The following case describes a 68 year-old woman with a 7(1/2) year history of worsening head and neck pain diagnosed as trigeminal neuralgia following surgical resection of a brain tumor. After years of unsuccessful management with medication and physical therapies, a therapeutic trial of chiropractic was carried out. Chiropractic care included ultrasound, manual therapies (manipulation and mobilization), soft tissue therapies, and home stretching exercises. After an initial treatment period followed by 18 months of supportive care the patient reported satisfactory improvement. It became evident that there were at least three sources of her symptoms: mechanical and/or degenerative neck pain, temporomandibular joint syndrome, and trigeminal neuralgia. While never completely pain-free, the patient continued to report that her pains reduced to minimal at times. At the most recent follow-up, the pain had not returned to pre-treatment intractable levels. This case study demonstrates the importance of diagnosing and treating multiple sources of pain and the positive role chiropractic care can have in the management of patients with these clinical conditions. The potential for convergence of sensory input from the upper three cervical segments and the trigeminal nerve via the trigeminocervical nucleus is discussed.

BACKGROUND:The use of complementary and alternative medicine has been increasing in Canada despite the lack of coverage under the universal public health insurance system. Physicians and other healthcare practitioners are now being placed in multidisciplinary teams, yet little research on integration exists.OBJECTIVE:We sought to investigate the effect of integrating chiropractic on the attitudes of providers on two healthcare teams.DESIGN:A mixed methods design with both quantitative and qualitative components was used to assess the healthcare teams. Assessment occurred prior to integration, at midstudy, and at the end of the study (18 months).SETTING:Multidisciplinary healthcare teams at two community health centers in Ottawa, Ontario, participated in the study.PATIENTS/PARTICIPANTS:All physicians, nurse practitioners, and degree-trained nurses employed at two study sites were approached to take part in the study.INTERVENTION:A chiropractor was introduced into each of the two healthcare teams.MAIN OUTCOME MEASURES:A quantitative questionnaire assessed providers' opinions, experiences with collaboration, and perceptions of chiropractic care. Focus groups were used to encourage providers to communicate their experiences and perceptions of the integration and of chiropractic.RESULTS:Twelve providers were followed for the full 18 months of integration. The providers expressed increased willingness to trust the chiropractors in shared care (F value = 7.18; P = .004). Questions regarding the legitimacy (F value = 12.33; P < .001) and effectiveness (F value = 11.17; P < .001) of chiropractic became increasingly positive by study end.CONCLUSION:This project has demonstrated the successful integration of chiropractors into primary healthcare teams.

Objective: This study was part of a larger demonstration project integrating chiropractic care into publicly funded Canadian community health centers. This pre/post study investigated the effectiveness of chiropractic care in reducing pain and disability as well as improving general health status in a unique population of urban, low-income, and multiethnic patients with musculoskeletal (MSK) complaints.Methods: All patients who presented to one of two community health center-based chiropractic clinics with MSK complaints between August 2004 and December 2005 were recruited to participate in this study. Outcomes were assessed by a general health measure (Short Form-12), a pain scale (VAS), and site-specific disability indexes (Roland-Morris Questionnaire and Neck Disability Index), which were administered before and after a 12-week treatment period.Results: Three hundred twenty-four patients with MSK conditions were recruited into the Study, and 259 (80.0%) of them were followed to the study's conclusion. Clinically important and statistically significant positive changes were observed for all outcomes (Short Form-12: physical composite score mean change = 4.9, 95% confidence interval [CI] = 3.8-6.0; VAS: current pain mean change 2.3, 95% CI = 1.9-2.6; Neck Disability Index: mean change 6.8, 95% CI = 5.4-8.1: Roland-Morris Questionnaire: mean change 4.3, 95% CI = 3.6-5.1). No adverse events were reported.Conclusions: Patients of low socioeconomic status face barriers to accessing chiropractic services. This study suggests that chiropractic care reduces pain and disability as well as improves general health status in patients with MSK conditions. Further studies using a more robust methodology are needed to investigate the efficacy and cost-effectiveness of introducing chiropractic care into publicly funded health care facilities.

