These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Contents
Clinical Application of Neuromuscular Techniques: Scalenes
Box 4.9 Notes on Scalenes
The scalenes are a controversial muscle since they seem to be both postural and phasic (Lin et al 1994), their status being modified by the type(s) of stress to which they are exposed (see Ch. 3 for discussion of this topic).
Janda (1988) reports that �spasm and/or trigger points are commonly present in the scalenes as also are weakness and/or inhibition�.
The attachment sites of the scalene muscles vary, as does their presence. The scalene posterior is sometimes absent, and sometimes blends with the fibres of medius.
Scalene medius is noted to frequently attach to the atlas (Gray 1995) and sometimes extend to the 2nd rib (Simons et al 1998).
The scalene minimus (pleuralis), which attaches to the pleural dome, is present in onethird (Platzer 1992) to three-quarters (Simons et al 1998) of people, on at least one side and, when absent, is replaced by a transverse cupular ligament (Platzer 1992).
The brachial plexus exits the cervical column between the scalenus anterior and medius. These two muscles, together with the 1st rib, form the scalene hiatus (also called the �scalene opening� or �posterior scalene aperture�) (Platzer 1992). It is through this opening�that the brachial plexus and vascular structures for the upper extremity pass. When scalene fibres are taut, they may entrap the nerves (scalene anticus syndrome) or may elevate the 1st rib against the clavicle and indirectly crowd the vascular, or neurologic, structures (simultaneous compromising of both neural and vascular structures is rare) (Stedman 1998). Any of these conditions may be diagnosed as �thoracic outlet syndrome�, which is �a collective title for a number of conditions attributed to compromise of blood vessels or nerve fibers (brachial plexus) at any point between the base of the neck and the axilla� (Stedman 1998).
Assessment of Shortness in Scalenes (14)
Assessment of cervical sidebending (lateral flexion) strength. This involves the scalenes and levator scapulae (and to a secondary degree the rectus capitis lateralis and the transversospinalis group).
The practitioner places a stabilising hand on the top of the shoulder to prevent movement and the other on the head above the ear, as the seated patient attempts to flex the head laterally against this resistance. Both sides are assessed.
Observation assessment (a) There is no easy test for shortness of the scalenes apart from observation, palpation and assessment of trigger point activity/tautness and a functional observation as follows:
In most people who have marked scalene shortness there is a tendency to overuse these (and other upper fixators of the shoulder and neck) as accessory breathing muscles.
There may also be a tendency to hyperventilation (and hence for there to possibly be a history of anxiety, phobic behaviour, panic attacks and/or fatigue symptoms).
These muscles seem to be excessively tense in many people with chronic fatigue symptoms.
The observation assessment consists of the practitioner placing his relaxed hands over the patient�s shoulders so that the fingertips rest on the clav-icles, at which time the seated patient is asked to inhale deeply. If the practitioner�s hands noticeably rise towards the patient�s ears during inhalation then there exists inappropriate use of scalenes, which indicates that they are stressed, which also means that, by definition, they will have become shortened and require stretching treatment.
Observation assessment (b) (Fig. 4.33) Alternatively, during the history taking interview, the patient can be asked to place one hand on the abdomen just above the umbilicus and the other flat against the upper chest.
Figure 4.33 Observation assessment of respiratory function. Any tendency for the upper hand to move cephalad, or earlier than the caudad hand, suggests scalene overactivity.
On inhalation, the hands are observed: if the upper hand initiates the breathing process and rises significantly towards the chin, rather than moving forwards, a pattern of upper chest breathing can be assumed, and therefore stress, and therefore shortness of the scalenes (and other accessory breathing muscles, notably sternomastoid).
MET Treatment of Short Scalenes (Fig. 4.34A, B, C)
Patient lies supine with a cushion or folded towel under the upper thoracic area so that, unless supported by the practitioner�s contralateral hand, the head would fall into extension. The head is rotated contralaterally (away from the side to be treated). There are three positions of rotation required:
Full contralateral rotation of the head/neck produces involvement of the more posterior fibres of the scalenes
A contralateral 45� rotation of the head/neck involves the middle fibres
A position of only slight contralateral rotation involves the more anterior fibres.
The practitioner�s free hand is placed on the side of the patient�s head to restrain the isometric contraction which will be used to release the scalenes. The patient�s head is in one of the above degrees of rotation, supported by the practitioner�s contralateral hand.
Figure 4.34A MET for scalenus posticus. On stretching, following the isometric contraction, the neck is allowed to move into slight extension while a mild stretch is introduced by the contact hand which rests on the second rib, below the lateral aspect of the clavicle.
Figure 4.34B MET treatment for the middle fibres of scalenes. The hand placement (thenar or hypothenar eminence of relaxed hand) is on the 2nd rib below the centre of the clavicle.
Figure 4.34C MET treatment of the anterior fibres of the scalenes; hand placement is on the sternum
The patient is instructed to try to lift the forehead a fraction and to attempt to turn the head towards the affected side, with appropriate breathing cooperation, while resistance is applied by the practitioner�s hand to prevent both movements (�breathe in and hold your breath as you �lift and turn�, and hold this for 7�10 seconds�). Both the effort and, the counter-pressure should be modest and painless at all times.
After a 7�10 second contraction, the head is placed into extension and one hand remains on it to prevent movement during the scalene stretch.
The patient�s contralateral hand is placed (palm down) just inferior to the lateral end of the clavicle on the affected side (for full rotation of the head, posterior scalenes). The practitioner�s hand which was acting to produce resistance to the isometric contraction is now placed onto the dorsum of the patient�s �cushion� hand.
As the patient slowly exhales, the practitioner�s contact hand, resting on the patient�s hand, which is itself resting on the 2nd rib and upper thorax, pushes obliquely away and towards the foot on that same side, following the rib movement into its exhalation position, so stretching the attached musculature and fascia. This stretch is held for at least 20 seconds after each isometric contraction. The process is then repeated at least once more.
The head is rotated 45� contralaterally and the �cushion� hand contact, which applies the stretch of the middle scalenes, is placed just inferior to the middle aspect of the clavicle. When the head is in the almost upright facing position for the anterior scalene stretch, the �cushion� hand contact is on the upper sternum itself.
In all other ways the methodology is as described for the first position above.
NOTE: It is important not to allow heroic degrees of neck extension during any phase of this treatment. There should be some extension, but it should be appropriate to the age and condition of the individual.
A degree of eye movement can assist scalene treatment and may be used as an alternative to the �lift and turn� muscular effort described above. If the patient makes the eyes look caudally (towards the feet) and towards the affected side during the isometric contraction, she will increase the degree of contraction in the muscles. If during the resting phase, when stretch is being introduced, she looks away from the treated side, with eyes looking towards the top of the head, this will enhance the stretch of the muscle.
This whole procedure should be performed bilaterally several times in each of the three head positions. Scalene stretches, with all their variable positions, clearly also influence many of the anterior neck structures.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
Additional Topics: Wellness
Overall health and wellness are essential towards maintaining the proper mental and physical balance in the body. From eating a balanced nutrition as well as exercising and participating in physical activities, to sleeping a healthy amount of time on a regular basis, following the best health and wellness tips can ultimately help maintain overall well-being. Eating plenty of fruits and vegetables can go a long way towards helping people become healthy.
The hips joints join the legs to the trunk of the body, and are formed by the femurs and pelvic bones. The hips are ball-and-socket type joints, where the femoral head (ball) fits into the cup-shaped acetabulum (socket) of the pelvis (Figure 1). When compared to the shoulder, which is also a ball-and-socket joint, the acetabulum is a deeper socket, and encompasses a greater area of the ball, or femoral head. This accommodation is necessary to provide stability for the hip, as it is a major weight-bearing joint, and one of the largest joints in the body. When not weight-bearing, the ball and socket of the hip joint are not perfectly fitted. However, as the hip joint bears more weight, the surface area contact increases, and the joint becomes more stable. When in a standing position, the body�s center of gravity passes through the center of the acetabula. While walking, weight-bearing stresses on the hips can be five times a person�s body weight. Healthy hips can support your weight and allow for pain-free movement. Hip injuries or disease can cause changes that affect your gait, as well as changes that affect the ability of the hips to distribute weight bearing. Abnormal stress is then placed on the joints that are above and below the hips.
The three fused hips or innominate bones that form the acetabulum include the ilium, pubis, and ischium. The ilium forms the superior aspect, the pubis forms the inferior and anterior aspect, and the ischium forms the inferior and posterior aspect. The depth of the acetabulum socket is further increased by the attached fibrocartilaginous labrum (Figure 2). In addition to providing stability to the hip joint, the labrum allows flexibility and motion. Hip joint stability can be hampered by injuries resulting from playing sports, running, overuse, or falling, as well as by disease or tumor. MRI of the hips may be ordered to assess the joint(s) for internal derangement, fracture, or degenerative joint disease. A blow to the hip joint or a fall can result in dislocation of the hip, or a hip fracture. Osteoporosis or low bone density can also lead to hip fractures. Successful prevention and/or treatment of osteoporosis may be achieved through nutrition (adequate amounts of calcium, vitamin D and phosphorus), exercise, safety measures, and medications.
Articular cartilage covers the femoral head and the acetabulum (Figure 3). This cartilage is thin but tough, flexible, smooth and slippery, with a rubbery consistency. It absorbs shock, and allows the bones to move against each other easily and without pain. It is kept lubricated by synovial fluid, which is made in the synovial membrane (joint lining). Synovial fluid is both viscous and sticky. This fluid is what allows us to flex our joints under great pressure without wear. The articular cartilage of the hip is typically about � inch thick, except in the posterior aspect of the hip socket (Figure 4). Here, the cartilage is thicker, as this area absorbs most of the force during walking, running, and jumping. MRI of the hip joint can detect problems involving both the articular cartilage and the fibrocartilaginous ring, or labrum. Cartilage has minimal blood vessels, so it is not good at repairing itself. Fraying, fissuring, and other abnormalities or defects of the cartilage can lead to arthritis in the hip joint. Contrast can be directly injected in the hip joint for a detailed look at the cartilage and labrum.
The femurs are the longest bones in the body, with large round heads that rotate and glide within the acetabula of the pelvis. The femoral head is particularly subject to pathologic changes if there is any significant alteration of blood supply (avascular necrosis). The femoral neck connects the head of the femur to the shaft. The neck ends at the greater and lesser trochanters, which are sites of muscle and tendon attachments. A disease characterized by an inadequate blood supply to the femoral head is Legg-Calve-Perthes disease, also known as LCP or simply Perthes disease. This is a degenerative disease of the hip joint that affects children, most commonly seen in boys ages two through twelve. One of the growth plates of the femoral head, the capital femoral epiphysis, is inside the joint capsule of the hip. Blood vessels that feed this epiphysis run along the side of the femoral neck, and are in danger of being torn or �pinched off� if the growth plate is damaged. This can result in a loss of blood supply to the epiphysis, leading to a deformity of the femoral head (Figure 5). The femoral head may become unstable and break easily, which can lead to incorrect healing and deformities of the entire hip joint (Figure 6). Treatment of Perthes disease is centered on the goal of returning the femoral head to a normal shape. Surgical and non-surgical treatments are used, based on the idea of �containment�- holding the femoral head in the acetabulum as much as possible, while still allowing motion of the hip joint for cartilage nutrition and healthy growth of the joint.
High level athletes and active individuals may be susceptible to a hip condition known as Femoro-Acetabular Impingement, or FAI. FAI is characterized by excessive friction in the hip joint. The femoral head and acetabulum rub abnormally, and can create damage to the articular or labral cartilage. FAI is also associated with labral tears, early hip arthritis, hyperlaxity and low back pain. FAI generally occurs in two forms: Cam and Pincer. The Cam form results in abnormal contact between the femoral head and the socket of the hip because the femoral head and neck relationship is aspherical (Figure 7). Males and those involved in significant contact sports typically display Cam impingement. Pincer impingement occurs when the acetabulum covers too much of the femoral head, resulting in the labral cartilage being pinched between the rim of the socket and the anterior femoral head-neck junction (Figure 8). Pincer impingement may be more common in women. Typically, these two forms exist together, and are labeled as �mixed impingement� (Figure 9).
Ewing�s sarcoma is a malignant bone tumor that may affect the pelvis and/or femur, thereby also affecting the stability of the hips. Like Perthes disease, Ewing�s sarcoma is more common in males, typically presenting in childhood or early adulthood. MRI is routinely used in the work-up of these malignant tumors to show bony and soft tissue extent of the tumor, and its relation to nearby anatomic structures (Figure 10). Contrast may be used to help determine the amount of necrosis within the tumor, which aids in determining the response to treatment before surgery.
Figure 10. MRI demonstrating Ewing�s sarcoma.
Ligaments Of The Hips
Hip stability is further increased by three strong ligaments that encompass the hip joint and form the joint capsule. These ligaments connect the femoral head to the acetabulum, with names suggestive of the bones they connect. They include the pubofemoral and iliofemoral ligaments anteriorly, and the ischiofemoral ligament posteriorly (Figure 11). The iliofemoral ligament is the strongest ligament in the body. However, sports and overuse can still result in sprains of these sturdy ligaments of the joint capsules of the hips. A smaller ligament, the ligamentum teres, is an intracapsular ligament that connects the tip of the femoral head to the acetabulum (Figure 12). A small artery within this ligament brings some of the blood supply to the femoral head. Damage to the ligamentum teres, and its enclosed artery, can result in avascular necrosis.
Muscles & Tendons Of The Hips
The muscles of the thigh and lower back work together to keep the hip stable, in alignment, and able to move. The hip gains stability because the hip muscles do not attach right at the joint. Hip muscles allow the movements of flexion, extension, abduction, adduction, and medial and lateral rotation. To better understand the functions of the muscles surrounding the hip, they can be divided into groups based on their locations- anterior, posterior, and medial.
The anterior thigh muscles are the main hip flexors, and are located anterior to the hip joint. Seventy percent of the thigh�s muscle mass is made up of the quadriceps femoris muscle, so named because it arises from four muscle heads- the rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis (Figures 13, 14). The rectus femoris is the only one of the �quad� muscles to cross the hip joint. The sartorius muscle is found anterior to the quadriceps, and also serves as an abductor and lateral rotator of the hip. The most powerful of the anterior thigh hip flexors is the iliopsoas, which originates in the low back and pelvis and attaches at the lesser trochanter.
Posterior hip muscles include those of both the thigh and gluteal regions. The posterior thigh muscles are also known as the hamstrings- semimembranosus, semitendinosus, and biceps femoris (Figure 15). These muscles originate at the inferior pelvis, and are the extensors for the hip. They are active in normal walking motions. When the hamstrings are �tight�, they limit hip flexion when the knee joint is extended (bending forward from the waist with knees straight), and can limit lumbar movement, leading to back pain. The gluteal muscles include the gluteus maximus, medius, and minimus, six deep muscles that serve as lateral rotators, and the tensor fasciae latae. The three gluteals and the anterior sartorius muscle are all involved in abduction. The gluteus maximus is the main hip extensor, and is the most superficial of the gluteal muscles. It is involved in running and walking uphill, and assists with normal tone of the iliotibial band, which lies lateral to it. The gluteus medius and minimus both insert at the greater trochanter of the femur. The minimus is the deepest of the three gluteal muscles. Anterior to the gluteus minimus is the tensor fasciae latae muscle. It is a flexor and medial rotator of the hip, originating from the anterior superior iliac spine (ASIS) and inserting on the iliotibial band. The term �tensor fasciae latae� defines this muscle�s job- �muscle that stretches the band on the side�. This muscle helps the iliopsoas, gluteus medius, and gluteus minimus muscles during flexion, abduction and medial rotation of the thigh by making the iliotibial band taut, thereby steadying the trunk and stabilizing the hip (Figure 16). The iliotibial band or tract is not a muscle, but a thickened, fibrous band of deep fascia, or connective tissue. It is found at the lateral aspect of the thigh, and runs from the ilium to the tibia. It encloses the muscles and helps with lateral stabilization of the knee joint, as well as helping to maintain both hip and knee extension. Tightening of the iliotibial (IT) band typically causes more problems at the knee as opposed to the hip, but hip pain can result from the IT band rubbing as it passes over the greater trochanter.
The medial thigh (groin) muscles include five muscles of adduction, and one lateral rotator (Figures 17, 18). The lone lateral rotator is the obturator externus, which covers the external surface of the obturator foramen in the deep upper medial thigh. The adductors include the gracilis, the pectineus, and the adductor brevis, longus and magnus. The gracilis is the longest adductor, extending from the medial inferior aspect of the pubic bone, to the medial aspect of the tibia. The adductor magnus is the most massive of the medial muscles of the thigh.
The tendons and muscles of the hips are very powerful and create great forces, making them prone to inflammation and irritation. Tendonitis of the hip can result from repetitive movements involving the soft tissues surrounding the hip joint. Overuse of the hip joint in fitness workouts can lead to tendonitis. Tendons lose their elasticity as we age, resulting in swelling and irritation when the tendons are no longer �gliding� on their normal paths. Iliopsoas tendonitis plays a major role in snapping hip syndrome, or dancer�s hip. A snapping sensation when the hip is flexed and extended may be accompanied by an audible snapping or popping noise, as well as pain. This can be both an extra-articular and an intra-articular occurrence. Extra-articular snapping is often found in those patients with a leg length difference (the longer leg is symptomatic), those with tightness of the iliotibial band on the involved side, and those with weak hip abductors and external rotators. Lateral extra-articular snapping can be caused by the iliotibial band, tensor fascia latae or gluteus medius tendon as they slide back and forth across the greater trochanter (Figure 19). If any of these connective tissue bands thickens, they can �catch� on the greater trochanter during the motion of hip extension, thereby creating the �snapping� sensation and sound. Medial extra-articular snapping, which is less common, can occur when the iliopsoas tendon catches on the anterior inferior iliac spine, lesser trochanter, or iliopectineal ridge during hip extension. Intra-articular snapping hip syndrome is similar in many ways to the extra-articular type, but often involves an underlying mechanical problem in the lower extremity, and more intense pain. Intra-articular snapping may be indicative of a torn acetabular labrum, recurrent hip subluxation, a tear of the ligamentum teres, loose bodies, articular cartilage damage, or synovial chondromatosis (cartilage formations in the synovial membrane of the joint). Snapping hip syndrome is usually found in those ages 15-40, often in those in training for the military. It can also affect athletes, especially those involved in dance, gymnastics, soccer, and track and field. These athletes will all be performing repeated hip flexions, which can lead to tendonitis in the hip area. The repetitive motions of those involved in weightlifting and running generally lead to a thickening of the tendons in the hip region, rather than snapping hip syndrome. Prevention, or at least a lessening, of this syndrome may be found with increased stretching of the iliopsosas muscle or the iliotibial band. Surgery is usually not required, unless intra-articular pathology is present.
Figure 19. Hip muscles.
Tendon or muscle strains can occur suddenly, as in sports injuries, or they can develop over time, with symptoms including pain, swelling, muscle spasms, and difficulty moving certain muscles. MRI can be used to detect tendon and muscle tears and strains, as well as bone tumors and infection. MRI has shown good accuracy for the diagnosis of tears of the gluteus medius and gluteus minimus tendons, which are both abductor tendons of the hip. An association was found between these tears and areas of high signal intensity superior or lateral to the greater trochanter on T2-weighted images, tendon elongation in the gluteus medius, and tendon discontinuity (Figure 20). STIR and fat-suppressed T2-weighted coronal images are very sensitive for detection of areas of high signal intensity superior to the greater trochanter. Coronal T1-weighted images demonstrate tendon elongation in the gluteus medius (Figure 21). Axial images may prove superior for localizing involvement to individual abductor tendons and confirming tendon discontinuity (Figure 22). Tears of the abductor tendons may be the leading cause of greater trochanteric pain syndrome.
Figure 20. Sag. T2 shows high signal intensity superior to greater trochanter (gt) corresponding to swollen bursa (*).
Figure 21. Coronal STIR shows high signal intensity superior to greater trochanter in bursa (*) between gluteus medius (me) and gluteus minimus (mi) tendons.
Figure 22. Axial T2 shows high signal intensity corresponding to fluid replacing distal rt. gluteus medius tendon (black arrow); normal left tendon (white arrow).
Nerves Of The Hips
The nerves of the hip supply the various muscles in the hip area. The major nerves include the femoral, obturator, and lateral femoral cutaneous nerves anteriorly, and the large sciatic nerve posteriorly (Figure 23). The femoral nerve innervates the quadriceps femoris and sartorius, and is the sensory nerve to the anterior thigh. Trauma to this nerve usually occurs in the pelvis, as it passes through or near the psoas muscle. The obturator nerve passes along the lateral pelvic wall and through the obturator foramen, then splits into branches that supply the adductor muscle group. This nerve can also be subject to trauma in the pelvis due to its passage through the obturator foramen. The lateral femoral cutaneous nerve is a sensory nerve that travels along the anterolateral aspect of the thigh. It supplies sensation to the skin surface of the thigh. This is the single nerve involved in a painful condition called meralgia paresthetica, which is characterized by tingling, numbness, and burning pain in the outer part of the thigh. Meralgia paresthetica results from focal entrapment of the lateral femoral cutaneous nerve as it passes through the tunnel formed by the lateral attachment of the inguinal ligament and the ASIS. The posterior sciatic nerve passes deep to the gluteus maximus into the posterior thigh, where it innervates the hamstring muscles, on its way down to the lower leg and foot. The sciatic nerve is approximately as big around as the thumb, and is the largest single nerve in the human body. It can be injured in cases of posterior hip dislocation. Pressure on this nerve can cause nerve pain, numbness, tingling and weakness (sciatica symptoms) in the buttocks, leg, or foot, depending on the site of origin of the sciatic nerve compression.
Figure 23. Anterior and posterior views of the nerves of the hip.
Arteries & Veins Of The Hips
The arterial blood vessels that supply the hips are branches of the internal and external iliacs. The internal iliac artery gives off the superior and inferior gluteals, and the obturator artery. The inferior gluteal flows to the posterior aspect of the hip joint and proximal femur, where it joins a branch of the femoral artery. The obturator artery runs through the obturator foramen, and sends its acetabular branch to the ligamentum teres as part of the blood supply to the femoral head. The external iliac becomes the femoral artery, which has numerous branches that supply the hip and proximal femur. The largest femoral branch is the profunda femoris, which branches superiorly into the medial and lateral circumflex femorals (Figure 24). The circumflex femorals and the inferior gluteal artery contribute to the anastomoses to supply the femoral head, femoral neck, and the hip joint. The medial circumflex also has an acetabular branch to the ligamentum teres. Congenital anomalies in the hip anastomoses, degenerative processes, and trauma can all compromise the blood supply to the hip joint area.
Figure 24. Anterior and posterior views of the arteries of the hip.
