Carpal Tunnel Pain: Ottis Hamlet depends largely on the use of his hands to carry out his important craftsmanship in the city of San Antonio, TX. However, Mr. Hamlet developed painful symptoms in both of his arms as a result of carpal tunnel syndrome, which tremendously affected his ability to engage in his job. Fortunately, Ottis Hamlet met Dr. Alex Jimenez during a visit to El Paso, TX and he received chiropractic treatment for his carpal tunnel syndrome, avoiding the need for surgery.
Carpal tunnel syndrome is a medical condition caused by the compression of the median nerve which travels through the wrist and into the carpal tunnel. Common symptoms include pain, tingling sensations and numbness, in the thumb, index finger, middle finger, and the thumb side of the ring fingers. Symptoms normally start gradually and during the evening. Symptoms can extend throughout the arm and weakened grip strength may also occur. Carpal tunnel syndrome can be diagnosed based on symptoms.
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Stress is a result of the human body's "fight or flight" response, a prehistoric defense mechanism triggered by the sympathetic nervous system (SNS). Stress is an essential component of survival. When stressors activate the fight or flight response, a mixture of chemicals and hormones are secreted into the blood flow, which prepare the body for perceived danger. Although short-term stress is helpful, however, long-term stress can lead to a variety of health issues. Furthermore, stressors in modern society have changed and it's become more difficult for people to manage their stress and maintain mindfulness.
How Does Stress Affect the Body?
Stress can be experienced through three different channels: emotion; body and environment. Emotional stress involves adverse situations which affect our mind and decision making. Bodily stress includes improper nutrition and a lack of sleep. And finally, environmental stress occurs based on external experiences. When you experience any of these types of stressors, the sympathetic nervous system will trigger the "fight or flight" response, releasing adrenaline and cortisol to increase heart rate and heighten our senses to make us more alert in order to face the situation ahead of us.
However, if perceived stressors are always present, the SNS's fight or flight response can remain active. Chronic stress can then lead to a variety of health issues, such as anxiety, depression, muscle tension, neck and back pain, digestive problems, weight gain and sleep problems as well as impaired memory and concentration. In addition, muscle tension along the spine due to stress can cause a spinal misalignment, or subluxation, which may in turn lead to disc herniation.
Headache and Disc Herniation from Stress
A herniated disc occurs when the soft, gel-like center of an intervertebral disc pushes through a tear in its outer, cartilage ring, irritating and compressing the spinal cord and/or the nerve roots. Disc herniation commonly occurs in the cervical spine, or neck, and in the lumbar spine, or low back. Symptoms of herniated discs depend on the location of the compression along the spine. Neck pain and back pain accompanied by numbness, tingling sensations and weakness along the upper and lower extremities are some of the most common symptoms associated with disc herniation. Headache and migraine are also common symptoms associated with stress and herniated discs along the cervical spine, as a result of muscle tension and spinal misalignment.
Mindfulness Interventions for Stress Management
Stress management is essential towards improving as well as maintaining overall health and wellness. According to research studies, mindfulness interventions, such as chiropractic care and mindfulness-based stress reduction (MBSR), among others, can safely and effectively help reduce stress. Chiropractic care utilizes spinal adjustments and manual manipulations to carefully restore the original alignment of the spine, relieving pain and discomfort as well as easing muscle tension. Additionally, a chiropractor may include lifestyle modifications to help further improve symptoms of stress.�A balanced spine can help the nervous system respond to stress more effectively. MBSR can also help reduce stress, anxiety and depression.
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If you are experiencing symptoms of stress with headache or migraine as well as neck and back pain associated with disc herniation, mindfulness interventions such as chiropractic care can be a safe and effective treatment for your stress. Dr. Alex Jimenez's stress management services can help you achieve overall health and wellness. Seeking the proper mindfulness interventions can get you the relief you deserve. The purpose of the following article is to demonstrate the effects of mindfulness-based stress reduction in patients with tension headache. Don't just treat the symptoms, get to the source of the issue.
Effects of Mindfulness-Based Stress Reduction on Perceived Stress and Psychological Health in Patients with Tension Headache
Abstract
Background: Programs for improving health status of patients with illness related to pain, such as headache, are often still in their infancy. Mindfulness-based stress reduction (MBSR) is a new psychotherapy that appears to be effective in treating chronic pain and stress. This study evaluated efficacy of MBSR in treatment of perceived stress and mental health of client who has tension headache.
Materials and Methods: This study is a randomized clinical trial. Sixty patients with tension type headache according to the International Headache Classification Subcommittee were randomly assigned to the Treatment As Usual (TAU) group or experimental group (MBSR). The MBSR group received eight weekly classmates with 12-min sessions. The sessions were based on MBSR protocol. The Brief Symptom Inventory (BSI) and Perceived Stress Scale (PSS) were administered in the pre- and posttreatment period and at 3 months follow-up for both the groups.
Results: The mean of total score of the BSI (global severity index; GSI) in MBSR group was 1.63 � 0.56 before the intervention that was significantly reduced to 0.73 � 0.46 and 0.93 � 0.34 after the intervention and at the follow-up sessions, respectively (P < 0.001). In addition, the MBSR group showed lower scores in perceived stress in comparison with the control group at posttest evaluation. The mean of perceived stress before the intervention was 16.96 � 2.53 and was changed to 12.7 � 2.69 and 13.5 � 2.33 after the intervention and at the follow-up sessions, respectively (P < 0.001). On the other hand, the mean of GSI in the TAU group was 1.77 � 0.50 at pretest that was significantly reduced to 1.59 � 0.52 and 1.78 � 0.47 at posttest and follow-up, respectively (P < 0.001). Also, the mean of perceived stress in the TAU group at pretest was 15.9 � 2.86 and that was changed to 16.13 � 2.44 and 15.76 � 2.22 at posttest and follow-up, respectively (P < 0.001).
Conclusion: MBSR could reduce stress and improve general mental health in patients with tension headache.
Chiropractic care is an effective stress management treatment because it focuses on the spine, which is the base of the nervous system. Chiropractic utilizes spinal adjustments and manual manipulations to carefully restore the alignment of the spine in order to allow the body to naturally heal itself. A spinal misalignment, or subluxation, can create muscle tension along the spine and lead to a variety of health issues, including headache and migraine, as well as disc herniation and sciatica. Chiropractic care can also include lifestyle modifications, such as nutritional advice and exercise recommendations, to further enhance its effects. Mindfulness-based stress reduction can also effectively help with stress management and symptoms.
Introduction
Tension headache constitutes 90% of total headaches. About 3% of the population are suffering from chronic tension headache.[1] Tension headaches are often associated with lower quality of life and high levels of psychological discomforts.[2] In recent years, several meta-analyses evaluating the established pain treatments used today have shown that medical treatments, which may be effective in acute pain, are not effective with chronic pain and may, in fact, be causing further problems. Most of the pain treatments are designed for and useful for acute pain but if used in the long run may create more problems such as substance abuse and avoidance of important activities.[3] A common element in most of the pain treatments is that they emphasize on either avoiding pain or fighting to reduce pain. The pain in tension headache can be intolerable. Painkillers and pain management strategies can increase intolerance and sensitivity to pain. Therefore, the treatments that increase acceptance and tolerance to pain, especially chronic pain, are effective. Mindfulness-based stress reduction (MBSR) is a new psychotherapy that appears to be effective in improving physical performance and psychological well-being in patients with chronic pain.[4,5,6,7,8] In the past two decades, Kabat-Zinn et al. in the US successfully used mindfulness for the relief of pain and illness related to pain.[9] Recent studies on acceptance-based methods, such as mindfulness, show improved performance in patients with chronic pain. Mindfulness modulates the pain using nonelaborative awareness of thoughts, feelings and sensations, and an emotionally distanced relationship with internal and external experience.[10] Studies found that MBSR program can significantly alleviate medical illness related to chronic pains such as fibromyalgia, rheumatoid arthritis, chronic musculoskeletal pain, chronic low back pain, and multiple sclerosis.[7,11,12,13] MBSR has significant changes in pain intensity, anxiety, depression, somatic complaints, well-being, adaptation, quality of sleep, fatigue, and physical functioning.[6,14,15,16,17] But the programs for improving health status of patients with illness related to pain, such as tension headache, are often still in their infancy. Therefore, the study was conducted to assess the effects of MBSR on perceived stress and general mental health in patients with tension headache.
