Journal of Chiropractic Medicine (2013) 12, 92–142

Abstracts of the Scientific Sessions from the WFC'S 12th Biennial Congress Proceedings, Durban, South Africa, April 10-13, 2013 Claire Johnson DC MSEd⁎, World Federation of Chiropractic Secretary to the WFC Research Council, Editor in Chief, JMPT, JCM, JCH, Professor, National University of Health Sciences Key indexing terms: Congresses [Publication Type]; Chiropractic

Abstract The World Federation of Chiropractic (WFC) celebrated the 25th year of the Congress by holding its 12th Biennial Congress in Durban, South Africa, on April 10 through 13, 2013. The WFC call for abstracts resulted in 173 submissions from 14 countries (Australia, Brazil, Canada, Denmark, Israel, Malaysia, New Zealand, Norway, Republic of Korea, South Africa, Spain, Switzerland, United Kingdom, and the United States). From these abstracts, 32 platform and 85 posters were selected for presentation. All authors were asked permission to have their abstract reproduced in the proceedings published in the Journal of Chiropractic Medicine. Of the authors who agreed and who attended the Congress, their abstracts are published here. These are abstracts only and do not represent completed research papers. The authors have been encouraged to complete their research publications as full papers and submit to the indexed, peer-reviewed journal of their choice. © 2013 National University of Health Sciences.

Introduction The World Federation of Chiropractic (WFC) celebrated the 25th year of the Congress by holding its 12th Biennial Congress in Durban, South Africa, on April 10 through 13, 2013. The Congress was hosted by the Chiropractic Association of South Africa (CASA), in association with Durban University of Technology and the University of Johannesburg. The Program Directors for this WFC Congress were Scott Haldeman, DC, MD, PhD, from the USA; and Charmaine Korporaal, MTech Chiro, from South Africa. The WFC call for abstracts resulted in 173 submissions from 14 countries (Australia, Brazil, Canada, Denmark, Israel, Malaysia, New Zealand, Norway, Republic of Korea, South Africa, Spain, Switzerland, United Kingdom, and the United States). From these, the abstract review committee (Fig 1) selected 32 platform and 85 posters for presentation at the Congress. All authors were asked if they wished to have their abstract reproduced in the proceedings published ⁎ Corresponding author. Claire Johnson, DC, MSEd, Secretary to the WFC Research Concil, 200 E. Roosevelt Rd Lombard, IL 60148. E-mail address: [email protected] (C. Johnson).

in the Journal of Chiropractic Medicine. Of the authors who agreed and who attended the Congress, their abstracts are published here. The peer review process for selection to the Congress was for selection purposes only and did not provide the opportunity for revision and resubmission. These are abstracts only and do not represent completed research papers. The authors have been encouraged to complete their research publications as full papers and submit to the indexed, peer-reviewed journal of their choice. The publishing of only the abstracts here allows the authors to publish their full papers in a journal without being considered duplicate publication, however it is the authors' responsibility to Phillip Bolton, DC, PhD; Australia Christine Goertz, DC, PhD; USA Heidi Haavik, BSc(Chiro), PhD; New Zealand Scott Haldeman, DC, MD, PhD; USA Claire Johnson, DC, MSEd; USA Greg Kawchuk, DC, PhD; Canada John J. Triano, DC, PhD; Canada

1556-3707/$ – see front matter © 2013 National University of Health Sciences.

Fig 1.

WFC Original Research Reviewers.

WFC 2013 Scientific Sessions abstracts inform the editor of the journal to which they submit that their abstract has been published in a proceeding document. For ease of searching through this publication, the order has been organized in platform and poster sections. Each abstract is listed alphabetically by primary author last name. The abstracts published in these proceedings were reproduced from those furnished by the authors. The information included in the abstracts is the responsibility of the authors and not the World Federation of Chiropractic or the Journal of Chiropractic Medicine.

93 compared to the Gmax. It was found that the TFL had a significantly greater (P = .05) activation in the manual muscle test position for the Gmed (123.69 μV ± 83.09 μV) than its own manual muscle testing position (92.69 μV ± 74.20 μV) using accepted testing positions. Conclusion: The results of this study allow a recommendation for exercises to strengthen the gluteal muscles, while decreasing TFL activation, progressing from PWB to FWB. This sequence is ClamsR for NWB, BridgeR and QuadrupedHipExtR for PWB, and RunningManR for FWB. It is also recommended that Standing HipAbd (stance leg) not be used, as it activates the TFL greater than the Gmax.

PLATFORM SCIENTIFIC PRESENTATIONS EMG activation of gluteal musculature during therapeutic exercises with and without Thera-Band resistance Barton Bishop, Jay Greenstein, Robert Topp, Jena Etnoyer Introduction: Over the past few years, the gluteus medius (Gmed)

and gluteus maximus (Gmax) muscles have been looked to as being important in the treatment of a myriad of conditions from knee to lower back pain. During that time, there have been studies to evaluate which exercises activate the Gmed and Gmax to the highest degree while limiting tensor fascia latae (TFL) activation. Purpose: This study was phase 2 of the developmental process, based off pilot data, evaluating Gmed, Gmax, and TFL in weight-bearing (FWB), partial weight-bearing (PWB), and non-weight-bearing (NWB) positions as well as performing exercises with resistance (R) and without elastic resistance (NR). It was hypothesized that resistance exercises will produce a greater percent maximum voluntary isometric contraction (%MVIC) for the Gmed and Gmax and lower %MVIC for TFL than those with NR. As the degree of weight-bearing increases, the %MVIC for gluteal muscles will increase. Methods: A convenience sample of 11 healthy male and females were recruited. Exclusionary criteria included: current hip or lower extremity injury, and history of hip surgery. Surface electromyography was used while performing 13 movements within 8 exercises of varying weightbearing and resistance levels. The participants' dominant leg was determined, and surface electrodes were placed on the corresponding muscles, based on recommendations from Rainoldi et al. The MVIC was established for each muscle by performing 3 maximal contractions and the order of exercises was randomized. EMG signals were smoothed, rectified and analyzed using a root-mean-square algorithm and data was expressed as %MVIC. Subgroups were compared: R versus NR; level of weight-bearing (NWB, PWB, FWB). Results: There was a significant difference (P .001) in NWB for Gmax%MVIC (36.32% ± 14.62%) and TFL%MVIC (11.16% ± 5.34%) and Gmed%MVIC (25.35% ± 10.39%) and TFL%MVIC (11.16% ± 5.34%) when performing ClamsR exercise. For PWB, the Gmax/TFL activation ratio, although not significant (P = .06), was greatest when the BridgeR was performed (38.34%MVIC Gmax and 19.16%MVIC TFL). The Gmed/TFL activation ratio was greatest during the QuadrupedHipExtR (24.68% and 18.23% respectively). Finally, for FWB there was a significant difference (P = .039) between Gmed%MVIC (55.36% ± 22.19%) and TFL%MVIC (40.11% ± 22.87%) when performing the RunningManR. There was no significant difference (P = .134) between Gmax%MVIC (50.94% ± 21.38%) and TFL%MVIC (40.11% ± 22.87). When performing Standing HipAbd (stance leg) as an exercise there was a significant difference (P .001) between Gmax%MVIC (20.29% ± 10.98%) and TFL%MVIC (41.62% ± 13.97%) but no significant difference (P = .496) between Gmed%MVIC (45.06% ± 9.84%) and TFL%MVIC (41.62% ± 13.97%). Thus, Standing HipAbd (stance leg) as an exercise produces significantly greater activation of the TFL

The effect of muscle vibration on force production parameters Jean-Alexandre Boucher, Martin C. Normand, Martin Descarreaux Introduction: Vibration exercises have been shown to improve muscle activity, force and power via neurogenic potentiation. When applied to a muscle, mechanical vibration is considered a valuable tool for studying the relative contribution of muscle spindles to proprioception and motor control. Acute muscle vibration may induce, in some circumstances, illusions of movements, a tonic vibration reflex and changes in the control of force production. It is not known, however, if vibration similarly affects force production in single-joint (ankle) and complex articular structures (lumbar spine). Therefore, the aim of the present study was to determine if vibration similarly alters the control of isometric force production of the ankle and the trunk. The results of this fundamental study will help clarify the mechanisms underlying the effects of vibration in the improvement or the deterioration of sensorimotor control while characterizing the vibration parameters most likely to create the desired changes. Methods: For this study, 41 healthy participants, 22 men and 19 women, engaged in the testing. All participants were recruited from the university student population. Written informed consent was provided by the participants. The experimental procedures were approved by the Ethic committee for human experiments of the Universite du Quebec a Trois-Rivieres CEREH, Canada. Force data (torque) in trunk extension and plantar flexion was obtained from an isokinetic device used in the isometric testing mode. Participants were asked to produce peak torques that were within 10% of the target goal set at 60% of their MVC under 3 vibration conditions : no vibration, 30 Hz and 80 Hz. Time to peak torque (TPT) and 3 measures of mean error in peak torque were measured: variable error (VE), constant error (CE) as well as absolute error (AE). Results: For both the trunk extension and the plantar flexion condition, the CE mean values were significantly higher in the presence of vibration (Ps b .001). Plantar flexion post hoc analysis also revealed a significant difference between 30 Hz and 80 Hz vibration conditions (P b .05). Therefore, having a high frequency vibration resulted in higher CE mean values than low frequency vibration or no vibration. Discussion: The main finding suggests that bouts of 30-second vibration stimulations of both low frequency and high frequency generate decreases in the accuracy (increases in magnitude of CE mean value) during an isometric trunk extension and plantar flexion force reproduction task. A modulating effect of vibration frequencies was only observed for the ankle. Surprisingly, the application of vibration did not alter the torque trial consistency (VE). It could be suggested that acute paraspinal and soleus muscle vibration interferes with torque generation sequence by distorting proprioceptive information. Conclusion: The current study provides evidence that muscle spindle inputs of the paraspinal and soleus muscles are crucial for accurate force production in trunk extension and plantar flexion. Vibration

94 also has the potential to modify neural activities involved in planning and executing a given movement.

The presence of abnormal lumbopelvic motion patterns as a clinical indicator of altered motor control during the prone hip extension test and active straight leg raise test Paul Bruno, David Millar, Dale Goertzen Introduction: Two clinical tests used to diagnose motor control impairments in low back pain (LBP) patients are the prone hip extension (PHE) test and active straight leg raise (ASLR) test. For these tests, it has been suggested that patients be classified as positive or negative based on the presence or absence (respectively) of specific “abnormal” lumbopelvic motion patterns. The inter-rater agreement of such a classification scheme has been reported for the PHE test, but not for the ASLR test. In addition, whether any differences exist in the frequency of examiner-reported classifications (positive/negative) between LBP patients and asymptomatic individuals has not been reported. Therefore, the objectives of this study were to: (1) investigate the inter-rater agreement of the examiner-reported classifications for these 2 tests, and (2) investigate whether LBP is associated with an increased frequency of positive classifications for these 2 tests. Methods: Twenty-two LBP patients and 40 asymptomatic volunteers participated in the study. Participants performed 3 to 4 repetitions of the PHE test and ASLR test. Two examiners classified the participants as positive or negative for each test based on the presence or absence (respectively) of specific“abnormal” lumbopelvic motion patterns. The inter-rater agreement (Kappa statistic) and relative risk (RR) of a positive result in the LBP patients were calculated for each test. The study was approved by the University of Regina Research Ethics Board. Results: Both tests demonstrated substantial inter-rater agreement for the LBP patients (PHE test: Kappa = 0.76, 95% CI = 0.54-0.98, P b .001; ASLR test: Kappa = 0.72, 95% CI = 0.50-0.95, P b .001). For the PHE test, the RR of positive classifications in the LBP patients was 1.31 (95% CI = 0.71-2.42, P = .39) and 1.36 (95% CI = 0.62-2.98, P = .46) for the 2 examiners. For the ASLR test, the RR of positive classifications in the LBP patients was 1.82 (95% CI = 0.86-3.85, P = .14) and 1.96 (95% CI = 1.01-3.79, P = .06). Discussion: The findings of this study suggest that the classification schemes described for the PHE test and ASLR test demonstrate acceptable reliability to be used clinically. Although the frequency of positive test classifications was not significantly greater in the LBP group for the PHE test, there was a non-significant trend for LBP patients to test positive more frequently for the ASLR test. These findings challenge the clinical relevance of such positive classifications. However, they may also reflect the non-specificity of the diagnostic criteria used for our LBP sample as it has been suggested that the these tests may be useful in distinguishing patients with lumbar spine pain and sacroiliac joint pain. In addition, the criteria used to indicate a positive test classification may be too general. Objectively quantifying the lumbopelvic motion patterns used by LBP patients during these tests may elicit specific motion patterns that are more indicative of motor control impairments in this population. Conclusion: Classification schemes for the PHE test and ASLR test based on the presence or absence of specific “abnormal” lumbopelvic motion patterns are reliable. However, further investigation is required to further comment on the clinical usefulness of the motion patterns demonstrated by LBP patients during these tests as a diagnostic tool or treatment outcome.

WFC 2013 Scientific Sessions abstracts Patient-reported perception of difficulty as a clinical indicator of altered motor control during the prone hip extension test and active straight leg raise test Paul Bruno, Dale Goertzen, David Millar Introduction: Two clinical tests used to diagnose motor control impairments in low back pain (LBP) patients are the prone hip extension (PHE) test and active straight leg raise (ASLR) test. For these tests, it has been suggested that patients be classified as positive or negative based on the presence or absence (respectively) of specific “abnormal” lumbopelvic motion patterns. For the ASLR test, the use of patient-reported perception of difficulty is also commonly used as an indication of impaired motor control. The clinimetric properties of scales of perceived difficulty have been relatively well-established for females with pregnancy-related pelvic pain. However, there are few reports investigating such properties in patients outside this sub-group of patients. In addition, whether an association exists between examiner-reported classifications (positive/negative) and patient-reported perceptions of difficulty during these tests has not been reported. Therefore, the objective of this study was to investigate the association between LBP and examiner-reported classifications, and patient-reported perceptions of difficulty for these 2 tests. Methods: Twenty-two LBP patients and 40 healthy volunteers participated in the study. Participants performed 3 to 4 repetitions of the PHE test and ASLR test. An examiner classified the participants as positive or negative for each test based on the presence or absence (respectively) of specific “abnormal” lumbopelvic motion patterns. The participants also rated their perceived difficulty in performing the tests using a six-point scale. A two-way ANOVA was used to examine the effects of group (LBP/asymptomatic) and examiner classification (postitive/negative) on the perceived difficulty scores for each test. The study was approved by the University of Regina Research Ethics Board. Results: For the PHE test, a significant main effect was found for group [F1,120 = 31.976, P b .001], but not for examiner classification (P = .18); no significant interaction between group and classification was found (P = .74). For the ASLR test, a significant main effect was found for group [F1,120 = 12.884, P b .001], but not for examiner classification (P = .20); no significant interaction between group and classification was found (P = .64). Discussion: The findings of this study suggest that LBP patients generally perceive more difficulty when performing the PHE test and ASLR test compared to asymptomatic individuals. However, the presence of specific “abnormal” lumbopelvic motion patterns during the tests does not seem to influence a person's perception of difficulty in performing the tests. There is debate in the literature regarding the association of patient-reported perception of difficulty during the ASLR test and LBP severity/disability, and there are no reports of whether such an association exists for the PHE test. In addition, there is a paucity of research regarding the association between such patient-reported scores and underlying lumbopelvic motor control parameters (motion patterns, muscle activation patterns) during either test. Objectively quantifying such parameters in LBP patients during these tests would allow for further comment on whether such an association exists. Conclusion: LBP is associated with changes in patient-reported perception of difficulty during the PHE test and ASLR test. The clinical usefulness of such scores as a diagnostic indicator of motor control impairment and treatment outcome in LBP patients requires further investigation.

WFC 2013 Scientific Sessions abstracts


PAASSPORT: primary care advanced access study—spreading the practice and optimizing interprofessional resources and treatment Yee-Ling Chang, Rick Glazier, Deborah Kopansky-Giles, Kamyab Ghatan, Judith Peranson

Biomechanical considerations of prone versus side-posture lumbar spine positioning Christopher Colloca, Jeb McAviney, Marek Szpalski, Laurent Fabeck, Robert Gunzburg, Mostafa Afifi, Robert Moore, Brian Freeman

Introduction: In the recent Commonwealth Fund survey, less than half of Canadians were able to access a healthcare provider (45%) the same or next day and 33% waited 6 days or more to be seen by a primary care physician or nurse. A poll conducted also found that 879,000 Ontarians do not have a primary care provider. This is not uncommon in other areas of the world. Without an available family physician, these patients subsequently access the emergency departments and are admitted to hospital more frequently than others. An innovative approach to optimizing practice management, open-access or advanced access scheduling, has been proposed as a method to address these issues. This concept aims to assist patients to access the providers of their choice in an appropriate time frame. Through improved access to one's interprofessional (IP) health team, continuity of care has been shown to increase with a subsequent decrease in repeat demand for the provider. By combining the advanced access concept with IP collaboration we expect to observe an increase in healthcare access and improvement in patient clinical outcomes. Objectives: In the Department of Family and Community Medicine at St. Michael's Hospital, a study team has been working within this advanced access model with respect to clinical visits. The purpose of this study is to expand the model to include chiropractors and psychologists, and to evaluate the model of IP team-based advanced access. Objectives include evaluating the: (1) Advanced access scheduling feasibility for all providers, (2) the ‘max-packing’ concept for patients requiring IP healthcare interventions (providing multiple services and providers on the same day), and (3) the impact of improved communication via the electronic health record. Methods: This project involves the implementation of open access to healthcare providers, both physicians and chiropractors, at the St. Michael's Hospital Department of Family and Community Medicine and the measurement of practice metrics of third next available appointment (TNA) and appointment supply and demand. The TNA provides an accurate measurement of wait times as it accommodates for fluctuations due to appointment cancellations. Measurement of the frequency of same-day appointment availability to patients was also conducted. To assess the impact of same-day access, we collected data on: external healthcare resources (ie, ED visits, after hour calls), preventative healthcare (ie, # of annual assessments), chronic health illnesses (ie, frequency/values of laboratory tests for diabetes), acute conditions seen (ie, infections, acute injuries), patient (via survey instrument) and provider satisfaction (focus groups). Results: Preliminary results (in the first 4 months of expanded data collection) have indicated that open access scheduling has reduced the wait times for patients requiring rapid access to their provider and shortened the time period for the TNA. In addition, patients have been able to ‘max pack’ their multiple provider appointments reducing repeat visits to the clinic and improving their access to care. Initial results have indicated an improvement in both patient and provider satisfaction with this model of delivery. Conclusions: Through the use of advanced access in IP care, we envision additional benefits including: increased comprehensive healthcare and decreased healthcare resource use such as, emergency and walk-in clinic care.

Introduction: Patient positioning is an important clinical consideration of chiropractic adjustment or spinal manipulative therapy for insuring patient comfort while providing a mechanical advantage in its delivery. Little is known, however, about the lumbar spine's biomechanical response to positioning. This study examined the effect of subject positioning on lumbar spine biomechanical responses in an in vivo ovine model. Methods: Following Animal Ethics IRB Committee approval (SA Pathology, Adelaide, Australia), 8 anesthetized adolescent Merino wethers 68.4 kg (SD = 4.5 kg) were biomechanically tested in vivo in the prone and side-posture positions using a previously validated mechanically testing apparatus mounted to an operating table. Ten-g tri-axial accelerometers were mounted to steel pins rigidly affixed to the L3 and L4 spinous processes to determine L3L4 intersegmental accelerations. Needle electromyographic (nEMG) electrodes were inserted into the multifidus muscles at the level of L3 and L4 and filtered nEMG data were used to determine the number of responses above 3.5 × baseline during testing in each posture and testing frequency. In each position, lumbar spine loads, displacements and intersegmental accelerations were quantified during 6 trials each at 2Hz, 12Hz, and 20Hz perpendicular oscillatory loads randomly applied for 10 seconds to the L3 spinous process under load control. Dynamic spinal stiffness was calculated from the load-deformation data. Dynamic stiffness, L3-L4 accelerations, and nEMG responses for each position and testing frequency were compared using one-way ANOVA with repeated measures and post hoc analyses. Results: Nearly 2-fold significant increases in lumbar spine stiffness were observed in the side-posture position at all 3 frequencies examined. Mean stiffness increased from 5.81 N/mm (SD = 0.27) to 9.32 N/mm (SD = 0.30) for 2 Hz testing (P = .001); 4.64 N/mm (SD = 0.18) to 10.11 N/mm (SD = 1.06) for 12 Hz testing (P = .002); and 10.21 N/mm (SD = 0.48) to 18.08 N/mm (SD = 2.09) comparing prone to side-posture (P = .009). Intersegmental accelerations were found to be significantly decreased in the dorsoventral (DV) and flexionextension (FE) planes for all frequencies except L3-L4 FE accelerations at 12Hz. Mediolateral (MED) accelerations were increased in the sideposture position for all frequencies examined (P b .05). Aside from 2 Hz vs 12 Hz testing in the side-posture position, significant differences in spinal stiffness (P b .01) and L3-L4 accelerations (P b .05) were found among all testing frequencies in each the prone and sidepostures. Increased nEMG responses were identified in the prone position compared with side-posture for 2 Hz and 20 Hz testing (P b .02). Discussion. Increases in dynamic lumbar spinal stiffness and reductions in L3-L4 accelerations in the DV and FE planes were observed in side-posture positioning. Because nEMG responses were decreased in the side-posture position, it is likely that these biomechanical outcomes are due to the anatomical constructs and frequency dependence of the passive viscoelastic properties of the lumbar spine. Increased MED L3-L4 accelerations in the side-posture position are consistent with the lumbar spine exposure to normal forces. Conclusions: In this ovine model, prone positioning provides the least lumbar spinal stiffness and larger physiologic responses compared to side-posture. These biomechanical findings may provide a mechanical advantage and have clinical relevance for practitioners applying lumbar spine chiropractic adjustments or spinal manipulation.

96 Alterations in cortical and cerebellar motor processing in neck pain patients following chiropractic manipulation Julian Daligadu, Paul Yielder, Julianne Baarb, Heidi Haavik, Bernadette Murphy Background: Chiropractic manipulation is one of the most common treatment methods for neck and back pain, however little is understood about the neurophysiological mechanisms of its efficacy. Subclinical neck pain (SCNP), affects a large amount of the population and is defined as recurring neck dysfunction, such as mild neck pain, ache, and/or stiffness in individuals who have not sought treatment for their condition. Recent evidence has shown that chiropractic manipulation results in changes to the central nervous system, and also changes cortical somatosensory processing and elbow joint position sense in SCNP groups of patients. Both the cerebellum and motor cortex have been demonstrated to be involved in the process of sensorimotor integration (SMI), and the motor cortex has been shown to be modulated via chiropractic manipulation. Due to the cerebellum being highly involved in the process of SMI, it is postulated that SCNP patients will have altered SMI leading to a disability to learn motor sequences, and that chiropractic manipulation of the neck will provide an alteration to this altered SMI in a SCNP group. Objective: To investigate if spinal manipulation and motor sequence learning (MSL) has an effect on SMI with respect to the cerebellum and motor cortex in SCNP patients. Methods: Electromyographic responses were recorded from the right first dorsal interosseous muscle in 10 volunteers who experienced subclinical neck pain (SCNP), before and after a combined intervention of chiropractic treatment and MSL. Transcranial magnetic stimulation (TMS) was performed on the left motor cortex and included the inhibitory measures of short interval intracortical inhibition (SICI) and long interval intracortical inhibition (LICI). Cerebellar TMS was performed over the right cerebellar hemisphere using the inhibitory measure of cerebellar inhibition (CBI), with conditioning stimulus intensities at 70, 80, and 90% maximal stimulator output. Changes in SICI and LICI were compared pre- to post-intervention using paired t tests; while the CBI measure was analyzed using a repeated measures ANOVA comparing factors of time and intensity. All participants consented to treatment by a registered chiropractor and the study received approval by the ethical committee at the University of Ontario Institute of Technology. Results: Following the intervention there was an improvement in MSL task performance as indicated by a 19% decrease in mean reaction time (P b .0001). There was a significant decrease in CBI following the combined spinal manipulation and MSL intervention with an overall significant effect for the factor time [F = (7,2) 7.92 (P b .05)]. No changes were seen in the inhibitory cortical measures. Conclusions: Altered SMI in SCNP patients may include modulation of cerebellar output to the motor cortex. The preliminary results of this study suggest that spinal manipulation is able to modify SMI in SCNP patient specifically involving the cerebellum, with concomitant improvements in motor skill acquisition. In light of the improved motor skill acquisition following the combined spinal manipulation and motor learning task, the neuroplastic changes that were also observed in cerebellar function are likely to be of benefit to the participants.

Access to traditional and CAM healthcare providers in Fortune 500 companies Peter Diakow Introduction: Corporate America funds a significant proportion of healthcare costs for their employees. Direct healthcare costs for

WFC 2013 Scientific Sessions abstracts work related injuries were reported to be $418 billion with indirect costs estimated at over $837 billion (Brady, Bass, Moser et al, 1997). Progressive companies are looking for cost effective ways to control these costs. In the last 15 years, scientific evidence began to emerge that significant health benefits and cost savings could be realized from more comprehensive strategies of care delivery (Green, Reiter & Kilpatrick, 2008; Lo, Rost & Beck, 2006). Inclusion of Complementary and Alternative Healthcare (CAM) providers who are often associated with wellness models of care may also offer cost effective alternatives. Data concerning access of the American workforce to complementary and alternative care providers is unknown. The purpose of this study is to determine corporate perceptions of employer provided access to CAM providers. Methods: This research proposal was passed by the Institutional Review Board of D'Youville College, Buffalo, N.Y. The study used survey methods in the form of a self administered paper questionnaire in a saturation sample of the Chief Medial Officers (CMO) (or their designates) of all Fortune 500 companies regarding current access to traditional and CAM providers. The details of access to each of the 5 traditional healthcare providers (medical doctors, nurses, physiotherapists, occupational therapists, and kinesiologists) either at the worksite or offsite are gathered. Details of access to each of the 6 CAM providers (chiropractors, massage therapists, dietitians, psychologists, acupuncturists, and naturopaths) either at the worksite of offsite are also gathered. Results: A total of 158 (31.6%) completed questionnaires were returned. Results suggest high rates of access to both traditional and CAM providers and common use of interdisciplinary health teams within the Fortune 500 companies. Eighty-eight percent of respondents indicated that company benefits allowed access to at least 1 of the 6 CAM providers listed and over 8% provided coverage for all 6 kinds of providers. The majority of respondents indicated that company benefits supported offsite access to between 2 and 4 CAM providers. The most common CAM providers for which company benefits allowed offsite access were chiropractors (79.1%) and psychologists (71.5%). Our data show that 44.3% of respondent companies provided coverage for onsite access to at least 1 CAM provider. Over 21% of respondent companies indicated onsite access was provided for 2 or more CAM providers. Conclusions: Fortune 500 companies in general are currently providing their employees access to a variety of traditional and CAM providers and many in the top 100 rankings are moving forward with integrated healthcare teams including both kinds of providers.

Manipulative therapies for infantile colic Dawn Dobson, Peter Lucassen, Joyce Miller, Arine Vlieger, Philip Prescott, George Lewith Objectives: To evaluate the results of studies designed to address the

impact of manipulative therapies (chiropractic, osteopathy and cranial manipulation) for infantile colic in infants less than 6 months of age. Methods: Systematic review and meta analysis (using RevMan software) of randomised trials evaluating the effect of chiropractic, osteopathy or cranial osteopathy for the treatment of infantile colic. Results: Six studies were identified for inclusion, representing a total of 325 infants. Meta analysis of the 5 studies that measured daily hours of crying suggest that manipulative therapies significantly reduced average crying time by 1.2 hours per day

WFC 2013 Scientific Sessions abstracts (95% CI − 1.89 to − 0.51). This conclusion is sustained for subgroups of studies with a low risk of selection bias (sequence generation/allocation concealment) (MD − 1.24; 95% CI − 2.16 to − 0.33); those with a low risk of attrition bias (MD − 1.95; 95% CI − 2.96 to − 0.94), and those that have been published in peerreviewed literature (MD − 1.01; 95% CI − 1.78 to − 0.24). However, in the subgroup of studies with a low risk of performance bias (parental ‘blinding’), the improvement in daily crying hours was not statistically significant (MD − 0.57; 95% CI − 2.24 to 1.09). One study considered whether the reduction in crying time was clinically significant, finding that a greater proportion of parents of infants receiving a manipulative therapy reported clinically significant improvements than did parents of those receiving no treatment (reduction in crying to less than 2 hours: odds ratio (OR) 6.33; 95% CI 1.54 to 26.00; more than 30% reduction in crying: OR 3.70; 95% CI 1.15 to 11.86). Analysis of data from 3 studies that measured ‘full recovery’ from colic found that manipulative therapies did not result in significantly higher proportions of parents reporting recovery (OR 11.12; 95% CI 0.46 to 267.52). One of the studies recorded adverse events and none were encountered. Conclusions: The studies included in this meta-analysis were generally small and methodologically prone to bias. The majority of the included trials appeared to indicate that the parents of infants receiving manipulative therapies reported fewer hours crying per day, based on contemporaneous crying diaries, and this difference was statistically significant. The trials also indicate that a greater proportion of those parents reported improvements that were clinically significant. However, most studies had a high risk of performance bias due to the fact that the assessors (parents) were not blind. When combining only those trials with a low risk of such performance bias, the results did not reach statistical significance. Further research is required where those assessing the treatment outcomes do not know whether or not the infant has received a manipulative therapy. There are inadequate data to reach any definitive conclusions about the safety of these interventions.

Manual and manipulative therapy plus exercise for symptomatic osteoarthritis of the knee: a multi-centre, single-blind, randomised, comparative trial Lauren Dwyer, Charmaine Korporaal, Gregory Parkin-Smith, James Brantingham, Tammy Cassa, Gary Globe, Debra Bonnefin, Victor Tong Objectives: Osteoarthritis (OA) of the knee is emerging as a major healthcare concern globally, with clinical guidelines and strategic health policy now recommending a combination treatments at an early stage for this disease. However, many of the recommended non-pharmacological treatments have yet to be compared to each other, so the purpose of this study was to test 3 treatment packages and to offer best-practice advice. Methods: Multi-centre, single-blind, randomised comparative trial of 83 participants with symptomatic knee OA, equally allocated to the 3 groups (28/group; Power = 82%). The 3 packages of care tested were manual and manipulative therapy (MMT), exercise prescription, and a combination of MMT plus exercise. Data were collected over a 4-week treatment period using the WOMAC questionnaire and the McMaster Overall Therapeutic Effectiveness (OTE) tool, alongside secondary outcomes, at baseline, the fourth visit, and at 1-

97 week follow-up. Missing data were replaced using a multiple imputation method and the data sets were analysed using repeated measures ANOVA with Bonferroni correction. Clinically meaningful outcomes were estimated by comparing results to a benchmark MCID of 20% (WOMAC). Results: Drop-out was 6% (n = 5) with missing data (7% of all data; 137/1966) being replaced. Within-group analyses demonstrated that all 3 groups had significant changes in scores from baseline to 1week follow-up (P ≤ .003), with the combination of MMT plus exercise showing the greatest statistical (P ≤ .0003) and clinically meaningful (≥ 53%) changes. Between-group comparison did not reveal any statistically significant differences (P = 1.0). Conclusions: All 3 packages of treatment appear to be equally as effective in the short term, so any could be offered to patients, although the combination of MMT plus exercise demonstrated the largest change in scores. Since contemporary care involves the optimisation of treatment alongside lifestyle modification to achieve the best possible outcomes, MMT plus exercise is proposed as best-practice.

Mechanical behavior of sacral and iliac cartilage under compression and pelvic rotation Dennis Enix, Douglas Smith Introduction: Articular cartilage is a complex viscoelastic macro-

molecular material that acts as a low friction surface to absorb and distribute the shearing forces that cross the sacroiliac joint under axial loading. Methods: Finite Element model of sacral and iliac cartilage was developed from a cadaveric specimen to examine compressive shearing forces on sacroiliac joint cartilage during angular rotation. A 1.81 mm and 0.80 mm layer of sacral and iliac cartilage was modeled as a linear elastic material with 1.2 MPa Young's modulus and Poisson's ratio of 0.049. Sacral bone was modeled with a Young's modulus of 16,000 MPa and a Poisson's ratio of 0.26.4 The model contained 31,080 elements that defined the separate layers of sacral and iliac cartilage. The sacral and iliac surfaces had a contact coefficient of friction of 0.005. A 445 N vertical load was placed across the sacroiliac joint while the joint was rotated through the angle α about the x-axis from a neutral pelvic position of 11.4° to 21.0°, compressing layers of sacral and iliac cartilage against non-deformable sacral bone. Donor consent and university ethics committee approval was obtained for this study. Results: Axial loading creates a lateral displacement of the sacrum and high shearing stresses at the sacral/iliac cartilage and cartilage/ bone borders. Angular rotation from 11.4° to 21.0° created Poisson effect deformation of 0.08 MPa for sacral cartilage and 0.010 MPa for iliac cartilage. Contact pressure on sacral cartilage decreased from 0.496 to 0.488 MPa, while contact pressure on iliac cartilage varied from 0.488 to 0.493 Mpa. Von Mises stresses on sacral cartilage increased from 0.334 to 0.364 to 0.385 MPa while iliac cartilage stresses decreased from 0.191 to 0.185 MPa then increased to 0.190 MPa. The point of load application at the center of the z-direction on the pelvic side of the SI joint had a slight linear and angular motion in each of the x,y, and z directions. The out-of-plane motion of the pelvic center ranged from − 0.0194 mm to + 0.008 mm, increasing with α while the reverse is true for maximum von-Mises stresses. Discussion: The Poisson effect on cartilage restricted tissue deformation in one direction by the non-deformable sacral bone

98 creating lateral displacement and high shearing stress between sacral and iliac cartilage. Angular stresses create irregular changes in cartilage that follow the geometric articular surface topography. Due to the interosseous connection of the sacral and iliac sides, the vertical shearing force on the sacroiliac side cause the cartilage surfaces of the joint to be compressed together. When an axial load is applied across the joint, the iliac side exerts a force on the sacral side displacing it superiorly in the y-direction. When the sacral side is pushed superiorly, the joint surfaces are compressed. These vertical displacements increased from 0.416 mm to 0.430 mm as the angle increased from 0° to 21.0°. Conclusions: As the pelvis rotates anteriorly sacral cartilage contact stresses decrease and iliac cartilage increases. Von Mises stresses however, increase on both sacral and iliac cartilage during rotation.

How the doctor-patient encounter and expectancy influence outcomes in an open-label randomized trial of spinal manipulation for the care of low back pain: a structural equation model Mitchell Haas, Darcy Vavrek, David Peterson, Moni Blazej Neradilek, Nayak Polissar

WFC 2013 Scientific Sessions abstracts generally well balanced across groups. Other relationships between variables will be presented. Discussion: The association of pain outcomes with the DPI was stronger than with the study intervention. Therefore, attempts should be made to balance DPI characteristics across groups to control its effects on outcomes in open-label randomized trials. We were successful in balancing the measured DPI characteristics with minimal training of the study chiropractors. This demonstrates the ability to mitigate, in part, the effects of the DPI in manipulation trials when blinding is not feasible. Conclusion: Patient perception of the DPI can confound outcomes in open-label trials if provider behavior is systematically different across treatment groups. The effects of a broader range of characterizing variables and methods for balancing them are a worthy topic of investigation.