Venous flow in the hip and proximal femur typically follows the arterial flow, including the same names for the vessels. The deep veins of the hip and thigh can be the origination of a deep vein thrombosis, which can result in a pulmonary embolus. This can be caused by immobility after hip surgery, sitting in cars or airplanes for extended trips, being overweight, or slow or low blood flow. These blood clots can break off, travel through the larger veins of the thigh and hip, continue through the heart, and become lodged in the smaller vessels of the lung. MRI is being used more frequently to diagnose this very serious condition.
Bursae Of The Hips
The hip joint is surrounded by bursae, similar to the shoulder. These fluid-filled sacs are lined with a synovial membrane, which produces synovial fluid. Their function is to lessen the friction between tendon and bone, ligament and bone, tendons and ligaments, and between muscles. There may be as many as 20 bursae around the hip. If they become infected or inflamed, the result is a painful condition called bursitis. Common hip bursae that may become inflamed include the greater trochanteric bursa, the iliopsoas bursa, and the ischial bursa (Figure 25). The greater trochanteric bursa is sandwiched between the greater trochanter of the femur, and the muscles and tendons that cross over it. If this bursal sac becomes inflamed, patients experience pain with every step they take, as each step requires the tendon to move over the femur at the hip joint. A tight iliotibial band can also cause irritation of the greater trochanteric bursa. Iliopsoas bursitis can result from irritation of the bursa found between the hip joint and the iliopsoas muscle that passes in front of it. Another common site for bursitis is the ischial bursa, which acts as a lubricating pad between tendons and the ischial tuberosity, which is the bony prominence of the pelvis that you sit on. The ischial bursa acts to prevent destruction of the tendons as they move over the ischial tuberosity. Prolonged sitting can cause ischial bursitis. Inflammation around the ischial tuberosity can irritate the sciatic nerve, and trigger symptoms similar to sciatica. Hip bursitis is seen in runners and athletes in sports that involve excessive running (soccer, football, etc.). It can also be caused by an injury (traumatic bursitis), and is seen in post-op hip replacement and hip surgery patients. Treatment for hip bursitis typically includes rest, anti-inflammatory medications, and ice. It may become necessary to aspirate the bursa, which can be combined with a cortisone injection. MRI may be needed if the diagnosis is unclear, or if the problem does not resolve with normal treatments.
Figure 25. Bursae of the hip.
Axial Scans
When positioning unilateral axial slices for the hip, a coronal image can be used to ensure inclusion of all pertinent anatomy. The slices should extend superiorly to include the entire femoral head and acetabulum, and inferiorly to include anatomy below the lesser trochanter. The slices should be aligned perpendicular to the shaft of the femur, as seen in the coronal image in Figure 39.
Figure 39. Axial slice setup using sagittal and coronal images.
For bilateral axial hip slice setup, parameters may have to be altered to maintain adequate resolution with the larger FOV that is required (Figure 40). The slice group may require angulation to maintain alignment of the femoral heads on the resultant images.
Figure 40. Bilateral axial slice setup using a coronal image.
Coronal Scans
Coronal slices of the hip should cover the area from the posterior margin to the anterior margin of the femoral head. The area from the proximal margin of the femoral shaft to the greater sciatic notch should be included in the image (Figure 41). Slices may be angled so that they are parallel to the femoral neck. Thinner slices may be requested for coronal scanning.
Figure 41. Coronal slice setup using axial and sagittal images.
Sagittal Scans
Sagittal slices of the hip should extend past the greater trochanter laterally, and through the acetabulum medially. The slices should be aligned along the long axis of the femur, and perpendicular to the coronal slices, as seen in the coronal image in Figure 42. Two different slice groups will be necessary when performing bilateral sagittal scans.
Figure 42. Sagittal slice setup using coronal and axial images.
Hips Arthrography
MR hip arthrography is often times referred to as the gold standard for assessment of the labrum of the hip. The most clinically significant abnormal findings that result from hip arthrography are labral detachments and tears. Detachment of the labrum, which is more common than a labral tear, can be diagnosed from the appearance of the injected contrast at the acetabular-labral interface (Figure 43). A labral tear can result in injected contrast appearing within the substance of the labrum (Figure 44). Contrast injection is necessary to differentiate torn or detached labra from other pathologic conditions, which may have separate signal intensities. The sensitivity and accuracy for the diagnosis of labral tears and detachment with MR arthrography vs. nonarthrographic MR is 90%. Hip arthrography with MR can also depict intrarticular loose bodies, osteochondral abnormalities, and abnormalities of soft-tissue structures.
Hip arthrography can be performed under fluoro in the x-ray dept., with the patient being moved to the MRI dept. for further imaging, or the entire procedure can be performed in the MRI suite, if MR compatible supplies are available for interventional techniques. The patient should be securely positioned with the hips in internal rotation.
T1-weighted imaging is performed post-contrast to visualize the high signal of the intraarticular contrast. T1 gradient echo sequences offer the benefits of thin sections, elimination of partial volume averaging, and increased detection of small tears. Fatsat sequences are helpful in increasing the contrast between the injected contrast and the adjacent soft tissue. STIR or fatsat T2 sequences performed in the coronal plane may help to detect unsuspected pathologic conditions in the soft tissue and adjacent osseous structures.
Post-contrast axial oblique images have been shown to optimize the detection of the most common sports-related acetabular labral tears, which are anterior or anterosuperior in location. Using a mid-coronal localizer, the axial oblique slices should be prescribed parallel to the long axis of the femoral neck.
Figure 43. Labral detachment as seen in a fat-suppressed T1-wtd. sag. image; arrowheads indicate involvement of anterior and anterosuperior labrum.
Figure 44. Labral tear as seen in a T1-wtd. image; arrowheads indicate enlarged labrum; short arrow indicates linear intralabral collection of contrast material; long arrow indicates communication between the joint and the iliopsoas bursa.
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Acknowledging statistical data, low back pain can be the result of a variety of injuries and/or conditions affecting the lumbar spine and its surrounding structures. Most cases of low back pain, however, will resolve on their own in a matter of weeks. But when symptoms of low back pain become chronic, its essential for the affected individual to seek treatment from the most appropriate healthcare professional. The McKenzie method has been used by many healthcare specialists in the treatment of low back pain and its effects have been recorded widely throughout various research studies. The following two articles are being presented to evaluate the McKenzie method in the treatment of LBP in comparison to other types of treatment options.
Contents
Efficacy of the McKenzie Method in Patients With Chronic Nonspecific Low Back Pain: A Protocol of Randomized Placebo-Controlled Trial
Presented Abstract
Background: The McKenzie method is widely used as an active intervention in the treatment of patients with nonspecific low back pain. Although the McKenzie method has been compared with several other interventions, it is not yet known whether this method is superior to placebo in patients with chronic low back pain.
Objective: The purpose of this trial is to assess the efficacy of the McKenzie method in patients with chronic nonspecific low back pain.
Design: An assessor-blinded, 2-arm, randomized placebo-controlled trial will be conducted.
Setting: This study will be conducted in physical therapy clinics in S�o Paulo, Brazil.
Participants: The participants will be 148 patients seeking care for chronic nonspecific low back pain.
Intervention: Participants will be randomly allocated to 1 of 2 treatment groups: (1) McKenzie method or (2) placebo therapy (detuned ultrasound and shortwave therapy). Each group will receive 10 sessions of 30 minutes each (2 sessions per week over 5 weeks).
Measurements: The clinical outcomes will be obtained at the completion of treatment (5 weeks) and at 3, 6, and 12 months after randomization. The primary outcomes will be pain intensity (measured with the Pain Numerical Rating Scale) and disability (measured with the Roland-Morris Disability Questionnaire) at the completion of treatment. The secondary outcomes will be pain intensity; disability and function; kinesiophobia and global perceived effect at 3, 6, and 12 months after randomization; and kinesiophobia and global perceived effect at completion of treatment. The data will be collected by a blinded assessor.
Limitations: Therapists will not be blinded.
Conclusions: This will be the first trial to compare the McKenzie method with placebo therapy in patients with chronic nonspecific low back pain. The results of this study will contribute to better management of this population.
Subject:Therapeutic Exercise, Injuries and Conditions: Low Back, Protocols
Issue Section:Protocol
Low back pain is a major health condition associated with a high rate of absenteeism from work and a more frequent use of health services and work leave entitlements.[1] Low back pain recently was rated by the Global Burden of Disease Study as one of the 7 health conditions that most affect the world’s population,[2] and it is considered a debilitating health condition that affects the population for the greatest number of years over a lifetime.[2] The point prevalence of low back pain in the general population is reported to be up to 18%, increasing to 31% in the last 30 days, 38% in the last 12 months, and 39% at any point in life.[3] Low back pain also is associated with high treatment costs.[4] It is estimated that in European countries, the direct and indirect costs vary from �2 to �4 billion a year.[4] The prognosis of low back pain is directly related to the duration of the symptoms.[5,6] Patients with chronic low back pain have a less favorable prognosis compared with patients with acute low back pain[5,7] and are responsible for most of the costs for management of back pain, generating the need for research aimed at finding better treatments for these patients.
There is a great variety of interventions for the treatment of patients with chronic low back pain, including the McKenzie method developed by Robin McKenzie in New Zealand in 1981.[8] The McKenzie method (also known as Mechanical Diagnosis and Therapy [MDT]) is an active therapy that involves repeated movements or sustained positions and has an educational component with the purpose of minimizing pain and disability and improving spinal mobility.[8] The McKenzie method involves the assessment of symptomatic and mechanical responses to repeated movements and sustained positions. Patients’ responses to this assessment are used to classify them into subgroups or syndromes called derangement, dysfunction, and posture.[8�10] Classification according to one of these groups guides the treatment principles.
Derangement syndrome is the largest group and characterized by patients who demonstrate centralization (transition of pain from distal to proximal) or disappearance of pain[11] with repeated movement testing in one direction. These patients are treated with repeated movements or sustained positions that could reduce pain. Patients classified as having dysfunction syndrome are characterized by pain that occurs only at the end of the range of motion of only one movement.[8] The pain does not change or centralize with repeated movement testing. The treatment principle for patients with dysfunction is repeated movements in the direction that generated the pain. Finally, patients classified as having postural syndrome experience intermittent pain only during sustained positioning at the end of the range of motion (eg, sustained slumped sitting).[8] The treatment principle for this syndrome consists of posture correction.[11]
The McKenzie method also includes a strong educational component based on the books titled The Lumbar Spine: Mechanical Diagnosis & Therapy: Volume Two[11] and Treat Your Own Back.[12] This method, unlike other therapeutic methods, aims to make the patients as independent of the therapist as possible and thus capable of controlling their pain through postural care and the practice of specific exercises for their problem.[11] It encourages patients to move the spine in the direction that is not harmful to their problem, thus avoiding movement restriction due to kinesiophobia or pain.[11]
Two previous systematic reviews have analyzed the effects of the McKenzie method[9,10] in patients with acute, subacute, and chronic low back pain. The review by Clare et al[9] demonstrated that the McKenzie method showed better results in short-term pain relief and improvement of disability compared with active interventions such as physical exercise. The review by Machado et al[10] showed that the McKenzie method reduced pain and disability in the short term when compared with passive therapy for acute low back pain. For chronic low back pain, the 2 reviews were unable to draw conclusions about the effectiveness of the McKenzie method due to the lack of appropriate trials. The randomized controlled trials that have investigated the McKenzie method in patients with chronic low back pain[13�17] compared the method with other interventions such as resistance training,[17] the Williams method,[14] unsupervised exercises,[16] trunk strengthening,[15] and stabilization exercises.[13] Better results in reducing pain intensity were obtained with the McKenzie method compared with resistance training,[17] the Williams method,[14] and supervised exercise.[16] However, the methodological quality of these trials[13�17] is suboptimal.
It is known from the literature that the McKenzie method yields beneficial results when compared with some clinical interventions in patients with chronic low back pain; however, to date, no studies have compared the McKenzie method against a placebo treatment in order to identify its actual efficacy. Clare et al[9] highlighted the need to compare the McKenzie method with placebo therapy and to study the effects of the method in the long term. In other words, it is not known whether the positive effects of the McKenzie method are due to its real efficacy or simply to a placebo effect.
The objective of this study will be to assess the efficacy of the McKenzie method in patients with chronic nonspecific low back pain using a high-quality randomized placebo-controlled trial.
Method
Study Design
This will be an assessor-blinded, 2-arm, randomized placebo-controlled trial.
Study Setting
This study will be conducted in physical therapy clinics in S�o Paulo, Brazil.
Eligibility Criteria
The study will include patients seeking care for chronic nonspecific low back pain (defined as pain or discomfort between the costal margins and the inferior gluteal folds, with or without referred symptoms in the lower limbs, for at least 3 months[18]), with a pain intensity of at least 3 points as measured with the 0- to 10-point Pain Numerical Rating Scale, aged between 18 and 80 years, and able to read Portuguese. Patients will be excluded if they have any contraindication to physical exercise[19] or ultrasound or shortwave therapy, evidence of nerve root compromise (ie, one or more motor, reflex, or sensation deficits), serious spinal pathology (eg, fracture, tumor, inflammatory and infectious diseases), serious cardiovascular and metabolic diseases, previous back surgery, or pregnancy.
Procedure
First, the patients will be interviewed by the study’s blinded assessor, who will determine eligibility. Eligible patients will be informed about the objectives of the study and asked to sign a consent form. Next, the patient’s sociodemographic data and medical history will be recorded. The assessor will then collect the data related to the study outcomes at the baseline assessment, after completion of 5 weeks of treatment, and 3, 6, and 12 months after randomization. With the exception of baseline measurements, all other assessments will be collected over the telephone. All data entry will be coded, entered into an Excel (Microsoft Corporation, Redmond, Washington) spreadsheet, and double-checked prior to the analysis.
Outcome Measures
The clinical outcomes will be measured at the baseline assessment, after treatment, and 3, 6, and 12 months after random allocation. The primary outcomes will be pain intensity (measured with the Pain Numerical Rating Scale)[20] and disability (measured with the Roland-Morris Disability Questionnaire)[21,22] after completion of 5 weeks of treatment. The secondary outcomes will be pain intensity and disability 3, 6, and 12 months after randomization and disability and function (measured by the Patient-Specific Functional Scale),[20] kinesiophobia (measured with the Tampa Scale of Kinesiophobia),[23] and global perceived effect (measured with the Global Perceived Effect Scale)[20] after treatment and 3, 6, and 12 months after randomization. On the day of the baseline assessment, each patient’s expectancy for improvement also will be assessed using the Expectancy of Improvement Numerical Scale,[24] followed by assessment using the McKenzie method.[8] Patients may experience an exacerbation of symptoms after the baseline assessment due to the MDT physical examination. All measurements were previously cross-culturally adapted into Portuguese and clinimetrically tested and are described below.
Pain Numerical Rating Scale
The Pain Numerical Rating Scale is a scale that assesses the levels of pain intensity perceived by the patient using an 11-point scale (varying from 0 to 10), in which 0 represents �no pain� and 10 represents the �worst possible pain.�[20] The participants will be instructed to select the average of pain intensity based on the last 7 days.
Roland-Morris Disability Questionnaire
This questionnaire consists of 24 items that describe daily activities that patients have difficulty performing due to low back pain.[21,22] The higher the number of affirmative answers, the higher the level of disability associated with low back pain.[21,22] The participants will be instructed to complete the questionnaire based on the last 24 hours.
Patient-Specific Functional Scale
The Patient-Specific Functional Scale is a global scale; therefore, it can be used for any part of the body.[25,26] The patients will be asked to identify up to 3 activities that they feel unable to perform or that they have difficulty performing due to their low back pain.[25,26] Measurement will be taken using Likert-type, 11-point scales for each activity, with higher average scores (ranging from 0 to 10 points) representing better ability to perform the tasks.[25,26] We will calculate the average of these activities based on the last 24 hours, with a final score ranging from 0 to 10.
Global Perceived Effect Scale
The Global Perceived Effect Scale is a Likert-type, 11-point scale (ranging from ?5 to +5) that compares the patient’s current condition with his or her condition at the onset of symptoms.[20] Positive scores apply to patients who are better and negative scores apply to patients who are worse in relation to the onset of symptoms.[20]
Tampa Scale of Kinesiophobia
This scale assesses the level of kinesiophobia (fear of moving) by means of 17 questions that deal with pain and intensity of symptoms.[23] The scores from each item vary from 1 to 4 points (eg, 1 point for �strongly disagree,� 2 points for �partially disagree,� 3 points for �agree,� and 4 points for �strongly agree�).[23] For the total score, it is necessary to invert the scores of questions 4, 8, 12, and 16.[23] The final score can vary from 17 to 68 points, with higher scores representing a higher degree of kinesiophobia.[23]
Expectancy of Improvement Numerical Scale
This scale assesses the patient’s expectancy for improvement after treatment in relationship to a specific treatment.[24] It consists of an 11-point scale varying from 0 to 10, in which 0 represents �no expectancy for improvement� and 10 represents �expectancy for the greatest possible improvement.�[24] This scale will be administered only on the first day of assessment (baseline) before the randomization. The reason for including this scale is to analyze whether the expectation of improvement will influence the outcomes.
Random Allocation
Before the treatment begins, the patients will be randomly allocated to their respective intervention groups. The random allocation sequence will be implemented by one of the researchers not involved with recruiting and assessing the patients and will be generated on Microsoft Excel 2010 software. This random allocation sequence will be inserted into sequentially numbered, opaque, sealed envelopes (to ensure that allocation is concealed from the assessor). The envelopes will be opened by the physical therapist who will treat the patients.
Blinding
Given the nature of the study, it is not possible to blind the therapists to the conditions of treatment; however, the assessor and the patients will be blinded to the treatment groups. At the end of the study, the assessor will be asked whether the patients were allocated to the real treatment group or to the placebo group in order to measure assessor blinding. A visual representation of the study design is presented in the Figure.
Figure 1: Flow Diagram of the Study.
Interventions
The participants will be allocated to groups receiving 1 of 2 interventions: (1) placebo therapy or (2) MDT. Participants in each group will receive 10 sessions of 30 minutes each (2 sessions per week over 5 weeks). The studies on the McKenzie method do not have a standard number of sessions given that some studies propose low doses of treatment,[16,17,27] and others recommend higher doses.[13,15]
For ethical reasons, on the first day of treatment, patients from both groups will receive an information booklet called The Back Book,[28] based on the same recommendations as the existing guidelines.[29,30] This booklet will be translated into Portuguese so that it can be completely understood by the study’s participants, who will receive additional explanations regarding the content of the booklet, if needed. Patients will be asked in each session if they have felt any different symptom. The chief investigator of the study will periodically audit the interventions.
Placebo Group
The patients allocated to the placebo group will be treated with detuned pulsed ultrasound for 5 minutes and detuned shortwave diathermy in pulsed mode for 25 minutes. The devices will be used with the internal cables disconnected to obtain the placebo effect; however, it will be possible to handle them and adjust doses and alarms as if they were connected to simulate the pragmatism of clinical practice as well as to increase credibility of use of these devices on the patients. This technique has been used successfully in previous trials with patients with low back pain.[31�35]
McKenzie Group
The patients of the McKenzie group will be treated according to the principles of the McKenzie method,[8] and the choice of therapeutic intervention will be guided by the physical examination findings and classification. Patients also will receive written instructions from the Treat Your Own Back[12] book and will be asked to perform home exercises based on the principles of McKenzie method.[11] The descriptions of the exercises that will be prescribed in this study are published elsewhere.[27] Adherence to home exercises will be monitored by means of a daily log that the patient will fill in at home and bring to the therapist at each subsequent session.
Statistical Methods
Sample Size Calculation
The study was designed to detect a difference of 1 point in pain intensity measured with the Pain Numerical Rating Scale[20 ](estimate for standard deviation=1.84 points)[31] and a difference of 4 points in disability associated with low back pain measured with the Roland-Morris Disability Questionnaire[21,22] (estimate for standard deviation=4.9 points).[31] The following specifications were considered: statistical power of 80%, alpha level of 5%, and follow-up loss of 15%. Therefore, the study will require a sample of 74 patients per group (148 in total).
Analysis of the Effects of Treatment
The statistical analysis of our study will follow intention-to-treat principles.[36] The normality of the data will be tested by visual inspection of histograms, and the characterization of the participants will be calculated using descriptive statistical tests. The between-group differences (effects of treatment) and their respective 95% confidence intervals will be calculated by constructing mixed linear models[37] using interaction terms of treatment groups versus time. We will conduct a secondary exploratory analysis to assess whether patients classified as having derangement syndrome have a better response to the McKenzie method (compared with placebo) than those with other classifications. For this assessment, we will use a 3-way interaction for group, time, and classification. For all of these analyses, we will use the IBM SPSS software package, version 19 (IBM Corp, Armonk, New York).
Ethics
This study was approved by the Research Ethics Committee of the Universidade Cidade de S�o Paulo (#480.754) and prospectively registered at ClinicalTrials.gov (NCT02123394). Any protocol modifications will be reported to the Research Ethics Committee as well as to the trial registry.
Dr. Alex Jimenez’s Insight
Low back pain is one of the most common reasons people seek immediate medical attention for every year. Although many healthcare professionals are qualified and experienced in the diagnosis of the source of the patient’s low back pain, finding the right healthcare specialist who can provide the proper treatment for the individual’s LBP can be the real challenge. A variety of treatments can be used to treat low back pain, however, a wide array of healthcare professionals have started utilizing the McKenzie method in the treatment of patients with nonspecific low back pain. The purpose of the following article is to evaluate the effectiveness of the McKenzie method for low back pain, carefully analyzing the data of the research study.
Discussion
Potential Impact and Significance of the Study
The existing randomized controlled trials investigating the McKenzie method in patients with chronic low back pain have all used an alternative intervention as the comparison group.[14�17] To date, no study has compared the McKenzie method with a placebo treatment in patients with low back pain in order to identify its real efficacy, which is an important gap in the literature.[9] Interpretation of the previous comparative effectiveness studies is limited by the lack of knowledge of the efficacy of the McKenzie method for people with chronic low back pain. This study will be the first to compare McKenzie method with placebo therapy in patients with chronic nonspecific low back pain. A proper comparison against a placebo group will provide more unbiased estimates of the effects of this intervention. This type of comparison has already been done in trials aiming to assess the efficacy of motor control exercises for patients with chronic low back pain,[31] spinal manipulative therapy and diclofenac for patients with acute low back pain,[38] and exercise and advice for patients with subacute low back pain.[39]
Contribution to the Physical Therapy Profession and for Patients
The McKenzie method is one of the few methods used in physical therapy that advocates for the independence of patients.[8,12] This method also provides patients with tools to promote their autonomy in managing the current pain and even future recurrences.[12] We expect that patients treated with the McKenzie method will benefit more than the patients treated with the placebo treatment. If this hypothesis is confirmed in our study, the results will contribute to better clinical decision making of physical therapists. Moreover, the approach has the potential to reduce the burden associated with the recurrent nature of low back pain if patients can better self-manage future episodes.
