George Lara, now retired, found relief with Dr. Alex Jimenez, back pain specialist and chiropractor, for his degenerative disk disease following two back injuries he experienced several years ago. After using drugs/medications and experiencing constant symptoms due to his DDD, Mr. Lara describes how Dr. Jimenez’s chiropractic treatment greatly helped restore his quality of life as well as promote his overall health and wellness. George Lara highly recommends Dr. Alex Jimenez as a non-surgical treatment choice for degenerative disc disease, and praises his dedication for treating his patients.
Degenerative disk disease, or DDD, refers to the natural breakdown of an intervertebral disk of the spine. Despite its title, DDD isn’t regarded as a disorder, nor is it degenerative. To the contrary, disk degeneration is frequently the consequence of ordinary daily stresses and minor accidents that cause spinal disks to slowly eliminate water in the anulus fibrosus, or even through the stiff outer layer of a disk. As water content decreases, they start to collapse. This could lead to pressure being placed on the nerves causing weakness and pain. While not necessarily symptomatic, DDD may lead to acute or chronic low back or neck pain in addition to nerve pain based on the positioning of the affected disk and the amount of strain it puts around the surrounding nerve roots.
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Hydration: There is no denying that a healthy diet is integral to overall wellness and staying hydrated is absolutely vital. Every organ, every cell in your body contains water. In fact, when you don�t drink enough water and keep your body properly hydrated, it does not function as it should.
The health of your spine and back depends heavily on whether you are properly hydrated. In fact, if you don�t drink enough water plain, pure water, it could affect your back, causing pain and limiting mobility.
Contents
Hydration
Overview Of Spinal Construction
To understand water�s role in spinal health, you first need to understand how the spine is constructed. The row of bones that make up the spine are called vertebrae. Between each vertebrae is a disc. This disc works like a shock absorber so as you bend, flex, and move about the disc provides a buffer so the bones do not rub together.
Each disc is comprised of two parts. The center of the disc is the nucleus pulposis. It is made up mostly of water. The nucleus pulposis is surrounded by a tough, flexible ring that contains a gelatinous substance. It protects the inner area which is the cushion for the vertebrae. Two factors that further complicate the rehydration of the discs are aging and sedentary lifestyles.
How Water Is Good For Your Back
As you go about your daily activities, each time you move, the spine compresses the disc, squeezing out the water within. Even walking or sitting upright can cause this as gravity causes the spine to compress. When the disc does not have adequate water, the result is pain and lack of mobility as well as increased risk of spinal injury.
When you are not properly hydrated your body cannot replenish the water in the discs, causing them to remain compressed. Beverages like soda are not adequate for effective hydration. You need to make sure that you drink enough water every day.
For years we were told that 8 eight ounce glasses of water a day was the rule for proper hydration, and that works for many people. However, an article in the Harvard Health Letter suggests that the body can be properly hydrated with 30 to 50 ounces of water a day. The article goes on to suggest that water can also be found in foods like spinach, watermelon, soups, and lettuce are also good sources for hydration.
Spinal Problems Caused By Dehydration
When the body is dehydrated the discs remain compressed instead of refilling. When that happens the overall function of the spine is compromised. Your constant back pain may actually be caused by dehydration. When the discs cannot refill they can�t do their job. This leads to immobility and a compromised range of motion.
Hydration also plays an important role in how the cerebrospinal fluid moves and works. While it does require more than water to function properly, water does play an important role. When the body is dehydrated this fluid cannot move as it should which can even affect brain function.
On a larger scale, when the body is dehydrated it begins to retrieve water from other parts of the body so it can reroute it to the vital organs and sustain life. The extremities are the first places it pulls water from and the spine is another. When it deprives the spine of water in order to supply the organs then you remain in a constant deficit which can cause pain and mobility problems.
How The Spine Rehydrates
As the body rehydrates itself, it does not assign the spine as a priority. The vital organs take precedence so the spine basically gets what is left over. If there is already a deficiency present, then there is nothing left over to rehydrate the spine.
When there is adequate water in the body, normal activity and movement aids in the rehydration of the discs. The most significant rehydration occurs while you sleep though. When you lie down and rest your body is best able to initiate the process of rehydrating your spinal discs via osmosis.
Chiropractic care is another way to adjust the spine and encourage the refilling of the discs. That depends, of course, on proper water intake. Be good to your spine; it�s the only one you have.
George Lara, now a retired construction contractor, experienced a back injury 20 years ago which affected his original state of well-being. Although he was promptly treated at the time of the incident, Mr. Lara suffered another back injury which manifested into sciatic nerve pain. George Lara had been greatly affected by his back injury, fortunately, he found Dr. Alex Jimenez, a back pain specialist, who restored his quality of life. Mr. Lara expresses his gratitude towards Dr. Alex Jimenez’s services and he greatly recommends chiropractic care as the non-surgical choice for alleviating back pain and sciatica.
Sciatic nerve pain�is a medical condition characterized by radiating pain down the leg from the lower back. Onset is often sudden following tasks like heavy lifting, even though slow onset may also occur. Normally, symptoms are only on one side of the body. Certain triggers, however, could lead to pain on both sides. Weakness or numbness may occur in a variety of areas of the affected leg and foot. About 90 percent of the time sciatica is due to a spinal disc herniation pressing on the lumbar or sacral nerve roots. Other problems that may bring about sciatica comprise of spondylolisthesis, spinal stenosis, piriformis syndrome, pelvic tumors, and compression.
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Migraine headaches have been considered to be one of the most frustrating ailments when compared to other common health issues. Generally triggered by stress, the symptoms of migraines, including the debilitating head pain, sensitivity to light and sound as well as the nausea, can tremendously affect a migraineur’s quality of life. However, research studies have found that chiropractic care can help reduce the frequency and the severity of your migraine pain. Many healthcare professionals have demonstrated that a spinal misalignment, or subluxation, may be the source of migraine headache pain. The purpose of the article below is to demonstrate the outcome measures of chiropractic spinal manipulative therapy for migraine.
Contents
Chiropractic Spinal Manipulative Therapy for Migraine: a Three?Armed, Single?Blinded, Placebo, Randomized Controlled Trial
Abstract
Background and purpose: To investigate the efficacy of chiropractic spinal manipulative therapy (CSMT) for migraineurs.
Methods: This was a prospective three?armed, single?blinded, placebo, randomized controlled trial (RCT) of 17 months duration including 104 migraineurs with at least one migraine attack per month. The RCT was conducted at Akershus University Hospital, Oslo, Norway. Active treatment consisted of CSMT, whereas placebo was a sham push manoeuvre of the lateral edge of the scapula and/or the gluteal region. The control group continued their usual pharmacological management. The RCT consisted of a 1?month run?in, 3 months intervention and outcome measures at the end of the intervention and at 3, 6 and 12 months follow?up. The primary end?point was the number of migraine days per month, whereas secondary end?points were migraine duration, migraine intensity and headache index, and medicine consumption.
Results: Migraine days were significantly reduced within all three groups from baseline to post?treatment (P < 0.001). The effect continued in the CSMT and placebo group at all follow?up time points, whereas the control group returned to baseline. The reduction in migraine days was not significantly different between the groups (P > 0.025 for interaction). Migraine duration and headache index were reduced significantly more in the CSMT than the control group towards the end of follow?up (P = 0.02 and P = 0.04 for interaction, respectively). Adverse events were few, mild and transient. Blinding was strongly sustained throughout the RCT.
Conclusions: It is possible to conduct a manual?therapy RCT with concealed placebo. The effect of CSMT observed in our study is probably due to a placebo response.
Neck pain and headaches are the third most common reason people seek chiropractic care. Many research studies have demonstrated that chiropractic spinal manipulative therapy is a safe and effective alternative treatment option for migraines. Chiropractic care can carefully correct any spinal misalignment, or subluxation, found along the length of the spine, which has been shown to be a source for migraine headaches. In addition, spinal adjustments and manual manipulations can help reduce stress and muscle tension by decreasing the amount of pressure being placed against the complex structures of the spine as a result of a spinal misalignment, or subluxation. By realigning the spine as well as reducing stress and muscle tension, chiropractic care can improve migraine symptoms and decrease their frequency.
Introduction
The socio?economic costs of migraine are enormous due to its high prevalence and disability during attacks [1, 2, 3]. Acute pharmacological treatment is usually the first treatment option for migraine in adults. Migraineurs with frequent attacks, insufficient effect and/or contraindication to acute medication are potential candidates for prophylactic treatment. Migraine prophylactic treatment is often pharmacological, but manual therapy is not unusual, especially if pharmacological treatment fails or if the patient wishes to avoid medicine [4]. Research has suggested that spinal manipulative therapy may stimulate neural inhibitory systems at different spinal cord levels because it might activate various central descending inhibitory pathways [5, 6, 7, 8, 9, 10].
Pharmacological randomized controlled trials (RCTs) are usually double?blinded, but this is not possible in manual?therapy RCTs, as the interventional therapist cannot be blinded. At present there is no consensus on a sham procedure in manual?therapy RCTs that mimics placebo in pharmacological RCTs [11]. Lack of a proper sham procedure is a major limitation in all previous manual?therapy RCTs [12, 13]. Recently, we developed a sham chiropractic spinal manipulative therapy (CSMT) procedure, where participants with migraine were unable to distinguish between real and sham CSMT evaluated after each of 12 individual interventions over a 3?month period [14].
The first objective of this study was to conduct a manual?therapy three?armed, single?blinded, placebo RCT for migraineurs with a methodological standard similar to that of pharmacological RCTs.
The second objective was to assess the efficacy of CSMT versus sham manipulation (placebo) and CSMT versus controls, i.e. participants who continued their usual pharmacological management.
Methods
Study Design
The study was a three?armed, single?blinded, placebo RCT over 17 months. The RCT consisted of a 1?month baseline, 12 treatment sessions over 3 months with follow?up measures at the end of intervention, 3, 6 and 12 months later.
Participants were, before baseline, randomized equally into three groups: CSMT, placebo (sham manipulation) and control (continued their usual pharmacological management).
The design of the study conformed to the recommendations of the International Headache Society (IHS) and CONSORT (Appendix S1) [1, 15, 16]. The Norwegian Regional Committee for Medical Research Ethics and the Norwegian Social Science Data Services approved the project. The RCT was registered at ClinicalTrials.gov (ID no: NCT01741714). The full trial protocol has been published previously [17].
Participants
Participants were recruited from January to September 2013 primarily through the Department of Neurology, Akershus University Hospital. Some participants were also recruited through General Practitioners from Akershus and Oslo Counties or media advertisement. All participants received posted information about the project followed by a telephone interview.
