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Physical Rehabilitation

Back Clinic Physical Rehabilitation Team. Physical medicine and rehabilitation, which is also known as physiatry or rehabilitation medicine. Its goals are to enhance, restore functional ability and quality of life to those with physical impairments or disabilities affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons. A physician that has completed training is referred to as a physiatrist.

Unlike other medical specialties that focus on a medical cure, the goals of the physiatrist are to maximize the patient’s independence in activities of daily living and improve quality of life. Rehabilitation can help with many body functions. Physiatrists are experts in creating a comprehensive, patient-centered treatment plan. Physiatrists are integral members of the team. They utilize modern, as well as, tried and true treatments to bring optimal function and quality of life to their patients. And patients can range from infants to octogenarians. For answers to any questions you may have please call Dr. Jimenez at 915-850-0900

Mindfulness Interventions in Chronic Pain Treatment in El Paso, TX

Mindfulness Interventions in Chronic Pain Treatment in El Paso, TX

by | Chiropractic, Chronic Pain, Physical Rehabilitation, Stress, Treatments

Stress has become a new standard in today’s society, however, a huge proportion of the United States population has experienced a significant impact on their health due to the stress in their lives. Approximately 77 percent of Americans claim they suffer stress related physical ailments on a regular basis. Also, 73 percent report experiencing stress related emotional symptoms, such as anxiety and depression. Stress management methods and techniques, including chiropractic and mindfulness interventions, are a valuable treatment option for a variety of diseases. Before addressing the symptoms associated with stress, its essential to first understand what stress is, what are the signs and symptoms of stress, and how can stress impact health.

 

What is Stress?

 

Stress is a condition of emotional or mental pressure which result from issues, adverse scenarios, or exceptionally demanding circumstances. However, the nature of stress by definition makes it rather subjective. A stressful situation to one person may not be considered stressful to another. This makes it challenging to come up with a universal definition. Stress is much more often used to refer to its symptoms and those symptoms can be as varied as the men and women who experience them.

 

What are the Signs and Symptoms of Stress?

 

The signs and symptoms of stress can impact the whole body, both physically and emotionally. Common signs and symptoms of stress include:

 

  • Sleep problems
  • Depression
  • Anxiety
  • Muscle tension
  • Lower back pain
  • Gastrointestinal problems
  • Fatigue
  • Lack of motivation
  • Irritability
  • Headache
  • Restlessness
  • Chest pain
  • Feelings of being overwhelmed
  • Decrease or increase in sex drive
  • Inability to focus
  • Undereating or overeating

 

How can Stress Impact Health?

 

People can experience different signs and symptoms of stress. Stress itself doesn’t directly impact an individual’s health. Instead, it is a combination of the signs and symptoms of stress as well how the person handles those that adversely impact health.

 

Ultimately, stress may result in some very serious ailments including: heart disease, hypertension, diabetes, obesity, and even certain cancers. Psychologically, stress can lead to social withdrawal and social phobias. It is also often directly linked to alcohol and drug abuse.

 

Chiropractic for Stress Management

 

Mindfulness interventions are common stress management methods and techniques which can help reduce the signs and symptoms of stress. According to several research studies, however, chiropractic care is an effective stress management treatment option, which together with mindfulness interventions, could help improve as well as manage stress.�Because the spine is the root of the nervous system, the health of your spine can determine how you will feel each day, both physically and emotionally. Chiropractic can help restore the balance of the body, aligning the spine, and decreasing pain.

 

A subluxation, or misalignment of the spine, can interfere with the way the nervous system communicates with the different parts of the body. This can lead to increased signs and symptoms of stress. A subluxation may also result in chronic pain, such as headaches, neck pain or back pain. The stress of a misalignment of the spine can aggravate the signs and symptoms of stress and make a person more susceptible to stress.�Correcting the alignment of the spine can help ease stress.

 

Regular chiropractic care can help effectively manage stress. Through the use of spinal adjustments and manual manipulations, a chiropractor can gently realign the spine, releasing the pressure being placed on the spinal vertebrae as well as reducing the muscle tension surrounding the spine. Furthermore, a balanced spine also helps boost the immune system, promotes better sleeping habits and helps to improve circulation, all of which are essential towards reducing stress. Finally, chiropractic care can “turn off” the flight or fight response which is commonly associated with stress, allowing the entire body to rest and heal.

 

Stress should not be ignored. The signs and symptoms of stress aren’t very likely to go away on their own. The purpose of the following article is to demonstrate an evidence-based review on the use of stress management methods and techniques along with mindfulness interventions in chronic pain treatment as well as to discuss the effects of these treatment options towards improving overall health and wellness. Chiropractic, physical rehabilitation and mindfulness interventions are fundamental stress management methods and/or techniques recommended for the improvement and management of stress.

 

Mindfulness Interventions in Physical Rehabilitation: A Scoping Review

 

Abstract

 

A scoping review was conducted to describe how mindfulness is used in physical rehabilitation, identify implications for occupational therapy practice, and guide future research on clinical mindfulness interventions. A systematic search of four literature databases produced 1,524 original abstracts, of which 16 articles were included. Although only 3 Level I or II studies were identified, the literature included suggests that mindfulness interventions are helpful for patients with musculoskeletal and chronic pain disorders and demonstrate trends toward outcome improvements for patients with neurocognitive and neuromotor disorders. Only 2 studies included an occupational therapist as the primary mindfulness provider, but all mindfulness interventions in the selected studies fit within the occupational therapy scope of practice according to the American Occupational Therapy Association�s Occupational Therapy Practice Framework: Domain and Process. Higher-level research is needed to evaluate the effects of mindfulness interventions in physical rehabilitation and to determine best practices for the use of mindfulness by occupational therapy practitioners.

 

MeSH TERMS: complementary therapies, mindfulness, occupational therapy, rehabilitation, therapeutics

 

Mindfulness interventions are frequently used in health care to assist patients in managing pain, stress, and anxiety and in targeting additional health, wellness, and quality-of-life outcomes. Although mindfulness practices originate from Buddhism, mindfulness interventions have become largely secular and are based on the philosophy that full and nonjudgmental experience of the present moment creates positive outcomes for mental and physical health (Williams & Kabat-Zinn, 2011). This paradigm assumes that many people experience a high volume of future- or past-focused thoughts that produce anxiety. Hence, mindfulness is the practice of refocusing away from these distractions and toward lived experiences.

 

The prevalence of mindfulness interventions in health care has grown substantially in recent decades, and several types of mindfulness interventions have emerged. The first and most widely recognized mindfulness intervention is mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1982). Initially called the stress reduction and relaxation program, MBSR was developed more than 30 years ago for patients with chronic pain and involves guided sitting meditation, mindful movement, and education on the effect of stress and anxiety on health and wellness. The evidence supporting mindfulness interventions in health care has grown since the inception of MBSR, and modern mindfulness interventions are shown to be effective at reducing pain severity (Reiner, Tibi, & Lipsitz, 2013), reducing anxiety (Shennan, Payne, & Fenlon, 2011), and enhancing well-being (Chiesa & Serretti, 2009).

 

Mindfulness-based interventions fit well with the strong emphasis on holism within occupational therapy practice (Dale et al., 2002). Specifically, valuing the mind�body whole is a core tenet that distinguishes occupational therapy practitioners from other health care providers (Bing, 1981; Kielhofner, 1995; Wood, 1998). Emerging literature suggests that mindfulness may enhance occupational engagement and be related to flow state (i.e., a state of timelessness within optimal experiences of activity engagement; Elliot, 2011; Reid, 2011). Mindfulness is both the meditative practice, which is an occupation itself, and a means to enhance the experience of occupations (Elliot, 2011). Moreover, a parallel exists between mindfulness practices and the occupational process of doing, being, and becoming (Stroh-Gingrich, 2012; Wilcock, 1999).

 

Mindfulness-based interventions in health care continue to grow in scope with the description of novel protocols, application of mindfulness to new populations, and targeting of diverse symptoms. The majority of current mindfulness literature focuses on helping people with mental health conditions and improving wellness in people, providing a wealth of evidence for occupational therapy practitioners who work in mental health or health promotion. However, the applicability and effect of mindfulness interventions for clients in rehabilitation for physical dysfunction are not as well established. Current literature that links mindfulness and occupational therapy is largely theoretical, and a translation to practice-based settings has yet to be fully explored. Therefore, the purpose of this review was to describe how mindfulness is currently used in physical rehabilitation, identify the potential applications of mindfulness interventions to occupational therapy practice, and illuminate gaps in knowledge to be explored in future research.

 

Method

 

Scoping reviews are rigorous review processes used to present the landscape of the literature on a broad topic, identify gaps in knowledge, and draw implications for further research and clinical application (Arksey & O�Malley, 2005). This type of review differs from a systematic review because it is not intended to answer questions about the efficacy of an intervention or provide specific recommendations for best practice. A scoping review is typically done in place of a systematic review when high-quality literature for a given topic is limited. Although the purpose and outcome of a scoping review differ from those of a systematic review, a systematic process is involved to ensure rigor and minimize bias (Arksey & O�Malley, 2005). A description of the methods used in this study for each of the systematic steps follows.

 

The question that guided this scoping review was, How is mindfulness being used in physical rehabilitation, and what are the implications for occupational therapy practice and research? Because the purpose of this review was to provide an overview of available literature, an exhaustive search using terms for all potential interventions or diagnoses was not used. Instead, we elected to combine the general key word mindfulness with each of the following major medical subheadings: therapeutics, rehabilitation, and alternative medicine. Searches were conducted in PubMed, CINAHL, SPORTDiscus, and PsycINFO and were limited to articles published in English before October 10, 2014 (i.e., the date the search was conducted). No additional limits were set, and no restrictions were placed on minimum level of evidence or study design.

 

Abstracts from the searches were compiled, duplicates were eliminated, and two reviewers independently screened all original abstracts. Initial inclusion criteria for abstract screening were a description of a mindfulness intervention, relevance to occupational therapy, and targeting of a disorder addressed in physical rehabilitation. A broad definition of mindfulness intervention was adopted to include any meditative practice, psychological or psychosocial intervention, or other mind�body therapeutic practice that directly mentioned or addressed mindfulness. Abstracts were considered relevant to occupational therapy if the diagnosis being evaluated was within the occupational therapy scope of practice. Disorder addressed in physical rehabilitation was defined as any illness, injury, or disability of the neurological, musculoskeletal, or other body system that could be treated within a medical or rehabilitation setting.

 

Any abstract identified as relevant by either author was brought to the full-text stage. In large part, these studies were conducted by scientists, psychologists, psychiatrists, or other medical doctors. Additionally, the interventions were often not implemented in settings where physical rehabilitation providers work. Therefore, to most appropriately answer the research question, final inclusion required that the study focus on an applied use of mindfulness in a rehabilitation context. This additional criterion was satisfied if the mindfulness intervention was provided by a rehabilitation professional (e.g., occupational therapist, physical therapist, speech therapist), was an addition or alternative to traditional rehabilitation, or was provided after traditional rehabilitation had failed. The two authors independently reviewed the full texts, and final study inclusion required agreement by both authors. Any disagreement on study selection was settled by deliberation ending in consensus.

 

For reporting, studies were primarily organized by type of physical disorder being targeted and secondarily sorted and described by type of mindfulness intervention and level of evidence. These data were summarized and are provided in the Results section to answer the first portion of the research question, that is, to describe how mindfulness is being used in physical rehabilitation. The interventions were compared with the �Types of Occupational Therapy Interventions� categories within the Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association [AOTA], 2014) to determine how occupational therapy practitioners might use the interventions in clinical practice. Multiple conversations and coediting of this article between the two authors resulted in the final description of implications for occupational therapy practice and research.

 

Results

 

Results of the systematic search and review process are shown in Figure 1. The searches produced a total of 1,967 abstracts across the four databases. After 443 duplicates were removed, 1,524 original abstracts were screened, and 188 full texts were evaluated for inclusion. Exclusion at the abstract review phase was largely the result of diagnoses or interventions outside the occupational therapy scope (e.g., therapy for tinnitus) or interventions not targeting a physical disorder (e.g., anxiety disorder). At the study selection stage, full-text articles were excluded if they failed to describe an applied use of mindfulness within a rehabilitation context (n = 82) or failed to meet other initial inclusion criteria (n = 90). Sixteen studies met all criteria and were included in the data extraction and synthesis.

 

Figure 1 Search and Inclusion Flow Diagram

Figure 1: Search and inclusion flow diagram.

 

As shown in Table 1, 14 studies used experimental or quasi-experimental designs, including pretest�posttest (n = 6), multiple case series (n = 4), randomized trials (n = 2), retrospective cohort (n = 1), and a nonrandomized comparative trial (n = 1). Two expert opinion articles were also included because both added anecdotal evidence for the applied use of mindfulness in physical rehabilitation practice settings. Five of the 16 studies reported the involvement of occupational therapists on the study team, but only 2 of these studies specified that an occupational therapist provided the mindfulness intervention. The remaining 11 studies provided mindfulness interventions to participants either in conjunction with rehabilitation interventions not described as part of the study or after rehabilitation had failed. Mindfulness interventions included MBSR (n = 6), general mindfulness and meditation (n = 5), acceptance and commitment therapy (ACT; n = 2), and other study-specific techniques (n = 3). Physical disorders targeted by mindfulness interventions in the included studies were primarily categorized as musculoskeletal and pain disorders (n = 8), neurocognitive and neuromotor disorders (n = 6), or disorders of other body systems (n = 2).

 

Table 1 Summary of Research on Mindfulness Interventions

Table 1: Summary of research on mindfulness interventions for people with musculoskeletal and pain disorders, neurocognitive and neuromotor disorders, and other disorders.

 

Common Mindfulness Interventions

 

Mindfulness-Based Stress Reduction. As referenced in Table 1, 3 studies used MBSR, each with an emphasis on meditation provided in a 2-hr group session, once a week for 8 wk. Three additional studies used an adapted MBSR protocol to meet the needs of the target population. Common adaptations of the MBSR protocol were to change the number of weeks the MBSR group met (Azulay, Smart, Mott, & Cicerone, 2013; B�dard et al., 2003, 2005) as well as to reduce the group size and session length (Azulay et al., 2013). The primary goal of MBSR and MBSR-based programs was to enhance trait-level mindfulness within the participants. Sessions included body scans (i.e., bringing attention to various parts of the body and the sensations felt), mindful yoga, guided mindful meditation, or education about stress and health. One or two people with intensive training in MBSR and who were practitioners of mindfulness themselves always facilitated MSBR sessions. Participants were expected to use recordings to meditate at home on a daily basis. Studies that implemented MBSR used it as a primary intervention to enhance mindfulness through mindfulness practices that patients were expected to integrate into their daily lives. This approach cast mindfulness as a new meaningful occupation for participants facilitated by the intervention. Therefore, the description and use of MBSR in these studies match with occupations and activities, education and training, and group interventions within occupational therapy practice (AOTA, 2014).

 

General Mindfulness. Five studies applied mindfulness principles generally, failed to fully describe the mindfulness portion of their intervention, or used mindfulness components (e.g., body scan only or guided meditation only) within a comprehensive rehabilitation intervention (see Table 1). Interventions varied widely between group or individual formats, in duration and frequency of sessions, and in duration of the full course of treatment. General mindfulness techniques were used as an opening to, as a closing to, or in parallel with traditional rehabilitation treatments. Therefore, the application of mindfulness was individually targeted to meet the specific needs and goals of clients. Examples of these goals included occupational engagement, engagement in therapy, reduced anxiety, awareness of bodily sensations, and nonjudgmental attitude. Given the holistic targets, general mindfulness interventions as used in these studies would be described as activities, education, or preparatory methods and tasks (AOTA, 2014).