Strengths and Weaknesses of the Study
This trial contemplates a substantial number of patients to minimize bias, and it was prospectively registered. We will use true randomization, concealed allocation, blinded assessment, and an intention-to-treat analysis. The treatments will be conducted by 2 therapists who were extensively trained to perform the interventions. We will monitor the home exercise program. Unfortunately, due to the interventions, we will not be able to blind the therapists to the treatment allocation. It is known from the literature that the McKenzie method yields beneficial results when compared with some clinical interventions in patients with chronic low back pain.[14�17] To date, however, no studies have compared the McKenzie method with a placebo treatment in order to identify its actual efficacy.
Future Research
The intention of this study group is to submit the results of this study to a top-level, international peer-reviewed journal. These published results may provide a basis for future trials that investigate the effectiveness of the McKenzie method when delivered at different doses (different numbers of sets, repetitions, and sessions), which is still unclear in the literature. Our secondary exploratory analysis aims to assess whether patients classified as having derangement syndrome have a better response to the McKenzie method (compared with placebo treatment) than those with other classifications. This assessment will contribute to a better understanding of possible subgroups of patients with chronic low back pain who respond best to specific interventions. This is an important issue, as exploring subgroups is currently considered the most important research priority in the field of low back pain.[40]
This study was fully funded by S�o Paulo Research Foundation (FAPESP) (grant number 2013/20075-5). Ms Garcia is funded by a scholarship from the Coordination for the Improvement of Higher Education Personnel/Brazilian Government (CAPES/Brazil).
The study was prospectively registered at ClinicalTrials.gov (trial registration: NCT02123394).
Predicting a Clinically Important Outcome in Patients with Low Back Pain Following McKenzie Therapy or Spinal Manipulation: A Stratified Analysis in a Randomized Controlled Trial
Presented Abstract
Background: Reports vary considerably concerning characteristics of patients who will respond to mobilizing exercises or manipulation. The objective of this prospective cohort study was to identify characteristics of patients with a changeable lumbar condition, i.e. presenting with centralization or peripheralization, that were likely to benefit the most from either the McKenzie method or spinal manipulation.
Methods: 350 patients with chronic low back pain were randomized to either the McKenzie method or manipulation. The possible effect modifiers were age, severity of leg pain, pain-distribution, nerve root involvement, duration of symptoms, and centralization of symptoms. The primary outcome was the number of patients reporting success at two months follow-up. The values of the dichotomized predictors were tested according to the prespecified analysis plan.
Results: No predictors were found to produce a statistically significant interaction effect. The McKenzie method was superior to manipulation across all subgroups, thus the probability of success was consistently in favor of this treatment independent of predictor observed. When the two strongest predictors, nerve root involvement and peripheralization, were combined, the chance of success was relative risk 10.5 (95% CI 0.71-155.43) for the McKenzie method and 1.23 (95% CI 1.03-1.46) for manipulation (P?=?0.11 for interaction effect).
Conclusions: We did not find any baseline variables which were statistically significant effect modifiers in predicting different response to either McKenzie treatment or spinal manipulation when compared to each other. However, we did identify nerve root involvement and peripheralization to produce differences in response to McKenzie treatment compared to manipulation that appear to be clinically important. These findings need testing in larger studies.
Electronic supplementary material: The online version of this article (doi:10.1186/s12891-015-0526-1) contains supplementary material, which is available to authorized users.
Keywords:Low back pain, McKenzie, Spinal manipulation, Predictive value, Effect modification
Background
The most recent published guidelines for the treatment of patients with persistent non-specific low back pain (NSLBP) recommend a program focusing on self-management after initial advice and information. These patients should also be offered structured exercises tailored to the individual patient and other modalities such as spinal manipulation [1,2].
Previous studies have compared the effect of the McKenzie-method, also known as Mechanical Diagnosis and Therapy (MDT), with that of spinal manipulation (SM) in heterogeneous populations of patients with acute and subacute NSLBP and found no difference in outcome [3,4].
Recently, the need for studies testing the effect of treatment strategies for subgroups of patients with NSLBP in primary care has been emphasized in consensus-papers [5,6] as well as the current European guidelines [7], based on the hypothesis that subgroup analyses, preferably complying with the recommendations of �Prognostic Factor Research�[8], will improve decision making towards the most effective management strategies. Although initial data show promising results, there is presently insufficient evidence to recommend specific methods of subgrouping in primary care [1,9].
Three randomized studies, comprising patients with predominantly acute or subacute low back pain (LBP), have tested the effects of MDT versus SM in a subgroup of patients that presented with centralization of symptoms or directional preference (favorable response to end range motions) during physical examination [10-12]. The conclusions drawn from these studies were not in concurrence and the usefulness was limited by a low methodological quality.
Our recent randomized study, comprising patients with predominantly chronic LBP (CLBP), found a marginally better overall effect of MDT versus SM in an equivalent group [13]. In order to pursue the idea of subgrouping further, it was part of the study plan to explore predictors based on patient characteristics that could assist the clinician in targeting the most favorable treatment to the individual patient.
The objective of this study was to identify subgroups of patients with predominantly CLBP, presenting with centralization or peripheralization, which were likely to benefit from either MDT or SM two months after the completion of treatment.
Methods
Data Collection
The present study is a secondary analysis of a previously published randomized controlled trial [13]. We recruited 350 patients from September 2003 through May 2007 at an outpatient back care centre in Copenhagen, Denmark.
Patients
Patients were referred from primary care physicians for treatment of persistent LBP. Eligible patients were between 18 and 60 years of age, suffering from LBP with or without leg pain for a period of more than 6 weeks, able to speak and understand the Danish language, and fulfilled the clinical criteria for centralization or peripheralization of symptoms during initial screening. Centralization was defined as the abolition of symptoms in the most distal body region (such as the foot, lower leg, upper leg, buttocks, or lateral low back) and peripheralization was defined as the production of symptoms in a more distal body region. These findings have previously been found to have acceptable degree of inter-tester reliability (Kappa value 0.64) [14]. The initial screening was performed prior to randomization by a physical therapist with a diploma in the MDT examination system. Patients were excluded if they were free of symptoms at the day of inclusion, demonstrated positive non-organic signs [15], or if serious pathology, i.e. severe nerve root involvement (disabling back or leg pain in combination with progressive disturbances in sensibility, muscle strength, or reflexes), osteoporosis, severe spondylolisthesis, fracture, inflammatory arthritis, cancer, or referred pain from the viscera, was suspected based on physical examination and/or magnetic resonance imaging. Other exclusion criteria were application for disability pension, pending litigation, pregnancy, co-morbidity, recent back surgery, language problems, or problems with communication including abuse of drugs or alcohol.
The trial population had predominantly CLBP lasting on average 95 weeks (SD 207), mean age was 37 years (SD10), mean level of back and leg pain was 30 (SD 11.9) on a Numeric Rating Scale ranging from 0 to 60, and mean level of disability was 13 (SD 4.8) on Roland Morris Disability Questionnaire (0-23). Our method of pain measurement reflects that back pain is often a fluctuating condition where pain location and severity might vary on a daily basis. Therefore, a validated comprehensive pain questionnaire [16] was used in order to guarantee that all aspects of back and leg pain intensity were recorded. The scales are outlined in the legend to Table 1.
After baseline measures were obtained, randomisation was carried out by a computer-generated list of random numbers in blocks of ten using sealed opaque envelopes.
Ethics
Ethical approval of the study was granted by Copenhagen Research Ethics Committee, file no 01-057/03. All patients received written information about the study and gave their written consent prior to participation.
Treatments
The practitioners performing the treatments had no knowledge of the results of the initial screening. The treatment programs were designed to reflect daily practice as much as possible. Detailed information on these programs have been published earlier [13].
The MDT treatment was planned individually following the therapist�s pre-treatment physical assessment. Specific manual vertebral mobilization techniques including high velocity thrust were not allowed. An educational booklet describing self care [17] or a �lumbar roll� for correction of the seated position was sometimes provided to the patient at the discretion of the therapist. In the SM treatment, high velocity thrust was used in combination with other types of manual techniques. The choice of combination of techniques was at the discretion of the chiropractor. General mobilizing exercises, i.e. self-manipulation, alternating lumbar flexion/extension movements, and stretching, were allowed but not specific exercises in the directional preference. An inclined wedged pillow for correction of the seated position was available to the patients if the chiropractor believed this to be indicated.
In both treatment groups, patients were informed thoroughly of the results of the physical assessment, the benign course of back pain, and the importance of remaining physically active. Guidance on proper back care was also given. In addition, all patients were provided with a Danish version of �The Back Book� which previously has been shown to have beneficial effect on patients� beliefs about back pain [18]. A maximum of 15 treatments for a period of 12 weeks were given. If considered necessary by the treating clinician, patients were educated in an individual program of self-administered mobilizing, stretching, stabilizing, and/or strengthening exercises at the end of the treatment period. Treatments were performed by clinicians with several years of experience. Patients were instructed to continue their individual exercises at home or at a gym for a minimum of two months after completion of the treatment at the back center. Because the patients suffered predominantly from CLBP we expected this period of self administered exercises to be necessary for the patients to experience the full effect of the intervention. Patients were encouraged not to seek any other kind of treatment during this two months period of self-administered exercises.
Outcome Measures
The primary outcome was the proportion of patients reporting success at follow-up two months after end of treatment. Treatment success was defined as a reduction of at least 5 points or a final score below 5 points on the 23-item modified Roland Morris Disability Questionnaire (RMDQ) [19]. A validated Danish version of RMDQ was used [20]. The definition of treatment success was based on the recommendations by others [21,22]. A sensitivity analysis using 30% relative improvement on RMDQ as definition of success was also performed. In accordance with the protocol [13], we considered a relative between-group difference of 15% in the number of patients with successful outcome to be minimal clinically important in our analysis of interaction.
Prespecified Predictor Variables
In order to reduce the likelihood of spurious findings [23], we restricted the number of candidate effect modifiers in the dataset to six. To increase the validity of our findings, a directional hypothesis was established for each variable according to the recommendations of Sun et al. [24] Four baseline variables have previously been suggested in randomized studies to be predictive of long term good outcome in patients with persistent LBP following MDT in comparison with strengthening training: centralization [25,26], or following SM in comparison to physiotherapy or treatment chosen by a general practitioner: age below 40 years [27,28], duration of symptoms more than 1 year [27], and pain below the knee [29]. As recommended by others [30], another two variables were added based on the participating experienced clinicians� judgments of which characteristics they would expect to predict good outcome from their treatment compared to the other. The additional variables prioritized by the physiotherapists in the MDT group were signs of nerve root involvement and substantial leg pain. The additional variables prioritized by the chiropractors in the SM group were no signs of nerve root involvement and not substantial leg pain.
In a supplementary analysis, we took the opportunity to explore whether the inclusion of further six baseline variables, assumed to have prognostic value for good outcome in either of the treatment groups, would appear to have an effect modifying effect as well. To our knowledge, no further variables from previous one arm studies have been reported to have prognostic value of long term good outcome in patients with persistent LBP following MDT, whereas three variables have been reported to have prognostic value following SM: male gender [28], mild disability [28], and mild back pain [28]. Another three variables were agreed upon by the clinicians to be included in the supplementary analysis as they were assumed by experience from clinical practice to have prognostic value for good outcome regardless of treatment with MDT or SM: low number of days on sick leave past year, high patient expectations to recovery, and high patient expectations about coping with work tasks six weeks after initiation of treatment.
Dichotomization of possible predictor variables were made to allow for comparisons to be made with those of earlier studies. In cases where no cut off values could be found in the literature, dichotomization was performed above/below the median found in the sample. Definitions of variables are presented in the legend to Table 1.
Statistics
The entire intention-to-treat (ITT) population was used in all the analyses. The last score was carried forward for subjects with missing two months RMDQ scores (7 patients in the MDT group and 14 patients in the SM group). In addition, a post hoc per protocol analysis was carried out comprising only those 259 patients that completed the full treatment. The analysis plan was agreed in advance by the trial management group.
The possible predictors were dichotomized and the chance of success was investigated by estimating the relative risk (RR) of success in each of the two strata. The impact of the investigated predictors was estimated by comparing the chance of success between the treatment groups when divided into the two strata. To test for treatment effect modification of the predictors we performed chi-squared tests for interaction between intervention and the two different strata for each of the predictors. This is basically the same as an interaction from a regression model. Confidence intervals were also inspected for potential clinically important effects.
Following the univariate analysis, a multivariate analysis was planned including effect modifiers with a p-value below 0.1.
Dr. Alex Jimenez’s Insight
Low back pain can occur due to several types of injuries and/or conditions and its symptoms may be acute and/or chronic. Patients with low back pain can benefit from a variety of treatments, including chiropractic care. Chiropractic treatment is one of the most common alternative treatment options utilized to treat low back pain. According to the article, the results of the improvement of LBP with spinal adjustments and manual manipulations, along with the use of exercise, vary considerably among the participants. The focus of the following research study is to determine which patients are most likely to benefit from the McKenzie method as compared to spinal adjustments and manual manipulations.
Results
Participants were similar with respect to socio-demographic and clinical characteristics at baseline in the treatment groups. An overview of the distribution of the included dichotomized variables at baseline is provided in Table 1. No differences were found between the treatment groups.
Overall, the post hoc per protocol analysis did not produce outcome results that were different from the results of the ITT analysis and therefore only the results of the ITT analysis will be reported.
Figure 1 presents the distribution of predictors with regards to effect modification in the MDT group versus SM. In all subgroups, the probability of success with MDT was superior to that of SM. Because of low sample size, confidence intervals were wide and none of the predictors had a statistically significant treatment modifying effect. The predictors with a clinically important potential effect in favor of MDT compared to SM were nerve root involvement (28% higher proportion of patients with success when nerve root involvement was present than when absent) and peripheralization of symptoms (17% higher proportion of patients with success in case of peripheralization than in case of centralization). If present, nerve root involvement increased the chance of success following MDT 2.31 times compared to that of SM and 1.22 times if not present. This means that for the subgroup of patients with nerve root involvement receiving MDT, compared to those receiving SM, the relative effect appeared to be 1.89 times (2.31/1.22, P?= 0.118) higher than for the subgroup with no nerve root involvement.
Figure 1: Treatment effect modified by predictors. The top point estimate and confidence intervals indicate overall effect without subgrouping. Subsequent pairs of point estimates and confidence intervals show the chances of treatment success.
Figure 2 presents the modifying effect of a composite of the two predictors with a clinically important potential effect. If signs of nerve root involvement and peripheralization were present at baseline, the chance of success with MDT compared to SM appeared 8.5 times higher than for the subgroup with no centralization and nerve root involvement. The number of patients was very small and the differences were not statistically significant (P?=?0.11).
Figure 2: Impact of the two clinically important predictors combined on treatment effect. RR?=?Relative Risk with Yates correction.
None of the prognostic candidate variables explored in the supplementary analysis appeared to have any clinically important modifying effect (Additional file 1: Table S1).
The results from the sensitivity analysis using 30% relative improvement on RMDQ as definition of success were not markedly different from those presented above (Additional file 2: Table S2).
Discussion
To our knowledge, this is the first study trying to identify effect modifiers when two mobilizing strategies, i.e. MDT and SM, are compared in a sample of patients with as changeable condition characterized by centralization or peripheralization.
Our study found that none of the potential effect modifiers were able to statistically significantly increase the overall effect of MDT compared to that of SM. However, the between-group difference for two of the variables exceeded our clinically important success-rate of 15% in number of patients with successful outcome, so our study is likely to have missed a true effect and, in that sense, did not have a large enough sample size.
The most apparent finding is that in our small subgroup of patients with signs of nerve root involvement, the relative chance of success appeared 1.89 times (2.31/1.22) higher than in patients with no nerve root involvement when treated with MDT, compared to those treated with SM. The difference was in the expected direction.
Although not statistically significant in our small sample, the variable peripheralization exceeded our clinically important success-rate of 15%, but was found not to be in the expected direction. No previous studies have assessed the effect modification of centralization or peripheralization in patients with CLBP. The RCT by Long et al. [25,26] concluded that patients with directional preference, including centralization, fared better 2 weeks after baseline than patients with no directional preference when treated with MDT in comparison with strengthening training. However, the outcome among peripheralizers was not reported, so the poor outcome reported in patients with no directional preference might be related to the subgroup of patients who responded with no change in symptoms during initial examination and not to those that responded with peripheralization. An alternative explanation might be that the effect modifying impact of centralization or peripheralization on MDT is dependent on the control treatment. Our findings suggest that future studies in this area need to involve predictive value of peripheralization as well as centralization.
When a composite of the two most promising predictors, peripheralization and signs of nerve root involvement, were present at baseline, the relative chance of success with MDT compared to SM appeared 8.5 times higher than for the subgroup with no centralization and nerve root involvement. The number of patients was very small and the confidence interval was wide. Therefore only a preliminary conclusion about interaction can be drawn and it calls for a validation in future studies.
In our study, there appeared to be no characteristic by which SM had better results compared to MDT. Thus, we could not support the results of two studies with a similar design as ours (two arms, sample of patients with persistent LBP, and outcome reported in terms of reduction of disability at long term follow up) [27,29]. In those studies, Nyiendo et al. [29] found a modifying effect of leg pain below knee on treatment by SM compared to that of the general practitioner six months after baseline, and Koes et al. [27] found a modifying effect of age below 40 years and symptom duration more than a year on treatment by SM compared to that of physiotherapy 12 months after baseline. However, results from those, as well as other previous RCTs comprising patients with persistent LBP, have supported our findings regarding the lack of effect modification of age [27,29,31], sex [29,31], baseline disability [27,29,31], and duration of symptoms [31], on SM when measured on reduction of disability 6-12 months after randomization. So, although evidence is emerging in patients with acute LBP regarding subgroup characteristics predictive of better results from SM compared to other types of treatment [32], we are still in the dark with respect to patients with persistent LBP.
The usefulness of choosing a criterion for success by combining an improvement of at least 5 points or an absolute score below 5 points on RMDQ is debatable. A total of 22 patients were considered successful based on score below 5 at follow up without having an improvement of at least 5 points. We therefore performed a sensitivity analysis using a relative improvement of at least 30% as criterion of success as recommended by others [22] (see Additional file 2: Table S2). As a result, the percentage of patients with successful outcome in the MDT group remained the same whereas 4 more patients were defined as successes in the SM group. Overall the sensitivity analysis did not produce outcome results that were markedly different from those of the primary analysis and therefore only those have been discussed above.
Strengths and Limitations
This study used data from a RCT, whereas many others have used single arm designs not suitable for the purpose of evaluating treatment effect modification [33]. In accordance with the recommendations by the PROGRESS group [8] we prespecified the possible predictors and also the direction of the effect. Furthermore, we limited the number of predictors included in order to minimize the chance of spurious findings.
The main limitation in secondary studies to previously conducted RCTs is that they are powered to detect overall treatment effect rather that effect modification. In recognition of the post hoc nature of our analysis, reflected in wide confidence intervals, we must emphasize that our findings are exploratory and require formal testing in a larger sample size.
Conclusions
In all subgroups, the probability of success with MDT was superior to that of SM. Although not statistically significant, the presence of nerve root involvement and peripheralization appear promising effect modifiers in favour of MDT. These findings need testing in larger studies.
Acknowledgements
The authors thank Jan Nordsteen and Steen Olsen for clinical expert advice, and Mark Laslett for comments and language correction.
This study was in part supported by grants from The Danish Rheumatism Association, The Danish Physiotherapy Organization, The Danish Foundation for Chiropractic Research and Continuous Education, and The Danish Institute for Mechanical Diagnosis and Therapy. RC/The Parker Institute acknowledge the funding support from the Oak Foundation. The funds were independent of the management, analyses, and interpretation of the study.
Footnotes
Competing interests: The authors declare that they have no competing interests.
Authors� contributions: All authors were involved in the data analysis and the writing process, and the requirements for authorship have been met. All analyses were conducted by TP, RC, and CJ. TP conceived and led the study and was responsible for writing the first draft of the paper, but the other authors have participated throughout the writing process and have read and approved the final version.
In conclusion,�the above two articles were presented in order to evaluate the McKenzie method in the treatment of LBP in comparison to other types of treatment options. The first research study compared the McKenzie method with placebo therapy in patients with low back pain, however, the results of the study still need additional evaluations. In the second research study, no significant results could predict a different response in the use of the McKenzie method. 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
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31. Underwood MR, Morton V, Farrin A. Do baseline characteristics predict response to treatment for low back pain? Secondary analysis of the UK BEAM dataset. Rheumatology (Oxford) 2007;46(8):1297�302. doi: 10.1093/rheumatology/kem113. [PubMed] [Cross Ref]
32. Slater SL, Ford JJ, Richards MC, Taylor NF, Surkitt LD, Hahne AJ. The effectiveness of sub-group specific manual therapy for low back pain: a systematic review. Man Ther. 2012;17(3):201�12. doi: 10.1016/j.math.2012.01.006. [PubMed] [Cross Ref]
33. Stanton TR, Hancock MJ, Maher CG, Koes BW. Critical appraisal of clinical prediction rules that aim to optimize treatment selection for musculoskeletal conditions. Phys Ther. 2010;90(6):843�54. doi: 10.2522/ptj.20090233. [PubMed] [Cross Ref][/accordion]
[/accordions]
Additional Topics: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
Low back pain, or LBP, is a very common condition which affects the lumbar spine, or the lower section of the spine. Approximately more than 3 million cases of LBP are diagnosed in the United States aline every year and about 80 percent of adults worldwide experience low back pain at some point during their lifetime. Low back pain is generally caused by injury to a muscle (strain) or ligament (sprain) or due to damage from a disease. Common causes of LBP include poor posture, lack of regular exercise,�improper lifting, fracture, herniated discs and/or arthritis. Most cases of low back pain may often go away on their own, however, when LBP becomes chronic, it may be important to seek immediate medical attention. Two therapeutic methods have been utilized to improve LBP. The following article compares the effects of Pilates and McKenzie training on LBP.
Contents
A Comparison of the Effects of Pilates and McKenzie Training on Pain and General Health in Men with Chronic Low Back Pain: A Randomized Trial
Abstract
Background: Today, chronic low back pain is one of the special challenges in healthcare. There is no unique approach to treat chronic low back pain. A variety of methods are used for the treatment of low back pain, but the effects of these methods have not yet been investigated adequately.
Aim: The aim of this study was to compare the effects of Pilates and McKenzie training on pain and general health of men with chronic low back pain.
Materials and Methods: Thirty-six patients with chronic low back pain were chosen voluntarily and assigned to three groups of 12 each: McKenzie group, Pilates group, and control group. The Pilates group participated in 1-h exercise sessions, three sessions a week for 6 weeks. McKenzie group performed workouts 1 h a day for 20 days. The control group underwent no treatment. The general health of all participants was measured by the General Health Questionnaire 28 and pain by the McGill Pain Questionnaire.
Results: After therapeutic exercises, there was no significant difference between Pilates and McKenzie groups in pain relief (P = 0.327). Neither of the two methods was superior over the other for pain relief. However, there was a significant difference in general health indexes between Pilates and McKenzie groups.
