Journal of Chiropractic Medicine- Volume 9(1); March 2010

Journal of Chiropractic Medicine (2010) 9, 1–2

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Editorial

Thank you to the Journal of Chiropractic Medicine peer reviewers for 2009 We wish to recognize the dedicated and supportive editorial board members and peer reviewers who completed manuscript reviews for the Journal of Chiropractic Medicine in 2009. Peer reviewers for the year 2009 include: Charles L Blum, DC Linda J Bowers, DC Eduardo Bracher, DC, MD James W Brantingham, DC, PhD Dale Buchberger, PT, DC Jeanmarie Burke, PhD Jerrilyn Cambron, DC, PhD Mabel Chang, DC Kim D Christensen, DC Jeffrey Cooley, DC Robert Cooperstein, DC James Cox, DC Edward Cremata, DC Arthur C Croft, DC, MS, MPH Leanne Cupon, DC Martin Descarreaux, DC, PhD Andrew Dunn, DC, MEd, MS Jonathon T Egan, DC, MPH Roger Engel, DC, DO Marion W Evans, Jr, DC, PhD, CHES Robert Ferrari, MD Robert Francis, DC Arlan W Fuhr, DC David Paige Gilkey, DC, PhD Brian J Gleberzon, DC Michael T Haneline, DC, MPH John Hart, DC, MHS Cheryl Hawk, DC, PhD Kathryn T Hoiriis, DC Warren Jahn, DC, MPS

Norman W Kettner, DC J Todd Knudsen, DC Charmaine Korporaal, MTChiro Reiner G Kremer, DC, ND, MPH Ron LeFebvre, MA, DC James J Lehman, MBA, DC Kat Linaker, DC Anthony J Lisi, DC Jan Martensen, DC, PhD Marc McRae, DC Christopher A Meseke, PhD Michael A Mestan, DC William Moreau, DC Mark Morningstar, DC Craig Morris, DC Donald R Murphy, DC Robert Nelson, DC Reed Phillips, DC, PhD Julie Plezbert, DC Alisa van Poecke, DC Katherine Pohlman, DC Kevin A Rose, DC, MPH Anthony L Rosner, PhD Drew Rubin, DC Brent Russell, DC Michael J Schneider, DC Clayton D Skaggs, DC Monica Smith, DC, PhD Gregory Snow, DC Richard Gerald Strunk, DC, MS

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2

Editorial Kent Stuber, DC, MSc John Taylor, DC Rodger Tepe, PhD David Ward, DC Christopher Watkins, DC Keith Wells, DC

Wayne M Whalen, DC Barry Wiese, DC, MS Jonathan C Williams, MAEd, DC Steven G Yeomans, DC Ken Young, DC John Zhang, MD, PhD

We appreciate the valuable contributions of all peer reviewers who contributed their time and expertise this past year for their important role in enhancing the quality and scientific integrity of research papers published in the Journal of Chiropractic Medicine. We apologize in advance if anyone provided peer review to the JCM in the year 2009 and was not acknowledged in this list. If this has occurred, please contact the journal editor and a correction will be printed with the next listing. Claire Johnson DC, MSEd Editor—Journal of Chiropractic Medicine, Lombard, IL Professor, National University of Health Sciences, Lombard, IL E-mail address: [email protected]

Journal of Chiropractic Medicine (2010) 9, 3–10

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Original articles

Intraexaminer comparison of applied kinesiology manual muscle testing of varying durations: a pilot study Katharine M. Conable DC⁎

Associate Professor, Chiropractic Division, Logan College of Chiropractic, St Louis, MO 63132 Received 3 July 2009; received in revised form 22 September 2009; accepted 5 October 2009 Key indexing terms: Kinesiology, Applied; Muscle strength; Muscle strength dynamometer

Abstract Objective: The purpose of this study is to investigate the difference in results (strong/facilitated vs weak/functionally inhibited) between short (1 second) and long (3 seconds) manual muscle tests (MMTs) on the same subject and to pilot the use of thin-film force transducers for characterizing the parameters of MMT and for measuring maximum voluntary isometric contraction (MVIC). Method: Forty-four healthy chiropractic students were tested. A thin-film force transducer recorded force over time during MVIC of the middle deltoid and 1- and 3-second MMTs of the same subjects. The MMTs were graded as strong (able to resist the testing pressure) or weak (unable to resist testing pressure, breaking away). Results: Forty-two short tests were strong, and 2 were weak. Thirty-nine long tests were strong, and 5 were weak. κ (0.54) showed fair agreement for results between short and long tests. Peak force in both short and long weak tests was higher than that in strong tests when expressed as a proportion of maximum contraction. All manual tests used less force than MVICs. Conclusions: This study demonstrated that a study of this nature is feasible. Longer test durations demonstrate some muscle weaknesses that are not evident on 1-second MMTs. Thin-film transducers show promise for recording MMT parameters for research purposes. © 2010 National University of Health Sciences.

Introduction Applied kinesiologists test muscles before and after challenges and treatments, and may make clinical judgments based on immediate changes in muscle tests.1 Muscles are tested according to similar methods described by Kendall et al2 from a contracted position ⁎ Corresponding author. Chiropractic Division, Logan College of Chiropractic, 608 No. McKnight Rd, St Louis, MO 63132. Tel.: +1 314 991 5655; fax: +1 314 991 4872. E-mail address: [email protected].

with pressure toward lengthening. If the subject can maintain the position against gradually increasing pressure, it is graded as “facilitated” or “strong” (grade 5). If the muscle weakens during the procedure, the muscle is rated as “inhibited” or “weak” (grade 4 or less). Applied kinesiology (AK) authors suggest that manual muscle testing (MMT) measures a complex proprioceptive response to changing pressure, rather than strength of the muscle itself.1,3 The range of parameters that yield similar results on this binary evaluation is not currently known. This information is important in training accurate muscle testers and in evaluating the reliability and

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2009.12.005

4 validity of other AK procedures based on muscle responses to various stimuli and challenges. The physiotherapy literature distinguishes between “make” or “active strength” and “break” or “passive strength” testing both in MMT and in handheld dynamometry. In both styles, the muscle is tested relatively isometrically, either near its most shortened position or in the middle of its range of motion. In break testing, there is also eccentric lengthening as the muscle breaks away. Both differ from isokinetic testing, such as the Cybex, 4 which tests the muscle through an entire range of motion at a constant speed. Active or “make” tests are similar to maximum isometric voluntary contraction tests—the subject presses against a fixed dynamometer, a strap with a force transducer is used, or the examiner acts as a fixed point.4,5 Given intact neurologic control, the subject's own initiative and muscle size determine the maximum force generated. In contrast, in break tests, the subject resists the examiner's increasing pressure until the muscle breaks away. This requires more complex proprioception than simply pressing against a fixed resistance. The subject must continually adjust muscular output to match the examiner's pressure. Breaking strength testing is frequently cited as yielding higher peak force measurements than make tests. If the breaking force of a muscle is to be measured with a dynamometer on each test, the examiner must be stronger than the subject.5 The key distinction between “make” and “break” in the physiotherapy literature is whether the resistance the tested muscle contracts against is constant at a fixed location or gradually increasing and mobile. This distinction might be purely academic except for the likelihood that the 2 styles to some degree monitor different aspects of neuromuscular control. Comparison of the results of measures of muscle force under various conditions is complicated by the wide range in size and fitness between subjects. Therefore, it is useful to normalize results of dynamometry by comparison to maximum contraction for each subject.6 This has not been done in previous AK studies. Maximum voluntary isometric contraction (MVIC) is tested, by definition, as a “make” or “active” contraction test. The subject pushes against a relatively stationary force-recording device that offers stable resistance. Methods for measuring MVIC are described in many studies. Some use strain gauges, and others have the subject press directly against some form of force transducer. 7-10 In a study of normative values for MVIC in healthy subjects, Meldrum et al 11 describe the method for measuring MVIC. They summarize references compar-

K. M. Conable ing MVIC and MMT, concluding that, generally, MVIC shows better sensitivity than does MMT for small changes in quantitative muscle strength in the context of monitoring patients with neuromuscular disease. Manual muscle test grading on a 5-point numerical scale does not allow for the fine objective gradations that can be done when measuring units of force. A muscle may fall within one grade at a range of forces, so small interval changes may be missed. These concerns are important for evaluation of progress or deterioration in a patient in rehabilitation or with neuromuscular pathology. Maximum voluntary isometric contraction testing is appropriate to test the size of the muscle itself or the changes in muscle in neurologic disease or recovery. It is equipment intensive and not easily adapted to clinical practice or to measuring rapid changes in muscle function over the short term. On especially strong muscles and for weaker testers, it is possible that clinicians may miss small short-term changes in strength with AK MMT as well. Schmitt 12 observed that subtle differences in timing seemed to yield different results in AK MMT. He described a “doctor-initiated” test in which the subject is asked to resist the doctor's gradually increasing force. “Patient-initiated” testing begins in the same position, but the patient is asked to push against the examiner's hand as hard as possible. This test style usually includes verbal encouragement to continue to push. In both tests, the examiner attempts to break the patient's contraction, the difference being timing. Schmitt postulated that the timing differences accessed different neurologic pathways. This model is similar but not identical to the make/break contrast. Conable et al 13 were unable to demonstrate a consistent difference in whether the patient's or the examiner's muscle contraction began first when 41 experienced AK testers attempted to perform both patient-started and doctor-started muscle tests of the middle deltoid. This study found that the mean duration of AK muscle testing was 1.3 seconds (range, .325-3.5 seconds). There was a suggestion of a bimodal distribution of durations above and below about 1.5 seconds as examiners attempted to execute different styles of muscle tests. This led to the question of whether the difference Schmitt observed was a matter of duration rather than whose contraction began first. This is important in that at least one study that purports to compare reliability of these 2 styles of muscle testing did not report duration. Hsieh and Phillips14 did a reliability study with a computerized dynamometer comparing doctor-initiated and patient-initiated testing of 3 muscles by 3 testers over 2 sessions on 2 separate

Duration variations in muscle testing groups of 15 subjects. The authors concluded that patient-initiated testing was more reliable than doctorinitiated testing with this instrument. However, when the details of this study are examined, problems with this conclusion are revealed. Only peak force was recorded, rather than a continuous recording of force over time, making it impossible to determine the actual timing of each method. Because the examiners were free to stop the “doctor-initiated” test whenever they were satisfied that the muscle had “locked” or “broken away,” it is unsurprising that these tests demonstrated quite a wide variation in peak force. The “patient-initiated” tests required the examiner to maintain pressure until an apparent maximum was achieved. It seems likely that this point would be more similar tester to tester and test to test. Subjects were tested by one or the other style of testing, not both, making comparison between styles problematic. This illustrates the need to better define the parameters of muscle tests used in AK research. Manual muscle testing in AK clinical practice uses direct hand contact with the subject. The interposition of an instrument for research alters the quality of the muscle test and the delicacy of the examiner's perception. The present study piloted the use of a thin-film force transducer to record MMT. Similar sensors have been used in research on prosthetics, ergonomics, and physical medicine. 15,16 This study compared results (strong/weak) between short (1 second) and long (3 seconds) MMTs of the same subject. The null hypothesis was good agreement between long- and short-duration muscle tests, in other words, that the duration of the test would not influence the outcome. The research hypothesis is that the 2 conditions are at least partially independent of each other and so would demonstrate a low κ. Secondarily, this study compared peak force of the MVIC tests between strong and weak tests and peak force of MMTs between strong and weak tests in absolute terms and as a percentage of estimated maximum voluntary contraction to further define the objective differences between the states applied kinesiologists refer to as “strong” and “weak.”

Methods The author, an applied kinesiologist with more than 30 years in the practice and teaching of AK, examined 44 chiropractic students (23 men, 21 women) with a mean age of 26 years (range, 20-54). Subjects were screened for major injuries or physical conditions preventing

5 testing the middle deltoid. No volunteers were excluded. Informed consent was obtained before testing. The study was approved by the Institutional Review Board of Logan College of Chiropractic and the Human Research Ethics Committee of Royal Melbourne Institute of Technology (RMIT) University, Bundoora, Australia. A 3/8-in–diameter Tekscan (Tekscan, South Boston, MA) Flexiforce 1-lb sensor was connected to a BioPac MP150 (BioPac Systems, Inc, Goleta, CA) modular physiology recording system with a DA100B amplifier (BioPac Systems, Inc) via a custom interface manufactured by BioPac Systems, Inc. The amplifier was set to load the sensor with .2 V, allowing the reading of a wide range of forces. The sensor was calibrated using a 5-lb weight and the BioPac system's calibration function. The sensor was attached to the subject's arm approximately 2 in proximal to the elbow over the humerus (Figs 1 and 2 ). All subjects were tested in 3 ways, including MVIC against a strap, MMT for 1 second, and MMT for 3 seconds. All subjects performed the MVIC contractions and then were manually tested. Subjects were assigned randomly by toss of a die to have the long manual test or the short manual test first. Die toss was done in advance for each subject number. Subject numbers where the toss was even had the short test first. Where the toss was odd, the long test was first. Estimation of MVIC The seated subject's arm was held at 90° abduction with the elbow at 90° of flexion and forearm parallel to the floor. A strap attached to the subject's chair was adjusted to allow the subject to abduct the shoulder to 90° (Fig 3). Neither subject nor examiner could see the computer tracing during tests. The subject was asked to push up against the strap as hard as possible until told to stop (5-10 seconds). Verbal encouragement was given throughout. The subject rested for 10 seconds, and the MVIC was repeated. The greatest force recorded was used as an estimate of the MVIC. Manual muscle tests After a 10-second rest, the examiner manually tested the middle deltoid (Fig 4). Short (1 second) and long (3 seconds) conditions were each tested 3 times in a row. Half the subjects had the short manual test first and half had the long manual test first according to randomization of subject numbers. Tests

6

K. M. Conable were timed visually with the clock positioned so the subject could not see it. A 5-second rest was given between tests. The examiner recorded the result (strong/facilitated or weak/inhibited). No warm-up was used to approximate the manner in which MMT is done in clinical practice. The .44-in 2 sensor covered only a fraction of the area of contact between the examiner's hand and the subject's arm (approximately 1 in 2 ) and the area of contact of the strap during MVIC, (2-3 in 2 ). No precise comparison of these measures is possible. Relative areas covered were similar for different subjects, enabling relative comparisons. The following parameters were recorded: estimate of MVIC (pound), result of the MMT (strong/facilitated vs weak/inhibited), duration of manual test, peak force of manual test (pound), and peak force as a percentage of MVIC. Data tracings were marked using AcqKnowledge software (BioPac Systems, Inc) supplied with the BioPac system. Results were analyzed with Statview 5.0 (SAS Institute Inc, Cary, NC).

Fig 1.

Fig 2.

Sensor placement.

Sensor and strap for measurement of MVIC.

Fig 3.

Measurement of MVIC.

Duration variations in muscle testing

7 long tests were strong, and 5 were weak. The 5 weak long tests demonstrated significantly higher peak force than the 39 strong ones in both absolute terms and relative to MVIC. In other words, weak tests engaged a higher proportion of available force than strong tests at both durations (Table 4). One might expect that muscles that test weak manually would also test weaker on MVIC than those that test strong manually. Although subjects with weak tests in both the long and short conditions had lower mean force on MVICs, by 7 and 12 pounds, respectively, than those who tested strong, this difference was not statistically significant. Because there were so few weak tests, it is unlikely that there was adequate power to show a difference not due to chance and variation in subject body size. Difference in MMT result—short vs long tests

Fig 4.

Manual muscle test.

Results

Both subjects who were weak on short tests were also weak in the long tests. Three subjects were weak on all 3 repeats of the long test, but strong on the short tests. Two other subjects had a single weak test in the long condition, both with the short condition strong. The κ statistic for agreement of results between the short and long conditions was .54, indicating only fair agreement between the 2 conditions. The null hypothesis was good agreement or better (κ ≥.61) 17 if the length of the muscle test did not affect the outcome. The null hypothesis is rejected—duration of MMTs does appear to matter.

Force results represent a fraction of the total force exerted by the patient, as the sensor only registered a part of the contact area of the strap for MVIC and a part of the examiner's hand contact for muscle testing. As seen in Table 1, maximum contraction tests averaged 7.16 seconds. Short tests averaged 1.09 seconds. The intended duration for the long condition was 3 seconds; however, long tests averaged only 2.34 seconds. Long tests averaged significantly higher peak force than short tests in absolute terms and as a proportion of MVIC (Tables 2 and 3).

Discussion

Strong vs weak tests

Some muscles that can hold an isometric contraction in an MMT for a short time cannot maintain the

Weak and strong tests were of similar durations in both the long and short conditions. Forty-two short tests were strong, and 2 were weak. Although peak force in strong and weak short tests appeared similar in terms of pounds, weak short tests used a higher proportion of MVIC than strong short tests. Thirty-nine Table 1

Durations of tests Mean SD

Duration MVIC 7.156 Duration Short MMT 1.092 Duration Long MMT 2.337

Minimum Maximum

.944 5.530 .242 .713 .489 1.710

10.310 1.927 3.640

Short MMT, short manual test (1 second); Long MMT, long manual test (3 seconds).

Table 2

Peak forces in pounds Mean SD

Peak Force Peak Force MMT Peak Force MMT Peak Force MVIC Peak Force MVIC

MVIC Short

Minimum Maximum

29.319 11.276 9.760 2.233 1.451 .610

49.885 7.210

Long

3.037

1.658

.937

8.240

Short/

.085

.057

.021

.240

Long/

.117

.074

.024

.362

Short/MVIC, Peak force of short manual test divided by peak force of MVIC; Long/MVIC, peak force of long manual test divided by peak force of MVIC.