 

Acceptance and Commitment Therapy. ACT is a psychological intervention stemming from clinical behavioral analysis and mindfulness principles. Two studies implemented ACT with different strategies. In 1 study (McCracken & Guti�rrez-Mart�nez, 2011), an intensive intervention was provided to participants in a group setting, 5 days per week, 6 hr per day, over a 4-wk interval. The other study (Mahoney & Hanrahan, 2011) integrated ACT as part of individual routine physical therapy interventions. In both studies, the primary goals of ACT were to improve psychological flexibility and engagement in therapy through pain acceptance and buffering of other psychological experiences. Similar to the integrative use previously described for general mindfulness, ACT was also used in these studies as activities, education, or preparatory methods and tasks (AOTA, 2014).

 

Targets of Mindfulness Interventions

 

Musculoskeletal and Pain Disorders. Musculoskeletal and pain disorders targeted by mindfulness interventions included chronic musculoskeletal pain (n = 6), work-related musculoskeletal injury (n = 1), and knee surgery (n = 1). Five of the 6 studies using mindfulness for chronic pain were experimental. In 3 of these studies, a significant reduction in pain severity was found after participation in mindfulness interventions (Kabat-Zinn, Lipworth, & Burney, 1985; McCracken & Guti�rrez-Mart�nez, 2011; Zangi et al., 2012). One randomized trial contrasted with the other studies; Wong et al. (2011) found that pain was reduced over time, but the amount of pain reduction was not significantly different between clients receiving the mindfulness intervention and a control group. The fifth experimental study (Kristj�nsd�ttir et al., 2011) piloted a mindfulness intervention by using a mobile phone application. This study�s sample size was not large enough to evaluate a significant change in the outcome measures; however, the participants reported that the mobile mindfulness intervention was helpful and appropriate for treating their symptoms. Although these studies demonstrated varied results in reducing pain severity, secondary outcomes such as increased acceptance of pain, improved functioning with pain, and decreased distress produced larger effect sizes and were consistently significant.

 

A retrospective study (Vindholmen, H�igaard, Espnes, & Seiler, 2014) sought to predict treatment outcomes based on the trait-level mindfulness of patients at a vocational rehabilitation center receiving therapeutic interventions for work-related musculoskeletal disorders. The observational facet of trait-level mindfulness was found to significantly predict time until return to work, but only for highly educated patients. The authors noted that mindfulness interventions may moderate quality of life, which was a significant predictor of time until return to work for all participants.

 

Two studies, 1 with Level IV (i.e., case series; Mahoney & Hanrahan, 2012) and 1 with Level V (i.e., expert opinion; Pike, 2008) evidence, suggested that combining traditional therapeutic rehabilitation interventions with mindfulness for patients with musculoskeletal and pain disorders has benefits. Clients receiving ACT integrated into their physical therapy sessions after knee surgery reported that the mindfulness intervention was helpful to their rehabilitation process and increased their engagement in therapy (Mahoney & Hanrahan, 2012). In his commentary, Pike (2008) argued for implementing mindfulness interventions in combination with physical therapy for patients who suffer from chronic pain, noting that mindfulness is similar to more widely used awareness-based interventions (e.g., Pilates). Similar to the positive reception noted by Mahoney and Hanrahan (2012), Pike noted that integrating mindfulness into his physical therapy practice had proven to be clinically useful and well tolerated by patients. He hypothesized that the mechanism of mindfulness interventions may either directly reduce pain or improve functional outcomes despite pain, concepts validated by the experimental studies previously discussed in this section.

 

Neurocognitive and Neuromotor Disorders. Studies using mindfulness interventions for people with neurocognitive and neuromotor disorders included participants with diagnoses of aphasia (n = 1), traumatic brain injury (TBI; n = 4), and developmental coordination disorder (n = 1). Orenstein, Basilakos, and Marshall (2012) found no change attributed to a mindfulness intervention on divided attention tasks or symptoms of aphasia when used with 3 clients. However, 3 pretest�posttest studies using mindfulness interventions for patients with TBI showed more promising results. Azulay et al. (2013) reported a trend (p = .07) toward improved cognitive functioning, with moderate effect sizes (d = 0.31 and 0.32). B�dard et al. (2003) found trends toward reduced symptom distress and improved physical health, with small to moderate effect sizes (0.296 < d < 0.32). They also demonstrated significant improvements in secondary measures such as self-efficacy, quality of life, and mental health. Moreover, a 12-mo postintervention follow-up of their 2003 study showed significant maintenance or improvement in patients with TBI across time in vitality, emotional role, and mental health, but fluctuating pain (B�dard et al., 2005). Of note is that although participants reported that they valued the mindfulness intervention, gender played a role in recruitment and retention because most young men either chose to not participate in or dropped out of the study (B�dard et al., 2005).

 

In Meili and Kabat-Zinn (2004), Meili, a woman who sustained a TBI, recounted that mindfulness was central to her journey of healing. Using Meili�s experience as an example, Kabat-Zinn asserted that helping patients understand, accept, and adjust to their illness or disability through both inner adjustment to new bodily experiences, or mindfulness, and external restoration of physical functioning, or physical rehabilitation, are essential to the healing process. Moreover, Kabat-Zinn stated that occupational therapy practitioners and other rehabilitation professionals are well equipped to implement mindfulness interventions because these interventions complement their existing practice of facilitating the outer work of healing the body. Adding mindfulness interventions would be clinically appropriate to foster the inner work necessary for patients to heal. Jackman (2014) also suggested that mindfulness is appropriate as part of the rehabilitative process. Jackman discussed the use of mindfulness in occupational therapy for children with developmental coordination disorder. Children who participated in mindfulness-enhanced therapy improved on at least one component of motor coordination. This therapy also helped parent�child dyads meet their self-directed goals.

 

Other Conditions. Two additional studies targeted physical diagnoses that were not explicitly musculoskeletal or neuromotor. In the first, MBSR was provided to women with urge-predominant urinary incontinence by an occupational therapist who had received intensive training in mindfulness (Baker, Costa, & Nygaard, 2012). Seven women who had an average of 4.14 episodes of urinary incontinence per day participated in an 8-wk MBSR group. In contrast to other studies that combined mindfulness with traditional rehabilitation, participants in this study received no other treatment or traditional interventions for urinary incontinence (e.g., pelvic floor muscle exercises, bladder education). At posttest, participants had significantly fewer episodes (p = .005), averaging 1.23 per day. Although limited by a small sample size and lack of a control group, this study demonstrated preliminary support for stand-alone mindfulness interventions provided by occupational therapists for a physical condition.

 

The second study used mindfulness-based cognitive therapy in the rehabilitation of vestibular dysfunction and dizziness (Naber et al., 2011). In this study, group-based mindfulness components were nested within standard vestibular rehabilitation practices, dialectical behavioral therapy, and cognitive�behavioral therapy over five biweekly sessions. In addition, participants met individually with a physical therapist who provided personalized exercises. Significant improvement in vestibular symptoms, including functional level, impairment, coping, and skill use (p < .0001), was noted.

 

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Dr. Alex Jimenez’s Insight

Mindfulness interventions, such as mindfulness-based stress reduction, general mindfulness and acceptance and commitment therapy, are prevalent stress management methods and techniques frequently used in health care to help�relieve symptoms of stress, mental health issues and physical pain as well as to address and treat a variety of symptoms and diseases. Mindfulness interventions are believed to increase the outcome measures of alternative and complementary treatment options. Chiropractic care is another popular stress management option which can help improve as well as manage stress. The use of mindfulness interventions and chiropractic care with other treatments, such as physical rehabilitation, has been determined to increase their results. The article above demonstrated evidence-based results on the effectiveness of mindfulness interventions for symptoms of stress, including chronic pain.

 

Discussion

 

This scoping review describes how mindfulness is used in physical rehabilitation, identifies implications for occupational therapy, and illuminates gaps in current research. The studies included in the review provide preliminary support that mindfulness interventions can improve urinary incontinence, chronic pain, and vestibular functioning. These studies also show a promising trend toward improved outcomes for cognitive and behavior targets for patients with TBI. Across the studies, the strongest findings were for improvements in adaptation to illness or disability such as self-efficacy for disease management, increased quality of life, and acceptance of pain symptoms. In addition, mindfulness interventions for these outcomes not only were immediately effective but also maintained effectiveness at follow-up at a clinically significant level. This result suggests that adaptation-based outcomes are an important complement to function- and symptom-based outcomes in clinical mindfulness research. Moreover, patient appraisals of mindfulness interventions were positive, and no studies reported adverse or negative effects.

 

Occupational therapists were the primary providers of mindfulness interventions in 2 studies (Baker et al., 2012; Jackman, 2014). Although these studies showed promising results, both were limited by small sample size and lack of control conditions. In addition, Jackman (2014) failed to report numeric values for the findings, limiting interpretation. In 3 additional studies, occupational therapists had an ancillary role in providing mindfulness interventions (McCracken & Guti�rrez-Mart�nez, 2011; Vindholmen et al., 2014; Zangi et al., 2012). However, because of the complementary nature of the interventions with the occupational therapy scope of practice (AOTA, 2014) and the manner in which they were implemented, occupational therapy practitioners could have been active providers of the mindfulness interventions in these studies, highlighting the feasibility of integrating mindfulness into occupational therapy practice in future research. Moreover, although MBSR was the primary intervention that promoted engagement in mindfulness as an occupation, general mindfulness interventions and ACT also served as appropriate activity-based, preparatory, and educational interventions in these studies. Given the results of these studies and support from additional literature describing the use of mindfulness by occupational therapists (Moll, Tryssenaar, Good, & Detwiler, 2013; Stroh-Gingrich, 2012), further investigation of best practices for integrating mindfulness techniques into physical rehabilitation is warranted.

 

Although the literature suggests that mindfulness interventions can have positive effects in physical rehabilitation, substantial limitations exist in the current evidence. First, the majority of the positive studies are limited by their study design, being, at best, Level III evidence (i.e., cohort design). In contrast, an appropriately powered randomized controlled trial found a significant pretest�posttest effect of mindfulness interventions on pain reduction but also noted a similar reduction in pain for control group participants (Wong et al., 2011). Second, the wide variability in mindfulness intervention protocols makes it challenging to reach any general conclusions about intervention effectiveness. Finally, many studies overrepresented middle-aged White women, limiting interpretation of the acceptability of mindfulness interventions by or their effects in other demographics. Specifically, B�dard et al. (2005) noted decreased interest and adherence to their mindfulness intervention by male participants.

 

More information is needed to understand best practices for integration of mindfulness into occupational therapy practice. Specifically, the mindfulness interventions included in this review were generally complex, used a standardized protocol, were not fully integrated with standard rehabilitation interventions, and required intensive training for providers. Thus, further investigation is needed to:

 

  • Establish the effectiveness of mindfulness interventions in various settings and patient populations with physical diagnoses in high-level, randomized trials;
  • Examine the utility of training methods for occupational therapy practitioners in the delivery of mindfulness interventions for physical disorders as part of professional curricula, through continuing education programs or other postprofessional training;
  • Describe best practices for clinical integration of mindfulness into occupational therapy practice; and
  • Explore the implications related to reimbursement for and cost-effectiveness of the delivery of mindfulness interventions in occupational therapy practice.

 

Implications for Occupational Therapy Practice

 

The results of this study have the following implications for occupational therapy practice:

 

  • Mindfulness in physical rehabilitation is primarily used to help clients with chronic pain and TBI adapt to illness and disability, which promotes functional recovery as complementary to symptom remediation.
  • Mindfulness for physical disorders has yet to be substantiated as an evidence-based intervention within occupational therapy; however, promising preliminary evidence exists, and current mindfulness protocols fit within the occupational therapy scope of practice as preparatory, activity, or occupation-based interventions.
  • Higher level research is needed to address the substantial limitations in current efficacy studies on mindfulness for physical conditions and to determine best practices for the use of mindfulness in physical rehabilitation by occupational therapy practitioners.

 

Acknowledgments

 

Many thanks for the support and guidance received from Dr. Gelya Frank. Work on this review was partially supported by Grant No. K12�HD055929, National Institute of Child Health and Human Development/National Institute of Neurological Disorders and Stroke Rehabilitation Research Career Development Program. The contents of this article are solely the responsibility of the authors and do not necessarily represent the views of the National Institutes of Health. Portions of this work were presented at the 2015 Occupational Therapy Summit of Scholars in Los Angeles, CA.

 

Footnotes

 

Indicates studies that were included in the scoping review for this article.

 

Contributor Information

 

Ncbi.nlm.nih.gov/pmc/articles/PMC4834757/

 

In conclusion,�although stress is common in today’s society, stress can lead to a variety of physical and emotional diseases. Stress management methods and techniques are growing as popular treatment options to treat stress and its associated ailments, including chronic pain. Chiropractic care helps reduce stress by correcting subluxations, or spinal misalignments, to release pressure on the vertebrae and reduce muscle tension. The article above also demonstrates the effectiveness of mindfulness interventions in physical rehabilitation, although further research studies are needed. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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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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EXTRA IMPORTANT TOPIC: Managing Workplace Stress

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Choosing Chiropractic? | Familia Dominguez | Patients | El Paso, TX Chiropractor

 

 

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Stress Management & Chiropractic Treatment in El Paso, TX

Stress Management & Chiropractic Treatment in El Paso, TX

by | Back Pain, Chiropractic, Physical Rehabilitation, Stress, Treatments

Many people utilize chiropractic treatment for stress management. If you haven’t already considered chiropractic to help reduce your stress, then it might still be in your best interest to know if it actually can help manage stress. If that’s the case, how exactly can chiropractic treatment help reduce stress levels? Every individual experiences stress. If chiropractic is so effective for stress management, why isn’t it more well-known? Although the answer to that is complex, the popularity of chiropractic treatment for stress management is growing. The article below discusses how chiropractic can help reduce your stress.

 

What Causes Stress?

 

Stress is difficult to define, however, it can be identified as a physical and/or psychological reaction to pressure. Stress may be caused by numerous factors, including environmental, bodily and emotional channels. When we become stressed, the sympathetic nervous system triggers the “fight or flight” response, a defense mechanism which prepares the body for perceived danger. While short-term stress is helpful, long-term stress has been connected to a variety of health issues. For instance, too much stress can create excess tension on the neck, back and low back, which may in turn lead to subluxation or spinal misalingment. This can ultimately also be bad for the heart, digestion, metabolism, and the immune system.

 

How Can Chiropractic Care Help?

 

As mentioned above, stress can frequently take a toll on the spine. Tension may continue to build up as a result of chronic stress, eventually resulting in pain and discomfort, among other symptoms, such as back pain and sciatica. Chiropractic care can help in two ways. First, through the use of spinal adjustments and manual manipulations, a chiropractor will carefully correct the misalignment of the spine, or subluxation, releasing tension and stress and relaxing the body to decrease the physical and psychological strain on the body. Second, once the spine is properly realigned, the central nervous system can function effectively.

 

A doctor of chiropractic will always be happy to speak with you and get you on the path towards a healthy and stress free life. A chiropractor can offer stress management chiropractic treatment to help you feel healthy. The purpose of the following systematic review is to demonstrated how effective mindfulness-based stress reduction methods and techniques can help low back pain.

 

Mindfulness-Based Stress Reduction for Low Back Pain: A Systematic Review

 

Abstract

 

Background

 

Mindfulness-based stress reduction (MBSR) is frequently used for pain conditions. While systematic reviews on MBSR for chronic pain have been conducted, there are no reviews for specific pain conditions. Therefore a systematic review of the effectiveness of MBSR in low back pain was performed.

 

Methods

 

MEDLINE, the Cochrane Library, EMBASE, CAMBASE, and PsycInfo were screened through November 2011. The search strategy combined keywords for MBSR with keywords for low back pain. Randomized controlled trials (RCTs) comparing MBSR to control conditions in patients with low back pain were included. Two authors independently assessed risk of bias using the Cochrane risk of bias tool. Clinical importance of group differences was assessed for the main outcome measures pain intensity and back-specific disability.