Conclusion: Pilates and McKenzie training reduced pain in patients with chronic low back pain, but the Pilates training was more effective to improve general health.
Keywords:Chronic back pain, general health, Mckenzie training, pain, Pilates training
Introduction
Low back pain with a history of more than 3 months and without any pathological symptom is called chronic low back pain. For patient with chronic low back pain, the physician should take into consideration the likelihood of muscle pain development with spinal origin, in addition to low back pain with unknown origin. This type of pain may be mechanical (increase in pain with movement or physical pressure) or nonmechanical (increase in pain at the rest time).[1] Low back pain or spine pain is the most common musculoskeletal complication.[2] About 50%�80% of healthy people may experience low back pain during their lifetime, and about 80% of the problems are related to the spine and occur in the lumbar area.[3] Low back pain may be caused by trauma, infection, tumors, etc.[4] Mechanical injuries which are caused by overuse of a natural structure, deformity of an anatomical structure, or the injury in the soft tissue are the most common reasons for back pain. From occupational health perspective, back pain is among the most important reasons for the absence from work and occupational disability;[5] in fact, the longer the period of disease,[6] the less likely it is to improve and return to work.[1] Disability due to low back pain in addition to disturbance in doing daily and social activities has a very negative effect, from social and economic perspectives, on the patient and the community, which makes chronic low back pain highly important.[3] Today, chronic low back pain is one of the critical challenges in medicine. Patients with chronic low back pain are responsible for 80% of the costs paid for the treatment of low back pain that is also the reason for mobility restrictions in most people under 45 years.[7] In the developed countries, the overall cost paid for low back pain per year is 7.1 of total share of the gross national product. Clearly, most of the cost is related to counseling and treatment of patients with chronic low back pain rather than with intermittent and recursive low back pain.[8] The existence of various methods of treatment is because of no single cause of low back pain.[9] A variety of methods such as pharmacotherapy, acupuncture, infusions, and physical methods are the most common interventions for treatment of low back pain. However, the effects of these methods remain to be fully known.[6] An exercise program, developed based on the physical conditions of patients, can promote the quality of life in patients with chronic disease.[10,11,12,13,14]
Literature shows that the effect of exercise in controlling chronic low back pain is under study and there is strong evidence about the fact that movement therapy is effective to treat low back pain.[15] However, no specific recommendations exist about the type of exercise, and the effects of certain types of movement therapies have been determined in few studies.[9] Pilates training consists of the exercises that focus on improving flexibility and strength in all the body organs, without increasing the mass of muscles or destroying them. This training method consists of controlled movements that form a physical harmony between the body and brain, and can raise the ability of the body of people at any age.[16] In addition, people who do Pilates exercise would have better sleep and less fatigue, stress, and nervousness. This training method is based on standing, sitting, and lying positions, without intervals, jumping, and leaping; thus, it may reduce injuries resulting from the joint damage because the exercise movements in the ranges of motion in the above three positions are performed with deep breathing and muscle contraction.[17] McKenzie method, also called mechanical diagnosis and therapy and based on the patient’s active participation, is used and trusted by patients and the people who use this method worldwide. This method is based on physical therapy which has been frequently studied. The distinctive characteristic of this method is the principle of initial assessment.[18] This principle is a reliable and safe method to make a diagnosis that makes the correct treatment planning possible. In this way, the time and energy are not spent for costly tests, rather McKenzie therapists, using a valid indicator, quickly recognize that how much and how this method is fruitful for the patient. More appropriately, McKenzie method is a comprehensive approach based on the correct principles whose full understanding and following is very fruitful.[19] In the recent years, non-pharmacological approaches have attracted the attention of physicians and patients with low back pain.[20] Complementary therapies[21] and treatments with holistic nature (to increase physical and mental well-being) are appropriate to manage physical illness.[13] Complementary therapies can slow down disease progression and improve capacity and physical performance. The aim of the present study is to compare the effect of the Pilates and McKenzie training on pain and general health in men with chronic low back pain.
Materials and Methods
This randomized clinical trial was conducted in Shahrekord, Iran. The total study population screened was 144. We decided to enroll at least 25% of the population, 36 individuals, using a systematic random sampling. First, the participants were numbered and a list was developed. The first case was selected using random number table and then one out of four patients was randomly enrolled. This process continued till a desired number of participants were enrolled. Then, the participants were randomly assigned to experimental (Pilates and McKenzie training) groups and control group. After explaining the research purposes to the participants, they were asked to complete the consent form for participation in the study. Furthermore, the patients were ensured that the research data are kept confidential and used only for research purposes.
Inclusion Criteria
The study population included men aged 40�55 years in Shahrekord, South-West Iran, with chronic back pain, that is, history of more than 3 months of low back pain and no specific disease or other surgery.
Exclusion Criteria
The exclusion criteria were low back arch or so-called army back, serious spinal pathology such as tumors, fractures, inflammatory diseases, previous spinal surgery, nerve root compromise in the lumbar region, spondylolysis or spondylolisthesis, spinal stenosis, neurological disorders, systemic diseases, cardiovascular diseases, and receiving other therapies simultaneously. The examiner who assessed the outcomes was blinded to group assignment. Twenty-four hours before the training, a pretest was administered to all three groups to determine pain and general health; and then, the training began after completion of the McGill Pain Questionnaire (MPQ) and the General Health Questionnaire-28 (GHQ-28). The MPQ can be used to evaluate a person experiencing significant pain. It can be used to monitor the pain over time and to determine the effectiveness of any intervention. Minimum pain score: 0 (would not be seen in a person with true pain), maximum pain score: 78, and the higher the pain score the more severe the pain. Investigators reported that the construct validity and the reliability of the MPQ were reported as a test-retest reliability of 0.70.[22] The GHQ is a self-administered screening questionnaire. Test-retest reliability has been reported to be high (0.78�0 0.9) and inter- and intra-rater reliability have both been shown to be excellent (Cronbach’s ? 0.9�0.95). High internal consistency has also been reported. The lower the score is, the better the general health is.[23]
The participants in the experimental groups started training program under supervision of a sports medicine specialist. The training program consisted of 18 sessions of supervised individual training for both groups, with the sessions held three times per week for 6 weeks. Each training session lasted for an hour and was performed at the Physiotherapy Clinic in the School of Rehabilitation of the Shahrekord University of Medical Sciences in 2014�2015. The first experimental group performed Pilates training for 6 weeks, three times a week about an hour per session. In each session, first, a 5-min warm-up and preparation procedures were run; and at the end, stretching and walking were done to return to the baseline condition. In the McKenzie group, six exercises were used: Four extension-type exercises and two flexion-types. The extension-type exercises were performed in prone and standing positions, and the flexion-type exercises in the supine and sitting positions. Each exercise was run ten times. In addition, the participants conducted twenty daily individual training sessions for an hour.[18] After training of both groups, the participants filled out the questionnaires and then the collected data were presented in both descriptive and inferential statistics. Furthermore, the control group without any training, at the end of a period when other groups have completed, filled the questionnaire. Descriptive statistics were used for central tendency indicators such as mean (� standard deviation) and relevant diagrams were used to describe the data. Inferential statistics, one-way ANOVA and post hoc Tukey’s test, were used to analyze the data. Data analysis was done by SPSS Statistics for Windows, Version 21.0 (IBM Corp. Released 2012. IBM Armonk, NY: IBM Corp). P < 0.05 was considered statistically significant.
Dr. Alex Jimenez’s Insight
Alongside the use of spinal adjustments and manual manipulations for low back pain, chiropractic care commonly utilizes therapeutic exercise methods to improve LBP symptoms, restoring the affected individual’s strength, flexibility and mobility as well as promoting a faster recovery. The Pilates and McKenzie method of training, as mentioned in the article, are compared to determine which therapeutic exercise is best for treating low back pain. As�a Level I Certified Pilates Instructor, Pilates training is implemented with chiropractic treatment to improve LBP more effectively. Patients participating in a therapeutic exercise method alongside a primary form of treatment for low back pain can experience additional benefits. McKenzie training can also be implemented with chiropractic treatment to further improve LBP symptoms. The purpose of this research study is to demonstrate evidence-based information on the benefits of Pilates and McKenzie methods for low back pain as well as to educate patients on which of the two therapeutic exercises should be considered to help treat their symptoms and achieve overall health and wellness.
Level I Certified Pilates Instructors at Our Location
Dr. Alex Jimenez D.C., C.C.S.T | Chief Clinical Director and Level I Certified Pilates Instructor
Truide Torres | Director of Patient Relations Advocate Dept. and Level I Certified Pilates Instructor
Results
The results showed no significant difference between the case and control groups regarding the gender, marital status, job, educational level, and income. The results showed changes in pain index and general health in the participants before and after Pilates and McKenzie training in the two experimental and even control groups [Table 1].
A significant difference was seen in pain and general health between the control and the two experimental groups at the pre- and post-test, so that the exercise training (both Pilates and McKenzie) resulted in reduced pain and promoted general health; while in the control group, pain increased and general health declined.
Discussion
The results of this study indicate that back pain reduced and general health enhanced after exercise therapy with both Pilates and McKenzie training, but in the control group, pain was intensified. Petersen et al. study on 360 patients with chronic low back pain concluded that at the end of 8 weeks of McKenzie training and high-intensity endurance training and 2 months training at home, pain and disability decreased in McKenzie group at the end of 2 months, but at the end of 8 months, no differences were seen among the treatments.[24]
The results of another study show that McKenzie training is a beneficial method for reducing pain and increasing the movements of the spine in patients with chronic low back pain.[18] Pilates training can be an effective method for improving general health, athletic performance, proprioception, and reduction of pain in patients with chronic low back pain.[25] The improvements in strength seen in the participants in the present study were more likely to be due to decrease in pain inhibition than to neurological changes in muscle firing/recruitment patterns or to morphological (hypertrophic) changes in the muscle. In addition, neither of the treatments was superior over the other in view of reducing the intensity of pain. In the present study, 6 weeks of McKenzie training led to significant reduction in pain levels in men with chronic low back pain. The rehabilitation of patients with chronic low back pain is aimed to restore strength, endurance, and flexibility of soft tissues.
Udermann et al. showed that McKenzie training improved pain, disability, and psychosocial variables in patients with chronic low back pain, and back stretching training did not have any additional effect on pain, disability, and psychosocial variables.[26] The results of another study show that there is a reduction in pain and disability due to McKenzie method for at least 1 week in comparison with the passive treatment in patients with low back pain, but reduction in pain and disability due to McKenzie method in comparison with the active treatment methods is desirable within 12 weeks after treatment. Overall, McKenzie treatment is more effective than passive methods to treat low back pain.[27] One of the popular exercise therapies for patients with low back pain is McKenzie training program. McKenzie method leads to improvement of low back pain symptoms such as pain in the short-term. Moreover, McKenzie therapy is more effective in comparison with passive treatments. This training is designed to mobilize the spine and to strengthen the lumbar muscles. Previous studies have shown that weakness and atrophy in the body central muscles, particularly the transverse abdominal muscle in patients with low back pain.[28] The results of this research also showed that there was a significant difference in the general health indexes between Pilates and McKenzie groups. In the present study, 6 weeks of Pilates and McKenzie training led to a significant reduction in the level of general health (physical symptoms, anxiety, social dysfunction, and depression) in men with chronic low back pain and the general health in Pilates training group improved. The results of most studies show that exercise therapy reduces pain and improves general health in patients with chronic low back pain. Importantly, the agreement about the duration, type, and intensity of the training remains to be achieved and there is no definite training program that can have the best effect on patients with chronic low back pain. Therefore, more research is needed to determine the best duration and treatment method to reduce and improve general health in patients with low back pain. In the Al-Obaidi et al. study, pain, fear, and functional disability improved after 10 weeks of treatment in patients.[5]
Besides that McKenzie training increases the range of motion of lumbar flexion. Overall, neither of the two methods of treatment was superior over the other.[18]
Borges et al. concluded that after 6 weeks of treatment, the average index of pain in experimental group was lower than the control group. Furthermore, the general health of the experimental group exhibited greater improvement than the control group. The results of this research support recommending Pilates training to patients with chronic low back pain.[29] Caldwell et al. on the university students concluded that Pilates training and Tai chi guan improved mental parameters such as self-sufficiency, quality of sleep, and morality of students but had no effect on physical performance.[30] Garcia et al. study on 148 patients with nonspecific chronic low back pain concluded that treating patients with nonspecific chronic low back pain by McKenzie training and back school caused disability to improve after treatment, but quality of life, pain, and the range of motor flexibility did not change. McKenzie treatment is typically more effective on disability than back school program.[19]
The overall findings of this study are supported by the literature, demonstrating that a Pilates program may offer a low-cost, safe alternative to the treatment of low back pain in this specific group of patients. Similar effects have been found in patients with unspecific chronic low back pain.[31]
Our study had good levels of internal and external validity and thus can guide therapists and patients considering therapies of choice for back pain. The trial included a number of features to minimize bias such as prospectively registering and following a published protocol.
Study Limitation
Small sample size enrolled in this study limits the generalization of the study findings.
Conclusion
The results of this study showed that 6-week Pilates and McKenzie training reduced pain in patients with chronic low back pain, but there was no significant difference between the effect of two therapeutic methods on pain and both exercise protocols had the same effect. In addition, Pilates and McKenzie training improved general health; however, according to the mean general health changes after the exercise therapy, it can be argued that the Pilates training has a greater effect in improving general health.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
In conclusion,�when comparing the effects of Pilates and McKenzie training on general health as well as on painful symptoms in men with chronic low back pain, the evidence-based research study determined that both the Pilates and the McKenzie method of training effectively reduced pain in patients with chronic LBP. There was no significant difference between the two therapeutic methods altogether, however, the mean results of the research study demonstrated that Pilates training was more effective towards improving general health in men with chronic low back pain than McKenzie training.� 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: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
1. Bergstr�m C, Jensen I, Hagberg J, Busch H, Bergstr�m G. Effectiveness of different interventions using a psychosocial subgroup assignment in chronic neck and back pain patients: A 10-year follow-up. Disabil Rehabil. 2012;34:110�8. [PubMed]
2. Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010;24:783�92. [PubMed]
3. Balagu� F, Mannion AF, Pellis� F, Cedraschi C. Non-specific low back pain. Lancet. 2012;379:482�91. [PubMed]
4. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. New York: Lippincott Williams & Wilkins; 2011.
5. Al-Obaidi SM, Al-Sayegh NA, Ben Nakhi H, Al-Mandeel M. Evaluation of the McKenzie intervention for chronic low back pain by using selected physical and bio-behavioral outcome measures. PM R. 2011;3:637�46. [PubMed]
6. Dehkordi AH, Heydarnejad MS. Effect of booklet and combined method on parents’ awareness of children with beta-thalassemia major disorder. J Pak Med Assoc. 2008;58:485�7. [PubMed]
7. van der Wees PJ, Jamtvedt G, Rebbeck T, de Bie RA, Dekker J, Hendriks EJ. Multifaceted strategies may increase implementation of physiotherapy clinical guidelines: A systematic review. Aust J Physiother. 2008;54:233�41. [PubMed]
8. Maas ET, Juch JN, Groeneweg JG, Ostelo RW, Koes BW, Verhagen AP, et al. Cost-effectiveness of minimal interventional procedures for chronic mechanical low back pain: Design of four randomised controlled trials with an economic evaluation. BMC Musculoskelet Disord. 2012;13:260. [PMC free article][PubMed]
9. Hernandez AM, Peterson AL. Handbook of Occupational Health and Wellness. Springer: 2012. Work-related musculoskeletal disorders and pain; pp. 63�85.
10. Hassanpour Dehkordi A, Khaledi Far A. Effect of exercise training on the quality of life and echocardiography parameter of systolic function in patients with chronic heart failure: A randomized trial. Asian J Sports Med. 2015;6:e22643. [PMC free article][PubMed]
11. Hasanpour-Dehkordi A, Khaledi-Far A, Khaledi-Far B, Salehi-Tali S. The effect of family training and support on the quality of life and cost of hospital readmissions in congestive heart failure patients in Iran. Appl Nurs Res. 2016;31:165�9. [PubMed]
12. Hassanpour Dehkordi A. Influence of yoga and aerobics exercise on fatigue, pain and psychosocial status in patients with multiple sclerosis: A Randomized Trial. J Sports Med Phys Fitness. 2015 [Epub ahead of print] [PubMed]
13. Hassanpour-Dehkordi A, Jivad N. Comparison of regular aerobic and yoga on the quality of life in patients with multiple sclerosis. Med J Islam Repub Iran. 2014;28:141. [PMC free article][PubMed]
14. Heydarnejad S, Dehkordi AH. The effect of an exercise program on the health-quality of life in older adults. A randomized controlled trial. Dan Med Bull. 2010;57:A4113. [PubMed]
15. van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol. 2010;24:193�204. [PubMed]
16. Critchley DJ, Pierson Z, Battersby G. Effect of pilates mat exercises and conventional exercise programmes on transversus abdominis and obliquus internus abdominis activity: Pilot randomised trial. Man Ther. 2011;16:183�9. [PubMed]
17. Kloubec JA. Pilates for improvement of muscle endurance, flexibility, balance, and posture. J Strength Cond Res. 2010;24:661�7. [PubMed]
18. Hosseinifar M, Akbari A, Shahrakinasab A. The effects of McKenzie and lumbar stabilization exercises on the improvement of function and pain in patients with chronic low back pain: A randomized controlled trial. J Shahrekord Univ Med Sci. 2009;11:1�9.
19. Garcia AN, Costa Lda C, da Silva TM, Gondo FL, Cyrillo FN, Costa RA, et al. Effectiveness of back school versus McKenzie exercises in patients with chronic nonspecific low back pain: A randomized controlled trial. Phys Ther. 2013;93:729�47. [PubMed]
20. Hassanpour-Dehkordi A, Safavi P, Parvin N. Effect of methadone maintenance treatment of opioid dependent fathers on mental health and perceived family functioning of their children. Heroin Addict Relat Clin. 2016;18(3):9�14.
21. Shahbazi K, Solati K, Hasanpour-Dehkordi A. Comparison of hypnotherapy and standard medical treatment alone on quality of life in patients with irritable bowel syndrome: A Randomized Control Trial. J Clin Diagn Res. 2016;10:OC01�4. [PMC free article][PubMed]
22. Ngamkham S, Vincent C, Finnegan L, Holden JE, Wang ZJ, Wilkie DJ. The McGill Pain Questionnaire as a multidimensional measure in people with cancer: An integrative review. Pain Manag Nurs. 2012;13:27�51. [PMC free article][PubMed]
23. Sterling M. General health questionnaire-28 (GHQ-28) J Physiother. 2011;57:259. [PubMed]
24. Petersen T, Kryger P, Ekdahl C, Olsen S, Jacobsen S. The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain: A randomized controlled trial. Spine (Phila Pa 1976) 2002;27:1702�9. [PubMed]
25. Gladwell V, Head S, Haggar M, Beneke R. Does a program of pilates improve chronic non-specific low back pain? J Sport Rehabil. 2006;15:338�50.
26. Udermann BE, Mayer JM, Donelson RG, Graves JE, Murray SR. Combining lumbar extension training with McKenzie therapy: Effects on pain, disability, and psychosocial functioning in chronic low back pain patients. Gundersen Lutheran Med J. 2004;3:7�12.
27. Machado LA, Maher CG, Herbert RD, Clare H, McAuley JH. The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: A randomized controlled trial. BMC Med. 2010;8:10. [PMC free article][PubMed]
28. Kilpikoski S. The McKenzie Method in Assessing, Classifying and Treating Non-Specific Low Back Pain in Adults with Special Reference to the Centralization Phenomenon. Jyv�skyl� University of Jyv�skyl� 2010
29. Borges J, Baptista AF, Santana N, Souza I, Kruschewsky RA, Galv�o-Castro B, et al. Pilates exercises improve low back pain and quality of life in patients with HTLV-1 virus: A randomized crossover clinical trial. J Bodyw Mov Ther. 2014;18:68�74. [PubMed]
30. Caldwell K, Harrison M, Adams M, Triplett NT. Effect of pilates and taiji quan training on self-efficacy, sleep quality, mood, and physical performance of college students. J Bodyw Mov Ther. 2009;13:155�63. [PubMed]
31. Altan L, Korkmaz N, Bingol U, Gunay B. Effect of pilates training on people with fibromyalgia syndrome: A pilot study. Arch Phys Med Rehabil. 2009;90:1983�8. [PubMed]
Chiropractic Management of Low Back Pain and Low Back-Related Leg Complaints: A Literature Synthesis
Chiropractic care is a well-known complementary and alternative treatment option frequently used to diagnose, treat and prevent injuries and conditions of the musculoskeletal and nervous systems. Spinal health issues are among some of the most common reasons people seek chiropractic care, especially for low back pain and sciatica complaints. While there are many different types of treatments available to help improve low back pain and sciatica symptoms, many individuals will often prefer natural treatment options over the use of drugs/medications or surgical interventions. The following research study demonstrates a list of evidence-based chiropractic treatment methods and their effects towards improving a variety of spinal health issues.
Abstract
Objectives: The purpose of this project was to review the literature for the use of spinal manipulation for low back pain (LBP).
Methods: Asearch strategymodified fromthe Cochrane Collaboration reviewforLBP was conducted through the following databases: PubMed, Mantis, and the Cochrane Database. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input.
Results: A total of 887 source documents were obtained. Search results were sorted into related topic groups as follows: randomized controlled trials (RCTs) of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnostic-related articles, methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. The team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and coh ort studies. This yielded a total of 12 guidelines, 64 RCTs, 13 systematic reviews/meta-analyses, and 11 cohort studies.
Conclusions: As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy. (J Manipulative Physiol Ther 2008;31:659-674)
The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was formed in 1995 by the Congress of Chiropractic State Associations with assistance from the American Chiropractic Association, Association of Chiropractic Colleges, Council on Chiropractic Education, Federation of Chiropractic Licensing�Boards, Foundation for the Advancement of Chiropractic Sciences, Foundation for Chiropractic Education and Research, International Chiropractors Association, National Association of Chiropractic Attorneys, and the National Institute for Chiropractic Research. The charge to the CCGPP was to create a chiropractic �best practices� document. The Council on Chiropractic Guidelines and Practice Parameters was delegated to examine all existing guidelines, parameters, protocols, and best practices in the United States and other nations in the construction of this document.
Toward that end, the Scientific Commission of CCGPP was charged with developing literature syntheses, organized by region (neck, low back, thoracic, upper and lower extremity, soft tissue) and the nonregional categories of nonmusculoskeletal, prevention/health promotion, special populations, subluxation, and diagnostic imaging.
The purpose of this work is to provide a balanced interpretation of the literature to identify safe and effective treatment options in the care of patients with low back pain (LBP) and related disorders. This evidence summary is intended to serve as a resource for practitioners to assist them in consideration of various care options for such patients. It is neither a replacement for clinical judgment nor a prescriptive standard of care for individual patients.