8 Table 3

K. M. Conable Paired t tests for force and duration differences in short vs long MMTs

Comparison

Mean Difference

DF

t Value

P Value

Mean Duration Short − Long MMT Mean Force Short − Long MMT Normalized Force Difference: Short MMT/MVIC − Long MMT/MVIC

−1.245 −.804 −.032

43 43 43

−17.875 −.4023 −4.276

b.0001 .0002 .0001

Force in pounds, duration in seconds. Short tests, approximately 1 second; long tests, approximately 3 seconds. MVIC, Peak force during MVIC.

contraction for the 2.5 to 3 seconds of a longer test. Short and long MMTs sometimes yield different results. Because many AK examiners use tests of 1 second or less in practice, 18 muscle weaknesses that develop later may be missed. It is possible that the differences observed by Schmitt 12 between “patient-started” and “examinerstarted” tests may well be differences in duration of tests. Schmitt states that if an “examiner-started” test is weak, then a “patient-started” test of that muscle will be weak, but not vice versa. We observed that if a short test was weak, the long test would be weak, but not vice versa. This is consistent with the theory that “examinerstarted” tests are generally shorter tests and “patientstarted” tests are longer tests. Different durations of testing may measure different aspects of neuromuscular function—the initial rapid response to external pressure and the ability to sustain a contraction against increasing pressure. Vasilyeva

Table 4 Unpaired t tests for differences in force between facilitated (strong) and inhibited (weak) MMTs Mean DF t P Difference Value Value 1-s Tests Mean Force Short MMT −.755 Strong vs Weak Mean Force of MVIC 12.390 Strong vs Weak on Short Tests Mean Force Short MMT/ −.103 MVIC Strong vs Weak 3-s Tests Mean Force Long MMT −2.131 Strong vs Weak 7.059 Mean Force of MVIC Strong vs Weak on Long Tests Mean Force Long MMT/ −.116 MVIC Strong vs Weak

42

−.714 .4789

42

1.542 .1305

42

−2.646 .0114

42

−2.936 .0054

42

1.330 .1908

42

−3.772 .0005

Force in pounds. Short MMT/MVIC, Peak force of short manual test divided by peak force of MVIC; Long MMT/MVIC, peak force of long manual test divided by peak force of MVIC.

et al 19 describe 2 stages of muscle contraction. In phasic contraction, the length of the muscle changes concentrically or eccentrically; but its tonus remains the same. The balance between agonists and antagonists determines the length of the muscle. This is the initial type of contraction in voluntary movement, regulated by the cerebral cortex. Tonic contraction involves no change in length of the muscle (isometric) but a change in tone. Vasilyeva et al cite NA Bernstein's 1929 and 1947 work stating that these 2 phases are also seen in an isometric contraction. The initial contraction is phasic/voluntary. Tonic contraction appears after 3 seconds of an isometric contraction, fatigues slowly, and is involuntary. It is regulated at the striatopallidar level. A large-amplitude pallidar tremor can be seen to develop in the second 3 seconds after passive stretch in a dysfunctional muscle with a hypoactive stretch reflex. Vasilyeva18 et al19 demonstrated differences between normal and dysfunctional muscles by testing in two or three 3-second increments with force and surface electromyographic (EMG) recordings. The EMG findings paralleled the perception of the manual muscle tester. In normal muscles, after 3 seconds of an isometric contraction, if the subject is asked to push harder, an increase in force output is seen. In dysfunctional muscles, there is either no rise or a decline. They also found that, in normal muscles, after rapid stretching, the force of the muscle contraction increased, but in a dysfunctional muscle, force decreased after stretching, indicating abnormal proprioception. Muscles that break away exhibit higher peak forces during MMT than muscles that can hold. This may reflect a tendency of the examiner to allow the force to plateau when it is apparent that the muscle is holding, or it may reflect a recruitment of more fibers in a dysfunctional muscle to try to avoid failure. This is consistent with the observations of Nicholas et al 20 that break tests generate higher peak forces than make tests and that the peak force occurs after the breaking point. It is consistent with the observations of Leisman et al21 that muscles that test weak exhibit higher EMG

Duration variations in muscle testing output and less efficient contractions than muscles that test strong. Leisman et al compared AK MMT results to force/ integrated EMG data showing effects of fatigue and task repetition. 21 Several muscles for each subject were manually tested and rated as “strong” or “weak.” Electrophysiologic testing was then conducted by examiners blind to the previous MMT results. Maximum voluntary contraction (MVC) was determined by having the subject contract each muscle as hard as possible for 3 seconds against a force transducer. Subjects then did a series of short (5 seconds) and long (as long as possible) isometric contractions at a series of increasing percentages of MVC while EMG data were recorded. Even at 75% of MVC, “weak” muscles did not give out until 20 seconds, much longer than the MMT in their study (maximum of 2.5 seconds) or in any other studies reporting AK muscle tests. 18,19 The EMG findings for “weak” muscles differed from the effects of fatigue and from ”strong” muscles. In the present study, each subject was able to maintain the MVIC contraction against the fixed strap at higher forces and for a longer time than any of the manual tests. The breaking away that occurs in AK MMT at the durations commonly used (1-3.5 seconds) is unlikely to be due to fatigue. Applied kinesiology MMT does not involve the full force that a muscle can generate, even when the muscle tests “weak.” This may seem paradoxical, but supports applied kinesiologists' contention that MMT tests the ability of the neuromuscular system to adapt to changing pressure, not the total or peak force the muscle can produce. The thin-film force sensor was very comfortable to use and did not interfere with testing. It is flexible and would allow testing in many positions for a variety of muscles, especially if attached to the tester's hand rather than to the subject's limb. It will also allow accurate measurement of forces for controlled studies of a variety of AK challenge procedures in a manner approximating what is actually done in a clinical setting without the interposition of a bulky dynamometer. Limitations Testing done by a single examiner may not be representative of other AK muscle testers. The small group of subjects and use of one examiner demonstrated feasibility that this study can be done on a larger scale. Another weakness of this study is the use of healthy subjects. Future studies should be designed to

9 increase the yield of dysfunctional muscles by testing symptomatic subjects or more muscles per subject. Although the long manual tests were intended to be 3 seconds, the range actually achieved was 1.7 to 3.6 seconds, averaging 2.3 seconds. This appeared to be due to mistakes in visual timing of the long tests by the examiner. Long tests were clearly longer than the “short” tests, but not consistently as long as the 3second mark that Vasilyeva cites as distinguishing different phases of neuromuscular control. Future studies in which duration is a variable should consider an audible or other standardized time signal to ensure that long tests are sustained for the full time intended. The small sensor captured only a fraction of the force used and could not show any changes in hand contact by the examiner. In future studies, a fullhand array of sensors would better capture the full force used in testing and could document any variations in tester contact during repeated testing. In addition, during MVIC testing, if the strap shifted, the sensor could slip off the most solid contact over bone. Although the examiner watched for this, it may have occurred, reducing the relative percentage of force captured on some tests. Another weakness of this study is that the subjects were chiropractic students, so they may have been biased or unintentionally performed differently than laypeople or patients. Future studies including MVIC should include better stabilization of the subjects. Despite cautions by the examiner, some of the subjects in this study leaned away from the strap during the MVIC test, potentially increasing the recorded force beyond what was being generated by the deltoid muscle. This may have obscured differences between strong and weak muscles on MVIC. Strapping the subject to a chair or table is described in norming studies of MVIC 7-10 and should be considered.

Conclusion Applied kinesiology muscle testing uses submaximal forces and measures neuromuscular response to gradually increasing pressure, rather than total force that the muscle is capable of generating. Longer tests may demonstrate weakness that is not evident when the muscle is tested for 1 second. Duration of tests should be controlled for and specified in future AK research, particularly when testing before and after diagnostic or therapeutic interventions and challenges. Thin-film Flexiforce force sensors show promise to record AK

10 muscle testing and other manual techniques under conditions similar to clinical practice.

Acknowledgment This project was part of a master's degree program through RMIT University in Australia. The author thanks her RMIT advisor, Dr Max Walsh, and Logan College of Chiropractic Research Division for the use of their space, equipment, and work-study students during data collection. The author also thanks Dr Quinggen Zhang for his help and advice in developing the instrumentation.

Funding sources and potential conflicts of interest No outside funding was received for this project. The costs for sensors and the custom interface were paid personally by the author. The author teaches applied kinesiology at Logan College of Chiropractic, is a Certified Teaching Diplomate of the International College of Applied Kinesiology, and serves on the International Board of Standards and the International Board of Examiners of the International College of Applied Kinesiology.

References 1. Walther D.S. Applied kinesiology synopsis. 2nd ed. Pueblo, CO: Systems DC; 2000. pp. 37,71,2. 2. Kendall FP, Kendall McCreary E, Provance PG. Muscles— testing and function. 4th ed. Baltimore: Williams and Wilkins; 1993. p. 179-90. 3. Blaich RM, Mendenhall EI. Manual muscle testing and Cybex machine muscle testing, a search for a correlation. 1984 Selected papers of the International College of Applied Kinesiology; 1984. 4. Rarick L, Gross K, Mohns M. Comparison of two methods of measuring strength of selected muscle groups in children. Res Q 1955;26:76-9. 5. Wilkhom JB, Bohannon RW. Hand-held dynamometer measurements: tester strength makes a difference. J Orthop Sports Phys Ther 1991;13(4):191-7. 6. Laprade J, Culham E, Brouwer B. Comparison of five isometric exercises in the recruitment of the vastus medialis oblique in persons with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther 1998;27:197-204. 7. National Isometric Muscle Strength Database Consortium. Muscular weakness assessment: use of normal isometric strength data. Arch Phys Med Rehabil 1996;77:1251-5.

K. M. Conable 8. Colombo R, Mazzini L, Mora G, Parenzan R, Creola G, Pirali I, et al. Measurement of isometric muscle strength: a reproducibility study of maximal voluntary contraction in normal subjects and amyotrophic lateral sclerosis patients. Med Eng Phys 2000;22(3):167-74. 9. Great Lakes ALS Study Group. A comparison of muscle strength testing techniques in amyotrophic lateral sclerosis. Neurology 2003;61(11):1503-7. 10. Stoll T, Huber E, Seifert B, Michel BA, Stucki G. Maximal isometric strength: normative values and gender-specific relation to age. Clin Rheumatol 2000;19(2):105-13. 11. Meldrum D, Cahalane E, Conroy R, Fitzgerald D, Hardiman O. Maximum voluntary isometric contraction: reference values and clinical application. Amyotroph Lateral Scler 2007;8:47-55. 12. Schmitt WH. Muscle testing as functional neurology: differentiating functional upper motor-neuron and functional lower motor-neuron problems. Selected papers of the International College of Applied Kinesiology: Shawnee Mission, KS:ICAK; 1986. p. 21-32. 13. Conable K, Corneal J, Hambrick T, Marquina N, Zhang Q. Electromyogram and force patterns in variably timed manual muscle testing of the middle deltoid muscle. J Manipulative Physiol Ther 2006;29(4):305-14. 14. Hsieh C, Phillips R. Reliability of manual muscle testing with a computerized dynamometer. J Manipulative Physiol Ther 1990;13:72-82. 15. Smit E, Conradie M, Wessels J, Witbooi I, Otto R. Measurement of the magnitude of force applied by students when learning a mobilization technique. SA J Physiother 2003;59(4):3-8. 16. Conradie M, Smit E, Louw M, Prinsloo M, Loubser L, Wilsdorf A. Do experienced physiotherapists apply equal magnitude of force during a grade I central PA on the cervical spine? SA J Physiother 2004;60(4):18-25. 17. Dawson B, Trapp R. Basic and clinical biostatistics. 4th ed. New York: Lang Medical Books/McGraw-Hill; 2004. p. 119. 18. Vasilyeva LF. Clinical and experimental substantiation of the functional muscle weakness phenomenon. Proceedings of the International College of Applied Kinesiology Annual Meeting [CD-ROM], 2004. Rome, Italy [CD-ROM]-Shawnee Mission, KS:ICAK; 2004. 19. Vasilyeva LF, Chernysheva TN, Korenbaum VI, Aukhtina TO. About peculiarities of the effect of muscle functional weakness. Proceedings of the Annual Meeting of the International College of Applied Kinesiology-USA, Volume 1, 2001-2002. Kansas City: International College of Applied Kinesiology; 2001. p. 63-6. 20. Nicholas J, Sapega B, Kraus H, Webb J. Factors influencing manual muscle tests in physical therapy. J Bone Joint Surg 1978;60-A(2):186-90. 21. Leisman G, Zenhausern R, Ferentz A, Tefera T, Zemcov A. Electromyographic effects of fatigue and task repetition on the validity of estimates of strong and weak muscles in applied kinesiological muscle-testing procedures. Percept Mot Skills 1995;80:963-77.

Journal of Chiropractic Medicine (2010) 9, 11–16

www.journalchiromed.com

Abdominal and back pain in a 65-year-old patient with metastatic prostate cancer Theodore L. Johnson Jr DC⁎

Assistant Dean for Chiropractic Medicine, National University of Health Sciences, Lombard, IL 60148 Received 20 July 2009; received in revised form 22 September 2009; accepted 5 October 2009 Key indexing terms: Chiropractic; Low back pain; Neoplasm metastasis; Prostate-specific antigen; Digital rectal examination; Prostate

Abstract Objective: Prostate cancer remains the second leading cause of cancer-related deaths, and African American men are affected with this disease disproportionately in terms of incidence and mortality. The purpose of this article is to present a case report that illustrates the importance of a careful evaluation, including a comprehensive historical review and appropriate physical and laboratory assessment, of a patient with back pain and seemingly unrelated symptoms. Clinical Features: A 65-year-old African American man presented to a chiropractic clinic after experiencing lower back pain for 1 month. The digital rectal examination was unremarkable, but the serum prostate-specific antigen was markedly elevated. A suspicion of metastatic prostate cancer resulted in subsequent referral, further diagnostic evaluation, and palliation. Intervention and Outcome: The patient was referred for medical evaluation and palliation of his condition. Spinal decompression surgery of the thoracic spine was initiated, resulting in weakness and paresthesia in the lower limbs bilaterally. The patient died because of the complications associated with the medical interventions and the disease about 12 months after the referral. Conclusion: Chiropractic physicians should maintain a high degree of suspicion for catastrophic causes of back-related complaints, such as metastatic prostate cancer. The Prostate Cancer Prevention Trial Risk Calculator, a research validated instrument, should be used in the assessment of prostate cancer risk. Performance of the digital rectal examination and of the prostate-specific antigen determination remains integral in the clinical assessment of the health status in aging men, with or without back pain. © 2010 National University of Health Sciences.

⁎ Assistant Dean for Chiropractic Medicine, National University of Health Sciences, 200 East Roosevelt Rd, Lombard, IL 60148. Tel.: +1 630 889 6559; fax: +1 630 889 6559. E-mail address: [email protected]. 1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2009.12.004

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Introduction Prostate cancer is the most frequently diagnosed cancer in men. It is the second-leading cause of cancer death in men, second only to lung cancer. An estimated 192 280 new cases of prostate cancer will occur in the United States during 2009 along with an estimated 27 360 deaths.1 The incidence rates are significantly higher in African Americans compared with other ethnic groups. In addition, death rates in African American men remain more than twice as high as that in whites. 1 Prostate cancer is largely a disease of the elderly. Between 2001 and 2005, the median age at diagnosis for white men was 68 years; and the median age at death was 80 years. The median age at diagnosis for African American men was 65 years, and the median age at death was 77 years. The number of both African American and white men diagnosed before the age of 50 years is small; approximately 2.5% of white men diagnosed with prostate cancer are younger than 50 years, whereas approximately 5.2% of African American men are younger than 50 years at the time of diagnosis. 2 Routine screening for the detection of prostate cancer remains controversial. The primary screening procedures for detecting prostate cancer are the prostate-specific antigen (PSA) blood test and the digital rectal examination (DRE). The American College of Preventive Medicine and the United States Preventive Services Task Force conclude that there is insufficient evidence to support the recommendation for routine screening for the detection of prostate cancer. 3,4 In addition, the United States Preventive Services Task Force recommends that screening for prostate cancer not be performed in men 75 years or older. 4 The American Cancer Society recommends that health care providers discuss the potential benefits and limitations of prostate cancer early detection testing with men and offer the PSA blood test and the DRE annually, beginning at age 50 years, to men who are at average risk of prostate cancer and who have a life expectancy of at least 10 years. Those men who indicate a preference for testing after this discussion should be tested. Men at high risk of developing prostate cancer (African Americans or men with a close relative diagnosed with prostate cancer before age 65 years) should have this discussion with their provider beginning at age 45 years. Men at even higher risk (because they have several close relatives diagnosed with prostate cancer at an early age) should have this discussion with their provider at age 40 years. 1,5

T. L. Johnson Jr As primary care practitioners, chiropractic physicians routinely evaluate and therapeutically manage patients with complaints of back pain and associated symptoms. The initial evaluation of such patients requires a patient-centered, systematic, and comprehensive review of historical data. Taking his or her cue from information gathered through the historical interview process, the physician tailors the physical examination accordingly. Laboratory testing and/or special diagnostic imaging procedures are included in the examination process, as warranted. Individual state licensure or jurisdictional restrictions pertaining to the chiropractic profession will dictate the level and types of services a chiropractic physician can provide, but the responsibility to appropriately manage patients' healthrelated matters can never be waived. The purpose of this article is to present a case report that illustrates the importance of a careful evaluation, including a comprehensive historical review and appropriate physical and laboratory assessment, of a patient with back pain and seemingly unrelated symptoms.

