Back Clinic Chiropractic. This is a form of alternative treatment that focuses on the diagnosis and treatment of various musculoskeletal injuries and conditions, especially those associated with the spine. Dr. Alex Jimenez discusses how spinal adjustments and manual manipulations regularly can greatly help both improve and eliminate many symptoms that could be causing discomfort to the individual. Chiropractors believe among the main reasons for pain and disease are the vertebrae’s misalignment in the spinal column (this is known as a chiropractic subluxation).
Through the usage of manual detection (or palpation), carefully applied pressure, massage, and manual manipulation of the vertebrae and joints (called adjustments), chiropractors can alleviate pressure and irritation on the nerves, restore joint mobility, and help return the body’s homeostasis. From subluxations, or spinal misalignments, to sciatica, a set of symptoms along the sciatic nerve caused by nerve impingement, chiropractic care can gradually restore the individual’s natural state of being. Dr. Jimenez compiles a group of concepts on chiropractic to best educate individuals on the variety of injuries and conditions affecting the human body.
When we think of cheerleaders we usually think of pretty girls in colorful outfits, pom pom’s in hand, cheering for their team. They are way more than that though. Cheerleaders are serious athletes.
It has taken a while, but the public is finally starting to realize just how true this is. Data collected by the National Center for Catastrophic Sports Injury Research (NCCSIR), between 1982 and 2009 cheerleaders made up for more than 70 percent of catastrophic injuries in women�s college sports. At the high school level that number exceeded 60 percent.
Some claim that this high percentage of injuring among cheerleaders to be due to lax regulations at the state level. Some states refuse to recognize cheerleading as a sport and organizations such as the NCAA don�t either.
This leaves an already potentially dangerous activity without proper oversight of the government or regulating agencies. It also means that some people who manage cheer squads and organize competitions are not required to get the same coaching and safety training standards that those in other sports do.
Since chiropractic treats the whole body through not just structurally via spinal adjustments, but also through soft tissue techniques, patients can receive complete care after an injury and during rehabilitation. Cheerleaders are finding that chiropractic treatment provides numerous benefits and can even make them better athletes.
Cheerleaders
Chiropractic Helps To Improve Range Of Motion
Chiropractic care helps to improve a person�s range of motion which in turn helps to prevent injury and relieve the pain of injury. Chiropractic is growing in its popularity within the field of sports medicine because of its effectiveness. A 2010 study published in The Journal of the Canadian Chiropractic Association showed that chiropractic made a significant difference in performance.
Chiropractic Helps To Prevent Injury
Even when no injury is present, athletes can benefit from chiropractic care. This is especially true in high impact sports like cheerleading where athletes push their bodies beyond limits through acrobatics and some of the strenuous tricks that they do in the course of their sport. Chiropractic helps to loosen muscles, making them more pliable and flexible, thus less prone to injury.
Chiropractic Helps To Relieve Pain From Injury
A study published in the Journal of Manipulative and Physiological Therapeutics in March 2011 shows that chiropractic for pain relief can alleviate the pain of hamstring injury. The study was conducted over the course of a football season and involved 43 professional cheerleaders for football various football teams.
Throughout the study the cheerleaders received specific exercise intervention. At the end of the study those who had reported pain due to a hamstring injury experienced significant pain reduction after receiving chiropractic treatment.
Chiropractic Can Increase Physical Strength
While chiropractic is typically considered a therapy for alleviating skeletal and muscular complaints, a study in 2011 showed that it can also improve physical strength. The study involved judo athletes competing at the national level who used cervical spinal manipulative therapy (SMT). The final results of the study showed a 16 percent improvement in grip strength among the athletes who received only three SMT sessions.
The case for chiropractic treatment for athletes is very strong. It can help during training, recovery from injury, rehabilitation, and at every point in between. Although cheerleaders are still in their infancy of being recognized as serious athletes, the case for chiropractic care as a viable sports medicine therapy to improve performance and recover from injury is significant. The benefits that cheerleaders can receive from chiropractic treatment, as we can see, can really give them something to cheer about both on the field and off.
A herniated disc, also known as a slipped or ruptured disc, is a healthcare condition which occurs when a tear in the outer, fibrous ring of an intervertebral disc causes its soft, central portion to bulge out from the damaged, surrounding cartilage. Disc herniations are generally due to the degeneration of the outer ring of an intervertebral disc, known as the anulus fibrosus. Trauma, lifting injuries or straining may also cause a herniated disc. A tear in the intervertebral disc may result in the release of chemicals which may cause irritation and ultimately become the direct cause of severe back pain, even without nerve root compression.
Disc herniations also commonly develop following a previously existing disc protrusion, a healthcare condition in which the outermost layers of the anulus fibrosus remain intact, however, these can bulge if the disc is placed under pressure. Unlike a disc herniation, none of the gel-like section escapes the intervertebral disc. Herniated discs often heal on their own within several weeks. Severe disc herniations may require surgery, however, a variety of research studies have demonstrated that nonoperative treatment may help improve and manage the recovery process of a herniated disc without the need for surgical interventions.
Surgical vs Nonoperative Treatment for Lumbar Disk Herniation Using The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial
Abstract
Context: Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial.
Objective: To assess the efficacy of surgery for lumbar intervertebral disk herniation.
Design, Setting, and Patients: The Spine Patient Outcomes Research Trial, a randomized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states. Patients were 501 surgical candidates (mean age, 42 years; 42% women) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks.
Interventions: Standard open diskectomy vs nonoperative treatment individualized to the patient.
Main Outcome Measures: Primary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version) at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment. Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status.
Results: Adherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes.
Conclusions: Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis.
Lumbar diskectomy is the most common surgical procedure performed in the United States for patients having back and leg symptoms; the vast majority of the procedures are elective. However, lumbar disk herniation is often seen on imaging studies in the absence of symptoms[1,2] and can regress over time without surgery.[3] Up to 15-fold variation in regional diskectomy rates in the United States[4] and lower rates internationally raise questions regarding the appropriateness of some of these surgeries.[5,6]
Several studies have compared surgical and nonoperative treatment of patients with herniated disk, but baseline differences between treatment groups, small sample sizes, or lack of validated outcome measures in these studies limit evidence-based conclusions regarding optimal treatment.[7-12] The Spine Patient Outcomes Research Trial (SPORT) was initiated in March 2000 to compare the outcomes of surgical and nonoperative treatment for lumbar intervertebral disk herniation, spinal stenosis, or degenerative spondylolisthesis.[13] The trial included both a randomized cohort and an observational cohort who declined to be randomized in favor of designating their own treatment but otherwise met all the other criteria for inclusion and who agreed to undergo follow-up according to the same protocol. This article reports intent-to-treat results through 2 years for the randomized cohort.
Methods
Study Design
SPORT was conducted at 13 multidisciplinary spine practices in 11 US states (California, Georgia, Illinois, Maine, Michigan, Missouri, Nebraska, New York, New Hampshire, Ohio, Pennsylvania). The human subjects committee of each participating institution approved a standardized protocol. All patients provided written informed consent. An independent data and safety monitoring board monitored the study at 6-month intervals.[13]
Patient Population
Patients were considered for inclusion if they were 18 years and older and diagnosed by participating physicians during the study enrollment period as having intervertebral disk herniation and persistent symptoms despite some nonoperative treatment for at least 6 weeks. The content of preenrollment nonoperative care was not prespecified in the protocol but included education/counseling (71%), physical therapy (67%), epidural injections (42%), chiropractic therapy (32%), anti-inflammatory medications (61%), and opioid analgesics (40%).
Specific inclusion criteria at enrollment were radicular pain (below the knee for lower lumbar herniations, into the anterior thigh for upper lumbar herniations) and evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise�positive between 30� and 70� or positive femoral tension sign) or a corresponding neurologic deficit (asymmetrical depressed reflex, decreased sensation in a dermatomal distribution, or weakness in a myotomal distribution). Additionally, all participants were surgical candidates who had undergone advanced vertebral imaging (97% magnetic resonance imaging, 3% computed tomography) showing disk herniation (protrusion, extrusion, or sequestered fragment)[14] at a level and side corresponding to the clinical symptoms. Patients with multiple herniations were included if only one of the herniations was considered symptomatic (ie, if only one was planned to be operated on).
Exclusion criteria included prior lumbar surgery, cauda equina syndrome, scoliosis greater than 15�, segmental instability (>10� angular motion or >4-mm translation), vertebral fractures, spine infection or tumor, inflammatory spondyloarthropathy, pregnancy, comorbid conditions contraindicating surgery, or inability/unwillingness to have surgery within 6 months.
Study Interventions
The surgery was a standard open diskectomy with examination of the involved nerve root.[15,16] The procedure agreed on by all participating centers was performed under general or local anesthesia, with patients in the prone or knee-chest position. Surgeons were encouraged to use loupe magnification or a microscope. Using a midline incision reflecting the paraspinous muscles, the interlaminar space was entered as described by Delamarter and McCullough.[15] In some cases the medial border of the superior facet was removed to provide a clear view of the involved nerve root. Using a small annular incision, the fragment of disk was removed as described by Spengler.[16] The canal was inspected and the foramen probed for residual disk or bony pathology. The nerve root was decompressed, leaving it freely mobile.
The nonoperative treatment group received �usual care,� with the study protocol recommending that the minimum nonsurgical treatment include at least active physical therapy, education/counseling with home exercise instruction, and nonsteroidal anti-inflammatory drugs, if tolerated. Other nonoperative treatments were listed, and physicians were encouraged to individualize treatment to the patient; all nonoperative treatments were tracked prospectively.[13,17]
Study Measures
The primary measures were the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) bodily pain and physical function scales[18-21] and the American Academy of Orthopaedic Surgeons MODEMS version of the Oswestry Disability Index (ODI).[22] As specified in the trial protocol, the primary outcomes were changes from baseline in these scales at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment.
