ClickCease
+1-915-850-0900 spinedoctors@gmail.com
Select Page
Amazing Results from Herniated Disc Early Treatment | El Paso, TX

Amazing Results from Herniated Disc Early Treatment | El Paso, TX

by | Cohort Studies, Herniated Disc, Research Studies, Spinal Decompression Treatments, Treatments

A herniated disc is typically a very painful condition, especially if the inner gel-like substance of the intervertebral disc, known as the nucleus pulposus, pushes through the thick, outer ring of cartilage and puts pressure on the sensitive nerves of the spine. Discs are soft, rubbery pads found between each vertebrae of the spine that act as shock-absorbers, allowing the spine to bend and/or flex. An intervertebral disc may begin to rupture as a result of wear-and-tear or due to a sudden injury. Fortunately, most individuals who’ve suffered a herniated disc can find relief from a variety of non-operative treatments before considering surgery. The following article highlights the impact of early treatment for herniated discs in the lumbar spine, or low back.

 

The Impact of Early Recovery on Long-Term Outcomes in a Cohort of Patients Undergoing Prolonged Non-Operative Treatment for Lumbar Disc Herniation: Clinical Article

 

Abstract

 

Object

 

The authors comprehensively studied the recovery of individual patients undergoing treatment for lumbar disc herniation. The primary goal was to gain insight into the variability of individual patient utility scores within a treatment cohort. The secondary goal was to determine how the rates and variability of patient recovery over time, represented by improvement in utility scores, affected long-term patient outcomes.

 

Methods

 

EuroQol Group�5 Dimension (EQ-5D) scores were obtained at baseline and at 2, 4, 8, 12, 26, 38, and 52 weeks for 93 patients treated under a prolonged conservative care protocol for lumbar disc herniation. Gaussian kernel densities were used to estimate the distribution of utility scores at each time point. Logistic regression and multistate Markov models were used to characterize individual patient improvement over time. Fisher exact tests were used to compare the distribution of EQ-5D domain scores.

 

Results

 

The distribution of utility scores was bimodal at 1 year and effectively sorted patients into a �higher� utility group (EQ-5D = 1; 43% of cohort) and a �lower� utility group (EQ-5D ? 0.86; 57% of cohort). Fisher exact tests revealed that pain/discomfort, mobility, and usual activities significantly differed between the 2 utility groups (p ? 0.001). The utility groups emerged at 8 weeks and were stable for the remainder of the treatment period. Using utility scores from 8 weeks, regression models predicted 1-year outcomes with 62% accuracy.

 

Conclusions

 

This study is the first to comprehensively consider the utility recovery of individual patients within a treatment cohort for lumbar disc herniation. The results suggest that most utility is recovered during the early treatment period. Moreover, the findings suggest that initial improvement is critical to a patient’s long-term outcome: patients who do not experience significant initial recovery appear unlikely to do so at a later time under the same treatment protocol.

 

Abbreviations used in this paper: AUC = area under a receiver-operating curve; EQ-5D = EuroQol Group�5 Dimension. Address correspondence to: Matthew C. Cowperthwaite, Ph.D., The University of Texas at Austin, Texas Advanced Computing Center, J.J. Pickle Research Campus, ROC 1.101, 10100 Burnet Rd., Austin, TX 78758. email: mattccowp@mac.com.

 

Plublished online June 28, 2013; DOI: 10.3171/2013.5.SPINE12992.

 

Introduction

 

Lumbar disc herniation is one of the most common causes of low-back pain and radiculopathy.[4] Treatment for patients with a herniated lumbar disc usually begins with conservative care such as analgesics, epidural steroid injections, and physical therapy,[1,5] with surgery reserved for patients with severe nerve root or cauda equina dysfunction or if conservative therapy is unsuccessful in controlling the symptoms.

 

Several recent studies have compared the effectiveness of conservative care and surgical treatment protocols for treating herniated lumbar discs, and have arrived at varying conclusions.[2,3,9,10,15�18] However, these studies have generally considered outcomes over a period of years, which is a significant length of time for patients who are waiting for their quality of life to improve. In clinical practice, this often leads to the following dilemma: most patients, particularly those with moderate symptoms, would prefer to avoid surgery, but are unwilling to wait an indefinite period of time for their symptoms to resolve. Unsurprisingly, lumbar discectomy is the most frequently performed surgical procedure in the US.[17,18]

 

Moreover, the above-mentioned studies have typically compared the average difference between treatment groups, without regard for individual recovery within the cohort. Additionally, this approach assumes that recovery in the protocols being compared proceeded similarly between observation intervals. To better understand the treatment responses of individual patients and the time frames of their responses, we comprehensively analyzed a cohort of patients undergoing a prolonged conservative care treatment protocol to gain insight into the dynamics of individual patient recovery over time, and whether these recovery dynamics influence long-term outcomes.

 

Methods

 

Study Data Set

 

The data set contained 142 patients randomized to a protocol of prolonged conservative care as part of the Leiden�The Hague Spine Intervention Prognostic Study.[10,15] The Sciatica Trial was reviewed and approved by the Medical Ethics Committee of Leiden University Medical Center.[11] Patients were enrolled into the Sciatica Trial entirely in the Netherlands.

 

In the Sciatica Trial, all patients aged 18 to 65 years, with persistent radicular pain in the L-4, L-5, or S-1 dermatome (with or without mild neurological deficit), severe disabling leg pain (lumbosacral radicular syndrome) lasting 6�12 weeks, and radiologically (MRI) confirmed disc herniation were considered eligible to enroll in the trial. Cauda equina syndrome or severe paresis, prior complaints of lumbosacral radicular syndrome in the previous 12 months, history of same-level unilateral disc surgery, spinal canal stenosis, and degenerative or lytic spondylolisthesis were all exclusion criteria. Cohort demographics and baseline characteristics were previously described; all patients reported both back and leg pain, but leg pain was generally more severe (mean leg pain 67.2 � 27.7 vs back pain 33.8 � 29.6, measured on a 100-point, horizontal visual analog scale).[15]

 

The Sciatica Trial used a pragmatic study design: conservative-care management was influenced as little as possible and was supervised by each patient’s general practitioner. Use of analgesics and physical therapy was determined by the treating physician. In this cohort, 46 patients (32%) elected to have surgery before the end of the 1st year; the mean timing of surgery was 12.6 weeks after the start of treatment. The surgical patients and 3 additional subjects with more than 2 missing utility measures were removed from the sample, resulting in a cohort of 93 patients considered in the present study; the crossover patients will be discussed in a separate study (manuscript in preparation). Our results were qualitatively unchanged when the excluded patients were retained in the analyses (data not shown).

 

In the Leiden�The Hague Spine Intervention Prognostic Study the EQ-5D instrument was used to measure patient utility at baseline and at 2, 4, 8, 12, 26, 38, and 52 weeks after enrollment into the study. The average duration of sciatica prior to enrollment was 9.5 weeks.[10,15] Utility is a valuation of a patient’s quality of life on a scale between 0 (as bad as dead) and 1 (perfect health). To estimate utility, the EQ-5D assesses a patient’s functional impairment in 5 domains: mobility, self-care, usual activities, pain, and anxiety.[6] For each domain, patients self-report the scores of 1 (no problems), 2 (some problems), or 3 (extreme problems). Utility scores were computed using the US valuation model,[12] which clearly distinguishes patients reporting no health problems (EQ-5D = 1) from those reporting at least some health problems (EQ-5D ? 0.86). Our results are independent of the particular valuation model (not shown). Completeness of the EQ-5D measures during follow-up ranged from 98% at 2 weeks to 90% at 38 weeks.

 

Statistical Analysis

 

All statistical analyses were conducted using the R statistical environment (version 2.9.2; www.rproject.org/) with the additional �msm,�[8] �ROCR,�[14] and �rms�[7] packages (all freely available from cran.rproject.org). Continuous variables are presented as means (� SEM) and were compared using 2-tailed Student t-tests. Significance was assessed at an ? ? 0.05 significance level, unless otherwise indicated. Missing EQ-5D measures were imputed using the mean of the measures at adjacent time points; our results are qualitatively similar under forward or backward imputation schemes (not shown).

 

Gaussian kernel density estimates were computed to estimate the distribution of utility scores. The kernel density estimates were estimated using a Silverman’s �rule-of-thumb� bandwidth and a Gaussian smoothing kernel.[13] The left- and right-most points were set to the theoretical minimum and maximum EQ-5D values, respectively, so that the area under the density curve summed to 1.

 

To determine whether specific EQ-5D domains differed between utility groups, Fisher-exact tests were conducted on contingency tables of the number of patients in each utility group that reported scores of 1, 2, or 3. Significance was assessed using a Bonferroni-corrected p value of 0.01.

 

Two-state, continuous-time Markov models were used to study the patterns and probabilities of patients transitioning between a �lower� utility (EQ-5D ? 0.86) and a �higher� utility group (EQ-5D = 1). The threshold utility value defining the groups remained fixed over time and was used to assign each patient to a utility group at each observation time. The models were fitted using the �msm� package[14] with piecewise-constant transition intensity matrices (Qt) estimated for each time interval between the points t = 0, 4, 8, 12, 26, 38, 52 (t = 2 was omitted because there were insufficient transitions to yield a robust model). Transition intensities were permitted to change between subsequent observation intervals, but remained homogeneous within each observation interval. The starting transition intensities were based on the observed frequencies of transitions in the data set and were calculated using the formula

 

Article-Formula.jpg

 

in which nij is the observed number of transitions from Group i to Group j over the duration of the study period (T), and nj is the initial number of patients in Group j. The fitted models were robust to the choice of starting transition intensities and yielded qualitatively similar parameter estimates over a range of starting parameters (not shown). The likelihood function was maximized using a Nelder-Mead algorithm, and convergence was visually verified and typically occurred well short of the maximum number of iterations.

 

Logistic regression models were used to test whether utility measurements from earlier time points could predict long-term outcomes. These models only included utility values up to a particular time point as predictors, with the response variable being the patient’s 1-year outcome (higher or lower utility group) modeled as a dichotomous variable; no additional clinical or demographic covariates were included in the models. The models were fitted using the �rms� package[7] and the fit was assessed using chi-square tests (? ? 0.05). Separate regression models were created for all utility measurements up to and including those for 2, 4, 8, 12, and 26 weeks; for example, the 8-week model would include utility measurements at 0, 2, 4, and 8 weeks. The AUC statistic was used to assess the performance of the models and was calculated using the ROCR package.[14]

 

Results

 

Delineation of Higher and Lower Utility Groups

 

The distributions of patient utility scores markedly changed over the course of 1 year of conservative care (Fig. 1). At baseline, the majority of patients reported a relatively poor quality of life; the mean EQ-5D score was 0.55 (median 0.60). Two distinct utility groups were found to be present at baseline: a �lower� utility group (EQ-5D ? 0.86) and a �higher� utility group (EQ-5D = 1). At 6 months, the lower utility group (n = 62, 67%) was larger than the higher utility group (n = 31, 33%); at 1 year, the lower utility group (n = 53, 57%) had declined, but remained larger than the higher utility group (n = 40, 43%).

 

Figure 1 Distribution of EQ-5D Patient Utilities | El Paso, TX Chiropractor

Figure 1: Distribution of EQ-5D patient utilities at baseline, 6 months, and 1 year. The solid lines depict Gaussian kernel density estimates (right axis) of each distribution. The gray lines outline the histogram with the height of each bar representing the frequency of patients (left axis) in the equal-width bins (0.05) with utility greater than the lower bound and less than or equal to the upper bound. The bounds of both distributions are set to the theoretical minimum and maximum of the EQ-5D utility instrument.

 

EQ-5D Domain Scores Between Groups

 

The average scores in each domain of the EQ-5D (Table 1) suggested that the pain/discomfort (low score = 1.9, high score = 1.0), mobility (low score = 1.4, high score = 1.0), and usual activities (low score = 1.5, high score = 1.0) domains differed most significantly between the high and low utility groups (p ? 0.001). The anxiety (low score = 1.2, high score = 1.0) and self-care (low score = 1.1, high score = 1.0) domains differed much less between the 2 utility groups, although they were also significant (p < 0.01).

 

Table 1 Distribution of Scores in Each EQ-5D Domain | El Paso, TX Chiropractor

 

Trajectory of Patient Utility Over Time

 

The series of patient utility scores measured over the study period are referred to as utility �trajectories,� which were studied to understand how patients recovered over the study period. In the study cohort, all patients experienced improvement during at least 1 observation period; only 19.3% (n = 18) never experienced a decline during their recovery. Recovery was variable: 49.5% of the patients (n = 46) experienced at least 2 reversals, which were defined as improvements (declines) immediately followed by declines (improvements) at the next observation. Furthermore, only 29% of patients (n = 27) had stable trajectories with no reversals. Overall, increases in utility were 4 times more common than decreases in utility.

 

The utility of the entire cohort increased by 0.296 (51.8% above baseline; p ? 0.001, Wilcoxon Mann-Whitney test) over the year (Fig. 2), but was markedly faster during the first 2 months (0.022/week) than the final 3 months (0.005/week). Over the same time frames, utility scores improved by 0.178 (35.2% above the baseline average) over the first 2 months and by 0.063 (1.3% above the 9-month average) during the final 3 months. The mean utility scores significantly differed between the 2 final utility groups at 8 weeks and remained significant for the rest of the year (p < 0.01, Student t-test; Fig. 2).

 

Figure 2 Graph of Mean Patient Utilities | El Paso, TX Chiropractor

Figure 2: Graph of mean patient utilities at each measurement time point. Error bars represent 95% CIs about the mean. High and low utility group refers to the final group in which the patient belongs at the 1-year time point.

 

Modeling Patient Recovery

 

Given that 2 utility groups were present over the study period, Markov models were used to study the robustness of these groups by estimating the likelihood of patients switching between the groups. The models suggested that the average probability of a patient remaining within their utility group was 97.9% and 97.6% for patients currently in the low and high utility groups, respectively (Fig. 3). The probability of a patient transitioning from the low to the high utility group was 2.1%; the corresponding probability for transitions from the high to the low utility group was 2.3%.

 

Figure 3 Graphs of the Markov Transition Probabilities | El Paso, TX Chiropractor

Figure 3: Graphs of the Markov transition probabilities (per week) for transitions within (lower) and between (upper) utility groups. Each point is centered at the middle of each time interval and represents the maximum-likelihood estimate of the per-week transition probability during the entire interval. Error bars (mean width of the 95% CI was 1.8) were omitted for clarity because the differences were not significant.

 

The models also suggested that the likelihood of a patient transitioning to another utility group declined over the study period. During the first 8 weeks, 2.8% and 3.5% of patients experienced low-to-high and high-to-low transitions, respectively; over the last 3 months, 1.6% and 1.3% of patients experienced low-to-high and high-to-low group transitions, respectively.

 

Predicting Individual Patient Outcome

 

At 8 weeks, logistic regression models could predict a patient’s outcome (final utility group) with modest accuracy (AUC = 0.62, or 62%). The accuracy of the models steadily increased as data from later time points were included; the 26-week model performance was good with an AUC of 0.78 (Fig. 4). The amount of improvement in utility scores from baseline to 8 weeks was also investigated as a predictor of good outcome (higher utility group). Patients with EQ-5D scores that improved by at least 0.30 during the first 8 weeks of treatment were 60% more likely to have a good outcome.

 

Figure 4 Graph Showing the Accuracy of Classifiers Based on Patient Utilities | El Paso, TX Chiropractor

Figure 4: Graph showing the accuracy of classifiers based on patient utilities. The horizontal line is drawn at 0.50, above which models would perform better than randomly assigning patients to utility groups.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Herniated disc commonly develop in the lumbar spine, or lower back. Also referred to as a slipped disc or a ruptured disc, a herniated disc occurs when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding outer ring, known as the annulus fibrosus. The symptoms of a herniated disc are generally specific to the exact level of the spine where the disc herniation occurs and whether or not the nerve tissue has been irritated by the intervertebral disc material leaking out of the inside of the disc. The most common symptoms of a disc herniation include pain, numbness, weakness and tingling sensations as well as causing radiating symptoms along the upper or lower extremities. Depending on the severity of the symptoms, herniated disc treatment can include, drugs and/or medications, epidural injections, physical therapy, chiropractic, and surgery, among others. According to the following article, early treatment can help promote and manage a faster herniated disc recovery from prolonged non-operative treatment methods.

 

Discussion

 

Several studies have sought to compare the relative effectiveness of surgery and conservative care for treatment of a lumbar disc herniation.[4�9,11] Generally, these studies have compared �average� differences between the study cohorts, while the individual trajectories by which patient utility changes over time have received less attention. To our knowledge, this study provides the first comprehensive statistical analysis of individual patient-level utility data from a large cohort of patients randomized to a prolonged conservative-care treatment protocol for lumbar disc herniation.[9]

 

The decision to proceed with surgery is straightforward in patients with severe, disabling symptoms or neurological deficits. Likewise, the decision to continue conservative care is simple for patients with mild symptoms or those who are content to live with their symptoms indefinitely. However, patients with moderate symptoms often present a greater challenge because most patients would prefer to avoid surgery if possible, but are also not content to wait indefinitely for their pain to resolve. These patients often ask for more than just the overall probability they will improve eventually; they usually want to know when they will recover. Moreover, they are usually interested in whether their current symptoms and progress affect the probability and extent of their future improvement.

 

For patients with moderate symptoms, the following observations from our study may be useful. First, the utility scores for individual patients diverged sharply at 8 weeks and were thereafter easily classified as either those reporting no health problems (higher utility, EQ-5D = 1) or those reporting at least some health problems (lower utility, EQ-5D ? 0.86). Among the lower utility group, the �pain/discomfort,� �mobility,� and �usual activities� domains of the EQ-5D differed most significantly from the higher utility group, which could potentially represent incompletely treated radiculopathy. Second, most improvement occurred early: almost one-third of the overall improvement in utility came in the first 2 months, while only 1% occurred in the last 3 months. Third, recovery is variable, with most patients (80%) experiencing at least 1 interval of deterioration and only 19% continuously improving without any setbacks. This may provide some reassurance to patients with generally good recovery to �stay the course� without resorting to more invasive measures such as surgery simply because of what may be a brief transient decrease in quality of life. Lastly, the probability of moving into another group was quite low (2%), which may be considered when counseling a patient who is not improving with his or her current treatment regimen.

 

We note the following limitations inherent in this cohort study. First, this is an observational study, and therefore we cannot infer causality for the emergence of the 2 utility groups, and because the individual treatment plans were unknown to us, we cannot comment on any specific type of conservative therapy. However, even if one considers the patients in the low utility group as nonresponders to conservative therapy (which is likely at least partly incorrect), the study does not imply that surgery would necessarily be beneficial in these patients. Second, the EQ-5D scores a patient’s overall health, and therefore unknown comorbid conditions likely account for at least some of the patients residing in the lower utility group and for part of the utility fluctuations. However, in the clinical setting, it should be obvious as to whether a patient’s symptoms are resulting from unresolved radiculopathy or from preexisting comorbidities. Lastly, we excluded crossover patients from our analysis. Crossover patients are likely those with the most severe symptoms and thus our results may be limited to patients with mild to moderate symptoms. However, we believe this exclusion is appropriate because, as mentioned above, the decision to operate is fairly straightforward when a patient has severe symptoms. From a clinical standpoint, patients with moderate symptoms and without neurological deficits after 8 weeks need the most information about the potential time course and extent of their nonoperative recovery to make an informed treatment decision.

 

The focus of the present study is individual utility recovery within a patient cohort rather than comparing average response to different treatment protocols. The goal was to gain insight into the dynamics of utility recovery among individual patients treated conservatively, but our approach could be applied to almost any treatment protocol. Studies of the changes (improvements or declines) in individual utility over time are useful because they may provide insights into a patient’s perception of their current treatment protocol (for example, patients in the low utility group would likely report a poor response to treatment), and also to identify a point at which continuing the same treatment is unlikely to improve a patient’s quality of life. Patients entering a conservative-care treatment protocol are likely to experience an initial period of rapid recovery, followed by a longer phase of more modest recovery. Our results suggest that, once the long-term recovery phase begins, patients are unlikely to spontaneously change their recovery for better or worse under the same treatment protocol. Lastly, patient utility scores early in the treatment process were reasonable predictors of long-term outcomes. This study is a comprehensive characterization of individual patients’ recovery of health utility from a lumbar disc herniation, and provides a unique picture for clinicians taking care of these patients. Our findings suggest that most recovery occurs early during treatment, and this early recovery period is important to long-term outcomes.

 

Conclusions

 

In a cohort of patients undergoing prolonged conservative care for treatment of lumbar disc herniation, 57% of the patients had lingering health problems at 1 year. Utility was recovered most rapidly early in the treatment process, and the majority of utility was also recovered in the initial treatment period. After the initial recovery period, we could identify with reasonable accuracy those patients who would fully recover and those who would not. Over the course of the year, recovery was observed to be highly variable, although most fluctuations were relatively small and only transient. These findings suggest that patients not initially responding to their treatment protocol should consider other options because they are unlikely to respond at a later time. However, patients and clinicians should also be mindful of transient decreases in quality of life, and carefully consider any changes in their treatment plan.

 

Disclosure

 

This work was partially supported by a charitable grant from the St. David’s Foundation Impact Fund to Dr. Cowperthwaite, and does not necessarily represent the views of the Impact Fund or the St. David’s Foundation.

 

Author contributions to the study and manuscript preparation include the following. Conception and design: all authors. Acquisition of data: Cowperthwaite, van den Hout. Analysis and interpretation of data: all authors. Drafting the article: Cowperthwaite. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Cowperthwaite. Statistical analysis: Cowperthwaite, van den Hout. Administrative/technical/material support: Cowperthwaite. Study supervision: Cowperthwaite.

 

In conclusion, early non-operative treatment of lumbar herniated disc can effectively improve as well as manage recovery outcomes in patients with the condition. It’s important for patients with disc herniations in the lumbar spine to comprehend the source of their issue before receiving appropriate treatment for their symptoms. Furthermore, non-operative treatment is effective in most patients, surgical interventions may be considered according to the individual’s recovery outcome. 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

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Neck Pain

 

Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.

 

blog picture of cartoon paperboy big news

 

IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

 

OTHER IMPORTANT TOPICS: EXTRA: Sports Injuries? | Vincent Garcia | Patient | El Paso, TX Chiropractor

 

 

Blank
References

1. Andersson GB, Brown MD, Dvorak J, Herzog RJ, Kambin P, Malter A, et al.: Consensus summary of the diagnosis and treatment of lumbar disc herniation. Spine (Phila Pa 1976) 21:24 Suppl75S�78S, 1996 Medline
2. Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, et al.: The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica. Spine (Phila Pa 1976) 21:1777�1786, 1996 Crossref, Medline
3. Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, et al.: The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine (Phila Pa 1976) 21:1787�1795, 1996 Crossref, Medline
4. Baldwin NG: Lumbar disc disease: the natural history. Neurosurg Focus 13:2E2, 2002
5. Dawson E, Bernbeck J: The surgical treatment of low back pain. Phys Med Rehabil Clin N Am 9:489�495, x, 1998
6. EuroQol Group: EuroQol�a new facility for the measurement of health-related quality of life. The EuroQol Group Health Policy 16:199�208, 1990 Crossref, Medline
7. Harrell FE: Regression Modeling Strategies: With Applications to Linear Models, Logistic Regression and Survival Analysis New York, Springer, 2001
8. Jackson CH, Sharples LD, Thompson SG, Duffy SW, Couto E: Multistate Markov models for disease progression with classification error. The Statistician 52:193�209, 2003
9. Keller RB, Atlas SJ, Singer DE, Chapin AM, Mooney NA, Patrick DL, et al.: The Maine Lumbar Spine Study, Part I. Background and concepts. Spine (Phila Pa 1976) 21:1769�1776, 1996 Crossref, Medline
10. Peul WC, van den Hout WB, Brand R, Thomeer RTWM, Koes BW: Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ 336:1355�1358, 2008 Crossref, Medline
11. Peul WC, van Houwelingen HC, van der Hout WB, Brand R, Eekhof JA, Tans JT, et al.: Prolonged conservative treatment or �early� surgery in sciatica caused by a lumbar disc herniation: rationale and design of a randomized trial [ISRCT 26872154]. BMC Musculoskelet Disord 6:8, 2005 Crossref, Medline
12. Shaw JW, Johnson JA, Coons SJ: US valuation of the EQ-5D health states: development and testing of the D1 valuation model. Med Care 43:203�220, 2005 Crossref, Medline
13. Silverman BW: Density Estimation for Statistics and Data Analysis London, Chapman & Hall, 1986
14. Sing T, Sander O, Beerenwinkel N, Lengauer T: ROCR: visualizing classifier performance in R. Bioinformatics 21:3940�3941, 2005
15. van den Hout WB, Peul WC, Koes BW, Brand R, Kievit J, Thomeer RTWM, et al.: Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial. BMJ 336:1351�1354, 2008 Crossref, Medline
16. Weber H: Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 8:131�140, 1983 Crossref, Medline
17. Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson ANA, et al.: Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 296:2451�2459, 2006 Crossref, Medline
18. Weinstein JN, Tosteson TD, Lurie JD, Tosteson ANA, Hanscom B, Skinner JS, et al.: Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 296:2441�2450, 2006 Crossref, Medline

Close Accordion
Blank
Cited By

1. Anurekha Ramakrishnan, MS, K. Michael Webb, MD, and Matthew C. Cowperthwaite, PhD. (2017) One-year outcomes of early-crossover patients in a cohort receiving nonoperative care for lumbar disc herniation. Journal of Neurosurgery: Spine 27:4, 391-396. . Online publication date: 1-Oct-2017. Abstract | Full Text | PDF (2037 KB)
2. Kimberly A Plomp, Una Strand Vi�arsd�ttir, Darlene A Weston, Keith Dobney, Mark Collard. (2015) The ancestral shape hypothesis: an evolutionary explanation for the occurrence of intervertebral disc herniation in humans. BMC Evolutionary Biology 15:1. . Online publication date: 1-Dec-2015. [Crossref]

Close Accordion
Migraine Pain & Lumbar Herniated Disc Treatment in El Paso, TX

Migraine Pain & Lumbar Herniated Disc Treatment in El Paso, TX

by | Cohort Studies, Herniated Disc, Migraine, Randomized Controlled Trial, Spinal Decompression Treatments, Treatments

One of the most prevalent causes of lower back pain and sciatica may be due to the compression of the nerve roots in the low back from a lumbar herniated disc, or a ruptured disc in the lumbar spine. Common symptoms of lumbar herniated discs include varying intensities of pain, muscle spasms or cramping, sciatica and leg weakness as well as loss of proper leg function. While these may not appear to be closely associated with each other, a lumbar herniated disc may also affect the cervical spine, manifesting symptoms of migraine and headache. The purpose of the following articles is to educate patients and demonstrate the relation between migraine pain and lumbar herniated disc, further discussing the treatment of these two common conditions.

 

A Critical Review of Manual Therapy Use for Headache Disorders: Prevalence, Profiles, Motivations, Communication and Self-Reported Effectiveness

 

Abstract

 

Background

 

Despite the expansion of conventional medical treatments for headache, many sufferers of common recurrent headache disorders seek help outside of medical settings. The aim of this paper is to evaluate research studies on the prevalence of patient use of manual therapies for the treatment of headache and the key factors associated with this patient population.

 

Methods

 

This critical review of the peer-reviewed literature identified 35 papers reporting findings from new empirical research regarding the prevalence, profiles, motivations, communication and self-reported effectiveness of manual therapy use amongst those with headache disorders.

 

Results

 

While available data was limited and studies had considerable methodological limitations, the use of manual therapy appears to be the most common non-medical treatment utilized for the management of common recurrent headaches. The most common reason for choosing this type of treatment was seeking pain relief. While a high percentage of these patients likely continue with concurrent medical care, around half may not be disclosing the use of this treatment to their medical doctor.

 

Conclusions

 

There is a need for more rigorous public health and health services research in order to assess the role, safety, utilization and financial costs associated with manual therapy treatment for headache. Primary healthcare providers should be mindful of the use of this highly popular approach to headache management in order to help facilitate safe, effective and coordinated care.

 

Keywords: Headache, Migraine, Tension headache, Cervicogenic headache, Manual therapy, Physical therapy, Chiropractic, Osteopathy, Massage

 

Background

 

The co-occurrence of tension headache and migraine is very high [1]. Respectively, they are the second and third most common disorders worldwide with migraine ranking as the seventh highest specific cause of disability globally [2] and the sixteenth most commonly diagnosed condition in the US [3]. These common recurrent headache disorders place a considerable burden upon the personal health, finances and work productivity of sufferers [3�5] with migraine further complicated by an association with cardiovascular and psychiatric co-morbidities [6, 7].

 

Preventative migraine drug treatments include analgesics, anticonvulsants, antidepressants and beta-blockers. Preventative drug treatments for tension-type headaches can include analgesics, NSAIDs, muscle relaxants and botulinum toxin as well as anticonvulsants and antidepressants. While preventative drug treatments are successful for a significant proportion of sufferers, headache disorders are still reported as under-diagnosed and under-treated within medical settings [8�16] with other studies reporting sufferers can cease continuing with preventative headache medications long-term [9, 17].

 

There is a number of non-drug approaches also utilized for the prevention of headaches. These include psychological therapies such as cognitive behavioral therapy, relaxation training and EMG (electromyography) biofeedback. In addition, there is acupuncture, nutritional supplementation (including magnesium, B12, B6, and Coenzyme Q10) and physical therapies. The use of physical therapies is significant, with one recent global survey reporting physical therapy as the most frequently used �alternative or complementary treatment� for headache disorders across many countries [18]. One of the most common physical therapy interventions for headache management is manual therapy (MT), [19�21] which we define here as treatments including �spinal manipulation (as commonly performed by chiropractors, osteopaths, and physical therapists), joint and spinal mobilization, therapeutic massage, and other manipulative and body-based therapies� [22].