Methods
Process development was guided by experience of commission members with the RAND consensus process, Cochrane collaboration, Agency for Health Care and Policy Research, and published recommendations modified to the needs of the council.
Identification and Retrieval
The domain for this report is that of LBP and low backrelated leg symptoms. Using surveys of the profession and publications on practice audits, the team selected the topics for review by this iteration.
Topics were selected based on the most common disorders seen and most common classifications of treatments used by chiropractors based on the literature. Material for review was obtained through formal hand searches of published literature and of electronic databases, with assistance from a professional chiropractic college librarian. A search strategy was developed, based upon the CochraneWorking Group for Low Back Pain. Randomized controlled trials (RCTs), systematic reviews/meta-analyses, and guidelines published through 2006 were included; all other types of studies were included through 2004. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. Searches focused on guidelines, meta-analyses, systematic reviews, randomized clinical trials, cohort studies, and case series.
Evaluation
Standardized and validated instruments used by the Scottish Intercollegiate Guidelines Network were used to evaluate RCTs and systematic reviews. For guidelines, the Appraisal of Guidelines for Research and Evaluation instrument was used. A standardized method for grading the strength of the evidence was used, as summarized in Figure 1. Each team’s multidisciplinary panel conducted the review and evaluation of the evidence.
Search results were sorted into related topic groups as follows: RCTs of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnosticrelated articles; methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. On the basis of the CCGPP formation of an iterative process and the volume of work available, the team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and cohort studies.
Dr. Alex Jimenez’s Insight
How does chiropractic care benefit people with low back pain and sciatica?�As a chiropractor experienced in the management of a variety of spine health issues, including low back pain and sciatica, spinal adjustments and manual manipulations, as well as other non-invasive treatment methods, can be safely and effectively implemented towards the improvement of back pain symptoms. The purpose of the following research study is to demonstrate the evidence-based effects of chiropractic in the treatment of injuries and conditions of the musculoskeletal and nervous systems. The information in this article can educate patients on how alternative treatment options can help improve their low back pain and sciatica. As a chiropractor, patients may also be referred to other healthcare professionals, such as physical therapists, functional medicine practitioners and medical doctors, to help them further manage their low back pain and sciatica symptoms. Chiropractic care can be used to avoid surgical interventions for spine health issues.
Results and Discussion
A total of 887 source documents were initially obtained. This included a total of 12 guidelines, 64 RCTs, 20 systematic reviews/meta-analyses, and 12 cohort studies. Table 1 provides an overall summary of the number of studies evaluated.
Assurance and Advice
The search strategy used by the team was that developed by van Tulder et al, and the team identified 11 trials. Good evidence indicates that patients with acute LBP on bed rest have more pain and less functional recovery than those who stay active. There is no difference in pain and functional status between bed rest and exercises. For sciatica patients, fair evidence shows no real difference in pain and functional status between bed rest and staying active. There is fair evidence of no difference in pain intensity between bed rest and physiotherapy but small improvements in functional status. Finally, there is little difference in pain intensity or functional status between shorter-term or longer-term bed rest.
A Cochrane review by Hagen et al demonstrated small advantages in short-term and long-term for staying active over bed rest, as did a high-quality review by the Danish Society of Chiropractic and Clinical Biomechanics, including 4 systematic reviews, 4 additional RCTS, and 6 guidelines, on acute LBP and sciatica. The Cochrane review by Hilde et al included 4 trials and concluded a small beneficial effect for staying active for acute, uncomplicated LBP, but no benefit for sciatica. Eight studies on staying active and 10 on bed rest were included in an analysis by the group of Waddell. Several therapies were coupled with advice to stay active and include analgesic medication, physical therapy, back school, and behavioral counseling. Bed rest for acute LBP was similar to no treatment and placebo and less effective than alternative treatment. Outcomes considered across the studies were rate of recovery, pain, activity levels, and work time loss. Staying active was found to have a favorable effect.
Review of 4 studies not covered elsewhere assessed the use of brochures/booklets. The trend was for no differences in outcome for pamphlets. One exception was noted�that those who received manipulation had less bothersome symptoms at 4 weeks and significantly less disability at 3 months for those who received a booklet encouraging staying active.
In summary, assuring patients that they are likely to do well and advising them to stay active and avoid bed rest is a best practice for management of acute LBP. Bed rest for short intervals may be beneficial for patients with radiating leg pain who are intolerant of weight bearing.
Adjustment/Manipulation/Mobilization Vs Multiple Modalities
This review considered literature on high-velocity, lowamplitude (HVLA) procedures, often termed adjustment or manipulation, and mobilization. The HVLA procedures use thrusting maneuvers applied quickly; mobilization is applied cyclically. The HVLA procedure and mobilization may be mechanically assisted; mechanical impulse devices are considered HVLA, and flexion-distraction methods and continuous passive motion methods are within mobilization.
The team recommends adopting the findings of the systematic review by Bronfort et al, with a quality score (QS) of 88, covering literature up to 2002. In 2006, the Cochrane collaboration reissued an earlier (2004) review of spinal manipulative therapy (SMT) for back pain performed by Assendelft et al. This reported on 39 studies up to 1999, several overlapping with those reported by Bronfort et al using different criteria and a novel analysis. They report no difference in outcome from treatment with manipulation vs alternatives. As several additional RCTs had appeared in the interim, the rationale for reissuing the older review without acknowledging new studies was unclear.
Acute LBP. There was fair evidence that HVLA has better short-term efficacy than mobilization or diathermy and limited evidence of better short-term efficacy than diathermy, exercise, and ergonomic modifications.
Chronic LBP. The HVLA procedure combined with strengthening exercise was as effective for pain relief as nonsteroidal antiinflammatory dugs with exercise. Fair evidence indicated that manipulation is better than physical therapy and home exercise for reducing disability. Fair evidence shows that manipulation improves outcomes more than general medical care or placebo in the short-term and to physical therapy in the long-term. The HVLA procedure had better outcomes than home exercise, transcutaneous�electrical nerve stimulation, traction, exercise, placebo and sham manipulation, or chemonucleolysis for disk herniation.
Mixed (Acute and Chronic) LBP. Hurwitz found that HVLA was the same as medical care for pain and disability; adding physical therapy to manipulation did not improve outcomes. Hsieh found no significant value for HVLA over back school or myofascial therapy. A short-term value of manipulation over a pamphlet and no difference between manipulation and McKenzie technique were reported by Cherkin et al. Meade contrasted manipulation and hospital care, finding greater benefit for manipulation over both short-term and long-term. Doran and Newell found that SMT resulted in greater improvement than physical therapy or corsets.
Acute LBP
Sick List Comparisons. Seferlis found that sick patients listed were significantly improved symptomatically after 1 month regardless of the intervention, including manipulation. Patients were more satisfied and felt that they were provided better explanations about their pain from practitioners who used manual therapy (QS, 62.5). Wand et al examined the effects of sick-listing oneself and noted that a group receiving assessment, advice, and treatment improved better than did a group getting assessment, advice, and who were put on a wait list for a 6-week period. Improvements were observed in disability, general health, quality of life, and mood, though pain and disability were not different at longterm follow-up (QS, 68.75).
Physiologic Therapeutic Modality and Exercise. Hurley and colleagues tested the effects of manipulation combined with interferential therapy compared to either modality alone. Their results showed all 3 groups improved function to the same degree, both at 6-month and at 12-month follow-up (QS, 81.25). Using a single-blinded experimental design to compare manipulation to massage and low-level electrostimulation, Godfrey et al found no differences between groups at the 2 to 3-week observation time frame (QS, 19). In the study by Rasmussen, results showed that 94% of the patients treated with manipulation were symptom-free within 14 days, compared to 25% in the group that received short-wave diathermy. Sample size was small, however, and as a result, the study was underpowered (QS, 18). The Danish systematic review examined 12 international sets of guidelines, 12 systematic reviews, and 10 randomized clinical trials on exercise. They found no specific exercises, regardless of type, that were useful for the treatment of acute LBP with the exception of McKenzie maneuvers.
Sham and Alternate Manual Method Comparisons. The study of Hadler balanced for effects of provider attention and physical contact with a first effort at a manipulation sham procedure. Patients in the group that entered the trial with greater prolonged illness at the outset were reported to have benefited from the manipulation. Similarly, they improved faster and to a greater degree (QS, 62.5). Hadler demonstrated that there was a benefit for a single session of manipulation compared to a session of mobilization (QS, 69). Erhard reported that the rate of positive response to manual treatment with a hand-heel rocking motion was greater than with extension exercises (QS, 25). Von Buerger examined the use of manipulation for acute LBP, comparing rotational manipulation to soft tissue massage. He found that the manipulation group responded better than the soft tissue group, although the effects occurred mainly in the short-term. The results were also hampered by the nature of the forced multiple choice selections on the data forms (QS, 31). Gemmell compared 2 forms of manipulation for LBP of less than 6 weeks of duration as follows: Meric adjusting (a form of HVLA) and Activator technique (a form of mechanically assisted HVLA). No difference was observed, and both helped to reduce pain intensity (QS, 37.5). MacDonald reported a short-term benefit in disability measures within the first 1 to 2 weeks of starting therapy for the manipulation group that disappeared by 4 weeks in a control group (QS, 38). The work of Hoehler, although containing mixed data for patients with acute and chronic LBP, is included here because a larger proportion of patients with acute LBP were involved in the study. Manipulation patients reported immediate relief more often, but there were no differences between groups at discharge (QS, 25).
Medication. Coyer showed that 50% of the manipulation group was symptom-free within 1 week and 87% were discharged symptom-free in 3 weeks, compared to 27% and 60%, respectively, of the control group (bed rest and analgesics) (QS, 37.5). Doran and Newell compared manipulation, physiotherapy, corset, or analgesic medication, using outcomes that examined pain and mobility. There were no differences between groups over time (QS, 25). Waterworth compared manipulation to conservative physiotherapy and 500 mg of diflunisal twice per day for 10 days. Manipulation showed no benefit for the rate of recovery (QS, 62.5). Blomberg compared manipulation to steroid injections and to a control group receiving conventional activating therapy. After 4 months, the manipulation group had less restricted motion in extension, less restriction in side-bending to both sides, less local pain on extension and right sidebending, less radiating pain, and less pain when performing a straight leg raise (QS, 56.25). Bronfort found no outcome differences between chiropractic care compared to medical care at 1 month of treatment, but there were noticeable improvements in the chiropractic group at both 3 and 6-month follow-up (QS, 31).
Subacute Back Pain
Staying Active. Grunnesjo compared combined effects of manual therapy with advice to stay active to advice alone in patients with acute and subacute LBP. The addition of�manual therapy appeared to reduce pain and disability more effectively than the �stay active� concept alone (QS, 68.75).
Physiologic Therapeutic Modality and Exercise. Pope demonstrated that manipulation offered better pain improvement than transcutaneous electrical nerve stimulation (QS 38). Sims-Williams compared manipulation to �physiotherapy.� Results demonstrated a short-term benefit for manipulation on pain and ability to do light work. Differences between groups waned at 3 and 12-month follow-ups (QS, 43.75, 35). Skargren et al compared chiropractic to physiotherapy for patients with LBP who had no treatment for the prior month. No differences in health improvements, costs, or recurrence rates were noted between the 2 groups. However, based on Oswestry scores, chiropractic performed better for patients who had pain for less than 1 week, whereas the physiotherapy seemed to be better for those who had pain for more than 4 weeks (QS, 50).
The Danish systematic review examined 12 international sets of guidelines, 12 systematic reviews, and 10 randomized clinical trials on exercise. Results suggested that exercise, in general, benefits patients with subacute back pain. Use of a basic program that can be readily modified to meet individual patient needs is recommended. Issues of strength, endurance, stabilization, and coordination without excessive loading can all be addressed without the use of high-tech equipment. Intensive training consisting of greater than 30 and less than 100 hours of training are most effective.
Sham and Alternate Manual Method Comparisons. Hoiriis compared efficacy of chiropractic manipulation to placebo/ sham for subacute LBP. All groups improved on measures of pain, disability, depression, and Global Impression of Severity. Chiropractic manipulation scored better than placebo in reducing pain and Global Impression of Severity scores (QS, 75). Andersson and colleagues compared osteopathic manipulation to standard care to patients with subacute LBP, finding that both groups improved for a 12-week period at about the same rate (QS, 50).
Medication Comparisons. In a separate treatment arm of the study of Hoiriis, the relative efficacy of chiropractic manipulation to muscle relaxants for subacute LBP was studied. In all groups, pain, disability, depression, and Global Impression of Severity decreased. Chiropractic manipulation was more effective than muscle relaxants in reducing Global Impression of Severity scores (QS, 75).
Chronic LBP
Staying Active Comparisons. Aure compared manual therapy to exercise in patients with chronic LBP who were sick listed. Although both groups showed improvements in pain intensity, functional disability, general health, and return to work, the manual therapy group showed significantly greater improvements than did the exercise group for all outcomes. Results were consistent for both the short-term and the longterm (QS, 81.25).
Physician Consult/Medical Care/Education. Niemisto compared combined manipulation, stabilization exercise, and physician consultation to consultation alone. The combined intervention was more effective in reducing pain intensity and disability (QS, 81.25). Koes compared general practitioner treatment to manipulation, physiotherapy, and a placebo (detuned ultrasound). Assessments were made at 3, 6, and 12 weeks. The manipulation group had a quicker and larger improvement in physical function compared to the other therapies. Changes in spinal mobility in the groups were small and inconsistent (QS, 68). In a follow-up report, Koes found during subgroup analysis that improvement in pain was greater for manipulation than for other treatments at 12 months when considering patients with chronic conditions, as well as those who were younger than 40 years (QS, 43). Another study by Koes showed that many patients in the nonmanipulation treatment arms had received additional care during follow-up. Yet, improvement in the main complaints and in physical functioning remained better in the manipulation group (QS, 50). Meade observed that chiropractic treatment was more effective than hospital outpatient care, as assessed using the Oswestry Scale (QS, 31). An RCT conducted in Egypt by Rupert compared chiropractic manipulation, after medical and chiropractic evaluation. Pain, forward flexion, active, and passive leg raise all improved to a greater degree in the chiropractic group; however, the description of alternate treatments and outcomes was ambiguous (QS, 50).
Triano compared manual therapy to educational programs for chronic LBP. There was greater improvement in pain, function, and activity tolerance in the manipulation group, which continued beyond the 2-week treatment period (QS, 31).
Physiologic Therapeutic Modality. A negative trial for manipulation was reported by Gibson (QS, 38). Detuned diathermy was reported to achieve better results over manipulation, although there were baseline differences between groups. Koes studied the effectiveness of manipulation, physiotherapy, treatment by a general practitioner, and a placebo of detuned ultrasound. Assessments were made at 3, 6, and 12 weeks. The manipulation group showed a quicker and better improvement in physical function capacity compared to the other therapies. Flexibility differences between groups were not significant (QS, 68). In a follow-up report, Koes found that a subgroup analysis demonstrated that improvement in pain was greater for those treated with manipulation, both for younger (b40) patients and those with chronic conditions at 12-month follow-up (QS, 43). Despite many patients in the nonmanipulation groups received additional care during follow-up, improvements remained better in the manipulation group than in the physical therapy group (QS, 50). In a separate report by the same group, there were improvements in both the physiotherapy and manual therapy groups with regard to severity of complaints and global perceived effect compared to general practitioner care;�however, the differences between the 2 groups was not significant (QS, 50). Mathews et al found that manipulation hastened recovery from LBP more than the control did.
Exercise Modality. Hemilla observed that SMT led to better long-term and short-term disability reduction compared to physical therapy or home exercise (QS, 63). A second article by the same group found that neither bone-setting nor exercise differed significantly from physical therapy for symptom control, though bone-setting was associated with improved lateral and forward-bending of the spine more than exercise (QS, 75). Coxhea reported that HVLA provided better outcomes when compared to exercise, corsets, traction, or no exercise when studied in the short-term (QS, 25). Conversely, Herzog found no differences between manipulation, exercise, and back education in reducing either pain or disability (QS, 6). Aure compared manual therapy to exercise in patients with chronic LBP who were also sick listed. Although both groups showed improvements in pain intensity, functional disability, and general health and returned to work, the manual therapy group showed significantly greater improvements than did the exercise group for all outcomes. This result persisted for both the short-term and the long-term (QS, 81.25). In the article by Niemisto and colleagues, the relative efficacy of combined manipulation, exercise (stabilizing forms), and physician consultation compared to consultation alone was investigated. The combined intervention was more effective in reducing pain intensity and disability (QS, 81.25). The United Kingdom Beam study found that manipulation followed by exercise achieved a moderate benefit at 3 months and a small benefit at 12 months. Likewise, manipulation achieved a small to moderate benefit at 3 months and a small benefit at 12 months. Exercise alone had a small benefit at 3 months but no benefit at 12 months. Lewis et al found improvement occurred when patients were treated by combined manipulation and spinal stabilization exercises vs use of a 10-station exercise class.
The Danish systematic review examined 12 international sets of guidelines, 12 systematic reviews, and 10 randomized clinical trials on exercise. Results suggested that exercise, in general, benefits patients with chronic LBP. No clear superior method is known. Use of a basic program that can be readily modified to meet individual patient needs is recommended. Issues of strength, endurance, stabilization, and coordination without excessive loading can all be addressed without the use of high-tech equipment. Intensive training consisting of greater than 30 and less than 100 hours of training are most effective. Patients with severe chronic LBP, including those off work, are treated more effectively with a multidisciplinary rehabilitation program. For post surgical rehabilitation, patients starting 4 to 6 weeks after disk surgery under intensive training receive greater benefit than with light exercise programs.
Sham and Alternate Manual Methods. Triano found that SMT produced significantly better results for pain and disability relief for the short-term, than did sham manipulation (QS, 31). Cote found no difference over time or for comparisons within or between the manipulation and mobilization groups (QS, 37.5). The authors posed that failure to observe differences may have been due to low responsiveness to change in the instruments used for algometry, coupled with a small sample size. Hsieh found no significant value for HVLA over back school or myofascial therapy (QS, 63). In the study by Licciardone, a comparison was made between osteopathic manipulation (which includes mobilization and soft tissue procedures as well as HVLA), sham manipulation, and a no-intervention control for patients with chronic LBP. All groups showed improvement. Sham and osteopathic manipulation were associated with greater improvements than seen in the no-manipulation group, but no difference was observed between the sham and manipulation groups (QS, 62.5). Both subjective and objective measures showed greater improvements in the manipulation group compared to a sham control, in a report by Waagen (QS, 44). In the work of Kinalski, manual therapy reduced the time of treatment of patients with LBP and concomitant intervertebral disk lesions. When disk lesions were not advanced, a decreased muscular hypertonia and increased mobility was noted. This article, however, was limited by a poor description of patients and methods (QS, 0).
Harrison et al reported a nonrandomized cohort controlled trial of treatment of chronic LBP consisting of 3-point bending traction designed to increase curvature of the lumbar spine. The experimental group received HVLA for pain control during the first 3 weeks (9 treatments). The control group received no treatment. Follow-up at a mean of 11 weeks showed no change in pain or curvature status for controls but a significant increase in curvature and reduction of pain in the experimental group. Average number of treatments to achieve this result was 36. Long-term followup at 17 months showed retention of benefits. No report of relationship between clinical changes and structural change was given.
Haas and colleagues examined the dose-response patterns of manipulation for chronic LBP. Patients were randomly allocated to groups receiving 1, 2, 3, or 4 visits per week for 3 weeks, with outcomes recorded for pain intensity and functional disability. A positive and clinically important effect of the number of chiropractic treatments on pain intensity and disability at 4 weeks was associated with the groups receiving the higher rates of care (QS, 62.5). Descarreaux et al extended this work, treating 2 small groups for 4 weeks (3 times per week) after 2 baseline evaluations separated by 4 weeks. One group was then treated every 3 weeks; the other did not. Although both groups had lower Oswestry scores at 12 weeks, at 10 months, the improvement only persisted for the extended SMT group.
Medication. Burton and colleagues demonstrated that HVLA led to greater short-term improvements in pain and disability than did chemonucleolysis for managing disk�herniation (QS, 38). Bronfort studied SMT combined with exercise vs a combination of nonsteroidal antiinflammatory drugs and exercise. Similar results were obtained for both groups (QS, 81). Forceful manipulation coupled with sclerosant therapy (injection of a proliferant solution composed of dextrose-glycerine-phenol) was compared to lower force manipulation combined with saline injections, in a study by Ongley. The group receiving forceful manipulation with sclerosant fared better than the alternate group, but effects cannot be separated between the manual procedure and the sclerosant (QS, 87.5). Giles and Muller compared HVLA procedures to medication and acupuncture. Manipulation showed greater improvement in frequency of back pain, pain scores, Oswestry, and SF-36 compared to the other 2 interventions. Improvements lasted for 1 year. Weaknesses of the study were use of a compliers-only analysis as intention to treat for the Oswestry, and Visual Analogue Scale (VAS) was not significant.
Sciatica/Radicular/Radiating Leg Pain
Staying Active/Bed Rest. Postacchini studied a mixed group of patients with LBP, with and without radiating leg pain. Patients could be classified as acute or chronic and were evaluated at 3 weeks, 2 months, and 6 months postonset. Treatments included manipulation, drug therapy, physiotherapy, placebo, and bed rest. Acute back pain without radiation and chronic back pain responded well to manipulation; however, in none of the other groups did manipulation fare as well as other interventions (QS, 6).
Physician Consult/Medical Care/Education. Arkuszewski looked at patients with lumbosacral pain or sciatica. One group received drugs, physiotherapy, and manual examination, whereas the second added manipulation. The group receiving manipulation had a shorter treatment time and a more marked improvement. At 6-month follow-up, the manipulation group showed better neuromotor system function and a better ability to continue employment. Disability was lower in the manipulation group (QS, 18.75).
Physiologic Therapeutic Modality. Physiotherapy combined with manual manipulation and medication was examined by Arkuszewski, in contrast to the same scheme with manipulation added, as noted above. Outcomes from manipulation were better for neurologic and motor function as well as disability (QS, 18.75). Postacchini looked at patients with acute or chronic symptoms evaluated at 3 weeks, 2 months, and 6 months postonset. Manipulation was not as effective for managing the patients with radiating leg pain as the other treatment arms (QS, 6). Mathews and colleagues examined multiple treatments including manipulation, traction, sclerosant use, and epidural injections for back pain with sciatica. For patients with LBP and restricted straight leg raise test, manipulation conferred highly significant relief, more so than alternate interventions (QS, 19). Coxhead et al included among their subjects patients who had radiating pain at least to the buttocks. Interventions included traction, manipulation, exercise, and corset, using a factorial design. After 4 weeks of care, manipulation showed a significant degree of benefit on one of the scales used to assess progress. There were no real differences between groups at 4 months and 16 months posttherapy, however (QS, 25).