Increased upper limb cortical excitability following cervical spinal manipulation Heidi Haavik, Imran Khan Niazi, Diane Sherwin, Stanley Flavel Objective: Over the past decade there has been a growing body of

Introduction: The influence of the doctor-patient interaction (DPI)

and the expectations of treatment success they generate are important in unblinded randomized trials. We have previously reported a modest effect of the number of treatments with spinal manipulation on chronic low back pain (LBP), but it remains to be determined if patient perceptions of the treatment encounter make an important contribution to these outcomes. We therefore conducted a secondary analysis to identify the effects of DPI and determine if doctor influence can be balanced across treatment groups. Funding by grant NCCAM/NIH (U01AT001908). Methods: We randomized 400 patients with chronic LBP to receive one of 4 dose levels of care: 0, 6, 12, or 18 sessions of lumbar spinal manipulation from a chiropractor. All participants were scheduled for 3 visits per week for 6 weeks. Care was rendered at each visit, either the index intervention or light massage to control attention and hands on from a chiropractor. Patients were treated at one of 8 clinics. Chiropractors were instructed to treat patients in all treatment groups with equal enthusiasm. Structural equation modeling was conducted to identify the direct, indirect, and total effects of study intervention, DPI, and expectation of treatment success on LBP intensity. Study treatment was represented by the linear dose-response of spinal manipulation across treatment groups. The DPI at 6 and 12 weeks was characterized by patient perception of chiropractor enthusiasm for, confidence in, and comfort with the treatment rendered. Standardized path coefficients (Î 2) evaluated on a − 1 to 1 scale quantified the strength of the relationship between variables and showed the relative magnitude of variable effects on LBP intensity. Their interpretation is similar to that of a correlation coefficient. Results: The strongest determinant of LBP intensity was earlier pain intensity (|Î 2|total = 0.44 to 0.66). The total effects of the DPI evaluated at 6 weeks on 6 and 12-week pain were |Î 2|total = 0.22 and 0.15. The linear dose effects at the 2 time points were |Î 2|total = 0.11 and 0.12. Expectation at 6 weeks had a total effect of |Î 2|total = 0.13 on 12-week pain. The effects of the DPI on pain were both direct and mediated through expectations and earlier pain. Despite the relationship of DPI with pain outcomes, the DPI variables were

research demonstrating neural plastic changes following spinal manipulation. Several studies have shown neuroplastic changes to early sensorimotor integration and motor control. Two of these studies, utilizing specific transcranial magnetic stimulation (TMS) protocols prior to and after spinal manipulation, have demonstrated alterations in the activity within specific intracortical facilitatory and intracortical inhibitory pathways for an upper limb muscle (abductor pollicis brevis; APB). This current study sought to investigate whether the previously shown motor control changes of the APB could be due to alterations in recruitment patterns of the APB motor neuron pool following spinal manipulation. Methods: Motor evoked potentials (MEPs) were recorded from APB of the dominant limb following single pulse TMS of the contralateral motor cortex in 8 subjects (24.12 ± 2.85 years, 4 male and 4 females) before and after either a spinal manipulation intervention or a control intervention. Recruitment curves were compiled from the averages of 10 MEP amplitudes recorded at each of 5 different stimulus intensities (90%, 100%, 110%, 120% and 130% of rest threshold). To investigate the effect of spinal manipulation on the amplitude of the MEPs a two-way repeated measures ANOVA with factors time (pre vs. post), and stimulus intensity (90%, 100%, 110%, 120% and 130% RTh) was carried out separately for the manipulation and control intervention data. To assess for changes in parameters of the recruitment curve the maximum value or plateau (MEPmax), the stimulus intensity required to obtain a 50% response (S50) and the slope parameter k of the Boltzmann-fitted data were assessed with paired t tests. To assess spinal excitability changes F wave persistence and amplitudes were recorded following median nerve stimulation at the wrist. The Northern Y Regional Ethics Committee approved this study in accordance with the Declaration of Helsinki. Results: The analysis of the spinal manipulation data revealed a significant effect for the MEP amplitudes for factors time (F = 9.88, P = .0024) and intensities (F = 18.13, P b .0001). Paired t tests revealed that MEPmax following spinal manipulation had increased significantly by 89 ± 95% (P = .012). The S50-variable and the slope parameter k of the Boltzmann-fitted data remained unchanged. No changes were observed following the control

WFC 2013 Scientific Sessions abstracts intervention. No changes in F-wave parameters were observed for either intervention. Conclusion: The preliminary results of this study add to the growing body of evidence that suggests spinal manipulation leads to neuroplastic changes in cortical excitability of upper limb muscles. Previous research exploring the neural mechanisms which underlie the shape and parameters of the input-output relation have suggested that the MEPmax, also known as the plateau of the sigmoidal shaped recruitment curve most likely reflects the balance between excitatory and inhibitory components of the corticospinal volley. The finding from the current study therefore suggests that spinal manipulation alters the balance between excitatory and inhibitory components of the corticospinal volley. This is in accordance with earlier TMS studies that found muscle specific changes in intracortical inhibitory and excitatory pathways following spinal manipulation.

Cortical representation of perceived harmfulness of daily activities in healthy subjects Sabina Hotz-Boendermaker, Michael Meier, Philipp Staempfli, Erich Seifritz, Kim Humphreys Background: Fear-avoidance beliefs (FABs) are represented by a specific fear related to movement and physical activity that is wrongfully assumed to cause (re)-injury. FABs represent significant cognitive factors in explaining the transition from acute to chronic condition. Given the importance of the topic, there is only sparse evidence of FABs in the general population. The aim of the present investigation was therefore to investigate FABs in healthy subjects behaviorally and with neuroimaging methods. Methods: FABs were measured in 37 subjects, (mean age 29 SD 6, 22 female) using a German Version of the Tampa Scale for Kinesiophobia for the general population (TSK-G). In addition, pictures of harmful (lifting a flowerpot, shoveling, vacuumcleaning) and harmless activities (walking, going up/down the stairs) were presented. Participants rated each picture by an 11-point visual analogue scale (VAS) anchored with the terms harmless/most harmful for the back. The same harmful/harmless activities were displayed as videos during functional magnetic resonance imagining (fMRI) and 15 of all subjects had to observe the activities. Immediately after the presentation, subjects rated the harmfulness/ harmlessness of the displayed activities on a similar VAS. Results: The TSK-G revealed a good internal reliability (Cronbach Alpha = 0.78) and mean of 33 sum points (SD 7.4) (Houben 2005). Six out of 37 subjects were above the threshold (N 37 sum points) that indicate kinesiophobia in LBP patients. The ratings of the harmless (mean 0.51, SD 1.1) versus harmful pictures (mean 3.4, SD 3.4) were significantly different (t test; P = .000). Similarly, there was a significant difference (P = .000) between harmless (mean 0.65 SD 1.4) and harmful videos (mean 4.8, SD 2.3). There was also a significant correlation between harmless activities for pictures and movement observation (rS = 0.5, P = .003) and harmful activities rS = 0.4, P = .025). No relationship was found between the TSK-G and the ratings of the harmful/harmless activities. The fMRI results revealed similar activation patterns for observed harmful and harmless activities bilaterally in premotor, parietal and temporal cortices. The contrast between harmful and harmless activities revealed a neural correlate of perceived harmfulness in the extra striate body area (EBA) at the posterior

99 end of the inferior temporal sulcus, a region responding selectively to natural human body movements. Discussion: The behaviorally computed significant difference of harmful/harmless activities of the VAS ratings revealed its cortical representation in the EBA. This region might be responsible for the integration of visual body representation with somatosensory information. This result could indicate the salience of perceived harmful activities for the back in pain-free healthy subjects. Similarly, 6 of 37 subjects showed a sum score in the TSK-G that point toward high FAB, although there is no actual danger of harm to the back. Conclusions: This study suggests that inappropriate perception of harmful/harmless activities and back pain exists in the asymptomatic general population. This may have important implications for early identification of patients at risk of becoming chronic and the need for greater public education regarding perceptions related to FAB in back pain.

The incidence of hypochondia in healthcare education: a survey of chiropractic students Tony Hubbard, Adrian Hunnisett, Christina Cunliffe Introduction: Hypochondriacal concerns are reportedly associated

among people in certain occupations including doctors and medical students resulting in a widely acknowledged phenomenon called Medical Students' Disease (MSD), a transient form of hypochondriasis. Heathcare education exposes students to various stresses, anxieties and pressures linked to the study of illness and disease and such factors can make students vulnerable to psychosocial health problems and dysfunctions that may compromise physical, mental, and social health and can include anxiety, stress, depression and other related concerns such as hypochondriasis. Presently, no existing studies address hypochondriacal concerns in the chiropractic student population and in identifying the presence of MSD. This study attempts to address these factors and it is hoped that the findings will help to fill gaps in present knowledge and offer a basis for future student support in both medical and non-medical student courses. Method: Following ethical approval, an observational, crosssectional survey was undertaken using a semi structured, self administered questionnaire addressing health issues. The degree of hypochondriacal concerns was assessed using The Medical Students' Disease Perception Scale, developed by Moss-Morris and Petrie, (2001). Participants were selected from all year groups of a 5 year Master of Chiropractic programme at a College of Chiropractic. Questionnaires were issued mid-point through the year, towards the end of the first semester. Data was collated for descriptive and appropriate inferential analysis. Results: A total of 132 responses were received from a target population of 155, giving an overall response rate of 85%. Over half of respondents (52%) rated their overall health as good. However 31% claim that their health has changed for the worse. The relationship between stress and disease perception was significant (P b .05). A fifth (20%) of respondents developed new concerns or conditions during their studies, particularly in Year 4. Half of new conditions across the entire respondent population were musculoskeletal, with emotional being the next largest (22%). A significant relationship was found between hypochondriacal concerns and development of a new condition (P b .05). Perception and

100 hypochondriacal concerns, as measured by the medical students disease questionnaire, increased after Year 1 and continued to increase until Year 4 before starting to reduce. Differences were not strictly statistically significant (P N .05), but near significance was reached (P = .07). Conclusion: The presence of health anxiety in chiropractic college students has been demonstrated to exist at a variety of levels. Previous studies have argued the prevalence and timing of the occurrence of medical students' disease in medical and non medical school populations but have paid less attention to what can be learned about health anxiety management in students (Woods, 1996; Singh, 2004; Dyrbye et al, 2006). Medical education, in any form, is undoubtedly a stressful experience for all students but an awareness and support of increased health anxiety in an educational setting may minimise a phenomenon that can undoubtedly cause significant distress.

Prognostic factors for improvement in the short- and medium terms in musculoskeletal patients presenting for chiropractic treatment Hugh Hurst, Jennifer Bolton Introduction: Predicting patients undergoing treatment who are

more likely to improve than others remains both a research and clinical priority. In spite of a plethora of research into prognostic factors, there appears to be little consistency between studies regarding these factors. Where they are identified they appear only moderately predictive at best. This study explored prognostic variables in a group of patients seeking chiropractic care for a musculoskeletal condition, predominantly back and/or neck pain. We have previously reported on this topic, but this study reports on additional patients using a more robust measure of improvement. Method: Consecutive patients with a new episode of musculoskeletal pain completed a questionnaire at baseline, then again at the fifth visit, and if they were still consulting, at the 10th visit. Improvement was defined as those patients reporting a clinically significant raw change score (15 points) from baseline on the Bournemouth Questionnaire (BQ). Independent predictors were identified using a forward stepwise multivariate logistic regression model. ROC curve analysis (area under the curve, AUC) was used to determine the validity of the predictive model to distinguish patients who had improved from those who had not. Results: Data were collected from 2654 patients with musculoskeletal pain amenable to chiropractic treatment at baseline and at the fifth visit. Of these, 600 patients were still consulting and reported their outcomes at the 10th visit. At baseline, age, inappropriate markings on a pain diagram, duration of the episode, expectation to be working normally in 6 months time, expectation of recovery in the next few weeks, and scores on the pain severity, disability in activities of daily living (ADL) and social interactions, anxiety and work fear avoidance scales of the BQ all independently predicted improvement at the fifth visit. This predictive model had a sensitivity and specificity of 61.2% and 81.9% respectively, and AUC of 0.78 (95% CI 0.76 to 0.80). The predictive model of improvement at the 10th visit consisted of the baseline variables inappropriate markings on a pain diagram, duration of the episode and scores on the disability (ADL), depression and locus of control scales of the BQ, as well as self-reported improvement and a clinically significant raw change score on the BQ at the fifth visit.

WFC 2013 Scientific Sessions abstracts The sensitivity, specificity and AUC of this predictive model were 69.1%, 82.3% and 0.89 (0.86 to 0.92) respectively. Conclusion: These findings support those of others in identifying duration of the episode and early improvement as strong predictors of improvement. Patient expectations regarding their condition appear to be predictors of early improvement, but not of later improvement presumably because by then these expectations have been realised (or not). The pain diagram, for some time now out of fashion as a ‘yellow flag’, was a predictor of both early and later improvement, and should be reconsidered in this light. Moreover, all the scales on the BQ proved useful predictors either in the short or medium terms, highlighting its clinical utility in prediction as well as a measure of outcome.

The effect of impulsive spinal manipulation on sciatic nerve regeneration HanSuk Jung, JooHyun Ham, JinOk Choi, Christopher J. Colloca, Xiaohua He, Barry Draper, SungEun Kim, IlGyu Ko, MalSoon Shin Objective: The purpose of this study was to elucidate the effects of impulsive spinal manipulation on the regeneration of the sciatic nerve crush injury in the rats. Methods: Thirty-five adult female Sprague-Dawley rats were randomly assigned into 5 groups (n = 7 in each group) to study the effect of sciatic nerve injury and spinal manipulation interventions: a sham operation group (Sham), a sciatic crushed nerve injury group (SNI), a sciatic crushed nerve injury and single impulse thrust treated group (SNI + Impulse 1), a sciatic crushed nerve injury and 5 impulse thrusts treated group (SNI + Impulse 5), and a sciatic crushed nerve injury and 10 impulse thrusts treated group (SNI + Impulse 10). Sciatic nerve crush injury was induced using a validated method and after one day, we applied the impulsive spinal manipulation at the level of L6-S1 using an Impulse Adjusting Instrument whose force was calibrated to normalize the body weight of the animals. The spinal manipulation interventions were conducted once a day for 7 consecutive days consisting of a single impulse thrust, 5 impulse thrusts (6 Hz), and 10 impulse thrusts (6 Hz) in the respective groups. To measure the functional recovery of sciatic nerve, sciatic function index (SFI) was analyzed, and the expressions of the myelin basic protein (MBP) and myelin proteolipid protein (mPLP) in the sciatic nerve were determined by western blot. Results: Induction of sciatic nerve crush injury significantly decreased the SFI, and the expressions of MBP and mPLP in the proximal sciatic nerve to the injury site were decreased as compared with Sham (P b .05). Impulsive spinal manipulation significantly improved the SFI, and also significantly increased the expressions of MBP and mPLP in the sciatic nerve in all 3 treatment groups as compared with SNI (P b .05). When comparing the treatment groups, the 5 impulse group showed a trend for benefit over the single thrust or 10 thrust group. Conclusion: In the present study, sciatic nerve crush injury impaired the function of sciatic nerve by decreasing the expressions of MBP and mPLP which play important roles in myelin formation. Impulsive spinal manipulation significantly improved the function of sciatic nerve through enhancing the expressions of MBP and mPLP. From these results, it can be inferred that impulsive spinal manipulation may facilitate regeneration of the sciatic nerve after injury. The exact mechanisms of such improvement need further investigation.

WFC 2013 Scientific Sessions abstracts Peripheral oxidative stress blood markers in patients with chronic back or neck pain treated with high velocity–low amplitude manipulation Carolina Kolberg, Andréa Horst, Ana Paula Konzen Riffel, Taína Scheid, Maira Silmara Moraes, Felipe Coutinho Kullmann Duarte, Wania Aparecida Partata Objective: Some evidence supports that high velocity–low amplitude (HVLA) manipulation beyond the analgesic effect may evoke some visceral and motor reflexes by changes in neuron excitability. Reactive oxygen and nitrogen species (RS) is well known to cause oxidative stress and is related to certain pathogenic status and aging. In addition, RS can also serve as signaling molecules to regulate gene expression of proteins and enzymes that modulate neuron excitability and for this reason it seems to be involved in persistent pain. We demonstrated previously a possible correlation between the HVLA manipulation and oxidative stress parameters. An increase in systemic catalase activity was demonstrated after 6 sessions of HVLA manipulation in 2 weeks of treatment. Besides, glutathione peroxidase (GPx) activity seemed to require a longer period of treatment (ie, more than 2 weeks) to show a significant change. For this reason, the aim of this study was to investigate the effect of a longer period of HVLA treatment in oxidative stress status in individuals with chronic back or neck pain. Methods: After approval by the Ethical Committee of the Federal University of Rio Grande do Sul, twenty-three individuals aged 38.2 ± 11.7 years with chronic back or neck pain defined by the Chronic Pain Grade Brazil, with a sedentary life-style, no comorbidities or in adjuvant therapy underwent a treatment of 10 sessions of HVLA manipulation 2 times a week for 5 weeks. All patients were treated by the same chiropractor and under the same conditions. Pre and post-treatment peripheral oxidative stress blood markers were accessed by xylenol orange method to determine lipid hydroperoxide plasmatic. Also, to determine plasmatic levels of nitric oxide (NO), nitrate + nitrite were measured. Red blood cells were analyzed for the activity of antioxidant enzymes superoxide dismutase (SOD), catalase and GPx. The results were analyzed by Paired t test. Differences were considered significant when P b .05. Results: The formation of lipid hydroperoxides and NO metabolites did not differ after treatment. Also, the antioxidant enzyme catalase had no change after treatment, but there was a significant increase in SOD (0.35 ± 0.03 versus 0.44 ± 0.04; mean ± SEM; P = .005) and GPx (7.91 ± 0.61 versus 14.07 ± 1.07; mean ± SEM; P b .001) activities. Discussion: The increase in SOD and GPx activities may be related to the lack of change in RS, since SOD is specific to superoxide radicals detoxification and GPx is an important enzymatic mechanism for the disposal of peroxides, producing water or alcohol and reduced glutathione. Thus, a longer period of HVLA treatment changes differently the activities of antioxidant enzymes compared to our previous studies. Conclusion: HVLA spinal manipulation seems to change antioxidant enzymes activities which could prevent from possible oxidative stress damage.

An assessment of chiropractic adjustment beds as reservoirs for normal flora and infectious bacterial pathogens, at a chiropractic teaching clinic Jana Logtenberg, Aadil Docrat, Bharti Odhav

101 is therefore expected that these beds are hygienic, clean and free of infective organisms. However, research has indicated the majority of bacteria on beds, can persist on these dry inanimate surfaces for months. Thus, insufficient disinfection procedures create continuous sources of pathogens endangering patients, healthcare workers and students. This research study aimed to assess the beds as reservoirs for micro-organisms, at a chiropractic teaching clinic (clinic) in South Africa. Method: After IRB approval was obtained, a selection of samples obtained from the headrests and armrests of the beds were serially diluted, plated in duplicate (using the spread plate technique) and incubated for 24 to 48 hours at 37°C. After inspection for the presence of micro-organisms, those present were enumerated to determine their quantities, the microbial build-up throughout the day, as well as the degree of the transmission from the patients to the beds during treatment. The incidence of the micro-organisms was established, along with their identities, using microscopic and macroscopic characteristics. These micro-organisms were also used to assess the efficacy of the disinfectant currently in use by the clinic. Results: Microbial growth was present on 89,4% of the beds sampled. The quantities of the micro-organisms increased significantly (P = .027) from 7:30 AM to 16:30 PM, with the median increasing from 25 colony forming units (cfu)/cm 2 to 714 792 cfu/cm 2. The microbial build-up was highly significant (P b .001), with a median of 346 cfu/cm 2 at 7:30 AM and 10:30 AM; increasing to 162 291 cfu/cm 2 by 13:30 PM and 250 million cfu/ cm 2 by 16:30 PM. There was also a significant increase (P b .001) in the quantity of micro-organisms during treatment with a median of 0 cfu/cm 2 before treatment that rose to 281 750 (ml −1) (23 479 cfu/cm 2) after treatment, indicating that the micro-organisms present on the beds were being deposited by the patient's skin during the treatment. The most prevalent micro-organisms identified were Staphylococci and Serratia, with an average of 59% and 40% of colonies; while Micrococci and Bacilli were relatively uncommon. No growth was evident after 5 minutes of exposure to the disinfectant during the growth inhibition test. For the Kirby Bauer test, the average size of the zone of inhibition increased as the dilution decreased. The disinfectant is effective but more so against the Gram-positive than the Gram-negative bacteria. The disinfectant was 5,0, 5,5 and 5,6 times more effective than phenol in eradicating Staphylococci, Serratia and Bacilli, respectively. Conclusions and Recommendations: This study showed that microorganisms were present on the beds. Staphylococci and Serratia have been implicated in many healthcare associated infections. The present disinfectant is effective, but should be used in between every patient. A different or additional disinfectant that is more effective against the Gram-negative bacteria should be considered for future use.

Manual and manipulative therapy plus rehabilitation for chronic ankle instability: a exploratory, randomized, single-blind, comparative trial Danella Lubbe, James Brantingham, Ekta Lakhani, Gregory Parkin-Smith, Tammy Cassa, Gary Globe, Charmaine Korporaal Objectives: Symptom improvement and risk reduction of repeated

Background: Chiropractic adjustment beds (beds) are always at the

clinical interface, whether it be with patients or training students. It

ankle injury or sprain are important outcomes for recurrent lateral ankle sprain or (preliminary) chronic ankle instability (CAI),

102 particularly in athletes where persistent pain or repeated injury may impair or prohibit participation in sport. Manipulative therapy (MT) is emerging as a potentially effective treatment for ankle injury, particularly inversion sprain, but this therapy still requires testing as an adjunct to standard rehabilitative care for CAI. The purpose of this study was to compare manipulative therapy plus rehabilitation with standard rehabilitation only for chronic lateral ankle pain due to lateral ankle sprain ≥ 7 weeks duration. Methods: We performed a randomised comparative clinical trial set in an outpatient university teaching clinic.A convenience sample of 33 eligible participants with Grade I and II CAI were consented and randomly allocated to either the Comparison Group (standard rehabilitation only) or the Experimental Group (MT plus standard rehabilitation), with 18 and 15 participants in the 2 groups, respectively. All participants undertook a rehabilitation protocol daily over the course of the 5-week treatment period. The participants in the experimental group received 6 manipulative therapy treatments in addition to rehabilitation over the same 5-week treatment period. The outcome measures were the Foot & Ankle Disability Index (FADI), The Visual Analogue Pain Scale (VAS), the Berg Balance Scale (BBS) and weight-bearing lunge-test for ankle dorsiflexion. Data were collected at 3 time-points over the treatment period, inclusive of baseline. Missing scores were replaced using multiple imputation and statistical analysis of the data comprised of repeatedmeasures ANOVA with Bonferroni correction. Results: The data from the 33 participants was available for analysis with 9% (36/396 scores) of scores missing, which included missing data due to 3 dropouts. Between-group analysis did not show any statistically significant changes in scores across any of the outcome measures (P ≥ .10). Within-group analysis demonstrated a majority significant change in scores for all outcome measures from baseline to the final consultation for both intervention groups (P ≤ .02). Conclusions: Although the treatment in both groups in this trial showed a statistically significant change in scores from baseline to the final consultation (week 5) across almost all outcome measures, the addition of manipulative therapy to standard rehabilitation, did not appear to be beneficial for lateral ankle sprain N 7 weeks or preliminary CAI in terms of improvement in ankle function and pain.

The knowledge and perceptions of provincial and national health Portfolios Committee Members of South Africa regarding the chiropractic profession Praveena Maharaj, Charmaine Maria Korporaal Objectives: Literature has outlined the importance of health policy makers having knowledge of the various health professions under their jurisdiction, to most effectively and efficiently employ these healthcare professionals in the best of the population that they are required to service. Thus this IRB approved study set out to establish the relationship between the demographic profiles of the honourable members related to Health Portfolio Committees under the structure of the Department of Health within South Africa, their level of knowledge of and the perceptions of the chiropractic profession. Methods: A questionnaire-based survey was administered to 84 HPC members. The questionnaire was developed from literature identified associations between perception, knowledge and utilization, after which it was refined through a Delphi process. This process contextualized the questionnaire to the South African context and ensured that the questionnaire could be administered in a

WFC 2013 Scientific Sessions abstracts semi supervised manner. The honourable members of the HPC were addressed regarding the research at one of their scheduled meetings, prior to being requested to participate and complete the questionnaire. Knowledge and perception scores were expressed as a percentage of 55 by dividing the raw score by 55 and multiplying it by 100. Comparisons between variables were assessed using bivariate statistical methods. Pearson correlation analysis was used to assess relationships between quantitative variables, while Pearson χ 2 tests were used to assess associations between categorical variables. Student t tests and ANOVA tests were used to compare mean knowledge and perception scores between 2 independent groups. A P value b .05 was considered as statistically significant. Results: A response rate of 64% revealed that the mean knowledge score of 31.4% was relatively low. The mean perceptions score was 38.2%, indicating an overall negative perception of chiropractic amongst this population. Experience did indeed influence perceptions significantly (P = .035) with those having consulted a chiropractor before having higher perceptions scores. No significant correlations existed between knowledge and perception and the demographic variables with the exception of ethnicity. This was enhanced by a weak statistically significant positive correlation between knowledge and perceptions score (r = 0.394, P = .004). The weak strength of the correlation shows that in general, as knowledge increased so did perceptions. Conclusion: Generally knowledge and perception of chiropractic was low in this population and seems to be influenced principally by the ethnicity/culture within which the honourable HPC members operate (whether it is within the medical paradigm or their individual cultural orientation). Thus increasing the awareness and knowledge of chiropractic in this group may lead to more positive knowledge scores and perception levels.

Inter- and intra-examiner reliability in paraspinal thermographic pattern analysis using the Tytron C-3000 scanner Barbara Mansholt, Cynthia Long, Robert Vining, Christine Goertz Introduction: Thermography is used in a variety of healthcare settings to diagnose impaired nerve conduction due to nerve root compression and chronic regional pain syndrome. Historically, chiropractic students have been and continue to be taught to use skin temperature instruments as a clinical decision-making tool. Thermography is one such tool used to detect and record paraspinal skin temperature differences. A few chiropractic techniques use repeated paraspinal thermographic findings to establish a patient's baseline measure or pattern to use as reference for subsequent clinical decisions. The reliability of multiple examiners to interpret thermographic findings has not yet been reported. The purpose of this paper is to report inter/intraexaminer reliability of interpreted paraspinal thermographic findings. Methods: This IRB exempted study is a secondary analysis of data collected under a clinical trial conducted at the Palmer Center for Chiropractic Research, Davenport, Iowa. Thirty participants screened for a hypertension study were scanned according to a specific protocol designed in collaboration with the Palmer Technique department using the Tytron C-3000 thermographic scanning instrument. Twenty-five de-identified thermographic scans were selected; seventeen original and 8 duplicates. Repeat view intervals varied by an average of 5.5 scans. Interested doctors of chiropractic were eligible to participate if they reported a minimum of 2 years experience with the Tytron thermographic instrument using scans as part of their clinical decision-making process. Eligible participants

WFC 2013 Scientific Sessions abstracts identified scans under 5 categories: pattern, partial (+), partial, partial (−), and adaptation. Kappa statistics were calculated for inter/intraexaminer reliability to evaluate agreement on clinical interpretation. Results: Seventeen (17) doctors of chiropractic participated with a mean of 8 years experience using the Tytron thermographic instrument; 5 held faculty status at a chiropractic college that teaches thermographic analysis as part of the core curriculum. Interexaminer reliability revealed fair to good reliability overall: k = 0.43 (CI 0.38, 0.47). Individual categories were k = 0.73 (CI 0.59, 0.87) for full pattern, k = 0.22 (CI 0.11, 0.33) for partial (+), k = 0.05 (CI − 0.05, 0.15) for partial, k = 0.22 (CI 0.08, 0.37) partial (−), and k = 0.54 (CI 0.34, 0.76) for adaptation. Intra-examiner ranged from k = 0.33 (CI − 0.67, 0.73) to k = 1.00 (CI 0.05, 1.50). Discussion: These preliminary results suggest that identification of a patient's pattern presentation is reliable only when these findings occur as full pattern or adaptation and is poor for partial (+), partial, or partial (−).Teaching protocol for certain techniques currently suggests determining when to treat primarily based on pattern findings. If these preliminary results hold in a larger study, clinical decisions should not be based solely on the presence of pattern. Findings currently taught as secondary (eg, atlas fossa reading, static/motion palpation, leg length, symptoms) may carry greater clinical import; however reliability and validity of these findings requires further study. This study is limited by low participation and does not address the issue of validity. Conclusion: Inter-examiner reliability for thermographic analysis ranges from good to excellent for findings in the full pattern or adaptation categories. Intra-examiner majority ranges from poor to excellent. Further investigation is needed.

Brain activation induced by spinal movement: a novel and promising method for investigating neuroplastic changes in chronic low back pain Michael Meier, Sabina Hotz-Boendermaker, Bart Boendermaker, Roger Luechinger, Kim Humphreys Introduction: Treatments based on functional and structural abnor-

malities of CLBP subjects in the musculoskeletal system are frequently unsuccessful suggesting other pathological mechanisms beside end organ dysfunction . A plethora of research focused on revealing the process of chronification of low back pain in the fields of methodology, psychology, anatomy and neurophysiology have thus far been disappointing. However, recent neuroscientific research has revealed neuroplasctic changes in the brain of CLBP subjects which are strongly related to the chronification of low back pain. Unfortunately, these studies used intracutaneous electrical or thermal stimuli, which have limited validity for low back pain because of a lack of mechanoreceptor activation. Other attempts to record and localize brain responses after mechanical stimulation of the back have thus far been discouraging. Therefore, the study aim was to develop a new paradigm to mechanically stimulate lumbar spine structures (spinous processes) to induce brain activation patterns by using functional magnetic resonance imaging (fMRI). As alterations in brain activity of CLBP subjects have been observed with non-painful stimuli, our first interest was in brain activation patterns induced by painless stimulations of healthy controls. Methods: The study was approved by the Cantonal Ethics Committee (Zurich, Switzerland). Subjects were investigated in the prone position with the face lying on a special pillow to allow normal breathing. An experienced manual therapist applied controlled, nonpainful pressure stimuli (30 N) to 10 healthy subjects (7 females) at 3

103 different lumbar vertebrae (L1,3,5) and the thumb as a control condition. The stimulation consisted of postero-anterior (PA) movements at each spinous process and pressure on the thumb. The pressure force was controlled by 4 pressure sensors attached to the subjects' spinous processes and thumb, respectively. The therapist followed a randomized stimulation protocol projected onto a screen in the MR room. The experiment consisted of 68 stimuli of 5 seconds duration and an inter-stimulus interval of 7 seconds. Subjects underwent the fMRI protocol in a Philips 3-T System. Blood oxygenation level dependent (BOLD) responses were analyzed in relation to the different stimulations of the lower back and the thumb. Results: Whole brain analysis of spinal stimulation revealed significant activation in the somatosensory cortex (SI) as well as insular and frontal cortices at a conservative threshold (P b .05, family-wise corrected). The thumb stimulation elicited mainly contralateral activation of the SI cortex (P b .001, uncorrected). In agreement with Penfield's described sensory homunculus, a clear topographical arrangement of S1 activation could be detected, comprising medial bilateral responses by spinal stimulation and contralateral responses by thumb stimulation in more lateral parts. Conclusion: The tactile mechanical stimulus on the lumbar spinous processes induced powerful activation in somatosensory and insular cortices in healthy subjects. Our method is a promising tool for further investigations by disentangling neuroplastic changes of painful and non-painful stimuli in CLBP subjects which might serve as a neurophysiological marker for evidence-based diagnosis and interventions.

Increased cortical drive and altered net excitability of low-threshold motor units levels to the lower limb following spinal manipulation Imran Khan Niazi, Kemal S. Türker, Stanley Flavel, Mat Kingett, Jens Duehr, Heidi Haavik Objective: Over the past decade there has been a growing body of

research demonstrating neural plastic changes following spinal manipulation. Several studies have shown neuroplastic changes to early sensorimotor integration and motor control. This current study sought to investigate whether spinal manipulation leads to neural plastic changes involving cortical drive and the H-reflex pathway to a lower limb muscle using recently published H-reflex data collection and analysis methodologies. Method: Eight healthy subjects were recruited for this study and attended 2 recording sessions in random order. During one of the session spinal manipulation occurred and during the second session a passive movement control intervention took place. Soleus evoked V-wave, H-reflex, and M-wave recruitment curves and maximal voluntary contraction (MVC) of the plantar flexors were recorded before and after both interventions. Dependent measures were H reflex area under curve normalized to Mmax (Harea/Mmax), Normalized MVC, H-reflex threshold, V wave normalized to Mmax (V/Mmax), M wave slope and H reflex slope. Repeated measures ANOVA for each measure was carried out with factors time (pre vs. post) and intervention (spinal manipulation vs. control). The Northern Y Regional Ethics Committee approved this study in accordance with the Declaration of Helsinki. Results: Following spinal manipulation there was a non-significant increase in MVC by 72.9 ± 112.9% (P N .05) of the plantar flexors. Following the control intervention there was a significant decrease of the plantar flexors MVC by 15.3 ± 6.7% (P = .003). The V waveto-maximal M wave (V/Mmax) ratio increased significantly (47.7 ±

104 39.8%; P = .003) following spinal manipulation, but the maximal H area-to-maximal M wave (Hmax/Mmax) ratio remained unchanged. Conversely, in the control session the V/Mmax ratio decreased significantly (28.8 ± 18.5%; P = .03), while the Hmax/Mmax ratio remained unchanged. Following spinal manipulation there was also a reduction in the H-reflex excitability threshold (P = .02) with no changes observed for the H reflex slope or M wave slope. No significant changes in H-reflex threshold, H reflex slope or M wave slope was observed in the control session. Discussion: These preliminary results indicate that the H-reflex pathway is involved in the neural plastic changes that occur following spinal manipulation, as this intervention lowered the recruitment threshold of motor neurons to Ia afferent input. Spinal manipulation appears to alter the net excitability for the lowthreshold motor units. Furthermore, the results suggest that the improvements in MVC following spinal manipulation are likely attributed to increased descending drive and/or modulation in afferents other than Ia afferents. The findings also suggest that fatigue occurred in the control condition, whereas this was not evident following spinal manipulation. Interestingly, these findings following a single session of spinal manipulation are similar to what has been observed following 3 weeks of strength training.

