Back Clinic Sciatica Chiropractic Team. Dr. Alex Jimenez organized a variety of article archives associated with sciatica, a common and frequently reported series of symptoms affecting a majority of the population. Sciatica pain can vary widely. It may feel like a mild tingling, dull ache, or burning sensation. In some cases, the pain is severe enough to make a person unable to move. The pain most often occurs on one side.
Sciatica occurs when there is pressure or damage to the sciatic nerve. This nerve starts in the lower back and runs down the back of each leg as it controls the muscles of the back of the knee and lower leg. It also provides sensation to the back of the thigh, part of the lower leg, and the sole of the foot. Dr. Jimenez explains how sciatica and its symptoms can be relieved through the use of chiropractic treatment. For more information, please feel free to contact us at (915) 850-0900 or text to call Dr. Jimenez personally at (915) 540-8444.
Sciatica Nerve Pain:�Edgar M. Reyes works for the city of El Paso and his ability to properly engage in his occupation is an essential part of his job, however, Mr. Reyes developed sciatica, which affected his everyday performance. Unable to walk due to his sciatica nerve pain, Edgar M Reyes found chiropractic treatment with Dr. Alex Jimenez. Chiropractic care provided Mr. Reyes with the relief he deserved from his sciatica and restored his ability to walk as well as his health and wellness.
Sciatica is a set of symptoms characterized by radiating pain from the lumbar spine. This pain may go down the back, into the buttocks, hips, legs and feet. Onset is frequently sudden following tasks like heavy lifting, though slow onset may also occur. Symptoms may occur on one or both sides of the body. Pain, numbness and weakness can occur depending on the type of compression on the sciatic nerve. About 90% of sciatica cases are often due to a spinal disc herniation pressing on one of the lumbar or sacral nerve roots. Other issues that may cause sciatica include spondylolisthesis, spinal stenosis and piriformis syndrome.
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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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22.�Daltroy LH, Cats-Baril WL, Katz JN, Fossel AH, Liang MH. The North American Spine Society lumbar spine outcome assessment instrument: reliability and validity tests.�Spine.�1996;21:741�749.[PubMed]
23.�Deyo RA, Diehl AK. Patient satisfaction with medical care for low-back pain.�Spine.�1986;11:28�30.[PubMed]
24.�Atlas SJ, Deyo RA, Patrick DL, Convery K, Keller RB, Singer DE. The Quebec Task Force classification for spinal disorders and the severity, treatment, and outcomes of sciatica and lumbar spinal stenosis.�Spine.�1996;21:2885�2892.�[PubMed]
25.�Patrick DL, Deyo RA, Atlas SJ, Singer DE, Chapin A, Keller RB. Assessing health-related quality of life in patients with sciatica.�Spine.�1995;20:1899�1908.�[PubMed]
26.�Phelan EA, Deyo RA, Cherkin DC, et al. Helping patients decide about back surgery: a randomized trial of an interactive video program.�Spine.�2001;26:206�211.�[PubMed]
27.�Weinstein JN. Partnership: doctor and patient: advocacy for informed choice vs. informed consent.�Spine.�2005;30:269�272.�[PubMed]
28.�Friedman L, Furberg C, DeMets D.�Fundamentals of Clinical Trials.�3rd ed. Springer-Verlag; Cambridge, Mass: 1998. The randomization process; pp. 61�81.
29.�Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, II: 1-year outcomes of surgical and nonsurgical management of sciatica.�Spine.�1996;21:1777�1786.�[PubMed]
30.�Little R, Rubin D.�Statistical Analysis With Missing Data.�2nd ed. John Wiley & Sons; Philadelphia, Pa: 2002.
31.�Diggle P, Haeagery P, Liang K, Zeger S.�The Analysis of Longitudinal Data.�2nd ed. Oxford University Press; Oxford, England: 2002.
32.�Fitzmaurice G, Laird N, Ware J.�Applied Longitudinal Analysis.�John Wiley & Sons; Philadelphia, Pa: 2004.
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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
Low back pain, or LBP, is a very common condition which affects the lumbar spine, or the lower section of the spine. Approximately more than 3 million cases of LBP are diagnosed in the United States aline every year and about 80 percent of adults worldwide experience low back pain at some point during their lifetime. Low back pain is generally caused by injury to a muscle (strain) or ligament (sprain) or due to damage from a disease. Common causes of LBP include poor posture, lack of regular exercise,�improper lifting, fracture, herniated discs and/or arthritis. Most cases of low back pain may often go away on their own, however, when LBP becomes chronic, it may be important to seek immediate medical attention. Two therapeutic methods have been utilized to improve LBP. The following article compares the effects of Pilates and McKenzie training on LBP.
A Comparison of the Effects of Pilates and McKenzie Training on Pain and General Health in Men with Chronic Low Back Pain: A Randomized Trial
Abstract
Background: Today, chronic low back pain is one of the special challenges in healthcare. There is no unique approach to treat chronic low back pain. A variety of methods are used for the treatment of low back pain, but the effects of these methods have not yet been investigated adequately.
Aim: The aim of this study was to compare the effects of Pilates and McKenzie training on pain and general health of men with chronic low back pain.
Materials and Methods: Thirty-six patients with chronic low back pain were chosen voluntarily and assigned to three groups of 12 each: McKenzie group, Pilates group, and control group. The Pilates group participated in 1-h exercise sessions, three sessions a week for 6 weeks. McKenzie group performed workouts 1 h a day for 20 days. The control group underwent no treatment. The general health of all participants was measured by the General Health Questionnaire 28 and pain by the McGill Pain Questionnaire.
Results: After therapeutic exercises, there was no significant difference between Pilates and McKenzie groups in pain relief (P = 0.327). Neither of the two methods was superior over the other for pain relief. However, there was a significant difference in general health indexes between Pilates and McKenzie groups.
Conclusion: Pilates and McKenzie training reduced pain in patients with chronic low back pain, but the Pilates training was more effective to improve general health.
Keywords:Chronic back pain, general health, Mckenzie training, pain, Pilates training
Introduction
Low back pain with a history of more than 3 months and without any pathological symptom is called chronic low back pain. For patient with chronic low back pain, the physician should take into consideration the likelihood of muscle pain development with spinal origin, in addition to low back pain with unknown origin. This type of pain may be mechanical (increase in pain with movement or physical pressure) or nonmechanical (increase in pain at the rest time).[1] Low back pain or spine pain is the most common musculoskeletal complication.[2] About 50%�80% of healthy people may experience low back pain during their lifetime, and about 80% of the problems are related to the spine and occur in the lumbar area.[3] Low back pain may be caused by trauma, infection, tumors, etc.[4] Mechanical injuries which are caused by overuse of a natural structure, deformity of an anatomical structure, or the injury in the soft tissue are the most common reasons for back pain. From occupational health perspective, back pain is among the most important reasons for the absence from work and occupational disability;[5] in fact, the longer the period of disease,[6] the less likely it is to improve and return to work.[1] Disability due to low back pain in addition to disturbance in doing daily and social activities has a very negative effect, from social and economic perspectives, on the patient and the community, which makes chronic low back pain highly important.[3] Today, chronic low back pain is one of the critical challenges in medicine. Patients with chronic low back pain are responsible for 80% of the costs paid for the treatment of low back pain that is also the reason for mobility restrictions in most people under 45 years.[7] In the developed countries, the overall cost paid for low back pain per year is 7.1 of total share of the gross national product. Clearly, most of the cost is related to counseling and treatment of patients with chronic low back pain rather than with intermittent and recursive low back pain.[8] The existence of various methods of treatment is because of no single cause of low back pain.[9] A variety of methods such as pharmacotherapy, acupuncture, infusions, and physical methods are the most common interventions for treatment of low back pain. However, the effects of these methods remain to be fully known.[6] An exercise program, developed based on the physical conditions of patients, can promote the quality of life in patients with chronic disease.[10,11,12,13,14]
Literature shows that the effect of exercise in controlling chronic low back pain is under study and there is strong evidence about the fact that movement therapy is effective to treat low back pain.[15] However, no specific recommendations exist about the type of exercise, and the effects of certain types of movement therapies have been determined in few studies.[9] Pilates training consists of the exercises that focus on improving flexibility and strength in all the body organs, without increasing the mass of muscles or destroying them. This training method consists of controlled movements that form a physical harmony between the body and brain, and can raise the ability of the body of people at any age.[16] In addition, people who do Pilates exercise would have better sleep and less fatigue, stress, and nervousness. This training method is based on standing, sitting, and lying positions, without intervals, jumping, and leaping; thus, it may reduce injuries resulting from the joint damage because the exercise movements in the ranges of motion in the above three positions are performed with deep breathing and muscle contraction.[17] McKenzie method, also called mechanical diagnosis and therapy and based on the patient’s active participation, is used and trusted by patients and the people who use this method worldwide. This method is based on physical therapy which has been frequently studied. The distinctive characteristic of this method is the principle of initial assessment.[18] This principle is a reliable and safe method to make a diagnosis that makes the correct treatment planning possible. In this way, the time and energy are not spent for costly tests, rather McKenzie therapists, using a valid indicator, quickly recognize that how much and how this method is fruitful for the patient. More appropriately, McKenzie method is a comprehensive approach based on the correct principles whose full understanding and following is very fruitful.[19] In the recent years, non-pharmacological approaches have attracted the attention of physicians and patients with low back pain.[20] Complementary therapies[21] and treatments with holistic nature (to increase physical and mental well-being) are appropriate to manage physical illness.[13] Complementary therapies can slow down disease progression and improve capacity and physical performance. The aim of the present study is to compare the effect of the Pilates and McKenzie training on pain and general health in men with chronic low back pain.
Materials and Methods
This randomized clinical trial was conducted in Shahrekord, Iran. The total study population screened was 144. We decided to enroll at least 25% of the population, 36 individuals, using a systematic random sampling. First, the participants were numbered and a list was developed. The first case was selected using random number table and then one out of four patients was randomly enrolled. This process continued till a desired number of participants were enrolled. Then, the participants were randomly assigned to experimental (Pilates and McKenzie training) groups and control group. After explaining the research purposes to the participants, they were asked to complete the consent form for participation in the study. Furthermore, the patients were ensured that the research data are kept confidential and used only for research purposes.
Inclusion Criteria
The study population included men aged 40�55 years in Shahrekord, South-West Iran, with chronic back pain, that is, history of more than 3 months of low back pain and no specific disease or other surgery.
Exclusion Criteria
The exclusion criteria were low back arch or so-called army back, serious spinal pathology such as tumors, fractures, inflammatory diseases, previous spinal surgery, nerve root compromise in the lumbar region, spondylolysis or spondylolisthesis, spinal stenosis, neurological disorders, systemic diseases, cardiovascular diseases, and receiving other therapies simultaneously. The examiner who assessed the outcomes was blinded to group assignment. Twenty-four hours before the training, a pretest was administered to all three groups to determine pain and general health; and then, the training began after completion of the McGill Pain Questionnaire (MPQ) and the General Health Questionnaire-28 (GHQ-28). The MPQ can be used to evaluate a person experiencing significant pain. It can be used to monitor the pain over time and to determine the effectiveness of any intervention. Minimum pain score: 0 (would not be seen in a person with true pain), maximum pain score: 78, and the higher the pain score the more severe the pain. Investigators reported that the construct validity and the reliability of the MPQ were reported as a test-retest reliability of 0.70.[22] The GHQ is a self-administered screening questionnaire. Test-retest reliability has been reported to be high (0.78�0 0.9) and inter- and intra-rater reliability have both been shown to be excellent (Cronbach’s ? 0.9�0.95). High internal consistency has also been reported. The lower the score is, the better the general health is.[23]
The participants in the experimental groups started training program under supervision of a sports medicine specialist. The training program consisted of 18 sessions of supervised individual training for both groups, with the sessions held three times per week for 6 weeks. Each training session lasted for an hour and was performed at the Physiotherapy Clinic in the School of Rehabilitation of the Shahrekord University of Medical Sciences in 2014�2015. The first experimental group performed Pilates training for 6 weeks, three times a week about an hour per session. In each session, first, a 5-min warm-up and preparation procedures were run; and at the end, stretching and walking were done to return to the baseline condition. In the McKenzie group, six exercises were used: Four extension-type exercises and two flexion-types. The extension-type exercises were performed in prone and standing positions, and the flexion-type exercises in the supine and sitting positions. Each exercise was run ten times. In addition, the participants conducted twenty daily individual training sessions for an hour.[18] After training of both groups, the participants filled out the questionnaires and then the collected data were presented in both descriptive and inferential statistics. Furthermore, the control group without any training, at the end of a period when other groups have completed, filled the questionnaire. Descriptive statistics were used for central tendency indicators such as mean (� standard deviation) and relevant diagrams were used to describe the data. Inferential statistics, one-way ANOVA and post hoc Tukey’s test, were used to analyze the data. Data analysis was done by SPSS Statistics for Windows, Version 21.0 (IBM Corp. Released 2012. IBM Armonk, NY: IBM Corp). P < 0.05 was considered statistically significant.
Dr. Alex Jimenez’s Insight
Alongside the use of spinal adjustments and manual manipulations for low back pain, chiropractic care commonly utilizes therapeutic exercise methods to improve LBP symptoms, restoring the affected individual’s strength, flexibility and mobility as well as promoting a faster recovery. The Pilates and McKenzie method of training, as mentioned in the article, are compared to determine which therapeutic exercise is best for treating low back pain. As�a Level I Certified Pilates Instructor, Pilates training is implemented with chiropractic treatment to improve LBP more effectively. Patients participating in a therapeutic exercise method alongside a primary form of treatment for low back pain can experience additional benefits. McKenzie training can also be implemented with chiropractic treatment to further improve LBP symptoms. The purpose of this research study is to demonstrate evidence-based information on the benefits of Pilates and McKenzie methods for low back pain as well as to educate patients on which of the two therapeutic exercises should be considered to help treat their symptoms and achieve overall health and wellness.
