish from which side and vertebral level the audible release occurs during the manipulative process.
Objective: To assess the reliability and accuracy of multiple surface mounted microphones to detect the audible release of the target joint during manipulation of the third metacarpophalangeal joint.
Design: Observational study.
Setting: Private practice of chiropractic, Ringwood, Victoria, Australia.
Participants: Twenty volunteers recruited from staff and patients of the private practice of chiropractic.
Method: Eight omnidirectional microphones were affixed to the palmar surface of the hand. Microphone No.1 was positioned directly over the third metacarpophalangeal joint while the remaining microphones were arranged in a uniform pattern over the palmar surface of the hand. Manipulation in the form of long axis traction was then applied to the third metacarpophalangeal joint. Where an audible release was associated with the manipulation the resultant signals were captured via computer and stored for later analysis.
Main Outcome Measure: A difference of greater than one volt in peak amplitude between the microphone positioned over the target joint and the other microphones. The student's t-test was then applied to the data in order to determine if the mean output of the target joint microphone was statistically different to the mean output of the other microphones.
Results: A total of eighteen manipulations resulted in nineteen audible release signals. The mean voltage of channel 1 was consistently greater than all the other channels in this group of subjects. This difference was statistically significant for all the channels.
Conclusion: This research suggests that multiple surface mounted microphones are capable of consistently detecting the audible release from the target joint, with manipulation directed to the third MCP joint. It is hoped that this method will be able to be applied to the audible release associated with spinal manipulative therapy and a better understanding of the manipulative process will ensue.
PMCID: PMC2051087  PMID: 17987189
Joint crack; cavitation; noise; sound; audible release; vibration; recording; manipulation; metacarpophalangeal joint; spine
Objective: To discuss a case of leptomenigeal disease mimicking a lower lumbar disc lesion and accompanying neurological deficit.
Clinical Features: A 62 year old male presented with a 3-4 day history of left low back and left posterior thigh pain. The patient had a previous history of non-specific low back pain for approximately 10-25 years, which was relieved in the past by manual therapy. He was also currently being treated by a medical oncologist with chemotherapy for low grade non-Hodgkin's lymphoma, which was considered stable.
Intervention and Outcome: After a favourable initial response to therapy, the patient developed a noticeable left-sided limp. Computed tomography scanning of the lumbar spine and pelvis was then performed, which revealed a mild posterior annular bulging of the intervertebral disc at the L4/5 level. The patient was then treated with axial lumbar spine traction but on review two days later had also developed a left sided facial droop, consistent with a Bell's palsy. A subsequent magnetic resonance imaging scan of the brain and lumbar spine revealed sites of abnormal enhancement of multiple cranial nerves, the cauda equina and the vertebral bodies L1 and L5. The findings were consistent with widespread leptomeningeal disease or leptomenigeal carcinomatosis and unfortunately the patient died as a direct consequence of the disease approximately three weeks after diagnosis.
Conclusion: Although relatively rare, leptomenigeal disease must considered as a differential diagnosis in a patient with a history of carcinoma who presents with low back pain and/or any neurological signs and symptoms.
PMCID: PMC2050809  PMID: 17987161
Non-Hodgkin's lymphoma; leptomeningeal disease/carcinomatosis; radiculopathy; lumbar disc herniation; chiropractic; spinal manipulative therapy
Objective: To review the available literature pertaining to the therapeutic benefits of the audible release associated with spinal manipulative therapy. A critical appraisal of the scientific literature, empirical evidence and theories relating to this aspect of manipulation is presented.
Data Source: A broad based search of the English language literature was conducted utilising the databases Medline (1966-1998), Mantis (Health Index) (1880-1998) and Cumulative Index to Nursing and Allied Health (CINAHL) (1982-1998), using the key words crack/ing, cavitation, audible release, gapping, sound/s, noise/s, vibration, biomechanics, coupled with joint, articular, manipulation, spinal manipulation and spinal manipulative therapy. A manual search was also conducted of non-indexed journals and text books relating to manual therapy of the library of RMIT University, Bundoora, Victoria as well as a broad based Internet search.
Results: There is a paucity of scientific research relating to this specific aspect of spinal manipulative therapy. Although there is ample empirical evidence to support some therapeutic benefit from the audible release, only one scientific study specifically relating to this topic was uncovered.