Outcomes from MRI confirmed symptomatic cervical disc herniation patients treated with high velocity, low amplitude, spinal manipulative therapy: a prospective cohort study with 3-month follow-up Cynthia Peterson, Christof Schmid, Serafin Leemann, Bernard Anklin, B. Kim Humphreys Background: Patients with radiculopathy from cervical disc herniations typically have acute neck pain with associated arm pain following the distribution of the involved nerve root. However, disc protrusions are also a common finding on MRI scans of asymptomatic people. The treatment of patients with cervical radiculopathy is often surgical if conservative therapies fail. Conservative treatments for cervical disc herniation patients may include lifestyle changes, pain medications, physiotherapy, epidural steroid injections or spinal manipulative therapy (SMT). The research evidence supporting SMT as a treatment for cervical disc herniations is severely lacking. The purpose of this study is to address this paucity of research evidence and investigate the clinical outcomes of patients with cervical radiculopathy from disc herniation who are treated with spinal manipulative therapy. Methods: Ethics approval was obtained from the hospital and Canton of Zurich ethics committees prior to the start of the study. Patients between 18 and 65 years of age with no contraindications to cervical SMT and with neck pain and moderate to severe arm pain in a dematomal pattern, sensory, motor or reflex changes corresponding to the involved nerve root and at least one positive orthopaedic test for cervical radiculopathy were included. MRI proven CDH at the corresponding spinal segment was required. Before the first treatment the patients completed a questionnaire consisting of a numeric pain scale (NRS) and the Neck Pain and Disability (NDI) questionnaire. At two-weeks, one-month and three-months after the initial consultation the patients were called by a trained research assistant and the NDI, NRS and patient's own global impression of change (PGIC) data were collected. The manipulative procedure was a high velocity, low amplitude adjustment with rotation to the opposite side

WFC 2013 Scientific Sessions abstracts and lateral flexion to the same side of the affected arm. Treatments were repeated 3 to 5 times per week for the first 2 to4 weeks and continued 1 to 3 times per week until the patient was asymptomatic. In addition to descriptive statistics, scores on the pre- and posttreatment NRSs and NDI were compared using the Wilcoxon test for matched pairs. Only patients responding ‘better’ or ‘much better’ on the PGIC scale were categorized as ‘improved’. The proportion (%) of patients improved with the intervention was calculated. Results: 39 patients with baseline and 3 month outcome data were included (Table 1). At 2 weeks 53.3% of patients were ‘improved’, 64.4% at 1 month and 84.6% at 3 months. No patients were ‘worse’. Statistically significant decreases in neck pain, arm pain and NDI scores were noted for all time points compared to the baseline scores (P b .0001 for all comparisons). In patients with symptoms over 4 weeks (n = 15), 71.4% were ‘improved’ at 3 months (Table 2). Conclusions: A high proportion of patients with symptomatic, MRI confirmed cervical disc herniations treated with SMT report significant improvement at 3 months after start of treatment. No cases of worsening of symptoms were reported. Even subacute and chronic patients showed significant improvement.

Vestibulomotor balance control in young adults with adolescent idiopathic scoliosis: effect of various treatments Jean-Philippe Pialasse, Simon Laurendeau, Pierre Mercier, Martin Descarreaux, Martin Simoneau Introduction: Adolescent Idiopathic Scoliosis (AIS) is defined as a 3D deformity of the spine due to multiple factors. Current treatments are only symptomatic and tend to reduce spinal deformity progression. Vestibular impairment is thought to be associated with scoliosis. It has been demonstrated that AIS patients have lower cognitive vestibular integration compared to controls, suggesting alteration in the cortical mechanisms processing vestibular signals. Furthermore, compared to healthy participants, AIS patients show a larger body sway to pure vestibular perturbation. The aim of this study was to assess whether adults with idiopathic scoliosis also show impaired balance control during or after vestibular perturbation and if treatments aimed at reducing spine deviation improved their balance. Methods: 18 healthy young adults (22.1 ± 2.5 years, 17 females) and 30 young adults with AIS were enrolled. Sixteen underwent observation (22.3 ± 3.1 years, maximum Cobb's angle: 25.9 ± 10.7, current Cobb's angle: 25.4 ± 9.8, 14 females), 9 were braced during adolescence (21.2 ± 1.7 years, maximum Cobb's angle: 39.4 ± 15.6, current Cobb's angle: 30.7 ± 16.9, 11 females) and 5 had surgery during adolescence (22.8 ± 3.7 years, maximum Cobb's angle: 62.8 ± 7.9, current Cobb's angle: 18.6 ± 17.4, 5 females). Galvanic vestibular stimulation (GVS) delivered a pure disturbance to the vestibular system with amplitude of 1 mA lasting 2 seconds. Participants were exposed to 30 trials; 15 with the anode on the left and 15 with the anode on the right mastoid. Balance control was quantified 2 seconds (pre-GVS) prior GVS, during GVS and 3 seconds (post-GVS) after. Root-mean-squared (RMS) value of the vertical forces (Fz) under both feet and the kinematics of the upper body (ie, seventh cervical vertebra (C7)) along the frontal plane were calculated. Results: Balance control was similar among all groups during preGVS. Altering the vestibular signals impaired balance control of all groups and no group difference was observed. During the first second after GVS cessation, AIS group with surgery showed greater balance impairment than the other groups. During the following 2

WFC 2013 Scientific Sessions abstracts seconds, balance control was impaired in the AIS groups; RMS values were still larger than those measured in pre-GVS. Discussion: Adults with scoliosis also showed abnormal vestibulomotor control. Impaired balance control, however, was smaller than what have been reported for adolescent with AIS . This result suggests that impaired vestibulomotor control is present even after growth. It is worth mentioning that correcting spine curvature did not improve vestibulomotor control, as balance control in participants from the surgically corrected group was impaired following GVS (post-GVS). Because 4 out of 5 (80%) patients that had surgical correction were first braced, this observation suggests that alteration of the cortical mechanisms associated with vestibulomotor control could be related to spinal deformity progression. The fact that no difference between the braced and the observational groups was observed seems to indicate that bracing does not reduce vestibulomotor control impairment. Conclusion: Overall, the present results suggest that sub-types of AIS are linked to vestibulomotor control impairment, which impairment could be a risk factor of curve progression. This latest hypothesis, however, should be investigated through a longitudinal study.

Patient education with or without manual therapy compared to a control group in patients with hip osteoarthritis: a proof-of-principle three-arm parallel group randomized clinical trial Erik Poulsen, Jan Hartvigsen, Henrik Wulff Christensen, Ewa Roos, Werner Vach, Soeren Overgaard Background: Hip osteoarthritis (OA) is a common joint disease with a lifetime risk of 25% and when symptomatic has a negative impact on activities of daily living and quality of life. Core interventions for patients with hip OA include patient education (PE) but PE is currently not a standard treatment option for OA patients in many countries. Manual therapy (MT) is recommended as an adjunct intervention but evidence for effectiveness is limited to a few randomized clinical trials. Purpose: To investigate the feasibility of including a PE program and MT in a randomized clinical trial in a Danish healthcare setting and specifically examine the effectiveness of a PE program alone or in combination with MT when compared to a minimal control intervention. Secondary purpose was to explore any benefit of the addition of MT to the PE program. Methods: Patients with unilateral clinical and radiographic defined hip OA from primary care were randomized into one of 3 groups: PE, PE plus MT, and a home-based stretching program. PE involved 5 educational individual and group sessions taught by a physiotherapist and MT involved 12 sessions delivered by a chiropractor. Primary outcome was patient-rated pain intensity on an 11-box numerical rating scale and primary end-point was at 6 weeks immediate following interventions. Secondary outcome measures included the Hip disability and Osteoarthritis Outcome Score (HOOS) and numbers having had hip replacement surgery at 12 month follow-up. The study was approved by the Regional Ethics Committee of Southern Denmark, approval number S-20080027. Results: Follow-up data was available for 111/118 patients. Baseline-adjusted reduction in pain intensity was 1.9 points (95% CI 0.9-2.9) greater for the combined PE/MT group when compared with the home-based stretching group. No difference was found between the PE and home-based stretching group (− 1.0 to 1.0).

105 Exploratory analysis revealed a reduction in pain intensity of 1.9 points (95% CI 0.8-2.9) greater in the PE/MT group when compared to the PE group. The HOOS scale demonstrated similar results as the primary outcome. At 12 months, 12 patients in the PE group had received hip replacement surgery, 4 in the PE/MT group and 7 in the home-based stretching group (P N .05). Discussion: Results from this trial strengthen the evidence that manual therapy may be an effective treatment option for patients with hip OA and future trials should investigate the effectiveness in comparison to other non-pharmacological therapies. Limitations include the MT was administered by only one chiropractor, possible attention bias as the PE/MT group received 12 sessions more than the PE group and objective measures of physical function were not incorporated. Conclusions: The chosen trial set-up and selected outcome measures were feasible in a Danish healthcare setting and a combined patient education and manual therapy intervention is an effective treatment option for patients with hip OA. It appears the manual therapy is the active ingredient in the combined treatment group.

A randomised controlled trial of chiropractic multi-modal treatment for shoulder pain Mario Pribicevic, Peter Tuchin, Rod Bonello, Henry Pollard Introduction: Shoulder pain is a common cause of disability throughout the community and frequently encountered in clinical practice. The impact of shoulder pain on the community is significant, with one-year prevalence figures of shoulder pain ranging from 6.7% to 66.7%. It is estimated that 95% of people with shoulder pain are treated in primary care settings, including medical, chiropractic and physiotherapy practices. The most common source of shoulder pain originates from the rotator cuff, with the most prevalent clinical diagnosis being impingement syndrome and or rotator cuff tendinosis. The evidence of chiropractic treatment for shoulder pain is limited with only one clinical trial published. Methods: This study was an RCT of multimodal treatment for shoulder pain, mostly subacromial impingement syndrome and rotator cuff tendinosis. Forty-two participants were randomised into 3 groups: a control group (n = 12), a manipulation group (n = 15), and a multimodal treatment group (n = 15). Each participant was treated for a total of 8 visits over a four-week period. Reassessment occurred at the end of the four-weeks and 4 months after treatment. Outcome measures included patient's perception of pain, VAS(metal slider), range of motion anddiagnostic orthopaedic testing. Results: Both treatment approaches significantly reduced pain levels, however the mean level of change was more significant in the multimodal group. At 4 weeks, the multimodal group reduction in the verbal response and a metal slider VAS pain level was 73% and 78%, respectively (P b .001). This result was higher compared to themanipulation-only group, which was 52% and 45%, respectively (P b .001). The control group was 5% and 12%, respectively (P N .05). Other outcome measures, such as shoulder range of motion, Neer's test, Hawkins/Kennedy test, Jobe's test and painful arc testing demonstrated significant changes when compared to the control group, for both treatment approaches. However, the results consistently favoured the multimodal therapeutic approach supporting the initial findings from both VAS values. These favourable effects were also demonstrated at the end of the study after 4 months.


WFC 2013 Scientific Sessions abstracts

The control group demonstrated no statistically significant detectable change. Participants also reported some other favourable changes which included better sleep patterns, being able to lie on the effected side, restoration of muscular strength and improved ability in performing activities of daily living. Conclusions: This study demonstrates the potential benefit of a multimodal manipulative protocol and a manipulation only protocol in managing pain syndromes associated with dysfunction of synovial structures of the shoulder and or shoulder girdle.

Discussion: No evidence of cerebrovascular hemodynamic effects, often postulated as a result of mechanical interactions with the vertebral artery during head motions, were identified. Evaluation of sample populations deemed of higher risk than healthy adult males may be warranted. Conclusions: This study contributes to a limited body of knowledge regarding the vascular impacts of head position and cervical manipulation and is the first to obtain direct flow and velocity data across a range of mechanical challenges to the cervical spine.

Changes in vertebral blood flow following various head positions and manipulation Jairus Quesnele, John Triano, Greg Wells

A systematic literature review of intracranial hypotension following chiropractic Peter Tuchin

Background: While rare in the general population, vertebrobasilar

Background: Intracranial Hypotension (IH) is due to a leakage of

artery (VBA) stroke, such as spontaneous vertebral artery (VA) dissection, is a leading cause of nonatherosclerotic stroke in young adults. However, the exact pathogenesis of VBA stroke is poorly understood. Authors speculate that mechanical compression or stretching of the VA at extreme head positions, particularly in the V3 segment, is a potential causative factor for VA blood flow change which may lead to VBA stroke. A change in VA blood flow following head rotation, especially contralateral to the direction of rotation has been demonstrated in several studies. However, these results yield some inconsistencies, are inconclusive with respect to clinical relevancy, and use less sensitive ultrasonography for flow quantification. There is continuing controversy about the effects of cervical range of motion and therapeutic physical interventions, including cervical spinal manipulation (CSM) on the blood flow within the VAs and cerebrum. At the mechanistic level, few studies have examined the effects of CSM on vertebral artery blood flow. This has led to uncertainty on whether there is potential risk in apparently healthy individuals for minor trauma or altered hemodynamics in cervical blood vessels from these maneuvers. Objectives: The objective of the study is to extend the understanding of the cerebrovascular hemodynamic consequences of cervical spine positions, including rotation and manipulation in vivo, under clinically relevant circumstances using MRI technology on the VA. Methods: This is a pilot blinded examiner cohort with 4 randomized clinical tasks. Ten healthy male subjects aged 24 to 30 (mean 26.8) volunteered for participation in the study. None of the participants had a history of disabling neck, arm, or headache pain within the last 6 months; nor did they have current or prior history of neurological symptoms. Physiologic measures of VA blood flow and velocity at the C1-2 spinal level were obtained using phase contrast magnetic resonance imaging in 3 different head positions and following an upper cervical spinal manipulation. Multiple magnetic resonance imaging sequences were collected in each of the 4 conditions and were averaged to provide a blood flow profile for one complete cardiac cycle. Differences between flow and velocity variables were evaluated using repeated measures ANOVA. The study was approved by the local Ethics Committees of St. Joseph's Healthcare Hamilton (SJHH) at McMaster University in Hamilton, Ontario and Canadian Memorial Chiropractic College (CMCC) in Toronto, Ontario. Results: There were no significant changes following various head positions and manipulation on blood flow and velocity in the vertebral arteries of healthy young male adults.

cerebrospinal fluid (often from a tear in the dura) which often produces an orthostatic headache. It has been reported to occur after trivial cervical spine trauma including spinal manipulation. Some authors have recommended specifically questioning patients regarding any chiropractic SMT. Therefore, it is important to review the literature regarding chiropractic and IH. Objective: To identify key factors that may increase the possibility of Intracranial Hypotension after chiropractic spinal manipulation therapy (CSMT). Method: A systematic search of the Medline, Embase and Pubmed databases (from 1991 to 2011) was conducted for studies using the keywords chiropractic and IH. Each paper was reviewed to examine any description of the key factors for IH, the relationship or characteristics of treatment, and the significance of CSMT to IH. In addition, other items that were assessed included the presence of any risk factors, neck pain, and headache. Results: The search of the databases identified 39 papers that fulfilled initial search criteria, from which only 8 case reports were relevant for review (after removal of duplicate papers or papers excluded after the abstract was reviewed). The key factors for IH (identified from the existing literature) were recent trauma, connective tissue disorders, or otherwise cases were reported as spontaneous. A detailed critique of these cases demonstrated that 5 of 8 cases (63%) had non-chiropractic SMT, (that is, SMT technique typically used by medical practitioners). In addition, most cases (88%) had minimal or no discussion of the onset of the presenting symptoms prior to SMT and whether the onset may have indicated any contra-indications to SMT. No case reports included information on recent trauma, changes in headache patterns or connective tissue disorders. Discussion: Even though type of SMT often indicates that a chiropractor was not the practitioner that delivered the treatment, chiropractic is specifically cited as either the cause of IH or an important factor. There is so much missing data in the case reports, one cannot determine whether the practitioner was negligent (in clinical history taking) or whether the SMT procedure itself was poorly administered. Conclusions: This systematic review revealed that case reports on IH and SMT have very limited clinical details and therefore cannot exclude other theories or plausible alternatives to explain the IH. To date, the evidence that chiropractic SMT is a cause of IH is inconclusive. Further research is required before making any conclusions that chiropractic SMT is a cause of IH. Chiropractors should be vigilant in recording established risk factors for IH in all

WFC 2013 Scientific Sessions abstracts cases. It is possible that the published cases of CSMT and IH may have missed important confounding risk factors (eg, a new headache, or minor neck trauma in young or middle-aged adults).

Cost-effectiveness related to dose-response of spinal manipulation for low back pain: outcomes from a randomized trial Darcy Vavrek, Rajiv Sharma, Mitchell Haas, David Peterson Background: This is the first full-scale trial to evaluate the dose-

response and its cost effectiveness of spinal manipulation for any condition. Methods: We randomized 400 patients with chronic low back pain to receive one of 4 dose levels of care: 0, 6, 12, or 18 sessions of spinal manipulation from a chiropractor. All participants were scheduled for 3 visits per week for 6 weeks. Either the index intervention or light massage control was rendered at each visit. Economic analyses utilized U.S. Medicare 2009 non-facility and facility payments to estimate costs of patient-reported visits to healthcare providers. Cost-effectiveness outcomes include health outcomes in qualityadjusted life years (QALYs), treatment costs in preceding 4 weeks, and cost of treatment plus time lost due to disability in preceding 4 weeks measured at weeks 6, 12, 18, 24, 39, and 52 after enrollment. Multiple regression was performed on QALY data looking at a linear dose effect and group comparisons to the light massage control. Similarly, multiple regression was performed on logtransformed cost data with results reported as percentages for interpretability. Missing data were imputed by linear interpolation. Results: Improvements in cost of treatment plus time lost to disability were observed at 52 weeks, the end of follow-up. A decrease of 64% (83%, 23%) was observed at 52 weeks comparing SMT 12 to control. Annual costs of treatment plus time lost were mildly improved for 12 SMT compared to control 3% (−62%, 42%) but this was not statistically significant. No differences remained statistically significant when summarized annually. No statistically significant comparisons were observed in QALY scores or in cost of treatment as a linear dose effect or when comparing SMT groups to control at any time point or when summarized annually in adjusted models. Conclusions: Reduction in cost of treatment and disability compared to control is sustainable to 52 weeks, and is greatest in the 12 SMT sessions vs. 0 SMT control in the adjusted analysis. SMT 12 is also favored, versus SMT 0, in annual costs but is not statistically significant. Twelve SMT treatments appear to be reasonable for use in a comparative effectiveness trial.

Examining the relationship between theory-driven policies and allowed lost-time back claims in workers' compensation: a system dynamics model Jessica J. Wong, Silvano Mior, Patrick Loisel Background: No systems-based perspective on back claims in workers' compensation is currently available to help evaluate the impact of policy decisions. Objective: The objective was to develop a model to evaluate the impact of policy changes on the number of workers' compensation lost-time back claims in Ontario, Canada over a 30-year timeframe. This model aimed to test the hypothesis that an economic theorybased model would be sufficiently realistic to reproduce historical

107 claims data driven by workers' compensation policy changes. The secondary objective was to determine the robustness of the developed model in order to determine its utility and flexibility in evaluating proposed policy changes. Methods: The model was developed using system dynamics methods in the Vensim simulation program, with variables based in economic theory of workers' compensation. Yearly aggregated totals of all lost-time back claims documented by Ontario's workers' compensation board from 1980 to 2009 were used as reference data for the study outcome, capturing 3 key eras of policy changes. The primary outcome of interest was the predicted annual number of lost-time back claims from 1980 to 2009 as per the model output. Modeled data was compared with historical claims data through statistical analysis and visual comparison for its validity. The degree of predictive value of the modeled data was measured by the coefficient of determination, root mean square error and Theil's inequality coefficients. Sensitivity analysis was used to evaluate the modeled data at extreme endpoints of variable input and timeframes. Results: The coefficient of determination for all model variables was consistently high. Correlation between modeled data and actual data was found to be meaningful (R 2 = 0.934) and the modeled data was stable at extreme endpoints. When comparing the model simulation without policy changes to the model simulation with policy changes, the coefficient of determination was 0.882 and 0.934, respectively. Policy changes accounted for a 13% improvement in the proportion of root mean square error in the modeled data, as compared to a model simulation without policy changes. Simulation results suggested unemployment, number of no-lost-time claims, multiple injuries per worker and recovery rate from back injuries (outside of claims management) to be sensitive drivers of back claims data. Evaluation of model robustness, through extending the timeframe by 100 years, indicated that the modeled data was stable over time. Extreme variable input into policy changes also indicated that the modeled data was stable and provided reasonable boundaries for model robustness. Conclusion: The model yielded a high correlation between modeled data and actual data (R 2 = 0.934) and was stable in various input and endpoints of the model, posing as a viable approach to evaluating policy changes in workers' compensation in Ontario. Policy changes were found to be relatively minor drivers of back claims data in the model, accounting for a 13% improvement of error. The study findings suggest that other sensitive drivers of the model (ie, unemployment, no-lost-time claims, multiple injuries and recovery rates) need to be considered when evaluating and changing policies around back claims in workers' compensation.

POSTER SCIENTIFIC PRESENTATIONS The effect of 12 weeks of manipulative care on the cervical flexion relaxation response: a pilot study Ian Barker, Paul Yielder, Heidi Haavik, Bernadette Murphy Introduction: Individuals with chronic and/or recurrent neck pain

(NP) have a decreased ability to relax their cervical extensor muscles as well as demonstrating increased muscle activity during full forward flexion of the neck. The cervical flexion relaxation ratio (FRR) is a measure of the ability to relax the cervical extensors and is generally represented as the ratio of the root mean square of EMG

108 activity during re-extension as compared to full flexion of the neck. Recent research indicates that the cervical FRR is able to discriminate between patients with and without chronic neck pain. There has only been one pilot study to date which looked at the effect of treatment on the cervical FRR and this study only included 4 weeks of chiropractic care in a group of people with a lifetime history of chronic neck pain. It is highly likely that a longer period of care would be needed to produce significant changes in the cervical FRR in a group with chronic or recurrent neck pain. The overwhelming lack of research on the role of altered neuromuscular function in neck pain chronicity, as well as necessary frequency and duration of treatment needed to improve altered neuromuscular function needs to be addressed, and was a key motivation for the current study. Aim: The aim of this pilot study was to determine whether a 12-week period of chiropractic care could significantly improve the FRR ratio in a group of patients with chronic neck pain. Methods: Eleven subjects were tested, aged 18 years and older (31.2 ± 12 years), including 4 males and 7 females with chronic or recurrent NP persisting for at least 3 months prior to treatment with no history of whiplash injuries and no chiropractic care in the 1 month prior to data collection. The cervical FRR was examined using surface electromyography (EMG) at baseline, week 6, and week 12 of chiropractic care along with the Neck Disability Index (NDI), The Short Form-36 (SF-36), and The Short Form McGill Pain Questionnaire (SF-MPQ). Results: The average baseline FRR was 2.25 ± 1.12, improving to 2.55 ± 1.62 at 6 weeks and 3.27 ± 1.52 by 12 weeks. The repeated measures ANOVA for both right and left sided data was significant (F2,42 = 6.24, P = .004) with pre-planned contrasts indicated significant improvement between baseline and 12 weeks (F1,21 = 9.39, P = .006). There were no significant changes in other measures. Discussion: A positive trend of improved FRR from baseline to 6 weeks was demonstrated, which continued and reached statistical significance for the total duration of treatment, baseline to 12 weeks. This is important as it provides a potential time frame for clinicians and patients pertaining to when a notable benefit from manipulation based treatment can be seen. It is also important because it is the first study to show an improving profile over time, suggesting that once pain has become chronic, a longer period of care may be needed to fully reverse the neuromuscular alterations associated with chronic neck pain.

Chiropractic multimodal therapeutic protocol for degenerative spondylotic myelopathy and myelomalacia: case series Ofer Baruch Introduction and Background: Cervical spondylopathy is a relatively

common spinal degenerative condition, which theoretically, if not addressed therapeutically early in life, is said to be advanced onto cervical osteophytosis of the vertebral end-plates posteriorly and/or anteriorly in addition at the lateral ends, the joints of lushka. These osteophytes enlarge as a result of shearing forces exerted on the cervical spine and its inter-vertebral hydrostatic discs based on the person's cervical spine posture, head carriage angle and the directions of shearing forces. Posterior osteophytes or posterior bars were found to be associated with disc degeneration. These degenerative processes can be initiated by an injury such as AccelarationDeccelaration injury mechanism during a motor vehicle or a pushpull accident or can be exacerbated by it. Stooping posture or mal-

WFC 2013 Scientific Sessions abstracts sleeping posture may exacerbate it as well as lifting and carrying. Additional predisposing factors to cervical intervertebral disc dysfunction are heavy lifting, smoking, diving, operating heavy equipment with vibration, and driving. Repetitive activities such as pushing, carrying loads or weights, carrying children on the shoulders may all cause it as well. The osteophytic bars have being found to narrow the spinal canal diameter and cause degenerative spinal stenosis. Depend on the direction of spur growing, and the degree of stenosis, compression and cord tethering result. Chronic friction of the spinal arteries has being found to cause central and radicular spinal pain, neuropraxia, spinal edema and softening of the spinal tracts known as myelomalacia. The prevalence of symptoms is wide and range from central deep or burning pain, radicular limb pain and numbness to weakness that depends on the spinal tracts affected. If progressed long enough, gait disturbances may follow. Past international chiropractic manipulative guidelines indicated myelomalacia as an absolute contra-indication for manipulative care. Recent updated manipulative guidelines have being published and are based on emerging studies over the past decade. By-definition, where there are no fast progressive neurological deterioration signs, myelomalacia is considered as a relative-contraindication. Methods: Three patients with the above processes were functionally examined and contemporary neurological reflexes examinations were added to assess cord compression and to determine the risk management and therapeutic protocol. Each patient was consulted as to their condition, the possible sources of pain and weakness, and the available therapeutic interventions suitable for a chiropractic clinic, concomitant to their medical care. Therapeutic protocols composed of a full-spine multimodal approach, patient-guided intensity in the non-aggravating direction, initially bellow and above the involved segments, and later, including them as well. Each visit included monitoring the pre and post cord reflexes. Results: Patients responded well and relatively fast to care. After 5 to 8 visits, they were found with improved posture, pain-free ROM, full strength regain and with normal sensations. Due to the chronicity of their degeneration, continuation with supportive care was advised. Conclusion: This study supports current guidelines indications. The astute physician should examine, assess and may treat conservatively and cautiously with a multimodal manipulative approach for the welfare of the patient. Further large scale cohort studies are called upon to validate and confirm these results.

A pre-post experimental investigation to determine the clinical responsiveness of motion palpation as a post-manipulation diagnostic tool in patients with chronic ankle instability syndrome Kym Belling, Ekta Lakhani, Charmaine Maria Korporaal Introduction: Motion palpation is a commonly utilised clinical

assessment tool of joint fixations. The majority of research surrounding motion palpation discusses inter and/or intra-examiner reliability as a pre-treatment tool. However, only 2 studies have assessed the reliability of motion palpation as a post-treatment diagnostic tool, and both these studies demonstrated that motion palpation has the ability to identify end-feel improvement in a restricted segment which had been manipulated. Therefore the use of motion palpation as a post-manipulation tool within the spine showed a relatively high level of responsiveness/efficacy of motion palpation. However little research has yet to be conducted on the

WFC 2013 Scientific Sessions abstracts use of motion palpation as a post-manipulation tool on the extremities and therefore this study aimed to provide a clearer insight into the use of motion palpation as a post-treatment assessment tool in an extremity in terms of clinical responsiveness/ validity of motion palpation. Furthermore the relationship between motion palpation and other clinical measures/short term outcomes, such as pain, functionality, range of motion and proprioception had yet to be seen (ie, when motion palpation indicates a reduction in a fixation due to manipulation does this correlate to a decrease in pain and increase in functionality, range of motion and proprioception). Therefore the primary aim of this study was to determine the clinical responsiveness of motion palpation as a post-manipulation diagnostic tool within the joints of the ankle in symptomatic participants with Chronic Ankle Instability (CAI). Method: Forty participants with CAI (Grade I and II) were recruited. One Group received manipulation (n = 21), the other Group received no treatment (n = 19). Motion palpation was performed, and subjective/objective measures were taken in both Groups pre- and post-treatment. Statistical analysis was performed using SPSS 15.0. Results: The findings of this study demonstrated that when using motion palpation as a post-treatment assessment tool a high level of responsiveness was observed (a highly significant association between being manipulated and End-Feel Improvement (EFI) occurred (P b .001)); it was highly sensitive (0.90); and was highly specific (0.95). Overall no statistically significant association was observed in either group between, motion palpation results (with respect to EFI or no EFI noted) and any of the short term outcomes (the 5 subjective/objective clinical measures). Within the manipulation group; Visual Analogue Scale (VAS) (P = .944), Functional Ankle Disability Index (FADI) (P = .490), Pressure Algometer (P = .634), Berg Balance Scale (BBS) (P = .512) and Weight Bearing Dorsiflexion (WBD) (P = .966). In comparison, the control group achieved a Visual Analogue Scale (VAS) (P = .063), Functional Ankle Disability Index (FADI) (P = .491), Pressure Algometer (P = .828), Berg Balance Scale (BBS) (P = .695) and Weight Bearing Dorsiflexion (WBD) (P = .747). The most common fixations noted in this study, were mortise Long Axis Distraction (LAD), subtalar LAD and subtalar eversion. Conclusion: Therefore, motion palpation appears to be valid when used as a post-treatment tool in the foot and ankle; and overall, common fixations found in symptomatic participants with CAI in this study are similar to those found in previous studies.

SOT cranial and TMJ therapy for unresolved BPPV: a case report Thomas Bloink, Charles Blum

109 her symptoms were unresponsive. Her vertigo would last the whole day, with peaks and valleys related to intensity. This affected her ability to function at home, drive her car and even walk “out of the door” of her home. Methods: Patient presented with a sacro occipital technique category 2 (sacroiliac joint hypermobility syndrome), right temporal bone with external rotation, and significant malocclusion with clenching and anterior interferences. Her malocclusion was affected by the stress of the anterior interferences, particularly on the right side, and the repetitive stress on occlusion appeared to create right temporomandibular (TMJ) stress summating at the right temporal fossa. It was theorized this possibly contributed to the patient's vertigo presentation. Category 2 protocols for the pelvis were applied and an intraoral cranial adjustment to the temporal bone, maxilla, sphenoid, and zygoma were performed. Reduction of palpatory pain in and around the TMJ along with joint translation was used to help guide treatment. Cotreatment with a dentist was used to help stabilize and maintain the chiropractic cranial and TMJ corrections. Results: By the seventh-office visit (3-4 weeks of care) the patient's vertigo had resolved. In addition her TMJ translation and opening had improved significantly with right TMJ and related tissue pain eliminated. The anterior interferences were treated with a nighttime dental appliance that allowed the patient to have bilateral posterior teeth contact and reduced contact to the front teeth. Discussion: Occlusion and condylar position is purported to be affected by or affect cranial bone distortion patterns. When there is malocclusion affecting the cranial suture and local periosteal tissue, it is theorized that with some patients, possibly the internal periosteal dura, CSF circulation, and related cortical region might be affected. On the other hand reliving the stressors of restricted cranial motion and malocclusion could lead to improved function just by reducing global stress to the CNS due to reduced pain and related myofascial tension. Conclusion: In this case report the patient's response to care was quite dramatic. She was unresponsive to prior care and her quality of life was profoundly affected. It is difficult to extrapolate from this one case and apply this to the general population however the patient's rapid response to care suggests that further investigation into this method of care for patients presenting with vertigo be considered.

Integration of SOT cranial therapy with an occlusal splint for the treatment of obstructive sleep apnea: a case report Thomas Bloink, Charles Blum, Mamal Rahimi Introduction: Obstructive sleep apnea (OSA) relates to an

Introduction: Vertigo, also called dizziness, accounts for about

6 million clinic visits in the U.S. every year, and 17% to 42% of these patients eventually are diagnosed with benign paroxysmal positional vertigo (BPPV). Two-treatments have been found helpful for BPPV: the canalith repositioning procedure (CRP) or Epley maneuver, and the liberatory or Semont maneuver. The following is a case study that discusses another possible treatment for BPPV. A 37-year-old female with acute benign vertigo was referred to this office by her allopathic physician to determine the need for interdisciplinary care. The patient had 2 to 3 months of constant vertigo, diagnosed as BPPV. She had been treated with the Epley Maneuver and various medications, but

obstruction to the continuum of airway expressed as sleepdisordered breathing associated with multiple co-morbidities and societal implications. With untreated sleep apnea patient the risk of automobile accidents are approximately 8 times more likely than that of a normal sleeper and in the work arena likewise productivity and safety suffer. Common treatments for OSA usually start with a continuous positive airway pressure (CPAP) machine and can progress to surgery to facilitate airway expansion and/or increase function. Surgery is costly and invasive and patient compliance with CPAP machines is estimated at only 40% . A 56-year-old female patient presented for chiropractic and dental care with persistent symptoms of sleep apnea, excessive daytime sleepiness,

110 short-term memory loss, foggy-headedness, temporomandibular joint (TMJ) pain, chronic myofascial neck and shoulder pain, fatigue, and vertigo. Methods/Intervention: Cranial-dental exam revealed a dental class II, narrow arches and premature anterior contacts with evidence of clenching and bruxism. The sleep study revealed a Respiratory Disturbance Index (RDI) of 17.1 and Apnea Hypopnea Index (AHI) of 16.3, with the lowest oxyhemoglobin saturation (SaO2) of 89% during sleep. Six-treatments over a 3- to 4-week period of time consisted of sacro-occipital technique (SOT) care, cranial-dental treatments incorporating SOT intra-oral cranial adjustments, and spheno-maxillary cranial care. Dental care was provided in conjunction utilizing occlusal balancing by a mandibular flat plane dental splint. Results: Following the 6-office visits the patient reported significant reduction of all symptoms. Follow-up polysomnogram was performed one-month following prior study and with the dental appliance in her mouth. RDI and AHI were both reduced to 2.9 and lowest Sa02 was 92% during sleep. The patient had significantly reduced TMJ pain and the chronic myofascial neck and shoulder pain had gradually resolved over the 3 to 4 weeks of care. Due to her increased ability to sleep and increased oxygenation, she had less daytime fatigue and greater function. Discussion: The combination of SOT cranial therapy with a flat plane mandibular occlusal splint appeared to help resolve this patient's apnea and accompanied symptoms. This intervention was minimally invasive, less costly than a CPAP, and only required a 3- to 4-week treatment program. Splint type therapy has been found to be helpful for OSA patients and one prospective randomized study found that a dental appliance could be an alternative treatment for some patients with severe OSA. Ascending and descending kinematic postural influences have been found between posture and occlusion, condylar position, and airway space—suggesting that the treatment of TMJ disorders and sleep apnea may be an opportunity for dental and chiropractic collaboration. Clinically, chiropractors and dentists are realizing a relationship between posture and the OSA, supporting the need for interdisciplinary efforts. Conclusion: The persistent nature of the patient's apnea, the pre and post-sleep study objective findings, and the patient's significant reduction in pain and improved function are compelling features of this case. Greater study is needed to identify the subset of apnea patients that could benefit from this approach.