Level I Certified Pilates Instructors at Our Location
Dr. Alex Jimenez D.C., C.C.S.T | Chief Clinical Director and Level I Certified Pilates Instructor
Truide Torres | Director of Patient Relations Advocate Dept. and Level I Certified Pilates Instructor
Results
The results showed no significant difference between the case and control groups regarding the gender, marital status, job, educational level, and income. The results showed changes in pain index and general health in the participants before and after Pilates and McKenzie training in the two experimental and even control groups [Table 1].
A significant difference was seen in pain and general health between the control and the two experimental groups at the pre- and post-test, so that the exercise training (both Pilates and McKenzie) resulted in reduced pain and promoted general health; while in the control group, pain increased and general health declined.
Discussion
The results of this study indicate that back pain reduced and general health enhanced after exercise therapy with both Pilates and McKenzie training, but in the control group, pain was intensified. Petersen et al. study on 360 patients with chronic low back pain concluded that at the end of 8 weeks of McKenzie training and high-intensity endurance training and 2 months training at home, pain and disability decreased in McKenzie group at the end of 2 months, but at the end of 8 months, no differences were seen among the treatments.[24]
The results of another study show that McKenzie training is a beneficial method for reducing pain and increasing the movements of the spine in patients with chronic low back pain.[18] Pilates training can be an effective method for improving general health, athletic performance, proprioception, and reduction of pain in patients with chronic low back pain.[25] The improvements in strength seen in the participants in the present study were more likely to be due to decrease in pain inhibition than to neurological changes in muscle firing/recruitment patterns or to morphological (hypertrophic) changes in the muscle. In addition, neither of the treatments was superior over the other in view of reducing the intensity of pain. In the present study, 6 weeks of McKenzie training led to significant reduction in pain levels in men with chronic low back pain. The rehabilitation of patients with chronic low back pain is aimed to restore strength, endurance, and flexibility of soft tissues.
Udermann et al. showed that McKenzie training improved pain, disability, and psychosocial variables in patients with chronic low back pain, and back stretching training did not have any additional effect on pain, disability, and psychosocial variables.[26] The results of another study show that there is a reduction in pain and disability due to McKenzie method for at least 1 week in comparison with the passive treatment in patients with low back pain, but reduction in pain and disability due to McKenzie method in comparison with the active treatment methods is desirable within 12 weeks after treatment. Overall, McKenzie treatment is more effective than passive methods to treat low back pain.[27] One of the popular exercise therapies for patients with low back pain is McKenzie training program. McKenzie method leads to improvement of low back pain symptoms such as pain in the short-term. Moreover, McKenzie therapy is more effective in comparison with passive treatments. This training is designed to mobilize the spine and to strengthen the lumbar muscles. Previous studies have shown that weakness and atrophy in the body central muscles, particularly the transverse abdominal muscle in patients with low back pain.[28] The results of this research also showed that there was a significant difference in the general health indexes between Pilates and McKenzie groups. In the present study, 6 weeks of Pilates and McKenzie training led to a significant reduction in the level of general health (physical symptoms, anxiety, social dysfunction, and depression) in men with chronic low back pain and the general health in Pilates training group improved. The results of most studies show that exercise therapy reduces pain and improves general health in patients with chronic low back pain. Importantly, the agreement about the duration, type, and intensity of the training remains to be achieved and there is no definite training program that can have the best effect on patients with chronic low back pain. Therefore, more research is needed to determine the best duration and treatment method to reduce and improve general health in patients with low back pain. In the Al-Obaidi et al. study, pain, fear, and functional disability improved after 10 weeks of treatment in patients.[5]
Besides that McKenzie training increases the range of motion of lumbar flexion. Overall, neither of the two methods of treatment was superior over the other.[18]
Borges et al. concluded that after 6 weeks of treatment, the average index of pain in experimental group was lower than the control group. Furthermore, the general health of the experimental group exhibited greater improvement than the control group. The results of this research support recommending Pilates training to patients with chronic low back pain.[29] Caldwell et al. on the university students concluded that Pilates training and Tai chi guan improved mental parameters such as self-sufficiency, quality of sleep, and morality of students but had no effect on physical performance.[30] Garcia et al. study on 148 patients with nonspecific chronic low back pain concluded that treating patients with nonspecific chronic low back pain by McKenzie training and back school caused disability to improve after treatment, but quality of life, pain, and the range of motor flexibility did not change. McKenzie treatment is typically more effective on disability than back school program.[19]
The overall findings of this study are supported by the literature, demonstrating that a Pilates program may offer a low-cost, safe alternative to the treatment of low back pain in this specific group of patients. Similar effects have been found in patients with unspecific chronic low back pain.[31]
Our study had good levels of internal and external validity and thus can guide therapists and patients considering therapies of choice for back pain. The trial included a number of features to minimize bias such as prospectively registering and following a published protocol.
Study Limitation
Small sample size enrolled in this study limits the generalization of the study findings.
Conclusion
The results of this study showed that 6-week Pilates and McKenzie training reduced pain in patients with chronic low back pain, but there was no significant difference between the effect of two therapeutic methods on pain and both exercise protocols had the same effect. In addition, Pilates and McKenzie training improved general health; however, according to the mean general health changes after the exercise therapy, it can be argued that the Pilates training has a greater effect in improving general health.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
In conclusion,�when comparing the effects of Pilates and McKenzie training on general health as well as on painful symptoms in men with chronic low back pain, the evidence-based research study determined that both the Pilates and the McKenzie method of training effectively reduced pain in patients with chronic LBP. There was no significant difference between the two therapeutic methods altogether, however, the mean results of the research study demonstrated that Pilates training was more effective towards improving general health in men with chronic low back pain than McKenzie training.� Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
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2. Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010;24:783�92. [PubMed]
3. Balagu� F, Mannion AF, Pellis� F, Cedraschi C. Non-specific low back pain. Lancet. 2012;379:482�91. [PubMed]
4. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. New York: Lippincott Williams & Wilkins; 2011.
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9. Hernandez AM, Peterson AL. Handbook of Occupational Health and Wellness. Springer: 2012. Work-related musculoskeletal disorders and pain; pp. 63�85.
10. Hassanpour Dehkordi A, Khaledi Far A. Effect of exercise training on the quality of life and echocardiography parameter of systolic function in patients with chronic heart failure: A randomized trial. Asian J Sports Med. 2015;6:e22643. [PMC free article][PubMed]
11. Hasanpour-Dehkordi A, Khaledi-Far A, Khaledi-Far B, Salehi-Tali S. The effect of family training and support on the quality of life and cost of hospital readmissions in congestive heart failure patients in Iran. Appl Nurs Res. 2016;31:165�9. [PubMed]
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20. Hassanpour-Dehkordi A, Safavi P, Parvin N. Effect of methadone maintenance treatment of opioid dependent fathers on mental health and perceived family functioning of their children. Heroin Addict Relat Clin. 2016;18(3):9�14.
21. Shahbazi K, Solati K, Hasanpour-Dehkordi A. Comparison of hypnotherapy and standard medical treatment alone on quality of life in patients with irritable bowel syndrome: A Randomized Control Trial. J Clin Diagn Res. 2016;10:OC01�4. [PMC free article][PubMed]
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Chiropractic Management of Low Back Pain and Low Back-Related Leg Complaints: A Literature Synthesis
Chiropractic care is a well-known complementary and alternative treatment option frequently used to diagnose, treat and prevent injuries and conditions of the musculoskeletal and nervous systems. Spinal health issues are among some of the most common reasons people seek chiropractic care, especially for low back pain and sciatica complaints. While there are many different types of treatments available to help improve low back pain and sciatica symptoms, many individuals will often prefer natural treatment options over the use of drugs/medications or surgical interventions. The following research study demonstrates a list of evidence-based chiropractic treatment methods and their effects towards improving a variety of spinal health issues.
Abstract
Objectives: The purpose of this project was to review the literature for the use of spinal manipulation for low back pain (LBP).
Methods: Asearch strategymodified fromthe Cochrane Collaboration reviewforLBP was conducted through the following databases: PubMed, Mantis, and the Cochrane Database. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input.
Results: A total of 887 source documents were obtained. Search results were sorted into related topic groups as follows: randomized controlled trials (RCTs) of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnostic-related articles, methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. The team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and coh ort studies. This yielded a total of 12 guidelines, 64 RCTs, 13 systematic reviews/meta-analyses, and 11 cohort studies.
Conclusions: As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy. (J Manipulative Physiol Ther 2008;31:659-674)
The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was formed in 1995 by the Congress of Chiropractic State Associations with assistance from the American Chiropractic Association, Association of Chiropractic Colleges, Council on Chiropractic Education, Federation of Chiropractic Licensing�Boards, Foundation for the Advancement of Chiropractic Sciences, Foundation for Chiropractic Education and Research, International Chiropractors Association, National Association of Chiropractic Attorneys, and the National Institute for Chiropractic Research. The charge to the CCGPP was to create a chiropractic �best practices� document. The Council on Chiropractic Guidelines and Practice Parameters was delegated to examine all existing guidelines, parameters, protocols, and best practices in the United States and other nations in the construction of this document.
Toward that end, the Scientific Commission of CCGPP was charged with developing literature syntheses, organized by region (neck, low back, thoracic, upper and lower extremity, soft tissue) and the nonregional categories of nonmusculoskeletal, prevention/health promotion, special populations, subluxation, and diagnostic imaging.
The purpose of this work is to provide a balanced interpretation of the literature to identify safe and effective treatment options in the care of patients with low back pain (LBP) and related disorders. This evidence summary is intended to serve as a resource for practitioners to assist them in consideration of various care options for such patients. It is neither a replacement for clinical judgment nor a prescriptive standard of care for individual patients.
Methods
Process development was guided by experience of commission members with the RAND consensus process, Cochrane collaboration, Agency for Health Care and Policy Research, and published recommendations modified to the needs of the council.
Identification and Retrieval
The domain for this report is that of LBP and low backrelated leg symptoms. Using surveys of the profession and publications on practice audits, the team selected the topics for review by this iteration.
Topics were selected based on the most common disorders seen and most common classifications of treatments used by chiropractors based on the literature. Material for review was obtained through formal hand searches of published literature and of electronic databases, with assistance from a professional chiropractic college librarian. A search strategy was developed, based upon the CochraneWorking Group for Low Back Pain. Randomized controlled trials (RCTs), systematic reviews/meta-analyses, and guidelines published through 2006 were included; all other types of studies were included through 2004. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. Searches focused on guidelines, meta-analyses, systematic reviews, randomized clinical trials, cohort studies, and case series.
Evaluation
Standardized and validated instruments used by the Scottish Intercollegiate Guidelines Network were used to evaluate RCTs and systematic reviews. For guidelines, the Appraisal of Guidelines for Research and Evaluation instrument was used. A standardized method for grading the strength of the evidence was used, as summarized in Figure 1. Each team’s multidisciplinary panel conducted the review and evaluation of the evidence.
Search results were sorted into related topic groups as follows: RCTs of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnosticrelated articles; methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. On the basis of the CCGPP formation of an iterative process and the volume of work available, the team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and cohort studies.
Dr. Alex Jimenez’s Insight
How does chiropractic care benefit people with low back pain and sciatica?�As a chiropractor experienced in the management of a variety of spine health issues, including low back pain and sciatica, spinal adjustments and manual manipulations, as well as other non-invasive treatment methods, can be safely and effectively implemented towards the improvement of back pain symptoms. The purpose of the following research study is to demonstrate the evidence-based effects of chiropractic in the treatment of injuries and conditions of the musculoskeletal and nervous systems. The information in this article can educate patients on how alternative treatment options can help improve their low back pain and sciatica. As a chiropractor, patients may also be referred to other healthcare professionals, such as physical therapists, functional medicine practitioners and medical doctors, to help them further manage their low back pain and sciatica symptoms. Chiropractic care can be used to avoid surgical interventions for spine health issues.
Results and Discussion
A total of 887 source documents were initially obtained. This included a total of 12 guidelines, 64 RCTs, 20 systematic reviews/meta-analyses, and 12 cohort studies. Table 1 provides an overall summary of the number of studies evaluated.
Assurance and Advice
The search strategy used by the team was that developed by van Tulder et al, and the team identified 11 trials. Good evidence indicates that patients with acute LBP on bed rest have more pain and less functional recovery than those who stay active. There is no difference in pain and functional status between bed rest and exercises. For sciatica patients, fair evidence shows no real difference in pain and functional status between bed rest and staying active. There is fair evidence of no difference in pain intensity between bed rest and physiotherapy but small improvements in functional status. Finally, there is little difference in pain intensity or functional status between shorter-term or longer-term bed rest.
A Cochrane review by Hagen et al demonstrated small advantages in short-term and long-term for staying active over bed rest, as did a high-quality review by the Danish Society of Chiropractic and Clinical Biomechanics, including 4 systematic reviews, 4 additional RCTS, and 6 guidelines, on acute LBP and sciatica. The Cochrane review by Hilde et al included 4 trials and concluded a small beneficial effect for staying active for acute, uncomplicated LBP, but no benefit for sciatica. Eight studies on staying active and 10 on bed rest were included in an analysis by the group of Waddell. Several therapies were coupled with advice to stay active and include analgesic medication, physical therapy, back school, and behavioral counseling. Bed rest for acute LBP was similar to no treatment and placebo and less effective than alternative treatment. Outcomes considered across the studies were rate of recovery, pain, activity levels, and work time loss. Staying active was found to have a favorable effect.
Review of 4 studies not covered elsewhere assessed the use of brochures/booklets. The trend was for no differences in outcome for pamphlets. One exception was noted�that those who received manipulation had less bothersome symptoms at 4 weeks and significantly less disability at 3 months for those who received a booklet encouraging staying active.