Eligible participants were migraineurs of 18�70 years old with at least one migraine attack per month and were allowed to have concomitant tension?type headache but no other primary headaches. All participants were diagnosed by a chiropractor with experience in headache diagnostics during the interview and according to the International Classification of Headache Disorders?II (ICHD?II) 2. A neurologist had diagnosed all migraineurs from Akershus University Hospital.
Exclusion criteria were contraindication to spinal manipulative therapy, spinal radiculopathy, pregnancy, depression and CSMT within the previous 12 months. Participants who received manual therapy [18], changed their prophylactic migraine medicine or became pregnant during the RCT were informed that they would be withdrawn from the study at that time and regarded as drop?outs. Participants were allowed to continue and change acute migraine medication throughout the study period.
Eligible participants were invited to an interview and physical assessment including meticulous spinal column investigation by a chiropractor (A.C.). Participants randomized to the CSMT or the placebo group had a full spine radiographic examination.
Randomization and Masking
After written consent was obtained, participants were equally randomized into one of the three study arms by drawing one single lot. Numbered sealed lots with the three study arms were each subdivided into four subgroups by age and gender, i.e. 18�39 or 40�70 years, and men or women.
After each treatment session, the participants in the CSMT and the placebo group completed a questionnaire on whether they believed CSMT treatment was received, and how certain they were that active treatment was received on a 0�10 numeric rating scale, where 10 represented absolute certainty [14].
Both the block randomization and the blinding questionnaire were exclusively administered by a single external party.
Interventions
The CSMT group received spinal manipulative therapy using the Gonstead method, a specific contact, high?velocity, low?amplitude, short?lever spinal with no post?adjustment recoil that was directed to spinal biomechanical dysfunction (full spine approach) as diagnosed by standard chiropractic tests at each individual treatment session [19].
The placebo group received sham manipulation, a broad non?specific contact, low?velocity, low?amplitude sham push manoeuvre in a non?intentional and non?therapeutic directional line of the lateral edge of the scapula and/or the gluteal region [14]. All of the non?therapeutic contacts were performed outside the spinal column with adequate joint slack and without soft tissue pre?tension so that no joint cavitations occurred. The sham manipulation alternatives were pre?set and equally interchanged among the placebo participants according to protocol during the 12?week treatment period to strengthen the study validity. The placebo procedure is described in detail in the available trial protocol [17].
Each intervention session lasted for 15 min and both groups underwent the same structural and motion assessments prior to and after each intervention. No other intervention or advice was given to participants during the trial period. Both groups received interventions at Akershus University Hospital by a single experienced chiropractor (A.C.).
The control group continued their usual pharmacological management without receiving manual intervention by the clinical investigator.
Outcomes
The participants filled in a validated diagnostic headache diary throughout the study and returned them on a monthly basis [20]. In the case of unreturned diaries or missing data, the participants were contacted by phone to secure compliance.
The primary end?point was number of migraine days per month (30 days/month). At least 25% reduction of migraine days from baseline to end of intervention, with the same level maintained at 3, 6 and 12 months follow?up was expected in the CSMT group.
Secondary end?points were migraine duration, migraine intensity and headache index (HI), and medicine consumption. At least 25% reduction in duration, intensity and HI, and at least 50% reduction in medicine consumption were expected from baseline to end of intervention, with the same level maintained at 3, 6 and 12 months follow?up in the CSMT group.
No change was expected for primary and secondary end?point in the placebo and the control group.
A migraine day was defined as a day on which migraine with aura, migraine without aura or probable migraine occurred. Migraine attacks lasting for >24 h were calculated as one attack unless pain?free intervals of ?48 h had occurred [21]. If a patient fell asleep during a migraine attack and woke up without a migraine, in accordance with the ICHD?III ?, the duration of the attack was recorded as persisting until the time of awakening [22]. The minimum duration of a migraine attack was 4 h unless a triptan or drug containing ergotamine was used, in which case we specified no minimum duration. HI was calculated as mean migraine days per month (30 days) � mean migraine duration (h/day) � mean intensity (0�10 numeric rating scale).
The primary and secondary end?points were chosen based on the Task Force of the IHS Clinical Trial Subcommittee’s clinical trial guidelines [1, 15]. Based on previous reviews on migraine, a 25% reduction was considered to be a conservative estimate [12, 13].
The outcome analyses were calculated during the 30 days after the last intervention session and 30 days after the follow?up time points, i.e. 3, 6 and 12 months, respectively.
All adverse events (AEs) were recorded after each intervention in accordance with the recommendations of CONSORT and the IHS Task Force on AEs in migraine trials [16, 23].
Statistical Analysis
We based the power calculation on a recent study of topiramate in migraineurs [24]. We hypothesized the average difference in reduction of number of migraine days per month between the active and the placebo, and between the active and the control groups of 2.5 days, with SD of 2.5 for reduction in each group. As primary analysis includes two group comparisons, the significance level was set at 0.025. For the power of 80%, a sample size of 20 patients was required in each group to detect a significant difference in reduction of 2.5 days.
Patient characteristics at baseline were presented as means and SD or frequencies and percentages in each group and compared by independent samples t?test and ? 2 test.
Time profiles of all end?points were compared between the groups. Due to repeated measurements for each patient, linear mixed models accounting for the intra?individual variations were estimated for all end?points. Fixed effects for (non?linear) time, group allocation and interaction between the two were included. Random effects for patients and slopes were entered into the model. As the residuals were skewed, the bootstrap inference based on 1000 cluster samples was used. Pairwise comparisons were performed by deriving individual time point contrasts within each group at each time point with the corresponding P?values and 95% confidence intervals. Medicine consumption within groups was reported by mean doses with SD, and groups were compared by an independent samples median test. A dose was defined as a single administration of a triptan or ergotamine; paracetamol 1000 mg � codeine; non?steroidal anti?inflammatory drugs (tolfenamic acid, 200 mg; diclofenac, 50 mg; aspirin, 1000 mg; ibuprofen, 600 mg; naproxen, 500 mg); and morphinomimetics (tramadol, 50 mg). None of the patients changed study arm and none of the drop?outs filled in headache diaries after withdrawal from the study. Hence, only per protocol analysis was relevant.
The analyses were blinded to treatment allocation and conducted in SPSS v22 (IBM Corporation, Armonk, NY, USA) and STATA v14 (JSB) (StataCorp LP, College Station, TX, USA). A significance level of 0.025 was applied for the primary end?point, whereas elsewhere a level of 0.05 was used.
Ethics
Good clinical practice guidelines were followed [25]. Oral and written information about the project was provided in advance of inclusion and group allocation. Written consent was obtained from all participants. Participants in the placebo and control group were promised CSMT treatment after the RCT, if the active intervention was found to be effective. Insurance was provided through the Norwegian System of Compensation to Patients (Patient Injury Compensation), an independent national body that compensates patients injured by treatments provided by the Norwegian health service. A stopping rule was defined for withdrawing participants from this study in accordance with the recommendations in the CONSORT extension for Better Reporting of Harms [26]. All AEs were monitored during the intervention period and acted on as they occurred according to the recommendations of CONSORT and the IHS Task Force on AEs in migraine trials [16, 23]. In case of severe AE, the participant would be withdrawn from the study and referred to the General Practitioner or hospital emergency department depending on the event. The investigator (A.C.) was available by mobile phone at any time throughout the study treatment period.
Results
Figure ?1 shows a flow chart of the 104 migraineurs included in the study. Baseline and demographic characteristics were similar across the three groups (Table 1).
Figure 1: Study flow chart.
Outcome Measures
The results on all end?points are presented in Fig. ?2a�d and Tables 2, 3, 4.
Figure 2: (a) Headache days; (b) headache duration; (c) headache intensity; (d) headache index. Time profiles in primary and secondary end?points, means and error bars represent 95% confidence intervals. BL, baseline; control, control group (�); CSMT, chiropractic spinal manipulative therapy (?); placebo, sham manipulation (?); PT, post?treatment; 3 m, 3?month follow?up; 6 m, 6?month follow?up; 12 m, 12?month follow?up; VAS, visual analogue scale.
Primary end?point. Migraine days were significantly reduced within all groups from baseline to post?treatment (P < 0.001). The effect continued in the CSMT and the placebo groups at 3, 6 and 12 months follow?up, whereas migraine days reverted to baseline level in the control group (Fig. ?2a). The linear mixed model showed no overall significant differences in change in migraine days between the CSMT and the placebo groups (P = 0.04) or between the CSMT and the control group (P = 0.06; Table 2). However, the pairwise comparisons at individual time points showed significant differences between the CSMT and the control group at all time points starting at post?treatment (Table 3).
Secondary end?points. There was a significant reduction from baseline to post?treatment in migraine duration, intensity and HI in the CSMT (P = 0.003, P = 0.002 and P < 0.001, respectively) and the placebo (P < 0.001, P = 0.001 and P < 0.001, respectively) groups, and the effect continued at 3, 6 and 12 months follow?up.
The only significant differences between the CSMT and control groups were change in migraine duration (P = 0.02) and in HI (P = 0.04; Table 2).
At 12 months follow?up, change in consumption of paracetamol was significantly lower in the CSMT group as compared with the placebo (P = 0.04) and control (P = 0.03) groups (Table 4).
Blinding. After each of the 12 intervention sessions, >80% of the participants believed they had received CSMT regardless of group allocation. The odds ratio for believing that CSMT treatment was received was >10 at all treatment sessions in both groups (all P < 0.001).
Adverse effects. A total of 703 of the potential 770 intervention sessions were assessed for AEs (355 in the CSMT group and 348 in the placebo group). Reasons for missed AE assessment were drop?out or missed intervention sessions. AEs were significantly more frequent in the CSMT than the placebo intervention sessions (83/355 vs. 32/348; P < 0.001). Local tenderness was the most common AE reported by 11.3% (95% CI, 8.4�15.0) in the CSMT group and 6.9% (95% CI, 4.7�10.1) in the placebo group, whereas tiredness on the intervention day and neck pain were reported by 8.5% and 2.0% (95% CI, 6.0�11.8 and 1.0�4.0), and 1.4% and 0.3% (95% CI, 0.6�3.3 and 0.1�1.9), respectively. All other AEs (lower back pain, face numbness, nausea, provoked migraine attack and fatigue in arms) were rare (<1%). No severe or serious AEs were reported.
Discussion
To our knowledge, this is the first manual?therapy RCT with a documented successful blinding. Our three?armed, single?blinded, placebo RCT evaluated the efficacy of CSMT in the treatment of migraine versus placebo (sham chiropractic) and control (usual pharmacological treatment). The results showed that migraine days were significantly reduced within all three groups from baseline to post?treatment. The effect continued in the CSMT and placebo groups at all follow?up time points, whereas the control group returned to baseline. AEs were mild and transient, which is in accordance with previous studies.