WFC 2013 Scientific Sessions abstracts Methods: Adult patients receiving care for at least 4 weeks from their

GP for either neck pain or back pain were subsequently offered a course of manual therapy, and in consultation with their GP a choice of provider (chiropractor, osteopath or physiotherapist working in the private sector). Treatment costs (up to 6 visits) were covered by the local NHS Trust. At entry into the service patients were asked to complete a questionnaire, and again on discharge from the service. Results: To date, we have data from this phase of the service of 1380 patients. Of these, 81.3% had back pain, 42.9% had neck pain, and 24.2% had both back and neck pain. Of the sample, 516 (37.4%) were treated by chiropractors, 610 (44.2%) by osteopaths and 252 (18.3%) by physiotherapists. The mean age of the sample was 52.0 ± 16.12 years, and 62.2% were female. Almost two-thirds of patients had had their pain for more than 3 months, 44% of those in work had taken some time off for their complaint, 30% had had some form of imaging for the current episode of their complaint, and around half (51.6%) reported that would have liked more advice from their GP on self-management of their condition. During the service, the mean number of treatments was 5.2 ± 1.17 over an average of 6.5 weeks. In terms of health outcomes, 58.4% (Bournemouth Questionnaire) 68.2% (Bothersomeness scale) and 69.3% (Global Improvement) reported significant improvement, and 99.5% that they were satisfied or very satisfied with treatment. Other benefits included a reduction in medication use (45.5%) and very little use of secondary care services (b 2%). Moreover, 93.8% of the sample felt they had been given sufficient information to selfmanage their complaint in the future. At discharge, 96 patients (7.1%) were recommended for onward referral to secondary care. Discussion: This service reduced GP and secondary care services, and most patients reported improvement in their condition, and felt equipped to self-manage their condition in the future. Not only did this service save costs, but also provided patients with provider choice and shorter waiting times. Conclusion: Routinely evaluating service provision through patientreported outcomes provides robust evidence to healthcare commissioners and has already facilitated the start of integration of chiropractic services into mainstream healthcare in the UK.

An exploration of the current status quo of animal chiropractic in South Africa Pieter Jacobus Bosman, Deirdre Pratt, Laura Wilson Evaluation of a GP-referral multidisciplinary service for manual treatment of back and neck pain: an update Jennifer Bolton, Mark Gurden, Marcel Morelli, Greg Sharp, Katie Baker, Nicola Betts Introduction: In line with the 2009 NICE guideline, patients seeking

care from a GP for low back pain lasting 6 weeks or more should be referred, amongst others, for a course of manual therapy. We previously reportedon evaluation of the pilot phase of a multidisciplinary primary care service provided by chiropractors, physiotherapists and osteopaths in NE Essex, UK. This update presents data from the now established service from November 2011. As part of the service evaluation, quality of care was assessed by documenting patient-reported health outcomes and satisfaction with care. In addition we aimed to detail other health resource use during the treatment period, and referral rates into secondary care services.

Introduction: Animal chiropractic assists veterinarians with a complementary approach to animal healthcare therapy. Animal chiropractic in South Africa, however, is currently in its novel stages of development. Consequently, there are no clear parameters defining its position within the South African animal healthcare community. However, there is presently an increased awareness within the complementary and alternative medicine (CAM) field to apply such complementary therapies in animal healthcare. Here, we aimed to identify the current status of animal chiropractic in South Africa, and, to explore possible ways in which the integration of animal chiropractic into the animal healthcare setting of South Africa might be realized. Methods: We made use of an interpretive investigation set in a postpositivistic paradigm, and used a grounded theory approach. Data was collected from twelve semi-structured, face-to-face interviews with persons knowledgeable within their respective fields (animal chiropractic; veterinary health science; respective governing bodies;

WFC 2013 Scientific Sessions abstracts and owners of animals which had received treatment from animal chiropractic). Ethical clearance for these interviews was obtained through Durban University of Technology. Questions were specifically structured to prompt interviewee perceptions and experiences of animal chiropractic with regard to (1) the current role it plays in the animal healthcare profession, (2) current interprofessional interactions, and (3) future developmental and/or integration issues of animal chiropractic in the South African animal healthcare context. Qualitative analysis of the data was done using NVIVO 9 software (NVivo 9, QSR International Pty Ltd). Results: Analysis of interviewee responses indicated that 4 key prerequisites are needed for the successful integration of animal chiropractic within the animal healthcare profession. Discussion: The general trend in the data was that the animal chiropractic profession in South Africa should grow within the next decade if a set of key prerequisites are incorporated into the development strategy of the profession. The prerequisites identified were seen to have parallels with the “essential functions” found in the Makhubu's model of service delivery, ie, functions which must be carried out for service delivery to take place. Importantly, all the identified categories are interlinked, and must be managed as such for the successful integration of animal chiropractic in the animal healthcare community. The immediate recognition and implementation of these identified needs of animal chiropractic relevant to the mainstream animal healthcare profession, is therefore essential. This will allow for the profession to become more organized prior to approaching legislation and ultimately integration within animal healthcare in South Africa. Conclusion: With CAVM therapies becoming more popular, more people are becoming interested in animal chiropractic. Here, we showed that if the animal chiropractic profession in South Africa makes provision for achieving the prerequisites of competence, acceptance, regulation and resources in its future development strategy, it might be possible to achieve professional integration within the mainstream animal healthcare profession within the next 10 years.

The effect of spinal manipulation on sensorimotor integration and cortical effects of motor training in a cohort of participants with subclinical neck pain Jessica Bosse, Steven Passmore, Paul Yielder, Heidi Haavik, Bernadette Murphy Background: Previous work demonstrates that spinal manipulation leads to neural plastic changes in subjects with spinal dysfunction and subclinical neck pain (SCNP). The definition of SCNP is recurring neck dysfunction such as stiffness and pain for which the patients have not yet sought treatment. A limitation of previous studies is that they applied simple repetitive movement sequences, measuring the effects of repetitive motor movements rather than motor skill acquisition. If the presence of SCNP affects the way the central nervous system (CNS) responds when learning upper limb motor tasks it could have important implications for the relationship between SCNP and the development of overuse injuries. The present study sought to investigate the immediate effects of spinal manipulation on CNS processing in a group with SCNP following a motor skill acquisition task. Methods: Peripheral (N9), spinal (N13), brainstem (P14, N18) and cortical (N20 and N30) somatosensory evoked potentials (SEP)

111 were recorded following median nerve stimulation before and after passive head movement (PHM), or cervical spinal manipulation (SM). The study was a between-group experimental design, where SEPS were collected before SM or PHM, following SM or PHM, and following a complex motor task. Twenty one individuals participated in the study, eleven (mean age 22.2) in the PHM group and twelve (mean age 22.4) in the SM group. All participants consented to treatment by a licensed chiropractor and the study received approval by the ethical committee at the University of Ontario, Institute of Technology. Data was analyzed in SPSS as a mixed design split-plot repeated measures ANOVA with 3 levels; pre-intervention, post-intervention and post-motor training, and 2 groups; PHM and SM. Post hoc comparisons were done with paired 2 samples t tests were also performed as needed. Results: There was a significant main effect of the repeated measures ANOVA [F2,38 = 12.87, P b .001] as well as an interaction between group and repeated measure [F2,38 = 4.38, P = .02] for the N30 SEP peak. Post hoc analysis revealed a significant 12.1% increase (P = .05) in the N30 SEP peak amplitude post SM and an 18.01% increase (P = .02) for the same peak following the subsequent motor training. There was a 47.63% increase in the N30 peak following motor training in the PHM group (P = .04). There were no other significant findings for any of the other SEP peaks. Conclusion: These preliminary results have shown an increase in cortical SEP amplitudes following a cervical spine manipulation intervention in subclinical neck pain participants. The changes occurred for a SEP peak known to be involved in early sensorimotor integration. The results also suggest that a complex motor training task induces changes in neural processing, supporting previous work. That the N30 SEP peak amplitude increase was attenuated following motor learning when preceded by spinal manipulation (compared to what occurred after PHM) provides evidence that SM has the potential to normalize the afferent processing that takes place during early motor learning in a SCNP population.

The objective measurement of continuous cervical inter-vertebral motion in living subjects Jonathan Branney, Alan Breen Introduction: Most neck pain is believed to be mechanical in origin

and spinal manipulation is predicated on the idea that inter-vertebral motion can be changed. Attempts to accurately measure intervertebral motion have previously been prevented by the lack of an objective reproducible method. Quantitative fluoroscopy (QF), the measurement of inter-vertebral motion from digital fluoroscopic sequences, has solved this problem for the lumbar spine but not yet for the cervical spine. This paper reports on adaptations to the QF method as well as accuracy and reproducibility for the measurement of inter-vertebral range-of-motion (IV-ROM) and the location of instantaneous axes of rotation (IAR) for cervical inter-vertebral motion in the sagittal plane. Methods: A patient stabilisation and motion-control frame was adapted from the standard lumbar spine apparatus for interfacing with a Siemens Arcadis Avantic C-arm fluoroscope. Sequential images were captured in DICOM format at 15 frames per second for export and image processing using bespoke tracking codes written in Matlab (Mathworks, R2007b). IV-ROMs and IAR locations from C1-6 were extracted from the resulting continuous inter-vertebral motion pattern data. 1. Accuracy: A model was constructed from 2

112 dry human cervical vertebrae (C4-5) with a digital inclinometer (Penny & Giles STT 280; resolution ± 0.07°) fixed to the superior segment. The model was rotated through 20° flexion then 20° extension while simultaneously being imaged. This was repeated with the model 10° out-of-plane to the x-ray beam. 2. Reproducibility (agreement and reliability): Flexion and extension fluoroscopic sequences were obtained from a sample of 10 (5 males, 5 females) adult participants aged 23 to 50 years using a standardised image acquisition protocol. Sequences were analysed twice 6 weeks apart by one observer and once by a second observer. Results: IV-ROMs and IAR locations were comparable to previously published plain radiograph and cineradiography studies. 1. The root-mean-square (RMS) error for IV-ROM against the reference standard was 0.21° and 0.34° in-plane and 0.50° and 0.40° for out-of-plane flexion and extension. For IAR location (x, y co-ordinates) RMS error was (x 1.06mm, y 0.79mm) for flexion and (x 0.73mm, y 0.98mm) for extension. IAR location was only marginally affected by out-of-plane imaging. 2. Maximum intraobserver standard error of measurement (SEM) for IV-ROM was 1.14° (C5/6 in extension) and the lowest intra-class correlation coefficient (ICC) (95% confidence interval) was 0.895 (0.635 to 0.973) (C1/2 in extension). For IAR location the maximum SEM was 3.56mm and the lowest ICC was 0.040 (− 0.726 to 0.937). Maximum inter-observer SEM for IV-ROM was 0.80° (C3/4 in extension) with the lowest ICC 0.921 (0.711 to 0.981) (C3/4 in extension). The maximum SEM for IAR location was 7.66mm with the lowest ICC − 0.080 (− 0.866 to 0.937). Conclusion: Cervical spine QF demonstrated good agreement for IVROM and IAR locations so can be used to identify changes in these parameters in patients before and after an intervention, or to determine normal variation in controls when measured at 2 or more time points. However IAR differences between individuals cannot be confidently identified in the current population due to poor reliability.

The demographic profile of infants presenting to a chiropractic teaching clinic Madelon Bredie, Joyce Miller Objectives: The purpose of this project was to investigate the

demographic profile, presentation and any observable trends of infants who presented to a university affiliated chiropractic teaching clinic between the years of 2008 and 2011 and to provide evidence for the demographic trends of the types of problems and associated factors of a cohort of infants who present to a chiropractic teaching clinic. Methods: A quantitative questionnaire-based survey, collecting data from infants presenting to Anglo-European College of Chiropractic clinic. Surveys had been given out to 2078 infants which were aged 0 to 12 months. Numbers, not names were used and the survey was completely anonymous. Results: Fifty-five percent were male and 45% were female. Crying (38.1%), musculoskeletal problems (15.5%), feeding problems (23.7%) and positional head deformity (5.0%) were the most common complaints. The most common referral was from healthcare professionals (n = 1226; 63.3%), followed by parents (n = 358; 18.5%), friends (n = 312; 16.1%) and adverts (n = 39; 2.0%). Vaginal unassisted was the most common type of birth reported (n = 896; 43.9%), followed by vaginal assisted (n = 619; 30.4%) emergency caesarean section (n = 345; 16.9%) and planned caesarean section (n = 179; 8.8%). Over-all, 56.1% births were classified as assisted.

WFC 2013 Scientific Sessions abstracts When asked preferred postural position, parents reported infants preferably lying supine (n = 1246; 67.1%), lying prone (n = 187; 10.0%), on the right side (n = 148; 8.0%), left side (n = 90; 4.8%) and others (n = 187; 10.1%). More infants showed a preferred head position to the right side (n = 273; 59.6%) compared to infants who had a preferred head position to the left side (n = 182; 39.7%). Prone positioning was investigated in 355 infants and 70% were given some tummy time daily. Eight hundred twenty-nine infants (44.2%) took one or more medications. The Edinburgh Postnatal Depression Scale (EPDS) was used as a self-report instrument for 677 mothers. Most Mothers (n = 499;73.6%) reported a score of 0 to 9 or unlikely postnatal depression; 81 (12%) gave a score from 10 to 12 indicating possible post-natal depression and a score of 13 or more was found in 97 mothers (14.4%) indicating probable post-natal depression. One thousand and seventy-four mothers reported at least some breastfeeding (55.0%) compared to infants who were exclusively formula fed (n = 878; 45.0%). Conclusion: This study provides evidence that parents commonly present infants to a chiropractic clinic for the routine and common problems during infancy, particularly excess crying, feeding and musculoskeletal disorders. Referrals to this clinic were mostly from other healthcare professionals. Further studies should be aimed at determine efficacy and effectiveness of chiropractic treatment for these conditions.

Biomechanical and somatosympathetic responses to spinal manipulation in an in vivo model of cervical intervertebral disc degeneration Christopher Colloca, Robert Gunzburg, Mostafa Afifi, Robert Moore Introduction: Cervical disc degeneration is a common finding among patients presenting for spinal manipulative care. Few biomechanical studies have examined the kinematics of the degenerated cervical spine or its response to spinal manipulation. The objective of this prospective in vivo experimental animal study was to determine the effects of intervertebral disc (IVD) degeneration on the dynamic dorsoventral (DV) cervical spine stiffness and subsequent neuromechanical responses to spinal manipulation. Methods: Adolescent merino wethers (n = 24, mean 50.1 kg) were mechanically tested in vivo using a previously validated technique to quantify DV stiffness. Twelve sheep randomly received induced anular injury via scalpel wound a minimum of 4 months earlier that resulted in degeneration of the C4-C5 intervertebral disc. Twelve age and weight-matched animals served as controls having cervical spine exposure surgery only without anular contact. Dynamic swept-sine mechanical loads were applied (~5% body weight) from 0.5 to 19.7 Hz (pseudo-chirp sweep) to the C6 spinous process under load control and with the animals lying prone on an operating table. DV cervical spine stiffness (load/deformation, N/mm) at C6 was determined from 6 trials in each animal at 32 distinct loading frequencies. Tri-axial accelerometers were rigidly attached to steel pins implanted into the spinous process of C4 and C5, 4 needle electromyographic (nEMG) electrodes were inserted adjacent, and following surgical exposure, bipolar platinum electrodes were cradled around the left C5 spinal nerve root and nearby sympathetic chain. Spinal manipulative thrusts were delivered to C4 with an Impulse Adjusting Instrument and 3 trials of repeated (6 Hz) impulsive (~100 N, 2 milliseconds) thrusts were administered by a clinician blinded to the groups. Dynamic cervical spine stiffness, vertebral accelerations, nEMG, spinal nerve root and sympathetic responses were compared between animals with

WFC 2013 Scientific Sessions abstracts cervical disc degeneration and controls using a one-way ANOVA with repeated measures. Post hoc analysis with Bonferroni correction was used when significant differences were observed. Results: Histological analyses confirmed anular disruption and degradation in the disc degeneration group. Dynamic DV spinal stiffness ranged from 4.33 N/mm (1.8 Hz) to 7.69 N/mm (10 Hz) for animals with disc degeneration and 3.62 N/mm (1.8 Hz) to 6.00 N/ mm (13.1 Hz) for control animals, respectively. Dorsoventral stiffness at C6 was significantly increased at 31 of 32 mechanical excitation frequencies (P b .05) among animals with cervical disc lesions (all frequencies mean = 7.32 N/mm) compared with control animals (all frequencies mean = 5.47 N/mm). In response to spinal manipulation, vertebral accelerations were significantly reduced in 4 of 6 axes in the animals with disc degeneration (P b .05) while a significant reduction in nEMG response was observed. Marked spinal nerve root and sympathetic responses occurred during manipulation, however, there was no difference in these responses among the groups with and without disc lesions. Conclusion: In vivo dorsoventral vertebral motions of the cervical spine are significantly reduced in animals with degenerated discs which in turn influences neuromechanical responses to spinal manipulation. These biomechanical findings may be useful in understanding the biomechanical consequences of cervical IVD pathology and their contribution in patients undergoing spinal manipulative care.

Activator with adapter for use in animal models increases peak force Felipe Coutinho Kullmann Duarte, Carolina Kolberg, Rodrigo R. Barros, Günther Gehlen, Vivian Germano Alvares da Silva, Jakson Manfredini Vassoler, Wania Aparecida Partata Objective: One of the treatments in chiropractic is to apply handheld adjusting instrument (HIA) (Activator). Recently, the HIA with force setting I was applied along the remobilization time to treat rats that knee was immobilized. This treatment improved mechanical sensibility in the animals. However, this study used adapter placed at the end of the HIA. It is possible that this adapter can vary significantly the force-delivery characteristics. Thus, the aim of our study was to compare the peak force of the HIA with adapter and original rubber tip in force setting I and IV (minimum and maximal force settings). Methods: Peak force was determined by thrusting HIA with adapter and rubber tip in the center of a load cell (30 kgf, “S” type, manufactured by GMAp-UFRGS). A total of 50.000 samples per second over a period of 3 seconds were collected with a 16-Bits converter (Measurement Computing) connected to a signal conditioner with 5 inputs (manufactured by GMApUFRGS) and current amplifier (model TL074) which was connected to a computer. Trials were performed with HIA in force settings I and IV. First, the preload was applied manually in a manner consistent with routine clinical use of the HIA instrument by a chiropractor. A second experimental condition was to apply preload with force adjustment knob from HIA displaced 0, 1, 2 and 3 mm by dial indicator. All data were analyzed by Agilent software (VEE Pro 7.5). Results: When preload was applied manually by chiropractor, HIA with adapter and force setting I showed peak force that increased around 39% when compared to HIA with rubber tip in the same force setting. However, in force setting IV no difference in the peak force between HIA with adapter and rubber tip was found. In

113 the second condition there was also increment in the peak force for HIA with adapter in force setting I, but no difference was observed when force setting was in IV. The increase was 12, 27, 24 and 67% when force adjustment knob was displaced 0, 1, 2 and 3 mm, respectively. Discussion: Peak force only increases when the HIA with adapter was used in force setting I. It is possible that the absence of the increase in force setting IV result of the limitations imposed by the device itself, which makes it impossible to increase the thrust. Thus, studies with animal as experimental model must consider the effects of increased force when HIA with adapter is applied. Conclusion: HIA with adapter increase the peak force only in the force setting I.

Postural static evaluation immediate after chiropractic intervention through the basic protocol from Activator Methods chiropractic technique Carlos Henrique da Silva Diaz, Hanna Josefa Kratz Censon, Camila de Carvalho Benedicto, Djalma José Fagundes, Jorge Arantes Castro Netto, Ana Paula A. Facchinato Introduction: The concept of posture is based on the relationship that occurs between the sensory system that provides information about the position of the body segments, the motor system that activates the muscles adequately to perform the movement and the nervous system that integrates all this information to maintaining a neuromuscular stability. This concepts associated with the position adopted and maintained by the body in space. Photogrammetry is considered a relatively simple, easy and low cost, which allows a precise and objective measurement of different body parts and can be done by several software programs that evaluate distances, vertical and horizontal angles free. SAPO is a free program that provides easy to use, beyond the linear measurements angles. It is based on scanning points specifically defined, which enables various functions such as calibration of the image, use the zoom, free from marking points, distance measurement and angle measurement bodily. Currently the Activator Methods Chiropractic Technique is one of the most used by chiropractors worldwide, about 45,000 practitioners, but notes as hortage of these professionals in Brazil and studies linking technique with postural evaluation5. Objective: Evaluate the head posture and shoulder girdle in students from Universidade Anhembi Morumbi using the Posture Evaluation Software (SAPO) and to evaluate whether the Activator can cause posture alterations after a single application with the basic protocol. Methods: Study conducted in São Paulo, between September/2011 and May/2012, with 55 randomly selected students from Universidade Anhembi Morumbi-Campus Centro. Photographic registries were made at 6 anatomic points at the shoulder girdle and head in the antero posterior view, before and after the intervention with the Activator technique basic protocol. After the intervention, the pictures were analyzed by the SAPO software, measuring 3 angles. Results: There was no significant statistic decrease in individuals' posture evaluation (P = .085), however, analyzing the angles individually, it was observed that there was significant alteration only in angle 1 (P = .038), unlike angles 2 and 3, which had values P = .174 and P = .996 respectively. Conclusion: The Activator technique did not present postural alteration in the head and shoulder girdle in students of

114 Universidade Anhembi Morumbi, according to SAPO software, after a single intervention with the basic protocol.

Prevalence of musculoskeletal thoracic pain in pregnant women Fabiola da Silva Santos, Nara Gehlen

During pregnancy hormonal changes cause changes that may have consequences for some pregnant women, been committing particularly the structure of the musculoskeletal system. This study was characterized as a descriptive cross-sectional study aiming to identify the prevalence of musculoskeletal pains in the dorsal region, pregnant women in the second and third quarter in 3 of obstetrics and gynecology clinics in the metropolitan region of Porto Alegre, which was a questionnaire consisting of 70 closed questions pregnant women who were at prenatal clinics in the study between September and October 2012. The sample was a convenience of the non probabilistic composed of women aged between 18 and 38 years, and were not experiencing a high risk pregnancy, according to the obstetrician, and showing that all study participants received a leaflet about spine care during pregnancy to prevent and relieve some symptoms. The results show that most of the women had musculoskeletal pains, addressing primarily the lumbar region 43 (61.4%), followed by the Thoracic 8 (11.4%), sacroiliac Region 8 (11.4%) and Leg 2 (2.8%). Isolating the numbers of the purpose of the study, I conclude that the third quarter is where there is the largest number of cases of chest pain, totaling 6 (75%) of the women, these pains occur 3 times during the week, with the intensity of pain moderate. The other 2 patients (25%) with hits in the second quarter related pain 3 to 4 times per week with moderate intensity between the little pain. It follows a low prevalence of pains in the chest during pregnancy.

The effects of diversified chiropractic manipulation versus sacro-occipital technique in chiropractic management of sacroiliac syndrome Charmaine Dell, Barrett Losco, Dominique Losco Purpose: The purpose of this pilot study was to assess the effects of

diversified manipulation versus sacro-occipital technique in the management and treatment of sacroiliac syndrome.method: This study consisted of 2 groups, a diversified group consisting of 15 subjects with sacroiliac syndrome and a sacro-occipital technique group consisting of 15 subjects with sacroiliac syndrome. The subjects were between the ages of 18 and 55 years. Potential candidates were examined and accepted based on the inclusion and exclusion criteria. The diversified group received diversified manipulative therapy to the sacroiliac joint, while the sacrooccipital group received Sacro-Occipital Technique (SOT) Category 2 blocking, from which the subjective and objective findings were based. Procedure: Each successful candidate was treated 6 times over a twoweek period. Before the commencement of the treatment one, 3 and six, the candidate completed the Oswestry Back Pain and Disability Index questionnaire and the Numerical Pain Rating Scale. Digital Inclinometer readings were taken of the thoracolumbar and lumbosacral regions of the spine. Sacroiliac manipulation was then administered to the diversified group based on the restrictions obtained during motion palpation. Category 2 blocking was administered to the SOT group based on the SOT Category 2

WFC 2013 Scientific Sessions abstracts categorization test findings. The same treatment was administered at each of the 6 treatment sessions. Results: Objective statistically significant differences were noted on lateral flexion range of motion, in favour of the SOT group. Subjective readings also showed statistically significant differences with regards to Oswestry Back Pain and Disability Index and Numerical Pain Rating Scale in favour of both the diversified group and the Sacro-Occipital Technique group. Conclusion: The results of the study indicate that both SOT and Diversified have a positive effect on patients with Sacroiliac Syndrome. However, SOT proved to have a greater overall benefit compared to diversified manipulation in the treatment and management of Sacroiliac Syndrome. It should be emphasized that the present study was a pilot study to determine the effects of Diversified manipulation versus SOT in the management of sacroiliac syndrome. Accurate conclusions could not be formulated due to the remainder non-significant statistical findings obtained from the study; therefore further research needs to be conducted on this comparative study.

Do school bags influence musculoskeletal health in secondary school children? A cross-sectional cohort study Morna Dodd, James O'Dell, Adrian Hunnisett, Christina Cunliffe Introduction: Recent research has shown that back pain is common amongst children and there is a clear correlation between childhood/ adolescent low back pain (LBP) and future adult LBP. From an early age, schoolchildren carry weighty bags to school each day. Although musculoskeletal symptoms in schoolchildren are believed to result from many different factors, carrying schoolbags play a significant role and many studies have positively linked weight bearing with detrimental effects on the gait cycle and/or posture of children. Korovessis et al found an association between the height of a child, backpack weight and pain, concluding that shorter children who carry backpacks of the same weight as taller children of the same age are more prone to low back pain (LBP). There is a need for further research in this area, particularly the relationships between schoolbag weight and the height of schoolchildren in the development of musculoskeletal pain. Method: A cross-sectional survey was conducted of 100 children between ages 11 to 18 attending secondary school. The study comprised a questionnaire regarding any musculoskeletal pain experienced in the preceding month and year, height and weight measurements and a second questionnaire regarding details of their individual schoolbags. Results were collated and then analysed descriptively and inferentially as appropriate. Results: A total of 100 pupils participated, 56 females and 44 males. The majority (56%) of the sample had experienced musculoskeletal pain in the last month, with 35.7% experiencing shoulder pain, 27% low back pain, 24% neck pain and 20% upper back pain. There was no significant difference between the use of either a backpack or a shoulder bag. There was a significant association of pain with relative schoolbag weight (P b .02), especially in girls (P b .05). There was a highly significant association between height and pain (P b .01), especially in boys (P b .05). Conclusion: A number of statistically significant findings were made linking height, bag weight and gender in schoolchildren. It is apparent from the results here, that there is a gender difference with regard to musculoskeletal pain. Girls tend to experience pain

WFC 2013 Scientific Sessions abstracts purely due to the weight of their bag, as expected, but boys would appear to be more at risk due to their height combined with the weight of their bag. It is clearly seen that shoulder pain is the most prolific area of pain out of the 4 under investigation, followed by LBP, neck pain and UBP. The higher level of shoulder pain found in this study confirms previous findings by other researchers and indicates that further research is required regarding shoulder pain.

115 Conclusion: The factors associated with LBP predisposition in some instances were at odds with the prevailing literature, indicating that further research is required on White population group in Africa.

The validity and specificity of the arm fossa test Andrew Evans, Christopher Yelverton Introduction: Sacroiliac joint dysfunction (SJD) is a common An epidemiological investigation of low back pain in the white population in the greater eThekwini metropolitan area Brinique Ann Dyer, Andrew Douglas Jones, Charmaine Maria Korporaal Objectives: Previous investigations on the epidemiology of low back

pain (LBP) in South Africa where limited to Black, Indian and Coloured populations to the exclusion of Whites. Thus the aim of this study was to determine a LBP profile and an overview of risk factors in the White population in the eThekwini metropolitan area. These included documenting the point, period and lifetime prevalence of LBP, describing the characteristics of LBP, identifying the risk factors of LBP and assessing the effect on activities of daily living in the White population in the greater eThekwini metropolitan area. Methods: The 3 most densely populated White suburbs in the greater eThekwini metropolitan were chosen and classified according to income potential (high/middle/low income) to ensure a balanced sample. Six hundred White participants were used in the study having 200 White participants in each suburb. For the analysis, a P value b .05 was considered as statistically significant. Associations between categorical covariates and prevalence of back pain were assessed using Pearson χ 2 test, and differences in means between 2 independent groups were tested using t tests. The risk factors for lifetime prevalence of back pain were tested using a binary logistic regression model in order to control for confounding factors. Odds ratios and 95% confidence intervals were reported. Results: The prevalence of LBP was recorded as follows: lifetime prevalence (48%), period prevalence from 0 to 3 months (21.3%), 6 to 12 months (18.3%) and 12 months to 24 months (7.8%) and point prevalence was 34%. The majority of the participants reporting current LBP indicated their pain was moderate (54.3%) [14.9% had severe pain], occurred in the evening and was non-progressive (41%), worsening (35.2%) or getting better (18%). Associated disability was mild (51.8%), with the pain associated most often with bending and lifting. Only 16.8% were absent from work due to LBP. It was further found that when comparing different income groups (low, middle and high) that age (P = .024), gender (P = .035), height (P = .056), marital status (P b .001), education (P b .001), work (P b .001) and occupation (P b .001) were significanly different. These significant findings indicated that the low income group was greatest at risk for LBP. These findings were further supported when analysis found significant associations between LBP and smoking (P = .098), exercise (P = .000), medical aid (P = .000), comprehensive medical aid (P = .000), hospital scheme (P = .000) and access to health services (P = .000), which again indicted that the low income group was more predisposed to LBP. Interestingly, it was found that the high income group perceived that they had a greater likelihood to the development of LBP, which contrasts with the findings.

problem in the general population and diagnosis is primarily made with the use of manual orthopedic tests . Whether clusters of these tests can be used to accurately diagnose SJD is being studied. This study is designed to assess the validity and specificity of the Arm Fossa Test (AFT), which is part of the Sacro Occipital Technique (SOT) evaluation protocols. This may contribute to the research related to diagnostic tests that assess the specific joint dysfunction related to SJD. An ethics committee at Technikon Witwatersrand (TWR) (now Johannesburg University) approved the study in January 2005. Methods: To perform the AFT, the examiner tests the responsiveness of the latissimus dorsi muscle on the supine patient, as the examiner successively makes light contact with the upper and lower portions of the left and right inguinal ligaments. The finding of a delayed or slow responding latissimus dorsi muscle is thought to be consistent with sacroiliac hypermobility; whereas a strong muscle points toward either a normal sacroiliac joint or one with sacroiliac hypomobility. Eighty subjects were selected for the study, 35 females and 45 males. They were sourced from the TWR health clinic. Prior to testing subjects a case history was taken, and they underwent a full sacroiliac regional examination using generally accepted diagnostic techniques. The subjects were then taken to a different room where an assessor tested for SJD using the AFT. This was done by 2 different assessors, each without knowledge of the other's results and was therefore double blinded. Results: Of the 160 sacroiliac joints (right and left side for each of the 80 subjects) evaluated, the AFT correctly evaluated 166 (28 true positives and 88 true negatives). This gives a percentage correlation of 72.5%. The AFT incorrectly evaluated 44 (40 false positive and 4 false negatives) as shown by the misclassification rate of 27.5%. The Kappa Coefficient, indicated as 0.40, is bordering on a moderate strength of agreement. Discussion: Since the AFT's main purpose is to assess the presence of a specific type of SJD hypermobility, it is possible that it is not as sensitive for assessing SJD associated with hypomobility. Yet in several separate studies of various SOT examination procedures including the AFT test, Leboeuf-Yde reported the following for the AFT. - intraexaminer reliability: high in one study and low in another; - interexaminer reliability: low; validity: some value in correctly distinguishing a correctly treated from an incorrectly treated group of participants; - validity: in relationship to lumbopelvic pain: sensitivity = 54%, specificity = 69%; - validity: no relation between side of involved fossa and side of sacroiliac fixation. Conclusion: The AFT clearly has some validity but should not be used on its own as a tool for the diagnosis of SJD but rather as part of a comprehensive diagnostic evaluation of the joint. Further research is needed to determine whether the AFT is better suited for

116 evaluating the subset of patients with SJD that is related to hypermobility or SJD associated with hypomobility.

Management and treatment of low back pain at the Integrated Health Center University Anhembi Morumbi Brazil: a cross-sectional retrospective study Ana Paula A. Facchinato, Camila de Carvalho Benedicto, Djalma Jose Fagundes, Magellan Takanori Amanuma, Mariana Ferreira Paganelli Lopes Introduction: The chiropractic graduation at Anhembi Morumbi

University (UAM) started in 2000, and the curriculum is based on the World Health Organization Guidelines on Basic Training and Safety in Chiropractic. The main technique taught is the diversified technique (DT) but in the seventh semester students also learn other chiropractic techniques such as Activator Methods Chiropractic Technique (AMCT), Sacro-Occipital Technique (SOT) and others. The purpose of this study was to evaluate treatment patterns made by interns by examining the techniques used, the clinical outcome between the evaluation day and the first return, and the relationship between clinical outcome and the segments adjusted. The objectives were to analyze the patients' records with back pain complaint, with or without radiculopathy, at the chiropractic clinic at Anhembi Morumbi University's Integrated Health Center (IHC), to establish standards for the treatment carried out by the interns, and identify the patients' profile. Methods: Patients' records in the IHC were selected and analyzed from August 2010 to December 2011. Information was collected from clinical records and recorded on a form designed by the students. Initially all variables were analyzed descriptively. To test the homogeneity between the ratios the χ 2 or Fisher exact test was used. Results: There was a predominance of women in the sample (66.5%), with a mean age of 47.56 years. The duration of low back complaint had a mean of 6.7 years, and a daily frequency in 66.5% of the cases. 54.6% of patients had sought some type of previous treatment for low back pain, and 32.7% were still undergoing treatment when started chiropractic care. DT was the most used technique (66.2%), followed by AMCT (22.2%) and SOT (5.6%). 78.5% of the cases reported overall or temporary improvement, and in 15.5% of cases symptoms remained unchanged. No significant results were found in the analysis that tested the homogeneity between the ratios of the sample. Conclusions: The 78.5% of patients that reported improvement after initial consultation proves that chiropractic care is effective starting from the first intervention. No significant result was found in the relationship of the segments that received the intervention and the progress reported by the patient, as there was no difference in the comparison of the techniques used on the evaluation day and the reported improvement in the first return.

The clinical effectiveness of therapeutic exercises alone and in combination with orthotic bracing in the treatment of lateral epicondylalgia Megan Flanders, Charmaine Maria Korporaal, Praveena Maharaj Introduction: Lateral epicondylalgia (LE) is a common diagnosis in

elbow pathology. The aetiology is poorly understood but it is

WFC 2013 Scientific Sessions abstracts generally accepted to be as a result of repetitive microtrauma, affecting the proximal end of the extensor carpi radialis brevis tendon. Elbow bracing and exercise modification are often utilised by patients in order to reduce symptoms. In addition, there have been multiple treatment regimes used in practice to treat LE, but none has stood out as being more effective than another. Thus, the aim of this study was to investigate the relative clinical effectiveness of therapeutic exercises alone and in combination with orthotic bracing, in terms of subjective and objective clinical findings. Method: This stratified (gender), quantitative, prospective clinical trial consisted of 2 equal groups (n = 15) diagnosed with LE. Group One received strengthening and stretching programme alone, and Group Two received a combination of the same programme and an orthotic brace. The participants performed the programme daily at home for 6 weeks, and the brace was worn throughout the day for 6 weeks. Each participant was assessed before, during and after the programme, in terms of pain free grip strength, pressure pain threshold, numerical pain rating scale and the patient rated tennis elbow evaluation questionnaire. Repeated measures ANOVA testing was also used to compare the outcomes between the groups over the time points, with the P value being less than .05 for statistical significance. Results: Both groups showed significant statistical improvement in terms of pain free grip strength (P b .001 per group; P = .180 between groups), pressure pain threshold (P b .001 per group; P = .110 between groups), numerical pain rating scale (P b .001 per group; P = .791 between groups) and the patient rated tennis elbow evaluation questionnaire (P b .001 per group; P = .174 between groups). The groups also showed a clinically significant improvement (compared to literature reported minimally clinically important differences) for all the outcome measures, with the exception of pressure pain threshold where Group Two showed clinically significant and Group One did not. Conclusion: The results show that there was negligible benefit when combining an orthotic brace with therapeutic exercises as opposed to performing the therapeutic exercises alone.