 

Results

 

Three RCTs with a total of 117 chronic low back pain patients were included. One RCT on failed back surgery syndrome reported significant and clinically important short-term improvements in pain intensity and disability for MBSR compared to no treatment. Two RCTs on older adults (age???65 years) with chronic specific or non-specific low back pain reported no short-term or long-term improvements in pain or disability for MBSR compared to no treatment or health education. Two RCTs reported larger short-term improvements of pain acceptance for MBSR compared to no treatment.

 

Conclusion

 

This review found inconclusive evidence of effectiveness of MBSR in improving pain intensity or disability in chronic low back pain patients. However, there is limited evidence that MBSR can improve pain acceptance. Further RCTs with larger sample sizes, adequate control interventions, and longer follow-ups are needed before firm conclusions can be drawn.

 

Keywords: Low back pain, Mindfulness-based stress reduction, MBSR, Complementary therapies, Review

 

Background

 

Low back pain is a major public health problem, with 76 % of the population experiencing low back pain in a given year [1]. It has become the largest category of medical claims, placing a major burden on individuals and health care systems [2]. Low back pain is the most common condition for which complementary therapies are used [3]. In the US, more than half of patients suffering from low back pain use complementary therapies [4].

 

Mindfulness is the common ground of several complementary therapies. Derived from Buddhist spiritual tradition, mindfulness has been secularized and integrated into behavioral treatment approaches [5]. While mindfulness has been described as the core construct of Buddhist meditation [5], it also comprises a specific state of consciousness that has been characterized as non-elaborative, non-judgmental moment-to moment awareness, a way to accept and trust in one�s own experience [6]. Therefore, mindfulness-based therapies not only include training in so-called formal practice of mindfulness, this is meditation, but also training in so-called informal practice of mindfulness, this is retaining a mindful state of consciousness during routine activities in everyday life [7,8].

 

The most commonly used mindfulness-based intervention is mindfulness-based stress reduction (MBSR). MBSR has originally been developed in a behavioral medicine setting for patients with chronic pain and stress-related complaints [9,10]. MBSR is a structured 8-week group program of weekly 2.5-hour sessions and 1 all-day (7 to 8-hour) silent retreat. Key components of the program are sitting meditation, walking meditation, hatha yoga and body scan, a sustained mindfulness practice in which attention is sequentially focused on different parts of the body [6]. Another important component is the transition of mindfulness into everyday life.

 

Mindfulness-based cognitive therapy (MBCT) combines MBSR with cognitive-behavioral techniques [11,12]. It retains the original 8-week group-based approach. Originally developed as a treatment for major depression [11], MBCT is more and more adapted for other specific conditions [12]. Other mindfulness-based interventions include mindful exercise [13] and acceptance and commitment therapy [14] that do not necessarily include formal meditation practice.

 

Pain has been a key topic of research on MBSR from the beginning [9]. Several trials assessed the effect of MBSR on patients with heterogeneous chronic pain conditions, mainly reporting positive results [15-19]. A recent comprehensive meta-analysis of mindfulness-based interventions for chronic pain conditions found small effects on pain, depression and physical well-being when considering only randomized controlled trials [14]. However, this meta-analysis included only one trial on low back pain.

 

The aim of this review was to systematically assess and – if possible – meta-analyze the effectiveness of MBSR and MBCT in patients with low back pain.

 

Methods

 

PRISMA guidelines for systematic reviews and meta-analyses [20] and the recommendations of the Cochrane Collaboration [21] were followed.

 

Literature Search

 

The literature search comprised the following electronical databases from their inception through November 2011: Medline, EMBASE, the Cochrane Library, PsycINFO, and CAMBASE. The complete search strategy for Medline was as follows: (MBSR[Title/Abstract] OR MBCT[Title/Abstract] OR mindful*[Title/Abstract]) AND (low back pain[MeSH Terms] OR low back pain[Title/Abstract] OR lower back pain[Title/Abstract] OR lumbago[Title/Abstract] OR low backache[Title/Abstract] OR low back ache[Title/Abstract] OR sciatica[MeSH Terms] OR sciatica[Title/Abstract]). The search strategy was adapted for each database as necessary. No language restrictions were applied. In addition, reference lists of identified original articles were searched manually. All retrieved articles were read in full to determine eligibility.

 

Eligibility Criteria

 

Intervention

 

Studies that assessed MBSR or MBCT as the main intervention were included. Studies on mindfulness-based interventions that were clearly different from the original MBSR/MBCT programs, such as mindful exercise or acceptance and commitment therapy, were excluded while studies that used variations of the MBSR/MBCT programs, such as variations in program length, frequency or duration were included.

 

Study Type

 

Only randomized controlled trials (RCTs) were included, while observational studies or non-randomized trials were excluded. No treatment (�wait-list�), usual care or any active treatment were acceptable as control interventions.

 

Studies were included only if they were published as full-text articles in peer reviewed scientific journals.

 

Patients

 

Studies of patients with a diagnosis of low back pain were included regardless of pain cause, duration and intensity.

 

Data Extraction

 

Two reviewers independently extracted data on characteristics of the study (e.g. trial design, randomization, blinding), characteristics of the patient population (e.g. sample size, age, diagnosis), characteristics of the intervention and control condition (e.g. type, program length, frequency and duration), drop-outs, outcome measures, follow-ups, results and safety. Discrepancies were rechecked with a third reviewer and consensus achieved by discussion.

 

Risk of Bias in Individual Studies

 

Risk of bias was assessed by two authors independently using the Cochrane risk of bias tool. This tool assesses risk of bias on the following domains: selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias [21]. Discrepancies were rechecked with a third reviewer and consensus achieved by discussion. Trial authors were contacted for further details if necessary.

 

Data Analysis

 

Main outcome measures were pain intensity and back-related disability. Safety was defined as secondary outcome measure. Other outcome measures used in the included studies were analyzed exploratively.

 

Meta-analysis was planned if sufficient homogeneous RCTs were available for statistical pooling. However, as only 3 RCTs were available that were heterogeneous regarding characteristics of patients, interventions, and control conditions, no meta-analysis was performed.

 

To determine clinical importance of group differences the following criteria were used: 10 mm (or 10 %) difference in post-treatment scores or change scores on a 100 mm visual analog scale of pain intensity [22], and 2�3 points (or 8 %) difference in post-treatment or change scores on the Roland-Morris Disability Questionnaire for back-specific disability [23].

 

Results

 

Literature Search

 

Twenty-five records were retrieved in literature search, 10 of them were duplicates. Three full-text articles with a total of 117 patients were assessed for eligibility and all of them were eligible for qualitative analysis (Figure ?1).

 

Figure 1 Flowchart of the Results of the Literature Search

Figure 1: Flowchart of the results of the literature search.

 

Study Characteristics

 

Characteristics of the study, patient population, intervention, control condition, outcome measures, follow-ups and results are shown in Table ?1.

 

Table 1 Characteristics of the Included Studies

 

Setting and Patient Characteristics

 

All 3 included RCTs were conducted in the USA. Patients were recruited from a multidisciplinary spine and rehabilitation center [24], an adult pain clinic [25], and by posted flyers and newspaper advertisements [25,26]. Patients in 2 RCTs were older adults (age???65 years) with chronic (duration???3 months) low back pain [25,26]. In one of the two RCTs, minimal pain intensity was not defined [25] while in the other RCT pain had to be of at least moderate intensity on the �pain thermometer� [26]. Patients with non-specific low back pain, as well as specific low back pain, mainly due to osteoarthritis, were included [25,26]. The third RCT included patients of any age with failed back surgery syndrome; this is persistent back pain and/or leg pain of any duration and any intensity that persisted after lumbosacral surgery (within???2 years) [24].

 

MBSR

 

All included RCTs used MBSR interventions that were adapted from the original MBSR program developed at the University of Massachusetts. The two trials of older adults [25,26] utilized adapted 8-week programs with weekly 90-minute sessions. Roughly half of each session was dedicated to mindful meditation (body scan, sitting meditation, walking meditation), the other half to education and discussion. The programs did not incorporate yoga or an all-day silent retreat.

 

Patients in the trial on failed back surgery syndrome [24] participated in a MBSR intervention including 8 weekly 2.5 to 3.5-hour sessions and an additional 6-hour session in the 6th week. Besides education, the program included mindful meditation (sitting meditation, walking meditation) and gentle yoga.

 

Daily homework of 45 minutes meditation was recommended 6 days a week in all 3 trials [24-26].

 

In all 3 trials, MBSR was taught by 2 instructors each who completed the MBSR teacher training and had a long-standing meditation practice. In 2 trials, 1 of the instructors was a physician [25,26], while in the other trial 1 instructor was an osteopathic physician and the other 1 held a master�s degree in psychotherapy [24].

 

Control Conditions

 

Two RCTs compared MBSR to a waiting list control group [24,25]. Control patients did not receive any specific treatment during the course of the study but were offered the MBSR intervention after the post-treatment assessment. One of the RCTs of older adults [26] compared MBSR to a health education program that controlled for time, group size, and homework. Roughly half of each 90-minute session was dedicated to health-related, mainly back pain-related, education, the other half to mental exercise and discussion. Patients were provided a book and a games console with a “brain training” program as homework.

 

Co-Interventions

 

One RCT explicitly allowed patients in both groups to use additional usual medical care including pain medication during the course of the study [24]. The other 2 RCTs did not specify (dis-)allowance or actual use of co-interventions during the course of the study [25,26].

 

Outcome Measures

 

All 3 RCTs assessed post-intervention pain intensity using visual analog scales (VAS) [24], the McGill Pain questionnaire (MPQ) total score [25,26] or the MPQ current pain score [26]. Disability was also assessed post-intervention by all 3 RCTs, all using the Roland Morris Disability Questionnaire (RMDQ). Two RCTs [24,25] measured pain acceptance post-treatment using the Chronic Pain Acceptance Questionnaire (CPAQ). Two RCTs assessed quality of life [25,26] with the Medical Outcomes Study 36-item short-form survey (SF-36). One trial assessed analgesic use with an analgesic medication log [24] and sleep quality with the Pittsburgh Sleep Quality Index (PSQI) [24]. Another trial assessed self-efficacy using the Chronic Pain Self-Efficacy Scale (CPSS) [26] and mindfulness using the Mindful Attention Awareness Scale (MAAS) and the Five Facet Mindfulness Questionnaire (FFMQ) [26].

 

Only one RCT [26] reported group comparisons at longer-term follow-up.

 

Risk of Bias

 

Risk of bias for each study is shown in Table ?2. Risk of selection bias was low in all included RCTs. Only 1 study [26] reported blinding of outcome assessment and no study reported blinding of participants and personnel. However, one study [26] used an adequate active comparison group and treatment expectancy was comparably high in intervention and control group at baseline and post-treatment. Therefore it was judged that outcomes in this study were not likely to be influenced by lack of blinding. Risk of attrition bias was high in 2 out of 3 RCTs, while risk of reporting bias and other bias were low in all 3 RCTs.

 

Table 2 Risk of Bias Assessment of the Included Studies

Table 2: Risk of bias assessment of the included studies using the Cochrane risk of bias tool.

 

Effectiveness of MBSR Compared to No Treatment for Chronic Low Back Pain

 

One trial on mixed non-specific and specific chronic low back pain in older adults did not find any differences between MBSR and a wait-listed control group on pain intensity on the MPQ or back-specific disability as assessed with the RMDQ [25]. While disability improved within the MBSR group, group differences were not of clinical importance. This RCT reported MBSR being superior to wait-list in improving physical functioning, but not bodily pain, global health composite, physical health composite, or mental health composite on the SF-36. Pain acceptance on the CPAQ was reported to be significantly higher after MBSR as compared to no treatment. No differences in outcomes within the MBSR group were reported from end of intervention to 1-month follow-up.

 

One RCT on failed back surgery syndrome reported significant group differences between MBSR and a wait-listed control group in change of pain intensity immediately after the intervention period [24]. The difference in change scores between groups (MBSR: -6.9 cm vs. wait-list: -0.2 cm; sum score of 3 10 cm-VAS) was deemed clinically important. Significant and clinically important group differences after the intervention also were reported for change in disability on the RMDQ (MBSR: -3.6 vs. wait-list +0.1). Further, larger improvements were found for pain acceptance on the CPAQ, medication intake, and sleep quality on the PSQI for the MBSR group. While no group differences were assessed at 40-week follow-up, improvements in the MBSR group were reported to persist at this time point.

 

Effectiveness of MBSR Compared to Health Education for Chronic Low Back Pain

 

One RCT on mixed non-specific and specific chronic low back pain in older adults reported no differences between MBSR and health education on pain intensity on the MPQ or back-specific disability on the RMDQ [26]. While disability improved in both groups, group differences did not reach clinical importance. Group differences at short-term follow-up were reported for emotional role functioning on the SF-36, but not for bodily pain on the SF-36, self-efficacy on the CPSS or mindfulness on the MAAS or the FFMQ [26]. No group differences in disability, pain intensity, self-efficacy, quality of life or mindfulness were found at 4-month follow-up.

 

Safety

 

One RCT did neither report occurrence (or absence) of adverse events nor reasons for drop-outs [24]. Another RCT reported that no serious adverse events occurred [25]. However, 3 patients dropped out from the MBSR group due to unexpected health or family obligations [25]. The third RCT reported that there were no adverse events or drop-outs due to health obligations [26].

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

Chronic stress can lead to prolonged muscle tension and other health issues. Too much tension in the muscles can begin to place unnecessary amounts of pressure on the bony structures of the body, which may lead to the misalignment of the spine, known as a subluxation. Chronic stress can also lead to nerve irritation. Chiropractic treatment is an effective stress management procedure because careful spinal adjustments and manual manipulations release muscle tension and help restore the body to a more balanced and relaxed state. Chiropractic treatment also helps reduce spinal nerve irritation as well as improve blood circulation. A healthy and balanced spine can be the key to effective stress management.

 

Discussion

 

This systematic review found only limited evidence that MBSR can provide short-term relief of pain and back-related disability in low back pain patients. Statistical significant and clinically relevant group differences were reported in only 1 out of 3 RCTs. Single studies reported effects on physical or emotional well-being but overall, only little effects on quality of life were reported. These results are only partly in line with a recent meta-analysis on mindfulness-based interventions for chronic pain that found MBSR to be superior to controls in reducing pain intensity and increasing physical wellbeing but not in increasing quality of life [14]. However, this meta-analysis included only 1 of the RCTs included in the present review [25].

 

Methodological differences between the included RCTs might explain some of the differences in results: firstly, different control groups were chosen; while 1 RCT used an adequate active control group [26], 2 RCTs compared MBSR to no treatment [24,25] and 1 of those was the only study that reported positive intervention effects on most of the study outcomes [24]. Secondly, another source of heterogeneity are differences in inclusion criteria between studies: the study that showed favorable effects of MBSR included a sample of highly chronified specific low back pain patients [24] while the 2 trials that showed little effects included patients with specific or unspecific low back pain [25,26]. Moreover, the 2 RCTs that did not report significant group differences in pain intensity or back-related disability included only older adults [25,26] while no age restriction was posed in the only RCT that reported effectiveness of MBSR for most outcome measures [24]. It has been argued that standard pain measurement instruments might not be suitable for elderly patients [27,28]. Specialized comprehensive approaches might be needed to correctly assess pain intensity in elderly patients [28]. Thirdly, the 2 RCTs that did not report significant group differences did not include yoga or an all-day retreat in their MBSR program [25,26]. Yoga has been reported to increase back-related function and to decrease disability in patients suffering from low back pain [29,30]. As the only RCT that reported favorable effects of MBSR on functional disability actually included yoga in the MBSR program [24], yoga might be crucial for this effect. Further research should include dismantling studies that separately evaluate the effects of different components of MBSR such as mindful meditation and yoga.