Materials and Methods
This randomized controlled clinical trial was performed in 2012 in Shahid Beheshti Hospital in Kashan City. The Research Ethics Committee of the Kashan University of Medical Sciences approved this study (IRCT No: 2014061618106N1). The participants of the study included adults with tension headache who were referred by the psychiatrists and neurologists in Kashan. The inclusion criteria were as follows: Having tension headache according to the International Headache Classification Subcommittee, willing to participate in the study, not having a medical diagnosis of organic brain disorder or psychotic disorder, and not having a history of psychological treatment during the preceding 6 months. The patients who did not complete the intervention and missed more than two sessions were excluded from the study. The participants, who signed an informed consent form, completed the measures as a pretest. For estimating the sample size, we referred to another study in which changes in mean of scores of fatigue was 62 � 9.5 in the pretreatment period and 54.5 � 11.5 in the posttreatment period.[18] Then, by utilizing the sample size calculation, 33 participants (with attrition risk) in each group with ? = 0.95 and 1 � ? = 0.9 were segregated. After sample size calculation, 66 patients with tension headache were selected via convenient sampling according to the inclusion criteria. Then, the patients were called and invited to participate in the study. If a patient agreed to participate, then he/she was invited to attend the study-briefing session and if not another patient was selected similarly. Then using a random number table, they were assigned either to the experimental group (MBSR) or to the control group that treated as usual. Finally, 3 patients were excluded from each group and 60 patients were included (30 patients in each group). The TAU group was treated only by antidepressant medication and clinical management. The MBSR group received MBSR training in addition to TAU. The patients in MBSR group were trained for 8 weeks by a clinical psychologist with PhD degree. The Brief Symptom Inventory (BSI) and Perceived Stress Scale (PSS) were administered before the first treatment session in the MBSR group, after the eighth session (posttest), and 3 months after the test (follow-up) in both groups. The TAU group was invited to Shahid Beheshti Hospital to fill out the questionnaires. Figure 1 shows a Consolidated Standards of Reporting Trials (CONSORT) diagram depicting the flow of study participants.
Figure 1: CONSORT diagram depicting flow of study participants.
Intervention
The intervention group (MBSR) was trained in Shahid Beheshti Hospital. The eight weekly sessions (120 min) were held according to the standard MBSR protocol as developed by Kabat-Zinn.[11] Additional sessions were held for the participants who had missed one or two sessions. At the end of the training and 3 months later (follow-up), both MBSR and TAU groups were invited to Shahid Beheshti Hospital (the place of MBSR trial) and were instructed to complete the questionnaires. During the MBSR sessions, the participants were trained to be aware of their thoughts, feelings, and physical sensations nonjudgmentally. Mindfulness exercises are taught as two forms of meditation practices � formal and informal. Formal type exercises include trained sitting meditation, body scan, and mindful yoga. In informal meditation, attention and awareness are focused not only on daily activities, but also on thoughts, feelings, and physical sensation even they are problematic and painful. The overall content of the sessions were mentioned in Table 1.
Table 1: Agendas for sessions of mindfulness-based stress reduction.
Measurement Tools
International Headache Classification Subcommittee Diary Scale for Headache
Headache was measured by diary scale for headache.[19] The patients were asked to record the pain severity diary on a 0-10 rating scale. Absence of pain and the most intense disabling headache were characterized by 0 and 10, respectively. The mean of headache severity in a week was calculated by dividing the sum of the severity scores by 7. Moreover, the mean of headache severity in a month was calculated by dividing the sum of the severity scores by 30. The minimum and maximum scores of headache severity were 0 and 10, respectively. Headache diary was given to five patients and a neurologist and a psychiatrist confirmed the content validity of the instrument.[20] The reliability coefficient of Persian version of this scale was calculated as 0.88.[20]
Brief symptom Inventory (BSI)
Psychological symptoms were assessed with the BSI.[21] The inventory consist 53 items and 9 subscales that assess psychological symptoms. Each item scores between 0 and 4 (for example: I have nausea or upset in my stomach). BSI has a global severity index (GSI) achieved a total score of 53 items. The reliability of the test has reported a score of 0.89.[22] In our study, GSI test�retest estimate was .90 based on a sample of 60 patients with tension headache who completed the BSI.
Perceived Stress Scale (PSS)
Perceived stress was assessed using the PSS,[21,23] a 10-item scale that assesses the degree of uncontrollable and unpredictable situations of life during the past month (for example: Felt that you were unable to control the important things in your life?). Respondents report the prevalence of an item within the last month on a 5-point scale, ranging from 0 (never) to 4 (very often). Scoring is completed by reverse scoring of four positively worded items[4,5,7,8] and summing all item scores. The scale scores range from 0-40. Higher scores indicate higher levels of stress. It assumes that people depending on their coping resources evaluate level of threatening or challenging events. A higher score indicates a greater degree of perceived stress. Adequate test�retest reliability and convergent and discriminate validity have also been reported.[19] In our study, Cronbach's alpha coefficients for assessing internal consistency of this scale were calculated to be 0.88.
The repeated measures analysis of variance was performed to compare the MBSR and TAU groups on measures of perceived stress and GSI at pretreatment, posttreatment, and 3-month follow-up. Also, Chi-square test was used to compare the demographics in the two groups. P value less than 0.05 was considered significant in all tests.
Results
Among 66 subjects, 2 participants from the MBSR group were excluded because of missing more than 2 sessions. Also, three participants were excluded because of did not complete the questionnaires in post-test or follow-up who one of them were from MBSR group and three participants from TAU group. Table 2 showed demographic characteristics of the subjects and results of the randomization check. The results of t-test for differences between the MBSR and TAU groups in age variable and Chi-square test in other variables showed that there was no significant difference between demographic variables in two groups and the subjects were randomly assigned to two groups.
Table 2: Demographic characteristics of the subjects a,b.
Table 3 provides the mean scores and standard deviations of the dependent variables (perceived stress and GSI) and comparison of outcome measures at pretreatment period, post-treatment period, and 3-month follow-up.
Table 3: Means, standard deviations, and comparison of outcome measures at pretreatment, posttreatment, and follow-up stages in the MBSR and TAU groups a,b.
Table 3 shows the more reduction in received stress and GSI in the intervention group (MBSR) compared to TAU group, while the reduction in received stress and GSI were not observed in the TAU group. The results revealed the significant effect of time and interaction between time and type of treatment on the changes of scores (P < 0.001).
Figures ?2 and ?3 present mean received stress and GSI scores for MBSR and TAU groups at posttest and follow-up stages.
Figure 2: CONSORT diagram depicting flow of study participants.
Figure 3: Mean of perceived stress in MBSR and control groups in pretest, posttest, and follow-up.
Discussion
This study compared efficacy of MBSR and Treatment As Usual (TAU) in perceived stress and mental health of patients with tension headache. Although MBSR is recognized as an effective treatment for stress symptoms and pain, there is a need to examine its efficacy for the treatment of mental health problems in patients with tension headache, which is one of the common complaints in the population.
The findings of our study demonstrate enhanced general mental health in the GSI index of BSI. In some study, significant improvements by MBSR intervention were reported on all indexes of the 36-item Short Form Health Survey (SF-36).[20,24] Studies showed significant reduction in psychological problems in the Symptom Checklist-90-Revised (SCL-90-R) subscale such as anxiety and depression by MBSR after intervention and 1-year follow-up.[5] Reibel et al. showed MBSR in patients with chronic pain reported a decrease in medical symptoms such as anxiety, depression, and pain.[5] It has been shown that tension headache and anxiety are accompanied with deficits in controlled cognitive processing such as sustained attention and working memory.[25] Negative emotions may amplify suffering associated with pain perception.
MBSR implements the following mechanisms to improve the patient's mental status: First, mindfulness leads to increased awareness for what is happening in each moment, with an accepting attitude, without getting caught up in habitual thoughts, emotions, and behavior patterns. The increased awareness then gives rise to new ways to respond and cope in relation to oneself and the world around.[3] Mindfulness establishes a sense of self that is greater than one's thoughts, feelings, and bodily sensation such as pain. Mindfulness exercises, learned clients develop an �observer�self�. With this ability, they can observe their thoughts and feelings in a nonreactive and nonjudgmental way that previously avoided, that previously avoided thoughts and feelings be observed in a nonreactive and nonjudgmental way. The clients learn to notice thoughts without necessarily acting on them, being controlled by them, or believing them.[3]
Second, mindfulness helps the client develop persistence in taking steps in valued directions that are important to them. Most clients with chronic pain want to become pain free rather than living the vital lives of their choice. But the MBSR program trained them to engage in valued action despite the the pain. Studies have shown attention and emotional reaction to pain has an important role in becoming persistent the pain.[26] Emotional and cognitive components can modulate attention to pain and worry about it that could intensify pain and disrupt the patients activities.[27,28]
Third, findings from some studies indicate that MBSR can alter the function of the brain that is responsible for affect regulation and the areas that govern how we react to stressful impulses, and this in turn may normalize body functions such as breathing, heart rate, and immune function.[29,30] Mindfulness practice reduces reactivity to distressing thoughts and feelings that comorbid and strengthen pain perception.[31] Also mindfulness may lessen psychophysiological activation related to stress and mood dysfunction by strengthening positive reappraisal and emotion regulation skills.[32]
The strength of this study is the use of a new effective psychotherapy in reducing the stress on a complaint that is less studied, but it is a common medical problem. The implications of our study are using a simple psychotherapy that does not make too much cognitive demand and is readily usable as a coping skill for the patient with tension headache. Therefore, the health-care professionals related to this complaint and the patient will be able to use this treatment. Also, MBSR will change the patient's lifestyle who would be exacerbated by his/her problem. The main limitation of this study was the lack of comparison between MBSR and the gold standard psychotherapies such as cognitive behavior therapy (CBT). It is suggested that future studies need to compare the efficacy of MBSR and other traditional and newer cognitive behavioral therapies in patients with tension headache.