Identification of suspicious skin lesions in chiropractic practice: a cross-sectional study Sarah Glithro, David Newell, Adrian Hunnisett, Christina Cunliffe Introduction: Skin cancer is the only form of cancer visible to the naked eye, making it easier to spot, treat and prevent early mortality. However, the morbidity and mortality rates from skin cancers are increasing. Research points to early detection and patient education programmes improving morbidity and mortality rates. More health practitioners with the opportunity, skills and willingness to perform such tasks need to be involved to slow the rate of increase. Based on General Chiropractic Council UK guidelines, it could be argued that chiropractors have a duty to provide a level of care which includes additional health checks where appropriate to their patients' needs. Assessments for suspicious skin lesions could fall within this remit if the patients skin was visible. Despite 42% of chiropractors regularly examining patients in their underwear, no evidence exists to determine whether chiropractors are taking advantage of this opportunity to perform skin examinations. Chiropractors are highly trained primary healthcare providers with excellent clinical experience. They generally see more skin than any other clinician and with additional training they could provide an invaluable service.

WFC 2013 Scientific Sessions abstracts Method: Following ethical approval, a semi-structured, selfadministered, quantitative, questionnaire-based survey was used amongst a sample of final year chiropractic interns and registered chiropractors to gather information on the accuracy and incidence of detecting suspicious skin lesions. The survey had 4 principal aims: (1) To obtain participant demographic information. (2) To discover whether interns/chiropractors are willing to assess patients for skin lesions. (3) To discover whether interns/chiropractors have the skills to detect suspicious skin lesions and to test those skills using test images. (4) To identify the training required to improve those skills. Results were collated and analysed descriptively and inferentially as appropriate. Results: The survey achieved a response rate of almost 90%. A majority agreed that screening was part of the chiropractic role, 68% (n = 44) of responding chiropractors and 91% (n = 54) of interns (P b .005; Fisher Exact). Odds ratio calculations suggest that interns are 5 times more likely to answer “yes”, than those in the chiropractor group. On identification of lesions, 75% labelled examples of malignant melanoma and squamous cell carcinoma as suspicious, b 45% did so for BCC and actinic keratosis. Twice as many chiropractors would refer lesions on compared with interns (P b .05, Fisher Exact). Whilst 74% had received some related training, 78% would be interested in attending more, either at undergraduate level or as postgraduate CPD. Conclusion: Early detection and treatment of suspicious skin lesions could improve patient outcomes and provide other benefits. Health professionals should diagnose and use their professional judgment to identify and refer those patients requiring help beyond their expertise. The chiropractic profession is already playing an important role in this respect and could improve patient care and raise the positive profile of the profession.

Co-management of older adults with low back pain by doctors of chiropractic and family medicine physicians: study design and participant recruitment Christine Goertz, Stacie Salsbury, Robert Vining, Cynthia Long, Andrew Andresen, Mark Jones, Kevin Lyons, Maria Hondras, Lisa Killinger, Fredric Wolinsky, Robert Wallace Introduction: Older adults experience low back pain (LBP) at similar rates as the adult population and report higher levels of severe LBP than their younger counterparts. Older people may consult their family medicine physicians (MDs) about back pain, while also receiving concurrent care from doctors of chiropractic (DCs). The purpose of this study is to evaluate the feasibility and clinical effectiveness of a patient-centered model for DC-MD collaborative care for LBP treatment in older adults. In this paper, we describe the study protocol, participant recruitment, and enrollment results of this pilot randomized controlled trial (RCT). Methods: Ethics approval was granted by the Institutional Review Boards of Palmer College of Chiropractic and Genesis Health System in Davenport, Iowa, USA. We chose a pragmatic RCT design to enroll persons age 65 years or older with LBP lasting at least one month from the community. Eligible participants could receive up to 12 weeks of individualized LBP treatment through 3 treatment groups: medical care only (n = 43), concurrent medical and chiropractic care (n = 44), or collaborative medical and chiropractic care (n = 44). DCs/MDs delivering the collaborative care intervention completed interprofessional education sessions

117 and shared treatment records through a secure website. Primary outcomes were back pain and back-related disability at 12 weeks. Participants were recruited through successful strategies previously used at the research center. Results: Participant recruitment began 03/04/11 with the final participant allocated to treatment on 08/21/12 (77 weeks). Community interest was consistent throughout the recruitment period with 842 potential participants contacting the research center to learn about the study. We conducted 634 telephone screens with 324 participants eligible for the initial baseline evaluation. We allocated 131 participants to 3 treatment groups. Referral sources included direct mail postcard (n = 507; 79%), newspaper articles (n = 57; 9%), word of mouth (n = 26; 4%), current patient letter (n = 18; 3%), and other sources (n = 35; 5%). Most common reasons for study nonparticipation included costs (n = 49), time commitment (n = 35), treatment group concerns (n = 28), health conditions (n = 16), no perceived treatment benefit (n = 16), clinic no show (n = 10), transportation (n = 9), current doctor concern (n = 7), and other/ multiple (n = 62). Most common exclusion reasons were current LBP treatment (n = 105), multiple exclusions (n = 53), LBP attributes (n = 52), current cancer (n = 11), further evaluation needed (n = 8), other health problem (n = 7), compliance concerns (n = 7), alcohol/drug abuse (n = 5), aortic aneurysm (n = 3), and other exclusions (n = 17). 127 participants completed at least 1 treatment. Nine participants withdrew prior to primary outcomes assessment. Discussion/ Conclusion: Many community-dwelling older adults expressed interest in learning more about a RCT involving LBP co-management between family medicine physicians and doctors of chiropractic leading to timely completion of study enrollment and active care. Direct mail and newspaper articles from press releases were our strongest referral sources. This study demonstrates that it is feasible to recruit and retain older adults into clinical trials that evaluate both medical and chiropractic management for low back pain.

A study to explore the perceptions that South African chiropractors have regarding the perceived role and impact of research within the profession Julani Gordon, Charmaine Maria Korporaal Background: The Chiropractic profession has made significant

progress with the production of high quality and clinically relevant research in the last 20 years. This correlates with development of the chiropractic profession and its acceptance by the medical fraternity and public. The responsibility for continuing this positive trend is dependent on graduates and practitioners of the future. Therefore, it is important to establish the perceptions and utilization of research by chiropractors. This enables research to be built around the needs and requirements of the profession. The aim of this IRB approved study was to determine the perceptions that South African chiropractors held of research and its relevance/utilization in their practices. Method: The study was a quantitative questionnaire based, self administered survey. The questionnaire was developed from the literature and validated through a Delphi process, contextualising it in the South African context. The sample group included all chiropractors practising in South Africa (N = 515) at the time of the study. For the statistical analysis, a P value b .05 was considered as statistically significant. Perceptions and utilisation of research were scored as a percentage such that the higher the score, the more positive the perceptions/the higher the utilisation. Perceptions and

118 utilization scores were compared between binary factors using independent samples t tests and between more than 2 groups using ANOVA testing. Pearson correlation analysis was used to assess relationships between 2 quantitative variables. Results: There was a response rate of 35% (n = 174). The results indicated that the perception of research was very positive overall, with the strongest positive response being that research adds credibility to the profession. However, most respondents disagreed with the statement that chiropractors who had done research had an advantage over those who had not. There was a positive, albeit weak correlation between perceptions and utilization of research, indicating that as perceptions increased, so did utilization of research. The area of greatest concern was that even though a high degree of research utilization was reported by chiropractors, research was least likely to be used to change conditions, policies or practices in practice. The most significant factors associated with positive perceptions and utilization were found to be publishing in a journal; receiving referrals from other healthcare practitioners and chiropractors who indicated an interest in doing further research. It would seem that even though chiropractors perceive research positively, their implementation into practice has some hurdles that impede the full integration of research into practice. As very few demographic and personal attributes of the South African chiropractor were found to be primarily responsible for low utilization of research in practice, it is hypothesised that the factors impeding research implementation are most likely environmental in nature. Conclusion: Further research is required to determine the reasons for lack of translation of research into practice, as these do not seem to be primarily related to practitioner demographics, personal attributes and/or perception.

Plausible theories for the association between smoking and back pain: review of the literature Bart Green, Claire Johnson, Andrew Dunn, Cassius Lockett, Jeff Snodgrass Background: Back pain is a common musculoskeletal problem with

a lifetime prevalence of 80%. Several studies have demonstrated an association between back pain and smoking, revealing smoking as one of few potentially modifiable back pain risk factors. While associations between smoking and back pain have been made, few studies have tested causal hypotheses between smoking and back pain. If smoking is causal for back pain, a primary back pain prevention strategy is smoking cessation. The aim of this study is to identify plausible hypotheses related to smoking and back pain in the published literature and to ascertain if there is any evidence cited or produced within the study to support the proposed causal relationship. Methods: PubMed, ProQuest and the Networked Digital Library of Theses and Dissertations were searched from the earliest month and year available through June 2012. The search terms were smoking and back pain. We also reviewed the references of each article for any additional source materials not obtained from the initial search. Articles were excluded if they did not discuss a potential theoretical relationship between smoking and back pain, were not in English, or unrelated to the thoracic or lumbar spine. Each hypothesis included in the study was checked for plausibility against Sir Austin Bradford Hill's 9 criteria for causation, namely: Strength of association (OR, RR, etc); Consistency (repeated observations); Temporality (outcome follows exposure); Biological gradient

WFC 2013 Scientific Sessions abstracts (dose-response); Specificity of the association; Plausibility; Coherence with other data; Experimentation is supportive; and Analogy to other exposure/outcome associations. Results: There were 555 citations in the initial search. After reviewing the titles and abstracts, 215 full papers were obtained for further review. Several theories are postulated in the literature to explain a causal link between smoking and back pain. The theories fall into 7 general categories including: (1) smoking affects pain perception; (2) smoking induces chemobiomechanical stress; (3) smoking causes inflammation; (4) smoking causes loss in bone mineral density; (5) smoking causes genetic changes in intervertebral disc cells; (6) smoking causes an immune reaction; (7) smoking causes general sickness and overall poor health. Previous research shows that 3 of Bradford Hill's criteria are satisfied by data provided in the literature. Biological gradient has some evidence to support it. There is a lack of plausibility, specificity, coherence, experimentation, and analogy to other exposures. Conclusion: The results of this review can help to better inform spine pain research by presenting biologically plausible hypotheses pertaining to smoking and back pain to test in future studies and identify theories in need of improved evidence to support their supposed relationships.

Management and satisfaction index to chiropractic treatment in professional soccer players Nara Isabel Gehlen, Felippe Guariglia, Danilo Messa da Silva, João Batista Mendes Rodrigues Introduction: The current reality of the sporting is characterized by professionalism, intense training and repetition that results in higher incidence of orthopedic injuries, justified by excessive gaming and decisive matches. Given this, there are several ways to rehabilitate, among them stands chiropractic management, which is proving increasingly present in sports, working in rehabilitation and/or prevention. There is little literature explaining the scope of practice of chiropractic and sports management, particularly in football soccer. The chiropractic care is being increasingly discussed in sports for their contribution with immediate results regarding the reduction of pain and increased range of motion. Methods: This study aimed to analyze the body parts commonly treated in a medical department of a professional football soccer team of Brazil, observe the chiropractic procedures used and analize the level of satisfaction after chiropractic treatment. It was a quantitative analytical pre experimental cross study. The study was approved by the ethics committee of the University Feevale. The sample consisted of 25 male athletes, aged 18 to 35 years belonging to a professional football club in the region of Porto Alegre-Brazil. Were performed 1 to 12 sessions with each athlete, which was observed the number of musculoskeletal complaints. Results: The total injuries treated was 24, the highest body part incidence was the knee with 6 individuals, followed by pelvis with 4, ankle, neck and lumbar 3, 2 toes, shoulder and hip with a femoral complaint. Throughout the study were conducted 61 sessions with 168 chiropractic manipulation, the segments manipulated were the thoracic 78, followed by lumbar/pelvis 46, cervical 25 and extremities 18. The index of satisfaction after chiropractic treatment was score average of 7.72 on a total of ten, showing satisfactory scores regarding the perception of chiropractic care for athletes.

WFC 2013 Scientific Sessions abstracts Discussion: Increasingly in the rehabilitation process has been used manipulative joint techniques due to neurophysiological responses observed. Studies have shown that spinal manipulation increases pain tolerance or its threshold, as well as strength and muscle activation especially in the lower limbs. The sports chiropractic presents a major focus in the management of lesions in the extremities, and with positive results. Interdisciplinarily this practice provides primary healthcare and attention ndividualized. The scope of practice of chiropractic is not limited only to joints, but also in the use of myofascial techniques. Conclusion: It was observed a high percentage of lesions in the lower limb. The chiropractic care was inserted into a multidisciplinary context, having a good acceptance by the athletes.

119 were 20% to 30% less than the others. Intradiscal pressures decreased linearly as a function of the increased traction forces. Variation between cadaver specimens was high, as indicated by the large standard deviations. Conclusions: This study reports distraction forces and intradiscal pressure changes during a conservative manual manipulation procedure simulated on cadavers, each with intact head, neck and trunk. Decreases in intradiscal pressures were observed at all cervical levels. The traction forces observed were in the range of traction forces used during home traction therapy.

Bone mineral density in pre-menopausal women and their socio-demographic profile: a survey Samantha Hayes, Joyce Miller, Karen Knapp Cervical intradiscal pressure changes during manual distraction Maruti Gudavalli, Tejaswy Potluri, Gerard Carandang, Robert Havey, Leonard Voronov, James Cox, Robert Rowell, Ralph Kruse, George Joachim, Avinash Patwardhan, Charles Henderson, Christine Goertz Introduction: Neck pain is a common musculoskeletal complaint

that is often associated with disability and lost work days. Pain and/ or numbness radiating down one or both arms (radiculopathy) often accompanies neck pain. Current treatment approaches range from surgical intervention (eg, disc decompression) to conservative treatments (eg, spinal manipulation, spinal mobilization, or traction). These therapeutic approaches may be used alone or in combination with other physical therapy modalities. Intervertebral disc pressure reduction has been the primary therapeutic rationale for both surgical and conservative therapies. The objective of this cadaveric study was to measure real-time intradiscal pressure changes in the lower cervical spine during a manual cervical distraction procedure that is commonly used in clinical practice. Methods: Nine unembalmed cadavers with intact head, neck, trunk, and shoulders were procured. Anterior incisions were made to insert pressure transducers into the disc nuclei at C4-C5, C5-C6, C6-C7, and C7-T1 under video fluoroscopic guidance. The cadavers were then placed prone on a custom designed cervical spine distraction table that was equipped with sensors to measure traction forces and axial displacements. The table's mobile headpiece allowed axial glide with either a fixed head position or concurrent active head flexion. Four skilled clinicians applied 5 manual cervical traction cycles with the headpiece in each of 3 configurations: i) head fixed in neutral position, ii) head fixed in flexion, iii) head in active flexion. The clinicians distracted the cervical spine by applying manual traction force to either the C5 or C6 spinous-lamina region. The mobile headpiece was thus distracted for 5 cycles at each of 2 configurations; fixed neutral and fixed flexion. Intradiscal pressures, traction forces, and manually applied posterior-to-anterior forces were recorded during all procedures. Descriptive statistics were calculated and data were graphically analyzed for changes in intradiscal pressure and applied traction and posterior-to-anterior forces. Results: Observed intradiscal pressure reductions were, mean mm Hg (SD): 502 (644) at C4-C5, 367 (401) at C5-C6, 414 (393) at C6C7, and 6 (436) at C7-T1. Mean traction forces were: 87 (26) N. Posterior-to-anterior forces applied during manual traction were 42 (21) N. The ratio of traction force to posterior-to-anterior force was 2.6 (1.7). Intradiscal pressure decreases and applied forces were similar for the 3 doctors. One of the 3 doctors applied forces that

Objectives: There are gaps in the knowledge concerning risks for

low bone density in young women. Further research is needed to clarify what lifestyle factors may be involved. The goal was to describe the prevalence of osteopenia/osteoporosis in premenopausal women and whether lifestyle factors influence bone density. Methods: Lifestyle questionnaires and bone density T-scores to determine associations. 263 pre-menopausal caucasian females aged between 20 and 55. Exclusion criteria included menopause before 55; amenorrhea for 6 months; history of drugs or diseases known to affect bone metabolism; or a history of low trauma fracture. Methods: Subjects completed a bone questionnaire before undergoing BMD measurements of the lumbar spine, femoral neck and total hip by DEXA equipment, according to WHO criteria. Statistical analysis with descriptive statistics, one-way ANOVA and t tests were used. Results: Osteopenia occurred in 18.3% at the lumbar spine; 34.6% at the femoral neck; and 16.5% at the hip. A small percentage (b 2%) were found to have osteoporosis. BMI was statistically significant for the spine (P value b .01), femoral neck (P value b .001) and total hip (P value b .001). Subjects with a BMI of 30 to 39.9 kg/m 2 had an increased T-score compared to subjects with lower BMIs. The age of menarche had statistical significance for the femoral neck (P value b .05) and total hip (P value b .01). The early menarche category (9-11 years) had an increase in T-score compared to the late menarche category (15-17 years). The amount of alcohol consumed per week was found to be statistically significant for the spine (P value b .05), femoral neck (P value b .05) and total hip (P value .05). Subjects who consumed N 15 U per week had higher T-scores than those subjects who abstained from alcohol. All other factors: amount of exercise, vegetarian diet, smoking, caffeine intake and family history showed no statistical significance. Conclusion: Osteopenia is occurring in some premenopausal women and the lifestyle factors in this study which appeared beneficial to bone health were a high BMI of 30 to 39.9 kg/m2, an early age of menarche and consuming a moderate amount of alcohol per week (N 15 U).

The relative effectiveness of non-steroidal anti-inflammatory drugs (ibuprofen) and a taping method (Kinesio Taping Method) in the treatment of episodic tension-type headaches Justin Henry, Charmaine Maria Korporaal Background: Headaches are one of the most common clinical

conditions in medicine, and 80% of these are tension-type

120 headaches (TTH). TTH has a greater socioeconomic impact than any other type of headache due to its prevalence. Within the TTH category, episodic TTH (ETTH) are more prevalent than chronic TTH. The mainstay in the treatment of TTH are simple analgesics and NSAIDs. Unless contraindicated, NSAIDs are often the most effective treatment for ETTH. However patients with TTH tend to relate their headaches to increased muscle stiffness in the neck and shoulders and thus the non-pharmacological treatment of ETTH could be directed at the associated musculoskeletal components of ETTH. It was therefore proposed that the Kinesio Taping Method may have an effect in the treatment of the muscular component of ETTH. Method: This study was a prospective randomised clinical trial with 2 intervention groups (n = 16) aimed at determining the relative effectiveness of a NSAID and the Kinesio Taping Method in the treatment of ETTHs. The patients were treated at 5 consultations over a 3 week period. Feedback was obtained using the: NRS 101, the CMCC Neck Disability Index and a Headache Diary. SPSS version 15.0 (SPSS Inc, Chicago, IL) was used to analyze the data. A P value b .05 was considered as statistically significant. Independent samples t test was used to compare quantitative normally distributed variables between the 2 treatment groups. Pearson χ 2 test was used to compare categorical variables between the treatment groups. Repeated measures ANOVA testing was used to compare CCMC between treatment groups over time. The generalized estimating equations (GEE) family of generalized linear models were used to assess the Headache Diary variables which were collected over a period of 21 days each. Results: At baseline, there was a significant difference between the groups in terms of age (P = .011) and the presence of headaches (P = .007) (older and more headaches in the NSAID group). After analysis controlling for these baseline differences, The CMCC showed an improvement in the functional ability of the patients in both groups and the Headache Diary showed a reduction in the presence and number, mean duration and pain intensity of ETTH in both groups to similar extends. These treatment effects were sustained after the cessation of treatment with the exception of mean pain intensity in the Kinesio Taping Method group. The mean NRS score decreased in both groups but at a slightly faster rate in the Kinesio Taping Method group. Conclusion: There seems to be no significant difference in the relative effectiveness of the treatment modalities. However it would seem that the Kinesio Taping Method is as effective in younger people with fewer headaches than NSAIDS in older people with more headaches. Thus a question around the effectiveness of the Kinesio Taping Method in patients that may already have a significant degenerative component to their headaches (eg, cervicogenic headaches) needs to be considered in future research.

Using evidence to inform chiropractic professionalism curriculum Glori Hinck

WFC 2013 Scientific Sessions abstracts faculty. The problem of unprofessional social media use is not limited to the medical profession. An observational study of the Facebook profiles of chiropractic students found that 62% allowed public viewing of their sites and of these 42% posted unprofessional content. It is important that the chiropractic profession address the appropriate use of social media as unprofessional sites reflect negatively on the individual as well as the profession. No studies were found describing social media professionalism training in chiropractic institutions. Methods: This paper describes the social media professionalism training delivered by one institution since 2011. Training involves online and face-to-face formats and is offered to clinicians, faculty, and students. Two one-hour online modules related to social media are offered through the continuing education department using the Moodle learning management system. Formative assessment quizzes were embedded throughout the content and successful completion (80%) of a final quiz was required to obtain boundary hours for continuing education. These same online modules have been integrated into the chiropractic curriculum as a graded exercise in the Business and Professional Foundations course series. A faceto-face social media session was delivered at the annual Homecoming continuing education seminar and social media training was presented to faculty at a monthly case conference seminar. All social media related content was created by a faculty member with a master's degree in educational technology. Study design was approved by the Northwestern Health Sciences University IRB process. Results: The online continuing education social media courses were the top online offering in 2011 and have been successfully completed by 216 clinicians. All (n = 465) chiropractic students enrolled during the spring of 2012 completed the online social media modules as part of their coursework with a passing score of at least 70%. The Facebook Homecoming session was attended by 780 participants and 68 faculty attended the social media case conference. Discussion: Previous research has shown that chiropractic students commonly use Facebook to communicate and interact online8 and a simple Google search suggests that the chiropractic profession is increasingly turning to social media as a practice management tool. It is important that we promote a positive and professional social media presence. Training can help guide those using social media to understand the legalities as well as potential ramifications and effects of unprofessional online behavior. Once content is developed, social media training can easily be adapted for a variety of formats and audiences to include students, faculty, and clinicians. The next step is to determine if such training leads to changes in undesirable social media behaviors.

Facebook and professionalism: it's complicated Glori Hinck, Roni Evans Introduction: The use of Facebook and other online social media

Introduction: Social media is now a way of life with 75% of online

young adults using social networking sites. Medical schools have begun introducing social media professionalism training into the curriculumin response to research indicating that medical students are posting unprofessional content to their social media profiles. Since many educators may not be familiar with social media, it is important that social media training also be addressed within the

sites has changed how people engage, communicate and interact and has had a significant impact on the field of healthcare. Facebook is commonly used by healthcare professional students with a reported 44% of medical trainees, 82% of pharmacy students, 73% of residents and fellows and 65% of young medical school graduates having Facebook accounts. No reference was found in the literature related to the use of social media by chiropractic students.

WFC 2013 Scientific Sessions abstracts Students may intend to use Facebook solely for social activities not recognizing that colleagues, future employers and patients may view their site to gain insight into personal character, judgment and professionalism. They may not realize that posts involving drug/ alcohol use, racism, sexism, violence, or sexuality may have negative consequences related to educational and career opportunities. Unprofessional behavior has been found on the social media sites of medicaland pharmacy students. Unprofessional content posted to social media sites can negatively impact the individual as well as their institution and profession. It is important that healthcare educational institutions encourage professionalism and guide their students in the appropriate use of social media. Methods: This observational study evaluated the publicly available Facebook sites of all chiropractic students (n = 492) enrolled at our institution during the summer of 2011. The study was approved by the Northwestern Health Sciences University Institutional Review Board. The type of content made available to the public was determined for each Facebook profile and each site was qualitatively evaluated for content deemed “unprofessional”. Content was defined as unprofessional if it illustrated evidence of alcohol consumption or illegal drug use, overt sexuality, violent behavior, or patient privacy violations. Descriptive statistics were used to analyze the data. Results: 308/492 (62%) students had publicly available Facebook sites in which their identity could be confirmed. Unrestricted viewing of personal information was most frequently allowed for profile picture (90%), friends list (75%), interests (66%), personal photos (36%), posts (26%) and relationship status (24%). Forty-two percent of the Facebook sites contained content that could be perceived as unprofessional, most commonly in the format of photos related to alcohol consumption. Discussion: Results suggest that Facebook is a common means of interaction among chiropractic students. Many students do not select adequate privacy settings allowing unrestricted access to any unprofessional content that they might post. This is concerning since almost half (42%) of viewable chiropractic student Facebook sites contained unprofessional content. Professionalism curriculum may not have kept up with recent social media trends and healthcare educators may not be adequately prepared to guide students in this area. Students need to understand that their online Facebook conversationsare not private and that photos and posts of unprofessional behavior do not bestow confidence in a potential patient or employer. They also need to understand that they are generating a digital footprint via their social media sites that will follow them throughout their careers. Chiropractic colleges have an obligation to include training related to social media and professionalism in their curriculums.

121 development initiatives may not adequately address this new educational model. Training budgets may not support large inhouse faculty development programs or advanced educational degrees for multiple faculty. Rosenbaum et al suggest increasing the number of faculty with advanced expertise in education and then using these faculty to train peers. This paper discusses a variation of this model using a peer-facilitated online faculty development course. Methods: During the summer of 2012 faculty in a CAM institution were offered an opportunity to participate in an asynchronous online course called How to Teach Online. This four-week course was created and facilitated by a faculty member with a master's degree in educational technology and experience in online teaching. Participation was voluntary and no work release time was granted. Online modules were presented in the Moodle learning management system and introduced faculty to online learning, online content creation, Moodle, and reflective learning. Faculty participated in discussion forums, created multimedia video presentations, and used a Moodle sandbox to present their work for peer and instructor evaluation. Participants were surveyed upon entry and following course completion. Results: 19/20 faculty from across programs (chiropractic, acupuncture and oriental medicine, library, clinics, undergraduate and graduate) successfully completed at least 80% of the required coursework. All completed the pre-course survey and 17 completed the post-survey. A majority (n = 13) indicated that they spent from 3 to 5 hours per week on related coursework. Qualitative analysis indicates that faculty appreciated the opportunity to participate in this online course. They want more assistance in learning how to use technology and how to teach online and would like additional course offerings as well as individualized support. Faculty found the opportunities for peer interaction with fellow participants as well as with the instructor to be an important part of this experienceboth online and outside of the formal course structure. There was great individual variation in the types of activities that faculty found helpful and activities they planned to add to their own courses as well as in the type of ongoing assistance they would like to support their further efforts to embrace online teching and learning. Discussion: A customized online course created and delivered by a faculty member with an advanced educational degree can be an efficient and effective means of faculty development training for technology and online learning in a CAM institution. Such a program can allow faculty to experience online education at the same time they learn how to teach using this model. As programs are developed, it is important take into consideration and support individual faculty preferences and needs.

Chiropractic in allergic rhinitis: is it of value? Kate Hutton, Adrian Hunnisett, Christina Cunliffe How to teach online: an online faculty development program Glori Hinck Introduction: Many chiropractic faculty are clinicians with little

formal education related to teaching and learning. Lawrence suggests that there is a need to offer faculty development programs which enhance teaching skills in chiropractic faculty. Educational institutions are increasingly moving toward greater use of online course delivery which further increases the need for teacher training. Many faculty teach as they learned, have not experienced online learning as a student, and feel ill-prepared to teach online. Typical faculty

Introduction: The majority of treatments in chiropractic clinics are

for musculoskeletal conditions. However, many chiropractic practitioners are of the opinion that spinal adjustment have a role in the management of patients with non-musculoskeletal conditions, in particular asthma. Allergic Rhinitis is common, affects the lives of a high proportion of the population and is generally a chronic condition that people often suffer from for a number of years. It represents a global health problem, affecting 5-50% of the population, and its prevalence is increasing. There is a general paucity of evidence examining the effect of chiropractic on allergic

122 rhinitis. Case studies relating to treatment of this condition were limited to patient testimonials. Leboeuf-Yde et al, found that 11% of chiropractic patients reported that allergies in general were definitely better following chiropractic treatment. The aim of this study is to progress research into chiropractic care for the treatment of non-MS conditions, in particular allergic rhinitis as it is common and usually chronic in nature facilitating measurement of changes in symptoms. It represents the next step in the evidence base for chiropractic care in the treatment of non-musculoskeletal conditions, moving from case studies to cohort studies, in order to evaluate whether the evidence base warrants progression towards randomized controlled trials. Method: Following ethical approval, an interventional study comprising of a retrospective cohort and a prospective cohort was undertaken with participants selected from patients attending a chiropractic college clinic. The retrospective cohort consisted of participants with allergic rhinitis and had already started a course of chiropractic care. They were asked to complete a single questionnaire. The prospective cohort consisted of participants with allergic rhinitis and were about to start a course of chiropractic care. They were asked to complete a questionnaire before their first treatment and again before each of 6 subsequent treatments. The questionnaires asked about symptomatic months of the year, symptom type, frequency and severity. Results were collated and analysed descriptively and then inferentially using appropriate statistical tests. Results: A total of 17 completed questionnaires were returned, comprising of 8 participants in the retrospective cohort and 9 participants in the prospective cohort. A total of 76% patients reported a reduction in symptoms, 76% reported a reduction in symptom severity (P b .05), and 53% reported a reduction in frequency of symptoms. Conclusion: The reduction in severity of symptoms was found to be statistically significant following chiropractic treatment. It appears that 2 to 3 treatments were enough to achieve the changes reported. Although patient numbers were low, improvements have been observed for those with allergic rhinitis following a period of chiropractic care. Substantial improvements were seen in all 3 of the measures of change and the fact that similar improvements were seen in both groups suggests that the data obtained for these patients may be transferrable to larger groups of patients.

WFC 2013 Scientific Sessions abstracts vertebral surface models were created (IRB approved). The origin of a floating spherical coordinate system was moved along with a virtual axis line of the nerve root in each foramen and the closest points from the origin to determine the 3D boundaries of the foramen were searched. The longest axis of foramen was determined by the line which connected 2 points with the longest distance in each foraminal boundary and defined as foraminal height (FH). The least width (FW) was defined as the least distance between the postero-inferior corner of the proximal vertebral body for each motion segment and the closest point on the opposing boundary line. 3D disc height (DH) distribution was calculated by the least distances between the endplates. Intervertebral discs were graded according to the Pfirrmann MRI scale. ANOVA and Pearson correlation were used for statistical analyses. Significant level was set at P b .05. Results: FH did not show significant differences between genders (P = .07) except 20s (MNF) and L1/2 (MNF). Overall, FH decreased with age. When the data were split by gender, while more significant differences were found in male (20 s N 40 s, 20 s N 50 s, 30 s N 50 s, 40 s N 50 s), there was no significant differences in female. Lower lumbar levels had significantly smaller FH than upper ones except L1/2 and L2/3 in both genders. FW showed significant differences between genders. FW decreased with age in male (20 s N 30 s, 20 s N 50 s, 30 s N 50 s, 40 s N 50 s) and in female (20 s N 30 s, 20 s N 40 s, 20 s N 50 s, 30 s N 40 s, 30 s N 50 s). Between each lumbar level, L4/5 and L5/S had significantly smaller FW than the upper lumbar levels in both genders. In L5/S, there was moderate or weak negative correlation between FH and ages. There was moderate or weak negative correlation between FW and ages. Discussion: Disc height loss associated with disc degeneration may have caused the decreased FH in male. Decreased FW with age may also be explained by progression of the disc degeneration with age. The present study showed that the FH decreased as the spinal level being lower in both genders. Although the data are limited in the bony geometry, these data measured in asymptomatic cohort could be used as base line data for diagnosis of foraminal stenosis and planning of treatment modality.

The effectiveness of a unique cervical pillow in the management of chronic non-specific neck pain Kathleen Jagarnath, Laura Wilson, Junaid Shaik In vivo measurements of 3D lumbar foraminal geometry Nozomu Inoue, Issei Senoo, Alejandro Espinoza Oras, Howard An, Gunnar Andersson, John Triano Introduction: Although the mechanisms of spinal manipulation

therapy for low back pain patients are not fully understood, reduction of compressive or irritative insults to neural tissues at the neural foramen is reported as a neurologic/mechanical mechanism of spinal manipulation for low back pain patients. Effects of the spinal manipulation on alteration of the neural foramen size have been reported: therefore, geometry of the neural foramen is a key valuable for investigations on the possible mechanisms of spinal manipulation. The purpose of this study was to utilize a novel 3D CT-based measurement approach to obtain an accurate measurement of the lumbar foramen. Methods: A total of 59 asymptomatic healthy subjects (31 M, 28 F, ages: 22-58 years) underwent lumbar CT scans and 3D lumbar

Introduction: A lack of peaceful sleep and adequate neck support

during sleep has been described as a significant contributing factor to the development of chronic non-specific neck pain. Chiropractors and other healthcare practitioners often prescribe a cervical pillow for the treatment of chronic non-specific neck pain despite the lack of robust research findings to support this practice. Recently a unique pillow made of an inner coil system wrapped and embedded within a polyester foam covering was introduced to the South African market by an internationally-known bed and pillow manufacturer. The pillow is described as being comfortable and supportive to the cervical spine during sleep and would, therefore, contribute to alleviating neck pain. However there are no independent studies to support the manufacturer's claims. The purpose of this study was to assess the effectiveness of this unique pillow compared to the participant's standard pillow in the management of chronic non-specific neck pain.

WFC 2013 Scientific Sessions abstracts Methods: Permission to conduct the study was obtained from the

Durban University of Technology ethics board. Forty individuals, aged 18 to 45 years of age, experiencing chronic non-specific neck pain were recruited via convenience sampling. The study was a single-blinded, cross-over interventional study. All participants underwent a case history, physical and cervical orthopedic examination. Objective (algometer and Cervical Range of Motion measurements) and subjective (Numerical Pain Rating Scale, Neck Disability Index, sleep and pain diary) outcome measures were obtained at 5 consultations over a four-week period, with the crossover occurring after 2 weeks. SPSS version 18.0 was used to analyze the data. Demographic data was analyzed using the χ 2 tests and t tests. The consultations were averaged for each phase of the cross-over design to result in a two-treatment, two-period crossover design. Repeated measures ANOVA testing was used to evaluate the effect of the intervention on subjective and objective measurements according to the method of Dallal. The sleep and pain diary data was analyzed using repeated measures ANOVA and Wald χ 2 test. Ethical clearance for this study was obtained from the Institutional Research Ethics Committee of the Durban University of Technology. Discussion: A significant difference in the perceived comfort levels between the 2 pillows (P b .001) was observed with the Simmons Beautyrest pillow having a higher comfort rating. A significant decrease in NRS scores (P = .018); NDI scores (P b .001); and NRS scores on awakening (P b .001); neck stiffness rating on awakening (P b .00); headache rating on awakening (P = .043) was observed in relation to the Simmons Beautyrest pillow. A significant improvement (P = .001) in algometer readings was observed when using the Simmons Beautyrest pillow when compared to participants usual pillow. A significant increase in mean right lateral flexion measurements was observed in both groups when using the Simmons Beautyrest pillow (P = .001). Conclusion: The Simmons Beautyrest pillow was effective in improving chronic non-specific neck pain. It was regarded as comfortable and provided relief with regards to the clinical features of non-specific neck pain. However the results must be interpreted with caution due to the small sample size. Further robust studies are required to confirm the findings of this study.