 

Although the use of pain intensity and disability as main outcome measures is in accordance with the IMMPACT recommendations [31], pain relief is not the main aim of MBSR [14]. Instead, patients are guided to accept all varieties of experience, be them pleasant or unpleasant, without elaboration or judgment [5,6]. In accordance with this approach, 2 RCTs reported increased pain acceptance after MBSR interventions [24,25]. Pain acceptance describes patients� attempt to maintain function in spite of their pain as far as possible [32]. Higher pain acceptance has been found to be associated with lower pain intensity and disability [33]. However, whether or not pain acceptance is a mechanism by which MBSR relieves pain in low back pain patients is beyond the scope of this review.

 

At the moment there is no evidence for longer-term effects of MBSR in low back pain. More RCTs with longer follow-ups are needed.

 

Generally, adverse events and reasons for drop-outs were poorly reported. This is unsatisfying since safety is a major issue in evaluating therapies. Further trials should put a focus on detailed reporting of safety data.

 

All included RCTs used MBSR as an intervention. No RCT assessing the effectiveness of MBCT in low back pain patients could be located. This is in line with the aforementioned meta-analysis of chronic pain that could not locate any trials on MBCT either [14].

 

The evidence found in this review is clearly limited due to several reasons. Firstly, the total number of eligible RCTs was small and clinical heterogeneity was high between RCTs. Thus, no meta-analysis could be performed. This review only included trials that were published in peer reviewed scientific journals. Therefore, some RCTs that were published in �grey literature� or conference proceedings only might have been missed. Secondly, the total number of included patients was low. No study included more than 20 patients in each group. More large RCTs are needed to definitely judge the effects of MBSR in low back pain. Thirdly, the evidence was suspect to high attrition bias. Fourthly, 2 out of 3 RCTs compared MBSR with wait-lists. While there is limited evidence that MBSR is effective in low back pain, more research is needed to evaluate superiority or inferiority of MBSR to other active treatments.

 

Conclusions

 

This systematic review found only inconclusive evidence of short-term effectiveness of MBSR in improving pain intensity and disability in patients suffering from low back pain. However, there is limited evidence from 2 wait-list controlled trials that MBSR can improve pain acceptance. Further trials with larger sample size, active control groups and longer follow-up are needed before the evidence for MBSR in low back pain can conclusively be judged.

 

Competing Interests

 

All authors disclose any commercial association that might create a conflict of interest in connection with the submitted manuscript. There is especially no competing financial interest for any of the authors.

 

Authors� Contributions

 

HC was responsible for conception and design of the review, carried out the literature search, performed data analysis, and drafted the manuscript. HH and RL performed data extraction and assessment of risk of bias, participated in conception and design of the review, and critically revised the manuscript. GD participated in conception and design of the review, and critically revised the manuscript. All authors read and approved the final manuscript.

 

Pre-Publication History

 

The pre-publication history for this paper can be accessed here:

www.biomedcentral.com/1472-6882/12/162/prepub

 

Acknowledgements

 

This review was partly supported by a grant from the Rut- and Klaus-Bahlsen-Foundation. The founding source had no influence on the design or conduct of the review; the collection, analysis, or interpretation of the data; or in the draft, revision, or approval of the manuscript.

 

Stress Management: an Exploratory Study of Chiropractic Patients

 

Abstract

 

Background

 

Stress is a recognized variable in the diagnosis, management, and prognosis of musculoskeletal conditions; chiropractic care is reputed to be successful in the management of stress-related visceral conditions. It may be useful for chiropractors to include stress management as a clinical care option.

 

Objective

 

To explore screening tools to aid stress self-assessment, investigate patients’ perceptions of stress management as a chiropractic care option, and examine which stress-management strategies chiropractic patients perceive as most useful.

 

Design

 

A multiphase qualitative study with purposive sampling of chiropractic clinics to maximize the diversity of the patient population. Convenience sampling of patients was undertaken in a Western Australian case study, an inner city, and a national exploratory study. Data for the case study were collected by semistructured interview. Questionnaires and a self-assessed stress-management task were used to collect data from the inner city and national studies. Data was thematically analyzed, and results were triangulated.

 

Results

 

The sample size of chiropractic patients in the West Australian case study was 48, 15 in the Western Australia exploratory study and 36 in the national study. A number of chiropractic patients participating in this study perceive themselves to be stressed and were interested in having stress-management strategies included in their chiropractic care. Individual patients preferred different stress-management options. This qualitative study found little justification for routinely using a stress-assessment technique more complex than asking the patient to rate his or her stress level as absent, minimal, moderate, or severe. Exercise, particularly walking, was found to be a prevalent pasttime among participants in the case study.

 

Conclusion

 

This study was too small to warrant statistical analysis; nonetheless, the results of this study are relevant because some patients believe they would benefit from chiropractic care that includes information about stress-management strategies.

 

In conclusion, chiropractic treatment is growing as a popular stress management option. When we become stressed, the spine can build up continuous tension which can ultimately affect our overall health and wellness. While the research studies above require additional evidence to support the findings, chiropractic treatment has been considered by more individuals as an alternative option for stress management methods and techniques. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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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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EXTRA IMPORTANT TOPIC: Managing Workplace Stress!

 

 

MORE IMPORTANT TOPICS: EXTRA EXTRA: Choosing Chiropractic? | Familia Dominguez | Patients | El Paso, TX Chiropractor

 

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18. Vowles KE, McCracken LM. Acceptance and values-based action in chronic pain: a study of treatment effectiveness and process. J Consult Clin Psychol. 2008;76:397�407. [PubMed]
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Stress Management & Low Back Pain in El Paso, TX

Stress Management & Low Back Pain in El Paso, TX

by | Back Pain, Physical Rehabilitation, Randomized Controlled Trial, Research Studies, Treatments

People experience stress on a regular basis. From worries about finances or employment to problems with your kids or significant other, even concerns about the condition of the world, can register as stressors for many individuals. Stress causes both acute (immediate) and chronic (long-term) health issues, including low back pain, a common symptom frequently reported by many patients who suffer from constant stress. Fortunately, several holistic treatment approaches, including chiropractic care, can help alleviate both the feelings and effect of stress, ultimately guiding people through proper stress management methods.

 

Symptoms of Stress

 

Stress triggers the body’s fight or flight response. The adrenaline surge you experience after hearing a loud sound is simply one of the remaining characteristics of our ancestors, afraid that that loud noise came from something which wanted to eat them.

 

Stress causes a number of physical changes in the body, starting with the brain. The heart rate increases and starts directing blood to the other extremities. Hearing and eyesight become more acute. And the adrenal glands begin secreting adrenaline as a means of preparing the body for physical exertion. This is exactly what the “flight or fight response” really means.

 

If you are walking alone at night and hear footsteps behind you, the fight of flight response can be incredibly effective towards your safety. However, if you experience prolonged stress, this sort of physical reaction contributes to a variety of health issues, such as high blood pressure, diabetes, a compromised immune system and muscle tissue damage. That’s because your body doesn’t recognize that there are different kinds of stress; it only knows that stress represents danger and it reacts accordingly.

 

Stress Management with Chiropractic Care

 

Chiropractic care can help improve as well as manage many symptoms of stress. This is because the spine is the root of the nervous system. Spinal adjustments and manual manipulations calm the fight or flight response by activating the parasympathetic system. Additionally, chiropractic can relieve pain and muscular tension, improve circulation, and correct spinal misalignments. These benefits all combine to ease the symptoms of stress, which reduces how stressed the patient feels.

 

A Well-Rounded Strategy

 

Chiropractors guide their patients through an assortment of stress management procedures, including dietary changes, exercise, meditation, and relaxation methods. A healthy diet can help the body handle an assortment of issues, including stress. Following a diet rich in fruits and vegetables, lean proteins, and complex carbohydrates, with minimal processed and prepackaged foods, can significantly improve overall health and wellness. Exercise is an effective stress reliever. The energy you expend through exercise relieves tension as well as the energy of stress. It also releases endorphins, which help elevate mood. Yoga is an especially effective kind of physical activity for relieving stress.

 

Meditation can be performed in a variety of ways and it can be practiced by various healthcare professionals. For some, writing in a journal is a kind of meditation, while others are more conventional in their strategy. Many relaxation techniques are closely linked to meditation, such as breathing exercises, releasing muscle tension, and listening to calming music or nature sounds.

 

  • Breathing exercises are simple and offer immediate stress relief. Begin with inhaling slowly and deeply through your nose, while counting to six and extending your stomach. Hold your breath for a count of four, then release the breath through your mouth, counting to six again. Repeat the cycle for three to five occasions.
  • Release muscle tension through a technique known as “progressive muscle relaxation”. Find a comfortable position, either sitting with your feet on the ground, or lying on your back. Work your way through each muscle group, beginning at your toes or your head, tensing the muscle for a count of five, and then releasing. Wait 30 minutes and then proceed to the next muscle group. Wondering how to tense the muscles of your face? For the face, raise your eyebrows as large as you can and feel the tension in your forehead and scalp. For the central portion of your own face, squint your eyes and wrinkle your nose and mouth. Finally, for the lower face, clench your teeth and pull back the corners of your mouth.
  • Soothing sounds like instrumental music or nature sounds help relax the body and the brain.

 

Maintaining a balanced lifestyle while also incorporating chiropractic care as a stress management strategy is an effective way to help improve and cope with the symptoms of stress. Reducing stress can ultimately help maintain your overall well-being.

 

Mindfulness-Based Stress Reduction and Cognitive-Behavioral Therapy for Chronic Low Back Pain: Similar Effects on Mindfulness, Catastrophizing, Self-Efficacy and Acceptance in a Randomized Controlled Trial

 

Abstract

 

Cognitive-behavioral therapy (CBT) is believed to improve chronic pain problems by decreasing patient catastrophizing and increasing patient self-efficacy for managing pain. Mindfulness-based stress reduction (MBSR) is believed to benefit chronic pain patients by increasing mindfulness and pain acceptance. However, little is known about how these therapeutic mechanism variables relate to each other or whether they are differentially impacted by MBSR versus CBT. In a randomized controlled trial comparing MBSR, CBT, and usual care (UC) for adults aged 20-70 years with chronic low back pain (CLBP) (N = 342), we examined (1) baseline relationships among measures of catastrophizing, self-efficacy, acceptance, and mindfulness; and (2) changes on these measures in the 3 treatment groups. At baseline, catastrophizing was associated negatively with self-efficacy, acceptance, and 3 aspects of mindfulness (non-reactivity, non-judging, and acting with awareness; all P-values <0.01). Acceptance was associated positively with self-efficacy (P < 0.01) and mindfulness (P-values < 0.05) measures. Catastrophizing decreased slightly more post-treatment with MBSR than with CBT or UC (omnibus P = 0.002). Both treatments were effective compared with UC in decreasing catastrophizing at 52 weeks (omnibus P = 0.001). In both the entire randomized sample and the sub-sample of participants who attended ?6 of the 8 MBSR or CBT sessions, differences between MBSR and CBT at up to 52 weeks were few, small in size, and of questionable clinical meaningfulness. The results indicate overlap across measures of catastrophizing, self-efficacy, acceptance, and mindfulness, and similar effects of MBSR and CBT on these measures among individuals with CLBP.

 

Keywords: chronic back pain, self-efficacy, mindfulness, acceptance, catastrophizing, CBT, MBSR

 

Introduction

 

Cognitive-behavioral therapy (CBT) has been demonstrated effective, and is widely recommended, for chronic pain problems.[20] Mindfulness-based interventions (MBIs) also show promise for patients with chronic pain[12,14,25,44,65] and their use by this population is increasing. Understanding the mechanisms of action of psychosocial treatments for chronic pain and commonalities in these mechanisms across different therapies is critical to improving the effectiveness and efficiency of these treatments.[27,52] Key mechanisms of action of CBT for chronic pain include decreased catastrophizing and increased self-efficacy for managing pain.[6-8,56] Increased mindfulness is considered a central mechanism of change in MBIs,[14,26,30] which also increase pain acceptance.[16,21,27,38,59] However, little is known about the associations among pain catastrophizing, self-efficacy, acceptance, and mindfulness prior to psychosocial treatment or about differences in effects of CBT versus MBIs on these variables.

 

There is some evidence suggesting significant associations among these therapeutic mechanism variables. Evidence regarding relationships between catastrophizing and mindfulness is mixed. Some studies[10,18,46] have found negative associations between measures of pain catastrophizing and mindfulness. However, others found no significant relationship[19] or associations (inverse) between catastrophizing and some aspects of mindfulness (non-judging, non-reactivity, and acting with awareness) but not others (e.g., observing).[18] Catastrophizing has also been reported to be associated negatively with pain acceptance.[15,22,60] In a pain clinic sample, general acceptance of psychological experiences was associated negatively with catastrophizing and positively with mindfulness.[19] Pain self-efficacy has been observed to be correlated positively with acceptance and negatively with catastrophizing.[22]

 

Further suggesting overlap across mechanisms of different psychosocial treatments for chronic pain, increases in mindfulness[10] and acceptance[1,64] have been found after cognitive-behavioral pain treatments, and reductions in catastrophizing have been observed after mindfulness-based pain management programs.[17,24,37] Little research has examined effects of MBIs for chronic pain on self-efficacy, although a small pilot study of migraine patients found greater increases in self-efficacy with Mindfulness-Based Stress Reduction (MBSR) training than with usual care.[63] We were unable to identify any studies of the relationships among all these therapeutic mechanism variables or of changes in all these variables with CBT versus an MBI for chronic pain.

 

The aim of this study was to replicate and extend prior research by using data from a randomized controlled trial (RCT) comparing MBSR, CBT, and usual care (UC) for chronic low back pain (CLBP)[12] to examine: (1) baseline relationships among measures of mindfulness and pain catastrophizing, self-efficacy, and acceptance; and (2) short- and long-term changes on these measures in the 3 treatment groups. Based on theory and previous research, we hypothesized that: (1) at baseline, catastrophizing would be inversely related to acceptance, self-efficacy, and 3 dimensions of mindfulness (non-reactivity, non-judging, acting with awareness), but not associated with the observing dimension of mindfulness; (2) at baseline, acceptance would be associated positively with self-efficacy; and (3) from baseline to 26 and 52 weeks, acceptance and mindfulness would increase more with MBSR than with CBT and UC, and catastrophizing would decrease more and self-efficacy would increase more with CBT than with MBSR and UC.

 

Methods

 

Setting, Participants and Procedures

 

Study participants were enrolled in an RCT comparing group MBSR, group CBT, and UC for non-specific chronic back pain between September 2012 and April 2014. We previously reported details of the study methods,[13] Consolidated Standards of Reporting Trials (CONSORT) flow diagram,[12] and outcomes.[12] In brief, participants were recruited from Group Health, an integrated healthcare system in Washington State, and from mailings to residents of communities served by Group Health. Eligibility criteria included age 20 – 70 years, back pain for at least 3 months, patient-rated bothersomeness of pain during the previous week ?4 (0 – 10 scale), and patient-rated pain interference with activities during the previous week ?3 (0 – 10 scale). We used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)43 diagnostic codes from electronic medical records (EMR) of visits in the previous year and telephone screening to exclude patients with specific causes of low back pain. Exclusion criteria also included pregnancy, spine surgery in the previous 2 years, disability compensation or litigation, fibromyalgia or cancer diagnosis, other major medical condition, plans to see a medical specialist for back pain, inability to read or speak English, and participation in a �mind-body� treatment for back pain in the past year. Potential participants were told that they would be randomized to one of �two different widely-used pain self-management programs that have been found helpful for reducing pain and making it easier to carry out daily activities� or to continued usual care. Those assigned to MBSR or CBT were unaware of the specific treatment they would receive until the first intervention session. The study was approved by the Group Health institutional review board and all participants provided informed consent.