Conclusion
Our study supports the hypothesis that patients suffering from tension headache can enhance their general mental health by participating in the MBSR program. In summary, the results of the present study suggest that MBSR can reduce pain-related anxiety and interference in daily activities in the short term. The unique features of mindfulness exercises are easy training and no need to complex cognitive abilities.
Financial support and sponsorship: Nil.
Conflicts of interest: There are no conflicts of interest.
Author's Contribution
AO contributed in the conception of the work, conducting the study, and agreed for all aspects of the work. FZ contributed in the conception of the work, revising the draft, approval of the final version of the manuscript and agreed for all aspects of the work.
Acknowledgments
Authors are grateful to the staff of Shahid Beheshti Hospital and participants. Authors also express their gratitude to Kabat-Zinn from the Center for Mindfulness (CFM) at the University of Massachusetts who graciously provided electronic copies of the MBSR guidelines.
In conclusion,�while short-term stress is helpful, long-term stress can eventually lead to a variety of health issues, including anxiety and depression as well as neck and back pain, headache and disc herniation. Fortunately, mindfulness interventions, such as chiropractic care and mindfulness-based stress reduction (MBSR) are safe and effective stress management alternative treatment options. Finally, the article above demonstrated evidence-based results that MBSR could reduce stress and improve general mental health in patients with tension headache. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Back Pain
According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.
1.�Trkanjec Z, Aleksic-Shihabi A. Tension-type headaches.�Acta Med Croatica.�2008;62:205�10.[PubMed]
2.�Zirke N, Seydel C, Szczepek AJ, Olze H, Haupt H, Mazurek B. Psychological comorbidity in patients with chronic tinnitus: Analysis and comparison with chronic pain, asthma or atopic dermatitis patients.�Qual Life Res.�2013;22:263�72.�[PubMed]
3.�Dionne F, Blais MC, Monestes JL. Acceptance and commitment therapy in the treatment of chronic pain.�Sante Ment Que.�2013;38:131�52.�[PubMed]
4.�Cathcart S, Galatis N, Immink M, Proeve M, Petkov J. Brief mindfulness-based therapy for chronic tension-type headache: A randomized controlled pilot study.�Behav Cogn Psychother.�2013;42:1�15.[PubMed]
5.�Reibel DK, Greeson JM, Brainard GC, Rosenzweig S. Mindfulness-based stress reduction and health-related quality of life in a heterogeneous patient population.�Gen Hosp Psychiatry.�2001;23:183�92.[PubMed]
6.�Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis.�J Psychosom Res.�2004;57:35�43.�[PubMed]
7.�Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley D. Mindfulness-based stress reduction for chronic pain conditions: Variation in treatment outcomes and role of home meditation practice.�J Psychosom Res.�2010;68:29�36.�[PubMed]
8.�Kerrigan D, Johnson K, Stewart M, Magyari T, Hutton N, Ellen JM, et al. Perceptions, experiences, and shifts in perspective occurring among urban youth participating in a mindfulness-based stress reduction program.�Complement Ther Clin Pract.�2011;17:96�101.�[PubMed]
9.�Kabat-Zinn J. New York: Dell Publishing; 1990. Full Catastrophe Living; p. 185.
10.�Hayes AM, Feldman G. Clarifying the construct of mindfulness in the context of emotion regulation and the process of change in therapy.�Clin Psychol-Sci Pr.�2004:255�62.
11.�Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. Treating fibromyalgia with mindfulness-based stress reduction: Results from a 3-armed randomized controlled trial.�Pain.�2011;152:361�9.�[PubMed]
12.�Pradhan EK, Baumgarten M, Langenberg P, Handwerger B, Gilpin AK, Magyari T, et al. Effect of Mindfulness-Based Stress Reduction in rheumatoid arthritis patients.�Arthritis Rheum.�2007;57:1134�42.[PubMed]
13.�Cramer H, Haller H, Lauche R, Dobos G. Mindfulness-based stress reduction for low back pain. A systematic review.�BMC Complement Altern Med.�2012;12:162.�[PMC free article]�[PubMed]
14.�Bazarko D, Cate RA, Azocar F, Kreitzer MJ. The impact of an innovative mindfulness-based stress reduction program on the health and well-being of nurses employed in a corporate setting.�J Workplace Behav Health.�2013;28:107�33.�[PMC free article]�[PubMed]
15.�Carlson LE, Garland SN. Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients.�Int J Behav Med.�2005;12:278�85.�[PubMed]
16.�Lengacher CA, Kip KE, Barta M, Post-White J, Jacobsen PB, Groer M, et al. A pilot study evaluating the effect of mindfulness-based stress reduction on psychological status, physical status, salivary cortisol, and interleukin-6 among advanced-stage cancer patients and their caregivers.�J Holist Nurs.�2012;30:170�85.�[PubMed]
17.�Simpson J, Mapel T. An investigation into the health benefits of mindfulness-based stress reduction (MBSR) for people living with a range of chronic physical illnesses in New Zealand.�N Z Med J.�2011;124:68�75.�[PubMed]
18.�Omidi A, Mohammadi A, Zargar F, Akbari H. Efficacy of mindfulness-based stress reduction on mood States of veterans with post-traumatic stress disorder.�Arch Trauma Res.�2013;1:151�4.�[PMC free article][PubMed]
19.�Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress.�J Health Soc Behav.�1983;24:385�96.�[PubMed]
20.�Roth B, Robbins D. Mindfulness-based stress reduction and health-related quality of life: Findings from a bilingual inner-city patient population.�Psychosom Med.�2004;66:113�23.�[PubMed]
21.�Brown KW, Ryan RM. The benefits of being present: Mindfulness and its role in psychological well-being.�J Pers Soc Psychol.�2003;84:822�48.�[PubMed]
22.�Astin JA, Shapiro SL, Lee RA, Shapiro DH., Jr The construct of control in mind-body medicine: Implications for healthcare.�Altern Ther Health Med.�1999;5:42�7.�[PubMed]
23.�Cohen S, Williamson G. Perceived stress in a probability sample of the United States. In: Spacapan S, Oskamp S, editors.�The Social Psychology of Health.�Newbury Park, CA: Sage; 1988. p. 185.
24.�Geary C, Rosenthal SL. Sustained impact of MBSR on stress, well-being, and daily spiritual experiences for 1 year in academic health care employees.�J Altern Complement Med.�2011;17:939�44.[PubMed]
25.�Dick BD, Rashiq S, Verrier MJ, Ohinmaa A, Zhang J. Symptom burden, medication detriment, and support for the use of the 15D health-related quality of life instrument in a chronic pain clinic population.�Pain Res Treat 2011.�2011:809071.�[PMC free article]�[PubMed]
26.�McCabe C, Lewis J, Shenker N, Hall J, Cohen H, Blake D. Don�t look now! Pain and attention.�Clin Med.�2005;5:482�6.�[PMC free article]�[PubMed]
27.�Bener A, Verjee M, Dafeeah EE, Falah O, Al-Juhaishi T, Schlogl J, et al. Psychological factors: Anxiety, depression, and somatization symptoms in low back pain patients.�J Pain Res.�2013;6:95�101.[PMC free article]�[PubMed]
28.�Lee JE, Watson D, Frey-Law LA. Psychological factors predict local and referred experimental muscle pain: A cluster analysis in healthy adults.�Eur J Pain.�2013;17:903�15.�[PMC free article]�[PubMed]
29.�Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, et al. Alterations in brain and immune function produced by mindfulness meditation.�Psychosom Med.�2003;65:564�70.[PubMed]
30.�Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, et al. Meditation experience is associated with increased cortical thickness.�Neuroreport.�2005;16:1893�7.�[PMC free article]�[PubMed]
31.�McCracken LM, Jones R. Treatment for chronic pain for adults in the seventh and eighth decades of life: A preliminary study of Acceptance and Commitment Therapy (ACT)�Pain Med.�2012;13:860�7.[PubMed]
32.�McCracken LM, Guti�rrez-Mart�nez O. Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy.�Behav Res Ther.�2011;49:267�74.�[PubMed]
Chiropractic Benefits: Curvature of the spine, even slight, can cause pain and postural problems. When the curve is more than 10 degrees, it is considered to be scoliosis.