In summary, assuring patients that they are likely to do well and advising them to stay active and avoid bed rest is a best practice for management of acute LBP. Bed rest for short intervals may be beneficial for patients with radiating leg pain who are intolerant of weight bearing.
Adjustment/Manipulation/Mobilization Vs Multiple Modalities
This review considered literature on high-velocity, lowamplitude (HVLA) procedures, often termed adjustment or manipulation, and mobilization. The HVLA procedures use thrusting maneuvers applied quickly; mobilization is applied cyclically. The HVLA procedure and mobilization may be mechanically assisted; mechanical impulse devices are considered HVLA, and flexion-distraction methods and continuous passive motion methods are within mobilization.
The team recommends adopting the findings of the systematic review by Bronfort et al, with a quality score (QS) of 88, covering literature up to 2002. In 2006, the Cochrane collaboration reissued an earlier (2004) review of spinal manipulative therapy (SMT) for back pain performed by Assendelft et al. This reported on 39 studies up to 1999, several overlapping with those reported by Bronfort et al using different criteria and a novel analysis. They report no difference in outcome from treatment with manipulation vs alternatives. As several additional RCTs had appeared in the interim, the rationale for reissuing the older review without acknowledging new studies was unclear.
Acute LBP. There was fair evidence that HVLA has better short-term efficacy than mobilization or diathermy and limited evidence of better short-term efficacy than diathermy, exercise, and ergonomic modifications.
Chronic LBP. The HVLA procedure combined with strengthening exercise was as effective for pain relief as nonsteroidal antiinflammatory dugs with exercise. Fair evidence indicated that manipulation is better than physical therapy and home exercise for reducing disability. Fair evidence shows that manipulation improves outcomes more than general medical care or placebo in the short-term and to physical therapy in the long-term. The HVLA procedure had better outcomes than home exercise, transcutaneous�electrical nerve stimulation, traction, exercise, placebo and sham manipulation, or chemonucleolysis for disk herniation.
Mixed (Acute and Chronic) LBP. Hurwitz found that HVLA was the same as medical care for pain and disability; adding physical therapy to manipulation did not improve outcomes. Hsieh found no significant value for HVLA over back school or myofascial therapy. A short-term value of manipulation over a pamphlet and no difference between manipulation and McKenzie technique were reported by Cherkin et al. Meade contrasted manipulation and hospital care, finding greater benefit for manipulation over both short-term and long-term. Doran and Newell found that SMT resulted in greater improvement than physical therapy or corsets.
Acute LBP
Sick List Comparisons. Seferlis found that sick patients listed were significantly improved symptomatically after 1 month regardless of the intervention, including manipulation. Patients were more satisfied and felt that they were provided better explanations about their pain from practitioners who used manual therapy (QS, 62.5). Wand et al examined the effects of sick-listing oneself and noted that a group receiving assessment, advice, and treatment improved better than did a group getting assessment, advice, and who were put on a wait list for a 6-week period. Improvements were observed in disability, general health, quality of life, and mood, though pain and disability were not different at longterm follow-up (QS, 68.75).
Physiologic Therapeutic Modality and Exercise. Hurley and colleagues tested the effects of manipulation combined with interferential therapy compared to either modality alone. Their results showed all 3 groups improved function to the same degree, both at 6-month and at 12-month follow-up (QS, 81.25). Using a single-blinded experimental design to compare manipulation to massage and low-level electrostimulation, Godfrey et al found no differences between groups at the 2 to 3-week observation time frame (QS, 19). In the study by Rasmussen, results showed that 94% of the patients treated with manipulation were symptom-free within 14 days, compared to 25% in the group that received short-wave diathermy. Sample size was small, however, and as a result, the study was underpowered (QS, 18). The Danish systematic review examined 12 international sets of guidelines, 12 systematic reviews, and 10 randomized clinical trials on exercise. They found no specific exercises, regardless of type, that were useful for the treatment of acute LBP with the exception of McKenzie maneuvers.
Sham and Alternate Manual Method Comparisons. The study of Hadler balanced for effects of provider attention and physical contact with a first effort at a manipulation sham procedure. Patients in the group that entered the trial with greater prolonged illness at the outset were reported to have benefited from the manipulation. Similarly, they improved faster and to a greater degree (QS, 62.5). Hadler demonstrated that there was a benefit for a single session of manipulation compared to a session of mobilization (QS, 69). Erhard reported that the rate of positive response to manual treatment with a hand-heel rocking motion was greater than with extension exercises (QS, 25). Von Buerger examined the use of manipulation for acute LBP, comparing rotational manipulation to soft tissue massage. He found that the manipulation group responded better than the soft tissue group, although the effects occurred mainly in the short-term. The results were also hampered by the nature of the forced multiple choice selections on the data forms (QS, 31). Gemmell compared 2 forms of manipulation for LBP of less than 6 weeks of duration as follows: Meric adjusting (a form of HVLA) and Activator technique (a form of mechanically assisted HVLA). No difference was observed, and both helped to reduce pain intensity (QS, 37.5). MacDonald reported a short-term benefit in disability measures within the first 1 to 2 weeks of starting therapy for the manipulation group that disappeared by 4 weeks in a control group (QS, 38). The work of Hoehler, although containing mixed data for patients with acute and chronic LBP, is included here because a larger proportion of patients with acute LBP were involved in the study. Manipulation patients reported immediate relief more often, but there were no differences between groups at discharge (QS, 25).
Medication. Coyer showed that 50% of the manipulation group was symptom-free within 1 week and 87% were discharged symptom-free in 3 weeks, compared to 27% and 60%, respectively, of the control group (bed rest and analgesics) (QS, 37.5). Doran and Newell compared manipulation, physiotherapy, corset, or analgesic medication, using outcomes that examined pain and mobility. There were no differences between groups over time (QS, 25). Waterworth compared manipulation to conservative physiotherapy and 500 mg of diflunisal twice per day for 10 days. Manipulation showed no benefit for the rate of recovery (QS, 62.5). Blomberg compared manipulation to steroid injections and to a control group receiving conventional activating therapy. After 4 months, the manipulation group had less restricted motion in extension, less restriction in side-bending to both sides, less local pain on extension and right sidebending, less radiating pain, and less pain when performing a straight leg raise (QS, 56.25). Bronfort found no outcome differences between chiropractic care compared to medical care at 1 month of treatment, but there were noticeable improvements in the chiropractic group at both 3 and 6-month follow-up (QS, 31).
Subacute Back Pain
Staying Active. Grunnesjo compared combined effects of manual therapy with advice to stay active to advice alone in patients with acute and subacute LBP. The addition of�manual therapy appeared to reduce pain and disability more effectively than the �stay active� concept alone (QS, 68.75).
Physiologic Therapeutic Modality and Exercise. Pope demonstrated that manipulation offered better pain improvement than transcutaneous electrical nerve stimulation (QS 38). Sims-Williams compared manipulation to �physiotherapy.� Results demonstrated a short-term benefit for manipulation on pain and ability to do light work. Differences between groups waned at 3 and 12-month follow-ups (QS, 43.75, 35). Skargren et al compared chiropractic to physiotherapy for patients with LBP who had no treatment for the prior month. No differences in health improvements, costs, or recurrence rates were noted between the 2 groups. However, based on Oswestry scores, chiropractic performed better for patients who had pain for less than 1 week, whereas the physiotherapy seemed to be better for those who had pain for more than 4 weeks (QS, 50).
The Danish systematic review examined 12 international sets of guidelines, 12 systematic reviews, and 10 randomized clinical trials on exercise. Results suggested that exercise, in general, benefits patients with subacute back pain. Use of a basic program that can be readily modified to meet individual patient needs is recommended. Issues of strength, endurance, stabilization, and coordination without excessive loading can all be addressed without the use of high-tech equipment. Intensive training consisting of greater than 30 and less than 100 hours of training are most effective.
Sham and Alternate Manual Method Comparisons. Hoiriis compared efficacy of chiropractic manipulation to placebo/ sham for subacute LBP. All groups improved on measures of pain, disability, depression, and Global Impression of Severity. Chiropractic manipulation scored better than placebo in reducing pain and Global Impression of Severity scores (QS, 75). Andersson and colleagues compared osteopathic manipulation to standard care to patients with subacute LBP, finding that both groups improved for a 12-week period at about the same rate (QS, 50).
Medication Comparisons. In a separate treatment arm of the study of Hoiriis, the relative efficacy of chiropractic manipulation to muscle relaxants for subacute LBP was studied. In all groups, pain, disability, depression, and Global Impression of Severity decreased. Chiropractic manipulation was more effective than muscle relaxants in reducing Global Impression of Severity scores (QS, 75).
Chronic LBP
Staying Active Comparisons. Aure compared manual therapy to exercise in patients with chronic LBP who were sick listed. Although both groups showed improvements in pain intensity, functional disability, general health, and return to work, the manual therapy group showed significantly greater improvements than did the exercise group for all outcomes. Results were consistent for both the short-term and the longterm (QS, 81.25).
Physician Consult/Medical Care/Education. Niemisto compared combined manipulation, stabilization exercise, and physician consultation to consultation alone. The combined intervention was more effective in reducing pain intensity and disability (QS, 81.25). Koes compared general practitioner treatment to manipulation, physiotherapy, and a placebo (detuned ultrasound). Assessments were made at 3, 6, and 12 weeks. The manipulation group had a quicker and larger improvement in physical function compared to the other therapies. Changes in spinal mobility in the groups were small and inconsistent (QS, 68). In a follow-up report, Koes found during subgroup analysis that improvement in pain was greater for manipulation than for other treatments at 12 months when considering patients with chronic conditions, as well as those who were younger than 40 years (QS, 43). Another study by Koes showed that many patients in the nonmanipulation treatment arms had received additional care during follow-up. Yet, improvement in the main complaints and in physical functioning remained better in the manipulation group (QS, 50). Meade observed that chiropractic treatment was more effective than hospital outpatient care, as assessed using the Oswestry Scale (QS, 31). An RCT conducted in Egypt by Rupert compared chiropractic manipulation, after medical and chiropractic evaluation. Pain, forward flexion, active, and passive leg raise all improved to a greater degree in the chiropractic group; however, the description of alternate treatments and outcomes was ambiguous (QS, 50).
Triano compared manual therapy to educational programs for chronic LBP. There was greater improvement in pain, function, and activity tolerance in the manipulation group, which continued beyond the 2-week treatment period (QS, 31).
Physiologic Therapeutic Modality. A negative trial for manipulation was reported by Gibson (QS, 38). Detuned diathermy was reported to achieve better results over manipulation, although there were baseline differences between groups. Koes studied the effectiveness of manipulation, physiotherapy, treatment by a general practitioner, and a placebo of detuned ultrasound. Assessments were made at 3, 6, and 12 weeks. The manipulation group showed a quicker and better improvement in physical function capacity compared to the other therapies. Flexibility differences between groups were not significant (QS, 68). In a follow-up report, Koes found that a subgroup analysis demonstrated that improvement in pain was greater for those treated with manipulation, both for younger (b40) patients and those with chronic conditions at 12-month follow-up (QS, 43). Despite many patients in the nonmanipulation groups received additional care during follow-up, improvements remained better in the manipulation group than in the physical therapy group (QS, 50). In a separate report by the same group, there were improvements in both the physiotherapy and manual therapy groups with regard to severity of complaints and global perceived effect compared to general practitioner care;�however, the differences between the 2 groups was not significant (QS, 50). Mathews et al found that manipulation hastened recovery from LBP more than the control did.
Exercise Modality. Hemilla observed that SMT led to better long-term and short-term disability reduction compared to physical therapy or home exercise (QS, 63). A second article by the same group found that neither bone-setting nor exercise differed significantly from physical therapy for symptom control, though bone-setting was associated with improved lateral and forward-bending of the spine more than exercise (QS, 75). Coxhea reported that HVLA provided better outcomes when compared to exercise, corsets, traction, or no exercise when studied in the short-term (QS, 25). Conversely, Herzog found no differences between manipulation, exercise, and back education in reducing either pain or disability (QS, 6). Aure compared manual therapy to exercise in patients with chronic LBP who were also sick listed. Although both groups showed improvements in pain intensity, functional disability, and general health and returned to work, the manual therapy group showed significantly greater improvements than did the exercise group for all outcomes. This result persisted for both the short-term and the long-term (QS, 81.25). In the article by Niemisto and colleagues, the relative efficacy of combined manipulation, exercise (stabilizing forms), and physician consultation compared to consultation alone was investigated. The combined intervention was more effective in reducing pain intensity and disability (QS, 81.25). The United Kingdom Beam study found that manipulation followed by exercise achieved a moderate benefit at 3 months and a small benefit at 12 months. Likewise, manipulation achieved a small to moderate benefit at 3 months and a small benefit at 12 months. Exercise alone had a small benefit at 3 months but no benefit at 12 months. Lewis et al found improvement occurred when patients were treated by combined manipulation and spinal stabilization exercises vs use of a 10-station exercise class.
The Danish systematic review examined 12 international sets of guidelines, 12 systematic reviews, and 10 randomized clinical trials on exercise. Results suggested that exercise, in general, benefits patients with chronic LBP. No clear superior method is known. Use of a basic program that can be readily modified to meet individual patient needs is recommended. Issues of strength, endurance, stabilization, and coordination without excessive loading can all be addressed without the use of high-tech equipment. Intensive training consisting of greater than 30 and less than 100 hours of training are most effective. Patients with severe chronic LBP, including those off work, are treated more effectively with a multidisciplinary rehabilitation program. For post surgical rehabilitation, patients starting 4 to 6 weeks after disk surgery under intensive training receive greater benefit than with light exercise programs.