Secondary measures included patient self-reported improvement, work status, and satisfaction with current symptoms and with care.[23] Symptom severity was measured by the Sciatica Bothersomeness Index (range, 0-24; higher scores represent worse symptoms).[24,25]
Recruitment, Enrollment, and Randomization
A research nurse at each site identified potential participants and verified eligibility. For recruitment and informed consent, evidence-based videotapes described the surgical and non-operative treatments and the expected benefits, risks, and uncertainties.[26,27] Participants were offered enrollment in either the randomized trial or a concurrent observational cohort, the results of which are reported in a companion article.
Enrollment began in March 2000 and ended in November 2004. Baseline variables were collected prior to randomization. Patients self-reported race and ethnicity using National Institutes of Health categories.
Computer-generated random treatment assignment based on permuted blocks (randomly generated blocks of 6, 8, 10, and 12)[28] within sites occurred immediately after enrollment via an automated system at each site, ensuring proper allocation concealment. Study measures were collected at baseline and at regularly scheduled follow-up visits. Short-term follow-up visits occurred at 6 weeks and 3 months. If surgery was delayed beyond 6 weeks, additional follow-up data were obtained 6 weeks and 3 months postoperatively. Longer-term follow-up visits occurred at 6 months, 1 year from enrollment, and annually thereafter.
Statistical Analyses
We originally determined a sample size of 250 patients in each treatment group to be sufficient (with a 2-sided significance level of .05 and 85% power) to detect a 10-point difference in the SF-36 bodily pain and physical functioning scales or a similar effect size in the ODI. This difference corresponded to patients’ reports of being �a little better� in the Maine Lumbar Spine Study (MLSS).[29] The sample size calculation allowed for up to 20% missing data but did not account for any specific levels of nonadherence.
The analyses for the primary and secondary outcomes used all available data for each period on an intent-to-treat basis. Predetermined end points for the study included results at each of 6 weeks, 3 months, 6 months, 1 year, and 2 years. To adjust for the possible effect of missing data on the study results, the analysis of mean changes for continuous outcomes was performed using maximum likelihood estimation for longitudinal mixed-effects models under �missing at random� assumptions and including a term for treatment center. Comparative analyses were performed using the single imputation methods of baseline value carried forward and last value carried forward, as well as a longitudinal mixed model controlling for covariates associated with missed visits.[30]
For binary secondary outcomes, longitudinal logistic regression models were fitted using generalized estimating equations[31] as implemented in the PROC GENMOD program of SAS version 9.1 (SAS Institute Inc, Cary, NC). Treatment effects were estimated as differences in the estimated proportions in the 2 treatment groups.
P<.05 (2-sided) was used to establish statistical significance. For the primary outcomes, 95% confidence intervals (CIs) for mean treatment effects were calculated at each designated time point. Global tests of the joint hypothesis of no treatment effect at any of the designated periods were performed using Wald tests[32] as implemented in SAS. These tests account for the intraindividual correlation due to repeated measurements over time.[32]
Nonadherence to randomly assigned treatment may mean that the intention-to-treat analysis underestimates the real benefit of the treatment.[33,34] As a preplanned sensitivity analysis, we also estimated an �as-treated� longitudinal analysis based on comparisons of those actually treated surgically and nonoperatively. Repeated measures of outcomes were used as the dependent variables, and treatment received was included as a time-varying covariate. Adjustments were made for the time of surgery with respect to the original enrollment date to approximate the designated follow-up times. Baseline variables that were individually found to predict missing data or treatment received at 1 year were included to adjust for possible confounding.
Results
SPORT achieved full enrollment, with 501 (25%) of 1991 eligible patients enrolled in the randomized trial. A total of 472 participants (94%) completed at least 1 follow-up visit and were included in the analysis. Data were available for between 86% and 73% of patients at each of the designated follow-up times (Figure 1).
Figure 1: Flow Diagram of the SPORT Randomized Controlled Trial of Disk Herniation: Exclusion, Enrollment, Randomization, and Follow-up.
Patient Characteristics
Baseline patient characteristics are shown in Table 1. Overall, the study population had a mean age of 42 years, with majorities being male, white, employed, and having attended at least some college; 16% were receiving disability compensation. All patients had radicular leg pain, 97% in a classic dermatomal distribution. Most of the herniations were at L5-S1, posterolateral, and were extrusions by imaging criteria.[14] The 2 randomized groups were similar at baseline.
Nonoperative Treatments
A variety of nonoperative treatments were used during the study (Table 2). Most patients received education/counseling (93%) and anti-inflammatory medications (61%) (nonsteroidal anti-inflammatory drugs, cyclooxygenase 2 inhibitors, or oral steroids); 46% received opiates; more than 50% received injections (eg, epidural steroids); and 29% were prescribed activity restriction. Forty-four percent received active physical therapy during the trial; however, 67% had received it prior to enrollment.
Surgical Treatment and Complications
Table 3 gives the characteristics of surgical treatment and complications. The median surgical time was 75 minutes (interquartile range, 58-90), with a median blood loss of 49.5 mL (interquar-tile range, 25-75). Only 2% required transfusions. There were no perioperative deaths; 1 patient died from complications of childbirth 11 months after enrollment. The most common intraoperative complication was dural tear (4%). There were no postoperative complications in 95% of patients. Reoperation occurred in 4% of patients within 1 year of the initial surgery; more than 50% of the reoperations were for recurrent herniations at the same level.
Nonadherence
Nonadherence to treatment assignment affected both groups, ie, some patients in the surgery group chose to delay or decline surgery, and some in the nonoperative treatment group crossed over to receive surgery (Figure 1). The characteristics of crossover patients that were statistically different from patients who did not cross over are shown in Table 4. Those more likely to cross over to receive surgery tended to have lower incomes, worse baseline symptoms, more baseline disability on the ODI, and were more likely to rate their symptoms as getting worse at enrollment than the other patients receiving nonoperative treatment. Those more likely to cross over to receive nonoperative care were older, had higher incomes, were more likely to have an upper lumbar disk herniation, less likely to have a positive straight leg�raising test result, had less pain, better physical function, less disability on the ODI, and were more likely to rate their symptoms as getting better at enrollment than the other surgery patients.
Missing Data
The rates of missing data were equivalent between the groups at each time point, with no evidence of differential dropout according to assigned treatment. Characteristics of patients with missed visits were very similar to those of the rest of the cohort except that patients with missing data were less likely to be married, more likely to be receiving disability compensation, more likely to smoke, more likely to display baseline motor weakness, and had lower baseline mental component summary scores on the SF-36.
Intent-to-Treat Analyses
Table 5 shows estimated mean changes from baseline and the treatment effects (differences in changes from baseline between treatment groups) for 3 months, 1 year, and 2 years. For each measure and at each point, the treatment effect favors surgery. The treatment effects for the primary outcomes were small and not statistically significant at any of the points. As shown in Figure 2, both treatment groups showed strong improvements at each of the designated follow-up times, with small advantages for surgery. However, for each primary outcome the combined global test for any difference at any period was not statistically significant. This test accounts for intraindividual correlations as described in the �Methods� section.
Figure 2: Mean Scores Over Time for SF-36 Bodily Pain and Physical Function Scales and Oswestry Disability Index.
Table 5: Treatment Effects for Primary and Secondary Outcomes Based on Intent-to-Treat Analyses*
For the secondary outcome of sciatica bothersomeness, Table 5 and Figure 3 show that there were greater improvements in the Sciatica Bothersomeness Index in the surgery group at all designated follow-up times: 3 months (treatment effect, ?2.1; 95% CI, ?3.4 to ?0.9), 1 year (treatment effect, ?1.6; 95% CI, ?2.9 to ?0.4), and 2 years (treatment effect, ?1.6; 95% CI, ?2.9 to ?0.3), with results of the global hypothesis test being statistically significant (P=.003). Patient satisfaction with symptoms and treatment showed small effects in favor of surgery while employment status showed small effects in favor of nonoperative care, but none of these changes was statistically significant. Self-rated progress showed a small statistically significant advantage for surgery (P=.04).
Figure 3: Measures Over Time for Sciatica Bothersomeness Index, Employment Status, Satisfaction With Symptoms, Satisfaction With Care, and Self-rated Improvement.
As-treated analyses based on treatment received were performed with adjustments for the time of surgery and factors affecting treatment crossover and missing data. These yielded far different results than the intent-to-treat analysis, with strong, statistically significant advantages seen for surgery at all follow-up times through 2 years. For example, at 1 year the estimated treatment effects for the SF-36 bodily pain and physical function scales, the ODI, and the sciatica measures were 15.0 (95% CI, 10.9 to 19.2), 17.5 (95% CI, 13.6 to 21.5), ?15.0 (95% CI, ?18.3 to ?11.7), and ?3.2 (95% CI, ?4.3 to ?2.1), respectively.
Sensitivity analysis was performed for 4 different analytic methods of dealing with the missing data. One method was based on simple mean changes for all patients with data at a given time point with no special adjustment for missing data. Two methods used single imputation methods�baseline value carried forward and last value carried forward.[32] The latter method used the same mixed-models approach for estimating mean changes as given in Table 5 but also adjusted for factors affecting the likelihood of missing data. Treatment effect estimates at 1 year ranged from 1.6 to 2.9 for the SF-36 bodily pain scale, 0.74 to 1.4 for the physical function scale, ?2.2 to ?3.3 for the ODI, and ?1.1 to ?1.6 for the sciatica measures. Given these ranges, there appear to be no substantial differences between any of these methods.