The primary symptom of scoliosis is a significant curvature of the spine and is the majority of cases the cause is not known. Even mild cases can cause pain and a decrease in mobility.
In more advanced cases the effects of the condition are more pronounced. Chiropractic has been a regular course of therapy for many scoliosis patients and recent studies provide even more evidence that it is highly effective and that there are many benefits to using it as a treatment.
Chiropractic Benefits
Detection Of Scoliosis In Early Stages
Typically, slight curvatures in the spine are ignored in traditional medicine. Many times scoliosis is not diagnosed until the curvature presents significant distortion, pain, or indications of structural destruction.
Chiropractic treatment enables early detection by identifying minor degrees of curvature or distortion. This essentially has the probability of detecting scoliosis at an early enough stage to halt progression of the condition or treat it before the symptoms negatively impact the patient�s mobility or quality of life.
Relieve Pain And Mobility Caused by Scoliosis
Pain and mobility can be debilitating for the scoliosis patient. While there is no solid evidence at this time that supports chiropractic as a cure for significant scoliosis but it also has not been shown to worsen the curvatures either. However, adjustments of the spine through chiropractic treatment, both pain and mobility have been shone to improve.
Studies are currently being conducted and some recent research suggests that chiropractic can significantly improve the pain and mobility caused by scoliosis, as well as help with other symptoms the patient may have.
Improvement In Cobb Angle
Cobb angle is a term used to describe the degree of spinal deformities a patient experiences. It is broadly used to describe spinal damage due to injury or disease, but it is also commonly used to describe the curvature of a scoliosis patient�s spine. This measurement is used to track progression of the condition and determine what therapies or treatments are required.
In a study published in September 2011, 28 patients were evaluated and monitored in two clinics in Michigan. All patients, ranging from age 18 to 54, had been diagnosed with scoliosis. The study involved exposing the subjects to regular, consistent multimodal chiropractic rehabilitation treatment over a period of time. Once their treatment cycle was complete, the patients were monitored or a period of 24 months.
At the conclusion of the study, the patients reported improvement in pain and mobility. Additionally, the Cobb angle of each patient as well as the level of disability improved during the treatments and at the conclusion of the treatment cycle. What was most remarkable, though, was that in the subsequent follow ups, even at the end of the study 24 months later, the patients were still reporting these improvements.
Current Studies
Charles A Lantz, D.C., Ph.D. of the Life Chiropractic College West in San Lorenzo, California, where he is the Director of Research, is currently involved in a research project studying the effectiveness of chiropractic for scoliosis in children. The subjects range from 9 years old to 15 years old and have been diagnosed with scoliosis at a mild to moderate level (curve is less than 25).
Lantz embarked on this project to answer a need for more research on the topic. Currently, there are few formal research endeavors regarding scoliosis and chiropractic as an effective treatment. In 1994, Lantz published an article in the October issue of Chiropractic: The Journal of Chiropractic: Research and Clinical Investigation, Volume 9, Number 4. The article, titled Conservative Management of Scoliosis, stressed Lantz�s observation that more clinical trials are needed to be conducted for adults as well as adolescents with scoliosis to study and measure how chiropractic benefits scoliosis.
Being involved in an automobile accident is an undesirable situation which can result in a variety of physical trauma or injury as well as lead to the development of a number of aggravating conditions. Auto accident injuries, such as whiplash, can be characterized by painful symptoms, including chronic neck pain, however, recent research studies have found that emotional distress resulting from an auto collision could manifest into physical symptoms. Stress, anxiety, depression and post traumatic stress disorder, or PTSD, are common psychological issues which may occur as a result of an automobile accident.
The researchers of the research studies also determined that cognitive-behavioral therapy may be an effective treatment for emotional distress and psychological issues which may have developed as a result of the auto accident injuries. Additionally, auto accident injuries may also cause stress, anxiety, depression and even PTSD if left untreated for an extended amount of time. The purpose of the article below is to demonstrate the effects of cognitive-behavioral therapy, together with alternative treatment options like chiropractic care and physical therapy. for auto accident injuries, such as whiplash.
Neck Exercises, Physical and Cognitive Behavioural-Graded Activity as a Treatment for Adult Whiplash Patients with Chronic Neck Pain: Design of a Randomised Controlled Trial
Abstract
Background
Many patients suffer from chronic neck pain following a whiplash injury. A combination of cognitive, behavioural therapy with physiotherapy interventions has been indicated to be effective in the management of patients with chronic whiplash-associated disorders. The objective is to present the design of a randomised controlled trial (RCT) aimed at evaluating the effectiveness of a combined individual physical and cognitive behavioural-graded activity program on self-reported general physical function, in addition to neck function, pain, disability and quality of life in patients with chronic neck pain following whiplash injury compared with a matched control group measured at baseline and 4 and 12 months after baseline.
Methods/Design
The design is a two-centre, RCT-study with a parallel group design. Included are whiplash patients with chronic neck pain for more than 6 months, recruited from physiotherapy clinics and an out-patient hospital department in Denmark. Patients will be randomised to either a pain management (control) group or a combined pain management and training (intervention)group. The control group will receive four educational sessions on pain management, whereas the intervention group will receive the same educational sessions on pain management plus 8 individual training sessions for 4 months, including guidance in specific neck exercises and an aerobic training programme. Patients and physiotherapists are aware of the allocation and the treatment, while outcome assessors and data analysts are blinded. The primary outcome measures will be Medical Outcomes Study Short Form 36 (SF36), Physical Component Summary (PCS). Secondary outcomes will be Global Perceived Effect (-5 to +5), Neck Disability Index (0-50), Patient Specific Functioning Scale (0-10), numeric rating scale for pain bothersomeness (0-10), SF-36 Mental Component Summary (MCS), TAMPA scale of Kinesiophobia (17-68), Impact of Event Scale (0-45), EuroQol (0-1), craniocervical flexion test (22 mmHg - 30 mmHg), joint position error test and cervical range of movement. The SF36 scales are scored using norm-based methods with PCS and MCS having a mean score of 50 with a standard deviation of 10.
Discussion
The perspectives of this study are discussed, in addition to the strengths and weaknesses.
The Danish National Board of Health estimates that 5-6,000 subjects per year in Denmark are involved in a traffic accident evoking whiplash-induced neck pain. About 43% of those will still have physical impairment and symptoms 6 months after the accident [1]. For Swedish society, including Swedish insurance companies, the economic burden is approximately 320 million Euros [2], and this burden is likely to be comparable to that of Denmark. Most studies suggest that patients with Whiplash-Associated Disorders (WAD) report chronic neck symptoms one year after the injury [3]. The main problems in whiplash patients with chronic neck pain are cervical dysfunction and abnormal sensory processing, reduced neck mobility and stability, impaired cervicocephalic kinaesthetic sense, in addition to local and possibly generalised pain [4,5]. Cervical dysfunction is characterised by reduced function of the deep stabilising muscles of the neck.
Besides chronic neck pain, patients with WAD may suffer from physical inactivity as a consequence of prolonged pain [6,7]. This influences physical function and general health and can result in a poor quality of life. In addition, WAD patients may develop chronic pain followed by sensitisation of the nervous system [8,9], a lowering of the threshold for different sensory inputs (pressure, cold, warm, vibration and electrical impulses) [10]. This can be caused by an impaired central pain inhibition [11] - a cortical reorganisation [12]. Besides central sensitisation, the group with WAD may have poorer coping strategies and cognitive functions, compared with patients with chronic neck pain in general [13-15].
Studies have shown that physical training, including specific exercises targeting the deep postural muscles of the cervical spine, is effective in reducing neck pain [16-18] for patients with chronic neck pain, albeit there is a variability in the response to training with not every patient showing a major change. Physical behavioural-graded activity is a treatment approach with a focus on increasing general physical fitness, reducing fear of movement and increasing psychological function [19,20]. There is insufficient evidence for the long-term effect of treatment of physical and cognitive behavioural-graded activity, especially in chronic neck pain patients. Educational sessions, where the focus is on understanding complex chronic pain mechanisms and development of appropriate pain coping and/or cognitive behavioural strategies, have shown reduced general pain [6,21-26]. A review indicated that interventions with a combination of cognitive, behavioural therapy with physiotherapy including neck exercises is effective in the management of WAD patients with chronic neck pain [27], as also recommended by the Dutch clinical guidelines for WAD [28]. However, the conclusions regarding the guidelines are largely based on studies performed on patients with either acute or sub-acute WAD [29]. A more strict conclusion was drawn for WAD patients with chronic pain in the Bone and Joint Decade 2000-2010 Task Force, stating, that 'because of conflicting evidence and few high-quality studies, no firm conclusions could be drawn about the most effective non-invasive interventions for patients with chronic WAD" [29,30]. The concept of combined treatment for WAD patients with chronic pain has been used in a former randomised controlled trial [31]. The results indicated that a combination of non-specific aerobic exercises and advice containing standardised pain education and reassurance and encouragement to resume light activity, produced better outcomes than advice alone for patients with WAD 3 months after the accident. The patients showed improvements in pain intensity, pain bothersomeness and functions in daily activities in the group receiving exercise and advice, compared with advice alone. However, the improvements were small and only apparent in the short term.