 

Positive results have been reported in many clinical trials comparing MT to controls [23�27], other physical therapies [28�30] and aspects of medical care [31�34]. More high quality research is needed however to assess the efficacy of MT as a treatment for common recurrent headaches. Recent systematic reviews of randomized clinical trials of MT for the prevention of migraine report a number of significant methodological short-comings and the need for more high quality research before any firm conclusions can be made [35, 36]. Recent reviews of MT trials for tension-type headache and cervicogenic headache are cautious in reporting positive outcomes and the strong need for further robust research [37�41]. Despite the limited clinical evidence there has been no critical review of the significant use of MT by headache populations.

 

Methods

 

The aim of this study is to report from the peer-reviewed literature; 1) the prevalence of MT use for the treatment of common recurrent headaches and 2) factors associated with this use across several key themes. The review further identifies key areas worthy of further research in order to better inform clinical practice, educators and healthcare policy within this area.

 

Design

 

A comprehensive search of peer-reviewed articles published in English between 2000 and 2015 reporting new empirical research findings of key aspects of MT use among patients with migraine and non-migraine headache disorders was undertaken. Databases searched were MEDLINE, AMED, CINAHL, EMBASE and EBSCO. The key words and phrases used were: �headache�, �migraine�, �primary headache�, �cephalgia�, �chronic headache� AND �manual therapy�, �spinal manipulation�, �manipulative therapy�, �spinal mobilization�, �chiropractic�, �osteopathy�, �massage�, �physical therapy� or �physiotherapy� AND then �prevalence�, �utilization� or �profile� was used for additional searches against the previous terms. The database search was accompanied by a hand search of prominent peer-reviewed journals. All authors accessed the reviewed literature (data) and provided input to analysis.

 

Due to the focus of the review, literature reporting randomized control trials and similar clinical research designs were excluded as were articles identified as letters, correspondence, editorials, case reports and commentaries. Further searches were undertaken of the bibliographies in the identified publications. All identified articles were screened and only those reporting new empirical findings on MT use for headache in adults were included in the review. Articles identified and selected for the review were research manuscripts mostly within epidemiological and health economics studies. The review includes papers reporting MT use pooled with the use of other therapies, but only where MT patients comprised a large proportion (as stated) of the included study population. Results were imported into Endnote X7 and duplicates removed.

 

Search Outcomes, Analyses and Quality Appraisal

 

Figure 1 outlines the literature search process. The initial search identified 3286 articles, 35 of which met the inclusion criteria. Information from each article was organized into a review table (Table 1) to summarise the findings of the included papers. Information is reported under two selected headache groups and within each individual MT profession – chiropractic, physiotherapy, osteopathy and massage therapy � where sufficient detail was available.

 

Figure 1 Flow Chart of Study Selection

Figure 1: Flow Chart of Study Selection.

 

Table 1 Research Based Studies of Manual Therapy Use

Table 1: Research-based studies of manual therapy use for headache disorders.

 

An appraisal of the quality of the articles identified for review was conducted using a quality scoring system (Table 2) developed for the critical appraisal of health literature used for prevalence and incidence of health problems [42] adapted from similar studies [43�45]. This scoring system was applicable to the majority of study designs involving surveys and survey-based structured interviews (29 of the 35 papers) but was not applicable to a small number of included studies based upon clinical records, secondary analysis or practitioner characteristics.

 

Table 2 Description of Quality Criteria and Scoring

 

Two separate authors (CM and JA) independently searched and scored the articles. Score results were compared and any differences were further discussed and resolved by all the authors. The quality score of each relevant article is reported in Table 3.

 

Table 3 Quality Score for Selected Studies

 

Results

 

The key findings of the 35 articles were grouped and evaluated using a critical review approach adapted from previous research [46, 47]. Based on the limited information available for other headache types, prevalence findings are reported within one of two categories – either as �migraine� for papers reporting studies where the population was predominately or entirely made up of migraine patients or as �headache� for papers where the study population was predominately other headache types (including tension-type headaches, cluster headaches, cervicogenic headache) and/or where the headache type was not clearly stated. Ten papers reported findings examining prevalence rates for the �migraine� category alone, 18 papers reported findings examining prevalence for the �headache� category alone and 3 papers reported findings for both categories. Based on the nature of the information available, prevalence use was categorised by manual therapy providers. The extracted data was then analysed and synthesized into four thematic categories: prevalence; profile and motivations for MT use; concurrent use and order of use of headache providers; and self-reported evaluation of MT treatment outcomes.

 

Prevalence of MT Use

 

Thirty-one of the reviewed articles with a minimum sample size (>100) reported findings regarding prevalence of MT use. The prevalence of chiropractic use for those with migraine ranged from 1.0 to 36.2% (mean: 14.4%) within the general population [19�21, 48�52] and from 8.9 to 27.1% (mean: 18.0%) within headache-clinic patient populations [53, 54]. The prevalence of chiropractic use for those reported as headache ranged from 4 to 28.0% (mean: 12.9%) within the general population [20, 48, 51, 55�57]; ranged from 12.0 to 22.0% (mean: 18.6%) within headache/pain clinic patient populations [58�60] and from 1.9 to 45.5% (mean: 9.8%) within chiropractic patient populations [61�69].

 

The prevalence use of physiotherapy for those with migraine ranged from 9.0 to 57.0% (mean: 24.7%) within the general population [19, 20, 48, 52] and from 4.9 to 18.7% (mean: 11.8%) within headache-clinic patient populations [54, 70]. The prevalence use of physiotherapy for those reported as headache ranged from 12.2 to 52.0% (mean: 32.1%) within the general population [20, 48] and from 27.8 to 35.0%% (mean: 31.4%) within headache/pain clinic populations [60, 70].

 

Massage therapy use for those with migraine ranged from 2.0 to 29.7% (mean: 15.6%) within the general population [49, 50, 71] and from 10.1 to 56.4% (mean: 33.9%) within headache-clinic populations [53, 54, 72, 73]. Massage/acupressure use for those reported as headache within headache/pain clinic patient populations ranged from 12.0 to 54.0% (mean: 32.5%) [58�60, 70].

 

Osteopathy use for those with migraine was reported as 1% within the general population [49]; as 2.7% within a headache-clinic patient population [53] and as 1.7% within an osteopathy patient population [74]. For headache the prevalence was 9% within a headache/pain clinic population [60] and ranged from 2.7 to 10.0% (mean: 6.4%) within osteopathy patient populations [74, 75].

 

The combined prevalence rate of MT use across all MT professions for those with migraine ranged from 1.0 to 57.0% (mean: 15.9%) within the general population; ranged from 2.7 to 56.4% (mean: 18.4%) within headache-clinic patient populations and was reported as 1.7% in one MT patient population. The combined prevalence rate of MT use across all MT professions for those reported as headache ranged from 4.0 to 52.0% (mean: 17.7%) within the general population; ranged from 9.0 to 54.0% (mean: 32.3%) within headache-clinic patient populations and from 1.9 to 45.5% (mean: 9.25%) within MT patient populations.

 

Profile and Motivations for MT Use

 

While patient socio-demographic profiles were not reported within headache populations that were exclusively using MT, several studies report these findings where MT users made up a significant percentage of the non-medical headache treatments utilized by the study population (range 40% � 86%: mean 63%). While findings varied for level of income [58, 70] and level of education, [70, 72, 73] this patient group were more likely to be older [70, 72], female [20], have a higher rate of comorbid conditions [58, 70, 76] and a higher rate of previous medical visits [20, 58, 70] when compared to the non-user group. Overall, this group were reported to have a higher level of headache chronicity or headache disability than non-users [20, 54, 58, 70, 72, 77].

 

Several studies within headache-clinic populations report patient motivations for the use of complementary and alternative headache treatments where MT users made up a significant proportion of the study population (range 40% � 86%: mean 63%) [58, 70, 72, 78]. From these studies the most common motivation reported by study patients was �seeking pain relief� for headache which accounted for 45.4% � 84.0% (mean: 60.5%) of responses. The second most common motivation was patient concerns regarding the �safety or side effects� of medical headache treatment, accounting for 27.2% � 53.0% (mean: 43.8%) of responses [58, 70, 72]. �Dissatisfaction with medical care� accounted for 9.2% � 35.0% (mean: 26.1%) of responses [58, 70, 72].

 

A limited number of reviewed papers (all from Italy) report on the source of either the referral or recommendation to MT for headache treatment [53, 58, 59]. From these studies, referral from a GP to a chiropractor ranged from 50.0 to 60.8% (mean: 55.7%), while referral from friends/relatives ranged from 33.0 to 43.8% (mean: 38.7%) and self-recommendation ranged from 0 to 16.7% (mean: 5.6%). For massage therapy, referral from a GP ranged from 23.2 to 50.0% (mean: 36.6%), while referral from friends/relatives ranged from 38.4 to 42.3% (mean: 40.4%) and self-recommendation ranged from 7.7 to 38.4% (mean: 23.1%). For acupressure, referral from a GP ranged from 33.0 to 50.0% (mean: 41.5%), while referral from friends/relatives was reported as 50% and self-recommendation ranged from 0 to 16.6% (mean: 8.3%). One study reported findings for osteopathy where referral from both GP�s and friends/relatives was reported as 42.8% and self-recommendation was reported as 14.4%. Overall, the highest proportion of referrals within these studies was from GPs to chiropractors for chronic tension-type headache (56.2%), cluster headache (50%) and migraine (60.8%).

 

Concurrent Use and Order of Use of Headache Providers and Related Communication of MT Users

 

Several studies report on the concurrent use of medical headache management with complementary and alternative therapies. In those studies where the largest percentage of the patient population were users of MT�s (range 57.0% � 86.4%: mean 62.8%), [58, 70, 78] concurrent use of medical care ranged between 29.5% and 79.0% (mean: 60.0%) of the headache patient population.

 

These studies further report on the level of patient non-disclosure to medical providers regarding the use of MT for headache. Non-disclosure ranged between 25.5 and 72.0% (mean: 52.6%) of the patient population, with the most common reason for non-disclosure reported as the doctor �never asking�, ranging from 37.0 to 80.0% (mean: 58.5%). This was followed by a patient belief that �it was not important for the doctor to know� or �none of the doctor�s business�, ranging from 10.0 to 49.8% (mean: 30.0%). This was followed by a belief that either �the doctor would not understand� or �would discourage� these treatments, ranging from 10.0 to 13.0% (mean: 11.5%) [53, 77].

 

One large international study reported the ordering of the typical provider of headache care by comparing findings between several countries for migraine patients [21]. Primary care providers followed by neurologists were reported as the first and second providers for migraine treatment for nearly all countries examined. The only exception was Australia, where those with chronic migraine selected chiropractors as typical providers at equal frequency to neurologists (14% for both) while those with episodic migraine selected chiropractors at a greater frequency to neurologists (13% versus 5%). Comparatively, chiropractors were selected as the typical provider for those with chronic migraine by 10% in USA and Canada, 1% in Germany and 0% for UK and France. Chiropractors were selected as the typical provider for those with episodic migraine by 7% in USA, 6% in Germany, 4% in Canada and by 1% in both the UK and France.

 

Self-Reported Effectiveness of MT Treatment Outcomes

 

Several headache and pain-clinic population studies provide findings for the self-reported effectiveness of MT headache treatment. For chiropractic, patient self-reporting of partially effective or fully effective headache relief ranged from 27.0 to 82.0% (mean: 45.0%) [53, 58�60, 78]. For massage therapy, patient self-reporting of partially effective or fully effective headache relief ranged from 33.0 to 64.5% (mean: 45.2%)[53, 58, 60, 73, 78], and for acupressure this ranged from 33.4 to 50.0% (mean: 44.5%) [53, 58, 59]. For osteopathy and physiotherapy, one study reported effectiveness as 17 and 36% respectively [60].

When results are combined across all MT professions the reporting of MT as either partially or fully effective ranged from 17.0 to 82.0% (mean 42.5%) [53, 58�60, 73, 78]. In addition, one general population study provides findings for the self-reported effectiveness for chiropractic and physiotherapy at 25.6 and 25.1% respectively for those with primary chronic headache and 38 and 38% respectively for those with secondary chronic headache [79].

 

Discussion

 

This paper provides the first critical integrative review on the prevalence and key factors associated with the use of MT treatment for headaches within the peer-reviewed literature. While study methodological limitations and lack of data prevent making strong conclusions, these findings raise awareness of issues of importance to policy-makers, educators, headache providers and future research.

 

Our review found that MT use was generally higher within medical headache-clinic populations when compared to general populations. However, the use of individual MT providers does vary between different regions and this is likely due to a number of factors including variation in public access, healthcare funding and availability of MT providers. For example, the use of physiotherapy for some headache types may be relatively higher in parts of Europe [20, 60] while the use of chiropractors for some headache types may be relatively higher in Australia and the USA [19, 21]. Overall, the prevalence use of MT for headache appears to be substantial and likely to be the most common type of physical therapy utilized for headache in many countries [19�21, 49]. More high quality epidemiological studies are needed to measure the prevalence of MT use across different headache types and sub-types, both within the general population and clinical populations.

 

Beyond prevalence, data is more limited regarding who, how and why headache patients seek MT. From the information available however, the healthcare needs of MT headache patients may be more complex and multi-disciplinary in nature compared to those under usual medical care alone. Socio-demographic findings suggest that users of MT and other complementary and alternative therapies have a higher level of headache disability and chronicity compared to non-users. This finding may correlate with the higher prevalence of MT users within headache-clinic populations and a history of more medical appointments. This may also have implications for future MT trial designs both in terms of the selection of trial subjects from inside versus outside MT clinical settings and the decision to test singular MT interventions versus MT in combination with other interventions.

 

Limited information suggests that a pluralistic approach toward the use of medical and non-medical headache treatments such as MT is common. While findings suggest MT is sought most often for reasons of seeking headache relief, the evidence to support the efficacy of MT for headache relief is still limited. MT providers must remain mindful of the quality of the evidence for a given intervention for a given headache disorder and to inform patients where more effective or safer treatment interventions are available. More research is needed to assess these therapies individually and through multimodal approaches and for studies to include long-term follow-up.

 

Information limited to Italy, suggests referral from GPs for MT headache treatment can be common in some regions, while this is less likely to widespread given the issue of patient non-disclosure to medical doctors regarding the use of this treatment in other studies. High quality healthcare requires open and transparent communication between patients and providers and between the providers themselves. Non-disclosure may adversely influence medical management should unresponsive patients require further diagnostic investigations [80] or the implementation of more effective approaches to headache management [81] or prevents discussion in circumstances where MT may be contraindicated [82]. Primary headache providers may benefit from paying particular attention to the possibility of non-disclosure of non-medical headache treatments. Open discussion between providers and patients about the use of MT for headache and the associated outcomes may improve overall patient care.

 

Future Research

 

Despite the strong need for more high quality research to assess the efficacy of MT as a treatment for headache, the substantial use of MT brings attention to the need for more public health and health services research within this area of headache management. The need for this type of research was identified in a recent global report on the use of headache-related healthcare resources [18]. Furthering this information can lead to improvements in healthcare policy and the delivery of healthcare services.

 

The substantial use of physical therapies such as MT has been under-reported within many of the national surveys reporting headache-related healthcare utilization [3, 5, 83�85]. Regardless, the role of physical therapies in headache management continues to be assessed, often within mainstream and integrated headache management settings [86�89]. Continuing this research may further our understanding of the efficacy and outcomes associated with a more multidisciplinary approach to headache management.

 

Further to this is the need for more research to understand the healthcare utilization pathways associated with those patients who use MT in their headache management. Little is known about the sociodemographic background, types of headaches, level of headache disability and comorbidities more common to this patient population. In turn, such information can provide insights that may be valuable to provider clinical decision-making and provider education.

 

Limitations

 

The design and findings of our review has a number of limitations. The design of the review was limited by a search within English language journals only. As a result, some research on this topic may have been missed. While the quality scoring system adopted for this review requires further validation, the data we collected was limited by the low to moderate quality of available papers which averaged 6.4 out of 10 points (Table 3). The low scoring was largely due to significant methodological issues and the small sample size associated with much of the collected papers. Much of the data on this topic was heterogeneous in nature (telephone, postal surveys and face-to-face interviews). There was a lack of validated practitioner and patient questionnaires to report findings, such as for questions on prevalence, where the time frames utilized varied between �currently�, �last 12 months� and �ever�.

 

Data on the prevalence of MT use for headache was limited particularly within individual MT provider populations when compared to data found within the general population and headache-clinic populations. Many studies assessed the use of MT for headache without identifying headache types. Only one study inside an MT population had reported the percentage of patients attending for reasons of migraine alone (osteopathy). The prevalence of MT use for headache was reported most within chiropractic patient population studies, however information was limited on the types of headache. We found no studies reporting the prevalence of headache patients within physiotherapy or massage therapy patient populations using our search terms.

 

A lack of data for some themes necessitated providing findings pooled with users of other non-medical headache providers. Data within many geographical regions was very limited with the most limited data was on the source of referral to MT headache providers (three papers from Italy only). These limitations support the call for more research to be focused exclusively within MT populations and different regional areas before stronger conclusions can be drawn.

 

Conclusion

 

The needs of those with headache disorders can be complex and multi-disciplinary in nature. Beyond clinical research, more high quality public health and health services research is needed to measure and examine a number of issues of significance to the delivery and use of MT�s within headache management. With unmet needs still remaining for many who suffer recurrent headaches, clinicians should remain cognizant of the use of MT�s and remain open to discussing this approach to headache management in order to ensure greater safety, effectiveness and coordination of headache care.

 

Acknowledgements

 

Not applicable.

 

Funding

 

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors while the first author on this paper receives a PhD scholarship made available by the Australian Chiropractors� Association.

 

Availability of Data and Materials

 

Not applicable (all data is reported in article).

 

Authors’ Contributions

 

CM, JA and DS designed the paper. CM carried out the literature search, data collection and selection. CM and DS provided the analysis and interpretation. CM and JA wrote the drafts. All authors contributed to the critical review and intellectual content. All authors read and approved the final manuscript.

 

Competing Interests

 

The authors declare that they have no competing interests.

 

Consent for Publication

 

Not applicable.

 

Ethics Approval and Consent to Participate

 

Not applicable.

 

Publisher�s Note

 

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

 

Abbreviations

 

  • MT Manual therapy
  • EMG Electromyography

 

Contributor Information

 

Ncbi.nlm.nih.gov/pmc/articles/PMC5364599/

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

A staggering 15% of the population suffers from migraines, a debilitating condition which affects an individual’s ability to engage in everyday activities. Although widely misunderstood by researches today, I believe that migraine pain can be a symptom of a much bigger underlying health issue. Lumbar herniated discs, or ruptured discs in the lumbar spine, are a common cause of lower back pain and sciatica. When the soft, gel-like center of a lumbar herniated disc compresses the nerve roots of the low back, it can result in symptoms of pain and discomfort, numbness and weakness in the lower extremities. What’s more, a lumbar herniated disc can unbalance the structure and function of the entire spine, eliciting symptoms along the cervical spine that could ultimately trigger migraines. People who constantly experience migraine pain often have to carefully go about their day in hopes of avoiding the blaze of another painful episode. Fortunately, many migraine pain and lumbar herniated disc treatment methods are available to help improve as well as manage the symptoms. Other treatment options can also be considered before surgical interventions.

 

Surgical versus Non-Operative Treatment for Lumbar Disc Herniation: Eight-Year Results for the Spine Patient Outcomes Research Trial (SPORT)

 

Abstract

 

Study Design

 

Concurrent prospective randomized and observational cohort studies.

 

Objective

 

To assess the 8-year outcomes of surgery vs. non-operative care.

 

Summary of Background Data

 

Although randomized trials have demonstrated small short-term differences in favor of surgery, long-term outcomes comparing surgical to non-operative treatment remain controversial.

 

Methods

 

Surgical candidates with imaging-confirmed lumbar intervertebral disc herniation meeting SPORT eligibility criteria enrolled into prospective randomized (501 participants) and observational cohorts (743 participants) at 13 spine clinics in 11 US states. Interventions were standard open discectomy versus usual non-operative care. Main outcome measures were changes from baseline in the SF-36 Bodily Pain (BP) and Physical Function (PF) scales and the modified Oswestry Disability Index (ODI – AAOS/Modems version) assessed at 6 weeks, 3 and 6 months, and annually thereafter.

 

Results

 

Advantages were seen for surgery in intent-to-treat analyses for the randomized cohort for all primary and secondary outcomes other than work status; however, with extensive non-adherence to treatment assignment (49% patients assigned to non-operative therapy receiving surgery versus 60% of patients assigned to surgery) these observed effects were relatively small and not statistically significant for primary outcomes (BP, PF, ODI). Importantly, the overall comparison of secondary outcomes was significantly greater with surgery in the intent-to-treat analysis (sciatica bothersomeness [p > 0.005], satisfaction with symptoms [p > 0.013], and self-rated improvement [p > 0.013]) in long-term follow-up. An as-treated analysis showed clinically meaningful surgical treatment effects for primary outcome measures (mean change Surgery vs. Non-operative; treatment effect; 95% CI): BP (45.3 vs. 34.4; 10.9; 7.7 to 14); PF (42.2 vs. 31.5; 10.6; 7.7 to 13.5) and ODI (?36.2 vs. ?24.8; ?11.2; ?13.6 to ?9.1).

 

Conclusion

 

Carefully selected patients who underwent surgery for a lumbar disc herniation achieved greater improvement than non-operatively treated patients; there was little to no degradation of outcomes in either group (operative and non-operative) from 4 to 8 years.

 

Keywords: SPORT, intervertebral disc herniation, surgery, non-operative care, outcomes

 

Introduction

 

Lumbar discectomy for relief of sciatica in patients with intervertebral disc herniation (IDH) is a well-researched and common indication for spine surgery, yet rates of this surgery exhibit considerable geographic variation.[1] Several randomized trials and large prospective cohorts have demonstrated that surgery provides faster pain relief and perceived recovery in patients with herniated disc.[2�6] The effect of surgery on longer term outcomes remains less clear.

 

In a classic RCT evaluating surgery versus non-operative treatment for lumbar IDH, Weber et al. showed a greater improvement in the surgery group at 1 year that was statistically significant; there was also greater improvement for surgery at 4 years, although not statistically significant, but no apparent difference in outcomes at 10 years.[2] However, a number of patients in the non-operative group eventually underwent surgery over that time, complicating the interpretation of the long-term results. The Maine Lumbar Spine Study, a prospective observational cohort, found greater improvement at one year in the surgery group that narrowed over time, but remained significantly greater in the surgical group for sciatica bothersomeness, physical function, and satisfaction, but no different for work or disability outcomes.[3] This paper reports 8-year results from the Spine Patient Outcomes Research Trial (SPORT) based on the continued follow-up of the herniated disc randomized and observational cohorts.

 

Methods

 

Study Design

 

SPORT is a randomized trial with a concurrent observation cohort conducted in 11 US states at 13 medical centers with multidisciplinary spine practices. The human subjects committees at each participating institution approved a standardized protocol for both the observational and the randomized cohorts. Patient inclusion and exclusion criteria, study interventions, outcome measures, and follow-up procedures have been reported previously.[5�8]

 

Patient Population

 

Men and women were eligible if they had symptoms and confirmatory signs of lumbar radiculopathy persisting for at least six weeks, disc herniation at a corresponding level and side on imaging, and were considered surgical candidates. The content of pre-enrollment non-operative care was not pre-specified in the protocol.[5�7] Specific enrollment and exclusion criteria are reported elsewhere.[6,7]

 

A research nurse at each site identified potential participants, verified eligibility and used a shared decision making video for uniformity of enrollment. Participants were offered enrollment in either the randomized trial or the observational cohort. Enrollment began in March of 2000 and ended in November of 2004.

 

Study Interventions

 

The surgery was a standard open discectomy with examination of the involved nerve root.[7,9] The non-operative protocol was �usual care� recommended to include at least: active physical therapy, education/counseling with home exercise instruction, and non-steroidal anti-inflammatory drugs if tolerated. Non-operative treatments were individualized for each patient and tracked prospectively.[5�8]

 

Study Measures

 

Primary endpoints were the Bodily Pain (BP) and Physical Function (PF) scales of the SF-36 Health Survey[10] and the AAOS/Modems version of the Oswestry Disability Index (ODI)[11] as measured at 6 weeks, 3 and 6 months, and annually thereafter. If surgery was delayed beyond six weeks, additional follow-up data was obtained 6 weeks and 3 months post-operatively. Secondary outcomes included patient self-reported improvement; work status; satisfaction with current symptoms and care;[12] and sciatica severity as measured by the sciatica bothersomeness index.[13,14] Treatment effect was defined as the difference in the mean changes from baseline between the surgical and non-operative groups.

 

Statistical Considerations

 

Initial analyses compared means and proportions for baseline patient characteristics between the randomized and observational cohorts and between the initial treatment arms of the individual and combined cohorts. The extent of missing data and the percentage of patients undergoing surgery were calculated by treatment arm for each scheduled follow-up. Baseline predictors of time until surgical treatment (including treatment crossovers) in both cohorts were determined via a stepwise proportional hazards regression model with an inclusion criterion of p < 0.1 to enter and p > 0.05 to exit. Predictors of missing follow-up visits at yearly intervals up to 8 years were separately determined via stepwise logistic regression. Baseline characteristics that predicted surgery or a missed visit at any time-point were then entered into longitudinal models of primary outcomes. Those that remained significant in the longitudinal models of outcome were included as adjusting covariates in all subsequent longitudinal regression models to adjust for potential confounding due to treatment selection bias and missing data patterns.[15] In addition, baseline outcome, center, age and gender were included in all longitudinal outcome models.

 

Primary analyses compared surgical and non-operative treatments using changes from baseline at each follow-up, with a mixed effects longitudinal regression model including a random individual effect to account for correlation between repeated measurements within individuals. The randomized cohort was initially analyzed on an intent-to-treat basis.[6] Because of cross-over, additional analyses were performed based on treatments actually received. In these as-treated analyses, the treatment indicator was a time-varying covariate, allowing for variable times of surgery. Follow-up times were measured from enrollment for the intent-to-treat analyses, whereas for the as-treated analysis the follow-up times were measured from the beginning of treatment (i.e. the time of surgery for the surgical group and the time of enrollment for the non-operative group), and baseline covariates were updated to the follow-up immediately preceding the time of surgery. This procedure has the effect of including all changes from baseline prior to surgery in the estimates of the non-operative treatment effect and all changes after surgery in the estimates of the surgical effect. The six-point sciatica scales and binary outcomes were analyzed via longitudinal models based on generalized estimating equations[16] with linear and logit link functions respectively, using the same intent-to-treat and adjusted as-treated analysis definitions as the primary outcomes. The randomized and observational cohorts were each analyzed to produce separate as-treated estimates of treatment effect. These results were compared using a Wald test to simultaneously test all follow-up visit times for differences in estimated treatment effects between the two cohorts.[15] Final analyses combined the cohorts.

 

To evaluate the two treatment arms across all time-periods, the time-weighted average of the outcomes (area under the curve) for each treatment group was computed using the estimates at each time period from the longitudinal regression models and compared using a Wald test.[15]

 

Kaplan-Meier estimates of re-operation rates at 8 years were computed for the randomized and observational cohorts and compared via the log-rank test.[17,18]

 

Computations were done using SAS procedures PROC MIXED for continuous data and PROC GENMOD for binary and non-normal secondary outcomes (SAS version 9.1 Windows XP Pro, Cary, NC). Statistical significance was defined as p < 0.05 based on a two-sided hypothesis test with no adjustments made for multiple comparisons. Data for these analyses were collected through February 4, 2013.

 

Results

 

Overall, 1,244 SPORT participants with lumbar intervertebral disc herniation were enrolled (501 in the randomized cohort, and 743 in the observational cohort) (Figure 1). In the randomized cohort, 245 were assigned to surgical treatment and 256 to non-operative treatment. Of those randomized to surgery, 57% had surgery by 1 year and 60% by 8 years. In the group randomized to non-operative care, 41% of patients had surgery by 1 year and 48% by 8 years. In the observational cohort, 521 patients initially chose surgery and 222 patients initially chose non-operative care. Of those initially choosing surgery, 95% received surgery by 1 year; at 8 years 12 additional patients had undergone primary surgery. Of those choosing non-operative treatment, 20% had surgery by 1 year and 25% by 8 years. In both cohorts combined, 820 patients received surgery at some point during the first 8 years; 424 (34%) remained non-operative. Over the 8 years, 1,192 (96%) of the original enrollees completed at least 1 follow-up visit and were included in the analysis (randomized cohort: 94% and observational cohort 97%); 63% of initial enrollees supplied data at 8 years with losses due to dropouts, missed visits, or deaths (Figure 1).

 

Figure-1-Exclusion-Enrollment-Randomization-and-Follow-Up

Figure 1: Exclusion, enrollment, randomization and follow-up of trial participants.

 

Patient Characteristics

 

Baseline characteristics have been previously reported and are summarized in Table 1.[5,6,8] The combined cohorts had an overall mean age of 41.7 with slightly more men than women. Overall, the randomized and observational cohorts were similar. However, patients in the observational cohort had more baseline disability (higher ODI scores), were more likely to prefer surgery, more often rated their problem as worsening, and were slightly more likely to have a sensory deficit. Subjects receiving surgery over the course of the study were: younger; less likely to be working; more likely to report being on worker�s compensation; had more severe baseline pain and functional limitations; fewer joint and other co-morbidities; greater dissatisfaction with their symptoms; more often rated their condition as getting worse at enrollment; and were more likely to prefer surgery. Subjects receiving surgery were also more likely to have a positive straight leg test, as well as more frequent neurologic, sensory, and motor deficits. Radiographically, their herniations were more likely to be at the L4�5 and L5-S1 levels and to be posterolateral in location.

 

Table 1 Patient Baseline Demographic Characteristics, Comorbidities and Health Status Measures

Table 1: Patient baseline demographic characteristics, comorbidities and health status measures according to study cohort and treatment received.