STUDY DESIGN:Systematic review. OBJECTIVE:To determine whether results and conclusions on the effectiveness of exercise for workers with neck pain vary with the Cochrane Back Review Group Guidelines and best-evidence synthesis review methods. To identify methodologic weaknesses associated with these review methods that may impact on the validity of their results. SUMMARY OF BACKGROUND DATA:The Cochrane Back Review Group Guidelines and best-evidence synthesis have different approaches to appraising trial quality and incorporating quality into data synthesis. The impact of different review methods on the reproducibility and validity of review results is unknown. METHODS AND RESULTS:Systematic search of Medline, Embase, CINAHL, and Cochrane databases, without language restrictions. Twelve trials were selected. Two review methods were used to appraise trial quality and to incorporate quality into data synthesis. As recommended by the Cochrane Back Review Group Guidelines, trials were assigned quality scores using a scale. Results of all 12 trials were stratified into levels of evidence according to their scores. Based on these results, no treatment recommendation could be formulated. Best-evidence synthesis critically appraised methodology; trials were accepted on the strength of their scientific merit or rejected due to risk of bias. According to the 4 trials accepted for best-evidence synthesis, workers should be activated with exercise given its beneficial effect on patient-perceived recovery. Both the Cochrane Back Review Group Guidelines and best-evidence synthesis reviews were found to have weaknesses associated with their methods. CONCLUSIONS:Review results and conclusions are sensitive to methods for appraising trial quality and incorporating quality into data synthesis when the evidence consists largely of low-quality trials. Both the Cochrane Back Review Group Guidelines and best-evidence synthesis methods were found to have strengths and methodologic weaknesses that healthcare decision-makers should be aware of when interpreting systematic reviews.

Analyse van de literatuur vanaf 1996 tot heden met betrekking tot manipulatie en mobilisatie van de cervicale wervelkolom.

Objectives: To review the scientific evidence for both manipulation and mobilization therapies for the cervical spine. This report presents the results from a review of the medical, chiropractic, osteopathic, physical therapy, and dental literature on the efficacy, complications, and indications for manipulation and mobilization of the cervical spine, and the appropriateness ratings of indications for manipulation and mobilization. Methods: Articles were identified through searches of computerized databases [MEDLINE [Index Medicus], CHIROLARS [Chiropractic Literature Analysis and Retrieval System] etc.], review of article's bibliographies, and advice from experts. This yielded 362 primary articles on cervical spine manual therapy and 145 articles on complications. Priority was given to research that used randomized, controlled trial [RCT] designs. Second priority was given to non-experimental studies including cohort, case-control, and cross sectional studies. Case series and case reports were given lowest priority. This process produced 108 studies [16RCTs; 13 cohort; 27 case series; 52 case reports]. A panel of nine experts were provided with the literature review and were then used to complete two rounds of ratings for appropriateness of indications for manipulation and mobilization. The panel was multidisciplinary in composition. Results: 1. Literature Review. The review provided 67 articles on efficacy; 14 RCTs. For acute neck pain there were three RCTs for mobilization but only one for manipulation. Results varied but mobilization is probably better than collar and rest, but exercises are equally effective and the one trial of manipulation showed an immediate improvement that was not sustained at one week. For sub-acute and chronic neck pain there was one RCT for mobilization and four for manipulation. Results show short-term pain relief and motion enhancement. A small but significantly significant outcome was shown for manipulation compared to physiotherapy. For headache there were five RCTs, 10 case series, 19 case reports for manipulation and one RCT for mobilization. For muscle tension headaches the data support but do not prove that manipulation and/or mobilization may provide short-term relief for some patients. Evidence for long-term benefit is less conclusive. For migraine, one RCT and five other studies for manipulation were reviewed. The literature neither supports nor refuses manipulation/mobilization for migraine. For shoulder/arm/hand pain, thoracic outlet syndrome, carpel tunnel, temporomandibular joint [TMJ] disorders; blood pressure and heart rate, cervical spine/intersegmental motion, cervical spine curvature, miscellaneous conditions, there is insufficient evidence to refute or support either manipulation or mobilization. Articles documented 110 cases of complications published in English relating to manipulation. The vast majority involved vertebrobasilar accidents [VBA]. Based on the available evidence we estimate the rate of complications to be 1 per million manipulations. 2. Panel Ratings. The panel rated 1,436 indications [clinical scenarios of patients who might be considered for cervical manipulation or mobilization] in the final roung, with disagreement on 2% of the indications. They rated 43% as inappropriate for manipulation or mobilization. Appropriate and uncertain indications accounted for 16% and 41%, respectively. The frequency with which indications occur in a population is unknown and therefore the rate of inappropriate manipulation/mobilization being rendered to patients cannot be determined at this time.KEYWORDS: Manipulationmobilizationcervical spine