The study design adhered to the recommendations for pharmacological RCTs as given by the IHS and CONSORT [1, 15, 16]. Manual?therapy RCTs have three major obstacles as compared with pharmacological RCTs. Firstly, it is impossible to blind the investigator in relation to the applied treatment. Secondly, consensus on an inert placebo treatment is lacking [11]. Thirdly, previous attempts to include a placebo group have omitted validating the blinding, thus, it remains unknown whether active and placebo treatment were concealed [27]. Due to these challenges we decided to conduct a three?armed, single?blinded RCT, which also included a control group that continued usual pharmacological treatment in order to obtain an indication of the magnitude of the placebo response.
It has been suggested that, in pharmacological double?blind placebo RCTs, only 50% will believe that they receive active treatment in each group, if the blinding is perfect. However, this may not be true in manual?therapy RCTs, because the active and placebo physical stimulus might be more convincing than a tablet [28]. A single investigator reduces inter?investigator variability by providing similar information to all participants and it is generally recommended that the placebo intervention should resemble the active treatment in terms of procedure, treatment frequency and time spent with the investigator to allow for similar expectations in both groups [28]. The importance of our successful blinding is emphasized by the fact that all previous manual?therapy RCTs on headache lack placebo. Thus, we believe that our results discussed below are valid at the same level as a pharmacological RCT [14].
Prospective data are more reliable than retrospective data in terms of recall bias; however, non?compliance can be a challenge, especially at the end of the study. We believe the frequent contact between participants and the investigator, including monthly contact in the follow?up period, probably maintained high compliance throughout our study.
Although our study sample ended with 104 participants in the three groups, the power calculation assumption and the high completion rate support the data achieved being valid for the investigated population. The Gonstead method is used by 59% of chiropractors [19] and, thus, the results are generalizable for the profession. Diagnostic certainty is one of our major strengths as nearly all of the participants had been diagnosed by a neurologist according to the ICHD?II [2]. In contrast to previous chiropractic migraine RCTs that recruited participants through media such as newspapers and radio advertisement [12], the majority of our participants were recruited from the Department of Neurology, Akershus University Hospital, indicating that the migraineurs may have more frequent/severe attacks that are difficult to treat than the general population, as they were referred by their General Practitioner and/or practicing neurologist. Thus, our study is representative of primarily the tertiary clinic population, and the outcome might have been different if participants had been recruited from the general population. The percentage of neck pain has been found to be high in patients with migraine [29] and, thus, the high percentage of non?radicular spinal pain in our study might be a confounder for which effect was seen on migraine days.
Three pragmatic chiropractic manual?therapy RCTs using the diversified technique have previously been conducted for migraineurs [12, 30, 31, 32]. An Australian RCT showed within?group reduction in migraine frequency, duration and intensity of 40%, 43% and 36%, respectively, at 2 months follow?up [30]. An American study found migraine frequency and intensity to reduce within?group by 33% and 42%, respectively, at 1 month follow?up [31]. Another Australian study, which was the only RCT to include a control group, i.e. detuned ultrasound, found a within?group reduction of migraine frequency and duration of 35% and 40%, respectively, at 2 months follow?up in the CSMT group, as compared with a within?group reduction of 17% and 20% in the control group, respectively [32]. The reduction in migraine days was similar to ours (40%) in the CSMT group from baseline to 3 months follow?up, whereas migraine duration and intensity were less reduced at 3 months follow?up, i.e. 21% and 14%, respectively. Long?term follow?up comparisons are impossible as neither of the previous studies included a sufficient follow?up period. Our study design including strong internal validity allows us to interpret the effect seen as a placebo response.
Our RCT had fewer AEs as compared with previous manual?therapy studies, but of similar transient and mild character [33, 34, 35, 36, 37, 38, 39]. However, it was not sufficiently powered to detect uncommon serious AEs. In comparison, AEs in pharmacological migraine prophylactic placebo RCTs are common including non?mild and non?transient AEs [40, 41].
Conclusion
The blinding was strongly sustained throughout the RCT, AEs were few and mild, and the effect in the CSMT and placebo group was probably a placebo response. Because some migraineurs do not tolerate medication because of AEs or co?morbid disorders, CSMT might be considered in situations where other therapeutic options are ineffective or poorly tolerated.
Disclosure of Conflicts of Interest
All authors have completed the International Committee of Medical Journal Editors uniform disclosure form and declare no financial or other conflicts of interest.
The authors want to express their sincere gratitude to Akershus University Hospital, which kindly provided the research facilities, and Chiropractor Clinic 1, Oslo, Norway, which performed all x?ray assessments. This study was supported by grants from Extrastiftelsen, the Norwegian Chiropractic Association, Akershus University Hospital and University of Oslo in Norway.
In conclusion, the debilitating symptoms of migraines, including the severe head pain and the sensitivity to light and sound as well as the nausea, can affect an individual’s quality of life, fortunately, chiropractic care has been demonstrated to be a safe and effective treatment option for migraine headache pain. Furthermore, the article above demonstrated that migraineurs experienced reduced symptoms and migraine days as a result of chiropractic care.�Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Back Pain
According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.
1.�Tfelt?Hansen P, Block G, Dahlof C,�et al�International Headache Society Clinical Trial Subcommittee. Guidelines for controlled trials of drugs in migraine: second edition.�Cephalalgia�2000;�20: 765�786.[PubMed]
2.�Headache Classification Subcommittee of the International Headache Society .�The International Classification of Headache Disorders: 2nd edition.�Cephalalgia�2004;�24(Suppl. 1): 9�160.�[PubMed]
3.�Vos T, Flaxman AD, Naghavi M,�et al�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�2196.�[PubMed]
4.�Diener HC, Charles A, Goadsby PJ, Holle D.�New therapeutic approaches for the prevention and treatment of migraine.�Lancet Neurol�2015;�14: 1010�1022.�[PubMed]
5.�McLain RF, Pickar JG.�Mechanoreceptor endings in human thoracic and lumbar facet joints.�Spine (Phila Pa 1976)�1998;�23: 168�173.�[PubMed]
6.�Vernon H.�Qualitative review of studies of manipulation?induced hypoalgesia.�J Manipulative Physiol Ther�2000;�23: 134�138.�[PubMed]
8.�Boal RW, Gillette RG.�Central neuronal plasticity, low back pain and spinal manipulative therapy.�J Manipulative Physiol Ther�2004;�27: 314�326.�[PubMed]
9.�Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ.�The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model.�Man Ther�2009;�14: 531�538.�[PubMed]
10.�De Camargo VM, Alburquerque?Sendin F, Berzin F, Stefanelli VC, de Souza DP, Fernandez?de?las?Penas C.�Immediate effects on electromyographic activity and pressure pain thresholds after a cervical manipulation in mechanical neck pain: a randomized controlled trial.�J Manipulative Physiol Ther�2011;�34: 211�220.�[PubMed]
11.�Hancock MJ, Maher CG, Latimer J, McAuley JH.�Selecting an appropriate placebo for a trial of spinal manipulative therapy.�Aust J Physiother�2006;�52: 135�138.�[PubMed]
12.�Chaibi A, Tuchin PJ, Russell MB.�Manual therapies for migraine: a systematic review.�J Headache Pain2011;�12: 127�133.�[PubMed]
13.�Chaibi A, Russell MB.�Manual therapies for primary chronic headaches: a systematic review of randomized controlled trials.�J Headache Pain�2014;�15: 67.�[PubMed]
14.�Chaibi A, Saltyte Benth J, Bjorn Russell M.�Validation of placebo in a manual therapy randomized controlled trial.�Sci Rep�2015;�5: 11774.�[PubMed]
15.�Silberstein S, Tfelt?Hansen P, Dodick DW,�et al�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: 484�495.�[PubMed]
16.�Moher D, Hopewell S, Schulz KF,�et al�CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials.�BMJ�2010;�340: c869.�[PubMed]
17.�Chaibi A, Saltyte Benth J, Tuchin PJ, Russell MB.�Chiropractic spinal manipulative therapy for migraine: a study protocol of a single?blinded placebo?controlled randomised clinical trial.�BMJ Open2015;�5: e008095.�[PMC free article]�[PubMed]
18.�French HP, Brennan A, White B, Cusack T.�Manual therapy for osteoarthritis of the hip or knee ? a systematic review.�Man Ther�2011;�16: 109�117.�[PubMed]
20.�Russell MB, Rasmussen BK, Brennum J, Iversen HK, Jensen RA, Olesen J.�Presentation of a new instrument: the diagnostic headache diary.�Cephalalgia�1992;�12: 369�374.�[PubMed]
21.�Tfelt?Hansen P, Pascual J, Ramadan N,�et al�Guidelines for controlled trials of drugs in migraine: third edition. A guide for investigators.�Cephalalgia�2012;�32: 6�38.�[PubMed]
22.�Headache Classification Subcommittee of the International Headache Society .�The International Classification of Headache Disorders, 3rd edition (beta version).�Cephalalgia�2013;�33: 629�808.[PubMed]
23.�Tfelt?Hansen P, Bjarnason NH, Dahlof C, Derry S, Loder E, Massiou H.�Evaluation and registration of adverse events in clinical drug trials in migraine.�Cephalalgia�2008;�28: 683�688.�[PubMed]
24.�Silberstein SD, Neto W, Schmitt J, Jacobs D.�Topiramate in migraine prevention: results of a large controlled trial.�Arch Neurol�2004;�61: 490�495.�[PubMed]
25.�Dixon JR.�The International Conference on Harmonization Good Clinical Practice guideline.�Qual Assur�1998;�6: 65�74.�[PubMed]
26.�Ioannidis JP, Evans SJ, Gotzsche PC,�et al�Better reporting of harms in randomized trials: an extension of the CONSORT statement.�Ann Intern Med�2004;�141: 781�788.�[PubMed]
27.�Scholten?Peeters GG, Thoomes E, Konings S,�et al�Is manipulative therapy more effective than sham manipulation in adults: a systematic review and meta?analysis.�Chiropr Man Therap�2013;�21: 34.�[PMC free article]�[PubMed]
28.�Meissner K, Fassler M, Rucker G,�et al�Differential effectiveness of placebo treatments: a systematic review of migraine prophylaxis.�JAMA Intern Med�2013;�173: 10.�[PubMed]
29.�Ashina S, Bendtsen L, Lyngberg AC, Lipton RB, Hajiyeva N, Jensen R.�Prevalence of neck pain in migraine and tension?type headache: a population study.�Cephalalgia�2015;�35: 211�219.�[PubMed]
30.�Parker GB, Tupling H, Pryor DS.�A controlled trial of cervical manipulation of migraine.�Aust NZ J Med�1978;�8: 589�593.�[PubMed]
31.�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]
32.�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.�[PubMed]
33.�Cagnie B, Vinck E, Beernaert A, Cambier D.�How common are side effects of spinal manipulation and can these side effects be predicted?�Man Ther�2004;�9: 151�156.�[PubMed]
34.�Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM.�Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study.�J Manipulative Physiol Ther�2004;�27: 16�25.�[PubMed]
35.�Thiel HW, Bolton JE, Docherty S, Portlock JC.�Safety of chiropractic manipulation of the cervical spine: a prospective national survey.�Spine (Phila Pa 1976)�2007;�32: 2375�2378.�[PubMed]
36.�Rubinstein SM, Leboeuf?Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW.�The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study.�J Manipulative Physiol Ther�2007;�30: 408�418.�[PubMed]
37.�Eriksen K, Rochester RP, Hurwitz EL.�Symptomatic reactions, clinical outcomes and patient satisfaction associated with upper cervical chiropractic care: a prospective, multicenter, cohort study.�BMC Musculoskelet Disord�2011;�12: 219.�[PubMed]
38.�Walker BF, Hebert JJ, Stomski NJ,�et al�Outcomes of usual chiropractic. The OUCH randomized controlled trial of adverse events.�Spine�2013;�38: 1723�1729.�[PubMed]
39.�Maiers M, Evans R, Hartvigsen J, Schulz C, Bronfort G.�Adverse events among seniors receiving spinal manipulation and exercise in a randomized clinical trial.�Man Ther�2015;�20: 335�341.�[PubMed]
40.�Jackson JL, Cogbill E, Santana?Davila R,�et al�A comparative effectiveness meta?analysis of drugs for the prophylaxis of migraine headache.�PLoS One�2015;�10: e0130733.�[PubMed]
41.�Ferrari MD, Roon KI, Lipton RB, Goadsby PJ.�Oral triptans (serotonin 5?HT(1B/1D) agonists) in acute migraine treatment: a meta?analysis of 53 trials.�Lancet�2001;�358: 1668�1675.�[PubMed]
Chiropractic Helps:Tendonitis is a condition that occurs when a tendon that connects bone to muscle is injured, overused, or used improperly. The result is inflammation, pain and sometimes swelling. In the case of an injury where the tendon is stressed to otherwise injured, soft tissue around the area may also become involved. Each year more than 4 million people in the U.S. seek medical treatment for symptoms of tendonitis.