 

Participants were randomized to the MBSR, CBT, or UC conditions. Randomization was stratified based on the baseline value of the primary outcome, a modified version of the Roland Disability Questionnaire (RDQ),[42] into 2 back pain-related physical limitation stratification groups: moderate (RDQ score ?12 on the 0 – 23 scale) and high (RDQ scores ?13). To mitigate possible disappointment with not being randomized to CBT or MBSR, participants randomized to UC received $50 compensation. Data were collected from participants in computer-assisted telephone interviews by trained survey staff. All participants were paid $20 for each interview completed.

 

Measures

 

Participants provided descriptive information at the screening and baseline interviews, and completed the study measures at baseline (before randomization) and 8 (post-treatment), 26 (the primary study endpoint), and 52 weeks post-randomization. Participants also completed a subset of the measures at 4 weeks, but these data were not examined for the current report.

 

Descriptive Measures and Covariates

 

The screening and baseline interviews assessed, among other variables not analyzed for the present study, sociodemographic characteristics (age, gender, race, ethnicity, education, work status); pain duration (defined as length of time since a period of 1 or more weeks without low back pain); and number of days with back pain in the past 6 months. In this report, we describe the sample at baseline on these measures and on the primary outcome measures in the RCT: the modified Roland-Morris Disability Questionnaire (RDQ)[42] and a numerical rating of back pain bothersomeness. The RDQ, a widely-used measure of back pain-related functional limitations, asks whether 24 specific activities are limited today by back pain (yes or no).[45] We used a modified version that included 23 items[42] and asked about the previous week rather than today only. Back pain bothersomeness was measured by participants� ratings of how bothersome their back pain was during the previous week on a 0 to 10 numerical rating scale (0 = �not at all bothersome� and 10 = �extremely bothersome�). The covariates for the current report were the same as those in our prior analyses of the interventions� effects on the outcomes:[12] age, gender, education, and pain duration (less than one year versus at least one year since experiencing 1 week without low back pain). We decided a priori to control for these variables because of their potential to affect the therapeutic mechanism measures, participant response to treatment, and/or likelihood of obtaining follow-up information.

 

Measures of Potential Therapeutic Mechanisms

 

Mindfulness. Mindfulness has been defined as the awareness that emerges through purposeful, non-judgmental attention to the present moment.[29] We administered 4 subscales of the Five Facet Mindfulness Questionnaire-Short Form (FFMQ-SF):[5] Observing (noticing internal and external experiences; 4 items); Acting with Awareness (attending to present moment activities, as contrasted to behaving automatically while attention is focused elsewhere; 5 items); Non-reactivity (non-reactivity to inner experiences: allowing thoughts and feelings to arise and pass away without attachment or aversion; 5 items); and Non-judging (non-judging of inner experiences: engaging in a non-evaluative stance towards thoughts, emotions, and feelings; 5-item scale; however, one question [�I make judgments about whether my thoughts are good or bad�] inadvertently was not asked.). The FFMQ-SF has been demonstrated to be reliable, valid, and sensitive to change.[5] Participants rated their opinion of what generally is true for them in terms of their tendency to be mindful in their daily lives (scale from 1 = �never or very rarely true� to 5 = �very often or always true�). For each scale, the score was calculated as the mean of the answered items and thus the possible range was 1-5, with higher scores indicating higher levels of the mindfulness dimension. Prior studies have used sum scores rather than means, but we elected to use mean scores given the greater ease of interpretation.

 

Pain catastrophizing. The Pain Catastrophizing Scale (PCS) is a 13-item measure assessing pain-related catastrophizing, including rumination, magnification, and helplessness.[50] Participants rated the degree to which they had certain thoughts and feelings when experiencing pain (scale from 0 = �not at all� to 4 = �all the time�). Item responses were summed to yield a total score (possible range = 0-52). Higher scores indicate greater endorsement of catastrophic thinking in response to pain.

 

Pain acceptance. The Chronic Pain Acceptance Questionnaire-8 (CPAQ-8), an 8-item version of the 20-item Chronic Pain Acceptance Questionnaire (CPAQ), has been shown to be reliable and valid.[22,23] It has 2 scales: Activity Engagement (AE; engagement in life activities in a normal manner even while pain is being experienced) and Pain Willingness (PW; disengagement from attempts to control or avoid pain). Participants rated items on a scale from 0 (�never true�) to 6 (�always true�). Item responses were summed to create scores for each subscale (possible range 0-24) and the overall questionnaire (possible range 0-48). Higher scores indicate greater activity engagement/pain willingness/pain acceptance. Prior research suggests that the 2 subscales are moderately correlated and that each makes an independent contribution to the prediction of adjustment in people with chronic pain.[22]

 

Pain self-efficacy. The Pain Self-efficacy Questionnaire (PSEQ) consists of 10 items assessing individuals� confidence in their ability to cope with their pain and engage in activities despite their pain, each rated on a scale from 0 = �not at all confident� to 6 = �completely confident.�[39] The questionnaire has been demonstrated to be valid, reliable, and sensitive to change.[39] Item scores are summed to yield a total score (possible range 0-60); higher scores indicate greater self-efficacy.

 

Interventions

 

The 2 interventions were comparable in format (group), duration, frequency, and number of participants per group cohort. Both the MBSR and CBT interventions consisted of 8 weekly 2-hour sessions supplemented by home activities. For each intervention, we developed a therapist/instructor’s manual and participant’s workbook, both with structured and detailed content for each session. In each intervention, participants were assigned home activities and there was emphasis on incorporating intervention content in their daily lives. Participants were given materials to read at home and CDs with relevant content for home practice (e.g., meditation, body scan, and yoga in MBSR; relaxation and imagery exercises in CBT). We previously published detailed descriptions of both interventions,[12,13] but describe them briefly here.

 

MBSR

 

The MBSR intervention was modeled closely after the original program developed by Kabat-Zinn[28] and based on the 2009 MBSR instructor’s manual.[4] It consisted of 8 weekly sessions and an optional 6-hour retreat between the 6th and 7th sessions. The protocol included experiential training in mindfulness meditation and mindful yoga. All sessions included mindfulness exercises (e.g., body scan, sitting meditation) and mindful movement (most commonly, yoga).

 

CBT

 

The group CBT protocol included the techniques most commonly applied in CBT for CLBP[20,58] and used in prior studies.[11,33,41,51,53-55,57,61] The intervention included: (1) education about (a) chronic pain, (b) maladaptive thoughts (including catastrophizing) and beliefs (e.g., inability to control pain, hurt equals harm) common among individuals with chronic pain, (c) the relationships between thoughts and emotional and physical reactions, (d) sleep hygiene, and (e) relapse prevention and maintenance of gains; and (2) instruction and practice in identifying and challenging unhelpful thoughts, generating alternative appraisals that are more accurate and helpful, setting and working towards behavioral goals, abdominal breathing and progressive muscle relaxation techniques, activity pacing, thought-stopping and distraction techniques, positive coping self-statements, and coping with pain flare-ups. None of these techniques were included in the MBSR intervention, and mindfulness, meditation, and yoga techniques were not included in CBT. CBT participants were also given a book (The Pain Survival Guide[53]) and asked to read specific chapters between sessions. During each session, participants completed a personal action plan for activities to do between sessions.

 

Usual Care

 

Patients assigned to UC received no MBSR training or CBT as part of the study and received whatever health care they would customarily receive during the study period.

 

Instructors/Therapists and Treatment Fidelity Monitoring

 

As previously reported,[12] all 8 MBSR instructors received formal training in teaching MBSR from the Center for Mindfulness at the University of Massachusetts or equivalent training and had extensive previous experience teaching MBSR. The CBT intervention was conducted by 4 Ph.D.-level licensed psychologists with previous experience providing individual and group CBT to patients with chronic pain. Details of instructor training and supervision and treatment fidelity monitoring were provided previously.[12]

 

Statistical Analyses

 

We used descriptive statistics to summarize the observed baseline characteristics by randomization group, separately for the entire randomized sample and the subsample of participants who attended 6 or more of the 8 intervention classes (MBSR and CBT groups only). To examine the associations between the therapeutic mechanism measures at baseline, we calculated Spearman rho correlations for each pair of measures.

 

To estimate changes over time in the therapeutic mechanism variables, we constructed linear regression models with the change from baseline as the dependent variable, and included all post-treatment time points (8, 26, and 52 weeks) in the same model. A separate model was estimated for each therapeutic mechanism measure. Consistent with our approach for analyzing outcomes in the RCT,[12] we adjusted for age, gender, education, and baseline values of pain duration, pain bothersomeness, the modified RDQ, and the therapeutic mechanism measure of interest in that model. To estimate the treatment effect (difference between groups in change on the therapeutic mechanism measure) at each time point, the models included main effects for treatment group (CBT, MBSR, and UC) and time point (8, 26, and 52 weeks), and terms for the interactions between these variables. We used generalized estimating equations (GEE)[67] to fit the regression models, accounting for possible correlation between repeated measures from individual participants. To account for potential bias caused by differential attrition across treatment groups, our primary analysis used a 2-step GEE modeling approach to impute missing data on the therapeutic mechanism measures. This approach uses a pattern mixture model framework for non-ignorable non-response and adjusts the variance estimates in the final outcome model parameters to account for using imputed data.[62] We also, as a sensitivity analysis, conducted the regression analyses again with observed rather than imputed data to evaluate whether using imputed data had a substantial effect on the results and to allow direct comparison to other published studies.

 

The primary analysis included all randomized participants, using an intent-to-treat (ITT) approach. We repeated the regression analyses using the subsample of participants who were randomized to MBSR or CBT and who attended at least 6 of the 8 sessions of their assigned treatment (�as-treated� or �per protocol� analysis). For descriptive purposes, using regression models for the ITT sample with imputed data, we estimated mean scores (and their 95% confidence intervals [CI]) on the therapeutic mechanism variables at each time point adjusted for age, gender, education, and baseline values of pain duration, pain bothersomeness, and the modified RDQ.

 

To provide context for interpreting the results, we used t-tests and chi-square tests to compare the baseline characteristics of participants who did versus did not complete at least 6 of the 8 intervention sessions (MBSR and CBT groups combined). We compared intervention participation by group, using a chi-square test to compare the proportions of participants randomized to MBSR versus CBT who completed at least 6 of the 8 sessions.

 

Dr. Alex Jimenez’s Insight

Stress is primarily a part of the “fight or flight” response which helps the body effectively prepare for danger. When the body enters�a state of mental or emotional strain or tension due to adverse or very demanding circumstances,�a complex mix of hormones and chemicals, such as adrenaline, cortisol and norepinephrine, are secreted in order to prepare the body for physical and psychological action.�While short-term stress provides us with the necessary amount of edge required to improve our overall performance, long-term stress has been associated to a variety of health issues, including low back pain and sciatica. Stress management methods and techniques, including meditation and chiropractic care, have been demonstrated to help improve treatment outcomes of low back pain and sciatica. The following article discusses several types of stress management treatments and describes their effect on overall health and wellness.

 

Results

 

Characteristics of the Study Sample

 

As previously reported,[12] among 1,767 individuals who expressed interest in the study and were screened for eligibility, 1,425 were excluded (most commonly due to pain not present for more than 3 months and inability to attend the intervention sessions). The remaining 342 individuals enrolled and were randomized. Among the 342 individuals randomized, 298 (87.1%), 294 (86.0%), and 290 (84.8%) completed the 8-, 26-, and 52-week assessments, respectively.

 

Table 1 shows the characteristics of the sample at baseline. Among all participants, the mean age was 49 years, 66% were female, and 79% reported having had back pain for at least one year without a pain-free week. On average, PHQ-8 scores were at the threshold for mild depressive symptom severity.[32] Mean scores on the Pain Catastrophizing Scale (16-18) were below the various cut-points suggested for clinically relevant catastrophizing (e.g., 24,47 3049). Pain Self-Efficacy Scale scores were somewhat higher on average (about 5 points on the 0-60 scale) in our sample as compared with the primary care patients with low back pain enrolled in an RCT evaluating group CBT in England,[33] and about 15 points higher than among individuals with chronic pain attending a mindfulness-based pain management program in England.[17]

 

Table 1 Baseline Characteristics

 

About half of participants randomized to MBSR (50.9%) or CBT (56.3%) attended at least 6 sessions of their assigned treatment; the difference between treatments was not statistically significant (chi-square test, P = 0.42). At baseline, those randomized to MBSR and CBT who completed at least 6 sessions, as compared to those who did not, were significantly older (mean [SD] = 52.2 [10.9] versus 46.5 [13.0] years) and reported significantly lower levels of pain bothersomeness (mean [SD] = 5.7 [1.3] versus 6.4 [1.7]), disability (mean [SD] RDQ = 10.8 [4.5] versus 12.7 [5.0]), depression (mean [SD] PHQ-8 = 5.2 [4.1] versus 6.3 [4.3]), and catastrophizing (mean [SD] PCS = 15.9 [10.3] versus 18.9 [9.8]), and significantly greater pain self-efficacy (mean [SD] PSEQ = 47.8 [8.3] versus 43.2 [10.3]) and pain acceptance (CPAQ-8 total score mean [SD] = 31.3 [6.2] versus 29.0 [6.7]; CPAQ-8 Pain Willingness mean [SD] = 12.3 [4.1] versus 10.9 [4.8]) (all P-values < 0.05). They did not differ significantly on any other variable shown in Table 1.

 

Baseline Associations Between Therapeutic Mechanism Measures

 

Table 2 shows the Spearman correlations between the therapeutic mechanism measures at baseline. Our hypotheses about the baseline relationships among these measures were confirmed. Catastrophizing was correlated negatively with 3 dimensions of mindfulness (non-reactivity rho = ?0.23, non-judging rho = ?0.30, and acting with awareness rho = ?0.21; all P-values < 0.01), but not associated with the observing dimension of mindfulness (rho = ?0.01). Catastrophizing was also correlated negatively with acceptance (total CPAQ-8 score rho = ?0.55, Pain Willingness subscale rho = ?0.47, Activity Engagement subscale rho = ?0.40) and pain self-efficacy (rho = ?0.57) (all P-values < 0.01). Finally, pain self-efficacy was correlated positively with pain acceptance (total CPAQ-8 score rho = 0.65, Pain Willingness subscale rho = 0.46, Activity Engagement subscale rho = 0.58; all P-values < 0.01).

 

Table 2 Spearman rho Correlations

 

Treatment Group Differences in Changes on Therapeutic Mechanism Measures Among all Randomized Participants

 

Table 3 shows the adjusted mean changes from baseline in each study group and the adjusted mean differences between treatment groups on the therapeutic mechanism measures at each follow-up in the entire randomized sample. Figure 1 shows the adjusted mean PCS scores for each group at each time point. Contrary to our hypothesis that catastrophizing would decrease more with CBT than with MBSR, catastrophizing (PCS score) decreased significantly more from pre- to post-treatment in the MBSR group than in the CBT group (MBSR versus CBT adjusted mean [95% CI] difference in change = ?1.81 [?3.60, ?0.01]). Catastrophizing also decreased significantly more in MBSR than in UC (MBSR versus UC adjusted mean [95% CI] difference in change = ?3.30 [?5.11, ?1.50]), whereas the difference between CBT and UC was not significant. At 26 weeks, the treatment groups did not differ significantly in change in catastrophizing from baseline. However, at 52 weeks, both the MBSR and the CBT groups showed significantly greater decreases than did the UC group, and there was no significant difference between MBSR and CBT.

 

Figure 1 Adjusted Mean PCS Scores

Figure 1: Adjusted mean Pain Catastrophizing Scale (PCS) scores (and 95% confidence intervals) at baseline (pre-randomization), 8 weeks (post-treatment), 26 weeks, and 52 weeks for participants randomized to CBT, MBSR, and UC. Estimated means are adjusted for participant age, gender, education, whether or not at least 1 year since week without pain, and baseline RDQ and pain bothersomeness.