This project is formulated on the expectation that rehabilitation of WAD patients with chronic neck pain must target cervical dysfunctions, training of physical function and the understanding and management of chronic pain in a combined therapy approach. Each single intervention is based upon former studies that have shown effectiveness [6,18,20,32]. This study is the first to also include the long-term effect of the combined approach in patients with chronic neck pain after whiplash trauma. As illustrated in Figure ?Figure1,1, the conceptual model in this study is based upon the hypothesis that training (including both individually-guided specific neck exercises and graded aerobic training) and education in pain management (based on a cognitive behavioural approach) is better for increasing the patients' physical quality of life, compared with education in pain management alone. Increasing the physical quality of life includes increasing the general physical function and level of physical activity, decreasing fear of movement, reducing post-traumatic stress symptoms, reducing neck pain and increasing neck function. The effect is anticipated to be found immediately after the treatment (i.e. 4 months; short-term effect) as well as after one year (long-term effect).
Figure 1: Hypothesis of the intervention effect for patients with chronic neck pain after a whiplash accident.
Using a randomised controlled trial (RCT) design, the aim of this study is to evaluate the effectiveness of: graded physical training, including specific neck exercises and general aerobic training, combined with education in pain management (based on a cognitive behavioural approach) versus education in pain management (based on a cognitive behavioural approach), measured on physical quality of life', physical function, neck pain and neck functions, fear of movement, post-traumatic symptoms and mental quality of life, in patients with chronic neck pain after whiplash injury.
Methods/Design
Trial Design
The study is conducted in Denmark as an RCT with a parallel group design. It will be a two-centre study, stratified by recruitment location. Patients will be randomised to either the Pain Management group (control) or the Pain Management and Training group (intervention). As illustrated in Figure ?Figure2,2, the study is designed to include a secondary data assessment 12 months after baseline; the primary outcome assessment will be performed immediately after the intervention program 4 months after baseline. The study utilises an allocation concealment process, ensuring that the group to which the patient is allocated is not known before the patient is entered into the study. The outcome assessors and data analysts will be kept blinded to the allocation to intervention or control group.
Figure 2: Flowchart of the patients in the study.
Settings
The participants will be recruited from physiotherapy clinics in Denmark and from The Spine Centre of Southern Denmark, Hospital Lilleb�lt via an announcement at the clinics and the Hospital. Using physiotherapy clinics spread across Denmark, the patients will receive the intervention locally. The physiotherapy clinics in Denmark receive patients via referral from their general practitioners. The Spine Centre, a unit specialising in treating patients with musculoskeletal dysfunctions and only treating out-patients, receives patients referred from general practitioners and/or chiropractors.
Study Population
Two hundred adults with a minimum age of 18 years, receiving physiotherapy treatment or having been referred for physiotherapy treatment will be recruited. For patients to be eligible, they must have: chronic neck pain for at least 6 months following a whiplash injury, reduced physical neck function (Neck Disability Index score, NDI, of a minimum of 10), pain primarily in the neck region, finished any medical /radiological examinations, the ability to read and understand Danish and the ability to participate in the exercise program. The exclusion criteria include: neuropathies/ radiculopathies (clinically tested by: positive Spurling, cervical traction and plexus brachialis tests) [33], neurological deficits (tested as in normal clinical practice through a process of examining for unknown pathology), engagement in experimental medical treatment, being in an unstable social and/or working situation, pregnancy, known fractures, depression according to the Beck Depression Index (score > 29) [18,34,35], or other known coexisting medical conditions which could severely restrict participation in the exercise program. The participants will be asked not to seek other physiotherapy or cognitive treatment during the study period.
Intervention
Control
The Pain Management (control) group will receive education in pain management strategies. There will be 4 sessions of 11/2 hours, covering topics regarding pain mechanisms, acceptance of pain, coping strategies, and goal-setting, based upon pain management and cognitive therapy concepts [21,26,36].
Intervention
The Pain Management plus Training (intervention) group will receive the same education in pain management as those in the control group plus 8 treatment sessions (instruction in neck exercises and aerobic training) with the same period of 4 months length. If the treating physiotherapist estimates additional treatments are needed, the treatment can be extended with 2 more sessions. Neck training: The treatment of neck-specific exercises will be progressed through different phases, which are defined by set levels of neck function. At the first treatment session, patients are tested for cervical neuromuscular function to identify the specific level at which to start neck training. A specific individually tailored exercise program will be used to target the neck flexor and extensor muscles. The ability to activate the deep cervical neck flexor muscles of the upper cervical region to increase their strength, endurance and stability function is trained progressively via the craniocervical training method using a biopressure feedback transducer [18,37]. Exercises for neck-eye coordination, neck joint positioning, balance and endurance training of the neck muscles will be included as well, since it has been shown to reduce pain and improve sensorimotor control in patients with insidious neck pain [17,38]. Aerobic training: The large trunk and leg muscles will be trained with a gradually increasing physical training program. Patients will be allowed to select activities such as walking, cycling, stick walking, swimming, and jogging. The baseline for training duration is set by exercising 3 times at a comfortable level, that does not exacerbate pain and aims at a rated perceived exertion (RPE) level of between 11 and 14 on a Borg scale [39]. The initial duration of training is set 20% below the average time of the three trials. Training sessions are carried out every second day with a prerequisite that pain is not worsened, and that RPE is between 9 and 14. A training diary is used. If patients do not experience a relapse, and report an average RPE value of 14 or less, the exercise duration for the following period (1 or 2 weeks) is increased by 2-5 minutes, up to a maximum of 30 minutes. If the RPE level is 15 or higher, the exercise duration will be reduced to an average RPE score of 11 to 14 every fortnight [20,40]. By using these pacing principles, the training will be graded individually by the patient, with a focus on perceived exertion - with the aim of increasing the patient' s general physical activity level and fitness.
Patients' compliance will be administered by registration of their participation in the control and intervention group. The patients in the control group will be considered to have completed the pain management if they have attended 3 out of 4 sessions. The patiesnts in the intervention group will be considered to have completed if the patient has attended a minimum of 3 out of 4 pain management sessions and a minimum of 5 out of 8 trainings sessions. Each patient's home training with neck exercises and aerobic training will be registered by him/her in a logbook. Compliance with 75% of the planned home training will be considered as having completed the intervention.
Physiotherapists
The participating physiotherapists will be recruited via an announcement in the Danish Physiotherapy Journal. The inclusion criteria consist of: being a qualified physiotherapist, working at a clinic and having at least two years of working experience as a physiotherapist, having attended a course in the described intervention and passed the related exam.
Outcome Measures
At baseline the participants' information on age, gender, height and weight, type of accident, medication, development of symptoms over the last two months (status quo, improving, worsening), expectation of treatment, employment and educational status will be registered. As a primary outcome measure, Medical Outcomes Study Short Form 36 (SF36) - Physical Component Summary (PCS) will be used [41,42]. The PCS scales are scored using norm-based methods [43,44] with a mean score of 50 with a standard deviation of 10. The primary outcome with respect to having an effect, will be calculated as a change from baseline [45]. Secondary outcomes contain data on both clinical tests and patient-reported outcomes. Table ?Table11 presents clinical tests for measuring the intervention effect on neuromuscular control of the cervical muscles, cervical function and mechanical allodynia. Table ?Table22 presents the patient-related outcomes from questionnaires used to test for perceived effect of the treatment, neck pain and function, pain bothersomeness, fear of movement, post-traumatic stress and quality of life and potential treatment modifiers.
Table 1: Clinical outcomes used for measurement of treatment effect on muscle strategy, function and treatment modifiers.
Table 2: Patient reported outcomes used for measured of treatment effect on pain and function.
Patients will be tested at baseline, 4 and 12 months after baseline, except for GPE, which will only be measured 4 and 12 months after baseline.