Sham and Alternate Manual Methods. Triano found that SMT produced significantly better results for pain and disability relief for the short-term, than did sham manipulation (QS, 31). Cote found no difference over time or for comparisons within or between the manipulation and mobilization groups (QS, 37.5). The authors posed that failure to observe differences may have been due to low responsiveness to change in the instruments used for algometry, coupled with a small sample size. Hsieh found no significant value for HVLA over back school or myofascial therapy (QS, 63). In the study by Licciardone, a comparison was made between osteopathic manipulation (which includes mobilization and soft tissue procedures as well as HVLA), sham manipulation, and a no-intervention control for patients with chronic LBP. All groups showed improvement. Sham and osteopathic manipulation were associated with greater improvements than seen in the no-manipulation group, but no difference was observed between the sham and manipulation groups (QS, 62.5). Both subjective and objective measures showed greater improvements in the manipulation group compared to a sham control, in a report by Waagen (QS, 44). In the work of Kinalski, manual therapy reduced the time of treatment of patients with LBP and concomitant intervertebral disk lesions. When disk lesions were not advanced, a decreased muscular hypertonia and increased mobility was noted. This article, however, was limited by a poor description of patients and methods (QS, 0).
Harrison et al reported a nonrandomized cohort controlled trial of treatment of chronic LBP consisting of 3-point bending traction designed to increase curvature of the lumbar spine. The experimental group received HVLA for pain control during the first 3 weeks (9 treatments). The control group received no treatment. Follow-up at a mean of 11 weeks showed no change in pain or curvature status for controls but a significant increase in curvature and reduction of pain in the experimental group. Average number of treatments to achieve this result was 36. Long-term followup at 17 months showed retention of benefits. No report of relationship between clinical changes and structural change was given.
Haas and colleagues examined the dose-response patterns of manipulation for chronic LBP. Patients were randomly allocated to groups receiving 1, 2, 3, or 4 visits per week for 3 weeks, with outcomes recorded for pain intensity and functional disability. A positive and clinically important effect of the number of chiropractic treatments on pain intensity and disability at 4 weeks was associated with the groups receiving the higher rates of care (QS, 62.5). Descarreaux et al extended this work, treating 2 small groups for 4 weeks (3 times per week) after 2 baseline evaluations separated by 4 weeks. One group was then treated every 3 weeks; the other did not. Although both groups had lower Oswestry scores at 12 weeks, at 10 months, the improvement only persisted for the extended SMT group.
Medication. Burton and colleagues demonstrated that HVLA led to greater short-term improvements in pain and disability than did chemonucleolysis for managing disk�herniation (QS, 38). Bronfort studied SMT combined with exercise vs a combination of nonsteroidal antiinflammatory drugs and exercise. Similar results were obtained for both groups (QS, 81). Forceful manipulation coupled with sclerosant therapy (injection of a proliferant solution composed of dextrose-glycerine-phenol) was compared to lower force manipulation combined with saline injections, in a study by Ongley. The group receiving forceful manipulation with sclerosant fared better than the alternate group, but effects cannot be separated between the manual procedure and the sclerosant (QS, 87.5). Giles and Muller compared HVLA procedures to medication and acupuncture. Manipulation showed greater improvement in frequency of back pain, pain scores, Oswestry, and SF-36 compared to the other 2 interventions. Improvements lasted for 1 year. Weaknesses of the study were use of a compliers-only analysis as intention to treat for the Oswestry, and Visual Analogue Scale (VAS) was not significant.
Sciatica/Radicular/Radiating Leg Pain
Staying Active/Bed Rest. Postacchini studied a mixed group of patients with LBP, with and without radiating leg pain. Patients could be classified as acute or chronic and were evaluated at 3 weeks, 2 months, and 6 months postonset. Treatments included manipulation, drug therapy, physiotherapy, placebo, and bed rest. Acute back pain without radiation and chronic back pain responded well to manipulation; however, in none of the other groups did manipulation fare as well as other interventions (QS, 6).
Physician Consult/Medical Care/Education. Arkuszewski looked at patients with lumbosacral pain or sciatica. One group received drugs, physiotherapy, and manual examination, whereas the second added manipulation. The group receiving manipulation had a shorter treatment time and a more marked improvement. At 6-month follow-up, the manipulation group showed better neuromotor system function and a better ability to continue employment. Disability was lower in the manipulation group (QS, 18.75).
Physiologic Therapeutic Modality. Physiotherapy combined with manual manipulation and medication was examined by Arkuszewski, in contrast to the same scheme with manipulation added, as noted above. Outcomes from manipulation were better for neurologic and motor function as well as disability (QS, 18.75). Postacchini looked at patients with acute or chronic symptoms evaluated at 3 weeks, 2 months, and 6 months postonset. Manipulation was not as effective for managing the patients with radiating leg pain as the other treatment arms (QS, 6). Mathews and colleagues examined multiple treatments including manipulation, traction, sclerosant use, and epidural injections for back pain with sciatica. For patients with LBP and restricted straight leg raise test, manipulation conferred highly significant relief, more so than alternate interventions (QS, 19). Coxhead et al included among their subjects patients who had radiating pain at least to the buttocks. Interventions included traction, manipulation, exercise, and corset, using a factorial design. After 4 weeks of care, manipulation showed a significant degree of benefit on one of the scales used to assess progress. There were no real differences between groups at 4 months and 16 months posttherapy, however (QS, 25).
Exercise Modality. In the case of LBP after laminectomy, Timm reported that exercises conferred benefit both for pain relief and cost-effectiveness (QS, 25). Manipulation had only a small influence on improvement of either symptoms or function (QS, 25). In the study by Coxhead et al, radiating pain to at least the buttocks was better after 4 weeks of care for manipulation, in contrast to other treatments that disappeared 4 months and 16 months posttherapy (QS, 25).
Sham and Alternate Manual Method. Siehl looked at the use of manipulation under general anesthesia for patients with LBP and unilateral or bilateral radiating leg pain. Only temporary clinical improvement was noted when traditional electromyographic evidence of nerve root involvement was present. With negative electromyography, manipulation was reported to provide lasting improvement (QS, 31.25) Santilli and colleagues compared HVLA to soft tissue pressing without any sudden thrust in patients with moderate acute back and leg pain. The HVLA procedures were significantly more effective in reducing pain, reaching a pain-free status, and the total number of days with pain. Clinically significant differences were noted. The total number of treatment sessions was capped at 20 on a dosage of 5 times per week with care depending on pain relief. Follow-up showed relief persisting through 6 months.
Medication. Mixed acute and chronic back pain with radiation treated in a study using multiple treatment arms were evaluated at 3 weeks, 2 months, and 6 months postonset by the group of Postacchini. Medication management fared better than did manipulation when radiating leg pain was present (QS, 6). Conversely, for the work of Mathews and colleagues, the group of patients with LBP and limited straight leg raise test responded more to manipulation than to epidural steroid or sclerosants (QS, 19).
Disk Herniation
Nwuga studied 51 subjects who were having a diagnosis of prolapsed intervertebral disk and who had been referred for physical therapy. Manipulation was reported to be superior to conventional therapy (QS, 12.5). Zylbergold found that there were no statistical differences between 3 treatments�lumbar flexion exercises, home care, and manipulation. Short-term follow-up and a small sample size were posed by the author as a basis for failing to reject the null hypothesis (QS, 38).
Exercise
Exercise is one of the most well-studied forms of treatment of low back disorders. There are many different approaches to�exercise. For this report, it is important only to differentiate multidisciplinary rehabilitation. These programs are designed for patients with especially chronic condition with significant psychosocial problems. They involve trunk exercise, functional task training including work simulation/vocational training, and psychological counseling.
In a recent Cochrane review on exercise for the treatment of nonspecific LBP (QS, 82), effectiveness of exercise therapy in patients classified as acute, subacute, and chronic was compared to no treatment and alternate treatments. Outcomes included the assessment of pain, function, return to work, absenteeism, and/or global improvements. In the review, 61 trials met the inclusion criteria, most of which dealt with chronic (n = 43), whereas smaller numbers addressed acute (n = 11) and subacute (n = 6) pain. The general conclusions were as follows:
exercise is not effective as a treatment of acute LBP,
evidence that exercise was effective in chronic populations relative to comparisons made at follow-up periods,
mean improvements of 13.3 points for pain and 6.9 points for function were observed, and
there is some evidence that graded-activity exercise is effective for subacute LBP but only in the occupational setting
The review examined population and intervention characteristics, as well as outcomes to reach its conclusions. Extracting data on return to work, absenteeism, and global improvement proved so difficult that only pain and function could be quantitatively described.
Eight studies scored positively on key validity criteria. With regard to clinical relevance, many of the trials presented inadequate information, with 90% reporting the study population but only 54% adequately describing the exercise intervention. Relevant outcomes were reported in 70% of the trials.
Exercise for Acute LBP. Of the 11 trials (total n = 1192), 10 had nonexercise comparison groups. The trials presented conflicting evidence. Eight low-quality trials showed no differences between exercise and usual care or no treatment. Pooled data showed that there was no difference in shortterm pain relief between exercise and no treatment, no difference in early follow-up for pain when compared to other interventions, and no positive effect of exercise on functional outcomes.
Subacute LBP. In 6 studies (total n = 881), 7 exercise groups had a nonexercise comparison group. The trials offered mixed results with regard to evidence of effectiveness, with fair evidence of effectiveness for a graded-exercise activity program as the only notable finding. Pooled data did not show evidence to either support or refute the use of exercise for subacute LBP, either for decreasing pain or improving function.
Chronic LBP. There were 43 trials included in this group (total n = 3907). Thirty-three of the studies had nonexercise comparison groups. Exercise was at least as effective as other conservative interventions for LBP, and 2 high-quality studies and 9 lower-quality studies found exercise to be more effective. These studies used individualized exercise programs, focusing mainly on strengthening or trunk stabilization. There were 14 trials that found no difference between exercise and other conservative interventions; of these, 2 were rated highly and 12 rated lower. Pooling the data showed a mean improvement of 10.2 (95% confidence interval [CI], 1.31-19.09) points on a 100-mm pain scale for exercise compared to no treatment and 5.93 (95% CI, 2.21- 9.65) points compared to other conservative treatments. Functional outcomes also showed improvements as follows: 3.0 points at earliest follow-up compared to no treatment (95% CI, ?0.53 to 6.48) and 2.37 points (95% CI, 1.04-3.94) compared to other conservative treatments.
Indirect subgroup analysis found that trials examining health care study populations had higher mean improvements in pain and physical functioning compared to their comparison groups or to trials set in occupational or general populations.
The review authors offered the following conclusions:
In acute LBP, exercises are not more effective than other conservative interventions. Meta-analysis showed no advantage over no treatment of pain and functional outcomes over the short or long-term.
There is fair evidence of effectiveness of a gradedactivity exercise program in subacute LBP in occupational settings. The effectiveness for other types of exercise therapy in other populations is unclear.
In chronic LBP, there is good evidence that exercise is at least as effective as other conservative treatments. Individually designed strengthening or stabilizing programs appear to be effective in health care settings. Meta-analysis found functional outcomes significantly improved; however, the effects were very small, with a less than 3-point (of 100) difference between the exercise and comparison groups at earliest follow-up. Pain outcomes were also significantly improved in groups receiving exercises relative to other comparisons, with a mean of approximately 7 points. Effects were similar over longer follow-up, though confidence intervals increased. Mean improvements in pain and functioning may be clinically meaningful in studies from health care populations in which improvements were significantly greater than those observed in studies from general or mixed populations.
The Danish group review of exercise was able to identify 5 systematic reviews and 12 guidelines that discussed exercise for acute LBP, 1 systematic review and 12 guidelines for subacute, and 7 systematic reviews and 11 guidelines for chronic. Furthermore, they identified 1 systematic review that selectively evaluated for postsurgical�cases. Conclusions were essentially the same as the Cochrane review, with the exceptions that there was limited support for McKenzie maneuvers for patients with acute condition and for intensive rehabilitation programs for 4 to 6 weeks after disk surgery over light exercise programs.
Natural and Treatment History for LBP
Most studies have demonstrated that nearly half of LBP will improve within 1 week, whereas nearly 90% of it will be gone by 12 weeks. Even more, Dixon demonstrated that perhaps as much as 90% of LBP will resolve on its own, without any intervention whatsoever. Von Korff demonstrated that a significant number of patients with acute LBP will have persistent pain if they are observed up to 2 years.
Phillips found that nearly 4 of 10 people will have LBP after an episode at 6 months from onset, even if the original pain has disappeared because more than 6 in 10 will have at least 1 relapse during the first year after an episode. These initial relapses occur within 8 weeks most commonly and may reoccur over time, though in decreasing percentages.
Workers’ compensation injury patients were observed for 1 year to examine symptom severity and work status. Half of those studied lost no work time in the first month after injury, but 30% did lose time from work due to their injury over the course of 1 year. Of those who missed work in the first month due to their injury and had already been able to return to work, nearly 20% had absence later in that same year. This implies that assessing return to work at 1 month after injury will fail to give an honest depiction of the chronic, episodic nature of LBP. Although many patients have returned to work, they will later experience continuing problems and work-related absences. Impairment present at more than 12 weeks postinjury may be far higher than what has been previously reported in the literature, where rates of 10% are common. In fact, the rates may go up to 3 to 4 times higher.
In a study by Schiotzz-Christensen and colleagues, the following was noted. In relation to sick leave, LBP has a favorable prognosis, with a 50% return to work within the first 8 days and only 2% on sick leave after 1 year. However, 15% had been on sick leave during the following year and about half continued to complain of discomfort. This suggested that an acute episode of LBP significant enough to cause the patient to seek a visit to a general practitioner is followed by a longer period of low-grade disability than previously reported. Also, even for those who returned to work, up to 16% indicated that they were not functionally improved. In another study looking at outcomes after 4 weeks after initial diagnosis and treatment, only 28% of patients did not experience any pain. More strikingly, the persistence of pain differed between groups that had radiating pain and those that did not, with 65% of the former feeling improvement at 4 weeks, vs 82% of the latter. The general findings from this study differ from others in that 72% of patients still experienced pain 4 weeks after initial diagnosis.