 

Table 3 Adjusted Mean Change from Baseline and Adjusted Mean Differences

 

Figure 2 shows the adjusted mean PSEQ scores for each group at each time point. Our hypothesis that self-efficacy would increase more with CBT than with MBSR and with UC was only partially confirmed. Self-efficacy (PSEQ scores) did increase significantly more from pre- to post-treatment with CBT than with UC, but not with CBT relative to the MBSR group, which also increased significantly more than did the UC group (adjusted mean [95% CI] difference in change on PSEQ from baseline for CBT versus UC = 2.69 [0.96, 4.42]; CBT versus MBSR = 0.34 [?1.43, 2.10]; MBSR versus UC = 3.03 [1.23, 4.82]) (Table 3). The omnibus test for differences across groups in self-efficacy change was not significant at 26 or 52 weeks.

 

Figure 2 Adjusted Mean PSEQ Scores

Figure 2: Adjusted mean Pain Self-Efficacy Questionnaire (PSEQ) scores (and 95% confidence intervals) at baseline (pre-randomization), 8 weeks (post-treatment), 26 weeks, and 52 weeks for participants randomized to CBT, MBSR, and UC. Estimated means are adjusted for participant age, gender, education, whether or not at least 1 year since week without pain, and baseline RDQ and pain bothersomeness.

 

Our hypothesis that acceptance would increase more with MBSR than with CBT and with UC was generally not confirmed. The omnibus test for differences across groups was not significant for the total CPAQ-8 or the Activity Engagement subscale at any time point (Table 3). The test for the Pain Willingness subscale was significant at 52 weeks only, when both the MBSR and CBT groups showed greater increases as compared with UC, but not as compared with each other (adjusted mean [95% CI] difference in change for MBSR versus UC = 1.15 [0.05, 2.24]; CBT versus UC = 1.23 [0.16, 2.30]).

 

Our hypothesis that mindfulness would increase more with MBSR than with CBT was partially confirmed. Both the MBSR and CBT groups showed greater increases as compared with UC on the FFMQ-SF Non-reactivity scale at 8 weeks (MBSR versus UC = 0.18 [0.01, 0.36]; CBT versus UC = 0.28 [0.10, 0.46]), but differences at later follow-ups were not statistically significant (Table 3, Figure 3). There was a significantly greater increase on the Non-judging scale with MBSR versus CBT (adjusted mean [95% CI] difference in change = 0.29 [0.12, 0.46]) as well as between MBSR and UC (0.32 [0.13, 0.50]) at 8 weeks, but no significant difference between groups at later time points (Figure 4). The omnibus test for differences among groups was not significant for the Acting with Awareness or Observing scales at any time point.

 

Figure 3 Adjusted Mean FFMQ-SF Non Reactivity Scores

Figure 3: Adjusted mean Five Facet Mindfulness Questionnaire-Short Form (FFMQ-SF) Non-reactivity scores (and 95% confidence intervals) at baseline (pre-randomization), 8 weeks (post-treatment), 26 weeks, and 52 weeks for participants randomized to CBT, MBSR, and UC. Estimated means are adjusted for participant age, gender, education, whether or not at least 1 year since week without pain, and baseline RDQ and pain bothersomeness.

 

Figure 4 Adjusted Mean FFMQ-SF Non Judging Scores

Figure 4: Adjusted mean Five Facet Mindfulness Questionnaire-Short Form (FFMQ-SF) Non-judging scores (and 95% confidence intervals) at baseline (pre-randomization), 8 weeks (post-treatment), 26 weeks, and 52 weeks for participants randomized to CBT, MBSR, and UC. Estimated means are adjusted for participant age, gender, education, whether or not at least 1 year since week without pain, and baseline RDQ and pain bothersomeness.

 

The sensitivity analyses using observed rather than imputed data yielded almost identical results, with 2 minor exceptions. The difference between MBSR and CBT in change in catastrophizing at 8 weeks, although similar in magnitude, was no longer statistically significant due to slight confidence interval changes. Second, the omnibus test for the CPAQ-8 Pain Willingness scale at 52 weeks was no longer statistically significant (P = 0.07).

 

Treatment Group Differences in Changes on Therapeutic Mechanism Measures Among Participants Randomized to CBT or MBSR Who Completed at Least 6 Sessions

 

Table 4 shows the adjusted mean change from baseline and adjusted mean between-group differences on the therapeutic mechanism measures at 8, 26, and 52 weeks for participants who were randomized to MBSR or CBT and completed 6 or more sessions of their assigned treatment. The differences between MBSR and CBT were similar in size to those in the ITT sample. There were only a few differences in statistical significance of the comparisons. In contrast to the results using the ITT sample, the difference between MBSR and CBT in catastrophizing (PCS) at 8 weeks was no longer statistically significant and at 52 weeks, the CBT group increased significantly more than did the MBSR group on the FFMQ-SF Observing scale (adjusted mean difference in change from baseline for MBSR versus CBT = ?0.30 [?0.53, ?0.07]). The sensitivity analyses using observed rather than imputed data yielded no meaningful differences in results.

 

Table 4 Adjusted Mean Change from Baseline and Adjusted Mean Differences

 

Discussion

 

In this analysis of data from an RCT comparing MBSR, CBT, and UC for CLBP, our hypotheses that MBSR and CBT would differentially affect measures of constructs believed to be therapeutic mechanisms generally were not confirmed. For example, our hypothesis that mindfulness would increase more with MBSR than with CBT was confirmed for only 1 of 4 measured facets of mindfulness (non-judging). Another facet, acting with awareness, increased more with CBT than with MBSR at 26 weeks. Both differences were small. Increased mindfulness after a CBT-based multidisciplinary pain program[10] was reported previously; our findings further support a view that both MBSR and CBT increase mindfulness in the short-term. We found no long-term effects of either treatment relative to UC on mindfulness.

 

Also contrary to hypothesis, catastrophizing decreased more post-treatment with MBSR than with CBT. However, the difference between treatments was small and not statistically significant at later follow-ups. Both treatments were effective compared with UC in decreasing catastrophizing at 52 weeks. Although previous studies demonstrated reductions in catastrophizing after both CBT[35,48,56,57] and mindfulness-based pain management programs,[17,24,37] ours is the first to demonstrate similar decreases for both treatments, with effects up to 1 year.

 

Increased self-efficacy has been shown to be associated with improvements in pain intensity and functioning,[6] and an important mediator of CBT benefits.[56] However, contrary to our hypothesis, pain self-efficacy did not increase more with CBT than with MBSR at any time point. Compared with UC, there were significantly greater increases in self-efficacy with both MBSR and CBT post-treatment. These results mirror previous findings of positive effects of CBT, including group CBT for back pain,[33] on self-efficacy.[3,56,57] Little research has examined self-efficacy changes after MBIs for chronic pain, although self-efficacy increased more with MBSR than with usual care for patients with migraines in a pilot study[63] and more with MBSR than with health education for CLBP in an RCT.[37] Our findings add to knowledge in this area by indicating that MBSR has short-term benefits for pain self-efficacy similar to those of CBT.

 

Prior uncontrolled studies found equivalent increases in pain acceptance after group CBT and Acceptance and Commitment Therapy64 (which, unlike traditional CBT, specifically fosters pain acceptance), and increased acceptance after CBT-based multidisciplinary pain treatment.[1,2] In our RCT, acceptance increased in all groups over time, with only 1 statistically significant difference among the 3 groups across the 3 acceptance measures and 3 follow-up time points (a greater increase with both MBSR and CBT than with UC on the Pain Willingness subscale at 52 weeks). This suggests that acceptance may increase over time regardless of treatment, although this needs to be confirmed in additional research.

 

Two possibilities could explain our previously-reported findings of generally similar effectiveness of MBSR and CBT for CLBP:[12] (1) the treatment effects on outcomes were due to different, but equally effective, therapeutic mechanisms, or (2) the treatments had similar effects on the same therapeutic mechanisms. Our current findings support the latter view. Both treatments may improve pain, function, and other outcomes through different strategies that decrease individuals� views of their pain as threatening and disruptive and encourage activity participation despite pain. MBSR and CBT differ in content, but both include relaxation techniques (e.g., progressive muscle relaxation in CBT, meditation in MBSR, breathing techniques in both) and strategies to decrease the threat value of pain (education and cognitive restructuring in CBT, accepting experiences without reactivity or judgment in MBSR). Thus, although CBT emphasizes learning skills for managing pain and decreasing negative emotional responses, and MBSR emphasizes mindfulness and meditation, both treatments may help patients relax, react less negatively to pain, and view thoughts as mental processes rather than as accurate representations of reality, thereby resulting in decreased emotional distress, activity avoidance, and pain bothersomeness.

 

Our analyses also revealed overlap among measures of different constructs believed to mediate the effects of MBSR and CBT on chronic pain outcomes. As hypothesized, prior to treatment, pain catastrophizing was associated negatively with pain self-efficacy, pain acceptance, and 3 dimensions of mindfulness (non-reactivity, non-judging, and acting with awareness), and pain acceptance was associated positively with pain self-efficacy. Pain acceptance and self-efficacy were also associated positively with measures of mindfulness. Our results are consistent with prior observations of negative associations between measures of catastrophizing and acceptance,[15,19,60] negative correlations between measures of catastrophizing and mindfulness,[10,46,18] and positive associations between measures of pain acceptance and mindfulness.[19]

 

As a group, to the extent that these measures reflect their intended constructs, these findings support a view of catastrophizing as inversely associated with two related constructs that reflect participation in customary activities despite pain but differ in emphasis on disengagement from attempts to control pain: pain acceptance (disengagement from attempts to control pain and participation in activities despite pain) and self-efficacy (confidence in ability to manage pain and participate in customary activities). The similarity of some questionnaire items further supports this view and likely contributes to the observed associations. For example, both the CPAQ-8 and the PSEQ contain items about doing normal activities despite pain. Furthermore, there is an empirical and conceptual basis for a view of catastrophizing (focus on pain with highly negative cognitive and affective responses) as also inversely associated with mindfulness (i.e., awareness of stimuli without judgment or reactivity), and for viewing mindfulness as consistent with, but distinct from, acceptance and self-efficacy. Further work is needed to clarify the relationships between these theoretical constructs and the extent to which their measures assess (a) constructs that are related but theoretically and clinically distinct versus (b) different aspects of an overarching theoretical construct.

 

It remains possible that MBSR and CBT differentially affect important mediators not assessed in this study. Our results highlight the need for further research to more definitively identify the mediators of the effects of MBSR and CBT on different pain outcomes, develop measures that assess these mediators most comprehensively and efficiently, better understand the relationships among therapeutic mechanism variables in affecting outcomes (e.g., decreased catastrophizing may mediate the effect of mindfulness on disability[10]), and refine psychosocial treatments to more effectively and efficiently impact these mediators. Research is also needed to identify patient characteristics associated with response to different psychosocial interventions for chronic pain.

 

Several study limitations warrant discussion. Participants had low baseline levels of psychosocial distress (e.g., catastrophizing, depression) and we studied group CBT, which has demonstrated efficacy,[33,40,55] resource-efficiency, and potential social benefits, but which may be less effective than individual CBT.[36,66] The results may not generalize to more distressed populations (e.g., pain clinic patients), which would have more room to improve on measures of maladaptive functioning and greater potential for treatments to differentially affect these measures, or to comparisons of MBSR with individual CBT.

 

Only somewhat over half of the participants randomized to MBSR or CBT attended at least 6 of the 8 sessions. Results could differ in studies with higher rates of treatment adherence; however, our results in �as-treated� analyses generally mirrored those of ITT analyses. Treatment adherence has been shown to be associated with benefits from both CBT for chronic back pain[31] and MBSR.[9] Research is needed to identify ways to increase MBSR and CBT session attendance, and to determine whether treatment effects on therapeutic mechanism and outcome variables are strengthened with greater adherence and practice.

 

Finally, our measures may not have adequately captured the intended constructs. For example, our mindfulness and pain acceptance measures were short forms of original measures; although these short forms have demonstrated reliability and validity, the original measures or other measures of these constructs might perform differently. Lauwerier et al.[34] note several problems with the CPAQ-8 Pain Willingness scale, including under-representation of pain willingness items. Furthermore, pain acceptance is measured differently across different pain acceptance measures, possibly reflecting differences in definitions.[34]

 

In sum, this is the first study to examine relationships among measures of key hypothesized mechanisms of MBSR and CBT for chronic pain – mindfulness and pain catastrophizing, self-efficacy, and acceptance – and to examine changes in these measures among participants in an RCT comparing MBSR and CBT for chronic pain. The catastrophizing measure was inversely associated with moderately inter-related measures of acceptance, self-efficacy, and mindfulness. In this sample of individuals with generally low levels of psychosocial distress at baseline, MBSR and CBT had similar short- and long-term effects on these measures. Measures of catastrophizing, acceptance, self-efficacy, and mindfulness may tap different aspects of a continuum of cognitive, affective, and behavioral responses to pain, with catastrophizing and activity avoidance at one end of the continuum and continued participation in usual activities and lack of negative cognitive and affective reactivity to pain at the other. Both MBSR and CBT may have therapeutic benefits by helping individuals with chronic pain shift from the former to the latter. Our results suggest the potential value of refining both measures and models of mechanisms of psychosocial pain treatments to more comprehensively and efficiently capture key constructs important in adaptation to chronic pain.

 

Summary

 

MBSR and CBT had similar short- and long-term effects on measures of mindfulness and pain catastrophizing, self-efficacy, and acceptance.

 

Acknowledgements

 

Research reported in this publication was supported by the National Center for Complementary & Integrative Health of the National Institutes of Health under Award Number R01AT006226. Preliminary results related to this study were presented in a poster at the 34th annual meeting of the American Pain Society, Palm Springs, May 2015 (Turner, J., Sherman, K., Anderson, M., Balderson, B., Cook, A., and Cherkin, D.: Catastrophizing, pain self-efficacy, mindfulness, and acceptance: Relationships and changes among individuals receiving CBT, MBSR, or usual care for chronic back pain).

 

Footnotes

 

Conflict of interest statement: Judith Turner receives royalties from PAR, Inc. on sales of the Chronic Pain Coping Inventory (CPCI) and CPCI/Survey of Pain Attitudes (SOPA) score report software. The other authors report no conflicts of interest.

 

In conclusion, stress is part of an essential response necessary to keep our body’s on edge in the case of danger, however, constant stress when there’s no real danger can become a real issue for many individuals, especially when symptoms of low back pain, among others begin to manifest. The purpose of the article above was to determine the effectiveness of stress management in the treatment of low back pain. Ultimately, stress management was concluded to help with treatment. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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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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IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

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

 

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Cheerleaders Benefit From Chiropractic Treatment In El Paso, TX.

Cheerleaders Benefit From Chiropractic Treatment In El Paso, TX.

by | Athletes, Chiropractic, Mobility & Flexibility, Physical Rehabilitation, PUSH-as-Rx

When we think of cheerleaders we usually think of pretty girls in colorful outfits, pom pom’s in hand, cheering for their team. They are way more than that though. Cheerleaders are serious athletes.

It has taken a while, but the public is finally starting to realize just how true this is. Data collected by the National Center for Catastrophic Sports Injury Research (NCCSIR), between 1982 and 2009 cheerleaders made up for more than 70 percent of catastrophic injuries in women�s college sports. At the high school level that number exceeded 60 percent.

Some claim that this high percentage of injuring among cheerleaders to be due to lax regulations at the state level. Some states refuse to recognize cheerleading as a sport and organizations such as the NCAA don�t either.

This leaves an already potentially dangerous activity without proper oversight of the government or regulating agencies. It also means that some people who manage cheer squads and organize competitions are not required to get the same coaching and safety training standards that those in other sports do.

Since chiropractic treats the whole body through not just structurally via spinal adjustments, but also through soft tissue techniques, patients can receive complete care after an injury and during rehabilitation. Cheerleaders are finding that chiropractic treatment provides numerous benefits and can even make them better athletes.