Conclusion: Currently there is little scientific evidence to support any therapeutic benefit derived from the audible release and in fact, it appears the available evidence tends to refute many of the alleged beneficial effects. Given that many practitioners and patients alike place an importance on this aspect of manipulation further research is required in order to fully investigate this phenomenon.
PMCID: PMC2050802  PMID: 17987158
Audible release; cavitation; joint crack; joint noise; joint sound; vibration; spinal manipulative therapy
Objective: To review the available literature pertaining to the recording and analysis of the joint crack/cavitation sound produced as a result of spinal manipulative therapy. A critical appraisal of the recording and analysis techniques is presented.
Data Source: A broad based search of the English language literature was conducted utilising the databases Medline (1966-1996) and Chirolars (1800-1996), using the key words cavitation, noise, sound, audible release, crack/s/ing, vibration, sound recording, acoustic recording and accelerometers, coupled with the terms facet joint, spinal joint and apophyseal joint and chiropractic, osteopathic and spinal manipulation. A manual search was also conducted of non-indexed journals and text books relating to manual therapy of the library at RMIT University, Bundoora, Victoria.
Results: There appears to be a paucity of this research relating to spinal manipulative therapy. Research to date has focused on recording the joint crack sounds via microphones or piezoelectric accelerometers both of which appear to have limited applications.
Conclusion: Some worthwhile information may be gained by conducting further research into the joint crack phenomenon, particularly with respect to spectral analysis. However, before this research is undertaken a more reliable and accurate means of capturing and processing the joint crack signal needs to be established.
PMCID: PMC2050620  PMID: 17987144
Joint crack; cavitation; noise; sound; audible release; vibration; recording; spinal manipulative therapy.
Objectives: This research was designed to analyse the frequency spectra of joint crack sounds produced during spinal manipulative therapy applied to the upper cervical spine of 50 volunteers and to determine if the spectra differed between the sexes and or for those with a history of previous neck trauma compared with those without a history of trauma.
Design: Randomised experimental study.
Setting: Macquarie University, Centre for Chiropractic, Summer Hill, New South Wales.
Subjects: Fifty asymptomatic subjects were recruited from the students and staff of the above college.
Intervention: Single, unilateral “diversified”, high velocity, low amplitude, rotatory thrust technique applied to the region of the C3/4 zygapophyseal joints.
Main Outcome Measures: Joint crack sound wave analysis of Digital Audio Tape (DAT) recordings, taken from two skin mounted microphones positioned on either side of the cervical spine and later analysed by the use of a computer equipped with professional quality frequency spectrum analysis software.
Results: All fifty manipulations resulted in at least one audible joint crack sound and in total the fifty subjects combined produced 123 individual joint cracks. Only 9 subjects (18%) produced a single joint crack, the majority of the subjects (82%) produced either two (22 subjects) or three (10 subjects) distinct joint crack signals, while seven subjects produced four and two subjects five separate joint crack signals. Frequency analysis was performed on a total of 122 individual wave forms. Peak frequencies for all analysed crack signals ranged from 1,830 Hz to 86 Hz with an mean of 333 Hz (95% C.I., 285-380 Hz), a mode of 215 Hz and a median of 215 Hz. Statistical analysis for recorded signals revealed 95% Confidence Interval for the mean of 285-380 Hz. No statistically significant differences were found for peak frequencies between the sexes or for a previous history of trauma and no trauma and for pre-manipulative and manipulative joint cracks.
PMCID: PMC2050616  PMID: 17987137
Chiropractic; zygapophyseal joints; cervical spine; joint crack; joint cavitation; manipulation; frequency analysis; spectra; sound recording.
This case report describes a relatively uncommon presentation of herpes zoster affecting the cutaneous distribution of the L2 spinal nerve. The coexistence of a previous history of leg pain, cortical thickening of the femoral shaft on plain film x-ray examination, and the absence, at the time of examination, of the tell tale rash of herpes zoster provided the clinician with a diagnostic challenge. Furthermore, this case stresses the importance of a thorough neurological and orthopaedic examination as well as careful visual inspection of the painful region.
PMCID: PMC2050615  PMID: 17987138
Herpes zoster; spinal nerves; chiropractic; spinal manipulative therapy.

Results 1-9 (9)