Dr. Alex Jimenez’s Insight
Herniated disc symptoms vary on the location of the condition and on the surrounding soft tissues affected along the spine. Lumbar disc herniations, one of the most common area for herniated discs to occur, are characterized by the compression of the nerve roots along the lower back and can generally cause symptoms of sciatica. Surgery is commonly recommended to treat disc herniations, however, numerous treatment methods can help manage the condition without the need of surgical interventions. A research study conducted on sciatica caused by herniated discs determined that about 73 percent of participants experienced an improvement in symptoms with nonoperative treatment. The results of this article concluded that nonoperative treatment can be as effective as surgery in the treatment of herniated discs.
Comment
Both operated and nonoperated patients with intervertebral disk herniation improved substantially over a 2-year period. The intent-to-treat analysis in this trial showed no statistically significant treatment effects for the primary outcomes; the secondary measures of sciatica severity and self-reported progress did show statistically significant advantages for surgery. These results must be viewed in the context of the substantial rates of nonadherence to assigned treatment. The pattern of nonadherence is striking because, unlike many surgical studies, both the surgical and nonoperative treatment groups were affected.[35] The most comparable previous trial[8] had 26% crossover into surgery at 1 year, but only 2% crossover out of surgery. The mixing of treatments due to crossover can be expected to create a bias toward the null.[34] The large effects seen in the as-treated analysis and the characteristics of the crossover patients suggest that the intent-to-treat analysis underestimates the true effect of surgery.
SPORT findings are consistent with clinical experience in that relief of leg pain was the most striking and consistent improvement with surgery. Importantly, all patients in this trial had leg pain with physical examination and imaging findings that confirmed a disk herniation. There was little evidence of harm from either treatment. No patients in either group developed cauda equina syndrome; 95% of surgical patients had no intraoperative complications. The most common complication, dural tear, occurred in 4% of patients, similar to the 2% to 7% noted in the meta-analysis by Hoffman et al,7 2.2% seen in the MLSS,[29] and 4% in the recent series from Stanford.[36]
One limitation is the potential lack of representativeness of patients agreeing to be randomized to surgery or nonoperative care; however, the characteristics of patients agreeing to participate in SPORT were very similar to those in other studies.[29,36] The mean age of 42 years was similar to the mean ages in the MLSS,[29] the series of Spangfort,[37] and the randomized trial by Weber,[8] and only slightly older than those in the recent series from Stanford (37.5 years).[36] The proportion of patients receiving workers’ compensation in SPORT (16%) was similar to the proportion in the Stanford population (19%) but lower than that in the MLSS population (35%), which specifically oversampled patients receiving compensation. Baseline functional status was also similar, with a mean baseline ODI of 46.9 in SPORT vs 47.2 in the Stanford series, and a mean baseline SF-36 physical function score of 39 in SPORT vs 37 in the MLSS.
The strict eligibility criteria, however, may limit the generalizability of these results. Patients unable to tolerate symptoms for 6 weeks and demanding earlier surgical intervention were not included, nor were patients without clear signs and symptoms of radiculopathy with confirmatory imaging. We can draw no conclusions regarding the efficacy of surgery in these other groups. However, our entry criteria followed published guidelines for patient selection for elective diskectomy, and our results should apply to the majority of patients facing a surgical decision.[38,39]
To fully understand the treatment effect of surgery compared with nonoperative treatment, it is worth noting how each group fared. The improvements with surgery in SPORT were similar to those of prior series at 1 year: for the ODI, 31 points vs 34 points in the Stanford series; for the bodily pain scale, 40 points vs 44 in the MLSS; and for sciatica bothersomeness, 10 points vs 11 in the MLSS. Similarly, Weber[8] reported 66% �good� results in the surgery group, compared with the 76% reporting �major improvement� and 65% satisfied with their symptoms in SPORT.
The observed improvements with nonoperative treatment in SPORT were greater than those in the MLSS, resulting in the small estimated treatment effect. The nonoperative improvement of 37, 35, and 9 points in bodily pain, physical function, and sciatica bothersomeness, respectively, were much greater than the improvements of 20, 18, and 3 points reported in the MLSS. The greater improvement with nonoperative treatment in SPORT may be related to the large proportion of patients (43%) who underwent surgery in this group.
The major limitation of SPORT is the degree of nonadherence with randomized treatment. Given this degree of crossover, it is unlikely that the intent-to-treat analysis can form the basis of a valid estimate of the true treatment effect of surgery. The �as-treated� analysis with adjustments for possible confounders showed much larger effects in favor of surgical treatment. However, this approach does not have the strong protection against confounding that is afforded by randomization. We cannot exclude the possibility that baseline differences between the as-treated groups, or the selective choice of some but not other patients to cross over into surgery, may have affected these results, even after controlling for important covariates. Due to practical and ethical constraints, this study was not masked through the use of sham procedures. Therefore, any improvements seen with surgery may include some degree of �placebo effect.�
Another potential limitation is that the choice of nonoperative treatments was at the discretion of the treating physician and patient. However, given the limited evidence regarding efficacy for most nonoperative treatments for lumbar disk herniation and individual variability in response, creating a limited, fixed protocol for nonoperative treatment was neither clinically feasible nor generalizable. The nonoperative treatments used were consistent with published guidelines.[17,38,39] Compared with the MLSS, SPORT had lower use of activity restriction, spinal manipulation, transcutaneous electrical nerve stimulation, and braces and corsets, and higher rates of epidural steroid injections and use of narcotic analgesics. This flexible nonoperative protocol had the advantages of individualization that considered patient preferences in the choice of nonoperative treatment and of reflecting current practice among multidisciplinary spine practices. However, we cannot make any conclusion regarding the effect of surgery vs any specific nonoperative treatment. Similarly, we cannot adequately assess the relative efficacy of any differences in surgical technique.
Conclusion
Patients in both the surgery and nonoperative treatment groups improved substantially over the first 2 years. Between-group differences in improvements were consistently in favor of surgery for all outcomes and at all time periods but were small and not statistically significant except for the secondary measures of sciatica severity and self-rated improvement. Because of the high numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis alone.
Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study
Abstract
Objective: The purpose of this study was to compare the clinical efficacy of spinal manipulation against microdiskectomy in patients with sciatica secondary to lumbar disk herniation (LDH).
Methods: One hundred twenty patients presenting through elective referral by primary care physicians to neurosurgical spine surgeons were consecutively screened for symptoms of unilateral lumbar radiculopathy secondary to LDH at L3-4, L4-5, or L5-S1. Forty consecutive consenting patients who met inclusion criteria (patients must have failed at least 3 months of nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture) were randomized to either surgical microdiskectomy or standardized chiropractic spinal manipulation. Crossover to the alternate treatment was allowed after 3 months.
Results: Significant improvement in both treatment groups compared to baseline scores over time was observed in all outcome measures. After 1 year, follow-up intent-to-treat analysis did not reveal a difference in outcome based on the original treatment received. However, 3 patients crossed over from surgery to spinal manipulation and failed to gain further improvement. Eight patients crossed from spinal manipulation to surgery and improved to the same degree as their primary surgical counterparts.
Conclusions: Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. Of 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider spinal manipulation followed by surgery if warranted.
In conclusion, a herniated disc causes the soft, central portion of an intervertebral disc to bulge out a tear in its outer, fibrous ring as a result of degeneration, trauma, lifting injuries or straining. Most disc herniations can heal on their own but those considered to be severe may require surgical interventions to treat them. Research studies, such as the one above, have demonstrated that nonoperative treatment may help the recovery of a herniated disc without the need for surgery. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Back Pain
According to statistics, approximately 80% of people will experience symptoms of back pain at least once throughout their lifetimes. Back pain is a common complaint which can result due to a variety of injuries and/or conditions. Often times, the natural degeneration of the spine with age can cause back pain. Herniated discs occur when the soft, gel-like center of an intervertebral disc pushes through a tear in its surrounding, outer ring of cartilage, compressing and irritating the nerve roots. Disc herniations most commonly occur along the lower back, or lumbar spine, but they may also occur along the cervical spine, or neck. The impingement of the nerves found in the low back due to injury and/or an aggravated condition can lead to symptoms of sciatica.
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Constipation is an uncomfortable and common side effect of lower back and leg pain conditions. Sciatic nerve pain can occur at the same time as constipation does, but can also alternate where constipation ensues followed by sciatica.
Finding lasting relief is crucial, but understanding the exact reasons why the symptoms occur is just as important. These two conditions can be related or they may be completely coincidental. But the more they occur together, or in succession, there is greater chance that some structural or body connection is happening between the two.
The Facts: Sciatica & Constipation
Investigate why the source process may be the same for both conditions in some.
Constipation,�known as a recurrent and chronic health concern which plagues some people their entire lives. It can be caused by a variety of anatomical reasons, but many of these are fairly easy to diagnose, despite being difficult to cure using traditional medical therapy.
Sciatica is very much the same in that it can be chronic, recurrent and sometimes treatment-resistant.
What these disorders have in common is that they are often linked by nerve compression conditions within the spine. The source can be central or foraminal stenosis, which leads to compression of one or more of the lumbar nerve roots.
It is also possible for cervical central spinal stenosis to cause sciatica and may contribute to constipation, as well.
Both conditions are associated with the mind and body processes, that is physical illness caused or aggravated by mental factors, i.e. stress or some type of conflict. Constipation can be linked to conscious and subconscious emotional issues, while sciatica is just starting to receive the same recognition as a possible mind and body disorder.
