That makes it critical, both for patient safety, and our professions reputation to establish methods to detect a stroke patient before any manipulation is provided. In the past, orthopedic tests have been notoriously inaccurate (Drift Test, George’s, etc..) and thus many doctors do not even use them. To date, our best indicator was the patient’s presenting history.

But in addition to a proper history, a new serious of neurological bedside tests finally provide some solid clinical data. Dr. David Newman-Toker recently presented a short series of examinations that proved to be 100% sensitive and 96% specific. Of course further testing needs to be done, as this was a single center study of high risk patients, but regardless it is quite promising.

Newman’s tests included:

1. Strong Horizontal head impulse (a normal patient & a stroke patient’s eyes stays stable during the impulse, an inner ear complication would result in an ‘eye flick’).
2. Nystagmus (Lateral in the same direction as the patient is looking, occurs when the patient looks in either direction)
3. Downward alignment of the eyes when one is rapidly covered and uncovered.

As I research continues on this subject I will update this article.

View the demonstration here… http://www.medscape.com/viewarticle/710698 (you may be required to sign up to view it).

Is it really worth it?

Discography, a painful imaging technique for the spine that involves the injection of a contrast medium, has long been debated for its efficacy and utility(1,2,3). Even though it has been around since 1948, research to this day still fails to establish Discography as a effective test. It has been suggested that it is an accurate test for only a minute group of conditions, while it is unreliable for disk degeneration, disk bulges and protrusions, as it lacks specificity and leads to unnecessary back surgery (4). Regardless, this procedure is still sees widespread usage as doctors argue it is better than MRI or CT.

New research published in Spine, decided to take a different role, and examine the risks to benefits ratio of a discography. In their experimental animal model, it was shown that the rats that received small needle punctures exhibited a significantly higher rate of herniation, endplate changes, disc grade progression and annular fissures; both in frequency and severity. They also demonstrated a statistically significant decrease in disk height and signal after the injection (5).

Dr. Carragee et al.’s study brings up serious concerns with the usage of discography. Why countinue to utilize a technique that has been so poorly proven to provide usable & correct clinical data, and that also causes what you are attempting to locate and fix. It appears that this is a classic case of Risks far outweighing the benefits.

For a further information on Discography, and a slightly more pro-discography viewpoint, eMedicince provides a good overview.

Sources

1. Derby R, Howard MW, Grant JM, et al. The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes. Spine. Feb 15 1999;24(4):364-71; discussion 371-2

2. Parker LM, Murrell SE, Boden SD, Horton WC. The outcome of posterolateral fusion in highly selected patients with discogenic low back pain. Spine. Aug 15 1996;21(16):1909-16; discussion 1916-7.

3. Knox BD, Chapman TM. Anterior lumbar interbody fusion for discogram concordant pain. J Spinal Disord. Jun 1993;6(3):242-4.

4. Nachemson A. Lumbar discography–where are we today? Spine. Jun 1989;14(6):555-7

5. Eugene J. Carragee, MD; Angus S. Don, FRACS; Eric L. Hurwitz, DC, PhD; Jason M. Cuellar, MD, PhD; John Carrino, MD; Richard Herzog, MD

MRI

In October’s issue of Science a study showed a physiological response to a placebo topical analgesia. This article addresses the study design and findings, and concludes with its relation to chiropractic.

The study contained a population of 13 subjects, who were told that they were part of a trial to test the efficacy of a new pain killer cream. First patients were exposed to a painful heat source on their arm, and then researchers applied the ‘control cream’ (which was the same cream as the supposed pain-reducing cream). The patients’ pain ratings were then recorded. Next, researchers repeated the experiment but this time with the pain reducing cream, however, after administering the cream they lowered the temperature of the heat source without informing the patient. Therefore, the patients felt less pain with the pain-reducing cream.

In the second phase of the study, researchers performed functional MRIs at the C5-C6 junction on the patient while exposing the arm to a painful heat stimulus.  One part of the forearm was covered with the ‘control’ and the other with the ‘pain-reducing’ cream; each spot was exposed 25 times and at the same heat. The placebo effect took hold, and patients reported an average of 26% less pain in the analgesic arm.

Of course, proving the placebo effect is nothing new. What is amazing is that the fMRIs revealed that the ipsilateral dorsal horns lit up when the ‘control’ was exposed to the heat, but did not equally activate during the ‘pain-killer’ trials.

So what may this mean to our profession?

1. This study can be looked at in a reverse placebo manner. When a patient is at their doctor, and they are told to go to a DO, but they haven’t had relief in the past with DO’s (even if it was for a different condition), the patients ability to improve under a DO would be greatly decreased, as compared to a chiropractor administering the exact same treatment. The patient may be actively not allowing the natural placebo effect to apply.

2. This study supports the top-down effect gate-theory, and thus may lend some credence to upper cervical practioners. It is wholly possible that a subluxation, and its effects on the spinal cord, may disrupt the descending pain pathways. If the pathway’s function is altered, the brain may be unable to properly block the ascending pain signals. Of course, an adjustment at any level of the spine should affect this process for pain generated at or below the segment, but I mention upper cervicals because if there is a disrupting dysfunction at C0-C1, the whole system will be affected, all the way to your toes.

Now I know the suggestion above is not new to upper cervical practioners, but for the rest of us, it can help to see why a patient with fibromyalgia, psychosomatic pain, or other chronic pain syndromes may be benefited by a seemingly unrelated subluxation/dysfunction at the C/T junction for example, even in the absence of a mechanical dysfunction.

Of course, under that theory one would have to ask why the descending pathways are affected, and not the ascending pathways. I honestly do not know as the tracts are varying in many factors; although their locations may provide a slight clue as the descending pathway is somewhat more centrally located in the spinal cord. If the stress upon the spine is in rotary fashion, the central tissue would be subjected to a higher degree of stress. This theory would support both the classical ‘bone out of place’ model (bone shift to the left, applying a physical stressor), and the ‘restricted joint’ model (superior or inferior joints applying compensation stresses due to the restricted joint).

3. This shows the placebo effect is not just in the mind, its in the spine…

4. If we are smart, and can find the funding, this study may provide our profession a platform for demonstrating real physiological and neural effects from adjustments. Of course, it can also be used against us if the trials are poorly designed…

Direct Evidence for Spinal Cord Involvement in Placebo Analgesia

Science 16 October 2009:
Vol. 326. no. 5951, p. 404

http://www.sciencemag.org/cgi/content/abstract/326/5951/404