Power and Sample Size Estimation
The power and sample size calculation is based on the primary outcome, being SF36-PCS 4 months after baseline. For a two-sample pooled t-test of a normal mean difference with a two-sided significance level of 0.05, assuming a common SD of 10, a sample size of 86 per group is required to obtain a power of at least 90% to detect a group mean difference of 5 PCS points [45]; the actual power is 90.3%, and the fractional sample size that achieves a power of exactly 90% is 85.03 per group. In order to adjust for an estimated 15% withdrawal during the study period of 4 months, we will include 100 patients in each group. For sensitivity, three scenarios were applied: firstly, anticipating that all 2 � 100 patients complete the trial, we will have sufficient power (> 80%) to detect a group mean difference as low as 4 PCS points; secondly, we will be able to detect a statistically significant group mean difference of 5 PCS points with sufficient power (> 80%) even with a pooled SD of 12 PCS points. Thirdly and finally, if we aim for a group mean difference of 5 PCS points, with a pooled SD of 10, we will have sufficient power (> 80%) with only 64 patients in each group. However, for logistical reasons, new patients will no longer be included in the study 24 months after the first patient has been included.
Randomisation, Allocation and Blinding Procedures
After the baseline assessment, the participants are randomly assigned to either the control group or the intervention group. The randomisation sequence is created using SAS (SAS 9.2 TS level 1 M0) statistical software and is stratified by centre with a 1:1 allocation using random block sizes of 2, 4, and 6. The allocation sequence will be concealed from the researcher enrolling and assessing participants in sequentially numbered, opaque, sealed and stapled envelopes. Aluminium foil inside the envelope will be used to render the envelope impermeable to intense light. After revealing the content of the envelope, both patients and physiotherapists are aware of the allocation and the corresponding treatment. Outcome assessors and data analysts are however kept blinded. Prior to the outcome assessments, the patients will be asked by the research assistant not to mention the treatment to which they have been allocated.
Statistical Analysis
All the primary data analyses will be carried out according to a pre-established analysis plan; all analyses will be done applying SAS software (v. 9.2 Service Pack 4; SAS Institute Inc., Cary, NC, USA). All descriptive statistics and tests are reported in accordance with the recommendations of the 'Enhancing the QUAlity and Transparency Of health Research' (EQUATOR) network; i.e., various forms of the CONSORT statement [46]. Data will be analysed using a two-factor Analysis of Covariance (ANCOVA), with a factor for Group and a factor for Gender, using the baseline value as covariate to reduce the random variation, and increase the statistical power. Unless stated otherwise, results will be expressed as the difference between the group means with 95% confidence intervals (CIs) and associated p-values, based on a General Linear Model (GLM) procedure. All the analyses will be performed using the Statistical Package for Social Sciences (version 19.0.0, IBM, USA) as well as the SAS system (v. 9.2; SAS Institute Inc., Cary, NC, USA). A two-way analysis of variance (ANOVA) with repeated measures (Mixed model) will be performed to test the difference over time between the intervention and the control groups; interaction: Group � Time. An alpha-level of 0.05 will be considered as being statistically significant (p < 0.05, two- sided). The data analysts will be blinded to the allocated interventions for primary analyses.
The baseline scores for the primary and secondary outcomes will be used to compare the control and intervention groups. The statistical analyses will be performed on the basis of the intention-to-treat principle, i.e. patients will be analysed in the treatment group to which they were randomly allocated. In the primary analyses, missing data will be replaced with the feasible and transparent 'Baseline Observation Carried Forward' (BOCF) technique, and for sensitivity also a multiple imputation technique will apply.
Secondarily, to relate the results to compliance, a 'per protocol' analysis will be used as well. The 'per protocol' population he patients who have 'completed' the intervention to which they were allocated, according to the principles described in the intervention section above.
Ethical Considerations
The Regional Scientific Ethical Committee of Southern Denmark approved the study (S-20100069). The study conformed to The Declaration of Helsinki 2008 [47] by fulfilling all general ethical recommendations.
All subjects will receive information about the purpose and content of the project and give their oral and written consent to participate, with the possibility to drop out of the project at any time.
Dr. Alex Jimenez's Insight
Managing stress, anxiety, depression and symptoms of post traumatic stress disorder, or PTSD, after being involved in an automobile accident can be difficult, especially if the incident caused physical trauma and injuries or aggravated a previously existing condition. In many cases, the emotional distress and the psychological issues caused by the incident may be the source of the painful symptoms. In El Paso, TX, many veterans with PTSD visit my clinic after manifesting worsening symptoms from a previous auto accident injury. Chiropractic care can provide patients the proper stress management environment they need to improve their physical and emotional symptoms. Chiropractic care can also treat a variety of auto accident injuries, including whiplash, head and neck injuries, herniated disc and back injuries.
Discussion
This study will contribute to a better understanding of treating patients with chronic neck pain following a whiplash accident. The knowledge from this study can be implemented into clinical practice, as the study is based on a multimodal approach, mirroring the approach, which in spite of the current lack of evidence, is often used in a clinical physiotherapy setting. The study may also be included in systematic reviews thereby contributing to updating the knowledge about this population and to enhancing evidence-based treatment.
Publishing the design of a study before the study is performed and the results obtained has several advantages. It allows the design to be finalised without its being influenced by the outcomes. This can assist in preventing bias as deviations from the original design can be identified. Other research projects will have the opportunity to follow a similar approach with respect to population, interventions, controls and outcome measurements. The challenges of this study are related to standardising the interventions, treating a non-homogeneous population, defining and standardising relevant outcome measures on a population with long-lasting symptoms and having a population from two different clinical settings. Standardisation of the interventions is obtained by teaching the involved physiotherapists in an instructional course. Population homogeneity will be handled by strict inclusion and exclusion criteria and by monitoring the baseline characteristics of the patients, and differences between groups based on other influences than the intervention/control will be possible to analyse statistically. This research design is composed as an 'add-on' design: both groups receive pain education; the intervention group receives additional physical training, including specific neck exercises and general training. Today there is insufficient evidence for the effect of treatment for patients with chronic neck pain following a whiplash accident. All participating patients will be referred for a treatment (control or intervention), as we consider it unethical not to offer some form of treatment, i.e. randomising the control group to a waiting list. The add-on design is chosen as a pragmatic workable solution in such a situation [48].
For whiplash patients with chronic pain, the most responsive disability measures (for the individual patient, not for the group as a whole) are considered to be the Patient Specific Functional Scale and the numerical rating scale of pain bothersomeness [49]. By using these and NDI (the most often used neck disability measure) as secondary outcome measures, it is anticipated that patient-relevant changes in pain and disability can be evaluated. The population will be recruited from and treated at two different clinical settings: the out-patient clinic of The Spine Centre, Hospital Lilleb�lt and several private physiotherapy clinics. To avoid any influence of the different settings on the outcome measures, the population will be block randomised related to the settings, securing equal distribution of participants from each setting to the two intervention groups.
Competing Interests
The authors declare that they have no competing interests.
Authors' Contributions
IRH drafted the manuscript. IRH, BJK and KS participated in the design of the study. All contributed to the design. RC, IRH; BJK and KS participated in the power and sample size calculation and in describing the statistical analysis as well as the allocation and randomization procedure. All authors read and approved the final manuscript. Suzanne Capell provided writing assistance and linguistic corrections.
This study has received funding from the Research Fund for the Region of Southern Denmark, the Danish Rheumatism Association, the Research Foundation of the Danish Association of Physiotherapy, the Fund for Physiotherapy in Private Practice, and the Danish Society of Polio and Accident Victims (PTU). The Musculoskeletal Statistics Unit at the Parker Institute is supported by grants from the Oak Foundation. Suzanne Capell provided writing assistance and linguistic correction.
A Randomized Controlled Trial of Cognitive-Behavioral Therapy for the Treatment of PTSD in the context of Chronic Whiplash
Abstract
Objectives
Whiplash-associated disorders (WAD) are common and involve both physical and psychological impairments. Research has shown that persistent posttraumatic stress symptoms are associated with poorer functional recovery and physical therapy outcomes. Trauma-focused cognitive-behavioral therapy (TF-CBT) has shown moderate effectiveness in chronic pain samples. However, to date, there have been no clinical trials within WAD. Thus, this study will report on the effectiveness of TF-CBT in individuals meeting the criteria for current chronic WAD and posttraumatic stress disorder (PTSD).
Method
Twenty-six participants were randomly assigned to either TF-CBT or a waitlist control, and treatment effects were evaluated at posttreatment and 6-month follow-up using a structured clinical interview, self-report questionnaires, and measures of physiological arousal and sensory pain thresholds.
Results
Clinically significant reductions in PTSD symptoms were found in the TF-CBT group compared with the waitlist at postassessment, with further gains noted at the follow-up. The treatment of PTSD was also associated with clinically significant improvements in neck disability, physical, emotional, and social functioning and physiological reactivity to trauma cues, whereas limited changes were found in sensory pain thresholds.