 

Surgical Treatment and Complications

 

Overall surgical treatment and complications were similar between the two cohorts (Table 2). The average surgical time was slightly longer in the randomized cohort (80.5 minutes randomized vs. 74.9 minutes observational, p=0.049). The average blood loss was 75.3cc in the randomized cohort vs. 63.2cc in the observational, p=0.13. Only 6 patients total required intra-operative transfusions. There were no perioperative mortalities. The most common surgical complication was dural tear (combined 3% of cases). Re-operation occurred in a combined 11% of cases by 5 years, 12% by 6 years, 14% by 7 years, and 15% by 8 years post-surgery. The rates of reoperation were not significantly different between the randomized and observational cohorts. Eighty-seven of the 119 re-operations noted the type of re-operation; approximately 85% of these (74/87) were listed as recurrent herniations at the same level. One death occurred within 90 days post-surgery related to heart surgery at another institution; the death was judged to be unrelated and was reported to the Institutional Review Board and the Data and Safety Monitoring Board.

 

Table 2 Operative Treatments, Complications and Events

Cross-Over

 

Non-adherence to treatment assignment affected both treatment arms: patients chose to delay or decline surgery in the surgical arm and crossed over to surgery in the non-operative arm. (Figure 1) Statistically significant differences of patients crossing over to non-operative care within 8 years of enrollment were that they were older, had higher incomes, less dissatisfaction with their symptoms, more likely to have a disc herniation at an upper lumbar level, more likely to express a baseline preference for non-operative care, less likely to perceive their symptoms as getting worse at baseline, and had less baseline pain and disability (Table 3). Patients crossing over to surgery within 8 years were more dissatisfied with their symptoms at baseline; were more likely to perceive they were getting worse at baseline; more likely to express a baseline preference for surgery; and had worse baseline physical function and more self-rated disability.

 

Table 3 Statistically Significant Predictors of Adherence to Treatment

Table 3: Statistically significant predictors of adherence to treatment among RCT patients.

 

Main Treatment Effects

 

Intent-to-Treat Analysis In the intention-to-treat analysis of the randomized cohort, all measures over 8 years favored surgery but there were no statistically significant treatment effects in the primary outcome measures (Table 4 and Figure 2). In the overall intention-to-treat comparison between the two treatment groups over time (area-under the curve), secondary outcomes were significantly greater with surgery in the intention-to-treat analysis (sciatica bothersomeness (p=0.005), satisfaction with symptoms (p=0.013), and self-rated improvement (p=0.013)) (Figure 3) Improvement in sciatica bothersomeness index was also statistically significant in favor of surgery at most individual time point comparisons (although non-significant in years 6 and 7) (Table 4).

 

Figure-2-Primary-Outcomes-in-the-Randomized-and-Observational-Cohorts

Figure 2: Primary outcomes (SF-36 Bodily Pain and Physical Function, and Oswestry Disability Index) in the randomized and observational cohorts during 8 years of follow-up.

 

Figure-3-Secondary-Outcomes-in-the-Randomized-and-Observational-Cohorts.

Figure 3: secondary outcomes (Sciatica Bothersomeness, Satisfaction with Symptoms, and Self-rated Global Improvement) in the randomized and observational cohorts during 8 years of follow-up.

 

Table 4 Primary Analysis Results for Years 1 to 8

Table 4: Primary analysis results for years 1 to 8. Intent-to-treat for the randomized cohort and adjusted* analyses according to treatment received for the randomized and observational cohorts combined.

 

As-Treated Analysis The adjusted as-treated effects seen in the randomized and observational were similar. Accordingly, the cohorts were combined for the final analyses. Treatment effects for the primary outcomes in the combined as-treated analysis were clinically meaningful and statistically significant out to 8 years: SF-36 BP 10.9 p < 0.001 (95% CI 7.7 to 14); SF-36 PF 10.6 p<0.001 (95% CI 7.7 to 13.5); ODI ?11.3 p<0.001 (95% CI ?13.6 to ?9.1) (Table 4). The footnote for Table 4 describes the adjusting covariates selected for the final model.

 

Results from the intent-to-treat and as-treated analyses of the two cohorts are compared in Figure 2. In the combined analysis, treatment effects were statistically significant in favor of surgery for all primary and secondary outcome measures (with the exception of work status which did not differ between treatment groups) at each time point (Table 4 and Figure 3).

 

Loss-to-Follow-Up

 

At the 8-year follow-up, 63% of initial enrollees supplied data, with losses due to dropouts, missed visits, or deaths. Table 5 summarized the baseline characteristics of those lost to follow-up compared to those retained in the study at 8-years. Those who remained in the study at 8 years were – somewhat older; more likely to be female, white, college educated, and working at baseline; less likely to be disabled, receiving compensation, or a smoker; less symptomatic at baseline with somewhat less bodily pain, better physical function, less disability on the ODI, better mental health, and less sciatica bothersomeness. These differences were small but statistically significant. Table 6 summarizes the short-term outcomes during the first 2 years for those retained in the study at 8 years compared to those lost to follow-up. Those lost to follow-up had worse outcomes on average; however this was true in both the surgical and non-operative groups with non-significant differences in treatment effects. The long-term outcomes are therefore likely to be somewhat over-optimistic on average in both groups, but the comparison between surgical and non-operative outcomes appear likely to be un-biased despite the long-term loss to follow-up.

 

Table 5 Patient Baseline Demographic Characteristics, Comorbidities and Health Status Measures

Table 5: Patient baseline demographic characteristics, comorbidities, and health status measures according to patient follow-up status as of 02/01/2013 when the IDH8yr data were pulled.

 

Table 6 Time Weighted Average of Treatment Effects

Table 6: Time-weighted average of treatment effects at 2 years (AUC) from adjusted* as-treated randomized and observational cohorts combined primary outcome analysis, according to treatment received and patient follow-up status.

 

Discussion

 

In patients with a herniated disc confirmed by imaging and leg symptoms persisting for at least 6 weeks, surgery was superior to non-operative treatment in relieving symptoms and improving function. In the as-treated analysis, the treatment effect for surgery was seen as early as 6 weeks, appeared to reach a maximum by 6 months and persisted over 8 years; it is notable that the non-operative group also improved significantly and this improvement persisted with little to no degradation of outcomes in either group (operative and non-operative) between 4 and 8 years. In the longitudinal intention-to-treat analysis, all the outcomes showed small advantages for surgery, but only the secondary outcomes of sciatica bothersomeness, satisfaction with symptoms, and self-rated improvement were statistically significant. The persistent small benefit in the surgery group over time has made the overall intention-to-treat comparison more statistically significant over time despite high levels of cross-over. The large effects seen in the as-treated analysis after adjustments for characteristics of the crossover patients suggest that the intent-to-treat analysis may underestimate the true effect of surgery since the mixing of treatments due to crossover can be expected to create a bias toward the null in the intent-to-treat analyses.[4,19] Loss to follow-up among patients who were somewhat worse at baseline and with worse short-term outcomes probably leads to overly-optimistic estimated long-term outcomes in both surgery and non-operative groups but unbiased estimates of surgical treatment effects.

 

Comparisons to Other Studies

 

There are no other long-term randomized studies reporting the same primary outcome measures as SPORT. The results of SPORT primary outcomes at 2 years were quite similar to those of Peul et al but longer follow up for the Peul study is necessary for further comparison.[4,20] In contrast to the Weber study, the differences in the outcomes in SPORT between treatment groups remained relatively constant between 1 and 8 years of follow-up. One of the factors in this difference may be the sensitivity of the outcome measures � for example, sciatica bothersomeness, which was significantly different out to 8 years in the intention-to-treat, may be a more sensitive marker of treatment success than the general outcome measure used by Weber et al.[2]

 

The long-term results of SPORT are similar to the Maine Lumbar Spine Study (MLSS).[21] The MLSS reported statistically significantly greater improvements at 10 years in sciatica bothersomeness for the surgery group (?11.9) compared to the nonsurgical groups (?5.8) with a treatment effect of ?6.1 p=0.004; in SPORT the improvement in sciatica bothersomeness in the surgical group at 8 years was similar to the 10 year result in MLSS (?11) though the non-operative cohort in SPORT did better than their MLSS counterparts (?9.1) however the treatment effect in SPORT, while smaller, remained statistically significant (?1.5; p<0.001) due to the much larger sample size. Greater improvements in the non-operative cohorts between SPORT and MLSS may be related to differences in non-operative treatments over time, differences between the two cohorts since the MLSS and did not require imaging confirmation of IDH.

 

Over the 8 years there was little evidence of harm from either treatment. The 8-year rate of re-operation was 14.7%, which is lower than the 25% reported by MLSS at 10 years.[22]

 

Limitations

 

Although our results are adjusted for characteristics of cross over patients and control for important baseline covariates, the as-treated analyses presented do not share the strong protection from confounding that exists for an intent-to-treat analysis.[4�6] However, However, intent-to-treat analyses are known to be biased in the presence of noncompliance at the level observed in SPORT, and our adjusted as-treated analyses have been shown to produce accurate results under reasonable assumptions about the dependence of compliance on longitudinal outcomes.[23] Another potential limitation is the heterogeneity, of the non-operative treatment interventions, as discussed in our prior papers.[5,6,8] Finally, attrition in this long-term follow-up study meant that only 63% of initial enrollees supplied data at 8 years with losses due to dropouts, missed visits, or deaths; based on analyses at baseline and at short-term follow-up, this likely leads to somewhat overly-optimistic estimated long-term outcomes in both treatment groups but an unbiased estimation of surgical treatment effect.

 

Conclusions

 

In the intention-to-treat analysis, small, statistically insignificant surgical treatment effects were seen for the primary outcomes but statistically significant advantages for sciatica bothersomeness, satisfaction with symptoms, and self-rated improvement were seen out to 8 years despite high levels of treatment cross-over. The as-treated analysis combining the randomized and observational cohorts, which carefully controlled for potentially confounding baseline factors, showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over 8 years compared to patients treated non-operatively. The non-operative group, however, also showed substantial improvements over time, with 54% reporting being satisfied with their symptoms and 73% satisfied with their care after 8 years.

 

Acknowledgments

 

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (U01-AR45444; P60-AR062799) and the Office of Research on Women�s Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention grant funds were received in support of this work. Relevant financial activities outside the submitted work: consultancy, grants, stocks.

 

This study is dedicated to the memories of Brieanna Weinstein and Harry Herkowitz, leaders in their own rights, who simply made the world a better place.

 

Footnotes

 

Other comorbidities include: stroke, diabetes, osteoporosis, cancer, fibromyalgia, cfs, PTSD, alcohol, drug dependency, heart, lung, liver, kidney, blood vessel, nervous system, hypertension, migraine, anxiety, stomach, bowel

 

In conclusion, individuals who suffer from migraine pain require the most effective type of treatment in order to help improve as well as manage their symptoms, particularly if their migraines were elicited from a lumbar herniated disc. The purpose of the following articles was to associate the two conditions with each other and demonstrate the results of the research above. Various treatment options can be considered before surgery for migraine pain and lumbar herniated disc treatment. 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

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Neck Pain

 

Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.

 

blog picture of cartoon paperboy big news

 

IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

OTHER IMPORTANT TOPICS: EXTRA: Sports Injuries? | Vincent Garcia | Patient | El Paso, TX Chiropractor

 

Blank
References
1. Lyngberg AC, Rasmussen BK, J�rgensen T, Jensen R. Has the prevalence of migraine and tension-type headache changed over a 12-year period? a Danish population survey. Eur J Epidemiol. 2005;20:243�9. doi: 10.1007/s10654-004-6519-2. [PubMed] [Cross Ref]
2. Vos T, Flaxman A, Naghavi M. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990�2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2012;380:2163�96. doi: 10.1016/S0140-6736(12)61729-2. [PubMed] [Cross Ref]
3. Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the united states: updated statistics from government health surveillance studies. Headache. 2015;55:21�34. doi: 10.1111/head.12482. [PubMed] [Cross Ref]
4. Lanteri-Minet M. Economic burden and costs of chronic migraine. Curr Pain Headache Rep. 2014;18:385. doi: 10.1007/s11916-013-0385-0. [PubMed] [Cross Ref]
5. Bloudek L, Stokes M, Buse D, Wilcox T, Lipton R, Goadsby P, Varon S, Blumenfeld A, Katsarava Z, Pascual J, et al. Cost of healthcare for patients with migraine in five European countries: results from the international burden of migraine study (IBMS) J Headache Pain. 2012;13:361�78. doi: 10.1007/s10194-012-0460-7. [PMC free article] [PubMed] [Cross Ref]
6. Antonaci F, Nappi G, Galli F, Manzoni GC, Calabresi P, Costa A. Migraine and psychiatric comorbidity: a review of clinical findings. J Headache Pain. 2011;12:115�25. doi: 10.1007/s10194-010-0282-4. [PMC free article] [PubMed] [Cross Ref]
7. Kurth T, Chabriat H, Bousser M-G. Migraine and stroke: a complex association with clinical implications. Lancet Neurol. 2012;11:92�100. doi: 10.1016/S1474-4422(11)70266-6. [PubMed] [Cross Ref]
8. Lipton R, Goadsby P, Sawyer J, Blakeborough P, Stewart W. Migraine: diagnosis and assessment of disability. Rev Contemp Pharmaco. 2000;11:63�73.
9. Diamond S, Bigal ME, Silberstein S, Loder E, Reed M, Lipton RB. Patterns of diagnosis and acute and preventive treatment for migraine in the united states: results from the American migraine prevalence and prevention study. Headache. 2007;47:355�63. [PubMed]
10. Lipton RB, Bigal ME, Diamond M, Freitag F, Reed M, Stewart WF. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68:343�9. doi: 10.1212/01.wnl.0000252808.97649.21. [PubMed] [Cross Ref]
11. Berger A, Bloudek LM, Varon SF, Oster G. Adherence with migraine prophylaxis in clinical practice. Pain Pract. 2012;12:541�9. doi: 10.1111/j.1533-2500.2012.00530.x. [PubMed] [Cross Ref]
12. Peres MFP, Silberstein S, Moreira F, Corchs F, Vieira DS, Abraham N, Gebeline-Myers C. Patients’ preference for migraine preventive therapy. Headache. 2007;47:540�5. doi: 10.1111/j.1526-4610.2007.00757.x. [PubMed] [Cross Ref]
13. Nicholson RA, Rooney M, Vo K, O’Laughlin E, Gordon M. Migraine care among different ethnicities: Do disparities exist? Headache. 2006;46:754�65. doi: 10.1111/j.1526-4610.2006.00453.x. [PMC free article] [PubMed] [Cross Ref]
14. Lafata JE, Tunceli O, Cerghet M, Sharma KP, Lipton RB. The use of migraine preventive medications among patients with and without migraine headaches. Cephalalgia. 2010;30:97�104. doi: 10.1111/j.1468-2982.2009.01909.x. [PubMed] [Cross Ref]
15. Cevoli S, D’Amico D, Martelletti P, Valguarnera F, Del Bene E, De Simone R, Sarchielli P, Narbone MC, Testa L, Genco S, et al. Underdiagnosis and undertreatment of migraine in Italy: a survey of patients attending for the first time 10 headache centres. Cephalalgia. 2009;29:1285�93. doi: 10.1111/j.1468-2982.2009.01874.x. [PubMed] [Cross Ref]
16. Stark RJ, Valenti L, Miller GC. Management of migraine in Australian general practice. Med J Aust. 2007;187:142. [PubMed]
17. Lipton RB, Buse DC, Serrano D, Holland S, Reed ML. Examination of unmet treatment needs among persons with episodic migraine: results of the American migraine prevalence and prevention (AMPP) study. Headache. 2013;53:1300�11. doi: 10.1111/head.12154. [PubMed] [Cross Ref]
18. WHO Lifting the Burden 2011: www.who.int/mental_health/management/who_atlas_headache_disorders.pdf?ua=1. Retrieved 8 August 2015
19. Bigal ME, Serrano D, Reed M, Lipton RB. Chronic migraine in the population Burden, diagnosis, and satisfaction with treatment. Neurology. 2008;71:559�66. doi: 10.1212/01.wnl.0000323925.29520.e7. [PubMed] [Cross Ref]
20. Kristoffersen ES, Grande RB, Aaseth K, Lundqvist C, Russell MB. Management of primary chronic headache in the general population: the Akershus study of chronic headache. J Headache Pain. 2012;13:113�20. doi: 10.1007/s10194-011-0391-8. [PMC free article] [PubMed] [Cross Ref]
21. Sanderson JC, Devine EB, Lipton RB, Bloudek LM, Varon SF, Blumenfeld AM, Goadsby PJ, Buse DC, Sullivan SD. Headache-related health resource utilisation in chronic and episodic migraine across six countries. J Neurol Neurosurg Psychiatry. 2013;84:1309�17. doi: 10.1136/jnnp-2013-305197. [PMC free article] [PubMed] [Cross Ref]
22. Biology of Manual Therapies (R21) National Institute of Health, 2014: grants.nih.gov/grants/guide/pa-files/PA-14-167.html Retrieved 11 August 2015
23. Marcus D, Scharff L, Mercer S, Turk D. Nonpharmacological treatment for migraine: incremental utility of physical therapy with relaxation and thermal biofeedback. Cephalalgia. 1998;18:266�72. doi: 10.1046/j.1468-2982.1998.1805266.x. [PubMed] [Cross Ref]
24. Lawler SP, Cameron LD. A randomized, controlled trial of massage therapy as a treatment for migraine. Ann Behav Med. 2006;32:50�9. doi: 10.1207/s15324796abm3201_6. [PubMed] [Cross Ref]
25. Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. J Manipulative Physiol Ther. 2000;23:91�5. doi: 10.1016/S0161-4754(00)90073-3. [PubMed] [Cross Ref]
26. Hoyt W, Shaffer F, Bard D, Benesler J, Blankenhorn G, Gray J, Hartman W, Hughes L. Osteopathic manipulation in the treatment of muscle-contraction headache. J Am Osteopath Assoc. 1979;78:322�5. [PubMed]
27. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine (Phila Pa 1976) 2002;27:1835�43. doi: 10.1097/00007632-200209010-00004. [PubMed] [Cross Ref]
28. Haas M, Spegman A, Peterson D, Aickin M, Vavrek D. Dose-Response and Efficacy of Spinal Manipulation for Chronic Cervicogenic Headache: A Pilot Randomized Controlled Trial. Spine J. 2010;10:117�28. [PMC free article] [PubMed]
29. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA. 1998;280:1576�9. doi: 10.1001/jama.280.18.1576. [PubMed] [Cross Ref]
30. Parker GB, Pryor DS, Tupling H. Why does migraine improve during a clinical trial? Further results from a trial of cervical manipulation for migraine. Aust N Z J Med. 1980;10:192�8. doi: 10.1111/j.1445-5994.1980.tb03712.x. [PubMed] [Cross Ref]
31. Hsieh LL-C, Liou H-H, Lee L-H, Chen TH-H, Yen AM-F. Effect of acupressure and trigger points in treating headache: a randomized controlled trial. Am J Chin Med. 2010;38:1�14. doi: 10.1142/S0192415X10007634. [PubMed] [Cross Ref]
32. Boline P, Kassack K, Bronfort G, Nelson C, Anderson A. Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther. 1995;18:148�54. [PubMed]
33. Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. J Manipulative Physiol Ther. 1998;21:511�9. [PubMed]
34. Castien RF, Windt DA, Grooten A, Dekker J. Effectiveness of manual therapy for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia. 2011;31:133�43. doi: 10.1177/0333102410377362. [PubMed] [Cross Ref]
35. Chaibi A, Tuchin P, Russell M. Manual therapies for migraine: a systematic review. J Headache Pain. 2011;12:127�33. doi: 10.1007/s10194-011-0296-6. [PMC free article] [PubMed] [Cross Ref]
36. Posadzki P, Ernst E. Spinal manipulations for the treatment of migraine: a systematic review of randomized clinical trials. Cephalalgia. 2011;31:964�70. doi: 10.1177/0333102411405226. [PubMed] [Cross Ref]
37. Posadzki P, Ernst E. Spinal manipulations for tension-type headaches: a systematic review of randomized controlled trials. Complement Ther Med. 2012;20:232�9. doi: 10.1016/j.ctim.2011.12.001. [PubMed] [Cross Ref]
38. Racicki S, Gerwin S, DiClaudio S, Reinmann S, Donaldson M. Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review. J Man Manip Ther. 2013;21:113�24. doi: 10.1179/2042618612Y.0000000025. [PMC free article] [PubMed] [Cross Ref]
39. Chaibi A, Russell MB. Manual therapies for cervicogenic headache: a systematic review. J Headache Pain. 2012;13:351�9. doi: 10.1007/s10194-012-0436-7. [PMC free article] [PubMed] [Cross Ref]
40. Chaibi A, Russell MB. Manual therapies for primary chronic headaches: a systematic review of randomized controlled trials. J Headache Pain. 2014;15:67. doi: 10.1186/1129-2377-15-67. [PMC free article] [PubMed] [Cross Ref]
41. Mesa-Jim�nez JA, Lozano-L�pez C, Angulo-D�az-Parre�o S, Rodr�guez-Fern�ndez �L, De-la-Hoz-Aizpurua JL, Fern�ndez-de-las-Pe�as C. Multimodal manual therapy vs. pharmacological care for management of tension type headache: A meta-analysis of randomized trials. Cephalalgia. 2015;35:1323�32. doi: 10.1177/0333102415576226. [PubMed] [Cross Ref]
42. Loney PL, Chambers LW, Bennett KJ, Roberts JG, Stratford PW. Critical appraisal of the health research literature prevalence or incidence of a health problem. Chronic Dis Inj Can. 1998;19:170. [PubMed]
43. Fejer R, Kyvik KO, Hartvigsen J. The Prevalence of neck pain in the world population: a systematic critical review of the literature. Eur Spine. 2006;15:834�48. doi: 10.1007/s00586-004-0864-4. [PMC free article] [PubMed] [Cross Ref]
44. Bishop F, Prescott P, Chan Y, Saville J, von Elm E, Lewith G. Complementary medicine use by men with prostate cancer: a systematic review of prevalence studies. Prostate Cancer Prostatic Dis. 2011;14:1�13. doi: 10.1038/pcan.2010.38. [PubMed] [Cross Ref]
45. Adams J, Barbery G, Lui C-W. Complementary and alternative medicine use for headache and migraine: a critical review of the literature. Headache. 2013;53:459�73. doi: 10.1111/j.1526-4610.2012.02271.x. [PubMed] [Cross Ref]
46. Adams J, Chi-Wai L, Sibbritt D, Broom A, Wardle J, Homer C. Attitudes and referral practices of maternity care professionals with regard to complementary and alternative medicine: an integrative review. J Adv Nurs. 2011;67:472�83. doi: 10.1111/j.1365-2648.2010.05510.x. [PubMed] [Cross Ref]
47. Solomon D, Adams J. The use of complementary and alternative medicine in adults with depressive disorders. A critical integrative review. J Affect Disord. 2015;179:101�13. doi: 10.1016/j.jad.2015.03.031. [PubMed] [Cross Ref]
48. Vukovi? V, Plavec D, Lovrenci? Huzjan A, Budisi? M, Demarin V. Treatment of migraine and tension-type headache in Croatia. J Headache Pain. 2010;11:227�34. doi: 10.1007/s10194-010-0200-9. [PMC free article] [PubMed] [Cross Ref]
49. Cooke LJ, Becker WJ. Migraine prevalence, treatment and impact: the canadian women and migraine study. Can J Neurol Sci. 2010;37:580�7. doi: 10.1017/S0317167100010738. [PubMed] [Cross Ref]
50. Wells RE, Bertisch SM, Buettner C, Phillips RS, McCarthy EP. Complementary and alternative medicine use among adults with migraines/severe headaches. Headache. 2011;51:1087�97. doi: 10.1111/j.1526-4610.2011.01917.x. [PMC free article] [PubMed] [Cross Ref]
51. Wells RE, Phillips RS, Schachter SC, McCarthy EP. Complementary and alternative medicine use among US adults with common neurological conditions. J Neurol. 2010;257:1822�31. doi: 10.1007/s00415-010-5616-2. [PMC free article] [PubMed] [Cross Ref]
52. Lyngberg AC, Rasmussen BK, J�rgensen T, Jensen R. Secular changes in health care utilization and work absence for migraine and tension-type headache: a population based study. Eur J Epidemiol. 2005;20:1007�14. doi: 10.1007/s10654-005-3778-5. [PubMed] [Cross Ref]
53. Rossi P, Di Lorenzo G, Malpezzi MG, Faroni J, Cesarino F, Di Lorenzo C, Nappi G. Prevalence, pattern and predictors of use of complementary and alternative medicine (CAM) in migraine patients attending a headache clinic in Italy. Cephalalgia. 2005;25:493�506. doi: 10.1111/j.1468-2982.2005.00898.x. [PubMed] [Cross Ref]
54. Minen MT, Seng EK, Holroyd KA. Influence of family psychiatric and headache history on migraine-related health care utilization. Headache. 2014;54:485�92. doi: 10.1111/head.12300. [PubMed] [Cross Ref]
55. Xue C, Zhang A, Lin V, Myers R, Polus B, Story D. Acupuncture, chiropractic and osteopathy use in Australia: a national population survey. BMC Public Health. 2008;8:105. doi: 10.1186/1471-2458-8-105. [PMC free article] [PubMed] [Cross Ref]
56. Gaumer G. Factors associated with patient satisfaction with chiropractic care: survey and review of the literature. J Manipulative Physiol Ther. 2006;29:455�62. doi: 10.1016/j.jmpt.2006.06.013. [PubMed] [Cross Ref]
57. Ndetan HT, Bae S, Evans MW, Jr, Rupert RL, Singh KP. Characterization of health status and modifiable risk behavior among United States adults using chiropractic care as compared with general medical care. J Manipulative Physiol Ther. 2009;32:414�22. doi: 10.1016/j.jmpt.2009.06.012. [PubMed] [Cross Ref]
58. Rossi P, Di Lorenzo G, Faroni J, Malpezzi MG, Cesarino F, Nappi G. Use of complementary and alternative medicine by patients with chronic tension-type headache: results of a headache clinic survey. Headache. 2006;46:622�31. doi: 10.1111/j.1526-4610.2006.00412.x. [PubMed] [Cross Ref]
59. Rossi P, Torelli P, Di Lorenzo C, Sances G, Manzoni GC, Tassorelli C, Nappi G. Use of complementary and alternative medicine by patients with cluster headache: results of a multi-centre headache clinic survey. Complement Ther Med. 2008;16:220�7. doi: 10.1016/j.ctim.2007.05.002. [PubMed] [Cross Ref]
60. Ossendorf A, Schulte E, Hermann K, Hagmeister H, Schenk M, Kopf A, Schuh-Hofer S, Willich SN, Bergh�fer A. Use of complementary medicine in patients with chronic pain. Eur J Integrative Med. 2009;1:93�8. doi: 10.1016/j.eujim.2009.05.002. [Cross Ref]
61. Brown BT, Bonello R, Fernandez-Caamano R, Eaton S, Graham PL, Green H. Consumer characteristics and perceptions of chiropractic and chiropractic services in Australia: results from a cross-sectional survey. J Manipulative Physiol Ther. 2014;37:219�29. doi: 10.1016/j.jmpt.2014.01.001. [PubMed] [Cross Ref]
62. Cherkin DC, Deyo RA, Sherman KJ, Hart LG, Street JH, Hrbek A, Davis RB, Cramer E, Milliman B, Booker J, et al. Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. J Am Board Fam Med. 2002;15:463�72. [PubMed]
63. Jackson P. Summary of the 2000 ACA professional survey on chiropractic practice. J Am Chiro Assn. 2001;38:27�30.
64. French S, Charity M, Forsdike K, Gunn J, Polus B, Walker B. Chiropractic Observation and Analysis Study (COAST): providing an understanding of current chiropractic practice. Med J Aust. 2013;10:687�91. [PubMed]
65. Ailliet L, Rubinstein SM, de Vet HCW. Characteristics of chiropractors and their patients in Belgium. J Manipulative Physiol Ther. 2010;33:618�25. doi: 10.1016/j.jmpt.2010.08.011. [PubMed] [Cross Ref]
66. Coulter I, Hurwitz E, Adams A, Genovese B, Hays R, Shekelle P. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine (Phila Pa 1976) 2002;27:291�8. doi: 10.1097/00007632-200202010-00018. [PubMed] [Cross Ref]
67. Rubinstein S, Pfeifle CE, van Tulder MW, Assendelft WJJ. Chiropractic patients in the Netherlands: A descriptive study. J Manipulative Physiol Ther. 2000;23:557�63. doi: 10.1067/mmt.2000.109675. [PubMed] [Cross Ref]
68. Hartvigsen J, Bolding-Jensen O, Hviid H, Grunnet-Nilsson N. Danish chiropractic patients then and now�a comparison between 1962 and 1999. J Manipulative Physiol Ther. 2003;26:65�9. doi: 10.1067/mmt.2003.14. [PubMed] [Cross Ref]
69. Brown B, Bonello R, Fernandez-Caamano R, Graham P, Eaton S, Green H. Chiropractic in Australia : a survey of the general public. Chiropractic J Aust. 2013;43:85�92.
70. Gaul C, Eismann R, Schmidt T, May A, Leinisch E, Wieser T, Evers S, Henkel K, Franz G, Zierz S. Use of complementary and alternative medicine in patients suffering from primary headache disorders. Cephalalgia. 2009;29:1069�78. doi: 10.1111/j.1468-2982.2009.01841.x. [PubMed] [Cross Ref]
71. Malone CD, Bhowmick A, Wachholtz AB. Migraine: treatments, comorbidities, and quality of life, in the USA. J Pain Res. 2015;8:537�47. doi: 10.2147/JPR.S88207. [PMC free article] [PubMed] [Cross Ref]
72. Gaul C, Schmidt T, Czaja E, Eismann R, Zierz S. Attitudes towards complementary and alternative medicine in chronic pain syndromes: a questionnaire-based comparison between primary headache and low back pain. BMC Complement Altern Med. 2011;11:1�8. doi: 10.1186/1472-6882-11-89. [PMC free article] [PubMed] [Cross Ref]
73. Karakurum Goksel B, Coskun O, Ucler S, Karatas M, Ozge A, Ozkan S. Use of complementary and alternative medicine by a sample of Turkish primary headache patients. Agri Dergisi. 2014;26:1�7. [PubMed]
74. Morin C, Aubin A. Primary reasons for osteopathic consultation: a prospective survey in quebec. PLoS One. 2014;9:e106259. doi: 10.1371/journal.pone.0106259. [PMC free article] [PubMed] [Cross Ref]
75. Orrock PJ. Profile of members of the Australian osteopathic association: part 2 � the patients. Int J Osteopath Med. 2009;12:128�39. doi: 10.1016/j.ijosm.2009.06.001. [Cross Ref]
76. Bethell C, Kemper KJ, Gombojav N, Koch TK. Complementary and conventional medicine use among youth with recurrent headaches. Pediatrics. 2013;132:e1173�e83. doi: 10.1542/peds.2013-1816. [PMC free article] [PubMed] [Cross Ref]
77. Lambert TD, Morrison KE, Edwards J, Clarke CE. The use of complementary and alternative medicine by patients attending a UK headache clinic. Complement Ther Med. 2010;18:128�34. doi: 10.1016/j.ctim.2010.05.035. [PubMed] [Cross Ref]
78. von Peter S, Ting W, Scrivani S, Korkin E, Okvat H, Gross M, Oz C, Balmaceda C. Survey on the use of complementary and alternative medicine among patients with headache syndromes. Cephalalgia. 2002;22:395�400. doi: 10.1046/j.1468-2982.2002.00376.x. [PubMed] [Cross Ref]
79. Kristoffersen ES, Aaseth K, Grande RB, Lundqvist C, Russell MB. Self-reported efficacy of complementary and alternative medicine: the Akershus study of chronic headache. J Headache Pain. 2013;13:113�20. doi: 10.1007/s10194-011-0391-8. [PMC free article] [PubMed] [Cross Ref]
80. Sobri M, Lamont A, Alias N, Win M. Red flags in patients presenting with headache: clinical indications for neuroimaging. Br J Radiol. 2014;76(908):532�35. [PubMed]
81. Carville S, Padhi S, Reason T, Underwood M, Group GD. Diagnosis and management of headaches in young people and adults: summary of NICE guidance. BMJ. 2012;345:e5765. doi: 10.1136/bmj.e5765. [PubMed] [Cross Ref]
82. Puentedura EJ, March J, Anders J, Perez A, Landers MR, Wallmann HW, Cleland JA. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? a review of 134 case reports. J Man Manip Ther. 2012;20:66�74. doi: 10.1179/2042618611Y.0000000022. [PMC free article] [PubMed] [Cross Ref]
83. Becker C, Brobert GP, Almqvist PM, Johansson S, Jick SS, Meier CR. Migraine incidence, comorbidity and health resource utilization in the UK. Cephalalgia (Wiley-Blackwell) 2008;28:57�64. doi: 10.1111/j.1468-2982.2007.01469.x. [PubMed] [Cross Ref]
84. Brandes JL. Global trends in migraine care: results from the MAZE survey. CNS Drugs. 2002;16:13�8. doi: 10.2165/00023210-200216001-00003. [PubMed] [Cross Ref]
85. Radtke A, Neuhauser H. Prevalence and burden of headache and migraine in Germany. Headache. 2009;49:79�89. doi: 10.1111/j.1526-4610.2008.01263.x. [PubMed] [Cross Ref]
86. Zeeberg P, Olesen J, Jensen R. Efficacy of multidisciplinary treatment in a tertiary referral headache centre. Cephalalgia (Wiley-Blackwell) 2005;25:1159�67. doi: 10.1111/j.1468-2982.2005.00980.x. [PubMed] [Cross Ref]
87. Wallasch T-M, Angeli A, Kropp P. Outcomes of a headache-specific cross-sectional multidisciplinary treatment program. Headache. 2012;52:1094�105. doi: 10.1111/j.1526-4610.2012.02189.x. [PubMed] [Cross Ref]
88. Wallasch T-M, Hermann C. Validation of criterion-based patient assignment and treatment effectiveness of a multidisciplinary modularized managed care program for headache. J Headache Pain. 2012;13:379�87. doi: 10.1007/s10194-012-0453-6. [PMC free article] [PubMed] [Cross Ref]
89. Gaul C, Visscher CM, Bhola R, Sorbi MJ, Galli F, Rasmussen AV, Jensen R. Team players against headache: multidisciplinary treatment of primary headaches and medication overuse headache. J Headache Pain. 2011;12:511�9. doi: 10.1007/s10194-011-0364-y. [PMC free article] [PubMed] [Cross Ref]
Close Accordion
Blank
References
1. Dartmouth Atlas Working Group. Dartmouth Atlas of Musculoskeletal Health Care. Chicago, IL: American Hospital Association Press; 2000.
2. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine. 1983;8:131�40. [PubMed]
3. Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica. Spine. 1996;21:1777�86. [PubMed]
4. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356:2245�56. [PubMed]
5. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. Jama. 2006;296:2451�9. [PMC free article] [PubMed]
6. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. Jama. 2006;296:2441�50. [PMC free article] [PubMed]
7. Birkmeyer NJ, Weinstein JN, Tosteson AN, et al. Design of the Spine Patient outcomes Research Trial (SPORT) Spine. 2002;27:1361�72. [PMC free article] [PubMed]
8. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT) Spine (Phila Pa 1976) 2008;33:2789�800. [PMC free article] [PubMed]
9. Delamarter R, McCullough J. Microdiscectomy & Microsurgical Laminotomies. In: Frymoyer J, editor. The Adult Spine: Principles and Practice. 2. Philadelphia: Lippincott-Raven Publishers; 1996.
10. McHorney CA, Ware JE, Jr, Lu JF, et al. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32:40�66. [PubMed]
11. Daltroy LH, Cats-Baril WL, Katz JN, et al. The North American Spine Society lumbar spine outcome assessment Instrument: reliability and validity tests. Spine. 1996;21:741�9. [PubMed]
12. Deyo RA, Diehl AK. Patient satisfaction with medical care for low-back pain. Spine. 1986;11:28�30. [PubMed]
13. Atlas SJ, Deyo RA, Patrick DL, et al. The Quebec Task Force classification for Spinal Disorders and the severity, treatment, and outcomes of sciatica and lumbar spinal stenosis. Spine. 1996;21:2885�92. [PubMed]
14. Patrick DL, Deyo RA, Atlas SJ, et al. Assessing health-related quality of life in patients with sciatica. Spine. 1995;20:1899�908. discussion 909. [PubMed]
15. Fitzmaurice G, Laird N, Ware J. Applied Longitudinal Analysis. Philadelphia, PA: John Wiley & Sons; 2004.
16. Diggle PJ, Liang K-Y, Zeger SL. Analysis of Longitudinal Data. Oxford, England, UK: Oxford University Press; 1994.
17. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. Journal of the American Statistical Association. 1958;53:457�81.
18. Peto R, Peto J. Asymptotically Efficient Rank Invariant Test Procedures. Journal of the Royal Statistical Society Series a-General. 1972;135:185.
19. Meinert CL. Clinical Trials: Design, Conduct, and Analysis. New York, NY: Oxford University Press, Inc; 1986.
20. Peul WC, van den Hout WB, Brand R, et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. Bmj. 2008;336:1355�8. [PMC free article] [PubMed]
21. Atlas SJ, Keller RB, Chang Y, et al. Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: five-year outcomes from the Maine Lumbar Spine Study. Spine. 2001;26:1179�87. [PubMed]
22. Atlas SJ, Keller RB, Wu YA, et al. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine. 2005;30:927�35. [PubMed]
23. Sitlani CM, Heagerty PJ, Blood EA, et al. Longitudinal structural mixed models for the analysis of surgical trials with noncompliance. Statistics in medicine. 2012;31:1738�60. [PMC free article] [PubMed]
Close Accordion
Migraine and Cervical Disc Herniation Treatment In El Paso, TX Chiropractor