Exercise Modality. In the case of LBP after laminectomy, Timm reported that exercises conferred benefit both for pain relief and cost-effectiveness (QS, 25). Manipulation had only a small influence on improvement of either symptoms or function (QS, 25). In the study by Coxhead et al, radiating pain to at least the buttocks was better after 4 weeks of care for manipulation, in contrast to other treatments that disappeared 4 months and 16 months posttherapy (QS, 25).
Sham and Alternate Manual Method. Siehl looked at the use of manipulation under general anesthesia for patients with LBP and unilateral or bilateral radiating leg pain. Only temporary clinical improvement was noted when traditional electromyographic evidence of nerve root involvement was present. With negative electromyography, manipulation was reported to provide lasting improvement (QS, 31.25) Santilli and colleagues compared HVLA to soft tissue pressing without any sudden thrust in patients with moderate acute back and leg pain. The HVLA procedures were significantly more effective in reducing pain, reaching a pain-free status, and the total number of days with pain. Clinically significant differences were noted. The total number of treatment sessions was capped at 20 on a dosage of 5 times per week with care depending on pain relief. Follow-up showed relief persisting through 6 months.
Medication. Mixed acute and chronic back pain with radiation treated in a study using multiple treatment arms were evaluated at 3 weeks, 2 months, and 6 months postonset by the group of Postacchini. Medication management fared better than did manipulation when radiating leg pain was present (QS, 6). Conversely, for the work of Mathews and colleagues, the group of patients with LBP and limited straight leg raise test responded more to manipulation than to epidural steroid or sclerosants (QS, 19).
Disk Herniation
Nwuga studied 51 subjects who were having a diagnosis of prolapsed intervertebral disk and who had been referred for physical therapy. Manipulation was reported to be superior to conventional therapy (QS, 12.5). Zylbergold found that there were no statistical differences between 3 treatments�lumbar flexion exercises, home care, and manipulation. Short-term follow-up and a small sample size were posed by the author as a basis for failing to reject the null hypothesis (QS, 38).
Exercise
Exercise is one of the most well-studied forms of treatment of low back disorders. There are many different approaches to�exercise. For this report, it is important only to differentiate multidisciplinary rehabilitation. These programs are designed for patients with especially chronic condition with significant psychosocial problems. They involve trunk exercise, functional task training including work simulation/vocational training, and psychological counseling.
In a recent Cochrane review on exercise for the treatment of nonspecific LBP (QS, 82), effectiveness of exercise therapy in patients classified as acute, subacute, and chronic was compared to no treatment and alternate treatments. Outcomes included the assessment of pain, function, return to work, absenteeism, and/or global improvements. In the review, 61 trials met the inclusion criteria, most of which dealt with chronic (n = 43), whereas smaller numbers addressed acute (n = 11) and subacute (n = 6) pain. The general conclusions were as follows:
exercise is not effective as a treatment of acute LBP,
evidence that exercise was effective in chronic populations relative to comparisons made at follow-up periods,
mean improvements of 13.3 points for pain and 6.9 points for function were observed, and
there is some evidence that graded-activity exercise is effective for subacute LBP but only in the occupational setting
The review examined population and intervention characteristics, as well as outcomes to reach its conclusions. Extracting data on return to work, absenteeism, and global improvement proved so difficult that only pain and function could be quantitatively described.
Eight studies scored positively on key validity criteria. With regard to clinical relevance, many of the trials presented inadequate information, with 90% reporting the study population but only 54% adequately describing the exercise intervention. Relevant outcomes were reported in 70% of the trials.
Exercise for Acute LBP. Of the 11 trials (total n = 1192), 10 had nonexercise comparison groups. The trials presented conflicting evidence. Eight low-quality trials showed no differences between exercise and usual care or no treatment. Pooled data showed that there was no difference in shortterm pain relief between exercise and no treatment, no difference in early follow-up for pain when compared to other interventions, and no positive effect of exercise on functional outcomes.
Subacute LBP. In 6 studies (total n = 881), 7 exercise groups had a nonexercise comparison group. The trials offered mixed results with regard to evidence of effectiveness, with fair evidence of effectiveness for a graded-exercise activity program as the only notable finding. Pooled data did not show evidence to either support or refute the use of exercise for subacute LBP, either for decreasing pain or improving function.
Chronic LBP. There were 43 trials included in this group (total n = 3907). Thirty-three of the studies had nonexercise comparison groups. Exercise was at least as effective as other conservative interventions for LBP, and 2 high-quality studies and 9 lower-quality studies found exercise to be more effective. These studies used individualized exercise programs, focusing mainly on strengthening or trunk stabilization. There were 14 trials that found no difference between exercise and other conservative interventions; of these, 2 were rated highly and 12 rated lower. Pooling the data showed a mean improvement of 10.2 (95% confidence interval [CI], 1.31-19.09) points on a 100-mm pain scale for exercise compared to no treatment and 5.93 (95% CI, 2.21- 9.65) points compared to other conservative treatments. Functional outcomes also showed improvements as follows: 3.0 points at earliest follow-up compared to no treatment (95% CI, ?0.53 to 6.48) and 2.37 points (95% CI, 1.04-3.94) compared to other conservative treatments.
Indirect subgroup analysis found that trials examining health care study populations had higher mean improvements in pain and physical functioning compared to their comparison groups or to trials set in occupational or general populations.
The review authors offered the following conclusions:
In acute LBP, exercises are not more effective than other conservative interventions. Meta-analysis showed no advantage over no treatment of pain and functional outcomes over the short or long-term.
There is fair evidence of effectiveness of a gradedactivity exercise program in subacute LBP in occupational settings. The effectiveness for other types of exercise therapy in other populations is unclear.
In chronic LBP, there is good evidence that exercise is at least as effective as other conservative treatments. Individually designed strengthening or stabilizing programs appear to be effective in health care settings. Meta-analysis found functional outcomes significantly improved; however, the effects were very small, with a less than 3-point (of 100) difference between the exercise and comparison groups at earliest follow-up. Pain outcomes were also significantly improved in groups receiving exercises relative to other comparisons, with a mean of approximately 7 points. Effects were similar over longer follow-up, though confidence intervals increased. Mean improvements in pain and functioning may be clinically meaningful in studies from health care populations in which improvements were significantly greater than those observed in studies from general or mixed populations.
The Danish group review of exercise was able to identify 5 systematic reviews and 12 guidelines that discussed exercise for acute LBP, 1 systematic review and 12 guidelines for subacute, and 7 systematic reviews and 11 guidelines for chronic. Furthermore, they identified 1 systematic review that selectively evaluated for postsurgical�cases. Conclusions were essentially the same as the Cochrane review, with the exceptions that there was limited support for McKenzie maneuvers for patients with acute condition and for intensive rehabilitation programs for 4 to 6 weeks after disk surgery over light exercise programs.
Natural and Treatment History for LBP
Most studies have demonstrated that nearly half of LBP will improve within 1 week, whereas nearly 90% of it will be gone by 12 weeks. Even more, Dixon demonstrated that perhaps as much as 90% of LBP will resolve on its own, without any intervention whatsoever. Von Korff demonstrated that a significant number of patients with acute LBP will have persistent pain if they are observed up to 2 years.
Phillips found that nearly 4 of 10 people will have LBP after an episode at 6 months from onset, even if the original pain has disappeared because more than 6 in 10 will have at least 1 relapse during the first year after an episode. These initial relapses occur within 8 weeks most commonly and may reoccur over time, though in decreasing percentages.
Workers’ compensation injury patients were observed for 1 year to examine symptom severity and work status. Half of those studied lost no work time in the first month after injury, but 30% did lose time from work due to their injury over the course of 1 year. Of those who missed work in the first month due to their injury and had already been able to return to work, nearly 20% had absence later in that same year. This implies that assessing return to work at 1 month after injury will fail to give an honest depiction of the chronic, episodic nature of LBP. Although many patients have returned to work, they will later experience continuing problems and work-related absences. Impairment present at more than 12 weeks postinjury may be far higher than what has been previously reported in the literature, where rates of 10% are common. In fact, the rates may go up to 3 to 4 times higher.
In a study by Schiotzz-Christensen and colleagues, the following was noted. In relation to sick leave, LBP has a favorable prognosis, with a 50% return to work within the first 8 days and only 2% on sick leave after 1 year. However, 15% had been on sick leave during the following year and about half continued to complain of discomfort. This suggested that an acute episode of LBP significant enough to cause the patient to seek a visit to a general practitioner is followed by a longer period of low-grade disability than previously reported. Also, even for those who returned to work, up to 16% indicated that they were not functionally improved. In another study looking at outcomes after 4 weeks after initial diagnosis and treatment, only 28% of patients did not experience any pain. More strikingly, the persistence of pain differed between groups that had radiating pain and those that did not, with 65% of the former feeling improvement at 4 weeks, vs 82% of the latter. The general findings from this study differ from others in that 72% of patients still experienced pain 4 weeks after initial diagnosis.
Hestbaek and colleagues reviewed a number of articles in a systematic review. The results showed that the reported proportion of patients who still experienced pain after 12 months after onset was 62% on average, with 16% sick-listed 6 months after onset, and with 60% experiencing relapse of work absence. Also, they found that the mean reported prevalence of LBP in patients who had past episodes of LBP was 56%, compared to just 22% for those who had no such history. Croft and colleagues performed a prospective study looking at the outcomes of LBP in general practice, finding that 90% of patients with LBP in primary care had stopped consulting with symptoms within 3 months; however, most were still experiencing LBP and disability 1 year after the initial visit. Only 25% had fully recovered within that same year.
There are even different results in the study by Wahlgren et al. Here, most patients continued to experience pain at both 6 and 12 months (78% and 72%, respectively). Only 20% of the sample had fully recovered by 6 months and only 22% by 12 months.
Von Korff has provided a lengthy list of data he considers relevant to assessing the clinical course of back pain as follows: age, sex, race/ethnicity, years of education, occupation, change in occupation, employment status, disability insurance status, litigation status, recency/age at first onset of back pain, recency/age when care was sought, recency of back pain episode, duration of current/most recent episode of back pain, number of back pain days, current pain intensity, average pain intensity, worst pain intensity, ratings of interference with activities, activity limitation days, clinical diagnosis for this episode, bed rest days, work loss days, recency of back pain flare-up, and duration of the most recent flare-up.
In a practice-based observational study by Haas et al of almost 3000 patients with acute and chronic condition treated by chiropractors and primary care medical doctors, pain was noted in patients with acute and chronic condition up to 48 months after enrollment. At 36 months, 45% to 75% of patients reported at least 30 days of pain in the prior year, and 19% to 27% of patients with chronic condition recalled daily pain over the previous year.
The variability noted in these and many other studies can be explained in part by the difficulty in making an adequate diagnosis, by the different classification schemes used in classifying LBP, by the different outcome tools used in each study and by many other factors. It also points up the extreme difficulty in getting a handle on the day-to-day reality for those who have LBP.
Common Markers and Rating Complexity for LBP
What Are the Relevant Benchmarks for Evaluating Process of Care?. One benchmark is described above, that being natural history. Complexity and risk stratification are important, as�are cost issues; however, cost-effectiveness is beyond the scope of this report.
It is understood that patients with uncomplicated LBP improve faster than those with various complications, the most notable of which is radiating pain. Many factors may influence the course of back pain, including comorbidity, ergonomic factors, age, the level of fitness of the patient, environmental factors, and psychosocial factors. The latter is receiving a great deal of attention in the literature, though as noted elsewhere in this book, such consideration may not be justified. Any of these factors, alone or in combination, may hamper or retard the recovery period after injury.
It seems that biomechanical factors play an important role in the incidence of first-time episodes of LBP and its attendant problems such as work loss; psychosocial factors come into play more in subsequent episodes of LBP. The biomechanical factors can lead to tissue tearing, which then create pain and limited ability for years to follow. This tissue damage cannot be seen on standard imaging and may only be apparent upon dissection or surgery.
abnormal joint motion or decreased body mechanics;
prolonged static posture or poor motor control;
work-related such as vehicle operation, sustained loads, materials handling;
employment history and satisfaction; and
wage status.
IJzelenberg and Burdorf investigated whether demographic, work-related physical, or psychosocial risk factors involved in the occurrence of musculoskeletal conditions determine subsequent health care use and sick leave. They found that within 6 months, nearly one third of industrial workers with LBP (or neck and upper extremity problems) had a recurrence of sick leave for that same problem and a 40% recurrence of health care use. Work-related factors associated with musculoskeletal symptoms were similar to those associated with health care use and sick leave; but, for LBP, older age and living alone strongly determined whether patients with these problems took any sick leave. The 12- month prevalence of LBP was 52%, and of those with symptoms at baseline, 68% had a recurrence of the LBP. Jarvik and colleagues add depression as an important predictor of new LBP. They found the use of MRI to be a less important predictor of LBP than depression.
What Are the Relevant Outcome Measures?. The Clinical Practice Guidelines formulated by the Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory Boards note that there are a number of outcomes that may be used to demonstrate change as a result of treatment. These should be both reliable and valid. According to the Canadian guidelines, appropriate standards are useful in chiropractic practice because they are able to perform the following:
consistently evaluate the effects of care over time;
help indicate the point of maximum therapeutic improvement;
uncover problems related to care such as noncompliance;
document improvement to the patient, doctor, and third parties;
suggest modifications of the goals of treatment if necessary;
quantify the clinical experience of the doctor;
justify the type, dose, and duration of care;
help provide a database for research; and
assist in establishing standards of treatment of specific conditions.
The broad general classes of outcomes include functional outcomes, patient perception outcomes, physiologic outcomes, general health assessments, and subluxation syndrome outcomes. This chapter addresses only functional and patient perception outcomes assessed by questionnaires and functional outcomes assessed by manual procedures.
Functional Outcomes. These are outcomes that measure the patient’s limitations in going about his or her normal daily activities. What is being looked at is the effect of a condition or disorder on the patient (ie, LBP, for which a specific diagnosis may not be present or possible) and its outcome of care. Many such outcome tools exist. Some of the better known include the following:
Roland Morris Disability Questionnaire,
Oswestry Disability Questionnaire,
Pain Disability Index,
Neck Disability Index,
Waddell Disability Index, and
Million Disability Questionnaire.
These are only some of the existing tools for assessing function.
In the existing RCT literature for LBP, functional outcomes have been shown to be the outcome that demonstrates the greatest change and improvement with SMT. Activities of daily living, along with patient selfreporting of pain, were the 2 most notable outcomes to show such improvement. Other outcomes fared less well, including trunk range of motion (ROM) and straight leg raise.
In the chiropractic literature, the outcome inventories used most frequently for LBP are the Roland Morris Disability Questionnaire and the Oswestry Questionnaire. In a study in 1992, Hsieh found that both tools provided consistent results over the course of his trial, although the results from the 2 questionnaires differed.
Patient Perception Outcomes. Another important set of outcomes involve patient perception of pain and their satisfaction with care. The first involves measuring changes in pain perception over time of its intensity, duration, and frequency. There are a number of valid tools available that can accomplish this, including the following:
Visual analog scale�this is a 10-cm line that has pain descriptions noted at both ends of that line representing no pain to intolerable pain; the patient is asked to mark a point on that line that reflects their perceived pain intensity. There are a number of variants for this outcome, including the Numerical Rating Scale (where the patient provides a number between 0 and 10 to represent the amount of pain they have) and the use of pain levels from 0 to 10 depicted pictorially in boxes, which the patient may check. All of these appear to be equally reliable, but for ease of use, either the standard VAS or Numerical Rating Scale is commonly used.
Pain diary�these may be used to help monitor a variety of different pain variables (for example, frequency, which the VAS cannot measure). Different forms may be used to collect this information, but it is typically completed on a daily basis.
McGill Pain Questionnaire�this scale helps quantify several psychologic components of pain as follows: cognitive-evaluative, motivational-affective, and sensory discriminative. In this instrument, there are 20 categories of words that describe the quality of pain. From the results, 6 different pain variables can be determined.
All of the above instruments have been used at various times to monitor the progress of treatment of back pain with SMT.
Patient satisfaction addresses both the effectiveness of care as well as the method of receiving that care. There are numerous methods of assessing patient satisfaction, and not all of them were designed to be specifically used for LBP or for manipulation. However, Deyo did develop one for use with LBP. His instrument examines the effectiveness of care, information, and caring. There is also the Patient Satisfaction Questionnaire, which assesses 8 separate indices (such as efficacy/outcomes or professional skill, for example). Cherkin noted that the Visit Specific Satisfaction Questionnaire can be used for chiropractic outcome assessment.
Recent work has shown that patient confidence and satisfaction with care are related to outcomes. Seferlis found that patients were more satisfied and felt that they were provided better explanations about their pain from practitioners who used manual therapy. Regardless of treatment, highly satisfied patients at 4 weeks were more likely than less satisfied patients to perceive greater pain improvement throughout 18-month follow-up in a study by Hurwitz et al. Goldstein and Morgenstern found a weak association between treatment confidence in the therapy they received and greater improvement in LBP. A frequent assertion is that benefits observed from application of manipulation methods are a result of physician attention and touching. Studies directly testing this hypothesis were conducted by Hadler et al in patients with acute condition and by Triano et al in patients with subacute and chronic condition. Both studies compared manipulation to a placebo control. In the study of Hadler, the control balanced for provider time attention and frequency, whereas Triano et al also added an education program with home exercise recommendations. In both cases, results demonstrated that although attention given to patients was associated with improvement over time, patients receiving manipulation procedures improved more quickly.
General Health Outcome Measures. This has traditionally been a difficult outcome to effectively measure but a number of more recent instruments are demonstrating that it can be done reliably. The 2 major instruments for doing so are the Sickness Impact Profile and the SF-36. The first assesses dimensions such as mobility, ambulation, rest, work, social interaction, and so on; the second looks primarily at well being, functional status, and overall health, as well as 8 other health concepts, to ultimately determine 8 indices that can be used to determine overall health status. Items here include physical functioning, social functioning, mental health, and others. This tool has been used in many settings and has also been adapted into shorter forms as well.
Physiologic Outcome Measures. The chiropractic profession has a number of physiologic outcomes that are used with regard to the patient care decision-making process. These include such procedures as ROM testing, muscle function testing, palpation, radiography, and other less common procedures (leg length analysis, thermography, and others). This chapter addresses only the physiologic outcomes assessed manually.
Range of Motion. This examination procedure is used by nearly every chiropractor and is used to assess impairment because it is related to spinal function. It is possible to use ROM as a means to monitor improvement in function over time and, therefore, improvement as it relates to the use of SMT. One can assess regional and global lumbar motion, for example, and use that as one marker for improvement.
Range of motion can be measured via a number of different means. One can use standard goniometers, inclinometers, and more sophisticated tools that require the use of specialized equipment and computers. When doing so, it is important to consider the reliability of each individual method. A number of studies have assessed various devices as follows:
Zachman found the use of the rangiometer moderately reliable,
Nansel found that using 5 repeated measures of cervical spine motion with an inclinometer to be reliable,
Liebenson found that the modified Schrober technique, along with inclinometers and flexible spinal rulers had the best support from the literature,
Triano and Schultz found that ROM for the trunk, along with trunk strength ratios and myoelectrical activity, was good indicator for LBP disability, and
a number of studies found that the kinematic measurement of ROM for spinal mobility is reliable.
Muscle Function. Evaluating muscle function may be done using an automated system or by manual means. Although manual muscle testing has been a common diagnostic practice within the chiropractic profession, there are few studies demonstrating clinical reliability for the procedure, and these are not considered to be of high quality.
Automated systems are more reliable and are capable of assessing muscle parameters such as strength, power, endurance, and work, as well as assess different modes of muscle contraction (isotonic, isometric, isokinetic). Hsieh found that a patient-initiated method worked well for specific muscles, and other studies have shown the dynamometer to have good reliability.
Leg Length Inequality. Very few studies of leg length have shown acceptable levels of reliability. The best methods for assessing reliability and validity of leg length involve radiographic means and are therefore subject to exposure to ionizing radiation. Finally, the procedure has not been studied as to validity, making the use of this as an outcome questionable.
Soft Tissue Compliance. Compliance is assessed by both manual and mechanical means, using the hand alone or using a device such as an algometer. By assessing compliance, the chiropractor is looking to assess muscle tone.
Early tests of compliance by Lawson demonstrated good reliability. Fisher found increases in tissue compliance with subjects involved in physical therapy. Waldorf found that prone segmental tissue compliance had good test/retest variation of less than 10%.
Pain tolerance assessed using these means has been found reliable, and Vernon found it was a useful measure in assessing the cervical paraspinal musculature after adjusting. The guidelines group from the Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory Boards concluded that �the assessments are safe and inexpensive and appear to be responsive to conditions and treatments commonly seen in chiropractic practice.�
Conclusion
Existing research evidence regarding the usefulness of spinal adjusting/manipulation/mobilization indicates the following:
As much or more evidence exists for the use of SMT to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP.
Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence.
There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.
Cases with high severity of symptoms may benefit by referral for comanagement of symptomswith medication.
There was little evidence for the use of manipulation for other conditions affecting the low back and very few articles to support a higher rating.
Exercise and reassurance have been shown to be of value primarily in chronic LBP and low back problems associated with radicular symptoms. A number of standardized, validated tools are available to help capture meaningful clinical improvement over the course of low back care. Typically, functional improvement (as opposed to simple reported reduction in pain levels) may be clinically meaningful for monitoring responses to care. The literature reviewed remains relatively limited in predicting responses to care, tailoring specific combinations of intervention regimens (although the combination of manipulation and exercise may be better than exercise alone), or formulating condition-specific recommendations for frequency and�duration of interventions. Table 2 summarizes the recommendations of the team, based on the review of the evidence.
Practical Applications
Evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic, acute, and subacute LBP.
Exercise in conjunction with manipulation is likely to speed and improve outcomes and minimize recurrence
In conclusion,�more evidence-based research studies have become available regarding the effectiveness of chiropractic care for low back pain and sciatica. The article also demonstrated that exercise should be used together with chiropractic to help speed up the rehabilitation process and further improve recovery. In most cases, chiropractic care can be used for the management of low back pain and sciatica, without the need for surgical interventions. However, if surgery is required to achieve recovery, a chiropractor may refer the patient to the next best healthcare professional. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
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Based on statistical findings, approximately more than three million people in the United States are injured in an automobile accident every year. In fact, auto accidents are considered to be one of the most common causes for trauma or injury. Neck injuries, such as whiplash, frequently occur due to the sudden back-and-forth movement of the head and neck from the force of the impact. The same mechanism of injury can also cause soft tissue injuries in other parts of the body, including the lower back as well as the lower extremities. Neck, hip, thigh and knee injuries are common types of injuries resulting from auto accidents.
Contents
Abstract
Objective: The purpose of this systematic review was to determine the effectiveness of exercise for the management of soft tissue injuries of the hip, thigh, and knee.