Common types of tendonitis include runner�s knee, tennis elbow, and pitcher�s shoulder. However, other tendons in the body can also experience tendonitis symptoms. The Achilles tendon, ankle, wrist, and even fingers can all become inflamed from the condition.
Often a primary care physician diagnoses the injury, but once there is a definitive diagnosis, the best treatment is one that is natural and holistic. Chiropractic care is an outstanding choice for treatment.
Contents
Chiropractic Helps: Thorough Healing
Tendonitis often recurs in many people. This is due, at least in part to improper or incomplete healing. Many people will resume normal activities as soon as the pain subsides when they should continue caring for the injury so that it can heal completely. This leads to inflammation of the area again as the original injury is aggravated, but it can also lead to re-injury in that same area. Chiropractic care can help tendonitis heal completely and help prevent re-injury to the area.
Chiropractic Helps: Tendonitis
Since tendonitis symptoms can mimic other serious conditions, the first step in treatment is confirming the diagnosis. The doctor may use X-rays, MRIs, or CAT scans to make a positive diagnosis of tendonitis.
From there, the chiropractor will work with the patient to develop a treatment plan that is natural and effective, tailored to the patient�s unique needs. At the core of this treatment is a targeted plan that treats the cause of the problem, not just the symptoms.
If there is a great deal of inflammation the chiropractor may employ inflammation reducing techniques such as bracing, rest, ice, electrical muscle stimulation, and other therapies. This helps to loosen the tendon and lessen the inflammation so that treatment can progress.
Once the inflammation is under control, the chiropractor may begin massage, physical therapy, joint manipulation, or strengthening exercises. If the patient has diminished or limited joint mobility then joint manipulation or adjustments may be the best option.
Chiropractic Helps: Length Of Treatment
The initial pain may subside or even disappear within the first two to three weeks. However, that does not mean that the patient is out of the woods. This is where many patients go wrong. They mistakenly believe that once the pain is gone the condition is healed.
This is not true. While the inflammation may indeed decrease over the first three weeks, the complete healing takes around six weeks and often longer. Scar tissue is formed during this time which helps the body repair the injury. Once the injury is repaired though, that scar tissue must be broken down in order for the area to regain its mobility and flexibility.
The chiropractor will use various techniques including massage and ultrasound to break down the scar tissue. Mild stretches may be incorporated into the treatment plan. Once the tissues are fully healed, exercise can aid in breaking down the scar tissue even more. These exercises will work the muscles but they won�t involve the tendons.
Chiropractic Helps: Healing Tendonitis For Good
Tendonitis can be healed completely and a good chiropractor can help. Most chiropractors take a whole body approach, including diet, specific supplements, and lifestyle choices that will help the healing process of tendonitis. Once chiropractic treatment is complete for tendonitis, the patient can usually return to normal activities without the risk of re-injury or re-inflammation.
Migraine headache pain can be characterized as a throbbing pain or a pulsing sensation of varying intensity, which is generally accompanied by nausea as well as extreme sensitivity to light and sound. According to the American Migraine Association, migraines affect about 36 million Americans, or approximately 12 percent of the population in the United States. Because the symptoms can often become very debilitating, many migraine sufferers will have tried everything to attempt to relieve their headache pain, including avoiding triggers and using drugs and/or medications to reduce the symptoms. However, research studies have found that one alternative treatment option can greatly benefit migraineurs: chiropractic care.
Contents
Chiropractor Treating Migraine Pain
Chiropractic care is a safe and effective alternative treatment option which focuses on the diagnosis, treatment and prevention of a variety of injuries and/or conditions associated with the musculoskeletal and nervous system. A doctor of chiropractic, or chiropractor, will commonly utilize a series of chiropractic methods and techniques, including spinal adjustments and manual manipulations, to carefully correct any spinal misalignment, or subluxation, located along the length of the spine. Although the true source of migraines is still misunderstood today, healthcare professionals believe that a misalignment of the cervical spine, or neck, may trigger migraine symptoms. By correcting the alignment of the spine, a chiropractor can release the pressure being placed against the spinal column which may be irritating and/or compressing the complex structures surrounding the spine, manifesting the well-known symptoms of migraines. Furthermore, chiropractic care can decrease muscle tension and increase circulation, eliminating stress in the body which is also known to be a factor behind migraines, promoting further relief.
The Efficacy of Chiropractic Spinal Manipulative Therapy (SMT) in the Treatment of Migraine
Abstract
Objective: To test the efficacy of Chiropractic spinal manipulative therapy (SMT) in the treatment of migraine, using an uncontrolled clinical trial.
Design: A clinical trial of six months duration. The trial consisted of 3 stages: two months of pre-treatment, two months of treatment, and two months post treatment. Comparison was made to initial baseline episodes of migraine preceding commencement of SMT.
Setting: Chiropractic Research Centre of Macquarie University
Participants: Thirty two volunteers, between the ages of 23 to 60 were recruited through media advertising. The diagnosis of migraine based on a detailed questionnaire, regarding self reported symptoms or signs, with minimum of one migraine with aura per month.
Interventions: Two months of SMT provided by an experienced chiropractor at a university clinic.
Main Outcome Measures: 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.
Results: A total of fifty nine participants responded to the advertising, with twenty five being excluded or deciding not to continue in the trial. Two participants (5.9%) withdrew during the trial, one due to alteration in work situation and one following soreness after SMT. The Chiropractic SMT group showed statistically significant improvement (p < 0.05) in migraine frequency and duration, when compared to initial baseline levels. Only one participant (3.1%) reported that the migraine episodes were worse after the two months of SMT, and this was not sustained at the two month post treatment follow up period.
Conclusion: The results of this study suggest that Chiropractic SMT is an effective treatment for migraine with aura. However, due to the cyclical nature of migraine with aura, and the finding that episodes usually reduce following any intervention, further research 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.
According to the American Chiropractic Association, a 2011 report published in the Journal of Manipulative and Physiological Therapeutics, or JMPT, found that chiropractic care, including spinal adjustments and manual manipulations, can improve migraine and cervicogenic headache symptoms. Healthcare professionals have associated primary headaches with stress and muscle tension. Chiropractic care can help decrease the frequency of migraines and manage its symptoms by carefully correcting any spinal misalignment, or subluxation, found along the spine. By restoring the proper alignment of the spine, chiropractic care can improve overall spinal function by alleviating pressure on the nervous system, increasing circulation and reducing muscle tension and stress which causes migraine pain.
Introduction
Some studies appear to have demonstrated significant reduction in migraines following chiropractic intervention (1-8). However, this reduction may in part have been due to inaccurate diagnosis or overlapping symptoms (4,9,10). Many different conditions of the cervical spine, including mechanical and joint pathology, have been reported to cause headache (10-16). Sjaastad (17) used the term �cervicogenic headache� to describe a type of the chronic paroxysmal unilateral headache, which is accompanied by autonomic symptoms and provacated by movements of the head and neck. Sjaastad proposed that entrapment of the occipital nerve or a C2-C3 rhizopathy may produce this headache (18).
There are a number of aetiologies of migraines proposed in the literature. These include: vascular (19-21); autonomic (22); biochemical/cellular/immunological (23- 27); psychophysiological (28,29); neurogenic (9,15,25,30) and somatic (1-9,31,32). This has made a common treatment regime difficult. One early medical model was vascular cause of migraine, where a migrainous attack is initiated by a decreased blood flow to the cerebral vasculature or a cerebrovascular spasm, but characterized by extracranial vasodilation during the headache phase (19,20). However, later aetiological models have demonstrated more complex vascular changes with associated neurological changes (9).
Many practitioners involved in the treatment of migraine would, however, accept that a number of aetiological factors are involved and that there is substantial overlap in both aetiology or diagnosis (9,15,26,33,34). In addition, no single model appears to explain all the possible symptoms associated with migraine.
One possible aetiological factor is cervical spondylosis with associated neck pain and stiffness (34). Anthony states �when this is recognised, appropriate treatment can give impressive results…the aim is to relieve pressure on nerve roots in the upper neck thereby reducing activation of the spinal tract of the trigeminal nerve, which is part of the pain centre in the head and neck� (34). Surgical decompression of the lower cervical nerve�roots as carried out by Ghavamian (36) showed relief of migraine symptoms. He proposed that irritation and compression of the deep sympathetic fibres incited such symptomatology.