Hestbaek and colleagues reviewed a number of articles in a systematic review. The results showed that the reported proportion of patients who still experienced pain after 12 months after onset was 62% on average, with 16% sick-listed 6 months after onset, and with 60% experiencing relapse of work absence. Also, they found that the mean reported prevalence of LBP in patients who had past episodes of LBP was 56%, compared to just 22% for those who had no such history. Croft and colleagues performed a prospective study looking at the outcomes of LBP in general practice, finding that 90% of patients with LBP in primary care had stopped consulting with symptoms within 3 months; however, most were still experiencing LBP and disability 1 year after the initial visit. Only 25% had fully recovered within that same year.
There are even different results in the study by Wahlgren et al. Here, most patients continued to experience pain at both 6 and 12 months (78% and 72%, respectively). Only 20% of the sample had fully recovered by 6 months and only 22% by 12 months.
Von Korff has provided a lengthy list of data he considers relevant to assessing the clinical course of back pain as follows: age, sex, race/ethnicity, years of education, occupation, change in occupation, employment status, disability insurance status, litigation status, recency/age at first onset of back pain, recency/age when care was sought, recency of back pain episode, duration of current/most recent episode of back pain, number of back pain days, current pain intensity, average pain intensity, worst pain intensity, ratings of interference with activities, activity limitation days, clinical diagnosis for this episode, bed rest days, work loss days, recency of back pain flare-up, and duration of the most recent flare-up.
In a practice-based observational study by Haas et al of almost 3000 patients with acute and chronic condition treated by chiropractors and primary care medical doctors, pain was noted in patients with acute and chronic condition up to 48 months after enrollment. At 36 months, 45% to 75% of patients reported at least 30 days of pain in the prior year, and 19% to 27% of patients with chronic condition recalled daily pain over the previous year.
The variability noted in these and many other studies can be explained in part by the difficulty in making an adequate diagnosis, by the different classification schemes used in classifying LBP, by the different outcome tools used in each study and by many other factors. It also points up the extreme difficulty in getting a handle on the day-to-day reality for those who have LBP.
Common Markers and Rating Complexity for LBP
What Are the Relevant Benchmarks for Evaluating Process of Care?. One benchmark is described above, that being natural history. Complexity and risk stratification are important, as�are cost issues; however, cost-effectiveness is beyond the scope of this report.
It is understood that patients with uncomplicated LBP improve faster than those with various complications, the most notable of which is radiating pain. Many factors may influence the course of back pain, including comorbidity, ergonomic factors, age, the level of fitness of the patient, environmental factors, and psychosocial factors. The latter is receiving a great deal of attention in the literature, though as noted elsewhere in this book, such consideration may not be justified. Any of these factors, alone or in combination, may hamper or retard the recovery period after injury.
It seems that biomechanical factors play an important role in the incidence of first-time episodes of LBP and its attendant problems such as work loss; psychosocial factors come into play more in subsequent episodes of LBP. The biomechanical factors can lead to tissue tearing, which then create pain and limited ability for years to follow. This tissue damage cannot be seen on standard imaging and may only be apparent upon dissection or surgery.
abnormal joint motion or decreased body mechanics;
prolonged static posture or poor motor control;
work-related such as vehicle operation, sustained loads, materials handling;
employment history and satisfaction; and
wage status.
IJzelenberg and Burdorf investigated whether demographic, work-related physical, or psychosocial risk factors involved in the occurrence of musculoskeletal conditions determine subsequent health care use and sick leave. They found that within 6 months, nearly one third of industrial workers with LBP (or neck and upper extremity problems) had a recurrence of sick leave for that same problem and a 40% recurrence of health care use. Work-related factors associated with musculoskeletal symptoms were similar to those associated with health care use and sick leave; but, for LBP, older age and living alone strongly determined whether patients with these problems took any sick leave. The 12- month prevalence of LBP was 52%, and of those with symptoms at baseline, 68% had a recurrence of the LBP. Jarvik and colleagues add depression as an important predictor of new LBP. They found the use of MRI to be a less important predictor of LBP than depression.
What Are the Relevant Outcome Measures?. The Clinical Practice Guidelines formulated by the Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory Boards note that there are a number of outcomes that may be used to demonstrate change as a result of treatment. These should be both reliable and valid. According to the Canadian guidelines, appropriate standards are useful in chiropractic practice because they are able to perform the following:
consistently evaluate the effects of care over time;
help indicate the point of maximum therapeutic improvement;
uncover problems related to care such as noncompliance;
document improvement to the patient, doctor, and third parties;
suggest modifications of the goals of treatment if necessary;
quantify the clinical experience of the doctor;
justify the type, dose, and duration of care;
help provide a database for research; and
assist in establishing standards of treatment of specific conditions.
The broad general classes of outcomes include functional outcomes, patient perception outcomes, physiologic outcomes, general health assessments, and subluxation syndrome outcomes. This chapter addresses only functional and patient perception outcomes assessed by questionnaires and functional outcomes assessed by manual procedures.
Functional Outcomes. These are outcomes that measure the patient’s limitations in going about his or her normal daily activities. What is being looked at is the effect of a condition or disorder on the patient (ie, LBP, for which a specific diagnosis may not be present or possible) and its outcome of care. Many such outcome tools exist. Some of the better known include the following:
Roland Morris Disability Questionnaire,
Oswestry Disability Questionnaire,
Pain Disability Index,
Neck Disability Index,
Waddell Disability Index, and
Million Disability Questionnaire.
These are only some of the existing tools for assessing function.
In the existing RCT literature for LBP, functional outcomes have been shown to be the outcome that demonstrates the greatest change and improvement with SMT. Activities of daily living, along with patient selfreporting of pain, were the 2 most notable outcomes to show such improvement. Other outcomes fared less well, including trunk range of motion (ROM) and straight leg raise.
In the chiropractic literature, the outcome inventories used most frequently for LBP are the Roland Morris Disability Questionnaire and the Oswestry Questionnaire. In a study in 1992, Hsieh found that both tools provided consistent results over the course of his trial, although the results from the 2 questionnaires differed.
Patient Perception Outcomes. Another important set of outcomes involve patient perception of pain and their satisfaction with care. The first involves measuring changes in pain perception over time of its intensity, duration, and frequency. There are a number of valid tools available that can accomplish this, including the following:
Visual analog scale�this is a 10-cm line that has pain descriptions noted at both ends of that line representing no pain to intolerable pain; the patient is asked to mark a point on that line that reflects their perceived pain intensity. There are a number of variants for this outcome, including the Numerical Rating Scale (where the patient provides a number between 0 and 10 to represent the amount of pain they have) and the use of pain levels from 0 to 10 depicted pictorially in boxes, which the patient may check. All of these appear to be equally reliable, but for ease of use, either the standard VAS or Numerical Rating Scale is commonly used.
Pain diary�these may be used to help monitor a variety of different pain variables (for example, frequency, which the VAS cannot measure). Different forms may be used to collect this information, but it is typically completed on a daily basis.
McGill Pain Questionnaire�this scale helps quantify several psychologic components of pain as follows: cognitive-evaluative, motivational-affective, and sensory discriminative. In this instrument, there are 20 categories of words that describe the quality of pain. From the results, 6 different pain variables can be determined.
All of the above instruments have been used at various times to monitor the progress of treatment of back pain with SMT.
Patient satisfaction addresses both the effectiveness of care as well as the method of receiving that care. There are numerous methods of assessing patient satisfaction, and not all of them were designed to be specifically used for LBP or for manipulation. However, Deyo did develop one for use with LBP. His instrument examines the effectiveness of care, information, and caring. There is also the Patient Satisfaction Questionnaire, which assesses 8 separate indices (such as efficacy/outcomes or professional skill, for example). Cherkin noted that the Visit Specific Satisfaction Questionnaire can be used for chiropractic outcome assessment.
Recent work has shown that patient confidence and satisfaction with care are related to outcomes. Seferlis found that patients were more satisfied and felt that they were provided better explanations about their pain from practitioners who used manual therapy. Regardless of treatment, highly satisfied patients at 4 weeks were more likely than less satisfied patients to perceive greater pain improvement throughout 18-month follow-up in a study by Hurwitz et al. Goldstein and Morgenstern found a weak association between treatment confidence in the therapy they received and greater improvement in LBP. A frequent assertion is that benefits observed from application of manipulation methods are a result of physician attention and touching. Studies directly testing this hypothesis were conducted by Hadler et al in patients with acute condition and by Triano et al in patients with subacute and chronic condition. Both studies compared manipulation to a placebo control. In the study of Hadler, the control balanced for provider time attention and frequency, whereas Triano et al also added an education program with home exercise recommendations. In both cases, results demonstrated that although attention given to patients was associated with improvement over time, patients receiving manipulation procedures improved more quickly.
General Health Outcome Measures. This has traditionally been a difficult outcome to effectively measure but a number of more recent instruments are demonstrating that it can be done reliably. The 2 major instruments for doing so are the Sickness Impact Profile and the SF-36. The first assesses dimensions such as mobility, ambulation, rest, work, social interaction, and so on; the second looks primarily at well being, functional status, and overall health, as well as 8 other health concepts, to ultimately determine 8 indices that can be used to determine overall health status. Items here include physical functioning, social functioning, mental health, and others. This tool has been used in many settings and has also been adapted into shorter forms as well.
Physiologic Outcome Measures. The chiropractic profession has a number of physiologic outcomes that are used with regard to the patient care decision-making process. These include such procedures as ROM testing, muscle function testing, palpation, radiography, and other less common procedures (leg length analysis, thermography, and others). This chapter addresses only the physiologic outcomes assessed manually.
Range of Motion. This examination procedure is used by nearly every chiropractor and is used to assess impairment because it is related to spinal function. It is possible to use ROM as a means to monitor improvement in function over time and, therefore, improvement as it relates to the use of SMT. One can assess regional and global lumbar motion, for example, and use that as one marker for improvement.
Range of motion can be measured via a number of different means. One can use standard goniometers, inclinometers, and more sophisticated tools that require the use of specialized equipment and computers. When doing so, it is important to consider the reliability of each individual method. A number of studies have assessed various devices as follows:
Zachman found the use of the rangiometer moderately reliable,
Nansel found that using 5 repeated measures of cervical spine motion with an inclinometer to be reliable,
Liebenson found that the modified Schrober technique, along with inclinometers and flexible spinal rulers had the best support from the literature,
Triano and Schultz found that ROM for the trunk, along with trunk strength ratios and myoelectrical activity, was good indicator for LBP disability, and
a number of studies found that the kinematic measurement of ROM for spinal mobility is reliable.
Muscle Function. Evaluating muscle function may be done using an automated system or by manual means. Although manual muscle testing has been a common diagnostic practice within the chiropractic profession, there are few studies demonstrating clinical reliability for the procedure, and these are not considered to be of high quality.
Automated systems are more reliable and are capable of assessing muscle parameters such as strength, power, endurance, and work, as well as assess different modes of muscle contraction (isotonic, isometric, isokinetic). Hsieh found that a patient-initiated method worked well for specific muscles, and other studies have shown the dynamometer to have good reliability.
Leg Length Inequality. Very few studies of leg length have shown acceptable levels of reliability. The best methods for assessing reliability and validity of leg length involve radiographic means and are therefore subject to exposure to ionizing radiation. Finally, the procedure has not been studied as to validity, making the use of this as an outcome questionable.
Soft Tissue Compliance. Compliance is assessed by both manual and mechanical means, using the hand alone or using a device such as an algometer. By assessing compliance, the chiropractor is looking to assess muscle tone.
Early tests of compliance by Lawson demonstrated good reliability. Fisher found increases in tissue compliance with subjects involved in physical therapy. Waldorf found that prone segmental tissue compliance had good test/retest variation of less than 10%.
Pain tolerance assessed using these means has been found reliable, and Vernon found it was a useful measure in assessing the cervical paraspinal musculature after adjusting. The guidelines group from the Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory Boards concluded that �the assessments are safe and inexpensive and appear to be responsive to conditions and treatments commonly seen in chiropractic practice.�
Conclusion
Existing research evidence regarding the usefulness of spinal adjusting/manipulation/mobilization indicates the following:
As much or more evidence exists for the use of SMT to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP.
Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence.
There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.
Cases with high severity of symptoms may benefit by referral for comanagement of symptomswith medication.
There was little evidence for the use of manipulation for other conditions affecting the low back and very few articles to support a higher rating.
Exercise and reassurance have been shown to be of value primarily in chronic LBP and low back problems associated with radicular symptoms. A number of standardized, validated tools are available to help capture meaningful clinical improvement over the course of low back care. Typically, functional improvement (as opposed to simple reported reduction in pain levels) may be clinically meaningful for monitoring responses to care. The literature reviewed remains relatively limited in predicting responses to care, tailoring specific combinations of intervention regimens (although the combination of manipulation and exercise may be better than exercise alone), or formulating condition-specific recommendations for frequency and�duration of interventions. Table 2 summarizes the recommendations of the team, based on the review of the evidence.
Practical Applications
Evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic, acute, and subacute LBP.
Exercise in conjunction with manipulation is likely to speed and improve outcomes and minimize recurrence
In conclusion,�more evidence-based research studies have become available regarding the effectiveness of chiropractic care for low back pain and sciatica. The article also demonstrated that exercise should be used together with chiropractic to help speed up the rehabilitation process and further improve recovery. In most cases, chiropractic care can be used for the management of low back pain and sciatica, without the need for surgical interventions. However, if surgery is required to achieve recovery, a chiropractor may refer the patient to the next best healthcare professional. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
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Cause Of Sciatica: Several lumbar spine (lower back) disorders can cause sciatica. Sciatica is often described as mild to intense pain in the left or right leg. Sciatica is caused by compression of one or more of the 5 sets of nerve roots in the lower back. Sometimes doctors call sciatica a radiculopathy. Radiculopathy is a medical term used to describe pain, numbness, tingling, and weakness in the arms or legs caused by a nerve root problem. If the nerve problem is in the neck, it is called a cervical radiculopathy. However, since sciatica affects the low back, it is called a lumbar radiculopathy.