Case report A 65-year-old African American man presented to a chiropractic clinic having experienced low back pain for approximately 1 month. The patient attributed the onset of this complaint to “working out” at the gym. However, he could not point out a specific exercise maneuver that initiated the pain. He described the pain in his lower back as a “dull ache” that was constant and relieved by sitting or lying recumbent. He denied being awakened by the pain during the night. No positions or activities increased the intensity or altered the character of the lower back pain. The patient had not sought care from any other provider, nor had he been taking any medications for pain relief for this condition. In addition to the lower back pain, the patient also complained of being “constipated.” He stated that he had not had a bowel movement in the past 5 days before the initial office visit. He admitted to experiencing constant abdominal discomfort and an associated discomfort located posteriorly in the region between the shoulder blades. He attributed these symptoms to a “build up of gas” in his body, but he correlated the onset of his symptom of constipation with the addition of a self-selected regimen of Slim-Fast meal replacement shakes (Unilever, Englewood Cliffs, NJ) to his diet. He stated that he was attempting to facilitate weight loss by the incorporation of these meal

Metastatic prostate cancer replacement shakes to his dietary plan. Some relief of the abdominal discomfort and the pain between the shoulder blades was afforded by the passage of flatus. These symptoms were reported as being increased by leaning forward or bending at the waist. He inquired of the therapeutic benefit of colon irrigation as a possible remedy for these later symptomatic complaints. It was noted that about 2 weeks prior, the patient had visited an emergency department because of a sudden onset of “abdominal pain.” Evaluation at the emergency department revealed that the patient had experienced a “urinary tract infection” and had been “passing kidney stones.” The emergency department physician had prescribed for the patient levofloxacin, cyclobenzaprine, and ibuprofen for prophylaxis. In addition to seeking assistance with the previously mentioned symptoms, the patient requested that a “full physical examination” be performed to give him assurance of his health status before he embarked on an extensive travel itinerary. The patient reported that he last had his prostate evaluated 2 years ago at a local Veterans Affairs Medical Center and was told his DRE and PSA test were “normal.” A review of the patient's past medical history revealed a previous history of high blood pressure (not medicated), duodenal ulcer, hemorrhoidectomy for external hemorrhoids, benign prostatic hyperplasia (treated with Prostata, Pygeum africanum [GVI, Costa Mesa, CA]), urinary frequency, asymptomatic varicose veins in the lower extremities, and gonorrhea infection (contracted while in his 20s). The patient had smoked 1 pack of cigarettes per week for 7 years, but had quit 13 years ago. He drank alcohol infrequently. The patient was sexually active and was HIV negative. His exercise consisted of walking 3 miles at least 3 times each week. The patient had been retired from the United States Navy as an officer for 7 years. His family history was positive for type 2 diabetes mellitus (mother), heart disease (father, died of myocardial infarction at age 77 years), hypothyroidism (mother), and high blood pressure (father and numerous relatives of the father). The patient was a well-nourished man in no apparent distress. He stood 69.5 in tall and weighed 194 lb. His gait appeared normal, and he walked without support. Vital signs were normal except for a pulse rate of 104 beats per minute and blood pressure of 146/78 mm Hg. There was a palpable symmetrical arrhythmia detected when the radial pulse was assessed. There was no apparent lymphadenopathy in the cervical, supraclavicular, or inguinal/groin regions. Bruits were not detected in the carotid arteries, abdominal aorta, or the renal and femoral

13 arteries. A careful inspection of the patient revealed no rashes, abnormal skin discolorations, lesions, ecchymosis, swelling, edema, or joint deformities. Palpation of the back (from the thoracic area to the sacrum) did not elicit any tenderness or noticeable discomfort. Active motions of the trunk were full and essentially pain-free. However, it was noted that extension of the trunk relieved the patient's lower back pain. There was very mild discomfort reported at the end range of forward flexion of the trunk. The symptom of lower back pain was localized to the midline at approximately the L4-L5 spinal vertebral levels. No orthopedic or provocative testing could reproduce or exacerbate the patient's symptoms in the lower back and scapular regions. A rectal examination, which included anoscopy and a DRE, did not reveal pathology. The prostate gland palpated as being nontender, about 3 finger breadths in width; and its consistency was assessed as being firm with no apparent endurations or nodules. The stool on the examining finger tested negative for occult blood. Results of urinalysis showed trace blood and 5 red blood cells per high-power field (reference range, 0-3). The hemogram indicated low hemoglobin and hematocrit values: 12.9 g/dL (reference range, 14.0-18.0) and 38.4% (reference range, 42.0%-52.0%), respectively. Total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides were reported as 243 mg/dL (reference range, 110200), 36 mg/dL (reference, 36-60), 164 mg/dL (reference range, 0-129), and 109 mg/dL (reference range, 1-199), respectively. Alkaline phosphatase was 242 U/L (reference range, 39-117), and PSA was 173.2 ng/mL (reference, range 0-4). The electrocardiogram tracing revealed indication of an old posterior myocardial wall infarct and regularly occurring preventricular contractions after every fourth regularly occurring QRS complex. This finding is usually associated with coronary artery disease. Visual analog scale measurements corresponding to the patient's lower back pain and the pain between the shoulder blades were 46 and 47 mm, respectively. On the basis of the historical, physical, and laboratory evaluations, a working diagnosis of metastatic prostate cancer was determined. The patient was referred to a urological oncologist for further diagnostic assessment and therapeutic management. Subsequently, metastasis to the lumbar spine was confirmed. A magnetic resonance imaging was performed and revealed evidence of metastatic cancer extension into midthoracic region spinal canal, resulting in spinal cord compression at the level of T6-T7, with impingement

14 of the spinal cord, as well as evidence of metastatic disease in the bone at that level. Biopsy of the prostate revealed poorly differentiated adenocarcinoma with a Gleason score of 9. Spinal decompression surgery of the thoracic spine was performed followed by adjuvant radiation therapy sessions and antiandrogen hormonal therapy (flutamide). The patient did not recover sufficiently from the surgery, which resulted in lower limb weakness and paresthesias bilaterally. The patient died because of complications of the medical therapy and the disease approximately 1 year after the initial referral. It should be noted that before the patient saw the oncologist, the patient received a session of colonic irrigation to help ameliorate his symptoms of constipation. He reported complete resolution of the pain between the shoulder blades and the abdominal pain immediately after the procedure. There were no observed or reported untoward effects as a result of the single session of colonic irrigation.

Discussion Prostate cancer is diagnosed in very few people younger than 50 years (b0.1% of all patients). The mean age of patients with this disorder is 72 to 74 years, and about 85% of patients are diagnosed after age 65 years. 6 Early prostate cancer usually has no specific symptoms. Lower urinary tract symptoms may be present, but these are neither specific nor sensitive enough to diagnose prostate cancer. Lower urinary tract symptoms are more specific to another condition known as benign prostatic hyperplasia and should not be correlated directly to the presence of prostate cancer. 7 However, with more advanced disease, individuals may experience weak or interrupted urine flow; inability to urinate or difficulty starting or stopping the urine flow; the need to urinate frequently, especially at night; blood in the urine; or pain or burning with urination. Advanced prostate cancer commonly spreads to the bones, which can cause pain in the hips, spine, ribs, or other areas. 1,8 A recent population-based, case-control study demonstrated a strong association of impotence and prostate cancer. Impotence was considered to be an important and early marker for prostate cancer. 9 Other symptoms, such as constipation and abdominal pain, have not be implicated as being significantly associated with the diagnosis of prostate cancer. Assessing risk factors is an important consideration in the evaluation of chronic degenerative diseases,

T. L. Johnson Jr especially prostate cancer. The only well-established risk factors for prostate cancer are age, race/ethnicity, and family history of the disease. African American men and Jamaican men of African descent have the highest prostate cancer rates in the world. Familial predisposition may account for 5% to 10% of prostate cancers. Diets high in animal fat may also be a risk factor. 1 Prior sexual practices (increased number of sexual partners), exposures to sexually transmitted microbial agents, and history of prostatitis play a significant role in the natural history of prostate cancer in black men.10 The recently developed risk calculator (available at www.compass.fhcrc.org/edrnnci/bin/calculator/main.asp) derived from analysis of results from the Prostate Cancer Prevention Trial, which integrates family history of prostate cancer, DRE findings, PSA test result, age, ethnicity, and history of prior prostate biopsy with a negative result, is said to allow clinicians the ability to assess a patient's individual risk of prostate cancer. 2,11 Screening for prostate cancer has been a controversial subject in the realm of preventive health care. The PSA and the DRE have remained the primary tools used for screening and early detection of prostate cancer for over 2 decades. The controversy surrounding screening for prostate cancer stems from the fact that there has not been demonstrable evidence that mass screening programs for the detection of prostate cancer have resulted in a significant reduction in the morbidity or the mortality associated with the disease. Adding to the debate, various guidelines and screening recommendations offered on behalf of individual health care organizations have not indicated a consensus of opinion. 1,3-5 Although routine screening for prostate cancer is controversial, the controversy is decreased when we consider screening in African American men or men with African ancestry. African American men suffer disproportionally from the disease, having a 50% higher incidence and a 2-fold greater mortality than do white men.12 Although the PSA and the DRE may not be ideal screening tools, they are the centerpieces of 2 large prospective randomized clinical trials (Prostate, Lung, Colon, and Ovary screening trial in the United States and the European Randomized Study of Screening for Prostate Cancer in Europe). 13,14 Preliminary results of these trials were issued earlier this year. Unfortunately, it is unlikely that we will learn much about screening in individuals of African decent from either trial because of the low recruitment and participation of this group in these clinical trials. It is recommended that continued education and screening in hopes of early detection of

Metastatic prostate cancer prostate cancer in African American communities should continue until the true culprit of this disparity in morbidity and mortality is identified. 12 More than 90% of all prostate cancers are discovered in the local and regional stages. The 5-year relative survival rate for patients whose tumors are diagnosed at these stages approaches 100%. This survival rate has been attributable to earlier diagnosis and improvement in treatment. 1 Unfortunately, the prognosis for advanced disease or metastasis is poor, with no promise of a cure. One study found that, for the two thirds of men who presented with early-stage prostate cancer, death from heart disease and from other cancers was more common than death from prostate cancer. 15 Bone metastasis is a common form of metastatic disease among patients with prostate cancer. It is reported that 65% to 80% of men with metastatic disease have bone metastasis. In addition, as many as 20% of men who are newly diagnosed as having prostate cancer already have bone metastases. Bone metastases are complicated by significant morbidity, including skeletal-related events (SREs), which are local irreversible changes and include pathologic fracture, bone surgery, radiation therapy to the bone, and spinal cord compression. Medically treating SREs for these patients annually cost more than $12 000 (mean 1-year cumulative costs associated with SREs per patient). These events negatively affect quality of life and present a challenge for the goals of palliative therapy, which include managing these patients' pain, preventing further deterioration, and preserving quality of life.16 A quantifiable risk of prostate cancer exists at any level of PSA, making it impossible to establish a cutoff for PSA below which the risk of prostate cancer is negligible. 17 Biopsy-detected prostate cancer, including high-grade cancers, is not rare among men with PSA levels of 4.0 ng/mL or less—levels generally thought to be in the reference range. 18 The importance of an adequate clinical examination is essential to detecting prostate cancer. A normal PSA level alone cannot eliminate the possibility of a diagnosis of prostate cancer. Relying on PSA alone will result in up to 2.2% of prostate cancers remaining undetected. This may have considerable medicolegal consequences into the future should these men develop clinically apparent prostate cancer. Therefore, DRE and PSA should be interpreted as being collaborative, rather than competitive, in the detection of prostate cancer. 19,20 Paradoxically, results of a previous study suggested that prostate carcinomas with established malignant potential are more likely to be identified in black than in

15 white men with PSA elevation as the only indication of malignancy. 21 However, it is not recommended that performing PSA determinations alone be performed in this population. A DRE allows the examining physician to examine the contour, firmness, symmetry, and presence of nodules or endurations of the prostate. A DRE is a useful screening tool to detect prostate cancer, but it can miss cancer that is confined to the prostate; so this means that it misses nearly half of the cases of prostate cancer. When combined with a PSA test, an accurate DRE improves the detection of prostate cancer. An abnormal DRE may detect prostate cancer that is higher grade and different from that detected by PSA tests. Anatomically, the prostate is divided into different zones. The peripheral zone is the most common site of malignancy; and this may be palpable, unlike malignancies in the transition zone, which may not be palpable but can manifest as obstructive urinary symptoms. 22 There is a significant concern for micrometastatic disease beyond the local-regional area in patients who present with PSA greater than 20 ng/mL. This concern is intensified in the subset of patients who have PSA greater than 50 ng/mL. In this challenging clinical situation, the utility of aggressive local and regional therapy is unclear. Appropriate options for initial treatment may include either radical radiation with adjuvant androgen suppression or androgen suppression alone. In addition, the clinical criteria for the appropriate integration of radical prostatectomy in this patient population are unknown. 23 Gerstenbluth et al 24 have shown that alone, serum PSA of at least 20 ng/ mL had a positive predictive value of 87%. When the PSA was increased to greater than 50 ng/mL, a positive predictive value of 98.5% accuracy in predicting the presence of prostate cancer on tissue biopsy was obtained. These findings suggest that a tissue biopsy to confirm the presence of prostate cancer may be foregone, and proceeding directly to treatment is warranted.

Conclusion Prostate cancer, a leading cause of morbidity and mortality in aging men, is still an enigma in terms of its natural history. It affects African American men disproportionately in terms of prevalence and mortality, compared with white/European men. Although mass screening for the detection of prostate cancer remains

16 controversial, the clinical encounter between the physician and the patient ultimately determines the course of action through shared decision making. Metastatic prostate cancer carries a poor prognosis, with estimated survival being between 12 to 24 months after the initial diagnosis. There is no hope for cure. Palliative care for relief of pain and other complications related to disease extension to areas beyond the confines of the prostate gland is the primary therapeutic goal. Chiropractic physicians are educated and trained to provide primary care–related services, as well as specialty care. As such, chiropractic physicians should maintain a high degree of suspicion for catastrophic causes of back-related complaints, such as metastatic prostate cancer. The Prostate Cancer Prevention Trial Risk Calculator, a research validated instrument, should be used in the assessment of prostate cancer risk. Performance of the DRE and of the PSA determination remains integral in the clinical assessment of the health status in aging men, with or without back pain.

Funding sources and potential conflicts of interest No funding sources or conflicts of interest were reported for this study.

References 1. American Cancer Society. Cancer facts & figures 2009. Atlanta, GA: Elsevier. Available at http://www.cancer.org/ downloads/STT/500809web.pdf. Accessed June 28, 2009. 2. Brawley OW, Ankerst DP, Thompson IM. Screening for prostate cancer. CA Cancer J Clin 2009;59:264-73. 3. Lim LS, Sherin K, ACPM Prevention Practice Committee. Screening for prostate cancer in U.S. men: ACPM position statement on preventive practice. Am J Prev Med 2008;34 (2):164-70. 4. U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:185-91. 5. Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2008: a review of current American Cancer Society guidelines and cancer screening issues. CA Cancer J Clin 2008;58:161-79.

T. L. Johnson Jr 6. Grönberg H. Prostate cancer epidemiology. Lancet 2003;361: 859-64. 7. Strief DM. An overview of prostate cancer: diagnosis and treatment. Medsurg Nurs 2008;17(4):258-63. 8. Lishchyna N, Henderson S. Acute onset-low back pain and hip pain secondary to metastatic prostate cancer: a case report. J Can Chiropr Assoc 2004;48(1):5-12. 9. Hamilton W, Sharp DJ, Peters TJ, Round AP. Clinical features of prostate cancer before diagnosis: a population-based, casecontrol study. Br J Gen Pract 2006;56:756-62. 10. Sarma AV, McLaughlin JC, Wallner LP, et al. Sexual behavior, sexually transmitted diseases and prostatitis: the risk of prostate cancer in black men. J Urol 2006;176:1108-13. 11. Thompson IM, Ankerst DP. Prostate-specific antigen in the early detection of prostate cancer. CMAJ 2007;176(13):1853-8. 12. Rosser CJ. Prostate cancer—to screen, or not to screen, is that the question? BMC Urol 2008;8:20. 13. Andriole GL, Crawford ED, Grubb RL, et al. PLCO Project Team. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009;360:1310-9. 14. Fritz FH, Hugosson J, Roobol MJ, et al, ERSPC Investigators. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009;360:1320-8. 15. Ketchandji M, Kuo YF, Shahinian VB, Goodwin JS. Cause of death in older men after the diagnosis of prostate cancer. J Am Geriatr Soc 2009;57:24-30. 16. Lage MJ, Barber BL, Harrison DJ, Jun S. The cost of treating skeletal-related events in patients with prostate cancer. Am J Manag Care 2008;14(5):317-22. 17. Canby-Hagino E, Hernandez J, Brand TC, et al. Prostate cancer risk with positive family history, normal prostate examination findings, and PSA less than 4.0 ng/mL. Urol 2007;70:748-52. 18. Thompson IM, Pauler DK, Goodman PJ, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level ≤4.0 ng per milliliter. N Engl J Med 2004;350:2239-46. 19. Quinlan MR, Teahan S, Mulvin D, Quinlan DM. Is digital rectal examination still necessary in the early detection of prostate cancer? Ir J Med Sci 2007;176:161-3. 20. Galic J, Karner I, Cenan L, et al. Comparison of digital rectal examination and prostate specific antigen in early detection of prostate cancer. Coll Antropol 2003;27(Suppl 1):61-6. 21. Fowler JE, Bigler SA, Farabaugh PB. Prospective study of cancer detection in black and white men with normal digital rectal examination but prostate specific antigen equal or greater than 4.0 ng/mL. Cancer 2002;94:1661-7. 22. LaSpina M, Haas GP. Update on the diagnosis and management of prostate cancer. Can J Urol 2008;15(Suppl 1):3-13. 23. Wiebe E, Rodrigues G, Lock M, D'Souza D, Stitt L. Outcome analysis of prostate cancer patients with pre-treatment PSA greater than 50 ng/ml. Can J Urol 2008;15(3):4078-83. 24. Gerstenbluth RE, Seftel AD, Hampel N, Oefelein MG, Resnick MI. The accuracy of the increased prostate specific antigen level (greater than or equal to 20 ng./ml.) in predicting prostate cancer: is biopsy always required? J Urol 2002;168:1990-3.

Journal of Chiropractic Medicine (2010) 9, 17–21

www.journalchiromed.com

Resolution of low back and radicular pain in a 40-year-old male United States Navy Petty Officer after collaborative medical and chiropractic care☆ Gregory R. Lillie DC, MS⁎

Chiropractic Physician, Naval Branch Health Clinic NATTC, Department of Orthopedics, Naval Hospital, Pensacola, FL 32508 Received 30 August 2009; received in revised form 23 November 2009; accepted 8 December 2009 Key indexing terms: Manipulation, spinal; Intervertebral disk displacement; Military medicine; Patient care team; Military personnel; Chiropractic

☆

Abstract Objective: The aim of this study is to describe the interdisciplinary care, including chiropractic services, in a military health care facility of an active duty member of the United States Navy with low back pain, leg pain, and foot numbness. Clinical Features: A 40-year-old patient developed low back pain, leg pain, and foot numbness after moving furniture. The patient described his symptoms as pain in the right low back, pain shooting into the right lateral thigh and lower leg, and numbness into the right lateral foot. Magnetic resonance imaging confirmed disk extrusion at L4/L5 occupying the lateral recess and abutting the exiting right L5 nerve root. Intervention and Outcome: Providers, including primary care, chiropractic, and orthopedics, in an established multidisciplinary health care system contributed to the case management. The patient received 11 chiropractic treatments (spinal manipulation, flexion-distraction, abdominal rehab exercises) over 72 days. Subjective complaints resolved, and the patient was released back to full duty. Conclusion: Integrative care, using medical and chiropractic services, was successful in the conservative management of a patient with low back pain and radicular symptoms secondary to disk extrusion. © 2010 National University of Health Sciences.