Vernon (7), proposed a vertebrogenic model which involves components from the different categories previously stated. One part involves lesions in the low cervical/upper thoracic spine and the upper cervical spine. The low cervical spine/upper thoracic spine (C7-T4) model proposed that dysfunction (i.e. somatic dysfunction) at these vertebral levels causes joint fixation and pain. This pain alters the neural messages received, and therefore sent, by the Central Nervous System (CNS). The Autonomic Nervous System which controls, amongst other functions, blood supply, is thus also affected. It is proposed that when certain threshold levels of transient cerebral ischaemia (due to vasoconstriction caused by the above mechanism) are reached, a migraine cascade of symptomatology may be precipitated.
A second part involves somatic dysfunction in the upper cervical spine (Occiput-C2), which produces local pain and fixation leading to increased neural input to the CNS. This results in a reduction in descending pain-inhibiting impulses from the CNS and consequently increases activity within the spinal trigeminal tract (which transmits the majority of sensory afferents and pain signals from the upper cervical region to the brain). Having exceeded a threshold level, this excessive afferent input to the CNS will trigger focal, and spreading vasoconstriction within the intracerebral vasculature. This will in turn promote extra-carotid vasodilation and cranial pain which is mediated by the ipsilateral trigeminal nerve (7).
Another model contends that irritation of the vertebral nerve by cervical lesions can produce a sympathetic syndrome, giving symptoms of headache, vertigo, visual disturbances and tinnitus. However, this model has not been well substantiated and appears more likely a cause of vascular headache as opposed to migraine (11). The source of pain in migraines is found in the intra- and extracranial blood vessels. 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 of migraine type (26).
Migraine has a well established symptomatology that has been outlined in various studies (4,12,15). The debilitating and frequent nature of symptoms that include head pain, nausea, vomiting, phonophobia, and photophobia, costs our society both socially and economically (4,12,15,20). As such, effective treatment has long been sought, therefore justifying study in this area. However, there is substantial overlap of symptoms between migraine and cervicogenic�headache, and some authors believe elements of the migraine headache continuum involve cervical headache (9,10).
The Headache Classification Committee of the International Headaches Society, has discarded the former terms classical migraine and common migraine in favour of migraine with aura and migraine without aura. In migraine with aura (MA), this condition is defined as recurrent, periodic, unilateral headache which is preceded or accompanied by transient visual, sensory, motor, or other focal neurological symptoms which localise to the cerebral cortex or brainstem. Migraine without aura, (MWA) is defined as a vascular headache without striking prodromal or associated symptoms of cerebral dysfunction (37).
The incidence of migraine in Australia is estimated at 12%, with the cost to industry an estimated $250 million (38). In the USA approximately 8% of headaches diagnosed by medical practitioners are called migraine headaches (39). Migraine, in its various forms, affects an estimated 5-20% of people throughout the world (40).
A review of the literature appears to indicate that migraine is an associated feature of cervical dysfunction. This paper will evaluate chiropractic spinal manipulative treatment directed towards improving vertebral function, and its role in the management of the migraines.
Methodology
Chiropractic spinal manipulative therapy (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 (41). 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.
The study design was based on a previous study which involved 82 subjects who received either chiropractic SMT, physiotherapy manipulation, or a control treatment of medical mobilization (1). Parker et al, concluded that manipulation was not found to be more effective than mobilisation, and chiropractic treatment not more effective than the other two groups (3). However, much criticism was received over the study, especially the statistical analysis (42).
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 (12), which contains over 25 sections, including details of the initial�history, frequency, severity, location and reaction to the pain, associated symptoms, precipitating or aggravating factors, relieving factors, past treatment for migraines, medical history including medications and other diagnostic tests.
The participants to take part in the trial were selected according to responses in the questionnaire of specific symptoms. The criteria for migraine 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.
Participants were informed that they were involved in a trial of manipulative therapy for migraine, and that they may be randomly assigned to a control group which would receive a placebo (non effective) treatment, or to an intervention group which would receive Chiropractic SMT. However, because of the small numbers of participants that were involved in the trial, a control group was not used. Participants were also informed that a thorough physical examination would be performed prior to commencement of treatment to assess any physical problems precluding them receiving SMT. Patients were blinded, by believing that they may or may not receive an effective treatment. In addition, practitioners were not aware of ongoing treatment results, therefore they were also �blinded� to the stage of progress of the patients condition or response to treatment.
The trial was conducted over six months, and consisted of 3 stages: two months pretreatment, 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 month and asked to describe the migraine episodes for comparison to their diaries.
Patients were instructed at the beginning of the study on the use of the diary and were given an instruction sheet to use throughout the course of the trial. The diary consisted of a table for entries of each of the outcome measures. This included noting the date of each episode, a number representing a visual analogue score, letters denoting associated symptoms, the length (in hours) of each migraine, the time (in hours) before the person could return to normal duties, type and use of medications and the overall relief from the medication. The diaries were modified from standard diaries used by the Brain Foundation of Australia.
A detailed history of the patient’s 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.
Factors for assessing 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 included: 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. Patients were allowed a maximum of sixteen treatments, and the frequency of treatment was dependent on the clinicians opinion of the severity of the vertebral dysfunction. The majority of patients received a minimum of twelve treatments.
Comparison was made to initial baseline episodes of migraine preceding commencement of SMT. Statistical analysis involved comparing the effects of the different treatment regimes on the incidence, intensity, and duration of migraines throughout the trial. Statistical tests employed were a students 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. Statistical calculations were performed via a computer software program Minitab for Macintosh.
Results
A total of fifty nine participants responded to the�advertising, with twenty five being excluded or deciding not to continue in the trial. These included: six cases of infrequent recurrence of the migraines (less than one per month); two cases of contraindications to SMT; one case of cluster headache; one case of motor vehicle accident during pre treatment; one case of fear of SMT; fourteen cases where the university clinic was inconvenient or time constraints were too difficult for participants. Two participants (5.9%) withdrew during the trial, one due to alteration in work situation and one following soreness after SMT.
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 Chiropractic SMT group showed statistically significant improvement (p < 0.05) in migraine severity (Figure 1), duration (Figure 2) and disability (Figure 3), when compared to initial baseline levels. 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 2 demonstrates variate scores in each of the six diary categories for the three phases of the trial.
The greatest area for improvement was with disability scores (p < 0.01), where participants were asked to rate the time that elapsed before they could return to normal activities (Table 3). In addition, the duration of the migraine and the use of medication, reduced significantly following the SMT intervention (p < 0.05). Table 3 shows mean variate scores for the three phases of the trial�and statistical significance by analysis of variance (ANOVA).
There was no apparent difference in the number of associated symptoms and the time taken for treatment to give relief of each migraine episode (Table 3). In addition, self reported possible trigger factors demonstrated no significant findings, predominantly due to the small sample size. Common trigger factors that were cited included stress, lack of sleep, work changes, or family situations. Most participants could not state a particular trigger factor.
Discussion
The majority of people who participated in this trial had chronic migraines that were severe and debilitating. However, the results have demonstrated a significant (p< 0.05) reduction in their�migraine episodes and their associated disability. The mean number of migraine per month reduced from 7.6 to 4.9 episodes.
This trial was conducted using a similar design to a previous study which demonstrated significant improvement in migraines following chiropractic SMT (1,3). The initial trial had limitations due to an inadequate control group, and this could also be a limitation with this study(2). However, the use of self reported, non treatment period as a control, allows flexibility regarding use of medication and any alteration during the trial.
Figure 1: Comparison of visual analogue scores for pre-treatment, treatment and post-treatment group means.
Figure 2: Comparison of duration time of migraine (hours) for pre-treatment, treatment and post-treatment group means.
Figure 3: Comparison of disability time of migraine (hours) for pre-treatment, treatment and post-treatment group means.
A similar design to this study has also been used in a study of headache and SMT (14). The Boline study was a randomised controlled trial using two parallel groups, with a two week baseline, a six week treatment period and a four week post treatment period. The results of this study show that SMT was an effective method of treatment for tension type headaches, and that the benefit was sustained for the four weeks after cessation of the treatment.
The present study was conducted over a six month period which gives the results substantial significance because early criticisms of studies were that the length of the trial was too short to allow for the cyclical nature of migraines. However, the study is limited in the sample size and the fact that the trial was a pragmatic study which did not consider what aspects of chiropractic SMT had contributed to the improvement in the migraine episodes.
In addition, the study is limited due to the lack of a control group. However, the fact that the trial was conducted over a six month period, with two months pre-treatment, it could be argued that participants acted as their own form of control.
A further limitation of this study, as with other studies of migraine or headaches is 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 (12). An advantage with the design of this study is that regardless of the exact �diagnosis� of the migraine, self reported, non-treatment controls still allow assessment of the therapy in question.
The measurement used for relief scores proved to be poor, which was probably due in part to the small scale for response that participants were given. Future studies should address this issue. In addition, associated symptoms did not give a clear result because the study only measured the total number of associated symptoms, and the sample size was too small for a significant percentage breakdown. Future studies should also address this issue.
Conclusion
The results of this study suggest that Chiropractic SMT may be an effective treatment for migraine. However, due to the cyclical nature of migraine, and the finding that episodes usually reduce following any intervention, further research 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.
In conclusion,�chiropractic care is a safe and effective alternative treatment option which can be used to improve migraine symptoms as well as decrease their frequency. A chiropractor will utilize spinal adjustments and manual manipulations to correct spinal misalignments, or subluxations, releasing pressure being placed against the complex structures surrounding the spine, decreasing muscle tension and improving circulation to eliminate stress, ultimately benefitting migraine sufferers. Finally, the purpose of the article above was to demonstrate the efficacy of chiropractic spinal manipulative therapy, or SMT, in the treatment of migraine. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Back Pain
According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.
1. Parker GB, Tupling H, Pryor DS. A controlled trial of cervical manipulation for migraine. Aust NZ J Med 1978; 8: 585-93.
2. Parker GB, Tupling H, Pryor DS. Letters to the editor: cervical manipulation for migraine. Aust NZ J Med 1979; 9: 341-2.
3. 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.
4. Tuchin PJ, Bonello R. Classic migraine or not classic migraine, that is the question. Aust Chiro & Osteo 1996; 5: 66-74.
5. 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.
6. Wight JS. Migraine: a statistical analysis of chiropractic treatment. J Am Chiro Assoc 1978; 12: 363-7.
7. 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
8. Lenhart LJ. Chiropractic management of migraine without aura: a case study. JNMS 1995; 3: 20-6.
9. Nelson CF. The tension headache, migraine continuum: a hypothesis. J Manipulative Physiol Ther 1994; 17(3): 157-67.
10. Jull GA. Cervical headache: a review. In: Greive GP, ed. Modern manual therapy of the vertebral column. 2nd ed. Edinburgh: Churchill Livingstone, 1994: 333-46
11. Bogduk N. Cervical causes of headache and dizziness In: Greive GP, ed. Modern manual therapy of the vertebral column. 2nd ed. Edinburgh: Churchill Livingstone, 1994: 317-31.