Pathways To Sciatic Nerve Pain
Five sets of paired nerve roots in the lumbar spine combine to create the sciatic nerve. Starting at the back of the pelvis (sacrum), the sciatic nerve runs from the back, under the buttock, and downward through the hip area into each leg. Nerve roots are not “solitary” structures but are part of the body’s entire nervous system capable of transmitting pain and sensation to other parts of the body. Radiculopathy occurs when compression of a nerve root from a disc rupture (herniated disc) or bone spur (osteophyte) occurs in the lumbar spine prior to it joining the sciatic nerve.
What Causes Sciatic Nerve Compression?
Several spinal disorders can cause spinal nerve compression and sciatica or lumbar radiculopathy. The 6 most common are:
a bulging or herniated disc
lumbar spinal stenosis
spondylolisthesis
trauma
piriformis syndrome
spinal tumors
Sciatica�Cause:�6 Leading Sources
Several lumbar spine (lower back) disorders can cause sciatica. Sciatica is often described as mild to intense pain in the left or right leg. Sciatica is caused by compression of one or more of the 5 sets of nerve roots in the lower back. Sometimes doctors call sciatica a radiculopathy. Radiculopathy is a medical term used to describe pain, numbness, tingling, and weakness in the arms or legs caused by a nerve root problem. If the nerve problem is in the neck, it is called a cervical radiculopathy. However, since sciatica affects the low back, it is called a lumbar radiculopathy.
Sciatica Cause #1: Lumbar Bulging Disc Or Herniated Disc
A bulging disc is also known as a contained disc disorder. This means the gel-like center (nucleus pulposus) remains “contained” within the tire-like outer wall (annulus fibrosus) of the disc.
A herniated disc occurs when the nucleus breaks through the annulus fibrosus. It is called a “non-contained” disc disorder. Whether a disc bulges or herniates, disc material can press against an adjacent nerve root and compress delicate nerve tissue and cause sciatica.
The consequences of a herniated disc are worse. Not only does the herniated disc cause direct compression of the nerve root against the interior of the bony spinal canal, but the disc material itself also contains an acidic, chemical irritant (hyaluronic acid) that causes nerve inflammation. In both cases, nerve compression and irritation cause inflammation and pain, often leading to extremity numbness, tingling, and muscle weakness.
Herniated disc is a relatively common condition that can occur anywhere along the spine, but most often affects the lower back or neck region. Also known as a slipped disc or ruptured disc, a herniated disc develops when one of the cushion-like pads between the vertebrae moves out of position and presses on adjacent nerves.
Herniated discs are typically caused by overuse injuries or trauma to the spine; however, disc conditions can also develop as a result of the normal aging process. It is also known that there is a genetic factor that contributes to the development of disc degeneration and herniated disc. In most cases, a herniated disc in the lower back will heal within six months, as the size of herniation shrinks with time via resorption. Surgery may be needed if medication, physical therapy and other treatments fail.
What Is A Disc?
Spinal discs are cushion-like pads located between the vertebrae. Without these �shock absorbers,� the bones in the spine would grind against one another. In addition to giving the spine flexibility and making movements such as twisting and bending possible, discs protect the spine by absorbing the impact of trauma and body weight. Each disc has a strong outer layer called annulus fibrosus and a soft, gel-like center, called nucleus pulposus. There are fibers on the outside of each disc that attach to adjacent vertebrae and hold the disc in place. A herniated disc occurs when the outer layer tears or ruptures and the gel-like center leaks into the spinal canal.
The spinal canal has just enough space to house the spinal cord and spinal fluid. When a disc herniates and spills into the spinal canal, it can cause compression of the nerves or spinal cord. Intense, debilitating pain and alterations in sensation often occur. In addition, the gel-like substance inside the disc releases chemical irritants that contribute to nerve inflammation and pain.
What Causes A Herniated Disc?
As we age, the spinal discs gradually lose fluid volume. This process starts at about age 30 and progresses slowly, over time. As the discs dry out, microscopic cracks or tears can form on the outer surface, causing it to become brittle, weak and more susceptible to injury. The most common causes of herniated disc are:
Wear and tear: Discs dry out and aren�t as flexible as they once were.
Repetitive movements: Work, lifestyle, and certain sports activities that put stress on the spine, especially the lower back, further weaken an already vulnerable area.
Lifting the wrong way: Never lift while bent at the waist. Proper lifting entails lifting with your legs and a straight back.
Injury: High-impact trauma can cause the disc to bulge, tear or rupture.
Obesity: Carrying excess weight puts an undue amount of strain on the spine.
Genetics: There are some genes that are more commonly present in individuals with disc degeneration. More research is needed to investigate the role of these genes�they could be targets of biological treatment in the future.
What Are The Symptoms Of A Herniated Disc?
Pain from a herniated disc can vary, depending on the location and severity of the injury. It is typically felt on one side of the body.
If the injury is minimal, little or no pain may be felt. If the disc ruptures, pain can be severe and unrelenting. Pain may radiate to an extremity in a specific nerve root distribution if significant nerve impingement has occurred. For example, sciatica is frequently caused by a herniated disc in the lower back. Herniated disc can manifest itself with a range of symptoms, including:
Dull ache to severe pain
Numbness, tingling, burning
Muscle weakness; spasm; altered reflexes
Loss of bowel or bladder control (Note: These symptoms constitute a medical emergency. If they occur, seek medical attention immediately).
How Is A Herniated Disc Diagnosed?
History and physical examination point to a diagnosis of herniated disc. A herniated disc is likely if low back pain is accompanied by radiating leg pain in a nerve root distribution with positive straight leg raising test (ie, elevating the leg while lying down causes radiating pain down the leg), and other neurologic deficits such as numbness, weakness, and altered reflexes.
Imaging studies are usually ordered to confirm a diagnosis of herniated disc. X-rays are not the imaging medium of choice because soft tissues (eg, discs, nerves) are hard to capture with this technology. However, they may be used as an initial tool to rule out other disorders such as a growth or fracture. Confirmation of the suspicion of herniated disc is generally accomplished with:
Magnetic Resonance Imaging (MRI): This technology reveals the spinal cord, surrounding soft tissue and nerves. It is the best imaging study to support the diagnosis of a herniated disc.
Nerve Conduction Studies (NCS) and Electromyogram (EMG): These studies use electrical impulses to measure the degree of damage to the nerve/s caused by compression from a herniated disc and other conditions that cause nerve impingement can be ruled out. NCS and EMG are not routine tests to diagnose herniated disc.
Herniated discs sometimes heal on their own through a process called resorption. This means that the disc fragments are absorbed by the body. Most people suffering from herniated disc respond well to conservative treatment and do not require surgery.
Sciatica Cause #2: Lumbar Spinal Stenosis
Spinal stenosis is a nerve compression disorder most often affecting older adults. Leg pain similar to sciatica may occur as a result of lumbar spinal stenosis. The pain is usually positional, often brought on by activities such as standing or walking and relieved by sitting down.
Spinal nerve roots branch outward from the spinal cord through passageways called neural foramina comprised of bone and ligaments. Between each set of vertebral bodies, located on the left and right sides, is a foramen. Nerve roots pass through these openings and extend outward beyond the spinal column to innervate other parts of the body. When these passageways become narrow or clogged causing nerve compression, the term foraminal stenosis is used.
What Is Spinal Stenosis?
A clue to answering this question is found in the meaning of each word. Spinal refers to the spine. Stenosis is a medical term used to describe a condition where a normal-size opening has become narrow. Spinal stenosis may affect the cervical (neck), thoracic (chest), or lumbar (lower back) spines.
The most commonly area affected is the lumbar spine followed by the cervical spine.
Visualize Spinal Stenosis?
Consider a water pipe. Over time, rust and debris builds up on the walls of the pipe, thereby narrowing the passageway that normally allows water to freely flow. In the spine, the passageways are the spinal canal and the neuroforamen. The spinal canal is a hollow vertical hole that contains the spinal cord. The neuroforamen are the passageways that are naturally created between the vertebrae through which spinal nerve roots exit the spinal canal.
The neuroforamen are the passageways that are naturally created between the vertebrae through which spinal nerve roots exit the spinal canal.
Illustration above: The spine’s bony structures encase and protect the spinal cord. Small nerve roots shoot off from the spinal cord and exit the spinal canal through passageways called neuroforamen.
Lumbar (low back) spinal stenosis is illustrated below. Notice the narrowed areas in the spinal canal (reddish-colored areas). As the canal space narrows, the spinal cord and nearby nerve roots are squeezed causing different types of symptoms. The medical term is nerve compression.
Anatomy Overview Can Help You Understand Spinal Stenosis
The spine is a column of connected bones called vertebrae. There are 24 vertebrae in the spine, plus the sacrum and tailbone (coccyx). Most adults have 7 vertebrae in the neck (the cervical vertebrae), 12 from the shoulders to the waist (the thoracic vertebrae), and 5 in the lower back (the lumbar vertebrae). The sacrum is made up of 5 vertebrae between the hipbones that are fused into one bone. The coccyx is made up of small fused bones at the tail end of the spine.
Lamina and Spinous Processes: At the back (posterior) of each vertebra, you have the lamina, a bony plate that protects your spinal canal and spinal cord. Your vertebrae also have several bony tabs that are called spinous processes; those processes are attachment points for muscles and ligaments.
Ligaments, Especially the Ligamentum Flavum: Vertebrae are connected by ligaments, which keep the vertebrae in their proper place. The ligamentum flavum is a particularly important ligament. Not only does it help stabilize your spine, it also protects your spinal cord and nerve roots. Plus, the ligamentum flavum is the strongest ligament in your spine.
The ligamentum flavum is a dynamic structure, which means that it adapts its shape as you move your body. When you’re sitting down and leaning forward, the ligamentum flavum is stretched out; that gives your spinal canal more room for the spinal nerves. When you stand up and lean back, though, the ligamentum flavum becomes shorter and thicker; that means there’s less room for the spinal nerves. (This dynamic capability helps explain why people with spinal stenosis find that sitting down feels better than standing or walking.)
Discs: In between each vertebra are tough fibrous shock-absorbing pads called the intervertebral discs. Each disc is made up of a tire-like outer band (annulus fibrosus) and a gel-like inner substance (nucleus pulposus).
Spinal Nerves and the Spinal Cord: Nerves are also an important part of your spinal anatomy�after all, they’re what sends messages from your brain to the rest of your body. The spinal cord, the thick bundle of nerves that extends downward from the brain, passes through a ring in each vertebra. Those rings line up into a channel called the spinal canal.
Between each vertebra, two nerves branch out of the spinal cord (one to the right and one to the left). Those nerves exit the spine through openings called the foramen and travel to all parts of your body.
Normally, the spinal channel is wide enough for the spinal cord, and the foramen are wide enough for the nerve roots. But either or both can become narrowed, and cause spinal stenosis.
Sciatica Cause #3: Spondylolisthesis
Spondylolisthesis is a disorder that most often affects the lumbar spine. It is characterized by one vertebra slipping forward over an adjacent vertebra. When a vertebra slips and is displaced, spinal nerve root compression occurs and often causes sciatic leg pain. Spondylolisthesis is categorized as developmental (found at birth, develops during childhood) or acquired from spinal degeneration, trauma or physical stress (eg, lifting weights).
Spondylolisthesis occurs when one vertebra slips forward over the vertebra below it. The term is pronounced spondy-low-lis-thesis and is derived from the Greek language: spondylo means vertebra and listhesis means to slip. There are several types or causes of spondylolisthesis; a few are listed below.
Congenital spondylolisthesis means the disorder is present at birth.
Isthmic spondylolisthesis occurs when a defect, such as a fracture occurs in a bony supporting vertebral structure at the back of the spine.
Degenerative spondylolisthesis is more common and is often associated with degenerative disc disease, wherein the discs (eg, due to the effects of growing older) lose hydration and resilency.
How Spondylolisthesis May Develop
The lumbar spine is exposed to directional pressures while it carries, absorbs, and distributes most of your body’s weight at rest and during activity. In other words, while your lumbar spine is carrying and absorbing body weight, it also moves in different directions (eg, rotate, bend forward). Sometimes, this combination causes excessive stress to the vertebra and/or its supporting structures, and may lead to a vertebral body slipping forward over the vertebrae beneath.
Who May Be At Risk
If a family member (eg, mother, father) has spondylolisthesis, your risk for developing the disorder may be greater. Some activities make you more susceptible to spondylolisthesis. Gymnasts, linemen in football, and weight lifters all put significant pressure and weight on their low backs. Think about gymnasts and the positions they put their body in: They practically bend in half backwards�that’s an extreme arched back. They also twist through the air quickly when doing flips and then land, absorbing the impact through their legs and low back. Those movements put substantial stress on the spine, and spondylolisthesis can develop as a result of repeated excessive strains and stress.
X-Ray View Of Spondylolisthesis
The x-ray below shows you a good example of a lumbar spondylolisthesis. Look at the area the arrow is pointing to: You can see that the vertebra above the arrow isn’t in line with the vertebra below it. It’s slipped forward; it’s spondylolisthesis.
Arrow Points To A Lumbar Spondylolisthesis
Grading Spondylolisthesis
Doctors “grade” the severity of a spondylolisthesis using five descriptive categories. Although there are several factors your doctor considers when evaluating your spondylolisthesis, the grading scale (below) is based on the far forward a vertebral body has slid forward over the vertera beneath. Often, the doctor uses a lateral (side view) x-ray to examine and grade a spondyloisthesis. Grade I is a smaller slip than Grade IV or V.