Migraine and Cervical Disc Herniation Treatment In El Paso, TX Chiropractor

by | Herniated Disc, Migraine, Physical Rehabilitation, Randomized Controlled Trial, Treatments

Migraine is a debilitating condition characterized by a headache of varying intensity, often accompanied by nausea and sensitivity to light and sound. While researchers today still don’t understand the true reason behind this primary headache disorder, many healthcare professionals believe a misalignment of the cervical spine can lead to migraine. However, new evidence-based research studies have determined that cervical disc herniation, a health issue associated with the intervertebral discs of the upper spine, may also cause head pain. The purpose of the following article is to educate patients and help them understand the source of their symptoms as well as to demonstrate several types of treatment effective for migraine and cervical disc herniation.

 

Manual Therapies for Primary Chronic Headaches: a Systematic Review of Randomized Controlled Trials

 

Abstract

 

This is to our knowledge the first systematic review regarding the efficacy of manual therapy randomized clinical trials (RCT) for primary chronic headaches. A comprehensive English literature search on CINHAL, Cochrane, Medline, Ovid and PubMed identified 6 RCTs all investigating chronic tension-type headache (CTTH). One study applied massage therapy and five studies applied physiotherapy. Four studies were considered to be of good methodological quality by the PEDro scale. All studies were pragmatic or used no treatment as a control group, and only two studies avoided co-intervention, which may lead to possible bias and makes interpretation of the results more difficult. The RCTs suggest that massage and physiotherapy are effective treatment options in the management of CTTH. One of the RCTs showed that physiotherapy reduced headache frequency and intensity statistical significant better than usual care by the general practitioner. The efficacy of physiotherapy at post-treatment and at 6 months follow-up equals the efficacy of tricyclic antidepressants. Effect size of physiotherapy was up to 0.62. Future manual therapy RCTs are requested addressing the efficacy in chronic migraine with and without medication overuse. Future RCTs on headache should adhere to the International Headache Society�s guidelines for clinical trials, i.e. frequency as primary end-point, while duration and intensity should be secondary end-point, avoid co-intervention, includes sufficient sample size and follow-up period for at least 6 months.

 

Keywords: Randomized clinical trials, Primary chronic headache, Manual therapies, Massage, Physiotherapy, Chiropractic

 

Introduction

 

Primary chronic headaches i.e. chronic migraine (CM), chronic tension-type headache (CTTH) and chronic cluster headache has significant health, economic and social costs. About 3% of the general population suffers from chronic headache with female predominance [1]. The International Classification of Headache Disorders III ? (ICDH-III ?) defines CM as ?15 headache days/month for at least 3 months with features of migraine in ?8 days/month, CTTH is defined as on average ?15 days/month with tension-type headache for at least 3 months, and chronic cluster headache as attacks at least every other day for more than 1 year without remission, or with remissions lasting <1 month [2].

 

About 80% consult their primary physician for primary chronic headache [3], and pharmacological management is considered first line of treatment. However, the risk is that it may cause overuse of acute headache medication due to frequent headache attacks. 47% of those with primary chronic headache in the general Norwegian population overused acute headache medication [1,4]. Considering the high use of acute medication, both prophylactic medication and non-pharmacological management should therefore be considered in the management [5,6]. Prophylactic medication is used only by 3% in the general Norwegian population, while 52% have tried physiotherapy and 28% have tried chiropractic spinal manipulative therapy [3]. Non-pharmacological management has furthermore the advantage of few and usually minor transient adverse events and no pharmacological interaction/adverse event [7].

 

Previous systematic reviews have focused on RCTs for tension-type headache, migraine and/or cervicogenic headache, but not on efficacy on primary chronic headache [5,6,8-11]. Manual therapy is a physical treatment used by physiotherapists, chiropractors, osteopaths and other practitioners to treat musculoskeletal pain and disability, and includes massage therapy, joint mobilization and manipulation [12].

 

This is to our knowledge the first systematic review assessing the efficacy of manual therapy randomized controlled trials (RCT) for primary chronic headache using headache frequency as primary end-point and headache duration and intensity as secondary end-points.

 

Review

 

Methods

 

The English literature search was done on CINHAL, Cochrane, Medline, Ovid and PubMed. Search words were; migraine, chronic migraine, tension-type headache, chronic tension-type headache, cluster headache, chronic cluster headache combined with the words; massage therapy, physiotherapy, spinal mobilization, manipulative therapy, spinal manipulative therapy, osteopathic treatment or chiropractic. We identified studies by a comprehensive computerized search. Relevant reviews were screened for additional relevant RCTs. The selection of articles was performed by the authors. All RCTs written in English using either of the manual therapies for CM, CTTH and/or chronic cluster headache were evaluated. Studies including combined headache types without specific results for CM, CTTH and/or chronic cluster headache were excluded. The review included manual therapy RCTs presenting at least one of the following efficacy parameters; headache frequency, duration and pain intensity for CM, CTTH and/or chronic cluster headache as recommended by the International Headache Society�s clinical trial guidelines [13,14]. Headache frequency is a primary end-point, while duration and pain intensity are secondary end-points. Headache diagnoses were preferentially classified according to the criteria of ICHD-III ? or previous editions [2,15-17]. The methodological quality of the included RCTs was evaluated using the PEDro scale, Table 1[18]. A RCT was considered to be of high quality if the PEDro score was ?6 of a maximum score of 10. The methodological quality of the RCTs was assessed by AC. The PRISMA 2009 checklist was applied for this systematic review. Effect size was calculated when possible. Effect size of 0.2 was regarded as small, 0.5 as medium and 0.8 as large [19].

 

Table-1-PEDro-Score-Yes-or-No-Items.png

Table 1: PEDro score yes or no items.

 

This systematic review was executed directly based on the ascertained RCTs available and has not been registered as a review protocol.

 

Results

 

The literature search identified six RCTs that met our inclusion criteria. One study applied massage therapy (MT) and five studies applied physiotherapy (PT) [20-25]. All studies assessed CTTH, while no studies assessed CM or chronic cluster headache.

 

Methodological quality Table 2 shows that the methodological PEDro score of the included RCTs ranged from 1 to 8 points. Four RCTs were considered of good methodological quality, while two RCTs had lower scores.

 

Table 2 The Methodological PEDro Score of the Included RCTs

Table 2: The methodological PEDro score of the included randomized controlled trials (RCTs).

 

Randomized controlled trials (RCT) Table 3 shows the study population, intervention and efficacy of the six RCTs.

 

Table 3 Results of Manual Therapy RCTs of CTTH

Table 3: Results of manual therapy randomized controlled trials (RCTs) of chronic tension-type headache (CTTH).

 

Massage therapy A Spanish physiotherapist conducted a 2-armed prospective crossover RCT with pairwise comparisons and blinded outcome measures [20]. The study included participants with CTTH diagnosed by a neurologist. The ICHD-II criteria for CTTH were slightly modified, i.e. pain intensity was defined as ?5 on a 0-10 numeric pain rating scale, and the accompanying symptoms photophobia, phonophobia or mild nausea was not allowed [16]. Primary and secondary end-points were not specified. Results are shown in Table 3.

 

Physiotherapy An American 3-armed retrospectively RCT had unblinded outcome measures [21]. The diagnostic criteria were ?25 headache days/month for >6 months without associated symptoms nausea, vomiting, photo- and phonophobia, but with tender muscles, i.e. CTTH with pericranial tenderness. Participants with cervicogenic headache or neurological findings were excluded. Primary and secondary end-points were not pre-specified, but headache index, defined here as headache frequency � severity, was the evaluated end-point.

 

A Turkish study conducted a 2-armed prospective RCT with unblinded outcome measures [22]. The participants were diagnosed with CTTH according to ICHD-I [15]. Participants with mixed headache, neurological and systemic aliment, or participants whom had received physiotherapy within 6 months prior to the study were excluded. Primary end-points was headache index defined as frequency � severity.

 

A Danish study conducted a 2-armed prospective RCT with blinded outcome measures [23]. Participants were diagnosed CTTH by a neurologist according to the criteria of ICHD-I [15]. Participants with other primary headaches, neuralgia, neurological, systemic or psychiatric disorders or medication overuse defined as >100 analgesic tablets or >2 doses of triptans and ergotamine per month were excluded. The primary end-point was headache frequency, and the secondary end-points were headache duration and intensity. The results shown in Table 3 were not influenced by pericranial muscles tenderness.

 

A Dutch study conducted a 2-armed prospective, multicentre RCT with blinded outcome measures [24]. Participants were diagnosed with CTTH by a physician according to ICHD-I [15]. Participants with multiple headache types or those whom had received physiotherapy within the last 6 months were excluded. Primary end-points were headache frequency while duration and intensity were secondary end-points.

 

The 2nd Dutch study conducted a 2-armed prospective pragmatic, multicentre RCT with self-reported primary and secondary end-points, i.e. headache frequency, duration and intensity [25]. Participants were diagnosed by a physician according to the criteria of ICHD-II [16]. Participants with rheumatoid arthritis, suspected malignancy, pregnancy, non-Dutch speaking, those whom had received physiotherapy within the last 2 months, triptan, ergotamine or opiods users were excluded.

 

Discussion

 

The current systematic review evaluating the efficacy of manual therapy in RCTs for primary chronic headaches only identified RCTs treating CTTH. Thus, the efficacy of CM and chronic cluster headache could not be evaluated in this review.

 

Methodological considerations The methodological quality of studies assessing manual therapies for headache disorders are frequently being criticised for being too low. Occasionally rightly so, but often do the methodological design prevent manual therapy studies from reaching what is considered gold standard in pharmacological RCTs. For instance, a placebo treatment is difficult to establish while the investigator cannot be blinded for its applied intervention. The average score of the included studies was 5.8 (SD 2.6) points and four studies were considered of good quality. All RCTs failed to include sample size ?50 in the smallest group. Sufficient sample size with power calculation prior is important to confine type 2 errors. Three studies did not state primary and secondary end-points, which confound effect-size calculation, and risk of type 2 errors inferred from multiple measures [20-22]. Conducting a manual therapy RCT is both time and cost consuming, while blinding often is difficult as there is no single validated standardized sham-treatment which can be used as a control group to this date. Thus, all of the included studies were pragmatic or used no treatment as a control group.

 

Apart from the participants in the retrospective study [21], all participants were diagnosed by a physician or neurologist. A diagnostic interview is the gold standard, while questionnaire and lay interviews are less precise diagnostic tools regarding headache disorders [26].

 

Co-intervention was only avoided in two studies [22,20]. Two studies performed intention-to-treat analysis which is recommended to protect against odd outcome values and preserve baseline comparability [24,25,27].

 

Results The massage therapy study included only 11 participants, but the massage group had significantly more reduction in their headache intensity than detuned ultrasound group [20].

 

54%, 82% and 85% of the participants in three of the physiotherapy RCTs had a ?50% reduction in headache frequency post-treatment [23-25], and the effect was maintained in the two studies that had a 6 months follow-up [24,25]. This is comparable with the 40-70% of participants whom have a similar effect using tricyclic antidepressants [28,29]. The effect of tricyclic also seems to improve over time, i.e. after more than 6 months treatment [29]. However, tricyclic antidepressants have a series of side effects in contrast to physiotherapy, while manual therapy requires more consultations. Two studies assessed headache index defined as headache frequency � intensity [21,22]. Both studies showed a significant improvement post-treatment and at 1 month and 6 months follow-up respectively.

 

Four of the studies reported 10.1 mean years with headache, thus, the effect observed is likely to be due to the therapeutic effect rather than spontaneous improvement or regression to the mean [21-23,25].

 

Acute headache medication is frequently used for primary headaches, and if the headache frequency increases, there is an increased risk for medication overuse headache. Increased use of prophylactic medication has thus been suggested in the management for primary chronic headaches [3]. Since manual therapies seems to have a beneficial effect that equals the effect of prophylactic medication [28,29], without the pharmacological side effects, manual therapies should be considered on an equal level as pharmacological management strategies.

 

Effect size could be calculated in three of the six RCTs. Effect size on headache frequency was up to 0.62, while it was less regarding duration and intensity, while headache index (frequency � intensity) was up to 0.37 (Table 3). Thus, a small to moderate effect size might however, be substantial to the individual, especially considering that nearly daily headache i.e. mean 12/14 days reduced to mean 3/14 days [25], which equals ?75% reduction in headache frequency. Usually a ?50% reduction is traditionally used in pain trails, but considering the fact that CTTH is difficult to treat, some investigators operate with ?30% improvement of primary efficacy parameter compared with placebo [30].

 

Limitations The present study might have possible biases. One of them being publication bias as the authors made no attempt to identify unpublished RCTs. Although we did perform a comprehensive search, we acknowledge it is possible to miss a single or few RCT, especially non-English RCT.

 

Conclusion

 

Manual therapy has an efficacy in the management of CTTH that equals prophylactic medication with tricyclic antidepressant. At present no manual therapy studies exist for chronic migraine or chronic cluster headache. Future manual therapy RCTs on primary chronic headache should adhere to the recommendation of the International Headache Society, i.e. primary end point is headache frequency and secondary end-points are duration and intensity. Future manual therapy studies on CM with and without medication overuse is also warranted, since such studies do not exist today.

 

Competing Interests

 

The authors declare that they have no competing interests.

 

Authors� Contributions

 

AC prepared the initial draft and performed the methodological assessment of the included studies. MBR had the original idea of the study, planned the overall design and revised the drafted manuscript. Both authors have read and approved the final manuscript.

 

Authors� Information

 

Aleksander Chaibi is a BPT, MChiro, PhD student and Michael Bj�rn Russell is a professor, MD, PhD, DrMedSci.

 

Acknowledgements

 

Akershus University Hospital, Norway, kindly provided research facilities.

 

Funding: The study received funding from Extrastiftelsen, the Norwegian Chiropractic Association in Norway and University of Oslo.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Cervical disc herniation is a common condition which occurs when an intervertebral disc in the neck, or cervical spine, ruptures and its soft, gel-like center leaks out into the spinal canal, adding pressure to the nerve roots. Cervical herniated discs can cause symptoms of pain, numbness and weakness in the neck, shoulders, chest, arms and hands as well as radiating symptoms along the lower extremities. Migraine can also be a symptoms associated with herniated discs in the neck. As we age, the intervertebral discs naturally begin to degenerate, making them more susceptible to damage or injury. Common causes of cervical disc herniation include wear and tear, repetitive movements, improper lifting, injury, obesity and genetics.

 

Long Term Follow-Up of Cervical Intervertebral Disc Herniation in Patients Treated with Integrated Complementary and Alternative Medicine: a Prospective Case Series Observational Study

 

Abstract

 

Background

 

Symptomatic cervical intervertebral disc herniation (IDH) presenting as neck pain accompanied by arm pain is a common affliction whose prevalence continues to rise, and is a frequent reason for integrative inpatient care using complementary and alternative medicine (CAM) in Korea. However, studies on its long term effects are scarce.

 

Methods

 

A total 165 patients with cervical IDH admitted between January 2011 and September 2014 to a hospital that provides conventional and Korean medicine integrative treatment with CAM as the main modality were observed in a prospective observational study. Patients underwent CAM treatment administered by Korean medicine doctors (KMDs) in accordance with a predetermined protocol for the length of hospital stay, and additional conventional treatment by medical doctors (MDs) as referred by KMDs. Short term outcomes were assessed at discharge and long term follow-ups were conducted through phone interviews after discharge. Numeric rating scale (NRS) of neck and radiating arm pain, neck disability index (NDI), 5-point patient global impression of change (PGIC), and factors influencing long term satisfaction rates in PGIC were assessed.

 

Results

 

Of 165 patients who received inpatient treatment 20.8?�?11.2 days, 117 completed the long term follow-up up at 625.36?�?196.7 days post-admission. Difference in NRS between admission and discharge in the long term follow-up group (n?=?117) was 2.71 (95 % CI, 2.33, 3.09) for neck pain, 2.33 (95 % CI, 1.9, 2.77) for arm pain, and that of NDI 14.6 (95 % CI, 11.89, 17.32), and corresponding scores in the non-long term follow-up group (n?=?48) were 2.83 (95 % CI, 2.22, 3.45) for neck pain, 2.48 (95 % CI, 1.84, 3.12) for arm pain, and that of NDI was 14.86 (95 % CI, 10.41, 19.3). Difference in long term NRS of neck pain and arm pain from baseline was 3.15 (95 % CI, 2.67, 3.64), and 2.64 (95 % CI, 1.99, 3.29), respectively. PGIC was reported to be �satisfactory� or higher in 79.5 % of patients at long term follow-up.

 

Conclusions

 

Though the observational nature of this study limits us from drawing a more decisive conclusion, these results suggest that integrative treatment focused on CAM in cervical IDH inpatients may achieve favorable results in pain and functional improvement.

 

Trial Registration

 

ClinicalTrials.gov Identifier: NCT02257723. Registered October 2, 2014.

 

Keywords: Cervical intervertebral disc herniation, Complementary and alternative medicine, Integrative treatment, Inpatient treatment

 

Background

 

Neck pain is a common compliant whose point prevalence is estimated at 10�18 %, with lifetime prevalence reaching 30�50 %. Prevalence of neck pain in populations aged 40 or older is approximately 20 % [1, 2]. Neck pain is also related with restricted neck movement [3], and frequently accompanied by headache, dizziness, visual impairment, tinnitus, and autonomic nervous system dysfunction [4, 5]. Frequent concurrent symptoms include upper extremity pain and neurological disorders [6], and neck pain symptoms also persist in many cases leading to work loss due to discomfort [7]. Neck-related disability is generally more serious in patients with radiating pain than pain limited to the neck area [8, 9], and the main characteristic of cervical intervertebral disc herniation (IDH) is arm pain in the region innervated at the herniated disc level and/or compressed nerve root [10, 11].

 

The range of available treatments for cervical IDH is vast, spanning conservative treatments to various surgical modalities. Conservative treatments include NSAIDs, oral steroids, steroid injections, patient education, rest, Thomas collars, and physical therapy [12�14]. Surgical treatment may be considered when conservative treatment fails. Neuropathy from spinal cord compression is an absolute indication for surgery. Other indications include nerve root compression signs and related motor and sensory loss. Relative indications may involve decreased quality of life due to prolonged chronic pain [15]. While surgical treatment may benefit some patients suffering severe neurological symptoms, most studies on neuropathic pain of the spine state that the long term effects are not significant [16�20]. Although studies on the effect of conservative treatment in cervical IDH patients have occasionally been reported, whether it is effective is yet a matter of controversy, and there is a paucity of studies on the effect of complementary and alternative medicine (CAM) treatment.

 

According to Benefits by Frequency of Disease data from the 2013 Korean National Health Insurance Statistical Yearbook [21], 5585 patients received treatment for cervical disc disorders for 99,582 days in outpatient care, of which 100,205 days were covered by the National Health Insurance, and medical treatment expenses eligible for reimbursement surmounted to 5,370,217 Korean Won, with 4,004,731 Korean Won reimbursed. Cervical disc disorders was the 12th most frequent reason for admission to Korean medicine hospitals, showing that it is not uncommon to receive inpatient care for cervical IDH.

 

Such CAM treatments as acupuncture, pharmacopuncture, herbal medicine, and manual therapy are well-sought in Korea to the aim of securing a less invasive, non-surgical method of treatment. Jaseng Hospital of Korean medicine, a Korean medicine hospital accredited by the Korean Ministry of Health and Welfare to specialize in spine disorders, treats over 900,000 spinal disease outpatient cases per year. This hospital manages patients with an integrative system utilizing conventional and Korean medicine, where conventional doctors and Korean medicine doctors (KMDs) cooperate for optimal treatment results. Conventional doctors participate in diagnosis using imaging technology such as X-rays and MRIs, and in treatment by caring for a small percentage of patients potentially in need of more intensive care. KMDs supervise and manage the main treatment of all patients, and decide whether the patient requires additional diagnosis and treatment from a conventional doctor. Cervical IDH patients suffering neck pain or radiating pain unable to receive outpatient treatment are thus provided with concentrated non-surgical integrative treatment during admission.

 

Despite the widespread use of inpatient treatment for cervical IDH encompassing a number of treatment modalities, studies on its treatment effect in patients admitted for cervical IDH are scarce. An integrative inpatient treatment approach with focus on CAM may not be widely available to patients, and the objective of this study is to introduce and assess the feasibility and long term effect of this integrative treatment model in inpatients with cervical IDH using a practical study design.

 

Methods

 

Study Design

 

This study is a prospective observational study. We observed patients with a main complaint of neck pain or radiating arm pain diagnosed as cervical IDH and admitted from January 2011 to September 2014 at Jaseng Hospital of Korean medicine in Korea which provides integrated conventional and Korean medicine services with CAM as the main modality. The authors conducted a long term follow-up by phone interview during March 2015. Outcome measures covered 5 parts: numeric rating scale (NRS), neck disability index (NDI), patient global impression of change (PGIC), ever-surgery after discharge, and current treatment.

 

This study is a report on part of a registry collecting prospective data on integrated treatment for musculoskeletal disorder patients (ClinicalTrials.gov Identifier: NCT02257723). The study protocol was approved by the Institutional Review Boards of Jaseng Hospital of Korean medicine. All participants gave written informed consent prior to participation.

 

Participants

 

Patients meeting the following criteria were included.

 

  1. Admission for treatment of neck pain or radiating arm pain
  2. Cervical IDH confirmed on MRI
  3. Diagnosis by KMD that main cause of chief complaint (neck pain or radiating pain) is cervical IDH

 

Patients meeting the following criteria were excluded.