12. Vernon H. ed. Upper cervical syndrome: cervical diagnosis and treatment. In: Differential diagnosis of headache. Baltimore: Williams & Wilkins. 1988: l46
13. Vernon HT. Spinal manipulation and headache of cervical origin. J Manipulative Physiol Ther 1989; 12: 455-68
14. Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulations vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther 1995; 18(3): 148-54.
15. Milne E. The mechanism and treatment of migraine and other disorders of cervical and postural dysfunction. Cephalgia 1989; 9 (suppl 10): 381-2.
16. Young K, Dharmi M. The efficacy of cervical manipulation as opposed to pharmocological therapeutics in the treatment of migraine patients. Transactions of the Consortium for Chiropractic Research. 1987
17. Sjaastad O, Saunte C, Hovdahl H, Breivok H, Gronback E. Cervical headache: an hypothesis. Cephalgia 1983; 3: 249-56.
18. Sjaastad O, Fredricksen TA, Stolt-Nielsen A. Cervicogenic headache, C2 rhizopathy, and occipital neuralgia: a connection. Cephalgia 1986; 6: 189-95.
19. Wolff�s Headache and other head pain. Revised by Dalessio DJ. 3rd ed. New York: Oxford University Press. 1972.
20. Selby G, Lance JW. Observations on 500 cases of migraine and allied vascular headache. J Neurol Neurosurg Psychiatry 1960; 23: 23-32.
21. Anderson A, Friberg L, Olsen T, Olsen J. Delayed hyperemia following hypoperfusion in classic migraine. Arch Neurol 1988; 45: 154-9.
22. Appel S, Kiritzky A, Zahavi I, et al. Evidence for instability of the autonomic nervous system in patients with migraine headache. Headache 1992; 32: 10-7.
23. Takasha T, Shimomura T, Kazuro T. Platelet activation in muscle contraction headache and migraine. Cephalgia 1987; 7: 239-43.
24. Lance J, Lambert G, Goadsby P, et al. 5-Hydroxytryptamine and its putative aetiological involvement in migraine. Cephalgia 1989; 9(Suppl 9): 7-13
25. Ferrari M, Odink J, Tapparelli C, et al. Serotonin metabolisminmigraine.Neurology1989;39:1239-42.
26. Dalassio D. The pathology of migraine. Clin J Pain 1990; 6: 235-9.
27. Stellar S, et al. Migraine prevention with timolol. JAMA 1984; 252(18): 2576-80.
28. Couch J, Hassanein R. Amitriptyline in migraine prophylaxis. Arch Neurol 1979; 36: 695-9.
29. Zeigler D, Hurwitz A, Hassanein R, et al. Migraine prophylaxis: a comparison of propranolol and amitriptyline. Arch Neurol 1987; 44: 486-9.
30. Anthony MN, Lance JW. Plasma serotonin in patients with chronic tension headache. J Neurol Neurosurg Psychiatry 1989; 52: 182-4.
31. Sjasstad 0, Fredricksen TA, Sand T. The localization of the initial pain of attack: a comparison between classic migraine and cervicogenic headache. Functional Neurololgy 1989; 4: 73-8
32. Commission of Enquiry Into Chiropractic. Chiropractic in New Zealand. 1979 NZ PD Hasselburg.
33. Marcus DA. Migraine and tension type headaches: the questionable validity of current classification systems. Pain 1992; 8: 28-36
34. Anthony M. Migraine and its management. Aust
Fam Phys 1986; 15(5): 643-9.
35. Grayham JR. Migraine headache: diagnosis and
management. Headache 1979; 19(3): 133-41.
36. Ghavamian T. Cervical discopathy and a new concept in the sympathetics of the cervical spine and
head. J Bone Joint Surg 1971; 53A: 1233.
37. 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.
38. King J. Migraine in the workplace. Brainwaves. Australian Brain Foundation 1995 Hawthorn, Victoria.
39. Lipton RB, Stewart WE. Migraine in the United States: a review of epidemiology and health care use. Neurology 1993; 43(Suppl 3): S6-10.
40. Stewart WE, Lipton RB, Celentous DD, et al. Prevalence of migraine headache in the United States. JAMA 1992; 267: 64-9.
41. Brunarski DJ. Clinical trials of spinal manipulation: a critical appraisal and review of the literature. JMPT 1984; 7(4): 243-7.
42. Marosszeky JE. Letters to the editor: cervical manipulation for migraine. Aust NZ J Med 1979; 9: 339.
Volleyball Injury: James Hill is a school teacher and father of two older sons and his youngest daughter Madison Hill. As a part of an athletic family, Madison has been involved in sports since a young age, however, she experienced many injuries as a result. Fortunately, James Hill and his daughter Madison Hill met Dr. Alex Jimenez and he’s helped her get back up on her feet ever since. They both have learned to believe in chiropractic care due to Dr. Alex Jimenez’s innovative treatment methods and techniques. Mr. Hill expresses how much Dr. Alex Jimenez’s knowledge in sports injury treatment has expanded his overall understanding of the human body’s recovery process. After Madison suffered a recent ankle sprain, she was immediately reassured by Dr. Alex Jimenez regarding how much faster she could return-to-play with chiropractic care. James Hill and Madison Hill highly recommend Dr. Alex Jimenez and his staff as the non-surgical choice for volleyball sports injuries and other types of injuries.
Each year, millions of teenagers take part in high school sports. However, when an injury to a young athlete occurs, it can be disappointing to them and the family as well as to the coaches. The pressure to continue participating in their specific sport or physical activity can cause the young athlete to avoid receiving proper treatment, which could then lead to further injury with long-term effects. Sports injuries among young athletes fall into two primary categories: overuse injuries and acute injuries. Both kinds include injuries to the soft tissues (muscles and ligaments) and bones. Whether an injury is acute or due to overuse, a young athlete who develops a symptom that persists or that impacts their athletic performance ought to be examined by a healthcare professional. Sports injuries that are untreated could lead to permanent disability or damage. Many high school sports injuries can be avoided through proper conditioning, training, and gear.
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Chiropractic care is extremely beneficial for many different conditions; some obvious while others are more obscure. Structural issues that affect the knees are often very responsive to chiropractic treatment. In the case of chondromalacia patellae and other knee problems, it has proven to reduce pain and help improve the condition considerably, providing the patient with increased mobility and flexibility.
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Chondromalacia Patellae (aka Runner�s Knee)
Approximately 40 percent of injuries that runners experience are knee injuries. These injuries fall under the umbrella term of �runner�s knee.� This includes chondromalacia patellae which may also be referred to as patellofemoral pain syndrome (PFMS).
Other runner�s knee injuries include iliotibial band syndrome, and plica syndrome. Chondromalacia patellae is one of the more common forms of runner�s knee, along with PFMS. Rest and ice are typical remedies, but when that doesn�t work or when the pain and mobility difficulties return once the patient returns to normal activities, chiropractic care is often a good treatment option.
Chondromalacia Patella
The knee is a marvelous piece of machinery. It is constructed to take the impact of the body�s weight, bending, and moving. Under the kneecap is a layer of cartilage which acts as a natural shock absorber. Injury, overuse, aging, or other conditions can cause damage to that cartilage.
This condition causes pain and impaired mobility, most commonly when the knees are in use such as walking up or down stairs. The pain may decrease with rest and ice, but sometimes that simply isn�t enough. Traditional treatments include physical therapy, medication for pain, and surgery.
Symptoms
The most common symptom of chondromalacia patellae is pain in the front of the knee. It is often described as a dull ache that is deep in the knee. This pain is often made worse when the patient sits with their knee bent for a long time, when they squat or kneel, or when they walk up and down stairs.
The more the patient uses the knee, the worse it is. However, rest and ice can work fairly quickly to help relieve the pain. If the pain persists even with rest and ice, then more aggressive care is usually advised. While traditionally doctors prescribe medication and even surgery, more patients are gravitating to drug free, less invasive treatments for knee pain. Chiropractic is a viable option.
Causes & Risk Factors
The exact cause of chondromalacia patellae is not known. Doctors have been able to link the condition to several factors. Overuse of the knee places repetitive stress on the joint. This is commonly seen in sports or activities that involve a lot of jumping or running.
Poor muscle control is another common factor. The muscles that surround the knee and hip don�t function properly so that tracking of the kneecap is �off.� Injury is another common factor with chondromalacia patellae. When the kneecap endures a trauma such as fracture or dislocation.
There are several factors that may increase a person�s risk of developing chondromalacia patellae. Age is often noted in young adults and adolescents. Older individuals with knee pain are usually experiencing effects of arthritis.
Gender is another risk factor. Women develop the condition twice as often as men. Doctors theorize that this is due to the skeletal structure of a woman � the pelvis is wider which increases the angle where the bones of the knee joint meet.
Individuals who participate in certain sports, such as those that involve a lot of jumping and running, are at an increased risk of developing the condition. This is particularly true if they suddenly increase their level of training.
Chiropractic Treatment
Successful chiropractic treatments for chondromalacia patellae include nutritional intervention as well as adjustments and stretches. The treatment is designed to stretch shortened hamstrings and adjust the sacroiliac joint.
The point of much of the treatment is to improve tracking of the kneecap and increase motor control. Some practitioners use soft tissue work to help patients with knee pain. The whole body approach that chiropractic care offers not only provides relief from knee pain, but often cures or reduces the condition itself.
If you or a loved one are suffering from knee pain, give us a call. Our Doctor of Chiropractic will do a thorough exam to determine the proper treatment protocol for your condition. You don�t have to live with pain. Again, give us a call. We�re here to help!
Leg Length: One side of the human body doesn’t necessarily match the other perfectly. In fact, there is almost always a tiny disparity of size and length in a person’s hands, feet, arms, and legs.
Think about it, a ring may fit on one hand but be tight on the other, a shoe may feel loose on one foot but be comfortably worn on the other. Most of the time these slight discrepancies in size are normal and have no bearing on an individual’s well-being.
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Leg Length Inequality, Unfortunately, Is The Exception
According to the American Chiropractic Association, a study found 75% of subjects who suffered from lower back pain had legs that were slightly different lengths (5 millimeters or more). This condition is called Short Leg Syndrome, and causes a variety of issues for its sufferers. The symptoms can be quite severe, depending on the degree of difference in the leg length.