Grade I: Less than 25% slip
Grade II: 25% to 49% slip.
Grade III: 50% to 74% slip.
Grade IV: 75% to 99% slip.
Grade V: The vertebra that has fallen forward off the vertebra below it. This is the most severe type of spondylolisthesis and is termed spondyloptosis.
Sciatica Cause #4: Trauma
Sciatica can result from direct nerve compression caused by external forces to the lumbar or sacral spinal nerve roots. Examples include motor vehicle accidents, falling down, football and other sports. The impact may injure the nerves or, occasionally, fragments of broken bone may compress the nerves.
Sciatica Cause #5: Piriformis Syndrome
Piriformis syndrome is named for the piriformis muscle and the pain caused when the muscle irritates the sciatic nerve. The piriformis muscle is located in the lower part of the spine, connects to the thighbone, and assists in hip rotation. The sciatic nerve runs beneath the piriformis muscle. Piriformis syndrome develops when muscle spasms develop in the piriformis muscle thereby compressing the sciatic nerve. It may be difficult to diagnose and treat due to the lack of x-ray or magnetic resonance imaging (MRI) findings.
If you�ve ever felt pain in the hip, pain in the center of the butt, or pain down the back of the leg, you are likely suffering, at least partially, with piriformis syndrome. The piriformis is a muscle which runs from your sacrum (mid-line base of spine) to the outer hip bone (trochanter). This muscle truly works overtime on anyone who runs at all.
The muscles in and around the gluteal region help with three areas
rotation of the hip and leg;
balance while one foot is off the ground; and
stability for the pelvic region.
Needless to say, all of these characteristics are highly needed by runners (and everyone else, when you come to think of it).
Injuries To The Piriformis
This muscle is a prime candidate for repetitive motion injury (RMI). RMI occurs when a muscle is asked to perform beyond it�s level of capability, not given enough time to recover, and asked to perform again. The typical response from a muscle in this situation is to tighten, which is a defensive response of the muscle. This tightness, however, manifests itself in several ways to a runner.
The first symptom suggesting piriformis syndrome would be pain in and around the outer hip bone. The tightness of the muscle produces increased tension between the tendon and the bone which produces either direct discomfort and pain or an increased tension in the joint producing a bursitis. Again, a bursitis is an inflammation of the fluid filled sac in a joint caused by an elevation of stress and tension within that joint.
The second symptom suggesting piriformis syndrome would be pain directly in the center of the buttocks. Although this is not as common as the other two symtpoms, this pain can be elicited with direct compression over the belly of the buttocks area. A tight muscle is a sore muscle upon compression due to a reduced blood flow to that muscle.
The third symptom suggesting piriformis syndrome would be a sciatic neuralgia, or pain from the buttocks down the back of the leg and sometimes into different portions of the lower leg. We have an article that can teach you more about how piriformis syndrome and sciatica are related.
The sciatic nerve runs right through the belly of the piriformis muscle and if the piriformis muscle contracts from being overused, the sciatic nerve now becomes strangled, producing pain, tingling and numbness.
Simple Physiology
Any muscle repetitively used needs to have an opportunity to recover. This recovery can either be on Nature�s clock, or can be facilitated and sped up with proper knowledge and treatment. Since the muscle is tightening due to overuse, continued use will only make it worse. This injured muscle needs to relax and have increased blood flow encouraged to it for more rapid healing. This tightness that exists also reduces the normal blood flow going to the muscle reducing the speed with which the muscle can recover. To encourage fresh, oxygen-rich blood to the muscle is the most powerful means of getting the muscle to begin to relax and function normally. Multiple massages per day to this area is greatly encouraged.
The next step in this “recovery” process is to use a tennis ball under the butt and hip area. While sitting down on the floor, roll away from the side of involvement and place a tennis ball just inside the outer hip bone under the butt area. As you begin to allow your weight onto the tennis ball, note areas of increased pain and soreness. Trigger points will tend to accumulate in a repetitively used muscle, and until these toxins are manually broken up and eliminated, the muscle will have an artificial ceiling with regard to flexibility potential and recovery potential. So, if it�s sore and hurts while your sitting on it, you�re doing a good job. Let the ball work under each spot for 15-20 seconds before moving it to another area. Once you�ve been on the ball for 4-5 minutes, now put the ankle of the involved leg over the knee of the non-involved leg (crossing your legs). Now place the tennis ball just inside the outer hip bone again and work the tendon of the piriformis muscle. While this pain is typically excruciating and takes some time to effectively reduce, the benefits here are huge. Be patient, be consistent and good things will happen.
Additional Treatments
Due to the fact that the sciatic neuralgia and the hip bursitis or tendonitis are both inflammatory in nature, ice, or cryotherapy, over the involved area 15-20 minutes at a time will be beneficial. This should be done multiple times per day.
Stretching of the hip muscles should not be done until the acute pain is gone. At that point in time, begin with gentle stretching, such as the cross-legged stretch while pulling up on the knee. The muscle should have increased flexibility before an active return to running.
Finally, I�m always discouraging the use of pharmaceutical anti-inflammatories. Not only do they greatly aggravate the intestines, but they also suggest an artificial wellness that can lead to bigger problems. Proteolytic enzymes, such as bromelain, are both natural and extremely beneficial with no side effects.
Conclusion: The piriformis muscle is pretty important for all of us.
Sciatica Cause #6: Spinal Tumors
Spinal tumors are abnormal growths that are either benign or cancerous (malignant). Fortunately, spinal tumors are rare. However, when a spinal tumor develops in the lumbar region, there is a risk for sciatica to develop as a result of nerve compression.
If you think you have sciatica, call your doctor or chiropractor. The first step toward relieving pain is a proper diagnosis.
Written by Jean-Jacques Abitbol, MD; Reviewed by Brian R. Subach, MD
Howard S. An, MD, Stewart G. Eidelson, MD; Reviewed by Howard S. An, MD, Jason M. Highsmith, MD
Timothy J. Maggs, D.C.; Reviewed by Edward C. Benzel, MD
Understanding the following, traditional Chinese medicine utilizes herbal medicines as well as various mind and body practices, such as acupuncture and tai chi, in order to treat or prevent numerous health issues. Traditional Chinese medicine, or TCM, originated in ancient China and has evolved over thousands of years. TCM has been primarily used as a complementary health approach along with other alternative treatment options like chiropractic care. Like TCM, chiropractic care is an alternative healthcare approach focused on the diagnosis, treatment and prevention of a variety of injuries and conditions of the musculoskeletal and nervous system, with an emphasis on manual manipulations and adjustments of the spine. As a doctor of chiropractic, or DC, TCM can also be offered to treat various types of injuries and conditions.
On a personal note, integrative TCM conservative therapies have been utilized to help treat symptoms of low back pain due to lumbar disc herniation, or LDH. Disc material from a ruptured or herniated disc in the lumbar spine can irritate or compress one or several of the nerves found in the lower spine. Pressure along the sciatic nerve can cause symptoms of sciatica, such as pain and discomfort, burning and tingling sensations, and numbness which may radiate from the buttocks into the leg and occasionally, down to the foot.�A randomized controlled trial was conducted in order to measure the outcomes of traditional Chinese medicine for low back pain due to LDH. The results have been recorded below.
Abstract
Low back pain due to lumbar disc herniation (LDH) is very common in clinic. This randomized controlled trial was designed to investigate the effects of integrative TCM conservative therapy for low back pain due to LDH. A total of 408 patients with low back pain due to LDH were randomly assigned to an experimental group with integrative TCM therapy and a control group with normal conservative treatment by the ratio of 3?:?1. The primary outcome was the pain by the visual analogue scale (VAS). The secondary outcome was the low back functional activities by Chinese Short Form Oswestry Disability Index (C-SFODI). Immediately after treatment, patients in the experimental group experienced significant improvements in VAS and C-SFODI compared with the control group (between-group difference in mean change from baseline, ?16.62 points, P < 0.001 in VAS; ?15.55 points, P < 0.001 in C-SFODI). The difference remained at one-month followup, but it is only significant in C-SFODI at six-month followup (?7.68 points, P < 0.001). No serious adverse events were observed. These findings suggest that integrative TCM therapy may be a beneficial complementary and alternative therapy for patients with low back pain due to LDH.
Introduction
Lumbar disc herniation (LDH) is a common disease and a major contributing factor of low back pain. Although many studies have confirmed that surgery is more effective for LDH, conservative therapies have also been recognized for their therapeutic efficacy. Considering the fact that 20% of patients still have pain after surgery, 7% to 15% of surgical patients may have failed back surgery syndrome, and some patients are scared of surgery, conservative treatment is still one of the primary means for LDH.
In China, TCM is one of the main conservative treatments for LDH. Previous studies have confirmed that some TCM therapies have certain effects on low back pain due to LDH. These include acupuncture, oral administration of Chinese medicine, external application of Chinese medicine, Chinese Tuina (massage), and TCM-characteristic functional exercise. Clinically, these therapeutic methods are not used alone but often in combination. Recently, the clinical pathway of treating LDH with integrative TCM therapy has attracted attention. The Shi’s Traumatology Medical Center of Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine is well recognized for its long-term commitment to the research on conservative treatment for LDH, coupled with a package protocol for LDH. However, high-quality research evidence is needed to support the effectiveness of the protocol.
This clinical trial aims to study the efficacy and safety of integrative TCM therapy for LDH and thus confirm its clinical effect.
Materials and Methods
Design
We conducted a multicenter, randomized controlled trial to evaluate the effectiveness of integrative TCM conservative treatment for patients with low back pain due to LDH. Patients were randomly assigned to an experimental group and a control group by the ratio of 3?:?1 using computer-generated numbers. The randomized treatment assignments were sealed in opaque envelopes and opened individually for each patient who agreed to be in the study. The nurse, who had no role in the design and conduct of the study, prepared the envelopes. Patients in the experimental group were treated with integrative TCM therapy once a day, for two weeks, whereas patients in the control group were treated with a two-week normal conservative intervention. At baseline, immediately after treatment, one and six months after treatment, visual analogue scale (VAS) and the Chinese Short Form Oswestry Disability Index (C-SFODI) were used as outcome assessment. This trial is registered in Chinese Clinical Trial Registry (No. ChiCTR-TRC-11001343).
Subjects
Patients were recruited from Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Ruijin Hospital Affiliated to Shanghai Jiaotong University, and Yueyang Integrative Traditional Chinese and Western Medicine Hospital Affiliated to Shanghai University of Traditional Chinese Medicine between January 2011 and August 2012.
Inclusion criteria: (1) aging 20�60 years; (2) having low back pain due to LDH (MRI scan confirmed lumbar disk herniation) and ruling out other relevant ongoing pathologies such as fractures, lumbar spondylolisthesis, tumor, osteoporosis, or infection; (3) willing to participate in this study and signing the informed consent.
Exclusion criteria: (1) having other pain syndromes; (2) experiencing a history of spinal surgery; (3) having neurological disease; (4) having psychiatric disease; (5) having serious chronic diseases that could interfere with the outcomes (e.g., cardiovascular disease, rheumatoid arthritis, epilepsy, or other disqualifying conditions); (6) scared of acupuncture; (7) pregnant or planning to become pregnant during the study; (8) having other diseases that the researchers believe is not suitable for the study.
Treatment
Experimental Group
Patients in the experimental group receive a two-week integrative TCM treatment. They were further divided into three subgroups (according to the duration from initial low back pain to getting treatment) for different treatment methods: acute stage (0�14 days), subacute stage (15�30 days), and chronic stage (>30 days).
Acute stage: (1) Electroacupuncture + (2) Chinese herbal injection (Salvia miltiorrhiza injection) + (3) external plaster (Compound Redbud Injury-healing Cataplasms); Subacute stag: (1) Chinese Tuina (massage) + (2) hot compress using Chinese medicine + (3) external plaster (Compound Redbud Injury-healing Cataplasms); Chronic stage: (1) TCM functional exercise + (2) external plaster (Compound Redbud Injury-healing Cataplasms).
Treatment Parameters
Electroacupuncture. Points: bilateral Dachangshu (BL 25) and Baihuanshu (BL 30).
Method: Insert the needles (the sterile, disposable needles, 0.3 � 75?mm, manufactured by Suzhou Medical Supplies Factory Co., Ltd.) 2.5 to 2.8?cun. Upon De Qi (needling sensation), connect the needles with the electroacupuncture device (Model: G6805-II, manufactured by Guangzhou KangMai Medical Devices Co., Ltd.), using a continuous wave, an electrical stimulation pulse wave of approximately 0.6?ms and a frequency of 20?Hz. The treatment was conducted once every day, 30?min for each treatment.
Main ingredients: Zi Jing Pi (Cortex Cercis Chinensis), Huang Jing Zi (Negundo Chastetree Fruit), Da Huang (Radix et Rhizoma Rhei), Chuan Xiong (Rhizoma Chuanxiong), Tian Nan Xing (Rhizoma Arisaematis), and Ma Qian Zi (Semen Strychni).
Functions: Circulates blood, resolves stasis, eliminates swelling, and alleviates pain.
Method: Apply the cataplasms to the most painful area, one plaster each time, once a day.
Chinese Herbal Injection. Salvia miltiorrhiza injection (Approval no. Z51021303, manufactured by Sichuan ShengHe Pharmaceutical Co., Ltd.).
The main ingredient of the injection is Salvia root P.E. It acts to circulate blood and resolve stasis.
Method: Intravenous dripping of 20?mL salvia miltiorrhiza injection and 250 mL 5% glucose, once a day.
Hot Compress Using Chinese Medicine. Ingredients: 20?g of Cang Zhu (Rhizoma Atractylodis), Qin Jiao (Radix Gentianae Macrophyllae), Sang Zhi (Ramulus Mori), Mu Gua (Fructus Chaenomelis), Hong Hua (Flos Carthami), Chuan Xiong (Rhizoma Chuanxiong), Hai Feng Teng (Caulis Piperis Kadsurae) and Lei Gong Teng (Radix Tripterygii Wilfordii), respectively. All herbs were provided by Shanghai Hongqiao Pharmaceutical Co., Ltd. and have been tested and qualified.