Discussion
This study provides support for the effectiveness of TF-CBT to target PTSD symptoms within chronic WAD. The finding that treatment of PTSD resulted in improvements in neck disability and quality of life and changes in cold pain thresholds highlights the complex and interrelating mechanisms that underlie both WAD and PTSD. Clinical implications of the findings and future research directions are discussed.
In conclusion, being involved in an automobile accident is an undesirable situation which can result in a variety of physical trauma or injury as well as lead to the development of a number of aggravating conditions. However, stress, anxiety, depression and post traumatic stress disorder, or PTSD, are common psychological issues which may occur as a result of an automobile accident. According to research studies, physical symptoms and emotional distress may be closely connected and treating both physical and emotional injuries could help patients achieve overall health and wellness. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Back Pain
According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.
1. The National Institute of Public H. Folkesundhedsrapporten, 2007 (engl: Public Health Report, Denmark, 2007) 2007. p. s.112.
2. Whiplash kommisionen och Svenska Lkl. Diagnostik och tidigt omh�ndertagande av whiplashskador (engl: Diagnostics and early treatment of Whiplash Injuries) Sandviken: Sandvikens tryckeri; 2005.
3. Carroll LJ, Hogg-Johnson S, van dV, Haldeman S, Holm LW, Carragee EJ, Hurwitz EL, Cote P, Nordin M, Peloso PM. et al. Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;12(4 Suppl):S75�S82. [PubMed]
4. Nijs J, Oosterwijck van J, Hertogh de W. Rehabilitation of chronic whiplash: treatment of cervical dysfunctions or chronic pain syndrome? ClinRheumatol. 2009;12(3):243�251. [PubMed]
5. Falla D. Unravelling the complexity of muscle impairment in chronic neck pain. ManTher. 2004;12(3):125�133. [PubMed]
6. Mannerkorpi K, Henriksson C. Non-pharmacological treatment of chronic widespread musculoskeletal pain. BestPractResClinRheumatol. 2007;12(3):513�534. [PubMed]
7. Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G. Exercises for mechanical neck disorders. CochraneDatabaseSystRev. 2005. p. CD004250. [PubMed]
8. Kasch H, Qerama E, Kongsted A, Bendix T, Jensen TS, Bach FW. Clinical assessment of prognostic factors for long-term pain and handicap after whiplash injury: a 1-year prospective study. EurJNeurol. 2008;12(11):1222�1230. [PubMed]
9. Curatolo M, Arendt-Nielsen L, Petersen-Felix S. Central hypersensitivity in chronic pain: mechanisms and clinical implications. PhysMedRehabilClinNAm. 2006;12(2):287�302. [PubMed]
10. Jull G, Sterling M, Kenardy J, Beller E. Does the presence of sensory hypersensitivity influence outcomes of physical rehabilitation for chronic whiplash?--A preliminary RCT. Pain. 2007;12(1-2):28�34. doi: 10.1016/j.pain.2006.09.030. [PubMed] [Cross Ref]
11. Davis C. Chronic pain/dysfunction in whiplash-associated disorders95. JManipulative Physiol Ther. 2001;12(1):44�51. doi: 10.1067/mmt.2001.112012. [PubMed] [Cross Ref]
12. Flor H. Cortical reorganisation and chronic pain: implications for rehabilitation. JRehabilMed. 2003. pp. 66�72. [PubMed]
13. Bosma FK, Kessels RP. Cognitive impairments, psychological dysfunction, and coping styles in patients with chronic whiplash syndrome14. Neuropsychiatry NeuropsycholBehavNeurol. 2002;12(1):56�65. [PubMed]
14. Guez M. Chronic neck pain. An epidemiological, psychological and SPECT study with emphasis on whiplash-associated disorders9. Acta OrthopSuppl. 2006;12(320):receding-33. [PubMed]
15. Kessels RP, Aleman A, Verhagen WI, van Luijtelaar EL. Cognitive functioning after whiplash injury: a meta-analysis5. JIntNeuropsycholSoc. 2000;12(3):271�278. [PubMed]
16. O'Sullivan PB. Lumbar segmental 'instability': clinical presentation and specific stabilizing exercise management. ManTher. 2000;12(1):2�12. [PubMed]
17. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the effect of two exercise regimes. JOrthopRes. 2007;12(3):404�412. [PubMed]
18. Falla D, Jull G, Hodges P, Vicenzino B. An endurance-strength training regime is effective in reducing myoelectric manifestations of cervical flexor muscle fatigue in females with chronic neck pain. ClinNeurophysiol. 2006;12(4):828�837. [PubMed]
19. Gill JR, Brown CA. A structured review of the evidence for pacing as a chronic pain intervention. EurJPain. 2009;12(2):214�216. [PubMed]
20. Wallman KE, Morton AR, Goodman C, Grove R, Guilfoyle AM. Randomised controlled trial of graded exercise in chronic fatigue syndrome. MedJAust. 2004;12(9):444�448. [PubMed]
21. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: model, processes and outcomes. BehavResTher. 2006;12(1):1�25. [PubMed]
22. Lappalainen R, Lehtonen T, Skarp E, Taubert E, Ojanen M, Hayes SC. The impact of CBT and ACT models using psychology trainee therapists: a preliminary controlled effectiveness trial. BehavModif. 2007;12(4):488�511. [PubMed]
23. Linton SJ, Andersson T. Can chronic disability be prevented? A randomized trial of a cognitive-behavior intervention and two forms of information for patients with spinal pain. Spine (Phila Pa 1976) 2000;12(21):2825�2831. doi: 10.1097/00007632-200011010-00017. [PubMed] [Cross Ref]
24. Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. AustJPhysiother. 2002;12(4):297�302. [PubMed]
25. Soderlund A, Lindberg P. Cognitive behavioural components in physiotherapy management of chronic whiplash associated disorders (WAD)--a randomised group study6. GItalMedLavErgon. 2007;12(1 Suppl A):A5�11. [PubMed]
26. Wicksell RK. Exposure and acceptance in patients with chronic debilitating pain - a behavior therapy model to improve functioning and quality of life. Karolinska Institutet; 2009.
27. Seferiadis A, Rosenfeld M, Gunnarsson R. A review of treatment interventions in whiplash-associated disorders70. EurSpine J. 2004;12(5):387�397. [PMC free article] [PubMed]
28. van der Wees PJ, Jamtvedt G, Rebbeck T, de Bie RA, Dekker J, Hendriks EJ. Multifaceted strategies may increase implementation of physiotherapy clinical guidelines: a systematic review. AustJPhysiother. 2008;12(4):233�241. [PubMed]
29. Verhagen AP, Scholten-Peeters GG, van WS, de Bie RA, Bierma-Zeinstra SM. Conservative treatments for whiplash34. CochraneDatabaseSystRev. 2009. p. CD003338.