The views, positions, and/or opinions of this article are those of the author and do not necessarily reflect the policies of the Departments of Defense and Navy. ⁎ Corresponding author. Chiropractic Physician, Naval Branch Health Clinic NATTC, 760 East Ave, Bldg 3911, Pensacola, FL 32508. E-mail address: [email protected].

Introduction Low back pain (LBP) is a major concern to the military. 1 Active duty service members may be predisposed to both acute and chronic episodes of LBP, related to their high levels of physical activity. Essential to operational readiness, military physical

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2009.12.006

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G. R. Lillie

training programs are used to maintain physical fitness. 2 Active duty service members are required to complete a physical readiness test every 6 months. Performance is graded, 3 with a less than satisfactory performance leading to a probationary status. Disability discharges related to back conditions are issued when a service member cannot perform his or her job and/or complete the required physical readiness test satisfactorily. A study of 15 268 active duty military personnel hospitalized for musculoskeletal conditions concluded that back conditions had the greatest 5-year cumulative risk of disability, with 40% being related to intervertebral disk displacement and degeneration. 4 The clinical management of service members with disk degeneration or injury may be a challenge in the military setting. Each member has a primary care manager (PCM), who manages and coordinates the care of each patient. Deployments, temporary duty assignments, and patient compliance all affect the smooth transition of care between specialists and, ultimately, the outcome of each case. Considering the direct and indirect costs of back surgery 5 and the impact surgery may have on a service member's career, it becomes imperative that, when appropriate, nonoperative therapy is included in the management of these cases. Since the addition of their services to the military health care system in 1995, chiropractic physicians have become part of the health care delivery team at 49 military treatment facilities in the United States. An additional 11 sites are scheduled to be opened, including 3 overseas, by the end of 2009. 6 This case review demonstrates how one patient, with a confirmed disk extrusion at L4/L5, achieved a successful outcome after interdisciplinary management in a military treatment facility that included chiropractic services.

Case report A 40-year-old male active duty United States Naval Petty Officer first class presented to his PCM with complaints of LBP, pain shooting into the right lateral

Fig 1.

thigh and lower leg, and numbness into the right lateral foot. The patient's job consisted of a variety of responsibilities, including desk work, heavy lifting, and a considerable amount of travel, which involved sitting several hours in the back of a C-130 transport plane traveling to and from work sites. Having experienced mild, intermittent bouts of LBP since driving a truck long distance 4 years prior, this was his first ordeal with pain or numbness into either lower extremity. This episode began after lifting furniture while moving to a new house. The PCM's working diagnosis was LBP with radiculopathy into the right lower extremity to the foot. This patient was part of an elite Navy squadron, with which he was required to travel a considerable amount of the time, both stateside and overseas. The first clinical contact the patient had for this condition was with his PCM, a naval flight surgeon. It took place 4 days after the onset of pain. Besides the right leg pain, he had experienced transient right testicular pain that lasted for 2 days. No bowel or bladder changes, or lower extremity weaknesses were noted. The PCM prescribed 800 mg ibuprofen and 975 mg acetaminophen twice daily. Lumbar radiographs and a magnetic resonance imaging (MRI) were ordered, and consults were placed to both chiropractic and orthopedic services. The patient was instructed to schedule a follow-up appointment with the PCM after seeing the orthopedic specialist or if symptoms worsened. Over the course of the next 2 weeks, he continued to work with limitations on lifting and exercise, and took his medications as prescribed. Initial presentation to the chiropractic clinic was 14 days after the appointment with his PCM. The patient indicated that his chief complaint was constant dull aching pain in the low back, radiating into the right “hip” (sacroiliac joint), buttock, and leg and numbness in the lateral right foot. An examination was performed (Fig 1), and copies of a noncontrast MRI were reviewed. This revealed a prominent disk extrusion at L4/L5, occupying the lateral recess and abutting the

Examination findings.

Low back pain and radiculopathy

Fig 2. Sagittal T2-weighted MRI without contrast showed posterior disk extrusion at the L4/L5 level and diminished disk height with posterior bulging at L5/S1.

right L5 nerve root. There was also prominent posterior bulging at L5/S1 (Fig 2). The initial chiropractic treatment plan was for appointments 3 times per week for 2 weeks. Treatments consisted of interferential therapy, 7 cryotherapy, 8,9 moist heat, flexion/distraction, 10,11 prone spinal manipulative therapy 12,13 with drop pieces, side posture spinal manipulative therapy, and core conditioning exercises 14,15 with postural modifications. In addition to these physical techniques and modalities, nutritional16-18 and psychosocial factors 19,20 were included in the treatment plan. The patient's first orthopedic consultation was 33 days after his symptoms began. The orthopedic surgeon recommended surgery; however, spine surgery was not available at this naval hospital. Therefore, a consult was placed with a spine surgeon in the civilian community. By this time, the patient had completed 7 chiropractic appointments. Another 22 days passed before the patient was seen by the spine surgeon. This was 51 days after originally presenting to his PCM. While waiting to be seen by the spine surgeon, the patient stated that he was compliant with his prescribed home exercise program and he continued with chiropractic management. At the time he presented to the spine surgeon, the patient had kept 9 appointments with the chiropractic physician. The

19 spine surgeon advised against surgical intervention and scheduled one follow-up appointment. The patient continued with chiropractic care. Seventy-two days after initially seeking care, the patient presented to the chiropractic clinic for his last appointment. The patient had resumed his normal work activities. Indicating that he had been keeping up with the core exercises as prescribed, he reported being painfree for 3 weeks, had regained the feeling in his toes, and was no longer taking pain medications. After an exit examination (Fig 1), he was released from active care, with instructions to call for an appointment if there were any exacerbations. Later the same day, he kept his second appointment with the civilian spine surgeon, who released him from care. Throughout the course of care, the patient was on light duty, limiting his exercise to specific activities prescribed by the chiropractic physician. Once released, he returned to his regular exercise routine and was able to perform all required Navy Physical Readiness Tests. Required every 6 months, a passing score for his age group would require him to do 39 crunches and 32 push-ups (having 2 minutes to do each). Also required is to run 1.5 miles in at least 14:45, or swim 500 yards in 12:30. 3 In summary, the patient was initially seen by his PCM, who prescribed medications, ordered imaging studies, and placed referrals to chiropractic and orthopedics. Working in the same area as the patient, the PCM was able to monitor progress and coordinate changes to medical follow-up if necessary. The patient was seen 11 times by the chiropractic physician and 3 times by orthopedic surgeons. Before submission for publication, the patient provided consent to have elements of case management published without personal identifiers.

Discussion This article has described the case management of an active duty United States Navy Petty Officer who presented to his PCM with LBP and right leg pain. Radiologic studies confirmed posterior disk extrusion at L4/L5, abutting the right L5 nerve root, and posterior bulging of the L5/S1 disk. The primary purpose of this case report was to describe the interdisciplinary collaboration of chiropractic and medical services in a military setting. This article does not go into detail of the chiropractic treatments rendered, as several studies and trials on the use of manipulation and other forms of conservative

20 care to treat patients with acute lumbar radiculopathy may be found in a systematic review by Lawrence et al. 21 Rather, it hoped to depict the unique inclusion of chiropractic management as part of available treatments within a military treatment facility. Integration of chiropractic services into multidisciplinary and military health care facilities is relatively new. This naval hospital added chiropractic services in 2003. Chiropractic in the military is considered a specialty service; therefore, patients are directed to the chiropractic clinic by referral from their PCM. Military health care uses electronic medical records. The referral process is built into the electronic medical record program, making it a simple undertaking. When the PCM decides which specialist(s) a patient should see, a brief history and the diagnosis are entered and sent electronically directly to the specialty clinic as a referral. Each incoming referral to this particular chiropractic clinic is screened by a chiropractic assistant, who will then approve access for an appointment. In this clinic, the patient may contact the chiropractic clinic directly or call a central appointment number to schedule the initial appointment. The chiropractic physician reviews all referrals before the appointment and, if there are any questions, will contact the referring provider. Health care notes are entered into the electronic medical record with each visit. Available for all military providers to view, this allows various providers the ability to review respective cases, keeping abreast of all treatments and patient progress. The PCM may survey each case by opening the relevant electronic case file. In the chiropractic clinic, periodic examinations are performed to monitor progress. Once a patient has met established goals or it is deemed maximum improvement has been attained, it is noted in the record; and the patient is released with verbal instructions to follow up with the PCM or as needed in the chiropractic clinic. If there is lack of sufficient progress other follow-up may occur, which includes the patient being released back to the PCM. Military electronic medical records are maintained in a secure network. If a patient is sent off base for care, that provider does not have direct access to the electronic notes; and arrangements must be made for applicable notes to be delivered. After appointments off base, the daily notes will be sent to the naval hospital, which will then be scanned into the record. Many military providers may not be familiar with chiropractic. Each facility may vary as to what services are offered. As an example, this chiropractic physician is contracted to provide services to active duty beneficiaries.

G. R. Lillie Attending a weekly meeting with specialty providers is encouraged, at which time specific cases are discussed. Specialists at the weekly meeting often have exchanges on evidence-based approaches to care; this includes evidence supporting chiropractic care. The PCM responsible for overall management of the patient described in this article had visited the chiropractic clinic and was familiar with the approach to care. Other examples of chiropractic integration in this facility include family medicine residents observing in the chiropractic clinic, the chiropractic physician doing in-service presentations, and chiropractic representation on sports medicine and research teams. These open lines of communication between providers have helped chiropractic become better integrated in this particular facility. Limitations In this case, the relative contribution of any specific treatment or modality in the interdisciplinary approach to care is unclear. The possibility of natural course of the disorder or spontaneous remission must also be considered. The patient response in this case may not necessarily be the same as others.

Conclusion The results show integrative and interdisciplinary health care, which includes the integration of chiropractic services in a military treatment facility, may provide a beneficial treatment option for active duty service members. More research is needed to help providers differentiate which patients will respond best from a combined treatment approach including chiropractic care.

Acknowledgment The author thanks Mark Goto, MD, and Jerrilyn Cambron, DC, PhD, for assistance in organizing and editing of this paper and Ms Connie C Walker for assistance with literature searches.

Funding sources and potential conflicts of interest There were no funding source or conflicts of interest identified. The author is a contract provider with the

Low back pain and radiculopathy

21

Department of Navy, providing chiropractic services for Naval Hospital Pensacola, FL. 11.

References 1. Woodruff S, Conway T, Bradway L. The U.S. Navy healthy back program: effect on back knowledge among recruits. Mil Med 1994;159(7):475-84. 2. Kaufman K, Brodine S, Shaffer R. Military training-related injuries: surveillance, research, and prevention. Am J Prev Med 2000;18(3S):54-63. 3. Physical readiness test standards, appendix A. OPNAVINST 6110.1H; 15AUG05. Available at http://www.jag.navy.mil/ careers/careers/docs/PRT.pdf. 4. Lincoln A, Smith G, Amoroso P, Bell N. The natural history and risk factors of musculoskeletal conditions resulting in disability among US Army personnel. Work 2002;18(2): 99-113. 5. Tosteson A, Lurie J, Tosteson T, Skinner J, Herkowitz H, Albert T, et al. Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years. Ann Intern Med 2008;149(12):845-53. 6. TRICARE Management Activity [homepage on the internet]. Falls Church (VA). Designated locations. [updated 2007 Apr 10; cited 2009 Aug 03]. http://www. tricare.mil/mybenefit/home/overview/SpecialPrograms/ChiropracticCare/DesignatedLocations. 7. Jorge S, Parada CA, Ferreira SH, Tambeli CH. Interferential therapy produces antinociception during application in various models of inflammatory pain. Phys Ther 2006;86: 800-8. 8. French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. A Cochrane review of superficial heat or cold for low back pain. Spine 2006;31:998-1006. 9. Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue injury? J Athl Train 2004;39(3):278-9. 10. Gudavalli MR, Cambron JA, McGregor M, Jedlicka J, Keenum M, Ghanayem AF, et al. A randomized clinical trial and subgroup analysis to compare flexion-distraction with active

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exercise for chronic low back pain. Eur Spine J 2006;15(7): 1070-82. Cambron JA, Gudavalli MR, Hedeker D, McGregor M, Jedlicka J, Keenum M, et al. One-year follow-up of a randomized clinical trial comparing flexion distraction with an exercise program for chronic low back pain. J Altern Complement Med 2006;12(7):659-68. Chou R, Qaseem A, Snow V, Casey D, Cross JH, Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147: 478-91. Chou R, Hoyt Huffman L. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American pain society/American college of physicians clinical practice guideline. Ann Intern Med 2007;147: 492-504. Stanton T, Kawchuk G. The effect of abdominal stabilization contractions on posteroanterior spinal stiffness. Spine 2008;33: 694-701. McGill SM. Stability: from biomechanical concept to chiropractic practice. J Can Chiropr Assoc 1999;43(2):75-88. James MH, Gibson RA, Cleland LG. Dietary polyunsaturated fatty acids and inflammatory mediator production. Am J Clin Nutr 2000;71(1 Suppl):3435-85. Simopoulos AP. Essential fatty acids in health and chronic disease. Am J Clin Nutr 1999;70(3 Suppl):5605-95. Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr 2002;21:495-505. Thomas E, Silman AJ, Croft PR, Papageoraiou AC, Jayson MI, Macfarlane GJ. Predicting who develops chronic low back pain in primary care: a prospective study. BMJ 1999;318(7199): 1662-7. Macfarlane G, Jones GT, Hannaford PC. Managing low back pain presenting to primary care: where do we go from here? Pain 2006;122(3):219-22. Lawrence D, Meeker W, Branson R, et al. Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis. J Manipulative Physiol Ther 2008;31(9):659-74.

Journal of Chiropractic Medicine (2010) 9, 22–27

www.journalchiromed.com

Chiropractic management of a 40-year-old female patient with Ménière disease Peter C. Emary DC⁎

Private Practice, Parkway Back Clinic, Cambridge, Ontario, Canada Received 4 August 2009; received in revised form 21 September 2009; accepted 2 October 2009 Key indexing terms: Ménière disease; Vertigo; Temporomandibular joint; Chiropractic; Spinal manipulation

Abstract Objective: The purpose of this case report is to describe the chiropractic management of a patient with Ménière disease. Clinical Features: A 40-year-old woman presented with a diagnosis of Ménière disease including a 2-month history of vertigo and a 16-month history of left-sided tinnitus, lowfrequency hearing loss, and aural fullness. The patient's other symptoms included left-sided neck pain, temporomandibular joint pain, and headaches. Examination revealed left-sided upper cervical joint dysfunction along with myofascial trigger points in the middle and upper trapezius muscle. Intervention and Outcome: Treatment included primarily high-velocity, low-amplitude spinal manipulation to the upper cervical and thoracic spine, along with soft-tissue trigger-point therapy, and stretching exercises. Within 2 weeks of treatment, the patient's tinnitus had resolved; and all other symptoms (including vertigo) were improved. The patient's headaches, neck pain, and vertigo were subsequently resolved within 3 months of treatment. The patient experienced only 2 minor episodes of self-resolving “light-headedness” over that time. After 2½ years of follow-up, any occasional episodes of mild aural fullness and/or light-headedness are either self-resolving or relieved with cervical spinal manipulation and soft-tissue treatment. Conclusion: This case report suggests that chiropractic care, including upper cervical spinal manipulation and soft-tissue therapy, may be beneficial in treating some patients with Ménière disease. © 2010 National University of Health Sciences.

Introduction

⁎ Private Practice, Parkway Back Clinic, 201C Preston Parkway, Cambridge, Ontario, Canada N3H 5E8. Tel.: +1 519 653 2101; fax: +1 519 653 4953. E-mail address: [email protected].

Prosper Ménière 1 first described Ménière disease (MD) in 1861 as a syndrome characterized by hearing loss, tinnitus, and episodic vertigo. In 1938, endolymphatic hydrops—thought to be the principal underlying pathology of MD—was described by Hallpike and Cairns 2 ; however, the precise etiology still remains

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2009.12.007

Patient with Ménière disease controversial. 3-5 The prevalence of MD is estimated to be 100 cases per 100 000, as studied in the United Kingdom. 6 MD primarily affects white people, both sexes equally, and has a peak onset between 20 and 50 years of age. 6 MD is typically diagnosed clinically from the classic triad of symptoms including recurrent and spontaneous vertigo, hearing loss, and tinnitus/sensation of aural fullness. 7 The vertigo attacks vary in severity, last from several minutes to several hours, and are often accompanied by nausea. 8 Patients with MD typically experience remissions and exacerbations. 9 The disease can also stabilize, where the vertigo attacks disappear, or at least diminish over time. However, patients with MD can still have severe symptoms of dizziness even after a 20-year disease history. 10 Medical treatment of MD has historically been empirical, 3 and the evidence base for its management is limited. 11 In a review by Saeed, 3 he states, “As yet, no treatment has prospectively modified the clinical course of the condition and thereby prevented the progressive hearing loss.” The traditional medical management of MD has primarily been directed at controlling the vertigo attacks. 12 Interestingly, several chiropractic studies have shown improvement in patients with vertigo symptoms when treated for upper cervical spine and temporomandibular joint (TMJ) dysfunction. 13-17 There may be a relationship between MD and cervicogenic vertigo (CV), a condition chiropractors often diagnose and treat. The purpose of this case report is to describe the chiropractic management of a patient with MD.