Methods: We conducted a systematic review and searched MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL Plus with Full Text from January 1, 1990, to April 8, 2015, for randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effect of exercise on pain intensity, self-rated recovery, functional recovery, health-related quality of life, psychological outcomes, and adverse events. Random pairs of independent reviewers screened titles and abstracts and assessed risk of bias using the Scottish Intercollegiate Guidelines Network criteria. Best evidence synthesis methodology was used.
Results: We screened 9494 citations. Eight RCTs were critically appraised, and 3 had low risk of bias and were included in our synthesis. One RCT found statistically significant improvements in pain and function favoring clinicbased progressive combined exercises over a �wait and see� approach for patellofemoral pain syndrome. A second RCT suggests that supervised closed kinetic chain exercises may lead to greater symptom improvement than open chain exercises for patellofemoral pain syndrome. One RCT suggests that clinic-based group exercises may be more effective than multimodal physiotherapy in male athletes with persistent groin pain.
Conclusion: We found limited high-quality evidence to support the use of exercise for the management of soft tissue injuries of the lower extremity. The evidence suggests that clinic-based exercise programs may benefit patients with patellofemoral pain syndrome and persistent groin pain. Further high-quality research is needed. (J Manipulative Physiol Ther 2016;39:110-120.e1)
Soft tissue injuries of the lower limb are common. In the United States, 36% of all injuries presenting to emergency departments are sprains and/or strains of the lower extremity. Among Ontario workers, approximately 19% of all approved lost time compensation claims are related to lower extremity injuries. Moreover, 27.5% of Saskatchewan adults injured in a traffic collision report pain in the lower extremity. Soft tissue injuries of the hip, thigh, and knee are costly and place a significant economic and disability burden on workplaces and compensation systems. According to the US Department of Labor Bureau of Statistics, the median time off work for lower extremity injuries was 12 days in 2013. Knee injuries were associated with the longest work absenteeism (median, 16 days).
Most soft tissue injuries of the lower limb are managed conservatively, and exercise is commonly used to treat these injuries. Exercise aims to promote good physical health and restore normal function of the joints and surrounding soft tissues through concepts which include range of motion, stretching, strengthening, endurance, agility, and proprioceptive exercises. However, the evidence about the effectiveness of exercise for managing soft tissue injuries of the lower limb is unclear.
Previous systematic reviews have investigated the effectiveness of exercise for the management of soft tissue injuries of the lower extremity. Reviews suggest that exercise is effective for the management of patellofemoral pain syndrome and groin injuries but not for patellar tendinopathy. To our knowledge, the only review reporting on the effectiveness of exercise for acute hamstring injuries found little evidence to support stretching, agility, and trunk stability exercises.
The purpose of our systematic review was to investigate the effectiveness of exercise compared to other interventions, placebo/sham interventions, or no intervention in improving self-rated recovery, functional recovery (eg, return to activities, work, or school), or clinical outcomes (eg, pain, health-related quality of life, depression) of patients with soft tissue injuries of the hip, thigh, and knee.
Methods
Registration
This systematic review protocol was registered with the International Prospective Register of Systematic Reviews on March 28, 2014 (CRD42014009140).
Eligibility Criteria
Population. Our review targeted studies of adults (?18 years) and/or children with soft tissue injuries of the hip, thigh, or knee. Soft tissue injuries include but are not limited to grade I to II sprains/strains; tendonitis; tendinopathy; tendinosis; patellofemoral pain (syndrome); iliotibial band syndrome; nonspecific hip, thigh, or knee pain (excluding major pathology); and other soft tissue injuries as informed by available evidence. We defined the grades of sprains and strains according to the classification proposed by the American Academy of Orthopaedic Surgeons (Tables 1 and 2). Affected soft tissues in the hip include the supporting ligaments and muscles crossing the hip joint into the thigh (including the hamstrings, quadriceps, and adductor muscle groups). Soft tissues of the knee include the supporting intra-articular and extra-articular ligaments and muscles crossing the knee joint from the thigh including the patellar tendon. We excluded studies of grade III sprains or strains, acetabular labral tears, meniscal tears, osteoarthritis, fractures, dislocations, and systemic diseases (eg, infection, neoplasm, inflammatory disorders).
Interventions. We restricted our review to studies that tested the isolated effect of exercise (ie, not part of a multimodal program of care). We defined exercise as any series of movements aimed at training or developing the body by routine practice or as physical training to promote good physical health.
Comparison Groups. We included studies that compared 1 or more exercise interventions to one another or one exercise intervention to other interventions, wait list, placebo/sham interventions, or no intervention.
Outcomes. To be eligible, studies had to include one of the following outcomes: (1) self-rated recovery; (2) functional recovery (eg, disability, return to activities, work, school, or sport); (3) pain intensity; (4) health-related quality of life; (5) psychological outcomes such as depression or fear; and (6) adverse events.
Study Characteristics. Eligible studies met the following criteria: (1) English language; (2) studies published between January 1, 1990, and April 8, 2015; (3) randomized controlled trials (RCTs), cohort studies, or case-control studies which are designed to assess the effectiveness and safety of interventions; and (4) included an inception cohort of a minimum of 30 participants per treatment arm with the specified condition for RCTs or 100 participants per group with the specified condition in cohort studies or case-control studies. Studies including other grades of sprains or strains in the hip, thigh, or knee had to provide separate results for participants with grades I or II sprains/strains to be included.
We excluded studies with the following characteristics: (1) letters, editorials, commentaries, unpublished manuscripts, dissertations, government reports, books and book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, or guideline statements; (2) study designs including pilot studies, cross-sectional studies, case reports, case series, qualitative studies, narrative reviews, systematic reviews (with or without meta-analyses), clinical practice guidelines, biomechanical studies, laboratory studies, and studies not reporting on methodology; (3) cadaveric or animal studies; and (4) studies on patients with severe injuries (eg, grade III sprains/strains, fractures, dislocations, full ruptures, infections, malignancy, osteoarthritis, and systemic disease).
Information Sources
We developed our search strategy with a health sciences librarian (Appendix 1). The Peer Review of Electronic Search Strategies (PRESS) Checklist was used by a second librarian to review the search strategy for completeness and accuracy. We searched MEDLINE and EMBASE, considered to be the major biomedical databases, and PsycINFO, for psychological literature through Ovid Technologies, Inc; CINAHL Plus with Full Text for nursing and allied health literature through EBSCOhost; and the Cochrane Central Register of Controlled Trials through Ovid Technologies, Inc, for any studies not captured by the other databases. The search strategy was first developed in MEDLINE and subsequently adapted to the other bibliographic databases. Our search strategies combined controlled vocabulary relevant to each database (eg, MeSH for MEDLINE) and text words relevant to exercise and soft tissue injuries of the hip, thigh, or knee including grade I to II sprain or strain injuries (Appendix 1). We also hand searched the reference lists of previous systematic reviews for any additional relevant studies.
Study Selection
A 2-phase screening process was used to select eligible studies. Random pairs of independent reviewers screened citation titles and abstracts to determine the eligibility of studies in phase 1. Screening resulted in studies being classified as relevant, possibly relevant, or irrelevant. In phase 2, the same pairs of reviewers independently screened the possibly relevant studies to determine eligibility. Reviewers met to reach consensus on the eligibility of studies and resolve disagreements. A third reviewer was used if consensus could not be reached.
Assessment of Risk of Bias
Independent reviewers were randomly paired to critically appraise the internal validity of eligible studies using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. The impact of selection bias, information bias, and confounding on the results of a study was qualitatively evaluated using the SIGN criteria. These criteria were used to guide reviewers in making an informed overall judgment on the internal validity of studies. This methodology has been previously described. A quantitative score or a cutoff point to determine the internal validity of studies was not used for this review.
The SIGN criteria for RCTs were used to critically appraise the following methodological aspects: (1) clarity of the research question, (2) randomization method, (3) concealment of treatment allocation, (4) blinding of treatment and outcomes, (5) similarity of baseline�characteristics between/among treatment arms, (6) cointervention contamination, (7) validity and reliability of outcome measures, (8) follow-up rates, (9) analysis according to intention-to-treat principles, and (10) comparability of results across study sites (where applicable). Consensus was reached through reviewer discussion. Disagreements were resolved by an independent third reviewer when consensus could not be reached. The risk of bias of each appraised study was also reviewed by a senior epidemiologist (PC). Authors were contacted when additional information was needed to complete the critical appraisal. Only studies with low risk of bias were included in our evidence synthesis.
Data Extraction and Synthesis of Results
Data were extracted from studies (DS) with low risk of bias to create evidence tables. A second reviewer independently checked the extracted data. We stratified results based on the duration of the condition (recent onset [0-3 months], persistent [N3 months], or variable duration [recent onset and persistent combined]).
We used standardized measures to determine the clinical importance of changes reported in each trial for common outcome measures. These include a between-group difference of 2/10 points on the Numeric Rating Scale (NRS), 2/10 cm difference on the Visual Analog Scale (VAS), and 10/100 point difference on the Kujala Patellofemoral scale, otherwise known as the Anterior Knee Pain Scale.
Statistical Analyses
Agreement between reviewers for the screening of articles was computed and reported using the ? statistic and 95% confidence interval (CI). Where available, we used data provided in the studies with a low risk of bias to measure the association between the tested interventions and the outcomes by computing the relative risk (RR) and its 95% CI. Similarly, we computed differences in mean changes between groups and 95% CI to quantify the effectiveness of interventions. The calculation of 95% CIs was based on the assumption that baseline and follow-up outcomes were highly correlated (r = 0.80).
Reporting
This systematic review was organized and reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.
Dr. Alex Jimenez’s Insight
As a doctor of chiropractic, automobile accident injuries are one of the most common reasons people seek chiropractic care. From neck injuries, such as whiplash, to headaches and back pain, chiropractic can be utilized to safely and effectively restore the integrity of the spine after a car crash. A chiropractor like myself will often use a combination of spinal adjustments and manual manipulations, as well as a variety of other non-invasive treatment methods,�to gently correct any spinal misalignments resulting from an auto accident injury. Whiplash and other types of neck injuries occur when the complex structures along the cervical spine are stretched beyond their natural range of movement due to the sudden back-and-forth movement of the head and neck from the force of the impact. Back injury, particularly in the lower spine, are also common as a result of an automobile accident. When the complex structures along the lumbar spine are damaged or injured, symptoms of sciatica may radiate down the lower back, into the buttocks, hips, thighs, legs and down into the feet. Knee injuries may also occur upon impact during an auto accident. Exercise is frequently used with chiropractic care to help promote recovery as well as improve strength, flexibility and mobility. Rehabilitation exercises are offered to patients to further restore the integrity of their body. The following research studies demonstrate that exercise, compared to non-invasive treatment options, is a safe and effective treatment method for individuals suffering with neck and lower extremity injury from a car crash.
Results
Study Selection
We screened 9494 citations based on the title and abstract (Figure 1). Of these, 60 full-text publications were screened, and 9 articles were critically appraised. The primary reasons for ineligibility during full text screening were (1) ineligible study design, (2) small sample size (n b 30 per treatment arm), (3) multimodal interventions not allowing isolation of the effectiveness of exercise, (4) ineligible study population, and (5) interventions not meeting our definition of exercise (Figure 1). Of those critically appraised, 3 studies (reported in 4 articles) had low risk of bias and were included in our synthesis. The interrater agreement for the screening of the articles was ? = 0.82 (95% CI, 0.69-0.95). The percentage agreement for the critical appraisal of studies was 75% (6/8 studies). Disagreement was resolved through discussion for 2 studies. We contacted authors from 5 studies during critical appraisal to request additional information and 3 responded.
Study Characteristics
The studies with low risk of bias were RCTs. One study, conducted in the Netherlands, examined the effectiveness of a standardized exercise program compared to a �wait and see� approach in participants with patellofemoral pain syndrome of variable duration. A second study, with outcomes reported in 2 articles, compared the benefit of closed vs open kinetic chain exercises in individuals with�variable duration patellofemoral pain syndrome in Belgium. The final study, conducted in Denmark, investigated active training compared to a multimodal physiotherapy intervention for the management of persistent adductor-related groin pain.
Two RCTs used exercise programs that combined strengthening exercises with balance or agility training for the lower extremity. Specifically, the strengthening exercises consisted of both isometric and concentric contractions of the quadriceps, hip adductor, and gluteal muscles for the management of patellofemoral pain46 and hip adductors and muscles of the trunk and pelvis for adductor-related groin pain. The exercise programs ranged from 646 to 1243 weeks in duration and were supervised and clinic based with additional daily home exercises. The exercise programs were compared to a �wait and see� approach or to multimodal physiotherapy. The third RCT compared 2 different 5-week protocols which combined either closed or open kinetic chain strengthening and stretching exercises for the lower extremity musculature.
Meta-analysis was not performed due to heterogeneity of accepted studies with respect to patient populations, interventions, comparators, and outcomes. Principles of best evidence synthesis were used to develop evidence statements and perform a qualitative synthesis of findings from studies with low risk of bias.
Risk of Bias Within Studies
The studies with low risk of bias had a clearly defined research question, used appropriate blinding methods where possible, reported adequate similarity of baseline characteristics between treatment arms, and performed an intention-to-treat analyses where applicable (Table 3). The RCTs had follow-up rates greater than 85%. However, these studies also had methodological limitations: insufficient detail describing methods for allocation concealment (1/3), insufficient detail describing methods of randomization (1/3), the use of outcome measures that have not been demonstrated to be valid or reliable (ie, muscle length and successful treatment) (2/3), and clinically important differences in baseline characteristics (1/3).
Of 9 relevant articles, 5 were deemed to have high risk of bias. These studies had the following limitations: (1) poor or unknown randomization methods (3/5); (2) poor or unknown allocation concealment methods (5/ 5); (3) outcome assessor not blinded (4/ 5); (4) clinically important differences in baseline characteristics (3/5); (5) dropouts not reported, insufficient information regarding dropouts per group or large differences in dropout rates between treatment arms (N15%) (3/5); and (6) a lack of information about or no intention-to-treat analysis (5/5).
Summary of Evidence
Patellofemoral Pain Syndrome of Variable Duration. Evidence from 1 RCT suggests that a clinic-based progressive exercise program may provide short- and long-term benefit over usual care for the management of patellofemoral pain syndrome of variable duration. van Linschoten et al randomized participants with a clinical diagnosis of patellofemoral pain syndrome of 2 months to 2 years duration to (1) a clinic-based exercise program (9 visits over 6 weeks) consisting of progressive, static, and dynamic strengthening exercises for the quadriceps, adductor, and gluteal muscles and balance and flexibility exercises, or (2) a usual care �wait and see� approach. Both groups received standardized information, advice, and home-based isometric exercises for the quadriceps based on recommendations from Dutch General Practitioner guidelines (Table 4). There�were statistically significant differences favoring the exercise group for (1) pain (NRS) at rest at 3 months (mean change difference 1.1/10 [95% CI, 0.2-1.9]) and 6 months (mean change difference 1.3/10 [95% CI, 0.4-2.2]); (2) pain (NRS) with activity at 3 months (mean change difference 1.0/10 [95% CI, 0.1-1.9]) and 6 months (mean change difference 1.2/10 [95% CI, 0.2-2.2]); and (3) function (Kujala Patellofemoral Scale [KPS]) at 3 months (mean change difference 4.9/100 [95% CI, 0.1-9.7]). However, none of these differences were clinically important. Furthermore, there were no significant differences in the proportion of participants reporting recovery (fully recovered, strongly recovered), but the exercise group was more likely to report improvement at 3-month follow-up (odds ratio [OR], 4.1 [95% CI, 1.9-8.9]).
Evidence from a second RCT suggests that physiotherapist- supervised closed kinetic chain leg exercises (where the foot remains in constant contact with a surface) may provide short-term benefit compared to supervised open kinetic chain exercises (where the limb moves freely) for some patellofemoral pain syndrome symptoms (Table 4). All participants trained for 30 to 45 minutes, 3 times per week for 5 weeks. Both groups were instructed to perform static lower limb stretching after each training session. Those randomized to closed chain exercises performed supervised (1) leg presses, (2) knee bends, (3) stationary biking, (4) rowing, (5) step-up and step-down exercises, and (6) progressive jumping exercises. Open chain exercise participants performed (1) maximal quad muscle contraction, (2) straight-leg raises, (3) short arc movements from 10� to full knee extension, and (4) leg adduction. Effect sizes were not reported, but the authors reported statistically significant differences favoring closed kinetic chain exercise at 3 months for (1) frequency of locking (P = .03), (2) clicking sensation (P = .04), (3) pain with isokinetic testing (P = .03), and (4) pain during night (P = .02). The clinical significance of these results is unknown. There were no statistically significant differences between groups for any other pain or functional measures at any follow-up period.
Persistent Adductor-Related Groin Pain
Evidence from 1 RCT suggests that a clinic-based group exercise program is more effective than a multimodal program of care for persistent adductor-related groin pain. H�lmich et al studied a group of male athletes with a clinical diagnosis of adductor-related groin pain of greater than 2 months duration (median duration, 38-41 weeks; range, 14-572 weeks) with or without osteitis pubis. Participants were randomized to (1) a clinic-based group exercise program (3 sessions per week for 8-12 weeks) consisting of isometric and concentric resistance strengthening exercises for the adductors, trunk, and pelvis; balance and agility exercises for the lower extremity; and stretching for the abdominals, back, and lower extremity (with the exception of the adductor muscles) or (2) a multimodal physiotherapy program (2 visits per week for 8-12 weeks) consisting of laser; transverse friction massage; transcutaneous electrical nerve stimulation (TENS); and stretching for the adductors, hamstrings, and hip flexors (Table 4). Four months after the intervention, the exercise group was more likely to report that their condition was �much better� (RR, 1.7 [95% CI, 1.0-2.8]).
Adverse Events
None of the included studies commented on the frequency or nature of adverse events.
Discussion
Summary of Evidence
Our systematic review examined the effectiveness of exercise for the management of soft tissue injuries of the hip, thigh, or knee. Evidence from 1 RCT suggests that a clinic-based progressive combined exercise program may offer additional short- or long-term benefit compared to providing information and advice for the management of patellofemoral pain syndrome of variable duration. There is also evidence that supervised closed kinetic chain exercises may be beneficial for some patellofemoral pain syndrome symptoms compared to open kinetic chain exercises. For persistent adductor-related groin pain, evidence from 1 RCT suggests that a clinic-based group exercise program is more effective than a multimodal program of care. Despite the common and frequent use of exercise prescription, there is limited high-quality evidence to inform the use of exercise for the management of soft tissue injuries of the lower extremity. Specifically, we did not find high-quality studies on exercise for the management of some of the more commonly diagnosed conditions including patellar tendinopathy, hamstring sprain and strain injuries, hamstring tendinopathy, trochanteric bursitis, or capsular injuries of the hip.
Previous Systematic Reviews
Our results are consistent with findings from previous systematic reviews, concluding that exercise is effective for the management of patellofemoral pain syndrome and groin pain. However, the results from previous systematic reviews examining the use of exercise for the management of patellar tendinopathy and acute hamstring injuries are inconclusive. One review noted strong evidence for use of eccentric training, whereas others reported uncertainty of whether isolated eccentric exercises were beneficial for tendinopathy compared to other forms of exercise. Furthermore, there is limited evidence of a positive effect from stretching, agility and trunk stability exercises, or slump stretching for the management of acute�hamstring injuries. Differing conclusions between systematic reviews and the limited number of studies deemed admissible in our work may be attributed to differences in methodology. We screened reference lists of previous systematic reviews, and most studies included in the reviews did not meet our inclusion criteria. Many studies accepted in other reviews had small sample sizes (b30 per treatment arm). This increases the risk of residual confounding while also reducing the effect size precision. Furthermore, a number of systematic reviews included case series and case studies. These types of studies are not designed to assess the effectiveness of interventions. Finally, previous reviews included studies where exercise was part of a multimodal intervention, and as a consequence, the isolated effect of exercise could not be ascertained. Of the studies that satisfied our selection criteria, all were critically appraised in our review, and only 3 had low risk of bias and were included in our synthesis.
Strengths
Our review has many strengths. First, we developed a rigorous search strategy that was independently reviewed by a second librarian. Second, we defined clear inclusion and exclusion criteria for the selection of possibly relevant studies and only considered studies with adequate sample sizes. Third, pairs of trained reviewers screened and critically appraised eligible studies. Fourth, we used a valid set of criteria (SIGN) to critically appraise studies. Finally, we restricted our synthesis to studies with low risk of bias.
Limitations and Recommendations for Future Research
Our review also has limitations. First, our search was limited to studies published in the English language. However, previous reviews have found that the restriction of systematic reviews to English language studies has not led to a bias in reported results. Second, despite our broad definition of soft tissue injuries of the hip, thigh, or knee, our search strategy may not have captured all potentially relevant studies. Third, our review may have missed potentially relevant studies published before 1990. We aimed to minimize this by hand searching the reference lists of previous systematic reviews. Finally, critical appraisal requires scientific judgment that may differ between reviewers. We minimized this potential bias by training reviewers in the use of the SIGN tool and using a consensus process to determine study admissibility. Overall, our systematic review highlights a deficit of strong research in this area.
High-quality studies on the effectiveness of exercise for the management of soft tissue injuries of the lower extremity are needed. Most studies included in our review (63%) had a high risk of bias and could not be included in our synthesis. Our review identified important gaps in the literature. Specifically, studies are needed to inform the specific effects of exercises, their long-term effects, and the optimal doses of intervention. Furthermore, studies are needed to determine the relative effectiveness of different types of exercise programs and if the effectiveness varies for soft tissue injuries of the hip, thigh, and knee.
Conclusion
There is limited high-quality evidence to inform the use of exercise for the management of soft tissue injuries of the hip, thigh, and knee. The current evidence suggests that a clinic-based progressive combined exercise program may lead to improved recovery when added to information and advice on resting and avoiding pain provoking activities for the management of patellofemoral pain syndrome. For persistent adductor-related groin pain, a supervised clinic- based group exercise program is more effective than multimodal care in promoting recovery.
Funding Sources and Potential Conflicts of Interest
This study was funded by the Ontario Ministry of Finance and the Financial Services Commission of Ontario (RFP no. OSS_00267175). The funding agency was not involved in the collection of data, data analysis, interpretation of data, or drafting of the manuscript. The research was undertaken, in part, thanks to funding from the Canada Research Chairs program. Pierre C�t� has previously received funding from a Grant from the Ontario Ministry of Finance; consulting for the Canadian Chiropractic Protective Association; speaking and/or teaching arrangements for the National Judicial Institute and Soci�t� des M�decins Experts du Quebec; trips/travel, European Spine Society; board of directors, European Spine Society; grants: Aviva Canada; fellowship support, Canada Research Chair Program�Canadian Institutes of Health Research. No other conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): D.S., C.B., P.C., J.W., H.Y., S.V.
Design (planned the methods to generate the results): D.S., C.B., P.C., H.S., J.W., H.Y., S.V.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): D.S., P.C.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): D.S., C.B., H.S., J.W., D.e.S., R.G., H.Y., K.R., J.C., K.D., P.C., P.S., R.M., S.D., S.V.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): D.S., C.B., P.C., H.S., M.S., K.R., L.C.