Constipation/Sciatica: Solutions
Sciatica cases where constipation is also present involves the nerve roots in the lower spinal regions. These types of symptomatic expressions will be blamed on a variety of structural abnormalities in the lumbosacral region, which include degenerative discdisease, herniated discs and spinal osteoarthritis.
An alternative explanation for many cases of constipation accompanied by sciatica is regional oxygen deprivation. The solution to this condition is the treatment option invented by Dr. John Sarno. This simple treatment can usually solve even the most harmful of sciatica concerns. But the therapy remains controversial as it helps some and not others.
Sciatica/Constipation: Analysis
Once the symptoms have been diagnosed, if symptoms are structural, then treatments should resolve them or at least help in controlling the pain. If various treatments have been utilized with no relief, then it could be misdiagnosis.
Another anatomical condition that could be responsible for the symptoms or the cause could be a combination of the aforementioned mind and body issues working together. An epidemic problem that the healthcare system and one of the underlying reasons why so many with back, neck and sciatica pain never find a lasting cure. Don’t be surprised if to find out the pain was inaccurately diagnosed. This happens to millions every day.
Constipation can also be a result of serious internal diseases or organ malfunctions. Request a complete workup, which includes appropriate diagnostic testing for any significant or chronic constipation case.
Sometimes, this combination of symptoms may indicate the first signs of cauda equina syndrome.�This is a medical emergency and must be treated immediately.
Many will disregard any notion that sciatica is caused by constipation. Constipation can cause sciatica check other websites. Doctors do agree that constipation is one of a many of causes of sciatica.
But the bowels and the lower back are different parts of the body. It is important to understand that all parts of the body are connected in some way or other.
Sciatica?
If there is pain in the lower back near the buttocks and that pain travels down one or both legs, then chances are sciatica is present. Sciatica has become a common lower back pain that doctors, chiropractors, acupuncturists and physical therapists treat frequently. The pain is characterized with a combination of dull and sharp aches that create a feeling of pins and needles. With nerve conditions pins and needles are the most common type of pain.
Sciatica is the result of sciatic nerve compression. Constipation is a non-spinal condition that can cause sciatica. Just trying to use the bathroom can cause pain by irritating the sciatic nerve.
Sciatica happens when the sciatic nerve, which is the largest in the body, is compressed by an external pressure. Women in child birth and men who carry their wallets in the back pocket can experience sciatica.
Sciatica is treatable; if experiencing constipation and lower back pain at the same time, ask a doctor to test for sciatica. Doctors will order a CT scan, MRI, X-Ray or nerve conduction test.
Solving The Problem:
Experiencing sciatica related to constipation, then the first course of action is diet change. A fiber-infused diet that combines fruits and vegetables can relieve constipation. Or consider a fiber supplement.
Pain Reduction:
While waiting for constipation relief, there are various ways to reduce pain.
Take aspirin or ibuprofen, Anti-inflammatory medications reduce nerve and muscle inflammation, which alleviate nerve irritation.
Alternate hot and cold compresses, which reduce inflammation and sooth the pain. Can also be applied to the legs if the pain travels down the body.
Consider a firm mattress to support the back and alleviate any sciatica that may be the result from back strain.
A doctor may recommend several days of rest in order to allow the nerve damage time to heal.
Rules To Remember:
Do not bend or sit in a soft chair. Back support is critical.
Do not ignore the pain. Nerve pain heals within a week or gets worse.
Move slowly when standing or getting in and out of bed.
No heavy lifting & sometimes no lifting at all.
Good Nutrition & Chiropractic Treatment Contribute To Overall Well-Being
Manual therapy migraine treatment, or manipulative therapy, is a physical treatment approach which utilizes several specific hands-on techniques to treat a variety of injuries and/or conditions. Manual therapy is commonly used by chiropractors, physical therapists and massage therapists, among other qualified and experienced healthcare professionals, to diagnose and treat soft tissue and joint pain. Many healthcare specialists recommend manual therapy, or manipulative therapy as a treatment for migraine headache pain. The purpose of the following article is to educate patients on the effects of manual therapies for migraine treatment.
Manual Therapies for Migraine: a Systematic Review
Abstract
Migraine occurs in about 15% of the general population. Migraine is usually managed by medication, but some patients do not tolerate migraine medication due to side effects or prefer to avoid medication for other reasons. Non-pharmacological management is an alternative treatment option. We systematically reviewed randomized clinical trials (RCTs) on manual therapies for migraine. The RCTs suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine. However, the evaluated RCTs had many methodological shortcomings. Therefore, any firm conclusion will require future, well-conducted RCTs on manual therapies for migraine.
Migraine is usually managed by medication, but some patients do not tolerate acute and/or prophylactic medicine due to side effects, or contraindications due to co-morbidity of myocardial disorders or asthma among others. Some patients wish to avoid medication for other reasons. Thus, non-pharmacological management such as massage, physiotherapy and chiropractic may be an alternative treatment option. Massage therapy in Western cultures uses classic massage, trigger points, myofascial release and other passive muscle stretching among other treatment techniques which are applied to abnormal muscle tissue. Modern physiotherapy focuses on rehabilitation and exercise, while manual treatment emphasis postural corrections, soft tissue work, stretching, active and passive mobilization and manipulation techniques. Mobilization is commonly defined as movement of joints within the physiological range of motion [1]. The two most common chiropractic techniques are the diversified and Gonstead, which are used by 91 and 59% of chiropractors [2]. Chiropractic spinal manipulation (SM) is a passive-controlled maneuver which uses a directional high-velocity, low-amplitude thrusts directed at a specific joint past the physiological range of motion, without exceeding the anatomical limit [1]. The application and duration of the different manual treatments varies among those who perform it. Thus, manual treatment is not necessarily as uniform as, for instance, specific treatment with a drug in a certain dose.
This paper systematically review randomized controlled trials (RCTs) assessing the efficacy of manual therapies on migraine, i.e., massage, physiotherapy and chiropractic.
Method
The literature search was done on CINAHL, Cochrane, Medline, Ovid and PubMed. Search words were migraine and chiropractic, manipulative therapy, massage therapy, osteopathic treatment, physiotherapy or spinal mobilization. All RCTs written in English using manual therapy on migraine were evaluated. Migraine was preferentially classified according to the criteria of the International Headache Societies from 1988 or its revision from 2004, although it was not an absolute requirement [3, 4]. The studies had to evaluate at least one migraine outcome measure such as pain intensity, frequency, or duration. The methodological quality of the included RCT studies was assessed independently by the authors. The evaluation covered study population, intervention, measurement of effect, data presentation and analysis (Table 1). The maximum score is 100 points and ?50 points considered to be methodology of good quality [5�7].
Results
The literature search identified seven RCT on migraine that met our inclusion criteria, i.e., two massage therapy studies [8, 9], one physiotherapy study [10] and four chiropractic spinal manipulative therapy studies (CSMT) [11�14], while we found no RCTs studies on spinal mobilization or osteopathic as a intervention for migraine.
Methodological Quality of the RCTs
Table 2 shows the authors average methodological score of the included RCT studies [8�14]. The average score varied from 39 to 59 points. Four RCTs were considered to have a good quality methodology score (?50), and three RCTs had a low score.
Randomized Controlled Trials
Table 3 shows details and the main results of the different RCT studies [8�14].
Massage Therapy
An American study included 26 participants with chronic migraine diagnosed by questionnaire [8]. Massage therapy had a statistically significant effect on pain intensity as compared with controls. Pain intensity was reduced 71% in the massage group and unchanged in the control group. Interpretation of the data is otherwise difficult and results on migraine frequency and duration are missing.
A New Zealand study included 48 migraineurs diagnosed by questionnaire [9]. The mean duration of a migraine attack was 47 h, and 51% of the participants had more than one attack per month. The study included a 3 week follow-up period. The migraine frequency was significantly reduced in the massage group as compared with the control group, while the intensity of attacks was unchanged. Results on migraine duration are missing. Medication use was unchanged, while sleep quality was significantly improved in the massage group (p < 0.01), but not in the control group.
Physical Therapy
An American physical therapy study included female migraineurs with frequent attacks diagnosed by a neurologist according to the criteria of the International Headache Society [3, 10]. Clinical effect was defined as >50% improvement in headache severity. Clinical effect was observed in 13% of the physical therapy group and 51% of the relaxation group (p < 0.001). The mean reduction in headache severity was 16 and 41% from baseline to post-treatment in the physical therapy and relaxation groups. The effect was maintained at 1 year follow-up in both groups. A second part of the study offered persons without clinical effect in the first part of the study, the other treatment option. Interestingly, clinical effect was observed in 55% of those whom received physical therapy in the second round who had no clinical effect from relaxation, while 47% had clinical effect from relaxation in the second round. The mean reduction in headache severity was 30 and 38% in the physical therapy and relaxation groups. Unfortunately, the study did not include a control group.
Chiropractic Spinal Manipulative Treatment
An Australian study included migraineurs with frequent attacks diagnosed by a neurologist [11]. The participants were divided into three study groups; cervical manipulation by chiropractor, cervical manipulation by physiotherapist or physician, and cervical mobilization by physiotherapist or physician. The mean migraine attack duration was skewed in the three groups, as it was much longer in cervical manipulation by chiropractor (30.5 h) than cervical manipulations by physiotherapist or physician (12.2 h) and cervical mobilization groups (14.9 h). The study had several investigators and the treatment within each group was beside the mandatory requirements free for the therapists. No statistically significant differences were found between the three groups. Improvement was observed in all three groups post-treatment (Table 3). Prior to the trial, chiropractors were confident and enthusiastic about the efficacy of cervical manipulation, while physiotherapists and physicians were doubtful about the relevance. The study did not include a control group although cervical mobilization is mentioned as the control group in the paper. A follow-up 20 months after the trial showed further improvement in the all three groups (Table 3) [12].