What do the Cochrane reviews say about the treatment and/or management of low back pain? Fay Karpouzis, Rod Bonello Objectives: Low back pain (LBP) is one of the most prevalent problems afflicting society. Although a large variety of therapeutic interventions are available for the treatment and/or management of LBP, reviews continue to provide ambivalent evidence for their efficacy. The purpose of this study was to summarize the conclusions drawn by the Cochrane Back Group as published in the Cochrane Database of Systematic Reviews for conventional and non-conventional management and treatment for acute, sub-acute and chronic non-specific LBP. Method: The Cochrane Database of Systematic Reviews was searched using the search terms: low back pain with a date range between January 2000 and August 2012. The conclusions of all retrieved articles were reviewed by the authors of this paper and included if they performed an analysis of efficacy of a modality,

123 which included pain and/or function outcomes. Interventions had to be compared to placebo, sham or alternate treatment. Results: The search revealed 100 results and of those only 28 papers were selected as they included a review of a therapeutic modality for LBP. The modalities assessed by the Cochrane reviewers that met inclusion criteria for this paper were: non-steroidal anti-inflammatory drugs; opioids; muscle relaxants; anti-depressants; botulinum toxin injections; injection therapy; prolotherapy; surgical interventions; combined chiropractic interventions; spinal manipulative therapy; traction; massage therapy; lumbar supports; shoe insoles; neuroreflexotherapy; behavioural therapy; individual patient education; back schools; multidisciplinary biopsychosocial rehabilitation; manual material handling advice; advice to rest in bed versus advice to stay active; superficial heat or cold; exercise therapy; Transcutaneous electrical nerve stimulation; low level laser therapy; herbal medicines; acupuncture and dry-needling. Discussion: Of the 28 papers which met inclusion criteria, 26 different therapies were reviewed. Of these, 16 papers showed efficacy equal to or above standard treatments or against a therapeutic comparator, sham or placebo for at least one outcome. Five of the reviews produced inconclusive results and the remaining 7 did not show efficacy. The modalities that produced positive results to varying degrees were: NSAIDs; muscle relaxants; botulinum toxin injections; combined chiropractic interventions; SMT; massage therapy; individual patient education; back schools; multidisciplinary biopsychosocial rehabilitation; behavioural therapy; advice to stay active; exercise therapy; superficial heat; acupuncture; herbal medicines and Neuroreflexotherapy. Conclusions: Whilst low back pain remains a complex and controversial area, healthcare workers need to review new evidence on management of low back pain as it arises. The authors hope that papers such as this one will assist clinicians to weigh up treatment options to best suit their patients.

The combined effect of creatine and sodium bicarbonate supplementation on blood lactate and anaerobic power in young taekwondo players Mohsen Kazemi, Seyed Abdollah Hashemvarzi, Zia Fallah Mohammadi

Taekwondo (TKD) is a Korean martial art practiced in over 197 countries and has gained full-medal status since the 2000 Olympics in Sydney, Australia. A match consists of 3 rounds of 2 minutes each and requires both high-intensity exercise and endurance. TKD can be considered as an interval activity with main resource of energy provided through anaerobic lactic acid system. These resources are being depleted and restored during activity constantly. So in such interval activities, rapid depletion of energy resources and increased lactic acid accumulation are the cause of early fatigue and consequently reduction of performance during the tournament. Hence one can assume that consumption of supplements that will enhance rapid recovery of energy resources and prevent the disturbance of PH levels may enhance the athlete's performance. Creatine (Cr) is one of the most commonly used dietary supplements, as it has been shown to be beneficial in improving performance during repeated bouts of high-intensity anaerobic activity. It is not included in the International Olympic Committee (IOC) list of banned substances. Theoretically, increasing Creatine Phosphate (PCr) content via Cr supplementation may increase PCr content and fasten resynthesis of ATP during intermittent bouts or short bursts of high-intensity anaerobic activity. Sodium bicarbonate (SB) is one of the buffers that

124 its ingestion has been shown to increase blood pH and carbonate ion (Hco3−) concentration. Thus, ingestion of alkalinizing agent by increasing the extracellular pH may create a favorable pH gradient for efflux of intracellular lactate and hydrogen ion (H +) from contracting muscle cells. This, in turn, may delay the decrease in intramuscular pH to the critical level at which detrimental effects on muscle performance occur during intense exercise, but its effects on anaerobic performance and blood lactate is not well understood. The aim of this study was to investigate the combined effect of Creatine (Cr) and sodium bicarbonate (SB) supplementation on blood lactate and anaerobic power during 2 bouts of repeated vertical jump test in Taekwondo players. Sixteen young male Taekwondo players were matched in 2 treatments (Cr+SB, n = 8 and placebo (P), n = 8) according to weight, Vo2max and anaerobic power in double-blinded procedure. Both treatments consisted of placebo (20 g maltodextrine per day) or Cr supplementation (20 g Cr per day) in a period of 6 days. In the morning of the seventh day and after the blood taking, there was P or SB supplementation (0.065 g per kg body weight), an hour before 2 repeated vertical jump test that was performed in 30 seconds with an hour of active recovery between sets. Blood samples were taken in 2 phases, each phase in 3 steps after an overnight fast. The data was analyzed via repeated measures, post hoc least significant difference (LSD) and independent t test in significant level P ≤ .05. Mean of anaerobic power increased significantly during first (P = .006) and especially in second (P = .001) bout of test in combined group at posttest, but blood lactate levels were not affected by Cr and SB supplementation. Also anaerobic power increased significantly in second bout of test at post-test in combined group than placebo group (P = .049). The main finding of the study was that supplementation of CrSB improved the anaerobic power but they do not have significant effect on response of blood lactate.

Outcomes of acute and chronic patients with MRI confirmed symptomatic lumbar disc herniations receiving high velocity, low amplitude, spinal manipulative therapy: a prospective observational cohort study with 1 year follow-up Serafin Leemann, Cynthia Peterson, Christof Schmid, Bernard Anklin, B. Kim Humphreys Background: Approximately 70% of the population will have low

back pain (LBP) at some point in time. LBP with associated leg pain from a herniated intervertebral disc is one of the most severe and disabling forms of LBP. A variety of treatment options are available that can be categorized as either surgical or conservative care. Conservative care may include medication, corticosteroid nerve root or epidural infiltrations, bed rest, physical therapy, flexion/ distraction therapy and spinal manipulation (SMT). The most recent systematic review evaluating manipulation for patients with radiculopathy stated that there is moderate evidence that SMT is better than sham SMT in the short and long terms, but the evidence comparing SMT with other therapies is of low quality. Despite the fact that there is only moderate evidence supporting the use of spinal manipulation to treat LDH, it is widely used within chiropractic practice. Therefore, the purpose of this study is to evaluate the short, medium and long-term outcomes of acute and chronic patients with symptomatic, MRI confirmed lumbar disc herniations treated with SMT using a prospective, cohort design. Methods: Ethics approval was obtained from the hospital and Cantonal ethics committees prior to the start of the study and all

WFC 2013 Scientific Sessions abstracts patients signed informed consent. Consecutive adult patients with LBP, leg pain and related abnormal physical examination findings due to MRI confirmed lumbar disc herniations were included. Baseline pain data (numerical rating scale (NRS)) for LBP and leg pain plus the Oswestry questionnaire were obtained prior to treatment. Follow-up outcome data included the NRS for LBP, leg pain, the patient's global impression of change (PGIC) scale for over-all improvement, and the Oswestry questionnaire obtained at 2 weeks, 1 month, 3 months, 6 months and 1 year after the first treatment. All patients were treated with high velocity, low amplitude SMT at the level of their disc herniation. Pre and posttreatment NRS scores were compared for each time point using the paired t test. Baseline and follow-up Oswestry scores were compared using the Wilcoxon test for matched pairs. The proportion of patients reporting “improvement” on the PGIC scale was calculated for all patients and acute vs. chronic patients. NRS and Oswestry scores for acute vs. chronic patients were compared using the unpaired t test for NRS scores and the Mann-Whitney U test for Oswestry scores. Results: One hundred consecutive patients with baseline and 1 year data were analyzed. Statistically significant improvement in all outcome measures at all time points was reported. By 3 months 90% of patients were “improved” with 89% improved at 1 year. Acute patients improved faster and more dramatically. By 3 months 84.0% of chronic patients reported clinically relevant “improvement” with 88.9% of chronic patients improved at 1 year. There were no adverse events. Conclusions: A large percentage of acute and importantly chronic lumbar disc herniation patients treated with high velocity, low amplitude SMT reported clinically relevant “improvement”; better than the proportion of acute patients who improve due to natural history.

A systematic literature review of the location or type of artery dissection following cervical spine manipulation Christopher Lewis, Peter Wise, Peter Tuchin Background: The use of cervical manipulation is sometimes

questioned due to some authors' perception regarding the risks and efficacy of the procedure. While studies into the mechanism of dissection following manipulation point away from a causal relationship, there are many case studies and case series linking manipulation with vascular incidents. This paper reviewed cases of cervical manipulation with vascular incidents to examine the type and location of the dissection. Methods: A systematic review of CINAHL, PUBMED and MEDLINE databases (from 2002 to 2012) was conducted for publications using the keywords chiropractic, manipulation and vertebral artery dissection (VAD). Articles were screened using strict inclusion criteria and were sorted determining the relevance of the paper. Papers were analysed for the location of the vascular dissection and time between causative treatment and adverse effect. The treating practitioner and any predisposing risk factors of the patient were also noted. Results: A total of 14 articles met the inclusion criteria and were analysed, culminating in 51 reported cases of vascular incident. A common site for dissection was the V2/V3 segment of the vertebral artery (at the level of the second cervical vertebrae). There were a total of 27 reported incidence of VAD dissection

WFC 2013 Scientific Sessions abstracts (53%), 4 were bilateral injuries (8%), 5 cases of internal carotid artery dissection (9%) and 15 (30%) cases where the site was not clearly delineated. In addition, in 25 cases (48%) there were numerous other combinations of stroke, haematoma, basilar artery dissection, thrombus formation and haemorrhage. The time line between practitioner visit and onset of neurological signs or symptoms ranged was often poorly described or not reported. Also, clinical factors prior to the treatment were not reported or had minimal description. Conclusion: Vertebral artery dissection is a very rare and complex event occurring in less than 1/100,000 of the population. Preliminary data shows the V2/3 portion of the vertebral artery is commonly involved in vascular incident, but many case reports do not specific the exact location of the VAD. In addition, many cases analysed reported a significant lag between causative event and the occurrence of serious adverse effect, further highlighting the complexity of the issue. Given the vast number of predisposing and causative factors reported in previous studies, there is no clear correlation associating manipulation directly with vascular dissection.

Treatment of chronic coccydynia by chiropractic manipulation per rectum under epidural sedation: a multiple case study Nimrod Liram, Amir Hasharoni, Eliad Davidson Objectives: Hadassah University Medical Center first initiated

treating patients with coccydynia by intrarectal manipulation under epidural sedation in 1988. This technique was developed by the hospital's pain management unit in collaboration with the spine unit's chiropractor. Over the years, dozens of patients with chronic coccydynia received this treatment. This work's purpose and range is a 5 year prospective evaluation of the efficacy of this treatment, including all referrals between 2007 and 2011. Methods: Patients selected and referred for this treatment were assessed using a VAS, modified functional coccydynia Ostwestry and a modified short version McGill Pain Questionnaires. Of these referrals, 21 were female and 12 male. Age ranged from 17 to 67. Assessment was done pre manipulation, 1 month and 6 months post treatment. 30 of 33 cases were followed up (telephone) up to 3 years after treatment. The combined manual and epidural procedure was guided by lateral coccyx radiographs before, and one week after treatment. With the exception of one case, all patients received one internal coccyx manipulation. Results: At 1 month, the median VAS and functional questionnaire values showed significant improvement (over 30%) in 19 of 33 cases. At 6 months, significant improvement remained in 16 cases. Telephone follow up of 30 of 33 cases showed the following profile: Of the 19 showing improvement following treatment, 12 remained functionally and symptomatically improved. Of the 14 who showed no significant improvement, 10 remained symptomatic and reported disability. One patient had undergone coccygectomy with a satisfactory outcome. Typically, long term improvement was achieved in those with a traumatic aetiology and up to 3 years of symptoms. Hyper flexion or lateral (scoliosis) deformities played no predictive role and by and large, were unaffected by treatment. Conclusions: It was found that at long term analysis, about one-third of those with chronic coccydynia who underwent internal coccyx manipulation under sedation benefited from this treatment. Shorter range analysis indicated that higher percentages of improvement prevail for a few months following therapy. Typically, patients with

125 traumatic aetiology and shorter symptomatic duration stand better chances for improvement by this treatment option.

Intrarectal spinal adjustments for traumatic coccydynia: a report of 2 cases Natalia Lishchyna Introduction: Although coccydynia is a relatively rare condition, the accompanying pain and suffering can be debilitating. Patients frequently do nothing or try other treatments prior to consulting a chiropractor often because of the lack of knowledge that chiropractic care may be beneficial or they are embarrassed given the location of the pain. Traumatic etiology for coccydynia is a common historical feature. Generally, the patient reports pain while sitting on hard surfaces, arising from a seated position, turning in bed and defication. Conservative treatment is usually recommended. Intrarectal coccygeal adjustments/manipulation is a viable option. Methods and Results: Two cases of trauma related coccydynia are described. The patients received intrarectal coccygeal adjustments as described by Heller with positive outcomes. Case 1. A 64-year old female presented with moderate tailbone pain that started 2 weeks following a colonoscopy. The aching pain was present when sitting or slouching. Her pain of chief complaint was reproduced with direct external pressure over the tip of the coccyx and internal exam revealed painful right lateral deviation of the coccyx and restriction in flexion. The remainder of the physical exam was unremarkable. She was diagnosed with coccydynia following trivial trauma (colonoscopy). After 3 treatments of intrarectal coccygeal adjustments and soft tissue therapy to the associated ligaments, she reported being pain free. Case 2. A 19year old male presented with a complaint of immediate dull achy tailbone pain following a fall on his buttock during an ice hockey game. Forward bending and getting up from a seated position were aggravating. Radiographs were suggestive of a partial anterior subluxation of the second coccygeal segment at the first intercoccygeal joint. External pressure over the tip of the coccyx was painful and internal exam revealed a tender coccygeal restriction in extension. A diagnosis of coccydynia following acute onset trauma was given and 2 intra-rectal adjustments were delivered within a week. He reported that there was irritation following the second adjustment however 2 days later his pain resolved and he returned to his normal activities. Discussion: Maigne et al suggested that trauma-induced coccydynia responds better to intrarectal manipulation than non-trauma related cases. They also noted that the procedure should be performed as early as possible to achieve better results. Both of these cases illustrate that timely chiropractic treatment can provide relief and return patients to normal function. Patients with marked anterior angulation of the coccyx are more at risk of developing idiopathic coccydynia. Although a traumatic cause (incidental trauma following a colonoscopy and singe direct axial trauma following a fall on the ice) can be attributed in these cases, both were either clinically or radiologically determined to have increased forward angulation. Conclusion: Coccygeal pain can be very uncomfortable and embarrassing for patients. Where permitted by legislation as part of the chiropractic scope of practice, intrarectal spinal adjustments of the coccyx should be offered as part of the plan of management.

126 Chiropractors providing this treatment option should have appropriate training and expertise.

Survey of financial health attitudes, knowledge, and habits of chiropractic students Julie Lorence Kumar, Stacie Salsbury, Christine Goertz, Dana Lawrence Purpose: The economic climate of healthcare is changing rapidly, including within the chiropractic profession. At a time when average salaries for doctors of chiropractic (DC) are decreasing, chiropractic students are assuming sizable student loans, followed by substantial business loans for practice start-up. The purpose of this descriptive study was to explore the financial knowledge, attitudes, and habits of DC students enrolled in a chiropractic college. Methods: DC students in trimesters 1, 7, 8, 9, and 10 at Palmer College of Chiropractic Davenport completed an 81-item paper survey designed from modified sources including the Federal Reserve basic financial knowledge quiz, the Rutgers Financial Fitness Quiz, and a domain specific financial risk tolerance questionnaire. Descriptive statistics were used to analyze survey responses. Results: Our response rate was 23% (57/250). Nearly 75% of DC students reported anticipating more than $125K in student loan debt upon graduation. While 65% of respondents correctly identified the average salary range for DCs, only 21% considered this range as financially successful. Among our respondents, 72% rated themselves“average” or “low” financial risk takers. The majority (63%) also were “unlikely”or “extremely unlikely” to take a commission- only job, equivalent to a single-doctor private practice. Most respondents were not currently practicing many moneymanagement habits considered by experts to indicate financial literacy and personal financial health. Conclusion: Our self-report survey of DC students identified a gap between their financial knowledge and attitudes and their money management habits. DC students may perceive themselves as low financial risk takers, but many engage in practices that suggest a high tolerance for financial risk. While a relatively low response rate of DC students from a single chiropractic college means these results may not be generalizable, our findings may help faculty develop business curriculum that ensures the success of both new practitioners and the profession of chiropractic.

Myositis ossificans traumatica in a football player: a case report Melissa Loschiavo, Inger Roug Introduction: Myositis ossificans traumatica (MOT) is a commonly encountered condition in the athlete. It is skeletal muscle ossification as a result of muscle injury. The clinical signs and symptoms of this non-neoplastic process may vary from case to case depending on the extent of involvement and location. An acute posttraumatic hematoma is an unequivocal diagnosis given a classic history and clinical findings, however a soft tissue mass with a vague history should warrant further investigation as the differential may include malignant disease. We report a case of posttraumatic myositis ossificans of the hamstring muscle in a chiropractic student football player. Plain film features, types and incidences of MOT, sports biomechanics and treatment modalities are discussed.

WFC 2013 Scientific Sessions abstracts Methods: A 30 year old male, chiropractic student presents with a history of multiple hamstring injuries while playing football. An AP pelvic radiograph revealed a calcified soft tissue mass in the proximal medial thigh tissues. Results: A radiographic diagnosis of posttraumatic myositis ossificans of the hamstring muscle was made based on the radiographic and clinical presentation. Review of the literature revealed that the thigh muscles are the most common muscle group to have associated MOT in an athlete. Discussion: There are 3 main types of MOT; congenital, idiopathic and traumatic. Muscle strains and contusions account for over 90% of all sports-related injuries. Of these injuries, approximately 9% to 20% are complicated with MOT. The typical patient with MOT presents with a history of direct and/or repetitive trauma to a muscle. Associated clinical findings include decreased mobility with progressively worsening tenderness, antalgic gait and difficulty bearing weight. A superficial hematoma may also be present. Upon radiographic examination the affected muscle will demonstrate ectopic bone 3 to 5 weeks post injury. Current literature states that most cases of MOT resolve spontaneously within 3 years through innate reabsorption. Complications may include long- term disability and fracture of the heterotopic bone, to name a few. Acute cases resolve best with the RICE principle of rest, ice, compression and elevation to limit intramuscular bleeding. This may be followed by active and resistive exercises to restore strength and range of motion. More invasive treatment options include aspiration and surgery. Conclusion: The case presented demonstrates the classic radiographic changes of myositis ossificans traumatica. This article has reviewed the common clinical features, radiographic signs, types and incidence of MOT. Management principles for MOT were also discussed. The intent of this report is to provide chiropractors with guidelines on presentation, diagnosis and management.

Postural control of the lumbar spine: evidence of self-sustained firing in motoneurons Lise R Lothe, Tim JL Raven, Torsten Eken Objectives: The underlying neurophysiology of low back pain is

poorly understood. We have characterized motor unit firing activity in the lumbar multifidus muscle in healthy subjects as a reference before studying low back pain patients. Three 50 μm diameter Teflon-insulated platinum/iridium wires were implanted in the deepest part of lumbar multifidus at L4 spinal level in 11 subjects (10 bilateral, 1 unilateral) using ultrasound guidance. EMG activity was recorded differentially during unhindered standing and during voluntary force production while standing in slight forward flexion. Individual motor units were identified using Spike2 software and analysed with regard to instantaneous firing frequency, alternation of activity between units, and cross correlation between smoothed firing rates for concurrently active units. The common drive coefficient (CDC) was defined as the maximum value of the cross correlogram lying within 0 ± 50 milliseconds. Results are given as medians with 25th and 75th percentiles. Results: Total recording time in each subject was at least 20 minutes. Median firing frequency in 67 units from 9 subjects (7 males, 2 females; age 25 years (range 20-40)) was 6.9 Hz (6.6-7.8) for spontaneous activity and 7.2 Hz (6.2-8.8) for voluntary activity. Cross correlograms from 97 unit pairs with median recording duration of 21.6 seconds (range 4-793) showed a CDC in spontaneous activity of

WFC 2013 Scientific Sessions abstracts 0.48 (0.35-0.60) for ipsilateral units and 0.42 (0.22-0.55) for contralateral units. In voluntary activity, CDC was 0.28 (0.18-0.34) for ipsilateral units and 0.22 (0.16-0.31) for contralateral units. CDC in spontaneous activity was significantly higher than in voluntary activity (P b .005; Wilcoxon rank-sum test) both ipsi- and contralaterally. In multi-unit recordings using one tonically active motor unit as a reference to monitor common synaptic drive, we found that slight postural changes could recruit new units to prolonged firing while the reference unit remained in its initial firing-frequency range. Similarly, after a period of concurrent firing one unit would stop firing while another simultaneously active unit continued to fire in its initial range. Conclusions: We interpret our findings as evidence of self-sustained firing properties in motoneurons projecting to lumbar multifidus muscles in humans. Self-sustained firing would enable motoneurons to fire action potentials at a steady frequency for a sustained period of time, generating stable long-lasting muscle contractions. This finding represents an alternative model for tonic muscle control in the lumbar spine to currently held ideas. Further studies are needed in order to determine if disturbance in this activity might contribute to low back pain and whether the self-sustained firing activity can be influenced by spinal manipulation.

Children with headache: a demographic survey and treatment outcome of those presenting to a chiropractor Susanne Lynge Rosing, Joyce Miller Introduction: Headache is one of the most common pain symptoms in

children. Research and treatment have predominantly been concentrated on migraine and Tension Type Headache. Cervicogenic headache in children has not been thoroughly investigated, and the impact of trauma to the head and/or neck on the development of pediatric headache is only sparsely described in pediatric headache research. Objective: The purpose of this study was to provide baseline information of a group of children with headache coming to a chiropractor, and to describe the experiences this group had with chiropractic treatment in terms of possible changes in headache duration, frequency and severity. Methods: A quantitative prospective observational survey was performed among a convenience sample of children aged 7 to 18 with headache utilizing a questionnaire. Furthermore reports of changes on headache were recorded by one subset of children on an evaluation questionnaire post treatment and by another subset in a headache diary. Data was entered into the SPSS 2011/2012 program for statistical analysis. Results: There were 30 females and 14 males in the study. Most common age groups in the study were 7,9,12 and 15 years old. The majority had headaches for more than a year and the mean severity of headache was rated 5.75 (SD = 2.19) on a 0 to 10 pain scale. Fifty percent of subjects reported that neck pain could initiate a headache and 74% reported headache as a reason for school absence. Almost two-thirds of subjects reported that they had at least one trauma to the head and/or neck in the past. Most of the subjects exercised at least 13/wk, had no sleep disturbances and came from non-smoking families. Stomach pain was reported by half of all subjects. Computer/TV time was investigated and 79.1% of the children spent 2 hours or more in front of computer/TV per day regardless of age. Subjects had a mean of 5.27 (SD = 2.815) treatments and were treated for a mean of 5.05 (SD = 2.260) weeks. Most subjects were treated full spine and most common treated cervical vertebra was C7. In both subsets (post

127 treatment evaluation questionnaire and headache diary) the majority of subjects experienced a reduction in number of headaches, a decrease in duration of headache and a decrease in headache severity. There were no reports of worsening during treatment. Conclusion: This study provided baseline information of children aged 7 to 18 with headache presenting to a chiropractor. It is possible that cervicogenic headache is overlooked in children and that the importance of trauma to the head and/or neck in the development of pediatric headache has been underestimated. Efficacy of chiropractic treatment of pediatric headache should be investigated with a randomized controlled trial.

Professional expectations of Brazil's chiropractic students Inajara Maciel dos Santos, Bruna Magnaguagnoe, Francielle, Braz Oliveira da Silva, Marcia Augusta Basso de Alexandre Objectives: This study seeks to identify how prepared Brazilian chiropractic students are to the labor market and the importance of the deployment professional career classes in the academic studies. Preparing for an occupation and for marital life are essential components of young adults' life and part of the maturing process. The search for personal and professional achievement often goes through youth followed by an eagerness of being important. Educational institutions are efficient in teaching a profession and in training professionals, enabling them for the labor market. The chiropractic profession has been growing and has a great labor market both in Brazil and abroad. Chiropractors work autonomously in specialized clinics offering their patients better quality of life. This study aims at identifying the Brazilian chiropractic students' expectations and at identifying their profile to verify how prepared they are to enter the job market, which has been rising in Brazil. This is an exploratory, descriptive and quantitative research study. A multiple choice questionnaire was answered by 170 people, accounting for 76% of the students enrolled in a chiropractic in a higher education institution. There were 69% female, 31% were male, and 61% aged between 20 and 25 years. Eight percent had other academic qualifications. Those students dependent on parents represented 61% and 14% have a full scholarship. REgarding their professional expectations after graduating, 40% have not decided where to work and 26% want to stay in their living city or region; 39% have not decided about any specialization area and 19% want to work in sports chiropractic. When graduating 38% want to open their own clinic, 19% want to associate with some healthcare clinic and 30% have not decided yet. Fifty one percent intend to start practicing right after their graduation to be a good professional and 31% are interested in practicing and teaching in any higher education institution. The major current concern for 42% is promoting their career/business and for 21% is deciding in which city to practice. We concluded that it would be relevant for students to develop their career management and planning skills from the beginning of the graduation course to the end of it.

Chiropractors' inter and intra-examiner reliability of cervical spine radiographic analysis and its impact on clinical management Carla Anne Marais, Charmaine Maria Korporaal Objectives: Radiography is the most common imaging technique

requested by chiropractors to assist in the management of patients

128 with musculoskeletal complaints. This results from radiographs playing an important role in chiropractic, as they are utilised to exclude contraindications to spinal manipulative therapy (SMT) that may cause injury to a patient if SMT is not modified or excluded as a treatment option. Currently, there is a paucity literature evaluating the consistency of chiropractors' interpretive radiographic skills, to achieve the same outcome given a particular set of radiographs. Thus, this study investigated the inter- and intra-examiner reliability of chiropractor's diagnosis on cervical spine radiographs (with and without information on the patient's clinical history). Methods: This Institutional Research and Ethics Committee approved study was a prospective inter- and intra-examiner reliability study. A reference standard was drawn up for each of the 30 radiographs through a Delphi process, allowing comparison with respondent responses. The evaluations of the respondents (six qualified chiropractors) occurred on 2 consecutive days (one week apart) of the same 30 radiographs (firstly with no clinical history (round one) and secondly with a clinical history (round two)). The radiographs remained the same but were presented in a different sequence and with patient data removed. The analysis classified responses as accurate or not based on comparison with the reference standard. Fleiss Kappa statistics, standard errors of the estimates, 95% CI were calculated in rounds one and 2 separately by comparing the ratings between all 6 examiners. A Kappa of b 0.2 was considered poor agreement, 0.21-0.4 fair, 0.41-0.6 moderate, 0.61-0.8 strong, and more than 0.8 near complete agreement. In contrast the comparison between the ratings of the same assessor in rounds one and 2 provided the intra-observer agreement, which was computed using McNemar χ 2 test for paired proportions, with a P value b .05 being considered statistically significant. Results: The inter-observer agreement for categorisation and management went from “poor agreement” in round one (K = 0.1962 and K = 0.1996 respectively) to “fair agreement”(K = 0.2041 and K = 0.2036 respectively) beyond that expected by chance in round two. Identification of pathology remained “fair agreement” beyond that expected by chance over both rounds (K = 0.3113 and K = 0.2159). Sensitivity at round one was 94.4% and the specificity was 61.1%; whereas in round 2 the sensitivity had decreased to 93.8% and the specificity had decreased to 50%. There was no significant difference between the accuracy of the round one and round 2 results for categorisation (P = .243) and management (P = .220), but there was a clinical difference for identification (P = .014). Conclusion: Differences in the result were small indicating clinical relevance with regards to inter-examiner reliability was fair. The clinical history did not influence categorisation or management, but it did improve accuracy of pathology identification. Chiropractors identified between 93.8% and 94.4% of abnormal radiographic findings demonstrating that chiropractors use of radiographs as a diagnostic tool when looking for contraindications to spinal manipulative therapy was sensitive. This demonstrates that its use as a diagnostic tool for contraindications to SMT is sensitive.

An injury profile in South African cyclists and its association to bicycle set-up Barry Mills, Andrew Douglas Jones, Charmaine Maria Korporaal Objectives: Cycling is an increasingly popular leisure and

competitive sport. It is important to determine injuries and their

WFC 2013 Scientific Sessions abstracts causes to eliminate their effect on the cyclist. This study therefore profiled cyclist injuries and determined any association between injuries and bicycle set-up. Methods: This IRB approved study, utilized a non-probability purposive sampling technique (stratification was based on type of bike ridden) to attain 125 cyclists. On agreeing to participate the cyclists completed a pre-validated questionnaire and a clinical examination was performed, lastly the bicycle parameters were recorded (type, bicycle dimensions, and bicycle set-up). All analyses were performed SPSS 11.0, where the data was analysed both descriptively and inferentially. Associations were examined bivariately using Pearson χ 2/Fisher exact and Mann-Whitney tests. Bivariate analysis, multivariate binary logistic regression where used to detect associations. χ 2 and Crude odds ratios were utilised to assess the strength of the relationship and the degree of significance of the relationship. All statistics were analyzed at a confidence interval of 95% and a level of significance where P b .05. Results: The sample of 125 included 49 male and 25 female road cyclists and 25 male and 26 female mountain bike cyclists on road. Injury profiles: It was found that lower limb complaints were the most common for road cyclists (74%) and head/neck/thoracic/ rib complaints were the most frequent for cyclists on mountain bikes (61%). Cycling complaints: The odds of having injuries related to the head/ neck/thoracic/rib region increased by 90% for each size too large the bike was for the cyclist. This contrasts with injuries to the low back and buttocks, where the odds increased by 0.7% for each additional kilometer ridden per week. Additionally lower limb injuries were more probable for platform pedals (with and without cages) (odds were 47% greater). Clinical Presentations: The odds of head/neck/thoracic region injuries were greatest for cyclists who used aluminium forks (76% increase in odds); whereas injuries to the pelvis and lumbar spine, erector spinae and quadratus lumborum muscles had greater odds of 7.8% for each centimeter reduction in the difference between handlebar and shoulder width. Injuries to the lower limb, rectus femoris, iliopsoas, and gluteus medius muscles had greater odds at 8.6% for each centimeter reduction in handlebar width versus shoulder width. Generally myofascial injuries odds increased 1% and the odds of SI syndrome increased 0.7% for each additional km ridden per week. Conclusion: Lower body complaints (lower back; knee) were associated with road cyclists and upper body complaints associated with mountain bike cyclists. Pelvis/lumbar injuries were equally prevalent. Myofascial and sacro-iliac joint syndrome conditions were more frequently in males versus females and in road bikes versus mountain bikes. The most common variables affecting injuries in terms of bike type included road surface, higher tyre pressures, higher average mileage per week (km/wk), lower stem angle and more time on the bike (h/wk).

Chiropractor perceptions and practices regarding inter-professional healthcare delivery in the Danish primary care context Corrie Myburgh, Henrik Wulff Christensen, Anders Lyck Fogh-Schultz Objectives: Since receiving its landmark legislation in 1992, the

chiropractic profession in Denmark has undergone rapid educational and professional change. For example, chiropractors study and train alongside medical practitioners, physiotherapists and

WFC 2013 Scientific Sessions abstracts sport scientists in the open Danish university system. It is therefore conceivable that contemporary models of practice reflect this greater level of inter-professional contact. This investigation formed part of an ongoing study exploring the identity of Danish chiropractors engaged in primary care practice. The purpose of this study was to explore current inter-professional activity and perceptions in chiropractic primary care practices regarding the operationalization of “tværfaglig” (inter-professional/ disciplinary) practice. Methods: Electronic questionnaire with a mixture of closed and open-ended questions. A Census of primary care practices in Denmark. E-survey consisting of 9 questions covering 3 items, namely: practice characteristics, current inter-professional activity and perceptions regarding team-oriented practice. The university IRB/ethics board exempted this study. Results: The population of 252 chiropractic practices was sampled, with a response rate of 63.3%. Seventy-two percent of responders considered their practice model to be “tværfaglig”(inter-disciplinary). Ninety-five percent of respondents considered inter-professional models of service profession as important for chiropractic practice in the primary (private) care setting. Seventy percent indicated that they would like to work alongside a physiotherapist, 61% a medical practitioner, 51% a massage therapist, 50% a medical specialist, 42% an acupuncturist and 23% a reflexologist. Of the professions currently engaged in inter-professional practices, massage therapists were the most commonly involved (82%), followed by physiotherapists (58%) and acupuncturists (37%). Interestingly only 11% considered a medical practitioner to be an active participant in their interprofessional service delivery model. A spectrum of perceptions regarding what classifies their particular practice model as interprofessional/inter-disciplinary was observed. For example: “I recommend other treatment forms if it seems necessary.” “Masseur employed and [I] cooperate with physiotherapists in town.” “chiropractic, physiotherapy and massage at the same clinic. Weekly multidisciplinary meetings and interdisciplinary patient courses.” Discussion: Massage therapists, physiotherapists and acupuncturist are commonly engaged as stakeholders during inter-professional activities. However, few chiropractors consider themselves to be actively engaged with medical professionals in service delivery and a clear perception was observed for greater contact with both general practitioners and medical specialists. Although this level of interaction reflects what has been observed elsewhere in Scandinavia, this observation was somewhat surprising given the legislative equivalence and greater level of contact between medical practitioners and chiropractors over the past 2 decades in the Danish healthcare setting. In relation to the wide spectrum of inter-professional practice models identified, it is unclear from this study whether a consensus understanding of an appropriate model(s) for practice in the Danish primary care setting currently exists. For example, it is unclear whether team-based practice is implied and given the inclusion of both orthodox and complementary and alternative professionals, whether models of practice currently (or envisioned) operationalize the principles of integrative healthcare. Conclusion: Danish chiropractors consider inter-disciplinary practice to be important in the primary care context and as a group, perceive themselves to be offering such models of service provision. Medical practitioners are a desirable, but under utilized professional group. To define and characterize appropriate

129 model(s) for inter-professional practice further in-depth qualitative investigation is required.