The premise of this condition is that the leg length inequality disrupts the body’s entire balance, possibly resulting in issues in the knees, hips, and back. The spinal system is designed to bear weight evenly, and, when one leg is shorter than the other, this places additional weight and stress on one side.
According to The Back Pain Authority, common causes of Short Leg Syndrome are a past history of fractures, hip or knee issues, or the individual was simply born that way.
Unfortunately, the condition often brings about recurring and sometimes intense spells of lower back pain and mobility issues for the patient. The good news is that once it’s diagnosed, the patient who commits to consistent treatment measures can manage the condition and resulting lower back pain.
Patients can choose two vital options that help control and manage Short Leg Syndrome’s symptoms:
Chiropractic Care
Visiting an experienced chiropractor and mapping out a treatment plan for lower back pain caused by Short Leg Syndrome is a smart first step. Leg length inequality results in pain because it puts excess pressure and weight on one side of the body. Over time, this creates misalignment in the spine and stiff muscles and joints.
Chiropractic care including spinal adjustments re-align the spine, loosens up the body’s muscles and joints, and promotes healing. A series of visits helps the body gain its balance, and pain hopefully begins decreasing during this period.
However, depending on the degree of leg length inequality, chiropractic treatment alone may not be enough to manage the symptoms long-term. That’s where the second step presents itself as valuable.
Orthotic Heel Lifts
Chiropractic care does wonders for helping individuals regain their spinal alignment and loosen the joints and muscles affected by leg length inequality, but the underlying issue of Short Leg Syndrome remains. The goal of an orthotic heel lift is to balance out the legs, which in turn balances the hips and pelvis.
An orthotic equals out the weight, helping reduce the condition’s symptoms and resulting pain. A treatment of chiropractic care and orthotics gain great advantages over Short Leg Syndrome, and, when used together consistently, offer less pain and fewer recurrences.
An individual who suffers from recurring lower back pain should visit a chiropractor to pursue a diagnosis. If leg length inequality is the cause, patients must rest assured it is manageable in most cases.
Talk with your chiropractor about the recommended regimen of chiropractic adjustments, and the possibility of utilizing an orthotic heel lift. Together, these two steps can decrease pain and the chances of recurrence, and increase overall mobility.
If you or a loved one is suffering from this condition, please give us a call. Our Doctor of Chiropractic is here to help!
A migraine is a neurological condition commonly characterized by an intense, debilitating headache. Approximately 12 percent of the population in the United States suffers from migraines. Other symptoms may include: nausea, vomiting, difficulty speaking, numbness or tingling, and sensitivity to light and sound. Several factors can trigger a migraine. These include: stress, lack of food or sleep, exposure to light, hormonal changes in women and anxiety. Although healthcare professionals have yet to understand the true source of migraines, doctors of chiropractic have concluded that a spinal misalignment, or subluxation, may be associated with different types of headaches. The purpose of the following article is to demonstrate the results of a case of chronic migraine remission after a 72-year-old woman with a 60-year history of migraine headaches received chiropractic care.
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A Case of Chronic Migraine Remission After Chiropractic Care
Abstract
Objective: To present a case study of migraine sufferer who had a dramatic improvement after chiropractic spinal manipulative therapy (CSMT).
Clinical features: The case presented is a 72-year�old woman with a 60-year history of migraine headaches, which included nausea, vomiting, photophobia, and phonophobia.
Intervention and outcome: The average frequency of migraine episodes before treatment was 1 to 2 per week, including nausea, vomiting, photophobia, and phonophobia; and the average duration of each episode was 1 to 3 days. The patient was treated with CSMT. She reported all episodes being eliminated after CSMT. The patient was certain there had been no other lifestyle changes that could have contributed to her improvement. She also noted that the use of her medication was reduced by 100%. A 7-year follow-up revealed that the person had still not had a single migraine episode in this period.
Conclusion: This case highlights that a subgroup of migraine patients may respond favorably to CSMT. While a case study does not represent significant scientific evidence, in context with other studies conducted, this study suggests that a trial of CSMT should be considered for chronic, nonresponsive migraine headache, especially if migraine patients are nonresponsive to pharmaceuticals or prefer to use other treatment methods.
Migraine is a prevalent and debilitating condition which affects about 12 percent of the population in the U.S.� Furthermore, migraine affects more women than men. While the causes and symptoms of migraine headache pain have been identified, many healthcare professionals believe that a spinal misalignment, or subluxation, may often lead to various types of headaches. Chiropractic care utilizes spinal adjustments and manual manipulations to carefully correct the alignment of the spine, restoring proper structure and function. According to the research study below, chiropractic can be an effective migraine headache treatment. Chiropractic care is a safe and effective alternative treatment option for patients with migraine who seek a natural method and technique to reduce their symptoms without the use of drugs and/or medications.
Introduction
Migraine remains a common and debilitating condition.[1,2] It has an estimated incidence of 6% in males and 18% in females.[2] A study in Australia found the cost to industry to be an estimated $750 million.[3] Lipton et al found that migraine is one of the most frequent reasons for consultations with general practitioners, affecting between 12 million and 18 million people each year in the United States.[4] The estimated cost in the United States is $25 billion in lost productivity due to 156 million full-time work days being lost each year.[5] Recent information has suggested that these older figures above are still current, but also underestimated, because of many sufferers not stating their problem because of a perceived poor social stigma.[6]
The Brain Foundation in Australia notes that 23% of households contain at least one migraine sufferer. Nearly all migraine sufferers and 60% of those with tension-type headache experience reductions in social activities and work capacity. The direct and indirect costs of migraine alone would be about $1 billion per annum.[3]
The Headache Classification Committee of the International Headache Society (IHS) defines migraines as having the following: unilateral location, pulsating quality, moderate or severe intensity, and aggravated by routine physical activity. During the headache, the person must also experience nausea and/or vomiting, photophobia, and/or phonophobia.[7] In addition, there is no suggestion either by history or by physical or neurologic examination that the person has a headache listed in groups 5 to 11 of their classification system.[7] Groups 5 to 11 of the classification system include headache associated with head trauma, vascular disorder, nonvascular intracranial disorder, substances or their withdrawal, noncephalic infection, or metabolic disorder, or with disorders of cranium, neck, eyes, nose, sinuses, teeth, mouth, or other facial or cranial structures.
Some confusion relates to the �aura� feature that distinguishes migraine with aura (MA) and migraine without aura (MW). An aura usually consists of homonymous visual disturbances, unilateral paresthesias and/or numbness, unilateral weakness, aphasia, or unclassifiable speech difficulty.[7] Some migraineurs describe the aura as an opaque object, or a zigzag line around a cloud; even cases of tactile hallucinations have been recorded.[8] The new terms MA and MW replace the old terms classic migraine and common migraine, respectively.
The IHS diagnostic criteria for MA (category 1.2) is at least 3 of the following:
1) One or more fully reversible aura symptoms indicating focal cerebral cortex and/or brain stem dysfunction.
2) At least 1 aura symptom develops gradually over more than 4 minutes or 2 or more symptoms occurring in succession.
3) No aura symptom lasts more than 60 minutes.
4) Headache follows aura with a free interval of less than 60 minutes.
Migraine is often still nonresponsive to treatment.[9] However, several studies have demonstrated statistically significant reduction in migraines after chiropractic spinal manipulative therapy (CSMT).[10-15]
This article will discuss a patient presenting with MW and her response after CSMT. The discussion will also outline specific diagnostic criteria for migraine and other headaches relevant to chiropractors, osteopaths, or other health practitioners.
Case Report
A 72-year�old 61-kg white woman presented with migraine headaches that had commenced in early childhood (approximately 12 years old). The patient could not relate anything to the commencement of her migraines, although she believed there was a family history (father) of the condition. During the history, the patient stated that she suffered regular migraine headaches (1-2 per week) with which she also experienced nausea, vomiting, vertigo, and photophobia. She needed to cease activities to alleviate the symptoms, and she often required acetaminophen and codeine medication (25 mg) or sumatriptan succinate for pain relief. The patient was also taking verapamil (calcium ion antagonist, for essential hypertension), calcitriol (calcium uptake, for osteoporosis), pnuemenium on a daily basis, and carbamazipine (antiepileptic, neurotropic medication) twice daily.
The patient reported that an average episode lasted 1 to 3 days and that she could not perform activities of daily living for a minimum of 12 hours. In addition, a visual analogue scale score for an average episode was 8.5 out of a possible maximum score of 10, corresponding to a description of �terrible� pain. The patient noted that stress or tension would precipitate a migraine and that light and noise aggravated her condition. She described the migraine as a throbbing head pain located in the parietotemporal region and was always left-sided.
The patient had a previous history of a pulmonary embolism (2 years before treatment) and had a partial hysterectomy 4 years before treatment. She also stated she had hypertension that was controlled. She was a widow with 2 children, and she had never smoked. The patient had tried acupuncture, physiotherapy, substantial dental treatment, and numerous other medications; but nothing had changed her migraine pattern. She stated that she had never had previous chiropractic treatment. The patient also stated that she had been treated by a neurologist for �migraines� over many years.
On examination, she was found to have very sensitive suboccipital and upper cervical musculature and decreased range of motion at the joint between the occiput and first cervical vertebra (Occ-C1), coupled with pain on flexion and extension of the cervical spine. She also had significant reduction in thoracic spine motion and a marked increase in her thoracic kyphosis.
Blood pressure testing revealed she was hypertensive (178/94), which the patient reported was an average result (stage 2 hypertension using the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 7 guidelines).
Based on the IHS Headache Classification Committee classification and diagnostic criteria, the patient had an MW�category 1.1, previously called common migraine (Table 1). This appeared secondary to moderate cervical segmental dysfunction with mild to moderate suboccipital and cervical paraspinal myofibrosis.
The patient received CSMT (diversified chiropractic �adjustments�) to her Occ-C1 joint, upper thoracic spine (T2 through T7), and the affected hypertonic musculature. Hypertonic muscles were released through gentle massage and stretching. An initial course of 8 treatments was conducted at a frequency of twice a week for 4 weeks. The treatment program also included recording several features for every migraine episode. This included frequency, visual analogue scores, episode duration, medication, and time before they could return to normal activities.
The patient reported a dramatic improvement after her first treatment and noticed a reduction in the intensity of her head and neck pain. This continued with the patient reporting having no migraines in the initial month course of treatment. Further treatment was recommended to increase her range of motion, increase muscle tone, and reduce suboccipital muscle tension. In addition, monitoring of her migraine symptoms was continued. A program of treatment at a frequency of once a week for a further 8 weeks was instigated. After the next phase of treatment, the patient noted much less neck tension, better movement, and no migraine. In addition, she no longer used pain-relieving medication (acetaminophen, codeine, and sumatriptan succinate) and noted that she did not experience nausea, vomiting, photophobia, or phonophobia (Table 2). The patient continued treatment at 2-weekly intervals and stated that, after 6 months, her migraine episodes had disappeared completely. In addition, she was no longer experiencing neck pain. Examination revealed no pain on active neck movement; however, a passive motion restriction at the C1-2 motion segment was still present.