Case report A 40-year-old white female presented with a 2-month history of vertigo, along with left-sided hearing loss and tinnitus of 16 months' duration. The tinnitus was described as a loud “ringing tone” mixed with a sensation of “swooshing” or fullness in the left ear. The patient's symptoms also included chronic, left-sided neck and TMJ pain, along with intermittent headaches. The pain severity for each was graded as a 6.5 on a numeric rating scale of 10 and was typically worse toward the end of the day. Use of a dental bite splint over the past 3 years provided only mild relief of the headaches and TMJ pain. The vertigo attacks occurred monthly and would each last for approximately 3 hours. The vertigo was described as if the room was spinning in a slow, clockwise motion, while

23 the patient's eyes involuntarily moved repeatedly back and forth (ie, nystagmus). During a vertigo attack, rotating the neck to either side aggravated the neck and TMJ pain, headache, vertigo, and nausea symptoms. Sitting down with the head flexed between the knees was the only palliative position. The patient had originally presented to her family physician for evaluation of the left-sided aural fullness, tinnitus, and hearing loss. A referral was made to a hearing clinic for audiometric testing, which revealed a mild, low-frequency hearing loss and difficulty with speech discrimination on the left. A few months later, the patient experienced her first vertigo attack, which prompted a return to her family physician. The patient was diagnosed with MD and prescribed a vestibular suppressant for the vertigo. Instead of filling the prescription, the patient visited a naturopath for treatment. After another bout of vertigo and nonresolution of the MD symptoms, the patient presented for chiropractic assessment. Examination including DeKlyn Test (ie, neck held in extension and rotation for 30 seconds) did not produce nystagmus or dizziness. Blood pressure was normal at 106/62. Postural examination revealed a high left shoulder and forward head carriage. Motion palpation of the spine revealed joint restriction at C2-3 in right rotation, T1-2 in left rotation, and T5-6 in extension. Static palpation of the neck revealed localized tenderness of the left C2-3 joint and a large myofascial trigger point within the left middle trapezius muscle. Cervical spine range of motion (ROM) was restricted and mildly painful in extension. Depression of the left shoulder while holding the neck in flexion and right rotation (ie, Shoulder Depression Test) produced some left upper trapezius pain. Upper extremity neurologic examination was unremarkable for motor, reflex, and sensory testing. Cranial nerve examination was normal. Cervical spine radiographs revealed mild-to-moderate discogenic spondylosis at C5-6. The patient was diagnosed with left-sided cervicogenic headache and vertigo, with underlying degenerative disk disease at C5-6. This diagnosis was secondary to the patient's primary diagnosis of MD. The patient underwent a course of chiropractic treatment consisting of spinal manipulative therapy (SMT) to the cervical (Fig 1A) and thoracic spine, softtissue trigger-point therapy to the left middle and upper trapezius muscle (Fig 1B), home ice therapy (as needed), and cervical spine rehabilitation exercises (Figs 2 and 3). The initial treatment frequency was 3 times per week for 2 weeks. Outcome measures used were numeric rating scale for pain; the number and

24

P. C. Emary shoulder pain, likely as a result of postural strain from sitting at work at a computer. These symptoms are all typically mild and are either self-resolving or relieved with manipulation and soft-tissue triggerpoint therapy. In addition, the patient continues to report that she has not used any prescription or overthe-counter medications during the entire course of treatment. The patient has given written consent to having her personal health information, including photographs of her likeness, published.

Discussion The central medical hypothesis for the etiology of MD is bound to endolymphatic hydrops—thought to be responsible for the classic symptoms of MD (ie, episodic vertigo, tinnitus/aural fullness, and sensorineural hearing loss). Endolymphatic hydrops is caused by impaired filtration and excretion of endolymph

Fig 1. Cervical SMT (A). Soft-tissue trigger-point therapy (B).

severity of acute vertigo attacks and headaches; and subjective changes in hearing, tinnitus, and perception of aural fullness. Objective measures used were visual estimation for ROM and orthopedic examination. After 2 weeks of treatment, the patient's TMJ pain and clicking, headache frequency and intensity, and vertiginous symptoms had improved; and the tinnitus had resolved. The neck pain and TMJ pain were each reduced to 2 out of 10. Objectively, cervical ROM was within normal limits; and the result of the Shoulder Depression Test was negative. Based on these improvements, the treatment frequency progressively decreased to once every 3 weeks. At 3-month followup and after a total of 12 treatments, the left-sided neck pain, headaches, and vertigo were resolved. Only 2 minor episodes of “light-headedness” (ie, not vertigo and lasting only a few minutes) were reported. After 2½ years, the patient continues to experience occasional symptoms of aural fullness or mild lightheadedness (without vertigo) about 2 to 3 times per year. She also experiences intermittent neck and

Fig 2. Cervical spine scalene (A) and paraspinal stretches (B) (each held for 15 seconds); 2 repetitions, 1 to 2 sets per day.

Patient with Ménière disease

25 ble vertigo, transtympanic perfusion with gentamicin can be used. Gentamicin, an aminoglycoside, directly destroys the epithelial cells in the cochlea and the labyrinth. 21 This treatment provides good control of patients' vertigo; and when administered in lower doses, the risk of hearing loss can be reduced.22,23 Other surgical procedures such as endolymphatic sac surgery, vestibular nerve section, or labyrinthectomy are usually reserved for the most severe, unresponsive cases of MD. 3,12 Nonconventional treatment

Fig 3. Cervical spine retraction exercise showing protraction (A) and retraction (B) (held for 6 seconds); 3 repetitions, 1 to 2 sets per day.

within the inner ear leading to a buildup of fluid. This endolymphatic buildup results in distension of the endolymphatic compartment, thereby leading to vestibulocochlear dysfunction. 2,18 Conventional medical treatment The traditional medical management of MD is primarily designed to lower endolymphatic pressure. A low-salt diet (ie, less than 1 to 2 g of salt per day) and diuretics (ie, most commonly the combination of hydrochlorothiazide and triamterene) are commonly prescribed. 19,20 However, in a recent Cochrane review, 11 the authors concluded that “there is no good evidence for or against the use of diuretics in [MD] or syndrome” and recommended further research. For patients who do not respond to diet and diuretic treatment, oral steroid or intratympanic steroid injection can be attempted. 21 In patients with intracta-

In contrast to the traditional medical approach, Bjorne et al24-26 have studied the association between patients with MD, and concomitant TMJ and cervical spine disorders. In successive studies, 24,25 they found a much higher prevalence of signs and symptoms of craniomandibular and cervical spine disorders, respectively, in patients diagnosed with MD compared with controls. The MD patients from the 2 aforementioned studies participated in a 3-year longitudinal study involving “coordinated treatment” of their TMJ and cervical spine disorders. 26 The treatment consisted of a range of therapies including education; stress, relaxation, and postural training; stretching exercises; periodontal grinding; custom bite splints; lidocaine injections; and physiotherapy. The study results showed significant, simultaneous improvements (throughout the 3-year follow-up) for all MD symptoms, as well as neck/shoulder, jaw, and headache pain. The researchers concluded that MD has a clear association with TMJ and cervical spine disorders. However, this study was not a randomized, controlled trial; therefore, more research is warranted to provide further evidence of this association. A recent review by Long et al27 investigated the evidence for acupuncture as a treatment of MD. The overall conclusion by the authors was that there is “potential benefit” of acupuncture for patients with MD. However, further research is needed, particularly in a Western health care context. Chiropractic care Research involving chiropractic treatment of MD is extremely scarce. Only 2 studies, both involving “upper cervical specific” treatment, were found in PubMed and Index to Chiropractic Literature relating chiropractic care and MD. 28,29 Kessinger and Boneva 28 reported on a chiropractic patient treated for symptoms “consistent with [MD].” Their

26 patient had a longstanding history of vertigo, tinnitus, and hearing loss, which had progressively worsened 5 weeks before presenting for care. The patient's vertigo symptoms were alleviated within the first few weeks, and her hearing improved (as measured by audiometric testing) after 13 weeks of care. The patient was treated on each office visit with an upper cervical, toggle-type SMT. In a case series, Burcon29 treated 10 patients diagnosed with MD (9 of whom had a history of neck trauma). All 10 patients also responded favorably to upper cervical, toggle SMT (reportedly within the first few treatment visits). However, this study lacks rigorous outcome measures; therefore, the results need to be interpreted judiciously. Other studies have investigated the effectiveness of chiropractic treatment for patients with CV. 13-17 In a review by Hawk et al, 14 they conclude that there is evidence from both controlled studies and usual practice that is adequate to support the “total package” of chiropractic care, including SMT and other procedures, as providing benefit to patients with CV (among other conditions). Fitz-Ritson 17 explains that cervical spine trauma (eg, whiplash) can damage the proprioceptors of the neck muscles, joints, and tendons. This damage changes the afferent input into the spinal cord and brainstem nuclei, which may result in CV. Therefore, treatment of the neck and TMJ (ie, SMT and soft-tissue therapy) can restore the normal afferent input from the neck proprioceptors, thereby decreasing vertigo symptoms. TMJ and cervical spine Disease symptoms involving the TMJ and cervical spine often overlap. 30,31 In a series of articles written by a dental physicist, 32-34 he found that the functional center of rotation of the mandible and TMJ exists at a point between the atlas and axis. According to this theorem, mandibular dysfunction (eg, abnormal dental occlusion) can result in mechanical stress to not only the TMJ, but the upper cervical spine as well. Fink et al 30 showed that imbalanced dental occlusion in healthy subjects resulted in upper cervical (C0-C3) joint dysfunction/hypomobility. They also found the same relationship between dental occlusion and the sacroiliac joint. In some cases, treatment of the TMJ results in improvement of the cervical spine, and vice versa. In a retrospective study, Steigerwald et al 31 investigated a group of 43 patients who had undergone arthroscopic surgery for arthrogenous TMJ dysfunction. Ninety-five

P. C. Emary percent of respondents reported statistically significant levels of symptom reduction for neck pain, shoulder pain, and headaches, as well as symptoms of tinnitus and dizziness. Alcantara et al35 reported on a 41-yearold patient who experienced complete remission of her TMJ symptoms after 9 SMT treatments to the upper cervical spine. Interestingly, this patient also experienced improvement with other symptoms including tinnitus, vertigo, hearing difficulty, and headaches. Blum 36 reported on a patient with tinnitus who also improved with chiropractic care. Therefore, the scientific literature supports a functional relationship between disorders of the cervical spine and TMJ. The literature also supports the use of nonconventional therapy (including upper cervical SMT) in the treatment of TMJ pain, as well as other MD symptoms such as tinnitus, vertigo, and/ or dizziness. Limitations Single case studies do not provide conclusive evidence for treatment effectiveness. The natural course of MD often includes remissions and exacerbations. Therefore, the patient in this case may have improved without treatment. In addition, rigorous outcome measures (eg, Dizziness Handicap Inventory, Neck Disability Index, and Headache Disability Index) were lacking in this study. Subjective changes in hearing, tinnitus, and aural fullness were also used rather than audiometric reevaluation. Any future studies of chiropractic treatment of MD should include more rigorous outcome measures.

Conclusion Presented here was a patient with MD that responded very favorably to chiropractic care. In light of the paucity of research in the chiropractic literature reporting on the treatment of MD, more studies are needed to determine whether chiropractic care, including cervical SMT, is an effective alternative treatment for patients with MD. Chiropractic physicians may have a significant role to play in treating MD symptoms, such as vertigo and tinnitus, due primarily to the success reported in the literature on treating patients with CV and TMJ disorders. Again, however, more research is necessary to determine the link, if any, between these conditions and MD.

Patient with Ménière disease

Acknowledgment The author thanks Carolyn Simolo and the staff at the New York Chiropractic College Library for their assistance in retrieving reference articles for this paper.

Funding sources and potential conflicts of interest No funding sources or conflicts of interest were reported for this study.

References 1. Ménière P. Pathologie auriculaeire: mémoires sur des lésions de l'oreille interne donnant lieu à des symptoms des congestion cérébrale apoplectiforme. Gaz Med Paris 1861;16:597-601. 2. Hallpike CS, Cairns H. Observations on the pathology of Ménière's syndrome. J Laryngol Otol 1938;53:625-55. 3. Saeed SR. Fortnightly review. Diagnosis and treatment of Ménière's disease. BMJ 1998;316:368-72. 4. Mancini F, Catalini M, Carru M, Monti B. History of Ménière's disease and its clinical presentation. Otolaryngol Clin North Am 2002;35:565-80. 5. Merchant SN, Adams JC, Nadol Jr JB. Pathophysiology of Ménière's syndrome: are symptoms caused by endolymphatic hydrops? Otol Neurotol 2005;26:74-81. 6. Morrison AW. Anticipation in Ménière's disease. J Laryngol Otol 1995;109:499-502. 7. Monsell EM, Balkany TA, Gates GA, Goldenberg RA, Meyerhoff WL, House JW. Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Ménière's disease. American Academy of Otolaryngology Head and Neck Foundation, Inc. Otolaryngol Head Neck Surg 1995;113:181-5. 8. Pearson BW, Brackmann DE. Committee on Hearing and Equilibrium guidelines for reporting treatment results in Ménière's disease. Otolaryngol Head Neck Surg 1985;93:579-81. 9. Green Jr JD, Blum DJ, Harner SG. Longitudinal follow-up of patients with Ménière's disease. Otolaryngol Head Neck Surg 1991;104:783-8. 10. Havia M, Kentala E. Progression of symptoms of dizziness in Ménière's disease. Arch Otolaryngol Head Neck Surg 2004; 130:431-5. 11. Thirlwall A, Kundu S. Diuretics for Ménière's disease or syndrome. Cochrane Database Syst Rev 2006(3), doi:10.1002/ 14651858.CD003599.pub2 Art. No.:CD003599. 12. Swartz R, Longwell P. Treatment of vertigo. Am Fam Physician 2005;71:1115-22. 13. Côté P, Mior SA, Fitz-Ritson D. Cervicogenic vertigo: a report of three cases. J Can Chiropr Assoc 1991;35:89-94. 14. Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research. J Altern Complement Med 2007;13:491-512. 15. Bracher ES, Almeida CI, Almeida RR, Duprat AC, Bracher CB. A combined approach for the treatment of cervical vertigo. J Manipulative Physiol Ther 2000;23:96-100.

27 16. Collins ME, Misukanis TM. Chiropractic management of a patient with post traumatic vertigo of complex origin. J Chiropr Med 2005;4:32-8. 17. Fitz-Ritson D. Assessment of cervicogenic vertigo. J Manipulative Physiol Ther 1991;14:193-8. 18. Paparella MM. Pathogenesis and pathophysiology of Ménière's disease. Acta Otolaryngol Suppl 1991;485:26-35. 19. Van Deelen GW, Huizing EH. Use of a diuretic (Dyazide) in the treatment of Ménière's disease. A double-blind cross-over placebo-controlled study. ORL J Otorhinolayngol Relat Spec 1986;48:287-92. 20. Santos PM, Hall RA, Snyder JM, Hughes LF, Dobie RA. Diuretic and diet effect on Ménière's disease evaluated by the 1985 Committee on Hearing and Equilibrium guidelines. Otolaryngol Head Neck Surg 1993;109:680-9. 21. Sajjadi H, Paparella MM. Ménière's disease. Lancet 2008;372: 406-14. 22. Nedzelski JM, Bryce GE, Pfleiderer AG. Treatment of Ménière's disease with topical gentamicin: a preliminary report. J Otolaryngol 1992;21:95-101. 23. Driscoll CL, Kasperbauer JL, Facer GW, Harner SG, Beatty CW. Low-dose intratympanic gentamicin and the treatment of Ménière's disease: preliminary results. Laryngoscope 1997;107:83-9. 24. Bjorne A, Agerberg G. Craniomandibular disorders in patients with Ménière's disease: a controlled study. J Orofac Pain 1996; 10:28-37. 25. Bjorne A, Berven A, Agerberg G. Cervical signs and symptoms in patients with Ménière's disease: a controlled study. Cranio 1998;16:194-202. 26. Bjorne A, Agerberg G. Symptom relief after treatment of temporomandibular and cervical spine disorders in patients with Ménière's disease: a three-year follow-up. Cranio 2003;21: 50-60. 27. Long AF, Xing M, Morgan K, Brettle A. Exploring the evidence base for acupuncture in the treatment of Ménière's syndrome—a systematic review. Evid Based Complement Alternat Med 2009 [Epub ahead of print]. 28. Kessinger RC, Boneva DV. Vertigo, tinnitus, and hearing loss in the geriatric patient. J Manipulative Physiol Ther 2000;23:352-62. 29. Burcon M. Upper cervical protocol to reduce vertebral subluxation in ten subjects with Ménières: a case series. J Vertebral Subluxation Res 2008;2:1-8. 30. Fink M, Wähling K, Stiesch-Scholz M, Tschernitschek H. The functional relationship between the craniomandibular system, cervical spine, and the sacroiliac joint: a preliminary investigation. Cranio 2003;21:202-8. 31. Steigerwald DP, Verne SV, Young D. A retrospective evaluation of the impact of temporomandibular joint arthroscopy on the symptoms of headache, neck pain, shoulder pain, dizziness, and tinnitus. Cranio 1996;14:46-54. 32. Guzay CM. Introduction to the quadrant theorem. Basal Facts 1976;1:153-60. 33. Guzay CM. Quadrant theorem—part two. Basal Facts 1977;2: 19-33. 34. Guzay CM. Quadrant theorem. Part III. Basal Facts 1977-1978; 2:171-83. 35. Alcantara J, Plaugher G, Klemp DD, Salem C. Chiropractic care of a patient with temporomandibular disorder and atlas subluxation. J Manipulative Physiol Ther 2002;25:63-70. 36. Blum CL. Spinal/cranial manipulative therapy and tinnitus: a case history. Chiropr Tech 1998;10:163-8.

Journal of Chiropractic Medicine (2010) 9, 28–31

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Chiropractic management of a 5-year-old boy with urinary and bowel incontinence Keith R. Kamrath DC, FACO⁎

Chiropractor, Private Practice, Hutchinson, MN 55350 Received 3 August 2009; received in revised form 11 September 2009; accepted 24 September 2009 Key indexing terms: Spina dysraphism; Urinary incontinence; Fecal incontinence; Meningocele; Manipulation, Chiropractic

Abstract Objective: The purpose of this article is to describe chiropractic management of a 5-year-old boy with urinary and bowel incontinence. Clinical Features: A 5-year-old boy presented with the primary symptoms of a complete lack of bowel and bladder control with prior surgical correction for lumbar meningocele, spinal lipoma, and tethered spinal cord. Examination revealed spinal and pelvic dysfunction. Intervention and Outcome: Chiropractic treatment methods included using the Activator adjusting instrument and shortwave diathermy to the lumbar spine and sacrum. A total of 5 treatments were initially provided over a period of 4 weeks. After the initial treatment period, he was able to maintain satisfactory control of his bladder and bowel, day and night, for a period of approximately 6 months. A second course of treatments was initiated approximately 6 months later because of a recurrence of bladder and bowel incontinence. Four additional treatments were provided over a period of 4 weeks. This second course of treatment reestablished satisfactory control of bladder and bowel function. Conclusion: For this patient, chiropractic care was successful in establishing satisfactory bladder and bowel control. © 2010 National University of Health Sciences.