Parental report of satisfaction following an episode of chiropractic treatment for their infant: a survey Ida Marie Navrud, Joyce Miller Objectives: The purpose of this project was to investigate the

parent's rating of satisfaction as well as their rating of improvement in the child's condition in a cohort of infants who were presented at a university-affiliating chiropractic teaching clinic in 2012. The purpose of this study was to investigate levels of satisfaction of parents as well as to view associated trends after an episode of treatment of infants presented for chiropractic care. Methods: A quantitative questionnaire-based survey, collecting data from parents of infants presenting to Anglo-European College of Chiropractic clinic. Surveys were given out to 230 parents of infants who were presented to the teaching clinic between the ages of 0 to 12 months. At the end of an episode of care, parents were asked to rate on a Likert Scale of 0 to 10 how much their child had improved, if any, how much their distress level had changed, if any, and their degree of satisfaction or dis-satisfaction with the treatment. The survey was completely anonymous and identifiable only by number so that surveys from the same parent could be observed over time. Results: In general, parents were satisfied with care, rating their satisfaction as 9.55 out of a possible score of 10 at the end of the episode of care (N = 229). The rating of over-all improvement was 7.92 out of 10 (N = 227). The rating of parental distress decreased significantly from a rating of 5.14 before treatment to a score of 2.48 after, on average 4.42 treatments, over, on average 2.77 weeks (or a time span of 19 days) (N = 227). Parental distress showed a reciprocal correlation with satisfaction, noting that the higher the parent stress at the end of treatment the lower the satisfaction rating and vice versa. Parents who presented their child for disturbed sleep were significantly more distressed than those presented for other conditions. Likewise, the sleep of those children improved significantly more than the others, although the trend indicated that parents reported improved sleep in most of the children (N = 202). Conclusion: Although this study had significant limitations, it may provide initial evidence that parents report a high level of satisfaction at the end of an episode of chiropractic treatment for the common conditions of infancy. Further investigation should be made on what is the actual basis of the ratings that they report. The findings indicate that at least a part of the rating is based on the reducing level of distress that the parent reports.

A case-control study exploring factors associated with neck pain in the indigenous African population in the greater Durban area Prisca Zandile Ndlovu-Twala, Charmaine Maria Korporaal Background: Neck pain is a common complaint and source of disability in the general population (point prevalence of 13%; lifetime incidence of 50%), accounting for as many days of absenteeism. With the reports being population specific, this study explored factors associated with neck pain in the indigenous African population in the greater Durban area.

130 Methods: This IRB approved study included 200 participants with neck pain and 200 asymptomatic participants (stratified according to age and gender). Once clinically assessed, the participants completed a questionnaire on factors identified from the literature related to neck pain. The data was analysed both descriptively and inferentially. Associations were examined bivariately using Pearson χ 2/Fisher exact tests/Mann-Whitney tests. Bivariate analysis, multivariate binary logistic regression analysis using a backwards elimination modelling technique was used, based on likelihood ratios, with entry and exit probabilities (P b .05 and .010, respectively). χ 2 analyses were utilised to assess the strength of the relationship and the degree of significance of the relationship. All statistics were analyzed at a confidence interval of 95% and a level of significance where P b .05). Results: The symptomatic participants seemed to be less well educated, less in full time employment, less unemployed, and more self employed than the controls. Symptomatic participants who were working seemed to earn less than their control counterparts. The duration of having neck pain was one month, classified as mild, worst in the afternoons or related to activities. Symptomatic participants reported their pain began without injury (gradually in 67.5% and abruptly in 13.5%). The majority, 156 (78%) reported having concomitant headaches. The majority reported their neck pain to be stable (38%) (34% were getting worse and 19% getting better). More than half of the cases (52%) reported difficulty with work due to neck pain. Thirty-three percent (n = 66) reported having been absent from work due to neck pain. The duration of absence in those who were absent was 0 to 1 week (89.4%), with 59 (29%) reported being bed-ridden. Only 16% reported severe disability. Of these 6 (3%) were demoted, 5 (2.5%) boarded, and 2 (1%) fired from work. Participants who worked in occupations that involved driving, turning their neck, answering the telephone, working in an airconditioned room, and bending over a desk were significantly more at risk of being cases than controls. Fewer reported difficulties with daily activities such as washing (30%), sleeping (26%), and lifting (24%). Occupational activities causing neck pain were stress (22%) and bad posture (17%). Non-occupational factors associated with neck pain were worrying a lot, motor vehicle accident, not enough bed support, not using arms to support a book, sitting without back or arm support, not watching TV a lot, and exercising. Results: Indicate that the neck pain prevalence in the indigenous African population in the greater Durban area, seems to be consistent with the literature variables attributed to neck pain globally.

WFC 2013 Scientific Sessions abstracts so that they can add this approach to SUS through the National Policy on Complementary and Integrative Practice (PNPIC). Methods: This study used an experimental quantitative exploratory approach and included 56 SUS users that were previously evaluated utilizing a questionnaire that showed their profile regarding previous treatment for musculoskeletal conditions, lumbar and cervical pain scales (survey prepared by the author) and medication usage. Intervention consisted of 5 chiropractic treatments consisting of high-velocity, low-amplitude spinal manipulation. Pre and post intervention measures were obtained for spinal range of motion through the inclinometer method, survey of pain and drug usage. Results: 78.6% of the surveyed users were females, averaging 46 years of age. The main occupational situation among the sample was retiree/pensioner (23.2%). 33.9% did not complete elementary education. Low back pain was the main complaint reported by patients. 92.9% of the sample was not referred by a medical doctor and 64.3% did not know if they had any pain related pathology. Most users went to the doctor when the pain started (62.5%) and 55.4% improved slightly but still remained in pain with chiropractic treatment. As for the quality, 50% of the patients considered the chiropractic treatment received “Good” for their pain. 41.1% sought chiropractic because they thought that it was the right treatment for their condition. Conclusion: The survey for low back pain and cervical spine pain showed significant reduction in pain levels. Furthermore, there was great range of motion improvements in all evaluated segments measured by inclinometer method. From the interviewed patients, 69,1% related reduction of drugs use after chiropractic treatment, and 20% related complete ending of drugs use (from these ones that had changes, 87,2% said that the reason of reduction/ending of the pain was because of chiropractic treatment). All of the evaluated variables showed satisfactory results indicating a good performance of the chiropractor's treatment for musculoskeletal conditions, thus providing valuable data for policymakers interested in implementing chiropractic treatment at the SUS through PNPIC. In conclusion, chiropractic had great effects on musculoskeletal disorders at patients of SUS, which is of great importance to its inclusion in the brazilian health system.

Increased lower limb cortical excitability and alterations to early bereitschafts potential following spinal manipulation Imran Khan Niazi, Heidi Haavik Objective: Over the past decade there has been a growing body of

Chiropractic in the treatment of musculoskeletal conditions in brazilian Unified Health System's (SUS) users Paulo Gomes Oliveira Neto, Thiana Paula Schmidt Introduction: Chiropractic is a healthcare profession that focuses on

studying and treating musculoskeletal disturbances and its implications on general health. As it is not yet available at the Brazilian Unified Health System (Sistema Único de Saúde; SUS) this work had the objective of demonstrating the results of a chiropractic approach in that system, showing its clinical relevance on musculoskeletal disturbances and other results obtained after its implementation in a primary care SUS unit. This serves the purpose of providing evidence of chiropractic effectiveness to policymakers

research demonstrating neural plastic changes following spinal manipulation. Several studies have shown changes to corticospinal excitability following spinal manipulation. The level(s) of the central nervous system where these changes take place are not yet clear. This study sought to explore whether such neuroplastic changes in motor control observed following spinal manipulation at least in part occur at the cortical level by recording a particular electroencephalographic measure, known as movement related cortical potential (MRCP) or bereitschafts potential (BP) that can be recorded just prior to self-paced movements. Methods: 16 subjects (23.25 ± 2.56 years, 10 male and 6 females) participated in a 2 group, cross study design (8 in each group). In one group motor evoked potentials (MEPs) were recorded from the right tibialis anterior (TA) following single pulse TMS before and after a spinal manipulation intervention. Recruitment curves were compiled

WFC 2013 Scientific Sessions abstracts from the averages of 10 MEP amplitudes recorded at each of 5 different stimulus intensities (90%, 100%, 110%, 120% and 130% of rest threshold; RTh). To investigate the effect of spinal manipulation on the amplitude of the MEPs a two-way repeated measures ANOVA with factors time (pre vs post), and stimulus intensity (90%, 100%, 110%, 120% and 130% RTh) was carried out. To assess for changes in parameters of the recruitment curve the maximum value or plateau (MEPmax), the stimulus intensity required to obtain a 50% response (S50) and the slope parameter k of the Boltzmann fitted data were assessed with paired t tests. In another group MRCP were recorded for morphological analysis prior to and following a spinal manipulation intervention. The amplitude of the early BP, the amplitude of the late BP, latency of peak negativity with respect to onset of task and rebound rate of movement monitoring potential were analyzed with paired t tests. Participants were randomly allocated to groups. The Northern Y Regional Ethics Committee approved this study in accordance with the Declaration of Helsinki. Results: The analysis of the MEP amplitudes revealed a significant effect for factors time (F = 7.88, P = .006) and intensities (F = 17.8, P b .0001). Paired t tests revealed that TA MEPmax increased significantly by 53 ± 46% (P = .012). No changes were observed in the S50variable or the slope parameter k of the Boltzmann fitted data. Morphological analysis of the individual components of the MRCP showed significant 73 ± 56% increase in amplitude of the early BP (P b .05). No significant changes were observed for any of the other measures. Conclusion: The self-paced early BP component of the MRCP is a slow negativity beginning up to 2 s prior to movement onset. It is known to reflect motor preparatory activity, mainly from the supplementary motor area (SMA). In the current study, spinal manipulation lead to an increase in the amplitude of the early BP, suggesting a change in motor preparatory activity occurring in the SMA, supporting previous studies suggesting spinal manipulation changes leads to cortical neuroplastic changes.

131 method of coding, emerging categories were used to analyse openended responses and interviews. Questionnaire data was collated and analysed descriptively and inferentially as appropriate. Interviews and were transcribed and analysed thematically within a week of the interview taking place. Results: A 70% response rate was achieved from the questionnaire element of the study and indicated that long-term participants are more likely to have an unresolved chronic condition requiring pain relief. There is a distinction between participants on regular treatment and those on ad-hoc visits. Those respondents that considered themselves under long-term chiropractic care had attended a chiropractor for and average of 9.5 years of chiropractic care, compared to 7.1 years those that did not (P b .05). Participant qualitative interviews revealed 4 main themes around treatment and appropriateness. Pain relief and maintaining flexibility was the most common reasons for seeking treatment amongst the “regular” patients. The chiropractor interviews described re-alignment, advice and touch as important factors. Conclusion: Preventive approaches to health are an important aspect to the healthcare provided to this age-group. Patients experiences of long-term chiropractic treatment fell into 4 dimensions; the results, the right thing to do, re-assuring, and clinic characteristics. This is relevant to the experiences of long-term treatment and suggests that outcomes based measures need to account for a range of possible levels of experience. This type of care is predominantly for patients with a recurring condition. These results slightly contrast each other as the more in depth analysis revealed much more breadth to patients’ motivations for treatment.

Cervicogenic headache and spinal manipulative therapy: a retrospective case series Torje Oesttun, Mats Thorbeck, Haakon Sagstuen, Baard Naess, Peter Tuchin Introduction: Cervicogenic headache (CEH) is a secondary

Chiropractic treatment in the elderly population Jacob Nowinski, Gabrielle Swaite, Adrian Hunnisett, Christina Cunliffe Introduction: There is much to learn about the role of maintenance or wellness care in the chiropractic profession, especially in the over 65 year age group. The over-65 age group is over-represented at the chiropractor and, as a percentage of the United Kingdom population, is predicted to rise from 16% to 23% by 2034. They are distinct from younger populations, often presenting with other conditions for which they are being treated medically. It is logical to assume therefore that their care requirements are also distinct from the younger population. There is a lack of research in this age group. A qualitative study was developed coupled with a quantitative survey aiming to provide a more expansive range of data on the topic and derive new insight and understanding of treatment in this age group. Method: Following ethical approval, a mainly exploratory study comprising a descriptive survey in addition to a series of semistructured interviews with a sub-sample of participants was undertaken. The target participant population was those over the age of 65, attending a Chiropractic College clinic for more than one year. All participants received a self-administered postal questionnaire and a sub-sample of participants was chosen for interview. A sample of chiropractors was also interviewed. Using an inductive

headache characterized by pain which usually originates in the upper cervical spine and can spread to the occipital area giving rise to a unilateral headache. The prevalence in the general population varies depending on the criteria used, but ranges from 1%, to 4.6%. The cost of headache in Australia is estimated at over $2billion per annum, however the specific cost of CEH has not been accurately measured. There is also some controversy over the existence and significance of CEH. Objective: The aim of this study was to investigate the effectiveness of spinal manipulative therapies (SMT) for patients with cervicogenic headaches (CEH) through a case series. Method: We conducted a retrospective analysis of 2200 randomly selected files from Macquarie University's chiropractic clinic. All files were screened according to presenting complaint and diagnosis. All files with headache as presenting complaint and further diagnosed as CEH based on the diagnostic criteria set by the Cervicogenic Headache International Study group (CHISG) and International Headache Society Classification System (IHS) were evaluated. Results: Based on the prevalence figures reported in the literature, we estimated that 2200 files would give us a total of between 20 and 100 cases for analysis. The total number of headaches cases was 110, from which 48 (44%) were migraine and 38 (35%) were tension headache. The remaining 24 cases were diagnosed with CEH, which account for approximately 1% of the screened files.

132 Six of these cases met all the inclusion criteria and were further evaluated in a case series. Discussion: The majority of screened files did not contain all of the pertinent information in regards to diagnostic criteria for CEH and outcome measures. This may in part be due to inadequate record keeping, but also due the variability of headache, especially CEH. It is important for clinicians (including chiropractors) to be vigilant in clinical record keeping as the diagnosis of a treatable condition may be overlooked. Conclusion: The small number of cases reviewed in detail (n = 6) showed positive outcomes when using SMT as a treatment for CEH. Further studies investigating the effectiveness of SMT for CEH are needed.

Bone setting practices in West Africa Tolu Oyelowo Objective: To assess the history and current status of bone setting practices in Nigeria and other West African countries for the purpose of understanding the implications for chiropractic practice. Methods: A systematic literature review and key informant interviews was performed. We conducted an electronic search from 1995 to 2012 using PubMed to identify literature on bone setting practices. In addition, we interviewed a practicing bone setter, an orthopedic surgeon, a bone setting practitioners patient and a chiropractic practitioner in West Africa. Results: The practice of bone setting continues to be utilized by West Africans. Nigerians and other West Africans have for hundreds of years engaged in bone setting practices. These practices are used to reduce fracture, treat malpositions and dislocations and provide general pain relief. Nigerian bone setting has traditionally been an inter-generational practice, passed down to younger generations by older family members. Bone setters have minimal formal education and have learned their skills by observation. Bone setters enjoy a steady clientele due to trust based on familiarity with the community. Further the practice occurs at a reduced cost to the patient when compared with orthopedic practice. Bone setting clients are of all ages. Bone setters frequently employ spiritual practices concurrent with the bone setting practices. This is viewed positively as there is the belief among many Nigerians and other West Africans that physical and spiritual illnesses co-exist. This study has implications for the practice of chiropractic, and the development of a chiropractic training institution in West Africa.

A review of the literature on the current state of healthcare payment models in the Economic Community of West African States (ECOWAS) Tolu Oyelowo Objectives: The purpose of this study was to conduct a review of the

literature on the current state of healthcare payment models in the Economic Community of West African States (ECOWAS). Methods: We conducted electronic searches from 1995 to 2012 using PubMed and African Journals Online (AJOL) to identify studies on healthcare utility and payment structures in West Africa. We used the key words West Africa, Health, Insurance, Compensation. Results: The fifteen countries that comprise ECOWAS work together to facilitate economic trade, national cooperation, and monetary union for growth and development in West Africa. Among its core

WFC 2013 Scientific Sessions abstracts functions are to address social and cultural issues in the region. While health services exist independently, they are dependent on the economic conditions of the individual countries and the region. Several of these West African countries have adopted compensation schemes which enable low and middle income residents to gain access to healthcare at no or minimal cost. Utility and outcomes are varied and dependent on such factors as co-payments, fees, availability of healthcare providers, material resources and community education. Cultural factors such as willingness to pay and bidding for services have some influence. Some countries are adopting national health insurance policies, while others have elected to advance health maintenance organizations and private insurance.

The effect of cervical and thoracic spinal manipulations on blood pressure in normotensive males Angela Pastellides, Aadil Docrat Objectives: Increased blood pressure (hypertension) is a global disorder, whose incidence is increasing. Concomitantly complications associated with hypertension and the use of medication for hypertension are increasing. Chiropractic manipulation is a load delivered by hand, to specific tissues with therapeutic intent. In this context manipulation of the upper cervical and upper thoracic spinal regions has been reported to have somatovisceral reflex effects, which are thought to affect the cardiovascular system by changing blood pressure. The objectives of this study were to determine whether spinal manipulation evokes somatovisceral reflexes and causes a reduction in blood pressure following an sham intervention, manipulation to the atlanto-axial (C0/C1) joint and manipulation to thoracic segments (T1-T5). Methods: IRB approval was obtained to recruit forty, asymptomatic, normotensive males between the ages of 20 to 35 years of age. Once screened through inclusion criteria, all subjects underwent 4 consecutive days of intervention. Day one included sham intervention (laser) only; day 2 included C0/C1 spinal manipulation only; day 3 included T1-T5 manipulation only and day 4 included a combination of C0/C1 and T1-T5 manipulation. Blood pressure was measured directly after the intervention and at 5-minute, 15minute and 30-minute intervals thereafter. Results: The results of this study suggest that systolic blood pressure decreases following a cervical (P = .005) or a thoracic (P = .004) manipulation, at all time points, however a combination of the manipulations does not have a significant cumulative effect on the reduction of blood pressure over time as the (P = .001) significance is not maintained over time. Changes in diastolic pressure where only noted as significant in the sham intervention group (P = .045). Conclusions: Somatovisceral reflexes were evoked following a spinal manipulation, causing a reduction systolic blood pressure after upper cervical and/or upper thoracic manipulation. This substantiates the neurophysiological effects occurring as a result of spinal manipulation.

The prevalence and risk factors for occupational low back pain in manual therapists Nicole Pereira, Charmaine Maria Korporaal Objectives: Low back pain (LBP) is a common condition that affects a

significant portion of the general population, but has also been

WFC 2013 Scientific Sessions abstracts reported to affect manual therapists to a greater extent. This assertion was tested in this study, along with the prevalence and risk factors for occupational LBP in manual therapists. Additionally the study set out to compare the prevalence and risk factors for occupational LBP among various types of manual therapists in South Africa. Method: This study was IRB approved as a cross-sectional survey based on a self-administered questionnaire. This was developed from the literature and validated prior to the study through a Delphi process. It was mailed through the postal system to 1500 randomly selected manual therapists (physiotherapists, occupational therapists, biokineticists, chiropractors, reflexologists, aromatherapists and massage therapists). Risk factors for LBP were examined using Pearson χ 2 tests/Fisher exact tests, and Student t tests where appropriate. For quantitative variables, which were non-normally distributed, non-parametric Mann-Whitney or Kruskal-Wallis tests were used. Multivariate logistic regression analysis was used to assess the independent effects of various risk factors on current LBP, whilst controlling for confounders. The prevalence of LBP between the various types of manual therapists was compared using Pearson χ 2 test. A P value of b .05 was considered as statistically significant. Results: A total of 233 completed questionnaires were returned, giving a response rate of 24% (varying from 20% - 43% within each of the professions). Results revealed that the point prevalence of LBP in manual therapists was high at 41%, the one-year prevalence was 59% and the career prevalence was 74%. The point prevalence of LBP was highest in aromatherapists and biokineticists, while both the one-year and career prevalence of LBP was highest in occupational therapists and massage therapists. The significant risk factors for LBP in manual therapists were: BMI (OR 1.157, P = .001); previous abdominal surgery (OR 2.458, P = .025); previous trauma to the low back, hips, knees or ankles (P b .001); a physically stressful job (OR 7.5, P = .001); not having an assistant (OR 2.2, P = .074) and work in a hospital or other setting (P = .001). in contrast, various work-related factors were implicated in the development and/or exacerbation of LBP in certain manual therapists, which was in keeping with the literature. LBP history in the different manual therapists was also found to be in accordance with the literature. Conclusion: LBP is prevalent among South African manual therapists and the development and implementation of preventative programs to reduce rates of occupational LBP in manual therapists is important to consider in order to sustain their contribution to the healthcare system in South Africa.

Relation of comfort, effectiveness and quality to biomechanical parameters of thoracic manipulation Stephen M. Perle, Harrison Ndetan, John Koloski, Gregory N. Kawchuk Introduction: Chiropractic patients are generally satisfied with their clinical encounters. Elements of satisfaction may include a patient's perception of spinal manipulative therapy (SMT) effectiveness, over-all quality and comfort. Unfortunately, few studies have addressed these elements. This study will quantify the relation between patient rating of effectiveness, quality and comfort of SMT and various application parameters of SMT. Methods: Data were collected at a large chiropractic meeting using the chiropractic tables displayed by a manufacturer. Chiropractors who asked permission to use an adjusting table to perform SMT on a colleague were asked to participate in the study. Both the

133 chiropractor performing the SMT and the chiropractor receiving the SMT provided informed consent. Ethical approval for the study was given by the University of Bridgeport IRB. The treating DC determined the SMT application parameters pragmatically. Data were only collected from thoracic SMT by a thin (0.3 mm) flexible pressure sensitive mat (Tactilus, Sensor Products Inc, Madison, NJ) placed in-between the SMT provider and recipient. After SMT, the 2 chiropractors were separated and asked to rate the effectiveness and quality of the manipulative thrust using a standardized survey. The recipient also rated the comfort of the thrust. The provider was interviewed about SMT application parameters. In some cases the roles were reversed and the process repeated. The relation between provider's and recipient's rating of quality, comfort and effectiveness of SMT was assessed using Pearson correlation coefficient. Results: Thirty-eight DCs volunteered to participate in this study. Data were collected on a total of 44 SMTs. The provider's rating of SMT quality and recipient's rating of SMT quality and effectiveness were moderately and significantly correlated. The same relation was observed for the provider's rating of SMT effectiveness and the recipient's rating of quality and effectiveness. There was no correlation between the provider's rating of effectiveness or quality and the recipient's ratings of SMT comfort. The provider's and the recipient's positive ratings of quality and effectiveness were significantly associated with reporting of cavitation. The recipient's rating of both quality and comfort were moderately and significantly correlated to average pressure during peak force of the SMT. Discussion: In this sample, perceptions of SMT providers and recipients are congruous with respect to quality and effectiveness. Contrary to current opinion, these parameters may be associated positively with the presence of cavitation. Despite this, recipient comfort was not related to provider perceptions of SMT delivery while a biomechanical factor (average SMT pressure at peak SMT force) was related to patient comfort. Conclusion: Perception of SMT comfort is multifactorial and is likely not captured by all the factors measured in this study; however, while SMT provider and recipient impressions are often congruous for parameters such as effectiveness and quality, SMT comfort is most strongly related to the biomechanics of SMT provision.

Primary headaches in Allied Health students at the Durban University of Technology Johan Prangley, Julian David Pillay, Charmaine Maria Korporaal Objectives: A headache is a common complaint in daily clinical practice and occurs across all ethnicities and both genders. These headaches can cause a decrease in productivity and quality of life. Studies carried out in defined population groups are useful in developing an understanding of the factors that influence headaches, however these are limited. Therefore this study investigated the prevalence of primary headaches in students at the Durban University of Technology (DUT). Additionally the factors that influenced the prevalence of these headaches were recorded and the association of these headaches with activities of daily life and productivity was assessed. Methods: The study as an epidemiological, cross-sectional survey of primary headaches, was approved by the Institutional Research and Ethics Committee. The total study population of ± 420 students, each received a Letter of Information outlining the study and a questionnaire about their headaches, factors affecting and

134 associated with their headaches, for completion. The data was analysed with a P value set at b .05 for statistical significance. Analysis was descriptive; however inferential statistics were used to determine the factors associated with headaches, where crosstabulations and χ 2 tests were used for categorical risk factors, while t tests were used for quantitative risk factors. Results: Three hundred eleven questionnaires (74% of population) were utilized in the analysis. Of these 24.1% (n = 75) did not experience headaches and the remaining 75.9% (n = 236) were classified as having had either non-primary headache, migrainetype headache (MTH), tension-type headache (TTH) or a clustertype headache (CTH). Headaches were prevalent amongst the student population and several factors were associated with the headaches (viz. Programme the students belonged to (P = .004), gender (P b ,001), ethnicity (P = .04), smoking (smokers: P = .004; ex-smokers: P = .003), caffeine consumption (P b ,001), difficulty sleeping (P = .017), being under stress (P = .006), being depressed (P = .041). CTHs tended to have the most impact on the student due to its intensity; whereas MTHs and TTHs tended to have an effect based mainly on their high incidence. All headaches had an impact on productivity, lecture attendance and ability to concentrate in class. Conclusion: The study supports previous findings on the prevalence of headaches in student populations. Additionally, primary headaches were found to have an effect on student productivity, attendance at university and an overall negative effect on the quality of life.

A comparative study between the effects of side-lying sacroiliac adjustments and Sacro Occipital Technique on the muscle strength of the gastrocnemius muscle in asymptomatic adult males Grant Pretorius, Christopher Yelverton, Malany Moodley Objectives: Comparative studies of the effectiveness of chiropractic techniques have not been readily described in the chiropractic literature. One study attempted to rate specific chiropractic technique procedures for common low back conditions while 2 others studies compared assessment and outcomes for Sacro Occipital Technique (SOT) and other chiropractic techniques. The purpose of this unblinded, randomised pilot comparative study was to determine if diversified chiropractic manipulation and/or SOT adjustments of the sacroiliac (SI) joint could increase short-term strength of the gastrocnemius muscle. IRB approval was granted by the Technikon of the Witwatersrand (TW). Methods: Ninety-asymptomatic male patients between the ages of 20 to 30 years were randomly divided into three-specific groups and received the diagnostic assessment and treatment intervention specific to that particular group. These patients were recruited by the use of posters placed around the TW campus. Group FA (force adjustment) received diversified adjustments to the sacroiliac joint (SIJ). Group NA (non-force adjustment) received SOT adjustments to the SIJ with SOT blocking technique. Group C (control) received detuned ultrasound over the SIJ. Each patient received only one treatment. The inclusion criteria required that the patient was male, fall inside the above age range, and presented with asymptomatic SIJ dysfunction as determined by motion palpation or SOT category analysis. Only category one patients (pelvic torsion affecting sacral nutation) were used in this study and treated with pelvic blocks in a prone position whereas the diversified group was treated with a thigh ilio-deltoid technique. The objective data was collected using a

WFC 2013 Scientific Sessions abstracts plantar flexion isometric dynamometer measuring gastrocnemius muscle strength before and after the treatment. Results: Inter-group analysis was achieved using the analysis of variance (ANOVA) technique, which noted a trend. The validity of the procedures was determined with a t test for paired observations (before and after treatment) and the P value b .05. The results indicated that there was a statistically significant increase in gastrocnemius muscle strength in both experimental groups. Discussion: Previous studies have shown similar statistical evidence that active muscle strength is positively affected by a diversified adjustment, however only proximal muscles were used for assessment purposes. Therefore in this study the gastrocnemius was used to determine if an underlying neurological effect might be associated with the chiropractic treatment. Since both the non-force and force adjustments groups showed statistically significant increases in muscle strength it was hypothesised that the capsular reflex, and its effect on the alpha motor neuron via the mechanoreceptors of the joint capsule, may have played a role in the production of an increased muscle contraction post treatment. It is of interest that this and prior studies found different chiropractic techniques had similar outcomes. Conclusion: The positive effect noted in the non-force adjustment group suggests that force may not always be required to produce a therapeutic effect. It is possible that safer and less invasive techniques may thus be indicated on a more regular basis supporting both practitioner and patient alike. This study contributes to information about possible underlying mechanisms of the chiropractic adjustment and may support greater study of non-force chiropractic techniques.

The prevalence and associated risk factors of low back pain in an automotive production company Tarnia Raad, Charmaine Maria Korporaal Objectives: Low back pain is a common condition, that affects a

significant portion of the population. This impact is felt personally, socially, economically and societally from disability, psychosocial and financial perspectives. Therefore this study set out to determine the prevalence and associated risk factors of low back pain (LBP) in an automotive production company, evaluating the relationship between selected risk factors, type of occupational activity (manual or sedentary) and the prevalence of LBP. Methods: This was a descriptive study at a large automotive production company entailing 275 physical production employees and 275 sedentary employees and was approved by the Institutional Research and Ethics Committee. Using a cross-sectional study design, a retrospective analysis investigated the LBP prevalence, by means of a questionnaire. Employees reported on demographics, injury location/aetiology/nature, extent of treatment rendered and time lost from work. Additionally, data was obtained regarding smoking, occupational stressors and fitness levels. Results: A significant difference was found between sedentary and manual employees with regards to age, gender, ethnicity, marital status, educational status and medical aid availability. Similarly a significant difference between the groups was found for the point prevalence of LBP, current LBP description (sharp, shooting, dull aching, stabbing and catching pain descriptions), past LBP description (catching pain description), sidedness/location of pain as well as associated features of the current LBP (viz. pins and

WFC 2013 Scientific Sessions abstracts needles, pain to the knees, numbness, bed rest, absence from work, pain at work and pain on weekends) and associated features of past LBP (viz. pins and needles, pain to the knees, numbness, bed rest, absence from work, pain at work and pain on weekends). There were no noted psychosocial factors that impacted on a difference between the groups, but there was a significant difference between the manual and sedentary employees with regards to absenteeism. Conclusion: A significant level of LBP was reported amongst both the sedentary (59.6%) and the manual (89%) employees, implying that the costs to the company are relatively high. It is, therefore, suggested that the company looks at a variety of strategies to reduce the burden of LBP in their employees with particular attention to varying these strategies in relation to the sedentary or manual employee.

The perception, knowledge and utilization of the chiropractic profession amongst Durban University of Technology students Melvin Ralekwa, Prisca Zandile Ndlovu-Twala, Charmaine Maria Korporaal Objectives: To investigate the perception, knowledge and

utilization of chiropractic profession by Durban University of Technology students. Methods: One thousand quantitative questionnaires were handed to students during lecture times. The sample was selected through representative sampling of all the Durban University of Technology students. The questionnaire was developed utilizing a Delphi process of focus group refinement and piloting. Data was entered ontoa spreadsheet before being computed using SPSS version 15.0. Results: A response rate of 94.6% (946/1000) was obtained. There was a low level of knowledge, perception and utilization of chiropractic amongst Durban University of Technology students, only 37% had knowledge about chiropractic which most of them admitted to having a fair knowledge. White females had a higher knowledge about chiropractic than any other group. The perceptions about the suitability of chiropractic to treat different conditions were low. Low back pain was the condition for which respondents most commonly consulted a chiropractor, with 30% of participants being referred by a doctor and another 30% referred by family members. Conclusions: The overall knowledge of chiropractic in this population was relatively poor but a better perception of chiropractic existed in some ethnic groups which was not statistically significant. The results indicated that no statistically significant relationship exists between demographic factors and perception and knowledge of DUT students with respect to chiropractic.

135 instability. Brain eschemia resulting from vascular insufficiency can result in dizziness, diplopia, drop attacks, dysarthria, dysphagia, nystagmus, numbness and nausea. Symptomatology with BHS includes vertigo, hearing loss, recurrent attacks of ischemia, dizziness, tinnitus, ataxia, migraines, drop attacks, paresthesia and extremities numbness. Positional occlusions are commonplace for this condition, symptomatology occurs typically between 45° and 60° of head rotation. The anatomical relationship of the C1 and C2 to the vertebral artery render it a probable site, however the lower cervical spine can be the site of the occlusions. There are cases of disc herniations and degenerative joint changes as the anatomical obstructions. There is no evidence in the literature of noninvasive treatments for BHS. In terms of conservative care, neck braces are used to limit head rotation.8 Surgical intervention is recommended in cases of life threatening symptoms, disruption of activities of daily living with unbearable symptoms, and with the possibility of cerebral stroke. This case report discusses the treatment outcomes of a 39-year old female with bow hunter's syndrome (BHS) using Atlas Orthogonal (AO) chiropractic adjusting technique. Clinical features: History: This 39-year-old female began experiencing problems with neck pain, bilateral arm numbness, and loss of vision upon head rotation after a motor vehicle collision. She was examined at a medical center and diagnosed with BHS. She was offered no treatment option. She presented to a chiropractic clinic 18 months later with the same symptoms. Examination: Palpation elicited pain at the occiput and C1 area over the dorsal root ganglion and over the facet joints of C4,5,6. Posture revealed right head tilt and anterior head carriage. Cervical active rotation was limited to 32° and resulted in a loss of vision after 5 seconds in head rotation. An ultrasound vascular study was performed by a registered sonographer, measuring left vertebral artery speed of 27.6 centimeters/second (cm/s), and volume of 159 milliliters/minute (mL/min). The right vertebral artery measured 29.8 cm/s and 162 mL/min. Intervention and outcome: The patient was treated for 9 weeks, using Atlas Orthogonal (AO) cervical adjustments. The vascular study was repeated following the first treatment, revealing: left vertebral artery 26.0 cm/s. and 172 mL/ min, right vertebral artery 32.4 cm/s and 198 mL/min, representing an improvement in volume and speed of blood flow of 8.2% in the left vertebral artery and 22.2% in the right vertebral artery. On visit 8 the patient was able to rotate her head 42° right and left with no vision disturbance. Conclusion: In this case, the speed and volume of blood flow in the vertebral arteries was increased with a corresponding reduction in the primary symptom of vision loss after treatment with AO chiropractic adjustments of the cervical spine.

Case report: improvement in vascular ultrasound measurements following atlas orthogonal chiropractic adjustments for a patient with bow hunter's syndrome Robert Rectenwald, Roy Sweat

Evidence-based guidelines for the chiropractic treatment of adults with neck pain Rick Ruegg, Martin Descarreaux, Roly Bryans, Phil Decina, Mireille Duranleau, Henri Marcoux, Brock Potter, Lynn Shaw, Robert Watkin, Eleanor White

Objectives: Bow hunter's syndrome (BHS), also known as bow

Objective: This guideline updates an earlier neck pain guideline

hunter’s stroke, is a vertebrobasilar insufficiency. Pathophysiology can include mechanical occlusion or a stenosis of the vertebral artery at the C1-C2 vertebral level upon head rotation. The incidence is uncommon and causes include trauma, osseous abnormalities of the occiput or the cervical spine and atlantoaxial

published in 2005. It includes studies on the treatment of nonspecific, mechanical neck pain of unknown origin. The results of studies on neck pain that were associated with serious local pathology, systemic disease, whiplash-associated disorder or radical pain were excluded.