Cheerleaders

Chiropractic Helps To Improve Range Of Motion

Chiropractic care helps to improve a person�s range of motion which in turn helps to prevent injury and relieve the pain of injury. Chiropractic is growing in its popularity within the field of sports medicine because of its effectiveness. A 2010 study published in The Journal of the Canadian Chiropractic Association showed that chiropractic made a significant difference in performance.

Chiropractic Helps To Prevent Injury

Even when no injury is present, athletes can benefit from chiropractic care. This is especially true in high impact sports like cheerleading where athletes push their bodies beyond limits through acrobatics and some of the strenuous tricks that they do in the course of their sport. Chiropractic helps to loosen muscles, making them more pliable and flexible, thus less prone to injury.

cheerleaders el paso tx.

Chiropractic Helps To Relieve Pain From Injury

A study published in the Journal of Manipulative and Physiological Therapeutics in March 2011 shows that chiropractic for pain relief can alleviate the pain of hamstring injury. The study was conducted over the course of a football season and involved 43 professional cheerleaders for football various football teams.

Throughout the study the cheerleaders received specific exercise intervention. At the end of the study those who had reported pain due to a hamstring injury experienced significant pain reduction after receiving chiropractic treatment.

Chiropractic Can Increase Physical Strength

While chiropractic is typically considered a therapy for alleviating skeletal and muscular complaints, a study in 2011 showed that it can also improve physical strength. The study involved judo athletes competing at the national level who used cervical spinal manipulative therapy (SMT). The final results of the study showed a 16 percent improvement in grip strength among the athletes who received only three SMT sessions.

The case for chiropractic treatment for athletes is very strong. It can help during training, recovery from injury, rehabilitation, and at every point in between. Although cheerleaders are still in their infancy of being recognized as serious athletes, the case for chiropractic care as a viable sports medicine therapy to improve performance and recover from injury is significant. The benefits that cheerleaders can receive from chiropractic treatment, as we can see, can really give them something to cheer about both on the field and off.

Cheerleader Discusses Chiropractic Treatment

Rapid Pain Relief for Herniated Discs in El Paso, TX

Rapid Pain Relief for Herniated Discs in El Paso, TX

by | Cohort Studies, Conditions Treated, Herniated Disc, Physical Rehabilitation, Research Studies, Spinal Decompression Treatments, Treatments

Herniated discs are a debilitating condition characterized by pain, numbness and weakness in one or more limbs. While some people may experience no pain at all, those that do may often wish for fast pain relief to avoid long periods of sick leave from their jobs. Many healthcare professionals recommend surgery for patients with persistent and/or worsening herniated disc symptoms but other non-operative treatment options can help treat disc herniations. The purpose of the following article is to demonstrate how a�structured physiotherapy treatment model can provide rapid relief to patients who qualify for lumbar disc surgery.

 

A Structured Physiotherapy Treatment Model Can Provide Rapid Relief to Patients Who Qualify for Lumbar Disc Surgery: A Prospective Cohort Study

 

Abstract

 

  • Objective: To evaluate a structured physiotherapy treatment model in patients who qualify for lumbar disc surgery.
  • Design: A prospective cohort study.
  • Patients: Forty-one patients with lumbar disc herniation, diagnosed by clinical assessments and magnetic resonance imaging.
  • Methods: Patients followed a structured physiotherapy treatment model, including Mechanical Diagnosis and Therapy (MDT), together with graded trunk stabilization training. Study outcome measures were the Oswestry Disability Index, a visual analogue scale for leg and back pain, the Tampa Scale for Kinesiophobia, the European Quality of Life in 5 Dimensions Questionnaires, the Zung Self-Rating Depression Scale, the Self-Efficacy Scale, work status, and patient satisfaction with treatment. Questionnaires were distributed before treatment and at 3-, 12- and 24-month follow-ups.
  • Results: The patients had already improved significantly (p<0.001) 3 months after the structured physiotherapy treatment model in all assessments: disability, leg and back pain, kinesiophobia, health-related quality of life, depression and self-efficacy. The improvement could still be seen at the 2-year follow-up.
  • Conclusion: This study recommends adopting the structured physiotherapy treatment model before considering surgery for patients with symptoms such as pain and disability due to lumbar disc herniation.
  • Keywords: intervertebral disc displacement; rehabilitation; physical therapy modalities.

 

Introduction

 

Symptoms of lumbar disc herniation are relatively common in the general population, although the prevalence rates vary widely between different studies (1). Symptom severity also varies and, in many patients, pain and loss of function may lead to disability and long periods of sick leave (2). Spontaneous resolution of symptoms after a lumbar disc herniation is regarded as common, which makes it difficult to evaluate the effects of treatment. Furthermore, in studies evaluating spontaneous healing, different physiotherapy treatments are often included, together with pain medication (3�5), which makes it difficult to determine the extent of natural healing. On the other hand, in patients with sciatica, but without confirmed disc herniation on magnetic resonance imaging (MRI), approximately one-third of subjects recover 2 weeks after the onset of sciatica and approximately three-quarters recover after 3 months (6).

 

In contrast to evaluating spontaneous healing, surgery for lumbar disc herniation has been investigated in numerous studies. Surgery has been compared with a variety of treatments, such as education, chiropractic, unspecified physiotherapy, acupuncture, injections and medication (7�10). The non-surgical treatments have, however, been described only in vague terms, and variations in treatments have been used. Previous studies have reported favourable short-term (after 1 year) outcomes for surgery, but no major differences between surgical and other treatments have been demonstrated in the long term (over 2 years) (7, 10, 11). The conclusions that are drawn from the comparison between surgery and non-systematic non-surgical treatments may thus be misleading. This has been confirmed in a systematic review, which concluded that there is conflicting evidence as to whether surgery is more beneficial than nonsurgical care for both short- and long-term follow-up (12).

 

Kinesiophobia has been evaluated in patients after lumbar disc surgery, and almost 50% of patients were classified as having kinesiophobia (13). To our knowledge kinesiophobia has not been evaluated in patients with lumbar disc herniation treated with a structured physiotherapy treatment.

 

There are many different non-surgical treatment methods for patients with low-back pain and sciatica. One common management method is Mechanical Diagnosis and Therapy (MDT), also known as the McKenzie method, which aims to eliminate or minimize pain (14). A systematic review from 2004 of the efficacy of MDT showed that patients with low-back pain treated�with MDT reported a greater, more rapid reduction in pain and disability compared with non-steroidal anti-inflammatory drugs (NSAIDs), educational booklets, back massage and back care advice, strength training, spinal mobilization and general exercises (15). In a randomized controlled trial with a 1-year follow-up from 2008, Paatelma and co-workers (16) found that the McKenzie method was only marginally more effective compared with only giving advice to patients with low-back pain. For patients with low-back pain, sciatica and a verified lumbar disc herniation, it has, however, been shown that a selected group of patients who responded to MDT after 5 days of treatment also reported that they were satisfied after 55 weeks (17). The patients started treatment just 12 days after the onset of symptoms and the effects of spontaneous healing cannot therefore be excluded. Taken together, the treatment effects of MDT for patients with a verified lumbar disc herniation appear to require further evaluation.

 

Trunk stabilization exercises, which aim to restore deep trunk muscle control, have been used for the prevention and rehabilitation of low-back pain (18). A randomized controlled trial revealed a reduction in the recurrence of low-back pain episodes after specific trunk stabilization exercises compared with a control group receiving advice and the use of medication (19). Dynamic lumbar stabilization exercises have been found to relieve pain and improve function in patients who have undergone microdiscectomy (20). The effects of trunk stabilization exercises combined with MDT have, however, not been studied in patients with non-operated lumbar disc herniation. MDT is seldom recommended for patients with MRI verified lumbar disc herniation with a broken outer annulus. At our hospital, however, we have several years of good clinical experience of a combination of MDT and trunk stabilization exercises for this category of patients. To our knowledge, no previous study has investigated whether patients with a lumbar disc herniation verified by MRI, symptoms for at least 6 weeks (minimizing effects of spontaneous healing) and who qualified for disc surgery could improve with a structured physiotherapy treatment model including MDT and gradually progressive trunk stabilization exercises. The aim of this study was therefore to�evaluate a structured physiotherapy treatment model in patients who qualified for lumbar disc surgery.

 

Material and Methods

 

During the study inclusion period, 150 patients, who were referred to the orthopaedic clinic at Sahlgrenska University Hospital, Gothenburg, from November 2003 to January 2008, were identified as potential participants since disc herniation was confirmed with MRI. Inclusion criteria were: 18�65 years of age; MRI confirming disc herniation explaining the clinical findings; symptoms for at least 6 weeks (minimizing the effects of spontaneous healing) and pain distribution with concomitant neurological disturbances correlated to the affected nerve root. Exclusion criteria were: cauda equina syndrome, previous spinal surgery, other spinal diseases, such as spinal stenosis and spondylolisthesis, and inadequate command of Swedish. However, 70 patients were excluded because of spontaneous resolution of pain and symptoms. The remaining 80 patients met the inclusion criteria and qualified for surgery. Orthopaedic surgeons determined whether the patients qualified for lumbar disc surgery after MRI and physical examination according to the recommendations of the American Academy of Orthopaedic Surgeons for patients with lumbar disc herniation (21).

 

Figure 1 Study Flowchart

Initially, the study was planned as a randomized controlled trial (RCT) between a structured physiotherapy treatment model and surgery, but the number of patients was not sufficient to obtain acceptable power. Eighteen of the 80 patients were initially randomized to physiotherapy, 17 patients were randomized to surgery and 45 patients did not agree to undergo randomization. Twenty-seven of the 45 patients who did not agree to randomization agreed to take part in the structured physiotherapy treatment and 18 patients agreed to undergo surgery. A decision was therefore made solely to present a cohort of 45 patients treated according to the structured physiotherapytreatment protocol (Fig. 1). Patients were given verbal and written information and informed consent was obtained. The study was approved by the Regional Ethical Review Board.

 

Before structured physiotherapy treatment began, 4 patients recovered to the extent that they could no longer be accepted as surgical candidates and they were therefore excluded from the study. The remaining 41 patients treated according to the structured physiotherapy model are presented in this paper.

 

A Structured Physiotherapy Treatment Model

 

Six physiotherapists with credentialed examinations in MDT, which is an examination within the MDT concept after completing 4 courses of 4 days each for evaluating and treating patients with spinal problems. Following completion of these courses, an extensive literature study and practice in evaluating and treating patients is required before the examination can be completed. The physiotherapists involved in the study had 5�20 years of clinical experience of treating patients with back problems and herniated lumbar disc. The inter-examiner reliability of the MDT assessment has been shown to be good if the examiner is trained in the MDT method (22). The physiotherapists examined and treated the patients during a 9-week period (Table I). For the first 2 weeks of treatment, an MDT protocol was followed, based on clinical examinations of individual mechanical and symptomatic responses to positions and movements, with the aim of minimizing pain and with the emphasis on self-management (14). During the third week of treatment, graded trunk stabilization exercises were added to the MDT protocol. The purpose of graded trunk stabilization exercises was to improve muscle control (23). The low-load muscular endurance exercises were gradually increased in intensity on an individual�basis with respect to the patients� reported leg pain and the observed movement control and quality. During treatment, the patients were encouraged to continue exercising on their own at a gym, or to perform some other type of physical training of their own choice after the structured physiotherapy treatment was concluded. Four weeks after the completion of the 9-week physiotherapy treatment period, the patients attended a follow-up visit with the physiotherapist who had treated them. The aim of this visit was to encourage a high level of compliance with respect to continued trunk stabilization exercises and MDT practice (Table I).

 

Table 1 Treatment Procedures

 

Study Outcome Measures

 

The patients were given a battery of questionnaires to complete. Independent examiners, who were not involved in the treatment, distributed the questionnaires before treatment (baseline) and at the 3-, 12- and 24-month follow-ups.

 

The primary outcome measures were pain intensity in the leg, rated using a visual analogue scale (VAS) 0�100 mm (24) and the Oswestry Disability Index (ODI) 0�100 % (25). A score of 0�10 mm on the VAS was defined as no pain according to �berg et al. (26). An ODI score of 0�20% was defined as minimal or no disability, and a score of over 40% was defined as severe disability (25). These primary outcome measures are commonly used in evaluations after surgery for lowback pain and for assessing patients with lumbar disc herniation (27).

 

Secondary outcome measures included pain intensity in the back rated using a VAS and the degree of kinesiophobia using the Tampa Scale for Kinesiophobia (TSK). The TSK score varies between 17 and 68 and a cut-off more than 37 was defined as a high degree of kinesiophobia (28). Health-Related Quality of Life (HRQoL) in the European Quality of Life in 5 Dimensions Questionnaires (EQ-5D) was used. The EQ-5D includes 2 parts, EQ-5Dindex ranges from 0 to 1.0, where 1.0 is optimal health and EQ-5DVAS is a vertical visual analogue scale ranging from 0 (worst possible health state) to 100 (best possible health state) (29). The Zung Self-Rating Depression Scale (ZDS) ranges from 20�80 and the more depressed the patient is, the higher score (30). The Self-Efficacy Scale (SES) ranges from 8 to 64, with higher scores indicating more positive beliefs (31) was also used. Work status was measured using a 3-grade Likert scale: working full time, full-time sick leave and part-time sick leave. Likewise, patient�satisfaction with treatment was measured on a 3-grade Likert scale; satisfied, less satisfied and dissatisfied (32). These secondary outcome measures evaluate bio-psychosocial factors described as important in connection with lumbar disc surgery (33).

 

Table 2 Baseline Characteristics for the 41 Patients

 

Statistical Analyses

 

The results are presented as median values and interquartile range (IQR), except for age, which is presented as the mean and standard deviation (SD). Changes over time within the group were analysed with the Wilcoxon signed-rank test. Statistical significance was set at an alpha level of 0.05.

 

Results

 

The baseline characteristics are shown in Table II. No patient had undergone surgery at the 3-month follow-up. At the 12-month follow-up, 3 patients had undergone surgery and, at the 24-month follow-up, 1 additional patient had been operated on. After surgery, these 4 patients were excluded from further follow-ups (Fig. 1).

 

Change Over Time in Primary Outcome Measures

 

Disability. The patients showed significant improvements (p < 0.001) in ODI at the 3-month follow-up compared with baseline. The median (IQR) score decreased from 42 (27�53) to 14 (8�33). This improvement could still be seen at 12 and 24 months (Table III and Fig. 2). At baseline, 22 patients reported�severe disability (54%) and 3 patients reported no disability. The degree of disability decreased at the 3-month follow-up, as only 9 patients (22%) reported severe disability and 26 (64%) reported no disability. At 12- and 24-month follow-ups only 2 patients (5%) reported severe disability. At 12-month followup 26 patients still reported no disability, and at 24-month follow-up 27 patients reported no disability.

 

Figure 2 Visual Analogue Scale Leg Pain and Oswestry Disability Index

 

Leg pain. A significant reduction in patients� leg pain was found at the 3-month follow-up (p < 0.001) on the VAS compared with baseline. The median (IQR) on the VAS decreased from 60 (40�75) to 9 (2�27). This improvement could still be seen at the 12- and 24-month follow-ups (Table III and Fig. 2). Before treatment, all patients reported leg pain. Three months after treatment, the median on the VAS was 9 mm, i.e. classified as no leg pain (26). Twenty-three patients (56%) reported no leg pain at the 3-month follow-up. At the 12-month follow-up 22 patients reported no leg pain, and after 24 months 24 patients reported no leg pain.

 

Table 3 Changes Over Time in Primary and Secondary Outcome Measures

 

Change in Secondary Outcome Measures Over Time

 

Back pain. A significant improvement in back pain was found at the 3-month follow-up (p < 0.001) on the VAS compared with baseline. This improvement could still be seen at 12 and 24 months (Table III). At baseline, 6 patients (15%) reported no back pain. Three months after treatment began, 20 patients (49%) reported no back pain.