Literature search (performed the literature search): A.T.V.
Writing (responsible for writing a substantive part of the manuscript): D.S., C.B., P.C., H.S.
Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): D.S., P.C., H.S., J.W., D.e.S., R.G., M.S., A.T.V., H.Y., K.R., J.C., K.D., L.C., P.S., S.D., R.M., S.V.
Practical Applications
There is evidence to suggest that clinic-based exercises may benefit patients with patellofemoral pain syndrome or adductor-related groin pain.
Supervised progressive exercises may be beneficial for patellofemoral pain syndrome of variable duration compared to information/advice.
Supervised closed kinetic chain exercises may provide more benefit compared to open kinetic chain exercises for some patellofemoral pain syndrome symptoms.
Self-rated improvement in persistent groin pain is higher after a clinic-based group exercise program compared to multimodal physiotherapy.
Are Non-Invasive Interventions Effective for the Management of Headaches Associated with Neck Pain?
Furthermore,�other non-invasive interventions, as well as non-pharmacological interventions, are also commonly utilized to help treat symptoms of neck pain and headaches associated with neck injuries, such as whiplash, caused by automobile accidents. As mentioned before, whiplash is one of the most common types of neck injuries resulting from auto accidents. Chiropractic care, physical therapy and exercise, can be used to improve the symptoms of neck pain, according to the following research studies.
Abstract
Purpose
To update findings of the 2000�2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and evaluate the effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain (i.e., tension-type, cervicogenic, or whiplash-related headaches).
Methods
We searched five databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case�control studies comparing non-invasive interventions with other interventions, placebo/sham, or no interventions. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria to determine scientific admissibility. Studies with a low risk of bias were synthesized following best evidence synthesis principles.
Results
We screened 17,236 citations, 15 studies were relevant, and 10 had a low risk of bias. The evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises. Patients with chronic tension-type headaches may also benefit from low load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction. For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful.
Conclusions
The management of headaches associated with neck pain should include exercise. Patients who suffer from chronic tension-type headaches may also benefit from relaxation training with stress coping therapy or multimodal care. Patients with cervicogenic headache may also benefit from a course of manual therapy.
We would like to acknowledge and thank all of the individuals who have made important contributions to this review: Robert Brison, Poonam Cardoso, J. David Cassidy, Laura Chang, Douglas Gross, Murray Krahn, Michel Lacerte, Gail Lindsay, Patrick Loisel, Mike Paulden, Roger Salhany, John Stapleton, Angela Verven, and Leslie Verville. We would also like to thank Trish Johns-Wilson at the University of Ontario Institute of Technology for her review of the search strategy.
Compliance with Ethical Standards
Conflict of Interest
Dr. Pierre C�t� has received a grant from the Ontario government, Ministry of Finance, funding from the Canada Research Chairs program, personal fees from National Judicial Institute for lecturing, and personal fees from European Spine Society for teaching. Drs. Silvano Mior and Margareta Nordin have received reimbursement for travel expenses to attend meetings for the study. The remaining authors report no declarations of interest.
Funding
This work was supported by the Ontario Ministry of Finance and the Financial Services Commission of Ontario [RFP# OSS_00267175]. The funding agency had no involvement in the study design, collection, analysis, interpretation of data, writing of the manuscript or decision to submit the manuscript for publication. The research was undertaken, in part, thanks to funding from the Canada Research Chairs program to Dr. Pierre C�t�, Canada Research Chair in Disability Prevention and Rehabilitation at the University of Ontario Institute of Technology.
In conclusion,�exercise included in chiropractic care and other non-invasive interventions should be utilized as an essential part of treatment to further help improve the symptoms of neck injury as well as that of hip, thigh and knee injury. According to the above research studies, exercise, or physical activity, is beneficial towards speeding up recovery time for patients with automobile accident injuries and for restoring strength, flexibility and mobility to the affected structures of the spine. 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: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
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Crash: Few instances shatter our normal world into pieces more quickly than an automobile accident. Never expected, a wreck causes bodily injury, stress, and, in some cases, ongoing financial litigation issues.
Unfortunately, the vast number of vehicles on the road today, as well as drivers’ penchant for distracted driving, dramatically increases an individual’s chances of being involved in a crash. If you already suffer from an injury or medical condition, you must do your part to ensure it is not aggravated or exacerbated.
If a car crash happens to you, it’s essential to recognize and follow these six tips to keep you safe and your injuries to a minimum.
Contents
Car Crash: Immediately Take Stock Of The Situation
The way you react seconds after a crash impacts the situation tremendously. Determine what area you are injured, and if you are in imminent danger in the vehicle.
For example, if the automobile is on fire, or you are sinking into a lake, rescue yourself as quickly as possible. Otherwise, stay inside your vehicle.
Analyze Your Injured Areas
How injured do you appear to be? Keep in mind you are not a doctor. So, even if you feel fine, your neck or back could still have been impacted. Identify which areas of your body hurts, and the intensity of the pain.
Wait For The Authorities
Stay calm inside your vehicle and wait for the police and ambulance to arrive. This is imperative if your vehicle has flipped and you are hanging from your seatbelt.
Many head and neck injuries result from automobile occupants releasing their seat belts after a crash that has left them upside down.
Inform The Emergency Technicians
Once help arrives, it’s vital to explain to them, if you can, the areas of injury. If you have previously suffered from injury or medical condition to your neck, back, or spine, let them know that, too.
This information helps them formulate the form of extraction and emergency treatment that minimizes the chance of creating further harm. Be calm and specific when you relay the information, using simple language and the 1-10 pain scale to describe your level of discomfort.
Visit Your Chiropractor
If your injuries are deemed minimal and you are released, be happy and grateful that you were not hurt worse! Then, make an appointment with your chiropractor, and explain the nature of the wreck.
Certain injuries take a few days to show up, and the crash could have impacted bones, joints, and ligaments that went undiscovered during the initial after-crash exam. Ask for a complete examination, and talk with your chiropractor about any treatment deemed necessary.
Minimize The Chances Of Another Automobile Accident
While you cannot control being in a wreck, you can take measures to guard against the occurrence, and give yourself a greater chance to avoid injury. Always wear your seatbelt, avoid distracted driving (this means your cell phone), maintain your vehicle’s brakes and tires, and understand the current traffic laws. Commit to driving at a safe speed depending on the weather conditions, and never, ever drive after imbibing alcohol.
Being in an automobile accident is scary business, and we hope it never happens to you. There is increased risk to individuals who already deal with medical conditions or bodily injuries from sports, work, or falls.
However, by maintaining a clear head and following these six tips, you can minimize the chance of being seriously injured in many car wreck situations and return to your normal life quickly, putting this awful incident behind you.
Basketball Hall Of Famer Nancy Lieberman Rear Ended
This article is copyrighted by Blogging Chiros LLC for its Doctor of Chiropractic members and may not be copied or duplicated in any manner including printed or electronic media, regardless of whether for a fee or gratis without the prior written permission of Blogging Chiros, LLC.
Chiropractic Care: Our neck is a busy body part. It holds up and turns our head, allowing us to see, hear, and speak in the direction we choose.
Although the neck is a real “team player” it’s a bit of a diva, meaning it’s fairly delicate. There are many ways everyday motion injures the neck, ending up causing pain, decreased mobility, and varying degrees of short and long-term misery.
Whiplash is a common neck injury caused by a sudden movement that jerks the neck forth and then back in a whipping motion. Automobile accidents frequently result in whiplash, as the vehicle is moving and then stopping rapidly.
This affects the neck’s ligaments and joints in various degrees, depending on the speed of the vehicle and the site of the impact. In severe cases, the discs and the nerves may also be damaged.
Symptoms of whiplash include varying degrees of pain, stiffness in the neck, headaches, and sometimes dizziness, blurred vision, and nausea. Some people only suffer with whiplash a few days, while others experience ongoing issues.
If you have been injured in an automobile crash, it’s in your best interest to immediately schedule an appointment with a chiropractor. There are a myriad of ways chiropractic care assists in managing the pain and minimizing the symptoms of whiplash.
Contents
Here Are The 5 Best Reasons For Chiropractic Care:
#1: Reduces Inflammation To Promote Healing
The first order of business for whiplash sufferers is to get the neck’s inflammation reduced, as this hinders proper healing. Your chiropractor will utilize chiropractic adjustments, along with other forms of treatment based on your specific injury. It�s essential to undergo this type of treatment as soon after the injury occurs as possible in order to reach optimum results.
#2: Minimizes Pain For Greater Comfort
Whiplash can be extremely painful, as so many of the neck’s components may be involved, and the neck is such a mobile body part. Every neck movement hurting is no way to live! Chiropractic care soothes the pain of whiplash through therapeutic techniques that promote healing of the damaged area.
#3: Returns Proper Body Alignment
When the inflammation and the pain of whiplash are reduced, the next step is to promote healing and alignment within the body. A chiropractor will perform a series of chiropractic adjustments that includes the neck and spine, but may also incorporate other parts of the body. Whiplash does a number on the body’s natural alignment, and it’s the chiropractor’s job to put it all back together in workable order.
#4: Offers Exercises To Increase Mobility
Contrary to old movies where the whiplash sufferer wears a cumbersome neck brace, it’s vital to the rehabilitation process to keep moving. During chiropractic visits, patients receive a regimen of exercises to perform regularly at home. These, combined with chiropractic care, lessen the time it takes to recover.
#5: Provides An Alternative To Surgery
The good news is that a whiplash injury rarely requires surgery. However, it’s best to not tempt fate and visit a chiropractor to make certain your injuries are treated and begin healing. A chiropractor monitors improvements and keeps you apprised of your progress, empowering you to get better and back to normal activity faster than simply suffering through the symptoms, hoping they go away.
If you are involved in a motor vehicle crash and end up with whiplash, don’t despair. A chiropractor will map out a treatment regimen that will decrease inflammation and pain, increase mobility, and promote healing. Remember, the sooner you see your chiropractor, the faster the treatment begins, and the sooner you see results. Don’t suffer needlessly!
Chiropractic Care & Headaches
This article is copyrighted by Blogging Chiros LLC for its Doctor of Chiropractic members and may not be copied or duplicated in any manner including printed or electronic media, regardless of whether for a fee or gratis without the prior written permission of Blogging Chiros, LLC.
Soccer is one of the most popular team sports in the United States, and offers an excellent form of exercise to children and adults alike. Unfortunately, the nature of the sport, the repeated movement and the chance of collision, add up to quite a few opportunities for injury.
Lower and upper extremity injuries, overuse injuries, and head, neck, and face injuries are commonplace. According to Stanford Children’s Health, “88,000 children 8-14 were treated in an emergency room for soccer-related injuries.”
Soccer players who take certain precautionary measures decrease their chances of injury. Let�s look at three ways you can avoid injury as a soccer player:
Contents
#1: Soccer: Use Proper Equipment
Donning proper fitting cleats, uniforms, and shin guards decrease the risk of being hurt in the first place. Make adjustments often, especially if the player is growing rapidly or fluctuates in weight.
#2: Get Checked Out By A Chiropractor Pre-Season
Soccer players who allow their fitness less to lapse increase the chance of injury. Visit a Doctor of Chiropractic to ensure there are no underlying issues with participating in strenuous activity. A chiropractor is also able to make sure the spine is aligned and muscles and joints are strong and functioning properly.
#3: Pay Attention To The Surroundings
A field that is not kept up well offers a greater chance of turning an ankle or falling. It’s vital to check out the playing area beforehand and note any uneven areas that could cause a player to trip.
In addition, consider the weather. Muddy, slick fields create extra issues, and particularly hot temperatures make players run the risk of dehydration or heat stroke. Prepare for weather issues in advance of the game.
If, even though you take all of these precautions, you still end up injured, there are several options for treatment. The injury is hopefully mild and heals on its own after a few days of rest. More serious injuries require a doctor visit, and one of these three treatments.
First, ice and elevate it: Keep weight off the injured area as much as possible, and elevate it with pillows. Use an ice bag wrapped in a towel to keep down swelling and inflammation. If the injury is painful, over the counter medication helps reduce discomfort.
Then, take a break: The last decision you want to make is to begin playing too soon and re-injure yourself. With more serious injuries, sitting out of a few games, or even an entire season, is a choice that promotes healing and health. Talk to your chiropractor about the timeframe the injury needs to be able to recover correctly, and follow his or her advice.
Finally, keep your chiropractic adjustments: Chiropractors are trained in treating the neuromusculoskeletal system as a whole. Many of the injuries suffered from soccer show an improvement after a few chiropractic visits.
Spinal and joint alignment, muscle healing, and tendon relaxation are all techniques chiropractors employ to promote and hasten healing. Additionally, chiropractors give insight on valuable ways to use nutrition and exercise to keep the body functioning at optimum capacity, to avoid re-injury.
Enjoying physical activity is essential to maintain a routine that provides a healthy, active lifestyle, and joining a soccer team is a great choice for children as well as adults. Knowing the advance precautions to put in place to avoid injury will help keep you strong and safe.
If, however, you or your child end up hurt, these forms of treatment will lessen healing time and get you back in the game at full speed. So give us a call to schedule your next appointment before you get back out on the pitch.
Chiropractic Treatment For Concussions
This article is copyrighted by Blogging Chiros LLC for its Doctor of Chiropractic members and may not be copied or duplicated in any manner including printed or electronic media, regardless of whether for a fee or gratis without the prior written permission of Blogging Chiros, LLC.
Back pain is one of the most common causes people visit their healthcare professional every year. A primary care physician is often the first doctor who can provide treatment for a variety of injuries and/or conditions, however, among those individuals seeking complementary and alternative treatment options for back pain, most people choose chiropractic care. Chiropractic care focuses on the diagnosis, treatment and prevention of trauma and disease of the musculoskeletal and nervous systems, by correcting misalignments of the spine through the use of spinal adjustments and manual manipulations.
Approximately 35% of individuals seek chiropractic treatment for back pain caused by automobile accidents, sports injuries, and a variety of muscle strains. When people suffer an trauma or injury as a result of an accident, however, they may first receive treatment for their symptoms of back pain in a hospital. Hospital outpatient care describes treatment which does not require an overnight stay at a medical facility. A research study conducted an analysis comparing the effects of chiropractic care and hospital outpatient management for back pain. The results are described in detail below.
Contents
Abstract
Objective: To compare the effectiveness over three years of chiropractic and hospital outpatient management for low back pain.
Design: Randomised allocation of patients to chiropractic or hospital outpatient management.
Setting: Chiropractic clinics and hospital outpatient departments within reasonable travelling distance of each other in I I centres.
Subjects: 741 men and women aged 18-64 years with low back pain in whom manipulation was not contraindicated.
Outcome measures: Change in total 0swestry questionnaire score and in score for pain and patient satisfaction with allocated treatment.
Results: According to total 0swestry scores improvement in all patients at three years was about 291/6 more in those treated by chiropractors than in those treated by the hospitals. The beneficial effect of chiropractic on pain was particularly clear. Those treated by chiropractors had more further treatments for back pain after the completion of trial treatment. Among both those initially referred from chiropractors and from hospitals more rated chiropractic helpful at three years than hospital management.
Conclusions: At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals.
Introduction
In 1990 we reported greater improvement in patients with low back pain treated by chiropractic compared with those receiving hospital outpatient management. The trial was “pragmatic” in allowing the therapists to treat patients as they would in day to day practice. At the time of our first report not all patients had been in the trial for more than six months. This paper presents the full results up to three years for all patients for whom follow up information from Oswestry questionnaires and for other outcomes was available for analysis. We also present data on pain from the questionnaire, which is by definition the main complaint prompting referral or self referral.
Methods
Methods were fully described in our first report. Patients initially referred or presenting either to a chiropractic clinic or in hospital were randomly allocated to be treated either by chiropractic or in hospital. A total of 741 patients started treatment. Progress was measured with the Oswestry questionnaire on back pain, which gives scores for I 0 sections for example, intensity of pain and difficulty with lifting, walking, and travelling. The result is expressed on a scale ranging from 0 (no pain or difficulties) to 100 (highest score for pain and greatest difficulty on all items). For an individual item, such as pain, scores range from 0 to 10. The main outcome measures are the changes in Oswestry score from before treatment to each follow up. At one, two, and three years patients were also asked about further treatment since the completion of their trial treatment or since the previous annual questionnaire. At the three year follow up patients were asked whether they thought their allocated trial treatment had helped their back pain.
In the random allocation of treatment minimisation was used within each centre to establish groups for the analysis of results according to initial referral clinic, length of current episode (more or less than ‘a month), presence or absence of a history of back pain, and an Oswestry score at entry of > 40 or <=40%.
Results were analysed on an intention to treat basis (subject to the availability of data at follow up as well as at entry for individual patients). Differences between mean changes were tested by unpaired t tests, and X2 tests were used to test for differences in proportions between the two treatment groups.
Dr. Alex Jimenez’s Insight
Chiropractic is a natural form of health care which purpose is to restore and maintain the function of the musculoskeletal and nervous systems, promoting spinal health and allowing the body to heal itself naturally. Our philosophy emphasizes on the treatment of the human body as a whole, rather than on the treatment of a single injury and/or condition. As an experienced chiropractor, my goal is to properly assess patients in order to determine which type of treatment will most effectively heal their individual type of health issue. From spinal adjustments and manual manipulations to physical activity, chiropractic care can help correct spinal misalignments that cause back pain.
Results
Follow up Oswestry questionnaires were returned by a consistently higher proportion of patients allocated to chiropractic than to hospital treatment. At six weeks, for example, they were returned by 95% and 89% of chiropractic and hospital patients, respectively and at three years by 77% and 70%.
Mean (SD) scores before treatment were 29-8 (14-2) and 28-5 (14-1) in the chiropractic and hospital treatment groups, respectively. Table I shows the differences between the mean changes in total Oswestry scores according to randomly allocated treatment group. The difference at each follow up is the mean change for the chiropractic group minus the mean change for the hospital group.
Positive differences therefore reflect more improvement (due to a greater change in score) in those treated by chiropractic than in hospital (negative differences the reverse). The 3-18 percentage point difference at three years in table I represents a 29% greater improvement in patients treated with chiropractic compared with hospital treatment, the absolute improvement in the two groups at this time being 14-1 and 10-9 percentage points, respectively. As in the first report those with short current episodes, a history of back pain, and initially high Oswestry scores tended to derive most benefit from chiropractic. Those referred by chiropractors consistently derived more benefit from chiropractic than those referred by hospitals.
Table II shows changes between the scores on pain intensity before treatment and the corresponding scores at the various follow up intervals. All these changes were positive that is, indicated improvement but were all significantly greater in those treated by chiropractic, including the changes early on that is, at six weeks and six months, when the proportions returning questionnaires were high. As with the results based on the full Oswestry score the improvement due to chiropractic was greatest in those initially referred by chiropractors, although there was also a non-significant improvement (ranging from 9% at six months to 34% at three years) due to chiropractic at each follow up interval in those referred by hospitals.
Other scores for individual items on the Oswestry index to show significant improvement attributable to chiropractic were ability to sit for more than a short time and sleeping (P=0’004 and 0 03, respectively, at three years), though the differences were not as consistent as for pain. Other scores (personal care, lifting, walking, standing, sex life, social life, and travelling) also nearly all improved more in the patients treated with chiropractic, though most of the differences were small compared with the differences for pain.
Higher proportions of patients allocated to chiropractic sought further treatment (of any kind) for back pain after completion of trial treatment than those managed in hospital. For example, between one and two years after trial entry 122/292 (42%) patients treated with chiropractic compared with 80/258 (3 1%) of hospital treated patients did so (Xl=6 8, P=0 0 1).
Table III shows the proportions of patients at three years who thought their allocated trial treatment had helped their back pain. Among those initially referred by hospitals as well as among those initially referred by chiropractors higher proportions treated by chiropractic considered that treatment had helped compared with those treated in hospital.
Key Messages
Back pain often remits spontaneously
Effective treatments for non-remitting episodes need to be more clearly identified
Chiropractic seems to be more effective than hospital management, possibly because more treatments are spread over longer time periods
A growing number of NHS purchasers are making complementary treatments, including chiropractic, available
Further trials to identify the effective components of chiropractic are needed
Discussion
The results at six weeks and six months shown in table I are identical with those in our first report, as all patients had then been followed up for six months. The findings at one year are similar as many patients had also been followed up then. The considerably larger numbers of patients with data now available at two and three years show smaller benefits at these intervals than previously, though these still significantly favour chiropractic. The substantial benefit of chiropractic on intensity of pain is evident early on and then persists. The consistently larger proportions lost to follow up throughout the trial in those treated in hospital than in those treated by chiropractic suggests greater satisfaction with chiropractic. This conclusion is supported (table III) by the higher proportions in each referral group considering chiropractic helpful by comparison with hospital treatment.
The main criticism of the trial after our first report centred on its “pragmatic” nature, particularly the larger number of chiropractic than hospital treatments and the longer period over which the chiropractic treatments were spread and which were deliberately allowed. These considerations and any consequences of the higher proportions of patients allocated to chiropractic who received further treatment in the later stages of follow up, however, do not apply to the results at six weeks and only apply to a limited extent at six months, when the proportions followed up were high and extra treatment had either not occurred at all or was not yet extensive. Benefits atributable to chiropractic were already evident (especially on pain, table II) at these shorter intervals.
We believe there is now more support for the need for “fastidious” trials focusing on specific components of management and on their feasibility. Meanwhile, the results of our trial show that chiropractic has a valuable part to play in the management of low back pain.
We thank Dr Iain Chalmers for commenting on an earlier draft of the paper. We thank the nurse coordinators, medical staff, physiotherapists, and chiropractors in the 11 centres for their work, and Dr Alan Breen of the British Chiropractic Association for his help. The centres were in Harrow Taunton, Plymouth, Bournemouth and Poole, Oswestry, Chertsey, Liverpool, Chelmsford, Birmingham, Exeter, and Leeds. Without the assistance of many staff members in each the trial could not have been completed.
Funding: Medical Research Council, the National Back Pain Association, the European Chiropractors Union, and the King Edward’s Hospital Fund for London.
Conflict of interest: None.
In conclusion,�after three years, the results of the research study comparing chiropractic care and hospital outpatient management for low back pain determined that people treated by chiropractic experienced more benefits as well as long-term satisfaction than those treated by hospitals. Because back pain is one of the most common�causes people visit their healthcare professional every year, its essential to seek the most effective type of health 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
References
Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment.�BMJ.�1990 Jun 2;300(6737):1431�1437.�[PMC free article]�[PubMed]
Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry low back pain disability questionnaire.�Physiotherapy.�1980 Aug;66(8):271�273.�[PubMed]
Pocock SJ, Simon R. Sequential treatment assignment with balancing for prognostic factors in the controlled clinical trial.�Biometrics.�1975 Mar;31(1):103�115.�[PubMed]
Additional Topics: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
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