Selasa, 11 Mei 2010

Chiropractic: a little physical therapy, a lot of nonsense

CHIROPRACTIC MEANS DIFFERENT things to different people. For some, it is a practical way to get quick relief from mechanical back pain. For others, it is a cult-like belief system based on demonstrably false ideas and a magnet for every kind of quackery that endangers our public health and sometimes even kills patients.
A science like chemistry develops gradually over many decades with input from many different scientists. A pseudoscience like chiropractic can be invented instantaneously by one person. D.D. Palmer, a grocer and magnetic healer, invented chiropractic on September 18, 1895. He did something to a deaf man's back. The man said he could hear again. This is particularly ironic, because the nerves to the ear don't go anywhere near the spine, and no chiropractor today claims to be able to cure deafness. Palmer immediately deduced that all disease was caused by out of place bones (95% in the spine and 5% in other bones), but he never tried to test his hypothesis in any way; he just forged ahead and treated thousands of patients.
Ironically, 1895 was also the year that Louis Pasteur died. Most rational people accept the germ theory of disease, but chiropractic theory rejects it, and many chiropractors today continue to believe that germs can't hurt you if your spine is in alignment. And 1895 was the year Wilhelm Roentgen discovered x-rays. D. D. Palmer thought he could feel bones out of place in the spine; he called them subluxations (partial dislocations). There are such things as true medical subluxations that show up clearly on x-rays. When they got around to documenting chiropractic "subluxations" with x-rays, nothing showed up. But that didn't matter to the chiropractors. Their belief system had already been established, and nothing was going to change their minds. They just changed their definition: instead of an actual subluxation, they were treating a "vertebral subluxation complex": "A complex of functional and/or structural and or pathological articular changes that compromise neural integrity and may influence organ system and general health." Translated: "We are going to call anything we want to manipulate a subluxation."
Chiropractic theory is based on three principles:
(1) bony displacement causes all disease;
(2) displacement interferes with nerve function;
(3) removing the interference allows Innate (a vitalistic force) to heal the body.
All three of these principles are false.
(1) Chiropractic subluxations have never been demonstrated;
(2) No impairment of nerve function has been documented;
(3) No such vitalistic force has been detected.
Palmer was under the misconception that all bodily functions are controlled by the nerves. He didn't know about hormones. He didn't know we would learn to transplant organs that would function in the new body with no nerve connections at all. He reasoned in a prescientific manner, and his attitude was more that of a religious believer than a rationalist; he spoke of a God-given calling and seriously considered making chiropractic a religion. D.D. Palmer's son B.J. was unscrupulous and a marketing genius. The success of chiropractic is largely due to his early efforts.
Spinal manipulation was nothing new. Others offered it, particularly osteopaths (they thought it restored blood flow rather than nerve function). During the course of the 20th century, osteopaths accepted scientific medicine. Today, American osteopaths take the same specialty training residencies and pass the same licensing exams as MDs. Chiropractic chose to remain in its own limbo. No school of chiropractic has ever been associated with a university, unless you count the University of Bridgeport, an institution closely associated with the Unification Church of Sun Myung Moon.
What does the evidence show? Spinal manipulation therapy (SMT) is as effective as other treatments for certain types of low back pain, and may offer superior early relief, but the long-term outcome is no better. That's it. There is no good evidence that anything else about chiropractic is effective. It certainly is not effective for asthma, ear infections and other somatovisceral conditions that some chiropractors claim to benefit. So the one thing chiropractors do that works is something that is not uniquely chiropractic but is also used by physical therapists, physical medicine specialists, and osteopaths.
Chiropractors have accumulated over 200 different treatment methods. Instead of comparing two methods to see which works better and rejecting the other, they just keep adding new methods. I have only found one thing that chiropractic as a whole has ever given up as ineffective: a nerve-tracing method invented by B.J. Palmer, who convinced himself he could feel nerves through the skin, nerves unknown to anatomists.
The Risk of Stroke
There is a very small but very real risk of stroke with neck manipulation. Because of the anatomy of the neck, a bone-tethered kink in the vertebral artery is stressed with high velocity neck manipulations and the lining of the artery can tear, causing immediate bleeding or sending delayed clots to the brain. Chiropractors try to deny this and say those patients probably went to the chiropractor because they had neck pain and were already starting to have a stroke. But we have plenty of "smoking gun" cases where healthy young people with no neck pain or stroke symptoms and no risk factors for stroke collapsed on the chiropractor's table and were found to have tears in their vertebral arteries. In one study, patients under the age of 45 with a vertebral artery stroke were 5 times as likely as controls to have seen a chiropractor in the previous week.
Risks should be weighed against benefits, but there don't seem to be any clear benefits of neck manipulation. A recent database summary of medical research--the Cochrane review--showed that gentle mobilization worked just as well as high-velocity manipulation, but both had to be used in conjunction with exercise to be effective. The real tragedy is that chiropractors are manipulating necks for "health maintenance," low back pain and other conditions where there is no evidence of benefit and no plausible rationale, but very real risks. For example, 20-year-old Laurie Jean Matthiason saw her chiropractor for low back pain; she had 186 neck manipulations over a six month period and the last one killed her. Sandra Nette had a neck manipulation only because she thought it would help maintain her already good health; she suffered a severe stroke and has filed a class action suit asking the government of Canada for $525 million dollars for failure to regulate a dangerous practice.
Other Risks
Half of all chiropractic patients report mild to moderate side effects, from local discomfort to headache. Manipulations have caused broken bones and herniated discs. Chiropractors expose patients to radiation from unnecessary x-rays. Some discourage patients from taking medications or having needed surgery; some want to serve as the initial point of contact for all health care. Chiropractors are notorious for adopting all kinds of quackery from applied kinesiology to colonic irrigation. My biggest concern is that over half of chiropractors don't support immunizations, thereby endangering public health.
Just a few examples of chiropractic insanity from my local community:
1. A chiropractor claims a baby's neck is stretched 2.5 times normal length by childbirth (an anatomical impossibility) and should have neck adjustments starting in the delivery room.
2. A chiropractor treated his own son's meningitis with manipulations only; the child died.
3. A chiropractor diagnosed allergies by having a patient hold a sealed vial of allergen in one hand while he judged the muscle strength in the patient's other arm. He suspected one patient was allergic to something at work, and since he didn't have a vial of "Boeing," he had the patient just think about "Boeing" and that worked just as well.
4. A chiropractor informed me that if germs caused disease we'd all be dead and insisted that you can't become ill if your spine is properly aligned.
5. A chiropractor claims to be able to tell if you have a good brain or a bad brain based on a paper and pencil measurement of the normal blind spots in your eyes, and then offers to correct it by manipulation.
6. Several chiropractors offer $5000 series of spinal decompression treatments with a computerized machine that has not been shown to offer any benefit.
How to Choose a Sale Chiropractor
Some chiropractors are skilled at SMT and at treating low back pain. You can look for one who rejects the subluxation myth and limits his practice to short-term treatment of mechanical back pain and doesn't use any quack treatments. But then you're not getting chiropractic treatment, you're getting physical therapy from a chiropractor. Edzard Ernst, the world's first professor of complementary and alternative medicine, reviewed the scientific evidence for chiropractic and concluded "Chiropractors ... might compete with physiotherapists in terms of treating some back problems, but all their other claims are beyond belief and can carry a range of significant risks."
A friend of mine had a narrow escape. He had back pain that just wouldn't quit, and decided to try a chiropractor. He called on a Friday to make an appointment for the following Monday. Over the weekend, his pain stopped and it never came back. If he had seen the chiropractor on Friday, he would have been convinced the chiropractor had cured him, and probably would have spent the rest of his life faithfully getting useless maintenance adjustments.