 

  1. Main complaint other than neck pain or radiating pain
  2. Concomitant musculoskeletal complaint (e.g. low back pain, knee pain)
  3. Cause of neck pain unrelated to cervical IDH (e.g. spinal tumor, pregnancy, rheumatoid arthritis)
  4. Refusal to participate in the study or nonagreement to collection and disclosure of personal information for study purposes

 

KMDs assessed the cause of current neck pain or arm pain symptoms with reference to neurological test results (sensory loss, motor weakness, and tendon reflex) and MRI readings by radiology specialists. Patients who met the proposed inclusion criteria were visited at the inpatient ward on the first day of admission for assessment by a KMD, and followed up using a similar interview and survey process upon discharge. If a patient was admitted multiple times during the study period, only the first admission record was appraised and included.

 

Interventions

 

Though the treatment protocol was comprised with most frequented treatments for cervical IDH patients, any and all treatment methods not included in the treatment protocol were allowed and available to all physicians and patients and use of these treatments (type and frequency) were recorded in electronic medical records pragmatically. Conventional treatments such as pain medications and epidural injections (using local anesthetics such as lidocaine, steroids, and anti-adhesion adjuvants) were administered by a conventional rehabilitation specialist through KMD referral. Only non-surgical treatments were allowed during admission.

 

Complementary and Alternative Medicine Treatment Protocol

 

Herbal medicine was taken 3 times/day in pill (2 g) and water-based decoction form (120 ml) (Ostericum koreanum, Eucommia ulmoides, Acanthopanax sessiliflorus, Achyranthes bidentata, Psoralea corylifolia, Saposhnikovia divaricata, Cibotium barometz, Lycium chinense, Boschniakia rossica, Cuscuta chinensis, Glycine max, and Atractylodes japonica). These herbs were carefully selected from herbs frequently prescribed for IDH treatment in Traditional Chinese Medicine and Korean Medicine [22] and the prescription was further developed through clinical practice [23]. The main ingredients of the herbal medicine used in this study (Acanthopanax sessiliflorus Seem, Achyranthes japonica Nakai, Saposhnikovia divaricata Schischk, Cibotium barometz J. Smith, Glycine max Merrill, and Eucommia ulmoides Oliver) have been studied in vivo and in vitro as GCSB-5 for their anti-inflammatory [24], and nerve [25] and joint protective effects [26], and clinically for non-inferiority in safety and efficacy compared to Celecoxib in treatment of osteoarthritis [27].

 

Acupuncture was administered 1�2 sessions/day at cervical Ah-shi points and acupuncture points pertaining to neck pain. Ah-shi point acupuncture refers to acupuncture needling of painful or pathological sites. Ah-shi points do not exactly match tender points or Buding, Tianying points, but generally correspond to points that induce relaxation or pain upon palpation [28].

 

The pharmacopuncture solution was prepared with ingredients similar to the orally administered herbal medicine (Ostericum koreanum, Eucommia ulmoides, Acanthopanax sessiliflorus, Achyranthes bidentata, Psoralea corylifolia, Saposhnikovia divaricata, Cibotium barometz, Lycium chinense, Boschniakia rossica, Cuscuta chinensis, Glycine max, and Atractylodes japonica) by decocting and freeze drying, then mixing the prepared powder with normal saline and adjusting for acidity and pH. Pharmacopuncture was administered 1 session/day at cervical Hyeopcheok (Huatuo Jiaji, EX B2) and Ah-shi points up to 1 cc using disposable injection needles (CPL, 1 cc, 26G x 1.5 syringe, Shinchang medical co. Korea).

 

Bee-venom pharmacopuncture was applied if the skin reaction test to bee-venom was negative. Diluted bee-venom solution (mixed with normal saline at a ratio of 1000:1) was injected at 4�5 cervical Hyeopcheok (Huatuo Jiaji, EX B2) and Ah-shi points at the physician�s discretion. Each point was injected with about 0.2 cc up to a total 0.5�1 cc using disposable injection needles (CPL, 1 cc, 26G x 1.5 syringe, Shinchang medical co. Korea)

 

Chuna spinal manipulation [29, 30], which is a Korean manipulation method that combines conventional manipulation techniques with high-velocity, low amplitude thrusts to joints slightly beyond the passive range of motion, and manual force within the passive range, was conducted 3�5 sessions/week.

 

Outcome Measures

 

All outcomes were assessed by KMDs who had received prior training and education. Demographic and health behavior characteristics (sex, age, occupation, smoking, alcohol consumption, and underlying disease) were collected on the first day of admission using short surveys on current pain levels and neurological exams. Follow-ups were conducted at 2 weeks post-admission or upon discharge and after discharge.

 

NRS [31] uses an 11-point scale to evaluate current neck pain and radiating pain where no pain is indicated by �0�, and the worst pain imaginable by �10�. NRS was assessed at admission, discharge, and long term follow-up. Due to lack of references on minimum clinically important difference (MCID) of neck pain or radiating pain for NRS, MCID for visual analogue scale (VAS) was used for further evaluation of NRS.

 

The NDI [32] is a 10-item survey that assesses the degree of disability from 0 to 5 in fulfilling daily activities. The total is divided by 50, then multiplied by 100. NDI was assessed at admission and discharge.

 

PGIC [33] was used to assess patient satisfaction rate of current state after admission. Satisfaction was rated with a 5-point scale ranging from very satisfactory, satisfactory, slightly satisfactory, dissatisfactory, and very dissatisfactory at discharge and long term follow-up.

 

Participants underwent physical and neurological examination at admission and discharge for objective motor and sensory evaluation of the cervical region. Range of motion (ROM) for neck flexion and extension, distraction, compression, Valsalva, Spurling, Adson�s, and swallowing tests, and upper extremity motor strength and sensory tests and deep tendon reflex tests were performed.

 

Safety Assessments

 

All potential adverse events regarding treatment, ranging from skin and local reactions to systemic reactions, and including change or aggravation in pain patterns were carefully observed, recorded and reported during admission. Adverse events associated with bee-venom therapy are known to range from skin reactions to severe immunological responses, and therefore adverse reactions including systemic immunological reactions requiring additional treatment (e.g. antihistaminic agents) were closely monitored. . Blood cell count, liver and renal function tests, and inflammatory activity tests were conducted in all patients at admission, and if there was an abnormal finding requiring follow-up as assessed by KMDs and conventional doctors, relevant markers were rechecked. A total 46 patients were judged to require follow-up at admission by KMDs and conventional doctors and were followed up accordingly during hospital stay, of which 9 patients showed abnormal findings in liver function at admission. Liver function was tracked in these nine patients. Presence of liver injury was also measured to assess possibility of drug-induced liver injury from herbal or conventional medicine intake using a definition of (a) ALT or DB increase of 2� or over the upper limit of normal (ULN) or (b) combined AST, ALP, and TB increase, provided one of them is above 2?�?ULN.

 

Statistical Methods

 

All analyses were conducted using statistical package SAS version 9.3 (SAS Institute, Cary, NC, USA), and p?<?0.05 was regarded to be statistically significant. Continuous data is presented as mean and standard deviation, and categorical data as frequency and percent (%). The mean difference in NRS of neck pain, NRS of radiating pain, and NDI between admission (baseline), discharge and long term follow-up was analyzed for significance with 95 % confidence intervals (CIs). Satisfaction rate assessed with a 5-point Likert scale at long term follow-up was recategorized into binary values of satisfactory (very satisfactory, or satisfactory) and dissatisfactory (slightly satisfactory, dissatisfactory, and very dissatisfactory). Multivariable logistic regression analysis was conducted to calculate odds ratios (ORs) and 95 % CIs, and estimate the influence of predictive factors on satisfaction rate. Baseline factors that met p?<?0.10 in univariate analysis were included in the final model with age and sex, and factors were selected using stepwise method (p?<?0.05).

 

Results

 

During the study period 784 patients with neck disorders were admitted, and of these, 234 patients were diagnosed with cervical IDH with no other major musculoskeletal complaints. Of the 234 cervical IDH patients, 175 patients had no missing values in NRS and NDI at admission and at 2 weeks post-admission or at discharge (short term follow-up). Ten patients were re-admissions and after inclusion of initial admission data if initial admission was during the study period, 165 patients remained. Long term follow-up assessments were conducted in 117 patients. In the non-long term follow-up group (n?=?48), 23 patients did not answer the phone, 10 refused to participate in the long term follow-up, and 15 had since changed number or had incoming calls barred (Fig. 1). Baseline characteristics by long term follow-up group and non-long term follow-up group are listed in Table 1. Though there were no other marked differences between the 2 groups, 29 patients in the long term follow-up group had been recommended surgery (24.8 %), while only 1 patient in the non-long term follow-up group (0.02 %) had been recommended.

 

Figure 1 Flow Diagram of the Study

Figure 1: Flow Diagram of the Study

 

Table 1 Baseline Demographic Characteristics

Table 1: Baseline demographic characteristics.

 

Average length of hospital stay was 20.8?�?11.2 days. The majority of participants received inpatient treatment focused on Korean medicine and CAM. Herbal medicine was taken in accordance with the treatment protocol in decoction form by 81.8 % of patients and in pill form in 86.1 %, and the other patients were prescribed other herbal medicines at the KMD�s discretion. In use of conventional treatments not specified in the CAM treatment protocol, 18.2 % patients took analgesic medications or intramuscular injections an average 2.7?�?2.3 times, and 4.8 % patients were administered 1.6?�?0.5 epidural injections during hospital stay (Table 2). We did not implement restrictions in pharmacological treatment for study purposes, and allowed conventional medicine physicians full freedom to assess and prescribe conventional medicine as the physician deemed necessary for the patient. NSAIDs, antidepressants, and muscle relaxants were the main medicines used, and opioids were administered in the short-term in only 2 patients.

 

Table 2 Length of Hospital Stay and Interventions Administered During Stay

Table 2: Length of hospital stay and interventions administered during stay.

 

NRS of neck pain, NRS of radiating pain, and NDI all decreased significantly at discharge and at long term follow-up compared to baseline (admission) (Table 3). The major site of pain of neck and radiating arm pain showed a decrease larger than MCID (NRS decrease of 2.5 or larger in neck pain or radiating pain), and NDI scores also improved over the MCID score of 7.5 [34, 35]. Difference in NRS at discharge in the long term follow-up group (n?=?117) was 2.71 (95 % CI, 2.33, 3.09) for neck pain, 2.33 (95 % CI, 1.9, 2.77) for arm pain, and that of NDI, 14.6 (95 % CI, 11.89, 17.32). Difference in NRS at long term follow-up for neck pain and arm pain from baseline was 3.15 (95 % CI, 2.67, 3.64) and 2.64 (95 % CI, 1.99, 3.29), respectively. Difference in NRS at discharge in the non-long term follow-up group (n?=?48) was 2.83 (95 % CI, 2.22, 3.45) for neck pain, 2.48 for arm pain (95 % CI, 1.84, 3.12), and that of NDI was 14.86 (95 % CI, 10.41, 19.3). The between-group difference in effect between admission and discharge in the long term follow-up and non-long term follow-up patients was not significant (NRS of neck pain : p-value?=?0.741; NRS of radiating arm pain: p-value?=?0.646; Neck disability index: p-value?=?0.775).

 

Table 3 Comparison of Numeric Rating Scale, Radiating Arm Pain and Neck Disability Index Score

Table 3: Comparison of numeric rating scale for neck and radiating arm pain and neck disability index score in long term follow-up group and non-long term follow-up group.

 

The average period from admission to long term follow-up was 625.36?�?196.7 days. All 165 patients answered the PGIC at discharge, and of these patients 84.2 % replied that their state was �satisfactory� or higher. A total 117 patients replied to PGIC at long term follow-up, and 79.5 % rated their current state to be �satisfactory� or higher. PGIC was reported to be very satisfactory in 48 patients (41.0 %), satisfactory in 45 (38.5 %), slightly satisfactory in 18 (15.4 %), and dissatisfactory in 6 (5.1 %). Nine patients had undergone surgery (7.6 %), while 21 patients replied that they were currently receiving treatment. Of patients currently under treatment, 10 patients (8.5 %) continued to receive CAM, 12 patients (10.3 %) had selected conventional treatment, and 1 patient was receiving both (Table 4).

 

Table 4 Period from Admission Date to Long Term Follow Up and Patient Global Impression of Change

Table 4: Period from admission date to long term follow-up, and patient global impression of change, ever-surgery and current treatment status in long term follow-up group.

 

Sex, age, and unilateral radiating pain satisfied p?<?0.10 in univariate analysis of baseline characteristics. Satisfaction rate increased with older age in multivariate analysis. Patients with unilateral radiating arm pain tended to be more satisfied with treatment that those without radiating pain. Also, patients receiving CAM treatment showed higher satisfaction rates than patients receiving no treatment (Table 5).

 

Table 5 Assessment of Predictive Baseline Factors

Table 5: Assessment of predictive baseline factors associated with satisfaction rate.

 

Liver function was measured in all patients at admission, and nine patients with liver enzyme abnormalities at admission received follow-up blood tests at discharge. Liver enzyme levels returned to normal in 6 patients at discharge, while 2 retained liver enzyme abnormalities, and 1 patient sustained liver injury and on further assessment was diagnosed with active hepatitis showing Hbs antigen positive and Hbs antibody negative. There were no cases of systemic immunological reactions to bee venom pharmacopuncture requiring additional treatment and no other adverse events were reported.

 

Discussion

 

These results show that inpatient treatment primarily focused on CAM maintains long term effects of pain relief and functional improvement in cervical IDH patients with neck pain or radiating arm pain. NRS and NDI scores at discharge and at long term follow-up all displayed significant decrease. Also, as statistical significance and clinical significance may differ, we checked for MCID and confirmed that both NRS and NDI scores improved over MCID. MCID has been reported at 2.5 in VAS for neck pain and radiating arm pain, and 7.5 in NDI scores [34, 35]. Average improvement in pain and functionality scales all exceeded MCID, and these results are likely to be reflected in patient satisfaction rate. Out of 165 patients, 128 patients (84.2 %) rated their current state as �satisfactory� or higher at discharge. At long term follow-up, 9 (7.6 %) out of 117 patients were confirmed to have received neck surgery, and most patients showed continued decrease in NRS and NDI. In addition, 96 patients (82.1 %) currently did not receive treatment for neck pain symptoms, and 93 patients (79.5 %) replied their state was �satisfactory� or higher. As comparison of between-group difference in the long term follow-up and non-long term follow-up patients was not designed a priori, this data may be regarded to be a post hoc data analysis. The between-group difference in effect between admission and discharge in the long term follow-up and non-long term follow-up patients was not significant, and in MCID, which could be considered a more clinical measure, the 2 groups produced comparable results.

 

Despite the fact that all patients underwent intensive Korean medicine treatment for the duration of hospital stay, no adverse events related to treatment were reported, demonstrating the safety of integrative medicine with focus on CAM. The authors had previously conducted a retrospective study to assess safety of herbal medicine and combined intake of herbal and conventional medicine in liver function test results of 6894 inpatients hospitalized at Korean medicine hospitals, and test results of the cervical disc herniation patients included in the present study were also described [36].

 

A major strength of this study is that it depicts clinical practice and the results reflect treatment as it is actually practiced in Korea in conventional and Korean medicine integrative treatment settings focused on CAM. Protocol treatment was standardized and comprised of interventions whose efficacy has been confirmed in pilot studies and frequently used in clinical practice, but the protocol also allowed for individual tailoring according to patient characteristics and symptoms as seen necessary by KMDs, and the percentage and frequency of these deviations were recorded. The satisfaction rate assessed at discharge not only reflects patient attitude toward treatment effect, but also increased medical costs entailed by inclusion of various treatments. Taking into account that the participants of this study were not patients recruited through advertisements, but patients visiting a Korean medicine hospital from personal choice receiving no economic compensation for study participation, the fact that most patients� satisfaction rate was high is particularly noteworthy. The results of this study contribute to an evidence base for superior efficacy of compositive treatment over individual treatment in patients diagnosed with cervical IDH, and verify feasibility of clinical implementation with consideration for increased compositive treatment costs.

 

The largest limitation of our study is probably the inherent quality of a prospective observational study lacking a control. We are unable to draw conclusions on whether the suggested CAM integrative treatment is superior to an active control (e.g. surgery, conventional non-surgical intervention) or the natural course of disease. Another limitation is the heterogeneity of the patient groups and treatment composition. Participants were cervical IDH patients of varying symptoms, severity and chronicity whose progress are generally known to differ, and interventions included conventional treatments such as epidural injections or pain medications in some cases. Therefore it would be more accurate to construe these results to be the effect of a conventional and Korean medicine integrative treatment system than that solely of CAM integrative treatment. The compliance rate of 74 % (n?=?175) at 2 weeks post-admission or discharge out of 234 admitted patients is low, especially considering the short follow-up period. This low compliance may be related to patient attitude toward study participation. As participants did not receive direct compensation for trial participation, they may have lacked incentive to continue participation, and the possibility that patients who refused follow-up assessment were dissatisfied with admission treatment should be considered. Long term assessment was conducted by phone interview in 117 patients (70 %) out of 165 baseline participants partly due to lapse in time, which limited the amount and quality of long term information that could be gathered and led to further patient loss from loss of contact.

 

Another limitation is that we failed to conduct more comprehensive medical evaluations. For example, although participants were diagnosed as disc herniation to be the main pathology based on MRI readings and neurological symptoms by KMDs, additional imaging information such as pathological disc level and severity of herniation were not collected. Also, data on subsequent recurrences, duration of all episodes and whether some were absolutely cured were not included in long term follow-up assessments, limiting multidimensional evaluation. In addition, while these cervical IDH patients required admission for severe neck and arm pain and consequent functional disability, the fact that this was the first attack of neck pain for many may have been cause for more favorable outcome.

 

However, the influence of long term follow-up compliance may not be confined to availability but potentially be associated with long term treatment effectiveness. As difference in characteristics of long term follow-up and non-long term follow-up patients may be reflected in short-term outcomes assessed at discharge and types and amount of additional conventional treatment, the fact that this study did not consider for these potential effects through additional analyses is a further limitation of this study.

 

Controversy still surrounds the efficacy of treatments for cervical IDH. While epidural steroid injections are the commonest modality of conservative treatment used in the United States [37] various systematic reviews show that effects are highly variable and not conclusive [38�44]. Two approaches are widely used in epidural injections: interlaminar and transforaminal approaches. The transforaminal approach has been criticized for safety risks [45�50], and though safer than the transforaminal approach, the interlaminar approach also holds potential risks [51�56]. Reports on the efficacy of conventional medicine for neuropathic pain show conflicting results [57�61], and study results on physical therapy are also inconsistent [62�64].

 

Gebremariam et al. [65] evaluated the efficacy of various cervical IDH treatments in a recent review, and concluded that though the single published study on conservative treatment versus surgery showed that surgery led to better results than conservative treatment, lacking intergroup analysis, there is no evidence supporting that one treatment is more superior. Despite recommendations for initial conservative treatment and management, some patients may select surgery for cervical IDH to the main aim of alleviating radiating pain in neuropathy and preventing progression of neurological damage in myelopathy [66]. Although the evidence base of conventional conservative and surgical treatments for cervical IDH weighing the benefits and harms is somewhat insufficient, the area has been extensively studied, while there is a distinct paucity of correlative studies on CAM.

 

Manchikanti et al. [67] stated in a 2 year follow-up study comparing epidural injection treatment with lidocaine and a mix of lidocaine and steroids for cervical IDH that NRS in the lidocaine group was 7.9?�?1.0 at baseline, and 3.8?�?1.6 at the 2 year follow-up, while NRS in the lidocaine and steroid group was 7.9?�?0.9 at baseline, and 3.8?�?1.7 at the 2 year follow-up. NDI in the lidocaine group was 29.6?�?5.3 at baseline, and 13.7?�?5.7 at the 2 year follow-up, and NDI in the lidocaine and steroid group was 29.2?�?6.1 at baseline, and 14.3?�?6.9 at the 2 year follow-up. When compared to our study, though improvement in NRS is slightly bigger in the study by Manchikanti et al., that of NDI is similar. The baseline NRS was higher at 7.9 in this previous study, and they did not differentiate between neck pain and radiating pain in NRS assessment.

 

The 1 year follow-up results comparing conservative treatment and plasma disc decompression (PDD) for contained cervical IDH show that VAS scores decreased 65.73, while NDI decreased 16.7 in the PDD group (n?=?61), and that VAS scores decreased 36.45, and NDI decreased 12.40 in the conservative treatment group (n?=?57) [68]. However, the study subject was limited to contained cervical IDH, the outcome measure for pain was VAS preventing direct comparison, and the follow-up period was shorter than our study.

 

The model of integrative treatment used at a Korean medicine hospital may be highly disparate from CAM treatment models used in Western countries. Although CAM treatment is gaining widespread popularity in the West, CAM is usually limited to �complementary� rather than �alternative� medicine, and is generally practiced by conventional practitioners as an adjunctive to conventional treatment after education on acupuncture/naturopathy/etc. or through referral to CAM specialists, of whom some do not hold individual practice rights. On the other hand, Korea adopts a dual medical system where KMDs hold practice rights equal to conventional practitioners, and she does not employ a primarily family practice-based medical system, allowing patients the freedom of primary treatment selection of conventional treatment or Korean medicine treatment. The participants of this study were patients visiting and admitted to a Korean medicine hospital for Korean medicine treatment of cervical IDH, and the integrative treatment model implemented at this Korean medicine hospital does not use CAM as a supplementary measure. Therefore, treatment comprised of CAM treatment such as acupuncture, herbal medicine, Chuna manipulation, and bee-venom pharmacopuncture in most patients, and conventional treatment was administered by conventional doctors through referral in a select few. A total 18.2 % of patients received analgesic medications prescriptions 2.7 times over an average admission period of 20.8 days, which is equivalent to 1�2 days worth�s prescription (calculated as 2 times/day), and epidural injections were administered to only 4.8 %, which is low considering that these patients required admission. It can be surmised that the main objective of admission in conservative treatment for most cervical IDH patients is alleviation of pain. The fact that many inpatients displayed significant pain and functional recovery in this study holds relevance for patients considering selecting a Korean medicine hospital for conservative treatment over surgery. Also, patients were confirmed to have maintained their improved state at long term follow-up, and only 9 received surgery out of the 117 patients assessed in the long term.

 

Patients were divided into 2 groups by satisfaction rate as evaluated at long term follow-up with PGIC, and multivariable logistic regression analysis was conducted on baseline characteristics to assess predictive factors for satisfaction and dissatisfaction. Older age was associated with higher satisfaction rate, and unilateral radiating pain was shown to be related with higher satisfaction rates than no radiating pain. In addition, patients receiving CAM treatment were associated with higher satisfaction rates compared to those not receiving treatment. This could be partly explained by the fact that more older patients may have higher levels of pain and be in more advanced stages of degeneration, resulting in more favorable and satisfactory treatment outcomes. Similarly, patients with unilateral radiating pain suffer neurological symptoms likely to be more severe than those with no radiating pain. In addition, patients continuing to receive CAM treatment may be more favorably predisposed toward CAM, resulting in higher satisfaction rates.

 

While numerous prospective long term studies have been conducted on injection treatment or surgical procedures, those on CAM treatment and inpatient treatment are few. The results of this study are comparable to the prospective long term results of injection treatment. Few studies have been conducted on admission treatment for patients with a main complaint of cervical IDH, which may be related with the difference in general healthcare systems.

 

Conclusions

 

In conclusion, although the observational nature of this study limits us from drawing more decisive conclusions lacking a control, 3 weeks� integrative inpatient treatment mainly comprised of CAM applied to actual clinical settings may result in satisfactory results and pain and functional improvement maintained in the long term in neck pain or radiating arm pain patients diagnosed with cervical IDH.

 

Acknowledgements

 

This work was supported by Jaseng Medical Foundation.

 

Abbreviations

 

  • IDH Intervertebral disc herniation
  • CAM Complementary and alternative medicine
  • KMD Korean medicine doctor
  • NRS Numeric rating scale
  • NDI Neck disability index
  • PGIC Patient global impression of change
  • MCID Minimum clinically important difference
  • VAS Visual analogue scale
  • ROM Range of motion
  • ULN Upper limit of normal
  • CI Confidence interval
  • OR Odds ratio
  • PDD Plasma disc decompression

 

Footnotes

 

Competing interests: The authors declare that they have no competing interests.

 

Authors� contributions: SHB, JWO, JSS, JHL and IHH conceived of the study and drafted the manuscript, and SHB, MRK and IHH wrote the final manuscript. SHB, JWO, YJA and ARC participated in data acquisition, and KBP performed the statistical analysis. YJL, MRK, YJA and IHH contributed to analysis and interpretation of data. SHB, JWO, JSS, JHL, YJL, MRK, YJA, ARC, KBP, BCS, MSL and IHH contributed to the study design and made critical revisions. All of the authors have read and approved the final manuscript.

 

Contributor information:�Ncbi.nlm.nih.gov/pmc/articles/PMC4744400/

 

In conclusion, migraine and cervical disc herniation treatment such as manual therapy as well as integrated complementary and alternative medicine may be effective towards the improvement and management of their symptoms. Information referenced from the National Center for Biotechnology Information (NCBI). The above research studies utilized a variety of methods to conclude the final results. Although the findings were shown to be effective migraine and cervical disc herniation treatment, further research studies are required to determine their true efficacy. 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

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Neck Pain

 

Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.

 

blog picture of cartoon paperboy big news

 

IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

OTHER IMPORTANT TOPICS: EXTRA: Sports Injuries? | Vincent Garcia | Patient | El Paso, TX Chiropractor

 

Blank
References

1. Grande RB, Aaseth K, Gulbrandsen P, Lundqvist C, Russell MB. Prevalence of primary chronic headache in a population-based sample of 30- to 44-year-old persons: the Akershus study of chronic headache. Neuroepidemiology. 2008;30(2):76�83. doi: 10.1159/000116244. [PubMed] [Cross Ref]
2. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (beta version) Cephalalgia. 2013;33:629�808. [PubMed]
3. Kristoffersen ES, Grande RB, Aaseth K, Lundqvist C, Russell MB. Management of primary chronic headache in the general population: the Akershus study of chronic headache. J Headache Pain. 2012;13(2):113�120. doi: 10.1007/s10194-011-0391-8. [PMC free article] [PubMed] [Cross Ref]
4. Aaseth K, Grande RB, Kvaerner KJ, Gulbrandsen P, Lundqvist C, Russell MB. Prevalence of secondary chronic headaches in a population-based sample of 30-44-year-old persons: the Akershus study of chronic headache. Cephalalgia. 2008;28(7):705�713. doi: 10.1111/j.1468-2982.2008.01577.x. [PubMed] [Cross Ref]
5. Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, Assendelft WJ, Bouter LM. Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database Syst Rev. 2004;3:1�69. [PubMed]
6. Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraine: a systematic review. J Headache Pain. 2011;12(2):127�133. doi: 10.1007/s10194-011-0296-6. [PMC free article] [PubMed] [Cross Ref]
7. Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: a systematic review. Man Ther. 2010;15(4):355�363. doi: 10.1016/j.math.2009.12.006. [PubMed] [Cross Ref]
8. Lenssinck ML, Damen L, Verhagen AP, Berger MY, Passchier J, Koes BW. The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review. Pain. 2004;112(3):381�388. doi: 10.1016/j.pain.2004.09.026. doi:10.1016/j.pain.2004.09.026. [PubMed] [Cross Ref]
9. Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA. Are manual therapies effective in reducing pain from tension-type headache: a systematic review. Clin J Pain. 2006;22(3):278�285. doi: 10.1097/01.ajp.0000173017.64741.86. doi:10.1097/01.ajp.0000173017.64741.86. [PubMed] [Cross Ref]
10. Chaibi A, Russell MB. Manual therapies for cervicogenic headache: a systematic review. J Headache Pain. 2012;13(5):351�359. doi: 10.1007/s10194-012-0436-7. [PMC free article] [PubMed] [Cross Ref]
11. Posadzki P, Ernst E. Spinal manipulations for tension-type headaches: a systematic review of randomized controlled trials. Complement Ther Med. 2012;20(4):232�239. doi: 10.1016/j.ctim.2011.12.001. doi:10.1016/j.ctim.2011.12.001. [PubMed] [Cross Ref]
12. French HP, Brennan A, White B, Cusack T. Manual therapy for osteoarthritis of the hip or knee � a systematic review. Man Ther. 2011;16(2):109�117. doi: 10.1016/j.math.2010.10.011. doi:10.1016/j.math.2010.10.011. [PubMed] [Cross Ref]
13. Tfelt-Hansen P, Block G, Dahlof C, Diener HC, Ferrari MD, Goadsby PJ, Guidetti V, Jones B, Lipton RB, Massiou H, Meinert C, Sandrini G, Steiner T, Winter PB. International Headache Society Clinical Trial Subcommittee. Guidelines for controlled trials of drugs in migraine: second edition. Cephalalgia. 2000;20(9):765�786. [PubMed]
14. Silberstein S, Tfelt-Hansen P, Dodick DW, Limmroth V, Lipton RB, Pascual J, Wang SJ. Task Force of the International Headache Society Clinical Trial Subcommittee. Guidelines for controlled trials of prophylactic treatment of chronic migraine in adults. Cephalalgia. 2008;28(5):484�495. doi: 10.1111/j.1468-2982.2008.01555.x. [PubMed] [Cross Ref]
15. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain: Headache Classification Committee of the International Headache Society. Cephalalgia. 1988;8(suppl 7):1�96. [PubMed]
16. Headache Classification Subcommittee of the International Society. The international classification of headache disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9�160. [PubMed]
17. Olesen J, Bousser MG, Diener HC, Dodick D, First M, Goadsby PJ, Gobel H, Lainez MJ, Lance JW, Lipton RB, Nappi G, Sakai F, Schoenen J, Silberstein SD, Steiner TJ. International Headache Society New appendix criteria open for a broader concept of chronic migraine. Cephalalgia. 2006;26(6):742�746. [PubMed]
18. Moseley AM, Herbert RD, Sherrington C, Maher CG. Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro) Aust J Physiother. 2002;48(1):43�49. doi: 10.1016/S0004-9514(14)60281-6. [PubMed] [Cross Ref]
19. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2. Routledge, USA; 1988.
20. Toro-Velasco C, Arroyo-Morales M, Fernandez-de-las-Penas C, Cleland JA, Barrero-Hernandez FJ. Short-term effects of manual therapy on heart rate variability, mood state, and pressure pain sensitivity in patients with chronic tension-type headache: a pilot study. J Manipulative Physiol Ther. 2009;32(7):527�535. doi: 10.1016/j.jmpt.2009.08.011. [PubMed] [Cross Ref]
21. Jay GW, Brunson J, Branson SJ. The effectiveness of physical therapy in the treatment of chronic daily headaches. Headache. 1989;29(3):156�162. doi: 10.1111/j.1526-4610.1989.hed2903156.x. [PubMed] [Cross Ref]
22. Demirturk F, Akarcali I, Akbayrak T, Citak I, Inan L. Results of two different manual therapy techniques in chronic tension-type headache. Pain Clin. 2002;14(2):121�128. doi: 10.1163/156856902760196333. [Cross Ref]
23. Torelli P, Jensen R, Olesen J. Physiotherapy for tension-type headache: a controlled study. Cephalalgia. 2004;24(1):29�36. doi: 10.1111/j.1468-2982.2004.00633.x. [PubMed] [Cross Ref]
24. Ettekoven VH, Lucas C. Efficacy of physiotherapy including a craniocervical training programme for tension-type headache; a randomized clinical trial. Cephalalgia. 2006;26(8):983�991. doi: 10.1111/j.1468-2982.2006.01163.x. [PubMed] [Cross Ref]
25. Castien RF, Van der Windt DA, Grooten A, Dekker J. Effectiveness of manual therapy for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia. 2011;31(2):133�143. doi: 10.1177/0333102410377362. [PubMed] [Cross Ref]
26. Rasmussen BK, Jensen R, Olesen J. Questionnaire versus clinical interview in the diagnosis of headache. Headache. 1991;31(5):290�295. doi: 10.1111/j.1526-4610.1991.hed3105290.x. [PubMed] [Cross Ref]
27. 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. BMJ. 2010;340:c869. doi: 10.1136/bmj.c869. [PMC free article] [PubMed] [Cross Ref]
28. Bendtsen L, Jensen R, Olesen J. A non-selective (amitriptyline), but not a selective (citalopram), serotonin reuptake inhibitor is effective in the prophylactic treatment of chronic tension-type headache. J Neurol Neurosurg Psychiatry. 1996;61(3):285�290. doi: 10.1136/jnnp.61.3.285. [PMC free article] [PubMed] [Cross Ref]
29. Jackson JL, Shimeall W, Sessums L, Dezee KJ, Becher D, Diemer M, Berbano E, O�Malley PG. Tricyclic antidepressants and headaches: systematic review and meta-analysis. BMJ. 2010;341:c5222. doi: 10.1136/bmj.c5222. [PMC free article] [PubMed] [Cross Ref]
30. Bendtsen L, Bigal ME, Cerbo R, Diener HC, Holroyd K, Lampl C, Mitsikostas DD, Steiner TJ, Tfelt-Hansen P. Guidelines for controlled trials of drugs in tension-type headache: second edition. Cephalalgia. 2010;30(1):1�16. [PubMed]