Introduction Spina bifida is a birth defect in which the neural tube does not fully close, resulting in an open or imperfectly formed spinal cord. Neural tube defects, including spina bifida as one of the most common forms, occur in approximately 300 000 neonates each year throughout

⁎ 125 Main Street South, Hutchinson, MN 55350. Tel.: +1 320 587 3888; fax: +1 320 587 3888. E-mail address: [email protected].

the world. 1 Typical treatment of bladder and bowel incontinence related to spina bifida includes early intervention with medication, 2,3 catheterization, 4 enema, 5 or surgery. 6 Urinary and bowel incontinence occurs with myelomeningocele in 90% of cases. 4 There is 1 case study7 that describes successful manipulative treatment of spina bifida occulta, but there are no available studies involving meningocele or similar condition. A large number of young adults diagnosed with spina bifida exhibit chronic bladder and bowel incontinence. 8 The psychosocial impact of incontinence, including depression, anxiety, isolation,

1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2009.12.003

Urinary and bowel incontinence caregiver stress, and family stress, is an important consideration. 9,10 The economic impact for the care of urinary continence is approximately $16.3 billion annually.9 In addition, renal damage and renal failure can be sequelae of spina bifida as a result of longstanding bladder dysfunction. 6 Bladder and bowel incontinence has biological, psychosocial, and economic effects on the patient. The purpose of this case report is to describe the chiropractic treatment and results for a 5-year-old patient presenting with urinary and bowel incontinence and spina bifida.

Case report A father and mother brought their 5-year-old son in for assessment for the primary symptoms of a complete lack of bowel and bladder control. His father reported that his son had never had voluntary control over his bowel and bladder function since birth. His son wore absorbent underpants day and night, and the father was concerned about the implications of starting kindergarten without the ability to control bowel and bladder functions. The patient's mother reported that his bladder and bowel would “empty completely” without warning. The patient was also concerned about the need to wear absorbent underpants during the daytime and that other children teased him. The mother related she worried about the emotional development of her son. Other motor and sensory functions seem to be normal. He was able to run and play normally and had no complaints of pain. The patient's mother gave written permission to publish the patient's personal health information without divulging the identity of the patient. Neurosurgical reports indicated that the patient was diagnosed at birth with an intradural, intramedullary spinal cord lipoma with tethering of the spinal cord affecting the L5 through S4 nerve roots. At approximately 2 months of age, the patient had a surgical procedure in which the lamina of L2-5 and the sacrum were exposed, an osteoplastic laminotomy at L3/4 was performed, the dura was retracted, and a 4.5 × 3.0 × 1.0-cm lipoma was removed from the sacral nerve roots. The spinal cord was also untethered during this procedure. A preoperative magnetic resonance imaging of the lumbar spine revealed a meningocele and lipoma over the sacral nerve roots. This examination also revealed an abnormally low cord extending to approximately the S1 level. A recent magnetic resonance imaging of the lumbar spine revealed partial lumbarization of S1 that was more conspicuous on the left.

29 Physical examination revealed an alert, cooperative 5-year-old boy in no acute distress. He moved easily about the examination room and exhibited no discoordination, weakness, or spasticity. Heel and toe walking was normal. No sensory deficits were elicited. Deep tendon reflexes at the knee and ankle were +2 bilaterally. Lumbar and thoracic range of motion was full and pain-free. A healed surgical scar was visible in the midline from L1 to S3. Postural evaluation revealed a posterior and inferior positioning of the left ilium. There was also a left rotational fixation at L5. Joint dysfunction was assessed by evaluating symmetry of the pelvis with the patient in a standing and prone position and by assessing leg length in the prone position. Static palpation of spinal asymmetry, tenderness, and muscle spasm was also used. The treatment plan consisted of treatments once per week for several weeks to correct the joint dysfunctions using the Activator adjusting instrument. The Activator instrument was applied in a cephalad line of drive at the left ischial tuberosity, left posterior superior iliac spine, and approximately 0.5 cm left of the midline at L5. In addition, shortwave diathermy was applied to the lumbar spine for 15 minutes per treatment. He began showing improved bladder and bowel control after approximately 2 treatments. After a total of 5 treatments, the patient was able to control his bowel and bladder during the day and at night and was able to discontinue wearing absorbent underpants. Because of the loss of his mother's employment, the patient discontinued treatment after 5 visits. He maintained satisfactory control of his bowel and bladder for approximately 6 months and then gradually began having bladder and bowel incontinence again. His mother brought him back for treatment after he had persistent symptoms for approximately 1 month. She reported that his bowel and bladder would empty completely during the day and at night and that he needed to wear absorbent underpants again. She reported no intervening trauma, and the history and examination were essentially unchanged from his initial visit. Treatment at this time only used the Activator adjusting instrument. No shortwave diathermy was used during this second course of treatment. Once again, he began to have improved bowel and bladder control. Within 2 treatments, his mother reported that he was experiencing only trace amounts of urine or fecal material that would be involuntarily released. She stated that he also seemed to have more warning that his bowel/bladder needed to be emptied, so he could get to the bathroom before having an accident. After 4 treatments, applied 1 time per week

30 for 4 weeks, he was able to discontinue wearing absorbent underwear and wear normal underpants.

Discussion Pediatric urinary incontinence can be categorized as organic (apparent structural or neurologic condition) or functional (no structural or neurologic abnormality can be identified). Organic causes of incontinence can be further subdivided into either structural or neurogenic causes. 11 Structural defects typically involve defects of the lower urinary tract. Neurogenic causes of urinary incontinence include spina bifida, sacral agenesis, spinal cord injury, cerebral palsy, and tethered spinal cord. 12 Given that the history of this patient includes meningocele, spinal lipoma, and tethered spinal cord, it is likely that the cause of his urinary incontinence was of neurogenic origin. Sacral neuromodulation, the transcutaneous electrical stimulation of the sacral nerve roots, has been shown to significantly improve fecal incontinence as compared with a control group treated with medical therapy. 13 Sacral nerve stimulation has been shown to provide medium-term success in 80% of patients treated for fecal incontinence. 14 Although the mechanism remains unknown, sacral neuromodulation causes stimulation of the anal sphincter and produces changes in rectal sensation. 15 In addition, sacral transcutaneous electrical nerve stimulation appears to be superior to a placebo. 16 Spinal mobilization has been shown to cause measureable changes in the sympathetic nervous system in the lower extremities. 17 It seems possible that improved sacroiliac joint function could produce sacral nerve root stimulation with resulting improved urinary and bowel continence. At the time that this case report was written, the patient's progress had been followed for approximately 12 months. During this time, the patient experienced a recurrence of bladder and bowel incontinence approximately 6 months after the initial course of treatment. This exacerbation prompted the patient to return for a second course of treatment, which provided relief of his incontinence symptoms. Apparently, the changes associated with chiropractic spinal manipulation are not permanent for this condition. However, the desired therapeutic effect remained for several months after the withdrawal of treatment. This appears to be somewhat better than a common pharmacologic treatment using oxybutynin where urinary incontinence recurs almost immediately upon withdrawal. 3 Additional study may provide guidance regarding a treatment regimen of

K. R. Kamrath chiropractic spinal manipulation that is effective for pediatric patients with incontinence and what, if any, follow-up treatment is expected. Pelvic floor exercises 18,19 and/or biofeedback 19 may enhance the treatment regimen. A longer-term follow-up of this patient may provide additional insight. Limitations Limitations of this case study include the lack of an objective measure of incontinence such as the Fecal Incontinence Quality of Life Index. Monitoring of progress was based on the patient/parent's recollection of the number of episodes of incontinence since the previous office visit. There may be a discrepancy between patient and parent reporting of the frequency and type of incontinence episodes. It is possible that the patient improved because of other factors not related to treatment such as psychosocial motivation associated with starting school.

Conclusion For this patient, chiropractic spinal manipulation provided improvement in both bladder and bowel control. Continence was achieved within a few weeks, and the treatment was well tolerated by the patient without unwanted adverse effects. This case study provides support for further study of chiropractic care for the treatment of urinary and bowel incontinence.

Funding sources and potential conflicts of interest No funding sources or conflicts of interest were reported for this study.

References 1. Kondo A, Kamihira O, Ozawa H. Neural tube defects: prevalence, etiology and prevention. Int J Urol 2009;16 (1):49-57. 2. Palmer LS, Zebold K, Firlit CF, Kaplan WE. Complications of intravesical oxybutynin chloride therapy in the pediatric myelomeningocele population. J Urol 1997;157(2):638-40. 3. Ab E, Dik P, Klijn AJ, van Gool JD, de Jong TP. Detrusor overactivity in spina bifida: how long does it need to be treated? Neurourol Urodyn 2004;23(7):685-8.

Urinary and bowel incontinence 4. Kari JA, Safdar O, Jamjoom R, Anshasi W. Renal involvement in children with spina bifida. Saudi J Kidney Dis Transpl 2009;20(1):102-5. 5. Eire PF, Cives RV, Gago MC. Faecal incontinence in children with spina bifida: the best conservative treatment. Spinal Cord 1998;36(11):774-6. 6. de Jong TP, Chrzan R, Klijn AJ, Dik P. Treatment of the neurogenic bladder in spina bifida. Pediatr Nephrol 2008;23 (6):889-96. 7. Borregard PE. Neurogenic bladder and spina bifida occulta: a case report. J Manipulative Physiol Ther 1987;10(3):122-3. 8. Verhoef M, Lurvink M, Barf HA, et al. High prevalence of incontinence among young adults with spina bifida: description, prediction and problem perception. Spinal Cord 2005;43 (6):331-40. 9. Miner Jr PB. Economic and personal impact of fecal and urinary incontinence. Gastroenterology 2004;126(1 Suppl 1):S8-S13. 10. Kinavev C. Adolescents born with spina bifida: experiential worlds and biopsychosocial developmental challenges. Issues Compr Pediatr Nurs 2007(4):147-64. 11. Komissarov IA. The classification and choice of the method of treatment in fecal incontinence in children. Vestn Khir Im I I Grek 1997;156(2):85-8. 12. Reitz A, Fisang C, Muller SC. Neuromuscular dysfunction of the lower urinary tract dysfunction beyond spinal cord injury

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and multiple sclerosis. A challenge for urologists. Urologe A. 2008 Sep; 47(9): 1097-8, 1100-2, 1104-5. Tiandra, Chank MK, Yeh CH, Murray-Green C. Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study. Dis Colon Rectum 2008;51(5):494-502. Tiandra, Lim JF, Matzel K. Sacral nerve stimulation: an emerging treatment for faecal incontinence. ANZ J Surg 2004;74(12):1098-106. Govaert B, Van Gemert WG, Baeten CG. Neuromodulation for functional bowel disorders. Best Pract Res Clin Gastroenterol 2009;23(4):545-53. Hagsstoem S, Mahler B, Madsen B, Djurhuus JC, Rittig S. Transcutaneous electrical nerve stimulation for refractory daytime urinary urge incontinence. J Urol 2009. Perry J, Green A. An investigation into the effects of a unilaterally applied lumbar mobilization technique on peripheral sympathetic nervous system activity in the lower limbs. Man Ther 2008;13(6):492-9. Vasconcelos M, Lima E, Calafa L, Noronha A, Canqussu R. Voiding dysfunction in children. Pelvic-floor exercises or biofeedback therapy: a randomized study. Pediatr Nephol 2006 Dec;21(12):1858-64. Nicastro A, Stella LP, Nicolai AP. Fecal incontinence: role of anal sphincter rehabilitation. Chir Ital 2006;58(4): 493-500.

Journal of Chiropractic Medicine (2010) 9, 32–37

www.journalchiromed.com

Community-acquired methicillin-resistant Staphylococcus aureus: a potential diagnosis for a 16-year-old athlete with knee pain Susan M. Larkin-Thier DC a,b,⁎, Virginia A. Barber DC a,c , Phyllis Harvey MLn b,d , Anna B. Livdans-Forret DC b,e a

Faculty Clinician, Palmer College of Chiropractic, Davenport, IA Professor, Palmer College of Chiropractic, Davenport, IA c Associate Professor, Palmer College of Chiropractic, Davenport, IA d Collection Management Librarian, Palmer College of Chiropractic, Davenport, IA e Director, Campus Health Center, Palmer College of Chiropractic, Davenport, IA b

Received 15 May 2009; received in revised form 24 September 2009; accepted 7 October 2009 Key indexing terms: Staphylococcal skin infections; Knee; Adolescent; Diagnosis, Differential; Decision making; Chiropractic

Abstract Objective: This case report aims to raise awareness in chiropractic physicians of the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in adolescents who participate in sports activities and to alert the chiropractic physician of the necessity to consider potential diagnoses that are not within their typical clinical heuristic. Clinical Features: A 16-year-old adolescent girl entered the clinic with a complaint of left knee pain that had an insidious onset during her involvement in sports activities. Later that same day, her knee became enlarged, red, and had pustular formations with a discharge. She was taken to an urgent care facility and subsequently diagnosed with MRSA. Her history included treatment of a left knee musculoskeletal condition 6 weeks prior to which she had responded favorably. Interventions and Outcomes: She was treated medically with an aggressive course of antibiotic therapy and excision of the furuncle. The chiropractic physician played a role in patient education and notifying local school authorities of the case. Conclusion: Doctors of chiropractic must prepare themselves for the unexpected and remain open to diagnostic possibilities outside of the normal scope of practice. Knee pain or cellulitis of any type may require additional diagnostic and patient care protocols to make the correct

⁎ Corresponding author. Faculty Clinician, Palmer College of Chiropractic, Academic Health Center, 1000 Brady St, Davenport, IA 52803. Tel.: +1 563 884 5832; fax: +1 563 884 5470. E-mail address: [email protected] (S. M. Larkin-Thier). 1556-3707/$ – see front matter © 2010 National University of Health Sciences. doi:10.1016/j.jcm.2009.12.001

A potential diagnosis of CA-MRSA

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diagnosis. With the incidence of community-acquired MRSA increasing at an alarming rate, it is certainly a diagnosis doctors of chiropractic should be aware of when treating patients, especially those involved in sports activities. © 2010 National University of Health Sciences.

Introduction Accurate differential diagnosis requires a rigorous set of thought processes that need to be both thorough and efficient. Two of the most common cognitive errors in this process are “search satisfying,” in which the physician stops investigation once an initial plausible diagnosis is put forth, and “availability,” 1 in which the physician evaluates the “probability of a (diagnosis) by the ease with which relevant instances come to mind.”1,2 In other words, the physician subconsciously sees as more likely in a new case those diagnoses that he or she has made frequently and recently in other cases. In this case, a 16-year-old female basketball player with a previous history of left knee pain that resolved 6 weeks earlier after treatment with spinal manipulative therapy and home care presented anew with what appeared to be the same left knee pain. Because chiropractic physicians report that they frequently treat musculoskeletal conditions and rarely treat infectious conditions, 3 some may be unaware that athletes are at increased risk for community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) and may not initially consider a diagnosis of infection when maybe they should. In the athlete population, direct contact of players' exposed extremities during practice or competition can lead to minor abrasions, thereby creating a portal of entry for bacteria. 4 A CA-MRSA infection, which can present with symptoms of joint pain, swelling, and restricted motion, may mimic musculoskeletal conditions: extremity joint dysfunction, sprain, or strain. The purpose of this article is to share an example of a case in which an assumption was made that the patient was experiencing an exacerbation of a previously diagnosed musculoskeletal condition of the knee instead of considering the CA-MRSA infection. This case discusses lessons learned, how to recognize CAMRSA, and how to follow up cases of CA-MRSA.

Case report A 16-year-old female high school athlete with a complaint of left knee pain presented to a chiropractic

clinic accompanied by her parent. The complaint began 2 days prior after a basketball game. There was no trauma, and the complaint was becoming progressively more debilitating. She described the pain as severe and as restricting her mobility. Physical examination revealed altered gait due to the knee pain. Her knee was moderately edematous with no discoloration or temperature change. There were no visible skin lesions. The joint was very sensitive to the touch. She rated the pain as 8 of 10 on a visual verbal pain scale, with 10 being the most severe. Her parent reported that her daughter had recently received what they perceived to be an insect bite on her knee. Her history revealed that, 6 weeks prior, she had been treated in the same clinic for joint dysfunction of the left knee. She had responded favorably to the treatment and had returned to her normal activities including playing basketball. Because of the perceived exacerbation of her knee condition, a magnetic resonance imaging was ordered and scheduled to be performed within 3 days. The chiropractic physician contacted the parent later that evening to follow up. She was informed that the daughter's knee condition had worsened and that, by earlier that afternoon, her knee had become enlarged and was red with a “pimple” formation with discharge. By evening, there were several “pimples”; and the central “pimple” had black tissue surrounding the center accompanied by a cloudy discharge. Because of these developments, she had been taken to an express care facility where the discharge was cultured and an initial diagnosis of cellulitis was established. She was then treated with sulfamethoxazole, an oral antibiotic, twice a day and a topical antibiotic ointment. According to the parent, they were informed that the condition was a severe Staphylococcus infection or possibly MRSA. Subsequently, the culture result was positive for MRSA. Fortunately, the patient responded well to the medical treatment regimen. The chiropractic physician instructed the family on proper wound care and prevention of further transmission of infection. When the parents reported that 2 other teammates had recently been treated for skin infections, we contacted the local school officials and informed them of the occurrence of MRSA infection within the team. The officials then arranged for sanitation of the

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locker room and instruction of the coaches regarding infectious diseases. Investigation of the Iowa law indicated that the physician who prescribed the antibiotic regimen is the responsible party to inform the state health department.