An American study included 218 migraineurs diagnosed according to the criteria of the International Headache Society by chiropractors [13]. The study had three treatment groups, but no control group. The headache intensity on days with headaches was unchanged in all three groups. The mean frequency was reduced equally in the three groups (Table 3). Over the counter (OTC) medication was reduced from baseline to 4 weeks post-treatment with 55% in the CSMT group, 28% in the amitriptyline group and 15% in the combined CSMT and amitriptyline group.
The second Australian study was based on questionnaire diagnoses on migraine [14]. The participants had migraine for mean 18.1 years. The effect of CSMT was significant better than the control group (Table 3). The mean reduction of migraine frequency, intensity and duration from baseline to follow-up were 42, 13, and 36% in CSMT group, and 17, 5, and 21% in the control group (data calculated by the reviewers based on figures from the paper).
Discussion
Methodological Considerations
The prevalence of migraine was similar based on a questionnaire and a direct physician conducted interview, but it was due to equal positive and negative misclassification by the questionnaire [15]. A precise headache diagnosis requires an interview by a physicians or other health professional experienced in headache diagnostics. Three of the seven RCTs ascertained participants by a questionnaire, with the diagnostic uncertainty introduced by this (Table 3).
The second American study included participants with at least four headache days per months [13]. The mean headache severity on days with headache at baseline varied from 4.4 to 5.0 on a 0�10 box scale in the three treatment groups. This implies that the participants had co-occurrence of tension-type headache, since tension-type headache intensity usually vary between 1 and 6 (mild or moderate), while migraine intensity can vary between 4 and 9 (moderate or severe), but usually it is a severe pain between 7 and 9 [16, 17]. The headache severity on days with headache was unchanged between baseline and at follow-up, indicating that the effect observed was not exclusively due to an effect on migraine, but also an effect on tension-type headache.
RCTs that include a control group are advantageous to RCTs that compare two active treatments, since the effect in the placebo group rarely is zero and often varies. An example is RCTs on acute treatment of migraine comparing the efficacy of subcutaneous sumatriptan and placebo showed placebo responses between 10 and 37%, while the therapeutic effect, i.e., the efficacy of sumatriptan minus the efficacy of placebo was similar [18, 19]. Another example is a RCT on prophylactic treatment of migraine, comparing topiramate and placebo [20]. The attack reduction increased along with increasing dose of topiramate 50, 100 and 200 mg/day. The mean migraine attack frequency was reduced from 1.4 to 2.5 attacks per month in the topiramate groups and 1.1 attacks per month in the placebo group from baseline, with mean attack frequencies varying from 5.1 to 5.8 attacks per month in the four groups.
Thus, interpretation of the efficacy in the four RCTs without a control group is not straight forward [9�12]. The methodological quality of all seven RCTs had room for improvement as the maximum score 100 was far from expectation, especially a precise migraine diagnosis is important.
Several of the studies relatively include a few participants, which might cause type 2 errors. Thus, power calculation prior to the study is important in the future studies. Furthermore, the clinical guidelines from the International Headache Society should be followed, i.e., frequency is a primary end point, while duration and intensity can be secondary end points [21, 22].
Dr. Alex Jimenez’s Insight
Manual therapies, such as massage therapy, physical therapy and chiropractic spinal manipulative treatment are several well-known migraine treatment approaches recommended by healthcare professionals to help improve as well as manage the painful symptoms associated with the condition. Patients who are unable to use drugs and/or medications, including those who may prefer to avoid using these, can benefit from manual therapies for migraine treatment, according to the following article. Evidence-based research studies have determined that manual therapies might be equally as effective for migraine treatment as drugs and/or medications. However, the systematic review determined that future, well-conducted randomized clinical trials on the use of manual therapies for migraine headache pain are required to conclude the findings.
Results
The two RCTs on massage therapy included relatively a few participants, along with shortcomings mentioned in Table 3 [8, 9]. Both studies showed that massage therapy was significantly better than the control group, by reducing migraine intensity and frequency, respectively. The 27�28% (34�7% and 30�2%) therapeutic gain in migraine frequency reduction by massage therapy is comparable with the 6, 16 and 29% therapeutic gain in migraine frequency reduction by prophylactic treatment with topiramate 50, 100 and 200 mg/day [20].
The single study on physiotherapy is large, but do not include a control group [10]. The study defined responders to have 50% or more reduction in migraine intensity. The responder rate to physical therapy was only 13% in the first part of the study, while it was 55% in the group that did not benefit from relaxation, while the responder rate to relaxation was 51% in the first part of the study and 47% in the group that did not benefit from physical therapy. A reduction in migraine intensity often correlates with reduced migraine frequency. For comparison, the responder rate was 39, 49, 47 and 23% among those who received topiramate 50, 100 and 200 mg/day and placebo as defined by 50% or more reduction in migraine frequency [20]. A meta-analysis of 53 studies on prophylactic treatment with propranolol showed a mean 44% reduction in migraine activity [23]. Thus, it seems that physical therapy and relaxation has equally good effect as topiramate and propranolol.
Only one of the four RCTs on chiropractic spinal manipulative therapy (CSMT) included a control group, while the other studies compared with other active treatment [11�14]. The first Australian study showed that the migraine frequency was reduced in all three groups when baseline was compared with 20 months post trail [11, 12]. The chiropractors were highly motivated to CSMT treatment, while physicians and physiotherapist were more sceptical, which might have influenced on the result. An American study showed that CSMT, amitriptyline and CSMT + amitriptyline reduced the migraine frequency 33, 22 and 22% from baseline to post-treatment (Table 3). The second Australian study found that migraine frequency was reduced 35% in the CSMT group, while it was reduced 17% in the control group. Thus, the therapeutic gain is equivalent to that of topiramate 100 mg/day and the efficacy is equivalent to that of propranolol [20, 23].
Three case reports raise concerns about chiropractic cervical SMT, but a recent systematic review found no robust data concerning the incidence or the prevalence of adverse reactions following chiropractic cervical SMT [24�27]. When to refer migraine patients to manual therapies? Patients not responding or tolerating prophylactic medication or who wish to avoid medication for other reasons, can be referred to massage therapy, physical therapy or chiropractic spinal manipulative therapy, as these treatments are safe with a few adverse reactions [27�29].
Conclusion
Current RCTs suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally efficient as propranolol and topiramate in the prophylactic management of migraine. However, a firm conclusion requires, in future, well-conducted RCTs without the many methodological shortcomings of the evaluated RCTs on manual therapies. Such studies should follow clinical trial guidelines from the International Headache Society [21, 22].
Conflict of Interest
None declared.
Open Access: This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution and reproduction in any medium, provided the original author(s) and source are credited.
In conclusion,�chiropractors, physical therapists and massage therapists, among other qualified and experienced healthcare professionals, recommend manual therapies as a treatment for migraine headache pain. The purpose of the article was to�educate patients on the effects of manual therapies for migraine treatment. Furthermore, the systematic review determined that�future, well-conducted randomized clinical trials are required to conclude the findings. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Neck Pain
Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.
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23. Holroyd KA, Penzien DB, Cordingley GE. Propranolol in the management of recurrent migraine: a meta-analytic review. Headache. 1991;31:333�340. doi: 10.1111/j.1526-4610.1991.hed3105333.x. [PubMed][Cross Ref]
24. Khan AM, Ahmad N, Li X, Korsten MA, Rosman A. Chiropractic sympathectomy: carotid artery dissection with oculosympathetic palsy after chiropractic manipulation of the neck. Mt Sinai J Med. 2005;72:207�210. [PubMed]
25. Morelli N, Gallerini S, Gori S, Chiti A, Cosottini M, Orlandi G, Murri L. Intracranial hypotension syndrome following chiropractic manipulation of the cervical spine. J Headache Pain. 2006;7:211�213. doi: 10.1007/s10194-006-0308-0. [PMC free article][PubMed][Cross Ref]
26. Marx P, P�schmann H, Haferkamp G, Busche T, Neu J. Manipulative treatment of the cervical spine and stroke. Fortschr Neurol Psychiatr. 2009;77:83�90. doi: 10.1055/s-0028-1109083. [PubMed][Cross Ref]
27. Gouveia LO, Gastanho P, Ferreira JJ. Safety of chiropractic intervention. A systematic review. Spine. 2009;34:E405�E413. doi: 10.1097/BRS.0b013e3181a16d63. [PubMed][Cross Ref]
28. Ernst E. The safety of massage therapy. Rheumatology. 2003;42:1101�1106. doi: 10.1093/rheumatology/keg306. [PubMed][Cross Ref]
29. Zeppos L, Patman S, Berney S, Adsett JA, Bridson JM, Paratz JD. Physiotherapy in intensive care is safe: an observational study. Aust J Physiother. 2007;53:279�283. [PubMed]
These assessment and treatment recommendations represent a synthesis of information derived from personal clinical experience and from the numerous sources which are cited, or are based on the work of researchers, clinicians and therapists who are named (Basmajian 1974, Cailliet 1962, Dvorak & Dvorak 1984, Fryette 1954, Greenman 1989, 1996, Janda 1983, Lewit 1992, 1999, Mennell 1964, Rolf 1977, Williams 1965).
Clinical Application of Neuromuscular Techniques: the Subscapularis Muscle
The subscapularis is a large triangular muscle which fills the subscapular fossa and inserts into the lesser tubercle of the humerus and the front of the capsule of the shoulder-joint.