Close Accordion
Blank
References

1. Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine (Phila Pa 1976) 1994;19(12):1307�1309. doi: 10.1097/00007632-199406000-00001. [PubMed] [Cross Ref]
2. Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population. The results of a postal survey in a county of Sweden. Pain. 1989;37(2):215�222. doi: 10.1016/0304-3959(89)90133-4. [PubMed] [Cross Ref]
3. Hagen KB, Harms-Ringdahl K, Enger NO, Hedenstad R, Morten H. Relationship between subjective neck disorders and cervical spine mobility and motion-related pain in male machine operators. Spine (Phila Pa 1976) 1997;22(13):1501�1507. doi: 10.1097/00007632-199707010-00015. [PubMed] [Cross Ref]
4. Fricton JR, Kroening R, Haley D, Siegert R. Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients. Oral Surg Oral Med Oral Pathol. 1985;60(6):615�623. doi: 10.1016/0030-4220(85)90364-0. [PubMed] [Cross Ref]
5. Stovner LJ. The nosologic status of the whiplash syndrome: a critical review based on a methodological approach. Spine (Phila Pa 1976) 1996;21(23):2735�2746. doi: 10.1097/00007632-199612010-00006. [PubMed] [Cross Ref]
6. Frank AO, De Souza LH, Frank CA. Neck pain and disability: a cross-sectional survey of the demographic and clinical characteristics of neck pain seen in a rheumatology clinic. Int J Clin Pract. 2005;59(2):173�182. doi: 10.1111/j.1742-1241.2004.00237.x. [PubMed] [Cross Ref]
7. Andersson G. The epidemiology of spinal disorders. In: Frymoyer J, editor. The adult spine: principles and practice. Philadelphia: Lippincott Raven; 1997. pp. 130�141.
8. Rasmussen C, Leboeuf-Yde C, Hestbaek L, Manniche C. Poor outcome in patients with spine-related leg or arm pain who are involved in compensation claims: a prospective study of patients in the secondary care sector. Scand J Rheumatol. 2008;37(6):462�468. doi: 10.1080/03009740802241709. [PubMed] [Cross Ref]
9. Daffner SD, Hilibrand AS, Hanscom BS, Brislin BT, Vaccaro AR, Albert TJ. Impact of neck and arm pain on overall health status. Spine (Phila Pa 1976) 2003;28(17):2030�2035. doi: 10.1097/01.BRS.0000083325.27357.39. [PubMed] [Cross Ref]
10. Abbed KM, Coumans JV. Cervical radiculopathy: pathophysiology, presentation, and clinical evaluation. Neurosurgery. 2007;60(1 Supp1 1):S28�34. [PubMed]
11. Lauerman W, Scherping S, Wiesel S. The spine. In: Wiesel S, Delahay J, editors. Essentials of Orthopedic Surgery. 3. New York: Springer; 2007. pp. 276�332.
12. Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy. N Engl J Med. 2005;353(4):392�399. doi: 10.1056/NEJMcp043887. [PubMed] [Cross Ref]
13. Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, 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 (Phila Pa 1976) 2008;33(4 Suppl):S123�52. doi: 10.1097/BRS.0b013e3181644b1d. [PubMed] [Cross Ref]
14. Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine (Phila Pa 1976) 1996;21(16):1877�1883. doi: 10.1097/00007632-199608150-00008. [PubMed] [Cross Ref]
15. Clark C. The Cervical Spine. 4. Philadelphia: Lippincott Williams & Wilkins; 2005.
16. Engquist M, Lofgren H, Oberg B, Holtz A, Peolsson A, Soderlund A, et al. Surgery versus nonsurgical treatment of cervical radiculopathy: a prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow-up. Spine (Phila Pa 1976) 2013;38(20):1715�1722. [PubMed]
17. Nikolaidis I, Fouyas IP, Sandercock PA, Statham PF: Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev 2010, (1):CD001466. doi(1):CD001466. [PubMed]
18. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296(20):2441�2450. doi: 10.1001/jama.296.20.2441. [PMC free article] [PubMed] [Cross Ref]
19. Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA, Tans JT, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356(22):2245�2256. doi: 10.1056/NEJMoa064039. [PubMed] [Cross Ref]
20. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976) 1983;8(2):131�140. doi: 10.1097/00007632-198303000-00003. [PubMed] [Cross Ref]
21. Kim JD, Son MS. 2013 National Health Insurance Statistical Yearbook. Seoul: Health Insurance Review and Assessment Service and National Health Insurance Service; 2014.
22. Lin XJ, Chen CY. Advances on study of treatment of lumbar disk herniation by Chinese medicinal herbs. Zhongguo Zhong Yao Za Zhi. 2007;32(3):186�191. [PubMed]
23. Stevens L, Duarte H, Park J. Promising implications for integrative medicine for back pain: a profile of a Korean hospital. J Altern Complement Med. 2007;13(5):481�484. doi: 10.1089/acm.2007.6263. [PubMed] [Cross Ref]
24. Chung HJ, Lee HS, Shin JS, Lee SH, Park BM, Youn YS, et al. Modulation of acute and chronic inflammatory processes by a traditional medicine preparation GCSB-5 both in vitro and in vivo animal models. J Ethnopharmacol. 2010;130(3):450�459. doi: 10.1016/j.jep.2010.05.020. [PubMed] [Cross Ref]
25. Kim TH, Yoon SJ, Lee WC, Kim JK, Shin J, Lee S, et al. Protective effect of GCSB-5, an herbal preparation, against peripheral nerve injury in rats. J Ethnopharmacol. 2011;136(2):297�304. doi: 10.1016/j.jep.2011.04.037. [PubMed] [Cross Ref]
26. Kim JK, Park SW, Kang JW, Kim YJ, Lee SY, Shin J, et al. Effect of GCSB-5, a Herbal Formulation, on Monosodium Iodoacetate-Induced Osteoarthritis in Rats. Evid Based Complement Alternat Med. 2012;2012:730907. [PMC free article] [PubMed]
27. Park YG, Ha CW, Han CD, Bin SI, Kim HC, Jung YB, et al. A prospective, randomized, double-blind, multicenter comparative study on the safety and efficacy of Celecoxib and GCSB-5, dried extracts of six herbs, for the treatment of osteoarthritis of knee joint. J Ethnopharmacol. 2013;149(3):816�824. doi: 10.1016/j.jep.2013.08.008. [PubMed] [Cross Ref]
28. Xu RD, Li H. Conception of Ashi points. Zhongguo Zhen Jiu. 2005;25(4):281�283. [PubMed]
29. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med. 2003;138(11):871�881. doi: 10.7326/0003-4819-138-11-200306030-00008. [PubMed] [Cross Ref]
30. Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J. 2008;8(1):213�225. doi: 10.1016/j.spinee.2007.10.023. [PubMed] [Cross Ref]
31. Turk DC, Rudy TE, Sorkin BA. Neglected topics in chronic pain treatment outcome studies: determination of success. Pain. 1993;53(1):3�16. doi: 10.1016/0304-3959(93)90049-U. [PubMed] [Cross Ref]
32. Ponce de Leon S, Lara-Munoz C, Feinstein AR, Wells CK. A comparison of three rating scales for measuring subjective phenomena in clinical research. II. Use of experimentally controlled visual stimuli. Arch Med Res. 2004;35(2):157�162. doi: 10.1016/j.arcmed.2003.07.009. [PubMed] [Cross Ref]
33. Farrar JT, Young JP, Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94(2):149�158. doi: 10.1016/S0304-3959(01)00349-9. [PubMed] [Cross Ref]
34. 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;10(6):469�474. doi: 10.1016/j.spinee.2010.02.007. [PubMed] [Cross Ref]
35. Parker SL, Godil SS, Shau DN, Mendenhall SK, McGirt MJ. Assessment of the minimum clinically important difference in pain, disability, and quality of life after anterior cervical discectomy and fusion: clinical article. J Neurosurg Spine. 2013;18(2):154�160. doi: 10.3171/2012.10.SPINE12312. [PubMed] [Cross Ref]
36. Lee J, Shin JS, Kim MR, Byun JH, Lee SY, Shin YS, et al. Liver enzyme abnormalities in taking traditional herbal medicine in Korea: A retrospective large sample cohort study of musculoskeletal disorder patients. J Ethnopharmacol. 2015;169:407�412. doi: 10.1016/j.jep.2015.04.048. [PubMed] [Cross Ref]
37. Manchikanti L, Falco FJ, Singh V, Pampati V, Parr AT, Benyamin RM, et al. Utilization of interventional techniques in managing chronic pain in the Medicare population: analysis of growth patterns from 2000 to 2011. Pain Physician. 2012;15(6):E969�82. [PubMed]
38. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 2009;34(10):1078�1093. doi: 10.1097/BRS.0b013e3181a103b1. [PubMed] [Cross Ref]
39. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15(Suppl 2):S192�300. doi: 10.1007/s00586-006-1072-1. [PMC free article] [PubMed] [Cross Ref]
40. Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine (Phila Pa 1976) 2009;34(1):49�59. doi: 10.1097/BRS.0b013e3181909558. [PubMed] [Cross Ref]
41. Armon C, Argoff CE, Samuels J, Backonja MM, Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007;68(10):723�729. doi: 10.1212/01.wnl.0000256734.34238.e7. [PubMed] [Cross Ref]
42. Parr AT, Diwan S, Abdi S. Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review. Pain Physician. 2009;12(1):163�188. [PubMed]
43. DePalma MJ, Slipman CW. Evidence-informed management of chronic low back pain with epidural steroid injections. Spine J. 2008;8(1):45�55. doi: 10.1016/j.spinee.2007.09.009. [PubMed] [Cross Ref]
44. Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell JP. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med. 2013;38(3):175�200. doi: 10.1097/AAP.0b013e31828ea086. [PubMed] [Cross Ref]
45. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine (Phila Pa 1976) 2007;32(11):1249�1256. doi: 10.1097/BRS.0b013e318053ec50. [PubMed] [Cross Ref]
46. Rathmell JP, Benzon HT. Transforaminal injection of steroids: should we continue? Reg Anesth Pain Med. 2004;29(5):397�399. [PubMed]
47. Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J. 2004;4(4):468�474. doi: 10.1016/j.spinee.2003.10.007. [PubMed] [Cross Ref]
48. Brouwers PJ, Kottink EJ, Simon MA, Prevo RL. A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root. Pain. 2001;91(3):397�399. doi: 10.1016/S0304-3959(00)00437-1. [PubMed] [Cross Ref]
49. Wallace MA, Fukui MB, Williams RL, Ku A, Baghai P. Complications of cervical selective nerve root blocks performed with fluoroscopic guidance. AJR Am J Roentgenol. 2007;188(5):1218�1221. doi: 10.2214/AJR.04.1541. [PubMed] [Cross Ref]
50. Rathmell JP, Aprill C, Bogduk N. Cervical transforaminal injection of steroids. Anesthesiology. 2004;100(6):1595�1600. doi: 10.1097/00000542-200406000-00035. [PubMed] [Cross Ref]
51. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician. 2012;15(2):131�140. [PubMed]
52. Abbasi A, Malhotra G, Malanga G, Elovic EP, Kahn S. Complications of interlaminar cervical epidural steroid injections: a review of the literature. Spine (Phila Pa 1976) 2007;32(19):2144�2151. doi: 10.1097/BRS.0b013e318145a360. [PubMed] [Cross Ref]
53. Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C. Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports. Spine (Phila Pa 1976) 1998;23(19):2137�42. doi: 10.1097/00007632-199810010-00020. [PubMed] [Cross Ref]
54. Kaplan MS, Cunniff J, Cooke J, Collins JG. Intravascular uptake during fluoroscopically guided cervical interlaminar steroid injection at C6-7: a case report. Arch Phys Med Rehabil. 2008;89(3):553�558. doi: 10.1016/j.apmr.2007.08.165. [PubMed] [Cross Ref]
55. McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011;12(5):726�731. doi: 10.1111/j.1526-4637.2011.01077.x. [PubMed] [Cross Ref]
56. Shanthanna H, Park J. Acute epidural haematoma following epidural steroid injection in a patient with spinal stenosis. Anaesthesia. 2011;66(9):837�839. doi: 10.1111/j.1365-2044.2011.06770.x. [PubMed] [Cross Ref]
57. McCleane G. Does gabapentin have an analgesic effect on background, movement and referred pain? A randomized, double-blind, placebo controlled study. Pain Clinic. 2001;13:103�107. doi: 10.1163/156856901753420945. [Cross Ref]
58. Yildirim K, Sisecioglu M, Karatay S, Erdal A, Levent A, Ugur M, et al. The effectiveness of gabapentin in patients with chronic radiculopathy. Pain Clinic. 2003;15:213�218. doi: 10.1163/156856903767650718. [Cross Ref]
59. Khoromi S, Cui L, Nackers L, Max MB. Morphine, nortriptyline and their combination vs. placebo in patients with chronic lumbar root pain. Pain. 2007;130(1-2):66�75. doi: 10.1016/j.pain.2006.10.029. [PMC free article] [PubMed] [Cross Ref]
60. Khoromi S, Patsalides A, Parada S, Salehi V, Meegan JM, Max MB. Topiramate in chronic lumbar radicular pain. J Pain. 2005;6(12):829�836. doi: 10.1016/j.jpain.2005.08.002. [PubMed] [Cross Ref]
61. Baron R, Freynhagen R, Tolle TR, Cloutier C, Leon T, Murphy TK, et al. The efficacy and safety of pregabalin in the treatment of neuropathic pain associated with chronic lumbosacral radiculopathy. Pain. 2010;150(3):420�427. doi: 10.1016/j.pain.2010.04.013. [PubMed] [Cross Ref]
62. Hahne AJ, Ford JJ, McMeeken JM. Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review. Spine (Phila Pa 1976) 2010;35(11):E488�504. [PubMed]
63. Salt E, Wright C, Kelly S, Dean A. A systematic literature review on the effectiveness of non-invasive therapy for cervicobrachial pain. Man Ther. 2011;16(1):53�65. doi: 10.1016/j.math.2010.09.005. [PubMed] [Cross Ref]
64. Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial. BMJ. 2009;339:b3883. doi: 10.1136/bmj.b3883. [PMC free article] [PubMed] [Cross Ref]
65. Gebremariam L, Koes BW, Peul WC, Huisstede BM. Evaluation of treatment effectiveness for the herniated cervical disc: a systematic review. Spine (Phila Pa 1976) 2012;37(2):E109�18. doi: 10.1097/BRS.0b013e318221b5af. [PubMed] [Cross Ref]
66. Boselie TF, Willems PC, van Mameren H, de Bie RA, Benzel EC, van Santbrink H. Arthroplasty versus fusion in single-level cervical degenerative disc disease: a Cochrane review. Spine (Phila Pa 1976) 2013;38(17):E1096�107. doi: 10.1097/BRS.0b013e3182994a32. [PubMed] [Cross Ref]
67. Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. Cervical epidural injections in chronic discogenic neck pain without disc herniation or radiculitis: preliminary results of a randomized, double-blind, controlled trial. Pain Physician. 2010;13(4):E265�78. [PubMed]
68. Cesaroni A, Nardi PV. Plasma disc decompression for contained cervical disc herniation: a randomized, controlled trial. Eur Spine J. 2010;19(3):477�486. doi: 10.1007/s00586-009-1189-0. [PMC free article] [PubMed] [Cross Ref]

Close Accordion
Manual Therapy for Migraine Treatment In El Paso

Manual Therapy for Migraine Treatment In El Paso

by | Chiropractic, Functional Medicine, Migraine, Physical Rehabilitation

Manual therapy migraine treatment, or manipulative therapy, is a physical treatment approach which utilizes several specific hands-on techniques to treat a variety of injuries and/or conditions. Manual therapy is commonly used by chiropractors, physical therapists and massage therapists, among other qualified and experienced healthcare professionals, to diagnose and treat soft tissue and joint pain. Many healthcare specialists recommend manual therapy, or manipulative therapy as a treatment for migraine headache pain. The purpose of the following article is to educate patients on the effects of manual therapies for migraine treatment.

 

Manual Therapies for Migraine: a Systematic Review

 

Abstract

 

Migraine occurs in about 15% of the general population. Migraine is usually managed by medication, but some patients do not tolerate migraine medication due to side effects or prefer to avoid medication for other reasons. Non-pharmacological management is an alternative treatment option. We systematically reviewed randomized clinical trials (RCTs) on manual therapies for migraine. The RCTs suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine. However, the evaluated RCTs had many methodological shortcomings. Therefore, any firm conclusion will require future, well-conducted RCTs on manual therapies for migraine.

 

Keywords: Manual therapies, Massage, Physiotherapy, Chiropractic, Migraine, Treatment

 

Introduction

 

Migraine is usually managed by medication, but some patients do not tolerate acute and/or prophylactic medicine due to side effects, or contraindications due to co-morbidity of myocardial disorders or asthma among others. Some patients wish to avoid medication for other reasons. Thus, non-pharmacological management such as massage, physiotherapy and chiropractic may be an alternative treatment option. Massage therapy in Western cultures uses classic massage, trigger points, myofascial release and other passive muscle stretching among other treatment techniques which are applied to abnormal muscle tissue. Modern physiotherapy focuses on rehabilitation and exercise, while manual treatment emphasis postural corrections, soft tissue work, stretching, active and passive mobilization and manipulation techniques. Mobilization is commonly defined as movement of joints within the physiological range of motion [1]. The two most common chiropractic techniques are the diversified and Gonstead, which are used by 91 and 59% of chiropractors [2]. Chiropractic spinal manipulation (SM) is a passive-controlled maneuver which uses a directional high-velocity, low-amplitude thrusts directed at a specific joint past the physiological range of motion, without exceeding the anatomical limit [1]. The application and duration of the different manual treatments varies among those who perform it. Thus, manual treatment is not necessarily as uniform as, for instance, specific treatment with a drug in a certain dose.

 

This paper systematically review randomized controlled trials (RCTs) assessing the efficacy of manual therapies on migraine, i.e., massage, physiotherapy and chiropractic.

 

Method

 

The literature search was done on CINAHL, Cochrane, Medline, Ovid and PubMed. Search words were migraine and chiropractic, manipulative therapy, massage therapy, osteopathic treatment, physiotherapy or spinal mobilization. All RCTs written in English using manual therapy on migraine were evaluated. Migraine was preferentially classified according to the criteria of the International Headache Societies from 1988 or its revision from 2004, although it was not an absolute requirement [3, 4]. The studies had to evaluate at least one migraine outcome measure such as pain intensity, frequency, or duration. The methodological quality of the included RCT studies was assessed independently by the authors. The evaluation covered study population, intervention, measurement of effect, data presentation and analysis (Table 1). The maximum score is 100 points and ?50 points considered to be methodology of good quality [5�7].

 

 

Results

 

The literature search identified seven RCT on migraine that met our inclusion criteria, i.e., two massage therapy studies [8, 9], one physiotherapy study [10] and four chiropractic spinal manipulative therapy studies (CSMT) [11�14], while we found no RCTs studies on spinal mobilization or osteopathic as a intervention for migraine.

 

Methodological Quality of the RCTs

 

Table 2 shows the authors average methodological score of the included RCT studies [8�14]. The average score varied from 39 to 59 points. Four RCTs were considered to have a good quality methodology score (?50), and three RCTs had a low score.

 

Table 2 Quality Score of the Analyzed Randomized Controlled Trials

 

Randomized Controlled Trials

 

Table 3 shows details and the main results of the different RCT studies [8�14].

 

Table 3 Randomized Controlled Trials for Migraine

 

Massage Therapy

 

An American study included 26 participants with chronic migraine diagnosed by questionnaire [8]. Massage therapy had a statistically significant effect on pain intensity as compared with controls. Pain intensity was reduced 71% in the massage group and unchanged in the control group. Interpretation of the data is otherwise difficult and results on migraine frequency and duration are missing.

 

A New Zealand study included 48 migraineurs diagnosed by questionnaire [9]. The mean duration of a migraine attack was 47 h, and 51% of the participants had more than one attack per month. The study included a 3 week follow-up period. The migraine frequency was significantly reduced in the massage group as compared with the control group, while the intensity of attacks was unchanged. Results on migraine duration are missing. Medication use was unchanged, while sleep quality was significantly improved in the massage group (p < 0.01), but not in the control group.

 

Image of an olden man receiving massage therapy to improve their migraine | El Paso, TX Chiropractor

 

Physical Therapy

 

An American physical therapy study included female migraineurs with frequent attacks diagnosed by a neurologist according to the criteria of the International Headache Society [3, 10]. Clinical effect was defined as >50% improvement in headache severity. Clinical effect was observed in 13% of the physical therapy group and 51% of the relaxation group (p < 0.001). The mean reduction in headache severity was 16 and 41% from baseline to post-treatment in the physical therapy and relaxation groups. The effect was maintained at 1 year follow-up in both groups. A second part of the study offered persons without clinical effect in the first part of the study, the other treatment option. Interestingly, clinical effect was observed in 55% of those whom received physical therapy in the second round who had no clinical effect from relaxation, while 47% had clinical effect from relaxation in the second round. The mean reduction in headache severity was 30 and 38% in the physical therapy and relaxation groups. Unfortunately, the study did not include a control group.

 

Image of an older man receiving physical therapy for migraine | El Paso, TX Chiropractor

 

Chiropractic Spinal Manipulative Treatment

 

An Australian study included migraineurs with frequent attacks diagnosed by a neurologist [11]. The participants were divided into three study groups; cervical manipulation by chiropractor, cervical manipulation by physiotherapist or physician, and cervical mobilization by physiotherapist or physician. The mean migraine attack duration was skewed in the three groups, as it was much longer in cervical manipulation by chiropractor (30.5 h) than cervical manipulations by physiotherapist or physician (12.2 h) and cervical mobilization groups (14.9 h). The study had several investigators and the treatment within each group was beside the mandatory requirements free for the therapists. No statistically significant differences were found between the three groups. Improvement was observed in all three groups post-treatment (Table 3). Prior to the trial, chiropractors were confident and enthusiastic about the efficacy of cervical manipulation, while physiotherapists and physicians were doubtful about the relevance. The study did not include a control group although cervical mobilization is mentioned as the control group in the paper. A follow-up 20 months after the trial showed further improvement in the all three groups (Table 3) [12].

 

Dr Jimenez works on wrestler's neck_preview

 

An American study included 218 migraineurs diagnosed according to the criteria of the International Headache Society by chiropractors [13]. The study had three treatment groups, but no control group. The headache intensity on days with headaches was unchanged in all three groups. The mean frequency was reduced equally in the three groups (Table 3). Over the counter (OTC) medication was reduced from baseline to 4 weeks post-treatment with 55% in the CSMT group, 28% in the amitriptyline group and 15% in the combined CSMT and amitriptyline group.

 

The second Australian study was based on questionnaire diagnoses on migraine [14]. The participants had migraine for mean 18.1 years. The effect of CSMT was significant better than the control group (Table 3). The mean reduction of migraine frequency, intensity and duration from baseline to follow-up were 42, 13, and 36% in CSMT group, and 17, 5, and 21% in the control group (data calculated by the reviewers based on figures from the paper).

 

Discussion

 

Methodological Considerations

 

The prevalence of migraine was similar based on a questionnaire and a direct physician conducted interview, but it was due to equal positive and negative misclassification by the questionnaire [15]. A precise headache diagnosis requires an interview by a physicians or other health professional experienced in headache diagnostics. Three of the seven RCTs ascertained participants by a questionnaire, with the diagnostic uncertainty introduced by this (Table 3).

 

The second American study included participants with at least four headache days per months [13]. The mean headache severity on days with headache at baseline varied from 4.4 to 5.0 on a 0�10 box scale in the three treatment groups. This implies that the participants had co-occurrence of tension-type headache, since tension-type headache intensity usually vary between 1 and 6 (mild or moderate), while migraine intensity can vary between 4 and 9 (moderate or severe), but usually it is a severe pain between 7 and 9 [16, 17]. The headache severity on days with headache was unchanged between baseline and at follow-up, indicating that the effect observed was not exclusively due to an effect on migraine, but also an effect on tension-type headache.

 

RCTs that include a control group are advantageous to RCTs that compare two active treatments, since the effect in the placebo group rarely is zero and often varies. An example is RCTs on acute treatment of migraine comparing the efficacy of subcutaneous sumatriptan and placebo showed placebo responses between 10 and 37%, while the therapeutic effect, i.e., the efficacy of sumatriptan minus the efficacy of placebo was similar [18, 19]. Another example is a RCT on prophylactic treatment of migraine, comparing topiramate and placebo [20]. The attack reduction increased along with increasing dose of topiramate 50, 100 and 200 mg/day. The mean migraine attack frequency was reduced from 1.4 to 2.5 attacks per month in the topiramate groups and 1.1 attacks per month in the placebo group from baseline, with mean attack frequencies varying from 5.1 to 5.8 attacks per month in the four groups.

 

Thus, interpretation of the efficacy in the four RCTs without a control group is not straight forward [9�12]. The methodological quality of all seven RCTs had room for improvement as the maximum score 100 was far from expectation, especially a precise migraine diagnosis is important.

 

Several of the studies relatively include a few participants, which might cause type 2 errors. Thus, power calculation prior to the study is important in the future studies. Furthermore, the clinical guidelines from the International Headache Society should be followed, i.e., frequency is a primary end point, while duration and intensity can be secondary end points [21, 22].

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Manual therapies, such as massage therapy, physical therapy and chiropractic spinal manipulative treatment are several well-known migraine treatment approaches recommended by healthcare professionals to help improve as well as manage the painful symptoms associated with the condition. Patients who are unable to use drugs and/or medications, including those who may prefer to avoid using these, can benefit from manual therapies for migraine treatment, according to the following article. Evidence-based research studies have determined that manual therapies might be equally as effective for migraine treatment as drugs and/or medications. However, the systematic review determined that future, well-conducted randomized clinical trials on the use of manual therapies for migraine headache pain are required to conclude the findings.

 

Results

 

The two RCTs on massage therapy included relatively a few participants, along with shortcomings mentioned in Table 3 [8, 9]. Both studies showed that massage therapy was significantly better than the control group, by reducing migraine intensity and frequency, respectively. The 27�28% (34�7% and 30�2%) therapeutic gain in migraine frequency reduction by massage therapy is comparable with the 6, 16 and 29% therapeutic gain in migraine frequency reduction by prophylactic treatment with topiramate 50, 100 and 200 mg/day [20].