 

Figure 3 Number of Patients Classified with Kinesiophobia at Baseline

 

Kinesiophobia. The degree of kinesiophobia showed a significant improvement at the 3-month follow-up (p < 0.001) and the improvement could be seen throughout the follow-up period (Table III). Before treatment, 25 patients (61%) were classified as having kinesiophobia and 15 patients (37%) had no kinesiophobia, while data for 1 patient was missing. After 3 months, 15 patients (37%) had kinesiophobia and 26 (63%) had no kinesiophobia. At the 12-month follow-up, the number of patients with kinesiophobia had reduced to 4 (11%) (Fig. 3).

 

Health-related quality of life, depression and self-efficacy. All 4 assessments (EQ-5Dindex, EQ-5DVAS, ZDS and SES) showed significant improvements at the 3-month follow-up (p < 0.001). This improvement could still be seen at 12 and 24 months (Table III).

 

Sick leave. At baseline, 22 patients (54%) were on full-time sick leave (Table IV), compared with 9 (22%) patients at�the 3-month follow-up. At baseline, 14 patients (34%) were working full time, compared with 22 (54%) at the 3-month follow-up.

 

Table 4 Number of Patients on Sick Leave at Each Follow Up

 

Satisfaction with Treatment

 

At the 3-month follow-up, 32 (78%) of 41 patients were satisfied with the structured physiotherapy treatment. Seven patients were less satisfied and 2 patients were dissatisfied. Both of the dissatisfied patients were later operated. At the 2-year follow-up, the number of satisfied patients was 29 (80%) of 36. Seven patients were less satisfied, but none dissatisfied after structured physiotherapy treatment.

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

A disc herniation in the lumbar spine can cause pain, numbness and weakness in the lower back. Because of the severity of the symptoms, many patients seeking fast pain relief consider surgery. However, many non-operative treatment options can help improve as well as manage lumbar herniated disc symptoms.�A structured physiotherapy treatment model can provide rapid pain relief to patients who would otherwise qualify for lumbar disc surgery, according to the following article. Patients looking to avoid taking long periods of sick leave from work due to their symptoms may benefit from a structured physiotherapy treatment model. As with any type of injury and/or condition, the use of other treatment options should be properly considered before turning to surgical interventions for fast pain relief.

 

Discussion

 

The principal finding of this study was that patients who qualified for lumbar disc surgery improved to a statistically significant and clinically substantial degree just 3 months after the start of the structured physiotherapy treatment in all assessments: disability, leg and back pain, kinesiophobia, health-related quality of life, depression and self-efficacy. The improvements could still be seen at the 2-year follow-up.

 

The natural course of healing must be considered carefully, especially when evaluating treatment effects in patients with disc herniation. The symptoms often vary over time and many discs heal spontaneously and the symptoms cease. Approximately 75% of patients with sciatica, without an MRI-verified disc herniation, recover within 3 months, and approximately one-third of patients recover within 2 weeks after the onset of sciatica (6). The natural course of sciatica was evaluated in a randomized controlled trial (34), which compared NSAIDs with placebo. The patients were, however, examined within 14 days after the onset of radiating leg pain. After 3 months, 60% of the patients had recovered and, after 12 months, 70% had recovered. In order to minimize the influence of spontaneous healing in the present study, the patients were therefore included only if they had had persistent pain and disability for more than 6 weeks. In fact, the majority of the patients had had pain and disability for more than 3 months. It is therefore most likely that the effects of treatment seen in the present study are, in the majority of patients, an effect of the structured physiotherapy treatment model and not a result of spontaneous healing.

 

In the study by Weber et al. (34), the VAS leg pain mean score was reduced from 54 mm at baseline to 19 mm within 4 weeks for all 183 patients, regardless of treatment. After 1 year, the VAS leg pain mean score was 17 mm. The patients in the present study who were a little worse at baseline (60 mm) reported 9 mm on the VAS leg pain just 3 months after treatment. Consequently, in the present study, the median VAS level had already been reduced to under the no-pain score, defined as 0�10 on the VAS (26), at the 3-month follow-up and this was maintained to the 12- and 24-month follow-ups.

 

Physiotherapy treatment for patients with lumbar disc herniation can lead to improvements. Br�tz et al. (17) included a selected group of patients who responded with the centralization of pain after the first 5 daily sessions of treatment according to the MDT method. Centralization of pain is defined as a clinically induced change in the location of pain referred from the spine, that moves from the most distal position toward the lumbar midline (35). However, the patients� medium duration of symptoms before treatment was only 12 days and the possibility that patients recovered naturally cannot therefore be excluded (17).

 

In a retrospective study, 95 patients were treated with a functional restoration programme (36). The patients achieved significant improvements after a mean treatment period of 8.7 months. The evaluation was performed at discharge only. With a treatment period of this length, it is, however, difficult to differentiate between the effects of treatment and the natural healing process. In the present study, a shorter treatment period was adopted, and large and significant improvements were found after just 3 months and were still present at the 24-month follow-up. It is therefore not likely that the natural healing process was responsible for the positive results in the present study.

 

In a prospective study of 82 consecutive patients with acute severe sciatica, included for conservative management, only a minority of the patients had made a full recovery after 12 months (37). Twenty-five percent of the patients underwent surgery within 4 months and one-third had surgery within 1 year. In spite of the fact that the inclusion criteria in the present study followed the recommendations for surgery (21, 38), no patient required surgery at the 3-month follow-up and, after 12 months, only 3 patients (7%) had undergone surgery. The interpretation of the divergence could be that the structured physiotherapy treatment model used in the present study appeared to influence patients with lumbar disc herniation in a very positive direction. One recommendation is therefore to follow the structured physiotherapy treatment model before considering surgery.

 

In this study, MRI verification of disc herniation was an inclusion criterion. In clinical practice, MRI verification is not mandatory, as it is in surgical treatment, before introducing structured physiotherapy treatment to patients with symptoms from a disc herniation. Consequently, treatment according to the structured physiotherapy treatment model can start early after the commencement of symptoms, as it is not necessary to wait for an MRI. It is possible to speculate that, if treatment with a structured physiotherapy model starts earlier than in the present study, the improvements would be even better, further reducing the risk of persistent pain and accompanying problems. Moreover, the need for MRI is likely to diminish; this, however, should be further evaluated in future studies.

 

One explanation for the good results of this study could be that the patients followed a structured physiotherapy treatment model, comprising MDT and trunk stabilization exercises, allowing for an individual design and progression of the treatment. Similar results were described in a retrospective cohort study (39) using several treatment methods for pain control as well as for exercise training for patients with lumbar disc herniation. The evaluation was not carried out until approximately 31 months after treatment. The results of Saal et al. (39) and of the present study are in agreement, in that structured physiotherapy treatment can reduce symptoms, but symptoms were relieved much more rapidly in the present study.

 

In a multicentre study comprising 501 patients, randomized to surgery or non-operative care, 18% of the patients assigned to non-operative treatment underwent surgery within 6 weeks and 30% had surgery at approximately 3 months (7). The nonoperative treatment group received non-specified �usual care�, which could include a variety of different treatment methods. In contrast, the patients in the present study were offered a structured physiotherapy treatment model that included both bio-psychological and social components, as described in the International Classification of Functioning, Disability and Health (40).

 

There are many possible explanations for the positive effects seen in this present study, and 5 of these will now be discussed. Firstly, the patients were well informed about the design of the structured physiotherapy treatment model, including the timetable for different phases of the treatment and when the treatment was planned to end. This information enhanced the patients� opportunity for self-management and gave them an active role in treatment decision-making.

 

Secondly, the patients acquired strategies to deal with their pain by using the different activities and movements in order to reduce pain according to the MDT method (14). The MDT method aims to enhance the patients� ability to cope with the symptoms, motivate the patient to comply with the treatment and empower them to achieve independence. Leijon et al. (41) have shown that low levels of motivation plus pain are important factors that enhance non-adherence to physical activity. It therefore appears important to reduce pain and increase motivation as early as possible. It is reasonable to believe that, when the patients participated in the evaluation of different activities and exercises, this augmented their opportunity to discover the connection between activities and the following reduction or increase in symptoms. This could have led to the increased self-efficacy and empowerment of the patients. The use of empowerment in physiotherapy has been recommended in a review by Perrault (42), who argues that empowerment improves the intervention.

 

Thirdly, the intensity of exercises was gradually increased on an individual basis with respect to the patients� reported pain. The objective was to strengthen the patients� self-efficacy, which also improved significantly in the present study. Fourthly, the trunk stabilization exercises were conducted with the aim of increasing deep trunk muscle control (23). It can be speculated that the physiological effects of training may also have led to reduced pain through increased blood circulation, muscle relaxation and the release of pain-reducing substances, such as endorphins.

 

Finally, one reason for the improvements could be that the physiotherapists were experienced and well educated in the MDT method. Subsequently, the physiotherapists were able to guide the patients during the rehabilitation process. It is, however, not possible to determine whether and how much each of the reasons discussed above contributed to the improvements. It seems reasonable to assume that all 5 factors were operating.

 

In this study, the majority of patients experienced kinesiophobia before treatment started. As early as 3 months after the structured physiotherapy treatment started, the number of patients with kinesiophobia fell dramatically and the majority of patients no longer experienced kinesiophobia. These results are in agreement with those of a study of patients with chronic pain and high kinesiophobia who increased their physical activity level after a pain management programme designed to enable the patients to regain overall function (43).

 

There are some limitations to this study. It is not possible to exclude the possibility that some patients may have improved spontaneously without treatment. Measures were taken to limit this risk by using symptoms for at least 6 weeks as an inclusion criterion. Again, the majority of patients had symptoms for more than 3 months. Another limitation might relate to whether the patients were selected accurately for the study. Clinically experienced orthopaedic surgeons evaluated the clinical findings and the MRI scans and classified the patients as surgical candidates based on recommendations from the American Academy of Orthopaedic Surgeons for intervention for disc herniation published in 1993 (21). The patients included in the present study also fulfilled the recommendations as presented by Bono and co-workers in 2006 (38). The patients can therefore be regarded as serving as their own controls, and comparisons can be made with baseline symptoms and with patients from other studies. An RCT would have been the best way to explore different treatment options; however, we did not reach the number of patients required for an RCT. As the treatment model used in the present study has not been evaluated previously in a group of patients with long-standing pain, with the majority of the patients having pain for more than 3 months due to disc herniation, and, as the results are clinically interesting, it was decided to present the results as a cohort study.

 

In conclusion, this study shows that patients eligible for lumbar disc surgery improved significantly after treatment with the structured physiotherapy model, as early as 3 months after treatment, and the results could still be seen at the 24-month follow-up. Consequently, these patients did not qualify for lumbar disc surgery 3 months after the physiotherapy treatment started. Moreover, the majority of patients had symptoms for more than 3 months at the start of treatment and, for this reason, most of the spontaneous healing ought to have occurred before this study started. This study therefore recommends adoption of the structured physiotherapy treatment model before considering surgery when patients report symptoms such as pain and disability due to lumbar disc herniation.

 

Acknowledgements

 

The authors would like to thank physiotherapists Patrik Drevander, Christina Grund�n, Sofia Frid�n and Eva Fahlgren for treating the patients and Valter Sundh for statistical support. This study was supported by grants from the Health & Medical Care Committee of the V�stra G�taland Region, Ren�e Eander�s Foundation and Wilhelm & Martina Lundgren�s Foundation of Science.

 

Herniated discs can cause pain, numbness and weakness, a variety of symptoms which may often become so severe, that surgery might seem like the only option for fast relief. However, a�structured physiotherapy treatment model can provide rapid relief to patients who qualify for lumbar disc surgery, according to the results of the research study. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Neck Pain

 

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

 

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IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

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

 

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

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

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

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

 

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

 

Abstract

 

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

 

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

 

Introduction

 

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

 

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

 

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

 

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

 

Review

 

Methods

 

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

 

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

Table 1: PEDro score yes or no items.

 

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

 

Results

 

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

 

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

 

Table 2 The Methodological PEDro Score of the Included RCTs

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

 

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

 

Table 3 Results of Manual Therapy RCTs of CTTH

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Discussion

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Conclusion

 

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

 

Competing Interests

 

The authors declare that they have no competing interests.

 

Authors� Contributions

 

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

 

Authors� Information

 

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

 

Acknowledgements

 

Akershus University Hospital, Norway, kindly provided research facilities.

 

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

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

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

 

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

 

Abstract

 

Background

 

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

 

Methods

 

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

 

Results

 

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

 

Conclusions

 

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

 

Trial Registration

 

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

 

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

 

Background

 

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

 

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

 

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

 

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

 

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

 

Methods

 

Study Design

 

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

 

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

 

Participants

 

Patients meeting the following criteria were included.

 

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

 

Patients meeting the following criteria were excluded.

 

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

 

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

 

Interventions

 

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

 

Complementary and Alternative Medicine Treatment Protocol

 

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

 

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

 

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

 

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

 

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

 

Outcome Measures

 

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

 

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

 

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

 

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

 

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

 

Safety Assessments

 

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

 

Statistical Methods

 

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

 

Results

 

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

 

Figure 1 Flow Diagram of the Study

Figure 1: Flow Diagram of the Study

 

Table 1 Baseline Demographic Characteristics

Table 1: Baseline demographic characteristics.

 

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

 

Table 2 Length of Hospital Stay and Interventions Administered During Stay

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

 

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

 

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

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

 

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

 

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

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

 

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

 

Table 5 Assessment of Predictive Baseline Factors

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

 

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

 

Discussion

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Conclusions

 

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

 

Acknowledgements

 

This work was supported by Jaseng Medical Foundation.

 

Abbreviations

 

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

 

Footnotes

 

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

 

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

 

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

 

In conclusion, migraine and cervical disc herniation treatment such as manual therapy as well as integrated complementary and alternative medicine may be effective towards the improvement and management of their symptoms. Information referenced from the National Center for Biotechnology Information (NCBI). The above research studies utilized a variety of methods to conclude the final results. Although the findings were shown to be effective migraine and cervical disc herniation treatment, further research studies are required to determine their true efficacy. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Neck Pain

 

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

 

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IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

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

 

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Manual Therapy for Migraine Treatment In El Paso

Manual Therapy for Migraine Treatment In El Paso

by | Chiropractic, Functional Medicine, Migraine, Physical Rehabilitation

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

 

Manual Therapies for Migraine: a Systematic Review

 

Abstract

 

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

 

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

 

Introduction

 

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

 

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

 

Method

 

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

 

 

Results

 

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

 

Methodological Quality of the RCTs

 

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

 

Table 2 Quality Score of the Analyzed Randomized Controlled Trials

 

Randomized Controlled Trials

 

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

 

Table 3 Randomized Controlled Trials for Migraine

 

Massage Therapy

 

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

 

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

 

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

 

Physical Therapy

 

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

 

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

 

Chiropractic Spinal Manipulative Treatment

 

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

 

Dr Jimenez works on wrestler's neck_preview

 

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

 

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

 

Discussion

 

Methodological Considerations

 

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

 

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

 

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

 

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

 

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

 

Dr Jimenez White Coat

Dr. Alex Jimenez’s Insight

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

 

Results

 

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

 

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

 

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

 

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

 

Conclusion

 

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

 

Conflict of Interest

 

None declared.

 

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

 

In conclusion,�chiropractors, physical therapists and massage therapists, among other qualified and experienced healthcare professionals, recommend manual therapies as a treatment for migraine headache pain. The purpose of the article was to�educate patients on the effects of manual therapies for migraine treatment. Furthermore, the systematic review determined that�future, well-conducted randomized clinical trials are required to conclude the findings. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .

 

Curated by Dr. Alex Jimenez

 

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Additional Topics: Neck Pain

 

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

 

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IMPORTANT TOPIC: EXTRA EXTRA: A Healthier You!

 

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

 

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