136 Methods: Systematic literature searches of controlled clinical trials published through December 2011 relevant to chiropractic practice were conducted using the databases MEDLINE; EMBASE; Allied and Complementary Medicine; the Cumulative Index to Nursing and Allied Health Literature; Manual, Alternative, and Natural Therapy Index System; Alt HealthWatch; Index to Chiropractic Literature; and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, limited, or conflicting) and to formulate practice recommendations. Results: Forty-two RCTs meeting the inclusion criteria scored a low risk of bias and were used to develop fourteen treatment recommendations. A strong recommendation was made for the treatment of acute neck pain with manipulation and the treatment of chronic neck pain with manipulation, mobilization, manual therapy, exercise, laser and massage. Moderate recommendations were made for the treatment of acute neck pain with mobilization, exercise, laser and the treatment of chronic neck pain with manipulation, and TENS. Based on this review process thoracic manipulation, traction or trigger point therapy could not be recommended for the treatment of neck pain. Four additional recommendations were made for future research. Adverse events were not addressed in most clinical trials; and if they were, there were none or they were minor. Conclusions: The low risk of bias research published since 2005 indicates that some of the interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain. Increased benefit has been shown in several instances where a multi-modal approach to neck pain has been used. Further research is needed.

WFC 2013 Scientific Sessions abstracts Index (SI) was calculated for magnitudes and timing for the first and second peak forces and mid-stance between peak forces; loading rate from heel strike to first peak force; unloading rate from the second peak force to toe-off: SI = 2(xR − xL) × 100/(xR + xL). Analysis was for pre-care differences between control and CLBP groups (dependent t tests) and pre-post differences for the CLBP group (independent t tests). Results: Both MSD and MCV were higher for CLBP participants than controls, and decreased for CLBP participants post-care; the differences were not statistically significant. There were small-tomedium effect sizes (Cohen d = 0.29-0.45), with differences according to outcome measure and left-right sides. Participants with higher pre-care variability tended to have lower post-care variability; those with low pre-care variability showed little change. No variables of asymmetry were significantly different for CLBP vs. controls or CLBP pre-post-care. The first and second treadmill assessments showed acceptable agreement (ICCs 0.866-0.611, P b .05.). Discussion: Measures of variability and asymmetry are common in gait research but able-bodied gait is somewhat variable and asymmetrical, so distinctions between “normal” and “abnormal” can be unclear. For this study, a master's thesis project, some CLBP participants had low baseline levels of pain, disability, walking impairment, and unilateral dysfunction; project extension would require better screening or definition of subgroups. Conclusions: CLBP participants had slightly more variability in vertical GRF than controls, without statistical significance; and there were no significant differences in gait symmetry. Slight post-care decreases in variability, with small-to-medium effect sizes, were not statistically significant; and no significant differences in pre-care to post-care symmetry was noted. These findings will guide future research designs.

Variability and asymmetry of vertical ground reaction forces during walking in adults with chronic low back pain, before and after chiropractic care Brent Russell, Mark Geil, Jianhua Wu, Kathryn Hoiriis

Measurement of lordosis by the Spinal Mouse as compared to lateral lumbar radiographs Brent Russell, Kimberly Muhlenkamp Wermert, Kathryn Hoiriis

Introduction: The scientific literature provides little evidence of beneficial effects from spinal manipulation (SM) on gait. This pilot study reports on the evaluation of gait variability and symmetry in adults with chronic low back pain (CLBP) following SM and hip joint manipulation from a single session of care. Large amounts of variability can be a product of injury, disease, or aging. Asymmetry is a feature of various types of neurological disorders. Study procedures were approved by the Institutional Review Boards of Georgia State University and Life University. Methods: Using a Zebris FDM-T treadmill, the gait of 9 CLBP participants (3 M, 6 F) were compared to 6 controls (4 M, 2 F); with similar ages and BMI. Two pre-treatment evaluations performed at a preferred walking speed for 30 seconds were averaged; CLBP participants received a post-treatment evaluation. Spinal manipulations consisted of “high velocity low amplitude” thrusts with a drop-section treatment table and/or use of flexion distraction or pelvic wedges for articular fixations in lumbar, sacroiliac, and hip regions. Vertical components of the ground reaction force (GRF) during the stance phase of walking gait measurements were analyzed using a MATLAB program. Stance phase was normalized into 100 equal intervals; Mean Standard Deviation (MSD), and Mean Coefficient of Variation (MCV) were calculated. Agreement between first and second pre-care treadmill assessments was examined using Intraclass Correlation Coefficients. A Symmetry

Introduction: The measurement of lordosis in the human lumbar spine is an active topic in recent literature, having been investigated in relationship to degenerative spondylolisthesis, growth patterns in children, spinal stiffness, osteoporosis and back muscle strength, hip flexion contracture, and other conditions. In a study of the effect of wearing high-heeled shoes on measured lumbar lordosis, a nonradiographic assessment was needed. The Spinal Mouse (SM) (idiag AG, Fehraltorf, Switzerland; version 3.28) was chosen for its ease of use and reliability. Because lordosis is often determined by radiographic analysis, this current study compares the SM measurements against those derived from participants' Aeradiographs. This study was approved by the Life University Institutional Review Board. Methods: Of 55 participants in the high-heels-lordosis study, 16 had digital lateral lumbopelvic radiographs available. The first and second authors independently each performed 2 lordosis analyses, using the Harrison Posterior Tangent Method (HPTM). The mean of 4 HPTM lordosis values was compared to the SM lordosis value using Pearson r. Intra- and inter-rater reliability for the HPTM analysis was calculated using Intraclass Correlation Coefficients. Results: The mean SM lordosis was 21.6; the mean HPTM lordosis value was 73.3 . The differences in the magnitudes of values of the methods is not unexpected, as the SM measures skin-surface external contours, while the HPTM measures angles between lines drawn along the posterior margins of vertebral

WFC 2013 Scientific Sessions abstracts bodies and the sacrum. There was a high amount of correlation between the sets of measurements: Pearson r = 0.80. Reliability for the HPTM analysis was high, with ICCs ranging from 0.972 to 0.982. Discussion: The description of this reliability study has not been published, although the reliability of the spinal mouse has been previously reported by the authors. While it is likely that most clinicians would consider radiographic analysis of lordosis as the gold standard, there are potential sources of inconsistency for each of these methods. For the Spinal Mouse, skin surface contours would not necessarily match the underlying contour of the spine, and may be different from left to right, due to asymmetry in vertebral architecture, fat distribution, or muscle tone; and measurement could be affected by the examiner's placement lateral to the spinous processes, and start-stop locations. Radiographic analysis is affected by landmark visibility and consistency in locating the same points on subsequent analysis. These factors could reduce the amount of possible correlation between the methods. If a practitioner wished to use the SM as a substitute for radiographs, interpretation might be a challenge, as there is no established normal value for SM lordosis values; the group mean for the present study was lower than the 32 found by Mannion. Generalizability may be limited, however the amount of consistency found for the SM implies that it could be used for pre-post monitoring. Conclusions: The Spinal Mouse appears to be an acceptable method of lumbar lordosis assessment. Further study of a larger number of patients in a clinical setting is recommended.

Proprioceptive neurons in the cervical myodural bridge: a feedback mechanism of dural tension monitoring Frank Scali, Matthew Pontell, Dennis Enix Objectives: The recent literature describes soft-tissue communica-

tions which link the suboccipital muscles with the cervical dura mater. In addition to their role in the etiology of cervicogenic headaches, these myodural communications may be part of a system that monitors dural tension. This study examines the upper cervical myodural communications at a microscopic level for the presence of proprioceptive neurons. Evidence of neuronal tissue embedded in these structures support the hypothesis that these epidural structures may be involved in a feedforward mechanism which monitors dural tension during head and neck movements. Methods: Gross dissection was performed on 5 cadavers to remove the rectus capitis posterior major, minor, and obliquus capitis inferior muscles, their soft tissue communications, and their related section of posterior cervical dura mater as one continuous unit. Paraffin embedding and sectioning followed by hematoxylin and eosin staining was conducted to validate the connection. Staining with anti-neurofilament protein fluorescent antibodies was performed to identify proprioceptive neural tissue on each specimen and all findings were recorded via photographic documentation. University ethics committee approval and donor consent was obtained for this study. Results: Histological analysis revealed a continuous tendinous structure bridging the rectus capitis posterior major, minor, and obliquus capitis inferior to the posterior aspect of the cervical dura mater in all 5 specimens. Anti-neurofilament protein fluorescence revealed proprioceptive neurons within their communications.

137 Immunoperoxidase staining demonstrated that the neuronal structures originate at the suboccipital structures, are continuous throughout the myodural structures within the epidural space, and insert directly into the dura mater. Conclusions: The presence of neural tissue within these myodural communications suggests that these epidural structures may serve other functions in addition to the mechanical anchoring of dura mater. The myodural structures may also be involved in directly monitoring dural tension, maintaining patency of the cervical thecal sac ultimately insuring normal flow of the cerebral spinal fluid. Failure of this system may result in certain cervicogenic, dura related pathologies, and may prevent proper flow of cerebral spinal fluid.

Investigating the impact of school bags on children's posture Patrick Sim, Jason Dunstan Introduction: Empirical evidence suggests that school bags have a negative impact on the posture of school children. This relationship was examined and behaviours associated with school backpacks were investigated including modes of wearing and their impact on posture. This project was undertaken in 2 phases. The first was an observational ethnographic study of school children in a busy railway station looking at bag type and size, method of support and posture. The second was a survey of parents across Australia conducted through an online provider. Results: A total of 364 observations and 423 surveys were completed. Backpacks are by far the most used bag [94%]. School children are most likely to use non-school issued backpacks [53%] One-third [35%] of these backpacks have no features thought by chiropractors as important to posture and comfort. School children carry their school bags with both straps across their shoulders [63%] but there are signs of a reluctance to use any of the schoolbag features [12%]. One-quarter of parents surveyed reported they felt their child's bag was either too big or packed too full. A result from Phase one indicated three-quarters [75%] of school bags were over packed. Half of parents [51%] believe their child to have good posture while carrying their schoolbag. A result from Phase one revealed only 11% had good posture. Discussion: Both the ethnographic study and the survey revealed that a proportion of school children are carrying schoolbags that are either too large for them or packed to capacity. In addition, half of school children were identified by their parents to have poor posture while carrying their school bags; this finding was strongest in the observation phase. These are indicators of the need for there to be a focus on reducing the size of school bags and educating students, staff and parents on the correct method of carrying these bags. There are also indicator for parents to be educated on identifying postural problems. The discrepancy between the ethnography and the survey indicates a gap exists between actual posture and perceived posture. Helping parents to identify when their child has poor posture may assist in reducing postural problems amongst children. Conclusion: The results indicate that while students are likely to be carrying backpacks with chiropractic features, they are unlikely to be using these features. Parents and staff should encourage students to wear these backpacks correctly and use all of the bag's chiropractic features. There is evidence to suggest a link between school bags and

138 poor posture and we recommend a rigorous study be undertaken that controls multiple variables integral to this question.

An epidemiological investigation of neck pain in the white population in the greater Durban Warren Slabbert, Vilash Boodhoo, Charmaine Maria Korporaal Background: Neck pain has a high incidence, point, period and lifetime prevalence and therefore has the ability to impact negatively on patients and the societies in which they live. Discrepancies however exist between population groups, therefore it is possible that different population groups would suffer differently when confronted with neck pain. Therefore the aim of this IREC (Institutional Research and Ethics Committee) approved study was to determine the prevalence of and risk factors for neck pain in the White population in the greater Durban area. Methodology: This study was conducted at 3 randomly selected (from within specific socio-economic areas) shopping centres around Durban. Three hundred participants were surveyed at each shopping centre by means of a questionnaire. The data were then statistically analysed utilising descriptive and inferential statistics. Associations between demographic and risk factors and neck pain were examined bivariately using Pearson χ 2/Fisher exact tests for categorical factors, or Student t tests in the case of quantitative parametric data. In order to examine the adjusted independent effects of all factors which were found to be individually significant in the bivariate analysis, multivariate binary logistic regression analysis was done. Results were reported as odds ratios, 95% confidence intervals and P values. A P value of b .05 was considered as statistically significant. Results: It was found that the overall prevalence of neck pain was 45%. The participants in this study that had neck pain were significantly more likely to be females (P = .003) that were single (P = .023), had a job that caused their heads to turn (P = .012) or to work with their arms above their heads (P = .038) and lived a lifestyle that had one or a combination of the following: lead a stressful lifestyle (P = .036), were emotional (P = .000), had perceived bad posture (P = .000), had previously experienced neck or head trauma (P = .000) and required glasses (P = .009). Conclusion: In conclusion, it is found that this particular population group had factors that were unique to them. Therefore physicians dealing with a variety of patients with neck pain should use these particular risk factors that have been established in this and other such studies and integrate them in their treatment and management protocols.

The role of and relationship between hamstring and quadriceps muscle myofascial trigger points in patients with patellofemoral pain syndrome Louise Smith, Brian Kruger, Charmaine Korporaal Objectives: Patellofemoral Pain Syndrome (PFPS) is a common

condition in all age groups and in many sports. With its multifactorial and overlapping aetiologies, there is often confusion and debate, yet it is the most likely cause of the varying clinical presentations of PFPS. Included in this clinical presentation, but not included in the classic definition of PFPS is the presence of

WFC 2013 Scientific Sessions abstracts myofascial pain syndromes (viz myofascial trigger points). Therefore this IREC (Institutional Research and Ethics) approved study aimed to determine the association between the Quadriceps femoris muscle group, Hamstring muscle group and Adductor muscle group in terms of the presence of MFTPs in these muscle groups and their relationship to PFPS. Methods: A cross-sectional, observational, quantitative non-intervention clinical assessment study was conducted at the Chiropractic Day Clinic at Durban University of Technology (DUT), to determine the extent of the PFPS, the MFTPs and thus the relationship between the two. The study included eighty patients with PFPS, who were recruited by convenience sampling and screened utilising a clinical assessment and inclusion criteria. The results were captured using Microsoft excel and SPSS version 15.0 was used to analyze the data. A P value b .05 was considered as statistically significant. Correlations between measurements of objective and subjective pain was assessed using Pearson correlation or Spearman rank correlation coefficient. The subjective and objective pain measurements were computed using MannWhitney tests and Spearman rank correlation was used to correlate the number of MFTPs with the pain measurements. Results: Quadriceps femoris muscle group MFTPs were noted in 92.5% of the patients (most prevalent being Vastus medialis TP1 (63.8%), Vastus lateralis TP1 (33.8%) and Vastus intermedius at (27,5%)). Least common was Vastus lateralis TP2 only presenting in 2,5% of the patients. Hamstring muscle group MFTPs were found overall in 86.3% of patients (most prevalent being in Biceps femoris muscle (66%), and least prevalent being in Semitendinosus muscle (11,3%)). MFTPs were present in 64% overall of the Adductor muscle group (Adductor magnus muscle being the most common). Significant associations were made between the presence of MFTPs in the Vastus lateralis TP2 (P = .00), Vastus medialis TP1 (P = .046; .005; .004), the NRS and the Patellofemoral Pain Severity Scale. Also significant was the relationship between the NRS, PPSS and the Semimembranosus and Adductor magnus muscles, which indicated that these muscles were the most likely causes of pain even though they had fewer MFTPs than other comparable muscles. Conclusion: The outcomes of this study supports previous research indicating that an extensor dysfunction of the Quadriceps femoris muscle group may be of MFTP origin. It further agrees with literature indicating that the pain along the lateral thigh may be primary to the development of MFTPs on the medial aspect of the thigh, which may explain why rehabilitation of the VMO has limited success without concomitant MFPT intervention. It is also suggested that other muscle groups in the thigh and lower extremity are assessed in patients with PFPS.

Study guide drawings, learning style and student performance Guy Sovak, Loretta Howard, Marion McGregor Objectives: This study explored the relationship between student

performance, the completion of study guides and kinesthetic versus non-kinesthetic learning styles. Two main approaches are often utilized in teaching histology: Reception learning via lectures; and self-discovery learning in labs for observation-based instruction. In both approaches complementary learning strategies are utilized including texts, atlases, internet, study guides and tutorials. The [institution name] employs both approaches, with 48 lecture hours and

WFC 2013 Scientific Sessions abstracts 28 microscopic laboratory hours in this course. Historically faculty have required learners to complete study guide drawings as a means to enhance student learning believing that drawings are key element in the learning processes. Recently, faculty question the effectiveness of study guide drawings noting students often invest little time and effort into the task. Research indicates that, in many cases, a significant relationship between overall academic achievement and learning styles exists.Given that study guide drawing is a highly kinesthetic process, researchers in this study sought to determine if a kinesthetic learning style related to academic performance. Methods: In this study 194 students were assessed twice via 2 sets of exams. Each set was conducted at the end of a learning module and included theoretical and practical exams. The practical exam employed microscopic views of histology slides. After the first module exam set students submitted a study guide with illustrations of specific tissues. In the second module exam set students also completed a survey that identified their type of learning style, either kinesthetic or non kinesthetic. Statistical analysis, t tests and Pearson correlation test, examined student grades in both exam sets and the relationship between study guide completion and student performance. Grades of kinesthetic versus non-kinesthetic learners were compared to above and below average exam performance (theory and practical) and study guide drawing grades. Results: Findings contradict researcher expectations as it was found that study guide drawings did not relate to the overall class performance between the first and second modular exams neither in the practical portion (77.9Â ± 17.8 and 77.4Â ± 18.18 respectively) nor the theory portion (82.9Â ± 16.5 and 80.9Â ± 26.6). Higher marks in the study guide were correlated with higher marks in both the practical exam r = 0.76 and the theoretical exam r = 0.85 indicating that those students that did well in their study guide also did well in exam performance. Also contradictory to researcher expectations, no significant difference was found between kinesthetic learning style and practical and theoretical exam grades. Discussion: Although no substantial evidence was found to support the hypothesis that higher exam grades are related to the completion of drawing histological slides researchers in this study still see added value to the practice of histology study guide drawings. Evidence to support this notion was found in the positive correlation between study guide grades and overall exam grades. Researchers conclude that further research is required to investigate the benefits of study guide completion more specifically and examine other aspects of learning styles related to academic performance that may be of influence in this learning context.

139 consensus regarding the methodology applied in these studies. Other inconsistencies regarding the efficacy of laser in the treatment of RA exist due to the wide range of differing wavelengths and doses that have been used in the published reports, thereby making it difficult to effectively compare studies. Thus the purpose of this pragmatic controlled clinical trial was to investigate the efficacy of low-level laser therapy (LLLT) as a part of the palliative management of the hand symptoms of rheumatoid arthritis (RA). Methods: This IRB approved study, included a sample of 24 patients with RA, divided into 2 groups based on their DASH score and their primary medication. The treatment group received LLLT of the metacarpophalangeal (MCP) joints and proximal interphalangeal (PIP) joints of their more severely affected hand. Patients in the placebo group were treated with a placebo laser. Both groups received 9 treatments over 3 consecutive weeks (three treatments per week). Follow-ups were done the week after the treatments were completed and then again at one month. Measurements were obtained using the Numerical Rating Scale101 (NRS-101), Disability of the Arm, Shoulder and Hand (DASH) Questionnaire, the duration of morning stiffness and algometer readings. Baseline comparisons between the categorical baseline variables and the group to which the participant was assigned were done using Fisher exact test. Continuous normally distributed baseline data were compared using the 2 sample t test. A paired t test was done between the baseline and endpoint to determine whether there was any treatment difference between the 2 groups. Data analysis was done using SAS with the repeated measures analysis of variance (ANOVA). Results: The results of the study suggest that there was no statistically significant difference in the treatment effect between the treatment and placebo groups. The visit effect was statistically significant for most outcomes, meaning that there was a significant improvement from one visit to the next but that neither the placebo nor the laser treatment was significantly more effective than the other. The treatment group showed better improvement (but not statistically significantly so) for all the outcomes than the placebo did. Conclusion: Therefore, laser therapy may be more effective than the placebo in the management of the hand symptoms of rheumatoid arthritis.

Analysis of the prevalence of pediatric complaints in a chiropractic clinic at a university of the Vale dos Sinos region between 2006 and 2012 Clarissa Taniguchi, Ranieli Zapelini A pragmatic controlled clinical trial investigating the efficacy of low-level laser therapy as a component of the palliative management of the hand symptoms of rheumatoid arthritis Keriann Stagg, Heidi Marise Kretzmann, Charmaine Maria Korporaal Objectives: Low-level laser therapy (LLLT) may offer a viable treatment option for the hand symptoms of Rheumatoid Arthritis as its application theoretically supports and suggests that the physiological effects of LLLT are biostimulation, improved metabolism, increased cell metabolism, improved blood circulation, vasodilatation, analgesic effects, anti-inflammatory and antiedematous effects; all of which are desired in the treatment of RA. There is however controversy within in the literature as to the efficacy of LLLT. This is partially attributable to the lack of

Introduction: According to researches, pediatric chiropractic care

increased from 9.7% of chiropractic patients to more than 18% from 1991 to 2003. That suggests a growing number of conditions that present to chiropractor's offices and a great awareness of this category of complementary medicine. This analysis aimed at determining the prevalence of pediatric complaints at a chiropractic school clinic at a university in the Vale dos Sinos region from 2006 to 2012; relating the more prevalent ones to age and gender; verifying the average number of chiropractic appointments and mean treatment time. Methods: Clinic records were analyzed, classified and quantified. Children aged from 0 to 12 years were considered for the pediatric complaints analysis.

140 Results: From 5940 new patients in the period, 141 were children, 48.2% were male and 51.8% were female; mean age 7.3 years (standard deviation 3.7 years). The seek care reasons were musculoskeletal pain (46%), prevention/health promotion (11%), scoliosis (6%), colic (6%), cerebral palsy (5%), posture (5%), headache (5%), enuresis (4%), ear/nose/throat (1%), asthma (1%), Attention Deficit Hyperactive Disorder (ADHD) (1% ) and other conditions (9%). There was a predominance of males in musculoskeletal complaints and of females in colic and scoliosis. Average of 7 visits (SD, 16.71) and an average treatment time of 8.6 weeks (SD, 61.35). Conclusions: there was a small number of pediatric patients and the most common complaint among them was musculoskeletal pain.The study showed a low adherence to the chiropractic treatment, once most of the parents brought in their children only to participate on academic researches. Therefore we suggest an educational program to show parents its importance in children's life.

WFC 2013 Scientific Sessions abstracts participants reporting an average to complete improvement in their condition. Patients expressed great satisfaction with the treating interns communication skills. Finally, this study has highlighted the effect cost of care has on finance satisfaction ratings, both between the public and the DITCDC. Conclusion: It would seem that the results from a student based clinic are similar to those studies completed in private practice. It is however suggested that future research should examine the patient satisfaction questionnaires more closely as internal reliability for the finance scale and communication subscale were not satisfactory, although the finance scale reliability may be explained as the result of uncertainty of participants about their medical aid providers.

Identifying the site of care for manual treatment methods: what does the evidence say? John Triano, Brian Budgell Background: A convincing body of evidence has accumulated

Patient satisfaction at the Durban Institute of Technology Chiropractic Day Clinic Bruce Thoresen, Charmaine Maria Korporaal Background: Patient satisfaction is an important, desired measure of quality of care and has a significant influence on the perceived quality of care and outcome of treatment. For this reason, it holds great value to the treating clinician, as satisfied patients are more likely to comply with treatment instructions and advice, remain with their service provider and refer others. Dissatisfaction, in the event of an unfavourable outcome, can by contrast result in legal action and complaints to regulatory bodies. Studies generally, have indicated a high level of satisfaction with chiropractic care; however, none had been in a student clinic setting. In view of this significance and lack of understanding of the patients' satisfaction/dissatisfaction in the history of DIT's clinic operation, the question remains as to what extent the students at the DIT Chiropractic Day Clinic (DITCDC) satisfy their patients. This study evaluated the patient satisfaction at the DITCDC in order to establish a baseline for future comparisons. Methods: This was questionnaire-based survey, evaluating patient satisfaction of 303 English literate patients at the DITCDC by methods of convenience sampling, after approval by the IRB Committee. The data was collected by means of questionnaire completed either in the clinic reception area after the consultation, at which consent was obtained, or taken home and returned at a following visit or via a prepaid, self-addressed envelope. Cronbach's alpha scores were used to determine questionnaire reliability in a South African student context. Results: The results of this study were based on the mean response range possibilities 1.0 (Strongly agree) to 5.0 (Strongly disagree). There was a high degree of satisfaction overall ranging from a mean of 1.99 (humaneness) to 1.53 (communication). Participants were less satisfied with the finance (1.78) and intern conduct scales (1.76) than with general satisfaction (1.55). Reliability as measured by Cronbach's alpha was moderate in the scales, to low in the subscales. The alpha value was highest in the total satisfaction score (computed using all the items in the questionnaire). The finance scale showed a low level of reliability (0.3140). The results of this study indicate that patients attending the DITCDC report a high degree of satisfaction with the care they received. It has also shown chiropractic to be an effective form of intervention with 82% of the

demonstrating that spinal manipulation is an appropriate treatment option for several biomechanical disorders affecting the spine and for articulations of the extremities. Given that manipulation is a localized treatment, that is to say, it is directed at a specific vertebra/ joint or a localized series of vertebra, it would seem a priori that the methods used to identify the site of care should be reliable and valid. These characteristics of diagnostic assessment, for the many methods used to locate the site for treatment, have not been adequately surveyed within the literature and are a primary motivation for the work in this report. Methods: A team of 7 reviewers (1 PhD; 2 DC, PhD; 1 DC MSc; 2 DC) was assembled representing 5 chiropractic institutions, internationally. Articles were sought from the Medline and CINAHL databases and considered if they met 5 criteria: (1) topics focused on diagnostic reliability and/or validity for methods of patient evaluation to site the location for care by means of manual methods, (2) articles were primary source research reports containing original data conducted on humans, (3) examiners were experienced providers or health sciences students, (4) for validity studies, at least some of the subjects must have been symptomatic or have had a known anatomical anomaly, and (5) publication was in the indexed and peer-reviewed English language literature. Standardized instruments, QUADAS (Whiting et al 2003) for validity and QAREL (Lucas et al 2010) QUADAS for reliability were used to evaluate quality of the research. Topics were given high evidence ratings if at least 2 high scored articles or one high plus 2 moderate scored articles were available; 2 moderate articles lead to a moderate rating and all other cases were ranked as a low level of evidence. Results: Over 2600 articles were screened. The quality of evidence on validity and reliability to identify a specific site for the application of care ranged from low to high and from favorable to unfavorable. A number of assessment methods were judged to be useful for patient screening or for narrowing the topographical focus of examination, sometimes with limitations. The evidence supports more direct, mechanical methods of assessing and identifying the site of care, including postural assessment, orthopedic testing in general, and range of motion testing, as well as assessment of leg length inequality, sometimes with limitations. In general, evidence is not supportive of indirect methods such as manual muscle testing, thermography, surface electromyography

WFC 2013 Scientific Sessions abstracts and measures of electrodermal activity, again with exceptions. The evidence is mixed on static palpation, motion palpation, manual assessment of joint stiffness, and integrated assessment. The highest quality evidence favoured examination techniques which provoke or reproduce the patient's familiar pain.

Vertebral artery dissection following chiropractic: a systematic review of stroke case reports Peter Tuchin Objectives: Vertebral artery dissections (VAD) and internal carotid

artery dissection (ICAD) are rare causes of stroke. However, in the younger adult population (under 45 years of age), as much as 20% of stroke appears to be associated with arterial dissection. Spinal manipulative therapy (SMT) and chiropractic are commonly used as treatment for spinal pain, but are also cited as a cause of VAD. The purpose of this study was to assess the potential relationship of vertebral artery dissection (VAD) following chiropractic spinal manipulative therapy (SMT), by critically reviewing case study papers on VAD and SMT. Method: A systematic review examined case reports involving SMT and VAD or stroke. The review assessed significance of recognised risk factors for stroke in each case report. This included the use of the oral contraceptive pill, history of hypertension, hyperlipidaemia, atherosclerosis, connective tissue abnormalities, recent infection, neck pain, headache and migraine. Other items that were assessed included the description of the treatment, the time lapse to onset of the adverse event (AE) and the administration of the SMT. Results: A total of 20 papers (detailing 72 cases) were retrieved and reviewed, which identified many interesting anomalies. One case received no SMT and from the remaining 71 cases, 45 were denoted as chiropractic but the paper reported the SMT was delivered by a non-chiropractor. From the remaining 26 cases, 18 were from countries where chiropractic was not regulated at the time of treatment, which is likely to mean that any person (including nonqualified laymen) could have used the title chiropractor. This leaves a total of 8 cases where the person giving the SMT was likely to be a qualified chiropractor. In these 8 cases, 6 had plausible alternative explanations for the VAD occurring not as a consequence of the SMT. Conclusion: Case reports have many weaknesses which can invalidate the reported outcomes. The evidence does not demonstrate chiropractic SMT to be a significant risk factor for VAD and stroke.

The effectiveness of 3 treatment protocols in the treatment of iliotibial band friction syndrome Grant Turnbull, Brian Kruger, Charmaine Maria Korporaal Objective: Iliotibial band friction syndrome (ITBFS), is a common syndrome in both professional and recreational athletes, which has been linked to changes in the biomechanics of the pelvis and lower extremity. This IRB approved study aimed to determine the comparative effectiveness of dry needling alone versus manipulation alone, as well as a combination therapy in the treatment of Iliotibial Band Friction Friction Syndrome (ITBFS). Methods: The study was a randomised, trial of 47 participants with ITBFS, which were divided into 3 groups, each group receiving a

141 different intervention; ie, group one received dry needling of the active MFTP's, group 2 received sacroiliac joint manipulation, group 3 received a combination of the 2 interventions. Subjective measurements, in the form of the NRS scale, and objective measurements, in the form of algometer readings in the TFL, ITB and Nobles Compression test as well as digital inclinometer readings of Modified Obers test, were utilised to determine the effects of the respective interventions. Each participant received 4 treatments over a 2 week period. Results: There were no statistically significant differences between the 3 treatment groups as they all seemed to parallel one another with regards to overall improvement in subjective and objective measurements (P b .05). However on closer examination subtle differences between the groups were noted. Conclusion: An interesting endpoint is that the combination group did not fair the best throughout the study, which was contrary to the original hypothesis. The groups receiving only the single intervention appeared to improve marginally better over the combination group. This could direct treatment in the future to assess the condition more accurately and decide which intervention is best suited to that particular individual at that point in time. A secondary endpoint that became evident during the study and on analysis of the data, was that hip joint instability should also be considered when treating ITBFS when there is concomitant sacroiliac joint dysfunction.

A randomised clinical trial to investigate whether Kinesiotape or dry needling is more effective in the treatment of upper trapezius myofascial pain Jandre van der Westhuizen, Charmaine Maria Korporaal Objective: Therapeutic dry needling is an established modality for

the treatment of myofascial pain. This intervention is however invasive and as such has several possible contraindications and complications. In contrast to this, the non-invasive Kinesiotaping has become popular, with the main benefit of being long wearing and thereby extending the treatment to the patient. As a result this study aimed to determine the relative effectiveness of these 2 treatment modalities in patients with myofascial pain syndrome of the Trapezius muscle. Methods: The study design was approved by the Institutional Research and Ethics Committee, as a quantitative prospective randomised clinical trial. Fifty patients were equally and randomly allocated (randomization table) into either the dry needling or Kinesiotape groups. Each patient received 2 treatments on separate visits to the upper trapezius muscle. Follow-ups were scheduled 2 to 4 days after the previous visit. Subjective measures were the Visual Analog Scale (VAS) and the Neck Disability Index (NDI), whilst objective measures were pain pressure threshold (PPT) and cervical range of motion (CROM). Baseline demographic factors were compared between the 2 treatment groups using the Student t test and χ 2 test to ensure group comparability at baseline. Repeatedmeasures ANOVA tests were used to assess whether the Kinesiotape was effective at improving outcomes compared with dry needling. Results: Kinesiotape demonstrated statistical significant treatments with the VAS (P b .001), NDI (P b .001) and PPT (P = .022) (95% CI). Dry needling showed statistical improvements in VAS (P = .001) and NDI (P b .001) only. Also, Kinesiotape demonstrated a

142 clinically significant improvement with the VAS when compared to the minimal clinically important differences (MCIDs). Trends of a superior treatment effect of Kinesiotape over dry needling was observed in the VAS and PPT groups (P = .155; P = .428). Future studies could repeat the study with larger sample sizes to determine if these trends can be validated. Conclusion: This study demonstrated that Kinesiotape was at least as effective as dry needling in the treatment of Myofascial Pain Syndrome. Kinesiotape therapy resulted in a greater change in pain and disability scores than did dry-needling, implying that Kinesiotape may be a non-invasive alternative to dry needling.

Prone positioning in an infant population: a cross-sectional survey of parents Nina Van Dyk, Joyce Miller Objectives: Parental knowledge about Back to Sleep (BTS) has been

researched extensively; however there has been little exploration of parental knowledge about “Tummy Time” (TT) (supervised prone play). This study aims to establish if there is a need for further parental education in this regard. The purpose of this study was to ascertain parental knowledge and practices related to infant positioning, including TT and BTS during infancy. Specifically the relationship between knowledge of TT and the timing of education parents received, by whom it is given, and the action taken (giving TT to the infant) by the parents. Methods: The study design was a retrospective cross-sectional anonymous survey. The survey was distributed in the South of England (two North London chiropractic clinics and the Anglo-

WFC 2013 Scientific Sessions abstracts European College of Chiropractic clinic (AECC)). Mothers of newborn infants up to 12 months of age participated. Five hundred questionnaires were distributed within the chiropractic clinics, 406 were completed and analysed. Results: Mothers were well informed on back to sleep (97%) and 2 times less likely to have had instruction on TT. Most parents starting implementation of TT shortly after they were informed (mode of 4 weeks) at a mean age 5. 4 weeks. Parents responded well to instruction with a significant correlation (P = .000) between timing of instruction and implementation of TT. Six percent of infants started TT at birth and 10% b 3 weeks of age. Overall, 17% of infants received more than 30 minutes a day, at a mean age 17 weeks, with the majority of infants (71% at a mean age 12 weeks) receiving TT well below the AAP recommendations. The amount of TT given to the infant was significantly linked with tolerance (P = .000), with infants receiving the most TT much more tolerant of this position. The overall tolerance rating (scale of 0-4) for this cohort was 1.4 (low tolerance) which may make parents apprehensive in giving their infants TT. In this study, 47% infants demonstrated a positional preference for sleep with 30% favouring head rotated to left or right side and 7% infants preferred sleeping prone. A cohort of 60 infants presenting to the AECC chiropractic clinic with PHD were significantly more likely to be male, have a positional preference, twins and receive TT less than 30 minutes a day. Conclusion: Less than a third of mothers reported receiving instruction on giving their infant TT. Mothers did report being given clear instruction on sleeping their infant supine. This study found that, if instructed, parents respond and implement prone play as soon as they are aware of the benefits. It is up to healthcare providers to give sufficient and timely information regarding infant position during both awake and asleep times according to the AAP guidelines.

Abstracts of the Scientific Sessions from the WFC'S 12th Biennial Congress Proceedings, Durban, South Africa, April 10-13, 2013.

Abstracts of the Scientific Sessions from the WFC'S 12th Biennial Congress Proceedings, Durban, South Africa, April 10-13, 2013. - PDF Download Free
532KB Sizes 0 Downloads 0 Views