 

The single study on physiotherapy is large, but do not include a control group [10]. The study defined responders to have 50% or more reduction in migraine intensity. The responder rate to physical therapy was only 13% in the first part of the study, while it was 55% in the group that did not benefit from relaxation, while the responder rate to relaxation was 51% in the first part of the study and 47% in the group that did not benefit from physical therapy. A reduction in migraine intensity often correlates with reduced migraine frequency. For comparison, the responder rate was 39, 49, 47 and 23% among those who received topiramate 50, 100 and 200 mg/day and placebo as defined by 50% or more reduction in migraine frequency [20]. A meta-analysis of 53 studies on prophylactic treatment with propranolol showed a mean 44% reduction in migraine activity [23]. Thus, it seems that physical therapy and relaxation has equally good effect as topiramate and propranolol.

 

Only one of the four RCTs on chiropractic spinal manipulative therapy (CSMT) included a control group, while the other studies compared with other active treatment [11�14]. The first Australian study showed that the migraine frequency was reduced in all three groups when baseline was compared with 20 months post trail [11, 12]. The chiropractors were highly motivated to CSMT treatment, while physicians and physiotherapist were more sceptical, which might have influenced on the result. An American study showed that CSMT, amitriptyline and CSMT + amitriptyline reduced the migraine frequency 33, 22 and 22% from baseline to post-treatment (Table 3). The second Australian study found that migraine frequency was reduced 35% in the CSMT group, while it was reduced 17% in the control group. Thus, the therapeutic gain is equivalent to that of topiramate 100 mg/day and the efficacy is equivalent to that of propranolol [20, 23].

 

Three case reports raise concerns about chiropractic cervical SMT, but a recent systematic review found no robust data concerning the incidence or the prevalence of adverse reactions following chiropractic cervical SMT [24�27]. When to refer migraine patients to manual therapies? Patients not responding or tolerating prophylactic medication or who wish to avoid medication for other reasons, can be referred to massage therapy, physical therapy or chiropractic spinal manipulative therapy, as these treatments are safe with a few adverse reactions [27�29].

 

Conclusion

 

Current RCTs suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally efficient as propranolol and topiramate in the prophylactic management of migraine. However, a firm conclusion requires, in future, well-conducted RCTs without the many methodological shortcomings of the evaluated RCTs on manual therapies. Such studies should follow clinical trial guidelines from the International Headache Society [21, 22].

 

Conflict of Interest

 

None declared.

 

Open Access: This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution and reproduction in any medium, provided the original author(s) and source are credited.

 

In conclusion,�chiropractors, physical therapists and massage therapists, among other qualified and experienced healthcare professionals, recommend manual therapies as a treatment for migraine headache pain. The purpose of the article was to�educate patients on the effects of manual therapies for migraine treatment. Furthermore, the systematic review determined that�future, well-conducted randomized clinical trials are required to conclude the findings. 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

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Neck Pain

 

Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.

 

blog picture of cartoon paperboy big news

 

IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

OTHER IMPORTANT TOPICS: EXTRA: Sports Injuries? | Vincent Garcia | Patient | El Paso, TX Chiropractor

 

Blank
References
1. Esposito S, Philipson S. Spinal adjustment technique the chiropractic art. Alexandria: Craft Printing; 2005.
2. Cooperstein R, Gleberson BJ. Technique systems in chiropractic. 1. New York: Churchill Livingstone; 2004.
3. Headache Classification Committee of the International Headache Society (1988) Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society. Cephalalgia 8 (suppl 7):1�96 [PubMed]
4. Headache Classification Subcommittee of the International Society (2004) The international classification of headache disorders, 2nd edn, Cephalagia 24 (suppl 1):1�160 [PubMed]
5. Ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criteria-based meta-analysis. J Clin Epidemiol. 1990;43:1191�1199. doi: 10.1016/0895-4356(90)90020-P. [PubMed] [Cross Ref]
6. Koes BW, Assendelft WJ, Heijden GJ, Bouter LM, Knipschild PG. Spinal manipulation and mobilisation for back and neck pain: a blinded review. BMJ. 1991;303:1298�1303. doi: 10.1136/bmj.303.6813.1298. [PMC free article] [PubMed] [Cross Ref]
7. Fernandez-de-las-Penas C, Alonso-Blanco C, San-Roman J, Miangolarra-Page JC. Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache, migraine, and cervicogenic headache. J Orthop Sports Phys Ther. 2006;36:160�169. [PubMed]
8. Hernandez-Rief M, Dieter J, Field T, Swerdlow B, Diego M. Migraine headache reduced by massage therapy. Int J Neurosci. 1998;96:1�11. doi: 10.3109/00207459808986453. [Cross Ref]
9. Lawler SP, Cameron LD. A randomized, controlled trial of massage therapy as a treatment for migraine. Ann Behav Med. 2006;32:50�59. doi: 10.1207/s15324796abm3201_6. [PubMed] [Cross Ref]
10. Marcus DA, Scharff L, Mercer S, Turk DC. Nonpharmacological treatment for migraine: incremental utility of physical therapy with relaxation and thermal biofeedback. Cephalalgia. 1998;18:266�272. doi: 10.1046/j.1468-2982.1998.1805266.x. [PubMed] [Cross Ref]
11. Parker GB, Tupling H, Pryor DS. A controlled trial of cervical manipulation of migraine. Aust NZJ Med. 1978;8:589�593. [PubMed]
12. Parker GB, Pryor DS, Tupling H. Why does migraine improve during a clinical trial? Further results from a trial of cervical manipulation for migraine. Aust NZJ Med. 1980;10:192�198. [PubMed]
13. Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. J Manipulative Physiol Ther. 1998;21:511�519. [PubMed]
14. Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. J Manipulative Physiol Ther. 2000;23:91�95. doi: 10.1016/S0161-4754(00)90073-3. [PubMed] [Cross Ref]
15. Rasmussen BK, Jensen R, Olesen J. Questionnaire versus clinical interview in the diagnosis of headache. Headache. 1991;31:290�295. doi: 10.1111/j.1526-4610.1991.hed3105290.x. [PubMed] [Cross Ref]
16. Lundquist YC, Benth JS, Grande RB, Aaseth K, Russell MB. A vertical VAS is a valid instrument for monitoring headache pain intensity. Cephalalgia. 2009;29:1034�1041. doi: 10.1111/j.1468-2982.2008.01833.x. [PubMed] [Cross Ref]
17. Rasmussen BK, Olesen J. Migraine with aura and migraine without aura: an epidemiological study. Cephalalgia. 1992;12:221�228. doi: 10.1046/j.1468-2982.1992.1204221.x. [PubMed] [Cross Ref]
18. Ensink FB. Subcutaneous sumatriptan in the acute treatment of migraine. Sumatriptan International Study Group. J Neurol. 1991;238(suppl 1):S66�S69. doi: 10.1007/BF01642910. [PubMed] [Cross Ref]
19. Russell MB, Holm-Thomsen OE, Rishoj NM, Cleal A, Pilgrim AJ, Olesen J. A randomized double-blind placebo-controlled crossover study of subcutaneous sumatriptan in general practice. Cephalalgia. 1994;14:291�296. doi: 10.1046/j.1468-2982.1994.1404291.x. [PubMed] [Cross Ref]
20. Brandes JL, Saper JR, Diamond M, Couch JR, Lewis DW, Schmitt J, Neto W, Schwabe S, Jacobs D, MIGR-002 Study Group Topiramate for migraine prevention: a randomized controlled trial. JAMA. 2004;291:965�973. doi: 10.1001/jama.291.8.965. [PubMed] [Cross Ref]
21. Tfelt-Hansen P, Block G, Dahl�f C, Diener HC, Ferrari MD, Goadsby PJ, Guidetti V, Jones B, Lipton RB, Massiou H, Meinert C, Sandrini G, Steiner T, Winter PB, International Headache Society Clinical trials Subcommittee Guidelines for controlled trials of drugs in migraine: 2nd ed. Cephalalgia. 2000;20:765�786. doi: 10.1046/j.1468-2982.2000.00117.x. [PubMed] [Cross Ref]
22. Silberstein S, Tfelt-Hansen P, Dodick DW, Limmroth V, Lipton RB, Pascual J, Wang SJ, Task Force of the International Headache Society Clinical Trials Subcommittee Guidelines for controlled trials of prophylactic treatment of chronic migraine in adults. Cephalalgia. 2008;28:484�495. doi: 10.1111/j.1468-2982.2008.01555.x. [PubMed] [Cross Ref]
23. Holroyd KA, Penzien DB, Cordingley GE. Propranolol in the management of recurrent migraine: a meta-analytic review. Headache. 1991;31:333�340. doi: 10.1111/j.1526-4610.1991.hed3105333.x. [PubMed] [Cross Ref]
24. Khan AM, Ahmad N, Li X, Korsten MA, Rosman A. Chiropractic sympathectomy: carotid artery dissection with oculosympathetic palsy after chiropractic manipulation of the neck. Mt Sinai J Med. 2005;72:207�210. [PubMed]
25. Morelli N, Gallerini S, Gori S, Chiti A, Cosottini M, Orlandi G, Murri L. Intracranial hypotension syndrome following chiropractic manipulation of the cervical spine. J Headache Pain. 2006;7:211�213. doi: 10.1007/s10194-006-0308-0. [PMC free article] [PubMed] [Cross Ref]
26. Marx P, P�schmann H, Haferkamp G, Busche T, Neu J. Manipulative treatment of the cervical spine and stroke. Fortschr Neurol Psychiatr. 2009;77:83�90. doi: 10.1055/s-0028-1109083. [PubMed] [Cross Ref]
27. Gouveia LO, Gastanho P, Ferreira JJ. Safety of chiropractic intervention. A systematic review. Spine. 2009;34:E405�E413. doi: 10.1097/BRS.0b013e3181a16d63. [PubMed] [Cross Ref]
28. Ernst E. The safety of massage therapy. Rheumatology. 2003;42:1101�1106. doi: 10.1093/rheumatology/keg306. [PubMed] [Cross Ref]
29. Zeppos L, Patman S, Berney S, Adsett JA, Bridson JM, Paratz JD. Physiotherapy in intensive care is safe: an observational study. Aust J Physiother. 2007;53:279�283. [PubMed]
Close Accordion
Assessment and Treatment of the Subscapularis | Dr. Alex Jimenez

Assessment and Treatment of the Subscapularis | Dr. Alex Jimenez

by | Chiropractic, Chiropractic Examination, Functional Medicine

These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).

 

Clinical Application of Neuromuscular Techniques: the Subscapularis Muscle

 

The subscapularis is a large triangular muscle which fills the subscapular fossa and inserts into the lesser tubercle of the humerus and the front of the capsule of the shoulder-joint.

 

The subscapularis rotates the head of the humerus medially (internal rotation) and adducts it; when the arm is raised, it draws the humerus forward and downward. It is a powerful defense to the front of the shoulder-joint, preventing displacement of the head of the humerus.

 

Damage or trauma from an injury or an aggravated condition can cause shortness in the subscapularis muscle. The following assessments and treatments can help improve structure and function.

 

Assessment of Shortness in the Subscapularis Muscle

 

Subscapularis shortness test (a) Direct palpation of subscapularis is required to define problems in it, since pain patterns in the shoulder, arm, scapula and chest may all derive from subscapularis or from other sources.

 

The patient is supine and the practitioner grasps the affected side hand and applies traction while the fingers of the other hand palpate over the edge of latissimus dorsi in order to make contact with the ventral surface of the scapula, where subscapularis can be palpated. There may be a marked reaction from the patient when this is touched, indicating acute sensitivity.

 

Subscapularis shortness test (b) (as seen on Fig. 4.39 below) The patient is supine with the arm abducted to 90�, the elbow flexed to 90�, and the forearm in external rotation, palm upwards. The whole arm is resting at the restriction barrier, with gravity as its counterweight.

 

If subscapularis is short the forearm will be unable to rest easily parallel with the floor but will be somewhat elevated.

 

 

Figure 4.39A, B Assessment and MET self-treatment position for subscapularis. If the upper arm cannot rest parallel to the floor, possible shortness of subscapularis is indicated.

 

Care is needed to prevent the anterior shoulder becoming elevated in this position (moving towards the ceiling) and so giving a false normal picture.

 

Assessment of Weakness in the Subscapularis Muscle

 

The patient is prone with humerus abducted to 90� and elbow flexed to 90�. The humerus should be in internal rotation so that the forearm is parallel with the trunk, palm towards ceiling. The practitioner stabilises the scapula with one hand and with the other applies pressure to the patient�s wrist and forearm as though taking the humerus towards external rotation, while the patient resists.

 

The relative strength is judged and the method discussed by Norris (1999) should used to increase strength (isotonic eccentric contraction performed slowly).

 

MET Treatment of the Subscapularis Muscle

 

The patient is supine with the arm abducted to 90�, the elbow flexed to 90�, and the forearm in external rotation, palm upwards. The whole arm is resting at the restriction barrier, with gravity as its counterweight. (Care is needed to prevent the anterior shoulder becoming elevated in this position (moving towards the ceiling) and so giving a false normal picture.)

 

The patient raises the forearm slightly, against minimal resistance from the practitioner, for 7�10 seconds and, following relaxation, gravity or slight assistance from the operator takes the arm into greater external rotation, through the barrier, where it is held for not less than 20 seconds.

 

Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

By Dr. Alex Jimenez

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Wellness

 

Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.

 

blog picture of cartoon paperboy big news

 

IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

OTHER IMPORTANT TOPICS: EXTRA: Sports Injuries? | Vincent Garcia | Patient | El Paso, TX Chiropractor

 

Chiropractic Migraine Pain Treatment vs. Medication | El Paso, TX

Chiropractic Migraine Pain Treatment vs. Medication | El Paso, TX

by | Chiropractic, Functional Medicine, Migraine

Migraine pain is among one of the most common and debilitating conditions of the human population. As a result, many migraine cases are often misdiagnosed, leading to their improper treatment. With the proper treatment, however, a patient’s overall health and wellness as well as their quality of life may improve considerably. In addition, patient education is essential to help patients take appropriate self-care measures and for them to learn how to cope with the chronic nature of their condition. Chiropractic spinal manipulative therapy and the use of medication has been previously compared to determine the effectiveness of each for migraine pain. The purpose of the following article is to demonstrate the efficacy of each migraine pain treatment.

 

A Case Series of Migraine Changes Following a Manipulative Therapy Trial

 

Abstract

 

  • Objective: To present the characteristics of four cases of migraine, who were included as participants in a prospective trial on chiropractic spinal manipulative therapy for migraine.
  • Method: Participants in a migraine research trial, were reviewed for the symptoms or clinical features and their response to manual therapy.
  • Results: The four selected cases of migraine responded dramatically to SMT, with numerous self reported symptoms being either eliminated or substantially reduced. Average frequency of episodes was reduced on average by 90%, duration of each episode by 38%, and use of medication was reduced by 94%. In addition, several associated symptoms were substantially reduced, including nausea, vomiting, photophobia and phonophobia.
  • Discussion: The various cases are presented to assist practitioners making a more informed prognosis.
  • Key Indexing Terms (MeSH): Migraine, diagnosis, manual therapy.

 

Introduction

 

Migraine, in its various forms, affects approximately 12 to 15% of people throughout the world, with an estimated incidence in the USA of 6% of males and 18% of females (1). Depending on the severity of a migrainous attack it is apparent that most, if not all, of the body systems can be affected (2). Consequently migraine poses a substantial threat to regular sufferers, which debilitates them to varying degrees from slight to severe (3).

 

One early definition of migraine highlights some potential difficulties in research assessing treatment for migraine. �A familial disorder characterised by recurrent attacks of headache widely variable in intensity, frequency and duration. Attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting. In some cases they are preceded by, or associated with neurological and mood disturbances. All of the above characteristics are not necessarily present in each attack or in each patient� (4). (Migraine and headache of the World Federation of Neurology in 1969).

 

Some of the more common symptoms of migraine include headache, an aura, scotoma, photophobia, phonophobia, scintillations, nausea and/or vomiting (5).

 

The source of pain in migraines is to found in the intra- and extracranial blood vessels (6). The blood vessel walls are pain sensitive to distension, traction or displacement. The idiopathic dilation of cranial blood vessels, together with an increase in a pain-threshold-lowering substance, result in headache for migraine headache (7).

 

Migraine has been shown to be reduced following chiropractic spinal manipulative therapy (8-18). In addition, other research suggests a potential role of musculoskeletal conditions in the aetiology of migraine (19-22). A misdiagnosis of migraine or cervicogenic headache could give a misleading positive result for improvement (23). Therefore, an accurate diagnosis needs to be made, based on standard accepted taxonomy.

 

A new classification system of headaches has been developed by the Headache Classification Committee of the International Headache Society (IHS), which contains a main category covering migraine (24). However, this taxonomy system still has several areas of potential overlap or controversy regarding the diagnosis of the headache (23).

 

This paper presents three cases of migraine with aura (MA) and one of migraine without aura (MW), detailing their symptoms, clinical features and response to chiropractic Spinal Manulative Therapy (SMT). The authors hope to enhance practitioners knowledge for migraine conditions that may respond favourably with SMT.

 

Features of Migraine

 

The IHS defines migraines as having at least two of the following: unilateral location, pulsating quality, moderate or severe intensity, aggravated by routine physical activity. During the headache the person must also experience either nausea &/or vomiting, and photophobia &/or phonophobia (24). In addition, there is no suggestion either by history, physical or neurological examination that the person has a headache listed in groups 5-11 of their classification system (23-25).

 

A previous study by the author has detailed features of the different classifications of migraine (8). The aura is the distinguishing feature between the old classifications of common (MW) and classic migraine (MA) (24). It has�been described by migraine sufferers as an opaque object, or a zigzag line around a cloud, even cases of tactile hallucinations have been recorded (6,7). The most common auras consist of homonymous visual disturbances, unilateral parathesias &/or numbness, unilateral weakness, aphasia or unclassifiable speech difficulty.

 

The potential mechanisms for the different migraine types are poorly understood. There have been a number of aetiologies proposed in the literature, but none seem to be able to explain all the potential symptoms experienced by migraine sufferers (26). The IHS describe changes in blood composition and platelet function as a triggering role. Processes which occur in the brain act via the trigemino-vascular system and the intra and extracranial vasculature and perivascular spaces (24).

 

Methodology

 

Based on a previous reported study (9) which involved 32 subjects who received chiropractic SMT for MA, three cases are presented which were selected due to the significant changes the patient experienced.

 

People with migraines were advertised for participation in the study, via the radio and newspapers within a local region of Sydney. All applicants completed a questionnaire, developed from Vernon (27) and has been reported in a previous study (9).

 

The participants to take part in the trial were selected according to responses in the questionnaire of specific symptoms. The criteria for MA diagnosis was compliance with at least 5 out of the following indicators: reaction to pain requiring cessation of activities or the need to seek a quiet dark area; pain located around the temples; pain described as throbbing; associated symptoms of nausea, vomiting, aura, photophobia or phonophobia; migraine precipitated by weather changes; migraine aggravated by head or neck movements; previous diagnosis of migraine by a specialist; and a family history of migraine.

 

Participants also had to experience migraine at least once a month, but not daily and the migraines could not have been initiated by trauma. Participants were excluded from the study if there were contra-indications to SMT, such as meningitis or cerebral aneurysm. In addition, participants with temporal arteritis, benign intracranial hypertension or space occupying lesions, were also excluded due to safety aspects.

 

The trial was conducted over six months, and consisted of 3 stages: two months pre-treatment, two months treatment, and two months post treatment. Participants completed diaries during the entire trial noting the�frequency, intensity, duration, disability, associated symptoms and use of medication for each migraine episode. In addition, clinic records were compared to their diary entries of migraine episodes. Concurrently, the subjects were contacted by telephone by the author every two weeks and asked to describe the migraine episodes for comparison to their diaries.

 

A detailed history of the patients� subjective pain features was taken during the initial consultation. This included the type of pain, duration, onset, severity, radiation, aggravating and relieving factors. The history also included medical features, a systems review for potential pathologies, previous treatments and its effects. Assessment of subluxation included: orthopaedic and neurological testing, segmental springing, mobility measures such as visual estimation of range of motion, assessment of previous radiographs, specific chiropractic vertebral testing procedures, as well as response of the patient to SMT.

 

In addition, several vascular investigations were performed where indicated, which include: vertebral artery test, manipulative provocation test, blood pressure assessment, and abdominal aortic aneurysm screening.

 

During the treatment period, the subjects continued to record migraine episodes in their diary, and receive telephone calls from the authors. Treatment consisted of short amplitude, high velocity spinal manipulative thrusts, or areas of fixation determined by the physical examination. Comparison was made of initial baseline episodes of migraine prior to commencement of the study and at six months following its cessation.

 

Case 1

 

A 25 year old, 65kg Caucasian male presented with neck pain which had commenced in early childhood, that he felt may have been related to his prolonged birth. During the history the patient stated that he suffered a regular migraine headaches (3-4 per week) which he supposed was related to a motor vehicle accident, two years prior to his presentation. He reported that his �migraine� symptoms were a unilateral throbbing headache, an aura, nausea, vomiting, vertigo, and photophobia. Sleep tended to alleviate the symptoms and he required Allegren medication (25mg) on a daily basis.

 

From diaries the patient was required to complete in the study, a migraine would occur 14 times a month, last an average 12.5 hours and he could perform duties after 8 hours. In addition a visual analogue scale score (VAS) for an average episode was 8.5 out of a possible maximum score of ten, corresponding to a description of �terrible� pain.

 

On examination, he was found to have sensitive suboccipital and upper cervical musculature, and decreased range of motion at the joint between the occiput and first cervical vertebra, the atlanto-occipital facet joint (Occ-C1), coupled with pain on flexion and extension of the cervical spine. He also had significant reduction in thoracic spine motion and an increase in thoracic kyphosis.

 

Treatment

 

The patient received chiropractic adjustments (described above) to his Occ-C1 joint, upper thoracic spine and the affected hypertonic musculature. An initial course of 16 diversified chiropractic treatments was conducted as part of a research program that the patient was participating in. The program involved recording several features for every migraine episode, including visual analogue scores, duration, medication and time before they could return to normal activities. In addition, he was shown some stretches and other exercises for his neck muscles and proved compliant.

 

Outcome

 

The patient reported a dramatic improvement after the course of treatment and had noticeably reduced frequency and intensity of migraines. This had continued when the patient was contacted at a period of 6 months after the study had ceased (Fig 1). At that point the patient reported having 2 migraines a month, with a VAS score of 5 out of ten, and the average duration had fallen to 7 hours (Fig�s 1-3). In addition, he now used no medication and noted that he no longer experienced nausea, vomiting, photophobia or phonophobia (Table 1).

 

Table 1 Review of Selected Cases Presenting with Migraine

 

Case 2

 

A 43 year old female university clerk presented complaining of chronic recurring headaches each lasting on average five days, sinus trouble due to allergy, and disturbed vision. The patient stated she experienced �migraines� which had been occurring since the age of eight. During the migraines she experienced nausea, visual disturbances, photophobia, phonophobia and scotoma. The pain usually began around her right eye but would often change to the left temple. She did not describe the pain as throbbing and the pain only stopped activities on a few occasions each year.

 

The patient stated she experienced the migraines once a month, except during springtime, when the migraines would occur at least once a week. She had been prescribed hormone replacement therapy (HRT) for twelve months following menopause, which had not changed the migraines. She also reported a VAS score of eight for an average episode and that an average episode lasted between six to eight hours.

 

In her history she reported that she had experienced many falls while horse riding between the ages of eight to ten. However, she believed that no bones were broken at the time of the falls, although this was not confirmed by radiographs at the time of injury. She had two children and was active, currently playing tennis, walking and was a keen gardener. Her past treatment included non- prescription medication for her sinus problems (Teldane),�however this did not seem to relieve the migraine. The patient stated she had previously had pethadine injections due to the severity of the migraines.

 

On examination she had an increased thoracic kyphosis, associated Trapezius hypertonicity and trigger points. She exhibited slight scoliosis (negative on Adams test) in the lumbar and thoracic regions. The patient also had moderate limitation in cervical spine mobility, notably in left lateral flexion and right rotation.

 

Treatment

 

Treatment consisted of diversified chiropractic spinal adjustments, especially to the C1-2, T5-6, L4-5 joints to correct the restriction of movement. Vibrator massage, and infra-red therapy were used to complement the�treatment, releasing muscles spasm of the region before the adjustments were delivered. The patient was given 14 treatments over the two months of the research trial. Following the initial treatment she experienced some moderate neck pain which resolved following the next session.

 

Figure 1 Changes in Frequency of Migraine Episodes for the Four Cases

 

Figure 2 Changes in VAS Scores of Migraines for the Four Cases

 

Figure 3 Changes in Duration of Migraines for the Four Cases

 

Figure 4 Changes in Medication of Migraines for the Four Cases

 

Outcome

 

When contacted six months following the study, the patient stated the migraines had not experienced a migraine in the last four months. The last episode she had noted a VAS score reduced to four, the average duration had reduced to three days and she had now reduced her medication to nil (Fig�s 1-4). In addition, she now experienced minor nausea, no photophobia or phonophobia, and she had substantially improved neck�mobility. She had continued to have chiropractic treatment at a frequency of once a month, following the end of the research trial.

 

Case 3

 

A 21 year old female, 171cm tall Caucasian presented with a chief complaint of severe migraines. Each episode lasted two to four hours, at a frequency of three to four episodes per week, and they had occurred for five years. The patient reported moderate posterior neck and shoulder pain, associated with the migraines. She also believed the initial migraine to be induced by stress and subsequent episodes were also aggravated by emotional stress. The patient reported no other health problems except very mild hypotension, for which she was not taking medication.

 

The patient�s migraines were located in the frontal, temporal and occipital regions bilaterally. No symptoms occurred premonitory to the onset of her migraines, nor did she experience visual disturbances prior to or during the migraine episodes. She described the pain as a constant dull ache, which was local and she did not complain of any parathesias.

 

At the initial visit, she rated each migraine between 4 and 5 on a VAS of 1-10. She also noted she experienced nausea, vomiting, dizziness, photophobia and phonophobia.

 

The cervical ranges of motion were restricted, predominantly in right rotation. Palpation findings were obvious at trapezius, suboccipital and supra scapulae muscles due to increased tone, colour and temperature. Motion palpation indicated restricted movement of the C1-2 facet joint on the right side. Further palpation of the supra scapular and suboccipital indicated myofibrotic tissue. Neurological tests such as Rhombergs, and vertebrobasilar (Maines) test, were negative.

 

Treatment

 

The initial treatment was muscle stripping technique aided by a masseter machine massage across the muscle fibres of the trapezius, suprascapularis and temporal regions. The patient also had a cervical adjustment of C1- 2, and adjustment to the T3-4 & T4-5 segments.

 

The patient was seen three days later, at which point she reported that her neck was less painful. However, she still complained of right neck pain and dizziness. Examination revealed passive motion restriction at C1-2 motion segment. Her thoracic spine was found to be restricted at segment T5-6. In addition, she had mild to moderate hypertonicity in suboccipital and cervical paraspinal muscles and supra scapular area. She was again treated�with adjustments and soft tissue technique. The C1-2 restriction to the right was adjusted with a cervical adjustment. The T5-6 restriction was also adjusted and the myofibrotic tissues were treated with the masseter.

 

The patient returned four days later. She reported that her migraine had improved. She no longer experienced the symptoms of a non-classical migraine. However, the pressure sensation was still present around her head, but less so than prior to the commencement of treatment. No neck pain was reported. Examination revealed a passive motion restriction of C1-2 motion segment. There was hypertonicity in the suboccipital and supra scapular muscles. The patient was treated with a cervical adjustment at C1-2 and muscle work on the above muscle groups. Neck stretching exercises were also advised.

 

Table 2 Changes in Outcome Measures of Migraine Episodes for the Mean of the Four Cases

 

The patient was seen a total of thirteen times over a two month period, and stated that her migraine episodes had reduced significantly at the last treatment. In addition, she was no longer experiencing neck pain. Examination revealed passive motion restriction at the C1-2 motion segment, which was reduced by adjustment.

 

Outcome

 

The patient was contacted six months after the trial for a follow-up, at which point she reported she had experienced a reduction of migraine episodes to once every two months. However, her VAS scores for an average episode was now 5.5, but the duration of an average episode was reduced by 50%. In addition, she noted a reduction in photophobia and phonophobia, but still experienced some dizziness. The patient also noted a reduction in use of medication from three Nurofen a week (12 per month) to three per month, representing a 75% reduction (Fig�s 1- 4).

 

Case 4

 

A 34 year old, 75kg Caucasian male presented with neck pain and migraines which had commenced after he had hit his head whilst surfing at a beach. This incident occurred when the patient was 19 years old but the patient said the migraines had peaked at 25 years of age. The patient stated that at 25 years of age he suffered a�migraine headaches (three to four times per week) but now in the last year prior to his presentation he experienced them twice a week. He reported that his migraines started in the suboccipital region, and radiated to his right eye. He also reported they were a unilateral throbbing headache, an aura, nausea, vomiting, vertigo, and photophobia. The patient stated taking aspirin and mersyndol medication approximately four to five times a week.

 

The patient reported that an average episode lasted twelve to eighteen hours and he could perform duties after eight to ten hours. In addition a visual analogue scale score (VAS) for an average episode was 7.0 out of a possible maximum score of ten, corresponding to a description of �moderate� pain. He also reported that he had osteopathic treatment approximately three years earlier, which had given some short term relief, however, physiotherapy had proven ineffective.

 

On examination, he was found to have significant reduction in thoracic spine motion and an increase in thoracic kyphosis, and decreased range of motion at the joint between the first and second cervical vertebra (C1- 2), the atlanto-occipital facet joint (Occ-C1), coupled with pain on flexion and extension of the cervical spine. He also had sensitive suboccipital and upper cervical musculature, especially the upper Trapezius muscle.

 

Treatment

 

The patient received chiropractic diversified adjustments to his C1-2 joint, upper thoracic spine and the affected hypertonic musculature. After a course of 14 treatments (conducted as part of a research program) the patient found he was experiencing one migraine per fortnight. The patient also reported that the nausea had decreased and that the aura was less significant.