The subscapularis rotates the head of the humerus medially (internal rotation) and adducts it; when the arm is raised, it draws the humerus forward and downward. It is a powerful defense to the front of the shoulder-joint, preventing displacement of the head of the humerus.
Damage or trauma from an injury or an aggravated condition can cause shortness in the subscapularis muscle. The following assessments and treatments can help improve structure and function.
Assessment of Shortness in the Subscapularis Muscle
Subscapularis shortness test (a) Direct palpation of subscapularis is required to define problems in it, since pain patterns in the shoulder, arm, scapula and chest may all derive from subscapularis or from other sources.
The patient is supine and the practitioner grasps the affected side hand and applies traction while the fingers of the other hand palpate over the edge of latissimus dorsi in order to make contact with the ventral surface of the scapula, where subscapularis can be palpated. There may be a marked reaction from the patient when this is touched, indicating acute sensitivity.
Subscapularis shortness test (b) (as seen on Fig. 4.39 below) The patient is supine with the arm abducted to 90�, the elbow flexed to 90�, and the forearm in external rotation, palm upwards. The whole arm is resting at the restriction barrier, with gravity as its counterweight.
If subscapularis is short the forearm will be unable to rest easily parallel with the floor but will be somewhat elevated.
Figure 4.39A, B Assessment and MET self-treatment position for subscapularis. If the upper arm cannot rest parallel to the floor, possible shortness of subscapularis is indicated.
Care is needed to prevent the anterior shoulder becoming elevated in this position (moving towards the ceiling) and so giving a false normal picture.
Assessment of Weakness in the Subscapularis Muscle
The patient is prone with humerus abducted to 90� and elbow flexed to 90�. The humerus should be in internal rotation so that the forearm is parallel with the trunk, palm towards ceiling. The practitioner stabilises the scapula with one hand and with the other applies pressure to the patient�s wrist and forearm as though taking the humerus towards external rotation, while the patient resists.
The relative strength is judged and the method discussed by Norris (1999) should used to increase strength (isotonic eccentric contraction performed slowly).
MET Treatment of the Subscapularis Muscle
The patient is supine with the arm abducted to 90�, the elbow flexed to 90�, and the forearm in external rotation, palm upwards. The whole arm is resting at the restriction barrier, with gravity as its counterweight. (Care is needed to prevent the anterior shoulder becoming elevated in this position (moving towards the ceiling) and so giving a false normal picture.)
The patient raises the forearm slightly, against minimal resistance from the practitioner, for 7�10 seconds and, following relaxation, gravity or slight assistance from the operator takes the arm into greater external rotation, through the barrier, where it is held for not less than 20 seconds.
Dr. Alex Jimenez offers an additional assessment and treatment of the hip flexors as a part of a referenced clinical application of neuromuscular techniques by Leon Chaitow and Judith Walker DeLany. The scope of our information is limited to chiropractic and spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
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.
Migraine pain is among one of the most common and debilitating conditions of the human population. As a result, many migraine cases are often misdiagnosed, leading to their improper treatment. With the proper treatment, however, a patient’s overall health and wellness as well as their quality of life may improve considerably. In addition, patient education is essential to help patients take appropriate self-care measures and for them to learn how to cope with the chronic nature of their condition. Chiropractic spinal manipulative therapy and the use of medication has been previously compared to determine the effectiveness of each for migraine pain. The purpose of the following article is to demonstrate the efficacy of each migraine pain treatment.
A Case Series of Migraine Changes Following a Manipulative Therapy Trial
Abstract
Objective: To present the characteristics of four cases of migraine, who were included as participants in a prospective trial on chiropractic spinal manipulative therapy for migraine.
Method: Participants in a migraine research trial, were reviewed for the symptoms or clinical features and their response to manual therapy.
Results: The four selected cases of migraine responded dramatically to SMT, with numerous self reported symptoms being either eliminated or substantially reduced. Average frequency of episodes was reduced on average by 90%, duration of each episode by 38%, and use of medication was reduced by 94%. In addition, several associated symptoms were substantially reduced, including nausea, vomiting, photophobia and phonophobia.
Discussion: The various cases are presented to assist practitioners making a more informed prognosis.
Migraine, in its various forms, affects approximately 12 to 15% of people throughout the world, with an estimated incidence in the USA of 6% of males and 18% of females (1). Depending on the severity of a migrainous attack it is apparent that most, if not all, of the body systems can be affected (2). Consequently migraine poses a substantial threat to regular sufferers, which debilitates them to varying degrees from slight to severe (3).
One early definition of migraine highlights some potential difficulties in research assessing treatment for migraine. �A familial disorder characterised by recurrent attacks of headache widely variable in intensity, frequency and duration. Attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting. In some cases they are preceded by, or associated with neurological and mood disturbances. All of the above characteristics are not necessarily present in each attack or in each patient� (4). (Migraine and headache of the World Federation of Neurology in 1969).
Some of the more common symptoms of migraine include headache, an aura, scotoma, photophobia, phonophobia, scintillations, nausea and/or vomiting (5).
The source of pain in migraines is to found in the intra- and extracranial blood vessels (6). The blood vessel walls are pain sensitive to distension, traction or displacement. The idiopathic dilation of cranial blood vessels, together with an increase in a pain-threshold-lowering substance, result in headache for migraine headache (7).
Migraine has been shown to be reduced following chiropractic spinal manipulative therapy (8-18). In addition, other research suggests a potential role of musculoskeletal conditions in the aetiology of migraine (19-22). A misdiagnosis of migraine or cervicogenic headache could give a misleading positive result for improvement (23). Therefore, an accurate diagnosis needs to be made, based on standard accepted taxonomy.
A new classification system of headaches has been developed by the Headache Classification Committee of the International Headache Society (IHS), which contains a main category covering migraine (24). However, this taxonomy system still has several areas of potential overlap or controversy regarding the diagnosis of the headache (23).
This paper presents three cases of migraine with aura (MA) and one of migraine without aura (MW), detailing their symptoms, clinical features and response to chiropractic Spinal Manulative Therapy (SMT). The authors hope to enhance practitioners knowledge for migraine conditions that may respond favourably with SMT.
Features of Migraine
The IHS defines migraines as having at least two of the following: unilateral location, pulsating quality, moderate or severe intensity, aggravated by routine physical activity. During the headache the person must also experience either nausea &/or vomiting, and photophobia &/or phonophobia (24). In addition, there is no suggestion either by history, physical or neurological examination that the person has a headache listed in groups 5-11 of their classification system (23-25).
A previous study by the author has detailed features of the different classifications of migraine (8). The aura is the distinguishing feature between the old classifications of common (MW) and classic migraine (MA) (24). It has�been described by migraine sufferers as an opaque object, or a zigzag line around a cloud, even cases of tactile hallucinations have been recorded (6,7). The most common auras consist of homonymous visual disturbances, unilateral parathesias &/or numbness, unilateral weakness, aphasia or unclassifiable speech difficulty.
The potential mechanisms for the different migraine types are poorly understood. There have been a number of aetiologies proposed in the literature, but none seem to be able to explain all the potential symptoms experienced by migraine sufferers (26). The IHS describe changes in blood composition and platelet function as a triggering role. Processes which occur in the brain act via the trigemino-vascular system and the intra and extracranial vasculature and perivascular spaces (24).
Methodology
Based on a previous reported study (9) which involved 32 subjects who received chiropractic SMT for MA, three cases are presented which were selected due to the significant changes the patient experienced.
People with migraines were advertised for participation in the study, via the radio and newspapers within a local region of Sydney. All applicants completed a questionnaire, developed from Vernon (27) and has been reported in a previous study (9).
The participants to take part in the trial were selected according to responses in the questionnaire of specific symptoms. The criteria for MA diagnosis was compliance with at least 5 out of the following indicators: reaction to pain requiring cessation of activities or the need to seek a quiet dark area; pain located around the temples; pain described as throbbing; associated symptoms of nausea, vomiting, aura, photophobia or phonophobia; migraine precipitated by weather changes; migraine aggravated by head or neck movements; previous diagnosis of migraine by a specialist; and a family history of migraine.
Participants also had to experience migraine at least once a month, but not daily and the migraines could not have been initiated by trauma. Participants were excluded from the study if there were contra-indications to SMT, such as meningitis or cerebral aneurysm. In addition, participants with temporal arteritis, benign intracranial hypertension or space occupying lesions, were also excluded due to safety aspects.
The trial was conducted over six months, and consisted of 3 stages: two months pre-treatment, two months treatment, and two months post treatment. Participants completed diaries during the entire trial noting the�frequency, intensity, duration, disability, associated symptoms and use of medication for each migraine episode. In addition, clinic records were compared to their diary entries of migraine episodes. Concurrently, the subjects were contacted by telephone by the author every two weeks and asked to describe the migraine episodes for comparison to their diaries.
A detailed history of the patients� subjective pain features was taken during the initial consultation. This included the type of pain, duration, onset, severity, radiation, aggravating and relieving factors. The history also included medical features, a systems review for potential pathologies, previous treatments and its effects. Assessment of subluxation included: orthopaedic and neurological testing, segmental springing, mobility measures such as visual estimation of range of motion, assessment of previous radiographs, specific chiropractic vertebral testing procedures, as well as response of the patient to SMT.
In addition, several vascular investigations were performed where indicated, which include: vertebral artery test, manipulative provocation test, blood pressure assessment, and abdominal aortic aneurysm screening.