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Senin, 10 Mei 2010

Mandibular coronoid hyperplasia: a case report

ABSTRACT: A case of unilateral coronoid hyperplasia successfully treated by corenoidotomy with prolonged postoperative physiotherapy and reveal the postoperative radiographic changes between the sectioned part of the coronoid process and the mandibular ascending ramus is described. The patient was a 28-year-old man whose maximum mouth opening was 30 mm. A coronoidotomy of the left coronoid process was performed. Nine days after surgery, the patient started physiotherapy with a HU-OSr appliance. After coronoidotomy and physiotherapy, the maximum mouth opening had increased to 43 mm. Radiographic follow-up showed that the coronoid process apparently united with the mandibular ascending ramus, with moderate dislocation and inclination posteriorly. In the case presented, an intraoral coronoidotomy with postoperative physiotherapy for treatment of coronoid process hyperplasia allowed satisfactory and stable results in the correction of coronoid-malar interference.
In patients with coronoid process hyperplasia, which presents essentially a mechanical problem such as limited mouth opening, a surgical treatment with prolonged postoperative physiotherapy is performed. The surgical treatment for coronoid process hyperplasia is correction of the coronoid-malar interference by a coronoidectomy or simply coronoidotomy. Gerbino, et al., (1) reported that coronoidotomy was performed intraorally by an osteotomy at the base of the coronoid process in five patients and that this approach notably reduces the need for bone exposure and consequent surgical trauma compared to the coronoidectomy. With respect to postoperative physiotherapy, several devices are used for maintenance of sufficient interincisal distance. (1-3) Previously, a mouth-opening exerciser (HU-OS II) (4-6) was introduced for postoperative mouth-opening exercises in patients with severe trismus due to temporomandibular joint ankylosis after maxillectomy. The exerciser is available for increasing the mouth opening range without help postoperatively.
A case of unilateral coronoid hyperplasia is described that was successfully treated by coronoidotomy with prolonged postoperative physiotherapy, using a HU-OS II appliance and revealed the postoperative radiographic changes between the sectioned part of the coronoid process and the mandibular ascending ramus.
Case Report
A 28-year-old man was referred for evaluation of a persistent limited mouth opening. The patient first noticed the difficulty opening his mouth when he was 15 years old. He consulted a dentist and was given a diagnosis of temporomandibular joint disorder. There was no history of maxillofacial injury or familial occurrence of similar problems.