Discussion Signs and symptoms of CA-MRSA Skin and soft tissue infections are by far the most common clinical manifestation in CA-MRSA 5 and represent 75% to 77% of such cases in the United States. 5,6 In many instances, the initial skin lesions are frequently confused with a spider bite by both patients and clinicians. 7 Community-acquired MRSA and the brown recluse spider bite have similar clinical presentations. Brown recluse spiders are more prevalent in the South and in warmer climates. Unless the physician practices in an area where the brown recluse is endemic, it is far more likely that the initial skin lesion is a CA-MRSA presentation. 6,8 Community-acquired MRSA infections usually occur after the protective barrier of the skin has been compromised, for example, from trauma, ulcers, or turf abrasion, which allows bacterial access to the subepidermal tissues. 9,10 Fig 1 lists the most common signs and symptoms of CA-MRSA skin infections that clinicians should be aware of. 6-8 The most frequently reported presentations of CA-MRSA skin infection are furuncles (abscessed hair follicles or boils), carbuncles (coalesced masses of furuncles), and abscesses. 6,8 Fig 2 provides a list of infection presentations and their descriptions. 10,11 Pain and systemic symptoms that seem more severe than what the history and physical examination findings reveal may indicate CA-MRSA infection. 8 Community-acquired MRSA skin infections commonly present as an erythematous abscess with surrounding cellulitis. 12,13 Fig 3 shows the appearance of a skin infection associated with CAMRSA. The hallmarks of the presentation include

Fig 1.

Signs and symptoms of CA-MRSA.

Fig 2.

Common CA-MRSA skin and soft tissue infections.

erythema, warmth, swelling, and tenderness at the affected area. 9 These infections can develop anywhere in the body, but most likely occur on extremities where they are susceptible to microtrauma. 9 Fig 4 shows an infection location at the knee joint. The organisms most commonly found on cultures are the normal dermatologic flora 14 and include S aureus and group A βhemolytic Streptococcus. MRSA—a worldwide problem In the middle of the 20th century, knowledge of preventive measures in infection control along with advances in antibacterial drug development gave us

Fig 3. The appearance of a skin infection associated with CA-MRSA. Photograph courtesy of the CDC Public Health Image Library.

A potential diagnosis of CA-MRSA

Fig 4. Community-acquired MRSA infection at the knee joint. Photograph courtesy of the CDC Public Health Image Library.

hope that the tide had been turned on infection control.15 Unfortunately, the misuse and overuse of these drugs and the bacterial organisms' ability to mutate and develop resistance have resulted in drugresistant strains. In 1959, methicillin was introduced; but within 2 years, hospital-acquired MRSA was described in the United Kingdom. 12 By 1968, the first major nosocomial (an infection that develops in the hospital and was not incubating at the time of admission) outbreak in the United States was reported. 16 In 1982, the first instance of MRSA

Fig 5.

Populations at risk for CA-MRSA.

35 developing outside of a hospital was reported in Detroit, MI; this occurred among intravenous drug users. 12 The first report of MRSA among healthy children with no identifiable risks was published a year later. 6 By the late 1990s, instances of MRSA were reported by people in communities with no known risk factors. 6,17,18 In 1999, 4 pediatric deaths were reported from CA-MRSA. 19 By 2004, a number of researchers had come to the conclusion that the infections resulting from CA-MRSA had reached the proportions of a worldwide epidemic. 12 It is estimated that invasive MRSA infections occur in approximately 94 000 persons each year and lead to approximately 19 000 deaths. Roughly 86% of these infections are health care–associated cases, and 14% are community-associated cases. 20-22 There are several populations, listed in Fig 5, that are at risk for CAMRSA. 6,7,12,16,23-27 Community-acquired MRSA seems to be on the rise particularly in children and young adults. 28-30 In particular, athletes participating in contact sports are at increased risk of developing CA-MRSA. 4-6 ,31 The infection spreads via sharing of equipment and personal items, and through direct physical contact, especially when abrasions or lacerations of the skin are present. 5 Community-acquired MRSA infections have been documented in baseball, basketball, volleyball, weightlifting, rugby, canoeing, cross-country running 31 , football, 4,31-35 fencing, 32 wrestling, 32,36 and soccer. 27 The chiropractic physician's role For chiropractic physicians, a viable treatment protocol is to recognize key signs and symptoms and to make an immediate referral to the patient's medical physician, and then to comanage patients with CA-MRSA through patient education. Patients should be advised to keep wounds covered with clean dry bandages, clean hands with soap and water or waterless hand sanitizer after changing dressings, bathe regularly, and avoid sharing of potentially contaminated items such as towels, washcloths, bedding, bar soap, razors, clothing, or athletic equipment. They should not participate in sports or childcare unless their wounds are covered or healed. Patients should be instructed to seek medical care promptly if systemic symptoms develop or local symptoms worsen or do not improve within 48 hours. The Centers for Disease Control and Prevention (CDC) has also issued formal recommendations regarding measures to prevent the spread of staphylococcal skin infections among sports participants. These recommendations can be used as a guideline for patient education and are summarized in Fig 6.4

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References

Fig 6. The CDC recommendations for the prevention of staphylococcal skin infections in athletes.

Conclusion In retrospect, the incidental statement that the patient had had an insect bite on her knee and the fact that her pain seemed out of proportion to the history and examination results were significant findings. Knowing that participation in team sports is a risk factor for CA-MRSA and that “… musculoskeletal infections are the most common of the invasive infections caused by CA-MRSA isolates in children ages 2 to 18” coupled with an awareness that, in many cases of CA-MRSA, the initial skin lesion is easily confused with a spider or insect bite might have increased the probability in the doctor's mind of infection as a differential diagnosis.8,23 The application of this knowledge would have raised a “red flag” to consider CA-MRSA as a differential diagnosis. We hope the reporting of this case report will assist others in similar clinical situations. Being aware of other possibilities and the willingness to be open to new situations and unexpected diagnoses can help us be successful in our diagnosis when these unique situations arise. With the incidence of CA-MRSA increasing at an alarming rate, it certainly is a differential diagnosis the chiropractic physician has to consider when treating patients.

Funding sources and potential conflicts of interest No funding sources or conflicts of interest were reported for this study.

1. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med 2002;9:1184-204. 2. Tversky A, Kahneman D. Availability: a heuristic for judging frequency and probability. Cognit Psychol 1973;5: 207-32. 3. Christensen MG, National Board of Chiropractic Examiners. Job analysis of chiropractic 2005: a project report, survey analysis, and summary of the practice of chiropractic within the United States. Greeley, CO: National Board of Chiropractic Examiners; 2005. p. 68, 98, 105, 107. 4. Bowers AL, Huffman GR, Sennett BJ. Methicillin-resistant Staphylococcus aureus infections in collegiate football players. Med Sci Sports Exerc 2008;40:1362-7. 5. Jones RN. Key considerations in the treatment of complicated staphylococcal infections. Clin Microbiol Infect 2008;14(Suppl 2):3-9. 6. Gorwitz RJ. A review of community-associated methicillinresistant Staphylococcus aureus skin and soft tissue infections. Pediatr Infect Dis J 2008;27:1-7. 7. Centers for Disease Control and Prevention (U.S.). Strategies for clinical management of MRSA in the community: summary of an experts' meeting convened by the Centers for Disease Control and Prevention. Atlanta, GA: Centers for Disease Control and Prevention; 2006. Available from: http://www.cdc. gov/ncidod/dhgp/ar_mrsa_ca.html. Accessed 10/14/2008. 8. Pankey GA. Managing MRSA in the community practice setting. Available from: http://cme.medscape.com/viewarticle/ 705555. Accessed 9/9/2009. 9. Rogers RL, Perkins J. Skin and soft tissue infections. Prim Care 2006;33:697-710. 10. Sedgwick PE, Dexter WW, Smith CT. Bacterial dermatoses in sports. Clin Sports Med 2007;26:383-96. 11. MedlinePlus medical dictionary. Available from: http://www2. merriam-webster.com/cgi-bin/mwmednlm. Accessed 9/11/ 2009. 12. Cohen PR. Community-acquired methicillin-resistant Staphylococcus aureus skin infections: implications for patients and practitioners. Am J Clin Dermatol 2007;8:259-70. 13. Gould SD, Spandorfer JM. Unilateral leg swelling: clues to cause and ways to treat. Patient Care 2005;39:49-55. 14. Bass AR, Schoen RT. Bacterial arthritis: aggressive diagnosis, effective therapy. J Musculoskelet Med 1996;13:13-22. 15. Tenover FC. Mechanisms of antimicrobial resistance in bacteria. Am J Med 2006;119(6 Suppl 1):S3-S10 [discussion S62-70]. 16. Hinckley J, Allen PJ. Community-associated MRSA in the pediatric primary care setting. Pediatr Nurs 2008;34:64-71. 17. Centers for Disease Control and Prevention (CDC) [homepage on the Internet]. Atlanta, GA: Centers for Disease Control and Prevention. CA-MRSA: clinician FAQs | CDC Infection Control in Healthcare. Available from: http://www.cdc.gov/ncidod/ dhqp/ar_mrsa_ca_clinicians.html#. Accessed 10/14/2008. 18. Herold BC, Immergluck LC, Maranan MC, et al. Communityacquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA 1998;279:593-8. 19. From the Centers for Disease Control and Prevention. Four pediatric deaths from community-acquired methicillin-resistant

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Staphylococcus aureus—Minnesota and North Dakota, 19971999. JAMA 1999;282:1123-5. Centers for Disease Control and Prevention (CDC) [homepage on the Internet]. Atlanta, GA: Centers for Disease Control and Prevention. S. aureus and MRSA surveillance summary 2007 | CDC Infection Control in Healthcare. Available from: http:// www.cdc.gov/ncidod/dhqp/ar_mrsa_surveillanceFS.html. Accessed 9/18/2008. Centers for Disease Control and Prevention (CDC) [homepage on the Internet]. Atlanta, GA: Centers for Disease Control and Prevention. Fact sheet: invasive MRSA | CDC Infection Control in Healthcare. Available from: http://www.cdc.gov/ncidod/ dhqp/ar_mrsa_Invasive_FS.html. Accessed 10/14/2008. Klevens RM, Morrison MA, Nadle J, et al. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007;298:1763-71. Kaplan SL. Community-acquired methicillin-resistant Staphylococcus aureus infections in children. Semin Pediatr Infect Dis 2006;17:113-9. Kaplan SL. Implications of methicillin-resistant Staphylococcus aureus as a community-acquired pathogen in pediatric patients. Infect Dis Clin North Am 2005;19:747-57. Levenhagen KM. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging concern for physical therapists: discussion. Physiother Res Int 2008;13:9-17. Farley JE. Epidemiology, clinical manifestations, and treatment options for skin and soft tissue infection caused by communityacquired methicillin-resistant Staphylococcus aureus. J Am Acad Nurse Pract 2008;20:85-92. Huijsdens XW, van Lier AM, van Kregten E, et al. Methicillinresistant Staphylococcus aureus in Dutch soccer team. Emerg Infect Dis 2006;12:1584-6.

37 28. Salgado CD, Farr BM, Calfee DP. Community-acquired methicillin-resistant Staphylococcus aureus: a meta-analysis of prevalence and risk factors. Clin Infect Dis 2003;36:131-9. 29. Moran GJ, Amii RN, Abrahamian FM, Talan DA. Methicillinresistant Staphylococcus aureus in community-acquired skin infections. Emerg Infect Dis 2005;11:928-30. 30. Ochoa TJ, Mohr J, Wanger A, Murphy JR, Heresi GP. Community-associated methicillin-resistant Staphylococcus aureus in pediatric patients. Emerg Infect Dis 2005;11:966-8. 31. Cohen PR. Cutaneous community-acquired methicillin-resistant Staphylococcus aureus infection in participants of athletic activities. South Med J 2005;98:596-602. 32. Centers for Disease Control and Prevention (CDC). Methicillin-resistant Staphylococcus aureus infections among competitive sports participants—Colorado, Indiana, Pennsylvania, and Los Angeles County, 2000-2003. MMWR Morb Mortal Wkly Rep 2003;52:793-5. 33. Kazakova SV, Hageman JC, Matava M, et al. A clone of methicillin-resistant Staphylococcus aureus among professional football players. N Engl J Med 2005;352:468-75. 34. Begier EM, Frenette K, Barrett NL, et al. A high-morbidity outbreak of methicillin-resistant Staphylococcus aureus among players on a college football team, facilitated by cosmetic body shaving and turf burns. Clin Infect Dis 2004;39: 1446-53. 35. Nguyen DM, Mascola L, Brancoft E. Recurring methicillinresistant Staphylococcus aureus infections in a football team. Emerg Infect Dis 2005;11:526-32. 36. Lindenmayer JM, Schoenfeld S, O'Grady R, Carney JK. Methicillin-resistant Staphylococcus aureus in a high school wrestling team and the surrounding community. Arch Intern Med 1998;158:895-9.

Journal of Chiropractic Medicine (2010) 9, 38–41

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Clinical detection of abdominal aortic aneurysm in a 74-year-old man in chiropractic practice Nathan J. de Boer DC, MChiro, MSc a , Simone F.C. Knaap DC, MAppSc b,⁎, Annemarie de Zoete DC c a

Private Practice, Rijswijk, The Netherlands Private Practice, Borger, The Netherlands c Private Practice, Heiloo, The Netherlands b

Received 30 July 2009; received in revised form 30 September 2009; accepted 12 October 2009 Key indexing terms: Aortic aneurysm, Abdominal; Chiropractic; Low back pain; Diagnosis

Abstract Objective: The purpose of this article is to present a case of abdominal aortic aneurysm to illustrate its clinical detection through history and physical examination and the importance of this condition to the chiropractic clinical setting. Clinical Features: A 74-year-old retired man consulted a doctor of chiropractic for chronic low back pain. The history and physical examination confirmed chronic sacroiliac and a lumbar facet dysfunction. After 5 weeks, the patient stated he had stomach cramps. After this, a more thorough abdominal examination was done. The doctor of chiropractic detected an enlarged pulsatile mass upon abdominal palpation. Intervention and outcome: The patient was sent to the cardiologist and had successful surgery within weeks. Conclusion: An abdominal aortic aneurysm has specific symptoms and associated risk factors. If known risk factors are present, a clinical examination needs to be carried out, even though sensitivity of the clinical examination may be low. It should be a differential diagnosis in every male patient older than 50 years with low back pain. In case of suspicion, the patient should be referred for advanced imaging. © 2010 National University of Health Sciences.

Introduction Most types of low back pain are caused by biomechanical disorders, but sometimes may be caused ⁎ Corresponding author. Eeserstraat 14, 9531 CM Borger, The Netherlands. Tel.: +31 599 323020; fax: +31 599 323033. E-mail address: [email protected] (S.F.C. Knaap).

by visceral disease. 1 One of these causes is abdominal aortic aneurysm (AAA), defined as an aortic diameter more than 30 mm. 2,3 Many case studies have been written; however, the prevalence is not well known. It has been suggested to be 5% in men older than 50 years. 2 Abdominal aortic aneurysm is 10 times more common in 65- to 75-year-old men compared with women of the same age. Often, they are asymptomatic;

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Abdominal aortic aneurysm but they can present as low back pain. 4 About 50% of the patients presenting to a doctor of chiropractic complain of low back pain. Although most of these patients have no underlying pathology, the doctor of chiropractic must be aware that in some of these patients AAA can be the cause of their low back pain. 5 The following case describes a patient with AAA and concurrent low back pain, who was referred for further examination after a pulsating abdominal mass was found on physical examination.

Case report A 74-year-old retired man consulted a doctor of chiropractic for chronic low back pain. The low back pain developed slowly and was rated on a pain scale as 5 of 10. The most painful region was at the right sacroiliac joint and radiated to the patellar region. There was also a dull ache at the erector spinae muscle region. The pain worsened with walking, standing, and most particularly while stair-climbing. The patient's pain diminished when he was lying down. Previous treatments by other therapists, namely, chiropractic, general medical practitioner, physiotherapist, and manual therapist, were without permanent results. The patient reported no known accidents that may have caused back injury. The patient was a heavy smoker, but had stopped 15 years ago. Further history was unremarkable. He was not using any medication. The physical examination showed normal vital signs. The orthopedic examination showed the following results: Adam's test showed a left concave s-curve scoliosis with ribs raised on the right while standing, increasing during forward flexion. There was reduced lumbar range of motion in right lateral flexion and extension, and prone sacroiliac joint springing revealed a painful right sacroiliac joint. The neurologic examination was positive for the following tests: no Achilles and patellar reflexes were found. There was hypoesthesia on the right L4 to S1 dermatome. Erector spinae and piriformis muscles were bilaterally painful on palpation. The chiropractic spinal and postural examination showed a leg length difference of 1.5 cm on the right while lying supine, coinciding with posterior inferior positioning of the right posterior superior iliac spine. Left lumbar facet joints were hypomobile. The working diagnosis was chronic, moderate sacroiliac and lumbar facet dysfunction complicated by muscle hypertonicity of the piriformis and erector spinae muscles. Treatments were planned for 10 weeks, once a week followed by reexamination. The first 3

39 treatments used Thompson drop technique. After the third treatment, the patient noted that the daily pain had improved; however, the pain would return after 1 day. Trigger point therapy was used during the fourth treatment to reduce the hypertonicity. A side posture lumbar adjustment was applied at treatment 5; and together with the trigger point therapy, it provided immediate relief of the low back pain. During the fifth treatment (week 5), the patient stated he had a stomach ache while lying supine that was aggravated in side lying. The aches were described as sharp intermittent pain. Therefore, abdominal examination was performed immediately. Strong pulsations were found with light palpation over the middle of the abdomen. With deeper palpation, the aorta was estimated at 5 cm in diameter; and aortic bruits were detected by auscultation. Because an aortic aneurysm was suspected, the patient's general practitioner was informed immediately. An ultrasound examination was conducted the following day, and the abdominal aorta was measured to be 5.3 cm. Within 2 weeks, surgery was performed. Five months later, the patient had completely recovered from surgery.