30. Hurwitz EL, Carragee EJ, van dV, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Cote P, Hogg-Johnson S. et al. Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;12(4 Suppl):S123�S152. [PubMed]
31. Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N, Nicholas M. Randomized controlled trial of exercise for chronic whiplash-associated disorders. Pain. 2007;12(1-2):59�68. doi: 10.1016/j.pain.2006.08.030. [PubMed] [Cross Ref]
32. Ask T, Strand LI, Sture SJ. The effect of two exercise regimes; motor control versus endurance/strength training for patients with whiplash-associated disorders: a randomized controlled pilot study. ClinRehabil. 2009;12(9):812�823. [PubMed]
33. Rubinstein SM, Pool JJ, van Tulder MW, Riphagen II, de Vet HC. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. EurSpine J. 2007;12(3):307�319. [PMC free article] [PubMed]
34. Peolsson M, Borsbo B, Gerdle B. Generalized pain is associated with more negative consequences than local or regional pain: a study of chronic whiplash-associated disorders7. JRehabilMed. 2007;12(3):260�268. [PubMed]
35. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. ArchGenPsychiatry. 1961;12:561�571. [PubMed]
36. Wicksell RK, Ahlqvist J, Bring A, Melin L, Olsson GL. Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial. Cogn BehavTher. 2008;12(3):169�182. [PubMed]
37. Falla D, Jull G, Dall'Alba P, Rainoldi A, Merletti R. An electromyographic analysis of the deep cervical flexor muscles in performance of craniocervical flexion. PhysTher. 2003;12(10):899�906. [PubMed]
38. Palmgren PJ, Sandstrom PJ, Lundqvist FJ, Heikkila H. Improvement after chiropractic care in cervicocephalic kinesthetic sensibility and subjective pain intensity in patients with nontraumatic chronic neck pain. JManipulative Physiol Ther. 2006;12(2):100�106. doi: 10.1016/j.jmpt.2005.12.002. [PubMed] [Cross Ref]
39. Borg G. Psychophysical scaling with applications in physical work and the perception of exertion. ScandJWork EnvironHealth. 1990;12(Suppl 1):55�58. [PubMed]
40. Wallman KE, Morton AR, Goodman C, Grove R. Exercise prescription for individuals with chronic fatigue syndrome. MedJAust. 2005;12(3):142�143. [PubMed]
41. McCarthy MJ, Grevitt MP, Silcocks P, Hobbs G. The reliability of the Vernon and Mior neck disability index, and its validity compared with the short form-36 health survey questionnaire. EurSpine J. 2007;12(12):2111�2117. [PMC free article] [PubMed]
42. Bjorner JB, Damsgaard MT, Watt T, Groenvold M. Tests of data quality, scaling assumptions, and reliability of the Danish SF-36. JClinEpidemiol. 1998;12(11):1001�1011. [PubMed]
43. Ware JE Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A. Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study. MedCare. 1995;12(4 Suppl):AS264�AS279. [PubMed]
44. Ware JE Jr. SF-36 health survey update. Spine (Phila Pa 1976) 2000;12(24):3130�3139. doi: 10.1097/00007632-200012150-00008. [PubMed] [Cross Ref]
45. Carreon LY, Glassman SD, Campbell MJ, Anderson PA. Neck Disability Index, short form-36 physical component summary, and pain scales for neck and arm pain: the minimum clinically important difference and substantial clinical benefit after cervical spine fusion. Spine J. 2010;12(6):469�474. doi: 10.1016/j.spinee.2010.02.007. [PubMed] [Cross Ref]
46. Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, Elbourne D, Egger M, Altman DG. CONSORT 2010 Explanation and Elaboration: Updated guidelines for reporting parallel group randomised trials. JClinEpidemiol. 2010;12(8):e1�37. [PubMed]
47. Subjects WDoH-EPfMRIH. WORLD MEDICAL ASSOCIATION DECLARATION OF HELSINKI. WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects. 2008.
48. Dworkin RH, Turk DC, Peirce-Sandner S, Baron R, Bellamy N, Burke LB, Chappell A, Chartier K, Cleeland CS, Costello A. et al. Research design considerations for confirmatory chronic pain clinical trials: IMMPACT recommendations. Pain. 2010;12(2):177�193. doi: 10.1016/j.pain.2010.02.018. [PubMed] [Cross Ref]
49. Stewart M, Maher CG, Refshauge KM, Bogduk N, Nicholas M. Responsiveness of pain and disability measures for chronic whiplash. Spine (Phila Pa 1976) 2007;12(5):580�585. doi: 10.1097/01.brs.0000256380.71056.6d. [PubMed] [Cross Ref]
50. Jull GA, O'Leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. JManipulative Physiol Ther. 2008;12(7):525�533. doi: 10.1016/j.jmpt.2008.08.003. [PubMed] [Cross Ref]
51. Revel M, Minguet M, Gregoy P, Vaillant J, Manuel JL. Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study. ArchPhysMedRehabil. 1994;12(8):895�899. [PubMed]
52. Heikkila HV, Wenngren BI. Cervicocephalic kinesthetic sensibility, active range of cervical motion, and oculomotor function in patients with whiplash injury. ArchPhysMedRehabil. 1998;12(9):1089�1094. [PubMed]
53. Treleaven J, Jull G, Grip H. Head eye co-ordination and gaze stability in subjects with persistent whiplash associated disorders. Man Ther. 2010. [PubMed]
54. Williams MA, McCarthy CJ, Chorti A, Cooke MW, Gates S. A systematic review of reliability and validity studies of methods for measuring active and passive cervical range of motion. JManipulative Physiol Ther. 2010;12(2):138�155. doi: 10.1016/j.jmpt.2009.12.009. [PubMed] [Cross Ref]
55. Kasch H, Qerama E, Kongsted A, Bach FW, Bendix T, Jensen TS. Deep muscle pain, tender points and recovery in acute whiplash patients: a 1-year follow-up study. Pain. 2008;12(1):65�73. doi: 10.1016/j.pain.2008.07.008. [PubMed] [Cross Ref]
56. Sterling M. Testing for sensory hypersensitivity or central hyperexcitability associated with cervical spine pain. JManipulative Physiol Ther. 2008;12(7):534�539. doi: 10.1016/j.jmpt.2008.08.002. [PubMed] [Cross Ref]
57. Ettlin T, Schuster C, Stoffel R, Bruderlin A, Kischka U. A distinct pattern of myofascial findings in patients after whiplash injury. ArchPhysMedRehabil. 2008;12(7):1290�1293. [PubMed]
58. Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. JManipulative Physiol Ther. 1991;12(7):409�415. [PubMed]
59. Vernon H. The Neck Disability Index: state-of-the-art, 1991-2008. JManipulative Physiol Ther. 2008;12(7):491�502. doi: 10.1016/j.jmpt.2008.08.006. [PubMed] [Cross Ref]
60. Vernon H, Guerriero R, Kavanaugh S, Soave D, Moreton J. Psychological factors in the use of the neck disability index in chronic whiplash patients. Spine (Phila Pa 1976) 2010;12(1):E16�E21. doi: 10.1097/BRS.0b013e3181b135aa. [PubMed] [Cross Ref]
61. Sterling M, Kenardy J, Jull G, Vicenzino B. The development of psychological changes following whiplash injury. Pain. 2003;12(3):481�489. doi: 10.1016/j.pain.2003.09.013. [PubMed] [Cross Ref]
62. Stalnacke BM. Relationship between symptoms and psychological factors five years after whiplash injury. JRehabilMed. 2009;12(5):353�359. [PubMed]
63. Rabin R, de CF. EQ-5D: a measure of health status from the EuroQol Group. AnnMed. 2001;12(5):337�343. [PubMed]
64. Borsbo B, Peolsson M, Gerdle B. Catastrophizing, depression, and pain: correlation with and influence on quality of life and health - a study of chronic whiplash-associated disorders4. JRehabilMed. 2008;12(7):562�569. [PubMed]
Terry Peoples is a cosmetic beauty advisor in El Paso, TX, who relies on her independence to carry out her daily responsibilities.After suffering a car accident injury, she was left her having to rely on others to perform her everyday activities. That’s when Terry Peoples received a recommendation to seek chiropractic care with Dr. Alex Jimenez. Terry Peoples leaves the Dr. Alex Jimenez’s office everyday, feeling much better and refreshed.
According to the National Highway Traffic Safety Administration (NHTSA), over three million people are injured every year in automobile accidents throughout the nation. The various injuries caused by a car crash can be as diverse as the individual conditions of every incident, but some types of auto accidents are more prevalent than others. The symptoms of some auto collisions may resolve on their own, however, most injuries and/or conditions resulting from the impact of a car crash may require immediate medical attention, such as chiropractic care, to improve the symptoms.
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Auto Accident Injury: As a wife, mother and grandmother, Leticia must rely on her well-being to care for her family. But, after being involved in a car accident several years back, everyday activities, such as walking and even picking up her granddaughter, became difficult. That’s when she received chiropractic treatment with Dr. Alex Jimenez, D.C., for her auto accident injuries. Leticia high recommends Dr. Alex Jimenez after chiropractic care restored her quality of life.
Approximately more than 3 million people are injured every year as a result of an automobile accident. The type and severity of�the auto accident injuries can vary depending on the specific circumstances of the car crash. Soft tissue injuries affecting the neck and back, such as whiplash, are some of the most common types of injuries resulting from auto collisions. Head injuries can also occur as a result of the force of the impact. It’s essential for the victim involved in the automobile accident to seek immediate medical attention for their injuries.
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Sciatica Nerve Pain:�Edgar M. Reyes works for the city of El Paso and his ability to properly engage in his occupation is an essential part of his job, however, Mr. Reyes developed sciatica, which affected his everyday performance. Unable to walk due to his sciatica nerve pain, Edgar M Reyes found chiropractic treatment with Dr. Alex Jimenez. Chiropractic care provided Mr. Reyes with the relief he deserved from his sciatica and restored his ability to walk as well as his health and wellness.
Sciatica is a set of symptoms characterized by radiating pain from the lumbar spine. This pain may go down the back, into the buttocks, hips, legs and feet. Onset is frequently sudden following tasks like heavy lifting, though slow onset may also occur. Symptoms may occur on one or both sides of the body. Pain, numbness and weakness can occur depending on the type of compression on the sciatic nerve. About 90% of sciatica cases are often due to a spinal disc herniation pressing on one of the lumbar or sacral nerve roots. Other issues that may cause sciatica include spondylolisthesis, spinal stenosis and piriformis syndrome.
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Sciatica is a set of symptoms characterized by radiating pain from the 