Clinical examination revealed limited mouth opening but no temporomandibular joint pain and no masticatory muscle tenderness. The maximum mouth opening was 30 mm. Left and right excursions were seven mm each and protrusive excursion was six mm. There was no dentofacial abnormality.
Orthopantomography showed the right coronid processes with normal length and the elongation of the left coronid processes (Figure 1). Computed tomography demonstrated the contact of the left zygomatic bone and the coronoid process in the open mouth position. Bone formation at the contact point on the posterior surface of the left zygomatic bone was observed (Figure 2 A-B). A diagnosis of left coronoid process hyperplasia was confirmed using the characteristic radiographic and clinical findings.

With the patient under general anesthesia, a coronoidotomy of the left coronoid process was performed intraorally by an osteotomy at the base of the coronoid process. A horizontal osteotomy was made with a Lindemann bur from the sigmoid incision to the anterior aspect of the ascending ramus (Figure 3A). The maximum mouth opening was 50 mm immediately after the osteotomy. The sectioned coronoid was not removed because there was no interference with enforced mandibular movement (Figure 3B).
Nine days after surgery, the maximum mouth opening was 33 mm. The patient started physiotherapy with a mouth-opening exerciser (HU-OS II) (Figure 4). The patient used the mouth-opening exerciser to do 100 consecutive openings using the exerciser with no other assistance--one opening per second, 100 seconds total. This exercise was done twice a day, once in the morning and once at night. Thirty days after surgery, the maximum mouth opening had increased to 40 mm, and at the three month follow-up, it had stabilized at 43 mm. The mechanical physiotherapy was then interrupted. At the 15 month follow-up, the maximum mouth opening range was still 43 mm, with good protrusion and lateral mandibular excursion, no displacement of the mandible, and no pain in the temporomandibular joint region.

Radiographic follow-up showed that the coronoid process apparently united with the mandibular ascending ramus, with moderate dislocation and inclination posteriorly (Figures 5 and 6).

The treatment of coronoid process hyperplasia, which presents essentially a mechanical problem, is primarily surgical. In a coronoidectomy, the ascending ramus of the mandible is exposed as far as the top of the coronoid process, and then the temporalis muscle is detached from the coronoid. The entire coronoid process is removed. Change in muscle activity with detachment of the temporalis muscle and postoperative fibrosis with removal of the coronoid may lead to displacement of the mandible and the other disappointing results. (1,2) However, Gerbino, et al., (1) described five patients with coronoid process hyperplasia, who were successfully treated by coronoidotomy, and reported that this approach notably reduces the need for bone exposure and consequent surgical trauma compared to the coronoidectomy. Furthermore, this technique without removal of the coronoid process also reduces the organization of a postsurgical hematoma, with consequential fibrosis at the site of the operation. In the current patient, a simple coronoidotomy was performed intraorally by an osteotomy at the base of the coronoid process. The favorable outcome of the coronoidotomy in this case may have been because there is less postsectioned fibrosis with this procedure and because the sectioned part of the coronoid can position itself and consolidated posteriorly.

The coronoid process heals onto the mandibular ascending ramus in such a posterior position that it does not cause further obstruct jaw movement. This may occur because it is pushed during mouth opening by the action of the temporal muscle during the early postoperative period, when the patient is most motivated to do the correct exercises. We introduced a mouth-opening exerciser (HU-OS II) (4-6) for postoperative mouth-opening exercises in the current patient. The exerciser is made of a five mm thick acrylic resin plate and is wedge-shaped with a cut tip. The exerciser has three mm long stairs so that patients can notice improvement in mouth-opening during exercise. Every stair has an extremely gentle slope so that it permits gradual mouth opening without severe pain. In previous reports, the management after coronoidotomy is not described in detail. (1,2) Tieghi, et al., (3) reported on two cases that received postoperative mouth opening exercises with a dynamic device (Darcissac type). The device was used for 10 hours per day for 30 days. In those two cases, three months after surgery, the maximum mouth opening increased to 40 mm. In the present case, 30 days after surgery, the maximum mouth opening had increased to 40 mm. HU-OS II is easy to use and very effective for postoperative mouth opening exercises.

In conclusion, in the present case, an intraoral coronoidotomy with postoperative physiotherapy for treatment of coronoid process hyperplasia allowed satisfactory and stable results in the correction of coronoid-malar interference.

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Rabu, 17 Maret 2010


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