Method: Place the previous medicinal into a gauze bag, decoct with water for 20?mins and take it out. After the temperature cooled to 40~45�C, apply the back to the affected low back area for 30�40 minutes, once a day. The hot compress can help circulate blood and resolve stasis.
TCM Functional Exercise. The exercise is known as �Fei Yan Shi� (literally meaning �the flying swallow style�) in Chinese.
Method: Ask the patient to take a prone position, extend both hands backwards, lift the chest and lower limbs off the bed using the abdomen as a pivot, and then relax. Conduct this exercise once a day and repeat 4-5 times each time.
Functions: Strengthens the power of back muscles, increases the stability of the spine, and thus prevents relapses.
Chinese Tuina (Massage). Ask the patient to take a prone position and find the tenderness spots on the low back. Then apply gun-rolling (10?min), Anrou-pressing and kneading (10?min), and Tanbo-plucking (5?min) manipulation to the tenderness spots and surrounding areas. Conclude with oblique pulling manipulation of the low back. Conduct the treatment once a day.
Functions: Relaxes spasm of the low back muscles and adjusts lumbar subluxation.
After one week TCM treatment, if the patient’s lower back pain without any relief or even aggravated, the prescription of pain medication was adjusted according to clinical guidelines, detailed records the type and dose of pain medication taken by patients, and the patient was identified as no effect.
Control Group
Patients in the control group receive a two-week normal conservative treatment. Intervention measures include three sections, (1) health education. The patients were invited to receive LDH health education twice a week in outpatient; the health education was designed exclusively to inform patients about the natural course of their illness and the expectation of successful recovery, irrespective of the initial intensity of their pain, educate patients to avoid some bad habits that aggravate the disease, such as a sitting position for a long time and carrying heavy loads, and encourage patients to participate in social activities. (2) Rest: in addition to the normal sleep, the patients need to rest in bed for at least 1-2 hours a day. (3) Pain medication or physical therapy: after one week health education, if the patient’s lower back pain without any relief or even aggravated, the prescription of pain medication was adjusted according to clinical guidelines, detailed records the type and dose of pain medication taken by patients. And if the patients do not want to take pain medication, then the patients were referred to a physiotherapist.
Measurements
All outcomes were assessed by observers unaware of the grouping, at baseline (M1), immediately after the last intervention (M2). The followup included the assessments at one month (M3) and six months (M4) after the last intervention.
The primary outcome measure was the change in pain by the visual analogue scale (VAS), scores range 0 to 100, and a higher score indicates a greater pain, 0 means no pain, and 100 means intolerable pain.
The secondary outcome measure was the change in the Chinese Short Form Oswestry Disability Index (C-SFODI), range 0 to 100%. The C-SFODI consists of nine questions, which come from Oswestry Disability Index (ODI); omit the sex life question in Section??8, because this question is always unacceptable by Chinese. The C-SFODI calculation formula is actual cumulative score/45 � 100%, with higher percentage indicating more severe functional disability. And the study has shown that the C-SFODI has good reliability and validity.
Statistical Analysis
Our pretrial power calculation indicated that 81 patients in experimental group were required to detect a difference in pain relief based on the preliminary experiment data at a significant level of 5% (a two-sided t-test) with 80% power. In anticipation of a 20% attrition rate, we sought 102 patients at least in experimental group. Taking into account the poor effect of control therapy, 102 patients were included in the control group.
Between-group difference at baseline was analyzed using independent-samples t-test or Chi-square test. Changes in continuous measures were analyzed by analysis of variance (ANOVA). Effects were evaluated on an intention-to-treat basis (ITT), and participants who did not complete the followup period were considered not having any changes in scores. A two-sided P value of less than 0.05 indicated statistical significance. Results are presented as mean and standard deviation (SD) at M1 and as between-group difference with 95% confidence intervals (CI) at M2, M3, and M4.
Quality Control
Before the beginning of the study, all researchers have to receive protocol training. A clinic research coordinator (CRC) was employed to assist researchers in each center. A monitor was also appointed to ensure the quality of the research.
Dr. Alex Jimenez’s Insight
The above clinical trial focused on investigating the safety and effectiveness of TCM, or traditional Chinese medicine, for low back pain due to lumbar disc herniation as well as to confirm its clinical result. The participants of the research study with low back pain due to LDH were divided into two groups: the experimental group, which was treated with integrative TCM conservative therapy; and the control group, which was treated normal conservative treatment. The experimental group was then further divided into three subgroups. The details of each TCM treatment method used in the subgroups, including the name, ingredients, method and function of each, are described above. The outcomes were measured accordingly by observers unaware of the specific group divisions. The statistic results were properly analyzed by researchers who received protocol training before the start of the study.
Results
Between January 2011 and August 2012, a total of 480 patients with low back pain due to LDH were recruited, 72 were rejected due to exclusion criterions, and 408 eligible patients were randomly assigned in accordance with the ratio of 3?:?1 to the experimental group and the control group, 306 in the experimental group and 102 in the control group. Patients in the experimental group all completed a two-week treatment. In the control group, at the second week one patient in the control group was unwilling to continue to participate and withdrew his informed consent, and two patients took Fenbid (500?mg for each dose, 2 doses a day) since the pain worsened during treatment (Figure 1).
Figure 1: Screening, randomization, and completion evaluations from the baseline to six-month followup, LDH = lumbar disc herniation.
Baseline Characteristics of the Patients
Table 1 shows the baseline data for the 408 participants. The mean age of all patients is 45 years, and 51% were women. In terms of disease staging, experimental group and control group were comparable. And the baseline outcome including VAS scores and C-SFODI were also reasonably well balanced between experimental group and control group.
Table 1: Baseline characteristics of the study participants.
Improvement in the Primary Outcome
The changes in the primary outcomes from baseline to six-month followup are shown in Table 2 and Figure 2. Immediately after the intervention, two groups showed significant decrease in VAS than the baseline. And the experimental group showed a more significant decrease than the control group (?16.62 points [95% confidence interval {CI}, ?20.25 to ?12.98]; P < 0.001).
Figure 2: Mean changes of the primary and secondary outcomes. The means of outcomes are shown for the experimental group (diamond) and the control group (squares). Measurements were obtained at baseline (M1), immediately after the last intervention (M2).
Table 2: Changes in primary and secondary outcomes.
One month after intervention, two groups also had significantly greater reduction in VAS than the baseline. And again, the experimental group showed a more significant decrease than the control group (?6.37 points [95% CI, ?10.20 to ?2.54]; P = 0.001).
Six months after intervention, compared with the baseline, the changes in VAS remained significant in the experimental group and control group, but between-group difference was not significant (P = 0.091).
Improvement in the Secondary Outcome
Immediately after intervention, two groups had significant improvement in C-SFODI than the baseline, and the experimental group showed a more significant improvement than the control group (?15.55 points [95% CI, ?18.92 to ?12.18]; P < 0.001).
One month after intervention, two groups also had significant improvement in C-SFODI than the baseline. And again, the experimental group improved more (?11.37 points [95% CI, ?14.62 to ?8.11]; P < 0.001).
Six months after intervention, two groups also maintained significant improvement, and the experimental group showed superiority (?7.68 points [95% CI, ?11.42 to ?3.94]; P < 0.001).
Adverse Events
One patient in the experiment group had mild fainting during acupuncture, remission by bed rest, and then completed the remaining treatment. Two patients in the control group were given Fenbid orally due to aggravated low back pain. No other adverse events were noted in either experimental group or control group.
Discussion
Although the mechanism of low back pain caused by lumbar disc herniation (LDH) is still not very clear, the prevailing view is that low back pain due to LDH was found to occur not only in response to mechanical stimuli but also to chemical irritation around the nerve root sheath and sinuvertebral nerve.
Different TCM therapies have different advantages in the treatment of LDH. Pain is the main symptom in the acute stage of LDH; acupuncture has good analgesic effect on low back pain due to LDH. Lumbar dysfunction is the main symptom in the remission stage; Chinese massage has good effect on improving dysfunction. Oral Chinese herbal formulae, external use of Chinese medicine, and Chinese herbal injection also showed good effect in relieving pain and improving dysfunction caused by LDH. And one study also found that Salvia miltiorrhiza injection especially works better and faster for the acute stage when compared with mannitol. Although the mechanism of acupuncture, Chinese massage, and traditional Chinese herbs in the treatment of LDH remains unclear, it is generally agreed that these treatment methods play a role by increasing local blood circulation, relieving nerve root edema, and speeding up the metabolism of the local inflammatory mediators. In recovery stage of the disease, the major task is to strengthen the muscles of the waist and abdomen to prevent relapse, and TCM functional exercise has advantages in this regard and can subsequently increase the lumbar stability to prevent recurrence.
Treating LDH according to different stages has been more and more accepted. In China, LDH is mainly divided into three stages, including acute stage, subacute stage (or remission stage), and chronic stage (or recovery stage). Studies have proven that treating LDH according to different stages has obtained a good clinical effect. In addition, studies have also suggested that it can obtain a better effect than treatment without differentiating different stages.
The past 20 years of clinical practice have witnessed the safety of the treatment regimens used in this study. At the same time, its efficacy has been preliminarily confirmed; however, high quality research evidence is still needed. In the treatment regimens, different TCM therapies were selected according to the characteristics of different stages. Specifically, acupuncture and Chinese herbal injections were used in the acute stage for fast pain relief, Chinese Tuina (massage) and external application of Chinese medicine were used in the subacute stage for improvement of the lumbar functions, and low back muscle exercise was used in the chronic stage to increase the stability of the spine and prevent relapses.
In China, nonsurgical treatment of lumbar disc herniation mainly uses drugs, physical therapy, or TCM treatment. TCM treatment used in the experimental group has been used in clinical routine and is considered to have good clinical efficacy; the efficacy of conservative treatment used in the control group is considered very weak, usually as auxiliary treatment of other therapies. Ethics Committee considers that in order to maximize the protection of the interests of the patients, it is necessary to let the patients have more opportunity to receive TCM treatment, so in this research the sample size of the experimental group and the control group is 3?:?1.
The findings of this study have shown that immediately and one month after intervention, integrative TCM conservative treatment can significantly reduce the VAS scores and C-SFODI, and at six month after intervention, integrative TCM conservative treatment can also significantly reduce the C-SFODI, but two groups have no significant difference in reducing VAS score. VAS is an international general pain visual analog scale, and C-SFODI is the improved version of the ODI (Oswestry Disability Index), and it consists of 9 questions, a higher percentage indicating a more severe functional disability.
Regarding adverse events, one patient had mild fainting in the experiment group, two patients in the control group were given Fenbid oral due to low back pain aggravation, and no other adverse events were noted in either experimental group or control group. The mechanism of integrative TCM conservative treatment for LDH remains unclear, and it will be our future research orientation.
The main limitation of this study is the short followup time. As a result, we failed to conduct comprehensive evaluation regarding the long-term efficacy of integrative TCM conservative treatment for LDH.
Conclusions
This randomized controlled clinical trial provides reliable evidence regarding the effectiveness of integrative TCM conservative treatment for patients with low back pain due to lumbar disc herniation. A large sample of long-term followup is further needed for future research.
Conflict of Interests
No potential conflict of interests relevant to this study was reported.
Acknowledgments
This work is supported by the Key Discipline of TCM Orthopaedic and Traumatic of the Ministry of Education of the People’s Republic of China (100508); the Medical Key Project of Shanghai Science and Technology Commission (09411953400); the project of Shanghai Medical leading talent (041); the National Natural Science Foundation of China (81073114, 81001528); the National Key New Drugs Creation Project, innovative drug research and development technology platform (no. 2012ZX09303009-001); Shanghai University Innovation Team Construction Project of the Spine Disease of Traditional Chinese Medicine (2009-26).
In conclusion, with the measured outcomes and final results of the two groups of participants with low back pain due to lumbar disc herniation, the randomized controlled trial helped contribute valuable information regarding the safety and effectiveness, as well as the clinical effect of integrative TCM conservative therapy. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Sciatica
Sciatica is referred to as a collection of symptoms rather than a single type of injury or condition. The symptoms are characterized as radiating pain, numbness and tingling sensations from the sciatic nerve in the lower back, down the buttocks and thighs and through one or both legs and into the feet. Sciatica is commonly the result of irritation, inflammation or compression of the largest nerve in the human body, generally due to a herniated disc or bone spur.
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Sciatica is a set of symptoms characterized by radiating pain from the lumbar spine. This pain may go down the back, into the buttocks, hips, legs and feet. Onset is frequently sudden following tasks like heavy lifting, though slow onset may also occur. Symptoms may occur on one or both sides of the body. Pain, numbness and weakness can occur depending on the type of compression on the sciatic nerve. About 90% of sciatica cases are often due to a spinal disc herniation pressing on one of the lumbar or sacral nerve roots. Other issues that may cause sciatica include spondylolisthesis, spinal stenosis and piriformis syndrome.
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.
What Causes Sciatic Nerve Compression?
Spinal stenosis is a nerve compression disorder most often affecting older adults. Leg pain similar to sciatica may occur as a result of lumbar spinal stenosis. The pain is usually positional, often brought on by activities such as standing or walking and relieved by sitting down.
The neuroforamen are the passageways that are naturally created between the vertebrae through which spinal nerve roots exit the spinal canal.
Anatomy Overview Can Help You Understand Spinal Stenosis
Normally, the spinal channel is wide enough for the spinal cord, and the foramen are wide enough for the nerve roots. But either or both can become narrowed, and cause spinal stenosis.
Arrow Points To A Lumbar Spondylolisthesis
The muscles in and around the gluteal region help with three areas