During the treatment period, the subjects continued to record migraine episodes in their diary, and receive telephone calls from the authors. Treatment consisted of short amplitude, high velocity spinal manipulative thrusts, or areas of fixation determined by the physical examination. Comparison was made of initial baseline episodes of migraine prior to commencement of the study and at six months following its cessation.
Case 1
A 25 year old, 65kg Caucasian male presented with neck pain which had commenced in early childhood, that he felt may have been related to his prolonged birth. During the history the patient stated that he suffered a regular migraine headaches (3-4 per week) which he supposed was related to a motor vehicle accident, two years prior to his presentation. He reported that his �migraine� symptoms were a unilateral throbbing headache, an aura, nausea, vomiting, vertigo, and photophobia. Sleep tended to alleviate the symptoms and he required Allegren medication (25mg) on a daily basis.
From diaries the patient was required to complete in the study, a migraine would occur 14 times a month, last an average 12.5 hours and he could perform duties after 8 hours. In addition a visual analogue scale score (VAS) for an average episode was 8.5 out of a possible maximum score of ten, corresponding to a description of �terrible� pain.
On examination, he was found to have sensitive suboccipital and upper cervical musculature, and decreased range of motion at the joint between the occiput and first cervical vertebra, the atlanto-occipital facet joint (Occ-C1), coupled with pain on flexion and extension of the cervical spine. He also had significant reduction in thoracic spine motion and an increase in thoracic kyphosis.
Treatment
The patient received chiropractic adjustments (described above) to his Occ-C1 joint, upper thoracic spine and the affected hypertonic musculature. An initial course of 16 diversified chiropractic treatments was conducted as part of a research program that the patient was participating in. The program involved recording several features for every migraine episode, including visual analogue scores, duration, medication and time before they could return to normal activities. In addition, he was shown some stretches and other exercises for his neck muscles and proved compliant.
Outcome
The patient reported a dramatic improvement after the course of treatment and had noticeably reduced frequency and intensity of migraines. This had continued when the patient was contacted at a period of 6 months after the study had ceased (Fig 1). At that point the patient reported having 2 migraines a month, with a VAS score of 5 out of ten, and the average duration had fallen to 7 hours (Fig�s 1-3). In addition, he now used no medication and noted that he no longer experienced nausea, vomiting, photophobia or phonophobia (Table 1).
Case 2
A 43 year old female university clerk presented complaining of chronic recurring headaches each lasting on average five days, sinus trouble due to allergy, and disturbed vision. The patient stated she experienced �migraines� which had been occurring since the age of eight. During the migraines she experienced nausea, visual disturbances, photophobia, phonophobia and scotoma. The pain usually began around her right eye but would often change to the left temple. She did not describe the pain as throbbing and the pain only stopped activities on a few occasions each year.
The patient stated she experienced the migraines once a month, except during springtime, when the migraines would occur at least once a week. She had been prescribed hormone replacement therapy (HRT) for twelve months following menopause, which had not changed the migraines. She also reported a VAS score of eight for an average episode and that an average episode lasted between six to eight hours.
In her history she reported that she had experienced many falls while horse riding between the ages of eight to ten. However, she believed that no bones were broken at the time of the falls, although this was not confirmed by radiographs at the time of injury. She had two children and was active, currently playing tennis, walking and was a keen gardener. Her past treatment included non- prescription medication for her sinus problems (Teldane),�however this did not seem to relieve the migraine. The patient stated she had previously had pethadine injections due to the severity of the migraines.
On examination she had an increased thoracic kyphosis, associated Trapezius hypertonicity and trigger points. She exhibited slight scoliosis (negative on Adams test) in the lumbar and thoracic regions. The patient also had moderate limitation in cervical spine mobility, notably in left lateral flexion and right rotation.
Treatment
Treatment consisted of diversified chiropractic spinal adjustments, especially to the C1-2, T5-6, L4-5 joints to correct the restriction of movement. Vibrator massage, and infra-red therapy were used to complement the�treatment, releasing muscles spasm of the region before the adjustments were delivered. The patient was given 14 treatments over the two months of the research trial. Following the initial treatment she experienced some moderate neck pain which resolved following the next session.
Outcome
When contacted six months following the study, the patient stated the migraines had not experienced a migraine in the last four months. The last episode she had noted a VAS score reduced to four, the average duration had reduced to three days and she had now reduced her medication to nil (Fig�s 1-4). In addition, she now experienced minor nausea, no photophobia or phonophobia, and she had substantially improved neck�mobility. She had continued to have chiropractic treatment at a frequency of once a month, following the end of the research trial.
Case 3
A 21 year old female, 171cm tall Caucasian presented with a chief complaint of severe migraines. Each episode lasted two to four hours, at a frequency of three to four episodes per week, and they had occurred for five years. The patient reported moderate posterior neck and shoulder pain, associated with the migraines. She also believed the initial migraine to be induced by stress and subsequent episodes were also aggravated by emotional stress. The patient reported no other health problems except very mild hypotension, for which she was not taking medication.
The patient�s migraines were located in the frontal, temporal and occipital regions bilaterally. No symptoms occurred premonitory to the onset of her migraines, nor did she experience visual disturbances prior to or during the migraine episodes. She described the pain as a constant dull ache, which was local and she did not complain of any parathesias.
At the initial visit, she rated each migraine between 4 and 5 on a VAS of 1-10. She also noted she experienced nausea, vomiting, dizziness, photophobia and phonophobia.
The cervical ranges of motion were restricted, predominantly in right rotation. Palpation findings were obvious at trapezius, suboccipital and supra scapulae muscles due to increased tone, colour and temperature. Motion palpation indicated restricted movement of the C1-2 facet joint on the right side. Further palpation of the supra scapular and suboccipital indicated myofibrotic tissue. Neurological tests such as Rhombergs, and vertebrobasilar (Maines) test, were negative.
Treatment
The initial treatment was muscle stripping technique aided by a masseter machine massage across the muscle fibres of the trapezius, suprascapularis and temporal regions. The patient also had a cervical adjustment of C1- 2, and adjustment to the T3-4 & T4-5 segments.
The patient was seen three days later, at which point she reported that her neck was less painful. However, she still complained of right neck pain and dizziness. Examination revealed passive motion restriction at C1-2 motion segment. Her thoracic spine was found to be restricted at segment T5-6. In addition, she had mild to moderate hypertonicity in suboccipital and cervical paraspinal muscles and supra scapular area. She was again treated�with adjustments and soft tissue technique. The C1-2 restriction to the right was adjusted with a cervical adjustment. The T5-6 restriction was also adjusted and the myofibrotic tissues were treated with the masseter.
The patient returned four days later. She reported that her migraine had improved. She no longer experienced the symptoms of a non-classical migraine. However, the pressure sensation was still present around her head, but less so than prior to the commencement of treatment. No neck pain was reported. Examination revealed a passive motion restriction of C1-2 motion segment. There was hypertonicity in the suboccipital and supra scapular muscles. The patient was treated with a cervical adjustment at C1-2 and muscle work on the above muscle groups. Neck stretching exercises were also advised.
The patient was seen a total of thirteen times over a two month period, and stated that her migraine episodes had reduced significantly at the last treatment. In addition, she was no longer experiencing neck pain. Examination revealed passive motion restriction at the C1-2 motion segment, which was reduced by adjustment.
Outcome
The patient was contacted six months after the trial for a follow-up, at which point she reported she had experienced a reduction of migraine episodes to once every two months. However, her VAS scores for an average episode was now 5.5, but the duration of an average episode was reduced by 50%. In addition, she noted a reduction in photophobia and phonophobia, but still experienced some dizziness. The patient also noted a reduction in use of medication from three Nurofen a week (12 per month) to three per month, representing a 75% reduction (Fig�s 1- 4).
Case 4
A 34 year old, 75kg Caucasian male presented with neck pain and migraines which had commenced after he had hit his head whilst surfing at a beach. This incident occurred when the patient was 19 years old but the patient said the migraines had peaked at 25 years of age. The patient stated that at 25 years of age he suffered a�migraine headaches (three to four times per week) but now in the last year prior to his presentation he experienced them twice a week. He reported that his migraines started in the suboccipital region, and radiated to his right eye. He also reported they were a unilateral throbbing headache, an aura, nausea, vomiting, vertigo, and photophobia. The patient stated taking aspirin and mersyndol medication approximately four to five times a week.
The patient reported that an average episode lasted twelve to eighteen hours and he could perform duties after eight to ten hours. In addition a visual analogue scale score (VAS) for an average episode was 7.0 out of a possible maximum score of ten, corresponding to a description of �moderate� pain. He also reported that he had osteopathic treatment approximately three years earlier, which had given some short term relief, however, physiotherapy had proven ineffective.
On examination, he was found to have significant reduction in thoracic spine motion and an increase in thoracic kyphosis, and decreased range of motion at the joint between the first and second cervical vertebra (C1- 2), the atlanto-occipital facet joint (Occ-C1), coupled with pain on flexion and extension of the cervical spine. He also had sensitive suboccipital and upper cervical musculature, especially the upper Trapezius muscle.
Treatment
The patient received chiropractic diversified adjustments to his C1-2 joint, upper thoracic spine and the affected hypertonic musculature. After a course of 14 treatments (conducted as part of a research program) the patient found he was experiencing one migraine per fortnight. The patient also reported that the nausea had decreased and that the aura was less significant.
The patient reported the improvement after the initial treatment had continued when the patient was contacted 6 months after the study had ceased. At that point the patient reported having one migraine a month, and that the VAS score had fallen to 6 out of ten. However, the average duration and return to normal activities time had remain the same as before the treatment had commenced. The patient reported that he now used only one medication per month and that he no longer experienced nausea, vomiting, and the aura (Fig�s 1-4).