 

The patient reported the improvement after the initial treatment had continued when the patient was contacted 6 months after the study had ceased. At that point the patient reported having one migraine a month, and that the VAS score had fallen to 6 out of ten. However, the average duration and return to normal activities time had remain the same as before the treatment had commenced. The patient reported that he now used only one medication per month and that he no longer experienced nausea, vomiting, and the aura (Fig�s 1-4).

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

“How does the effectiveness of chiropractic care and the use of medication vary when it comes to migraine pain?”�Chiropractic migraine pain treatment, such as chiropractic spinal manipulative treatment or spinal manipulation, is commonly utilized to help improve as well as manage migraine symptoms. Many healthcare professionals also frequently use medication, such as amitriptyline, to help relieve migraine symptoms although this treatment option may only temporarily relieve the symptoms rather than treat the condition from the source. Chiropractic care and the use of medication can be used together to help increase the relief of the treatments, as recommended by a healthcare professional. Several evidence-based studies, like the ones in the article, have demonstrated the effectiveness of chiropractic migraine pain treatment, however, more research studies are required to determine their specific result on migraine pain management. Furthermore, other research studies have shown that medication may be as effective as chiropractic spinal manipulative treatment but was associated with more side effects. Common side effects of medications like amitriptyline include: drowsiness, dizziness, dry mouth, blurred vision, constipation, trouble urinating or weight gain. Additional assessments on the effectiveness of spinal manipulation and amitriptyline is needed.

 

Conclusion

 

These four case studies highlight an apparent significant reduction in disability associated with migraines (Table 1). The conclusions are limited however, because the study does not contain a control group for comparison of placebo effect. Therefore chiropractic SMT appears to have significantly reduced migraine disability for these individuals.

 

Practitioners need to be critically aware of diagnostic criteria when presenting studies or case studies on effectiveness of their treatment (8). This is especially important in presentation of migraine and manipulative therapy research (12, 23).

 

Changes in outcome measures of migraine episodes for the mean of the four cases revealed some interesting findings (Table 2 ). As can be seen in the table, the frequency of episodes and the use of medication were substantially reduced for the four cases. However, one cannot conclude that this could be the case for other migraine sufferers due to the small number of cases presented.

 

Acknowledgement

 

The author greatly appreciates the contribution of Dr Dave Mealing in the preparation of the paper.

 

A Randomized Controlled Trial of Chiropractic Spinal Manipulative Therapy for Migraine.

 

Abstract

 

  • Objective: To assess the efficacy of chiropractic spinal manipulative therapy (SMT) in the treatment of migraine.
  • Design: A randomized controlled trial of 6 months’ duration. The trial consisted of 3 stages: 2 months of data collection (before treatment), 2 months of treatment, and a further 2 months of data collection (after treatment). Comparison of outcomes to the initial baseline factors was made at the end of the 6 months for both an SMT group and a control group.
  • Setting: Chiropractic Research Center of Macquarie University.
  • Participants: One hundred twenty-seven volunteers between the ages of 10 and 70 years were recruited through media advertising. The diagnosis of migraine was made on the basis of the International Headache Society standard, with a minimum of at least one migraine per month.
  • Interventions: Two months of chiropractic SMT (diversified technique) at vertebral fixations determined by the practitioner (maximum of 16 treatments).
  • Main Outcome Measures: Participants completed standard headache diaries during the entire trial noting the frequency, intensity (visual analogue score), duration, disability, associated symptoms, and use of medication for each migraine episode.
  • Results: The average response of the treatment group (n = 83) showed statistically significant improvement in migraine frequency (P < .005), duration (P < .01), disability (P < .05), and medication use (P< .001) when compared with the control group (n = 40). Four persons failed to complete the trial because of a variety of causes, including change in residence, a motor vehicle accident, and increased migraine frequency. Expressed in other terms, 22% of participants reported more than a 90% reduction of migraines as a consequence of the 2 months of SMT. Approximately 50% more participants reported significant improvement in the morbidity of each episode.
  • Conclusion: The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic SMT. A high percentage (>80%) of participants reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced.

 

Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-Type Headaches: a Randomized Clinical Trial

 

Abstract

 

  • Objective: To compare the effectiveness of spinal manipulation and pharmaceutical treatment (amitriptyline) for chronic tension-type headache.
  • Design: Randomized controlled trial using two parallel groups. The study consisted of a 2-wk baseline period, a 6-wk treatment period and a 4-wk posttreatment, follow-up period.
  • Setting: Chiropractic college outpatient clinic.
  • Patients: One hundred and fifty patients between the ages of 18 and 70 with a diagnosis of tension-type headaches of at least 3 months’ duration at a frequency of at least once per wk.
  • Interventions: 6 wk of spinal manipulative therapy provided by chiropractors or 6 wk of amitriptyline treatment managed by a medical physician.
  • Main Outcome Measures: Change in patient-reported daily headache intensity, weekly headache frequency, over-the-counter medication usage and functional health status (SF-36).
  • Results: A total of 448 people responded to the recruitment advertisements; 298 were excluded during the screening process. Of the 150 patients who were enrolled in the study, 24 (16%) dropped out: 5 (6.6%) from the spinal manipulative therapy and 19 (27.1%) from the amitriptyline therapy group. During the treatment period, both groups improved at very similar rates in all primary outcomes. In relation to baseline values at 4 wk after cessation of treatment, the spinal manipulation group showed a reduction of 32% in headache intensity, 42% in headache frequency, 30% in over-the-counter medication usage and an improvement of 16% in functional health status. By comparison, the amitriptyline therapy group showed no improvement or a slight worsening from baseline values in the same four major outcome measures. Controlling for baseline differences, all group differences at 4 wk after cessation of therapy were considered to be clinically important and were statistically significant. Of the patients who finished the study, 46 (82.1%) in the amitriptyline therapy group reported side effects that included drowsiness, dry mouth and weight gain. Three patients (4.3%) in the spinal manipulation group reported neck soreness and stiffness.
  • Conclusions: The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline therapy was slightly more effective in reducing pain at the end of the treatment period but was associated with more side effects. Four weeks after the cessation of treatment, however, the patients who received spinal manipulative therapy experienced a sustained therapeutic benefit in all major outcomes in contrast to the patients that received amitriptyline therapy, who reverted to baseline values. The sustained therapeutic benefit associated with spinal manipulation seemed to result in a decreased need for over-the-counter medication. There is a need to assess the effectiveness of spinal manipulative therapy beyond four weeks and to compare spinal manipulative therapy to an appropriate placebo such as sham manipulation in future clinical trials.

 

In conclusion,�the following research studies demonstrated the effectiveness of chiropractic spinal manipulative therapy while one research study compared it with the use of amitriptyline for migraine. The article concludes that both chiropractic migraine pain treatment as well as medication were significantly effective in the improvement of migraine headache, however, amitriptyline is reported to present various side effects. Finally, patients may choose the best possible treatment for their migraine pain, as recommended by a healthcare professional. 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

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Neck Pain

 

Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.

 

blog picture of cartoon paperboy big news

 

IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

OTHER IMPORTANT TOPICS: EXTRA: Sports Injuries? | Vincent Garcia | Patient | El Paso, TX Chiropractor

 

Blank
References

1. Lipton RB, Stewart WF. Migraine in the United States: a review of epidemiology and health care use. Neurology 1993; 43(Suppl 3): S6-10.
2. Stewart WF, Lipton RB, Celentous DD, et al. Prevalence of migraine headache in the United States. JAMA 1992; 267: 64-9.
3. King J. Migraine in the Workplace. Brainwaves. Australian Brain Foundation 1995. Hawthorn, Victoria.
4. Wolff�s Headache and other head pain. Revised by Dalessio DJ. 3rd Ed 1972 Oxford University Press, New York.
5. Linet OS, Stewart WF, Celentous DD, et al. An epidemiological study of headaches among adolescents and young adults. JAMA 1989; 261: 221-6.
6. Anthony M. Migraine and its Management, Australian Family Physician 1986; 15(5): 643-9.
7. Sjasstad O, Fredricksen TA, Sand T. The localisation of the initial pain of attack: a comparison between classic migraine and cervicogenic headache. Functional Neurology 1989; 4: 73-8
8. Tuchin PJ, Bonello R. Classic migraine or not classic migraine, that is the question. Aust Chiro & Osteo 1996; 5: 66-74.
9. Tuchin PJ. The Efficacy Of Chiropractic Spinal Manipulative Therapy (SMT) In The Treatment Of Migraine – A Pilot Study. Aust Chiro & Osteo 1997; 6: 41-7.
10. Parker GB, Tupling H, Pryor DS. A Controlled Trial of Cervical Manipulation for Migraine, Aust NZ J Med 1978; 8: 585-93.
11. Hasselburg PD. Commission of Inquiry Into Chiropractic. Chiropractic in New Zealand. 1979 Government Printing Office New Zealand.
12. Parker GB, Tupling H, Pryor DS. Why Does Migraine Improve During a Clinical Trial? Further Results from a Trial of Cervical Manipulation for Migraine. Aust NZ J Med 1980; 10: 192-8.
13. Vernon H, Dhami MSI. Vertebrogenic Migraine, J Canadian Chiropractic Assoc 1985; 29(1): 20-4.
14. Wight JS. Migraine: A Statistical Analysis of Chiropractic Treatment. J Am Chiro Assoc 1978; 12: 363-7.
15. Vernon H, Steiman I, Hagino C. Cervicogenic Dysfunction in muscle contraction headache and migraine: a descriptive study. J Manipulative Physiol Ther 1992; 15: 418-29.
16. Whittingham W, Ellis WS, Molyneux TP. The effect of manipulation (Toggle recoil technique) for headaches with upper cervical joint dysfunction: a case study. J Manipulative Physiol Ther. 1994; 17(6): 369-75.
17. Lenhart LJ. Chiropractic Management of Migraine without Aura: A case study. JNMS 1995; 3: 20-6.
18. Tuchin PJ, Scwafer T, Brookes M. A Case Study of Chronic Headaches. Aust Chiro Osteo 1996; 5: 47- 53.
19. Nelson CF. The tension headache, migraine continuum: A hypothesis. J Manipulative Physiol Ther 1994; 17(3): 157-67.
20. Kidd R, Nelson C. Musculoskeletal dysfunction of the neck in migraine and tension headache. Headache 1993; 33: 566-9.
21. Milne E. The Mechanism and treatment of migraine and other disorders of cervical and postural dysfunction. Cephalgia 1989; 9(Suppl 10): 381-2.
22. Young K, Dharmi M. The Efficacy Of cervical manipulation as opposed to pharmacological therapeutics in the treatment of migraine patients. Transactions of the Consortium for Chiropractic Research. 1987.
23. Marcus DA. Migraine and tension type headaches: the questionable validity of current classification systems. Pain 1992; 8: 28-36.
24. Headache Classification Committee of the International Headache, Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalgia 1988; 9(Suppl 7): 1-93.
25. Rasmussen BK, Jensen R, Schroll M, Olsen J. Interactions between migraine and tension type headaches in the general population. Arch Neurol 1992; 49: 914-8.
26. Vernon H. Upper Cervical Syndrome: Cervical Diagnosis and Treatment. In Vernon H. (Ed): Differential Diagnosis of Headache. 1988 Baltimore, Williams and Wilkins.
27. Vernon HT. Spinal manipulation and headache of cervical origin. J Manipulative Physiol Ther 1989; 12: 455-68.

Close Accordion
Migraine Headache Chiropractic Treatment | El Paso, TX Chiropractor

Migraine Headache Chiropractic Treatment | El Paso, TX Chiropractor

by | Chiropractic, Functional Medicine, Migraine

A migraine is commonly identified by a moderate to severe throbbing pain or a pulsing sensation, usually on one side of the head, often accompanied by nausea, vomiting and extreme sensitivity to light and sound. Migraine headache pain can last for hours to even days and the symptoms can become so severe they may be disabling. Many doctors can treat varying intensities of head pain, however, the use of drugs and/or medications may only temporarily relieve the painful symptoms. Evidence-based research studies like the one described below, have determined that chiropractic spinal manipulative therapy may effectively improve migraine headaches. The purpose of the article is to educate patients on migraine headache chiropractic treatment.

 

A Twelve Month Clinical Trial of Chiropractic Spinal Manipulative Therapy for Migraine

 

Abstract

 

  • Objective: To assess the efficacy of Chiropractic spinal manipulative therapy (SMT) in the treatment of migraine.
  • Design: A prospective clinical trial of twelve months duration. The trial consisted of 3 stages: two month pre- treatment, two month treatment, and two months post treatment. Comparison of outcomes to the initial baseline factors was made and also 6 months after the cessation of the study.
  • Setting: Chiropractic Research Centre of Macquarie University
  • Participants: Thirty two volunteers, between the ages of 20 to 65 were recruited through media advertising. The diagnosis of migraine was based on a self reported detailed questionnaire, with minimum of one migraine per month.
  • Interventions: Two months of chiropractic SMT at vertebral fixations determined by the practitioner, through orthopedic and chiropractic testing.
  • Main Outcome Measures: Participants completed diaries during the entire trial noting the frequency, intensity (visual analogue score), duration, disability, associated symptoms and use of medication for each migraine episode.
  • Results: The initial 32 participants showed statistically significant (p < 0.05) improvement in migraine frequency, VAS, disability, and medication use, when compared to initial baseline levels. A further assessment of outcomes after a six month follow up (based on 24 participants), continued to show statistically significant improvement in migraine frequency (p < 0.005), VAS (p < 0.01), disability (p < 0.05), and medication use (p < 0.01), when compared to initial baseline levels. In addition, information was collected regarding any changes in neck pain following chiropractic SMT. The results indicated that 14 participants (58%) reported no increase in neck pain as a consequence of the two months of SMT. Five participants (21%) reported a slight increase, three participants (13%) reported mild pain, and two participants (8%) reported moderate pain.
  • Conclusion: The results of this study support the hypothesis that Chiropractic SMT is an effective treatment for migraine, in some people. However, a larger controlled study is required.
  • Key Indexing Terms (MeSH): Migraine; chiropractic; spinal manipulation; prospective trial; neck.

 

Introduction

 

The cervical spine as a cause of headache has been well described in the literature (1,2). The Headache Classification Committee of the International Headaches Society, has defined cervicogenic headache, in addition to the other types of headaches, including migraine and tension type headache (3).

 

However, the role of spinal conditions (especially the cervical spine) and their associated treatment for migraine does not have a well established causal relationship or clear aetiological pathway (4-7). In addition, migraine often has uncertain or overlapping diagnostic criteria thus making the role of the cervical spine as an aetiological factor even more uncertain (8,9).

 

Migraine Headache Chiropractic Treatment | El Paso, TX Chiropractor

 

Migraines are a common and debilitating conditions yet because of this uncertain aetiology, the most appropriate long term treatment has not been established (9,10). Most aetiological models relate to vascular causes of migraine, where episodes seem to be initiated by a decreased blood flow to the cerebrum followed by extracranial vasodilatation during the headache phase (11,12). However, other aetiological models seem connected with vascular changes related to neurological causes and associated serotonergic disturbances (10). Therefore, previous treatments have focused on pharmacological modification of blood flow or serotonin antagonist block (11).

 

This paper will evaluate the efficacy of chiropractic spinal manipulative treatment during a prospective clinical trial of twelve months duration.

 

Chiropractic Treatment

 

Chiropractic SMT is defined as a passive manual manoeuvre during which the three joint complex is carried beyond the normal physiological range of movement without exceeding the boundaries of anatomical integrity (4). SMT requires a dynamic force in a specific direction, usually with a short amplitude to correct a problem of reduced vertebral motion or positional fault. Treatment usually consists of short amplitude, high velocity spinal manipulative thrusts (diversified technique), on areas of vertebral fixation determined by a clinical history and physical examinations.

 

Dr Jimenez works on wrestler's neck_preview | El Paso, TX Chiropractor

 

The most commonly used factors to locate vertebral fixation (denoted vertebral subluxation complex by�chiropractors) are a clinical history relating to mechanical pain patterns and medical details to excluded possible non- mechanical causes (4). These findings would then be confirmed by a thorough physical examination, by assessing which tests/signs (orthopaedic and chiropractic) were able to reproduce the presenting symptom (7).

 

Studies in effectiveness and cost-effectiveness of treatment for back pain have found significant benefit for chiropractic spinal manipulative therapy (SMT). These studies have been detailed in a previous publication by this author on chiropractic in the workers compensation system (13). In addition, numerous studies have identified improvement in neck pain and headache following chiropractic SMT (4,7,14-17).

 

This paper will test an hypothesis that spinal conditions appear to contribute to the aetiology and morbidity of migraine.

 

Methodology

 

The study was twelve month prospective clinical trial which involved 32 subjects who received a two month course of chiropractic SMT. Treatment consisted of short amplitude, high velocity spinal manipulative thrusts (chiropractic adjustive technique), on areas of vertebral subluxation determined by the physical examination.

 

Participants were recruited via the radio and newspapers in the Sydney region. Applicants completed a previously reported questionnaires, and were selected according to responses in the following symptoms. The participants needed to a minimum of 5 of the following IHS indicators: reaction to pain requiring cessation of activities, the need to seek a quiet dark area, unilateral pain located parieto- temporal, pain described as pulsating/throbbing, associated symptoms of nausea &/or vomiting, photophobia &/or phonophobia, migraine aggravated by head or neck movements, and a family history of migraine (3).

 

Inclusion was also based on participants experiencing at least one migraine a month. Exclusion was based on non- migraine indicators of a daily migraine or the initiating factor being trauma. Participants were also excluded from the study if there were contra-indications to SMT, such as meningitis or cerebral aneurysm. In addition, participants with temporal arteritis, benign intracranial hypertension or space occupying lesions were also excluded due to safety aspects.

 

Participants completed diaries during the initial six month trial noting the frequency, VAS, duration, disability, associated symptoms and use of medication for each migraine episode. Participants were instructed how to complete the diary which contained a table and an�instruction sheet. Participants had to note the date of the migraine, an intensity score based on a visual analogue scale, the hours the migraine lasted and the time before they could return to normal activities. In addition, participants noted associated symptoms using a letter abbreviation and they noted the type and strength of medication for each migraine episode.

 

Patient’s blinding was achieved by participants being informed that they may be randomly assigned to a control group which would receive a placebo (non effective) treatment. Concurrently, the practitioners were “blinded” to previous treatment results, assignment of control procedures and other outcome measures.

 

The first aspect of the trial was conducted over six months, and consisted of 3 stages: two months pre-treatment, two months treatment, and two months post treatment. Participants were contacted by the author a further six months after the initial trial and asked to complete another questionnaire regarding their current migraine episodes for comparison to baseline data. The follow up questionnaire sought information on the same outcome measures, as detailed in the diaries described above.

 

Comparison was made to initial baseline outcome measurements of migraine preceding commencement of SMT, data at the end of the two months post SMT, and to the six month follow up data. Statistical analysis involved comparing the changes of the different outcome measurements of frequency, VAS, duration, disability, and medication use throughout the trial. Statistical tests employed were a paired t test to test for significant difference between each group and a one way analysis of variance (ANOVA) to test for changes for all groups.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

“How can chiropractic spinal manipulative therapy help manage my migraine headache pain?”�Although researchers today don’t know the definitive cause behind these complex headaches, many healthcare professionals believe migraines are often the result of an underlying issue along the cervical spine, or neck. If you suffer from migraine headache pain, chiropractic treatment can help correct spinal misalignments, or subluxations, in the cervical spine to improve the severity of the headache and decrease their frequency. It’s not necessary to rely on drugs and/or medications to relieve the painful symptoms, however, these may be used if properly directed by a healthcare professional. Rather than focusing on the head pain alone, a doctor of chiropractic will target the source of the issue and help improve your overall health and wellness.

 

Results

 

Thirty two participants, between the ages of 23 to 60, joined the study with there being 14 males and 18 females. Table 1 gives the comparative descriptive statistics for the group. The length of time the person had migraines ranged between 5 to 36 years for the group, with the average being 18.1 years. The duration of a typical migraine episode ranged between 0.75 to 108 hours for the group, with the average being 23.3 hours. The disability (length of time before the person could return to normal activities) of a typical migraine ranged between 0 to 108 hours for the group, with the average being 25.0 hours.

 

Table 1 Comparative Statistics for Group Prior to Commencement of Study | Dr. Alex Jimenez | El Paso, TX Chiropractor

 

The percentage response for each of the diagnostic criteria of the IHS guidelines is detailed in table 2 (Table 2). The highest responses were for photophobia (91%), nausea (88%), reaction to pain requiring the person to seek a quiet dark area (84%), phonophobia (72%), throbbing pain characteristic (69%), parieto-temporal pain location (69%), inability to continue normal activities (66%), and family history (63%).

 

Table 2 IHS Criteria Questionnaire Responses for Group Prior to Commencement of Study | Dr. Alex Jimenez | El Paso, TX Chiropractor

 

The IHS diagnostic criteria with the lowest responses were aura (31%), migraines aggravated by head or neck movement (53%), and vomiting (56%). A moderate number (44%) of people did not indicate aura as a feature, however, they described either homonymous visual changes or parasthesias. Therefore, the number of people experiencing migraine with aura (MA) for this group was twenty four (75%) of a total group of thirty two.

 

The group showed statistically significant improvement (p < 0.05) in migraine frequency, VAS, duration and disability, when compared to initial baseline levels. The frequency rates reduced by 46% for the group, severity reduced by 12%, duration reduced by 20%, disability reduced by 14% only one participant (3.1 %) reported that their migraine episodes were worse after the two months of SMT, but this was not sustained at the two month post treatment follow up period. Table 3 demonstrates variate scores in each of the six diary categories for the three phases of the trial.

 

Table 3 Comparative Results for Group Prior to Commencement of Study | Dr. Alex Jimenez | El Paso, TX Chiropractor

 

From the initial thirty two participants who entered the study, four participants failed to complete the entire trial, one due to alteration in work situation, one due to a fractured ankle, one due to soreness after SMT, and one ACO�following a perceived worsening of their migraine due to chiropractic SMT. In addition, four people failed to return their six month follow up data, and were excluded from the assessment. Therefore the assessment of changes in migraine at the twelve month period was based on 24 participants. Table 4 gives the comparative statistics for this group at the end of the 12 month period.

 

Table 4 Changes in Outcome Measures for Group Baseline Levels Compared to the 12 Month Follow Up | Dr. Alex Jimenez | El Paso, TX Chiropractor

 

The average response at twelve months (n=24) showed statistically significant improvement in migraine frequency (p < 0.005), VAS (p < 0.01), duration (p < 0.05), and medication use (p < 0.01), when compared to initial baseline levels (Figure ????). The greatest area for improvement was with the frequency of episodes (60% reduction), and the associated severity of each migraine (14% reduction). In addition, the duration of the migraine (20% reduction) and the use of medication, reduced significantly following the SMT intervention (36% reduction). Table 3 shows mean variate scores for the three phases of the trial and statistical significance by analysis of variance (ANOVA).

 

Another additional result related to associated neck pain. Fourteen participants (58%) reported no increase in neck pain as a consequence of the two months of SMT. Five participants (21%) reported slight pain, three participants (13%) reported mild pain, and two participants (8%) reported moderate pain.

 

Discussion

 

The majority of participants were chronic migraine sufferers, on average they had experienced migraines for 18.1 years. However, the results have demonstrated a significant (p< 0.005) reduction in their migraine episodes and their associated disability. The mean number of migraines per month reduced from 7.6 to 2.6 episodes.

 

A twelve month study gives the results substantial significance because a criticism of early studies were that the length of the trial was too short to allow for the cyclical nature of migraines (18). However, the study was limited in the sample size and the fact that the trial was a pragmatic study which did not consider what aspects of chiropractic SNIT had contributed to the improvement in the migraines.

 

In addition, the study was limited due to the lack of a control group. However, it could be argued that participants acted as their own form of control, due to the�baseline two months data collection, especially given the fact that this group were chronic migraine sufferers.

 

A further limitation of this study, as with other studies of migraine or headaches was that there is substantial overlap in diagnosis and classification of migraines. The questionnaire used in this study proved to have good reliability, however, there is strong suggestion that many headache sufferers may have more than one type of headache (6-9). An advantage with the design of this study is that regardless of the exact “diagnosis” of the migraine, self reported improvement of outcome measures allow assessment of the validity of the therapy in question (4).

 

This study appears to confirm that there are a number of precipitating or aggravating factors involved in migraine episodes and therefore a single treatment regime may prove ineffective in the long term (4,5,9,15).

 

Practitioners need to be aware of the various treatment strategies and their relative advantages or limitations.

 

Importantly, many of the associated symptoms suffered by participants on the trial were reported to be decreased following the SMT. The associated symptoms which decreased following the trial included nausea (41% of participants felt reduction), photophobia (31 % felt reduction), vomiting (25% felt reduction), and phonophobia (25% felt reduction). Commonly reported side effects which often increase following pharmaceutical trials include nausea, vomiting, fatigue, chest pain, paraesthesia, somnolence, syncope, vertigo and less commonly atrial fibrillation. In addition, recent evidence has identified sumatriptan to be a potential cause of birth defects and myocardial infarction (19,20).

 

Dr Jimenez works on back treatment at Push crossfit competition | El Paso, TX Chiropractor

 

Whilst not a factor noted by the IHS, stress as either an aggravating or precipitating factor was cited by 73% of participants. In addition, 66% of people reported neck pain at the time of the migraine, with a further 31 % of people reporting upper back pain (some people noted both simultaneously).

 

Interestingly, five people at the end of the 12 months followup had no migraines and had decreased need for medication by 100% following chiropractic SMT. No patients reported that their migraines had increased as a result of the SMT trial.

 

Conclusion

 

The results of this study support the hypothesis that Chiropractic SMT is an effective treatment for migraine, in some people. However, due to the multifactorial nature of migraine, and the finding that episodes usually reduce following any intervention, further larger controlled study is required.

 

A prospective randomised controlled trial utilising detuned EPT (interferential), a sham manipulation group and an SMT group is nearing conclusion. It is anticipated this trial will provide further information of the efficacy of Chiropractic SMT in the treatment of migraine with aura.

 

In conclusion,�because migraine headache pain can be significantly debilitating, it’s essential for patients who suffer from this complex type of head pain to understand the effectiveness of chiropractic spinal manipulative therapy. According to the results of the research study above, migraine headache chiropractic treatment can be effectively used to as migraine treatment. Regardless of the results of the twelve month clinical trial, further research studies are still required. 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

 

Green-Call-Now-Button-24H-150x150-2-3.png

 

Additional Topics: Neck Pain

 

Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.

 

blog picture of cartoon paperboy big news

 

IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

OTHER IMPORTANT TOPICS: EXTRA: Sports Injuries? | Vincent Garcia | Patient | El Paso, TX Chiropractor

 

Blank
References

1. Bogduk N. Cervical causes of headache and dizziness. In: Greive GP (ed) Modern manual therapy of the vertebral column. 2nd ed 1994. Churchill Livingstone, Edinburgh. p3l7-31.
2. Jull GA. Cervical Headache: a review. In: Greive GP (ed) Modem manual therapy of the vertebral column. 2nd ed 1994. Churchill Livingstone, Edinburgh. p 333-34,6
3. Headache Classification Committee of the International Headache, Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalgia 1988, 9. Suppl. 7: 1-93.
4. Tuchin PJ. The efficacy of chiropractic spinal manipulative therapy (SMT) in the treatment of migraine – a pilot study. Aust Chiro & Osteo 1997; 6: 41-7.
5. Milne E. The mechanism and treatment of migraine and other disorders of cervical and postural dysfunction. Cephaigia 1989; 9, Suppi 10: 381-2.
6. Kidd R, Nelson C. Musculoskeletal dysfunction of the neck in migraine and tension headache. Headache 1993; 33: 566-9.
7. Tuchin PJ, Bonello R. Classic migraine or not classic migraine, that is the question. Aust Chiro & Osteo 1996; 5: 66-74.
8. Marcus DA. Migraine and tension type headaches: the questionable validity of current classification systems. 1992; Pain 8: 28-36.
9. Rasmussen BK, Jensen R, Schroll M, Olsen J. Interactions between migraine and tension type headaches in the general population. Arch Neurol 1992; 49: 914-8.
10. Lance JW. A concept of migraine and the search for the ideal headache drug. Headache 1990; 1: 17-23.
11. Dalassio D. The pathology of migraine. Clin J Pain 1990 6: 235-9.
12. Moskowitz MA. Basic mechanisms in vascular headache. Neurol Clin 1990; 16: 157-68
13. Tuchin PJ, Bonello R. Preliminary Findings of Analysis of Chiropractic Utilisation and Cost in the Workers Compensation System of New South Wales. J Manipulative Physiol Ther 1995; lg: 503-11.
14. Tuchin PJ, Scwafer T, Brookes M. A Case Study of Chronic Headaches. Aust Chiro & Osteo 1996; 5: 47-53.
15. Parker GB, Tupling H, Pryor DS. A Controlled Trial of Cervical Manipulation for Migraine. Aust NZ J Med 1978; 8: 585-93.
16. Young K, Dharmi M. The efficacy of cervical manipulation as opposed to pharmacological therapeutics in the treatment of migraine patients. Transactions of the Consortium for Chiropractic Research. 1987.
17. Vernon H, Steiman I, Hagino C. Cervicogenic dysfunction in muscle contraction headache and migraine: a descriptive study. J Manipulative Physiol Ther 1992; 15: 418-29
18. Parker GB, Tupling H, Pryor DS. Why does migraine improve during a clinical trial? Further results from a trial of cervical manipulation for migraine. Aust NZ J Med 1980; 10: 192-8.
19. Ottervanger JP, Stricker BH. Cardiovascular adverse reactions to sumatriptan: cause for concern? CNS Drugs 1995; 3: 90-8.
20. Simmons VE, Blakeborough P. The safety profile of sumatriptan. Rev Contemp Pharmacother 1994; 5: 319-28.

Close Accordion