The patient is currently having treatment every 4 weeks, and she still reports no return of her migraine episodes or neck pain. The patient has now not experienced any migraines for a period of more than 7 years since her last episode, which was immediately before her having her first chiropractic treatment.
Discussion
Case studies do not form high levels of scientific data. However, some cases do present significant findings. For example, cases with long (chronic) and/or severe symptomatology can highlight alternative treatment options. With case studies such as this, there is always a possibility that the symptoms spontaneously resolved, with no effective from the treatment. The case presented highlights a potential alternative treatment option. A 7-year follow-up revealed that the person had still not had a single migraine episode in this period. The patient was certain that there had been no other lifestyle changes that could have contributed to her improvement. She also noted that the migraines had stopped after her first treatment.
The average frequency of her migraines before treatment was 1 to 2 per week, with episodes that always included nausea, vomiting, photophobia, and phonophobia. In addition, the average duration of each episode was 1 to 3 days before her receiving CSMT. The person also noted that the use of her pain-relieving medication was also reduced by 100% (Table 3).
Table 3: Summary of key changes for this case.
Migraines are a common and debilitating condition; yet because they have an uncertain etiology, the most appropriate treatment regime is often unclear.[16] Previous etiological models described vascular causes of migraine, where episodes seem to be initiated by a decreased blood flow to the cerebrum followed by extracranial vasodilation during the headache phase.[8] However, other etiological models seem connected with vascular changes related to neurologic changes and associated serotonergic disturbances.[9] Therefore, previous treatments have focused on pharmacological modification of blood flow or serotonin antagonist block.[17]
Studies examining the role of the cervical spine to headache (ie, �cervicogenic headache�) have been well described in the literature.[18-30] However, the relation of the cervical spine to migraine is less well documented.[10-15] Previous studies by this author have demonstrated an apparent reduction in migraines after CSMT.[10,11] In addition, other studies have suggested that CSMT may be an effective intervention for migraine.[14,15] Although, previous studies have some limitations (inaccurate diagnosis, overlapping symptoms, inadequate control groups), the level of evidence gives support for CSMT in migraine treatment.[11] However, practitioners need to be critically aware of potential overlap of diagnoses when reviewing migraine research or case studies on effectiveness of their treatment.[18-22] This is especially important in comparison of migraine patients who may be suitable for chiropractic manipulative therapy.[23-28]
Between 40% and 66% of patients with migraine, particularly those with severe or frequent migraine attacks, do not seek help from a physician.[29] Among those who do, many do not continue regular physician visits.[30] This may be due to patients’ perceived lack of empathy from the physician and a belief that physicians cannot effectively treat migraine. In a 1999 British survey, 17% of 9770 migraineurs had not consulted a physician because they believed their condition would not be taken seriously; and 8% had not seen a physician because they believed existing migraine medications were ineffective.[30] The most common reason for not seeking a physician’s advice (cited by 76% of patients) was the patients’ belief that they did not need a physician’s opinion to treat their migraine attacks.
The case was presented to assist practitioners making a more informed decision on the treatment of choice for migraines. The outcome of this case is also relevant in relation to other research that concludes that CSMT is a very effective treatment for some people. Practitioners could consider CSMT for migraine based on the following:
1) Limitation of passive neck movements.
2) Changes in neck muscle contour, texture, or response to active and passive stretching and contraction.
3) Abnormal tenderness of the suboccipital area.
4) Neck pain before or at the onset of the migraine.
5) Initial response to CSMT.
As with all case reports, results are limited in application to larger populations. Careful clinical decision making should be used when applying these results to other patients and clinical situations.
Conclusion
This case demonstrates that some migraine sufferers may respond well with manual therapies, which includes CSMT. Therefore, migraine patients who have not received a trial of CSMT should be encouraged to consider this treatment and assess any potential response. Where there are no contraindications to CSMT, an initial trial of treatment may be warranted. Following evidence-based medicine guidelines, medical practitioners should discuss CSMT with migraine patients as an option for treatment.[31,32] Subsequent studies should address this issue and the role that CSMT has in migraine management.
In conclusion, a�migraine is a debilitating and intense type of headache which is often accompanied by a variety of other symptoms. Although still misunderstood today, doctors of chiropractic have shown that a spinal misalignment, or subluxation may trigger migraine headaches. According to the article above, chiropractic care may effectively help individuals who suffer from migraine headaches. However, further research studies are 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
Additional Topics: Back Pain
According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.
1.�Bigal M.E., Lipton R.B., Stewart W.F. The epidemiology and impact of migraine.�Curr Neurol Neurosci Rep.�2004;4(2):98�104.�[PubMed]
2.�Lipton R.B., Stewart W.F., Diamond M.L., Diamond S., Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study 11.�Headache.�2001;41:646�657.�[PubMed]
3.�Alexander L.�Migraine in the workplace. Brainwaves.�Australian Brain Foundation; Hawthorn, Victoria: 2003. pp. 1�4.
4.�Lipton R.B., Bigal M.E. The epidemiology of migraine.�Am J Med.�2005;118(Suppl 1):3S�10S.[PubMed]
5.�Lipton R.B., Bigal M.E. Migraine: epidemiology, impact, and risk factors for progression.�Headache.�2005;45(Suppl 1):S3�S13.�[PubMed]
6.�Stewart W.F., Lipton R.B. Migraine headache: epidemiology and health care utilization.�Cephalalgia.�1993;13(suppl 12):41�46.�[PubMed]
7.�Headache Classification Committee of the International Headache, Society Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain.�Cephalgia.�2004;24(Suppl. 1):1�151.[PubMed]
8.�Goadsby P.J., Lipton R.B., Ferrari M.D. Migraine�current understanding and treatment.�N Engl J Med.�2002;346:257�263.�[PMID 11807151]�[PubMed]
9.�Goadsby P.J. The scientific basis of medication choice in symptomatic migraine treatment.�Can J Neurol Sci.�1999;26(suppl 3):S20�S26.�[PubMed]
10.�Tuchin P.J., Pollard H., Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine.�J Manipulative Physiol Ther.�2000;23:91�95.�[PubMed]
11.�Tuchin P.J. The efficacy of chiropractic spinal manipulative therapy (SMT) in the treatment of migraine�a pilot study.�Aust Chiropr Osteopath.�1997;6:41�47.�[PMC free article]�[PubMed]
12.�Tuchin P.J., Bonello R. Classic migraine or not classic migraine, that is the question.�Aust Chiropr Osteopath.�1996;5:66�74.�[PMC free article]�[PubMed]
13.�Tuchin P.J., Scwafer T., Brookes M. A case study of chronic headaches.�Aust Chiropr Osteopath.�1996;5:47�53.�[PMC free article]�[PubMed]
14.�Nelson C.F., Bronfort G., Evans R., Boline P., Goldsmith C., Anderson A.V. 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]
15.�Parker G.B., Tupling H., Pryor D.S. A controlled trial of cervical manipulation for migraine.�Aust NZ J Med.�1978;8:585�593.�[PubMed]
16.�Dowson A.J., Lipscome S., Sender J. New guidelines for the management of migraine in primary care.�Curr Med Res Opin.�2002;18:414�439.�[PubMed]
17.�Ferrari M.D., Roon K.I., Lipton R.B. Oral triptans (serotonin 5-HT1B/1D agonists) in acute migraine treatment: a meta-analysis of 53 trials.�Lancet.�2001;358:1668�1675.�[PubMed]
18.�Sjasstad O., Saunte C., Hovdahl H., Breivek H., Gronback E. Cervical headache: an hypothesis.�Cephalgia.�1983;3:249�256.
19.�Vernon H.T. Spinal manipulation and headache of cervical origin.�J Manipulative Physiol Ther.�1989;12:455�468.�[PubMed]
20.�Sjasstad O., Fredricksen T.A., Stolt-Nielsen A. Cervicogenic headache, C2 rhizopathy, and occipital neuralgia: a connection.�Cephalgia.�1986;6:189�195.�[PubMed]
21.�Bogduk N. Cervical causes of headache and dizziness. In: Greive G.P., editor.�Modern manual therapy of the vertebral column.�2nd ed. Edinburgh; Churchill Livingstone: 1994. pp. 317�331.
22.�Jull G.A. Cervical headache: a review. In: Greive GP, editor.�Modern manual therapy of the vertebral column.�2nd ed. Edinburgh; Churchill Livingstone: 1994. pp. 333�346.
23.�Boline P.D., Kassak K., Bronfort G. Spinal manipulations vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial.�J Manipulative Physiol Ther.�1995;18:148�154.[PubMed]
24.�Vernon H., Steiman I., Hagino C. Cervicogenic dysfunction in muscle contraction headache and migraine: a descriptive study.�J Manipulative Physiol Ther.�1992;15:418�429.�[PubMed]
25.�Kidd R., Nelson C. Musculoskeletal dysfunction of the neck in migraine and tension headache.�Headache.�1993;33:566�569.�[PubMed]
26.�Whittingham W., Ellis W.S., Molyneux T.P. The effect of manipulation (Toggle recoil technique) for headaches with upper cervical joint dysfunction: a case study.�J Manipulative Physiol Ther.�1994;17:369�375.�[PubMed]
27.�Jull G., Trott P., Potter H., Zito G., Shirley D., Richardson C. A randomized controlled trial of exercise and spinal manipulation for cervicogenic headache.�Spine.�2002;27:1835�1843.�[PubMed]
28.�Bronfort G, Nilsson N, Assendelft WJJ, Bouter L, Goldsmith C, Evans R, et al. Non-invasive physical treatments for chronic headache (a Cochrane review). In: The Cochrane Library Issue 2 2003. Oxford: Update Software.
29.�Dowson A., Jagger S. The UK migraine patient survey: quality of life and treatment.�Curr Med Res Opin.�1999;15:241�253.�[PubMed]
30.�Solomon G.D., Price K.L. Burden of migraine: a review of its socioeconomic impact.�Pharmacoeconomics.�1997;11(Suppl 1):1�10.�[PubMed]
31.�Bronfort G., Assendelft W.J.J., Evans R., Haas M., Bouter L. Efficacy of spinal manipulation for chronic headache: a systematic review.�J Manipulative Physiol Ther.�2001;24:457�466.�[PubMed]
32.�Vernon H.T. Spinal manipulation in the management of tension-type migraine and cervicogenic headaches: the state of the evidence.�Top Clin Chiropr.�2002;9:14�21.
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