Dr. Alex Jimenez’s Insight
“How does the effectiveness of chiropractic care and the use of medication vary when it comes to migraine pain?”�Chiropractic migraine pain treatment, such as chiropractic spinal manipulative treatment or spinal manipulation, is commonly utilized to help improve as well as manage migraine symptoms. Many healthcare professionals also frequently use medication, such as amitriptyline, to help relieve migraine symptoms although this treatment option may only temporarily relieve the symptoms rather than treat the condition from the source. Chiropractic care and the use of medication can be used together to help increase the relief of the treatments, as recommended by a healthcare professional. Several evidence-based studies, like the ones in the article, have demonstrated the effectiveness of chiropractic migraine pain treatment, however, more research studies are required to determine their specific result on migraine pain management. Furthermore, other research studies have shown that medication may be as effective as chiropractic spinal manipulative treatment but was associated with more side effects. Common side effects of medications like amitriptyline include: drowsiness, dizziness, dry mouth, blurred vision, constipation, trouble urinating or weight gain. Additional assessments on the effectiveness of spinal manipulation and amitriptyline is needed.
Conclusion
These four case studies highlight an apparent significant reduction in disability associated with migraines (Table 1). The conclusions are limited however, because the study does not contain a control group for comparison of placebo effect. Therefore chiropractic SMT appears to have significantly reduced migraine disability for these individuals.
Practitioners need to be critically aware of diagnostic criteria when presenting studies or case studies on effectiveness of their treatment (8). This is especially important in presentation of migraine and manipulative therapy research (12, 23).
Changes in outcome measures of migraine episodes for the mean of the four cases revealed some interesting findings (Table 2 ). As can be seen in the table, the frequency of episodes and the use of medication were substantially reduced for the four cases. However, one cannot conclude that this could be the case for other migraine sufferers due to the small number of cases presented.
Acknowledgement
The author greatly appreciates the contribution of Dr Dave Mealing in the preparation of the paper.
A Randomized Controlled Trial of Chiropractic Spinal Manipulative Therapy for Migraine.
Abstract
Objective: To assess the efficacy of chiropractic spinal manipulative therapy (SMT) in the treatment of migraine.
Design: A randomized controlled trial of 6 months’ duration. The trial consisted of 3 stages: 2 months of data collection (before treatment), 2 months of treatment, and a further 2 months of data collection (after treatment). Comparison of outcomes to the initial baseline factors was made at the end of the 6 months for both an SMT group and a control group.
Setting: Chiropractic Research Center of Macquarie University.
Participants: One hundred twenty-seven volunteers between the ages of 10 and 70 years were recruited through media advertising. The diagnosis of migraine was made on the basis of the International Headache Society standard, with a minimum of at least one migraine per month.
Interventions: Two months of chiropractic SMT (diversified technique) at vertebral fixations determined by the practitioner (maximum of 16 treatments).
Main Outcome Measures: Participants completed standard headache diaries during the entire trial noting the frequency, intensity (visual analogue score), duration, disability, associated symptoms, and use of medication for each migraine episode.
Results: The average response of the treatment group (n = 83) showed statistically significant improvement in migraine frequency (P < .005), duration (P < .01), disability (P < .05), and medication use (P< .001) when compared with the control group (n = 40). Four persons failed to complete the trial because of a variety of causes, including change in residence, a motor vehicle accident, and increased migraine frequency. Expressed in other terms, 22% of participants reported more than a 90% reduction of migraines as a consequence of the 2 months of SMT. Approximately 50% more participants reported significant improvement in the morbidity of each episode.
Conclusion: The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic SMT. A high percentage (>80%) of participants reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced.
Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-Type Headaches: a Randomized Clinical Trial
Abstract
Objective: To compare the effectiveness of spinal manipulation and pharmaceutical treatment (amitriptyline) for chronic tension-type headache.
Design: Randomized controlled trial using two parallel groups. The study consisted of a 2-wk baseline period, a 6-wk treatment period and a 4-wk posttreatment, follow-up period.
Setting: Chiropractic college outpatient clinic.
Patients: One hundred and fifty patients between the ages of 18 and 70 with a diagnosis of tension-type headaches of at least 3 months’ duration at a frequency of at least once per wk.
Interventions: 6 wk of spinal manipulative therapy provided by chiropractors or 6 wk of amitriptyline treatment managed by a medical physician.
Main Outcome Measures: Change in patient-reported daily headache intensity, weekly headache frequency, over-the-counter medication usage and functional health status (SF-36).
Results: A total of 448 people responded to the recruitment advertisements; 298 were excluded during the screening process. Of the 150 patients who were enrolled in the study, 24 (16%) dropped out: 5 (6.6%) from the spinal manipulative therapy and 19 (27.1%) from the amitriptyline therapy group. During the treatment period, both groups improved at very similar rates in all primary outcomes. In relation to baseline values at 4 wk after cessation of treatment, the spinal manipulation group showed a reduction of 32% in headache intensity, 42% in headache frequency, 30% in over-the-counter medication usage and an improvement of 16% in functional health status. By comparison, the amitriptyline therapy group showed no improvement or a slight worsening from baseline values in the same four major outcome measures. Controlling for baseline differences, all group differences at 4 wk after cessation of therapy were considered to be clinically important and were statistically significant. Of the patients who finished the study, 46 (82.1%) in the amitriptyline therapy group reported side effects that included drowsiness, dry mouth and weight gain. Three patients (4.3%) in the spinal manipulation group reported neck soreness and stiffness.
Conclusions: The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline therapy was slightly more effective in reducing pain at the end of the treatment period but was associated with more side effects. Four weeks after the cessation of treatment, however, the patients who received spinal manipulative therapy experienced a sustained therapeutic benefit in all major outcomes in contrast to the patients that received amitriptyline therapy, who reverted to baseline values. The sustained therapeutic benefit associated with spinal manipulation seemed to result in a decreased need for over-the-counter medication. There is a need to assess the effectiveness of spinal manipulative therapy beyond four weeks and to compare spinal manipulative therapy to an appropriate placebo such as sham manipulation in future clinical trials.
In conclusion,�the following research studies demonstrated the effectiveness of chiropractic spinal manipulative therapy while one research study compared it with the use of amitriptyline for migraine. The article concludes that both chiropractic migraine pain treatment as well as medication were significantly effective in the improvement of migraine headache, however, amitriptyline is reported to present various side effects. Finally, patients may choose the best possible treatment for their migraine pain, as recommended by a healthcare professional. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Neck Pain
Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.
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3. King J. Migraine in the Workplace. Brainwaves. Australian Brain Foundation 1995. Hawthorn, Victoria.
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Why Chiropractic Works:�PUSH-as-Rx ��: 915-203-8122 | Dr. Alex Jimenez � Chiropractor: 915-850-0900
PUSH-as-Rx �� & Chiropractor Dr. Alex Jimenez are leading the field with laser focus supporting our youth sport programs.� The�PUSH-as-Rx ���System is a sport specific athletic program designed by a strength-agility coach and physiology doctor with a combined 40 years of experience working with extreme athletes. At its core, the program is the multidisciplinary study of reactive agility, body mechanics and extreme motion dynamics. Through continuous and detailed assessments of the athletes in motion and while under direct supervised stress loads, a clear quantitative picture of body dynamics emerges. Exposure to the biomechanical vulnerabilities are presented to our team. �Immediately,�we adjust our methods for our athletes in order to optimize performance.� This highly adaptive system with continual�dynamic adjustments has helped many of our athletes come back faster, stronger, and ready post injury while safely minimizing recovery times. Results demonstrate clear improved agility, speed, decreased reaction time with greatly improved postural-torque mechanics.��PUSH-as-Rx ���offers specialized extreme performance enhancements to our athletes no matter the age.
Why Chiropractic Works
We Welcome You ??. Purpose & Passions: I am a Doctor of Chiropractic specializing in progressive cutting-edge therapies and functional rehabilitation procedures focused on clinical physiology, total health, functional strength training and complete conditioning. We focus on restoring normal body functions after neck, back, spinal and soft tissue injuries. We use Specialized Chiropractic Protocols, Wellness Programs, Functional & Integrative Nutrition, Agility & Mobility Fitness Training and Cross-Fit Rehabilitation Systems for all ages. As an extension to dynamic rehabilitation, we too offer our patients, disabled veterans, athletes, young and elder a diverse portfolio of strength equipment, high performance exercises and advanced agility treatment options. We have teamed up with the cities premier doctors, therapist and trainers in order to provide high level competitive athletes the options to push themselves to their highest abilities within our facilities. We’ve been blessed to use our methods with thousand of El Pasoan’s over the last 3 decades allowing us to restore our patients health and fitness while implementing researched non-surgical methods and functional wellness programs. Our programs are natural and use the body’s ability to achieve specific measured goals, rather than introducing harmful chemicals, controversial hormone replacement, un-wanted surgeries, or addictive drugs. We want you to live a functional life that is fulfilled with more energy, positive attitude, better sleep, and less pain. Our goal is to ultimately empower our patients to maintain the healthiest way of living. With a bit of work, we can achieve optimal health together, no matter the age or disability. Join us in improving your health for you and your family. Its all about: LIVING, LOVING & MATTERING! �And this is why chiropractic works!�?
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Investigate why the source process may be the same for both conditions in some.
Sciatica cases where constipation is also present involves the nerve roots in the lower spinal regions. These types of symptomatic expressions will be blamed on a variety of structural abnormalities in the lumbosacral region, which include degenerative disc disease, herniated discs and spinal osteoarthritis.