Discussion Abdominal aortic aneurysm is an unusual cause of low back pain, compared with the frequency of mechanical low back pain. Abdominal aortic aneurysm is uncommon before 50 years of age and is asymptomatic in 66% to 75% of cases. 4,6 When there are signs, the classic complaints are back ache and abdominal pain. 1 It is important to know the signs and symptoms and the risk factors because the diagnosis is often not obvious. This results in a misdiagnosis in 20% to 30% of cases. 7 Patients may mention hip, flank, groin, or buttock pain in addition to their back or abdominal pain.6,8 The pain is often vague; but when there is compression of an AAA on an adjacent structure such as a vertebral end plate, the pain may be described as sharp or stabbing. 6 Patients may also report nausea, weight loss, early satiety, or a feeling of fullness. 7,8 Distal embolization or aortic occlusion due to thrombosis may give leg symptoms, with symptoms of sudden ischemia, painful cyanotic toes, and palpable pedal pulses. A rupture or dissection (in which hemorrhage into the media separates the layers of the vessel) causes more acute pain and has a sudden onset.6,7 The patient described in this case did have low back pain radiating into the

40 leg, but did not show any signs of thrombosis as described above. Age, sex, smoking, and family history are the most significant AAA risk factors. 3 The majority of those diagnosed with AAA are 65 years and older. 8 Abdominal aortic aneurysm is 5 to 10 times more common in men than in women. 2,6,7 This particular patient matches the criteria for risk factors of age, sex, and history of smoking. A history of smoking, defined as a consumption of more than 100 cigarettes in a lifetime, is a significant risk factor. 9 Cessation of smoking is the only modifiable factor associated with AAA expansion. 2 First-degree family members of a known aneurysm patient, male relatives in particular, are also at increased risk. 10 It is not known whether the patient had any relatives with AAA. One more positive association with AAA is atherosclerotic disease, which includes coronary heart disease and claudication. 4,6,8,9 Patients who have had abdominal imaging performed in the past 5 years are less likely to have AAA larger than 4.0 cm. 9 This patient did not have any other health complaints, which means that he either did not have any of the abovementioned risk factors or that he had not been questioned about it. No single risk factor or characteristic will definitively prove AAA because it is a multifactorial disorder with multiple genetic and environmental risk factors. 10 The usefulness of the clinical examination to detect AAA is limited. However, Mechelli et al 8 state that abdominal palpation and auscultation are important, especially when there is a suspicion of a nonmechanical or abdominal pathology for low back pain or when patients do not respond to the treatment. Another reason for clinical examination is when the clinical history gives a suspicion for AAA. In this case, the abdominal palpation was not performed at initial examination because of presenting symptoms; but the change in pain pattern warranted the examination to be done at a later visit. The abdominal aorta can be palpated at or slightly above the umbilicus in the epigastrium in the supine position with the knees bent.6 In thin people, an abdominal pulse can easily be felt. In the case of AAA, a prominent and often nontender, strong, pulsatile mass is felt.7,8 The accuracy of detecting AAA is dependent upon the patient's girth as well as the size of the aneurysm. When the patient's girth is 100 cm or greater, very few AAAs are palpable. However, as aneurysm size increases, the chance of clinical detection increases.11 This means that, in an obese patient, when

N. J. de Boer et al. the history has enough signs and risk factors present, a referral for an ultrasound evaluation may be warranted.12 In this average-sized patient, the AAA was so large that it was easy to find with palpation. In addition to abdominal palpation, auscultation for abdominal or femoral bruits may be useful for clinical detection of AAA. Auscultation is performed along the course of the aortic and femoral arteries. However, absence of a bruit does not exclude an aneurysm. 8 In this patient, auscultation was performed after the pulsatile mass was found on abdominal palpation and proved to strengthen the diagnostic suspicion. Abdominal aortic aneurysm is often an incidental finding with lumbar spine radiography. 6 Prior practitioners/therapists did not perform radiography, although the age of the patient may have been a reason to do so. Some authors have researched the viability of screening for AAA; however, abdominal palpation is not a very sensitive tool for this. 3,4,13 It is however suggested that screening of male smokers in the 65- to 75-year age group may be useful to diagnose asymptomatic abdominal aneurysms. 7,8 Because some of the risk factors were present, a screening palpation could have been done. These risk factors may be an indicator for an abdominal examination. Compared with abdominal palpation, ultrasound is an effective screening tool in men, but not in women. 14 An initial screening test in men older than 65 years reduces mortality by half from AAA in the population. 3,13,15 In this patient, the aneurysm was confirmed by ultrasound examination. Elective surgical repair of AAA has associated risks. Operative mortality rates vary from 1.4% to 5.8%, with a complication rate of 32.4%. 4,8,16 Therefore, aneurysms are not repaired until they are at least 43 mm; some studies even mention diameters of larger than 50 to 55 mm. 8,16 Greatest mortality is seen in patients with associated morbidity and those awaiting surgical repair for AAA, but age alone is not a limitation to surgery as seen in this patient. 4,16

Conclusion An AAA has specific symptoms and associated risk factors. If known risk factors are present, a clinical examination needs to be carried out, even though the sensitivity of the clinical examination is low. It should be a differential diagnosis in every male patient older than 50 years with low back pain. In case of suspicion, the patient should be referred for advanced imaging.

Abdominal aortic aneurysm

Acknowledgment The authors would like to thank John Nee for proofreading this manuscript.

Funding sources and conflicts of interest No funding sources or conflicts of interest were reported for this study.

References 1. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med 2002;137 (7):586-97. 2. Brady AR, Thompson SG, Fowkes FG, Greenhalgh RM, Powell JT. UK Small Aneurysm Trial Participants. Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance. Circulation 2004;110(1):16-21. 3. Fleming C, Whitlock EP, Beil TL, Lederle FA. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2005;142(3):203-11. 4. Crawford CM, Hurtgen-Grace K, Talarico E, Marley J. Abdominal aortic aneurysm: an illustrated narrative review. J Manipulative Physiol Ther 2003;26(3):184-95. 5. Rubinstein S, Pfeifle CE, van Tulder MW, Assendelft WJ. Chiropractic patients in the Netherlands: a descriptive study. J Manipulative Physiol Ther 2000;23(8):557-63. 6. Patel SN, Kettner NW. Abdominal aortic aneurysm presenting as back pain to a chiropractic clinic: a case report. J Manipulative Physiol Ther 2006;29(5):409.e1-7.

41 7. Dargin JM, Lowenstein RA. Ruptured abdominal aortic aneurysm presenting as painless testicular ecchymosis: the scrotal sign of Bryant revisited. J Emerg Med 2008. 8. Mechelli F, Preboski Z, Boissonnault WG. Differential diagnosis of a patient referred to physical therapy with low back pain: abdominal aortic aneurysm. J Orthop Sports Phys Ther 2008;38(9):551-7. 9. Lederle FA, Johnson GR, Wilson SE, et al. The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. Arch Intern Med 2000;160(10):1425-30. 10. Kuivaniemi H, Shibamura H, Arthur C, et al. Familial abdominal aortic aneurysms: collection of 233 multiplex families. J Vasc Surg 2003;37(2):340-5. 11. Fink HA, Lederle FA, Roth CS, Bowles CA, Nelson DB, Haas MA. The accuracy of physical examination to detect abdominal aortic aneurysm. Arch Intern Med 2000;160(6):833-6. 12. Lynch RM. Accuracy of abdominal examination in the diagnosis of non-ruptured abdominal aortic aneurysm. Accid Emerg Nurs 2004;12(2):99–107. 13. Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev 2007(2):CD002945. 14. Scott RA, Bridgewater SG, Ashton HA. Randomized clinical trial of screening for abdominal aortic aneurysm in women. Br J Surg 2002;89(3):283-5. 15. Thompson SG, Ashton HA, Gao L, Scott RA, Multicentre Aneurysm Screening Study Group. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. BMJ 2009;b2307:338. 16. Brady AR, Fowkes FG, Greenhalgh RM, Powell JT, Ruckley CV, Thompson SG. Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial. On behalf of the UK Small Aneurysm Trial participants. Br J Surg 2000;87(6):742-9.

Journal of Chiropractic Medicine (2010) 9, 42–43

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American Chiropractic Board of Sports Physicians President's message for 2010 There is an old proverb that notes, “May you live in interesting times.” We certainly live in interesting times; and we are facing interesting, and sometimes fearful, conditions. There are avenues to manage these times and conditions. We need only to think outside the box instead of being imprisoned by it. The President's message from William Moreau, DC, DACBSP, 1 year ago echoed the seriousness of the State of the Union by President Obama. Challenging times are still upon us. Our daily news is filled with the national home foreclosure rate, climbing unemployment rate, and the status of our tax dollars in the corporate bailout and more recent stimulus plan. The health care plan debate is the first story of the nightly news reports. I hear stories of practices downsizing by reducing office square footage, employees, and rehabilitation areas. Spouses have returned to work to make up the difference in net income loss. Impacts such as these are difficult and stressful, but they often bring a new set of solutions. Many doctors are thinking outside the box to find new solutions to business development and clinical skill sets. Many chiropractic students and recent graduates today are pursuing additional certifications, licenses, and skills. Many chiropractic colleges and universities offer acupuncture and oriental medicine (often as a dual program). Some colleges are now affiliated with nurse practitioner programs and accept the educational curriculum of chiropractic. Still other students are pursuing a Physician's Assistant certification. Other areas of markedly rising interest include strength and conditioning. Many doctors have obtained their Certification as a Strength and Conditioning Specialist through the National Strength and Conditioning

Association. A small number of doctors have challenged the Certified Athletic Trainer examination and completed the 1500 hours of practical experience to have an added certification. What do all of these added qualifications have in common? These are valid demonstrations of added clinical knowledge; and they are tools that can be used to access new environments, settings, and patients. The new doctors of chiropractic have recognized that they must have more to offer society and their patients to be competitive today, and they are seeking it. We are witnessing the continuing evolution of chiropractic. Doctors who are in full-time practice often state, “We don't have the time the new doctors have to participate in these programs.” This is often the case for doctors who are 5 to 15 years in private practice. There are a number of specialties and certifications that the practicing doctor can still access and complete. These subspecialties include chiropractic sports medicine and chiropractic orthopedics, to name a few. Some colleges and universities now offer part of the program from a distance-learning platform, which makes these rigorous programs more manageable for working doctors. Once again, the added qualifications enhance the ability of the doctor to provide a higher level of care and to have legitimacy in more aggressive marketing endeavors. Specialties in these areas have an inherent improvement in musculoskeletal diagnostic skills. Enhanced diagnostic skills are critical to enhance, and truly serve the role as, a portal of entry status. A justified musculoskeletal portal of entry status improves patient access and good patient outcomes by appropriate patient selection for conservative care or for referral to an indicated specialist. A

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News item portal of entry doctor will serve as a gatekeeper by definition and will also serve as an important member of the health care team. Chiropractic sports medicine is an avenue to legitimacy as viewed by the public at large, and it is concurrently an avenue to new business. We live in a sports-focused society. Advanced chiropractic sports medicine certification can, and does, provide knowledge and skills that can be implemented in practice and in marketing efforts to schools, teams, clubs, and sports organizations. As you may already know, the Diplomate of the American Chiropractic Board of Sports Physicians (DACBSP) has received external certification from the National Commission of Certifying Agencies. The National Commission of Certifying Agencies found that the ACBSP met the standards with the DACBSP certification to achieve this recognition. The process to obtain this included reviews of our examination processes, policies and procedures, appeals processes, continuing education, ethics, and assurance that no other organization has administrative or financial control over the ACBSP. This is a major step of which the ACBSP is proud. This external certification should be used by our certificants as well during their meetings to develop their businesses. Multidisciplinary groups have existed previously, but there is a new wave of increasing numbers of multidisciplinary practices. Added qualifications and certifications are critical in the selection of doctors for these groups. Although we are seeing difficulty in many practices, we are also at a time of unprecedented chiropractic achievement. Michael Reed, DC, DACBSP, is the

43 Director of Sports Medicine for the United States Olympic Committee. William Moreau, DC, DACBSP, is the Director of the Clinics of all 3 Olympic Training Centers. The Professional Football Chiropractic Society has members who serve all but one professional football teams. The greater the height of achievement of these doctors, the greater we can leverage their achievement to penetrate new markets and inform administrators, allied physicians, and coaches of the positions that doctors of chiropractic now hold. As one can see, there are many options and avenues to address the changing environment. The environment will always change as life always changes. The information technology industry has a simple expression—“Adapt or perish.” It is folly to think that we are immune to change in our thought process, knowledge, and skills. How we market these factors will change, too. The common, lay definition of insanity (most often referenced in business) is one keeps performing the same action again and again but expects a different outcome. If the conditions of your environment have changed, you must change as well. We cannot keep doing the same things we did in the past but expect a better outcome, even if the actions worked in the past. The previous actions may be obsolete now. There are ethical, honest avenues to further develop one's clinical skills and business. Consider chiropractic sports medicine as an option to further your career (www.acbsp.com). Joseph M. Horrigan DC, DACBSP Phone: (310) 279-4355 E-mail address: [email protected]

Journal of Chiropractic Medicine (2010) 9, 44–45

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Council on Forensic Sciences: an historical perspective Forensics is the science that deals with the application of medical facts to legal issues and/or proceedings. In chiropractic, most expert witnesses morphed from the ranks of diplomate programs that had little to no forensic components within their syllabi. The National Board of Forensic Chiropractors (NBOFC) was created to promote competency in the chiropractic professional's ability to perform forensic activities. This corporation began offering classes in the field of chiropractic forensics in 1997. 1 In 1998, the advisory executive board asked Steve Baker, DC, to investigate the requirements to achieve national accreditation in the field of chiropractic forensics. Based on this investigation, it became apparent that it would become necessary to form a separate nonprofit examination and certification organization. This entity would determine the job description for a forensic chiropractor, evaluate the credentials of applicants, administer specific examinations, and certify the successful completion of these activities as required by the National Organization of Credentialing Agencies. This corporation (circa 2000) was named the International Board of Forensic Scientists and Examiners (IBOFSE) and was awarded nonprofit status. The goal was to award a certificate entitled Certified Independent Forensic Chiropractic Medical Examiner. At the recommendation of legal counsel, the IBOFSE attempted to trademark this title to ensure unfettered usage of the title as required per national accrediting standards. The NBOFC preempted this endeavor and acquired a trademark for Certified Independent Forensic Chiropractic Medical Examiner. Subsequently, the president and CEO of the NBOFC stated that his goal was to acquire royalties for the use of this trademark. The IBOFSE determined that this would potentially disqualify the credentialing efforts under National Organization of Credentialing Agencies standards. On June 10, 1556-3707/$ – see front matter doi:10.1016/j.jcm.2010.01.003

2000, the president and CEO of NBOFC (for-profit) indicated that there “was a failure to develop volunteers or secure adequate financial resources to continue as a professional membership organization beyond 2000.” Therefore, per the recommendation of legal counsel, the IBOFSE applied for and received permission from the Arizona Corporation Commission for a name change to the American Board of Forensic Professionals (ABFP). The ABFP has received a service mark for a Diplomate of the American Board of Forensic Professionals (DABFP). A forensics syllabus was formulated before 2000. There was a concerted effort not to reinvent educational requirements that had been transcripted through recognized diplomate programs, but rather to use those hours (advanced standing toward core requirements) and to supplement where appropriate. Completion of these educational requirements (www.ChiroCredit.com) and passing the forensics-specific examination lead to certification as a forensic professional (DABFP). An example of such certification would be as follows: If one is a Diplomate of the American Board of Chiropractic Orthopedists (DABCO), one would be identified as a forensic professional concentrating in chiropractic orthopedics in legal matters. On January 01, 2001, the Council on Forensic Sciences (CFS) was formed. The CFS is a not-for-profit professional organization that establishes and promotes educational and training parameters, improve skill sets, and encourage collaboration in the practice of forensics. The CFS provides graduate and postdoctoral needsbased and evidenced-influenced educational activities, training, tools, and technology recommendations to meet the current and future needs of the forensic examiner. The CFS recognizes the ABFP as its certifying board. The CSF strives to offer courses leading to diplomate status, advocate current diplomates in other specialties

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to attain additional board certification in forensics, advocate that a core series of courses (similar to a master's degree core) be formulated and endorsed by all diplomate examining boards, systematically raise professional standards, be vigilant of developments in forensic science, and cooperate in a manner that reflects the interdisciplinary nature of forensic problem solving. During 2001, the CFS worked aggressively to gain a seat in the American Chiropractic Association (ACA) House of Delegates (HOD). On August 30, 2002, the ACA HOD established the CFS as a College and subsidiary of the Council on Chiropractic Orthopedics (http://www.acatoday.org/content_css.cfm?CID=3622). Past Presidents 2008-2009 2007-2008 2006-2007 2005-2006 2004-2005 2002-2003 2001-2002

Terrance M Eyerly, DC, DABFP Max L Denton, DC, DABFP, DABCO Thomas Ray, DC, DABFP, DABCOH Steven G Baer, DC, DABFP, DABCOH Richard Tesoriero, DC, DABFP Clayton W Hopkins, DC, DABFP Leanne N Cupon, DC, DABFP, DACRB

The CFS became the newest society to offer the Journal of Chiropractic Medicine as a membership benefit beginning with the journal's September 2009 issue.2 The Journal of Chiropractic Medicine is a peerreviewed journal indexed in PubMed. Effective October 01, 2009, the ACA HOD approved the elevation of the CFS to council status. Council status brings a greater voice for the CFS membership and will ensure increased awareness and education for forensic science in the chiropractic profession.

The CFS (http://www.forensic-sciences.org) offers education in forensic sciences for those interested in the field of forensics (ie, application of medical facts to legal issues and/or proceedings). This includes such topics as disability determination systems or programs, impairment rating systems, independent medical examinations, functional (work) capacity and physical assessment (federal) systems, return to work and fitness for duty (Department of Transportation [DOT]) assessment, fraud and abuse investigation, compliance issues, postpayment audits, ethics issues, documentation formulation, informed consent, and/or expert witness activities. Leanne N. Cupon DC Private Practice, Roswell, GA 30076 E-mail address: [email protected] Warren T. Jahn DC, MPS Private Practice, Roswell, GA 30076 Terrance M. Eyerly DC Private Practice, Hazelton, PA 18201

References 1. Fitzgerald P. The forensic chiropractic examiner, part I. Dynamic Chiropractic 2002;20(13). 2. Johnson C. The College on Forensic Sciences includes the Journal of Chiropractic Medicine as a membership benefit. J Chiropr Med 2009;8(3):A10.